Bubbleher PDF

Preview

Summary

Maternal...

Description

8-POINT POSTPARTUM ASSESSMENT (BUBBLEHER) Before beginning the postpartum assessment, check vital signs and have the new mother empty her bladder and lie in a supine position on a flat bed. Explain each procedure to the patient and inform her of your findings. B

Breasts – Gently palpate each breast. Note the contour, color, and temperature. Are the breasts full, firm, tender, or shiny? Are the veins distended? Is the skin warm? Does the patient complain of sore nipples? Has she requested pain medicine for breast or nipple pain? Take this opportunity to explain the process of milk production and offer information about relieving breast engorgement (this advice will vary depending upon her method of infant feeding – breast or bottle). Teaching about self breast exam can also be done at this time.

U

Uterus – Palpate the fundus of the uterus. It should be firm and should decrease approximately one fingerbreadth below the umbilicus each day. Have the patient feel her own uterus as you explain the process of involution. If the uterus is not involuting properly, check for signs of infection, fibroids, or lack of tone. Unsatisfactory involution may also result from retained placental fragments or a bladder that is not emptying completely.

B

Bladder – Inspect and palpate the bladder simultaneously while checking the height and firmness of the uterine fundus. Bladder distention should not be present after recent emptying. If the bladder is found to be distended, catheterization may be necessary to prevent bladder damage and infection. Voidings following delivery should measure at least 150 cc per voiding. Frequent small voidings, with or without pain or burning, may indicate infection or retention. If voidings are frequent and large, explain the process of diuresis to the woman. Instruct the woman regarding proper perineal care. Explain the importance of wiping front to back after voiding and defecating. This helps prevent urinary tract infection and is a hygienic principle that pertains to females of all ages.

B

Bowel Function – Question the patient about daily bowel movements. Encourage her to drink extra fluids and eat plenty of fruits and vegetables to prevent constipation. A mild stool softener or laxative may be necessary.

L

Lochia – Assess the amount and type of lochia on the perineal pad in relation to the number of postpartum days. For the first three days, the lochia will be bright red, similar to menstrual flow and should not saturate a pad in less than an hour.

Notify the primary care provider if the lochia looks abnormal in color or amount, if it has an unusual odor, or if large clots are present. Instruct the mother about the changes she will see in the lochia and when to expect it to cease. This may also be a good opportunity to discuss when it is safe to resume sexual relations and her family planning needs. E

Episiotomy – Ask the patient to turn to her side and flex the upper knee to expose the perineal area. Inspect the suture line for evidence of healing, inflammation, swelling, bruising, tight shiny skin, infection, or suture sloughing. Is the surrounding skin warm to the touch? Does the patient complain of excessive discomfort? At the same time, check the rectal area for hemorrhoids. Answer any questions the patient may have about her “stitches.”

H

Homan’s Sign – (Note agency policy regarding the assessment of Homan’s Sign). Press down gently on the patient’s knee (with her legs extended flat on bed) and push up on the bottom of her foot. Pain or tenderness in the calf is a positive Homan’s Sign and is indicative of thrombophlebitis. This finding should be reported to the primary care provider.

E

Emotional status – Throughout the physical assessment, be alert to cues about the mother’s emotional well-being. Does she appear dependent or independent? Is she elated or despondent? What does she say about family support? Are there any nonverbal clues? Explain to the patient and her family that she may cry easily for awhile and that her emotions may suddenly shift from high to low. These changes are normal and are probably caused by hormone changes and realization of the increased responsibilities that accompany the birth of a child. Help the family differentiate between postpartum blues, depression, and psychosis.

R

RhoGam & Rubella Status What is the Rh status of the mother and the newborn? RhoGam is given to mothers who are Rh negative who have given birth to Rh positive newborns. The direct Coombs of the newborn needs to be “negative” and the indirect Coombs of mother needs to be “negative” indicating that no maternal antibodies have been produced. If the Coombs tests are negative, the mother is Rh negative and the newborn is Rh positive, the mother is then a candidate for Rhogam. This needs to be administered in the first 72 hours after birth (the sooner, the better). Also refers to Rubella status (immune or non-immune)...