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POSTPARTUM

NURSING CARE

Diana Barrios RN, MSN

Merritt College ADN Program

Nursing 3A: Perinatal Nursing

EXPECTED OUTCOMES DURING

THE POSTPARTAL PERIOD

� The woman will:

� Undergo a normal involution process with normal lochia discharge

� Remain comfortable and injury free

� Demonstrate normal bladder and bowel function

� Demonstrate knowledge of breast care

� Demonstrate knowledge of infant safety, infant care activities, and infant feeding

� Integrate the newborn into the family

POSTPARTUM ASSESSMENTS

� Initial general assessment

� Body systems assessment

� Assessment specific to postpartum changes

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GENERAL ASSESSMENT

� Enter the room quietly, speak quietly. Wash

hands and provide for privacy. Inform patient before turning on lights.

� Note LOC, activity level, position, color, general demeanor.

� Take note of the total environment:

� Safety/patient considerations

� Note equipment and medical devices

BODY SYSTEMS ASSESSMENT

� Vital signs

� Level of pain

� Neurological

� Pulmonary

� Cardiovascular

� Musculoskeletal

� Gastrointestinal

� Genitourinary

� Integumentary

� Psychosocial

ALTA BATES’ MATERNAL FLOWSHEET

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ASSESSMENT SPECIFIC TO

POSTPARTUM ADAPTATION

� Vital signs (q 4-8 hrs)

� Breasts/breastfeeding

� Uterus

� Lochia/perineum

� Bladder & bowel function

� Edema, Homan’s sign

� Bonding & attachment process

� Teaching/learning/referral needs assessment

VITAL SIGNS

� SBP 90-140, DBP 50-90 (compare to

baseline values)

� Pulse 60-100 bpm

� RR 10-24 breaths/min

ASSESSMENT OF

BREASTS & BREASTFEEDING

� Breasts soft & non-tender; nipples everted

� Begin by asking how feedings are going.

� Ask if patient feels lumps in breasts, or has redness, soreness, or blisters on nipples.

� Observe for signs that might indicate incorrect latch

� LATCH score

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THE POSTPARTUM DECISION

NURSING DIAGNOSES RELATED

TO BREASTS & BREASTFEEDING

� Pain r/t improper positioning, engorged

breasts

� Ineffective breastfeeding r/t maternal discomfort, improper infant positioning

� Knowledge deficit r/t normal physiologic

changes, breastfeeding

� Infection r/t improper breastfeeding techniques, improper breast care

ASSESSMENT OF THE

UTERUS

� Uterus midline, FF @ U/U or below following the first 12-24 hrs after birth

� Rising uterus, displaced to side � full bladder?

� Boggy uterus � subinvolution?� Lochia: scant-moderate, rubra-serosa� Perineal lacerations/episiotomy – well-

approximated, no signs of infection

� C/S dressing: CDI, REEDA� Patient should be educated about normal and

abnormal changes, what to report, and when to ask for help.

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PAD COUNT: LOCHIA

� Scant: 1-inch stain on pad in 1 hour

� Light/small: 4 inches in 1 hour

� Moderate: 6 inches in 1 hour

� Heavy/large: Pad saturated in 1 hour

� Excessive: Pad saturated in 15 min

� Can estimate blood loss by weighing

pads

� 500 mL = 1 lb. or 454 g

LOCHIA AMOUNTS

ASSESSMENT OF BOWEL &

BLADDER FUNCTION

� Void without difficulty/pain, urine may be blood-tinged from lochia

� Possible diagnosis: Urinary retention or constipation r/t post childbirth discomfort or tissue trauma

� Expected outcome: Return to normal bowel and bladder habits, void at least 240mL in 8 hrs, bowel movement in 3 days without pain.

� Nursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Measure 1st 2 voids after SVD or Foley catheter removed. Encourage use of peribottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

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ASSESSMENT OF EDEMA &

HOMAN’S SIGN

� Assess legs for presence and degree of edema; may have dependent edema in feet

and legs (facial and hand edema may indicate preeclampsia)

� Assess for Homan’s sign (thromboembolism);

should be negative

� Obtain lab values: 8-hr post-delivery hemogram, urinalysis/C&S, blood type/Rh

status

CHECKING HOMAN’S SIGN

SUMMARY OF POSTPARTUM

ASSESSMENT & CARE

� Box 16-1, page 468: Postpartum

Assessment

� Care Path: 24-Hour Vaginal Birth without Complications, page 470-471