August 19, 2017 | Author: Jeffrey Viernes | Category: Blood Pressure, Infants, Anatomical Terms Of Motion, Breast, Human Anatomy
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“BUBBLEHEB” Breast Uterus Bladder Bowel Lochia Episiotomy Homan Sign/ Hemorroids Emotional Status/ Edema Bonding What’s First? - Empty bladder o full bladder- as the uterus is pushed up and usually to the right, pressure on it interferes with effective uterine contraction - Positioning 1. Assess q 15 min x 4; then q 30 min x 2; then q 4hrs first 24 hrs (if stable); then q 8 hrs a. BP should be WNL for patient b. Pulse: 50-90 bpm c. Temp: 98-100.4 F (36.6-38 C) OK 1st 24 hrs d. RR: 16-24/min “Teach as you go” 1. Breast- smooth, even pigmentation, changes of pregnancy still apparent; one may appear larger a. Assess i. Bra- a properly fitting bra supports the breast and helps maintain breast shape by limiting stretching of supporting ligaments and connective tissue. ii. Inspection- (reddened area) assess for mastitis (infection) iii. Palpation- depending on postpartal day, may be soft, filling, full, or engorged 1. Palbable mass (caked breast, mastitis) 2. Engorgement (venous stasis 3. Tenderness, heat, edema (engorgement, caked breast, mastitis) a. Assess for other signs of infection, if blocked duct, consider heat, massage, position change for breastfeeding. iv. Nipples- supple, pigmented, intact, become erect when stimulated v. Discomfort b. Teach i. BSE

1. Visually inspect the breast, looking for dimpling, lumps, skin irregularities, symmetry, or nipple d/c 2. Visually inspect in several positions, may accentuate an abnormality a. Hands at the side b. Hands above the head c. Hands pressed onto hips d. Leaning over 3. Feel the breast tissue and lymph node chain for lumps or thickening by using three fingers pads while exerting light, medium, and deep pressure in a systematic fashion. 4. Begin by lying down on a flat surface with arm raised and a folded towel under the back on the side of the breast being examined 5. After examining breast tissue, bring arm toward body and feel the axilla and the skin above as well as below the collarbone 6. Repeat technique on the other breast 7. Report lumps, thickening, nipple d/c, or any suspicious findings to HCP

ii. Engorgement relief 1. Ice packs/analgesics iii. Milk production and breastfeeding questions 1. Soap should not be used on breast (drying)

2. After feedings, leaving colostrum/breast milk on nipples and expose the breasts to air 3. Nonlactating mothers a. Breast binder or sports bra b. No nipple stimulation c. Do not express breast milk c. Fundus i. Support uterus with one hand under, palpate with other hand ii. Assess iii. Relation to umbilicus iv. Midline or displaced firmness d. Teach i. Process of involution Postpartum Period Level of Fundus Document Immediately after birth At the umbilicus U/U 12 hours after birth 1 FB above umbilicus 1/U 24 hours after birth 1 FB below the umbilicus U/1 Day 2 2 FB below the umbilicus U/2 Day 3 3 FB below the umbilicus U/3

ii. Fundal massage 1. If fundus is not firm, perform fundal massage a. Support the lower uterine segment during massage to prevent inversion of the uterus

iii. Post partum hemorrhage treatment: fundal massage 1. If fundus is boggy after massage a. Check bladder status and encourage voiding b. Catheterize if unable to void c. Notify physician e. Fundus i. Firm ii. Boggy- hemorrhage risk 1. If fundus is boggy after massage a. Check bladder status and encourage voiding b. Catheterize if unable to void c. Notify physician iii. Midline 1. Measures that promote uterine involution a. Breastfeeding b. Voiding c. Fundal massage d. Medications prn i. Oxytocin ii. Methergine iii. Ergotrate iv. Hemabate iv. Displaced- ? full bladder, need to assess further v. C-section 1. Be gentle 2. Check incision 3. REEDA 2. Bladder a. Assess i. Distention- should not be palpable above the symphysis pubis 1. Decreased uretheral sensation from pressure exerted by the passage of the fetus 2. Side effects of local/epidural anesthesia 3. Delivery trauma of the perineum ii. Uterus boggy or displaced iii. Palpate bladder iv. Voiding pattern b. Teach i. Ambulation ii. Fluids- increase fluid intake iii. UTI s/sx 1. Burning sensation on urination 2. Cloudy urine 3. Strong-smelling urine 3. Lochia a. Assess

i. Character

ii. Amount- if weighing perineal pads 1 g=1 mL of blood loss iii. Color 1. Lochia rubra (red): day 1-3 2. Lochia serosa (brownish-pink): day 4-9 3. Lochia alba (yellow-white): day 10-14 iv. Odor- determine odor for presence of infection v. Presence of clots 1. Document number and size of blood clots 2. Turn patient to assess blood loss under buttocks b. Teach i. Expected changes ii. Onset of menses iii. Resumption of sexual activity 4. Legs a. Assess i. Homan’s sign 1. Assess circulation to lower extremities a. Pedal pulse b. Color, temperature, blanching ii. Edema, Redness, warmth, tenderness b. Teach i. Prevention of DVT 1. Encourage ambulation ii. s/sx of DVT 1. pain 2. swelling 3. redness 4. increase skin temperature 5. + Homan’s sign a. calf pain with dorsiflexion of the foot 5. Episiotomy a. “REEDA” i. Redness ii. Ecchymosis iii. Erythema

iv. Drainage v. Approximation Degree 1st 2nd 3rd 4th

Definition Vaginal mucous membrane and skin of perineum Subcutaneous tissue of the perineal body Involves fibers of the external rectal sphincter Through rectal sphincter exposing the lumen of the rectum

vi. Presence of hemorrhoids vii. Effectiveness of comfort measure 1. No enemas or rectal suppositories with 3rd and 4th degree laceration 2. Assess for presence of hematoma b. Teach i. General info re: episiotomy ii. Care of site iii. s/s to report 6. Emotions a. Assess i. Attitude 1. Eye contact with infant 2. Talks with infant 3. Holds infant close 4. Feeds infant ii. Feelings of competence iii. Support system iv. Fatigue level v. Ability to accomplish task b. Teach i. Effects of hormonal changes 1. Postpartum blues a. Common occurrence in the immediate postpartum period b. Period vacillating emotions c. Related to physiological changes after birth, intensified with sleep deprivation/postpartum or newborn complications d. Resolves by 2 weeks postpartum ii. Importance of rest iii. Available resources c. Assessment of Early Attachment i. Engrossment/ eye contact

ii. iii. iv. v. vi.

Nursing behavior Consistency Sensitivity Enjoyment Cultural factors

Assessment of Neonates

Head Assessment Hair: color, amount Circumference Sutures and Fontanels


Mouth / lips/ gums



Eyes: color, pupil reaction, discharge

Norms Distributed over top of head 32 cm - 35 cm Sutures may override, called molding, lasting 5-7 days. May bulge when infant is crying or coughing. Depressed fontanels indicates dehydration. 
 Anterior - diamond-shaped, at front and top of head; may notice it pulsate; closes between 12 and 18 months. Posterior - is triangle-shaped, at top and to the back of the head; closes at birth or within 2 months. May be asymmetrical due to molding, this should disappear in 5-7 days. May have edema formation (caput succedaneum not bound by suture lines) or bleeding into subperiosteum (cephalhematoma - not crossing suture lines). Mouth should be round, symmetrical. Hard palate should be intact with high arch. 
 Epstein's pearls are common (small, white, epithelial cysts along sides of midline of hard palate) and will disappear in a few weeks. Face may be asymmetrical due to soft tissue damage and swelling during birth process. Milia - pin-head sized white spots (clogged oil glands) over the nose, chin, or cheeks. These are normal and disappear within a few weeks without treatment. Should not be picked or squeezed. Visualize the uvula and pharynx when the infant is crying. Tonsils are not visible in the newborn. Check for extrusion, sucking and rooting reflexes. See section on normal reflexes. Eyes may be swollen and red from trauma of birth or from reaction to medication routinely used in infant's eyes upon admission. Tears my not be present for several weeks or even 3-4 months. Eyes will be dark blue at birth, and will become their permanent color at 3 months of age. Color changes may not be complete for one year.
 Check for red reflex; blink, corneal and pupil reflexes.
 Nystagmus is a common finding.

Ears: size, placement, hearing, symmetry, amount of cartilage

Top of ears should be level with outer canthus of eye. Ear

Nose: shape, placement, patency

Nose should be midline, symmetrical. Check for nasal flaring. Nose may need to be suctioned with bulb syringe to maintain patency. Infants are obligate nose breathers - they cannot breathe through their mouths at birth. It is common for neonates to sneeze frequently. Thin white mucus is common.

cartilage should be formed so that ear holds shape.
 Audiology screening

Chest Assessment Circumference Clavicles Breast Tissue

Norms 30 - 35 cms, 12.5-13.5". Chest is almost circular. Slight intercostal retractions are normal. Check for bumps, clavicle may have been broken during birth. Should be smooth. Breast of the newborn of both sexes may be swollen the first few days due to high level of maternal hormones. They may also excrete a whitish fluid that looks like milk (witch's milk). These are both normal and will disappear without treatment by 4-6 weeks of age. Breasts of infants should never be squeezed.

Integument Assessment Color, consistency,


Norms Newborn is usually bright red with puffy skin. By the second to third day the skin should be pink, dry and flaky. Normal color changes: • Acrocyanosis - blueness of hands and feet • Mottling - transient when infant exposed to cold • Jaundice - yellow skin due to increased breakdown of red blood cells • "Newborn rash" - eruptions that appear 'hive-like' and may appear and disappear at intervals during the first few days of life. • Milia • Mongolian spots • Stork bites - telangiectatic nevi - flat, deep pink areas seen on the upper eyelids, between the eyebrows,

on the upper lip, or at the nape of the neck. These eventually fade and disappear between 1 and 2 years of age. Vernix caseosa. 

Vernix, lanugo

Vital Signs


Assessment Apgar Temperature (axillary) Heart
 rate and rhythm 
 murmurs Pulses
 femoral Perfusion, capillary refill Lungs
 rate and rhythm, 
 breath sounds, 

Apgar 97.5 to 99 120 - 160
 Blood Pressure only taken with signs of illness.
 Blood pressure based upon age
 Heart rate based upon age Strong & equal bilaterally. Refill less than 3 seconds Normal rate is 30-60 breaths per minute. Periods of apnea less than 15 seconds is normal.

Abdomen Assessment Bowel sounds Size, Contour

Norms 2-4 per minute Usually rounded with prominent veins. If scaphoid, suspect a diaphragmatic hernia. Liver is usually palpable 2-3 cm below costal margin.

Vessels (abdominal) Condition of cord Number of vessels

Will fall off in approximately 7-14 days. There may be brownish- colored drainage after the cord falls off. Cord should be cleansed with alcohol and cotton balls until area is completely healed and drainage has ceased. There should be 3 vessels present in the cord.

Genitalia Assessment


Male: Scrotum may appear swollen at birth due to maternal hormones. testes,
 scrotum Check that both testes are descended. , penis Female:

• Smegma - white, mucous discharge secreted for about 6 weeks

 clitoris, vagina,
 discha rge

• •

that protects the area. Pseudo-menstruation - pinkish-red discharge from the vagina, caused by the withdrawal of maternal hormones. Labia - may be swollen and red due to high level of maternal hormones.

Extremities Norms

Assessment Arms/Hands
 Number of Fingers 
 Range of Motion 
 Palmar Creases Legs/Feet
 Sole Creases 
 Number of Toes 
 Range of Motion 
 Hip Dysplasia 
 Major Gluteal Folds

 Should have 10 fingers. Look for polydactyly and syndactyly. Nail beds should be pink. Slight blueness is common when extremities are cold. 
 Should have 10 toes. Sole usually flat with creases on anterior 2/3 of foot. Symmetry of legs with equal muscle tone and resistance to opposing flexion. Extremities usually have flexion.
 Ortolani's sign for hip dislocation

Back/Spine Assessment Spinal Column

Assessment Awake Asleep

Norms Spine intact, no openings, masses or prominent curves. Spine usually rounded with none of curves seen later in life. Trunk incurvation reflex present - stroke back along one side of the vertebral column will cause the infant to move hips toward the stimulated side.

Posture/Muscle Tone Norms General appearance Neuromuscular

Reflexes Assessment Rooting/Sucking Moro's


Norms When cheek stroked child turns head toward side touched. Strongest during first 2 months. Disappears at 3-4 months. Sudden loud noise causes abduction of arms with elbow flexion, hands

 Plantar Tonic Neck Pull-to-Sit Babinski's Trunk Incurvature Stepping Extrusion Scarf sign

clenched. Should disappear by 4 months. Infant will grasp anything placed in hand. Touching sole of foot will cause grasping motion of toes. Should disappear by 3 months. Palmar grasp reflex will gradually become voluntary. When head is quickly turned to one side, arm and leg will extend on that side. Opposite arm and leg will flex. Should disappear by 3-4 months. Head lag common until 3-4 months. Great toe flares and other toes spread when outer edge of sole is stroked. Should disappear about 12 months. When back is stroked beside spinal column, the infant will move hips toward side stimulated. Infant held so sole touches surface, flexion and extension of leg resembling walking. Should disappear by 3-4 weeks. When object is placed in mouth, the infant will push it out with tongue. With the infant supine, take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it across the body. Infant should resist elbow movement past midline of body.

Urine Assessme nt Color, Number of voidings

Norms Should void within 24 hours. With adequate hydration should have 6-10 diapers per day. Urine is straw color and odorless. Dark yellow urine indicates dehydration.

Stools Assessme nt Color, Type


Meconium is passed 8-24 hours. After the infant begins eating transitional stools are passes - less sticky and brownish yellow. By the fourth day a milk stool should be passed - breast fed infants have pasty yellow to golden stools with an odor similar to sour milk. Bottle fed infants have pale yellow to light brown stools, firmer consistency and stronger odor. Placement of Midline. Anus Patency of Patent anal opening. Passing of meconium stool indicates patent anus Anus

Gestational Age Assessment Ballard Score

Norms Dubowitz/Ballard Exam - Includes instructions on how to conduct assessment for gestational age.

Vital Signs • Approach: Formulas and General Rules (Children over 1 year old) Formulas (Systolic Blood Pressure) Median SBP = 90 mmHg + (2 x Age in years) Minimum SBP = 70 mmHg + (2 x Age in years) Rough Approximations Pulse or Heart Rate (HR) Infant Pulse: 160 Preschool Pulse: 120 Adolescent Pulse: 100 Systolic Blood Pressure (SBP) Infant SBP: 80 Preschool SBP: 90 Adolescent SBP: 100 Respiratory Rate (RR) Infant RR: 40 Preschool RR: 30 Adolescent RR: 20 • Indications: Rapid cardiopulmonary assessment (e.g. Pediatric Assessment Triangle) Systolic Blood Pressure is observed to drop 10 mm Hg Respiratory Rate >60 Heart Rate outside ranges shown below Increased work of breathing Retractions Nasal Flaring Grunting Cyanosis or decreased Oxygen Saturation Altered LOC (irritability, lethargy) Seizures Fever with Petechiae Trauma

Burns >10% of body surface area • Evaluation: Age associated Vitals Term Newborn (3 kg) Blood Pressure: Age 12 hours: 50-70 / 25-45 Age 96 hours: 60-90 / 20-60 Age 7 days: 74 +/- 22 mmHg (Systolic BP) Age 42 days: 96 +/- 20 mmHg (Systolic BP) Pulse: 80-200 Respiratory Rate: 40-60 Infant (6 months old) Blood Pressure: 87-105 / 53-66 Pulse: 80-180 Toddler (2 years old) Blood Pressure: 95-105/53-66 Pulse: 80-180 Respiratory Rate = 24 School age (7 years old) Blood Pressure: 97-112 / 57-71 Pulse: 60-160 Adolescent (15 years old) Blood Pressure: 112-128 / 66-80 Pulse: 60-160 Respiratory Rate = 12

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