The nurse is caring for a patient that delivered 6 hours ago. She had a spontaneous vaginal delivery (SVD) with a second degree laceration that was repaired. She pushed for three hours and has swollen perineum and inflamed hemorrhoids. The patient complains of overall perineal discomfort and rates it a 6/10 on the pain scale. Which of the following interventions would the nurse include in the client’s plan of care for pain management? Select all that apply.
Warm compress.
Tucks pads.
Dermaplast spray.
Ibuprofen 600 mg PO.
Encourage the patient to sit in a high Fowler’s position.
Correct Answer : A,B,C,D
Choice A rationale
Warm compresses can help to reduce perineal pain and swelling by increasing blood flow to the area, which promotes healing and provides comfort. The warmth can also help to relax the muscles and reduce discomfort.
Choice B rationale
Tucks pads, which contain witch hazel, are effective in reducing perineal pain and swelling. Witch hazel has anti-inflammatory and astringent properties that help to soothe irritated skin and reduce swelling, providing relief from discomfort.
Choice C rationale
Dermaplast spray is a topical anesthetic that provides temporary relief from perineal pain. It contains benzocaine, which numbs the area and reduces pain. It also has antiseptic properties that help to prevent infection in the perineal area.
Choice D rationale
Ibuprofen 600 mg PO is a nonsteroidal anti-inflammatory drug (NSAID) that helps to reduce pain and inflammation. It works by inhibiting the production of prostaglandins, which are chemicals that cause inflammation and pain. Taking ibuprofen can provide significant relief from perineal discomfort.
Choice E rationale
Encouraging the patient to sit in a high Fowler’s position is not recommended for perineal pain management. This position can increase pressure on the perineum, potentially worsening the pain and discomfort.
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Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Washing hands before and after perineal care or voiding is essential to prevent infection. Proper hand hygiene reduces the risk of introducing bacteria to the perineal area, which is particularly vulnerable to infection postpartum.
Choice B rationale
Leaving the current pad on until it is fully saturated is not recommended. Changing pads frequently helps to maintain cleanliness and reduce the risk of infection. A saturated pad can harbor bacteria and increase the risk of infection.
Choice C rationale
Wiping the perineum thoroughly with a back-and-forth motion is not recommended. Instead, the perineum should be wiped from front to back to prevent the spread of bacteria from the rectal area to the perineal area, reducing the risk of infection.
Choice D rationale
Using a perineal squeeze bottle to cleanse the perineum is recommended. It helps to gently clean the area without causing irritation or discomfort. The warm water can also provide soothing relief to the perineal area.
Choice E rationale
Applying ice or cold packs to the perineum can help to reduce swelling and provide pain relief. The cold temperature constricts blood vessels, reducing inflammation and numbing the area to alleviate discomfort.
Correct Answer is D
Explanation
Choice A rationale
Using a bladder scanner to assess for urinary retention is a non-invasive and appropriate intervention. It helps determine the volume of urine in the bladder and can guide further management. This method avoids unnecessary catheterization and reduces the risk of infection.
Choice B rationale
Catheterizing to empty the bladder is a common intervention for urinary retention. However, it should be done with caution and only when necessary to avoid the risk of infection. In this scenario, it is not contraindicated but should be considered after other non-invasive methods have been tried.
Choice C rationale
Placing peppermint oil on a cotton ball and placing it in the urinary “hat” while the client is on the toilet is a non-invasive method that can help stimulate urination through the scent of peppermint. This method is safe and can be effective for some clients.
Choice D rationale
Assisting the client back to bed and telling her to try to void again in 2 hours is contraindicated because it delays the intervention for a distended bladder. A distended bladder can cause discomfort and potential complications, so timely intervention is necessary.