71
1 PERFORMING URETHRAL URINARY CATHETERIZATION PREPARATION 1. Assess The client’s overall condition If the client is able to cooperate and hold still during procedure If the client can be positioned supine with head relatively flat When the client last voided or was last catheterized Percuss the bladder to check for fullness or distension 2. Determine The most appropriate method of catheterization 3. Assemble Equipment Sterile catheter of appropriate size. An extra catheter should also be at hand. Catheterization kit or individual sterile items o 1-2 pair of sterile gloves o Water proof drape(s) o Antiseptic solution o Cleansing balls o Forceps o Water soluble lubricant o Urine receptacle o Specimen container For an indwelling catheter o Syringe prefilled with sterile water in amount specified by the catheter’s manufacturer o Collection bag and tubing o 2% xylocaine gel (if agency permits) o Disposable clean gloves o Supplies for performing perineal cleansing o Both blanket or sheet for draping the client o Adequate lighting obtain a flashlight or lamp if necessary 4. Perform routine perineal care to cleanse the meatus from gross contamination.

Related Learning Experience (RLE)

Embed Size (px)

DESCRIPTION

for nursing Student RLE 101

Citation preview

Page 1: Related Learning Experience (RLE)

1

PERFORMING URETHRAL URINARY CATHETERIZATION

PREPARATION

1. Assess

The client’s overall condition

If the client is able to cooperate and hold still during procedure

If the client can be positioned supine with head relatively flat

When the client last voided or was last catheterized

Percuss the bladder to check for fullness or distension

2. Determine

The most appropriate method of catheterization

3. Assemble Equipment

Sterile catheter of appropriate size. An extra catheter should also be at hand.

Catheterization kit or individual sterile items

o 1-2 pair of sterile gloves

o Water proof drape(s)

o Antiseptic solution

o Cleansing balls

o Forceps

o Water soluble lubricant

o Urine receptacle

o Specimen container

For an indwelling catheter

o Syringe prefilled with sterile water in amount specified by the catheter’s

manufacturer

o Collection bag and tubing

o 2% xylocaine gel (if agency permits)

o Disposable clean gloves

o Supplies for performing perineal cleansing

o Both blanket or sheet for draping the client

o Adequate lighting – obtain a flashlight or lamp if necessary

4. Perform routine perineal care to cleanse the meatus from gross contamination.

Page 2: Related Learning Experience (RLE)

2

Procedure

1. Check the doctor’s order for catheterization.

2. Introduce yourself and verify the client’s identity. Explain to the client what you

are going to do, why it is necessary and how the client can cooperate.

3. Perform hand hygiene and observe for other appropriate infection control

procedure.

4. Provide for the client’s privacy.

5. Place the client in the appropriate position and drape all the areas except the

perineum.

o Female: Supine, kness flexed 2 feet apart

o Male supine, legs slightly abducted

6. Establish adequate lighting. Stand on the client’s right if you are a right handed.

On the client’s left if you are a left handed.

7. If using a collecting bag not contained within the catheterization kit. Open the

drainage package and place the end of the tubing within reach.

8. If agency policy permits, apply clean gloves and inject 10-15 mL Xylocaine gel

into the urethra of the female client. Wipe the underside of the shaft to distribute

to get up the urethra. Wait atleast 5 minutes for the gel to take effect before

inserting the catheter. Remove the gloves.

9. Open the catheterization kit. Place the waterproof drape under the buttocks

(female) or penis (male) without contaminating the center of the drape with your

hands.

10. Apply sterile gloves.

11. Organize the remaining supplies.

o Saturate the cleansing balls with the antiseptic solution

o Open the lubricant package

o Remove the specimen container and place it nearby with the lid loosely on

top

12. Attach the prefilled syringe to the indwelling catheter inflation hub.and test the

balloon.

13. Lubricate the catheter and place it with drainage end inside the collecting

container.

14. If desired, place the fenestrated drape over the perineum exposing the urinary

meatus.

15. Cleanse the meatus

Page 3: Related Learning Experience (RLE)

3

Female:

1. The nondominant hand is considered contaminated once it touches the client’s

client.

2. Use your nondominant hand to spread labia. Establish a firm but gentle position.

3. Pick up a cleansing ball with the forceps in your dominant hand and wipe one

side of the labia majora in a anteroposterior direction.

4. Use a new ball for the opposite side.

5. Repeat for the labia minora.

6. Use the past ball to cleanse directly over one meatus.

Male:

1. Use the nondominant hand to grasp the penis just below the glans. If necessary,

retract the foreskin. Hold the penis firmly upright with slightly tension.

2. Pick up a cleansing ball with the forceps in your dominant hand and wipe from

the m.eatus in a circular motion around the glands.

3. Use a new ball and repeat 3 more times.

16. Insert the catheter Grasp the catheter firmly 2-3 inches from the tip. Ask the client to take a slow deep

breath and insert the catheter as the client exhales.

Advance the catheter 2 inches further after the urine begins to flow through it or per

agency policy.

If the catheter accidentally contacts the labia or slips into the vagina, it is considered

contaminated and a new sterile catheter must be used. The contaminated catheter may

be left in the vagina until the new catheter is inserted to help avoid mistaking the vaginal

opening for the urethral meatus.

Page 4: Related Learning Experience (RLE)

4

17. Hold the catheter with the nondominant hand. In males, lay the penis down onto

the drape, being careful that the catheter does not pull out.

18. For indwelling catheter inflate the retention balloon with the designated volume.

Without releasing the catheter, hold the inflation valve between two fingers

of your nondominant hand while you attach the syringe and inflate with

your nondominant hand.

If the client complains of discomfort immediately withdraw the instilled

fluid, advance the catheter further and attempt to inflate the balloon again.

Pull gently on the catheter until resistance is felt to insure that the balloon

has inflated and to place it in the trigone of the bladder.

19. Collect a urine specimen, if needed. Allow 20-30 mL to flow into the bottle

without touching the catheter to the bottle.

Page 5: Related Learning Experience (RLE)

5

20. Allow straight catheter to continue draining. If necessary attach the drainage end

of an indwelling catheter to the collecting tubing and bag.

21. Examine and measure the urine. In some cases only 750-1000 mL of urine are to

be drain from the bladder at one time. Check agency policy.

22. Remove the straight catheter, secure the catheter tubing to the inner thigh for

female clients or the upper thigh/abdomen for the male clients, with enough slack

to allow usual movement.

Also secure the collecting tubing to the bed linens and hang the bag below the

level of the bladder. No tubing should fall below the top of the bag.

23. Wipe the perineal area of any remaining antiseptic or lubricant. Replace the

foreskin, if retracted earlier. Return the client to a comfortable position.

24. Discard all used supplies in appropriate receptacles and perform hand hygiene.

25. Document the catheterization procedure including catheter procedure and result

in the client records.

Page 6: Related Learning Experience (RLE)

6

REMOVING AND SERVING OF BED PAN

PURPOSE:

To facilitate and encourage normal elimination of urinary abd bowel wastes

for patient confined to bed.

EQUIPMENT:

Obtain from central supply or from designated storage area:

1. Disposable bedpan or urinal

2. Disposable washbasin

3. Bedpan cover (towel)

4. Disposable gloves

5. Disposable “wet” wiped

6. Linen saver pad

Obtain from the laundry:

1. Hand towel

2. Wash cloth

Have soap available

Page 7: Related Learning Experience (RLE)

7

PROCEDURE

Giving a bedpan:

1. Provide screen or close door. To minimize embarrassment and ensure privacy.

2. Wash hands, and apply disposable glove. To prevent cross-contamination.

3. Obtain bedpan from designated area or bedside stand. Make certain it is labeled with

the patient’s name and number if bedpan is being re-used for the same patient. To

Avoid cross-contamination.

4. Turn bedding back, exposing as little of the patient as possible. To maintain the

patient’s privacy.

5. Have patient flex his knees and raise buttocks, if possible. Assist him where it is

necessary by placing hand under low back and lifting. Allows space for bedpan between

the individual and bed. Check to ensure that he is not restricted from moving or certain

types of posture.

6. If patient cannot use his legs to raise himself, turn him on his side. Position

bedpan to buttocks and roll him onto his back with bedpan under him. Be sure bedpan

is in proper position.

7. Adjust the bed to the most comfortable position for the patient if orders allow. If

possible, elevate the head of the bed slightly to prevent hyperextension of the spine. If

elevation of the head is contraindicated, tuck a pillow or folded blanked under the

patient’s back to cushion the sacrum against he bedpan and support the lumbar area.

Using the bedpan is difficult for most people. When permitted elevating the head of the

bed aids in elimination.

8. Leave the patient alone with the toilet tissue within easy reach (Unit 1 ensures patient

has access to call bell). Minimizes patient embarrassment.

9. Dispose of gloves, wash hands per hand hygiene policy.

Page 8: Related Learning Experience (RLE)

8

Removing a bedpan:

1. Apply disposable gloves. The patient’s condition and the physicians order will

determine how much he is able to do for himself.

2. . Lower head of bed have patient flex his knees and rise up buttocks; then

remove the bedpan. Assist and support the patient as necessary. The patient’s

condition and the physicians order will determine how much he is able to do for himself.

3. If the patient is unable to care for and clean himself, hold the bedpan firmly and turn

the patient to his side off the bedpan. Hold the bedpan to prevent it from tipping as the

patient turns.

4. Remove and cover bedpan and place it to the side of the bed. To protect bedding and

prevent odors.

5. Cleanse anal area with disposable “wet” wipe, then wash, and dry anal area and

buttocks. To prevent excoriation and breakdown of skin

6. Provide materials for patient to wash and dry his hands and position him for comfort.

To provide hygiene and comfort.

7. Empty contents of bedpan into toilet and flush. Discard per I.C.M. All disposable

items will be discarded per I.C.M. III.C. To Eliminate risk of cross contamination and

reduce the risk of communicable disease transmission.

8. Open door or remove screen

9. Measure and record contents if patients are on I&O and dispose of contents in toilet

room. Return urinal to bedside stand. Disposable articles will be discarded per ICM. To

eliminate risk of cross contamination and reduce risk of communicable disease

transmission.

Page 9: Related Learning Experience (RLE)

9

HOT SITZ BATH

Definition

Sitz bath or hip bath is a bath in which a patient sits in water up to the hips to relieve

discomfort and pain in the lower part of the body. Sitz bath works by keeping the

affected area clean and increasing the flow of blood.

A sitz bath may be created simply by filling a bathtub with some water and sitting in it

for a few minutes. Alternatively, a large basin can be used. There are also special

devices that fit into toilet bowls. Sitz baths may either be warm or cool. Some people

find alternating between hot and cold water soothing. Sitz baths may be filled with just

water, or substances such as salt, baking soda or vinegar can be added.

Origin of Term

The term sitz bath is derived from the German word Sitzbad,meaning a bath (Bad) in

which one sits (sitzen).

Objectives

To relieve muscle spasm

To soften exudates

To hasten the suppuration process

To hasten healing

To reduce congestion and provide comfort in the perineal area

Purposes

To aid healing a wound in the area by cleaning on discharges and slough

To induce voiding in urinary retention

To relieve pain, congestion and inflammation in cases of: hemorroids, tenesmus,

rectal surgery, anal fissures, after proctoscopic or cycloscopic exams., sciatica,

uterine and renal colic.

To induce menstruation.

Indications

Hemorrhoids

Anal Fissures/Surgery

Episiotomy

Uterine Cramps

Page 10: Related Learning Experience (RLE)

10

Important Considerations

Warm water should not be used if considerable congestion is already present.

The patient should be observed closely for signs of weakness and faintness.

After the patient is in the tub or the chair, check to see whether or not there is

pressure against the patient’s thighs or legs.

Support patient’s back in the lumbar region.

Contraindication

Menstruating or pregnant women

Equipment

Sitz tub half filled with water 105F

Pitcher of water 130F

Bath thermometer

Ice cap-with cover

Fresh camisa

Bath towel

Bath blanket

Rubber ring p.r.n.

Preparation

Take all necessary equipment to bathroom or treatment room.

Run water into tub and check temperature—105F or 40.5C

Place rubber ring at bottom of tub p.r.n. or line bottom with towel.

Charting

Type of solution

Length of time of application

Type of heat application

Condition and appearance of wound

Comfort of patient

Equipment

Available bathroom with appropriate size tub for patient.

Towels and bathmat

Bath blanket

Inflatable ring

Patient’s clean clothes

Page 11: Related Learning Experience (RLE)

11

Procedure

Nursing Interventions Rationale

Check physician’s order for sitz

bath patient. To know if it is indicated for the patient.

Prepare the materials needed:

Take linen to bathroom.

Fill clean tub about one-third full

with warm water.

Check with your hand to determine

that temperature of water is

between 105°F and 110°F (40.5°C

to 43.3°C).

Place towel or inflatable ring, if

appropriate, on tub bottom and

bathmat on floor beside tub.

To save time and effort

Explain purpose and procedure to

patient.

For the patient to be aware on the purpose and

procedure.

Test the water in a sitz with a

thermometer before the patient

enters the tub. If the purpose of the

sitz bath is to apply heat, water at

a temperature of 43°C to 46°C for

15 minutes will produce relaxation

of the parts involved after a short

contraction.

Warm water should not be used if considerable

congestion is already present. If the purpose of the sitz

bath is to produce relaxation or to help promote

healing in a wound by cleaning it of discharge and

debris, then water at a temperature of 34°C to 37°C is

used.

Page 12: Related Learning Experience (RLE)

12

Assist the patient into the tub and

position him properly.Check to see

whether there is pressure against

the patient’s thighs or legs.If the

patient’s feet do not touch the

floor, and the weight of the legs is

resting on the edge of the tub, a

stool should be used to support the

feet and to relieve the pressure on

the back of the legs.It may also be

necessary to place a towel in the

water to support the patient’s back

in the lumbar region.The bath can

seem very long if one’s body is not

in good alignment and

comfortable.

Wrap a bath blanket around the

patient’s shoulders, and drape the

ends over the tub.

This protects the patient’s from feeling chilly and form

exposure.

Observe the patient closely for

signs of weakness and fatigue. A

cold compress may be placed at

the back of the neck or forehead,

to help prevent the patient from

feeling weak. Discontinue the bath

if the patient’s condition warrants.

Typical signs of faintness include skin pallor, a rapid

pulse rate, and nausea.

Test the water in the tub several

times, and keep it at the desired

temperature. Additional hot water

may be added by pouring it slowly

form a pitcher or by opening a hot-

water fauce a little bit.

The water should be agitated by stirring it as hot water

and added to prevent burning the patient.

Do not leave the patient alone

unless it is absolutely certain that it

is safe to do so.

Page 13: Related Learning Experience (RLE)

13

Help the patient out of the tub

when the bath is completed.

Normally, a hot sitz bath should be

continued for 15 to 30 minutes.

Help the patient dry, and cover the patient adequately.

Assist the patient to his bed, where it is best for him to lie down, and out of drafts until

normal circulation returns.

Page 14: Related Learning Experience (RLE)

14

APPLICATION OF HOT AND COLD

COLD

Cold causes vasoconstriction (shrinkage of blood vessels), decreasing blood flow

to an area, and slowing the body’s metabolism and its demand for oxygen. The

therapeutic goals of cold applications include controlling hemorrhage, reducing edema,

easing inflammation, and blocking pain receptors.

Rationale for Cold Application

Cold application prevents escape of heat from the body by slowing circulation,

which also relieves congestion and often relieves muscle pain. A cold

application: • Slows or stops bleeding

• Slows bacterial activity in clients with an infection

• Relieves pain following some types of surgery, tooth extraction, headache, or muscle or joint injury

• Reduces swelling in injured tissues, including sprains and fractures

• Prevents peristalsis in clients with abdominal inflammation

• Relieves pain in engorged breasts

Page 15: Related Learning Experience (RLE)

15

• Controls pain and fluid loss in the initial treatment of burns

• Diminishes muscle contraction and muscle spasms

• Slows the basal metabolism for certain types of surgery.

APPLYING COLD THERAPY

• Stop the cold application immediately if the client complains of numbness or the

skin appears white or spotty. Rationale: Cold numbs nerve endings.

• As cold decreases the flow of blood in one area of the body, flow increases to

other areas. Rationale: This explains why cold or chilling drafts striking the body often

cause congestion in the nasal passages.

• Continued application of cold affects deeper tissues. It is important to monitor the

client closely. Rationale: Prolonged exposure to extreme cold may cause serious injury.

• Cold often is applied to a sprain, strain, fracture, or burn. Rationale: This helps

remove blood and lymph congestion in the area and reduces pain.

HEAT

Heat is often applied in general client care. Heat causes vasodilation (enlargement of

blood vessels), increasing blood flow to a specific area. This increases the oxygen,

nutrients, and various blood cells delivered to body tissues. Vasodilation also aids in

removal of wastes from injured tissues, such as debris from phagocytosis.

Page 16: Related Learning Experience (RLE)

16

Rationale for Heat Application

Heat application serves to: • Relieve local pain, stiffness, or aching, particularly of muscles and joints

• Assist in wound healing

• Reduce inflammation and infection

• Make the chilly client more comfortable

• Raise body temperature to help maintain normothermia

• Promote drainage (draw infected material out of wounds)

Because heat must be fairly intense to be effective, burns may result if heat is

applied improperly or for too long. The application must be sufficiently hot to accomplish

its purpose, but within a safe temperature range. Box 54-1 provides temperature ranges

for hot and cold applications. Heat applied over a large area affords more warmth;

however, the potential for injury is greater than that of heat applied over a small area.

Protect the client from possible burn injury by observing safety precautions. In Practice:

Nursing Care Guidelines 54-1 outlines steps for applying heat therapy.

Both dry heat and moist heat have local effects. Apply dry heat with a heating

blanket, warm-water bag, waterproof, water-filled heating pad (aquathermia pad), heat

lamp, electric heat cradle, or electric heating pad. Moist heat warms the skin more

quickly and is more penetrating than dry heat, because water is a better heat conductor

than air. Apply moist heat with compresses, packs, or soaks, including the sitz bath.

Sometimes wet compresses are used in combination with the aquathermia pad to

provide longer-lasting moist heat. Skin maceration (abnormal softening) may develop

when moisture is applied directly to the skin for long periods. The client’s skin may be

protected by first applying a thin layer of petroleum jelly, if ordered. The provider’s order

typically specifies the length of time for heat applications to be administered. For

Page 17: Related Learning Experience (RLE)

17

example, the order may be: “Moist compresses for 15 minutes every hour WA (while

awake).”

Approximate Range of Temperatures for Hot and Cold Applications

Hot 37.7°C-40.5°C I00°F-I05°F

Warm 35°C-37.7°C 95°F-!00°F

Tepid 26.6°C-35°C 80°F-95°F

Cool 8.3°C-26.6°C 65°F-80°F

Cold 0°C-!8.3°C 50°F-65°F

To convert Fahrenheit to Celsius: C = (F – 32) X 5/9

To convert Celsius to Fahrenheit: F = (C X 9/5) + 32

APPLYING HEAT THERAPY

• Heat is applied only when specifically ordered by a primary provider and applied

with the utmost caution. Rationale: Nerves in the skin are numbed easily. The client

may not feel the pain of a burn, especially if heat has been applied often.

• Specific body parts, such as the eyelids, neck, and inside an arm, are especially

sensitive to heat.

• Each person has his or her own sensitivity to heat. Apply the heat source slowly

and ask the client for feedback. Rationale: This helps determine how much heat is safe

and for how long.

Page 18: Related Learning Experience (RLE)

18

• Infants, older people, and those with fair, thin skin have less heat resistance.

Lowered body resistance because of illness also makes body tissues less resistant to

heat. Rationale: It is important to consider each client individually.

• Clients who are unresponsive or anesthetized and those with neurologic or

psychological disorders or dementia are at increased risk for injury from heat

applications. Rationale: These clients are often unable to report when heat is too

intense.

• Impaired circulation and some metabolic diseases make people more susceptible

to burns (e.g., clients who are in shock or have any type of peripheral vascular disorder,

or clients who have diabetes). Rationale: Changes in body systems interfere with skin

integrity and healing and may impair the client’s ability to identify discomfort.

• Clients receiving radiation therapy or chemotherapy and those with any degree of

paralysis are particularly susceptible to burns. Rationale: Such clients have

compromised immune systems or skin integrity.

• Client complaints are very important. Listen to the client; if he or she complains of

pain or discomfort, stop the treatment and consult the primary provider Rationale: Each

client is different. Only the client can state how the treatment feels.

Page 19: Related Learning Experience (RLE)

19

PERINEAL HEAT APPLICATION

Purpose:

1. To increase the flow of blood to relieve congetion over the perineum. 2. To hasten the absorption of inflammatory exudates. 3. To hasten the healing of wounds by stimulating granulation of tissue and drying the

exudation.

Equipments:

Heat lamp

Bed sheet

Bath towel

Tape measure

Procedure

Assemble equipment To prevent errors 2. Identify the patient by checking the ID Bracelet.

To prevent errors Explain the procedure and provide privacy and proper draping technique.

To ensure cooperation. 4. Remove the underware and the peripad.

To expose the perineal area.

Position if modified lithotomy position, keeping feet on mattress with knees bent and separated.

Distance of heat lamp from area of exposure is 18 inches unless otherwise indicated.

To prevent burning, blanching of skin from too much heat.

Keep all linens away from the lamp. NOTE: contact with lamp may lead to accidental burning of linens.

8. Expose the area for 10 minutes unless otherwise ordered. NOTE: prolonged exposure leads to burn.

9. Check the skin for redness or blanching from time to time. 10. After the procedure, keep the patient as comfortable as possible. Replace

peripad. 11. Clean and return the equipment properly. 12. Chart the following:

Time the heat was apllied and lenght of treatment.

Relavant observations.

Page 20: Related Learning Experience (RLE)

20

Patient’s response

BREAST CARE

Purpose:

To train all nursing staff who care for the new mother - baby dyad in the skills

necessary to implement this policy.

To inform all pregnant patients about the benefits and management of

breastfeeding.

To assist the staff in providing consistent breastfeeding information to all

maternity patients and assistance to the breastfeeding mother - baby couplet to

best support exclusive breastfeeding for her baby for the first six months of life.

Procedure:

1. Gather equipment

• Breastfeeding handouts/resources - Breast feeding Resources/Log, Breast

Engorgement, Breast Milk Collection and Storage.

• Breast pump (if needed)

• Breast cream (if needed)

• Bed pillows or Breastfeeding pillow

2. Within 30 minutes of delivery place the infant skin-to-skin across the mother’s

chest. Maintain infant's body temperature with a knit cap and warm blankets

tucked close. Encourage eye contact and light touch.

3. Encourage the mother to breast feed the infant within the first hour after birth,

preferably within the first 20-30 minutes, prior to initial bath.

4. Assist mother with breast-feeding and provide teaching and support as indicated.

Points to include are:

Use pillows to support the mother’s arms and to position infant level with

the breast.

Express a small amount of colostrum onto the nipple to interest the infant

in sucking.

Mother supports her breast using the "C” hold. The thumb is placed on

top of the breast and the four fingers support the breast underneath. All

fingers should be well back from the areola.

Mother tickles the center of the infant’s lower lip with her nipple until the

infant opens his mouth wide as possible. This may take several attempts

to do.

When infant’s mouth is open very wide with the tongue down, mother

Page 21: Related Learning Experience (RLE)

21

should center her nipple quickly and draw the baby in close to her body.

Infant’s mouth and lips should form a flanged seal around the breast

tissue. The tongue should be curved around the areola, cupping it and

extending over the gum line.

Infant’s nose and chin should be touching the breast. There is no need to

create an air space for most infants.

Identify nutritive sucking, which is 8 -10 long, drawing sucks w/ audible

swallows followed with a 5 -10 second rest period. Non-nutritive sucking is

usually 2-3 short, choppy sucks that are ineffective.

Identify quiet sounds of swallowing i.e. a “k” or “h” phonics sound.

Infant should finish the first breast or self-detach before offering the

second breast.

De-latch the infant if feeding becomes uncomfortable, latch does not

appear deep enough, or a non-nutritive sucking pattern is seen, by placing

a clean finger in the side of the infant’s mouth between his jaws to release

the suction. Then assist mother to correctly re-latch the infant.

Frequency and duration of feedings at the breast should be infant - led.

Infant is expected to nurse approximately 8-12 times in 24 hours. Feeding

sessions may last 5-50 minutes or longer.

Page 22: Related Learning Experience (RLE)

22

Breastfeeding Interventions

1. If a mother has a flat or inverted nipple and the infant is unable to latch, the nurse

may use a manual breast pump or inverted syringe to draw out nipple prior to

initiating latch. After consulting with a lactation team member, consider a nipple

shield to attain latch.

2. Provide a functional assessment of the infant at the breast during a feeding,

utilizing the LATCH tool a minimum of once every shift, to be documented on

infant’s chart.

3. The Lactation Consultant/Educator/mother-baby nurse examines nipples

whenever mother expresses concerns or complaints of sore nipples.

LC/LE/mother-baby nurse to observe/assess the next feeding.

4. When prolonged separation of mother and infant is expected (i.e. premature, ill

infant), help the mother initiate pumping as soon as medically feasible, optimally

within 3 hours and no later than 6 hours after delivery.

5. The colostrum or milk obtained by expression should be collected and made

available to the baby when feedings begin.

6. For mothers experiencing a fetal demise or newborn loss, provide the “Milk

Suppression” handout.

Breast Care/Education

1. Examine mother's breasts and nipples during daily shift assessments. The nurse

can demonstrate breast care by teaching hand expression of colostrum/breast

milk onto the areola after feeds, then allow to air dry. The nurse may provide

breast cream if there are visible signs of redness, cracking or bleeding of the

nipple or if the mother complains of soreness.

2. Encourage exclusive breast feeding for the first 6 months of infant’s life.

3. If the mother insists on supplementing after breastfeeding, recommend limiting

the amount of formula to ½ - 1 oz and to discontinue supplementation once the

milk has come in (approximately day 3-5). Offer alternative feeding methods in

lieu of traditional bottle- feeding and provide the printed handout on “Breast

feeding and Alternative Feeding Choices”.

4. Instruct the mother on pumping techniques using the electric breast pump, when

the infant demonstrates inadequate suckling or if the mother-baby dyad are

separated indefinitely.

5. When pumping is necessary, provide written guidelines to the mother on

pumping, collection bottles, labels and lids for expressed milk. The information

will include resource numbers for rental of a hospital grade electric breast pump

for use after discharge.

Page 23: Related Learning Experience (RLE)

23

6. Instruct all patients regarding infant-led feeding cues-Watch the infant for signs

of readiness to feed such as increased alertness or activity, mouthing or rooting,

rapid eye movement while asleep, and hand-to-mouth movement. Crying is a late

sign of hunger. If feeding cues are not responded to in a timely manner, the

infant may not be cooperative.

7. Instruct all patients regarding cluster feeding patterns-Frequent feeding, during

periods of increased wakefulness; a series of mini-feedings snacks or courses,

usually followed by a period of deep sleep; normal in the first 3 weeks.

8. Instruct all patients how to manually ex press their milk, in the eve nt a feeding is

delayed, or they are separated from their infant.

9. Instruct all patients in t he use of the feeding log, and to monitor diaper count for

the first week of their infant’s life; evidence of adequate nourishment from the

breast would be sufficient output of urine and stool. Day 1>one urine, one stool;

Day 2>two urine, two stools; Day 3>three urine, two stools; etc.-Day 6 and

beyond>5-6 urine, 4+stools. Instruct mother to contact pediatrician if diaper

count not as described on breastfeeding resource log.

10. Instruct all patients in the “Supply and Dem and” principle of milk production-

The more the infant breastfeeds, the more milk will be produced. During growth

spurts infants nurse more often to stimulate the mother’s milk supply to meet

their new requirements.

11. Educate the mothers who are undecided about breastfeeding on the benefits of

breastfeeding and human milk. Points to include are:

American Academy of Pediatrics recommends exclusive breastfeeding for the

first six months of life.

Breast milk provides optimal composition for brain and eye development,

decreases incidence of diarrhea, upper respiratory infections and some allergies,

promotes bonding and mother/infant closeness, reduces incidence of postpartum

hemorrhage for mother and is economical and convenient.

12. Provide the mother with the postpartum parent educational booklet on self-care,

nutrition, infant care and infant feeding. Encourage the mother to watch the

Newborn Channel to reinforce other teaching provided for infant care and

feeding.

13. Provide all patients with a breastfeeding packet with additional breastfeeding

recommendations including feeding/diaper log and resource numbers for

breastfeeding assistance after discharge

14. Instruct mothers on normal infant weight loss.

Page 24: Related Learning Experience (RLE)

24

Page 25: Related Learning Experience (RLE)

25

Documentation

1. Document on the infant's chart the attempt to get the infant to breast feed; if

supplementation medically indicated, document rationale in electronic medical

record prior to supplementation.

2. Document the infant's response and the method of feeding used to provide

nourishment to the infant.

3. If the mother insists that the baby be fed in the nursery during the night, requests

a pacifier or bottle supplementation, document in the mother’s electronic medical

record the mother’s request and the education provided as to the impact

separation and/ or use of artificial nipples and/or formula, may have on the

success of breastfeeding

4. Document observed or patient reported LATCH assessment with each feeding

on infant’s chart.

Page 26: Related Learning Experience (RLE)

26

ORAL MEDICATION

The most common way people take medications is orally (by mouth). Depending on what your

doctor has prescribed, your oral medication can be swallowed, chewed or placed under your

tongue to dissolve.

Assess

Allergies.

Client’s ability to swallow medication.

Presence of vomiting or diarrhea that would interfere with the ability to absorb the

medication.

Specific drug action, side effects, interactions, and adverse reaction.

Client’s knowledge of and learning needs about the medication.

Perform appropriate assessment specific to the medication.

Determine if the assessment date influences the administration of the medication.

Assemble equipment and supplies:

Dispensing system.

Disposable medication cups: small paper or plastic cups for tablets and capsules, or

waxed or plastic calibrated medication cups for liquids.

Medication administration record (MAR), or computer printout.

Pill crusher/cutter.

Straws to administer medication that might discolor the teeth, or to facilitate the ingestion

of liquid medication for clients.

Drinking glass and water or juice.

Applesauce or pudding to use for crushed medication.

Know the reason why the client is receiving the medication, the drug classification,

contradiction, usual dosage range, side effects, and nursing considerations for

administrating and evaluating the intended outcomes for the medication.

Check the MAR

Check the MAR for the drug name, dosage, and frequency, route of administration, and

expiration, date for administering the medication, if appropriate.

If the MAR is unclear or pertinent information is missing, compare the MAR with the

most recent primary care provider’s written order.

Report any discrepancies to the charge nurse or the primary care provider, as agency

policy dictates.

Page 27: Related Learning Experience (RLE)

27

Verify the client’s ability to take medication orally.

Determine whether the client can swallow, is NPO, is nauseated or vomiting, has gastric

suction, or has diminished or absent bowel sounds.

Organized the supplies.

Assemble the MAR(s) for each client together so that medication can be prepared for

one client at a time.

PROCEDURE

Perform hand hygiene, and observe other appropriate infection control procedures.

Unlock the dispensing system

Obtain appropriate medication

Read the MAR and take the appropriate medication from the shelf, drawer, or

refrigerator.

Compare the label of the medication container or unit-dose package with the order on

the MAR or computer printout. If they are not identical, recheck the prescriber’s written

order in the clients chart. If there is still is a discrepancy, check with the nurse in charge,

or with the pharmacist.

Check the expiration date of the medication. Return expired medication to the pharmacy.

Use only medications that have clear, legible labels.

Prepare the medication.

Calculate medication dosage accurately.

Prepare the correct amount of medication for the required dose, without contaminating

the medication.

While preparing the medication, recheck each prepared drug and container with the

MAR again.

Tables of Capsules

Place package unit-dose capsules or tablets directly into the medicine cup. Do not

remove the medication from the wrapper until at the bedside.

If using a stock container, pour the required number into the bottle cap, the transfer the

medication to the disposable cup without touching the tablets.

Keep narcotics and medication that require specific assessment-such as pulse

measurements, respiratory rate or depth, or blood pressure-separate from others.

Break scored tablets only, if necessary to obtain the correct dosage. Use a file or cutting

devise if needed. Check the agency policy as to whether unused portions of a

medication can be discarded and, if so how they are to be discarded.

Page 28: Related Learning Experience (RLE)

28

If the client has difficulty swallowing, crush the tablets (check to make sure tablets may

be crushed) to a fine powder with a pill crusher, or between two medication cups. Then

mix the powder with a small amount of soft food such as applesauce.

Liquid Medication

Thoroughly mix the medication before pouring. Discard any medication that has changed

color or turned cloudy.

Remove the cap, and place it upside down on the countertop.

Hold the bottle so the label is next to your palm, and pour the medication away from the

label.

Place the medication cup at eye level, and fill it to the desired level, using the bottom of

the meniscus to align with the container scale.

Before capping the bottle, wipe the lip with paper towel.

When giving small amounts of liquids (< 5ml), prepare the medication in a syringe

without the needle, or in a specially designed oral syringe. Label the syringe with the

name of the medication and route (PO).

Keep unit-dose liquids in their packages, and open them at

the bedside.

Oral Narcotics

If an agency uses a manual recording system for controlled substances, check the

narcotic record for the previous drug count, and compare it with the supply available.

Remove the next available tablet, and drop it in the medicine cup.

After removing a tablet, record the necessary information on the appropriate narcotic

control record, and sign it.

Page 29: Related Learning Experience (RLE)

29

Note: Computer-controlled dispensing system allow access only to the selected drug,

and automatically record its use.

All Medication

Place the prepared medication and MAR together on the medication chart.

Recheck the label on the container before returning the bottle, box, or envelope to its

storage place.

Avoid leaving prepared medication unattended.

Lock the medication cart entering the clients room.

Check the room number against the MAR if agency policy does not allow the MAR to be

removed from the medication cart.

Provide for client privacy.

Prepare the client.

Check the client’s identification band.

Assist the client to sitting position or, if not possible, to a side lying position.

If not previously assessed, take the required assessment measures such as pulse and

respiratory rates or blood pressure.

Explain the purpose of the medication and how it will help, using language that the client

can understand, Include relevant information about effects.

Administer the medication at the correct time.

Take the medication to the client within 30 minutes before or after the scheduled time.

Give the client sufficient water or preferred juice to swallow the medication. Before using

juice, check for any food and medication incompatibilities.

If the client is unable to hold the pill cup, use it to introduce the medication into the

client’s mouth, and give only one tablet or capsule at a time.

If an older child or adult ha difficulty swallowing, and ask the client to place the

medication on the back of the tongue before taking the water.

If the medication has an objectionable taste, ask the patients to suck a few ice chips

beforehand, or give the medication with juice, applesauce, or bread, if there are no

contraindications.

If the client says that the medication you are about to give is different from what the

client has been receiving, do not give the medication without first checking the original

order.

Stay with the client until all medications have been swallowed.

Page 30: Related Learning Experience (RLE)

30

Document each medication given.

Record the medication given, dosage, time, any complaints or assessment of the client,

and your signature

If medication was refused or omitted, record this fact on the appropriate record;

document the reason, when possible, and the nurse’s actions, according to agency

policy.

Dispose of all supplies appropriately.

Replenish stock, and return the cart to the appropriate place.

Discard used disposable supplies.

Evaluate the effects of the medication.

Return to the client when the medication is expected to take effect to evaluate the effects

of the medication on the client.

Page 31: Related Learning Experience (RLE)

31

Subcutaneous Injection

Where can I give a subcutaneous injection?

The following are sites where you can give a subcutaneous injection:

Abdomen: Uncover your abdomen. You may give an injection within the following area: below the waist to just above the hip bone and from the side to about 2 inches from the belly button. Avoid the belly button.

Thigh: Uncover the entire leg. Find the area halfway between the knee and hip and slightly to the side. Gently grasp the area to make sure you can pinch 1 to 2 inches of skin.

Upper Arm: Uncover the arm to the shoulder. Have the person getting the injection stand with his hand on his hip. Stand next to and a little behind the person. Find the area halfway between the elbow and shoulder. Gently grasp the skin at the back of the arm between your thumb and first 2 fingers. You should be able to grasp 1 to 2 inches of skin

Page 32: Related Learning Experience (RLE)

32

Materials needed

Syringe with the drug to be administered (without air), needle (Gauss 25, short and thin; on syringe), liquid disinfectant, cotton wool, adhesive tape.

Technique

1. Wash hands.

2. Reassure the patient and explain the procedure.

3. Uncover the area to be injected (upper arm, upper leg, abdomen).

4. Disinfect skin.

5. ‘Pinch’ fold of the skin.

6. Insert needle in the base of the skin-fold at an angle of 20 to 30 degrees.

7. Release skin.

8. Aspirate briefly; if blood appears: withdraw needle, replace it with a new one, if possible, and start again from point 4.

9. Inject slowly (0.5 - 2 minutes!).

10. Withdraw needle quickly.

11. Press sterile cotton wool onto the opening. Fix with adhesive tape.

12. Check the patient's reaction and give additional reassurance, if necessary.

13. Clean up; dispose of waste safely; wash hands.

Page 33: Related Learning Experience (RLE)

33

INTRAMUSCULAR INJECTION

Safe areas to give an IM injection:

Vastus Lateralis Muscle (Thigh): Look at your thigh and divide it into 3 equal parts. The middle third is where the injection will go. The thigh is a good place to give yourself an injection because it is easy to see. It is also a good spot for children younger than 3 years old.

Ventrogluteal Muscle (Hip): Have the person getting the injection lie on his or her side. To find the correct location, place the heel of your hand on the upper, outer part of the thigh where it meets the buttocks. Point your thumb at the groin and your fingers toward the person's head. Form a V with your fingers by separating your first finger from the other 3 fingers. You will feel the edge of a bone along the tips of your little and ring fingers. The place to give the injection is in the middle of the V. The hip is a good place for an injection for adults and children older than 7 months.

Page 34: Related Learning Experience (RLE)

34

Deltoid Muscle (Upper arm muscle): Completely expose the upper arm. You will give the injection in the center of an upside down triangle. Feel for the bone that goes across the top of the upper arm. This bone is called the acromion process. The bottom of it will form the base of the triangle. The point of the triangle is directly below the middle of the base at about the level of the armpit. The correct area to give an injection is in the center of the triangle, 1 to 2 inches below the acromion process.

Dorsogluteal Muscle (buttocks): Expose one side of the buttocks. With an alcohol wipe draw a line from the top of the crack between the buttocks to the side of the body. Find the middle of that line and go up 3 inches. From that point, draw another line down and across the first line, ending about halfway down the buttock. You should have drawn a cross. In the upper outer square you will feel a curved bone. The injection will go in the upper outer square below the curved bone. Do not use this site for infants or children younger than 3 years old. Their muscles are not developed enough.

Page 35: Related Learning Experience (RLE)

35

PROCEDURE:

Wash your hands with soap and dry them completely. Put on gloves if necessary.

Open the alcohol wipe: Wipe the area where you plan to give the injection. Let the area dry. Do not touch this area until you give the injection.

Prepare the needle: Hold the syringe with your writing hand and pull the cover off with your other hand. Place the syringe between your thumb and first finger. Let the barrel of the syringe rest on your second finger.

Hold the skin around where you will give the injection: With your free hand, gently press on and pull the skin so that it is slightly tight.

Insert the needle into the muscle: Hold the syringe barrel tightly and use your wrist to inject the needle through the skin and into the muscle at a 90 degree angle.

Check the needle: Let go of the skin with your other hand. Hold the syringe so it stays pointed straight in. Pull back on the plunger a little to make sure you did not hit a blood vessel. If blood comes back, remove the needle immediately. Do not inject the medicine. Dispose of both the syringe and the medicine. Get more medicine in a new syringe. When you give the second injection, give it on the other side.

Inject the medicine: Push down on the plunger to inject the medicine. Do not force the medicine by pushing hard. Some medicines hurt. You can inject the medicine slowly to reduce the pain.

Remove the needle: Once the medicine is injected, remove the needle at the same angle as it went in. Place gauze over the area where you gave the injection.

Page 36: Related Learning Experience (RLE)

36

ADMINISTERING INTRADERMAL INJECTIONS

GENERAL

a. An intradermal (ID) injection is the injection of a small amount of fluid into the dermal

layer of the skin (see figure 2-10). It is frequently done as a diagnostic measure, such

as for tuberculin testing (screening test for tuberculosis referred to as a tine test) and

allergy testing (placing very small amounts of the suspected antigen or allergen in a

solution under the skin). The intradermal injection is made in skin areas of the body that

are soft and yielding.

b. Often the tuberculin syringe is the only syringe with fine enough calibrations to

measure the minute dose that is used. A 26-gauge needle, which is one-fourth to one-

half inch in length, is usually selected. The fluid is in a small welt or "wheal" (a small

swelling of the skin due to the medication placed under the skin) just under the surface

of the skin and between its layers.

Page 37: Related Learning Experience (RLE)

37

PROCEDURE FOR ADMINISTERING AN INTRADERMAL INJECTION

Select Injection Site and Prepare Patient.

1. Selecting site. Usually palmer (inner) forearm or subscapular region of the back is

selected. The site selected should be an easily obtainable area and relatively free from

being rubbed by clothing.

2. Position patient. To position the patient, proceed as follows:

(a) Place arm in a relaxed position, elbow flexed.

(b) Place palm up, exposing palmer or inner arm area.

c. Prepare Injection Site d. Remove Needle Guard. Pull the guard straight off. e. Stabilize Injection Site. 1. Using your nondominant thumb, apply downward pressure, directly below and outside the prepared injection site. (Do not draw the skin back or move the skin to the side because the skin will return to its normal position when pressure is released and will cause the needle bevel to either go deeper into the skin or to leave the skin, depending upon which direction the skin moves.) 2Hold the skin taut until the needle bevel has been inserted between the skin layers. f. Insert Needle. 1. Using your dominant hand, hold syringe, bevel up, with fingers and thumb resting on the sides of the barrel. If you insert the needle at a 20 degree angle, lower it at once to 15 degrees. Do not place thumb or fingers under syringe because this will cause the angle of insertion to exceed 15 degrees causing the needle to insert beyond the dermis. 2.Insert needle, bevel up, just under the skin at an angle of 15 to 20 degrees until the bevel is covered. Continue stabilizing thumb pressure. You should feel some resistance. If the needle tip moves freely, you have inserted the needle too deeply. At this point, withdraw needle slightly and check again for resistance.

Page 38: Related Learning Experience (RLE)

38

g. Inject Medication. It is not necessary to aspirate the syringe since no large vessels are commonly found in the superficial layer of the skin. Inject the medication as follows: 1. Continue holding syringe with same hand. 2. Release skin tension with other hand. 3. With free hand, push plunger slowly forward until the medication is injected and a wheal appears at the site of the injection. The appearance of a wheal indicates that the

Page 39: Related Learning Experience (RLE)

39

medication has entered the area between the intradermal tissues. If a wheal does not appear, withdraw the needle and repeat the procedure in another site. h. Withdraw Needle. To withdraw the needle, quickly withdraw it at the same angle that it was inserted. i. Cover Injection Site. Without applying pressure, quickly cover injection site with a dry sterile small gauze. j. Perform Post injection Patient Care. k. Evaluate Reaction of Medication. Usually you, as the medical specialist, will not evaluate the reaction of a suspected allergic reaction or a tuberculin test, but will record the reaction. For a tuberculin test, the patient will wait 48 to 72 hours and then return to have an evaluation to determine if the patient has been exposed to tuberculosis. If the intradermal injection is done to determine if the patient is allergic to dust, pollen, or similar substances, a reaction will take place in a few minutes after the substance has been placed under the skin. (1) Instruct the patient to wait or return to have the test read according to local SOP. (2) Caution patient not to rub, scratch, or wash injection site. Rubbing, scratching, or washing may spread or dilute the medication, causing a false reading at a later time. l. Dispose of Equipment. Dispose of equipment according to local SOP. m. Record Administration of Intradermal Injection. Record the injection information on the patient's chart or record.

Page 40: Related Learning Experience (RLE)

40

Stages of labor First stage: Cervical Dilatation Stage -begins with the onset of regular contractions. Phases of labor: Latent phase: dilation of cervix to3 to 4 cm. contraction become increasing Active phase: dilation continues from 3 to 4 cm to 7 cm. Contraction become stronger and painful Transition phase: cervix dilates from 8 to 10 cm What happen during the first stage of labor? Cervical dilatation and effacement Causes of cervical dilatation Contraction and retraction of the cervical dilation of uterine musculature Mechanical pressure by the bulging membrane(forewater) The descend of the presenting part Phases of cervical dilatation Latent phase- the first 3cm dilatation; a slow process(8 hours in nulliparous and 3 hours in multiparous) Active phase - this is active process of cervical dilatation; the normal rate is 1cm/hour

Latent phase Active phase

Begins with onset of contraction Slow progress. Little cervical dilatation Progressive cervical effacement Ends once the cervix reaches 3cm dilatation Duration - 8 hours nulliparous - 6 hours multiparous

Active process Begins after 3 cm cervical dilatation Period of active cervical dilatation(average rate 1cm/hour) S-shaped curved which is usedto defined the progress of labor It has three components A. Acceleration - slow B. Maximum- fast C. Deceleration- slow

Page 41: Related Learning Experience (RLE)

41

Contraction: is the power of labor Type of contraction: Regular Increasing in frequency Irregular Second stage. (expulsive stage) begins with complete dilatation of the cervix and ends with delivery of the newborn. -it should be complete within one hour after complete dilatation. Two phases of expulsive stage Propulsive phase- from full dilatation until presenting part has descended to the pelvic floor. Expulsive phase- which end in the complete delivery of the baby. Features of expulsive phase: Mothers irresistible desire to bear down Distension of the perinium. Dilatation of the anus. Average length: Nulliparous: 40 minutes Multiparous: 20 minutes Mechanism of labor

Descent

Flexion

Internal rotaion

Extension

Internal rotation

Expulsion ”crowning” occurs when the newborns head or presenting part appears at the vaginal opening. -”Episiotomy” surgical incision in the perineum-may be done to facilitate delivery and avoid laceration of the perineum. Progress of second stage of labor Finding suggestive of satisfactory progress of second stage of labor are: - steady descent of fetus - onset of expulsive(pushing phase) Findings suggestive of unsatisfactory progress in the second stage of labor are: - lack of descent of fetus through the birth canal

Page 42: Related Learning Experience (RLE)

42

- failure of expulsion during the late (expulsive) phase. Third stage (placental stage) -This stage begins with delivery of the newborn and ends with delivery of placenta. -It occurs in two phases –placental separation and placental expulsion. Two phases: Separation phase Expulsion phase Duration: 15-20 minutes for separation Average blood loss: 150ml to 250 ml Fourth stage: Postpartum -It lasts from 1 to 4 hours after birth. -the mother and the newborn recover from physical process of labor. -systems readjustment. Newborn body systems begins to adjust to extrauterine life. PHYSIOLOGICAL MATERNAL CHANGES LOCHIA – discharge from the uterus during the first 3 weeks after delivery. Increasing Lochia as the day passes by may indicate Heparin Intoxication. LOCHIAL CHANGES LOCHIA RUBRA -Dark red discharge occurring in the first 2-3 days. -Contains epithelial cells, erythrocytes and decidua. -Characteristic human odor. LOCHIA SEROSA -Pinkish to brownish discharge occurring 3-10 days after delivery. -Serosanguineous discharge containing decidua, erythrocytes, leukocytes, cervical mucus and microorganisms. -Has a strong odor. LOCHIA ALBA -Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks after delivery.

Page 43: Related Learning Experience (RLE)

43

-Contains leukocytes, decidua,epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria. -Has no odor. B. UTERUS -Process of involution takes 4-6 weeks to complete. -Weight decreases from 2 lbs to 2 oz. -Fundus steadily descends into true pelvis; Fundal height decreases about 1 fingerbreadth (1 cm)/day; by -10-14 days postpartum, cannot be palpated abdominally. Uterine Involution Description a. The rapid decrease in the size of the uterus as it returns to the nonpregnant state b. Clients who breastfeed may experience a more rapid involution Assessment a. Weight of the uterus decreases from 2 pounds to 2 ounces in 6 week b. Endometrium regenerates c. Fundus steadily descends into the pelvis d. Fundal height decreases about 1 fingerbreadth (1 cm) per day e. By 10 days postpartum, uterus cannot be palpated abdominally

Page 44: Related Learning Experience (RLE)

44

ENEMA

It is an introduction of a solution into the large intestine, generally for the purpose of

removing feces. The instilled solution distends the intestine, may irritate intestinal

mucosa, thus increases peristalsis.

Types of Enema:

1. Cleansing Enema – given to remove feces from the colon.

Purposes:

To relieve constipation or fecal impaction.

To prevent involuntary escape of fecal material during surgical

procedures.

To promote visualization of the intestinal tract by x-ray film or instrument

examination.

To help establish regular bowel function during a bowel training program.

2. Retention Enema – retained in the bowel for a prolonged period for different

reasons.

3. Retention Flow Enemas – or Harris Flush enemas are used to expel flatus.

Types of Solutions:

Solution Amount Action Time to take effect

Adverse Side Effect

Page 45: Related Learning Experience (RLE)

45

Tap Water (Hypotonic)

500-1000 ml Distends intestine, increases peristalsis,

softens stool

15 min. Fluid and Electrolyte imbalance,

water intoxication

Normal Saline (Isotonic)

500-1000 ml Distends intestine, increases peristalsis,

softens stool

15 min. Fluid and Electrolyte imbalance,

sodium retention

Soap Solution 500-1000 ml (concentrate at

3ml-5ml/ 1000ml)

Distends intestine, irritates

intestinal mucosa,

softens stool

10-15 min. Rectal mucosa irritation or

damage

Hypertonic solutions

70ml – 130ml Distends intestine, irritates

intestinal mucosa

5-10 min. Sodium retention

Oil solutions (mineral, olive, or cottonseed

oil)

150-200ml Lubricate stool and intestinal

mucosa

30min.

Equipments:

- enema can - kelly forcep - IV pole - solution - KY jelly - rectal tube - gloves - hose

Procedure:

Nursing action Rationale 1. Inform the client about the procedure To promote cooperation

2. Assemble articles For efficiency

3. If using an enema bag, fill it with 750-1000 ml warm tap water

Hot water can burn intestinal mucosa, cold water can cause abdominal cramping

4. Clamp tubing To keep solution intact

Page 46: Related Learning Experience (RLE)

46

5. Place waterproof pad absorbent To prevent soiling

6. Assist client into the left side lying with knee flexed

Allows enema solution to flow downward by gravity

7. Cover client with bath blanket exposing only rectal area

Provide warmth, allows client to feel more relaxed

8. Lubricate 3-4 inches tip of rectal tube Provides smooth insertion without irritation and trauma

9. Gently separate buttocks and locate anus

For accurate exposure

10. Instruct client to relax It promotes relaxation of external anal sphincter

11. Insert tip of rectal tube 3-4 inches Careful insertion prevents trauma to rectal mucosa

12. Hold tubing in rectum constantly until end of instillation

/ Bowel contraction can cause expulsion of tube

13. With container at client's hip level, open regulating clamp and allow solution to enter slowly

Rapid infusion can stimulate evacuation and cause cramping

14. Raise height of enema bag slowly to 30-45cm (12-18 inches)

Raising container too high causes rapid infusion and possible painful distention of colon

15. Hang container on IV pole

16. Clamp tubing if client complains of cramping

Temporary cessation minimizes cramping

17. Tell client that the procedure is completed and that you will be removing rectal tube

Client may misinterpret the sensation of removing the tube as a loss of control

18. Explain feeling of distention is normal. Tell client to retain 5-10 minutes

Solution distend bowel. Longer retention promotes more effective stimulation.

19. Assist to bathroom

20. Instuct client with a history of cardiovascular disease to exhale while expelling enema to avoid valsalva maneuver

Valsalva maneuver- strenuously trying to move a constipated stool and may result in cardiac arrest

21. Assist client to wash anal area with wearm soap and water

Fecal content can irritate the skin. Hygiene promotes comfort.

22. Do after care Characteristics of a Good Recording: 1. Accuracy 2. Conciseness 3. Thoroughness 4. Currentness

Page 47: Related Learning Experience (RLE)

47

ESSENTIAL NEWBORN CARE

Before you look at the eight steps of essential newborn care (ENC) you need to remember the importance of the ‘three cleans’ that you learned in Study Session 3 of the Labour and Delivery Care Module. These are clean hands, clean surface and clean equipment. Your equipment should include two clean dry towels, cord clamps, razor blade, cord tie, functional resuscitation equipment, vitamin K, syringe and needles, and tetracycline eye ointment.

Figure 2.1 Drying and wrapping the newborn baby.

Step 1 Deliver the baby onto the mother’s abdomen or a dry warm surface close to the mother.

Continue to support and reassure the mother. Tell her the sex of the baby and congratulate her.

Step 2 Dry the baby’s body with a dry warm towel as you try to stimulate breathing. Wrap the baby with another dry warm cloth and cover the head (Figure 2.1).

Dry the baby well, including the head, immediately and then discard the wet cloth. Wipe the baby’s eyes. Rub up and down the baby’s back, using a clean, warm cloth. Drying

often provides sufficient stimulation for breathing to start in mildly depressed newborn babies. Do your best not to remove the vernix (the creamy, white substance which may be on the skin) as it protects the skin and may help prevent infection. Then wrap the baby with another dry cloth and cover the head.

Step 3 Assess breathing and colour; if not breathing, gasping or there are less than 30 breaths per minute, then resuscitate.

You will remember that you learned how to manage a newborn baby with birth asphyxia in Study Session 7 of the Labour and Delivery Care Module.

As you dry the baby, assess its breathing. If a baby is breathing normally, both sides of the chest will rise and fall equally at around 30–60 times per minute. Thus, check if the baby is:

Breathing normally

Having trouble breathing

Breathing less than 30 breaths per minute, or

Page 48: Related Learning Experience (RLE)

48

Not breathing at all.

Resuscitation of a baby who is not breathing must start within one minute of birth.

If the baby needs resuscitation, quickly clamp or tie and cut the cord, leaving a stump at least 10 cm long for now and then start resuscitation immediately. Functional resuscitation equipment should always be ready and close to the delivery area since you must start resuscitation within one minute of birth. It may sound as if you have a lot to do in one minute, but the steps described here are ones that you can take simultaneously. That is, while you are delivering the baby onto the mother’s abdomen and drying the baby, you can assess breathing and colour and take urgent action if necessary.

Figure 2.2 Tying and cutting the cord.

Step 4 Tie the cord two fingers’ length from the baby’s abdomen and make another tie two fingers from the first one (Figure 2.2). Cut the cord between the first and second tie. If the baby needs resuscitation, cut the cord immediately. If not, wait for 7–3 minutes before cutting the cord.

1. Tie the cord securely in two places:

o Tie the first one two fingers away from the baby’s abdomen.

o Tie the second one four fingers away from the baby’s abdomen.

o Make sure that tie is well secured; the thread you use to tie the cord must be clean.

2. Cut the cord between the ties:

o Use a new razor blade, or a boiled one if it has been used before, or sterile scissors.

o Use a small piece of cloth or gauze to cover the part of the cord you are cutting so no blood splashes on you or on others.

o Be careful not to cut or injure the baby. Either cut away from the baby or place your hand between the cutting instrument and the baby.

3. Do not put anything on the cord stump.

Page 49: Related Learning Experience (RLE)

49

Step 5 Place the baby in skin-to-skin contact with the mother, cover with a warm cloth and initiate breastfeeding.

The newborn loses heat in four ways (see Figure 2.3 below):

Evaporation: when amniotic fluid evaporates from the skin.

Conduction: when the baby is placed naked on a cooler surface, such as the floor, table, weighing scales, cold bed.

Convection: when the baby is exposed to cool surrounding air or to a draught from open doors and windows or a fan.

Radiation: when the baby is near cool objects, walls, tables, cabinets, without actually being in contact with them.

Figure 2.3 The newborn can lose heat in four ways. (Source: WHO, 1997, Safe Motherhood: Thermal Protection of the Newborn, a Practical Guide

The warmth of the mother passes easily to the baby and helps stabilise the baby’s temperature.

1. Put the baby on the mother’s chest, between the breasts, for skin-to-skin warmth.

2. Cover both mother and baby together with a warm cloth or blanket.

3. Cover the baby’s head.

The first skin-to-skin contact should last uninterrupted for at least one hour after birth or until after the first breastfeed. The baby should not be bathed at birth because a bath can cool the baby dangerously. After 24 hours, the baby can have the first sponge bath, if the temperature is stabilized.

Page 50: Related Learning Experience (RLE)

50

Figure 2.4 Initiating immediate breastfeeding.

If everything is normal, the mother should immediately start breastfeeding.

For optimal breastfeeding you should do the following:

1. Help the mother begin breastfeeding within the first hour of birth (Figure 2.4).

2. Help the mother at the first feed. Make sure the baby has a good position, attachment, and is sucking well. Do not limit the length of time the baby feeds; early and unlimited breastfeeding gives the newborn energy to stay warm, nutrition to grow, and antibodies to fight infection.

The steps to keep the newborn warm are called the warm chain.

1. Warm the delivery room.

2. Immediate drying.

3. Skin-to-skin contact at birth.

4. Breastfeeding.

5. Bathing and weighing postponed.

6. Appropriate clothing/bedding.

7. Mother and baby together.

8. Warm transportation for a baby that needs referral.

Step 6 Give eye care (while the baby is held by its mother).

Figure 2.5 Putting tetracycline eye ointment into the eyes of the newborn baby.

Shortly after breastfeeding and within one hour of being born, give the newborn eye care with an antimicrobial medication. Eye care protects the baby from serious eye infection which can result in blindness or even death.

The steps for giving the baby eye care are these:

First, wash your hands, and then using tetracycline 1% eye ointment:

Page 51: Related Learning Experience (RLE)

51

1. Hold one eye open and apply a rice grain size of ointment along the inside of the lower eyelid. Make sure not to let the medicine dropper or tube touch the baby’s eye or anything else (see Figure 2.5).

2. Repeat this step to put medication into the other eye.

3. Do not rinse out the eye medication.

4. Wash your hands again.

Step 7 Give the baby vitamin K, 1 mg by intramuscular injection (IM) on the outside of the upper thigh (while the baby is held by its mother).

After following correct infection prevention steps, with the other hand stretch the skin on either side of the injection site and place the needle straight into the outside of the baby’s upper thigh (perpendicular to the skin). Then press the plunger to inject the medicine. You will be learning more about safe injection techniques in your practical skills training sessions. There is also a study session on routes of injection in the Immunization Module.

Step 8 Weigh the baby.

Weigh the baby an hour after birth or after the first breastfeed. If the baby weighs less than 1,500 gm you must refer the mother and baby urgently.

Page 52: Related Learning Experience (RLE)

52

INTRAPARTUM CARE

1. Examine the woman for emergency signs.

Unconscious, Convulsing

Vomiting

Severe headache with blurring of vision

Vaginal bleeding

Severe abdominal pain

Looks very ill

Fever

Severe breathing difficulty

Do NOT make a very sick woman wait, attend to her quickly!

2. Greet the woman and make her comfortable.

Ask for informed consent before examination or any procedure

Respect privacy

Communicate result of examination

3. Assess the woman in labor.

Take the history of labor and record on the labor form.

Review Home Based Maternal Record (HBMR)/ Mother and Child Book

When is delivery expected? Preterm or term?

Prior pregnancies

Birth plan

Assess uterine contractions: intensity, duration, and interval

Observe the woman’s response to contractions.

Perform abdominal exam: (Leopold’s maneuver, FHT) between

contractions

Page 53: Related Learning Experience (RLE)

53

4) Determine the stage of labor.

Explain to the woman that you will perform a vaginal examination and ask for her

consent.

Respect privacy

Observe standard precautions

4) Determine the stage of labor.

Inspect the vulva for:

Bulging perineum

Any visible fetal parts

Vaginal bleeding

Leaking amniotic fluid; if yes, is it meconium stained, foul smelling?

Warts, keloid tissue or scars that may interfere with delivery

4) Determine the stage of labor.

Perform gentle vaginal examination (do not start during contraction).

Explain findings to the woman. Reassure her.

RECORD findings in labor record or in partograph.

Determining Stage of Labor

Determining Stage of Labor

5. Decide if the woman can safely deliver. If there is indication for referral …

in early labor and the referral hospital can be timely reached:

Refer urgently

in late active labor:

Monitor progress of labor and deliver the baby

Prepare for immediate referral if still necessary

If the woman or her family refuses referral

Page 54: Related Learning Experience (RLE)

54

Explain the possible consequences

6. Give supportive care throughout labor.

7. Monitor and manage labor.

First stage: not yet in active labor, cervix is dilated 0-3 cm., contractions are

weak, <2 in 10 minutes

Every hour: check for emergency signs, frequency, intensity & duration of

contractions, FHR, mood and behavior.

Every 4 hours: check vital signs and cervical dilatation.

Record findings in Labor record

Assess progress of labor: After 8 hrs, if contractions are stronger & more

frequent but no progress in cervical dilatation: REFER

First stage: in active labor, cervix is dilated at 4 cm or more

Check every 30 mins for emergency signs, frequency and duration of

contractions, FHR, mood and behavior.

Check every 4 hours: fever, PR, BP, cervical dilatation.

Record time of rupture of membranes and color of the amniotic fluid.

Record findings in partograph.

RELIEF of PAIN and DISCOMFORT

Suggest change of position

Encourage mobility as comfortable for her

Encourage proper breathing: breath more slowly, make a sighing noise, make 2

short breaths followed by a long breath out.

Massage her lower back if she finds it helpful

CAUTION

DO NOT do IE more frequently than every 4 hours unless necessary.

DO NOT allow the woman to push unless delivery is imminent → pushing does

not speed up labor, mother will become tired, cervix will swell.

Page 55: Related Learning Experience (RLE)

55

DO NOT give medications to speed up labor → DANGEROUS: may cause

trauma to the mother and baby (ex: Uterine rupture)

DO NOT DO FUNDAL PRESSURE-

may cause uterine rupture, fetal death

Second stage: from full dilatation (10cm) of the cervix until birth of baby.

How to tell if a woman is in the 2nd stage:

On IE, cervix is fully dilated

Woman wants to bear down

Strong uterine contractions every 2-3 minutes

Bulging thin perinium fetal head visible during

contractions.

BOW will rupture

Monitoring the 2nd stage

Check uterine contractions, fetal heart rate, mood and behavior

Continue recording in the partograph

REMINDER:

1. Massaging or stretching the perineum have not been shown to be

beneficial.

2. DO NOT apply fundal pressure to help deliver the baby → may harm

mother and baby.

8. Deliver the Baby

Implement the 3 CLEANS

1. Clean hands

2. Clean delivery surface

3. Clean cutting and care of the cord

WEAR DOUBLE GLOVES

Page 56: Related Learning Experience (RLE)

56

Stay with the woman and encourage her. Make her comfortable.

Check fetal heart tones every 15 minutes

Deliver the Baby

When the birth opening is stretching, support the perineum and anus with a clean

swab to prevent lacerations

Ensure controlled delivery of the head

Controlled delivery of the head

Keep one hand on the head as it advances during contractions. Keep the head

from coming out too quickly.

Support the perineum with other hand.

Controlled delivery of the head, cont’d . .

Discard pad and replace when soiled to prevent infection.

During delivery of the head, encourage woman to stop pushing and breathe

rapidly with mouth open.

Delivering the Baby

Gently feel if the cord is around the neck

If it is loosely around the neck, slip it over the shoulders or head

If it is tight, place a finger under the cord, clamp and cut the cord, and

unwind it from around the neck.

Delivering the Baby

Gently wipe the baby’s nose and mouth with a clean gauze or cloth.

Wait for external rotation (within 1-2 min), head will turn sideways bringing one

shoulder just below the symphysis pubis and other facing the perineum

Delivering the baby

1. Put baby on mother’s abdomen in prone position. Cover with dry towel.

2. Thoroughly dry the baby immediately. Wipe eyes.

3. Discard wet cloth.

Page 57: Related Learning Experience (RLE)

57

4. Put baby prone, in skin-to-skin contact on mother’s abdomen,. Keep the baby

warm.

5. Exclude 2nd baby by palpating mother’s abdomen.

6. Give 10 IU oxytocin IM to the mother.

active management of the 3rd stage of labor.)*

*May be done by the midwife under supervision of doctor.

7. Watch for vaginal bleeding.

8. Remove first set of gloves.

9. When no more cord pulsation is felt on the cord (usually within 3 mins.)

clamp the cord 2cm from the base using sterile plastic cord clamp

10. Sweep the cord and apply a second Kelly forceps 5cm from the base and then

cut in-between.

Third Stage: Between birth of the baby and delivery of the placenta

11. Deliver the placenta by controlled cord traction (with counter traction on the

uterus above the symphysis pubis).

12. Massage uterus over the fundus.

13. Inject oxytocin.

(if not yet given as part of active management)

14. Encourage initiation of breastfeeding. Let baby stay on mother’s abdomen for

60-90 min

Third stage: between birth of the baby and delivery of the placenta.

ACTIVE MANAGEMENTof the third stage of labor

Cord is clamped

Oxytocin is given within 2 min of delivery of the baby

Placenta is delivered by controlled cord traction with countertraction above the

symphysis pubis.

Massage fundus.

Page 58: Related Learning Experience (RLE)

58

May only be done by a midwife under supervision of doctor.

9. Monitor closely within 1-hour after delivery (Immediate postpartum period) and give

supportive care.

Check for vaginal tears and bleeding.

Clean the woman and make her comfortable.

Check BP, PR, emergency signs & uterine contraction every 15 minutes.

Initiate breastfeeding within 1-hour when the baby is ready.

10. Continue care after 1 hour postpartum. Keep watch closely for at least 2 hours.

Temperature, BP and pulse every 30 minutes

Check at 2, 3 and 4 hours, then every 4 hours:

emergency signs

uterine contraction

Check for bladder distension if unable to void.

Advise clean cloth/napkin to collect vaginal blood.

Eat and drink high-energy food that are easily digestible.

Companion: to watch her and to call you for bleeding or pain, dizzy or for any other

problem

Keep the baby in the room with the mother, in her bed or within easy reach.

Support exclusive breastfeeding on demand, day and night, as often and as long

as the baby wants.

Immunize according to the EPI schedule.

Mother and companion to watch the baby:

breastfeeding difficulty

difficulty of breathing

cold feet

bleeding from the cord

Page 59: Related Learning Experience (RLE)

59

Check baby at around 4 and 8 hours and then daily:

cold feet, breastfeeding and breathing difficulty.

Advise postpartum care and hygiene.

Wash from waist down or have a sponge bath or a shower with warm

water each morning or when she feels like it.

Use guava leaves decoction if woman prefers, for her wash or bath.

Continue care after 1 hour postpartum.

Medications

Iron 60 mg/ Folic acid 400ug 1 tablet daily… until 3 months postpartum

Vitamin A 200, 000 IU, 1 capsule after delivery or within 1 month

postpartum

11. Educate and counsel on family planning and provide the family planning method if

available.

Ask what are the couple’s plans regarding having more children.

Give relevant information and advice.

Advice that exclusive breastfeeding is the best contraceptive in the 1st six

months.

Help her to choose the most appropriate method for her and her partner.

12. Inform, teach and counsel the woman on important MCH messages.

Talk to the woman when she is rested and comfortable.

Also give important information and advice to her companion.

13. Discharge the woman and her baby.

The woman and her baby may be discharged 24 hours after delivery.

Ensure that the woman is able to breastfeed successfully before discharge.

Repeat important health information.

Check understanding and arrange follow-up.

Page 60: Related Learning Experience (RLE)

60

POSTPARTUM NURSING INTERVENTIONS

Monitor Vital Signs

NOTE: Maternal temperature during the first 24 hours following delivery may rise

to 100. 4` F (38`C) as a result of dehydration. The nurse can reassure the new

mother that these symptoms are normal.

Postpartum Exercise

Supine Position with the knee’s flexed, and then inhale deeply while allowing the

abdomen to expand and exhale while contracting the abdominal muscles. The

purpose of this exercise is to strengthen the abdominal muscles. Examples are

reaching for the knees; push ups and sits ups on the first postpartum day.

Assess height, consistency, and location of the fundus

Monitor color, amount, and odor of lochia

Assess lochia and color volume

Give RhoGAM to mother if ordered. RhoGAM promotes lysis of fetal Rh (+)

RBCs. Administer RhoGam as prescribed within 72 hours postpartum to

the Rh-negative client who has given birth to an Rh-positive neonate.

Rhogam (D) immune globulin is given by intramuscular injection

Check episiotomy and perineum for signs of infection.

Promote successful feeding.

Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast

stimulation.

Nursing woman- success depends on infant sucking and maternal

production of milk.

“Postpartum Blues” (3-7 days) – Normal occurrence of “roller coaster”

emotions

Sexual activities- abstain from intercourse until episiotomy is healed and

lochia ceased around 3-4 weeks. Remind that Assess height, consistency, and

location of the fundus breastfeeding does not give adequate protection.

Assess breasts for engorgement

Monitor episiotomy for healing ( assess dehiscence & evisceration)

Page 61: Related Learning Experience (RLE)

61

Assess incisions or dressings of cesarean birth client ( prone to infection)

Monitor bowel status ( prone to constipation)

Monitor I &0

Encourage frequent voiding (prevent urinary retention which will predispose the

mother to uterus displacement & infection)

Encourage ambulation ( to prevent thromboplebitis & paralytic ileus

Assess bonding with the newborn infant ( to prevent failure to thrive)

NOTE:

A positive bonding experience is indicated when the mother turns her face

toward the baby to initiate eye-to-eye contact. Observation of new mothers has

shown that a fairly regular pattern of maternal behaviors is exhibited at first

contact with the newborn. The mother follows a progression of touching activities

from fingertip exploration toward palmar contact to enfolding the infant with the

whole hand and arm. The mother also increase the time spent in the en face

position. The mother arranges herself or the newborn so that her face and eyes

are in the same plane as in her infant.

III. POSTPARTUM DISCOMFORTS

A. Perineal discomfort

Apply ice packs to the perineum during the first 24 hours to reduce swelling after

the first 24 hours, apply warmth by sitz baths

B. Episiotomy

1. Instruct the client to administer perineal care after each voiding

2. Encourage the use of an analgesic spray as prescribed

3. Administer analgesics as prescribed if comfort measures are unsuccessful

C. Breast discomfort

PREVENTION:

The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND

FREQUENTLY WITH FEEDINGS. The 2nd is EXPRESSING A LITTLE MILK BEFORE

Page 62: Related Learning Experience (RLE)

62

NURSING, MASSAGING THE BREASTS GENTLY OR TAKING A WARM SHOWER

BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW.

Placing as much of the areola as possible into the neonate’s mouth is one method.

Other methods include changing position with each nursing so that different areas of the

nipples receive the greatest stress from nursing and avoiding breast engorgement,

which make I difficult for the neonate to grasp. In addition, nursing more frequently, so

that a ravenous neonate is not sucking vigorously at the beginning of the feedings, AND

FEEDING ON DEMAND to prevent over hunger is helpful. AIRDRYING THE NIPPLES

AND EXPOSING THEM TO THE LIGHT HAVE ALSO BEEN RECOMMENDED. Warm

Tea bags, which contain tannic acid also, will sooth soreness. WEARING A

SUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT.

APPLYING ICE and LANOLIN DOES NOT RELIEVE BREAST ENGORGEMENT.

INTERVENTION: Measures that help relieve nipple soreness in a breast-feeding client

include lubricating the nipples with a few drops of expressed milk before feedings,

applying ice compresses just before feedings, letting the nipples air dry after feedings,

and avoiding the use of soap on the nipples.

NOTE: Specific nursing care for breast Engorgement

Breastfeed frequently

Apply warm packs before feeding

Apply ice packs between feedings

NOTE: Specific Nursing Care for Cracked nipples

Expose nipples to air for 10 to 20 minutes after feeding

Rotate the position of the baby for each feeding

Be sure that the baby is latched on to the areola, not just the nipple

NOTE: Do not use soap on the breasts, as it tends to remove natural oils, which

increases the chance of cracked nipples

IV. POST PARTUM COMPLICATIONS

A. HEMORRHAGE

B. THROMBOPLEBITIS

Inflammation of the vein caused by a clot

The positive Homan’s sign indicate is possibility of thrombophlebitis or a deep

venous thrombosis that is present in the lower extremities.

Page 63: Related Learning Experience (RLE)

63

When assessing for Homan’s sign ask the patient to stretch her kegs out with the

knee slightly flexed while dorsiflex the foot. A positive sign is present when pain

is felt at the back of the knee or calf. It is normal for a patient on magnesium

sulfate to feel tired because it acts as a central nervous depressant and often

makes the patient drowsy.

C. INFECTION

D. MASTITIS

E. Postpartum Mood Disorders

POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN

Increased bleeding, clots or passage of tissue.

Bright red vaginal bleeding anytime after birth.

Pain greater than expected.

Temperature elevation to 100.4º F.

Feeling of full bladder accompanied by inability to void.

Enlarging hematoma.

Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness;

and visual disturbance.

Pain, redness, and warmth accompanied by a firm area in the calf.

Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension,

pale, cold, or blue skin color

V. Psychological Adaptation

Rubin's Postpartum Phases of Regeneration (POSTPARTUM

PSYCHOSOCIAL ADAPTATION)

“TAKING IN” PHASE (DEPENDENT) First 3 Days

During this time, food and sleep are a major focus for the client. In addition, she

works through the birth experience to sort out reality from fantasy and to clarify

any misunderstandings. This phase lasts 1 to 3 days after birth. The primary

concern is to meet her own needs.

Page 64: Related Learning Experience (RLE)

64

• Takes place 1-2 days postpartum

• Mother is passive and dependent; concerned with own needs.

• Verbalizes about the delivery experience.

• Sleep/food important.

• Mother focuses on her own primary needs, such as sleep and food

Important for the nurse to listen and to help the mother interpret the events

of delivery to make them more meaningful

Not an optimum time to teach the mother about baby care

“TAKING HOLD” PHASE (DEPENDENT/INDEPENDENT)

The client is concerned regarding her need to resume control of all facets of her

life in a competent manner. At this time, she is ready to learn self-care and infant

care skills.

• 3-10 days postpartum

• Mother strives for independence and begins to reassert herself.

• Mood swings occur. May cry for no reason.

• Maximal stage of learning readiness.

• Mother requires reassurance that she can perform tasks of motherhood.

• Begins to assume the tasks of mothering

• An optimum time to teach the mother about baby care.

“LETTING GO” PHASE (INTERDEPENCE)

• 10 to 6 weeks postpartum

• Realistic regarding role transition.

• Shows pattern of life-style that includes the new baby but still focuses on entire family

as a unit.

• Accepts baby as separate person.

Mother may feel deep loss over separation of the baby from part of the body and

may grieve over the loss

Page 65: Related Learning Experience (RLE)

65

Mother may be caught in a dependent/independent role, wanting to feel safe and

secure yet wanting to make decisions

Teenage mothers need special consideration because of the conflict taking place

within them as part of adolescence

Page 66: Related Learning Experience (RLE)

66

Unang yakap

A program that been formulated by Department of Health to decrease the Newborn Mortality Rate and improving Maternal Health. AO 25 (2009), it is a time bound intervention. A protocol that must be carried out in a specific time. Preparation: 3 Pairsof surgical glove 2 Warm blankets 1 Bonnet Cordcare Set Erythromycin Vitamin K Hepa. B Shot Other requirements: Breastfeeding Delayed bathing until 6 hours of life New born Screening

Steps 1. Immediate and thorough drying for 30 seconds to stimulate breathing after delivery

of the baby and prevent heat loss.

2. Early skin to skin contact maintaining a delivery room temperature of 25-28 degrees

centigrade andwrapping the newborn with clean, dry cloth. (To promote bonding and

prvent heat loss).

3. Properly timed clamping and cutting of umbilical cord 1-3 minutesoruntil cord

pulsation stops.(To reduce anemia or intraventricular hemorrage on pre-term

newborn).

4. Non separation of the newborn and mother for early breast-feeding. Immediate

latching on and initiation of breastfeeding within the firsthour after birth. (To provide

support for early breastfeeding and transfer of colostrum)

Page 67: Related Learning Experience (RLE)

67

PERINEAL CARE

Assessment

Check for the skin redness, inflammation,excoriation, irritation

Excessive discharge

Odor pain discomfort

Urinary or fecal incontinence

Recent rectal or perineal surgery

An indwelling catheter

Determine:

Perianeal genital practices

Self care abilities

Assesmble equipment

Perineal genital care provided in conjunction with the bed bath:

Bath towel

Bath blanket

Clean gloves

Bath basin with water @ 43 degree to 46 degree

Soap

Washcloth Special perineal genital care:

Bath towel

Bath blanket

Clean gloves

Cotton balls or swab

Solution bottles, pitcher, or container filled with warm water or a prescribed solution

Bedpan to receive rinse water

Moisture resistant bag or receptacle for use cotton swabs

Perineal pad

Procedure:

4. Introduce your self and verify the clients identity.explain to the client what is the procedure are you going to do, why it is necessary, and how the client can cooperate,being sensitive to any embarrassment felt by the client. 5. Perform hand hygiene and other appropriate infection control procedure.

Page 68: Related Learning Experience (RLE)

68

6. Provide for client privacy by drawing the curtains and closing the door. 7. Prepare the client:

Fold the top bedlinen to the foot of the bed the gown up to expose the genital area

Place a bath towel under the clients hip

Position and drape the client, and clean the upper inner thighs.

Females

Position the female in back lying position with knees flexed and spread well a part.

Cover her body and legs with the bath blanket drape the legs by tucking the bottom corners of the blanket under the inside of the legs. Bring the middle portion of the base of the blanket up over the pubic area.

Put on gloves and wash and dry the under inner thighs.

For males

Position the male client in a supine position with his knees are flexed and his hips slightly externally rotated.

Put on gloves, and wash and dry the upper inner thighs.

Inspect the perineal area.

Note particular areas of inflammation, excoriation,or swelling,especially between the labia in females or the scrotal folds in male.

Also note excessive discharge or secretion from the orifices, and the presence of odors.

Wash and dry the perineal genital area. For female

Clean the labia majora. Then spread the labia to wash the folds between the labia majora and the labia minora.

Use separate quarter of the wash cloth of the wash cloth for each stroke, and wipe from the pubis to the rectum. For menstruating woman and clients with indwelling catheter,use clean wipes,cotton balls, or gauze.take a clean wipe for each stroke.

Rinse the perineal area as well.

Dry the perineum thoroughly.

For male

Wash and dry the penis,using firm strokes.

If the client is uncircumcised,retract the prefuce foreskinto expose the glans penis for cleaning. Replace the foreskin after cleaning the glans penis.

Wash and dry the scrotum. The posterior fold of the scrotum might need to be cleaned in step 9, with the buttocks.

Inspect perineal orifices for intactness.

Page 69: Related Learning Experience (RLE)

69

Inspect particularly around the urethra in clients with indwelling catheter.

Clean between the buttocks.

Pay particular attention to the anal area and posterior fold of the scrotum in males.clean the anus with toilet tissue before washing it, if necessary.

Dry the area well.

For post delivery or menstruating females, apply the perineal pad as needed, from front to back.

10. Clean the area and equipment.

11.Document the procedure done.

PERINEAL SHAVING

Assessment

Check for the skin redness, inflammation,excoriation, irritation

Excessive discharge

Odor pain discomfort

Urinary or fecal incontinence.

Determine:

Perianeal genital practices

Self care abilities

Assesmble equipment

Perineal genital care provided in conjunction with the bed bath:

Bath towel

Bath blanket

Clean gloves

Bath basin with water @ 43 degree to 46 degree

Soap

Cotton balls

Shaving cream if necessary

Shaving blade

Straight forceps

Procedure:

Introduce your self and verify the clients identity.explain to the client what is the

Page 70: Related Learning Experience (RLE)

70

procedure are you going to do, why it is necessary, and how the client can cooperate,being sensitive to any embarrassment felt by the client. 2.Perform hand hygiene and other appropriate infection control procedure.

3.Provide for client privacy by drawing the curtains and closing the door.

4.Prepare the client:

Fold the top bedlinen to the foot of the bed the gown up to expose the genital area

Place a bath towel under the clients hip

5. Position and drape the client, and clean the upper inner thighs.

Females

Position the female in back lying position with knees flexed and spread well a part.

Cover her body and legs with the bath blanket drape the legs by tucking the bottom corners of the blanket under the inside of the legs. Bring the middle portion of the base of the blanket up over the pubic area.

Put on gloves and wash and dry the under inner thighs.

For males

Position the male client in a supine position with his knees are flexed and his hips slightly externally rotated.

Put on gloves, and wash and dry the upper inner thighs. 6. Inspect the perineal area.

Note particular areas of inflammation, excoriation,or swelling,especially between the labia in females or the scrotal folds in male.

Also note excessive discharge or secretion from the orifices, and the presence of odors.

Apply cotton balls with soap the perineum. Shave the perineum starts from the symphisis pubis down to the labia majora. Wash the genitals using the clean water. Dry the area well. Clean the area and equipment. Document the procedure done.

Page 71: Related Learning Experience (RLE)

71

References:

American Academy of P ediatrics Policy Statement (2005) Breastfeeding and the use of human milk. Pediatrics, 115, 496-505. Jensen, D., et al . (1993) LA TCH: A breastfeeding charting system and doc umentation Tool. JOGGN, 23 (1), 27-32. Lawrence, R. M. & R. A. (2005). Breastfeeding: A guide f or the medical profession (6th Ed.). St. Louis: C.V. Mosby. Lawers, J., Swis her, A. (2000). Counseling the Nursing Mother (3rd Edition). Sudbury, Massachusetts. Jones & Bartlett Publishers. Lazaroy, M., Fedlman, A. WHO/UNIFCEF Ten Steps to Successful Breastfeeding, United States Committee for UNICEF Annotated Bibliography for each step, 1995. Riordan, J . (2005). Breastfeeding and Human Lactation (3rd Edition). Sudbury, Massachusetts. Jones & Bartlett Publishers. [Howard, C. R., et al. (1999). The effects of early pacifier use on breastfeeding duration. Pediatrics, 103, 659.] http://carolmelcher.com/assets/Assisting%20with%20Breastfeeding.pdf Kozier & Erb's Fundamentals of Nursing http://www.drugs.com/cg/how-to-give-an-intramuscular- injection.html http://nurseslabs.com/hot-sitz-bath-nursing-interventions-procedure/ http://nursingreviewbyozlek.blogspot.com/2010/08/enema.html http://labspace.open.ac.uk/mod/oucontent/view.php?id=452806&section=1.4