Help with a postpartum hemorrhage care plan

  1. 0
    Hello,

    I am worried that my care plan for a postpartum hemorrhage is not sounding correct. The pt is a 2 day post op c-section. I really appreciate any comments. Thank you very much in advance.

    Nursing Diagnosis: Risk for late postpartum hemorrhage related to macrosomnia
    (since she is a 2 day post op c-section is it considered a late postpartum hemorrhage?

    Assessment
    (subjective and objective)

    Uterine Overdistention:
    Macrosomnia
    10lb. 12 oz. infant

    Prolonged Labor:
    29 hours

    EBL during C-section:
    1,000 ML

    ď It seems like I am not bleeding as heavy as I was beforeĒ



    Patient Outcome
    (measurable goal/s)
    Pt will not experience a late postpartum hemorrhage

    Plan/Implementation
    Assess ptís, blood pressure, pulse and respirations. IF PT IS 48 HOURS POST-OP HOW OFTEN SHOULD THIS BE DONE DURING A SHIFT?
    Rationale:
    Assessment will provide information regarding any excessive blood loss with a decreased BP and increased P and R.
    Evaluation
    At the end of shift the ptís vitals all remained steady and within the range of normal limits. BP 120/78, R 16, P 74


    Plan/Implementation
    Assess fundus, perineum and bleeding. Evaluate blood loss by weighing peri pads. IF PT IS 48 HOURS POST-OP HOW OFTEN SHOULD THIS BE DONE DURING A SHIFT? Notify healthcare provider of any increased blood loss.
    Rationale:
    Assessment gives information about uterine tone and position, hematoma development and extent of blood loss.
    Evaluation
    At two days post-op, fundus was firm and at the level of the umbilicus and blood loss was decreased and no evidence of hematomas or increased blood, at the end of shift.

    Plan/Implementation
    Assess pt for abdominal pain, rigidity, increasing abdominal girth, vulvar or vulvovaginal hematomas.
    Rationale:
    Assesment will provide information regarding a possible uterine rupture or hematoma formation or hidden bleeding.
    Evaluation
    Pt had no complaints of abdominal pain or rigidity. No evidence of increased abdominal girth, vulvar or vulvovaginal hematomas.
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