Question

A multigrada patient (G2P1, 26 weeks AOG came in for check-up.

This is her 3^rd visit since her pregnancy started. Her ultrasound revealed multi fetal gestation. She is a laundry woman and her husband is a carpenter. She is pale looking and is observed to be weak. She claimed that she has recently lost appetite because she is afraid to eat a lot because it might lead to a possible CS delivery.

2. Write an NCP regarding Risk for Post partum Hemorrhage
3. Prepare an NCP following the format:

3.1. Subjective/objective data

3.2. Nursing Diagnosis

3.3 Rationale (should indicate book sources or references)

3.4 Goals/ objectives

3.5 Nursing interventions

3.6. Scientific rationale for the interventions

3.7. Evaluation criteria

Answer 1

Postpartum hemorrhage is defined as any blood loss from the uterus of more than 500ml during or after delivery. It may occur either early (within the first 24 hours after delivery), or late (anytime after the 24 hours during the remaining days of the six-week puerperium).

3.1) Subjective/ Objective data :

Multigrada patient G2 P1 26 weeks AOG came in for check up. 3rd visit. Multi fetal gestation.

Pale looking, weak, recently lost appetite,

3.2) Nursing Diagnosis

Anemia and deficient fluid volume related to excessive bleeding after birth.

3.3) Rationale :

*)Heavy uterine bleeding. Bleeding of more than 500 mL in a normal vaginal delivery and more than 1000 mL in a cesarean birth qualifies for a postpartum hemorrhage.

*)Tense and rigid uterus. This may also indicate internal bleeding and possible external bleeding.

*)Changes in the mental status.

*)Concentrated urine.

*)Delayed capillary refill.

*)Decrease in the red blood cell count (hematocrit).

*)Decrease blood pressure (hypotension).

*)Dry skin/mucous membrane.

*)Increase heart rate (tachycardia).

3.4) Goals / Objectives :

The primary role of the nurses is to assess and intervene early or during a hemorrhage to help the patient regain her strength and to prevent complications. Data such as the amount of bleeding, the condition of the uterus, checking of the maternal vital signs and observing for signs of shock would play a vital role in the care of the patient with hemorrhage.

3.5) and 3.6) Nursing intervention and Rationale

1) Intervention : Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if possible save blood clots to be evaluated by the physician.

Rationale : The amount of blood loss and the presence of blood clots will help to determine the appropriate replacement need of the patient.

2) Intervention : Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis.

Rationale : The degree of the contractility of the uterus will measure the status of the blood loss. Placing one hand just above the symphysis pubis will prevent possible uterine inversion during a massage.

3) Intervention : Review the records and note certain conditions such as retained placental fragments, any laceration, abruptio placenta, etc.

Rationale : This will help in determining the management of the situation thus preventing further complications.

4) Intervention : Monitor vital signs including systolic and diastolic blood pressure, pulse and heart rate. Check for the capillary refill and observe nail beds and mucous membranes.

Rationale : Increased heart rate, low blood pressure, cyanosis, delayed capillary refill indicates hypovolemia and impending shock. Decrease fluid volume of 30-50% will reflect changes in the blood pressure.

5) Intervention : Note for the presence of vulvar hematoma and apply an ice pack if indicated.

Rationale : Small hematoma can be managed by an ice pack and rest.

6) Intervention : Measure a 24-hour intake and output. Observe for signs of voiding difficulty.

Rationale : This will help in determining the fluid loss.A urine output of 30-50 ml/hr or more indicates an adequate circulating volume. Voiding difficulty may happen with hematomas in the lower portion of the uterus causing pressure in the urethra

7) Intervention : Observe for reports of persistent perineal pain or feeling of vaginal fullness. Apply counterpressure on labial or perineal lacerations.

Rationale : Hematomas often result from continued bleeding from laceration of the birth canal.

3.7) Evaluation :

*) Hemoglobin and Hematocrit - Hgb and Hct determine the amount of blood loss. Each milliliter of blood carries 0.5 mg of hemoglobin.

*) Platelet count, activated partial thromboplastin time (APTT), fibrinogen and Fibrin degradation products (FDP) - Measures severity of Disseminated intravascular coagulation (DIC); determines replacement needs and effects of therapy.