Postpartum hemorrhage nursing care plan

The vital signs were: blood pressure 70/58 mmHg, pulse rate 116 b/m, respiratory rate 26 b/m and temperature of 37. 00C. Introduction Postpartum hemorrhage is the blood loss of more than 500 ml after vaginal delivery or more than 1000 ml after cesarean delivery. Clinically, any blood loss that compromises the normal functioning of the body should be considered postpartum hemorrhage. It can either be primary (early) or secondary (late) postpartum hemorrhage depending on the time in which it happens. The patient presents with tachycardia, oliguria/anuria, agitation, confusion and impairment of consciousness. Review of Systems/Head to Toe Assessment Skin: the patient has brown skin; smooth and soft with tinny sweats on the face. The skin temperature is within the normal range (370 C). The nails are of creamy texture, and the capillary refill is 4 minutes.

The palms are pale in color. Gastrointestinal /Abdomen: has striae and linea nigra on inspection of the abdomen; normal bowel sounds. Urinary: reports oliguria Reproductive: per vagina hemorrhage Musculoskeletal / Extremities: cold extremities, pale palms Neurologic: agitated, confused, restless 1. DEFICIENT BODY FLUID VOLUME Cues Nursing diagnosis Goal /plan Nursing Intervention Rationale Implementation Evaluation Subjective: ‘I'm bleeding a lot,' says Ms. TK. Objective: patient manifests with Oliguria, dry lips and mucous membrane high pulse rate 116b/m Hypotension 70/58mmHg Deficient body fluid volume related to excess blood loss Short Term: After 1-2 hours of nursing intervention, the patient will be able to demonstrate no blood loss and a stable pulse rate and blood pressure. Monitor fluid input and output 11. Maintain bed rest To rule out uterine atony and determine the amount of blood loss the patient is experiencing.

Full bladder hinders uterine contraction. To contract uterine muscles and stop bleeding. To rule of remains of placenta and membranes. The obstetrician does perineum assessment, and it is intact. The lab technician does the test. The assistant midwife gives 1L IV Normal saline in 15-20 minutes and another 1L IV Normal saline in 30 minutes at 30ml/min. The nurse started monitoring the peripheral pulses. They were low The nurse started monitoring and documenting fluid input and output. Objective : On assessment, the patient has cold extremities, diminished peripheral pulses, hemoglobin of 7g/dl, prolonged capillary refill> 3minutes, Respiratory rate of 26 b/m Ineffective tissue perfusion related to decreasing volume of circulating blood in the body Short term: after 1-2 hours, the patient will have adequate tissue perfusion evidenced by presence of peripheral pulses and warm extremities.

Long term: After 2-3 days, the patient will be able to demonstrate blood pressure, pulse, arterial blood gas, hematocrit levels within normal range. • Administer oxygen therapy • Give blood products as ordered by the physician • Monitor vitals every 5 to 10 minutes • Monitor blood gas and pH levels • Put the patient in a high Fowler's position. • Position the patient with legs elevated To maximize oxygen circulation to body tissues. To replace the lost blood components. TK. Objective : • Inability to do activities of daily living • Pallor • Exertional dyspnea • The heart rate of 116 b/m Activity intolerance related to inadequate oxygen supply as evidenced by the verbal report of weakness After 2-3 days the patient will be able to maintain activity level within capabilities as evidenced by being able to do activities of daily living with little or no assistance, the absence of dyspnea and average heart rate • Instruct client energy-conserving techniques • Assist in doing activities of daily living • Progress activity gradually • Encourage adequate rest periods • Energy saving techniques help to reduce excess oxygen consumption allowing more prolonged activity ( sitting to do work, pushing rather than pulling, sliding rather than lifting ).