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216 Cards in this Set
- Front
- Back
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puerperium
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period after completion of third stage of labor until involution of the uterus is complete, usually 6 weeks
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involution
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the reduction in size of the uterus following childbirth
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factors that retard uterine involution
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prolonged labor; anesthesia; difficult birth; grand multiparity; full bladder; incomplete expulsio of placenta or membranes; infection; overdistention of uterus
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factors that enhance involution
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uncomplicated labor and birth; complete expulsion of placenta or membranes; breastfeeding; manual removal of placenta during cesarean; early ambulation
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fundus
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upper portion of the uterus between the fallopian tubes
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immediately after birth of placenta what happens to uterus
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contracts to size of large grapefruit
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a fundus that is above the umbilicus and feels soft/spongy is termed ? And is associated with ?
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boggy; excessive uterine bleeding
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boggy uterus aka
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uterine atony
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boggy uterus
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used to describe the uterine fundus when it is not firmly contracted after the birth of the baby and in the early postpartum period; excessive bleeding occurs from the placental site and maternal hemorrhage may occur
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if the fundus is higher than expected and is not midline what is usually suspected first
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distention of the bladder
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subinvolution
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failure of a part to return to its normal size after functional enlargement, such as failure of the uterus to return to normal size after pregnancy
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the top of the fundus descends approx ? Per day until it descends into the pelvis on about the ? Day
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1cm (one finger breadth) per day; descends completely about the 10th day
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lochia
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maternal discharge of blood, mucus and tissue from the uterus; may last for several weeks after birth
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lochia rubra
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red, blood tinged vaginal discharge that occurs following birth and lasts 2-4 days
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lochia serosa
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pink, serous, and blood tinged vaginal discharge that follows lochia rubra and lasts until the 7th to 10th day after birth
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lochia alba
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white vaginal discharge that follows lochia serosa and that lasts from about the 10th day to the 21st day after birth
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clots in lochia should be no bigger than a ?
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nickel
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menstruation generally returns when
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bw 4-6 weeks for nonbreastfeeding mothers; in breastfeeding mothers can vary from 1-3 months depending on consistency and volume of breastfeeding
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diastasis recti abdominis
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separation of the recti abdominus muscles along the median line; seen with repeated childbirths or mutiple gestations
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striae
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stretch marks that occur as a result of stretching and rupture of the elastric fibers of the skin
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what are expected trends in a woman's temp after birth
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may increase to 100 to 102.2 F with milk letdown; up to 100.4 as a result of exertion; if these criteria don't exist needs to further evaluated
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what causes the prolonged risk of thromboembolism in the first 6 weeks following birth
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diameter of deep veins can take up to 6 weeks to return to prepregnant levels
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afterpains
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cramplike pains due to contractions of the uterus that occur after childbirth; more common in multiparas, tend to be most severe during breastfeeding and lasts 2-3 days
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maternal role attainment
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process by which a woman learns mothering behaviors and becomes comfortable with her identity as a mother
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four stages of maternal role attainment
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anticipatory, formal, informal, personal
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what is the #1 reason for slowed involution
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full bladder
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why is intercourse often painful after pregnancy
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low estrogen levels lead to decreased vaginal lubrication
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what hormone contributes to GI sluggishness
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progesterone
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how much urinary output will we often see in first 24 hours after pregnancy and why?
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2K-3K mL/24 hrs; called puerperal diuresis; kidneys must eliminate extracellular fluid from pregnancy
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failure to diurese in the first 48 hours can lead to what
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pulmonary edema and CHF
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what is the most common neurological symptom experienced after birth
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headache resulting from fluid shift; leakage of CSF, stress or pregnancy induced HTN
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describe the postpartal chill
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usually within 2 hours after delivery; may be result of sudden release of pressure on pelvic nerves, response to mother-to-fetus transfusion that occurred during placental separation, reaction to maternal adrenaline production or to epidural anesthesia
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how can we help decrease discomfort of postpartal chill
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cover with warmed blanket, reassure that it is a common, self limiting situation; warm beverage
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taking in
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1-2 days after delivery; sorting reality from fantasy in birth experience
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taking hold
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2-3 days after delivery; ready to resume control over life
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letting go
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10 days-6 weeks; mothering functions established; sees infant as separate person
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acquaintance phase of maternal bonding
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fingertip exploration; en face position; responds verbally to sounds of infant
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phase of mutual regulation
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adjustment between needs of mother and needs of infant
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anticipatory stage of maternal role attainment
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occurs during pregnancy; woman looks to role models for examples of how to mother
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formal stage of maternal role attainment
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begins when child is born; woman is still influenced by guidance of others and tries to act as she believes others expect her to
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informal stage of maternal role attainment
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begins when mother begins to make her own choices about mothering
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personal stage of maternal role attainment
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final stage; woman is comfortable with the notion of herself as a mother
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maternal role attainment occurs when
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within 3-6 months after delivery
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postpartum blues
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maternal adjustment reaction occurring in the first few postpartal days, characterized by mild depression, tearfulness, anxiety, headache and irritability
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suspected causes of baby blues
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changing hormone levels; psychological adjustments; unsupportive environment; insecurity/low self esteem; discomfort; overstimulation
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causes of feelings of dizziness or faintness after delivery
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fatigue, effects of meds, loss of blood, lack of food intake
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what is BUBBLEHEB and what does each stand for
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nursing assessment; Breast, Uterus, Bladder, Bowel, Lochia, Episiotomy/Laceration, Hemorrhoids, Emotional, Emothional, Bonding
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colostrum
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yellowish fluid rich in antibodies and high in protein
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infant suckling promotes the release of which hormones
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prolactin, oxytocin
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when does lactation cease
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within a week if breastfeeding is stopped or never started
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oxytocin released during breastfeeding also causes what
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uterine contractions/cramping
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prolactin is important for
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milk production
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how are breasts cared for while breastfeeding
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no soap, air dry after feeding, use lanolin
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what is engorgement and when does it occur
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occurs by day 3 or 4; due to vasoconstriction as milk production begins; full congested breast
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how can we ease pain assoc with engorgement
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warm packs prior to feeding, manually express milk to ease latchon; feed or pump every 3-4 hours
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how do we treat plugged ducts
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massage, warm packs, continued pumping/feeding
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how do we suppress lactation
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wear supportive well fitting bra; ice packs to axillary for 20 mins 4X/day if engorgement occurs; avoid stimulation and heat; analgesic agents; encourage bottle feeding q3-4 hours
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how often do we assess the uterus after delivery
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every 15 mins for first hour, 30 mins for 2nd hour, hourly for 2 more then every 4 hours
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side effect of pitocin
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hypotension
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side effect of methergine
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hypertension
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what things should pt not have after C/S or BTL
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straws, carbonated drinks, lots of sweets
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how can we prevent abdominal distention after delivery
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early and frequent ambulation, encourage fluids, encourage high protein, fiber diet; administer stool softeners; rectal suppositories/enemas
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when are rectal suppositories/enemas contraindicated after delivery and why
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with 3rd-4th degree lacerations; increased chance of infection
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how can we estimate blood loss after delivery
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by weighing pads; 500mL=1lb or 454g
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which acronym is used to assess episiotomy, lacerations and perineal repair
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REEDA; redness, edema/swelling, ecchymosis/bruising, drainage, approximation of episiotomy/laceration/repair
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describe first degree perineal laceration
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involve vaginal mucous membrane and the skin of perineium to the fourchette
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describe second degree perineal laceration
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involve vagina, perineal skin, fascia, levator ani muscle and perineal body
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describe third degree perineal laceration
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involve entire perineium and reach external sphincter of rectum
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describe fourth degree perineal laceration
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involve entire perineum, rectal sphincter and some of the mucous membranes of the rectum
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how can we relieve perineal discomfort
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ice packs; peribottle; blot dry front to back; apply perineal pad front to back; infection prevention; sitz bath
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a positive homan's sign indicates
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possible DVT
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prevention of DVTs
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early ambulation; leg exercises; SCDs; rocking chair
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two types of cesarean section incisions
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low transverse abdominal; midline abdominal
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C section incisions typically heal in
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6-8 weeks
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what is rhogam given for
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prevents Rh sensitization
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what are some signs of good parent child interaction
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speaks of infant as desirable/attractive; not upset by vomiting etc; holds baby warmly; makes eye contact with infant; plays with and soothes infant; talks or sings to baby; expresses confidence that infant is well; admires attributes of baby; is able to discriminate signs of hunger,sleep etc
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most common complications of postpartal period
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hemorrhage, infection, thromboembolic disorders, postpartal psychiatric disorders
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surgical interventions for uterine bleeding
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uterine balloon tamponade, selective radiographic guided pelvic arterial embolization, uterine suturing techniques, ligation of uterine or hypogastric arteries, hysterectomy
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early (primary) postpartal hemorrhage
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occurs in first 24 hours after childbirth
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late (secondary) postpartal hemorrhage
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occurs from 24 hours to 6 weeks after birth
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most common cause of late postpartal hemorrhage
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retained placental fragments
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when should a woman contact her PCP after delivery
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sudden, persistent or spiking fever; change in character of lochia; evidence of mastitis; evidence of thrombophlebitis; evidence of UTI; continued depression
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for what degree of fever should woman call PCP after delivery
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anything over 101F
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what is one of the most important things to do when mastitis develops
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keep breastfeeding!!
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patient should have a normal bowel movement following delivery when
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2-3 days after delivery
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common postpartum drugs
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tylenol no 3; percocet; rubella virus vaccine; rhogam; ambien
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uterine stimulants used to prevent and manage uterine atony
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oxytocin, methylergonovine maleate, ergonovine maleate, prostaglandin, misoprostol, dinoprostone
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describe the characteristics of engorgement (onset, site, swelling/heat, pain, body temp, symptoms)
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gradual, immediately postpartum; bilateral; generalized swelling/heat; generalized pain; body tem < 101.1; generally feels well
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describe the characteristics of plugged ducts (onset, site, swelling/heat, pain, body temp, symptoms)
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gradual onset after feedings; unilateral; swelling/heat may shift, little or no heat; mild but localized pain; body temp < 101.1F; generally feels well
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Describe the characteristics of mastitis (onset, site, swelling/heat, pain, body temp, symptoms)
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sudden onset, after 10 days; usually unilateral; localized swelling, red hot and swollen; intense but localized pain; body temp of > 101.1 F; flulike symptoms
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3 subclasses of postpartum psychiatric disorders
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adjustment reaction with depressed mood; postpartum psychosis; postpartum major mood disorder
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postpartum psychosis
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psychosis occurring within the first 3 months after birth
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symptoms of postpartum psychosis
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agitation, hyperactivity, insomnia, mood lability, confusion, irrationality, difficulty remembering or concentrating, poor judgement, delusions, hallucinations which tend to be related to infant
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postpartum major mood disorder
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aka postpartum depression; severe depression that occurs within the first year after giving birth with increased incidence at about the 4th week postpartum just before resumption of menses and upon weaning
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when is it considered appropriate to resume sexual activity after delivery
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once episiotomy is healed and lochia flow has stopped
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measures to decrease discomfort during sexual activity
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water soluble lubricant; female superior or side lying position
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maternal pt should avoid what activities until 6 weeks after delivery
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heavy lifting (heavier than baby); excessive stair climbing; strenuous activity
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what must parents have before they can leave the hospital
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car seat!
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retained placental fragments are caused by
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pulling on cord; uterine massage prior to separation; placenta accreta
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how do we treat retained placental fragments
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uterine massage; manual removal; oxytocin, methergine; D&E
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endometritis
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infection of uterine lining
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what is the most common postpartal infection
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endometritis
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symptoms of superficial thromboembolism
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tenderness, hot to touch, redness, low grade fever, tachycardia, +/- homans sign
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how do we treat superficial thromboembolism
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elevate extremity, heat, TEDs, analgesics, bedrest?
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symptoms of DVT
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low grade fever, chills, edema, extremity pain below clot, decreased peripheral pulse
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how can we treat DVT
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heparin/coumadin; TEDs; bedrest; elevate extremity; analgesics
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what is LEVD
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lower extremity venous doppler; physician orders to diagnose DVT
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signs of pulmonary embolism
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sudden onset of dyspnea, SOB, sweating, pallow, cyanosis, confusion, HTN, cough/hemoptysis; tachycardia; chest pain; sense of impending death
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treatment for pulmonary embolism
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call MD, oxygen, demerol/morphine, aminophylline, heparin, streptokinase
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what is DIC
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disseminated intravascular coagulation; increased prothrombin/platelets leading to widespread formation of clots and severe generalized hemorrhaging
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what are potential causes of DIC
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septic shock, placental/uterine hemorrhage; IUFD; amniotic fluid embolism; thrombi secondary to preeclampsia; thrombi secondary to thrombophlebitis
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early s/s of DIC
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increased PT, thrombocytopenia, bleeding (gums, puncture sites), ecchymosis
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treatment for DIC
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very complex; involves transfusions of PRBC, plasma, whole blood, fibrinogen
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what is the only right restricted for mental health patients
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the right to leave the hospital in the case of involuntary commitment
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bill of rights for mental health patients
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least restrictive environment, confidentiality, access to attorneys/courts; access to belongings; informed of rights; refuse meds/treatment; visitors; telephone; writing materials/uncensored mail
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voluntary admission
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patient is agreeable to in house treatment
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involuntary admision
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pt admitted without their consent through legal processes
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a person may be detained for how long on an emergency basis until hearing can occur
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48-72 hours
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types of involuntary admissions
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evaluation/emergency care; order of protective custody; extended/indeterminate care; magistrates warrant
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describe evaluation/emergency care involuntary admission
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form filled out by police/others; usually for 48-72 hours
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describe order of protective custody involuntary admission
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legal papers filed in court; varies from days to weeks
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describe extended/indeterminate care involuntary admission
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legal system involved; long term; may be 90 days
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describe magistrates warrant involuntary admission
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legal sworn statement issued about a pt through a judge
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when a pt has an order of protective custody (OPC) what is important that we as nurses know?
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when it expires; if we need extension, we need to get it prior to the expiration
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what criteria must be present for a person to be held without their consent
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must present a danger to themselves or others
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when are MH patients allowed to be discharged
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if hospitalized voluntarily may request at any time; if involuntarily, when they are no longer dangerous or court order runs out
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describe mandatory outpatient treatment
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requires that pt continues to participate in treatment on involuntary basis after release from hospital
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examples of mandatory outpatient treatment
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taking prescribed meds, keeping appts for follow up and attending specific treatment programs or groups
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mandatory outpatient treatment is also called
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conditional release or outpatient commitment
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describe a conservatorship
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for people who are gravely disabled, found to be incompetent, cannot provide food, clothing, shelter for themselves, cannot act in their own best interests
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an incompetenet client can no longer
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enter into legal contracts with a signature; sign checks; use a credit card; make a will; open bank accounts; sell property; get married; give consent for surgery
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there are more lawsuits regarding what with MH patients than anything else
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restraints; restrictive environments
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restraint
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application of force without the patient's permission (human, mechanical, chemical)
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seclusion
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involuntary confinement in specially constructed, locked room equipped with security window or camera
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when a MH pt is in restraints/seclusion how are we required to evaluate them
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face to face eval in 1 hr and every 8 hours; physicians order every 4 hours; documented assessment every 1-2 hours; debriefing session within 24 hours of release
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describe duty to warn third parties
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an exception to pt confidentiality; clinicians must warn identifiable third parties of threats made by a pt
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what are the criteria that should be satisfied for duty to warn
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is the pt dangerous to others; is the danger the result of serious mental illness; is the danger serious; are the means to carry out the threat available; is the danger targeted at identifiable victims; is the victim accessible
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standards of care for nurses
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the care they provide to clients meets set expectations and is what any nurse would do in a similar situation; developed from professional standards, state nurse practice acts, federal agency regulations, agency policy and procedures, job descriptions, civil and criminal laws
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tort
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a wrongful act that results in injury, loss or damage; can be unintentional or intentional
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unintentional torts
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negligence, malpractice
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intentional torts
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assault, battery, false imprisonment
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negligence
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harm caused by failure to do what is reasonable and prudent
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malpractice
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breach of duty directly causes injury or loss to the client
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assault
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causes person to fear being touched in an offensive manner; I.e. threats
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battery
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harmful or unwanted actual contact
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false imprisonment
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unjustifiable detention
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four elements that must be proved for a malpractice suit to be successful
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duty, breach of duty, injury or damage, causation
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3 elements for proving leability for an intentional tort
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act was willful and voluntary on part of defendant (nurse); nurse intended to bring about consequences or injury to person; act was a substantial factor in causing injury or consequences
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how can nurses minimize the risk of lawsuits
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through sfe, competent nursing care and descriptive, accurate documentation
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ethical dilemma
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a situation in which ethical principles conflict or there is no one clear course of action
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ethical theories
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sets of principles used to describe what is morally right or wrong
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ethics
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branch of philosophy that deals with values of human conduct related to the rightness or wrongness of actions and to the goodness and badness of the motives and ends of such actions
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most ethical dilemmas in MH involve which two concepts
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client's right to self determination and independence and concern for the public good
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anger
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normal human emotion; strong uncomfortable emontional response to real or perceived provocation; results usually when a person is hurt, frustrated or afraid
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anger prepares our body for what defense
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flight or fight response
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when is anger a positive force
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if handles appropriately; can help resolve conflicts, solve problems and make decisions
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when is anger a negative force
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if expression is inappropriate or suppressed; can cause physical or emotional problems, interfere with relationships and lead to possible hostility and aggression
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catharsis
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activities that are supposed to provide a release for strong feelings such as anger or rage
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hostility
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aka verbal aggression; an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms or threatening behavior; usually occurs when feeling threatened or powerless
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physical aggression
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behavior in which person attacks or injures another person or that involves destruction of property
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stages of hostility/aggression
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triggering phase, escalation phase, crisis phase, recovery phase and a postcrisis phase
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triggering phase of aggression cycle
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an event or circumstances in the environment initiates the client's response which is often anger or hostility
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escalation phase of aggression cycle
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client's responses represent escalating behaviors that indicate movement toward a loss of control
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crisis phase of aggression cycle
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during a period of emotional and physical crisis, the client loses control
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recovery phase of aggression cycle
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client regains physical and emotional control
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postcrisis phase of aggression cycle
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client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents
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psychosocial theories assoc with hostility and aggression
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failure to develop impulse control and inability to delay gratification
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how can we prevent anger from escalating into physical aggression
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early assessment, judicious use of meds and verbal interaction with an angry client
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how to manage pt aggression in the triggering phase
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approach in nonthreatening, calm manner; convey empathy; listen; encourage verbal expression of feelings; suggest pt go to quieter area; use PRN meds; suggest physical activity
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how to manage pt aggression in the escalation phase
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take control; provide directions in calm, firm voice; direct pt to room or quiet area; offer mds again; let pt know aggression is unacceptable; obtain help from other staff (show of force)
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how to manage pt aggression in the crisis phase
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inform pt that behavior is out of control and that the staff is taking control to provide safety and prevent injury; use of restraint or seclusion only if necessary
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how to manage pt aggression in the recovery phase
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talk about situation or trigger; help pt relax or sleep; explore alternatives to aggressive behavior; provide documentation of any injuries; debrief staff
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how to manage pt aggression in the postcrisis phase
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remove pt from restraint/seclusion to rejoin milieu; calmly discuss behavior; focus on appropriate expression of feelings and resolution of problems or conflicts in nonaggressive manner
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abuse
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wrongful use, maltreatment of another
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common characteristics of abusive situations
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social isolation; abuse of power, control; alcohol, other drug abuse; intergenerational transmission process
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intimate partner violence
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mistreatment of misuse of one person by another in context of emotionally intimate relationship
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examples of emotional/psychological abuse
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name calling, belittling, screaming, yelling, destroying property, threatening, refusing to speak or ignoring victim
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describe the cycle of abuse and violence
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violent episode - honeymoon phase - tension building - violent episode
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the screening/assessment for intimate partner abuse is known as
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SAFE
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what does SAFE (assessment) stand for
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Stress/safety; afraid/abused; friends/family; emergency plan
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elder abuse
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maltreatment of older adults
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elder abuse includes what kind of things
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physical, sexual, psychological abuse or neglect; self neglect; financial exploitation; denial of adequate medical treatment
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rape
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crime of violence, humiliation of victim expressed through sexual means
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sexual assault
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any form of forced sexual contract (from touch to mutilation) besides rape
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PTSD
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post traumatic stress disorder; disturbing behavior resulting from a traumatic event at least 3 months after event occurred
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3 clusters of symptoms present with ptsd
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reliving the event; avoiding reminders of the event; being on guard, or experiencing hyperarousal
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symptoms of PTSD
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flashbacks, insomnia, irritability, persistent nightmares, memories, hypervigilance, angry outbursts, emotional numbness
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dissociation
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subconsciousness defense mechanism that helps a person protect the emotional self from recognizing the full impact of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory
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dissociative disorders
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amnesia, fugue, disorder, depersonalization disorder, dissociative identity disorder
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definition of child maltreatment
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intentional-physical abuse or neglect, emotional abuse or neglect, sexual abuse of children
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term used in hospital to identify child abuse victims
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kempes
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characteristics of child abuse victims
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behavior disorders, temperament; less than 3 years old; premature; illegitimate; brain damaged; unwanted; hyperactive; physically disabled
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usually ? Child is the victim of abuse
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ONE
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when we remove the victim of abuse what can unintentionally happen
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can put other siblings at risk
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parental characteristics of child abusers
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history of abuse/neglect; difficulty controlling aggressive behavior; drug addiction/alcohol abuse; social isolation/inadequate support system; marital stress; teenage mother; low self esteem; inadequate knowledge of child rearing/inappropriate expectations for child's developmental level
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environmental contributors to child abuse situations
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chronic stress, poverty, unemployment, poor housing, frequent relocation, crowded living conditions, rehousing, marital discord, addition of a child
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most common type of child maltreatment
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neglect
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s/s of child neglect
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unclean or inappropriate clothing; poor personal hygiene; failure to thrive; frequent injuries; evidence of poor health care
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emotional neglect
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failure to meet the needs of affection, attention and emotional nurturance
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emotional abuse
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deliberate attempt to destroy or significantly impair a child's self esteem or competence
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failure to thrive is the result of
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neglect; physical problems, psychosocial issues, poverty, health beliefts, family stress, feeding issues
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what is the 2nd most common cause of death in child abuse
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suspicious abdominal injuries
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what is the #1 cause of death in child abuse
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suspicious head injuries
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s/s shaken impact syndrome
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poor feeding, altered LOC, seizures, bruising of upper extremities or ribs, serious head injury with retinal hemorrhages
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common triggers for shaking
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crying, toilet training, feeding issues, interrupting
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munchausen's syndrome by proxy
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illness that one person fabricates or induces in another to gain attention from medical staff
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warning signs of munchausen's syndrome of proxy
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discrepancies; uniqueness of illness; s/s only occurring in parent's presence; parents knowledgeable; highly interactive with health team; overly attentive toward child; similar symptoms in other family members
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the typical sexual abuser of children is
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a male who the victim knows
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s/s of sexual abuse
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bed wetting; injury to/discharge from genitalia; difficulty walking or sitting; chronic dysuria; enuresis, constipation or encopresis; STD or pregnancy; sexual comments, behavior, play; regressive resistance of child to remove clothes for exam
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enuresis
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bed wetting
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encopresis
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repeated voluntary or involuntary passage of feces of normal or near normal consistency
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health issues or practices mimicking maltreatment/abuse of children
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mongolian spots, SIDS, osteogenesis imperfecta, congenital anomalies of genitalia; diaper rash, erythema multiform; idiopathic thrombocytopenia purpura; leukemia; accidental straddle injuries
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SIDS
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sudden infant death syndrome; sudden death of an infant less than one year old; death is unexplained post autopsy, exam of the scene of death and a review of the case
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SIDS peaks when
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between 2-4 months of age
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SIDS occurs when
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during sleep
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what is the nurses role in reporting child abuse
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we are mandatory reporters; failure to report is against the law; person making the report is immune from civil or criminal liability provided the report is made in good faith
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