عملي صحةمجتمع

Community health nursing department
2023-2024
Contents
Procedures Pages
1. Growth chart 3
2. Nurse’s bag. 8
3. Home visit for Antenatal care 12
Home visit for Antenatal care (First visit). 22
Home visit for Antenatal care (Second visit) 26
Home visit for Antenatal care (Third visit) 28
Home visit for Antenatal care (Fourth visit) 30
4. Post-partum care at home First visit 35
Post-partum care at home Second visit 38
Post-partum care at home Third visit 41
Post-partum care at home Fourth visit 43
Post-partum care at home Fifth visit 46
Post-partum care at home Sixth visit 48
Post-partum care at home Seventh visit 50
Post-partum care at home Eighth visit 52
5. Eye care 54
6. Wound dressing at home 56
7. Newborn bilirubin blood test 60
8. Immunization and cold chain 66
9. Child vaccination 76
10. Blood sugar test 80
11. Mantoux skin test 84
12. First aid at school, fainting 93
13. First aid at school, nose bleeding 98
14. First aid at school, Burn 103
15. First aid at school, fracture 109
16. Vision test. 117
17. Hearing test. 124
2
Growth chart
Description of growth chart
This chart shows the patterns of height (length) and weight for children from
birth to 36 months.
Purpose of growth chart:
Enable health care providers to
 Assess physical growth among children using head circumferences,

weight, and length of infants and children up to 2 years of age.
 To identify potential health or nutrition-related problems.
 Comparing body measurements with the appropriate age and sex
Step in the interpretation of growth chart:
1- Obtain accurate measurements of head circumference, weight and height

or length.
 Head circumference: A soft tape measure is wrapped around the

widest part of baby’s head from above the eyebrows, passing above
the ears, to the back of head.
 Length: provider will lay the baby on a flat table, and stretch the
baby’s legs out to get an accurate measurement from the top of the
head to the soles of the feet.
3
 Weight: The provider will ask the mother to undress the baby and use
a baby scale to get the most accurate reading.
2-Select the appropriate growth chart according to age and sex of child
3-Record data:
 Entering today's date
 Entering child's name
 Entering child's age of birth
 Entering child's weight and length
 Add any notable comments
4- Plot measurements on appropriate growth chart
 Find the child's age on horizontal axis (up and down)
4
 Find the child's weight and length on vertical axis (right and left)
 Normal range in growth chart (5th to 95th)
5-Interpret the plotted measurements:
Anthropometric Percentile value Nutritional status

index indicate ( comment)
>95th Overweight
Weight for age < 5th Under weight
5th -95th Normal
On line of 5th Border line for
underweight
On line of 95th Border line for overweight
>95th Taller (giant)
Length for age < 5th Short stature (stunting)
5th -95th Normal
On line of 5th Border line for stunting
On line of 95th Border line for taller
(giant)
5
6
7
Community Health Nursing Bag
Community Health Nursing Bag: is essential equipment for the community

health nurse which he/she has to carry along when he/she goes out home
visiting. It contains basic equipment which are necessary for giving care.
Bag Technique: - is a tool making use of community health nursing bag during
the home visit ease, neat, saving time and effort to perform nursing procedures.
Objectives of CHN Bag Technique procedure:-
1. To render effective nursing care to clients and /or members of the family
during home visit.
2. To prevent the spread of infection from individuals to families, then, to the
community.
3. To save time and effort on the part of the nurse in the performance of nursing
procedures.
I- Preparation: -
Equipment: To make them readily accessible.

 Metal container (tongue depressor, two test tube, scissors, forceps, test
tube holder, handler and syringe).
 Iodine ball.
8
 Muslin bag (containing cotton sponges and cord dressing).
 Soap in soap dish – 2 hand towels - 2 fanfold.
 Extra paper for making bag for waste materials (paper bag)
 Note book, pencil, health education materials
 Apron
 Hand towel
 Thermometers in case [one oral and rectal]
 Muslin bag (containing cotton sponges and cord dressing).
 Sphygmomanometer, stethoscope.
 Sterile Cord Tie
 Adhesive Plaster
 Cotton ball
 Tape Measure
 Baby’s scale
 One pair of rubber gloves (sterile and disposable),
 Betadine
 70% alcohol
 Baby oil
 Vaseline
II. Safety Measures:
♦ General management: -
Care of bag and equipment: -
1- Never put the bag on the floor at any time, keep the bag on your lap when
sitting the home, bus and tram.
2- Use medical aseptic technique, absolutely clean, because the inside of the
bag is considered clean
3- Return the center following home visits to change the hand towel.
4- The apron is changed according to the situation from time to time.
9
5- The equipment used in the home must be washed with soap, rinsed and
sterilized.
6- Bottles must be checked and refilled daily.
7- Clean the bag inside and out with soap and water every 2 weeks
8- You must check the bag before making home visits and before leaving the
home, to make sure you have all your equipment.
9- Soiled articles must be placed on the top of the bag.
III. Implementation:-
Steps Rationale
 Remove all equipment from the bag To maintain cleaning equipment
 Inventory of the bag, check and refilled
the bottles.
 Wash and sterilize the equipment. To prevent infection
 Clean the bag from inside & outside.
 Place the bag on a clean surface (not the To avoid infection

floor).
 Hand washing and wear gloves To prevent spread of

microorganisms
 Arrangement of equipment: from Provides for organized approach
(frequently used above less frequently to task & facilitate procedure
used.
 Oral thermometer in the far right side.
 Rectal thermometer in the far left side.
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 Bottles: of baby oil or Vaseline at right
side.
 Bottles: of alcohol & Betadine at left side.
 Metal container (with all its contents) at
the bottom of the bag.
 Sphygmomanometer, stethoscope.
 Baby scale, measuring tape.
 Muslin bag.
 Apron.
 Paper bags.
 Soap at (dish) – 2 hand towels - 2

fanfold.
 Note book, pencil, health education
materials at external pocket of the bag.
 Remove gloves
11
Home visit
Definitions:
A home visit is defined as the process of meeting the health needs of people
at their doorsteps. Health services given at home for patient, family and the
community in general for nursing service and health counseling.
Purpose of home visit

 To find out needs of individual, family and community in relation to
health, socio- economic and cultural aspects.
 To provide domiciliary midwifery as care for pregnant, delivery, and
puerperal mother and infant.
 To give care to the sick, to a postpartum mother and her newborn with the
view teach a responsible family member to give subsequent care.
 To provide basic health services for minor ailments. (i.e. injury, boils,
abrasions)
 To provide counseling on family planning, immunization, nutrition.
 To give health teaching regarding the prevention and control of diseases.
 To establish a close relationship between the nurses and the public for
promotion of health.
 To make use of an inter-referral system and to promote the utilization of
community services.
Phases of home visit includes: -
1. Preplanning
2. Initiation phase
3. Implementation phase
4. Termination phase
5. Post home visit and preplanning
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Points for safe home visit:
 Carry a mobile phone
 Be sure the agency knows your visit
 Dress simply without jewelry
 Don't carry a large amount of cash
 Wear agency badge
 Never implement the visit alone
Notes must be taken in consideration during home visit:
 Use proper communication technique
 Teaching must be related to individual and family needs
 Use simple and understandable language
 Use appropriate methods & materials in the instruction process
 Maintain safe environment
 Appropriate referral should used
Antenatal care
Definition
Antenatal period starts from the time of conception to the onset of labor
Goals of antenatal care:
- The safety of the mother and her fetus
- The preparation of mother for labor, lactation and subsequent care of her
child
- The early detection and appropriate treatment of high-risk conditions
- The reduction of maternal and infant mortality, stillbirth and prematurity
-To increase the number of breastfeed babies
13
Antenatal visits:
WHO Antenatal care model recommended 4 visits:
Visit 1: 8-12 weeks in 1st trimester
Visit 2: 24-26 weeks in 2nd trimester
Visit 3: 32 weeks in 3rd trimester
Visit 4: 36-38 weeks in 4th trimester
1. History taking
• Personal and social history includes:
(Name-Age-Address, it is important to be filled out clearly, so that the

individual woman can be traced by a home visit it she tails to keep her next
appointment.-Occupation (both couples)-Duration of marriage
 Menstrual history:
 Age of menarche
 Regularity and frequency of menstrual cycle
 Duration and nature of menstrual flow
 Any previous treatment of menstrual problems or infertility
 Date and character of last menstrual period(LMP)
 Expected date of delivery (EDD) is calculated as follows
o 1st day of LMP +7days – 3 months +1year
o 1st day of LMP +7days – 9 months
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Obstetrical history:
 Ante partum care, labor and puerperium of previous pregnancies.
 Mode of delivery
 Number and sex of living children
 Birth weights
 Mode of infant feeding
 Date of last labor and last abortion (LL and LA)
Medical history:
 Diabetes mellitus- Hypertension - Urinary tract infections
 Heart diseases- Viral infection- Drugs/allergies
- Other: Blood transfusion- Rh incompatibility -X-ray
Family history as
Diabetes mellitus, hypertension, multiple pregnancies, congenital anomalies
2. Physical Examination:
Conduct a complete general examination with special emphasis on the
reproductive organs and systems most influenced by pregnancy. Examination of
the head, ears, eyes, nose, and throat should be recorded. Serious diseases often
are first noted during an obstetric physical examination (e.g., anemia,
tuberculosis, and breast tumors), the assessment emphasizes the following.
Local abdominal examination:
- Inspection:
 shape and size of abdomen
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 Scars of previous operations
 Signs of pregnancy ( linea nigra and stria gravidarium)
*Linea-nigra: which is define as normal dark line of pigmentation running

longitudinally on the center of the abdomen to the pubis.
*Stria-gravidarium: silver stretch marks from previous pregnancies and recent

ones appear pink.
 Fetal movements
 Varicose veins
 Hernia orifices and back
 Edema
-Palpation: the uterus will be palpable per abdomen after the 12th week of
gestation, palpation helps to determine: the duration of pregnancy, the lie, the
attitude, the presentation, and the position, of the fetus, it includes:
* The lie of fetus: Relationship between the longitudinal axis of fetus and
mother.
*The attitude of fetus: Relationship of fetal head to spine.
*The presentation of fetus: refers to which anatomical part of the fetus in the
pelvic.
*The position of fetus: Relationship of presenting part to maternal pelvis.
 Fundal level (FL)to estimate the period of gestation
 Fundal grip
- Auscultation – Fetal Heart Sounds (FHS)

 The normal fetal heart rate is 120-160 beats/minute
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5- Investigations:
Urinalysis
 Urine is tested for glucose, ketones, and protein (albumin).

Albumin is a type of protein that is normally found in the blood. Body needs
protein. It is an important nutrient that helps build muscle, repair tissue, and
fight infection. But it should be in blood, not urine. When albumin (protein)
appears in urine, it is called ―albuminuria‖ or ―proteinuria.‖
Simple urine test: This is part of a routine exam. Ask to pee into a clean cup
called a ―specimen cup.‖ Only a small amount of urine is needed (about two
tablespoons) to do the test. Some of the urine is tested right away with a
dipstick — a thin, plastic strip that is placed in the urine.
The rest is looked at under a microscope and sent to a laboratory, where a test
called an ACR (albumin-to-creatinine ratio) is done. An ACR shows whether
you have albumin in your urine. A normal amount of albumin in your urine is
less than 30 mg/g. Anything above 30 mg/g may mean you have kidney
disease, even if your GFR number is above 60.
Albumin test needed when appears
 Bruises.
 Dark urine.
 Fatigue.
 Jaundice (yellow skin or whites of the eyes).
 Loss of appetite.
 Stool changes, like pale-colored stool.
 Edema (swelling) in your belly or legs.
 Unexplained weight loss
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Pathological conditions which have albumin in urine:
1- Preeclampsia
2- Fever
3- High blood pressure
4- Cancer
5- Heart attack
6- Kidney failure
7- Mercury poisoning
8- Taking insulin
9- Sick cell anemia
Blood tests
 Hemoglobin levels average 12 to 16 g/dL.

 Blood type, Rh factor, and antibody screen, if the woman is found to be Rh
negative or to have a positive antibody screen, her partner is screened and a
maternal antibody titer is drawn as indicated.
B. Subsequent Prenatal Assessments:
 Uterine growth and estimated fetal growth

o Fundus at symphysis pubis indicates 12 weeks' gestation.
o Fundus at umbilicus indicates 24 weeks' gestation.
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 Fundus at lower border of rib cage indicates 36 weeks' gestation.
 Uterus becomes globular, and drop indicates 40 weeks' gestation.
 FHTs, palpate abdomen for fetal position

 Blood pressure should remain near woman's pre- pregnant baseline
 Complete blood count at 28 and 32 weeks' gestation
 Culture smears for gonorrhea, chlamydia, group B beta-hemolytic
streptococcus and herpes, as indicated; usually at 36 and 40 weeks' gestation.
 Urinalysis for protein, glucose, blood, and nitrates.
 Diabetic screening done as indicated at 24 to 28 weeks.
 Edema, check the lower legs, face, and hands.
 Evaluate discomforts of pregnancy fatigue, heartburn, hemorrhoids,
constipation and backache.
 Evaluate eating and sleeping patterns, general adjustment and coping with
the pregnancy.
 Evaluate preparation for labor, delivery, and parenting.
Dangerous (Warning) Symptoms of Pregnancy:
1. edema of lower limbs or face,

2. persistent headache, blurring of vision,
3. Persistent vomiting. & epigastric pain.
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4. Sudden escape of liquor amni (ROM)
5. Vaginal bleeding
6. Dyspnea chills or fever.
7. Severe abdominal or back pains or symptoms of preterm labor.
8. Decreased fetal kick (F.K).
9. Vaginal discharge with itching or odor.
10. Dysuria
 Weight: The average weight gain during pregnancy from 10-12 kg. Excessive
weight gain may denote occult edema (developing preeclampsia), while
inadequate weight gain may reflect nutritional deficit, I.U.G.R. or I.U.F.D.
 From the 32nd week, assessment of the lie, presentation and position of the
fetus.
 At 36 weeks, cephalopelvic disproportion tests may be done.
Antenatal (prenatal) advices:

1- Sleep, working & exercises:
 Sleep: 8 hours at night & 2 hours afternoon. Sims' position is the best position
during sleeping because of put weight of fetus on bed not on women; allow good
circulation in lower extremities. Avoid lying in supine position due to
hypotension syndrome can develop.
Sims' position
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 Exercises & Working: Mild exercise (best is walking) is advised but walk for
long period is avoided, avoid standing for long period, avoid lifting heavy
weights. Mild house work is allowed.
2- Teeth care: to avoid caries caused by increased acidity.
3- Breast care:
 Bra: to support heavy breasts
 Massage of nipple and traction (with a mixture of glycerin and alcohol) during
the last 6 weeks. Start from top to down until reach center by using panthenol or
olive oil.
 Retracted nipple is withdrawn by the thumb and finger using a lubricant or

sometimes a metal breast shield with an opening in the center is used. It is
applied so that the nipple projects through it
 Dried secretions are removed using water and soap.
4- Diet in pregnancy:
 As the increased metabolism is compensated for by the decreased activity. The
caloric requirement is only slightly increased in late pregnancy (2300 – 2500
calories).
5- Bowel care: Constipation tendency is managed by:
 High fiber diet & increased fluid (milk).
 Increased physical activity & regular habit.
 Avoid laxatives (may induce uterine contraction).
6- Clothing: Loose, light clothes of no synthetic material. Avoid high heeled
shoes
21
7- Sexual activities: Some obstetricians advise abstinence in the 1st 3 months
to avoid abortion and in the last 4 weeks for ascending infection.
8- Traveling: Comfortable traveling is allowed. However, traveling should be
avoided in the last month, and completely prevented in patients with history of
habitual abortion or premature labor.
9- Special habits: Coffee and tea are minimized and smoking is avoided,
smoking may result in intrauterine growth retardation (IUGR) or premature
labor.
10- Vaccination (immunization) during pregnancy: Live attenuated vaccines are
contraindicated.
 Tetanus: the mother should receive 5 doses of tetanus toxoid, the 1st dose
should be at first contact, or as early as possible during pregnancy, 2 nd dose after
4 weeks (give 80% protection). 6-12 months after the 2nd dose or during the
subsequent pregnancy, give the 3rd dose (give 95% protection). Another 2 dose
given during the subsequent pregnancy or every 1-3 for the 4th dose & 1-5 years
for the 5th dose (give 99% lifelong protection).
11- Medications: Not be taken without doctor order.
Procedures of: Home visit for Antenatal care first Visit ( 8-12 weeks)
STEP/TASK RATIONAL
Preplanning phase:
1. Review of the family’s chart
2. Prepare nursing care plan To arrange the care
3. Contact the family to set up To encourage family participation

appropriate time for home visit.
22
STEP/TASK RATIONAL
4. Prepare necessary supplies & To identify efficiency of equipment
equipment.
5. Ensure the equipment are To facilitate the visit
functioning properly.
6. Prepare the nursing bag To facilitate procedure
Initiation Phase:
7.Knock on the door & gain entrance
into the residence
8.Introduce self, other colleague and To facilities the visit

the agency
9. Clearly states the expected purpose

of the visit
10. Allow a few moments of
socialization before beginning the visit
11. Ask the family if there is a
pressing concern that they would like
to deal with first, and if so, follows
their needs
12. If this is the first visit, discuss
expectations and management of
future visits
Implementation Phase:
13. Place the bag on a clean surface To avoid contamination
(not the floor )
14. Wash hands before removing To prevent infection
equipment from the bag.
15. Wear apron
16- Assessment the following:
- History taken
- Client’s environment - To collect information about the
- Psychosocial needs family
- Medication
- Nutrition
23
STEP/TASK RATIONAL
17- Carry out the prepared procedures
- Take vital signs. - To provide adequate nursing care, and
- General examination (as chest, health education
neck observation of skin and
hair and vital signs).
- Available investigation at home
(as urine analysis).
- Weight the mother.
18- Health education for mother by
using appropriate methods & materials
in the instruction process. which
includes:
 Nutrition
 Cloths
 Hygiene (personal and
environmental).
 Rest and sleep
 Fresh air
 Work
 Marital relation
 Smoking
 Medication
 Danger signs
19-Wash hands between family
Members
20- Clean, dispose contaminated To avoid contamination
materials. The client & caregivers
should be taught proper management
of contaminated wastes & rational
behind such management.
21- Replace the equipment.
Termination phase:
22- Briefly summarizes the plan of Actively involving the family by
care both procedures and health ensuring they receive and understand
education that implemented with the the information
Family
23- Set up a time & the purpose for the To be ready for the next visit
next home visit
Post home visit and preplanning phase
24. Record home visit in complete, To provide accurate documentation
24
STEP/TASK RATIONAL
concise & accurate manner
25- Communicate finding to other
health care provider (report any
abnormalities).
25
Procedures of: Home visit for Antenatal care Second Visit ( 24 -26 weeks )
STEP/TASK RATIONAL
Preplanning phase:
3. Contact the family to set up appropriate time To encourage family
for home visit participation
4. Prepare necessary supplies & equipment To identify efficiency of
equipment
5. Ensure the equipment are functioning properly To facilitate the visit
6. Prepare nursing bag To facilitate procedure
Initiation phase:
7. Knock on the door & gain entrance into the
Residence
8. Clearly states the expected purpose of the visit
9. Allow a few moments of socialization before
beginning the visit
10. Ask the family if there is a pressing concern
that they would like to deal with first, and if so,
follows their needs
11. Place the bag on a clean surface (not the To avoid contamination
floor )
12. Wash hands before removing equipment To prevent infection
from the bag
13. Wear apron
14.Carry out the prepared procedures
1- Take vital signs.
2- General examination as examine the
legs for edema
3- Local examination as (abdominal and
breast examination).
4- Weight the mother
5- Test urine for albumin
26
STEP/TASK RATIONAL
15. Health education for mother which include:-
Danger signs (as edema of lower limb or
face, persistent headache, blurring of vision
and sever abdominal pain).
 Immunization (tetanus immunization
schedule).
 Exercises as (mild house work and
walking).
 Nutrition
 Personnel hygiene
 Clothes
16- Wash hands between family members To avoid contamination
17- Clean, dispose contaminated materials. The To avoid contamination
client & caregivers should be taught proper
management of contaminated wastes & rational
behind such management.
18- Replace the equipment. To maintain environment
Termination phase:
19- Briefly summarizes the plan of care both Actively involving the
procedures and health education that family by ensuring they
implemented with the family receive and understand the
information
20- Set up a time & the purpose for the next To be ready for the next visit
home visit
Post home visit and preplanning phase
21. Record home visit in complete, concise, & To provide accurate
accurate manner documentation
22. Communicate finding to other health care
provider ( or report any abnormalities)
27
Procedures of: Home visit for Antenatal care Third Visit (32 weeks)
STEP/TASK RATIONAL
Preplanning phase:
3. Contact the family to set up appropriate time for To encourage family
home visit participation
4. Prepare necessary supplies & equipment To identify efficiency
of equipment
5. Ensure the equipment are function properly. To facilitate the visit
6. Prepare nursing bag. To facilitate the
procedure
Initiation Phase:
Residence
8. Clearly states the expected purpose of the visit
9. Allow a few moments of socialization before
beginning the visit
10. Ask the family if there is a pressing concern that
they would like to deal with first, and if so, follows
their needs
11. Place the bag on a clean surface (not the floor ) To avoid contamination
12. Wash hands before removing equipment from the To prevent infection
Bag
13. Wear apron
14. Carry out the prepared procedures
1. Take vital signs.
2. General examination as examine the legs
for edema
3. Local examination as (abdominal and
breast examination).
4. Weight the mother
5. Test urine for albumin
28
STEP/TASK RATIONAL
15. Health education for mother by using appropriate
methods & materials in the instruction process. which
includes:
 Danger signs (as edema in lower limb or face,

persistent headache, blurring of vision and severe
abdominal pain).
 Signs of labor (contracted uterus with regular
interval and frequency, presence of show and pain
in lower back and extended to abdomen).
 Place of delivery
 Exercises (mild house work and walking)
 Nutrition
17- Clean, dispose contaminated materials. The client To avoid contamination
& caregivers should be taught proper management of
contaminated wastes & rational behind such
management.
18- Replace the equipment. To maintain
environment
Termination phase:
19- Briefly summarizes the plan of care both Actively involving the
procedures and health education that implemented family by ensuring they
with the family receive and understand
the information
20- Set up a time & the purpose for the next home To be ready for the next
visit visit
Post home visit and preplanning phase:

21. Record home visit in complete, concise, & To provide accurate
accurate manner documentation
22. communicate finding to other health care provider
(or report any abnormalities )
29
Procedures of: Ante natal care at home Fourth Visit ( 36-38 weeks)
STEP/TASK RATIONAL
Preplanning phase:
3. Contact the family to set up appropriate To encourage family
time for home visit participation
4. Prepare necessary supplies & equipment To identify efficiency of
equipment
5. Ensure the equipment are function To facilitate the visit.
properly.
6. Prepare nursing bag. To facilitate the procedure
Initiation Phase:
Residence
8. Clearly states the expected purpose of the
Visit
9. Allow a few moments of socialization
before beginning the visit
10. Ask the family if there is a pressing
concern that they would like to deal with first,
and if so, follows their needs
11. Place the bag on a clean surface (not the To avoid contamination
floor )
12. Wash hands before removing equipment To prevent infection
from the bag
13. Wear apron
14. Carry out the prepared procedures
 Take vital signs.
 General examination as examine
the legs for edema
 Local examination as (abdominal
and breast examination).
 Weight the mother
 Test urine for albumin
 Observe danger signs.
30
STEP/TASK RATIONAL
15- Health education for mother by using
appropriate methods & materials in the
instruction process. which includes:
 Signs of labor (contracted uterus with

regular interval and frequency, presence
of show and pain in lower back and
extended to abdomen).
 Place of delivery
 Relaxation and breathing exercises for
preparation of labor.
 Family planning
 Breast care technique for preparation of
breast feeding.
 Nutrition
 Care of the baby as clothes, bathing, eye
and cord care.
17- Clean, dispose contaminated materials. To avoid contamination
The client & caregivers should be taught
proper management of contaminated wastes
& rational behind such management.
18- Replace the equipment. To maintain environment
Termination phase:
19- Briefly summarizes the plan of care both Actively involving the family
procedures and health education that by ensuring they receive and
implemented with the family understand the information
20- Set up a time & the purpose for the next To be ready for the next visit
home visit
Post home visit and preplanning phase:
21. Record home visit in complete, concise, To provide accurate
& accurate manner documentation
22- Communicate finding to other health care
provider (or report any abnormalities)
31
Postpartum care
Definition: It is the period of time from the end of the third stage of labor until
the time at which the pelvic organs have returned to normal about 6-8 weeks.
Another definition: Is a critical time in the women life. During that time
women need physical and psychological cares as well as guidance for healthy
practices for themselves and their babies. The period of post-natal care is six
weeks which is considered enough for the women to resume her physical status
and adjust to her new life with the baby.
Objectives:-
 Help women to resume physical and mental health.
 Detect and arrange proper management and follow up of obstetric injuries,
health problems and pregnancy associated complication as well as treat
reproductive tract infection.
 Examine the newborn for early detection of congenital malformation and
jaundice.
 Provide health education for the mother regarding hygiene, nutrition, child
care, breast feeding, immunization and family planning method.
Postnatal women health assessment:
After delivery care given to mother is called postnatal care
1. Immediate care of the mother: Watch for bleeding, vital signs
2. Vulvae toilet: Use aseptic and antiseptic technique must be followed
3. Bladder: Mother should pass urine within 24 hours after delivery.
4. Bowels: get enough amounts of roughage and fluid through her diet
which stimulates bowel movement.
5. Rest and sleep: Prevent mental illness 6 positions: must be sit or move
and take lie down in prone some time that will in better drainage of
lochia.
32
6. Diet: Well-balanced diet
7. See uterus fundal height and lochia
8. Early ambulation: in normal delivered women allowed being out of bed
on the first day of the puerperium.
9. Post-natal exercises: advice for postnatal exercises.
After 6 weeks: Urine: for protein, weight of mother, blood, Hb, vaginal and
speculum examination, there are always opportunities in the school
environment to teach important heath messages.
Schedule of postpartum visits

 First visit (1st postpartum day).
 Second visit (3rd postpartum day).
 Third Visit: (5th postpartum day).
 Fourth visit (7th postpartum day).
 Fifth visit: (10th postpartum day).
 Sixth visit: (15th postpartum day).
 Seventh visit: (22nd postpartum day).
 Eighth visit: (40th postpartum day).
Apgar Scoring
Items Score of 0 Score of 1 Score of 2

1- Appearance Blue or pale blue at extremities body and
body pink extremities pink
2-pulse Absent Less than 100 beats More than 100 beats
per minute per minute
3-Grimace reflex No response Cry, some motion Cough or sneeze,
irritability to and sluggish vigorous, cry
catheter in nose
4-Activity muscle Flaccid some flexion of flexed arms and legs
tone extremities that resist extension
5-Respiration Absent Slow , irregular Good -strong cry
33
34
Procedures of Post-Partum Care (First Visit)
Step/Task Rational
1. Hand washing. To prevent spread of
microorganisms
2. Prepare necessary equipment and supply. Provides for organized
approach to task.
3. Ensure the equipment is functioning To facilities the visits and
properly. identify efficiency of equipment
4. Contact mother according to the time To encourages mother
schedule. cooperation
5. Prepare Nursing care plan. To facilitate procedure
6. Prepare Nursing Bag It clearly defines guidelines
along with the nurse’s role in
patient care and helps them
create and achieve a solid plan
of action.
7- Procedure:
First visit (1st postpartum day).
For the mother:
8. Wash hands
9. Wear apron and gloves
10. Check vital signs. To detect any signs of
infection (as feverish,
tachycardia).
35
11. Estimate the Fundal level (immediately
after labor uterus above umbilicus level (1/U)
and then decrease 1finger/day.)
To determine progress of return

normal level
12. Ask about Lochia (rubra, red color), To identify any problems
bleeding, urine and bowel movement.
13. Episiotomy care (if performed).
 Remove the soiled dressing from above to
down ward by using disposable glove
 Wash hands and wear sterile gloves.
 Use one direction swapping cotton with
septic solution from above to down
 Dry from above to down ward (at the
same direction)
14. Check the condition of the lower
extremities for deep venous thrombosis.
15. Assess the condition of the breast - To provide breast feeding
(engorgement, observe nipple for crackles,
inverted, or flat)
16.Remove gloves
For baby:
17. wash hand and wear gloves
18. Assessment of baby condition (APGAR To identify any problems
score)
A : Appearance
P: Pulse
G: Grimes (reflexes)
A: Activity (muscle tone).
R: Respiration
19. Take anthropometric measurement To identify physical growth of
36
(Weight, length, head and chest the baby
circumference).
20.Assess the eye condition (as jaundice, To identify any problems
pupils react to light, blink reflex).
21. Make cord dressing. To determine progress of
healing
Post Procedure Activities:
22. Remove gloves and Wash hands. To prevent spread of
microorganisms
23. Educate the mother for: Health education for postnatal
 Early ambulation mothers has an impact on infant
 Nutrition.
feeding and care. Moreover,
 Breast-feeding.
 Rest & sleep. help women to resume physical
 Postpartum exercise. and mental health
 Personal hygiene
 New born care (as skin, eye, ear, and
diaper care).
24. Clean and dispose the contaminated To avoid contamination.
materials.
25. Replace the equipment. To maintain environments
26. Terminate the Visit To identify feedback of the
mother and focused on missing
points.
27. Make appointment for the next visit. To ready to next visit
28. Record all data about the mother and the To provides accurate
newborn. documentation.
29. Report & communicate findings to MCH. To provide early management
for any abnormalities.
37
Procedures of: Post-Partum Care (Second Visit)
Step/Task Rational
1. Hand washing. To prevent spread of microorganisms
2. Prepare necessary equipment and Provides for organized approach to task.
supply.
3. Ensure the equipment are To facilities the visits and identify
functioning properly. efficiency of equipment
4. Contact mother according to the To encourages mother cooperation
time schedule.
5. Prepare Nursing Bag. To facilitate procedure
6. Prepare Nursing care plan. It clearly defines guidelines along with
the nurse’s role in patient care and helps
them create and achieve a solid plan of
action.
7. Procedure
Second visit (3rd postpartum day).
For the mother:
8. Wash hands
10. Assess the mother's general
condition (as appearance, color and
ambulation).
11. Check vital signs. To detect any signs of infection (as
feverish and tachycardia)
12. Estimate the Fundal level (U/1). To determine progress of return normal
level
13. Check Lochia ( rubra), and To identify any problems
perineal condition.
38
14. Check flow of milk and breast To provide breast feeding
condition for engorgement.
15.Remove gloves
For baby:
16. Wash hand and wear gloves
17. Check vital signs.
18. Make baby bath. To prevent infection
19. Make cord care.
To determine physical growth

20. Assess color of skin for jaundice. To identify any problems
21. Remove gloves and wash hands. To prevent spread of infection
22. Educate the mother for: Health education for postnatal mothers
1- Personal hygiene. has an impact on infant feeding and
2- Rest & sleep. care. Moreover, help women to resume
3- Postpartum exercise. physical and mental health
4- Breast-feeding.
5- Nutrition.
23. Clean and dispose contaminated To avoid contamination.

materials.
24. Replace Equipment. To maintain environments
25. Terminate the Visit To identify feedback of the mother and
focused on missing points.
26. Make appointment for the next To ready to next visit
visit.
39
27. Record all data about the mother To provides accurate documentation.
and the newborn.
28. Report & communicate findings To provide early management for any
to MCH. abnormalities.
40
Procedures of: Post-Partum Care (Third Visit)
Step/Task Rational
2. Prepare necessary equipment and Provides for organized approach to
supply. task.
3. Ensure the equipment are functioning To facilities the visits and identify
properly. efficiency of equipment
4. Contact mother according to the time To encourages mother cooperation
schedule.
6. Prepare Nursing care plan. It clearly defines guidelines along
with the nurse’s role in patient care
and helps them create and achieve a
solid plan of action.
7. Procedure: Third Visit: (5th postpartum day).
For the mother:
8. Wash hands
10. Assess mother's general condition To detect any signs of infection
(as appearance, color and ambulation).
11. Check the vital sign. To detect any signs of infection (as
feverish and tachycardia).
12. Check the level of the fundus (U/3). To determine progress of return
normal level
13. Check the Lochia (serosa, pale To identify any problems
color).
14. Check the breast condition for To facilities breast feeding
engorgement.
41
15. Ensure the mother is assuming
normal activities.
16.Remove Gloves
For baby:
17.Wash hand and wear gloves
19. Make cord care.
20. Remove gloves and Wash hands
1- Personal hygiene. mothers has an impact on infant
2- Rest & sleep. feeding and care. Moreover, help
3- Postpartum exercise. women to resume physical and mental
4- Breast-feeding. health
5- Nutrition.
materials.
24 Terminate the Visit To identify feedback of the mother
and focused on missing points.
26. Record all data about the mother To provides accurate documentation.
and the newborn.
27. Report & communicate findings to To provide early management for any
MCH. abnormalities.
42
Procedures of: Post-Partum Care (Fourth Visit)
Step/Task Rational
microorganisms
2. Prepare necessary equipment and supply. Provides for organized approach
to task.
with the nurse’s role in patient
care and helps them create and
achieve a solid plan of action.
7. Procedure
Fourth visit: (7th day).
For the mother:
8. Wash hands
10. Assess mother's general condition (as To detect any signs of infection
appearance, color of skin and ambulation).
11. Check the vital sign. To detect any signs of infection
(feverish and tachycardia).
normal level
13. Check the Lochia serosa. To determine types of lochia
14. Check the breast condition. - To provide breast feeding
43
15.Remove gloves
For baby:
18. Weight the baby.
To identify physical growth of the

baby
19. Check the cord drop.
20. Newborn care (as eye, ear, and diaper

care).
21. Remove gloves and Wash hands To prevent spread of
microorganisms
2- Rest & sleep. feeding and care. Moreover, help
3- Postpartum exercise. women to resume physical and
4- Breast-feeding. mental health
5- Nutrition.
44
materials.
24. Terminate the Visit To identify feedback of the mother
26. Record all data about the mother and To provides accurate
the newborn. documentation.
27. Report & communicate findings to To provide early management for
MCH. any abnormalities.
45
Procedures of: Post-Partum Care (Fifth Visit)
Step/Task Rational
18.Prepare necessary equipment and Provides for organized approach to
supply. task.
19.Ensure the equipment are functioning To facilities the visits and identify
schedule.
7. Procedure
Fifth visit: (10th day visit).
For the mother:
8. Wash hands
10. Assess the vital signs. To detect any signs of infection
normal level
12. Check the Lochia (alba, yellowish, To identify any problems
white color).
13.Remove gloves
For baby:
14.Wash hand and Wear Gloves
46
16. Check the cord drop.
17. Remove gloves and Wash hands To prevent spread of microorganisms
2 - Breast-feeding. feeding and care. Moreover, help
3 - Nutrition. women to resume physical and
4- Rest & sleep. mental health
5- Postpartum exercise
materials.
23. Record all data about the mother and To provides accurate documentation.
the newborn.
24. Report & communicate findings to To provide early management for any
MCH. abnormalities.
47
Procedures of: Post-Partum Care (Sixth visit)
Step/Task Rational
microorganisms
supply. task.
schedule.
7. Procedure
Sixth visit: (15th day visit).
For the mother:
8. Wash hands
10. Assess the vital signs. To detect any problems.
11. Check the color of discharge. To identify any problems
12. Check the uterus involution To determine progress of return
normal level
13.Remove gloves
For the Infant:
15- Weight the baby. To identify physical growth of the
48
baby
16-Baby care (as diaper and skin care).
17- Check BCG vaccination
18.Remove gloves and Wash hands To prevent spread of
microorganisms
2 - Breast-feeding. feeding, care, or immunization,
3 - Nutrition. although uptake of family planning
4- Counsel for mother about family will be enhanced
planning.
5- Compulsory vaccination.
materials.
24. Record all data about the mother and To provides accurate documentation.
the newborn.
49
Procedures of: Post-Partum Care: (Seventh Visit)
Step/Task Rational
microorganisms
supply. task.
7. Procedure
Seventh visit: (22nd day visit).
For the mother:
8. Wash hands
10. Assess the vital signs. To detect any problems.
11. Check the uterus involution. To determine progress of return
normal level
13.Remove gloves
For the Infant:
14.Wash hand and Wear gloves
15. Baby care (as skin, and diaper care).
50
16. Check BCG vaccination
17. Remove gloves and wash hands To prevent spread of
microorganisms
2 - Breast-feeding. feeding, care, or immunization,
3- Nutrition. although uptake of family planning
4- Counsel for mother about family will be enhanced
planning.
materials.
51
Procedures of Post-Partum Care (Eighth Visit)
Step/Task Rational
microorganisms
supply. task.
3. Ensure the equipment is functioning To facilities the visits and identify
7- Procedure
Eighth visit: (40th day visit).
For the mother:
8. Wash hands
10. Assess the vital signs. To detect any problem.
11. Check the uterus involution. To determine the progress of
returning the uterus to normal level
13. Family planning.
14. Remove gloves
For the Infant:
52
16- Take anthropometric measurement (as To identify physical growth of the
weight, length, head and chest baby
circumference).
17- Check BCG vaccination
18- Bath the infant.
19. Remove Gloves and Wash hands To prevent spread of
microorganisms
20. Educate the mother for:
1- Personal hygiene.
2 - Breast-feeding.
3 - Nutrition.
4- Counsel for mother about family
planning.
materials.
53
Eye care
Definition:
It's a procedure of cleaning the eyes by maintaining a sepsis
Purpose:
1-clean the eyes and protect the eyes
2-prevent infection
3- for the sense of well -being and aesthetic
sense
4- Promote and maintain the health of the eye
Principles:
1. Always keep the bag on another place
and clean place with paper linking or plastic sheet
2. Wash hands before taking out the articles
3. All articles needed are taken out at one time then close the bag
4. Never mix the bag articles with the home articles
5. Wash and boil the articles before use
6. Never keep moist articles inside the bag. It's cause of infection
Equipment:
Bowl with boiled cooled swabs, spoon, extra cotton, paper bag.
Points to be kept in mind during procedure:
1- Area of swab touched by the fingers should not come in contact with the
eyes
2- Squeeze off the excessive water from the swabs
3-No pressure on the eyeball should be given
4-Gently wire the lids from the inner to the outer canthus
5-One swab for one swabbing
6-Separate swab for separate eyes
54
Procedure Rationale
1. Wash the hands and plug the ear. To prevent spread of
microorganisms
2. Take out the swap from the
bowel with spoon.
3. Take the swap from spoon
touching only one side of the
swab, squeeze in the paper bag.
4. Clean from inner canthus to outer
canthus with one swab for one
stroke and discard the swab in the
paper bag.
5. Continue cleaning till all To avoid contamination.
discharge is removed from the
eyes.
After Procedure
6. Make the patient comfortable.
7. Boil and dry the articles and To maintain environments
place in the bag.
8. Record and report done. To provides accurate
documentation & To provide
early management for any
abnormalities
.
55
Wound Dressing at Home
Wound Dressing
It is a protective covering of a wound. This can be done by some medicine
or without medicine for the soakage of drained material.
Purpose
 Prevent infection and further complication
 Absorb any blood or discharge
 Promote healing and prevent tissue damage
 Prevent hemorrhage
 Prevent skin excoriation
 Apply the medication and prevent contamination of wound
 Restore function of affected part
Principles
 Do procedure in systematic way to save time, material and energy.
 Respiratory tract harbors micro -organism that can enter the wound.
 A break in the skin and mucous membrane act as the portal of the entry
for the pathogenic organisms.
 Always keep wound cover, because bacteria travel along with the dust
particulars.
 Always clean area from less contaminated toward more contaminated.
This prevents the further infection.
 Fluid more through materials by capillary action.
Points to Remember during procedure
 Explain the procedure to patient as well as relatives.
 Dressing should be done aseptically.
 Always clean wound from less contaminated towards more
contaminated.
56
 Give antibiotics to prevent infection.
 Handle the wound area with caution to reduce pain or discomfort.
 Apply antiseptic medicine over wound as prescribed by doctor.
 Keep wound clean and dry.
 Provide well balance diet to patient specially protein for wound healing.
 The bandage Applied over wound should not be tight because it will
affect blood supply over area.
 Remove dead skin during dressing to promote early healing.
 Change dressing frequently when it is wet with wound drainage.
 Place dressing in such a way, so that it does not interfere in movements.
Equipment:
Spirit or hydrogen peroxide, dressing packet (scissor , forceps ,cotton bowl
, gauze pieces , artery forceps ) bandages , gloves, masks and gowns ,
dressing towels , kidney tray , paper bag , mackintosh , and cleaning
solutions , ointment.
57
Procedure of wound care at home
Procedure Rationale
1-Tie the mask and wash hands thoroughly To prevent spread of
microorganisms
2-Put on gown and gloves To prevent spread of
microorganisms
3-Open the sterile tray , spread the sterile
towel around the wound
4-Pick up a dressing forceps and remove To avoid contamination.
the dressings and put it in the paper bag
.discard the dissecting forceps in the bowl
of lotion
5-Note the type and amount of drainage
Present
6-Ask the assistant to pour small amount of cleansing solution into the bowl
7-Clean the wound from the center to
periphery discarding the used swabs after
each stroke
8-After thoroughly cleaning of the wound ,
58
dry the wound with a dry swabs using the
same precautions .discard the forceps in
the bowl of lotion
9-Apply medications if ordered
10-Apply the sterile dressing, apply the
gauze pieces first and then the cotton pads.
Reinforce the dressing on the dependent
parts where the drainage may collect.
11-Remove the gloves and discard it into
the bowl with lotion
After procedure:
12-Help the patient to dress up and to
make a comfortable position in the bed.
Change the garments if soiled with
Drainage
13-Remove the mackintosh and towel and To maintain environments
all articles
14-Wash hands To prevent spread of
microorganisms
15- Record and report To provides accurate
documentation & To provide
early management for any
abnormalities
16-Tidy up the bed and unit of the patient.
.
59
Newborn Bilirubin Blood Test
Introduction:
Newborn babies, often have high bilirubin level and might need a
bilirubin test. It measures how much bilirubin in blood. Bilirubin is made when
red blood cells break down. The liver changes the bilirubin so that it can be
excreted from the body. High bilirubin level can make skin and eyes look yellow
and might mean there's a problem with the liver.
Risk Factors for Hyperbilirubinemia

About 60% of all babies have jaundice. Some babies are more likely to have
severe jaundice and higher bilirubin levels than others.
1. Preterm Babies
Babies born before 37 weeks, or 8.5 months, of pregnancy might have jaundice
because their liver is not fully developed. The young liver might not be able to
get rid of so much bilirubin.
60
2. East Asian or Mediterranean Descent
A baby born to an East Asian or Mediterranean family is at a higher risk of
becoming jaundiced. Also, some families inherit conditions (such as G6PD
Glucose-6-phosphate dehydrogenase deficiency), and their babies are more
likely to get jaundice.
3. Feeding Difficulties
A baby who is not eating, wetting, or stooling well in the first few days of life is
more likely to get jaundice.
4. Blood Type
Women with an O blood type or Rh negative blood factor might have babies
with higher bilirubin levels.
Effects of Bilirubin Toxicity in Newborns

 Early effects: Lethargy, Poor feeding, High-pitched cry
 Late effects: Irritability, Seizures, Apnea, Fever
Definition of newborn bilirubin blood test
A bilirubin test measures the levels of bilirubin in blood. Bilirubin is a

yellowish pigment that is made during the normal breakdown of red blood cells.
Bilirubin passes through the liver and is eventually excreted out of the body.
Indications of bilirubin blood test
o Investigate jaundice — a yellowing of the skin and eyes caused by elevated

levels of bilirubin. A common use of this test is to measure bilirubin levels in
newborns to check for infant jaundice.
o Determine whether there might be congenital blockage in bile ducts, in either
the liver or the gallbladder.
o To evaluate anemia caused by the destruction of red blood cells.
61
In newborn Less than 24 hours
 Premature baby Less than 8.0 mg/dL or less than 137 mmol/L
 Full-term baby Less than 6.0 mg/dL or less than 103 mmol/L
From 3 to 5 days
 Premature baby Less than 15.0 mg/dL or less than 256 mmol/L
 Full-term baby Less than 12.0 mg/dL or less than 205 mmol/L
The equipment
a) Lancet.
b) Container with dry cotton.
c) Antiseptic swab.
d) Heel sticks collection.
e) Sharp container.
f) Hand washing equipment
g) Disposable gloves.
h) Adhesive patch
The procedure of bilirubin blood test Rational
1. Hand washing To prevent spread of microorganisms
2. Prepare the equipment To save time and facilitates accurate
skill performance when equipment
was available.
3. Explain the procedure to the Reduces anxiety and encourages
mother/family member. cooperation
62
4. Instruct the mother/family member To protect the child from any harmful
to carefully support the child.
5. Done the disposable gloves Gloves protect the hands of the
healthcare provider from coming into
contact with body fluids (e.g., blood,
urine, feces, mucous membranes, and
non-intact skin) or equipment and
other surfaces that may have been
contaminated with body fluids.
6. Proper identification and careful To protect the child from any harmful
handling of the infant's heel.
7. The area is prepared by wrapping the It helps in bring blood to the surface
baby's foot in a warm cloth for a few and allow it to flow more easily
minutes to bring blood to the surface
and allow it to flow more easily.
8. The heel is then wiped with alcohol To disinfect the surface
and/or an antibacterial solution to
sterilize the surface.
9. The heel is then punctured with a Heel bones in infants are close to the
lancet, avoiding the center of the surface of the skin, so the lancet
heel, in order to prevent should puncture less than 2.0 mm
inflammation of the bone. deep.
63
10. Gently squeeze the heel and the It is necessary for a consistent and
blood sample is taken in the heel adequate blood flow
stick collection
64
11. A small adhesive patch may be To protect the site
used to protect the site.
12. Remove gloves. To decreases contamination risk from
dirty gloves
13. Hand washing. To prevent the risk of healthcare
provider colonization or infection
caused by germs acquired from the
patient
Documentation: An accurate written record detailing
14.Record data and report for any all aspects of patient monitoring is
abnormal findings. important because it contributes to
the circulation of information
amongst the different teams involved
in the patient's treatment or care.
65
Immunization and cold chain
Introduction:
Immunity to a disease is achieved through the presence of antibodies to
that disease in a person’s system. Antibodies are proteins produced by the body
to neutralize or destroy toxins or disease-carrying organisms. Antibodies are
disease-specific. For example, measles antibody will protect a person who is
exposed to measles disease but will have no effect if he or she is exposed to
mumps.
There are two types of immunity: active and passive.
1. Active Immunity results when exposure to a disease organism triggers the
immune system to produce antibodies to that disease. Active immunity can
be acquired through natural immunity or vaccine-induced immunity.
 Natural immunity is acquired from exposure to the disease organism
through infection with the actual disease.
 Vaccine-induced immunity is acquired through the introduction of a killed
or weakened form of the disease organism through vaccination.
2. Passive Immunity
Passive immunity is provided when a person is given antibodies to a
disease rather than producing them through his or her own immune system.
 A newborn baby acquires passive immunity from its mother through the
placenta.
 People can also get passive immunity through antibody-containing blood
products such as immune globulin, which may be given when immediate
protection from a specific disease is needed.
66
Types of vaccine:
 Live attenuated vaccine: is a vaccine created by reducing the virulence of a
pathogen, but still keeping it viable (or "live").Attenuation takes an infectious
agent and alters it so that it becomes harmless or less virulent as:
a. BCG vaccine against TB
b. Polio vaccine against poliomyelitis
c. Measles vaccine
 Killed vaccine: An inactivated vaccine (or killed vaccine) is a vaccine
consisting of virus particles, bacteria, or other pathogens that have been
grown in culture and then lose disease producing capacity.
a. Pertussis vaccine
b. Salk vaccine against poliomyelitis
c. Hepatitis B vaccine
 Toxoid vaccine: A toxoid is an inactivated toxin (usually an exotoxin)
whose toxicity has been suppressed either by chemical (formalin) or heat
treatment, while other properties, typically immunogenicity, are maintained
such as Diphtheria toxoid and Tetanus toxoid.
67
Obligatory immunization schedule for children in Egypt
Age Vaccine Dose Route Amount
first 24 - HBV Zero dose IM Rt. Thigh 0.5 ml
hours)
At birth( - OPV(oral polio Zero dose Oral 2 drops
first month) vaccine)
- BCG(Bacillus of Zero dose ID (Lt. Arm) 0.05 ml

Calmette &Guerin).
At 2 months - OPV 1st Oral 2 drops
- Penta vaccine (DPT,
Haemophils influenza 1st IM Rt. Thigh 0.5 ml
and HBV)
- IPV (SALK) 1 st IM Lt. Thigh 0.5 ml
At 4 months - OPV 2nd Oral 2 drops
- Penta vaccine (DPT, IM Lt. Thigh 0.5 ml
Haemophilus influenza
and HBV) 2 nd IM Rt. Thigh 0.5 ml
- IPV (SALK)
2 nd IM Lt. Thigh 0.5 ml
At 6 months - OPV 3 rd Oral 2 drops
- Penta vaccine (DPT, 3 rd (IM Rt. Thigh) 0.5 ml
Haemophilus influenza
and HBV)
- IPV (SALK) 3 rd IM Lt. Thigh 0.5 ml
At 9 months - OPV 4 th Oral 2 drops

- Vit A 1st Oral 100,000 unit
At 12 - OPV 5th Oral 2 drops
months - MMR(Measles, 1 st SC (Rt. Arm) 0.5 ml
Mumps, Rubella)
At 18 - OPV Booster Oral 2 drops
months - MMR Booster SC (Rt. Arm) 0.5 ml
- DPT Booster IM (Lt. Thigh) 0.5 ml
- Vit A Oral 200.000 unit
68
Definition of cold chain:
It is the system of storage and transportation of the vaccine at low
temperature (cold condition) from the manufacture till it is consumed. Vaccines
should be maintained within the recommended temperature range of 2°C to 8°C.
69
Equipment for Transporting and Storing Vaccines:-
The essential cold chain equipment needed to transport and store vaccines
within a consistent safe temperature range include:
 A refrigerator for storing vaccines
 A digital, electronic or mercury/maximum thermometer and chart for
recording daily temperature reading
 Cold boxes for transporting and storing vaccines
 Ice packs to keep vaccines cool
Maintenance of the vaccine refrigerator
 It should place in the coolest place of the health centers away from
sunlight.
 Always keep a thermometer in the refrigerator; read and record the
temperature twice daily;
 Never store vaccines in the door shelves or the very bottom of the
refrigerator, as both get warmer than the center of the compartment;
 Store vaccine boxes or trays with spaces between to allow air circulation
inside the refrigerator;
 Kept locked and open only when necessary.
 Defrosted regularly.
 Ice packs are kept in the freezer.
 Drugs, drinks or food must not be stored in the refrigerator.
 The diluents should be kept on the lowest shelf.
Storage of the vaccine

• Polio and ice packs are kept on freezing compartments
• BCG and measles vaccines are kept on the top shelf of the refrigerator
under the freezer. The rest of the vaccines, DPT, DT, TT and hepatitis B
are kept on the middle shelf of the refrigerator.
70
• Diluent is kept on lower of the refrigerator.
Notes:
• Shake vial vigorously before withdrawal and use.
• Do not use if resuspension does not occur with vigorous shaking.
• The vaccine should be administered shortly after withdrawal from the
vial.
Tools for monitoring the cold chain:

1- Cold Chain Monitor Card.
2- Freeze Watch Indicator.
3- Cold Chain Refrigerator Graph.
4- Vaccine Vial Monitors.
5- Shake Test.
1. Cold Chain Monitor Card:
It is used to show cumulative exposure to temperature above the safe range

during storage& transportation. It has an indicator that responds to two different
71
Temps: the first part marked as ABC, responds to Temp above +10ºC; the 2nd
part marked as D responds to temperature above +34ºC.
2. Freeze watch indicator

A freeze watch indicator consists of a small vial of red liquid attached to a
white card and covered in plastic. The vial breaks if the temperature where the
indicator is located drops below 0° C for more than one hour, and the vaccine
must then be destroyed.
72
3. Cold Chain Refrigerator Graph
The vaccines are stored in refrigerators, they are monitored twice a day and
readings are recorded on a chart to ensure a safe temperature is maintained.
Emergency provisions made. Vaccines moved to cold storage for 48 hours.
+8°C
+2°C
4. Vaccine vial monitors (VVMs):
VVMs are small indicators that adhere to vaccine vials and change colour as the
vaccine is exposed to cumulative heat, letting health workers know whether the
vaccine has exceeded a pre-set limit beyond which the vaccine should not be
used.
The colour of the inner square of the VVM starts with a shade that is lighter than
the outer circle and continues to darken with time and/or exposure to heat
Once a vaccine has reached or exceeded the discard point, the colour of the
inner square will be the same colour or darker than the outer circle.
73
SAFE
If the inner square is lighter than
the outer ring and the expiration
date is valid, the vaccine is
Usable
SPOILED
If the inner square matches or is
darker than the outer ring, the
vaccine must be discarded.
[[
74
5- The shake test
DPT, hepatitis B and tetanus toxoid vaccines can all be damaged by freezing.
By shaking two vials, side-by-side, one that might have been frozen and one
that has never been frozen, health workers can determine if a vaccine has
spoiled.
75
Child Vaccination
Instruction about immunizing a child:

I. Environment:
1- Keep the child's privacy.
2- Maintain safe environment (calm, clean and tidy area not directly
exposed to sun light, rain or dust).
3- Be alert that toddlers can walk around and got harmed.
II. Safety Measures:
1- There are no contraindications to the vaccine(s) being given to the child.
2- Parent (s) is fully informed about the vaccine(s) to be given and
understands the vaccination procedure.
3- Parent (s) is aware of possible adverse reactions and how to treat them.
III. Health Education for mother
1. Encourage mother to tell their experiences and opinions, and ask
questions.
2. Instruct the parent the date, time and the name of the next vaccine.
3. Instruct the number of visit a child still needs in order to be fully
vaccinated.
4. Instruct the parent that side effect may occur or expected for each vaccine
given and what to do about it.
5. Check parent understands by asking questions.
6. Advice parents about side effects.
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Pentavalent vaccine (Penta vaccine)
Steps Rational
1- Prepare the equipment: To save time and facilitates accurate
1- Appropriate syringe and needle size.
skill performance when equipment
2- Container with dry cotton.
available.
3- Antiseptic swab.
4- Vaccines to be administered.
5- Ice box, and ice packs.
6- A disposal box of used single-use
need.
7- Sharp container.
8- Paper bag.
9- Disposable gloves.
2- Introduce self to the mother/family
member.
3- Before immunization, assess child's
conditions and if there is any
complain, refer to the doctor in charge
to decide whether to give or to
postpone the vaccine.
4- Check the name in the ID bracelet.  To ensure that the right child
5- Ask the mother / family member receives the vaccine
about the child's name. .
6- Wash hands before and after  To safeguard child's safety and
procedure. prevent spread of infection from
7- Explain procedures to the child to another.
mother/family member.  To facilitate acceptance and
8- Instruct the mother/family member to compliance with the schedule of
expose the required area of vaccination till the end.
77
immunization in child's body.  To construct the child trusts
9- Instruct the mother/family member to his/her mother/family member,
carefully support the child. so always let her be in direct
10- In the beginning of an immunization touch with the child to be calm.
session, get the vaccines out of the To protect the child from being
refrigerator injured.
11- Check the expiry date, color and
clearness of the vaccine before use.
12- Discard any suspected vaccine vials
before starting the immunization
session.
13- Shake the vial.
14- Remove the center of the metal cap on  To prevent leakage
the vial.
15- Load the syringe with 0.5 cm Penta  To secure child
vaccine.
16- Sit the child on the examination table  To optimize immune response
and asked the mother for hold the and to reduce the risk of
child’s legs firmly. injection site reactions.
17- Collect muscles on the outer part of
the middle of the child’s thigh.  To ensure giving the
18- Quickly push the needle straight down recommended dose.
through the skin, go deep into the  To avoid inadvertent injection
muscle. into a blood vessel or injury to a
19- Press plunger with her thumb to inject nerve.
0.5 cm of the left thigh.  To prevent bleeding.
20- Withdraw the needle; quickly & To prevent inflammation
straight.
21- Press the site with cotton wool.
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22- Register the following items on the
back of the birth certificate at the end
of session:
 Types, date, dose, route, and time
of immunization
 Date of the next immunization
 Signature of the nurse in charge.
79
Blood sugar test
Definition:
A blood sugar test is a procedure that measures the amount of sugar, or glucose,
in the blood.
Indication:
 A blood glucose test is used to help diagnose and monitor diabetes.
 Monitor the effect of diabetes medications on blood sugar levels
 Patients use this test to manage their condition to identify if blood sugar
levels are within a healthy range.
 Testing allows for quick response to high blood sugar (hyperglycemia) or
low blood sugar (hypoglycemia).
 Diet adjustments, exercise and insulin.
Precautions:
 Review the patient’s medical history for diabetes type, medications,
and/or anticoagulant therapy.
 Determine if the test requires special timing; for example, before or after
meals. Blood glucose monitoring is usually done prior to meals and the
administration of antidiabetic medications.
 For a fasting blood glucose test, the client can’t eat or drink anything but
water for eight hours before the test.
Types of blood sugar tests:

A blood sugar test can be done in two ways: -
 Self-monitoring of blood glucose (SMBG) This
is typically achieved using conventional personal blood glucose meters to
measure finger prick blood samples several times per day
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 Venipuncture blood test sample is generally used to screen for diabetes.
This test measures blood sugar levels, or glycosylated hemoglobin also
called a hemoglobin A1C test.
Procedure of blood sugar test

Steps Rational
1.Hand washing Reduce risk for infection.
2. Prepare equipment. To save time.

Equipment:
1. Medication tray.
2. Blood glucose meter
reads blood sugar.
3. Test strip collects blood
sample.
4. Lancet.
5. Alcohol wipes or soap
and water to clean fingers
or other testing site.
6. Patient card or papers.
3.Explain procedure to the To reduce anxiety
client
4. Done sterile gloves. Gloves protect health care provider from

contamination by blood.
5. Insert the test strip in the

blood glucose meter.
6. Clean the finger with To reduce infection.

alcohol let it dry.
81
7. Prick the site with a lancet.
8. Gently squeeze above the Do not contaminate the site by touching it.
site to produce a large droplet The droplet of blood needs to be large enough
of blood. to cover the test pad on the reagent strip.
9. Put a little drop of blood
on a test strip.
10. In seconds, the blood

glucose meter reads your
blood sugar level.
11. Discard lancet and strip
into sharp container.
12. Remove gloves and place
them in the appropriate
receptacle.
13. Hand washing. Reduce transmission of micro-organism.
14.Documentation:-
Record data and report Provide information and accountability.
abnormal findings.
82
Interpretation the results of blood glucose test
For a fasting test
 A normal blood glucose level is between 70 and 100 milligrams per
deciliter (mg/dL).
 A blood glucose level of 100–125 mg/dL indicates that patient have
prediabetes.
 A blood glucose level of 126 mg/dL and higher indicates patients have
diabetes.
For a random blood glucose test
 A normal level is usually under 125 mg/dL. However, the exact level will
depend on when the patient last ate.
 A blood glucose level of 140–199 mg/dL indicates that patient may have
prediabetes.
 A blood glucose level of 200 mg/dL and higher indicates that the patient
likely has diabetes.
- If random blood glucose test results are abnormal, a fasting blood glucose
test may be required to confirm the diagnosis or another test such as
glycosylated hemoglobin (HgbA1C).
- The A1C test measures average blood sugar level over the past 2 or 3
months. An A1C below 5.7% is normal, between 5.7 and 6.4% indicates
prediabetes and 6.5% or higher indicates diabetes.
83
Mantoux Skin Test
Definition:
It is the standard method of determining whether a person is infected with

Mycobacterium tuberculosis. The skin test should be read between 48 and 72
hours after administration. A patient who does not return within 72 hours will
probably need to be rescheduled for another skin test.
Mantoux Skin Test also known as Tuberculin Skin Test (TST), Tuberculin
Test (TB test) , Purified Protein Derivative (PPD).
Important points regarding TST:
 The PPD test determines if someone has developed an immune response

to the bacterium that causes tuberculosis (TB).
 The basis of the reading of the skin test is the presence or absence and the
size of induration (localized swelling).
 A negative test does not always mean that a person is free of tuberculosis.
 A person who received a BCG vaccine against tuberculosis may also
have a positive skin reaction to the TB test, although a person is may be
free of tuberculosis.
 The tuberculosis skin test determines if someone has developed an
immune response to the bacterium that causes tuberculosis (TB). This
response can occur if someone currently has TB, if they were exposed to
it in the past, or if they received the BCG vaccine against TB.
 An incubation period of two to 12 weeks is usually necessary after
exposure to the TB bacteria in order for the PPD test to be positive.
 Anyone can have a TB test, and physicians can perform the test on
infants, pregnant women, or HIV-infected people with no danger.
84
 It is only contraindicated in people who have had a severe reaction to a
previous tuberculin skin test.
Equipment:
 Tuberculin Syringes with blunt fill filter needle

 Alcohol Wipes
 Mantoux Solution (purified protein derivative "PPD")
 Sharps Box
 Rubbish Container
 Emergency Equipment
 Consent Form
 Patient Chart
 Transparent Ruler in millimeters (mm)
Procedure:
Preparation
 Wash hands.
 Gather neccessary equipment.
 Prepare the vial contains tuberculin.
 Explain the procedure to the client.
Locate and clean injection site
 Place forearm palm side up on a firm, well-lit surface

 Select an area free of barriers (e.g., scars, sores) to placing and readin
 Clean the area with an alcohol swab
85
2-4 inches below elbow joint
Prepare syringe
 Check expiration date on vial and ensure vial contains tuberculin (5 TU

per 0.1 ml)
 Use a single-dose tuberculin syringe with a ¼- to ½-inch, 27-gauge needle
with a short bevel
 Fill the syringe with 0.1 ml of tuberculin
Inject tuberculin
 Insert slowly, bevel up, at a 5- to 15-degree angle Needle bevel can be

seen just below skin surface
 After injection, a tense, pale wheal should appear over the needle
86
Check skin test
 To ensure correct injection , Wheal should be measured transversely 6 to

10 mm in diameter. If not, repeat test at a site at least 2 inches away from
original site
 Do not recap the needle. Discard it in the sharp boxes.
 Assist the client to return to a comfort position.
 Remove the glove & wash hands.
 Record all the information required for documentation (e.g., date and time
of test administration, injection site location, lot number of tuberculin)
87
Reading
Inspect site
 Visually inspect site under good light
 Use fingertips to find margins of induration
 Marking widest edges of induration transversely (right and left) across

forearm.
 Place ―0‖ ruler line inside left dot edge
88
 Read ruler line inside right dot edge (use lower measurement if between
two gradations on mm scale)
 Record measurement of induration in mm
 If no induration, record as 0 mm
 Do not record as ―positive‖ or ―negative‖
 Only record measurement in mm
Classification of tuberculin skin test reaction:
0-4 mm (Negative) 5-9 mm( Douptful) 10-14 mm (Positive)
The Classification of tuberculin reactions catograized as:
 0-4 mm (Negative)
 5-9 mm( Douptful)
 10-14 mm (Positive)
89
Interpretation of TST
 It is important to note that redness is not measured.
 A tuberculin reaction is classified as positive based on the diameter

of the induration in conjunction with certain patient-specific risk
factors. In a healthy person whose immune system is normal,
induration greater than or equal to 15 mm is considered a positive
skin test.
 There are false positive reaction and false negative reaction to TST.
 People who have been infected with TB may not have a positive skin test
(known as a false negative result) if their immune function is
compromised by chronic medical conditions, cancer chemotherapy,
or AIDS.
 Additionally, 10%-25% of people with newly diagnosed tuberculosis of
the lungs will also have a negative result, possibly due to poor immune
function, poor nutrition, accompanying viral infection, or steroid
therapy.
 1``Over 50% of patients with widespread, disseminated TB (spread
throughout the body, known as miliary TB) will also have a negative TB
test.
Interpretation of False-Positive Reactions

Some persons may react to the TST even though they are not infected with M.
tuberculosis. The causes of these false-positive reactions may include, but are
not limited to, the following:
 Infection with nontuberculosis mycobacteria
 Previous BCG vaccination
 Incorrect method of TST administration

90
 Incorrect interpretation of reaction
 Incorrect bottle of antigen used
Interpretation of False-Negative Reactions

Some persons may not react to the TST even though they are infected with M.
tuberculosis. The reasons for these false-negative reactions may include, but are
not limited to, the following:
 Cutaneous anergy (anergy is the inability to react to skin tests because of a

weakened immune system)
 Recent TB infection (within 8-10 weeks of exposure)
 Very old TB infection (many years)
 Very young age (less than 6 months old)
 Recent live-virus vaccination (e.g., measles and smallpox)
 Overwhelming TB diseasem, due to secondary immuno-compromized
 Some viral illnesses (e.g., measles and chicken pox)
 Incorrect method of TST administration
 Incorrect interpretation of reaction
91
First aid
It is an immediate and temporary treatment of a victim of sudden illness or

injury while awaiting the arrival of medical aid. Proper early measures may be
instrumental in saving life and ensuring a better and more rapid recovery.
First aid kit
Contents of first aid kit
1 –First-aid manual 10- Safety pins.
2-Sterile gauze pads of different 11- Antiseptic solution (like hydrogen

izes. peroxide).
3-Adhesive tape 12-Antibiotic ointment.
4- A splint. 13- Soap.
5-Acetaminophen and ibuprofen. 14-Tweezers.
6- Sharp scissors. 15-Disposable cold packs.

7-Thermometer 16-Plastic non-latex gloves (at least 2 pairs).
8-Flashlight and extra batteries. 17- A blanket.

9-List of emergency phone
numbers.
92
Fainting
Definition:
Fainting, also called syncope it is a sudden temporary loss of consciousness
when the brain's blood flow is interrupted. Fainting can be the sign of a medical
condition, like a heart or brain disorder.
Causes of fainting: -
Medical reasons include:
 Diabetes Mellitus
 Pregnancy: - Low blood sugar (hypoglycemia) which is common in
early pregnancy.
 Anemia.
 Any condition in which there is a rapid loss of blood.
 Heart and circulatory problems such as abnormal heart rhythm, heart attack
or stroke.
 Heat stroke or heat exhaustion
 Eating disorders such as anorexia, bulimia.
 Otitis media.
93
Other things that can lead to feeling faint or fainting include:
 A sudden change in body position like standing up too quickly (postural

hypertension).
 Extreme pain.
 Sudden emotional stress or fright.
 Anxiety
 Taking some prescription medicines. Examples are: some that lower high
blood pressure, tranquilizers, antidepressants, or even some over-the-counter
medicines when taken in excessive amounts.
♦ Signs and symptoms of fainting:

Fainting may occur sudden or proceeded by warning sings :-
Dizziness, nausea, paleness, sweating and rapid heartbeat or palpitations
94
First Aid at School for Fainting
(Some of the following steps/tasks should be performed simultaneously)
Step/Task Rational
1- Prepare necessary equipment’s and supplies (first
aid kit).
2- Ensure the equipment’s are functioning properly.
3- Place the child in appropriate position.
4- Maintain body mechanic.
5- Have an assistant.
Immediate first aid for fainting:
6- Wash hand.
7- Catch the child before he or she falls.
8- Lie the fainting child down with the

head below heart level.
9- Raise the child's legs 8-12 inch. To promote blood

flow to the brain
95
10- Loose any tight clothes. To facilitate
ventilation
11-Turn child's head to the side To prevent the

tongue, fall back
into the throat.
12- Maintain body mechanic for child and nurse.

o Don't give anything to the child to eat or drink. To avoid
-Don't slap or shake child's who's just fainted suffocation
14- Keep the child lying for 5 minutes.
96
15-Keep child setting up for 5 minutes before To avoid fainting
standing up again. again
16-After the child regains consciousness; avoid
stuffy rooms and hot and humid places as using of
fan.
17-If fainting prolonged, call physician.
Post Procedure Activities.

18-Provide reassurance for the fainting child.
19-Measure of vital signs (temperature, pulse,
respiration and blood pressure).
20-Record the results in complete, concise and
accurate manner.
21-Reporting of any abnormality.
22-Wash hands after removing equipment’s.
97
Epistaxis
♦ Definition:
It is escape of blood out the blood vessels it can be internal or external. It is
occur when a small vein, along the lining of nose, bursts and it is common in
children/elderly.
♦ Common causes of nosebleeds include:

 Dry, heated, indoor air, which dries out the nasal membranes and causes
them to become cracked or crusted and bleed when rubbed.
 Dry, hot, low-humidity climates, which can dry out the mucus membranes.
 Colds (upper respiratory infections) and sinusitis, especially episodes that

cause repeated sneezing, coughing, and nose blowing.
 The insertion of a foreign object into the nose (mostly in children).
 Injury to the nose and/or face.
 Allergic and non-allergic rhinitis (inflammation of the nasal lining).
 Use of drugs that thin the blood (aspirin, non-steroidal anti-inflammatory

medications, warfarin, and others), and high blood pressure.
 Chemical irritants (e.g., cocaine, industrial chemicals, others).
 Deviated septum (an abnormal shape of the structure that separates the two
sides of the nose).
 Tumors or inherited bleeding disorders (rare).
 Facial and nasal surgery.
98
Risk factors for nose bleeding: -
Anyone can get a nosebleed. Most people will have at least one in their lifetime.
However, there are people who are more likely to have a nosebleed. They
include:
 Children between ages two and 10. Dry air, colds, allergies and sticking
fingers and objects into their nose make children more prone to nosebleeds.
 Adults between ages 45 and 65. Blood may take longer to clot in mid-life and
older adults. They are also more likely to be taking blood thinning drugs (such
as daily aspirin use), have high blood pressure, atherosclerosis (hardening of the
walls of arteries) or a bleeding disorder.
 Pregnant women. Blood vessels in the nose expand while pregnant, which
puts more pressure on the delicate blood vessels in the lining of the nose.
 People who take blood-thinning drugs, such as aspirin or warfarin.
 People who have blood clotting disorders, such as hemophilia .
♦ Treatments, depending on the cause, could include:

 Cauterization: The application of a chemical substance (silver nitrate) or
heat energy (electrocautery) to seal the bleeding blood vessel.
99
 Nasal packing: The placement of strips of gauze into the nasal cavity to
create pressure on the bleeding site. Alternately, other materials that
promote clotting may be used.
 Medication adjustments: Reducing or stopping the amount of blood

thinning medications can be helpful. In addition, medications for
controlling blood pressure may be necessary.
 Foreign body removal.
 Repair of nasal fracture.
 Correction of a deviated septum.
100
Procedures of: First Aid at School for nose bleeding (Epistaxis)
First Aid At School For Nose Bleeding (Epistaxis)
Step/Task Rational
1- Prepare necessary equipment and supplies. To save time and
facilitates accurate skill
performance when
equipment was available.
2-Ensure the equipment is functioning properly. To identify efficiency of
equipment
3- Place the child in appropriate position Proper positioning is
important for a patient's
comfort and well
4- Maintain body mechanic Correct application of
body mechanics prevents
unnecessary fatigue and
strain, saves energy.
5- Have an assistant. To help the nurse if
needed
Immediate First Aid for Nose Bleeding (Epistaxis):
6- Wash hand
7- Sit the student erect with the head tilted forward Sitting forward will
slightly. prevent the swallowing
blood
8-Apply aseptic techniques
101
9- Apply simple pressure to the sides of the nose by
grasping it with thumb and forefinger (pinch the soft
part of the nose).
10- Place cold packs on the nose.
11- Release the pressure after 10 minutes. If the

bleeding has not stopped, continue pressure for a
further 10 minutes, or as necessary
12- Clean the nose by wet cotton after bleeding
stopped.
13- When the bleeding stops, tell the student to avoid
exertion.
14- Seek medical aid. If after 30 minutes the bleeding
persists or recurs
15- Provide reassurance for the child
16- Measure Vital Signs.
17- Record the results in complete, concise and
accurate manner in the child file.
18- Reporting of any abnormality.
19- Wash hands after removing equipment.
102
Burns
Burns are a global public health problem, accounting for an estimated 180 000
deaths annually. The majority of these occur in low- and middle-income
countries. The rate of child deaths from burns is currently over 7 times higher in
low- and middle-income countries than in high-income countries.
A burn: is an injury to the skin or other organic tissue primarily caused by heat
or due to radiation, radioactivity, electricity, friction or contact with chemicals.
Classification of burns:
Burns are classified as first- second- or third-degree depending on how deep and
severe they penetrate the skin's surface.
 First-degree (superficial) burns:
First-degree burns affect only the epidermis, or outer layer of skin. The burn site
is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term
103
tissue damage is rare and usually consists of an increase or decrease in the skin
color.
 Second-degree (partial thickness) burns:
Second-degree burns involve the epidermis and part of the dermis layer of
skin. The burn site appears red, blistered, and may be swollen and painful.
 Third-degree (full thickness) burns:
Third-degree burns destroy the epidermis and dermis. Third-degree burns

may also damage the underlying bones, muscles, and tendons. The burn site
appears white or charred. There is no sensation in the area since the nerve
endings are destroyed.
 The rule of nines is a tool used in pre-hospital and emergency medicine to

estimate the total body surface area (BSA) affected by a burn. In addition
to determining burn severity, the measurement of burn surface area is
important for estimating patients' fluid requirements and determining
hospital admission criteria.
104
Body Part Estimated BSA
Adults Children
Entire left arm 9% 9%
Entire right arm 9% 9%
Head & neck 9% 18%
Entire chest 9% 9%
Entire abdomen 9%+ 1% (Genitals) 9%
Entire back 18% 18%
Entire left leg 18% 14%
Entire right leg 18% 14%
105
Causes of burns and treatment
Burns can be separated into five different areas, the treatment for each burn will
differ slightly depending on the cause.
 Electrical burns:
 Dry heat burns:
 Wet heat burns (scalds):
 Chemical burns:
 Radiation (sun) burns:
Seek medical advice for burns if:
 The burn is larger than 1 square inch.
 The casualty is a baby or child.
 The burn is all the way around a limb.
 Any part of the burn appears to be full thickness.
 The burn is to the hands, feet, genitals or face.
Never do any of the following when burns are concerned:
 Burst a blister or blisters (the blisters are there to protect against
infection).
 Touch the burn.
 Apply lotions, ointments or fats to a burn as they may introduce infection
and will need to be removed once the casualty is in hospital.
 Apply adhesive tape or dressings as the burn may be larger than it first
appears.
 Remove clothing that is stuck to the wound, as this will invariably cause
more damage.
Complications of burns:
 Infections
 Blood loss
 Shock which is often what could lead to death.
106
 Tetanus is another possible complication with burns of all levels. Like
sepsis, tetanus is a bacterial infection. It affects the nervous system,
eventually leading to problems with muscle contractions.
 Severe burns also carry the risk of hypothermia and hypervolemia.
 Arrhythmia, or heart rhythm disturbances, caused by an electrical burn.
 Dehydration.
 Disfiguring scars and contractures.
 Edema (excess fluid and swelling in tissues).
 Organ failure.
 Pneumonia.
 Seriously low blood pressure (hypotension) that may lead to shock.
 Severe infection that may lead to amputation or sepsis.
First aid at School for Burn

Step/Task Rational
1- Prepare necessary equipment and supplies. To save time and
facilitates accurate skill
performance when
2-Ensure the equipment is functioning properly. To identify efficiency of
equipment
3- Place the child in appropriate position Proper positioning is
important for a patient's
comfort and well
4- Maintain body mechanic Correct application of
body mechanics prevents
unnecessary fatigue and
strain, saves energy.
5- Have an assistant. To help the nurse if
needed
Immediate First Aid for Burn:
6- Wash hand.
107
7- Apply aseptic techniques To avoid spread of
microorganism
8- Reassure the child.
9- Remove hot or burned cloth.
10- If burn is 1st degree Cooling the burn will
- Put cold or tape water only. reduce pain, swelling and
- Cover the burn with a nonstick, sterile bandage. the risk of scarring. The
- Protect the area from the sun sooner and longer a burn is
cooled with cold running
water, the less the impact
of the injury.
11- If burn is 2nd degree

- Use saline or tap water with Antiseptic solution.
- Remove jewelry or clothing that could become
too tight if the area swells.
- Don't break blisters.
- Cover loosely with sterile, nonstick bandage
- Separate burned toes and fingers with dry, sterile
dressings.
12- If burn is 3rd degree
- Do not soak the burn with water.
- Do not remove clothing that is stuck to the area.
- Cover the area with a sterile bandage or a clean
loose cloth.
13- Check vital signs.
14-Assess the child for chilling, fatigue
consciousness.
15- Seek medical aid.
Post Burn procedures:
18- Record the results in complete, concise and
accurate manner in the child file.
20- Wash hands after removing equipment.
108
Fracture
♦ Definition of fracture:
A bone fracture is a medical condition in which there is a partial or
complete break in the continuity of a bone. In more severe cases, the bone may
be broken into several pieces.
♦ Causes of fracture:
 Different types of force can cause injury to the bones, muscles and
joints.
- Direct force damage will result at the location of the force, such as a
kick or blow.
- Indirect force damage will result away from the point where the force
was applied, for example a fractured collar bone may result from
landing on an outstretched arm.
- Twisting force damage will result from torsion force on the bones and
muscles, for example a twisted ankle.
- Violent movement damage will result from sudden, violent movements,
for example a knee injury from violently kicking.
- Pathological damage will result from the bones becoming weak or brittle
due to disease or old age.
♦ Types of fractures:
- Open fracture: where the skin is torn and penetrated by the damaged
bone resulting in an open wound.
- Closed fracture: is when the bone breaks but there is no puncture or

open wound in the skin.
109
- Complicated fractures: Associated injury to a major nerve, blood
vessel, or vital organs
- Stress fracture: tiny cracks in a bone. They're caused by repetitive

force, often from overuse — such as repeatedly jumping up and
down or running long distances. Stress fractures can also develop
from the normal use of a bone that's weakened by a condition
such as osteoporosis.
110
- Greenstick fracture: occurs when a bone bends and cracks, instead
of breaking completely into separate pieces. The fracture looks
similar to what happens when you try to break a small, "green"
branch on a tree. Most greenstick fractures occur in children
younger than 10 years of age.
Transverse Fracture
Transverse fractures are breaks that are in a straight line across the bone. This
type of fracture may be caused by traumatic events like falls or automobile
accidents.
Spiral Fracture
As the name suggests, this is a kind of fracture that spirals around the bone.
Spiral fractures occur in long bones in the body, usually in the femur, tibia, or
fibula in the legs. However, they can occur in the long bones of the arms. Spiral
111
fractures are caused by twisting injuries sustained during sports, a physical
attack, or an accident.
Oblique Fracture
An oblique fracture is when the break is diagonal across the bone. This kind of
fracture occurs most often in long bones. Oblique fractures may be the result of
a sharp blow that comes from an angle due to a fall or other trauma.
♦ Signs & symptoms of fractures:
1- Severe pain.
2- Difficulty in movement.
3- Swelling/ bruising / bleeding.
4- Deformity / abnormal twist of the limb.
112
5- Tenderness on applying pressure. This occurs at the site of the
injury.
6- Crepitus: This is the feeling, or sound, of bone grating on bone
when the broken ends rub together.
Management of fracture
For injury to an upper limb:
 Carefully, and gently place the arm in a sling against the body. It is common
to use a support sling for arm fractures. For collar bone fractures, it is common
to use an elevated sling (keep the ca patient elbow down at their side when using
an elevated sling for a fractured collar bone).
For injury to a lower limb:
 Keep the patient still, and ensure they are kept warm. Call an ambulance
immediately.
 If there is any delay to the ambulance reaching the patients, immobilize the
injury by gently bandaging the injured leg to the uninjured one.
 Check that their circulation has not been cut off beyond the injury and
bandages. If necessary, loosen the bandages
113
For spinal injury:
 If the patient is conscious tell them not to move and keep reassuring them.
 Do not allow the patient to move, keep them in the position you found them in
until help arrives. They should only be moved if they are in severe and
immediate danger.
 Call an ambulance immediately. Keep the patient still and warm until help
arrives.
First Aid at School for fracture

Step/Task Rational
1- Prepare necessary equipment and To save time and facilitates
supplies. accurate skill performance when
2- Ensure the equipment is functioning To identify efficiency of
properly. equipment
3- Place the child in an appropriate position Proper positioning is
important for a patient's comfort
and well
4- Maintain body mechanic Correct application of body
mechanics prevents unnecessary
fatigue and strain, saves energy.
5- Have an assistant. To help the nurse if needed
6- Explain the procedure to the child and the Reduces anxiety and encourages
instructor. cooperation
Immediate First Aid for fracture:
7- Hand washing.
8- Apply aseptic techniques To prevent spread of
microorganisms
9- Keep the child comfortable. To avoid chock
10- Gentle handling of the fractured part.
114
11- Place a splint under the fractured part
12- Apply adequate supports before and

after the fracture part
13- Keep the child warm.

14- Do not:
 Attempt to set the bone in anatomical
position.
 Massage the affected area.
 Move without support to broken bone.
 Move joints above/below the fracture.
 Give oral liquids/food.
15- Assess the child for chilling, fatigue, and
consciousness.
Post fracture procedures:
18- Recording of the results in complete and An accurate written record
an accurate manner in the child's ,concise detailing all aspects of patient
file. monitoring is important because
it contributes to the circulation of
information amongst the different
teams involved in the patient's
treatment or care.
20- Wash hands after removing equipment. To prevent the risk of healthcare
provider colonization or infection
caused by germs acquired from
the patient
115
116
Distance Vision Test
Definition
Distance Vision Test is standard test for measuring distance acuity by

using eye chart as Snellen eye chart (Multi-letter Snellen chart, E or C
Snellen chart).
Definition of visual acuity (VA)
Visual acuity is acuteness or clearness of vision, especially form vision,

which is dependent on the sharpness of the retinal focus within the eye and the
sensitivity of the interpretative faculty of the brain.
Definition of Snellen eye chart
A chart for testing used by eye care professionals and others to measure
visual acuity., usually consisting of letters, numbers, or pictures printed in lines
of decreasing size which a patient is asked to read or identify at a fixed distance.
Snellen charts are named after the Dutch ophthalmologist Herman Snellen who
developed the chart during 1862.
117
What is the normal vision?
To understand how certain problems can affect the vision, it’s important to
know how normal vision happens. The following things happen in this order:
1. Light enters the eye through the cornea. This is the clear, dome-shaped
surface that covers the front of the eye.
2. From the cornea, the light passes through the pupil. The iris, or the
colored part of your eye, controls the amount of light passing through.
3. From there, it then hits the lens. This is the clear structure inside the
eye that focuses light rays onto the retina.
4. Next, light passes through the vitreous humor. This is the clear, jelly-
like substance that fills the center of the eye. It helps to keep the eye
round in shape.
5. Finally, the light reaches the retina. This is the light-sensitive nerve
layer that lines the back of the eye. Here the image is inverted.
118
6. The optic nerve is then responsible for carrying the signals to the
visual cortex of the brain. The visual cortex turns the signals into
images (for example, our vision).
Common refractive defects of vision
There are three common refractive defects of vision.
(i) Myopia or near-sightedness

(ii)Hypermetropia or far – sightedness
(iii) Presbyopia.
Myopia
Myopia is also known as near-sightedness. A person with myopia can see

nearby objects clearly but cannot see distant objects distinctly.
Correction of myopia
This defect can be corrected by using a concave lens of suitable power.
119
Hypermetropia
Hypermetropia is also known as far sightedness. A person with hypermetropia

can see distant objects clearly but cannot see nearby objects distinctly.
Correction of hypermetropia
This defect can be corrected by using a convex lens of appropriate power. Eye-
glasses with converging lenses provide the additional focusing power required
for forming the image on the retina.
120
Presbyopia
The power of accommodation of the eye usually decreases with ageing. For
most people, the near point gradually recedes away. They find it difficult to see
nearby objects comfortably and distinctly without corrective eye-glasses. This
defect is called Presbyopia. Arises due to the gradual weakening of the ciliary
muscles and diminishing flexibility of the eye lens.
Correction of presbyopia: By bifocal lenses
What about Snellen chart
The traditional Snellen chart is printed with eleven lines of block letters. The
first line consists of one very large letter, which may be one of several letters,
for example E, H, or N which called optotype. Subsequent rows have increasing
numbers of letters that decrease in size. A patient taking the test covers one eye,
and reads aloud the letters of each row, beginning at the top. The smallest row
that can be read accurately indicates the patient's visual acuity in that eye.
A Snellen eye chart is used to determine how "normal" vision is. It sets a
standard for what most people should be able to see when they stand 20 feet
away from the chart (6 meters). 20/20 vision (6/6) just means that when you
stand 20 feet (6 meters) away from a Snellen eye chart, client see what a normal
human being can see. If client see 20/40 (6/9), that means that when you stand
20 feet away from the chart, client see what a normal person sees standing 40
feet away from it.
The higher the second number, the worse your vision is. 20/200 (6/ 60)
(client see at 20 feet what a normal person sees at 200) is the number for legal
blindness in the United States.20/20 vision isn't perfect, it's just "normal‖ client
can have better vision than 20/20. If you have 20/10 you see at 20 feet what
most people see at 10.
121
Indications
 To provide a baseline recording of visual acuity (VA)

 To aid examination and diagnosis of eye disease.
 For medico-legal reasons
Equipment
 Multi-letter Snellen chart or E or C Snellen chart or a chart with

illustrations for patients who cannot read or speak
 Plain Occluder.
 A room that is well-lighted
 Patient's documentation
 Equipment for hand washing
Step/Task Rational
1. Prepare necessary equipment
2. Explain the procedure to the client. Reassure the client
3. Wash and dry the occluder. If no plain they will use a hand to cover
occluder is available, ask the patient to wash one eye at a time
his/her hands.
4. Perform the vision test in a room that is For accurate measurement

well-lighted
5. Use the Snellen chart containing various
Sized
6. Position the client (6 meter) in front of the
Chart
7. Direct him/her to cover the left eye start
reading from the top of the chart to the
122
smallest line of print possible. Then, repeat
with the right eye.
8. If the client wears glasses, first test with To measure distance vision
glasses, then without glasses with out and with glasses
9. Record the result in complete, concise, and
accurate manner
10. Report of finding to other health care
provider (clinical instructor)
Feet Meter
Snellen chart
123
Hearing Test
Definition:
A test made by different methods to establish whether someone's hearing is
normal or whether they have some degree of hearing loss
Hearing tests are performed in the conditions mentioned below.
To screen babies and young children for hearing problems that might interfere
with their ability to learn, speak, or understand language.
To screen children and teens for hearing loss. Hearing should be checked by a
doctor at each well-child visit. In children, normal hearing is important for
proper language development. American Academy of Pediatrics recommends a
formal hearing test at ages 4, 5, 6, 8, and 10 years.
As part of a routine physical exam. In general, unless hearing loss is

suspected, only a simple whispered speech test is done during a routine physical
exam.
To evaluate possible hearing loss in anyone who has noticed a persistent

hearing problem in one or both ears or has had difficulty understanding words in
conversation.
To screen for hearing problems in older adults. Hearing loss in older adults is
often mistaken for diminished mental capacity (for instance, if the person does
not seem to listen or respond to conversation).
To screen for hearing loss in people who are repeatedly exposed to loud
noises or who are taking certain antibiotics, such as gentamicin.
124
Methods of hearing tests:
Hearing of a person can be tested by three methods.
1. Clinical tests (Physical Examination)
The audiologist will look at the outer ear (the pinna) checking for any
malformation. The audiologist will use an otoscope, an instrument that contains
a light and a magnifying lens, to examine the ear canal and eardrum. The ear
canal is examined for the presence of excessive wax, or foreign objects (food,
toys, pieces of cotton swabs, etc.). The eardrum (tympanic membrane) is
examined for any perforation and signs of fluid or infection. The audiologist will
look for any indicators suggesting the need for referral for a medical evaluation
and/or treatment.
Anatomy of ear
125
2. Audiometric tests
An audiometer hearing test is usually administered to a person sitting in a
soundproof booth wearing a set of headphones which is connected to an
audiometer
3. The automated otoacoustic emission (AOAE) test

The newborn hearing test is called the automated otoacoustic emission (AOAE)
test. It takes just a few minutes. Soft foam or rubber tips are placed in Newborn
ear.
126
The results are either present or absent
Present OAEs are consistent with normal to near normal hearing
Absent OAEs may be a sign of a problem. It could be hearing loss, wax in the
ears, fluid or infection in the middle ear or a malformed inner ear. This indicates
that more testing needs to find out why the AOAEs were absent.
4. Whispered Speech Tests:

This type of test is a very basic testing technique and can be tried at home to
discover whether there is any degree of hearing impairment. It is useful as an
indicator of a problem that will require further testing by a specialist. All that’s
involved is to simply stand behind the person being tested and whispering words
or commands and finding out if anything has been heard or not. This test can be
tried in the pres ence of background noise or without.
127
Step/Task Rational
1. Explain the procedure to the client. Reduces anxiety and encourages
cooperation
2. Ask the client to wash their hands. Prevents transfer of
microorganisms.
3. Ask the client to occlude one ear with a
finger.
4. Test the other ear by standing behind the to prevent lip reading
client at a distance of 30 to 36 cm.
5. Whisper a word or phrase.
6. Ask client to repeat what was whispered. To finding out if a word or phrase
has been heard or not.
7. Repeat for the other ear. To test the other ear
8. Record the result in complete, concise, and
accurate manner
9. Report of finding to other health care
provider (clinical instructor)
10.Ask the client to wash their hands.
128

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Community health nursing department

Description of growth chart

Purpose of growth chart:

Enable health care providers to

 Assess physical growth among children using head circumferences,

 To identify potential health or nutrition-related problems.

 Comparing body measurements with the appropriate age and sex

Step in the interpretation of growth chart:

1- Obtain accurate measurements of head circumference, weight and height

 Head circumference: A soft tape measure is wrapped around the

 Entering today's date

 Entering child's name

 Entering child's age of birth

 Entering child's weight and length

 Add any notable comments

4- Plot measurements on appropriate growth chart

 Find the child's age on horizontal axis (up and down)

 Normal range in growth chart (5th to 95th)

5-Interpret the plotted measurements:

Anthropometric Percentile value Nutritional status

Community Health Nursing Bag: is essential equipment for the community

Equipment: To make them readily accessible.

 Place the bag on a clean surface (not the To avoid infection

 Hand washing and wear gloves To prevent spread of

 Soap at (dish) – 2 hand towels - 2

Purpose of home visit

Goals of antenatal care:

- The safety of the mother and her fetus

- The reduction of maternal and infant mortality, stillbirth and prematurity

-To increase the number of breastfeed babies

WHO Antenatal care model recommended 4 visits:

Visit 1: 8-12 weeks in 1st trimester

Visit 2: 24-26 weeks in 2nd trimester

Visit 3: 32 weeks in 3rd trimester

Visit 4: 36-38 weeks in 4th trimester

(Name-Age-Address, it is important to be filled out clearly, so that the

 Regularity and frequency of menstrual cycle

 Duration and nature of menstrual flow

 Any previous treatment of menstrual problems or infertility

 Date and character of last menstrual period(LMP)

 Expected date of delivery (EDD) is calculated as follows

o 1st day of LMP +7days – 3 months +1year

o 1st day of LMP +7days – 9 months

 Ante partum care, labor and puerperium of previous pregnancies.

 Number and sex of living children

 Mode of infant feeding

 Date of last labor and last abortion (LL and LA)

 Diabetes mellitus- Hypertension - Urinary tract infections

 Heart diseases- Viral infection- Drugs/allergies

- Other: Blood transfusion- Rh incompatibility -X-ray

Diabetes mellitus, hypertension, multiple pregnancies, congenital anomalies

Local abdominal examination:

 Signs of pregnancy ( linea nigra and stria gravidarium)

*Linea-nigra: which is define as normal dark line of pigmentation running

*Stria-gravidarium: silver stretch marks from previous pregnancies and recent

 Hernia orifices and back

*The attitude of fetus: Relationship of fetal head to spine.

*The position of fetus: Relationship of presenting part to maternal pelvis.

 Fundal level (FL)to estimate the period of gestation

- Auscultation – Fetal Heart Sounds (FHS)

 Urine is tested for glucose, ketones, and protein (albumin).

 Hemoglobin levels average 12 to 16 g/dL.

 Uterine growth and estimated fetal growth

o Fundus at umbilicus indicates 24 weeks' gestation.