lesson plan

ON
“BUBBLE-HE”

SUBMITTED TO SUBMI

SPECIFIC OBJECTIVES:
 Definition of BUUBB HELE –HE
 Meaning of BUBBLE HE
 Forms of BUBBLE –HE
 Description of BUBBLE HE
S Specific Time Contents A/V Teaching evalua
No. Objective aids and tion
Learner
activity
1 To 2min BUBBLE-HE Chart Lecture cum What is
Introduce utes is a acronym used to denote the discussion. BUBBLE
the components of the postpartum maternal –HE?
BUBBLE- nursing
HE. assessment. This method enhances the
standard physical assessment process
typically performed
on hospitalized patients by the RN, such as
those on a Medical-Surgical floor. For stable
patients,
vital signs are taken every 15 minutes during
the first hour following delivery and then
gradually
less frequently. While performing the
BUBBLE-HE, the RN often uses the
To explain assessment time to Which
the full provide for patient education. all are
form of 20 The BUBBLE-HE Acronym Chart Lecture cum the
2 B: Breast
BUBBLE – min discussion function
HE and U: Uterus of
function B: Bladder BUBBLE-
and role of B: Bowels HE ?
each L: Lochia
H: Homan’s
wards(BUB
E: Episiotomy and perineum
BLE -HE).
B: Breast
Breast Assessment
Assessment include evaluating the breast in
the postpartum period
The first step is to determine if the new
mamma is breastfeeding or bottle-feeding:
This
will guide the assessment along with patient
education
Breast Evaluation
Size
Shape
Firmness
Redness
Symmetry
Bottle-Feeding Mom: Lactation
Suppression
Teach the mom about breast engorgement.
This usually occurs about 72 hours after
birth
The breasts will be very tender with a
feeling of heaviness
A firm, snug-fitting bra is ideal for the
woman whose not breastfeeding. Also this
will
help, engorgement may still occur
Ice and cabbage leaves can provide relief.
There is an enzyme in the cabbage leaves
that
helps
Do not express milk as it will encourage
additional production
Any warmth over the breasts and
stimulation of the nipples will create a
faucet-like effect
Breastfeeding Mom
Focus on the nipple and areola. The nipple
should be erect, but some are flat or inverted.
Hopefully, this was identified during the
pregnancy in order for shield to be placed
upon
them
Assess the nipples for signs of bruising,
crackling, chapping. A deep crack or blister
may
indicate incorrect placement or another issue
Avoid placing want cold packs on the
breasts
Mastitis Infection: Nursing
Considerations
Mastitis is an infection of the breast
surrounding the ducts that’s characterized by
fullness, pain, warmth, and hardness of the
breast. It’s crucial to differentiae
infection from engorgement. Mastitis may
involve fever, while localized symptoms
are limited to specified area that usually
appears red and feels warm and possibly
hardened
Mastitis needs to be treated with antibiotics
and the patient is usually encouraged to
continue breastfeeding. The cause of
infection is associated with stagnant milk in
the
ducts. In most cases, the milk is not infected;
only the ducts
The best way to feed is to start on the
uninfected breast first. The mother should
then switch to the affected breast within a
few minutes so this breast can be fully
emptied
and drained. The infant is the best drainer-
no breast pump can ever compare. The only
time a breastfeeding mom is asked to stop is
when boils and/or cysts are present
Breast and Bottle Feeding
The decision to breast or bottle feed is
highly personal. While the benefits of breast
milk
nutritionally and physiologically outweigh
those of formula, it may not always be
possible or in
the best interest of the mom and baby to
breastfeed. The nurse’s role is to educate the
mom and
support the family in whatever choice is
made, not pass judgment.
Benefits of Bottle Feeding
Not solely a “Mom-only” responsibility
Breastfeeding does not always “come
naturally” to all moms- it may be difficult
for some
May be considered more socially
acceptable to whip out a bottle in the middle
of a
restaurant versus a breast
May be easier for moms who work outside
of the home
Bonding ↔ dad and baby or other relatives
who feed
Disadvantages of Bottle Feeding
No passive immunity
Harder for baby to digest
Expensive, especially if a specialized
formula is needed
More allergies
Overfeeding is easier
Stool is more odorous
Benefits of Breast Feeding
Passive immunity
Less incidents of ear infections (formula
pools into the Eustachian tube)
Easy digestibility
Bonding between mom and baby
No cost and always available and at the
right temperature
For the foodies: Some moms may enjoy
being able to eat an extra 500 calories/day
Benefits to Mom: Release of oxytocin (the
“let-down”) causes the uterus to contract,
which promotes quicker return to pre-
pregnancy weight. It also decreases risks of
ovarian
and breast cancer
Breastfeeding Teaching
Positioning: holds- chest to chest or tummy
to tummy in some way, grab under the
breasts and push down and out (taking the
milk ducts and pushing it forward, make a
CHold
around the areola (pull back, down, and
forward while bringing forward)
get a nice big drop of colostrum on the
nipple
tickle the lip with nipple, shove as much
breast as possible into the mouth once it’s
open
5 to 15 minutes a first to prevent soreness
Start with the breasts that was left from
Try to feed every 2 hours
Formula Teaching
Ready-to-feed: most expensive but
convenient
Concentrate: do not ever add more water or
concentrate it
Powder: follow directions per label
Throw the bottle contents out after the
feeding- do not save for next feeding
Start off small by only preparing 2 ounces
at a time
No need to warm formula up
 U: Uterus
Uterine Assessment
1. Fundus: firm or boggy- make a “C-
shape” with your hand and push up on the
lower
fundus; if it’s not stabilized, the uterus can
prolapse, or fall into the vagina. Massage of
not firm- secure lower uterine segment. The
concern is for hemorrhage; the primary
causes are a distended bladder (uterus can’t
contract or uterine atony, or failure to
contract fully) and retrained placental
fragments (usually a later cause)
2. Fundal Height: where is it in relation to
the umbilicus? “U/U” or “At the U” (1/U =
1 cm above the umbilicus)- drops one
centimeter or finger width. The position
drops one
centimeter every 24 hours for 10 days
postpartum
3. Midline or Deviated to the Left or
Right: if deviated, it’s usually a sign of a
full
bladder
Uterine afterpains of a breastfeeding mom
get worse with each pregnancy. The uterus is
a muscle
and the more it is stretched, the more force is
needed in order to contract.
Nursing Consideration. A boggy fundus
To enhance may be a sign of uterine atony, which places Tell
the nursing 15 the about
skills. Min. patient at risk for developing a postpartum nursing
hemorrhage and other complications. Also, planning
fundal ?
location that lies out of range with
anticipated location according to postpartum
status may be
another indication. The nurse should
perform a uterine massage, which promotes
blood
movement out of the uterus, and also
encourage the patient to void, as a full or
distended bladder
can impede uterine involution and
contractions. The nurse is often in the
position as the first
member health care team to learn of these
warning signs and therefore must take swift
action if
an issue is suspected.
Read more about uterine atony and
postpartum hemorrhage treatment under the
Perinatal
Complications Page

B: Bladder
Bladder Assessment
Ask mom when she last voided
Establish a Voiding Schedule to prevent
bladder distension and urinary stasis
Encourage mom to urinate every time
before she feed baby (as they may fall
asleep)
Possible Obstacles to Voiding
Mom may become so engrossed with baby
that she forgets to void
Internal inflammation from labor trauma
may impair ability to void
Mom may hesitate to void from fear of
pain, especially if she has an episiotomy or
vaginal tearing
C-section patients may also have issue with
voiding following removal of the folly
Nursing Interventions for Postpartum
Bladder Care
Peri-bottle- teach mom to always bring the
bottle, which is used for perineal irrigation,
to
the restroom to use rather than toilet paper;
the bottle is filled with warm (NOT hot)
water from the faucet and occasionally
mixed with an antiseptic or analgesic
solution if
ordered by the provider or permitted by
hospital policy. The contents are sprayed on
the
area following each void/bowel movement
to use rather than toilet paper
Teach mom to use Tuck’s Pads, which
contain witch hazel
Dermaplast is a topical spray, may be
applied to help control pain
A strait cath may need to be used if mom
doesn’t void within an acceptable time
(usually
12 hours postpartum)
WARNING SIGNS: Perineal area is dark,
moist, and bloody, especially when
combined urinary
stasis

B: Bowels
Bowels Assessment
Bowels in shock- just moved into some
strange positions.
Take a stool softener- don’t want ripping or
the episiotomy or trauma to the C-section
incision

L: Lochia
Lochia Assessment
Assess the color, odor, and amount
The lochia color should forward in the
progression of lightness, never go backwards
Lochia Color
Lochia Rubra: bright red, may have small
clots, usually lasts 3 days
Lochia Serosa: pink, serous, other tissues
Lochia Alba: tissue, whitish
Lochia Odor
NCLEX: lochia should have “no odor” or
“no foul odor”
Real world: virtually all lochia has an
unpleasant or at least a neutral odor
associated with
it and moms may be quick to describe it as
“foul”
It’s important for the nurse to assess the
odor to eliminate subjective patient
description
of the scent
A truly foul odor or a change in odor may
be a sign of infection
Lochia Amount
Scant = 2.5 centimeters saturation *
Light = < 10 centimeters saturation
Moderate = > 10 centimeters saturation
Heavy = pad is completely saturated within
2 hours
Postpartum hemorrhage is clinically
defined as a pad saturated within 15-30
minutes
NCLEX world: The pad is saturated within
15 minutes to be considered a hemorrhage
situation. In the real world, a pad that
becomes saturated within 30 minutes is a
cause for
additional evaluation
Scant saturation in the immediate
postpartum period can be just as concerning
as
excessive lochia production. Clots: up to
cherry sized are okay, peach or plum sized
is not. Clots are the most common in the
morning following the first void due to the
saggy texture of the vagina, which releases
the lochia build-up from the night.

E: Episiotomy and
Perineum
REEDA Assessment
R: Redness
E: edema
E: ecchymosis
D: discharge
A: approximation. Read more about
REEDA
Perineal Area Assessment
Pull the labia from front to back
Check the episiotomy or areas of vaginal
tearing
Look for hematoma formation- a collection
of blood in between tissue
Look for hemorrhoids (developed during
pregnancy or during labor from the pushing
process)
Nursing Intervention. Always help mom
get up and ambulate the first two times after
birth to assess for mobility, reduce the risk
of falling, and prevent trauma to the
perineum
and C-section incision
Hematoma Care
Start with cold to stop the bleeding, once it
stops, begin warm
Continue to monitor
If it get worse, that active area of bleeding
is non-healing and it will need to be opened
and the active area is discovered and
cauterized
May not appear so much of an out-
pouching as much as a disfigurement
Hemorrhoids
Vasculature that forms a pouch
Color can match the skin of the rectal area
and may look more like a blood blister when
irritated
Severe hemorrhoids appear as grape
clusters
Dermaplast spray
Patient may not be aware, may only known
that business down there is not as usual
Nursing Interventions. Seitz Bath: a
rotating fluid that moves the water. May fit
over the
commode or one can be performed with no
special equipment using the bathtub other
than a
bathing ring. Turn tub on and allow drain to
open and use a ring for circulating water. It’s
very
shallow and only bathes the perineal area.

H: Homan’s Sign
Assess for Signs of DVT by the Homan’s
Sign
A positive Homan’s sign is indicative of
DVT, although it’s not the most reliable
indicator
All of the characteristic changes to
maternal clotting factors are higher than any
other
point as the body prepares for labor
Combine this with being in bed, especially
if mom underwent a C-section, and it’s easy
to see why the postpartum woman is at such
a huge risk for DVT!
Performing the Homan’s Test
Most commonly performed with the mom
in a supine position while laying in bed
The calf is flexed at a 90° angle
The nurse manipulates the foot in a
dorsiflexion movement
If pain is felt in the calf, the Homan’s Sign
is said to be positive
Signs of DVT
A sudden and unexplainable pain, usually
in the back of the leg or calf
Tachycardia and shortness of breath or
dyspnea (from decreased oxygenation status)
Edema, redness, and warmth localized over
the area of the DVT (from the vascular
buildup
around the clot)
Preventing a DVT
Dangle at the side of the bed within 6 hours
Stand up within 8 hours
Encourage ambulation at first and
independent walking when ready
Potential Complications of a DVT
Pulmonary embolism (PE) occurs when a
clot breaks way from the leg area and travels
to
the lungs
A PE is medical emergency!

E: Emotional Status
Emotional Status and Bonding Patterns
Fluctuations in estrogen levels are blamed
for the emotional roller-coaster that many
moms experience after birth
High levels of stress, increased
responsibility, and sleep deprivation
exacerbate this
Bonding refers to the interactions between
the mamma and baby
Caregiving of self and baby is an indicator
of emotional status
Common Postpartum Assessment
Findings
The Taking In Phase. May be considered
as a self-focused, re-lived experience. This is
different from the maladaptive
Taking Hold Phase. A little bit about the
mamma, a little about the baby. The world
appears to be revolved around the baby and
mamma as an unit
Letting-In Phase. Mamma allows other
people in
Comparing Blues, Depression, and
Psychosis
Postpartum Blues. Usually occurs within
2-3 weeks. Mamma may be sensitive, such
as
crying during a commercial, mamma may
view it as humorous in hindsight
Postpartum Depression (PPD). When the
blues moves to the point where momma
can’t
care for herself or the baby
Postpartum Psychosis. A severe form of
depression that warrants immediate
intervention. When mamma harms herself or
the neonate or considers doing so. Typically
is predicated by depressive episodes
Nursing Interventions
The patient should fill out a form to assess
emotional risks. The form will ask if the
patient has a history of PPD or depression
not associated with pregnancy
There’s always a social worker available in
the event that the patient is acting strangely.
The nurse may need to fill out a document
such as a Risk Assessment Form.
Summary :
So for we have discussed about the meaning , full form , functions and roles of each
word of BUBBLE - HE , and nursing intervention regarding BUBBLE –HE.

Conclusion :
At last I conclude my topic by saying that BUBBLE-HE man have a significant role fom
pregnancy to puerperium periods . In many cultures, inability to fullfiy these requirements ,
which all are necessary for mother and baby for effective health and prevention of
diseases.Being a nurse,we can play a vital role in it by explain the advantages and benefits of
BUBBLE –HE .

Refferance :

 VG Padubidri & SN Daftary , “Howkins & Bourne Shaw ‘ Textbook of Gynecology”,

Specific Objectives :
 Introduce the BUBBLE-HE.
 Explain the full form and function of word BUBBLE- HE.
 Enhance the knowledge and practice of nursing.