Assessment Sheet

Student'sname:- Group 4 Group no:- 3B

Section:-Obstetrics Date:-15/1/2026

Patient'sData:-
Patient's name: Eman Mohamed Gamal Age: 33 Yrs Sex:♀
Occupation: Housewife Weight: 80 Kg
Marital Status: - M () - W (–) - S (–) D (–)
Admitted From:
Out Patient: (–) - Emergency () - Referred:(–)
Diagnosis:
Postpartum Hemorrhage
Health history :

1-Chiefcomplain: Heavy vaginal bleeding after delivery associated with dizziness

and weakness.
2 –Past medical history: Not Found

3- Family history: Not Found

Skin

- Rash (–) -Previouss care(–)

- Hot skin (–) -Cold skin()
- Pale skin () -Jaundice (–)
- Reddening of pressure areas(–)
- Skin ulceration/damage (–)

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 Respiration
A- Patternofrespiration:-
- Tachypnea ()- Bradepnea (–) - Shallow () - Deep (–)

Respiratory problems: -

Dyspenea:- onrest (–) -oneffort () -Orthopnea (–)

- Cough:- Not Found -dry (–) -Wet (–)

-Sputum:- Not Found -Red (–) -black(–) -yellow (–) -Green (–)

-Thick(–) - Watery(–) -Offensive odor(–)

-Amount: - B– Moderate(–)small (–) Large(–)

- Hemopttsis (–) Airentry
:
[Link] (–) - Absent (–) - Site(–)
[Link](–) - Absent (–) - Site(–)
Wheezes(–) - [Link](–) - [Link]:(–)
Crackles(–) - [Link](–) - [Link]:(–)

Circulation
Patient'scomplain:-

- Chestpain (–) -Dizziness ()

- Pitting edema (–) -Delayed capillary refill ()
- Cyanosis: Not Found -central (–) -peripheral(–)

Food and Nutrition

Patient'scomplain:
- Reduce tissue turgor () -Dry mouth ()
- Coated mouth () -Anorexia ()
- Nausea () -vomiting (–)
- Ordinary diet (–) Special
Al diet ()Type:protein rich diet -Abdominal distension(–)
- Method of feeding:
-Oral () -nasogastric(–) -Parental (–)

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on
A-Bowel elimination:
- Incontinence (–) -Diarrhea(–) -constipation ()
- Fecal impaction (–) -Melena (–) -Others (–)

B-Urinary elimination:
-Retention (–) -Incontinence(–) -Urgency (–)
- Frequency (–) -Dysuria (–) -Polyuria ()
- Oliguria () -Catheterized (–) -Others (–)

Wound

-Present (–) -Absent()

- Site: (–––––––)
- Type (–)
-Open (–) Closed
(–)
-Clean (– ) Septic (–)
-Drain:
-Present(––) -Absent ()
- Color of discharge:…… (–––––––)…….
-Amount of d ischar……(–––––––)………

Comfort and sleep

A-Pain

- Present (–) -Absent ()

If present
- Precipitating factories:………… (–––––––)…………..

- Quality:
-Stabbing (–) -Burning(–) -Pricking(–) -Aching (–)
-Cramping(–)-Pressing(–)–Squeezing(–)

- Region/Radiation:............ (–––––––).................
-Severity: -Mild (–) -Moderate (–) -Sever(–)
-Time: -Continuous(–) -Intermittent (–)

B-Insomnia:
-Present () -Absent (–)
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 Functional stautus
A-Energy level:

- Exhausted without activity () -Tires easily ()

- Activity of daily living: -Dependant() -Independent(–)
- Needs assistant with Eating(–) -Dressing() -Bathing ()

B-Mobility status:

-Immobile(–) -Mobile with assistance of other person()

- Mobile with device(–)
- Cratch(–) -Wheel chair (–) -walker(–)
-Physical handicapped (–––––)

Neuromuscular
A-Patient's complain :

- Headache () -Paraethesiae(–)

- Lethargic () -Disoriented (–)
-Slurred speech(–) -Dysphasia(–)

B-Limbs:
Weakness (–) -Flaccid (–)
-Joint stiffness (–) -Muscular pain (–)

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 Medication
Name of Dose route Main action Nursing role
medication
Taroxatron,500mg,amp 1×2 IV Antifibrinolytic Ensure the 10
(Anti-bleeding drug) rights of
Syntocinon10 1×1 IV infusion Uterotonic drug medication
IU/ml ,amp+500ml administration
normal saline0.9% including right
patient, right drug,
Ferrous fumarate 1×1 Oral Hematinic / Anti- right dose, right
200 mg, Capsule anemic drug route, right time,
right reason, right
assessment, right
education, right
documentation,
and the patient’s
right to refuse.
Assess vital signs,
level of
consciousness, and
the amount and
character of
vaginal bleeding
before and after
medication
administration.
Monitor
laboratory
investigations
especially
hemoglobin level,
hematocrit, and
coagulation profile
to evaluate
response to
treatment.
Observe the
patient for
therapeutic effects
and any adverse
drug reactions.
Monitor intake
and output and
assess for signs of
fluid volume

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 [Link]
Name of investigation Patient value Normal value
HB 8g/dl 12-16 g/dl
Hct 40% 46%-36%
RBC Count 3million/mm3 4 -5.2million/mm3
Platelet Count 250000/mm3 150000-400000/mm3
PT 12 seconds 11-14 seconds
aPTT 30seconds 25-35 seconds
Na+ Serum 133mmol/L 135-145mmol/L
K+ Serum 4mmol/L 3.5-5mmol/L
Serum Creatineine 0.9mg/dl 1.2/0.6mg/dl

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 Patient problems

Actual:

Active vaginal bleeding

Hypovolemia
Anemia
Dizziness
Fatigue
Weakness
Oliguria
Anxiety
Insomnia

Potential:
Hypovolemic shock
Impaired tissue perfusion
Acute kidney injury
Infectin
Maternal collapse

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 Nursing Diagnosis

1. Deficient fluid volume related to uterine atony as evidenced by heavy vaginal bleeding,
hypotension, tachycardia.
2. Decreased tissue perfusion related to blood loss.
3. Fatigue related to anemia.
4. Activity intolerance related to decreased
oxygen delivery
5. Anxiety related to postpartum complication.
6. Disturbed sleep pattern related to discomfort and fear.
7. Risk for shock related to massive blood loss.
8. Risk for infection related to invasive procedures.

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 Patientsname: Eman Mohamed Gamal BedNo: 9
Date of admission: 15/1/2026
Diagnosis: Postpartum Hemorrhage
[Link]
Department : Obstetrics

Date VitalSinges Intake OutPut Medication

Time T/ P R B.b Oral IV Urine Drain Vomiting Stool

c b/min c/min mmhg Type Am type Am
9:00Am 37.3C 100b/min 24c/min 110/60 Water 400ml N.S 500 200ml (–) (–) (–) Syntocinon10
mmhg 0.9% ml +30 ml IU/ml
Juice 200ml sweating

-Balance=intake–output = 1100-230 = +870ml

-Student signature Group 4

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 NURSING
Goals Nursing Intervention Evaluation
DIAGNOSIS
Deficient fluid Control Assess amount, color, and Bleeding
volume related vaginal frequency of vaginal bleeding reduced or
to excessive bleeding every 15 minutes stopped
blood loss Monitor vital signs Vital signs
secondary to Maintain continuously stable
postpartum stable vital Perform uterine fundal Adequate
hemorrhage as signs massage urine
evidenced by Maintain two large-bore IV output
heavy vaginal Urine lines No signs of
bleeding, output ≥ Administer IV fluids as hypovolemi
hypotension, 30 ml/hr prescribed c shock
tachycardia, and Administer uterotonic drugs
decreased urine Prevent (Oxytocin, Misoprostol)
output. hypovolem Monitor urine output hourly
ic shock Prepare blood and blood
products if indicated
Administer oxygen therapy as
ordered
Prepare for surgical
intervention if bleeding
persists

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 NURSING
Goals Nursing Intervention Evaluation
DIAGNOSIS
Decreased tissue Maintain Assess level of consciousness Improved
perfusion adequate regularly skin color
related to tissue Monitor capillary refill time and warmth
reduced perfusion Position patient in supine with Normal
circulating Improve legs elevated capillary
blood volume as level of Monitor hemoglobin and refill
evidenced by consciousn hematocrit levels Patient alert
pallor, dizziness, ess Administer oxygen therapy and
delayed Maintain Monitor ECG and pulse oriented
capillary refill, normal oximetry No signs of
and cold skin. capillary Maintain adequate IV fluid organ
refill replacement hypoperfusi
Prevent Observe for signs of shock on
organ Collaborate with medical team
dysfunctio for rapid intervention
n

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 NURSING
Goals Nursing Intervention Evaluation
DIAGNOSIS
Anxiety related Reduce Patient
to postpartum anxiety Assess level of anxiety reports
complication level Encourage verbalization of reduced
and fear of Patient fears anxiety
bleeding as verbalizes Provide clear explanations
evidenced by understan about condition and Appears
restlessness, ding of procedures calm
verbalization of condition Maintain calm and supportive
fear, and Patient environment Improved
insomnia. appears Allow presence of family sleep
calm and member if possible pattern
cooperativ Provide emotional reassurance
e Teach relaxation and deep
Demonstrat
Promote breathing techniques
es
adequate Monitor sleep pattern
understandi
rest Administer anti-anxiety
ng of care
medications if prescribed
plan

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