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Nursing Management in the Postpartum Period
Terms in this set (22)
Postpartum Assessments - Frequency
During the first hour: every 15 minutes
During the second hour: every 30 minutes
During the first 24 hours: every 4 hours
After 24 hours: every 8 hours
Breasts (size, contour, engorgement)
Uterus (height of fundus, firmness)
Bladder (voiding, bladder emptying)
Bowels (bowel sounds, distention)
Lochia (amount, color, odor)
Episiotomy and perineum (lacerations, hematoma)
Extremities (edema, erythema)
Emotional status (warning signs)
Vital Signs Assessment
Temperature: Slight elevation (up to 100.4) during first 24 hours
Pulse:60 to 80 bpm
Blood pressure:Within usual range
Orthostatic hypotension common
Pain goal:0 to 2 on 0-10 pain scale
Postpartum Danger Signs
Box 16.2, pg. 559)
Fever more than 100.4°F (38°C)
Foul-smelling lochia or an unexpected change in color or amount
Large blood clots, or bleeding that saturates a peripad in an hour
Severe headaches or blurred vision
Visual changes, such as blurred vision or spots, or headaches
Calf pain with dorsiflexion of the foot
Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites
Dysuria, burning or incomplete emptying of the bladder
Shortness of breath or difficulty breathing without exertion
Depression or extreme mood swings
Risk Factors for Postpartum Infection
Box 16.1, pg 559)
Diabetes / HIV
Pronged membrane rupture
Indwelling urinary catheter
Manual placenta removal
Risk factors for Postpartum Hemorrhage
Box 6.1, pg. 559)
Prolonged second stage of labor
Previa / abruption
Induction or augmentation of labor
Inspect the breasts for size, contour, asymmetry, engorgement, or erythema. Check the nipples for cracks, redness, fissures, or bleeding, and note whether they are erect, flat, or inverted. Flat or inverted nipples can make breast-feeding challenging for both mother and infant. Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are generally indications that the baby is improperly positioned on the breast. Palpate the breasts lightly to ascertain if they are soft, filling, or engorged, and document your findings.
Assess the fundus (top portion of the uterus) to determine the degree of uterine involution. If possible, have the woman empty her bladder before assessing the fundus and auscultate her bowel sounds prior to uterine palpation.
Uterus/location in relation to umbilicus
The fundus should be midline and should feel firm. A boggy or relaxed uterus is a sign of uterine atony (loss of muscle tone in the uterus).Once the fundus is located, place your index finger on the fundus and count the number of fingerbreadths between the fundus and the umbilicus (1 fingerbreadth is approximately equal to 1 cm). One to 2 hours after birth, the fundus typically is between the umbilicus and the symphysis pubis. Approximately 6 to 12 hours after birth, the fundus usually is at the level of the umbilicus. If the fundal height is above the umbilicus, which would be an abnormal finding, investigate this immediately to prevent excessive bleeding. Frequently the woman's bladder is full, thus displacing the uterus up and to either side of the midline. Ask the woman to empty her bladder and reassess the uterus again.
Diuresis after 12 hours
500mL per void
Decreased bladder tone
Straight catheterize if needed
Signs if infection
Use of stool softeners
1-2 inch stain
4 inch stain / 10 - 25mL
4-6 in stain / 25-50mL
Saturate pad in 1 hour
Saturate paid in 15 minutes
Turn on side, lift buttock up
Signs of infection
Lacerations to the perineal area
First-degree laceration: involves only skin and superficial structures above muscle
Second-degree laceration: extends through perineal muscles
Third-degree laceration: extends through the anal sphincter muscle
Fourth-degree laceration: continues through anterior rectal wall
Side effects from medication
Monitor I & O
Catheter intact when removed
Risk factors for VTE / PE
Antiembolitic stockings or SCD for high risk patients
Close emotional attraction to a newborn by the parents
Develops the first 30 to 60 minutes after birth
Development of a strong affection between an infant and a significant other or caregiver
Develops over time
Witch hazel pads
2500ml fluid day
Eat high nutrition foods
Nutritional needs for the breast-feeding woman
+20 grams protein
USING A SITZ BATH
Close clamp on tubing before filling bag with water to prevent leakage.
Fill sitz bath basin and plastic bag with room-temperature water (comfortable to touch).
Place the filled basin on the toilet with the seat raised and the overflow opening facing toward the back of the toilet.
Hang the filled plastic bag on a hook close to the toilet or an IV pole.
Attach the tubing to the opening on the basin.
Sit on the basin positioned on the toilet seat and release the clamp to allow warm water to irrigate the perineum.
Remain sitting on the basin for approximately 15 to 20 minutes.
Stand up and pat the perineum area dry. Apply a clean peripad.
Tip the basin to remove any remaining water and flush the toilet.
Wash the basin with warm water and soap and dry it in the sink.
Store basin and tubing in a clean, dry area until the next use.
Wash hands with soap and water.
Preparing for Discharge
No signs of infection
Sexuality and contraception
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