7.1b Care Management - Physical Needs

Question 1

Model of Care

Answer 1

• Plan includes woman, newborn, and family

- Couplet or Mother-Baby Model of Care

Question 2

On-going physical assessment

Answer 2

• VS
• Physical Assessment
• Evaluation of breasts
• Uterine Fundus
• Lochia
• Perineum
• Bladder/Bowel Function
• Lower Extremities

Question 3

Routine Lab Tests (Postpartum)

Answer 3

• Hemoglobin/hematocrit
• Urinalysis (especially if indwelling catheter was used)
• Rubella immunity
• rH status

Question 4

Nursing Interventions (Postpartum)

Answer 4

• Assessment periodically to detect variations from normal physical changes
• Relieve discomfort/pain
• Prevent injury/infection
• Education on self-management and infant care

Question 5

Blood Pressure

Answer 5

• Normal to return to baseline BP with transient increases by 5%
• Patient may have orthostatic hypotension for the first 48 hours postpartum

COMPLICATIONS

• Hypertension
• Preeclampsia
• Essential hypertension (not due to medical cause)
• Hypotension (hemorrhage)

Question 6

Temperature

Answer 6

• Should be between 97.2 - 100.4

- Greater than 100.4 after 24 hours could mean there is an infection

Question 7

Pulse

Answer 7

• Should be 50-90 bpm

COMPLICATIONS
- Tachycardia due to pain, fever, dehydration, or hemorrhage

Question 8

Respirations

Answer 8

• Normal 16-20 breaths per minute

COMPLICATIONS
Bradypnea - due to opioid effects
Tachycardia - due to anxiety or respiratory disease

Question 9

Breath sounds

Answer 9

• Should be clear to auscultate

- Crackles could be due to fluid overload

Question 10

Breast Exam

Answer 10

• Days 1-2 breasts should be soft
• Days 2-3 breast should be filling
• Days 3-5 breasts should be full with breastmilk

COMPLICATIONS

Engorgement - Firmness, head, pain which can lead to mastitis (infection of breasts)

Question 11

Nipples

Answer 11

• Skin should be intact with no soreness

COMPLICATIONS
- Redness, bruising, cracks, fissures usually associated with latching issues

Question 12

Fundus

Answer 12

• After 24 hours fundus should be firm, midline and at level of umbilicus
• Goes down at about 1cm (finger length) a day

COMPLICATIONS

• Soft, boggy, higher than expected level, atony (uterus fails to contract after birth)
• Can be caused by distended bladder

Question 13

Lochia

Answer 13

Days 1-3 (Rubra) - Dark red
Days 4-10 (Serosa) - Brownish Red/Pink
After day 10 (Alba) - Yellowish White
Amount should be scant-moderate

COMPLICATIONS

• Large amounts of lochia
• Uterine atony
• Large clots
• Foul odor (infection)

Question 14

Perineum

Answer 14

NORMAL
- Minimal Edema
- Pain minimal-moderate controlled by analgesia
ABNORMAL
- Pronounced edema, bruising, or hematoma
- Redness/Warmth/Drainage (Infection)
- Excessive discomfort for first 1-2 days and hematoma after the 3rd (infection)

Question 15

Rectal Area

Answer 15

ABNORMAL

- Discolored Hemorrhoids with severe pain

Question 16

Bladder

Answer 16

• Able to void spontaneously with no pain
• Diuresis begins 12 hours after birth (3000 mL/day)
  COMPLICATIONS
• Distended bladder which can cause uterine atony and excessive lochia
• Dysuria, burning, urgency which can mean infection

Question 17

Bowel Movements

Answer 17

• Should start 2-3 days after birth
  COMPLICATIONS
• No bowel movement after 3-4 days (constipation/diarrhea)

Question 18

Legs

Answer 18

• DTR should be +1 - +2

- >3 can mean preeclampsia

Question 19

Excessive Bleeding Interventions

Answer 19

• Monitor lochia and pad saturation to evaluate bleeding
• Monitor/palpate fundus to determine tone. Uterine atony is the most common cause of postpartum hemorrhage
• Gently massage fundus if it is boggy to promote uterine contractions
• Teach client to assess for bogginess and how to massage fundus to involve patient in self management.

Question 20

Acute Pain Nursing Interventions

Answer 20

• Assess the location, type and quality of pain
• Explain the reason for their pain, expected duration and treatment to lower patient anxiety and increase sense of control
• Administer pain medication and evaluate effectiveness in an hour
• Use ice packs in the first 24 hours and sitz baths after 24 hours to reduce edema and vulvar irritation

Question 21

Difficulty urinating

Answer 21

• Patient should void 3-4 hours after emptying their bladder
• Assess for fundus displacement
• Increase fluid intake, pour warm water over perineum to promote voiding
• Assess intake and output to assess adequate fluid intake
• Administer analgesics to reduce perineal pain

Question 22

Preventing Post-Partum Hemorrhage

Answer 22

• Most common cause is uterine atony
• Best management is to maintain good uterine tone and prevent bladder distension
• Atony is usually cause by retained placental fragments

Question 23

Post-Partum Hemorrhage

Answer 23

• A perineal pad that is saturated within 15 minutes and pooling under the butt requires immediate intervention
• To assess blood loss ask patient how long it has been since they have changed their pad to measure accurately

Question 24

Assessing Post-Partum Hemorrhage

Answer 24

• Monitor VS closely
• BP is not reliable measure of impending shock because compensatory mechanisms prevent a drop in blood pressure until the patient has lost 30-40% of their blood volume.
• RR, Pulse, Skin color, UO, and LOC are better indicators of hypovolemic shock

Question 25

How to Maintain Uterine Tone

Answer 25

- Best way to alleviate atony and restoring tone is by gently massaging the fundus until firm - This can increase vaginal bleeding and expel clots. - Additional interventions include IV fluids and oxytocic medications

Question 26

Preventing Bladder Distention

Answer 26

- Atony and bleeding can also be caused by bladder distention - Distended bladder displaces uterus up and to the side which prevents it from contracting properly CAN BE CAUSED BY - Epidural anesthesia - Episiotomy - Perineal lacerations - Vacuum/forceps birth - Prolonged labor (patients may experience issues voiding after having a catheter removed)

Question 27

Bladder Distention Intervention

Answer 27

- Encourage patient to empty bladder as soon as possible post-partum INTERNTIONS - Assist patient to bathroom/bedpan - Place hand in warm water/pour water over perineum - Assist into shower or sitz bath to encourage voiding - Relaxation techniques - Analgesic administration if patients are fearful of voiding due to anticipated pain - Catheter can be used as a last resort

Question 28

Preventing Infection

Answer 28

- Maintain clean environment - Change bed linens, disposable pads, draw sheets - Hand hygiene, patients should wear slippers - Proper perineal care for those with lacerations or episiotomies - Education on wiping from front to back (urethra to anus) - Squeeze bottle with antiseptic should be used after each voiding - Perineal pads should be changed from front to back each time she voids or defecates

Question 29

Promoting Comfort

Answer 29

Common reasons for pain include - Uterine contractions (afterpain) - Lacerations/episiotomies - Hemorrhoids - Sore nipples - Breast engorgement - EXTREME PERINEAL PAIN AFTER MEDICATION - Assess perineum for hematoma or infection - Can also be caused by rare perineal cellulitis, necrotizing factors, or angioedema

Question 30

Non-Pharmacological Interventions

Answer 30

- Warm compress or lying prone is good for uterine contraction discomfort. You can also provide distractions by interaction with infant - Afterpains are more severe during and after breast feeding - If patient had an episiotomy, encourage side lying position - Sore nipples occur from improper latching technique. Assist with feeding. - Topical or hydrogel pads can ease nipple discomfort - Breast engorgement can be reduced with ice packs or cabbage leaves as well as wearing a well supported bra. (Anti-inflammatories such as ibuprofen can help as well) - Breast feeding moms can use breast pump to reduce engorgement and formula moms should not stimulate milk production.

Question 31

Perineal Lacerations, Episiotomies, and Hemorrhoids Pain

Answer 31

- Cleanse area at least once a day from front to back - Peripad can be used to protect the skin (change at least 4 times a day) - Icepack during first 24 hours to decrease edema and after 24 hours to provide anesthetic effect - Squeeze bottle with warm water and use entire bottle to cleanse perineum. Blot dry with paper towels after.

Question 32

Sitz Bath (Perineal Laceration and Episiotomy continued)

Answer 32

- Fill with warm water and add ice if patient requests a cooler bath - Use sitz bath 20 minutes 2 times a day - Check patient in 15 minutes

Question 33

Topical Applications

Answer 33

- Apply anesthetic cream after cleaning perineal area (3-4 times a day) - Apply hazel pads after cleansing - Apply hemorrhoidal crème as ordered to anal area after cleaning

Question 34

Promoting Rest

Answer 34

- Lack of sleep and fatigue is of the most common complaints of new parents - Fatigue will likely worsen over the next 6 weeks due to - Household responsibilities - Lack of family support - Limited resources - Lack of sleep may lead to post-partum depression - Screening for fatigue can be done by phone call within the first 2 weeks and routine follow-ups

Question 35

Promoting Ambulation

Answer 35

- Ambulation reduces risk of Venous Thromboembolism (VTE) - Orthostatic Hypotension - Rapid decrease in intra-abdominal pressure after birth that results in dilation of blood vessels supplying the intestines (splanchnic engorgement) causes orthostatic hypotension WHAT TO CONSIDER DURING AMBULATION - Baseline BP - Amount of Blood Loss - Type/Amount of analgesic/anesthesia used - Epidural (Time since it was used, ability to bend knees and lift off bed) - Medications since birth - VS - Ability to stand un-assisted - Exercise should be promoted if patient is in bed longer than 8 hours post-partum

Question 36

Promoting Exercise

Answer 36

- Can begin soon after birth - Start slow and gradually move up - Abdominal exercises are postponed until 4-6 weeks after c-section

Question 37

Promoting Nutrition

Answer 37

- Well balanced diet promotes healing in post partum - 1800-2200 kcal for moderate activity non-lactating women - Lactating women need 450-500 calories more a day - 200-300 omega 3 fatty acids daily and 1-2 weekly portions of low mercury fish - Prenatal vitamins for 6 weeks after birth - Iron supplements for those with low hemoglobin and hematocrit

Question 38

Normal Bladder Function

Answer 38

- Void within 6-8 hours after birth - First few void should be measured for adequate emptying of bladder - At least 150 mL is expected for each voiding - Urinary incontinence common for those who experienced perineal trauma - Kegel exercises can help with urinary incontinence

Question 39

Normal Bowel Function

Answer 39

``` Risk of constipation due to - Opioids, Iron, Magnesium Sulfate - Dehydration - Immobility - Episiotomy/Lacerations - Hemorrhoids - Fear of pain with first bowel movement INTERVENTIONS - Ambulation and Fiber increase - Education on side effects of medication - Stool softener and Laxatives if indicated by provider ```

Question 40

Promoting Breastfeeding

Answer 40

- Within first 1-2 hours after birth - Skin to skin contact as soon as possible after birth for at least an hour - Breastfeeding helps uterus contract and prevent hemorrhage

Question 41

Lactation Suppression

Answer 41

- Needed for those who are not breastfeeding - Wear well supported bra for 72 hours after birth - Avoid breast stimulation (running warm water over breast, newborn suckling) - Icepacks can help with engorgement and cabbage leaves - Analgesics and anti-inflammatory medication can help with engorgement

Question 42

Rubella Vacination

Answer 42

- Given as MMR vaccine - Recommended if Titer or Vaccine have not been given - Teratogenic, so do not get pregnant within 28 days after vaccine - Not communicable in breast milk - Should not be given if mother/household member is immunocompromised

Question 43

Varicella Vaccine

Answer 43

- Given before discharge | - Second dose 4-8 weeks after first dose

Question 44

TDAP Vaccine

Answer 44

- Recommended for those who are unvaccinated - Those who are around the baby should also be vaccinated (older children) - Should occur 2 weeks before contact with newborn to allow immunity to happen - Can continue to breastfeed

Question 45

Preventing rH Immunization

Answer 45

- Injection of Rh immunoglobins within 72 hours after birth prevents sensitization - Promotes lysis of rH positive blood cells before antibodies form

Question 46

Kleihauer-Betke Test

Answer 46

- Detects amount of fetal blood in moms circulation - Used if large amounts of fetal blood is suspected in moms circulation - Increased immunoglobin dosage if more than 30 mL of fetal blood is in moms circulation - Must be scanned again for vaccine success (such as rubella), they will need another dose if vaccine did not work.

Question 47

Adverse Effects of rH Immunoglobins

Answer 47

Rhogam - Myalgia - Lethargy - Localized tenderness at injection site - Transient Fever

Question 48

Nursing Considerations of Rhogam

Answer 48

- Prophylactic dose at 28 weeks of gestation - Standard dose within 72 hours if baby is rH positive - Dosage must be confirmed by 2 nurses - Consideration for Jehovah Witness patients because vaccine is made from human plasma