Assessment and Family-Centered Nursing Care During the Postpartum Period – Flashcards

Placental -Human Placental Lactogen (HPL) -Estrogen -Progesterone Pituitary -Prolactin -Oxytocin -FSH & LH Decrease in Human Placental Lactogen (HPL) or placental enzyme insulinase (with delivery of placenta): -results in lower blood glucose levels immediately postpartum. Feeding new mothers is very important!!! Decrease in Estrogen (with delivery of placenta): -associated with breast engorgement, diaphoresis and diuresis, and diminishes vaginal lubrication Decrease in Progesterone (with delivery of placenta): -increases muscle tone throughout the body *progesterone is smooth muscle relaxer during pregnancy Increase in Prolactin: -associated with breast milk formation and production *"happy hormone"; melows new moms out *primarily responsible for milk production; if you aren't prego or breastfeeding this isn't around Increase in Oxytocin: -breastfeeding stimulates release of oxytocin from pituitary gland -stimulate uterine contractions (prevents hemorrhage) -uterine contractions (AFTER PAINS) compress the intramyometrial blood vessels as the uterine muscle contracts, resulting in constriction of the blood vessels, thereby achieving and maintaining hemostasis -associated with breast milk release of "let down" *oxytocin and prolactin increase in postpartum period Decrease in FSH and LH (breastfeeding): -LAM=Lactational Amenorrhea Method

Blood and volume loss=normal 500 cc (NSVD), 1000cc (C/S) and orthostatic hypotension CBC=hemo-concentration, then hemo-dilution WBC=normally elevated after delivery Clotting factors=predisposition to thrombus formation Labs return to pre-pregnant state by 4 weeks Blood and volume loss: -decrease in blood volume postpartum is related to blood loss during childbirth -blood loss average is 500 cc for a Normal Spontaneous Vaginal Delivery (NSVD) and 1000 cc for Cesarean Section -greater than 500 or 100 (c/s) 0 cc respectively is abnormal and is considered postpartum hemorrage -Orthostatic hypotension due to volume loss resolves within 48 hours postpartum CBC: -decrease of 2-3% in HCT from admission=500ml -loss of excess fluid or diaphoresis occurs over 2-3 days postpartum -increase hematocrit and hemoglobin up to 72 hours postpartum due to hemo-concentration as a result of greater loss of plasma volume than number of RBCs; then hemodilution occurs or a decrease in hematocrit and hemoglobin WBC: -Elevated WBCs 25,000-30,000 and increased sedimentation rate is back to normal by 7 days postpartum Clotting Factors: -Coagulation factors and fibrinogen levels increase during pregnancy and remain elevated for 2 to 3 weeks postpartum -Consequent predisposition for emboli, thrombus formation (immobile, venous stasis, vessel damage during birth, and increased maternal blood volume of pregnancy, and deep pelvic veins stay dilated until 6 weeks postpartum)

Postpartum chill -Nervous response or vasomotor change -Treat with warm blanket or warm beverage, assure woman that this is a common occurrence and short-lived Postpartum diaphoresis Excessive perspiration, hot flashes as a result of hormone changes Elimination of excess fluids and waste products Prevent chilling After pains (intermittent uterine contractions) More common and severe in multiparas Lasts 2 to 3 days More severe and frequent in lactating women as they breastfeed

Select the time that will provide the most accurate data Introduce yourself Provide an explanation of the purpose of the assessment Ensure that the woman is relaxed before starting/ensure privacy Teach as you go! Record and report the results clearly Body fluid precautions

Initial weight loss of 10 to 12 lbs (baby, amniotic fluid, placenta) Postpartum diuresis causes a loss of 5 lbs (more with significant edema) 25 to 30 pounds by 6 to 8 weeks after delivery Return to their pre-pregnant weight depends on pregnancy weight gain

Cultural food preferences Breast or bottle feeding calorie adjustments Diagnosis of anemia (Hgb < 10gm/dl) following birth -Increase calories to total of 500kcal if breastfeeding -Decrease calories by 300 if bottle feeding -Note Hgb on admission and at 24 hours after birth -Diagnosis of postpartum anemia is based on 24 hour Hgb result

Listen to the story!!! A great ice breaker Comfort/pain (prevention of breakthrough pain, particularly in Cesarean Section patients) Fatigue (rest) Address concerns Afterpains, or intermittent uterine contractions, cause discomfort for many women (multiparas, breastfeeding) Postpartum pain management is accomplished by alternating analgesics with NSAIDS q 3 hours to prevent breakthrough pain

Breastfeeding or formula feeding Soft, firm, hard (engorgement occurs 3-7 days after birth) Nipples non-tender/tender, cracking, bleeding Inverted, flat, everted (ideal)

Uterine involution-fundal changes or finger breaths above/below umbilicus, firm, boggy, displaced to the right? Incisional (REEDA) with Cesarean Section or Tubal Ligation Stretch marks (striae) Stretch marks or striae occur in 50-90% of women and fade over time, but never completely disappear Appears loose and flabby and responds to exercise Diastasis recti abdominis responds to exercise

Three processes -Contraction of the muscle fibers -Catabolic processes -Regeneration of uterine epithelium The site of placental attachment heals by a process of exfoliation...Leaves the endometrium smooth and without scars -constriction of intramyometrial vessels controls uterine bleeding, rather than blood clotting -uterine atony=boggy uterus Involution can be evaluated by measuring the descent of the fundus -about 1 cm per day (*1 finger width) -fourteen days after childbirth, the fundus should no longer be palpable. Uterine involution examples: =1/U or +1/U F=fundus is 1 fingerbreadth above the umbilicus and firm =U/1 or U/-1 F =fundus is 1 fingerbreadth below the umbilicus and firm =U/U B =fundus is at the level of the umbilicus and boggy

separation of the rectus muscles--responds to exercise

Measure first 2 voids post birth Voiding every 3-4 hours Straight catheterization if not voided within 4-8 hours of delivery or after urinary catheter removal 8 glasses of fluid in 24 hours Over distention of bladder caused by rapid filling of bladder due to diuresis Dilated ureters and renal pelves return to pre-pregnant state by 6 weeks full bladder is more prone to post partum hemmorage

Location of fundus above baseline level (determine with empty bladder) Fundus displaced from midline Excessive lochia Bladder discomfort Bulge of bladder above symphysis Frequent voidings of less than 150 ml

Perineal care, peri-bottle, pat dry, wipe front to back Change pads REE and DA for laceration or episiotomy Hemorrhoids Ice x 24 hours and sitz bath after 48 hours Topical agents, witch hazel Vagina -it takes 6-10 weeks for the vagina to regain its non-pregnant size and contour Perineum -perineal trauma and hemorrhoids cause discomfort and can interfere with activity and bowel elimination

Acronym REEDA R= redness E=edema (swelling) E=ecchymosis (bruising) D=discharge (not lochia, but discharge from the laceration or incision) A=approximation

Blood (Lochia): -Rubra (0-3 days) -Serosa (4-10 days) -Alba (mostly WBC's10 days and continue 2 or 6 weeks) Assessment -Amount, type, and odor (foul odor suggests endometrial infection) -Normal gush of blood=Recumbent--> vaginal pooling of blood-->stands-->gush of blood -Increased rubra bleeding indicates sub involution or postpartum hemorrhage Placental site heals by exfoliation and regrowth of endometrial tissue rather than scarring Endometrial tissue in the decidua basalis grows up and the endometrial edges grow inwards to the center The infarcted superficial tissue becomes necrotic and is sloughed off-->lochia Note if healing were to leave a fibrous scar, the chance for future pregnancies would be limited Cervix is less than 2 cm within a couple hours after birth, finger tip by 1 week, closed when the lochia stops

-scant: <2.5 cm -light: 2.5-10 cm -moderate: 10-15 cm -heavy: saturated in 1 hour

Gas especially with Cesarean Section Increase fluids/fiber Stool softener BM usually within 2-3 days following birth Sluggish due to progesterone and decreased abdominal musculature leading to constipation Fear of pain and tearing laceration/episiotomy delays elimination After cesarean section, bowel tone returns in few days and flatulence causes abdominal discomfort Prevent constipation: stool softeners, ambulation, increased fluid intake (2000mL/day or more), adding fruits and roughage to diet

Edema (swelling or pitting) Look for signs of phlebitis/blood clots (pain, redness or hot areas) Homan's sign

Initial attraction felt by parents Unidirectional from parent to child Contact should occur as early as possible and as frequently as possible Allow time for attachment to occur with all members of the family

Bond that endures over time Occurs through mutually satisfying experiences Reciprocity=Mutually gratifying interaction among mother, infant, other parent

Enface: infants face on same vertical plane as parent. mutual gazing. explore with finger tips hand and palmar contact whole arms-enfolds whole baby close to body Attachment behaviors: -Talks to newborn -Seeks eye contact -Face to face -Touches and holds -Cuddles -Sooths -Feeds newborn -Changes diaper -Keeps baby clean -Appropriate clothing -Checks while sleeping

The Claiming Process includes the identification of the baby's specific features, relating them to other family members

Eye contact with prolonged, intense mutual gazing Eye movements with attempts to "track" parent's face Grasping and holding of parent's finger Synchronous movements in response to rhythms and patterns of parent's voice Rooting, suckling, and latching on to breast Being comforted by parent's voice or touch

Incorporate family goals in plan of care Encourage skin-to-skin contact Encourage breastfeeding in the first hour Postpone eye prophylaxis for 1 hour Provide private time for the family to become acquainted Encourage involvement of the siblings Initiate and support measures to minimize fatigue Prepare parents for potential problems with adjustment Help parents identify, understand, and accept feelings

Taking-In Phase=Birth to 2nd Postpartum Day (PPD) Needs to tell her story (pregnancy, labor, birth) Pre-occupied with her own needs (food, sleep) Dependence on others, passive behavior Taking-Hold Phase=3rd to 10th Postpartum Day (PPD) Ready to deal with the present and resume control Wants to do the right thing for her newborn Risk for feeling like a failure (Reva Rubin, 1961; May & Mahlmeister, 2002) TAKING-IN -Both delighted and concerned -Bonding process (e.g. kissing, fondling, talking to & about the infant, cuddling, and eye contact) -Learning new role/tasks/like a student/novice -Easily overwhelmed! Main nursing implication is to listen and help the mother interpret events of pregnancy and birth to make them more meaningful and clarify any misconceptions TAKING-HOLD -Optimal time for teaching -Unfortunately occurs after discharge from hospital for most mothers/parents.

Assess taking-in vs. taking-hold cues Reassure, give positive feedback Expressed interests or identified need of parents/family Identifying parents' needs vs. nurses need to "teach everything"

-Self care -Newborn care -Resources -Home visit -When and who to contact for self and newborn -F/U appointments -Postpartum exercise Self-care=signs and symptoms of complications, rest and activity, hygiene, sexual activity and family planning, postpartum depression Resources=telephone #s and written information Newborn care=nutritional needs, signs and symptoms of illness or problem, safety Follow-up appointments for mother and newborn Need for home care/PHN referral Exercise=doing too much, simple exercises to start

Oral temperature > 38.0C (100.4F) Hot tender breasts Nausea and vomiting Painful urination, burning or increased frequency Bleeding heavier than a normal period Persistent perineal and/or incisional pain with increasing tenderness Pain, swelling or tenderness in legs Chest pain or cough Provider appointment 6 weeks postpartum

Postpartum care modeled on concept of health Cultural beliefs and practices affect patient's response to postpartum period or puerperium Nursing plan of care includes: -Assessment to detect deviations from normal -Comfort measures to relieve discomfort or pain -Safety measures to prevent injury or infection Teaching/counseling to promote woman's feelings of competence in self- and baby care Common nursing interventions include: -Evaluating and treating boggy uterus and the full urinary bladder -Pharmacologic and non-pharmacologic relief of pain and discomfort associated with episiotomy or lacerations -Measures to promote or support lactation Meeting psychosocial needs of new mothers involves planning care that considers composition and functioning of entire family Early postpartum discharge will continue to be trend as result of: -Consumer demand -Medical necessity -Discharge criteria for low risk childbirth -Cost-containment measures Effective means to prevent crisis and facilitate physiologic and psychological adjustments in combination include: -Early discharge classes -Telephone follow-up -Home visits -Warm lines -Support groups