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26 Cards in this Set

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What is the nursing postpartum care for a vaginal delivery?
Vitals Q 15 minutes, Fundus checks, Lochia checks, Episiotomy and perineal care – ice packs PRN – Use ice in the first 8-24 hours if lots of swelling. After 24 hours, use warm pack., Bonding and breast feeding if desired., Rest and nutrition.
What is the nursing postpartum care for a cesarean delivery?
Vital signs Q 5 minutes, then Q 15 minutes when stable., Oxygen status, pulse ox and TDBC, I/O, NPO, IV, Foley. The IV will be 10-20 U of Pitocin. Used to cause involution of the uterus., Incision and dressing – If bleeding, circle, date and time., Fundus and lochia checks.,Assess post-anesthesia state – epidural and general.
What are the postpartum vital signs changes?
Temperature: slightly increases in the first 24 hours due to dehydration intrapartum. A temp > 100.4 = febrile. The increase is due to dehydration. If > 101.00 after 24 hours = infection., Pulse: Slightly slower than normal – evaluate according to baseline norms of postpartum., Blood Pressure: Compare with pre-brith levels. Above 140/90 consider PIH. Watch for orthostatic hypotension. ***Pt can be pre-eclamptic and eclamptic postpartum.
What are the postpartum breast changes?
Establishment of milk production. Day 1 – 2: Breasts soft – secretes colostrum, Day 3 – 4: Breasts firm or filling milk forms within the breast ducts. Beyond 4th day: Breasts may become engorged. Breast are taut, shiny and enlarged.
What is involution?
Uterus reduction to pre-pregnancy state.
What are the postpartum uterus changes?
Immediately after birth: Uterus felt halfway between symphisis pubis and umbilicus., One hour after birth: Uterus rises to umbilicus and stays there for 24 hours., After 24 hours: Decreases one fingerbreadth per day., Fundal height assessment: Location, Height, Firmness, If Boggy then massage.
What is lochia? What are the types of lochia?
Lochia is uterine flow consisting of blood flow, decidua, WBCs and bacteria. Measured according to amount.
Rubra – 1st 3 days consisting mainly of blood.
Serosa – About 4-10 days consiting of blood and WBCs.
Alba – From 10th day up to 3 weeks consisting of mucus and WBCs.

** It should follow that order: Rubra, Serosa, Alba. It should not go backwards.
What are important things to remember about menstruation postpartum?
Once the placenta has been delivered, the effects of estrogen and progesterone no longer inhibit the FSH – hence – ovulation will begin.
If the pt is not breastfeeding, menstruation will return in 6 –10 weeks. If it happens prior, it is anovulation (a menstrual cycle in which ovulation is absent.) If breastfeeding, menstruation may return in 3-4 months or even longer. ***Pt can still become pregnant while breastfeeding.
What are the postpartum reproductive organ (cervix, vagina, perineum, labia) changes?
Cervix – Following a vaginal birth, the external os will contract by the 7th day. It remains slightly open with a slit-like shape.

Vagina – The hymen is permanently torn. Immediately after birth, the mucosa is soft with few rugae. Thickened walls or dryness is due to decreased estrogen and may cause dyspareunia (Pain in the labia or vagina after intercourse.) Instruct patient that they can use KY Jelly.

Perineum – maybe swollen, tender or bruised from trauma of birth and pushing.
Instruct on Kegel Exercises – helpful
Instruct on perineal care

Labia majora & minora – Remain atrophied and soft.
What are the postpartum gastrointestinal changes?
If not under the influence of anesthesia, the mother is usually very hungry and thirsty.
Pt may have hemorrhoids – May use sitz bath.
Due to the effects of relaxin, bowels may be sluggish – may require a stool softener
Pain from an episiotomy or hemorrhoids may cause or hinder bowel movement.
What are the postpartum integumentary changes?
Straie – appear reddened and more prominent. This will fade into pale white streaks in caucasians or darker pigmentation in african americans.

Linea negra and cholasma will also disappear.

Diastasis recti – Overstretching and/or seperation of the musculature
This area appears indented or bluish tinged.
What are the postpartum voiding changes?
Voiding more than normal is okay after delivery.
What are the phases of postpartum psyche, according to Reva Rubin?
According to Reva Rubin, there are three phases:
Taking in – (Seen in first few days)
Taking hold
Letting go
What is the Taking In Phase of postpartum psyche?
Pt receptive to the nurse taking care of her. Passive. Wants to be catered to. Has others make decisions for her. Wants to talk about the pregnancy, labor and birth. Encourage her to talk about the birth. Encourage rest. This can occur for the 1st couple of days. However, if the mother avoids contact with the baby, there is a problem.
What is the Taking Hold Phase of postpartum psyche?
After the 1st few days of delivery. Begins to initiate actions and make decisions. Assumes the care of the infant and shows more interest. Nurse should offer reassurance and praise. Nurse should give guidance or instruction as needed. Can also occur in prenatal classes – teaching is important postpartum.
What is the Letting Go phase in the postpartum psyche?
Takes on the new roll of a mother. Mother adjusts to her new role. Mother establishes and accepts the new image of her baby, family and role.
What does BUBBLE HE stand for?
B-Breast, U-Uterus, B-Bowel, B-Bladder, L-Lochia, E-Episiotomy, H-Homan's Sign & hemorrhoids, E-Education
What does the 1st B in BUBBLE HE stand for? What are the actions?
B – Breasts – encourage the use of a supportive bra regardless of breast feeding. For lactating breasts, empty by pumping, manual expression or feeding frequently. Avoid creams and perfumes. For non-lactating breasts – avoid stimulation by heat, water, clothing or sexual arousal. Do not express milk. Discuss self breat exams – encourage 7-10 days after mensus.
What does the U in BUBBLE HE stand for? What are the actions?
U – Uterus: Check fundal height according to centimeters or fingerbreadth. Check fundal firmness – Massage fundus if boggy. Check fundal position – deviation to the side may indicate a full bladder. Have client empty bladder or catheterize.
What does the 2nd B in BUBBLE HE stand for? What are the actions?
B – Bowel Feeding clear fluids 8 hours post C-sec. Assess bowel status. Presence of bowel sounds. The need for laxatives. No cold liquids or liquids through a straw to prevent gas. Encourage walking and increased fluids for constipation.
What does the 3rd B in BUBBLE HE stand for? What are the actions?
B – Bladder - Must empty bladder. Vag delivery – within 7st hour of delivery.
C-sec = foley. After foley removed, measure next time to void and record. Promote diuresis to prevent Urinary tract infections (UTIs). Promote proper female hygiene.
What does the L in BUBBLE HE stand for? What are the actions?
L – Lochia Assess lochia amount: Scant / light, Moderate, Heavy / profuse. Assess lochia color in relation to puerperium: Rubra, serosa, alba. Assess odor. Teach if lochia starts to smell = infection
What does the 1st E in BUBBLE HE stand for? What are the actions?
E – Episiotomy Know type of episiotomy (midline / lateral) – Check delivery sheet. Assess site. Assess presence of lacerations and/or hematomas, edema. Encourage proper perineal care, frequent changing of perineal pads and the use of sitz bath when indicated.
**If mom complains of wanting to have a bowel movement soon after delivery, check to see if a hematoma has formed. Assess for REEDA
What does the H in BUBBLE HE stand for? What are the actions?
H – Homan’s sign, Hemorrhoids
Homan’s Sign: Check for Homan’s sign – document if (+) or (-). Assess legs for presence of hot spots or tender areas. Assess the need for antiembolic hose. Hemorrhoids: Assess for pain or swelling at the site. Use sitz bath, tucks, as needed. Use diet and laxatives to prevent further irritation
What does the 2nd E in BUBBLE HE stand for? What are the actions?
E – Education. Self breast examinations. Care of breasts. Fundal firmness. Pericare. Sitz bath. Diet and medication. Postpartum exercises. Discharge and baby care.
What does REEDA stand for and what is it used for?
For wound assessment: R–Redness, E–Edema, E–Ecchymosis, D–Discharge / Drainage, A-Approximation