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UniCollab (2013, February 21). Blood Drop [Digital image]. Retrieved from https://upload.wikimedia.org/wikipedia/commons/thumb/f/fb/Blood_drop_plain.svg/2000px-Blood_drop_plain.svg.png

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Thinkstock (n.d.). Healthcare innovation [Digital image]. Retrieved from http://www.cio.com/article/3161886/innovation/top-3-practical-innovations-from-yale-healthcare-hackathon.html

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Madden, C. (n.d.). Hemorrhaging cartoon 1 of 4 [Digital image]. Retrieved from https://www.cartoonstock.com/directory/h/hemorrhaging.asp

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Community Health Nursing (n.d.). Nursing [Digital image]. Retrieved from https://www.comhs.org/careers/nursing

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Nurse working on desktop [Digital image]. (2017). Retrieved from http://www.innerbody.com/careers-in-health/how-to-become-a-utilization-review-nurse.html

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Scientific Research Publishing (2014, August 10). Blood collection drape [Digital image]. Retrieved from http://file.scirp.org/Html/5-1430593_49132.htm

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Health Tap (n.d.). CBC hemoglobin [Digital image]. Retrieved from https://www.healthtap.com/topics/what-is-mch-in-a-cbc

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Pinterest (n.d.). Lochia saturation levels [Digital image]. Retrieved from https://www.pinterest.com/pin/551057704383853594/

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Weighing scales [Digital image]. (2017). Retrieved from https://www.continenceproductadvisor.org/advice/bladderleakage/amount/padweighing

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Challenges or barriers for nurse involvement:

Resources: low-resource hospitals may not have the funding to invest in blood collection drapes and calibrated supplies. Scales are initially costly but can be cost-effective in the long run since scales can be used over and over again

Time: accurate methods of measurement (such as WBL) can be more time-consuming than visual estimation.

Reasons for limited nurse participation:

Ethical implications: a nurse's work environment may fail to advocate and protect the health and safety of their patients, an essential ethical obligation within the nursing profession (American Nurses Association, 2015) If institutional guidelines are not met, errors and near-misses related to postpartum blood loss estimation may not be addressed promptly.

Legal implications:  if a nurse fears he/she may face legal consequences related to excessive bleeding and untimely management, he/she might underestimate blood loss and pass responsibility onto the next nurse. If a patient was showing signs of hemorrhage, it is the nurse's legal obligation to document and report the assessment findings as well as advocate for the patient's health and safety.

Financial implications: hospitals may not have the funds to support the use of WBL and blood collection drapes; thus, nurse participation is limited to methods such as visual estimation.

Social implications: nurses may feel hesitant to adopt new protocols that require more time and skill than the visual estimation method.

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The importance of nursing involvement in this issue:

Nurses take part in monitoring blood loss during and after delivery, and they are the primary individuals responsible for monitoring blood loss in the postpartum period.

Nurses should be aware that visual estimation of blood loss alone can lead to underestimation and delayed diagnosis of PPH.

As PPH worsens, this can lead to shock and death. Nurses have a duty to promote safety and advocacy for their patients; this includes the use of preventative measures and early interventions for PPH.

How nurses can help:

Be aware of the signs of PPH (e.g. low blood pressure, tachycardia, pallor, dizziness, heavy bleeding)

Measure blood loss with accurate methods such as WBL

Document blood loss promptly and effectively

How nurse involvement will improve this issue:

Many cases of PPH could be treated or even prevented if nurses use accurate methods of blood loss estimation in conjunction with visual estimation.

Nurses spend the most time monitoring patients in the postpartum period; therefore, their involvement is paramount in reducing PPH rates.

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https://youtu.be/uMM-0CmgU0g

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Sentara College of Health Sciences has prepared me to assume a leadership role once I graduate and practice as a registered nurse. In order to lead others, however, I must be able to manage myself and my relationships with others. The first curricular concept that has influenced my leadership role comes from NUR 415; it involves emotional intelligence domains, which include personal and social competence:

Self-awareness: being aware of my own emotions, knowing my strengths and weaknesses, having a sense of self-worth and capabilities

Self-Management: displaying honesty and integrity, adapting to changing situations, striving to improve my performance, seizing opportunities being optimistic

Social Awareness: being empathetic towards others, having organizational awareness, meeting patient needs

Relationship Management: having a vision and motivating others, giving feedback, resolving disagreements, utilizing cooperation and team building (Sullivan, 2013, p. 48)

Another aspect that has shaped my ability to assume a leadership role is the concept of holistic care; it has resonated throughout all of my classes and continues to be a challenge among nurses in the clinical setting. Holistic care requires the nurse to understand and address all aspects of the patient, including emotional, spiritual, and cultural needs. I have seen some nurses embrace this concept and I have seen other nurses shy away from it. Some aspects of holistic care are uncomfortable or may inconvenience the nurse, but they still impact the overall health of the patient. This concept has taught me what it truly means to advocate for the patient and be a positive influence for other nurses.

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Continue to support the use of blood collection drapes and standardize nursing protocol to include WBL, especially if the patient is at a higher risk for PPH.

Continue to utilize blood collection drapes immediately after delivery of the infant and placenta.

Implement a protocol based on a patient's prenatal and antenatal history, and weigh pads according to the level of risk for developing PPH

Continue to assess for saturation of pad in one hour.

Improve communication between nurse and patient by implementing a perineal pad-changing chart and reinforce teaching about excessive bleeding

Just as women have a feeding chart for their infants in the hospital, having a perineal pad chart (or merely adding a 'pad-changing' column to the feeding chart) will greatly improve communication between the nurse and patient

The chart is not intended to replace nurse assessments; rather, it does help the nurse in calculating the timing and amount of pad saturation as the patient becomes more ambulatory and independent in perineal care.

Reinforce teaching regarding warning signs of excessive bleeding (e.g. golf-ball-sized clots, saturated pad in 1 hour). If these warning signs occur, the patient should alert the nurse immediately and the pad should be weighed.

Do not rely solely on visual estimation of blood loss and take the whole patient into account.

Know the signs of shock and be aware that blood may be retained or collecting in other areas of the body (such as a hematoma).

Monitor laboratory values, such as falling hemoglobin and hematocrit values > 10%.

Listen to the patient and believe the patient when something 'doesn't feel right.'

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The nurse’s current role:

Calibrated bags attached to blood collection drapes are used immediately after delivery, which a nurse can assess

Visual estimation: the main method of measuring blood loss in the postpartum period

Weighing pads once they become completely saturated the patient shows signs of shock/hemorrhage.

How the issue has been improved:

Some protocols require descriptive terms for the visual estimation method (e.g. scant, light, moderate, heavy)

Weighing perineal pads when they become saturated

Stocking postpartum hemorrhage carts and treating PPH promptly

How the issue has been exacerbated:

Inconsistent visual estimation due to patient changing her own pads and miscommunication between the nurse and patient

Relying too heavily on the visual estimation method, which can lead to underestimation of blood loss

No special protocols are in place for patients who are more at risk for developing PPH based on their prenatal and antenatal histories

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Visual estimation is often an inaccurate method for measuring blood loss and frequently leads to underestimation of blood loss.

Other methods such as WBL (weighed blood loss) and the use of a blood collection drape can help significantly reduce the risk of delayed PPH diagnosis.

In one study, visually estimated blood losses were 30% lower than gravimetric (weighed) estimates across all professional groups (Hancock, Weeks, & Lavender, 2015)

In another study, the use of a blood collection drape produced results very similar to standard photospectrometry, a gold standard for blood loss measurement (Lertbunnaphong et al., 2016)

WBL has a poor sensitivity for detection of PPH compared to a reference standard of hemoglobin drop > 10%,  but it is effective in detecting PPH when blood loss exceeds 750 mL at less than 2 hours or exceeds 1,000 mL at any time (Atukunda et al., 2016)

While WBL, blood collection drapes, and hemoglobin monitoring have their own drawbacks, the literature shows that visual estimation is one of the least accurate methods for measuring blood loss.

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Issue: Underestimation of postpartum blood loss using the visual estimation method

Postpartum hemorrhage (PPH) affects mothers worldwide, especially in low-resource hospitals

PPH typically arises during the first 2 hours after giving birth, when hemorrhage rates are highest. However, it can occur hours or days after childbirth.

Using inaccurate methods of measuring blood loss such as visual estimation could delay PPH diagnosis

Serious complications can result from PPH such as shock and even death. Nurses should use accurate methods for measuring blood loss in order to alleviate the rates of postpartum hemorrhage

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https://youtu.be/9oahxpdBUQI

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Trisha Hammond