Postpartum Hemorrhage

Nursing Diagnosis

Potential risk for hemorrhage r/t labor and delivery

Supporting Data:

Objective: delivered 0741 am 3/1/07.

Objective: Vaginal delivery.

Objective: gravida 2

Goal & Goal Criteria

Goal: Patient will show no s/s of hemorrhage in 48 h post delivery.

1. V/S will remain in wnml:

T: up to 100.4 F

P: 60-90 bpm

R: 12-20 brpm

BP :120/70

Pulse OX: 95-100%

2. Hct & hgb will remain WNML.

HCT=>33%

HGB= 10.5g/dl

3. Fundus will be midline & firm.

4. IV Fluids infusing as ordered.

5. Total number of pads used will be WNML. 1 pad q hourly.

6. Skin will be warm & dry.

7. Level of consciousness will remain intact

Nursing Actions

On 3/1/07-3/2/07 1st shift 7-3

The Nurse will:

1. Assess vital signs q4h. Rationale: Increase in pulse rate decrease in BP , Increase in respirations could possibly be s/s of hypovolemia. If true hemorrhage; place in Trendelenburg position; assist with blood back to the brain. Foundations of Maternity-Newborn Nsg pg 299

2. Assess lochia, bladder and fundus q 4h . Rationale: Lochia needs to be assessed for amount of blood, color; Fundus assessed for position, & tone. Bladder for distention, and position. Foundations of Maternity-Newborn Nsg pg 299

3. Assess intake & output q 8 h .

Rationale: Kidneys will decrease output and eventually cease, if hypovolemia in progress, to compensate for fluid loss. IV fluids administered to prevent hypovolemic shock from becoming irreversible. Foundations of Maternity- Nursing pg 741.

Implementation

On 3/1/07 -3/2/07 1st shift 7-3

1. The Nurse took V/S@ 0800

T97.6 T 97.8

P 102 P 94

R 20