Nursing Diagnosis Deficient Fluid Volume r/t uterin atony aeb cesarian section with anesthesia, Grav 3 Par 2

Long Term Goal Pt will maintain adequate fluid volume

Data postpartum day 1 and 2, pale: skin for race, nailbeds, lips, conjunctivae, Hgb: 11, 6.2 Hct: 31.7, 17.3, EBL 400ml during caesarian
section, firm fundus 1cm below umbilicus and midline, scant Lochia Rubra, pass small nickel sized clot x1 in pad, UO 1400-8hr shift,
straw colored, perineum +1 edema, RR 22, HR 112, 100, BP 106/67, SBP <99, approx. 8 lateral surgical incision midline and
anterior to symphis pubis, pt c/o lightheaded/dizzy upon position change x1, Hx of anemia, 2 unit PRBC admininstered postpartum
day 1
Outcome Criteria Nursing Actions Scientific Rationale Evaluation
Outcome Intervention

RR >20 per minute can be due to blood loss and decreased oxygen carrying
capacity of blood. HR >100 BPM could be caused by and increased need for the
heart to work harder due to insufficient volume as well. And, when circulating blood Plan ongoing,
Pt BP 115-130/65-85, volume falls, as in hemorrhage which occurs in the postpartum period, blood outcome not met. Pt
HR 60-100, RR 14-20 Assess HR, BP, RR pressure falls. The body can only remain in this altered state for so long before HR>100, RR>20, SBP
as assessed q4h and q4h and PRN decompensation occurs quickly. Sudden changes or numbers trending outside the <115
PRN expected range need to be closely monitored as hemorrhage can had fatal
consequences. (Olds866, class notes)

Outcome Intervention

Administering supplemental oxygen therapy will maximize oxygen transport needed

to tissue. In the event of deficient fluid volume in the vasculature, cardiovascular
Plan ongoing,
changes start to occur and HR increases, the workload on the myocardium
Administer 2L O2 NC outcome met, O2Sat
increases, which only intensifies the need for more oxygen to supply to the
Pt 02Sat >92% at all PRN SOB or O2 Sat >99% on room air,
overworking myocardium. When the body loses volume it loses its capacity to
times <92% on room air as continue until
supply oxygen to tissues, and administration of supplemental oxygen increases the
ordered discharge
supply to the tissues which can decrease the workload on the myocardium until
other interventions can take place if hemorrhage is occurring. (class notes)

Outcome Intervention Assessing output and bladder fullness frequently is important because a full bladder Outcome met. Plan
Pt will void q3-4 h Monitor urinary interferes with involution of the uterus. In the immediate postpartum period many ongoing until
(awake) and PRN: and
output q shift
UO >30ml/hr q shift women may not be aware of a full bladder because the ligaments are still stretched. discharge.
Postpartum period a woman experiences diuresis and the bladder may fill more
rapidly than normal, and a full bladder can displace the uterus affecting its
contractility and tone, putting the patient at risk for increased blood loss. A
decreasing urine output could be indicative of insufficient renal perfusion and further
interventions would take place to determine if there is adequate fluid volume before