POSTPARTUM ASSESSMENT Flashcards
(37 cards)
CLINICAL ASSESSMENT
- review antepartum and intrapartum history
- determine educational needs
- consider religious and cultural factors
- assess for language barriers
- check your own feelings
ANTEPARTUM AND INTRAPARTUM HISTORY
type of delivery instrumentation complications duration of labor allergies feeding method chosen meds used and given last feeding of baby last voiding of mother exam of fundus and body blood type RH educational needs
POSTPARTUM
- begins immediately after child birth through the 6th post partum week
- reproductive track returns to non pregnant state
- adaptation to the maternal role and modification to the family system
DISCHARGE HOURS
48- VAGINAL BIRTH
72- C-section
SAFTEY FOR MOTHER AND INFANT
- prevent infant abductions
- check ID bands
- educate mother about safety measures
- right baby to right mother
POST PARTUM ASSESSMENT BUBBLE-HE
breast uterus bladder bowel lochia episiotomy homans/legs emotion
EARLY ASSESSMENT
VITAL SIGNS
- blood pressure
- pulse (50-70bpm)
- respirations (12-20)
- Temperature (100.4 24 hrs after birth due to dehydration or epidural
- Orthostatic hypertension
- watch red heads with warm water
POST PARTUM INFECTION INDICATION
the presence of fever of 38C or more on 2 successive days of the first 10 postpartum days ( not including the first 24 hrs) is indicative of a postpartum infection
- shimmering and shakes is normal after birth
PAIN ASSESSMENT
-determine source
- document location , type and duration
-interventions
~medication, positioning, ice, baths, heat lamps
BREAST ASSESSMENT
- inspect for size , contour , asymmetry and engoregement
- nipples check for cracks, redness, fissures
- note if nipples are flat, inverted or erect
- evalutate for mastitis(infection of breasts)
milk comes in on day 3 , progesterone decreases, prolactin increases= milk production stimulation is needed
after 3 hrs with no stimulation prolactin will decrease
NURSING CARE FOR NON- LACTATING MOTHER
- avoid stimulation
- wear support bra 24hrs
- ice packs or cabbage leaves
- mild analgesic fro discomfort
BREAST FEEDING NOTES
- baby face toward breast (lead with chin )
- nipple toward upper mouth
- mouth covers most of nipple ( bottom of it mostly)
- baby aligned with breast
ASSESSMENT OF UTERUS/ FUNDUS
- location immediately after birth
- descends 1cm/ day
- consistency - firm/ boggy
- location height - measured in fingerbreadths
- placenta birth is 15min after fetus
- 5 fingers above umbilicus and moves to umbilicus ( 12 hrs later )
INVOLUTION
oxytocin is released and cause uterus to contract
NURSING CARE FOR A BOGGY FUNDUS
-massage until firm
MEDICATIONS
- Pitocin,methergine, hemabate
- teach new mom to massage her fundus
- make sure mom empties bladder 1hr before assessment 200ml X 2 are recorded
AFTERPAINS
- intermittent uterine contractions due to involution
- primiparous- mild
- multipara- more pronounced
NURSING INTERVENTIONS FOR AFTERPAINS
- patient in prone position and place a small pillow under her abdomen
- ambulation
- heating pad
- medicate with a mild analgesic( for breastfeeding women 30min before nursing)
BLADDER
spontaneous void 4-6 hrs
-monitor output 200 ml X 2
- postpartum diuresis
palpate, bladder scan, decreased bladder tone, uterus cant contract, pain meds
NURSING CARE FOR BLADDER
- encourage frequent voiding every 4-6 hrs
- monitor intake and output for 24 hours
- early ambulation
- void within 4 hrs after birth
- catheterization if unable to void
BOWEL
- anatomy returns to normal
- relaxin (hormone secreated during pregnancy ) depresses bowel motility
- diminished intraabdominal pressure
- incontinence if sphincter lacerated
- spontaneous BM 2nd- 3rd post partum day
NURSING CARE FOR BOWEL
- increase fiber in diet
- 8 glasses of water or juice(more if nursing )
- stool softener
- laxative
- sitz bath for discomfort
- medications for hemrrhoids
LOCHIA
- mixture of erythrocytes, epithelial cells, blood, fragments of decidua, mucus and bacteria
- as involution preceeds it is the necrotic sloughed off decidua
- 240-270 ml
- cesarean less
- present for 3-6 weeks
STAGES OF LOCHIA
RUBRA -dark red 1-3 days
SEROSA- pink,brown 3-10 day
ALBA - yellow white 10 days - 2 weeks
DOCUMENTATION : odor color amount presence of clots
4-8 pads a day is normal
may need to weigh pads 1gm=1ml of blood loss
NURSING CARE FOR LOCHIA
- educate mother on the stages of lochia ]
- caution mother that an increase, foul odor or return to rubra lochia is not normal
- instruct patient to change peripad frequently
- peri care after each void
warm water
blot dry front to back
remove and apply pad front to back
wash every 24 hrs
