Postpartum Student PDF

Chapter 9 Nursing Care and Assessment After Birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Class Objectives 1. Describe how to individualize postpartum and newborn nursing care for different patients. 2....

Chapter 9 Nursing Care and Assessment After Birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. Class Objectives 1. Describe how to individualize postpartum and newborn nursing care for different patients. 2. Describe specific cultural beliefs that the nurse may encounter when providing postpartum and newborn care. 3. Describe postpartum changes in maternal systems and the nursing care associated with those changes. 4. Modify nursing assessments and interventions for the person who has a cesarean birth. 5. Explain the emotional needs of postpartum people and their families. Elsevier items and derived items © 2015, 2011, 2007, 2006 by 2 Saunders, an imprint of Elsevier Inc. Puerperium (p. 216)  Known as postpartum period  Six weeks following childbirth  Sometimes referred to as the fourth trimester of pregnancy Elsevier items and derived items © 2015, 2011, 2007, 2006 by 3 Saunders, an imprint of Elsevier Inc. Nursing Considerations for Specific Groups of Patients  Adolescents – need help learning parenting skills, peer groups are important, lack finances, lack family support in some cases connect with SW  Lone parents – support system, SW, less time on mat leave due to finances  Families who live with poverty - social services referral Elsevier items and derived items © 2015, 2011, 2007, 2006 by 4 Saunders, an imprint of Elsevier Inc. Nursing Considerations for Specific Groups of Patients  Homelessness – support system, SW, social services to connect with housing, outreach programs, shelters – important to confirm place to go and follow up care for mother and baby  LGBTQ2+ families – support, resources available in community if needed  Families who have twins (multiples) – maybe have medical needs, one may be at different hospital – delays bonding with baby, support system Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, 5 an imprint of Elsevier Inc. Cultural Influences on Postpartum Care  Communication  Use an interpreter where appropriate  Should not be a family member or in cultural/religious conflict with the patient/family  Providing written material in correct language  Dietary practices – be aware certain cultures may adhere to a specific diet after giving birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by 6 Saunders, an imprint of Elsevier Inc. Postpartum Changes  Immediately after birth, the birthing person experiences multiple physiological and psychological changes.  It is important for the nurse to assess all body systems and not just focus on the reproductive system changes.  Specific postpartum assessment: BUBBLLEE Copyright © 2020 by Elsevier, Inc. All Rights Reserved. BUBBLLEE – Table 9.1 Pg 218  Breasts – observe redness, tender, sore nipples, fullness  Uterus – bladder distention if fundus is not midline  Bladder – burning or pain on urination  Bowel – bowel sounds present, hemorrhoids, constipation  Lochia – clots, heavy blood loss  Legs (swelling) – pain may indicate VTE – Venus Thromboembolism  Episiotomy/Laceration/Incision – REEDA – Redness, edema, ecchymosis, drainage, approximation  Emotions – blues, bonding Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Clinical Assessment  Vital signs  Blood pressure  Pulse  Respiratory rate  Temperature Abnormalities may be consistent with comorbidities, pain, pre-eclampsia, shock, infection © 2002 Delmar, a Thomson Learning company 9 Reproductive System Uterus Cervix Involution Vagina Uterine lining Stress importance of Descent of uterine discussing with health fundus care provider when to Afterpains resume vaginal intercourse postpartum Lochia Breasts Rubra Engorgement Serosa Nursing care Alba Elsevier items and derived items © 2015, 2011, 2007, 2006 by 10 Saunders, an imprint of Elsevier Inc. Reproductive System Uterus Involution – changes after birth to return to prepregnancy size and condition. Rapid reduction in size and weight. Returns to to prepregnant state after 6 weeks called subinvolution Uterine lining – “endometrium” when not pregnant and “decidua” during pregnancy is shed when the placenta detaches, a basal layer of the lining remains to generate new endometrium to prepare for future pregnancies. It is fully healed in 6 to 7 weeks. Afterpains - intermittent uterine contractions may cause afterpains similar to menstrual cramps. Occurs during breastfeeding – baby suckling causes the posterior pituitary to release oxytocin, a hormone that contracts the uterus. Usually gone within 48 hours Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, 11 an imprint of Elsevier Inc. Descent of uterine fundus  The fundus descends at a predictable rate as the muscle cells contract to control bleeding  After placenta delivery fundus is midline (umbilicus or slightly below) May rise slightly after 12 hours, but after 24 hours starts to descend about 1 to 2 cm each day  By 2 weeks post partum the fundus will no longer be palpable  Fundus should feel firm, if not firm it is boggy and fundal massage needs to take place as it can increase risk of postpartum bleeding  A full bladder interferes with contractions as it pushes the fundus up and causes it to deviate to one side usually the right side Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, 12 an imprint of Elsevier Inc. Fundal Height Elsevier items and derived items © 2015, 2011, 2007, 2006 by 13 Saunders, an imprint of Elsevier Inc. Reproductive System Lochia – vaginal discharge post birth – composed of endometrial tissue, blood Rubra – red, composed mostly of blood, may have small clots and lasts for 3-4 days Serosa – pinkish brown – consists of old blood, serum, leukocytes and tissue debris, lasts 3rd day to 10th but can last up to 25 days Alba – mostly mucus and is yellow or white and usually starts around the tenth day and can last up to 4- to 6 weeks Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, 14 an imprint of Elsevier Inc. Abnormal Conditions Related to Lochia Foul-smelling Lochia rubra that lochia, with or persists beyond without fever the fourth day Lochia that returns to a bright Unusually heavy red colour after it flow of lochia has progressed to serosa or alba Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Reproductive System Cervix – regains muscle tone but never closes tightly as prepregnancy Vagina Stretches, the rugae or vaginal folds disappear and the walls become smooth and spacious Rugae reappears 3 weeks postpartum 6 weeks returned to prepregnancy form but never returnsto the size it was before pregnancy Stress importance of discussing with health care provider when to resume vaginal intercourse postpartum Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, 16 an imprint of Elsevier Inc. Reproductive System Breasts Engorgement – occurs due to an increased blood and lymph supply to the breasts a the body produces milk When milk comes in day 2 or 3, the supply of the milk exceeds the newborn’s needs Ensure to breastfeed 8 or more times in a 24 hr period If still painful and engorged can pump, or manually express Nursing care Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, 17 an imprint of Elsevier Inc.  Reproductive System Perineum – often edematous, tender and bruised – may have laceration or Episiotomy REEDA assessment Nursing care and patient teaching Cold packs Topical and systemic medications Nonpharmacological pain relief methods Return of ovulation and menstruation Menstrual cycle typically resumes in 6-8 weeks if not breastfeeding Return of ovulation is delayed if breastfeeding; however, it can occur at any time after birth (pregnancy is possible) Elsevier items and derived items © 2015, 2011, 2007, 2006 by 18 Saunders, an imprint of Elsevier Inc. Nutrition for 3 or 4 rd th Degree Laceration  A high-fibre diet and adequate fluids help to prevent constipation that might result in a breakdown of the perineal area where the laceration was sutured. Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Breasts First 2-3 days postpartum, breasts are full but soft Day 3, breasts become firm, lumpy due to increased blood flow and milk production Engorged breasts occur in both nursing and nonnursing mothers Nipples should be assessed for redness and cracking and washed with plain water Support bra should be worn Elsevier items and derived items © 2015, 2011, 2007, 2006 by 20 Saunders, an imprint of Elsevier Inc. Pain  Sources of Pain  Perineum  Uterus  Breasts  Hemorrhoids  Strategies for Pain  Ice  Heat  Medication Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Cardiovascular System  Cardiac output and blood volume – 50% increase in blood volume during pregnancy  Normal blood loss during birth – 300-5—ml in vag and 500- 1000 in c section  Diaphoresis  Diuresis – increased urination up to 3,000 L/day  Orthostatic hypotension  Coagulation – blood clotting factors are higher during and 4-6 weeks postpartum – prone to VTE  Blood values – return to normal by 8 weeks postpartum  Chills – immediately after birth – related to a sudden release of pressure on the pelvic nerves and vasomotor response of epinephrine during the birth process Elsevier items and derived items © 2015, 2011, 2007, 2006 by 22 Saunders, an imprint of Elsevier Inc. Urinary System  A full bladder can displace the uterus and lead to postpartum hemorrhage  Kiidney function returns to normal one month after birth  Strategies to encourage voiding  Provide privacy.  Do not rush.  Run water in the sink.  Have them place hands in warm water.  Use the peri-bottle to squirt warm water over the perineal area to relax the urethral sphincter. Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Gastrointestinal System  Constipation  To help alleviate this problem, encourage:  Increased fluid and fiber intake  Increased activity, such as walking Elsevier items and derived items © 2015, 2011, 2007, 2006 by 24 Saunders, an imprint of Elsevier Inc. Integumentary System  Hyperpigmentation of the skin changes as hormone levels decrease  Linea gravidarum (pregnancy line) disappears  Striae fade to silver Elsevier items and derived items © 2015, 2011, 2007, 2006 by 25 Saunders, an imprint of Elsevier Inc. Musculoskeletal System  Diastasis recti – the muscles from the chest to the symphysis pubis are separated  Hypermobility of the joints  Exercises – 4 weeks post birth  Abdominal muscle tightening  Head lift  Pelvic tilt  Kegel exercises Elsevier items and derived items © 2015, 2011, 2007, 2006 by 26 Saunders, an imprint of Elsevier Inc. Immune System  Prevent blood incompatibilities and infection  Rh (D) immune globulin if pregnant person is o Rh negative and baby is Rh positive Rh immune-globulin shots – 28th week of pregnancy and second within 72hrs of birth  Give immunization for rubella if person is not immune  Titre less than 1:8 requires immunization Elsevier items and derived items © 2015, 2011, 2007, 2006 by 27 Saunders, an imprint of Elsevier Inc. Adaptation of Care Following Cesarean Birth  Same as with vaginal delivery except  Monitoring of abdominal dressing  Lochia generally less  Urinary catheter  Respiratory care  Prevention of thrombophlebitis (swollen or inflame vein due to a blood clot)  Pain management Elsevier items and derived items © 2015, 2011, 2007, 2006 by 28 Saunders, an imprint of Elsevier Inc. Emotional Care  Rubin’s Psychological Changes of Postpartum  Taking-in (24 to 48 hrs) – lets others help  Taking-hold (day 2 to 10 or several weeks) critical of self and abilities to care for baby, interested in learning to care for herself and baby  Letting-go – giving up previous lifestyle, incorporate newborn, give up fantasy child and accept real child  Postpartum blues – conflicting emotions of joy and emotional let down, depression, fatigue and cry for no reason – if longer than 2 weeks seek professional help  Perinatal mood and anxiety disorders (PMAD’s) – can be psychosis – discussed more later in course  Fatigue – need to sleep when baby sleeps Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Parenthood  Can affect communication between partners  Division of responsibility can be source of conflict  Fatigue increases irritability  Loss of freedom and decreased socializing may cause couple to feel lonely Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Engrossment Four phases of adjustment Partner Having expectations and personal intentions s Confronting reality and overcoming frustrations Creating one’s own personal parent role Reaping rewards of parenthood Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Other Family Members  Siblings  Age-dependent on how older sibling will respond to new baby  Parents need to be prepared for the behaviours that an older child might display  Grandparents Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Family Care Plan  Studying the family as well as the patient can offer insight into community-based care Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Discharge Planning  Begins on admission  Often done before mother is psychologically ready to learn  Clinical pathways may be used  Use ‘teachable moments’  Written materials and online sources should be provided Copyright © 2020 by Elsevier, Inc. All Rights Reserved. Postpartum Self-Care Teaching  Hygiene – showering, care of self, perineal care until flow stops  Diet and exercise – healthy well-balanced diet, high fibre, moderate exercise  Follow-up appointments – usually 6 weeks after birth  Screen for PMAD’s  Danger signs to watch for and report  High fever  Lochia with foul odour  Bright red bleeding, after lochia has already changed from rubra  Pain, large clots, VTE, breast tender, red, SOB, Headache Copyright © 2020 by Elsevier, Inc. All Rights Reserved.