Blood disorders Flashcards
What must you know first before you receive the mother from the PACU?
Does your patient have risk factors? o Bleeding disorders o Diabetes o Heart disease o URI o Liver disease o COPD o Fever o Drug use
Your patient just arrived from the PACU to MBU (mother to baby unit) what questions do you ask when receive them?
- How much blood did she loose in the OR
- What type of incision?
- What is the condition of the dressing? (type)
- Has her uterus been firm?
- How much pitocin did she receive?
- How is her pain being manage and has it been effective?
- What were her vitals
Define thrombophlebitis?
Formation of blood clot inside a blood vessel and causes inflammation
Name the three thromboembolic disorders that are a concerned during the postpartum period?
- Superficial venous thrombosis
- Deep venous thrombosis
- Pulmonary embolism
What are the causes of the thromboembolic disorders? (think of virch triad)
- Hypercoagulability of blood
- Venous stasis
- Injury to epithelium of vessels
How RN’s prevent this thromboembolic disorders from occurring?
- Make sure mother is hydrated
- Encourage early postpartum ambulation
- Help perform Leg exercises to support venous return
- No smoking
- Antiembolism stockings
What mothers are a higher risk for thromboembolic disorders?
Cesarean birth related mothers
When do superficial thrombophlebitis usually occur for mothers postpartum
- 3rd and 4th day after delivery
* It is the most common form of postpartum thrombophlebitis
What are the assessment findings of superficial thrombophlebitis?
- Tenderness
- Swelling
- Low fever
- Localized heat
- Redness
Name a few nursing interventions for superficial thrmobophlebitis
- Bed rest
- Treated with Analgesia
- Elevate the leg
- Local moist heat
- Support hose
Women with superficial thrombophlebitis, are they at a high risk for pulmonary embolism?
little risk
When does deep vein thrombosis usually occur for mothers postpartum
10-20 days after delivery
In assessing for DVT the nurse would do what?
Homans sign (dorsiflex the ankle)
What must you never do to a mother who has DVT?
Do not MASSAGE the affected limb
How would you assess a mother for these disorders?
- Inspect and palpate the area
- Palpate pulses
- Capillary refill
- Homans sign
- Measuring and comparing leg circumferences
What are the assessment findings of deep vein thrombosis
- Swelling
- Pain
- Erythema
- Heat
- Pedal edema
- Low to high fever
- Decrease perfusion
- chills
Name a few nursing interventions for management of DVT
- Treated with anticoagulant therapy
- bed rest
- Elevate legs
- analgesia
What two types of anticoagulant therapy is administer to the mother with DVT
- IV Heparin
* Warfarin (coumadin) for 2-6 months
What antidote should be available when administering heparin?
Protamine sulfate
After the symptoms of DVT decrease, what is the next nursing action?
Fit antiembolism stockings
Women with DVT are they at a high risk for pulmonary embolism?
YES
Name two important nursing actions for DVT and Superficial thrombophlebitis
- Make sure sequential compression device or TED hose are on
* Ambulate as soon as possible
What makes pulmonary embolism so dangerous?
•Clot from the lower extremities moves to pulmonary artery (lungs)
What types of assessment findings do we find if this was to occur?
- Chest pains
- Hemoptysis
- Hypotension
- Tachycardia
- IT IS A MEDICAL EMERGENCY
