Tuesday, 3 April 2012

continuation: Caring for the Postpartal Woman and Her Family


Phagocytosis (the engulfment and destruction of cells) contributes to the process of uterine involution by removing elastic and fibrous tissue from the uterus. The process is further hastened by autolysis (self-digestion) that results from migration of macrophages to the uterus. Subinvolution is the failure of the uterus to return to the non-pregnant state. Uterine involution may be inhibited by multiple births, hydramnios, prolonged labor or difficult birth, infection, grand multiparity, or excessive maternal analgesia. In addition, a full bladder or retained placental tissue may prevent the uterus from sustaining the contractions needed to prevent hemorrhage or to facilitate involution. (See Chapter 16 for further discussion.)
The placental site heals by a process called exfoliation. Exfoliation is the scaling off of dead tissue. New endometrial tissue is generated at the site from the glands and tissue that remain in the lower layer of the decidua after separation of the placenta. This physiological process results in a uterine lining that contains no scar tissue, which could impede implantation in future pregnancies. Regeneration of the endometrium is complete by the 16th postpartum day, except at the placental site, where regeneration is usually not complete until approximately 6 weeks after childbirth.
Figure 15-1 To palpate the uterus, the upper hand is cupped over the fundus; the lower hand stabilizes the uterus at the symphysis pubis.


To perform the uterine assessment, the nurse assists the patient to a supine position so that the height of the uterus is not influenced by an elevated position. The patient’s abdomen is observed for contour to detect distention and the presence of striae or a diastasis (separation), which appears as a slightly indented groove in the midline. When present, the width and length of a diastasis are recorded in fingerbreadths. The uterine fundus is palpated by placing one hand immediately above the symphysis pubis to stabilize the uterus and the other hand at the level of the umbilicus (Fig. 15-1). The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a Firm, globular mass located at or slightly above the umbilicus during the first hour after birth.
Clinical alert
Proper technique for uterine palpation
The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage.

FUNDUS. Immediately after childbirth, the uterus rapidly contracts to facilitate compression of the intra myometrial blood vessels. The uterine fundus can be palpated midline, midway between the umbilicus and symphysis pubis.
Figure 15-2 Fundal heights postpartum.

Within an hour, the uterus settles in the midline at the level of the umbilicus. Over the course of days, the uterus descends into the pelvis at a rate of about 1 cm/day (one fingerbreadth) (Fig. 15-2). After 10 days, the uterus has descended into the pelvis and is no longer palpable. The fundus is assessed for consistency (firm, soft, or boggy), location (should be midline), and height (measured in finger breadths). During the fundal assessment, the nurse notes whether it is located midline or deviated to one side. On occasion, the fundus can be palpated slightly to the right because of displacement from the sigmoid colon during pregnancy. Assessment of the fundus should be made shortly after the patient has emptied herbladder. A full bladder prevents the uterus from contracting and instead pushes the uterus upward and may deviate it from the midline, due to laxness of the uterine ligaments. A flabby, non-contracted, boggy uterus is associated with increased bleeding. A well-contracted fundus is firm, round, and midline. The nurse documents the location of the fundus according to fingerbreadths above or below the umbilicus (Table 15-4).


Table 15-4 Assessment and Documentation of Uterine Involution
Time
Location of Fundus
Documentation
Immediately after birth
Midline, midway between umbilicus and symphysis pubis

1–2 hours
At the level of the umbilicus
at U (umbilicus)
12 hours
1 cm above umbilicus (1 fingerbreadth)
U + 1
24 hours
1 cm below umbilicus
U - 1
2 days
2 cm below umbilicus (2 fingerbreadths)
U - 1
3 days
3 cm below umbilicus (3 fingerbreadths)
U - 1
7 days
Palpable at the symphysis pubisl

10 days
Not palpable





Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Patients often describe the sensation as a discomfort similar to menstrual cramps. The primiparous woman typically has mild afterpains, if she notices them at all, because her uterus is able to maintain a contracted state. Multiparas and patients with uterine overdistention (e.g., large baby, multifetal gestation, hydramnios) are more likely to experience afterpains, due to the continuous pattern of uterine relaxation and vigorous contractions. When the uterus maintains a constant contraction, the afterpains cease. Breastfeeding and the administration of exogenous oxytocin usually produce pronounced afterpains because both cause powerful uterine contractions. Afterbirth pain is often severe for 2 to 3 days after childbirth.
Nursing interventions for discomfort include assisting the patient into a prone position with a small pillow placed under her abdomen, initiating sitz baths (for warmth), encouraging ambulation, and administrating mild analgesics.

Optimizing Outcomes— Breastfeeding and Afterpains
Analgesics such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Anaprox) are frequently administered to lessen the discomforts of afterpains. Breastfeeding women should take pain medication approximately 30 minutes before nursing the baby to achieve maximum pain relief and to minimize the amount of medication that is transferred in the breast milk.

Now Can you— Discuss changes in the breasts and uterus during the postpartum period?
1. Name each component of the BUBBLE-HE mnemonic for the postpartum assessment?
2. Explain normal breast changes that occur during the first few postpartal days?
3. Explain what is meant by “involution”?

Bladder
After childbirth, spontaneous voiding should occur within 6 to 8 hours and the first few voiding amounts should be monitored. Urinary output of at least 150 mL/hr is necessary to avoid urinary retention or stasis. Generalized edema is often present in the early puerperium. It is related to the fluid accumulation that normally occurs during pregnancy combined with intravenous fluids frequently administered during labor and birth. Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days.
Decreased bladder tone is normal during pregnancy, and results from the effects of progesterone on the smooth muscle, edema from pressure of the presenting part, and mucosal hyperemia from the increase in blood vessel size. Prolonged labor, the use of forceps, analgesia, and anesthesia may intensify the changes in the immediate postpartum period. Pressure caused by the fetal head pressing on the bladder during labor can result in trauma and a transient loss of bladder sensation during the first few postpartal days or weeks. These changes can result in incomplete bladder emptying and overdistention.
Bladder and urethral trauma is not uncommon during the intrapartal period and may be associated with a decreased flow of urine immediately after a vaginal birth. An increase in the voided volume, the total flow time (how long it takes to empty the bladder) and the time to peak urine flow (the maximum urinary flow rate) begins to occur during the first postpartum day. Urine volume and flow time should return to pre-pregnant levels by 2 to 3 days after childbirth. Epidural anesthesia, catheterization before birth, and an instrument-facilitated birth are associated with an increased risk of postpartum urinary retention. Urethral and bladder trauma and lacerations may accompany vaginal or cesarean birth.
Urinary retention can also result from bladder hypotonia after childbirth since the weight of the gravid uterus no longer limits bladder capacity. Assessment of the maternal bladder is an extremely important component of the nursing evaluation (Table 15-5). An overdistended bladder, which displaces the uterus above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage.

above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage.

Table 15-5 Nursing Assessment and Interventions for the Urinary System
Patient’s Signs and Symptoms
Nursing Interventions
Location of fundus above
baseline level
• Fundus displaced from midline
• Excessive lochia
• Bladder discomfort
• Bulge of bladder above symphysis pubis
• Frequent voiding of less than 150 mL of urine; urinary output disproportionate to fluid intake
• Promote hydration
• Promote ambulation
• Administer an analgesic before voiding, as prescribed
• Place ice on perineum to reduce swelling and pain
• Encourage the use of a sitz bath
• Provide privacy
• Turn on the bathroom faucet

Other assessment findings may include presence of the bladder palpated as a hard or firm area just above the symphysis pubis and a urinary output that is disproportionate to the fluid intake. Bladder percussion enhances the assessment. To percuss the bladder, the nurse places one finger fl at on the patient’s abdomen over the bladder and taps it with the finger of the other hand. A full bladder produces a resonant sound. An empty bladder has a dull, thudding sound. Patients may express an urge to void but
be unable to void. Fortunately, spontaneous voiding typically returns within 6 to 8 hours after childbirth. Until this time, the nurse should support and enhance the woman’s attempts to void. Nursing interventions may include assisting the patient to the toilet, providing privacy and a unhurried environment, turning on the lavatory faucet, and assisting the patient into a sitz bath.

Bowel
The gastrointestinal system becomes more active soon after childbirth. The patient often feels hungry and thirsty after the food and fluid restrictions that usually accompany the intrapartal experience. The peptide hormone relaxin, which reaches high circulating levels during pregnancy, depresses bowel motility (Cunningham et al., 2005). The relaxed condition of the intestinal and abdominal muscles, combined with the continued effects of progesterone on the smooth muscles, diminishes bowel motility. These factors commonly result in constipation during the early puerperium. After childbirth, bowel movements are typically delayed until the second or third puerperal day and hemorrhoids (distended rectal veins), perineal trauma, and the presence of an episiotomy may be associated with painful defecation. Early ambulation, abundant fluids, and a high-fiber diet are a few strategies to help prevent constipation (Box 15-1).

Box 15-1 Nursing Interventions to Facilitate Normal Bowel Function During the Puerperium
To facilitate the return of normal bowel function in the puerperium, the nurse should:
• Encourage the patient to drink at least six to eight 8-oz. glasses of water every day to help keep the stool soft.
• Encourage the patient to eat a high-fiber diet that includes an abundance of fruits and vegetables, oat and bran cereal, whole-grain bread, and brown rice.
• Encourage the patient to avoid ignoring the urge to defecate.
• Encourage the patient to avoid straining to have a bowel movement.
• Encourage the patient to initiate early ambulation.
• Administer stool softeners and/or laxatives as ordered.
• Explain that after hospital discharge, over-the-counter medications may be helpful for hemorrhoidal symptoms of pain, itching, or swelling but encourage the patient to consult with her caregiver before using such medications.

Lochia
Separation of the placenta and membranes occurs in the spongy or outer layer of the decidua basalis. The uterine decidua basalis reorganizes into the basal and superficial layers. The inner basal layer becomes the foundation from which new layers of endometrium will form. The superficial layer becomes necrotic and sloughs off in the uterine discharge, called lochia. Lochia is composed of erythrocytes; epithelial cells; blood; and fragments of decidua, mucus, and bacteria (Cunningham et al., 2005). The characteristics of the lochia are indicative of the woman’s status in the process of involution.
During the first few days postpartum, the lochia consists mostly of blood, which gives it a characteristic red color known as lochia rubra. Lochia rubra also contains elements of amnion, chorion, decidua, vernix, lanugo, and meconium if the fetus had passed any stool in utero. These components cause the fleshy odor associated with lochia rubra.
After 3 to 4 days, the lochia becomes the pinkish brownish lochia serosa. Lochia serosa contains blood, wound exudates, erythrocytes, leukocytes, and cervical mucosa. After approximately 10 to 14 days, the uterine discharge has a reduced fluid content and is largely composed of leukocytes. This combination produces a white or yellow-white thick discharge known as lochia alba. Lochia alba also contains decidual cells, mucus, bacteria, and epithelial cells. It is present until about the third week after childbirth but may persist for 6 weeks. The pattern of lochia flow, from lochia rubra to serosa to alba, should not reverse. A return of lochia rubra after it has turned pink or white may indicate retained placental fragments or decreased uterine contractions and new bleeding. Lochia should contain no large clots, which may indicate the presence of retained placental fragments that are preventing closure of maternal uterine blood sinuses. The odor of lochia is similar to that of menstrual blood. An offensive odor is indicative of infection.
After assessment of the lochia, the nurse may find it difficult to document the findings correctly. Lochia is typically documented in amounts described as scant, small, moderate, or heavy. The amount of vaginal discharge is not a true indicator of the lochia flow unless the time factor is also considered. For example, a perineal pad (peripad) that accumulates less than 1 cm of lochia in 1 hour is associated with scant flow (Fig. 15-3). Nurses must also be certain to take into account the specific type of peripad used, since some are more absorbent than others. At times, visually assessing the amount of lochia flow can be difficult and inaccurate.

Optimizing Outcomes— Abnormal findings in a postpartal patient
During a routine postpartal assessment conducted 2 hours after childbirth, the nurse records the following vital signs: pulse _ 102 beats/minute; blood pressure _ 130/86 mm Hg; respirations _ 21 breaths/minute; temperature _ 98.9°F (37.1°C). The nurse’s first action is to assess the fundus. With the cupped palm placed directly over the uterine fundus, the nurse uses palpation to assess for the state of contraction (e.g., soft, boggy, or firmly contracted), along with the location and height of the fundus. If soft, the fundus is massaged in a circular motion with the cupped palm until the uterus is well contracted. The nurse inspects the peripad for the lochia amount and color, and the presence of odor. The physician or nurse midwife is notified of the findings. If excessive blood loss has occurred or if the uterus is not well contracted, the nurse administers appropriate prn medication(s) (e.g., Methylergonovine [Methergine]) as ordered.


Episiotomy
An episiotomy is a 1- to 2-inch surgical incision made in the muscular area between the vagina and the anus (the perineum) to enlarge the vaginal opening before birth. The midline episiotomy is a straight incision extending toward the anus. A mediolateral episiotomy extends downward and to the side. Typically, the episiotomy edges have become fused (the edges have sealed) by the first 24 hours after birth. Although the patient’s perineal folds may interfere with full visualization of a midline episiotomy, it is important for the nurse to carefully assess the episiotomy for redness, edema, ecchymosis, discharge, and approximation (REEDA) and then document all findings.

Clinical alert
Hematoma after an episiotomy
Severe hemorrhage after an episiotomy is possible. Maternal complaints of excessive perineal pain should alert the nurse to the possibility of a perineal, vulvar, vaginal, or ischiorectal hematoma (a blood-filled swelling that occurs from damage to a blood vessel).

Medication: Methylergonovine
Methylergonovine (meth-ill-er-goe-noe-veen)
Methergine
Pregnancy Category: C
Indications: Prevention and treatment of postpartum and post-abortion hemorrhage caused by uterine atony or subinvolution
Actions: Directly stimulates uterine and vascular smooth muscle.
Therapeutic Effects: Uterine contraction
Pharmacokinetics:
ABSORPTION: Well absorbed after oral or IM administration
ONSET OF ACTION: Oral: 5–10 minutes; IM: 2–5 minutes; IV: Immediately
DISTRIBUTION: Oral: 3 hours; IM: 3 hours; IV: 45 minutes. Enters breast milk in small quantities.
METABOLISM AND EXCRETION: Probably metabolized by the liver
HALF-LIFE: 30–120 minutes
Contraindications and Precautions
CONTRAINDICATED IN: Hypersensitivity. Should not be used to induce labor.
USE CAUTIOUSLY IN: Hypertensive or eclamptic patients (more susceptible to hypertensive and arrhythmogenic side effects); severe hepatic or renal disease; sepsis
EXERCISE EXTREME CAUTION IN: Third stage of labor
Adverse Reactions and Side Effects:
CENTRAL NERVOUS SYSTEM: Dizziness, headache
EYES, EARS, NOSE, THROAT: Tinnitus
RESPIRATORY: Dyspnea
CARDIOVASCULAR: Hypotension, arrhythmias, chest pain, hypertension, palpitations
GASTROINTESTINAL: Nausea, vomiting
GENITOURINARY: Cramps
DERMATOLOGICAL: Diaphoresis
Route and Dosage:
PO: 200–400 mcg (0.4–0.6 mg) q6–12h for 2–7 days
IM, IV: 200 mcg (0.2 mg) after delivery of fetal anterior shoulder, after delivery of the placenta, or during the puerperium; may be repeated as required at intervals of 2–4 hours up to fi ve doses.
Nursing Implications:
1. Physical assessment: Monitor blood pressure, heart rate and uterine response frequently during medication administration. Notify the primary health care provider if uterine relaxation becomes prolonged or if character of vaginal bleeding changes.
2. Assess for signs of ergotism (cold, numb fingers and toes, chest pain, nausea, vomiting, headache, muscle pain, weakness)
Data from Deglin, J.H, and Vallerand, A.H. (2009). Davis’s drug guide for nurses (11th ed.). Philadelphia: F.A. Davis.


To assess for perineal hematoma, the nurse should:
1. Look for discoloration of the perineum.
2. Listen for the patient’s complaints or expression of severe perineal pain.
3. Observe for edema of the area.
4. Listen for the patient’s expression of a need to defecate (the hematoma may cause rectal pressure).
5. Don sterile gloves, gently palpate the area, and observe for the patient’s degree of sensitivity to the area by touch.
6. Call the physician or nurse-midwife to report the findings immediately. The bleeding that has produced the hematoma must be promptly identified and halted.


Optimizing Outcomes— Early episiotomy care
The nurse should apply an ice bag or commercial cold pack to the perineum during the first 24 hours after childbirth. The ice bag should be wrapped in a towel or disposable paper cover to prevent a thermal injury. Application of cold provides local anesthesia and promotes vasoconstriction while reducing edema and the incidence of peripheral bleeding. Later (after 24 hours), the nurse encourages the use of moist heat (sitz bath) between 100o and 105°F (37.8–40.5oC) for 20 minutes three to four times per day. The sitz bath increases circulation to the perineum, enhances blood flow to the tissues, reduces edema, and promotes healing. Dry heat, in the form of a commercial perineal “hot pack,” may also be used. The packs are “cracked” to generate heat. Women should be cautioned to apply a washcloth or gauze square between the hot pack and their skin to prevent a potential burn.


ASSESSMENT OF PAIN.
Pain, sometimes considered the fifth “vital sign,” must be recognized as an important assessment focus throughout the postpartum period. Nurses play an important role in assessing, planning, and implementing interventions to manage maternal pain effectively.
Pain should be recognized and treated in a timely manner.
The failure to manage pain effectively has been associated with numerous complications, including prolonged recovery, increased length of hospital stay, depression, anxiety, poor coping, and altered sleep patterns.
Discomfort and pain may occur from several sources. Afterpains, which most commonly occur in the multiparous patient, can be quite intense, especially after breastfeeding. Analgesics such as acetaminophen (e.g., Tylenol) or nonsteroidal anti-inflammatory agents (NSAIDs) such as ibuprofen (e.g., Motrin, Advil) are effective and safe for use. Heat is not applied to the abdomen because of the potential for uterine relaxation and bleeding. Muscular aches and cramps related to the physical exertion expended during labor and birth may be relieved with back rubs and massage. When necessary, acetaminophen (e.g., Tylenol) may be used to alleviate the discomfort. Pain occurring in the calf of the leg must be carefully evaluated for thromboembolic disease. Episiotomy pain and discomfort may be associated with sitting, walking, bending, urinating, and defecating. It may interfere with the woman’s ability to comfortably hold and feed her infant. Interventions to decrease discomfort from the episiotomy include the application of cold (first 24 hours) and heat, and the use of topical anesthetic creams, sprays, and sitz baths. The sitz bath is a portable unit with a reservoir that fits on the toilet. When filled with warm water, the swirling action of the fluid soothes the tissue, reduces inflammation by promoting vasodilation to the area, and provides comfort and healing. The nurse prepares and assists the patient to the sitz bath, which should be used for 20 minutes three to four times a day (Procedure 15-1).

Optimizing Outcomes— Enhancing comfort and healing with a sitz bath
A sitz bath is a warm-water bath taken in the sitting position that covers only the perineum and buttocks. It can be placed in the toilet, with the seat raised. Other mechanisms for taking a sitz bath include sitting in a tub filled with 4–6 inches of warm water or the use of a non-portable sitz bath unit (similar to a toilet that fills up with warm water). A sitz bath may be used for either healing or hygiene purposes. The water may contain medication. Sitz baths are used to relieve pain, itching, or muscle spasms.

The patient likely has expectations regarding pain management during the postpartum phase. She should be encouraged to express her requests or concerns regarding pain control. Education regarding the available modalities is essential and will likely enhance the patient’s perception of control, as well as her level of satisfaction with the nursing care received. The nurse should regularly assess for pain and medication side effects and actively involve the patient in her pain management regimen. Use of a standardized pain rating scale enhances the assessment by allowing the patient to select the pain intensity level being experienced.

The nurse assesses and documents the patient’s pain behavior regarding the:
• Location of the pain
• Type of pain: stabbing, burning, throbbing, aching
• Duration of pain: intermittent or continuous
Nursing interventions include the administration of analgesics and patient education about other measures to promote comfort.
• Suggest non-pharmacological methods for pain relief such as imagery, therapeutic touch, relaxation, distraction, and interaction with the infant.
• Provide pain relief by administering prescribed agents such as ibuprofen, propoxyphene napsylate/ acetaminophen (Darvocet-N), or oxycodone/acetaminophen (Percocet).
• Suggest over-the-counter medications and alternative therapies such as tea tree oil for self-care after hospital discharge. Teach the patient that medication such as acetaminophen or ibuprofen may be equally as effective as narcotic analgesics.
• Reassure the patient that the pain and discomfort should not persist beyond 5 to 7 days and that since the episiotomy sutures are made of an absorbable material, they will not need to be removed.

Complementary Care: Tea tree oil to facilitate episiotomy healing
Tea tree (Melaleuca alternifolia) oil applied to the perineum is believed to be beneficial in facilitating healing of the episiotomy site. Melaleuca alternifolia oil has been in use as a botanical medicine in various forms for centuries. For hundreds of years, the Australian aboriginal people have used tea tree oil as an antiseptic, antimicrobial, and anti-inflammatory agent. The anti-inflammatory properties are believed to be particularly helpful in promoting incisional healing (Halon & Milkus, 2004) although allergic contact dermatitis may occasionally occur (Stonehouse & Studdiford, 2007).
Postpartum women with episiotomies may be taught to fill an applicator with tea tree oil and then apply the oil directly to the wound. A few drops of the oil provide cooling to the wound, relieve pain, enhance comfort, and promote healing
.
Procedure 15-1 Preparing a Sitz Bath
Purpose
To facilitate healing through the application of moist heat.

Equipment
• Sitz bath tub/toilet insert with water receptacle
• Medications to be added to water or saline, as ordered
• Towels for drying the perineal area after the treatment
• Clean perineal pad to be applied after the treatment
Steps
1. Wash your hands, identify the patient, and explain the procedure.
RATIONALE: Hand washing helps to prevent infection. Patient identification ensures that the procedure is performed on the correct patient. Providing an explanation educates the patient and helps to alleviate anxiety.
2. Assess the patient to confirm that she is able to ambulate to the bathroom.
RATIONALE: A sitz bath can cause dizziness and increase the potential for injury. It is important to ascertain that the patient can safely ambulate to the bathroom before initiating the procedure.
3. Assemble equipment and ensure that all equipment is clean.
RATIONALE: Gathering all equipment before the procedure enhances efficiency.
4. Raise the toilet seat in the patient’s bathroom.
5. Insert the sitz bath apparatus into the toilet. The overflow opening should be directed toward the back of the toilet.


6. Fill the collecting bag with water or saline, as directed, at the appropriate temperature (105°F [41°C]).
7. Test the water temperature. It should feel comfortably warm on the wrist.
RATIONALE: Ensuring a correct water temperature reduces the chance of thermal injury. The flow of warm water to the perineum promotes healing by increasing circulation and reducing inflammation.
8. If prescribed, add medications to the solution.
9. Hang the bag overhead to allow a steady stream of water to flow from the bag, through the tubing, and into the reservoir.
10. Assist the ambulating patient to the bathroom. Help with removal of the perineal pad from front to back. Assist the patient to sit in the basin.
RATIONALE: Assistance with ambulation reduces the chance for patient injury. Removal of the pad from front to back decreases the risk for infection transmission. Proper placement on the seat ensures comfort and effectiveness of the treatment.
11. Instruct the patient to use the tubing clamp to regulate the flow of water. Ensure that the patient is adequately covered with a robe or blankets to prevent chilling.
RATIONALE: The swirling warm water helps to reduce edema and promote comfort. Clothing and extra blankets for warmth prevent chilling and enhance patient comfort.
12. Verify that the call bell is within reach and provide for privacy.
RATIONALE: Easy access to the call bell reassures the patient that prompt assistance is readily available when needed.
13. Encourage the patient to remain in the sitz bath for approximately 20 minutes.
RATIONALE: After 20 minutes, vasoconstriction occurs and heat is no longer therapeutic.
14. Provide assistance with drying the perineal area and applying a clean perineal pad by grasping the pad by the ends or bottom side.
RATIONALE: Holding the pad correctly decreases the risk for contamination and subsequent infection.
15. Assist the patient back to the room.
RATIONALE: After the procedure, the patient may be fatigued or light headed from the warm water; assistance minimizes the risk of injury.
16. Assess the patient’s response to the procedure.
Reinforce teaching about continued perineal care at home.
RATIONALE: Assessment helps to determine the effectiveness of the procedure; teaching enhances understanding and promotes continuity of care after discharge.
17. Record completion of the procedure, the condition of the perineum, and the patient’s tolerance.
RATIONALE: Documentation provides evidence of the intervention and an additional opportunity for evaluation of care and the patient’s tolerance of the procedure.
Clinical Alert The warm environment associated with a sitz bath may cause the patient to feel light-headed or dizzy. It is important to monitor the patient frequently throughout the intervention to ensure safety and tolerance.
Teach the Patient
1. The benefits of using the sitz bath, which include enhanced hygiene, comfort, and improved circulation2. To use the sitz bath as often as recommended— usually three to four times per day or as needed for discomfort
3. To contact the nursing staff immediately if she becomes light-headed or dizzy
4. To check the temperature of the solution before use. Applying water or solution that is too warm may result in local trauma or burns to the area
Note
If the patient prefers to prepare a sitz bath in the tub at home, she should be instructed not to use the same water for bathing. Instead, fresh water should be drawn for washing to diminish the potential for infection.
Caution: The nurse must check the temperature of the water before administration of the sitz bath to ensure that it is not too warm.
Documentation
6/29/09 1500 Patient reported perineal discomfort. Mild perineal edema noted. Patient assisted into bathroom for sitz bath. Tolerated sitz bath with warm water for 20 minutes. She denied any discomfort or syncope throughout treatment. Perineal care was provided and a new peripad was applied. The patient was assisted back into bed. She denies perineal pain at present.
—Olga Sanchez, RN

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