NURS 407 Concepts of Women’s Health & Obstetrical Nursing

DISCHARGE PLAN: NURSING CARE GUIDELINES

1. BREASTS
a. Bottle feeding Clients
i. Engorgement
1. Teaching points: Formula-feeding mothers with engorged breasts
should not express breast milk as it can stimulate milk production
and worsen engorgement. Instead, pt is directed to wear a
well-fitted support bra for the first 72 hours, as well as to avoid
breast stimulation. Engorgement can be managed satisfactorily
non-pharmacologically. Periodic application of ice packs to the
breasts can help to decrease the discomfort associated with
engorgement.
b. Breastfeeding Clients
i. Nipple care
1. Teaching points: The woman is taught to cleanse the nipples with
warm water to keep the ducts from being blocked with dried
colostrum. Soap, ointments, alcohol, and tinctures should not be
applied because they remove protective oils that keep the nipples
supple. Breast pads with plastic liners should be avoided. Women
with nipple piercings should be instructed to remove jewelry
during pregnancy to allow the nipple to recover, which will help to
prevent infection.
ii. Engorgement (milk coming in)
1. Teaching points: The discomfort associated with engorged breasts
may be reduced by applying ice packs or cabbage leaves to the
breasts and wearing a well-fitted support bra.
iii. Dealing with sore nipples
1. Teaching points: Assessment and assistance with feeding can help
to alleviate the cause. To ease discomfort associated with sore
 nipples, the mother may apply topical preparations or hydrogel
pads.
iv. Dealing with reddened areas/lumps in breasts
1. Teaching points:
a. Prevention of mastitis: Abrupt weaning is likely to be
distressing for mother and baby and physically
uncomfortable for the mother because it can cause
engorgement and mastitis.
b. Recognizing plugged ducts & what to do for plugged ducts:
An area of the breast becomes swollen and tender. A small
white pearl may be visible on the tip of the nipple; this
pearl is the curd of milk blocking the flow. Application of
warm compresses to the affected area and to the nipple
before feeding helps promote emptying of the breast and
release of the plug. Varying feeding positions and feeding
without wearing a bra may be useful in resolving a plugged
duct.
c. Recognizing mastitis: Sudden onset of flu-like symptoms,
including fever, chills, malaise, body aches, headache,
nausea, and vomiting. The woman usually has localized
breast pain and tenderness and a hot, reddened area on the
breast.
d. What to do for mastitis: Treatment includes antibiotics such
as cephalexin or dicloxacillin for 10 to 14 days and
analgesic and antipyretic medications such as ibuprofen. In
most cases, mothers with mastitis can continue to
breastfeed. The mother is advised to rest as much as
possible and breastfeed or pump frequently, striving to
empty the affected side adequately.
2. UTERUS
 a. The uterus will contract and involution will be completed at 4-6 weeks
postpartum.
i. Teaching points:
1. Involution: Return of the uterus to a nonpregnant state after birth.
Process begins immediately after expulsion of the placenta. The
uterus should have returned to its nonpregnant location by 6 weeks
after birth.
2. Afterpains: Uncomfortable cramping, more common in subsequent
pregnancies, which typically resolve in 3 to 7 days.
3. Lochia progression: Postbirth uterine discharge which correlates
with uterine involution and changes in the endometrium. Most
women experience lochia for 4 to 6 weeks after birth. For the first
2 hours after birth, the amount of uterine discharge should be about
that of a heavy menstrual period. After that time, the lochial flow
will steadily decrease in amount and the characteristic appearance
of the lochia will change.
4. Signs of complications: Excessive vaginal bleeding is a sign of an
obstetric emergency called postpartum hemorrhage (PPH). It can
occur with little warning and often is not recognized until the
mother has profound symptoms.
3. PERINEUM
a. Cleansing:
i. Teaching points:
1. Peri-bottle: Fill the squeeze bottle with warm water and position
the nozzle so that it sprays over the entire perineum. Blot dry with
clean wipes/toilet paper. Clean front to back.
2. Hand washing: wash hands before and after changing pad and after
elimination
3. Changing pads: apply pad from front to back, making sure not to
touch the inner surface because that can cause contamination.
Change with each void and defecation.
 ii. Comfort:
1. Teaching points:
a. Topical preparations: Anesthetic and antiseptic spray can
be admin Witch hazel on pads can also decrease pain
b. Oral pain medication: Much of the medicine is also found
in breast milk. Most of them are considered safe for the
baby. Timing the dosages at the end of breastfeeding can
help minimize the amount of medicine exposed to the baby
by the next feeding. Ibuprofen and naproxen are more
commonly used because they give better pain relief.
Opioids can also be administered prn.
c. Sitz bath: Clean tub before and after use.Fill tub with 2-3
inches of warm water. Warm water helps promote
circulation and decrease pain/itchiness. You can do a sitz
bath twice a day for about 20 minutes each time.
d. If hemorrhoids: Usually decreases within 6 weeks of
delivery. Sitz bath and hemorrhoid cream will help
decrease symptoms.
4. ELIMINATION
a. Bladder:
i. Teaching points:
1. Intake/output: voiding within 6-8 hours after birth. 150 mL is
expected with each void. First couple voids should be measured.
Excessive urination after birth is normal (roughly 3000mL in a
day, occurs 12 hours after birth).
2. Signs of UTI: pain/burning on urination, frequency, urgency
b. Bowel:
i. Teaching points:
1. BM by: 2 to 3 days after birth
 2. Diet and fluids: Well rounded diet. Increased fiber and fluids help
promote bowel movement. Avoid legumes, beans, broccoli or any
other food known to cause gas.
3. Stool softeners and laxatives: Can be used if HCP recommends it
4. Ambulation and activity: adequate movement will help move
things along. Rocking back and forth in a chair can help with gas
relief/pain. Constipation is more likely without movement.
5. When to call health care provider: If no bowel movement within
3-4 days
5. NUTRITION
a. Teaching points:
i. Prenatal vitamins: Should be continued until 6 weeks after birth or longer
if desired. Nutrients help the body recoup and it gives additional nutrients
to breastfeeding baby..
ii. Iron supplementation: May be given due to low hemoglobin and
hematocrit levels to help replenish blood supply.
iii. Other medications: Stool softeners for those with perineal lacerations or
episiotomies. Pain medications especially for cesarean births.
iv. Breastfeeding mothers (special information): Daily calorie consumption
should be greater than non-breastfeeding mothers. Lots of water to
increase breastmilk supply. Mother eats lots of protein and vegetables.
6. ACTIVITY/REST
a. Teaching points:
i. Naps: Get plenty of rest, nap when the baby does when possible.
ii. Exercise/activity: Gradual exercising beginning after birth working up to
more strenuous activity. If the patient had a c-section, 4 to 6 weeks
recommended wait time for abdominal exercising.
iii. Signs of over activity/sleepover activity:
Some signs of over activity include pain, fatigue, problems with
breastfeeding or mastitis, increased lochia flow, and symptoms of
postpartum depression. (Olshansky, 2020, p. 437)
 iv. Tips for coping with over activity/sleepover activity:
Things that can help a new mother with issues due to over activity are
limiting visitors and having a supportive partner or other help in place to
relieve some of the duties of baby and home care. Breastfeeding mothers
can use the side-lying position while feeding to support more rest. Women
may also need referral to community resources that are available to her.
(Olshansky, 2020, p.430, 458)

Patient specific teaching:

The patient’s husband was stationed away for 8 weeks for lineman schooling so there needed to
be a support system in place, via the mother who was moving in with the patient.

7. DISCOMFORT
a. Teaching points:
i. Palliative measures:
1. RX:
a. NSAIDS: commonly used ibuprofen and naproxen, provide
relief from uterine cramping and perineal pain, preferred
since it has a low concentration and a short half-life
b. Topical anesthetic ointments: used to relieve pain and are
more commonly used after cesarean births, relatively safe
for infant but final decision should be made by mother
2. Non-RX:
a. Ice pack: applying a covered ice pack to the perineum from
front to back during the first 24 hours will decrease edema
and increase comfort, while after the first 24 hours it can be
used as needed for an anesthetic effect
b. Squeeze bottle: filling a bottle with warm tap water and
having the mother squirt it to reach the perineum as she sits
on the toilet will help to clean and soothe the perineum.
 i. Make sure to squeeze the entire bottle and to blot
dry with toilet paper and/or clean wipes
c. Heating pad: lying prone and using a heating pad can help
to ease the pain and discomfort
ii. Danger signs:
1. Lack of sleep/exhaustion: if the family/patient notices that the
patient is showing signs of sleep loss or exhaustion, the patient
should make use of palliative measures to try and relieve pain
and/or stress to increase sleep efficacy.
2. Ambulation: an increase of ambulation shows a decrease in VTE,
so the patient should attempt to ambulate as early as possible, if the
family/patient notices that the patient feels lightheaded or dizzy
when standing then they should remind her to stand slowly and sit
on the edge of the bed before moving, and to be cautious in warm
baths or showers due to orthostatic hypotension
8. EMOTIONAL/PSYCHOSOCIAL ADJUSTMENT
a. Teaching points:
i. 3rd or 4th postpartum day - postpartum blues - what to expect - what is not
normal: PPD is known to worse after discharge, patient will become
saddened which is normal, but when suicidal/homicidal ideations occur or
the patient begins showing signs of major depression, the family should
contact the provider
ii. Coping strategies: nutrition, exercise, family planning, mediations, deep
breathing, meditation, various cultural or religious practices
iii. Mobilization of support: having the family/spouse/significant other be a
part of the teaching can help to reduce the severity of PPD, as they will be
able to help reinforce the coping strategies and notice the signs
9. SEXUALITY/SEXUAL RELATIONS
a. Teaching points:
i. Vaginal/pelvic rest: The pelvic floor is weakened and can take 6 weeks to
heal. Patient can use kegel exercises to promote strengthening the muscles.
 ii. Return of fertility/family planning/contraception: Talk with patient about
contraceptive information before discharge; many women can ovulate as
early as the month after birth. Most couples resume sexual activity 2-4
weeks postpartum (depending on degree of tears, bleeding, desire). Inform
patient dyspareunia (painful intercourse) may occur and can be offset by
use of lubricants and positioning during intercourse.
iii. Infection risk/ signs of infection: Proper perineal care. Hand hygiene to
prevent spread of infection. Signs: redness, warmth and drainage from
perineum; elevated temperature. Bladder infection: dysuria, burning,
frequency.
iv. Comfort considerations - episiotomy: Initial healing can take 2 to 3 weeks.
Use of warm compresses and ice packs to the area of discomfort. May use
a squeeze bottle when using the restroom and blot dry to prevent
discomfort. Have patient lie on their side as much as possible. Sitz baths.
10. INFANT CARE
a. Teaching points:
i. Bathing/Demonstration: Use a neutral pH cleanser preferably preservative
free (antimicrobials not to be used to protect skin surface). Immersion
bathing: warm water, deep enough to cover only to the shoulders. Daily
baths not necessary. Daily cleaning of the perineum and face are sufficient.
Only wash hair once or twice per week.
ii. General Daily Care:
1. Eyes: Wash with water starting from the inner canthus outward.
Use clean part of the washcloth with every wipe.
2. Cord: Clean the cord with water. Keep the area dry after bathing.
The cord will fall off on its own-report any active bleeding to PCP.
3. Diaper area: Cleanse after voiding or stooling. Girls: separate the
labia and wash from front to back. Uncircumcised: wash and rinse
with soap and warm water. Allow skin to dry before applying a
new diaper. Zinc oxide ointments to protect infants skin from
moisture.
 4. Circumcision: Check for bleeding with each diaper change (apply
gentle pressure with a gauze pad if active bleeding), make sure
voiding is occuring, first 3 to 4 days only cleanse area with water,
4 to 7 days apply petroleum jelly to the area, sponge bath only for
a week. Check for signs of infection: red, swelling, discharge and
odor). There will be a yellow ‘crust’ on the site, this is normal and
should not be manually removed.
5. What method was used?
iii. Discharge Instructions and plan for follow-up with pediatric health care
provider: Usually 48 to 72 hours after discharge.
iv. Signs of complications and what to do: Diaper rash: change infant
promptly, use of zinc oxide. Notify the healthcare provider if: the infant
has little interest in feeding or is feeding poorly (2 or more feedings in a
row), bright green emesis, forceful vomiting, fewer than 6 to 8 wet diapers
in a day, labored breathing, cyanosis, inconsolable crying
v. Safety Issues: Safe sleeping: lay baby flat on their back, do not put
cushions, pillows or items in the crib with the infant. Do not use soft
bedding or blankets on the infant. Bathing: always check the temperature
of bath water, never leave infants alone in bathwater.
vi. Car safety seat: Placing infant into seat: shoulder harness in/below
shoulders and should fit snug. The clip should be at armpit level. The child
should not have bulky clothing. Installation: install at a 45 degree angle
for best airway positioning, should be rear facing in a back seat. The seat
should be chosen based on weight, size and age of the infant.
vii. Siblings: Sibling rivalry and jealousy due to the time the parents spend
with the infant. Older siblings may actively help the parents with the
infant. Strategic integration for siblings meeting for the first time.
References
Olshansky, D.L.M.C.C.S.P.K.A. E. (2023). Maternity and Women's Health Care (12th ed.).
Elsevier Health Sciences (US). https://online.vitalsource.com/books/9780323556293