School of Nursing and Allied Medical Sciences

Holy Angel University

Angeles City

Name: Mercado, Shan Patrick Date: 9-25-22

Sibal III, Francis
Section: NU-201

Read Module 7 to complete the table. Work individually or with your buddy. Points will be
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Complete the table below. Use brief description. Do not copy and paste the module. (10 pts)

ASSESSMENT WHAT TO ACCESS DEVIATIONS FROM NORMAL, CAUSE,

AND EXPECTED AND NURSING ACTION
FINDINGS

FUNDUS Assessing the fundus After a woman delivers Postpartum Hemorrhage

after the childbirth is the baby, it is important Cause:
important to to assess the patient's ● After the patient delivers the baby,
determine if shifting fundus. Because the the uterus continues to contract after
occurs as the body fundus continues to delivery, and its size decreases
returns to its pre descend into the pelvis rapidly as estrogen and progesterone
pregnant state. at the rate of levels diminish. As a result, the
approximately one fundic height also changes after the
centimeter delivery. As the uterus declines, its
(fingerbreadth) per day upper portion, known as the fundus,
and should be would change; it would be in the
nonpalpable by two midline and palpable halfway
weeks postpartum, between the symphysis pubis and the
changes in this umbilicus. Moreover, by
progression may approximately one hour after
indicate a problem with delivery, the fundus is firm and at the
the body's physiologic level of the umbilicus. A different
adaptation to the progression with the fundus may
reproductive system. indicate that the uterus is not
contracting.
● Uterine atony, happens when the
patient's uterine muscles don't
contract enough in response to
oxytocin, a hormone that a woman's
body releases before and during
childbirth to make contractions
happen.
Nursing Action:
● The nurse can palpate the client’s fundus
at frequent intervals as this is the best
 safeguard against uterine atony because
it ensures that the patient uterus remains
contracted. As a result the nurse should
palpate the fundus if it is firm to
compress the bleeding vessels at the
placenta site.
● Massage the boggy uterus using one
hand and place the second hand
above the symphysis pubis.
● Apply an ice pack on the hematomas
if indicated. Because cold application
can limit small hematoma and reduce
blood flow to the area. Also a cold
numbs the area and makes the client
more comfortable.

BREAST Assessing the breast Postpartum Ineffective Breastfeeding

after the childbirth is After a woman delivers Causes:
important to the baby, it is important ● Engorgement, when milk is coming
determine if there to assess the patient's in there is more blood supply to the
are any signs of breast. Ask the patient breast as well as more milk. If this
abnormalities. Some if there is any pain or milk is not removed, the milk, blood,
of the common difficulty as this may and lymph become congested and
things that a nurse indicate a breastfeeding stop flowing well, which result in
can assess are the problem. also assessing swelling and edema.
such and shape, the fullness of the Nursing Action:
engorgement of the breast to determine if ● Checking the attachment if the baby
breast, breast the milk flows well. is well attached at the breast. If not,
inflammation, sore Because engorgement Help the mother to attach her baby at
nipples. may cause swelling, the breast well enough to remove the
edema may be milk. Suggest that she gently express
expected. By doing so milk from her breasts herself before a
the nurse can also feed to soften the areola and make it
assess if there is a easier for the baby to attach.
presence of blocked ● If breastfeeding alone does not
duct. Taking a history reduce the engorgement, advise the
of the sore nipple can mother to express milk between
help the nurse figure feeds a few times until she is
out what is causing the comfortable.
pain.
Causes:
● Blocked milk ducts and mastitis,
this is when the milk seems to get
stuck in one part of the breast. If
milk remains in a part of the breast
this can cause inflammation
Nursing Action:
 ● Explain to the mother that she must
remove the milk frequently (if not
removed, an abscess may form). also,
advice her that the best way to do this
is to continue breastfeeding her baby
frequently. Check that her baby is
well attached and offer her baby the
affected breast first (if not too
painful), as this can help the milk to
flow. Gently massage the blocked
duct or tender area down towards the
nipple before and during the feed.
Rest with the baby so that the baby
can feed often. The mother should
drink plenty of fluids. The employed
mother should take sick leave if
possible.
Cause:
● Sore Nipples, some mothers find
their nipples are slightly tender at the
beginning of a feed for a few days.
This initial tenderness disappears in a
few days as the mother and baby
become better at breastfeeding. If
this tenderness is so painful that the
mother dreads putting the baby to the
breast, or there is visible damage to
the nipples, this soreness is not
normal, and needs attention.
Nursing Action:

● Reassure the mother that sore nipples

can be healed and prevented in
future.
● Treat the cause of the sore nipples
- Help the mother improve
attachment and positioning.
This may be all that is
needed. If necessary, show
the mother how to feed the
baby in different feeding
positions. This helps to ease
any pain the mother is
experiencing because the
baby will be putting pressure
on a different area of the sore
nipple and allows her to
continue feeding while the
nipple heals.
 - Treat skin conditions or
remove source of irritation.
- Treat Candida both on the
mother's nipples and in the
baby's mouth.
- If the baby's frenulum is so
short that the tongue cannot
extend over the lower gum,
and the mother's nipples have
been sore for two to three
weeks, consider if the baby
should be referred and the
frenulum clipped.

LONCHIA Postpartum Puerperal Infection

Assessing the lochia After a woman gives Causes:
after childbirth is birth, as nurses, we
important to need to assess the ● The risk for infection can grow if
determine if there condition of lochia, we edema and trauma are present in the
are any signs of can ask the patient tissue, because the uterus is sterile
abnormalities or about the character of during pregnancy and up until the
complications. the odor of the membranes rupture. After this
Among the discharge to determine rupture, pathogens can begin to
complications that if there are any invade, causing puerperal infection.
may occur, the infections. because a
following are foul-smelling discharge Nursing Action:
possible: Lochia may indicate an
with a foul odor, and infection. Also, we can ● Demonstrate and maintain a strict
an unusual ask about the progress hand-washing policy for staff,
progression of lochia or condition of the clients, and visitors. Because proper
from rubra, serosa, color of the lochia, hygiene is the primary method for
and alba. A constant because a progression preventing the spread of infectious
trickle, frequent of the color should be organisms.
changes of sanitary from rubra, serosa to ● The nurse can demonstrate correct
pads, and the alba, and changes in perineal cleaning after voiding and
presence of this progression may defecation and frequent changing of
excessive and large indicate abnormalities. peripads. Because changing pads
blood clots are some Furthermore, we can remove the moist environment that
of the common ask if the patient is encourages bacterial growth Certain
abnormalities that changing sanitary pads instructions can also help the
the mother may more than usual or postpartum client with proper
experience after every thirty (30) perineal care, including wiping from
front to back to prevent the spread of
childbirth. minutes or has a
constant trickle
because this can be an
indication that the
patient is at risk for
bleeding. Lastly, we
can also ask the patient
if there is any evidence
of large blood clots,
because this can be an
indication of a serious
problem that needs to
be addressed
immediately.
Postpartum Systematic Blood Clot
Cause:
Nursing Care
certain bacteria from the rectum.
● Encourage the patient to consume a
high-protein and vitamin C-rich diet.
Because nutrition is an essential
component of her body’s defenses.
As a result, the client can overcome
the infection as well as heal any
wound. Information about foods that
are high in protein, such as meats,
cheese, milk, legumes, etc., can be
provided by the nurse.
● Encouraging semi-Fowler’s position
Sitting in a semi-Fowler’s position or
walking encourages lochia drainage
by gravity and helps prevent the
pooling of infected secretions.
● In the first 24 hours after birth,
bleeding is heaviest, and clots may
range in size from large to small.
After several days, the bleeding
should become lighter along with the
clots as their size becomes smaller,
until the day that it will improve to
the point that there will be no
bleeding at all. However, any new
bleeding or clots should be checked
by a doctor or midwife. Moreover,
passing blood clots in the lochia is
normal after giving birth and cannot
be prevented. As a result, the patient
is also at risk of having systematic
blood clotting. Having said that,
there are ways to help reduce the risk
of having a complication that is life-
threatening with blood clots.
● Even though blood clotting is normal
after birth. The nurse can inform the
patient about her risk for large blood
clots in arteries as this can lead to
certain conditions.
The nurse can inform the patient
about the ways to prevent
 complications.
● The nurse can inform the patient the
symptoms that she may experience in
relation to systematic blood clotting.
● Encourage the patient to seek
immediate medical attention if she
experiences any symptoms of
systematic blood clot.

Postpartum Hemorrhage

Causes:

● Primary postpartum hemorrhage may

occur within the first 24 hours after
birth, while secondary postpartum
hemorrhage occurs more than 24
hours and up to 12 weeks after
delivery. The four main causes for
postpartum hemorrhage are the four
Ts. This includes tone, which is
caused by uterine atony. Trauma is
caused by laceration, hematomas,
uterine inversion, or rupture. and
tissue, as caused by retained
placental fragments. as well as
thrombin, as potential causes of
disseminated intravascular
coagulation.

Nursing Action:

• Assess the lochia for color, quantity and

clots. Observing the lochia to estimate the
actual blood loss, it should not be more than
one saturated perineal pad per hour.

• Assess the location of the uterus and the

degree of contractility of the uterus. The
degree of uterine contractility will measure
the status of blood loss. The nurse should
palpate the patients fundus at frequent
intervals to ensure her uterus remain
contracted. Thus, preventing uterine atony.

• Assess for additional risk factors for

postpartum hemorrhage. Identifying the
presence of risk factors for hemorrhages
such as retained placental fragments, uterine
or cervical lacerations, abnormal
 attachments to the placental site, uterine
atony, or inadequate blood coagulation will
help determine the management of the
situation, thus preventing further
complications.

BOWEL Assessing the bowel After a woman Postpartum Hemorrhoids

MOVEMENT movement after a delivery, as nurses we Causes:
childbirth is need to assess the ● Stress on the perineum due to
important for bowel movement of the carrying a baby for a long time and
determining woman by asking if she exerting too much pressure to push
different conditions has been able to fart to out the baby which cause veins in the
such as determine if the perineum to pop out
hemorrhoids, digestive system of the Nursing Action:
constipation, woman is working ● Encourage the patient to use sitz bath
diarrhea, etc, that properly after (a basin filled with warm water) to
can lead to worse undergoing C-Section. soak her buttocks to help the
health condition of a Also we need to assess hemorrhoids to shrink.
woman. the color of the stool if ● Encourage the patient to sit on a
its red, green or black, pillow, waffle cushion, rocking chair
because stool colors or recliner instead of straight chair to
can determine the relieve the pressure on the rectum.
condition of a patient ● Encourage the patient to increase
like when stool is black consuming dietary fibers and intake
tarry. This means that of fluids to prevent constipation and
the patient is worsening her hemorrhoids.
experiencing bleeding ● Encourage the patient to apply ice at
in the upper digestive her buttocks by wrapping the ice in a
tract cloth for about 10 minutes to reduced
swelling and irritation of the
hemorrhoid.
● Encourage the patient to consult with
her health care provider for a
prescription of recommended
suppositories, ointment or creams for
relief.
Postpartum Constipation
Causes:
● C-Section - take up to 3-4 days for
the digestive system to start working
 normally again following major
surgery.
● Damage to the anal sphincter or
pelvic floor muscles - stretching that
occurs during labor and delivery can
make it more difficult for the body to
efficiently move bowels.
● Dehydration or Lack of Fluids -
happen due to not drinking water
during labor,vomiting or
experiencing blood loss can slows
down the body’s elimination process.
● Hormonal Changes - begin while
pregnant and adjust rapidly right
after delivery which can slow bowel
function.
● Using pain medication or epidural
during labor - medications
particularly systemic narcotics are
known to slow down digestive tract.
Nursing Action:
● Encourage patient to drink plenty of
water to make stool softer and easier
to pass.
● Encourage patient to eat high fiber
foods to get the digestive system
moving.
● Encourage patient if did not undergo
c-section to walk a little bit to help
move bowels.
Postpartum Diarrhea
Causes:
● Medication - during C-Section, the
mother will receive antibiotic to
prevent infection in the wound site.
Unfortunately, antibiotics can cause
diarrhea or other bowel issues
because antibiotics not only targets
harmful bacteria but also the good
bacteria in the body that maintain
healthy gut.
● Difficulty of Labor - prolonged
labor or how long the mother push
affects the chances of developing not
only diarrhea but also stress
incontinence.
Nursing Action:
● Encourage the patient to stay
hydrated especially when
 breastfeeding to relieve diarrhea.
● Encourage the patient to focus first
on a BRAT diet (Banana, Rice,
Applesauce and Toast) for the body
to easily digest the foods.

PERINEUM Assessing the After delivery, due to Postpartum Perineal Pain

perineum after the great amount of Causes:
delivery is important pressure that is brought ● Childbirth
to determine if there by the pushing of the ● Episiotomy
is any tear, wound or woman during ● Perineum Tear
infection whether is childbirth. It is Nursing Action:
an NSD or C- expected that the ● Encourage patient to hold an ice pack
Section, to quickly perineum will feel or something cold on her perineum to
provide the proper edematous or swollen reduce swelling and pain.
care to the patient and tender. If an ● Encourage the patient to place a
and prevent episiotomy is done pillow under when sitting.
worsening the during childbirth, it is ● Encourage the patient to always rinse
condition. also expected to see the perineum after urinating
stitches in the ● Encourage the patient to use over-
perineum, which is the-counter pain relief medication if
more tender and advisable by a physician
painful; that is why ● Encourage the patient to fill a bath
when a woman has an with enough warm water to cover her
episiotomy, it is our hips and soak for a few minutes.
duty as nurses to
provide wound care to
the episiotomy site of
the woman by
monitoring the
woman’s pad exchange
to determine if blood
loss is excessive,
encourage the patient
to always clean or do
perineal care to the
episiotomy site after
using the bathroom to
prevent infection and
worsening the wound.
 PHASE MATERNAL BEHAVIOUR
TAKING IN Passive Dependence - in this
phase, the mother is dependent
on other people around her,
especially the nurses; when the
mother needs something, the
nurse or SO must bring the
mother's wants to her because
the mother doesn't want to do
anything besides pondering
and relaxing to regain her
energy and emotion. This
happens due to her painful and
exhausting experience brought
by childbirth, afterpains, or
hemorrhoids resulting when
the mother bears down when
delivering the baby.
TAKING HOLD Strong Independence - in this
phase, the mother’s behavior is
now independent of others
which means that the mother
prefers to do everything she
wants to do, such as cleaning,
getting a piece of bread,
making her own decisions, and
taking care of her child.
LETTING GO
This phase usually occurs
when the mother returns home.
At this time, the mother must
achieve two separations. This
separation is to recognize and
accept the baby’s bodily
separation and to abandon her
former status as a childless
NURSING CONSIDERATION
The nurse must understand that the
mother's behavior, which is being
passive dependent or dependent on
others, is a normal postpartum
psychological effect because the
mother underwent painful and
exhausting labor and delivery.
That is why her body reacts
differently to that experience so
that the mother can relax and
regain her energy and herself. This
is also the phase where the mother
usually ponders about her new role
as a mother to her child; that is
why the nurse also must encourage
the mother to talk about her labor
and delivery experience so that she
can integrate that experience with
her life experiences
The nurse must understand that
even though the mother has strong
independent behavior when caring
for her child, the mother also often
feels insecure about her ability and
skills in caring for her child. That
is why nurses must be
understandable, supportive, and
educative to the mother by
teaching the mother a brief
demonstration on how to take care
of the baby like breastfeeding,
clothing, washing, etc.; they must
also praise the mother’s actions in
taking care of her child so that her
confidence can be boosted and
enhanced.
The nurse must recognize and
inform the SO that the mother may
experience a let-down feeling,
which is called postpartal, or baby,
"blues." This is a form of
depression that is usually
temporary and may occur in the
hospital. The nurse may consider
individual. This is the time
when the mother is adjusting
her life to the relative
dependency and helplessness
of her child. During this phase,
two choices are contradicting
her decision. She might think
that she has to deal with more
stress, like finding babysitters
and taking on more work, if
she keeps working. And if she
quits work, she may think that
she must adapt, even if it is
temporarily to less freedom,
less autonomy, and less social
stimulation. As a result, some
problems that are associated
with this phase may occur and
be experienced by the mother.
assessing the risk factors that may
cause the problem, such as
psychological health, before
surgery. If a problem is present,
the nurse must consider assisting
the woman in planning for her
daily activities, such as her
nutrition program, exercise, and
sleep. The nurse may also consider
advising the mother to take some
time for herself every day so she
can have a break from her regular
baby care. Also, recommend
support groups to the woman so
she can have a system where she
can share her feelings. Through
this management, she can prevent
problems from developing and
have healthy psychological and
physical health.
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