Question

The patient is a 22-year-old G1P1 who delivered vaginally a healthy 7 lb 8 oz boy approximately 3 hours ago with a midline episiotomy. The fundus is above the umbilicus, lochia is moderate. She has an intravenous infusion with Pitocin 20 units in her right arm. The patient is complaining of an excruciating headache, blurred vision, and epigastric pain that radiates to the upper right quadrant of her abdomen. The patient is also complaining of perineal pain. Her deep tendon reflexes are brisk, and vital signs are: T. 38.2, HR 98, RR. 18, BP 169/102, SpO² = 92% Physical examination of the patient’s abdomen reveals a boggy uterus, massage done with the expulsion of medium to large clots and small gushes of blood from the vagina. Her right labia is swollen and firm to touch. A retaining urinary catheter was placed with a urinary output measured in the last hour is 25 mL. Stat laboratory blood was drawn and sent including complete blood count (CBC), liver function test (LFTs), and comprehensive metabolic panel (CMP). The lab results are 1. CBC: White cell count = 9,000 x 10³; Hemoglobin = 9.2mg/dL; Hematocrit =27.6%; platelets = 8,000 x 10³ 2. LFTs: Alanine Aminotransferase (ALT) = 379 IU/L; Aspartate Aminotransferase (AST) = 425 IU/L; Alkaline Phosphatase (ALP) = 380 3. Comprehensive Metabolic Panel: Na = 138 mEq/L; K = 4.9 mEq/L; Calcium = 8.5 mg/dL, carbon dioxide (CO2) = 21 mmol/L; chloride (Cl) = 103 mmol/L; albumin = 4.3 g/dL, total protein = 6.0 g/dL, bilirubin = 0.1m, BUN = 25 mg/dL, Creatinine = 0.6 mg/dL

Questions:

What are the nurse’s priorities for this patient?

What symptoms and signs should alert the nurse to potential problems that might need an immediate intervention?

What would be the best way for the nurse to respond to the patient’s condition?

What might be the significance of the patient’s perineal pain? Explain the significance of the patient’s laboratory CBC, and LFT results.

How would you measure the patient's blood loss?

Answer 1

1.Nursing priorities in the postpartum period focus on

• preventing excessive bleeding
• bladder distention
• infection
• providing nonpharmacologic and pharmacologic relief of discomfort associated with the episiotomy, lacerations,
• breastfeeding and instituting measures to promote lactation.

2.Symptoms and signs should alert the nurse to potential problems that might need an immediate intervention

• The patient is complaining of an excruciating headache, blurred vision, and epigastric pain that radiates to the upper right quadrant of her abdomen. The patient is also complaining of perineal pain.
• Hemoglobin = 9.2mg/dL; Hematocrit =27.6%
• BP 169/102, SpO² = 92%

3. The best way for the nurse to respond to the patient’s condition

• The nurse should provide adequate patient education regarding the patient condition to her and family
• continuing monitoring of the patient is required
• Adequate fluid management,intravenous fluids should be planned to improve haemoglobin level of the mother.
• Continuous monitoring of blood pressure should be monitored.
• Episiotomy wound care and perineal care to be provided to avoid post partum hemorrhage and infection.

Measuring the patient's blood loss

1. 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).

2. pulse rate and blood pressure measurement.

3. A fall of hematocrit more than 10 points or by a fall of haemoglobin by more than 3g/dL, measured 3 days postpartum as a reference standard