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Nursing Care Plan

The patient is at risk for ineffective tissue perfusion related to postpartum hemorrhage due to low lab results and vital signs. The nursing diagnosis is risk for ineffective tissue perfusion related to postpartum hemorrhage. The plan is to assess skin color, temperature, moisture and perfusion changes to determine the location and type of perfusion problem. Interventions include monitoring fluids, encouraging early ambulation, emphasizing avoiding blood thinners and smoking, and administering medications to improve perfusion as needed. The goal is for the patient to demonstrate adequate perfusion and stable vital signs after 8 hours of nursing intervention.

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Vic Intia Paa
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406 views2 pages

Nursing Care Plan

The patient is at risk for ineffective tissue perfusion related to postpartum hemorrhage due to low lab results and vital signs. The nursing diagnosis is risk for ineffective tissue perfusion related to postpartum hemorrhage. The plan is to assess skin color, temperature, moisture and perfusion changes to determine the location and type of perfusion problem. Interventions include monitoring fluids, encouraging early ambulation, emphasizing avoiding blood thinners and smoking, and administering medications to improve perfusion as needed. The goal is for the patient to demonstrate adequate perfusion and stable vital signs after 8 hours of nursing intervention.

Uploaded by

Vic Intia Paa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

Assessments Nursing Rationale Planning Intervention Rationale Evaluation


Diagnosis
SUBJECTIVE: RISK FOR Postpartum After 8 hour of INDIPENDENT: Goal met
Patient reported a INEFFECTIVE Hemorrhage due to Nursing Assess skin color, Helps in determining After 8hour of
medical history of TISSUE retained placenta. Intervention the temperature, moisture, and location and type of Nursing
Iron Deficiency PERFUSION Due to low result patient will be whether changes are perfusion problem. Intervention the
Anemia and Patient RELATED TO of Lab work and able to: widespread or localized. patient was able
said “gets tired POSTPARTUM vital signs and to:
easily”, and has HEMORRHAGE Patient medical Demonstrate Measure capillary refill To determine adequacy Demonstrate
“poor appetite”.  history of Iron adequate of systemic circulation adequate
Deficiency perfusion and perfusion and
OBJECTIVE: Anemia. stable vital Monitor fluid intake and Dehydration reduces vital signs are
She looks pale and signs. output blood volume and stable.
weak, hands and feet compromises peripheral
are cold and circulation.
clammy, and Discourage sitting or
capillary refill is 5 standing for extended Which restrict circulation
seconds period of time, wearing and leads to venous stasis
constrictive clothing, or and edema
BP: 90/60;  closing leg when sited
PR: 120 bpm; RR:
31/min;  Encourage early To reduce venous
T: 38.5 ⁰C;  ambulation when possible pooling and increase
O2 Sat-88-89% and recommend regular venous return
exercise
WBC: 12.2
10e6/Ul; 
RBC: 3.2 10e6/uL;  Note client’s nutritional Protein- energy
Hgb: 90 g/L; Hct: Status malnutrition and weight
0.20 L/L;  loss make ischemic tissue
Plt count:150 more prone to
10e3/uL breakdown.
Emphasized importance of
avoiding use of aspirin,
some over- the- counter Blood thinners may
drugs and supplements, or interact with certain
alcohol when taking foods, medicines,
anticoagulant and avoid vitamins, and alcohol.
Smoking Make sure that your
health care provider
knows all of the
DEPENDENT: medicines and
supplements you are
Administer fluids, using.
electrolytes, nutrients, and
oxygen, as prescribed
To promote optimal
blood flow organ
perfusion and function
Administer medications
such as antiplatelet agents,
thrombolytic, antibiotics
To improve tissue
perfusion or organ
COLLABORATIVE: function

Refer to dietician for well-


balanced, low-saturated
fat, low-cholesterol diet or
other modification as Discuss care of
indicated dependent limbs/foot
care, as appropriate.
When circulation is
impaired, changes in
sensation plays client at
risk for development of
lesions or ulcerations that
are often slow to heal.

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