GEORGIA PERIMETER COLLEGE
DEPARTMENT OF NURSING
Childbearing Family Concepts of Nursing
(Obstetric Nursing Concepts)
CLINICAL PREPARATION AND STUDY GUIDE
I. REQUIRED PREPARATION FOR CLINICAL
Murray, S., & McKinney, E. (2010). Foundations of Maternal-Newborn and Women’s
Health Nursing (5th ed.).Maryland Heights: Saunders Elvsevier
1. Chapter 17: Postpartum Physiologic Adaptations, pg. 390-419
2. Chapter 18: Postpartum Psychosocial Adaptations, pg. 421-440
You are responsible to know the material covered in this study guide prior to coming to clinical.
II. ASSESSMENT GUIDE AND EXPECTED CARE FOR POSTPARTAL PATIENTS
A. VITAL SIGNS
1. Assess and evaluate according to the parameters for the postpartal patient and report abnormal findings to primary nurse. Temperature, pulse and blood pressure may be altered; respirations should fall within pre-delivery range. Temperature may rise as high as 100.4 in the first 24 hours due to the dehydration experienced during labor and delivery. Offering adequate fluids will decrease it.
2. Notify the nursery if the mother's temperature is elevated above 100.4 degrees F. (In some institutions, the infant will not be allowed to be in contact with the mother until her temperature stays below 100.4 degrees F. for a specified period of time.). This is to prevent the exposure of all infants to an infant exposed to a possibly infected mother.
3. Patients may experience episodes of diaphoresis, frequently occurring at night. These "night sweats", are not considered clinically significant unless accompanied by fever. Patients need to be aware that this is a normal occurrence in the first 2-3 days of the postpartum period.
B. MENTAL/EMOTIONAL STATUS
1. Evaluate mental/emotional status; what phase the mother is in according to Rubin. The three phases are: Taking In, Taking hold, Letting Go
Evaluate how she is bonding with her infant.
1. Examine the breasts and describe as soft, filling, firm, or engorged.
2. Evaluate nipples as to everted, inverted, flat, red, cracked, sore, or bleeding.
3. Encourage the use of a good supportive bra; regular for non-nursing mothers, nursing bra for nursing mothers.
4. Teach how to alleviate engorgement (both nursing and non-nursing mothers).
5. Teach the mother about the care of her breasts and breast-feeding.
6. Evaluate how well the infant is breast-feeding by observing for 6-8 wet diapers and 2-3 stools in 24 hours.
7. Assist the mother with breastfeeding.
8. If the mother is pumping her breasts, assist her and teach her about same.
9. Colostrum is replaced by transitional milk within 2-5 days after birth. True or mature breast milk is produced by 2 weeks postpartum.
1. Have the patient void prior to the exam. A full bladder will displace the fundus upward and to the right or left of the umbilicus, and may cause the uterus to become boggy which can increase bleeding.
2. Describe the location and consistency (firm or boggy) of the fundus. The fundus should be firm, midline and descend 1 cm (centimeter) or fb (finger-breadth) every 24 hours. Immediately after delivery the fundus of the uterus will be midway between the symphysis pubis and umbilicus. Within 6-12 hours after birth the fundus of the uterus rises to the level of the umbilicus. It should be at the level of the umbilicus for the first 24 hours.
3. Know the nursing actions for a boggy uterus (gentle massage, administer oxytocin and/or methergine, have patient empty bladder if indicated) and institute same if indicated.
4. Evaluate her progress of involution; teach her about same.
5. Evaluate for the presence of afterpains and teach her about same.
1. Examine and evaluate the abdomen as soft, distended or firm. Inquire about passage of flatus and bowel movements.
2. Auscultate the abdomen for presence of bowel sounds.
3. Teach the mother about the normal resumption of bowel habits and encourage activities to promote same.
4. Administer a stool softener if ordered. Enemas are rarely used for relief of constipation postpartally and are contraindicated in patients with 3rd or 4th degree extensions or lacerations.
5. Discourage straws, ice and apple juice (may promote gas formation).
1. Describe the lochial phases.
2. Evaluate peripad for the amount and color of lochia and for presence of clots. Ask the patient when the peripad was last changed and how often she changes it.
3. Teach the mother about the lochial phases and warning signs of infection.
4. Assess lochia and define scant, light, moderate, heavy, and excessive.
G. PERINEUM (Episiotomy/laceration)
1. Evaluate the episiotomy/laceration site according to the REEDA scale (R=redness, E=edema, E=ecchymosis, D=discharge (from wound site, not lochia), A=approximation of suture line).
2. Administer stool softeners for 3rd or 4th degree tears/lacerations (some institutions order routinely on all postpartum patients).
Know the tissues involved in the following lacerations:
a. First degree
b. Second degree
c. Third degree
d. Fourth degree
3. Teach and encourage the following routine care of the perineum:
a. Ice packs/cold peripads are applied for the first 24 hours after delivery.
b. Heat application to the perineum after 24 hours post delivery.
· Sitz baths are then used T.I.D. PRN.
The appropriate water temperature is 100 to 105 degrees
· If desired, a warm peripad may be applied after a sitz bath. After its heat has dissipated, (or after a sitz bath if a warm peripad is not used) a regular peripad is used, and the patient may apply "comfort meds" (topical anesthetic ointments/sprays). "Comfort meds" are NEVER applied while a warm peripad is in use, as they will intensify the heat to an uncomfortable level.
d. Each time the patient voids she will rinse her perineum with a squirt bottle containing a solution of warm water. Instruct the patient to spray front to back. This is called Pericare. Proper instruction is important.
e. Teach the patient the warning signs of infection. Be sure they remember to wipe from front to back after voiding and to remove their peripad front to back as well. Frequent pericare will help prevent infection. The patient should be taught to continue pericare until the lochia stops (3-6 weeks post delivery).
1. Evaluate hemorrhoids. Describe as to size, amount (few, cluster), appearance (red, swollen).
2. Encourage the use of warm sitz baths after the first 24 hours, and application of comfort meds such as ointments, anesthetic sprays and Witch Hazel pads (Tucks) and the administration of a stool softener.
3. Encourage lying in a Sim’s position several times a day to relieve discomfort and promote good venous return of the rectal area. Discourage the use of sitting on pillows or "doughnuts", explain the rationale. Teach the patient to tighten her buttocks before sitting: TYTU (“Tuck your tail under”)
1. Evaluate the legs for the presence of thrombus formation: Assessment for abnormal warmth, redness, tenderness(pain), and swelling. Know the nursing actions if symptomology is present and DO NOT MASSAGE the leg.
2. Teach the mother these warning signs and appropriate actions to take if they occur.
3. Teach the mother self-care measures to promote circulation and prevent thrombus.
1. Monitor the first three voids after delivery/and or removal of a Foley catheter. Spontaneous voiding should occur within 6 to 8 hours after delivery. Patients may normally void up to 3,000 ml/day in the first few days after delivery.
2. Assist the mother with procedures to encourage voiding; catheterize if necessary. Check doctor’s order first.
3. Assess whether the patient is voiding without difficulty or pain, how often she is voiding, and palpate the bladder area to evaluate whether emptying has occurred.
4. Encourage the patient to void every four hours.
5. Teach the patient the signs and symptoms of a bladder infection and preventative measures.
1. Early ambulation is encouraged.
2. The patient is to call for assistance for the first few times out of bed. Routine procedure is as follows:
a. Dangle patient first.
b. Assess the patient's stability and continue to have her call for assistance until she is stable out of bed.
c. Do not leave the patient alone, stay by the bathroom and assist her back to bed. Always assist the patient with the first void. For subsequent voids, instruct her as to the use of the emergency bathroom call light if light headed.
d. Know and institute the procedure for fainting patients as needed.
L. CESAREAN DELIVERY PATIENTS
1. Cesarean delivery patients will be assessed according to the same
postpartum guidelines as vaginal delivery patients (with the exception of episiotomy/laceration if not applicable).
2. Routine post-op care as indicated is given these patients.
3. The typical cesarean delivery patient has an IV, Foley catheter, TED hose and a PCA (patient controlled analgesia) pump, compression boots, or an epidural catheter in place with medication infusing for analgesia. Additional patient assessment and completion of additional data recording forms are required when these methods of pain relief are in use.
4. Incision site care:
a. Evaluate according to the REEDA scale.
b. Change dressing when indicated.
c. Remove skin staples and apply steri-strips when
d. Teach the patient wound care and the signs and symptoms of infection.
5. Assess the patient’s bowel sounds for readiness to progress diet from clear liquids to solid food.
M. DISCHARGE INSTRUCTIONS
1. Patients should be instructed in self-care methods, activity limitations (rest, lifting, driving restrictions), nutrition, signs and symptoms of infection, contraception and fertility information, and instructions for the next medical appointment. The nurse should also find out what assistance will be available when the patient goes home.
2. It is generally recommended that intercourse, tampons and douches (“pelvic rest”) be postponed for approximately 3-6 weeks for the vaginal delivery patient (after first medical appointment) and approximately 3 weeks after delivery for the cesarean delivery patient. Cesarean delivery patients will have their first medical appointment approximately one week after delivery. The amount of stairs in their home should be ascertained and infant care should be designed to limit stair climbing.
III. POSTPARTUM MEDICATIONS
The following is a list of common medications used on a postpartal unit. Be familiar with these medications, their uses in the care of the postpartal patient, and their common side effects.
A. "Comfort Meds"
C. Analgesics for PCA's
D. Analgesic for epidurals
E. Stool softeners and laxatives
Hepatitis B Vaccine
Rhogam (Rho(D) immune globulin, human)
IV. POSTPARTUM STUDY GUIDE QUESTIONS
Define the following terms and know the following acronyms
Lochia: serosa, alba, rubra
First degree, second degree, third degree, fourth degree
A. Vital Signs:
1. Describe the normal alterations in vital signs and blood pressure that occur in the postpartal patient.
2. What are "night sweats" and when do they occur in the postpartal period?
1. Describe the postpartal changes in the breasts of the nursing mother.
2. Describe colostrum.
3. When does transitional breast milk appear in the postpartal mother?
4. Describe nonpharmacological measures to suppress lactation. How long are they needed?
5. Describe measures to relieve breast engorgement in the lactating mother and in the non-lactating mother.
1. What are afterpains?
2. Are they found typically in the primigravida or multigravida?
3. How many days do they last?
4. What effect does breastfeeding have on afterpains?
1. Define involution.
2. Describe the changes in the size of the uterus and location of the fundus during the postpartal period.
3. Where is the fundus located at 12 hours after delivery?
4. How many centimeters or fingerbreadths does the fundus descend every 24 hours?
5. Compare and contrast a firm and boggy uterus. What does each indicate?
6. Describe the nursing actions for a boggy uterus.
7. Describe the correct technique for assessing fundal height and consistency in the postpartal patient.
1. Define lochia and describe its three phases.
2. Define and compare scant, light, moderate and heavy lochia.
1. Describe the nursing care of the patient with an episiotomy or laceration.
2. What is a sitz bath?
3. What are "comfort meds?" Give examples.
4. Describe the nursing care of the patient with hemorrhoids.
5. Know the different tissues involved in the following lacerations: first degree
Second degree, third degree and fourth degree.
G. Incision/wound sites:
1. Describe the REEDA scale.
2. What are the signs and symptoms of an infection of an incision/wound site?
1. Describe the signs and symptoms of thrombophlebitis.
2. Describe nursing actions if the signs and symptoms of thrombophlebitis are present.
1. How many hours after delivery should a patient spontaneously void?
2. How much may the patient normally void within the first 24 hours?
3. How often should a patient be encouraged to void?
4. Why would a postpartal patient's fundus be displaced above and to the right of the umbilicus?
5. Describe the procedure for assisting a postpartal patient out of bed to the bathroom for the first initial times after delivery.
1. How long after delivery might a spontaneous bowel movement typically be delayed?
a. List reasons why.
b. When might an enema be considered?
2. Describe actions to promote the resumption of normal bowel habits.
3. Which conditions contraindicate the administration of an enema and why?
4. Differentiate which of the following are stool softeners and which are laxatives:
Colace, Doxidan, Dialose, Dulcolax, Senokot.
K. Resumption of menstruation/fertility:
1. Discuss when menstruation will typically resume in breast-feeding and non-breast-feeding mothers.
2. Can pregnancy occur in a breast-feeding mother?
L. Emotional adjustment phases:
1. List and compare Rubin's three maternal adjustment phases.
1. Describe the postpartal indications of each of the following:
Methergine, Rhogam, Rubella vaccine.
2. What should be discussed with the patient prior to administering a Rubella vaccine?
3. What should be discussed with the patient prior to administering Rhogam?
4. What are the two most important side effects of narcotic analgesics for the postpartal patient?
Developed 7/01 abp
Revised 8/08 dhl
Revised 05/10 mal
Revised 08/10 mal
Revised 10/10 mal