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Mother/Infant > POSTPARTUM ASSESSMENT > Flashcards

POSTPARTUM ASSESSMENT Flashcards

1
Q

CLINICAL ASSESSMENT

A
  • review antepartum and intrapartum history
  • determine educational needs
  • consider religious and cultural factors
  • assess for language barriers
  • check your own feelings
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2
Q

ANTEPARTUM AND INTRAPARTUM HISTORY

A 
type of delivery 
instrumentation
complications 
duration of labor 
allergies
feeding method chosen 
meds used and given 
last feeding of baby 
last voiding of mother 
exam of fundus and body 
blood type
RH 
educational needs
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3
Q

POSTPARTUM

A
  • begins immediately after child birth through the 6th post partum week
  • reproductive track returns to non pregnant state
  • adaptation to the maternal role and modification to the family system
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4
Q

DISCHARGE HOURS

A

48- VAGINAL BIRTH

72- C-section

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5
Q

SAFTEY FOR MOTHER AND INFANT

A
  • prevent infant abductions
  • check ID bands
  • educate mother about safety measures
  • right baby to right mother
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6
Q

POST PARTUM ASSESSMENT BUBBLE-HE

A 
breast 
uterus
bladder
bowel 
lochia
episiotomy 
homans/legs
emotion
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7
Q

EARLY ASSESSMENT

A

VITAL SIGNS

  • blood pressure
  • pulse (50-70bpm)
  • respirations (12-20)
  • Temperature (100.4 24 hrs after birth due to dehydration or epidural
  • Orthostatic hypertension
  • watch red heads with warm water
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8
Q

POST PARTUM INFECTION INDICATION

A

the presence of fever of 38C or more on 2 successive days of the first 10 postpartum days ( not including the first 24 hrs) is indicative of a postpartum infection

  • shimmering and shakes is normal after birth
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9
Q

PAIN ASSESSMENT

A

-determine source
- document location , type and duration
-interventions
~medication, positioning, ice, baths, heat lamps

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10
Q

BREAST ASSESSMENT

A
  • inspect for size , contour , asymmetry and engoregement
  • nipples check for cracks, redness, fissures
  • note if nipples are flat, inverted or erect
  • evalutate for mastitis(infection of breasts)

milk comes in on day 3 , progesterone decreases, prolactin increases= milk production stimulation is needed

after 3 hrs with no stimulation prolactin will decrease

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11
Q

NURSING CARE FOR NON- LACTATING MOTHER

A
  • avoid stimulation
  • wear support bra 24hrs
  • ice packs or cabbage leaves
  • mild analgesic fro discomfort
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12
Q

BREAST FEEDING NOTES

A
  • baby face toward breast (lead with chin )
  • nipple toward upper mouth
  • mouth covers most of nipple ( bottom of it mostly)
  • baby aligned with breast
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13
Q

ASSESSMENT OF UTERUS/ FUNDUS

A
  • location immediately after birth
  • descends 1cm/ day
  • consistency - firm/ boggy
  • location height - measured in fingerbreadths
  • placenta birth is 15min after fetus
  • 5 fingers above umbilicus and moves to umbilicus ( 12 hrs later )
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14
Q

INVOLUTION

A

oxytocin is released and cause uterus to contract

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15
Q

NURSING CARE FOR A BOGGY FUNDUS

A

-massage until firm
MEDICATIONS
- Pitocin,methergine, hemabate

  • teach new mom to massage her fundus
  • make sure mom empties bladder 1hr before assessment 200ml X 2 are recorded
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16
Q

AFTERPAINS

A
  • intermittent uterine contractions due to involution
  • primiparous- mild
  • multipara- more pronounced
17
Q

NURSING INTERVENTIONS FOR AFTERPAINS

A
  • patient in prone position and place a small pillow under her abdomen
  • ambulation
  • heating pad
  • medicate with a mild analgesic( for breastfeeding women 30min before nursing)
18
Q

BLADDER

A

spontaneous void 4-6 hrs
-monitor output 200 ml X 2

  • postpartum diuresis
    palpate, bladder scan, decreased bladder tone, uterus cant contract, pain meds
19
Q

NURSING CARE FOR BLADDER

A
  • encourage frequent voiding every 4-6 hrs
  • monitor intake and output for 24 hours
  • early ambulation
  • void within 4 hrs after birth
  • catheterization if unable to void
20
Q

BOWEL

A
  • anatomy returns to normal
  • relaxin (hormone secreated during pregnancy ) depresses bowel motility
  • diminished intraabdominal pressure
  • incontinence if sphincter lacerated
  • spontaneous BM 2nd- 3rd post partum day
21
Q

NURSING CARE FOR BOWEL

A
  • increase fiber in diet
  • 8 glasses of water or juice(more if nursing )
  • stool softener
  • laxative
  • sitz bath for discomfort
  • medications for hemrrhoids
22
Q

LOCHIA

A
  • mixture of erythrocytes, epithelial cells, blood, fragments of decidua, mucus and bacteria
  • as involution preceeds it is the necrotic sloughed off decidua
  • 240-270 ml
  • cesarean less
  • present for 3-6 weeks
23
Q

STAGES OF LOCHIA

A

RUBRA -dark red 1-3 days
SEROSA- pink,brown 3-10 day
ALBA - yellow white 10 days - 2 weeks

DOCUMENTATION :
odor
color
amount 
presence of clots

4-8 pads a day is normal
may need to weigh pads 1gm=1ml of blood loss

24
Q

NURSING CARE FOR LOCHIA

A
  • educate mother on the stages of lochia ]
  • caution mother that an increase, foul odor or return to rubra lochia is not normal
  • instruct patient to change peripad frequently
  • peri care after each void

warm water
blot dry front to back
remove and apply pad front to back
wash every 24 hrs

25
Q

EPISIOTOMIES /LACERATION

A
  • 1-2 inch incision in the muscular area between the vagina and the anus
  • assess REEDA (redness, edema, ecchymosis, discharge, approximation)
  • episotomy care
26
Q

NURSING CARE FOR EPISIOTOMY

A
  • peri care
  • ice packs
  • sitz bath
  • dry heat
  • topical medications
  • tighten butt before sitting down
27
Q

HOMANS/LEGS

A

-homan’s sign (DVT assessment)
- clinical assessment
color,temp , present pain= DVT

28
Q

NURSING CARE FOR LEGS

A
  • encourage early ambulation
  • hydration
  • SCD’S
  • leg exercises if on bed rest

decreases afterbirth pains, DVT, constipation,promotes urination

29
Q

EMOTIONS/POSTPARTUM BLUES

A
  • transient periods of depression during the first 1-2 weeks
  • tearfulness
  • sad feeling
  • confusion
  • insomnia
30
Q

NURSING CARE FOR POST PARTUM BLUES

A
  • remind mom that the blues are normal
  • encourage rest
  • utilize relaxation techniques
  • share her feelings with her partner
  • if symptoms do not resolve and progress to depression medical treatment needs to be sought
31
Q

POSTPARTUM LAB CHANGES

A 
-changes in H/H
placental detachment 
fluid shifts 
diuresis
HGB <11.5 and HCT <30% considered too low
  • coagulation factors
    white blood cell count often elevated 30,000= normal
    predisposed to thrombus formation
    platlets

normal 2-3% loss of HCT= 500ml vaginal= >1000 bad for c section

32
Q

TYPICAL POSTPARTUM MEDICATIONS

A 
ibuprofen
acetaminophen 
Colace
ferrous sulfate
epi foam 
Percocet 
multivitamin
33
Q

VACINATIONS

A

RUBELLA/MMR
administer to non immune mothers
safe for nursing mothers
avoid pregnancy for 1 month flu type symptoms may occur

titers < 1-8 vaccine is needed

34
Q

RH

A

RHO immune globulin
mother is RH negative, infant RH positive
negative comb’s test then give RHOgram
300Mcg of RHO gram within 72hrs after delivery

35
Q

FAMILY AND INFANT BONDING

A
  • transitioning to parenthood assuming the mother role
  • assuming the mothering role
  • parental bonding
  • factors that interrupt bonding
36
Q

transitioning to parenthood

A
  • difficult and challenging
  • provide emotional support
  • accurate information
  • nursing goal create a supportive teaching environment
37
Q

ATTACHMENT

A
  • attachment process helps to lay the foundation for nurturing care
  • touch skin to skin
  • face to face contact with eye contact
  • breast feeding

Mother/Infant (8 decks)

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