Postpartum Nursing Assessment and Care – Flashcards
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Puerperium
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interval between the birth of the newborn and the return of the reproductive organs to their normal non-pregnancy state about 6 weeks
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physiologic adaptation postpartum
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Involution of the uterus restoration of the uterine lining and discharge of lochia healing of the vagina, cervix and perineum
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Uterine involution
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return of the uterus to non-pregnant state- involution - decreased estrogen and progesterone after birth --> autolysis or self destruction of excess hypertrophied tissue
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Uterus
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firm, midline, decreases 1-2 cm every 24 hours
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postpartum uterine contractions
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postpartum hemostasis is achieved primarily by compression of intramyometrial blood vessels as the uterine muscle contracts rather than by platelet aggregation and clot formation. hormone responsible -> oxytocin
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Uterine afterpains
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uterine cramping due to periodic uterine relaxation and vigorous contraction more common in multips and with uterine over distension enhanced with breast feeding and exogenous oxytocin
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Uterine placental site
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vascular constriction & thromboses placental site -> irregular nodular and elevated area upward growth of endometrium causes sloughing of necrotic tissue and prevents typical scar formation of normal wound healing promotes future implantation and placentation
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uterine lochia
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post partum uterine discharge C/S vs Vaginal Birth increase with ambulation and breastfeeding
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Lochia Rubra
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Day 1-3 bloody/small clots mod-scant increased flow w/ standing and breast feeding fleshy odor abnormal large clots saturated pad every 15 min foul odor
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Lochia serosa
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Day 4-10 pink/brown color scant increased during physical activity fleshy odor abnormal not changing to serosa saturated pad every 15 min foul odor
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Lochia Alba
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Day 10 yellow/white color scant fleshy odor abnormal: Bright red bleeding foul odor
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subinvolution
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most common cause retained placental fragments cause infection Full Bladder -> uterine atony-> bleeding
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factors enhancing involution
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uncomplicated labor and birth complete expulsion of placenta and membranes brastfeeding manual removal of placenta during CS early ambulation
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Factors which slow involution
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prolonged labor anesthesia difficult birth grand multiparity full bladder incomplete expulsion of placenta and membranes infection over distension of uterus
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cervix
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soft immediately following birth may be bruised/ small lacerations 2-3 days PP firm, shortens and regains form cervical os gradually closes Jagged slit not circular
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Vagina and perineum
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edematous hematoma lacerations 1st, 2nd, 3rd, 4th episiotomy 3rd and 4th degree lacerations- do not give suppositories or enemas or anything per rectum
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Hemorrhoids
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decrease after birth itching discomfort red bleeding with stools
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Abdomen
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1st two weeks abdominal wall is relaxed 6 weeks to return to pre-pregnant state diastasis recti abdominis- separation of the abdominal muscles, lessens over time
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Placental Hormones
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decrease in Human Placental Lactogen (HPL), estrogens, cortisol lower insulinase- lower blood glucose lower estrogen- postpartal diuresis
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pituitary hormones
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increase in prolactin levels - breast feeding prolactin level influences ovulation differences in return of ovarian function with lactating women
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postpartal diuresis
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decrease renal function 2-8 weeks dilation of ureters and renal pelvis to return to normal could have birth induced trauma edematous- difficult to void bladder tone- normal 5-7 days
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GI system
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hungry 2-3 days before BM -anesthesia -analgesics -episiotomy -lacerations -labor -dehydration - No PO intake
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Breasts
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colostrum- clear/yellowish fluid rich in immunoglobins, increased proteins, vitamins, less fat than mature milk milk production enorgement breast care
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Cardiovascular
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pregnancy= increase in blood volume prepares for blood loss by 3rd post partal day plasma volume replenished (shift extra-intra vascular space HR and BP monitoring
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blood componets
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H/H decrease post delivery until about 8 weeks post postpartum
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Leukicytosis
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20,000-25,000/mm3 is common
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Elecated clotting factors in pregnancy and immediate postpartum
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increased risk with thromboembolism especially with C/S birth
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Neurologic
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discomfort due to edema improves. assessment of headache and visual disturbances
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Musculoskeletal
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hyper mobility of joints revered
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integumentary
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hair loss, hyper pigmention (chloasma), stretch marks fade but do not disappear
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Immune systems
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assess rubella and RH status
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8 points of assessment of the woman post partum
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vital signs breasts uterus bladder lochia perineum vascular system / homan's sign emotional status
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purpose of the postpartum assessment
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to gather data about involutional changes and her need for nursing intervention and teaching * ask mother to empty her bladder before assessment
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BDH postpartum assessments/ VS/ I&O
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SVD (delivery Day) -one hr after transfer form L&D -Q 4 hours x 24 hours SVD (1st postpartum Day) -Q shift (about every 12 hours) surgical and high acuity patients -Q 1 hr x 2; Q 2 hr x 2 then Q 4 hrs or -Q 30 min x2, Q 1 hr x4 then Q4 hrs
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temp
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transient increases in maternal temp normal vs infection >38 c after 24 hours- investigates
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Pulse
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bradycardia (50-70 bpm) for 6-10 days Tachycardia (>100 bpm)
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BP
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expected to be normal, compare to first trimester BPs -low BP -High BP: increase of 30 mm Hg Sys or 15 mm Hg diastolic, especially when associated with headache or vision changes needs to be investigated
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Respirations
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should be normal
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Pain
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-mismanaged pain = prolonged recovery depression, anxiety, poor coping, altered sleep patterns -pharmacological -non-pharmacological
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Fundus
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in relation to umbilicus -firm, boggy, firm with massage -U+2... ect, U-2 ect saturation of perineal pad in 15 min? what should the nurse do? not leave patient call for help, continue with massage
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Lochia
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2 hours post bith uterine discharge equivalent to a heavy menstrual period then streadily decrease a perineal pad saturated in under or = to 15 min or pooling of blood = excessive blood loss requiring immediate intervention may persist for 4-8 weeks after birth
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Bladder
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voiding: spontaneous or catheter Palpable/ Non palpable Urine: color, odor, amount patient should void 6-8 hours after birth normal output: interventions: assessment, running water, hands in warm H2O, warm water poured over perineum, peppermint oil, analgesics, catherization
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Episiotomy healing
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Redness, Edema, Ecchymosis, Discharge, Drainage, Approximation
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Perineum/ incision
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assessment of episiotomy or lacerations assessment of incisional dressing for C/S interventions -ice pack for first 24 hours, sitz bath, peri-bottle, hemorrhoidal topicals
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Breast care
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Assessment of nipples proper latch and breast feeding technique interventions -lansinoh cream, engorgement-frequent feedings, ice packs soothies Nipples: sore, inverted/flat/everted Breast tissue: Days 1-2 soft, days 2-3 filling, Days 3-5 full Temp and color: warm, pink, cool red streaked erythematous
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Bowel function
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avoid constipation may not have bowel movement for 2 to 3 days due to dehydration perspiration, emesis, NPO Gas pains- can be sharp and stabbing also felt in shoulder blades Rx- stool softeners, laxatives
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Legs
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Assess Homan's sign -warmth, redness, tenderness Edema DTR's- Deep tendon reflexes Early ambulation/ sensation after spinal/ epidural varicosities
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BUBBLE
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Breast, Uterus, Bladder, Bowel, Lochia, Episiotomy, Homan's sign, Emotional status
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Cesarean Section
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Pain relief, monitor VS, incision, I &O voiding after foley removal, ambulation, Gas/ BM
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Post -Anesthesia/ post operative care
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assess for spinal headache after spinal or epidural anesthesia
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Postpartum assessment health promotion
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Rubella status- if rubella non immune needs vaccination before D/C Varicella vaccination- breast feeding ok, need informed consent- must practice contraception for 1 month after vaccination with both vaccines Tdap recommend in postpartum period if not perviously vaccinated influenza vaccine
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RH status
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Rh neg mom and Rh positive baby Rh immune globulin considerations -within 72 hours after delivery -verify that mob Rh neg & has not been sensitized and the infant is Rh positive
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psychosocial assessment
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Bonding/ support system mental status home needs
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transition to parenthood
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Attachment and bonding- occurs over time -holding -eye contact -talking -smiling -learn to read cues
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foster parent infant attachment and care of newborn
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promote rest, food, and fluid intake pain management discuss baby's unique characteristics encourage family to hold, cuddle, inspect and feed the infant point out normal newborn reflexes and abilities provide privacy and an environment that enhances family infant interaction
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factors affecting bonding/ attachment
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-factors affecting emotional and physical condition after labor -infant's condition and behavior -separation of mother and infant after birth due to maternal or infant illness -contrast of fantasy infant with real infant -maternal drug and alcohol use -neonatal congenital anomalies -prematurity -teenage mother -unwanted pregnancy -infant is the product of rape or incest
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Attachment
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new patents concerned they were not able to bond with baby due to emergency C/S.
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Parental behaviors indicating bonding/ attachment problems
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ignoring infant's presence turning away from infant wakes baby when sleeping; handles roughly expresses disappointment, displeasure in infant disgusted by infant's body fluids
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potential complications
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infant failure to thrive and neglect non attachment leading to physical abuse emotional detachment
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maternal adjustment
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50-80% have PP blues (7-10 days) -crying easily for no reason, overwhelmed, fatique, insomnia, anxiety, headache, sadness, restlessness, anger -self image -role change Taking in- 1 to 2 days - focus on self and needs taking hold about 3 to every weeks -focus on baby care and mothering Letting go- forward movement of family as unit
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sibling adaptation
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positive VS Negative behaviors - (+) interest or concern, increased independence - (-) regression, aggression, whining Involve other children -classes, tour, holding equal attention
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Infant abduction
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Code Pink Identification Bracelets Line of Sight
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Care of infant
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Bottle feeding Breast feeding Newborn care
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Discharge Teaching
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"back to sleep"- sids car seat bathing cord care diapering stols circumcision care temp axillary 97.7-99.5 feeding jaundice
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Common postpartum concerns
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Gush of blood that sometimes occurs when she first arises night sweats after pains large stomach after birth and failure to lose all weight gained during pregnancy postpartal chills
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signs and symptoms to report
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fever localized area of redness or pain in either breast persistent abdominal tenderness feelingof pelvic fullness or pelvic pressure persistent perineal pain frequency, urgency or burning on urination change in character of lochia localized tenderness, redness swelling or warmth of legs swelling redness drainage from or separation of abdominal incision
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Discharge
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discarge packet discharge order discharge instrucitons -danger signs -follow up medication reconciliation virtual nursery photo birth certificate
