T4 MATERNAL #4

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BHAVES
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146730
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T4 MATERNAL #4
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2012-04-11 03:54:02
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T4 MATERNAL
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T4 MATERNAL #4
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  1. POSTPARTUM
    Postpartum - also known as Puerperium last 6 weeks, following 6 weeks after Birth
  2. Physiological Maternal Changes During Postpartum - Lochial Flow - Moderate to Scant
  3. 4th STAGE OF LABOR
    • Monitor V/S uterine firmness, uterine position - midline of abdomen
    • Every 15 mins x 4 for first hour, every 30 mins x 2 for second hour, hourly x2, then every 4-8 hr
  4. ASSESSING THE FUNDUS
    • If Fundus becomes SOFT & BOGGY, HEMORRHAGE CAN OCCUR -> MASSAGE THE FUNDUS
    • A Fundus RIGHT of the MIDLINE often FULL BLADDER
    • Encourage to Void REEVALUATE AFTER VOIDING
  5. LOCHIA - MENSES --> Observe the amount Character & Color
  6. TYPES OF LOCHIA
    • Lochia RUBRA - Bright RED color, Small CLOTS - nickle size, Last 1-3 days after delivery -> moderate amount ok
    • Lochia SEROSA - Pinkish BROWN color, Lasts from 4-10 days after delivery
    • Lochia ALBA - YELLOWISH WHITE CREAMY color, Last from 11 days - 6 weeks Postpartum
  7. ABNORMAL LOCHIA - Persistent Lochia Rubra > 3 days suggests retained Placental fragments
  8. UTERINE INVOLUTION - (Volume) Contraction of the Uterine
    • Fundal Height - 1 FINGER BREATH (1-2 CM)
    • After Delivery: Fundus at Midline, at level of Umbilicus - (FIRM) 1 hour after delivery
    • By 10 days Postpartum Uterus should not be Palpated - UNPALPABALE (lies within the Pelvis)
  9. CERVICAL VAGINAL & PERINEAL CHANGES
    • Promote measures to Soften Stools - DRINK LOTS OF FLUIDS & ENCOURAGE FIBER
    • Educate Client for Proper Cleansing - Use Squeeze Bottle (PERI BOTTLE) after Voiding & Passing Stool; Cleanse from FRONT to BACK after each VOIDING & BOWEL MOVEMENT
    • Promote Comfort Measures - ICE PACKS for first 24-48 hrs, SITZ BATHS after 24 hrs
    • EPISIOTOMY - ice pack 1st day of Postpartum
  10. BREAST CHANGES - Secretion of Clustrum, a Thin yellowish secretion
    • BREAST ENGORGEMENT - Both Breastfeeding Mom and None Breastfeeding can have a BREAST ENGORGEMENT
    • Encourage WELL FITTING BRASSIERE - for NON-BREASTFEEDING to PREVENT ENGORGEMENT
    • Breastfeeding --> release of OXYTOCIN --> let down Reflex & Uterine Contractions
    • Teach Client storke Infants lips with Nipple--> Infant takes in part of ARREOLA & NIPPLE not just nipple tip
  11. BREASTFEEDING --> Teach to Prevent Mastitis
    • Wash Hands before Handling the Breasts or Breastfeeding
    • Wash Nipples with WARM WATER ONLY- do not use soap
    • Expose Nipples to AIR to keep them DRY
    • Change Breast Pads Frequently
    • Baby should grasp Both Nipple & Areola
    • Rls baby Grasp on Nipple b4 removing baby from the Breast
  12. CHANGES IN VITAL SIGNS - Insignificant Slight Transient Increase
    • Elevation of Temperature (low grade) due to dehydration - ENCOURAGE FLUID INTAKE
    • Low Grade 99.6 first due to DEHYDRATION - PUSH FLUIDS
  13. CHANGES IN GASTROINTESTINAL SYSTEM
    CONSTIPATION - delayed 2-3 days after Birth --> ENCOURAGE AMBULATION, FIBER, FLUID ENCOURAGE STOOL SOFTENERS
  14. CHANGES IN MUSCULOSKELETAL SYSTEM
    • Assess Clients Abdominal Wall --> usually resolves within 6 weeks
    • Teach Client KEGAL EXERCISES - to STRENGTHEN PERINEAL MUSCLES --> PRIMARY PURPOSE IS TO STRETCH PERINEAL MUSCLES

    • COMFORT LEVEL:
    • AFTERPAINS common when BREASTFEEDING; Assess Location, Type & Quality (Abdomen/Cramps/8/10)
  15. IMMUNE SYSTEM - (RhoGAM) IM within 72 hrs of delivery to Suppress Antibody formation
    BONDING & INTEGRATION --> Culture age & socioeconomic - BE SENSITIVE
  16. Psychosocial Adaptation & Maternal Adjustment
    • TAKING-HOLD PHASE -->
    • Begins 2nd & 3rd Postpartum; EVIDENCE HEALTHY ATTACHMENT SHE TALKS TO BABY EYE CTC/CUDDLES
    • Eye Contact is GOOD EVIDENCE of Maternal Bonding

    • LETTING-go-PHASE -->
    • Begins to accept Neonate as Separate Individual

    • Nx Interventions:
    • Placing Infant SKIN TO SKIN --> Do you have any Concerns
  17. POSTPARTUM HEMORRHAGE
    • Serious Complication of Childbirth that can Result in HYPOVOLEMIC SHOCK
    • B/P Drop Systolic; SYSTOLIC of <90 or LESS report Immediately
  18. INVERSION OF THE UTERUS --> The Turning INSIDE OUT of the Uterus --> may be partial or Complete (Cervix/Vagina)
  19. RETAINED PLACENTA -
    Monitor for Uterine Atony --> Excessive Bleeding or Clots larger than a quarter TOO LARGE ->PROBLEM
  20. LACERATIONS &/or HEMATOMAS
    PAIN is most common symptom - ICE PACKS, SITZ BATH , LIDOCAINE

    • Risk Factors:
    • CPD - Cephalopelvic Disproportion

    • Monitor S/S:
    • Constant Oozing, slow tricle, or frank bright red blood flow from Vagina

    • Visually or Manually Inspect the PERINEUM & RECTUM.
    • Apply Ice Packs to Small Vulvar Hematoma's & encourage Sitz Bath - DO NOT RUB
  21. THROMPOPHLEBITIS
    • PT/INR if clientis on Warfarin (Coumadin)
    • Platelet count, PT & PTT if Client is on Heparin

    Monitor for S/S Thromphlebitis -->Assess lower extremities --> CHECK DORSIFLEXION; ABNORMAL TO FIND CALF PAIN IF DORSIFLEX
  22. PUERPERAL INFECTIONS --> After Birth
    • If any Discomfort & Tenderness in Abdomen Suspect Infection
    • Monitor for S/S of Endometritis, Wound Infection, Mastitis - ASSESS FOR DISCOMFORT/PAIN in ABDOMEN

    • NX INTERVENTION:
    • Encourage use of Ice Packs/ or MOIST WARM PACKS especially on affected Side->PAINFUL AREA
    • Encourage client completely empty Breasts at each Feeding to prevent Milk Stasis -> CAUSES CLOGGED MILK DUCT
    • Instruct Client to Report of REDNESS & fever / WARM PAIN IN THE BREASTS.
    • Most Effective to Prevent Engorgement Feed Baby Every 2-3 hrs
  23. URINARY TRACT INFECTIONS (UTI) -> Signs of Cystitis --> Blood Tinged & Painful Urination
  24. POSTPARTUM DEPRESSION
    10-15% of New Mothers; assess for suicidal thoughts, delusion, flat affect
  25. NORMAL NEWBORN - Neonate 4 dramatic changes to adapt outside Uterus
    • Respiration - suction mouth then nose
    • Circulation -
    • Temperature Regulation
    • Nourishment
  26. GESTATIONAL AGE ASSESSMENT
    • Weight: 2500 - 4000 grams (51/2 - 10 lbs) same time daily
    • Length: 45 -55cm (18 - 22 inches) top of head to heel
    • Head Circumference: 32-36.8 (12.6 - 14.5 inches) at level of Infant's eyebrows
    • Chest Circumference: 30-33 cm (12-13 inches) at the nipple line
    • Normal HR: 100-160 <100 call MD
  27. PHYSICAL EXAM
    • Respirations-> 30-60 bpm
    • HR--> 100-160 bpm
    • B/P-->60-89 mm Hg systolic 40-50 mmHg diastolic
    • Temperature--> 97.4 -98.9 axillary
  28. NORMAL SKIN DEVIATIONS
    • Milia - white spots on the chin nose forehead
    • Mongolian Spots - present on dark skinned infants
    • Telangiectatic Nevi (Stork Bites) flat pink or red marks
    • Nevus Flammeus (Port Wine stain) - capillary angioma
    • Erythema Toxicum (Neonatorum) - pink rash
    • EPSTEINS PEARLS - SMALL WHITE CYST

    • Physical Exam:
    • Mouth - Epstein Pearls --> Symmetrical Lip Movement
    • Abdomen - Umbilical Cord 2 ateries 1 vein
    • Anogenital: Male/Female - Must Void/Stool within 24 hrs
  29. REFLEXES
    • Sucking - Place finger in Baby's mouth
    • Moro - Suddenly lowering the body & assessing Bilateral Arm Extension & leg Flexion
    • Rooting - Baby's Head will turn
    • Palmar - Holding Baby's Palm
    • Stepping -
  30. SENSES -
    • Vision -
    • Hearing -
    • Touch -
    • Taste -
    • Smell -
  31. CIRCUMCISION CARE -
    Nursing Action --> AFTER CIRCUMCISION CARE CHECK SWELLING /BLEEDING
  32. PRETERM INFANT
    S/S: Respiratory Distress --> NOTIFY MD IMMEDIATELY
  33. POST TERM INFANT
    Peeling Cracked, --> QUESY'S IN A SOLES of the FEET
  34. HYPERBILIRUBINEMIA
    • Physiologic Jaundice - AFTER 24 HRS of AGE
    • Pathologic Jaundice - BEFORE 24 HRS of age or is PERSISTENT AFTER DAY 7, BILIRUBIN > 13 mg//DL
  35. SETTING UP PHOTOTHERAPY
    • Maintain Eye Mask over Newborn's Eyes -
    • COVER INFANTS EYE FOR PHOTOTHERAPY
  36. CONGENITAL ANOMALIES
    • CLEFT LIP/PALATE -Opening of the Palate
    • PKU - Phenylkenonuria - to prevent mental retardation
    • GALACTOSEMIA - Inability -> LACTOSE INTO GALACTOSE INTO GLUCOSE
    • HYDROCEPHALUS -
    • RN measures head Circumference for HYDROCEPHALUS
    • increase size of Head most characteristics of hydrocephalus

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