Families Exam 2

What does BUBBLEHEB stand for?

1. Breast

2. Uterus

3. Bowel

4. Bladder

5. Lochia

6. Episiotomy

7. Hemorrhoids

8. Emotional status

9. Bonding

BUBBLEHEB Assessment: Breast

look for any abnormalities or skin breakdown/cracked nipples (mastitis)

BUBBLEHEB Assessment: Uterus

check fundal height, uterine placement, consistency

BUBBLEHEB Assessment: Bowel

GI function – check bowel sounds & movements

BUBBLEHEB Assessment: Bladder

make sure they can void, especially if they had an epidural

BUBBLEHEB Assessment: Lochia

COCA (color, odor, consistency & amount)

BUBBLEHEB Assessment: Episiotomy

REEDA (redness, edema, ecchymosis, D/C & drainage, & approximation) healing evaluation

BUBBLEHEB Assessment: Emotional Status

PP blues, depression, psychosis

BUBBLEHEB Assessment: Bonding

are they bonding with baby?

BUBBLEHEB Assessment: Hemorrhoids'

presence and appearance

BUBBLEHEB Nursing care: Breasts

- Well fitted bra

- Allow infant to nurse on demand (8-12 times a day)

- Sore nipples: Breastmilk or lanolin (don't use if allergic to wool)

- Non-breastfeeding: bra continuously for 72 hrs, cold cabbage leaves inside bra, cold compress 15 min on 45 min off

BUBBLEHEB nursing care: Uterus

- Assess fundal height, placement & consistency (tone) Q8: fundus should be firm and in the midline/center (+1/U is normal)

- 12 hrs postpartum: will be back at the umbilicus, day 10 no longer palpated

BUBBLEHEB nursing care: Bowel

- if constipation occurs admin. stool softeners (docusate sodium!!!)

- Early ambulation/increased fluids/high fiber

- Hemorrhoids are normal: can give meds &/or comfort measures

BUBBLEHEB nursing care: Bladder

- Retention from loss of bladder elastictiy/anesthesia/trauma can cause uterine atony & displacement to one side leading to PPH

- Should void every 2-3 hr to prevent displacement of uterus & atony

- Measure urine output; excessive voiding ( >3,000 mL/day) is normal

BUBBLEHEB nursing care: Lochia

(should follow in this order)

Rubra (2-3 days) (RUBBY RED)

- Dark red, fleshy odor

- Small clots ok

- Increase with breastfeeding & ambulation

Serosa (4-10 days)

- Pinkish brown

- Serosanguineous

- Small clots ok

Alba (10-28 days)

- Whitish yellow, fleshy odor

- May contain mucus

BUBBLEHEB nursing care: Episiotomy/laceration/hematoma

- Peri ice pack 24hrs for edema, heat therapy, sitz baths (20 min day) (increase circulation)

- Pain meds as needed, hemorrhoidal cream, stool softeners

- Benzocaine spray, witch hazel

- Peri bottle & pat dry only (warm water/antiseptic to clean peri area)

BUBBLEHEB nursing care: Emotional Status

- PP blues are normal

BUBBLEHEB nursing care: Bonding

Bonding

- Rooming in & skin-skin, on chest, immediately after birth

BUBBLEHEB interventions: Breasts

- Engorgement(too much milk in breast): warm shower/compress before feeding to promote letdown & cold compress after feeding

BUBBLEHEB interventions: Uterus

- If midline or displaced L/R = have them use the rr & reassess

- Boggy(bleeding): massage until FIRM

BUBBLEHEB interventions: Bladder (distended)

- Fundal height above the umbilicus or baseline level

- Fundus displaced from midline (L/R)

- Bladder bulges above pubic symphysis

- Tenderness over bladder area

- Voiding < 150 mL = retention with overflow

BUBBLEHEB interventions: Lochia

- Saturating pad in 15 min or less = postpartum hemorrhage

- Foul odor = infection

- Persistent heavy lochia beyond day 3 = retained placental fragments

BUBBLEHEB interventions: Episiotomy/ Laceration

- Vaginal bleeding even with a firm uterus: continuous bleeding

- Continuous trickle of bright red blood

BUBBLEHEB interventions: Hematoma

- Pain (not bleeding)

- Pressure in rectum or vagina

- Difficulty voiding

BUBBLEHEB interventions: Emotional Status

- PP depression & psychosis is not normal

- Psychosis: mom can be threat to self, baby, &/or other family members

Post-Partum (PP) physical adaptations: when to call provider

- Fever 100.4 or higher past 24hrs or for 2 days

- Change in vaginal D/C: increased, large clots, change in lochia color, foul/odor drainage

- Pain unrelieved with pain meds

- Thoughts of harming yourself or infant

- UTI (burning urinating & frequency/urgency)

- Calf pain: tenderness, swelling, redness

Pain assessment

- Assess origin of pain and use pain scale
- Evaluate for hematomas - valvular, vaginal, pelvic
· Severe pain with firm uterus
- Anxiety & fear, muscle tension increases

Pain priority interventions

- Note patient response to pain meds
- Monitor for side effects

Pain pharmacological interventions

· Acetaminophen
· Ibuprofen
· Codeine, hydrocodone
· PCA pump after c-section

Pain non-pharmacological interventions

· Heating pads
· Position changes
· Ice packs

Pain post-epidural

· Ensure sensation is back before standing up first time
· Do not drive after 2 weeks or while on narcotics
· No housework/heavy lifting for 6 weeks
· Ambulate frequently to prevent clots

Lab Results: Rubella

non-immune, negative or low titer (<1.8) = give MMR shot (can't get while pregnant/breatfeeding nor don't get pregnant for 4 wks after)

Lab Results: Varicella

non-immune = vaccine before D/C

Lab Results: Tdap

(pertussis-whooping cough): recommended during pregnancy because immunity takes 6 weeks, give before discharge

Lab Results: Rh

Rh-negative clients who have Rh-positive newborns = RhoGAM within 72 hours to suppress antibody formation in mom (Kleihauer-Betke test determines amount of fetal blood in maternal blood - more than 15 mL need rhogam)

Lab Results: CBC

· H/H, WBC, PLT levels drop for 3-4 days & increase by 8 weeks

· Postpartum leukocytosis = WBC can be 20,000 within first 4-7 days (normal)(watch temp)

Lab Results: Hep B

· Obtain consent

· Newborn born to healthy mom: at birth, 1 month, 6 month

· Newborn born to infected mom: Hep B immunoglobulin & vaccine within 12 hrs of birth, vaccine at 1 month, 2 month, 12 month

Lab Results: VS

· Puerperal bradycardia --> HR can decrease to 40 bpm due to elevation in stroke volume

· Orthostatic hypotension from engorgement can occur within first 48 hours (sit on side of bed before standing)

· Temp can be elevated during first 24 hours too 100.4; fever after 24 hours needs to be evaluated

Transition: maternal role attainment- Taking-in (dependent)

24-48 hours post birth

- Focus on personal needs

- Relates birth story & needs assistance

- Talkative, excited

Transition: maternal role attainment- Letting go (interdependent)

- Focus on family (becomes normal to have a new baby)

- resume role (individual, partner) back to work about 12 weeks after

Transition: maternal role attainment-Taking-hold (dependent-independent)

day 2-4, lasts 10 weeks

- Becoming competent at caregiving

- Need acceptance from others – am I doing this right?

- Physical & emotional changes (PP blues)

- Practice time and best time to teach bc wants to learn (diapers, car seats)

Transition: sibling adaptations- Positive

- Interest & concern for infant

- Increased independence

Transition: sibling adaptations- Adverse responses from sibling

- Indications for rivalry & jealousy

- Regression in toileting & sleep habits

- Aggression toward infant

- Increased attention-seeking behaviors & whining

Transition: sibling adaptations nursing actions

· Take a sibling on a tour of the unit
· Tell the parents the sibling should be the 1st one to meet the baby
· Provide a gift from the infant to give the sibling
· Allow them to help with care
· Facilitate bonding; skin-to-skin or face position immediately after birth
· Early breastfeeding; educate abt hunger cues (hand to mouth/hand to hand, sucking motion, rooting reflex)
· Keep a quiet environment

Pregnancy-induced hypertension (PIH): risk factors

· Pre-existing HTN
· Kidney disease, cardiac disease
· Pre-eclampsia in previous pregnancies

Pregnancy-induced hypertension (PIH): nursing actions

· Monitor FHR
· Check newborn BP when born
· Educate: BP should go back to normal after delivery but if not, BP meds

Postpartum hemorrhage (PPH): risk factors

· Uterine atony (relaxation/ lack of tone of uterus) , over-distended uterus, ruptured uterus

· Prolonged labor (Uterus tired), oxytocin-induced labor

· Precipitous delivery (born within 3 hrs)

· Lacerations(stage 3) & hematomas

· Retained placental fragments

· high parity (multiple fetuses)

· Gestational DM --> macrsomia

· Boggy fundus

Postpartum hemorrhage (PPH): nursing actions

· Determine Quantitative Blood Loss (QBL) immediately following birth

· Weigh blood-saturated items

· Massage fundus until firm, monitor VS

· Maintain or initiate IV fluids to replace fluid volume loss

· Provide O2 10-12 L via nonrebreather

· Elevate legs to increase circulation

Postpartum disorders: pharmacological interventions

Oxytocin: promotes contractions & used to prevent postpartum hemorrhage

- A/E: lightheadedness, N/V, HA, malaise

Methylergonovine: controls PPH

- CONTRAINIDCATED in clients with HTN

- A/E: HTN, N/V, HA

Magnesium sulfate: prophylaxis or treatment to prevent seizures (smooth muscle relaxant/neuroprotectant bc of HTN)

- A/E: flushing, sedation, diaphoresis, burning at IV site, N/V

- Admin calcium gluconate/chloride for toxicity

Lacerations & hematomas: risk factors

· Forceps or vacuum-assisted birth
· Precipitous birth
· Macrosomic infant or abnormal presentation/position of fetus
· Prolonged pressure of fetal head on vaginal mucosa
· Previous scarring of birth canal from infection/injury/operation

Lacerations & hematomas: nursing actions

- assess pain, evaluate lochia, VS & hemodynamic status

- visually identify source of bleeding

- ice packs to treat small hematomas

- sitz baths and frequent perineal hygiene

Endometritis: manifestations

Infection of uterine lining or endometrium and begins on 3-4 postpartum day
- pelvic pain: uterine tenderness/enlargement
- chills/fatigue/loss of appetite
- dark, profuse lochia: malodorous or purulent
- temp > 100.4 after 24 hr and tachycardia

Endometritis, mastitis, UTI, vulvovaginitis: risk to neonate

· SGA or LGA
· Preterm birth or prolonged labor
· Uterine infection
· PROM
· Chorioamnionitis
· IUGR (intrauterine growth restriction)

Endometritis: priority interventions

- collect vaginal (lochia) & blood cultures
- IV antibiotics - clindamycin and gentamicin (cultures first!!!!)
- analgesics for pain as needed

Mastitis: manifestations

breast inflammation
· Staphylococcus aureus
· Painful/tender hard mass & redness on ONE breast (localized)(AXILLARY adenopathy-lymphnodes)
· Flu-like sx
· Fatigue

Mastitis: priority interventions

· Wash hands before breastfeeding & allow nipples to air dry, well-fitting bra

· Proper infant position & latch

· Completely empty breast with each feeding - use pump if needed

· Ice packs or warm packs

· Continue to breastfeed - & frequently on affected side to get the infection out

· Increase fluid intake (2-3L)

· Complete entire course of antibiotics

Vulvovaginitis: manifestations

- discharge
- itching pain
- fishy smell

Vulvovaginitis priority interventions

- culture
- admin metronidazole gel
· intravaginally 1x day for 5 days
· orally 5g on empty stomach at least 1-2hr after eating
· no alcohol with gel

Gonorrhea manifestations

· Yellowish-green D.C
· Easily induced cervical bleeding
· Dysuria (painful urination)
· Vaginal bleeding between periods & dysmenorrhea(pain during period)

Gonorrhea risk to neonate

· Increased risk of endometritis after delivery
· Miscarriage
· Amniotic fluid retention
· PROM
· Preterm labor

Gonorrhea priority interventions

erythromycin ABX ointment
- to lower the conjunctival sac in each eye
- can be delayed for 1 hour after birth to facilitate bonding

Post-Partum: Baby Blues

· NORMAL - resolves typically within 10 days
· Sadness/crying/anger/anxiety
· Lack of appetite
· Feeling inadequate
· Restlessness, insomnia, HA, fatigue

Post-Partum: Depression

· NOT NORMAL - lasts the longest
· Guilt & inadequacies
· Weight loss/intense mood swings
· Rejection of infant & flat affect & irritable
· Severe anxiety/panic attacks & fatigue
· Thoughts of harming self or newborn

Post-Partum: Blues/Depression Treatment

· Monitor interactions between client & infant

· Encourage bonding activities

· Reinforce that feeling down in PP is normal and self-limiting

· notify provider if condition persists

· Encourage client to communicate feelings, validate & address personal conflicts, & reinforce personal power & autonomy

· PRIORITY: provide safety of infant & client: ask if they are having thoughts of self-harm, suicide, or harming infant

· Assess for PP depression before discharge and then 4 weeks after birth

PP blues/depression patient & family education

· Get plenty of rest, nap when infant sleeps
· Schedule f/u visit prior to traditional PP visit if at risk
· Consider community resources & seek counseling as indicated

HIV nursing care

· Bathe infant immediately after birth before they remain with mother

· Do not give injections or blood tests until after first bath

· Standard precautions

· Retrovoir at delivery & 6 weeks after birth

· Mother CANNOT breastfeed

HIV medications for mom & neonate

Retrovir

- admin to mother at 14 weeks gestation --> throughout pregnancy --> before labor or c-section

- admin to infant at delivery then 6 weeks following birth

Maternal breastfeeding teaching: General

No underwire bras: can clog milk ducts

Feed 15-20 min per breast

Maternal Breastfeeding Teaching: Nipples

To prevent nipple soreness

- Nipple at eye level

- Open mouth wide

- Nose, cheeks, & chin will touch breast

Maternal breastfeeding teaching: Engorgement

- Warm compress before--> empty breast completely -->cold compress after feeding

- Wear breast shells: softens nipples

Maternal breastfeeding teaching: Positions

- Football (under arm)

- Cradle

- Across the lap (modified cradle)

- Side-lying: best after c-section

Maternal breastfeeding teaching: Done eating

- Slowing of sucking

- Softened breast

- Sleeping

Breastfeeding education:

how do you know if baby is getting enough?

· Weight gain
· 6-8 diapers/day
· Content between feedings

Maternal post-op care

- begin exercises as soon as birth and progress to strenuous one
- kegel exercises to regain pelvic muscle control
- c- section: no abdominal exercises/heavy lifting/strenuous activitys/stair climbing for 4-6 weeks
- No driving while on narcotics for 4-6 weeks
- do not lift more than 10 lbs for first 2 weeks
- look for signs of infection and temp (large shifts in H&H)

Basal body temperature

when is the best time to take a temperature?

Immediately after waking up & before getting out of bed (measures temp at lowest point)
- take after longest period of sleep (Ex: if working night shifts, don't take temp in the morning)

Diaphragm

what is it & how is it used?

· Dome-shaped cup with rim that fits over cervix with spermicidal cream or gel placed in cup around the rim, inserted vaginally before intercourse

· Spermicide destroys sperm before entering cervix

· Can be inserted 6 hours before intercourse but must stay in place 6 hour after intercourse, no more than 24 hours

· Empty bladder prior to insertion & wash w mild soap and warm water after each use - replace every 2 yrs

Diaphragm contraindications

· Clients with toxic shock syndrome, cystocele, uterine prolapse, or frequent UTI's
· Clients allergic to silicone or spermicide

Hormonal methods - advantages

- Highly effective if taken correctly & consistently (same time daily)

- Low-dose estrogen(<35mcg): decreased menstrual blood loss, iron deficiency anemia, regulation of heavy/irregular cycles

- Protects against endometrial, ovarian, & colon cancer, improves acne

Hormonal methods - disadvantages

- Does not protect against STI's

- Can increase risk of thromboembolism, stroke, heart attack, HTN, gallbladder disease, & liver tumor, some cancers

- Progestin can cause increased appetite, fatigue, depression, breast tenderness, oily skin & scalp

- CANNOT breast-feed on combined hormonal oral contraceptives (ONLY can on progestin only mini pills)

bilateral tube ligation (female sterilization)

burning/blocking of fallopian tubes to prevent fertilization

Surgical methods advantages: bilateral tube ligation (female sterilization)

- Permanent & can be done immediately after childbirth within 24-48 hour

- Sexual function not affected

Surgical methods disadvantages: bilateral tube ligation (female sterilization)

- Requires surgery ---> anesthesia, complications, infection, hemorrhage, or trauma

- Risk for ectopic pregnancy

- irreversible: so, this is NOT for mothers who are wanting more children in the future

- Does no protect against STI's

Surgical methods advantages: vasectomy (male sterilization

- Permanent contraceptive & is short, safe, simple

- Sexual function not affected

Surgical methods disadvantages: vasectomy (male sterilization

- Requires surgery

- Reversal is possible but not always successful

- Does not protect against STI's

- 20 ejaculations until sterile, sperm count must be 0 on 2 tests before cleared

Hysterosalpingography Dx

· Radiological procedure in which dye is used to assess the patency of the fallopian tubes

· Assess for history of allergies to iodine & seafood prior

Newborn assessment: VS & order

Order: RR, HR, BP, T

Respirations: 30-60/min with short (<15 sec) periods of apnea during sleep

- Crackles/wheezes = fluid

- Grunting/nasal flaring = respiratory distress

Heart rate: 110-160/min

- Apical pulse for 1 full minute; document/report any murmurs

Blood pressure: 60-80 systolic / 40-50 diastolic

- Taken on lower leg

Axillary Temperature: 97.7-99.5F

- Cold newborn - O2 demands increase & acidosis can occur

- temp instability = infection/hypoglycemia

Newborn assessment: Respiratory

- Function begins with cutting off umbilical cord and the first breaths inflate the lungs w air,: most critical adjustment

- resistance in the lungs decreases & air moves into lungs & pushes fluid out into capillaries

Newborn assessment: Circulatory

- Changes occurs with expulsion of placenta, cutting off umbilical cord, independent breathing of newborn

- 3 shunts: close d/t flow of oxygenated blood in the lungs & readjustment of arterial BP in heart

- foramen ovale - closes within min-hrs

- ductus arteriosus (PDA) closes within hrs

- ductus venosus - clot off within days

Suction MOUTH and then NOSE to avoid aspiration

Newborn assessment: skin deviations NORMAL

· Nevus flammeus (port wine stain): purple/red on face - does not blanch/disappear

· Erythema toxicum: newborn rash during first 3 weeks, no Tx needed

· Milia: small white/pearly raised spots on nose, chin, forehead (temporary)(don't squeeze)

· Telangiectatic nevi (stork bites): flat pink/red marks on neck, eyelids, middle of forehead, usually fade by 2nd year

· Mongolian spots: pigmentation that's blue/gray/brown/or black on shoulders, back, butt (more common in dark skin babies/genetics)

Newborn assessment: skin deviations ABNORMAL

· Acrocyanosis: blue hands & feet

· Jaundice: may appear on 3rd day and should decrease spontaneously

· Desquamation: peeling, occurs in full-term newborns a few days after birth

· Vernix caseosa: protective, thick, cheesy covering (more present in skin folds/creases)

· Lanugo: fine downy hair (pinna of ears/shoulders/forehead)

Newborn assessment reflexes: sucking & rooting reflex

· Elicit by stroking the cheek or edge of mouth
· Newborn turns head to toward side that is touched & starts to suck
· Disappears by 3-4 months

Newborn assessment reflexes: palmar grasp

· Place examiner finger in newborn's hand
· Newborn's fingers curl around finger
· Lessens by 3-4 months

Newborn assessment reflexes: plantar grasp

· Place examiner finger at base of newborn's toes
· Newborn curls toes downward
· Disappears by 8 months

Newborn assessment reflexes: moro/startle reflex

· Allowing head & trunk of abdomen of newborn in semi-sitting position to fall backward to an angle of at least 30 degrees
· Newborn will symmetrically extend & then abduct arms at the elbows & fingers spread to form a "C"
· Disappears by 6 months

Newborn assessment reflexes: tonic neck reflex (fencer position)

· Newborn supine, neutral position, examiner turns newborn's head quickly to one side
· Newborn's arm & leg on that side extend & opposing arm & leg flex
· Disappears by 3-4 months

Newborn assessment reflexes: Babinski reflex

· Stroking outer edge of sole of foot, moving up toward toes
· Toes will fan upward & out
· Disappears by 12 months

Newborn assessment reflexes: stepping

· Holding newborn upright with feet touching flat surface
· Newborn responds with stepping movements
· Disappears by 4 weeks

Newborn assessment expected findings: head

should be 2-3 cm larger than chest

- if >4 cm = hydrocephaly (neuro disorder due to build up of cerebrospinal fluid)

- if <32 cm = microcephaly (head smaller than expected)

Fontanels: soft/flat, may bulge with cry, cough, vomit

- Bulging - ICP, infection, hemorrhage

- Depressed - dehydration

- Anterior: diamond-shaped, closes 12-18 months

- Posterior: triangular-shaped, closes 6-8 weeks

Sutures: palpable, separated, may be overlapping (molding)

Caput succedaneum (baseball cap = covers entire head): localized swelling of soft tissue(edema) of scalp d/t pressure on head during labor (may cross suture line) & usually resolves within 3-4 days (no treatment needed)

Cephalohematoma: collection of blood between periosteum & skull bone d/t trauma during birth (does not cross suture line) & usually resolves within 2-3 weeks(appears in 1-2days)

Breakdown of RBC's: increases risk of hyperbilirubinemia

Newborn assessment expected findings: Eyes

- 1/3 distance across both eyes

- Blue or grey: permanent color in 3-12 months, tearless crying, random jerky movements

Newborn assessment expected findings: Ears

- Draw line through inner & outer canthus of eyes - line should be even with the top of newborn's ear, where ear meets scalp (Low-set ears = Down syndrome or kidney disorder)