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NUR1 233 Lecture Notes - Gamma Globulin, Orthostatic Hypotension, Immunodeficiency

Course Code
NUR1 233
Sonia Elizabeth Semenic

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Chapter 21: Nursing Care During the 4th Trimester
Laws relating to discharge
Newborns’ and Mothers’ Health Protection Act 1996 provided minimum federal standards for health plan coverage
for mothers and their newborns
All health plans required to allow the new mother and newborn to remain in hospital for minimum of 48 hrs for
vaginal birth and for 96 hours after cesarean birth
Interview: emotional status, energy level, physical discomfort, hunger, knowedge of self care and baby care
Physical examination
o Breasts: firmness
o Uterine fundus: location, consistency
o Bladder: amount, frequency
o Bowel: amount, frequency
o Lochia: amount, color, odour
o Episiotomy
Review of lab results: hemoglobin, hematocrit, rubella, Rh
Risk for deficient fluid volume (hemorrage) related to uterine atony after birth
Urinary retention or constipation related to postchildbirth discomfort, childbirth trauma to tissues
Acute pain related to uterine involution (contractions), episiotomy or lacerations, hemorrhoids, engorged breasts
Disturbed sleep pattern related to discomforts of postpartum period, long labor, infact care and hospital routine
Ineffective breastfeeding related to maternal discomfort and infant positioning
Signs of potential physiological complications
Temperature: more than 38 degrees celcius after first 24 hours
Pulse: tachycardia or bradycardia
BP: hypo or hypertension
Energy level: lethargy or extreme fatigue
Uterus: deviated from midline, boggy consistency, above umbilicus for 24 hours
Lochia: heavy, foul odour, bright red bleeding that is not lochia
Perineum: pronounced edema, not intact, infection, discomfort
Legs: Homa’s sign positive, painful, reddened area, warmth on posterior aspect of calf
Breasts: redness, heat, pain, cracked and fissured nipples, inverted nipples, palpable mass
Appetite: lack of appetite
Elimination: urine not able to void, urgency, frequency, dysuria, bowel constipation, diarrhea
Rest: inability to rest or sleep
Plan of care and implementation
Periodic assessments to detect deviations from normal physiological changes, measures to relieve discomfort or pain,
safety measures to prevent injury or infection, and teaching and couseling measures designed to promote the woman’s
feelings of competence in self-management and baby care
1st step: check wristband ID and matching infants ID number
Prevention of infection
Wipe genital area front to back after voiding or defecating
Change perineal pad from front to back each time voids or defecates and wash hands thoroughly
Prevention of excessive bleeding
Most frequent cause: uterine atony uterine can’t contract
o Caused by: placenta piece left inside, bladder distention, vaginal or vulvar hematomas, unrepaired lacerations
o Maintain good uterine tone and prevent bladder distention
If pad filled with blood in less than an hour PROBLEM
Maintainence of uterine tone
Stimulation by gently massaging uterine fundus until firm
Can cause temporary increase in amount of vaginal bleeding seen as pooled blood leaves the uterus can be
uncomfortable for mothers but explain causes and dangers of uterine atony
Prevention of bladder distention
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