109 24-25 semi

INTRAOPERATIVE CARE MEASURES

- Administration of Anesthesia - Skin Preparation - Surgical Incision - Birth of the Infant - Introduction of the Newborn

The Woman Whose Newborn Has Died management

- Clean the baby, wrap the baby in an infant blanket, and bring him or her to the parents - Remain with them, but give them time - Provide a private room

Assessment findings associated with a postpartum complication

- Elevated temperature - Feeling of extreme sadness or unreality - Pallor - Thready, rapid, weak pulse - Decreased blood pressure - Pain and swelling in breast - Relaxed uterus - Uterine hemorrhage - Abdominal pain - Pain of symphysis pubis on walking - Perineal pain - Lochia with foul odor - Pain and tenderness in calf of leg - Positive Homans sign

The Woman Whose Child Is Born With an Illness or a Physical Challenge management

- Encourage the parents to care for the child - Open lines of communication

PUERPERAL INFECTIONS

- Endometritis - Infection of the Perineum - Peritonitis

Immediate Preoperative Care Measures

- Informed Consent - Overall Hygiene - Gastrointestinal Tract Preparation - Baseline Intake and Output Determinations - Hydration - Preoperative Medication - Patient Chart and Presurgery Checklist - Transport to Surgery

management of Reproductive Tract Displacement

- Kegel exercises - injection of bulking agents, or Botox

Therapeutic Management of peritonitis

- NG tube - IV or TPN - analgesics - intravenous antibiotics

Operative Risk for a Woman

- Poor Nutritional Status - Age Variations - Altered General Health - Fluid and Electrolyte Imbalance - Fear

EMOTIONAL AND PSYCHOLOGICAL COMPLICATIONS OF THE PUERPERIUM

- Postpartal Depression - Postpartal Psychosis

CARDIOVASCULAR SYSTEM DISORDERS

- Postpartal Gestational Hypertension

Management Postpartal Psychosis

- Psychotherapy, drug therapy - safeguarding mother from injury to self and newborn

REPRODUCTIVE SYSTEM DISORDERS

- Reproductive Tract Displacement - Separation of the Symphysis Pubis

EFFECTS OF SURGERY ON A WOMAN

- Stress Response - Interference With Body Defenses - Interference With Circulatory Function - Interference With Body Organ Function - Interference With Self-Image or Self-Esteem

nsg responsibilities in Transport to Surgery

- Urge her to lie on her left side - raising the side rails - Cover her with a blanket or sheet - secure identification - chart or electronic record remains secure and will be available to OR personnel.

URINARY SYSTEM DISORDERS

- Urinary Retention - Urinary Tract Infections

Preoperative Diagnostic Procedures

- Vital sign - Urinalysis - CBC - Coagulation profile - Serum electrolytes and pH - Blood typing and cross-matching

DIC is usually associated with

- abruptio placentae - missed early miscarriage - fetal death

manifestations of Separation of the Symphysis Pubis

- acute pain on turning or walking; her legs tend to rotate externally, giving her a waddling gait. - defect over the symphysis pubis can be palpated: the area is swollen and feels tender to touch

Therapeutic Management of Endometritis

- antibiotic - methylergonovine - drink additional fluid - analgesic - semi-Fowler position - walking - good hand washing techniques

Therapeutic Management of mastitis

- antibiotics - Cold or ice compresses - good supportive bra - warm, wet compresses - continue to pump breast milk

Therapeutic Management of Femoral Thrombophlebitis

- anticoagulants - moist heat - bed rest with the affected leg elevated - moist compresses - Never massage the skin over the clotted area - antibiotic - Thrombolytics

management in Interference With Body Defenses

- aseptic techniques - prophylactic antibiotics

Preoperative Teaching

- assess how much a woman knows about her surgery - Be certain not to use hospital jargon - explain the immediate preoperative measures and method of transport to surgery - Review the necessity for an indwelling bladder catheter, IV fluid, placement of an epidural catheter - use visual aids as necessary - Deep Breathing - Incentive Spirometry - Turning - Ambulation

prevent nipples from cracking

- baby is positioned correctly and grasps the nipple properly - baby release a grasp on the nipple before removing the baby from the breast - Washing hands - Exposing nipples to air - vitamin E ointment - begin breastfeeding on unaffected nipple

avoid becoming depressed

- balanced program of nutrition, exercise, and sleep. - share your feelings with a support person - take time every day to do something for yourself - Do not try to be perfect - Do not let yourself be isolated by baby care

management of Separation of the Symphysis Pubis

- bed rest - snug pelvic binder - avoid heavy lifting - consider a cesarean birth for any future pregnancy

management of Postpartal Gestational Hypertension

- bed rest, a quiet atmosphere - vital signs and urine output - magnesium sulfate or an antihypertensive agent - dilatation and curettage

signs and symptoms of Retained Placental Fragments

- bleeding - uterus not fully contracted

manifestations of Mastitis

- breast feels painful and appears swollen and reddened. - Fever - breast milk becomes scant

therapeutic mgt of UTI

- broad-spectrum antibiotic - drink large amounts of fluid - analgesic

manifestations of Urinary Tract Infections

- burning on urination, possibly blood in the urine (hematuria), and a feeling of frequency - low-grade fever - lower abdominal pain.

management in Interference With Body Organ Function

- close postoperative assessment - bladder must be displaced anteriorly

Lacerations occur most often in conditions like

- difficult or precipitate births - primigravidas - large infant - use of lithotomy position and instruments

therapeutic mgt in Retained Placental Fragments

- dilatation and curettage - methotrexate - balloon occlusion - embolization of the internal iliac arteries - hysterectomy

nursing responsibilities in amniotomy

- dorsal recumbent position - amniohook or hemostat passed vaginally

manifestations of Pelvic thrombophlebitis

- extremely ill, with a high fever, chills, abdominal pain, weakness, and general malaise

Thrombophlebitis tends to occur because

- fibrinogen level is still elevated - Dilatation of lower extremity veins

risk in emergent cesarean birth

- fluid and electrolyte imbalance - physically and emotionally exhausted

therapeutic mgt of uterine atony

- fundal massage - bolus or a dilute intravenous infusion of oxytocin - carboprost tromethamine - methylergonovine maleat - Misoprostol - antiemetic - Elevate the woman's lower extremities - Offer a bedpan - Administer oxygen - Bimanual Compression - Blood Replacement - Hysterectomy or Suturing

NURSING CARE FOR A WOMAN HAVING AN EMERGENT CESAREAN BIRTH

- gaining an informed consent - application of SCDs or elastic stockings - preparing the gastrointestinal tract - bladder catheterization - establishing an IV line

Organisms commonly cultured postpartally include

- group B streptococci - staphylococci - aerobic gram-negative bacilli

components of Preoperative Interview

- health history - past surgeries, secondary illnesses, allergies to foods or drugs, reactions to anesthesia, bleeding problems, or current medications - body piercings that need to be removed - What the procedure will entail - Length of hospitalization - postsurgical equipment to be used - special precautions

Risk factors for postpartal depression

- history of depression, - troubled childhood - low self-esteem - stress - lack of effective support - different expectations between partners - disappointment in the child

Thrombophlebitis tends to occur most often in women who

- inactive in labor and during the early puerperium - prolonged time with their legs positioned in stirrups - preexistent obesity - preexisting varicose veins - postpartal infection - history of a previous thrombophlebitis - older than age 35 years or have increased parity - a high incidence of thrombophlebitis in their family - Smoke cigarettes

therapeutic mgt of Urinary Retention

- indwelling (Foley) catheter - strict antiseptic technique - offering fluid - analgesic

therapeutic mgt of hematomas

- mild analgesic - ice pack - sitz bath

manifestations of infection of the Perineum

- pain, heat, and a feeling of pressure - inflammation - purulent drainage present

stress response complications

- peripheral vasoconstriction - thrombophlebitis

complications of obesity

- pneumonia - thrombophlebitis

complications in Interference With Body Organ Function

- postpartum hemorrhage - paralytic ileus - thrombophlebitis

manifestations of hematomas

- pressure between her legs - severe pain in the perineal area

Retained Placental Fragments is associated with

- previous cesarean birth - in vitro fertilization

management in overall hygiene

- provide a clean hospital gown - braid hair or put it into a ponytail - removing nail polish, jewelry, contact lenses, lip or mouth piercings, or hair ornaments

Hematomas are most likely to occur with

- rapid, spontaneous births - perineal varicosities

manifestations of Femoral Thrombophlebitis

- redness, swelling, warmth, and a hard inflamed vessel - shiny and white leg

ligaments of the uterus are weakened

- retrofl xion, anteflexion, retroversion, and anteversion or prolapse of the uterus. - pain or a feeling of lower abdominal heaviness or discomfort

manifestations of peritonitis

- rigid abdomen - abdominal pain - high fever - rapid pulse - vomiting - appearance of being acutely ill.

nsg responsibilities in Skin Preparation

- shaving abdominal hair - washing the skin area over the incision site

preventing thrombophlebitis

- side-lying or back-lying (supine recumbent) position - padding on the stirrups - Drink adequate fluids - Do not sit with your knees crossed - avoid wearing constricting clothing - Ambulate as soon after birth as possible - Quit smoking

Retained Placental Fragments is most likely to happen with

- succenturiate placenta - Placenta accreta

Thrombophlebitis is classified as either

- superficial vein disease (SVD) - deep vein thrombosis (DVT).

Therapeutic Management of Perineal Lacerations

- suture - diet high in fluid - stool softener - enema or a rectal suppository

Therapeutic Management of Cervical Lacerations

- sutures - maintain an air of calm - stand beside the woman at the head of the table - regional anesthetic

Therapeutic Management of Vaginal Lacerations

- suturing - balloon tapenade - indwelling urinary catheter

Therapeutic Management of infection of the Perineum

- systemic or topical antibiotic - analgesic - Sitz baths, moist warm compresses, or Hubbard tank treatments - change perineal pads frequently - wipe from front to back - not to place the infant on the bottom bed sheet - ambulate

disadvantage of low segment incision

- takes longer to perform - impractical for an emergent cesarean birth

manifestations of Endometritis

- temperature over 100.4°F (38°C) for two consecutive 24-hour periods - chills, loss of appetite, and general malaise - uterus not well contracted and painful to the touch - strong afterpains - Lochia dark brown and has a foul odor

therapeutic mgt of Pelvic thrombophlebitis

- total bed rest - analgesics, antibiotics, and anticoagulants - wearing nonconstricting clothing - resting with the feet elevated - ambulating daily

four main reasons for postpartum hemorrhage

- uterine atony - trauma - retained placental fragments - DIC

greatest danger of hemorrhage is in the first ____ hours because of the grossly denuded and unprotected uterine area left after detachment of the placenta

24

blood loss in vaginal birth

300 to 500 ml

blood loss in cesarean birth

500 to 1,000 ml

major intervention after cesarean birth to prevent complications

AMBULATION

artificial rupturing of membranes

Amniotomy

symptoms Postpartal Depression

Anxiety, feeling of loss, sadness

uterine atony tends to occur most often in

Asian or Hispanic woman

primary care provider inserts one hand into a woman's vagina while pushing against the fundus through the abdominal wall with the other hand

Bimanual Compression

The nurse plans to instruct the post Cesarean Birth client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?

Breastfeeding the neonate at frequent intervals.

prophylactic measure to alleviate problems of birth

CESAREAN BIRTH

birth accomplished through an abdominal incision into the uterus

Cesarean birth

management in postpartal depression

Counseling, possibly antidepressant therapy

An exercise that fully aerate the lungs and help to prevent the stasis of lung mucus from the prolonged time spent in the supine position during surgery

DEEP BREATHING EXERCISE

defi ciency in clotting ability caused by vascular injury

Disseminated Intravascular Coagulation

The following are signs of possible complication after surgery EXCEPT

Dressing dry and intact

form of morphine commonly used in addition to a local anesthesia in epidurals

Duramorph

A morphine (Duramorph) or fentanyl added to the epidural catheter immediately after surgery, a technique that keeps them pain free for the next 24 hours, called

EPIDURAL ANESTHESIA

done for reasons that arise suddenly in labor,

Emergent Cesarean Birth

infection of the endometrium, the lining of the uterus

Endometritis

one of the precursors of postpartal infection because of the general debilitation that results

Extensive blood loss

Passage of _______is another indication that intestinal function is again active. As soon as these signs are present, intravenous fluid therapy is usually discontinued and the woman is allowed sips of fluid.

FLATUS

femoral, saphenous, or popliteal veins are involved.

Femoral Thrombophlebitis

Classification of Perineal Lacerations: Entire perineum, rectal sphincter, and some of the mucous membrane of the rectum

Fourth degree

ost operative, monitor blood pressure, pulse, and respiratory rate approximately every 15 minutes for the first hour after surgery, every 30 minutes for the next 2 hours, every hour for the next 4 hours, or as specifically ordered,to detect signs of_________

HEMORRHAGE

pain in the calf of the leg on dorsiflexion of the foot

Homans sign

Is the surgeon's responsibility, but you may be asked to witness a woman's signature on such a form. Before signing as a witness, be certain that the patient educate the risks and benefits of the procedure were explained in terms the woman could easily understand

INFORMED CONSENT

Is initiated preoperatively and continued postoperatively to prevent fluid and electrolyte imbalances.

INTRAVENOUS FLUID

A client who delivered by cesarean birth 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

Impaired bowel motility related to pain medication and immobility.

common device used three to four times a day postoperatively to encourage deep breathing

Incentive Spirometry

most precise method for assessing FHR and uterine contractions

Internal Electronic Monitoring

infection of the breast

Mastitis

Indications for Cesarean Birth

Maternal Factors - Active genital herpes - AIDS - CPD - Cervical cerclage - Disabling conditions (PIH) - failure to progress in labor - malignant tumor - Previous cesarean birth - Fear of birth Placental Factors - Placenta previa - abruptio placentae - Umbilical cord prolapse Fetal Factors - macrosomic fetus in a breech lie - Extreme low birth weight - Fetal distress - hydrocephalus - Multigestation or conjoined twins - Transverse fetal lie and perhaps breech presentation

prostaglandin E 1 analogue,

Misoprostol

_________ may be ordered to be added to the first 1or 2 L of intravenous fluid after surgery to ensure firm uterine contraction.

OXYTOCIN

is a method of pain control in which women administer doses of intravenous narcotic analgesia such as morphine to themselves as needed

PATIENT-CONTROLLED ANALGESIA

woman older than 40 years falls into a category of slightly higher risk because of associated conditions such as

PIH

collection of blood in the subcutaneous layer of tissue of the perineum

Perineal Hematomas

infection of the peritoneal cavity

Peritonitis

one of the gravest complications of childbearing and is a major cause of death from puerperal infection

Peritonitis

inflammation of the lining of a blood vessel.

Phlebitis

placenta that fuses with the myometrium because of an abnormal decidua basalis layer

Placenta accreta

occurs as a response to the anticlimactic feeling after birth

Postpartal Depression

response to the crisis of childbearing

Postpartal Psychosis

While the post Cesarean Birth client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy?

Protamine sulfate

obstruction of the pulmonary artery by a blood clot

Pulmonary Embolus

applying pressure with the fingers to the fetal scalp through the dilated cervix

Scalp Stimulation

assessment of acid-base balance in a fetus in labor.

Scalp Stimulation

there is time for thorough preparation for the experience throughout the antepartal period

Scheduled Cesarean Birth

Classification of Perineal Lacerations: Vagina, perineal skin, fascia, levator ani muscle, and perineal body

Second degree

fter teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective?

Shortens the second stage of labor.

reduces the possibility of bacteria entering the incision

Skin Preparation

incomplete return of the uterus to its prepregnant size and shape

Subinvolution

Small electrodes are attached to the woman's skin near her incision; when she feels pain, she pushes a transformer button.

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION

Classification of Perineal Lacerations: Entire perineum, extending to reach the external sphincter of the rectum

Third degree

inflammation with the formation of blood clots

Thrombophlebitis

important to prevent both respiratory and circulatory stasis

Turning

occurs when the bladder is unable to empty completely

Urinary Retention

relaxation of the uterus, is the most frequent cause of postpartum hemorrhage

Uterine Atony

prolapse of the fundus of the uterus

Uterine Inversion

necessary to ensure blood clotting after surgery

Vitamin K

most effective way to stimulate lower extremity circulation after a cesarean birth

ambulation

a long, thin crochet-like instrument

amniohook

used to support and encourage venous return in addition to ambulation

antiembolic stockings

prostaglandin F 2 a derivative

carboprost tromethamine

Lacerations may occur in the

cervix, vagina, perineum

Endometritis is usually associated with

chorioamnionitis and a cesarean birth

incision is made vertically through both the abdominal skin and the uterus

classic cesarean incision

disadvantage of amniotomy

cord prolapse

outpouching of the bladder into the vaginal wall

cystocele

If the walls of the vagina are weakened, _________ and ___________ may occur

cystocele, rectocele

Age affects surgical risk because it can cause both

decreased circulatory and renal function

rupture of the incision

dehiscence

side effects of prostaglandins

diarrhea and nausea

hormones released as a stress response

epinephrine and norepinephrine

surgical incision of the perineum made to prevent tearing of the perineum

episiotomy

Pregnant women who are iron deficient are at high risk for

extreme fatigue

veins involved in Femoral Thrombophlebitis

femoral, saphenous, popliteal veins

FHR recording is obtained from

fetal scalp electrode

Classification of Perineal Lacerations: Vaginal mucous membrane and skin of the perineum to the fourchette

first degree

prevention of Pelvic thrombophlebitis

good aseptic technique

a rigid abdomen

guarding

one of the primary causes of maternal mortality associated with childbearing, is a major threat during pregnancy, throughout labor, and continuing into the postpartum period.

hemorrhage

used To reduce bladder size and keep the bladder away from the surgical field

indwelling urinary catheter

one of the gravest dangers of any surgical procedure from the physiologic stress of surgery or lack of blood flow to the kidneys due to decreased blood pressure.

kidney failure

complication if the woman does not both inhales and exhales fully

light-headedness from hyperventilation

incision made horizontally across the abdomen just over the symphysis pubis and also horizontally across the uterus just over the cervix

low segment incision

complication if woman does not ambulate postoperatively

lower extremity circulatory stasis

episiotomy incision begun in the midline but directed laterally away from the rectum

mediolateral episiotomy

therapeutic mgt of Subinvolution

methylergonovine

ergot compound

methylergonovine maleate

episiotomy incision made with blunt-tipped scissors in the midline of the perineum

midline episiotomy

veins involved in Pelvic thrombophlebitis

ovarian, uterine, or hypogastric veins

therapeutic mgt of pulmonary embolus

oxygen administration

blockage of inflamed intestines

paralytic ileus

used to ensure that the newborn is wide awake at birth and can initiate respirations spontaneously

preoperative medication

a woman does not void at all.

primary overdistention

antagonist for heparin

protamine sulfate

necessary for new cell formation at the incision site

protein and vitamins C and D

begins as only a local infection, it has the potential to spread to the peritoneum or the circulatory system

puerperal infection

period of health

puerperium

outpouching of the rectum into the vaginal wall

rectocele

complications of Duramorph

respiratory depression

Operative Risk to the Newborn

respiratory difficulty (transient tachypnea)

Peritonitis can interfere with future fertility because it can leave

scarring and adhesions in the peritoneum

prevent potential urinary or anal incontinence

scheduled or elective cesarean births

primary line of defense against bacterial invasion

skin

may be done to detect possible retained placental fragments

sonogram

used to determine tubal patency

sonohysterosalpingogram

placenta with an accessory lobe

succenturiate placenta

signs of pulmonary embolus

sudden, sharp chest pain; tachypnea; tachycardia; orthopnea, cyanosis

four Ts of postpartum hemorrhage

tone, trauma, tissue, and thrombin

added danger of endometritis

tubal scarring and interference with future fertility

woman is able to void

urinary retention and overflow

Baseline readings that do not return to 20 mmHg or less

uterine hypertonia - compromise of fetal well-being

antagonist for warfarin

vitamin K

disadvantage of classic cesarean incision

wide skin scar - could rupture during labor