106 PP

-phycological adjustments during PP- Taking hold

"the teachable phase" MOM BECOMES MORE INDEPENDANT AND WANTS TO LEARN TO CARE FOR HER BABY Starts to assert independence -MIGHT FEEL ANXIOUS ABOUT ABILITY TO PARENT Assumes responsibility for "self-care" -nurse must let mom do her thing, dont try to do everythng -encourage dad too and give praise for each attempt

steps to treatment for hemmorage

1. fundal massage 2.pitocin 3. methergine 4. hemabate

when does transition milk come in?

3 days-2weeks -8-14 days - increased milk supply with increase infant sucking -3-6 weeks - mature milk

EAQ tweleve hrs after a spontaneous birth a clients temp is 100.4. which condition would the nurse suspect is the cause of the increase in temp? a) mastitis B) dehydration c) puerperal infection d) UTI

B a clients temp may increase during the 1st 24 hrs due to dehydration

what does the PP focused assessment consist of?

BUBBLE HEP Breast: cracked, bruised, blessing? how to latch? nipple type? Uterus: fundus @ umbilicus -1 per day, endometritis? Bowel return of bowel because narcs Bladder: foley, UTI Lochia: rubra normal at first, serosa, then alba Episiotomy: asses perineum Homans sign: DVT? kink in the knee, dorsiflexing the foot, caf size? redness , warmth? cap refil? Emotions: signs of possible PP depression/ psychosis Pain: always provide pharm/nonpharm measures, ibuprofen/Tylenol continuous

EAQ A nursing student is learning about expected PP anatomical and physiological changes> which statement made by the nursing student indicates a need for further teaching? a) the capacity of the bladder increases b) the uterus involutes to approximately 350 g by 2 weeks PP c) after birth, the vagina gradually decreases in size and return to pre-pregnancy state

C

define early/late hemorrhage and its potential causes

Early Hemorrhage - occurring within 24 hours after childbirth Causes: Uterine Atony Trauma to birth canal: Lacerations & Hematomas Late Hemorrhage - often occurs without warning 7 - 14 days after childbirth Common causes Subinvolution Retained placenta fragments

Cervical changes in PP

First 3 days cervix is flaccid and open 1-3 cms. End of first week - os contracted to 1 cm. Approx. 12 weeks resumes normal functional anatomy. will never look the same again

GI changes

First few days PP, bowel sluggish Increased flatulence Constipation 8-14 days PP, normal bowel pattern -first stool should occur within 2-3 days PP -stool softener, ambulate, fluids, fiber

PP complications

Hemorrhage: blood loss, t Thrombosis: increased clotting, Infection: tissue trauma, caesarean, episiotomy, PROM, UTI, mastitis endometritis Depression: can cause psychosis and a risk to mom/baby

interventions to prevent TE? DVT

If the nurse suspects thrombus formation -- call the physician. Preventative measures include: Ambulation TEDS- support stockings / Sequential compressions device (SCD) heparin If thrombus formation occurs, treatment is BED REST with gradual increase in activity Elevation of leg Initiation of Heparin therapy Not TEDS; could dislodge

-phycological adjustments during PP- Letting GO

Relinquishes previous labor / newborn / life style expectations--> role shifting for everyone -parents may feel disappointed by the size gender or characteristics of the infant -let them talk about unmet expectations Task is to integrate new member with adjustment to new family roles

what vaccines would you assess for and give in the PP period?

Rubella Varicella Tdap Influenza

what are the expected changes in lochia?

Rubra 2-3 d (bright red): small particles/clots are expected Serosa 4- days (light pink/light brown): decrease in clots and bleeding Alba 11 days - 4 to 8 weeks postpartum (whiteish/yellow): no clots or particles

Nursing interventions to promote involution

Teach fundal massage to prevent hemorrhage. empyting the bladder Educate client about analgesia available (Ibuprofen for cramping) Teach signs and symptoms of infection Teach perineal hygiene along with good hand- washing -topical spray -peri bottle -change pad 3-4 hrs -Tux pads Teach the importance of urinary elimination/bowel elimination--> full bladder can deviate and prevent the cervix to involute

what can cause infection in the PP period?

Tissue trauma Prolonged Rupture of Membranes

EAQ which conditions increase the risk of PPH? SATA a) twin birth b) overdistended c) hypertonic uterine dysfunction d) retained placental fragments e) Mild gestational hypertension

a,b,d -women with hypertonic uterine contractions are treated with rest and sedatives, although labor may be prolonged, we shouldn't expect hemorrhage.

PP changes in the siblings

depends on DL -may get jealous or see baby as competition -can see infantile behavior's; renewed bed wetting to (get attention) -affirm affection & love

what should be the expected breast assessment signs?

•1-2 days - breast tissue soft •3rd day - firm and warm (described as filling) •3rd or 4th day - breasts appear large, reddened, with taut, shiny skin (engorgement). On palpation, they feel hard, tense, painful.

mastitis patho, s/s & Tx

-Staphylococcus aureus Enters through injured area of nipple Preceded by engorgement and stasis of milk typically caused by Skipped or sudden stop to feeding Constriction of the breasts Fatigue / stress: lowers immunty S/S Initial flu-like with fatigue and body aches Fever Malaise Headache Localized redness (one area TX -antibiotics, continue to breast feed or pump!! analgesics for -pain and fluids to keep producing milk -heat to relive/ get more blood flow -Lanolin cream -teach breast care: no soap -LATCH technique -supptive bra -NON BREAST FEEDING- antibiotics ICE, ANALGESICS back facing the water in shower

breast changes in the PP period

-colostrum: thick yellow, first 1-2 days -Alveolar growth is regulated by estrogen, progesterone, -human placental lactogen, prolactin, cortisol and insulin -Initiation of lactation triggered by decrease in estrogen and progesterone --->prolactin produces milk -Oxytocin released by suckling at breast: Oxytocin stimulates release of milk -Montgomery tubercles lubricate and protect nipple area 3-5 min of suckling--> hypothalamus--> oxytocin--> milk let down--> causes cramping during breastfeeding

NAME THE PP DANGER SIGNS

-Bleeding heavily - soaking more than 1 pad in 1 hour. -Foul smelling discharge: infection, clots -Fever - temperature greater than 100 -Hard, red, warm or painful areas in breast or legs: mastitis, DVT Anorexia Positive signs of REEDA

main PP teachings focus

-Health Management -Process of Involution -Self-Care -Sleep-rest: sleep when baby sleeps -Nutrition -Exercise -Discharge -Resources

Namw the criteria for PP discharge

-Mother has no complications and assessments are normal -Labs (hemoglobin and hematocrit) have been reviewed Rh factor has been administered if needed -received instructions on self-care danger, abnormals and danger signs -shows knowledge ability and confidence to care for herself and baby -received instructions on PP activity ( exercises, relief measures) -appointments for postpartum care are made -family members or support sources are available for first few days after Mom gets back home

health management teaching points

-Ovulation and menstruation you ca still get prego!! period should resume x days, can vary with lactation -Birth control. This is a good time to educate a woman on the alternatives available. -Sexual activity can resume when perineum is healed and client is comfortable with the idea. -Postpartum checkup in 6 weeks

teaching for NON lactating moms

1-24 hours colostrum 3-4 days - engorgement (breast distention caused by increased fluid in breast). Also called primary engorgement use breast binder/supportive bra use cold to cut off milk supply do not not touch/massage breasts!-stimulates milk use heat/analgesiscs for pain 4-7 days - engorgement subsides

PP nutrition teaching

lactating: - extra 330 calories a day. -Increase fluids for hydration -Avoid / limit caffeine / alcohol -continue to take pre-natal vitamin to replenish stores -protein need to heals NON: -return to healthy diet -increase protein and vitamin C to promote healing -continue to take pre-natal vitamin to replenish stores

1. PP blues s/s 2. PP Psychosis s/s

1. insomnia, irritability, fatigue, tearfullness, mood instability and axiety 2. Agitation, irritability, rapidly shifting moods, disorientation, disorganized behavior delusions and hallucinations

types of lacerations/ espisiotomy

1st degree - superficial skin layer 2nd degree- skin, levator ani muscle and vagina 3rd degree- perineal muscle and rectal tissue 4th degree- entire rip of muscle from perineum to rectal muscle (takes a long time for obstetrician to repair. It also hurts A LOT!) this is nursing priority for the 1st 48 hrs!! teach to sit with cheeks together, doughnut, ice first 24 -when assessing have mom in sims position -squeeze butcheekcs when you sit -peri bottle, PAT DRY not rub! -topical anesthetic, tux -hemorrhoids, Kegels

potential complication of breast feeding?

mastitis ca be caused by stasis of milk, inverted nipple (not proper latch), injuries the skin -redness warmth, inflammation

-phycological adjustments during PP- Taking in

mom is tired and focused on herself and recovering, she is more open to being cared for first 24 hrs PP -she is TAKING IN the fact/ and entire experience that she just had a baby -talks about the experience Behavior is passive - allows others to take control

Afterpains tx & teaching

normal due to involution/ contactios of the uterus analgesics for pain and lying on the belly with a pillow under the abdomen should help -they decrease after 48 hrs on their own

PP discharge teaching

Bathing: Shower or bathe as needed Driving: Limit for first 2 weeks -TEACH DANGER SIGNS! Returning to work/school: generally by 6 weeks. -some women and students return earlier -There is then a risk of increase infection, and increased incidence of exhaustion. Lifting/Bending - teach good posture Stair climbing- limit Sexual activity - when healed and feels comfortable with idea Housework - limit or encourage family members to help. Exercise- gradual increase No douching or tampons

EAQ which area of the health teaching would the mom be most responsive to in the "taking in" phase a) peri-care b) infant feeding c) infant hygiene d) family planning

C during the taking in phase the woman is primary focused on self care needs & being cared for -the taking in phase generally occurs during the 1st 24 hrs -infant feeding and infant hygiene are best taught in the taking hold phase

EAQ which additional nursing care is needed for a pt after a cesarean section? a) encouraging early ambulation b) assessing the fundus gently but firmly c) assessing Vs for signs of shock d) administering prescribed pain meds

D because of increased pain and flatus, clients who have had cesarean births require more pain meds, this enables them to be more mobile and comfortable handling their infants -VS are checked routinely

warningn signs in lochia

Egg sized clots large amounts of blood : more then 2 in 2 hrs is 2 much foul smelling blood can mean hemmorage or edometritis

Nursing interventions for Urinary

Explain importance of an empty bladder Encourage voiding every 3-4 hours Offer ice packs to peri area or whirlpool, sitz bath- warmth helps relax Straight Cath before postpartum hemorrhage occurs s/s of UTI; flank pain, pain with urination, dysuria, suprapubic abdominal pain

changes in CV system during the PP period

H&H low & rises at day 7 hematocrit back to normal: pseudoanemia--> may still be low due to blood loss bradycardia

Vaginal changes PP

Immediate PP - edematous, bruised, low tone 3 weeks PP - gradual reappearance of rugae 6 weeks PP - regains tone as estrogen stabilizes.

PP nursing assessments of the caesarean section

Vital signs (especially BP and RR) LOC/sedation scale Leg movement (especially with spinal anesthesia) Uterine Fundus for firmness; lochial assessment Urine output and color--> risk for urine retention=subinvolution Abdominal dressing for drainage -Emphasis on bowel function--> bowel sounds=paralytic ileus Respiratory--> resp depression wtih anesthesia and opiods Emphasis on ambulation - WALK, WALK, WALK!--> up on the first day! Pain control control of nausea: dehisence, PONV, increase IV fluids Diet consistent with bowel status Incisional care (REEDA)

what are the goals of PP interventions?

Maintain physiologic safety through assessments Provide comfort Provide health education: how to care for baby Empower client: self-care

phycological adjustments during PP

Maternal role attainment - process by which a woman learns the role of mothering. Taking-In: Taking-Hold Letting Go

TYPES OF INFECTION in the PP period

Metritis Wound Infections Urinary Tract Mastitis

hormonal changes causes by lactation/ non lactation

NON: •Estrogen and progesterone return to normal 3-5th week •Menses return - average 7-10 weeks LACTATING: body is supressing estrogen/progesterone •Progesterone drop stimulates prolactin. •Ovulation can occur within 14-30 days of weaning. However breastfeeding is not a form of contraception.

what meds are typically used in the PP period? indication and side effects?

Oral or topical medications for perineal discomfort due to episiotomy Tylenol Ibuprofen: bleeding+ constipation and Percocet (oxy+ acetaminophen): resp depression, sedation, constipation, hypotension Vicodin, Norco: same as perc+ confusion, dizziness

1. considered the 4th trimester 2. peueruperium

PP period 2. last 6 weeks after delivery

PP BLUES vs PP psychosis

Postpartum blues is normal with expressions of sadness without reason. It generally goes away and does not interfere with activities of daily living. -begins on the 3rd PP day and can last uptp 10 days -symptoms lasting 2 + weeks should be evaluated Psychosis requires medical intervention. Woman becomes so depressed that she cannot function and/or ignores herself and baby.

what are we assessing when there's a break in skin integrity?

REEDA Redness; infection Edema: impedes blood flow/ stops healing Ecchymosis: bruising/ bleeding Discharge: bright red, serous? purulent? Approximation: dehiscence?

PP changes in the father

engrossement: intense interest in how the infants looks and responds, a desire to touch/hold baby -include dad in instructions; can feel left out

what assessment findings in the VS are normal for the PP pt?

bradycardia: initial bradycardia due to increased extra fluid volume/blood loss BP: normal , watch for preeclampisia? watch for hypotension/bleeding Resp: unchanged, ambulation and deep breathing monitor for resp depression temp: low grade fever (up to 100.4) is normal in first 24 hrs due to dehydration

EAQ a nurse on the PP unit is teaching self care to a group of mothers which color would she teach them that the lochia discharge would be on the 4th PP day? a) dark red b) dark brown c) pinksih brown d) yellowish white

c lochia serosa: PP days 3-10 lochia rubra days 2-3 lochia alba: yellowish starts 2 10 days-2 weeks PP -lochia is never Dark brown

Endometritis s/s TX

caused my normally inhabiting flora of the vagina & cervix appears dx: WBCs, high lactic acid & blood cultures & urine culture s/s Fever (over 100.4) Chills Malaise anorexia Abdominal pain cramping Foul smelling lochia tachycardia & subinvolution rise in WBCs after 24hrs considerations/ teaching -high fowlers to promote lochia drainage -analgesics for pain -assess for fever tx Atibiotics analgesics heat, heating pads, warm drinks

assesment of the uterus

should be firm and contracted after and before massage one cm below the umbiliucus per day always support with one hand to prevent subinvolution/ prolapsed uterus into the canal--> remember cervical os is still open -afterpains and cramping normal due to involution most likely to experience more afterpains: anything that streches out the uterus LGA, multiparity, primaparity, plohyhraminos

-Hemabate- action uses contraindications

used to abort, and to control PPH that hasnt responded to other theraphy Action: causes uterine contractions by directly stimulating the myometrium can cause really strong contractions=uterine rupture Implications: Given IM, give Q 15-90 min and repeat until bleeding has subsided, max dose is 2 Gm contraindications: PID Active pulmonary, renal, or hepatic disease.

-Pitocin/oxytocin- action uses contraindications

uses: induction, augmentation and prevents PPH after placenta Action: Stimulates uterine smooth muscle ONLY, producing uterine contractions similar to those in spontaneous labor. -Has vasopressor and antidiuretic effects. nursing implications: Given Iv/IM, watch bladder for distention, assess uterus, monitor electrolytes (water intoxication) contraindications:

-Methergine- action uses contraindications

uses: prevents hemorrhage caused by subinvolution or uterine atony Actions: stimulates ALL smooth muscle and cuases it to contract Implications: Give Im Q 2-4 hrs, max 5 doses contraindications: DO NOT USE DURING PREGNANCY OR TO INDUCE LABOR! women with hypertension, DVT, renal disease, CAD, peripheral vascular disease, hypocalcemia, sepsis, or before the fourth stage of labor