INTRAPARTAL ASSESSMENT

 Onset of labor until the delivery of placenta

1 Routine admission care (SPH)

1. Receive the patient
2. Don’t allow patient to walk (SOP wheelchair) if: RBOW, LBOW, severe vaginal
bleeding, increase BP, preterm labor, severely in pain, with bearing down sensation,
etc.
3. Change with DR slippers/ change wheelchair
4. Get the height & weight (Weight is use for the computation of drugs; Height can be
use to estimate the height of the baby)
5. Bring patient to receiving area (IE room)
6. Change street clothes to hospital gown. Remove underwear and jewelries, provide
privacy, if not contraindicated let patient void/urinate at CR or offer bedpan
7. Bring client to the IE bed, cover the legs with blanket
8. Ask about Demographics & OB data
9. Take VS
10. Measure Fundic height
11. Assist in attachment of EFM
12. Assist in lithotomy position on IE table
13. Do perineal flushing/shave
14. If patient is ready call OB
15. Bring client to labor room

2 History taking/Data gathering

1. Demographic data – complete name, age, address, reason or complaint on
admission, time uterine contraction started, passage of watery stool or bloody
mucoid vaginal discharge
2. Obstetrical Data
a. GPA - Gravidity (no. of pregnancy whether aborted of miscouraged), Parity
(no. of pregnancy that reaches the age of viability, either dead or alive basta
nakaabot 28 weeks), Abortion in pregnancy (termination of pregnancy before
the age of viability. Viability again in 28 weeks)
b. TPAL (per head)
 38-42 weeks AOG
 Preterm – 28-37 weeks
 Post term – 42 weeks above
 Living - # of children alive
c. AOG – computation of weeks of gestation based on LMP

 By weeks-based on LMP (ex. March 29, ang visit is today. 31 days

in march minus 29 = 2. April 30 May June July August 31
September October 7) (Total all and divide by 7 (days in a week)
  MC Donald’s Method – determination of AOG by measuring
Fundic Height (cm) divide by 4 equals results in months (FH/4=no.
in months)
Ex: 32 cm / 4 = 8 months
 Bartholomew’s rule – estimate AOG by relative position of the
uterus in the abdominal cavity (distance of the fungus to the
cyphoid process) (done through examination)
d. EDC (Expected date of confinement) (expected date of delivery)
 Nagele’s rule (-3+7+1) (constant minus 3 plus 7 plus 1) (Ex. March
29, 2021 – 3 + 7 + 1)

03 29 21
3 7 1
0 36 22
31
05. 22
Expected only. Pwede ma advance or ma delay
e. LMP (Last Menstrual Period) – 1ST day of LMP
f. Fundic Height in cms
g. EFW (Estimated Fetal Weight)
 Johnson’s Rule – estimates the weight of the fetus in grams
 FH – N x K (constant 155) (N is depende if engaged or not
engaged)
 11 – not engaged
 12 – engaged

Example: 32 – 12 x 155
20 x 155
= 3,100 grams / 3.1 kl / 3.1 x 2.2 = 6.82 lbs

EXERCISE:
 At 10AM, a pregnant client came in due to labor pains. Upon history
taking, it was revealed that her LMP wan on June 20, 2021. She already
has a 4-year-old son at home born at 39 weeks. Last year, she had a
miscarriage which made her so excited to have her current pregnancy.
You measured her fundic height which revealed 30cm

Answer:
EDC: MARCH 27, 2022
GPA: G3 P1 A1
TPAL: T1 P0 A1 L1

3 Medical Data
 a. Hypertension
b. Gestational Diabetes Mellitus
c. Laboratories:
i. CBC (hct, hgb – 12 – 16 gm/dl)
ii. UA (Urine analysis)
iii. Blood type (to check if compatible ba ang blood ng mother)
iv. RH factor
4 History of previous pregnancies
a. Method of delivery
b. Place of delivery
c. Risk involved/complications
5 Present Pregnancy – note danger signs
a. Nausea/vomiting
b. severe continuous headache
c. Vaginal bleeding
d. Pallor – indicates anemia, cardiac disorders
e. Absence of FHT (Normal FHT: 120-160)
f. sudden escape of fluid – indicates premature ruptured of the membrane
g. Swelling of face/lower extremities

Physical Assessment
1. Head to toe assessment (include mouth and teeth)
2. Baseline maternal and fetal status
a. VS for mother (BP: increase 15 mmHg in diastolic, refer immediately)
b. Uterine contractions
c. Weight
d. FHT, movements (Normal movements: 10x in 2 hours)
3. Leopold’s Maneuver
a. Not indicated to preterm and with severe bleeding
b. It is a standard palpation of the abdomen for assessing the fetal position,
presentation and degree of descent
 Steps: (Ask the mother to empty her
mother)
i. Presentation (Fundal Grip)
ii. Position (Umbilical grip) –
check position: fetal back and
extremities
iii. Engagement (Pawlik’s grip)
iv. Attitude (Pelvic grip) – the
degree of flexion especially if
it is Cephalic presentation

4. FHT – at the back

a. Normal range: 120 – 160 beats/min
b. Instrument used: Stethoscope, fetoscope, Doppler, Electronic fetal monitor
c. Should not be taken during uterine contraction

Pelvic Examination
1. Internal Examination
a. Let the patient void and explain the procedure
b. Place on lithotomy position
c. Shave halfmoon
d. Perineal flush
e. Call the OB resident/obstetrician
f. Assist the doctor-offer Sterile IE gloves, serve KY jelly
g. Take down notes of IE results:
i. Dilation – expressed in cm (Fully dilated is 10cm) (Some doctor will say, the
internal os is close, external os is open)
ii. Effacement – in % (Fully effaced is 100%)
iii. Station – expressed by – and + (Negative if above the ischial spine, positive if
below the ischial spine)
iv. Presentation – different presentation: cephalic (Type of delivery: NSVD),
breech (Type of delivery: CS), transverse
v. Bag of water – presented in L (leaking BOW), I (Intact BOW), R (Ruptured
BOW)
h. After care – to patient and to the area (Do after care of the mother first)

UTERINE CONTRACTION MONITORING

1. Frequency – beginning of one contraction to beginning
2. Interval – end of one contraction to the beginning of one contraction
 3. Duration – beginning to end of the same contraction
4. Intensity – strength of the contraction

PARTS OF ELECTRONIC FETAL MONITOR

1. Toco transducer – uterine contraction (no need toad gel)
2. Ultrasound transducer – fetal heart beat
3. Event marker – fetal movement

SURGICAL ASEPSIS
 Is the absence of all microorganisms within any type of invasive procedure. Sterile
technique is a set of specific practices and procedures performed to make equipment
and areas free from all microorganisms and to maintain that sterility (BC Centre for
Disease Control, 2010)

Principles of Surgical Asepsis

 All objects in the sterile field must be sterile
  Sterile objects become unsterile when touched with unsterile objects
 Sterile items that are out of vision or below the waist level of nurse must be considered
unsterile
 Sterile items become unsterile by prolonged exposure to airborne microorganisms
 Moisture that passes through sterile objects draws microorganisms from sterile surfaces
 Edges of sterile field must be considered unsterile
 Conscientiousness & honesty are essential qualities in performing surgical asepsis

When to Position patient for delivery?

S – Severe uterine contraction
U – Urge to defecate
B – Bearing down sensation
I – Increase bloody show
R – Ruptured bag of water
B – Bulging of perineum
A – Anal dilation/dilatation

INSTRUMENT USED IN DR
1. Allis Forcep – used to rupture bag of water

2. Blade & Blade holder – When attached it is called the Knife/Scalpel – used to incise the
perineum during episiotomy
3. Mayo scissors – used to cut the
perineal tissue during episiotomy
- Used to cut suture during episiorrhaphy

4. Curve/Straight clamps – 1st clamp used to clamp

umbilical cord; remaining two clamps would serve
as bleeders

5. Needle holder – hold the needles for episiorrhaphy

 6. Tissue Forcep with teeth – sued to hold perineal
tissue during episiorrhaphy\

7. Placental Curette – used to scrape remaining placental fragments in the uterus

8. Ovum Forcep – used to clean uterus with OS

Contents of OB pack:
 Big basin
 1 Pair of leggings
 3 towels
 1 Flannel
 1 Bonnet
 Arrangement:

Instrument Arrangement:
 Allis Forcep
 jSyringe 5cc
 Scalpel (blade holder with blade)
 Mayo scissors
 Clamps (3)
 Needle holder
 Tissue Forcep with teeth
 Placental curette
 Ovum forcep

Other Supplies needed: Chromic 2.0 double arm

 Cutting needle – used to suture perineal skin (1/3 length) – sa skin
  Round Needle – used to suture perineal tissues (2/3 length) – mahaba kasi sa inner
tissues na

 Plastic cord clamp

 Operating sponge
 Cotton ball in a bowl
 5cc syringe with needle
 Surgical blade
 Rubber suction bulb

ESSENTIAL INTRAPARTUM CARE

1. Wash your hands
2. Double glove (if solitary health care)
3. Call out time of birth
4. Dry baby thoroughly while observing for breathing
5. Remove all wet linen
6. DO NOT suction unless airway is obstructed
7. Place prone onto mother’s abdomen or chest
8. Cover with dry blanket and bonnet
 9. Inject oxytocin 10 IU IM, mother’s arm or thigh after excluding a second baby
10. Remove 1st set of gloves
11. Clamp and cut cord between 1-3 minutes or when pulsations stop
*clamp cord at 2cm with sterile cord clamp and at 5cm from base then cut close
to the first clamp

DO NOT apply anything (alcohol, providone-iodine) onto the stump

Once uterus is well contracted, do controlled cord traction with counter-traction and gentle
uterine massage
Deliver placenta into a .5% decontaminating solution
Examine the birth canal for bleeding and lacerations
Inspect the placenta and dispose appropriately

MANEUVERS DONE DURING DELIVERY

1. Ritgen’s Maneuver – applying pressure on the perineum after episiotomy to prevent
bleeding and further laceration during delivery
2. Brandt Andrew’s Maneuver – is the coiling of the cord to facilitate the delivery of the
placenta
3. Crede’s Maneuver – applying pressure on the abdomen to facilitate delivery of the
placenta

Note the presentation of the baby, time of delivery

SIGNS OF PLACENTAL SEPARATION

1. Sudden gush of blood
2. Globular shape of the abdomen (Calkin’s sign)
3. Lengthening of the umbilical cord
4. Rising of the fundus
TYPES OF PLACENTAL PRESENTATION
1. Schultz – clean, fetal side
2. Duncan – dirty, bloody, maternal side

Cotyledons – 15-25 Normal count

POST PARTUM ASSESSMENT

 AV – appearance/VS (Decrease BP because of blood loss of 500mg; increase
Temperature because of effort in labor and dehydration dahil naka NPO ang mother; No
changes in Respiratory rate unless with respiratory disease; Decrease pulse rate
because of decrease cardiac output)
 B – Breast (Mag engorge and if there is engorgement, there is pain so we need to apply
warm compress. To assess the breast of the mother check if inverted, if male you can
ask the mother if she can check it or ask other female St.Nurses. Aside from inverted
nipple, check also if there is crack and discharges, if ever there is discharges we need to
delay breastfeeding, it may be because of Mastitis)
  U – Uterus
 B – Bladder
 B – Bowel
 L – Lochia
 E – Episiotomy
 H – Homan’s sign
 E – Emotion
 R - Rhogam

Appearance
 Color of the skin
 Capillary refill
 Nail bed
 Proper assessment

Vital Signs
Temperature
- Increase on the 1st 24 hours – because of dehydration/effort in labor (it is normal)
- After 24 hours – infection
- After 3-4 days – milk production (allow the baby to suck even without milk)

Pulse
- Decrease due to decrease cardiac output (N: 80-90 bpm)
- Normally in 6 – 10 days the pulse will

Blood pressure
- Slightly decrease (because of blood loss)

Respiratory rate
- No changes (N: 16-23 but after delivery it will go back to normal which is 16-20)

Breasts
- Drop in estrogen and progesterone
- Lactating
- Colostrum is present (first milk that will come-out)
- Let-down reflex (magawas ang true milk)
- Warm and tenderness on the breast
- Engorgement
- Milk is produced by the 3rd – 4th day after delivery (will cause increased temperature)
- Veins are apparent (since the breast engorged)
 - Mammary gland – milk producing system
- Purpose is to nourish the child regardless of the size
- No redness or crack in the nipples upon assessment
- Before breastfeeding check if there in inverted because it will be hard for the mother
- When the mother chooses to the bottle feed, it is important for the nurse to teach
lactation suppression
- We do not use bottle feeding in the nursery, but instead we use cup feeding (30ml/1
cup) (Every feeding they consume 2 cups)
- Mandated for the government to encourage the mother to do breastfeeding (RA 10028)
- Best position for breastfeeding - Up-Right position

Uterus
- Size is reduced:
o immediately after delivery – 1000gms
o After and of 1st week – 500 grams
o After 6 weeks – 50 grams
- Placental; site is sealed off
- Cervical os are narrowed
- Painful during contraction
- Contracted (if not contracted could lead to postpartum bleeding) (If not contracted you
can instruct the mother to tickle the nipple to let oxytocin release)
- Involution – returning to their prepregnant state
- Located at the midline, if it is displaced on the right, it indicates a full bladder – what we
will do is to instruct the mother to empty the bladder
Bladder
- Voiding should occur 4-6 hours post partum (6-8 hours dapat naka urinate na si mother)
(In exam 6-8 hours but if in actual scenario is 4-6 hours) (if the mother do not have
output after 4 hours inform the CI, do not wait until the shift will end even if in the book
it is 6-8 hours) (but because of the trauma the mother is hesitant or will hold the
bladder because of the anticipated pain or trauma during the delivery)
- If you do your nursing intervention: Check first for the intake then palpate the bladder.
If Did not urinate ask to drink, touch or dip the hand in the water or basin, listen to the
running faucet, if not put a little water in the symphysis pubis (pus-on) – if still no
urination refer to the CI and then that is the time that the physician will administer
straight catheterization.
- At least 3000 ml per day – usually occurs for 2 to 3 days
- Diuresis – increase urine production (?)
- In post-partum, Residual urine may occur because of fear of mother or pain because of
trauma in bladder
- Full bladder will deviate the uterus in the right
- Incomplete emptying could cause edema
- After delivery encourage the mother to ambulate early
- Urine output = 30 CC/hour
- 90 – 100 CC/hour

Bowel
 - Becomes more active soon after birth (Active but you will not expect to immediately
excrete stool after birth because the mother is put on No per Orem (NPO) to prevent
defecating during delivery. But after 24 hours if the mother did not undergo epidural
anesthesia the mother is allowed to eat anything so you are expecting that after 24
hours the mother will excrete stool)
- Peptide hormone relaxin, - high circulating levels during pregnancy, depresses bowel
motility
- Continued effects of progesterone on the smooth muscles – decreases bowel motility
- Bowel movement typically delayed until 2nd or 3rd puerperal date
- Bowel tone is slowed (because the mother is lying only on bed. Walking will help
enhance the recovery of episiotomy that will facilitate defecating)
- During labor, restriction of food (or naka-NPO)
- Fear or tearing the stitches
- If after 3 days the mother still did not defecate – encourage fluid intake ang high fiber
intake, and allow the mother to walk/early ambulating, or you can also promote healing
of the stitches because she has fear of tearing – you can promote healing by performing
Sitz bath

Lochia
- Discharges of the uterus (no patient will submit to you to check so you will offer the
perineal care to check the discharges. When you assist you will be the one to pour the
water and remove the pad so that’s when you will observe the discharge – this is the
process of observation) (aside from that you can also offer cleaning – this way you can
also check for the external genitalia aside from the pad)
o Lochia rubra – 1-3 days bloody red in color
o Lochia serosa – 4-10 days pink or brown color
o Lochia alba – creamy, yellowish color
o Color should not interchange
- Pattern should not reverse
- Increase in activity
- Decrease in breastfeeding
- Not offensive in odor
- Without large clots
- Present in cesarean section
- Characteristics – indicative of the woman status in the process of healing and if this
discharge reverse it means there is no heeling in the site
- If there will be blood clot with the discharges of the uterus, as a student nurse you will
assess the firmness of the uterus or to assess if it is contracted or not and if you have
seen if there is discharges you will count the pads if it is saturated. Aside from that, you
have to assess for further inspection if there is occurrence of infection and then after
that this will be the time to report to the CI
Episiotomy/Episiorrhaphy
- Episiotomy is the cutting, laceration is more on the second layer
- Midline or mediolateral
- Lacerations
o 1st degree-skin, mucus membrane
o 2nd degree-skin, mucus membrane, fascia
o 3rd degree-skin, mucus membrane, muscles, rectal sphincter
o 4th degree-involve all these structures plus anal wall
- Assessment REEDA – redness, edema, echymosis, discharges and approximation (we use
chromic 2-0 suture) (approximation is when we check by asking if she can still palpate
the suture lines, if there’s none then the process is good – mostly it will fuse after 24
hours) (We can offer perineal care so we can do the Assessment- REEDA)
- If there is fever after 24 hours, you have to examine the episiorrhaphy
- To promote healing – you will apply ice pack to the hematoma
- If there is Bulbar hematoma, as a nurse you will ANALGESICS AS ORDERED
- You notice that there is slight separation in her episiorrhaphy – you will immediately
refer to the CI and then to the doctor
- You observe that there is Purulent discharges on the episiorrhaphy – you can encourage
Sitz bath because it can remove those discharges from the episiorrhaphy, or you can do
perineal flushing but you need to review the appropriate wiping (technique: from the
center going out)

EPISIOTOMY ASSESSMENT
 R – Redness
 E – Edema
 E – Ecchymosis
 D – Discharges
 A – Approximation

Homan’s sign
- Used in assessment of deep venous thrombosis (DVT) in the leg
- Varicosities and signs of thrombophlebitis
o Inflammatory process that causes blood clot to form and block one or more
veins
- Pedal pulses may be obstructed by thrombophlebitis and should be palpated with each
assessment
- To check, we allow the mother to dorsiflex the lower extremities and if there is pain in
the calf that means it is positive in Homan’s sign
- If positive (meaning there is thrombophlebitis), nursing responsibility is to refer
immediately to the doctor for further evaluation)
Emotional Status
- sense of elation immediately after birth
- Mother wanted to talk about her labor and delivery
- Exhausted, need rest and sleep to restore her body to health
- Normally during the 1st 24 hours – passive, preoccupied with own needs. Talkative if
unable to sleep
- 1-2 days beginning to assume responsibility
- Nurse should be sensitive of what the patient is manifesting, crying is sometimes means
joy
- Post-partum depression will not immediately occur
- When you gave birth there are patient who will have a sign of relief
- You have to continually asses the emotions of the mothers
- What will you do after assessing the patient post-partumly and after 24 hours you
observed that the mother is very quiet and frequently sleeping, and you think she will
just regaining energy, as a student nurse you will check and offer your healing patch of
pat the back of the mother, provide an opportunity for the mother to talk about her
problem and you will offer yourself and ear to relief her anxiety
- First hours the mother will wake up excited to see the baby and if she’s not there is
already alteration

Rh Incompatibility
- Possible when two specific circumstances exist:
o Mother is Rh negative
o Fetus is Rh positive – the father is Rh positive
- Causes no harm to the mother, but affects the fetus
- RhoGan – Rh immune globulin, unsensitized – 28/7AOG, 72 hours PP-IM lcterus Gravis-
RBC are destroyed, fetal bilirubin increases = kernicterus – bilirubin encephalopathy
- Erythroblastosis fetalis
- Coomb’s test
- Anti-bodies of the mother cannot recognize the antibody of the baby
- If there is incompatibility – EOG
- If not corrected it would cause to destroy the RBC that could cause Erythroblastosis
fetalis
- Can also be done after the delivery of the baby to know if they are compatible
- Nursing responsibility if there will be Rh incompatibility – another blood examination
will be done
- Within 72 hours dapat naka receive na si mother ng Rhogam injections
ESSEBTIAL NEWBORN CARE
 Wash your hands
 Keep in uninterrupted skin to skin contact until baby completes 1 st breastfeeding, or at
least 60-90 minutes even when transferring to the recovery room
 Time initiated
 Time stopped
 Watch for feeding cues at 20 to 90 minutes, encourage breastfeeding once present
 Time initiated
 Time completed
 Wash your hands
 Do eye care after the first breastfeeding
 Perform first complete PE, weighing and anthropometrics
 Give Vitamin K, Hepatitis B, BCG injections. After the first breastfeeding and PE
 Encourage breastfeeding per demand
 Observe at least one breastfeed for proper positioning and attachment
 Minimize handling of the newborn
 DO NOT bathe the baby for at least the 1st 6 hours
 DO NOT give sugar water, formula, or other liquids
 DO NOT use pacifiers or bottles

Video:
Newborn Care
1. Immediate and thorough drying
2. Early skin-to-skin contact
3. Properly timed cord clamping
4. Non-separation for early breastfeeding
a. Carry out eyecare and immunization procedures
b. Rooming in

ANTHROPOMETRIC MEASUREMENTS
Head circumference – 33-35 cms
Chest circumference – 31-33 cms
Abdominal circumference – 28-30 cms
Length – 48-53 cms
Weight – 2.35-4 kls
APGAR SCORING SYSTEM
SITE OF INJECTION

ENDORSEMENT
 It is the communication process that occurs between two shifts of nurses whereby the
specific purpose is to communicate information about patients under the care of nurses
for continuity of care
 It is also referred as Bedside Handover

NARRATIVE CHARTING
 Method of nursing interventions and the impact of these interventions on client
outcomes are recorded in chronological order covering a specific time frame
 Data is recorded in the progress notes, often without an organizing framework

 Record the time and date of the entry

 Assessment
 Record only facts. Leave out personal opinion and judgments
 Interventions
 Care provided
 Patient response to care

ENDORSEMENT PROCESS
 Begin: summary of the total census within the shift
 DR/Labor Room Bed. No., Patient’s complete name, age, religion
 Attending physician and respective co-managements (if any); take note: out-of-town
(OOT) & inclusive dates and “to-see-patient”
 House/private case
 Date of admission, chief complaint & tentative diagnosis/impression
 History of present illness
  Diet, allergies
 Laboratory/ diagnostic tests (done and pending)
 Vital signs, I&O, IE, EFM
 History of procedures/medications given
 Attachments (IV include also if with side drips, Cath, etc.)
 “end of endorsement”

DOCUMENTATION/CHARTING
Never send the chart home with the patient
Fill in the headings
Never write on medical sheet
Check for new orders; include orders for new lab tests in charting
PA, Nsg. Interventions r/t current situation
Record relevant details
Signing nurse’s notes
Avoid erasures, superimpositions
Use ME (Medical Error)
Post-Op charting: new sheet after the PACU notes
Chart usage
Include in health teachings
May NOT include:
 Routine doctors’ orders
 Endorsed to NOD
 Diet, unless for a certain procedure

IV INFUSION

IV COMPUTATION
INTRAVENOUS THERAPY
 Iv therapy is the administration of fluids or medication via a needle or catheter
(sometimes called a cannula) directly into the bloodstream

INDICATION FOR INTRAVENOUS THERAPY

 Patients can receive life-sustaining fluids, electrolytes, and nutrition when they are
unable to eat or drink adequate amounts
 The IV route also shows rapid delivery of medication in an emergency. Many
medications are faster acting and more effective when given via the IV route. Other
medications can be administered continuously via IV to maintain a therapeutic blood
level
 Patients with anemia or blood loss can receive lifesaving IV transfusions
 Patients who are unable to eat for an extent period can have their nutritional needs
met with total parenteral nutrition (TPN)

Types of Infusion
TYPES OF IVF SOLUTIONS
 COLLOIDS
 Fluids that expand the circulatory volume due to particles that cannot cross a
semipermeable membrane
 CRYSTALLOIDS
 Work much like colloids but do not stay in the intravascular circulation as well as
colloids do, so more of them need to be used

IVF CLASSIFICATION TONICITY

 Isotonic
 Have the same concentration of solutes to water as body fluids
 When administered to a patient requiring water. It neither enters cells nor pulls
water from cells; it therefore expands the extracellular fluid volume
 Hypotonic
 Have more solutes (i.e., are more concentrated) than body fluids
 Used when fluid is needed to enter the cells, as in the patient with cellular
dehydration. They are also used as fluid maintenance therapy
 Hypertonic
 Have fewer solutes (i.e., are less concentrated) than body fluids
 Hypertonic solutions are used to expand the plasma volume, as in the
hypovolemic patient. They are also used to replace electrolytes
FACTORS AFFECTING FLOW RATES
 Change in catheter position
 Height of the solution
 Patency of the catheter

COMMONLY ADMINSTERED IV FLUIDS WITH NURSING IMPLICATIONS

ISOTONIC SOLUTIONS  Monitor for fluid overload

0.9% Saline Lactated
Ringer’s solution

HYPOTONIC SOLUTIONS  Monitor for inflammation and infiltration at IV insertion

0.45% Saline or 0.25% site as hypotonic solutions may cause cells to swell and
Saline D5W burst, including those at the insertions site; this
narrows the lumen of the vein
  Do not administer to patients at risk for increased
intracranial pressure (e.g.

HYPERTONIC SOLUTIONS
Hypertonic fluids have a
tonicity >350 mEq/L and
include the ff: Fluids

IVF CLASSIFICATION ACCORDING TO PURPOSE

 HYDRATING
 Replace water loss
 Dilute meds
 Keep veins open
 MAINTENANCE
 Replace electrolyte loss at EFC level
 Maintenance in patients with no oral intake
 Replace fluid loss
  Treatment for dehydration
 NUTRITIONAL
 Promotes faster recuperation
 VOLUME EXPANDER
 Increase osmotic pressure thus maintain circulatory volume

INTRAVENOUS ACCESS
Intravenous therapy can be administered into the systemic circulation via the (1) peripheral or
(2) central veins
1. Peripheral veins – lie beneath the epidermis, dermis, and subcutaneous tissue of the
skin. They usually provide easy access to the venous system
2. Central veins – are located close to the heart. Special catheters that end in a large vessel
near the heart are called central lines

ADMINISTERING PERIPHERAL INTRAVENOUS THERAPY

 Check physician’s order
 Wash hands
 Gather Equipment
 Assess and prepare patient
 Select site and dilate vein

CONSIDERATIONS FOR VEIN SELECTION

 Age of patient
 Availability of sites
 Size of catheter to be used
 Purpose of infusion therapy
 Osmolarity of solution to be infused
  Volume, rate, and length of infusion
 Degree of mobility desired

NOTE:
- Hand veins are used first if long-term intravenous therapy is expected
- Hand veins can be used successfully for most hydrating solutions, but they are best
avoided when irritating solutions of potassium or antibiotics are anticipated
- Vein size must also be considered. Small veins do not tolerate large volumes of fluid,
high infusion rates, or irritating solutions. Large veins should be used for these purposes
SELECT THE NEEDLE (Catheter)
 Needles have been largely replaced with flexible plastic catheters that are inserted over
a needle. The needle (or stylet) is removed after the catheter is in place
 These are available in a variety of sizes (gauge) and lengths.
 For patient comfort, choose the smallest gauge catheter that will work for the intended
purpose
 Use smaller gauge catheters (20 to 24) for fluids and slow infusion rates
 Use larger catheters (18 gauge) for rapid fluid administration and viscous solutions such
as blood
 Also consider vein size when choosing a catheter gauge
ADMINISTERING PERIPHERAL INTRAVENOUS THERAPY
 Put on gloves
 Prepare the site
 Insert the catheter
 Stabilize the catheter and dress the site
 Label the site
 Dispose of equipment
  Educate the patient
 Calculate drip rate
 Document

*continue (3rd slide)

GENERAL CONSIDERATIONS WHEN INITIATING INTRAVENOUS THERAPY

 When multiple sticks are anticipated make the first venipuncture distally and work
proximal with subsequent punctures
 If therapy will be prescribed for longer than 3 weeks, along-term access device should
be considered
 Avoid using venipunctures in affected arms of patients with radical mastectomies or a
dialysis access site
 If possible, avoid taking a blood pressure in the arm receiving an infusion because the
cuff interferes with blood flow and forces blood back into the catheter. This may cause a
clot or cause the vein or catheter to rupture
 No more than two attempts should be made at venipuncture before getting help
 Immobilizers should not be placed on or above an infusion site

NOTE:
 Hand veins are used first if long-term intravenous therapy is expected
 Hand veins can be used successfully for most hydrating solutions, but they are best
avoided when irritating solutions of potassium or antibiotics are anticipated
 Veins size must also be considered. Small veins do not tolerate

COMPLICATIONS OF PERIPHERAL IV THERAPY

Local Complications of IV Signs and Symptoms Nursing Interventions

Therapy
Hematoma Ecchymoses Remove catheter
Swelling Apply pressure with 2x2
Inability to advance catheter Elevate extremity
Resistance during flushing
Thrombosis Slowed or stopped infusion Discontinue catheter
Fever/malaise Apply cold compress to site
Inability to flush catheter Assess for circulatory
impairment
Phlebitis Redness at site Discontinue catheter
Site warm to touch Apply cold compress initially;
Local swelling then warm
Pain Consult physician if severe
 Palpable cord
Sluggish infusion rate
Infiltration (Extravasation) Coolness of skin at site
Taut skin
Dependent edema
Backflow of blood absent
Infusion rate slowing
Local Infection Redness and swelling at site
Possible exudate
Increase WBC count
Elevated T lymphocytes
Venous Spasm Sharp pain at site
Slowing of infusion
SYSTEMIC COMPLICATION OF PERIPHERAL IV THERAPY
COMPLICATION Signs and Symptoms
Septicemia Fluctuating temperature
Profuse sweating
Nausea/vomiting
Diarrhea
Abdominal pain
Tachycardia
Hypotension
Altered mental status
Fluid Overload Weight gain
Puffy eyelids
Edema
Hypertension
Changes in input and output
(I&O)
Rise in central venous
pressure (CVP)
Shortness of breath
Crackles in lungs
Distended neck veins
Air Embolism Lightheadedness
Discontinue catheter
Apply cool compress
Elevated extremity slightly
Follow extravasation
guidelines
Have antidote available
Discontinue catheter and
culture site and catheter
Apply sterile dressing over
site
Administer antibiotics if
ordered
Apply warm compress to site
Restart infusion in new site if
spasm continues
Nursing Interventions
Restart new IV system
Obtain cultures
Notify physician
Initiate antimicrobial therapy
as ordered
Monitor patient closely
Decrease IV flow rate
Place patient in high fowler’s
position
Keep patient warm
Monitor vital signs
Administer oxygen
Use micro drip set or
controller
Call for help!
 Dyspnea, cyanosis,
tachypnea, expiratory
wheezes, cough, chest pain,
hypotension
Changes in mental status
Coma
Place patient in
Trendelenburg’s position
Administer oxygen
Monitor vital signs
Notify physician

EDUCATE THE PATIENT

 Proper regulation of the IV
 ….