NURS 2410 Unit 3

1. NURS 2410 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

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 • 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

15. 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 • 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

24. Mastitis

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

26. 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

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

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

38. Decreasing ThromboembolicRisk

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

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

49. Postnatal Depression

50. Postnatal Depression