Lochla-
Assess penpad daily (1 X each shrft) for color amount type and for
any foul odor. ' • ·
2 5trud
- ln Pl lo notify nurse if she passes clots. Note size and number.
3
· Can Doctor for any excessive bleeding
4. Peri-Care:
- Instruct pt to fill peri-bottle with warm water and rinse stitches area
after each voiding or BM
-Wipe from front to back. patting gently
-Change peripads after each voiding
-Spray episiotomy area with anesthetic spray after wiping
-Apply 1 - 2 Tucks (witch hazel) pads to peripad with each pad change
-Encourage use of srtz bath 24 hrs postpartum per Doctor's order for 20
min bid-tid especially if pt had a 3rd or 4th degree laceration
Epislotomy-
- i tt+M.t '. ~
CS~~
~
1.
1
, -R=redness
-E-edema
-E=ecchymosis
1 ..
Assess using REEDA every shift
~~
..1 ;
•~ f l ~
ll.tt' ~~rt\.l
• • +. . . 1 J (--¼ /
rl A u . ~ ~ - ~ -D=discharge
I
v ~ -A=approximation
2. Position in lateral Sims position with upper knee bent. Gently lift the
buttucks to view perineum. Flashlight may be helpful.
I
3. Apply ice bags if ordered. for 6 - 8 hours post delivery to minimize swelling
I 4. Assess for presence of hemorrhoids- Teach pt to apply medication as
ordered. - fI I t
5. Most women deliver with an episiotomy
-Midline
-R or L mediolateral
-3rd degree extension- laceration extends to the rectum
. -4th degree extension- laceration extends through the rectum
1 .$; • V ,to.l r, 1 ~ ( ~~ ~ r,µ,~}
I Homan's Sign-1 . Assess daily for redness, nodular or warm areas, discolorations, or leg
" - ~\ ~ H-,fl ~ varicosities and notify Doctor.
I( -+) -~V'(N'II
-
2. Assess Haman's Sign q shift '° M
3. Assess peripheral pulses and for presence of and amount of edema -
4. Women are more prone to thrombophlebitis post-partum related to -
LI I> ~B
J ,1,C,t-? ~ u.f" hypercoagulability of the 6food caused by:
fV 1, ~ r., -pregnancy( hormonal changes)
-anemia
-pelvic infection
-traumatic delivery
-obesity
Emotional Status- 3 Normal Phases
,.. e 1. ·raking In" ~mmediately after delivery till up to 2 days postpartum
-need rest and sleep _
-self-focus '
c1 ,
-relives events of Labor and Delivery .,R I "J ,; ;
J
2. "Taking Hold. -preoccupied with the present
-usually encompasses days 2 - 5 postpartum
r ~nterested in selk:are
-optimal time for teaching
-focus on caring for baby
3. "Letting Go"-reestablishes relationships with others with outward focus
**Postpartum Blues•- a normal temporary state related to hormonal changes,
role redefinition , fatigue, or pain. Pt may •cry for no reason·.
I J
I
Breasts-
BUBBLEHED Assessment Handout
1. Palpate both breasts tor engorgement/filling. Minimize palpation fOf' bottle-
feeding mother to avoid stimulation.
2. Check nipo!es for pressure sores, cracks, or fissures. Evaluate whether
nipples are everted, flat. or inverted.
11
·1
' i.J , u;: .,I
I
3. All mothers should wearasupportjye bra 24 hours a day for the first few ,.,, /
days postpartum.
( ~, J
,,
., I
Enooroement- usually Q,CCurs 2-3 days post-partum. Teach mom to: !,»,,. r,,, :I
a. apply warm packs or K-pad 15-20 minutes pre-nursing r. ,,J~ ll,~1· , .
b. try a warm shower before nursing
c. ice bags and/or binders for non-nursing moms
,, .J I
Uterus-
The fundus is palpated for the following:
C, ~- Height- Record finger widths above or below the umbilicus.
f\N f"Y',\ al, 1.
~\/(,~ e.g. Fundus 2jU (2 fingerbreadths above the umbilicus)
~ <...-1:i\U\M Vi:).A~ Fundus U/2 (2 fingerbreadths below the umbilicus
~ ~r~ 0 Fundus descends 1 fingerbreadth each day
1
~l-4 u,w 2. Positjon- Fundus should be midline near the umbilicus
Il"I (~ 'Lt iU).. •-O~ • -A full bladder may push the fundus to the R or L of the umbilicus
• ~ ~ and cause the pt's flow to be heavier.
. r/..M~ ,f/
-~ ~ 3. To@- Fundus should remain firm
-If uterus becomes boggy gently massage the uterus to help the
C.S · ~ J I muscles to contract
-Adjust IV flow rate to control bleeding if Pitocin is in the IV solution
-If no IV, administer p.o. or IM Methergine or ergotrate per Dr.'s order.
Bladder- Assess the following
~ r1~-1t,A.~ ~ 1. Accompany mother and record first~~- (More if voiding less than
. lW :;_;;, ~ 150cc each time) -
1
m · 2. Palpate for distention above the symphysis pubis
3. If patient has not voided in ~ ~hou~ post-delivery
( -straight cath per Doctor's order - C41ck ( J I ~
? -notify Doctor for any voiding difficulties - .., ..,
4. Be al~rttr,for signs ~d~ ~ of UTI: ..,,- , , ../
-m equent VOi rng /
-painful urination {dysuria) ,, ..:, ,. I
-burning ,,,
5 • l-'(,o ,...,< --frequency -;1~ ~ ; _ '/
r ~ ,J; J..-urinary retention - - t
r r,~ J. ;._..-foul.smelling urine -
A
5. Postpart_um voiding difficulties related: - ) / l ,. • • '~I " J
- fatigue - . r, ' ' ( I • J I l, I~
-perinea! swelling - I ,
-long, difficult Labor and Delivery eg.use of Forceps, Vacuum Extractor .,
Bowel- 1. Assess for presence of BS q shift; palpate abdomen for distension
~ 2. Administer daily stool softeners per doctor's order
~ 3. Avoid use of enemas and or supe<>5itories tor pts with a 3rd or 4th d~ree
.!9cerat;on. It needed, use with caution. J
4. First BM usually occurs on or after 2nd PP dai'.:
5. Best for pt to have BM before discharge but may not happen.
6. Often sent home with stool softeners &encouraged to eat fiber & exercise.
/•I ' • I
