ASSESSMENT OF THE POSTPARTUM PATIENT

8 POINT CHECK

On the following three pages, you will find guidelines for

assessment of the postpartum patients. At the beginning of
each shift, you will be expected to perform these
assessments on each patient assigned to your care. Please
note that each hospital ahs its own guidelines for the use of
abbreviations, so some of the abbreviations that you may
have learned in prior rotations may or may not be
acceptable. Your clinical instructor will be able to assist
you in determination of proper abbreviation, however,
when in doubt, write it out.

Please note that in most of the hospitals, we provide

mother-baby care. You will be expected to provide care to
both the mother and the baby, do assessments and complete
necessary charting. These assessments should be
completed at the beginning of the shift, and documented as
early as possible. Your individual clinical instructors will
provide you with the necessary information regarding
appropriate forms and process for documentation.

ASSESSMENT NORMAL ABNORMAL NURSING

AREA FINDINGS FINDINGS ACTIONS
Vital signs Within normal Temp greater than Increase oral/IV
parameters for an 100.4 or persistent fluids. Assess for
adult; Temp temp of 100.4 after excessive bleeding.
elevation up to 100.4 24 hours. Contact HCP for
within 24 hours B/P>140/90, pulse antihypertensive
considered normal >120, respirations therapy.
>24
Emotions & bonding appropriate Lack of interest, no Assess cultural norms.
 interaction with eye contact, Supervise visits with
infant; eye contact, disinterest in feeding infant.
holds infant closely, or care, refers to social service referral
identifies family infant in negative or for assessment.
resemblances, derogatory terms
interested in learning
about infant care
Breasts, Nipples soft to firm breast engorgement review chart for type
consistency of feeding.
Breastfeeding:
supportive bra, warm
compress, increase
feedings
Bottle feeding:
supportive bra, cold
compress, pain meds,
nipples everted nipples flat or binder, patience
inverted
Nipple roll, breast
nipples intact, no shield or Swedish
redness cracked, red, breast cups
bleeding
assess positioning and
latch, break suction,
refer to Lactation
Nurse
Fundus firm consistency, boggy, above massage to firm,
located at or below umbilicus empty bladder,
umbilicus provide oxytocics

Bladder not palpable suprapubic bulge assist to BR, cath prn

Lochia
type Lochia rubra Day 1- persistent lochia report to MD
2 rubra
Lochia serosa Day report to MD
2-10 return of lochia
amount odor Lochia alba Day 10- rubra massage fundus, pad
6 weeks count, describe clots,
profuse, clots oxytocics, IV
initially moderate to Report to MD
heavy continued heavy
clots
scant to moderate assess for S/S
 within 1-2 hours infection, perineal
foul odor hygiene, report to MD
musky, menstrual
like odor
Perineum – turn normal REEDA abnormal REEDA
patient to side and
raise buttock to view no redness, edema, redness of incision, document finding, ice
area ecchymosis, edema, ecchymosis, pack, or sitz bath,
drainage discharge assess for hematoma,
assess for S/S
infection, pericare,
report findings

edges well edges not report to MD

approximated approximated
Anal area sitz bath, topical spray
no hemorrhoids hemorrhoids or Tucks

Homan’s sign assess for redness,

no calf pain with calf pain with edema, pedal pulses,
dorsiflexion of foot dorsiflexion of foot warmth, red streaks,
respiratory difficulty
report to MD

THE FOLLOWING ASSESSMENTS ARE

INCLUDED FOR C-SECTION PATIENTS OR ANY
ABNORMAL ASSESSMENT AREA

Lung sounds clear breath sounds distant breath sounds, review for history of
in all fields rales, wheezes respiratory problems,
activity, C&DB,
incentive spirometry
Abdomen

general abdomen soft firm, distended increase activity,

assess bowel sounds,
anti-flatulents
abdominal normal REEDA abnormal REEDA
incision document findings,
 call MD
active in all absent, hypoactive
bowel sounds quadrants
increase activity, hold
diet, anti-flatulents