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Maternity > Postpartum Assessment > Flashcards

Postpartum Assessment Flashcards

1
Q

Preparing for PP Assessment: Before you enter the room

A

Plan ahead: what do you need?
Obtain baseline knowledge from chart review
Take care pathway, notepad and pen into room

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2
Q

Preparing for PP Assessment: When you enter the room

A
  • introduce yourself (to pt and family)
  • promote privacy and HH
  • do assessments methodologically and timely
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3
Q

Preparing for PP Assessment: before you start you assessment

A
  • work around the need of the clients
  • ensure comfort (pain control)
  • have mom void before the assessment (where applicable)
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4
Q

When to do a PP Assessment: SVD

A
  • Every 15 minutes since delivery for 1 hour (including a temperature)
  • At 2 hours post delivery
  • then once a shift (8-12) hours
  • As required by nursing judgement or self-report
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5
Q

When to do a PP Assessment: Caesarean Section

A
  • Every 15 minutes since delivery for 1 hour at 2 hours post delivery
  • Every 4 hours for the first 24 hours post delivery, then once a shift
  • as required by nursing judgement or self-report
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6
Q

Post Partum Head to Toe

A
  • vital signs, sedation scale
  • BUBBLE LEP
  • Skin to skin with baby (bonding and attachment)
  • Support, family function and family planning
  • Concerns and past history
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7
Q

Vital Signs

A

Temp: 36.7-37.9
Pulse: 55-100
Resps: 12-24 unlabored
Blood Pressure: 90-140/50-90
Manual BP, Pulse 1 min, oral temp, resps
Sedation Scale
1. fully awake and oriented
2. drowsy
3. eyes closed but rousable on command
4. eyes closed but rousable to mild physical stimulation
5. eyes closed but unrousable to mild physical stimulation

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8
Q

BUBBLE LEP

A

B - breasts
U - uterus
B - bladder
B - bowel
L - lochia
E - episiotomy/Perineum
L - legs and feet
E - emotional coping and mental health
P - pain

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9
Q

Breasts and Newborn Feeding

A
  • ask permission
  • normal: soft, filling from day 3-5
  • intact skin on nipples and areola; not sore, nipples may be flat or inverted, but protrude with baby’s feeding attempts
  • able to express small amount of colostrum
  • support non-breastfeeding mom
  • BF/bottle feeding well
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10
Q

Uterus and incision in C-Secions

A
  • Firm, midline, at or below umbilicus
  • void before palpate
  • woman supine, knees flexed, support uterus above symphysis except with C-section
  • No S&S of infection
  • Incision healing, dressing dry & intact
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11
Q

Bladder

A
  • void comfortably 2/3 times a shift
  • able to empty bladder
  • no feelings of pressure or fullness
  • dysuria following catheter removal
  • postpartum diuresis and diaphoresis
  • catheter drainage 30 ml/hour post C-section
  • keep in mind factors such as episiotomy, tears
  • peri-bottle, hydration
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12
Q

Bowels

A
  • May or may not have BM (3x a day or once in 3 days)
  • use stool softeners when needed
  • Post C-section bowel sounds present
  • may eat and drink post section when hungry or thirsty, minimal abdominal distension, flatus passed
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13
Q

Lochia

A

Assess amount, colour, clots, odor, stage of involution
Rubra - bright dark red (1-3 days pp)
Serosa - pink/brown (3-10 days pp) - dark red shedding from the placenta site
Alba - yellow whitish (10 days -6 weeks pp)
Absence of loonie size or bigger clots and any trickling. no saturation of pad in one hour
- no foul smell
- increased flow when bf/ambulating
- overall 4-8 weeks, generally lessens & follows expected progression

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14
Q

Episiotomy/Perineum/Extremities

A
  • Discomfort (less than 4/10 pain scale)
  • Tears/episiotomy stitched, well approximated
  • Episiotomy considered 2nd degree laceration
  • No swelling, bruising, hematoma, discharge
  • Analgesics, comfort measures (teabags, ice packs, sitz baths, peri-care, stool softeners)
  • no s&s of infection
  • Edema lower extremities
  • Pedal pulses present
  • No signs of DVT
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15
Q

Emotional coping and mental Status

A
  • Explore response to delivery experience.
  • C/S, Birth Trauma
  • Assess PPD, emotional status, mood variations
  • Feels supported
  • Feels able to care for self and infant. confidence & competence
  • excited: interested or involved in infant care
  • able to sleep
  • accepts assistance in care and willingness to learn
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16
Q

Primary concern that we are watching for in a postpartum assessment? Postpartum Hemorrhage

A

Signs: V/S are out of range -> U = uterus is boggy -> L = lochia is a steady trickle or gush with uterine massage or ambulation. saturated pad < 1 hr -> P = pain. pain could indicated retained tissue. no pain could indicated lack of contracting in the uterus
Action = Report now!
- retake VS and watch sedation
- Massage
- Observe flow during fundal massage: check under buttocks for pooling. weigh pads or clots
- compare against previous pain assessments

17
Q

Skin to Skin (Bonding and attachment)

A
  • Maternal and paternal skin to skin
  • parents respond to feeding cues
  • interaction between parents and infant by holding, talking, cuddling, eye contact, seem to enjoy interaction with infant
  • effective consoling techniques
  • respond to needs of infant in loving and sensitive manner, emotionally and physically available
18
Q

Supports, Family Assessment and Family Planning

A
  • maternal support system
  • family function, interaction, and positive coping
  • no signs of intimate partner violence, family abuse
  • family understanding of family planning and resumption of intercourse
  • safe home environment
  • healthy lifestyle (free of second-hand smoke, drug free, alcohol use)
  • healthy eating and fluid intake
  • activity/rest/ambulation
19
Q

Concerns and Past History

A
  • Communicable diseases
  • RH
  • Blood group
  • Gestational diabetes
  • Hypertension
  • Birth history
  • Baseline vitals
  • GTPAL
20
Q

RH Factor

A

RH factor: fetal RBCs enter into maternal circulation at time of birth. The mothers natural defense mechanism responds to alien cells by producing anti-RH antibodies. Normally there is not effect during the first pregnancy with an RH + fetus as initial sensitization rarely occurs before the onset of labour.
However, with increased risk of fetal blood being transferred to maternal circulation during placental separation, maternal antibody production is stimulated. During a subsequent pregnancy with a RH + fetus, maternal antibodies enter fetal circulation where they attack and destroy fetal erythrocytes

21
Q

Discharge Criteria

A
  • Postpartum pathway
  • must have all maternal & infant criteria as normal or plan in place for variances
  • Must have completed all discharge education
22
Q

Gravida

A

woman who is pregnant

23
Q

Gravidity

A

pregnancy

24
Q

Multigravida

A

woman who has had two or more pregnancies

25
Q

Multipara

A

woman who has completed two or more pregnancies at 20+ weeks gestation

26
Q

Nulligravida

A

woman who has never been pregnant

27
Q

Nullipara

A

woman who has not completed a pregnancy with beyond 20 weeks gestation

28
Q

Preterm

A

pregnancy between 20-0 and 36-6

29
Q

Primigravida

A

woman who is pregnant for the first time

30
Q

primipara

A

woman who has completed one pregnancy with fetus or fetuses who have reached 20 weeks of estation

31
Q

Term

A

pregnancy from 37-0 to 41-6

32
Q

Viability

A

capacity to live outside the uterus (22-25 weeks gestation)

33
Q

GTPAL

A

G- gravida: total # of pregnancies
T - Term: # of births 37-0 + weeks gestation
P - Preterm: # of births 20-0 to 36-6 weeks
A - abortion: any spontaneous (miscarriage) or induced birth < 20 weeks
L- living: total # of children currently living

34
Q

Discharge Criteria

A

Need to have normals
Need plan in place for variances
Need to have completed all education

Maternity (16 decks)

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