Kinh Nghiệm Hướng dẫn Which nursing actions should decrease the discomfort of an episiotomy? select all that apply. 2022
Hoàng Đức Anh đang tìm kiếm từ khóa Which nursing actions should decrease the discomfort of an episiotomy? select all that apply. được Cập Nhật vào lúc : 2022-10-08 13:00:37 . Với phương châm chia sẻ Kinh Nghiệm về trong nội dung bài viết một cách Chi Tiết 2022. Nếu sau khi Read tài liệu vẫn ko hiểu thì hoàn toàn có thể lại phản hồi ở cuối bài để Tác giả lý giải và hướng dẫn lại nha.Postpartum hemorrhage (PPH) is defined as a cumulative blood loss greater than or equal to 1,000 mL of blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process, regardless of route of delivery. Nevertheless, a blood loss greater than 500 mL in a vaginal delivery should be considered abnormal (American College of Obstetricians and Gynecologists [ACOG], 2022).
Nội dung chính- Which nursing intervention is most appropriate for relieving discomfort associated with episiotomy repair?Which would the nurse ask the postpartum client to do before assessing her uterine fundus?Which interventions are appropriate to promote comfort and healing for a woman during the first 24 hours after a cesarean delivery?Which type of Lochia should the nurse expect to find in a client 2 days PP?
Postpartum hemorrhage is the fifth leading cause of maternal mortality in the United States and causes approximately 11-12% of maternal deaths. It is the leading cause of maternal morbidity and mortality globally (Nathan, 2022).
Primary postpartum hemorrhage may occur within the first 24 hours after birth, while secondary postpartum hemorrhage occurs more than 24 hours and up to 12 weeks after delivery. The four main causes for postpartum hemorrhage are the four T’s: tone (uterine atony), trauma (lacerations, hematomas, uterine inversion or rupture), tissue (retained placental fragments), and thrombin (disseminated intravascular coagulation).
The primary role of the nurse in caring for patients with postpartum hemorrhage is to assess and intervene early or during a hemorrhage to help the client regain her strength and prevent complications. Early recognition and treatment of PPH are critical to care management. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage.
Here are eight nursing care plans and nursing diagnoses for postpartum hemorrhage:
Acute Pain
Perineal hematomas or extensive perineal lacerations may cause discomfort or pain for the client. If the client reports severe pain in the perineal area or a feeling of pressure between her legs, a hematoma could be causing this. The overlying skin is intact with no noticeable trauma. However, blood accumulates underneath from injury to blood vessels in the perineum during birth. They may occur the site of an episiotomy or laceration repair if a vein was punctured during suturing.
Nursing Diagnosis
- Acute Pain
May be related to
- Tissue damageAccumulation of blood underneath the skin of the perineumFailure of the uterus to return to its nonpregnant state
May be evidenced by
- Discomfort or pain the perineal areaPelvic pain or heavinessInability to urinate
Goals and desired outcomes
- The client will identify appropriate methods to provide relief from pain.The client will demonstrate the use of relaxation skills and diversional activities as indicated.The client will verbalize relief from pain and discomfort.
Nursing Assessment and Rationales
1. Assess psychological causes of pain and discomfort.
Emergencies may precipitate
fear and anxiety, raising the perception of pain and discomfort. PPH causes psychological sequelae with a major negative impact on the quality of life. The incidence of adverse psychological outcomes was equally common in the study by Sentilhes et al. They found that 67% of 68 women had a negative experience after managing severe PPH (Grönvall et al., 2022).
2.
Perform pain assessment by identifying the pain’s type, location, characteristic, severity, and duration. Use a pain scale of 0-10.
This will help in differential diagnosis and in determining the applicable treatment method. The Numerical Rating Scale provides enough response options to allow for adequate precision in rating intensity, while the same time, the 0 to 10 scale provides the client with some limits in the number of responses; limits which may help minimize the
complexity of the rating task (Pathak et al., 2022).
3. Assess for the extent of perineal or vaginal lacerations.
Lacerations may occur in the cervix, the vagina, or the perineum and are common causes for PPH. Lacerations should be suspected if the bleeding continues even after a firm, contracted uterine fundus. Bleeding from lacerations can be described as oozing, slow trickle, or frank hemorrhage. If the laceration appears to be extensive, the client may need pain
relief or anesthesia before the repair to prevent pain.
4. Inspect the client’s perineal area for the presence of a hematoma.
If the client reports severe pain in the perineal area or a feeling of pressure between her legs, inspect the perineal area to see if a hematoma is
a cause. If a hematoma is present, it appears as an area of purplish discoloration with obvious swelling. At first, it may feel fluctuant, but as seepage into the area continues, and tissue is drawn taut, it palpates as a firm globe and feels tender.
5. Assess the client’s fundal height regularly.
One of the typical signs of subinvolution is pelvic pain or heaviness. Subinvolution is a slower than expected return of the uterus to its nonpregnant condition. The client
should report persistent pain in the pelvic area because it may also indicate the presence of mild endometritis.
1. Encourage relaxation techniques (e.g., deep breathing exercise) and diversional activities (e.g., watching TV).
Relaxation techniques help the client explore methods for the control of pain. Guided imagery, deep breathing exercises, back rubs, or
diversional activities such as watching TV or listening to music may distract the client from the presence of pain.
2. Provide comfort measures such as applying an ice pack into the perineum.
The cold application can limit small hematomas on the vulva because these applications reduce blood flow to the area; cold also numbs the area and makes the client more comfortable.
3. Promote using a hot sitz bath or a heat lamp to episiotomy
extension.
Frequent sitz baths or soaking the wound area in a small number of warm water for about 20 minutes several times a day can help the area clean and improve the wound healing. Studies indicate that a hot sitz bath with plain water reduces episiotomy pain and enhances wound healing in postnatal mothers. It is also a cost-effective and convenient intervention when the client has been discharged to recuperate home (Viswanath, 2022).
4. Encourage the client to
eat high-fiber foods and increase fluid intake to avoid constipation and prevent straining.
Pain the episiotomy site usually occurs, especially due to postpartum constipation. High-fiber foods, such as fruits and vegetables, can help relieve symptoms and prevent constipation during the postpartum period. Fiber is indigestible, adds bulk to the
stool, and stimulates bowel movements; it also improves digestion, helps the woman reestablish bowel habits, and prevents constipation by softening the stools without straining and putting stress on the suture lines. Adequate fluid intake will help soften the stool and ease bowel movement, thus preventing constipation (Turawa et al., 2022). See also:
Constipation Nursing Care Plan.
5. Administer pain medications (analgesic, narcotic, or sedative) as prescribed.
Administer mild analgesics as prescribed for relief of pain. Suppose the laceration is extensive or difficult to repair. In that case, it may be necessary for the client to be given a regional anesthetic to relax the uterine muscle and prevent
pain. Explain the need for an anesthetic and the procedures being carried out.
6. Administer laxatives for postpartum constipation as prescribed.
Osmotic laxatives help retain water in the colon, thereby softening the stool and increasing the volume of stools. A stool softener softens the stool and enhances
easy defecation. Stimulant laxatives directly stimulate the afferent nerves and irritate the intestinal wall, thereby easing bowel movement (Turawa et al., 2022).
7. Assist in the repair of perineal lacerations.
Perineal lacerations are sutured and treated the same as an episiotomy repair. Ensure the degree of the laceration is documented because clients with fourth-degree lacerations need extra precautions to avoid having sutures loosened or infected. Any client with a
third- or fourth-degree laceration should not have an enema or a rectal suppository prescribed or have her temperature taken rectally because the hard tips of equipment could open sutures to or include those of the rectal sphincter.
8. Assist in incision and drainage of a large hematoma.
Small hematomas usually resolve without treatment. Larger ones may require incision and drainage of clots. The bleeding vessel is ligated, or the area is packed with a hemostatic
material to stop the bleeding. If an episiotomy incision line was opened to drain a hematoma, it might be left open and packed with gauze rather than resutured. Assure accounting and recording of the packing gauze placed and removed in 24 to 48 hours.
More interventions for pain Acute Pain Nursing Care Plan.
Recommended nursing diagnosis and nursing care plan books and resources.
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Recommended journals, books, and other interesting materials to help you learn more about postpartum hemorrhage nursing care plans and nursing diagnosis:
Which nursing intervention is most appropriate for relieving discomfort associated with episiotomy repair?
To relieve pain or discomfort: Ask your nurse to apply ice packs right after the birth. Using ice packs in the first 24 hours after birth decreases the swelling and helps with pain. Take warm baths but wait until 24 hours after you have given birth.Which would the nurse ask the postpartum client to do before assessing her uterine fundus?
Patients are encouraged to void before palpation of the uterine fundus because a full bladder displaces the uterus and can lead to excessive bleeding.Which interventions are appropriate to promote comfort and healing for a woman during the first 24 hours after a cesarean delivery?
For comfort and healing: Apply ice packs in the first 24 hours. Sit in a sitz bath for 20 minutes, three times a day. Take pain medication as recommended by your physician or midwife.Which type of Lochia should the nurse expect to find in a client 2 days PP?
Lochia (vaginal discharge) It has a stale, musty odor like menstrual discharge. Lochia for the first 3 days after delivery is dark red in color. A few small blood clots, no larger than a plum, are normal. For the fourth through tenth day after delivery, the lochia will be more watery and pinkish to brownish in color. Tải thêm tài liệu liên quan đến nội dung bài viết Which nursing actions should decrease the discomfort of an episiotomy? select all that apply.