|
|
|
Breasts: breast or
bottle? Palpate for engorgement; inspect nipples for redness, cracks,
erectility, if nursing
|
|
Uterus: fundal
height, firmness, position r/t abdominal midline; fundal location r/t
expected descent’ inspect abdominal incisions, c-sec, or BTL for REEDA:
redness, edema, ecchymosis, discharge, & approximation of skin edges
|
|
Bladder: void within
6 - 8hrs of delivery; assess frequency , burning, urgency (UTI); retention,
distension
|
|
Bowel: passage of
flatus; signs of distension
|
|
Lochia: type,
quantity, amount, & presence of odor; expected findings? C-sec pts may
have < bleeding; refer to Figure 21-6, p 457
|
|
Episiotomy: inspect
perineum for REEDA; hemorrhoids
|
|
Assess for lacerations: 1. 1st
degree: ; limited to perineal skin & vaginal mucous membrane2. 2nd
degree: involves perineal skin, vaginal mucous membrane, underlying fascia,
& muscles; 3. 3rd degree: through perineal skin, vaginal
mucous membrane, involves anal sphincter, possibly anterior wall of rectum
|
|
4. 4th degree:
same as 3rd but extends through rectal mucosa to lumen of rectum
|
|
Homan’s sign: pain in
calf upon dorsiflexion of foot – possible thrombophlebitis; pedal edema/pedal
pulse
|
|
Emotional Status:
appropriate for situation; phase of psychological adjustment; “postpartum
blues”
|
|
Bonding: interactions
with infant
|