RLE NOTES REVIEWER (EXAM) order such as total amount of urine to be removed or size

of catheter to be used:
URINARY CATHETERIZATION
Straight Catheter - use for a spot urine specimen -
Purposes:
amount of residual urine is being measured - temporary
 To relieve bladder distention or to provide gradual decompression / emptying of the bladder is required.
decompression of a distended bladder
Indwelling/Retention Catheter - if the bladder must
 To instill medication into the bladder
remain empty or continuous urine measurement and
 To irrigate the bladder collection is needed:
 To measure hourly urine output accurately
 To collect urine specimen  Determine if the client is able to cooperate and
 To measure residual urine Residual Urine, is the hold still during the procedure and if the client can
amount of urine retained in the bladder after be positioned supine with head relatively flat.
forceful voiding  Determine when the client last voided or was last
 To maintain continence among incontinent clients catheterized.
 To prevent urine from contracting an incision after  Percuss the bladder to check for fullness or
perineal surgery distention.
 To promote healing of the genito-urinary
structures postoperatively
Procedure
Equipment: Verify doctor’s order
Identify and inform the To allay anxiety
client and explain, why it
is necessary and how
he/she can cooperate.
Provide privacy To prevent feeling of
embarrassment
Wash hands and observe To prevent ascending
appropriate infection UTI
control procedures
Perform routine perineal To minimize
care before the microorganism at the
procedure external genitals

Have adequate lighting To visualize urethral

meatus properly
Place the client in
appropriate position:
Indwelling
Male: Supine, legs
abducted and extended
Female: Dorsal
recumbent
Don sterile gloves
Inflate the balloon of
catheter with air to check
that it is intact then
deflate.
Locate the urinary
meatus properly:

Male: at the tip of the

glans penis
Female: between the
clitoris and vaginal orifice
Straight

Urinary Catheterization

 Is the introduction of catheter through the urethra

into the bladder in order to withdraw urine.
 Tube commonly made of rubber(good for 1wk),
plastic(2-3wks), latex(1-2mons).
 Normal length of urethra:
o Female – 3 to 4 inches
o Male – 6 to 9 inches
 Appropriate size:
o Female – Fr 12-14
o Male - Fr 16 to 18

Assessment
Determine the most appropriate method of catheterization
based on the purpose and any criteria specified in the
 Cleanse urinary meatus with antiseptic solution
 Note: The nondominant hand is considered
contaminated once it touches the client skin.

Male: - Use your nondominant Lifting the penis

hand to grasp the penis just firmly and upright
below the glans. - Hold the penis prevents possible
firmly upright with slight tension - erection and helps
Pick up a cleansing ball with the strengthen the
forceps and wipe from the center urethra
of the meatus in circular motion
Note: The foreskin must not be
allowed to return over the
cleanse meatus nor the penis be
dropped

Female: - Use your

nondominant hand to spread the
labia
 Pick up a cleansing ball Note: If the purpose of catheterization is to relieve bladder
with the forceps in your distention, practice GRADUAL DECOMPRESSION, to
dominant hand and wipe prevent shock, hemorrhage or bladder atony.
one side of the labia in
an anteroposterior Gradual Decompression may be done by the
direction. following actions:
 When cleansing the  Empty the bladder slowly by pinching the catheter
urinary meatus, move to reduce the size of the lumen.
the swab downward  Elevate urine receptacle at the level of symphysis
Lubricate catheter with water To prevent friction pubis to slow down expulsion of urine.
soluble lubricant before insertion and prevent  Do not remove more than 1000 ml of urine at a
Male: 6 – 7 inches trauma time
Female: 1 – 2 inches
Nursing Interventions for Client with
Insert catheter gently in rotating Indwelling/Retention Catheter
motion. Instruct the client to take  Practice asepsis. Proper handwashing should be
slow deep breaths to relax done before and after manipulating the device. To
sphincter or strain as if prevent infection
attempting to void to opens  Increase fluid intake. To enhance excretion of
urinary meatus. microorganism and body wastes
 Acidify urine (diet: meat,fish.eggs and cereals)
During insertion of catheter in To straighten the Acidic urine inhibits proliferation of
male, hold the penis at 90 urethra and microorganism.
degree angle or perpendicular to facilitate insertion  Maintained closed drainage system. Do not
the body detach catheter from the connecting tubing,
For indwelling or retention unnecessarily.
catheter, inflate the balloon with  Meticulous perineal care. To prevent ascending
5 – 10 ml. of PNSS UTI
Placement of indwelling / retention catheter and  Ensure patency of urinary catheter. Avoid kinks.
inflated balloon Irrigate with sterile PNSS as ordered.
 Ensure that gravity drainage of urine is
maintained. Hold the urinary drainage bag below
the level of bladder when ambulating
 Monitor I & O
 Change urinary catheter, tubing and bag when
sediments accumulates, if leakage is present or if
a strong odor is evident.

Removal of Indwelling / Retention Catheter

 Check doctor’s order
 Wash hands. Remove the tape that secured the
catheter to the client’s body
Gently pull on the
 Don clean disposable gloves. Handwashing and
catheter. If resistance is
gloving prevent transfer of microorganism
felt, the catheter balloon
 Insert hub of the syringe into balloon inflation port
is properly inflated in the
and draw out all the liquid. The balloon must be
bladder.
completely deflated to prevent trauma to the
Anchor catheter properly:
urethra as the catheter is remove.
Male: laterally or upward To prevent penoscrotal
 Instruct the client to inhale and then pinch and
over the lower abdomen / pressure
remove the catheter slowly and carefully as the
upper thigh Female:
clients exhales. Breathing provides distraction
inner aspect of the thigh
and exhalation prevents tightening of abdominal
Attach drainage bag to
and perineal muscles as the catheter is withdraw.
the bed frame, ensuring
Pinching catheter prevents urine from dribbling
that tubing should fall
onto the bed linens.
below the top of the bag.
 After removal of catheter, allow the urine to drain
Keep client comfortable
into collection bag. Measure and record the
Do after-care amount of urine remaining in the collection bag.
Do relevant  Assess client’s perineum and meatus for any
documentation signs of redness or irritation.
  Assist client to do perineal care and dry genitals. IMPORTANT:
To ensure client comfort.
 Discard contaminated equipment and articles in Size 12-14 Fr for women draining clear urine
appropriate containers. To prevent contamination Size 14-16 Fr for men draining clear urine
of the environment.
 Make relevant document Size 16-18 Fr for patients with debris or
mucous in their urine
NOTE:
 Voiding should be expected within 6 – 8 hours Sizes in excess of 18 Fr for patients with
from the time of removal of catheter. Some hematuria,
dribbling of urine may be experienced.
 Continue to assess I & O Size 22 Fr for continuous bladder irrigations
 If the client has not voided in 8 hours, assess for WOUND CARE
urinary retention
 If the client has difficulty establishing voluntary OPEN WOUND
control of voiding, notify the physician. It may be
necessary to reinsert the catheter or to perform in - An open wound is an injury involving an external
and out (intermittent) catheterization or internal break in body tissue, usually involving
the skin.
Nursing Interventions for Clients with Urinary - Nearly everyone will experience an open wound
Incontenence at some point in their life.
 Bladder Retraining Program. Determine the - Most open wounds are minor and can be treated
client’s voiding pattern or establish a regular at home.
voiding time. - Falls, accidents with sharp objects, and car
 Lengthen the intervals of voiding once the client’s accidents are the most common causes of open
voiding can be controlled. wounds.
 Regulate fluid intake - In the case of a serious accident, you should seek
 Avoid large amounts of fruit juices and immediate medical care.
carbonated beverages.
- This is especially true if there’s a lot of bleeding
 Avoid stimulants at bedtime
or if bleeding lasts for more than 20 minutes.
 Schedule diuretics in the morning.
- Types of open wounds:
 Adequate fluid intake in the morning.
o Incision
 Kegel’s Exercise (alternating tension and o Abrasion
relaxation of the pubococcygeal muscles )
o Laceration
Nursing Interventions to Induce Voiding/Urination o Puncture
 Provide privacy o Avulsion
 Provide fluids to drink INSCISION
 Assist the patient in the anatomical position of
voiding o Caused by Sharp Instrument like knife or scalpel
 Serve clean, warm and dry bedpan (female) or o It is an open wound; deep or shallow; once the
urinal (male) edges have been sealed together as a part of
 Allow the client to listen to the sound of running treatment or healing, the incision becomes a
water closed wound.
 Dangle fingers in warm water
 Pour warm water over the perineum
 Promote relaxation
 Provide adequate time for voiding
 Perform Crede’s Maneuver as ordered ( this is
done by applying pressure on the suprapubic
area)
 Administer cholinergics as ordered
 Last resort: URINARY CATHETERIZATION ABRASION

o An abrasion occurs when your skin rubs or

Risks associated with catheterization: scrapes against a rough or hard surface. Road
rash is an example of an abrasion. There’s
 Urethral trauma and bleeding from inappropriate usually not a lot of bleeding, but the wound needs
catheter size or use of force. to be scrubbed and cleaned to avoid infection.
 Urinary tract infections related to poor sterile
technique or long-term catheterization.

 Bladder spasms and pain

Equipments:

- catheterization tray: sterile gloves, drapes, cotton

balls, forceps, prefilled 10cc syringe with sterile
water to inflated the balloon, sterile specimen
container for urine sample collection
- sterile catheter
- chlorhexidine 2% aqueous solution
- catheter-secure device or adhesive tape
- urinary drainage bag
- medicated lubricant (Xylocaine jelly)
LACERATION the capillary network develops, the tissue
becomes a translucent red color. This tissue,
o A laceration is a deep cut or tearing of your skin. called granulation tissue, is fragile and bleeds
Accidents with knives, tools, and machinery are easily.
frequent causes of lacerations. In the case of
deep lacerations, bleeding can be rapid and Maturational Phase
extensive.
- The maturation phase begins on about day 21
and can extend 1 or 2 years after the injury.
- The wound is remodeled and contracted. The
scar becomes stronger but the repaired area is
never as strong as the original tissue. In some
individuals, particularly dark-skinned individuals,
an abnormal amount of collagen is laid down.
This can result in a hypertrophic scar, or keloid.
PUNCTURE WOUND EXUDATE

o A puncture is a small hole caused by a long, Exudate is material, such as fluid and cells, that has
pointy object, such as a nail or needle. escaped from blood vessels during the inflammatory
Sometimes, a bullet can cause a puncture process and is deposited in tissue or on tissue surfaces.
wound. The nature and amount of exudate vary according to the
o Punctures may not bleed much, but these tissue involved, the intensity and duration of the
wounds can be deep enough to damage internal inflammation, and the presence of microorganisms.
organs. If you have even a small puncture wound,
visit your doctor to get a tetanus shot and prevent SEROUS
infection. ◼ A serous exudate consists chiefly of serum (the
clear portion of the blood) derived from blood and
the serous membranes of the body, such as the
peritoneum. It looks watery and has few cells.

◼ An example is the fluid in a blister from a burn.

AVULSION

o An avulsion is a partial or complete tearing away

of skin and the tissue beneath. Avulsions usually
occur during violent accidents, such as body-
crushing accidents, explosions, and gunshots.
They bleed heavily and rapidly.
SANGUINEOUS

- A sanguineous exudate consists of large

amounts of red blood cells, indicating damage to
capillaries that is severe enough to allow the
escape of red blood cells from plasma. This type
of exudate is frequently seen in open wounds.

PHASES OF WOUND HEALING

Inflammatory Phase

- The inflammatory phase begins immediately after

injury and lasts 3 to 6 days.
- Two major processes occur during this phase:
hemostasis, or the cessation of bleeding and
phagocytosis, or when macrophages engulf
microorganisms and cellular debris SEROSANGUINEOUS

Proliferative Phase - A serosanguineous exudate consisting of both

clear and blood-tinged drainage, is commonly
- The proliferative phase, the second phase in seen in surgical incisions.
healing, extends from day 3 or 4 to about day 21
postinjury.
- Fibroblasts (connective tissue cells), which
migrate into the wound starting about 24 hours
after injury, begin to synthesize collagen.
Collagen is a whitish protein substance that adds
tensile strength to the wound.
- If the wound is sutured, a raised “healing ridge”
appears under the intact suture line.
- In a wound that is not sutured, the new collagen
is often visible. Fibroblasts move from the
bloodstream into the wound, depositing fibrin. As
PURULENT provides easy access to the comfort and warmth.
wound area. Use the bath Waterproof pad protects
- A purulent exudate is thicker than serous exudate blanket to cover any exposed underlying surfaces
because of the presence of pus, which consists area other than the wound.
of leukocytes, liquefied dead tissue debris, and Place a waterproof pad under
the wound site.
dead and living bacteria. The process of pus Check the position of drains, Checking ensures that a drain
formation is referred to as suppuration. Purulent tubes, or other adjuncts is not removed accidentally if
exudates vary in color, some acquiring tinges of before removing the dressing one is present
blue, green, or yellow. The color may depend on Put on clean, disposable Gloves protect the nurse from
the causative organism. gloves contaminated dressings and
prevent the spread of
microorganisms.
Loosen tape on the old Adhesive-tape remover helps
dressings. If necessary, use reduce patient discomfort
an adhesive remover or during removal of dressing.
normal saline to help get the
tape off.
Carefully remove the soiled Cautious removal of the
dressings. If any part of the dressing is more comfortable
PROCEDURE RATIONALE dressing sticks to the for the patient and ensures
Review the medical orders for Reviewing the order and plan underlying skin, use small that any drain present is not
wound care or the nursing of care validates the correct amounts of sterile saline to removed. A Silicone-based
plan of care related to wound patient and correct procedure. help loosen and remove adhesive remover allows for
care. the easy, rapid, and painless
Gather the necessary Preparation promotes removal without the
supplies and bring to the efficient time management associated problems of skin
bedside stand or overbed and organized approach to stripping. Sterile saline
table. the task. Bringing everything moistens the dressing for
to the bedside conserves time easier removal and minimizes
and energy. Arranging items damage and pain.
nearby is convenient, saves After removing the dressing, The presence of drainage
time, and avoids unnecessary note the presence, amount, should be documented.
stretching and twisting of type, color, and odor of any
muscles on the part of the drainage on the dressings.
nurse. Place soiled dressings in the Proper disposal of soiled
appropriate waste receptacle. dressings
Remove your gloves and Used gloves prevents spread
dispose of them in an of microorganisms.
appropriate waste receptacle
Perform hand hygiene Hand hygiene and PPE Inspect the wound site for Wound healing or the
prevent the spread of size, appearance, and presence of irritation or
microorganisms drainage. Assess if any pain is infection should be
present. Check the status of documented.
Identify the patient. Identifying the patient ensures
sutures, adhesive closure
the right patient receives the
strips, staples, and drains or
intervention and helps prevent
tubes, if present. Note any
errors.
problems to include in your
documentation.
Using sterile technique, Supplies are within easy
prepare a sterile work area reach and sterility is
and open the needed supplies maintained
Open the sterile cleaning Sterility of dressings and
solution. Depending on the solution is maintained.
Close curtains around bed This ensures the patient’s amount of cleaning needed,
and close door to room if privacy. the solution might be poured
possible. directly over gauze sponges
over a container for small
cleaning jobs, or into a basin
Explain what you are going to Explanation relieves anxiety
for more complex or larger
do and why you are going to and facilitates cooperation.
cleaning.
do it to the patient.
Put on sterile gloves Use of sterile gloves
maintains surgical asepsis
and sterile technique and
reduces the risk for spreading
microorganisms.
Assess the patient for Pain is a subjective Clean the wound with gauze Cleaning from top to bottom
possible need for experience influenced by past dampened with Normal and center to outside ensures
nonpharmacologic pain- experience. saline. that cleaning occurs from the
reducing interventions or Wound care and dressing a. Clean the wound from top least to most contaminated
analgesic medication before changes may cause pain for to bottom and from the center area and a previously cleaned
wound care dressing change. some patients. to the outside. Following this area is not contaminated
Administer appropriate pattern, use new gauze for again. Using a single gauze
prescribed analgesic. Allow each wipe, placing the used for each wipe ensures that the
enough time for analgesic to gauze in the waste previously cleaned area is not
achieve its effectiveness. receptacle. contaminated again.
b. If a drain is in use at the Cleaning the insertion site
Place a waste receptacle or Having a waste container
wound location, clean around helps prevent infection
bag at a convenient location handy means the soiled
the drain from center to
for use during the procedure. dressing may be discarded
outside
easily, without the spread of
microorganisms Once the wound is cleaned, Moisture provides a medium
dry the area using a gauze for growth of microorganisms.
Adjust bed to comfortable Having the bed at the proper
sponge in the same manner.
working height, usually elbow height prevents back and
height of the caregiver muscle strain. Apply betadine, ointment or The growth of
antiseptic medications, as microorganisms may be
Assist the patient to a Patient positioning and use of
ordered, in the same manner. inhibited, and the healing
comfortable position that a bath blanket provide for
 process improved with the BLOOD TRANSFUSION
use of ordered medications
Apply layers of dry, sterile Use of forceps helps ensure - Is the introduction of whole blood components
dressing over the wound. that sterile technique is into the venous circulation
Forceps may be used to apply maintained.
the dressing. Dressing must be at least 1 PURPOSES:
a. 1st layer serves as a wick inch larger than the wound.
for drainage - To restore blood volume after severe hemorrhage
b. 2nd layer is for increased - To restore the oxygen-carrying capacity of the
absorption of drainage
c. 3rd layer act as additional
blood.
protection for the wound - To provide plasma factors which prevent or treat
against microorganism bleeding
Remove and discard gloves. Proper disposal of gloves
prevents the spread of BLOOD GROUPS
microorganisms
Apply tape Tape or other securing Human blood is commonly classified into four main
products are easier to apply groups, A, B, AB, and O. The surface of an individual red
after gloves have been blood cells contains a number of proteins known as
removed antigens. Many blood antigen have been identified, but
After securing the dressing, Recording date and time
label dressing with date and provides communication and the antigens A, B, and RH are the important in
time. demonstrates adherence to determining blood group or type. Type O blood is a
plan of care. Proper patient universal donor and type AB blood is a universal recipient.
and bed positioning
promotes safety and comfort Blood Type RBC antigens Plasma
Remove all remaining Removing PPE properly (Agglutinogens) antibodies
equipment; place the patient reduces the risk for infection
in a comfortable position, with transmission and (Agglutinins)
side rails up and bed in the contamination of other items. A A B
lowest position. B B A
Perform hand hygiene. Hand hygiene prevents the
spread of microorganisms. AB A and B -
Check all wound dressings Checking dressings ensures O - A and B
every shift. More frequent the assessment of changes in
checks may be needed if the patient condition and timely
wound is more complex or intervention to prevent
dressings become saturated complications
quickly.
Document procedure. Procedures that are not
documented are considered
not done.

RHESUS (RH) FACTOR

RH+ - blood that contains the Rh factor.

Rh- – blood not contain the Rh factor.

In contrast to the ABO blood groups, Rh blood does not

naturally contain Rh antibodies. However, on exposure to
blood containing Rh factor, Rh antibodies develop.
Subsequent exposures to Rh+ blood place the client at
risk for an antigen antibody reaction and hemolysis of
RBCs.

BLOOD TYPING & CROSSMATCHING

- To avoid transfusing incompatible red blood cells,

both blood donors and recipient are typed and
their blood cross-matched.
- Blood typing is done to determine the ABO blood
group and RH factor status.
- Cross-matching is also necessary prior to
transfusion to identify possible interactions of
minor antigens with their corresponding
antibodies.

Blood Donation Requirements:

- Body weight should be at least 50 kg (110lbs.)

- Oral temperature should not exceed 37.5 degree
Celsius
- Blood pressure is 90-120 mmHg/50-100 mmHg
- Hemoglobin level should be at least 12.5 g/dl for
women 13.5 g/dl for men.BLOOD PRODUCTS
FOR TRANSFUSION
 PRODUCT USE - A #18 – 20 gauge needle or catheter (if not
Whole Blood Not commonly used already in place) or if blood is to be administered
except for extreme cases quickly, a larger catheter.)
of acute hemorrhage. - chlorhexidine solution
Packed red blood cells Used to increase the - alcohol swabs
(PRBCs) oxygen-carrying capacity - adhesive tape
of blood in anemias, - clean gloves
surgery, and disorders
with slow bleeding.
Autologous red blood Used for blood
cells replacement following
planned elective surgery.
Platelets Replaces platelets in
client with bleeding
disorders or platelet
deficiency.
Fresh frozen plasma Expands blood volume
and provides clotting
factors.
Albumin and plasma Blood volume expander;
protein fraction provides plasma protein.
Clotting factors and Used for clients with
cryoprecipitate clotting factor
deficiencies.

COMPLICATIONS:
IMPORTANT RATIONALES:
Acute Hemolytic Reaction – incompatibility between
client blood and donors blood. - RBC’s deteriorate and lose their effectiveness
after 2 hours at room temperature.
Clinical Signs: - Blood filters have a surface area large enough to
allow the blood components through easily but
Chills, fever, headache, backache, dyspnea, cyanosis, are designed to trap clots.
chest pain, tachycardia, hypotension. - Infusing normal saline before initiating the
Febrile Reaction – sensitivity of the client’s blood to white transfusion also clears the iv catheter of
blood cells, platelets, or plasma protein. incompatible solutions.
- Rough handling can damage the cells.
Clinical Signs: - The earlier a transfusion reactions occurs, the
more severe it tends to be. Identifying such
Fever, chills, flushed skin, headache, anxiety, muscle
reactions promptly helps to minimize the
pain.
consequences.
Allergic reaction (mild) – due to sensitivity reaction to a
DELIVERY ROOM INSTRUMENTATION
plasma protein within the blood component being
transfused.

Allergic reaction (severe)- due to antibody – antigen

reaction

Clinical signs:

Mild- flushing, itching, urticaria, bronchial wheezing

Severe – dyspnea, chest pain, circulatory collapse,

cardiac arrest

Circulatory overload – fast transfusion too quickly

Clinical signs: cough, dyspnea, crackles (rales),

distended neck veins, tachycardia, hypertension.

Sepsis – contaminated blood administered

Clinical signs:

high fever, chills, vomiting, diarrhea, hypotension

Delayed hemolytic reaction – occur within 14 days after

transfusion when the level of antibody has been increased
to the extent that the reaction can occur.

EQUIPMENT

- Blood product
- Blood administration set
- 250 ml normal saline solution
- IV pole venipuncture set containing
EINC (Essential Intrapartum and Newborn Care) Antibiotic eye drops or ointment are placed in a
newborn's eyes after birth. Ilotycin is an antibiotic
Four time-bound steps in Essential Newborn Care: ointment is routinely put in the eyes of all newborns to
prevent neonatal conjunctivitis (pink eye). While
1 Immediate drying Use clean, dry cloth, dry the baby,
wiping face, ice, head, front and
Chlamydia and Gonorrhea are the most serious
back, arms and legs. pathogens that are treated with Ilotycin, this treatment
Rationale: Stimulate breathing and also prevents less severe infection with other common
prevent hypothermia which may bacteria such as e. coli. These common bacteria are
result to brain hemorrhage, hypoxia, found in everyone’s genital/rectal area. The medical term
acidosis, coagulation defects, and for newborn eye infections is “ophthalmia neonatorum”.
infection. The newborn obtains these infections during passage
2 Skin-to-skin Place the newborn prone on the through the vagina. Neonatal conjunctivitis can cause
contact mother’s abdomen or chest skin to blindness. However, antibiotic eye medications can easily
skin.
prevent it shortly after birth.
3 Proper Cord Clamp and cut the cord after cord
clamping and pulsations have stopped typically
cutting one to three minutes. Once - The average head circumference at birth is about
palpation has ceased, clamped cord 13.5 in. (34.5 cm). HC less than 32 cm is
using the plastic clamp 2 cm from indicative of microcephaly in term infants. HC that
the base. With dominant hand, hold is 4 cm and greater than CC or more than 37 cm
cord clamp and with non-dominant is indicative of neurologic involvement such as
hand, milk cord away from base. hydrocephalus
Using dominant hand, clamp Kelly - A baby's length is measured from the top of their
forceps 5 cm from base. Cut cord
head to the bottom of one of their heels. The
close to cord clamp, in between
cord clamp and Kelly forceps average length of full-term babies at birth is 20 in.
4 Non-separation of Observe the newborn council on (50 cm), although the normal range is 18 in. (45.7
baby from mother positioning and attachment initiate cm) to 22 in. (60 cm).
and breastfeeding breastfeeding. - CHEST CIRCUMFERENCE
initiation - Feeding cues: baby will Normal CC range from 30.5 to 33 (12 to 13
open mouth tongue out, inches), usually 2 cm less than HC. A CC less
rooting reflex, licking than 30 cm indicates prematurity. An enlarged
- Signs of good attachment: heart may make the left side of the chest larger.
chin touching breast, lower
lip turned outward, mouth
wide open, more areola
showing above

Critical period of labor – During 4th stage or within 24

hours after birth because of a possible postpartum
hemorrhage/bleeding of mother, sepsis, and unstable
vital signs of mother.

Tetanus Interval Protection

vaccine
TT1 1st check-up
TT2 4 weeks after TT1 3 years for mother
TT3 6 months after TT2 5 years for mother
TT4 1 year after TT3 10 years for mother
TT5 1 year after TT4 Lifetime for mother

Breastfeeding benefits:

B-est for baby

R-educe allergy
E-motional bonding
A-ntibody present-IgA
S-tool inoffensive
T-emperature always right
F-resh always
E-conomical
E-asy once established
D-igested easily
I-mmediately available
N-utritious
G-astroenteritis is avoided

Heart Rate:
- Newborns 0 to 1 month old: 70 to 190 beats per
minute.
- Infants 1 to 11 months old: 80 to 160 beats per
minute.
Weight:
- 5.5 lb (2.5 kg) - 10 lb (4.5 kg) is considered
normal
- The average birth weight for babies is around
7.5 lb (3.5 kg)
Temperature:
- 36.5 to 37.4 degrees Celsius
PARENTERAL No Notes :’(

INTRAVENOUS THERAPY No Notes :’(

VITAL SIGNS

Vital signs are the evidence of the current physical

functioning of the body. They provide critical information
that is 'vital' for life, and so they are called vital signs.

Body Temperature: The balance between the heat

produced by the body and the heat lost from the body.

Types of Body Temperature:

- Core Temperature: The temperature of the deep

tissues of the body. Measured by taking oral and
rectal temperature.
- Surface Temperature: The temperature of the
skin, subcutaneous tissue and fat. Measured by
taking axillary temperature.
Alterations in Body Temperature:

- Pyrexia- Body temperature above normal range.

(also called hyperthermia/fever)
- Hyperpyrexia- Very high fever, 41 degrees
Celsius (105.8 degrees Fahrenheit) and above.
- Hypothermia- Subnormal core body temperature.
(caused by excessive heat loss, inadequate heat
production or impaired hypothalamic function)

Types of Fever:

- Intermittent Fever: The temperature fluctuates

between periods of fever and periods of
normal/subnormal temperature.
- Remittent Fever: The temperature fluctuates
within a wide range over the 24 hour period but
remains above normal range.
- Relapsing Fever: The temperature is elevated for
few days, alternated with 1 or 2 days of normal
temperature.
- Constant Fever: Body temperature is consistently
high. Very high temperatures (41-42 degrees
Celsius) cause irreversible brain cell damage.

C= (Fahrenheit Temperature – 32) x 5/9

F= (Celsius Temperature x 9/5) + 32

Pulse Rate: It is a wave of blood created by contraction

of the left ventricle of the heart. The pulse rate is regulated
by the autonomic nervous system (ANS).

Pulse sites: Tachycardia: pulse rate above 100 bpm (adult)

o Temporal- over the temporal bone of the head, Bradycardia: pulse rate below 60 bpm (adult)
superior and lateral to the eye
o Carotid- at the lateral aspect of the neck, below
the ear lobe.
Respiratory Rate
o Apical- at the left midclavicular line (MCL) fifth
intercostal space (ICS). Use stethoscope. Respiration - The act of breathing.
o Brachial- at the inner aspect of the upper arm
(biceps muscles) or medially at the antecubital TERMINOLOGIES:
space.
o Eupnea- Normal respiration that is quiet,
o Radial- On the thumb side of the inner aspect of
rhythmic and effortless.
the wrist. o Tachypnea- Rapid respiration, above 20
o Femoral- Along side the inguinal ligament. breaths/minute in an adult.
o Posterior Tibial- At the medial aspect of the ankle, o Bradypnea- Slow breathing, less than 12
behind the medical malleolus. breaths/minute in an adult.
o Popliteal- at the back of the knee. o Hyperventilation- Deep rapid respiration. Carbon
o Pedal (Dorsalis Pedis)- At the dorsum of the foot. dioxide is excessively exhaled.
o Hypoventilation- Slow, shallow respiration.
*Use the middle two to three fingertips to palpate the Carbon dioxide is excessively retained.
pulse. Do not use the thumb. The normal pulse is detected o Dyspnea- Difficult and labored breathing.
readily, obliterated by strong pressure. o Orthopnea- Ability to breathe only in upright
position.
o Apnea- Absence of respirations.
 benefits as attested by the national science and
development board

Medicinal plant preparations

Decoction

Procedure:
Boil the recommended part of the plant material in water.
Recommended
boiling time is 20 minutes.

Infusion
BLOOD PRESSURE: The measure of the pressure Procedure:
exerted by the blood as it pulsates through the arteries. Plant material is soaked in hot water, much like making a
tea.
﹡ Systolic Pressure: Is the pressure of blood as a Recommended period of soaking is 10-15 minutes.
result of contraction of the ventricles.
﹡ Diastolic Pressure: Is the pressure when the
ventricles are at rest. Herbal infusions offer an easy method for consuming the
oils and flavors from favorite herbs. Infusion is the
﹡ Pulse Pressure: The difference between the
systolic pressure and diastolic pressure. Normal process of steeping (soaking) herbs in water until the
is 30-40 mmHg. water absorbs the oils and flavors, then drinking the liquid
for the taste or for the medicinal value
﹡ Hypertension is an abnormally high blood
pressure over 140 mmHg systolic and or above Poultice
90 mmHg diastolic for at least two (2) consecutive
readings. Procedure:
﹡ Hypotension is an abnormally low blood Directly apply recommended plant material on the part
pressure, systolic pressure below 100/60 mmHg. affected usually used on bruises, wounds, or rashes.
a systolic reading consistently between 85 and
110 mmHg in an adult whose normal pressure is
A poultice is a method of applying herbs to the skin.
higher than this.
﹡ Orthostatic Hypotension- Is a blood pressure Tincture
that decreases when the client sits or stands.
Procedure:
Mix the plant material in alcohol.

Tinctures are concentrated herbal extracts made by

soaking the bark, berries, leaves (dried or fresh), or roots
from one or more plants in alcohol or vinegar.

Steeping a medicinal plant in alcohol extracts the alcohol-

soluble principles into a liquid form that can be stored for
long periods. Herbalists may mix several herbal tinctures
to form an individualized prescription for each patient.
Plant tinctures are also the basis for many homeopathic
medicines.

To prepare your herbal tincture you will need:

8 ounces of finely cut dried herbs

1 large glass jar that can hold 4 cups of liquid
HERBAL MEDICATION 2 cups of vodka
The 10 medicinal plants
As part of primary health care and because of the
increasing cost of drugs, the use of locally available
medicinal plants and herbs in the Philippine backyard and THE 10 MEDICINAL PLANTS
field have been found to be effective in the treatment of
1. SAMBONG
common ailments as attested to by the national science
development board, other government and private Scientific name: Blumea Balsamifera
agencies/ persons engaged in research. English name: Ngai camphor or Blumea camphor
Use/indication: antiedema/antiurolithiasis
R.A. 8423 known as TAMA Preparation: decoction
◦ Traditional and alternative medicine act of 1997

◦ Signed: secretary of health Juan Flavier

◦ Created: Philippine institute of traditional and

alternative health care (PITAHC)

Tasked: to promote and advocate care modalities through

scientific research and product development

The doh through its "traditional health program" has

endorsed 10 medicinal plants to be used as herbal
medicines in the Philippines due to their proven health
 2. AKAPULKO 6. LAGUNDI

Scientific name: Cassia Alata Scientific Name: Vitex negundo

English name: Acapulco English name: 5-leaved chaste tree
Medicinal plant: ringworm bush or schrub Use/indication: Asthma, cough and colds, fever,
Use/indication: antifungal dysentery, pain, skin diseases (scabies, ulcer, eczema),
wounds
Preparation: Decoction, Wash affected site with
decoction

Preparation: poultice
3. NIYOG-NIYOGAN
7. ULASIMANG BATO
Scientific Name: Quisqualis indica L.
Scientific Name: Peperomia pellucida
English name: Chinese honey suckle
Use/indication: Lowers blood uric acid (rheumatism and
Use/indication: Antihelminthic
gout)
Preparation: Seeds are used (eaten raw)
Preparation: Decoction, Eaten raw

4. TSAANG GUBAT
8. BAWANG
Scientific Name: Ehretia microphylla Lam.
English name: Wild tea Scientific name: Allium Sativum
Use/indication: Diarrhea, Stomachache English name: Garlic
Preparation: Decoction Use/indication: hypertension, lowers blood cholesterol,
toothache preparation: eaten raw/fried, apply on part

5. AMPALAYA
9. BAYABAS
Scientific Name: Momordica charantia
English name: bitter melon or bitter gourd Scientific Name: Psidium guajava
Use/indication: Diabetes mellitus (mild non-insulin- English name: Washing wounds, Diarrhea, gargle,
dependent) toothache
Preparation: Decoction, Steamed Use/indication: Decoction
 10. YERBA BEUNA f) Turn head away from sterile field to have
perspiration mopped from brow.
Scientific Name: Clinopodium douglasii g) Stand back at a safe distance from the
English name: Peppermint operating table when draping the patient.
Use/indication: Headache, stomachache, Cough and h) Members of the sterile team remain in the
colds, Rheumatism, arthritis operating room if waiting for the case.
Preparation: Decoction, Infusion, Massage sap i) Do not wander around the room or go out in the
corridors.
7. Sterile persons keep contact with sterile areas to a
minimum.
a) Do not lean on the sterile tables or on the
draped patient.
b) Do not lean on the nurse's mayo tray.
8. Non-sterile persons - when you are observing a case,
please stay in the room until the case is completed. Do
not wander from room to room as traffic in the operating
room should be kept as a minimum. Patient privacy
needs to be respected.
9. Keep non-essential conversation to a minimum.
10. The circulating nurse is in charge of the room
(unsterile) - If you have any questions, please refer them
PRINCIPLES OF HANDWASHING to her, the supervisor or your instructor. Ask circulating
nurse when it is an appropriate time to ask questions so
that explanations/rationale can be given.

INSTRUMENTS NEEDED FOR NSVD (Normal

Spontaneous Vaginal Delivery)

Asepsis – The absence of pathogenic microorganisms.

Cleaning – To remove all soiled particles
Disinfection – Process that eliminates many or all
microorganisms with the exception of bacterial spores
from inanimate objects.
Sterilization – The complete elimination of all
microorganisms including spores.

PRINCIPLES OF STERILE TECHIQUE

1. All articles used in an operation have been sterilized

previously.
2. Persons who are sterile touch only sterile articles;
persons who are not sterile touch only unsterile articles.
3. Sterile persons avoid leaning over an unsterile area;
non-sterile persons avoid reaching over a sterile field.
Unsterile persons do not get closer than 12 inches from a
sterile field.
4. If in doubt about the sterility of anything consider it not
sterile. If a non-sterile person brushes close consider
yourself contaminated.
5. Gowns are considered sterile only from the waist to
shoulder level in front and the sleeves to 2 inches above
the elbows.
a) Keep hands in sight or above waist level away
from the face.
b) Arms should never be folded.
c) Articles dropped below waist level are
discarded.
6. Sterile persons keep well within the sterile area and
follow those rules from passing:
a) Face to face or back to back.
b) Turn back to a non-sterile person or when
passing.
c) Face a sterile area when passing the area.
d) Ask a non-sterile person to step aside rather
than trying to crowd past him.
e) Step back away from the sterile field to sneeze
or cough.
 METHERGINE - Treating bleeding during and after
delivery of a baby.
Methergine is an ergot alkaloid uterine stimulant. It works
by increasing uterine contractions, which helps reduce
blood loss after the baby is delivered. Given to help deliver
the placenta

MAGNESIUM SULFATE (MGSO4) - Magnesium sulfate

(MgSO4) is the agent most commonly used for treatment
of eclampsia and prophylaxis of eclampsia in patients with
severe pre-eclampsia. It is usually given by either the
intramuscular or intravenous routes. Magnesium sulfate It
has a role as an anticonvulsant, a cardiovascular drug. a
calcium channel blocker.

3 Uses for Magnesium Sulfate

﹡ Preventing seizures in women with severe
preeclampsia
﹡ Slowing or stopping premature labor.
﹡ Protecting the brains of premature babies.

Magnesium Sulfate Toxicity

﹡ Blood pressure decreased
Evacuation and Curettage Set ﹡ Urine output decreased
﹡ Respirations below 12
﹡ Patellar reflex absent

Other medications:

COMMON DRUGS USED IN DELIVERY ROOM

OXYTOCIN - Oxytocin is a Hormone that is used as a

uterine stimulant to induce labor or strengthen uterine
contractions, or to control bleeding after childbirth.
 2. The relationship of the location of the spine of the fetus
with the spine of the mother. It is cephalic (vertex) or
breech?

Procedure:
Using both hands, feel for the fetal part lying in the fundus.

Findings:
Head is more firm, hard and round that moves
independently of the body. Breech is less well defined that
moves only in conjunction with the body.

The fetal presentation is that part of the fetus which enters

the pelvis during the birth process:
1. Longitudinal lie (parallel)

1A. Cephalic- head is presenting part; usually vertex

(occiput) which is the most favorable for birth. Head is
flexed with chin on chest.
i. face or brow - poor flexion
ii. Consistency- the head feels firmer than breech
LEOPOLDS MANUEVER iii. Shape- head is round and hard; breech is less
well defined
﹡ Are Common and Systematic way to determine iv. Mobility of palpated part- head moves
the position of a fetus inside the woman’s uterus. independently of the body; breech moves only in
﹡ They are also Used to estimate term and fetal conjunction with the body.
weight.
﹡ The Maneuvers consist of four distinct action, 1B. Breech-buttocks or lower extremities present first.
each helping to determine the position of the i. frank: thigh flexed, legs extended on anterior
fetus. body surface, buttocks presenting
ii. Full or complete: thigh and legs are flexed,
﹡ This can help determine whether the delivery buttocks and feet (baby is squatting position)
is going to be complicated, or whether a esarean
iii. Footling: one or both feet are presenting;
section is necessary danger of breech birth is meconium staining.
Leopold's Maneuver is preferably performed after 24 2. Transverse Lie (perpendicular) or Perpendicular lie –
weeks’ gestation when fetal outline can be already shoulder presentation
palpated.

First Manuever
• Is also known as fundal grip

a. Shoulder: presenting part is the scapula and

baby is in horizontal or transverse position.
Caesarian birth indicated.
Palpate superior surface of the fundus. Facing the head
part of the patient palpate for the fetal part found in the
fundus.

Purpose:
﹡ To determine fetal part lying in the fundus.
﹡ To determine presentation.
﹡ To assess the following:
1. The size, shape, movement and firmness of the part to
determine presentation or lie which is the relationship of
the long axis (spine) of the fetus to the long axis of the
mother.
Second Manuever Fourth Manuever
 Involves palpation of the sides of the maternal  Also known as Pelvic grip
abdomen. This is also called the umbilical grip.

Purpose:
Purpose: ﹡ To determine the degree of flexion of fetal head.
﹡ To identify location of the fetal back. ﹡ To determine attitude or habitus.
﹡ To determine position.
Procedure:
Procedure: Facing foot part of the woman, palpate fetal head
One hand is used to steady the uterus on one side of the pressing downward about 2 inches above the inguinal
abdomen while the other hand moves slightly on a circular ligament. Use both hands.
motion from top to the lower segment of the uterus to feel
for the fetal back and small fetal parts. Findings:
Use gentle but deep pressure. ﹡ Good attitude – if brow correspond to the side
(2nd maneuver) that contained the elbows and
Findings: knees.
Fetal back is smooth, hard, and resistant surface
﹡ Poor attitude - if examining fingers will meet an
Knees and elbows of fetus feel with a number of angular
obstruction on the same side as fetal back
nodulation. The hand on the fetal arms and legs feels
(hyperextended head)
irregular bumps, and also perhaps kicking if the fetus is
awake and active.
 Also palpates infant's anteroposterior position. If
brow is very easily palpated, fetus is at posterior
Third Manuever
position (occiput pointing towards woman's
 Also known as the Lower pole or Pawlick grip.
back)

HOME VISIT

Phases of Home visit

 Pre-visit – determine family’s willingness, set an

appointment with them, formulate plan for the
home visit.

 In-home – Initiation, Implementation,

Termination
Initiation – knock and ring doorbell, loud
and nonthreatening voice say “Tao po”.
To determine engagement of presenting part. The nurse observes environment for his
Is it firm? If yes, the head is the presenting part. or her safety, the nurse initiates short
Is it soft? If yes, then the presenting part is breech. social conversation and states the
Is it engaged? (firmly settled into the pelvis) purpose of visit and sources of
Or not yet engaged? (if the presenting part moves upward information.
so that the examiners hands can be pressed together, Implementation – application of nursing
then the head is not yet engaged.) process-assessment, provision of direct
Use gentle but deep pressure. nursing care as needed and evaluation,
Monitor the fetal heartbeat using fetoscope, or if not family assessment form guides this
available, use the stethoscope. purpose.
Procedure: The nurse performs assessment and
Using thumb and finger, grasp the lower portion of the physical care of clients, so she should
abdomen above symphysis pubis, press in slightly and observe aseptic practices such as hand
make gentle movements from side to side. washing before and after touching family
members, proper disposal of soiled
Findings: materials and body secretions. Coupled
The presenting part is engaged if it is not movable. with explanation. This is an opportunity
It is not yet engaged if it is still movable. for the nurse to teach family by visual
demonstration practical methods of
preventing spread of infection.
Termination – summarizing with the
family the events during home visit and
setting a subsequent home visit or
another form of family nurse contact
examples clinical visit. The nurse may
record findings, example vital signs of
family members and body weight.
  Post-visit – takes place when the nurse has
returned to health facility. Documentation of the
visit. A referral may be made. If a subsequent visit
has been set, planning for the next visit is done at
this time.

THE NURSING BAG – usually has the following:

 Articles for infection control/emergency purposes
 Articles for assessment of family members
 Articles for nursing care (sterile items, clean
articles, pieces of paper)

Rationale: to render effective nursing care to client and

members of family during home visit.

Principles:
﹡ Bag technique should minimize or prevent cross
contamination
﹡ Bag technique should save time and effort bad
technique should not over shadow concern to
patient, but rather show effectiveness in
rendering care.
﹡ Bag technique should be performed variety of
ways as long as infection prevention measures
are performed associated with agency policy.
﹡ Bag technique helps the nurse in infection control
﹡ Bag technique allows nurses to give care
efficiently.
﹡ Bag technique should not take away the nurses
focus on the patient and the family.
﹡ Bag technique may be performed in different
ways.

Sterile items inside the bag:

﹡ dressings
﹡ cotton balls
﹡ cotton tip applicator
﹡ syringes with needles
﹡ surgical gloves
﹡ cord clamp
﹡ 1 pair surgical scissors
﹡ sterile pad with kidney basin
﹡ 2 pair forceps (straight and curve)

Clean items inside the bag:

﹡ Adhesive tape
﹡ Bandage scissors
﹡ Pieces of paper