BUBBLE HE Assessment Flashcards
Breasts Normal Assessment
Soft
Start to fill up and 3-5 days it are full
Nipple are intact and not sore
Breasts Potential Complication
Firm, painful, warm/hot to touch or shiny (engorgement)
Nipples are cracked, bleeding, blisters present (difficultly with breastfeeding)
Uterus Normal Assessment
Fundus should be midline, firm, and at the umbilicus during the 1st 24 hrs
Uterus Potential Complication
Deviation of the fundus to the right or left (bladder distention)
Soft or boggy (uterine atony)
Bowel Normal Assessment
Abdomen soft and BS x4 quads
When should the mother has a bowel movemeent
2-3 PP
Bowel Potential Complication
No BM after 3 days (constipation), diarrhea, CS incision not approximated, bleeding, oozing, warm/hot to touch (infection)
Bladder Normal Assessment
No bladder distention, voiding w/o difficulty
Bladder Potential complication
Bladder distension, painful urination, urgency or frequency
Lochia Normal Assessment
Rubra day 1-3
Serosa 3-10
Alba 10+
Scant to moderate
Fleshy odor
few small clots
Lochia Potential Complications
Large clots, saturating pad/hr (uterine atony from bladder distension), heavy bleeding w/ firm fundus (laceration or tear that need to be repaired, foul odor (infetion)
Episiotomy/Laceration Normal Assessment
Minimal edema notes
Epis/lac edges approximated
Discomfort/pain managed w/ pain meds or soaking in tub, peri-products
Episiotomy/Laceration Potential Complication
Several perineal edema, bruising, hematoma, redness/warm/drainage (infection) pain is getting worse
Pain not controlled
Who do the first dressing of the incision (Cesearen section)
MD
Heaviness/Hemorrhoids Normal Assessment
Negative
DTR (1+ to 2+)
No hemorrhoids (present; soft and pink)
