Problem: Risk for bleeding r/t postpartum complications.
Patient Centered Goal: Patient will not experience any abnormal/excessive bleeding by the end of clinical shift.
1. Patient will experience lochia reducing in amount and lightening in color by the end of clinical shift.
2. Patient will observe fundus that is firm, midline, and decreasing in height by the end of clinical shift.
3. Patient will verbalize understanding of signs and symptoms of hemorrhage by the end of clinical shift.
| Patient Responses
(Number, written rationale w/ footnote, minimum of 6)
| (Number to match each intervention, include factual data)
| 1. Monitor bleeding/lochia for color and amount and keep a pad count as indicated. * Monitoring bleeding (amount/characteristics) serve as early indicators hemorrhage. Bleeding can progress rapidly to massive hemorrhage and should be monitored closely. * A perineal pad saturated in < 15 minutes or pooling of blood under the buttocks is an indication of excessive blood loss and required immediate assessment, intervention, and notification of the HCP.(3: 540, 579; 9: 611, 613)
| * Patient experienced blood loss as would be expected with a vaginal birth. A count of pads used was also documented – during the clinical shift, following the birth of the baby, the mother’s pad was changed once.
| 2. Monitor/palapte fundus for location/tone. * Helps to determine the status of the uterus and may indicate additional interventions. * Uterine atony – as evidence by a boggy uterus is the most common cause of postpartum hemorrhage. * If fundus is boggy apply gentle massage and assess tone response to promote uterine contractions and increase uterine tone. (3: 539, 542)
| * Patient’s fundus was firm and located at the umbilicus as would be expected.
| 3. Monitor intake/output, assess for bladder fullness, and encourage the patient to void. *...
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