OB1 SAS 17 PDF

Care of Mother, Child and Adolescent (Well- Clients) STUDENT ACTIVITY SHEET...

Care of Mother, Child and Adolescent (Well- Clients) STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR Session # 17 Materials: LESSON TITLE: NURSING CARE OF A POSTPARTAL Book, pen, notebook and SAS FAMILY LEARNING OUTCOMES: At the end of the lesson, the student nurse can: Reference: 1. Describe the physiologic and psychological changes that occur in a postpartal woman and her family Pilliteri, Adele and Silbert-Flagg, JoAnne (2018) 2. Assess the physiologic and psychological condition of Maternal and Child Health Nursing, 8th Edition. a postpartal woman and her family USA: Lippincott Williams and Wilkins 3. Formulate a plan for the care of a postpartal woman and her family LESSON REVIEW/PREVIEW (5 minutes) MAIN LESSON (45 minutes) Please refer to Chapter 17: Nursing Care of a Postpartal Family p. 396 POSTPARTAL PERIOD/ PUERPERIUM POSTPARTAL PERIOD/ PUERPERIUM B. TAKING-HOLD PHASE ❖ Lat. Puer, “child,” and parere “to bring forth” ❖ 3rd to the 10th day ❖ 6-week period after childbirth ❖ less dependent, take a strong interest in the care ❖ retrogressive (involution of the uterus & of her child and make her own decisions but still vagina) and progressive (production of milk feels insecure about her mothering skills for lactation) ❖ give guidance and demonstrations on how to care ❖ FOURTH TRIMESTER OF PREGNANCY for her child C. LETTING-GO PHASE I. PSYCHOLOGICAL CHANGES OF THE POSTPARTAL ❖ 10 days to 6 weeks PERIOD ❖ woman redefines her new role & motherhood A. TAKING-IN PHASE functions are established ❖ 1st 2 to 3 days postpartum ❖ gives up her fantasized image of her child and ❖ passive and dependent accepts her child as a unique person ❖ preoccupied with her own needs ❖ wants to talk about her pregnancy, labor and birth ❖ Touches & explores her baby ❖ Encourage her to talk about the birth to help her integrate it into her life experience DEVELOPMENT OF PARENTAL LOVE & POSITIVE POSTPARTUM BLUES/BABY BLUES FAMILY RELATIONSHIPS 2nd, 3rd postpartal day or within the 1st 2 weeks ❖ En face position- looking directly at her mood swings, anger, tearfulness, feeling let-down, newborn’s face with direct eye contact anorexia, insomnia, overwhelming sadness, ❖ Engrossment- fathers staring at the NB for long feeling of inadequacy, mood lability periods of time related to hormonal changes (sudden decrease in 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 1 of 11  ❖ Complete rooming-in- mother and child are E/P), fatigue & psychological stress related to together 24h a day infant dependency ❖ Partial rooming-in- infant remains in the Anticipatory guidance, individualized support, woman’s room most of the time chance to verbalize are necessary ❖ Sibling preparation resolves spontaneously II. REPRODUCTIVE SYSTEM CHANGES A. The UTERUS ❖ 1st postpartal day,1 fingerbreadth below the ❖ 2 processes: umbilicus; on 2nd day, 2 fingerbreadths below the ❖ area where the placenta was implanted is sealed umbilicus, and so on. off to prevent bleeding and the ❖ By the 9th or 10th day, it can no longer be palpated ❖ uterus is reduced to its approximate ❖ A well-contracted uterus feels firm, like a pregestational size grapefruit in size & tenseness; if it is boggy (soft & flabby), it is not contracted INVOLUTION- reduction in size of the uterus after delivery to prepregnant size caused by uterine contractions that AFTERPAINS- uterine cramps similar to menstrual constrict or occlude underlying blood vessels cramps caused by intermittent uterine contractions after delivery; more painful in breastfeeding & multiparous ❖ Immediately after birth, the uterus weighs about women 1,000g; after a week, 50g; after involution is complete(6 weeks), 50g Factors that enhance involution ❖ Uncomplicated labor & delivery FUNDUS- the top portion of the uterus; an indicator of ❖ Breastfeeding involution ❖ Early ambulation ❖ after delivery, fundus is palpated halfway between ❖ Complete expulsion of placenta & membranes the umbilicus & symphysis pubis, at midline or ❖ Factors that slow involution slightly to the right. ❖ Prolonged labor & difficult delivery ❖ 1 hour after, fundus will rise to the level of the ❖ Anesthesia umbilicus & remain there for 24 hours. From then ❖ Grand multiparity on, it decreases 1 fingerbreadth per day (1 cm). ❖ Retained placental fragments ❖ Full urinary bladder ❖ Infection ❖ Overdistention of the uterus LOCHIA ❖ should not contain large clots ❖ Total volume is 240 to 270 ml, gradually decreasing daily; increased by exertion or breast-feeding ❖ Unexplained increase in amount or reappearance of lochia rubra is abnormal Type of Lochia Appearance Occurrence Composition Type 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 2 of 11 Lochia Rubra Dark red, bloody; fleshy, 1 to 3 days Blood, mucus, fragments of musty, stale odor that is decidua, epithelial cells, non-offensive; may have WBC’s, fetal meconium, tiny clots lanugo, vernix caseosa Lochia Serosa Pink or brownish; watery; 4 to 10 days Serum, RBC’s shreds of odorless decidua, WBC’s, cervical mucus, bacteria Lochia Alba Yellow to white; may have 11 to 21 days, my persist WBC’s. decidual cells, slightly stale odor for 6 weeks in lactating epithelial cells, fat cervical women mucus, cholesterol, bacteria B. The CERVIX C. The VAGINA ❖ Soft, irregular & edematous; may appear bruised ❖ The vagina is soft, edematous, with greater with multiple small lacerations diameter & multiple small lacerations ❖ Both internal & external os are open ❖ Low E levels postpartum lead to decreased ❖ By the end of 1 week, the external os has vaginal lubrication & vasocongestion for 6 to 10 narrowed to the size of a pencil opening (may weeks, which can result in painful intercourse admit 1 fingertip) and it will be firm once again ❖ KEGEL’s exercises will improve the strength & ❖ The internal os closes as before but the external tone of the vagina os remains slightly open and slit-like or stellate (star shaped) D. The PERINEUM III. SYSTEMIC CHANGES A. The ABDOMINAL WALL D. The CIRCULATORY SYSTEM ❖ Soft & flabby with decreased muscle tone ❖ Blood Volume returns to normal levels by within 2 ❖ DIASTASIS RECTI- may improve depending on weeks, eliminated by diuresis the physical condition, number of pregnancies, ❖ 1st 48 hours are the time of greatest risk for type & amount of exercise complications for clients with heart disease ❖ Bradycardia of 50 to 70 bpm is common in the 1st B. The HORMONAL SYSTEM 6 to 10 days; tachycardia is related to blood loss, ❖ hCG & HPL are almost negligible by 24 hours by temperature elevation or difficult, prolonged birth week 1, progestin, estrone & estradiol are at pre- ❖ Fibrinogen remains increased for 1 week pregnancy levels increasing the risk for thrombophlebitis ❖ FSH is low for about 12 days & will begin to rise ❖ WBC count is up to 30,000/mm3 especially if the and initiate a new menstrual cycle labor is prolonged or difficult; aids healing & ❖ Menstruation usually resumes in 7 to 9 weeks in prevents infection non-lactating women (90% in 12 weeks); 1st cycle ❖ Varicosities will recede but won’t disappear is usually anovulatory ❖ Hemoglobin returns to normal in 2 to 6 weeks ❖ Return of ovulation varies from 2 to 18 months E. The GASTROINTESTINAL SYSTEM C. The URINARY SYSTEM ❖ Hunger and thirst are common following birth ❖ On palpation, a full bladder is felt as a firm or hard ❖ Risk for constipation increases due to decreased area just above the symphysis pubis peristalsis, use of analgesics, dehydration, ❖ Postpartal diuresis/Diaphoresis of 2 to 3 L decreased mobility during labor, & fear of pain increases the output in the 1st 12 to 24 hours & from having a bowel movement accounts for a 5-pound weight loss ❖ Risk for hemorrhoids increases because of pushing during the 2nd stage of labor F. The INTEGUMENTARY SYSTEM ❖ Stretch marks will fade over the next 6 months ❖ Chloasma & linea nigra will become barely detectable in 6 weeks III. EFFECTS OF RETROGRESSIVE CHANGES ❖ Exhaustion due to pregnancy, labor & delivery ❖ Weight loss (19 lbs from delivery to the 5th day postpartum/ initially due to diuresis, influenced by breastfeeding, 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 3 of 11  exercise, nutrition IV. VITAL SIGN CHANGES Temperature Blood Pressure ❖ Slight increase during 1st 24 hours due to ❖ Assess for orthostatic hypotension dehydration; relieved by adequate fluid intake ❖ Monitor if woman has history of preeclampsia ❖ Any woman whose oral temperature rises above 100.4°F (38°C) excluding the 1st 24 hours is considered febrile Respirations ❖ Normal range is 16 to 24 breaths per minute Pulse ❖ Normal postpartal range is 50 to 80 bpm ❖ PR is usually slightly lower than normal & will return to normal levels at the end of the week ❖ A rapid & thready pulse indicates hemorrhage ❖ Pulse > 100 bpm should be reported to the healthcare provider V. PROGRESSIVE CHANGES LACTATION Advise to drink adequate fluids daily, eat a nutritious diet and consult the doctor before Lactation or formation of breastmilk begins in a ingesting alternative therapies and supplements postpartal woman whether or not she plans to as they may be found in breast milk breastfeed Breast milk forms in response to decrease in E/P levels following delivery of the placenta (which RETURN OF MENSTRUAL FLOW stimulates Prolactin release) With delivery of the placenta, E/P levels decrease leading to ovulation Nipple stimulation leads to release of OXYTOCIN from the pituitary gland; this stimulates the release Not breastfeeding- menstrual flow returns in 6 to of PROLACTIN from the pituitary gland which 8 weeks causes production of milk & the let-down reflex, release of milk by the contractions of the alveoli of Breastfeeding- menstrual flow returns in 3 to 4 the breasts mos (lactational amenorrhea) or in some, during the entire lactation period Primary engorgement- 3rd or 4th day as the supply of blood & lymph in the breast is increased She may ovulate before menstruation occurs & transitional milk is produced; fades as effective sucking and emptying begins NURSING CARE OF A WOMAN & FAMILY DURING THE 1ST 24 HOURS AFTER BIRTH POSTPARTUM ASSESSMENT General Considerations 1. Evaluate prenatal & intrapartal history for complications 2. Provide privacy & encourage client to void prior to assessment 3. Position client in bed with head flat for accurate findings 4. Proceed in a head-to-toe direction 5. Vital Signs 6. Monitor breath sounds & practice deep breathing & coughing exercises Assessment 5. EPISIOTOMY OR PERINEAL LACERATIONS 1. BREASTS Inspect the perineum for REEDA Determine if bottle feeding or breast feeding Episiotomy is usually 1 to 2 in long Palpate for engorgement or tenderness Inspect for hemorrhoids Inspect the nipples for redness, cracks & erectility if nursing 2. UTERUS 5. LOCHIA 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 4 of 11  Gently place the non-dominant hand on the lower Inspect type, quantity, odor & color uterine segment just above the symphysis pubis; the dominant hand palpates the fundus Correlate findings with expected characteristics of bleeding Palpation should not cause pain CS- delivered women may have less lochia Determine uterine firmness, height of the fundus, & ascertain the position of the fundus in relation to 6. HOMAN’S SIGN the midline of the abdomen Pain in the calf upon dorsiflexion of the foot is a positive sign & may indicate thrombophlebitis If the uterus is boggy, massage gently using a gently, rotating motion to induce contraction; Inspect for pedal edema, redness, or warmth; if administer oxytocin as ordered abnormal changes are present, assess pedal pulse The fundal location must descend 1 cm each postpartal day 7. EMOTIONAL STATUS Assess if the client’s emotions are appropriate for Inspect any abdominal incisions, CS delivery, or the situation tubal ligation, for REEDA: redness, edema, ecchymosis, discharge, and approximation of the Determine the client’s phase of postpartal skin edges psychological adjustment 3. BLADDER Assess for postpartum blues The client should void within 6 to 8 hours after delivery; catheterization may be necessary if 8. BONDING delayed & bladder is distended Describe how the parents interact with the infant Assess frequency, burning or urgency, which could indicate UTI Evaluate the ability to completely empty the bladder Palpate for bladder distention, if unable to vid or complete emptying is in question 4. BOWEL Assess for passage of flatus Inspect for signs of distention Auscultate for bowel sounds in all 4 quadrants for postoperative patients IMPLEMENTATION 1. PREVENT HEMORRHAGE 6. PROMOTE REST & GRADUAL RETURN TO Assess for risk factors ACTIVITY Organize nursing care to avoid frequent Keep bladder empty interruptions Gently massage fundus, if boggy; teach self- Plan maternal rest periods when baby is expected massage of uterus to sleep Administer OXYTOCIC medications if ordered; Teach woman to resume activity gradually over 4 oxytocin (Pitocin), methylergonovine maleate to 5 weeks; avoid lifting, stair-climbing & (Methergine), ergonovine maleate (Ergotrate) strenuous activity Monitor for side effects of oxytocics; Simple postpartal exercises may be started: hypotension with rapid IV bolus of Pitocin, Kegel’s exercises, raising the chin to the chest, hypertension with Methergine & Ergotrate 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 5 of 11  knee rolls, buttocks lifts 2. PROVIDE COMFORT Apply ice to perineum for 20 mins on/10 mins off Increases lochia indicates overexertion; modify for 1st 24 hours exercise plan Encourage Sitz bath, warm or cool, TID & PRN 7. PROMOTE ADEQUATE NUTRITIONAL INTAKE after the 1st 12 to 24 hours Add 500 kcal/day to pre-pregnancy diet; bottle-feeding mothers should return to pre-pregnancy diet Teach client perineal care after every elimination Fluid intake of 2 liters/day Teach client to tighten buttocks, then sit and relax muscles Continue prenatal vitamins & iron; iron is best absorbed in the presence of Vitamin C & may increase constipation Apply topical anesthetics or witch hazel compresses 8. PROMOTE PSYCHOLOGICAL WELL-BEING Monitor for side effects of morphine epidural: late- Encourage & support expression of feelings, onset respiratory depression ( 8 to 12 hours), N/V, positive & negative, without guilt itching, urinary retention, and somnolence Encourage client to recount birth experience to be able to integrate expectations & fantasies with 3. PROMOTE BOWEL ELIMINATION reality Encourage early & frequent ambulation Provide recognition & praise for self- & infant-care Encourage increased fluids & fiber activities Administer stool softeners; suppositories are 9. PROMOTE FAMILY WELL-BEING contraindicated is client has a 3rd- or 4th-degree Encourage rooming-in, presence of family perineal laceration involving the rectum members & their participation Teach client to avoid straining; normal bowel Advise resumption of sexual activities after patterns return in 2 to 3 weeks episiotomy has healed & lochia has stopped, about 3 weeks after delivery 4. URINARY ELIMINATION Encourage voiding every 2 to 3 hrs even if no Counsel the couple regarding contraception urge is felt before discharge Catheterize, as ordered, for urinary retention; 10. PROMOTE MATERNAL SAFETY Foley catheter for 12 to 24 hours after CS Give RhoGAM or RhIg to Rh (-) mom not sensitized (- indirect Coomb’s test) 5. PROMOTE SUCCESSFUL INFANT FEEDING PATTERN Give rubella vaccine if titer is < 1:8 (0.5 ml SC) and advise to avoid pregnancy for at least 3 months Suppression of lactation & bottle feeding Teach postpartum warning signs to be reported: -utilize snug bra or breast binder continuously for 5 to 7 days preventing engorgement -bright red bleeding saturating > 1 pad/hr or passing of large clots -avoid heat & stimulation of breasts -temp > 100.4°F, chills, excessive pain, reddened or warm -apply ice packs for 20 min qid, if engorgement occurs areas of the breast, reddened or gaping episiotomy, foul- smelling lochia -encourage demand feedings q 3 to 4 hours, awakening during the day & allowing to sleep at night -inability to urinate; burning, frequency, or urgency Establishment of lactation & successful breast- feeding -calf pain, tenderness, redness or swelling -utilize well-fitting bra for support 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 6 of 11  -teach breast care including no use of soap & air-drying nipples after feedings -encourage nursing on demand q 2 to 3 hours, awakening during the day 7 allowing to sleep at night -advise mother to nurse 10 to 15 min on 1st breast until the baby lets go of the 2nd; alternate the breast used first & rotate positions -suggest football hold or side-lying position for moms with CS or tubal ligation to avoid discomfort -provide help with positioning, latching-on, & breaking suction when done nursing Caselet: You are a nurse in SWU-Med Hospital. You are tasked to assess Rosario, 1 day postpartum, G1P1. She asked you what are the possible changes she might experience physically? What is the best response? 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 7 of 11 CHECK FOR UNDERSTANDING (25 minutes) You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. Multiple Choice 1. A woman delivered a newborn 12 hours ago. Which of the following assessment would the nurse expect to find? A. Lochia alba B. Soft, boggy fundus C. Transient tachycardia D. Complaints of hunger ANSWER: RATIO: 2. Lochia serosa is characterized by which of the following? A. Creamy yellow color B. No odor C. Serosanguinous appearance D. White to colorless ANSWER: RATIO: 3. During lecture of a childbirth class, the nurse explains that in the postpartum period the process whereby the uterus returns to its pre-pregnancy state is called: A. Involution B. Puerperium C. Uterine atony D. Lochia rubra ANSWER: RATIO: 4. The labor and delivery experience is frequently reviewed by the mother. During which of the following periods according to Reva Rubin, is this commonly done? A. Letting-down B. Letting go 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 8 of 11  C. Taking hold D. Taking in ANSWER: RATIO: 5. Nurse Mara is aware that periodic contraction and relaxation of the uterine muscles cause pains and cramping after birth. Which of the following patients is more likely to experience severe pain after giving birth? A. A gravida 1 para 1001 patient who is bottle feeding B. A gravida 3 para 2002 patient who is breastfeeding C. A gravida 3 para 1102 patient who is bottle feeding D. A gravida 2 para 1001 patient who is breastfeeding ANSWER: RATIO: 6. The nurse is assessing a patient in the fourth stage of labor. She notes that the fundus is firm, globular and located midline of the abdomen. But she assessed that bleeding is excessive. Which of the following is the most appropriate initial nursing action? A. Massage the fundus B. Place the patient in Trendelenburg position C. Notify the physician D. Document the findings ANSWER: RATIO: 7. The nurse is assessing a patient in the immediate postpartum period for signs of hemorrhage. Which of the following assessment findings indicates an early sign of excessive blood loss? A. An increase in pulse rate from 78 to 106 bpm B. A blood pressure change from128/88 to 118/80 mm Hg. C. A body temperature of 37.4C D. A respiratory rate of 24/min. ANSWER: RATIO: 8. Which of the following 1-day postpartum patients should be given the highest priority by the nurse? A. The patient with bright red lochia with blood clots greater than 1 cm. B. The patient who complains of afterpains C. The client with a pulse rate of 62 bpm D. the patient with colostrum discharge from both breasts. ANSWER: RATIO: 9. The nurse is providing postpartum instructions to a patient after delivery of a healthy newborn. Which of the following instructions should be given by the nurse to the patient? A. Breasts become distended with milk on the third day. 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 9 of 11  B. Normal bowel elimination returns by the 4th or 5th day C. Temperature may be elevated after 2 days. D. Pulse rate of 96 to 110 bpm is normal during the first week. E. Depressed feelings for the first 4 weeks is to be expected. ANSWER: RATIO: 10. The nurse is assessing Homan’s sign on a postpartum patient. Which statement of the student indicates an understanding of this assessment technique? A. “I will ask the patient to raise her extended leg and lower her legs slowly.” B. “I will ask the patient to extend her legs flat on bed and dorsiflex her foot forward.” C. “I will ask the patient to extend her legs flat on bed and sharply extend her foot backward. ” D. “I will ask the patient to raise her legs against pressure from my hand.” ANSWER: RATIO: RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION) The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves. Write the correct answer and correct/additional ratio in the space provided. 1. ANSWER: RATIO: 2. ANSWER: RATIO: 3. ANSWER: RATIO: 4. ANSWER: RATIO: 5. ANSWER: RATIO: 6. ANSWER: RATIO: 7. ANSWER: RATIO: 8. ANSWER: RATIO: 9. ANSWER: 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 10 of 11  RATIO: 10. ANSWER: RATIO: LESSON WRAP-UP (5 minutes) You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you track how much work you have accomplished and how much work there is left to do. You are done with the session! Let’s track your progress. Period 1 Period 2 Period 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 AL STRATEGY: CAT: Student Response Cards 1. The instructor will give you response card and will explain the choices that was included with the card. 2. The Instructor will give a question to the class regarding information just covered in your lesson. 3. Hold up your card with the corresponding answer to the instructor’s question. For the next session: Kindly refer to Chapter 18: Nursing Care of a Family with a Newborn p. 425 10 This document and the information thereon is the property of PHINMA Education (Department of Nursing) 11 of 11