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