Chapter 21
Unfolding Case Study
e, g, h
Rationale: The patient’s lochia is heavier than normal due to displacement of the uterus by the bladder, as indicated by the position of the uterus. Massaging the uterus will expel anymore lochia and cause it to become firm. Emptying the bladder will change the lochia and consistency of the uterus to normal expectations. Determining the cumulative QBL will show if the amount of bleeding indicates a postpartum hemorrhage. Administration of pain medication and education are not the priority nursing actions at this time; the priority is adequate perfusion. Insertion of a Foley catheter is an invasive procedure and should not be performed unless the patient is unable to void spontaneously.
| Patient Data | Data Obtained prior to Nursing Actions | New Patient Data after Nursing Actions | Effective, Ineffective, or Unchanged |
| Pain/location | 5/uterine cramping | 2/uterine cramping | a. effective |
| Location of fundus | Deviated to right/2 finger breaths above umbilicus | Midline/at the umbilicus | a. effective |
| Consistency of fundus | Boggy | Firm | a. effective |
| Color of lochia | Rubra | Rubra | c. unchanged |
| Amount of lochia | Saturated peripad and passed two walnut-sized clots | Saturated ¼ of the peripad | a. effective |
| Laceration | Intact | Intact | c. unchanged |
| Perineum | Soft, no bruising | Soft, no bruising | c. unchanged |
Rationale: Massaging the uterus and assisting the patient to void are effective, as evidenced by the location and consistency of the uterus, amount of lochia, and decrease in the pain level. The data for the color of the lochia and assessment of the laceration and perineum are the same, therefore, unchanged.