nursing care plan on hemorrhage example

Care Plan on Hemorrhage

 

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COURSE CODE: Course Title

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Care Plan on Hemorrhage

Case Scenario

30-year-old G1 P1, Caucasian female, came to the facility at 0800hrs today, 40-week gestation female  baby weighing 10lbs 3oz, prolonged labor under  vacuum-assisted delivery and a midline episiotomy, EBL of 250ml during delivery, 600ml Oxytocin IV in 1000ml of LR given after delivery, labor complicated with chorioamnionitis, IV antibiotics given immediately after delivery, history of Asthma with inhaler use, and fundus is boggy at midline umbilicus that firms with massage, moderate bleeding and passing of clots with massage, lochia soaked 3 perineal pads within the last hour.

Pathophysiology of the disease

Hemorrhage entails blood leaking from the blood vessels to the surrounding tissue. When a vessel is damaged, the hemorrhage occurs as long as the vessel stays open and the pressure inside the vessel dominates the pressure outside of the vessel. Coagulation usually seals the vessel and prevents bleeding (Macdonald & Schweizer, 2017). Uncontained hemorrhage can lead to anticoagulant medication, hemophilia, or substantial injury to the blood vessel, resulting in extensive loss of blood and shock. The signs and symptoms include breathlessness, unconsciousness, vomiting, nausea, and swollen abdomen.

Steps of the disease

The steps of hemorrhage disorder which involve four classes. The first class involves loss of around 15% of the amount of blood. There is generally no improvement in common signs, and there is typically no need for fluid resuscitation (Gayet-Ageron et al., 2018). The second class involves 20 percent of the overall blood flow. The patient is frequently tachycardic (increased heartbeat) with a drop in the disparity among diastolic and systolic blood pressures. The body is attempting to recompense for peripheral vasoconstriction. Skin may start to appear thin and be soft when touched. The patient can undergo minor behavioral changes. Volume recovery with colloids is all that is usually needed. Transfusion of blood is not typically needed.

The third class entails a reduction of 30 to 40 per cent of flowing blood volume. The client’s blood pressure reduces, the pulse rate elevates, peripheral hypo perfusion and reduced capillary fill-up develops, and the emotional state worsens (Gayet-Ageron et al., 2018). Fluid rebirth with crystalloid and transfusion of blood is typically expected.  Class IV Hemorrhage entails a depletion of less than40 per cent of circulating blood flow. The body’s remuneration cap is exhausted and rapid resuscitation is needed to avoid death.

Nursing Diagnosis: Measurable Goal: Nursing Interventions: Outcome:
Interrupted

Breastfeeding R/T

separation of

infant for medical

treatment AEB

emotional distress

second to balloon

tamponade and

uterine curettage

Patient will achieve

satisfaction with

effective breastfeeding

before discharge home

from hospital

1. Assess patients’

level of distress

and support her by

teaching that

breastfeeding can

continue when the

procedures are

complete and PPH

is under control

2. Teach patient the

importance of the

medical treatments

to manage

postpartum

hemorrhage and

complications

3. Notify Lactation

Consultant/Specialist

st to schedule time

when mother can

breastfeed after

procedure

4. Assist with

emotional distress

by providing skin to

skin, comfort,

holding techniques,

support with

latching to breast,

identifying infant

cues, and providing

resources for

breastfeeding once

bleeding is under

control

The goal was partially

met. The mother was

able to effectively

breastfeed her infant

once the postpartum

hemorrhage was under

control, but she is not

completely satisfied

with breastfeeding. She

expressed that she

would continue to

work on breastfeeding,

and she will use the

resources she was

given to get more

lactation help with a

Specialist.

Scarce Fluid

Volume R/T

extreme blood

loss after giving birth AEB

3 soaked perineal

pads within 1 hr second

to postpartum

hemorrhage

Client will have a

lochia drift of less than

1 saturated perineal

pad/hr by discharge

from hospital

1. Evaluate and record

type, quantity, and

bleeding site

2. Weigh and count

perineal pads to

assess accurate

amount of bleeding

3. Consider the location

and level  of

contractility of the

uterus/fundus with

massage

4. Monitor VS- BP and

HR to assess for s/s

of hypovolemia or

shock

The goal was met. With

the interventions in

place, the postpartum

hemorrhage was

managed and the

patient now has a

lochia flow of less than

1 saturated perineal

pad/hr before

discharge home

Severe Pain R/T

nursing and

therapeutic

interventions to

manage bleeding

AEB pain of 7 on 0-

10 pain assessment

scale second to

postpartum haemorrhage

Patient will report

below 3 on the pain

assessment scale

within 2 hours after

interventions are

performed

Clean and position

patient to promote

comfort and

decrease bleeding

2. Provide icepacks

and proper

padding to help

with pain and

swelling

3. Provide pain

medication

ordered for

interventions as

needed per patient

Provide adequate teaching for interventions such as fundal massage to manage bleeding so the patient knows what to expect

The goal was met. The

pain management and

comfort techniques in

place allowed the

patient to report a pain

of 2 on the pain

assessment scale 2

hours after

interventions were

performed

 

 

 

References

Gayet-Ageron, A., Prieto-Merino, D., Ker, K., Shakur, H., Ageron, F. X., Roberts, I., … & Gilliam, C. (2018). Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. The Lancet391(10116), 125-132.

-Macdonald, R. L., & Schweizer, T. A. (2017). Spontaneous subarachnoid haemorrhage. The Lancet389(10069), 655-666.

Shakur, H., Roberts, I., Edwards, P., Elbourne, D., Alfirevic, Z., & Ronsmans, C. (2016). The effect of tranexamic acid on the risk of death and hysterectomy in women with post-partum haemorrhage: statistical analysis plan for the WOMAN trial. Trials17(1), 249.