12 - Postpartum Assessments and Nursing Care Flashcards
Involution
the uterus returns to its pre-pregnant size, shape, + location
Involution occurs thru
- contractions
- atrophy of uterine muscle
- decr in size of uterine cells
complete involution takes ____ post-delivery
6-8 wks
afterpains
mod-severe cramp-like pains r/t uterus working to stay contract and/or incr of oxytocin released in response to infant suckling
-common in multiparous or women who breastfeed
during first few postpartum days
-decr 3 days after delivery
Postpartum Assessment
- VS, pain
- breath + heart sound
- lab findings (CBC, rubella, Rh)
- BUBBLELE
BUBBLELE
breast uterus bladder bowel lochia episiotomy (laceratn, perineum, hemorrhoids) lower extremities emotions
frequency of fundal assessment post partum
1st hr: Q15min
2nd hr: Q30min
next 22 hr: Q4hr
after 24hr: Qshift
Encourage voiding before palpating uterus
over distended bladder can lead to uterine displacement + atony
Support the lower uterine segment by
placing one hand above the symphysis pubis
-prevents uterine inversion
If uterus is boggy…
- give oxytocin
- massage fundus w palm of hand
Immediately after birth, the uterus fundus is located _____, and is ____.
12 hrs after brith of placenta, it is located _____, and is ___.
24 hrs after brith of placenta, it is located _____, and is ___.
midway bw umbilicus + symphysis pubis
+firm + midline
at or 1cm above umbilicus
+firm + midline
1cm below the umbilicus
+firm + midline
The uterus descends __ per day,
by day 14, the fundus has descended into ____
1cm
pelvis> not palpable
Subinvolution
failure of uterus to descend
Subinvolution may be caused by
- retained placental fragments
- infection
- over-distended uterus
most common form of PPH
uterine atony aka “boggy”
Uterine Atony aka boggy + nursing action
uterus is not contracted
- immediate action is to massage fundus w palm of hand in circular motion until firm
- reevaluate in 5-10min
- if unresponsive to massage, admin oxytocin
Afterpains nursing care
- empty bladder
- warm blanket to abdomen
- analgesic (ibuprofen)
- relaxatn technq
How to assess endometrium
check lochia
Lochia
bloody discharge
-contains RBC, sloughed decidual tissue, epithelial cells, bacteria
primary complication of endometrium
metritis
Assess lochia for…
color, amount, odor, + clotting
Scant, Light, Moderate, Heavy, Excessively Heavy
Scant: <1in Light: <4in Mod: <6in Heavy: pad is saturated w/in 1 hr EH: soaked w/in 15 min
how to assess for clots
- small is normal but should be documented
- egg or bigger should be weighed + report to HCP
- 1g = 1 mL
stages of lochia
RUBRA (1-3 dy)
SEROSA (4-10 dr)
ALBA (day 10)
Lochia Rubra
expected findings
days 1-3
- red bloody w sml clots
- scant - mod
Lochia Rubra
abnormal findings
- lrg clots
- heavy amount
- foul odor
- placental fragments
Causes of increased in flow based onstages
RUBRA (1-3 dy)- stand + breastfeed
SEROSA (4-10 dr)- phys activity
ALBA (day 10)- no incr flow
Lochia Serosa
expected findings
days 4-10
- pink/brown
- scant
- fleshy odor
Lochia Serosa
abnormal findings
- cont of rubra stage after day 4
- heavy amt
- foul odor
Lochia Alba
expected findings
- yellow-white color
- scant
- fleshy odor
Lochia Alba
abnormal findings
- bright red
- heavy
- foul odor
REEDA
assessment for perineum Redness Edema Ecchymosis Discharge Approximation of edges
expected perineum findings
- mild edema
- minor ecchymosis
- visible approximation of edges
- mild-mod pain
Perineum discomfort teaching
- ice or cold therapy for 1st 24 hr
- heat therapy/sitz bath after 24 hr 2x/day for 20 min
- lie on side
- tighten glutes before sitting, relax glutes when sitting
- peripads to prevent rubbing
- topica anesthetic + analgesic
How to reduce infection w perineum
- peri-bottle w warm water to rinse perineum after poop
- change peripad frequently
- hand washing
local anesthetics + analgesic for perineum
- witch hazel
- NSAID like ibuprofen/motrin: 400-800mg Q4-6hr
- opioids
Hormone related breasts
- fall in E + P
- rise in prolactin
- infant suckles> release of oxytocin> let down reflex
Primary Engorgement
incr in vascular + lymphatic system
- precedes lactogenesis
- breasts become larger, firm, warm, tender, maybe throbbing
- subsides w/in 24-48 hr
Subsequent Engorgement
occurs in women who breastfeed
- engorgement r/t distention of milk glands
- relieved by expressing milk
primary complication of breastfeeding
mastitis
-infection of breast fr stagnant milk
Breasts expected findings (24 hr, day 2, day 3)
24 hr: soft + nontender
day 2: slightly firm + nontender
day 3: firm, tender, warm to touch
Pathological Engorgement
- hard, swollen, red, tender, painful
- elevated temp
Plugged milk ducts symptoms + nursing action
palpation of pea sized breast lumps
- freq feedings, changing infant position
- warm compress or shower before feeding
- massage breasts before feeding
Teaching for NonBreastfeeding women
- milk leakage, pain, + engoregment should subside after 4 days
- supportive bra
- avoid stim breasts to lead to atrophy of milk ducts
- ice packs to breasts
- analgesic
- avoid heat
avg blood loss fr vaginal birth and c section
V: 200-500mL
C: 1000mL
-minimal effects bc of pregnancy-induced hypervolemia
Cardiac Output is ___ for ___ and returns to pre-pregnant levels within ____
increased for 24-48hr
returns to norm in 10 days
WBC rise by ___ within a fe hours of birth, then returns to normal in ___
25,000/mm
7days
orthostatic hypotensin is r/t
decreased vascular resistance in pelvis
postpartum chills
feeling cold + shaky in first few hours after postpartum
-r/t vascular instability
Cardiac expected findings
- 5% incr in BP
- bradycardia
- blood loss wnl
- postpartum chills w norm temp
risk for DVT
- dont cross legs
- frequent ambulation
- compression stockings
- check legs for warm, swelling, edema
when is checking for breath sounds indicated?
- oxytocin
- large amt of IV fluid
- tocolytics (Mg sulfate, pr terbutaline)
- infection
- preeclampsia
- bed rest
bc all are at risk for pulmo edema
expected resp findings
-clear lung sounds
12-20 bmp
PaO2 95% or more
For women w a temp of less than 100.4, ____
For women w a temp greater than 100.4, ____
<8-10 glasses of fluids, promote rest + relax, reassess after 1 hr
> drink minimum of 10 glasses of fluids, contact HCP
type of incontinence
transient stress incontinence
-assoc w pelvic muscle function involving urethra in first 6 wk postpartum
primary bladder complications
1 bladder distention
2 cystitis
bladder nursing actions
- encourage voiding 2-4hr after delivery
- measure voidings
- assess for signs of bladder distention
- use peppermint oil bc relaxing effect on sphincter
how much should patient void 2-4 hr after delivery?
300 ml w/in 2-4 hrs after delivery
-palpate if void is less than 150mL> sign of urinary retention
bladder distention 4 s/s
- uterine atony
- displacement of uterus above umbilicus to the right
- incr lochia
- fullness in suprapubic area
Diuresis
incr UO of 3,000 mL or more per day
- caused by DECR in E levels w/in 12 hr after birth
- aids in elimination of excess fluid
if pt is unable to void + has over-distended bladder..
indwelling urinary catheter in place for 24 hr
cystitis + s/s
bladder inflammation/infection
- freq
- urge
- pain/burn
- suprapubic tenderness
- malaise
cystitis Tx
- abx therapy
- incr hydratn
- rest
menses begins __ after childbirth
7-9 wk
- avg 10 wk for nonlactating
- 17 wk for lactating
For nonlactating women, prolactin cont to decline for _____. For lactating women, prolactin ___
> 3 wks
> incr in response to infant suckling
Diaphoresis + Diuresis is caused by
decline in estrogen
>aids in excretion of incr fluid accumulation from pregnancy
Diaphoresis nursing action + education
- assess for infectn by checking temp
- –norm if temp is wnl
- –should be no signs of fever, warmth, + chills
- wear cotton
Normal muscular/nervous system findings
- diastasis recti
- diminished lower body sensation fr epidural
- mild to no muscle tenderness
- assess for headache, notify HCP if it seems like preeclampsia
- fatigue
if diminished lower body fr epidural is present…
then delay ambulation
GI muscle + motility decr postbirth but return to normal by end of…
2nd week
constipation
decr motility r/t dresidual effects of progesterone, decr phys activity, + dehydratn, fluid loss, anxiety r/t apisiotomy/laceratn
-usually returns to norm in 2-3 days
hemorrhouds
common due to birthing process
- sometimes persists but most slowly resolve
- painful
appetite
often exceptionally hungry after birth for first few days
wt loss
significant wt loss in first 2-3 wks
- immediately after birth lose 11-12 lb
- diureses causes another 5-8 lb
avg woman at the end of 6 mos postpartum is approximately ___ abover her prepartum wt
3 lb
GI teaching
- incr diber> induce peristalsis
- incr fluid intake (3,000ml) to soften bowel
- assess bowel sounds + constipatn
- encourage ambulatn
- stool softener
- assess appetite
- assess n/v
hemorrhoid teaching
- lie on side
- avoid sitting for long periods
- witch hazel or topical anesthetics
- sitz bath aid in circulation + reducing pain
docusate colace
stool softener PO 100 mg daily -admin w full glass of water -may take 1-3 days to take effect -DONT GIVE W/IN 2 HRS OF OTHER LAXATIVES
Laceration degrees
1st: vag mucosa membrane + perineal skin
2nd: +peri fascia
3rd: + rectal sphincter
4th: + rectal mucosa + lumen
