BUBBLE HE
AREAS ASSESSMENT
 Soft/Engorged/Lactating
 Assess for inflammation,
redness, swelling.
 Assess nipple for soreness,
flat, normal, inverted, large
B – Breast
 Assess for tone: contracted,
relaxed, or soft.
 Assess level of fundus (U/1,
U/2).
U – Uterus
 Assess after pains.
 Check for bladder fullness.
 Check voiding 4-6 hours
after delivery.
 Elimination problems
B – Bladder
 For CS patients, check for
color, presence of blood, and
amount of urine.
 Check for bowel movement
after delivery.
 For CS patients, check for
B – Bowel bowel sounds, flatus, and
bowel movement.
 Assess COCA
 Color (rubra, serosa, alba)
 Odor (non-foul smelling)
L – Lochia  Consistency (check for blood
clots)
 Amount (minimal, moderate,
profuse)
 Check for REEDA (redness,
edema, ecchymosis,
E – Episiotomy for NSD
discharge, and
approximation)
Abdominal Incision for
CS
 Assess for presence of calf
pain upon dorsiflexion of
foot.
 Edema, varicosities, and
H – Homan’s Sign redness and swelling of
Hemorrhoids affected area.
 For hemorrhoids:
 Assess for tenderness,
pain, blood, and lumps
or masses.
 Mother’s participation in the
care of the neonate.
 Psychological phase (taking-
E – Emotional in, taking hold, letting go)
Attachment/Bonding  Check family support
HEALTH TEACHING Findings and Nursing
Interventions done
 Care of the breast
 Benefits of breastfeeding,
encourage breastfeeding every
2-3 hours.
 Breastfeeding positions/proper
latching on.
 Manual breastmilk expression.
 Proper storage of breastmilk.
 For inverted nipples, use
improvised syringe or manual
extraction of the nipple.
 Ways to keep uterus contracted
(uterine massage,
breastfeeding, nipple
stimulation, ice pack)
 Increase fluid intake.
 Report any abnormalities in
elimination.
 Refer if unable to void after 6
hours.
 For CS patients, check urine
output every hour and refer if
less than 30cc/hr.
 Increase fiber in diet.
 Increase fluid intake.
 Encourage ambulation if not
contraindicated.
 Educate about the:
 Normal process of lochia
changes.
 Proper perineal care
 Perineal pad change
 If with profuse bleeding,
massage uterus and refer.
 Care of episiotomy site and
abdominal incision.
 Proper perineal care and wound
care.
 Refer for any signs of infection.
 Report signs of
thrombophlebitis (inflammation
and swelling, pain)
 Early ambulation if not
contraindicated.
 For hemorrhoids:
 High fiber diet
 Increase fluid intake
 Educate patient or mother on
how to perform baby’s bath,
cord, and oral care.
 Educate about the benefits of
breastfeeding.
 Mother care