Nursing Case Analysis Essay
1. Diagnosis: Risk for injury r/t bleeding from uterine atony, retained placental fragments, lacerations, or hematoma.
Short term goal: Patient will not experience any excessive bleeding & Patient will verbalize an understanding about warning signs of excessive bleeding
Long term goal: Patient’s bleeding will be lighter in color and she will regain her prepregnant state without complications to hemorrhage.
1. Assess and teach pt to palpate uterus for height and firmness and location
- Following birth the fundus has to be firm and should decrease one finger breath a day or more if breastfeeding from the umbilicus. A fundus that is hard tells you the uterus is contracting. If the fundus is above the umbilicus, boggy, blood may be collecting in the …show more content…
Long term goal: By the end of the postpartum period the patient will be free of pain.
1. Assess pain location, intensity, and level by using pain scale from 0-10.
- Location of pain is necessary for proper treatment. Pain is subjective and must be described by the patient in order to plan effective pharmacological and non pharmacological treatments.
Evaluation: My patient was not experiencing pain at this time. She had a midline episiotomy done and from a scale of 0-10 she said her pain level was a 3. I taught her that if she is in pain to ask for pain medication.
2. Administer pain medications.
- Analgesics inhibits the synthesis of prostaglandins that may serve as mediators or pain, primarily in the CNS. This will provide relief of pain in the post partum period.
Evaluation: My patient was not given any pain meds at this time. She did have an order however for Motrin 600mg po q6h and Percocet i tab prn for pain. If she was experiencing severe pain I would administer these medications.
3. Instruct patient to empty bladder frequently and
Short term goal: Patient will not experience any excessive bleeding & Patient will verbalize an understanding about warning signs of excessive bleeding
Long term goal: Patient’s bleeding will be lighter in color and she will regain her prepregnant state without complications to hemorrhage.
1. Assess and teach pt to palpate uterus for height and firmness and location
- Following birth the fundus has to be firm and should decrease one finger breath a day or more if breastfeeding from the umbilicus. A fundus that is hard tells you the uterus is contracting. If the fundus is above the umbilicus, boggy, blood may be collecting in the …show more content…
Long term goal: By the end of the postpartum period the patient will be free of pain.
1. Assess pain location, intensity, and level by using pain scale from 0-10.
- Location of pain is necessary for proper treatment. Pain is subjective and must be described by the patient in order to plan effective pharmacological and non pharmacological treatments.
Evaluation: My patient was not experiencing pain at this time. She had a midline episiotomy done and from a scale of 0-10 she said her pain level was a 3. I taught her that if she is in pain to ask for pain medication.
2. Administer pain medications.
- Analgesics inhibits the synthesis of prostaglandins that may serve as mediators or pain, primarily in the CNS. This will provide relief of pain in the post partum period.
Evaluation: My patient was not given any pain meds at this time. She did have an order however for Motrin 600mg po q6h and Percocet i tab prn for pain. If she was experiencing severe pain I would administer these medications.
3. Instruct patient to empty bladder frequently and