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21 Cards in this Set
- Front
- Back
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elevated temperature
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*normal during 1st 24 hrs
*sign of dehydration after 1st 24 hrs *sign of infection after 1st 24 hrs |
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Bradycardia
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normal finding after delivery.
40-70 is normal after delivery, usually comes back to normal by day 3-4. |
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tachycardia
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over 100bpm
sign of: infection hemorrhage pain anxiety |
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elevated blood pressure
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PIH
Hx of chronic HTN |
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lowered blood pressure
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orthostatic hypotension
shock hypovolemia |
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BUBBLE HE
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Breasts
Uterus Bladder Bowel Lochia Episiotomy Homan's sign emotions/engagement |
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Breasts
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assess breasts/nipples
"do they feel different today?" soft, firm, can be lumpy secretion of colostrum/lactation |
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Uterus
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*assess the process of involution
*fundal height - usually at umbilicus during 1st 12 hrs, starts to decrease at 12 hrs, some drop right away (decreases 1cm each day) *consistency - firm, round, smooth, not "boggy"; should feel like a tennis ball. *uterus location - midline but can shift over to side especially if bladder is full |
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Bladder
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cath'd immediately post delivery in L&D. C-sections have foley; vaginals straight cath'd.
Assess for bladder distention. Measure urinary output (hoping for 300ml) |
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Bowel
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Assessment of bowels - gas counts as BM
auscultate bowel sounds "any gas pains?" BM usually 2-3 days post delivery |
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Lochia
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*amount - red drainage - tells us how the lining is healing. Vaginal has lots of red drainage. Watch for how often pads are being changed, if q hr=too much, hemorrhaging.
Color: Rubra - red (0-3 days) Serosa - pinkish red (3-10 days) Alba - white (10 days-6wks) Odor: musty/musky odor, should not be obnoxious Should not be green, should not have any sutures in pad. |
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Episiotomy
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if green, gaping holes, sutures laying on pad = big probs (infection).
Look for anything abnormal Hematomas ecchymosis edema |
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Homan's Sign
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assessing for thrombophlebitis.
Looking for a cluster of symptoms: >swelling - measure calf to see difference b/t two calves >redness or any change in color (pale white) >Warmth >unilateral calf pain; other leg would be normal >all these symptoms would happen on one leg |
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Emotions/Engagement
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Observe bonding behavior:
>attachment >en face (lift baby up & look eye-to-eye) >taking in - 1st day, mother taking in all the info >taking hold - 2nd day, takes hold of mother role & starts caring for baby >letting go - more for first time mom; let go of their previous role **Assess ability to care for newborn. |
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Add'l assessments for mother who had epidural delivery
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assessment of lower extremities:
sensation movement stability |
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Endometritis
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localized infection of uterine wall.
develops 2-7 days post delivery Tx: IV anti-Bs, analgesics, antipyretics; fluids, comfort measures Probable need for re-hospitalization & isolation |
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Wound infection
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c-section or episiotomy
Assess REEDA (redness, erythema, edema, drainage, approximation), odor TX: opening & cleaning wound, meds (anti-Bs, analgesics); fluids |
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Mastitis
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*concern if mom is breastfeeding; cannot breastfeed if draining.
*acute infection of glandular tissue of the breast *Staph or E.Coli *assess: unilateral condition; engorgement; nipple drainage; flu-like symptoms TX: drain abscess; meds (anti-Bs & analgesics); firm supportive bra, ice packs |
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UTI
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*Risk factors: indwelling catheter, c-section
*Assess: c/o burning on urination, urgency, frequency, fever TX: meds, fluids, repeat urine cultures until UTI is gone. |
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DVT
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*Clot formation attached to vessel wall
*Risk Factors: Hx of DVT/PE, venous stasis (on complete bedrest), hypercoagulation, smoking, over 35, multiparity *Prevention is goal with early ambulation. *Assess: unilateral findings of + homan's sign, calf pain, swelling, color change, warmth; low pulse ox. *TX: bedrest (RN can delegate), elevation of leg (RN intervention), Meds (analgesics & anticoagulants) |
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PE
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High mortality rate; fast deterioration
*Assess: sudden sharp chest pain, tachycardia, cough, hemoptysis, SOB *TX: bedrest, heparin therapy, O2 therapy |
