Postpartum Assessment Flashcards
(48 cards)
What does BUBBLE TEA stand for?
B → Breast Assessment
U → Uterus Assessment
B → Bladder Assessment
B → Bowel Function Assessment
L → Lochia (Postpartum Vaginal Discharge)
E → Episiotomy
T → Thromboembolism Check
E & A → Emotional Adaptation
List the expected findings of breasts during the postpartum assessment (5)
- Soft
- Non-tender
- Intact skin on nipples
- Nipples everted
- Absence of lumps or swelling
When is milk produced?
typically produced by days 3-5, before that, colostrum
*keep this in mind during postpartum assessment of breasts**
What are potential problems found during postpartum assessment of breasts? (3)
- cracked nipples
- inverted nipples
- engorgement
what causes cracked nipples postpartum?
improper latch
how does inverted nipples present? what might be needed?
nipples retract into skin and it is very hard for babies to latch
may require nipple shield
how does engorgement present?
the breasts are red, swollen, warm and very painful
palpation will reveal tenderness
What is the purpose of the uterine postpartum assessment?
the uterus must contract to stop postpartum bleeding
How is the fundal check performed? What should it feel like?
One hand supports symphysis pubis, the other palpates the fundus
It should feel like a firm melon
a firm fundus controls what?
bleeding
Where should the fundus be on the day of delivery? How much does it shrink after the day of delivery? When should it no longer be palpable?
at the level of the umbilicus
It shrinks ~1 cm (or fingerbreadth) per day after delivery
By day 10, it should no longer be palpable.
What does it mean if the fundus is not going down a finger per day?
subinvolution is occurring and there is a risk for hemorrhage/bleeding
What is an abnormal finding during the uterine postpartum assessment?
boggy uterus → soft, non-contracted uterus
How can the bladder cause a boggy uterus?
a full bladder can displace the uterus upward and to the right, making it boggy, and increases the risk for hemorrhage
Post-delivery, the bladder can lose ___
tone
There is increased diuresis after delivery. What does this mean?
there is an excessive amount of urine production by the kidneys
What urinary infection are postpartum women at risk for?
Urinary tract infections
What interventions should the nurse make during the bladder assessment? (3)
- ask her when she last voided
- encourage her to empty bladder
- if ineffective, perform a straight catherization
how can the nurse encourage the postpartum woman to empty her bladder? (3)
- use running water
- pour warm water on perineum
- encourage forward leaning to help void
What makes the postpartum woman at risk for urinary retention? (3)
- Bladder → tone decreased
- Periurethral trauma (tearing downward)
- Pitocin can cause urinary retention
Regarding bowel function post-delivery, there is decreased peristalsis due to what?
elevated progesterone
What meds can constipate the bowel? (3)
- continuance of prenatal vitamins postpartum
- iron
- opioid pain meds
Why are C-section patients especially at risk for constipation postpartum?
due to surgery and anesthesia slowing down bowel function
*It is not uncommon for mom to have absent bowel sounds after surgery and anesthesia as they slow peristalsis
How is postpartum constipation managed? (4)
Fluids
Ambulation
Fiber
Stool softeners & laxatives as prescribed
