Chapter 16: Nursing Management During The postpartum Period Flashcards
Physical assessment timing
Every 15 minutes during the first hour.
Every 30 minutes during the second hour.
Every four hours during the first 24 hours.
Every eight hours after 24 hours
Includes vital signs, pain level, epidural site inspection, head to toe review of body systems, the acronym BUBBLE-EEE includes breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, emotional status
Postpartum danger signs
Fever of more than 100.4
foul-smelling lochia or unexpected change in color or amount. Large blood clots or bleeding that saturate pad in one hour. Severe headaches or blurred vision.
Pain in calf.
Swelling, redness, discharge at that episiotomy epidural or abdominal site
Dysuria, burning, or incomplete emptying of the bladder. Shortness of breath or difficulty breathing.
Depression or extreme mood swings
Vital signs
Temperature under 100.4 after 24 hours
Pulse 40-80 (watch for orthostatic hypotension)
Respirations 16-20
BP- same as during labor, assess in same position each time
Pain: goal 0-2
Immediate fundal height
1-2 hours between umbilicus and symphysis pubis.
6-12 hours at umbilicus level
Above umbilicus: abnormal and investigate for bleeding, full bladder
1 finger below = u/1
Bowels
May not occur for 2 to 3 days because of the decrease in muscle tone in the intestines. Normal bowel illumination usually returns in a week. Use stool softeners and laxatives to treat constipation.
Lochia amount
Scant: 1 to 2 inch stain on pad approximately 10 mL
Light or small: 4 inch stain or 10 to 25 mL
Moderate: 4 to 6 inch stain 25 to 50 mL
Larger happy: a pattern saturated within one hour after changing it.
Perineal lacerations
Mostly healed within two weeks but up to 4 to 6 month.
First degree: involves only skin and superficial structures above muscle
Second Degree: extends through perineal muscles
Third-degree: it extends through the anal sphincter muscle
Fourth degree: continues to anterior rectal wall
Assessed every eight hours. Large areas of swollen, bluish skin with severe pain indicate pelvic or vulvar hematomas.
White line the length of the episiotomy is a sign of infection.
Severe, intractable pain, perennial discoloration, ecchymosis indicates a perennial hematoma and dangerous condition. Apply ice to relieve pain and edema. Sitz bath promote comfort and healing.
Risk factors associated with thromboembolic condition
Anemia, diabetes, cigarette smoking, obesity, preeclampsia, hypertension, varicose veins, pregnancy, oral contraceptives, cesarean birth, infection, previous thromboembolic disease, multiparity, bedrest or immobility, advanced age.
Bonding
Close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is from parents to infant.
Attachment
Development of strong affection between an infant and a significant other. It is reciprocal. Both people exhibit attachment behaviors.
Becoming a parent: four stages
- Commitment, attachment, preparation for infant during pregnancy
- Acquaintance with an increasing attachment to the infant, learning how to care for the infant, physical restoration afterbirth
- Moving toward a new normal routine in the first four months after birth
- Achievement of a parenthood role around four months
Factors affecting attachment
Parents backgrounds including the care they received, cultural practices, relationship within families, previous pregnancies and planning during pregnancy, postpartum depression. The infant temperament and health at birth. Care practices of the facility and support personnel. If the infant does not meet expectations attachment can be delayed. Separation of the infant and parents after birth, policies that discouraged unwrapping, intensive care, staff in difference.
Stages of attachment
Proximity, reciprocity, commitment
Proximity
Refers to the physical and psychological experience of parents being close to the infant. It includes contact, emotional state, and individualization which is to differentiate the infants needs from themselves and respond to them.
Reciprocity
The process by which the infant abilities and behaviors elicit parental response. Complementary behavior involves taking turns and stopping when the other is not interested or becomes tired. Parents who are sensitive and responsive will promote development and growth.
Commitment
Refers to the enduring nature of the relationship. Centrality, parents place the infant at the center of their lives. They acknowledge and accept the responsibility to promote the infant safety growth and development. The parental role exploration is the parents ability to find their own way and integrate the parental identity into themselves.
Cold and heat applications
Ice packs are used during the first 24 hours to reduce perineal edema and prevent hematoma. It is applied during the fourth stage of labor. 20 minutes on 10 minutes off. The paribottle is a plastic squeeze Bottle filled with warm tapwater and sprayed over the Perenial area after each voiding and before applying a new pad. Introduce it to the woman when she gets to go to the bathroom the first time. Direct the flow from front to back.
After the first 24 hours, a sitz bath with room temperature water can be prescribed. This enhances vascular circulation and healing. The area should be cleansed with the peribottle or shower first. Use it several times a day.
Topical treatments
Local anesthetic spray such as Dermoplast or Americaine. Cleanse the area first.
Hemorrhoids: ice pack, sitz baths, cool witch hazel pads, Tucks. Local anesthetics or steroids. Prevent constipation, encourage sidelying position, avoid straining.
Nutrition for the breast-feeding woman
An increase of 500 cal a day for the first and second six months of lactation. Extra 20 g of protein which is 2 cups of skim milk. An extra 400 mg of calcium which is four or more servings of milk. And extra 2 to 3 quarts of fluid daily. No sodas and at least 2500 mL
Women who should not breast-feed
Being on anti-thyroid drugs, antineoplastic drugs, alcohol, or street drugs. HIV-positive should not breast-feed. A new born with PKU or galactosemia. And mother with mental health disorder that would forget to feed the infant.
Criteria for discharge
No fever and vital signs are within normal limits. Lochia it is appropriate amount and color. Hemoglobin and hematocrit values are in normal range. Uterine fundus is firm. Urinary output is adequate. Blood status is known and if needed anti-immunoglobulin has been given. No evidence of infection with surgical wounds. Mother can ambulate without difficulty. Tolerates food and fluids. Self-care and infant care are understood and demonstrated. Have support available. Mother is aware of complications.
Immunizations
Check for rubella immunity and give a subQ injection if needed. Do not give if immunocompromise. Adverse effects include rash, joint symptoms, low-grade fever. Must avoid pregnancy for 28 days after.
If mom is Rh negative, check Rh status of baby. Check an indirect coombs test which should be negative. If the baby is Rh positive, that mom should receive injection of rH immunoglobulin within 72 hours. The usual rhogam protocol for the Rh negative woman is to receive two doses of rH immunoglobulin. One at 28 weeks and the second within 72 hours after birth. The standard dose is 300 mcg given IM. Must have a signed consent.
DtAP if not vaccinated within the past 2 years.
