Flashcards in T3 - Nursing Care During Postpartum (Josh) Deck (46):
What are we assessing during the 4th stage?
PAR (post-anesthesia record)
How often do we access VS, etc.?
First hour…q15 minutes
Second hour…q30 minutes if stable
Then every hour for 4 hours
Then every 8 hours until discharge
How to remember when to access?
q15 x 4 (first hr)
q30 x 2 (second hr)
q1hr x 4 (next four hrs)
q8hr until discharge
Risk factors for excessive bleeding postpartum?
Macrosomic (4000g) baby or multiple birth
When would a baby be large for gestational age?
When would a baby be small for gestational age?
above 90th percentile
below 10th percintile
Large baby is --
Small baby is ---
Fundus should drop --- every day
What is the most common cause of postpartum hemorrhage?
***assess for boggy uterus
What is left on the endometrial wall after placenta is expelled?
denuded area of exposed blood vessels about the size of a fist
***why there is still some bleeding
Interventions for boggy uterus.
Immediate response may be to massage the fundus until firm...Express any clots that may be present
Check bladder for distention…Assist patient to empty bladder
Change pad…note quantity of lochia (pad soaked in
Meds used to stimulate contractions postpartum.
Methergine (hold if BP 140/90 or greater)
If temp is up during first 24 hours postpartum, what is likely cause?
Call provider if HR ---
What temp indicates infection in postpartum client?
Temperature greater than 100.4 that persists X2 days (exclusive of first 24 hours)
***after 24 hrs, think infection
Nursing actions to prevent infection during postpartum stage?
Change perineal pad with each voiding or defecation
How do we assess the perineum?
Lochia for color, quantity, and odor
***C-section have less bleeding
Nursing interventions to promote healing of perineum
Ice pack (cold) X 1st 24 hours to decrease edema
Sitz bath (warm) after 24 hours – tid X 20 minutes
Peri care with warm water with each urination
Blot dry, wipe from front to back
Apply new pad after each voiding
Why does bladder fill so quickly postpartum?
(remember carrying 50% more volume during preg)
How much fluids should we encourage to prevent UTI?
When do we cath a postpartum client?
6hrs elapsed since last void
voiding less than 150 mL
Breast care for lactating client
Wash nipples and areola with water (NO SOAP)
Airdry X 20 minutes
Apply expressed breast milk or nonalcohol cream to prevent drying and cracking (Cracks in skin = pathogens mastitis)
Empty engorged breasts manually or with breast pumpSupport bra
Nonlactating mom needs --- calories.
Lactating mom needs -- calories
Nutrition for lactating client
Increase caloric intake to 2700 kcal/day
No meds without consulting physician
Avoid foods gastric irritation, gas or diarrhea
When they have mastitis, do they need to stop breastfeeding?
yes, b/c they are likely on antibiotics
***pump and dump
How to suppress lactation
Avoid stimulation to breastIce packs …15 minutes q hour
Comfort measures for breast engorgement
Analgesic or anti-inflammatory medication
Cool clean cabbage leaves
--- during pregnancy can continue into postpartum period.
***lasts up to 6 wks after delivery
***investigate pitting edema
What is a safe anticoagulant for breastfeeding clients?
What is Homan's Sign?
calf tenderness upon dorsiflexion of foot
***sign of DVT
What is best prevention for DVT postpartum?
What is the purpose of the Indirect Coombs test?
detect anti Rh antibodies in mother's blood
***administer 300 mcg of Rhogam within 72 hrs
Prevention of Iso-immunization
Indirect Coombs test negative = no anti Rh antibodies in mother’s blood.
Administer RhoGAM 300 mcg IM within 72 hours of delivery
Administer as for blood productTest immunity in 3 months
When would Rubella vaccine be administered postpartum?
after birth and again at 1 mth
Nursing education regarding Rubella Immnization
Teach client to avoid pregnancy X 1 month after each dose
Safe for breast feeding patients
May develop rash…
***can't take if allergic to eggs
What is Hot-Cold Asian Culture?
Pregnancy is considered hot condition, heat is depleted during birth, now she is in a cold state for 40 days. She consumes only hot food, & beverages. She may be discourage from showering or bathing because this could cause heat loss
What is the 'Taking In' Phase?
First 1-2 days postpartum
Introspective and preoccupied with own needs rather than new baby
Excited & talkative
Touches and explores infant
Needs to verbalize L&D experience
What is the 'Taking Hold' Phase?
Begins by 2nd to 3rd postpartum day, lasts 10 days up to several weeks
Moves toward more independent behavior
Desires to take charge
More receptive to teaching
What is the 'Letting Go' Phase?
Achieves realistic independent role
Establishes norms for self and family
Mothering functions established
Resumption of relationship with partner
Resumption of sexual activity
Family system enters new phase of development
Transient depression usually b/t 2nd and 3rd PP day or within 2 wks?
Characteristics of PP Blues
Usually between 2nd and 3rd postpartum day or within two weeks
Characterized by mood swings, anger, tearfulness, feeling let down, anorexia and insomnia
Emotionally labile, cries for no reason
What happens if Postpartum Blues persist and don't resolve spontaneously?
evaluate for PP depression
Temperature may be elevated after delivery r/t ---.
After 24h a temp elevation of --- correlates to postpartum infection.
***This is lower temp than usually considered an infection.
--- can occur postpartum.
What does BUBBLE-HE stand for?
Scant Lochia =
Small Lochia =
Moderate Lochia =
Heavy Lochia =
Scant Lochia = 10 cm (25-50 mL or 25-50 g)
Heavy Lochia = 1 pad saturated within 2 hrs