BUBBLEHE help?

quiet_one · Nov 24, 2008

My textbook (pearson i think) comes with access to mynursinglab.com and it has a skills video that is very helpful.....not sure what text you have but it may be helpful to check out their website to see what videos they offer.

This is also a form my instructor gave for the bubblehe assessment....just follow it step by step and you will be fine. Hope you are able to use some of this info and good luck with your assessment :)

Breast-

Assess lactation status

Inspect and palpate breast

Condition: Soft, Filling, Full, Firm, Engorged, Red, Pain

Nipples: Normal, Red, Pain, Cracked Inverted

Uterus-

Assess fundus

Location: fingerbreadths or cm ↑ or ↓ the umbilicus (e.g., “2 FB ↓ U)

Position: M=Midline, Right=R or L=Left of the umbilicus

Consistency: Firm, Boggy

Assess the bladder prior to voiding and then again after voiding

(Indwelling Foley catheter)-assess color, quantity, quality, odor of urine, etc.)

I & 0 (if not on accurate I&O, record # of voids)__________

Bowel-

Auscultate bowel sounds:

Absent, Hypoactive, Active, Hyperactive

Palpate Abdomen: Soft, Distended

Lochia-

Discharge from uterus following delivery

Color: Rubra, Serosa, Alba

Amount: None, Scant, Small, Moderate, Heavy, Clots: describe size

Odor: Present, Absent

Episotomy-

Assess Perineum

Condition: Use REEDA –Redness, Edema, Ecchymosis, Drainage, Approximation- to assess

Hemorrhoids:+ = Present, Edematous, Thrombosed, Soft, Painful

C/S Incision: Clean, Dry, Intact (CD &I), OPA(Open to air)

Dressing: Clean, Dry & Intact, Changed,

Homan's-

Homan’s

0=Negative

Plus (+) positive (indicate R or L)

Calf pain might be normal due to stress of delivery.

Clonus:: With the woman’s knee flexed and the leg supported, vigorously dorsiflex the foot, maintain the dorsiflexion momentarily, and then release. Normally no clonus is present. Record the number of beats: 0= no clonus 1=beat of clonus, 2 = 2 beats of clonus, 3=3 beats of clonus

Edema-Assess edema by weight gain (more than 3.3 lbs in the 2nd trimester or more than 1.1 lbs in the 3rd trimester). Edema is assessed on a 1+ to 4+ scale

Reflexes-Elicit at least one pair of reflexes Patellar reflex, Biceps reflex, Triceps reflex, Brachioradialis reflex

Grade reflexes:

0-no response; abnormal

1+-Diminished response; low normal

2+-Average response; normal

3+-Brisker than average; may not be abnormal

4+-Hyperactive; very brisk, jerky, or clonic response; abnormal

Emotional-

Maternal-Infant Attachment

The mother has direct face-to-face and eye-to-eye contact in the en face position

Holds, cuddles, asks questions and cares for infant

Bonding or not bonding with infant

Postpartum blues

NursingIs4CoolPeople · Nov 24, 2008

I wish i can thank you again :-D, thank you so much it helps alot

gigi01 · Mar 17, 2009

thanks this helped me for my OB clinicals

Pediatric Critical Care Columnist · Mar 17, 2009

Quiet One, you forgot the second B for BLADDER. Check for adequate urine output, complete emptying (residual urine is often a problem), normal sensation of fullness, force of stream and so on.