nursing management during postpartum period

postpartum assessment VS

BP (pre-pregnant level). pulse (60-80, bradycardic). respirations (12-20 bpm). temp (98-100). pain status.

temperature greater than 100.4 within first 24 hours may indicate...

infection or anytime (push fluids)

up to and equal to 100.4 may be d/t...

dehydration during 1st 24 hours

PP assessment - 1st hour

every 15 min

PP assessment - 2nd hr

every 30 min

PP assessment - 1st 24 hours

every 4 hours

PP assessment - after 4 hrs for a whole day then...

every 8 hours

PP physical assessment - BUBBLEHE

breasts, uterus, bladder, bowel, lochia, episiotomy, homan's sign, emotional status

PP physical assessment - breasts

soft, filling, or engorged; check nipples (cracks, bruising, bleeding)

PP physical assessment - uterus

firm or boggy; midline or deviated, relation to umbilicus

U-1 is what?

midline

PP physical assessment - bladder

empty, emptying w/o difficulty, retaining urine, full

PP physical assessment - bowel

bowel movement or constipated, bowel sounds (all 4 quadrants)

PP physical assessment - lochia

rubra, serosa or alba, amount, clots

PP physical assessment - episiotomy

intact, healing, infected

PP physical assessment - homan's sign

negative or positive

PP physical assessment - emotional status

talkative or withdrawn

scant lochia

10 ml. 1-2" stained pad.

light/small lochia

10-25 ml. 4" stained pad.

moderate lochia

25-50 mL. 4-6" stained pad.

heavy/large lochia

Saturated pad within 1 hr. of changing pads

evaluate lochia if...

saturating more than 1 pad/hr

how to chart lochia?

amount, odor, clots, size of clots, color

perineum

sim's position. gloves. irritation, ecchymosis, tenderness, hematoma, hemorrhoids.

perineum tissue surrounding episiotomy may be...

edematous, slight bruising (normal)

episiotomy should not have...

erythema, discharge, or edema

first degree laceration

involves only skin and superficial structures above muscle (skin tore a little)

second degree laceration

extends through perineal muscles

third degree laceration

extends through anal sphincter muscle

fourth degree laceration

continues through anterior rectal wall

signs of hematoma

large area of swollen, bluish skin. c/o of severe pain. assess for s/s of infection.

true or false - normal hematoma, size of a walnut, will break down

true

do we have to open hematoma and drain it if extremely large?

yes

catching a hematoma early, what do we want to do?

side lie cold packs, assessing with HCP

cultural care

provide optimal cultural care. support person, use of hot/cold, bathing rituals, traditional folk beliefs. diet restrictions, certain clothes, taboos, use of silence/prayer/meditation. breast vs bottle feeding, modesty, eye contact

cold application - ice pack 1st 24 hours

reduce edema, prevent hematomas, decrease pain, apply for 20 min then remove for 10

peribottle

warm water. cleanses periarea after voiding, defecating, or pad changes. direct water from front to back.

warm pack/pad after...

24 hours

sitz bath after 24 hours

helps vascular circulation and healing. use peribottle to cleanse before sitz bath. emergency call light available. stay in room if first time OOB or any c/o of dizziness.

analgesics - topical preparations

dermoplast spray (local anesthetics/numbs area). tucks pads. hydrocortisone cream.

analgesics - mild to moderate pain

ibuprofen (pain/fever/inflammation) and acetaminophen (pain/fever)

analgesics - moderate/severe (first 12 hours for c/s)

codeine/oxycodone combine with tyelnol/aspirin

educate on s/e of analgesics

dizziness, n/v, constipation, sedation

can we medicate an hour prior to BF to promote comfort if needed?

yes

breast care for lactating women

supportive bra, warm showers, correct position and latch on technique, nipple inspection, exposure to air, frequent nursing, increased fluid intake

breast care for non-lactating women

avoid stimulation, cold showers, supportive bra on 24 hrs, use icepacks or cabbage leaves for engorgement, avoid manually expressing milk from breasts, take mild analgesic for discomfort.

postpartum danger signs

fever, foul smelling lochia or unexpected change in color/amount, saturates pad within in an hour, large blood clots, severe h/a, blurred vision, calf pain, episiotomy/epidural site/abdominal site (swelling, redness, d/c) SOB, dysuria or burning/difficulty voiding, depression or extreme mood swings

causes of postpartum hemorrhage

uterine atony. retained placental fragments. cervical/perineal lacerations. subinvolution. bleeding d/o.

management of postpartum hemorrhage

fundal massage. teach woman to massage own fundus and assess bleeding.

fundal massage

stimulate uterus to contract

bladder care conditions

immediately pp, bladder is edematous and hypotonic d/t labor. profuse diuresis (>3000 ml/day), occurs 24 to 48 hours after birth.

problems with bladder

urinary distention, incomplete emptying, retention with overflow

management of bladder care

early ambulation; void within 4-6 hours after birth, using nursing interventions to stimulate voiding

postpartum blues

emotional lability (normal d/t estrogen and progesterone levels dropping)

blues s/s

crying spells, sadness, confusion, insomnia, poor appetite and anxiety. affects 75% of all new mothers. self-limiting, mildest form.

postpartum blues begins and ends when?

begins day 3 postpartum, resolved by day 10.

postpartum depression

same s/s of depression, not self-limiting, need to see HCP, medication, therapy

postpartum psychosis

most dangerous. feelings of harming self, baby, or both. happens from chemical imbalance. safe person?

rubella vaccine

if not immune. consent form. avoid pregnancy for at least 4 wks, some suggest up to 3 mo. (risk for teratogenic effects)

rubella s/e

rash, soreness, joint s/s, fever

rhogham (Rh IgG)

for Rh- mothers with Rh+ infant. give injection within 72 hours after birth. prevent sensitization reaction. consent required.

rhogham dosing

2 doses. one at 28 wks gestation, second before 72 hours after childbirth consent required

Tdap (tetanus, diptheria, pertussis)

after delivery before d/c, if have not received

discharge planning

no lifting for first few weeks. pelvic rest for 4 to 6 weeks. sleep when infant sleeps. accept help from others when offered. use a lubricant to help with vaginal dryness. keep a pp. follow up appointment. report any s/s of sickness to PCP.

exercise

gradual return. pelvic floor exercises. walking. abdominal breathing. head lifts. modified sit ups. knee and leg rolls. chest exercise. pelvic tilt.

abdominal breathing

supine position with knees bent, contract abdominal muscles, exhale

head lifts

supine with knees bent, raise head slowly

modified sit ups

progression of head lifts

knee and leg rolls

supine, knees flexed, keep shoulders on bed and roll hips

chest exercise

supine, knees bent raise arms

self care misc.

frequent pad changes. no tampons, tub baths 4-6 wks. hand washing.

safety

check BP before ambulating. elevate HOB a few minutes before ambulating. dangle patient. assist to stand and stay with patient. frequent questioning. stay close with ambulating.

safety - sexuality

3-6 wks must be healed, bleeding stopped.

contraception counseling

some ovulate before menses returns. possible to become pregnant before first follow up visit.

nutrition

greater needs for BF moms (+500 cal/day). adequate fluids: at least 2500 ml/daily. discourage diets. easy recipes. avoid fast foods.

home care

infant issues. bathing. nail care. dressing. temp. stools and urine. sleep patterns. crying. safety. immunizations. medical screenings. follow-up. maternal issues. breast feeding. cracked nipples. engorgement. plugged ducts. working and breast feeding. sex. help lines.bab

plugged ducts

warmth, heat, massage

baby care

ease in handling (encouragement and praise). involve family members. safety. feeding position. wet diapers, formula preparation. handling. cord care. temp. taking. female genitalia. circ. care.

nutritional needs

100-115 kcal/kg/day

formula

milk based. specialized/therapeutic for protein allergies. soy based. preparation.

milk based formula

enfamil and similac

specialized/therapeutic for protein allergies formula

nutramigen and alimentum

soy based formula

isomil, prosobee, nursoy

preparation formula

powder, concentrate, ready to feed

formula fed regain to birth wt...

10 days; double 3.5-4 mo

BF regain to birth wt...

14 days; doubles 5 mo.

BF education

sole nutrient for 6-12 mo

3 stages of milk

colostrum, transitional milk, mature milk

colostrum

lasts 2-4 days. high in protein, vitamins, minerals, and IgA

transitional milk

4 days to 2 wks. increase in calories and fat

mature milk

20 cal/oz

foremilk

beginning of feed. high in H2O, protein, and minerals.

hind milk

after letdown. high in fat.

BF within first 20-30 min; alert stage

on demand 8-10 feeds/day. at least every 2-3 hrs, wake up for feeds in hospital. cluster feed. crying as sign. rooming in enhances response. sleep through night (8-12 wks)

contraindications of BF

HIV and metronidazole

contraindications to bottle

allergies, over dilution

other nutritional needs

promoting BF, positioning, c hold or scissor hold. belly to belly. most areola in baby's mouth. offer each breast q2 hrs initially. limited to no pacifier recommended.

BF problems

leaking. supplemental bottles. pumping. storing. la leche league. lactation consultants. drugs all pass to some extent. nipple soreness.

storing BM in refrigerator

2 days

storing BM in freezer

2 weeks