Puerperal Infection Nursing Care Plan & Management

Notes

Description
  1. Puerperal infection is an infection developing in the birth structures after delivery.
  2. Puerperal infection is a major cause of maternal morbidity and morality.
  3. The incidence ranges from 14% and to 8% of all deliveries; there is a higher incidence in cesarean deliveries.
  4. The major site of postpartum infections is the pelvic cavity; other common sites include the breast, urinary tract, and venous system.
  5. Localized infections may affect the vagina, vulva, and perineum.
  6. Endometritis, localized infection of the uterine lining, occurs 48 to 72 hours after delivery.
Etiology
  • Puerperal infections can be caused by poor sterile technique, delivery with significant manipulation, cesarean birth, or overgrowth of local flora.
Pathophysiology

1. Causative organisms

  • Aerobic organisms include beta-hemolytic streptococci, Escherichia coli, Klebsiella, Proteus mirabilis, Pseudomonas, Staphylococcus aureus, and Neisseria.
  • Anaerobic organisms include Bacteroides, Peptostreptococcus, Peptococcus, and Clostridium perfringens.

2. In parametritis (pelvic cellulitis), infection spreads by way of the lymphatics of the connective tissue          surrounding the uterus.

3. Puerperal infection may extend to the peritoneum by way of the lymph nodes and uterine wall.

Assessment Findings

1. Clinical manifestations

  • Puerperal morbidity is marked by a temperature of 38°C (100.4°F) or higher after the first 24 hours postpartum on any two of the first 10 postpartum days.
  • Localized vaginal, vulval, and perineal infections are marked by pain, elevated temperature, edema, redness, firmness, and tenderness at the sit of the wound; sensations of heat; burning on urination; and discharge from the wound.
  • Manifestations of endometritis include a rise in temperature for several days. In severe endometritis, symptoms include malaise, headache, backache, general discomfort, loss of appetite, large tender uterus, severe postpartum cramping, and brownish red, foul-smelling lochia.
  • Parametritis (pelvic cellulitis) commonly produces elevated temperature of more than 38.6°C (102° to 104°F), chills, abdominal pain, subinvolution of uterus, tachycardia, and lethargy.
  • Signs and symptoms of peritonitis include high fever, rapid pulse, abdominal pains, nausea, vomiting, and restlessness.

Nursing Management

1. Promote resolution of the infectious process.

  • Inspect the perineum twice daily for redness, edema, ecchymosis, and discharge.
  • Evaluate for abdominal pain, fever, malaise, tachycardia, and foul-smelling lochia.
  • Obtain specimens for laboratory analysis; report the findings.
  • Offer a balanced diet, frequent fluids, and early ambulation.
  • Administer prescribed antibiotics or medications; document the client’s response.

2. Provide client and family teaching. Describe and demonstrate self-care, stressing careful perineal hygiene and handwashing.

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Nursing Care Plan

Risk For Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.

Risk Factors:
  • Presence of infection, broken skin and/or traumatized tissues.
  • high vascularity of involved area.
  • Invasive procedures and/or increased environmental exposure.
  • Chronic disease (e.g., diabetes), anemia, malnutrition.
  • Immunosuppression and/or untoward effect of medication (e.g., opportunistic/secondary infections)
Possibly evidenced by
  • [Not applicable]
Desired Outcomes
  • Patient will verbalize understanding of individual causative risk factors.
  • Patient will initiate behaviors to limit the spread of infection, as appropriate, and reduce the risk of complications.
  • Patient will achieve timely healing, free of additional complications.
Nursing Interventions Rationale
Review prenatal, intrapartal, and postpartal record. Identifies factors that place client in high-risk
category for development/spread of postpartal infection.
Demonstrate and maintain a strict hand-washing policy for staff, client, and visitors. Helps prevent cross-contamination.
Instruct the proper disposal of contaminated linens, dressings, and peripads. Maintain isolation, if indicated. Prevents spread of infection.
Demonstrate correct perineal cleaning after voiding and defecation, and frequent changing of peripads. Cleaning removes urinary/fecal contaminants. Changing pad removes moist medium that favors bacterial growth.
Demonstrate proper fundal massage. Review importance and timing of the procedure. Enhances uterine contractility; promotes involution and passage of any retained placental fragments.
Monitor temperature, pulse, and respirations. Note presence of chills or reports of anorexia or malaise. Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. Note: Persistent fever unresponsive to antibiotic therapy may indicate pelvic thrombophlebitis.
Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge and approximation [REEDA scale]). Note subinvolution of uterus, extreme uterine tenderness. Allows early identification and treatment; promotes resolution of infection. Note: Although localized infections are usually not severe, occasional progression to necrotizing fasculitis can be life-threatening.
Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day. Note urine output, degree of hydration, and presence of nausea, vomiting, or diarrhea. Increased intake replaces losses and enhances circulating volume, preventing dehydration and aiding in fever reduction.
Encourage semi-Fowler’s position. Enhances flow of lochia and uterine/pelvic drainage.
Promote early ambulation, balanced with adequate rest. Advance activity as appropriate. Increases circulation; promotes clearing of respiratory secretions and lochial drainage; enhances healing and general well-being. Note: Presence of pelvic/femoral thrombophlebitis may require strict bed rest.
Investigate reports of leg or chest pain. Note pallor, swelling, or stiffness of lower extremity. These signs and symptoms are suggestive of septic thrombus formation. Note: Embolic sequelae, especially pulmonary embolism, may be initial indicator of thrombophlebitis.
Recommend that breastfeeding mother periodically check infant’s mouth for presence of white patches. Oral thrush in the newborn is a common side effect of maternal antibiotic therapy.
Encourage client/couple to prioritize postdischarge responsibilities (e.g., homemaking tasks, child care) Client will require additional rest to facilitate recuperation/healing. Household duties need to be reassigned or delayed as appropriate.
Instruct in proper medication use (e.g., with or without meals,take entire course of antibiotic, as prescribed). Oral antibiotics may be continued after discharge. Failure to complete medication may lead to relapse.
Discuss the importance of pelvic rest as appropriate (avoidance of douching, tampons, and intercourse). Promotes healing and reduces the risk of reinfection.
Monitor laboratory studies, as indicated: Identifies infectious process/causative organism and appropriate antimicrobial agents.
  • Culture(s)/sensitivity;
    CBC, WBC count, differential, and ESR;
Aids in tracking resolution of infectious or inflammatory process. Identifies degree of blood loss and determines presence of anemia.
  • Partial thromboplastin time/prothrombin time (PTT/PT), clotting times;
Helps in identifying alterations in clotting associated with development of emboli. Aids in determining effectiveness of anticoagulation therapy.
  • Renal/hepatic function studies.
Hepatic insufficiency and decreased renal function may develop, altering drug half-life and increasing risks of toxicity
Encourage application of moist heat in the form of sitz baths and of dry heat in the form of perineal lights for 15 min 2–4 times daily. Water promotes cleansing. Heat dilates perineal blood vessels, increasing localized blood flow and promotes healing.
Provide supplemental oxygen when necessary. Promotes healing and tissue regeneration, especially in presence of anemia; may enhance oxygenation when pulmonary emboli are present.
Demonstrate perineal application of antibiotic creams, as appropriate. Eradicates local infectious organisms, reducing risk of spreading infection.
Administer medications as indicated:
  • Antibiotics, initially broad-spectrum, then organism-specific, as indicated by results of cultures/sensitivity
Combats pathogenic organisms, helping prevent infection from spreading to surrounding tissues and bloodstream. Note: Parenteral route is preferred for parametritis, peritonitis, and, on occasion, endometritis.
  • Oxytocics, such as pitocin and methylergonovine maleate (Methergine);
Promotes myometrial contractility to retard the spread of bacteria through the uterine walls, and aids in the expulsion of clots and retained placental fragments.
  • Anticoagulants (e.g., heparin).
In presence of pelvic thrombophlebitis, anticoagulants prevent or reduce additional thrombi formation and limit spread of septic emboli.
Administer whole blood/packed RBCs, if needed. Replaces blood losses and increases oxygen-carrying capacity in presence of severe anemia and/or hemorrhage.
Arrange for transfer to intensive care setting as appropriate. May be necessary for client with severe infection (e.g., peritonitis, sepsis) or pulmonary emboli to provide appropriate care leading to optimal recovery.
Assist with procedures, such as incision and drainage (I&D) or D & C, as necessary. Draining the infected area, and possible insertion of iodoform gauze packing, promotes healing and reduces risk of rupture into peritoneal cavity. D & C may be needed to remove retained products of conception and/or placental fragments.

 


Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.

May be related to
  • Intake insufficient to meet metabolic demands (anorexia, nausea/vomiting, medical restrictions).
Possibly evidenced by
  • Aversion to eating.
  • Decreased oral intake or lack of oral intake.
  • Unanticipated weight loss
Desired Outcomes
  • Patient will meet nutritional needs, as evidenced by timely wound healing, appropriate energy level, and Hb/Hct within normal postpartal expectations.
Nursing Interventions Rationale
Discuss eating habits including, food preferences and intolerances. To appeal to client what she likes/desires.
Note total daily intake. Maintain diary of calorie intake, patterns and times of eating. To reveal changes that should be made in client’s dietary intake.
Promote intake of at least 2000 ml/day of juices, soups, and other nutritious fluids. Provides calories and other nutrients to meet metabolic needs and replaces fluid losses, thereby increasing circulating fluid volume.
Encourage choice of foods high in protein, iron, and vitamin C when oral intake permitted. Protein helps promote healing and regeneration of new tissue. Iron is necessary for Hb synthesis. Vitamin C facilitates iron absorption and is necessary for cell wall synthesis.
Encourage adequate sleep/rest. Reduces metabolic rate, allowing nutrients and oxygen to be used for the healing process.
Assist with placement of nasogastric (NG) or Miller- Abbott tube. May be necessary for gastrointestinal decompression in presence of abdominal distension or peritonitis.
Administer parenteral fluids/nutrition, as indicated. May be necessary to combat dehydration, replace fluid losses, and provide necessary nutrients when oral intake is limited/restricted.
Administer iron preparations and/or vitamins, as indicated. Useful in correcting anemia or deficiencies when present.


Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to
  • Body response to infective agent, properties of infection (e.g., skin/tissue edema, erythema)
Possibly evidenced by
  • Verbalizations, restlessness, guarding behavior, self-focusing.
  • Autonomic responses
Desired Outcomes
  • Patient will identify/use individually appropriate comfort measures.
  • Patient will report decreased level of pain/discomfort.
Nursing Interventions Rationale
Assess location and nature of discomfort or pain, rate pain on a 0–10 scale. Helps in the differential diagnosis of tissue involvement in the infectious process.
Assess for non-verbal pain cues. Non-verbal cues such as crying, grimacing, or withdrawn behavior may indicate pain.
Provide instruction regarding, and assist with, maintenance of cleanliness and warmth. Promotes sense of general well-being and enhances healing. Alleviates discomfort associated with chills.
Instruct client in relaxation techniques; provide diversionary activities such as radio, television, or reading. Refocuses client’s attention, promotes positive attitude, and enhances comfort.
Encourage continuation of breastfeeding as client’s condition permits. Otherwise suggest and provide instruction in the use of manual or electric breast pump. Prevents discomfort of engorgement; promotes adequacy of milk supply in breastfeeding client.
Change client’s position frequently. Provide comfort measures; e.g., back rubs, linen changes. Reduces muscle fatigue, promotes relaxation and comfort.
Encourage the woman to ask for pain medications before the pain becomes severe/intolerable. Pain is a lot easier to control before it becomes severe.
Apply local heat using heat lamp or sitz bath as indicated. Heat promotes vasodilation, increasing circulation to the affected area and promoting localized comfort.
Administer analgesics or antipyretics. Reduces associated discomforts of infection.

 


Risk For Altered Parent-Infant Attachment

Risk for Altered Parent-Infant Attachment: Defined as a disruption of the interactive process between a parent and infant that promote the development of a protective and sustaining reciprocal relationship.

Risk Factors
  • Interruption in bonding process.
  • Physical illness.
  • Perceived threat to own survival.
Possibly evidenced by
  • [not applicable]
Desired Outcomes
  • Patient will exhibit ongoing attachment behaviors during parent-infant interactions.
  • Patient will maintain/assume responsibility for physical and emotional care of the newborn, as able.
  • Patient will express comfort with parenting role.
Nursing Interventions Rationale
Monitor client’s emotional responses to illness and separation from infant, such as depression and anger. Encourage client to verbalize feelings and reinforce normalcy as appropriate. Normal expectations are of an uncomplicated postpartal period with the family unit intact. Illness due to infection alters the situation and may result in separation of client from family or newborn, which can contribute to feelings of isolation and depression.
Observe maternal-infant interactions Provides information regarding status of bonding process and client needs.
Provide opportunities for maternal-infant contact whenever possible. Place pictures of infant at client’s bedside (especially if nature of infection/client’s condition or hospital policy requires separation of infant from mother during febrile period). Facilitates attachment, prevents client from engaging in self-preoccupation to the exclusion of the infant.
Encourage father or other family members to care and interact with the infant. May be encouraging to mother to know that family is caring for the infant and providing emotional support. Note: Unexpected/prolonged hospital stay may reduce father’s ability to spend time with newborn because of other responsibilities, including care of siblings. Father may require additional support during this stressful time.
Discuss availability or effectiveness of support systems in home setting. Client requires additional support to accomplish homemaker tasks, allowing client to obtain adequate rest and spend time with infant/other children.
Identify individual support systems. Refer to visiting nurse services, home care agencies, as indicated. Client may require assistance with home maintenance and activities of daily living while following discharge instructions for rest and recuperation.
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