okay so i know that risk for hemorrhage is not a NANDA approved care plan but my :heartbeatLOVELY:heartbeat OB professor wants us to pretend like it is
for our postpartum patients and i am having trouble finding interventions and rationales for it... here's what i have for it so far...
1) G 2 P 1
2) Length labor 37 weeks completed.
3) Anesthesia/analgesia- Spinal epidural.
4) Moderate Lochia, rubra, 1 clot.
5) Fundus U/2, soft
6) HGB 10.5
7) HCT 29.5
8) WBC 21.9
9) Platelets 253
T 98.0, P 52, R 18, BP 109/64, O2 98
11) Voided 3 hours after delivery.
12) No BM, bowel sounds present Qx4
13) Patient's membranes were artificially ruptured.
14) Foley catheter was placed with use of spinal epidural- per protocol.
1) "My bleeding has slowed down a lot today"
2) "Is this clot normal?"
3) "I change my pads about every 3-4 hours"
Risk for hemorrhage r/t childbirth.
Expected outcomes/Goal statements:
- Pt will not hemorrhage.
- All vital signs will remain WNL.
- Lochia will reduce in amount and lighten in color as time progresses.
- Fundus will remain firm, midline, and progressively lower.
- Pt will demonstrate ability to recognize signs of hemorrhage and when to report to MD.
...help!!! need interventions!!