ASSESSMENT OF THE BREAST

ASSESSMENT NORMAL ABNORMAL NURSING CARE

TECHNIQUE
1.Increase in size Cracked and irritated 1.Breast Care
2. Milk changes from nipples Tenderness , 2.Clean with water and
thin watery to bluish redness, pain, swelling, wipe dry
white foul odor discharges, 3. No soap please
3. Becomes heavier contracted, feeling of 4. Instruct not to
4. Veins become fullness, inverted scratch the site, and
Inspection apparent nipple, everted nipple, Cut finger nails
flat nipple, swollen 5. Place cold compress
5. Check for Colostrum: nipple, soreness on PRN
yellow milk which are site, with scratches, 6. Give Analgesic like
essential for newborn nor wound mefenamic Acid o
to receive so it will ibuprofen
protect them from 7. Give antibiotics as
getting sick. ordered if there is
mastitis
6. 6. Check if the: 8. Let the affected
breastmilk is flowing. breast rest
9. Breastfeed on the
unaffected breast, can
breastfeed on affected
side provided she can
tolerate the discomfort

Notes:

- they do not advice to clean the breast prior to breastfeeding because they will the normal smell of the
mother and milk that the baby will look for.
- do not scratch because it can cause irritation

- there is a open wound because of poor sucking and can be healed by proper latching to heal the
wound
-
 Assessment of the uterus
Assessment normal abnormal Nursing care
technique

Inspection Weight 1000 grams No weight changes 1. Assess for uterine

immediately after atony
birth 500 grams at Visible cervix or 2. Massage the
the end of first week uterus uterus
SO grams at 6th week 3.Regulate the IVF
Severe abdominal with Oxytocin
pain and tenderness 4.Place ice pack over
5O grams at 6th week the fundus
5. Nipple stimulation
6. Breastfeeding
7.Administer
Oxytocin
8.Administer
Methergine
Palpation After pains during Lateral displacement
contractions of the uterus
Firm & contracted
Board like abdomen Soft and boggy
Contracted, cervix is Uterus
soft and malleable,
cervical os is
narrowed

Notes:

- 1000 grams/500 grams- weight of uterus: the term is involution.

- lateral displacement of the uterus- it indicates that bladder of the patient is full that’s why empty the
bladder before assessing the uterus

- soft and boggy uterus-it indicates that the mother is risk for bleeding or post partum hemorrhage

- oxytocin- for contraction of uterus

- uterine atony- the uterus fails to contract after delivery that can lead to post partum hemorrhage

- ice pack- help in the contraction

- nipple stimulation- to produce oxytocin that helps for the contraction if the uterus
Rule: Involution of the uterus: 1cm/day from umbilicus

- we are going to palpate the fundus

 Assessment of the bladder
Assessment technique NORMAL ABNORMAL Nursing care

inspection NORMAL Burning sensation 1. Encourage to void

Temporary difficulty of 2. Expected to
voiding Hematuria Void between 4 to 6
hours
Void within 6 to 8 hours Frequency 3. encourage to increase
postpartum oral fluid intake
Inability to void more 4. listen to running water
3 liters urinary than 10 hours 5. wet hands with water
output/day 6. cold compress
Oliguria 7. inform AP if measure
Zero- trace protein are not effective
Severe proteinuria 8. catheterization
Zero- trace sugar
glycosuria
Urinary stasis

Note: Patient that have catheter during the delivery they need to void 6 to 8 hours after the removal of
the catheter

Assessment of the bowel

Assessment technique normal abnormal Nursing care

Inspection Constipation Passage of the stool out 1. Check for the bowels
Flatus from the vaginal orifice sounds
Abnormal distention 2. Perform abdominal
bowel movement assessment
Hemorrhoids 3. increase oral fluid
intake
Auscultation 5-35 bowel sound Absent bowel sound 4. easy ambulation
5. soft diet
6. BM returns 24 hours
post partum
7. encourage to eat
8. move around while on
the bed
 The Normal Stages of Lochia
(Postpartum Bleeding And Discharge)

Lochia Rubra Lochia serosa Lochia alba Nursing care

Dark Red Pinkish brown Whitish yellow

1. assess for the
Last 3-4 days Lasts 4-day days Last 10-20 days lochia’s color, amount,
others
Occurring a few days It contains less red For about another 1-2 2.encourage to change
after delivery. It is blood cells and has weeks, whitish turbid napkin/diaper
mainly made up of more white blood fluid drains from the frequently
blood, bits of fetal cells, wound vagina which mainly 3. perineal flushing
membranes, decidua, discharges from the consists of decidual 4. teach client to wipe
meconium and cervical placental and other cell, mucus, white from front to back
discharge sites, and mucus from blood cells and 5. tell client no to
the cervix epithelial cells touch the site
6. no use of douching
7. no colored tissues

Assessment of episiotomy
Assessment technique normal abnormal Nursing care
Inspection REEDA Hematomas 1. assess for REEDA and
Redness, edema, others
ecchymosis, discharges 1 or 2 stitches sloughed 2. Encourage to change
and approximation away napkin or diaper
Slight separation of 3. perineal flushing
wound edges Large lacerations 4. teach client to wipe
1st degree laceration from front to back
Purulent discharges 5. tell client not touch
the site
6. no use of douching
7. no use of colored
tissue
8. adminter antibiotics
9. report for pain and
discomfort
Notes:
Approximation- no separation of stitches, dapat looks normal

Homan signs – to check for thromplopehtis:

Assessmnet technique Normal abnormal

Homan’s sign Negtaive pain upon Postive pain upon If postive homan’s signs
Dorsiflexion of the foot dorsiflexion dorsiflexion 1. elevate feet
While supporting the cell No swelling Varicoses veins 2. wear anti-embolic
No bruises at the calf Bruises over calf stockings
Deep vein 3. do not stand for long
thrombosis period of the time

EMOTIONAL PHASES OF PUERPERIUM

1. TAKING-IN PHASE

• Woman is passive and dependent

• Prefers talking about pregnancy, labor and delivery

• Uncertain in caring for newborn

• Energies are focused on bodily concerns

• Uninterrupted sleep is important

• Additional nourishment is necessary

• Happens 1-2 days after delivery

2. TAKING-HOLD PHASE

-woman begin to initiate action

-Interested in taking care of newborn

-Asserts independence

-mother focuses on regaining control over her bodily functions-bowel and bladder; strength and
endurance

-happens 2 to 4 days after delivery

3. LETTING-GO PHASE

- Gives up old role

- Ready for her new role

- Cares for the baby

- Able to take care of herself, ADL

- Breastfeed the baby

- Able to do new role as mother

EMOTIONAL ADJUSTMENT

Assessment Normal Abnormal

technique

1. Taking -in The client focus on herself sleeps Shows signs of self pity
most of the time Does not eat
Tired Does not care of baby
Think only of her brain

2. Taking hold The client start to touch the baby Signs of depression
Move around with assistance Sleepless, no appetite to eat
Do ADL with assistance Mix emotions
Does not touch her baby

3. Letting go The client finally take care of her May develop postpartum blues
baby and depression
Accept the experience Does not take her baby at all
RH INCOMPATIBILITY
1. Rh negative woman and Rh positive man conceive a child

2. Rh negative woman with Rh positive fetus

3. Cells from Rh positive fetus enter woman’s bloodstream

4. Woman becomes sensitized-antibodies form to fight Rh positive blood cells

5. In the next Rh positive pregnancy, maternal antibodies attack fetal red blood cells

RHOGAM
• Given IM at 28 weeks gestation and within 72 hours of birth.

• This rh mom has no rh+ antibodies and we need to keep it that way

• You’re right this Rh + baby can send Rh + antibodies to mom… that’s bad news for future babies

• Stop right there! I'm here to prevent mom from developing Rh+ antibodies that could affect
future pregnancies.

CONDUCT IN THE CLINICAL AREA

1. Roll call
• Done to check the attendance; appropriateness of the uniform and completeness of
paraphernalia

• Is done 30 mins before the prescribed duty time

• 15 mins or less
• Reading related to the experience
• More than 15 mins. But less than 30 mins
• 1 day extension
• More than 30 mins
- Considered present absent - 2 day extension

Sanctions:
Excused-
• Illness
• Death
• School representation
• Force majeure
Unexcused
• All other absences not covered as excuse

PROCESSING IN SECURING EXCUSE/ABSENCE SLIP

1. Student will fill out the form
2. Email the accomplished form with necessary attachments to the level coordinator
3. The coordinator will send the slip to the CI

Dean of nursing and Respiratory therapy - Dr. Sarah Bernadette L. Balena, RN

Nursing Level Coordinators
Level 1 - Marie Glen, G, Geronan, RN, MN, RTRP
• Soraya D. jaictin RN,MN, RTRP
Level 2 - Etta C. Catacutan, RN, MN RTRP
Level 3- Jocelyn A. Cataraja, RN,MN

DECORUM ON SYNCHRONOUS VIRTUAL MEETING

• Color hair dye is not allowed
• Wear decent attire
• Ladies with long hair should be tied ponytail
• Prescribed haircut for men, shaved mustache
• Note if going to a barber shop poses risk and violates LGU safety protocol on Covid 19 please
inform your CI
• Settle down and be attentive
• Not allowed lying, slouching, walking, traveling, eating, chatting with other
• Chat Room will only be the matters concerning the discussions
• Making unnecessary annotations on the presentations is vandalism
• Using foul languages, crash talking and demeaning words, either written or spoken is an offense
Virtual RLE Guidelines
1. conducted according to rotational schedule (all in a 7-3 shift)
2. attendance will be checked at 7:00am
3. tardiness and absences will be determined whether excused or unexcused basing on the clinical
handbook policies on absences
- to be included in the justification of excuses tardiness/ absences are problems with
connectivity and/or power interruptions
4. student shall submit to the CI proof to justify tardiness/absences like screenshots of low connectivity
and all those stipulated in the clinical handbook for excuse absences
- attached is an excuse letter with a photocopy of parents/guardian’ valid ID with signature
5. Sanctions stipulated in the Nursing Clinical handbook will apply for unexcused tardiness or absences