Hemorrhage Nursing Diagnosis

Nursing Diagnosis
Potential risk for hemorrhage r/t labor and delivery
Supporting Data:
Objective: delivered 0741 am 3/1/07.
Objective: Vaginal delivery.
Objective: gravida 2
Goal & Goal Criteria
Goal: Patient will show no s/s of hemorrhage in 48 h post delivery.
1. V/S will remain in wnml: T: up to 100.4 F
P: 60-90 bpm
R: 12-20 brpm
BP :120/70
Pulse OX: 95-100%
2. Hct & hgb will remain WNML.
HCT=>33%
HGB= 10.5g/dl
3. Fundus will be midline & firm.
4. IV Fluids infusing as ordered.
5. Total number of pads used will be WNML. 1 pad q hourly.
6. Skin will be warm & dry.
7. Level of consciousness will remain intact
Nursing Actions On 3/1/07-3/2/07 1st shift 7-3
The Nurse will:
1. Assess vital signs q4h.
Rationale: Increase in pulse rate decrease in BP , Increase in respirations could possibly be s/s of hypovolemia. If true hemorrhage; place in Trendelenburg position; assist with blood back to the brain. Foundations of Maternity-Newborn Nsg pg 299
2. Assess lochia, bladder and fundus q 4h . Rationale: Lochia needs to be assessed for amount of blood, color; Fundus assessed for position, & tone. Bladder for distention, and position. Foundations of Maternity-Newborn Nsg pg 299
3. Assess intake & output q 8 h .
Rationale: Kidneys will decrease output and eventually cease, if hypovolemia in progress, to compensate for fluid loss. IV fluids administered to prevent hypovolemic shock from becoming irreversible. Foundations of Maternity- Nursing pg 741.
Implementation
On 3/1/07 -3/2/07 1st shift 7-3
1. The Nurse took V/S@ 0800
T97.6 T 97.8
P 102 P 94
R 20 R 16
BP 111/80 BP 118/67
3/1/07-3/2/07 @ 1200
T96.7 T 97.6
P92 P 83
R 16 R 18
BP 107/69 BP 114/66

2. On 3/1/07-3/2/07 1st shift 7-3 The Nurse assessed the fundus, lochia and Bladder q 4h.

3.On 3/1/07-3/2/07 I&O was assessed and measured q 8h.
Evaluation
Goal was met by AEB:
1. 3/1/07-3/2/07 1st shift 7-3 V/S remained within normal limits.
Temp: up to 100.4 F Pulse: 60-90 bpm Resp: 12-20 brpm BP: 120/70
2. On 3/2/07 1st shift 7-3 Hct and Hgb remained WNML
HCT=31.2%
HGB= 11.8g/dl
3. 3/1/07 1st shift 7-3 The fundus was midline, firm,and U1+FB @ 0800,1000,1200 (storm)
3/2/07 The fundus was midline, firm and U1- FB @ 0800, 1000.(discharged)
4. 3/1/07 1st shift IV fluids infused for 12hours after delivery.
5. 3/1/07-3/2/07 1st shift 7-3 Patient used one pad q1h with moderate amount of lochia.
6. On 3/1/07-3/2/07 1st shift 7-3 Skin was warm & dry.
7. On 3/1/07-3/2/07 1st shift 7-3 Patient was A&Ox3