ch. 21: nursing care during postpartum period Flashcards
(43 cards)
What are normal assessment findings of the BREASTS?
soft ,filling, full, soften w/ breastfeeding, nipple skin intact, no soreness
What are signs of potential complications when assessing BREASTS?
-engorgement: firmness, heat, pain
-nipple redness, pain, crackles usually associated w/ latching prblms
What are normal assessment findings of the UTERUS?
-firm, midline
-first 24 hrs at umbilicus level
-involutes 1 FB/cm a day
What are signs of potential complications when assessing the UTERUS?
-ATONY: soft, boggy, higher than expected
-LATERAL DEVIATION: due to distended bladder
What are normal assessment findings of the BLADDER?
-able to void spontaneously
-no distention
-able to empty bladder completely
-no dysuria
-diuresis begins 12 hrs after birth, can void 3,000 ml/day
What are signs of potential complications when assessing the BLADDER?
-overdistended bladder
-excessive lochia
-infection: dysuria, frequency, urgency, burning
What are normal assessment findings of the BOWELS?
-abdomen soft
-active bowel sounds q4
-BM by day 2 or 3 after birth
What are signs of potential complications when assessing the BOWELS?
-NO BM by day 3 or 4
-constipation
-diarrhea
When is LOCHIA RUBRA present and what color is it?
-days 1-3
-dark red color
When is LOCHIA SEROSA present and what color is it?
-days 4 to 10
-brownish, red, or pink color
When is LOCHIA ALBA present and what color is it?
-after 10 days
-yellowish white color
What are normal assessment findings of LOCHIA?
-amount: scant to moderate
-few clots
fleshy odor
What are signs of potential complications when assessing LOCHIA?
-uterine atony, vaginal or cervical lacerations: a large amount of lochia, large clots (bigger than fists)
-infection: foul odor
What are normal assessment findings of an EPISIOTOMY?
-edges approximated
-pain minimal to moderate
What are signs of potential complications when assessing an EPISIOTOMY?
-infection: redness, warmth, drainage
-excessive discomfort first 1 to 2 days: hematoma
-after 3 days: infection
What are normal assessment findings of the LEGS/ HOMANS SIGN?
-DTRs 1 + to 2 +
-peripheral edema possible
-NEGATIVE Homans sign
What are signs of potential complications when assessing the LEGS/ HOMANS SIGN?
-preeclampsia: DTRs ≥ 3+
-positive homans sign
What are normal assessment findings of their EMOTIONAL STATE?
-excited, happy, interested or involved in infant care
What are signs of potential complications when assessing their EMOTIONAL STATE?
-pospartum depression: lethargy, extreme fatigue, difficulty sleeping
-postpartum blues/depression: sad, tearful, disinterested in infant care
Why is an H&H ordered for a postpartum pt?
to assess blood loss during birth, especially c-section
Why is a URINALYSIS ordered for a postpartum pt?
for routine urinalysis or culture, especially if pt had a urinary catheter
Why is a RUBELLA TITER ordered for a postpartum pt?
-to determine the status- and possible treatment
-if woman hasn’t had rubella or is serologically nonimmune (titer of 1:8 or less) they shou;d get a SUBQ INJ OF RUBELLA VACCINE before discharge
Why is a RHOGAM (FETAL SCREEN) ordered for a postpartum pt?
to detect pts who may need more than one dose of RHOGAM due to sig fetal bleeding
What is considered SCANT bleeding/lochia?
< 2.5 cm pad saturation
