i need help with my care plan. this is the patient story:
pt. 28 years old, g2p1. two hours post delivery, boggy uterus at +2 from umbilicus. one hour later, 1200cc blood clot was expelled. heavy rubra. 1st post-op day, wbc 15.7, 7.2 hgb, 26.9 hct. post-partum assessment: c/o slight burning with urination and cloudy, dark urine. pain 7/10. temp 37.8 c (100.04 f). pulse 112. resp 28. c/o dizziness when out of bed to bathroom. pt reports weight loss of 60 pounds.
list of concerns:
1200cc blood clot
c/o burning with urination
dizziness when oob to br
weight loss of 60 lbs
priority nsg dx:
1. risk for hemorrhage
goal: pt rubra flow will decrease from heavy to moderate with the admin of methergine po as ordered by md 2 days post-partum.
interventions: place in trendelenburg's position, give 02, increase ns iv fluid, initiate standing order (airway or iv infusion) as per protocol/md
2. risk for infection
goal: patient's pain will be relieved or controlled at the end of 12 hour shift.
interventions: increase (encourage) fluid intake. provide comfort message (back rub - to take her mind off the pain in her lower abdomen, change position in bed, provide sitz bath, warm soaks to the perineum to relax muscle)
okay, so my concerns are in red. my instructor would like the goals to be measurable, have a time frame, and specific to patient and problem. monitoring and assessment are not interventions by themselves. interventions need to improve the condition, not watch it.
are my goals and interventions specific enough? do they seem correct to you?
please don't suggest new nursing diagnoses. they are correct. she mentioned them during lecture.