NUR 335 EXAM 3
What is the acronym for post partum assessments?
B- breasts
U- uterus
B- bladder
B- bowel
L- lochia
E- episiotomy/lacerations/hemorrhoids
L- lower extremities
E- emotions/bonding/psychosocial
What are abnormal BUBBLEE assessment findings?
- Breasts: mastitis, extreme pain with breastfeeding, cracking or bleeding,
engorgement for more than 2 days
- Uterus: difficult to palpate, boggy, tender/excess contractions, uncentered, at or
above umbilicus, afterpains for more than 3 days (primipara)
- Bladder: bladder palpable/distended, cystitis (urgency/burning), incontinence
more than 6 hours PP
- Bowel: constipation more than 3 days PP, hemorrhoids, n/v
- Lochia: rubra pad saturation within 1 hour, foul odor, placental fragments in lochia
- Episiotomy: bruising, excess edema, discharge, tender, erythema, pain
,- Lower extremities: tender, warm to touch, painful, edema, 2+ or greater DTR
(indicates severe HTN), weak pulses, DVT
- Emotions: bonding issues, fatigue, PPD, thoughts of harming self or others
What are some cardiovascular changes in the PP period? assessment?
- QBL: Vaginal delivery < 500 mL; C-section <1000 mL; both within 24 hours
- DTV: increased risk because of decreased plasma volume and high clotting factors
up to 2 weeks PP
- Orthostatic hypotension: due to decreased vascular resistance in the pelvis and
anemia (Hgb < 11 and Hct < 32%)
- PP chills: feeling cold and shaky for a few hours PP due to vascular instability
Cardiovascular assessment frequency in PP?
- check pulse and BP every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 4
hours for 1 day, then once a shift if there are no complications until discharge
What are some respiratory changes in the PP period?
- increased risk for pulmonary edema due to oxytocin, IV fluids, tocolytics, multiples,
infection, pre-e, and increased bedrest
Respiratory assessment frequency in PP?
, - assess RR and breath sounds every 15 minutes for first hour, every 30 minutes for
second hour, every 4 hours for next 22 hours, and every shift after first day PP
What are some immune system considerations associated with PP?
- mild hyperthermia w/in first 24 hrs PP (anything above 100.4 F or 38 C may indicate
infection)
- Rubella: non-immune moms should receive vaccine before discharge and should
avoid pregnancy for 4 weeks after administration
- Rhogam: given to Rh- moms to prevent antibody production
- Tdap, flu, Hep B, and varicella vaccines should also be given if indicated (avoid preg
for 4 weeks)
What actions are appropriate if the PP mom has an elevated temp?
< 100.4 F= encourage fluids (64 oz./day) and rest
>100.4 F= same as above + notify physician and anticipate antibiotics
What are some common alterations in the urinary system in the PP period?
- transient stress incontinence (up to 6 weeks)
- bladder distention related to IV fluids, decreased sensation, urethral edema,
lacerations, operative vaginal delivery, bladder trauma
- urine output up to 3000 mL/day due to diuresis
What is the acronym for post partum assessments?
B- breasts
U- uterus
B- bladder
B- bowel
L- lochia
E- episiotomy/lacerations/hemorrhoids
L- lower extremities
E- emotions/bonding/psychosocial
What are abnormal BUBBLEE assessment findings?
- Breasts: mastitis, extreme pain with breastfeeding, cracking or bleeding,
engorgement for more than 2 days
- Uterus: difficult to palpate, boggy, tender/excess contractions, uncentered, at or
above umbilicus, afterpains for more than 3 days (primipara)
- Bladder: bladder palpable/distended, cystitis (urgency/burning), incontinence
more than 6 hours PP
- Bowel: constipation more than 3 days PP, hemorrhoids, n/v
- Lochia: rubra pad saturation within 1 hour, foul odor, placental fragments in lochia
- Episiotomy: bruising, excess edema, discharge, tender, erythema, pain
,- Lower extremities: tender, warm to touch, painful, edema, 2+ or greater DTR
(indicates severe HTN), weak pulses, DVT
- Emotions: bonding issues, fatigue, PPD, thoughts of harming self or others
What are some cardiovascular changes in the PP period? assessment?
- QBL: Vaginal delivery < 500 mL; C-section <1000 mL; both within 24 hours
- DTV: increased risk because of decreased plasma volume and high clotting factors
up to 2 weeks PP
- Orthostatic hypotension: due to decreased vascular resistance in the pelvis and
anemia (Hgb < 11 and Hct < 32%)
- PP chills: feeling cold and shaky for a few hours PP due to vascular instability
Cardiovascular assessment frequency in PP?
- check pulse and BP every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 4
hours for 1 day, then once a shift if there are no complications until discharge
What are some respiratory changes in the PP period?
- increased risk for pulmonary edema due to oxytocin, IV fluids, tocolytics, multiples,
infection, pre-e, and increased bedrest
Respiratory assessment frequency in PP?
, - assess RR and breath sounds every 15 minutes for first hour, every 30 minutes for
second hour, every 4 hours for next 22 hours, and every shift after first day PP
What are some immune system considerations associated with PP?
- mild hyperthermia w/in first 24 hrs PP (anything above 100.4 F or 38 C may indicate
infection)
- Rubella: non-immune moms should receive vaccine before discharge and should
avoid pregnancy for 4 weeks after administration
- Rhogam: given to Rh- moms to prevent antibody production
- Tdap, flu, Hep B, and varicella vaccines should also be given if indicated (avoid preg
for 4 weeks)
What actions are appropriate if the PP mom has an elevated temp?
< 100.4 F= encourage fluids (64 oz./day) and rest
>100.4 F= same as above + notify physician and anticipate antibiotics
What are some common alterations in the urinary system in the PP period?
- transient stress incontinence (up to 6 weeks)
- bladder distention related to IV fluids, decreased sensation, urethral edema,
lacerations, operative vaginal delivery, bladder trauma
- urine output up to 3000 mL/day due to diuresis
