1. Diagnosis: Risk for injury r/t bleeding from uterine atony, retained placental fragments, lacerations, or hematoma.
Short term goal: Patient will not experience any excessive bleeding & Patient will verbalize an understanding about warning signs of excessive bleeding Long term goal: Patient’s bleeding will be lighter in color and she will regain her prepregnant state without complications to hemorrhage.
1. Assess and teach pt to palpate uterus for height and firmness and location
- Following birth the fundus has to be firm and should decrease one finger breath a day or more if breastfeeding from the umbilicus. A fundus that is hard tells you the uterus is contracting. If the fundus is above the umbilicus, boggy, blood may be collecting in the uterus and will stop effective contractions leading to hemorrhage.
Evaluation: My patient’s uterus was firm and 1 finger breath below the umbilicus. This is appropriate for her 1st postpartum day. I taught my patient how to feel her own uterus and the early signs of bleeding. She was able to repeat back the information I provided her. My patient is at low risk for injury.
2. Assess patient’s bladder.
- Incomplete emptying of the bladder can lead to bladder distention, which can interfere with the ability of the uterus to contract. If the uterus does not contract properly this can increase the risk of bleeding. A full bladder would also push the fundus to the right.
Evaluation: My patient was up and about voiding twice during my care. She told me that she was not having any trouble or pain urinating. Her urine was clear with tiny drops of blood. Her bladder was not distended.
3. Assess and teach patient to check amount, consistency, and color of lochia.
- The type, amount, and consistency of lochia determine the stage of healing of the placenta site, and a progressive change from bright red at birth to dark red to pink and then to white or clear drainage should occur. Saturation of a pad within 15 to 30 minutes may indicate hemorrhage.
Evaluation: I assessed my patient’s lochia by checking her peripad. Lochia was a moderate amount and dark rubra. She had changed her pad twice during my care. I taught the patient about her lochia and explained to her that increased amount on lochia on the peripads should be reported as it may be an indication of hemorrhaging. Patient stated that she would monitor her peripads daily.
4. Assess vital signs along with labs (H+H).
- A decrease in blood pressure and increase in heart rate may be a sign of hypovolemic shock (bleeding). Her labs will show a decrease in hemoglobin and hematocrit if there is bleeding present. If labs were to be drawn up stat, it would take less than an hour to get the results back. I would also assess her O2 saturation and check her ABG values. This would be able to also show me if she is bleeding.
Evaluation: My patient’s vital signs were within normal limits. Her blood pressure was 123/67, HR 77, Temp 98.1, R 20, and pulse ox 98%. Her H+H were 11.4L and 33.8L. This was slightly low but not a big issue because she is pp day 1 and the normal H+H is 11.5-15.5 and 34.5-45.0.
5. Encourage breast feed.
- This will stimulate the release of oxytocin from the pituitary gland. Oxytocin promotes constriction of the blood vessels and the uterus, thus preventing postpartum hemorrhage promoting involution.
Evaluation: Pt was able to breast feed her son for 20 minutes aiding the release of oxytocin. She did not complain of any pain at this time after breastfeeding.
6. Teach patient to eat foods rich in protein, iron and vitamin C.
- Protein is essential for tissue healing, iron is good for RBC restoration which helps to prevent anemia and vitamin c helps in iron absorption and also aid in tissue healing from the placental site.
Evaluation: Pt ate 100% of her breakfast and lunch. She is 18 years old and has a good appetite being at this...
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