BUBBLE HE ASSESSMENT

Actual/ risk for

Subjective data – Patient Interview Objective Data – Nursing assessment
Nursing DX
1. Do you have any nipple discharge? Comments:
 Yes
 No
2. Is there any presence of milk?
 Yes
 No
3. Is your nipple inverted/ overted?
 Yes
 No
4. Do you feel any tenderness/pain in your
breast?
 No
 Right
 Left
Acute Pain
Breast

 Bilateral
Since when?
5. Is there any redness and swelling in your
impaired skin
breast?
integrity
 No
 Right
 Left
 Bilateral
Since When?
6. Have you noticed any change in the size or
shape of your breast?
 Yes
 No
7. Do you feel any lumps in your breast?
 Yes
 No
Since When?
 Actual/ risk for
Subjective data – Patient Interview Objective Data – Nursing assessment
Nursing DX
Comments:
1. Do you experience contractions?
 Yes
 No
2. How will you rate your pain?
1 2 3 4 5 6 7 8 9 10
3. How long do this contractions occur?
___mins ___hours ___day
4. How many times does it occur?
 2-3x
 once
5. Are there any discharges of blood?
 Yes
 No Constipation
6. If yes can you describe is it blood
Uterus

 serum
 yellowish
7. If there is (can you rate like number of
diapers)
1 2 3 4
8. Is there any pain at uterine area? Acute pain
 Yes, rate it 1 2 3 4 5 6 7 8 9 10
 No
9. Do you experience uterine atony?
 Yes
 No
10. Is there any tenderness?
 Yes
 No
 Actual/ risk for
Subjective data – Patient Interview Objective Data – Nursing assessment
Nursing DX
Comments:
1. Do you frequently have a strong, sudden
urge to urinate?

2. Do you sometimes not make it to the

bathroom in time?

3. Do you go to the bathroom more than 8

times in 24 hours?

4. Do you get up 2 or more times through

the night to urinate?

5. How long have you had these

Functional urinary
symptoms?
Bladder

incontinence
6. Do you experience a loss of urine
during physical exertion?
Total urinary
incontinence
7. Do you experience a loss of urine when
you sneeze or laugh?
Impaired urinary
8. Do you experience a burning sensation
elimination
when you urinate?

9. Do you frequently have a strong, sudden

urge to urinate?

10. Do you have to go to the bathroom more

than 8 times in 24 hours?

11. Did your symptoms come on suddenly?

 Subjective data – Patient Interview Objective Data – Nursing assessment Actual/ risk for
Nursing DX
1. How often do you have bowel movements 1. Color of stool:
in a week?  Brown
 Once a week  Green
 2x a week  Yellow
 3x a week  Pale
____other *indicate  Black
2. Do you experience pain when having bowel  Red
movement? 2. Consistency of stool:
 Yes  Soft but firm
 No  Loose/watery
3. Hard Presence of mucous in stool:
3. Do you experience a need to strongly strain  Present
when having bowel movement?  None Bowel incontinence
Bowel

 Yes 4. Presence of blood in stool:

 No  Present Constipation
4. Do you sometimes feel a need to pass more  None
stool after having bowel movement? Diarrhea
 Yes Comments:
 No Dysfunctional GI
5. Do you exceed from 15 minutes when motility
having bowel movement?
 Yes
 No
6. Do you experience constipation?
 Yes
 No
7. Do you experience diarrhea?
 Yes
 No
 Subjective data – Patient Interview Objective Data – Nursing assessment Actual/ risk for
Nursing DX
1. Did you experience any vaginal bleeding? Comments:

2. What is the intensity of the bleeding?

 Heavy
 Normal
 Light

3. How many pads did you use in a day?

4. Is there any foul odor? Risk for pain

5. What is the color of it? Risk For infection

 Red
Lochia

Anxiety
 Pink
 Brown Deficient knowledge
 yellowish white
risk for Excessive
6. Number of days in the occurrence of fluid
discharge
1 2 3 4 5 6 7 Deficient fluid volume

Risk for altered

parent -infant
attachment
 Actual/ risk for
Subjective data – Patient Interview Objective Data – Nursing assessment
Nursing DX
1. Do you feel pain in your genitalia? Redness:
 Yes
 No Edema/Swelling:
If yes, rate it 1-10:
2. How often do you wash your genitalia? Ecchymosis:

3. What do you use in washing/cleaning your Discharge:

genitalia?
Approximation:
4. Is there any blood in your underwear?
 Yes Length of stitches: Blood Loss
 No
Ephysiotomy

5. Do you feel pain when urinating? No. of stitches Acute Pain

 Yes
 No Sit/Location: Severe pain
6. Is the wound already healed?  Left lateral perineum
 Yes  Right lateral perineum Risk of infection
 No
Comments:
 Subjective data – Patient Interview Objective Data – Nursing assessment Actual/ risk for
Nursing DX
1. Can you raise your leg ma'am? Comments:
 yes
 no
2. Do you feel pain when raising your leg?
 Yes
 No presence of pain
3. Can you bend your legs ma'am? (How
far?)
 yes, full flexion
Activity Intolerance
 yes, but a little
 no not at all
4. Do you experience pain while bending
your legs?
 Yes, a radiating pain
Homan’s Sign

Impaired sensory
 NO function
5. Can extend your legs?
 Yes, I can fully extend
 Yes, but only partial extension
 No
6. Any pain when your foot is dorsiflexed?
• Delayed surgical
 yes recovery
 Radiating pain
7. In what angle can you dorsiflex your
foot? (Use goniometer)
 55°
 45°
 35°
 25°
 10°

8. Do you feel pain on your calves?

 No pain
 Yes, but only when I move
  Yes, even if I'm not moving
9. Do you experience cramps on your
calves?
 Episodes of cramps
 No cramps at all
10. Can you feel your legs?
 No sensation
 Yes

Subjective data – Patient Interview Objective Data – Nursing assessment Actual/ risk for
Nursing DX
1. What do you feel? Comments:
 happy
 sad
 restless restlessness
2. Are you prepared?
 Yes, I’m expecting the baby
Emotional

 No Iam
3. Are you happy and contented?
 yes health deficit
 no
4. How would you handle the situation?

5. Are you confused?

6. Do you experience any mood swings?

7. Disturbances in sleeping?

 complete8-10 hours
 6-5hours
8. Difficulty in focusing/decision making?
 Yes I need help
 no
9. Are you afraid/doubtful?
 yes
 no