- Acute Pain related to Hematoma and Uterine atony as evidenced by Reports of pain intensity and Pelvic pain and heaviness
- Anxiety related to Traumatic delivery and Threat of death as evidenced by Awareness of physiological symptoms and Restlessness
- Deficient Fluid Volume related to Blood loss after birth (haemorrhage) as evidenced by Hypotension, decreased urine output and Decreased haemoglobin
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviors | Acute Pain related to Hematoma and Uterine atony as evidenced by Reports of pain intensity and Pelvic pain and heaviness | Patient will identify and demonstrate appropriate interventions for pain relief. Patient will report relief from pain or discomfort. | 1. Encourage relaxation techniques and diversional activities. Relaxation techniques like deep breathing, meditation, back rubs, and diversional activities can refocus the patient’s attention to reduce discomfort. 2. Administer pain medications as indicated. Pain medications are indicated to help provide pain relief to patients with acute pain from perineal trauma or surgical interventions to stop haemorrhaging. 3. Encourage the use of a cold compress or sitz bath to the perineum. Cold compresses can reduce the formation of hematomas in the perineal area and vulva and promote pain relief. A warm sitz bath can reduce episiotomy pain and provide relaxation. 4. Prepare for surgical intervention. Pain can signal the need for surgical intervention, such as laceration repair, laparotomy for uterine repair or Cesarean incision repair, artery ligation, or incision and drainage of large hematomas. | Patient identified and demonstrated appropriate interventions for pain relief. Patient reported relief from pain or discomfort. |
Subjective data: -Feeling nervous -Verbalizing a sense of impending danger Objective data: -Restlessness and tense appearance -Tachycardia -Tachypnea Hyperventilation Diaphoresis Trembling/tremors Weakness or tiredness -Difficulty concentrating -Difficulty sleeping | Anxiety related to Traumatic delivery and Threat of death as evidenced by Awareness of physiological symptoms and Restlessness | Patient will report decreased anxiety and feeling in control. Patient will implement two strategies to decrease anxiety. | 1. Maintain clear communication. The nurse should communicate the interventions taken and outcomes. The nurse should remain supportive and empathetic and provide calm reassurance to decrease anxiety. 2. Involve support system. The patient’s support system such as the spouse/partner and family should be included in teaching and instruction. They can support the nurse in reducing the fear of the patient and supporting the treatment plan. 3. Keep baby and mother together when possible. Separating the mother from their newborn can cause unnecessary stress. If the mother is being treated in her room, try and keep the baby with her to promote bonding and distraction. 4. Provide therapy resources. Experiencing a life-threatening situation can cause long-term stress and anxiety. Additional counseling following the event can assist the patient and family in coping. Post-partum depression is also more likely to occur after PPH. | Patient reported decreased anxiety and feeling in control. Patient implemented two strategies to decrease anxiety. |
| Subjective data: -Feeling thirsty -Verbalizing a sense of impending danger Objective data: -Hypotension, -Decreased urine output -Decreased haemoglobin | Deficient Fluid Volume related to Blood loss after birth (haemorrhage) as evidenced by Hypotension, decreased urine output and Decreased haemoglobin | Patient will maintain blood pressure above 90/60 mm Hg for perfusion to vital organs. Patient will not experience more than 1000 mL of blood loss following vaginal birth. Patient will maintain hemoglobin level within normal limit | 1. Massage uterus. Massaging of the uterus after delivery can promote contractions and prevent PPH. 2. Administer oxytocin. Oxytocin is routinely administered immediately following birth to prevent and/or treat PPH. 3. Maintain bed rest. To maintain the safety of the patient with hypovolemia, encourage bed rest to prevent orthostatic hypotension, dizziness, and falling. This can also decrease bleeding. Keep legs elevated to promote venous return. 4. Administer IV fluids. Administration of IV fluids will be a priority intervention to increase the intravascular volume. Normal saline is usually ordered. 5. Administer blood products. Packed red blood cells and/or plasma may be ordered to replace blood loss. 6. Prepare for surgery. If hemorrhage is due to lacerations, hematoma, trauma, or retained tissues (placental fragments) surgery may be required. | Patient maintained blood pressure above 90/60 mm Hg for perfusion to vital organs. Patient not experienced more than 1000 mL of blood loss following vaginal birth. Patient maintained haemoglobin level within normal limit |