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
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
