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).
Nursing Care Plans
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.
- Deficient Fluid Volume (isotonic)
- Risk for Excess Fluid Volume
- Risk For Infection
- Risk For Pain
- Risk for Altered Parent-Infant Attachment
- Deficient Knowledge
Risk for Excess Fluid Volume
- Risk for Excess Fluid Volume
- Excessive/rapid replacement of fluid losses, intravascular fluid shifts (PIH).
Possibly evidenced by
- [Not applicable]
- Patient will demonstrate pulse, blood pressure, urine specific gravity and neurologic signs within expected ranges and without any respiratory complications.
|Assess neurologic status, observing for any behavioral changes and increasing irritable episodes.||Changes in the neurologic status or behavior may serve as early signs of cerebral edema caused by the fluid retention.|
|Monitor for signs of hypertension and tachycardia; Observe for signs of dyspnea; Auscultate for signs of stridor, rhonchi or moist crackles.||Symptoms of circulatory overload and respiratory difficulties may occur as a result of excessive fluid replacement.|
|Monitor for the intake/output, urine specific gravity if indicated. Check the infusion rate of the fluids manually or preferably through the use of infusion pumps.||With the stabilization of fluid levels, intake should approximate/equal to the output; Urine specific gravity results change inversely to output so that as kidney function improves, specific gravity readings decreases, and vice versa. Note: In the client with glomerular spasms caused by pregnancy-induced hypertension (PIH), the output may reduce until extracellular fluids return to the general circulation.|
|Monitor the hematocrit levels.||As plasma volume is restored, the hematocrit level decreases.|
Ineffective Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
May be related to
- Hypovolemia (a decreased volume of circulating blood in the body).
Possibly evidenced by
- Diminished arterial pulsations, cold extremities.
- Decreased capillary refill.
- Decreased milk production.
- Changes in the vital signs.
- Changes in the neurologic status.
- Patient will demonstrate blood pressure, pulse, arterial blood gasses (ABGs), and Hematocrit/hemoglobin level within the expected range.
- Patient will demonstrate normal hormonal functioning by adequate milk supply for lactation (as appropriate) and resumption of normal menstruation.
|Monitor vital signs closely; record the degree and duration of any hypovolemic episodes.||Extent of pituitary involvement may be related to the degree and duration of hypotension. A respiratory difficulty may indicate an effort to combat metabolic acidosis.|
|Observe the color of the nail beds, gums, tongue and buccal mucosa; Note the temperature of the skin.||With the vasoconstriction compensation and shunting to vital organs, circulation in the peripheral blood vessels is diminished, resulting in cyanosis and cold skin temperatures.|
|Evaluate the neurologic status and observe for any behavioral changes.||Changes in the mentation is an early sign of hypoxia. Cyanosis, on the other hand, is a late sign which may not appear until the PO2 levels drop below 50 mm Hg,|
|Check the breast at least daily; Inspecting for changes in breast size and the presence or absence of lactation.||Sheehan’s syndrome, also known as postpartum hypopituitarism reduces prolactin levels, resulting in agalactorrhea (absence of lactation) and a decrease in breast tissue.|
|Monitor Hemoglobin and hematocrit values before and after blood loss. Check for the height and weight; Assess the nutritional status of the client.||Such values indicate the severity of blood losses. Preexisting poor health status increases the extent of injury brought about by the oxygen deficits.|
|Monitor arterial blood gasses (ABGs) and PH levels.||To determine the degree of tissue hypoxia or acidosis, indicating the build uo of lactic acid resulting anaerobic metabolism.|
|Administer sodium bicarbonate as indicated.||To correct metabolic acidosis.|
|Insert airway; suction as indicated.||Facilitates oxygen administration in presence of retained secretions.|
|Provide supplemental oxygen as indicated.||Maximizes available oxygen for circulatory transport to tissues.|
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Maternal and Newborn Care Plans
Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Care Plans
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 4 Care Plans
- Prenatal Hemorrhage | 7 Care Plans
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Pregnancy Induced Hypertension | 6 Care Plans
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Care Plans