Using principles of body mechanics

“Body Mechanics” is using the body in an efficient and careful way to save energy and prevent injury. It
includes good posture, balance, and using the strongest and largest muscles to do the work. “Body
Mechanics” is the way a body moves and keeps its balance through the use of all its parts.

“Posture” is another word for “body alignment”. Good posture means keeping major body parts,
including head, trunk, arms, and legs in a straight line to allow the body to move and function with
strength and efficiency.

“Base of support” is the foundation for an object or individual. A human being’s feet are the person’s
base, their source of support and balance. When the feet are wide apart, the person’s “base of support”
is at its most stable foundation.

Transferring, lifting, moving, and positioning care recipients can be a major safety problem unless you
learn how to use good body mechanics. ‘Body mechanics’ involves how you stand, move, and position
your body to prevent injury, avoid fatigue, and make the best use of your strength. Understanding the
principles of good body mechanics and applying them to your everyday routine, whether at home or at
work, enables you to feel better and less tired at the end of the day.

Purposes

- To maintain good balance.

- To reduce the energy required.
- To avoid excessive fatigue.
- To avoid muscle strains or tears.
- To avoid skeletal injuries.
- To avoid injury to the patient.
- To avoid injury to assisting staff members

● Stand close to the care recipient.

● Create a base of support by placing your feet wide apart.
● Make sure the area is safe for a move or a lift.
● Bend at your hips and knees with your back straight.
● Push up with your leg muscles to a standing position. Back injuries are not usually the result of
one incident but of the constant use of smaller back muscles.

DON’T Lift With Your Back, Lift With Your Head!!!!!!

Every effort is made to protect employees from injury, but they must also use good judgment to avoid
injuries. The most common injury to health care workers is a back injury. Employees are encouraged to
strengthen their backs through daily exercise in order to prevent injuries.
Using principle of medical asepsis hand washing
Medical asepsis, also called “clean technique,” reduces the number and transmission of disease-causing
microorganisms after they leave the body, but doesn’t necessarily eliminate them. It is used to care for
clients with infectious diseases; to prevent reinfection of the client; and to avoid spreading infection
from one person to another, or throughout the facility.

● Handwashing
● Utilizing gloves, gown, mask, hair, shoe cover
● Cleaning instrument
● Disinfecting surfaces

Medical asepsis protects both residents and caregivers from becoming ill. personnel must follow in an
attempt to control the spread of germs/infection. Microorganisms are too small to be seen, located
everywhere, air, water, food, and clothes.

Microorganisms can be spread by touching someone who has an infection, touching the linens or other
belongings of a person who has an infection, sneezing or coughing, and handling or consuming
contaminated food, medications or water.
Establishing a Nurse - Client relationship
A therapeutic nurse-patient relationship is defined as a helping relationship that's based on mutual trust
and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the
gratification of your patient's physical, emotional, and spiritual needs through your knowledge and skill.
This caring relationship develops when you and your patient come together in the moment, which
results in harmony and healing. Effective verbal and nonverbal communication is an important part of
the nurse-patient interaction, as well as providing care in a manner that enables your patient to be an
equal partner in achieving wellness.
● Introduce yourself to your patient and use her name while talking with her. A handshake at your

initial meeting is often a good way to quickly establish trust and respect.

● Make sure your patient has privacy when you provide care. Be sure that her basic needs are met,

including relieving pain or other sources of discomfort.

● Actively listen to your patient. Make sure you understand her concerns by restating what she has

verbalized. However, don't use restating too much in a conversation because it can be perceived

by your patient that you aren't really listening to her. Be real, showing your genuine self when

communicating with her.

● Maintain eye contact. Remember, too much eye contact can be intimidating. Smile at intervals

and nod your head as you and your patient engage in conversation. Speak calmly and slowly in

terms that she can understand. Your voice inflection should say "I care about you."

● Maintain professional boundaries. Some patients need more therapeutic touch, such as

hand-holding and hugging, than others and some patients prefer no touching. Always respect

differences in cultures.

You can help your patient achieve harmony in mind, body, and spirit when engaging in a therapeutic
relationship based on effective communication that incorporates caring behaviors. It's a win-win
situation in which you and your patient can experience growth by sharing "the moment" with each other
Nursing process
Understanding the nursing process is key to providing quality care to your patients. The nursing process
is a patient-centered, systematic, evidence-based approach to delivering high-quality nursing care. The
nursing process is a cyclical process used to assess, diagnose, and care for patients as a nurse. In 1958,
Ida Jean Orlando began developing the nursing process still evident in nursing care today.It includes 5
progressive steps often referred to with the acronym:
ADPIE
● Assessment
● Diagnosis
● Planning/outcomes
● Implementation
● Evaluation

1. Assessment

• First phase; involves collecting, organizing, validating and documenting the client’s health status.
Critical thinking skills are essential to the assessment.

• Data collected about a client generally falls into objective (overt, measurable) or subjective (covert
information that is shared by the patient) categories, but data can also be verbal (spoken or written data)
and nonverbal (observable behaviors like body language, appearance, and expressions).

• Sources of data can be primary, secondary, and tertiary. The client is the primary source of data, while
family members, support persons, records and reports, other health professionals, laboratory and
diagnostics fall under secondary sources. Tertiary naman kapag galing sa books or journals.

• The main methods used to collect data are health interviews, physical examination, and observation.

2. Diagnosis

• In this phase, the nurse will analyze all the gathered information and diagnose the client’s condition
and needs. Diagnosing involves analyzing data, identifying health problems, risks, and strengths, and
formulating diagnostic statements about a patient’s potential or actual health problem.

3. Planning

• Planning is the third step of the nursing process. It provides direction for nursing interventions. When
the nurse, any supervising medical staff, and the patient agree on the diagnosis, the nurse will plan a
course of treatment that takes into account short and long-term goals.
A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes
potential needs or risks. Care plans provide communication among nurses, their patients, and other
healthcare providers to achieve health care outcomes. Without the nursing care planning process, the
quality and consistency of patient care would be lost.

4. Implementation

• The implementation phase of the nursing process is when the nurse puts the treatment plan into
effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan
of care.

5. Evaluation

• Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a
positive patient outcome. Once all nursing intervention actions have taken place, the team now learns
what works and what doesn’t by evaluating what was done beforehand.

Vital signs
Vital signs are measurements of the body's most basic functions. The four main vital signs routinely
monitored by medical professionals and health care providers include the following:

● Body temperature
● Pulse rate
● Respiration rate (rate of breathing)
● Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with
the vital signs.)

Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a
medical setting, at home, at the site of a medical emergency, or elsewhere.
The normal body temperature of a person varies depending on gender, recent activity, food and fluid
consumption, time of day, and, in women, the stage of the menstrual cycle.

Normal body temperature can range from 97.8 degrees F (or Fahrenheit, equivalent to 36.5 degrees C, or
Celsius) to 99 degrees F (37.2 degrees C) for a healthy adult. A person's body temperature can be taken
in any of the following ways:
 ● Orally. Temperature can be taken by mouth using either the classic glass thermometer, or the
more modern digital thermometers that use an electronic probe to measure body temperature.
● Rectally. Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7
degrees F higher than when taken by mouth.
● Axillary. Temperatures can be taken under the arm using a glass or digital thermometer.
Temperatures taken by this route tend to be 0.3 to 0.4 degrees F lower than those temperatures
taken by mouth.
● By ear. A special thermometer can quickly measure the temperature of the eardrum, which
reflects the body's core temperature (the temperature of the internal organs).
● By skin. A special thermometer can quickly measure the temperature of the skin on the
forehead.

The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute.
As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the
blood. Taking a pulse not only measures the heart rate, but also can indicate the following:
● Heart rhythm
● Strength of the pulse

The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may
fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general,
tend to have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular
conditioning, may have heart rates near 40 beats per minute and experience no problems.

As the heart forces blood through the arteries, you feel the beats by firmly pressing on the arteries,
which are located close to the surface of the skin at certain points of the body. The pulse can be found
on the side of the neck, on the inside of the elbow, or at the wrist. For most people, it is easiest to take
the pulse at the wrist. If you use the lower neck, be sure not to press too hard, and never press on the
pulses on both sides of the lower neck at the same time to prevent blocking blood flow to the brain.
When taking your pulse:

● Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.
● Begin counting the pulse when the clock's second hand is on the 12.
 ● Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats
per minute).
● When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.
● If unsure about your results, ask another person to count for you.

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured
when a person is at rest and simply involves counting the number of breaths for one minute by counting
how many times the chest rises. Respiration rates may increase with fever, illness, and other medical
conditions. When checking respiration, it is important to also note whether a person has any difficulty
breathing.

Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.

Blood pressure is the force of the blood pushing against the artery walls during contraction and
relaxation of the heart. Each time the heart beats, it pumps blood into the arteries, resulting in the
highest blood pressure as the heart contracts. When the heart relaxes, the blood pressure falls.

Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure,
refers to the pressure inside the artery when the heart contracts and pumps blood through the body.
The lower number, or diastolic pressure, refers to the pressure inside the artery when the heart is at rest
and is filled with blood. Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of
mercury). This recording represents how high the mercury column in an old-fashioned manual blood
pressure device (called a mercury manometer or sphygmomanometer) is raised by the pressure of the
blood. Today, your doctor's office is more likely to use a simple dial for this measurement.

High blood pressure, or hypertension, directly increases the risk of heart attack, heart failure, and stroke.
With high blood pressure, the arteries may have an increased resistance against the flow of blood,
causing the heart to pump harder to circulate the blood.
Blood pressure is categorized as normal, elevated, or stage 1 or stage 2 high blood pressure:

● Normal blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80)
● Elevated blood pressure is systolic of 120 to 129 and diastolic less than 80
● Stage 1 high blood pressure is systolic is 130 to 139 or diastolic between 80 to 89
● Stage 2 high blood pressure is when systolic is 140 or higher or the diastolic is 90 or higher

These numbers should be used as a guide only. A single blood pressure measurement that is higher than
normal is not necessarily an indication of a problem. Your doctor will want to see multiple blood
pressure measurements over several days or weeks before making a diagnosis of high blood pressure
and starting treatment. Ask your provider when to contact him or her if your blood pressure readings are
not within the normal range.

Providing backcare

It is cleaning and massaging the back, paying attention to pressure points. It provides comfort and
relaxes the client as well as facilitates the physical stimulation to the skin.

Purpose

- To stimulate the circulation and give general relief.

- To prevent bedsore
- To give comfort to the patient.

Equipment

- Powder or Lotion
- Bath Towel

Perform Hand Hygiene

Procedure

• Help the patient to turn on his abdomen or on his side with his back toward the nurse and his body
near the edge of the bed so that he is as near the operator as possible.

• Raise the gown.

• Apply to back rubbing lotion or talcum powder to reduce friction. In rubbing the back use firm long
strokes and kneading motions
• Massage with both hands working with a strong stroke. In upward then in downward motions

• Powder again the area at the completion of the rubbing process which should consume from 3-5
minutes.

• Turn patient on his back and put on the gown.

• Fix and make patient comfortable

Movements Used

Effleurage (stroking) —is a long sweeping movement with the palm of hand conforming to the contour of
the surface treated, over a small surface (on the neck) the thumb and fingers are used. Strokes should be
slow, rhythmical, and gentle with pressure constant and in the direction of the venous stream.

Kneading—performed with the ulnar side palm resting on the surface and the fingers, and thumb
grasping the skin and subcutaneous tissues which move with the hand of the operator.

Friction—is performed with the whole palmar surface of the hand or fingers and thumbs over limited
areas.

Bed making
The technique of preparing different types of bed making patients / clients comfortable in his/ her
suitable position for a particular condition.

Purpose of bed making:

1- To promote clients' comfort.
2- To provide a clean environment for the clients.
3- To provide a smooth, wrinkle- free bed foundation, thus minimizing sources of skin irritation.
4- To conserve the clients energy and maintain current healthy status.
5- To prevent or avoid microorganisms to come in contact with the patient which could cause
tribulations.

Common types of bed:

Occupied Bed: Is made when the patient is not able or not permitted to get out of the bed.
Unoccupied Bed: Is made when there is no patient confined in bed, while a patient is in the shower or
sitting up in a chair.
Types of unoccupied bed
1- Open bed: the top covers are folded back so the patient can easily get back into bed.
2- Closed bed: the top sheet blankets and bedspreads are drawn up to the head of the mattress and
under the pillow; this is prepared in a hospital room before a new client is admitted to the room.
3- Post-operative bed: known as a recovery bed or anesthetic bed, and used for a patient with a large
cast or other circumstance that would make it difficult for him to transfer easily into bed.

Materials:
Gloves, Alcohol, towel, Mackintosh, Draw sheet, Top sheet, Blanket, Pillow case
- Prepare the equipment before entering the room to reduce time.
- Do handwashing
- Introduce yourself and identify the client
- Tell the client the procedure
- Then, proceed to the procedure
Hair care
means maintaining cleanliness of hair, i.e., free from dandruff, dirt, nits, lice, flakes, dryness and
irritation.
Purpose
1. To the comfort of the patient.
2. To remove tangles from the hair.
3. To preserve or keep the hair in good condition during illness.
4. To observe the presence of lice without the patient’s being aware of it.
5. To prevent infection.
6. In preparation for diagnostic procedures involving the head.
Equipment
● Patient’s bath towel
● Hair comb
● Hair Brush
● Vaseline
● Clips
● Rubber bands or tapes
Procedure
1. Move the patient’s head near the edge of the bed, her face turned away from you.
2. Place towel under the head of the patient extending down the chest and shoulders.
3. Loose the hair and part it in the middle.
4. Brush hair thoroughly.
5. In combing or brushing, comb small stands at a time. Hold the strand at a time wrapping
around the forefinger. Hold the stand above the part being combed so that the pull
comes on your baud, not on the hair roots and comb the tangles from the end first.
6. Comb gently especially when removing tangles. If the hair is badly tangled, apply Vaseline
or oil or wet hair with alcohol but time, patience and skill are required.
7. If the hair is long, part down and middle and plaid into two braids shirting towards the
front so that a patient lying on her back will not be conscious of this coronet across the
front of the head or let them freely down holding the ends with ribbon or tape or rubber
bands.
8. Gather all used articles. Clean and disinfect brush and comb and return them into their
proper places.
Providing oral care
Oral care is the mechanical removal of oral bacteria by brushing the entire oral cavity.
Purposes
- To keep mucosa clean, soft, moist, and intact.
- To keep the lips, clean, soft, moist and intact.
- To prevent oral infections.
- To remove the food debris as well as dental plague without damaging the gum.
- To alleviate pain, discomfort and enhance oral intake with appetite.
Equipments
A clear tray containing:
- sterile dressing tray.
- Mackintosh and towel.
- Toothbrush and paste.
- Mouth wash solution.
- Cup of water.
- Face towel.
- Sponge cloth.
- A tongue depressor/spatula.
- A pair of gloves
- Gauze pieces.
- Emollient.
- Kidney tray.
- A bowl with clean water.

Procedure

1. Explain the procedure to the client (if the client is conscious) to gain the co-operation and confidence
of the client.
2. Provide privacy.
3. Maintain a safe comfortable position for the client. Place the client in a sitting position or in a fowler’s
position with a cardiac table in front. Arrange all articles on the cardiac table and assist him as needed.
4. Place the mackintosh and face towel across the chest and under the chin to protect the bed clothes
and garment.
5. Place the kidney tray close to the cheek with the concave side towards the client or allow the client to
adjust the kidney, if he can, according to his convenience, to receive the wastewater.
6. Remove dentures (if any) and place it in a bowel of clean water.
7. Arrange the articles conveniently convenient for nurse and the client to avoid overreaching.

Action

Procedure Rationale

Explain the procedure to patient to reduce the unease and get the cooperation
from the patient.

Wash hands to reduce transmission of microorganisms.

Gather all equipment near the patient side. to promote efficiency.

Discuss procedure with patient to discover hygiene preferences.

Wear clean gloves. to prevent contact with microorganisms or body

fluids.

Assess oral mucosa, teeth and throat. to determine the status of the oral cavity and
patient’s need for care and teaching.

Take the patient to the edge of bed and if for no difficulty of doing the procedure and to
possible,in semi-fowler if it is not contraindicated. prevent the aspiration.

Put a small mackintosh with a face towel on the to prevent the soil and make the patient
patient’s chest and tuck it under the chin. comfortable.

Place the kidney tray against the cheek and to dispose of the used gauze.
directly under the mouth.

Raise the head end of the bed to 45 degrees. to avoid the aspiration

If the patient is unconscious; with the help of a To Prevent injury and bleeding.
tongue depressor, gently open the jaw.
Examine the patient’s oral cavity completely with to identify any changes in moistures, cleanliness,
the help of torch, tongue depressor or spatula infection or bleeding, ulcers in the oral cavity.
and gauze.

Pour antiseptic gauze into a cup, soak gauze in to prevent infections and easy to do the
solution, and squeeze with help of artery forceps. procedure.

Clean teeth from incisors to molars using up and to promote the circulation and proper
down movement from gums to crown. cleanliness.

Use one clamp to pick up gauze and the other to to avoid cross contamination.
clean.

Clean the oral cavity from proximal to distal using to avoid cross contamination.
one gauze for each stroke with wet gauze.

For supportive and oriented patients, a This facilitates the patient to be involved in
toothbrush might be used to clean the teeth. self-care.

Discard used gauze into the basin. to help for proper disposal and make the patient
comfortable.

Provide a tumbler of water and instruct the Rinsing takes away loosened debris and makes
patient to gargle mouth. the mouth taste and fresher.

Position K- basin properly To prevent the spillage to other areas.

Clean tongue from inner to outer aspect folding to prevent injury and remove the bad taste in the
rag piece in such a way that the tip. mouth

Provide water to rinse your mouth. rinsing removes loosened debris and makes the
mouth taste fresher.

Lubricate lips using a swab stick. to prevent dry lips and lips crack.

Wipe your face with a towel. To make the patient comfortable and promote a
positive body image.

Rinse used articles and replace equipment. To Promote the safe and comfortable
environment to the patient
Using principles of medication administration

Medication administration: the direct application of a prescribed medication—whether by injection,

inhalation, ingestion, or other means—to the body of the individual by an individual legally authorized to
do so.

Rationale

1. Right Drug.
- The first right of drug administration is to check and verify if it’s the right name and form
2. Right Patient.
- Ask the name of the client and check his/her ID band before giving the medication.
3. Right Dose.
- Check the medication sheet and the doctor’s order before medicating.
4. Right Route.
- Check the order if it’s oral, IV, SQ, IM, etc..
5. Right Time and Frequency.
- Check the order for when it would be given and when was the last time it was given.
6. Right Documentation.
- Make sure to write the time and any remarks on the chart correctly.
7. Right History and Assessment.
- Secure a copy of the client’s history to drug interactions and allergies.
8. Drug approach and Right to Refuse.
- Give the client enough autonomy to refuse the medication after thoroughly explaining the
effects.
9. Right Drug-Drug Interaction and Evaluation.
- Review any medications previously given or the diet of the patient that can yield a bad
interaction to the drug to be given
10. Right Education and Information.
- Provide enough knowledge to the patient of what drug he/she would be taking and what are the
expected therapeutic and side effects.
Administration of oral medicine
Oral administration of medication is a convenient, cost-effective, and most commonly used medication
administration route.

Purposes
Oral medications are convenient and are indicated for patients who can ingest and tolerate an oral form
of medications.
Procedure
- Prepare the drug before entering the room.
- Identify the patient to make sure it is the right patient.
- Give the medicine
- And so the water
- If the patient, ask why she/he need to take the medication give the patient an explanation why
he needed it.

Administration Buccal and Sublingual

- Sublingual administration involves placing a drug under the tongue and

- Buccal administration involves placing a drug between the gums and cheek.

Purposes

- Sublingual administration facilitates rapid absorption of the drug into the systemic circulation
- Buccal administration to take effect quickly or when the child is not conscious.

Preparing medicine from a vial

- A vial is a single- or multi-dose plastic container with a rubber seal top, covered by a metal or
plastic cap.
- The vial is a closed system, and air must be injected into the vial to permit the removal of the
solution
- Vials are typically used to store medicines or laboratory samples.
- Vials have overtaken ampoules as the delivery method of choice for many parenteral products
due to a lower risk of breakage and contamination.

Equipments

- Medicine vial, syringe, alcohol pad, sharps container, and filter needle.
Procedure

- Prepare vial containing powder (reconstituting medications).

- Remove cap covering vial of powdered medication and cap covering vial of proper diluent.
- Firmly swab both rubber seals with alcohol swab and allow alcohol to dry.
- Draw up manufacturer suggestion for volume of diluent into syringe
- Insert tip of needle through center of rubber seal of vial of powdered medication. Inject diluent
into vial. Remove needle.
- Mix medication thoroughly. Roll in palms. Do not shake.
- Reconstituted medication in vial is ready to be drawn into new syringe. Read label carefully to
determine dose after reconstitution.
- Draw up reconstituted medication into syringe
- Compare label of medication with MAR, computer screen, or computer printout
- Dispose of soiled supplies. Place used vials and used needle or needleless device in puncture-
and leak-proof container.
- Clean work area and perform hand hygiene.

Preparing medicine from an ampule

Ampules are glass containers in 1 ml to 10 ml sizes that hold a single dose of medication in liquid form.
They are made of glass and have a scored neck to indicate where to break the ampule

Medication is withdrawn using a syringe and a filter needle. A blunt fill needle with filter must be used
when withdrawing medication to prevent glass particles from being drawn up into the syringe. Never use
a filter needle to inject medication.

The way that an ampoule is sealed shut means that the chemical compound inside is protected from
exterior elements like oxygen. Because they cannot be reused, ampoules are usually used to store and
transport single doses of medicines or samples.

Equipments

- Ampule, syringe, alcohol swab, gauze pad, sharps container, and filter needle.

Procedure

- Clean the neck of the ampule with an alcohol swab. Allow it to dry.
- Remove the syringe from its package and attach the filter needle to the syringe, securing
snuggly.
- Tap top of ampule lightly and quickly with finger until fluid moves from its neck.
- Place small gauze pad around neck of ampule
- Snap neck of ampule quickly and firmly away from hands
 - Draw up medication quickly, using filter needle long enough to reach bottom of ampule to access
medication.
- Hold ampule upside down or set it on flat surface. Insert filter needle into center of ampule
opening. Do not allow needle tip or shaft to touch rim of ampule.
- Aspirate medication into syringe by gently pulling back on plunger.
- Keep needle tip under surface of liquid. Tip ampule to bring all fluid within reach of needle.
- If you aspirate air bubbles, do not expel air into ampule.
- To expel excess air bubbles, remove needle from ampule. Hold syringe vertically with needle
pointing up. Tap side of syringe to cause bubbles to rise toward needle. Draw back slightly on
plunger and push plunger upward to eject air. Do not eject fluid.
- If syringe contains excess fluid, use sink for disposal. Hold syringe vertically with needle tip up
and slanted slightly toward sink. Slowly eject excess fluid into sink. Recheck fluid level in syringe
by holding it vertically.
- Cover needle with its safety sheath or cap. Replace filter needle with regular sharps with
engineered sharps injury protection (SESIP) needle.

Mixing Medication

Some medications must be mixed from two vials or from a vial and an ampule. Mixing compatible
medications avoids the need to give a patient more than one injection. Most nursing units have
medication compatibility charts. Compatibility charts are in drug reference guides or are posted within
patient care areas.

When mixing medications, fluid must be correctly aspirated from each type of container. When using
multidose vials, the nurse must not contaminate the vial’s contents with medication from another vial or
ampule.

When mixing medications from a vial and an ampule, the nurse should prepare medications from the vial
first and then withdraw medication from the ampule using the same syringe and a filter needle.

When mixing medications from two vials, the nurse must not contaminate one medication with another
and must ensure that the final dose is accurate. Aseptic technique must be maintained. Single-dose vials
do not contain antimicrobials; therefore, multiple accesses place the patient at risk for infection.
Procedure

1. Remove the cap covering the top of an unused vial to expose the rubber seal.

2. Disinfect vials by cleansing the access diaphragm using friction and a sterile 70% isopropyl
alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab and allow to dry at least 10
seconds.

Rationale: Not all drug manufacturers guarantee that rubber seals of unused vials are sterile;
therefore, the seal must be swabbed with alcohol while applying friction before preparing the
medication. Allowing alcohol to dry prevents it from coating the needle and mixing with the
medication.

3. Using a syringe with an attached needleless access device or filter needle, aspirate a volume of
air equivalent to the first medication dose (which will come from vial A).

4. Inject the air into vial A, making sure that the needle or needleless access device does not touch
the solution (Figure 2A).

Rationale: Air is injected into vial A to create the positive pressure that will be needed to
withdraw the desired dose later.

5. Holding the plunger in place, withdraw the needle or needleless access device and syringe from
vial A.

Rationale: If the plunger is not held in place while the needle or needleless access device is
withdrawn, injected air may escape from vial A.

6. Aspirate a volume of air equivalent to the second medication dose (which will come from vial B)
into the syringe.
7. Insert the needle or needleless access device into vial B. Inject the air into vial B and then draw
up medication from vial B into the syringe (Figure 2B).

Rationale: Air is injected into vial B to create the positive pressure needed to withdraw the
desired dose without aspirating.

8. Withdraw the needle or needleless access device and syringe from vial B, holding the plunger in
place. Ensure that the proper volume of medication has been obtained.

9. Determine what the combined volume of the medications should measure on the syringe scale.

Rationale: Determining the correct combined volume helps prevent accidental withdrawal of too
much medication from vial B.

10. Insert the needle or needleless access device into vial A, being careful not to push the plunger
and expel medication from the syringe into the vial. Invert the vial and carefully draw up the desired
amount of medication from vial A into the syringe (Figure 2C).

Rationale: Positive pressure within vial A allows fluid to fill the syringe without the need to
aspirate.

If too much medication is withdrawn from vial A, discard the syringe and start over. Do not push
medication back into the vial.

11. Withdraw the needle or needleless access device and expel any excess air from the syringe.

12. Check that the fluid level in the syringe reflects the prescribed combined dose. The medications
are now mixed.

13. Label the prepared syringe.

14. Replace the filter needle with a needleless system or with the appropriate-size needle according
to the route of medication.

15. Compare the practitioner’s original order with the prepared medication and labels from vials.

16. Keep the needle of the prepared syringe sheathed or capped until ready to administer the
medication.

17. Check the syringe again carefully for the total combined dose of medications before
administering to the patient.

18. Place used medication containers, all single-dose or empty multidose vials, and the needle or
needleless access device in a puncture-proof and leak proof container.
 Rationale: Correct disposal of medication containers and needles into the appropriate waste
receptacle prevents accidental injury to health care team members.

Follow the organization’s practice for safe disposal of ampules, vials, needles, syringes, and
supplies.

19. Discard supplies, remove PPE, and perform hand hygiene.

20. Document the procedure in the patient’s record.

Administering intradermal medicines

- Intradermal injections (ID) are administered into the dermis just below the epidermis.
- Intradermal (ID) injections have the longest absorption time of all parenteral routes because
there are fewer blood vessels and no muscle tissue. These types of injections are used for
sensitivity testing because the patient’s reaction is easy to visualize, and the degree of reaction
can be assessed.

Examples of intradermal injections include tuberculosis (TB) and allergy testing.

The most common anatomical sites used for intradermal injections are the inner surface of the forearm
and the upper back below the scapula.

- The dosage of an intradermal injection is usually 0.01 to 0.05 mL.

Equipments

- Syringe, Alcohol swabs, gloves, tray, sharps bin, pen, and vial/ampule.

Procedure

- Stretch (taunt) skin at selected site.

- Hold syringe at 5-15 degrees angle, with needle bevel.
- Facing up
- Insert needle just until bevel is no longer visible.
- Inject medication slowly, withdraw needle, DO NOT MASSAGE.
- Encircle site (wheal or bleb) with marking pen (black ink), write name of drug and time of skin
test reaction after 30 minutes (c/o doctor).
- Assess site for reaction at appropriate time.
 - Return to room in 15 to 30 minutes and ask if patient feels any acute pain, burning, numbness,
or tingling at injection site. Inspect site.
- Document medication, dosage, route, time, and signature.

Administering subcutaneous medicines

In this type of injection, a short needle is used to inject a drug into the tissue layer called “subcutis”
below the dermis. Medication given this way is usually absorbed more slowly than if injected into a vein,
sometimes over a period of 24 hours.

Sites for subcutaneous injections include the outer lateral aspect of the upper arm, the abdomen (from
below the costal margin to the iliac crest and more than two inches from the umbilicus), the anterior
upper thighs, the upper back, and the upper ventral gluteal area. These areas have large surface areas
that allow for rotation of subcutaneous injections within the same site when applicable.

Insulin and Heparin are injected through subcutaneous injection.

The volume of solution in a subcutaneous injection should be no more than 1 mL for adults and 0.5 mL
for children. A 45- or 90-degree angle is used for a subcutaneous injection. A 90-degree angle is used for
normal-sized adult patients or obese patients, and a 45-degree angle is used for patients who are thin or
have with less adipose tissue at the injection site.

Procedure

- Place swab between fingers on non-dominant hand.

- Pinch skin between thumb and index finger to elevate
- subcutaneous tissue.
- Use 45 degrees angle (SC)
- Insert needle at appropriate depth.
- Inject medication slowly
- Withdraw needle after introducing the medication.
- Cover the site with sterile cotton and tape to secure.
 - Do not massage the site.
- Discard syringe and needle in “sharps” container.
- Leave patient in a comfortable position.
- Remove gloves and wash your hands.
- Return to room in 15 to 30 minutes and ask if patient feels any acute pain, burning, numbness,
or tingling at injection site. Inspect site.
- Document medication, dosage, route, time, and signature.

Administering intramuscular medicines

- An intramuscular injection is a technique used to deliver a medication deep into the muscles.
This allows the medication to be absorbed into the bloodstream quickly.
- Intramuscular injections are a common practice in modern medicine. They’re used to deliver
drugs and vaccines. Several drugs and almost all injectable vaccines are delivered this way.
- Intramuscular injections are absorbed faster than subcutaneous injections.
- Intramuscular injections are often given in the following areas: ventrogluteal, deltoid, vastus
lateralis.
- 2-5 ml can be given

Procedure

- Place swab between fingers on non-dominant hand.

- Pinch skin between thumb and index finger to elevate
- subcutaneous tissue.
- Use 90-degree angle (IM)
- Insert needle at appropriate depth.
- Inject medication slowly
- Withdraw needle after introducing the medication.
- Cover the site with sterile cotton and tape to secure.
- Do not massage the site.
- Discard syringe and needle in “sharps” container.
- Leave patient in a comfortable position.
- Remove gloves and wash your hands.
- Return to room in 15 to 30 minutes and ask if patient feels any acute pain, burning, numbness,
or tingling at injection site. Inspect site.
 - Document medication, dosage, route, time, and signature

Administering topical medicine

Drugs that are applied to specific areas of the body. In most cases, topical administration means
application to body surfaces such as skin and mucous membranes to treat various types of such as
creams, foams, gels, lotions, and ointments.

The purpose is to apply medication to the skin or mucous membranes allowing it to enter the body from
there. Medication applied in this way is known as a topical medication. It can also be used to treat pain
or other problems in specific parts of the body. Topical medication can also be used to nourish the skin
and protect it from harm.

In this section, we address how to administer topical medication using three distinct delivery methods:
transdermal patches; creams, lotions, or ointments; and powder.

Ointment

- semisolid preparations of medicinal substances in an oily base, such as lanolin or petrolatum.

- can be applied directly to the skin or mucous membrane
- it generally cannot be removed easily with water

Transdermal patch
- also called a transdermal disk
- provides for the controlled release of a prescribed medication through a semipermeable
membrane for several hours to 3 weeks when applied to intact skin.
- e.g., nitroglycerin, clonidine, estrogen, nicotine, scopolamine, fentanyl

Powder
- are finely ground particles of medication that are contained in a talc base.
- They generally produce a cooling, drying, or protective effect where applied
 - The base helps to keep the medicinal substance in prolonged contact with the skin

Administering rectal medicine

Rectal drugs are administered (dosed) through the anus into the rectum (back passage or bottom). Do
not take it orally. Wash hands thoroughly with soap and warm water before and after administering
rectal medicine.

The purpose of it is that Rectal formulations for systemic drug delivery are used clinically for the
treatment of pain, fever, nausea and vomiting, migraines, allergies, and sedation. Rectal absorption
results in more of the drug reaching the systemic circulation with less alteration on route. As well as
being a more effective route for delivering medication, rectal administration also reduces side-effects of
some drugs, such as gastric irritation, nausea, and vomiting.

Rectal medications are contraindicated after rectal or bowel surgery, with rectal bleeding or prolapse,
and with low platelet counts.

Procedure

1. If possible, have the patient defecate prior to rectal medication administration.

2. Ensure that you have water-soluble lubricant available for medication administration.

3. Explain the procedure to the patient. If a patient prefers to self-administer the

suppository/enema, give specific instructions to the patient on correct procedure.

4. Raise the bed to working height:

o Position the patient on left side with the upper leg flexed over the lower leg toward the
waist (Sim’s position).

o Provide privacy and drape the patient with only the buttocks and anal area exposed.

o Place a drape underneath the patient’s buttocks.

5. Apply clean, nonsterile gloves.

6. Assess the patient for diarrhea or active rectal bleeding.

7. Remove the wrapper from the suppository/tip of enema and lubricate the rounded tip of the
suppository and index finger of the dominant hand with lubricant. If administering an enema,
lubricate the tip of the enema.

8. Separate the buttocks with the nondominant hand and, using the gloved index finger of
dominant hand, insert the suppository (rounded tip toward patient) into the rectum toward the
 umbilicus while having the patient take a deep breath, exhale through the mouth, and relax the anal
sphincter. Insert the suppository against the rectal mucosa for optimal absorption, about 3 to 4
inches for an adult and 1 to 2 inches for a child. Do not insert the suppository into feces. If
administering an enema, expel the air from the enema and then insert the tip of the enema into the
rectum toward the umbilicus while having the patient take a deep breath, exhale through the
mouth, and relax the anal sphincter. Roll the plastic bottle from bottom to tip until all solution has
entered the rectum and colon. Remove the bottle.

9. Monitor the patient for signs of dizziness. Unintended vagal stimulation may occur, resulting in
bradycardia in some patients. Be aware that the rectal route may not be suitable for certain cardiac
conditions.

10. When administering a suppository, ask the patient to remain on side for 5 to 10 minutes.

o When administering an enema, ask the patient to retain the enema until the urge to
defecate is strong, usually about 5 to 15 minutes.

11. Discard gloves by turning them inside out before disposing them. Discard used supplies as per
agency policy and perform hand hygiene.

12. Assist the patient to a comfortable position, ask if they have any questions, and thank them for
their time.

13. Ensure safety measures when leaving the room:

o CALL LIGHT: Within reach

o BED: Low and locked (in lowest position and brakes on)

o SIDE RAILS: Secured

o TABLE: Within reach

o ROOM: Risk-free for falls (scan room and clear any obstacles)

14. Perform hand hygiene.

15. Document medication administration and the related assessment findings. Report any
unexpected findings according to agency policy.

Maternal Assessment (Ante, Intra, & postpartum)

POSTPARTUM
postpartum women should have regular assessments of vaginal bleeding, uterine contraction, fundal
height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour
after birth. Blood pressure should be measured shortly after birth.

The Purpose of the postpartum nursing assessment is an important aspect of care to identify early signs
of complications in a woman who has just given birth. Following pregnancy, the woman is at risk for
infection, hemorrhage, and the development of a Deep Vein Thrombosis (DVT).

How do postpartum moms feel?

Nurses can be reminded of key points in postpartum assessment by learning the acronym BUBBLE-LE for
Breast, Uterus, Bladder, Bowel, Episiotomy, Legs, and Emotion. BUBBLE-LE is an acronym for
remembering key points in postpartum care assessment.

Maternal exercises

Most data suggest that maternal exercise during pregnancy positively impacts offspring metabolic
health. Offspring from exercised mothers have improved insulin sensitivity, glucose handling, increased
lean mass, and decreased fat mass compared to offspring from sedentary mothers

It is well established that maternal exercise during pregnancy has many beneficial health outcomes for
mothers, such as improved fitness, a reduction of excessive weight gain, reduced risk for gestational
diabetes, and better postpartum recovery

Best cardio workouts during pregnancy

- Swimming and water aerobics may just be the perfect pregnancy workout. …
- Walking. …
- Running. …
- Ellipticals, stair climbers, treadmills and rowing machines. …
- Group dance or aerobics classes. …
- Indoor cycling. …
- Kickboxing. …
- High-intensity interval training workouts (HIIT)

The procedure you should start an exercise session with a warm-up of about 5 to 10 minutes. Start by
slowly stretching your muscles, and then gradually increase the intensity of your activity. For example,
begin walking slowly and gradually pick up the pace. After you are finished exercising, cool down for
about 5 to 10 minutes.
Prenatal (Assessment & care)
Prenatal Care is a healthcare given to a pregnant woman throughout the pregnancy. Regular check-up
helps identify concerns and decrease risk during pregnancy and
Increase the chance of safe and healthy delivery.
Purpose:
Helps to catch potential concerns early and reduces the risk of pregnancy and birth complications.

Equipments:
Sphygmomanometer
Thermometer
Weighing Scale
Tape Measure
Stethoscope

Procedure:
- Check the vital signs of the mother (BP, Temperature, Pulse Rate, Heart Rate)
- Then, check the height and weight of the mother (Make sure to remove any accessories that can
manipulate the findings.)
- Check for the lower extremities for any signs of edema
- Checking of urine specimen
- Leopold’s maneuver
*(Fundal Height, Fetal Heart Rate)
*(Fetal Presentation, Fetal Back, Degree of Engagement, Fetal Attitude) or
(Fundal grip, Umbilical grip, Pawlick’s grip, Pelvic grip)

Measuring fundic height

A fundal height measurement is typically done to determine if a baby is small for its gestational age. The
measurement is generally defined as the distance in centimeters from the pubic bone to the top of the
uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby
will match the number of weeks of pregnancy — plus or minus 2 centimeters. For example, if you're 27
weeks pregnant, your health care provider would expect your fundal height to be about 27 centimeters.
Measure from the notch of the symphysis pubis to over the top of the uterine fundus as the woman lies
supine. Place the zero line of the tape measure on the anterior border of the symphysis pubis and stretch
tape over the midline of abdomen to top of fundus. The tape should be brought over the curve of the
fundus. The height of the fundus in centimeters equals the number of weeks gestation plus or minus 2.
(inaccurate in the 3rd trimester esp after 32 wks)

Purpose:
To assess the baby’s growth and development.

Equipments:

Tape measure

Procedure:
1. Introduce yourself to the patient.
2. Make sure that the bladder is empty
3. Encourage the patient to lay back on the exam table
4. Then, nurse will extend the tape measure from the top of the SYSMPHYSIS PUBIS (Pubic Bone) to the
UTERUS (Fundus) of the mother.

Additional Info:

Around week 24, this is the time when we see things start to match up.

Example:

24 weeks = 22cm - 24cm

(- 2cm or + 2cm)

This is less accurate in some women, so women who have a higher BMI (higher that 30) or women with
fibroids.

- Big (>26cm)

- Macrosomia (Bigger than normal baby)

- Multiple (Pregnant with more than one baby)

- Polyhydramnios (Excess of amniotic fluid)

-Small (<22cm)

- Inter Uterine Growth Restriction (IUGT), baby is much smaller than it should be. OR chronic disease
(Hypertension or diabetes, smokers etc).

- Oligohydramnios - Lack of amniotic fluid, mother has a much smaller amount than normal.

Leopold’s maneuver

A SYSTEMATIC METHOD OF OBSERVATION & PALPATION TO DETERMINE THE PRESENTATION OR FETAL

LIE, FETAL POSITION, ATTITUDE, & DEGREE OF ENGAGEMENT. THE WOMAN SHOULD BE IN SUPINE
POSITION WITH HER KNEES FLEXED SLIGHTLY SO AS TO RELAX THE ABDOMINAL MUSCLES.
** INSTRUCT THE CLIENT TO VOID
** PUT TOWEL UNDER HHEAD & RIGHT HIP TO PREVENT VENA CAVA SYNDROME
** PALPATE WITH WARM HANDS. COLD HANDS CAUSE ABDOMINAL MUSCLES TO CONTRACT.
** USE GENTLE BUT FIRM MOTIONS.
PROCEDURE:
1.FIRST MANEUVER = ( DETERMINES THE FETAL PRESENTATION)= “ FUNDIC GRIP”

** FACING THE HEAD PART OF THE CLIENT, PALPATE THE SUPERIOR SURFACE OF THE
FUNDUS.DETERMINE CONSISTENCY, SHAPE & MOBILITY. A HARD BALLOTABLE MASS AT THE FUNDUS
MEANS THE FETUS IS IN BREECH PRESENTATION.

2. SECOND MANEUVER = ( DETERMINES THE FETAL BACK)= “UMBILICAL GRIP”

**MOVE BOTH HANDS TO THE SIDES OF THE MOTHER’S ABDOMEN TO DETERMINE WHERE THE FETAL
BACK IS FACING. THE LEFT HAND IS LEFT STATIONARY ON THE LEFT SIDE OF THE UTERUS WHILE THE
RIGHT HAND PALPATES OPPOSITE SIDE OF THE UTERUS FROM TOP TO BOTTOM. DO ON THE OPPOSITE
SIDE.WHERE BACK IS LOCATED, THE FHR IS HEARD LOUDEST.

3.THIRD MANEUVER = ( DETERMINES DEGREE OF ENGAGEMENT)- “ PAWLICK’S GRIP”

> PALPATE TO DISCOVER THE PART OF THE FETUS AT THE INLET & ITS MOBILITY. GRASP THE LOWER
PORTION OF THE ABDOMEN JUST ABOVE THE SYMPHYSIS PUBIS BETWEEN THE THUMB & INDEX
FINGER . DETERMINE ANY MOVEMENT & WHETHER THE PART IS FIRM OR SOFT. IF THE PRESENTING
PART MOVES UPWARD,SO AN EXAMINING FINGERS CAN BE PRESSED TOGETHER, THE PRESENTING PART
IS NOT ENGAGED ( NOT FIRMLY SETTLED INTO THE PELVIS). IF THE PART IS FIRM , IT IS THE HEAD; IF SOFT
THEN IT IS IN BREECH POSITION.
4. FOURTH MANEUVER = ( DETERMINES FETAL ATTITUDE & DEGREE OF FLEXION OR EXTENSION).NOTE:
THIS SHOULD ONLY BE DONE IF THE FETUS IS IN CEPHALIC PRESENTATION. = “PELVIC GRIP”

** FACING THE FEET PART OF THE PATIENT, PLACE FINGERS ON BOTH SIDES OF THE UTERUS
APPROXIMATELY 2 INCHES ABOVE THE INGUINAL CANAL PRESSING DOWNWARD & INWARD IN THE
DIRECTION OF THE BIRTH CANAL. ALLOW FINGERS TO BE CARRIED DOWNWARD. IF THE FINGERS OF
ONE HAND WILL SLIDE ALONG THE UTERINE CONTOUR & MEET NO OBSTRUCTION, IT INDICATES NECK
OF THE FETAL BACK. THE OTHER HAND WILL MEET AN OBSTRUCTION AN INCH OR SO ABOVE THE
LIGAMENT – THIS IS THE FETAL BROW. THE POSITION OF THE FETAL BROW SHOULD CORRESPOND TO
THE SIDE OF THE UTERUS THAT CONTAINED THE ELBOWS & KNEES OF THE FETUS. IF THE FETUS IS IN A
POOR ATTITUDE, THE EXAMINING FINGER WILL MEET AN OBSTRUCTION ON THE SAME SIDE AS THE
FETAL BACK, THAT IS, THE FINGERS WILL TOUCH THE HYPEREXTENDED HEAD.

Auscultating fetal heart heart tones

Auscultating the fetal heart tone is a method of periodically listening to the fetal heartbeat.

- FHR should be 120-160 beats per minute

- Can be heard with a Doppler : 10 – 12th week of pregnancy ( 3 months)
- Fetoscope: 18-20 weeks ( 4 months) Stethoscope: 20 weeks
FHT’s sound like a clock ticking distinctly. Other sounds that may be auscultated include maternal
souffle & fetal souffle

MATERNAL SOUFFLE - LOCATING FETAL HEART SOUNDS BY FETAL POSITION

FHT – heard best at the FETAL BACK ( 5 months)

Computation EOC/AOG
- EDC/EDD (Estimated Date of Confinement or Estimated Delivery)
- The due date or estimated calendar date when a baby will be born.
- AOG (Age of Gestation)
Intrapartal (IE & Partograph)

Partograph is a tool to help in the management of labor

Purpose:

It guides birth attendant to identify women whose labor is delayed and therefore decide appropriate
action

Equipments:
- Partograph Form
- Ballpen
Procedure:
1. Check the condition of the patient.
 2. Fill-out the partograph form, write the relevant information of the patient.

Findings:
1. Hours in active labor
2. Hours since ruptured membranes
3. Rapid assessment
4. Vaginal bleeding (0 + + +)
5. Amniotic fluid (meconium stained)
6. Contractions in 10 minutes
7. Fetal heart rate (beats per minute)
8. Urine voided
9. T (axillary)
10. Pulse (beats per minute)
11. Blood pressure (systolic/diastolic)
12. Cervical Dilation (cm)
13. Delivery of placenta (time)
14. Oxytocin ( time given)
15. Problem (NOTE onset/ describe below)

Unang yakap (4 immediate step)

Unang Yakap is the campaign to spread the use of the Essential Newborn Care protocol. The ENC
protocol can prevent at least half of newborn deaths without additional cost to both families and
hospitals. It is time to rapidly reduce neonatal mortality. On December 7, 2009, the DOH issued an
administrative order to implement the ENC protocol with the goal of rapidly reducing the number of
newborn deaths in the Philippines.

Four actions performed step by step:

1. Immediate drying - Immediate and thoroughly drying the newborn for 30 seconds to 1 minute.
● (this warms the newborn and stimulates breathing)
● Use dry and clean cloth in cleaning the eyes,face, head, front, back, arms and legs.
During the first 30 seconds
*DO NOT ventilate unless the baby is floppy/limp/not breathing
*DO NOT suction unless the mouth/nose are blocked with secretions or other materials.

2. Early skin to skin contact - Early skin to skin contact between the mother and newborn.
● Place the newborn on the abdomen or chest of the mother.
● Cover the newborn’s back with a blanket and head with a bonet.
● Delayed washing for at least 6 hours to prevent hypothermia, infection and hypoglycemia

3. Proper cord clamping and cutting - Clamp and cut the cord after cord pulsation have stopped
for 1 minute to 3 minutes without milking the cord. Cord care helps prevent infection around
your baby's cord stump. Very rarely, these infections can enter the baby's body and cause severe
or even life-threatening disease.

● Clamp the first cord for 2 cm from umbilical base

● Clamp the second cord for 5 cm from umbilical base
● CUT BETWEEN TIES
● Observe for oozing blood

4. Non separation of newborn and mother, and breastfeeding initiation - continuous non
separation of newborn and mother for early breastfeeding protects infants from dying from
infection. The first feed provides colostrum, a substance equivalent to the babies’ first
immunization in its protective properties.

● Observe newborn for feeding cues (opening of mouth, tonguing, licking or rooting) suggest to
mother to move toward the breast
● Within 90 minutes provide support for initiation of breastfeeding
● Counsel the mother of position and attachment

APGAR scoring
- The Apgar score is a test given to newborns soon after birth. This test checks a baby's heart rate,
muscle tone, and other signs to see if extra medical care or emergency care is needed.
- The test is usually given twice: once at 1 minute after birth, and again at 5 minutes after birth.
Sometimes, if there are concerns about the baby's condition, the test may be given again.
- Apgar stands for "Appearance, Pulse, Grimace, Activity, and Respiration."
- In the test, five things are used to check a baby's health. Each is scored on a scale of 0 to 2, with
2 being the best score:
*Appearance (skin color)
*Pulse (heart rate)
*Grimace response (reflexes)
*Activity (muscle tone)
*Respiration (breathing rate and effort)

APGAR SCORE INTERPRETATION

- Normal – a total score of 7 or higher suggests that the condition of baby is good to excellent.
- A score of 6 or less at 1 minute and a score of 7 or more at 5 minutes is also normal.
- A score below 7 in the second test at 5 minutes is considered low.
- If your baby’s score was low in the first Apgar test and hasn’t improved in the second test at 5
minutes, or there are other concerns, the doctors and nurses will closely monitor your baby and
continue any necessary medical care.
- A lower score does not mean that your baby is unhealthy. It means that your baby may need
some immediate medical care, such as suctioning of the airways or oxygen to help him or her
breathe better. Perfectly healthy babies sometimes have a lower-than-usual score, especially in
the first few minutes after birth.
- A slightly low score (especially at 1 minute) is common, especially in babies born:

*after a high-risk pregnancy

*through a C-section

*after a complicated labor and delivery

* prematurely
Anthropometric measurement

Crede’s prophylaxis

- to prevent Ophthalmia Neonatorum or

- Gonorrheal Conjunctivitis (Neisseria gonorrhea) which causes blindness if not treated.
- - Infection can be acquired during delivery from a mother with untreated gonorrhea

Equipment:

- eye ointment
- gauze pad
 - gloves

Procedure:

1. Use gauze pad to dry the baby’s eye, to avoid slippery, one eye at a time

2. Open one eye and apply the ointment from inner to outer canthus

3. Close the eye for 5 seconds, to allow the ointment to spread across the conjunctiva

4. Repeat to the other eye

Ophthalmic drops
- Ointment – inner to outer canthus
- Terramycin
- Gentamycin
- Chloramphenicol
- Erythromycin – drug of choice of Chlamydial Trachomatis
*Chemical Conjunctivitis

Newborn injection (Vit k, hepa B and BCG vaccines)

Vitamin K facilitates production of the clotting factor ( Prothrombin) ; thus, prevents bleeding, should be
given within one hour after birth.
Preterm 0,5 ml; term 1 ml Aquamephyton (generic: phytonadione)

Route: IM into the lateral anterior thigh (Vastus lateralis). In children below 12 months of age who have
not yet learned how to walk, this is the preferred site of injection because the gluteal muscles are not yet
fully developed.

Hepa B
- reduce the risk getting the disease from family who may not know they are infected with hep b
- 1st dose (given within 24hrs of birth)
- 2nd dose (given one to two months after the 1st dose)
- 3rd dose (given between 6-18months old of age)
- injection site: anterolateral thigh

BCG vaccine (Bacillus Calmette-Guerin)

- reduce the risk of getting tuberculosis (TB)
- it can cause TB meningitis in babies if not treated
 - injection site: left upper arm

Equipment:
- Ampule/ vaccine
- 1 cc syringe
- wet/dry alcohol
- tape

Route: IM (intramuscular)

Procedure:

1. withdraw medication/vaccine

- 0.5 ml for preterm

- 1 ml normal

2. clean the injection site w/ wet alcohol

3. aspirate first (to know if there is blood)

4. inject the medication

5. put cotton w/ tape

Postpartum (Assessing hemorrhage,infection, lochial discharge)

B - breast
U - uterus
B - bladder
L - lochia
E - episiotomy

Breast
- colostrum appears within first 12 hrs.
- breast milk appears about 72 hrs.
 - evaluate the size, shape, firmness, redness & symmetry

For Bottle feeding mom:

- teach the mother about breast engorgement (occurs 72 hrs. after birth)
- breast will be tender w/ a feeling of heaviness
- a firm, snug-fitting bra is normal who’s not breastfeeding
- give ice & cabbage leaves to provide relief

For breastfeeding mom:

- nipple should be erect or flat/inverted
- assess the nipples for signs of bruising, crack or chapping. A deep crack or blister may indicate
incorrect placement
- avoid placing cold packs on the breasts

Mastitis infection
- an infection of the breast surrounding the ducts that’s characterized by fullness, pain, warmth and
hardness of the breast
- cause: bacteria grow in the stagnant milk, but milk is not infected only the ducts
- give antibiotics and continue breastfeeding

Uterus
- umbilical level
- should be hard (contracted)
- continue to monitor the uterine
- a boggy fundus may be a sign of uterine atony,
- provide ice pack or soft massage in a circular motion to promote blood movement out of the uterus,
encourage the patient to void

Bladder
- establish a voiding schedule to prevent bladder distension and urinary stasis
- encourage to void every time before she feed the baby

Possible obstacles of voiding

- the mother engrossed with baby that she forgets to void
- internal inflammation from labor trauma may impair ability to void
- hesitation to void from fear of pain
- c section mom may also have issue w/ voiding
- nursing intervention: offer bedpan

Lochia
- assess the color, odor and amount
- should have no odor or no foul odor
- foul odor may be a sign of infection
- normal: 300-500ml blood loss, cs – 500-1000

3 stages of lochia

> Rubra: bright red, may have small clots, usually last 3 days

> Serosa: pink, serous, other tissues

> Alba: tissue whitish

Episiotomy
assess for REEDA

R-redness

E-edema

E-ecchymosis

D-discharge

A- approximation

- look for cut if lateral or transverse

- check for swelling or bleeding
- perineal hygiene (douche)
- continue to monitor

Vital Signs

- temp. of 38 degrees Celsius is considered normal, if above 38 check the ff. for possible infection:

> lacerations

> sutures

> breasts
 > lochia (foul odor may indicate infections

> urine

- pulse elevation may be first sign of hemorrhage

- Decrease pulse rate as low as 50 is considered normal during post partal week.
- Decrease BP and or narrowed pulse pressure are signs of shock.
- Orthostatic hypertension is common during the early post partal period. The patient should rise
slowly from lying or sitting to prevent blackouts or falls.

Frequency of vital signs

- 1st hour (every 15 mins)

- 2nd hour (every 30 mins)
- 3rd/4th hour (once)

Assess BP every hour if patient has pre-eclampsia

Herbal medicines
- plants that are used to treat diseases
- RA 8423 ‘’Traditional and Alternative Medicine Act of 1997”
- 10 herbal plants approved by DOH

1. SAMBONG (blumea balsamifera)

- use for: anti edema, diuretic, anti-urolithiasis

2. AKAPULKO (cassia alata)

- use for: anti-fungal, ringworm, athlete’s foot and scabies

3. NIYUG-NIYUGAN (Quisqualis indica L.)

- use for: anti helminthic

4. TSAANG GUBAT (Camona retusa)

- use for: diarrhea & stomachache

5. AMPALAYA (Momordica charantia)

- use to lower blood sugar levels, diabetes mellitus

6. LAGUNDI (vitex negundo)

- use for: asthma, cough, fever, dysentery, colds, pains, skin diseases, wounds, headaches, rheumatism,
sprain, contusions, insect bites, & aromatic bath for sick patients

7. ULMASING BATO (peperomia pellucida)

- use to lower uric acid (rheumatism & gout)

8. GARLIC (allium sativum)

- use for: hypertension, toothache, lowers cholesterol

9. BAYABAS (Psidium guajava)

- use for: washing wounds, toothache, diarrhea

10. YERBA BUENA (mentha cordifelia)

- use for: headache, stomachache, rheumatism, arthritis, cough, cold, swollen gums, toothache,
menstrual & gas pain, nausea, fainting, insect bites & pruritus

Bag technique
- A tool making use of a public health bag through which the nurse, during his/her home visit, can
perform nursing procedures with ease and deftness, saving time and effort with the end in view of
rendering effective nursing care

- to carry out nursing procedure at home

- to perform minor dressing
- to conduct delivery in emergency situations
- check v/s, do cord care for a newborn
- to do collection and transportation of sample
- to treat minor ailments

Principles:
- cleanliness
- handwashing
- protecting and taking care of bag
- keep the instruments after sterilization
- protect the bag away from children, animals and others
- avoid cross infection from the place
- keep the bag always upper surface area

Compartments of bag

- Outer, front, inner, lower compartment

Contents and Arrangement of the Bag:

> Front of Bag, Left to Right

· Thermometer in case
· Tape measure
· Adhesive plaster
· Cotton Applicator

>On Right Rear of Bag

· 2 Test tubes and holder
· Medicine Dropper
· Alcohol Lamp

> On Left Rear of Bag

· Medicine Glass
· Baby Scale
· Bandage scissors
· Rubber suction
> Back of Bag, Left to Right
· 70% Alcohol
· Betadine solution
· Hydrogen Peroxide
· Ophthalmic Ointment
· Zephiran Solution
· Spirit of Ammonia
· acetic Acid
· Benedict’s Solution
· Liquid Soap
· Cotton in Sterile Water

> In the Center of the Bag

· 2 pairs of forceps (curved and straight)
· 1 surgical scissors
· Sterile Dressing (OS & cotton balls)
· Roller Bandage
· Syringe (5 ml, 2 ml)
· Hypodermic needle (g 19,22,23,25)
· Sterile cord clamp
· Kidney basin

> On the top pile, center of bag

· Hand towel in plastic bag
· Soap in soap dish
· Apron
· Plastic/ linen lining
· Pocket of Bag
· Surgical Gloves
· Wastepaper Receptacle
· Note: Folded paper lining inserted between the flaps and cover of the bag.
· *** BP apparatus and stethoscope are carried separately.

Points to consider
1. The bag should contain all the necessary articles, supplies and equipment that will be
used to answer the emergency needs
2. The bag and its contents should be cleaned very often, the supplies replaced and ready
for use anytime.
3. The bag and its contents should be well protected from contact with any article in the
patient’s home.
4. Consider the bag and its contents clean and sterile, while articles that belong to the
patients as dirty and contaminated.
 5. The arrangement of the contents of the bag should be the one most convenient to the
user, to facilitate efficiency and avoid confusion.

Action Rationale

Upon arrival at the patient’s home, place the bag To protect the bag from getting contaminated.
on the table lined with a clean paper. The clean
side must be out and the folder part, touching
the table

Ask for a basing of water or a glass of drinking To be used for hand washing.
water if tap waster is not available.

Open the bag and take out the towel and soap. To prepare for hand washing.

Wash hands using soap and water, wipe to dry. To prevent infection from the care provider to the
client.

Take out the apron from the bag and put it on To protect the nurse’s uniform.
with the right side

Put out all the necessary articles needed for the To have them readily accessible
specific care.

Close the bag and put it in one corner of the To prevent contamination
working area.

Proceed in performing the necessary nursing care To give comfort and security and hasten recovery
treatment.

After giving the treatment, clean all things that To protect the caregiver and prevent infection
were used and perform hand washing.
 Open the bag and return all things that were used in their proper places after cleaning them.

Remove apron, folding it away from the person, Remove apron, folding it away from the person,
the soiled side in and the clean side out. the soiled side in and the clean side out. Place it
in the bag.

Fold the lining, place it inside the bag and close

the bag

Take the record and have a talk with the mother. Write down all the necessary data that were
gathered, observations, nursing care and treatment rendered. Give instructions for care of patients in
the absence of the nurse.

Make appointment for the next visit (either home For follow-up care
or clinic) taking note of the date and time.

After care
· Before keeping all articles in the bag, clean, and alcoholize them.
· Get the bag from the table, fold the paper lining (and insert) , and place in between the flaps and
cover the bag.

Documentation
· Record all relevant findings about the client and members of the family
· Take note of environmental factors, which affect the clients/ family health
· Include quality of nurse-patient relationship
· Assess effectiveness of nursing care provided.