Postpartum head to toe Assessment/ Bubble He

1. Wash hand to prevents possible infection from one care provider to the client. . Provide patient privacy. To
gain patient’s respect and trust. Verify patient using 2 identifiers (name & date of birth). To properly identify
the patient.
2. Wear gloves. To prevent the spread of infection.
3. Good day Mrs. Johnson. I’m Ice. I’ll be your nurse for today. How are you feeling? I’m gonna do a
postpartum head-to-toe assessment on you.
4. First thing to check out is the breast. We are gonna ask the mom do you rest view and the patient could
say a variety of different things like heavy because it’s full of milk or normal. With that information, we can
now assess the breast. So here it’s normal for one breast to be slightly larger than the other one. Also, in
nipples. It’s normal to have different sizes of nipples on each breast.
5. So here, we are looking at the skin. Condition of the skin in the breast. For example, does she have stretch
marks, an orange peel appearance, or appears like smooth the condition.
6. Using the back of our (nurse’s) hand to determine if it is cool, warm, and hot when touch). We are gonna
take note of the temperature of the nipple.
7. After that, we are going to access the nipple. We will have 3 dimensions.
- Everted-nipples out or sticking out
- Inverted- concave and going in
- Flat-unable to become like everted. Whatever type, it is normal and not a barrier to breastfeeding. For
assessing the ariola. We are also looking here at the bruising, suck marks, cracks, and bleeding in nipples
signs of no-good latch. If that the case, what you are gonna tell her is next time you put baby to breast put on
your call light and let me know so I can help you because we don’t want it too hurts breastfeeding.
8. For the assessment of the uterus, position the mother perfectly flat for her safety. Also, to provide
comfort and the right assessment. Then if she is still pregnant she would be at risk for the supine
hypotensive syndrome. Expose the abdomen to detect the location of the fundus. We are going to use 2 hands
for a fundal check (1 hand supports the bottom of the uterus and the other hand actually feeling the fundus).
So the good way to describe a fundus is the firm, firm with massage or boggy. The fundus is firm:
- -when the mother is thin in appearance- the fundus is hard(like-rock hard) which is normal
- -most women- fundus is firm(like-tennis ball)- squishy bouncing back, squishy but can be located
- firm with massage- massage a little bit and it starts to firm up and get hard that's good that's firm, which is
normal
- Fundus is boggy:
- -the boggy uterus is not good which is squishy but when massage failure to be firmed which is a sign of
possible hemorrhage
- Also, consider some post-CS mothers with their pain in the incision site
- - position of the fundus: left or right or even above the belly button
- -to detect possible conditions: hemorrhage, blood clots or full bladder
9. In the assessment of the bladder, we should ask the patient the last time when the mother went to the
CR to void and remind the mother to try to empty the bladder every 2-3 hours with or without assistance
(depending upon the patient’s capability). So the benefits of this is gonna bleed less, heal faster and be less
pain for her. Also, it is important to empty the bladder in order to prevent urinary retention, bladder
distention resulting in postpartum hemorrhage, for faster healing and less painful situation.
-instruct the patient proper perennial care/or perform perennial care to the patient. After emptying the
bladder, do re-check the fundal height. To recheck/ inspect if there is no displacement of the fundus.
10. For the assessment of bowels, we are going to a stethoscope for listening. ( 1 each side)
-there's no reason why a postpartum woman who delivered a normal vaginal delivery would not have bowel
sounds, instead, they will have active bowel sound
-spinal anesthesia does not have an impact on the bowels and epidural anesthesia;
-if mom had a C-section and was under general anesthesia may have hypoactive or absent bowel sounds in a
short period of time
Next, ask the patient when was the last time she had anything to eat or drink and encourage her to eat. most
of the postpartum women they've been NPO for a really long time and they don't realize that after the baby is
born, they're allowed to eat so they can eat food anything they want (but depending if they have some food
restrictions like comorbid or food allergies) because they need calories and energy especially if they will be
breastfeeding.
11. For the assessment of lochia, adjust the head part of the bed slightly or place one pillow on the head
part of the patient. To prevent patients from staying long in a flat position. Now, we are going to check the
lochia and emphasized to the patient about taking note of the presence and size of blood clot import
- important to inform the nurse about the bleeding
Discuss the rubra, serosa, and alba. Rubra. first discharge, Composed of blood, shreds of fetal membranes.
This is kind of red blood. serosa -is the darker brown color which is like old blood appearance. Alba- yellow
or whitish blood.
- ask when was the last time she changes this pad. Because if its 20 mins ago it’s a lot of blood and it’s an
emergency. Change the peri pad every 2-3 hours after perennial care has been done even there is not
alot of blood in pad we need to change it. To provide comfort and prevent UTI.
12. Assessment of the episiotomy. Check the perineum if there is first, second, third or fourth laceration
-Some women do not anymore give an episiotomy
-Noting the degree of laceration
b. Assess the degree of laceration of the perineum by using the REEDA Scale (Episiotomy healing
assessment):
R-Redness-noting any redness at the episiotomy site
E-Ecchymosis-bruising
E-Edema- swelling
D- Discharge/Drainage-absence of discharge normal
A-Approximation-there should be no opening in the sutures done (normal)
some slight redness, some slight edema, and slight bruising from a laceration to the Episiotomy site- normal
-not slight, over and beyond it is not normal
-presence of discharge and drainage (pus) in the episiotomy site is not normal and a sign of infection
- gaps or any active bleeding in that area
-space in between the episiotomy (suture) done -not approximated- not normal
. Emphasized that sutures in episiotomy do not need to be removed because they are dissolvable and don’t
need to make a separate doctor’s appointment to get the sutures removed. Some patients may ask about
suture removal.
-Proper information regarding sutures.
13. Assessment of the Homans sign. Check for Deep Vein Thrombosis. Pregnancy, delivery and
postpartum is a hypercoagulable state which makes the postpartum mother at high risk for a DVT to make
sure she don’t have it. Expose the mother’s legs. To relax the leg. Inform the patient not to do that and just
relax their legs because the nurse will be holding it in his/her hand. Then we gonna sharply dorsiflex. Then
ask the patient if she feels pain and tenderness. Do forget to support her back knee with your hand. Presence
of pain or tenderness in the calf-positive Homan’s sign and there is the presence of deep vein thrombosis
-Absence of pain or tenderness in the calf-negative Homan’s sign