NURS 2410 Unit 3

1. NURS 2410 Unit 3 Nancy Pares, RN, MSN Metro Community College

2. Objective 1 and 2 • Relate specific pathophysiology and nursing process specific to postpartum. • Idenitify specific post partum complications and nursing management • Placental issues, uterine issues, vaginal issues

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

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

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

6. Causes of Postpartum Hemorrhage (continued) • Uterine inversion • Uterine rupture • Problems of placental implantation • Coagulation disorders

7. 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

8. 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

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

10. Postpartal Hemorrhage

11. 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

12. 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

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

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

15. Uterine Atony

16. Uterine Atony

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

18. Placental Adherence Accreta villi attach to the outer layer myometrium Increta villi attach within the muscle layer of the myometrium Percreta villi attach deep within the myometrium

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

20. Lacerations • Risk factors • Operative delivery • Precipitous delivery • Extension of the episiotomy • Varices • Assessment findings • Excessive bleeding with a firm uterus • Management • Suture if needed • Blood products if loss is excessive

21. Objective 2 • Identify nursing process for post partum psycho social disorders

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

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

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

25. 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

26. 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

27. Postnatal Depression

28. Prevention of Depression

29. 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

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

31. 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

32. Nursing Diagnoses: Postpartum Psychiatric Disorder • Ineffective Individual Coping related to postpartum depression • Risk for Altered Parenting related to postpartal mental illness • Risk for Violenceagainst self (suicide), newborn, and other children related to depression

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

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

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

36. Objective 4 • Review nursing interventions associated with • DVT, Hematoma, hemorrhoids, endometritis, wound infections, urinary infections and STD

37. Assessment of Infection: REEDA Scale • R: redness • E: edema • E: ecchymosis • D: discharge • A: approximation

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

39. 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

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

41. Metritis

42. Mastitis

43. Assessment of Mastitis • Breast consistency • Skin color • Surface temperature • Nipple condition • Presence of pain

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

45. 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.

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

47. 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

48. Breast Problems

49. 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

50. 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