How to Make a Nursing Care Plan for a Postpartum Hemorrhage
Familiarize yourself with the sections of a Nursing Care Plan., Collect the necessary information., Form a Nursing diagnosis., Plan accordingly for your short and long term goals., Determine the short-term goal first., Determine the long-term goal...
Step-by-Step Guide
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Step 1: Familiarize yourself with the sections of a Nursing Care Plan.
A Nursing Care Plan arranges a nurse's approach to patients in order to deliver their specific needs.
It is composed of Assessment, Diagnosis, Planning, Intervention, Rationale and Evaluation.Each Assessment can aid in creating the Nursing Diagnosis and Planning which corresponds to a sequence of Interventions that are done according to priority.
Each intervention has its specific Rationale which explains why it is done.
The process of Evaluation gives the nurse insight into whether the Interventions made have been effective or not. -
Step 2: Collect the necessary information.
This step is referred to as Assessment.
You can directly ask the patient about what she feels.
Examples are the amount of blood that results from vaginal bleeding, the type of pain, fever, weakness and other symptoms that the patient has experienced.
The data you will get that is verbalized by the patient is called subjective data, while the data that the healthcare provider gets upon assessing the patient is called objective data.
Aside from the patient, you can read the patient’s chart and browse the recent laboratory or diagnostic results.
In this way, you will know what significant values affect the condition of the patient. , This diagnosis must be approved by the North American Nursing Diagnosis Association (NANDA) based on the patient’s signs and symptoms.
In order to form the Nursing diagnosis, you must prioritize based on the ABC's of life (Airway, Breathing and Circulation).
In postpartum hemorrhage, if the patient does not experience breathing problems, then the priority is the loss of blood because of vaginal bleeding.
A suitable NANDA diagnosis is Fluid Volume Deficit that is related to specific problems that cause bleeding. , In planning, have a short-term goal and a long-term goal.
Usually, you will state your plan in a future tense form.
You will state what you will expect from the patient after undergoing all of the interventions. , In postpartum hemorrhage, the short-term goal will be “Client will maintain a functional level of fluid volume as evidenced by normal blood tests after one week”.
Keep in mind that in postpartum hemorrhage, the priority is to restore blood loss due to vaginal bleeding.This can be done through blood transfusion per the doctor’s order.
The short-term goal will focus on the number one priority: blood loss. , The long-term goal is “Client will be able to regain her normal activities of daily living before discharge”.
This describes a much longer time frame and it is of least priority.
This can be achieved when the person no longer has vaginal bleeding and has already fully recovered.
As you can see, there is always a time frame in the nursing plan.
Always make sure that your plan is specific, measurable, attainable, realistic and time-bounded. , The nursing interventions can be dependent or independent.
Dependent nursing actions are those that need collaboration with the doctor.
Examples are prescription of medicines, ordering laboratory and diagnostic tests and doing medical procedures.
Independent nursing interventions are those that do not require collaboration with the doctor and are part of the scope of the practice of a nurse. , In the case of a postpartum hemorrhage, nursing interventions will be based on the nursing diagnosis, which, as previous discussed, is Fluid Volume Deficit.
The primary nursing intervention here is to replace the lost fluids and blood products through blood transfusion, which requires proper collaboration with the physician.
After each nursing intervention, mention in the Rationale section why each nursing intervention is done.
So in the replacement of fluids and blood products, the Rationale is to replace the lost blood in the body that has been lost because of the hemorrhage.
The other nursing interventions can be found in the patient’s chart, specifically the section that deals with the doctor’s orders. , Write down your patient’s observations after the time frame you specify in the Planning section.
For example, your short-term goal is “Client will maintain a functional level of fluid volume as evidenced by normal blood tests after one week”.
So after the time frame of one week, you can check the patient’s blood tests result, specifically the haemoglobin level (protein in red blood cells that supplies oxygen) to make sure that it is within the normal range.
Although the normal range greatly varies in different laboratories, the general rules are:
For female:
12.1 to
15.1 grams per decilitre., After checking if your short-term goal is achieved, check if the long-term goal (which is “Client will be able to regain his normal activities of daily living before discharge”) is also achieved.
You can ask the patient if she is able to do normal activities of daily living or you can simply observe them do the activities. -
Step 3: Form a Nursing diagnosis.
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Step 4: Plan accordingly for your short and long term goals.
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Step 5: Determine the short-term goal first.
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Step 6: Determine the long-term goal.
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Step 7: Familiarize yourself with different nursing interventions.
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Step 8: Plan to replace lost fluids and make Rationale notes accordingly.
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Step 9: Evaluate the nursing interventions.
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Step 10: Mark down the achievement of short and long term goals.
Detailed Guide
A Nursing Care Plan arranges a nurse's approach to patients in order to deliver their specific needs.
It is composed of Assessment, Diagnosis, Planning, Intervention, Rationale and Evaluation.Each Assessment can aid in creating the Nursing Diagnosis and Planning which corresponds to a sequence of Interventions that are done according to priority.
Each intervention has its specific Rationale which explains why it is done.
The process of Evaluation gives the nurse insight into whether the Interventions made have been effective or not.
This step is referred to as Assessment.
You can directly ask the patient about what she feels.
Examples are the amount of blood that results from vaginal bleeding, the type of pain, fever, weakness and other symptoms that the patient has experienced.
The data you will get that is verbalized by the patient is called subjective data, while the data that the healthcare provider gets upon assessing the patient is called objective data.
Aside from the patient, you can read the patient’s chart and browse the recent laboratory or diagnostic results.
In this way, you will know what significant values affect the condition of the patient. , This diagnosis must be approved by the North American Nursing Diagnosis Association (NANDA) based on the patient’s signs and symptoms.
In order to form the Nursing diagnosis, you must prioritize based on the ABC's of life (Airway, Breathing and Circulation).
In postpartum hemorrhage, if the patient does not experience breathing problems, then the priority is the loss of blood because of vaginal bleeding.
A suitable NANDA diagnosis is Fluid Volume Deficit that is related to specific problems that cause bleeding. , In planning, have a short-term goal and a long-term goal.
Usually, you will state your plan in a future tense form.
You will state what you will expect from the patient after undergoing all of the interventions. , In postpartum hemorrhage, the short-term goal will be “Client will maintain a functional level of fluid volume as evidenced by normal blood tests after one week”.
Keep in mind that in postpartum hemorrhage, the priority is to restore blood loss due to vaginal bleeding.This can be done through blood transfusion per the doctor’s order.
The short-term goal will focus on the number one priority: blood loss. , The long-term goal is “Client will be able to regain her normal activities of daily living before discharge”.
This describes a much longer time frame and it is of least priority.
This can be achieved when the person no longer has vaginal bleeding and has already fully recovered.
As you can see, there is always a time frame in the nursing plan.
Always make sure that your plan is specific, measurable, attainable, realistic and time-bounded. , The nursing interventions can be dependent or independent.
Dependent nursing actions are those that need collaboration with the doctor.
Examples are prescription of medicines, ordering laboratory and diagnostic tests and doing medical procedures.
Independent nursing interventions are those that do not require collaboration with the doctor and are part of the scope of the practice of a nurse. , In the case of a postpartum hemorrhage, nursing interventions will be based on the nursing diagnosis, which, as previous discussed, is Fluid Volume Deficit.
The primary nursing intervention here is to replace the lost fluids and blood products through blood transfusion, which requires proper collaboration with the physician.
After each nursing intervention, mention in the Rationale section why each nursing intervention is done.
So in the replacement of fluids and blood products, the Rationale is to replace the lost blood in the body that has been lost because of the hemorrhage.
The other nursing interventions can be found in the patient’s chart, specifically the section that deals with the doctor’s orders. , Write down your patient’s observations after the time frame you specify in the Planning section.
For example, your short-term goal is “Client will maintain a functional level of fluid volume as evidenced by normal blood tests after one week”.
So after the time frame of one week, you can check the patient’s blood tests result, specifically the haemoglobin level (protein in red blood cells that supplies oxygen) to make sure that it is within the normal range.
Although the normal range greatly varies in different laboratories, the general rules are:
For female:
12.1 to
15.1 grams per decilitre., After checking if your short-term goal is achieved, check if the long-term goal (which is “Client will be able to regain his normal activities of daily living before discharge”) is also achieved.
You can ask the patient if she is able to do normal activities of daily living or you can simply observe them do the activities.
About the Author
Rebecca Rodriguez
Writer and educator with a focus on practical practical skills knowledge.
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