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Nancy Pares, RN, MSN Metro Community College

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Presentation on theme: "Nancy Pares, RN, MSN Metro Community College"— Presentation transcript:

1 Nancy Pares, RN, MSN Metro Community College
NURS Unit 3 Nancy Pares, RN, MSN Metro Community College

2 Assessment of Postpartum Hemorrhage
Fundal height and tone Vaginal bleeding Signs of hypovolemic shock Development of coagulation problems Signs of anemia

3 Risk Factors for Postpartum Hemorrhage
Cesarean delivery Unusually large episiotomy Operative delivery Precipitous labor Atypically attached placenta Fetal demise Previous uterine surgery

4 Causes of Postpartum Hemorrhage
Uterine atony Lacerations of the genital tract Episiotomy Retained placental fragments Vulvar, vaginal, or subperitoneal hematomas

5 Causes of Postpartum Hemorrhage (continued)
Uterine inversion Uterine rupture Problems of placental implantation Coagulation disorders

6 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

7 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

8 Prevention of Postpartum Hemorrhage
Adequate prenatal care Good nutrition Avoidance of traumatic procedures Risk assessment Early recognition and management of complications

9 Postpartal Hemorrhage
Table 38–2 Signs of postpartal hemorrhage.

10 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

11 Community Based Care: Postpartum Hemorrhage
Clear explanations about condition and the woman’s 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

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

13 Uterine Atony (continued)
Management Fundal massage Blood products if loss is excessive Medications Oxytocin, methergine, carboprost tromethamine (Hemabate)

14 Uterine Atony Table 38–1 Uterine stimulants used to prevent and manage uterine atony.

15 Uterine Atony Table 38–1 (continued) Uterine stimulants used to prevent and manage uterine atony.

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

17 Retained Placental Fragments (continued)
Management Manual exploration of the uterus D&C Blood products if loss is excessive

18 Assessment of Infection: REEDA Scale
R: redness E: edema E: ecchymosis D: discharge A: approximation

19 Assessment of Infection (continued)
Fever Malaise Abdominal pain Foul-smelling lochia Larger than expected uterus Tachycardia

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

21 Lacerations (continued)
Management Suture the laceration Blood products if loss is excessive

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

23 Metritis Table 38–3 Common causative organisms in metritis.

24 Mastitis Table 38–4 Factors associated with development of mastitis.

25 Assessment of Mastitis
Breast consistency Skin color Surface temperature Nipple condition Presence of pain

26 Mastitis Infection of the breast Risk factors Assessment findings
Damaged nipples Failure to empty breasts adequately Assessment findings Fever, chills Breast pain, swelling, warmth, redness Management Antibiotics Complete breast emptying

27 Figure 38–2 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.

28 Prevention of Mastitis
Proper feeding techniques Supportive bra worn at all times to avoid milk stasis Good handwashing Prompt attention to blocked milk ducts

29 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

30 Breast Problems Table 38–5 Comparison of findings of engorgement, plugged duct, and mastitis.

31 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

32 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

33 Assessment of Thrombophlebitis
Homan’s sign Pain in the leg, inguinal area, or lower abdomen Edema Temperature change Pain with palpation

34 Figure 38–3 Homans’ sign. With the client’s knee flexed to decrease the risk of embolization, the nurse dorsiflexes the client’s foot. Pain in the foot or leg is a positive Homans’ sign. SOURCE: Photographer, Elena Dorfman

35 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

36 Thrombophlebitis (continued)
Assessment findings Pain, fever, redness, warmth, tender abdomen/calf Management Anticoagulants Antibiotics for septic pelvic thrombophlebitis

37 Thromboembolic Factors
Table 38–6 Factors associated with increased risk of thromboembolic disease.

38 Decreasing Thromboembolic Risk
Table 38–7 Measures to decrease risk of thromboembolic disease in childbearing women.

39 Prevention of Thrombophlebitis
Avoid prolonged standing or sitting Avoid crossing her legs Take frequent breaks while taking car trips

40 Self-Care: Thromboembolic Disease
Condition and treatment Importance of compliance and safety factors Ways of avoiding circulatory stasis Precautions while taking anticoagulants

41 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

42 Vitamin K Foods Table 38–8 Foods high in vitamin K.

43 Assessment of Postpartum Psychiatric Disorders
Depression scales Anxiety and irritability Poor concentration and forgetfulness Sleeping difficulties Appetite change Fatigue and tearfulness

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

45 Postpartum Blues (continued)
Etiology Hormonal changes and adjustment to motherhood Longer than two weeks in duration requires medical evaluation

46 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

47 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

48 Postnatal Depression Table 38–9 Edinburgh postnatal depression scale.

49 Postnatal Depression Table 38–9 (continued) Edinburgh postnatal depression scale.

50 Postnatal Depression Table 38–10 Postpartum depression predictors inventory (PDPI)—revised and guide questions for its use.

51 Postnatal Depression Table 38–10 (continued) Postpartum depression predictors inventory (PDPI)—revised and guide questions for its use.

52 Postnatal Depression Table 38–10 (continued) Postpartum depression predictors inventory (PDPI)—revised and guide questions for its use.

53 Prevention of Depression
Table 38–11 Primary prevention strategies for postpartum depression.

54 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

55 Self-Care: Postpartum Psychiatric Disorders
Signs and symptoms of postpartum depression Contact information for any questions or concerns

56 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

57 Assessment of Overdistention of the Bladder
Large mass in abdomen Increased vaginal bleeding Boggy fundus Cramping Backache Restlessness

58 Assessment of Cystitis
Frequency and urgency Dysuria Nocturia Hematuria Suprapubic pain Slightly elevated temperature

59 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

60 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

61 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

62 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

63 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

64 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

65 Self-Care Measures: Puerperal Infection
Activity and rest Medications Diet Signs and symptoms of complications Importance of completion of antibiotic therapy

66 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

67 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

68 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

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

70 Pelvic Hematoma (continued)
Treatment Surgical drainage Antibiotics Analgesics Blood products if loss is excessive

71 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

72 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

73 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

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

75 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 woman’s pain and other symptoms of infection

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

77 Reproductive Loss (continued)
Four stages of grief Shock and numbness Searching and yearning Disorientation Reorganization Symptoms of normal grief

78 Examples of Reproductive Loss
Inability to conceive Spontaneous abortion Preterm delivery Congenital anomalies Fetal demise Neonatal death Relinquishment SIDS

79 Warning signs of illness PP
Fever > 100.5 Severe pain, redness,swelling at incision site Passing of large clots Increased bleeding Burning on urination Insomnia Impaired concentration Feeling inadequate

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