CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

LOCAL COMPLICATIONS

COURSE OUTLINE: (TERM) Infiltration

1. Medical Terminologies
2. IV Therapy Complications
3. Common Hospital Policies & IV Cannulation
4. Nursing Care for a Child with a Respiratory Syndrome
5. Early Essential Newborn Care
Definition: fluid escapes to subcutaneous tissue
Assessment: Swelling, pale, cool to touch, no blood
backflash

Intervention: Discontinue IV, Warm compress (needs

order), restart in new site
MEDICAL TERMINOLOGIES Prevention: discourage movement of limb with IV

KVO HD BUN Phlebitis

Keep Vein Hemodialysis Blood, Urea,
Open Nitrogen Definition: inflammation of veins
ROD PTA CKD Thrombus
Resident on Prior to Chronic Kidney
Duty Admission Disease Definition: blood clot, IV stops due to obstruction
H R SH Assessment: red line, burning pain along course of vein,
Hold Refuse Shift heat, swelling
DC DD DI
Intervention: discontinue IV, warm compress (needs
Discontinue Dose Dose Increase order), do not massage/rub, notify MD, restart in new site
Decrease
NGS NGV KUB Prevention: discourage movement, flush, rotate sites
every 72-96hrs
Not given due Not given due Kidney, ureter,
to sleeping to sleeping bladder Thrombophlebitis
TPR DAMA HDT
Temperature, Discharge Hepato Billary Definition: combination of inflammation of veins and blood
clot.
Pulse, against Tract
Respiration patient advice Extravasation
LD HVT AC(antecebum)
Last dose Hepatic Vein Before meals Definition:
Thrombosis
PC(postcebum NPO DX
) Nothing per Diagnosis SYSTEMIC IV COMPLICATIONS
After meals orem
HX BMI ABD Fluid Overload
history Body mass Abdomen
Definition: rate is faster than ordered; patient cannot
index tolerate rate of infusion
DNR GCS HS
Do not Glasgow Hours of sleep Assess: for hypovolemia: increased P BP R, lung base
crackles, dyspnea, distended neck veins
resuscitate coma scale
PRN OTC SC/SQ Intervention: notify MD experiencing respiratory
Pro re nata (as Over-the- Subcutaneous complications
needed) counter Prevention: Monitor rate regularly, use time tape and
QAM QPM IM volume control device.
Every morning Ever night Intramuscular
Incorrect IV solution
IV I/O SX
intravenous Intake and symptoms Definition: incorrect IV is infused
output
Intervention: check order to maintain patency,
immediately hang correct IV, notify MD, record and
complete incident report

IV THERAPY COMPLICATIONS

1|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
Prevention: verify solution against MD order 3 times  If injected directly (should be diluted to a
before hanging IV solution
saline solution) may cause cardiac arrest
IV rate is too slow 5. Vitamin B-complex
 For immune system and metabolism
Definition: volume absorbed is decreased than volume
ordered. B1- Thiamin
Inspect factors: kink, lying on tubing, dependent loops, IV B2 – Riboflavin
bag too low, arm position that decreases flow rate. B3 – Niacin
Intervention: set at ordered rate, ensure bag is 3ft above B5 – Pantothenic Acid
IV site, coil tubing on bed surface, remove tubing from B7 – Biotin
under patient, reposition arm B9 – Folic Acid
Prevention: monitor rate routinely, use time tape, B12 - Cobalamin
discourage movement of limn with IV

Air Embolus/ Embolism

6. Sodium bicarbonate
Definition: Air in intravascular compartment  Used to treat low sodium
 Such as metabolic acidosis
Assess: respiratory distress, increased pulse, cyanosis,
decreased BP, decreased loss of consciousness (LOC) 7. Metoclopramide
 To treat vomiting and hiccup
Intervention: secure system to prevent entry of air, place pt
on left side in Trendelenburg position, notify MD 8. Magnesium sulfate
immediately.  For preeclampsia
Prevention:
9. EPAL(epinephrine, amlodipine, lidocaine)
 Epinephrine for Anaphylaxis
Hematoma  Amlodipine & lidocaine for anti-arrythmias
Definition:
10. Furosemide
 diuretics
Sepsis

Definition:
IV CANNULATION
Intervention:
IV Cannulation
Prevention
 2nd most common invasive procedure
Allergic Reactions
Indications
Definition:
1. Administration of anesthesia
COMMON HOSPITAL POLICIES
2. Administration of medicines
3. Administration of fluids
4. Administration of blood or blood products
EMERGENCY CART

1. Norepinephrine, dopamine, dobutamine, Contraindications

verapamine 1. Sites close to side of infection
 To increase blood pressure 2. Side of mastectomy
2. Nicardipine 3. Where AV fistula is located
 To lower blood pressure 4. Veins of fractured limbs
3. Paracetamol
 Analgesic for pain Vein of selection
 Antipyretic for fever 1. Dorsal
4. Potassium chloride 2. Forearm
 To treat potassium deficiency 3. Antecubital fossa

2|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
Location of veins  Bacterial form of croup
 Inflammation of the epiglottis, which may
1. Cephalic  thumb along forearm
be caused by Haemophilus influenza type b
2. Basilic  pinky
or streptococcus pneumonia
3. Dorsal venous network  near wrist
 children immunized with H.influenzae type
4. Dorsal metacarpal  in between fingers
b( HIB vaccine ) are at least risk for
5. Digital dorsalis vein  fingers
epiglottis.
SIZES AND COLORS  occurs most frequently in children 2-8 years
old, but can occur from infancy to
SIZE COLOR INDICATION adulthood
26G Violet Neonate
24G Yellow Neonate and children • onset is abrupt, ad the condition
22G Blue Children & older adult occurs most often in winter
20G Pink Formal IV & blood
transfusion • considered an emergency situation
18G Green Trauma, quick BT because it can progress rapidly to
16G Gray Trauma or surgical severe respiratory distress.
procedure
14G orange Trauma or surgical
procedure

GRADING OF PULSES

GRADE DESCRIPTION
0 Not palpable
+1 Thready and weak
+2 May be obliterated
+3 Normal
+4 Strong bounding

APGAR SCORING
LARYNOTRACHEOBRONCHITIS
O 1 3
ACTIVITY No Some Active
moveme moveme movement
nt nt
PULSE No pulse <100bpm >100bpm
GRIMACE No grimace Sneezing
response and
coughing
APPEARAN Blue all Blue on No blue
CE over extremiti discolorati
es only on
RESPIRATI absent Irregular, Good
ON weak strong cry
crying

NURSING CARE FOR CHILD WHO HAS

RESPIRATORY SYNDROME I. Inflammation of the larynx, trachea, and
bronchi
EPIGLOTTITIS

3|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
 Most common type of croup; may be
viral or bacterial and most frequently
occurs in the children younger than 5
years.
 Common causative organisms include
parainfluenza virus types 2 and 3,
respiratory syncytial virus (RSV),
Mycoplasma pneumoniae, and
influenza A and B.
 Characterized by the gradual onset that
may be preceded by an upper
respiratory infection .

BRONCHITIS

 Inflammation of the trachea and

bronchi; maybe referred to as
tracheobronchitis

 usually occurs in association with an

upper respiratory infection

 Is usually a mils disorder; causative

agent is most often viral.

PNEUMONIA

 Inflammation of the pulmonary parenchyma

or alveoli or both, cause by a virus
mycoplasma agents, bacteria or aspirations
of foreign substances.

EMPHYSEMA VS CHRONIC BRONCHITIS

LUNG SOUNDS

ASTHMA

4|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
GLASGOW COMA SCALE DIFFERENT ACTIVE LABORING POSITIONS

Side-Lying

 Redistributed pressure on the cervix

 Relaxing
 Helps prevent tears to vagina or perineum

Supported Squat

 Uses gravity to help the baby’s descent and

widens the pelvic outlet, providing more
room for the baby

Birth Pool

 May relieve pressure on the lower back

Asymmetrical Kneeling

 Uses gravity to help the baby’s descent and

widens the pelvic outlet, providing more
room for the baby

Kneeling

 May relieve pressure on the back and help

the baby rotate to a favorable position

Sitting

 Uses gravity to help the baby’s descent

Hand and Knees

 May relieve pressure on the back and help

EARLY ESSENTIAL NEWBORN CARE
the baby rotate to a favorable position
Intrapartum Period
Semi-Sitting
 extends from the onset of contractions that
 Most comfortable position
cause cervical dilatation to the first 1 to 4
 Easier for birth attendant to guide the birth
hours after the birth of the neonate and the
of baby’s head.
placenta.
 Refers to the medical and nursing care given SECOND STAGE: EXPULSION OF BABY
to the pregnant woman during labor &
delivery  from full cervical dilatation to birth of the
newborn.
STAGES OF LABOR
 Duration of 30 minutes to 3 hours for
STAGE I - Cervical Dilatation primigravidas
STAGE II – Expulsion of the baby  5 to 30 minutes for multigravidas
STAGE III – Placental stage  begins with full dilation and ends with
STAGE IV - Postpartum assessment delivery of the placenta.

STAGE ONE: CERVICAL DILATION Crowning

5|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
 fetal head is encircled by the external
opening of the vagina (introitus) and means
Engagement (normally the head) has
birth is imminent.
passed the pelvic inlet and
 Some women feel acute, increasingly severe
entered the pelvic cavity
pain and a burning sensation as the
perineum distends. the station of the presenting
 The woman may continue to fear that she part is zero or lower
will tear apart. The nurse needs to instruct
the woman to “push through the pain and takes place before onset of
burning.” labor in nulliparous women

Positional Changes of the Fetus some nulliparas, it does not

occur until after labor
cardinal movements or mechanisms of labor,
begins.
 the fetal head and body must adjust to the Descent (1) pressure of the amniotic
maternal pelvis by certain positional fluid,
changes. (2) direct pressure of the
 (Mnemonics – ED FIRE ERE): fundus of the uterus on the
breech of the fetus,
 E – ngagement (3) contraction of the
 D – escent abdominal muscles, and
(4) extension and
 F – lexion straightening of the fetal
 I – nternal Rotation body.
 E – xtension
head enters the inlet in the
 E – xternal Rotation occiput transverse or oblique
 E – expulsion position
 Flexion fetal head pushes against the
cervix, pelvic floor, or pelvic
wall

head flexes against the chest

to place the smallest
diameter for passage
through the pelvis.
Internal Rotation The fetal occiput rotates
laterally and anterior while
moving in a twisting motion
past the ischial spines
through the pelvis.
Extension resistance of the pelvic floor
and the mechanical
movement of the vulva
opening anteriorly and
forward assist with extension
of the fetal head as it passes
under the symphysis pubis.

head is “born” positional

change the occiput, then
brow and face, emerge from

6|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
the vagina.
Restitution After the head exits the
vagina it rotates into
alignment with the fetal
body and makes a 1/4 turn
External Rotation As the shoulder exits under
the maternal symphysis
pubis, the head is turned
farther to one side (external
rotation) and exits the
vagina.
Expulsion With the head and shoulders
out of the vagina, the
remaining newborn body
flexes toward the maternal
symphysis pubis and is born.
ascertained that the fundus is firm, gentle
traction may be applied to the cord while
pressure is exerted on the fundus.
 The weight of the placenta as it is guided
into the placental pan (a basin that holds
the placenta once it is expelled) aids in the
removal of the membranes from the uterine
wall.
 A placenta is considered, to be retained if
more than 30 minutes have elapsed from
completion of the second stage of labor.
If the placenta separates from the inside to the
outer margins:

THIRD STAGE: PLACENTA DELIVERY

period of time from the birth of the infant until the

completed delivery of the placenta.

Placental Separation

 uterus contracts firmly, diminishing its

capacity and the surface area of placental
attachment
 placenta begins to separate to uterine wall
because of this decrease in surface area
 This separation is accompanied by
bleeding, leading to the formation of a
hematoma between the placental tissue
and the remaining decidua
 Signs of placental separation usually appear
around 5 minutes after birth of the infant
but can take up to 30 minutes to manifest.
Schultze mechanism of placental delivery or, more
commonly, shiny Schultze.
 fetal (shiny) side presenting
the Duncan mechanism of placental delivery and is
commonly called dirty Duncan because the
 placental surface is rough
 present sideways with the maternal surface
delivering first

Signs: 2 arteries and 1 vein (AVA)

(1) a globular-shaped uterus,

(2) a rise of the fundus in the abdomen,

(3) a sudden gush or trickle of blood, and

(4) further protrusion or lengthening of the

umbilical cord out of the vagina.

Placental Delivery
 When the signs of placental separation
appear, the woman may bear down to aid in
placental expulsion. If this fails and the
certified nurse-midwife or physician has

7|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

FOURTH STAGE: POSTPARTUM ASSESSMENT the Essential Intrapartum Newborn Care

 time from 1 to 4 hours after birth in which
physiologic readjustment of the mother’s
body begins.
 hemodynamic changes occur
 Blood loss at birth ranges from 250 to 500
ml.
 This results in a moderate drop in
both systolic and diastolic blood
pressure, increased pulse pressure,
and moderate tachycardia
 The uterus remains contracted and is in the
midline of the abdomen. The fundus is
usually midway between the symphysis
pubis and umbilicus
(EINC) in the Philippines.
 The second edition of “First Embrace”
produced 2013 and 2014. The new name is
Early Essential Newborn Care.
Essential Intrapartum Newborn Care (EINC)
 series of time-bound and evidence-
based interventions for newborn babies
and their mothers that ensure the best
care for them.

 The bladder is often hypotonic due to

trauma during the second stage and/or the
administration of anesthetics that may
decrease sensations. Hypotonic bladder
leads to urinary retention.

ESSENTIAL NEWBORN CARE

Developed by: Newborn Care Technical Working

Group (TWG)

 An evidence-based draft was then

developed and reviewed by the Department
of Health (DOH), United Nations Children’s
Fund (UNICEF), United Nations Population
Fund (UNFPA), the Philippine Obstetrical
and Gynecological Society (POGS), other
health professional
organizations/associations, Save the
Children, the academe and other
stakeholders.
Administrative Order 2009-0025 last Dec. 1, 2009
 institutionalizes policies and guidelines for
government and private health facilities to
adopt the essential newborn care protocol.
Unang Yakap campaign
 launched Dec 9, 2009.
 a campaign of the Philippines’ Department
of Health (DOH), in cooperation with the
World Health Organization (WHO), to adopt
EARLY ESSENTIAL AND NEWBORN CARE
Definition: A nursing skills in providing care to
mother during the second stage of delivery to the of
the fetus and the placenta and to ensure the early
essential care to newborn.
Purposes:
1. To prevent or minimize vaginal
laceration.
2. To deliver the newborn safely.
3. To deliver the placenta timely.
4. Immediate and thorough drying
5. Early skin-to-skin contact
6. Properly-timed cord clamping
7. Non-separation of the newborn from
the mother for early breastfeeding
STEPS RATIONALE
Ensured that mother is Ask the mother what is

8|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
on her position of her preffered active Placed the baby on a To clean the baby
choice when in labor. labor position. clean, dry cloth/towel
Asked mother if she Less advisable because on the mother’s
wishes to eat/drink. it can increase the abdomen.
excretion of urine or Thoroughly dried baby
feces during delivery for at least 30 seconds,
Communicated with Inform woman about starting from the face
the mother- informed her labor and teach and head, going down
her of progress of techniques about to the trunk and
labor, gave delivery or relaxation. extremities.
reassurance and Removed wet cloth.
encouragement Placed baby on skin-to-
Checked temperature Test air draft using a skin contact on the
in DR area, checked for tissue, drop, and if the mother’s abdomen or
air draft. tissue landed quickly chest.
on the ground, air draft Covered the baby with To prevent
is not present a clean, dry hypothermia and keep
Asked patient if patient Semi-upright is always cloth/towel. the baby’s
is comfortable in the the default delivery temperature
semi-upright position position Covered baby’s head To prevent
which is the default with a bonnet. hypothermia
position. Excluded a 2nd baby by Assess for 2nd baby.
Removed all jewelry. palpating abdomen.
Washed hands To prevent spread of Used the wet cloth to Oxytocin aids in
thoroughly observing microorganism wipe the soiled gloves. contractions to epulse
the proper procedure. Gave IM oxytocin the placenta or
Arranged things in a To save time and effort within one minute of remaining baby
linear fashion: baby’s birth. Disposed
of the wet cloth
Gloves, dry linen, properly.
bonnet, oxytocin Removed the 1st set of
injection, plastic clamp, gloves.
instrument clamp, Decontaminated these
scissors, 2 kidney properly (by soaking in
basins 0.5% chlorine solution
Cleaned the perineum To prevent infection for at least 10 minutes)
with antiseptic Palpated umbilical cord Avoid milking the cord
solution. to check for pulsations.
Washed hands. After pulsations
Put on 2 pairs of sterile stopped, clamped cord
gloves aseptically. (if using the plastic cord
same worker handles clamp at 2 cm from
perineum and cord). base.
Encouraged woman to Teach the woman how Placed the instrument
push as desired. to push on delivery clamp 5 cm from the
Applied perineal base.
support and did Cut near plastic clamp
controlled delivery of (not midway).
the head. Performed the Important step is to
Called out time of birth remaining steps of massage the uterus
and sex of baby. the Active
Informed the mother Management of Third
of outcome. Stage of Labor:

9|Sachi Bernate
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
Waited for strong positioning and
uterine contractions attachment.
then applied Waited for FULL Wait for atleast 20-30
controlled cord BREASTFEED to be minutes
traction and counter completed.
traction on the After a complete Eye ointment-
uterus, continuing breastfeed, erythromycin, this
until placenta was administered eye avoids conjunctivitis
delivered. ointment (first), did
Massaged the uterus thorough physical Vitk(left leg)
until it is firm. examination, gave Vit. hepaB(right leg)
Inspected the lower K, hepatitis B and BCG(deltoid)
vagina and perineum BCG (simultaneously
for lacerations/tears explained purpose of
and repaired each intervention).
lacerations/tears if Advised 6 hours after birth
necessary. OPTIONAL/DELAYED advise to avoid
Examined the placenta Placental cord should bathing of baby (and bathing, after 6 to 24
for completeness and have AVA was able to explain the hours is the
abnormalities. rationale). recommended time to
Cleaned the mother: Perineal care is bathe the baby
flushed perineum and important Advised breastfeeding
applied perineal per demand and about
pad/napkin/cloth Danger Signs for early
Checked baby’s color Cyanosis – bluish referral
and breathing; checked discoloration In the first hour: 15 minutes for 1st hour
that mother was checked baby’s
comfortable, uterus breathing and color;
contracted. and checked mother’s
Disposed of the vital signs and
placenta in a leak- massaged uterus every
proof container or 15 minutes.
plastic bag. In the second hour: 2nd hour check for
Decontaminated checked mother-baby every 30 minutes to 1
(soaked in 0.5% dyad every 30 minutes hour
chlorine solution) to 1 hour.
instruments before Completed all
cleaning; RECORDS:
decontaminated 2nd administered eye
pair of gloves before ointment, vitamin K,
disposal. hepatitis B and BCG.
Advised mother to
maintain skin-to-skin
RITGEN MANEUVER
contact. Baby should
be prone on mother’s Objective:
chest/in between the  Demonstrate the ability to correctly
breasts with head perform the Ritgen Maneuver
turned to one side.
Advised mother to Look out for early,
observe for feeding middle, or late feeding Ritgen Maneuver
cues (cited examples) cues Preparation
Supported mother,
instructed her on

10 | S a c h i B e r n a t e
 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
1. Assess:
The latest FHR.
The crowning of the head.
2. Assemble equipment and supplies:
Sterile gauze 4X4s or clean cloth
Procedure
1. Explain to the client what you are going to
do, why it is necessary, and how she can
cooperate.
2. Control the birth of the baby’s head by doing
the following:
a. Cover the perineum up to anus
with a gauze or cloth
b. Apply counter pressure against
the tissue directly behind the
anus in order to prevent
laceration
c. Attempt to aid in the proper
flexion of the baby’s head with
counter pressure as the mother
pushes.
d. Apply upward pressure on the
baby’s face/chin at the
appropriate time.
e. Place your other hand against
the bay’s crowning head to
further control flexion
f. Aid in the extension of head and
help prevent a rapid expulsion.
other hand.
3. Recognize the “separation gush” of blood
and/or cord lengthening
4. Provide gentle traction on the cord during
the next contraction.
5. As the placenta emerges, watch for trailing
membranes, and manage appropriately,
while guiding the placenta into the kidney
basin.
6. Note the time of the delivery of the placenta
7. Assess the placenta and check the
membranes and note the placental delivery
(Scultze or Duncan Mechanism)
8. Assess if the membranes and blood vessels in
the cord are complete.
9. Do the following:
a. Palpate the uterus for firmness,
massaging if necessary
b. Eliminate the blood loss
c. Ensure that the bleeding is in normal
limits
d. Continue to assess the uterine
firmness
10. Document the findings.

DELIVERY OF THE PLACENTA

Objective:
 Demonstrate the ability to facilitate the
delivery of the placenta.

Delivery of the Placenta

Preparation

1. Assess:
The if there is still fetus inside the uterus.
2. Assemble equipment and supplies:
Kidney basin
Procedure
1. Explain to the mother that she will continue
to have contractions after the birth of the
baby and instruct her to push when she feels
a contraction
2. “Guard” the uterus with one hand. Use a
hemostat to hold the umbilical cord with the

11 | S a c h i B e r n a t e