Postpartum Maternal Physical Assessment Summary.docx

Postpartum Maternal Physical Assessment Summary- BUBBLE HEBreasts: inspect: size, symmetry, shape of breast and nipples taking note of erection, flatness, redness, bruising, open wounds, presence of mastitis and colostrum palpate: fullness, soft or engorged, firmness and lumps pain assessmentUterus (Fundus): palpate: firmness/bogginess, location of the fundus in relation to the abdomen, determine the location of the fundus in relation to the belly button to determine amount of fundal involution inspect incision site check policy: in some organizations, they may not assessfundalinvolution by palpation due to fear of dehiscenceBladder: void amount (~30ml/hr) assessfor distention, incontinence, urinary retention, urinary infection especially if the patient had a foley catheterBowel: last bowel movement/flatus assessfor distention, abdominal painLochia: amount, color, odour assessfor postpartum hemorrhageEpisiotomy level of laceration number of stitches, redness, edema, bruisin, discharge, approximation of wound edges assess perineal areaHomansSign-for DVT assessfor pain with dorsiflexion check policy: this is sometimes not done in organizationsEmotional State: assess for signs and symptoms of postpartum depression and infant-maternal bondingPostpartum physical adaptations

Uterus continued Changes in Fundal Position Immed after placenta expelled: Uterus contracts to compress blood vessels Size of large grapefruit

Fundus in midline, about half way to 2/3 way between umbilicus and symphysis pubis Rises to level of navel about 6-12 hours after delivery changes in ligaments Fundus above umbilicus and soft and spongy (boggy) associated with excess bleeding If high and displaced to side (usually right), prob secondary to full bladder Empty bladder and reassessPostpartum physical adaptations

Uterus continued Uterus remains at level of umbilicus about day after birth On first day following birth top of fundus about 1cm below umbilicus Fundus descends about 1 fingerbreadth or 1 cm daily Descends into pelvis on 10thday, can no longer be palpated Returns to pre-preg size and location by 5-6 wks If descends slower, called subinvolution

Postpartum physical adaptations

Lochia Debris eliminated in discharge called lochia, is classified according to appearance Lochia rubra: Dark red, first 2-3 days after delivery Clotting result of pooling in vagina, nickel size clots otherwise ok Lochia serosa: Pinkish to brownish 3-10 days pp Lochia alba: Yellowish-whitish Duration varies


Lochia When lochia stops, cervix is closed, less chance of uterine infection Total lochia blood loss volume is 225 mL Volume decreases gradually, may increase with nursing, exertion Normal odor slightly musty, non-offensive Foul odor to lochia suggests infection Assessment of lochia necessary Type, amt of lochia corresponds to involution & healing of placental site Failure of lochia to progress and decrease in amount = subinvolution or PP hemorrhage If continuous bright red seep with firm uterus right after birth, must consider possibility of laceration


Cervical Changes Spongy and flabby, formless after birth Reforms with in few hours & closes slowly, by end of first week will only admit fingertip Shape permanently changed Vaginal Changes May be edematous and bruised, no rugae Size decreases and rugae returns in 3-4 wks, normal by 6 wks Can improve tone with Kegels exercises If nursing may be dry, pale


Perineal Changes Appears swollen and bruised If episiotomy or laceration, should be well approx Should be healed by 2-3 weeks after delivery with complete healing by 4-6 months May have some discomfort during this time Recurrence of Ovulation and Menstruation Generally 6-10 wks after birth if not nursing If nursing, return is prolonged Depends on length of breastfeeding and supplements Not reliable form of contraception


Abdomen Appears loose and flabby Responds to exercise with in 2-3 months If abdomen over distended or poor muscle tone pre-preg, may not regain tone, remains flabby Diastasis recti abdominis Is separation of abdominis muscles Often occurs with preg, especially if poor abd tone Abdominal wall has no muscle support Improvement depends on cond of mom, type and amt of exercise, number of pregnancies and spacing May result in pendulous abd Striae Results from rupture of elastic fibers of skin Fade to silvery white if Caucasian If dark skin, they stay darker than surrounding skin


Gastrointestinal system Hunger, thirst immediately after birth common Bowels tend to be sluggish d/t progesterone, decreased abdominal tone If episiotomy scared will hurt or tear sutures with BM Nursing interventions may help prevent, relieve If C/S, clear liq till bowel sounds, then solid food


Urinary system At risk for over distention, incomplete emptying with residual urine d/t Increased bladder capacity Swelling and bruising of tissues around urethra Decreased sensation of full bladder (anesthetic block) Output first 12-24 hrs pp (PP diuresis) Eliminate 2000-3000 mL preg fluid, more if PIH Fills bladder quickly, watch closely for distention Risk of UTI high Full bladder will also uterine relaxation, bleeding


Vital signs Should be afebrile after 24 hrs May have temp up to 100.4 F (38 C) for 24 hrs d/t dehydration May also have elevation of 100 to 102 F (37.8-39 C) when milk comes in BP may spike immediately after delivery Should have normal BP within few days Orthostatic hypotension common first couple days Decrease = hemorrhage versus normal? Increase = preeclampsia, excess oxytocin use? Decreased pulse common for first 6-10 days PP Pulse > 100 related to hemorrhage, fear, pain, infection


Blood values Values return to normal by 6-8 wk after delivery Increased coagulation factors continue for variable time, increases risk for blood clot Blood loss averages H & H difficult to determine in first 2 days pp d/t changing blood volume (diuresis) 200-500 cc with vag del 700-1000cc with C/S Rule of thumb 2 point drop in Hct = 500 mL blood lost WBC increases in labor & early pp to 25,000-30,000 Platelets return to normal by 6 weeks


Cardiovascular changes Blood volume increases because no longer has blood circulating to placenta Works to protect mother against excess blood loss Diuresis decreases extracellular fluid If fails to happen, can lead to pulmonary edema esp in mother with preeclampsia or existing cardiac problems Weight loss 10-12 # immediately after birth (infant, placenta, amniotic fluid) Diuresis additional 5# first wk By 6-7 wks return to pre-preg wt if gained normal amt


Afterpains Are intermittent contrx of uterus More common in multips, retained placenta or with overdistention of uterus Oxytocin & breastfeeding increases afterpains Can use mild analgesic 1 hour before nursing May be very uncomfortable for 2-3 days Usually gone in 5 minutes

Postpartal Nursing Physical Assessment

Physical Assessment see guide pg 1001-1004 Explain to pt purposes Record and report results Avoid exposure to body fluids Teach pt as assess use q opportunity since limited time

Post Partum Nursing Assessment

Assessment necessary to identify individual needs or potential problems See page 1053-1055 for complete assessment guide Also see table on page 1052 about postpartal high risk factors and their implications Term BUBBLEHE can help remember components breast, uterus, bladder, bowel, lochia, episiotomy, Homans/hemorrhoids, emotional Principles in assessment of pp woman Provide explanation of assessment to client Perform procedures gently to avoid unnecessary discomfort Record and report results Take appropriate precautions to prevent exposure to body fluids Provides excellent opportunity for client teaching about physical changes of pp and common concerns


Vital signs Alterations in VS can indicate complications already discussed Lung auscultation Lungs should be clear Women treated for PTL, PIH @ risk for pulmonary edema


Breasts Assess fit and support of bra Helps maintain shape by limiting stretching of ligaments and connective tissue Bra for nursing mother Non-elastic straps Be one size larger than normal Have cups that fold down for nursing Breast assessment Inspect for redness, engorgement Palpate for warmth, firmness of filling or engorgement, tenderness In nursing women: Assess nipples for cracks, bleeding, soreness, fissures, inversion


Abdomen and Fundus pg 1057 -1058 Pt should void prior to checking fundus Uterus positioned better More comfortable to client Position pt on back with legs flexed Assess relationship of fundus to umbilicus, midline Assess firmness of uterus Massage prn if not firm Assess any blood discharged during massage Assess gently, uterus slightly tender Excessive pain with palpation clue to infection If cesarean Palpate fundus gently Assess incision (REEDA, patency of staples)


If uterine atony (boggy): Question patient about her bleeding, passage of clots Re-eval bladder Babe to breast if nursing Assess maternal BP, pulse Notify MD since may need oxytocic med


Lochia pg 1059 Assess for character, amt, odor, clots Should never be more than moderate amt with non-offensive odor: Partially saturate 4-8 pads, 6 average/day Women with C/S bleed less first day than vag del Also assess womans pad changing practices, her type of pad Assess chux pad If pt reports heavy bleeding, change pad, reassess in 1 hr If need accurate assessment, can weigh pad; 1g = 1cc Teach proper wiping, progression of lochia


Perineum pg 1061-1062 Inspect with pt in Sims position Lift buttock to expose perineum, anus If present, assess episiotomy or laceration for REEDA Should have minimal tenderness with gentle palpation No hardened areas or hematomas Also assess hemorrhoids: size, pain Evaluate effectiveness of any comfort measures performed Educate about suture absorption


Lower Extremities PP woman at increased risk of thrombophlebitis, thrombus formation; most likely site is legs To screen, use Homans sign (not diagnostic) Nurse grasps foot and dorsiflexes sharply Should have no calf pain If positive for pain notify MD Check for edema, redness, tenderness, warmth of leg Prevention best Early ambulation Passive ROM for cesarean client till sensation returns Teach Signs and symptoms to watch after discharge Self care for prevention ambulate, leg exercises in bed, avoid crossing legs and pressure behind knees


Elimination Urinary Should void within 4 hours, then q 4-6 hours Monitor bladder carefully first few hrs (diuresis) Watch for distention Misplaced or boggy uterus, palpable bladder signs Check to see if empty first few times Use techniques to encourage void If cant void after 8 hours or voiding small (2000mL/day) Fresh fruits and veggies


Rest status Requires energy to make adjustments to motherhood and infant Fatigue often significant problem Evaluate amount of rest mother is getting Determine cause of not sleeping, use appropriate interventions Encourage daily rest period Arrange activities in hospital


Nutritional status Non-nursing Decrease calories by 300/day Return to pre-preg nutritional requirements If nursing Increases calories by 200 over preg level or 500 over pre-preg level Refer to dietician if vegetarian, food allergies, lactose intolerance or have specific food needs related to culture/religion Advise iron supplements, prenatal vitamins for 3 months esp if nursing

Postpartal Psychologic Adaptations

PP time of adjustment and adaptation to new baby, pp discomfort, change in body, loss of pregnancy2 periods of adjustment: Taking in period First couple days, tends to be passive, dependent Hesitates to make decisions, follows suggestions Preoccupied with her needs Must assimilate experience Talks about labor, sorts out reality Sleep, eat is major focus

Postpartal Psychologic Adaptations

Periods of adjustment Taking hold period By 2nd 3rdday ready to resume control of body, mothering and her life Needs reassurance needed shes doing well as mother This theory 40 years old, slightly outdated as women more independent today Adjust more rapidly in shorter time periods than these

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Postpartum Maternal Physical Assessment Summary.docx