BUBBLE HED POSTPARTUM ASSESSMENT
POSTPARTUM ASSESSMENT SIMULATION
DISCUSSION
A. BREASTS
- Assess supply, latch, milk transfer, and pain due to engorgement- Assess for signs of infection / mastitis: fever, erythema of breasts
- Assess for breast engorgement with low grade fever, is common and normal
- Assess for cracked nipples, pressure sores, or fissures. Evaluate whether nipples are everted, flat, or inverted.
Rationale:
Promotes involution as breastfeeding causes the release of oxytocin which helps uterus to contract.
Nursing care:a. Breast engorgement usually occurs 2-3 days post partum; and pain can be relieved by heat packs. Teach mom to: apply warm packs or K-pad 15-20 minutes pre-nursing and try a warm shower before nursing.
b. All mothers should wear a supportive bra 24 hours a day for the first few days postpartum
Documentation:
1.) Take note of the size, shape and color
2.) Soft, secreting colostrum, and / or milk production
3.) Firm and warm
4.) Tender, hard, and tense upon palpation or fully engorged breasts.
5.) Small, firm nodules in the breast (indicates blockage of milk duct)
6.) Inspect nipples for cracks, fissures, or configuration. Flat, everted or inverted
7.) Level of pain
8.) Sucking reflex of the baby
9.) Note signs of infection or mastitis e.g fever, erythema of breasts
10.) NURSING INTERVENTIONS
2.) Soft, secreting colostrum, and / or milk production
3.) Firm and warm
4.) Tender, hard, and tense upon palpation or fully engorged breasts.
5.) Small, firm nodules in the breast (indicates blockage of milk duct)
6.) Inspect nipples for cracks, fissures, or configuration. Flat, everted or inverted
7.) Level of pain
8.) Sucking reflex of the baby
9.) Note signs of infection or mastitis e.g fever, erythema of breasts
10.) NURSING INTERVENTIONS
Sample Documentation:
BREASTS NORMAL FINDINGS>BREASTS ARE TENDER AND FULLY ENGORGED, WARM TO TOUCH, COMPLAINED OF PAIN (9/10), WITH SMALL NODULES UPON PALPATION, NO SIGNS OF INFECTION, CRACKS NOT NOTED ON BOTH NIPPLES, WITH GOOD AMOUNT OF MILK PRODUCTION. BABY HAS GOOD SUCKING REFLEX.>PROPER BREAST CARE DEMONSTRATED AND BREAST CLEANING PRE AND POST BREASTFEEDING ENCOURAGED.>CONTINUE BREASTFEEDING ENCOURAGED.>HOT PACKS ON BOTH BREASTS APPLIED FOR 15 MINUTES.>ADVISED TO WEAR COMFORTABLE SUPPORT BRASSIERE.
BREASTS ABNORMAL FINDINGS>LEFT BREAST IS TENDER AND FULLY ENGORGED, WARM TO TOUCH, WITH SEVERE PAIN OF 10/10, ERYTHEMA NOTED AROUND THE NIPPLE WITH CRACKS, WITH YELLOWISH PUS DISCHARGE IN THE NIPPLE.>PATIENT IS FEBRILE, T-39.1C>AFFECTED SITE ASEPTICALLY CLEANSED WITH SALINE AND BETADINE.>MOTHER INSTRUCTED TO BREASTFEED ON RT BREAST.>TSB RENDERED.>HOT PACK APPLIED ON BOTH BREASTS.>TEMPERATURE CLOSELY MONITORED.>DR. DURAN NOTIFIED WITH ORDERS GIVEN AND CARRIED OUT.>INCREASE ORAL FLUID INTAKE INSTRUCTED.>PARACETAMOL 1 TAB GIVEN PER OREM AS ORDERED.>ORAL ANTIBIOTICS STARTED AS ORDERED GIVEN ON FULL STOMACH.
B. UTERUS
- Immediately after delivery, uterine contractions begin triggering involution (the process whereby the uterus and other reproductive organs return to their state prior to pregnancy)
- Uterine contractions can be measured by fundal height. Assess and evaluate the height and consistency of the fundus (the part of the uterus that can be palpated abdominally) and measures by fingerbreadths
- Immediately after delivery, the upper portion of the uterus (fundus) is midline and palpable halfway between the symphysis pubis and the umbilicus. Aproximately one hour post delivery, the fundus should be firm and at the level of the umbilicus
- The uterus palpated off of midline, either right or left side is due to distended bladder. If possible, the woman should be encouraged to empty her bladder prior to assessment of the fundus. A full bladder can prevent uterine involution and may cause bleeding.
Purpose:
To determine the location and firmness of the uterus
Procedures:
1. Explain the procedure and rationale before beginning the procedure. Explanations reduce anxiety and elicit cooperation.
2. Ask the mother to empty her bladder if she has not voided recently. A distended bladder lifts and displaces the uterus.
3. Place the mother in the supine position with her knees flexed. This relaxes the abdominal muscles and permits accurate location of the fundus.
4. Place your non-dominant hand above the woman’s symphysis pubis (base of the uterus) in a cupping manner (to support the lower uterine ligaments).
5. Then, press in and downward with the other hand at the umbilicus until she makes contact with a hard, globular mass. Use the flat part of your fingers (not the fingertips) for palpation. Palpation may be painful, particularly for the mother who had a cesarean birth. The larger surface of the fingers provides more comfort.
6. Begin palpation at the umbilicus, and palpate gently until the fundus is located. It should be firm, in the midline, and approximately at the level of the umbilicus. Locating the fundus is more difficult if the woman is obese or if the abdomen is distended. Palpation helps determine the firmness and location of the fundus.
7. If the fundus is difficult to locate or is “boggy,” (soft) keep the non-dominant hand above the woman’s symphysis pubis and massage the fundus with the dominant hand until the fundus is firm. The non-dominant hand anchors the lower segment of the uterus and prevents inversion while the uterus is massaged. The uterus contracts in response to tactile stimulation, and this helps control excessive bleeding.
8. Identify if the fundus is above or below the level of the umbilicus. Use your fingers to determine the number of fingerbreadths between the fundus and the umbilicus. Using the fingers to measure allows an approximation of the number of centimeters. The height of the fundus after the first hour following delivery is at the umbilicus or above it. Every day the fundal height decreases by approximately the width of one finger (one cm) until it reaches 4 fingerbreadths.
2. Ask the mother to empty her bladder if she has not voided recently. A distended bladder lifts and displaces the uterus.
3. Place the mother in the supine position with her knees flexed. This relaxes the abdominal muscles and permits accurate location of the fundus.
4. Place your non-dominant hand above the woman’s symphysis pubis (base of the uterus) in a cupping manner (to support the lower uterine ligaments).
5. Then, press in and downward with the other hand at the umbilicus until she makes contact with a hard, globular mass. Use the flat part of your fingers (not the fingertips) for palpation. Palpation may be painful, particularly for the mother who had a cesarean birth. The larger surface of the fingers provides more comfort.
6. Begin palpation at the umbilicus, and palpate gently until the fundus is located. It should be firm, in the midline, and approximately at the level of the umbilicus. Locating the fundus is more difficult if the woman is obese or if the abdomen is distended. Palpation helps determine the firmness and location of the fundus.
7. If the fundus is difficult to locate or is “boggy,” (soft) keep the non-dominant hand above the woman’s symphysis pubis and massage the fundus with the dominant hand until the fundus is firm. The non-dominant hand anchors the lower segment of the uterus and prevents inversion while the uterus is massaged. The uterus contracts in response to tactile stimulation, and this helps control excessive bleeding.
8. Identify if the fundus is above or below the level of the umbilicus. Use your fingers to determine the number of fingerbreadths between the fundus and the umbilicus. Using the fingers to measure allows an approximation of the number of centimeters. The height of the fundus after the first hour following delivery is at the umbilicus or above it. Every day the fundal height decreases by approximately the width of one finger (one cm) until it reaches 4 fingerbreadths.
Nursing Care:
Assess the condition of the uterus frequently and may need to massage the uterus gently to encourage its clamping down on itself, especially when oxytocin has not been given.
Pharmacological management:
A woman sometimes receives the medication oxytocin (Pitocin) after the delivery of the placenta. Oxytocin causes the uterus to contract and can decrease the amount of postpartum bleeding.
Documentation:
1.) Palpate the uterine fundus to determine size, degree of firmness, contracted / relaxed and rate of descend using fingerbreadths.
2.) Record the position of the uterus.
2.) Record the position of the uterus.
3.) NURSING INTERVENTIONS
Sample Documentation:
UTERUS AND FUNDAL HEIGHT NORMAL FINDINGS>DAY 2 POSTPARTUM, UTERUS IS FIRM AND CONTRACTED LOCATED AT THE MIDLINE OF THE ABDOMEN, 2-3 FINGERBREADTHS BELOW THE UMBILICUS.UTERUS AND FUNDAL HEIGHT ABNORMAL FINDINGS>DAY 3 POSTPARTUM, UTERUS IS BOGGY AND RELAXED UPON PALPATION LOCATED AT THE RIGHT SIDE OF THE ABDOMEN.>BLADDER IS DISTENDED. MOTHER VERBALIZED DIFFICULTY OF URINATION FOR 5 HOURS.>VAGINAL BLEEDING CHECKED AND MONITORED.>DR. DURAN NOTIFIED WITH ORDERS GIVEN AND CARRIED OUT.>STRAIGHT CATHETERIZATION ASEPTICALLY DONE OBTAINING 800ML OF DARK YELLOWISH CLEAR URINE.>PERINEAL CARE DONE.>UTERUS CHECKED POST STRAIGHT CATHETERIZATION, PALPATED AT MIDLINE OF THE ABDOMEN, FIRM AND CONTRACTED. BLADDER NOT DISTENDED.>INCREASE FLUID INTAKE INSTRUCTED. INTAKE AND OUTPUT MONITORED.ANOTHER UTERUS ABNORMAL FINDINGS>DAY 1 POST PARTUM, UTERUS IS RELAXED AND BOGGY LOCATED AT THE MIDLINE OF THE ABDOMEN, 1 FINGERBREADTH BELOW THE UMBILICUS UPON PALPATION.>BLADDER NOT DISTENDED AND VOIDING FREELY.>SIGNS OF BLEEDING CLOSELY MONITORED.>UTERUS GENTLY MASSAGED UNTIL FULLY CONTRACTED.>DR. DURAN NOTIFIED AND ORDERED FOR OBSERVATION ONLY.ANOTHER UTERUS ABNORMAL FINDINGS>DAY 1 POST PARTUM, UTERUS IS RELAXED AND BOGGY LOCATED AT THE MIDLINE OF THE ABDOMEN, 1 FINGERBREADTH BELOW THE UMBILICUS UPON PALPATION.>BLADDER NOT DISTENDED AND VOIDING FREELY.>WITH SIGNS OF BLEEDING, PERIPADS HEAVILY SOAKED OF DARK COLORED BLOOD FOR AN HOUR WITH LARGE AMOUNT OF BLOOD CLOTS.>PATIENT IS TACHYCARDIC, PR- 110 BPM.>GENTLY MASSAGED THE UTERUS UNTIL CONTRACTED. UTERUS APPEARS TO BE RELAXED AFTER MASSAGE>PLACED ON TRENDELENBURG POSITION.>COLD COMPRESS APPLIED OVER THE ABDOMEN AT INTERVALS WITH MASSAGE>DR. DURAN NOTIFIED WITH ORDERS GIVEN AND CARRIED OUT.>OXYTOCIN GIVEN PER IV AS PER DOCTOR’S ORDER.>UTERINE MASSAGED AND COLD COMPRESS CONTINUOUSLY DONE, MONITORED ACCORDINGLY FOR CONTINOUS BLEEDING.
C. BLADDER
- Urine void should be documented within six hours. In the first 48 hours after delivery, it is normal to have an increase in the formation and secretion of urine (postpartum diuresis).- Prevent and monitor for signs of bladder distension
- Recommend kegel exercises
- Observe for urinary tract infection
Rationale:Promote involution (the process of returning back to its normal state wherein the uterus transformed from pregnant to non- pregnant state and restoration of ovarian function in order to prepare the body for a new pregnancy). Start from the expulsion of placenta and extends up to 5 to 6 weeks after delivery. The mother should empty the bladder every 2 hours.
If no urine output, palpate for bladder distension. Bladder distension can displaced uterus which my not contract effectively thus, causing bleeding. An over-distended bladder can even cause injury to the urinary system.
Procedures:1. Encourage patient to void within her first hour postpartum. Bladder should be palpated above symphysis pubis every after voiding to assess urinary retention. Record first 2 voidings (normal amount 150 cc per voiding).
2. If the woman had a cesarean section and has a Foley catheter in place in her bladder, then the output is checked every hour during the initial postpartum period. The Foley catheter is likely to be removed approximately eight hours after surgery. Monitor intake and output. The health care provider needs to assess for voiding after removal of the Foley catheter.
3. If patient has not voided in 6-8 hours post-delivery or with severe bladder distension; notify doctor for any voiding difficulties and bladder distension; straight urinary catheterization per Doctor’s order.
4. Be alert for signs and sx of UTI:
--infrequent voiding
--painful urination (dysuria)
--burning
--frequency
--urinary retention
--foul-smelling urine
5. Assess for postpartum voiding difficulties related:
--fatigue
--perineal swelling
--long, difficult Labor and Delivery eg.use of Forceps, Vacuum Extractor
Documentation:1.) Bladder distended / not distended. Note for urinary retention, dribbling or difficulty in urination
2.) First void post-partum, after how many hours of delivery
3.) Voiding frequency, amout, characteristics and color of urine
4.) Pain and discomforts upon urination
5.) Note for signs of UTI
6.) If with indwelling urinary catheter, take note of the size, placement and connected to urine bag, draining to amount, color, characteristics of urine every hour.
7.) NURSING INTERVENTIONS
Sample Documentation:
BLADDER NORMAL FINDINGS
>BLADDER NOT DISTENDED, ABLE TO URINATE 5X OF AMBER COLORED URINE 1500CC AMOUNT WITHIN THE SHIFT.
>INCREASE ORAL FLUID INTAKE ENCOURAGED.
>PERINEAL HYGIENE ENCOURAGED.
BLADDER ABNORMAL FINDINGS
>BLADDER ARE DISTENDED WITH DISCOMFORTS OF 9/10 PAIN SCALE, NO URINE OUTPUT FOR 6 HRS.
>ASSISTED MOTHER TO TOILET AND LET HER HEAR RUNNING WATER.
>STILL NO OUTPUT DESPITE THE INTERVENTIONS.
>DR. DURAN NOTIFIED WITH ORDERS GIVEN AND CARRIED OUT.
>STRAIGHT CATHETERIZATION ASEPTICALLY DONE OBTAINING DARK COLORED URINE 1200CC AMOUNT.
>PERINEAL CARE RENDERED.
>INTAKE AND OUTPUT MONITORED.
>MONITORED CLOSELY FOR BLADDER DISTENTION WITHIN THE SHIFT.
BLADDER DOCUMENTATION FOR PATIENT WITH INDWELLING FOLEY CATHETER>WITH INDWELLING URINARY FOLEY CATHETER, FR 16 PATENT AND INTACT CONNECTED TO URINE BAG DRAINING TO 450CC OF AMBER COLORED CLEAR URINE.>BLADDER NOT DISTENDED.>INCREASE ORAL FLUID INTAKE ENCOURAGED.>INTAKE AND OUTPUT MONITORED CLOSELY.>PERINEAL CARE RENDERED.
D. BOWEL
- Assess for peri-anal lacerations
- Assess for presence of perineal and anal pain
- Assess for complication of pregnancy and labor (ex. Haemorrhoids)
- Assess for presence of BS q shift; palpate abdomen for distension
- If constipated, administer daily stool softeners per doctor’s order. Avoid use of enemas and or suppositories for mothers with a 3rd or 4th degree laceration. If needed, use with caution. Often sent home with stool softeners & encouraged to eat high fiber diet & exercise.
Rationale:Promote returning back of intestine to its normal position. Expect resolution of normal bowel movement by 3 months.
Documentation:
1.) Bowel sounds and bowel movements, presence of flatus
2.) Abdominal distention
3.) Peri-anal lacerations
4.) Presence of perineal and anal pain
5.) Complication of pregnancy and labor (ex. Haemorrhoids)
6.) If constipated, administer daily stool softeners per doctor’s order.
7.) NURSING INTERVENTIONS (stool softeners, high fiber diet, exercise).
2.) Abdominal distention
3.) Peri-anal lacerations
4.) Presence of perineal and anal pain
5.) Complication of pregnancy and labor (ex. Haemorrhoids)
6.) If constipated, administer daily stool softeners per doctor’s order.
7.) NURSING INTERVENTIONS (stool softeners, high fiber diet, exercise).
Sample Documentation:BOWEL DOCUMENTATION NORMAL FINDINGS>WITH NORMO-ACTIVE BOWEL SOUNDS, ABLE TO PASSED OUT FLATUS AND DEFECATED SOFT FORMED STOOL 1X WITHIN THE SHIFT.>ENCOURAGED TO CONTINUE AMBULATION.>HIGH FIBER DIET MEAL SERVED.>INCREASE ORAL FLUID INTAKE ENCOURAGED.BOWEL DOCUMENTATION ABNORMAL FINDINGS>WITH HYPO-ACTIVE BOWEL SOUNDS, ABDOMINAL DISTENTION TYMPHANITIC UPON PERCUSSION, NO FLATUS, CONSTIPATED.>ENCOURAGED TO CONTINUE AMBULATION.>HIGH FIBER DIET MEAL SERVED.>INCREASE ORAL FLUID INTAKE ENCOURAGED.>DR. DURAN NOTIFIED WITH ORDERS GIVEN AND CARRIED OUT.>STOOL SOFTENER SUPPOSITORY GIVEN PER RECTAL AS ORDERED.>BOWEL MOVEMENT MONITORED.
E. LOCHIA
(Vaginal bleeding vs. Vaginal discharge)
-Assess peripad daily (1X each shift) for color, amount, type, and for any foul odor. Instruct pt to notify nurse if she passes clots. Note size and number.-The color and amount of vaginal discharge (lochia) should be noted.
-Assess lochia. Normal lochia is brown and light after 2 weeks and finished by 6-8 weeks after delivery
Types of lochia:
a.The vaginal discharge is red for one to three days following delivery and is called lochia rubra.b.Between days three and 10, the discharge changes to a pink or brownish color and is called lochia serosa.c.The last phase occurs when the vaginal discharge turns white is called lochia alba, whih may occur from 10-14 days postpartum.
-Peri-Care:
-- Instruct pt to fill peri-bottle with warm water and rinse stitches area after each voiding or BM--Wipe from front to back, patting gently--Change peripads after each voiding--Spray episiotomy area with anesthetic spray after wiping--Encourage use of sitz bath 24 hrs postpartum per Doctor’s order for 20 minutes bid or tid especially if pt had a 3rd or 4th degree laceration per Doctor’s order
-Call Doctor for any excessive bleeding
Rationale:
An excessive amount could be a sign of a complication such as clot formation or a retained portion of the placenta, bleeding from displaced and relaxed uterus.
The spotting can continue for another six weeks. It is common in mothers who breastfeed their babies. A constant trickling of blood or the soaking through of a perineal pad in an hour or less is not normal and should be further evaluated.
The spotting can continue for another six weeks. It is common in mothers who breastfeed their babies. A constant trickling of blood or the soaking through of a perineal pad in an hour or less is not normal and should be further evaluated.
Documentation:
1.) Amount, odor, color of lochia.
2.) Identify the types of lochia.
3.) Take note the peripads, number of peripads change per shift.
4.) Number and size of clots.
5.) Constant trickle, dribble or oozing lochia (bleeding).
6.) Excessive lochia with contracted uterus, suggests birth canal lacerations.
7.) Odor (fleshy, earthy, musty). Foul smelling / absence of lochia with foul smelling odor suggests endometrial infection or STD.
8.) If CS, lochia maybe scanty.
9.) Any other vaginal discharge, other than the lochia.
10.) NURSING INTERVENTIONS
2.) Identify the types of lochia.
3.) Take note the peripads, number of peripads change per shift.
4.) Number and size of clots.
5.) Constant trickle, dribble or oozing lochia (bleeding).
6.) Excessive lochia with contracted uterus, suggests birth canal lacerations.
7.) Odor (fleshy, earthy, musty). Foul smelling / absence of lochia with foul smelling odor suggests endometrial infection or STD.
8.) If CS, lochia maybe scanty.
9.) Any other vaginal discharge, other than the lochia.
10.) NURSING INTERVENTIONS
Sample Documentation:
LOCHIA DOCUMENTATION NORMAL FINDINGS
>DAY 2 POSTPARTUM, PATIENT HAS MODERATE AMOUNT OF LOCHIA RUBRA FLESHY IN ODOR, DARK RED IN COLOR, BLOOD CLOT NOT NOTED. NO SIGNS OF VAGINAL BLEEDING.
>PERINEAL HYGIENE ENCOURAGED.
>ABLE TO CONSUME 2 PADS WITHIN THE SHIFT.
F. EPISIOTOMY
- Observe for the presence of lacerations, episiotomy and episiorrhaphy- Note the location and type of episiotomy
Types of Episiotomy:--Midline--R or L mediolateral--3rd degree extension-- laceration extends to the rectum--4th degree extension-- laceration extends through the rectum
- Assess using REEDA every shift
--R=redness--E-edema--E=ecchymosis--D=discharge--A=approximation
- Observe for the presence of hematoma caused by rupture of small blood vessels during delivery.
- Application of hot and cold compress.
- Proper perineal care and hygiene.
Purpose:
To assess perineal trauma and the state of healing.
Procedures:
1. Provide privacy, and explain the purpose of the procedure. This elicits cooperation and reduces anxiety.
2. Put on clean gloves. Implements standard precautions to provide protection from possible contact with body fluids.
3. Ask the mother to assume the Sims (side-lying) position and flex her upper side leg. Lower the perineal pads, and lift her superior buttock. If necessary, use a flashlight to inspect the perineal area. Position provides an unobstructed view of the perineum and allows assessment of lochia that may be under the mother; light allows better visualization.
4. Note the extent and location of edema or bruising. Extensive bruising or asymmetric edema may indicate formation of a hematoma
5. Examine the episiotomy or laceration for redness, ecchymosis, edema, discharge, and approximation (“REEDA”). Redness, edema, or discharge may indicate infection of the wound; extensive bruising may delay healing; wound edges must be in direct contact for uncomplicated healing to occur.
6. Note the number and size of hemorrhoids. Swollen, painful hemorrhoids interfere with activity and bowel elimination.
2. Put on clean gloves. Implements standard precautions to provide protection from possible contact with body fluids.
3. Ask the mother to assume the Sims (side-lying) position and flex her upper side leg. Lower the perineal pads, and lift her superior buttock. If necessary, use a flashlight to inspect the perineal area. Position provides an unobstructed view of the perineum and allows assessment of lochia that may be under the mother; light allows better visualization.
4. Note the extent and location of edema or bruising. Extensive bruising or asymmetric edema may indicate formation of a hematoma
5. Examine the episiotomy or laceration for redness, ecchymosis, edema, discharge, and approximation (“REEDA”). Redness, edema, or discharge may indicate infection of the wound; extensive bruising may delay healing; wound edges must be in direct contact for uncomplicated healing to occur.
6. Note the number and size of hemorrhoids. Swollen, painful hemorrhoids interfere with activity and bowel elimination.
Documentation:
1.) With or without episiotomy wound / lacerations
2.) Location of episiotomy
2.) Location of episiotomy
- median or midline = extending straight back from the lower edge of the introitus toward the anus- mediolateral incision = begun at the introitus and directed laterally and downward away from the rectum to either the RIGHT OR LEFT
- 3rd degree extension-- laceration extends to the rectum- 4th degree extension-- laceration extends through the rectum
3.) If with lacerations (perineal tear), characeristics e.g. jarred
4.) Note for the five signs: redness (R), edema (E), ecchymosis (bruising) (E), discharge (D), and approximation (the edges of the wound should be close, as though stuck or glued together) (A).
5.) NURSING INTERVENTIONS
4.) Note for the five signs: redness (R), edema (E), ecchymosis (bruising) (E), discharge (D), and approximation (the edges of the wound should be close, as though stuck or glued together) (A).
5.) NURSING INTERVENTIONS
Sample Documentation:EPISIOTOMY DOCUMENTATION>WITH DRY AND INTACT EPISIORRHAPY. REDNESS, EDEMA, ECHYMOSIS, DISCHARGE NOT NOTED.OR>WITH RT MEDIOLATERAL EPISIOTOMY, STILL FRESH WITH REDNESS AND MINIMAL EDEMA. EPISIORRAPHY INTACT.>PERINEAL HYGIENE ENCOURAGED.>WOUND CARE DEMONSTRATED AND ENCOURAGED.>PERI-LITE ADMINISTERED FOR 15 MIN. AS PER DOCTOR'S ORDER.
G. HOMAN'S SIGN
- Assess daily for redness, nodular or warm areas, discolorations, leg varicosities or signs of DVT; and notify Doctor.- Assess Homan’s Sign (calf pain upon dorsiflexion fo the foot) q shift.
- Assess peripheral pulses and for presence of and amount of edema
Rationale:
Women are more prone to thrombophlebitis post-partum related to hypercoagulability of the blood caused by:
--pregnancy( hormonal changes)--anemia--pelvic infection--traumatic delivery--obesity
Documentation:
1.) Left, right or bilateral pain upon dorsiflexion of the foot / feet.2.) Redness, nodular or warm areas, discolorations, varicosities
3.) Peripheral pulses, type of edema
4.) NURSING INTERVENTIONS
3.) Peripheral pulses, type of edema
4.) NURSING INTERVENTIONS
Sample Documentation:HOMAN’S SIGN DOCUMENTATION NORMAL FINDINGS>NEGATIVE FOR HOMAN’S SIGN, ENCOURAGED TO ELEVATE BOTH LEGS WHEN AT REST.HOMAN’S SIGN DOCUMENTATION ABNORMAL FINDINGS>PATIENT COMPLAINED OF LT CALF PAIN UPON DORSIFLEXION OF THE FOOT, PRESENCE OF REDNESS AROUND THE CALF, PEDAL PULSES NOT PALPABLE, WITH EDEMA AT AFFECTED LEG.>BOTH LEGS ELEVATED AT ALL TIMES.>DR. DURAN NOTIFIED WITH ORDERS GIVEN AND CARRIED OUT.>CLEXANE INJECTION ASEPTICALLY GIVEN SC AS PER DR. ORDER.>LOWER LEG ULTRASOUND DONE AS PER DR. ORDER.
H. EMOTIONAL STATUS
- Expect mild mood changes that may last 1-6 weeks.3 Normal Phases
1. “Taking In” - immediately after delivery till up to 2 days postpartum
--need rest and sleep--self-focus--relives events of Labor and Delivery
2. “Taking Hold” - preoccupied with the present
--usually encompasses days 2-7 days postpartum
--interested in self-care--optimal time for teaching--focus on caring for baby
3. “Letting Go” -reestablishes relationships with others with outward focus
**Postpartum Blues / postpartum depression - a normal temporary state related to hormonal changes, role redefinition, fatigue, or pain. Patient may “cry for no reason”.
Sample Documentation:
EMOTIONAL STATUS DOCUMENTATION
> PATIENT VERBALIZES FEAR OF BATHING HER BABY.
> PROPER BABY BATHING PROCEDURE DEMONSTRATED.
> COUNSELLING GIVEN.
> ASSURANCE GIVEN.
I. DIASTASIS RECTI
- a separation of the rectus abdominis muscles, may occur with pregnancy, especially in women with poor abdominal muscle tone.
Procedures:
1. Following the uterine assessment, examine the abdomen for Diastasis Recti by asking the mother to lift her head and place her chin on her chest.
2. While mother maintains that position, the nurse should begin to palpate at the level of the umbilicus for a separation in the muscle.
3. Strive to measure both a length and a width and record on assessment, if indicated, as Diastasis: 2 cm X 8 cm.
4. Teach mother importance of exercise to regain muscle tone, in order to have strong abdominal support for future pregnancies. Reassure mom that diastasis recti does respond well to exercise.
2. While mother maintains that position, the nurse should begin to palpate at the level of the umbilicus for a separation in the muscle.
3. Strive to measure both a length and a width and record on assessment, if indicated, as Diastasis: 2 cm X 8 cm.
4. Teach mother importance of exercise to regain muscle tone, in order to have strong abdominal support for future pregnancies. Reassure mom that diastasis recti does respond well to exercise.
Documentation:
1.) Diastasis measurement e.g. 2cm x 8cm
2.) NURSING INTERVENTIONS
2.) NURSING INTERVENTIONS
Sample Documentation:DIASTASIS RECTI NORMAL FINDINGS>WITH INTACT ABDOMINAL MUSCLES>DAILY ABDOMINAL EXERCISES INSTRUCTED.DIASTASIS RECTI ABNORMAL FINDINGS>WITH DIASTASIS RECTI MESURES 8CM X 2 CM UPON PALPATION>DEMONSTRATED AND ENCOURAGED RIGID ABDOMINAL EXERCISE PROGRAM AND GRADUAL INCREASE OF ACTIVITIES>ASSURANCE GIVEN.
Additional Important Assessment:
1. TemperatureRationale:
A. High temperature – for early detection of infection, dehydration, hypovolemia, routine check for covid
B. Low temperature – indicates septic shock (severe infection), severe dehydration, hypovolemia
* for presence of infection, suspect retained placental fragments
2. Heart rate (pulse)
- routinely during the first 24 hours starting from the first hour after birth.
Rationale:
A. tachycardia – indicates early symptoms of bleeding / dehydration (compensatory), impending hypovolemia, and fever. Emotional and psychological origin. Emotional and psychological origin. Assess for history of hypertension, medication intake, psychological status.
B. bradycardia – indicates late symptoms of bleeding / dehydration / hypovolemia
3. Blood pressure
- should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours.
Rationale:
A. high blood pressure – indicates early symptoms of bleeding / dehydration (compensatory), impending hypovolemia. Emotional and psychological origin. Assess for history of hypertension, medication intake, psychological status. Assess for the history of pregnancy-induced hypertension.
B. low blood pressure – indicates late symptoms of bleeding/dehydration or hypovolemia.
*Evaluate pulse, respiratory rate, and blood pressure every 15 minutes during the first hour postpartum, every 30 minutes for two hours, and then every eight hours. Evaluate the woman's temperature at the end of the first hour postpartum and then every four hours for the first two to 12 hours postpartum.
4. Pain and Discomforts
- Assess for the degree of pain and discomfort from incisions, lacerations, and uterine cramping (afterbirth pains). As well as muscle and body pains.
- Observe for the presence of calf pain, suggesting thrombophlebitis or DVT.
- Spinal headache for those who underwent CS due to epidural anesthesia.
5. Birth Control
- Discuss by six weeks.
DOCUMENTATION:
I. ENDORSEMENT
1. Assessment can be subjective or objective2. Head to Toe assessment of the general condition of the patient
a. Level of consciousness (awake / asleep, conscious / semi-conscious / unconscious, coherent / disoriented)
b. Position (lying on bed, sitting at bedside, high fowlers’s position etc)c. Vital signsd. Contraptions (head to toe) or tubings connected / inserted to the patient
3. How many post-partum days.
II. PHYSICAL ASSESSMENT (BUBBLEHED ASSESSMENT)
a. BREASTSb. UTERUS AND FUNDAL HEIGHTc. BLADDERd. BOWELe. LOCHIA (Vaginal bleeding vs. Vaginal discharge)f. EPISIOTOMY / EPISIORRHAPYg. HOMAN’S SIGNh. EMOTIONAL STATUSi. DIASTASIS RECTI
III. OTHER PERTINENT ASSESSMENT OR PAIN AND DISCOMFORTS
- Other complaints
IV. EVALUATION
- is the output of your nursing care.
Sample Documentation:> LUNCH TAKEN WITH GOOD APPETITE.>SEEN AMBULATING INSIDE THE ROOM MOST OF THE TIMES.>SEEN BOTH LEG ELEVATED WHEN AT REST.>VAGINAL BLEEDING NOT NOTED WITHIN THE SHIFT.>NO COMPLAINT OF PAIN, ABLE TO TAKE A NAP.>ABLE TO URINATE 5X AND DEFECATE ONCE WITHIN THE SHIFT.>LATEST VITAL SIGNS: BP, T, RR, PR>ENDORSED PROPERLY TO AFTERNOON SHIFT.
References:
1.World Health Organization (2018) WHO recommendation on routine postpartum maternal assessment. https://extranet.who.int/rhl/topics/preconception-pregnancy-childbirth-and-postpartum-care/care-during-childbirth/who-recommendation-routine-postpartum-maternal-assessment#:~:text=All%20postpartum%20women%20should%20have,be%20measured%20shortly%20after%20birth.
2.Perry Potter (2014), Clinical Nursing Skills and Techniques, 8th Edition, Elsevier.
3.Geraldine Rebeiro (2012), Fundamentals of Nursing Clinical Workbook, Elsevier.
4.Adele Pilliteri (2010), Maternal & Child health Nursing, 6th Edition, Lippincott Williams.
5.Marilyn Doenges (2010), Nursing Care Plans, 8th Edition, F. A. Davis Company.
6.Murray, S.S. & Mc Kinney, E.S. (2014). Foundations of Maternal-Newborn and Women’s Health Nursing, 6th ed. Missouri: Elsevier Saunders.
7.Butkus, S.C. (2015). Maternal-Neonatal Nursing: Made Incredibly Easy. Texas: Wolters Kluwer.
8.Davidson, M., London, M., & Ladewi, P. (2012). Maternal-Newborn Nursing & Women’s Health Across Life Span, 9th ed. Pearson.
NCM107 GRP 9 : WHAT IS INVOLUTION?
ReplyDeleteInovulation,is a type of process where reproductive organs return to its unpregnant state.
DeleteThis comment has been removed by the author.
DeleteInvolution is the returning to a former size of the uterus after the pregnancy.
DeleteUterine involution happens when the uterus is transformed from pregnant to non-pregnant state. This is also the period wherein the ovarian function is restored so that the female's body will be prepared for a new pregnancy.
DeleteUterine involution happens when the uterus is transformed from pregnant to non-pregnant state. This is also the period wherein the ovarian function is restored so that the female's body will be prepared for a new pregnancy.
DeleteThis comment has been removed by the author.
DeleteThis comment has been removed by the author.
DeleteInvolution is a normal process of a shrinkin or rolling inward characterized by a decrease in size of an organ such as postpartum involution of the uterus.
DeleteInvolution is the process where the uterus as well as other reproductive organs return to their former state prior to the women's pregnancy, from pregnant to non-pregnant state, and the restoration of ovarian function in order to prepare the body for a new pregnancy
DeleteThis comment has been removed by the author.
DeleteInvolution is the process which restore the reproductive organs of a female by fully contracted uterus to prepare the body for a new pregnancy.
DeleteInvolution is the process in which the uterus returns in it's normal size after pregnancy.
DeleteInvolution is the process whereby the reproductive organs return to their nonpregnant state.
DeleteInvolution is the process of the uterus transforming from pregnant to non-pregnant state.
DeleteInvolution is the process wherein the uterus returns to its nonpregnant state or normal size and prepares the body for the new pregnancy.
DeleteInvolution is the process wherein the uterus returns to its nonpregnant state or normal size and prepares the body for the new pregnancy
DeleteNCM107 GRP 9: HOW MANY CM IS 5 FINGERBREADTHS?
ReplyDeleteThis comment has been removed by the author.
Delete5 fingerbreadths is equivalent to 9.525 cm
DeleteThis comment has been removed by the author.
DeleteThe conversion of 5 fingerbreadths to cm is 9.525.
Delete5 fingerbreadths is 9.525 cm (1 fingerbreadth = 1.905 cm)
Delete5 fingerbreadths = 9.525 cm
Delete5 fingerbreadths = 9.525 cm, since 1 fingerbreadth is equivalent to 1.905 cm
DeleteThe equivalent of 5 fingerbreadths is 9.525 cm
Delete5 fingerbreadths=9.525 cm
DeleteThe equivalent of 5 fingerbreadths in cm is 9.525
Delete5 fingerbreadths = 9.525 cm.
DeleteNCM107 GRP 9: WHAT IS THE NORMAL LOCATION OF THE UTERUS 1 HR AFTER GIVING BIRTH?
ReplyDeleteThis comment has been removed by the author.
Delete1 hour after birth,the upper portion of the uterus, called as the fundus, is in midline and palpable halfway between the symphysis pubis and the umbilicus. After the one hour post delivery, the fundus is firm and at the level of the umbilicus
DeleteAfter 1 hour of giving birth the fundus is now firm and the location of uterus is on the umbilical level of the mother.
DeleteThe fundus, which is known as the upper part of the uterus is in the midline. Approximately 1 hour after delivery, this is also firm and located at ths level of the umbilicus.
Delete1 hour after the delivery the normal location of the uterus is in the midline below the level of the umbilicus.
DeleteThe normal location of the uterus 1 hour after giving birth is in the midline and approximately at the level of the umbilicus.
DeleteAfter 1 hour of birth, the normal location of the uterus is supposed to be in the midline level of the umbilicus
DeleteThe normal location of the uterus after 1 hour of giving birth is in the midline and at the level of the umbilicus.
DeleteApproximately one hour after the delivery, the fundus is at the level of the umbilicus.
DeleteThe uterus after 1 hour of childbirth is at midline of umbilicus
DeleteNCM107 GRP 9: WHAT IS THE INDICATION OF A UTERUS PALPATED AT EITHER LEFT, RIGHT OR ABOVE THE UMBILICUS? WHAT ARE YOU GOING TO DO?
ReplyDeleteIf the uterus being palpated is either at left ,right or above the umbilicus ,the indication is a distended the bladder . my nursing action should be advising the woman /mother to empty bladder prior to the assessment of the fundus .
DeleteIf the uterus moved on the right or left side or above the umbilicus it may pertain to your bladder being full or distended so as a nurse I will advise my patient to urinate so that the bladder will be empty.
DeleteIt indicates distendtion in bladder. I should be encourage patient to empty her bladder due to the reason that it will prevent uterine involution and may cause bleeding.
DeleteWhen the uterus is palpated at the said locations, this basically indicates that the bladder of the patient is distended. In order to relieve this, I will tell the patient to urinate first.
DeleteIf the uterus is being palpated at either left, right, or above the umbilicus, it indicates that the bladder is distended, and the intervention that I will be doing is to encourage the patient to empty bladder by means of urinating.
DeleteIf the uterus is palpated at either left or right, it is an indication that the uterus is distended and the supposed intervention for this is to encourage the patient to urinate in order to empty the bladder
DeleteIf the uterus is palpated at either left or right then it indicates that the bladder of the patient is distended and will cause bleeding and overdistended bladder can cause injury to the urinary system. To prevent this thing from happening I will encourage the patient to void (urinate) to empty the bladder.
DeleteIt is an indication that the bladder is distended or full. Encourage the patient to empty her bladder.
DeleteIf the uterus palpated either left or right it indicates the bladder is full so prior to palpation we should encourage or advise the patient to empty the bladder.
DeleteNCM107 GRP 9: NORMALLY THE UTERUS IS CONTRACTED, WHAT ARE YOU GOING TO DO IF THE UTERUS IS TENDER AND BOGGY WHICH APPEARS TO BE RELAXED? WHAT IS GOING TO HAPPEN IF THE UTERUS IS RELAXED?
ReplyDeleteIf the uterus is boggy during palpation,keep the non dominant hand above the woman's symphysis pubis and massage fundus with dominant hand until it is firm. In the case the uterus is relaxed ,there is a high possibility of postpartum bleeding .
DeleteIf the uterus is boggy you have to do uterine massage firmly placing one hand in the vagina and pushing against the uterus while their other hand compresses the uterus through the abdominal wall . In the case that it is seen that uterus is relaxed It may indicate a post-partum haemorrhage wherein it should be reported because it can lead to serious problem but when it can be detected and treat early it can recover faster.
DeleteA boggy uterus usually happens due to uterine atony. In order to relieve this, the nurse should perform uterine massage to stimulate uterine contractions and to stop the bleeding.This is done through repetitive massaging or squeezing movement onto the lower abdomen, extracting any large clots or tissue that prevents the contractions. Relaxation of the uterus indicates that there is atony of the uterus/ postpartum hemorrhage.
DeleteIf the fundus is appears to be tender and boggy you have to massage the fundus with the dominant hand until the fundus is firm while keeping the non-dominant hand above the woman’s symphysis pubis. Because, relaxed uterus may result to post-partum bleeding.
DeleteIf there will be a tender and boggy uterus, I will be doing a uterine massage by placing my non dominant hand above the patient's symphysis pubis and massage fundus with the dominant hand, then repeat until the fundus is firm. Relaxed uterus indicates post-partum bleeding
DeleteIn the case of a tender or boggy uterus, the dominant hand must be placed above the patient's symphysis pubis and massage it. This must be repeated until the fundus is firm. A relaxed uterus may indicate bleeding
DeleteIf the uterus is tender and boggy ,the nurse should need to massage the fundus with the dominant hand until the fundus is firm while keeping the non-dominant hand above the woman's symphysis pubis. In the case the uterus is relaxed it may indicates pospartal hemorrhage, one of the most important causes of maternal mortality associated with childbearing, poses a possible threat throughout pregnancy and is a major potential danger in the immediate postpartal period.
DeleteIf the uterus appears to be relaxed, tender and boggy, it could result to bleeding. Gently massage the uterus until it contracts
DeleteIf the uterus is tender or boggy it indicates hemorrhage for the intervention we can massage the uterus by placing the non dominant hand over the patient's symphysis pubis and massage the uterus by dominant hand until it is firm. Relaxation of uterus may indicate postpartum hemorrhage that may lead to serious bleeding.
DeleteNCM107 GRP 9: THE UTERUS IS FULLY CONTRACTED AND THE BLADDER IS NOT DISTENDED, STILL THE PATIENT IS HAVING VAGINAL BLEEDING? WHAT IS YOUR SUSPECTED REASON AND WHAT ARE YOU GOING TO DO?
ReplyDeleteIn the case that the uterus is fully contracted and the bladder is not distended but still there is a vaginal bleeding ,there is a suspected possibility of internal bleeding due to tears or lacerations .My nursing action is to immediately inform the doctor incharge about the bleeding and observe the bleeding characteristics ; it's consistency and how heavy it is .
DeleteIt may indicate of vaginal bleeding because of the tears and laceration for example when the baby’s head is too large to fit in the vaginal opening. As a nurse what I am going to do is to report it to do the doctor so that I know what intervention is the best thing to do because some tears can heal on their own and some needs stitches.
DeleteThe bleeding may come from tears and lacerations when the baby is big and can't fit through, problems with placental attachment to the uterus, and in rare cases, it may be because of a ruptured uterus that happens in c-sections birth when the blood vessels are not stitched completely. Knowing the dangers, I will immediately refer the patient to a physician and monitor the bleeding from time to time.
DeleteIt may be beacuse of tears and bleeding from laceration that usually occurs as the fetal head is being born. I should inform the assigned physician for the further intevention and observe the patient assess the perineal laceration to promote healing.
DeleteVaginal bleeding may be the result of perineal lacerations and tears or can be caused by the baby's birth or delivery, especially if the baby is big. As a nurse, I will be informing and notifying the doctor or physician immediately regarding the patient's condition to give the appropriate intervention for the concern.
DeleteThis may be a result of a tear or laceration during birth. As a nurse, notifying the doctor or physician immediately is the appropriate intervention for this scenario
DeleteIn the case that the uterus is fully contracted and the bladder is not distended and the patient is still having vaginal bleeding because of the tears and laceration of the birth canal (cervical lacerations, vaginal lacerations, perineal lacerations) I will immediately report it the the doctor or physician for the appropriate intervention for the said concern.
DeleteIf vaginal bleeding is present despite uterus is fully contracted and bladder is not distended, it could be because of lacerations or tears which is the result of the delivery. Inform the attending physician and assess the bleeding from time to time.
DeleteIf the uterus is relaxed and the bladder is distended but there is a vahing a vaginal bleeding it may be caused by a laceration or tear that may be caused by episiotomy during delivery. Inform the doctor if there is a severe bleeding.
DeleteNCM107 GRP 9: WHY DO WE NEED TO PALPATE THE UTERUS IN A CUPPING MANNER?
ReplyDeleteWe need to palpate uterus in a cupping manner in order to support the lower uterine ligaments .
DeleteWe use cupping method so that we can support other ligaments in the uterine not just the uterus alone.
DeleteSo that we can also palpate the other ligaments of the uterus in order to properly check it's size and shape.
DeleteIts purpose is to support other ligament and it steadies the fundus and prevents downward displacement.
DeleteWe need to palpate the uterus in a cupping manner to in order to provide support to other ligaments and to also assess the uterus properly.
DeletePalpating the uterus in a cupping manner ensures that we can provide support to other ligaments and this way, we can assess the uterus properly
DeleteThe purpose of palpating the uterus in cupping manner is to provide support to other ligaments.
DeleteCupping manner is used in palpating the uterus in order to support the uterus because the ligaments are stretched and cannot fully support the uterus.
DeletePalpating uterus in a cupping manner supports the underlying ligaments.
DeleteNCM107 GRP 9: YOUR PATIENT COMPLAINS OF PAINFUL, REDNESS, INFLAMMATION AND HOT TO TOUCH LEFT BREAST. SHE IS FEBRILE WITH TEMP. 40C? WHAT WILL YOU DO?
ReplyDeleteThe nursing interventions in the case mentioned above are the ff;
DeleteFirst assess the nipple of the left breast for cracks and discharge then note .
Cleanse the affected area with saline and betadine to avoid infection.
Instruct mother to Breast feed on the RT breast .
Apply hot pack on both breast to relive inflammation
Monitor temperature since patient is febrile
And instruct to increase fuid intake .
The Nursing Intervention that I will do is first report it to the doctor as soon as possible to know what caused her to have a high fever because it might be because of an infection in her breast. I will also apply warm moist compress to the sore area, and if the patient can massage her breast she can massage it from the behind where it is sore and use circular motion on the nipple area. Monitor the temperature of the patient since she is febrile and her intake of fluid.
DeleteWith the symptoms that the patient have, this may indicate that she have Mastitis (or Lactation Mastitis). Knowing that this may be because of a blocked milk duct or when there is bacteria entering the breast, as a Nurse, I will immediately report it to the doctor. I will monitor her temperature and check if the mother is wearing a tight fitting bra and will ask her to remove it first. Then, I will also check if her nipples are sore or cracked and will massage it in a circular motion. Lastly, I will advice the patient to have her baby breastfeed on the affected side every 2 hours to prevent your breast from getting too full of milk.
DeleteBefore the intervention I will perform a thorough assessment about these signs and symptoms and Also, I'm going to inform the attending physician about the patient's situation. Since the patients has signs that indicates that she may be experiencing mastitis the nusing intervention that I will conduct is to demonstrate to the patient how to apply warm compresses to right breast and will will observe the mother breastfeeding her infant to assess the possible latching problems.
DeleteThe nursing intervention that I will be doing are:
Delete- Do a thorough assessment of the patient's condition, including the history taking in connection to the given signs and symptoms
- Refer to the physician right after the assessment to have the proper intervention for the patient's concern
- Monitor the patient's vital sign, specifically the temperature
- Check if her nipples are sore or cracked as well as massage it in a circular motion
- Advice the patient about the breastfeeding intervention
- Increase fluid intake, given the information that the patient is febrile
Nursing Interventions:
Delete✔️I will assess first the patient's condition and I will also inform the physician about the about the patient's situation for best intervention in the patient's concern.
✔️ Monitor the patient's temperature
✔️Apply warm compress to RT breast
✔️ Advise the PT to have her baby to breastfeed to prevent her breast from getting too full because of milk
✔️ Instruct her to increase fluid intake
It could be an indication of infection. Note the signs of infection and inform the attending physician. Perform the appropriate care for the mother (e.g. the nipple has cracks and yellowish pus discharge, clean the affected site aseptically with saline and beta dine).
DeleteAssess the breast for nodules and erythema.
DeleteAsk the physician regarding the intervention for the patient
Monitor patient's temperature
Check the breast for nodules, erythema and cracks around the nipples.
Advise to wear comfortable bra
Advise breastfeeding to the other breast.
Increase fluid intake
NCM107 GRP 9: YOUR PATIENT IS HAVING SEVERE VAGINAL BLEEDING. HER UTERUS IS STILL RELAXED AND BOGGY AFTER 30 MINUTES OF STRAIGHT CATHETERIZATION EMPTYING THE BLADDER, AND MASSAGED INTERVALS WITH ICE PACK APPLICATION OVER THE ABDOMEN. THERE IS NO SIGN OF PERINEAL LACERATION WITH BLEEDING. WHAT ARE YOU GOING TO DO?
ReplyDeleteMy nursing action would be,continue to massage uterus until it is contracted ,place the woman in a Trendelenburg position,apply cold compress on the abdomen and with intervals for massage and Monitor continuous bleeding. Inform the doctor incharge and administer oxytocin as ordered.
DeleteI will report it to the doctor in charge because it might cause a serious problem to the patient sincethe vaginal bleeding is too much even after massaging it and placing ice packs.
DeleteI will continue to put ice pack to the woman's abdomen and will immediately report it to the doctor in order to prevent further complications.
DeleteI will report it to the attending physician and perform uterine massage and cold compress and monitor accordingly for continous bleeding.
DeleteI will continue applying ice pack on the patient's abdomen and monitor the continuous bleeding, as well as inform the doctor in-charge immediately about the concern
DeleteI will inform the physician about the patient's condition, continue applying ice pack to patient's abdomen , and monitor for continuous bleeding.
DeleteInform the attending physician stat and apply immediate care to the mother.
DeleteInform the physician regarding the patients condition, apply ice pack on the abdomen and monitor. If there is a severe bleeding inform the physician immediately.
DeleteNCM107 GRP 9: YOUR PATIENT IS BLEEDING SHOWN IN HER DIAPER. THE UTERUS IS CONTRACTED AND NORMAL. NO SEVERE PERI-ANAL LACERATIONS. YOUR PATIENT IS COMPLAINING OF SEVERE ANAL PAIN? WHAT WILL BE YOUR SUSPECTED CASE? WHAT ARE YOU GOING TO DO?
ReplyDeleteIn the mentioned case above ,the suspected case is hemorrhoids where veins in the lower rectum are swollen ,painful and tends to bleed .My nursing action would include assessment and note the hemorrhoids size and number ,monitor bowel elimination since swollen and painful hemorrhoids can interfere the bowel movement and if there is an observed bowel elimination interference,give stool softener suppository by rectal as ordered.
DeleteMy diagnosis is a hemorrhoids which is very common to a post-partum mother. As a nurse the intervention that I will do is first to know the size of the hemorrhoids and put a warm compress to reduce pain and inflammation, apply a prescribed anal cream to relieve discomfort and Teach anal hygiene and measures to control moisture to prevent itching. We also need to determine the patient’s normal bowel habits because bowel movement shouldn’t be delay when you have haemorrhoids.
DeleteThe patient may be suffering from postpartum hemorrhoids due to the stress on the perineum months before and during the delivery. The nursing intervention that I will do is to monitor the swelling of the patient's anus, the size of the hemorrhoid and her bowel movements. If she feels pain or discomfort in her lower rectum, I will advise the patient to put warm compress on her anus 10 to 15 minutes, twice a day and apply an OTC hemorrhoid cream or suppository that contains Hydrocortisone to ease the discomfort and alleviate the pain.
DeleteThe patient shows signs of suffering from hemorrhoids so before intervention I'm going to Assess patient for the presence of hemorrhoids, discomfort or pain associated with hemorrhoids, and presence of constipation. Instruct patient and/or family regarding causes of hemorrhoids and treatments that can be performed. If constipated, administer daily stool softeners per doctor’s order. Encouraged to eat high fiber diet & exercise.
DeletePatient could be experiencing common postpartum hemorrhoids. The nursing intervention that I will be doing is to monitor and check the swelling of the anus, the size of the hemorrhoid as well as the bowel routine or habits of the patient. Moreover, I will be advising the patient to apply warm compress on anus and an anal or hemorrhoid cream to relieve discomfort and then instruct the patient regarding anal hygiene that could help prevent from resulting to this condition.
DeleteMy suspected case about the the mentioned case is the patient may br suffering from postpartum hemorrhoids, so assessments done during this time are some of the most critical assessment made im nursing. I will monitor the the swelling of the size of the hemorrhoids and her bowel movements . Advise the patient to put warm compress on her anus, apply hemorrhoid cream to relieve the discomfort, and teach anal hygiene.
DeleteIt could be an indication of hemorrhoids. Assess for complication of pregnancy and labor (ex. Hemorrhoids). Encourage the mother to increase oral fluid intake and eat high fiber meals, this decreases the chances of constipation because constipation may worsen the hemorrhoids. Notify the doctor with orders given and carried out. Stool softener suppository is given per rectal as ordered. Then bowel movement is monitored.
DeleteThe patient may be suffering to hemorrhoids which refers to the swollen veins in the rectum and anus that interferes with the stool control or bowel movement. You have to assess the size of hemorrhoids and bowel movements. Encourage the mother to increase fluid intake and oral intake like fruits and vegetables and if this inetrvention still not works you may advise mother to use soft stool softener or laxative. Also inform the physician about the patients condition.
DeleteNCM107 GRP 9: YOUR PATIENT IS COMPLAINING OF ABDOMINAL PAIN ON HER 1ST POST PARTUM DAY, WHAT WILL YOU APPLY, HOT OR COLD COMPRESS?
ReplyDeleteCold compress is to be applied with intervals and massage to relive pain
DeleteCold compress because it numbs the affected area, which can reduce pain and tenderness. It can also reduce swelling and inflammation.
DeleteI will apply cold compress on the patient's lower abdomen to relieve the pain as well as to prevent excessive bleeding to happen.
DeleteApply cold compress on the abdomen to relieve the pain.
DeleteCold compress should be applied on the patient's abdomen to relieve the pain
DeleteI will apply cold compress to the patient to relieve the pain
DeleteApply cold compress to relieve the pain.
DeleteApply cold compress to the abdomen relieve the pain.
DeleteNCM107 GRP 9: WHY HEMORRHOID IS COMMON TO POSTPARTUM MOTHERS? WHO IS MORE HIGH RISK TO HEMORRHOIDS POST NORMAL DELIVERY OR POST CAESARIAN OPERATION?
ReplyDeleteThis comment has been removed by the author.
DeletePost normal delivery mothers are more high risk to hemorrhoids (distended rectal veins )because these veins have been pushed out of the rectum because of the effort at pelvic stage pushing during delivery .
DeleteHemorrhoids common during pregnancy because of the extra pressure on the veins in the lower half from enlarged uterus.It is more risky to the post normal delivery because because of the intense pressure of pushing while giving birth.
DeleteLike what I said in my previous answer, hemorrhoids are due to stress that happens before and during the delivery. It frequently occurs in Post Normal delivery due to the extra pressure on the veins in the lower half of the uterus.
DeleteIt is usualy happens to postpartum mother who undergo normal delivery because hemorrhoids can be develop due to Stress on the perineum before and during delivery, the stress of carrying a baby, and pushing it out during labor.Also, an increase in the hormone progesterone during pregnancy relaxes the walls of your veins, allowing them to swell more easily.
DeleteHemorrhoids are common during pregnancy because of exerting extra pressure on the veins in the lower half of the uterus. It is mostly experienced by postpartum patients especially those who undergone post normal delivery because hemorrhoids are developed because of the stress before and during the delivery on the patient's perineum
DeleteHemorrhoids are often common a result of stress on the perineum in the months before, and during delivery. Veins work like valves to push blood back up to the heart and when those valves become weakened they can swell with blood. Mother in post normal delivery is more high risk of hemorrhoids because of stress before and during the delivery.
DeleteHemorrhoid is common to postpartum mothers because it results from the extra pressure on the veins in the lower half of the enlarged uterus in addition to the exerted pressure during the delivery. Post-normal delivery is at a higher risk of developing hemorrhoids than post caesarian operation because they undergo a serious amount of pressure during the delivery.
DeleteNormal delivery to postpartum mothers are more vulnerable to hemorrhoids since there is an extra pressure exerted before and during the delivery that causes stress on the perineum.
DeleteNCM107 GRP 9: WHAT ARE THE INDICATIONS THAT YOUR POST PARTUM MOTHERS BOTH NSD AND POST CS CAN START HER DIET OR MEAL?
ReplyDeleteThe woman feels hungry and thirsty and she eats without difficulty from nausea and vomiting , are indications that both NSD and POST CS mother's can start their diet or meal.
DeleteThe indicator is if she eat the meal without feeling the urge to vomit the food they can already start eating their meal or diet.
DeletePost partum mothers can start eating her meal when she no longer feels like vomiting.
DeleteWhen the mother is not feeling nauseous and can eat without vomitting, she can start eating her meal or diet.
DeleteThe indication that post partum mothers can already start their diet or meal is when they can eat without feeling nauseous or vomiting
DeleteIndications:
Delete✔️ Mother is not feeling nauseous and vomiting
The mother can start her diet or meal when she feels hungry and has the appetite to eat without feeling nauseous and vomiting.
DeleteMothers can start their meal when they feel that they are not nauseous and indicates hungry and thirsty.
DeleteNCM107 GRP 9: WHY POST CS MOTHER HAS SCANTY LOCHIA?
ReplyDeleteLochial Flow varies depending on exertion .In the case e of Post CS Mothers,they tend to have scanty lochia because they are preferably on bed rest and this bed rest can decrease the flow of lochia.
DeletePost CS mother are often on a bed rest after delivery so the tendency of this is the lochial flow is small or insufficient in quantity since they don’t do physical activities because of advise bed rest.
DeleteScanty lochia (less than 2.5 cm) happens to post cs mothers because they are advised to be on bed rest after delivery and because it is a major operation, the doctors are able to clean the uterus manually with a swab and they are also able to remove all of the placenta and it's membranes.
DeleteUsually, women undergo cesarean section will have a less lochia because they are on bed rest after delivery and advise to lessen movements and also because there is no risk of having a bleeding due to laceration or tearing.
DeletePost cesarean mothers are most likely to have the scanty lochia because they are often advised to be on a bed rest after their delivery. In addition to that, they do not engage to activities and do movements which can affect their condition.
DeletePost caesarian mothers are most likely to have scanty lochia because they are advised to be on bed rest after the delivery and will result in decreasing the lochial flow.
DeleteBecause post-cesarean mothers are advised to be on bed rest and they are not at risk of lacerations and tears.
DeleteCS mothers are advised to have bed rest after delivery so it is more risk for low flochial flow since they are not allowed to make movements.
DeleteNCM107 GRP9: WHAT ARE YOU GOING TO DO IF YOUR PATIENT COMPLAINED OF SEVERE LEG PAIN?
ReplyDeleteIn the case mentioned above ,as the nurse in charge I will do the assessment for nodular warm areas,leg varicosities,assess the peripheral pulse and pr sence of edema ,assess for Homans Sign and And for the intervention Elevate both legs and notify doctor for orders.
DeleteIf the patient has a severe leg pain the first thing that I need to do is to assess in which position does she feel the severe leg pain so that we can adjust or elevate the leg where she can feel lesser pain, assess if there is an edema or inflammation that causes the pain and after that I will report to the doctor for better intervention to follow.
DeleteAs a nurse, I will first assess the level of pain that the patient is feeling. I will palpate her peripheral pulse and check if there is an inflammation or an edema. I will also notify the doctor regarding the patient's condition for she may be experiencing DVT or Deep Vein thrombosis that may happen to post partum mothers without any symptoms. To alleviate the pain, I will advice the patient to elevate her legs, flex her feet in order to stretch out her calves, wear graduated compression stockings and to increase her fluid intake.
DeleteAssess the condition of the patient, assess peripheral pulses and for presence of and amount of edemaand inform the attending physician. After that, perform intervention according to the physician's order.
DeleteNursing interventions that I will be doing are:
Delete- Assess the patient by their peripheral pulses, the level of pain, and if there is possible presence of swelling or inflammation.
- Inform the physician about the patient by also providing the obtained data during the assessment
- Carry out the doctor's orders and proceed with nursing care
- Instruct the patient to elevate the legs and flex feet to relieve pain
Nursing Interventions:
Delete✔️Asses the condition of the patient, assess peripheral pulses, level of pain, and the possible presence of of inflammation .
✔️I will also inform the physician with regards of the patient's condition for the best intervention for that concern.
✔️I will instruct the patient to elevate her legs and feet flexed to relieve pain.
Assess Homan’s sign, nodular or warm areas, discolorations, leg varicosities, or signs of DVT. Also, assess the peripheral pulses and for the presence of edema. Encourage the mother to elevate both legs when at rest. Notify the doctor with orders given and carried out. Perform clexane injection aseptically given sc as per doctor’s order.
DeleteAssess the patient's peripheral pulse, inflammation, area and level of pain.
DeleteNotify or Inform the physician regarding the patients concern and best intervention for that concern.
Advise the patient to elevate the leg and flex knees to relieve pain.