Key Nursing Interventions PDF

**Key Nursing Interventions** Intervention Description ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- Perineal Care Cleanse the perineal...

**Key Nursing Interventions** Intervention Description ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- Perineal Care Cleanse the perineal area from front to back with warm water after each voiding and bowel movement. Blot perineal area from front to back. Breast Care (Lactating) Emphasize hand hygiene, allow newborn to breastfeed on demand, and relieve engorgement with warm compresses before feeding. Breast Care (Non-lactating) Wear a supportive bra, avoid breast stimulation, and apply cold compresses for engorgement. **Key Complications to Monitor** - **Postpartum Hemorrhage**: Excessive bleeding after childbirth that requires immediate medical attention. - **Infection**: Signs include fever, foul-smelling discharge, and localized pain in the breasts or perineal area. - **Postpartum Depression**: Emotional changes that may include apathy towards the newborn and feelings of self-harm. **Key Client Education Points** - **Nutrition**: Encourage a balanced diet with adequate caloric intake (1,800 to 2,200 kcal/day for non-lactating clients; additional 450-500 kcal/day for lactating clients). - **Sexual Activity**: Clients can resume sexual intercourse by the second to fourth week after birth, when bleeding has stopped and perineum has healed. - **Indications of Complications**: Report chills or fever greater than 38° C (100.4° F), changes in vaginal discharge, and persistent pain. **Key Dates** - **Follow-up Appointment**: Recommended within 3 weeks after birth to assess recovery and address any complications. **Facts to Memorize** - Normal lochial flow patterns: Rubra (1-3 days), Serosa (3-10 days), Alba (10 days to 8 weeks) - Recommended caloric intake for lactating clients: additional 450-500 calories/day - Normal postpartum temperature: should not exceed 38° C (100.4° F) after 24 hours - Safe resumption of sexual intercourse: 2-4 weeks postpartum when bleeding has stopped **Reference Information** - Signs of postpartum complications: chills, fever, changes in vaginal discharge, pain not relieved by analgesics, breast tenderness, localized pain in calves - Follow-up visit recommendations: within 3 weeks after birth for both vaginal and cesarean births - Importance of hand hygiene in preventing infections during breastfeeding **Concept Comparisons** Lactating Clients Nonlactating Clients ------------------------------------------------- ------------------------------------------------- Emphasize hand hygiene before breastfeeding Wear a supportive bra continuously for 72 hours Allow newborn to breastfeed on demand Avoid breast stimulation Use warm compresses to relieve engorgement Apply cold compresses for engorgement Increase caloric intake by 450-500 calories/day Consume 1,800-2,200 kcal/day **Cause and Effect** Cause Effect ------------------------------------------------- ------------------------------------------------------ Inadequate self-care education before discharge Increased risk of postpartum complications Lack of support system at home Difficulty in managing postpartum recovery Failure to recognize signs of infection Potential for severe health issues, including sepsis