week 5 COPY Flashcards
Postpartum physiological changes: Vitals
Expected findings
- Temp elevated up to 100.4 F for_____ hours after birth
- Afebrile after _____ hours
- Temp may continue to be increased for 24 hours after ______ comes in (low grade fever 99 F)
- BP slightly elevated or decreased?
- Bradycardia or tachycardia for 6-10 days?
Vitals
Expected findings
- Temp elevated up to 100.4 F for 24 hours after birth
- Afebrile after 24 hours
- Temp may continue to be increased for 24 hours after milk comes in (low grade fever 99 F)
- BP slightly elevated
- Bradycardia for 6-10 days
Postpartum physiological changes: Vitals
Unexpected/abnormal findings
- Temp > 100.4 F – we suspect ________
- low/high BP? - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety
- low/high BP? - we suspect r/t uterine hemorrhage, hematoma
- tachycardia/bradycardia? – we suspect r/t difficult labor and birth, hemorrhage, r/o fever (infection)
- marked tachypnea/bradypnea? – r/o respiratory disease and pulmonary edema
Unexpected/abnormal findings
- Temp > 100.4 F – we suspect infection
- High BP - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety)
- low BP - we suspect r/t uterine hemorrhage, hematoma)
- tachycardia – we suspect r/t difficult labor and birth, hemorrhage, r/o fever (infection)
- marked tachypnea – r/o respiratory disease and pulmonary edema
Postpartum physiological changes: Vitals
expected vs unexpected finding
- temp 100.1 F 12 hours after birth
- temp 100.1 F 36 hours after birth
- temp 99.1 F 24 hours after birth
- BP slightly elevated
- bradycardia 2 weeks after birth
- high BP
- temp 100.8 F 24 hours after birth
- low BP
- tachycardia
- tachypnea
E - temp 100.1 F 12 hours after birth
U - temp 100.1 F 36 hours after birth = should be afebrile within 24 hours
E - temp 99.1 F 24 hours after birth = low fever r/t milk coming in
E - BP slightly elevated
U - bradycardia 2 weeks after birth = should only be for 6-10 days
U - high BP
U - temp 100.8 F 20 hours after birth = too high to be considered expected
U - low BP
U - tachycardia
U - tachypnea
Postpartum physiological changes: Vitals
Unexpected/abnormal findings
- Temp > 100.4 F – we suspect ___________
- High BP - we suspect r/t ________, _________, ________, _________
- low BP - we suspect r/t ______, __________
- tachycardia – we suspect r/t ___________, _______________, r/o fever (infection)
- marked tachypnea – r/o ___________ and ____________
respiratory disease
pulmonary edema
infection
preeclampsia
HTN
difficult birth and labor
hemorrhage
renal disease
anxiety
uterine hemorrhage
hematoma
Unexpected/abnormal findings
- Temp > 100.4 F – we suspect infection
- High BP - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety)
- low BP - we suspect r/t uterine hemorrhage, hematoma)
- tachycardia – we suspect r/t difficult labor and birth, hemorrhage, r/o fever (infection)
- marked tachypnea – r/o respiratory disease and pulmonary edema
Postpartum physiological changes: Vitals
Unexpected/abnormal findings
High BP - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety)
Treatment T/F
- tocolytic: Procardia
- oxytocin
- Labetalol
- aldomet
- magnesium sulfate
- prostaglandin
- aspirin
Treatment
- tocolytic: Procardia - relaxes muscles
- Labetalol - HTN med
- aldomet - HTN med
- magnesium sulfate - relaxes muscles, prevents seizures
Postpartum physiological changes: Cardiovascular
Expected findings
- cardiac output decrease/increase? – up to 30% for 2 weeks, back to normal levels by 6-12 weeks post birth
- increased/decreased urination?
- weight loss/gain?
Unexpected/abnormal findings
- pulmonary edema, cardiac problems, adventitious lung sounds (crackles) – body is failing to ___________
Cardiovascular
Expected findings
- cardiac output decline – up to 30% decline for 2 weeks, back to normal levels by 6-12 weeks post birth
- diuresis, increased urination, weight loss – body is decreasing extracellular fluid
Unexpected/abnormal findings
- pulmonary edema, cardiac problems, adventitious lung sounds (crackles) – body is failing to eliminate extra fluid
Postpartum physiological changes: Respiratory
Expected findings
- clear lungs
- non-labored breathing
- eupnea = normal breathing
Unexpected/abnormal findings
- tachypnea/bradypnea? – we suspect r/t fever or pain
- tachypnea/bradypnea? – we suspect r/t respiratory compromise, meds, anesthesia
- ______________ – we suspect r/t fluid bolus, Pitocin (anti-diuretic), magnesium sulfate
Unexpected/abnormal findings
- tachypnea – we suspect r/t fever or pain
- bradypnea – we suspect r/t respiratory compromise, meds, anesthesia
- fluid overload – we suspect r/t fluid bolus, Pitocin (anti-diuretic), magnesium sulfate
Postpartum physiological changes: Neurological
Expected or unexpected findings:
- Headaches – may be r/t fluid shifts in first week after birth, stress and fatigue?
- Headaches – may be r/t leakage of CSF from epidural (spinal headache, gets worse when you sit up)?
- Headaches – may be r/t chronic or gestational HTN?
- Headaches – may be r/t preeclampsia – can continue up to 6 weeks PP?
- Headaches with vision changes – spots, blurry, bright lights?
Neurological
Expected findings
- *Headaches – may be r/t fluid shifts in first week after birth, stress and fatigue
Unexpected/abnormal findings
- *Headaches – may be r/t
- leakage of CSF from epidural (spinal headache, gets worse when you sit up)
- chronic or gestational HTN
- preeclampsia – can continue up to 6 weeks PP
- Vision changes – spots, blurry, bright lights
Postpartum physiological changes: Nutrition
Expected findings
- May need to eat foods high in iron/fat? – r/t blood loss during labor
- May need to continue taking prenatal vitamins – especially if breastfeeding/suppressing lactation?
- Breast feeding mothers – increase/decrease calorie intake by 300 cal?
- Non-breastfeeding mothers – increase/decrease calorie intake by 200 cal?
Nutrition
Expected findings
- May need to eat foods high in iron – r/t blood loss during labor
- May need to continue taking prenatal vitamins – especially if breastfeeding
- Breast feeding mothers – increase calorie intake by 300 cal
- Non-breastfeeding mothers – decrease calorie intake by 200 cal
Postpartum physiological changes: Labs
Expected findings
- Non-pathologic leukocytosis during first week post birth = WBC 25,000 – 30,000
- If its higher than this suspect ________
- Blood loss
- Vaginal birth _____ mL
- c/s birth ______ mL
- losing 500 mL of blood = Hematocrit/Hemoglobin decline of 2-3%?
- plasma levels go back to normal 4-6 weeks post birth
- platelet levels go back to normal by the 6th week post birth
- blood values go back to normal by the 6th week post birth
Labs
Expected findings
- Non-pathologic leukocytosis during first week post birth = WBC 25,000 – 30,000
- If its higher than this suspect infection
- Blood loss
- Vaginal birth 200-500 mL
- c/s birth 700-1000 mL
- losing 500 mL of blood = Hmt decline of 2-3%
- plasma levels go back to normal 4-6 weeks post birth
- platelet levels go back to normal by the 6th week post birth
- blood values go back to normal by the 6th week post birth
Postpartum physiological changes:
Ovulation/menstruation
Expected findings for non-breastfeeding women or breastfeeding women?
- menstruation occurs in 7-12 weeks
- ovulation occurs by 70-75 days
- menstruation may be delayed by 3 months +
T/F
breastfeeding is not a reliable source of birth control
Ovulation/menstruation
Expected findings
non-breastfeeding women
- menstruation occurs in 7-12 weeks
- ovulation occurs by 70-75 days
breastfeeding women
- menstruation may be delayed by 3 months +
T - breastfeeding is not a reliable source of birth control
Postpartum physiological changes: Weight changes
Expected findings
-initial weight loss of 10-20 lbs – r/t baby/placenta/ amniotic fluid or postpartum diuresis?
-weight loss of 5 lbs – r/t baby/placenta/ amniotic fluid or postpartum diuresis?
-may return to pre-pregnant weight by 6-8 weeks postpartum – depends on person, diet, exercise, etc.
- initial weight loss of 10-20 lbs – r/t baby, placenta, amniotic fluid
- weight loss of 5 lbs – r/t postpartum diuresis
- may return to pre-pregnant weight by 6-8 weeks postpartum – depends on person, diet, exercise, etc.
PP assessment - BUBBLEHE
which one?
- breast - size and shape
- nipples – cracks, fissures, soreness, inversion
- breast fullness – r/t milk presence
- abnormalities – reddened areas, engorgement
- not breastfeeding = how to prevent engorgement, proper bottle feed info
- breastfeed = assess how it is going, observe session, give praise and guidance, talk about prevent/treat engorgement/mastisitis/blocked ducts
Postpartum Assessment
B-Breasts
patients:
- non-lactating women
- breastfeeding mom
- women that doesn’t want to breastfeed
- women asking how to suppress lactation
- women with engorgement that is breastfeeding
- women with engorgement that isn’t breastfeeding
which of the above patients should the nurse advice do the following breast care:
- well-fitting bra or ace wrap binder
- cold compress or cabbage leaves
- anti-inflammatory meds
- avoid stimulating the breasts/nipples
- avoid warm water on breast in shower, shower with back to water
- avoid stimulating the nipple
- non-lactating women
- women that are not breastfeeding
- need to suppress lactation
- engorgement prevention/treatment for non-breastfeeding moms
lactation
- feed Q _____ hours (8-12 feedings/24 hours)
- feed _____ mins on 1st breast, offer 2nd breast but infant may not want it or feed as long on it
- expected/unexpected finding - breasts may feel heavy?
- expected/unexpected finding – breasts feel hardened, sore, reddened?
- breastfeeding women should only consume alcohol occasionally?
- don’t consume alcohol at least ___ hours before nursing?
- feed Q 1.5-3 hours (8-12 feedings/24 hours)
- feed 10-20 mins on 1st breast, offer 2nd breast but infant may not want it or feed as long on it
- expected finding - breasts may feel heavy
- unexpected finding – breasts feel hardened, sore, reddened
- breastfeeding women should only consume alcohol occasionally
- don’t consume alcohol at least 2 hours before nursing
breastfeeding positions
- _______ – both hands are around baby’s body
- ______________ – allows mom to have a free hand to manipulate breast
- _____________ – allows mom to have a free hand to manipulate breast and takes pressure off abdomen
- ___________ - allows mom to have a free hand to manipulate breast, risk of mom falling asleep and smothering baby
side-lying, cradle, football hold, modified cradle
breastfeeding positions
- cradle – both hands are around baby’s body
- modified cradle – allows mom to have a free hand to manipulate breast
- football hold – allows mom to have a free hand to manipulate breast and takes pressure off abdomen
- side-lying - allows mom to have a free hand to manipulate breast, risk of mom falling asleep and smothering baby
breastfeeding concerns and solutions
- __________ – r/t poor latch, allow nipples to dry to prevent breakdown
- ____________ – teach privacy tactics
- ____________ – mom can pump milk, others can feed the baby, mom doesn’t have to be there
- ____________ - mom can pump milk and fathers can bottle feed, fathers can take responsibility for other tasks
- ______________ -
- good signs to look for:
- milk at edges of mouth
- 6-8 wet diapers/day
- See Infant swallowing
- Breasts softer after feeding
worried infant isn’t getting enough milk,
unequal responsibility or fathers feeling left out, embarrassment in public,
mom feeling tied down to demands of breastfeeding, nipple tenderness/pain
breastfeeding concerns
-nipple tenderness/pain – r/t poor latch, allow nipples to dry to prevent breakdown
-embarrassment in public – teach privacy tactics
-mom feeling tied down to demands of breastfeeding – mom can pump milk, others can feed the baby, mom doesn’t have to be there
-unequal responsibility or fathers feeling left out - mom can pump milk and fathers can bottle feed, fathers can take responsibility for other tasks
-worried infant isn’t getting enough milk
- good signs to look for:
- milk at edges of mouth
- 6-8 wet diapers/day
- See Infant swallowing
- Breasts softer after feeding
how does the nurse know the baby is getting enough milk? SATA
- milk at edges of mouth
- 3-4 wet diapers/day
- See Infant swallowing
- Breasts softer after feeding
- milk at edges of mouth
X 6-8 wet diapers/day - See Infant swallowing
- Breasts softer after feeding
Breastfeeding difficulties: Mom not producing enough milk
Mom increase fluid intake = ___ L/day
- Mom increase fluid intake = 2 L/day
Breastfeeding difficulties: Sore nipples
- Must have good latch = ______ shape mouth
- Lanolin cream?
- Express some breast milk and let dry on nipples?
- Allow nipples to air dry?
- Begin nursing on breast that is less/more sore?
- Must have good latch = fish shape mouth
- Lanolin cream
- Express some breast milk and let dry on nipples
- Allow nipples to air dry
- Begin nursing on breast that is less sore – b/c baby will have stronger suck at the beginning of feed vs end of feed
Breastfeeding difficulties: Plugged ducts
- Frequent nursing, changing feeding positions, manual massage, warm compress?
- Start feeding on breast with plugged duct?
- Breast pump may help dislodge plug?
- Assess women for pressure from purse strap, infant sling, car seat belt, etc. that may cause _____________
- Plugged ducts can lead to ______!!
- Frequent nursing, changing feeding positions, manual massage, warm compress
- Start feeding on breast with plugged duct – vigorous suck may help dislodge plug
- Breast pump may help dislodge plug
- Assess women for pressure from purse strap, infant sling, car seat belt, etc. that may cause recurring plugged ducts in the compressed area
- Plugged ducts can lead to mastitis!!
Breastfeeding difficulties: Flat/inverted nipples
- Rolling, stimulating?
- Pump a little before breast feeding?
- Use a nipple shield?
- Rolling, stimulating
- Pump a little before breast feeding
- Use a nipple shield
Is this education for a weaning breastfeeding mom or a non-breastfeeding mom that is suppressing lactation?
- Over a few days to a week - Substitute one cup of formula for one breastfeeding session (so breasts gradually produce less milk)
- Over a period of several weeks – substitute more formula feedings for breastfeeding
weaning
Slow weaning is good b/c: SATA
- Prevents engorgement
- Allows infant to alter their own eating methods at their own rates
- Provides time for psychological adjustment
- mom can drink alcohol regularly
- Prevents engorgement
- Allows infant to alter their own eating methods at their own rates
- Provides time for psychological adjustment
mastitis vs engorgement?
mastitis vs engorgement?
s/s
- sudden onset
- chills
- fever 101 F +
- malaise
- red, painful, swollen AREA on breast
- usually one breast affected
- discharge
mastitis
mastitis vs engorgement?
treatment
- antibiotics (penicillin)
- warm compress
- analgesics
mastitis
mastitis vs engorgement?
prevention
- wear supportive bra at all times (not constricting bra, underwire bra, restrictive clothing) = prevents milk stasis where bacteria can grow
- good handwashing, hygiene, air dry breasts
- prompt attention to blocked milk ducts
- regular complete emptying of the breasts
- good infant positioning
- good latch
- supply and demand – if baby feeds more/mom pumps more = body will cue to make more milk
- report flulike symptoms
- alternate breasts at feeding
- treat cracked nipples
mastitis
mastitis vs engorgement?
s/s
- hard, painful breasts
- entire breast (not an area), or both breasts
- gradual onset
- NO fever
mastitis vs engorgement?
Treatment/prevention (for moms that are breastfeeding)
- Don’t miss a feeding
- Hand express or pump to soften breasts/nipples before feeding
- nurse 8-12x/24 hours and for 10-20 mins/breast each feeding
- warm compress before feedings – helps with let down before feeding
- cold compress between feedings – slows milk production
- well-fitted nursing bra 24/7
- cabbage leaves – help with edema
- breast feed more frequently – Q 1-1.5 hours
engorgement
engorgement treatment/prevention appropriate for moms that are breastfeeding or non-breastfeeding?
- Don’t miss a feeding
- Hand express or pump to soften breasts/nipples before feeding
- nurse 8-12x/24 hours and for 10-20 mins/breast each feeding
- warm compress before feedings – helps with let down before feeding
- cold compress between feedings – slows milk production
- well-fitted nursing bra 24/7
- cabbage leaves – help with edema
- breast feed more frequently – Q 1-1.5 hours
breastfeeding moms with engorgement
mastitis vs engorgement?
treatment/prevention (for non-breastfeeding moms)
- well-fitting bra or ace wrap binder
- cold compress or cabbage leaves
- anti-inflammatory meds
- avoid stimulating the breasts/nipples
- avoid warm water on breast in shower, shower with back to water
- avoid stimulating the nipple
engorgement
engorgement treatment/prevention appropriate for moms that are breastfeeding or non-breastfeeding?
- well-fitting bra or ace wrap binder
- cold compress or cabbage leaves
- anti-inflammatory meds
- avoid stimulating the breasts/nipples
- avoid warm water on breast in shower, shower with back to water
- avoid stimulating the nipple
non-breastfeeding moms with engorgement
postpartum assessment - BUBBLEHE
which one?
- abdomen
- uterine ligaments
- striae (stretch marks)
- after pains
- diastasis recti abdominis
U-Uterus/Abdomen
postpartum assessment: U-Uterus/Abdomen
- abdomen is loose and flabby?
- abdomen will not respond to exercise?
- uterine ligaments will quickly return to normal state?
- striae (stretch marks) – different colors based on moms skin and time lapsed?
- for c/s incision use REEDA scale when assessing?
- abdomen is loose and flabby
X- will respond to exercise
X- uterine ligaments will slowly return to normal state - striae (stretch marks) – different colors based on moms skin and time lapsed
- for c/s incision use REEDA scale when assessing
postpartum assessment: U-Uterus/Abdomen
after pains – intermittent uterine contractions r/t uterine involution/subinvolution?
the nurse should advice:
- rest prone/supine with pillow under abdomen?
- motrin for pain if platelets are less than 70,000?
- motrin for pain if has preeclampsia?
- motrin for pain if patient had multiples?
- after pains – intermittent uterine contractions r/t uterine involution
- rest prone with pillow under abdomen – helps keep uterus contracted
- motrin – for cramping
- contraindication – if platelets are less than 70,000, or pt has preeclampsia
postpartum assessment: U-Uterus/Abdomen
diastasis recti abdominis – separation of the ________ muscles
- common in multiples or G1?
- abdomen over distended?
- diastasis recti abdominis – separation of the rectus (abdominal) muscles
- common in multiples
- abdomen over distended
postpartum assessment: U-Uterus/Abdomen
uterus
- should be undergoing involution or subinvolution?
- decrease/increase in weight 100 g?
- spongy layer – sloughed off?
- basal layer – splits into 2?
outer layer - sloughed off?
inner layer – foundation for new endometrium?
- placenta site heals by exfoliation?
uterus
- involution
- decrease in weight 100 g
- spongy layer – sloughed off
- basal layer – splits into 2
- outer layer - sloughed off
- inner layer – foundation for new endometrium
- placenta site heals by exfoliation
postpartum uterine infection: Endometritis
infection that involves the lining of the uterus
s/s
- uterine tenderness
- temp spike 104 F
- chills
- foul smelling lochia or vaginal discharge
infection that involves the lining of the uterus
Endometritis
mastitis or endometritis?
s/s
- uterine tenderness
- temp spike 104 F
- chills
- foul smelling lochia or vaginal discharge
Endometritis
risks for developing mastitis or endometritis?
- c/s delivery
- PPROM
- Prolonged labor
- Multiple vaginal exams during labor, especially after ROM
- Use of FSE or IUPC
- Instrument assisted deliveries – vacuum or forceps
- Manual removal of placenta
- Chorioamnionitis – infection of chorion and amnion
postpartum uterine infection: Endometritis
Treatment for mastitis or endometritis?
- Antibiotics – clindamycin, gentamycin
- Culture and sensitivity (will show specific antibiotic that works on this infection)
- Continue treatment until afebrile for 24-48 hours
postpartum uterine infection: Endometritis
postpartum assessment: U-Uterus/Abdomen
Fundal assessment determines:
- position of fundus r/t __________ - above or below
- position of fundus r/t __________ - left, right, centered
- uterus tone - _______ or ________
Fundal assessment
Determines:
- position of fundus r/t umbilicus - above or below?
- position of fundus r/t midline - midline or offcentered?
- uterus tone - firm or boggy?
postpartum assessment: U-Uterus/Abdomen
Fundal assessment
- uterus should be at level of umbilicus for 6-12 or 12-24 hours post birth?
- uterus contracts 1 or 2 fingerbreadth per day (involution)?
- uterus descends 1 or 2 cm/day towards pelvis, until it is in the pelvis on the 10th day?
- uterus should be at level of umbilicus for 6-12 hours post birth
- uterus contracts 1 fingerbreadth per day (involution)
- uterus descends 1 cm/day towards pelvis, until it is in the pelvis on the 10th day
postpartum assessment: U-Uterus/Abdomen
Fundal assessment
place one hand below umbilicus and other hand on symphysis, apply downward pressure toward vagina = determines if _______ is firm and assists client in expelling ________
- place one hand below umbilicus and other hand on symphysis, apply downward pressure toward vagina = determines if fundus is firm and assists client in expelling clots
postpartum assessment: U-Uterus/Abdomen
expected or unexpected findings in fundal assessment? If unexpected, what do we suspect?
- uterus should be at level of umbilicus for 6-12 hours post birth
- uterus contracts 1 fingerbreadth per day (involution)
- uterus descends 1 cm/day towards pelvis, until it is in the pelvis on the 10th day
- uterus is off to one side (or is high in the abdomen)
- uterus did not change in size from yesterday to today
- uterus did not make descending progress towards pelvis
- uterus is firm
- uterus is soft
- uterus is midline
E - uterus should be at level of umbilicus for 6-12 hours post birth
E - uterus contracts 1 fingerbreadth per day (involution)
E - uterus descends 1 cm/day towards pelvis, until it is in the pelvis on the 10th day
U - uterus is off to one side (or is high in the abdomen) = pt needs to void (empty bladder)
U - uterus did not change in size from yesterday to today = subinvolution, suspect retained placenta fragments and infection
U - uterus did not make descending progress towards pelvis = subinvolution, suspect retained placenta fragments and infection
E - uterus is firm
U - uterus is soft = indicates uterine atony and increased bleeding, nurse should perform fundal massage
E - uterus is midline
causes of boggy uterus/fundus? SATA
- high levels of oxytocin
- multipara
- small for gestational age
- multiples
- LGA - Large for Gestational Age
- Red haired women
- trapped gas
- high levels of oxytocin = uterus no longer responding to meds that promote contraction of uterus
- multipara
X- small for gestational age - multiples
- LGA - Large for Gestational Age
- Red haired women
X- trapped gas
Documenting the fundal assessment
FF u/-2 =
UU =
FF u/-2
- Firm Fundus = FF
- 2 fingerbreadths below umbilicus u/-2
UU
- At level of the umbilicus
postpartum assessment - BUBBLEHE
which one considers bowel movements?
B - bowels
postpartum assessment: Bowels
Bowels will be sluggish r/t: SATA
- Progesterone
- increased muscle tone
- Birth process
- Anesthesia
T/F - Women should expect to have her first BM up to 3 days after delivery
Bowels will be sluggish r/t
- Progesterone
X - Decreased muscle tone
- Birth process
- Anesthesia
T - Women should expect to have her first BM up to 3 days after delivery
postpartum assessment: bowels
T/F
Episiotomy, lacerations, or hemorrhoids may speed up elimination/BM after birth?
Might moms have a fear tearing with BM?
would appropriate treatment include stool softeners for moms with Episiotomy, lacerations, or hemorrhoids ?
Are tucks pads appropriate to use for hemorrhoid itching and coolness?
does knee pain often indicate trapped gas?
F - Episiotomy, lacerations, or hemorrhoids may delay elimination
T - Mom may fear tearing
T - Treatment – stool softeners
T - Tucks pads for hemorrhoid itching and coolness
F - Shoulder pain = trapped gas (often right shoulder pain)
postpartum assessment - BUBBLEHE
which one considers
- bladder capacity
- urethra
- urinary output
- sensation and sensitivity
- infection
B - bladder
postpartum assessment: B-Bladder
- Increased/decreased bladder capacity during pregnancy?
- Swelling and bruising of tissues around urethra?
- Increase/decrease in sensitivity to fluid pressure?
- Increase/decrease in sensation of bladder filling (esp. w/ epidurals)?
- Urinary output is higher/lower due to diuresis?
- Increased/decreased chance of infection due to dilated ureters and renal pelvis?
- Monitor adequacy of urinary elimination and distention?
B-Bladder
- Increased bladder capacity during pregnancy
- Swelling and bruising of tissues around urethra
- Decrease in sensitivity to fluid pressure
- Decrease in sensation of bladder filling (esp. w/ epidurals)
- Urinary output is greater due to diuresis – kidneys rid 2000-3000 mL of extracellular fluid
- Increased chance of infection due to dilated ureters and renal pelvis
- Monitor adequacy of urinary elimination/distention
what type of infection should the nurse suspect with these s/s
- Frequency and urgency
- Dysuria
- Nocturia
- Hematuria
- Suprapubic pain
- Slightly elevated temp
UTI
postpartum assessment - BUBBLEHE
After delivery, vaginal discharge of blood, mucus, atrophied uterine cells/debris
L - Lochia
postpartum assessment: Lochia
_______ days = lochia rubra (red)
______ days = lochia serosa (pink)
_______ days (until cervix is closed) = lochia alba (white)
- 2-4 days = lochia rubra (red)
- 4-10 days = lochia serosa (pink)
- 10-20 days (until cervix is closed) = lochia alba (white)
postpartum assessment: Lochia
-2-4 days = lochia rubra= color ________
-4-10 days = lochia serosa = color _______
-10-20 days (until cervix is closed) = lochia alba = color __________
- 2-4 days = lochia rubra (red)
- 4-10 days = lochia serosa (pink)
- 10-20 days (until cervix is closed) = lochia alba (white)
The nurse is doing a fundal assessment on a postpartum patient. The nurse notes bleeding that saturates the peripad in 1 hour and a soft fundus.
What does the nurse suspect?
What should the nurse do?
saturated bleeding + boggy fundus = Uterine atony
perform fundal massage
The nurse is doing a fundal assessment on a postpartum patient. The nurse notes bleeding that saturates the peripad in 1 hour and a firm fundus.
What does the nurse suspect?
Should the nurse do a fundal massage?
saturated bleeding + firm fundus = Lacerations
fundal massage is not helpful, nurse should assess the perineum, REEDA
T/F - Weeks 5-6 uterus will return to normal size
True
postpartum assessment: Lochia
Amount
- Scant
- Light
- Moderate
- Heavy = saturated peripad within __ hour(s). This is too much bleeding = _________________
- Heavy = saturated peripad within 1 hour. This is too much bleeding = postpartum hemorrhage
-Uterine atony
-Lacerations
-Episiotomy
-Retained placenta fragments
-Hematomas
-Uterine inversion – prolapse of uterus
-Uterine rupture
-Placenta implantation problems (accrete, increta, percreta)
-Coagulation disorders – low platelets, DIC
these are all complications that can cause ________________ in a postpartum woman
Postpartum hemorrhage
s/s of postpartum hemorrhage include: SATA
- Excessive bleed, heavy bleed
- dark red bleed
- Boggy fundus that doesn’t respond to massage
- Abnormal clots
- Excessive bleed, heavy
X- Bright red bleed - Boggy fundus that doesn’t respond to massage
- Abnormal clots
s/s of postpartum hemorrhage include: SATA
- high temp
- Pelvis discomfort or backache
- Persistent bleed + firm uterus
- Fundus descends in abdomen
- High temp
- Pelvis discomfort or backache
- Persistent bleed + firm uterus
X - Fundus rises in abdomen
s/s of postpartum hemorrhage include: SATA
- Decreased pulse
- Decreased BP
- Decreased LOC
- Hematoma formation or bulging/shiny skin in the perineal area
X- Increased pulse
- Decreased BP
- Decreased LOC
- Hematoma formation or bulging/shiny skin in the perineal area
T/F - Breastfeeding regularly lowers risk of postpartum hemorrhage r/t oxytocin production
T
Treatment to prevent postpartum hemorrhage: SATA
-Uterine massage (for soft uterus)
-Assess perineum for bleeding or clots
-Frequent void or cath the woman
-Look for abnormal Hct levels – CBC repeated on 1st day postpartum
-Diet high in fat
- Uterine massage (for soft uterus)
- Assess perineum for bleeding or clots
- Frequent void or cath the woman
- Look for abnormal Hct levels – CBC repeated on 1st day postpartum
X - Diet high in iron
medications to prevent postpartum hemorrhage: SATA
- Magnesium Sulfate
- oxytocin
- Methylergonovine maleate (methergine)
- Carboprost
-Misoprostol (Cytotec)
X- Magnesium Sulfate
- oxytocin
- Methylergonovine maleate (methergine)
- Carboprost
-Misoprostol (Cytotec)
medications to prevent postpartum hemorrhage:
- give Oxytocin before/after delivery of placenta and early postpartum period?
- dont give Methylergonovine maleate (methergine) to woman with _________
- common side effect of Carboprost
- route of Misoprostol (Cytotec) is rectal, vaginal, or oral SATA
-Oxytocin – after delivery of placenta and early postpartum period
-Methylergonovine maleate (methergine) – don’t give to woman with HTN b/c of rebound HTN risk
-Carboprost – s/e diarrhea
-Misoprostol (Cytotec) – route: rectal, followed by oral (may be given vaginally before birth)
postpartum assessment - BUBBLEHE
which one considers
-the cervix
-external os
-vagina changes
-lacerations
-c/s incision
E-Episiotomy/Lacerations/Incision
postpartum assessment: E-Episiotomy/Lacerations/Incision
T/F - Cervical changes
- Cervix is spongy, flabby, maybe bruised
- External os may have lacerations, irregular, closes slowly
- Shape of external os changes to lateral slit
all true
postpartum assessment: E-Episiotomy/Lacerations/Incision
T/F - Vagina changes
-Edema, bruised, small superficial lacerations
-3-4 weeks size decreases and rugae reappear
-6 weeks vagina is back to normal size
-2-3 weeks initial healing of lacerations occur, completely healed in 6 months
all true
postpartum assessment: E-Episiotomy/Lacerations/Incision
Lacerations degree determined by provider
______ - Involves only the skin around the vaginal opening
________- Involves the skin and underlying muscles, requires stitching, most common
_________- Involves the skin, muscles, and anal sphincter
________ - Involves the skin, muscles, anal sphincter, and rectal lining.
- 1st - Involves only the skin around the vaginal opening
- 2nd - Involves the skin and underlying muscles, requires stitching, most common
- 3rd - Involves the skin, muscles, and anal sphincter
- 4th - Involves the skin, muscles, anal sphincter, and rectal lining.
scale used in assessing perineum
REEDA scale
R = redness
E = edema of swelling
E = ecchymosis or bruising
D = discharge
A = approximation – how well the edges of the laceration seem to be holding together
postpartum assessment: E-Episiotomy/Lacerations/Incision
REEDA scale
R =__________
E = __________
E = ___________
D = __________
A = __________
R = redness
E = edema of swelling
E = ecchymosis or bruising
D = discharge
A = approximation – how well the edges of the laceration seem to be holding together
Interventions are appropriate for what?
- Ice packs
- Topical anesthestics
- Waffle cushion
- Surgigator
- Sitz bath
Interventions for Episiotomy/Lacerations/Incision
Care after cesarean birth includes SATA:
-Minimize respiratory complications
-resume any activity level
-Deep breathing
-Incentive spirometry
-Ambulation
-Rest between infant care and self care
-Pain management - OTC med
-Minimize gas pains
-Mylicon - OTC gas med
- bedrest
-Minimize respiratory complications
X-resume any activity level
-Deep breathing
-Incentive spirometry
-Ambulation
-Rest between infant care and self care
-Pain management - OTC med
-Minimize gas pains
-Mylicon - OTC gas med
X- bedrest
Best position to assess perineal area
-side lying with superior leg elevated
-frog leg
-stirups
-side lying with superior leg elevated
postpartum assessment - BUBBLEHE
which one are we considering
-thrombophlebitis
-hemroids
H-Homan’s/Hemorrhoids
postpartum assessment: H-Homan’s/Hemorrhoids
is this thrombophlebitis or hemorrhoids care?
- Sitz bath
- Topical anesthetic ointments
- Rectal suppositories
- Witch hazel pads
- Side lying position
- Avoid prolonged sitting
- Adequate fluid intake
- Stool softeners
- Increase fiber and fluids
- No enemas or suppositories for 3rd and 4th degree lacerations
hemorrhoid care
which of these would indicate thrombophlebitis during postpartum assessment? SATA
- pt c/o pain when walking
- redness in calf
- warmth in calf
- homan’s negative sign
- pt c/o pain when walking
- redness in calf
- warmth in calf
X - homan’s positive sign
which of these would indicate thrombophlebitis during postpartum assessment? SATA
- pain in leg
- pain in inguinal area
- pain in lower abdomen
- one sided edema in leg
- pain in leg
- pain in inguinal area
- pain in lower abdomen
- one sided edema in leg
which of these would indicate thrombophlebitis during postpartum assessment? SATA
- temperature changes in extremity
- pain when the nurse palpates leg
- one sided itchiness in leg
- temperature changes in extremity
- pain when the nurse palpates leg
X- one sided itchiness in leg
which of these are good ways to prevent thrombophlebitis? SATA
-Avoid prolonged sitting
-Avoid prolonged standing
-Avoid crossing legs
-Take frequent breaks while traveling by car, plane, etc.
-SCDS
-Early ambulation
-Adequate fluid intake
-Avoid prolonged sitting
-Avoid prolonged standing
-Avoid crossing legs
-Take frequent breaks while traveling by car, plane, etc.
-SCDS
-Early ambulation
X-Adequate fluid intake
postpartum assessment - BUBBLEHE
which one considers
- depression
- phases and stages post birth
- psychosis
- parent/infant attachment and bonding
- cultural support
- rest and activity
- sex
E-Emotions/Psychological
postpartum assessment:
E-Emotions/Psychological
taking in phase or taking hold phase?
- 1-2 days after birth
- Passive, dependent
- Processes reality vs imagined birth experience
- Food and rest are important
- 2-3 days after birth
- Control, mothering
- Continue to provide assurance and support
“taking in” phase
- 1-2 days after birth
- Passive, dependent
- Processes reality vs imagined birth experience
- Food and rest are important
“Taking hold” phase
- 2-3 days after birth
- Control, mothering
- Continue to provide assurance and support
postpartum assessment:
E-Emotions/Psychological
Becoming a mother (BAM)
- ___________ – during pregnancy - role play, expectations
- __________ – birth – role guided by expectations of others in her social system
- _____________ – develops role individually
- ______________ – self, confidence, and competence as mother role
Formal stage, Personal stage, Anticipatory stage, Informal stage
Becoming a mother (BAM)
- Anticipatory stage – during pregnancy - role play, expectations
- Formal stage – birth – role guided by expectations of others in her social system
- Informal stage – develops role individually
- Personal stage – self, confidence, and competence as mother role
postpartum assessment:
E-Emotions/Psychological
PP blues, PP depression, or PP psychosis?
- Transient period of depression
- Occurs 3-5 days postpartum to 6 weeks
- Usually resolves itself in 10-14 days
PP blues
postpartum assessment:
E-Emotions/Psychological
PP blues, PP depression, or PP psychosis?
s/s
- Mood swings
- Self-limiting
- Irritable or overly sensitive
- Tearfulness without cause
- Difficulty sleeping
- Feeling of being let down
- Anxiety
PP blues
postpartum assessment:
E-Emotions/Psychological
Risk factors for getting PP blues, PP depression, or PP psychosis?
-Rapid hormonal changes
-Fatigue
-Discomfort
-Overstimulation
-Insecurity
-Anxiety
-Emotional let-down after birth
-Grief response to fantasized birth experience different than actual birth (c/s, vaginal birth , etc.)
-Seen more severe in first time moms
PP blues
postpartum assessment:
E-Emotions/Psychological
PP blues, PP depression, or PP psychosis?
- 4th week postpartum – greatest occurrence
- Depression not characterized by mood swings
- Suicide contemplation
PP depression
postpartum assessment:
E-Emotions/Psychological
Risk factors for getting PP blues, PP depression, or PP psychosis?
- Primigravida
- Ambivalence toward pregnancy
- History of previous PP depression
- Higher with history of depression
- Lack of social support
- Dissatisfaction with self or body image
- Adolescent
PP depression
postpartum assessment:
E-Emotions/Psychological
PP blues, PP depression, or PP psychosis?
- Occurs 1-3 months postpartum
s/s
- Agitation
- Hyperactivity
- Insomnia
- Confusion
- Difficulty remembering or concentrating
- Delusions and hallucinations/illogical thinking
- Suicide risk/infanticide risk
PP psychosis
postpartum assessment:
E-Emotions/Psychological
Is this nursing care for attachment/bonding or PP blues/depression/psychosis?
- Refer to mental health professional (psychosis should seek immediate care from ER)
- Educate and give expectations for changes and demands
- Anticipatory guidance
- Dispel myths about perfect mother and baby
- Educate s/s, and teach family members what to look for
- Help foster positive adjustment in the new family
- Look for mom depression s/s
- Screening tools
- Give resources
- Home health
- Telephone
- Classes
- Support groups
Nursing care: PP blues, PP depression, PP psychosis
Medical management: PP depression
1st line = sertraline or paroxetine?
2nd line = sertraline or paroxetine?
Is prozac safe for mothers?
1st line = sertraline
2nd line = parozetine
-Prozac not recommended with breastfeeding moms
Medical management for PP blues, PP depression, or PP psychosis?
- Lithium
- Antipsychotics
- Electroconvulsive therapy with psychotherapy
- Removal of infant
- Assess Social support
PP psychosis
Parent/infant attachment/bonding
- Enface (___________ response) – direct eye contact, face to face
- Engrossment (____________ response) – absorption, interest, preoccupation
maternal or paternal
- Enface (maternal response) – direct eye contact, face to face
- Engrossment (paternal response) – absorption, interest, preoccupation
postpartum Rest and activity
T/F
-Rest
-Resume normal activities
-Avoid heavy lifting
-Avoid climbing stairs multiple times a day
-Resume strenuous activity
-Rest
-Resume normal activities
-Avoid heavy lifting
-Avoid climbing stairs multiple times a day
X-Avoid strenuous activity
The postpartum patient asks the nurse when she can have Sex again. The nurse should teach? SATA
- Resume after lacerations healed and lochia stopped – about 4-6 months
- may need Lubrication
- need to decide on Contraception
X - Resume after lacerations healed and lochia stopped – about 4-6 weeks
- Lubrication
- Contraception
which of these is required for postpartum discharge? SATA
-Stable vitals
-Involution of uterus
-Lochia amount heavy but no sign of infection
- Education s/s of infection
- Lacerations well approximated
- Stable vitals
- Involution of uterus
X - Lochia amount must be ok (scant, light, moderate) + no sign of infection - Education s/s of infection
- Lacerations well approximated
which of these is required for postpartum discharge? SATA
- Ability to perform pericare and take meds as ordered
- Ability to void and pass gas
- Ability to take fluids and foods with slight difficulty
- Ability to identify s/s PP depression and resources
- Reviews teaching material and shows how to care for self and baby
- Ability to perform pericare and meds as ordered
- Ability to void and pass gas
X - must have ability to take fluids and foods without difficulty - Ability to identify s/s PP depression and resources
- Reviews teaching material and shows how to care for self and baby
which of these is required for postpartum discharge? SATA
-Appropriate interaction with baby such as leaving the baby unattended or incorrect feeding practices
-Practices principles of infant safety
-Rubella (MMR injection) – if non immune
-RhoGAM injection – if neg mom, pos baby, or direct combs neg
X- must show Appropriate interaction with baby such as not leaving the baby unattended and correct feeding practices
- Practices principles of infant safety
- Rubella (MMR injection) – if non immune
- RhoGAM injection – if neg mom, pos baby, or direct combs neg
