exxon sim paper
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Postpartum Nursing Care-Sim Prep
Review chapters 15 & 16 in your text for information to fill this out. Please download as a word document & type in answers. It should be fully filled out before the day of your SIM LAB. Hand it to your SIM LAB instructor. I will check them off & hand them back to you.
Student Name____Hope Guyton_____________________________
1. Summarize the physical postpartum assessment:
a. Breasts- Should be soft and non-tender, nipples check for retraction and trauma. The breast may feel lumpy due milk production
b. Uterus- Check fundus for location if the fondus is above the expected level or shifted the bladder may be disterted. Check for bogginess stimulate uterine muscle to contract by massaging if boggy
c. Bowel- Mother should move bowel within two days. Encourage fluid, fiber and exercise
d. Bladder- Mother may not have urge to void palpitate for bulge and encourage void.
e. Lochia- Assess the amount on perennial pads and while checking the perineum or massaging the fundus. Amount- constant trickle indicate excessive bleeding and requires attention Color- should be reddish in first 1 to 3 days then pinkish Odor – fleshy, earthy or musty but not four. No fever or tenderness should be present Presence of clots few small-normal, (large clots retained placental fragments)
f. Episiotomy/perineum- REEDA is a remainder to assess five signs R is for redness, E is Edema, E is ecchymosis (brushy) and is for discharge and A is approximation of the wound S & S Lacerations Hematoma- Treat with ice and pain management Infection- Monitor for fever, foul discharge and pain
g. Extremities- Monitor for edema and test deep tendon reflexes which should be t1 and t2 (1t-2t) assess for s/s of thrombophlebitis which is indicated be redness, heat, edema, and tenderness.
h. Emotional status- check for postpartum blues.
2. Why should you have the patient empty her bladder before you assess the fundus?
The patient should empty the bladder the bladder so the fudus can be properly assess
3. Explain boggy fundus. What could this indicate? What are nursing interventions for a boggy fundus?
The boggy fundus is when the fundus is soft and difficult to locate. This indicates clots in uterus. The interventions for a boggy fundus is to massage the fundus with your dominate hand while keeping the other hand above the woman’s symphysis pubis. 4. Describe the anatomic position where you would expect to find the fundus of the uterus at each of the time periods listed below.
a. 6-12 hours after delivery- It should be at the level of the umbilicus.
b. 2 days after delivery- Will be two fingers below umbilicus
c. 10 days after delivery- should be at the pubis symphis
5. Explain the standardized method for estimating lochia after delivery.
a. Scant> to 1-inch stain
b. Light or small- 1 to 4 inches
c. Moderate – 4 to 6 inches d. Large/heavy- saturated in 1 hour
6. What position should the patient assume to have her perineum assessed?
Position should be side lying with upper leg flexed
7. Describe the care of the episiotomy
Ice pack wraps in wash cloths is applied to perineum to prevent edema and numb area, sits baths can be used and topical medications. 8. Identify comfort measures and rationales for the discomforts listed below. a. Hemorrhoids- Can be caused by pushing and varicosities of the rectum, apply astringent ointments and apply topical anesthetics.
