BREAST AND PERINEAL Nursing CARE

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Breast Care: Care given to the breast tissue, nipple and supporting tissue during pregnancy and after delivery for nursing and non-nursing mothers.

Aims:

• Maintain proper support and cleanliness.

• Prevent trauma and infection of the nipples and breasts.

• Correct existing problems, such as flat or inverted nipples.

• Teach the technique of breast self examination on a monthly basis for life.

Nursing Assessment of the client

• Assess the condition of the breasts. Size of the breasts do not affect the ability to breast feed.

• Assess the nipples, Flat or inverted nipples require special attention for the client to breast feed successfully.

• Assess the presence of fissures on the nipple.

• Assess the client’s dietary habits. If she does not eat a balanced diet, educate her about nutrition and successful breast feeding.

• Assess whether the client will breast feed. If she will not, assess her knowledge of breast feeding and importance of care of the breasts to maintain tone after delivery.

Preparation of the client.

• Special care of the breasts during pregnancy should begin with a thorough explanation of the anatomical and physiological changes occurring during pregnancy. Explain to the client the need for support and cleanliness.

Equipment for breast care

• Mild soap and warm water

• Wash clothes and towels

• Well fitted support bra

 

Procedure

1- Antenatal client who will breast feed

Action

Rationale

Wash her hands before breast care.

To prevent cross contamination.

Do breast care daily by washing the nipples with warm water, from the nipple outward. Rinse and dry the breasts.
Breasts secrete colostrum early in the pregnancy. Unless this is cleansed regularly, infection may occur.
Drying of colostrum may result in crusts that irritates the breasts, cause cracking and potential for infection.
 

Wear a good support bra. Change the size as necessary.
Breasts become heavier and fuller during pregnancy. The hanging weight may cause strain or trauma, resulting in mastitis.

Prepare the nipples for the sucking action of the infant by toughening them. This may be accomplished by rubbing them with a rough towel several times a day during the last trimester. Nipple cream (optional) may be applied.

Correct flat or inverted nipples. (the 3 types of nipple are normal, flat and inverted). Therapy for correction should start at the 5th month of pregnancy.
Sucking action of the infant is traumatic to the sensitive tissue of the nipples until they become accustomed to this action. Preparing them before the baby is born facilitates breast feeding.

The infant must be able to grasp the nipple to nurse successfully. Any techniques applied to the breasts to remedy inverted nipples must be done gently, to avoid trauma to the delicate breast tissue.

• Nipple rolling

Roll the nipple very gently between the thumb and forefinger.

• Breast massage.

Hold the breast with both hands, support the breast tissue with extended fingers, massage the breast from the base towards the nipple.

• Hand expression

Pressing the areola and nipple with thumb and index finger try to express colostrum.

• Nipple stretching

Place the thumbs close to the inverted nipple, press firmly into the breast tissue, and gradually press away from the areola.

Another method to correct inverted nipples is by wearing breast shields to exert gentle pressure on the nipple

2. Non-nursing client

Antepartal care
Steps 1-3 same as for nursing mother.
Post- partal
Medication may be given to suppress lactation. Once lactation begins the breasts become engorged, or filled with milk. If the milk is not removed by the sucking of the infant or by manual expression, gradually the milk production is stopped. Breasts should not be pumped to relieve fullness.
If the engorgement is relieved by pumping the milk, milk production is stimulated and the problem will continue.

2. Non-nursing client  (postpartum)

Apply ice packs and wear a well fitted, supporting bra.

Palliative measures such as ice packs are successful in relieving engorgement and discomfort.
Advise the client to wear pads in the bra if the nipples leak.
Pads should be changed as soon as they become soiled.
A well fitted bra is one that lifts the breasts upward and in the direction of the opposite shoulder. This relieves discomfort and helps the breasts to return to normal muscle tone.
A warm moist environment is conducive to bacterial growth.

• Advise the client to perform breast self examinations on a regular basis after the breasts return to normal.

• The lactating breast contains nodules that makes BSE difficult during lactation and for several weeks thereafter.

 

Assessment

• Observe the breasts periodically for integrity of the nipple. Cracks or fissures should be noted at once and treated by proper cleansing and prescribed medications.

• Observe the client’s bra to see that it is well supported by strong straps that both lift and support the breasts and not constricting around the chest area.

• Observe for signs of infection such as redness or hardness of breast.

• Observe for secretion of colostrum.

 

• Observations – Nursing mother

• Physiological changes of breasts during pregnancy explained to client.

• Proper techniques for cleaning the breasts are explained.

• Pregnant client who will breast feed advised and checked for condition of nipples- Normal (erected/projected), flat, or inverted.

• Need for well supported bra.

• Knowledge of BSE technique

 

• Observations – Non-nursing mother

• Need for well fitting support bra.

• Engorgement of breasts.

• Application of ice or heat to prevent discomfort.

• Proper cleansing techniques.

• Effectiveness of lactation suppressing medications.

• Knowledge of BSE technique

 

Breast Self Examination (BSE)

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Step 1

• Begin by looking at the breasts in the mirror with your shoulders straight and your arms on your hips.

• look for breasts for their usual size, shape, and color.

• breasts are evenly shaped without visible distortion or swelling.

Abnormal findings

• dimpling, puckering, or bulging of the skin

• a nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)

• redness, soreness, rash, or swelling

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Step 2

• Raise your arms and look for the same changes.

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Step 3

• Gently squeeze each nipple between your finger and thumb and check for nipple discharge. Normal is no discharge unless pregnant or lactating.

• Abnormal findings are milky or yellow fluid or blood).

 

Step 4

• Feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast.

• Use a firm, smooth touch with the first few fingers of your hand, keeping them flat and together.

• Cover the entire breast from top to bottom, side to side

• Begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. Proceed in a clockwise manner.

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Step 5

• Finally, feel the breasts while standing or sitting.

• An easy way to do this is when the skin is wet and slippery, as in the shower.

• Cover entire breast, using the same hand movements described in Step 4.

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Perineal care

• Cleansing the vulva and perineal area during postpartum period.

• Aims:

• Prevent or reduce infection.

• Provide a dry area for healing.

• Observe the perineum.

• Teach the client to care for her own personal hygiene and that of her female children properly.

Pathophysiology

• After vaginal delivery, the mucosal surface of the vulval area may appear red for several weeks. The muscles of the pelvic floor may be torn and stretched. The perineum may be edematous and tender. Lacerations and bruising also may be present. The episiotomy and lacerations of the perineal area should heal within 4-6 weeks. Return of the muscle tone is expected in about 6 weeks.

• Major problem concerning the healing of perineum is infection. Signs of infection or failure to heal are bloody discharge from the incision, failure of the incision to heal properly, foul smelling discharge, and an increase in pulse and temperature.

Assessment of the client

• Assess the stage of healing of the perineal area – pain, discomfort and the effectiveness of the prescribed treatment measures such as medication or sitz bath.

• Assess the ability of the client to assume the needed position. If the client has pain, give analgesics.

• Assess the allergy history of the client if an anaesthetic spray is to be used.

Objectives

• Remove secretions and discharge from the vulva and perineal area.

• Promote and monitor proper healing of the perineal area.

• Reduce irritation and odor.

• Prepare the area for local applications (dressings, heat, ice)

• Provide comfort for the client.

• Teach self-care and genital hygiene.

• Record the condition of the area and the type and amount of discharge.

Preparation of the client.

• Explain the procedure and schedule for it. Tell her she can receive perineal care any time she feels uncomfortable, voids or has a bowel movement. Explain that she can care for herself as soon as she is ambulatory.

• Ask the client to empty the bladder.

• Ask the patient to remove the perineal pad before giving vulval and perineal care. While removing the pad the front is released and removed first and the back last. This helps to prevent contamination from the rectal area.

• Dispose the pad.

 

Equipment

• Cleansing solution or tap water.

• Soap

• Wash cloths, cotton balls or gauze sponges.

• Basin or spray can

• Bed pan

• Perineal pad

• Paper or plastic bag for soiled pad

 

Procedure: Client who can not get out of bed

Wash your hands.
Minimizes transfer of pathogenic microorganisms
Assist the client into a dorsal recumbent position on a bedpan.
 
Using soap and warm water on a wash cloth, wash the perineal area gently and thoroughly with strokes from front to back.
Use a different corner of the wash cloth for each stroke.
Avoid the rectal area.

Do not separate the labia during cleansing, and do not allow the rinse water to flow into the vagina.
Rinse the perineal area by pouring clean water over the area, letting it run into the bedpan or by using clean wash cloth.
All cleansing and rinsing should proceed from front to back.
Rinse water flowing into vagina may cause infection.
Dry the area gently with a clean cloth or towel.
To relieve irritation and to promote healing.

Turn the client to Sim’s position (Side lying with upper legs flexed). Wash and dry the anal region.
Cleansing the anal area last promotes freshness while preventing the spread of microorganisms.
•  Apply a clean perineal pad. Attach the front first.
Care must be taken to prevent contamination of the vulval area with organisms from the rectal area

Dispose of the soiled pad. Clean and replace articles, wash your hands and record the procedure.
Proper cleaning and disposal of articles enhances hygiene and reduces infection.

Ambulatory client

Explain to the client to clean the perineal area with a clean wash cloth after voiding or bowel elimination. Make 3 strokes from front to back. Use a different portion of wash cloth for each stroke.
Self-care enhances self image and minimizes chances of infection.

Sitz bath

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Other measures are warm sitz bath or heat lamp. An inflated ring may be used when the client sits up to prevent pressure on the episiotomy.
An ice pack covered with soft gauze and applied over the perineal area decreases edema in the 1st 12-24 hrs.
Anesthetic sprays may decrease discomfort.
Comfort measures decrease the swelling and tension on the suture line.

Observations

• Proper healing of the vulval and perineal area.

• Episiotomy site for edema, inflammation , Separation, Presence of hematoma

• The appearance of the lochia – color, amount and odor. Foul odor indicates infection.

• Technique explained to the client.

• Hand washing explained and demonstrated.

• Client instructions on vulval and perineal care frequency

• Method of cleansing from front to back.

• Proper placement of perineal pads

• Episiotomy or laceration , healing with out problems.

• Other comfort measures as inflated ring, sitz bath, perineal light, analgesics, ice packs, and anaesthetic spray.

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