Problem: Risk for Hemorrhage related to perineal laceration and delivery
Subjective and Objective:
Subjective: Janie expresses anxiety and discomfort with regular contractions
and reports mild discomfort.
Objective:
Vital signs
o Second-degree perineal laceration post-delivery.
o Heart rate at admission: 110 bpm
o Blood pressure: 90/60 mmHg
o FHT between 133 and 155 bpm.
o Post-delivery Apgar scores: 8 and 9.
Scientific Basis (With Reference):
The risk of postpartum hemorrhage (PPH) increases with perineal trauma,
particularly second-degree and more extensive lacerations, due to vascular
compromise and bleeding from injured tissues. Managing the risk of hemorrhage
involves monitoring vital signs and blood loss, providing uterine massage as
needed, and ensuring adequate hydration and pain control
Goals/Objectives Criteria:
Short-term goal: Janie will maintain stable vital signs within two hours post-
delivery, with blood pressure above 90/60 mmHg and heart rate below 100
bpm.
Long-term goal: Janie will exhibit no signs of hemorrhage (e.g., excessive
bleeding, tachycardia, hypotension) within 24 hours of delivery.
Nursing Interventions:
1. Monitor vital signs every 15 minutes in the immediate post-delivery period,
then every hour as stable.
2. Assess the perineal area for signs of excessive bleeding, including
checking for blood clots and monitoring for saturation of perineal pads.
3. Perform fundal massage as needed to ensure the uterus remains firm and
contracted, minimizing blood loss.
4. Encourage oral fluids to maintain hydration and prevent hypotension.
5. Educate Janie on the signs of hemorrhage, such as excessive bleeding,
dizziness, and rapid pulse, and instruct her to report any unusual symptoms.
Rationale:
1. Monitoring vital signs helps to detect early signs of hemorrhage, such as
tachycardia and hypotension.
2. Assessing the perineum and monitoring blood loss ensure prompt
identification of excessive bleeding and enable timely intervention.
3. Fundal massage promotes uterine contraction, decreasing the risk of uterine
atony and hemorrhage.
4. Maintaining hydration supports blood pressure stability and aids in the
prevention of hypovolemic shock.
5. Patient education empowers Janie to recognize and report symptoms of
hemorrhage, allowing for immediate action if needed.
Evaluation:
Short-term: Within two hours, Janie’s vital signs remain stable, with blood
pressure above 90/60 mmHg and heart rate below 100 bpm.
Long-term: Janie shows no signs of hemorrhage within 24 hours post-
delivery, with no abnormal bleeding or symptoms such as dizziness or
palpitations.