Test 5 Flashcards
- PP Hemorrhage Manifestations
• Greater than 500ml (after vaginal delivery)
• Greater than 1000ml (after c-section)
• Saturated pads
• Clots
• Steady flow
• Decrease H&H
• Palpitations
• Restlessness
• Changes in level of consciousness
• Hemorrhage shock;Hypotension &Tachycardia, pallor, weakness, diaphoresis, lightheadness)
- PP hemorrhage Risk factors
• Multiparity
• Precipitous birth
• Previous uterine surgery
• Tocolytics
• LGA-macrosomia
• Polyhydramnios
- PP hemorrhage Nursing Consideration
Goal to correct underlying cause while controlling hemorrhage and reduce effects (number 1 reason for maternal morbidity)
• Massage uterine fundus-priority q15 minutes for 1-2 hours
• Monitor VS (BP, HR, O2 sat)
• Palpate fundus for height, firmness and location
• Monitor lochia for color, quantity, and clots; check for pooled blood under buttocks
• Palpate bladder for distention; Empty Bladder
• Elevate legs
- if no change; give meds (oxytocin, misoprostol or surgery)
- Causes of PP hemorrhage the Four T’s
Tone; Trauma; Tissue; Thrombin
(Early postpartum hemorrhage occurs within the 1st 24 hrs.)
- Causes of PP Hemorrhage: TONE
Uterine atony: Most frequent reason for PP hemorrhage
o Fundus will be difficult to palpate; soft, boggy, spongy uterus; Assess location-displaced
Vaginal bleeding (lochia) typically is moderate to heavy with clots
• Check under buttocks for pooling of blood
• Treat with fundal massage
• Empty bladder
• Meds/ Surgery
• BIG BABY 8 pounds 13 ounces
- Causes of PP Hemorrhage: Trauma
• Hemorrhage caused by laceration:
o Fundus is firm on palpation
o Bleeding is bright red in color; can be steady or a trickle
• Hemorrhage caused by hematoma: TO ANY GENITAL STRUCTURE
o Persistent bright red bleeding with FIRM uterus
o Severe pain
o Bleeding may not be apparent
o Most commonly on one side of the perineum
o Deep pelvic hematoma: primary symptom is deep pain unrelieved by comfort measures or meds and is accompanied by V/S instability; Hgb and Hct low
- Causes of PP Hemorrhage: Tissue
• Retained placental tisssue
o Assess for intact placenta
- Causes of PP hemorrhage: Thrombin
• Genetic clotting disorder;
o Eclampsia
o Abruption
- Expected findings during the postpartum period (Slide 5)
• Temperature might be slightly elevated for the first 24 hours-100.4
• Blood pressure should remain at the level it was during labor.
• Mild bradycardia (50 to 60 bpm) in the early postpartum period is normal.
• Shaking and chills due to excess epinephrine could occur.
• The woman is at risk for a deep vein thrombosis, and her legs should be monitored for edema and excess heat or redness.
• When assessing pad, look under buttocks for pooling
- Vitamin K administration client education
• Decreases risk of infant hemorrhagic disorder
• Not produced in the GI tract of the newborn until around day 7
• Is produced in the colon by bacteria once formula or breast milk is introduced
• Administer 0.5 to 1mg IM into the vastus lateralis (thigh) within 1 hr after birth
VITAMIN K –VASTUS LATERALIS TO STIMULATE
APPROPRIATE CLOTTING.
- Mastitis manifestations
• General flu-like sx
• Fever of 101F (38.3C) or greater
• Malaise
• Possibly chills
• Tenderness
• Pain
• Heaviness in breast
• Erythema
• Edema in area localized to one breast
• Often pie-shaped wedge
- Mastitis nursing actions
• Support continued breast-feeding, preventing milk stasis, administering ordered antibiotics( 10 days if home) complete emptying of breast
• If not breast-feeding, encourage manually expressing breast milk or using breast pump
• Warm compresses or warm shower
• Analgesics
• Support and encouragement; liberal fluid intake
• Refer to lactation specialist
- Breastfeeding nursing considerations (slide 8)
• Encourage early feeding/helps prevent hemorrhage/will help with infant stools 2-3 day
• Engage a lactation consultant for proper latching
o Each feeding around 30 minutes
o Assess nipples
o Apply milk prior to feeding to breasts
o Change infant position
o Rotate breasts at beginning
o If nursing will expect 2-3 stools/day
- Difference between PP blues; PP depression; PP psychosis
PP Blues
• Mild sad or tearful
• 2-3 after delivery and may last 2 weeks
PP depression
• Severe sadness, guilt, anxiety
• Any time within the first year
PP Psychosis
• Hallucinations
• Delusions
• Can be danger to self or others
• More likely in woman with history of bipolar disorder
- Nursing Actions; PP blues, depression and Psychosis
• Utilize screening tools to assess the type
- RhoGAM criteria (Slide 12)
RH negative mom
• Provide education to mom about reason Rhogam is administered. Prevent the formation of antibodies
• Should be administered within 72 hours of delivery
- Know Uterine fundus location at PP intervals
• Immediately after birth: midline about 2cm below umbilicus
• 1 hour after: fundus will rise to the umbilicus
• At or near 12 hours: near the level of the umbilicus or 1cm above
• Then descend about 1-2 cm everyday
• If deviated check for full bladder, if no change after empty notify physician: this is a priority!
- Episiotomy, laceration manifestations
• Bright red Bleeding
- Episiotomy/laceration nursing actions
(Episiotomy discomfort without infection)
• Ice packs witch hazel with order
• Hand Washing priority teaching
- Endometritis manifestations
• Fever of 100.4F (38C) or higher
• Tachycardia
• Chills
• Anorexia , Malaise
• Uterine subinvolution & Tenderness
• Lochia typically increases in amount and is dark, purulent, and foul-smelling
- Endometritis Nursing Action
• Managing antibiotic therapy
• Providing comfort measures (pain control)
• Alleviating anxiety
• Providing client education (hygiene)
• SEMI-FOWLER position to promote uterine drainage, and possible spreading of infection.
- DVT complications
• PE
• Cardiovascular collapse which is fatal
- DVT manifestations
• Edema, warmth, redness, calf pain or tenderness
• Homan’s sign
• Avoids putting weight on affected leg when walking
• Leg may appear visibly pale or white
• Diminished pedal pulses
- Nursing considerations for hemorrhoids(Slide 17)
• Ice
• Witch hazel
• Sitz baths
- Pulmonary embolism manifestations (Slide 18)
(Must be reported immediately)
• Sudden onset of dyspnea
• Pleuritic chest pain and abdominal pain
• FOID
• Tachypnea & Tachycardia
• Hypotension
• Hemoptysis
• Cyanosis
• Change in LOC
- Lochia Nursing Action
• Assess color, amount and odor.
• Evidence of clots
• Look under buttocks to assess for any pooling of blood.
• Dark red first few days
• Should not fill more than a pad in an hour
• Filling every 15 minutes could indicate hemorrhage
• ASSESS Fundus first.
- Breast Care CE
• Cleanse with plain water; use of lanolin cream; rub drop of breast milk into each nipple and allow to dry
• Alternate breasts and empty completely
• Reposition the baby
• If bottle feeding, do not express milk, will gradually stop producing
- Perineum and Vaginal Care CE
• Teach how to use peribottle, handle peripads
- avoid using tampons or douches
- ice-packs
- handwashing
- avoid sexual intercourse, use birth control
- sitz bath- can be delegated to AP
