Nursing care plan for patient with postpartum hemorrhaged PDF

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Summary

PROBLEM BASED-LEARNING WRITTEN REQUIREMENTS FOR BSN 22ND SEMESTER 2021-LEVEL: BSN 2GROUP #: 23AREA OF ROTATION: Delivery room DATE: 02/10/SUMMARY/OVERVIEW OF THE CASE:Mrs.X 37 years old G7P7 postpartum patient with the weight- 130 lbs, height- 5’1 and BP of 80/50 mmHG. No prenatal visit upon onset o...

Description

PROBLEM BASED-LEARNING WRITTEN REQUIREMENTS FOR BSN 2 2ND SEMESTER 2021-2022 LEVEL: BSN 2 GROUP #: 23 AREA OF ROTATION: Delivery room

DATE: 02/10/2022

SUMMARY/OVERVIEW OF THE CASE: Mrs.X.Y 37 years old G7P7 postpartum patient with the weight- 130 lbs, height- 5’1 and BP of 80/50 mmHG. No prenatal visit upon onset of her pregnancy, she was also not taking any vitamins and iron supplements and has no history of abortion. She also mentioned that her mother was diagnosed to have a disseminated intravascular coagulation and her father died of tuberculosis at the age of 50 years old. After the delivery of the placenta, manual evacuation of blood clots and perineal care done while waiting to be transferred to the OB ward, The patient complained of profuse bleeding. Upon assessment, the patient's perineal pad is fully soaked of blood, cold clammy skin and pallor note with soft boggy uterus Decreased urine output and hypotension noted. Upon medical assessment by the physician, retained placental fragments were noted and evacuated and Tearing of the uterine artery, such as with cervical lacerations of the birth canal noted. Transferred to OB ward was deferred for further management.

DATE

Patient’s assessment (subjective, objective data/s, Diagnostic studies and procedures)

Analysis/Nursing Diagnosis:

Nursing Therapeutic Plan Development and Implementation of Care

Evaluation of the presented plan of Care

Formulation of Nursing Diagnosis based on the information gathered (FOR POST NURSING DIAGNOSIS SEMINAR)

02/10/22

Subjective Data

“HALA, miss nurse nga-a garabe gid nga dugo ang guwa sakun” “Miss nurse nakulbaan aku basi anu ang matabo sa akun indi gd ko kapati nga kadamu sang dugo” “Nurse gasakit ang akun pus-on nga daw kalumok ni man, anu ang natabo” “Sa tuod lang nurse kapito naku mag bato pero indi ko kabalo kung anu gakatabo sa lawas ko pero kaluy-an sang diyos wala man ko napatyan bata” “Wala man ko may gin eskwelahan labandera man lang ko”

PHYSIOLOGIC: •

NURSING OF THERAPEUTIC PLAN PHYSIOLOGIC:

IMPLEMENTATION CARE

PHYSIOLOGIC:

Altered in comfort related to uterine atony secondary to postpartum hemorrhage

Rationale:

The patient is experiencing altered comfort due to the failure of the uterus to contract that leads to bleeding in addition to this she has a family history of disseminated intravascular coagulation and retained placental

pieces were discovered and expelled during the physician's medical examination.

PHYSIOLOGIC: The patient was able to:

1. Assess baseline data of the patient.

1. Frequently monitor vital signs

1. Have a significant improvement on her physical state as evidenced by: • Vital Signs Blood Pressure: 110/80mmHg Temp: 36.3°C RR: 19 cpm PR: 85 bpm

“Kapigado gid ya sang pangabuhi namon, wala man ko gani na prenatal kay gasto sa plete, wala plete vitamins pa-ayhan”

2. Administer cold therapy.

2. Provide an ice pack in the fundus to help the uterus contract and reduce the blood discharge.

2. Uterus is well contracted and the lochia discharge of the patient are reduced

3. Provide stimulation of uterine contraction.

3. Perform Fundal Massage

3. Uterus has contracted upon palpation.

4. Determine the degree of postpartum hemorrhage.

4. Monitor the amount, consistency, pattern, and odor of lochia rubra by weighing the sanitary pads.

4. Moderate amount of bleeding noted in the sanitary pad amounting to 300mL of lochia rubra.

5. Assess bladder elimination

5. Measure a 24hour intake and output. Observe for any signs of voiding difficulty.

Objective Data G7P7 Weight: 130 lbs Height: 5’1 BP: 80/50 mmHg Lung sounds- clear bilaterally Anxious Cardiac Exam- murmur not noted Perineal pad is fully soaked Cold clammy skin Pallor noted with soft boggy uterus

5. The patient was able to void without difficulty.

Decreased urine output and hypotension Tearing of uterine artery, with cervical laceration or lacerations of the birth canal Complained of profuse bleeding

6. Encourage mother to breastfeed.

6. Provide health teaching regarding breast care and the importance of breastfeeding.

6. The patient was able to demonstrate successful breastfeeding and proper breast care.

DIAGNOSTIC WORK-UPS

TESTS/LABORATORY

7. Administer medications as prescribed.

SARS-CoV2 Viral RNA RT-PCR Negative for SARS-CoV-2 RNA

7. Administer the right medication safety to the patient as prescribed by the physician.

7. The patient was relieved by the pain and bleeding.

Beta hCG Quantitative BEHAVIORAL:

20 IU/L (nonpregnant normal value:...