Narrative Documentation Postpartum (Include Findings on focused assessment)
Postpartum assessment includes the phase BUBBLEHE:
Breast: gentle assess and palpate each breast to check for swelling, any drainage, redness around the
nipples, lymph node, and pain. Take opportunity to educate patient about milk production, self-breast
examination.
Uterus: palpate and massage uterus to feel for any lumps and have patient feel uterus for involvement.
Note findings.
Bladder: inspect and palpate bladder while checking on fundal height, check for order for catheter or if
catheter is in place, teach about proper perineal care.
Bowel function: Question daily about bowel movement, teach about increasing fibers and water in diet
to reduce and prevent constipation.
Lochia: Inform about changes she should expect, inform her when the next menstrual cycle would be
and what to expect.
Episiotomy: Check rectal area properly, check for redness swelling, skin breakdown, if hemorrhoids,
warm sitz bath and local analgesics.
Homan’s sign: Press on patient knee and ask to flex the foot, if pain in both might be from position
during labor, if only one foot, do follow up to check for DVT.
Emotional Support: Elevate from day of admission for emotional support, determine if additional
support is needed. Explain to family and mother that emotions may shift from high to low. Explains
changes she should expect.
Narrative Documentation Newborn (include findings on newborn assessment)