Exam 3 Flashcards
What is the BUBBLE Assessment?
Breast: symmetrical soft and nontender for the first 24 hrs. Becoming slowly and progressively more full until milk comes in between 2-5 days postpartum
Uterus: should be firm and midline, descending from the umbilicus toward the pelvis at predictable rate
Bladder: encourage frequent emptying of the bladder, full bladder can displace the uterus and cause atony
Bowels: may be slow to recover from the birth and hormones of pregnancy Women who had C-section: more likely to experience ileus (lack of movement in intestine)
Lochia: assess and record the amount of lochia per protocols of the institution
Episiotomy: assess the episiotomy wound or other lacerations: general condition of the perineum: assess for hemorrhoids
Extremities: assess patients’ legs for unilateral edema, warmth, induration, or tenderness any of which would indicate thromboembolism
Emotional State: extreme mood swings, anxiety, and depression are cause for concern
What are the Maternal Adaptation Phases after childbirth?
The taking-in phase, where the mother recovers and takes a passive, dependent role.
The taking-hold phase, where the mother processes the birth experience and transitions to independent behavior.
The letting-go phase, where she acknowledges her new normal and sees the baby as a person instead of an idea.
Postpartum Assessment: Uterus Position
expected findings: firm, midline, and near the level of the umbilicus
Uterine Involution
From birth – first 6 weeks postpartum, the uterus goes through involution (reduction in size)
if this does not occur the client is at risk for postpartum hemorrhaging
During involution process: oxytocin is released, expulsion of placenta, contraction of the uterus continues, and breastfeeding further reduce size of the uterus
Uterine Position: Postpartum
Right after Childbirth: the top, or fundus, of the uterus is usually about 2 cm, or two fingerbreadths, below the level of the umbilicus.
12 Hours: 12 hrs. Postpartum the fundus rises at or below the umbilicus ( can go above the fundus)
By 24 hours after the birth, the uterus is at the umbilicus—the same position as it was at 20 weeks of gestation.
After the first 24 hours, the appropriately involuting uterus has descended from the level of the umbilicus by 1 to 2 cm
By 2 weeks postpartum, the uterus should again be a pelvic organ, and by 6 weeks it should have been involuted completely
Uterine Tone: postpartum
Uterus should be firm after delivery
If a uterus is boggy(soft) indicates uterine atony, and a hemorrhage
Discharge: Activity Teaching
Start exercise gradually, as tolerated.
An increase in lochia may result from exercising too much, too early.
Abdominal exercises may not be possible in the early postpartum period due to muscle weakness or recent abdominal surgery (in the case of cesarean delivery).
Walk regularly to reduce the risk of a thrombus or constipation.
Discharge: Nutrition Teaching
If lactating, stay well hydrated and eat approximately 500 calories more than when not lactating.
Discharge: Sexual activity Teaching:
Resume sexual activity when you feel ready both physically and emotionally.
You may need to use additional lubrication because of hormonal changes to increase comfort.
Discharge: Contraception Teaching
Remember that it’s possible for you to get pregnant even before your first scheduled postpartum visit with the obstetrical provider.
Make a plan for contraception use prior to discharge.
Deep Vein Thrombosis:
Thrombophlebitis- Inflamed thrombus
In lower extremity can be of superficial or deep veins. PP client @ great risk, can lead to PE
Leg pain, tenderness, unilateral area of swelling, warmth, redness
Hardened vein over thrombosis, calf tenderness
Diagnostic procedures: Doppler USN, MRI
Risk Factors For DVT
Pregnancy
Operative vaginal birth
C/S (doubles the risk)
PE or varicosities
Immobility
Obesity
Smoking
Multiparity
Age > 35 yo
History of thromboembolism
Diabetes
Leg pain
DVT: Nursing Care
Compression device before ambulation
ROM with 8 hour of bedrest
Early, frequent ambulation
Elevate legs when sitting, avoid crossing legs
Maintain fluids
No smoking
Measure lower extremities
DVT: Management
Encourage rest, bedrest, elevate feet above level of heart
Warm moist compresses
Do not massage legs (Why?)
Measure leg circumference
Thigh high antiembolism stockings
Treat pain
Anticoagulants for DVT
Anticoagulant: Heparin
IV prevents formation of new clots & prevents enlargement of existing clots
IV Heparin for cont. infusion 3-5days with adjusted doses according to labs- (activated partial thromboplastin time- aPTT)
Protamine sulfate antidote
Client should report bleeding, bruising, blood in urine
Anticoagulant: Warfarin
Used to treat clots PO , 3 months
Phytonadione (Vitamin K) should be available for prolonged clotting time
Monitor PT (1.5-2.5) & INR (2-3)
Client should watch for bleeding & bruising
Use birth control but no oral contraceptives
Teratogenic effects to fetus
Patient Education: Anticoagulants:
Avoid Aspirin, Motrin/NSAIDS
(increases bleeding risk)
Use electric razor for shaving
Avoid alcohol
Use soft toothbrush
Do not rub/massage legs
Avoid prolonged sitting/leg crossing
Pulmonary Embolism
Fragments, clot dislodge into circulation
Complication of DVT, embolism moved into pulmonary artery, lodges into lung, obstructs blood flow to lungs
Expected findings: Apprehension, chest pain, dyspnea, Hemoptysis, Heart murmurs, Peripheral edema, distended neck veins, High temp, hypotension, Hypoxia
Place pt in semi-fowlers, Give O2, Lung scan, Chest X-Ray, same meds as for DVT & thrombolytics: Alteplase & Streptokinase
Coagulopathies: Idiopathic thrombocytopenic purpura (ITP)
Autoimmune disorder, platelet lifespan decreased by antiplatelet antibodies
Can result in severe hemorrhage after c/s or lacerations
Genetic origin
Coagulopathies: Disseminated intravascular coagulation (DIC)
Complication of underlying pathology (IE Amniotic fluid embolism)
Coagulation pathways hyperstimulated, breakdown of blood clots (faster than form), quick depletion of clotting factors ➔hemorrhage & death
Risk factors: Abruptio placenta, HELLP syndrome, Amniotic fluid embolism
Assessment findings:
Prolonged uncontrollable uterine bleeding,
Bleeding from IV site, gums, bladder
Purpuric areas at pressure sites (such as BP cuff)
Abnormal clotting study results
Anxiety
S/S of shock (Pale & clammy skin, HR, RR, BP)
Coagulopathies:
Unusual bleeding from nose, gums, IV site, incisions, petechiae, bleeding gums, hematuria, tachycardia, hypotension, diaphoresis, oliguria
Labs: CBC, Blood type/crossmatch, clotting factor
With DIC: Focus on assessing/correcting underlying cause (Ex preeclampsia, abruption etc)
Volume expanders, fluids, blood, antibiotics, uterogenic agents etc
Give Oxygen
Surgical intervention as needed
Coagulopathies: Patient Centered Care
Assess skin (Sites for possible bleeding)
Monitor VS & hemodynamic state
Monitor urinary output, foley cath
Transfusion, Plt as needed
Assist in prep client for splenectomy if ITP does not respond to medical care
With DIC, Correct cause
Hysterectomy may be needed
Care in ICU
Postpartum Hemorrhage:
Blood loss
>500 mL following a vaginal birth
>1,000 mL following a cesarean birth
Any amount of bleeding that places the mother in hemodynamic jeopardy
May result in hypovolemia and shock
Causes of Postpartum Hemorrhage
Most common uterine atony (current or past), subinvolution
Overdistended uterus, High parity
Prolonged labor, oxytocin induced or precipitous delivery
Lacerations of the genital tract
Episiotomy, lacerations, hematoma
Retained placental fragments
Uterine inversion, Ruptured uterus
Coagulation disorders
Hematomas of the vulva, vagina, or subperitoneal areas
Pregnancy complications (previa, abruption)
Magnesium Sulfate in labor
