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11 Cards in this Set
- Front
- Back
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What is BUBBLE HEN |
Breast, uterus, bowels, bladder, loch I a, episiotomy, Homan sign, emotions and nutrition |
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7 other assessment points |
1. Bonding 2. Taking in, taking hold, letting go 3. Education and support 4. Immunization needs rubella vaccine, RhoGAM 5. Contraceptive needs and preferences 6. Cultural and religious beliefs and practices affecting maternal and infant care 7. Breast or bottle feeding (nipples- cracked sore bruise)
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C-section assessment |
Incision site REED bowel sound all quadrants Lung fields Foley return of sensation, LOC, orientation after recovery. Pain control analgesic pca pump diagnostics ambulation
test cbc platelets
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What does REEDA |
Redness, edema, ecchymosis, discharge, approximation |
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Nursing implementions (7) |
1. Offer bed pan prn, q4h if uterus is deviated to the side, cath if needed measure urine output until at least 300 ml and bladder is empty 2. Bowel function AMBULATION FLUIDS FIBA 3. Offer pain med b4 breast feeding if client has surfer afterpains and other discomfort (investigate unexpected or servere pain) 4. Facilitate rooming in teach parents how to respond to cues of the infant. 5. Assist with ambulation the 1st time (within 4 hours of Vag delivery and when legs have sensation in c-section. 6. Adm ROGAM within 72 hours following delivery, rubella vaccine if titer is negative prior to discharge.
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Evaluation 12 |
1. Bonding attachment, parental roles 2. Client copes with mood changes 3. Void and stool return to normal 4. Clients uterus and lochia follow expected postpartum patterns 5. Nutrients diet 6. Pain management 7. Free of infection, incision episiotomy heeled 8. Verbalized adequate care for self and infant 9. Client is released to home 10. Appointment for followup 11. Follow up care is initiated 12. Clients decisions for birth control is discussed
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Physiologic and emotional return to non pregnant state take how long |
4-6 weeks |
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Placental site heals in how many weeks |
6 weeks |
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Endometrial area heals in how many weeks |
2-3 weeks |
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C-section skin incision heals in how many weeks |
1-2 weeks |
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Uterine incision heals how many weeks |
4-6 weeks |
