University:
West Coast University
Course:
NURS 100 | Fundamentals of Nursing
Academic year:

2020
Views:

442

Pages:

3
Author:

saireerowboz

REEDA - Redness - Edema - Ecchymosis - Discharge - Approximation BUBBLEHEAP B - Breasts - Nipples, engorgement, hard/soft, pain, discomfort - Latch feeding report, self-report FIRST - Physical assessment ONLY if necessary - Time this w/ feeding U - Uterus - Fundus position + Height in reference to umbilicus - At or 1cm above umbilicus shortly after delivery - Should be at or below umbilicus after 24 hours - Firmness - Associated with involution contractions - Should be midline and firm - Ask for voiding history! - Abnormal: - Hemorrhages related to LOW contractions, esp. 1st 24 hours - Uterine inversion - Deviation from midline - Interventions: - Massage the fundus to provoke contraction - LOWER THE BED FLAT TO CHECK FUNDUS - ROLLOVER TO CHECK THE PAD FOR DISCHARGE B - Bladder - Voiding history - Encourage washroom use even w/o urge - Beware of meds used during labour = late voiding expected - Interventions: - Peribottle to help void sensations - Peribottle to help relieve pain - Put hands in warm water or keep water running to promote urge B - Bowel - Hygiene, front to back, thoroughly cleaning of perianal area - Can be painful with lacerations - Abnormal: - - Hemorrhoids - Perineal lacerations Interventions: - Laxatives, anusol for hemorrhoids L- Lochia - Rubra 3-5 days - Reddish transition to brownish - Potential uric acid crystals in both mom and baby (pale pink) - Serosa ~ 5-10 days - Whitish - Alba 10+ days - Yellow-ish white - Abnormal: - Complete pad soaking ~ 1-2 hours - No recurrence/back pedalling of lochia - Lochia diminishes O/T E - Episiotomy - Rare - Assess healing, discharge, bleeding, site, contamination. - Pain! - 2nd degree tear is normal - 3rd + 4th is abnormal and HIGHLY painful - 4th = down to anal sphincter H - Hemorrhoids - Anusol - Ice ~ 24 hours - Sitz bath post 24 hours E - Emotional Assessment A - Ambulation - ASAP, prevents blood clots (thromboembolism) in the legs - DVT risk - Unilateral pain, swelling, heat, and redness P - Perineum - Ice 24 hours, 15 minutes on → 45 minutes off - Warm Heat packs after 24 hours on abdomen for cramps - Warm sitz bath after 24 hours - Especially for 3rd + 4th degree tears General Interventions: - Cramps = hot pack after 24 hours - - Perineum = ice pack + sitz after 24 hours General pain: - Tylenol, NSAIDs, Lidocaine - Stool laxatives - Anusol Showering is fine - Bathing ONLY after a thorough shower to reduce infection risk General Steps of Assessment: 1. Vitals 1st (know normal ranges of the post-partum mom) + Pain (PQRSTU) 2. BUBBLEHEAP 3. REEDA for lacerations/dressings 4. Self-report for breast 5. Self-report for voiding, encourage washroom use, urine history for pain 6. Physical assessment of legs for DVT, ask for ambulation 7. Self-report for locia, check pads (rollover) 8. Assess dressings → do not change unless discharge evident a. Dry, intact, no visible saturation