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Priority Nursing Interventions (Basic Care & Comfort/ Safety &

Infection Control) (2.5 pts)

Name: Jeanine Diaz Critical Thinking Map Date: 6/10/2017


1. Message fundus until firm or have patient void.
Priority Assessments (Physiological Adaptation) (2.5
pts).
Concept: Post-Partum Hemorrhage 2. Initiate Oxytocin therapy if fundal message does not resolve
bleeding and if that does not work administer methergine and or
1. Assess for uterine atony by palpating fundus to Brief Pathophysiology (Physiological Adaptation) Hemabate.
check if firm or boggy, midline or deviated. Assess (2.5pts.) Post-Partum Hemorrhage (PPH) is blood loss greater
bladder for fullness and distention. Assess for any 3. Provide support to the patient and explain all procedures/answer
than 500ml in vaginal births, or more than 1000ml blood loss in any questions patient or family may have. Provide patient comfort
lacerations or hematomas. cesarean deliveries with a 10% decrease in H&H. It can occur as much as possible.
either early (within 24 hrs) or late (After 24hrs. -6 weeks
2. Assess amount of bleeding (saturating one pad in 15
postpartum). PPH can be caused by uterine atony, retained Medications (Pharmacological & Parenteral Therapies) (5pts)
minutes), clots (if any and the size), and for lochia that 1. Oxytocin 10 units IM if no IV access; 10-40 units in 1,000 cc
is sudden and massive or slow and steady. placental fragments, fibroids, lower genital track lacerations, and
crystalloid IV fluid (lactated Ringer’s solution or normal saline) SE:
subinvolution.
water intoxication causing confusion, drowsiness, and vomiting,
3. Assess vitals paying special attention to blood uterine cramping (desired), redness or irritation at injection site,
Priority Nursing Diagnosis (2.5pts.)
pressure and respirations (hypotension and tachypnea) runny nose, sinus pain or irritation. Contraindicted with
and skin for pale color or clammy feel. hypersensitivity.
1. Fluid volume deficient r/t blood loss secondary to uterine
Risk Factors (Health Promotion & atony, lacerations, retained placental fragments and 2. Methergine 0.1-0.2 mg IM q2-4 h followed by 0.2 mg PO q4-6
Maintenance/Reduction of Risk Potential) (1pt) coagulopathies AEB: decreased H&H, confusion, tachycardia and times 24 hours for 6 doses. SE: Dizziness, headache, tinnitus, nausea,
hypotension. vomiting, cramping (desired). Contraindicted in patients with current
1. Neonatal macrosomia: birth weight greater than elevation of BP, hypersensitivity.

4500, polydramnios, high parity. 2. Tissue perfusion: Ineffective r/t hypovolemia AEB: tachycardia
3. Hemabate 0.25mg(250 mcg) IM or directly into the uterus q 15-90
hypotension, pale and clammy skin. min; 8 doses maximum. SE: fever, diarrhea, vomiting. Contraindicted
2. Operative vaginal delivery, augmented or inducted in patients with asthma, hepatic, renal, and cardiac disease.
labor, prolonged first/second stage of labor. 3. Risk for bleeding r/t lack of information about signs of delayed
post-partum hemorrhage. Patient Teaching (Health Promotion &
3. Choriamniotitis, maternal obesity, congenital or
acquired coagulation defects. Maintenance/Safety & Infection Control/
Psychosocial Concerns (Psychosocial Integrity) (1 pt) Management of Care) (2.5 pt)
Potential & actual complications from treatments/
1. Anxiety due to fear and concern, fear of dying.
procedures (Physiological Adaptation/Reduction of 1. Teach patient signs and symptoms of PPH to report,
2. Depression and PTSD due to stressful situation and Risk Potential) (2pt) increased bleeding (blood changing back to bright red color),
traumatic birth process. 1. Complications from tamponade balloon include possible clots larger than a nickel, soaking a pad in less than 1 hr, fast
infection, perforation of uterus during placement, inflation and heartbeat, dizziness, and foul smelling lochia.
3. Negative memories of delivery and postpartum period. cervical trauma due to inflation and incorrect location.
Labs & Diagnostics (Reduction of Risk Potential) (2.5 pt) 2. Teach patient how to assess own fundus and report if
2. Complications from embolization of uterine artery include higher level than before or palpable beyond 7-10 days,
1. 10 % decrease in hemoglobin (11-13) and or hematocrit infection, amenorrhea, scare tissue formation and persistent pain tender, or has a fever.
(33-39%) post birth. lasting for months.
3. Teach patient how to perform fundal message in case of
2. Blood loss of more than 500ml for vaginal delivery or 3. Complications from hysterectomy include infection, bladder
greater than 1000ml for c-section (weigh pads and linens for
increased bleeding at home or boggy fundus. Also teach to
injury, bowel injury, hemorrhaging, blood clots, difficulty keep bladder empty and limit activity during initial
accurate blood loss (1ml blood =1 gram).
urinating and complications from anesthesia. postpartum weeks including driving.
3. Decreased platelets (150,000-400,000) and fibrinogen
(200-400).