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NURS 4500: Final Material > Class 7: Postpartum Assessment - Postpartum Period > Flashcards

Class 7: Postpartum Assessment - Postpartum Period Flashcards

1
Q

what is included in assessments of the postpartum period (3)

A
  • BUBBLLEE
  • VS
  • lab work
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2
Q

what is the freq of VS and BUBBLLEE assessment in postpartum

A
  • done when admitted to postpartum unit
  • protocol for freq –> no specific number
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3
Q

what does each letter of BUBBLLEE stand for

A

Breasts
Uterine fundus
Bladder function
Bowel function
Lochia
Legs (extremities)
Episiotomy/laceration or c-section incision
Emotional status

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4
Q

what is included in assessment of breasts (2)

A
  • firmness
  • nipples
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5
Q

what is included in assessment of uterine fundus (2)

A
  • location
  • consistency
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6
Q

what is included in assessment of bowel function (2)

A
  • passing gas
  • bowel mvmt
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7
Q

what is included in assessment of lochia (2)

A
  • amount
  • color
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8
Q

what is included in assessment of legs (2)

A
  • peripheral edema? (normal)
  • rule out venous thromboembolism
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9
Q

what is included in assessment of episiotomy/laceration or c-section incision (3)

A
  • assess perineum
  • discomfort
  • condition of repair (if done)
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10
Q

what is included in assessment of emotional status (3)

A
  • mood
  • fatigue
  • confidence
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11
Q

see slide 13 for nursing care priorities in postpartum, too long for slides

A

..

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12
Q

describe the firmness of breasts for days 1-2 postpartum

A
  • soft –> no milk yet
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13
Q

describe the firmness of breasts for days 2-3 post-partum

A
  • getting firmer –> filling
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14
Q

describe the firmness of breasts for days 3-5 postpartum

A
  • full
  • soften w breast feeding (d/t release of pressure)
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15
Q

describe what the assessment of the nipples should be postpartum (3)

A
  • should be intact intact
  • should be no soreness reported
  • note any cracks, blisters, or abrasions
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16
Q

what could cracks, blisters, or abrasions of the nipples mean?

A
  • could be an issue w latching
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17
Q

before milk is present, what are newborns fed with?

A
  • colostrum
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18
Q

what is included in education regarding the changes to breasts postpartum (5)

A
  • during pregnancy & after birth breasts become bigger and heavier
  • 1st days after giving birth, breasts may become swollen due to increasing breast milk and fluid
  • imp to wear a supportive bra to keep you comfortable
  • first milk breasts make = colostrum
  • during the first few days after birth, breasts make small amt colostrum, enough for the small newborn
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19
Q

if the mother is not breastfeeding, what education should be given? (2)

A
  • your breasts will slowly become smaller within first week or two
  • put cold face cloths or ice packs on breasts to help lessen the swelling
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20
Q

describe placement of hands for uterine (fundal) assessment ? why is hand placement imp?

A
  • 1 hand @ fundus
  • other hand supports uterus @ symphysis pubis –> imp to prevent prolapsed/inverted uterus
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21
Q

what should be assessed at the same time as uterine (fundal) assessment

A
  • lochia
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22
Q

describe involution of the uterus at the end of the 3rd stage (~2h after birth)
how much does it weigh?

A
  • fundus at the umbilicus or 1-2 cm before umbilicus
  • weighs 1000g
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23
Q

describe involution 12 hrs after birth

A
  • may rise to 1cm above umbilicus
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24
Q

describe involution 24 hrs after birth

A
  • uterus is about the same size that it was at 20 weeks gestation
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25
describe involution after 2 weeks postpartum what is the weight?
- uterus no longer abdominally palpable, below symphysis pubis - 350 g
26
by 6 weeks postpartum, the uterus weighs??
- 60-80 g
27
involution of the uterus should be ~___ cm/day
- 1-2 cm
28
how is fundal height documented?
in reference to the umbilcus ex. 2/u = 2cm over umbilcus, @u or u/u = fundus at lvl of umbilicus
29
what is assessed r/t uterine assessment? (3)
- placement - size/shape - tone
30
what should be the placement of the uterine?
- should be midline on the abdomen
31
deflection of the uterus could indicate? what concerns does this cause?
- a distended bladder = concerns about poor contractions to control bleeding
32
what should the size/shape of the uterus be? (2)
- round - size of a grapefruit
33
larger uterine size could indicate?
- hemorrhage
34
what should the tone of the uterus be?
- firm (like grapefruit)
35
if the uterus is soft/boggy, what is the concern
- concern of hemorrhage
36
what are nursing interventions for a boggy uterus (3)
- fundal massage - notify primary HCP - uterotonics as ordered
37
prevention of excessive bleeding includes information for which parts of BUBBLLEE (3)? maintenance of uterine tone is connected to?
- U: uterus - L: lochiaq - E: episiotomies/lacerations - maintenance of uterine tone is connected to vaginal bleeding
38
what is deflection of the uterus?
- uterus higher, deflected to side (usually R)
39
what are afterpains?
- cramps of the womb that feel like belly pain
40
what do afterpains mean?
- they are keeping the womb firm and lessen the bleeding
41
describe when afterpains are felt the most (3)
- have them most often the first week after you have the baby - may be stronger w each added birth - may increase with breastfeeding (d/t release of oxytocin = more contractions)
42
to lessen the soreness of afterpains, what can be done? (3)
- do deep breathing like in labor - walk slowly when up and about - keep your bladder empty
43
what is included in assessment of the bladder?
assess for distension by: - visualization - palpation
44
bladder distension appears as?
- round, suprapubic bulge
45
describe palpation of a distended bladder
- may be able to palpate bladder
46
what impact might a distended bladder have on the uterus tone? placement? lochia?
- uterus boggy - uterus above umbilicus and to right - lochia heavier
47
what are postpartum interventions for the bladder? (3)
- assist woman to void spontaneously - if unable, catheterize as needed/ordered - use bladder scanner to assess urine retention
48
what are normal findings r/t the bladder postpartum? (4)
- should be able to void sponatneously within 8 hrs of birth - no distension - able to empty bladder completely - no dysuria or signs of infection (freq, urgency)
49
if the uterus is displaced above the umbilicus and well to one side of the midline, we should suspect?
- a distended bladder
50
due to postpartum diuresis within 12 hrs after birth, they may void up to ____ mL/day
- 3000 mL/day
51
why are we concerned w bladder distension PP
- due to risks for uterine bleeding
52
bladder distension is a risk due to the following intrapartum factors (4)
- epidural - trauma d/t extensive vaginal or perineal lacerations/episiotomy or instrument assisted birth - prolonged labor - indwelling cath during labor
53
what are other risk factors for bladder distension
- fear of discomfort
54
what is included in nursing care r/t bladder distension
- measure first several voids and document
55
how much should the first several voids be?
- at least 150 mLs/void
56
what are nursing interventions to help the birther empty bladder spontaneously (5)
- listen to running water - squeeze bottle of warm water --> spray perineum - shower or sitz bath - analgesics if ordered - catheter if necessary (if others dont work)
57
what is included in education r/t the bladder? (4)
- pass urine often to avoid distension - kegel exercises can help improve the passing of urine - after baby is born, your body needs to get rid of the extra fluid and does so by sweating & passing water - may pass lrg amts of urine for 2-5 days after your baby is born
58
in education r/t bladder, the birther should talk to your HCP is you: (5)
- have pain while passing urine - have trouble passing urine - cannot pass urine - cannot control ur urine - have a fever
59
the birther should have a BM by ...
- day 2 or 3 after birth --> may not have a BM while in hospital
60
describe the abdomen PP
- should be soft
61
in the case of a c-section, the nurse should..... r/t bowels
- nurse should be able to auscultate BS in all four quadrants
62
why is there a risk of constipation PP (5)
- medications - dehydration (d/t labor process) - perineal lacerations/episiotomy - hemorrhoids - fear of discomfort (esp. if had episiotomy/perineal laceration)
63
gas pains are more common w...
- c-section
64
you should provide education r/t bowel movements to the birther including: (4)
- consuming adequate roughage - increasing fluid intake - ambulation - risk of opioid analgesics
65
what are interventions for constipation PP? when esp should these be used?
- stool softeners/laxatives - during early postpartum period esp w extensive perineal repair
66
describe appetite PP
- usually have good appetite
67
describe use of prenatal vitamins and iron supplements PP (2)
- should be continued until 6 weeks after birth - may be longer if breast or chest feeding
68
describe caloric requirements PP for lactating vs nonlactating persons
- lactating: additional 350-400 / day - nonlactating: 1800-2200 /day
69
what might increase the caloric requirements PP (3)
- if multiple babies - exercising freq - under weight
70
what is included in education PP r/t constipation (4)
- lots of fluids - diet high in fiber - be active - constipation may lead to hemorrhoids and pain
71
what are examples of foods high in fiber
- fresh veggies and fruit - whole grain/bran
72
what are ways to lessen hemorrhoids and pain PP (3)
- avoid constipation - using a special ointment (buy in pharmacy) - sitz baths/soaks in clean tube
73
what is a way to prevent gas pains PP (3)
- eat a balanced diet - avoid pop - lie down on L side
74
define: lochia
- vaginal discharge after delivery
75
lochia is composed of.. (5)
- leukocytes - epithelial cells - decidua - auto-lysed protein - bacteria
76
what is a normal amt of lochia
- scant to moderate w few clots
77
what is assessed r/t lochia (4)
- color - amt - odor - clots
78
when is lochia rubra present? color?
- day 1-3 - dark red
79
when is lochia serosa present? color?
- day 3-10 (or longer) - pink/brownish red
80
when is lochia alba present? color?
- day 10 for up to 4-8 weeks - yellowish-white
81
blood loss after birth is assessed by?
- the extent of perineal pad saturation
82
how many cm of pad saturation is classified as scant bleeding? light? mod? large?
- scant: 5 cm - light: 10 cm - moderate: 15 cm - large: >15 cm
83
what do large amts of lochia usually indicate?
- uterine atony - OR cervical/vaginal laceration that has not been repaired
84
what would indicate excessive bleeding PP (2)
- perineal pad that is saturated in 15 min or less - or pooling of blood under buttocks noted
85
what is the main cause of excessive blood loss PP
- uterine atony
86
what should be done if there are signs of excessive bleeding PP (3)
- further assessment - intervention likely required - PCP should be notified
87
nurses tend to overestimate or underestimate blod loss PP?
- overestimate
88
estimation of the amt of blood on a perineal pad always needs to be considered in terms of...
- the timeframe ex. was the pad soaked in 1 hr or 8h?
89
what are the more accurate measurements of blood loss?
- serial measurements of hgb and hct - weighing perineal pads and blood clots --> 1g = 1mL of blood
90
in order to assess the measurement of blood loss by weighing the perineal pad, what must we know?
- must know the weight of the pad without blood
91
what is included in education r/t lochia in PP period (4)
- the amt of lochia will slowly lessen in amt and change in color - right after delivery will be red like your period - after first few days will change from red to pink & lessen in amt (may take up to 6 weeks) - lochia should not have bad smell or odor
92
when should the birther be educated to contact the HCP r/t lochia (2)
- if becomes a lot heavier - if has an odour
93
what is assessed for r/t legs? (2)
- assess for peripheral edema/swelling (could be present) - assess for VTE
94
what are signs of VTE (4)
- redness - tenderness - pain - warmth
95
VTE is an increased concern with.... due to?
- c-section - due to decreased mvmt after birth
96
what may be included for interventions due to the risk of VTE? (3)
- low molecular weight heparin - TED stockings - promote early ambulation
97
what is encouraged to reduce incidence of VTE
- encouragement of free mvmt once anesthesia wears off
98
before the pt ambulates, what should be assessed? (5)
- assess for dizziness (d/t risk of orthostatic hypotension in early PP) - be aware of baseline BP - amt of blood loss - type, amt, and timing of analgesics prior to ambulation - ensure have strength/motor fnxn due to epidural
99
what education should be given r/t activity PP (2)
- before c-section will have to put on stockings - walking is good exercise that helps with blood flow in legs
100
what education should be given about the first 2 weeks after c-section r/t activity (3)
avoid: - straining, bending, pulling, or lifting heavy objects - only lift baby - avoid driving until you feel comfortable
101
what education should be provided r/t self-readiness and activity (3)
- avoid activity ex. swimming until your wound has healed and/or lochia has stopped - slowly increase your activity (ex. walking) - avoid vacuuming, sweeping etc. for several weeks
102
what should be assessed r/t perineum if there were no lacerations or episiotomies? normal includes?
- assess for swelling - normal could include minimal edema
103
what should be assessed r/t episiotomy or laceration repairs?
- intactness --> are edges well approximated? - any signs of infection - any hematomas?
104
what are signs of infection r/t episiotomy or laceration repairs? (3)
- redness - warmth - drainage
105
what should not be present when assessing episiotomy or laceration repairs (4)? what should be done if these are present?
- pronounced edema - bruising - hematoma - signs of infection = notify PCP
106
what nursing intervention can be done for swelling of the perineum?
- offer ice pack - usually in 1st 2h for a max of ~15 min
107
what assessments should be done r/t c-section incision PP? (3)
- dressing should be clean and dry - suture line intact - monitor for S&S of infection
108
what should be assessed r/t rectal area PP? (2)
- no hemorrhoids should be present - if hemorrhoids present, should be soft and pink
109
what is a 1st degree laceration
- involves skin & structures to the muscles
110
what is a 2nd degree laceration
- extends thru the muscle
111
what is a 3rd degree laceration
- extends thru anal sphincter
112
what is a 4th degree laceraion
- involves anterior rectal wall
113
what degree of perineal lacerations are considered extensive repairs?
- 3rd degree - 4th degree
114
what are imp ways to prevent infection PP? (6)
- maintain clean enviro - maintain good hygiene - teach care of perineum & lacerations/episiotomy - encourage prior perineal care - teach care of c-section incision - teach to wipe from front to back
115
what is included in maintaining a clean enviro (2)
- clean bed linens - change perineal pads frequently
116
infection can also be an issue for...
- breast tissue --> mastitis
117
what are signs of mastitis (5)
- redness of breast tissue - heat - pain - fever - body aches
118
what is included in education r/t care for perineum
- perineum may receive small tears or is cut during childbirth - if stitches used, they will soft and do not need to be taken out - to avoid infection & heal perineum, keep it clean
119
what is included in education about how to care for the perineum to avoid infection & heal perineum? (7)
- use gentle soap & water while taking a shower or sponge bath, and rinse well and dry w clean towel - use plastic pericare or squirt bottle to spray or a clean jug to pour water over your perineum to lessen stinging when passing urine or rinse away lochia - gently wipe perineum from front to back - change sanitary pad often and always after being on toilet - try not to touch the inside of pad w fingers - do not use tampons for at least 4-6 weeks after having baby - expose perineum to air
120
what is included in education for incision care after c-section (6)
- dressing is usually removed on day 2, and then can shower - in shower, let warm water run over wound and gently pat dry w clean towel - leaving wound uncovered helps it to heal - do not have a tub bath for 2 weeks after c-section - wound takes time to heal - over time, incision will shrink and become paler in color
121
the birther should be educated to call the HCP with what signs of c-section incision? (5)
if wound: - opens - is swollen and red - becomes more painful - has fluid (blood, pus) coming from it - has odor
122
r/t infection, education should be given to the birther to contact their HCP if: (9)
- chills or fever of 38* or higher that lasts longer than 4 h - bad smelling vaginal flow - belly continues to be sore or get more painful - wound is red, swollen, sore, and/or draining fluid (blood, pus) - wound or suture have opened - episiotomy or tear is red, swollen, sore, and/or draining fluid - breast has a red, swollen, or warm area that feels sore - need to void often - pain or burning feeling when you void
123
what is uterine atony
- failure of uterus to contract firmly
124
what is the most freq cause of excessive bleeding?
- uterine atony
125
how can uterine atony lead to excessive bleeding?
- the relaxed uterus will fill w blood and clots, and blood vessels at the placental site are not clamped off = excessive bleeding - inhibits contractions
126
what can cause uterine atony?
- retained placental fragments/membranes
127
what plays an imp role in prevention of excessive bleeding
- VS & assessment monitored closely
128
describe BP with excessive bleeding PP
- compensatory mechanisms prevent a signif drop in BP until there is a loss of 30-40% of blood volume
129
what are the most reliable indicators of excessive bleeding PP? (5)
- resps - pulse - skin condition - urinary output - LOC
130
what are the most important interventions to address uterine activity? (2)
- maintain uterine tone - prevent bladder distension --> promote voiding
131
what are 2 ways to maintain uterine tone
- uterine/fundal massage - uterotonics
132
how does fundal massage help maintain uterine tone?
- causes uterus to firm up by activating muscle layer & contractions
133
describe hand placement w uterine/fundal massage
- upper hand cupped over fundus - lower hand dips in above symphysis pubis and supports uterus while its massaged gently
134
the downward pressure during uterine massage can cause?
- increase in vaginal bleeding to remove pooled blood from uterus to allow for increased contractions --> bleeding should slow down
135
what are birthers taught r/t uterine massage?
- taught to massage own uterus before DC
136
what uterotonics given for?
- to actively manage and prevent postpartum hemorrhage - encourages the uterus to "clamp down" on the open blood vessels at the open placental site
137
what is an example of a uterotonic
- oxytocin
138
how many units of oxytocin are given for the purpose of uterotonic? what stage of labor is this given?
- 5-10 units IM or IV common after delivery of the anterior shoulder - or oxytocin IV after delivery of the placenta - 3rd stage of labor
139
if excessive bleeding occurs in the presence of a firmly contracted uterus & proper placement, what should we suspect? (3)
suspect another source: - vaginal/vulval hematomas - unrepaired lacerations of the vagina or cervix - bleeding at c-section incision
140
if there is bleeding at c-section incision, what should be done? (3)
- mark on drsg - notify PCP - may require pressure dressing
141
what should be assessed r/t emotional status/energy lvl PP? (3)
- impact of birth experience, esp. if different than what they had planned - self-image, sexuality --> invite to discuss feelings - adaptation to parenthood --> realistic perception of infant's needs, take pleasure in infant, respond to infant's cues approp & provide comfort
142
what are normal assessment findings for emotional status/energy lvls (3)
- should be able to care for self and infant - able to sleep - excited, happy, interested/involved in infant care
143
approx 50-80% of all birthers experience ____ PP? what are signs of this?
- experience postpartum blues - may be sad & tearful on days 3-14 for no apparent reason
144
what is included in pt teaching r/t coping w postpartum blues (7)
- get plenty of rest - baby blues are normal - relax techniques - self care - share feelings w your partner or other support - plan activities out of the house - recognize that you are in a time of learning
145
what can impact fatigue PP? (4)
can be related to: - both the physical and psychological - pain - anemia - infection
146
what is imp in promotion of rest (2)
- address pain as needed - support the family w boundaries w visitors as need
147
what is included in education for postpartum emotional changes (3)
- new mothers often expect to feel happy about the baby and are upset that they feel sad, angry, fearful, or anxious - many mothers experience baby blues that may begin few days after birth --> these go away on their own by time baby is 2 weeks - baby blues are due to hormone changes and being a mother
148
what are signs of "baby blues" (7)
- crying often and not always for a reason - feeling v tired - having trouble falling asleep - having trouble thinking clearly or feel out of touch - feelings very nervous about baby - feeling annoyed, angry, and not understanding why - feeling that nothing will ever be the same
149
when should a birth be educated to see their HCP r/t postpartum emotional changes (2)
- if you feel "down", hopeless, and/or out of control and the feelings do not go away - if have thoughts about harming yourself or baby
150
PP pain can be related ? (6)
- afterpains/cramping - perineal laceration or episiotomy - hemorrhoids - sore nipples - breast engorgement - surgical pain w c-section
151
what is important to guide interventions for pain?
- proper assessment
152
for discomfort related to afterpains/uterine contractions, what interventions can be used? (2)
- heating pads - admin of pain meds
153
for discomfort related to the perineum (lacerations, episiotomies), what interventions can be used? (3)
- ice packs (first 24 hrs) - cleansing w warm water - tub bath or sitz bath
154
for discomfort related to sore nipples or breast engorgement, interventions depend on?
- depends on breast/chest feeding or not
155
what analgesics might be prescribed for pain PP (3)
- opioids - NSAIDs - self med packages --> provided instructions and advised to document when taken
156
NSAIDs are preferred for which type of birthers?
- breast/chest feeding persons
157
what type of pain mngmt might be used for people who had a c-section
- may have PCA pump in initial postpartum period
158
the birther should be educated to call the provider for what kinds of pain? (4)
- in your chest - in your belly that is getting worse and not going away - in your legs - sudden severe headache with or without dizziness and blurred vision
159
why should someone with sudden severe headache and blurred vision call the HCP?
- worried abt severe pre-eclampsia which can occur for the first time in PP
160
what exercise supports regaining muscle tone to the pelvic floor
- kegel exercises
161
what vaccination can be given PP if found non-immune? when is it contraindicated?
- rubella vaccine - can be given if breast/chest feeding - contraindicated if immunocompromised
162
when is Rh immune globulin given PP? dose?
- given within 72 hrs after birth to prevent sensitization in the Rh-negative birth - usually 300 mcg
163
Rh immune globulin is considered?
- a blood product = has certain protocol
164
what impact does Rh immune globulin have on the immune response?
- suppresses immune response
165
due to the impact of Rh immune globulin on the immune system, what consideration needs to be taken if also receiving rubella vaccine?
- may need a repeat dose of rubella vaccination in 3 months time if has not developed immunity by then
166
for most birthers, they can safely resume intercourse at how many weeks PP? and once what has happened? most resume by?
- 2-4 weeks PP - once bleeding has stopped and perineum has healed - most resume by 5-6 weeks PP
167
sexual activity PP is affect by?
- perineal discomfort
168
what is common after birth and what impact does this have sexual activity?
- vaginal dryness = may require lubricant
169
why is it imp to educate the birther on sexual activity?
- need to discuss sexual activity prior to discharge as many people will resume sexual activity before the postpartum check up w their primary care provider at 6 weeks
170
why should education r/t contraceptive options be given PP?
- should be discussed prior to d/c bc ovulation can occur prior to the 6 week visit
171
what is the specific criteria for discharge of the birther (13)
- perineum is healing --> appropriate care provided - no intrapartum or postpartum complications that require ongoing treatment or observation - mobile - adequate pain control - bladder & bowel functions adequate - has received Rh immune globulin if needed - contraception education provided - care provider and community liaison nurse (public health nurse) aware of discharge - home enviro has adequate supports/aware of community resources - rubella immunization, as needed - demonstrated ability to feed newborn and to provide newborn care - recognize S&S of illness or concerns r/t newborn - aware of appointment w newborn care provider arranged
172
when are appts w the primary care provider done for a vaginal birth? c-section?
- vaginal = 6 weeks PP - c-section = 2 weeks

NURS 4500: Final Material (16 decks)

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