post partum nursing notes

35
Physiologic Adaptations to Postpartum

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Page 1: Post Partum Nursing Notes

Physiologic Adaptations to Postpartum

Page 2: Post Partum Nursing Notes

“Making the decision to have a child – it’s momentous. It is to decide forever to have your heart go walking around outside your body.”

– Elizabeth Stone

Page 3: Post Partum Nursing Notes

Postpartum or Puerperium

First six weeks after delivery during which the reproductive system and the body returns to normal.

Although changes are normal, in no other period of life is there such marked and rapid physiological catabolism.

Page 4: Post Partum Nursing Notes

Changes in the following:

Cardiovascular Blood Vital Signs Abdominal

musculature Sleeping Psychological

Uterus Breasts Perineum Vagina Bowel Bladder Endocrine

Page 5: Post Partum Nursing Notes

Postpartum Assessment“BUBBLE-HE”

Breasts Uterus Bladder Bowel Lochia Episiotomy Homan Sign Emotion

Page 6: Post Partum Nursing Notes

Breast Changes Colostrum secreted from third tri. until

lactation begins Milk--lactation 3rd pp day Engorgement from increased vascular and

lymphatic circulation Decreased/absent placental hormones cause

prolactin to be secreted=lactation

Assessment- Engorgement, nipple cracks, soreness, or discomfort while breastfeeding

Page 7: Post Partum Nursing Notes

Uterine Changes

Blood vessels contract, uterus shrinks Involutes at 1cm/day 1cm=1fingerbreadth Below the symphysis by 10-12 days Process for involution=autolysis of protein

– 1000gm at delivery, 60gm at 6 wks pp

Assessment- palpate fundus at frequent intervals for position and firmness (ALWAYS support with two hands).

Page 8: Post Partum Nursing Notes

Bladder Changes

Bladder Changes– edema and hyperemia,extravasation– increased capacity, decreased sensitivity– overdistension with incomplete emptying– urethral trauma may cause dysuria– transient glycosuria, proteinuria, and keytonuria

are normal in immediate postpartum

Assessment- Dysuria, fullness, tone (ability to empty), placement, amount, frequency

Page 9: Post Partum Nursing Notes

Bowel Changes

decreased peristalisis decreased intra abdominal pressure hemorrhoidal discomfort perineal discomfort

Increase roughage and fluids, laxatives and suppositories--bowels normal by 1wk pp

Page 10: Post Partum Nursing Notes

LochiaVaginal discharge after delivery, composed of leukocytes, epithelial cells, decidua, autolysed protein and bacteria.– Rubra - delivery to 3rd day– Serosa - days 4-10– Alba -10--several weeks post

delivery

Assessment- color, amount, odor, & clots

Page 11: Post Partum Nursing Notes

Episiotomy

Episiotomy--subcuticular sutures Pain for 24-48 hrs

– ice for 24 hrs then heat (sitz baths)– Analgesics, systemic and topical– Sit properly– Keep clean--perineal care

Assessment-

Redness, Edema, Ecchymosis, Drainage, Approximation

Page 12: Post Partum Nursing Notes

Episiotomy

First Degree

Second Degree

Third Degree

Fourth Degree

Vaginal membranes

above include fascia

above, include anal sphincter

above, include anal canal

Page 13: Post Partum Nursing Notes

Homan’s Sign

Pregnancy and immediate pp is a hypercoagulable period placing a woman at risk for DVT.– Elevated clotting factors and fibrinogen

Assessment- Dorsiflexing the foot to assess calf for pain. Observe for redness, swelling, pain, or heat at site.

Page 14: Post Partum Nursing Notes
Page 15: Post Partum Nursing Notes

Emotion

Taking In

Taking Hold

Letting Go Giving up previous role See self as separate from infant Give up fantasy delivery and baby Readjustment Depression and grief work from 1wk

Moving from dependence to independence energy level focus on infant self care, focus on bowels, bladder, brfeed responds to instruction, praise Lasts from 2days to 1wk

Focused on self (not infant) dependent on others for help in care decision making difficult comfort-rest-food needs paramount relives delivery experience may last for several hours or days

Page 16: Post Partum Nursing Notes

Can you tell the difference?

Maternity Blues Postpartum Depression 13-20% of new mothers little interest or pleasure in

doing things feeling down, depressed, or

hopeless disturbed sleep patterns not wanting to socialize or “join

in”

50% to 80% of new mothers first few days- 2 weeks after

delivery mood swings feeling sad, anxious, or

overwhelmed crying spells loss of appetite trouble sleeping

Page 17: Post Partum Nursing Notes

The nurse becomes very frustrated with Maggie on day one, when she refuses to participate in the care of

her baby.

“All the patient wants to do is talk about how out of

shape she is.”

Page 18: Post Partum Nursing Notes

Endocrine Changes

Placental estrogen and progesterone removed

Prolactin increases, esp in breastfeeding women

Estrogen begins to increase to follicular levels at 3-4 wks after delivery

Menstruation returns--6 wks not breastfeeding, 2-18 mos breastfeeding

Page 19: Post Partum Nursing Notes

Vital Signs Change

BP first then – increases during uterine massage/pain– if PIH may stay elevated– orthostatic hypotension common

Temp first then P-- R--

Page 20: Post Partum Nursing Notes

Cardiovascular Changes

Blood volume goes rapidly from hypervolemia to hypovolemia– blood loss 400-500cc vaginal delivery

700-1000 cc C-section

Page 21: Post Partum Nursing Notes

Blood Changes

HCT (down 16% → in transient anemia) Leukocytes (20,000 to 25,000 mm3 for 10-12

days) Lymphocytes Fibrinogen--risk of thrombophlebitis Erythrocyte Sedimentation Rate (ESR)

Page 22: Post Partum Nursing Notes

Other Changes

Postpartum Chill

Shaking chill due to vasomotor instability

Postpartum diaphoresis

night sweats and increased odor

Page 23: Post Partum Nursing Notes

Maggie, 32 y/o G4 T2 P1A0 L3, delivered her infant son one hour ago

• Normal Vaginal Delivery• 3rd degree episiotomy• Catheterized just prior to delivery (200cc)• Epidural anesthesia

• Fundus @ the umbilicus• Lochia, moderate, Rubra with tissue debris• VSS• Bonding with newborn

Page 24: Post Partum Nursing Notes

QuestionA nurse is assessing the vital signs on a postpartum client who delivered vaginally 10 hours earlier.  Findings indicate a temperature of 100º, pulse 76 beats/minute, respirations 18/min, and blood pressure 124/70 mmHg.  The client reports feeling sweaty and having to urinate frequently but is otherwise comfortable.  How should the nurse interpret these findings?

a. The client is demonstrating signs and symptoms of hypovolemic shock indicated by her slow pulse and diaphoresis.

b. The client's elevated temperature and diaphoresis are an indication of puerperal infection and need to be addressed.

c. The client is bradycardic and the primary care provider should be notified for further assessment.

d. The client's vital signs and reports of feeling sweaty are normal and there is no need for intervention at this time.

Page 25: Post Partum Nursing Notes

Question

The nurse knows that subinvolution is most often the result of:

a. premature separation of the placenta

b. retained placental fragments and infection

c. self-destruction of excess hypertrophied tissue

d. velamentous insertion of the umbilical cord.

Page 26: Post Partum Nursing Notes

Essential Data

Blood Type Rh Status Rubella Status Infant Feeding Support System

Page 27: Post Partum Nursing Notes

Additional Assessment Data

• Blood type= O• Rh= Negative• Rubella titer= 1:4• Indirect Coombs= negative• Direct Coombs= negative• Infant Blood Type=O• Breastfeeding• Spouse and extended family in room

Page 28: Post Partum Nursing Notes

Rh Disease

• Affects mother’s with “negative Rh factor”• Fetal blood crosses placental barrier• Sensitization occurs• Administer Rhogam

• 28 weeks• within 72 hours after delivery

Rh -

Page 29: Post Partum Nursing Notes

48 hours post delivery

• Uterus @ 2cm below the umbilicus

• Lochia, rubra, large amount

• Diaphoretic

• Breasts- “filling”

• Last BM prior to delivery

• Voiding frequent small amounts

• Vital signs stable

Page 30: Post Partum Nursing Notes

Maggie calls the nurse to the room and she is crying. She tells the

nurse….“I can’t breastfeed…my stomach is

hurting all of the time.”

Page 31: Post Partum Nursing Notes

Lillian, a 22 y/o multipara, admitted from the L&D, 2 hours following vaginal birth of an 8

lb. 10 oz. girl

• Fundus is displaced to the right

• Perineal pads saturated

Page 32: Post Partum Nursing Notes

Four hours after delivery, a primipara c/o severe perineal pain.

i Second stage of labor lasted 2 1/2 hours

• Third degree extension of midline episiotomy

• Marked edema and bruising of perineum

Page 33: Post Partum Nursing Notes

A patient’s spouse rushes to the nurse for “HELP”…states “my

wife just passed out while walking to the bathroom.”

• Nursing Considerations

Page 34: Post Partum Nursing Notes

A patient asks the following questions during discharge

teaching:“When can I...

• Take a bath?• Return to work?• Resume sexual intercourse?• Stop talking my vitamins and iron?• Resume exercise?

Page 35: Post Partum Nursing Notes