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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

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2
Q

On-going physical assessment

A
  • VS
  • Physical Assessment
  • Evaluation of breasts
  • Uterine Fundus
  • Lochia
  • Perineum
  • Bladder/Bowel Function
  • Lower Extremities
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3
Q

Routine Lab Tests (Postpartum)

A
  • Hemoglobin/hematocrit
  • Urinalysis (especially if indwelling catheter was used)
  • Rubella immunity
  • rH status
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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
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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)
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6
Q

Temperature

A
  • Should be between 97.2 - 100.4

- Greater than 100.4 after 24 hours could mean there is an infection

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7
Q

Pulse

A
  • Should be 50-90 bpm

COMPLICATIONS
- Tachycardia due to pain, fever, dehydration, or hemorrhage

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8
Q

Respirations

A
  • Normal 16-20 breaths per minute

COMPLICATIONS
Bradypnea - due to opioid effects
Tachycardia - due to anxiety or respiratory disease

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9
Q

Breath sounds

A
  • Should be clear to auscultate

- Crackles could be due to fluid overload

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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)

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11
Q

Nipples

A
  • Skin should be intact with no soreness

COMPLICATIONS
- Redness, bruising, cracks, fissures usually associated with latching issues

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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
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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)
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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)

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15
Q

Rectal Area

A

ABNORMAL

- Discolored Hemorrhoids with severe pain

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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
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17
Q

Bowel Movements

A
  • Should start 2-3 days after birth
    COMPLICATIONS
  • No bowel movement after 3-4 days (constipation/diarrhea)
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18
Q

Legs

A
  • DTR should be +1 - +2

- >3 can mean preeclampsia

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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.
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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
Q

How to Maintain Uterine Tone

A
  • 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
Q

Preventing Bladder Distention

A
  • 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
Q

Bladder Distention Intervention

A
  • 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
Q

Preventing Infection

A
  • 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
Q

Promoting Comfort

A

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
Q

Non-Pharmacological Interventions

A
  • 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
Q

Perineal Lacerations, Episiotomies, and Hemorrhoids Pain

A
  • 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
Q

Sitz Bath (Perineal Laceration and Episiotomy continued)

A
  • 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
Q

Topical Applications

A
  • 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
Q

Promoting Rest

A
  • 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
Q

Promoting Ambulation

A
  • 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
Q

Promoting Exercise

A
  • Can begin soon after birth
  • Start slow and gradually move up
  • Abdominal exercises are postponed until 4-6 weeks after c-section
37
Q

Promoting Nutrition

A
  • 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
Q

Normal Bladder Function

A
  • 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
Q

Normal Bowel Function

A 
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
40
Q

Promoting Breastfeeding

A
  • 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
Q

Lactation Suppression

A
  • 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
Q

Rubella Vacination

A
  • 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
Q

Varicella Vaccine

A
  • Given before discharge

- Second dose 4-8 weeks after first dose

44
Q

TDAP Vaccine

A
  • 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
Q

Preventing rH Immunization

A
  • Injection of Rh immunoglobins within 72 hours after birth prevents sensitization
  • Promotes lysis of rH positive blood cells before antibodies form
46
Q

Kleihauer-Betke Test

A
  • 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
Q

Adverse Effects of rH Immunoglobins

A

Rhogam

  • Myalgia
  • Lethargy
  • Localized tenderness at injection site
  • Transient Fever
48
Q

Nursing Considerations of Rhogam

A
  • 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

OB (96 decks)

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