La Salle University: School of Nursing and Health SciencesObstetrical Simulation: Unfolding Case Study on Postpartum Hemorrhage

Mary Lou Gies, Ed.D., R.N.

Strategy Overview:

This simulation can take place in a Learning Resource Center or classroom setting at mid-semester or during the final weeks of a Nursing Care of Women and the Childbearing Family course. The goal of the simulation is to teach neophyte students about applying the QSEN KSA competencies to the care of a critically ill postpartum mother, by presenting them with an unexpected clinical situation. The learning objectives, equipment, and case study of a new mother with a postpartum complication are given. Students demonstrate skills on a manikin as the case study progresses. Questions about the situation are posed during the debriefing, to encourage critical thinking and patient-centered care.

Learning Objectives:At the end of this simulation of an unfolding case study, the learner will be able to:

1. Recognize the importance of family-centered and patient-centered care.2. Summarize the knowledge, skills, and attitude necessary for a nurse in a critical

care situation.3. Critique the student’s role during a simulation.4. Demonstrate professional behaviors during the simulation.5. Perform a focused and overall assessment of a postpartum mother.6. Use SBAR (Situation, Background, Assessment, Recommendation) reporting

during patient transfer from a labor and delivery unit to a postpartum unit.7. Implement The Joint Commission safety standards in the care of a postpartum

mother.8. Demonstrate standard infectious disease precautions when performing nursing

care.9. Provide safe nursing care to the newly delivered postpartum mother.10. Analyze a critical care clinical situation and respond appropriately within a safe

learning lab environment.

Learning Sub-objectives:

Core–Competency: Patient Centered CareThis teaching strategy is designed to evaluate the following KSAs:

Knowledge: Incorporates family-centered care for the newly delivered postpartum mother by communicating with the patient and family about the critical situation, including plan of care.

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Skills: Encourage open, effective communication, when possible, between patient, family, and multi-disciplinary team and family.

Attitude: Provide emotional support to patient and family and encourage support for one another.

Core-Competency: SafetyThis teaching strategy is designed to evaluate the following KSAs:

Knowledge: Demonstrates nurse’s role in providing safe and effective patient care according to The Joint Commission standards of nursing care of a critically ill patient.

Skills: Implements safe patient care when identifying patient, administering medication, transferring patient, and intervening with a critically ill patient.

Attitude: Promotes patient care in a safe and effective manner.

Core-Competency: Teamwork and CollaborationThis teaching strategy is designed to evaluate the following KSAs:

Knowledge: Recognizes the importance of effective communication with patient, family, and multi-disciplinary health care team in critical situation.

Skills: Gives report to health care team using SBAR reporting technique upon recognition of patient problem and upon transfer from the labor and delivery unit.

Attitude: Knows the importance of patient and family involvement in continuity of care. Maintains composure when communicating with health care team about patient status.

Equipment needed:

Student nametags with role assignmentsStatic manikin, low or high fidelity simulator; e.g. Vital Anne simulator with postpartum kitStretcher or hospital bedBlanketsPeri-padsUnder padsRed food coloringSphygmomanometer

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StethoscopePulse oximetryVariety of angiocathetersIntravenous fluids: 1000 ml Lactated Ringer’s, 1000 ml 0.9% NaCl, 1000 ml D5W, 1000 ml 0.45% NaClIntravenous tubingIntravenous pump and poleSimulated meds: oxytocin (Pitocin), methylergonovine (methergine)

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Faculty Facilitator

Simulators: static manikin, low or high fidelity simulator (with or with out postpartum kit)

Background information:

Tanya Eckland, 36, G5 P4, was in labor for 36 hours when she delivered, vaginally, a 9 lb. 8 oz. male infant at 1935 PM. Tanya’s labor was induced with oxytocin at 38 weeks gestation and continuous epidural was placed in active labor. The epidural was discontinued at 1930. She has iron deficiency anemia but otherwise an unremarkable medical history. She has NKDA. Her obstetrical history includes 1 spontaneous abortion 6 years ago, vaginal delivery of twins, 4 years ago, one singleton vaginal delivery, 2 years ago, and the vaginal delivery today. Tanya started to breastfeed her son immediately after the delivery. She tells the nurse she is very hungry and tired. Her history did not include any pregnancy or delivery complications and outcomes were positive.

Select 8 students for the role of labor and delivery nurse, postpartum nurse, and assisting RN, another assisting registered nurse, support person, and 3 family members (mother, father and sister of newly delivered patient).

Review the student expectations and patient’s background information with the students and their role in the simulation.

Give participating students role sheets. Give other students handout with background information on the patient.

Student Roles

Primary Labor and Delivery Registered NursePrimary Postpartum Registered NurseAssisting Registered NurseAnother assisting Registered Nurse

FamilySupport person MotherFatherSister

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Labor and Delivery Unit

Faculty Facilitating asks the group: How does a nurse ensure that Ms. Eckland is correctly identified?

Patient ID band placement, prior to and after delivery of the baby:

o 2 Patient Identifierso Patient, infant, and support person may have numbered, matching

bands that are checked every time infant moves from nursery to patient’s room.

National Patient Safety Goal presented by the Joint Commissiono Reliably identify as the person for whom the service or treatment is

intendedo Match the service or treatment to the individualo The patient wristband or chart label must be in the same location:

Name, ID number, telephone number, date of birth, or other specific identifier (Joint Commission, 2008)

Faculty Facilitator reports this assessment:

Vital signs: B/P 120/70, 80, 20, 98.6 Skin color: Pink Location and firmness of uterine fundus: Fundus firm, midline, at umbilicus Amount of lochia: Heavy rubra with nickel-sized clots Perineum: Episiotomy approximated, edema noted Presence and location of pain: uterine cramping, rates pain 4 out of 10 Intravenous infusions: 3000 ml of Lactated Ringers with 20 units of Pitocin in

each bag Urinary output: Has not voided since 4 hours prior to delivery Level of feeling and ability to move post-epidural: numbness of left thigh Patient: “I am really tired. I have been up for two nights”.

Labor and Delivery Nurse: performs the postpartum assessment.

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Faculty Facilitator

Asks Labor and Delivery Nurse : what findings would warrant further assessment and cause for concern by the nurse? What should the nurse do next?

Heavy rubra lochia with nickel-sized clotsHas not voided since 4 hours prior to delivery3000 ml of IV fluid

The nurse’s priority should assess amount of lochia with a pad count in 5 minutes, firmness of uterine fundus, and for bladder distension since distension can impede contraction of the uterus. She instructs the patient about increasing uterine firmness, using manual massage and breastfeeding (K).

The nurse should find out what she would like to eat and provide some quiet time when her condition is stable (S, A).

Faculty Facilitator

Ms. Eckland’s Support Person knows the nurse is concerned. He asks what is going on.

Labor and Delivery Nurse responds.

The labor and delivery nurse should inform the support person about the seriousness of Tanya’s condition and the need to act quickly to resolve the problem. She should involve the support person by having him reinforce the information with his partner (A, S).

Labor and Delivery Nurse performs postpartum re-assessment.

Patient assessment should be stable for transfer to postpartum unit.

Faculty Facilitator

Ms. Eckland’s family is in the waiting room to find out the outcome of the delivery including the sex, weight, and length of the baby.

When the Labor and Delivery Nurse walks by the waiting room, they stop her. Tanya and her partner did not want any other family members present for the delivery. The hospital policy allows two support people during the labor/delivery. She has not asked Tanya or her partner about talking to their families.

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*** Mother of newly delivered patient : Did my daughter deliver? Is she OK? I just want to know if she is OK?

*** Father of newly delivered patient : Can you at least tell us what she had? I know you are not supposed to tell us but we have been here all day and night.

*** Sister of newly delivered patient : Where is she, when will she be coming out here?

Labor and Delivery Nurse : what should the labor and delivery nurse tell the family when she passes the waiting room? HIPPA, Confidentiality

The nurse cannot offer any information about the woman’s delivery because of the Health Insurance Portability and Accountability Act privacy rule. She can relay to the patient’s partner that the family is anxiously waiting in the waiting room.

The Health Insurance Portability and Accountability Act privacy rule is part of a U.S. Department and Human Services Office for Civil Rights. The law gives patients the rights to their health information, sets rules and limits on who can look at and receive information, and protects the privacy of your health information.

All healthcare providers, health insurance companies, Medicare, and Medicaid programs, and any person working in patient care settings must comply with this law.

The law helps to protect healthcare information such as: information from the medical record, conversations carried out between patients and providers, information in healthcare computer systems, patient billing information, most other health information held by those who must follow this law.

Disclosure requires signed authorization Permitted disclosure includes: public health activities for infectious disease or

danger, law enforcement and judicial proceedings, and deceased individuals Incidental disclosure includes: use of sign in sheets, overhead conversation

provided attempt at privacy is made Use of white boards, x-ray light boards seen by passers-by, calling out names in a

waiting room, leaving appointment reminders on voicemail

(U.S. Department of Health and Human Services Office of Civil Right, 2007)

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The Labor and Delivery Nurse responds:

The nurse should speak to Tanya and her partner about sharing the delivery information before she leaves the unit, to avoid HIPPA violations.

The nurse tells the family that Tanya’s partner would come out and share the news with them. After he speaks to the family, the nurse shares all the vital statistics with them and tells them she will be coming out to her room, momentarily. The nurse asks if they will pick up Tanya’s favorite food since she is very hungry after her long labor (S, A).

Faculty Facilitator

Ms. Eckland has been in the labor unit for 1 1/2 hours after the delivery of her son and is stable. She is being transferred to the postpartum unit.

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Postpartum Unit

Labor and Delivery Nurse gives report to Postpartum Nurse using SBAR information below (S):

S (Situation)

Name: Ms. Eckland Room #: 204 Mother/Baby Doctor: Smith

Delivery Time: 1935

Delivery Type: Spontaneous vaginal

Assisted (Instruments): N/A

Infant Sex: Male Gestational Age: 38 APGARS: 8/9

Weight: 9 lbs. 8 oz. Length: 21 in.

Feeding: Breast: fed at 1800

Last ate: Prior to labor 36 hours ago

B (Background)

Risk Factors: 36 hour induced labor, G5 P4 epidural anesthesia, iron deficiency anemia,

large for gestational age infant, has not vided since delivery, 3000 ml of IV fluid

Comments: Patient had an episode of heavy bleeding, resolved with fundal massage.

Substance Use: N/A___________________________________________________________

Alcohol Use: Social, not while pregnant________________________________________

Tobacco Use: N/A Number of Cigarettes/day: N/A # of years smoking____________

No : ROM>18hrs? No: Maternal temp.>101? Highest Temp in Labor: 99.4

Antibiotics started:_N/A__________________ If Antibiotics, why?______________________

GBS Status: Negative Race/Ethnicity: Caucasian

Hep B Status: Immune English Spoken: Yes (If not English) Primary Language: English

Mother’s Blood Type: O+

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Cord blood specimen sent for type & Rh: X Yes ___No

Complications during/after delivery: N/A___________________________________________

Serology/Rubella status: Immune Last pain medication: Epidural stopped at 1930

Allergies: NKA

A (Assessment)

Newborn: Vital signs: 97.8

Abnormal physical assessment findings: N/A

Feeding Initiated? After delivery____________ Type of Feeding: Breast__________

Glucose Screening: Indication: LGA, long labor Time: 1830 Result: 30

Mother: Vital sign: 120/70, 80, 20, 98.6

BUBBLEHEP (Vaginal/ C/S), Overall Assessment: Breasts: soft; Uterus: firm, midline at

umbilicus; Bladder: non-distended; Bowel: Bowel sounds present, passed stool during

delivery; Lochia: moderate rubra; Episiotomy: intact, slight edema; Homan’s sign:

negative; Emotions: elated about having a new son since has three daughters at home;

Pain: 3 out of 10, uterine cramping and episiotomy pain; Diet: has not eaten since labor

started 36 hours ago

_____________________________________________________________________________

R (Recommendation)

Newborn: Eye care done? Yes Vit K given? Yes

ID Bands Checked? Yes

Mother: Special requests: She wants to eat as soon as possible. Her family is going to pick

up food.

Faculty Facilitator reports the patient’s medications:

Prenatal vitaminsFeosol3-1000 ml of Lactated Ringers with 20 units of Pitocin over 4-hour period

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Asks Postpartum Nurse : when completing medication reconciliation for Ms. Eckland on admission to the postpartum unit, what would be cause for concern?

Patient had 3000 ml of IV therapy within the last 4 hours without voiding.

Faculty Facilitator asks the group:

Identify priority-nursing care for Ms. Eckland on admission to the postpartum unit.

Prevent postpartum hemorrhage by:

Recognizing pre-disposing factorsFrequent uterine fundal assessmentFrequent lochia checksAssess for bladder distension

Give patient juice/liquids and a snack until her food arrives (A).

Faculty Facilitator: reports this assessment to the Postpartum nurse and the group:

VS: 110/76, 76, 16, 98.4Fundus deviated to right, firm at umbilicusModerate rubra lochiaReports decreased sensation in left leg, able to bend both legsHas not voided since delivery, states she does not feel like she has to void at this time.

Postpartum Nurse : performs initial assessment and orients patient to the room. She instructs her to call before getting out of bed for the first time. She reinforces the need for fundal massage, to prevent excessive vaginal bleeding (K).

What should the Postpartum nurse do next?

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Faculty Facilitator

Ms. Eckland puts on her call light 15 minutes later and said she just felt a “gush of blood down there”.

Fundus boggy and deviated to the rightExcessive rubra lochia (saturation of a pad every 15 minutes)

Postpartum nurse immediately comes into the room. What should the nurse do next?

The nurse should massage the fundus till firm. If the uterus continues to be boggy, the nurse should put on the emergency call light since she may need further assistance or emergency medication.

Faculty Facilitator reports:

Ms. Eckland uterus becomes firm with massage and notifies the staff that the patient is having complications. The team knows to assist her if she puts on the call light (S). The nurse explains excessive bleeding to the patient and her partner and how to resolve the problem (K). She asks if she has any questions or concerns (S).

Asks the Postpartum Nurse : what else can the nurse do to prevent further bleeding?

The IV with Pitocin rate should be increased, as per standing MD order. Ms. Eckland should be asked to use the bedpan to void since a full bladder can interfere with contraction of the uterus, causing increased bleeding.

Faculty Facilitator reports:

Ms. Eckland is not able to get out of the bed to the bathroom due to the numbness from the epidural anesthesia. The nurse puts her on the bedpan to void.

Asks Postpartum Nurse : what else can the nurse do to assist her with emptying her bladder?

The nurse can run water in the bathroom sink, have the patient spray warm water from the peri-bottle on the perineum, and give her a glass of water to drink. She can ask the patient if she feels the sensation to void and how the nurse can assist her in trying to void (K, S, A). The patient requests privacy while trying to void.

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Faculty Facilitator reports:

When the nurse leaves the room, Ms. Eckland cries out, “I’m really bleeding a lot!”The nurse comes in the room and notes increased vaginal bleeding. The patient is pale, diaphoretic, and the uterine fundus is boggy. The fundus does not firm with massage.

Asks Postpartum Nurse : what actions should the nurse perform at this time?

The nurse should call for assistance. When a team of staff members arrives, she should continue to massage the uterine fundus, increase IV fluid, assess the patient’s vital signs, and pulse oximetry reading. She should ask her team to increase IV Pitocin, bring in catheter kit, and catheterize the patient.

The nurse explains to the patient about her condition and how she can assist in her care (K, S, A).

Team member: Another Assisting Registered nurse : catheterizes patient.

The assisting nurse explains the purpose and details of catheterization procedure while starting to set up a sterile field since the procedure needs to be done stat (K, S, A).

Faculty Facilitator reports this assessment:

VS: 90/50, 120, 20, 98.6, PO2: 97%Fundus boggy, deviated to the right, 4 cm above the umbilicusExcessive rubra lochiaUrine output via catheter: 700 ml, amber colored urine

Postpartum Nurse performs assessment.

Faculty Facilitator reports:

After initiating priority interventions, the patient’s condition stabilizes:

Current assessment: fundus midline, firm at the umbilicus, moderate rubra lochia. Her physician is called about the postpartum hemorrhage and orders

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methylergonovine (methergine) 0.2 mg IM every 2 to 4 hours for five doses. Then, she wants the patient to take 0.2 mg po for 5 days.

Asks the Postpartum Nurse : what nursing implications are indicated before administering this medication? What patient teaching about this medication should be done for this patient?

The patient’s blood pressure needs to be assessed prior to administering this medication since it causes arterial vasoconstriction resulting in severe hypertension.

The patient is informed about of the side effects of the medication and the need to report them including the most common: increased gastrointestinal and uterine cramping (K, S).

The nurse asks the patient if she has any questions or concerns, at this time. She evaluates the patient’s pain level since uterine cramping is common in the multipara patient and this medication (K, S, A).

Assisting registered nurse: takes patient’s blood pressure and administers methergine IM, as ordered, if B/P within normal limits, using 6 rights of medication administration and 2 patient identifiers.

Faculty Facilitator

Ms. Eckland’s family is outside the room when the emergency call light goes on.

*** Support person: why is everybody running in and out of my wife’s room? I just went down to get a cup of coffee.

*** Mother of newly delivered patient : Is everything alright? I see you are running all around. Is my daughter OK?

*** Father of newly delivered patient : What is going on in there?!! I want to go in there and see what is happening. I need to see my daughter!!

*** Sister of newly delivered patient: Why isn’t someone telling us what is going on? Is my sister having a problem??

Postpartum Nurse : How can the nurse support the family during and after postpartum hemorrhage?

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The nurse should explain to the family that the patient is having excessive bleeding but the staff is working to resolve the problem. We will talk to them as soon as we can. They can go into the waiting room until someone can come in to talk to them. After the nurse speaks to the patient and her support person about the postpartum hemorrhage, the family is informed about what happened and why the nurses could not speak to them at the time of the problem. She can discuss with about how they can support the patient while in the hospital and upon discharge (K, S, A).

Faculty Facilitator

Asks Postpartum Nurse : what should be included in post hemorrhage care?

Blood pressure and pulse every 3-5 minutes till stableLocation and consistency of the fundusAmount of lochia: pad count every 5 minutes until stableSkin temperature and colorOxygen saturationInsertion of urinary catheterHourly outputLab studies: hemoglobin/hematocrit, clotting studies, type and cross matchAdminister fluids, medication, blood products as ordered Oxygen by mask as needed

Faculty Facilitator

Asks Postpartum Nurse : what should be included in this patient’s assessment and discharge teaching?

The patient should be assessed for orthostatic hypotension, anemia, and fatigue. Allow for rest periods and the need for assistance when getting out of bed. Patient may be prescribed iron supplements.

Tanya should be educated about the side effects of this therapy: constipation and black stools. Anemia and fatigue may interfere with infant bonding (K). The nurse should ask if she will have help at home upon discharge since she may be more fatigued than after previous deliveries (K, S, A).

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Post Simulation Debriefing

Faculty Facilitator

How do you think the simulation went?

How did you feel?

What else could the nurse do to involve the patient and family in her care?

What do you think the patient was going through in this simulation? her thoughts and feelings before and after the postpartum hemorrhage?

What are the labor and delivery and postpartum registered nurses impressions of the simulation?

What knowledge did you need to care for this patient?

What else could you do to prevent this postpartum complication?

Were you effective in your role?

What would you do different next time?

What skills would the nurse need to effectively care for this patient with postpartum hemorrhage?

How did you perform as a team?

What are the non-participating students observations?

Faculty facilitator gives impression of the simulation: correct and incorrect steps.

Probing and Reflection

How can the nurse provide patient-centered care to this patient?

How did the nurses exhibit professional behavior?

What assessments were done during the simulation? What information did they provide the nurse?

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Was the SBAR format of reporting effective?

How did the nursing staff demonstrate safe nursing care for this patient? What could have been improved?

What infectious disease precautions could have been incorporated into the simulation?

How familiar were you with postpartum hemorrhage nursing care prior to the scenario of this patient?

Were the problems recognized and acted on promptly?

How does the nurse implement HIPPA and Confidentiality laws?

What actions by the primary postpartum nurse and assisting nurses demonstrate teamwork?

In conclusion, the students who participated drew from their classroom and clinical knowledge during the postpartum hemorrhage simulation. They were able to practice their new assessment skills and implement a plan of care in a safe, controlled environment.

Quotes from students:

“This simulation made me so nervous, to think this could happen! Could this actually happen?”“It was really a helpful way to learn what I would need to know!”“I was able to use the stuff we learned in class”“I’m afraid I would not know what to do in an actual emergency”“It was reassuring to have the faculty there to help direct us.”“This lab was a very helpful way to learn what to do, without hurting any patients.”

The following N-CLEX style questions are used as exam questions in the course, to evaluate the effectiveness of the simulation exercise.

NCLEX Questions

A nurse receives a postpartum patient who delivered 5 hours ago. She has not voided since delivery. Her uterus is 3 fingerbreadths above the umbilicus, to the right of midline, and boggy. What is the priority nursing action?

a. Insert a foley catheter.b. Massage the uterus till firm and insert a straight catheter to empty her bladder.

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c. Evaluate bladder distension with a bladder scan.d. Reevaluate fundal height in 15 minutes.

The risk factors for postpartum hemorrhage include which of the following (Select all that apply):

a. primaparab. multiparac. over 24 hours of labord. epidural anesthesiae. pain level of 10f. LGA infantg. triplet pregnancyh. difficult pregnancy

Postpartum assessment immediately after delivery should be completed by the nurse every:

a. 5 minutesb. 10 minutesc. 15 minutesd. 20 minutes

A patient on the postpartum unit starts to have heavy vaginal bleeding. She asks the nurse what is wrong. The nurse’s best response is:

a. “Don't worry. I’ll take care of the problem.”b. “If you go to the bathroom, the bleeding will stop.”c. “It is not unusual to have this amount of bleeding after having a baby.”d. “I’ll show you how to massage the uterus to decrease the bleeding.”

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Student Roles

Participating Students are given a copy of the student roles. The faculty facilitator will have the completed answers and prompts for the simulation.

Simulators: static manikin, low or high fidelity simulator (with or without postpartum kit)

Background information:

Tanya Eckland, 36, G5 P4, was in labor for 36 hours when she delivered, vaginally, a 9 lb. 8 oz. male infant at 1935 PM. Tanya’s labor was induced with oxytocin at 38 weeks gestation and continuous epidural was placed in active labor. The epidural was discontinued at 1930. She has iron deficiency anemia but otherwise an unremarkable medical history. She has NKDA. Her obstetrical history includes 1 spontaneous abortion 6 years ago, vaginal delivery of twins, 4 years ago, one singleton vaginal delivery, 2 years ago, and the vaginal delivery today. Tanya started to breastfeed her son immediately after the delivery. She is very hungry and tired from a long labor. She did not have any complications with her pregnancies or deliveries and outcomes were positive.

Primary Labor and Delivery Registered NursePrimary Postpartum Registered NurseAssisting Registered NurseAnother assisting Registered Nurse

Family MembersSupport PersonMother of newly delivered patientFather of newly delivered patientSister of newly delivered patient

Labor and Delivery Unit

Faculty Facilitator reports:

Vital signs: B/P 120/70, 80, 20, 98.6 Skin color: Pink Location and firmness of uterine fundus: Fundus firm, midline, at umbilicus Amount of lochia: Heavy rubra with nickel-sized clots Perineum: Episiotomy approximated, edema noted Presence and location of pain: uterine cramping, rates pain 4 out of 10

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Intravenous infusions: 3000 ml of Lactated Ringers with 20 units of Pitocin in each bag

Urinary output: Has not voided since 4 hours prior to delivery Level of feeling and ability to move post-epidural: numbness of left thigh

Labor and Delivery Nurse: performs postpartum assessment.

Student reports all findings to group: Patient is some showing some signs of instability, at this time.

Postpartum assessment

Facilitator asks the Labor and Delivery Nurse: what findings would warrant further assessment and cause for concern by the nurse? What should the nurse do next?

Faculty Facilitator

Ms. Eckland’s support person knows the nurse is concerned. He asks what is going on.

Labor and Delivery nurse responds to support person.

Labor and Delivery Nurse

Performs a re-assessment of newly delivered postpartum patient. Report findings to the group. Report assessment that reflects that patient is stable.

Labor and Delivery Nurse: She passes by the waiting room and sees the patient’s family.

***Mother of newly delivered patient: Did my daughter deliver? Is she OK? I just want to know if she is OK?

***Father of newly delivered patient: Can you at least tell us what she had? I know you are not supposed to tell us but we have been here all day and night.

***Sister of newly delivered patient: Where is she, when will she be coming out here?

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Facilitator asks the Labor and Delivery Nurse: what should the labor and delivery nurse tell the family when she passes the waiting room? HIPPA, Confidentiality.

Labor and Delivery Nurse gives report to Postpartum Nurse using SBAR format.

Transfer report

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Postpartum Unit

Facilitator asks Postpartum Nurse: when completing medication reconciliation for Ms. Eckland on admission to the postpartum unit, what would be cause for concern?

Postpartum Nurse: orients patient to the room.

Faculty Facilitator reports the assessment below to the Postpartum nurse.

VS: 110/76, 76, 16, 98.4Fundus deviated to right, firm at umbilicusModerate rubra lochiaReports decreased sensation in left leg, able to bend both legsHas not voided since delivery, states she does not feel like she has to void at this time.

Faculty Facilitator

Asks the Postpartum nurse, what should you do next?

Ms. Eckland puts on her call light 15 minutes later and said she just felt a “gush of blood down there”.

Postpartum nurse immediately comes into the room.

Ms. Eckland uterus becomes firm with massage and Postpartum Nurse notifies the staff the patient is having complications by putting on the emergency call light.

Facilitator asks the Postpartum Nurse: what else can the nurse do to prevent further bleeding?

Ms. Eckland is not able to get out of the bed to the bathroom due to the numbness from the epidural anesthesia. The nurse puts her on the bedpan to void.

Facilitator asks the Postpartum Nurse: what else can the nurse do to assist her with emptying her bladder?

When the nurse leaves the room, Ms. Eckland cries out, “I’m really bleeding a lot!”

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The nurse comes in the room and notes increased vaginal bleeding. The patient is pale, diaphoretic, and the uterine fundus is boggy. The fundus does form with massage.

Facilitator asks the Postpartum Nurse: what actions should the nurse perform at this time?

Team member: Another Assisting Registered Nurse: catheterizes patient

Faculty Facilitator reports this assessment:

VS: 90/50, 120, 20, 98.6, PO2: 97%Fundus boggy, deviated to the right, 4 cm above the umbilicusExcessive rubra lochiaUrine output via catheter: 700 ml, amber colored urine

Postpartum Nurse performs assessment.

Facilitator asks the Postpartum Nurse: what nursing implications are indicated before administering this medication? What patient teaching about this medication should be done for this patient?

Facilitator asks: Assisting Registered Nurse: What actions should the assisting nurse do prior to administering the med?

Team member: Another Assisting Registered Nurse: Administers med using simulation meds

***Support person : why is everybody running in and out of my wife’s room? I just went down to get a cup of coffee.

***Mother of newly delivered patient: Is everything alright? I see you are running all around. Is my daughter OK?

***Father of newly delivered patient: What is going on in there?!! I want to go in there and see what is happening. I need to see my daughter!!

***Sister of newly delivered patient : Why isn’t someone telling us what is going on? Is my sister having a problem??

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Facilitator asks the Postpartum Nurse: How can the nurse support the family during and after postpartum hemorrhage?

Facilitator asks the Postpartum Nurse: what should be included in post hemorrhage care?

Facilitator asks the Postpartum Nurse : what should be included in this patient’s assessment and discharge teaching?

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References

Quality and Safety Education for Nurses. (2011). Quality and Safety Competencies. Retrieved from http://www.qsen.org/competencies.php

Joint Commission. (2011). Facts About Patient Safety: Safety Initiatives. Retrieved from

http://www.jointcommission.org/assets/1/18/Patient_Safety_1_14_11.pdf

Murray, S. S., & McKinney, E. S. (2011). Foundations of maternal-newborn nursing. St. Louis, MO: Saunders Elsevier

U.S. Department of Health and Human Services for Civil Rights. (2007). Medical privacy-National standards to protect the privacy of personal health information. Retrieved from

http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html

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