RLE NCM 107 Care of Mother, Child, Adolescent PDF

RLE NCM 107 CARE OF MOTHER, CHILD, ADOLESCENT 1M – LEOPOLD’S MANEUVER AND ANTE-POST NATAL EXERCISES DEFINITION OF TERMS ✓ A fundal height measurement is typically 1. Antepartum...

RLE NCM 107 CARE OF MOTHER, CHILD, ADOLESCENT 1M – LEOPOLD’S MANEUVER AND ANTE-POST NATAL EXERCISES DEFINITION OF TERMS ✓ A fundal height measurement is typically 1. Antepartum done to determine if a baby is of ✓ Means “before childbirth.” Antepartum appropriate size for its gestational age. depression happens only during ✓ The measurement is generally defined as pregnancy. It’s also sometimes called the distance in centimeters from the maternal depression, prenatal pubic bone to the top of the uterus. depression, and perinatal depression. ✓ The expectation is that after week 24 of ✓ Occurring prior to labor, with reference to pregnancy the fundal height for a the mother. normally growing baby will match the 2. Ballottement number of weeks of pregnancy — plus or ✓ An obsolete method of diagnosing minus 2 centimeters. pregnancy: with the tip of the forefinger 8. Leopold’s Maneuver in the vagina, a sharp tap is made against ✓ Also known as fetal palpation, are 4 the lower segment of the uterus; the maneuvers used to palpate a fetus inside fetus, if present, is tossed upward and (if a pregnant woman, from her abdomen. the finger is retained in place) will be felt FMF is shorthand for fetal movement felt. to strike against the wall of the uterus as 9. Lie it falls back. ✓ The position or attitude of the fetus in the 3. Bartholomew’s rule womb in relation to the long axis of the ✓ A rule for determining the duration of mother’s body pregnancy by measuring the height of 10. Longitudinal Lie the fundus of the uterus above the pubic ✓ A situation in which the long axis of the symphysis. fetus is parallel to that of the mother; in 4. Engagement the presentation, either the head or ✓ the entrance of the largest diameter of breech presents first the fetal head into the smallest diameter 11. Transverse Lie of the maternal pelvis or the mechanism ✓ A position in pregnancy means that the by which the biparietal diameter of the baby is horizontal in your belly. The fetal head enters the plane of the inlet. position of the baby becomes an issue as 5. Fingerbreadths your due date approaches. The optimal ✓ A clinical “ruler” for evaluating certain position for vaginal delivery is the head landmarks—e.g., the size of the liver down or vertex position. based on the number of fingerbreadths 12. Postpartum from right costal margin. ✓ The period after 6-12 hours after birth. ✓ Are just the width of a finger. If we Postpartum refers to the mother and palpate a pregnant uterus at about 18-19 postnatal to the baby weeks, it is one or two finger's widths 13. Position below the belly button. ✓ The position of the baby in your uterus is 6. Fundus called the presentation of the fetus ✓ The part of a hollow organ (such as the 14. Presentation uterus or the gallbladder) that is farthest ✓ Presentation refers to the part of the from the opening. fetus’s body that leads the way out ✓ The fundus of the uterus grows in a through the birth canal (called the predictable pattern during the weeks of presenting part). Usually, the head leads pregnancy the way, but sometimes the buttocks or 7. Fundal height a shoulder leads the way. The most common and safest combination consists of the following: Head first (called 1 N. TUMULAK – BSN 2F  ✓ vertex or cephalic presentation) LEOPOLD’S MANEUVER 15. Station A systematic method of observation and palpation to 1. Refers to the descent of the fetal determine fetal presentation and position and are done as presenting part (hopefully the head) in part of a physical examination for pregnant women. There the pelvis. are four classical maneuvers used to palpate the gravid 16. Fetal Heart Tone uterus systematically. This method of abdominal 2. A rate which, in the non-stressed fetus, palpation is of low cost, easy to perform, and non- reflects cardioaccelerator and invasive. It is used to determine the position, cardiodecelerator reflexes; analysis of presentation, and engagement of the fetus in utero. the FHR requires evaluation of a baseline FHR between uterine contractions or periodic changes in the FHR and non- Principles involved in Leopold’s Maneuver periodic, short-term fluctuations in the Safety and Awareness FHR. Explanation of the procedure reduces anxiety 17. Gravida and enhances cooperation of the patient. 3. is the number of times the mother has Safety, at all times, must be observed to keep been pregnant. This includes the current the mother and child safe. With the mother’s pregnancy if your patient is pregnant. awareness of the procedure, she will be at 18. Nulligravida ease and eradicate some anxiety when the 4. A woman who has never been pregnant procedure is performed. 19. Primigravida 5. A woman who is pregnant for the first Microbiology time Microbiology is the study of microorganisms. 20. Multigravida With this consideration in mind, hand 6. A woman who has had six or more washing must be performed. Hand washing previous pregnancies prevents the spread of a possible infection to 21. Para the mother. This also guarantees substantial 7. A woman who has produced one or more security and protection from microorganisms viable offspring. Used with numerals to when the procedure is done. designate the number of pregnancies that have resulted in the birth of viable Body Mechanics offspring, as para 0 (none—nullipara), Body mechanics must be observed so as to para I (one— unipara), para II (two— prevent harm to the mother and child when bipara), para III (three—tripara), para IV procedure is being performed. This also (four— quadripara). applies to the nurse performing the 22. Symphysis Pubis procedure so as to prevent harm to both the 8. A firm anterior fibrocartilaginous joint examiner and the client. between the two pubic bones, which loosens during late pregnancy and Anatomy and Physiology delivery to facilitate the passage of a A nurse performing the procedure must have baby. a solid knowledge on the anatomy and physiology of the human body to prevent mistakes such as palpating incorrect areas and applying the wrong pressure that can cause harm to both the mother and child. Nursing Responsibilities before, during, and after Leopold’s Maneuver Before Prepare the needed materials 2 N. TUMULAK – BSN 2F  The nurse must inform the client of the procedure During The nurse must inform the client that an The nurse keep in mind and observe the different empty bladder is best when the procedure is scientific principles such as body mechanics when being performed and assist the mother as she performing the procedure attends to her physiologic needs Take the relevant measurements such as the Perform medical handwashing fundal height Assist the client to a supine position with her Perform the maneuver, applying firm even knees slightly flexed pressure in palpation Before the procedure is being performed, drape the client to respect the client’s privacy After Warm hands by rubbing the palms against Assist the client as to wrap up the procedure each other to prevent discomfort for the Documentation of findings mother Leopold’s Procedure Findings with rationale Maneuver L1 – Fundal Grip Stand at the foot of the client and while facing The nurse should feel that the limb and her, place both hands on the abdomen. Palpate shoulder contain little bone processes that the superior surface of the fundus and moves with the trunk of the fetus; the head determine its consistency, shape, and mobility. should feel firm round and moves separately from the trunk; and the bottom is symmetric Using a tape measure, measure the and should feel soft. symphysis/fundal height in centimeters After 20 weeks gestation the fundal height in Fundal height should approximate the centimeters should approximate the weeks of weeks of gestation. gestation ± 4 centimeters in a singleton pregnancy. Example: 36 weeks pregnant, fundal height of 32 to 40 is considered normal. L2 – Umbilical Grip Face the client and holding the left hand still on Nurse should observe that the fetal back is the left side of the uterus, palpate with the right smooth and firm. Fetal extremities should feel hand on the opposite side of the uterus starting like small protrusions and irregularities; back from the top and moving down. Repeat should connect with the form felt in the lower palpation on the opposite side with opposite (maternal inlet) and upper abdomen. hands. Fetal heart rate is auscultated with stethoscope and is about twice as fast as a healthy adult’s heart rate - usually 120-160 beats a minute. L3 – Pawlick’s Grip Gently grasping the lower portion of the The nurse identifies the part of the fetus that abdomen above the symphysis pubis between is above the inlet. Findings in this maneuver the thumb and fingers, press the thumb and should validate what is determined in the first finger together. Determine for any movement maneuver. and whether the area feels firm or soft. L4 – Pelvic Grip Placing fingers on both sides of the uterus A well-flexed fetal head is located on the approximately 2 inches above the inguinal opposite side of the fetal back. If the head is ligaments, press downward and inward in the extended, back of the head is felt on the side direction of the birth canal and allow the the back is located. A head that cannot be felt fingers to be carried downward. has likely descended. 3 N. TUMULAK – BSN 2F  GUIDELINES for LEOPOLD’S MANEUVER Heartbeat heard below the To the client to reduce anxiety and maximize mother’s belly button means that the fetus is probably head down. cooperation from the client. Attending to physiologic Heartbeat above the mother’s needs must be done as an empty bladder is best when belly button means that possibly performing the procedure. the fetus is in a breech position. To prevent the spread of a possible infection, the nurse L3 – Fetal In a vertical or longitudinal lie, must perform medical handwashing. Warms hands after Presentation the fetal presentation can be either to provide comfort and prevent muscle contraction of the cephalic or head. abdomen during palpation. In a transverse lie, the Flex the knees to relax the abdominal muscles and presentation is usually the back or shoulder. utilizing a pillow or towel to tilt the uterus off the vena In oblique lie, the presentation is cava so as to prevent supine hypotension syndrome. usually the shoulder or the arm The axis is the length of the fetus where the location of L4 – Fetal The fetus head is engaged when the activity, most likely reflects the position of the feet. Engagement it is felt and means the largest part The maneuver is done to determine whether the fetal of the head has entered the pelvis. head or breech is in the fundus. The head is firmer than the breech, it is round and hard, and moves independently. Whereas the breech is softer and moves only in concurrence with the body. The maneuver located the back of the fetus. The fetal back will feel smooth, hard, and is a resistant surface. Whereas the knees and elbows of the fetus will feel like angular bumps or nodules when palpated. The maneuver also determines which part of the fetus is at the inlet as well as its mobility. If the presenting part moves upwards to which your fingers and thumb can be pressed together, the presenting part is not engaged, meaning it is not settled firmly into the pelvis. However, if the part is firm, it is the head and if it soft, it is the breech. This maneuver is done if the fetus is positioned head down (cephalic position) because it determines the fetal attitude as well as its degree of fetal extension into the pelvis. Document Client Responses and Outcomes L1 – Fundal When the head is in the fundus it Situation: Height and feels firm and round with smooth A pregnant mother visits the Health Center for her regular Content surface consistency and moves prenatal visit. Upon interviewing her, you recommend independently in the body. that ff: Breech when it gives a softer 1. She is presently pregnant for the third time. She feeling and moves only with gave birth to two male twins on her first conjunction with the body. pregnancy, delivered at 36 weeks AOG. She L2 – Fetal Back The fetal back will feel smooth, incurred miscarriage two years ago and Fetal Small hard and resistant to the surface; 2. Her Last Menstrual Period was on July 25, 2021 Parts with Fetal fetal extremities on the opposite 3. Her present Fundal Height is 30 cm Heart Tone and side will feel like small irregularities Location and protrusions. 4 N. TUMULAK – BSN 2F  GTPAL Computation of AOG using LONG METHOD G - Gravidity G3 (Use long division for this one) T - Term T0 LMP: July 25 – 31 = 6 Date of Examination: January 19, 2020 P – Preterm P2 A - Abortion A1 July 6 L - Living L2 Aug 31 Sept 30 Computation of Expected Date of Confinement Oct 31 (EDC) Nov 30 Last Menstrual Period (LMP) Dec 31 - The last menstrual period is considered the date Jan 19 of the first day of pregnancy 178 days Computation of Expected Date of Confinement Weeks: 178/7 = 25 3/7 weeks (EDC) using NEAGEL’s RULE Months: 25/3 = 8 1/3 = 8 months 1 week and 3 days Neagel’s Rule - is used to determine the due date of pregnancy on the basis of the first day of the last menstrual period by subtracting 3 for months, adding 7 for days and adding 1 for years. Example: LMP : July 25, 2020 Solution: 7 25 2020 -3 +7 +1 4 32 2022 +1 +30 2022 Answer: 5 2 2022 – MAY 2, 2022 Computation of AOG using MCDONALD’S RULE (Use long division for this one) McDonald’s rule is used to determine the age of gestation by measuring from the fundus to the symphysis In months: fundal height x 2/7 In weeks: fundal height x 8/7 Example: Fundal height = 30cm In months: 30 x 2/7 = 8 6/7months In weeks: 30 x 8/7 = 34 2/7 weeks 5 N. TUMULAK – BSN 2F RLE NCM 107 CARE OF MOTHER, CHILD, ADOLESCENT 2M – ADMISSION, LABOR WATCH, ENEMA & DIGITAL EXTRACTION ADMISSION AND LABOR WATCH DEFINITION OF TERMS ✓ The tightening and shortening of the 1. Admission uterine muscles ✓ act or process of accepting someone 12. Increment into a hospital, clinic, or other treatment ✓ An increasing value in the interval of facility as an inpatient. every uterine contraction 2. Kardex 13. Acrement ✓ is a medical information system used by ✓ a static state in the interval of every nursing staff as a way to communicate uterine contraction, neither increasing or important information on their patients. decreasing 3. Identification band 14. Decrement ✓ A band bearing the patient's identity. It ✓ A gradual decrease in the interval of comes in different colors depending on every uterine contraction the patient's type of condition. 15. Duration 4. Demographic data ✓ The length of time within a single ✓ data usually obtained including the uterine contraction name, age, address, telephone number, 16. Frequency e-mail address, religion, ethnicity, type ✓ The rate at which every uterine and place of employment, and health contraction occurs insurance information 17. Interval 5. Labor ✓ An intervening time or space between ✓ The process of expulsion of the fetus every uterine contraction and the placenta from the uterus 18. Intensity 6. Labor watch ✓ The strength of the contraction ✓ Act of assisting and monitoring the 19. Friedman’s curve mother during birth ✓ the gold standard for rates of cervical 7. Gravida dilation and fetal descent during active ✓ - the total number of confirmed labor. It facilitates the detection of pregnancies a woman has had, dysfunctional labor. regardless of the outcome of the 20. Fetal station pregnancy. ✓ is a measurement of how far the baby 8. Para has descended in the pelvis, measured ✓ The total number of pregnancies that a by the relationship of the fetal head to woman has carried past 20 weeks of the ischial spines pregnancy. This number includes both 21. Effacement live births and pregnancy losses after 20 ✓ The process by which the cervix weeks, such as stillbirths. prepares for delivery. After the baby has 9. Intrapartal engaged in the pelvis, it gradually drops ✓ occurring or provided during the act of closer to the cervix. The cervix will birth gradually soften, shorten and become 10. Engagement thinner ✓ The sensation that a pregnant woman 22. Dilation feels when the lowermost part of the ✓ Is the opening of the cervix, the fetus descends and is engaged in the entrance to the uterus, during childbirth, mother's pelvis, an event that typically miscarriage, induced abortion, or occurs 2 to 3 weeks before labor begins. gynecological surgery 11. Uterine contractions 23. Bishop’s scale 1 N. TUMULAK – BSN 2F  ✓ Is a pre-labor scoring system to assist in predicting whether PSYCHOLOGY induction of labor will be required. Psychology is applied by the explanation of the 24. Episiotomy procedure and ensuring that the woman is aware ✓ A surgical cut made at the opening of and knows what to expect. the vagina during childbirth, to aid a difficult delivery and prevent rupture of SOCIOLOGY tissues. It is imperative that the patient establishes trust 25. Episiorrhaphy and professional connection with the nurse to ✓ surgical repair of injury to the vulva by ensure that the patient is always comfortable. suturing TIME AND ENERGY Materials must be prepared ahead in order for further procedures to move without any ADMISSION disruptions or future problems. BODY MECHANICS MICROBIOLOGY During labor watch, it is imperative that the The principles of microbiology are applied to woman is supported through techniques and ensure that the environment is safe and clean. breathing patterns that will alleviate any pain Furthermore, this will protect and prevent any from contractions. As well as proper positions that bacteria, pathogens, or parasites to spread and will enhance the comfortability for the woman. harm the people. PSYCHOLOGY UTERINE CONTRACTIONS Psychology applies within the admission because when interacting with patients, it is imperative TRUE Contractions Irregular, but eventually become regular and that the nurse takes the time to explain any predictable. Initially felt in further procedures that the patient may the lower back and then is experience. By doing so, this will alleviate any felt around to the initial fears or worries that the patient may have. abdomen. To add, true SOCIOLOGY contractions continue In terms of sociology within the admission, it is regardless of what the important that the nurse and the patient builds a woman is doing. proper connection or rapport in order to Contractions increase in efficiently care for the needs with the patient. duration, frequency, and TIME AND ENERGY intensity. Moreover, It is important to prepare the environment ahead cervical dilatation is of time to ensure that the patient is safe and achieved. prevented from any accidents. FALSE Contractions Contractions begin and stays irregular. Initially felt abdominally and BODY MECHANICS remain in the abdomen Body Mechanics is applied in admission to ensure and groin. Additionally, that the patient is always in a comfortable and the contractions disappear safe position. while walking (ambulation) or sleeping. The contractions do not increase in duration, frequency, and intensity. LABOR WATCH Lastly, cervical dilatation MICROBIOLOGY is not achieved. Microbiology is applied in labor watch by the encouragement of the woman to practice proper PHYSIOLOGY hygiene in order to avoid any transmission or contamination from harmful pathogens and parasites. 2 N. TUMULAK – BSN 2F Uterine contractions occur when the muscles of the uterus frequency until the cervix is fully dilated. Moreover, with tighten and then relax, they happen involuntarily. Within abdominal muscle contractions, expulsion occurs as well. the first stage of labor, the uterine contractions’ purpose Throughout the final stages of pregnancy estrogens, is to push the baby out, and thus, smooth muscle relaxin hormones are secreted to further loosen the contractions eventually increase in strength and ligaments and connective tissue of the birth canal. After 2. ACTIVE PHASE the expulsion of the fetus, the stimulus for labor is In the active phase, the cervix removed and the uterine contractions compress into the continues to dilate rapidly from 4 to size of the uterus. Even after birth, uterine contractions 7 cm. As the contraction increases, occur in order to dislodge the placenta. Once the place is they last from 40 to 60 seconds at detached, the uterine contractions compress the uterine approximately 3 to 5 minutes. Due to the growing contractions lasting blood vessels to limit maternal blood loss longer, during this phase, the woman experiences more discomfort. The contractions last even longer and FIRST STAGE OF LABOR more painful, and some women may 1. LATENT PHASE experience feeling sick to the The initial stage of labor is referred stomach. The active phase is the to as latent or early labor. In the most predictable, and for a woman latent labor phase, the patient may experiencing pregnancy for the first experience mild and short time, this phase may last 5 hours; contractions that last 20 to 40 whereas, 2 hours in mothers with seconds. The contractions are previous pregnancies. In this phase, described as aching in the lower the woman may receive epidural to back, menstrual cramps, and relieve the pain. Furthermore, in the pressure or tightening in the pelvic active phase, vaginal secretions are area. For primigravid mothers, increased and possibly a membrane women experiencing labor for the may rupture as well. first time, may last in this phase 3. TRANSITION PHASE closer to 20 hours; whereas for a The Transition Phase is when the woman who had a previous uterine contractions are at the peak pregnancy, multigravida, may of intensity. Meaning, the experience the latent phase for 10 to contractions are incredibly intense, 12 hours. Moreover, the mild strong, long, and can overlap each contractions eventually become other. This phase is referred to as the stronger and more frequent. Due to hardest phase but is the shortest. the contractions, the cervix will dilate The woman commonly experience an and efface to prepare for delivery. intense and strong urge to push Additionally, the cervix dilates 0 to 3 along with the contractions. cm. Additionally, there is strong pressure in the lower back and/ or perineum, drowsiness between contraction, and exhaustion. The uterine contractions occur 60 to 90 seconds every 2 to 3 minutes; as a result, the cervical dilation increases to 8 to 10 cm. If there was no previous rupture by amniotomy, there will be a rupture at the full dilation of 10 cm. Overall, at the end of the transition phase, there will be am result of the complete dilation of 10 cm and cervical effacement. SECOND STAGE OF LABOR 3 N. TUMULAK – BSN 2F The woman is already at the state of full dilation and cervical effacement to birth to the infant. Within this second stage, the uterine contractions of the woman will have the characteristics of having an overwhelming and uncontrollable urge to push each contraction to move her bowels. The woman pushes intensely to aid the uterine contractions in which the fetus is finally pushed out of the birth canal. Contractions in the second stage of labor come every 2 to 3 minutes last 60 to 90 seconds. The woman will feel a burning and splitting sensation in either their perineum or vagina. For first time mothers, the delivery of the baby may last around two hours, and for mothers who have experienced labor may deliver the baby in one hour. However, if the woman has an epidural anesthetic, the process may take longer. THIRD STAGE OF LABOR During the third stage or also referred to as the placental stage, starts with the birth of the infant up until the delivery of the placenta. The birth of an infant leads to the events of the uterus being palpated, and after minutes Placental Separation of rest, uterine contractions begin again. To add, the After Placental Separation, the delivery of the placenta organ remains a discoid shape until the placenta has occurs through the natural bearing-down effort by the separated. This process may occur instantly or take up to mother or through a physician or nurse- midwife applying a maximum of 30 minutes. In the third stage there are gentle pressure on the contracted uterine fundus (Crede’s two different phases taking place: placental separation maneuver) and placental expulsion. If the placenta does not deliver, it may be Placental Separation removed manually. When the uterus contracts down on an almost empty The delivery of the placenta completes the third interior, the disproportion of the placenta and the stage of labor contracting wall of the uterus that folds and separates occur. Active bleeding contributes to the separation of the placenta by pushing it away to the attachment site; as a result, the placenta is located to the lower uterine segment or upper vagina Signs that signify a loosened placenta ready to deliver: Lengthening of the umbilical cord Sudden gush of vaginal blood Change in the shape of the uterus Firm contraction of the uterus GUIDELINES IN LABOR WATCH The normal consequence of placental separation includes Keep track of a woman's labor progress at all times. bleeding before the uterus contracts sufficiently to seal Monitor maternal condition by measuring her blood maternal sinuses. The normal blood loss ranges from 300 pressure and temperature every 4 hours, and her pulse to 500 mL rate every 30 minutes. Assess the progress of labor by checking uterine contractions (length, strength and frequency) every 30 minutes, descent of the head every two hours and cervical dilatation every four hours. 4 N. TUMULAK – BSN 2F  Keep an eye out for these maternal danger signs: Assess patient’s Provide Congratulate o Abnormal lower abdominal contour psychological positive on the delivery o High or Low Blood pressure readiness feedback as of the baby o Increasing apprehension the patient o Abnormal pulse Provide pushes Take vital signs o Inadequate or prolonged contractions material of the mother support Take note of the time od Monitor for any Look out for fetal danger sings while on labor: Allow patient to delivery and signs of o Severe vaginal bleeding be continually proceed to abnormal o Prolonged labor (>12h) active initiate bleeding or o High or low fetal rate newborn care shocks o Low oxygen saturation Conduct Health LABOR WATCH o Hyperactivity teaching on Assist in Encourage skin o Meconium staining effective restrictive to skin contact bearing down episiotomy for to facilitate Keep the patient well hydrated before epidural and different patients who bonding and anesthesia relaxation had vaginal early Reduce the number of unneeded interventions in labor techniques births breastfeeding as much as possible Advise the patient on how to breathe properly / Assist patient Provide quiet Promote rest breathing patterns with pant-blow and and breathing encouraging rehydration environment NURSING RESPONSIBILITIES Check room so the patient temperature can Before During After concentrate on Establish Take the Continue Instruct patient bearing down rapport with the pertinent observing the on quality patient and information situation pushing significant about the others pregnant Let the mother FIRST STAGE OF LABOR woman’s bond with the Explain the health history infant Assessment procedure to ✓ Vital signs: BP, PR, and temperature (assess the patient and Monitor vital Record the between contraction) ADMIISSION significant signs on a type of ✓ Nature of contractions (Intensity, duration, and others regular basis medication frequency) administered in ✓ Pain scale Take note of Monitor fetal the patient’s ✓ Presentation of the fetus the any heart rate at chart ✓ Ask question and communicate potential set times ✓ Complaints of pain and discomfort dangers of warning Diagnosis indications ✓ Labor pain due to increased of strong and frequent contractions Examine and ✓ Nausea related to anxiety and stress with the evaluate thoughts giving birth patient’s mental and emotional Planning readiness ✓ Teaching relaxation techniques and deep breathing techniques ✓ The woman must also be allowed to move freely throughout the labor ✓ Allow the woman to assume a non-supine position for the delivery. 5 N. TUMULAK – BSN 2F  Intervention ✓ Risk for Deficient Fluid Volume related to uterine ✓ Communicate with the patient, and report atony moderate pan level ✓ Impaired skin integrity: presence of laceration ✓ Provide use of comfort measures related to episiotomy ✓ Provide information about the labor process Planning ✓ Uplift and encourage the patient by using positive ✓ Placental delivery should be given focus at this reinforcement stage. Once the placenta is delivered, oxytocin should be administered intramuscularly to promote uterine contraction SECOND STAGE OF LABOR ✓ If there is episiotomy performed, perineal repair Assessment should be integrated into the care plan. ✓ Increase in apprehension or irritability Implementation ✓ Spontaneous rupture of membranes ✓ Assess maternal signs and uterine status ✓ Sudden appearance of sweat ✓ Observe mother for signs and altered color ✓ Complaints of rectal and perineal pressure respiration ✓ Assess the awareness of the mother by ✓ Monitor the vital signs of the mother observation ✓ Allow maternal-infant interaction as soon as possible Diagnosis ✓ Acute pain: related to dilation of tissues and ✓ Encourage her to drink fluids and eat if her care pressure on adjacent structure providers will allow it. Eating and drinking can ✓ Nausea due to lack of pressure in the stomach help restore used energy for the labor Planning ✓ During the second stage of labor, the place of delivery of the woman must be prepared FRIEDMAN’S CURVE AND LABOR ✓ The position of birth where the woman is most WATCH comfortable. ✓ Promotion of second stage effective pushing TIME Cervical Fetal Station ✓ Do backrubs to ease the pain Dilation 0800H 2cm -3 Implementation 1000H 4cm -2 ✓ Instruct mother to use specific techniques such 1200H 6cm 0 as focused breathing 1300H 7cm +1 ✓ Instruct the mother to push as if she’s having her 1400H 9cm +2 bowel movement ✓ Provide intensive support and encouragement for Take note of the following: the patient Beginning of True Labor Contractions: 09/1/20, 0400H (0400H = 0th hour) THIRD STAGE OF LABOR Assessment ✓ Monitoring placement separation by looking for the following signs: ✓ Firmly contracting uterus ✓ Change in uterine shape from discoid to globular ovoid ✓ Sudden gus of dark blood from vaginal opening ✓ Lengthening of umbilical cord protruding from vagina Diagnosis 6 N. TUMULAK – BSN 2F Rupture of Membranes (time, type, DURATION = Time END – Time START characteristics): 0800H, spontaneous rupture of membranes, clear Administration of IV Fluids and Oxytocin: 930H, administered 10 units of Oxytocin infused in 5% Dextrose in Lactated Ringer’s Solution running at 20 drops per minute Time of Delivery: 1445H, delivered a live term baby boy via Normal Spontaneous Vaginal Delivery with a Birth Weight of 2.5kg and an Apgar Score of 9,10 INTERVAL = Time START2 – Time END1 LABOR RECORD FREQUENCY = Time START2 – Time END1 7 N. TUMULAK – BSN 2F  ENEMA AND DIGITAL EXTRACTIONS DEFINITION OF TERMS who is assisting a person with a spinal 1. Cleansing enema cord injury or another health problem ✓ A water-based solution with a small that results in a problem with defecation. concentration of stool softener, baking soda, or apple cider vinegar is used to stimulate the movement of the large Purpose of administering ENEMA and DIGITAL intestine. A cleansing enema should EXTRACTION stimulate the bowels to quickly expel both the solution and any impacted fecal In some circumstances, due to diet, medical condition, or matter. medication, among other possible causes, your bowel 2. Lubricant may form stool that is hard to pass easily resulting in constipation. An enema may be helpful when there is a ✓ An oily or slippery substance. A vaginal problem forming or passing stool. Your doctor may lubricant may be helpful for women who recommend a therapeutic enema to treat diseases and feel pain during intercourse because of conditions of the colon or rectum including: vaginal dryness. Constipation: hard, dry, infrequent stools that are 3. Retention enema difficult to pass ✓ An enema that may be used to provide Excessive gas: belching, bloating, distended abdomen nourishment, medication, or anesthetic. Fecal impaction: a large amount of hard stool that is It should be made from fluids that will not stuck in the rectum stimulate peristalsis. A small amount of Ulcerative colitis: inflammation and bleeding in the solution (e.g., 100 to 250 mL) is typically colon. Your doctor may order an enema that contains used in adults. corticosteroids dissolved in water. Corticosteroids 4. Enema reduce inflammation. Doctors also prescribe enemas ✓ an instrument used to produce liquid into containing the anti-inflammatory drugs mesalamine the large intestine through the rectum. or 5-aminosalicylic acid (5-ASA). These are known as Also called enema bag, a rubber bag or topical therapies for colitis. other device for administering an enema. Digital removal of feces (DRF) is no longer necessary with 5. Peristalsis updated bowel care treatments like trans anal irrigation. ✓ a series of wave-like muscle contractions It is, however, an important aspect of the bowel- care that move food through the digestive routine for a select population of patients, such as those tract. It starts in the esophagus where who have suffered a spinal cord injury (SCI) or who have strong wave-like motions of the smooth a neurological illness like multiple sclerosis. Aside from muscle move balls of swallowed food to this, DRF may also be used as an acute intervention for the stomach. There, the food is churned patients who have impaction of stool that cannot be into a liquid mixture called chyme that resolved with medication. moves into the small intestine where peristalsis continues. 6. Harris flush enema ✓ is a type of enema aimed to evacuate INDICATIONS AND CONTRAINDICATIONS painful flatus from a patient who has 1. Administering Enema undergone abdominal surgery. It differs from a standard enema in that it is The use of an enema to induce stool evacuation is a intended to alleviate flatus, while the method. It's a liquid medication that's typically used to purpose of standard enemas is to treat severe constipation. When you can't push waste out principally remove stool. A Harris Flush of your rectum on your own, this procedure can assist. kit is required. Enemas may be purchased at pharmacies for home 7. Digital extraction usage, but you should get precise directions from a doctor ✓ the use of fingers to aid in the removal of or nurse to avoid damage. stool from the rectum. This may be done by a person who is experiencing constipation or by a medical professional 8 N. TUMULAK – BSN 2F 2. Digital Extraction another health condition that causes feces issues might accomplish this. similar action to digital A digital rectal examination is typically included in a evacuation is massaging the inside of the rectum, targeted urologic, gynecologic, gastrointestinal, and or the perineum in women, to encourage bowel neurologic examination as part of a comprehensive movement. physical examination. A digital rectal examination can be used to examine disease processes. MICROBIOLOGY The nurse in charge of the procedure must use Scientific Principles adequate infection control procedures, such as conducting a medical hand wash and correctly ENEMA wearing the gloves ANATOMY AND PHYSIOLOGY Any complaint, location of discomfort, and CHEMISTRY & PHYSICS anomalies of looks and functions of the patient's The medical lubricant will soften the fecal waste body should be described using medical words. as well as let your fingertips glide more easily in the cavity. You may properly hand evacuate your MICROBIOLOGY patient's intestines without creating excessive Cleanliness of the patient’s unit should be discomfort, humiliation, or feelings of checked before the patient is admitted. Medical vulnerability if done appropriately and with some hand washing is practiced before checking to conscious attention to patient comfort. avoid transmission of microorganisms PHARMACOLOGY CHEMISTRY Polypharmacy should be avoided, and the nurse Characters of the bowel content is a result of should make sure the patient isn't on any bowel- chemical reaction. slowing medications. PHYSICS BODY MECHANICS The solution that will be given out should be kept All nurses must have proper body mechanics in a prominent position. in order to do their work, which is equally PSYCHOLOGY beneficial to the patient; The client must have their privacy by the draping o Tiredness, musculoskeletal problems, and explain the procedure before inserting the and abnormalities may all be avoided tube in the rectum. with proper body alignment and posture. o A good posture can help the body's TIME AND ENERGY physiological functions, such as Preparing the material to be used must be circulation and digestion, to run prepared before performing the procedure. smoothly. o It has the potential to reduce energy consumption. Scientific Principles TIME AND ENERGY DIGITAL EXTRACTION To reduce the amount of time spent on this ANATOMY AND PHYSIOLOGY operation, the items required must be prepared ahead of time. Digital disimpassion is the use of fingers to help in the evacuation of feces from the rectum. A constipated person or a medical professional assisting a person with a spinal cord injury or 9 N. TUMULAK – BSN 2F  TYPES OF ENEMA Cleansing A cleansing enema is specifically utilized to quickly stimulate bowels in order to release the solution and fecal matter. The water-based solution may be integrated with a small concentration of stool softener, baking soda, or apple cider; this solution impacts the stimulation of the large intestine’s movement. Harris Flush or Return Flow or Colon Irrigation Harris Flush is a type of enema that is referred to as a Return Flow or Colon Irrigation. The Harris Flush enema is a procedure done on a patient who has gone through abdominal surgery and is a procedure that can be repeated multiple times. The purpose of this specific enema is to alleviate the flatus (excess gas) of the patient. Retention Retention is another type of enema that involves a specific solution utilized and held in the rectum for at least 15 minutes or more, this ensures the stimulation of the bowels. Oil Retention Oil Retention enema involves a low-pressure rectal injection of four to six ounces of mineral oil or vegetable oil at low pressure; the injection remains for 30 minutes to 3 hours. Additionally, the injection allows the feces to soften. Carminative Carminative Enema is given to release any flatus via three ounces of water, an ounce of magnesium sulfate (Epsom salts), and two ounces of glycerin. The components of the enema stimulate the peristalsis and bowel movement causing flatus and feces to be released. The Carminative Enema is given in low volume which ensures the patient to easily retain the enema for five to ten minutes. However, the Carminative Enema is not commonly used due to the use of Fleets saline enema which produces similar results. Medicated Medicated Enema is done to a patient in order to administer medication through the rectum 10 N. TUMULAK – BSN 2F  Anthelmintic Anthelmintic Enema is specifically used to contribute to destroying parasites in the intestines. Nutritive Nutritive Enema is referred to as feeding per rectum, rectal alimentation, or also recta feeding. To add, Nutritive Enema is used for the purpose of providing nutrition and replenishing fluids in the patient when eating is not possible. Astringent Enema Astringent Enema specifically relieves inflammation, contracts tissues, and blood vessels, and minimizes mucus discharge. In order to alleviate the pain of the patient, Astringent Enema utilizes a solution that must run slowly and return quickly through rectal or colonic irrigations. Emollient Emollient Enema is given to release irritation in an inflamed mucus membrane in cases such as diarrhea KINDS OF CLEANSING ENEMA Small Volume Enema Large Volume Enema - The small volume enema is used to clean the lower portion of the colon or the sigmoid. This - The purpose of large volume enema is to clean as type of cleansing enema is often used for the much of the colon as possible of feces, as an patient who is constipated but does not need intervention for constipation as well as “bowel cleansing of the higher colon. prep” before a diagnostic procedure. The amount used is 500-1000 ml and the bag is raised as high as 18 inches above the anal opening. The patient is instructed to retain and hold the fluid as long as possible to induce peristalsis and cause evacuation of feces. Prepackaged Disposable Enema - This is the most common enema used in the hospital. Fleet enema is one of the most common 11 N. TUMULAK – BSN 2F  brands. This can be used for tests also and for 15.Ensure the effect is noted and documented constipation. The enema solutions may contain accurately in the patient's chart. either bisacodyl or sodium phosphate, which are both rectal stimulants. The solution is hypertonic GUIDELINES IN ADMINISTERING and thus, draws fluid into the bowel, softening DIGITAL EXTRACTION and loosening the fecal mass. These enemas are 1. Identify the right patient. available in sizes: 150 ml and 37. 2. It must have a doctor’s order. 3. If the patient has had rectal/anal surgery or has been injured, don't proceed. 4. Perform hand washing, cover patient by pulling curtains around the bed for privacy 5. To protect the bed from feces, use a rubber sheet or a protective pad under the patient. 6. Explain the procedure to the patient. 7. Obtain a patient's baseline vital signs and assess level of comfort. 8. Keep the bedpan near the patient. 9. Perform hand hygiene and apply clean gloves, preferably non-latex, of suitable thickness. 10. Lubricate index finger of dominant hand with water- soluble lubricant. GUIDELINES IN ADMINISTERING 11. If the fecal mass is too hard or huge (more than 4cm) to break up, stop and consult a doctor for a possible digital ENEMA feces removal under anesthetics. 1. Obtain informed consent, identifying allergies and any contraindications. NURSING RESPONSIBILITIES 2. Assess patient privacy and dignity and take steps to maximize both. Before During After 3. Ascertain prescription details if required. Check the The nurse Observe and 4. Wash hands and don plastic apron. physician’s should explain evaluate 5. Check the enema for expiry and intactness. Warm the order the correct results solution to desired temperature procedure to 6. Position the patient on the left side, lying with the knees The nurse must the patient Record in the drawn to the abdomen. This eases the passage and flow be familiar with patient’s chart of fluid into the rectum. Gravity and the anatomical the various Assist the adult the type of structure of the sigmoid colon also suggest that this will kinds of enemas client to a left enema that may be lateral position, administered, ADMINISTERING ENEMA aid enema distribution and retention. ordered, their with the leg as amount of fluid 7. Position an ‘incontinence’ sheet underneath the patient. purpose and acutely fixed as instilled and 8. Break the enema seal. Lubricate the nozzle. Air should administration possible the time it was be expelled. given 9. Gently separate the buttocks, identifying the anus. Check the Nurse must see Insert the lubricated nozzle into the rectum slowly to a patient’s ability to it that depth of approximately 10cm (in adults). to retain fluid enema is 10.Gently expel the contents into the rectum, rolling the and tolerate the administered container from the bottom up to reduce backflow. activity to the correct 11.Keeping the container rolled/compressed withdraw the ordered, their patient container. Attend to peri- anal hygiene. purpose and 12.Ask the patient to retain the enema for as long as administration Encourage the required or suggested in the manufacturer’s patient to Determine the retain as long recommendations, providing a commode or nurse-call presence of as possible system as indicated. kidney or 13.Dispose of any waste, remove apron, wash hands. cardiac disease Assist the 14.Document the procedure accurately, completing drug patient to the record. bed pan 12 N. TUMULAK – BSN 2F  Read the none Examine the self- administering an enema, stop and patient’s chart feces and the contact the doctor. and laboratory solution that work was ejected After (e.g the ✓ Some client find that they have several Perform consistency, abdominal odor, color, additional bowel movements in the hours assessment amount of after an enema (IAPP) stool, and fluid ✓ For this reason, many plan to stay home for the rest of the day after an enema is ADMINSTERING DIGITAL EXTRACTION passed) Perform rectal administered. But for the most part, they may assessment to Abdominal carry on with their regular routine after the check for any assessment enema process is complete. hemorrhoids, must be sores, fissures, performed and or rectal again tears DIGITAL EXTRACTION Report if there DOCUMENT CLIENT RESPONSES AND OUTCOMES Assess the are any Before status of the abnormalities patient ✓ Client identify constipation on the basis of Record the their symptoms. Client with constipation may result of the experience a variety of symptoms, ranging procedure to from headache and fatigue to bloatedness the patient’s and/or loss of appetite leading to nausea and chart vomiting. Client who finds defecation difficult may complain physically of a 'full bottom' and Determine the amenability to have their bowels opened. patient’s and Older patients can describe constipation in family’s comprehension terms of 'urges' and having 'long tries'. of the During procedure done ✓ Client is likely to feel vulnerable and exposed. While you have to expose the buttocks and rectum, you can protect the client’s dignity by ENEMA allowing them to wear as much clothing as DOCUMENT CLIENT RESPONSES AND OUTCOMES they are comfortable with and covering as Before much of their body with a blanket that you can. As mentioned previously, ensure that ✓ Completely cleanse intestines as directed by the doctor. This may include a privacy is respected by clearing the room and combination of enemas, laxatives, and closing doors and blinds. not eating solid foods or drinking on the After day or night before the procedure. ✓ Client should be observed for symptoms such During as flushing, sweating, chills, nasal ✓ An enema should not be painful when congestion, blurred vision and headache. administered properly. ✓ Client may feel fullness, mild pressure, or brief, minimal cramping during the procedure. Client may also feel like they need to have a bowel movement. Take a few long, deep breaths to help relax. If the client have pain or discomfort while 13 N. TUMULAK – BSN 2F RLE NCM 107 CARE OF MOTHER, CHILD, ADOLESCENT 3M – SERVING BED PANS AND URINALS WITH PERINEAL CARE DEFINITION OF TERMS The area between the anus and scrotum 1. Bedside commode for the male, for females it is the area of A portable toilet that does not use between the anus and vulva running water. It is built like a chair with 6. Perineal Flushing a toilet seat and a bucket or container Known as Peri-care, involves cleaning the underneath. This is used when a patient private parts of a patient. Done at least is unable to go to the bathroom. once a day during bed bath, shower, or tub bath. It is done more often when a patient is incontinent prevent infection, odors, and irritation 7. Puerperium The time from the delivery of the placenta through the first weeks after the delivery. This period is considered to last for 6 weeks 2. Bedpan A bedpan is a receptacle for collecting urine or feces that fits beneath a person laying or sitting in bed. Bedpans come in a variety of materials, including plastic 8. Smegma and metal, and some come with liners to The thick, white substance that collects reduce splashing and make cleaning under the foreskin of the penis. Women easier. can also get smegma in the vaginal area. Smegma is made from fatty oils, shed skin cells and moisture like sweat. It is considered normal. 3. Edema Known as the swelling caused by fluid trapped in you body’s tissues. Edema 9. Urinal affects the feet, ankles, and legs the A urinal is used to collect urine when a most. It can also affect other parts of the person is unable to get out of bed. It is body such as the face, hands and shaped to fit either men or women but abdomen. some women may find it easier to use a bedpan 4. Micturition 10. Urinary Retention The act of urinating. This involves the Urinary retention is a condition wherein simultaneous coordinated contraction of the bladder does not empty all the way the bladder detrusor muscle, which is or at all when urinating. controlled by parasympathetic (cholinergic) nerves 5. Perineum 1 N. TUMULAK – BSN 2F Review of Anatomy and Physiology of any urine leftover in the urethra. of Male and Female Genitalia Ductus Deferens The ductus deferens, also Male Reproductive System known as the vas deferens, is a fibromuscular tube that runs parallel to the epididymis and serves as a testis excretory duct. Each ductus is 30-45 cm long and is responsible for transporting sperm cells from the epididymis to the ipsilateral ejaculatory Term Physiology duct. Ureter A duct that transmits urine Epididymis The epididymis is a long, from the kidney to the coiled tube that rests on bladder the backside of each Seminal vesicle Seminal vesicles (vesicular testicle. It transports and or seminal glands) are a stores sperm cells pair of glands located in produced in the testes. the male pelvis that create The epididymis is also many of the chemicals responsible for maturing that make up sperm. They sperm, as sperm that eventually provide about emerge from the testes 70% of the total volume are immature and of sperm incapable of fertilization. Ejaculatory duct The ejaculatory duct Testes The testes are oval organs transports sperm into the about the size of very urethra, as well as large olives that lie in the secretions and additives scrotum. The testes are from the prostate that are responsible for making necessary for sperm testosterone, the primary activity, and serves as a male sex hormone, and link between the male for producing sperm. reproductive and urinary Scrotum The scrotum is the loose systems. pouch-like sac of skin that Rectum The rectum is an 8-inch hangs behind the penis. It straight chamber that holds the testicles, as well links the colon and anus. as many nerves and blood The rectum's role is to vessels. Protects the collect feces from the testes, as well as provide colon, signal you that a sort of climate control stool has to be evacuated system. (pooped out), and keep Urethra The urethra is the tube the stool until it is that carries urine from the evacuated. bladder to outside of your Prostate Gland A walnut-sized gland body. In males, it has the located between the additional function of bladder and the penis. expelling (ejaculating) This secretes fluid that semen when you reach nourishes and protects orgasm. When the penis is sperm. erect during sex, the flow Bulbourethral Gland Provide mucus proteins of urine is blocked from that lubricate the urethra the and counteract the acidity 2 N. TUMULAK – BSN 2F  urethra, allowing only pheromones to induce semen to be ejaculated at sexual attraction. orgasm. Pudendal cleft It protects and contains Penis The male organ for sexual the vulva’s delicate intercourse. structures. These are Glans Penis The tube through which lined by skin on the semen and urine exits the outside and basal layers of body. cells. Labia Majora They are similar to Female Reproductive System scrotum for males. The labia majora contains sweat and sebaceous glands, which produce lubricating secretions. Labia Minora The labia minora are the inner folds which protect the opening of the urethra and the vagina. Bartholin’s Gland This secretes mucus to ensure vaginal and vulval Term Physiology lubrication. Internal Clitoris The clitoris has no Vagina A muscular canal that function in reproduction serves as the entrance to but is the main pleasure the reproductive tract. It center for females during Serves as the exit from sex. the uterus during menses and childbirth. Ovaries Female gonads. It produces eggs and hormones Layers of the Perineum Uterus The muscular organ that nourishes and supports the growing embryo. Fallopian tube The portion of the uterus superior to the opening of the uterine tubules. Cervix The narrow inferior portion of the uterus that projects into the vagina. The cervix produces mucus secretions that become thin and stringy under the influence of high systemic plasma estrogen concentrations, and these secretions can facilitate sperm