T3- Nursing Care During Post-Partum Flashcards
What are the assessments for the 4th stage of labor?
- VS
- Fundus (consistency and location)
- Lochia (amount, consistency)
- Perineum (REEDA)
- Bladder: Ability to void, distention
- PAR (return of sensation to legs and bladder)
What are the frequency of assessments in 4th stage of labor?
First hour q15 min
Second hour q 30 min (if stable)
Then q hour for 4 hours; then q8 hours till discharge
Who is at risk for excessive bleeding?
Those having macrocosmic or multiple birth, have a long/difficult labor, or a multipara
Large for gestational age
Mass is above 90th percentile at gest. age
Macrosomia
Mass is above a defined limit at any gest. age
Small for gest. age
Mass is below 10th percentile at gest. age
Low birth mass
Mass is below a defined limit at any gest. age
What are we palpating for when we check the fundus?
Palpate the uterine position and the firmness of it
What is the most common cause of uterine atony?
PPH
How do we know there is uterine atony?
It is boggy and not firm
What helps a boggy uterus?
Fundal massage; also check bladder
*over massage can make the fundus boggy
What is the expected outcome of this nursing diagnosis?
Risk for deficient fluid volume r/t blood loss associated with vaginal birth
The pt wil exhibit a firm uterus and moderate lochial flow
A full bladder inhibits ______
UC
What are 2 meds that can be given to stimulate UC?
- Pitocin
- Methergine
When would we NOT administer methergine?
If BP is 140/90 or greater
What is the temp like first 24 hours PP?
May have a fever and during first 24 hours this is OKAY
*a temp greater than 100.4 that persists 2 days (exclusive of first 24 hours) is indicative of infection
VS: PP
What HR would we report to caregiver?
Over 100
How can we prevent infection?
- Change peri pad with each void or defecation
- Peri care
- Dont forget if they had ROM longer than 24 hours before delivery, they are higher risk for infection
How do we promote healing of perineum?
- Ice pack for first 24 hours to decrease edema
- Sitz bath after 24 hours tidx20 min
- Peri care with warm water each urination
- Blot dry
- Wipe front to back
- Apply new pad at each void
What are signs of infection based on assessing lochia?
- Odor
- Reverts to earlier stage or amount
- Persists beyond normal time
How much is scant lochia?
Less than 2.5 cm (10 mL or 10 g)
How much is small/light lochia?
Less than 10 cm (10-25 mL)
How much is moderate lochia?
Greater than 10 cm (25-50 mL)
How much is heavy lochia?
1 pad saturated w/in 2 hours
If pad is saturated in 15 min or less, this constitutes what 3 things?
- Immediate assessment
- Intervention
- Notify physician
Early hemorrhage is in the first 24 hours past delivery. What is the color? What is it r/t?
Color: Bright red
R/t: Tears or lacerations
Late hemorrhage is past the first 24 hours. What is the color? What is it r/t?
Color: Dark red blood
R/t: Retained fragments of placenta or infection
Why does the bladder fill quickly past delivery?
Fluid shift
A full bladder contributes to a ____
Boggy uterus
What are interventions to prevent UTI?
- Assess residual urine
- Encourage fluids up to 3000 mL/d
- Catheterize if bladder is distended, uterus is displaced, 6 hours since last void, or voiding less than 150 mL
Breast care and breast feeding: What do we inspect and teach?
- Inspect breasts for redness, cracks in nipples
- Teach to “latch on” and to break suction correctly
- Alternate breasts to begin feeding
- Gradually increase length of time
What do we teach the lactating client about breast hygiene care?
- Wash nipples and areola w/ water (NO SOAP)
- Airdry for 20 min
- To prevent cracking apply expressed breast milk or nonalcohol cream
- Empty engorged breasts manually or with feeding
- Support bra
How can the woman prevent sore nipples?
- Vary infant position during feeding (side lying, cradle, football hold)
- Release suction correctly by inserting finger in neonates mouth
What is the nutrition like for lactating client?
- Increase fluid and caloric intake (2700kcal/d)
- No meds unless talked to doc
- Avoid foods that cause gastric irritation, gas, diarrhea
Nonlactating clients needs ___ cal/d
Lactating client needs to add ___ cal/d
Nonlactating: 1800-2200 kcal/d
Lactating: Add 450-500 kcal/d
What happens if the nipples become sore and cracked and bacteria enters in causing mastitis..how is it treated? can they still breastfeed?
Treated w/ antibiotics
Cant breastfeed baby but still need to pump so just pump and dump it
What do we teach about suppression of lactation?
- Support bra
- Avoid breast stimulation
- Ice packs 15 min q hr
- Comfort measures for breast engorgement
- Pain med
- Cool, clean cabbage leaves
How are DTRs graded?
0: No response
1: Hypoactive, diminished
2: Average, normal
3: More brisk than usual
4: Hyperactive, exaggerated
What may indicate venous thrombosis?
- Absent/diminished pulses
- Reddened areas, warmth
- Homan sign
What is prevention for venous thrombosis? Treatment?
Early ambulation
Treatment: Bedrest and anticoagulant like heparin (safe for breastfeeding clients)
If the indirect coombs test is negative that means there are no Rh antibodies in the _____. What do we do?
Mothers blood (direct coombs no rh antibodies in cord blood)
We administer RhoGam 300 mcg IM w/in 72 hours of delivery and test immunity in 3 months
If mom was not immune to rubella during pregnancy, then after delivery we will administer the rubella vaccine. What do we teach?
To avoid pregnancy for one month after each dose
It is safe for breastfeeding clients
And a rash may develop if you are allergic to duck eggs
What is the Hot-Cold adaptation asian women do?
Pregnancy= hot condition and heat is depleted during birth so now she is in cold state for 40 days PP. During cold state, you only eat hot food and beverages, there is also discourage from showering because a shower causes heat loss
Taking in phase is the first ___ PP. What goes on here?
1-2 days PP
- Introspective, preoccupied with own needs rather than new baby
- Passive/dependent behavior
- Excited/talkative
- Touches/explores infant
- Needs to verbalize L&D experience
Taking hold phase begins ____ PP and lasts _____. What goes on?
Begins 2-3rd day PP and lasts 10 days to several weeks
- More independent behavior
- Desires to take charge
- More receptive to teaching!!!!
What goes on in letting go phase
- Realistic independent role achieved
- Establishes norms for self and fam
- Mothering function est.
- Resumes relationship with partner and sexual activity
- Fam system enters new phase of dev
PP blues is transient depression usually between the ____ or within ____.
2nd and 3rd PP day or w/in 2 weeks
What is PP blues characterized by?
- Mood swings
- Anger
- Tearfulness
- Feeling let down
- Anorexia
- Insomnia
- Emotional labile
- Cries for no reason
PP blues usually resolves spontaneously. What if symptoms persist or are severe?
Evaluate for PP depression
