POSTPARTUM ASSESSMENT Flashcards
CLINICAL ASSESSMENT
- review antepartum and intrapartum history
- determine educational needs
- consider religious and cultural factors
- assess for language barriers
- check your own feelings
ANTEPARTUM AND INTRAPARTUM HISTORY
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
POSTPARTUM
- 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
DISCHARGE HOURS
48- VAGINAL BIRTH
72- C-section
SAFTEY FOR MOTHER AND INFANT
- prevent infant abductions
- check ID bands
- educate mother about safety measures
- right baby to right mother
POST PARTUM ASSESSMENT BUBBLE-HE
breast uterus bladder bowel lochia episiotomy homans/legs emotion
EARLY ASSESSMENT
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
POST PARTUM INFECTION INDICATION
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
PAIN ASSESSMENT
-determine source
- document location , type and duration
-interventions
~medication, positioning, ice, baths, heat lamps
BREAST ASSESSMENT
- 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
NURSING CARE FOR NON- LACTATING MOTHER
- avoid stimulation
- wear support bra 24hrs
- ice packs or cabbage leaves
- mild analgesic fro discomfort
BREAST FEEDING NOTES
- baby face toward breast (lead with chin )
- nipple toward upper mouth
- mouth covers most of nipple ( bottom of it mostly)
- baby aligned with breast
ASSESSMENT OF UTERUS/ FUNDUS
- 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 )
INVOLUTION
oxytocin is released and cause uterus to contract
NURSING CARE FOR A BOGGY FUNDUS
-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
AFTERPAINS
- intermittent uterine contractions due to involution
- primiparous- mild
- multipara- more pronounced
NURSING INTERVENTIONS FOR AFTERPAINS
- 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)
BLADDER
spontaneous void 4-6 hrs
-monitor output 200 ml X 2
- postpartum diuresis
palpate, bladder scan, decreased bladder tone, uterus cant contract, pain meds
NURSING CARE FOR BLADDER
- 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
BOWEL
- 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
NURSING CARE FOR BOWEL
- increase fiber in diet
- 8 glasses of water or juice(more if nursing )
- stool softener
- laxative
- sitz bath for discomfort
- medications for hemrrhoids
LOCHIA
- 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
STAGES OF LOCHIA
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
NURSING CARE FOR LOCHIA
- 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
EPISIOTOMIES /LACERATION
- 1-2 inch incision in the muscular area between the vagina and the anus
- assess REEDA (redness, edema, ecchymosis, discharge, approximation)
- episotomy care
NURSING CARE FOR EPISIOTOMY
- peri care
- ice packs
- sitz bath
- dry heat
- topical medications
- tighten butt before sitting down
HOMANS/LEGS
-homan’s sign (DVT assessment)
- clinical assessment
color,temp , present pain= DVT
NURSING CARE FOR LEGS
- encourage early ambulation
- hydration
- SCD’S
- leg exercises if on bed rest
decreases afterbirth pains, DVT, constipation,promotes urination
EMOTIONS/POSTPARTUM BLUES
- transient periods of depression during the first 1-2 weeks
- tearfulness
- sad feeling
- confusion
- insomnia
NURSING CARE FOR POST PARTUM BLUES
- 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
POSTPARTUM LAB CHANGES
-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
TYPICAL POSTPARTUM MEDICATIONS
ibuprofen acetaminophen Colace ferrous sulfate epi foam Percocet multivitamin
VACINATIONS
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
RH
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
FAMILY AND INFANT BONDING
- transitioning to parenthood assuming the mother role
- assuming the mothering role
- parental bonding
- factors that interrupt bonding
transitioning to parenthood
- difficult and challenging
- provide emotional support
- accurate information
- nursing goal create a supportive teaching environment
ATTACHMENT
- attachment process helps to lay the foundation for nurturing care
- touch skin to skin
- face to face contact with eye contact
- breast feeding
