NCLEX: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Complications During the Postpartum Period

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

I. DISORDERS AFFECTING FLUID-GAS TRANSPORT

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Postpartum hemorrhage

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Definition—loss of 500 mL of blood or more during first 24 hours postpartum in vaginal birth; 1000 mL in cesarean birth.

2. Pathophysiology—excessive loss of blood secondary to trauma, decreased uterine contractility; results in hypovolemia.

3. Etiology (in decreasing order of frequency):

a. Uterine atony

  • Uterine over-distention (multi-pregnancy, polyhydramnios, fetal macrosomia).
  • Multiparity.
  • Prolonged or precipitous labor.
  • Anesthesia—deep inhalation or regional (particularly saddle block).
  • Myomata (fibroids).
  • Oxytocin induction of labor.
  • Over-massage of uterus in postpartum.
  • Distended bladder.

b. Lacerations—cervix, vagina, perineum.

c. Retained placental fragments—usually delayed postpartum hemorrhage.

d. Hematoma—deep pelvic, vaginal, or episiotomy site.

4. Assessment:

a. Uterus—boggy, flaccid; excessive vaginal bleeding (dark; seepage, large clots)—due to uterine atony, retained placental fragments.

b. Late signs of shock—air hunger; anxiety/apprehension, tachycardia, tachypnea, hypotension.

c. Blood values (admission and postpartum)—hemoglobin (Hgb), hematocrit (Hct), clotting time.

d. Estimated blood loss: during labor/birth; in early postpartum.

e. Pain: vulvar, vaginal, perineal.

f. Perineum: distended—due to edema; discoloration—due to hematoma. May complain of rectal pressure.

g. Lacerations—bright red vaginal bleeding with firm fundus.

5. Analysis/nursing diagnosis:

a. Fluid volume deficit related to excessive blood loss secondary to uterine atony, retained placental fragments.

b. Anxiety/fear related to unexpected complication.

c. Altered tissue perfusion related to decreased oxygenation secondary to blood loss.

d. Activity intolerance related to fatigue.

6. Nursing care plan/implementation:

a. Medical management:

  • IV oxytocin infusion; IV or oral ergot preparations (ergonovine [Ergotrate Maleate]; methylergonovine [Methergine]; carboprost (Prostin/M15), an oxytocic; prostaglandin.
  • Order blood work: clotting time, platelet count, fibrinogen level, Hgb, Hct, CBC.
  • Type and cross-match for blood replacement.
  • Surgical:

(a) Repair of lacerations.
(b) Evacuation, ligation of hematoma.
(c) Curettage—retained placental fragments.

b. Nursing management:

  • Goal: minimize blood loss.

(a) Notify physician promptly of abnormal assessment findings.
(b) Order lab work STAT, as directed—to determine blood loss and etiology.
(c) Fundal massage.
(d) Administer medications to stimulate uterine tone. For ergot products and carboprost, monitor blood pressure (contraindicated in PIH).

  • Goal: stabilize status.

(a) Establish IV line—to enable administration of medications and rapid absorption/action. Administer whole blood (with larger catheter).
(b) Administer medications, as ordered to control bleeding, combat shock.
(c) Prepare for surgery, as ordered.

  • Goal: prevent infection. Strict aseptic technique.
  • Goal: continual monitoring. Vital signs, bleeding (do pad count or weigh pads), fundal status.
  • Goal: prevent sequelae (Sheehan’s syndrome).
  • Goal: health teaching—after episode: Reinforce appropriate perineal care and hand-washing techniques.

7. Evaluation/outcome criteria:

a. Maternal vital signs stable.
b. Bleeding diminished or absent.
c. Assessment findings within normal limits.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

B. Subinvolution—delayed return of uterus to normal size, shape, position.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—inability of inflamed uterus (endometritis) to contract effectively → incomplete uterine involution; failure of contractions to effect closure of vessels in site of placental attachment → bleeding.

2. Etiology:

a. PROM with secondary amnionitis, endometritis.

b. Retained placental fragments.

c. Oxytocin stimulation or augmentation of labor of over-distended uterine muscle may interfere with involution.

3. Assessment:

a. Uterus: large, boggy; lack of uterine tone; failure to shrink progressively.

b. Discharge: persistent lochia; painless fresh bleeding, hemorrhagic episodes.

4. Analysis/nursing diagnosis:

a. Pain related to tender, inflamed uterus secondary to endometritis.

b. Anxiety/fear related to change in physical status.

c. Knowledge deficit related to diagnosis, treatment, prognosis.

d. High risk for injury related to infection.

e. Fluid volume deficit related to excessive bleeding.

5. Nursing care plan/implementation:

a. Medical management:

  • Have woman void or catheterize; massage fundus.
  • Surgical (curettage)—to remove placental fragments.
  • Antibiotic therapy—to treat intrauterine infection.
  • Oxytocics—to stimulate/enhance uterine contractions.

b. Nursing management:

  • Goal: health teaching.

(a) Explain condition and treatment.
(b) Describe, demonstrate perineal care, pad change, hand washing.

  • Goal: emotional support. Encourage verbalization of anxiety regarding recovery, separation from newborn.
  • Goal: promote healing.

(a) Encourage rest, compliance with medical/nursing regimen.
(b) Administer oxytocics, antibiotics, as ordered.

6. Evaluation/outcome criteria:

a. Verbalizes understanding of condition and treatment.

b. Complies with medical/nursing regimen.

c. Demonstrates normal involutional progress.

d. All assessment findings (vital signs, fundal height, consistency, lochial discharge) within normal limits.

e. Expresses satisfaction with care.

C. Hypofibrinogenemia

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—decreased clotting factors, fibrinogen; may be accompanied by DIC.

2. Etiology:

a. Missed abortion (retained dead fetus syndrome).

b. Fetal death, delayed emptying of uterine contents.

c. Abruptio placentae; Couvelaire uterus.

d. Amniotic fluid embolism.

e. Hypertension.

3. Assessment:

a. Observe for bleeding from injection sites, epistaxis, purpura.

b. Maternal vital signs, color.

c. I&O.

d. Medical evaluation—procedures.

  • Thrombin clot test—important: size and persistence of clot.
  • Prothrombin time—prolonged.
  • Bleeding time—prolonged.
  • Platelet count—decreased.
  • Activated partial thromboplastin time—prolonged.
  • Fibrinogen (factor I concentration)—decreased.
  • Fibrin degradation products—present.

4. Analysis/nursing diagnosis:

a. Fluid volume deficit related to uncontrolled bleeding secondary to coagulopathy.

b. Anxiety/fear related to unexpected critical emergency.

c. Altered tissue perfusion related to decreased oxygenation secondary to blood loss.

5. Nursing care plan/implementation:

a. Medical management:

  • Replace platelets.
  • Replace blood loss.
  • IV heparin—to inhibit conversion of fibrinogen to fibrin.

b. Nursing management:

  • Goal: continuous monitoring.

(a) Vital signs.
(b) I&O hourly.
(c) Skin: color, emergence of petechiae.
(d) Note, measure (as possible), record, and report blood loss.

  • Goal: control blood loss.

(a) Establish IV line, administer fluids or blood products as ordered.
(b) Position: side-lying—to maintain blood supply to vital organs.

  • Goal: emotional support.

(a) Encourage verbalization of anxiety, fear, concerns.
(b) Explain all procedures.
(c) Remain with woman continuously.
(d) Keep woman and family informed.

6. Evaluation/outcome criteria:

a. Bleeding controlled.

b. Laboratory studies—returning to normal values.

c. Status stable.

II. DISORDERS AFFECTING PROTECTIVE FUNCTIONS: postpartum infection (Postpartum Infections).

A. General aspects

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Definition—reproductive system infection occurring during the postpartum period.

2. Pathophysiology—bacterial invasion of birth canal; most common: localized infection of the lining of the uterus (endometritis).

3. Etiology:

a. Anaerobic nonhemolytic streptococci.

b. E. coli.

c. C. trachomatis (bacteroides).

d. Staphylococci.

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4. Predisposing conditions:

a. Anemia.

b. PROM.

c. Prolonged labor.

d. Repeated vaginal examinations during labor.

e. Intrauterine manipulation (e.g., manual extraction of placenta).

f. Retained placental fragments.

g. Postpartum hemorrhage.

5. Assessment:

a. Fever 38°C (100.4°F) or more on two or more occasions, after first 24 hours postpartum.

b. Other signs of infection: pain, malaise, dysuria, sub-involution, foul lochial odor.

6. Analysis/nursing diagnosis:

a. Fluid volume deficit related to excessive blood loss, anemia.

b. Knowledge deficit related to danger signs of postpartum period.

c. High risk for injury related to infection.

7. Nursing care plan/implementation: prevention

a. Goal: prevent anemia.

  • Minimize blood loss—accurate postpartum assessment and management of bleeding.
  • Diet: high protein, high vitamin.
  • Vitamins, iron—suggest continuing prenatal pattern until postpartum checkup.

b. Goal: prevent entrance/transport of microorganisms.

  • Strict aseptic technique during labor, birth, and postpartum (standard precautions).
  • Minimize vaginal examinations during labor.
  • Perineal care.

c. Goal: health teaching.

  • Hand washing—before and after each pad change, after voiding or defecating.
  • Perineal care—from front to back; use clear, warm water or mild antiseptic solution as a cascade; do not separate labia.
  • Maintain sterility of pads; apply from front to back.
  • Avoid use of tampons until normal menstrual cycle resumes.

8. Evaluation/outcome criteria:

a. Woman has assessment findings within normal limits:

  • Vital signs.
  • Rate of involution (fundal height, consistency).
  • Lochia: character, amount, odor.

b. Woman avoids infection.

B. Endometritis—infection of lining of uterus.

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology.

2. Etiology—most common: invasion by normal body flora (e.g., anaerobic streptococci).

3. Characteristics:

a. Mild, localized—asymptomatic, or low-grade fever.

b. Severe—may lead to ascending infection, parametritis, pelvic abscess, pelvic thrombophlebitis.

c. If remains localized, self-limiting; usually resolves within 10 days.

4. Assessment:

a. Signs of infection: fever, chills, malaise, anorexia, headache, backache.

b. Uterus: large, boggy, extremely tender.

  • Sub-involution.
  • Lochia: dark brown; foul odor.

5. Analysis/nursing diagnosis:

a. Anxiety/fear related to effects on self and newborn.

b. Self-esteem disturbance and altered role performance related to inability to meet own expectations regarding parenting, secondary to unexpected hospitalization.

c. Pain related to inflammation/infection.

d. Ineffective individual coping related to physical discomfort and psychological stress associated with self-concept disturbance; worry, guilt, concern regarding newborn at home.

e. Altered family processes—interruption of adjustment to altered life pattern related to postpartum infection/hospitalization.

6. Nursing care plan/implementation:

a. Goal: prevent cross-contamination. Contactitem isolation.

b. Goal: facilitate drainage. Position: semi-Fowler’s.

c. Goal: nutrition/hydration.

  • Diet: high calorie, high protein, high vitamin.
  • Push fluids to 4000 mL/day (oral or IV, or both, as ordered).
  • I&O.

d. Goal: increase uterine tone/facilitate involution. Administer medications, as ordered (e.g., oxytocics, antibiotics).

e. Goal: minimize energy expenditure, as possible.

  • Bedrest.
  • Maximize rest, comfort.

f. Goal: emotional support.

  • Encourage verbalization of anxiety, concerns.
  • Keep informed of progress.

7. Evaluation/outcome criteria:

a. Vital signs stable, within normal limits.

b. All assessment findings within normal limits.

c. Unable to recover organism from discharge.

C. Urinary tract infections

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—normal physiological changes associated with pregnancy (e.g., ureteral dilation) and the postpartum period (e.g., diuresis, increased bladder capacity with diminished sensitivity of stretch receptors) → increased susceptibility to bacterial invasion and growth → ascending infections (cystitis, pyelonephritis).

2. Etiology: usually bacterial.

3. Predisposing factors:

a. Birth trauma to bladder, urethra, or meatus.

b. Bladder hypotonia with retention (due to intrapartum anesthesia or trauma).

c. Repeated or prolonged catheterization, or poor technique.

d. Weakening of immune response secondary to anemia, hemorrhage.

4. Assessment:

a. Maternal vital signs (fever, tachycardia).

b. Dysuria, frequency (flank pain—with pyelonephritis).

c. Feeling of “not emptying” bladder.

d. Cloudy urine; frank pus.

5. Analysis/nursing diagnosis:

a. Altered urinary elimination related to diuresis, dysuria, inflammation/infection.

b. Pain related to dysuria secondary to cystitis.

c. Knowledge deficit related to self-care (perineal care).

6. Nursing care plan/implementation:

a. Goal: minimize perineal edema. Perineal ice pack in fourth stage—to limit swelling secondary to trauma, facilitate voiding.

b. Goal: prevent over-distention of bladder.

  • Monitor level of fundus, lochia, bladder distention. (Note: Distended bladder displaces uterus, limits its ability to contract → boggy fundus, increases its vaginal bleeding.)
  • Encourage fluids and voiding; I&O.
  • Aseptic technique for catheterization.
  • Slow emptying of bladder on catheterization—to maintain tone.

c. Goal: identification of causative organism—to facilitate appropriate medication (antibiotics). Obtain clean-catch (or catheterized) specimen for culture and sensitivity.

d. Goal: health teaching. See previous discussion of fluids, general hygiene, diet, and medications.

7. Evaluation/outcome criteria:

a. Voiding: quantity sufficient (although small, frequent output may mean overflow with retention).

b. Urine character: clear, amber, or straw colored.

c. Vital signs: within normal limits.

d. No complaints of frequency, urgency, burning on urination, flank pain.

D. Mastitis—inflammation of breast tissue:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—local inflammatory response to bacterial invasion; suppuration may occur; organism can be recovered from breast milk.

2. Etiology—most common: Staphylococcus aureus; source—most common: infant’s nose, throat.

3. Assessment:

a. Signs of infection (may occur several weeks in postpartum).

  • Fever.
  • Chills.
  • Tachycardia.
  • Malaise.
  • Abdominal pain.

b. Breast

  • Reddened area(s).
  • Localized/generalized swelling.
  • Heat, tenderness, palpable mass.

4. Analysis/nursing diagnosis:

a. Impaired skin integrity related to nipple fissures, cracks.

b. Pain related to tender, inflamed tissue secondary to infection.

c. Disturbance in body image, self-esteem related to association of breastfeeding with female identity and role.

d. Anxiety/fear related to sexuality; impact on breastfeeding, if any.

5. Nursing care plan/implementation:

a. Goal: prevent infection. Health teaching in early postpartum:

  • Hand washing.
  • Breast care—wash with warm water only (no soap)—to prevent removing protective body oils.
  • Let breast milk dry on nipples to prevent drying of tissue.
  • Clean bra (with no plastic pads or liners) to support breasts, reduce friction, minimize exposure to microorganisms.
  • Good breastfeeding techniques.
  • Alternate position of infant for nursing to change pressure areas.

b. Goal: comfort measures.

  • Encourage bra or binder—to support breasts, reduce pain from motion.
  • Local heat or ice packs as ordered—to reduce engorgement, pain.
  • Administer analgesics, as necessary.

c. Goal: emotional support.

  • Encourage verbalization of feelings, concerns.
  • If breastfeeding is discontinued, reassure woman she will be able to resume breastfeeding.

d. Goal: promote healing.

  • Maintain lactation (if desired) by manual expression or breast pump, q4h.
  • Administer antibiotics as ordered.

6. Evaluation/outcome criteria:

a. Woman promptly responds to medical/nursing regimen.

  • Symptoms subside.
  • Assessment findings within normal limits.

b. Woman successfully returns to breastfeeding.

E. Thrombophlebitis

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—inflammation of a vein secondary to lodging of a clot.

2. Etiology:

a. Extension of endometritis with involvement of pelvic and femoral veins.

b. Clot formation in pelvic veins following cesarean birth.

c. Clot formation in femoral (or other) veins secondary to poor circulation, compression, and venous stasis.

3. Assessment:

a. Pelvic—pain: abdominal or pelvic tenderness.

b. Calf—pain: positive Homans’ sign (pain elicited by flexion of foot with knee extended).

c. Femoral

  • Pain.
  • Malaise, fever, chills.
  • Swelling—“milk leg.”

4. Analysis/nursing diagnosis:

a. Pain in affected region related to local inflammatory response.

b. Anxiety/fear related to outcome.

c. Ineffective individual coping related to unexpected postpartum complications, hospitalization, separation from newborn.

d. Impaired physical mobility related to imposed bedrest to prevent emboli formation and dislodging clot (embolus).

5. Nursing care plan/implementation:

a. Goal: prevent clot formation.

  • Encourage early ambulation.
  • Position: avoid prolonged compression of popliteal space, use of knee gatch.
  • Apply thromboembolic disease (TED) hose, or sequential compression device, as ordered, preoperatively or post-operatively, or both, for cesarean birth.

b. Goal: reduce threat of emboli.

  • Bedrest, with cradle to support bedding.
  • Discourage massaging “leg cramps.”

c. Goal: prevent further clot formation. Administer anticoagulants, as ordered.

d. Goal: prevent infection.

  • Administer antibiotics, as ordered.
  • Push fluids.

e. Goal: facilitate clot resolution. Heat therapy, as ordered.

6. Evaluation/outcome criteria:

a. Symptoms subside; all assessment findings within normal limits.

b. No evidence of further clot formation.

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III. DISORDERS AFFECTING PSYCHOSOCIAL-CULTURAL FUNCTIONS—postpartum depression/psychosis

A. General aspects

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Can occur in both new parents and experienced parents.

2. Usually occurs within 2 weeks of birth.

3. Increased incidence among single parents

4. Increased incidence among women with history of clinical depression.

5. Most common symptomatology: affective disorders.

6. Psychiatric intervention required if prolonged or severe; if underlying cause unresolved; increased risk in subsequent pregnancies.

B. Etiology—theory: birth of child may emphasize:

1. Unresolved role conflicts.

2. Unachieved normal development tasks.

C. Assessment:

1. Withdrawal.

2. Paranoia.

3. Anorexia, sleep disturbance, mood swings.

4. Depression—may alternate with manic behavior.

5. Potential for self-injury or child abuse/neglect.

D. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Ineffective individual coping related to perceived inability to meet role expectations (“mother”) and ambivalence related to dependence/independence.

2. Self-esteem disturbance and altered role performance related to “femaleness” and reaction to responsibility for care of newborn.

3. High risk for violence, self-directed or directed at newborn, related to anger or depression.

4. Ineffective family coping related to lack of support system in early postpartum.

5. Altered family processes related to psychological stress, interruption of bonding.

6. Altered parenting related to hormonal changes and stress.

E. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Goal: emotional support.

a. Encourage verbalization of feelings, fears, anxiety, concerns.

b. Support positive self-image, feelings of adequacy, self-worth.

  • Reinforce appropriate comments and behaviors.
  • Encourage active participation in self-care, comment on accomplishments.
  • Reduce threat to self-image, fear of failure. Maintain support, gradually increase tasks.

2. Goal: safeguard status of mother/newborn.

a. Unobtrusive, protective environment.

b. Stay with woman when she is with infant.

3. Goal: nutrition/hydration.

a. Encourage selection of favorite foods—to aid security in decision making; counteract anorexia (refusal to eat) by tempting appetite.

b. Push fluids (juices, soft drinks, milkshakes)—to maintain hydration.

4. Goal: minimize stress, facilitate effective coping. Administer therapeutic medications, as ordered.

a. Schizophrenia—phenothiazines.

b. Depression—mood elevators.

c. Manic behaviors—sedatives, tranquilizers.

F. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Woman increases interaction with infant.

2. Woman expresses interest in learning how to care for infant.

3. Woman evidences no agitation, depression.

4. Woman actively participates in caring for self and infant.

5. Woman demonstrates increasing comfort in mothering role.

6. Woman has positive family interactions.

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