“BUBBLEHEB” Breast Uterus Bladder Bowel Lochia Episiotomy
Homan Sign/ Hemorroids Emotional Status/ Edema
Bonding
What’s First? - Empty bladder
o full bladder- as the uterus is pushed up and usually to the right, pressure on it interferes with effective uterine contraction
- Positioning
1. Assess q 15 min x 4; then q 30 min x 2; then q 4hrs first 24 hrs (if stable); then q 8 hrs
a. BP should be WNL for patient b. Pulse: 50-90 bpm
c. Temp: 98-100.4 F (36.6-38 C) OK 1st 24 hrs d. RR: 16-24/min
“Teach as you go”
1. Breast- smooth, even pigmentation, changes of pregnancy still apparent; one may appear larger
a. Assess
i. Bra- a properly fitting bra supports the breast and helps maintain breast shape by limiting stretching of supporting ligaments and connective tissue.
ii. Inspection- (reddened area) assess for mastitis (infection)
iii. Palpation- depending on postpartal day, may be soft, filling, full, or engorged
1. Palbable mass (caked breast, mastitis) 2. Engorgement (venous stasis
3. Tenderness, heat, edema (engorgement, caked breast, mastitis)
a. Assess for other signs of infection, if blocked duct, consider heat, massage, position change for breastfeeding.
iv. Nipples- supple, pigmented, intact, become erect when stimulated v. Discomfort
b. Teach i. BSE
1. Visually inspect the breast, looking for dimpling, lumps, skin irregularities, symmetry, or nipple d/c
2. Visually inspect in several positions, may accentuate an abnormality
a. Hands at the side b. Hands above the head c. Hands pressed onto hips d. Leaning over
3. Feel the breast tissue and lymph node chain for lumps or thickening by using three fingers pads while exerting light, medium, and deep pressure in a systematic fashion.
4. Begin by lying down on a flat surface with arm raised and a folded towel under the back on the side of the breast being examined
5. After examining breast tissue, bring arm toward body and feel the axilla and the skin above as well as below the collarbone
6. Repeat technique on the other breast
7. Report lumps, thickening, nipple d/c, or any suspicious findings to HCP
ii. Engorgement relief
1. Ice packs/analgesics
iii. Milk production and breastfeeding questions 1. Soap should not be used on breast (drying)
2. After feedings, leaving colostrum/breast milk on nipples and expose the breasts to air
3. Nonlactating mothers
a. Breast binder or sports bra b. No nipple stimulation c. Do not express breast milk c. Fundus
i. Support uterus with one hand under, palpate with other hand ii. Assess
iii. Relation to umbilicus
iv. Midline or displaced firmness d. Teach
i. Process of involution
Postpartum Period Level of Fundus Document Immediately after birth At the umbilicus U/U 12 hours after birth 1 FB above umbilicus 1/U 24 hours after birth 1 FB below the umbilicus U/1
Day 2 2 FB below the umbilicus U/2
Day 3 3 FB below the umbilicus U/3
ii. Fundal massage
1. If fundus is not firm, perform fundal massage
a. Support the lower uterine segment during massage to prevent inversion of the uterus
iii. Post partum hemorrhage treatment: fundal massage 1. If fundus is boggy after massage
a. Check bladder status and encourage voiding b. Catheterize if unable to void
c. Notify physician e. Fundus
i. Firm
ii. Boggy- hemorrhage risk
1. If fundus is boggy after massage
a. Check bladder status and encourage voiding b. Catheterize if unable to void
c. Notify physician iii. Midline
1. Measures that promote uterine involution a. Breastfeeding b. Voiding c. Fundal massage d. Medications prn i. Oxytocin ii. Methergine iii. Ergotrate iv. Hemabate
iv. Displaced- ? full bladder, need to assess further v. C-section 1. Be gentle 2. Check incision 3. REEDA 2. Bladder a. Assess
i. Distention- should not be palpable above the symphysis pubis 1. Decreased uretheral sensation from pressure exerted by the
passage of the fetus
2. Side effects of local/epidural anesthesia 3. Delivery trauma of the perineum ii. Uterus boggy or displaced
iii. Palpate bladder iv. Voiding pattern b. Teach
i. Ambulation
ii. Fluids- increase fluid intake iii. UTI s/sx
1. Burning sensation on urination 2. Cloudy urine
3. Strong-smelling urine 3. Lochia
i. Character
ii. Amount- if weighing perineal pads 1 g=1 mL of blood loss iii. Color
1. Lochia rubra (red): day 1-3
2. Lochia serosa (brownish-pink): day 4-9 3. Lochia alba (yellow-white): day 10-14 iv. Odor- determine odor for presence of infection
v. Presence of clots
1. Document number and size of blood clots 2. Turn patient to assess blood loss under buttocks b. Teach
i. Expected changes ii. Onset of menses
iii. Resumption of sexual activity 4. Legs
a. Assess
i. Homan’s sign
1. Assess circulation to lower extremities a. Pedal pulse
b. Color, temperature, blanching ii. Edema, Redness, warmth, tenderness
b. Teach i. Prevention of DVT 1. Encourage ambulation ii. s/sx of DVT 1. pain 2. swelling 3. redness
4. increase skin temperature 5. + Homan’s sign
a. calf pain with dorsiflexion of the foot 5. Episiotomy
a. “REEDA” i. Redness ii. Ecchymosis iii. Erythema
iv. Drainage v. Approximation
Degree Definition
1st Vaginal mucous membrane and
skin of perineum
2nd Subcutaneous tissue of the
perineal body
3rd Involves fibers of the external
rectal sphincter
4th Through rectal sphincter
exposing the lumen of the rectum vi. Presence of hemorrhoids
vii. Effectiveness of comfort measure
1. No enemas or rectal suppositories with 3rd and 4th degree laceration
2. Assess for presence of hematoma b. Teach
i. General info re: episiotomy ii. Care of site
iii. s/s to report 6. Emotions
a. Assess
i. Attitude
1. Eye contact with infant 2. Talks with infant 3. Holds infant close 4. Feeds infant ii. Feelings of competence iii. Support system
iv. Fatigue level
v. Ability to accomplish task b. Teach
i. Effects of hormonal changes 1. Postpartum blues
a. Common occurrence in the immediate postpartum period
b. Period vacillating emotions
c. Related to physiological changes after birth, intensified with sleep deprivation/postpartum or newborn complications
d. Resolves by 2 weeks postpartum ii. Importance of rest
iii. Available resources c. Assessment of Early Attachment
ii. Nursing behavior iii. Consistency iv. Sensitivity
v. Enjoyment vi. Cultural factors
Assessment of Neonates
Head
Assessment
Norms
Hair: color, amount Distributed over top of head Circumference 32 cm - 35 cm
Sutures and Fontanels Sutures may override, called molding, lasting 5-7 days. May bulge when infant is crying or coughing. Depressed fontanels indicates dehydration. Anterior - diamond-shaped, at front and top of head; may notice it pulsate; closes between 12 and 18 months. Posterior - is triangle-shaped, at top and to the back of the head; closes at birth or within 2 months.
Shape May be asymmetrical due to molding, this should disappear in 57 days. May have edema formation (caput succedaneum -not bound by suture lines) or bleeding into subperiosteum (cephalhematoma - not crossing suture lines).
Mouth / lips/ gums Mouth should be round, symmetrical. Hard palate should be intact with high arch. Epstein's pearls are common (small, white, epithelial cysts along sides of midline of hard palate) and will disappear in a few weeks.
Face Face may be asymmetrical due to soft tissue damage and swelling during birth process.
Milia - pin-head sized white spots (clogged oil glands) over the nose, chin, or cheeks. These are normal and disappear within a few weeks without treatment. Should not be picked or squeezed.
Palate Visualize the uvula and pharynx when the infant is crying. Tonsils are not visible in the newborn. Check for extrusion, sucking and rooting reflexes. See section on normal reflexes. Eyes: color, pupil
reaction, discharge Eyes may bereaction to medication routinely used in infant's eyes upon
swollen and red from trauma of
birth or from admission. Tears my not be present for several weeks or even 3-4 months. Eyes will be dark blue at birth, and will become their permanent color at 3 months of age. Color changes may not be complete for one year. Check for red reflex; blink, corneal and pupil reflexes. Nystagmus is a common finding.
Ears: size, placement, hearing, symmetry, amount of cartilage
Top of ears should be level with outer canthus of eye. Ear cartilage should be formed so
that ear holds
shape. Audiology screening Nose: shape, placement,
patency Nose should be midline, symmetrical.flaring. Nose may need to be suctioned with bulb syringe to
Check for nasal maintain patency. Infants are obligate nose breathers - they cannot breathe through their mouths at birth. It is common for neonates to sneeze frequently. Thin white mucus is common.
Chest
Assessment
Norms
Circumference 30 - 35 cms, 12.5-13.5". Chest is almost circular. Slight intercostal retractions are normal.
Clavicles Check for bumps, clavicle may have been broken during birth. Should be smooth.
Breast Tissue Breast of the
newborn of both sexes may be swollen the first few days due to high level of maternal hormones. They may also excrete a whitish fluid that looks like milk (witch's milk). These are both normal and will disappear without treatment by 4-6 weeks of age. Breasts of infants should never be squeezed.
Integument
Assessment
Norms
Color, consistency, hydrationNewborn is usually bright red with puffy skin. By the second to third day the skin should be pink, dry and flaky. Normal color changes:
•
Acrocyanosis - blueness of hands and feet•
Mottling - transient when infant exposed to cold•
Jaundice - yellow skin due to increased breakdown ofred blood cells
•
"Newborn rash" - eruptions that appear 'hive-like' and may appear and disappear at intervals during the first few days of life.•
MiliaBirthmarks
•
Mongolian spots•
Stork bites - telangiectatic nevi - flat, deep pink areas seen on the upper eyelids, between the eyebrows,on the upper lip, or at the nape of the neck. These eventually fade and disappear between 1 and 2 years of age.
Vernix, lanugo Vernix caseosa. Lanugo
Vital Signs
Assessment
Norms
Apgar Apgar
Temperature (axillary) 97.5 to 99 Heart rate and rhythm
murmurs
120 - 160 Blood Pressure only taken with signs of illness. Blood pressure based upon age
Heart rate based upon age
Pulses apical femoral Strong & equal bilaterally. Perfusion, capillary refill Refill less than 3 seconds Lungs
rate and
rhythm, breath sounds, effort
Normal rate is 30-60 breaths per minute. Periods of apnea less than 15 seconds is normal.
Abdomen
Assessment
Norms
Bowel sounds 2-4 per minute
Size, Contour Usually rounded with prominent veins. If scaphoid, suspect a diaphragmatic hernia. Liver is usually palpable 2-3 cm below costal margin.
Vessels (abdominal)
Condition of cord
Number of vessels
Will fall off in approximately 7-14 days. There may be brownish- colored drainage after the cord falls off. Cord should be cleansed with alcohol and cotton balls until area is completely healed and drainage has ceased. There should be 3 vessels present in the cord.
Genitalia
Assessment
Norms
Male: testes, scrotum , penisScrotum may appear swollen at birth due to maternal hormones. Check that both testes are descended.
labia, clitoris, vagina, discha rge
that protects the area.
•
Pseudo-menstruation - pinkish-red discharge from the vagina, caused by the withdrawal of maternal hormones.•
Labia - may be swollen and red due to high level of maternal hormones.Extremities
Assessment
Norms
Arms/Hands Acrocyanosis Number of Fingers Range of Motion Palmar CreasesShould have 10 fingers. Look for polydactyly and syndactyly. Nail beds should be pink. Slight blueness is common when extremities are cold. Legs/Feet Sole Creases
Color Number of Toes
Range of Motion Hip Dysplasia Major Gluteal Folds
Should have 10 toes. Sole usually flat with creases on anterior 2/3 of foot. Symmetry of legs with equal muscle tone and resistance to opposing flexion. Extremities usually have
flexion. Ortolani's sign for hip dislocation
Back/Spine
Assessment
Norms
Spinal Column Spine intact, no openings, masses or prominent curves. Spine usually rounded with none of curves seen later in life.
Trunk incurvation reflex present - stroke back along one side of the vertebral column will cause the infant to move hips toward the stimulated side.
Posture/Muscle Tone
Assessment
Norms
Awake General appearance Asleep Neuromuscular
Reflexes
Assessment
Norms
Rooting/Sucking When cheek stroked child turns head toward side touched. Strongest during first 2 months. Disappears at 3-4 months.
clenched. Should disappear by 4 months. Grasp Palmar
Plantar
Infant will grasp anything placed in hand. Touching sole of foot will cause grasping motion of toes. Should disappear by 3 months. Palmar grasp reflex will gradually become voluntary.
Tonic Neck When head is quickly turned to one side, arm and leg will extend on that side. Opposite arm and leg will flex. Should disappear by 3-4 months. Pull-to-Sit Head lag common until 3-4 months.
Babinski's Great toe flares and other toes spread when outer edge of sole is stroked. Should disappear about 12 months.
Trunk Incurvature When back is stroked beside spinal column, the infant will move hips toward side stimulated.
Stepping Infant held so sole touches surface, flexion and extension of leg resembling walking. Should disappear by 3-4 weeks.
Extrusion When object is placed in mouth, the infant will push it out with tongue. Scarf sign With the infant supine, take the infant's hand and draw it across the neck
and as far across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it across the body. Infant should resist elbow movement past midline of body.
Urine
Assessme
nt
Norms
Color, Number of voidingsShould void within 24 hours. With adequate hydration should have 6-10 diapers per day. Urine is straw color and odorless. Dark yellow urine indicates dehydration.
Stools
Assessme
nt
Norms
Color, Type Meconium is passed 8-24 hours
.
After the infant begins eating transitional stools are passes - less sticky and brownish yellow. By the fourth day a milk stool should be passed - breast fed infants have pasty yellow to golden stools with an odor similar to sour milk. Bottle fed infants have pale yellow to light brown stools, firmer consistency and stronger odor.Placement of Anus
Midline. Patency of
Anus
Patent anal opening. Passing of meconium stool indicates patent anus
