LaGuardia Community College
Practical Nursing Program
SCL 115 Maternity Child Health Nursing
POST PARTUM OBSERVATION
Direction: Complete this observation chart by writing the appropriate value, observation
and nursing intervention for each of the nursing assessment areas
By
Anaise E. Ikama
Area of Nursing
Assessment
Fundus
Normal P. P. State
Describe your observation
Descend about 1 finger’s width
each day after 24 hours of delivery
Uterus three fingers below the
umbilicus and firm
Perineum
Is edematous, tender, and bruised
Lochia
Lochia rubra (red 3 days after
birth), lochia serosa (pinkish lasts
3-10 day), lochia alba (clear
mucus lasts 10-21 days)
Had perineal laceration of 1
degree
Moderate rubra
Rectal Area
Is edematous, tender, and bruised
Intact
Breasts
First 2-3 days breast are full but
soft. By the third day, they become
firm and lumpy as blood show
increases and milk production
begins
Soft, non-tender
Skin
Hyperpigmentation of the skin
Nursing Intervention
Assess firmness, location and
position of the uterus (below or
above the umbilicus)
Assess for redness (if associated
with pain = infection), Edema
(should be mild), ecchymosis
“bruising”, discharge (no discharge
from the perineum should be
present) and approximation (suture
line should not be separated). Teach
patient comfort and hygiene measure
Assess for foul odor, firmness,
location and position to prevent
hemorrhage. Because uncontracted
uterus allows blood to flow freely
from vessels at the placenta insertion
site
Assess for REEDA
Check the woman’s breast for
consistency, size, shape and
symmetry. Inspect nipples for
redness and cracking, flat or inverted
Puffy face, dark around the
Assess the skin, noticing its
Bladder
Abdomen
G. I. Elimination
Blood Pressure
Temperature
“chloasma”, and the linea nigra
neck area, linea nigra
and striae (fade from reddish to
silver)
Should not be characterized
bulging of lower abdomen; spongy
feeling mass pubis and fundus;
Not distended
displace uterus from the midline
and increase in lochia
Soft, non-tender with linea nigra
Soft and non-tender; linea
and striae
nigra and striae
Bowel sound: bursts of continuous
sound every 5 to 10 seconds with a
gurgling quality, representing the
movement of air and fluid through
the gastrointestinal tract
120mm Hg/80mm Hg
Ranges from 97.8° F (36.5°
Celsius) to 99° F (37.2° C).
Passed flatus. Growing sound
for bowel movement. Did
defecate (moderate soft)
127/74
99.4
Hemoglobin
12-16
11.5
Hematocrit
37-47
33.6
VDRL (venereal
A negative or nonreactive VDRL
Non-reactive
pigmentation, striae and linea nigra
Observe for fullness, output, burning
and pain
Continue assessing for tenderness;
normal color for linea nigra and
striae
Continue determining passage of
flatus, bowel sounds and defecation.
If client is constipated, suggest the
importance of eating fibers
Take BP, P, and R every 15 minutes
for an hour, then every 30 minutes
for an hour, and then every hour as
long as the patient is stable.
Report temperature above 38 C or
104 F and need to be evaluated
every 4 hours for the first 24 hours
Keep assessing the patient for signs
of bleeding
Assess patient for any type of
bleeding
Assess patient for sign and
disease research
laboratory
Urinalysis
is compatible with a person not
having syphilis
PH range from 4.6 to 8.0.
For a spot check by dipstick: for
Yellow, cloudy with PH of 6.5
protein, the normal values are
and no protein in urea
approximately 0 to 8 mg/dl.
For a 24-hour test: less than 150 mg
symptoms of syphilis
Continue assessing urine output
per 24 hours.
Rh Factor
Rh positive
A positive; negative antibodies
Assist the Rh negative mother in the
administration of the Rh(D) immune
globulin (within 72 hours) after
giving birth to a Rh negative infant.
Teach the patient about RoGAM