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
