Nursing Diagnosis: Risk for bleeding r/t uterine atony relaxation secondary to multiple pregnancies G-2 P-2
Long Term Goal: Patient will not hemorrhage
Outcome Criteria
Interventions
Scientific Rationale
Evaluation
1.Patients temperature will be
maintained at 36° to 38° C
(96.8° to 100.4° F), as assessed
qshift
Assess Temperature Qshift
This patient is a postpartum mother, with exception in the first 24 hrs,
she should remain afebrile. A maternal temperature of up to 38° C
(100.4° F) may occur up to 24 hrs after birth as a result of exertion and
dehydration of labor. While in my care this patients temperature
trended between 98° to 98.8° F. If the patient was not meeting these
criteria, hemorrhage or infection must be considered in the presence
of an increase temp. Olds p997 & p1123
Outcome is met. Plan is
resolved.
2.Patients HR will be 60-100
BPM qshift as assessed
Assess HR Qshift and PRN
An elevated heart rate may indicate a low blood volume. This patient is
a post partum mother who is at increased for hemorrhage. While in my
care this patient’s heart rate trended between 78-88 beats per minute.
Finding increased heart rate greater than 100 beats per minute on
assessment could be clinical indicators of bleeding or hemorrhage and
require the patient to have further assessment. Olds p997 & p1123
Outcome is met. Plan is
resolved.
3.Patients Respiration rate will
be 12-20 per min smooth and
effortless as assessed qshift
Assess Respirations Qshift &
PRN
If a post partum mother has increased blood loss this can increase her
respiration rate. This patient’s respiratory rate trended between 16-18
breaths a minute was smooth and effortless. A respiratory rate of
greater than 20 breaths a minute should be assessed in a post partum
mother because of their increased risk to hemorrhage. An increase in
blood loss can decreased hemoglobin levels which will reduce oxygencarrying capacity of the blood, which increases respiratory rate.
Saunders 364,Potter 529
Outcome is met. Plan is
resolved.
4.Patients BP will trend toward
120/80 mmhg qshift as
assessed
Assess BP Qshift & PRN
The volume of blood circulating within the vascular system affects
blood pressure. Normally the blood volume remains constant.
However, when circulating blood volume falls, as in the case of
hemorrhage which can occur in post partum mothers, blood pressure
falls. This patient’s blood pressure was 112/75 which is toward her
baseline. A decreased blood pressure may indicate physiologic
readjustment to decreased intrapelvic pressure or it may be related to
uterine hemorrhage. A low or decreasing blood pressure may reflect
hypovolemia secondary to hemorrhage but is a late sign. Olds p997
Outcome is met. Plan is
resolved.
Potter 536
Outcome Criteria
5. The fundus will decrease
one fingersbreadth daily,
assessed qshift
Interventions
Scientific Rationale
Assess Fundus height qshift and Assessing the height of the fundus gives information about the
prn
progress of involution. Although postpartum hemorrhage often
occurs within hours of birth, a delayed hemorrhage can occur
due to subinvolution which is failure to return to normal size.
This patient’s fundus was progressing well 2 fingerbreadths
below this umbilicus on second day post partum. Olds
1008,1120
Evaluation
Outcome is met. Plan is
resolved.
This patient’s fundus was firm which indicates that the uterine
muscles are contracted and bleeding will not occur. Her fundus
was also midline. The fundus can deviate from midline when
bladder is full because enlarged bladder pushes uterus aside.
During postpartum period because of diuresis the bladder may
fill more rapidly than normal, putting the woman at risk for
uterine atony and hemorrhage. Olds 1008
Outcome is met. Plan is
resolved.
The postpartal woman has an increased bladder capacity,
swelling and bruising of the tissues around the urethra,
decreased sensitivity to fluid pressure and decreased sensation
to bladder filling. A full bladder may also increase the tendency
of the uterus to relax by displacing the uterus and interfering
with contractility, leading to hemorrhage. This patient voided as
needed, urine output average 60 ml/hr while in my care. Olds
p997
Outcome is met. Plan is
resolved.
Evaluation of lochia is necessary not only to determine the
presence of hemorrhage but also to assess uterine involution.
Persistent discharge of lochia rubra indicates subinvolution or
late postpartum hemorrhage. This patient is day 2 postpartum
has a moderate amount of lochia with earthy small and no clots.
Length of lochia rubra phase lasts longer then generally
assumed. Olds p993
Outcome is met. Plan is
resolved.
6. The fundus will remain firm
and midline qshift as assessed
Assess fundal firmness and
position qshift & PRN
7. Patient will void 30ml per/hr
as assessed qshift
Assess urine output qshift
8. Patients lochia will trend
toward lighter amount of flow
and color with no clots and
earthy odor assessed q shift
Assess Lochia q shift and prn
Outcome Criteria
9. Patient will verbalize trends
in lochia q shift
Interventions
Teach patient trends in lochia q
shift
Scientific Rationale
Length of lochia rubra phase lasts longer then generally assumed
usually after patient is out of the hospital. This patient is 2 days
post partum and has a moderate flow of lochia rubra and will be
discharge, it is important for her to understand the trend of
lochia so she is able to determine if there are any complications.
Flow and color should get lighter and there should be no clots
present or odor. If the character of the lochia returns to bright
red bleeding, excessive amount, or clots she should contact her
healthcare provider because this is indicative of hemorrhage.
She should address fouls smalls with hcp as well. Olds p993
p1050
Evaluation
Outcome is met. Plan is
resolved.
10. Patient hemoglobin will
trend toward 12-16 g/dl
assessed as ordered
Monitor Hemoglobin values as
ordered
Hemoglobin levels may be difficult to interpret in the first 2 days
after birth because of the changing blood volume. This blood
loss in the first 24 hrs accounts for half of the RBC blood volume
gained during the course of pregnancy. This patient had a
vaginal birth and average blood loss for this is 200-500 ml. This
patient’s hemoglobin before delivery was 12.6 g/dl and
increased to 13.0 g/dl after delivery, blood values should return
to prepregnant state at the end of the postpartum period. A
decrease in levels should alert to further assessment because
this can be related to bleeding/hemorrhage. Saunders p 364,
Olds 997
Outcome is met
hemoglobin reached
desired level. Plan is
ongoing.
11. Patients hematocrit will
trend towards 37-47% assessed
as ordered
Monitor Hematocrit values as
ordered
Hematocrit levels may be difficult to interpret in the first 2 days
after birth because of the changing blood volume. This blood
loss in the first 24 hrs accounts for half of the RBC blood volume
gained during the course of pregnancy. This patient’s hematocrit
was, before birth at 35.5% and increased to 38.4% after delivery.
A 3-4% drop in hematocrit equals a blood loss of 500 ml. A drop
greater than that would indicate further bleeding and potential
for hemorrhage. Blood values should return to prepregnant
state at the end of the postpartum period. Olds 997,998
Outcome is met
hematocrit reached
desired level. Plan is
ongoing.
Outcome Criteria
Interventions
Scientific Rationale
Evaluation
12. Patients uterus will
contract preventing uterine
atony, decreasing blood loss to
moderate amount of lochia
rubra postpartum as assessed
Oxytocin in LR 20 units/1000ml
IV 250ml/hr one time only
Oxytocin is a hormone and oxytocic. Postpartum this helps with
control of bleeding after expulsion of the placenta. Oyxtocin
stimulates uterine contraction after delivery and there by
controls uterine atony which leads to decreased risk of
hemorrhage. Olds 733
Outcome is met. Plan is
resolved.
Outcome Criteria
Interventions
Scientific Rationale
Evaluation