NCM 213 Care of Mother, Child and Adolescent – RLE

ASEPSIS
 Medical - any practice that helps reduce the number and spread of microorganism
- The practice used to remove or destroy pathogens and to prevent their spread from
one person or place to another person or place; clean technique.
 Surgical – the complete removal of microorganisms and their spores from the surface of an
object
- Surgical asepsis or sterile technique
 All microorganisms and spores are destroyed before they can enter the
body
 Used when administering parenteral medications and performing surgical
and other procedures such as urinary catherization
 Often, clean technique (medical asepsis) is performed using sterile supplies
 Sterile to clean, dirty, or contaminated becomes contaminated.

Medical Asepsis Surgical Asepsis

Definition Clean Technique Sterile Technique
Emphasis Freedom from most Freedom from all pathogenic
pathogenic organisms organisms
Purpose Reduce transmission of Prevent introduction of any
pathogenic organisms from organism into an open
one patient-to-another wound or sterile body cavity

HANDWASHING (WHO Technique)

1. Wet hands with water
2. Apply enough soap to cover all surface
3. Rub hands palm to palm
4. Right palm over left dorsum with interlaced fingers and vice versa
5. Palm to palm with finger interlaced
6. Back of fingers to opposing palms with finger interlocked
7. Rotational rubbing of left thumb clasped in right palm and vice versa
8. Rotational rubbing, backwards and forward with clasped fingers of right hand in left palm and
vice versa
9. Rinse hands with water
10. Dry hands thoroughly with a single use towel
11. Your hands are safe.
12. Use towel to turn off faucet.

PRINCPLES AND PRACTICES OF ASEPSIS

Objectives
 Describes the principles and practice of asepsis
 Understand hand hygiene
 Understand the role of the environment in disease transmission

MEDICAL ASEPSIS

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Measures aimed to controlling the number of microorganisms and/or preventing or reducing the
transmissions of microbes from one person-to-another
 Know what is dirty
 Know what is clean
 Know what is sterile
 Keep the first three conditions separated
 Remedy contamination immediately

PRINCIPLES OF MEDICAL ASEPSIS

 When the body is penetrated, natural barriers such as skin and mucous membranes are
bypassed, making the patient susceptible to microbes that might enter.
 Perform hand hygiene and put on gloves
 When invading sterile areas of the body, maintain the sterility of the body system
 When placing an item into a sterile area of the body, make sure the item is sterile
 Even though skin is an effective barrier against microbial invasion, a patient can become
colonized with other microbes if precautions are not taken
 Perform hand hygiene between patient contacts
 When handling items that only touch patient’s intact skin or do not ordinarily touch the
patient, make sure item is clean and disinfected (between patients).
 All body fluids from any patient should be considered contaminated
 Body fluids can be the source of infection for the patient
 Utilize appropriate personal protective equipment (PPE)
 When performing patient care, work from cleanest to dirtiest patient area.
 The healthcare team and the environment can be a source of contamination for the patient
 Health care providers (HCP) should be free from disease
 Single use items can be a source of contamination
 Patients environment should be as clean as possible

SURGICAL ASEPSIS
Practices designed to render and maintain objects and areas maximally free from microorganisms:
 Know what is sterile
 Know what is not sterile
 Keep sterile and not sterile items apart
 Remedy contamination immediately

PRINCIPLES OF SURGICAL ASEPSIS

 The patient should not be the source of contamination
 The operating room (OR) team should not be the source of contamination
 The surgical scrub should be done meticulously
 The OR technique of the surgeon is very important
 Recognize potential environmental contamination

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REMEDY CONTAMINATION
 Every case is considered dirty and the same infection control
precautions are taken for all patients
 When contamination occurs, address it immediately
 Breaks in technique are pointed out and action is taken to
eliminate them.

HAND HYGIENE
 Hand washing
 Antiseptic hand wash
 Alcohol-based hand rub
 Surgical antisepsis

IMPORTANCE
 Hands are the most common mode of pathogen
 Reduce the spread of antimicrobial resistance
 Prevents healthcare-associated infections

HAND-BORNE MICROORGANISMS
Healthcare providers contaminate their hands with 100-1000 colony-forming units (CFU) of
bacteria during “clean” activities (lifting patients, taking vital signs)

TRANSMISSION OF PATHOGENS ON HANDS (Five Elements)

 Germs are present on patients and surfaces near patients
 By direct and indirect contact, patient germs contaminate healthcare provider’s hands
 Germs survive and multiply on healthcare provider hands
 Defective hand hygiene results in hands remaining contaminated
 Healthcare providers touch/contaminate another patient or surface that will have contact
with the patient.

REASON FOR NONCOMPLIANCE

 inaccessible hand hygiene supplies
 Skin irritation
 Too busy
 Glove use
 Didn’t think about it
 Lack of knowledge

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WHEN TO PERFORM HAND HYGIENE

The 5 Moments Consensus Recommendations
CDC Guidelines on Hand Hygiene in healthcare, 2002
1. Before touching - Before and after touching the patient
a patient
2. Before - Before donning sterile gloves for central venous
clean/aseptic catheter insertion; also for insertion of other
procedure invasive devices that do not require a surgical
procedure using sterile gloves
- If moving from a contaminated body site to
another body site during care of the same patient
3. After body fluid - After contact with body fluids or excretions,
exposure risk mucous membrane, non-intact skin or wound
dressing
- If moving from a contaminated body site to
another body site during care of the same patient
- After removing gloves
4. After touching a - Before and after touching the patient
patient - After removing gloves
5. After touching - After contact inanimate surfaces and objects
patient (including medical equipment) in the immediate
surroundings vicinity of the patient
- After removing gloves

HAND RUBBING HANDWASHING

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SUMMARY OF HAND HYGIENE

 Hand hygiene must be performed exactly where you are delivering healthcare to patients (at the
point-of-care)
 During healthcare delivery, there are 5 moments (indications when it is essential that you
perform hand hygiene
 To clean your hands, you should prefer hand rubbing with an alcohol-based formulation, if
available. Why? Because it makes hand hygiene possible right at the point-of-care, it is faster,
more effective and better tolerated.
 You should wash your hand with soap and water when visibly soiled
 You must perform hand hygiene using the appropriate technique and time duration.

DEFINITIONS
Spaulding classification of surfaces:
1. Critical – objects which enter normally sterile tissue or the vascular system and require
sterilization
2. Semi-Critical – object that contact mucous membranes or non-intact skin and require high-level
disinfection
3. Non-Critical – objects that contact intact skin but not mucous membranes, and require low or
intermediate-level disinfection

DISINFECTION LEVELS
 High – inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not necessarily high
number of bacterial spores
 Intermediate – destroys vegetative bacteria, most fungi, and most viruses; inactivates
mycobacterium tuberculosis
 Low – destroys must vegetative bacteria, some fungi and some viruses. Does not inactivate
mycobacterium tuberculosis.

CATEGORIES OF ENVIRONMENTAL SURFACES

CLINICAL CONTACT SURFACES
 Exam tables, counter tops, BP cuffs, thermometers
 Frequent contact with healthcare providers’ hands
 More likely contaminated
HOUSEKEEPING SURFACES
 Floors, walls, windows, side rails, over-bed table
 No direct contact with patients or devices
 Risk of disease transmission

SURVIVAL OF PATHOGEN ON SURFACES

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PATHOGEN SURVIVAL
MRSA 7 days – 7 months
VRE 5 days – 4 months
Acinetbacter 3 days – 5 months
C. difficile (spores) 5 months
Norovirus 12 – 28 days
HIV Minutes to hours
HBV 7 days
HCV 16 hours – 4 days

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SELECT, MIX AND USE DISINFECTANTS CORRECTLY

 Right product
 Right dilution
 Right preparation – not before low level disinfection
 Right application method
 Right contact time
 Wear appropriate PPE (gloves, gown, mask, eye protection)

LIQUID DISINFECTANTS
Disinfectant Agent Use Concentration
Ethyl or isopropyl alcohol 70% - 90%
Chlorine (bleach) 100 ppm
Phenolic UD
Iodophor UD
Quaternary ammonium UD
compound (QUAT)
Improved/Accelerated UD
hydrogen peroxide
UD = manufacturer’s recommended use dilution

CLEANING RECOMMENDATIONS
Clean and disinfect surfaces using correct technique
 Clean to dirty
 Prevent contamination of solutions (Don’t use dried out wipes)
 Physical removal of soil (elbow grease)
 Contact time
 Correct type of cleansing materials

OTHER ENVIRONMENTAL ISSUES

BLOOD AND BODY FLUID SPILLS
 Promptly clean and decontaminate
 Use appropriate PPE
 Clean spills with dilute bleach solution (1:10 or 1:100) or an EPA-registered hospital disinfectant
with a TB or HIV/HBV kill claim.

MEDICATION ADMINISTRATION
- Medication is a substance administered for the diagnosis, cure, treatment or relief of a symptom
or for prevention of disease
- The term drug also has the connotation of an illicitly obtained substances such as heroin, cocaine
or ampthamines.

PHARMACOLOGICAL CONCEPTS
 Prescription – written direction for the preparation and administration of the drug
 Kinds of Names:
1. Generic name – used throughout drug’s lifetime
2. Trade Name/Brand Name – given by the drug manufacturer as identifier of a property of
that company. The name selected is usually short and easy to remember.
3. Official Name – name under which the drug is listed as one of the official publication
4. Chemical Name – name at which the chemist knows it. This name describes the
constituency of the drug.
 Pharmacology – study of the effects of drugs in a living organism
 Pharmacy – the art of preparing, compounding and dispensing drugs. It also refers to the place
where the drugs are prepared and dispensed.
 Pharmacist – the one who prepares, makes, dispenses drugs as ordered by the physician.
 Clinical Pharmacist – the ones who often guides the physician in prescribing drugs
 Pharmacy Technician – member of the health team who in states administers drug

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 Pharmacopoeia – a book containing a list of products used in medicine with description of the
products, chemical test for determining identity, purity, formula and prescription.

TYPES OF DURG PREPARATION

 Aerosol Spray – a liquid/powder/foam deposited in a thin layer on the skin by air pressure
 Caplet – a solid form shaped like capsule, coated and easily swallowed
 Capsule – a gelatinous container that holds drug in powder, liquid or oil form
 Cream – a non-greasy, semi-solid preparation used in the skin
 Elixir – sweetened and aromatic solution of alcohol, used as a vehicle for medicinal agents
 Extract – concentrated form of drug made from vegetables or animals
 Gel or Jelly – clear or translucent, semi-solid that liquefies when applied to the skin
 Liniment – a medication mixed with alcohol, oil or soapy emollient applied to the skin
 Lotion – a medication in a liquid suspension that is applied to the skin
 Lozenges – a flat, round or oval preparation that dissolves and releases a drug when melted in the
mouth
 Ointment – a semi-solid preparation of one or more drugs used for application in the skin an
mucous membrane
 Paste – a preparation like an ointment but thicker and stiff that penetrates the skin less than an
ointment
 Pill – one or more drugs mixed in a cohesive material in an oval, round, or flattened shapes
 Powder – a finely ground drug that are sometimes used internally and externally
 Suppository – composed of one or several drugs mixed with a firm base such as gelatin and shape
for insertion inside the body. The base dissolves gradually in body temperature.
 Syrup – aqua solution of sugar, often used to disguise unpleasant tasting drugs
 Tablet – powder drug compressed in a hard small disk. Some are readily broken along scored line,
others are entirely coated to prevent them from dissolving in the stomach
 Tincture – an alcoholic or water solution prepared from drugs derived from plants
 Transdermal Patch – a semipermeable membrane shape in a form of a disk or patch that contains
a drug to be absorbed through the skin over a long period of time

EFFETCS OF DRUGS
 Therapeutic Effect (Desired Effect) – the expected or predicted psychological response that a
medication causes.
 Prednisone – a steroid which decreases swelling, inhibits inflammation, reduces allergic
response and prevents rejection of transplanted organs.
 Side Effects (Adverse Effects) – predictable and often unavoidable secondary effect produced at a
usual therapeutic dose. Either harmless or can cause injury. Unintended, undesirable and often
predictable severe responses to medication. Some are immediate whereas other takes weeks or
months to develop.
 Toxic Effects – this develops after prolonged intake of medication which accumulates in the blood
because of impaired metabolism or excretion. Excess amount of medication within the body,
sometimes has lethal effects depending on its action.
 Toxic levels of morphine causes severe respiratory depression and death. Antidotes are
available to treat specific types of medication toxicity
 Allergic Reaction – allergy is an unpredictable reaction to medications. Medication allergy varies
depending on the individual and the medication.
 Antibiotic causes high incident of allergic reactions. Anaphylactic reaction are life
threatening characterized by solid constriction of bronchiole muscles, edema of the
pharynx, larynx and severe wheezing and shortness of breath. Immediate medical
attention is required to treat anaphylactic reaction. A patient with known history of allergy
to a medication needs to avoid exposure to the medication in the future. Where an
identification bracelet to alert nurse and physician about the allergy.
 Medication Interaction – common among individual taking several medications. Some medication
increase or diminish the action of other and may alter the way another medication absorbed,
metabolized or eliminated into the body.

PHARMACOKINETICS AS THE BASIS OF MEDICATION ACTION

 Study of how medication enter the body to reach their site of action to metabolize and exit the
body

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 For medication to be therapeutic, one must be taken into the body, be absorbed and distributed
the cells and tissues or specific organs.
 ABSORPTION - The passage of medication molecules into the blood from the site of medication
administration
1. Route of Administration - each route has different rate of absorption.
Example: the oral route, it usually slowly because it passes through the gastrointestinal tract
2. Ability of the medication to dissolve - it depends largely on the form or preparation of the
medication. Solutions and suspensions in a liquid state absorb easily than tablets and
capsules.
3. Blood flow to the site of administration - medications are absorbed as blood comes in
contact with the site of administration. The richer the blood supply to the site of
administration the faster the medication is absorbed.
4. Body surface area - when medication comes in contact with al large surface area, it is absorb
at a faster way
5. Lipid solubility of medication - because the cell membrane has a lipid layer, highly lipids
soluble medication cross cell membrane easily and are absorb quickly
 DISTRIBUTION - After a medication has been absorb, it is distributed with a body tissues and
organs and ultimately to its specific site of actions.
1. Circulation - when medication enters the blood stream and carries through the tissues or
organ
2. Membrane permeability - ability of the medication to pass through tissues and membranes
to enter target cells
3. Protein binding- degree to which medication attach to proteins with the blood. A drugs
efficiency may be affected by the degree to which it binds.
 METABOLISM - after the medication reaches its site of action, it becomes metabolized into less
active or inactive form that is easier to excrete.
 EXCRETION - after the medication are metabolized, they exit the body through the kidneys, liver,
bowel, lungs and exocrine glands.

FACTORS AFFECTING MEDICATION ACTION

1. Sex - the distribution of body fats, fluid and hormonal differences among males and females
2. Diet – nutrients can affect the action of a medication. vitamin K found in green leaf vegetable can
counter at the effect of an anti-coagulant such as warfarin and Coumadin
3. Developmental factors – during infancy, the usually requires small dosage because of their body
size and immaturity of their organs specially the liver and kidney. In adolescence or adulthood,
allergic reactions may occur to drugs formerly tolerated in older adults they have different
responses to medications due to physiological changes that accompany aging. Changing includes
decrease liver and kidney functions. In addition, during pregnancy, women must be very careful
about taking medications.
4. Cultural, ethnic, and genetic factors – genetic variations such as genders, size and body
composition or pharmacokinetics are factors that may affect the medication actions. Metabolism
and variations and enzymes are genetically determine and as a result may afflict a drug response.
5. Environment – environmental temperature may affect child activity. When high temperature the
peripheral blood vessels dilate this intensifies the actions of vasodilators. In cold environment and
the consequence vasoconstrictors inhibits action of vasodilators but enhance the action of
vasoconstrictors. A client have taken a analectic in a noisy environment may not benefit as fully
as if the environment were quiet and peaceful
6. Psychological factors – a client’s expectations about what a drug can do affect the response to
the medication. example: a client who believes that nicotine is infective as analgesic may
experience no relief after it has been given
7. Illness and Disease – aspirin can reduce the body temperature of feverish client but has no effect
on the body temperature of a client without fever
8. Time and administration – some orally administered medications are absorbed more quickly if
the stomach is empty whereas other medications have a more rapid absorption in administered
with food.

ROUTES OF MEDICAL ADMINISTRATION

- Routes is a way or course taken in getting from the starting point to a destination.

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1. Oral – it is the most common least expensive, most convenient route for most clients. The drug is
being swallowed.
Major Disadvantages
 The medication may have unpleasant taste
 It may cause irritation of the gastric mucousa
 It has irregular absorption of tract gastrointestinal tract
 It may have slow absorption
 Some cases it may harm the client’s teeth
2. Sublingual – the drug is placed under the tongue where the medication is dissolved. The
medication should not be swallowed.
3. Buccal – the Buccal retrains the cheek, a medication is held in the mouth against the mucous
membrane of the cheek until the drug is dissolve
4. Parenteral – through the alimentary or respiratory tract that is by needle.
Common route: subcutaneous or hypothermate, this is into the subcutaneous tissue just below
the skin. Intramuscular into the muscles, intradermal under the epidermis, intravenous is in the
veins.
Less commonly used routes: intra-arterial into the artery, the intra-cardiac into the heart
muscles, intraosseous into the bones, intraspinal into the spinal canal, intra-pleaural into the
pleural space, epidural is into the epidural space, and intra-articular are into the joints.
5. Topical – those applied to a circumscribed surface area of the body. They affect only the area to
which they are applied, it includes dermatologic preparations which are applied to the skin,
insulation and allegations are applied in the body cavities or artifices such as the eyes, ears, nose,
rectum or vagina. Inhalations are administrated into the respiratory tract by inhale nebulizer of
positive pressure breathing apparatus. Air oxygen and vaper are generally used to carry the drug
into the lungs.

MEDICATION ORDERS
Safety Tips
- Encourage the prescribing care provider to provide the correct spelling of a drug
- Pronounce numbers separately to avoid confusion
1. Stat Order
- This medication should be given immediately as soon as possible and with sense of urgency.
Example : Morphine sulfate 10 mg IV stat
2. Single Order – one time order. The medication to be given once at a specified time. Example:
seconal 10mg at bedtime before surgery
3. Standard Order – may or may not have extermination date. It may be carried out indefinitely until
order is taken to cancel it or may be carried out for a specified number of days. In some agencies,
standing order are automatically after specified number of days and must be re-ordered. Example:
Multiple vitams daily, KCL twice daily x2 days
4. PRN Order – medicines that are taken as needed are known as PRN medicine. PRN is a Latin term
that stands for ‘pro re nata’ which means as the thing is needed. This permits the nurse to give a
medication when the nurse’s judgment the client’s requires it.

ESSENTIAL PARTS OF THE MEDICATION ORDER

1. Date and Time the order is written
- This eliminates errors with the nursing shifts changed and makes clear when certain order
automatically orders
2. Full name of the client
- The client’s full name includes the first and last names and middle initial or names. This is
to avoid confusion between two clients who have the same last name.
3. Name of the drug administered
- The name of the drug must be clearly written in some setting only generic names are being
permitted
4. Dosage and Drug
5. Frequency of administration
- Includes the amount, time, frequency of administration the shred. The metric system is
strongly suggested for safety reasons.
6. Route of administration

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- Frequently abbreviated. This is not usual for a drug to have a several possible route of
administration. Therefore it is important that the route being included in the order.
7. Signature of the person writing the order
- A signature of the ordering primary care provider or nurse makes the drug order a legal
request. An unsigned order has no validity.

THE TEN RIGHTS OF ADMINISTRATION

1. Right medication - The medication to be given to the patient should be the medicine ordered by
the physician. Always check the medication label with physician's order and remember never
administer medication prepared by another person and never administer medications without
label.
2. Right dose - The dose should be appropriate for a client. Double check calculations and know the
usual dosage range of a medication. Question a dose outside the usual dosage range. Remember
to measure liquids with a calibrated tool.
3. Right time - give the medication at the right frequency and at the time order according to agency
policy. Medications given within 30 minutes before or after the schedules time are considered to
meet the right time standard.
4. Right route – The medication should be given by the ordered route. Make certain that the route is
safe and appropriate to the client
5. Right client - the medication should be given to the intended client. Check client’s identification
band with each administration of a medication or ask the patient to verbalize his or her name and
also his birthday. Know the agency’s name alert procedure when the client with the same or similar
are on the nursing unit.
6. Right client education - the nurse should have to explain information about the medication to the
client.
7. Right documentation - remember never document before the medication is administered.
8. Right to refuse - the client has the right to refuse any medication, the nurses role is to ensure that
the client and his family is fully informed of the potential consequences of refusal and to
communicate the client’s refusal to the health care provider
9. Right assessments - some medication requires specific assessments prior to administration.
Medication orders may include specific parameters for administration such as taking vital signs
before or prior the administration of medication.
10. Right evaluation - the nurse should have to conduct a proper follow up after administering the
medication to the patient.

POINTS TO REMEMBER WHEN ADMINISTERING MEDICATION

1. Nurses who administer the medication are responsible for their own actions.
- You have to question any order that legible which you consider incorrect or either call the
person who prescribed the medication for clarification.
2. Be knowledgeable of the medications you administer
- you need to know why the client is receiving the medication, look up for necessary
information if not familiar with mediation
3. federal laws govern the use of narcotics and barbiturates
- this type of medication should be kept in a lock place to ensure the safety of all users
4. Do not use liquid medications that are loudly r have changed color
- Consider the medication are already expired. Dispose properly
5. Calculate drug doses accurately
- if uncertain, ask the other nurse to double check calculation
6. administer medications that are personally prepared
- Do not ask somebody to prepare the medications for you.
7. Identify client correctly before administering the medication
- using the appropriate of identification such as checking the identification band or asking the
name and the birth date of the patient
8. Do not leave the medications at the bedside
- Medications might not be taken by the patient accurately and correctly.
9. Report if the client vomits after taking an oral medication
- report for documentation purpose
10. Take special precautions when administering certain medications
11. Report any medication error made
12. Always check the medications expiration date

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TOPICAL ADMINISTRATION
Basic Concept: A topical medication is applied locally to the skin or mucous membrane. Topical skin or
dermatologic preparations include ointments, pastes, creams, lotions, powders, sprays and patches.
Purpose
1. Diaper rash, wounds, burns, dermatitis, and other skin conditions.
2. Used to decrease pruritus or to treat local or fungal infections.
Assessment
1. The need for topical administration
2. The part is clean
3. Redness, rashes, swelling and discharges or abnormalities on the administration site
4. Client’s level of consciousness
5. Any history of allergy
6. Availability of medications
Planning
1. Aware the patient
2. Organize supplies and equipment
 Medicine Tray
 Warm water or other specified solutions
 Clean Towel
 Sterile gauze squares or cotton balls
 Gloves
 Medication Card
3. Observe correct time
4. Recall guiding principles
5. Obtain appropriate medication

PREPARING AND ADMINISTERING PARARENTERAL MEDICATIONS

Basic concept: Parenteral administration is the administration of injection into the body tissues. These
medications are absorbed more quickly than oral medications and are irretrievable once injected. The
nurse must prepare and administer them carefully and accurately.

PARENTERAL MEDICATIONS ARE GIVEN THROUGH THE FOLLOWING ROUTES:

1. INTRAMUSCULAR INJECTIONS- Injections into the muscle tissue. They are absorbed more quickly than
subcutaneous injections because there is a greater blood supply to the body muscles
2. SUBCUTANEOUS INJECTIONS- Injections given just beneath the skin. Only small doses of medication
are usually injected via this route.
3. INTRADERMAL INJECTIONS- Is the administration of a drug into the dermal layer of the skin just
beneath the epidermis.
PURPOSE:
1. INTRAMUSCULAR INJECTIONS To provide a medication the client requires.
2. SUBCUTANEOUS INJECTIONS To allow slower absorption of a medication compared with either the
intramuscular or intravenous route
3. INTRADERMAL INJECTIONS To provide a medication that the client requires for allergy testing and TB
Screening
ASSESS FOR:
1. Client’ s allergies to medications
2. Specific drug action, side effects and adverse reaction. Client’ s knowledge of and learning needs
about the medication

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3. Tissue integrity of the selected site; check agency protocol about sites to use for skin tests.
4. Client’ s age and weight to determine site and needle size
5. Client’ s ability or willingness to cooperate
PREPARATION
1. Aware the patient
2. Assemble all supplies and equipment in a basic hypo tray
a. client’s medication card
b. required medication in a vial or ampule
c. sterile syringe and needle
d. cotton balls with alcohol in a container
e. dry cotton balls in a container
f. gauze for opening the ampule
g. picking forceps
h. metal file if necessary
3. Observe correct time
4. Recall guiding principles
5. Obtain appropriate medication

PREPARING AND ADMINISTERING ORAL MEDICATIONS

Basic Concept: Oral Administration is the easiest and most desirable way to administer medications by
mouth.

Purpose: To provide a medication that has a systemic or local effects on the gastrointestinal tract or
both.

Assess for:
1. Allergies to medications Assess for:
2. Client’s ability to swallow the medication Assess for:
3. Presence of vomiting or diarrhea that would interfere with the ability to absorb the medication
Assess for:
4. Specific drug action, side effects, interactions and side effects. Assess for:
5. Client’s knowledge of and learning needs about the medication. Assess for:
6. Prepare appropriate assessments specific to the medication. Assess for:
7. Determine if the assessment date influences the administration of the medication.
Planning:
1. Aware the patient Planning:
2. Organize supplies and equipment
 Medicine Tray
 Medicine Cup or Glass Tissue
 Paper Mortar and
 Pestle Medication Dropper/ Syringe
 Glass of Water and Straw
 Medication Card
3. Observe correct time Planning:
4. Recall guiding principles Planning:
5. Obtain appropriate medication

LEOPOLD MANEUVER
Abdominal Palpation for Fetal Position

Purpose

- Determine the position of the baby in utero

- Determine the expected presentation during labor and delivery

The fetal lie is either:

• Longitudinal
- Long axis of the fetus is aligned to the mother’s
- This is the only NORMAL position
• Transverse
- Long axis of the fetus is perpendicular to that of the mother’s

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• Oblique
- Long axis of the fetus is 0-90 degrees (or 90-180 degrees) to that of the

mother’s FETAL LIE

THE PRESENTATION IS EITHER:

1. Vertex- head down in the pelvis
2. Brow
3. Facial
4. Breech - head is up in the uterine fundus and the buttocks is down in the pelvis 5. Shoulder

ATTITUDE
The attitude is the relationship of the fetal parts to each other:

Flexed

Deflexed

Extended

DENOMINATOR - The denominator (center identifying letter) is

the fetal part presenting itself

Occiput - O

Sacrum - S

Mentum – M

Frontal - F

Acromion - AC or Scapula - SC

PRESENTATION ATTITUDE DENOMINATOR

Vertex Flexed Occiput
Brow Deflexed (vertex) Frontal
Facial Extended (vertex) Mentum
Breech Sacrum
Shoulder Acromion/ Scapula
Flexed Vertex Presentation 8 Possibilities

1. LOL 5. ROP
2. ROL 6. LOP
3. LOA 7. OP
4. ROA 8. OA
1. Full/Complete Breech
- arms & legs flexed in the
- fetal position
2. Incomplete Breech

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3. Frank Breech - arms flexed but legs extended straight up over head
4. Footling Breech - one or both feet extended downward and may exit the
birth canal first
ENGAGEMENT
- Determined by the amount of head that is above or below the pelvic brim
- This is usually done by dividing the head into ”fifths”
- If the head is still palpable abdominally, it is “2/5” or less engaged

LEOPOLD’S MANEUVER
- Four-part process
- Palpation of fetal position in-utero
Purposes
- To provide information about fetal presentation, position,
presenting part i.e. lie, attitude, and descent
- To aid in location of fetal heart rates
- To aid in assessment of fetal size
- To determination of single versus multiple gestation
Preparation
- Woman is supine, head slightly elevated and knees
slightly flexed
- Place a small rolled towel under her right hip
- If the nurse is Right handed, stand at the woman’s R side
facing her for the first 3 steps, then turn and face her feet
for the last step (L handed, left side).

1. First Maneuver (Fundal Grip)

• Facing the mother, palpate the fundus with both hands
- Assess for shape, size, consistency and mobility
• Fetal head: firm, hard, and round
- Moves independently of the rest
- Detectable by ballottement
• Breech/buttocks: softer and has
bony prominences
- Moves with the rest of the form

2. Second Maneuver (Umbilical Grip) Determine position

of the back.
• Still facing the mother, place both palms on the
abdomen
• Hold R hand still and with deep but gentle
Pressure, use L hand to feel for the firm, smooth back

• Repeat using opposite hands

• Confirm your findings by palpating the fetal extremities on the opposite side
• Small protrusions, “lumpy”

3. Third Maneuver (Pawlick’s Grip)

Determine what part is lying above the inlet

• Gently grasp the lower portion of the abdomen (just above symphysis pubis) with the thumb
and fingers of the R hand
• Confirm presenting part
- (opposite of what’s in the fundus)

• Head will feel firm

• Buttocks will feel softer and irregular
• If it’s not engaged, it may be gently pushed back and forth

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Proceed to the 4th step if it’s not engaged…

Fourth Maneuver (Pelvic Grip)

1. Locate brow.
2. Assess descent of the presenting part.
• Turn to face the woman’s feet
• Move fingers of both hands gently down the sides of the abdomen towards the pubis - Palpate
for the cephalic prominence (vertex)
• Prominence on the same side as the small parts suggests that the head is flexed (optimum)
• Prominence on the same side as the back suggests that the head is extended

Policies for EINC care

• 3.4 million pregnancies occur every year
• 11 mothers die of pregnancy - related causes everyday Leading cause of maternal deaths:
PPH

HPN d/o

Abortion related complications

Obstructed labor

• 40, 000 newborns die each year from causes that are most preventable such as complications
of: Prematurity (41%)
Birth asphyxia (15%)

Severe infection (16%)

NATIONAL POLICIES FOR MATERNAL AND NEWBORN CARE

• The Philippine government, along with the international community, has made legislative
efforts to ensure that care of a certain standard is accessible to all mothers and babies.
• The state specifically recognizes the vulnerability of mother and child and demands that
measures be enacted to ensure access to care for all mothers and children that is the most
current and of the highest standard such that in providing care, the dignity of every mother and
child is respected and maintained, and when receiving care, all women and children, regardless
of social or economic status, are treated equally.
• The Department of Health has issued directives to ensure the highest quality of care for
mothers and their newborns. DOH policies describe methods for providing standard maternal
and newborn care to the general population and demand that monitoring and evaluation
systems be put in place for these strategies.
• Similarly, the Philippine Health Insurance Corporation (Philhealth), insists on the importance of
safety and quality care that is patient-centered in its hospital accreditation process.

DOH POLICIES

A. Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities with Maternity and
Newborn Care
Services
• Administrative Order No. 2007-0026
• Main objective is to transform all health institutions with maternity and newborn services into
facilities that fully PROTECT, PROMOTE AND SUPPORT rooming – in, breastfeeding and mother-
baby friendly practices.

B. Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality
• Administrative Order No. 2008-0029 Issued on September 9, 2008.

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• End GOAL is to rapidly reduce maternal and neonatal death.

• 3 major pillars in reducing MMM:
Emergency obstetric care

Skilled birth attendants

Family planning

C. Adopting New Policies and Protocol on Essential Newborn Care

• Administrative Order
No. 2009-0025
Issued on December
7, 2009
• Outlines specific
policies & principles
to follow for all
health care
providers involved in
newborn health
care.

4 steps to save newborn lives:

1. Immediate and thorough drying of the newborn
2. Early skin-to-skin contact b/n mother & newborn
3. Properly timed cord clamping and cutting
4. Non-separation of newborn and mother for early breastfeeding.

D. The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos
• Administrative Order No. 2010-0036
• Millennium Development Goal – 8 international development goals that all 193 United Nation
Member have agreed to achieve by the year 2015.
• Millennium Development 4 & 5
• MDG 4 – to reduce child mortality by 2/3 between 1990 and 2015 the under-five mortality rate
MDG 5 - Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality
ratio.
• Target 5B: Achieve, by 2015, universal access to reproductive health

WORLD HEALTH ORGANIZATION (WHO) GUIDELINES

A. Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care
•
Section 4: Hospital Self-Appraisal and Monitoring, January 2006 Launched by WHO and
UNICEF in 1991.
• Promotes practices that PROTECT, PROMOTE and SUPPORT breastfeeding.
B. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice
• Integrated Management of Pregnancy and Childbirth, 2006
• Aims to provide evidence-based recommendations to guide health care professionals in giving
high-quality care during pregnancy, delivery and in the postpartun period, thereby making
pregnancy and childbirth SAFER.
C. WHO Recommendations for the Prevention of Postpartum Hemorrhage, 2006
1. Active management of the 3rd stage of labor should be offered by skilled attendants;
2. Use of oxytocin for prevention of PPH;
3. Cord should not be clamped earlier than is necessary
4. Delivery of placenta by controlled traction.

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D. Newborn Care until the First Week of Life Clinical Practice Pocket Guide, 2009
• This pocket guide is intended to provide health professionals with a simple, to-the-point, user-
friendly, globally accepted evidence-based protocol to essential newborn care focusing on the
first week of life which can fit in one’s pocket.

PHILHEALTH CIRCULARS AND BENCHBOOK GUIDELINES

A. Philhealth Bench book
B. New Philhealth Case Rates for Selected Medical Cases and Surgical Procedures and the No Balance
Billing Policy
Philhealth Circular No. 011-2011

ESSENTIAL INTRAPARTUM NEWBORN CARE

Neonatal period
- is the first 28 days (4 weeks) of life

A. Early neonatal period: 1st week of life

B. Late neonatal period: 7th day-28 days of life

Infant deaths occur in the neonatal period (birth-28days of life)

Essential newborn care

Objective: to assist the newborn in adaptation to the extra uterine environment

This involves the following:

1. Cardio- respiratory function: initiation of respiration and oxygenation of blood

2. Body temperature maintenance
3. Feeding establishment
4. Infection prevention
5. Early detection and management of: congenital disorders, other disorders, infections
1. Clearing the airway
Comprises of: 2. APGAR score
1. Immediate care 3. Care of the cord
2. Neonatal examinations 4. Care of the eyes
3. Identifying ‘high-risk’ infants 5. Care of the skin
6. Body temperature maintenance
Immediate care- at birth 7. Breast feeding initiation and
establishment
Preparing for birth

Make sure that the following materials/conditions are available for the newborn

1. Two clean and warm towels for thermal protection of the body
a) One for drying and wrapping the baby initially
b) The other for covering the newborn to prevent heat loss
2. A draught free delivery room with a temperature of at least 25C
3. Soap and water, clean gloves, cotton, gauze and a clean labor table for delivery to ensure the six “cleans” a) Clean
hands
b) Clean surface
c) Clean cord cut
d) Clean cord tie
e) Clean cord stump and
f) Clean perineum
4. A clean delivery kit for cord care
5. Self-inflating bags (two of a size appropriate for a newborn) and masks (sizes zero and one) for resuscitation

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6. A suction device (mucus extractor)

7. A radiant heater
8. A blanket
9. A clock/watch to note the time of delivery

Cleaning the airway

Establishment and maintenance of breathing is the most important immediately after birth, everything else is
secondary.

• The airways should be cleared of mucus and other secretions

positioning the baby with his head low may help in drainage of secretions

gentle sunction to remove mucus and amniotic fluid also helps

• If natural breathing fails to establish within a minute of birth. Resuscitation is necessary Suction
Assisted respirations (intubation, application of oxygen mask)

• All labor wards should be equipped with resuscitation equipment including oxygen
• If there is no gasping or breathing at all even after 20 minutes of effective ventilation (and cardiac massage, if
required) stop ventilation

Care of the cord

• If normal neonate: cut and tie the cord when it stops pulsating
The advantage is that the baby derives about 10ml of extra blood, if the cord is cut after pulsation
ceases Using properly sterilized instruments and cord ties

• Do not apply anything on the stump; keep the cord clean and dry.
• Inspect the cord for bleeding 2 hours after ligation
• Inspect for discharge or infection till healing occurs
• The cord should be kept as dry as possible
• It dries and shrivels up and separates by aseptic necrosis in 5-10 days

Maintaining the body temperature

• The normal body temperature of a newborn is between 36.5 to 37.5C
• Hypothermia is a body temperature of <36C
• A newborn baby is projected out of warm womb of the mother into an environment which may be 10 to 20C
• A newborn has little thermal control and cal lose body heat quickly
• Immediately after birth, most of the heat loss occurs through evaporation of the amniotic fluid from the body of
the wet child
• As much as 75% of the heat loss can occur from the hed
• Hypothermia results in
Increase oxygen consumption;hence hypoxaemia

Increase glucose consumption; hence hypoglycaemia and metabolic acidosis

• Hypoxaemia and hypoglycemia can result in the death of the newborn

Among survivors, it can lead to permanent impairment of the brain resulting in developmental handicaps
Received the baby in a dry, warm, clean towel

• Dry the baby well

• Discard the wet towel immediately and
• Wrap/cover the baby (except for the face and upper chest) in a fresh, warm, clean and dry towel
• The baby should be kept wrapped during the assessment and sunction ventilation applied (if required) Place the
baby near a source of warmth
A normal baby, who is crying well after birth, can be placed in skin-to-skin contact with mother’s abdomen and
covered with a dry cloth.

Additional heat can be provided by placing the baby under a source of heat such as
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- A lamp with a 200 watt bulb

- Under a radiant warmer
• Practices such as separating the baby from the mother for the first 12-24 hours of life are harmful
• Pre term and low birth babies lose hear more easily through their skin as they have less subcutaneous fat for
insulation
• Ensure that during and after the delivery, no fans are running in the delivery room, and no windows are open
through which are currents blow into the room/

Care of the skin

• Clean the blood, mucus and meconium on the newborn’s body before presenting it to the mother
• Bathing the newborn soon after birth is not recommended as it causes a drop in the body temperature
Discourage the mother from giving bath to the baby during the first day after birth

The mother or the attendant can clean the baby by wiping with a soft moist cloth

When the baby is given a bath, bathing should be done

- Quickly
- In a warm room
- Using warm water
• Low birth weight infants should not be given a bath
Blood, meconium and some of the vernix will have been wiped off during drying at birth

The remaining vernix does not need to be removed as it is harmless

If cultural tradition demands bathing, this should not be carried out before 6hours after birth, and preferably on
the second or third day of life as long as the baby is healthy and its temperature normal

Care of the eyes

• The eyes should be cleaned
At birth and

Once every day

• Using sterile cotton swabs soaked in

Sterile water or

Normal saline

• From inner to the outer side

• Each eye should be cleaned using a separate swab
• The routine use of local antiseptic drops for prophylaxis is not recommended
The earlier practice of instilling a drop of freshly prepared silver nitrate solution (1%) to prevent gonococcal
conjunctivitis is no longer recommended

Breastfeeding
• Breast feeding should be initiated within one hour of birth
• If suckling is poor, ensure correct positioning and attachment of the baby to the breast
• Although there is little milk at this time, it helps to establish
Feeding

A close mother child relationship known as ‘bonding’

• The first milk is called colostrum and is the most suitable food for the baby during this early period because it
contains a high concentration of
Protein and other nutrient the body needs

Anti-infective factors which protect the baby against respiratory infections and diarrheal diseases

• Supplementary feeds are not necessary, not even water

• The regular milk comes on the third to sixth day after birth
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• The baby should be allowed to breast feed whenever it wants

This is k/a “feeding on demand”
Feeding the baby on demand helps the baby to gain weight

• It is very important to advise mother to avoid feeding bottles

APGAR SCORE
• Taken at 1 minute and again at 5min
• If apgar scoring is omitted, it is considered as negligence

APGAR score is calculated by careful observation of the following:

1. Heart rate 4. Reflex response and
2. Respiration 5. Color of the infant
3. Muscle tone
• Each sin is given a score of 0,1,2
• It provides an immediate estimate of the physical condition of the baby
• A perfect score is 9 or 10
• An apgar score of >7 is considered satisfactory
• 4-6 indicates moderately depressed
• 0-3 indicates severely depressed baby
• A score below 5 needs prompt actions
• Infants with low apgar scores at 5 minutes of age are subject to a high risk of complications and death during the
neonatal period.

Sign 0 1 2
Heart rate Absent <100 >100
Respiratory effort absent Irregular or gasping Good crying
Muscle tone flaccid Partial flexion of Complete flexion or
extremities active movements
Reflex response No response grimace cry
color Blue (central Body pink but Completely pink
cyanosis) or pale extremities blue
(peripheral cyanosis)

FIRST EXAMINATION
- Made soon after birth and preferably in the delivery room

This examination is:

• To ascertain that the baby has not suffered injuries during the birth process
• To detect malformation especially those requiring urgent treatment
• To check for vital signs

1. Birth weight
• Should preferably be taken within first hour of life
• The naked baby should be placed on a clean towel on the scale pan
• Home deliveries: place the baby in a sling bag for using a salter weighing scaled
• The child is weighed to the nearest 100gm

2. Length
• With a measuring board (infantometer)
• Fixed head piece
• Legs fully extended and
• Feet flexed at right angle to lower legs

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• Two people are needed to hold the body correctly

• The sliding board is moved firmly against the feet before the reading is taken Length is taken to the nearest 0.1
cm
The length may be taken within first 3days, if not possible to take immediately at birth

3. head circumference
• Use a tape measure at the maximum circumference of the head in occipital front diameter The purpose is
To assess the baby’ size against known standards for the population

To compare the size with estimated period gestation

To provide a baseline against with subsequent progress can be measured

• The measurement may change slightly during the first 3days owing to molding during labor

4. The following abnormalities found on examination should be immediately attended to:

• Cyanosis - the lips and skin
• Any difficulty in breathing
• Imperforate anus
• Persistent vomiting
• Sighs of cerebral irritation s/a
- Convulsions
- Neck rigidity

SECOND EXAMINATION
• This should be made perfectly by a pediatrician within 24 hours after birth
• Ths examination should be form the first stage of a continual process of health care surveillance
• Is its a detailed systematic examination from head to foot, conducted in good light

The following protocol with be found useful for such an examination

1. Body size
• Body weight Eyes
• Crown heel length - Cataract
• Head and thoracic perimeters - Coloboma
2. Temperature - Conjuctivitis
3. Skin Ears
• Cyanosis of lips and skin - Dysmorphism
• Jaundice - Accessory auricles
• Pallor - Periauricular pits
• Generalized erythema Mouth and lips
• Vesicular and bullous lesions - Hare lips and cleft palate
4. Cardio respiratory activities 7. Abdomen
• Cardiac murmurs Sighs of distension

• Absence of femoral pulse Abnormal masses

• Central cyanosis Imperforate anus RR>60 8. Limbs and joints

• Thoracic cage retraction on inspiration Deformities

5. Neuro behavioral activity CDH

• Hyper extension of all limbs Extra digits

• Hyper flexion of all limbs 9. Spine: NT Defects
• Asymmetrical posture 10. External genetalia

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• Muscle tone Male

Cru - Hyposradius

Tendon reflexes - Underscended testis

Movements - Hyrocele

6. Head and face Female

• Hydrocephalus - Fused labia
- Large fontanels - Enlarged clitoris
- Prominent scalp veins

Late neonatal care

Hazards during the late neonatal period
• Infection
- Diarrhea
- Pneumonia
• Failure of satisfactory nutrition

Risks identification in the newborn

These newborns would need special care and should be referred to the FRU

1. Birth asphyxia
- Need referral to an FRU which is equipped to manage post-asphyxial problems such as convulsions, hypoxia,
hypoglycemia, hypocalcaemia, shock, renal failure, etc.

2. Danger signs
• Convulsions
• Fast breathing (60 breaths per minute or more)
• Severe chest in drawing
• Nasal flaring
• Grunting
• Bulging fontanelle
• 10 or more skin pustules or a big boil
• If axillary temperature 37.5C or above (or feels hot to
touch) or temperature less than 35.5 (or
feels cold to touch)

• Lethargic or unconscious
• less than normal movements
• Severed jaundice
• Blood in the stools
• Not able to feed
• No attachment at all
• Not sucking at all

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3. Major malformation:
• Meningo-myelocoele
• Large omphalocoele are easily identified on inspection of the baby
• Diaphragmatic hernia may be suspected in a baby with respiratory distress and a schapaloid abdomen
• Babies with excessive salivation and mucus discharge from the oral cavity may have esophageal atresia.
- There is an inability to pass a rubber catheter into the stomach
- Most of these babies require immediate surgery for them to survive, and therefore should be referred to
an FRU

Pericare or Perineal Care with Heat Lamp Treatment

- Perineal care is a procedure done for post-partum whether the woman delivers through Caesarian Section or
gives birth through the vagina. It cleanses and disinfects the perineal area using warm water, and antiseptic
solution. The heat lamp is used to promote wound healing and provide comfort to the post-partum.
- Objective:
1. To assess or observe the condition of the perineum and rectum.
2. To keep the perineal area clean and provide comfort to client.
3. To prevent infection and promote wound healing.
4. To assist and teach client how to perform perineal care while assessing perineal area.

Episiotomy
- An incision made in the perineum to enlarge the vaginal
outlet, to prevent tearing of the perineum, release
pressure on the fetal head with birth, and possibly shorten
the last portion of the second stage of labor.
• 1-3 inches cut
• Advantage of mediolateral: the tear will not be directed
toward the rectum, creating less danger of mucosal tear
causing loss of sphincter function and fecal incontinence in
later life
• Midline: heal more easily or faster, less blood loss, less
postpartal discomfort
• Baby is large or in breech presentation
• Labor going too quickly
• Extraction instruments are needed
• Speed up delivery mother or baby in distress labor going too slowly

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Assess lochia
Color Amount
Lochia rubra Scanty - 1-2 inch lochia stain on the perineal pad or
• Red approx. 10ml loss
• 1-3 days
• Blood fragments and mucus
Lochia serosa Light - 4-inch stain/ 10-25ml
• Pink
• 3-10 days
• Blood mucus and leukocytes
Lochia alba Moderate - 4-6 inches, of est. 25- 50ml loss
• White Heavy - A pad is saturate within 1 hour after changing
• 10-14 (may last 6 weeks)
• Mucus and leukocyte

ASSESSMENTS
Vaginal walls’ muscle tone are absent
Rugae reappears approx. 3 weeks post-partum and involution of vagina at 6 weeks
Edema and generalized tenderness
Ecchymosis
Laceration or episiotomy
Healing occurs within 2-4 weeks
Menstruation returns at 4-8 weeks (bottle-feeding) 4 mos. (Breastfeeding)

EPISIOOMY ASSESSMENT (REEDA)

• Redness Always Check!
• Edema • Episiotomy
• Ecchymosis • Tearing
• Discharge
• Hematoma Formation
• Approximation of skin
• Hemorrhoids
The REEDA Scale is a scale for grading the severity of perineal trauma associated with episiotomy or laceration associated
with delivery.

Assess incisions for signs of infection and healing.

Observe for elevated temperature.

Assess for pain, burning and frequency of urination.

Assess bladder

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Materials/Equipment:

Sterile tray with: Other materials:

Perineal balls soaked in antiseptic solution Clean bedpan with cover
Dry perineal balls/ 4 x 4 OS Sterile warm water
Picking forceps in holder Incontinent pad
Sterile forceps, packed 25 watts heat lamp
3 Kidney basins, packed 2 sets of clean gloves
Bath blanket

Penlight
Waste receptacle/ kidney basin

Preparation:

1. Review medical record and nursing plan of care.

2. Explain the procedure to the client’s and assess client’s level of understanding.
3. Gather and assemble needed materials or equipment at bedside or work area.
4. Determine the type of episiotomy the client has, whether mediolateral or midline.
5. Ask client if she has voided or moved her bowel.
6. Provide privacy to the patient by closing the room door or drawing curtains.
7. Ask client to remove underwear.
8. Pre-heat lamp.
9. Wash hands.

Procedure:

1. Do double gloving.
2. Assist the client nearest you or in the working area.
3. Drape client.
a. Change top sheet with bath blanket.
b. Place rubber sheet then cotton draw sheet.
c. Position bath blanket diagonally.
d. Position patient in dorsal recumbent position.
e. Tuck the corners on the sides of bath blanket at client’s legs anchoring at the foot.
f. While preparing or setting up supplies near the client cover perineum with one corner of the bath blanket.
4. Place bedpan.
a. Raise the head of the bed to at least 30 degrees.
b. Warm bedpan by pouring warm water at the rim, if it is made of metal; if made of plastic, rub the rim of the
bedpan with the bedpan cover.
c. Have patient lift her hips upward. While placing your palm under her lower back and assist with lifting. d. Slip
bedpan onto place.
e. The wider and rounded shelf part of the bedpan is the one that touches the buttocks.

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5. Expose perineal area.

6. Remove one set of gloves.
7. Test water temperature by pouring some water into either thigh.
8. Pour warm water into the vulva and inner thighs extending to 4 to 6 inches. a. Center
b. Farther side
c. Center
d. Nearer side
9. Cleanse the perineum.
a. Identify which of the forceps is your working and picking forceps.
b. Prepare 10 perineal balls soaked in antiseptic solution. Use one perineal ball per area or stroke. c. In zigzag
motion clean the mons pubis.
d. Then, the urinary meatus following the order of cleaning:

farther labia majora

nearer labia majora

farther labia minora
nearer labia minora
back to urinary meatus to the anus
farther thigh
nearer thigh
e. Repeat steps when needed.
10. Flush with warm water or rinse thoroughly.
11. Pat dry the vulva and thigh in the same order.
12. Remove the bedpan.
13. Assist patient to side lying position.
14. Assess anal region.
15. Clean and wipe dry the area.
16. Remove the rubber sheet and cotton draw sheet.
17. Position client exposing the perineum.
18. Remove gloves.
19. Position the heat lamp 12-14 inches from perineum.
To assess the episiotomy and perineal area, position the woman on her side with her top leg flexed upward
at the knee and drawn up toward her waist.

20. Leaves heat lamp for 15 to 20 minutes or as ordered.

21. Continue to reassess the area and discontinue treatment as specified.
22. Make patient comfortable.
23. Do after care of the unit.
24. Wash hands.
25. Document care rendered, observation or assessments, client reaction or complaints if any

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INFANT TUB BATH

- A process of cleansing or bathing an infant that provides the nurse a chance to give hygiene, an opportunity to
teach the mother on how to care for her newborn, and also for the nurse to observe infant’s behavior, alertness
and muscular activity.
- Objectives:
1. To cleanse the baby’s body from head-to toe.
2. To promote comfort.
3. To assess the general condition of the infant.

VITAL STATISTICS

• Newborns have trouble regulating their temperature; crucial

• Every 30 minutes for 2 hours thEn 8 hours
• 4th ICS , apical, femoral, brachial- presence of pulsations and equality
VITAL SIGNS • 30 to 60 breaths per minute – Irregular,
quiet, effortless
• 97.6 to 98.8 °F
• Weigh/Height
• > 60 mmHg (ave. SBP)
Newborn: 2500 to 3400g
• 100 to 160 beats per minute
Small – below or less than the 10th
percentile
Large- Above the 90th percentile
Weight loss up to 5 - 10% in early days
Weight regain in 10 days
Length: 46 – 54 cm
• Head Circumference
From birth to 36 months
During the first year of life the head
circumference increases by 1.2 cm or
0.5 inch each month Head is ¼ of the
newborn’s length 34 to 35 cm
Appear asymmetric
Abnormal rate of development
(microcephaly or macrocephaly), tumor
growth or an abnormal accumulation
Cerebrospinal Fluid (CSF) known as
hydrocephalus

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HEAD CHEST CIRCUMFERENCE

• The posterior fontanel is closed by age 2 to 3 • Newborn’s head circumference is larger than the chest
months. circumference.
• The anterior fontanel closes between 12 to 18 • 2-3 cm smaller than the head
months. • 32-33cm
• A sunken fontanel: dehydration • Chest circumference is almost equal with head
• Bulging: infant cries, coughs or vomits circumference after age 1 year.
• Nipple line (when measuring)

MID-ARM CIRCUMFERENCE
• Reflects muscle mass and fat
• With decrease in fat or muscle atrophy, midar m circumference decreases
• Increase with weight gain

NECK
Normal Abnormal
- Short neck - Weakness, contractures or rigidity
- Turns head easily from side to side - Webbing of the neck, large fat part at the back of the neck
- Raises head when prone
FACE EYES
• The face is assessed for dysmorphic features. • Difficult to evaluate in young child
• Spacing and symmetry of facial features are • At 3 years of age, visual acuity testing is recommended.
noted. • From birth to age 1 or 2 months gazes at black and white
• Ears should be aligned with the eye. contrasting figures.
• Low set ears may indicate an intellectual • At age 4 weeks or older, an infant fixates at brightly-
disability or renal anomaly. colored object, and follows it.
• Newborn before discharge is tested of the acoustic nerve.
• Infant turns to locate the sound.
• A very young infant, younger than 4 months, may
demonstrate a startle reflex to loud sounds.

POSTURE
Normal Abnormal
• Flexed extremities • Limp, flaccid or rigid extremities
• Move freely • Jitteriness or tremors
• Resist extension, returns quickly to flexed • Stiff Seizures
state
• Hands usually clenched
• Movements symmetric
• Slight tremors when crying
Responds to quieting when needs met.
REFLEXES
Moro reflex Palmar grasp reflex
- Dramatic reflex - Occurs when the infant’s palm is touched - The
- Drop back to 30 degrees hand closes into a tight fist.
- Arms extend and abduct, with the fingers - Weak or absent, injury to the nerves of the arms
fanning and thumbs and forefingers forming a - Disappears 2-3 months
C position
- Legs may also be extend and then flex
- Disappears 5-6 months

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Sucking Reflex Rooting Reflex
NCM 213 Care of Mother, Child and Adolescent RLE
Midterms

Tonic-clonic Reflex Stepping Reflex

- Trying to walk
- Disappears at 3-4 months

Plantar reflex Babinski reflex

- When the area below the toes is touched, the - Stroking the lateral sole of the foot from the heel forward
infant’s toes curl over the nurse’s finger. - and across the ball of the foot
Disappears 8-9 months - Causes the toes to flare outward and the big toe dorsiflex
- Disappears at 8-9 months

MATERIALS

• 70% alcohol (depending on the agency policy or

pediatrician’s order)
• Baby shampoo
• Clean clothes
• Cotton balls
• Diaper
• Neutral or hypoallergenic soap
• Kidney basins
• Plastic tub or sink

PREPARATION

1. Review medical record and plan of care.

2. Bathing should take place before feeding.
3. Consider culture and beliefs of mother or the family.
4. Prepare or gather materials needed.
• Powder, lotion or cream (Mother’s preference)
• Pail and small dipper (if necessary)
• Soft towel
• Tape measure
• Thermometer
• Warm water (37.7 °C or 100 ° F, should not exceed)
• Weighing scale
• Baby clothes pin/ Plaster (modification)

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NCM 213 Care of Mother, Child and Adolescent RLE
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5. Wash the sink or tub with disinfectant cleaner. Then, line the sink or tub with bath towel.
6. Place a towel on the counter next to the sink or tub and clothes.
7. Arrange materials in order of use.
8. Ensure baby’s safety.
9. Eliminate air draft or ensure that the environment is warm.
10. Wash hands.
11. Fill the tub with warm water and check using your elbow.
12. Bring the infant to the workplace.
13. Undress the infant.

PROCEDURE

1. Assess the infant.

a. Weigh infant and record weight.
b. Take axillary temperature.
c. Observe the respiratory rate, depth and ease of respiration.
d. Determine the other anthropometric measurements such as the height, head, chest and
mid-arm circumference.
2. Continue to assess the infant as you perform the procedure.
3. Wrap him/ her in a blanket or towel.
a. When wrapping the baby, place blanket or towel in a flat surface diagonally.
b. Place baby at the center, fold the lower corner of the blanket over the legs and feet.
c. Fold the two side corners under the arms over the chest.
4. Using a cotton ball or wash cloth moistened with water and squeezed out, clean/ wipe eyes
gently from inside corner outward.
5. Clean the nose, face and ears using washcloth. Using the different sides of clean washcloth.
6. Wash infant’s head, use a neutral soap or baby shampoo.
a. To wash the hair/ head, hold the infant in a football hold or manner. Support the baby’s
head on the palm of your left hand.
The baby’s back will be supported along your left forearm.

The hips will be pressed against your waist by your left elbow. You may use either arm
as long as you support the head and back.

b. Wash infant’s head or hair in a gentle circular motion. To prevent cradle cap
7. Dry the infant’s head with a towel carefully.
8. Unwrap the infant and gently place him on the tub lined with towel.
9. One hand should always be holding the baby
10. Tilt head back to cleanse the neck using the washcloth.
11. Wash and soap the baby’s chest, abdomen, arms, armpit, back and lower extremities. Pay
attention to creases or folds.
12. Refill the basin or tub with clean, clear, and warm water, then rinse thoroughly.
13. Clean the genitalia.
a. If the infant is female, wash perineal area from front to back.
b. Cleanse penis without retracting it.
c. Circumcision area, just keep area clean, you may apply petrolatum gauze. Observe for
bleeding.
14. Lift the infant out of the tub and dry thoroughly.
15. Do cord care. (Cord stump heals in 2 weeks.)
a. Inspect umbilical cord.
b. Check area for bleeding or foul odor.
c. A drying agent such as 70% alcohol may be used. Check agency policy and physician’s order.
d. Do not cover with diaper
16. You may apply powder, lotion or cream to the infant whichever the mother prefers.
17. Diaper and dress the infant.
18. Place infant in the crib or allow mother to hold the baby.

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19. Clean and return equipment used to their proper place.

20. Clean the area.
21. Wash hands.
22. Document care rendered and observations/ assessments.

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