Nursing Care Plan
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Date:
February 25, 2006
Nursing Diagnosis
Outcome Criteria (Goal)
Evaluation of Outcome Criteria (Goal)
PC: Postpartum Hemorrhage
Patient will develop no complications related to excessive bleeding, will maintain normal vital signs of express understanding of her condition, its management, and discharge instructions, identify and use available support systems.
R/T, RTRF and secondary to:
Pathophysiology Supporting
Nursing Diagnosis Statement (cite source)
Uterine atony (over distended uterus, anesthesia, analgesia, previous history of uterine atony, high parity, prolonged labor, ocytocin-induced labor, trauma during labor and birth)
Lacerations of the birth canal
Retained placental fragments
Ruptured uterus
Inversion of the uterus
Placenta accrete
Coagulation disorders
Placental abruption
Placenta previa
Manuel Removal of a retained placenta
Magnesium Sulfate administration during labor or postpartum period
Endometritis
Uterine suninvolution
A blood loss greater than 500 mls in the first 24 hours after a vaginal delivery and greater than 1000mls with cesarean delivery
Database – Subjective
(Defining characteristics, support for R/T, RTRF)
Database – Objective
(Defining characteristics, support for R/T, RTRF)
Dizziness, fatigue, Severe cramping, SOB, thirst, excitability, insomnia, lightheadedness, anxiety.
Tachycardia
Tachypnea
Hypotension
Decreased Hemoglobin & Hematocrit
Excessive blood loss
boggy fundus
Interventions:
Independent and Collaborative
Rationale
(cite source for each rationale)
Evaluation
(of each intervention)
Assess
Upon admission assess patients history and labor & delivery record for factors that might predispose the patient to postpartal hemorrhage.
Assess vaginal bleeding (locchia) after delivery every 15 minutes for one hour, then every 30 minutes for 1 hour, or until stable; more frequent assessments may be necessary depending upon the patients condition. Assist the patient to a side lying position and check the pad underneath frequently because blood may accumulate under the client.
Assess bladder for fullness and distention by noting location and firmness of uterine fundus and by palpating bladder. Distended bladder is seen as a supra pubic rounded bulge that is dull to percussion and fluctuates like a water filled balloon.
Assess fundus for height, firmness, and position in the pelvis.
5. Assess pulse rate which should normally be around 60bpm-100bpm. Pulse returns to nonpregnant levels within a few days postpartum, although the rate of return varies among individual women.
6. Assess respirations: Respirations should decrease to within the womans normal prepregnancy range by 6-8 weeks after birth.
7. Assess blood pressure for orthostatic hypotension, as indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48 hours as a result of the splanchnic engorgement that may occur after birth.
8. Take pulse, BP, and pulse pressure. Same schedule as fundal assessment or per pp of hospital.
9. Reassess after voiding or catheterization
10. Assess mothers buttocks as well as perineal pad for blood flow.
11. Assess for spontaneous bleeding of gums and nose, oozing, excessive bleeding from intravenous access site, petechiae, hematuria, and gastrointestinal bleeding.
12.) Assess capillary refill, mucous membranes, and skin temperature.
13.) Continue to assess vital signs and other clinical indicators of hypovolemic shock.
1. Identify risk factors for PP hemorrhage (long labor. Muliparity, large baby, manual removal of adherent placenta, previous history of PP hemorrhage, excessive uterine manipulation. Hemorrhage is the most common threat during the immediate PP period. If risk factors are present, and individualized nursing care plan should be instituted for the client. (FVD) (Green & Wilkinson p. 437)
2. Rubra: dark red to bright red in color, lasts for 2nd -3rd days. Serosa: pinkish to brownish thin in color, lasts from 3rd to 10th day. Alba: creamy white discharge lasts up to two weeks. (p. 456, Perry) Estimates amount of blood loss. Excessive blood loss can result in antepartum and postpartum anemia and infection, as well as maternal or fetal death. (Green & Wilkinson p.52)
3. It s important because a distended bladder