University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2021
Views:

35

Pages:

1
Author:

Efrain Villa

Evaluation Goals 1. The patient’s blood loss will be with normal limits within 1 hour. 2. Patient will verbalize in simple terms the pathophysiology, signs and symptoms and implications of her condition. 3. By the end of my shift, the patient will appear relaxed, and is able to sleep appropriately. 1. Goal not met; balloon tamponade needed to stop bleeding excess. 2. Goal met, patient knew the simple terms and reasons for her condition. 3. Goal met, patient slept soundly and was pleasant when awake. 1. Save all perineal pads used during bleeding and weigh them to determine the amount of blood loss. 2. Place the woman in a side lying position to make sure that no blood is pooling underneath her. 3. Assess lochia frequently to determine if the amount discharged is still within the normal limits. 4. Assess vital signs, especially the blood pressure. Fundus firm at 2 finger breadths below umbilicus and midline. Rubella immune, HIV-,HepB-, Hg 12, Ht 37%, Pain: 2/10 Medical History Reproduction: Nursing Interventions 1 HR 96, RR 12, BP 132/72, Temp 3.7c. 600ml bolus oxytocin of 20u in 1000ml LR, 250ml of blood loss estimated. Nursing Diagnosis 1. Deficient fluid volume R/T excessive bleeding after birth AEB 367g of blood loss within 1 hour. 2. Deficient knowledge R/T unfamiliar situation AEB request for more information. 3. Anxiety R/T situational crisis AEB expressed concerns due to the changes in the life events. Assessment Postpartum 28yr G1P1 African American delivered a 41 wk male infant, 9lbs 3oz. Vacuum assisted delivery. Labor complicated with chorioamnionitis. APGAR 7 & 8. History of asthma, treated with inhaler. Balloon Tamponade inserted after 367g of blood loss, treating Uterine Atony. Nursing Interventions 2 1. Assess the client’s level of knowledge, ability to learn. Provide time for questions and clarifications. 2. Talk and listen to the client in a calm demeanor. 3. Explain predisposing factors and treatment related to the cause of hemorrhage. 4. Explain short term implications of postpartum hemorrhage such as an interruption in the process of motherinfant bonding and inability to assume care of self and infant as soon. Nursing Interventions 3 1. Encourage the client and or the family to identify feelings of anxiety. 2. Stay with the client by providing a calm, empathic and supportive attitude. 3. Provide information about the treatment regimen and effectiveness of the interventions. 4. Evaluate the psychological response of the client to the postpartum hemorrhage and perception of the events happening.