ASSESSMENT
Subjective: “Halos ilang linggo na ako nakapanganak pero malakas pa rin ang pagdurugo ko ” (I’m still bleeding
heavily after weeks of giving birth) as
DIAGNOSIS
Risk for ineffective tissue perfusion related to hemorrhage.
INFERENCE
Postpartum hemorrhage is defined as a loss of blood in the postpartum period of more than 500 mL. The average, spontaneous vaginal birth will typically have a 500 mL blood loss. In cesarean births the average blood loss rises to 800-1000 mL. There is a greater risk of hemorrhage in the first 24 hours after the birth, called primary postpartum hemorrhage. A secondary hemorrhage occurs after the first 24 hours of birth. In the majority of cases the cause of hemorrhage is uterine atony, meaning that the uterus is not contracting enough to control the bleeding at the •
PLANNING
After 8 hours of nursing interventions , the patient will demonstrate adequate perfusion and stable vital signs.
INTERVENTION
Independent: • Monitor amount of bleeding by weighing all pads. • Frequently monitor vital signs. •
RATIONALE
To measure the amount of blood loss. Early recognition of possible adverse effects allows for prompt intervention. •
EVALUATION
After 8 hours of nursing interventions, the patient was able to demonstrate adequate perfusion and stable vital signs.
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verbalized by patient. Objective: • • • • Restlessness Confusion. Irritability. V/S taken as follows: T: 36.8 P: 105 R: 24 Bp: 100/70
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Massage the uterus.
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To help expel clots of blood and it is also used to check the tone of the uterus and ensure that it is clamping down to prevent excessive bleeding.
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Place the mother • in Trendelenberg position.
Encourages venous return to facilitate circulation, and prevent further bleeding.
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Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises.
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Promotes relaxation and may enhance patient’s coping abilities by refocusing attention.
placental site. Other reasons for a hemorrhage would include retained placental fragments (possibly including a placenta accreta), trauma of some form, like a cervical laceration, uterine inversion or even uterine rupture, and clotting disorders
Provide diversional activities. Collaborative: • Administer oxygen as indicated. •
To supply adequate oxygen to the fetus and mother and prevents further complication.
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Administer medication as indicated (e.g Pitocin, Methergin)
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To promote contraction and prevents further bleeding.