Families Exam 2
BUBBLEHEB assessment *** 1. Breast: look for any abnormalities or skin breakdown/cracked nipples
(mastitis)
2. Uterus: check fundal height, uterine placement, consistency
3. Bowel: GI function - check bowel sounds & movements
4. Bladder: make sure they can void, especially if they had an epidural
5. Lochia: COCA (color, odor, consistency & amount)
6. Episiotomy: REEDA (redness, edema, ecchymosis, D/C & drainage, & approximation) healing
evaluation
7. Hemorrhoids
8. Emotional status: PP blues, depression, psychosis
9. Bonding: are they bonding with baby?
BUBBLEHEB nursing care *** Breasts
Breast-feeding:
- Well fitted bra
- Allow infant to nurse on demand (8-12 times a day)
- Sore nipples: Breastmilk or lanolin (don't use if allergic to wool)
- Non-breastfeeding: bra continuously for 72 hrs, cold cabbage leaves inside bra, cold compress 15 min
on 45 min off
Uterus
- Assess fundal height, placement & consistency (tone) Q8: fundus should be firm and in the
midline/center (+1/U is normal)
- 12 hrs postpartum: will be back at the umbilicus, day 10 no longer palpated
Bowel
- if constipation occurs admin. stool softeners (docusate sodium!!!)
- Early ambulation/increased fluids/high fiber
,- Hemorrhoids are normal: can give meds &/or comfort measures
Bladder
- Retention from loss of bladder elastictiy/anesthesia/trauma can cause uterine atony & displacement to
one side leading to PPH
- Should void every 2-3 hr to prevent displacement of uterus & atony
- Measure urine output; excessive voiding ( >3,000 mL/day) is normal
BUBBLEHEB nursing care continued *** Lochia (should follow in this order)
Rubra (2-3 days)
- Dark red, fleshy odor
- Small clots ok
- Increase with breastfeeding & ambulation
Serosa (4-10 days)
- Pinkish brown
- Serosanguineous
- Small clots ok
Alba (10-28 days)
- Whitish yellow, fleshy odor
- May contain mucus
Episiotomy/laceration/hematoma
- Peri ice pack 24hrs for edema, heat therapy, sitz baths (20 min day) (increase circulation)
- Pain meds as needed, hemorrhoidal cream, stool softeners
- Benzocaine spray, witch hazel
- Peri bottle & pat dry only (warm water/antiseptic to clean peri area)
Emotional status
- PP blues are normal
, Bonding
- Rooming in & skin-skin, on chest, immediately after birth
BUBBLEHEB interventions for abnormal findings *** Breasts
- Engorgement(too much milk in breast): warm shower/compress before feeding to promote letdown &
cold compress after feeding
Uterus
- If midline or displaced L/R = have them use the rr & reassess
- Boggy(bleeding): massage until FIRM
Bladder (distended)
- Fundal height above the umbilicus or baseline level
- Fundus displaced from midline (L/R)
- Bladder bulges above pubic symphysis
- Tenderness over bladder area
- Voiding < 150 mL = retention with overflow
Lochia
- Saturating pad in 15 min or less = postpartum hemorrhage
- Foul odor = infection
- Persistent heavy lochia beyond day 3 = retained placental fragments
Episiotomy/laceration
- Vaginal bleeding even with a firm uterus: continuous bleeding
- Continuous trickle of bright red blood
Hematoma
- Pain (not bleeding)
- Pressure in rectum or vagina
- Difficulty voiding
BUBBLEHEB assessment *** 1. Breast: look for any abnormalities or skin breakdown/cracked nipples
(mastitis)
2. Uterus: check fundal height, uterine placement, consistency
3. Bowel: GI function - check bowel sounds & movements
4. Bladder: make sure they can void, especially if they had an epidural
5. Lochia: COCA (color, odor, consistency & amount)
6. Episiotomy: REEDA (redness, edema, ecchymosis, D/C & drainage, & approximation) healing
evaluation
7. Hemorrhoids
8. Emotional status: PP blues, depression, psychosis
9. Bonding: are they bonding with baby?
BUBBLEHEB nursing care *** Breasts
Breast-feeding:
- Well fitted bra
- Allow infant to nurse on demand (8-12 times a day)
- Sore nipples: Breastmilk or lanolin (don't use if allergic to wool)
- Non-breastfeeding: bra continuously for 72 hrs, cold cabbage leaves inside bra, cold compress 15 min
on 45 min off
Uterus
- Assess fundal height, placement & consistency (tone) Q8: fundus should be firm and in the
midline/center (+1/U is normal)
- 12 hrs postpartum: will be back at the umbilicus, day 10 no longer palpated
Bowel
- if constipation occurs admin. stool softeners (docusate sodium!!!)
- Early ambulation/increased fluids/high fiber
,- Hemorrhoids are normal: can give meds &/or comfort measures
Bladder
- Retention from loss of bladder elastictiy/anesthesia/trauma can cause uterine atony & displacement to
one side leading to PPH
- Should void every 2-3 hr to prevent displacement of uterus & atony
- Measure urine output; excessive voiding ( >3,000 mL/day) is normal
BUBBLEHEB nursing care continued *** Lochia (should follow in this order)
Rubra (2-3 days)
- Dark red, fleshy odor
- Small clots ok
- Increase with breastfeeding & ambulation
Serosa (4-10 days)
- Pinkish brown
- Serosanguineous
- Small clots ok
Alba (10-28 days)
- Whitish yellow, fleshy odor
- May contain mucus
Episiotomy/laceration/hematoma
- Peri ice pack 24hrs for edema, heat therapy, sitz baths (20 min day) (increase circulation)
- Pain meds as needed, hemorrhoidal cream, stool softeners
- Benzocaine spray, witch hazel
- Peri bottle & pat dry only (warm water/antiseptic to clean peri area)
Emotional status
- PP blues are normal
, Bonding
- Rooming in & skin-skin, on chest, immediately after birth
BUBBLEHEB interventions for abnormal findings *** Breasts
- Engorgement(too much milk in breast): warm shower/compress before feeding to promote letdown &
cold compress after feeding
Uterus
- If midline or displaced L/R = have them use the rr & reassess
- Boggy(bleeding): massage until FIRM
Bladder (distended)
- Fundal height above the umbilicus or baseline level
- Fundus displaced from midline (L/R)
- Bladder bulges above pubic symphysis
- Tenderness over bladder area
- Voiding < 150 mL = retention with overflow
Lochia
- Saturating pad in 15 min or less = postpartum hemorrhage
- Foul odor = infection
- Persistent heavy lochia beyond day 3 = retained placental fragments
Episiotomy/laceration
- Vaginal bleeding even with a firm uterus: continuous bleeding
- Continuous trickle of bright red blood
Hematoma
- Pain (not bleeding)
- Pressure in rectum or vagina
- Difficulty voiding
