POSTPARTUM HEAD TO TOE ASSESSMENT

(BUBBLE HE TECHNIQUE)
To camera
To patient
Patient response

Self Introduction: Good day everyone, I am Jay Bond B. Quiapo, a 2nd year
nursing student from JH Cerilles State College Pagadian Campus. Today, I will be
performing a postpartum head-to-toe assessment using the BUBBLE HE
Techniques. BUBBLE HE stands for BREAST, UTERUS, BLADDER, BOWEL, LOCHIA,
EPISIOTOMY, HOMAN'S SIGN, and EMOTIONAL STATUS, of the mother

• Before we proceed to the assessment, the first thing I must do is to perform

hand hygiene and gloving. I will be using gloves because I will be handling body
fluids such as breast milk and blood during the assessment.

• We also need to provide privacy to the client, introduce ourselves to the client,
and verify the patients identity using the patient's full name and date of birth.

ASSESSMENT
• Hello maam, good morning! I'm Jay Bond Quiapo, a 2nd year nursing student
from JH Cerilles State College, your student nurse for today, how are you feeling
today?  < Im good >
• Okay, your good
• Can you state your full name and your date of birth maam? < Stating name and
birth >
• Okay thank you maam. So for today maam, Im gonna do a postpartum head-to-
toe assessment on you. Are you okay with it maam? <Yes>
• Okay, so before we proceed maam, Im gonna check your vital signs, is that okay
with you maam? <yes>
• (Checking BP) So the mother's blood pressure is 120/80 which is normal.
(Checking Temperature) The mothers temperature is 37°C and it is normal.

-BREAST-
• Prior to performing the first assessment maam, this requires me to raise your
shirt po for accurate findings po, is that fine  with you po <yes>
• Alright, thats good
• So lets start with your breast maam. So, how do your breast feel? <I feel heavy,
its full of milk>
• (Use the back of the hand to palpate the breast) So maam, do you feel any
soreness or pain in your breast? <no>
• Thats good maam.
 The patients breast is warm to touch and smooth.
• The nipples in both breast are everted which is normal
• There are no signs of redness
• There are no bruises, cracks, and dryness
• Everything looks normal and good

-UTERUS
• So maam, Im gonna assess your UTERUS, is that okay with you? <yes>
• Alright. So maam, Im going to let you lie down flatly po, is that okay?
<yes>
• So, Im going to use my other hand to support the bottom the uterus.
• So, its good, fundus is firm

-BLADDER-
• So maam, when did the last time you went to the bathroom to pee? <not
yet>
• So maam, this is just an advice. So, every 2-3 hours, you have to try go to
the bathroom and pee so that your bladder wont full. Its only gonna benefit
you. Youre gonna bleed less, heal faster, and could be a lot less painful for
you. Okay, so if you are having a hardtime going to the bathroom, you can
call me so that I could assist you, okay? <okay>
• Okay good

-BOWEL-
• Okay maam, lets now proceed to your bowel. Im going to check it out
okay? <okay>
• (Auscultate tummy) So the bowel sounds are normal
• So maam, when was the last time you had anything to eat and drink?
<breakfast only and its evening>
• So maam, I am encouraging you to eat lots of fruit, vegetables, whole
grains, and foods that rich in protein. It is usualy good and important to eat
such kinds of food to help you recover from childbirth and keep your body
strong. You need those calories and energy to take care of your family.

-LOCHIA-
• (Turn the patient into normal position from flat)
• So now, I will be assessing the lochia
• So now, maam Im going to check your pad, is that okay with you? <yes>
• Maam, when was the last time you changed your pad? <20 mins ago>
• Ohh, 20 mins ago... Okay, thats good. Theres not a lot of blood.
• The patient's discharge is a bright-red color and there's not a lot blood.
• So maam, my advice is that, even if you dont feel like you have to pee, get
up and go every 2-3 hours or everytime you try going to the bathroom to
pee every 2-3 hours, you must change your pad every 2-3 hours even if
theres not a lot of blood on the pad. Since you a newly delivered patient,
you are at high risk of infection so its very essential to change your pad.
Okay? <okay>
-EPISIOTOMY-
• (Use penlight, have the patient into sims position)
• So maam, I will be checking your episiotomy.
• (Checking using fleshlight and observe) So the patient has normal
redness, slight edema, some bruising from a laceration in episiotomy which
is actually expected and very okay.
• The stiches or laceration are well approximated

-HOMAN'S SIGN-
• Okay maam, so for now, just relax your leg, okay? <yes>
• (Inspect and Palpate both legs) Do you feel pain or tenderness maam?
<no> Okay thats good
• Im going to check if it is inflamed. (Checking legs) So it is not.
• So, there's no swelling and redness also
• overall, the patient is good.

-EMOTIONAL STATUS-
• So, for this assessment, regarding the emotional status if the patient. I
can just observe the patient using the 3 stages which are the taking in,
taking hold, and let go.
• Since my patient just gave birth, I can assess that my patient is already in
the "taking hold" stage. The patient is very interested about the baby. She
has a strong support system, her husband is here as well as the family of
her and to her husband. Some of the relatives are here also. Overall, her
emotional status is good or normal.

-Okay maam, we are now done with the assessment. That would be all and
thank you so much for your cooperation.
-Do you have any questions maam regarding the baby? If you do, just call
me so that I could help you in that matter, okay? <okay>

Ending: So that would be all about postpartum head-to-toe assessment.

Thank you for watching and have a good day!