Priority Nursing Interventions (Basic Care & Comfort/ Safety &
Infection Control) (2.5 pts)
Name: Jeanine Diaz
Priority Assessments (Physiological Adaptation) (2.5
pts).
1. Assess for uterine atony by palpating fundus to
check if firm or boggy, midline or deviated. Assess
bladder for fullness and distention. Assess for any
lacerations or hematomas.
2. Assess amount of bleeding (saturating one pad in 15
minutes), clots (if any and the size), and for lochia that
is sudden and massive or slow and steady.
3. Assess vitals paying special attention to blood
pressure and respirations (hypotension and tachypnea)
and skin for pale color or clammy feel.
Risk Factors (Health Promotion &
Maintenance/Reduction of Risk Potential) (1pt)
1. Neonatal macrosomia: birth weight greater than
4500, polydramnios, high parity.
2. Operative vaginal delivery, augmented or inducted
labor, prolonged first/second stage of labor.
3. Choriamniotitis, maternal obesity, congenital or
acquired coagulation defects.
Psychosocial Concerns (Psychosocial Integrity) (1 pt)
1. Anxiety due to fear and concern, fear of dying.
2. Depression and PTSD due to stressful situation and
traumatic birth process.
3. Negative memories of delivery and postpartum period.
Labs & Diagnostics (Reduction of Risk Potential) (2.5 pt)
1. 10 % decrease in hemoglobin (11-13) and or hematocrit
(33-39%) post birth.
2. Blood loss of more than 500ml for vaginal delivery or
greater than 1000ml for c-section (weigh pads and linens for
accurate blood loss (1ml blood =1 gram).
3. Decreased platelets (150,000-400,000) and fibrinogen
(200-400).
Critical Thinking Map
Concept: Post-Partum Hemorrhage
Brief Pathophysiology (Physiological Adaptation)
(2.5pts.) Post-Partum Hemorrhage (PPH) is blood loss greater
than 500ml in vaginal births, or more than 1000ml blood loss in
cesarean deliveries with a 10% decrease in H&H. It can occur
either early (within 24 hrs) or late (After 24hrs. -6 weeks
postpartum). PPH can be caused by uterine atony, retained
placental fragments, fibroids, lower genital track lacerations, and
subinvolution.
Priority Nursing Diagnosis (2.5pts.)
1. Fluid volume deficient r/t blood loss secondary to uterine
atony, lacerations, retained placental fragments and
coagulopathies AEB: decreased H&H, confusion, tachycardia and
hypotension.
2. Tissue perfusion: Ineffective r/t hypovolemia AEB: tachycardia
hypotension, pale and clammy skin.
3. Risk for bleeding r/t lack of information about signs of delayed
post-partum hemorrhage.
Potential & actual complications from treatments/
procedures (Physiological Adaptation/Reduction of
Risk Potential) (2pt)
1. Complications from tamponade balloon include possible
infection, perforation of uterus during placement, inflation and
cervical trauma due to inflation and incorrect location.
2. Complications from embolization of uterine artery include
infection, amenorrhea, scare tissue formation and persistent pain
lasting for months.
3. Complications from hysterectomy include infection, bladder
injury, bowel injury, hemorrhaging, blood clots, difficulty
urinating and complications from anesthesia.
Date: 6/10/2017
1. Message fundus until firm or have patient void.
2. Initiate Oxytocin therapy if fundal message does not resolve
bleeding and if that does not work administer methergine and or
Hemabate.
3. Provide support to the patient and explain all procedures/answer
any questions patient or family may have. Provide patient comfort
as much as possible.
Medications (Pharmacological & Parenteral Therapies) (5pts)
1. Oxytocin 10 units IM if no IV access; 10-40 units in 1,000 cc
crystalloid IV fluid (lactated Ringer’s solution or normal saline) SE:
water intoxication causing confusion, drowsiness, and vomiting,
uterine cramping (desired), redness or irritation at injection site,
runny nose, sinus pain or irritation. Contraindicted with
hypersensitivity.
2. Methergine 0.1-0.2 mg IM q2-4 h followed by 0.2 mg PO q4-6
times 24 hours for 6 doses. SE: Dizziness, headache, tinnitus, nausea,
vomiting, cramping (desired). Contraindicted in patients with current
elevation of BP, hypersensitivity.
3. Hemabate 0.25mg(250 mcg) IM or directly into the uterus q 15-90
min; 8 doses maximum. SE: fever, diarrhea, vomiting. Contraindicted
in patients with asthma, hepatic, renal, and cardiac disease.
Patient Teaching (Health Promotion &
Maintenance/Safety & Infection Control/
Management of Care) (2.5 pt)
1. Teach patient signs and symptoms of PPH to report,
increased bleeding (blood changing back to bright red color),
clots larger than a nickel, soaking a pad in less than 1 hr, fast
heartbeat, dizziness, and foul smelling lochia.
2. Teach patient how to assess own fundus and report if
higher level than before or palpable beyond 7-10 days,
tender, or has a fever.
3. Teach patient how to perform fundal message in case of
increased bleeding at home or boggy fundus. Also teach to
keep bladder empty and limit activity during initial
postpartum weeks including driving.