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    Nursing Care Plan

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    api-315741653
    The nurse created a plan to address the patient's risk for bleeding related to childbirth with 5 interventions and outcomes. The interventions included assessing vital signs, level of consciousness, capillary refill, fundal height and tone, and characteristics of lochia every 4 hours or per shift. The rationales explained how each intervention would help monitor for signs of abnormal bleeding. After evaluating the patient, the nurse found that all outcome criteria were met and the plan was ongoing.

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    Nursing Care Plan

    Uploaded by

    api-315741653
    238 views3 pages
    The nurse created a plan to address the patient's risk for bleeding related to childbirth with 5 interventions and outcomes. The interventions included assessing vital signs, level of consciousness, capillary refill, fundal height and tone, and characteristics of lochia every 4 hours or per shift. The rationales explained how each intervention would help monitor for signs of abnormal bleeding. After evaluating the patient, the nurse found that all outcome criteria were met and the plan was ongoing.

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    The nurse created a plan to address the patient's risk for bleeding related to childbirth with 5 interventions and outcomes. The interventions included assessing vital signs, level of consciousness, capillary refill, fundal height and tone, and characteristics of lochia every 4 hours or per shift. The rationales explained how each intervention would help monitor for signs of abnormal bleeding. After evaluating the patient, the nurse found that all outcome criteria were met and the plan was ongoing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    238 views3 pages

    Nursing Care Plan

    Uploaded by

    api-315741653
    The nurse created a plan to address the patient's risk for bleeding related to childbirth with 5 interventions and outcomes. The interventions included assessing vital signs, level of consciousness, capillary refill, fundal height and tone, and characteristics of lochia every 4 hours or per shift. The rationales explained how each intervention would help monitor for signs of abnormal bleeding. After evaluating the patient, the nurse found that all outcome criteria were met and the plan was ongoing.

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    © All Rights Reserved
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    of 3

    Amy McDonald

    Planning/Implementation/Evaluation
    Nursing Diagnosis: Risk for Bleeding related to the effects of childbirth
    Long-Term Goal: The patient will not experience abnormal postpartum bleeding
    Outcome
    Criteria
    One outcome criteria
    for each intervention.
    Number each one.

    Interventions
    Label each as
    assess/monitor/independent/
    dependent/teaching/collaboration

    1. The patients
    HR will be 60100bpm, BP
    110/70-125/85,
    Respirations 1220 with regular
    depth/normal
    rhythm within 8H
    of initial VS
    assessment

    1. Assess HR, BP, and


    Respirations Q4H

    2. The patient
    will be alert and
    orientedx3 Q2H

    2. Assess level of
    consciousness Q2H

    Rationale

    Evaluation

    Answers why, how, what your interventions will help solve, prevent,
    Or lesson the stated problem specific to each patient.

    Evaluate the patient outcome,


    NOT the intervention

    1. Assessing the patient's vital signs will provide the


    caregiver with information regarding fluid and blood
    volumes. Tachycardia and a decrease in blood pressure
    are late sighs of blood loss. The pulse will be elevated
    because the heart will be contracting more to help to try
    to pump more blood to the rest of the body for
    oxygenation. The patients respirations will be elevated
    to try to bring in more oxygen into the lungs for
    oxygenation of the body. A low blood pressure indicates
    excessive blood loss or hypovolemia. Upon my
    assessment, the patients vital signs were within normal
    parameters. It is important to assess vital signs
    frequently to ensure they do not reach abnormal levels.
    2. A change in the patients level of consciousness can be
    a result of hypoxia, a reduction in cerebral perfusion, and
    blood loss. If this occurs the patient may display signs of
    irritability, restlessness, and difficulty in concentration.
    Assessing the patients level of consciousness can give
    insight into whether or not adequate amounts of
    oxygenated blood are reaching the brain. It is important
    to obtain a baseline status and monitor the patient
    frequently to detect any changes. During my care for the
    patient she was alert and oriented to person, place and
    time.

    1. Outcome Criteria Met.


    Plan is Ongoing

    2. Outcome Criteria Met.


    Plan is Ongoing

    3. The patients
    capillary refill will
    be less than 3
    seconds Q4H

    3. Assess capillary refill


    Q4H

    4. The patients
    fundus will be
    firm, midline, and
    descend 1 F/day.

    4. Assess fundal height and


    tone Q4H

    5. Pt. will have


    scant to
    moderate
    amounts of
    lochia rubia with
    no blood clots Q
    shift

    5. Assess characteristics of
    lochia Q shift

    3. Assessing the patient's capillary refill in their nail beds


    is a means of assessing circulatory function within the
    patient's body. A slow capillary refill is a late sign of blood
    loss. When blood volume decreases peripheral
    vasoconstriction occurs and will shunt blood away from
    the peripheral tissue and to the vital organs. Upon my
    assessment the patient had a capillary refill of less than
    three seconds and appeared to have adequate perfusion.
    4. It is important to assess fundal height and tone to
    determine the correct location and characteristics. The
    fundus should be firm. When the myometrium contracts
    it compresses blood vessels at the placental site, which
    keeps them from bleeding and allows clotting to begin.
    The fundus should remain firm and should start to
    diminish approximately one fingerbreadth in size daily. If
    the fundus is higher than normal, this could indicate
    bladder distention, that a clot is present in the uterus, or
    uterine atony, which would increase her risk for bleeding.
    This patients fundus was firm and midline with the
    umbilicus, which indicates there was not an issue at the
    present time.
    5. Assessing the patient's lochia will give insight into the
    characteristics of fluids and substances being discharged
    from the uterus. There should be a moderate amount of
    lochia rubia the first 2-3 days postpartum and may range
    from scant to moderate amounts. If the patient is
    consistently having heavy amounts of lochia with blood
    clots, this may indicate excessive bleeding and possible
    hemorrhage. Actions need to be taken to stop the
    hemorrhage and help replace fluid and blood loss. It is
    also important to assess the patients peri pads to assess
    blood loss. It is never normal for the patient to saturate
    the pad, therefore frequent inspection is important to
    detect any abnormalities. Assessing lochia every shift will
    help to determine the amount and characteristics. Upon
    assessment, my patient stated that she had a moderate
    amount of lochia, which diminished in amount from the
    previous day.

    3. Outcome Criteria Met.


    Plan is Ongoing

    4. Outcome Criteria Met.


    Plan is Ongoing

    5. Outcome Criteria Met.


    Plan is Ongoing

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