Help with a postpartum hemorrhage care plan

baglmae · May 2, 2011

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

" It seems like I am not bleeding as heavy as I was before"

Patient Outcome

(measurable goal/s)

Pt will not experience a late postpartum hemorrhage

Plan/Implementation

Assess pt's, 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 pt's 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 vulvolady partsl 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 vulvolady partsl hematomas.