Test #4 - Rest & Exercise/Oxygen Need Flashcards
What are some items that provide relief for hemorrhoids?
- Sltz baths
- Topical anesthetic ointments
- Rectal suppositories
- Witch hazel pads
What are some relief items of afterpains?
Positioning (prone position)
Analgesia administered an hour before breastfeeding
Encourage early ambulation - monitor for dizziness and weakness
What are some items to teach about postpartum medications?
Postpartum patient may need medications to promote comfort, treat anemia, immunize, and prevent development of antigens (in nonsensitized Rh-negative woman)
Postpartum patients should be informed about name of medication, expected action, possible side effects
Nurse must review safety measures with medications
What are some items to remember about rest postpartum?
Organize nursing care to avoid frequent interruptions, educate new mother that fatigue may persist for several weeks
Mother should be encouraged to rest when baby rests
Mother may need to make adjustments at home and work
What do you need to teach about ovulation and menstration for the postpartal woman?
- Menstruation returns between 6 and 10 weeks after birth in nonlactating mother. Lactating mothers may begin ovulation returns 3-6 months
- Return of ovulation and menstruation in breastfeeding mother is prolonged related to length of time breastfeeding continues
What do you need to teach them about sexual activity post partum?
Sleep deprivation, vaginal dryness, and lack of time together may impact resumption of sexual activity
Usually sexual intercourse is resumed once episiotomy has healed and lochia has stopped (about 6 weeks)
Breastfeeding mother may have leakage of milk from nipples with sexual arousal
What are some items to remember about contraception post partum?
Information on contraception should be part of discharge planning
Nursing staff need to identify advantages, disadvantages, risk factors, any contraindications
Breastfeeding mothers concerned that
contraceptive method will interfere with
ability to breastfeed - they should be given
available options
What are some postpartum C-Section assessments?
Breasts must be assessed, assess location and firmness of fundus, lochia, and incision site
Assess Foley catheter in place, color, and amount noted - bowel sounds are checked: present, decreased, or minimal
Abdominal Incision
What are some nursing care items for C-Section?
Cesarean birth is major abdominal surgery - if general anesthesia used, abdominal distension may cause discomfort
Turn every 2 hours, early ambulation, avoid carbonated beverages - may need enemas and stool softeners
Pulmonary infections may occur because of immobility and use of narcotics because of altered immune response
Encourage turn, cough, deep breath every 2 hours while awake until she is ambulating
What are some pain and comfort interventions postpartum?
Administer analgesics within the first 24 to 72 hours - allows woman to become more mobile and active
Encourage visits by family and newborn, which provides distraction from painful stimuli
Encourage non-pharmacologic methods of
pain relief (breathing, relaxation, and
distraction) - encourage rest
What happens for the attachment after a C-Section?
Physical condition of mother/newborn and maternal reactions to stress, anesthesia, and meds may impact mother-infant attachment
By 2nd or 3rd day, cesarean birth mother moves into “taking-hold period”
Emphasize home management and encourage mother to allow others to assume housekeeping responsibilities
-Stress how fatigue prolongs recovery and may
interfere with attachment process
What do you need to do to prepare mom for discharge?
Preparation for discharge should begin when expectant mother enters birthing unit
Mother needs to be aware of signs of postpartum complications and should be aware of her self-care needs
Nurses should begin first by assessing knowledge and expectations of new mother and family
Nurse should be available to answer questions and provide support to parents
Nurse should review with new mother any information she has received regarding postpartum exercises, prevention of fatigue, sitz bath and perineal care, etc. -nurse should spend time with parent to determine if they have any last-minute questions before discharge
What is postpartum hemorrhage defined as?
Blood loss that exceeds 500 ml after vaginal childbirth or 1000 ml after cesarean birth
What are some risk factors for postpartum hemorrhage?
Induction/Augmentation
Uterine infection
Maternal malnutrition
Anemia
Gestational hypertention
History of hemorrhage
History of blood clotting problems
What are some specific items that put a patient at risk for post partum hemorrhage?
Overdistention of uterus - from hydramnios, macrosomia, or multiple gestations
Grand muitip - old uterus with poor muscle tone
Anesthetics that relax uterus
Trauma - from use of mid forceps, intrauterine manipulation, forceps rotation - all could cause lacerations
Prolonged or rapid labor
What are some items to do and remember when dealing with postpartum hemorrhage? (What to monitor/might not see)
You must monitor uterine tone and lochia flow carefully
-Where is fundus? Is it firm? Is there large clots?Bleeding?
Do not rely on VS changes (BP usually remains normal)
Changes in BP or pulse may not be seen until there has been a significant blood loss because woman is starting off with a higher blood volume from pregnancy
What happens during early postpartum hemorrhage?
Occurring in the first 24 hrs after birth
Bleeding may be slow or heavy and massive
Uterine Atony
Trauma to birth canal during L&D
Abnormalities: Placenta accreta, inversion, retained placenta
DIC
What is Uterine Atony?
Relaxation of the uterus
It won’t contract
Lack of muscle tone that results in failure of uterine fibers to contract firmly around blood vessels when the placenta separates
Most common cause of PP hemorrhage
Blood may be flowing out of uterus or pooling inside of uterus
Causes 80% to 90% of early PP hemorrhages
What are some risk factors that can lead to Uterine Atony?
Overdistention
Dysfunctional or prolonged labor
Oxytocin augmentation, Use of anesthesia
Prolonged third stage of labor
Gestational hypertension
HX of hemorrhage, blood clotting problems, anemia
Retained placental fragments
Grandmultiparity
Placenta previa or Accreta
What is retained placenta and what do you need to check for?
Retained Placenta sometimes caused by it being peeled off instead of waiting for it to separate naturally
It’s usually caused by massaging thefundus before separation occurs
Need to check the placenta and make sure it’s intact
Treatment -manual extraction, D&C, or hysterectomy
What are some predisposing factors that lead to lacerations of the birth canal ?
Common cause of Hemorrhage (20%)
Includes: Vaginal, Perineal or Cervical Lacerations
Hematomas
Macrosomia
Rapid labor and delivery
Lacerations of Birth Canal - may be spontaneous or caused by instrument
The primary care provider usually checks for lacerations after a vaginal birth
What is DIC (Disseminated intravascular coagulation)?
Causes blood coagulation problems
Clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII
Widespread external bleeding, internal bleeding, or both can result
Vascular occlusion of small vessels resulting from small clots forming in the microcirculation can also occur
Unusual bleeding i.e. spontaneous bleeding from the woman’s gums or nose may be noted. Petechiae may appear around a blood pressure cuff placed on the woman’s arm
What can cause DIC?
May result from PIH
amniotic embolism
sepsis
abruptio placentae
prolonged fetal demise
excessive blood loss
What are some assessment findings for DIC?
Excessive bleeding may occur from the site of a slight trauma
Symptoms also may include tachycardia and diaphoresis
(e.g., venipuncture sites, intramuscular or subcutaneous injection sites, nicks from shaving of perineum or abdomen, and injury from insertion of a urinary catheter)
What are some lab tests for DIC?
Decreased levels of platelets, fibrinogen, proaccelerin, antihemophiliac factor, and prothrombin (the factors consumed during coagulation)
Fibrinolysis is increased at first but is later severely depressed. Degradation of fibrin leads to the accumulation of fibrin split products in the blood; these have anticoagulant properties and prolong the prothrombin time
What are some nursing interventions for DIC?
Assess for signs of bleeding and complications from the administration of blood and blood products
Administering fluid or blood replacement as ordered
Protecting client from injury
Urinary output is monitored due to renal failure, must maintain OP of 30 ml/hr or more
What is late postpartum hemorrhage?
Begins 24 hrs after birth, often 1-2 weeks after
Excessive activity can reopen the wound where the placenta was attached to the uterus
What can cause late postpartum hemorrhage?
Retained placental fragments
Hematomas
Subinvolution - failure of uterus, and therefore, the placental site to reduce in size and shape
Infection
What is late postpartum hemorrhage caused by subinvolution and what do you see and do?
Uterus remains higher in abdomen than expected and lochia stays rubra, or returns to rubra after progressing to serosa
Leukorrhea and backache may occur with infection
Treat with Methergine to contract uterus
Antibiotics if have infection
What is late postpartum hemorrhage caused by hematomas and what do you watch for?
Hematomas - injury to blood vessels without trauma to tissues; may contain 250-500 ml of blood
Monitor for S/S of shock - weak, rapid, irregular pulse, pallor, cold moist skin
Causes severe pain and feelings of pressure
What are some predisposing factors for hematomas?
PIH
Genital Varicosities
Pudendal block
Precipitous labor
Prolonged 2nd stage
LGA infant
What are some assessments for hematomas?
Assessment findings include c/o severe pain at “stitches” (episiotomy) that doesn’t ease up
See tense, bulging, bluish, firm, painful mass at perineum or buttocks
Estimate size or measure to monitor for increase or decrease in size
What are some nursing interventions for hematomas?
Treatment with ice if small vulvar
If large, need surgery to evacuate clot
Treat any infection with antibiotics
Monitor V/S
Foley-if unable to void
Replace blood lost
What are some medical managements of late postpartum hemorrhage?
Prevention is best, you need to know who is at risk
Diagnostics and Lab
Bimanual uterine compression - if mom is hemorrhaging the uterus is elevated and held out of the pelvis by pushing the lower hand onto the abdomen right above the symphysis pubis and then massaging the fundus till firm
Fix cause - check for retained placental fragments, hematoma, possible uterine rupture, lacerations, suspect a coagulation problem if you observe that blood fails to clot (DIC)
Hysterectomy if all else fails
02 by mask so you can fully oxygenate the RBC’s
What are some pharmacology to help with postpartum hemorrhage?
Oxytocin - infusion IV, 20 units in 1000 mis of LR or NS given over 3-4 hrs or bolused
Methergine - IM, PO- sustain uterine contractions-monitor for HTN & HA
Hemabate - used when uterine atony is not responding to other meds- N/V, fever, HA, diarrhea, and flushing may occur
Will need to medicate for pain of the contractions
What are some nursing interventions for postpartum hemorrhage?
Assessment
Prevention of hemorrhage is best
Frequent fundal and lochia checks - q 10-15 min
Weigh pads before and after 500 mis = 1 lb 1 gm = 1 ml
Be aware of who is at risk for hemorrhaging
Turn mom over to check for blood pooled under buttocks
Any excessive bleeding massage the fundus and turn up the oxytocin infusion
Plan - Women at risk for hemorrhage need frequent assessments
Need to maintain IV and patency
T and C and keep ahead if blood is ordered
What are some health promotions and teachings for discharge?
Discharge planning - often have early dismissals
Mom is in the “Taking-in” phase and not teachable so need to give her discharge instructions in written form
Teach client to report any return of bright red lochia after 4th PP day
S/S of infection which may cause delayed PP hemorrhage - Fever over 100.4, Foul smelling lochia, Flu like symptom
Teach them to conserve energy, get plenty of rest, find out who can come and help
Refer to social services if needed
What is thromboembolic disease?
Pathophysiology: venous stasis from inactivity
• Pregnancy increases the risk for thrombosis formation from hyper-coagulability, venous stasis associated with the pressure of an enlarged uterus, and the decreased activity of the woman
What is a Thrombus?
A collection of blood factors, primarily platelets and fibrin, on a vessel wall forming whenever blood flow is impeded
A partial obstruction of a vessel
If thrombus formed because of inflammation of venous wall, then tend not to move
If thrombus formed because of stasis of blood, it tends to move and become an embolus
What is thrombophlebitis?
An inflammatory process in the vessel wall
A thrombus formation that may be due to inflammation in the vein wall
Tends not to move, just stays there
3-4 PP day with you’ll find:
- Tenderness, heat, redness, may have fever
What are some S&S of Deep Vein Thrombosis?
S/S are often diffuse - difficult to DX
Obstruction of venous returnn causes edema of leg or ankle - decreased pedal pulses
Coolness and pale leg called “Milk Leg”
High fever, chills
Pain depending on location
What are some clinical manifestations of DVT?
Positive Homan’s- pain with dorsiflexion
May not have + Homan’s but will have pain with calf pressure
Call and inform doctor and keep mom on strict bedrest
Do not massage calf of client with + Homan’s !!
What do you want to assess for in a DVT?
Palpate pulses
Inspect the affected leg
Degree of discomfort, pain
Evaluate labs - clotting studies
Platelets
What is some pharmacology for DVT?
Heparin IV for DVT
Coumadin PO when mom starts improving
Heparin usually discontinued when PT is 1.5-1.7
Stay on Coumadin for 2-6 months
What are some preventions for DVT?
Activity, walking early during pregnancy and PP
Avoid prolonged sitting or standing
Support hose “
Adequate hydration
Teach mom to point toes toward her face
Avoid knee gatch, crossed legs
Promote venous return
Stop smoking
What is a pulmonary embolism?
An undissolved substance travels from the venous circulation to the right side of the heart and the pulmonary artery and lodges there obstructing blood flow
Which leads to pulmonary hypertension and possible infarction (tissue death)
Types include thrombus (blood clot is usual type seen PP), fat embolism (after fracture of long bone), and air embolism. VERY serious problem
Foreign substance goes to right heart, out pulmonary artery, lodges there blocking blood flow to lung
CRISIS!
What are some assessments for PE?
Sudden onset-acute chest pain
Sudden onset sweating
Pallor, cyanosis
Cough with or without blood
Dyspnea, SOB, tachycardia, tachypnea
Increased jugular pressure
Pressure in rectum
Apprehension-impending doom
Confusion
Hypotension
Auscultate friction rub on chest (rub thumb on a balloon)
Decreased breath sounds
Gallop heart rhythm
What are some nursing interventions for PE?
Start treatment immediately!
IV fluids, 02, High Fowlers, VS, l&O
Support respirations
What is some pharmacology for PE?
Demerol for pain
Aminophylline for bronchospasms Anticoagulants - Heparin Streptokinase, Urokinase - clot busters for fibrinolytic therapy
Lovenox
PE Mnemonic
