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10 Cards in this Set
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Nursing Care of the Postpartum Client
A. General considerations with pp assessment 1. Evaluate prenatal and intrapartal hx for risk factors 2. Provide privacy and encourage client to void prior to assessment 3. Position client in bed w/head flat for most accurate findings 4. Proceed in a head-to-toe direction 5. Measure VS w/woman at rest for better accuracy; will determine need or priority for other assessments a. Temp: above 100.4F after first 24h may indicate an infection; may be elevated initially after delivery r/t dehydration b. Pulse: nl range pp is 50 yto 80 bpm; report a rate > 100 to the health care provider c. RR: nl range is 16 to 24 bpm d. BP: assess for orthostatic hypotension; monitor more closely if clinet has a hx of preeclampsia 6. Women who experience operative prodedures, cesarean delivery, or tubal ligation have both ppp needs similar to those with vaginal births and needs of postop clients; monitor breath sounds and have client cough and take deep breaths |
Nursing Care of the Postpartum Client
B. Postpartum assessment 1. Breasts a. Determine if mother is breast-or bottle-feeding b. Palpate for engorgement or tenderness c. Inspect nipples for redness, cracks, and erectility if nursing |
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Nursing Care of the Postpartum Client
B. Postpartum assessment 2. Uterus a. Gently place nondominant hand on lower uterine segment just above symphysis pubis; dominant hand palpates top of fundus b. Determine uterine firmness, height of fundus, and position of fundus in relation to midline of the abdomen c. Correlate fundal location w/expected descent of 1cm each postpartum day d. Inspect any abd incisions, cesarean delivery, or tubal ligation, for REEDA: redness, edema, ecchymosis, discharge, and approximation of skin edges |
Nursing Care of the Postpartum Client
B. Postpartum assessment 3. Bladder a. Client should void w/in 6 to 8h after delivery b. Assess freq, burning, or urgency, which couldind a UTI c. Evaluate ability to completely empty bladder d. Palpate for bladder distention if client's ability to void or complete emptying is in question |
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Nursing Care of the Postpartum Client
B. Postpartum assessment 4. Bowel a. Assess for passage of flatus b. Inspect for signs of distention c. Austcultate bowel sounds in all four quadrants for postoperative clients 5. Lochia a. Inspect type, quantity, amt, and odor b. Correlate findings w/expected charactistics of blleding c. Cesarean-delivered women may have less lochia |
Nursing Care of the Postpartum Client
B. Postpartum assessment 6. Episiotomy or perineal lacerations a. Inspect perineum for REEDA b. Inspect for hemorrhoids 7. Homan's sign a. Pain in calf upon dorsiflexion of foot is recorded as a + sign and may indicate thrombophlebitis b. Inspect for pedal edema, redness, or warmth; if abnormal changes are present, assess pedal pulse |
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Nursing Care of the Postpartum Client
B. Postpartum assessment 8. Emotional status a. Assess if client's emotions are appropriate for situation b. Determine client's phase of pp psychological adjustment c. Assess for signs of pp blues 9. Bonding: describe how parents interact with infant |
Nursing Care of the Postpartum Client
C. Collaborative Management 1. Prevent hemorrhage a. Assess for risk factors b. Keep bladder empty c. Gently massage fundus if boggy; teach self-massage of uterus d. Admin oxytocic meds if ordered: oxytocin (Pitocin), methylergonovine maleate (Methergine), ergonovine maleate (Ergotrate) e. Monitor for SE of oxytocics if admin; hypotension w/rapid IV bolus of Pitocin, HTN with Methergine and Ergotrate |
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Nursing Care of the Postpartum Client
C. Collaborative Management 2. Promote comfort a. Apply ice to perineum 20min on/10min off for first 24h b. Encourage sitz bath, warm or cool, tid and prn after first 12 to 24 h c. Teach client to perform perineal care after every elimination: squirt of pour warm water over perineum; blot dry from fornt to back to prevent tissue trauma and contamination from anal area; apply clean perineal pad from front to back w/o touching surfact that will be next to client d. Teach client to tighten buttocks, then sit and relax muscles e. Apply topical anesthetics (Dermaplast or Americaine spray) or witch hazel compresses (Tucks) f. Admin analgesics; acetaminophen (Tylenol), nonsteroidal antiiflammatory agents (ibuprofen), narcotics (codeine, hydrocodone, oxycodone) g. Utilize PCA pump as needed or morphine epidual for cesarean deliveries h. Monitor for SE of morphine epidural if admin: late-onset rewp depression (8 to 12h), N&V (4 to 7j), itching (w/in 3 and up to 10h), urinary retention, and somnolence |
Nursing Care of the Postpartum Client
C. Collaborative Management 3. Promote bowel elimination a. Encourage early and freq ambulation b. Encourage inc fluids and fiber c. Admin stool softners as ordered; suppositories are contrindicated if client has a third-or fourth-degree perineal laceration involving rectum d. Teach client to avoid straining; normal bowel pattern returns in 2 to 3 weeks |
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Nursing Care of the Postpartum Client
C. Collaborative Management 4. Urinary elimination a. Encourage voiding q 2 to 3h even if no urge is felt |
Nursing Care of the Postpartum Client
C. Collaborative Management 5. Promote successful establishment of lactation and successful breast-feeding if desired a. Utilize well-fitting bra for continuous support of breasts b. Teach breast care, inc no use of soap and air drying nipples after feedings c. Encourage nursing on demand q 2 to 4h, awakening during day and allowing to sleep @ night d. Advise mother to nurse 10 to 15min on first breast and until infant lets go of second; alternate breast used first and roate positions e. Suggest football hold or side-lying position for mothers with cesarean delivery or tubal ligation to avoid discomfort caused by wt of infant on abd incision f. Provide help with positioning, latching on, and breaking suction when done nursing for woment nursing multiple births |
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Nursing Care of the Postpartum Client
C. Collaborative Management 6. Promote successful suppression of lactation and successful bottle-feeding a. Utilize snug bra or breast binder continuously for 5 to 7d to prevent engorgement b. Avoid heat and stimulation of breasts c. Apply ice packs for 20min qid if engorgement occurs d. Encourage demand feedings every 3 to 4h, awakening during day and allowing to sleep @ night |
Nursing Care of the Postpartum Client
C. Collaborative Management 7. Explore impact of culture on feeding practices and support family choices a. Amt of contact and degree of closeness b/w mother and newborn is often culturally determined b. Culture may influence how long breast-feeding continues c. Feeding practices vary across cultures |
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Nursing Care of the Postpartum Client
C. Collaborative Management 8. Promote rest and gradual return to activity a. Organize nursing care to avoid freq interruptions b. Plan maternal rest periods when infant is expected to sleep c. Teach client to resume activity gradually over 4 to 5 wks; avoid lifting, stair-climbing, and strenuous activity d. Simple pp exercises should be started, per orders, to strengthen muscles affected by childbearing; Kegel exercises tighten perineum by repeatedly attempting to stop flow of urine and then relacing; raising chin to chest and doing knee rolls and buttocks lifts strengthen the abd e. Inc lochia or pain indicates overexertion; modify exercise plan |
Nursing Care of the Postpartum Client
C. Collaborative Management 9. Promote adequate nutritional intake a. Encourage lactating mothers to add 500 kcal/day to prepregnancy diet; bottle-feeding mothers should return to prepregnancy diet b. Encourage fluid intake of 2,000 mL/day c. Continue admin of prenatal vit and iron, as ordered; iron is best absorbed in presence of vit C and may inc constipation |
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Nursing Care of the Postpartum Client
C. Collaborative Management 10. Promote psychological well-being a. Provide an environement that supports family unity and promotes attachmnent to the newborn b. Encourage roomin-in, presence of family members c. Assist parents in preparing siblings w/realistic expectations of the newborn; involve siblings in infant care d. Teach parents that sibling reqression is common e. Advise couple to resume sexual activity after episiotomy has healed and lochia has stopped, about 3 wks after delivery; level of sexual interest and activity may vary, additional water-soluble lubrication may be needed, and breast milk may be released with orgasm f. Counsel couples regarding contraception b4 discharge, assist couple to select a method compatible with health needs and individual preferences; a diaphragm or cercical cap will need to be refitted following delivery; oral contraceptives containing estrogen may interfere with lactation |
Nursing Care of the Postpartum Client
C. Collaborative Management 12. Give Rho (D) gamma globulin (Rhogam, RhIG, Gamulin) if needed to prevent Rh sensitization and future hemolytic dz of newborn a. Confirm woman is a candidate: Rh-negative mother not sensitized (negative indirect Coombs test), Rh-positive newborn not sensitized (negative direct Coombs test), and no known maternal allergy to globulin preparations b. Administer 300mcg IM w/in 72h of delivery |
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Nursing Care of the Postpartum Client
C. Collaborative Management 13. Give rubella vaccine to provide active immunity for mother and avoid fetal malformations if dz is contracted during a future pregnancy a. Confirm woman is a candidate: titer of < 1:8 (not immune); no known allergy to neomycin b. Admin 0.5mL sub-q prior to discharge c. If woman is a candidate for both Rhogam and rubella vaccine, delay rubella vaccine @ least 6 wks, and preferably 3mo, to avoid drug interaction and reduced rubella immunity d. Teach client to avoid pregnancy for at least 3mo following vaccination; vaccine contains live virus and can adversely affect fetus; SE include burning and stinging at injection site, warmth and redness, mild sx of dz |
Nursing Care of the Postpartum Client
C. Collaborative Management 14. Teach client pp warning signs to be reported a. Bright red bleeding saturating more than one pad per h or passing lg clots b. Temp > 100.4F c. Chills d. Excessive pain e. Reddened or warm areas of breast f. Reddened or gaping episiotomy, foul-smelling lochia g. Inability to urintate; burning, freq, or urgency w/urination h. Calf pain, tenderness, redness, or swelling 15. Outcomes are that assessment findings remain nl: maternal physical and psychological well-being is maintained, mother verbalizes or demonstrates techniques of self- and infant-care and shows positive signs of attachment with infant |
