NUR 113 Exam 2 Notes PDF

Module 3 – Previa / Abruption NUR 113 Learning Outcomes Describe the role of the placenta during pregnancy Discuss possible complications of placenta previa and placental abruption Discuss risk factors for placenta previa and placental abruption Compare signs and symptoms of pl...

Module 3 – Previa / Abruption NUR 113 Learning Outcomes Describe the role of the placenta during pregnancy Discuss possible complications of placenta previa and placental abruption Discuss risk factors for placenta previa and placental abruption Compare signs and symptoms of placenta previa and placental abruption. Illustrate the nursing process as it relates to placenta complications in pregnancy. Placenta Responsible for 5 major functions o Respiratory – provides oxygen to the baby o Excretion – removes harmful waste and CO2 from the baby o Nutrition – nutrients passed from mother o Immunity- immunity passes from the mother o Endocrine – produces hormones that assist in the growth of the baby Once placenta tears away is when baby has problems, can only take a minute or two for baby to have issues Placenta Previa (previa is not the emergency this is just when its in the wrong place) Risk Factors: o Uterine scarring o Multifetal gestation o Multiple gestations o Smoking o Mother’s age >35 Client Presentation (Previa) Fundal height greater than usually excepted for gestational age Uterus is SOFT NON TENDER with a normal tone o Mama not in any pain Fetus is breech, oblique, or in a transverse position Reassuring FHR PAINLESS; BRIGHT RED vaginal bleeding o Can happen after intercourse – not a problem just when it happens most often Vital signs within normal range If placenta is anterior placenta they may not feel baby move a lot - Nothing is going on bad – it is just attached in the wrong place - If mama comes in bleeding, ask when last time they had intercourse, and ask if they have been told they have previa Picture of types of placenta previa  Video about placenta previa – low lying placenta – placenta previa animation https://youtu.be/nEa6E-BtYRw?si=4QvrAC9amuFCLstg If mama comes in with a saturated pad its likely this is happening and a baby is coming now – even if not term. Will try and stop labor if not pretern but you need to do H&H type, PT PTT INR, platelets. CBC, U/ S, monitor, heart sounds etc (see below) Medical Interventions Labs Blood type and Rh factor Coagulation profile Ultrasound Monitor FHR Nursing care (Previa) Assess for bleeding, leaking fluid, and contractions  Fundal height Meds as ordered: Betamethasone, IV fluids, any blood products Oxygen if fetal distress Mama will be having LATES if this is happening. Do not do a vaginal exam will cause more bleeding (if complete previa for sure) Will do a skilled U/S to see how dialated she is. PREVIA o Painless bright red bleeding o Replace blood loss o Evident in the lower segment o Vital signs indicate shock o Inspect FHR o Avoid vaginal exams. Placenta Abruption (think if something just snapping away – like the top of the pineapple – just rips off. Risk Factors: o Trauma ▪ Violence/ beating/ physical abuse ▪ falling o Accident o Physical abuse o PROM o Multifetal (twins) pregnancy Chronic long-term processes o Hypertension o Smoking o Cocaine use Presentation (abruption) Sudden onset of abdominal pain with dark red vaginal bleeding o Does not need to be a LARGE amount of blood to be fatal for baby  Uterine tenderness Contraction increased in duration o Tummy is hard. We are touching tummy waiting for tummy to relax at end of contraction, will then maybe have some blood, and this is a common reason for CP Fetal distress o FHR if you have it it’s just LATE LATE LATE Is not the moms fault ever for this. (image of abruption) Video about placental abruption (high impact.com) https://youtu.be/Z9dBS1xLQMc?si=ROFCKTik81p-9w9U Medical interventions:  Hgb and Hct Type and cross for possible transfusion Coagulation profile PT PTT INR Nursing interventions: Nursing Care (Abruption) Check uterus for tenderness and tone Checking fundal height Assess FHR If an emergency delivery o Start IV, get blood product from the blood bank o 8-10 L of O2 via face mask o Monitor v/s; change in hemodynamic status o Assess urine output o Provide emotional support Placental abruptions Detached - Dark red Bleeding - Extended fundal height - Tender uterus - Abdominal pain - Concealed bleeding - Hard rigid abdomen - (get the rest) - Most common risk factor for abruption is hypertention Disseminated Intravascular Coagulation (DIC) Signs and Symptoms - Petechiae Confusion Respiratory distress Oozing from the IV site  Acute renal failure Acute liver failure (one more)? Condition affecting the blood ability to clot and stop bleeding In disseminated intravascular coagulation, abnormal clumps of thickened blood clots form inside blood vessels. The abnormal clots use up the bloods clotting factors and can lead to massive bleeding in other places. causes inflammation infection and cancer Symptoms can include blood clots and bleeding possibly from many sites in the body The goal is the treat the underlying cause and provide supportive care through intravenous fluids and blood transfusions If the mama is oozing blood, its likely DIC, can even ooze from nose and ears. IT can be fatal. Medical Interventions (DIC) Imminent delivery Treatment of hypovolemia Rapid fluid therapy Treat hypothermia Administer FFP Blood transfusion Treat hypothermia Disseminated Intravascular Coagulation (DIC) - Acute obstetrical hemorrhage - The leading cause of maternal mortality - Often secondary to underlying maternal and or fetal complications  o Placental abruption o HELLP syndrome o Post partum hemorrhage o Preeclampsia Can lead to organ dysfunction/ failure (liver) Excessive bleeding d/t depletion of platelets/coagulation factors Always assess the heart rate as a priority and maternal vital signs Assess a 28 week client with painless vaginal bleeding to assess for previa over a o Client who is at 38 weeks of gestation and report cough and fever o A client who missed a period and report vaginal spotting o A client who is at 14 weeks of gestation and reports nausea and vomiting Hypertensive Disorders in Pregnancy NUR 113 Learning Outcomes Describe the pathophysiology of hypertensive disorders in pregnancy Discuss risk factors of hypertensive disorders in pregnancy Identify the clinical manifestations of hypertensive disorders in pregnancy Summarize diagnostic testing/therapies Discuss client education for hypertensive disorders in pregnancy Perfusion  need to know this The passage of oxygenated capillary blood through body tissues - Peripheral perfusion is the passage (flow) of blood to the extremities of the body - Central perfusion is the passage (flow) of blood to the major body organs, including the heart and lungs How do you (as a nurse) assess perfusion? - Observing the temperature of the skin - The status of capillary perfusion - Urine output is a further indicator of the adequacy of perfusion - Abnormal blood pressure - Pulse oximetry: low levels reduce the uptake of oxygen at the alveolar-capillary membrane and oxygen delivery to the tissues - Check for pallor, cyanosis, mottling and cool or clammy skin. Pathophysiology Hypertensive disease in pregnancy is divided into subsets of the disease based on end-organ effects. Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hypertensive disorders. Gestational hypertension and chronic hypertension can occur simultaneously. Gestational hypertensive diseases are associated with o placental abruption, kidney failure, liver failure, preterm birth, and fetal and maternal mortality. Hypertensive Disorders in Pregnancy HTN Disorders of pregnancy are the second-leading cause of maternal death behind maternal hemorrhage o Chronic Hypertension o Gestational Hypertension o Preeclampsia o Eclampsia ▪ Only cure is delivery of placenta!!! Risk Factors First pregnancy Maternal age younger than 19 or older than 40 years o If your young your body is not fully developed Obesity Multifetal gestations (twins triplets etc) Chronic hypertension and chronic renal disease Diabetes mellitus Systemic lupus erythematosus and Rheumatoid arthritis Chronic Hypertension Hypertension that existed BEFORE or does not resolve after pregnancy Blood pressure > 140/90 PRIOR to pregnancy or BEFORE 20 weeks gestation And/or after 12 weeks postpartum Usually, asymptomatic Gestational Hypertension Gestational hypertension: BP elevation after 20 weeks of gestation Blood Pressure greater than 140/90 o Recorded on 2 different occasions at least 4 hours apart Abnormal Labs o CMP and will have elevated liver enzymes Blood pressure returns to baseline by 12 weeks postpartum NO proteinuria (no protein in urine) Preeclampsia A Multisystem disorder of unknown etiology Blood pressure140/90 or greater (in previously good BP women) Proteinuria of greater than or equal to 1+ Persistent headaches – does not have to be pounding but does not go away with tylonal High liver enzymes and low platelet count (they start fluctuating) Trouble breathing (rare – can mean fluid in lungs) Severe Preeclampsia Blood Pressure 160/110 or greater Proteinuria greater than 3+ Oliguria o Concentrated urine Visual disturbances o Headache not relieved with meds o Blurred vision ▪ May see multiple things (how many fingers do you see) Facial edema o Eyes puffy – look like they have been crying Epigastric/RUQ pain o Liver is involved – may be having pain due to liver Eclampsia Same manifestations of preeclampsia with SEIZURE activity o Preceded by headache o Severe epigastric pain o Hyperreflexia o Hemoconcentration’s o Immanent delivery HELLP Syndrome Same manifestations of preeclampsia Excess weight gain Nose bleeds Hematologic conditions coexist with hepatic dysfunction Diagnosed by lab test o H - Anemia o EL – ALT AST, epigastric pain o LP – Abnormal bleeding, petechiae Lab/Diagnostic CBC (low platelets) CMP (elevated ALT AST)  Coagulations panel (PT PTT INR clotting factors) Creatine, BUN, Uric acid (protein in urine) Diagnostic o testing of urine proteinuria o 24-hour urine collection for protein and creatinine o NST, BPP, Ultrasound ▪ May be doing these 2 week and if abnormal will be brought in for possible delivery Maintenance medications Aldomet Nifedipine Hydralazone hydrochloride Labetalol hydrocholiride Medications Magnesium Sulfate - Methyldopa (Aldomet) Nifedipine (Procardia) Hydralazine (Apresoline) Labetalol ( Trandate) Magnesium Sulfate - Treatment for clients with preeclampsia or eclampsia seizure activity o Ordered upon admission and infused until delivery o Typically ordered to infuse for 24 hours (post delivery) o Leading dose of 4-6g mag sulfate IV bolus as secondary infusion over 15 – 30 minutes ( do no leave the room with pt) o Administer maintenance dose by continuous infusion at 2g/hr o Monitor mag levels to maintain the therapeutic level at 4-7 mEq/l – labs every 4 hours o Antidote calcium gluconate at BEDSIDE  ▪ Always keep right there ready to go - Internal muscle relaxant - The longer pt is on the more they feel they have the flu - Check pt every hour o Med is toxic ▪ If pt is off – check labs stat Nursing care for mag - Hourly rounding o Monitor deep tendon reflexes o Monitor urine output o Monitor O2 saturation o Monitoring of respiratory status and lung sounds (for crackles) o Monitor urine output – at least 50ml every 2 hours o Monitoring of fetal heart rate. o Monitor for Magnesium Toxicity (stop med) ▪ Loss of deep tendon reflexes ▪ Shortness of breath ▪ Decreased urine output (oliguria) ▪ Decreased oxygen saturation Client Education for IV MAG Initial feelings of flush, heat, nausea, and burning at the IV site Remain in bed Maintain a dark quiet environment o Need mama to be non stressed ▪ No TV no large loud groups until blood pressure is ok or mama feels better Clear liquid diet Pt will be on seizure precautions  Should always have pulse ox on finger DM – risk due to kidney issues (high protein) FPP – Fresh frozen plasma when bleeding Never give oral coagulants they are too slow to work. Know calcuium gluconate 4g loading load – 15 min in the room Know next dose and how long to check and what to check on the pt 50ml every 2 hours Low stimulus dark room How does a placenta abruption present – rigid abd – painful Dark red urine Long contractions Types of pevia Anterior – wont feel baby as much Complete covering the cervix Complete Low lying 113 – Mod 4 – Know all this well Ms peshalk 211 Postpartum Care Discharge teaching starts at admission A lot of information Education is very important in post partum NUR 113 Learning Outcomes Summarize physiological adaptations of the body systems during the postpartum period. Describe the psychologic adaptations of the postpartum mother. Summarize alterations in the postpartum period. Evaluate expected outcomes of the postpartum mother. Overview The postpartum period o Begins after delivery of the placenta o Continues for approximately 6 weeks ▪ Can continue up to 1 year if needed o Woman readjusts physically, and psychologically from pregnancy and birth ▪ Can take up to one year Physiologic changes of pregnancy occur over several months The greatest risk during the postpartum period are hemorrhage, shock, and infection. o Infection is a risk due to cervical checks and especially after water breaks o Also after c-section ▪ We would assess the drainage on the dressing not the incision The MAIN goal during the immediate PP period (first 24hrs)is to prevent PPH. o Make sure pt knows the risks and when to report Involution Rapid reduction in size of the uterus Starts with delivery of placenta Assessment is monitoring fundal height o Hemorrhage inside if uterus is above umbilicus (if moves up)  o Multiple deliveries from mama o Mama has full bladder – will move to one side usually Involution: Rapid reduction in size as the uterus returns to a nonpregnant state o Cannot palpate uterus after the 9th PP day o The placental site heals over 6 weeks – can take this long to heal o Uterus approaches prepregnant size, location by 5–6 weeks (average) ▪ Depends on size of patient – unique to patient Bleeding in PPH comes from when uterus comes off the wall – it leaves a wound Guard the bottom of the uterus – to prevent prolapse Fundal Assessment Top portion of the uterus Located in the midline (if deviated check bladder) o Some women are always deviated. Sometimes this can cause heavier bleeding o Encourage mama to use bathroom especially if had pitocin at any time Palpable below the umbilicus After delivery contracts to the size of a grapefruit Boggy – associated with excessive uterine bleeding o Assess the whole uterus during checks – top can be firm and side can still be boggy. The top of the fundus descends into the pelvis by the 10th day Post partum Care Initial Assessment – (vaginal delivery) (Pearson pages 2362 great birds eye view images over two pages) Assessment schedule (first hour one to one care) Vital signs q 15 minutes 1st hour Fundal massage q 15 minutes 1st hour Vital signs 30 minutes 2nd hour Fundal massage q 30 minutes 2nd hour o Then assess every 4 hours and check uterus o Then once a shift C-sections o First 2 days we check more often – usually every four hours for the whole stay – standards may be different for each facility but for surgery you want to assess more often than with vag delivery/ Uterine Atony Atony – loss of muscle tone o Relaxation of the uterine muscle tone o Blood collects forming clots within the uterus o Causing fundus to rise o Interrupts contractions of the uterus o Sometimes this occurs when the uterus goes back up above umbilicus – you expect maybe something will come out and when it does it can be shocking. Not always will lead to this if above umbilicus Risk factors o Multiple births o Large infants o Multi babies in womb o Frequent births o Medications ▪ Oxytocin Prolonged labor process – lots of tonic meds After delivery body’s receptors are flooded, body may be at risk for PPH and may not produce enough to cause correct muscle tone Look at table on Pearson 2360 - 33.15 post partum risk factors Afterpains Cramp-like pains caused by intermittent contractions of the uterus after childbirth o If you have epidural you may not feel it right away, then mama will feel it several hours later More severe in multi-gravidas Can cause severe discomfort for 2-3 days Warm compress against the abdomen may provide relief Breastfeeding client- take medication approx. 1 hour before feedings o Breastfeeding can make cramping due to the oxytocin (education) Assure client prescribed medication is NOT harmful to the infant o Tylenol is common ▪ Try and help patient get in front of med, use PRN meds as scheduled Medication will help improve the quality of the breastfeeding experience o If narcotics given during birth it can cross over to breast milk but not enough to harm baby Lochia Vaginal discharge after birth; mixture of blood and mucus o Rubra – dark ruby red, resembles bleeding like a heavy period ▪ clots are normal, dime sized clots. ▪ Uterus cleaning itself out. Very normal, ▪ Clots larger than a golf ball are large – save for nurse to see. Need to chart and watch, but if there is a lot of them, nurse should be mindful of PPH ▪ 3-4 days o Serosa – Pinkish-brownish discharge ▪ 4-12 days (2 weeks post partum) ▪ Flow is moderate to small amount  ▪ Activity of stress may increase lochia flow or change from serosa back to rubra o Alba – from 12 days to 3 weeks postpartum o Gradually disappearing scant creamy whitish discharge Red lochia should NOT reappear once Alba appears (report to provider if this happens) Postpartum Psychological Assessment Blues vs depression o Does mama have a history of depression or anxiety? ▪ Its ok to ask – if you see meds on MAR you can ask further questions ▪ This can put patient (with any history of anxiety of depression) at risk for postpartum depression ▪ Baby blues last about 2 weeks, but if its longer it can be postpartum depression If PPD it will continue to get worse  By the time the client goes back for 6 week follow up the PPD can be very bad. Exhaustion o Maternal fatigue can also contribute to baby blues and postpartum depression Overwhelmed o There is a difference between first time parents and something more Lack of support o Is parent doing everything on their own? ▪ Will they get a chance to sleep? ▪ Does mama have any support person? o Other children they have to care for? o Other responsibilities and stressors? Bonding o Could be a lack of knowledge if mama is not involved – does mama not know how to change a baby’s diaper? o Is there something deeper causing an issue o Watch one, do one, teach one – this is a good way to remember how to share something with a patient. History o Does mama have any history of PPD or depression Knowledge Check: A patient just delivered on the first assessment the fundus is firm, when will the nurse next assess the patient – 15 minutes later Patient asks what is a fundis, and nurse repies it is the top portion of your uterus Alterations in PP Period Early (Primary) Hemorrhage o Occurs within the first 24 hours after childbirth – MOST commom  Late (Secondary) Hemorrhage o Occurs from 24 hours to 6 weeks after birth Vaginal blood loss >500 mL (greater than 500) Cesarean blood loss > 1000 mL (greater than 1000) Risk factors for PPH o Anemia in pregnancy ▪ We do H&H and platelets when admitted to L&D - Low platelet counts in pregnancy can mean no epidural (low pain control) and also PPH o Large baby o Multi babies in womb o Prolonged labor o High blood pressure Watching a video about PPH - https://youtu.be/jjy2Uevf7MM?si=OC5kgBeTQN7uUIoV This video talks about how the nurses can really understand the QBL – quantitative blood loss number There are different Stages of hemorrhage and blood loss – Stage 1: Nurses notice BP goes up in the beginning (then drops) HR goes up Blood loss of 1000mL O2 sats drop (want to keep over 95) Mama may become confused Get an IV in place if not already in place o Oxytocin Second IV o Other meds Insert a foley! Stage 2- Continued bleeding Blood loss of up to 1500 mL  Notify blood bank or you may need a small transfusion already Emergency release if not already signed Some providers may move pt to OR at this point in case they cannot stop bleeding Stage 3- Advanced, you have given all meds you can, and you have given blood – still bleeding More than 1500 mL cannot stop Worried about DIC Talking surgery – emergency hysterectomy Trauma: - Can get a hematoma behind a laceration and can be painful – but mama still having bleeding we are just not seeing it. Jada system: https://youtu.be/W8GfbFhtSQg?si=CusnVMzgxXfwGjxY Newer product – used mostly in last 5 years. Not all facilities will have this or use it. Has a 95% success rate. CFVH has JADA. Also is a Bakri balloon device that goes into uterus, 500ml sterile water and it helps uterus to retain tone. (might be more common) PPH Medications – that can be given in PPH hemorrhage - Know meds and contraindications etc - All of these are likely given if a stage 3 hemorrhage Oxytocin (Pitocin) o 20 units per liter (I bag) Misoprostol (Cytotec) o 200mcg Tablets (5 tabs) Methylergonovine (Methergine) o 0.2 mg/ml (1 ambule) o Contraindication if hypertension ▪ But we will use if needed Carboprost Tromethamine (Hemabate) o 250mcg (1 ampule) o Diarrhea is an adverse reaction Tranexamic Acid (TXA) o 1 gram o In IV over 10 minutes  All uterine stimulants Massage fundus until the medication is administered Knowledge Check - PPH is leading cause of maternal death - Immediate intervention if boggy – massage fundus Perineal Repairs - When you have a 3rd/ 4th degree that is when mama will have heavier post op meds Pearineal Care - Patient education o Perform hand hygiene before and after voiding o Clean front to back o Rinse with warm water in peri-bottle after using restroom o Blot perineal area dry - Episiotomy o Apply ice/ cool sitz baths ▪ Reduces perineal edema ▪ Reduces responses of nerve endings ▪ May have more pain meds ▪ Usually done to prevent shoulder dystocia Not done much now as it give direct place for more tear to begin o Sitz bath ▪ Warm water decreases pain ▪ Promotes circulation to the tissues ▪ Promote healing ▪ Reduces incidence of infection Reproductive Changes Cervical Flabby, formless and maybe appear bruised Vaginal Edematous, may have small superficial lacerations Perinatal Soft tissue in and around the perineum may be edematous ASSESS: Perineum for erythema, edema, and hematoma Cesarean Birth Still considered a complication of birth Some patients have a really hard time dealing with the disappointment of having to have a c-section o Be mindful of this o Mom may feel she did not do something right Most women ambulate the day after surgery discharged by day 3  o Mama may feel like her tummy is falling out, that’s normal, reassure mama she will be ok Encourage use of incentive spirometer every hour o Anytime we perform surgery the patient is at risk for pneumonia o Encourage deep breathing and coughing ▪ Not moving a lot ▪ May have blood clots o Also will have SCD on until they are walking Administer analgesics as needed o Stay on top of their pain o Reassure mama that pain meds are helpful to function with baby Promote comfort through positioning Get mama up as soon as possible – even if they still have a foley – walking is key Mama cannot shower until provider says – and when they can they need to keep incision clean and dry while healing Abdomen Uterine ligaments stretch Responds to exercise in 2-3 months Diastasis recti abdominis (see picture) Striae marks o Related to elastin in skin o Lotions wont prevent o Will never go away Breasts During pregnancy Lactation suppressed by elevated progesterone levels Delivery of placenta decreases levels of progesterone; triggers milk production Stages of Human Milk Colostrum Transitional milk Mature milk Gastrointestinal System Post-delivery o Increased appetite ( just ran a marathon!!) o Hemorrhoids  o Assess bowel sounds ▪ Poo and fart when you can!! Not always done before leaving hospital. Especially surgical patients o Encourage this! o Constipation ▪ Women with episiotomy, lacerations, or hemorrhoids may delay elimination for fear of increasing pain or tearing stitches ▪ Refusing or delaying bowel movement may cause increased constipation, pain ▪ Initial discomfort from flatulence can be relieved by early ambulation, use of antiflatulence medications, chamomile tea, peppermint tea ▪ Stool softeners may be helpful Urinary System Swelling and bruising around the urethra Risk for overdistention (if unable to void 6-8 hours after delivery; catheterization should be considered) o Increased bladder capacity o Swelling bruising of tissue around urethra, decreased sensitivity to fluid pressure o Adequate bladder elimination is immediate concern o Urine stasis increases chance for urinary tract infection UTI o Full bladder may displace uterus, interfere with its contractility - > hemorrhage Urinary output increases (12-24 hours) Diuresis occurs the first 2-5 days after delivery to rid the body of extra fluid accumulated Vital Signs Woman should be afebrile; elevation of temperature within 24hrs to 100.4 could indicate dehydration  Blood pressure changes after childbirth o Significant decrease could indicate bleeding (will increase quickly first then decrease- pt may feel nauseated) o Significant increase could indicate postpartum hypertension o Orthostatic hypotension in the first 48 hours due to abdominal engorgement o May experience tremors resembling shivering immediately after birth (hormonal effect) Cardiovascular Cardiac system undergoes a decrease in blood volume Diuresis in first 2-5 days helps to decrease extracellular fluid, results in weight loss Average blood loss 500ml vaginal; 500-1000ml cesarean birth Assess for Homans sign (indication of DVT) due to elevated clotting factors o Homans sign: Homans sign: Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight has been a time-honored sign of DVT. However, Homans sign is neither sensitive nor specific; it is present in less than one-third of patients with confirmed DVT, and is found in more than 50% of patients without DVT. Ovulation and Menstruation Varies for each postpartum woman o Return is DIRECTLY associated with a RISE in the serum progesterone level Usually prolonged in breastfeeding mothers o Usually experience a delay in menstruation of at least 3 months o Use protection for intercourse; greater chance of getting pregnancy because of irregular menstruation o Use secondary form of birth control Ovulation generally returns as soon as 7-9 weeks Menstruation generally resumes by 12 weeks postpartum Breasts First 2-3 days soft and full 3rd day become firm and milk production begins Breast engorgement may occur o Hard o Erect o Very uncomfortable Non Breast feeding o Wear supportive bra o Do NOT stimulate breast o Shower with back to water Breastfeeding Optimal time to initiate feeding is within the first hour of birth Place newborn skin-to-skin with mother Feeding cues (pay attention to these) o Rooting; sucking motion o Hand to hand or hand to mouth movements  o Typically feed 30-40 minutes Effective breastfeeding o Breast will soften o Newborn will suck slower and appear content Benefits Client: o Promotion of weight loss o Reduced risks of breast/ovarian cancer o Convenience/minimal cost Newborn benefits from human milk: o Enhanced immunity o Maturation of the GI tract Reduced risk of: o Asthma o Otitis Media o Childhood obesity Effectiveness Alternate periods of wakefulness after feedings Feeds 8-12 times in 24 hrs. Latches easily and swallows audibly How you know you are feeding enough: o 6-8 wet diapers per day o At least 3 stools per day Breast Care Administer pain medication 1-2 hours prior to feedings (assure client prescribed medications will not harm the newborn) - Engorgement – distended, firm, tender breasts - Deeding every 2 hours - Do NOT skip feedings if breast/ nipples are sore, can cause engorgement - Alternate breast per feeding - Mastitis – unilateral infection of breast, red and painful after lactation is established If NOT breastfeeding - Encourage the client to wear a right fitting bra - Avoid stimulation of breasts Psychologic Adaptations Postpartum period: time of readjustment, adaptation for family, especially mother Mother experiences a variety of responses as adjusts to a new family member o postpartum discomforts o changes in body image o reality of no longer being pregnant First day or two after birth o Mother may seem passive, more concerned with own needs  o Food and sleep are priority needs By the second or third day o New mother ready to resume control of mothering, her body, life o May experience anxiety and need reassurance o Feeding difficulties may be a particular source of anxiety PP Weight & Nutrition Initial weight loss of 4.5–5.4 kg (10–12 lb) as a result of birth, the expulsion of the placenta, amniotic fluid Many women return to approximately prepregnant weight by 6–8 weeks postpartum (may be a lot longer – everyone different) Hemoglobin and erythrocyte levels should return to normal within 2–6 weeks Iron supplements usually continued for 2–3 months after childbirth Encourage high nutritious meals for the mother Nutritional Care Nutritional needs of mother increase during breastfeeding Especially important to consume sufficient calories o Inadequate caloric intake can reduce milk volume o Protein intake should increase Calcium requirements same as during pregnancy Liquids especially important during lactation Discussion of specific foods, breastfeeding Mother should avoid foods that seem to cause distress to baby Lifespan Considerations Prior to discharge: o Client with NEGATIVE blood type must receive Rhogam Postpartum adolescent Postpartum mothers over the age of 35 o May be better prepared for parenthood by life experiences, education o Older couples must be made aware that newborns will alter established routines, practices Nursing Process During the first several postpartum weeks, a woman must: o Restore the physical condition o Develop competence in caring for, and meeting the needs of the baby o Establish a relationship with the new child o Adapt to altered family lifestyles, the family structure resulting from the addition of a new member Teaching during postpartum is a continuous process during all interactions o Support, and encourage culturally related activities unless harmful o Consider mother’s physical, and psychosocial needs Deliver information a little at a time, repeated Use a variety of instructional methods, discharge classes Cultural Diversity Families may embrace practices involving rest, seclusion and dietary constraints Periods of seclusion that coincides with lochia flow or PP bleeding Hispanic culture o Female relatives often assist the new mother and baby o Include these relatives in teaching sessions o Cultural diversity material in native languages when possible o Cover head and feet of baby 113 Mod 4 Sudden Infant Death Syndrome NUR 113 Learning outcomes Describe the pathophysiology of SIDS  Summarize the risk factors of SIDS Discuss the methods regarding the prevention of SIDS Apply the nursing process in providing care for a family experiencing the loss of a child Sudden Infant Death Unknown cause / most prevalent Leading cause of death among infants between the ages of 1 and 12 months Accidental suffocation and strangulation in bed (ASSB) Many times, infants are found in their cribs; referred to as “crib death” No warning signs or early manifestations After death infant is found to have frothy blood-tinged secretions from mouth and names and evidence the infant struggled or changed positions Always will have an autopsy Pathophysiology SIDS is called a syndrome because no disease process is involved No confirmed causative factor May be associated with defects in the portion of an infant’s brain that controls breathing and arousal from sleep Diagnosed only after a review of child’s o Clinical history o Examination of the death scene o Unmarkable autopsy Risk Factors Preterm and low birth weight Gender: o More common in males Sleeping o Side lying position/ prone o Soft mattress  o Loose bedding o Toys stuffed animals Internal or environmental exposure (ex) o Tobacco smoke Overheating o Only wear a onesie – let baby get used to how we live. Do not adjust our environment a crazy amount. Let baby adjust. (same with noise) Bed Sharing o Can be a risk of rolling on baby or blankets covering baby ▪ Use a pack and play to make it easier for mama without it being a potential risk Prevention Recommendations for safe infant sleeping o ALWAYS sleep on their back until 1 year of age o Sleep in the same room but NOT in the bed with the parents o NO objects in the sleeping area o AVOID exposure to smoke o Dress the infant appropriately for the environment Safe to sleep image:  I sleep Safest – Alone, Back, Crib Nursing Care Show empathy and compassion to the family in the acute phase of grief Services offered should include: o Religious o Grief counseling o Assist with arrangements 113 Mod 4 Perinatal Loss NUR 113 Learning Outcomes  Discuss the grieving Process Differentiate the types of perinatal loss Describe the effect of perinatal loss on mothers, partners and siblings Discuss the guidance for self-care after hospital discharge Discuss the Nursing process in the care of the perinatal patient Definition Perinatal loss is most often defined as the involuntary end of pregnancy from Conception, during pregnancy, and up to 28 days of the newborn’s life. Lethal Condition Identified: o through advanced prenatal testing ▪ Example trisomy 18 ▪ Issues found during u/s (anatomy scan) o Circumstances in which fetal or newborn death is inevitable o Death will occur during labor, birth, or within a very short time following birth Diagnostic tests o Offer Blood test on fetus and placenta ▪ Send placenta to determine if cause can be found Cytotec given up to 400 mcg – give every 4 hours then the fetus will be expelled after. (usually 3rd dose the fetus will be expelled) Perinatal Loss Early loss o Spontaneous abortion/ miscarriage ▪ Chromosomal abnormalities Most common ▪ Loss during first 20 weeks gestation Late loss o Stillbirth (intrauterine Fetal demise) IUFD  ▪ Birth defects/chromosomal disorders ▪ Placental problems ▪ Chronic maternal hearth conditions Diabetes (before pregnancy and not taking care of herself) ▪ Loss after 20 weeks gestation Neonatal death o Loss occurring from birth through 28 days of life. https://youtu.be/Xt4EPmYVpXI?si=6IafWagU65ITxpYN The key to IUFD is therapeutic communication o Keep her away from others but do not isolate o Ask mama what mama needs ▪ Could be time ▪ Could be company ▪ Could be family support ▪ Epidural ▪ Religious members Grief and loss Emotions Experienced by women and men o Disappointment o Anger o Betrayal o Pain o shock o numbness Stages of grief are the same no matter what the cause.  Coping strategies Mother o May cry and want to talk o Often feel responsible o May ask “ what did I do wrong” Partner o Keep busy with their work ▪ Can be an excuse to no handle grief o Suppress emotions ▪ Can cause issues with no communication between partners  Siblings Encourage parents to include in the grieving process Recommended sibling meets their brother or sister o Studies show siblings who experience the death mourn with less traumatic results Encourage to create memories (take pictures holding infant) Should NOT force sibling to hold, touch or experience the death Let the sibling lead the encounter Culture/Religious Allows for the family to find meaning in the death Involves family members in rituals and Mourning Significantly aids family in their coping ** Remember there is diversity within every culture; not all families will follow the same procedures Nursing care Allow parents time to absorb the news Provide physical, psychosocial, and spiritual care Ensure privacy but not isolation Place in a room far away as possible from other mothers Answer questions and prepare parents for the next steps Request a chaplain if desired Take as much time as needed Ask mama/ dad if they have a support system at home - At CFVH – Leaf with a tear drop on door. Post-delivery  Encourage parental behaviors o Care for the infant o Funeral arrangements Provide memory box o Include footprints o Lock of hair Provide photographs if desired Self-care normal postpartum care o lochia o signs of infection Breast care o Encourage tight fitting bra o Cold packs May require antidepressants Provide resources for counseling