LORMA COLLEGES CON TEMPLATE

Nursing Care Plan

RELATED LEARNING EXPERIENCE

STUDENT NAME: BALLON, Karlo C. ROTATION

:  5th Rotation AREA: OB WARD
  May 22, 27, 28, 29, June CLINICAL
 BSN 2-BETTY NEUMAN DATES: 3, 4,5. INSTRUCTOR:  Marites Gallardo

PROBLEM: Postpartum Hemorrhage

DIAGNOSIS: Deficient fluid Volume related to excessive blood loss after birth secondary to uterine atony as evidenced by decrease blood pressure
and increase pulse rate.
PRIORITIZATION: High

NURSING IMPLEMENTATIO
ASSESSMENT DIAGNOSIS PLANNING N   RATIONALE EVALUATION
Deficient fluid Short term Goal Independent The amount of blood FULLY MET:
Subjective:
Volume Assess and record the type of, loss and the presence of
“Why am I bleeding so related to After 8 hours of amount, and site of the bleeding; blood clots that will help Short term:
much?” As verbalized by excessive nursing intervention, Count and weigh perineal pads to determine the
the patient. blood the patient will be and save blood clots if possible appropriate replacement Patient was able to
loss after able to: to be evaluated by the physician. need of the patient. demonstrate
birth - Demonstrate hemodynamic
secondary to hemodynamic stability Assess the location of the uterus The degree of the stability
  uterine atony with a blood pressure and degree of the contractility contractility of the uterus with a blood
Objective: as evidenced of 100/60 mmHg uterus will measure the status pressure
- Client appeared pale by decrease - Obtain a pulse rate of the blood loss. of 100/60 mmHg
and diaphoretic blood between 70-90 beats Placing one hand just
with blood pressure of pressure and per minute. above the symphysis FULLY MET
90/55mmHg; pulse rate increase - Maintain lochia flow pubis will prevent
increased to 102-116 pulse rate. of less than one possible uterine Long term
bpm. saturated perineal pad inversion during a
per hour. massage. Patient was able to
- Estimated Blood Loss maintain fluid
of 550 ml at delivery and Long term Goal Monitor vital signs esp. blood Increased heart rate, low volume evidenced
puts her now a total of pressure, pulse and heart rate. blood pressure cyanosis, by decrease
900 ml. After 3 days of Check for the capillary refill and delayedcapillary refill dysfunctional
nursing interventions, observe nail beds and mucous indicates hypovolemia bleeding at a
- There were 5 the patient will be membranes. and impending shock. functional level as
Pads consumed for at able to improve fluid evidence by stable
least one hour. volume as evidenced Review the records and note This will help in vital signs, moist
by decreased certain conditions such as retained determining the mucous
-Pain rating of dysfunctional placental fragments, any laceration, management of the membranes, good
8/10 bleeding. abruption placenta, etc. situation thus preventing skin turgor and
further complications. decrease
dysfunctional
Measure a 24- hour intake and This will help in bleeding. The client
  output. Observe for signs of voiding determining the fluid is able to
difficulty. loss. A urine output of demonstrate all
30-50ml/hr or more three nursing
indicates an adequate interventions
Circulating volume. after 8 hours.
Voiding difficulty may
happen with
hematomas in the
  upper portion of

Massage boggy uterus using one The degree of the

hand and place the second hand contractility of the uterus
above the symphysis pubis. will measure the status
of the blood loss.
Placing one hand just
above the symphysis
pubis will prevent
possible uterine
inversion during a
massage

Maintain a bed rest with an The position increases

elevation of the legs by 20-30 venous return, making
degrees and trunk horizontal sure a greater
availability of blood to

Administered Oxytocin (Pitocin,
Methylergonovine maleate
(Methergine), Prostaglandin
F2a (Prostin 15M).
Collaborative
the brain and other vital
organs. Bleeding may
be decreased with the
bed rest.
Increases contractility of
the boggy uterus and
myometrium, closes off
exposed venous
sinuses, and stops
hemorrhage in the
presence of atony.