What information should the nurse include about perineal self care for a client who is 24 hours post?
Puerperal infection is a reproductive tract infection occurring within 28 days following childbirth or abortion. It is one of the major causes of maternal death (ranking second behind postpartum hemorrhage). It includes localized infectious processes and more progressive processes that may result in endometritis (inflammation of endometrium), peritonitis, or parametritis/pelvic cellulitis (infection of connective tissue of broad ligament and possibly connective tissue of all pelvic structures). Show
Theoretically, the uterus is sterile during pregnancy and up until the membranes rupture. After rupture, pathogens can begin to invade; the risk of infection grows even greater if tissue edema and trauma are present. Organisms commonly cultured post partially include group B streptococci, staphylococci, and aerobic gram-negative bacilli such as Escherichia coli. Tissue trauma during labor, the open wound of the placental insertion site, surgical incisions, cracks in the nipples of the breasts, and the increased pH of the vagina after birth are all risk factors for the postpartum woman. Prevention measures of puerperal infection should be taken before pregnancy and during pregnancy, delivery, and puerperium. During puerperium, it is recommended that puerperae get enough sleep, strengthen nutrition reasonably, and improve the body’s immunity, the health management is strengthened, and prevention measures be actively taken for puerperae with high-risk factors, thereby improving the prognosis of clients and reducing the incidence of puerperal infection (Song et al., 2019). The nursing management of clients diagnosed with puerperal infection includes preventing the spread of infection, promoting healing, and improving the attachment/bonding of parent and infant. Here are five nursing care plans and nursing diagnoses for puerperal and postpartum infections: Risk For InfectionDuring the delivery process, changes in the physiological structure of pregnant women, hemorrhage, delivery injury, etc., lead to the decline in the body’s immunity, resulting in puerperal infection under some risk factors. Birth canal injury is caused due to fetal delivery via the reproductive tract during the puerperium, and the body’s immunity of pregnant women significantly declines during the puerperium. As a result, pathogenic microorganisms invade the human body, leading to infection, septicopyemia, and threatening maternal life (Song et al., 2019). Nursing Diagnosis
Risk Factors
Possibly evidenced by
Desired Outcomes
Nursing Assessments and Rationales1. Review prenatal, intrapartal, and postpartal record. 2. Monitor temperature, pulse, and respiration. Note the presence of chills or reports of anorexia or
malaise. 3. Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge, and approximation [REEDA scale]). 4. Note subinvolution of uterus,
extreme uterine tenderness, and lochia. 5. Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day—note urine output, degree of hydration, and presence of nausea, vomiting, or
diarrhea. 6. Investigate reports of leg or chest pain. Note pallor, swelling, or stiffness of the lower extremity. Nursing Interventions and Rationales1. Demonstrate and maintain a strict hand-washing policy for staff, clients, and visitors. 2. Ensure the proper handling of sterile instruments and the proper use of personal protective equipment (PPE). 3. Demonstrate correct perineal cleaning after voiding and defecation and frequent changing of peripads. 4. Demonstrate proper fundal massage. Review the importance and timing of the procedure. 5. Encourage semi-Fowler’s position. 6. Encourage the client to consume a high-protein and vitamin C-rich diet. 7. Promote early ambulation, balanced with adequate rest—advance activity as appropriate. 8. Recommend that the breastfeeding mother periodically check the infant’s mouth for the presence of white patches. 9. Encourage client/couple to prioritize postdischarge responsibilities (e.g., homemaking tasks, child care) 10. Instruct proper medication use (e.g., with or without meals, take
the entire course of antibiotic, as prescribed). 11. Discuss the importance of pelvic rest as appropriate (avoidance of douching, tampons, and intercourse). 12. Monitor laboratory studies, as indicated:
13. Encourage the application of moist heat in the form of sitz baths, compresses, and dry heat in the form of perineal lights for 15 min 2–4 times daily. 14. Provide supplemental oxygen when necessary. 15. Demonstrate perineal application of antibiotic creams, as appropriate. 16. Administer medications as indicated:
17. Administer whole blood/packed RBCs, if needed. 18. Arrange for transfer to intensive care setting as appropriate. 19. Assist with procedures, such as incision and
drainage (I&D) or D&C, as necessary. Recommended nursing diagnosis and nursing care plan books and resources. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy. Recommended journals, books, and other interesting materials to help you learn more about puerperal and postpartum infections nursing care plans and nursing diagnosis: What information should the nurse include about perineal self care for a client who is 24 hours post delivery?What information should the nurse include about perineal self-care for a client who is 24-hours post delivery? Spray warm water from front to back using a squeeze bottle. Rationale: A postpartum client should use a squeeze bottle after each void and clean from front to back.
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What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an Abruptio placenta?What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? Maternal bradycardia.
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