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postnatalassessmentppt-190522071905.pptx
- 1.
- 2. ⚫BUBBLE- is aacronym used todenote the components of the postpartum maternal nursing assessment.
- 3. The BUBBLE- ⚫B: Breast ⚫U:Uterus ⚫B: Bladder ⚫B: Bowels ⚫L: Lochia ⚫H: Homan’s ⚫E: Episiotomyand perineum
- 4. B: BREAST ⚫BREAST ASSESSMENT: ⚫Assessmentincludeevaluating the breast in the postpartum period
- 5. ⚫The first stepis to determine if the new mamma is breastfeeding or bottle-feeding: This will guide the assessmentalong with patienteducation
- 6.
- 7. BOTTLE-FEEDING: LACTATION SUPPRESSION: ⚫Teach themotherabout breastengorgement. This usuallyoccursabout 72 hours after birth ⚫The breastswill bevery tenderwith a feeling of heaviness ⚫A firm, snug-fitting bra is ideal for thewomanwhose not breastfeeding. Also this will help, engorgement maystill occur
- 8. ⚫Iceand cabbage leavescanprovide relief. There is an enzyme in thecabbage leaves that helps ⚫Do notexpress milk as itwill encourageadditional production ⚫Anywarmthoverthe breastsand stimulationof the nipples will create a faucet-likeeffect
- 9. BREASTFEEDING: ⚫ ⚫Focus on thenipple and areola. The nipple should be erect, butsomeare flat or inverted. Hopefully, thiswas identified during the pregnancy in order for shield to be placed upon them.
- 10. ⚫Assess the nipplesforsigns of bruising, crackling, chapping. A deep crack or blister may indicate incorrect placementoranother issue. ⚫Avoid placing wantcold packson the breasts
- 11. MASTITIS INFECTION: ⚫Nursing ConsiderationsMastitis is an infectionof the breastsurrounding theducts that’scharacterized by fullness, pain, warmth, and hardness of the breast. It’s crucial todifferentiae infection from engorgement.
- 12. ⚫Mastitis may involvefever, while localized symptoms are limited to specified area that usually appears red and feels warm and possibly hardened Mastitis needs to be treated with antibioticsand the patient is usually encouraged tocontinue breastfeeding. The causeof infection is associated with stagnant milk in theducts. In mostcases, the milk is not infected; only theducts.
- 13. BREAST AND BOTTLEFEEDING
- 14. ⚫Thedecision to breastorbottle feed is highly personal. While the benefits of breast milk nutritionally and physiologically outweigh those of formula, it may not always be possibleor in the best interestof the mom and baby to breastfeed. The nurse’s role is to educate the mom and support the family in whateverchoice is made, not pass judgment.
- 15. BENEFITS OF BOTTLEFEEDING: ⚫Breastfeeding does notalways “come naturally” toall moms- it may bedifficult forsome ⚫May beconsidered more sociallyacceptable towhip out a bottle in the middle of a restaurant versus a breast. ⚫May beeasier for momswhowork outsideof the home.
- 16. DISADVANTAGES OF BOTTLE FEEDING: ⚫Nopassiveimmunity ⚫Harder for baby todigest ⚫Expensive, especially if a specialized formula is needed ⚫Moreallergies ⚫Overfeeding iseasier ⚫Stool is moreodorous
- 17. BENEFITS OF BREASTFEEDING : ⚫Passive immunity ⚫Less incidentsof ear infections (formulapools into the Eustachian tube) ⚫Easydigestibility ⚫Bonding between mom and baby ⚫Nocostand alwaysavailableand at the right temperature
- 18. ⚫Forthe foodies: Somemother mayenjoy being able toeatan extra 500 calories/day. ⚫Benefits to mother: Release of oxytocin (the “let- down”) causes the uterus tocontract, which promotes quickerreturn to pre-pregnancy weight. Italso decreases risksof ovarian and breastcancer.
- 19.
- 20. ⚫Positioning: Holds- chestto chest or tummy to tummy in someway, grab underthe breasts and push down and out (taking the milk ducts and pushing it forward, makea C-Hold around theareola (pull back, down, and forward while bringing forward).
- 21. ⚫Geta nice bigdropof colostrumon the nipple ⚫Tickle the lipwith nipple, shoveas much breastas possible into the mouthonce it’sopen ⚫5 to 15 minutesa first topreventsoreness ⚫Startwith the breasts thatwas left from ⚫Try to feed every 2 hours
- 22. FORMULA TEACHING : ⚫Ready-to-feed:mostexpensive butconvenient ⚫Concentrate: do noteveradd morewateror concentrate it Powder: followdirections per label ⚫Throw the bottlecontentsoutafter the feeding- do not save for next feeding ⚫Startoff small byonly preparing 2 ouncesata time ⚫No need towarm formulaup.
- 23. U: UTERUS UTERINE ASSESSMENT: ⚫1.FUNDUS: firm or boggy- make a “C-shape” with your hand and push up on the lower fundus; if it’s not stabilized, the uterus can prolapse, or fall into the vagina. Massageof not firm- secure loweruterine segment. The concern is for hemorrhage; the primary causesarea distended bladderand retrained placental fragments
- 24. ⚫2. FUNDAL HEIGHT:where is it in relation to the umbilicus? “U/U” or “At the U” (1/U = 1 cm above the umbilicus)- drops onecentimeteror fingerwidth. The position drops one centimeter every 24 hours for 10 days postpartum
- 25. ⚫3. MIDLINE ORDEVIATED TO THE LEFT OR RIGHT: if deviated, it’s usuallya sign of a full bladder. ⚫ Uterine afterpains of a breastfeeding mom get worse with each pregnancy . The uterus is a muscleand the more it is stretched, the more force is needed in order tocontract.
- 26. ⚫NURSING CONSIDERATION: Aboggy fundus may bea sign of uterineatony, which places the patientat risk fordeveloping a postpartum hemorrhage and othercomplications. ⚫Also, fundal location that lies out of range with anticipated locationaccording topostpartum status may beanother indication.
- 27. ⚫The nurse shouldperform a uterine massage, which promotes blood movementoutof the uterus, and also encourage the patient tovoid, as a full ordistended bladdercan impede uterine involutionand contractions. ⚫The nurse is often in the positionas the first member health care team to learn of these warning signs and therefore must take swift action if an issue is suspected.
- 28.
- 29. ⚫BLADDER ASSESSMENT: ⚫Ask motherwhenshe lastvoided ⚫Establish aVoiding Schedule to prevent bladder distensionand urinary stasis ⚫Encourage mom tourinateevery time before she feed baby (as they may fall asleep)
- 30. ⚫POSSIBLE OBSTACLES TOVOIDING: ⚫Mother may become soengrossed with baby thatshe forgets tovoid ⚫Internal inflammation from labor trauma may impair ability tovoid
- 31. ⚫Mother may hesitatetovoid from fearof pain, especially if she has an episiotomyorvaginal tearing ⚫C-section patients mayalso have issuewith voiding following removal of the folly.
- 32. ⚫ NURSING INTERVENTIONSFOR POSTPARTUM BLADDER CARE: Peri-bottle- teach mom to always bring the bottle, which is used for perineal irrigation, to the restroom to use rather than toilet paper; the bottle is filled with warm (NOT hot) water from the faucetand occasionally mixed with an antisepticoranalgesic solution if dered by the providerorpermitted by hospital policy . The contents are sprayed on the area following each void/bowel movementto use ratherthan toilet paper ⚫ Teach motherto use Tuck’s Pads, which contain witch hazel ⚫ Dermaplast is a topical spray, may beapplied to helpcontrol pain ⚫ A straitcath may need to be used if mom doesn’tvoid within an acceptable time (usually 12 hours postpartum)
- 33. WARNING SIGNS: ⚫Perineal areais dark, moist, and bloody, especially when combined urinary stasis
- 34.
- 35. ⚫BOWELS ASSESSMENT: ⚫Bowels inshock- just moved intosomestrange positions. ⚫Takea stool softener- don’twant ripping or the episiotomyor trauma to the C-section incision.
- 36. L: LOCHIA ⚫LOCHIAASSESSMENT: ⚫Assess thecolor,odor, and amount ⚫The lochiacolorshould forward in the progression of lightness, nevergo backwards
- 37. ⚫ LOCHIA COLOR ⚫LOCHIA RUBRA: Bright red, may havesmall clots, usually lasts 3 days ⚫ LOCHIA SEROSA: Pink, serous, othertissues ⚫ LOCHIAALBA: Tissue, whitish
- 38. ⚫LOCHIA ODOR ⚫Lochia shouldhave “noodor” or “no foul odor” ⚫Real world: virtually all lochia has an unpleasant or at least a neutral odor associated with it and moms may be quick todescribe itas “foul” . ⚫It’s important for the nurse to assess the odor to eliminatesubjectivepatientdescriptionof the scent ⚫A truly foul odor or a change in odor may be a sign of infection
- 39. ⚫LOCHIAAMOUNT: ⚫Scant = 2.5centimeters saturation ⚫Light = < 10 centimeters saturation ⚫ Moderate = > 10 centimeters saturation. ⚫Heavy = pad is completelysaturated within 2 hours ⚫Postpartum hemorrhage is clinicallydefined as a pad saturated within 15-30 minutes
- 40. ⚫ The padis saturated within 15 minutes to be considered a hemorrhage situation. In the real world, a pad that becomes saturated within 30 minutes is a cause foradditional evaluation. ⚫Scant saturation in the immediate postpartum period can be just as concerning as excessive lochia production. Clots: up tocherry sized areokay, peach or plum sized is not. Clots are the most common in the morning following the first void due to the saggy textureof thevagina, which releases the lochia build- up from the night.
- 41. E: EPISIOTOMY ANDPERINEUM
- 42. REEDA Assessment ⚫R: Redness ⚫E: Edema ⚫ E: Ecchymosis ⚫ D: discharge ⚫ A: approximation
- 43. PERINEAL AREA ASSESSMENT: ⚫Pullthe labia from front to back ⚫Check the episiotomyorareas of vaginal tearing ⚫Look for hematoma formation- a collection of blood in between tissue ⚫Look for hemorrhoids (developed during pregnancyor during labor from the pushing process).
- 44. ⚫Nursing Intervention; Alwayshelp mom get up and ambulate the first two times after birth to assess for mobility, reduce the risk of falling, and prevent trauma to the perineum and C-section incision
- 45. ⚫section incision ⚫HEMATOMA CARE: ⚫Startwith cold tostop the bleeding, once it stops, begin warm ⚫Continue to monitor ⚫If itgetworse, thatactivearea of bleeding is non- healing and itwill need to beopened and theactive area is discovered and cauterized ⚫May notappearso much of an out-pouching as much as a disfigurement.
- 46. ⚫HEMORRHOIDS: ⚫Vasculature that formsapouch ⚫Colorcan match the skin of the rectal area and may look more likea blood blisterwhen irritated ⚫Severe hemorrhoids appearas grape clusters Dermaplastspray ⚫Patient may not be aware, mayonly known that businessdown there is notas usual
- 47. ⚫ NURSING INTERVENTIONS: ⚫SeitzBath: a rotating fluid that moves thewater. May fit overthecommodeoronecan be performed with no special equipment using the bathtub other than a bathing ring. Turn tub on and allow drain to open and use a ring for circulating water. It’s very shallow and only bathes the perineal area.
- 48. H: HOMAN’S SIGN ⚫Assessfor Signsof DVT by the Homan’s Sign ⚫A positive Homan’ssign is indicativeof DVT, although it’s not the mostreliable indicator. ⚫All of thecharacteristic changes to maternal clotting factors are higher than any other point as the body prepares for labor. ⚫Combine this with being in bed, especially if mom underwent a C-section, and it’s easy to see why the postpartumwoman is at such a huge risk for DVT.
- 49. PERFORMING THE HOMAN’STEST: ⚫Mostcommonlyperformed with the mom in a supine positionwhile laying in bed ⚫Thecalf is flexed ata 90° angle ⚫The nurse manipulates the foot in a dorsiflexion movement ⚫If pain is felt in thecalf, the Homan’s Sign is said to be positive.
- 50. SIGNS OF DVT: ⚫Asudden and unexplainable pain, usually in the back of the leg orcalf ⚫Tachycardiaand shortnessof breath ordyspnea (from decreased oxygenation status) ⚫Edema, redness, and warmth localized overthearea of the DVT (from thevascular builduparound theclot)
- 51. PREVENTING A DVT: ⚫Dangleatthe side of the bed within 6 hours ⚫Stand upwithin 8 hours ⚫Encourageambulationat first and independent walking when ready
- 52. POTENTIAL COMPLICATIONS OFA DVT: ⚫Pulmonaryembolism (PE) occurswhen a clot breaks way from the leg areaand travels to the lungs. ⚫A PE is medical emergency.
- 53. E: EMOTIONAL STATUS ⚫EmotionalStatusand Bonding Patterns ⚫Fluctuations in estrogen levels are blamed for the emotional roller-coasterthat many momsexperience after birth. ⚫High levelsof stress, increased responsibility, and sleepdeprivation exacerbate this
- 54. ⚫Bonding refers tothe interactions between the mammaand baby ⚫Care giving of self and baby is an indicatorof emotional status
- 55. COMMON POSTPARTUM ASSESSMENT FINDINGS: ⚫TheTaking In Phase; May be considered as a self- focused, re-lived experience. This is different from the maladaptive. ⚫ Taking Hold Phase; A little bit about the mother, a little about the baby. The world appears to be revolved around the babyand mammaas an unit. ⚫ Letting-In Phase; Motherallowsotherpeople in.
- 56. COMPARING BLUES, DEPRESSION, ANDPSYCHOSIS
- 57. ⚫POSTPARTUM BLUES: Usuallyoccurswithin2-3 weeks. Mamma may be sensitive, such as crying during a commercial, mamma mayview itas humorous in hindsight.
- 58. ⚫POSTPARTUM DEPRESSION (PPD):When the blues moves to the pointwhere mommacan’t care for herself or the baby.
- 59. ⚫ POSTPARTUM PSYCHOSIS:A severe form of depression thatwarrants immediate intervention. When mamma harms herself or the neonate or considers doing so. Typically is predicated by depressiveepisodes.
- 60. NURSING INTERVENTIONS: ⚫The patientshouldfill outa form toassess emotional risks. The form will ask if the patient has a history of PPD ordepression notassociated with pregnancy. ⚫There’salways a social workeravailable in theevent that the patient is acting strangely. The nurse may need to fill outadocumentsuch as a Risk Assessment Form
- 61.