RELATED LEARNING EXPERIENCE

DRUG CALCUALTION - To avoid any cross-contamination of any

microorganism present in our
 Desired Dosage surroundings.
----------------- X Quantity/Volume 1. Empty the bladder of the pregnant woman.
2. Allow the pregnant woman to lie in a supine
Stock Dosage position or dorsal recumbent with the knees
 Volume slightly flexed with pillows or placing
-------- X gtts/ml wedge to right hip.
Minute 3. Drape the px
4. Ask permission to remove the gown
NURSING PROCESS surrounding her womb.
5. Warm hands by rubbing together (Cold
 ADPIE
hands can stimulate uterine contractions)
 ASSESSMENT
6. Use the PALM for palpation not the fingers.
 DIAGNOSIS 7. 1st MANEUVER (FUNDAL GRIP)
 PLANNING - The superior surface of the fundus is
 INTERVENTION palpated to determine consistency,
 EVALUATION shape, and mobility.
- Technique: Face the mother, palpate the
LEOPOLD’S MANUEVER fundal area with both hands.
(RETURN DEMONSTRATION) - Goal: To assess the fetal presentation
- Assessing and palpating the presentation
 Systematic assessment of maternal abdomen of the baby either breech or cephalic
by performing external palpation into the - BREECH (HEAD): round, hard, firm,
maternal uterus through the abdominal wall. movable, head of the baby.
 Primary tool: Palpation Technique More firm, hard and round mass that
 Performed: After 24 weeks (when fetal moves independently of the body. (If
outline can be already palpated) you
 Materials needed: - CEPHALIC: soft, and small, little
- Tape measure structure, foot part of the baby.
- Clean gloves 8. FUNDIC HEIGHT MEASUREMENT:
- Stethoscope - Using the tape measure, measure the
- Pillow mons pubis following the abdominal
- Rolled towel curve
 Make sure to gather all the equipment 9. 2ND MANEUVER (UMBICAL GRIP)
needed for this assessment -
 Introduce yourself 10. 3RD MANEUVER (PAWLICK GRIP)
 Very your patient’s information using the 3 -
identifiers 11. 4TH MANEUVER (PELVIC GRIP)
- Name, age, & birthday. -
 Provide privacy for the px.
 Explain the importance of assessment
- This is important for us to know the fetal
presentation and fetal status of the baby
inside the mother’s womb.
 Handwashing procedure or hand hygiene if CATHETERIZATION
handwashing is not possible.
(RETURN DEMONSTRATION)

1 BY: CHRSI DANIEL LEONOR, SN

 RELATED LEARNING EXPERIENCE
1. Introduce yourself
2. Verify patient’s information & check the
order given for the patient and assess if the
px is capable to do the catheterization (Px
might be comatose)
(Name, Age, & Birthday)
3. Handwashing / Hand sanitation
(For patient’s safety and avoid the cross
contamination from the patient to nurse or
vice versa.)
- Remove accessories and your watch
from your hand to avoid disturbance.
4. Prepare the equipment
- Catheter tray with sterile catheter
- Sterile gloves
- Pick-up forceps
- Container with cleansing solution
(Sodium chloride/ regular water)
- 10 cc syringe with sterile water
- Lubricant (KY Gel)
- Drainage tube
- Collection bag
- Tape
- Cotton balls in a container (7pcs if
female, 5 pcs if male) with betadine
(Povidone-iodine)
- Bed pan
- Urine bag
- Foley catheter
(Comes in sizes: Green 14 for children/
female virgin, Orange 16 for adult, red
20 multigravida/ stretched vaginas)
- Kidney basin
5. Provide privacy to the px (Close the curtains
or door) and position the patient
- Female: Dorsal recumbent with knee
flexed / lithotomy.
- Male: Supine position.
6. Arrange and adjust the lighting for clear
visualization of the procedure and perineum
7. Explain the procedure
- Why we do this?
- To relieve bladder distention
- To instill medications into the bladder
- To irrigate the bladder
- To measure hourly urine output
accurately
- To collect urine specimen
2 BY: CHRSI DANIEL LEONOR, SN
- To measure residual urine
- To maintain incontinence
- To promote healing of the genitor
urinary structure post operatively
- To empty the bladder in preparation to
diagnostic procedure
8. Do the perineal care prior to catheterization
(To assure the cleanliness of the vagina or
penis)
- Use sterile gloves for sterility and safety
purposes (hindi hahawakan yung labas,
yung loob lang)
- Female: Use the 7 strokes (3x to the
mons pubis, right labia majora, to anus,
then 3x also to mons pubis, left labia
majora, then anus, and lastly to the
center: mons pubis, clitoris, urethral
meatus, vagina, anus then discard the
cotton balls each stroke)
- Male: From the head to the shaft in a
circular motion
- Inform the mother that you will be
pouring the water into her vagina to wet
it.
- Do the perineal care
- After, inform the patient once again that
you will be pouring out water for rinsing
(from upward going to the downward
direction of the water)
9. Check the balloon of catheter and any
drainage for the urine bag using the syringe
and sterile water.
- Get 10cc of sterile water
- Open the tip only of the foley catheter
- From the hole of the orange part of the
catheter inject the 10 cc of the sterile
water
- Check for any presence of leakage or
drainage from the balloon part of the
foley catheter
- Aspirate the injected 10cc of sterile
water.
10. Connect the distal end of the catheter to the
drainage tube.
 RELATED LEARNING EXPERIENCE
(This prevents urine from spilling from 19. Hang up the drainage or urine bag to the
collecting container while you are railings of the bed.
performing the procedure) 20. Remove the gloves wrapping it up from its
11. Wear your sterile gloves and start the packaging and then discard
catheterization 21. Document and evaluate the findings
- Use the sterile part (inside) of the - Color of the urine: yellow amber
packaging of your sterile gloves and put - Transparency: clear
the KY gel or lubrication (Usually for an - Some special considerations that indicate
individual nurses doing this procedure) problems from urination such as pyuria
- Never touch the outside part of the (STD), glycosuria & proteinuria (DM),
sterile gloves while wearing it Hematuria (Internal Bleeding), Polyuria
12. Get the foley catheter from its packaging (Excessive urine), Oliguria (decreased
while rolling it over your index and middle amount of urine).
finger
13. Place the lubricant along the end of the
catheter.
(Can be offered into your non-dominant
hand by another nurse if available and rub it
to the end of the catheter)
14. Ask the patient to:
- Cough
- Deep breathing
Open the labia minora to easily assess the
urethral meatus while the patient is coughing
Once it is inside the urethra ask the patient
to breathe deeply to ease the pain feeling. PARENTERAL TECHNIQUE

15. Continue pushing the catheter inside the (RETURN DEMONSTRATION)

urethra until you assess urine getting in
through the tube
16. When urine is present already passing to
drainage bag, get the syringe and inject the
10cc sterile water inside the tip of orange
part of the catheter.
17. Pull back the foley catheter until the balloon
is near the urethral meatus part to block out
the urinary bladder and assess the urine
passing through the foley catheter.
18. Tape the foley catheter from the patient’s leg
near the perineum to support comfort of the
patient when lying down to bed.
- Male patient: tape the catheter without
tension to the side of the lower abdomen
- Woman: tape it along the inner thigh

3 BY: CHRSI DANIEL LEONOR, SN