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Nursing Care Plan

Student Name:

Date: February 25, 2006
Nursing Diagnosis Outcome Criteria (Goal) Evaluation of Outcome Criteria (Goal)

PC: Postpartum Hemorrhage
Patient will develop no complications related to excessive bleeding, will maintain normal vital signs of express understanding of her condition, its management, and discharge instructions, identify and use available support systems.



R/T, RTRF and secondary to: Pathophysiology Supporting
Nursing Diagnosis Statement (cite source)
• Uterine atony (over distended uterus, anesthesia, analgesia, previous history of uterine atony, high parity, prolonged labor, ocytocin-induced labor, trauma during labor and birth)
• Lacerations of the birth canal
• Retained placental fragments
• Ruptured uterus
• Inversion of the uterus
• Placenta accrete
• Coagulation disorders
• Placental abruption
• Placenta previa
• Manuel Removal of a retained placenta
• Magnesium Sulfate administration during labor or postpartum period
• Endometritis
• Uterine suninvolution A blood loss greater than 500 mls in the first 24 hours after a vaginal delivery and greater than 1000mls with cesarean delivery

Database - Subjective
(Defining characteristics, support for R/T, RTRF) Database - Objective
(Defining characteristics, support for R/T, RTRF)

Dizziness, fatigue, Severe cramping, SOB, thirst, excitability, insomnia, lightheadedness, anxiety.


Tachycardia
Tachypnea
Hypotension
Decreased Hemoglobin & Hematocrit
Excessive blood loss
CBC
boggy fundus
HGT
HCT

Interventions:
Independent and Collaborative

Rationale
(cite source for each rationale)

Evaluation
(of each intervention)

Assess

1. Upon admission assess patient's history and labor & delivery record for factors that might predispose the patient to postpartal hemorrhage.

2. Assess vaginal bleeding (locchia) after delivery every 15 minutes for one hour, then every 30 minutes for 1 hour, or until stable; more frequent...