Summary EXAM 2 (NUR2513) Concept Review Guide Notes

EXAM 2 (NUR2513) Concept Review Guide Notes Postpartum • Lochia assessment: • Rubra: 1-3 days PP (red) • Serosa: 3-10 days PP (brownish, pink) • Alba: 10-14 days PP (can last 6 weeks) (white, yellowish) • Expected amounts…how much is too much? o soaking through one pad in 60 minutes or less = heavy bleeding ▪ w/i 15 minutes = hemorrhage • Quantitative blood loss - weighing of pads • assess fundal height in the postpartum period: o one hand at pubic symphysis, one hand above fundus, 1 finger breadth = 1 cm o SHOULD be firm o Should NOT be boggy = hemorrhage massage the fundus keeping support to the lower segment of uterus (if not can lead to uterine inversion or hemorrhage) • Know the process of involution of the uterus: • Fundus to be after delivery: halfway between umbilicus & symphysis pubis, w/i 1 hr rises up at the umbilicus • (1 cm/ 1 finger breadth Q24h) • Day 1: below umbilicus- 1 cm lower from previous assessment • Day 2: 2 cm ( another 1 cm lower) • lower than expected is okay • HIGHER is BAD (subinvolution r/t flaccidity, full bladder) • Involution of the uterus involves two processes: o The area where the placenta was implanted is sealed off to prevent bleeding ▪ Accomplished by rapid contraction of the uterus immediately after delivery of the placenta. ▪ This contraction pinches the blood vessels entering the 7-cm-wide area left denuded by the placenta and halts bleeding. ▪ With time, thrombi form within the uterine sinuses and permanently seal the area ▪ Eventually, endometrial tissue undermines the site and obliterates the organized thrombi, covering and healing the area so completely the process leaves no scar tissue within the uterus so does not compromise future implantation sites • The organ is reduced to its approximate pregestational size ▪ The same contraction process reduces the bulk of the uterus ▪ Devoid of the placenta and the membranes, the walls of the uterus thicken and contract, gradually reducing the uterus from a container large enough to hold a full-term fetus to one the size of a grapefruit, a phenomenon that can be compared with a rubber band that has been stretched for many months and now is regaining its normal contour. • Involution will occur most dependably in a woman who is well nourished and who ambulates early after birth as gravity may play a role • Involution may be delayed by a condition such as the birth of multiple fetuses, hydramnios, exhaustion from prolonged labor, grand multiparity, or physiological effects of excessive analgesia • Be able to provide appropriate postpartum care to the woman after vaginal delivery: • Episiotomy/laceration o Episiotomy: a surgical incision of the perineum made to prevent tearing of the perineum, release pressure on the fetal head with birth and possibly shorten the last portion of the second labor stage o mediolateral incision turn patient so the incision is on the bottom buttock o inspect for hematoma, erythema, edema, intactness, bleeding, drainage ▪ REEDA Scale (Redness, Edema, Ecchymosis, Discharge, Approximation) • apply ice or cold pack (indirectly) to perineum first 24 hrs • heat to perineum + sitz baths AFTER first 24 hrs • teach perineal exercises • episiotomy suture care: anesthetic cream or spray, hydrocodone or acetaminophen for discomfort (NO aspirin) • perineal care after voiding, defecation, and daily- teach pt how to use spray bottle • Encourage mother to eat produce and soluble fiber foods, especially fruits, will help keep her stools naturally soft and ease in her bowel movements • Bladder assessment- what are the concerns • if uterus is shifted to side or higher than expected = FULL bladder • walk pt to bathroom, bedpan, bedside commode, straight cath or indwelling cath placement • voiding expected 6-8 hrs PP - measure first few voids. Should occur every 2-3 hours • diuresis between days 2-5 PP • If the woman still has not been able to void by 4-8 hours after birth, and bladder distention is present, she will need to be catheterized to relieve bladder pressure • Medications used during the postpartum period • stool softener (docusate sodium)- lowers surface tension of feces, water INTO stool) • Motrin (ibuprofen), acetaminophen • perineum pain ▪ lidocaine spray ▪ tucks- witch hazel pads ▪ ice w/i first 24 hours then sitz bath after first 24 hours • pre-eclampsia, seizure prevention ▪ magnesium sulfate • incisional pain, perineal pain ▪ vicodin, percocet • hemorrhage ▪ Oxytocin, methergine, hemabate • hypertension ▪ do NOT use methergine ▪ CAN use mag sulfate, hydralazine, labetalol, nifedipine • What infection risks present for the mom in the postpartum period? o uterine infection r/t lochia ▪ episiotomy increases risk ▪ leads to peritonitis, septicemia • Group B strep, staph, E Coli • endometritis (c-section, chorioamnionitis) • rupture of membranes more than 24 hours before birth • refrained placental fragments in uterus • PP hemorrhage- pre existing anemia • prolonged & difficult labor, instrumental births (lacerations, tissue trauma) • internal FHM electrode • local vaginal infection present at time of birth • uterus explored after birth • Mastitis • infection of the breast introduced through cracked nipples • Symptoms • unilateral usually but can be bilateral, scant breast milk production • affected breast is painful, red, swollen, tender to touch, & fever is present initially • malaise & flu like symptoms • Management • antibiotics, continue BFing or express milk manually, cold or ice compress, good supportive bra, wet compress, increase fluid intake • Differentiate between mastitis and blocked milk duct o blocked duct: same symptoms as mastitis but LOCAL, fever not involved. Hard nodules present in the breast- should resolve after infant feeds. • Rooming in: promotes bonding, BFing • Postpartum Preeclampsia: o Symptoms ▪ increase in HTN severity over first few days ▪ proteinuria, edema ▪ d/t refrained placental fragment ▪ seizure risk (6-24 h after birth) • Nursing care/management ▪ taken for D&C to remove retained placental fragments ▪ bed rest, quiet atmosphere, freq vitals, I&O ▪ admin magnesium sulfate, antihypertensives ▪ seizure precautions