Bubble Her Assessment

1 BUBBLE-HER Postpartum patients are normally healthy patients; however, complications are possible. Assessment on any patient should be from head to toe; and in postpartum, assessment expands to include focused valuation of specific areas. The following are some guidelines to assist nurses to promote biophysiological and psychological safety of the postpartum patient. BREASTS- Assess the breasts for signs of engorgement, palpating each breast for firmness, tenderness, contour, including fullness especially around postpartum days 3 and 4; assess for hot, red, painful, and edematous areas that could indicate mastitis; assess nipple condition for patients who are breastfeeding (soreness, redness, cracks). UTERUS- Assess the fundus for firmness. The fundus is supposed to remain firm and at the level of the umbilicus by approximately one hour post-delivery. The fundus continues to descend into the pelvis at the rate of approximately 1 cm or finger breadth per day and should be nonpalpable by 10 days postpartum. Encourage patients to void before palpation of the uterine fundus because a full bladder displaces the uterus and can lead to excessive bleeding. In addition, assess the patient for uterine cramping and treat for pain as needed. If the patient had a cesarean section, inspect the dressing or incision at this time and note the site for any redness, discharge, and approximation of the incision if uncovered. BOWEL FUNCTION- Assessment of the bowel is important for all postpartum patients; however, it is vital for patients following a cesarean section. Assess the patient’s bowel sounds (normal, hypo, hyper, absent), return of bowel function- passing of flatus, as well as color and consistency of stool. Encourage ambulation and increase in fluid and juices along with increasing intake of fiber-more fruits and vegetables in diet. BLADDER- Assess for the return of urination, which should occur within 4 to 6 hours of delivery. The amount of urine at each void should be assessed for approximately 8-12 hours after delivery. Urine should be measured the first three voiding for normal vaginal delivery and 24 hours for uncomplicated cesarean section patients to ensure adequate emptying of the bladder. Patients should void a minimum of 150cc per void. Blood volume increased during the second and third trimester, therefore diuresis is expected to take place immediately postpartum to return to pre-pregnancy status. Less than 150cc per void could indicate urine retention due to factors such as decreased bladder tone post-delivery, in the absence of pre-eclampsia or other significant health problems. It is important to assess for signs and symptoms of a urinary tract infection (UTI). The bladder should be non-palpable above the symphysis pubis. Instruct about peri-care and use of the peri-bottle. LOCHIA- When examining the fundus, assess the lochia noting any excessive amount, any large blood clots, or any foul odors emitted from the lochia. Saturating 1 pad in less than an hour, a constant trickle of lochia, or the presence of large blood clots is indicative of a more serious 2 complication (e.g. retained placenta fragments, hemorrhage) and should be investigated closely. If a patient has a significant amount of lochia despite a firm fundus, there may be a laceration in the birth canal that will need to be attended immediately. Furthermore, foul-smelling lochia typically indicates an infection and needs to be addressed immediately. Lochia RUBRA in the first 2-3 days is bright red, similar to menses. This is followed by a serous and watery lochia SEROSA. By day 10 to 14, lochia becomes thin and colorless known as ALBA. EPISIOTOMY/PERINEUM- The acronym REEDA is often used to assess an episiotomy or laceration of the perineum. REEDA stands for redness, edema, ecchymosis, discharge, and approximation. Redness is considered normal with episiotomies and lacerations. However, if there is significant pain present, further assessment is necessary. Excessive edema can delay wound healing and the use of ice packs during the immediate postpartum period is generally indicated. Note for any signs of hematoma especially in the vulvar area which is caused by rapid bleeding into soft tissue causing severe pain often described as pressure. There should be no discharge from the episiotomy or laceration and the wound edges should be well approximated. Perineal pain must be assessed and treated. Nurses should assess the rectal area for hemorrhoids and, if present, instruct the patient in hemorrhoid treatments as ordered (e.g. witch hazel pads, Tucks…) and initiate appropriate comfort measures. HOMAN’s SIGN- Homan’s sign can be obtained by dorsiflexion of the foot. This is not recommended practice, but it is important to assess for any presence of pain in BLE especially when in the calf area upon dorsiflexing, stretching, or ambulating as these may be signs indicative of a deep vein thrombosis (DVT). It is important to note that a DVT may be present despite a negative Homan’s sign or in absence of pain or discomfort and so nurses must monitor patients for other signs of DVT as well. The lower extremities should be assessed for the presence of hot, red, painful, and edematous areas. Assess the legs for adequate circulation by checking the pedal pulses and noting temperature and color. In addition, the lower extremities should be assessed for edema. Pedal edema is normally present for several days after delivery as fluids in the body shift. However, lasting edema should be reported for further assessment. EMOTION- Emotions are an essential element of the postpartum assessment. Patients typically exhibit symptoms of the ‘baby blues’, demonstrated by tearfulness, irritability, and sometimes insomnia. The postpartum blues are caused by a multitude of factors, including hormonal fluctuations, physical exhaustion, and maternal role adjustment that is a normal part of the postpartum experience. However, if these symptoms last longer than a few weeks, if the patient becomes nonfunctional, or if she expresses a desire to harm herself or her infant, you should report it immediately and implement appropriate interventions to protect the patient and infant. The behavior falls under the category of postpartum depression. REFLEXES- Reflexes are important to assess, especially Deep Tendon Reflexes (DTR). Normal DTRs are 1+ and 2+, and hyperactive reflexes are brisk 3+ and 4+ that can be indicative of cerebral irritability suggestive of preeclampsia that will require further assessment. Clonus should also be assessed and can be performed by dorsiflexing the woman’s foot sharply then releasing it while her knee is held in a flexed position. Clonus is positive if there is noted “beats of clonus” or foot pushing against the examiner’s hand (one beat=one push). 3 ***Do not forget to assess pain status regularly and initiate appropriate measures to promote comfort as needed.