BREASTS NEURO

1. Position pt / privacy 1. Presence and degree of pain/ discomfort

2. Assess 2. ID response and DTR when appropriate,
a. appearance sitting up
b. redness SBAR
3. Palpate - soft/ full/ engorged 1. Situ
4. Assess nipple - 2. Background
a. inversion/ 3. Asmt
b. cracks/ 4. Recom
c. soreness/ DOCUMENT
d. fissures 1. docucare
CARDIOVASCULAR
1. Edema/ pitting v non-pitting
2. DVT
GU-ABDOMEN
1. Assess - distension
2. If c/s pt - assess incision
3. Auscultate - bowel sounds
4. palpate fundus -
a. location/
b. firmness/
c. massage prn
5. Palpate bladder -
a. full/
b. monitor voiding
GU-PERINEUM
1. Position pt/ privacy
2. Assess perineum -
a. edema/
b. redness/
c. bruising/
d. hematoma
3. Assess episiotomy if present -
a. edema/
b. redness/
c. bruising/
d. discharge/
e. edge approximation
4. Assess lochia -
a. presence/
b. amount/
c. odor/
d. color/
e. presence of clots?
5. Assess hemorrhoids prn - presence and
condition