Transcript NURS 2410 Unit 3

NURS 2410 Unit 3
Nancy Pares, RN, MSN
Metro Community College
Assessment of Postpartum Hemorrhage
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Fundal height and tone
Vaginal bleeding
Signs of hypovolemic shock
Development of coagulation problems
Signs of anemia
Risk Factors for
Postpartum Hemorrhage
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Cesarean delivery
Unusually large episiotomy
Operative delivery
Precipitous labor
Atypically attached placenta
Fetal demise
Previous uterine surgery
Causes of Postpartum
Hemorrhage
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Uterine atony
Lacerations of the genital tract
Episiotomy
Retained placental fragments
Vulvar, vaginal, or subperitoneal hematomas
Causes of Postpartum
Hemorrhage (continued)
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Uterine inversion
Uterine rupture
Problems of placental implantation
Coagulation disorders
Nursing Interventions
• Uterine massage if a soft, boggy uterus is
detected
• Encourage frequent voiding or catheterize the
woman
• Vascular access
• Assess abnormalities in hematocrit levels
• Assess urinary output
• Encourage rest and take safety precautions
Nursing Diagnoses:
Postpartum Hemorrhage
• Health-seeking Behaviors related to lack of
information about signs of delayed postpartal
hemorrhage
• Fluid Volume Deficit related to blood loss
secondary to uterine atony, lacerations,
hematomas, coagulation disorders, or
retained placental fragments
Prevention of
Postpartum Hemorrhage
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Adequate prenatal care
Good nutrition
Avoidance of traumatic procedures
Risk assessment
Early recognition and management of
complications
Postpartal Hemorrhage
Self-Care Measures:
Postpartum Hemorrhage
• Fundal massage, assessment of fundal height and
consistency
• Inspection of the episiotomy and lacerations if
present
• Report:
– Excessive or bright red bleeding, abnormal clots
– Boggy fundus that does not respond to massage
– Leukorrhea, high temperature, or any unusual pelvic or
rectal discomfort or backache
Community Based Care:
Postpartum Hemorrhage
• Clear explanations about condition and the
woman’s need for recovery
• Rise slowly to minimize orthostatic
hypotension
• Woman should be seated while holding the
newborn
• Encourage to eat foods high in iron
• Continue to observe for signs of hemorrhage
or infection
Uterine Atony
• Risk factors
– Overdistension of the
uterus
– Uterine anomaly
– Poor uterine tone
• Assessment findings
– Excessive bleeding, boggy
fundus
Uterine Atony (continued)
• Management
– Fundal massage
– Blood products if loss is excessive
– Medications
• Oxytocin, methergine, carboprost tromethamine
(Hemabate)
Uterine Atony
Uterine Atony
Retained Placental Fragments
• Risk factors
– Mismanagement of third stage
– Placental malformations
– Abnormal placental implantation
• Assessment findings
– Excessive bleeding, boggy fundus
Retained Placental Fragments
(continued)
• Management
– Manual exploration of the uterus
– D&C
– Blood products if loss is excessive
Assessment of Infection:
REEDA Scale
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R: redness
E: edema
E: ecchymosis
D: discharge
A: approximation
Assessment of Infection
(continued)
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Fever
Malaise
Abdominal pain
Foul-smelling lochia
Larger than expected uterus
Tachycardia
Lacerations
• Risk factors
– Operative delivery
– Precipitous delivery
– Extension of the episiotomy
– Varices
• Assessment findings
– Excessive bleeding with a firm uterus
Lacerations (continued)
• Management
– Suture the laceration
– Blood products if loss is excessive
Endometritis
 Infection of the uterine
lining
 Risk factors
◦ Cesarean section
 Assessment findings
◦ Fever, chills
◦ Abdominal tenderness
◦ Foul-smelling lochia
 Management
◦ Antibiotics
Metritis
Mastitis
Assessment of Mastitis
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Breast consistency
Skin color
Surface temperature
Nipple condition
Presence of pain
Mastitis
• Infection of the breast
• Risk factors
– Damaged nipples
– Failure to empty breasts
adequately
• Assessment findings
– Fever, chills
– Breast pain, swelling, warmth,
redness
• Management
– Antibiotics
– Complete breast emptying
Figure 38–2 Mastitis. Erythema and swelling are present in the upper outer quadrant of the breast. Axillary lymph nodes are often enlarged
and tender. The segmental anatomy of the breast accounts for the demarcated, often V-shaped wedge of inflammation.
Prevention of Mastitis
• Proper feeding techniques
• Supportive bra worn at all times to avoid milk
stasis
• Good handwashing
• Prompt attention to blocked milk ducts
Self-Care Measures: Mastitis
• Importance of regular, complete emptying of
the breasts
• Good infant positioning and latch-on
• Principles of supply and demand
• Importance of taking a full course of
antibiotics
• Report flu-like symptoms
Breast Problems
Nursing Diagnoses: Mastitis
• Health-seeking Behaviors related to lack of
information about appropriate breastfeeding
practices
• Ineffective Breastfeeding related to pain
secondary to development of mastitis
Community Based Care:
Mastitis
• Home care nurse may be the first to suspect
mastitis
• Obtain a sample of milk for culture and
sensitivity analysis
• Teach mother how to pump if necessary
• Assist with feelings about being unable to
breastfeed
• Referral to lactation consultant or La Leche
League
Assessment of
Thrombophlebitis
• Homan’s sign
• Pain in the leg, inguinal area, or lower
abdomen
• Edema
• Temperature change
• Pain with palpation
Figure 38–3 Homans’ sign. With the client’s knee flexed to decrease the risk of embolization, the nurse dorsiflexes the client’s foot. Pain in the
foot or leg is a positive Homans’ sign. SOURCE: Photographer, Elena Dorfman
Thrombophlebitis
• Inflammation of the lining of the blood vessel
due to clot formation
– Can occur in the legs (DVT) or pelvis (SPT)
• Risk factors
– Cesarean section
– Prolonged bed rest
– Infection
Thrombophlebitis (continued)
• Assessment findings
– Pain, fever, redness, warmth, tender
abdomen/calf
• Management
– Anticoagulants
– Antibiotics for septic pelvic thrombophlebitis
Thromboembolic Factors
Decreasing Thromboembolic
Risk
Prevention of
Thrombophlebitis
• Avoid prolonged standing or sitting
• Avoid crossing her legs
• Take frequent breaks while taking car trips
Self-Care: Thromboembolic
Disease
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Condition and treatment
Importance of compliance and safety factors
Ways of avoiding circulatory stasis
Precautions while taking anticoagulants
Nursing Diagnoses:
Thromboembolic Disease
• Pain related to tissue hypoxia and edema
secondary to vascular obstruction
• Risk for Altered Parenting related to decreased
maternal-infant interaction secondary to bed
rest and intravenous lines
• Altered Family Processes related to illness of
family member
• Deficient Knowledge related to self-care after
discharge on anticoagulant therapy
Vitamin K Foods
Assessment of Postpartum
Psychiatric Disorders
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Depression scales
Anxiety and irritability
Poor concentration and forgetfulness
Sleeping difficulties
Appetite change
Fatigue and tearfulness
Postpartum Blues
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Occurs within 3 to 10 days of delivery
Generally transient
Usually resolves without treatment
Assessment findings
– Tearful, fatigue, anxious, poor appetite
Postpartum Blues (continued)
• Etiology
– Hormonal changes and adjustment to
motherhood
• Longer than two weeks in duration requires
medical evaluation
Postpartum Mood Disorder:
Depression
• Onset slow, usually around the fourth week
after delivery
• Assessment findings
– Depressed mood, fatigue, impaired concentration,
thoughts of death or suicide
• Risk factors
– History of depression, abuse, low self-esteem
• Management
– Psychotherapy, medications, hospitalization
Postpartum Psychosis
• Generally after the second PP week
• Assessment findings
– Sleep disturbance, agitation, delusions
• Risk factors
– Personal or family history of major psychiatric
illness
• Management
– May lead to suicide or infanticide
– Hospitalization, medications, psychotherapy
Postnatal Depression
Postnatal Depression
Postnatal Depression
Postnatal Depression
Postnatal Depression
Prevention of Depression
Prevention of Postpartum
Psychiatric Disorders
• Help parents understand the lifestyle changes
and role demands
• Provide realistic information
• Anticipatory guidance
• Dispel myths about the perfect mother or the
perfect newborn
• Educate about the possibility of postpartum
blues
• Educate about the symptoms of postpartum
depression
Self-Care: Postpartum
Psychiatric Disorders
• Signs and symptoms of postpartum
depression
• Contact information for any questions or
concerns
Nursing Diagnoses:
Postpartum Psychiatric Disorder
• Ineffective Individual Coping related to
postpartum depression
• Risk for Altered Parenting related to postpartal
mental illness
• Risk for Violence against self (suicide),
newborn, and other children related to
depression
Assessment of Overdistention
of the Bladder
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Large mass in abdomen
Increased vaginal bleeding
Boggy fundus
Cramping
Backache
Restlessness
Assessment of Cystitis
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Frequency and urgency
Dysuria
Nocturia
Hematuria
Suprapubic pain
Slightly elevated temperature
Prevention of Infection
• Good perineal care
• Hygiene practices to prevent contamination of
the perineum
• Thorough handwashing
• Sitz baths
• Adequate fluid intake
• Diet high in protein and vitamin C
Prevention of Bladder
Overdistension
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Frequent monitoring of the bladder
Encourage spontaneously voiding
Assist the woman to a normal voiding position
Provide medication for pain
Perineal ice packs
Prevention of a UTI
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Good perineal hygiene
Good fluid intake
Frequent emptying of the bladder
Void before and after intercourse
Cotton underwear
Increase acidity of the urine
Self-Care Measures: UTI
• Good perineal hygiene
• Maintain adequate fluid intake
• Empty bladder when she feels the urge to void
or at least every 2-4 hours while awake
Nursing Diagnoses:
Bladder Distention
• Risk for Infection related to urinary stasis
secondary to overdistention
• Urinary Retention related to decreased
bladder sensitivity and normal postpartal
diuresis
Nursing Diagnoses: UTI
• Pain with voiding related to dysuria secondary
to infection
• Health-seeking Behaviors related to need for
information about self-care measures to
prevent UTI
Self-Care Measures:
Puerperal Infection
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Activity and rest
Medications
Diet
Signs and symptoms of complications
Importance of completion of antibiotic
therapy
Community Based Care:
Puerperal Infection
• May need assistance when discharged from
the hospital
• May need a referral for home care services
• Instruct family on care of the newborn
• Instruct mother about breast pumping to
maintain lactation if she is unable to
breastfeed
Community Based Care:
Thromboembolic Disease
• Instruct family members on care of mother
and newborn
• Referral for home care if necessary
• Provide resources for follow-up or questions
• Teach all families to observe for signs and
symptoms
Community Based Care:
Postpartum Psychiatric Disorders
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Foster positive adjustments in the new family
Assessment of maternal depression
Teach families symptoms of depression
Give contact information for community
resources
• Make referrals as needed
Pelvic Hematoma
• Assessment findings
– Severe perineal pain
– Ecchymosis
– Visible outline of the
hematoma
– Blood loss may not be visible
Pelvic Hematoma (continued)
• Treatment
– Surgical drainage
– Antibiotics
– Analgesics
– Blood products if loss is excessive
Signs and Symptoms of Shock
• Hypotension
• Tachycardia, weak,
thready pulse
• Decreased pulse
pressure
• Cool, pale, clammy skin
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Cyanosis
Oliguria, anuria
Thirst
Hypothermia
Behavioral changes
(lethargy, confusion,
anxiety)
• Pg 664- table
Nursing Implications: Shock
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Monitor vital signs frequently
Large-bore IV for fluids, blood products
Administer oxygen, assess oxygen saturation
Assess hourly urine output
Assess level of consciousness
Nursing Implications: Shock (continued)
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Administer and monitor fluids, blood products
Draw/monitor laboratory results
Assess quantity and quality of bleeding
Provide emotional support to patient/family
Urinary Tract Infection
• Risk factors
– Urinary catheterization
– Long labor, operative delivery
• Assessment findings
– Dysuria, frequency, urgency
– Fever
– Suprapubic pain
• Management
– Antibiotics
Nursing Diagnoses:
Puerperal Infection
• Risk for Injury related to the spread of
infection
• Pain related to the presence of infection
• Deficient Knowledge related to lack of
information about condition and its treatment
• Risk for Altered Parenting related to delayed
parent-infant attachment secondary to
woman’s pain and other symptoms of
infection
Reproductive Loss
• Components of grief work
– Accepting the painful emotions involved
– Reviewing the experiences and events
– Testing new patterns of interaction and role
relationships
Reproductive Loss (continued)
• Four stages of grief
– Shock and numbness
– Searching and yearning
– Disorientation
– Reorganization
• Symptoms of normal grief
Examples of Reproductive Loss
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Inability to conceive
Spontaneous abortion
Preterm delivery
Congenital anomalies
Fetal demise
Neonatal death
Relinquishment
SIDS
Warning signs of illness PP
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Fever > 100.5
Severe pain, redness,swelling at incision site
Passing of large clots
Increased bleeding
Burning on urination
Insomnia
Impaired concentration
Feeling inadequate