Delivery Room

Tuesday, 3 May 2022 6:20 pm

• Process of Delivery

• Screen clipping taken: 31/08/2021 7:12 am

Action Rationale
Prior to Woman's Transfer in the
Delivery Room
1.Be sure that the woman in labor is To supervise the client for her comfort.
comfortable in her position of choice.
2.Communicate to woman if she wishes To maintain the hydration and nutritional
to eat or drink. status of the client; food should be easily

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to eat or drink. status of the client; food should be easily
digested.
3.Ask the woman if she wishes to have To provide additional significant others for
support. her companion.
4.Keep the woman informed of her To lessen the fear and anxiety that may be
progress of labor; Give encouragement felt by the client
and reassurance.
5.Maintain temperature of the To keep the humidity of the room, it should
delivery room, not too cold for the be 25-28°C; to eliminate airdraft.
comfort of the client.

Preparing for Delivery: Woman

Already in the Delivery Room
6.Position the client comfortably in To facilitate the descent of the fetus
semi-upright position on the DR table. during bearing down with contraction
8.Wash the perineum with antiseptic To eliminate micro-organisms in the
solution applying the 9-cotton ball external genitalia.
technique.
9.Drape the client with a sterile sheet. To prevent contamination and provide
privacy.
10.Prepare the materials / supplies on To facilitate easy reach of the supplies
Mayo tray and arrange accordingly during delivery sequence.
11.Put on 2 pairs of sterile gloves using To prevent contamination and spread of
aseptic technique. microorganisms

During Delivery
12.Place dry, clean linen on the
mother’s abdomen.
13.Encourage the woman to bear down
as desired with contraction.
14.Apply perineal support and gently
control the delivery of the head.
15.Call out the time of delivery and
the gender of the baby.
16.Inform the mother of the progress To keep the mother well-informed of her
of delivery.
17.Palpate the lower abdomen.
To absorb fluids/discharges from the body
and keep the baby dry.
To facilitate the descent of the presenting
part.
To prevent laceration of the cervix, vaginal
walls and perineum and prevent injury of the
fetal head.
To determine the duration of each stage of
labor particularly the second stage of labor
and to identify the gender of the baby.
present health status and of her baby
To determine if there is a twin pregnancy
and in preparation for administration of
Oxytocin.

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 Oxytocin.
18.Wipe the soiled glove with wet To dry up the soiled glove before injection
cloth and discard the wet cloth of oxytocin.
properly.
19.Within 1 minute of baby’s birth, To stimulate contraction to the uterus.
inject Oxytocin IM to the mother. To
• prevent postpartum bleeding, perform
the remaining steps of AMTSL.
20.Wait for a strong uterine To facilitate the delivery of the placenta.
contraction then apply controlled cord
traction and counter traction on the
uterus until placenta is delivered.
• Brandt-Andrews Maneuver -
expressing the
placenta by grasping the umbilical
cord with one
hand and placing the other hand
on the abdomen.

21.Together with the circulating To determine the duration of each stage of

nurse, call out the delivery of the labor particularly the third stage of labor
placenta and its mechanism. and its mechanism of expulsion.
22.Check the placenta for To determine if there are retained
completeness and abnormalities. placental fragments that can cause
postpartum bleeding and to know if there is
presence of abnormalities in the placenta.
23.Perform external lower abdominal To stimulate uterine contraction and
massage of the uterus between four prevent postpartum bleeding.
fingers and thumb until firm.
24.Inspect the lower vaginal walls and To check if there is presence of vaginal /
perineum. perineal laceration / tears
25.Do after-care of the mother, To make the client dry and comfortable and
remove the drape, wash and dry the to determine the amount of postpartum
genitalia. bleeding. Apply perineal pad/napkin.
26.Check the condition of the mother, To determine the general health status of
if comfortable with uterus well- the client
contracted.
27.Dispose the placenta in a leak- To prevent leakage and contamination of
proof container or plastic bag. other materials/articles.
28.Decontaminate / soak instruments To prevent contamination and spread of
before washing. Then soak the second microorganisms
pair of gloves in antiseptic solution for
10 minutes before disposal.

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 10 minutes before disposal.
29.Instruct the mother to maintain To keep the baby warm and maintain
skin to skin contact with the baby, spontaneous breathing.
with baby’s head turned to one side.

In 15 – 90 minutes
30.Instruct the mother to feeding
cues (Cite examples for feeding cues).
Advice breast feeding per demand.
31.Advice optional/delay bathing of
the baby.
32.In the first hour: Check vital signs
of the mother and massage uterus.
33.In the second hour: Check mother
and baby every 30 minutes to 1 hour
34.Complete all the records.
To motivate the mother for breastfeeding.
To keep the baby warm and prevent loss of
body heat.
To monitor the general condition of the
mother and the baby during the immediate
postpartum.
To ensure that all data in relation to labor,
delivery, medications, and general conditions
of the mother are documented accurately.

• 4 signs of placental separation

• 1. Sudden oozing and gushing of blood
• 2. Lengthening of the cord
• 3. Globular shape of the uterus (Calkin’s Sign)
• 4. Rise of the fundus to the abdomen

• EVALUATION & DOCUMENTATION

• Aseptic technique is correctly used during delivery.
• Essential intrapartal care protocols are practiced correctly.
• .Objective assessment of the health status of the mother.
• Potential intrapartum and postpartum complications were managed and
prevented

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 Draping
Tuesday, 3 May 2022 6:22 pm

DEFINITION
Draping
- a specific manner in covering the woman for delivery applying the sterile technique.
-

RATIONALE
1. To provide a sterile area during delivery.
2. To prevent post-partum and neonatal infection. -aseptically

EQUIPMENT
• Delivery table with stirrups
• Draping sheet (Gyne Sheet)

PLANNING AND IMPLEMENTATION

Action Rationale
1.Explain the procedure to client. To gain participation and cooperation.
2.Assist patient to the delivery table, place in
lithotomy position.
3.Adjust the stirrups according to the size of the To adjust the stirrups properly, thus prevent
client. injury and discomfort.
4.Instruct and assist client to place her buttocks To facilitate insertion of instrument.
at the edge of the delivery table and hands on
her sides.
5.Separate the legs and flex the thighs. To relax abdominal muscles.
Elevate the legs and support them with stirrups.
6.Perform perineal care. To reduce microorganisms and prevent contamination

Draping A Client With Sterile Gown

1.Grasp the folded gyne sheet at the center placed on

the sterile mayo tray.
2.Transfer hand at the edge of the folded gyne To facilitate draping of the client
sheet and let the other end hang freely at
your waist level.
3.Spread the gynedrape and look for the hole
where right and left legs are to be inserted.
4.Transfer your both hands at the outside part of To maintain sterility of the gloved hand and of the
the gyne drape which is considered to be sterile. outside surface of the sheet.
5.Insert the other hole of the leg into the right To ensure a wider sterile area during delivery.
leg, then the other hole into theleft leg. Instruct
the client to elevate the leg while inserting and
not to touch the sheet.

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not to touch the sheet.
6.Overlap the half part of the sheet over the
abdomen and allow the other half hanging below
the posterior perineum.
7.Fix the gyne sheet without touching the
edges.
NOTE:If draping the client with a clean hands, the
same steps are followed except your unglovedhands
should remain holding the inside part. (This is the
part that would be contaminated because this would
be the area of the sheet that directly touches
the patient.)

On Removing the Drape

1.Perform perineal washing. To cleanse the perineum with blood and other
discharge during delivery
2.Still with the gloved hands, pull out slowly the
half portion of the sheet overlapping the abdomen in
the direction toward the perineum.
3.Remove the sheet covering the right leg, then
on the left leg. Instruct the client to elevate each
leg while the drape is removed. When the client
is weak or unconscious, ask somebody to
elevate the patient’s leg while you are removing the
drape/sheet.
4.Fold the sheet once at the center (keeping the To keep the client dry and comfortable.
soiled part inside) and place under the buttocks.
Instruct the client to elevate her buttocks while
placing the dry part of the sheet.
5.Keep the client dry and comfortable. Apply an
adult diaper.

EVALUATION AND DOCUMENTATION

1. Correct technique of draping is applied without contaminating other sterile area.
2. The client is kept dry and comfortable after delivery.
3. Post-partum and neonatal infection are prevented.

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Screen clipping taken: 30/08/2021 10:25 pm

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 Providing Perineal Care/Perineal
Flushing
Tuesday, 3 May 2022 6:23 pm

Definition

Perineal Care
→ is the cleansing of the perineum in a systematic manner

Perineum
→ the region of the body between the anus and the pubis

Rationale

1. To remove normal perineal secretions and odors.

2. To prevent infection.
3. To render the perineum clean before and after childbirth as well as any treatment, surgery
or procedure involving the perineal area.

III. Equipment
sterile pitcher with sterile water rubber sheet lined with a cotton draw sheet

bedpan waste receptacle

bath blanket or bedsheet disposable gloves

sterile sponges/cotton soaked in a recommended disinfecting solution

1 sterile pick up forceps in a bottle of antiseptic solution

1 handling forceps in a bottle of antiseptic solution

Planning and Implementation

Action Rationale
1. Check to see specific physician’s orders to be To ensure accuracy.
followed.
2. Explain the procedure to the client. To gain the client’s cooperation.
3. Prepare all the necessary equipment. To save time and effort.
4. Provide client privacy. To promote comfort.
5. Place client on a dorsal recumbent position To prevent unnecessary exposure
with knees flexed and separated. Drape the of the client.
client appropriately.
6. Place the rubber sheet lined with cotton To prevent the beddings from

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6. Place the rubber sheet lined with cotton
draw sheet under the client’s buttocks.
7. Position the client on a bedpan.
8. Clean the perineum.
To prevent the beddings from
getting wet.
To prevent any liquid from spilling.

• Pour warm sterile water gently over the vulva. To avoid discomfort. Some client’s
will feel uncomfortably cold when
the solution is not warm.

• With a sponge held by a pair of forceps and

soaked in a recommended disinfecting solution,
clean the perineal area gently and thoroughly. This technique allows a thorough
Use a top down direction (follow the illustration cleaning of the perineum while
below when using the 9-cotton ball technique). preventing contamination.
Discard used sponges into the waste receptacle.

• Rinse with sterile water.

To wash out any remaining
disinfecting solution.

• Dry the perineal area with a dry sponge. Apply

a clean perineal pad as needed.
To promote comfort.
9. Return client to a comfortable safe position. To ensure client’s comfort.

Evaluation and Documentation

1. Any complaints of irritation or discomfort and their location.

2. Any inflammation or swelling observed.
3. Presence of unusual odor.
4. Other significant findings especially on clients with indwelling catheter.
5. Vaginal discharges washed out and removed.

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Screen clipping taken: 30/08/2021 9:52 pm

Perineal Care
9 Cotton balls technique
1. Center of Vulva or anterior inner portion of the external vagina
2. Pubis over the pubic bone
3. Right labia - up going downward
4. Left labia - up going downward
5. Right inner groin - inner to outer
6. Left inner groin - inner to outer
7. Posterior portion of the right lower buttocks
8. Posterior portion of the left lower buttocks
9. Anus - downward direction

Screen clipping taken: 30/08/2021 9:53 pm

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Nursery Room
Tuesday, 3 May 2022 6:25 pm

ESSENTIAL INTRAPARTUM NEWBORN CARE / UNANG YAKAP

PERFORMING IMMEDIATE NEWBORN CARE & INSTRUMENTATION

(Department of Health Unang Yakap Essentials of Newborn Care)

- save the new born lives.

- Aims to cut down the mortality rate

DEFINITION

Immediate Newborn Care

– early management of the newborn baby in the delivery or nursery room after or within few minutes after
birth.

RATIONALE

1. The newborn is unique, fragile being, who experiences the transition from comfortable uterine environment
to external environment.
2. Newborn should be regarded as individual and not just another new baby and receive the amount of care that
his condition demands so as to:
○ Establish and maintain respiration
○ Prevent aspiration
○ Maintain a stable temperature within normal range
○ Prevent infection
○ Establish an accurate identification
- Birth normally
- To be warm
- To be protected

EQUIPMENT

First Tray (Sterile)

Sterile glove 2 pairs of forceps (straight/curve)

Cord tie / cord clamp Betadine antiseptic

Sterile gauze Bulb syringe (optional)

Naso Gastric tubr (NGT) Fr. 5, 6, or 8 (optional) 1 pair of scissors (mayo scissors)

Second Tray (Nonsterile)

Eye drops / eye ointment - prevent infection /neonatal blindness ID band (identification
band)

Stethoscope Thermometer (Axilla/Digital)

Tape measure - anthropometric scale Stamp pad (optional)

1 ampule Vitamin K(1 cc syringe with needle G-26) 0.1 full term - 0.5 preterm

1 vial/ampule Hepa B (1 cc syringe with needle G-26) 0.5 full term -

1 vial/ampule BCG (1 cc syringe with needle G-26)

Cotton ball with alcohol Suction apparatus (optional)

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 Cotton ball with alcohol Suction apparatus (optional)

Weighing scale lined with towel Catheter Tube Fr. 8

Baby’s layette/diaper/close cap/mittens Drop light - to keep the baby warm

Ambu bag (optional) -

PLANNING AND IMPLEMENTATION

Nursing considerations:

1. Wear a prescribed nursery gown, mask, and close cap.

2. Aseptic technique should be observed at all times.

Action Rationale
TIME BOUND NURSING INTERVENTIONS:
1. Wash hands and wear double sterile gloves. To prevent the spread of infection.
2. Deliver the baby using aseptic technique.
3. Dry the baby’s skin immediately. To prevent loss of heat by evaporation.
a. Wipe the baby’s mouth then the nose with a sterile
gauze.
b. Wipe the back by rubbing, and other parts of the To stimulate the baby to cry.
body. (Be careful not to remove the vernix caseosa) and
do tactile stimulation of the soles of the feet.
c. Perform assessment of the newborn using the Apgar To determine the general condition of the
scoring tool. newborn within the first minute of life.
A - appearance
Respiration
4. Promote skin to skin contact between the mother and the To stabilize newborn’s temperature at birth
newborn. (37.2⁰C).
a. Place the newborn directly in prone position on mother’s
chest or abdomen.
b. Cover the newborn with a dry towel or blanket and cover the
head with a close cap or bonnet.
c. Reassess the newborn 5 minutes after birth using the Apgar To evaluate the condition of the newborn
scoring tool and from head to toe assessment. within 5 minutes of life after birth.
5. Remove the soiled outer pair of gloves. To prevent contamination.
6. Allow at least 3 minutes after the delivery to cut the cord or To allow more blood from the placenta to
until the cord stops pulsating. transfer to the baby.
a. Clamp the cord with a curved forceps with latex band (or
with umbilical clamp) 2 cm. away from the base of the cord.
b. Apply the straight forceps 3 cm. away from the first clamp.
c. Cut the cord and slide the latex band carefully and gently
towards the base of the cord (if cord clamp is not used) and be
careful not to overlap the latex band on the skin at the base of
the cord.
d. After clamping or tying the cord, check the presence of the
following:

• One umbilical vein

• Two umbilical arteries
• Bleeding near the base of the cord
7. Promote early breastfeeding. Observe for presence of

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 7. Promote early breastfeeding. Observe for presence of
rooting and sucking reflex and initiate feeding.
a. Clean the nipple with a clean cloth or gauze from inner to
outer direction
b. Introduce the mouth of the baby to mother’s nipple.
8. Administer the Crede’s Prophylaxis
a. Open the newborn’s one eye by gently holding the upper lid
upward with the index finger and the lower lid downward with
the thumb.
b. Squeeze eye ointment gently and deposit 1 cm. of medication
on the lower lid.
c. Apply the ointment from the inner to the outer canthus of
the eye. Do the same to the other eye.
9. Place the ID band with the complete name of the mother and
the baby preferably on the ankle of the newborn.
NON-TIME BOUND NURSING INTERVENTIONS
Perform the following procedures in the newborn under
droplight.
1. Line the table with a towel and place the newborn. To prevent heat loss from the newborn’s body.
2. With the use of the tape measure, measure the length from To determine if the intrauterine growth is
the crown of the head to the sole of the foot, head and chest within normal.
circumference.
3. Check the temperature. To assess the baseline temperature and to
determine further loss of body heat
4. Insert a small catheter tube into the anus. To check the patency of the anus.
5. Line the weighing scale with a towel and check the weight. To prevent loss of heat from the newborn.
6. Prepare and inject Vitamin K at the vastus lateralis muscle To prevent hemorrhage that may lead to
(prescribed according to the weight of the newborn). anemia of the baby.
Vitamin k left
Hepa B - right - vaccinate
7. Perform after-care of materials and equipment.
8. Provide gentle, minimal handling and watchful eyes.
a. Promote rooming in and breastfeeding. To promote mother and child bonding.
b. Bring the baby to the mother. Be sure to check the baby’s
identification with the mother.
c. Give instructions to the mother regarding breastfeeding and To promote and support R.A. 7600, Rooming in
care of the baby. and Breastfeeding Act of 1992, for Maternal
and Child Health.

Linen instead of disposable

DOCUMENTATION AND EVALUATION

3. Record the assessment result of the APGAR score.

4. Absence of respiratory distress.
5. Free of infection and other complications.
6. The baby is identified correctly and with complete and correct data.
7. Recording of the dose, route, and time the Vitamin K and ophthalmic ointment is administered.
8. Recording of V/S, anthropometric measurements, and unusualties.

EQUIPMENT AND INSTRUMENTATION

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EQUIPMENT AND INSTRUMENTATION
Basic Delivery Set (for multi gravida) (Additional instruments for Primi gravida)
- 2 clamps, one with Latex band - Additional gloves
- Scissors - Ovum forceps
- Rolled Gauze - Needle holder
- Kidney Basin - 5cc syringe with needle
- Sterile Gloves - Additional scissors
- Suction bulb - Additional gauze
- Straight Catheter - Tissue forceps
- Needle with suture

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 Tuesday, 3 May 2022 6:26 pm

Newborn Phototherapy
PHOTOTHERAPY
- A LAMP THAT GIVES OF THERAPEUTIC DOSES OF INFRARED LIGHT AND HEAT THAT
LOWERS THE BILIRUBIN LEVELS IN THE TISSUES.

RATIONALE:
1. TO REDUCE THE BILIRUBIN LEVELS OF THE NEWBORN
2. TO PROVIDE AN OPTIMUM THERMAL ENVIRONMENT
3. TO PREVENT PHYSIOLOGIC AND BREASTFEEDING JAUNDICE WITH EARLY
INTRODUCTION OF FEEDINGS IF WITHOUT SUPPLEMENTATION

Equipment:
▪ Heating Lamp/ Bili Lamp
▪ Eye Shield/Mask
▪ Diaper
Rolled Towel

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 ▪ Rolled Towel

PLANNING AND IMPLEMENTATION

NURSING CONSIDERATIONS
1. The infant under phototherapy is placed nude and repositioned frequently to expose all body
surface to light.
2. Serum bilirubin is frequently monitored every 4-12 after initiation of phototherapy because
visual assessment of jaundice is no longer valid.
3. Eye shield are removed during feeding to provide visual and sensory stimulation.
4. Infants who are in open crib must have protective plexiglass to protect from accidental
bulb breakage and minimize amount of undesirable ultraviolet light.

SIDE EFFECTS OF PHOTOTHERAPY

1. Skin rashes
2. Loose stools
3. overheating
4. Dehydration
5. Bronze Baby Syndrome

ACTION
1.Explain the therapy to significant others.
2. Assemble the things/articles to be used
near the infant’s crib or bililamp table.
3. Perform hand hygiene.
4. Keep the infants skin clean and dry.
5. Undress the baby and position comfortably
with two rolled towels or blankets on both
sides.
6. Cover both eyes with an opaque mask or eye 6. To prevent exposure to light and to
shield with proper size and shape not occluding maintain a patent airway
the nares. The infant’s eyelids are closed
before applying the shields.
7. Position the lamp approximately 45 cm (18
inches) from the skin and 60 cm (24 inches) if
the bulb is large
8. Check the baby frequently (every 15
minutes) especially the eyes
9. Note skin color changes (every 15 minutes)
and body temperature every 2-4 hours
RATIONALE
1. Lessen anxiety of mother an significant
other, and to gain cooperation.
2. For easy access on the part of the nurse.
3. To prevent spread of infection.
4. To ensure maximum therapeutic effect.
5. To ensure the baby’s safety and expose
all body surfaces.
7. To prevent the skin from burning
8. To determine the presence of
discharges, pressure on the eyelid, and
corneal irritation
9. To determine hypothermia and to assess
any changes on skin like drying or burning

EVALUATION AND DOCUMENTATION

1. Document the time when phototherapy has started and stopped.
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1. Document the time when phototherapy has started and stopped.
2. The type and number of lamps used and distance between surface of the lamps and
infant.
3. Photometer measurement of light intensity and occurrence of side effects in the
infant.
4. Monitored and recorded the level of infant’s bilirubin.

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 Tuesday, 3 May 2022 6:26 pm

Suctioning of the Newborn

SUCTIONING
- IS A METHOD OF REMOVING EXCESSIVE SECRETIONS FROM THE AIRWAY. IT MAY BE APPLIED TO THE ORAL,
NASOPHARYNGEAL OR TRACHEAL PASSAGES.
▪ Respiratory distress
▪ Crackles
▪ Bradycardia
▪ Clogging of the mucous

RATIONALE:
1. To provide patent airway to improve ventilation.
2. To remove mucus secretion in the upper airway
3. Increase tissue oxygenation

EQUIPMENT:
▪ Suction Catheter (Fr. 5-6 for preterm/Fr. 6-8 for fullterm)
▪ Suction Machine
▪ Tongue Depressor
▪ Gloves
▪ Sterile Water/ Normal Saline
▪ Lubricant
▪ PPE (mask with eyeshield)
▪ Ambubag

SPECIAL CONSIDERATION
1. Apply suction for 5 – 10 seconds only per suction to prevent suctioning of excessive oxygen from the lower airway.
2. Suction the orotracheal first then nasotracheal or nasopharynx to prevent swallowing of secretions that may escape to trachea
during crying.
3. Perform gentle suctioning as the mucous membrane of the upper and oral airway is very thin and sensitive that may lead to
trauma and injury.

EVALUATION AND DOCUMENTATION

1. The newborn has a clear, patent oral/pharyngeal airway
2. The newborn has an adequate oxygenation as evidenced of having pinkish color, normal ABG results.
3. The newborn has no signs of respiratory distress.

OROTRACHEAL SUCTIONING
ACTION RATIONALE
1. Gather equipment including To save time and energy. Equipment should be near the newborn area to be used in emergency
catheter of appropriate size. Connect cases.
collection bottle and tubing to vacuum
source.
2. Inform the parents or significant To allay fear and anxiety.
others about the procedure if
necessary.
3. Wash hands thoroughly. To reduce the number of microorganisms thus preventing infection.
4. Fill basin with sterile water or
normal saline.
5. Turn on suction machine to check To avoid any delay.
the system and regulate the pressure
if indicated and if equipment is
functioning.
6. Position the infant on his right side, To aid in pooling and draining the secretions.
with his head slightly lowered. If
necessary, seek for assistance in
maintaining his position.
7. Don gloves. Connect the catheter to To keep the hands clean.
the suction tubing.
8. Place catheter tip in the basin and To check the patency of the system, lubricate the catheter, and allow some water in the

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 8. Place catheter tip in the basin and To check the patency of the system, lubricate the catheter, and allow some water in the
draw sterile water through it. collection bottle which will prevent aspirated secretions from sticking to it.
9.Use padded tongue depressor to To prevent blocking of the catheter by compression of the lips.
separate the upper and lower lips.
10. Leave vent open to air and To avoid over stimulation of the gag reflex thus preventing vomiting.
introduce catheter into the area to be
suctioned. Insert the catheter 2-4
inches into the oral cavity.
11. Occlude vent with thumb and To remain in one place, the mucous membrane will be drawn against it. This will occlude the
slowly move the catheter in circular catheter and may injure the tissues.
motion in the area to be suctioned.
12. Dip catheter in and out of the To use about 50 cc of saline can adequately clean the catheter with secretions.
container of sterile water or saline.
13. Repeat steps 9 to 12 if necessary. To avoid prolonged suctioning as it can lead to laryngospasm, bradycardia and cardiac arrhythmias
Suctioning should be no longer than 10 from vagal stimulation and loss of Oxygen.
seconds at a time allowing 1-3 minute
interval between suction periods.

NASOTRACHEAL SUCTIONING
PLANNING & IMPLEMENTATION
ACTION RATIONALE
1. Ascertain that suction apparatus To avoid delay of work.
is functional. Place suction tubing and
other equipments within easy reach.
2. Inform the parents or significant To lessen anxiety.
others if necessary.
3. Position the newborn's head To elevate the bronchial
slightly higher than the body. passage on the opposite side,
making the catheter insertion
For left bronchial suctioning, turn easier.
the newborn''s head to the right
then, then chin up.

For, right bronchial suctioning, turn

the newborn's head to the extreme
left, then chin up.
4. Never apply suction until catheter To avoid tracheal injury. Entry
is in trachea. Once correct position is into the trachea is often
ascertain , apply suction and gently difficult; less change in
rotate catheter while pulling it arterial O2 may be caused by
slightly upward. Withdraw the leaving the catheter in the
catheter from the trachea. trachea rather than initiating
repeated catheter insertions.
5. Disconnect the catheter from the To allow re-Oxygenation of
suction machine after 5-15 seconds. the newborn.
Apply O2 by placing a face mask over
the nose and mouth.
6. Reconnect to suction source and To prevent suctioning of O2
repeat suctioning when necessary deposits in the lower airways.
within 10 seconds per suctioning; and
3-4 suctions per suction episode.
7. During the last suction, remove the To apply gentle motion and
catheter while applying suction in good oxygenation.
rotating motion gently. Apply O2
when catheter is removed.

EVALUATION AND DOCUMENTATION

1. The newborn has a clear, patent oral/pharyngeal airway.
2. The newborn has an adequate oxygenation as evidenced of having pinkish color, normal ABG results.

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2. The newborn has an adequate oxygenation as evidenced of having pinkish color, normal ABG results.
3. The newborn has no signs of respiratory distress.

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 OB and Pedia Ward
Tuesday, 3 May 2022 6:27 pm

Essential Prepartum Care

Recommended Practices During Labor:

1. Admission to labor when the parturient is already in the active phase

2. Continuous maternal support specifically with labor companions
3. Mobility and upright position during first stage of labor
4. Allow food and drink
5. Routine use of Partograph
6. Limit total number of IE to five or less

Practices That Are NOT Recommended During Labor:

1. Perineal shaving
2. Enema during first stage of labor
3. Vaginal douching
4. Amniotomy
5. Oxytocin augmentation
6. Intravenous fluids
7. Routine NPO

Immediate Post Partum Care

Provide comfort and privacy

• Assess general condition of patient
• Take and monitor vital signs
• Initial latch-on with newborn
• Apply ice pack on pubic area
• Observe and monitor lochia
• Proper perineal hygiene
• Observe for complications

Final Assessment
• check for bleeding at the vaginal opening or the episiotomy site
• check that all supplies and instruments used are complete
• take vital signs and assess condition of mother

Aftercare of Patient & Instrument

• ensure patient’s comfort and privacy
• give postpartum instructions
• wash all instruments and discard waste materials properly

Documentation
charting of the progress of labor

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• charting of the progress of labor
• 1st minute APGAR scoring
• medications given during labor
• complications or abnormalities

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Tuesday, 3 May 2022 7:00 pm

Essential Prepartum Care

Recommended Practices During Labor:

1. Admission to labor when the parturient is already in the active phase -
emotional support/significant others are not allowed
2. Continuous maternal support specifically with labor companions -
3. Mobility and upright position during first stage of labor - to
exercise/to gain extra strength
4. Allow food and drink - to have strength (soft diet)
5. Routine use of Partograph -know the status of mother and baby(assess
the development of labor
6. Limit total number of IE to five or less - to prevent infections

Practices That Are NOT Recommended During Labor:

1. Perineal shaving - dnagerous(basi ma gisi or ma pilas ang perineal area)
2. Enema during first stage of labor
3. Vaginal douching
4. Amniotomy
5. Oxytocin augmentation
6. Intravenous fluids
7. Routine NPO

ESSENTIAL INTRAPARTUM CARE:

- Care is given to the client during delivery, including preparation of

instruments and articles to be used and procedures to be done for the
safety and prevention of injury and complication for the mother and
the newborn during delivery

PRACTICES RECOMMENDED DURING DELIVERY

1. Upright position during delivery
2. Selective ( Non- routine episiotomy)
3. Use prophylactic oxytocin for the 3rd stage of labor
- (palpate first the lower abdomen)?

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1. Delayed cord clamping. ( 1 to 3 min after birth)

2.

3. Controlled cord traction with counter traction to deliver the

placenta

4. Uterine massage after placental delivery.

Screen clipping taken: 09/03/2022 8:09 am

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ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR (AMSTL)

1. Administration of uterotonic within 1 min. after the delivery of

the baby.

Screen clipping taken: 09/03/2022 8:10 am

2. Controlled traction with countertraction on the uterus.

3. Uterine massage.

PRACTICES NOT RECOMMENDED DURING DELIVERY

1. Coaching the mother to push.

Screen clipping taken: 09/03/2022 8:12 am

2. Perineal massage in the second stage.

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 Screen clipping taken: 09/03/2022 8:13 am

3. Fundal pressure during the second stage

Screen clipping taken: 09/03/2022 8:14 am

Vbac
- Fundal pressure - never attempt

Immediate Post Partum (puerperium) Care

• Provide comfort and privacy

• Assess the general condition of the patient
• Take and monitor vital signs
• Initial latch-on with newborn
• Apply ice pack on pubic area - prevent bleeding (cold - constriction)
• Observe and monitor lochia -
• Proper perineal hygiene - explain the importance
• Observe for complications - bleeding

1. Final Assessment
• check for bleeding at the vaginal opening or the episiotomy site
• check that all supplies and instruments used are complete
• take vital signs and assess the condition of the mother

2. Aftercare of Patient & Instrument

• ensure patient’s comfort and privacy
• give postpartum instructions - put ice pack to prevent bleeding
• wash all instruments and discard waste materials properly

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3. Documentation
• charting of the progress of labor
• 1st minute APGAR scoring- 9/10 perfect score
• medications given during labor
• complications or abnormalities

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 Immediate Post Partum Care
Tuesday, 3 May 2022 7:01 pm

• Provide comfort and privacy

• Assess general condition of patient
• Take and monitor vital signs
• Initial latch-on with newborn
• Apply ice pack on pubic area
• Observe and monitor lochia
• Proper perineal hygiene
• Observe for complications

A. Final Assessment
• check for bleeding at the vaginal opening or the episiotomy site
• check that all supplies and instruments used are complete
• take vital signs and assess the condition of the mother

B. Aftercare of Patient & Instrument

• ensure patient’s comfort and privacy
• give postpartum instructions
• wash all instruments and discard waste materials properly

C. Documentation
• charting of the progress of labor
• 1st minute APGAR scoring
• medications given during labor
• complications or abnormalities

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Vital Signs
Tuesday, 3 May 2022 6:29 pm

1. DEFINITION of TERMS

Vital signs
- cardinal signs
- reflect the body's physiological status and provides information critical to evaluating
homeostatic balance.

What are the critical assessment areas?

○ Temperature
○ Pulse
○ Respiration
○ Blood pressure
○ Pain

Rationale:
1. To determine if core temperature is within normal range.
2. To provide baseline data for further evaluation.
3. To determine alteration in disease condition.
4. To determine changes in body temperature in response to specific therapies.

1. ORAL TEMPERATURE
III. EQUIPMENT
○ Tray containing:
○ Thermometer (digital)
○ Container with thermometer wipes
○ Waste receptacle
○ Thermometer probe and cover

ORAL TEMPERATURE
IV. PLANNING AND IMPLEMENTATION
Special Considerations:
Contraindications for taking the temperature orally are:
a) disease of the oral cavity
b) surgery of the mouth and throat
c) infants and children under 10 years old
d) unconscious or irrational client
e) client on suture precaution
f) clients who are unable to keep their mouth closed for any reason
g) clients who have obstruction of both nostrils

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 CHN
Tuesday, 3 May 2022 6:44 pm

Home Visit
→ A professional, purposeful interaction that takes place in the family’s residence aimed
at promoting, maintaining or restoring the health of the family or its members.
• instead of the family going to the nurse, the nurse goes to the family.

Advantages:
○ It allows firsthand assessment of the home situation: family dynamics,
environmental factors affecting health, and resources within the home.
○ The nurse is able to seek out previously unidentified needs.
○ It gives the nurse an opportunity to adapt interventions according to family
resources.
○ It promotes family participation and focuses on the family as a unit.
○ Teaching family members in the home is made easier by the familiar environment
and the recognition of the need to learn as they are faced by the actual home
situation.
○ The personalize nature of a home visit gives the family a sense of confidence in
themselves and in the agency.

Disadvantages:
> relates to efficiency: the cost in terms of time and effort.
> because the nurse is unable to control the environment, there are more
distractions in the home.
> nurse’s safety may also be a concern

DEFINITION
• A professional face to face contact made by a nurse to the patient or the family to
provide necessary health care activities and to further attain an objective of the
agency.

PRINCIPLES
• A home visit should have a purpose or objective.
> Assessment
> Nursing Care
> Treatment
> Health education
> Referral (if care fails)
> Planning for home visit should make use of all available information about the
patient and her/his family.
Planning should revolve around the essential needs of the individual and family.

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 > Planning should revolve around the essential needs of the individual and family.
> Planning of continuing care should involve the individual and family.
> Planning should be flexible and practical.

• Planning for home visit should make use of all available information about the patient
and her/his family.
• Planning should revolve around the essential needs of the individual and family
• Two-way communication and respect for family is observed.
• Active participation of the client in the performance of actions is encourage.
• Planning should be flexible and practical.
• Health education is a major nursing activity during a home visit.
• Visit is promptly recorded.

FACTORS IN DETERMINING FREQUENCY OF HOME VISIT

• The physical, psychological and educational needs of the individual and family.
• The acceptance of the family for the services offered; the willingness and interest to
cooperate.
• Take into account other health agencies and the number of health personnel already
involved in the care.
• The policy given by the agency and the emphasis placed on giving health program.
• The ability of the patient and his family to recognize their own needs, their knowledge
of available resources and their abilities to use these resources.

Purposes of Home Visit

1. To assess the family situation (identification of nursing needs and problems
2. To assess the home environment
3. To implement a family nursing care plan
4. To conduct follow up for patients seen in the health center/outpatient clinic
5. To evaluate the results or outcomes of nursing service

PHASES OF HOME VISIT

1. Planning and Preparation Phase
▫ Starts at the health center
▫ Makes a study on the status of the family
▫ Statement of the problem
▫ Formation of objective

2. Socialization -
▫ first activity is to establish rapport
▫ and to gain the trust of the family

3. Activity
▫ Intervention / Professional Phase
Opportunity to provide or extend health services

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 ▫ Opportunity to provide or extend health services
▫ Standard Role of the Nurse: Independent, Dependent and interdependent

4. Summarization -
▫ ability to put into record & report (orally) about the outcome of the activity
Includes Evaluation:
a. evaluation of inputs (appropriateness, adequacy, effectiveness)
b. evaluation of process
c. evaluation of outcome

STEPS IN HOME VISIT

▫ Greet client or household member and introduce yourself.
▫ Explain purpose of home visit.
▫ Inquire about health and welfare of client/patient and other family members.
▫ Place the CHN bag in a convenient place before doing bag technique.
▫ Wash hands and wear apron.
▫ Perform physical assessment and nursing care needed.
▫ Give the necessary health teaching and advice based on client’s need and condition.
▫ Wash hands and close bag.
▫ Record findings and nursing care given.
▫ Make appointment either for clinic or home visit.
▫ On succeeding home visit and when nurse has gained the family’s trust and confidence,
she/he may look into more detailed aspects of the household and surroundings and
other health problems/concerns.

Recording the Home Visit

Things to remember:
1.When to record
2.What to record
1.date and time of visit
2.objectives (behavioral)
3.pertinent observations and impressions
4.Services or interventions provided
5.Observations on client’s response, progress made by the client
6.Appointments, schedule of next visit
3.How to record
1.brief, concise, organized and in a legible manner
2.record should be signed by the client and the nurse

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Screen clipping taken: 10/11/2021 6:04 pm

Screen clipping taken: 10/11/2021 6:05 pm

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 Bag Technique
Tuesday, 3 May 2022 6:54 pm

❖ The Community Health Nursing bag or the CHN bag is a tool used by the nurse during home visit and community visits to be able
to provide care safely and efficiently (Famorca, 2013).

DEFINITION: Bag Technique

❖ a tool making use of a community health bag through which the nurse, during her home visit can perform nursing procedures
with ease and deftness, saving time and effort with the end result of rendering effective nursing care.
❖ an essential and indispensable equipment of the community health nurse which she has to carry along with her when she goes
out for a home visit. It is composed of basic articles which are necessary for giving nursing care.

RATIONALE: To render effective nursing care during home visit in the community.

EQUIPMENT: Contents of the bag

> Paper lining
> Plastic lining
> Kidney basin
> Thermometer in case
> Paper squares
> Waste receptacle
> Tape measure
> Hand towel in a plastic bag / wrapper
> Apron in a plastic bag / wrapper
> Blood pressure apparatus (optional)
> Dressings (OS, cotton ball, plastic or adhesive tape in plactic bag)
> 6 small botttles with solutions/medicines (uniform in size if possible):
> 70% alcohol
> Betadine or Chlorhexidine

PLANNING AND IMPLEMENTATION

Special Considerations:

1. The bag should contain all the necessary articles, supplies, and equipment which may be used to answer emergency needs.

2. The bag and its contents should be cleaned as often as possible, supplies replaced and ready for use at any time.

3. The bag and its contents should be well protected from contact with any particle in the home of patients. Consider the bag and its
contents clean and/or sterile while any article belonging to the patient as dirty and contaminated.

4. The arrangement of the contents of the bag should be one which is most convenient to the user to facilitate efficiency and avoid
confusion.

5. is done as frequently as the situation calls for since it helps minimize or avoid contamination of the bag and its contents.

6. The bag when used for a communicable case should be thoroughly cleansed and disinfected before keeping and reusing.

7. The use of the bag technique should minimize, if not totally prevent the spread of infection from individuals to families, hence to the
community.

8. Bag technique should save time and effort on the part of the nurse in the performance of nursing procedure.

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9. Bag technique should not overshadow concern for the patient but rather should show effectiveness of total care given to an
individual or family.

10. Bag technique can be performed in a variety of ways depending upon agency policies, actual home situation, etc., as long as the
principles of avoiding the spread of infection are carried out.

IMPLEMENTATION

Action Rationale
1.Upon arriving at the client’s home after a short To prevent the bag from contamination.
interaction, place the bag on the table or any
flat surface lined with paper lining (inserted
beneath the cover of the bag), clean side out
(folded part touching the table).
2.Open the bag take the plastic lining and To provide a non-contaminated area.
spread over the paper lIning, clean side in
contact with the paper lining (folded part out).
Insert the handles/straps of the bag beneath it.
3. If a faucet is not available, ask for a basin and - To be used for handwashing and
a glass of water. If a faucet is available, ask cleaning of the thermometer, in case a
only for a glass of water. Place them outside the thermometer technique is used.
work area. - To protect the work area from being wet.
4. Take out the hand towel, soap dish and apron. To prepare for handwashing.
Leave their plastic wrappers in the bag. Place
them at one corner of the work area, within the
confines of the plastic lining.
5. Do handwashing (medical aseptic technique). To prevent contamination.
Wipe hands with towel.
6. Put on an apron, right side out and wrong side To protect the nurse’s uniform. Keeping the
with crease touching the body. Neatly tie the crease in creates an aesthetic
waste straps in the back, sliding the head into appearance.
the neck strap
7. Put out things needed for the case/procedure To make them readily accessible.
and place them at one corner of the work area.
8. Place paper waste receptacle outside of the To prevent the work area from possible
work area. contamination.
9. Close the bag. To prevent the contents of the bag from
possible contamination.
10. Proceed to the specific nursing care or To provide necessary treatment needed by
treatment. the client.
11. After completing the nursing care , clean and To protect the bag and its contents from
apply alcohol on the equipment used. possible contamination.
12. Do handwashing again (medical aseptic To protect the caregiver from
technique). contamination.
13. Remove the apron, folding away from the To prevent the spread of microorganisms.
body so that the soiled is folded inward and the
clean side outward. Place it inside the plastic
wrapper and return it to the bag.

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 wrapper and return it to the bag.
14. Open the bag and return all articles in their To prevent the spread of microorganisms.
proper places.
15. Fold the plastic lining, clean side out (folded To protect the bag and its contents from
part inward). Place it in the bag and close the possible contamination.
bag.
16. Get the bag from the table/ flat surface, fold The side which is in contact with the table
the paper lining (the side which is in contact is considered contaminated.
with the table is folded inward), and insert in
between side which is in contact with the table
is considered contaminated the flaps and cover
of the bag.
17. Make a post-visit conference on matters To be used as reference for future visits.
relevant to health care. Record all significant
findings.
18. Make an appointment for the next visit For follow-up care.
(either home or clinic), taking note of the date,
time and place.

EVALUATION AND DOCUMENTATION

1. All relevant findings about the client.
2. Environmental factors affecting the client’s health.
3. Nurse-patient interaction and if rapport was established.
4. Nursing care/treatment/procedure done.

TAKING TEMPERATURE/ VITAL SIGNS (Used in Bag Technique)

DEFINITION: It is a method of checking a client’s temperature with due attention given to the cleanliness of the thermometer
that is used.

RATIONALE:

1. To check a client’s temperature and assess any significant finding.

2. To keep the thermometer aseptically clean so as to prevent transfer of infection from one client to another.

3. To protect other contents of the bag by keeping the thermometer aseptically clean.

PLANNING AND IMPLEMENTATION

Action Rationale
1. Identify your client and explain the procedure. To prepare the client and relieve anxiety.
2. Using the bag technique lay out, put out the thermometer leaving To prevent contamination.
the case inside the bag.
3. Check if digital thermometer is functioning. For accurate findings.
4. Insert the thermometer into the client’s axilla and take the
temperature, pulse, and respirations following the procedure in
taking the vital signs.

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 5. Remove the thermometer from the client’s axilla and wipe with Wiping is done from a clean to a dirty area and to
clean tissue paper starting from the lower half going down to the remove any moisture or dirt from the thermometer.
bulb. Discard tissue paper in the waste receptacle.
6. Wiping is done from a clean to a dirty area and to remove any Obtain data for documentation.
moisture or dirt from the thermometer.
7. Clean the thermometer with alcohol swab in a downward spiral To disinfect the equipment
motion from the lower half of the stem to the bulb, holding it over
the waste receptacle.
8. Wipe the thermometer with a dry tissue paper from bulb to the To avoid moisture formation inside the case.
stem and return to the case.
9. Do hand washing again. To protect the caregiver from contamination.
10. Open the bag and put all articles in their proper places. To prevent the spread of microorganisms.

EVALUATION AND DOCUMENTATION

1. Client’s temperature.
2. Intervention done.
3. Health teachings given.
4. Client’s condition.

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