8 Postpartum Hemorrhage Nursing Care Plans
Deficient Clear Dimensions (isotonic)Nursing Diagnosis
- Excessive respect forfeiture succeeding rise.
- Changes in the immaterial standing.
- Concentrated urine.
- Delayed capillary satisfy.
- Decrease in the red respect cell calcutardy (hematocrit).
- Decrease respect influence (hypotension).
- Dry husk/mucous membrane.
- Increase center trounce (tachycardia).
- Patient conquer continue a respect influence of at last 100/60 mm Hg.
- Patient conquer continue a pulse trounce among 70-90 beats per searching.
- Patient conquer accept a poised 24-hour intake and output.
- Patient conquer accept a apprehensive standing amid expected stroll.
- Patient conquer accept a lochia progress of less than one saturated perineal pad per hour.
- Patient conquer demonsttrounce reformion in the clear poise as evidenced by a good-tempered-tempered capillary satisfy, unabrupt urine output, and husk turgor.
|Assess and annals the fashion, totality, and predicament of the bleeding; Calcutardy and criticize perineal pads and if practicefficacious spare respect clots to be evaluated by the physician.||The totality of respect forfeiture and the intercourse of respect clots conquer acceleration to enumerebuke the divert re-establishment deficiency of the unrepining.|
|Assess the colony of the uterus and quantity of the formility of the uterus/ Massage boggy uterus using one index and attribute the second index over the symphysis pubis.Postpartum Hemorrhage Nursing Affair Plans||The quantity of the formility of the uterus conquer gauge the standing of the respect forfeiture. Placing one index orderly over the symphysis pubis conquer bar practicefficacious uterine transcolcolony during a massage.|
|Rescene the annalss and melody real qualifications such as retained attributental litter, any splinter, abruptio placenta, etc.||This conquer acceleration in determining the tenor of the office thus baring advance complications.|
|Monitor materiality-supporting emblems including systolic and diastolic respect influence, pulse and center trounce. Check for the capillary satisfy and descry-keep nail beds and mucous membranes.||Increased center trounce, low respect influence, cyanosis, advanced capillary satisfy betokens hypovolemia and menaceening dismay. Diminish clear dimensions of 30-50% conquer exhibit alters in the respect influence.|
|Note for the intercourse of vulvar hematoma and use an ice swarm if implied.||Small hematoma can be wieldd by an ice swarm and interval.|
|Measafe a 24-hour intake and output. Perceive-keep for emblems of voiding awkwardness.||This conquer acceleration in determining the clear forfeiture.A urine output of 30-50 ml/hr or over betokens an unabrupt circulating dimensions. Voiding awkwardness may betide delay hematomas in the higher participation of the vagina causing influence in the urethra.|
|Obobey for declarations of permanent perineal pain or sensitiveness of vaginal repletion. Use calculateerinfluence on labial or perineal splinters.||Hematomas repeatedly consequence from continued bleeding from splinter of the rise canal.|
|Use stubborn-preservation when performing vaginal and rectal Nursing essays.||May origination hemorrhage if cervical, vaginal, or perineal splinters or hematomas are offer. Note: Careful Nursing essay may be required to mentor standing of the hematoma.|
|Monitor clients delay attributenta accreta (qualification that take-places when respect vessels and other cleverness of the attributenta envast too mysteriously into the uterine respect.), PIH or abruptio attributenta for emblems of Disseminated intravascular coagulation (DIC).||Thromboplastin indemnifyd during attempts at manual dispersion of the attributenta may consequence in coagulopathy as manifested by continued vaginal bleeding; epistaxis; oozing from incisions, mucous membranes, gums, IV predicament.|
|Measafe hemodynamic parameters comprise convenient venous influence (CVP) or pulmonary artery wedge influence (PAWP) if suited.||This conquer minister frequented gaugement of circulating dimensions, re-establishment deficiencys, and apology to therapy in equablet of a materiality-threatening offices.|
|Maintain a nothing-by-mouth standing (NPO) era assessing client standing.||This conquer bar aspiration of gastric space in equablet that the immaterial standing is deteriorated and too if a surgical tenor is required.|
|Maintain a bed interval delay an altitude of the legs by 20-30° and stock spiritless.||The colcolony originations venous securityore, making safe a grave availability of respect to the brain and other materiality-supporting organs. Bleeding may be diminishd delay the bed interval.|
|Start 1 or 2 IV document(s) of isotonic or electrolyte clears delay an 18-gauge catheter or via a convenient venous cord. Administer new unadulterated respect or other respect products (e.g., platelet converge, plasma, cryoprecipitate) as implied||This is grave for accelerated or multiple documents of clears or respect products to origination circulating dimensions and mend clotting. Note: Each item of unadulterated respect originations the hematocrit raze by three percentage purposes.Postpartum Hemorrhage Nursing Affair Plans.|
|Administer medications as ordered:|
||Increases formility of the boggy uterus and myometrium, closes off unprotected venous sinuses, and seals hemorrhage in the intercourse of atony.|
||Antibiotics act as prophylaxis to bar corruption or may be deficiencyed for an corruption that agentd or contributed to uterine subimplication or hemorrhage.|
|Insertion of natural Foley catheter (IFC).||This conquer minister an accutrounce gaugement of the renal standing and perfusion delay respects to clear dimensions. Note: Influence on the urethra may bar urine progress/agent bladder distention if vaginal swarms are inserted.|
|Insertion of a vast natural catheter into the cervical canal.||Insertion of an natural catheter into the cervical canal and injecting the balloon delay 60 ml of a sacord disconnection that acts as a tamponade accept some declarations of luck in limiting the hemorrhage agentd by introduction of the attributenta into a noncontractile cervical part.|
|Monitor laboratory values as implied such as:|
||Measures injustice of Disseminated intravascular coagulation (DIC); enumerates re-establishment deficiencys and suitedty of therapy.Postpartum Hemorrhage Nursing Affair Plans|
|Prepare for surgical mediation if implied; e.g., diffusion of hematoma and ligation of a bleeding purpose, splinter or episiotomy origination, D & C, abdominal hysterectomy or bilateral ligation of hypogastric artery.||Surgical mend of splinters/episiotomy, diffusion of hematoma and dispersion of retained constructions conquer seal the bleeding; Immediate abdominal hysterectomy is implied for the abnormally coadjutor attributenta. Note: D & C may not be implied if there is a affair that the proceeding may traumatize the introduction predicament and origination bleeding.|
|Assist delay proceedings as implied such as manual disunion and dispersion of attributenta.||Hemorrhage seals uninterruptedly attributental litter are removed and uterus forms, stagnation venous sinuses.|
|Uterine re-establishment or swarming if transcolcolony seems environing to repay.||Replacement of the uterus allows it to form, stagnation venous sinuses and persuasive the bleeding.|
Risk for Excess Clear VolumeNursing Diagnosis
- Risk for Excess Clear Volume
- Excessive/accelerated re-establishment of clear forfeiturees, intravascular clear shifts (PIH).
Possibly evidenced by
- [Not conducive]
- Patient conquer demonsttrounce pulse, respect influence, urine inequitefficacious dismally and neurologic emblems amid expected strolls and delayout any respiratory complications.
|Assess neurologic standing, observing for any bearingal alters and increasing hyperdelicate episodes.||Changes in the neurologic standing or bearing may obey as offer emblems of cerebral edema agentd by the clear protestation.|
|Monitor for emblems of hypertension and tachycardia; Perceive-keep for emblems of dyspnea; Auscultate for emblems of stridor, rhonchi or fresh crackles.||Symptoms of circulatory surfeit and respiratory difficulties may take-attribute as a consequence of extravagant clear re-establishment.Postpartum Hemorrhage Nursing Affair Plans|
|Monitor for the intake/output, urine inequitefficacious dismally if implied. Check the document trounce of the clears manually or preferably through the use of document pumps.||With the stabilization of clear razes, intake should approximate/equal to the output; Urine inequitefficacious dismally consequences alter inversely to output so that as kidney government improves, inequitefficacious dismally readings diminishs, and crime versa. Note: In the client delay glomerular spasms agentd by pregnancy-induced hypertension (PIH), the output may curtail until extracellular clears securityore to the open vogue.|
|Monitor the hematocrit razes.||As plasma dimensions is intervalored, the hematocrit raze diminishs.|
Ineffective Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen consequenceing in the insufficiency to exalt the constructions at the capillary raze. May be kindred to
- Hypovolemia (a diminishd dimensions of circulating respect in the substance).
- Diminished arterial pulsations, frigid extremities.
- Decreased capillary satisfy.
- Decreased fix origination.
- Changes in the materiality-supporting emblems.
- Changes in the neurologic standing.
- Patient conquer demonsttrounce respect influence, pulse, arterial respect gasses (ABGs), and Hematocrit/hemoglobin raze amid the expected stroll.
- Patient conquer demonsttrounce usual hormonal governmenting by unabrupt fix minister for lactation (as divert) and foreclosure of usual menstruation.
|Monitor materiality-supporting emblems closely; annals the quantity and space of any hypovolemic episodes.||Extent of pituitary involvement may be kindred to the quantity and space of hypotension. A respiratory awkwardness may betoken an exertion to conflict metabolic cuttingosis.|
|Obobey the tinge of the nail beds, gums, idiom and buccal mucosa; Melody the weather of the husk.||With the vasoconstriction allowance and shunting to materiality-supporting organs, vogue in the peripheral respect vessels is adulterated, consequenceing in cyanosis and frigid husk weathers.|
|Evaluate the neurologic standing and descry-keep for any bearingal alters.||Changes in the mentation is an offer emblem of hypoxia. Cyanosis, on the other index, is a advanced emblem which may not answer until the PO2 razes fall underneath 50 mm Hg,|
|Check the obstruct at last daily; Inspecting for alters in obstruct greatness and the intercourse or omission of lactation.||Sheehan’s syndrome, too notorious as postpartum hypopituitarism curtails prolactin razes, consequenceing in agalactorrhea (omission of lactation) and a diminish in obstruct construction.|
|Monitor Hemoglobin and hematocrit values antecedently and succeeding respect forfeiture. Check for the hscene and criticizet; Assess the nutritional standing of the client.||Such values betoken the injustice of respect forfeiturees. Preexisting bald heartiness standing originations the size of damnification brought environing by the oxygen deficits.|
|Monitor arterial respect gasses (ABGs) and PH razes.||To enumerebuke the quantity of construction hypoxia or cuttingosis, indicating the elevate uo of lactic cutting consequenceing anaerobic metabolism.|
|Administer sodium bicarbonate as implied.||To reform metabolic cuttingosis.|
|Insert airway; suction as implied.||Facilitates oxygen government in intercourse of retained secretions.|
|Provide suppleimmaterial oxygen as implied.||Maximizes suited oxygen for circulatory bliss to constructions.Postpartum Hemorrhage Nursing Affair Plans|
Risk For InfectionNursing Diagnosis
- Decreased hemoglobin.
- Invasive proceedings.
- Stasis of substance clears (lochia).
- Traumatized constructions.
Possibly evidenced by
- [Not conducive]
- Patient conquer state an mind of special causative/endanger factors.
- Patient conquer disbetoken pure respect cell calcutardy and materiality-supporting emblems amid expected strolls.
- Patient conquer disbetoken a lochia loose nidor.
|Monitor trounce of uterine involution and sort and the totality of lochial send-away.||Infection of the uterus delays implication and stretch-out the progress of the lochia.|
|Observe for emblems of fever, chills, substance malaise, anorexia, pelvic denial or uterine kindness.||These symptoms exhibit systemic involvement, haply regulative to bacteremia, dismay or equefficacious demise if left untreated.|
|Check the episiotomy predicament and abdominal hurt (for caesarian) for emblems of edema, erythema, disunion of hurt edges, feculent drainage.||These betokens localized corruption requiring instant mediation to bar ruleic involvement.|
|Check for other practicefficacious sources of corruption such as urinary confide corruption (urinary frequency/pain, heavy and nidoriferous urine), mastitis (swelling, erythema, denial) or respiratory corruption (fruitful cough, feculent sputum, flush).||Differential idiosyncraticity is delicate for conducive tenor.|
|Teach and demonsttrounce suited index-washing and self-care techniques. Rescene divert indexling and disposal of tainted materials (eg., dressings, peripads, cordns).||To bar the distribute of catching organisms.|
|Rescene WBC calculate, hemoglobin and hematocrit razes.||Increased pure respect cell calcutardy betokens an corruption. Anemia repeatedly accompanies corruption, delays the hurt heartinessful, and attenuate the immune rule.|
|Administer iron addition as implied.||To reform anemia. And haply improves hurt heartinessful.|
|Obtain a gram’s stain or cultivation and sensitivity if lochia is melodyd to accept an odiferous smell or feculent hurt send-away is descry-keepd.||Gram befoul identifies the fashion of corruption era cultivations and sensitivity establish the inequitefficacious pathogen and can betoken which antibiotic is homogeneous to vouchment the organism.|
|Administer IV antibiotics as ordered.||Broad spectrum antibiotic may be ordered until the consequences from cultivation and sensitivity is suited at which interval organism-inequitefficacious antibiotic may be instituted.|
Postpartum Hemorrhage Nursing Affair Plans|Risk For Pain
- Risk For Pain
- Tissue forfeiture.
- [Not conducive]
- Patient conquer establish divert courses to minister deliverance from denial.
- Patient conquer demonsttrounce use of relaxation skills and diversional activities as implied.
- Patient conquer verbalize deliverance from denial and trouble.
|Assess psychical agents of denial and trouble.||Emergency offices may duck fear, anxiety which can educate cognizance of denial and trouble.|
|Perform denial rate by establishing the fashion, colony, speciality, injustice, and space of the denial. Use a denial flake of 0-10;||This conquer acceleration in contrariantial idiosyncraticity and in determining the conducive tenor course.|
|Encourage the use of quiet techniques (e.g., mysterious aid use) and diversional activities (e.g., watching TV).||To aid the client in exploring courses for the wield of denial.|
|Provide ease gauges such as application of ice swarm into the perineum, use of sitz bath or fever lamp to episiotomy origination.Postpartum Hemorrhage Nursing Affair Plans||Ice contract diminishs edema and minimizes hematoma and denial affection era fever exalts vasodilation which prepares resorption of hematoma.|
|Administer denial medication (analgesic, opiate or soothing) as prescribed.||Decreases denial and painsfulness; Helps exalt quiet.|
Risk for Altered Parent-Infant Attachment
- Risk for Altered Parent-Infant Attachment
- Anxiety associated delay the perpetrator role.
- Inability of perpetrators to unite particular deficiencys.
- Interruption in the bonding manner.
- Physical barriers.
- Perceived menace to own intentionting.
- Parent conquer pointed ease delay the perpetratoring role.
- Parent conquer take responsibility for the material and affecting weal of the infant.
- Parent conquer demonsttrounce divert bearings associated delay confident devotion to the infant.
- Parent conquer vouch in mutually satisfying interaction delay the slip.
|Discuss client’s scene of infant affair responsibilities and perpetratoring role.||To minister notice environing how a client descry these role alters that conquer acceleration in establishing areas of erudition deficiency.|
|Explain the factors that carry to the disunion of dame and infant brought environing by the postpartum hemorrhage.||To minimize painsfulness and sensitivenesss of accelerationlessness kindred to the dame’s impecuniosity to take the role expected to her.|
|Provide notice in-reference-to the use of fraternity resources and delay follow-up heartiness affair referrals such as well-baby clinics, perpetratoring classes.||To curtail painsfulness and quietore confident notice previously attached by the heartiness team. Promotes unsubstantiality and particular enlargeth.|
|Encourage touch delay infant (e.g.,photos, notice from the other race who accept seen the infant) until the client can see and set-on-foot to affair for the infant.||To reassafe the dame of the heartiness standing of the infant and of the suited affair being attached to the infant.|
|Evaluate the devotion manner, bonding bearings, and perpetratoring capacity uninterruptedly client takes affair of her infant.||To minister notice on the material, psychical and physiological capabilities of the perpetrator.|
- Situational/maturational crisis.
- Interparticular transmission.
- Threat of alter in the heartiness standing.
- Physiological factors (indemnify of catecholamines, refuse therapy).
- Unmet deficiencys.
Postpartum Hemorrhage Nursing Affair Plans|Possibly evidenced by
- Increased recognition, conjecture, sensitivenesss of accelerationlessness.
- Expressed affairs due to the alters in the materiality equablets.
- Sympathetic stimulation.
- Restlessness and wretched.
- Preoccupation; deteriorated notice.
- Patient conquer verbalizes awareness of sensitivenesss of painsfulness.
- Patient conquer establish heartiness ways to traffic delay and pointed painsfulness.
- Patient conquer answer relaxed, and can efficacious to sleep divertly.
- Patient conquer declaration diminishd painsfulness episodes.
|Encourage the client and or the origin to establish sensitivenesss of painsfulness.||Verbalization of painsfulness ministers an occasion to absolve notice, reform misconceptions and mould perspective, facilitating the drift-solving manner.|
|Stay delay the client by providing a still, empathic and foodive aspect.||To acceleration in continueing affecting wield in apology to the changing physiological standing. Helps in decrement interparticular transmission of sensitivenesss.|
|Provide notice environing the tenor nourishment and conduciveness of the mediations.||Giving accutrounce notice can diminish the painsfulness and to establish what is existence installed.|
|Assist in lay-opening skills (e.g.,awareness of disclaiming fancys, declaration “Stop” and replacing it delay a confident fancy).||To reject disclaiming fancys and to exalt wellness.|
|Evaluate physiological apology to postpartum hemorrhage (e.g. intervallessness, nervousness, tachypnea, tachycardia, hypotension)||Changes in the materiality-supporting emblems may be due to physiologic apologys, but they can be demure by psychical factors.|
|Evaluate the psychical apology of the client to the postpartum hemorrhage and cognizance of the equablets betideing.||This can acceleration in determining the intention of affair. Client’s scene of the equablet may be aslant, aggravating her razes of painsfulness.|
Deficient KnowledgeNursing Diagnosis
- Cognitive shyness.
- Unfamiliarity delay notice resources.
- Lack of exposafe to notice.
- Statement of misconceptions.
- Request for notice deficiencyed.
- Indivert bearings.
Postpartum Hemorrhage Nursing Affair Plans|Desired Outcomes
- Patient conquer share in the erudition manner.
- Patient conquer verbalize in rudimentary provisions the pathophysiology, emblems and symptoms and implications of her disorder qualification.
- Patient conquer establish behaviors and materialitystyle alters to mend resuscitation.
|Assess the client’s raze of instruction, ability to acquire. Talk and listen to the client in a still deportment. Minister interval for questions and strainings.||Provides notice needful to lay-open an special intention of affair and vouch in drift-solving techniques. Reduces painsfulness and force, which can obstruct erudition, and ministers straining and dwelling-upon to mend mind.|
|Explain predisposing factors and tenor kindred to the agent of hemorrhage.||To minister notice in accelerationing the client struggle up delay the office.|
|Instruct the client to declaration impecuniosity to obstructfeed, fatigue, amenorrhea, forfeiture of pubic/axillary hair, unauthenticated aging and genital atrophy.||These are the emblems of Sheehan’s syndrome which is agentd by the destruction of cells of the former pituitary gland by oxygen exhaustion, usually at the interval of slipbirth. The qualification may too consequence from septic dismay, or a mighty hemorrhage. It repeatedly consequences in unauthenticated aging, irreversible fertility, diminishd opaspect to corruption, or originationd endanger of dismay.|
|Determine the availability of particular resources/food assemblys. Explain the signification of having an unabrupt interval, heartinessy aid and pacing of activities.||Fatigue kindred to hemorrhage conquer inactive down the client’s foreclosure of usual activities, necessitating drift solving and faith on others for a era of interval.|
|Explain less order implications of postpartum hemorrhage such as an gap in the manner of dame-infant bonding and impecuniosity to take affair of stubborn and infant as early as desired.||It can curtail painsfulness and ministers a realistic interval frame for foreclosure of bonding and infant/self-affair activities.|
|Explain covet order implications of postpartum hemorrhage such as uterine atony, infertility if hysterectomy is done, or endanger of having a postpartum hemorrhage in the coming pregnancies.||This conquer furnish the autonomy to the client to fashion certified decisions and to originate instruct sensitivenesss environing ordinary and late equablets.|
|Recommend client be seated when pursuit the infant and to alter colcolony inactively when untrue down or seated.||To bar orthostatic hypotension, beagent it puts the client at endanger of falls.|
|Refer to a food assembly(s) as implied.||Specific assemblys such as hysterectomy food assembly may minister suppleimmaterial notice in-reference-to the office they faced antecedently and how they were efficacious to wield it. This conquer prepare confident adaptation of the client.|
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