Transcript Nursing Care of the Postpartum Woman 2015 use this one

Nursing Care of the
Family During the
Postpatum Period
Key Points
• Postpartum care is family centered and
modeled on the concept of health.
• Cultural beliefs and practices affect the
maternal and family response to the
postpartum period.
• The nursing care plan includes
assessments to detect deviations from
normal, comfort measures to relieve
discomfort or pain, and safety measures to
prevent injury or infection.
Key Points (cont)
• Common nursing interventions in the postpartum
period focus on preventing excessive bleeding,
bladder distention, and infection; providing
nonpharmacologic and pharmacologic relief of
discomfort associated with the episiotomy,
lacerations, or breastfeeding; and instituting
measures to promote or suppress lactation.
• Teaching and counseling measures are
designed to promote the woman’s feelings of
competence in self-management and infant care.
Key Points (cont)
• Meeting the psychosocial needs of new
mothers involves taking into consideration
the composition and functioning of the
entire family.
• Early discharge classes, telephone followup, home visits, warm lines, and support
groups are effective means of facilitating
physiologic and psychologic adjustments
in the postpartum period.
Learning Objectives
• Describe components of a systematic
postpartum assessment.
• Recognize signs of potential complications
in the postpartum woman.
• Formulate a nursing care plan for a
woman in the postpartum period.
• Explain the influence of cultural beliefs and
practices on postpartum care.
Learning Objectives (cont)
• Identify psychosocial needs of the woman
in the early postpartum period.
• Prepare a plan for postpartum teaching for
self-management.
• Describe the nurse’s role in these
postpartum follow-up strategies: home
visits, telephone follow-up, warm lines and
help lines, support groups, and referrals to
community resources.
Nursing Care of the Postpartum
Woman
Goal of nursing care in
the immediate
postpartum period is:
to assist women and
their partners during
their initial transition
to parenting
Nursing Care of the Postpartum
Woman
Fourth Stage of Labor
 The first two hours after birth
 Maternal organs start to
undergo readjustments to the
nonpregnant state
Nurse’s role during the fourth
stage of labor is:
 Identify and manage
promptly any deviations
from the normal processes
that may occur
 Promote and support
parent-infant attachment
Nursing Care of the Postpartum
Woman
Fourth stage of Labor
 Assessment
 During the first hour in the
recovery room, physical
assessments of the mother
are frequent
 All factors but temperature
are assessed every 15
minutes for the first hour and
then every thirty minutes in
the second hour
 Temperature is assessed at
the beginning and end of the
recovery period
 Postpartum women
experience intense tremors or
shivering
 Provide warm blankets
Nursing Care of the Postpartum
Woman
• Physiologic Assessments
 Temperature
 First 24 hours every 4
hours
 Every 8 hours after that
till discharge
Pulse, Respirations, and
Blood Pressure
 Every 15 minutes-first
hour of delivery
 Every 30 minutes for the
next 2 hours after delivery
 Then every 4 hours for the
first 24 hours
 Then every 8 hours till
discharge
A postpartum nurse is taking the vital signs on a woman who delivered a
healthy newborn 4 hours ago. The nurse notes that the mother’s temperature is
100.2º F. Which of the following actions would be most appropriate?
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1.Retake the temperature in 15 minutes
2.Notify the physician
3.Document the finding
4.Increase hydration by encouraging oral
fluids
Nursing Care of the Postpartum
Woman
Physiologic Assessments
 Fundus, Lochia, and Bladder
 Assess every 15 minutes for
the first hour
 Assess ever 4 hours for the
next two hours after delivery
 Then assess every 8 hours
until discharge
Perineum
 Assess once the first hour
after delivery
 Then assess every four
hours for the first 24 hours
 Then after 24 hours of
delivery assess every 8 hours
until discharge
A nurse is preparing to perform a fundal assessment on a
postpartum client. The nurse first asks the client to:
• 1.Turn on her side
• 2.Lie flat on her back with the knees and
legs flat and straight
• 3.Urinate and empty her bladder
• 4.Massage the fundus gently
A nurse is assessing the fundal height on a postpartum woman and
notes that the fundus feels flaccid and soft. The nurse would
immediately:
• 1.Contact the physician
• 2.Document the findings and reassess in
1 hour
• 3.Massage the fundus
• 4.Ask the client to ambulate
A nurse is providing information about lochia flow to a
woman who just delivered a newborn. The nurse tells the
woman that the amount of lochia flow:
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1.Increases during ambulation
2.Increases during sleep
3.Is scant immediately following delivery
4.Increases in amount on the third
postpartum day
When performing a postpartum assessment on a client, the nurse notes the
presence of clots in the lochia. The nurse examines the clots and notes that
they are larger than 1 cm. Which of the following nursing actions is most
appropriate?
• 1.Document the findings
• 2.Encourage increased oral intake of
fluids
• 3.Reassess the client in 2 hours
• 4.Notify the physician
A nurse is preparing to perform a fundal assessment on a
postpartum client. The nurse first asks the client to:
• 1.Turn on her side
• 2.Lie flat on her back with the knees and
legs flat and straight
• 3.Urinate and empty her bladder
• 4.Massage the fundus gently
Nursing care of the Postpartum
Woman
Physiologic
Assessments
 Breasts, Legs
 Assess every four
hours in the first twentyfour hours
 Then assess every 8
hours thereafter until
discharge
Nursing Care of the Postpartum
Woman
Laws Related to Discharge
 Newborn’s and Mother’s Health
Protection Act of 1996
 Provided minimum federal
standards for health plan
coverage for mothers and their
newborns
 New mothers and newborns could
remain in the hospital for a
minimum of 48 hours after a
normal vaginal delivery
 New mothers and newborns could
remain in the hospital for a
minimum of 96 hours after a
normal cesarean birth
Nursing Care of the Postpartum
Woman
Routine Laboratory Test
 Hemoglobin
 Hematocrit
 Rubella
 Rh status
Nursing Care of the Postpartum
Woman
Nursing Diagnoses
 Alteration in comfort related to
afterpains, episiotomy,
laceration, hemorrhoids,
breast engorgement, surgical
incision
 Sleep pattern disturbances
 Health seeking behaviors
regarding self-care, newborn
care, health maintenance,
prevention of infections, or
complications
 Altered parenting
 Potential for
infection/hemorrhage
Nursing care of the Postpartum WWoman
Couplet Care
 Also called mother and
baby care or single-room
maternity care
 Nurse functions as the
primary nurse for both the
mother and baby, even if
the baby is in the nursery
Rooming-in
 Mother and baby room
together
 Mother and nurse share
the care of the infant
Nursing Care of the Postpartum
Woman
Plan of Care
 Perineal Care
 Pouring a stream of water
over the vulva and
perineum after voiding or
defecation
 Wiping from front to back
after voiding or defecation
 Change peri-pad with each
voiding or defecation
 Cold therapy for 24 to 48
hours
 Ice packs
 Cold packs
 Heat therapy
Nursing Care of the Postpartum
Woman
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Plan of Care
Perineal Care
Sitz bath 2-3 times a day
Warm packs
Medications
Anesthetic sprays,
epifoam, witch hazel pads
(tucks)
• Sitting with perineal
sutures
• Bring buttocks together
and contract pelvic floor
muscles
A nurse has provided instructions to a postpartum woman regarding
care of the episiotomy site to prevent an infection. Which statement by
the woman indicates a need for further instructions?
• 1.“I will wipe my perineum from front to
back after voiding and defecation.”
• 2.“I will use warm water to rinse the
perineum after elimination.”
• 3.“I will change the perineal pad three
times a day.”
• 4.“I will perform warm sitz baths three
times a day.”
Nursing Care of the Postpartum
Woman
Plan of Care
 Prevention of Excessive Bleeding
 Uterine Atony
 Failure of the uterine
muscle to contract firmly
 Most frequent cause of
excessive bleeding after
childbirth
 Two most important
interventions for
preventing excessive
bleeding are:
 Maintaining good uterine
tone
 Preventing bladder
distention
Nursing Care of the Postpartum
Patient
Plan of Care
 Maintenance of Uterine Tone
 Fundal massage
 Teaching patient to do
fundal self- massage
 IV oxytocin, such as
pitocin
 Oral or IM medications
(drugs that stimulate
contraction of the uterine
smooth muscle) such as
methergine, cytotec, and
hemobate
Nursing Care of the Postpartum
Woman
Plan of care
 Prevention of Bladder
Distention
 Full bladder causes the
uterus to be displaced
above the umbilicus
well to one side of the
midline of the abdomen
 Prevents uterus from
contracting normally
 Focus on helping the
woman to empty her
bladder spontaneously
as soon as possible
In the immediate postpartum period, the nurse monitors the new
mother for which risk related to the urinary system?
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1.Diuresis
2.Stress incontinence
3.Urge incontinence
4.Retention
Nursing Care of the Postpartum
Woman
• Prevention of Bladder
Distention
• Techniques to help the
woman void
• Assist woman to the
bathroom
• Have woman listen to
running water
• Pouring water from a
squeeze bottle over her
perineum
• Assisting woman into the
shower or sitz bath
Nursing Care of the Postpartum
Woman
• Afterbirth pains
• Menstrual-like cramps felt by
many women as the uterus
contracts after childbirth
• Warmth
• Distraction
• Deep breathing
• Imagery
• Therapeutic touch and
relaxation
• Interaction with the infant may
decrease the discomfort
associated with these uterine
contractions
Nursing Care of the Postpartum Woman
Plan of Care
 Ambulation
 Early ambulation is
successful in reducing
the incidence of
thromboembolism and
in promoting the
woman’s more rapid
recovery of strength
 Orthostatic hypotension
 Women with
varicosities are
encouraged to wear
support hose
Nursing Care of the Postpartum
Woman
Plan of Care
 Ambulation
Thrombus is suspected
Warmth, redness, or tenderness in the
suspected leg
Notify MD immediately
Confine woman to bed with affected limb
elevated on pillows
Nursing Care of the Postpartum
Woman
• Fatigue
• Common in the postpartum
period
• Interventions must be planned
to meet the woman’s individual
need for sleep and rest
• Support and encouragement in
mother’s behaviors help
reduce anxiety
• Hospital and nursing routines
also may be adjusted to meet
individual needs
Nursing Care of the Postpartum
Woman
Plan of Care
 Bladder
 After giving birth the
woman should void
spontaneously within 6 to
8 hours
 Several of the first
voidings should be
measured to document
adequate emptying of the
bladder
 A volume of 150 ml is
expected for each voiding
Nursing Care of the Postpartum
Woman
• Plan of Care
• Educating the woman about
measures to avoid constipation
• Adequate roughage
• Plenty of fluids
• Exercise
• Decreased narcotic usage
• Stool softeners and laxative
use
A postpartum nurse is providing home care instructions to a woman
following delivery of a healthy newborn. The nurse tells the mother that
she should expect normal bowel elimination to return:
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1. 1 day postpartum
2. 3 days postpartum
3. 7 days postpartum
4. Within 2 weeks postpartum
Nursing Care of the Postpartum
Woman
Plan of Care
 Breast Care
 Breastfeeding
 First 2 hours after birth
 Infant is an alert state
 Aids in the contraction of the
uterus
 Hygiene
 Avoid soap, alcohol, and
other drying agents
 Cleans nipple with clear
water
 Apply lanolin for sore or
cracked nipples
Lactation
• Benefits of breast feeding
• Mother
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Promotes bonding
Helps weight loss
Stimulates uterine contractions
Decreases risk of thromboembolism
Protects against breast cancer
Some contraceptive protection
Readily available
• Infant
Breast feeding benefits Con’t
• Infant
– Milk contains natural components to facilitate immune
system and anti-inflammatory agents
– Nutrients are easily tolerated and digested
– No artificial colorings, flavors, preservatives
– Active & passive protection against viral and bacterial
pathogens
– Promotes better tooth and jaw development
– Protects against food allergies
– Not likely to over feed
Lactation
• Nutritional needs
– Calories
• Increase calorie intake by 500 cal/day -6 mo
• 2300-2700 cal/day while breast feeding
– Protein
• Needs additional 20 gm
• Extra 2 c. of milk = 16g protein
– Fluid
• 2-3 quarts per day
• Water, milk, fruit juice
• Encourage 1 glass of fluid with each nursing of infant
Vitamins and minerals
– Balanced supplement for less than 1800 cal/da
A nurse is providing nutritional counseling to a new mother who is
planning to breast-feed her newborn. The nurse instructs the mother
that her calorie needs need to increase by:
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1.100 calories per day
2.300 calories per day
3.500 calories per day
4.1000 calories per day
A home care nurse visits a client who delivered a healthy newborn infant 2 days ago. The mother is
complaining of breast discomfort and the nurse notes that the mother is experiencing breast
engorgement. The nurse provides instructions to the mother regarding relief of the engorgement.
Which statement by the mother indicates a need for further instructions?
• 1.“I should feed my infant at least every 2½
hours for 15 to 20 minutes on each side.”
• 2.“I should avoid breast-feeding during the time
of breast engorgement.”
• 3.“I should apply moist heat to both breasts for
about 20 minutes before a feeding.”
• 4.“I should gently massage the breasts during a
feeding from the outer areas to the nipples.”
Nursing Care of the Postpartum
Woman
• Lactation Suppression
• Wearing a well-fitted
support bra or binder
• Avoid any breast
stimulation
• Severe breast
engorgement
• Ice packs to the breast
• Cabbage leaves
• Mild analgesics
Nursing Care of the Postpartum
Woman
• Rubella –women who have not had rubella
• Titer of 1:8 or enzyme immunoassay level
less than 0.8
• Given sub Q
• Women are cautioned to avoid pregnancy
for 28 days
Nursing Care of the Postpartum
Woman
Varicella Vaccine
Women with no immunity
Avoid pregnancy for 28 days
A second dose is given at the postpartum
follow-up visit (4 to 8 weeks after the first
dose
Nursing Care of the Postpartum
Womman
• Varicella Vaccination Before discharge in
women with no immunity
• Second dose 4-6 weeks postpartum
• Tetanus-Diphtheria-Acellular Pertussis
Vaccine (Tdap)
Nursing Care of the Postpartum
Woman
Prevention of RH Isoimmunization
 Injection of Rh immune
globulin (Rhogam) must be
given within 72 hours after
birth to prevent
sensitization in the RHnegative woman who has
had a fetomaternal
transfusion of Rh-positive
red blood cells
 Administration of 300 mcg
(1 vial) of Rh immune
globulin is usually sufficient
to prevent maternal
sensitization
Nursing Care of the Postpartum
Woman
Prevention of RH Isoimmunization
Large fetomaternal transfusions
Kleihauer-Betke- which detects the
amount of fetal blood in maternal
circulation
More than 30 ml of fetal blood is present
in maternal circulation, the dosage of Rh
immune globulin must be increased
Nursing Care of the Postpartum
Woman
Cultural Variations
 Mother” beliefs about
postpartal care influenced by
her culture and personal
values
 Many cultures emphasize
certain postpartal routines or
rituals for mother and baby
 Some Hispanics, African, and
Asian cultures may avoid cold
after birth
 Rest and seclusion
 Hygiene
Nursing Care of the Postpartum
Woman
• Follow-Up After
Discharge
• Home Visits
• Telephone follow-up
• Warm lines
• Support groups
• Referral to community
resources