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Gloria Hernandez Weekly Nursing Care Plan

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Course
NURS 2021H

Institution
Trent University (TrentU )

Weekly Nursing Care Plan Data/Information Analysis/Rationale (where applicable) BACKGROUND Use report sheet to gather information from report Pt Demographics Reason for admission Chief Complaint Relevant patient history ( current and past) Social History Gloria Hernandez is a 28-year-...

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Uploaded on August 2, 2022
Number of pages 25
Written in 2022/2023
Type Other
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post partum hemorrhage
hernandez’s uterus firmed and contracted

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Weekly Nursing Care Plan

Data/Information Analysis/Rationale
(where applicable)
BACKGROUND Gloria Hernandez is a 28-year-old postpartum patient of
Use report sheet to gather Pt Demographics
information from report Spanish- American background. Ms. Hernandez gave birth to her
Reason for admission
Chief Complaint daughter Beatriz at 0900 hours. At 1000 hours, Ms. Hernandez
Relevant patient history ( current
and past) had a postpartum hemorrhage, which was resolved through
Social History
fundal

massage, oxytocin increase, and oxygen administration.
Ms. Hernandez was admitted to our labor and delivery unit at

0600 hours, in labor with her second child. She was given an

epidural and started on 30 units of oxytocin in 500 mL 0.9%

normal saline at the rate of 90 mL/hr. At 0900 hours, Ms.

Hernandez gave birth to a healthy baby girl, via uncomplicated

vaginal delivery. At 1000 hours, Ms. Hernandez reported feeling

tired and that she could not remember feeling her uterus contract

after the birth. She had also not been breastfeeding, as she was

having difficulty getting her child to latch. Inspection of the

lochia revealed pad saturation and clotting, and fundal palpation

revealed a boggy uterus. I performed a fundal massage until Ms.

, Hernandez’s uterus firmed and contracted. I also gave Ms.

Hernandez oxygen and increased the rate of her oxytocin to 30

units in 500 mL 0.9% normal saline at the rate of 125 mL/hr.

Ms. Hernandez reports taking a daily prenatal vitamin at home,

and calcium carbonate as needed for acid reflux. She reports

having no allergies. She has a partner who accompanied her to

the hospital.

PATHOPHYSIOLOGY Provide a summary of the primary Early post-partum hemorrhage is excessive bleeding from
& ETIOLOGY disease or condition the patient is
admitted with including anywhere between the uterus and perineum; classified as 500mL
defining characteristics
or more for a vaginal birth and 1000mL for a cesarean birth. This

occurs within 24 hrs after birth for a few reasons (Nettina, 2018);

1. Atony of the uterus is when it fails to contract and this can

occur due to overdistension of uterus after multiple pregnancies,

macrosomia (a larger than average baby), polyhydramnios (too

much amniotic fluid), high parity (more than six pregnancies),

and prolonged labour. The administration of oxytocin,

magnesium sulfate, tocolytics, and anesthetics during labour are

also through to increase risk of urine atony and hemorrhage.

, Fibroids can create a pressure on the uterine lining which

can cause more bleeding than normal (Nettina 2018).

2. Uterine inversion is when the placenta does not detach from

the uterine wall and therefore brings the uterus out as it

leaves, creating a source of excessive bleeding (Nettina 2018).

3. Disseminated intravascular coagulation (DIC) is an

abnormal clotting in the bodies blood vessels in which it

becomes overactive. With increased clotting, the platelets and

clotting factors become depleted and bleeding cannot be

controlled (Nettina 2018).

4. If the patient experiences trauma, lacerations, or a hematoma

in either the vagina, cervix or perineum due to a forceps

delivery large infant or multiple gestation, a postpartum

hemorrhage may occur (Nettina 2018).

5. There is also the possibility of having difficulties in the third

stage of labour in which the fundus in aggressively

manipulated or there is aggressive cord traction (Nettina 2018).

6. If the uterus ruptures it is likely the patient will experience a

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