Postpartum Care PDF

Nursing Care in the Postpartum Period  Postdelivery Assessment Greatest risk for postpartum complications is during the first 24 hours after delivery Identification of potential problems; immediate intervention; reassessment  Assessment includes: – Condition of uterus...

Nursing Care in the Postpartum Period  Postdelivery Assessment Greatest risk for postpartum complications is during the first 24 hours after delivery Identification of potential problems; immediate intervention; reassessment  Assessment includes: – Condition of uterus – Amount of bleeding – Bladder & voiding – Vital Signs – Perineum  Fundus = Palpated to assess firm & well contracted Bleeding = Assess drainage on pad Pulse & Bp = Assess cardiovascular function Perineum = Assess for signs of hematoma, lacerations, & edema  Assessments are q 15 minutes for the first hour post delivery Temperature is taken at the end of first hour Transferred to Postpartum Unit when stable  Admission to Postpartum Unit Report between L&D Nurse & PP Nurse Preparations made for receiving the Mother such as: – Room Ready – IV Pole – Admission Assessment – Vital Signs Equipment  Assessment Assessment is immediately upon arrival to the PP Unit – Complete Assessment – BUBBLE HE & VS included Reassessment q Hour x 4 Hours – Uterus, Lochia, Bladder, Bp & Pulse – Abnormal Findings  Vital Signs Elevated Temperature – Normal finding for first 24 hours – Sign of Dehydration – Sign of Infection Bradycardia – Normal Finding  Tachycardia – Infection – Hemorrhage – Pain – Anxiety Lowered Blood Pressure – Orthostatic Hypotension – Shock  Elevated Blood Pressure – Pregnancy-induced Hypertension  Breasts Soft, firm, can be lumpy Secretion of Colostrum Engorgement Assessment of: – Breasts – Nipples  Uterus Process of Involution Height – First Day = at Umbilicus – Decreases 1 FB per Day Consistency – Firm, Round, Smooth; Not “Boggy” Location – Midline  Bladder Often times will be catheterized in L&D post delivery Assess for Bladder Distention: – Uterine Atony – UTI Recatheterize in 6 hours if not voided (Dr.) Measure Urine Output  Bowel Assessment for Bowel Sounds Complaints of Gas Pains Usually has Stool 2-3 days post delivery May need medication for gas pains, laxatives, stool softeners, enemas  Lochia Amount – Estimate of Drainage – Number of Pads Color – Rubra – Serosa – Alba  Episiotomy Assessment for: – Hematomas – Ecchymosis – Edema – Erythema – Intact Suture Line – Signs of Infection  Homan’s Sign Assessment for Thrombophlebitis – Swelling – Reddness – Warmth – Pain Unilateral Findings C/S Mother at Higher Risk  Emotional Status Can have Mood Swings Observing Bonding Behavior & Ability to give Infant Care – Rubin’s Phases – En face – Engrossment  Patient Post Epidural Assessment of Lower Extremities for: – Sensation – Movement Remains on Bedrest  Post C/S Additional Assessment: – Incision – Fluid Intake – Bladder & Bowel – Ambulation/Orthostatic Hypotention – Thrombophlebitis  Documentation of Findings Assessment Checklist Form Graphic Sheet Narrative Notes – Admission – Daily  Nursing Diagnoses Throughout the chapter NCP  Interventions Prevention of Complications Reduce Discomfort ADL – Nutrition – Rest & Sleep – Ambulation – Bathing – Kegel Exercises  Predischarge Rubella Vaccine – Titer – Hypersensitivity to eggs – Administration of Vaccine – Patient Teaching Rho Immune Globulin – Criteria – Administration of Rhogam  Discharge Instructions for Mother & Infant Care Next Appointment Referrals