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
