NEWBORN SCREENING
- Using the heel prick method, a few
RA 9288
Newborn Screening
- a simple procedure to find out if a
baby has a congenital metabolic
disorder that may lead to mental
retardation or even death if left
untreated.
- To assess for genetic and metabolic
abnormalities, hearing problems,
specific heart problems, and other
conditions that can hinder their
development.
Importance
- Most babies with metabolic disorder
look normal at birth.
- One will never know that the baby
has the disorder until the signs and
symptoms are manifested. By this
time, irreversible consequences are
already present.
- helps us find babies who have certain
serious medical conditions so that
they can begin treatment right away.
When is newborn screening done?
- Ideally done on the 48th to 72nd hour
of life (first 2 to 3 days of life).
- May also be done 24 hours from birth
since some disorders are not detected
if the test is done earlier than 24 hours
from birth.
PARTS of NBS
● Blood
● hearing
● heart screening.
How is newborn screening done?
drops of blood are taken from the
baby’s heel
- Blotted on a special absorbent filter
card
- Blood is dried for 4 hours and sent to
the Newborn
Blood spot collection
- Blood spot collection can be
performed by trained perspnnel such
as hospital nursery staff, laboratory
staff or out of hospital birth providers
- TIMING OF COLLECTION: blood spots
drawn too early or too late may yield
false results
- Best collected between 24 and 48 hrs
of age ( at least 24 hrs old)
- Blood spots collected before 24 hrs
generates an unsatisfactory results
that require another blood spot
collection
- Avoid touching the area within the
circles on the filter paper section
before, during and after collection of
th specimen since oils and other
materials from the hands might affect
or contaminate the card or specimen
- Do not allow water, feeding formulas,
antiseptic solutions, glove powder,
hand lotion or other materials to
come into contact with the specimen
card before of after use
- Blood collection from the heel is the
standard for newborn screening
- The medial and lateral parts of the
underfoot are preferred
Blood should NEVER be collected from:
● The arch of the foot
● The fingers
● The earlobes
● a swollen or previously punctured site
● IV lines containing other substances (TPN,
blood, drugs)
- Warm the heel with a warm
dampcloth or commercially available
heel warmer and position the leg
lower than the heart to increase
venous pressure before collecting the
blood spots.
- The infant should be swaddled in a
blanket with only one foot exposed.
- Powder free gloves are bestworn
while collecting the blood spots
- Lotion, vaseline and other substances
which can interfere with bloodspot
analysis should be kept off the infant’s
skin
- Wipe the skin clean with an alcohol
wipe and allow to thoroughly air dry
- Use a sterile lancet or heel incision
device to make an incision 1mm
deep and 2.5 mm long ( shallow
incision is more safer)
- Wipe away the first drop of blood with
a sterile gauze pad
- Allow a large drop of blood to form
using the thumb to intermittently
apply gentle pressure to the heel may
be helpful in encouraging the drop to
coalesce
- Touch the first circle on the newborn
screeningcare gently against the
large blood drop and in one step,
allow the blood to soak through the
filter paper and fill the circle.
- Do not press the paper directly
against the baby’s heel. Each of the
five/four circles need to be filled and
saturated through
- Apply the blood to any one side of
the filter paper
- Do not apply multiple layers of blood
drops to the same circle
- The circles are measures and should
contain a set volume of blood.
Layering can interfere with the
accuracy of the test by providing
non-standard amount of blood on
non-uniform analyte concentration
- Excessive milking or squeezing of the
puncture site can result in an
unsatisfactory specimen because of
hemolysis breaking down the blood
cells to be analyzed or mixing tissue
fluids in the specimen which can
dilute the blood
- Allow the specimen to dry flat at room
temperature for at least 3 hours ( this is
essential in maintaning the integrity of
the blood spots)
- Keep them out of direct sunlight and
way from other heat sources
- Avoid stacking the cards
- Do not close the biohazard flapover
the spots until they are completely dry
- Once the blood spots have dried
completely, the biohazard flap can
be closed and the newborn screening
card can be sent to the Newborn
screening program
When are newborn screening results
available?
- Seven (7) working days from the time
the newborn screening samples are
received parents should claim the
results from their physician, nurse,
midwife or health worker.
- Any laboratory result indicating an
increased risk of a heritable disorder
(i.e. positive screen) shall be
immediately released, within twenty-
 four (24) hours, so that confirmatory - Accumulation of excessive galactose
testing can be immediately done. in tha body can cause many
- A positive screen means that the problems including liver
newborn must be referred at once to damage,brain damage and
a specialist for confirmatory testing cataracts
and further management.
- An inherited disorder that lacks an
enzyme (Galactose-1-phophate uridyl
FIVE (5) DISORDERS CURRENTLY INCLUDED IN
transferase/Gal-1-PUT) which helps the
THE NEWBORN SCREENING PACKAGE
body break down the galactose

Screened Effect if NOT Effect if SCREENED

SCREENED and TREATED Management of Galactosemia
- Avoid milk and milk products
Congenital Severe Mental Normal substituted with Lactose free or
Hypothyroidism Retardation
Galactose Free milk such as Soy-
(CH)
based milk formula
Congenital Death Alive and Normal - Galactose restricted diet must be
Adrenal followed for life and requires close
Hyperplasia supervision and monitoring
(CAH)
CONGENITAL ADRENAL HYPERPLASIA
Galactosemia Death or Alive and Normal
(GAL) Cataracts
- An endocrine disorder caused by
abnormalities in specific enzyme of
Phenylketonuri Severe Mental Normal the adrenal gland that causes severe
a (PKU) Retardation salt lose, dehydration and abnormally
high levels of male sex hormones in
G6PD Severe Anemia, Normal
Deficiency Kernicterus
the both boys and girls.
- If not detected and treated early,
babies may die within 7-14 days

PHENYLKETONURIA (PKU)
GALACTOSEMIA (GAL)
- PKU is an autosomal recessive
metabolic disorder in which the body
cannot properly use one of the
building blocks of protein called
phenylalanine, an essential amino
acid that converts into tyrosine
causing elevation of phenylalanine in
the blood.
- Screening of newborns for PKU entails
- -GAL is a condition in which the bdy is
simple heel stick blood sampling test
unable to process gaactose, the
called Guthrie test
sugar present in milk.
 - Phenylalanine is neurotoxic
- Excessive accumulation of
phenylalanine in the body causes
brain damage
- Phenylalanine hydroxylase (PAH) is
either missing or not working properly
- The first effects are usally seen arounf
6 months of age
- Untreated infants may be late in
learning to sit, crawl and stand. They
may pay less attention to things
around them.
- Without treatment, a child with PKU
will become mentally retarded
CLINICAL Manifestations:
- Severe intellectual impairment
- Microcephaly
- Eczema
- Seizures
- Hypopigmentation
- Hyperactivity
- Autistic behavior
Management:
- Should start as soon a possible but no
later than 7 to 10 days
- Protein diet restriction
G6PD DEF
- G6PD deficiency is an X-linked
hereditary disease, which means it is
caused by a defective gene and
effects males almost exclusively and is
transmitted by the mother only to son
or daughter who will become another
carrier.
- Glocuse-6-Phosphate Dehydrogenase
Deficiency
- An inherited condition in which the
body lacks the enzyme glucose-6
phosphate dehydrogenase which
helps red blood cells function normally
- This deficiency can cause hemolytic
anemia usually after exposure to
certain medications, foods or even
infections
- G6PD is one of many enzymes that
help the body process carbohydrates
and turn them into energy
- G6PD also protects RBC from
potentially harmful byproducts that
can accumulate when a person takes
certain medications or when the body
is fighting an infection
- Without G6PD to protect the blood,
RBC can be damaged or destroyed
- Hemolytic anemia is a disorder in
which the RBCs are destroyed faster
than the bone marrow can produce
them
Kids with G6PD deficiency typically do not
show any symptoms of the disorder until
their RBC are exposed to certain triggers
which are:
● illness (bacterial and viral infections)
● certain painkillers and fever
reducing dtugs like aspirin
● certain antibiotics( especially those
that have‖su;f‖ in their nameslike
sulamethoxazole- bactrim)
● certain antimalarial drugs ( those
that with ―quine‖ in their names like
chloroquine(
● Soya foods-taho, tokwa, soy sauce
- Red wine
- Legumes- monngo, garnazos,
abitsuelas
- Vitamin K
- Naphthalene (moth balls)
- blueberries
- s/s: anemia like symptoms
● Paleness ) in darker-skinned children
paleness is sometimes best seen in the
 mouth, especially on the lips or
tongue)
● Extreme tiredness
● rApid heartbeat
● Rapid breathing or shortness of
breath
● Jaundice or yellowing of the skin
and eyes particularly on newborns
● Enlarged spleen
● Dark-tea-colored urine
- Prevention/treatment
● Limit exposure to the triggers
● Folic acid
● Phototherapy
● Blood transfusion

CONGENITAL HYPOTHYROIDISM
HYPOTHYROIDISM
- is a condition in which the person does not
make enough thyroid hormone.
APGAR SCORE and 10, it will receive normal care
from there on out
● if the newborn scores between a 4
and 6, they may need help breathing
● anything lower than a 4, would
What is the APGAR SCORE? mean that the infant needs extreme
- The Apgar score is a scoring system measures to save it's life
doctors and nurses use to assess
newborns one minute and five
A is for Activity
minutes after they’re born.
- How is your baby’s movement?
- Dr. Virginia Apgar created the system
● 0 point - no movement. Almost ―limp’’
in 1952, and used her name as a
● 1 point - some flexing in the arms an/or
mnemonic for each of the five
legs
categories that a person will score.
● 2 points - active. Arms and legs flex resist to
Since that time, medical professionals
extend
across the world have used the
scoring system to assess newborns in
P is for Pulse
their first moments of life.
- How fast is baby’s heart rate? (in 1
- Medical professionals use this
minute)
assessment to quickly relay the status
● 0 point - no pulse
of a newborn’s overall condition. Low
● 1 point - less than 100 beats per minute
Apgar scores may indicate the baby
● 2 points - higher or equal to 100 beats per
needs special care, such as extra help
minute
with their breathing.

G is for Grimace
What is the Apagar Score?
- How does your baby react when
● the first test given to a newborn to
being irritated?
determine it's physical condition
● 0 point - no response
(occurs right after birth)
● 1 point - only facia; expression
● recorded at 1 and 5 minutes after
● 2 points - pulls away, cries, sneezes etc
birth
● calculated by adding points, either
2,1, or 0
A is for Appearance
● best possible score is out of 10
- What color is your baby?
● points given for muscle tone, skin
BLUE (WHERE)
color, heart rate, respiratory effort,
● 0 point - Everywhere
and response to stimulation
● 1 point - everywhere but the torso
● 2 points - normal (PINK)
What do the Apgar Scores mean?
R is for Respirations
● after the 1 minute Apgar evaluation,
- What is the baby’s breathing like?
if the newborn scores between a 7
● 0 point - absent
● 1 point - slow,weak.irregular
● 2 points - strong cry, normal effort and rate

APGAR SCORE
SCORE OF 0 SCORE OF 1 SCORE OF
2
ACTIVITY absent Flexed arms and active
legs
(muscle tone)

PULSE RATE absent Below 100 bpm Above

100 bpm
(heart rate)

GRIMACE floppy Minimal Prompt

response to response
(reflex irritabilty) stimulation to
stimulatio
n
APPEARANCE blue/pale Pink body wih pink
blue
(skin color)
extremities

RESPIRATION absent Slow and Vigorous

irregular cry
(breathing)
DUBOWITZ/BALLARD SCORING PHYSICAL MATURITY

 Based on the neonate's physical and

neuromuscular maturity

 can be used up to 4 days after birth

 evaluates a baby's appearance, skin

texture, motor function, and reflexes.

 The physical maturity part of the

examination is done in the first 2 hours
of birth.

 The neuromuscular maturity

examination is completed within 24 NEUROMUSCULAR MATURITY
hours after delivery.

 This scoring allows for the estimation of

age in the range of 26 weeks-44
weeks.

 an extension of the above to include

extremely pre-term babies i.e. up to
20 weeks.

 The scoring relies on the intra-uterine

changes that the fetus undergoes
during its maturation.

POSTURE

 Total body muscle ton is reflected in

the infant’s preferred posture at rest
and resistance to stretch of individual
muscle group
 To elicit the posture item, the infant is
placed supine (if found prone) and
the examiner waits until the infant
settles into relaxed or preferred
posture.

SQUARE WINDOW
 Wrist flexibility and/or resistance to
extensor strethching are responsible
for the resulting angle of flexion at the
wrist.
 The examiner straightens the infant’s
fingers and applies gentle pressure on
the dorsum of the hand, close to the
fingers. From extremely pre-term to
post-term, the resuling angle between
the palm of the infant’s hand and
forearm is estimated at; >90 degrees,
90 degrees, 45 degrees, 30 degrees, 0
degree
 The appropriate square on the score
sheet is selected.
ARM RECOIL
 This maneuver focuses on passive
flexor tone of the biceps muscle by
measuring the angle of recoil
following very brief extension of the
upper extremity.
 With the infant lying supine, the
examiner places one hand beneath
the infant’s elbow for support. Taking
the infant’s hand, the examiner briefly
sets the elbow in flexion, then
momentarily extends the arm before
releasing the hand.
POPLITEAL ANGLE
 This maneuver assesses maturation of
passive flexor tone about the knee
joint by testing for resistance to
extension of the lower extremity. With
the infant lying supine, and with the
diaper re-moves, the thing is placed
gently on the infant’s abdomen with
the knee fully flexed. After the infant
has relaxed into this position, the
examiner gently grasps the foot at the
sides with one hand while supporting
the side of the thigh with the other.
SCARF SIGN
 This maneuver tests the passive tone
of the flexors about the shoulder
girdle.
 The examiner nudges the elbow
across the chest, felling for passive
 flexion or resistance to extension of
posterior shoulder girdle flexor
muscles.

HEEL TO EAR

 The examiner supports the infant’s

thigh laterally alongside the body with
the palm of one hand. The other hand
is used to grasp the infant’s foot at the
sides and to pull it toward the
ipsilateral ear.
NEWBORN ASSESSMENT
ANTHROPOMETRIC MEASUREMENT
Weight
 2.5-4.5 kg
Length
-measured from the top of the head to the
bottom of one of their heels
 Female – 53 cm (20.9 in)
 Males – 54 cm ( 21.3 in)
Head circumference
-Wrap a flexible, non-stretchable measuring
tape around their head at the widest part –
just above the eyebrows( 1-2 fingers) and
ears, and around the back where the head
slopes up prominently from the neck
 34-35cm
Chest circumference
-measured at the level of the nipple, at the
end of expiration
-2 cm less than the head circumference
 30-33 (12-13 inches)
Vital signs
1. TEMPERATURE
 99F ( 37.2 C) at the moment of
immature temperature regulating
mechanisms
 birth bec they have been confined in
an internal body organ.
 Falls immediately because of heat loss
 Convection – flow of heat to body
surface to cooler surrounding air.
 Conduction- transfer of heat to a
cooler solis object in contact with the
baby.
 Radiation – transfer of heat to a cooler
solid/object not in contact with the
baby.
 Evaporation – loss of heat through
conversion of a liquid to a vapor.
 loses heat easily
 has difficulty conserving heat under
any circumstances.
INSULATION
–effective for adults but not for newborns
because they have little subcutaneous fats
to provide insulation
-Constricting blood vessels
BROWN FAT
–a special tissue found in a mature
newborns helps to conserve or produce
body heat by increasing metabolism.
-Found in the intrascapular region, thorax,
perineal area
-Because newborns have difficulty 3. RESPIRATION
conserving heat, exposure to cold is
 1st few minutes of life - 80 breaths/min
detrimental, newborns tends to kick and cry
to increase metabolic rate to produce more  Average- 30-60 breaths/min
heat.
 Respiratory depth, rate and rhythm
 newborns tends to kick and cry to are irregular and short periods of
increase metabolic rate to produce apnea sometimes called PERIODIC
more heat. RESPIRATIONS which are normal.

 Coughing and reflexes are present at

birth to clear the airway.
HOW TO CONSERVE HEAT:
 Nose breathers
 Drying and wrapping newborns

 Placing them in a warmed crib

4. BLOOD PRESSURE
 Placing them in a radiant heat source
 at birth - 80/46 mm Hg
 KANGAROO CARE– placing the
newborn against the mother’s skin  10th day - 100/50 mmHg
and covering the newborn to help
transfer heat from the mother to the
newborn.
APPEARANCE OF A NEWBORN

SKIN
2. PR
A. Color
 Transient murmurs - incomplete
- ruddy/red ( term)- RBC and less SQ fats
closure of fetal circulation shunts
- cyanosis- decrease oxygenation
 Immediately after birth - 180bpm
- hyperbilirubinemia- yellow /jaundice
 Within an hour after birth- 120-140bpm
- pallor- pale( anemia)
 Irregular because of the immaturity of
the cardiac regulatory center in the B. Birthmarks
medulla.
C. Vernix caseosa
 Femoral pulses can be felt readily in a
D. Lanugo
newborn. If absent = suggest possible
coarctation ( narrowing) of the aorta. - fine downy hair

 Radial and temporal pulses are - disappears by 2 weeks

difficult to palpate
- covers NB’s shoulders, back, upper arms,
forehead and ears
E. Desquamation -localized softening of cranial bones

-dryness ( palms of the hand soles of the -Common in 1st born infants
feet)
-Cranium – skull
-No need treatment
-Tabes- wasting
-seen on postmature babies
F. Cephalhematoma
F. Milia
-collection of blood between the
-Pinpoint white papule foundon the cheeks periosteum of the skull
and on the bridge of the nose

-Disappear by 2-4 weeks( maturation of

EYES
sebaceous glands)
-no tears until 3 month
-Don’t squeeze or scratch
-subconjunctival hemorrhage
G. Erythema Toxicum
-periorbital edema( 2-3 days)
-Newborns rash

-Appears in the 1st to 4th day of life-2 weeks

of age EARS
H. Forcep Marks -not completely formed
-Disappears 1-2 days -term – pinna recoils

-visualizing tympanic membrane is difficult

HEAD

A. Fontanelle- shd not ne indented NOSE

B. Sutures -large
-Wide separation( increased ICP,
hydrocephalus, accumulation of blood from
birth injury) MOUTH

C. Molding opens evenly

D.Caput succedaneum -large tongue

-edema of the scalp -Epstein pearls (palate)

- disappear- 3rd day

E. Craniotabes NECK

-short and chubby, rotates freely

CHEST Swallowing reflex

-witch’s milk  Food that reaches the posterior

portion of the tongue is automatically
-rhonchi
swallowed.
-location of nipples
 Gag,cough and sneeze reflex are also
present to maintain a clear airway in
the event that normal swallowing
ABDOMEN does not keep the pharynx free of
obstructing mucus.
-slightly protuberant, umbilicus
Extrusion Reflex

 Extrude any substance that is placed

ANOGENITAL AREA
on the anterior portion of the tongue.
EXTREMITIES
 This protective reflex prevents the
swallowing of inedible substances.

NEWBORN REFLEXES  Disappears about 4 months of age-

until then, an infant may seem to be
Blink Reflex
spitting out or refusing solid food
 to protect the eye from any object placed in the mouth.
coming near it by rapid eyelid closure.
Palmar Grasp Reflex
Rooting reflex
 Grasp an object placed in their palm
 Serves to help the baby find food. by closing their fingers on it.

 Newborn’s cheek is brushed or  Mature newborns grasp so strongly

stroked near the corner of the mouth, they can be raised from a supine
the child will turn the head in that position and be suspended from the
direction. examiner’s fingers.

 Disappears abt the 6th week of life. -  Disappears at 6 weeks to 3 months

at this time, the eyes can already
focus and can already see.
Sucking Reflex
 When a newborn’s lips are touched,
the baby makes a sucking motion.
 Diminish at 6 months of age
 Disappears immediately if
stimulated.
 A baby begins to grasp meaningfully
at about 3 months of age.
Step (Walk) in place Reflex
 Newborns who are held in A vertical
position with their feet touching a
hard surface will take a few quick
alternating steps.
not
 Disappears by 3 months of age
Tonic neck Reflex Babinski Reflex

 When newborn’s lie on heir backs,  When the side of the sole of the foot is
their head usually turn to one side of stroked in an inverted ―J‖ curve from
the other. the heel upward.

 The arm and the leg on the side to
which the head turns extend, and the
opposite arm and leg contract
 Movement is evident in the arms
 This reaction occurs because nervous
system development is immature.
 Remains positive until 3 months of age

 Also called the Boxer or fencing reflex

 Disappears between the 2nd and 3rd

month of life.

Moro / Startle Reflex

 Can be initiated by startling the

newborn with a loud noise or by
jarring the bassinet

 The most accurate method to elicit

reflex is to hold newborns in a supine
position and allow their heads to drop
backward an inch .

 They abduct and extend their arms

and legs.

 Fingers assume a typical ―C‖ position

 The reflex stimulates the action of

someone trying to ward off an
attacker, then covering up to protect
himself.

 Strong for the 1st 8 weeks

 Disappears at the end of 4th or 5th

month when the infant can roll from
danger.
NOTES NURSING CARE PLAN

ASSESSMENT

 Subjective- patient only

PHYSICAL ASSESSMENT  Objective-observed, parents, relatives
GENERAL ASSESSMENT

-Vital signs NURSING DIAGNOSIS

-Anthropometric measurements PLANNING
-Cry  SMART
SKIN, HAIR, NAILS  State the exact nursing intervention

HEAD AND NEACK RATIONALE

-assess shape of head, movement of neck EVALUATION

EYES AND EARS

MOUTH, THROAT, NOSE, SINUSE FDAR

-assess opening of mouth, moisture, check FOCUS

palate, assess tounge, check potency, nasal DATA
falring, respiratory distress, check sinuses
-assess positioning and attachment
HEART AND NECK VESSEL
-describe mouth of newborn
-indicate heart rate
-describe the position of baby
ABDOMINAL
-related to problem
-assess bowel sound
-there should be introduction (received
EXTREMITIES baby boy
-assess movement of extremities ACTION
GENITALIA -past tense
-assess scrotum RESPONSE
NEUROLOGIC -state interventions
-describe mental assessement

RESPIRATORY RATE- first vital sign to be

monitored
DRUG STUDY VITAMIN K

HEPATITIS B VACCINE  0.1 ml

 Use to prevent further bleeding
 Intamuscular
 Neweborn does not have the
 0.5 ml
bacteria to produce vitamin k
 Vastus lateralis- first dose
 Intramuscular
 Engerix-a
 Vastus lateralis
 Contraindication-hypersensitivity to
 Given ate left thigh when hep in on
yeast
right
 Side effect- dizziness, inflammation
 Monitor for bleeding episodes, assess if
 Given after delivery
there is darkening of skin, assess for
 Second dose- after 1 month (left
gengival bleeding, check platelet
thigh)
count, check if there is a presence of
 3rd dose- after 2 months
blood in urine
 Given after delivery

BCG VACCINE

 Bacillus Calmette Guerin

 .05 ml
NEWBORN ASSESSMENT
 Given only at birth
 Intradermal-perpendicular, deltoid, 15  Dry from head to toe
degrees angle, insert the bevel not  Skin to skin
the needle, and observe bleb or  Place bonnet
wheel  Place towel
 Class- immunological,  Wait 2-3 mins before cutting umbilical
antisera/antiserum cord
 Use to prevent tuberculosis among  Inject oxytocin to mother
newborns  Observe, initiate breastfeeding
 Treat tb  Do anthropometric measurements
 Contraindication- severe illness, seve  Give eye ointment to baby (inner to
fever, malnourished outer canthus), do not touch eyes, do
 Side effect- small swelling in injection not remove excess
site, absessforsome, fever, rashes  Give hepa b, bcg, and vitamin k
 Responsibilities- advise parents not to vaccines
scratch it, assess if there is fever, assess  Rest the baby
allergic reactions

ANTHROPOMETRIC MEASUREMENTS

 Weight- undress, consider time, done

at the same time (at morning, then
another morning), no diaper
  Length- head to heels, side lying,  Average- 30-60 bpm
female- 53 cm (20.9 inches), males- 54  Irregular and shallow for newborn,
cm(21.3 inches) they also cough to clear airways
 Head circumference- place tape  Remove secretion on mouth and nose
measure around occiput, above
eyebrows, 34-35 cm, <33 is
microcephaly BLOOD PRESSURE
 Chest circumference- at level of niple,
taken at end of expiration, bigger  At birth- 80/46 mmHg
head-smaller chest  10th day- 100-50 mmHg

VITAL SIGNS SEQUENCE OF GETTING VITAL SIGNS

TEMPERATURE 1. RR
2. PR
 99 farenheit (37.2 degree celcius)- 3. TEMP
they have this temp. because they 4. BP
are in uterus
 drop in temp. (hypothermia, no
clothing)
 newborn have no brown fat,
especially immature, but term baby APPEARANCE OF NEWBORN
have which warm their bodies
SKIN
 brown fat (thorax, perineal)
 they are crying and kicking to Color
produce metabolism for heat
 ruddy/red- RBC, less subcutaneous
fat- grade of 2
 cyanosis- decrease oxygen
PULSE RATE
 yellow/jaundice
 180 beats per min., but after 3 mins or  pallor- pale (grade of 0)
1 hour, it becomes 120-140 bpm
Birth marks
 Transient murmurs is normal
 When palpating femoral pulse, you  vernix caseosa- skin folds, provides
can feel it, but if you can’t, there is a warmth, acts as a thermoregulator,
contraction of aorta do not remove
 Radial and tempral pulse are hard to  lanugo
palpate  desquamation- leather-like skin
 milia- bridge of nose, cheeks, related
to immature sebaceous glands, just
RESPIRATORY RATE like white heads, do not scratch
because it causes infection
 1 min- 80 bpm
 erythema toxicum
  forcep marks- assisted forcep delivery  open evenly, if not, there is a problem
in CN 7, tounge is large, epstein pearls
HEAD
(palate)- calcium
Fontanelle

 when palpated, not intended, but if, it

NECK
is abnormal condition
 baby should not be crying and eating  short and chubby, rotates freely

Sutures

Molding CHEST

 head is deformed- caused by  nipples (inflamed) and secretions

mother’s pushing, disappears in how  witch’s milk related to maternl
many days hormones
 caput succedaneum- pressure during
delivery
 craniotabes- palpate head (soft)- ABDOMEN
related to pressure
 cephalhematoma  slightly protuberant, umbilicus (check
color, 6-7 days will fall off)

ANOGENITAL AREA
EYES
 testes (pendulous)
 no tears until 3 months because of  female (big labia)
immature sweat glands
 presence of blood on conjunctiva
related to pressure
EXTREMITIES

 check for extra toes

EARS  check palms/soles for creases

 not completelt formed

 preterm- stays that way
 ears are still occupied with vernix and
amniotic fluid

NOSE

 large

MOUTH
LEOPOLD’S MANEUVER • Degree of the presenting part’s
descent into the pelvis

• Expected location of the point of

maximal impulse (PMI) of the fetal
heart tones on the woman’s
-are a common and systematic ways to abdomen.
determine the position of a fetus inside the
woman's uterus through observation and
palpation to determine fetal presentations EQUIPMENT
and positions.
• Examination table
-The maneuvers consist of four distinct
• Rolled Towel
actions, each helping to determine the
position of the fetus. • Top Sheet linen
-The maneuvers are important because they • Pillow
help determine the position and
presentation of the fetus, which in • Basin and warm water (for hand
conjunction with correct assessment of the washing)
shape of the maternal pelvis can indicate
whether the delivery is going to be
complicated, or whether a Cesarean NURSING CONSIDERATIONS
section is necessary.
1. Patient should empty her bladder
-The examiner's skill and practice in
2. Examiner’s hand should be warm
performing the maneuvers are the primary
factor in whether the fetal lie is correctly 3. Explain the procedure to the patient
ascertained, and so the maneuvers are not
truly diagnostic. 4. Provide privacy

-Actual position can only be determined by 5. Position patient in dorsal recumbent.

ultrasound performed by a competent 6. Gentle yet firm touch
technician or professional.

NURSE ALERT
PURPOSES
• The clinician notes the presence and
These maneuvers help identify the ff: rate of fetal heart sounds, as well as
• Number of fetuses location for auscultation.

• Presenting part, fetal lie and fetal • Preliminary estimates of the strength,
attitude frequency, and duration of
contractions are also recorded.
 • A helpful mnemonic device for 4. Wash your hands  Hand washing
evaluation is the 3 Ps: powers using warm water prevents the
(contraction strength, frequency, and spread of
possible
duration), passage (pelvic
infection. Using
measurements), and passenger (eg,
warm water
fetal size, position, heart rate pattern). aids in client
comfort and
prevents
IMPLEMENTATION WITH RATIONALE tightening of
abdominal
PREPARATIONS muscle.

1. Prepare the client  Explanation 5. Observe the  The longest

Explain the reduces woman’s abdomen diameter (axis)
procedure anxiety and for longest diameter is the length of
enhances and where fetal the fetus. The
cooperation movement is location of
apparent activity most
2. Instruct the client  Doing so likely reflects
to empty her promotes the position of
bladder. comfort and the feet.
allows for more
productive
palpation
because fetal THE FIRST MANEUVER (FUNDAL GRIP)
contour will not
be obscured • Upper pole
by a distended
• This maneuver determines whether
bladder
fetal head or breech is in the fundus
3. Position the  Flexing the
• To determine what part of the baby
woman supine with knees relaxes
lies in the upper part of the uterus.
knees slightly flexed. the abdominal
Place a small pillow muscles. Using • Palpating, with both hands, the
or rolled towel under a pillow or
uterine fundus to determine
one side towel tilts the
uterus off the PRESENTATION ("the presenting part"):
vena cava, that portion of the fetus in closest
thus proximity to the birth canal, i.e.,
preventing cephalic, breech, shoulder
supine presentations.
hypotension
syndrome. 1st M : 3 Questions to be asked

1. its relative consistency – the head is

harder than the breech.
 2. its shape – head is firm, round and • Palpating, with both hands
hard. Breech is softer and feels more simultaneously, the sides of the uterus
angular. to locate the fetal back and
determine (with about 99% certainty)
3. mobility - head will move
POSITION: the relationship of a given
independently of the trunk but the
landmark on the fetus to the mother's
breech only with the trunk.
right and left (Therefore there are two
Nurse Alert : If it is hard, round and basic positions = Rt. and Lt.). Knowing
movable, it is likely the head ( indicating a where the back is (Rt. and Lt.) tells
breech presentation) and if it is softer, more you the position 99% of the time.
triangular and not movable , it is probably
• Cephalic landmarks: occiput (vertex);
the buttock ( indicating a cephalic
sinciput (brow); mentum (face).
presentation)
• Breech landmark: sacrum

• Shoulder landmark: acromion process

1. Stand at the foot of  Proper
of the scapula
the client, facing her, positioning of
and place both hands ensures • LIE: the relationship of the long axis of
hands flat on her accurate
the baby to the long axis of the
abdomen. findings
mother, i.e. longitudinal, transverse
2. Palpate the  When and oblique lies.
superior surface of palpating, a
3. Face the client • Proper
the fundus. head feels
and place the palms positioning of
Determine more firm than
of each hand on hands ensures
consistency, shape, the breech. A
either of the accurate
and mobility. head is round
abdomen findings.
and hard; the
breech is well
4. Palpate the sides  This method is
defined. A
of the uterus. Hold most
head moves
the left hand successful to
independently
stationary on the left determine the
of the body;
side of the uterus direction the
the breech
while the right hand fetal back is
moves only in
palpates the facing. One
conjunction
opposite side of the hand will feel a
with the body.
uterus from top to smooth, hard,
bottom. Then hold resistant
the right hand surface (the
THE SECOND MANEUVER (UMBILICAL GRIP) steady, and repeat back), while
palpation using the on the
• Sides of maternal abdomen left hand on the left opposite side;
side. number of
• To determine in which side of the angular
uterus of the baby’s back is located. nodulations
(the knees and
 elbows of the thumb and finger part is not
fetus) will be together. engaged (not
felt. Determine any firmly settled
movement and into the
whether the part is pelvis). If the
firm or soft. part is firm, it
• Nurse Alert : If you feel a smooth, is the head; if
curved resistant plane in one side, you soft, and then
have located the back and on the it is breech.
other side, you feel smaller lumps,
irregular parts, those are the the knees
and elbows of the fetus. Nurse Alert : The examiner grasps the lower
abdomen just above the symphysis pubis,
between the thumb and fingers of the hand
THE THIRD MANEUVER (PAWLIK’S GRIP) as Pawlicks grip. If the presenting part is not
engaged, it will be movable.
• Lower pole

• This maneuver determines the part of

the fetus at the inlet and its mobility.
• to determine what occupies the lower
uterine segment and to determine
whether it is engaged or not.
• Pawlik's grip - grasping with the thumb
and fingers of one hand, the lower
portion of the maternal abdomen just
above the symphysis thus confirming
the impressions of the First Maneuver
as well as providing information
THE FOURTH MANEUVER (PELVIC GRIP)
Presenting part evaluation
• This maneuver determines fetal
attitude and degree of fetal extension
into the pelvis
• Should only be done if fetus is in
cephalic presentation. Information
about the infant’s antero-posterior
position may also be gained from this
final maneuver.

• ENGAGEMENT: when the biparietal • To determine the location of the

diameter of the fetal head reaches or cephalic prominence or the brow.
passes the plane of the pelvic inlet.
• With the fingers of each hand on the
• Standing to the mother's side and sides of the uterus suprapubicly,
facing the mother's feet exerting deep pressure in the direction
of the axis of the pelvic inlet to
5. Facing the client, • If the
reinforce the impression of
gently grasp the presenting
lower portion of the part moves engagement or lack thereof and to
abdomen just upward so an determine the ATTITUDE: the
above the examiner’s relationship of the long axis of the
symphysis pubis hands can be fetal head to the long axis of the fetal
between the thumb pressed trunk (neck flexed, neutral or
and index finger together, the extended)
and try to press the presenting
• CEPHALIC PROMINENCE: that portion the uterus
of the baby's head first encountered that
with the Fourth Maneuver; enabling contained
the elbows
the examiner to determine which fetal
and knees of
landmark to use to ultimately
the fetus.
determine position. •
• If the fetus is
• When the cephalic prominence is on
poor attitude,
the side opposite the baby's back, the the
occiput (vertex) is presenting. examining
finger will
• When the cephalic prominence is on meet an
the same side as the baby's back, the obstruction
mentum (face) is presenting. on the same
side as the
• When the cephalic prominence fetal back.
seems the same on both sides, the That is, the
sinciput (brow) is presenting. fingers will
touch the
• (When there is NO cephalic hyper
prominence, the head may be way extended
down in the pelvis or the breech may head. If the
brow is very
be presenting.)
easily
6. Facing the foot • The fingers of palpated (as
part of the client, one hand will if it lies under
place fingers on slide along the skin), the
both sides of the the uterine fetus is
uterus contour and probably in a
approximately 2 meet no posterior
inches above the obstruction, position (the
inguinal ligaments, indicating occiput is
pressing downward the back of pointing
and inward in the the fetal toward the
direction of the neck. The woman’s
birth canal. Allow other hand back).
fingers to be will meet an
carried downward. obstruction
an inch or so
above the Nurse Cautionl: Leopold's maneuvers are
ligament- this intended to be performed by health care
is the fetal professionals, as they have received training
brow. The and instruction in how to perform them. That
position of said, as long as care is taken not to roughly
the fetal brow or excessively disturb the fetus, there is no
should
real reason it cannot be performed at home
correspond
to the side of as an informational exercise. It is important
to note that all findings are not truly
diagnostic, and as such ultrasound is
required to conclusively determine fetal lie.
PARTOGRAPH • Contraction pattern

• Maternal well being

• Pulse, temperature, blood

pressure
I. The Partograph
• Urine voided
• A tool to help in management of
labor • Fetal well being

• Guides birth attendant to identify • Fetal heart rate and pattern

women whose labor is delayed and • Color of amniotic fluid
therefore decide appropriate action
• Vaginal bleeding
• The partograph is a useful tool for
monitoring the progress of labor. Use it
to avoid unnecessary interventions so
maternal and neonatal morbidity are
not needlessly increased, to intervene
in a timely manner to avoid maternal
and neonatal morbidity or mortality
and to ensure close monitoring of the
woman in labor.

 The upper colored portion is where

you plot the progress of labor.
 The lower portion is where you are
supposed to write your other
observations particularly the findings
of your monitoring of the maternal
and fetal well-being.
This is the newest version of the partograph
and the one that we will be using during this
training.

MONITOR DURING LABOR…

• Progress of labor

• Cervical dilatation

 Let us enlarge the upper portion of
the partograph. As you can see it is
divided evenly into small boxes by
gridlines vertically and horizontally.
 Each horizontal gridline corresponds
to the cervical dilatation in centimeter
from 4 to 10.
 While the vertical gridlines indicate
the time, in hours, the patient is in
active labor.
 The upper portion is also divided into 3
colors – green, yellow, and red.
 The boundary between the green
and yellow parts forms a diagonal line
which is highlighted here. This is
designated as the alert line which
starts at 4 cm. up to 10 cm.
 Parallel and 4 hours to the right of the
alert line is another line formed by the
boundary between the yellow and
red part which is again highlighted
here. This is the action line. Note that it
too starts at 4 cm and ends in 10 cm.
CONDITIONS THAT DOES NOT NEED THE USE
OF PARTOGRAPH
• Antepartum hemorrhage
• Severe pre-eclampsia and eclampsia
• Fetal distress
• Previous cesarean section
• Multiple pregnancy
• Malpresentation
• Very premature baby
• Obvious obstructed labor
-The partograph need not be used in all
pregnant or laboring patients especially
those who are for cesarean delivery like
those with malpresenting babies (breech or
transverse lie), those with scarred uteri, those
with antepartum hemorrhage (like placenta
previa). It is also not needed in those who
have to be delivered immediately because
of fetal distress or those with severe
uncontrolled pre-eclampsia and eclampsia.
Likewise it may not be appropriate for those
with twins or very premature baby.
II. Recording the findings in the partograph
• Start by labeling the record with
pertinent patient identifying
information.
Plotting the progress of labor

• Plot only the CERVICAL DILATATION

using the symbol “X”

• Start when woman is in ACTIVE LABOR

(4 cm or more) and is contracting
adequately (3-4 contractions in 10
minutes)

 If she is first seen at 8 cm, then start at

the 8 cm line but still on the alert line.

 You do not always have to start the

plotting in the 4 cm line since not all
patients are first seen at this cervical
dilatation. If the patient arrives at 6
cm cervical dilatation start plotting in
the 6 cm line but still in the alert line.
EXAMPLE III. Distinguishing normal from abnormal
labor pattern

 Encourage audience participation.

 If partograph passes action line, refer
urgently to an EmOC facility unless imminent
delivery.

If plotting reaches the action line…

• the patient must be already in an

EmOC facility, a decision made about
the cause of slow progress, and
appropriate action taken

IV. Other findings to note

If plotting passes alert line … (and record) during IE

• Reassess woman and consider referral • Status of membranes, write

if facilities are not available to deal
with obstetric emergencies, unless • “ I ” if intact
delivery is imminent • If ruptured, note color of amniotic
• Alert transport services fluid, write

• Monitor intensively • “ C ” if clear

• “ M ” if meconium stained

What to do if partograph passes alert line • “ A ” if absent

• Reassess woman and consider criteria • “ B ” if bloody

for referral.

• Alert transport services. Monitor every 4 hours* and record the

• Empty bladder. findings

• Ensure adequate hydration but omit • Blood Pressure

solid foods. • Pulse rate
• Encourage upright position and • Temperature
walking if woman wishes.
• Urine voided (yes or no)
• Monitor intensively. If referral long,
reassess in 2 hours and refer if no * More frequently, if indicated
progress.
Monitor more frequently and record the
findings

• Number of contractions in 10 minute

period

• Fetal heart rate in 1 full minute

-The findings for these should be recorded

every hour.

 If woman is admitted in LATENT PHASE

of labor (less than 4 cm dilated) –
record only other findings (BP, FHT
etc). -ABNORMAL

 If she remains in latent phase for next

8 hours (labor is prolonged), transfer
Case 4:
her to hospital.
A G2P1 was admitted at 2 am, IE showed a
4cm dilated cervix. The patient was still
EXAMPLES: smiling and she was hesitant to be admitted.

At 6 am, another IE was done … 8 cm

dilated cervix, 80% effaced, station 0.

At 8 am, fetal head was bulging at the

perineum.

-NORMAL

Case 5:

A G4P2 was referred at 5 pm. The midwife

said that the patient is at 4 cm cervical
dilatation. At 9 pm, your IE showed 6 cm
dilated cervix. At 1 am, another IE done
showed 8 cm dilated cervix, 50% effaced,
station -1, intact BOW.

RECAP

• Significance and use of the

partograph

• Parts of the partograph and

information contained in it

• Recording or plotting of clinical

observations

• Interpretation of the recorded findings

and decision on referral

-An ounce of prevention is better than a

pound of cure.
MEDICATION ADMINISTRATION -She is the last link in medication
administration and a safeguard against
error.

DEFINITION OF TERMS

 A medication is a substance 10 RIGHTS

administered for the diagnosis, sure,
treatment, or relief of a symptom or  Right drug
for prevention of disease.  Right patient
 Pharmacology is the study of the  Right dose
effect of drugs on living organisms.  Right route
 Time and frequency
 Documentation
 History and assessment drug
USES OF DRUGS
approach and right to refuse
 prevention- used as a prophylaxis to  Drug-drug interaction and evaluation
prevent diseases e.g. vaccines;  Education and information
fluoride- prevents tooth decay
 diagnosis- establishing the patient’s
disease or problem e.g. radio contrast BEFORE ADMINISTERING ANY MEDICATION…
dye; tuberculosis (mantoux) testing.
 Suppression- suppresses the signs and RIGHT PATIENT
symptoms and prevents the disease  Always check patient’s identification
process from progressing e.g. bracelet
anticancer, antiviral drugs.  Asl patient to state their name and
 Treatment- alleviate the symptoms for birth date
patients with chronic disease e.g. anti-  Compare medication order to
asthmatic drugs. identification bracelet and patient’s
 Cure- complete eradication of stated name and birth date
diseases e.g. anti-biotics, anti-  Veruy patient’s allergies with chart
helmintics. and with patient
 Enhancement aspect of health-
achieve the best state of helath e.g. RIGHT MEDICATION
vitamins, minerals
 Perform a triple check of the
medication’s label
1. When retrieving the medication
-The nurse literally plays the role of a 2. When preparing the medication
lifeguard in medication administration. 3. Before administering
-She often provides the last opportunity for medication to patient
the health-care team to identify and correct o Always check the medication
errors in prescribing and distributing label with the physician’s orders
medication. o Never administer medication
prepared by another person
 o Never administer medication  Medication may only be administered
that is not labeled via route specified in order

RIGHT DOSE RIGHT EDUCATION

 Check label for medication  Inform patient of medication being

concentration administered
 Compaer prepared dose with  Inform patient of desired effects of
medication order medication
 Triple all medication calculations  Inform patient of side effe of
 Check all medication calculations medication
with nurse  Ask patient if they have any known
 Verify that dosase is within allergies to medication
appropriate dose range for patient
RIGHT TO REFUSE
and medication
 The legally responsible party (pateint,
RIGHT TIME
parent, family member, guardian,
 Verify schedule of medication with etc.) for patient’s care has the right to
order refuse any medication
1. Date  Inform responsible party of
2. Time consequences of refusing medication
3. Specified period of time  Verify that responsible party
 Check last dose of medication given understands all of these
to patient consequences
 Administer medication within 30  Notify physician that ordered
minutes of schedule medication and document
notification
ABBREVIATIONS
 Document refusal of medication and
that responsible party understands
consequences
 Let the patient or the family to sign a
waiver

RIGHT ASSESSMENT

 Properly assess patient and tests to

determine if medication is safe and
appropriate
 If deemed unsafe or inappropriate,
notify ordering physician and
RIGHT ROUTE document notification
 Document that medication was not
 Verify medication route with
administered and the reason that
medication order before
administering dose was skipped
Example: Digoxin---withhold drug if HR is  Enteric ced- dissolves in small intestine
below 60  Time release- granules with different
coatings, or some tablets that dissolve
 Anti-HPN—Check BP
slowly
 Insulin—check blood sugar  Lozenge- dissolves in mouth
 Elixir- mixed with water or alcohol and
a sweetener
 Syrup- medication dissolved in a sugar
AFTER MEDICATION HAS BEEN
solution
ADMINISTERED…
 Suspension- drug particles in a liquid
RIGHT EVALUATION medium; when left alone will settle in
the bottom
 Assess patient for any adverse side
 Solution- sterile preparation that
effects
contains water and one or more
 Assess patient for effectiveness of
dissolved compunds (m, sq, or iv)
medication
 Lotion- liquid suspension for skin
 Compare patient’s prior status with
 Ointment- semisolid (salve another
post medication status
name
 Document patient’s response to
medication

FORMS OF TOPICAL

RIGHT DOCUMENTATION  Ointment- eye and skin

 Cream- eye and skin
 Never document before medication is
 Gel- oral and skin
administered
 Document FORMS OF RECTAL AND VAGINA
1. Medication
 Suppositories
2. Dosage
 V. tablets
3. Route
4. Date and time
5. Signature and credentials
6. When appropriate, signature of TRANSDERMAL PATCHES
other nurse checlking
 Apply the patch to clean, dry, hairless
medication
skin that is not irritated, scarred,
burned, broken, or calloused. Choose
a different area each day.
MEDICATION: FORMS  As the layers of skin absorb
medication from transdermal patches
 Caplet- shaped like a capsule and
(trans meaning through and dermal
coated for easier swallowing
referring to the dermis (skin)), the
 Capsule- poweder, liquid, or oil in
medication is absorbed via the blood
gelatin shell
vessels into the bloodstream. From
 Tablet- compressed powder
 there, the blood carries medication  Absorption- takes place along the
through the circulatory system and whole length of the gi tract
through a patient's body.  Cheap- compared to most other
parenteral routes
FORMS OF INJECTIONS
DISADVANTAGES
 Ampule
 Vial: a. powder  Sometimes inefficient- only part of the
 B. solution drug may be absorbed
 First-pass effect- drugs absorbed orallt
are initially transported to the liver via
CHANNELS OF DRUG ADMINISTRATION the portal vein
 Irritation to gastric mucosa- nausea
 ENTERAL and vomiting
 PARENTERAL  Destruction of drugs by gastric acid
 TOPICAL and digestive juices
 Effect too slow for emergencies
 Unpleasant taste of some drugs
 Unable to use in unconscious patient

FIRST PASS METABOLISM

ORAL ROUTE

Oral refers to two methods of administration:

 Applying topically to the mouth

ORAL DOSAGE FORMS
 Swallowing for absorption along the
gastrointestinal tract into systemic  Tablets capsules
circulation  Liquids
 Solutions
-po (from the latin per os) is the abbreviation
 Suspension
used to indicate oral route of medication
 Syrups
administration
 Elixirs
ADVANTAGES

 Convenient- can be self administered,

pain free, easy to take
PRIMARY ASSESSMENT  Provide patient education as
necessary
 Oral medications should be as
 Plan medication eadministration to
palatable as possible
avoid disruption:
 For liquid medication, measure the
1. dispense medication in a quiet
dose exactly using the proper
area
measuring device e.g., oral/liquid
2. avoid conversation with others
dispenser, medicine dropper, or
3. follow agency’s no-interruption
graduated emedicine cup
zone policy
 Do not put medications back in the
4. preparmedications for one
container after they have been
patient at a time
poured
5. follow the rights of medication
 Oral medicatins are given according
administration
to each unit’s posted medication
times unless a physician’s order states
differently
Solid preparations Do not handle pills or
 The person administering medication
(when pt. is present): capsules by hand.
shall have knowledge of the For solid floor stock Prevent
medication, including drug and food pour corerct amount contamination of
interactions, the usuzl dose, route of of medication into medicine.
administration, the expected side the ocntainer lid then Medication packets
effects, and any special precautions into the medicine are not opened until
for contraindications cup. For unit dose, individual is present.
open unit dose
 Oral medications are contraindicated
medication packet
for individuals who experience nausea and place in
and vomiting, are unable to take medicine cup.
medicatins by mouth because of a
disease condition, or are unconscious
 Always check the expiration date on Liquid preparations: Some mixtures
Shake mixtures or requires rolling
the label or container of the
suspensions before between ahnds while
medication to be administered pouring (follow other should be
 Check storage requirements as some instructions on shaken well. A
medications need to be refrigerated bottle). A medication medication that does
 Perform hand hygiene with an unexpected not appear normal is
 Check room for additional precipitate or a to be returned to the
precautions change of color is pharmacy.
not to be used.
 Introduce yourself to the client
Do not mix liquid They may cause an
 Confirm patient id using two patient medications undesirable
identifiers (name and date of birth) together interaction such as a
 Check allergy band for any allergies precipitate.
 Complete necessary focused
assessments and/or vital signs, and
document on MAR.
SUBLINGUAL ROUTE liquefies after it is inserted int the
rectum.
 sublingual administration is where the
 Ex. diazepam, indomethacin,
dosage form is placed under the
paraldehyde, ergotamine
tongue
 rapidly absorbed by the mucosa ADVANTAGES

ADVANATAGE  Uses in children

 Little or no first pass effect (ext
 quick termination
haemorrhoidal vein)
 first-pass avoided
 Used in vomiting or unconscious
 drug absorption is quick
 Higher concentratios rapidly achieved
DISADVANTAGE
DISADVANTAGES
 unpalatable and bitter drugs
 Inconvenient
 irritation of oral mucosa
 Absorption is slow and erratic
 large quatities not given
 Irritation or inflammation of rectal
 few drugs are absorbed
mucosa can occur

BUCCAL ROUTE TOPICAL ROUTES OF ADMINISTRATION

 buccal administration is where the  Topical administration is the appliction

dosage form is placed between gums of a drug directly to the surface of the
and inner lining of the cheeck(buccal skin
pouch)  Includes administration of drugs to
 absorbed by buccal mucosa any mucous membrane
1. Eye
ADVANTAGES 2. Nose
3. Ears
 avoid first pass effect
4. Lungs
 rapid absorption drug stability
5. Vagina
DISADVANTAGES 6. Urethra
7. Colon
 inconvenience
 advanatages lost if swallowed TOPICAL DOSAGE FORMS
 small dose limit
 SKIN
1. Creams
2. Ointments
RECTAL ROUTE
3. Lotions
 drugs thar are administered rectally as 4. Gels
a suppository. 5. Transdermal patches
 In this form, a drug is mixed with a 6. Disks
waxy substance that dissolves or
  EYE  Eliminate the adverse effects
1. Solutions associated with excessive absorption
2. Suspensions of drugs taken orally
3. Ointments  Thereby alleviate anxiety
 NOSE AND LUNGS  Offer more comfort to patients
1. Sprays and powders  Produce excellent prolonged effects
 Administration can be vidually
confirmed
ADVANTAGES AND DISADVANTAGES OF THE
TOPICAL ROUTE SIDE EFFECTS

 Local therapeutic effects  Light headaches

 Not well absorbed into the deeper  Dizziness
layers of the skin or mucous  Redness or irritation of the skin
membrane (covered by the patch)
-lower risk of side effects  Flushing
 Transdermal route offers steady level
Some other side effects can be serious:
of drug in the system
-sprays for inhalation through the nose  Slow or fast heart beat
may be for local or systemic effects  Worsening chest pain
 Fainting
 Rash
TRANSDERMAL PATCH  Itching
 Difficulty in breathing or swallowing

SPECIAL PRECAUTIONS WHEN USING

TRANSDERMAL PATCH:

 apply patch to clean, dry, unbroken

skin
 apply patch firmly ( it may take 20-30
seconds to get itstick firmly in place)
 wash your hands after applying
 use only one patch at a time
 if you need to conduct MRI test , the
patch may need to be removed
 if you develop skin irritation ( due to
ADVANTAGES OF TRANSDERMAL DRUG adhesive ), apply the next patch on
DELIVERY another area
 when you remove the skin patch, fold
 Do not put too much load on it so the adhesive edges stick together
digestive system and liver  gently wash the arca with soap and
 Avoid the pain on injection water
BASIC COMPONENTS OF TRANSDERMAL  to aid in removal of foreign body
DRUG DELIVERY trapped in the ear

 backing
 drug POSITIONING THE CLIENT FOR EARDROP
 membrane INSTILLATION
 adhesive
 before instilling eardrops, have the
 liner
client lie on his or her side. The
straighten the ear canal to help the
medication reach the eardrum. For
EYE DROPS AND OINTMENTS
adult, gently pull the auricle up and
back. For young child and infant,
gently pull down and back

INHALATION ROUTE

 eye ointment is applied in the same  is drugs administration by the nasal or

way as eye drops. Apply a one cm. oral respiratory route. This route of
ribbon of ointment in the pocket administration is used from drugs that
formed by pulling down the lower eye are gases (fo example, some
lid anesthetics) or those that can be
 to improve flow of ointment, hold tube dispersed in an aerosol
in hand for several minutes to warm
ADVANTAGES
before use
 fast and easy to take, can be self
administered
EAR (OTIC) INSTILLATION
DISADVANTAGES
 instill liquid medication into external
auditory canal for such therapeutic  increased bronchial and salivary
effects. secretions

PURPOSES

 to treat infection and inflammation  first be shaken to ensure that drug

 to soften cerumen for removel should be evenly distributed
 to produce local anesthesia
  held upright and the cap is removed

 breathes out gently, but not fully

 with the mouth around the

mouthpiece of the inhaler, the device
is pressed to release the drug as soon
as inspiration has begun

 inspiration should be slow and deep,

be held for 10 seconds if possible

 dose of inhalation will involve >1

―puff‖

 the length of time between inhalation

is 15-20 seconds

ROTAHALER

 insert a capsule into the rotahaler the

colour end first
 twist the rotahaler to break the
capsule
 inhale deeply to get powder into the
airway
 several breath may be required, does
not required the coordination of the
aerosol

NEBULIZERS

 patient coorperation and

coordination is not a critical
 it converts solution into aerosol
particles, <5 um.
 An acceptable time 5-10 minutes.
APGAR SCORING 10, it will receive a normal care from
there on out
 If the newborn scores between a 4
and 6, they may need help breathing
 Anything lower than a 4, would mean
that the infant needs extreme
measures to save its life
WHAT IS APGAR SCORE?

-The apgar score is a scoring system doctors APGAR SCORING SYSTEM

and nurses use to assess newbornes one
minute and five minute after they are born.

-Dr. Virginia Apgar created the system in

1952, and used her name as a mnemonic
for each of the five categories that a person
will score. Since that time, medical
professionals across the world have used the
scoring system to assess newborns in their
first moments of life.

-Medical professionals use this assessement

to quickly relay the status of a newborn’s
ACTIVITY
ovall condition. Low apgar scores may
indicate the baby needs special care, such  How is the baby’s movement?
as extra help with their breathing.  0- no movement. Almost limp
 1- some flexing in the arms or legs
-The first test given to a newborn to
 2- active. Arms and legs flec resist to
determine its physical condition (occurs right
extend
after birth)
PULSE
-recorder at 1 and 5 minutes after birth
 How fast is baby’s heart rate in 1
- calculated by adding points, either 2,2,or 0
minute?
-best possible socre is out of 10  0- no pulse
 1- less than 100 bpm
-points given for muscle tone, skin color,
 2- higher or equal to 110 bpm
heart rate, respiratory effort, and response
to stimulation GRIMACE

 How does you baby react when

being irritated?
WHAT DO APGAR SCORES MEAN?  0- no response
 After 1 minute apgar evaluation, if  1- only facial expression
the newborn scores between a 7 and  2- pulls wasy, cries, sneezes
APPEARANCE

 What color is your baby?

 0- blue or pale, cyanosis
 1- blue extremities, acrocyanosis
 2- pink

RESPIRATION

 What is baby’s breathing like?

 0-absent
 1-slow, weak, irregular
 2- strong cry, normal effort and rate
BALLARD SCORING NEUROMUSCULAR MATURITY

POSTURE

NEUROMUSCULAR MATURITY  At rest

 As maturation progresses increasing
 Developed by Dr. Jeanne L. Ballard, passive flexor te
MD, in 1979  Increasing passive flexor tone-
 Used by health care professionals to centripetal direction
determine gestational age  Lower extremities slightly ahead of
 Estimation of postnatal maturation for upper extremities (caudo cephalad)
an infant born after 20 weeks of
gestation SQUARE WINDOW TEST
 Based on the infant’s external  Tests wrist flexibility or resisitance to
characteristics extensor stretch
 Covers 12 categories of  At term and post term, the infant has
neuromuscular maturity and physical maximum passive flexor tone and
maturity minimum passive extensor tone
 Each category is scored between 0
and 5. Lowest score is 0 and the ARM RECOIL
highest is 54
 Focuses on passive flexor of biceps
 For example: score of 45= 42 weeks;
muscle
20=32 weeks
 Briefly flex the elbow extend
briefly release

NEUROMUSLUAR MATURITY POPLITEAL ANGLE

 Posture  This maneuver assesses maturation of

 Square window test passive flexor tone about the knee
 Arm recoil joint by testing for resistance to
 Popliteal angle extension of the lower extremity
 Scarf sign
SCARF SIGN
 Heel to ear test
 Tests the passive tone of the flexors
PHYSICAL MATURITY
about the shoulder girdle
 Skin  The point on the chest which the
 Lanugo elbow moves easily prior to significant
 Plantar surface resistance is noted
 Breast  Landmarks noted in order of
 Eyes/ears increasing maturity:
 Genitals 1. Full scarf at the level of the neck (-
1)
-neurological signs are more reliable than 2. Contralateral axillary line (0)
physical 3. Contralateral nipple line (1)
 4. Xyphoid process (2)
5. Ipsilateral nipple line (3)
6. Ipsilateral axillary line (4)

HEEL TO EAR

 Measures passive flexor tone about

the pelvic girdle by testing for passive
flexion or resistance to extension of
posterior hip flexor muscles
 Note location of heel where
significant resistance
 Landmarks noted in order of
increasing maturity include resistance
felt when the heel is at or near:
1. Ear (-1)
2. Nose (0)
3. Chin level (1)
4. Nipple line (2)
5. Umbilical area (3)
6. Femoral crease (4)
ESSENTIAL INTRAPARTUM mother – informed her of
progress of labor, gave
NEWBORN CARE reassurance and
encouragement
- Monitoring the progress of labor
with the use of partograph

Essential Intrapartum and Newborn Care

Unnecessary interventions eliminated
(EINC) Evidence-based Standard Practices
- The EINC practices are
● DURING LABOR AND DELIVERY
evidenced-based standards for
- enemas and shavings
safe and quality care of birthing
- fluid and food intake restriction
mothers and their newborns,
- routine insertion of intravenous
within the 48 hours of
fluids
Intrapartum period (labor and
- Fundal pressure to facilitate
delivery) and a week of life for
second stage of labor is no
the newborn.
longer practiced, because it
- EINC distinguishes the necessary
resulted to maternal and
practices in the delivery and
newborn injuries and death.
care for the newborn and the
mother, from the unnecessary.
Unnecessary interventions eliminated
- In December 2009, the
● FOR NEWBORN CARE
Secretary of the Department of
- routine suctioning
Health Francisco Duque signed
- early bathing
Administrative Order 2009-0025,
- routine separation from the
which mandates
mother
implementation of the EINC
- foot printing
Protocol in both public and
- application of various
private hospitals. Likewise, the
substances to the cord
Unang Yakap campaign was
- and giving pre-lacteals or
launched.
artificial infant milk formula or
other breast-milk substitutes.
PRIOR TO WOMAN’S TRANSFER TO THE DR
- Continuous maternal support,
WOMAN ALREADY IN THE DR
by a companion of her choice,
- Checked temperature in DR
during labor and delivery
area to be 25-28C, eliminated
- Mobility during labor – the
air draft
mother is still mobile, within
- Asked woman if she is
reason, during this stage
comfortable in the semi upright
- Ensured that mother is in her
position
position of choice while in labor
- Ensured the woman’s privacy
- Asked mother if she wishes to
- Non-drug pain relief, before
eat/drink or void
offering labor anesthesia
Communicated with the
 - Episiotomy will not be done, NURSING ACTION
unless necessary - Washed the hands and put on 2 pairs of
sterile gloves aseptically ( if same worker
PROCEDURE: handles perineum and cord)
- Removed all jewelry then RATIONALE
washed hands thoroughly - To prevent contamination.
observing the WHO 1-2-3-4-5
procedure AT THE TIME OF DELIVERY
- Prepared a clear, clean - Encouraged the woman to
newborn resuscitation area. push as desired
Checked the equipment if - Draped the clean, dry linen
clean, functional and within over the mother’s abdomen or
easy reach. arms in preparation for drying
the baby
NURSING ACTION - Applied perineal support and
- Arranged materials/supplies in a linear did controlled delivery of the
sequence head
- Called out time of birth and sex
RATIONALE of the baby
- To facilitate easy access of the materials - Informed the mother of
according to the order of use. outcome
● Gloves
● dry linen
FIRST 30 SECONDS
● Bonnet
● oxytocin injection • Thoroughly dried baby for at least 30
● plastic clamp seconds, starting from the face and
● instrument clamp head, going down to the trunk and
● Scissors/ surgical blade extremities while performing a quick
● 2 kidney basins. check for breathing
● In a separate sequence for after the 1st
breastfeed:
● eye ointment, 1-3 MINUTES
● (stethoscope to symbolize PE),
• Removed the wet cloth
● vit K,
● hep B and • Placed baby in skin-skin contact on
● BCG vaccines the mother’s abdomen and chest
● ( plus cotton balls)
• Covered baby with the dry cloth and
the baby’s head with a bonnet
NURSING ACTION
-Cleaned the perineum with antiseptic • Excluded a 2nd baby by palpating the
solution abdomen in preparation for giving
RATIONALE oxytocin.
- To prevent infection
• Used wet cloth to wipe the soiled
gloves. Give IM Oxytocin within one
minute of baby’s birth. Disposed of
wet cloth properly
• Removed 1st set of gloves
decontaminated them properly
• Palpate umbilical cord to check for
pulsations
• After pulsations stopped, clamp cord
using the plastic clamp or cord tie at
2cm from the base
• Place the instrument clamp 5 cm from
the base
• Cut near plastic clamp
• Performed the remaining steps of the
AMTSL:
0Waited for strong uterine
contractions then applied controlled
cord traction and counter traction on
the uterus, continuing until placenta
was delivered
• Massage the uterus until it is firm
• Inspected the lower vagina and
perineum for lacerations and repaired
lacerations/tears as necessary
• Examined the placenta
completeness and abnormalities
• Cleaned the mother. Flushed
perineum and applied perineal
pad/napkin
• Checked baby’s color and breathing;
checked that mother was
comfortable, uterus is contracted
• Disposed of the placenta in a leak
proof container or plastic bag
• Decontaminated instruments before
cleaning, decontaminated 2nd pair of
gloves before disposal, stating that
decontamination lasts at least 10
mins.
and
• Advised mother to maintain skin-skin
contact. Baby should be prone on
mother’s chest between the breasts
with head turned to one side.
15-90 MINUTES
• Advised mother to observe for
feeding cues
• Supported mother, instructed her on
positioning and attachment
• Waited for full breastfeed to be
completed
• After a complete breastfeed,
administered eye ointment ( first) did
thorough physical examination, then
did vit K, hep B and BCG injections(
simultaneously explained purpose of
each rationale)
• Advised OPTIONAL/DELAYED bathing
of baby ( AND was able to explain the
rationale)
for
• Advised breastfeeding per demand
• In the first hour: checked baby’s
breathing and color; and checked
mother’s vital signs and massaged
uterus every 15 minutes
• In the second hour; checked mother
baby dyad every 30 minutes to 1
hour
• Completed all records
VACCINATION • Supports the perineum.

• Eye Ointment- erythromycin- to • Calls out the time of birth and sex of
prevent pink eye in the first month of the baby.
life‖ ophthalmia neonatorum‖.
• Dries throrougly the baby for full 30
Common cause is chlamydia, a
seconds using the 1st towel.
sexually transmitted infection.
• Performs a rapid assessment of the
• Hepatitis B- given to newborn baby’s
baby’s breathing.
―insurance policy‖ against being
infected with the hepatitis virus. Within • Initiates immediate skin-to skin
12 hours contact.
• Vitamin K- given to form blood clots • Positions the newborn prone on the
and to stop bleeding. Vitamin mother’s abdomen.
deficiency bleeding(VKDB). (0.5mg-
weighing below 1,500g & 1.0mg- • Covers the newborn’s back with a dry
weighing above 1,500mg). blanket.

• BCG-Bacille Calmette-Guerin- • Covers the newborn’s head with a

vaccine given to baby to protect bonnet.
them from serious forms of
• Removes the 1st set of gloves prior to
tuberculosis(TB) such as TB
cord clamping and cutting.
meningitis(infection of the brain).
• Clamps and cuts properly timed cord
between 1-3 minutes.
ANTHROPOMETRIC MESAUREMENTS
• Injects oxytocin 10 IU to the mother’s
• LENGTH-48CM-50 CM deltoid.

• WEIGH- 2.5KG- 3.5KG • Checks the mother’s condition and

delivers the placenta.
• HEAD CC- 33 CM-35 CM
• Initiates breastfeeding for the 1st 30-60
• CHEST CC-30CM-33CM minutes.
• ABDOMINAL CC-33CM-35CM • Administer ointment, Vit K, Hep B and
BCG after the baby completes her
• THIGH CC-12-16CM
breastfeeding.
• ARM CC-8-9CM
• Performs anthropometric
measurements.

PROCEDURE (PORTFOLIO)

• Lays out material in linear manner.

• Wears sterile gloves. (Double gloving)

BAG TECHNIQUE  to demonstrate nursing procedures -to
provide appropriate health
educations

COMMUNITY/PUBLIC HEALTH BAG

 An essential and indispensable COMPARTMENTS /CONTENTS OF THE PUBLIC

equipment of a public health nurse HEALTH BAG:
which she has to carry along during
her home visits. Planning

BAG Supply/ Equipment's:

 It is a flexible, or dilated sac or pouch A. Outside pocket

designed to contain needed article to  soap and soap dish
carry from one place to other place  paper square bag
to do the health-related services to  2 hand towels
the people.
TOP
BAG TECHNIQUE
 Extra paper for making waste bag
 Skills and expertise in preparing and  Plastic/linen lining Plastic lining
using the supplies and equipment in  1 pair of sterile gloves
the Community Health Bag to  Apron
provide efficient nursing care to
clients while conserving time and FRONT
effort.
 Thermometer (oral/rectal)
 2 test tubes
 Test tube holders
For the following purposes bag technique is
employed: CENTER

 to assess the need of the individual  2 hand towels

and family  Soap in a soap dish
 Cotton balls
 to provide emergency first aid services  Baby’s scale
in case of minor ailments and  Tape measure
accidents-to provide primary medical  Sterile dressing
care in case of acute and  Micropore plaster
communicable diseases  2 pairs of scissors (surgical and
 to provide antenatal, postnatal and bandage)
intranatal care to  2 Pairs of forceps (curved and
straight)
 to provide essential care to infants  Cord Clamp
and children -to provide follow up  Disposable syringes with needles (g.
services in case of chronic illness 23 &25)
 - Hypodermic needles
(g.19,22,23,25)
 Alcohol lamp

REAR

 70% Alcohol

 Betadine

 Hydrogen peroxide

 Zephiran (Benzalkonium) –
disinfectant

 Opthalmic ointment

 Spirit of ammonia

 Benedict’s solution (detects glucose

in urine)

 Acetic acid (detects protein in urine)

IMPLEMENTATION

IMPORTANT POINTS TO CONSIDER IN THE USE

OF THE BAG TECHNIQUE

A.Handwashing is the single most important

way.

- to prevent the spread of disease.

-to prevent spread bacteria from the

environment of the patient to the patient
himself.
Source: Kozier & Erb, Fundamentals of
Nursing. Father of Handwashing – Ignaz
Semmelweis
POINTS TO CONSIDER IN THE USE OF THE BAG
TECHNIQUE
1. The bag should contain all necessary
articles, supplies and equipments that will be
used.
2. The bag and its contents should be
cleansed very often, supplies replaced and
ready for use anytime.
3. The bag and its contents should be well-
protected from contact with any article in
the patient’s home.
4. Consider the bag and its contents clean
and sterile, while articles that belong to the
patients as dirty and contaminated.
5. The arrangement of the contents of the
bag should be the one most convenient for
the user, to facilitate efficiency and avoid
confusion.
SPECIAL CONSIDERATIONS
B - bag and its contents must be free from
any contamination.
A - always perform handwashing.
G - gather necessary equipments to render
effective nursing care.
PRINCIPLES OF BAG TECHNIQUE
Bag Technique
1. Minimize, if not prevent the spread
infection.
2. Saves time and effort of the nurse.
3. Should show effectiveness of total
care given to an individual or family.
4. Can be performed in a variety of ways
PROCEDURE
1. Check bag and contents before
home visit
2. Choose a work area where the bag
can be placed without risk of
contamination. (verandah, etc.)
3. Prepare a clean upper surface
4. Check the bag according to the
sequence of procedure before hand
washing.
5. Upon arriving at the client's home, a.
place the bag on the table or any flat
surface lined with paper lining, clean
side out (folded part touching the
table).
6. b. puts the handle or strap beneath
the bag.
7. Asks for a basin of water if faucet is
not available.
8. Places this outside the work area
9. Opens the bag, a. takes the
linen/plastic lining and spread over
the work field or area. b. the paper
lining, clean side out (folded part out)
10. Takes out hand towel, soap dish and
apron and places them at one corner
of the work area (within the confines
of the linen/plastic lining)
of
11. Performs hand washing, a. wipes
hands with dry towel. b. Leaves the
plastic wrappers of the towel in soap
dish in the bag
12. Wears an apron: a. right side out and
wrong side with crease touching the
body b. slides the head into the neck
strap c. ties the straps neatly at the
back.
13. Puts out things most needed for the
specific care (e.g. thermometer,
kidney basin, cotton ball, waste
paper bag) and places at one corner
of the work area.
14. Places waste paper bag outside of
work area.
15. Closes the bag.
16. Proceeds to the specific nursing care
or treatment.
23. Makes appointment for the next visit
(either home or clinic), taking note of
the data, time and purpose.
24. Cleans and alcoholizes all articles
before keeping in the bag.
25. Get the bag from the table, a. folds
the paper lining (and inserts) b. and
places in between the flaps and
cover the bag.
26. Records all relevant findings about the
client and members of the family.
27. Takes note of the environmental
factors which affect the clients/family
health
28. Includes quality of nurse-patient
relationship.
29. Assess effectiveness of nursing care
provided.

17. Cleans and alcoholizes the things

after completing nursing care or
treatment.

18. Performs hand washing again.

19. Opens the bag and put back all the

cleaned materials.

20. Removes apron folding away from the

body, with soiled sidefolded inwards,
and the clean side out and places it
in the bag.

21. Folds the linen/plastic lining and

places in the bag and close.

22. Makes post visit conference on

matters relevant to health care, taking
anecdotal notes preparatory to final
reporting.
UNIVERSAL PRECAUTION What are Bloodborne Pathogens?

 Hepatitis B – HBV -- Extremely

What are “Universal Precautions"?
 Universal precautions are infection
control guidelines designed to
protect people from diseases spread
by blood and certain body fluids.
 Always assume that all "blood and
body fluids" are infectious for blood-
borne diseases such as HBV (Hepatitis
B Virus), HCV (Hepatitis C Virus) and
HIV (Human Immuno-deficiency Virus).
 These precautions are written in
accordance with guidelines
established by the Center for Disease
Control (CDC) and OSHA. • These
apply to all personnel.
 Universal precautions are the
standard preventive measures that
are normally taken by professional
and health persons when they are
handling sick people with
communicable diseases.
 This is for the purpose of preventing
the spread of a certain disease
through infection .
contagious.
About 10% of those infected become
carriers. Can live outside the body for
up to 2 weeks.
 Hepatitis C - Very contagious.
Can live outside the body for 3-4 days.
 HIV – AID - HIV attacks the immune
system, eventually destroying the
body’s ability to fight infection.
Note: There is no vaccine and no cure!!
Body Fluids which DO NOT require Universal
Precautions but are still a potential source
of many other types of infection.
• Urine
• Feces or stool ( with no visible blood)
• Saliva (with no visible blood)
• Sputum/mucous (with no visible
blood)
• Vomit (with no visible blood)

• Sweat
Body Fluids which require Universal
Precautions : • Tears

• Blood

• Any body fluid with visible blood How are Germs Transmitted?

• Wound secretions Five Modes :

• Vaginal secretions and semen • Airborne (Legionaires Disease)

• Droplets (Cold, Influenza, TB)

• Blood and Body Fluids

(STD’s,HBV,HIV)
 • Skin to Skin (Pinkeye, Ringworm) - Vector- insects or animals

• Oral/Fecal (Hepatitis A, Food - Vehicle- food, water, blood

Poisoning, e-coli) medication

PORTAL OF ENTRY TO SUSCEPTIBLE HOST

• Refers to the method by which the

pathogen enters the body

• It can be through skin, GIT, respiratory

tract, genito urinary tract

SUSCEPTIBLE HOST

• one whose biologic defense

mechanisms are weakened in some
way

MEDICAL ASEPSIS
AN INFECTIOUS AGENT/ETIOLOGIC AGENT:
 reduces number of pathogens
• Pathogen/ Microorganisms  referred to as clean techniques
• Capable of producing an infectious  used in administration of: medications,
process enemas, tube feedings, daily hygeine

RESERVOIR -handwashing is number 1

 Source SURGICAL ASEPSIS

• anything (a person or animal or plant  eliminates all pathogens

or substance) in which an infectious  referred to as sterile technique
agent normally lives and multiplies  used in: dressing changes,
catheterizations, surgical procedures
PORTAL OF EXIT/ FROM through sneezing,
coughing, talking; open wound; drainage.

MODE OF TRANSMISSION PRINCIPLES IN THE PREVENTION OF INFECTION

• way that the causative agent can be 1. Consider every person (patient or
transmitted to another reservoir or staff) infectious.
host where it can live by: 2. Wash Hands- the most practical
- Contact-Direct or indirect procedure for cross-
contamination(person to person).
- Airborne-droplet or droplet
nuclei 3. Wear gloves before touching
anything wet- broken skin, mucous
 membranes, blood or other body –Category of isolation precautions
fluids( secretions and excretions) or
2. Durability and appropriateness for the
soiled instruments.
task
4. Use physical barriers(protective
3. Fit
goggles, face masks and apron) if
splashes and spills of any body fluids
are anticipated
Sequence* for Donning PPE
5. Use safe work practices, such as not
recapping or bending needles, • Gown first
dispose properly.
• Mask or respirator
6. Isolate patient only if
• Goggles or face shield
secretions(airborne) or
excretions(urine and feces) cannot be • Gloves
contained

7. Decontaminate process for

How to Don a Gown
instruments and other items by
sterilizing. • Select appropriate type and size

• Opening is in the back

TYPES OF PPE USED IN HEALTHCARE SETTINGS • Secure at neck and waist

• Gloves – protect hands • If gown is too small, use two gowns

• Gowns/aprons – protect skin and/or – Gown #1 ties in front

clothing
– Gown #2 ties in back
• Masks and respirators– protect
mouth/nose

–Respirators – protect respiratory tract How to Don a Mask

from airborne infectious agents • Place over nose, mouth and chin
• Goggles – protect eyes • Fit flexible nose piece over nose
• Face shields – protect face, mouth, bridge
nose, and eyes • Secure on head with ties or elastic

• Adjust to fit
FACTORS INFLUENCING PPE SELECTION

1. Type of exposure anticipated

–Splash/spray versus touch

How to Don Eye and Face Protection
• Position goggles over eyes and
secure to the head using the ear
pieces or headband
• Position face shield over face and
secure on brow with headband
• Adjust to fit comfortably
How to Don Gloves
• Don gloves last
• Select correct type and size
• Insert hands into gloves
• Extend gloves over isolation gown
cuffs
How to Safely Use PPE
• Keep gloved hands away from face
• Avoid touching or adjusting other PPE
• Remove gloves if they become torn;
perform hand hygiene before
donning new gloves
• Limit surfaces and items touched
“Contaminated” and “Clean” Areas of PPE
• Contaminated – outside front
• Areas of PPE that have or are
likely to have been in contact
with body sites, materials, or
environmental surfaces where
the infectious organism may
reside
• Clean – inside, outside back, ties on
head and back
• Areas of PPE that are not likely
to have been in contact with
the infectious organism
Sequence for Removing PPE
• Gloves
• Face shield or goggles
• Gown
• Mask or respirator
Where to Remove PPE
• At doorway, before leaving patient
room or in anteroom*
• Remove respirator outside room, after
door has been closed*
How to Remove Gloves (1)
• Grasp outside edge near wrist
• Peel away from hand, turning glove
inside-out
• Hold in opposite gloved hand
• Slide ungloved finger under the wrist
of the remaining glove
• Peel off from inside, creating a bag
for both gloves
• Discard
Remove Goggles or Face Shield
• Grasp ear or head pieces with
ungloved hands
• Lift away from face
• Place in designated receptacle for
reprocessing or disposal
Removing Isolation Gown
• Unfasten ties
• Peel gown away from
shoulder
• Turn contaminated outside toward
the inside
• Fold or roll into a bundle
• Discard
Removing a Mask
• Untie the bottom, then top, tie
• Remove from face
• Discard
Removing a Particulate Respirator
• Lift the bottom elastic over your head
first
• Then lift off the top elastic
• Discard
Hand Hygiene
Perform hand hygiene immediately after
removing PPE.
– If hands become visibly contaminated
during PPE removal, wash hands before
continuing to remove PPE
Wash hands with soap and water or use an
alcohol-based hand rub
* Ensure that hand hygiene facilities are
available at the point needed, e.g., sink or
alcohol-based hand rub
neck and
What Type of PPE Would You Wear?
• Giving a bed bath?
• Generally none
• Suctioning oral secretions?
• Gloves and mask/goggles or a
face shield – sometimes gown
• Transporting a patient in a wheel
chair?
• Generally none required
• Responding to an emergency where
blood is spurting?
• Gloves, fluid-resistant gown,
mask/goggles or a face shield
• Drawing blood from a vein?
• Gloves
• Cleaning an incontinent patient with
diarrhea?
• Gloves w/wo gown
• Irrigating a wound?
 • Gloves, gown, mask/goggles or • After handling or feeding pets.
a face shield
• After working or playing outside.
• Taking vital signs?

• Generally none
DO HAND WASHING PROPERLY...

• Wash hands thoroughly with soap and

Use of PPE for Expanded Precautions water for 5 minutes. Rinse under
running water.
• Contact Precautions – Gown and
• Dry hands.
gloves for contact with patient or
environment of care (e.g., medical
equipment, environmental surfaces)
STEPS IN DOING HAND WASHING:
• In some instances these are
1. Wet hands before applying liquid
required for entering patient’s
soap.
environment
2. Rub palm to palm.
• Droplet Precautions – Surgical masks
within 3 feet of patient 3. Right palm over left dorsum and left
palm over right dorsum.
• Airborne Infection Isolation –
Particulate respirator* 4. Palm to palm with fingers interlaced.
*Negative pressure isolation room also 5. Back of fingers to opposing palms with
required fingers interlocked.

6. Rotational rubbing of the right thumb

clasped in left palm, and vice versa.
Handwashing
7. Rotational rubbing backwards and
The most effective means of preventing
forwards with tops of fingers and
disease transmission
thumb of right hand to left, and vice
• It should be done : versa.

• At the start of the day or when soiled. 8. Rinse hands under running water.

9. Dry hands using paper towels. Dry

• Before contact with food. palms and back of hands.

• After using toilet facilities or assisting

with personal hygiene.
Managing Exposure Incidents
• After coming into contact with any
• Immediately wash hands and other
Potential Infectious Material, *even if
skin surfaces that are contaminated.
gloves were worn.*
 • Mucous membranes or eyes must be drainage/secretions isolation, blood and
flushed with clear water. body fluid precaution

• Allowing puncture wounds to bleed 2. Disease –specific isolation precaution

for a short period prior to washing will
–for specific diseases.
help to clean the wound from the
inside

• All exposure incidents must be Transmission

reported to your supervisor or the On-
call supervisor as soon as it is safe to
do so.
• This includes :
- Staff to Staff, Individual to Individual,
Staff to Individual and Individual to
Staff.
-Based Precaution:
- use in addition to standard precaution, for
clients with known or suspected infections
that are spread in one of three ways: by
airborne, droplet transmission or contact.

• In addition to an Incident Report, an

Exposure Incident Report must be
filled out and given to your supervisor
by the end of your shift.

• All employees who have been

identified as having potential
exposure will be offered the HBV
vaccine.

• Receive prophylaxis

STANDARD PRECAUTIONS USE IN THE CARE

OF ALL HOSPITALIZED PERSONS REGARDLESS
OF THEIR DIAGNOSIS OR POSSIBLE
INFECTION STATUS.

Isolation- refers to measures design to

prevent the spread of infections or
potentially infectious microorganisms to
health personnel's.

Category:

1.Specific Isolation precaution-strict

isolation, contact isolation, enteric isolation,