Hi everybody, I am Net Nursing Prof and welcome to my channel. In today's video, we are going to be doing a postpartum head-to-toe assessment using the bubble heat technique. So just like everything else, first thing we're going to do is wash our hands, provide patient privacy, and then verify our patient using name and date of birth.
And we are going to be doing an assessment. We're going to be touching body fluids, so possible breast milk and blood, so we're definitely going to wear gloves. So let's jump into our assessment. Hi Mrs. Johnson, I'm Andrea.
I'm gonna be your nurse today. How are you feeling? I'm feeling good. Oh good.
So I'm just gonna do a postpartum head-to-toe assessment on you. I'm just gonna check you out, okay? Okay, that's fine. So the first thing we're gonna check out is the breasts. So the first B in bubble heat stands for breast.
We're gonna ask mom, how do your breasts feel? And she could say a variety of of different things. She could say they feel heavy, they feel full, like they're full of milk, or she could say that they feel normal and she hasn't experienced any changes yet. All of those are normal and okay answers. So with that information, now we're going to actually assess the breasts.
And just like with everything, when you have two of something you want to compare left and right. It's normal for one breast to be slightly larger than the other. It's normal to have different nipples on each breast. That's totally fine.
So knowing what we're looking for, we're looking the condition of the skin. So does she have you know stretch marks on her breast? Does she have an orange peel appearance? Or do they appear like smooth?
The condition, so like the color, so we're going to use the back of our hand and we're going to feel is it cool or is it warm or hot to the touch. When we're assessing mom's nipples, there's three different types of nipples. There's everted, which is what the mannequin has, where they're sticking out. There's inverted, where they're concave, so they kind of go in. And then there's flat, when they're unable to become everted like this.
And you can have one everted and one concave, one inverted, or one flat and one everted. That's fine. All of that is still considered normal. And none of that is a barrier to breastfeeding. All three nipple types you can see.
still breastfeed with. When we're assessing mom's nipple and we're assessing her areola, we also want to look for any like bruisings or suck marks or cracks or bleeding because this might indicate if she's breastfeeding that baby doesn't have a good latch. And if that's the case, what you're going to 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 to hurt. Breastfeeding shouldn't hurt. And when it hurts, women don't do it, right?
want to encourage mom to put baby to breast and if it's gonna hurt her she's not gonna want to do it so we're gonna help her do that and this is a way we can figure that out while doing our breast assessment. So everything looks normal and good so we're gonna move on now to U which is for uterus. Now we're ready to do our fundal check.
So the first thing we want to do is make sure that mom is perfectly flat. Now remember she is postpartum so it is perfectly safe for her to be flat if she was still pregnant she would be at risk for supine hypotensive syndrome and we wouldn't want her all the way flat but she's postpartum baby's been delivered so it's okay for her to be flat on her back now. As a matter of fact if you do this assessment and she's not perfectly flat like if you did it while she was up in the chair or something like that it's gonna be wrong it's gonna be inaccurate and that's very dangerous right that's not safe to do an assessment incorrectly so very important to make sure that mom is totally flat when you do a fundal check. What we'll do is we'll expose her abdomen. So two hands for a fundal check.
One is to support the bottom of the uterus and the other is to actually feel for the fundus. So what I recommend is to go where the fundus is supposed to be. So if she just delivered today, it should be.
midline which is in the middle of her stomach and it should be at the level of her belly button. So that's where we're gonna go and it's there it's good. The way we describe a fundus is firm, firm with massage, or boggy.
And there's variations on what firm is depending on the size of mom. If mom is really teeny tiny and skinny her fundus is gonna be like rock hard. It's gonna feel just like that hard like a rock.
Most women it's not gonna feel that way. It's gonna feel firm like a tennis ball is firm right. So if you think of a tennis ball and you kind of like squish on it a little bit it's hard right but there's a little bit of bounce back to it. That's what a normal What does a fundus feel like? A tennis ball or a rock depending on the size of mom.
Firm with massage is exactly what it sounds like. So you go to do your fundal check and it's there, it's a little squishy but you can find it. If you go like this and you rub on it a little bit, it starts to firm up and get hard, that's good. That's firm with massage.
Boggy, boggy is not good. Boggy is bad. Boggy is squishy.
So you go to find it and A you can't even find it or you find it and it's really squishy and hard to to firm up if you massage it, it doesn't firm up, that's bad, okay? So that could be indicative of like possible hemorrhage or something like that. So the three ways we describe a fundus are firm, firm with massage or boggy. And what I said before about going where it's supposed to be first is very important. You don't wanna put your hand on somebody and just start going like this and start looking for it all over the place.
Why? Because this is painful for mom, right? This hurts mom. Especially if she's just had. a c-section it's much much more painful for them.
So go where it's supposed to be first, try to do it as quick as possible and as painless as possible and then you get a good result. If you go to check for it and it's not where it's supposed to be, it's to the left or the right or even above the belly button, Then we got to figure out why. So it could be scary reasons, it could be hemorrhage, it could be blood clots, or it could be something as simple as mom has a full bladder. And that actually leads us into our next beat.
Remember our first beat was breast, now we're on the bladder. So ask mom, when is the last time you got up to go to the bathroom? It's actually very very common for Postpartum women to not feel the urge to void even if their bladder is completely full So what you want to do you want to assess when was the last time she went to the bathroom if she says oh?
I haven't gone. I don't feel like I have to go You want to remind her? Every two to three hours you want to try to go to the bathroom Even if you don't feel like it that's okay okay.
A lot of times what happens is women will say, well, I don't feel like I have to go. And then you'll get them up to the bathroom and they'll sit down and all of a sudden they'll start going and going and going. And they're like, so surprised, like, oh my gosh, what is this? I didn't know I had to go. And their bladder was completely full.
So making sure or recommending that mom gets up to go to the bathroom every two to three hours, it's only going to benefit her. She's going to bleed less. She's going to heal faster and it's going to be a lot less painful for her. So if she hasn't gotten up to go to the bathroom, get her up. up, take her to the bathroom, have her empty her bladder, and then have her come back and do a fundal check again and see if it's in the right spot after that.
So now moving on to the third B in bubble heat, bowels. So just like everybody else in a head to toe, you're gonna do bell sounds. You're gonna listen. There's no reason why a postpartum woman who delivered a normal vaginal delivery would not have bowel sounds.
Spinals do not impact your bowels and neither do epidurals. If mom had to have a c-section and was under general... anesthesia then yes she might have hypoactive or absent bowel sounds for a short period of time like in the PACU during recovery. But if this was a normal vaginal delivery even if she had an epidural that's not going to affect mom's bowel sounds.
should be active and normal. The next thing I like to do when it comes to bowels is I like to ask mom, when was the last time you had anything to eat or drink? Most of these women they've been NPO for a really long time and they don't realize that after baby is born that they're allowed to eat. So I like to feed them, I like to give them food, anything we have. You can have you know jello, you can have something from the cafeteria, or you can even have your husband come in and bring you a whole pizza and eat the whole thing.
That's totally... fine. So encouraging them to eat.
They need those calories that need that energy to take care of baby, especially if they're going to be breastfeeding. So we'll put mom back up. Just a little bit. She doesn't need to be on her back for long.
This is the only assessment that you need to do on the back. And now we're going to move on. We're going to check L which is lochia.
So exposing mom. So now we're going to be checking mom's pad. Okay, so if you can see, this is quite saturated with blood. So when you come to do your lochia assessment and you see this, you're going to ask this question.
When was the last time you changed this pad? Because if she says, oh, I just changed this 20 minutes ago, that's a lot of time. blood in 20 minutes.
Or if she says, oh I haven't changed it since yesterday, that's not a lot of blood since yesterday, right? So the timing of when did she last change this pad is very important to know. So If it has been 20 minutes, that's an emergency, right? We're going to keep an eye on it.
We might be thinking hemorrhage or something scary. If it's been yesterday, now we need to educate. So what we're going to teach her about her pad and changing her pad. is the same thing about training her bladder.
So even if you don't feel like you have to pee, get up and go every two to three hours. While you're in there, change your pad. Even if there's not a lot of blood on your pad, you should still change your pad every two to three hours, just like going to the bathroom.
Postpartum women are at high risk for infection. So very important that we teach them to change their pad regularly, to take it off front to back, to do peri care with the squeeze bottle every two to three hours. time they use the restroom and to wash their hands before and after.
There are three different types of lochia. So this here, this is lochia rubra. This is what we would expect on a newly delivered patient.
This is for the first three days after delivery. So days one through three, we have lochia rubra. And it's kind of this like bright red blood. After that, we have something called lochia serosa, which is kind of like a darker brown color, which is like an old blood appearance. and then that transitions to lochia alba, which is like a yellowish or a whitish discharge.
All lochia should go in that order. So you should go from rubra to serosa to alba. You should never go in the opposite.
So if you're already at alba, you should not go back to rubra. That's a red flag. That's bad. But in the hospital, most of them will be there for just a couple days, so we expect lochia rubra. Another thing with lochia rubra that we might expect to see are blood clots.
So what we need to do is we need to ask mom if we don't see any on the pad. Maybe she's gotten up, gone to the bathroom, she's changing her pad regularly like she should. We can ask her. into the restroom?
Did you notice any blood clots? For some reason our patients don't like to tell us that they're having blood clots. I don't know why.
I think maybe they just think because it's normal that it's not of alarm. But we do need to know and we do need to document. Normal blood clots are the size of nickels and dimes, coins, that kind of thing. An abnormal blood clot is like the size of an egg or bigger than an egg.
Mom needs to let us know if she's having those big clots. So we can change mom's pad and kind of keep an eye on everything. And now we can move on to E, which stands for episiotomy.
Now one thing I do want to let you know is most women do not get episiotomies anymore. Okay, it's not common practice. But if she does have an episiotomy, or if she has some sort of laceration, first, second, third, or fourth degree tear, we want to assess that. So assessing it, how do we do it?
We use something called the RITA scale. So that stands for redness, so noting any redness at the site, ecchymosis, which is bruising, edema, which is swelling, discharge or drainage which is our D and then A is for approximation. So there may be some normal redness, maybe some slight edema, and maybe some bruising from a laceration or episiotomy.
That's okay. We expect that. If it's over and beyond what we expect, what's normal, that's when we're a little bit concerned.
There should never be discharge or drainage. A is for approximation in our Rita scale. And if you're not sure what that means, it's when two tissues are sewn together and they're touching.
So if doctor did a really good job of sewing up mom, then you shouldn't even be able to see. the stitches. They should be like this. You shouldn't be able to see where they're touching. There shouldn't be any like openings or anything like that, any gaps or any active bleeding in that area.
That's not approximated. That's not good. So we want our episiotomies and our lacerations to be approximated.
Often women who experience an episiotomy repair or a laceration repair will ask what about the sutures? When do I need to get these removed? "And the answer to that is they don't. They are dissolvable and they don't need to make a separate doctor's appointment to get them removed. H is for Homan's sign. So with Homan's sign we are checking for DVTs. Remember pregnancy, delivery, postpartum. It's all very hypercoagulable state for mom to be in. So she is at high risk for a DVT, so we are going to check and make sure she doesn't have one. So the way we do that, we'll expose mom's leg, and I'll just expose both so you can see it better on camera. So you're going to take mom's leg. You're going to support behind the knee with your hand. Sometimes the patients like to help and then they like hold their legs straight out for you. Tell them please don't do that. Tell them just kind of relax your leg and I will hold it in my hand. So she's relaxing her leg. We're going to take her foot and then we're going to sharply dorsiflex it back. And then we're going to ask, any pain or tenderness in your calf? And she could say yes, which may indicate yes. positive Hohmann sign so maybe there is a DVT there or she could say no which is a negative Hohmann sign. One thing I really want to point out about this 50% of all DVTs are asymptomatic so even if you do your Holmanstein? And she says, no, no pain or tenderness. That doesn't mean she doesn't have a DVT. So you as the nurse also need to assess her calf. You need to look for redness, swelling, and heat. The other thing you need to do is check her pedal pulses. So they should be plus two normal. If they are absent or thready, if she has any redness or swelling in her calf that's abnormal and doesn't match the other side. Those are your red flags, even if her Hohmann sign was negative. And then just like we did on the breast, we assess one, we also have to do the same thing to the other. So we're gonna do the same thing, put our hand behind the knee and then dorsiflex the foot and then ask her any pain or tenderness in your calf when I do that and she says no no pain and I look no swelling no redness no heat plus two pedal pulses she's good our final E stands for emotional status that one we can simply assess by observation so how is mom acting is she happy is she crying is she in a lot of pain is she exhausted because she's been in labor for three days? Is she holding the baby? Has she called the baby by a name yet? That kind of thing. So how is mom acting? Some moms might not be acting like that, right? They might not be happy about the baby. They might not be holding the baby. They might be sitting there on their cell phone when baby's sitting off in the bassinet crying in the corner screaming. That's something you want to watch out for. Lack of interaction with the baby. Lack of wanting to hold or touch the baby. You also need to assess her support system. So is she here all alone? Is she by herself or does she have, you know, 500 family members in the room? Is dad here? The father of the baby, is he involved? Or maybe grandma's involved. Grandma's the support person. Who is her support system? You want to know that too. That all plays in to the emotional status. There are three stages that we quantify these in. The Rubin stages is what they're called. So taking in, taking hold, and letting go. In the first stage, stage taking in is when mom is kind of like all about mom and she's like I'm hungry and I'm tired and I'm in pain and you know I have my friends and family here so let me tell them all about my birth story and it's kind of all about mom in the second stage is called taking hold this is when she's more interested in the baby she maybe wants to take care of the baby she might ask you a bunch of questions like how do I feed the baby how do I change the diaper she's very interested in learning how to take care of the baby And then the letting go stage, that's not something we actually see usually in the hospital. That's more like when they get home and they kind of establish their own little routine at home. Now some women stay in the taking in stage for a long time. Some just jump right past it and go right away to taking hold. And then everybody's different. So don't think like, oh, she's still in taking in, or she just jumped right past it, she didn't experience it at all. That's okay. First time moms versus, you know, this is baby. number 10 for you. It's all going to be completely different. So just keeping an eye on your patient, observing how they're acting, how they're interacting with the baby and other people, and if it is something that we can fix, like maybe they're not holding the baby because they're in pain, we can do something about that, right? Give them pain meds, make them feel better. Now all of a sudden they've changed their tune and they want to do everything with the baby. So just keeping an eye on how they're acting and then charting it using those Ruben stages, taking in, taking hold. and letting go. So that was my video on postpartum head-to-toe assessment using the bubble heat technique. I hope you found this helpful. Any questions or comments please let me know. If not, I'll see you on the next one.