Care of Mother, Child, Adolescent (PDF)

CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 1: NURSING CARE OF A POSTPARTAL FAMILY POSTPARTUM OR PUERPERIUM Mother feels less important and abandoned. Period of 6 wks after delivery during...

CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 1: NURSING CARE OF A POSTPARTAL FAMILY POSTPARTUM OR PUERPERIUM Mother feels less important and abandoned. Period of 6 wks after delivery during which the reproductive o The baby becomes everyone’s chief interest. system and the body returns to normal. The father may express the same feeling. o Immediate – 1st 24 hrs o Bec. mother spends more time with their infant. o Early – 1st week DISAPPOINTMENT o Late – 2nd to 6th week All during pregnancy, they pictured a chubby-cheeked, curly- 4th Trimester of Pregnancy haired, smiling girl or boy. It is a time of maternal changes that are both retrogressive They may have instead a thinner baby, without any hair, who (involution of the uterus and vagina) and progressive seems to cry constantly, or may have a congenital condition. (production of milk for lactation, restoration of the normal This can make it difficult to feel positive immediately toward a menstrual cycle, and beginning of a parenting role). child who does not meet their expectations. PSYCHOLOGICAL CHANGES OF THE POSTPARTAL PERIOD You can never change the sex, size, or look of a child, but in the The new mother must move from dependent to independent short time you care for a postpartal family, it is possible for a in a short time. key person such as a nurse to tip a scale toward acceptance or REVA RUBINS THREE STAGES OF THE POSTPARTUM (PUERPERIUM) at least help a person involved to take a clearer look at his or 1. Taking in her situation and begin to cope with the new circumstances. 2. Taking hold o Handle the child warmly, to show you find the infant 3. Letting go (taking over) satisfactory or even special. 1. TAKING IN PHASE o Comment on the child’s good points, such as long fingers, lovely eyes, and healthy appetite. Focused on self (not infant) Dependent on others for help in care POSTPARTAL BLUES Needs assistance During the postpartal period, as many as 50% of women Decision-making difficult experience some feelings of overwhelming sadness or “baby Comfort-rest-food needs paramount blues” (Baselice & Lawson, 2012). Relives delivery experience o They may burst into tears easily or feel let down and Usually occurs 2 – 3 days PP irritable. This phenomenon may be caused by hormonal changes, 2. TAKING HOLD PHASE particularly the decrease in estrogen and progesterone that Moving from dependence to independence occurred with delivery of the placenta. Energy level Described as overwhelming sadness that occurs in most Focus on infant women during the first week or two after birth. Self-care, focus on bowels, bladder, breastfeeding May be manifested by mood swings, anger, weepiness, Responds to instruction, praise anorexia, difficulty sleeping, and a feeling of letdown. Lasts from 3rd day to 2 weeks PP Hormonal changes and psychological adjustments are thought 3. LETTING GO PHASE to be the main causes. Giving up previous role (role transition) Reduction of progesterone, delayed prolactin release and See self as separate from infant changes in other placental hormones may trigger emotional Give up fantasy delivery and baby instability. Readjustment of relationships necessary Body image changes and dependency needs may contribute. From 2wk → Overconcern re: infant and self, and emotional lability are She gives up the fantasized image of her child and accepts the “normal” during the first 5-10 days after delivery real one. Usually resolve naturally in 2 to 3 weeks with support and She gives up her old role of being childless or the mother of reassurance. If symptoms persist, the client should be only one or two (or however many children she had before this evaluated for postpartum depression. birth). Severe psychosis also can occur in women during this time This process requires some grief work and readjustment of (Heron, Gilbert, Dolman, et al., 2012). relationships, similar to what occurred during pregnancy. If a mother appears to have a level of depression that is beyond baby blues and/or has a history of previous postpartal MATERNAL CONCERNS AND FEELINGS depression (PPD), closer observation and referral is indicated ABANDONMENT immediately. Examination of these competitive feelings can help a couple Breastfeeding has been shown to help elevate baby blues and realize that parenthood involves some compromise in favor of counteract the effects of the hormonal drop that occurs after the baby’s interests. childbirth. Making infant care a shared responsibility can help alleviate For some women, it may be a response to dependence and these feelings and make both partners feel equally involved in low self-esteem caused by exhaustion, being away from home, the baby’s care. physical discomfort, and the tension engendered by assuming a o You can help parents or partners move past this new role, especially if a woman is not receiving support from competitive stage by pointing out positive parenting her partner. behaviors, positive self-care behaviors, and the warm In addition to crying, the syndrome is evidenced by feelings of infant response to their behaviors. inadequacy, mood lability, anorexia, and sleep disturbance. LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 1: NURSING CARE OF A POSTPARTAL FAMILY Anticipatory guidance and individualized support from 2) Factors that delay uterine involution: healthcare personnel are important to help the parents 1) Over distention of uterus from hydramnios and multiple understand that this unexpected response is normal. fetuses. Be certain support persons also receive assurance of this type, 2) Use of analgesia during labor or they can think the woman is unhappy with them or the new 3) Exhaustion due to prolonged & difficult labor. baby or is keeping some terrible news about the baby secret. 4) Multiparity Give the woman a chance to verbalize her feelings and make PROGRESSIVE REDUCTION IN UTERINE WEIGHT as many decisions as she wants to help her gain a sense of Right after delivery: 1,000 g control and move past this strange postpartal emotion. 1 week after delivery: 500 g Women are at greater risk (19% to 48%) for moderate to 2 weeks after delivery: 300 g severe depression after childbirth requiring formal counseling, 6 weeks after delivery: 50 g especially if they are economically stressed or have a comorbid condition such as diabetes (Farr, Dietz, Williams, et al., 2011). UTERINE CONTRACTION Uterine contraction begins immediately after placental POSTPARTUM DEPRESSION delivery. Rejection of infant, or fears that she may harm infant, call for Within a few minutes after birth immediate intervention. o The fundus of the uterus is palpable through the Remind mom during postpartum teaching that these feelings abdominal wall, halfway between the umbilicus and the sometimes occur and help is available. symphysis pubis. Interest in surroundings One hour later Interest in food o It will rise to the level of the umbilicus, where it remains Unable to feel pleasure for approximately the next 24 hours. Fatigue From then on, it decreases by one fingerbreadth, or 1 cm, per Sleep disturbance day; Panic attacks o For example, on the first postpartal day, it will be palpable Obsessive thinking 1 cm below the umbilicus. Hygiene By the 9th or 10th day Ability to concentrate o Can no longer be detected by abdominal palpation Odd food cravings Irritability Rejection of infant PHYSIOLOGIC CHANGES RETROGRESSIVE CHANGES Include those physiologic changes related specifically to the reproductive system as well as other systemic changes THE UTERUS TWO (2) PROCESSES OF INVOLUTION OF THE UTERUS 1) The area where the placenta was implanted is sealed off to prevent bleeding. - Is accomplished by rapid contraction of the uterus immediately after delivery of the placenta. FUNDUS - With time, thrombi form within the uterine sinuses and Palpate the uterus and assess for: permanently seal the area 1) Firmness 2) The organ is reduced to its approximate pregestational size. 2) Position Estrogen & progesterone 3) Height Empty the bladder first. Atrophy of myometrial cells NURSING CARE R/T UTERINE CHANGES Palpate fundus at frequent intervals Decrease in uterine size & weight o q. 15” X 1hr INVOLUTION o q. 1hr X 2 Reproductive organs return to their non-pregnant state. o q. 2hr X 2 Woman is in danger of hemorrhage until involution is complete o q. 4 hrs up to 24-48 hrs. post delivery (6 weeks). Massage if not firm Healing of placental site. Deviation to the sides and above umb. may signal full bladder FACTORS THAT PROMOTE UTERINE INVOLUTION Occasionally, the fundus can be felt slightly to the right 1) Breastfeeding o Because the bulk of the sigmoid colon forced it to that - Release of oxytocin stimulates uterine contractions. side during pregnancy and it tends to remain in that position. LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 1: NURSING CARE OF A POSTPARTAL FAMILY Assess fundal height shortly after a woman has emptied her CERVIX bladder for most accurate results. Soft, edematous and relaxed o Because a full bladder can keep the uterus from By end of 7 days, external os has narrowed to size of a pencil contracting, pushing it upward and increasing the risk of opening, appears slit-like, feels firm and non-gravid. excess bleeding. AFTERPAINS Strong uterine contractions that cause uncomfortable cramps. Uterine contractions prevent bleeding. Present 2 – 3 days after childbirth. NURSING MEASURES TO RELIEVE AFTERPAINS 1) Explain the cause & purpose of afterpains VAGINA 2) Keep bladder empty Right after childbirth, vagina is smooth & swollen 3) Instruct woman to assume PRONE POSITION. Lacerations and episiotomy are usually healed after 2 weeks. 4) NEVER APPLY HEAT on abdomen After 3 – 4 weeks, rugae reappear, but not as numerous as - Relaxes uterus leading to hemorrhage before pregnancy. 5) Administer analgesics as ordered (NO ASPIRIN). Returns to prepregnant condition after 6 – 8 weeks. CRAMPING OR “AFTERPAINS” Kegel exercise helps improve circulation to reduce edema and hasten return of vaginal muscle tone. Primiparas o Uterus tonically contracted unless clots or tissue remain in PERINEUM uterus. Swollen, ecchymosis from ruptured capillaries, painful Multipara immediately after delivery. o Uterus contracts and relaxes at intervals causing Perineal muscle tone is regained by 6 weeks. “afterpains”. Instruct woman on the following: o Afterpains tend to be noticed most by multiparas than by 1) Perineal care primiparas and by women who have given birth to large 2) Perineal hygiene babies or multiple births. EVALUATE EPISIOTOMY OR PERINEAL LAC. FOR REEDA More severe when breastfeeding in both primiparas and Redness multiparas. Edema LOCHIA Ecchymosis Uterine discharge after delivery consisting of blood, fragments Drainage of decidua, white blood cells, mucus, and some bacteria Approximation 1) LOCHIA RUBRA PERINEUM - From delivery up to 3rd day. PERINEAL CARE - Bright red and may contain small clots. - Consists of blood, fragments of decidua, and mucus 1) Ice packs - Applied on the perineum for the 1st 24 hrs. for 20 min. 2) LOCHIA SEROSA 2) Sitz Bath - 4th to 10th day - Done after 24 hrs. following delivery to promote - Pinkish to brownish in color circulation by vasodilation. - Consists of blood, mucus, and invading leukocytes - Done 3 – 4x/day for 20 min. 3) LOCHIA ALBA 3) Perilite exposure - 10–14 day (may last 6 weeks pp) - Place woman in dorsal recumbent position, drape thighs, - White or Cream to yellowish in color and place lamp between legs. - Largely mucus; leukocyte count high - Use 25 – 40 watt bulb - Lamp should be 12 – 18 inches away from the perineum. - Use perineal heat lamp for 20 min., 3x/day. PROGRESSIVE CHANGES THE HORMONAL SYSTEM Pregnancy hormones decrease with delivery of placenta. Levels of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) are almost negligible by 24 hours. By week 1, progestin, and estrogen (estradiol) are all at prepregnancy levels (estriol may take an additional week before it reaches prepregnancy levels). 4 MAJOR NATURALLY OCCURRING ESTROGENS: 1) Estrone (E1) 2) Estradiol (E2) - Predominant and most potent estrogen during reproductive years. LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 1: NURSING CARE OF A POSTPARTAL FAMILY 3) Estriol (E3) o Milk ducts become distended & fluid turns bluish-white - During pregnancy is synthesized by the placenta in Infant suckling on breast produces more prolactin, which in very high quantities. turn stimulates more milk production. 4) Estetrol (E4) Finally, oxytocin released > delivery of placenta causing Follicle-stimulating hormone (FSH) remains low for about 12 mammary glands to send milk to nipples [let down reflex]. days and then begins to rise as a new menstrual cycle is Progesterone, estrogen levels drop after delivery which leads initiated. to milk production. Menses resumes by 6 - 10 wks. if not Br. Fdg. THE URINARY SYSTEM MENSTRUATION & OVULATION During preg., 2,000-3,000 ml. of fluid accumulates in body – Woman who is NOT BREASTFEEDING: Client loses 5- 10 lbs. of weight in 1st wk. PP. o Menstrual flow return 6 – 10 weeks after birth, and o Extensive diaphoresis (excessive sweating) and diuresis ovulate by 8 – 10 weeks after delivery. (excess urine production) begin almost immediately after A woman who BREASTFEEDS CONSISTENTLY, and uses no birth to rid the body of this fluid. supplemental feeding This easily increases the daily urine output of a postpartal o Menstruation and ovulation may return in 6 months woman from a normal level of 1,500 ml to as much as 3,000 (Lactational amenorrhea) ml/day during the second to fifth day after birth. LACTATION This marked increase in urine production causes the bladder Estrogen & progesterone to fill rapidly. Decreased woman’s ability to sense when she has to void Stimulates prolactin production o Because during a vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it Milk production passes on the bladder’s underside, this may leave the bladder with a transient loss of tone that, together with Breast engorgement the edema surrounding the urethra. SUPPRESSION OF LACTATION A woman who has had epidural anesthesia can feel no sensation in the bladder area until the anesthetic has worn off. Avoid breast stimulation Ice THE CIRCULATORY SYSTEM Tight bra Blood volume 30 – 50% in pregnancy. Do not pump or express milk With diuresis & blood loss @ delivery, blood volume returns to Hormonal suppression (rarely) normal in 1-2 wks. Blood loss for NSVD = 300 – 500 cc. LACTATION & BREASTFEEDING C/S = 500 – 1,000 cc. Lactation starts regardless if pt. is breastfeeding or not. Non pregnant: Entirely up to mother o HCT = 37 – 47 % Must feel comfortable doing so. o HGB = 12 – 16 g/dL ADVANTAGES OF BREAST FEEDING Pregnant: Promotes bonding between mother & baby. o HCT = 32 – 42 % High nutritional value for infant. o HGB = 11.5 – 14 g/dL Promotes uterine involution through release of oxytocin from HCT drops by 4 % & HGB drops by 1 g. for every 250cc. of posterior pituitary. blood client loses. Reduces cost of feeding & preparation time. Patient should not be anemic entering delivery CONTRAINDICATIONS TO BREAST FEEDING Possible blood transfusion with large blood loss. Mother receiving meds not appropriate for Breast fdg. Average blood volume: [Lithium] o Pre-pregnant = 4000cc; Exposure to radioactive compounds [thyroid testing]; o Pregnant state = 5250cc. o Pump & dump breast milk x 48 hrs. Blood volume during pregnancy: o Flush in toilet. o Provides adequate exchange of nutrients in placenta & Breast Cancer; HIV compensates for blood loss during delivery. HR remains x 24-48 hrs. PP PHYSIOLOGY OF LACTATION With diuresis, HCT levels rise Early pregnancy, estrogen (placenta) stimulates growth of o [ hemoconcentration] reach pre-preg level by 6 wks. milk glands & size of breasts. Plasma fibrinogen Colostrum: middle of pregnancy & day 1-3 PP, o 50% during pregnancy & remains elevated 6 wks. PP. Thin, watery pre-lactation secretion. Rich in antibodies; passes [ estrogen levels] to baby in 1-3 days. o Can cause thrombus formation. Breasts begin to get tender; fill up w. milk. ▪ Assess pts. legs/calves for s/s thrombophlebitis Breast milk by 3rd to 4th day in response to: (Homan’s sign) o Falling levels of estrogen & progesterone > delivery of Rise in leukocytes placenta. o WBC protective measure to prepare for stress of o Production of prolactin by anterior pituitary delivery. As high as 20-25,000. LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 1: NURSING CARE OF A POSTPARTAL FAMILY THE GASTROINTESTINAL SYSTEM OTHER CHANGES NSVD: bowels sounds. EXHAUSTION o Eat right away. Common C/S: bowel sounds hypoactive 1st 8 hrs. Frequent rest periods o Epidural/spinal: po clear liquid after delivery, advance RN coordinates nursing care & infant feeding times diet if +BS. Provide maximum rest time. General anesthesia: usually NPO for 6-8 hrs. AVERAGE WEIGHT LOSS BM - difficult/painful d/t lacerations/hemorrhoids. 12 lb. [infant & placenta] C/S - BM 3rd - 4th day. 5 lbs. - diuresis & diaphoresis in wk. that follows. o GI activity slowed d/t surgery. Lochial flow - 2-3 lbs. Can go home without BM if + flatus. Total = approx. 19-20 lbs. {depends on total wt. gain} THE INTEGUMENTARY SYSTEM At 6 wks. wt. may still be above pre-preg. weight. Stretch marks RETURN OF MENSES [striae gravidarum] appear reddened on abdomen. After delivery, FSH levels rise causing ovulation o Fade by 3-6 months; o Pearly white marks may remain in lighter skinned pts. & No Breast Fdg.- menses resumes ~ 6 wks. darker marks in darker skinned pts. Lactation delays menses for several months (6 mos) Modified sit-ups strengthen abdomen NURSING MANAGEMENT OF POST PARTUM CLIENT VITAL SIGNS PP ASSESSMENT TEMPERATURE: SLIGHTLY ↑ Vital signs Emotional Status o Dehydration during labor 1st 24 hrs. o Returns to normal within 24 hrs. Breasts T = 100.4 (38°C) or > PP infection suspected. Fundus, lochia, & perineum Temp. also rises 3rd - 4th day with filling of breast milk (breast Voiding & bowel function - flatus, BM engorgement) Legs [+ Homan’s sign, ankle edema] Observe for s/s infection - nurse usually 1st to detect ↑ temp. S/S complications [PP hemorrhage, infection, ↑ BP ] [universal sign of infection 100.4 x 2 readings, on days 2-10 PP] NURSING CARE PULSE: HR ↑ SLIGHTLY X 1ST HR. SAFETY Stroke volume (vol. of blood pumped from the left ventricle per Prevent hemorrhage – massage uterus on admission and q 4 beat) & cardiac output also x 1st hr. then decreases for first 8 hrs. 8-10 wks., returns to pre-pregnant state. Prevent falls – assess when getting out of bed for 1st 8 hrs. Rapid, thready pulse: Assist when necessary. o Sign of PP hemorrhage, infection Check labs for low Hct & Hgb. BLOOD PRESSURE - MONITOR CAREFULLY BOWEL FUNCTION (1-3 DAYS TO RESUME) 1st trimester Stool softeners, as ordered o Heart works faster to handle volume. BP remains same. Encourage ambulation 2nd trimester Increase dietary fiber o BP drops slightly d/t lowered peripheral resistance in Provide adequate fluid intake blood vessels as placenta expands rapidly. HEALTH TEACHING & DISCHARGE PLANNING o Heart beats faster more efficiently d/t blood volume. Reinforce self-care – hand washing, perineal care, Self-breast o Pre-pregnant BP 120/80. Pregnant BP 114/65. exam q month; S/S PP Depression 3rd trimester o BP is back to pre-pregnant value. COMFORT MEASURES Ice, Sitz Baths, Topical Anesthetics BP COMPLICATIONS Analgesia, Kegels for NSVD; modified sit-ups for NSVD (10th – BP 12th day PP), Breast Care o [90/60 or less] with dizziness is “Orthostatic hypotension”; could signify hemorrhage. o Take BP/pulse lying/sitting/standing. Compare values. o Orthostatic: If BP drops 15-20 mmHg and pulse increases 20 bpm or more. Caution for falls. BP o [140/90 or >] could signify PP pre-eclampsia. o Notify physician. Could develop into serious complication. o Oxytocic meds [Pitocin] rapid delivery could BP LAMAGON | BSN 2A