Gloria Hernandez Weekly Nursing Care Plan

Document Content and Description Below

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 Com... plaint Relevant patient history ( current and past) Social History Gloria Hernandez is a 28-year-old postpartum patient of Spanish- American background. Ms. Hernandez gave birth to her daughter Beatriz at 0900 hours. At 1000 hours, Ms. Hernandez had a postpartum hemorrhage, which was resolved through 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 & ETIOLOGY Provide a summary of the primary disease or condition the patient is admitted with including defining characteristics Early post-partum hemorrhage is excessive bleeding from anywhere between the uterus and perineum; classified as 500mL 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. ...............................................................................CONTINUED......................................................................................... [Show More]

Last updated: 1 year ago

Preview 1 out of 25 pages