Postpartum Assessment Flashcards
Acronym for postpartum assessment
BUBBLE HE
Breast
Uterus
Bladder
Bowel
Lochia
Episiotomy/perineum
Hemorrhoids/ Homans sign
Emotional status
What’s the main question you ask before examining the breasts?
Breast-feeding or bottlefeeding
This will guide what you teach as you go through the exam
How do you examine the breast?
Inspect the breasts, noting reddened areas or engorgement
Inspect nipples for fissures, cracks or inversion
Palpate the breast lightly for softness, slight firmness associated with filling or tightness of engorgement, warmth or tenderness
Teachings for breast feedings moms?
Use supportive bra
Keep nipples dry and watch for fissures or cracks
Watch for reddened or tender spots on breast
Additional teaching during breast-feeding attempts as needed
What are some teachings for non-breast-feeding moms?
Use supportive bra
Avoid breast stimulation
Apply cold packs
Apply cold, raw cabbage leaves inside bra
How do you assess the uterus?
Palpate the position of the fundus in relation to the umbilicus
Is the fundus firm or boggy?
Is fundus in midline?
Inspect abdominal incision for patients with a C-section using REEDA mnemonic
Excessive pain may indicate infection
What is REEDA
Redness
Edema
Ecchymosis
Discharge
Approximation (glued together)
What are some uterus teachings?
Fundal position
How to determine firmness
How to massage her fundus
Where should the fundus be located?
At or below umbilicus and in the midline
What does a boggy uterus mean?
To relaxed, prone to bleeding
What is a sign of bladder distention?
A boggy uterus, displaced uterus, or palpable bladder
What are some bladder teachings?
Tips to facilitate elimination
-out of bed
-pouring warm water and perineum
-Running water in the sink
-Encourage relaxation and breathing
Encourage frequent voiding
Increase the amount of water she drinks
When does bowel movements return after childbirth?
2-3 days
What are some bowel teachings?
Help re establish normal bowel pattern
-encourage ambulation
-Encourage fluids
-Encourage fresh fruits/vegetables/fiber in diet
Stool softeners
How do you assess the lochia
Assess for character, amount, odor, and clots
Assess for rubra, serosa, and alba
Clots and heavy bleeding may be caused by what?
Clot and heavy bleeding may be caused by uterine relaxation, retained placenta fragments, or an unknown cervical laceration
What are some teachings regarding lochia?
Inform patient of the normal changes with color and characteristics
Effect of position changes
Hygienic measures
Patience who have a C-section may experience less bleeding
What do we mean by effects of position changes regarding lochia teachings?
As patient rest in a horizontal position, lochia may pull in vagina, and patient may notice setting gush or discharge as she sits or stands
How do we inspect episiotomy/perineum?
Inspect perineum area for REEDA
Redness
Edema
Ecchymosis (bruising)
Discharge (draining)
Approximation (of wound edges)
Episiotomy teachings?
Discuss the type of episiotomy or laceration patient has
Sutures will dissolve on its own
Ice packs
Sitz baths
Peri bottle after voiding and BM
Kegel exercises
Topical sprays or foam for pain control
What are postpartum women increased risk for?
Thrombophlebitis
Thrombus formation (PE)
If a thrombophlebitis occurs, where is the most likely site?
The woman’s legs
What predisposes a patient for thrombophlebitis
Hypercoagulability
Severe anemia
Obesity
Traumatic delivery
How do we assess for thrombophlebitis?
The nurse should have the woman stretch her legs out, with the knees slightly flexed and the legs relaxed. The nurse then grabs the foot and dorsiflexes it sharply. The second leg is assessed in the same way.
There should be no discomfort or pain
What is a positive Homans sign?
If there is pain, the nurse notifies the healthcare provider that the woman has a positive Homans sign
What is an important aspect of preventing thrombophlebitis
Early ambulation
If the mother is unable to get up soon after delivery, what can we do to prevent thrombophlebitis
Sequential compression devices
How do you assess a patient’s emotional status?
Assess amount of rest the patient is getting
Assess if patient emotions are appropriate for the situation
Fatigue can cause what appears to be disinterest in the newborn
Appropriate nursing measures are indicated if the woman is bothered by normal postpartum discomforts such as after pains, diaphoresis, episiotomy, or hemorrhoidal pain
What are some emotional status teachings?
Promote rest and gradual return to activity
Promote adequate nutrition
Encourage new mother to ask for help, before she becomes overwhelmed or exhausted
