N107 Skills Learning Module PDF

TARLAC STATE UNIVERSITYY COLLEGE OF SCIENCE DEPARTMENT OF NURSING Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines 2300 Tel.no.: (045)...

TARLAC STATE UNIVERSITYY COLLEGE OF SCIENCE DEPARTMENT OF NURSING Villa Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines 2300 Tel.no.: (045) 493-1865 Fax: (045) 982-0110 website: www.tsu.edu.ph Awarded Level 3 Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines Inc (AACCUP) VISION A globally competitive university recognized for excellence in sciences and emerging technologies. MISSION TSU shall develop highly competitive and empowered human resources fostering responsive global education, future-proof research culture, inclusive and relevant extension programs, and sustainable production projects. Core Values T-ruth in words, action and character S-ervice with excellence and compassion U-nity in diversity. GOAL The goal of the Nursing Department is on the holistic development of the person to be a professionally competent and caring nurse imbued with the following core values of love of God, love of country and service to man. OBJECTIVES To prepare graduates for the practice of nursing in various settings by providing the broadest basic education, skills, and competencies for future leadership positions in nursing. To develop among the students the spirit of compassionate caring, quality of service, social insight, and commitment in health care of the nation. To continue to strengthen and facilitate health research initiatives and maintain active outreach programs with the community through coordination and collaboration of undertakings. Strategic Directions (SOAR HIGHER): S - ustainable student support programs to improve access to quality education to become globally competitive. O- utstanding international reputation and visibility through Academic and Research Exchanges. A - ssurance of quality and excellence through accreditation, assessment, and certification with global standards. R - igorous Development Programs for executives, faculty, staff, and students. H - ighly responsive and innovative Research Development and Extension programs. I - nvestment on modern Infrastructures, facilities, and equipment to ensure inclusive and responsive delivery of services to clients and stakeholders. G - ood governance, management, and accountability characterized by Truth Service and Unity. H - arness active partnerships and collaboration with the local and international community. E - nhanced Production through Sustainable Income Generating Projects. R - esponsive, Innovative and Industry-based Curricula and Instruction MODULE TITLE: INSTRUCTIONAL MODULE IN NCM 107 COURSE CODE: NCM 107 RLE SKILLS LABORATORY COURSE NAME/TITLE: CARE OF MOTHER AND CHILD NURSING (WELLNESS) RELATED LEARNING EXPERIENCE LECTURER: Rowena B. Lamorena Email Address: [email protected] COLLEGE: College of Science Department: Department of Nursing COURSE DESCRIPTION: Principles and techniques of caring for normal mothers, infants, children, and family and the application of principles and concepts on the family and family health nursing process. COURSE OUTCOMES This learning module is designed to provide nursing students with a comprehensive understanding of prenatal care, focusing on the key concepts and nursing interventions required to ensure the well-being of both the expectant mother and her developing fetus. By the end of this module, students will be equipped with the knowledge and skills necessary to provide effective prenatal care and support to pregnant individuals. 1. Demonstrate Proficiency in Performing Leopold’s Maneuver. 2. Properly assess the fetal position and presentation and properly identify the fetal part in relation to the mother’s pelvis based on the result of Leopold’s maneuvers. 3. Interpret the clinical significance of the fetal position and presentation in the context of labor and delivery. 4. Differentiate various fetal positions (e.g., cephalic, breech) and presentations (e.g., vertex, face). 5. Perform proper documentation and communication accurately in the Patient’s Medical Records. INSTRUCTION TO THE USERS To complete the module, the formative and summative written tests need to be completed and handed in. TIME FRAME: WEEK ACTIVITY Week 1 Orientation Lecture discussion of Leopold’s Maneuver and Fundal Height. Week 2 Quiz Discussion of Checklists of Leopold’s Maneuver and Fundal Height. Practice demonstration of the checklists. Video presentation of Leopold’s Maneuver and Fundal Height. Week 3 Return demonstration of Leopold’s Maneuver and Fundal Height. Week 4 Return demonstration of Leopold’s Maneuver and Fundal Height. Evaluation Exam. Post conference. Discussion of results of a return demonstration. Instructions for midterms and revalida. LEARNING OUTCOMES Upon finishing this course, the students will be able to: 1. Describe purposes and terms used on prenatal care. 2. Identify the age of gestation using different rules. 3. Determine the fetal presentation and position of the fetus. 4. Identify expected findings during prenatal care. 5. Verbalize the steps used in assessing the pregnant woman through Leopold’s maneuver and measuring fundic height. 6. Describe suggested sequencing to conduct a prenatal examination in an orderly fashion. 7. Demonstrate appropriate documentation and reporting of health assessment TOPIC OUTLINE 1. Introduction to Prenatal Care 2. Prenatal Assessment 3. Purposes of Prenatal Care 4. Determination of Estimated Birth Date 5. Understanding Medical terms related to pregnancy 6. Fundal Height Measurement 7. Leopold’s Maneuvers and Fetal Position Assessment LEARNING CONTENT: PRENATAL CARE: LEOPOLD’S MANEUVER AND FUNDAL HEIGHT PRENATAL CARE: Prenatal care refers to the medical and supportive care provided to pregnant individuals to ensure the health and well-being of both the pregnant person and their developing fetus. Prenatal care aims to monitor the progress of pregnancy, identify any potential complications or risks, and provide interventions and education to promote a safe and healthy pregnancy, delivery, and postpartum period. Prenatal Care is essential in ensuring the overall health of newborns and their mothers, is a major strategy in helping to reduce the number of low-birth-weight babies born yearly. It is important because lack of it is associated with the birth of preterm infants and various complications for the woman. The major causes of death during pregnancy today for women are ectopic pregnancy, hypertension, hemorrhage, embolism, infection and anesthesia-related complications. Prenatal Care includes the following: 1. Regular Check-ups: Pregnant individuals receive a series of scheduled medical appointments with healthcare providers, such as obstetricians, midwives, or nurse practitioners. These appointments allow for the monitoring of the pregnancy's progress and the detection of any issues that may arise. 2. Health Assessments: Prenatal visits involve physical exams, screenings, and tests to assess the health of both the pregnant person and the fetus. This includes monitoring vital signs, measuring fundal height, checking weight gain, and assessing fetal heart rate. 3. Screening and Testing: Prenatal care includes various screenings and tests to identify potential risks and complications. These tests can include blood tests, ultrasounds, genetic screenings, and assessments for gestational diabetes and pregnancy-induced hypertension. 4. Nutrition and Lifestyle Guidance: Pregnant individuals receive guidance on maintaining a healthy diet and engaging in safe physical activity during pregnancy. Proper nutrition and exercise contribute to the overall well-being of both the pregnant person and the fetus. 5. Education and Counseling: Prenatal care providers offer information about the changes occurring during pregnancy, the progression of labor and delivery, and postpartum care. They also address any concerns or questions the pregnant person may have. 6. Monitoring Fetal Development: Prenatal care involves tracking the growth and development of the fetus, assessing its position, presentation, and well-being through methods like Leopold's maneuvers, ultrasounds, and fetal heart rate monitoring. 7. Identification and Management of Complications: Prenatal care aims to identify and manage any complications or medical conditions that may arise during pregnancy, such as preeclampsia, gestational diabetes, or preterm labor. 8. Birth Planning: Prenatal care providers assist in developing a birth plan, which outlines preferences for labor, delivery, and postpartum care. This plan helps ensure that the individual's wishes are respected during the birthing process. 9. Postpartum Preparation: Prenatal care often includes discussions about postpartum recovery, breastfeeding, and newborn care to help individuals prepare for the period after childbirth. PURPOSES OF PRENATAL CARE: 1. Establish baseline data on the present health of the mother and the fetus. 2. Determine the gestational age of the fetus. 3. Monitor fetal development. 4. Identify the woman's risk for complications. 5. Minimize the risk of possible complications by anticipating and preventing problems before they occur. 6. Provide time for education about pregnancy and possible dangers. MEDICAL TERMS RELATED TO PREGNANCY STATUS: 1. PARA – the number of pregnancies that reached viability (age of viability is 24 weeks), regardless of whether the infants were born alive or not. 2. GRAVIDA – a woman who is or has been pregnant. 3. PRIMIGRAVIDA – a woman who is pregnant for the first time. 4. PRIMIPARA – a woman who has given birth to one child past of viability. 5. MULTIGRAVIDA – a woman who has been pregnant previously. 6. MULTIPARA – a woman who has carried two or more pregnancies to viability. 7. NULLIGRAVIDA – a woman who has never been and is not currently pregnant. OBJECTIVE SYMPTOMS OF PREGNANCY- which are observable and measurable signs 1. Missed Period – a key indicator, (stress, illness) may delay periods. 2. Positive Pregnancy Test – typically reliable after a missed period. Home urine tests detect human chorionic gonadotropin (hCG) in urine. 3. Blood hCG Test – measures the exact level of hCG in the blood which is more accurate than urine test. 4. Enlarged Uterus – during a pelvic exam, a doctor may notice an enlarged, softened uterus as early as 6 weeks into pregnancy. 5. Breast Changes – Swelling, tenderness, and darkening of areola. 6. Ultrasound Visualization – the most conclusive early proof of pregnancy, visualizing the gestational sac or embryo as early as 5 weeks. 7. Fetal Heartbeat – detectable via ultrasound around 6-8 weeks of gestation Conclusive proof of pregnancy: ultrasound, detection of hCG, Fetal heartbeat PATHOLOGICAL STATE THAT CAN MIMIC PREGNANCY 1. Pseudocyesis (False Pregnancy) - This is a psychological disorder in which a woman has pregnancy-like symptoms (weight gain, nausea, missed periods), but no pregnancy really happens. 2. Ectopic Pregnancy- This happens when an egg that has been fertilized implants outside the uterus, generally in the fallopian tube. While symptoms like pelvic pain, missing periods, and a positive pregnancy test may initially seem like typical pregnancy, if left untreated, they can become life-threatening. 3. Ovarian Tumors or Cyst- Abdominal swelling, irregular periods, and hormone fluctuations—all of which might mimic pregnancy symptoms—can be caused by large ovarian cysts or tumors. 4. Molar Pregnancy (Hydatidiform Mole)- a form of gestational trophoblastic illness in which aberrant (abnormal) tissue rather than a healthy embryo develops in the uterus. Although the growth is non-viable, the patient may have sickness, an enlarged uterus, and a positive pregnancy test. 5. Hormonal Imbalances - Disorders such as thyroid dysfunction or polycystic ovarian syndrome (PCOS) can result in weight gain, irregular periods, and other pregnancy-like symptoms. 6. Obesity - Excessive weight gain might give the appearance of pregnancy, particularly in the stomach region.  7. Menopause or Perimenopause- Like the symptoms of early pregnancy, a woman in this stage may have mood swings, bloating, and irregular periods. 8. Ascites- Abdominal fluid accumulation, frequently brought on by liver illness or cancer, can resemble pregnancy by causing the abdomen to expand and dilate. 9. Uterine Fibroids - An enlarged abdomen and pregnancy-like pressure feelings can be caused by big fibroids in the uterus. 10. Gastrointestinal Disorders - conditions like irritable bowel syndrome (IBS), bloating, and even certain gastrointestinal cancer can mimic the abdominal distension seen in pregnancy. Note: Fetal heart tones are usually detectable by a Doppler device around 10 to 12 weeks of gestation. G-T-P-A-L G – Gravidity (number of pregnancies) T – number of term births P – number of preterm births A – number of abortions/miscarriages L – number of living children Example: 31112 GTPAL means 3 pregnancies, 1 term birth, 1 preterm birth, 1 abortion, and 2 living children. CLINIC VISITS: From 1st visit to 32 weeks: every 4 weeks/monthly visit From 32-36 weeks: every 2 weeks/twice a month From 36 weeks to delivery: every week/4x in a month Maternal Assessment: BP monitoring Weight and Edema Uterine changes Hemoglobin and Hematocrit Fetal Assessment: Fundal Height Measurement Fetal Heart Rate Fetal Movements Terms: 1. AOG – Age of Gestation 2. EDD – Estimated Date of Delivery 3. EDB – Estimated date of Birth 4. EDC – Estimated Date of Confinement 5. LMP – Last Menstrual Period THE WORLD HEALTH ORGANIZATION (WHO) ANTENATAL CARE (ANC) MODEL 2016 This model emphasizes the importance of providing comprehensive care throughout pregnancy. AIMS: 1. Lowering maternal and perinatal morbidity and mortality. 2. Enhancing the standard of care given to expectant mothers. 3. Securing a happy pregnancy. KEY COMPONENTS: 1. Minimum of 8 ANC Contacts 2. Key interventions in each contact 3. Nutritional Interventions 4. Infection Prevention 5. Counselling on Danger Signs 6. Health Promotion and Counselling 7. Pre-eclampsia Prevention and Mgt. 8. Ultrasound Recommendation 9. Mental Health Screening 10. HIV and Syphilis Testing WHO recommends a minimum of 8 contacts with healthcare providers throughout pregnancy, which contrast with the previous 4 visits recommendation. The idea is to improve the detection of complications and to provide better preventive care. SCHEDULE OF ANC CONTACTS: First contact: before 12 weeks gestation. Second contact: between 20-24 weeks Third contact: between 28-32 weeks Fourth contact: between 36 weeks Fifth contact – spanning from 38 to birth KEY INTERVENTION in each contact First Contact (before 12 weeks) 1. Pregnancy confirmation, initial evaluation (blood pressure, weight, and blood test), screening for infections such as HIV and syphilis, and starting an iron and folic acid supplement. 2. Counseling on quitting smoking, maintaining a healthy diet and lifestyle, and engaging in physical activity. Second contact (20-24 weeks) 1. Fetal growth monitoring 2. Ultrasound if available 3. Further screening for: preeclampsia and gestational diabetes. Third contact (28 - 32 weeks) 1. Immunization: tetanus toxoid 2. Continuous monitoring for complications, fetal assessment, and counselling of danger signs Fourth contact (36weeks) 1. Planning the birth, determining the fetal position, and continuously checking on the health of the mother and fetus. 2. Pregnancy confirmation, initial evaluation (blood pressure, weight, and blood test), screening for infections such as HIV and syphilis, and starting an iron and folic acid supplement. 3. Counseling on quitting smoking, maintaining a healthy diet and lifestyle, and engaging in physical activity. 3. Nutritional Interventions 1. Iron and folic acid supplements to prevent 7. anemia 8. white and red meat 2. dark-green leafy vegetables, such as 8. fish watercress and curly kale 9. tofu 3. iron-fortified cereals or bread 10. eggs 4. brown rice 11. dried fruit, such as dried apricots, prunes 5. pulses and beans and raisins 6. nuts and seeds Education on maintaining a healthy diet and managing appropriate weight gain during pregnancy Reference: https://www.haiderian.co.uk/info.aspx?p=15 4. Infection Prevention: Screening and treatment for sexually transmitted infections (HIV, syphilis), urinary tract infections, and other common infections. Malaria prevention in endemic areas through intermittent preventive treatment and the use of insecticide-treated bed nets. 5.Counselling on Danger Signs: Pregnant women should be educated on recognizing warning signs which could indicate serious complications such as: Pregnant women should be educated on recognizing warning signs which could indicate serious complications such as: 1. Severe headaches 2. Blurred vision 3. Bleeding 4. Abdominal pain 6. Health Promotion and Counseling: 1. Mental health 2. Breastfeeding 3. Birth preparedness 4. Family planning post delivery 7. Preventing and Managing Pre- eclampsia: 1. Routine blood pressure measurement at every visit. 2. Calcium supplement is recommended in populations with low dietary calcium intake to reduce the risk of pre-eclampsia.  3. Low-dose aspirin is recommended from 12 weeks in women at high risk for pre-eclampsia. 8. Ultrasound recommendation 1. Early ultrasound (before 24 weeks) is recommended to 2. Estimate gestational age 3. Detect multiple pregnancies 4. Identify potential anomalies 9. Mental Health Screening Regular screening for mental health for mental conditions like depression or anxiety 10. HIV and Syphilis Testing 1. all women should be screened for syphilis at their first prenatal visit. 2. those who are at high risk for syphilis, are previously untested, or live in areas of high syphilis morbidity should be screened again early in the third trimester and at delivery. RECOMMENDED: SAFE VACCINES DURING PREGNANCY 1. Tetanus, Diphtheria, and Pertussis (Tdap) Recommendation: Every pregnant woman should get the Tdap vaccine, ideally between weeks 27 and 36 of pregnancy Purpose: Tdap gives the infant, who is susceptible to serious problems from pertussis, passive protection while shielding the mother from whooping cough. 2. Influenza (Flu Vaccine): Recommendation: Any time during trimester is a good time to have the inactivated flu shot because it is safe. Purpose: Pregnant women are more susceptible to serious flu-related illnesses, and immunization helps avoid complications like pneumonia. Additionally, it aids in the newborn's protection during the initial months of life. 3. COVID – 19 Vaccine: Recommendation: COVID-19 vaccination, mRNA vaccine (Modera or Pfizer-BioNTech), at any stage of on trimester. Purpose: In pregnant women who are more susceptible to problems, vaccination lowers the chance of serious COVID-19 sickness and may provide some postpartum immunity to the unborn child. 4. Hepatitis B: Recommendation: For expectant mothers who are at risk of catching the illness, such as those with high-risk sexual behavior or chronic liver disease, this vaccine is safe and advised. Purpose: it protects the mother from hepatitis B, which can be transmitted to the baby during Childbirth. Vaccine Considered Safe but Given Only When Necessary 1. Hepatitis A Recommendation: safe to use while pregnant if exposure is possible (visit places where hepatitis A is prevalent). Purpose: Protects against hepatitis A, which can cause severe liver disease during pregnancy 2. Meningococcal Vaccine: Recommendation: Safe during pregnancy if there is a risk of meningococcal disease 9 travel to areas with high disease incidence. Purpose: Protects against bacterial meningitis 3. Pneumococcal vaccine: Recommendation: Safe if pregnant woman is at risk for pneumococcal infections (chronic disease or immune compromise) Purpose: Protects against pneumonia and other serious infection caused by pneumococcal bacteria VACCINES TO BE AVOIDED DURING PREGNANCY 1. MMR (Measles, Mumps, Rubella) should be administered BEFORE pregnancy, NOT DURING If needed: it should be given one month before conception. 2. Varicella (Chickenpox) Not advised during pregnancy if a woman lacks immunity, she should get vaccinated before getting pregnant. 3. Human Papillomavirus (HPV Vaccine) The remaining HPV vaccinations should be withheld until after delivery if a woman falls pregnant while still in the middle of her series. DETERMINATION OF ESTIMATED BIRTH DATE 1. Naegele’s Rule – used to determine the expected date of delivery (January, February and March (+9, +7)) Example: A. LMP – January 15, 2020 + 9 +7 EDD = 10 /22 / 2020 (April – December ( -3, +7, +1)) Example: B. LMP – July 15, 2020 -3, +7 +1 EDD = 04 / 22 / 2021 Exercises: Compute for the following EDD: 1. March 19, 2022 2. June 02, 2023 3. August 05, 2023 4. May 21, 2022 5. December 7, 2022 2. McDonald’s Rule / Fundal Height – is a method used to determine the age of gestation by measuring from the fundus (obtaining the fundal height) to the symphysis pubis. It is a symphysis-fundal height measurement, although not thoroughly documented to be reliable, and is a common method of determining, during mid-pregnancy, that a fetus is growing in utero. Typically, the distance from the uterine fundus to the symphysis pubis in centimeters is equal to the week of gestation between the 20th and 36th week of pregnancy. The measurement is made from the notch of the symphysis pubis to over the top of the uterine fundus as the woman lies supine. Mc Donald’s Rule is inaccurate during the third trimester of pregnancy because the fetus is growing more in weight than in height during this time. Until then a fundal height much greater than this standard suggests multiple pregnancy, a miscalculated due date, a large-for-gestational-age infancy, or possibly even H-mole. VIDEO REFERENCE:  HOW TO MEASURE FUNDAL HEIGHT_SKILL D 3. Bartholomew’s Rule - to determine the age of gestation by proper location of fundus in the abdominal cavity. JOHNSON’S RULE is a clinical technique that uses maternal characteristics and fundal height—the distance between the top of the uterus and the pubic symphysis—to estimate the fetal weight (EFW) during pregnancy. When ultrasound is not available, this straightforward bedside instrument provides a rapid method of estimating baby weight in grams; nevertheless, its accuracy may vary, particularly in situations involving multiple pregnancies or aberrant amniotic fluid levels. Johnson’s Formula for Estimating Fetal Weight (EFW)- the formula depends on whether the fetal head is engaged in the pelvis or not. 1. When the fetal head is engaged: EFW (grams)= (Fundal height (cm) – X) x 155 Where X=12 2. When the fetal head is not engaged EFW 9grams = (fundal height cm) – X) x 155 Where X=11 STEPS: Measure the fundal height – from the top of the pubic symphysis to the top of the uterus in centimeters. -Determine engagement of the fetal head: Subtract 12 from the fundal height if the fetal head is in the pelvis. Example: Mrs. Cruz’s fundal height is 36, the fetal head is engaged EFW= (32-12) x155 = 20 x 155 = 3,100 grams (3.1 kg) 2-2 -Fetal head is not engaged, subtract 11 2. Multiply by 155 to estimate the fetal weight in grams. HAASE’S RULE For babies weighing less than 1,000 grams. Length (cm) = Weight (grams) 1/3 x 10 Example: the estimated weight of a newborn is 729 grams, estimate the length. Length (cm) = (729)1/3 x 10 = 9 x 10 = 90 cm LEOPOLD’S MANEUVER Leopold's maneuver- are a set of four standardized steps that healthcare providers use to assess the position and presentation of a fetus in the mother's abdomen during pregnancy. These maneuvers were developed by the German obstetrician Christian Gerhard Leopold and are commonly performed as part of a prenatal examination, particularly during the third trimester. Leopold's maneuvers and fundal height measurement are essential components of prenatal care assessments performed by nurses and healthcare providers. These techniques help determine the position of the fetus and monitor the growth of the uterus during pregnancy. The four maneuvers involve palpating the mother's abdomen in a systematic way to determine the position of the baby within the uterus. The goal is to assess the following aspects: 1. Fundal Grip: The healthcare provider uses their hands to feel the top of the uterus (fundus) to determine the position of the baby's head or buttocks. 2. Umbilical Grip: The provider locates the umbilicus (belly button) and uses their hands to determine the presence of a fetal back or small parts (limbs). 1. Pawlik's Grip: This step involves feeling the sides of the uterus to assess the engagement of the baby's presenting part (usually the head) in the maternal pelvis. 2. Pelvic Grip: The healthcare provider assesses the descent of the baby's presenting part into the maternal pelvis and the level of engagement. These maneuvers can help the healthcare provider determine important information about the baby's position, presentation (the part of the baby that is closest to the birth canal), and engagement (how far the baby's head has descended into the pelvis). This information is crucial in planning labor and delivery, as well as determining if the baby is in a favorable position for a vaginal delivery. It's important to note that while Leopold's maneuvers are a useful clinical tool, they are not always definitive and may be complemented by other diagnostic techniques such as ultrasound if more detailed information is needed. Purposes: A. To determine the presentation and position of the fetus. B. To determine whether lightening and engagement has occurred. C. To identify the maximum impulse for auscultations of fetal heartbeat. D. To determine if the fetus is in normal flexion. E. To determine the presence of multiple pregnancies. F. To estimate fetal size and locate fetal parts. The Four Maneuvers  1. First - this maneuver determines whether the fetal head or breech (fetal lie) is in the fundus. 2. Second – also known as the lateral maneuver which determines the fetal lie, presentation, position, and attitude. 3. Third - this 1st pelvic maneuver determines the part of the fetus at the inlet and its mobility. The degree of engagement is observed here. 4. Fourth – this 2nd pelvic maneuver determines how the fetal head is flexed PREFORMING LEOPOLD'S MANEUVERS - SKILLS LEARNING ACTIVITY: PowerPoint presentations Video presentation of the procedure Quizzes/Examinations Return Demonstration PROCEDURAL CHECKLIST (See attached checklist) REFERENCES: 1. Leifer, G. 2019, Introduction to Maternity and Pediatric Nursing, Eighth Edition, Elsevier Inc 2. Pillitteri, A. 2022, Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. 9th Edition, Lippincott Williams & Wilkins Prepared by: ___________________________ ROWENA B. LAMORENA Clinical Instructor Recommending Approval: __________________________ PROF. REGIE S. JIMENEZ Chairperson Nursing Department Approved by: ________________________ PROF. MARYJANE N. RIGOR Dean, College of Science