Nursing Care of the child bearing family

Nursing Care of the child bearing family Goals of Healthy People 2020 Maternal-child focus: - ANS - Maternal illness and death rates - Increasing access to prenatal care - Decreasing infant mortality - Healthy birth outcomes and prevention of birth defects - Increase breast feeding initiation and duration Who is at risk? Risk Assessment: - ANS - Age - Global travel - Disease, vaccinations - Substance use/ Abuse - Stress - Sexual practices (STIs) - Medical Conditions Implications for nursing? - ANS Environmental and workplace hazzards comorbidities: - ANS - High blood pressure - diabetes - Obesity - HIV/STI - substance abuse - Too young (12 year olds) - Too old (50 year olds) - bleeding disorders - Smokers (effects vasoconstriction) - Intimate partner violence (increases during pregnancy) What is Culture? - ANS - Communication style - Family Patterns - Health Beliefs and Practices - Nutritional Patterns - Space orientation - Time orientation Culture does not equal - ANS ethnicity Standards of care - ANS developed by the ANA - 6 standards of practice (assessment, diagnosis, ect.) - Code of ethics Nurse Practice Acts - ANS at a state level - No Nurse Practice Act in Michigan. - Rules for nursing in Public Health Code Public Act - Defines the scope of practice - the "who"/"what"/"when"/"where" of nursing practice - Regulated by the State Board of Nursing - Protects the public, looks out for their safety and welfare of citizens Standards for Maternal-Newborn and Child Health Nursing - ANS - Speaks to Competency and Accountability of Nurses in Maternal Infant Health - Developed by research, professional associations and expert agreement • Association of Women's Health, Obstetric, and Neonatal Nursing (AWHONN), • American College of Obstetrics and Gynecology (ACOG), • American Academy of Pediatrics (AAP) Hospitals - ANS - have Policies, procedures, and protocols Malpractice • Many lawsuits occur in Labor & Delivery • Prevention: - ANS -Informed consent -Accurate documentation -Client advocate -Maintaining level of expertise -Strong interpersonal skills Good Communication Decreases Medical Errors Documentation... - ANS Documentation is the best evidence that a standard of nursing care has been maintained Accurate communication S B A R - ANS - Situation - Background - Assessment - Reccomendation Available Settings for Childbirth: - ANS • Traditional Hospital: -LDR (Labor, Deliver and Recover) -LDRP (Labor, Deliver, Recovery and post partum) • Alternative Birthing Center • Planned Home Birth It is always important to evaluate risk verses benefit intrapartum - ANS In labor postpartum - ANS After child birth LDR - ANS - Labor - Delivery - Recovery Postpartum Physiologic Adaptations Reproductive system: - ANS -Involution of uterus with descent of uterine fundus -Afterbirth pain -Lochia -Perineum -Breasts Other Postpartum Physiologic Adaptations - ANS • Cardiovascular System • Urinary System • Gastrointestinal System • Musculoskeletal System • Neurological System • Endocrine System Reproductive System Changes: - ANS Involution of Uterus (shrinkage) Contraction of the uterine muscle - Controls... - Decreasing... - Expect... - ANS - Controls bleeding from site of placental attachment - Decreasing height of fundus - Expect return to pre-pregnant size within 6 weeks Promote uterine contraction through: (2,-2) - ANS - Fundal massage - Oxytocin • Breast feeding • Pitocin - (IV or IM) Oxytocin - ANS releases from the body to help uterine contract (released when breast feeding) Squishy/boggy= - ANS not contracting Reproductive System Changes: Involution and Descent of Uterine Fundus • Assess... • Document in relation... • Recheck after... • Clots can interfere with... - ANS • Assess fundal height; support uterus to prevent inversion • Document in relation to umbilicus • Recheck after voiding • Clots can interfere with uterine contraction Reproductive System Changes: Involution and Descent of Uterine Fundus FUN not BAD - ANS Firm Umbilicus Not defeated NOT Boggy, Above umbilicus, Defeated Fundus above umbillicus means woman could be... - ANS bleeding internally ***CRITICAL ABNORMAL*** Factors that Enhance Uterine Involution: - ANS - Breastfeeding - Complete expulsion of placenta (forcing it out of the body) - Uncomplicated L/D Factors that Slow Uterine Involution - ANS Prolonged labor - Difficult delivery - Multiple children (multiparity) - Over-distention of uterus • Large baby, twins, excess fluid - Retained fragments of placenta - Full bladder - Infection Reproductive System Changes: After Pains Etiology: - ANS - Occur in all women - More acute for multiparas (has had more than one kid) - More severe with over distention of the uterus - More severe during breastfeeding Reproductive System Changes: After Pains Nursing considerations: - ANS - Analgesic frequently used - Offer to medicate before breastfeeding - Prone position may provide relief (on stomach) Cramping when breast feeding is... - ANS a good sign of hormone release of the stopping of bleeding Reproductive System Changes: Lochia Assess Color: rubra - ANS - first 3 days - the first discharge, Composed of blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo and membranes. It is red in color because of the large amount of blood it contains. Reproductive System Changes: Lochia Assess Color: serosa - ANS - days 4 through 10 - thinned and turned brownish or pink in color. It contains serous exudate, erythrocytes, leukocytes, cervical mucus and microorganisms. Reproductive System Changes: Lochia Assess Color: alba - ANS - after day 10 turned whitish or yellowish-white and contains fewer red blood cells and is mainly made up of leukocytes, epithelial cells, cholesterol, fat, mucus and microorganisms. Reproductive System Changes: Lochia Quantify Amount: Scant - ANS less than a 2.5-cm (1-inch) stain on the peripad Reproductive System Changes: Lochia Quantify Amount: Light - ANS less than 10-cm (4-inch) stain Reproductive System Changes: Lochia Quantify Amount: Moderate - ANS less than 15-cm (6-inch) stain Reproductive System Changes: Lochia Quantify Amount: Heavy - ANS saturated peripad in 1 hour Reproductive System Changes: Lochia Quantify Amount: Excessive - ANS saturated peripad 17 SJS in 15 minutes Reproductive System Changes: Perineum - ANS • May be edematous and bruised • Discomfort • Pelvic floor muscles stretch and thin - Kegel exercises encourage healing - Later in life women can experience pelvic relaxation • Laceration and episiotomy Reproductive System Changes: Perineum Nursing considerations: - ANS - Pain Relief - Decrease infection - Teach self-care measures Breasts Breastfeeding mothers Initial milk called: - ANS colostrum Breasts Breastfeeding mothers Volume of milk increases... - ANS 3-5 days after birth Reproductive System Changes: Breasts Ask your self...(3) - ANS Are breasts soft, firm, or engorged? Examine if infant is effectively breastfeeding - ANS LATCH SCORE Assess shape of nipples: - ANS flat or erect Assess for signs of nipple trauma: - ANS redness, cracks, or bleeding Non-breastfeeding mothers When does engorgement resolve? - ANS - Engorgement resolves spontaneously if no stimulus Non-breastfeeding mothers Manage discomfort with: - ANS breast binder, ice packs, mild analgesics Cardiovascular System Changes: Cardiac Output Readjustments in maternal vasculature are... - ANS dramatic and rapid Cardiovascular System Changes: Cardiac Output Increased flow of blood back to the heart - Decreased pressure from the - Excess - ANS - Decreased pressure from the pregnant uterus on the vessels - Excess extracellular fluid back into vascular compartment Cardiovascular System Changes: Cardiac Output Cardiac output returns to pre-pregnancy levels in - ANS 6 to 12 wk Mother's blood increases by - ANS 30-50% Cardiovascular System Changes: Blood Values Increased clotting factors - At risk for... - Compression stockings for... - Decreased risk with... - ANS - thrombus formation - caesarean section patients - early ambulation Cardiovascular System Changes: Blood Values White blood cell count - ANS increases -up to 30,000 is normal for pregnanr population (WBC) doesn't mean infection Cardiovascular System Changes: Blood Values Hemoglobin and hematocrit difficult to interpret - Plasma diluted by... - Returns to normal within... - ANS - remobilization of excess body fluid - 4 to 8 weeks Blood volume increase does not mean - ANS RBC increase Postpartum Physiologic Adaptations: Urinary System Changes Potential trauma to... - ANS urethra/meatus Postpartum Physiologic Adaptations: Urinary System Changes Diuresis - - ANS expect 3000 mL in the first 24 hours Postpartum Physiologic Adaptations: Urinary System Changes Loss of muscle tone in... - ANS bladder Postpartum Physiologic Adaptations: Urinary System Changes Diminished sensitivity to... - ANS fullness Postpartum Physiologic Adaptations: Urinary System Changes Over-distended bladder is the potential for: - ANS • Urinary retention and increased risk of UTI • Uterine atony and increased bleeding bare minimum urine output - ANS 30 ml/hr Postpartum Assessment: Bladder Elimination Assess for: (3) - ANS - Distention - Displacement of uterus - Fundus after emptying bladder Postpartum Assessment: Bladder Elimination Catheterize if: (3) - ANS - Unable to void - Voids less than 150 mL and the bladder can be palpated - The fundus is elevated or displaced from the midline Postpartum Physiologic Adaptations: Gastrointestinal System Changes • Digestion Increased... - ANS hunger and thirst Postpartum Physiologic Adaptations: Gastrointestinal System Changes • Constipation a common... - ANS problem Postpartum Physiologic Adaptations: Gastrointestinal System Changes Nursing Interventions (NICS) (3) - ANS • Encourage ambulation • Push fluids • Encourage high fiber dietary choices • Stool softeners as prescribed Postpartum Physiologic Adaptations: Musculoskeletal System Changes: Abdominal Wall Decreased... - ANS tone and strength Postpartum Physiologic Adaptations: Musculoskeletal System Changes: Abdominal Wall Diastasis recti: - ANS - If longitudinal muscles of the abdomen separate Postpartum Physiologic Adaptations: Neurologic System Changes Anesthesia and/or analgesia may produce... (2) - ANS temporary changes - Fall risk - Infant safety is a priority Postpartum Physiologic Adaptations: Neurologic System Changes Prevention of injury is a priority proper positioning...(2) - ANS - Proper positioning during the second stage of labor - Proper positioning during a cesarean delivery Postpartum Physiologic Adaptations: Neurologic System Changes Careful assessment of... - ANS headaches Postpartum Physiologic Adaptations: Endocrine System Changes • Return of... • Weight... • The hormones of Lactation (4) - ANS • ovulation and menstruation • Loss • - Estrogen - Progesterone - Prolactin - Oxytocin Postpartum Assessment Start with: - ANS Focused Assessment Postpartum Assessment - ANS - Level on Consciousness - Vital signs - Lung sounds - Bowel sounds - Skin color - Intravenous infusions (look at IV solution, rate, IV site) - Urinary output - Level of feeling and ability to move if regional anesthesia was administered • BUBBLE HEPP Postpartum Assessment: BUBBLE HEPP - ANS • B- Breasts • U- Uterus - Location and firmness of the fundus - Status of abdominal incision and dressing - REEDA • B- Bowel • B- Bladder • L- Lochia - Amount and color of lochia • E- Episiotomy/ Incision - Lacerations - Hematoma - REEDA • H- Homan's sign • E- Edema/ Emotions • P- Pain - Presence, location, intensity • Psychological adjustment - Maternal Attachment Incision Assessment R- E- E- D- A- - ANS Redness Ecchymosis (bruising from internal bleeding) Edema Drainage Approximation Postpartum Assessment: Lower Extremities • Examine for... • Palate... • Assess for... • Assess... - ANS - signs or symptoms of thrombophlebitis - pedal pulses - edema - deep tendon reflexes Care in Immediate Postpartum Period: Providing Comfort Measures: - ANS • Ice packs to the perineum • Perineal care with a water bottle • Topical medications • Sitting and standing techniques • Analgesics • Sitz baths • Provide food • Offer fluids- encourage 2500 mL per day - Consider cultural preferences of hot or cold fluids Application of the Nursing Process: Knowledge of Self-Care Assessment - Identify need for... - Determine... - Be aware of... - Determine need for... - ANS - education related to self-care - learning needs and major concerns of family - common barriers to learning - follow-up care and referrals Application of the Nursing Process: Knowledge of Self-Care Nursing Diagnoses - May be... - ANS Actual, Risk or Wellness Diagnosis • See Murray/McKinney Table 2-3--Page 24 Application of the Nursing Process: Knowledge of Self-Care (Cont.) Interventions: - ANS - Teach self-care - Promote rest and sleep - Provide nourishment and nutrition counseling - Promote regular bowel elimination - Counsel about sexual activity - Instruct about follow-up appointments - Teach about signs and symptoms to report - Teach infant safety! • Evaluation Process of Becoming Acquainted Bonding: - ANS • Initial attraction felt by the parents for the neonate • Delay procedures that may interfere with this time Process of Becoming Acquainted: Maternal Touch: • Initially holds baby in... • Mother gently explores... • May stroke with... • Gradually... - ANS • Initially holds baby in a face-to-face position • Mother gently explores infant with her fingertips • May stroke with palm of her hand • Gradually enfolds infant Psychological Adaption - ANS • "Taking In" • "Taking Hold" • "Letting Go" Process of Maternal Adaptation: Taking-in phase - ANS - Focused on own need for fluid, food, and sleep - Allows others to make decisions - Mother is integrating her birth experience into reality. - May be prolonged if complications occur ***Good care plan info Process of Maternal Adaptation: Taking-hold phase - ANS - Mother becomes more independent - Assumes responsibility for own self-care - Begins to shift attention to infant - May verbalize anxiety about her competence as a mother - Welcomes information about newborn behavior - Ideal time to provide instructions and demonstrations ***Good for education Process of Maternal Adaptation: Letting-go phase - ANS - Couple relinquishes role as a childless couple - Gives up idealized expectations of birth experience - Relinquishes infant of their fantasy, accepts real infant - Allow to verbalize feelings of grief ***Lets go of fantasy Process of Maternal Adaptation: Major Maternal Concerns - ANS • Body image • Role and functions of a mother • May have unrealistic expectations - perception of role differs from reality • Negotiate with other family members to take over household tasks • Cultural Influences Process of Maternal Adaptation: Major Maternal Concerns Assess parents' - ANS ability to provide a nurturing environment Nursing Interventions (NIC's) - ANS -Promote bonding -Listen -Teach about newborn -Involve parents in care -Foster independence -Help father co-parent -Help reduce sibling rivalry -Identify support -Make appropriate referrals The Nurse's Role as an Educator • First step, assess the... • Build on... • Use... • What can you... - ANS - parent's level of knowledge - client's current knowledge - multiple strategies, and reinforce information - teach your patient ?? *Teaching is a priority on the NCLEX Exam Contraception - ANS • Oral Contraception • Hormone Injection • Intrauterine Device • Condom • Diaphragm • Vaginal Spermicides • Steroid Implants • Coitus Interrupts • The "Morning After Pill" • Sterilization