2. Disorders affecting protective functions: postpartal infection (Table 4-13).
   1. General aspects
      1. Definition—reproductive system infection occurring during the postpartal perio
      2. Pathophysiology— bacterial invasion of birth canal; most common: localized infection of the lining of the uterus (endometritis).
      3. Etiology:
         1. Anaerobic nonhemolytic streptococci.
         2. £ coli
         3. trachomatis (bacteroides).
         4. Staphylococci
      4. Predisposing conditions:
         1. Anemi
         2. PROM.
         3. Prolonged labor.
         4. Repeated vaginal examinations during labor.
         5. Intrauterine manipulation—e.g., manual extraction of placent
         6. Retained placental fragments.
         7. Postpartum hemorrhag
      5. Assessment:
         1. Fever 38°C (100.4°F) or more on two or more occasions, after first 24 hr postpartum.
         2. Other signs of infection: pain, malaise, dysuria, subinvolution, foul lochial odor.
      6. Analysis/nursing diagnosis:
         1. Fluid volume deficit related to excessive blood loss, anemi
         2. Knowledge deficit related to danger signs of postpartum perio
         3. High risk for injury related to infection.
      7. Nursing care plan/implementation: prevention
         1. Goal: prevent anemia.
            1. Minimize blood loss - accurate postpartal assessment and management of bleeding.
            2. Diet: high protein, high vitamin.
            3. Vitamins, iron - suggest continuing prenatal pattern until postpartum checkup.
         2. Goal: prevent entrance/transport of microorganisms.
            Strict aseptic technique during labor, birth, and postpartum (standard precautions).
            1. Minimize vaginal examinations during labor.
            2. Perineal care.
         3. Goal: health teaching.
            1. Hand washing - before and after each pad change, after voiding or defecatin
            2. Perineal care - from front to back; use clear, warm water or mild antiseptic solution as a cascade; do not separate labi
            3. Maintain sterility of pads; apply from front to back.
            4. Avoid use of tampons until normal menstrual cycle resumes.
      8. Evaluation/outcome criteria:
         1. Woman has assessment findings within normal limits:
            1. Vital signs.
            2. Rate of involution (fundal height, consistency).
            3. Lochia: character, amount, odor.
         2. Woman avoids infection.
   2. Endometritis— infection of lining of uterus.
      1. Pathophysiology— see I General aspects, p. 15
      2. Etiology— most common: invasion by normal body flora (, anaerobic streptococci).
      3. Characteristics:
         1. Mild, localized—asymptomatic, or lowgrade fever.
         2. Severe—may lead to ascending infection, parametritis, pelvic abscess, pelvic thrombophlebitis.
         3. If remains localized, self-limiting; usually resolves within 10 days.
      4. Assessment:
         1. Signs of infection: fever, chills, malaise, anorexia, headache, backach
         2. Uterus: large, boggy, extremely tender.
            1. Subinvolution.
            2. Lochia: dark brown; foul odor.
      5. Analysis/nursing diagnosis:
         1. Anxiety/fear related to effects on self and newborn.
         2. Self-esteem disturbance and altered role performance related to inability to meet own expectations regarding parenting, secondary to unexpected hospitalization.
         3. Pain related to inflammation/infection.
         4. Ineffective individual coping related to physical discomfort and psychological stress associated with self-concept disturbance; worry, guilt, concern regarding newborn at hom
         5. Altered family processes— interruption of adjustment to altered life pattern related to postpartal infection/hospitalization.
      6. Nursing care plan/implementation:
         1. Goal: prevent cross-contamination. Contact-item isolation.
         2. B Goal: facilitate drainag Position: semiFowler’s.
         3. Goal: nutrition/hydration.
            1. (l) Diet: high-calorie, high-protein, highvitamin.
            2. Push fluids to 4000 mL/day (oral or IV, or both, as ordered).
            3. I&O.
         4. Goal: increase uterine tone/facilitate involution. Administer medications, as ordered (, oxytocics, antibiotics).
         5. Goal: minimize energy expenditure, as possibl
            1. Bed rest.
            2. Maximize rest, comfort.
         6. Goal: emotional support.
            1. Encourage verbalization of anxiety, concerns.
            2. Keep informed of progress.
      7. Evaluation/outcome criteria:
         1. Vital signs stable, within normal limits.
         2. All assessment findings within normal limits.
         3. Unable to recover organism from discharge.
   3. Urinary tract infections
      1. Pathophysiology - normal   physiological changes associated with pregnancy (, ureteral dilation) and the postpartal period (, diuresis, increased bladder capacity with diminished sensitivity of stretch receptors) —> increased susceptibility to bacterial invasion and growth —-» ascending infections (cystitis, pyelonephritis).
      2. Etiology: usually bacterial.
      3. Predisposing factors:
         1. Birth trauma to bladder, urethra, or meatus.
         2. Bladder hypotonia with retention (due to intrapartal anesthesia or trauma).
         3. Repeated or prolonged catheterization, or poor technique
         4. Weakening of immune response secondary to anemia, hemorrhage
      4. Assessment:
         1. Maternal vital signs (fever, tachycardia).
         2. Dysuria, frequency (flank pain—with pyelonephritis).
         3. Feeling of “not emptying” bladder.
         4. Cloudy urine; frank pus.
      5. Analysis/nursing diagnosis:
         1. Altered urinary elimination related to diuresis, dysuria, inflammation/infection.
         2. Pain related to dysuria secondary to cystitis, Knowledge deficit related to self-care (perineal care).
      6. Nursing care plan/implementation:
         1. Goal: minimize perineal edem Perineal ice pack in fourth stage—to limit swelling secondary to trauma, facilitate voidin
         2. Goal: prevent overdistention of bladder.
            1. Monitor level of fundus, lochia, bladder distention. (Note: Distended bladder displaces uterus, limits its ability to contract —> boggy fundus, increases its vaginal bleedin)
            2. Encourage fluids and voiding; I&O.
            3. Aseptic technique for catheterization.
            4. Slow emptying of bladder on catheterization—to maintain ton
         3. Goal: identification of causative organism— to facilitate appropriate medication (antibiotics). Obtain clean-catch (or catheterized) specimen for culture and sensitivity.
         4. Goal: health teachin See previous discussion of fluids, general hygiene, diet, and medications.
      7. Evaluation/outcome criteria:
         1. Voiding: quantity sufficient (although Urine character: clear, amber, or straw colore
         2. Vital signs: within normal limits.
         3. No complaints of frequency, urgency, burning on urination, flank pain.
   4. Mastitis - inflammation of breast tissue:
      1. Pathophysiology - local inflammatory response to bacterial invasion; suppuration may occur; organism can be recovered from breast milk.
      2. Etiology - most common: Staphylococcus aureus; source - most common: infant’s nose, throat.
      3. Assessment:
         1. Signs of infection (may occur several weeks: postpartum).
            1. Fever.
            2. Chills.
            3. Tachycardi
            4. Malais
            5. Abdominal pain.
         2. Breast
            1. Reddened area(s).
            2. Localized/generalized swellin
            3. Heat, tenderness, palpable mass.
      4. Analysis/nursing diagnosis:
         1. Impaired skin integrity related to nipple fissures, cracks.
         2. Pain related to tender, inflamed tissue secondary to infection.
         3. Disturbance in body image, self-esteem related to association of breastfeeding with female identity and rol
         4. Anxiety/fear related to sexuality; impact on breastfeeding, if any.
      5. Nursing care plan/implementation:
         1. Goal: prevent infection. Health teaching in early postpartum:
            1. Hand washin
            2. Breast care - wash with warm water only (no soap) - to prevent removing protective body oils.
            3. Let breast milk dry on nipples to prevent drying of tissu
            4. Clean bra (with no plastic pads or liners) to support breasts, reduce friction, minimize exposure to microorganisms.
            5. Good breastfeeding techniques (see p. 157).
            6. Alternate position of infant for nursing to change pressure areas.
         2. Goal: comfort measures.
            1. Encourage bra or binder - to support breasts, reduce pain from motion.
            2. Local heat or ice packs as ordered - to reduce engorgement, pain.
            3. Administer analgesics, as necessary.
         3. Goal: emotional support.
            1. Encourage verbalization of feelings, concerns.
            2. If breastfeeding is discontinued, reassure woman she will be able to resume breastfeeding
         4. Goal: promote healing.
         1. Maintain lactation (if desired) by manual expression or breast pump, q4h.
         2. Administer antibiotics as ordered
      6. Evaluation/outcome criteria:
         1. Woman promptly responds to medical/ nursing regimen.
            1. Symptoms subsid
            2. Assessment findings within normal limits.
         2. Woman successfully returns to breastfeedin
   5. Thrombophlebitis
      1. Pathophysiology— inflammation of a vein secondary to lodging of a clot.
      2. Etiology:
         1. Extension of endometritis with involvement of pelvic and femoral veins.
         2. Clot formation in pelvic veins following cesarean birt
         3. Clot formation in femoral (or other) veins secondary to poor circulation, compression, and venous stasis.
      3. Assessment:
         1. Pelvic—pain: abdominal or pelvic tenderness.
         2. Calf—pain: positive Homans' sign (pain elicited by flexion of foot with knee extended).
         3. Femoral
            1. Pain.
            2. Malaise, fever, chills.
            3. Swelling—“milk le”
      4. Analysis/nursing diagnosis:
         1. Pain in affected region related to local inflammatory respons
         2. Anxiety/fear related to outcom
         3. Ineffective individual coping related to unexpected postpartum complications, hospitalization, separation from newborn.
         4. Impaired physical mobility related to imposed bed rest to prevent emboli formation and dislodging clot (embolus).
      5. Nursing care plan/implementation:
         1. Goal: prevent clot formation.
            1. Encourage early ambulation.
            2. Position: avoid prolonged compression of popliteal space, use of knee gatc
            3. Apply thromboembolic disease (TED) hose, as ordered, preoperatively or postoperatively, or both, for cesarean birt
         2. Goal: reduce threat of embol
            1. Bed rest, with cradle to support beddin
            2. Discourage massaging “leg cramps.”
         3. Goal: prevent further clot formation. Administer anticoagulants, as ordere
         4. Goal: prevent infection.
            1. Administer antibiotics, as ordere
            2. Push fluids.
         5. Goal: facilitate clot resolution. Heat therapy, as ordere
      6. Evaluation/outcome criteria:
         1. Symptoms subside; all assessment findings within normal limits.
         2. No evidence of further clot formation.