7.1b Care Management - Physical Needs Flashcards
1
Q
Model of Care
A
- Plan includes woman, newborn, and family
- Couplet or Mother-Baby Model of Care
2
Q
On-going physical assessment
A
- VS
- Physical Assessment
- Evaluation of breasts
- Uterine Fundus
- Lochia
- Perineum
- Bladder/Bowel Function
- Lower Extremities
3
Q
Routine Lab Tests (Postpartum)
A
- Hemoglobin/hematocrit
- Urinalysis (especially if indwelling catheter was used)
- Rubella immunity
- rH status
4
Q
Nursing Interventions (Postpartum)
A
- Assessment periodically to detect variations from normal physical changes
- Relieve discomfort/pain
- Prevent injury/infection
- Education on self-management and infant care
5
Q
Blood Pressure
A
- Normal to return to baseline BP with transient increases by 5%
- Patient may have orthostatic hypotension for the first 48 hours postpartum
COMPLICATIONS
- Hypertension
- Preeclampsia
- Essential hypertension (not due to medical cause)
- Hypotension (hemorrhage)
6
Q
Temperature
A
- Should be between 97.2 - 100.4
- Greater than 100.4 after 24 hours could mean there is an infection
7
Q
Pulse
A
- Should be 50-90 bpm
COMPLICATIONS
- Tachycardia due to pain, fever, dehydration, or hemorrhage
8
Q
Respirations
A
- Normal 16-20 breaths per minute
COMPLICATIONS
Bradypnea - due to opioid effects
Tachycardia - due to anxiety or respiratory disease
9
Q
Breath sounds
A
- Should be clear to auscultate
- Crackles could be due to fluid overload
10
Q
Breast Exam
A
- Days 1-2 breasts should be soft
- Days 2-3 breast should be filling
- Days 3-5 breasts should be full with breastmilk
COMPLICATIONS
Engorgement - Firmness, head, pain which can lead to mastitis (infection of breasts)
11
Q
Nipples
A
- Skin should be intact with no soreness
COMPLICATIONS
- Redness, bruising, cracks, fissures usually associated with latching issues
12
Q
Fundus
A
- After 24 hours fundus should be firm, midline and at level of umbilicus
- Goes down at about 1cm (finger length) a day
COMPLICATIONS
- Soft, boggy, higher than expected level, atony (uterus fails to contract after birth)
- Can be caused by distended bladder
13
Q
Lochia
A
Days 1-3 (Rubra) - Dark red
Days 4-10 (Serosa) - Brownish Red/Pink
After day 10 (Alba) - Yellowish White
Amount should be scant-moderate
COMPLICATIONS
- Large amounts of lochia
- Uterine atony
- Large clots
- Foul odor (infection)
14
Q
Perineum
A
NORMAL
- Minimal Edema
- Pain minimal-moderate controlled by analgesia
ABNORMAL
- Pronounced edema, bruising, or hematoma
- Redness/Warmth/Drainage (Infection)
- Excessive discomfort for first 1-2 days and hematoma after the 3rd (infection)
15
Q
Rectal Area
A
ABNORMAL
- Discolored Hemorrhoids with severe pain
16
Q
Bladder
A
- Able to void spontaneously with no pain
- Diuresis begins 12 hours after birth (3000 mL/day)
COMPLICATIONS - Distended bladder which can cause uterine atony and excessive lochia
- Dysuria, burning, urgency which can mean infection
17
Q
Bowel Movements
A
- Should start 2-3 days after birth
COMPLICATIONS - No bowel movement after 3-4 days (constipation/diarrhea)
18
Q
Legs
A
- DTR should be +1 - +2
- >3 can mean preeclampsia
19
Q
Excessive Bleeding Interventions
A
- Monitor lochia and pad saturation to evaluate bleeding
- Monitor/palpate fundus to determine tone. Uterine atony is the most common cause of postpartum hemorrhage
- Gently massage fundus if it is boggy to promote uterine contractions
- Teach client to assess for bogginess and how to massage fundus to involve patient in self management.
20
Q
Acute Pain Nursing Interventions
A
- Assess the location, type and quality of pain
- Explain the reason for their pain, expected duration and treatment to lower patient anxiety and increase sense of control
- Administer pain medication and evaluate effectiveness in an hour
- Use ice packs in the first 24 hours and sitz baths after 24 hours to reduce edema and vulvar irritation
21
Q
Difficulty urinating
A
- Patient should void 3-4 hours after emptying their bladder
- Assess for fundus displacement
- Increase fluid intake, pour warm water over perineum to promote voiding
- Assess intake and output to assess adequate fluid intake
- Administer analgesics to reduce perineal pain
22
Q
Preventing Post-Partum Hemorrhage
A
- Most common cause is uterine atony
- Best management is to maintain good uterine tone and prevent bladder distension
- Atony is usually cause by retained placental fragments
23
Q
Post-Partum Hemorrhage
A
- A perineal pad that is saturated within 15 minutes and pooling under the butt requires immediate intervention
- To assess blood loss ask patient how long it has been since they have changed their pad to measure accurately
24
Q
Assessing Post-Partum Hemorrhage
A
- Monitor VS closely
- BP is not reliable measure of impending shock because compensatory mechanisms prevent a drop in blood pressure until the patient has lost 30-40% of their blood volume.
- RR, Pulse, Skin color, UO, and LOC are better indicators of hypovolemic shock
25
How to Maintain Uterine Tone
- Best way to alleviate atony and restoring tone is by gently massaging the fundus until firm
- This can increase vaginal bleeding and expel clots.
- Additional interventions include IV fluids and oxytocic medications
26
Preventing Bladder Distention
- Atony and bleeding can also be caused by bladder distention
- Distended bladder displaces uterus up and to the side which prevents it from contracting properly
CAN BE CAUSED BY
- Epidural anesthesia
- Episiotomy
- Perineal lacerations
- Vacuum/forceps birth
- Prolonged labor
(patients may experience issues voiding after having a catheter removed)
27
Bladder Distention Intervention
- Encourage patient to empty bladder as soon as possible post-partum
INTERNTIONS
- Assist patient to bathroom/bedpan
- Place hand in warm water/pour water over perineum
- Assist into shower or sitz bath to encourage voiding
- Relaxation techniques
- Analgesic administration if patients are fearful of voiding due to anticipated pain
- Catheter can be used as a last resort
28
Preventing Infection
- Maintain clean environment
- Change bed linens, disposable pads, draw sheets
- Hand hygiene, patients should wear slippers
- Proper perineal care for those with lacerations or episiotomies
- Education on wiping from front to back (urethra to anus)
- Squeeze bottle with antiseptic should be used after each voiding
- Perineal pads should be changed from front to back each time she voids or defecates
29
Promoting Comfort
Common reasons for pain include
- Uterine contractions (afterpain)
- Lacerations/episiotomies
- Hemorrhoids
- Sore nipples
- Breast engorgement
- EXTREME PERINEAL PAIN AFTER MEDICATION
- Assess perineum for hematoma or infection
- Can also be caused by rare perineal cellulitis, necrotizing factors, or angioedema
30
Non-Pharmacological Interventions
- Warm compress or lying prone is good for uterine contraction discomfort. You can also provide distractions by interaction with infant
- Afterpains are more severe during and after breast feeding
- If patient had an episiotomy, encourage side lying position
- Sore nipples occur from improper latching technique. Assist with feeding.
- Topical or hydrogel pads can ease nipple discomfort
- Breast engorgement can be reduced with ice packs or cabbage leaves as well as wearing a well supported bra. (Anti-inflammatories such as ibuprofen can help as well)
- Breast feeding moms can use breast pump to reduce engorgement and formula moms should not stimulate milk production.
31
Perineal Lacerations, Episiotomies, and Hemorrhoids Pain
- Cleanse area at least once a day from front to back
- Peripad can be used to protect the skin (change at least 4 times a day)
- Icepack during first 24 hours to decrease edema and after 24 hours to provide anesthetic effect
- Squeeze bottle with warm water and use entire bottle to cleanse perineum. Blot dry with paper towels after.
32
Sitz Bath (Perineal Laceration and Episiotomy continued)
- Fill with warm water and add ice if patient requests a cooler bath
- Use sitz bath 20 minutes 2 times a day
- Check patient in 15 minutes
33
Topical Applications
- Apply anesthetic cream after cleaning perineal area (3-4 times a day)
- Apply hazel pads after cleansing
- Apply hemorrhoidal crème as ordered to anal area after cleaning
34
Promoting Rest
- Lack of sleep and fatigue is of the most common complaints of new parents
- Fatigue will likely worsen over the next 6 weeks due to
- Household responsibilities
- Lack of family support
- Limited resources
- Lack of sleep may lead to post-partum depression
- Screening for fatigue can be done by phone call within the first 2 weeks and routine follow-ups
35
Promoting Ambulation
- Ambulation reduces risk of Venous Thromboembolism (VTE)
- Orthostatic Hypotension - Rapid decrease in intra-abdominal pressure after birth that results in dilation of blood vessels supplying the intestines (splanchnic engorgement) causes orthostatic hypotension
WHAT TO CONSIDER DURING AMBULATION
- Baseline BP
- Amount of Blood Loss
- Type/Amount of analgesic/anesthesia used
- Epidural (Time since it was used, ability to bend knees and lift off bed)
- Medications since birth
- VS
- Ability to stand un-assisted
- Exercise should be promoted if patient is in bed longer than 8 hours post-partum
36
Promoting Exercise
- Can begin soon after birth
- Start slow and gradually move up
- Abdominal exercises are postponed until 4-6 weeks after c-section
37
Promoting Nutrition
- Well balanced diet promotes healing in post partum
- 1800-2200 kcal for moderate activity non-lactating women
- Lactating women need 450-500 calories more a day
- 200-300 omega 3 fatty acids daily and 1-2 weekly portions of low mercury fish
- Prenatal vitamins for 6 weeks after birth
- Iron supplements for those with low hemoglobin and hematocrit
38
Normal Bladder Function
- Void within 6-8 hours after birth
- First few void should be measured for adequate emptying of bladder
- At least 150 mL is expected for each voiding
- Urinary incontinence common for those who experienced perineal trauma
- Kegel exercises can help with urinary incontinence
39
Normal Bowel Function
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Risk of constipation due to
- Opioids, Iron, Magnesium Sulfate
- Dehydration
- Immobility
- Episiotomy/Lacerations
- Hemorrhoids
- Fear of pain with first bowel movement
INTERVENTIONS
- Ambulation and Fiber increase
- Education on side effects of medication
- Stool softener and Laxatives if indicated by provider
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40
Promoting Breastfeeding
- Within first 1-2 hours after birth
- Skin to skin contact as soon as possible after birth for at least an hour
- Breastfeeding helps uterus contract and prevent hemorrhage
41
Lactation Suppression
- Needed for those who are not breastfeeding
- Wear well supported bra for 72 hours after birth
- Avoid breast stimulation (running warm water over breast, newborn suckling)
- Icepacks can help with engorgement and cabbage leaves
- Analgesics and anti-inflammatory medication can help with engorgement
42
Rubella Vacination
- Given as MMR vaccine
- Recommended if Titer or Vaccine have not been given
- Teratogenic, so do not get pregnant within 28 days after vaccine
- Not communicable in breast milk
- Should not be given if mother/household member is immunocompromised
43
Varicella Vaccine
- Given before discharge
| - Second dose 4-8 weeks after first dose
44
TDAP Vaccine
- Recommended for those who are unvaccinated
- Those who are around the baby should also be vaccinated (older children)
- Should occur 2 weeks before contact with newborn to allow immunity to happen
- Can continue to breastfeed
45
Preventing rH Immunization
- Injection of Rh immunoglobins within 72 hours after birth prevents sensitization
- Promotes lysis of rH positive blood cells before antibodies form
46
Kleihauer-Betke Test
- Detects amount of fetal blood in moms circulation
- Used if large amounts of fetal blood is suspected in moms circulation
- Increased immunoglobin dosage if more than 30 mL of fetal blood is in moms circulation
- Must be scanned again for vaccine success (such as rubella), they will need another dose if vaccine did not work.
47
Adverse Effects of rH Immunoglobins
Rhogam
- Myalgia
- Lethargy
- Localized tenderness at injection site
- Transient Fever
48
Nursing Considerations of Rhogam
- Prophylactic dose at 28 weeks of gestation
- Standard dose within 72 hours if baby is rH positive
- Dosage must be confirmed by 2 nurses
- Consideration for Jehovah Witness patients because vaccine is made from human plasma
