ASSESSMENT DIAGNOSI PLANNING INTERVENTION EVALUATION

S
bleeding Fluid To Administ the
volume minimiz er bleedin
deficit: e emergen g was
bleeding bleedin cy fluid minimi
related to g therapy zed
active as the
fluid loss ordered mother
from Administ verbali
hemorrha er I.V. zed "
ge oxytocin day, ni
secondary as less na
to uterine ordered akung
rupture Maintain
bed rest
to
decrease
metabolic
demands
Limit
activity
Prepare
the
woman
for a
possible
laparoto
my as an
emergen
cy
measure

Sudden, Altered To
severe pain Comfort: alleviat
during a Pain e pain
strong labor related to To
contraction tearing reduce
Report of a sensation pain
tearing secondary
sensation to uterine
Cessation of rupture
uterine
contractions

tachycardia Altered To Admister

tachypnea breathing regain O2
rapid rise pattern: breathi therapy
and fall of tachypne ng (face
the chest a related pattern mask at
to of the 8-12
hypovole mother L/min or
mic shock To as
caused by regain ordered
 hemorrha normal to
ge respirat provide
ory higher
rate of oxygen
the concentr
mother ation)
Monitor
oxygen
saturatio
n as
indicated
Re assess
the vital
signs of
the
mother.
- pallor Ineffectiv To Administ
- cold e tissue increas er O2
and perfusion: e therapy
clammy pallor r/t oxygen
skin decrease supply
d oxygen
supply s/t
bleeding

-decreased blood Decrease

pressure ( d cardiac
output:
hypotensi
on r/t
decrease
d blood
volume