Gloria Hernandez Weekly Nursing Care Plan 25pages

BACKGROUND Use report sheet to gather information from report Pt Demographics Reason for admission Chief Complaint Relevant patient history ( current and past) Social History Gloria Hernandez is a 28-year-old postpartum patient of SpanishAmerican background. Ms. Hernandez gave birth to her daughter Beatriz at 0900 hours. At 1000 hours, Ms. Hernandez had a postpartum hemorrhage, which was resolved through 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.