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.
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