Hemorrhage care plan...??

  1. 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...
    Objective Data:
    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
    10) VS=
    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.

    Subjective data

    1) "My bleeding has slowed down a lot today"
    2) "Is this clot normal?"
    3) "I change my pads about every 3-4 hours"

    Nursing Diagnosis:
    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!!
  2. 1 Comments

  3. by   Daytonite
    it doesn't matter what your "lovely ob professor" wants you to word the diagnosis. the diagnosis is merely a label. years ago in my bsn program we weren't allowed to use the new nanda labels at all. we had to make up our own which meant wearing out copies of roget's thesaurus.

    first of all, keep your focus in mind. with "risk for" diagnoses your focus is to prevent something specific from happening. the specific thing you want to prevent in this case is postpartum hemorrhage.

    secondly, what are the risk factors, i.e. risk for postpartum hemorrhage r/t ??? what causes postpartum hemorrhage? lets get that established. is there any possible failed mechanism that might go on that could result in a hemorrhage? if this patient had a multiple gestation (twins), hydramnios, macrosomnia, abruptio placentae, placenta previa or an inverted uterus, then you need to replace the word "childbirth" with one of those in your diagnostic statement since they are a more likely reason for hemorrhage to occur.
    (from page 385-6, maternal/newborn plans of care: guidelines for individual care, 3rd edition, by marilynn e. doenges and mary frances moorhouse)

    "postpartal hemorrhage is usually defined as the loss of more than 500 ml of blood during or after delivery."

    the assessment of hemorrhage includes. . ."uterus: soft boggy, or enlarging, difficult to palpate; bright red bleeding from vagina (slow or profuse); large clots expressed on massage of uterus (uterine atony) firm well-contracted or partially contracted, and slightly boggy (retained placental fragments, which may necrose and over time form polyps); fundus of uterus inverted; comes into close contact with, or may protrude through, the external os (uterine inversion); current pregnancy may have involved uterine overdistension (multiple gestation, hydramnios, macrosomnia), abruptio placentae, placenta previa."
    thirdly, interventions for these diagnoses are really rather easy. the goals are to prevent the occurrence of the problem (postpartum hemorrhage). your interventions are to create an environment so postpartum hemorrhage won't occur:
    • strategies to prevent the problem from happening in the first place
    • monitoring for the specific signs and symptoms of this problem
      • sit down right now and make a list of the signs and symptoms of blood loss anemia
    • reporting any symptoms that do occur to the doctor or other concerned professional
    • if symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis
    expected outcomes/goal statements:
    • pt will not hemorrhage.
    • all vital signs will remain wnl. (list the normal parameters)
    • lochia will reduce in amount and lighten in color as time progresses. (give the color and days. "as time progresses" says nothing)
    • fundus will remain firm, midline, and progressively lower. (give the inches and days. "progressively lower" says nothing)
    • pt will demonstrate ability to recognize signs of hemorrhage and when to report to md. (needs to be specific: by ___ patient will be able to state 3 signs of hemorrhage and why she needs to report them to the doctor.)
      • and, most important. . .you should have interventions that have addressed all of the above:
        • interventions to prevent hemorrhage, i.e. massaging the fundus regularly, regular assessment of the fundus, regularly vs assessment, checking and documenting pad counts and the color and character of lochia
        • interventions monitoring s/s of blood loss anemia and lab work
        • interventions to teach the patient the s/s of blood loss anemia and the normal progression of lochia. what is lochia, anyway?
    if you need answers to some questions that you may not find in your textbook, use the ob weblinks here. sometimes you will find more information posted for the public: