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Nursing Care of the High-Risk Post-Partal Clients By: Flas Julius A. Floresta, RN Post-partum Hemorrhage Blood loss of more that 500 ml within a 24 hour period following delivery Four types: y Uterine Atony y Lacerations y Retained placental fragments y DIC Uterine Atony Relaxation of the uterus Causes y Deep anesthesia or analgesia y Labor assisted with oxytocin agent y Greater than 30 years old y High parity y Previous uterine surgery y Abruptio placenta y Prolonged & difficult labor y Posible chorioamnionitis y Secondary maternal illness (anemia y Prior Hx of postpartum hemorrhage y Endometritis y Prolonged use of tocolytic drugs Assessment: y Gush of blood y Signs of shock may appear y Relaxation of the uterus Management: y Palpate woman s fundus at frequent interval y Massage the uterus y Observe for the consistency and amount of lochia y Assess vital signs y Encourage to empty the bladder y Administer oxygen 4L/m y Administer oxytocin/methergine as ordered y Bimanual massage y Prostaglandin administration y Blood replacement y hysterectomy y Lacerations Causes: y Difficult or precipitate labor y In primigravidas y With birth of large infants y Use of lithotomy position and instruments Types: y Cervical laceration
perineal body y 3rd Degree entire perineum. Perineal Hematomas . Reactally & Rectal suppository (3rd & 4th degree) y Episioraphy y Retained Placental Fragments May not be detected until 6 to 10 days post partum Uterus is not fully contracted Can be assessed using a sonogram Management y D&C y Methotrexate y Instruct the mother to observe lochial discharge Subinvolution Incomplete return of the uterus to its prepregnant size and shape. reaches the external sphincter of the rectum y 4th Degree entire perineum.y y y y y y y y y y y y y y y y y y y y Vaginal lacerations y Perineal lacerations Cervical Lacerations Usually found on the sides of the cervix. Causes: y Retained placental fragments y Mild endometritis y myoma Management: y Administration of methergine (4 times a day) y Educate woman of the normal process of involution and lochial discharges before going home y If endometritis is observe. suture supplies y Reassure the woman Vaginal Lacerations Hard to repair Management y Vagina may be packed to maintain pressure at the suture line y Insert indwelling catheter y Document Nursing care specially the insertion of packing. levator ani muscle. fascia. rectal sphincter. y Remove the packing after 24 hours Perineal Lacerations Categories: y 1st Degree vaginal mucous membrane and skin of the perineu to the fourchette y 2nd Degree vagina. some of the mucous membrane of the rectum Management: y Document the degree of laceration y Increase fluid intake y Stool softener as prescribed y No taking of temp. Uterus is still enlarged and soft at 4th-6th week post partum. lighting. perineal skin. oral antibiotic is initiated. near the branches of uterine artery Management: y Provide adequate space.
consistency. its size. shape and degree of woman s discomfort y Administer mild analgesic as for pain relief as prescribed y Apply ice pack y If episiotomy or line is opened to drain hematoma.y y y y y y y y y y y Collection of blood in the subcutaneous layer of tissue of the perineum Assessment y Severe pain in perineal area y Feeling of pressure between woman s leg y Purplish discoloration and swelling y Tender to palpation Causes: y Injury to blood vessels during birth y Precipitous births of woman with perineal varicosities y Often found at the site of episiotomy or laceration Management y Report presence of hematoma. odor) y Appropriate antibiotic y c/s culture should be from the vagina y Administration of methergine y Increase fluid intake y Analgesic for pain y Encourage ambulation/ semi-fowler s position . y Left it open and packed with a gauze y Document the insertion of packing y Remove packing after 24 to 48 hours. Puerperal Infection Causes: y Rupture of membranes more than 24 hours before birth y Retained placental fragments y Postpartal hemorrhage y Preexisting anemia y Prolonged and difficult labor/ use of instruments y Internal fetal heart monitoring y Local vaginal infection is present at the time of birth y Uterus was explored at the time of birth Management: y Antibiotics after C/S testing of microorganism Endometritis Infection of the endometrium Associated with chorioamnionitis and CS Assessment: y Elevation of temp after 24 hours postpartum y Increase WBC y Chills y Loss of appetite y Malaise y Locia dark brown & has a foul odor y Management: y Asess lochial discharge (amount. color.
y y y y y y y y y y y y y y y y y Wear gloves in helping the woman change perineal pads y Teach woman the proper hand washing technique Infection of the Perineum Occurs if woman have a suture line at the perineum. Assessment: y Pain. heat. feeling of pressure y Inflammation of the suture line y Purulent drainage may be pressent Management: y Remove perineal sutures to allow drainage y Packing the open lesion y Sitz baths or warm compresses to hasten drainage and cleanse the area y Frequent change of perineal pads y Wipe front to back after a bowel movement y Analgesic for pain as prescribed y Antibiotic after the c/s testing Peritonitis Infection of the peritoneal cavity May interfere with fertility in the future Assessment: y Rigid abdomen y Abdominal pain y High fever y Rapid pulse y Vomiting y Appearance of being acutely ill Management: y Insertion of NGT y IVF or TPN may be needed y Analgesic for pain relief as ordered y Large doses of anitibiotics Thrombophlebitis Phlebitis inflammation of lining of blood vessels Thrombophlebitis .Inflammation with the formation of blood clots. Risk factors: y Obesity y Varicose veins y Previous thrombophlebitis y Older than 30 years of age with increase parity y endometritis Prevention: y Prevention of endometritis by good aseptic technique y Ambulation y Limiting the time a woman remains in the stirrups y Wearing support stockings 2 weeks after delivery y Do not sit with knees bend sharply Femoral Thrombophlebitis Assessment: .
y Lochial discharge may increase y Avoid the use of salicylic acid for pain Pelvic Thrombophlebitis Involves the ovarian.y y y y y y y y y y y y y y y y y y Femoral. kidney & heart valve abscess Management: y Bed rest y Administration of anticoagulants/antibiotics y Abscess can be incised by laparotomy y Removal of the affected vessel before attempting to get pregnant again y Prevention: y Prevent wearing of tight clothing on the lower extremities y Resting with the feet elevated y Ambulating daily during pregnancy y Pulmonary Embolus Obstruction of pulmonary artery by a blood clot. redness in the affected leg y Swelling below the lesion y Homan s sign (+) Management: y Bed rest with affected leg elevated y Application of moist heat y Administration of anticoagulants/thrombolytics y Avoid massaging the affected area y Administration of analgesics If anticoagulant is given. lung. saphenous. pain. & hypogastric veins May interfere with future fertility Assessment: y Woman suddenly becomes extremely ill y High fever. malaise y Can cause pelvic. popliteal veins are involved y Edema y White leg appearance y Chills. chills. Complication of thrombophlebitis Signs/Symptoms: y Sudden sharp chest pain y Tachypnea y Tachycardia y Orthopnea y cyanosis Management: Administration of thrombolytics Woman is transferred to the ICU for continuing care Mastitis Infection of the breast Caused by cracked and fissured nipples Prevention: . uterine.
y Drainage may be necessary y Breast feeding on the affected side is discontinued y URINARY SYSTEM DISORDERS Two types: y Urinary Retention y Urinary Tract Infection Urinary Retention Results from inadequate bladder emptying. suspect urinary retention y Residual urine of more than 100 ml Management: y Urinary catheterization y Explain how catheter works y Remove catheter after 24 hours y Encourage woman to void 6 hours after the removal of catheter y If after 8 hour from removal of catheter. y Swelling y Redness y Fever y Breast milk becomes scant Management: y Broad spectrum antibiotic y Continue breast feeding y Cold or ice compresses y Wear supportive bra y Warm and wet compresses to reduce inflammation and edema y If abscess is present. thus leading to decreased sensation for voiding Leads to overdistention of urinary bladder Assessment: y Bladder distention y Frequent voiding but in small amount y Overall output is inadequate y If first voiding after birth is less than 100 ml. reinsertion may be necessary Urinary Tract Infection May result from urinary catheterization Assessment: y Burning sensation upon urination y Hematuria y . the woman has not voided.y y y y y y y y y y y y y making certain the baby is position correctly and grasps the nipple properly (both nipple and areola) y Releasing a baby s grasp on the nipple before removing the baby from the breast y Washing hands between handling perineal pads and touching the breast y Exposing nipples to air for at least part of every day y Vitamin A ointment to soften nipples daily Assessment: y Localized pain. Associated with the use of anesthesia and forceps during birth Pressure of birth causes edema.
the ff can happen to the uterus: y Retroflexion y Anteflexion y Retroversion y anteversion y If vaginal walls are weakened: y Cystocele y rectocele Separation of Symphysis Pubis y Causes: y Unusually large fetus y Fetal position is not optimal y Assessment: y Acute pain on turning or walking y Legs tend to rotate externally. feeling of loss. hallucinations of harming infant or self y Etiology: possible activation of previous mental illness.y y y y y y y Feeling of frequency y Sharp pain on voiding y Low-grade fever y Lower abdominal pain Management: y Instruct client how to obtain a clean-catch urine y Broad spectrum antibiotic (amoxicillin) y Encourage fluid intake y Analgesics for pain (tylenol) y REPRODUCTIVE SYSTEM CHANGES Reproductive Tract Displacement y if ligament are weakened. resulting to a waddling gate y Management y Bed rest application of snug pelvic binder to immobilize joint y Avoid lifting heavy objects y EMOTIONAL AND PSYCHOLOGICAL COMPLICATIONS Post-Partum Blues y Onset: 1 to 10 days after birth y Symptoms: sadness. empathy y Nursing role: offering compassion and understanding Post-Partum Depression y Onset: 1 to 12 months after birth y Symptoms: Anxiety. family history of bipolar disorder y Therapy: Psychotherapy. lack of social support y Therapy: Counseling. drug therapy y Nursing Role: referring to counseling Post-Partum Psychosis y Onset: within first month after birth y Symptoms: delusions. Sadness y Etiology: History of previous depression. tears y Etiology: hormonal changes. drug therapy . hormonal changes. stress of life changes y Therapy: Support. hormonal response.
y Nursing Role: referring to counseling. safeguarding mother from injury to self or to newborn .
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