Postnatal Assessment Chapter 17 PDF

Acronym for Postpartal Assessment (BUBBLEHE) B: BREAST U: UTERUS/FUNDUS B: BLADDER B: BOWEL L: LOCHIA E: EPISIOTOMY/INCISION/HEMERRHOIDS H: HOMAN'S/DVT SYMPTOMS E: EMOTIONAL STATUS/BONDING - **BREAST** - Colostrum - Secreted from the breast during pregnancy ad 2 -- 3 day...

Acronym for Postpartal Assessment (BUBBLEHE) B: BREAST U: UTERUS/FUNDUS B: BLADDER B: BOWEL L: LOCHIA E: EPISIOTOMY/INCISION/HEMERRHOIDS H: HOMAN'S/DVT SYMPTOMS E: EMOTIONAL STATUS/BONDING - **BREAST** - Colostrum - Secreted from the breast during pregnancy ad 2 -- 3 days after birth. - Milk is produced about 72 -- 96 hr after birth - Assessment - Engorgement (fullness) - Result of lymphatic circulation, milk production, and temporary vein congestion. - Breast will appear tight, tender warm, and full. - Non-Breastfeeding moms. - Will resolve on its own. - Breast binders or support bras, ice packs, or cabbage leaves can be applied. - Breastfeeding moms - Breast care, frequent feedings will prevent or manage engorgement. - Observe for - Erythema, breast tenderness, cracked nipples, & indications of mastitis (infection in a milk duct of the breast (Flu-like manifestations)) - Determine the clients ability to assist the newborn with latching on. - Ineffective newborn feeding are related to: - Maternal dehydration, maternal discomfort, newborn positioning, or difficulty with newborn latching onto breast. - Patient Centered care: - Promote early breastfeeding within the first 1 to 2 hr after birth. - Encourage early breastfeeding to clients that want to breastfeed - This will stimulate production of natural oxytocin and help prevent uterine hemorrhage. - Traditional positions for breastfeeding: (can prevent nipple soreness.) - Football hold (under the arm) - Cradle - Across the lap (modified cradle) - Side-laying - Advise clients that do not want to breastfeed not to stimulate or express the breast. - **UTERUS/FUNDUS** - Involution - Contractions of the uterine smooth muscles - Uterus returns to its prepregnant state. (1000g to 60g -- 80g at 6 weeks. - Fundal height steadily descending into the pelvis 1 fingerbreadth (1 cm) per day. - Immediately following birth: - Fundus should be palpable firm at midline and about 2 cm below the umbilicus. - 1 hr following birth: - The fundus should ride to the level of the umbilicus - 12 hr following birth - The fundus can rise and be palpated at 1 cm above the umbilicus. - Every 24 hr: - Fundus should descend approximately 1 -- 2 cm. - Should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum. - After about 2 weeks - The uterus should lie within the true pelvis and should not be palpable. - Assessment: - Fundal height, uterine placement, & uterine consistency every 8 hr after the recovery period has ended. - Explain the procedure to the client - Position the client supine with their knees slightly flexed. - Apply clean gloved and lower the perineal pad. - Observe lochia flow as the fundus is palpated. - Never palpate the fundus without cupping the uterus. - Document fundal height, location, & uterine consistency: - Determine the fundal height by placing fingers on the abdomen and measuring how many fingerbreadths fit between the fundus and the umbilicus above, below, or at the umbilical level. - Determine whether the fundus is midline in the pelvis or displaced laterally (caused by a full bladder). - Determine whether the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion. - If the uterus does not firm after massaging, keep massaging and notify the provider. - Document the position and location of the uterus: - Above the umbilicus = +1, U+1, or 1/U - Below the umbilicus = -1, U-1, or U/1 - Patient Centered Care. - Administer oxytocics IM or IV after the placenta is delivered to promote uterine contractions and to prevent hemorrhage. - Oxytocics include oxytocin, methylergonovine, and carboprost. Misoprostol, a prostaglandin, also can be administered. - Monitor for adverse effects of medications. - Oxytocin and misoprostol can cause hypotension. - Methylergonovine, ergonovine, and carboprost can cause hypertension. - Encourage early breastfeeding for a client who is lactating. This will stimulate the production of natural oxytocin and prevent hemorrhage. - Encourage emptying of the bladder to prevent possible uterine displacement and atony. - **BLADDER** - Can show evidence if the following: - Urinary retention can cause: - Distended bladder - Infection. - Uterine atony and displacement to one side. - Uterus contraction is lessened. - Assessment: - Ability to void - Perineal/urethral edema can cause pain and difficulty voiding during first 24-48 hr - Bladder elimination - 3,000 mL/day is normal within the first 2 -- 3 days after birth. - Evidence of distended bladder. - Fundal height above the umbilicus or baseline level - Fundus displaced from the midline over to the side - Bladder bulges above the symphysis pubis - Excessive lochia - Tenderness over the bladder area. - Frequent voiding of less than 150 mL is indicative of urinary retention with overflow. - Patient centered care: - Assist the client to void within 6 to 8 hr afterbirth. If unable to void, catheterization can be required. - Encourage the client to empty their bladder frequently. - Measure the client\'s first few voidings after birth to assess for bladder emptying. - Encourage the client to increase their oral fluid intake to replace fluids lost at delivery and to prevent or correct dehydration. - Catheterize if necessary for bladder distention if the client is unable to void to ensure complete emptying of the bladder and allow uterine involution. - - **BOWEL** - **Assessment** - Assess the gastrointestinal system including bowel function. - Assess for reports of hunger. Expect the client to have a good appetite. - Assess for bowel sounds and the return of normal bowel function. Spontaneous bowel movement might not occur for 2 to 3 days after birth secondary to decreased intestinal muscle tone during labor and puerperium, prelabor diarrhea, dehydration, or medication adverse effects. - Assess for discomfort with defecation due to perineal tenderness, episiotomy, lacerations, or hemorrhoids. - Assess the rectal area for varicosities (hemorrhoids). - **Patient-Centered Care** - Encourage interventions to promote bowel function (early ambulation, increased fluids, and intake of high-fiber foods).  - Administer stool softeners (docusate sodium) to prevent constipation. - Enemas and suppositories are contraindicated for clients who have third- or fourth-degree perineal lacerations.  - Flatus is common after a cesarean birth. Encourage the client to ambulate or rock in a chair to promote passage of flatus, and to avoid gas-forming foods. Anti-flatulence medications can be required. - **LOCHIA** - 3 Stages of Lochia - Lochia rubra: - Dark red color, bloody consistency, fleshy odor. Can contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days after birth. - Lochia serosa: - Pinkish brown color and serosanguineous consistency. Can contain small clots and leukocytes. Lasts from approximately day 4 to day 10 afterbirth. - Lochia alba: - Yellowish white creamy color, fleshy odor. Can consist of mucus and leukocytes. Lasts from approximately 10 days to 6 weeks postpartum. - Assessment - Lochia amount is assessed by the quantity of saturation on the perineal pad as being - Scant: less than 2.5 cm - Light: 2.5 to 10 cm - Moderate: more than 10 cm - Heavy: one pad saturated within 2 hr - Excessive blood loss: - One pad saturated in 15 min or less, or pooling of blood under buttocks - Assess the lochia for normal color, amount, odor, and consistency. - Assess lochia frequently to determine the amount of bleeding. - Check at least every 15 min for the first hour after birth, then every 1 hr for the next 4 hr, and then every 4 to 8 hr depending on facility policy. - Lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. - Assess for pooled lochia on the pad under the client, which they might not feel. This can identify heavy bleeding, which can be unnoticed. - Massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has pooled in the vagina, but should soon decrease back to a trickle of bright red lochia when in the early puerperium. - Pads can be weighed to give a better estimation as to the extent of bleeding. - If a cesarean section was performed, the amount of bleeding will be decreased because the provider cleans out the uterus after surgery. - Patient-Centered Care - Manifestations of Abnormal Lochia - Excessive spurting of bright red blood from the vagina, possibly indicating a cervical or vaginal tear - Saturation of one pad in 15 min or less which can indicate hemorrhage - Foul odor, which is suggestive of infection - Persistent heavy lochia rubra in the early postpartum period beyond day 3, which can indicate retained placental fragments - Continued flow of lochia serosa or alba beyond the normal length of time can indicate endometritis, especially if it is accompanied by fever, pain, or abdominal tenderness. - Client Education - Change pads frequently. - Perform hand hygiene after perineal care and changing of soiled pads. - Do not use tampons due to the increased risk for infection. - **EPISIOTOMY/INCISION/HEMERRHOIDS** - Promote measures to help soften the client's stools. - Promote comfort measures. - Apply ice/cold packs to the perineum for the first 24 hr to reduce edema and provide anesthetic effect. Do not apply directly to the perineum. - Heat therapies (hot packs), moist heat, and sitz baths can be used to increase circulation and promote healing and comfort. - Encourage sitz baths at a hot or cool temperature for 20 min at least twice a day.  ​​​ - Administer analgesics, such as nonopioids (acetaminophen), nonsteroidal anti-inflammatories (ibuprofen), and opioids (codeine, hydrocodone) for pain and discomfort. - Opioid analgesia can be administered via a patient-controlled analgesia (PCA) pump after cesarean birth. Continuous epidural infusions can also be used for pain control after cesarean birth. - Apply topical anesthetics (benzocaine spray) to the client's perineal area as needed or witch hazel compresses or hemorrhoidal creams to the rectal area for hemorrhoids.  - Educate the client about proper cleansing to prevent infection. - **Client Education** - Wash both hands thoroughly before and after voiding. - Use a squeeze bottle filled with warm water or antiseptic solution after each voiding to cleanse the perineal area. - Blot the perineal area to clean it after toileting, starting from front to back (urethra to anus). - Use topical antiseptic cream or spray sparingly. - Change the perineal pad by removing the front part first, peeling it toward the back after voiding or defecating. - **HOMAN'S/DVT SYMPTOMS** - - **EMOTIONAL STATUS/BONDING** -