Nursing Care During the Postpartum Period PDF

NURSING CARE DURING THE POSTPARTUM PERIOD NP03L004 ELO D · VERSION 2.0 THE FAMILY AFTER BIRTH Introduction to Maternity and Pediatric Nursing, 8th ed., pp. 208-246 TERMINAL LEARNING OBJECTIVE In a clinical setting, given a postpartum scenario, perform safe and effective nursing care for a p...

NURSING CARE DURING THE POSTPARTUM PERIOD NP03L004 ELO D · VERSION 2.0 THE FAMILY AFTER BIRTH Introduction to Maternity and Pediatric Nursing, 8th ed., pp. 208-246 TERMINAL LEARNING OBJECTIVE In a clinical setting, given a postpartum scenario, perform safe and effective nursing care for a postpartum family without harm. ENABLING LEARNING OBJECTIVE Perform postpartum nursing care for a patient and family who have had a vaginal or cesarean delivery. PUERPERIUM Known as postpartum period Six weeks after childbirth Sometimes referred to as the fourth trimester of pregnancy ADAPTING NURSING CARE FOR SPECIAL POPULATIONS Need significant teaching regarding parenting skills Adolescents Focus toward fitting in with peers Consider support system, marital status, & socioeconomic status Single May lack support system woman May have to return to work sooner ADAPTING NURSING CARE FOR SPECIAL POPULATIONS Poor Multiples Increased risk for Infants more likely to complications if prenatal need intensive care after care is inadequate birth if preterm May need social service Additional financial referrals strain CULTURAL CONSIDERATIONS The nurse must adapt care to fit Health beliefs Values Practices Use an interpreter when appropriate Should not be a family member Dietary practices POSTPARTUM ASSESSMENT Immediately after delivery, the mother experiences multiple physiological changes Assess all body systems Data collection is good time to teach the new mother on normal changes versus abnormal changes POSTPARTUM ASSESSMENT Use the acronym BUBBLE-HE to remember key components of the postpartum assessment Breast Uterus Bladder Bowel Lochia Episiotomy Homans’ Emotions REPRODUCTIVE SYSTEM Uterus Cervix Vagina Perineum Menstruation Breasts UTERUS Fundal Assessment Involution Decrease in size & descent of uterus into pelvic cavity Occurs via contraction, catabolism, & regeneration Location Midline or near level of umbilicus Tone Firmly contracted FUNDAL ASSESSMENT UTERINE COMPLICATIONS Boggy Uterus Massage until firm Observe perineum during massage to determine amount of clots & bleeding May need medication to maintain contraction Uterine Displacement Empty bladder AFTERPAINS Discomfort caused by intermittent uterine contractions, seen more often in: Multiparas Overdistention of the uterus Breastfeeding mothers Self-limiting, often within 48 hours Treated with mild analgesics LOCHIA Uterine discharge Endometrial tissue, blood, & lymph shed after delivery Assessed in conjunction with uterus Color Odor Amount Consistency Flow LOCHIA: CHARACTERISTICS Rubra Bright or dark red, red-brown discharge First 1-3 days postpartum Serosa Pink to brown discharge Postpartum days 3-10 Alba Yellow to white discharge May last up to 21 days postpartum Normal odor is fleshy, like menstrual discharge ABNORMAL LOCHIA Foul-smelling or green-tinged discharge Bright red discharge Regression in color of discharge Lochia rubra after 3rd day postpartum Pad saturated in less than an hour Frequent or large clots are passed CERVIX AND VAGINA Cervix regains muscle tone Vaginal rugae disappears during childbirth due to stretching, reappearing around 3 weeks postpartum Important to discuss when able to resume sexual activity with healthcare provider Often, sexual activity may resume when bleeding has stopped & perineum has healed Lubrication & Kegel exercises may be needed PERINEUM Encompasses lacerations & episiotomies Assessed for REEDA Redness Edema Ecchymosis Discharge Approximation ASSESSMENT OF PERINEUM Sims’ position with top leg flexed Opportune time to check for hemorrhoids COMFORT MEASURES Peri-bottle Ice Topical medications Dermoplast Epifoam Tucks pads Heat pack Sitz bath Body mechanics RETURN OF MENSTRUATION & CONTRACEPTION Menstruation returns Nonlactating 5 weeks postpartum Lactating 8 weeks postpartum Interconceptual care should be started at 6 weeks postpartum Consider contraceptive use Ideal spacing between pregnancies is 2 years BREASTS Assess for firmness, tenderness, & engorgement Milk production & lactation begin by 3rd day Assess nipples for condition & trauma BREASTS BREASTFEEDING FORMULA FEEDING Avoid products, to include Avoid stimulation to soap, on breasts nipples Moist heat, massage, & Engorgement should manual expression are resolve within 48 hours helpful in relieving milk Ice packs or cold cabbage leaves & analgesics are preferred SYSTEMS ASSESSMENT Cardiovascular Urinary Gastrointestinal Integumentary Musculoskeletal Immunologic CARDIOVASCULAR SYSTEM CARDIAC OUTPUT & BLOOD VOLUME Increased blood volume during pregnancy allows for blood loss during delivery Postpartum redirection of blood from reproductive tissues into main circulation temporarily increases volume Any excess fluid may present with edema ORTHOSTATIC HYPOTENSION May be due to decreased resistance in pelvic vessels or hypovolemia Dizziness, lightheadedness, & fainting Patient requires assistance with early ambulation CARDIOVASCULAR SYSTEM Chills or tremors may occur in the immediate postpartum period, for up to 20 minutes May be indicative of infection in the presence of a fever or after 24 hours postpartum COAGULATION Clotting factors increase during pregnancy & during first 6 weeks postpartum High risk for blood clot formation Varicose veins, delayed ambulation, cesarean delivery Lower extremities assessed for thrombosis Prevention Anticoagulant therapy, pneumatic compression devices Early & regular ambulation Dyspnea & tachypnea require immediate medical attention f BLOOD VALUES Red Blood Cells Hgb & Hct may be affected by postpartum fluid shifts White Blood Cells May increase up to 20,000mm3 Inflammation Pain Stress Healing  Temperature May be elevated up to 100.4ºF (38ºC) for first 24 hours after delivery Elevated temperature above 100.4ºF (38ºC) or for more than 24 hours is considered abnormal Bradycardia VITAL SIGNS Tachycardia Respirations Maintain normal rate of 12-20 bpm Blood Pressure URINARY SYSTEM Anesthesia during labor & decreased bladder tone during pregnancy affect ability to void Assess for distention Measure first voids after delivery Monitor for & educate regarding UTI signs and symptoms URINARY SYSTEM Promote relaxation of perineal muscles Stimulate urge to void Bladder training Analgesics Warm water over perineum Running water in sink Place patient’s hands in warm water GASTROINTESTINAL SYSTEM Assess bowel activity & sounds Prevent distention & constipation Hemorrhoids Perineal lacerations or episiotomy Cesarean incision Distended abdominal muscles Dehydration Anesthesia & opioids INTEGUMENTARY SYSTEM Reversal of pregnancy- induced skin changes Chloasma Linea nigra Striae gravidarum Will not disappear, but will fade over time Hyperpigmentation of areola MUSCULOSKELETAL SYSTEM Hypermobility of joints returns to normal Abdominal tone & stabilization by 6 weeks Common postpartum exercises Consult provider prior to starting exercise routine Utilize proper body mechanics IMMUNE SYSTEM Determine need for immunizations prior to discharge RhoGAM Within 72 hours postpartum if infant is Rh + MMR (Rubella) If non-immune Should not get pregnant for 28 days after administration Need consent & education May also get flu shot if didn’t already receive during pregnancy CHECK ON LEARNING A patient is admitted to the postpartum unit one hour after a vaginal delivery with an epidural. Upon assessment, you find that the patient’s fundus is 3 cm above the umbilicus, slightly boggy, & deviated to the right.You note that she has moderate lochia rubra on her pad. The patient’s last output was recorded 4 hours ago, prior to delivery.Your patient states that she still has some numbness in her legs, but that it is slowly wearing off. #1. What do these assessment findings indicate? CHECK ON LEARNING A patient is admitted to the postpartum unit one hour after a vaginal delivery with an epidural. Upon assessment, you find that the patient’s fundus is 3 cm above the umbilicus, slightly boggy, & deviated to the right.You note that she has moderate lochia rubra on her pad. The patient’s last output was recorded 4 hours ago, prior to delivery.Your patient states that she still has some numbness in her legs, but that it is slowly wearing off. #2. How should the nurse intervene? CHECK ON LEARNING Which assessments are expected 24 hours after birth? (Select all that apply.) a. Scant amount of lochia alba on the perineal pad b. Fundus firm & in the middle of the abdomen c. Breasts distended & hard with flat nipples d. Bradycardia e. Excretion of large amounts of urine ADAPTATION OF NURSING CARE AFTER CESEAREAN SECTION BIRTH Same as with normal vaginal delivery except Monitoring of abdominal dressing Lochia generally less Urinary catheter Respiratory care Prevention of thrombophlebitis Pain management POSTPARTUM ASSESSMENT: CESAREAN DELIVERY Assessment of the patient after a cesarean section includes ALL those previously discussed in addition to “postoperative” assessments Special consideration for emotional support and education if cesarean was unexpected or emergent  POSTPARTUM ASSESSMENT: CESAREAN DELIVERY Focused Abdominal Assessment Dressing should be clean & intact Initial dressing removed by physician Cover or change as needed for showering Monitor incision for REEDA Gentle fundal checks Lochia may appear scant immediately after surgery due to manual removal of contents INTAKE AND OUTPUT Maintain IV fluids per protocol Monitor for infiltration & fluid overload Assess & maintain Foley catheter Output, color, clarity Peri & Foley cares Usually removed within 24 hours postoperatively Monitor for signs and symptoms of UTI Progress from clears to normal diet Ensure GI function & stability first RESPIRATORY HYGIENE Lung sounds assessed at least once per shift Instruct patient to cough, deep breathe, & reposition frequently Use pillow or folded blanket to splint when coughing or moving Early ambulation & incentive spirometry are encouraged PAIN RELIEF Rated on a 0-10 pain scale to guide treatment Patient-Controlled Analgesia (PCA) Need continuous pulse oximetry, hourly respiratory assessments, & naloxone (Narcan) readily available Monitor for respiratory depression, itching, N&V, & urinary retention CHECK ON LEARNING A 36-year-old first-time mother develops complications during labor and requires an emergency cesarean section. #1. How does postpartum nursing care differ for this mother? CHECK ON LEARNING A 36-year-old first-time mother develops complications during labor and requires an emergency cesarean section. #2. What assessment and monitoring should the nurse perform? EMOTIONAL CARE OF THE FAMILY The birth of an infant brings about physical changes in the mother but also causes many emotional and relationship changes in all family members The family care plan integrates knowledge of family structure, culture, & community-based care into the care of the patient “Patient” encompasses the entire family  MOTHERS Rubin’s psychological adaptation of the puerperium Phase 1- Taking In Phase 2- Taking Hold Phase 3- Letting Go Postpartum blues Postpartum depression Fatigue  RUBIN’S PSYCHOLOGICAL ADAPTATION OF THE PUERPERIUM PSYCHOLOGICAL ADAPTATION NURSING RESPONSES Taking-In Phase Mother is passive and willing to let others do things for her. Provide opportunity for rest and appropriate nutrition. Provide Conversation centers on her birth experience. Has interest in opportunity to discuss birth experience and vent newborn but prefers that others care for newborn. Has little disappointments or share joys. interest in learning. Focus is on need for food, fluids, and restorative sleep. Taking-Hold Phase Mother begins to initiate action and becomes interested in Provide supportive atmosphere. Identify support system of caring for newborn. May be critical about her abilities. Has mother. Use teaching moments. Reinforce self-care and increased concern about her body functions and assumes self- newborn caretaking abilities. care needs. Is interested in learning how to care for self and baby. Letting-Go Phase Mothers and partners work through giving up their previous Provide supportive atmosphere. Provide referrals to lifestyle to incorporate newborn. Many mothers must give up community agencies as appropriate for assistance needed. their ideal of the birth experience and reconcile it with what Reinforce newborn caregiving abilities. really occurred. They give up the fantasy child and accept the real child. PARENTHOOD Learn new roles and expectations Affects communication between partners Feelings of ineptitude Fatigue and irritability Sense of loneliness Parents should Identify their own needs Set priorities Maintain sense of humor FATHERS Engrossment Four phases of adjustment Having expectations and personal intentions Confronting reality and overcoming frustrations Creating one’s own personal father role Reaping rewards of fatherhood OTHER FAMILY MEMBERS Siblings Age dependent on how older sibling will respond to new baby Preparation important Grandparents Involvement often dependent upon physical proximity to new family Assumed role may be dictated by new parents or cultural expectations THE GRIEVING FAMILY Therapeutic communication and nursing care Stages of the grief process Shock and disbelief Anger Guilt Sadness and depression Gradual resolution of sadness THE FAMILY CARE PLAN Patient Individualized by family Cultural considerations Community resources Follow-up appointments Selected Nursing Diagnosis: Compromised family coping resulting from a new family member (newborn) Goals Nursing Interventions Rationale Family members will express satisfaction 1. Determine relationship of family 1. Can help provide a positive with adaptation to newborn and members with one another experience to prepare the family for confidence in their roles. new development 2. Provide unlimited visiting privileges for 2. Facilitates the attachment and family and siblings bonding process 3. Initiate support group concerning 3. Verbalization of family culture, roles, breastfeeding and childcare and perceived responsibilities enables the appropriate person to be included in instruction concerning breastfeeding and childcare. 4. Provide anticipatory guidance 4. Meeting needs concerning housing concerning changes to expect and equipment, and community resources family adaptation options. available for assisting will help family adapt to changes. 5. Discuss sexuality needs and plans for 5. Clarification of contraception options contraception. acceptable to the cultural group will enhance learning and enable family to make informed decisions. 6. Provide written information and 6. Including the needs of each family suggested books for siblings member will promote family coping concerning the new child. Encourage and adaptation. sibling verbalization Introduction to Maternity and Pediatric Nursing, 8th Ed., pp. 224. CHECK ON LEARNING Your patient has just delivered twins. Baby A has been admitted to the NICU, while Baby B is admitted to the postpartum unit with his mother. The patient appears tired but very talkative about her delivery experience. Question: Explain why the patient is so talkative after delivery & how these stages influence when parent teaching would be most effective. (Reference: Rubin’s theory of psychological changes during the puerperium.) CHECK ON LEARNING The puerperium period refers to the _______. a. 9 weeks preceding birth b. 3 weeks preceding birth c. 12 weeks following birth d. 6 weeks follow birth. CHECK ON LEARNING The recommended time frame for becoming pregnant after receiving rubella vaccine is _________. a. 6 months. b. 4 months. c. 9 months. d. 1 month. CHECK ON LEARNING Vaginal discharge that lasts about 3 days after giving birth is called lochia ___________. a. Serosa. b. Rubra. c. Alba. d. Sanguineous. REVIEW OF MAIN POINTS Postpartum assessment of a mother following a vaginal birth Postpartum assessment of a mother following a cesarean birth Emotional care of the family The Family Care Plan QUESTIONS?