University:
Lincoln University
Course:
NUR301 | Fundamental of Nursing
Academic year:

2024
Views:

389

Pages:

2
Author:

Bobby E.

.Stage 3 Assessment - Activity or rest The client looks happy and exhausted. - Circulation Blood pressure increases when cardiac output increases and returns to normal quickly. Hypotension due to analgesics and anesthetics. Pulse slows. - Eat and fluids Normal blood loss is 250 – 300 ml. - Pain or discomfort Clients complain of leg tremors or shivering. - Sexuality. Black blood from the vagina occurs when the placenta separates. The umbilical cord becomes long at the opening of the vagina. Nursing Diagnosis and Nursing Plan 1) There is a lack of fluid volume related to vaginal discharge due to atonia. Objective: There is no lack of fluid volume due to HPP. With KH: - Adequate uterine contractions. - Blood loss is within normal limits (<500 ml). - Vital signs are within normal limits. Intervention: a) Advise the client to massage the fundus. b) Monitor vital signs and vaginal discharge. c) Palpate the uterus and gently massage the uterus after expulsion of the placenta. d) Note the time and mechanism of placental detachment. e) Monitor for signs and symptoms of excessive fluid loss. f) Inspect the surface of the maternal and fetal placenta, noting the size, insertion of the umbilical cord and amniotic fluid. g) Give oral fluids. h) Avoid excessive pulling on the umbilical cord. 2) Acute pain and comfort disorders related to tissue trauma, a physiological response after childbirth. Objective: Patients can adapt to pain with KH: - The client states that the pain has decreased or the client has adapted to the pain. - The facial expression is relaxed and not anxious. - The stomach is not sore, the wound is clean and not swollen. Intervention: a) Assist with the use of breathing techniques during wound repair. b) Apply an ice compress to the perineum after delivery. c) Care for the episiotomy wound using aseptic technique and apply topical ointment. d) Change wet clothes and clients, give them a warm blanket. e) Explain to the client the physiological changes after giving birth.