Assessment Diagnosis Planning Intervention Rationale Evaluation

Risk for infection STG: Independent: STG:

related to
episiotomy After 7 hours of 1. Establish rapport 1. To gain client’s After 7 hours of
nursing cooperation. nursing
intervention, the intervention, the
patient will patient was able
identify 2. Observe changes in color 2. That could to identify
interventions to and/or odor of secretions indicate onset interventions to
prevent or reduce (e.g., urine) of infections. prevent or reduce
risk of infection. risk of infection.
3. Recommend routine or
preoperative body 3. To reduce
shower or scrubs, when bacterial
indicated. colonization.

4. Cleanse incisions and

insertion sites per facility
protocol with 4. To reduce
appropriate antimicrobial potential for
topical or solution. catheter-
related
bloodstream
infections, and
to prevent
5. Encourage and teach growth of
perineal care. bacteria

5. Reduces risk of
ascending
urinary tract
infection.
 6. Inappropriate
6. Discuss importance of use can lead to
not taking antibiotics or development
using “leftover” drugs of drug
unless specifically resistant
instructed by healthcare strains or
provider secondary
infection

7. Emphasize necessity of 7. Premature

taking antivirals or discontinuation
antibiotics, as directed of treatment
(e.g., dosage and length when client
of therapy). begins to feel
well may result
in return of
infection and
potentiation of
drug resistant
Dependent:
strains
8. Administer/monitor
medication regimen (e.g.,
8. To determine
oral
effectiveness
sulphamethoxypyridazine
of therapy or
or chloramphenicol for
presence of
three to five days, and
side effects.
intravenous amoxicillin
and clavulanic acid in a
single dose one hour
after birth) and note
client’s response
Assessment Diagnosis Planning Intervention Rationale Evaluation
Risk for bleeding STG: Independent: STG:
related to post- After 7 hours of After 7 hours of
partum nursing 1. Establish rapport 1. To gain nursing
complications intervention, the client’s intervention, the
patient will identify cooperation. patient was able
individual risks and identify individual
engage in 2. Assess vital signs, 2. To determine risks and engage in
appropriate including blood if appropriate
behaviors or pressure, pulse, and intravascular behaviors or
lifestyle changes to respirations. fluid deficit lifestyle changes to
prevent or reduce Measure blood exists. prevent or reduce
frequency of pressure frequency of
bleeding episodes. lying/sitting/standing bleeding episodes.
as indicated to
evaluate for
orthostatic
hypotension;
monitor invasive
hemodynamic
parameters when
present.

3. Note client report of 3. Can help

pain in specific areas, identify
whether pain is bleeding into
increasing, diffuse, tissues,
or localized. organs, or
body cavities.

4. Assess skin color and 4. Changes in

moisture, urinary these signs
output, level of may be
consciousness, or indicative of
 mentation. blood loss
affecting
systemic
circulation or
local organ
function such
as kidneys or
brain.

5. Review laboratory 5. To evaluate

data (e.g., complete bleeding risk.
blood count [CBC], An abrupt
platelet numbers drop in Hb of
and function, and 2 g/dLl can
other coagulation indicate active
factors such as bleeding.
Factor I, Factor II,
prothrombin time
[PT], partial
thromboplastin time
[PTT], and
fibrinogen)

6. Importance of 6. To identify
periodic review of medications
client’s medication that might
regimen cause or
exacerbate
bleeding
problems

7. Instruct at-risk client

and family regarding
 specific signs of 7. To determine
bleeding requiring abnormal
healthcare provider signs and
notification, such as symptoms of
active bright bleeding.
bleeding anywhere,
prolonged epistaxis
or trauma in client
with known factor
bleeding tendencies,
black tarry stools,
weakness, vertigo,
and syncope.

8. Teach techniques for

postpartum client to
check her own 8. May prevent
fundus and perform blood loss
fundal massage as complications,
indicated and the especially if
need to contact client is
physician for post discharged
discharge bleeding early from
that is bright red or hospital.
dark red with large
clots.

Name of Dosage/Frequency Mechanism of Indication Contraindication Adverse effect Nursing

Drug /Route/Time action responsibilities
Generic IV INFUSION (drip Acts on Stimulation of Where there is  nausea  Assess vital
Name: method): smooth uterine significant cephalopelvic  vomiting signs for
Oxytocin muscle of the contractions disproportion.  rash baseline data
-Induction or uterus to during third  Cephalopelvic  hives  Monitor
Brand stimulation of stimulate stage of labor disproportion  itching frequency
Names: labor contractions; and control  Fetal  difficulty duration,
Pitocin Initial: 0.5-2 response of postpartum malpresentation breathing strength of
milliunits/min. depends on bleeding or  Umbilical cord or contractions
Drug Class: Increase dose the uterine hemorrhage prolapses swallowing  Monitor for
Oxytocic gradually in threshold of  Non-reassuring  swelling of signs of
agents increments of no excitability. Is fetal status the face, uterine
more than 1-2 selective for  Active genital throat, rupture,
milliunits/min at the uterus, herpes tongue, which include
30-60 min especially  Hypertonic lips, eyes, FHR
intervals until a toward the uterus hands, decelerations,
contraction end of  Unripe cervix feet, sudden
pattern has been pregnancy,  Grand ankles, or 1ncreased
established that is during labor, multiparity lower legs pain, loss of
similar to normal and  Uterine  fast uterine
labor. Rates immediately prolapse heartbeat contractions
exceeding 9-10 follow-  Clients at risk of  unusual hemorrhage,
milliunits/min are delivery. uterine rupture bleeding and rapidly
rarely required. Oxytocin developing
stimulates hypovolemic
-Control of rhythmic shock
postpartum contractions of  Maintain
bleeding. the uterus, careful I&O
Add 10-40 units increases the Be alert to
(maximum of 40 frequency of potential
units) to 1,000 mL existing water
of a non-hydrating contractions, intoxication.
diluent and run at and raises the Check for
a rate needed to tone of uterine blood loss.
control uterine musculature.  Report
 atony. changes in
vital signs and
-Treatment of FHR
incomplete or Specifically
inevitable late
abortion. decelerations
Infuse 10 units of and any
oxytocin with 500 vaginal
mL physiological bleeding
saline solution or
D5W in
physiological
saline infused at a
rate of 10-20
milliunits (20-40
drops/min). Do not
exceed 30 units in
a 12-hr period due
to the risk of water
intoxication.

IM

-Control of
postpartum
bleeding.
Give 10 units after
delivery of the
placenta

Name of Drug Dosage/Frequency Mechanism of Indication Contraindica Adverse effect Nursing

/Route/Time action tion responsibilities
Generic Name: Tablet: Unless Its anticholinergi Antispasmodic Hyoscine-N-  Constipation -Be alert for
Hyoscine N- otherwise c action exerts a drug indicated for butylbromid  Decreased adverse reactions
butylbromide prescribed by the smooth-muscle the treatment of e (Buscopan) sweating and drug
 (HnBB) physician, the relaxing/spasmo abdominal pain is  Mouth, skin, interactions.
following doses are lytic effect. associated with contraindica eye dryness -Assess for eye
Brand Names: recommended: Blockade of cramps induced ted in:  Blurred pain
Buscopan, the muscarinic by patients who feeling -Assess for
Syntocinon Adults and children receptors in the gastrointestinal have  Bloating urinary hesitancy
over 6 years: 1-2 GI tract is the (GI) spasms. demonstrate  Dysuria -Assess for
Drug Class: sugar coated basis for its use d prior  Nausea or constipation
Antispasmodics tablets 3-5 times in the treatment hypersensiti vomiting -Monitor urine
daily. of abdominal vity to  Lightheaded- output
The tablets should pain secondary Hyoscine-N- ness -Encourage
be swallowed to cramping. butylbromid  Headache patient to void.
whole with Hyoscine e or any  Weakness -Monitor BP for
adequate fluid. butylbromide other possible
also binds to component hypertension.
Injection:  Adults nicotinic of the -For pregnant
and adolescents receptors, product; women, monitor
over 12 years: 1-2 which induces a myasthenia cervical
ampoules of ganglion- gravis, effacement and
Hyoscine-N- blocking effect. mechanical dilatation.
butylbromide stenosis in
(BUSCOPAN) (20- the
40 mg) may be gastrointesti
administered by nal tract,
slow intravenous, paralytical or
intramuscular or obstructive
subcutaneous ileus,
injection several megacolon.
times daily.
The maximum daily
dose of 100 mg
should not be
exceeded.
 Infants and
children: In severe
cases: 0.3-0.6
mg/kg bodyweight,
to be administered
by slow
intravenous,
intramuscular or
subcutaneous
injection several
times daily.
The maximum daily
dose of 1.5 mg/kg
bodyweight should
not be exceeded.

Name of Drug Dosage/Frequency Mechanism of Indication Contraindication Adverse effect Nursing

/Route/Time action responsibilities
Generic Name: IM; IV Synthetic drug Following Pregnancy, Hypertension -assess for any
Methylergonovine (EMERGENCIES related to delivery of the toxemia, associated with adverse effects
maleate ONLY) ergonovine. placenta, for hypertension. seizure and/or - Tell patient to not
0.2 mg q 2-4 hr. Acts directly on routine Ergot headache, use methylergonovine
Brand Names: following delivery the uterine management of hypersensitivity. hypotension, during pregnancy. Thi
Methergine of placenta, of the smooth muscle uterine atony, To induce labor abdominal pain, s medication is to be
anterior shoulder, to stimulate hemorrhage, or threatened GI upset; rare: used only after
Drug Class: or during the the rate, tone, and spontaneous cardiovascular delivery of your baby.
Oxytocic Drug puerperium. and amplitude subinvolution abortions. effects (eg, -Remind patient to
of uterine of the uterus. Administration vasoconstriction, not breast-feed within
contractions. It For control of before delivery acute MI, 12 hours after taking
TABLETS: induces a rapid, uterine of the placenta. transient chest methylergonovine.
sustained hemorrhage in Use with CYP3A4 pains).
0.2 mg 3-4 times tetanic utero the second inhibitors (e.g
per day in the tonic effect stage of labor protease
puerperium for a that shortens following inhibitors,
maximum of 1 the third stage delivery of the macrolide
week of labor and anterior antibiotics, azole
reduces blood shoulder. antifungal drugs)
loss. The uterus
becomes more
sensitive to the
drug toward
the end of
pregnancy.

Name of Drug Dosage/Frequency Mechanism of Indication Contraindication Adverse Nursing responsibilities

/Route/Time action effect
Generic Name: Intramuscular Carboprost is a For aborting Acute pelvic Vomiting, -Monitor frequency, 
Carboprost Pregnancy synthetic pregnancy inflammatory diarrhea, duration, and force of con
tromethamine termination in the prostaglandin. disease; active nausea, tractions and uterine 
between
2nd trimester It binds the cardiac, transient resting tone. Notify physici
Brand Names: Adult: Initially, 250 prostaglandin the 13th and pulmonary, renal fever, an or other health care 
Hemabate mcg. Alternatively, E2 receptor, 20th weeks or hepatic flushing, professional if
initiate w/ test causing of gestation disease. increased BP, contractions are absent
Drug Class: dose of 100 mcg. myometrial in the bronchospas or last more than 
Abortifacient May be repeated at contractions, m, dyspnea, 1 min.
following
1.5- to 3.5-hr causing the pulmonary
intervals induction of conditions oedema. -Monitor temperature,
depending on labor or the related to pulse, and BP
uterine response. expulsion of second periodically throughout 
May be increased the placenta. trimester course of therapy. Large
to 500 mcg if Prostaglandins dose may cause 
abortion: 1)
uterine occur naturally hypertension. 
contractility is in the body and failure of Temperature elevation be
inadequate. Max: act at several expulsion of ginning 1 to 16 hr after 
12 mg. Max sites in the the fetus initiation of therapy and 
duration: 2 days. body including during the lasting for several hours is 
the womb not unusual.
course of
Intramuscular (uterus). They
Postpartum act on the treatment -Auscultate breath
haemorrhage muscles of the by another sounds. Wheezing and sen
Adult: Initially, 250 womb, causing method; 2) sation of chest tightness 
mcg by deep inj. them to premature may indicate hypersensitiv
May be repeated contract. ity reaction.
every 15-90-min.
rupture of
Max: 2 mg. membranes -Assess for nausea, 
in vomiting, and diarrhea. 
intrauterine Vomiting and diarrhea occ
methods ur in approximately two-
thirds of patients. Premedi
with loss of cation with antiemetic and 
drug and antidiarrheal is recommen
insufficient ded.
or absent
-Monitor amount and 
uterine type of vaginal discharge. 
activity; 3) Notify physician or other 
requirement health care professional 
of a repeat immediately if symptoms 
of hemorrhage (increased 
intrauterine
bleeding, hypotension, 
instillation pallor, tachycardia) occur.
of drug for
expulsion of
the fetus; 4)
inadvertent
or
spontaneou
s rupture of
membranes
in the
presence of
a previable
fetus and
absence of
adequate
activity for
expulsion