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CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite Expected Date of Confinement (EDC) and AOG a) Naegele’s Ru...

CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite Expected Date of Confinement (EDC) and AOG a) Naegele’s Rule ( based on LMP, for women with regular menstrual period ) b) McDonald’s Rule ( based on fundic height, for women with irregular menstrual period) Fundic height x 2/7 = in months Fundic height x 8/7 = in weeks - 38 weeks (9 months) - 24 weeks = 14 weeks due date c) Age of Gestation (AOG) - Gestational Age is calculated from the first day of the mother’s last menstrual period and not from the date of conception. Note : Birth normally occurs at a gestational age of 37 to 42 weeks. Childbirth occurring before 37 weeks of gestation is considered preterm, fetus could survive at 24 weeks is usually considered "viable" or fetus weighing more than 400 grams LEOPORD’S MANEUVER Systematic method of observation and palpation to determine the: Fetal presentation and position Fetal engagement Fetal attitude Fetal back Purposes: 1)First Maneuver: To determine the presentation of the fetus and the part which occupies the fundus. 2)Second Maneuver : To determine the fetal position and the location of fetal back which aids in the location of fetal heart tone. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 3)Third Maneuver : To determine descent of the presenting part of the fetus to the birth canal. 4) Fourth Maneuver: To determine degree of flexion of the fetal head and to determine fetal attitude or habitus Assessment: Review the available prenatal health record of the client to determine the Last Menstrual Period (LMP) Expected date of Confinement (EDC) and Age of Gestation (AOG). Planning: 1. Gather all the necessary equipment needed, linen, Divider, tape measure, Stethoscope/ Doppler if available, Pillow, gel, tissue paper IMPLEMENTATION: 1. Introduce self to the client. 2.Explain the purpose of the procedure to the client as well as how the procedure will be done 3. Instruct client to empty her To obtain accurate and productive palpation since fetal contour will not be bladder before doing the procedure. obscured by a distended bladder 4. Perform personal hand hygiene Use of warm water will prevent stimulation of uterine contraction or use of using warm water. friction by hands. (alcohol - rub - dry - rub) 5. Provide privacy for the client by using a divider and draping the client with linen below the hips 6. Position the client supine with Flexing the knees relaxes the abdominal muscles. And to overcome back knees sligthly flexed. Place a small sprain. pillow or towel under her right side. Using a pillow or small towel tilts the uterus off the vena cava (decompress the superior vena cava), preventing supine hypotension syndrome 7. Expose the client’s abdomen and The longest diameter (axis) is the length of the fetus. The location of activity observe for the longest diameter and most likely reflects the position of the feet where fetal movements are apparent. 8. Ask the client to lower down her underwear just below the hips to expose the symphysis pubis. Using a tape measure, measure the fundic height in centimeters by holding the 0 (zero) on the tape measure at the top of the pubic bone and follow the curve of her abdomen, and hold the tape at the top of her uterus. Record the fundic height 9. Perform the first maneuver. To know the PRESENTING PART (anong part and unang lalabas - Labor) FUNDAL GRIP Palpate the upper part of abdomen/fundal(upper part of uterus) This maneuver determines whether fetal head or breech is in the Findings: fundus Head is more firm, hard and round that moves independently of the body. 9.1. Stand at the foot of the client, Breech presentation is less well defined that moves only in conjunction with facing her and place both hands flat the body. on her abdomen. - Hard, smooth and round 9.2 Palpate the superior portion of fundus. Determine consistency, shape and mobility. Vertex/cephalic position/presentation - Soft and irregular CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 10. Perform Second Maneuver: 10.2 The fetal back feels like a smooth , hard , resistant surface, the knees and UMBILICAL GRIP elbows of the fetus on the opposite side feel more like a number of angular To identify location of fetal back bumps and nodules which aids in locating fetal heart tone 10.3 The fetal heart tone is best detected through the back of the fetus 10.1 Face the patient and place the palms of each hand on either side of 10.4 The gel improves the transmission and reception of the ultrasound the abdomen. waves to provide more accurate data 10.2 Palpate the sides of the uterus. 10.5 Ginagalaw galw dpt ung doppler para tumaas ung sound waves Hold the left hand stationary on the left side of the uterus while the right 10.6 Distinguishing sounds other than the fetal sounds like mother’s hand palpates the opposite side of heart sound , sounds from placental circulation will help ensure accurate the uterus from top to bottom. Then results. The normal fetal heart tone ranges from 120 to 160 beats per minute. hold the right hand steady, and repeat palpation using the left hand Findings: on the left side. Fetal back is smooth, hard, and resistant surface/irregular Knees and elbows of fetus feel with a number of angular nodulation 10.3Place the diaphragm of the stethoscope on the side where the Fetal Heart Tone: (FHT) fetal back is located and establish the 10-12 weeks of gestation (heard through Doppler) location of the fetal heart tone and 18-20 weeks of gestation (heard through regular stethoscope) count for 1 full minute. Normal FHT: 120-160 beats per minute 10. 4 In case a doppler device is available, apply a dollop of water soluble gel on the midline, halfway between the symphysis pubis and the umbilicus. 10. 5 Turn on the Doppler device and set the volume to the halfway mark. Place the probe on the gel and listen for the fetal heart sounds, adjusting the volume as needed. 10.6 Compare the audible heart sounds with your patient’s pulse. if the pulse rate is the same with the heart sound , you’re probably hearing the mother’s heart sounds and need to reposition the device. When you locate the fetal heartbeat, count it for a full minute and listen closely for any increases or decreases in rate. Record the fetal heart tone. 11. Perform the Third Maneuver: This maneuver determines the part of the fetus at the pelvic inlet and its PAWLIK’S GRIP mobility.It also determines if the presenting part is already engaged or have To determine engagement of descended into the pelvis. If the presenting part is not yet engaged , grasping presenting part. with fingers moves it upward in the uterus 11. 1 Gently grasp the lower portion of Engagement the abdomen just above symphysis - Largest diameter of head of the baby passed the pubic pubis between the thumb and index bone/pelvis finger ,and try to press the thumb and finger together. Determine any Findings: movement. The presenting part is engaged if it is not movable. (malapit na manganak) It is not yet engaged , if it is still movable. 12. Perform the Fourth Maneuver: The fingers of one hand will slide along the uterine contour and meet no PELVIC GRIP obstruction, indicating the back of the fetal neck. This maneuver determines fetal The other hand will meet an obstruction an inch or so above the attitude and degree of fetal ligament – this is the fetal brow. The position of the fetal brow extension into the pelvis. This should correspond to the side of the uterus that contains the elbows maneuver is only performed if the and knees of the fetus. If the fetus is in poor attitude, the examining fetus is in cephalic presentation fingers will meet an obstruction on the same side of the fetal back that is, the fingers will touch the hyperextended head 12.1 Facing foot part of the woman. 12.2 Place fingers on both sides of the uterus approximately 2 inches above CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite the inguinal ligaments, pressing downward and inward in the direction of the birth canal.Allow fingers to be carried downward. If the brow is very easily palpated ( as if it is just under the skin) , the fetus is probably in a posterior position, ( the occiput is pointing toward a woman’s back Findings: Good attitude – if brow correspond to the side (2nd maneuver) that contained the elbows and knees. (flexed head) Poor attitude – if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head) Also palpates infant’s anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards woman’s back) Evaluation: 1) Document the findings and immediately notify the health care provider for further assessment of fetal well-being in the following situations: 1.1 absence of fetal heart sounds 1.2 any decrease in FHR that doesn’t return to baseline immediately. 1.3 the mother’s report that she doesn’t feel the baby moving (after 22 weeks) or she’s having abdominal cramps or vaginal discharge or bleeding. Nursing Considerations: 1. Perform Leopold’s Maneuver after 28 weeks of gestation (6 months) because the uterine and abdominal muscles are stretched and thinned. 2. Leopold's Maneuver is difficult to perform in the following cases: - Women with polyhydramnios (placenta separates from the womb before the baby is born. umbilical cord prolapse) - Obese women - Presence of tumor or other unusual mass in the uterus - Multiple pregnancies - Placement of placenta which can obstruct palpation 3. Ask the client to empty the bladder before the procedure so as not to confuse it with the fetus head. 4. Perform Leopold’s maneuver with warm hands and gentle pressure. Use the palm of the hands when palpating and not the fingers 5. Palpate the abdomen for soft consistency, fluctuating amniotic fluid, indefinite outlines and baby’s small knobby parts. MODULE 1: Skills Procedure for Delivery Room According to Sustainable Development Goals (SDG) of United Nation , under Goal # 3 : Good Health and Well Being ,envision that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births , end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births (United Nation, SDG #3 Goals) CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite In the Philippines the number of women dying from childbirth in the country increased, data released by the Philippine Statistics Authority (PSA) showed. The data further showed maternal deaths increased to 1,616 in 2018 compared to 1,484 in 2017, or a two year high when maternal deaths reached 1,721 in 2015(Ordinario, 2020) The Philippines is one of the 42 nations that account for 90% of global under five mortality where it is estimated 82, 000 Filipino children die annually before their 5th birthday and 37 % of these children are newborns less than 28 days old. The Maternal Newborn, Child Health and Nutrition (MNCHN) Strategy is in line with the DOH Administrative Order 2008-0029 that seeks to rapidly reduce maternal and newborn morbidity and mortality. The Administrative Order 2009-0025 formalized the adoption of policies and guidelines on essential newborn care. Lesson 1: Essential Intrapartum Newborn Care Essential Intrapartum and Newborn Care(EINC) are a set of practices with evidence based standards that reduce maternal and newborn mortality rate. It supports the national commitment to the United Nations in the Sustainable Development Goals #3 on improving maternal health. 1. The EINC practices are evidenced-based standards for safe and quality care of birthing mothers and their newborns, within the 48 hours of Intrapartum period (labor and delivery) and a week of life for the newborn. (WPRO 2019) 2. These practices are totally different from the traditional newborn care. Some of its objectives are to provide evidence-based practices to ensure survival of the newborn from birth up to the first 28 days of life. 3. EINC delivers time-bound core intervention in the immediate period after the delivery of the newborn by immediate drying to stimulate the baby to cry, properly timed cutting of the umbilical cord and also routine suctioning is eliminated if the baby is considered well 4. The Department of Health embarked on Essential Newborn Care , a new program to address neonatal deaths in the country. Under the umbrella of the Unang Yakap Campaign, Essential Newborn Care is an evidenced based strategic intervention aimed at improving newborn care and helping cub neonatal mortality. Lesson 2: The Four Core Steps of EINC It supports the national commitment to the United Nations Millennium Development Goals (MDG) 4 and 5. MDG 4 on reducing child mortality and MDG 5 on improving maternal health. 1. Immediate and thorough drying of the newborn - Immediate and thorough drying for 30 seconds to one minute warms the newborn and stimulates breathing. 2. Early skin to skin contact between mother and newborn - Early skin to skin contact between mother and newborn and delayed washing for at least 6 hours - This prevents: * Hypothermia * Infection * Hypoglycemia 3. Properly timed cord clamping and cutting - Waiting for the cord pulsation to stop (Between 1 to 3 minutes) - Prevents anemia and protects against brain hemorrhage in premature newborn 4. Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in - Continuous non-separation of newborn and mother for early breastfeeding protects infants from infection. - The first feed provides colostrum. Lesson 3: Essential Intrapartum Newborn Care Procedure Purposes: - Reduce maternal and newborn mortality - Safe and quality care of birthing mothers and their newborns, within 48 hours of intrapartum period (labor and delivery) and a week of life for the newborn. Materials Needed: 2 Sterile gloves, 2 dry linens, bonnet plastic cord clamp, instrument clamp scissor 2 kidney basins oxytocin injection CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite antiseptic solution, cotton balls erythromycin eye ointment, vitamin k injection, hepatitis b vaccine. bcg vaccine Resuscitation set (ambubag, oxygen tubings, stethoscope, plaster). Planning: PRIOR TO WOMAN'S TRANSFER TO THE DR Criteria Rationale 1. Ensures that mother is in her No single position for childbirth exists. Labor is a dynamic, interactive process position of choice while in labor involving the woman’s uterus, pelvis and voluntary muscles. In addition, angles between the baby and the woman’s pelvis constantly change as the infants turns and flexes down the birth canal. The woman may want to assume various positions for child birth. She should be encouraged to change positions frequently and assisted in attaining and maintaining her positions. Supine, semi recumbent or lithotomy positions are still widely used in Western Societies despite evidence that women prefer upright position for their bearing down efforts and birth. (Perry et al, 2014). The choice of labor and birth positions plays a critical role in the mother's comfort level during birth and how quickly and effectively her labor does - or does not - progress. Effective positioning can speed labor and reduce discomfort by aligning the baby properly, by reducing area-specific pressure, and by reducing unnecessary muscular effort. ( Mendez-Bauer C, & Newton M. 1986) Research reports that position and frequency of position change have a profound effect on uterine activity and efficiency. Allowing the woman to obtain a position of comfort frequently facilitates a favorable fetal rotation altering the alignment of the presenting part with the pelvis. As the mother continues to change position based on comfort, the optimal presentation is afforded (Gilbert & Harmon, 2003). 2. Asks mother if she wishes to Eating and drinking during labor, especially in the early stages, can provide a eat/drink or void. pregnant woman with necessary energy and make labor more comfortable for her. Being properly nourished and hydrated can prevent a pregnant woman from becoming exhausted, which can prolong labor and lead to fewer contractions that are less effective. (https://www.beingtheparent.com/eat-and-drink-during-labor/) 3. Communicates with the Constant communication can reduce anxiety of the mother who is in labor. mother - informs her of progress of labor, gave reassurance and encouragement. Planning: WOMAN ALREADY IN THE DR (Preparing for Delivery) Criteria Rationale Ø Checks temperature in DR area to be 25-28 degrees A non-mercury room thermometer is used to test the Celsius; eliminates air draft. temperature, hanging a piece of tissue paper could test if the area is air draft free and if draft is present, fan or air-conditioning units should be turned off. (WHO,2014) It will ensure that the environment is appropriate for the adjustment of the baby outside from the uterine cavity of the mother. Ø Asks woman if she is comfortable in the One of your biggest allies is gravity. When you are semi-upright position (the default position of delivery upright—standing, sitting or kneeling—the weight of your baby table). presses on the cervix, encouraging it to open. An upright position may also help get your baby into the best position for birth (Elliot, 2015). Ø Prepares a clear, clean newborn resuscitation area. Resuscitation equipment should be ready at all times, in cases Checks the equipment if clean, functional and within of emergency during delivery and for high risk newborn. easy reach. Ø Ensures the woman's privacy. It gives comfort to the client. Ø Removes all jewelry then wash hands thoroughly It is the single most effective method of preventing the spread observing the WHO 1-2-3-4-5 procedure of infection. It must be performed thoroughly, properly, and consistently. (Carter, 2012) Ø Arrange materials/supplies in a linear sequence: Linear sequence means materials are arranged according to the Gloves, 2 dry linen, bonnet, oxytocin injection, plastic order of usage. This is for easy accessibility of the health care clamp, instrument clamp, scissors, 2 kidney basins. provider. Ø In a separate sequence, to be used after the 1st breastfeed: Eye ointment, stethoscope to symbolize PE, vit.K, hepatitis B and BCG CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite Cleans the perineum with antiseptic solution. Once the mother is positioned for birth, the vulva and perineum are cleansed. Hospital protocols and the preferences of primary health care providers for cleansing may vary. (Perry et al 2014). Wash hands, put 2 pairs of sterile gloves aseptically.(If This is done to prevent the spread of infection same worker handles perineum and cord). Implementation: AT THE TIME OF DELIVERY Criteria Rationale Encourages woman to push as The primary provider continues to coach and encourage the woman to push once desired. there is contraction. Drapes the clean, dry linen over Clean dry linen is spread in the abdomen of the mother and it is used to dry the baby. the mother's abdomen or arms in preparation for drying the baby. Applies perineal support and did As soon as the head of a fetus is prominent (approximately 8cm across) at the controlled delivery of the head. vaginal opening, one technique to help the fetus achieve extension and allow the smallest head diameter to present is for the care provider to place a sterile towel over the rectum and press forward of the fetal chin while the other hand presses downward to the occiput (a Ritgen maneuver). Pressure should never be applied to the fundus of the uterus to affect birth because uterine rupture could occur. The woman is asked to continue pushing until the occiput of the fetal head is firmly at the pubic arch. The head is then greatly born between contractions. (Pilliteri, 2014). ➔ Effacement means that the cervix stretches and gets thinner. ➔ Dilation means that the cervix opens. As labour nears, the cervix may start to thin (efface) and open (dilate) Calls out time of birth and sex of The time of birth is the precise time when the entire body is out of the mother, this baby. time should be recorded. In case of multiple birth each birth would be noted in the. same way. (Perry et al, 2014). The sex of the baby should be announced together with the time of birth. Informs the mother of outcome It is important that the mother will be informed of the outcome through showing the baby to her and let her determine the sex of her baby. This is to make her aware of the sex of the baby. Thoroughly dried baby for at Drying the newborn quickly can prevent heat loss. Keep the baby at the same level as least 30 seconds, starting from the mother’s uterus until the end of the cord stops pulsating. Note: The baby should the face and head, going down be kept at the same level as the mother’s uterus to prevent his or her blood from to the trunk and extremities flowing to or from the placenta and the resultant hypovolemia or hypervolemia. Do while performing a quick check not “milk” the cord. (Perry et al, 2014). for breathing. 1-3 MINUTES Removes the wet cloth. This is to prevent hypothermia. Places baby in skin-to-skin Skin-to-skin contact immediately after birth and then newborn’s first attempt at contact on the mother's breastfeeding further augment maternal oxytocin levels, strengthening the uterine abdomen or chest. contraction that will help the placenta to separate and the uterus to contract to prevent hemorrhage. Covers baby with the dry cloth Putting on a stockinette cap will further reduce heat loss after drying. and the baby's head with a bonnet. Excluded a 2nd baby by This is done to ensure that there is a single pregnancy. palpating the abdomen in preparation for giving oxytocin. Uses wet cloth to wipe the soiled Oxytocin is for the contraction of the uterus and it decreases bleeding. (Perry et al, gloves. Give IM oxytocin within 2014.) one minute of baby's birth. - Or IV drip (ihalo sa 1L of IVF), kpg IV push dedo ang mother Disposes wet cloth properly. Removes first set of gloves and This aseptic technique is being observed in preparation of the cutting of the decontaminates them properly umbilicus. Observation of decontamination is to prevent the spread of (in 0.5% chlorine solution for at microorganism in order to prevent infection. least 10 minutes). Palpates umbilical cord to check Wait for the pulsation to stop before cord clamping. for pulsations. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite After pulsation stops, clamp cord Delayed umbilical cord clamping appears to be beneficial for term and preterm using the plastic clamp or cord infants. In term infants, delayed umbilical cord clamping increases hemoglobin tie 2 cm from the base. levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes. ( American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice , 2017). Places the instrument clamp 5 Drain the cord of blood by stripping away from the baby then apply the second cm from the base. clamp (instrument clamp) at 5cm from the umbilical base (which is 3cm from the first clamp (plastic clamp.) (WHO,2014). Instrument clamp will hold the remaining cord that is still attached to the placenta. Cuts near plastic clamp (not This is to ensure that the cord stump is not too long after the cord clamp. midway). Performs the remaining steps of The most effective strategy to prevent postpartum hemorrhage is active the AMTSL (Active management of the third stage of labor (AMTSL). Active management of third stage Management of the Third labor is currently practiced in many countries around the world. Components of Stage of Labor: active management include administering an oxytocic medication (e.g. / oxytocin/Pitocin) when the anterior shoulder is birthed or immediately following the birth of the fetus, clamping and cutting the umbilical cord within 3 minutes after birth and gently controlling cord traction following uterine contraction and separation of the placenta. (Perry et al, 2014). - Waits for strong uterine Wait for the placenta to separate. Do not tug the cord. Inappropriate traction may contractions then tear the cord, separate the placenta, or invert the uterus. signs of placental separation applies controlled cord include a slight gush of dark blood from introitus, lengthening of the cord, and traction and counter change in the uterine contour from a discoid to globular shape. (Perry et al. 2014). traction on the uterus, continuing until placenta is delivered. - Massage the uterus until Gently massage the fundus and demonstrate to the mother how she can massage firm. her own fundus properly. Massage can prevent or minimize hemorrhage. (Perry et al, 2014). Inspects the lower vagina and The primary health care providers examine the woman for any perineal, vaginal or perineum for lacerations/tears cervical lacerations requiring repair. If an episiotomy was performed, it is sutured. and repair lacerations/tears, as Immediate repair promotes healing, limits residual damage and decreases possibility necessary. of infection. (Perry et al, 2014). Examines the placenta for Whether the placenta first appears by its shiny fetal surface (Schultze mechanism) completeness and or turns to show its dark roughened maternal surface first (Duncan Mechanism) is abnormalities. of no clinical importance. After the placenta and amniotic membranes emerge, the primary health care provider examines them for intactness to ensure that no portion remains in the uterine cavity (Perry et al, 2014). - Cotyledon must complete - 17pcs Cleans the mother; flush This hygienic action will make the mother feel comfortable. perineum and applies perineal pad/napkin or cloth. Checks baby color and Perform a brief assessment of the newborn immediately: Apgar score at 1 and 5 breathing; checks that mother is minutes after birth. (Perry et al, 2014). Check the mother uterus is if it is contracted. comfortable and uterus is contracted. Disposes the placenta in a This is to prevent the spread of infection leak-proof container or plastic bag. Decontaminates (soaked in 0.5% This is to prevent the spread of infection. chlorine solution) instruments before cleaning; decontaminates 2nd pair of gloves before disposal stating that decontaminations lasts for at least 10 minutes. Advises mother to maintain One of the method for promoting thermoregulation and maternal newborn skin-to-skin contact. Baby interaction is to place the naked newborn on the mother’s bare’s chest and cover should be prone on mother's both with blanket. Skin to skin contact reduces conductive and radiant heat loss and chest in between the breasts enhances newborn temperature control and maternal infant interaction. (Brown and with head turns to one side.15-90 Landers, 2011, Perry, 2014). MINUTES CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite Advises mother to observe for The mother needs to understand infant behaviors in relation to breastfeeding and feeding cues and cites example recognize that the baby is ready to feed. Infants exhibit feeding readiness cues or of feeding cues. early signs of hunger. Feeding cues: hand-to- mouth or hand-to-hand movements; suckling motion, rooting reflex-infants move toward whatever touches the area around the mouth and attempt to suck and mouthing. (Perry et al, 2014). Supports mother, instructs her For the initial feedings it can be advantageous to encourage and assist the mother to on positioning and attachment. breastfeed in semi reclining position with the newborn lying prone, skin to skin on mother’s bare chest. Her body supports the baby. (Perry et al 2014). Waits for FULL BREASTFEED to Milk production is supply meets demands system. (i.e as milk is removed from the be completed. breast, more is produced). Incomplete removal of milk from breasts can lead to decreased milk supply. (Perry et al., 2014) After a complete breastfeed, Please see separate procedures. administers eye ointment (first), did thorough physical examination, then did Vit. K, hepatitis B and BCG infections, (simultaneously explains purpose of each intervention). Advises delay bathing of baby World Health Organization advises delaying the bath for 24 hours. (Delisle, R. 2016) (After 24 hours of life). It is important to delay bathing because the vernix, removed during early bathing, contains antimicrobial proteins that are active against group B strep, E. coli and other common perinatal pathogens. (American Journal of Obstetrics & Gynecology). Delaying bathing a newborn was associated with a significant increase in exclusive breastfeeding rates, which may be due to limiting stress following delivery, when infants are working to stabilize their temperatures. (Boston Medical Center, 2010, Delisle 2016)) Advises breastfeeding per Breast milk contains vital antibodies that are passed from the mother that help demand and about Danger protect the infant against certain infections. Promoting breastfeeding needs to be a signs for referral. priority of all health care staff caring for both the mother and infant. (Ramos, J. 2014). EVALUATION Criteria Evaluation In the 1st hour: check baby's breathing and This is to ensure that the baby is in good condition and at the same to color, and check mother's vital signs and check the mother status on hemorrhage. massage uterus every 15 minutes. In the 2nd hour: check mother-baby dyad Constant checking will ensure the good condition of both mother and every 30 minutes to 1 hour. child. Complete all records. Documentation served as a monitoring on the condition of the baby and the mother as well as the management given to the patient. MODULE 2 : Skills Procedure for Maternal Health Nursing It has been proven that breastfeeding has multiple benefits for women and children. As shown on the image, a total of 153 countries practice this and it helped improved their everyday lives and even their community. (WHO, 2016) Lesson 1: Breast Care Breast care is the process of cleaning the breast of mother that helps in maintaining hygiene and prevent from cross examination PURPOSES: 1. To clean the breast. 2. To detect any abnormalities. 3. To stimulate milk ejection. 4. To prevent local infection. 5. To prevent breast complication. EQUIPMENT Nursing pads, Breast pumps, Lanolin or petroleum jelly ASSESSMENT: 1.Assesses the present health condition and medications taken of the lactating mother if there are any problem regarding health which may affect the infant. 2. Assesses the mother and infant's readiness to perform the technique 3. Assesses breast and it's discharge and if nipples are inverted. PLANNING Gathers and prepare necessary equipment CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite IMPLEMENTATION Performs hand hygiene and put on PPE, if indicated Introduces self to client. Explains the procedure to the client an encourage to participate as appropriate. Verifies the client using at least two identifiers Closes the room door and or curtains Positions the mother. Cleans the breast by using cotton balls moistened with water starting from the nipple moving outward in circular motion Places nursing pads inside the bra cup to absorb any milk leaking This is done to guard against infection between feedings and to collect commonly leaks between feeding. Expresses milk manually or with the use of a breast pump if breast feels Helps maintain or promote a good milk uncomfortable because of too much milk. supply during a period of engorgement. Applies adequate amount of lanolin or petroleum jelly over the nipples if This is done to promote healing and sore to soothe and relieve them. relief Use proper support for the breasts. A well fitted maternity brassiere with This is done to help minimize breast broad strap is advisable to give correct support and prevent undue engorgement sagging of the breast. A constricting brassier interferes with free circulation of fluid to and from the breast EVALUATION Documents for any pain and engorgement of the breast. NURSING CONSIDERATIONS: 1.Instruct mother to wear a firm, supportive bra with wide straps to spread breast weight across the shoulders. 3.Advise mother to change nursing pads frequently if they become damp, to maintain dryness. 2.Teach mother to wash her breast with clear tap water daily to remove the colostrum and reduce the risk for infection. 4.Advise mother to massage the breast with a few drops of breast milk before and after feeding, because fresh breast milk can heal sore nipples. Lesson 2 Breastfeeding Breastfeeding offers various benefits and advantages to the infant and mother because there is little to no risk of contamination. Moreover, it contributes even greater with the environment and society, as it lessens the requirement of the use of energy for manufacturing thus also minimizing the production of more wastes and all kinds of pollution. DOH has adopted the World Health Organization (WHO) guidance recommending exclusive breastfeeding for the first six months of an infant's life. It is recommended that breastfeeding should continue beyond six months, alongside the introduction of appropriate solid foods. Exclusive breastfeeding is defined as giving the baby no other food or drink except breast milk, but the baby can receive vitamin drops and medicine syrups. DOH has adopted the World Health Organisation (WHO) guidance recommending exclusive breastfeeding for the first six months of an infant's life. It is recommended breastfeeding should continue beyond six months, alongside the introduction of appropriate solid foods. Exclusive breastfeeding is defined as giving the baby no other food or drink except breast milk, but the baby can receive vitamin drops and medicine syrups). immunoglobulin A (contain in breastmilk) SIGN OF GOOD ATTACHMENT 1. More areola is seen on the upper lip 2. Lower lip turned outward. 3. Mouth wide open with chin touching the breast 4. Face of the baby turned towards the breast PURPOSES: 1. To ensure proper techniques of breastfeeding. 2. To give proper attachment of the newborn during feeding. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 3. To promote comfort both mother and newborn during breastfeeding. EQUIPMENT Pillow (as necessary) ASSESSMENT 1. Assesses the present health condition and medications taken of the lactating mother if there are any problem regarding health which may affect the infant. 2. Assesses mother and infant's readiness to perform the technique. 3. Assesses breast and its discharge and if nipples are inverted. 4. Assesses each family individuality to recognize cultural preferences. PLANNING Gathers and prepare necessary equipment. IMPLEMENTATION 1. Performs hand hygiene and put on PPE, if indicated 2. Introduces self to client. Explains the procedure to the client and encourage to participate as appropriate. 3. Verifies the client using at least two identifiers 4. Closes the room door and or curtains 5. Assumes a comfortable position. A semi reclining like being in a rocking chair or side lying with a pillow under the head is recommended. 6. Brushes or touch the baby's cheeks with the nipple to initiate Stimulates newborn's rooting reflex. feeding 7. Feeds the newborn on demand for only 5 minutes, Feeding for too short a time prevents the newborn increasing the time at each breast by one minute per day until from receiving the richer, more satisfying hind milk. the newborn is nursing for 10 minutes at each breast making a total feeding time of 20 minutes 7. Places the newborn first on the breast where he was fed Alternating breast ensures even stimulation last emptying and increasing milk. 8. Newborn's mouth should grasp not only the nipples but also Look for signs of good attachment and suckling to the areola to compress the ducts behind it. enhance milk ejection. 9. Inserts a little clean finger release the suction from the breast This is done to break the seal. Pulling the mouth then pull the chin gently downward. will cause sore nipples. EVALUATION: Documents for any pain and engorgement of the breast. NURSING CONSIDERATIONS: 1. A mother should taught how to properly take her newborn off the breast while he or she is sucking. 2. Advise the mother to place the newborn skin to skin while breastfeeding this will provide the environment to arouse the newborn to suck. 3. The nurse should guide the mother in adjusting the feeding pattern of the infant to meet its needs. 4. Instruct mother to choose a comfortable position when breastfeeding. 5. The nurse should provide a feeding plan for the mother upon discharge. PHYSIOLOGY OF THE MILK PRODUCTION Colostrum, a thin, watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies, is secreted by the acinar breast cells starting in the 4th month of pregnancy. After birth, colostrum production continues until it is replaced by transitional breast milk on the 2nd to 4th day. True or mature breast milk is produced by the 10th day. The image below shows how the hormonal control of lactation stimulates the process of milk let down or "let down reflex". (Seeley, 2014 - Oxytocin is produced more quickly than prolactin CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 1. Stimulation of the nipple by the baby’s suckling initiates action potentials in sensory neurons that connect with the hypothalamus. arrow 2. Hypothalamus stimulates the posterior pituitary to release oxytocin and the anterior pituitary to release prolactin arrow 3. Oxytocin stimulates milk release from the breast. Prolactin stimulates additional milk production arrow 4. Milk is secreted BENEFITS OF BREASTFEEDING B- est for babies R - educes incidence of allergies E - conomical A - ntibodies S - tool-inoffensive T - emperature always correct and constant F - resh E - motional bonding E - asy once established D- igested easily I - mmediately available N - utritionally balanced G- astroenteritis greatly reduced BREASTFEEDING BARRIERS Breast Pathology Flat/ inverted nipples, breast reduction surgery that severed milk ducts, previous breast abscess, extremely sore nipples (cracked, bleeding, blisters, abrasions) Hormonal Pathology Failure of lactogenesis, hypothyroidism Overall health Smoking , anemia, poor nutrition, depression Psychosocial Restrictive feeding schedules, mother without support system, not rooming in with baby, bottle supplementing when not medically required. Other Previous breastfed infant who failed to gain weight well, perinatal complication (hemorrhage, hypertension, infection) BREASTFEEDING TECHNIQUES POSITIONING AND ATTACHMENT The positioning of the baby’s body is important for maintaining good attachment and successful breastfeeding. Most difficulties of breastfeeding can be avoided altogether if good attachment and positioning can be achieved at the first and early feeds. (Degefa, 2019) In order to achieve successful breastfeeding, there are different common positions that the mother can try before finding the one that will work best for her and the baby. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 1. Cradle (cross-chest): The baby lies across mother’s lap; baby’s head lies on her forearm or in her hand on the side from which she is feeding. His head should not be in the crook of her arm because that takes him too far out to the side and he has to bend his head forward and cannot get his chin and tongue underneath the nipple. 2. Modified cradle: The baby lies across the mother’s lap; mother’s opposite arm and neck. This position is very useful for newborns and very small babies, giving the mother better control of the baby’s lead and neck than the cradle hold. 3. Side-sitting (“football”): Baby and mother sitting up; baby sits facing mother with his legs under other’s arm; mother’s hand supports baby’s back and neck. This position is comfortable after a cesarean delivery because the baby’s weight is away from the incision. Sleepy babies may stay awake and feed better in this more upright position. 4. Side-Lying: The mother and baby lie side by side with mother’s lower arm extended. 1 2 3 4 Lesson 3 Enema Introduction An enema is a solution introduced into the rectum and large intestine. The action of an enema is to distend the intestine and sometimes irritate the intestinal mucosa,thereby increasing peristalsis and excretion of feces and flatus. Definition An enema is a procedure used to stimulate bowel movement by inserting liquid or gas through the rectum. An enema may be given to administer medication, to stimulate bowel movements, or to treat constipation. An enema can even be given to pregnant women to ease constipation, which is a common problem during pregnancy. PURPOSE OF ENEMA 1. To promote defecation by stimulating peristalsis and loosening stool 2. To cleanse the bowel prior to surgery, childbirth, or diagnostic examination 3. To administer medication to exert a local effect on the rectal mucosa 4. To relieve constipation, abdominal distention and fecal impaction EQUIPMENT Clean gloves Water-soluble lubricant Waterproof, absorbent pads Bath blanket Toilet tissue Bedpan, beside commode or access to toilet Washbasin, washcloths, towel and soap IV pole EQUIPMENT (Enema kit with) Enema container Tubing and clamp Appropriate size rectal tube (adult: Fr 22-30 ) Correct volume of warmed solution ( adult: 750 to 100ml ) Prepackaged enema container with rectal tip ASSESSMENT 1. Checks doctor’s order. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 2. Assesses when the client had his/her last bowel movement- amount, color, and consistency of the feces and presence of abdominal distention as well as sphincter control. 3. Assesses the client’s ability to use a toilet or commode or must remain in bed and use a bedpan. PLANNING 1. Determines individualized client outcomes in relation to the enema administration: 1.1. The client understands the need for the enema. 1.2. The client experiences minimal discomfort during the procedure. 1.3. Stool and fluid are completely evacuated from the bowel. 1.4. The client is clean and comfortable 2. Gathers and prepare the needed equipment. IMPLEMENTATION 1. Performs hand hygiene and put on PPE, if indicated. Rationale: Hand Hygiene is the most effective way to help prevent the spread of organisms. PPE is required based on transmission precaution. The term hand hygiene applies to either the use of antiseptics hand rubs, including alcohol based products, hand washing with soap and water or surgical hand antisepsis. 2. Introduces self to client. Rationale: This is essential to foster therapeutic nurse-patient relationships based on mutual trust and respect 3. Verifies the client using at least two identifiers (i.e. name and birth date or name and identification number) and compares identifiers with information on the client's medical record, clients identification band. Rationale: Identifying the patient ensures the right patient, receives the right intervention/procedure and helps prevent errors. 4. Explains the procedure to the client and encourage to participate as appropriate. Rationale: Discussions and explanation encourages the patient's understanding, participation and reduces apprehension. 5. Closes the room door and or curtains around the bed if possible. Rationale: This ensures the patient's privacy. 6. Raises bed to an appropriate working height and raise side rail on client’s left side. Rationale: Promotes good body mechanics and patient safety. Appropriate positioning prevents back pain. 7. Places rubber sheet or waterproof pads under the client’s hips and buttocks. Rationale: Prevents soiling of linen. 8. Positions client on side lying position or Sim’s position with knees flexed. Covers client with bath blanket and making sure exposing only rectal area and clearly visualizing anus once procedure starts. Rationale: This position facilitates the flow of solution by gravity into the sigmoid and descending colon, which are on the left side. Having the right leg acutely flexed provides for adequate exposure of the anus. Allows enema solution to flow downward by gravity along the natural curve of sigmoid colon and rectum, this improving retention of solution. Provides warmth, reduces exposure of body parts and allow patient to feel more relaxed and comfortable. 9. Prepares the solution, making sure that the temperature is lukewarm (about 105-110 F). Hot water burns intestinal mucosa. Rationale: Cold water causes abdominal cramping and is difficult to retain. 10. Primes the tube and allowing the solution to run through the connecting tubing so that the air is removed. Clamp tubing. Rationale: Air instilled into the rectum although not harmful causes unnecessary distention. Introducing air into colon causes further distention and discomfort. 11. Hangs container on bedside IV stands no more than 18-24 inches above buttocks. Rationale: The higher the solution container is held above the rectum, the faster the flow and the greater the force (pressure) in the rectum. 12. Places bedpan or commode in easily accessible position. If client is expelling contents in toilet, ensure that toilet is free. (if client is getting up to bathroom to expel enema, place her slippers and bathrobe in easily accessible position).Rationale: Used in case patient is unable to retain enema solution. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 13. Positions client on side lying position or Sim’s position with knees flexed. Rationale: This position facilitates the flow of solution by gravity into the sigmoid and descending colon, which are on the left side. Having the right leg acutely flexed provides for adequate exposure of the anus. Allows enema solution to flow downward by gravity along the natural curve of sigmoid colon and rectum, this improving retention of solution. 14. Lubricate 4-5 inches of catheter tip rectal tube. Rationale: Lubrication facilitates insertion through the sphincter and minimizes trauma. Lubrication provides for smooth insertion of rectal tube without risk of irritation or trauma to mucosa. With presence of hemorrhoids, extra lubricant provides added comfort. Causing rectal irritation or trauma. Lubricating allows smooth insertion of rectal tube without risk of irritation or trauma to mucosa. 15. Gently spreads buttocks, instruct client to take a slow deep breaths through the mouth. Insert rectal tube into the rectum about 3-4 inches and hold in place. Rationale: Ensures good visualization of the anus. The angle follows the normal contour of the rectum. Slow insertion prevents spasm of the sphincter. Gentle insertion prevents trauma to rectal mucosa. Breathing out and touching skin with the tube promote relaxation of external anal sphincter. 16. Releases tubing clamp. Allow solution to flow slowly into colon while observing. If client complains of cramping, extreme anxiety or inability to retain solution: (1) lower solution container. (2) clamp or pinch tubing for few minutes. Rationale: Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution. Rapid instillation stimulates evacuation of rectal tube. Temporary cessation of instillation prevents cramping which prevents patient from retaining all fluid, altering effectiveness of enema. 17. Administers all of the solution or as much as the client can tolerate, be sure to clamp tubing just before solution clears tubing. Rationale: Clamping prevents air from entering rectum. 18. Instructs client to take a deep breathe while holding buttocks together and slowly remove rectal tube. Rationale: It is easier for the client to retain the enema when lying down because gravity promotes drainage and peristalsis. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 19. Assists the client to a sitting position on a bed pan, commode or toilet, and instruct the client not to flush the toilet. Rationale: A sitting position facilitates the act of defecation. Not flushing the toilet would help facilitates the nurse the need to observe the feces. Normal squatting position promote defecation. 20. Promotes client’s comfort by helping the client with cleaning the anorectal area, if needed. If the client can clean the area independently, provide an opportunity for hand washing and then assist him or her to return to bed or chair. Rationale: Fecal contents irritate the skin. Hygiene promotes patient’s comfort. Provides for patient’s comfort and cleanliness. 21. Cleans or disposes the enema equipment appropriately. Rationale: Reduces transmission and growth of microorganisms. 22. Removes gloves and discard. Wash or disinfect your hands. Rationale: It minimizes transmission of microorganism. Good hygiene reduces transmission of microorganisms. 23. Document the amount and type of enema, the amount and characteristics of the stool and the response of the client. EVALUATION 1. Determine individualized client outcomes in relation to the enema administration: 1.1. The client understands the need for the enema. 1.2. The client experiences minimal discomfort during the procedure. 1.3. Stool and fluid are completely evacuated from the bowel. 1.4. The client is clean and comfortable NURSING CONSIDERATIONS 1. For patients with cardiac disease or taking cardiac or hypertensive medication, obtain pulse rate because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate which increases the patient’s risk of fainting while on bedpan, beside commode or toilet. MODULE 3: Skills Procedure for Immediate Newborn Care Other Procedures for Newborns Soon After Birth may include: Anthropometric Measurement. Crede's Prophylaxis. Injection of Vitamin K. All newborns require essential newborn care to minimize the risk of illness and maximize their growth and development. Therefore it is important to provide proper care to all the neonates immediately after birth. This care will also prevent many newborn emergencies such as neonatal infection, very low birth weight infants, complications of asphyxia and severe neonatal jaundice. Lesson 1 : Anthropometric Measurements The term anthropometric refers to comparative measurements of the human body. The measurements commonly used as indices of growth and development for infants include body weight, length, head, chest and abdominal circumferences. Anthropos = man CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite Metron = measurements - Assessing size, proportions and composition of the human body Purposes: ➔ Newborn’s Weight – helps to determine maturity as well as establish a baseline against which all other weights can be compared. - 6.5-7.5 lbs (3.0- 3.4kg) - Male : 2.4kg to 4.1kg (Average 3.16kg) - Females: 2.1kg to 4.2kg (Average 3.11kg) ➔ Length/height/Stature – second important determinant used to confirm that a newborn is healthy. - 2 yrs old - Infantometer (recumbent length) - Older child - Stadiometer - Average Newborn Length: 47.5-53 cm (Ave: 50cm) - Male: 46.1cm to 51.4cm (Average: 48.91cm) - Female: 45.1cm to 51.7cm (Average:48.49cm ➔ Head circumference to detect abnormalities of head growth and determine the growth rate of the skull and brain. ★ HC is measured by placing the tape over the occipital protuberance at the back and just over the supraorbital ridge and the glabella in front - Brain growth takes place 70% during fetal life, 15% during infancy and 10% during pre-school yrs. - Head circumference are routinely recorded until 5 yrs or age - If scalp edema or cranial molding is present - measurement may be inaccurate until 4 or 5 day of life - Average Newborn HC 33-35cm (measure at the center of forehead and the prominence of occiput) ➔ Chest circumference to assure the proper development of the chest organs and the calcification of the rib cartilage. ★ Measured at the level of nipples, preferably in mid inspiration ★ Xiphisternum (lowest part of sternum/xiphoid process) - In children - less than or = 5 yrs — lying down position - Greater 5 yrs old —- standing position - 31-33 cm (measure at the level of nipples) ➔ Abdominal circumference - necessary to ascertain the size of the abdominal viscera in healthy newborns and to objectively determine and specify the abdominal circumference in patients with necrotizing enterocolitis (NEC) and other diseases of the abdominal cavity. ★ Same as CC 31-33cm ★ Measured just above the level of umbilicus - Below level of umbilicus is no longer recommended (full bladder may interfere measurement) Equipment: Tape measure, Infant weighing scale (Digital or Analog), Clean gloves, Paper or Drape Assessment: Check APGAR Score. Planning: Prepare all the necessary equipment. Implementation: 1. Perform hand hygiene and put on PPE, if indicated 2. Introduce self to client. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 3. Verify the patient 4. Explain the procedure to the patient and significant others and encourage the person to participate as appropriate. 5. Close the room door 6. Measuring Weight The newborn is highly susceptible to 6.1 Places light drape or paper on weighing scale. infection. The scale tray should be 6.2 Calibrates scale to “0” position. covered with a protective clothing or 6.3 Completely undresses infant. paper to ensure cleanliness of the 6.4 Places the newborn gently on the center of the weighing scale. surface and free from 6.5 Keeps one handover or near the newborn on scale at all times microorganism 6.6 Read the weight of the newborn. 6.5 This is to be able to catch the 6.7 Carefully removes newborn from the weighing scale. newborn if in case he/she slips of 6.8 Record the weight from the scale 7. Measuring the Length 7.1 Holds newborn’s head at midline point and extends legs fully. 7.2 Stretches a tape measure from crown of newborn’s head to heel of newborn’s foot alongside newborn’s body. 7.3 Notes and records newborn’s height in centimeters. 8. Measuring the Head Circumference 8.1 Places tape measure around fullest part of newborn’s brow and around occipital prominence. 8.2 Note and records the head circumference in centimeters 9. Measuring the Chest Circumference 9.1 Remove the clothing from the chest. 9.2 Measures around the chest at the nipple line, keeping the measuring tape at the same level, anterior and posterior. 9.3 Records the newborn’s chest circumference. 10. Measuring the Abdominal Circumference 10.1 Removes the clothing. 10.2 Measures around the abdomen at the level of the umbilicus 10.3 Record abdominal circumference in centimeter 11. Clean all the materials used Evaluation: Documents the procedure done and measurement obtained Nursing Considerations: 1. Birth weight of newborns varies depending on the racial, nutritional, intrauterine and genetic factors that were present during conception and pregnancy. 2. Note circumference of the head and chest approximately the same for first 1-2days after birth 3. The APGAR score is a rapid assessment of the newborn transition to extrauterine existence based on five signs that indicate the physiology state of the neonate: a. Heart rate based on auscultation; b. Respiratory effort based on the observed movement of the chest wall, c. Muscle tone based on the degree of flexion and movement of the extremities, d. Reflex irritability based on response to suctioning of the nares or pharynx and e. Generalized skin color, described as pallid, cyanotic or pink. Lesson 2 Crede's Prophylaxis Crede’s prophylaxis is the instilling of ordered ophthalmic ointment into the newborn’s eyes to avoid damage and blindness due to conjunctivitis brought about by Neisseria gonorrhoeae. This practice was introduced by Crede, a German gynecologist in1884. It is part of the routine care of the newborn to give prophylactic eye treatment against gonorrhea conjunctivitis or ophthalmia neonatorum or chlamydial infection. Neisseria gonorrhoeae, the causative agent, may be passed on the fetus from the vaginal canal during delivery. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite DRUGS USED: erythromycin and tetracycline ophthalmic ointments. ACTION: These antibiotic ointments are bacteriostatic. They provide prophylaxis against Neisseria gonorrhoeae and chlamydia trachamatis. INDICATION: These medications are applied to prevent ophthalmia neonatorum in newborns of mothers who are infected of gonorrhea and conjunctivitis in newborn of mothers infected with chlamydia. NEONATAL DOSAGE: Apply 1 to 2 cm ribbon of ointment to the lower conjuctival sac of eye; also may be used in drop form. ADVERSE REACTION: may cause chemical conjunctivitis that lasts 24 to 48 hrs; vision maybe blurred temporarily. Purposes 1. To prevent blindness caused by gonococcal organisms that may be present in the vagina. 2. To prevent ophthalmia neonatorum. Equipment: medicine tray, dry cotton balls, clean gloves, sterile gauze, sterile NSS syringe with needle (1-3 ml), Antibiotic Treatment (Erythromycin or tetracycline ophthalmic ointment) Assessment: Assess and inspect the external eye structure for excessive lacrimation. Planning: Prepare all necessary equipment. Implementation: 1. Perform hand hygiene and put on PPE, if indicated 2. Introduce self to client. 3. Verify the patient 4. Explain the procedure to the patient and significant others and encourage the person to participate as appropriate. 5. Close the room door 6. Position the baby properly in a table. 7. Clean the eyelids carefully with a sterile cotton ball Using each area of cotton balls once and going moistened with sterile NSS from the inner to outer canthus of from the inner canthus to the outer canthus, debris the eye. is kept away from the lacrimal duct. 8. Retract the lower eyelids using your thumb. ointment should be placed on the conjunctival sac and not directly on the eyeball 9. Apply prescribed amount of the prescribed antibiotic ointment in the lower conjunctival sac from inner to outer canthus of the eye and gently pressing on the periorbital ridges. 10. Wipe off excess medication with sterile gauze. 11. Do the same procedure with the other eye. Evaluation: Swelling, redness, irritation and any side effects. Nursing Considerations 1. Use a single dose application tube. 2. After gently pulling down the newborn’s lower eyelid, extrude a line of ointment to the length of the lower eyelid from the inner canthus outward. 3. Wipe away any excess ointment forms on the child’s face. 4. Massage eyelids gently to distribute the ointment. 5. Close the eyes and count to about five. 6. Teach parents about the need for eye prophylaxis. Educate them regarding side effects and signs that need to be reported to the healthcare provider. CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite 7. Assess eyes for swelling and draining pus. If present, consider gonococcal eye infection. Teach mother to treat eyes. Appropriate antibiotics will be given for eye infections. (WHO, 2009) 8. Administer within 1-2 hours of birth Lesson 3 : Vitamin K Administration Vitamin K is used by the body to form clots and to stop bleeding. Babies are born with very little vitamin K stored in their bodies. This is called " Vitamin K deficiency "and means that a baby has low levels of Vitamin K. Without enough Vitamin K babies cannot make the substances used to form clots called "clotting factors" When bleeding happens because of low levels of Vitamin K, this is called " Vitamin K deficiency bleeding " or VKDB, which is a serious and potentially life threatening cause of bleeding in infants up to six (6) months of age. A Vitamin K shot given at birth - is the best way to prevent low levels of Vitamin K and Vitamin K deficiency bleeding (VKDB). And when when they start eating solid foods, because primarily Vit K comes from plants. Fat soluble vitamin K- koagulation (German) process of blood clot formation Body stores very little amount, regular intake is needed. Also involved in building bones. Synthesized in large intestine Phytonadione, Aquamephyton Actions: – prevent and treat hemorrhagic disease in the newborn. – Necessary component for the production of certain coagulation factors (II, VII, IX,X) and is produced by microorganisms in the intestinal tract(intestinal flora) - factor II (prothrombin), - factor VII (proconvertin), - factor IX (plasma thromboplastin component) and factor X (Stuart – Power factor) in the clotting sequence. Dosage: Prophylaxis- 0.5 to 1.0 mg IM one time immediately after birth Possible adverse reactions: Local irritation and swelling at site of injection. Nursing Responsibilities: Anticipate the need for injection immediately after birth. Administer IM injection (anterolateral muscle) thigh / VASTUS LATERALIS If given for treatment, obtain PT before administration. Assess for signs of bleeding (indicate that more vitamin K is needed, because bleeding control has not been achieved) More info mema joke Because newborn’s intestine is sterile at birth unless membranes were ruptured more than 24 hours, it will take about 24 hours for the flora to accumulate and for ongoing vitamin K to be synthesized. This causes most newborns to have prolonged coagulation or prothrombin time. Since almost all newborns are predicted to have diminished blood coagulation ability, vitamin K is administered intramuscularly. An IM injection of 0.5 to 1.0 mg of vitamin K is administered during the first hour after birth Purpose: 1.To prevent hemorrhagic disease in newborns. 2. It is necessary for the production of certain clotting factors. Equipment: Vitamin K ampule, 1 mL syringe with 5/8 inch, 25 gauge needle, Cotton balls with 70% alcohol or alcohol swab, Dry cotton balls, Clean gloves, Micropore tape, Sharps container, Gauze CARE OF MOTHER, CHILD AND ADOLESCENT (well clients) First Semester BY: Cutieparasite Assessment: 1. Assess the vastus lateralis for lesions and deformities. Evaluates the muscle mass of vastus lateralis. 2. Assess the infant for signs of bleeding. 3. Observe 10 R’s in giving medication. Planning: Prepare necessary equipment Implementation 1. Perform hand hygiene and put on PPE, if indicated 2. Introduce self to client. 3. Verify the patient 4. Explain the procedure to the patient and significant others and encourage the person to participate as appropriate. 5. Close the room door 6. Prepare the Vitamin K. 7. Select the site for injection. The large vastus lateralis is located on the sciatic nerve to the femoral artery and vein. The rectus femoralis muscle is nearer to these structures which poses more of a danger. 8. Clean the site with cotton balls soaked in 70% alcohol using circular motion from inside going to outside. 9. Using the non-dominant hand, compress or grasp the muscle tissue between your fingers. 10. Pierce the skin straight down into the top of the thigh at 90 degree angle. 11. Aspirate to check for any backflow of blood. If none, give the injection slowly. 11. Remove the needle quickly and apply cotton ball over the site. Press to avoid gross bleeding 12. Place safety shield on needle and discard syringe in appropriate sharps container. 13. Discard supplies, remove gloves, and perform hand hygiene. Evaluation: Observe and document any signs of bleeding from the injection site. Nursing Considerations: 1. Administer IM injection into large muscles such as the anterolateral muscle of the newborn’s thigh, the preferred site for all injections in newborns immediately after birth. 2. Be certain to administer the injection at the time it doesn’t interrupt parent-child bonding or beginning breastfeeding. 3. Protect the drug from light. MEMA Lesson 4 VACCINES Hepatitis B and BCG Hepatitis - IM BCG - ID = for TB