Saturday, August 7, 2010

Nursing Care Plan | NCP Mastitis

Mastitis, parenchymatous infection of the mammary glands, is seen primarily in lactating women. It is estimated that 2% to 33% of lactating women develop mastitis, which is more common in primiparas. Typically, the lactation process is well established before mastitis develops; the highest incidence is seen in the second and third weeks postpartum. It can occur antepartum, but this is rare. The infection is usually unilateral, and is preceded by marked engorgement. If it is left untreated, mastitis may develop into a breast abscess.

Mastitis is usually caused by the introduction of bacteria from a crack, fissure, or abrasion through the nipple that allows the organism entry into the breast. The source of organisms is almost always the nursing infant’s nose and throat; other sources include the hands of the mother or birthing personnel and maternal circulating blood. The most common bacterial organism to cause mastitis is Staphylococcus aureus; others include beta-hemolytic streptococcus, Escherichia coli, Candida albicans, and rarely, streptococcus. Community-acquired and nosocomial methicillin-resistant S. aureus have also been found to cause mastitis. The actual organism can be cultured from the milk. Common predisposing factors relate to milk stasis and include incomplete or inadequate drainage of a breast duct and alveolus that occurs as a result of missed feedings; prolonged delay in infant feeding; abrupt weaning of the infant; and blocked ducts caused by tight clothing or poor support of pendulous breasts. Other predisposing factors include a history of untreated or undertreated infections and a lowered maternal immune function caused by fatigue, stress, or other health problems.
Nursing care plan
Nursing care plan assessment and physical examination
Before breast symptoms occur, chills, fever, and tachycardia are present. Usually the infection is unilateral; localized symptoms include intense pain, tenderness, redness, and heat at the infection site. In addition, the woman often feels as if she has the flu, with symptoms of muscular aching, fatigue, headache, and continued fever. In reviewing breastfeeding history, note if the frequency or regularity of feedings has changed. Fully investigate (1) the length of time the infant spends feeding; (2) the time between feedings; (3) if the infant is falling asleep at the breast; (4) if the infant is sleeping through the night; (5) if the infant receives supplementary water, juice, or formula; and (6) if the infant receives bottled breast milk.

Ask the family if schedule changes have occurred that may cause the woman to nurse her infant less frequently. In addition, ask if family members have cold or flu symptoms.

The breast may have a pink or red area that is swollen and often wedge-shaped, resulting from the septal distribution of the connective breast tissue. Most often, the upper outer quadrant is involved, but any area of the breast may be infected. You may also note cracked or sore nipples. Palpation of the area reveals a firm, tender area that is often warm to the touch. During palpation you may also feel enlarged axillary lymph nodes. Fever and tachycardia are also present.

The transition to motherhood is a time of many changes in the woman’s relationships: with the infant, the father, other children, and grandparents. It is important that the mother realize that mastitis is not a reason to discontinue breastfeeding and that her mothering skills are not inadequate because of it.

Nursing care plan primary nursing diagnosis: Breastfeeding, ineffective related to change in feeding patterns, inadequate sucking, incorrect positioning, or infrequent feedings.

Nursing care plan intervention and treatment plan
Pharmacologic treatment involves the use of antibiotics that are tolerated by the infant and mother. If antibiotic therapy is begun before suppuration begins, the infection usually resolves within 48 hours. Milk cultures are done prior to starting antimicrobial therapy to identify sensitivities and for successful surveillance on infections. Acetaminophen can be taken for discomfort; nonsteroidal anti-inflammatory drugs can be taken for fever and inflammation. If an abscess develops, it is surgically drained under general anesthesia.

Prevention is the most important aspect for nursing care. To prevent the development of mastitis, encourage frequent unrestricted nursing. The infant should be observed while nursing for techniques related to latching on, placement, positions, and suck. At the end of the feeding, evaluate the breast for emptiness. Instruct the woman to rotate feeding position of the infant to promote effective emptying of all lobes and to palpate her breast to evaluate emptiness after each feeding. If clogged ducts are noted, she should massage the area before the feeding and assess the area following subsequent feedings to see that it is completely emptied.

If mastitishas developed, encourage the woman to go to bed and stay there. She should only provide care for her infant, with a focus on frequent feeding and complete rest for her. Encourage the mother to continue breastfeeding frequently. If the infected breast is too sore to allow breastfeeding, gently pumping is recommended; emptying the breasts is an important intervention in preventing an abscess. Recommend that the woman massage her breasts before breastfeeding when she feels that her breasts are overly full or were not completely emptied at the previous feeding. In addition, instruct the woman to apply heat to the affected area, followed by gentle massage with the palm of the hand, immediately before feeding the infant to promote drainage. Encourage the woman to remove her brassiere during feedings so that constriction of the ducts does not occur from pressure. Tell the mother that some infants will not nurse on an inflamed breast. This is due to engorgement and edema, which makes the areola harder to grip; pumping may alleviate this.

Infant position during feeding is critical for effective drainage of the breast. Teach the woman to turn the infant fully on her or his side with the head placed at the mother’s breast. The head should face the areola without turning. One or more inches of the areola should be in infant’s mouth, and the baby’s chin and nose should rest lightly on the breast. In addition, the infant’s lips should be flared during nursing. As the infant nurses, the mother should hear swallowing. Encourage the mother to vary the infant’s position (cradle, cross-cradle, football, side-lying) at feedings so that all ducts of the breast are effectively emptied. Feeding should always begin on the affected breast.

Teach the mother that she needs to nurse the infant a minimum of every 2 to 3 hours around the clock. Frequent feedings may mean that the mother needs to wake the infant during the night. Pain is managed through the use of ice packs or warm packs applied to the breast. A supportive, well-fitting brassiere may also reduce pain if it does not apply pressure to the infected area. In addition, over-the-counter analgesics may be used. Encourage the mother to drink at least 3000 mL of fluid per day; light straw-colored urine is an indication of adequate hydration. The mother’s diet should meet the nutritional requirements for lactation.

Nursing care plan discharge and home health care guidelines
Teach the patient to prevent mastitis by the following interventions: Continue breastfeeding frequently. Wash hands before touching breast or beginning breastfeeding. Breastfeed every 2 to 3 hours around the clock (wake up the baby at night). Remove brassiere before beginning feeding. Always begin breastfeeding on the affected side. To promote emptying of the breast at a feeding, apply warmth to the breast immediately before feeding (a disposable diaper may be wet with warm water and wrapped around the breast) and massage the breast before placing the infant at the breast. Change the infant’s feeding position; use cradle, side-lying, cross-cradle, and football positions to promote emptying of the breast. Increase the mother’s fluid intake. Evaluate the breast after the feeding to see if the infant has completely emptied the breast. If the baby does not completely empty the breast, finish emptying the breast with a breast pump or manual expression. Rest and avoid fatigue. All medications should be taken until the prescription is finished, even if symptoms disappear.

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