NURS 2410 Unit 3

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NURS 2410 Unit 3

• Nancy Pares, RN, MSN
• Metro Community College

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Assessment of Postpartum Hemorrhage

• Fundal height and tone
• Vaginal bleeding
• Signs of hypovolemic shock
• Development of coagulation problems
• Signs of anemia

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Risk Factors for Postpartum Hemorrhage

• Cesarean delivery
• Unusually large episiotomy
• Operative delivery
• Precipitous labor
• Atypically attached placenta
• Fetal demise
• Previous uterine surgery

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Causes of Postpartum Hemorrhage

• Uterine atony
• Lacerations of the genital tract
• Episiotomy
• Retained placental fragments
• Vulvar, vaginal, or subperitoneal hematomas

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Causes of Postpartum Hemorrhage (continued)

• Uterine inversion
• Uterine rupture
• Problems of placental implantation
• Coagulation disorders

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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

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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

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Prevention of Postpartum Hemorrhage

• Adequate prenatal care
• Good nutrition
• Avoidance of traumatic procedures
• Risk assessment
• Early recognition and management of complications

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Postpartal Hemorrhage
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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

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Community Based Care Postpartum
Hemorrhage

• Clear explanations about condition and the
  womans 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

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Uterine Atony

• Risk factors
• Overdistension of the uterus
• Uterine anomaly
• Poor uterine tone
• Assessment findings
• Excessive bleeding, boggy fundus

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Uterine Atony (continued)

• Management
• Fundal massage
• Blood products if loss is excessive
• Medications
• Oxytocin, methergine, carboprost tromethamine
  (Hemabate)

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Uterine Atony
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Uterine Atony
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Retained Placental Fragments

• Risk factors
• Mismanagement of third stage
• Placental malformations
• Abnormal placental implantation
• Assessment findings
• Excessive bleeding, boggy fundus

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Retained Placental Fragments (continued)

• Management
• Manual exploration of the uterus
• DC
• Blood products if loss is excessive

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Assessment of Infection REEDA Scale

• R redness
• E edema
• E ecchymosis
• D discharge
• A approximation

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Assessment of Infection (continued)

• Fever
• Malaise
• Abdominal pain
• Foul-smelling lochia
• Larger than expected uterus
• Tachycardia

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Lacerations

• Risk factors
• Operative delivery
• Precipitous delivery
• Extension of the episiotomy
• Varices
• Assessment findings
• Excessive bleeding with a firm uterus

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Lacerations (continued)

• Management
• Suture the laceration
• Blood products if loss is excessive

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Endometritis

• Infection of the uterine lining
• Risk factors
• Cesarean section
• Assessment findings
• Fever, chills
• Abdominal tenderness
• Foul-smelling lochia
• Management
• Antibiotics

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Metritis
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Mastitis
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Assessment of Mastitis

• Breast consistency
• Skin color
• Surface temperature
• Nipple condition
• Presence of pain

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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

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Figure 382 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.
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Prevention of Mastitis

• Proper feeding techniques
• Supportive bra worn at all times to avoid milk
  stasis
• Good handwashing
• Prompt attention to blocked milk ducts

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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

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Breast Problems
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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

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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

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Assessment of Thrombophlebitis

• Homans sign
• Pain in the leg, inguinal area, or lower abdomen
• Edema
• Temperature change
• Pain with palpation

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Figure 383 Homans sign. With the clients
knee flexed to decrease the risk of embolization,
the nurse dorsiflexes the clients foot. Pain in
the foot or leg is a positive Homans sign.
SOURCE Photographer, Elena Dorfman
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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

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Thrombophlebitis (continued)

• Assessment findings
• Pain, fever, redness, warmth, tender abdomen/calf
• Management
• Anticoagulants
• Antibiotics for septic pelvic thrombophlebitis

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Thromboembolic Factors
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Decreasing ThromboembolicRisk
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Prevention of Thrombophlebitis

• Avoid prolonged standing or sitting
• Avoid crossing her legs
• Take frequent breaks while taking car trips

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Self-Care Thromboembolic Disease

• Condition and treatment
• Importance of compliance and safety factors
• Ways of avoiding circulatory stasis
• Precautions while taking anticoagulants

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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

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Vitamin K Foods
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Assessment of Postpartum Psychiatric
Disorders

• Depression scales
• Anxiety and irritability
• Poor concentration and forgetfulness
• Sleeping difficulties
• Appetite change
• Fatigue and tearfulness

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Postpartum Blues

• Occurs within 3 to 10 days of delivery
• Generally transient
• Usually resolves without treatment
• Assessment findings
• Tearful, fatigue, anxious, poor appetite

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Postpartum Blues (continued)

• Etiology
• Hormonal changes and adjustment to motherhood
• Longer than two weeks in duration requires
  medical evaluation

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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

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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

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Postnatal Depression
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Postnatal Depression
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Postnatal Depression
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Postnatal Depression
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Postnatal Depression
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Prevention of Depression
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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

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Self-Care Postpartum Psychiatric
Disorders

• Signs and symptoms of postpartum depression
• Contact information for any questions or concerns

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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

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Assessment of Overdistention of the Bladder

• Large mass in abdomen
• Increased vaginal bleeding
• Boggy fundus
• Cramping
• Backache
• Restlessness

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Assessment of Cystitis

• Frequency and urgency
• Dysuria
• Nocturia
• Hematuria
• Suprapubic pain
• Slightly elevated temperature

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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

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Prevention of Bladder Overdistension

• Frequent monitoring of the bladder
• Encourage spontaneously voiding
• Assist the woman to a normal voiding position
• Provide medication for pain
• Perineal ice packs

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Prevention of a UTI

• Good perineal hygiene
• Good fluid intake
• Frequent emptying of the bladder
• Void before and after intercourse
• Cotton underwear
• Increase acidity of the urine

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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

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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

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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

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Self-Care Measures Puerperal Infection

• Activity and rest
• Medications
• Diet
• Signs and symptoms of complications
• Importance of completion of antibiotic therapy

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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

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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

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Community Based Care Postpartum
Psychiatric Disorders

• 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

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Pelvic Hematoma

• Assessment findings
• Severe perineal pain
• Ecchymosis
• Visible outline of the hematoma
• Blood loss may not be visible

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Pelvic Hematoma (continued)

• Treatment
• Surgical drainage
• Antibiotics
• Analgesics
• Blood products if loss is excessive

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Signs and Symptoms of Shock

• Hypotension
• Tachycardia, weak, thready pulse
• Decreased pulse pressure
• Cool, pale, clammy skin

• Cyanosis
• Oliguria, anuria
• Thirst
• Hypothermia
• Behavioral changes (lethargy, confusion, anxiety)
• Pg 664- table

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Nursing Implications Shock

• Monitor vital signs frequently
• Large-bore IV for fluids, blood products
• Administer oxygen, assess oxygen saturation
• Assess hourly urine output
• Assess level of consciousness

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Nursing Implications Shock (continued)

• Administer and monitor fluids, blood products
• Draw/monitor laboratory results
• Assess quantity and quality of bleeding
• Provide emotional support to patient/family

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Urinary Tract Infection

• Risk factors
• Urinary catheterization
• Long labor, operative delivery
• Assessment findings
• Dysuria, frequency, urgency
• Fever
• Suprapubic pain
• Management
• Antibiotics

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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 womans
  pain and other symptoms of infection

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Reproductive Loss

• Components of grief work
• Accepting the painful emotions involved
• Reviewing the experiences and events
• Testing new patterns of interaction and role
  relationships

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Reproductive Loss (continued)

• Four stages of grief
• Shock and numbness
• Searching and yearning
• Disorientation
• Reorganization
• Symptoms of normal grief

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Examples of Reproductive Loss

• Inability to conceive
• Spontaneous abortion
• Preterm delivery
• Congenital anomalies
• Fetal demise
• Neonatal death
• Relinquishment
• SIDS

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Warning signs of illness PP

• Fever gt 100.5
• Severe pain, redness,swelling at incision site
• Passing of large clots
• Increased bleeding
• Burning on urination
• Insomnia
• Impaired concentration
• Feeling inadequate