Problem: Risk for bleeding r/t postpartum complications.
Patient Centered Goal: Patient will not experience any abnormal/excessive bleeding by the end of clinical shift.
Expected Outcomes: 1. Patient will experience lochia reducing in amount and lightening in color by the end of clinical shift.
2. Patient will observe fundus that is firm, midline, and decreasing in height by the end of clinical shift.
3. Patient will verbalize understanding of signs and symptoms of hemorrhage by the end of clinical shift.
Nursing Interventions | Patient Responses | (Number, written rationale w/ footnote, minimum of 6) | (Number to match each intervention, include factual data) | 1. Monitor bleeding/lochia …show more content…
| 4. Monitor vital signs for ↑ pulse, ↓ B/P, and ↑ respirations along with assessment of skin temperature/color. * Blood pressure monitoring along with assessment of respirations, pulse, skin color, and urinary output along with frequent physical assessments performed in the fourth stage of labor provide prompt identification of excessive bleeding. * (3: 541-542; 4: 671; 9: 613) | * Patient maintained vital signs within normal limits along with maintaining normal skin color and temperature. | 5. Educate the patient on the process of involution (the return of the uterus to a nonpregnant state) and teach her how to assess/massage the fundus and to report persistent bogginess to her HCP. * By educating the patient it allows her to become involved with her care and increases a sense of self-control which may also help to decrease anxiety related to deficient knowledge. (3: 542) | * Patient verbalized understanding of importance of monitoring the involution process to prevent related complications – since this is the patient’s second child she verbalized understanding of process from previous pregnancy, however, it is still the responsibility of the nurse to educate as if this was