Question

This is all information we have for patient #2

Patient # 2 Patient is currently in labor with spontaneous rupture of membranes after a prolonged induction using Misoprostol (Cytotec) and Oxytocin (Pitocin). Patient is nearing the active phase of labor.

Blood Type	B-
Rubella	Immune
Hepatitis B	Negative
HIV	Negative
Serology	NR
Red blood cell count	5.5 m/UL
Hemoglobin	18 G/dL
Hematocrit	35%
White blood cell count	7,000 K/UL
Platelet count	150 K/UL

Patient is at an increased risk for post-partum hemorrhage. Estimated fetal weight is over 4200 grams with an elevated 1 hour GTT of 156, no 3 hour GTT completed. Please complete the concept map for post-partum hemorrhage. Please include in your concept map HOW the two induction agents impact the risk for PPH AND any post-partum medications this patient will need.

• Medical diagnosis/admitting diagnosis. Include common presenting signs and symptoms that a patient having this type of medical condition would present with.
• “How is this medical problem diagnosed?” Diagnostic tests: list all pertinent lab tests, x-rays, and other diagnostic tests used to make this diagnosis
• “What is the treatment for this medical problem?” Treatments: list all pertinent medications (including oxygen) and or procedures/interventions that may be prescribed for your patient
• “What is the nursing focus for this patient?” List at least 5 priorities of care for this patient.
• “What do we teach the patient to help them now and in the future?” List 5 priority teaching topics for this patient
• “Did anything in their history contribute to the development of their admitting diagnosis? If not, what questions would you ask the patient?” Describe the relationship between relevant medical history and admitting diagnosis (if there is any).
• “Possible complications?” List 3 common complications that could occur with this patient and identify what the nurse should assess for to determine if the patient is developing the complication

Answer 1

Concept map for PPH includes the following :-

#. Pathophysiology :-

Tissue (retained placenta)

Uterine atony

Trauma (traumatic delivery, epis)

Uterine rupture, inversion

Thrombin (coag disorders, DIC)

#. Active management:

1. prophylactic oxytocic within 2 minutes of infants birth

2. immediate cutting and clamping the cord

3. delivery of the placenta by controlled cord traction or maternal effort

#. Etiologies of PPH :-

- uterine atonicity

- prolonged or rapid labor

- oxytocin induction

- full bladder

- previous PPH

- preeclampsia

- infection (chorio)

- uterine relaxing agents (terbutaline, MgSO4)

- genital tract trauma (lac, large epis)

- coagulopathy

- uterine inversion

- traumatic delivery

- rupture of previous c-section or hysterotomy scar

#. Management of PPH:

1. early assessment of risk factors

2. fundal massage, bimanual compression

3. IV access, large bore needle

4. admin oxytocin agent

5. inspect cervix/vagina

6. blood type and screen, type and cross if approp

7. empty bladder

8. consult if initial measures do not stop hemorrhage

The first line drug for PPH :-

10-20 U in 1000cc IV fluid, almost immediate effect

no diff clinically IV or IM

do not give as IV bolus

may be given intramyometrically

#. Other medications include :-

Methergine

Hemabate

Misoprostol

#. Medical diagnosis - Postpartum hemorrhage . It is blood loss of > 1000 mL or blood loss It is diagnosed by the sign and symptoms of hypovolemia within 24 hours of birth. Diagnosis is clinical.

Sign and symptoms :-

Boggy uterus

Excessive blood loss

Hypotension

Tachycardia

Altered mental status

Cool ,clammy ,pale skin

Saturation of one or more pads during first hour

Passage of large clots

Decreased urine output

#. Tests used to diagnose postpartum hemorrhage may include: Estimation of blood loss (this may be done by counting the number of saturated pads, or by weighing of packs and sponges used to absorb blood; 1 milliliter of blood weighs approximately one gram) Pulse rate and blood pressure measurement.

#. NURSING INTERVENTIONS FOR POSTPARTUM HEMORRHAGE :-

Check fundus for firmness, bleeding color, & amount

VS

Maintain venous access

Assess bladder distention

Give oxygen

Call primary healthcare provider

Draw labs = PT, pTT, HCT, HGB

#. MEDS FOR TREATMENT OF POSTPARTUM HEMORRHAGE

Pitocin - contraction of uterus, decrease bleeding 10-40 units

Cytotec (water soluble) - prosta glandin E1, rectal or sublingual

Methergine - contraction of uterus smooth muscle, IM up tp 5 doses, contraindicated with hx of cardiovascular disease/hypertension

Hemabate - contraction of uterus, reduce bleeding, up to 8 doses, contraindicated with hx of asthma

Hysterectomy if bleeding cannot be stopped