Your

Name: Apolonio, Justin C.

Section _A____________
Date submitted_9/8/2020______________ Score ________________

Identify the Word Assessment Nursing Independent Care

Soft, engorged, lactating Encouraged Breastfeeding

EXAMPLE: Everted, inverted, flat, short, every 2-3hrs, Breast/nipple
B- Breast large care. Manual BM expression
Nipple Sore or cracked nipples Apply warm compress
Assess if BF or Bottle Use improvised syringe
feeding
1 3 2
U - Uterus  Tone: firm/contracted  Massage gently
or boggy/relaxed (nondominant hand
 Location: Level of the support LVS)
fundus midline or
deviating to the right
or left (due to a full
bladder)
 @u (fundus firm @
the umbilicus)
u/1 (fundus firm 1cm
below umbilicus)
u/2 (fundus firm 2cm
below umbilicus)
1 3 3
B - Bowels  Bowel movement (CS  Increase fluid intake
and NSD)  Ambulate if not
 Flatus (in C-Section contraindicated
patients)  Increase fiber foods
 Active bowel sounds  Assist patient side to
in all four quadrants side
1 3 3
B – Bladder  Able to void within 4-  Increase fluid intake
6hours after delivery  Ambulate if not
 Assess for frequency, contraindicated
burning or urgency  Assist patient side to
(UTI) side
 For CS - assess urine
output, color, (red,
tea-colored)
 Bladder distention –
catheterization
 8 3
1  Color – rubra, serosa,  Educate normal
L - Lochia alba findings
 Odor – infection  Teach patient perineal
 Consistency – Check care
for clots  Change pads
 Amount – scant, light,  Encourage mom to
moderate, heavy change perineal bag
 CS – less lochia
 CS – assessment of
fundus is gentle
2 5 4
E/I- Episiotomy/Abdominal  Assess entire  Cold compress for
Incision perineum (area from first 24 hours
the opening of vagina  Perilight (12-24 inch)
to the rectum)  CS: clean incision
 Perineum may be  Perineal care
intact, lacerated or
required an
episiotomy
 Assess the
episiotomy/Abdomina
l incision for: REEDA
– Redness
– Edema or swelling
– Ecchymosis or bruising
– Drainage
– Approximation (of
laceration/episiotomy/wound
edges)
2 4 4
H – Homan’s Sign  Dorsiflex the foot  Bed rest – calf pain
 Assess for sharp,  Warm compress (x
H - Hemorrhoids knife-like pain in the massage)
calf area (Calf pain)  Early ambulation –
 If present, also assess thrombophlebitis
pedal pulses, edema,  Elevate feet higher
warmth, redness and than heart (45)
inflammation
 Assess for varicosities
 Assess for
Hemorrhoids.
(distendedrectal veins)
 1 5 3
 Assess for family  Educate: take care of
E/A – Emotional Adaptation support self and baby, baby’s
 Assess for readiness bath
towards the new role  Praise mother
 Assess phases of  Pray
postpartum maternal
behaviors (taking-in,
taking-hold, letting go
& postpartum blues or
evidence of
postpartum
depression)
 Bonding/attachment
Perfect Score 9 31 22
TOTAL = 62 PTS