Related Learning Experience (RLE)

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

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Procedure
1. Check the doctor’s order for catheterization.
2. Introduce yourself and verify the client’s identity. Explain to the client what you
are going to do, why it is necessary and how the client can cooperate.
3. Perform hand hygiene and observe for other appropriate infection control
procedure.
4. Provide for the client’s privacy.
5. Place the client in the appropriate position and drape all the areas except the
perineum.
o Female: Supine, kness flexed 2 feet apart
o Male supine, legs slightly abducted
6. Establish adequate lighting. Stand on the client’s right if you are a right handed.
On the client’s left if you are a left handed.
7. If using a collecting bag not contained within the catheterization kit. Open the
drainage package and place the end of the tubing within reach.
8. If agency policy permits, apply clean gloves and inject 10-15 mL Xylocaine gel
into the urethra of the female client. Wipe the underside of the shaft to distribute
to get up the urethra. Wait atleast 5 minutes for the gel to take effect before
inserting the catheter. Remove the gloves.
9. Open the catheterization kit. Place the waterproof drape under the buttocks
(female) or penis (male) without contaminating the center of the drape with your
hands.
10. Apply sterile gloves.
11. Organize the remaining supplies.
o Saturate the cleansing balls with the antiseptic solution
o Open the lubricant package
o Remove the specimen container and place it nearby with the lid loosely on
top
12. Attach the prefilled syringe to the indwelling catheter inflation hub.and test the
balloon.
13. Lubricate the catheter and place it with drainage end inside the collecting
container.
14. If desired, place the fenestrated drape over the perineum exposing the urinary
meatus.
15. Cleanse the meatus

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Female:
1. The nondominant hand is considered contaminated once it touches the client’s
client.
2. Use your nondominant hand to spread labia. Establish a firm but gentle position.
3. Pick up a cleansing ball with the forceps in your dominant hand and wipe one
side of the labia majora in a anteroposterior direction.
4. Use a new ball for the opposite side.
5. Repeat for the labia minora.
6. Use the past ball to cleanse directly over one meatus.
Male:
1. Use the nondominant hand to grasp the penis just below the glans. If necessary,
retract the foreskin. Hold the penis firmly upright with slightly tension.
2. Pick up a cleansing ball with the forceps in your dominant hand and wipe from
the m.eatus in a circular motion around the glands.
3. Use a new ball and repeat 3 more times.
16. Insert the catheter
Grasp the catheter firmly 2-3 inches from the tip. Ask the client to take a slow deep
breath and insert the catheter as the client exhales.
Advance the catheter 2 inches further after the urine begins to flow through it or per
agency policy.
If the catheter accidentally contacts the labia or slips into the vagina, it is considered
contaminated and a new sterile catheter must be used. The contaminated catheter may
be left in the vagina until the new catheter is inserted to help avoid mistaking the vaginal
opening for the urethral meatus.

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17. Hold the catheter with the nondominant hand. In males, lay the penis down onto
the drape, being careful that the catheter does not pull out.
18. For indwelling catheter inflate the retention balloon with the designated volume.
 Without releasing the catheter, hold the inflation valve between two fingers
of your nondominant hand while you attach the syringe and inflate with
your nondominant hand.
 If the client complains of discomfort immediately withdraw the instilled
fluid, advance the catheter further and attempt to inflate the balloon again.
 Pull gently on the catheter until resistance is felt to insure that the balloon
has inflated and to place it in the trigone of the bladder.
19. Collect a urine specimen, if needed. Allow 20-30 mL to flow into the bottle
without touching the catheter to the bottle.

20. Allow straight catheter to continue draining. If necessary attach the drainage end
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of an indwelling catheter to the collecting tubing and bag.
21. Examine and measure the urine. In some cases only 750-1000 mL of urine are to
be drain from the bladder at one time. Check agency policy.
22. Remove the straight catheter, secure the catheter tubing to the inner thigh for
female clients or the upper thigh/abdomen for the male clients, with enough slack
to allow usual movement.
Also secure the collecting tubing to the bed linens and hang the bag below the
level of the bladder. No tubing should fall below the top of the bag.
23. Wipe the perineal area of any remaining antiseptic or lubricant. Replace the
foreskin, if retracted earlier. Return the client to a comfortable position.
24. Discard all used supplies in appropriate receptacles and perform hand hygiene.
25. Document the catheterization procedure including catheter procedure and result
in the client records.

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REMOVING AND SERVING OF BED PAN
PURPOSE:
To facilitate and encourage normal elimination of urinary abd bowel wastes
for patient confined to bed.
EQUIPMENT:
Obtain from central supply or from designated storage area:
1. Disposable bedpan or urinal
2. Disposable washbasin
3. Bedpan cover (towel)
4. Disposable gloves
5. Disposable “wet” wiped
6. Linen saver pad
Obtain from the laundry:
1. Hand towel
2. Wash cloth
Have soap available

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PROCEDURE
Giving a bedpan:
1. Provide screen or close door. To minimize embarrassment and ensure privacy.
2. Wash hands, and apply disposable glove. To prevent cross-contamination.
3. Obtain bedpan from designated area or bedside stand. Make certain it is labeled with
the patient’s name and number if bedpan is being re-used for the same patient. To
Avoid cross-contamination.
4. Turn bedding back, exposing as little of the patient as possible. To maintain the
patient’s privacy.
5. Have patient flex his knees and raise buttocks, if possible. Assist him where it is
necessary by placing hand under low back and lifting. Allows space for bedpan between
the individual and bed. Check to ensure that he is not restricted from moving or certain
types of posture.
6. If patient cannot use his legs to raise himself, turn him on his side. Position
bedpan to buttocks and roll him onto his back with bedpan under him. Be sure bedpan
is in proper position.
7. Adjust the bed to the most comfortable position for the patient if orders allow. If
possible, elevate the head of the bed slightly to prevent hyperextension of the spine. If
elevation of the head is contraindicated, tuck a pillow or folded blanked under the
patient’s back to cushion the sacrum against he bedpan and support the lumbar area.
Using the bedpan is difficult for most people. When permitted elevating the head of the
bed aids in elimination.
8. Leave the patient alone with the toilet tissue within easy reach (Unit 1 ensures patient
has access to call bell). Minimizes patient embarrassment.
9. Dispose of gloves, wash hands per hand hygiene policy.

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Removing a bedpan:
1. Apply disposable gloves. The patient’s condition and the physicians order will
determine how much he is able to do for himself.
2. . Lower head of bed have patient flex his knees and rise up buttocks; then
remove the bedpan. Assist and support the patient as necessary. The patient’s
condition and the physicians order will determine how much he is able to do for himself.
3. If the patient is unable to care for and clean himself, hold the bedpan firmly and turn
the patient to his side off the bedpan. Hold the bedpan to prevent it from tipping as the
patient turns.
4. Remove and cover bedpan and place it to the side of the bed. To protect bedding and
prevent odors.
5. Cleanse anal area with disposable “wet” wipe, then wash, and dry anal area and
buttocks. To prevent excoriation and breakdown of skin
6. Provide materials for patient to wash and dry his hands and position him for comfort.
To provide hygiene and comfort.
7. Empty contents of bedpan into toilet and flush. Discard per I.C.M. All disposable
items will be discarded per I.C.M. III.C. To Eliminate risk of cross contamination and
reduce the risk of communicable disease transmission.
8. Open door or remove screen
9. Measure and record contents if patients are on I&O and dispose of contents in toilet
room. Return urinal to bedside stand. Disposable articles will be discarded per ICM. To
eliminate risk of cross contamination and reduce risk of communicable disease
transmission.

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HOT SITZ BATH
Definition
Sitz bath or hip bath is a bath in which a patient sits in water up to the hips to relieve
discomfort and pain in the lower part of the body. Sitz bath works by keeping the
affected area clean and increasing the flow of blood.
A sitz bath may be created simply by filling a bathtub with some water and sitting in it
for a few minutes. Alternatively, a large basin can be used. There are also special
devices that fit into toilet bowls. Sitz baths may either be warm or cool. Some people
find alternating between hot and cold water soothing. Sitz baths may be filled with just
water, or substances such as salt, baking soda or vinegar can be added.
Origin of Term
The term sitz bath is derived from the German word Sitzbad,meaning a bath (Bad) in
which one sits (sitzen).
Objectives
 To relieve muscle spasm
 To soften exudates
 To hasten the suppuration process
 To hasten healing
 To reduce congestion and provide comfort in the perineal area
Purposes
 To aid healing a wound in the area by cleaning on discharges and slough
 To induce voiding in urinary retention
 To relieve pain, congestion and inflammation in cases of: hemorroids, tenesmus,
rectal surgery, anal fissures, after proctoscopic or cycloscopic exams., sciatica,
uterine and renal colic.
 To induce menstruation.
Indications
 Hemorrhoids
 Anal Fissures/Surgery
 Episiotomy
 Uterine Cramps

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Important Considerations
 Warm water should not be used if considerable congestion is already present.
 The patient should be observed closely for signs of weakness and faintness.
 After the patient is in the tub or the chair, check to see whether or not there is
pressure against the patient’s thighs or legs.
 Support patient’s back in the lumbar region.
Contraindication
Menstruating or pregnant women
Equipment
 Sitz tub half filled with water 105F
 Pitcher of water 130F
 Bath thermometer
 Ice cap-with cover
 Fresh camisa
 Bath towel
 Bath blanket
 Rubber ring p.r.n.
Preparation
 Take all necessary equipment to bathroom or treatment room.
 Run water into tub and check temperature—105F or 40.5C
 Place rubber ring at bottom of tub p.r.n. or line bottom with towel.
 Charting
 Type of solution
 Length of time of application
 Type of heat application
 Condition and appearance of wound
 Comfort of patient
Equipment
Available bathroom with appropriate size tub for patient.
 Towels and bathmat
 Bath blanket
 Inflatable ring
 Patient’s clean clothes

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Procedure
Nursing Interventions Rationale
Check physician’s order for sitz
bath patient.
To know if it is indicated for the patient.
Prepare the materials needed:
Take linen to bathroom.
Fill clean tub about one-third full
with warm water.
Check with your hand to determine
that temperature of water is
between 105°F and 110°F (40.5°C
to 43.3°C).
Place towel or inflatable ring, if
appropriate, on tub bottom and
bathmat on floor beside tub.
To save time and effort
Explain purpose and procedure to
patient.
For the patient to be aware on the purpose and
procedure.
Test the water in a sitz with a
thermometer before the patient
enters the tub. If the purpose of the
sitz bath is to apply heat, water at
a temperature of 43°C to 46°C for
15 minutes will produce relaxation
of the parts involved after a short
contraction.
Warm water should not be used if considerable
congestion is already present. If the purpose of the sitz
bath is to produce relaxation or to help promote
healing in a wound by cleaning it of discharge and
debris, then water at a temperature of 34°C to 37°C is
used.

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Assist the patient into the tub and
position him properly.Check to see
whether there is pressure against
the patient’s thighs or legs.If the
patient’s feet do not touch the
floor, and the weight of the legs is
resting on the edge of the tub, a
stool should be used to support the
feet and to relieve the pressure on
the back of the legs.It may also be
necessary to place a towel in the
water to support the patient’s back
in the lumbar region.The bath can
seem very long if one’s body is not
in good alignment and
comfortable.
Wrap a bath blanket around the
patient’s shoulders, and drape the
ends over the tub.
This protects the patient’s from feeling chilly and form
exposure.
Observe the patient closely for
signs of weakness and fatigue. A
cold compress may be placed at
the back of the neck or forehead,
to help prevent the patient from
feeling weak. Discontinue the bath
if the patient’s condition warrants.
Typical signs of faintness include skin pallor, a rapid
pulse rate, and nausea.
Test the water in the tub several
times, and keep it at the desired
temperature. Additional hot water
may be added by pouring it slowly
form a pitcher or by opening a hot-water
fauce a little bit.
The water should be agitated by stirring it as hot water
and added to prevent burning the patient.
Do not leave the patient alone
unless it is absolutely certain that it
is safe to do so.

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Help the patient out of the tub
when the bath is completed.
Normally, a hot sitz bath should be
continued for 15 to 30 minutes.
Help the patient dry, and cover the patient adequately.
Assist the patient to his bed, where it is best for him to lie down, and out of drafts until
normal circulation returns.

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APPLICATION OF HOT AND COLD
COLD
Cold causes vasoconstriction (shrinkage of blood vessels), decreasing blood flow
to an area, and slowing the body’s metabolism and its demand for oxygen. The
therapeutic goals of cold applications include controlling hemorrhage, reducing edema,
easing inflammation, and blocking pain receptors.
Rationale for Cold Application
Cold application prevents escape of heat from the body by slowing circulation,
which also relieves congestion and often relieves muscle pain. A cold
application:
• Slows or stops bleeding
• Slows bacterial activity in clients with an infection
• Relieves pain following some types of surgery, tooth extraction, headache, or muscle
or joint injury
• Reduces swelling in injured tissues, including sprains and fractures
• Prevents peristalsis in clients with abdominal inflammation
• Relieves pain in engorged breasts

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• Controls pain and fluid loss in the initial treatment of burns
• Diminishes muscle contraction and muscle spasms
• Slows the basal metabolism for certain types of surgery.
APPLYING COLD THERAPY
• Stop the cold application immediately if the client complains of numbness or the
skin appears white or spotty. Rationale: Cold numbs nerve endings.
• As cold decreases the flow of blood in one area of the body, flow increases to
other areas. Rationale: This explains why cold or chilling drafts striking the body often
cause congestion in the nasal passages.
• Continued application of cold affects deeper tissues. It is important to monitor the
client closely. Rationale: Prolonged exposure to extreme cold may cause serious injury.
• Cold often is applied to a sprain, strain, fracture, or burn. Rationale: This helps
remove blood and lymph congestion in the area and reduces pain.
HEAT
Heat is often applied in general client care. Heat causes vasodilation (enlargement of
blood vessels), increasing blood flow to a specific area. This increases the oxygen,
nutrients, and various blood cells delivered to body tissues. Vasodilation also aids in
removal of wastes from injured tissues, such as debris from phagocytosis.

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Rationale for Heat Application
Heat application serves to:
• Relieve local pain, stiffness, or aching, particularly of muscles and joints
• Assist in wound healing
• Reduce inflammation and infection
• Make the chilly client more comfortable
• Raise body temperature to help maintain normothermia
• Promote drainage (draw infected material out of wounds)
Because heat must be fairly intense to be effective, burns may result if heat is
applied improperly or for too long. The application must be sufficiently hot to accomplish
its purpose, but within a safe temperature range. Box 54-1 provides temperature ranges
for hot and cold applications. Heat applied over a large area affords more warmth;
however, the potential for injury is greater than that of heat applied over a small area.
Protect the client from possible burn injury by observing safety precautions. In Practice:
Nursing Care Guidelines 54-1 outlines steps for applying heat therapy.
Both dry heat and moist heat have local effects. Apply dry heat with a heating
blanket, warm-water bag, waterproof, water-filled heating pad (aquathermia pad), heat
lamp, electric heat cradle, or electric heating pad. Moist heat warms the skin more
quickly and is more penetrating than dry heat, because water is a better heat conductor
than air. Apply moist heat with compresses, packs, or soaks, including the sitz bath.
Sometimes wet compresses are used in combination with the aquathermia pad to
provide longer-lasting moist heat. Skin maceration (abnormal softening) may develop
when moisture is applied directly to the skin for long periods. The client’s skin may be
protected by first applying a thin layer of petroleum jelly, if ordered. The provider’s order
typically specifies the length of time for heat applications to be administered. For

example, the order may be: “Moist compresses for 15 minutes every hour WA (while
awake).”
Approximate Range of Temperatures for Hot and Cold Applications
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Hot 37.7°C-40.5°C I00°F-I05°F
Warm 35°C-37.7°C 95°F-!00°F
Tepid 26.6°C-35°C 80°F-95°F
Cool 8.3°C-26.6°C 65°F-80°F
Cold 0°C-!8.3°C 50°F-65°F
To convert Fahrenheit to Celsius: C = (F – 32) X 5/9
To convert Celsius to Fahrenheit: F = (C X 9/5) + 32
APPLYING HEAT THERAPY
• Heat is applied only when specifically ordered by a primary provider and applied
with the utmost caution. Rationale: Nerves in the skin are numbed easily. The client
may not feel the pain of a burn, especially if heat has been applied often.
• Specific body parts, such as the eyelids, neck, and inside an arm, are especially
sensitive to heat.
• Each person has his or her own sensitivity to heat. Apply the heat source slowly
and ask the client for feedback. Rationale: This helps determine how much heat is safe
and for how long.

• Infants, older people, and those with fair, thin skin have less heat resistance.
Lowered body resistance because of illness also makes body tissues less resistant to
heat. Rationale: It is important to consider each client individually.
• Clients who are unresponsive or anesthetized and those with neurologic or
psychological disorders or dementia are at increased risk for injury from heat
applications. Rationale: These clients are often unable to report when heat is too
intense.
• Impaired circulation and some metabolic diseases make people more susceptible
to burns (e.g., clients who are in shock or have any type of peripheral vascular disorder,
or clients who have diabetes). Rationale: Changes in body systems interfere with skin
integrity and healing and may impair the client’s ability to identify discomfort.
• Clients receiving radiation therapy or chemotherapy and those with any degree of
paralysis are particularly susceptible to burns. Rationale: Such clients have
compromised immune systems or skin integrity.
• Client complaints are very important. Listen to the client; if he or she complains of
pain or discomfort, stop the treatment and consult the primary provider Rationale: Each
client is different. Only the client can state how the treatment feels.
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PERINEAL HEAT APPLICATION
Purpose:
1. To increase the flow of blood to relieve congetion over the perineum.
2. To hasten the absorption of inflammatory exudates.
3. To hasten the healing of wounds by stimulating granulation of tissue and drying the
exudation.
Equipments:
 Heat lamp
 Bed sheet
 Bath towel
 Tape measure
Procedure
 Assemble equipment
 To prevent errors
2. Identify the patient by checking the ID Bracelet.
 To prevent errors
 Explain the procedure and provide privacy and proper draping technique.
 To ensure cooperation.
4. Remove the underware and the peripad.
 To expose the perineal area.
 Position if modified lithotomy position, keeping feet on mattress with knees bent
and separated.
 Distance of heat lamp from area of exposure is 18 inches unless otherwise
indicated.
 To prevent burning, blanching of skin from too much heat.
 Keep all linens away from the lamp.
NOTE: contact with lamp may lead to accidental burning of linens.
8. Expose the area for 10 minutes unless otherwise ordered.
NOTE: prolonged exposure leads to burn.
9. Check the skin for redness or blanching from time to time.
10. After the procedure, keep the patient as comfortable as possible. Replace
peripad.
11. Clean and return the equipment properly.
12. Chart the following:
 Time the heat was apllied and lenght of treatment.
 Relavant observations.

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 Patient’s response
BREAST CARE
Purpose:
 To train all nursing staff who care for the new mother - baby dyad in the skills
necessary to implement this policy.
 To inform all pregnant patients about the benefits and management of
breastfeeding.
 To assist the staff in providing consistent breastfeeding information to all
maternity patients and assistance to the breastfeeding mother - baby couplet to
best support exclusive breastfeeding for her baby for the first six months of life.
Procedure:
1. Gather equipment
• Breastfeeding handouts/resources - Breast feeding Resources/Log, Breast
Engorgement, Breast Milk Collection and Storage.
• Breast pump (if needed)
• Breast cream (if needed)
• Bed pillows or Breastfeeding pillow
2. Within 30 minutes of delivery place the infant skin-to-skin across the mother’s
chest. Maintain infant's body temperature with a knit cap and warm blankets
tucked close. Encourage eye contact and light touch.
3. Encourage the mother to breast feed the infant within the first hour after birth,
preferably within the first 20-30 minutes, prior to initial bath.
4. Assist mother with breast-feeding and provide teaching and support as indicated.
Points to include are:
 Use pillows to support the mother’s arms and to position infant level with
the breast.
 Express a small amount of colostrum onto the nipple to interest the infant
in sucking.
 Mother supports her breast using the "C” hold. The thumb is placed on
top of the breast and the four fingers support the breast underneath. All
fingers should be well back from the areola.
 Mother tickles the center of the infant’s lower lip with her nipple until the
infant opens his mouth wide as possible. This may take several attempts
to do.
 When infant’s mouth is open very wide with the tongue down, mother

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should center her nipple quickly and draw the baby in close to her body.
 Infant’s mouth and lips should form a flanged seal around the breast
tissue. The tongue should be curved around the areola, cupping it and
extending over the gum line.
 Infant’s nose and chin should be touching the breast. There is no need to
create an air space for most infants.
 Identify nutritive sucking, which is 8 -10 long, drawing sucks w/ audible
swallows followed with a 5 -10 second rest period. Non-nutritive sucking is
usually 2-3 short, choppy sucks that are ineffective.
 Identify quiet sounds of swallowing i.e. a “k” or “h” phonics sound.
 Infant should finish the first breast or self-detach before offering the
second breast.
 De-latch the infant if feeding becomes uncomfortable, latch does not
appear deep enough, or a non-nutritive sucking pattern is seen, by placing
a clean finger in the side of the infant’s mouth between his jaws to release
the suction. Then assist mother to correctly re-latch the infant.
 Frequency and duration of feedings at the breast should be infant - led.
 Infant is expected to nurse approximately 8-12 times in 24 hours. Feeding
sessions may last 5-50 minutes or longer.

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Breastfeeding Interventions
1. If a mother has a flat or inverted nipple and the infant is unable to latch, the nurse
may use a manual breast pump or inverted syringe to draw out nipple prior to
initiating latch. After consulting with a lactation team member, consider a nipple
shield to attain latch.
2. Provide a functional assessment of the infant at the breast during a feeding,
utilizing the LATCH tool a minimum of once every shift, to be documented on
infant’s chart.
3. The Lactation Consultant/Educator/mother-baby nurse examines nipples
whenever mother expresses concerns or complaints of sore nipples.
LC/LE/mother-baby nurse to observe/assess the next feeding.
4. When prolonged separation of mother and infant is expected (i.e. premature, ill
infant), help the mother initiate pumping as soon as medically feasible, optimally
within 3 hours and no later than 6 hours after delivery.
5. The colostrum or milk obtained by expression should be collected and made
available to the baby when feedings begin.
6. For mothers experiencing a fetal demise or newborn loss, provide the “Milk
Suppression” handout.
Breast Care/Education
1. Examine mother's breasts and nipples during daily shift assessments. The nurse
can demonstrate breast care by teaching hand expression of colostrum/breast
milk onto the areola after feeds, then allow to air dry. The nurse may provide
breast cream if there are visible signs of redness, cracking or bleeding of the
nipple or if the mother complains of soreness.
2. Encourage exclusive breast feeding for the first 6 months of infant’s life.
3. If the mother insists on supplementing after breastfeeding, recommend limiting
the amount of formula to ½ - 1 oz and to discontinue supplementation once the
milk has come in (approximately day 3-5). Offer alternative feeding methods in
lieu of traditional bottle- feeding and provide the printed handout on “Breast
feeding and Alternative Feeding Choices”.
4. Instruct the mother on pumping techniques using the electric breast pump, when
the infant demonstrates inadequate suckling or if the mother-baby dyad are
separated indefinitely.
5. When pumping is necessary, provide written guidelines to the mother on
pumping, collection bottles, labels and lids for expressed milk. The information
will include resource numbers for rental of a hospital grade electric breast pump
for use after discharge.

6. Instruct all patients regarding infant-led feeding cues-Watch the infant for signs
of readiness to feed such as increased alertness or activity, mouthing or rooting,
rapid eye movement while asleep, and hand-to-mouth movement. Crying is a late
sign of hunger. If feeding cues are not responded to in a timely manner, the
infant may not be cooperative.
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7. Instruct all patients regarding cluster feeding patterns-Frequent feeding, during
periods of increased wakefulness; a series of mini-feedings snacks or courses,
usually followed by a period of deep sleep; normal in the first 3 weeks.
8. Instruct all patients how to manually ex press their milk, in the eve nt a feeding is
delayed, or they are separated from their infant.
9. Instruct all patients in t he use of the feeding log, and to monitor diaper count for
the first week of their infant’s life; evidence of adequate nourishment from the
breast would be sufficient output of urine and stool. Day 1>one urine, one stool;
Day 2>two urine, two stools; Day 3>three urine, two stools; etc.-Day 6 and
beyond>5-6 urine, 4+stools. Instruct mother to contact pediatrician if diaper
count not as described on breastfeeding resource log.
10. Instruct all patients in the “Supply and Dem and” principle of milk production-
The more the infant breastfeeds, the more milk will be produced. During growth
spurts infants nurse more often to stimulate the mother’s milk supply to meet
their new requirements.
11. Educate the mothers who are undecided about breastfeeding on the benefits of
breastfeeding and human milk. Points to include are:
American Academy of Pediatrics recommends exclusive breastfeeding for the
first six months of life.
Breast milk provides optimal composition for brain and eye development,
decreases incidence of diarrhea, upper respiratory infections and some allergies,
promotes bonding and mother/infant closeness, reduces incidence of postpartum
hemorrhage for mother and is economical and convenient.
12. Provide the mother with the postpartum parent educational booklet on self-care,
nutrition, infant care and infant feeding. Encourage the mother to watch the
Newborn Channel to reinforce other teaching provided for infant care and
feeding.
13. Provide all patients with a breastfeeding packet with additional breastfeeding
recommendations including feeding/diaper log and resource numbers for
breastfeeding assistance after discharge
14. Instruct mothers on normal infant weight loss.

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Documentation
1. Document on the infant's chart the attempt to get the infant to breast feed; if
supplementation medically indicated, document rationale in electronic medical
record prior to supplementation.
2. Document the infant's response and the method of feeding used to provide
nourishment to the infant.
3. If the mother insists that the baby be fed in the nursery during the night, requests
a pacifier or bottle supplementation, document in the mother’s electronic medical
record the mother’s request and the education provided as to the impact
separation and/ or use of artificial nipples and/or formula, may have on the
success of breastfeeding
4. Document observed or patient reported LATCH assessment with each feeding
on infant’s chart.

26
ORAL MEDICATION
The most common way people take medications is orally (by mouth). Depending on what your
doctor has prescribed, your oral medication can be swallowed, chewed or placed under your
tongue to dissolve.
Assess
 Allergies.
 Client’s ability to swallow medication.
 Presence of vomiting or diarrhea that would interfere with the ability to absorb the
medication.
 Specific drug action, side effects, interactions, and adverse reaction.
 Client’s knowledge of and learning needs about the medication.
 Perform appropriate assessment specific to the medication.
 Determine if the assessment date influences the administration of the medication.
Assemble equipment and supplies:
 Dispensing system.
 Disposable medication cups: small paper or plastic cups for tablets and capsules, or
waxed or plastic calibrated medication cups for liquids.
 Medication administration record (MAR), or computer printout.
 Pill crusher/cutter.
 Straws to administer medication that might discolor the teeth, or to facilitate the ingestion
of liquid medication for clients.
 Drinking glass and water or juice.
 Applesauce or pudding to use for crushed medication.
Know the reason why the client is receiving the medication, the drug classification,
contradiction, usual dosage range, side effects, and nursing considerations for
administrating and evaluating the intended outcomes for the medication.
Check the MAR
 Check the MAR for the drug name, dosage, and frequency, route of administration, and
expiration, date for administering the medication, if appropriate.
 If the MAR is unclear or pertinent information is missing, compare the MAR with the
most recent primary care provider’s written order.
 Report any discrepancies to the charge nurse or the primary care provider, as agency
policy dictates.

27
Verify the client’s ability to take medication orally.
 Determine whether the client can swallow, is NPO, is nauseated or vomiting, has gastric
suction, or has diminished or absent bowel sounds.
Organized the supplies.
 Assemble the MAR(s) for each client together so that medication can be prepared for
one client at a time.
PROCEDURE
Perform hand hygiene, and observe other appropriate infection control procedures.
Unlock the dispensing system
Obtain appropriate medication
 Read the MAR and take the appropriate medication from the shelf, drawer, or
refrigerator.
 Compare the label of the medication container or unit-dose package with the order on
the MAR or computer printout. If they are not identical, recheck the prescriber’s written
order in the clients chart. If there is still is a discrepancy, check with the nurse in charge,
or with the pharmacist.
 Check the expiration date of the medication. Return expired medication to the pharmacy.
 Use only medications that have clear, legible labels.
Prepare the medication.
 Calculate medication dosage accurately.
 Prepare the correct amount of medication for the required dose, without contaminating
the medication.
 While preparing the medication, recheck each prepared drug and container with the
MAR again.
Tables of Capsules
 Place package unit-dose capsules or tablets directly into the medicine cup. Do not
remove the medication from the wrapper until at the bedside.
 If using a stock container, pour the required number into the bottle cap, the transfer the
medication to the disposable cup without touching the tablets.
 Keep narcotics and medication that require specific assessment-such as pulse
measurements, respiratory rate or depth, or blood pressure-separate from others.
 Break scored tablets only, if necessary to obtain the correct dosage. Use a file or cutting
devise if needed. Check the agency policy as to whether unused portions of a
medication can be discarded and, if so how they are to be discarded.

 If the client has difficulty swallowing, crush the tablets (check to make sure tablets may
be crushed) to a fine powder with a pill crusher, or between two medication cups. Then
mix the powder with a small amount of soft food such as applesauce.
28
Liquid Medication
 Thoroughly mix the medication before pouring. Discard any medication that has changed
color or turned cloudy.
 Remove the cap, and place it upside down on the countertop.
 Hold the bottle so the label is next to your palm, and pour the medication away from the
label.
 Place the medication cup at eye level, and fill it to the desired level, using the bottom of
the meniscus to align with the container scale.
 Before capping the bottle, wipe the lip with paper towel.
 When giving small amounts of liquids (< 5ml), prepare the medication in a syringe
without the needle, or in a specially designed oral syringe. Label the syringe with the
name of the medication and route (PO).
 Keep unit-dose liquids in their packages, and open them at
the bedside.
Oral Narcotics
 If an agency uses a manual recording system for controlled substances, check the
narcotic record for the previous drug count, and compare it with the supply available.
 Remove the next available tablet, and drop it in the medicine cup.
 After removing a tablet, record the necessary information on the appropriate narcotic
control record, and sign it.

29
 Note: Computer-controlled dispensing system allow access only to the selected drug,
and automatically record its use.
All Medication
 Place the prepared medication and MAR together on the medication chart.
 Recheck the label on the container before returning the bottle, box, or envelope to its
storage place.
 Avoid leaving prepared medication unattended.
 Lock the medication cart entering the clients room.
 Check the room number against the MAR if agency policy does not allow the MAR to be
removed from the medication cart.
Provide for client privacy.
Prepare the client.
 Check the client’s identification band.
 Assist the client to sitting position or, if not possible, to a side lying position.
 If not previously assessed, take the required assessment measures such as pulse and
respiratory rates or blood pressure.
Explain the purpose of the medication and how it will help, using language that the client
can understand, Include relevant information about effects.
Administer the medication at the correct time.
 Take the medication to the client within 30 minutes before or after the scheduled time.
 Give the client sufficient water or preferred juice to swallow the medication. Before using
juice, check for any food and medication incompatibilities.
 If the client is unable to hold the pill cup, use it to introduce the medication into the
client’s mouth, and give only one tablet or capsule at a time.
 If an older child or adult ha difficulty swallowing, and ask the client to place the
medication on the back of the tongue before taking the water.
 If the medication has an objectionable taste, ask the patients to suck a few ice chips
beforehand, or give the medication with juice, applesauce, or bread, if there are no
contraindications.
 If the client says that the medication you are about to give is different from what the
client has been receiving, do not give the medication without first checking the original
order.
 Stay with the client until all medications have been swallowed.

30
Document each medication given.
 Record the medication given, dosage, time, any complaints or assessment of the client,
and your signature
 If medication was refused or omitted, record this fact on the appropriate record;
document the reason, when possible, and the nurse’s actions, according to agency
policy.
Dispose of all supplies appropriately.
 Replenish stock, and return the cart to the appropriate place.
 Discard used disposable supplies.
Evaluate the effects of the medication.
 Return to the client when the medication is expected to take effect to evaluate the effects
of the medication on the client.

31
Subcutaneous Injection
Where can I give a subcutaneous injection?
The following are sites where you can give a subcutaneous injection:
 Abdomen: Uncover your abdomen. You may give an injection within the
following area: below the waist to just above the hip bone and from the side to about
2 inches from the belly button. Avoid the belly button.
 Thigh: Uncover the entire leg. Find the area halfway between the knee and hip
and slightly to the side. Gently grasp the area to make sure you can pinch 1 to 2
inches of skin.
 Upper Arm: Uncover the arm to the shoulder. Have the person getting the
injection stand with his hand on his hip. Stand next to and a little behind the person.
Find the area halfway between the elbow and shoulder. Gently grasp the skin at the
back of the arm between your thumb and first 2 fingers. You should be able to grasp
1 to 2 inches of skin

32
Materials needed
Syringe with the drug to be administered (without air), needle (Gauss 25, short and thin;
on syringe), liquid disinfectant, cotton wool, adhesive tape.
Technique
1. Wash hands.
2. Reassure the patient and explain the procedure.
3. Uncover the area to be injected (upper arm, upper leg, abdomen).
4. Disinfect skin.
5. ‘Pinch’ fold of the skin.
6. Insert needle in the base of the skin-fold at an angle of 20 to 30 degrees.
7. Release skin.
8. Aspirate briefly; if blood appears: withdraw needle, replace it with a new one, if
possible, and start again from point 4.
9. Inject slowly (0.5 - 2 minutes!).
10. Withdraw needle quickly.
11. Press sterile cotton wool onto the opening. Fix with adhesive tape.
12. Check the patient's reaction and give additional reassurance, if necessary.
13. Clean up; dispose of waste safely; wash hands.

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INTRAMUSCULAR INJECTION
Safe areas to give an IM injection:
 Vastus Lateralis Muscle (Thigh): Look at your thigh and divide it into 3 equal
parts. The middle third is where the injection will go. The thigh is a good place to
give yourself an injection because it is easy to see. It is also a good spot for children
younger than 3 years old.
 Ventrogluteal Muscle (Hip): Have the person getting the injection lie on his or her
side. To find the correct location, place the heel of your hand on the upper, outer
part of the thigh where it meets the buttocks. Point your thumb at the groin and your
fingers toward the person's head. Form a V with your fingers by separating your first
finger from the other 3 fingers. You will feel the edge of a bone along the tips of your
little and ring fingers. The place to give the injection is in the middle of the V. The hip
is a good place for an injection for adults and children older than 7 months.

 Deltoid Muscle (Upper arm muscle): Completely expose the upper arm. You will
give the injection in the center of an upside down triangle. Feel for the bone that
goes across the top of the upper arm. This bone is called the acromion process. The
bottom of it will form the base of the triangle. The point of the triangle is directly
below the middle of the base at about the level of the armpit. The correct area to
give an injection is in the center of the triangle, 1 to 2 inches below the acromion
process.
 Dorsogluteal Muscle (buttocks): Expose one side of the buttocks. With an alcohol
wipe draw a line from the top of the crack between the buttocks to the side of the
body. Find the middle of that line and go up 3 inches. From that point, draw another
line down and across the first line, ending about halfway down the buttock. You
should have drawn a cross. In the upper outer square you will feel a curved bone.
The injection will go in the upper outer square below the curved bone. Do not use
this site for infants or children younger than 3 years old. Their muscles are not
developed enough.
34

35
PROCEDURE:
Wash your hands with soap and dry them completely. Put on gloves if necessary.
 Open the alcohol wipe: Wipe the area where you plan to give the injection. Let the
area dry. Do not touch this area until you give the injection.
 Prepare the needle: Hold the syringe with your writing hand and pull the cover off
with your other hand. Place the syringe between your thumb and first finger. Let the
barrel of the syringe rest on your second finger.
 Hold the skin around where you will give the injection: With your free hand,
gently press on and pull the skin so that it is slightly tight.
 Insert the needle into the muscle: Hold the syringe barrel tightly and use your
wrist to inject the needle through the skin and into the muscle at a 90 degree angle.
 Check the needle: Let go of the skin with your other hand. Hold the syringe so it
stays pointed straight in. Pull back on the plunger a little to make sure you did not hit
a blood vessel. If blood comes back, remove the needle immediately. Do not inject
the medicine. Dispose of both the syringe and the medicine. Get more medicine in a
new syringe. When you give the second injection, give it on the other side.
 Inject the medicine: Push down on the plunger to inject the medicine. Do not force
the medicine by pushing hard. Some medicines hurt. You can inject the medicine
slowly to reduce the pain.
 Remove the needle: Once the medicine is injected, remove the needle at the same
angle as it went in. Place gauze over the area where you gave the injection.

36
ADMINISTERING INTRADERMAL INJECTIONS
GENERAL
a. An intradermal (ID) injection is the injection of a small amount of fluid into the dermal
layer of the skin (see figure 2-10). It is frequently done as a diagnostic measure, such
as for tuberculin testing (screening test for tuberculosis referred to as a tine test) and
allergy testing (placing very small amounts of the suspected antigen or allergen in a
solution under the skin). The intradermal injection is made in skin areas of the body that
are soft and yielding.
b. Often the tuberculin syringe is the only syringe with fine enough calibrations to
measure the minute dose that is used. A 26-gauge needle, which is one-fourth to one-half
inch in length, is usually selected. The fluid is in a small welt or "wheal" (a small
swelling of the skin due to the medication placed under the skin) just under the surface
of the skin and between its layers.

37
PROCEDURE FOR ADMINISTERING AN INTRADERMAL INJECTION
Select Injection Site and Prepare Patient.
1. Selecting site. Usually palmer (inner) forearm or subscapular region of the back is
selected. The site selected should be an easily obtainable area and relatively free from
being rubbed by clothing.
2. Position patient. To position the patient, proceed as follows:
(a) Place arm in a relaxed position, elbow flexed.
(b) Place palm up, exposing palmer or inner arm area.
c. Prepare Injection Site
d. Remove Needle Guard. Pull the guard straight off.
e. Stabilize Injection Site.
1. Using your nondominant thumb, apply downward pressure, directly below and
outside the prepared injection site. (Do not draw the skin back or move the skin to the
side because the skin will return to its normal position when pressure is released and
will cause the needle bevel to either go deeper into the skin or to leave the skin,
depending upon which direction the skin moves.)
2Hold the skin taut until the needle bevel has been inserted between the skin layers.
f. Insert Needle.
1. Using your dominant hand, hold syringe, bevel up, with fingers and thumb resting on
the sides of the barrel. If you insert the needle at a 20 degree angle, lower it at once to
15 degrees. Do not place thumb or fingers under syringe because this will cause the
angle of insertion to exceed 15 degrees causing the needle to insert beyond the dermis.
2.Insert needle, bevel up, just under the skin at an angle of 15 to 20 degrees until the
bevel is covered. Continue stabilizing thumb pressure. You should feel some resistance.
If the needle tip moves freely, you have inserted the needle too deeply. At this point,
withdraw needle slightly and check again for resistance.

g. Inject Medication. It is not necessary to aspirate the syringe since no large vessels
are commonly found in the superficial layer of the skin. Inject the medication as follows:
38
1. Continue holding syringe with same hand.
2. Release skin tension with other hand.
3. With free hand, push plunger slowly forward until the medication is injected and a
wheal appears at the site of the injection. The appearance of a wheal indicates that the

medication has entered the area between the intradermal tissues. If a wheal does not
appear, withdraw the needle and repeat the procedure in another site.
h. Withdraw Needle. To withdraw the needle, quickly withdraw it at the same angle that
it was inserted.
i. Cover Injection Site. Without applying pressure, quickly cover injection site with a dry
sterile small gauze.
39
j. Perform Post injection Patient Care.
k. Evaluate Reaction of Medication. Usually you, as the medical specialist, will not
evaluate the reaction of a suspected allergic reaction or a tuberculin test, but will record
the reaction. For a tuberculin test, the patient will wait 48 to 72 hours and then return to
have an evaluation to determine if the patient has been exposed to tuberculosis. If the
intradermal injection is done to determine if the patient is allergic to dust, pollen, or
similar substances, a reaction will take place in a few minutes after the substance has
been placed under the skin.
(1) Instruct the patient to wait or return to have the test read according to local SOP.
(2) Caution patient not to rub, scratch, or wash injection site. Rubbing, scratching, or
washing may spread or dilute the medication, causing a false reading at a later time.
l. Dispose of Equipment. Dispose of equipment according to local SOP.
m. Record Administration of Intradermal Injection. Record the injection information on
the patient's chart or record.

40
Stages of labor
First stage: Cervical Dilatation Stage
-begins with the onset of regular contractions.
Phases of labor:
Latent phase: dilation of cervix to3 to 4 cm. contraction become increasing
Active phase: dilation continues from 3 to 4 cm to 7 cm. Contraction become stronger
and painful
Transition phase: cervix dilates from 8 to 10 cm
What happen during the first stage of labor?
Cervical dilatation and effacement
Causes of cervical dilatation
Contraction and retraction of the cervical dilation of uterine musculature
Mechanical pressure by the bulging membrane(forewater)
The descend of the presenting part
Phases of cervical dilatation
Latent phase- the first 3cm dilatation; a slow process(8 hours in nulliparous and 3 hours
in multiparous)
Active phase - this is active process of cervical dilatation; the normal rate is 1cm/hour
Latent phase Active phase
Begins with onset of contraction
Slow progress.
Little cervical dilatation
Progressive cervical effacement
Ends once the cervix reaches 3cm
dilatation
Duration
- 8 hours nulliparous
- 6 hours multiparous
Active process
Begins after 3 cm cervical dilatation
Period of active cervical
dilatation(average rate 1cm/hour)
S-shaped curved which is usedto
defined the progress of labor
It has three components
A. Acceleration - slow
B. Maximum- fast
C. Deceleration- slow

41
Contraction: is the power of labor
Type of contraction:
Regular
Increasing in frequency
Irregular
Second stage. (expulsive stage)
begins with complete dilatation of the cervix and ends with delivery of the newborn.
-it should be complete within one hour after complete dilatation.
Two phases of expulsive stage
Propulsive phase- from full dilatation until presenting part has descended to the pelvic
floor.
Expulsive phase- which end in the complete delivery of the baby.
Features of expulsive phase:
Mothers irresistible desire to bear down
Distension of the perinium.
Dilatation of the anus.
Average length:
Nulliparous: 40 minutes
Multiparous: 20 minutes
Mechanism of labor
 Descent
 Flexion
 Internal rotaion
 Extension
 Internal rotation
 Expulsion
”crowning” occurs when the newborns head or presenting part appears at the vaginal
opening.
-”Episiotomy” surgical incision in the perineum-may be done to facilitate delivery and
avoid laceration of the perineum.
Progress of second stage of labor
Finding suggestive of satisfactory progress of second stage of labor are:
- steady descent of fetus
- onset of expulsive(pushing phase)
Findings suggestive of unsatisfactory progress in the second stage of labor are:
- lack of descent of fetus through the birth canal

42
- failure of expulsion during the late (expulsive) phase.
Third stage (placental stage)
-This stage begins with delivery of the newborn and ends with delivery of placenta.
-It occurs in two phases –placental separation and placental expulsion.
Two phases:
Separation phase
Expulsion phase
Duration: 15-20 minutes for separation
Average blood loss: 150ml to 250 ml
Fourth stage: Postpartum
-It lasts from 1 to 4 hours after birth.
-the mother and the newborn recover from physical process of labor.
-systems readjustment.
Newborn body systems begins to adjust to extrauterine life.
PHYSIOLOGICAL MATERNAL CHANGES
LOCHIA – discharge from the uterus during the first 3 weeks after delivery.
Increasing Lochia as the day passes by may indicate Heparin Intoxication.
LOCHIAL CHANGES
LOCHIA RUBRA
-Dark red discharge occurring in the first 2-3 days.
-Contains epithelial cells, erythrocytes and decidua.
-Characteristic human odor.
LOCHIA SEROSA
-Pinkish to brownish discharge occurring 3-10 days after delivery.
-Serosanguineous discharge containing decidua, erythrocytes, leukocytes, cervical
mucus and microorganisms.
-Has a strong odor.
LOCHIA ALBA
-Almost colorless to creamy yellowish discharge occurring from 10 days to 3 weeks
after delivery.

-Contains leukocytes, decidua,epithelial cells, fat, cervical mucus, cholesterol crystals,
and bacteria.
-Has no odor.
B. UTERUS
-Process of involution takes 4-6 weeks to complete.
-Weight decreases from 2 lbs to 2 oz.
-Fundus steadily descends into true pelvis; Fundal height decreases about 1
fingerbreadth (1 cm)/day; by
-10-14 days postpartum, cannot be palpated abdominally.
43
Uterine Involution
Description
a. The rapid decrease in the size of the uterus as it returns to the nonpregnant state
b. Clients who breastfeed may experience a more rapid involution
Assessment
a. Weight of the uterus decreases from 2 pounds
to 2 ounces in 6 week
b. Endometrium regenerates
c. Fundus steadily descends into the pelvis
d. Fundal height decreases about 1 fingerbreadth (1 cm) per day
e. By 10 days postpartum, uterus cannot be palpated abdominally

44
ENEMA
It is an introduction of a solution into the large intestine, generally for the purpose of
removing feces. The instilled solution distends the intestine, may irritate intestinal
mucosa, thus increases peristalsis.
Types of Enema:
1. Cleansing Enema – given to remove feces from the colon.
Purposes:
 To relieve constipation or fecal impaction.
 To prevent involuntary escape of fecal material during surgical
procedures.
 To promote visualization of the intestinal tract by x-ray film or instrument
examination.
 To help establish regular bowel function during a bowel training program.
2. Retention Enema – retained in the bowel for a prolonged period for different
reasons.
3. Retention Flow Enemas – or Harris Flush enemas are used to expel flatus.
Types of Solutions:
Solution Amount Action Time to take
effect
Adverse Side
Effect

45
Tap Water
(Hypotonic)
500-1000 ml Distends
intestine,
increases
peristalsis,
softens stool
15 min. Fluid and
Electrolyte
imbalance,
water
intoxication
Normal Saline
(Isotonic)
500-1000 ml Distends
intestine,
increases
peristalsis,
softens stool
15 min. Fluid and
Electrolyte
imbalance,
sodium
retention
Soap Solution 500-1000 ml
(concentrate at
3ml-5ml/
1000ml)
Distends
intestine,
irritates
intestinal
mucosa,
softens stool
10-15 min. Rectal mucosa
irritation or
damage
Hypertonic
solutions
70ml – 130ml Distends
intestine,
irritates
intestinal
mucosa
5-10 min. Sodium
retention
Oil solutions
(mineral, olive,
or cottonseed
oil)
150-200ml Lubricate stool
and intestinal
mucosa
30min.
Equipments:
- enema can
- kelly forcep
- IV pole
- solution
- KY jelly
- rectal tube
- gloves
- hose
Procedure:
Nursing action Rationale
1. Inform the client about the procedure To promote cooperation
2. Assemble articles For efficiency
3. If using an enema bag, fill it with 750-
1000 ml warm tap water
Hot water can burn intestinal mucosa, cold
water can cause abdominal cramping
4. Clamp tubing To keep solution intact

46
5. Place waterproof pad absorbent To prevent soiling
6. Assist client into the left side lying with
knee flexed
Allows enema solution to flow downward
by gravity
7. Cover client with bath blanket exposing
only rectal area
Provide warmth, allows client to feel more
relaxed
8. Lubricate 3-4 inches tip of rectal tube Provides smooth insertion without irritation
and trauma
9. Gently separate buttocks and locate
anus
For accurate exposure
10. Instruct client to relax It promotes relaxation of external anal
sphincter
11. Insert tip of rectal tube 3-4 inches Careful insertion prevents trauma to rectal
mucosa
12. Hold tubing in rectum constantly until
end of instillation
/ Bowel contraction can cause expulsion of
tube
13. With container at client's hip level,
open regulating clamp and allow solution
to enter slowly
Rapid infusion can stimulate evacuation
and cause cramping
14. Raise height of enema bag slowly to
30-45cm (12-18 inches)
Raising container too high causes rapid
infusion and possible painful distention of
colon
15. Hang container on IV pole
16. Clamp tubing if client complains of
cramping
Temporary cessation minimizes cramping
17. Tell client that the procedure is
completed and that you will be removing
rectal tube
Client may misinterpret the sensation of
removing the tube as a loss of control
18. Explain feeling of distention is normal.
Tell client to retain 5-10 minutes
Solution distend bowel. Longer retention
promotes more effective stimulation.
19. Assist to bathroom
20. Instuct client with a history of
cardiovascular disease to exhale while
expelling enema to avoid valsalva
maneuver
Valsalva maneuver- strenuously trying to
move a constipated stool and may result in
cardiac arrest
21. Assist client to wash anal area with
wearm soap and water
Fecal content can irritate the skin. Hygiene
promotes comfort.
22. Do after care
Characteristics of a Good Recording:
1. Accuracy
2. Conciseness
3. Thoroughness
4. Currentness

47
ESSENTIAL NEWBORN CARE
Before you look at the eight steps of essential newborn care (ENC) you need to
remember the importance of the ‘three cleans’ that you learned in Study Session 3 of
the Labour and Delivery Care Module. These are clean hands, clean surface and clean
equipment. Your equipment should include two clean dry towels, cord clamps, razor
blade, cord tie, functional resuscitation equipment, vitamin K, syringe and needles, and
tetracycline eye ointment.
Figure 2.1 Drying and wrapping the newborn baby.
Step 1 Deliver the baby onto the mother’s
abdomen or a dry warm surface close to the
mother.
Continue to support and reassure the mother.
Tell her the sex of the baby and congratulate
her.
Step 2 Dry the baby’s body with a dry warm
towel as you try to stimulate breathing. Wrap the
baby with another dry warm cloth and cover the
head (Figure 2.1).
Dry the baby well, including the head,
immediately and then discard the wet cloth.
Wipe the baby’s eyes. Rub up and down the
baby’s back, using a clean, warm cloth. Drying
often provides sufficient stimulation for breathing to start in mildly depressed newborn
babies. Do your best not to remove the vernix (the creamy, white substance which may
be on the skin) as it protects the skin and may help prevent infection. Then wrap the
baby with another dry cloth and cover the head.
Step 3 Assess breathing and colour; if not breathing, gasping or there are less than 30
breaths per minute, then resuscitate.
You will remember that you learned how to manage a newborn baby with birth asphyxia
in Study Session 7 of the Labour and Delivery Care Module.
As you dry the baby, assess its breathing. If a baby is breathing normally, both sides of
the chest will rise and fall equally at around 30–60 times per minute. Thus, check if the
baby is:
 Breathing normally
 Having trouble breathing
 Breathing less than 30 breaths per minute, or

48
 Not breathing at all.
Resuscitation of a baby who is not breathing must start within one minute of birth.
If the baby needs resuscitation, quickly clamp or tie and cut the cord, leaving a stump at
least 10 cm long for now and then start resuscitation
immediately. Functional resuscitation equipment
should always be ready and close to the delivery area
since you must start resuscitation within one minute of
birth. It may sound as if you have a lot to do in one
minute, but the steps described here are ones that you
can take simultaneously. That is, while you are
delivering the baby onto the mother’s abdomen and
drying the baby, you can assess breathing and colour
and take urgent action if necessary.
Figure 2.2 Tying and cutting the cord.
Step 4 Tie the cord two fingers’ length from the baby’s
abdomen and make another tie two fingers from the
first one (Figure 2.2). Cut the cord between the first
and second tie. If the baby needs resuscitation, cut the
cord immediately. If not, wait for 7–3 minutes before
cutting the cord.
1. Tie the cord securely in two places:
o Tie the first one two fingers away from the
baby’s abdomen.
o Tie the second one four fingers away from
the baby’s abdomen.
o Make sure that tie is well secured; the thread you use to tie the cord must be
clean.
2. Cut the cord between the ties:
o Use a new razor blade, or a boiled one if it has been used before, or sterile
scissors.
o Use a small piece of cloth or gauze to cover the part of the cord you are
cutting so no blood splashes on you or on others.
o Be careful not to cut or injure the baby. Either cut away from the baby or
place your hand between the cutting instrument and the baby.
3. Do not put anything on the cord stump.

Step 5 Place the baby in skin-to-skin contact with the mother, cover with a warm
cloth and initiate breastfeeding.
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The newborn loses heat in four ways (see Figure 2.3 below):
 Evaporation: when amniotic fluid evaporates from the skin.
 Conduction: when the baby is placed naked on a cooler surface, such as the floor,
table, weighing scales, cold bed.
 Convection: when the baby is exposed to cool surrounding air or to a draught from
open doors and windows or a fan.
 Radiation: when the baby is near cool objects, walls, tables, cabinets, without
actually being in contact with them.
Figure 2.3 The newborn can lose heat in four ways. (Source: WHO, 1997, Safe
Motherhood: Thermal Protection of the Newborn, a Practical Guide
The warmth of the mother passes easily to the baby and helps stabilise the baby’s
temperature.
1. Put the baby on the mother’s chest, between the breasts, for skin-to-skin warmth.
2. Cover both mother and baby together with a warm cloth or blanket.
3. Cover the baby’s head.
The first skin-to-skin contact should last uninterrupted for at least one hour after birth or
until after the first breastfeed. The baby should not be bathed at birth because a bath
can cool the baby dangerously. After 24 hours, the baby can have the first sponge bath,
if the temperature is stabilized.

50
Figure 2.4 Initiating immediate breastfeeding.
If everything is normal, the mother should
immediately start breastfeeding.
For optimal breastfeeding you should do the
following:
1. Help the mother begin breastfeeding within the
first hour of birth (Figure 2.4).
2. Help the mother at the first feed. Make sure the
baby has a good position, attachment, and is
sucking well. Do not limit the length of time the
baby feeds; early and unlimited breastfeeding
gives the newborn energy to stay warm,
nutrition to grow, and antibodies to fight
infection.
The steps to keep the newborn warm are called the
warm chain.
1. Warm the delivery room.
2. Immediate drying.
3. Skin-to-skin contact at birth.
4. Breastfeeding.
5. Bathing and weighing postponed.
6. Appropriate clothing/bedding.
7. Mother and baby together.
8. Warm transportation for a baby that needs referral.
Step 6 Give eye care (while the baby is held by its
mother).
Figure 2.5 Putting tetracycline eye ointment into the eyes
of the newborn baby.
Shortly after breastfeeding and within one hour of being
born, give the newborn eye care with an antimicrobial
medication. Eye care protects the baby from serious eye
infection which can result in blindness or even death.
The steps for giving the baby eye care are these:
First, wash your hands, and then using tetracycline 1% eye
ointment:

1. Hold one eye open and apply a rice grain size of ointment along the inside of the
lower eyelid. Make sure not to let the medicine dropper or tube touch the baby’s
eye or anything else (see Figure 2.5).
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2. Repeat this step to put medication into the other eye.
3. Do not rinse out the eye medication.
4. Wash your hands again.
Step 7 Give the baby vitamin K, 1 mg by intramuscular injection (IM) on the
outside of the upper thigh (while the baby is held by its mother).
After following correct infection prevention steps, with the other hand stretch the
skin on either side of the injection site and place the needle straight into the outside of
the baby’s upper thigh (perpendicular to the skin). Then press the plunger to inject the
medicine. You will be learning more about safe injection techniques in your practical
skills training sessions. There is also a study session on routes of injection in
the Immunization Module.
Step 8 Weigh the baby.
Weigh the baby an hour after birth or after the first breastfeed. If the baby weighs
less than 1,500 gm you must refer the mother and baby urgently.

52
INTRAPARTUM CARE
1. Examine the woman for emergency signs.
 Unconscious, Convulsing
 Vomiting
 Severe headache with blurring of vision
 Vaginal bleeding
 Severe abdominal pain
 Looks very ill
 Fever
 Severe breathing difficulty
Do NOT make a very sick woman wait, attend to her quickly!
2. Greet the woman and make her comfortable.
 Ask for informed consent before examination or any procedure
 Respect privacy
 Communicate result of examination
3. Assess the woman in labor.
 Take the history of labor and record on the labor form.
 Review Home Based Maternal Record (HBMR)/ Mother and Child Book
 When is delivery expected? Preterm or term?
 Prior pregnancies
 Birth plan
 Assess uterine contractions: intensity, duration, and interval
 Observe the woman’s response to contractions.
 Perform abdominal exam: (Leopold’s maneuver, FHT) between
contractions

53
4) Determine the stage of labor.
Explain to the woman that you will perform a vaginal examination and ask for her
consent.
 Respect privacy
 Observe standard precautions
 Inspect the vulva for:
 Bulging perineum
 Any visible fetal parts
 Vaginal bleeding
 Leaking amniotic fluid; if yes, is it meconium stained, foul smelling?
 Warts, keloid tissue or scars that may interfere with delivery
 Perform gentle vaginal examination (do not start during contraction).
 Explain findings to the woman. Reassure her.
 RECORD findings in labor record or in partograph.
 Determining Stage of Labor
 Determining Stage of Labor
5. Decide if the woman can safely deliver. If there is indication for referral …
 in early labor and the referral hospital can be timely reached:
 Refer urgently
 in late active labor:
 Monitor progress of labor and deliver the baby
 Prepare for immediate referral if still necessary
 If the woman or her family refuses referral

54
 Explain the possible consequences
6. Give supportive care throughout labor.
7. Monitor and manage labor.
 First stage: not yet in active labor, cervix is dilated 0-3 cm., contractions are
weak, <2 in 10 minutes
 Every hour: check for emergency signs, frequency, intensity & duration of
contractions, FHR, mood and behavior.
 Every 4 hours: check vital signs and cervical dilatation.
 Record findings in Labor record
 Assess progress of labor: After 8 hrs, if contractions are stronger & more
frequent but no progress in cervical dilatation: REFER
 First stage: in active labor, cervix is dilated at 4 cm or more
 Check every 30 mins for emergency signs, frequency and duration of
contractions, FHR, mood and behavior.
 Check every 4 hours: fever, PR, BP, cervical dilatation.
 Record time of rupture of membranes and color of the amniotic fluid.
 Record findings in partograph.
 RELIEF of PAIN and DISCOMFORT
 Suggest change of position
 Encourage mobility as comfortable for her
 Encourage proper breathing: breath more slowly, make a sighing noise, make 2
short breaths followed by a long breath out.
 Massage her lower back if she finds it helpful
 CAUTION
 DO NOT do IE more frequently than every 4 hours unless necessary.
 DO NOT allow the woman to push unless delivery is imminent → pushing does
not speed up labor, mother will become tired, cervix will swell.

 DO NOT give medications to speed up labor → DANGEROUS: may cause
55
trauma to the mother and baby (ex: Uterine rupture)
 DO NOT DO FUNDAL PRESSURE-may
cause uterine rupture, fetal death
Second stage: from full dilatation (10cm) of the cervix until birth of baby.
How to tell if a woman is in the 2nd stage:
 On IE, cervix is fully dilated
 Woman wants to bear down
 Strong uterine contractions every 2-3 minutes
 Bulging thin perinium fetal head visible during
contractions.
 BOW will rupture
 Monitoring the 2nd stage
 Check uterine contractions, fetal heart rate, mood and behavior
 Continue recording in the partograph
REMINDER:
1. Massaging or stretching the perineum have not been shown to be
beneficial.
2. DO NOT apply fundal pressure to help deliver the baby → may harm
mother and baby.
8. Deliver the Baby
Implement the 3 CLEANS
1. Clean hands
2. Clean delivery surface
3. Clean cutting and care of the cord
WEAR DOUBLE GLOVES

56
 Stay with the woman and encourage her. Make her comfortable.
 Check fetal heart tones every 15 minutes
 Deliver the Baby
When the birth opening is stretching, support the perineum and anus with a clean
swab to prevent lacerations
 Ensure controlled delivery of the head
 Controlled delivery of the head
 Keep one hand on the head as it advances during contractions. Keep the head
from coming out too quickly.
 Support the perineum with other hand.
 Controlled delivery of the head, cont’d . .
 Discard pad and replace when soiled to prevent infection.
 During delivery of the head, encourage woman to stop pushing and breathe
rapidly with mouth open.
Delivering the Baby
 Gently feel if the cord is around the neck
 If it is loosely around the neck, slip it over the shoulders or head
 If it is tight, place a finger under the cord, clamp and cut the cord, and
unwind it from around the neck.
 Delivering the Baby
 Gently wipe the baby’s nose and mouth with a clean gauze or cloth.
 Wait for external rotation (within 1-2 min), head will turn sideways bringing one
shoulder just below the symphysis pubis and other facing the perineum
 Delivering the baby
1. Put baby on mother’s abdomen in prone position. Cover with dry towel.
2. Thoroughly dry the baby immediately. Wipe eyes.
3. Discard wet cloth.

4. Put baby prone, in skin-to-skin contact on mother’s abdomen,. Keep the baby
57
warm.
5. Exclude 2nd baby by palpating mother’s abdomen.
6. Give 10 IU oxytocin IM to the mother.
active management of the 3rd stage of labor.)*
*May be done by the midwife under supervision of doctor.
7. Watch for vaginal bleeding.
8. Remove first set of gloves.
9. When no more cord pulsation is felt on the cord (usually within 3 mins.)
clamp the cord 2cm from the base using sterile plastic cord clamp
10. Sweep the cord and apply a second Kelly forceps 5cm from the base and then
cut in-between.
Third Stage: Between birth of the baby and delivery of the placenta
11. Deliver the placenta by controlled cord traction (with counter traction on the
uterus above the symphysis pubis).
12. Massage uterus over the fundus.
13. Inject oxytocin.
(if not yet given as part of active management)
14. Encourage initiation of breastfeeding. Let baby stay on mother’s abdomen for
60-90 min
Third stage: between birth of the baby and delivery of the placenta.
ACTIVE MANAGEMENTof the third stage of labor
 Cord is clamped
 Oxytocin is given within 2 min of delivery of the baby
 Placenta is delivered by controlled cord traction with countertraction above the
symphysis pubis.
 Massage fundus.

58
May only be done by a midwife under supervision of doctor.
9. Monitor closely within 1-hour after delivery (Immediate postpartum period) and give
supportive care.
 Check for vaginal tears and bleeding.
 Clean the woman and make her comfortable.
 Check BP, PR, emergency signs & uterine contraction every 15 minutes.
 Initiate breastfeeding within 1-hour when the baby is ready.
10. Continue care after 1 hour postpartum. Keep watch closely for at least 2 hours.
 Temperature, BP and pulse every 30 minutes
 Check at 2, 3 and 4 hours, then every 4 hours:
 emergency signs
 uterine contraction
 Check for bladder distension if unable to void.
 Advise clean cloth/napkin to collect vaginal blood.
 Eat and drink high-energy food that are easily digestible.
Companion: to watch her and to call you for bleeding or pain, dizzy or for any other
problem
 Keep the baby in the room with the mother, in her bed or within easy reach.
 Support exclusive breastfeeding on demand, day and night, as often and as long
as the baby wants.
 Immunize according to the EPI schedule.
 Mother and companion to watch the baby:
 breastfeeding difficulty
 difficulty of breathing
 cold feet
 bleeding from the cord

59
 Check baby at around 4 and 8 hours and then daily:
 cold feet, breastfeeding and breathing difficulty.
 Advise postpartum care and hygiene.
 Wash from waist down or have a sponge bath or a shower with warm
water each morning or when she feels like it.
 Use guava leaves decoction if woman prefers, for her wash or bath.
Continue care after 1 hour postpartum.
Medications
 Iron 60 mg/ Folic acid 400ug 1 tablet daily… until 3 months postpartum
 Vitamin A 200, 000 IU, 1 capsule after delivery or within 1 month
postpartum
11. Educate and counsel on family planning and provide the family planning method if
available.
 Ask what are the couple’s plans regarding having more children.
 Give relevant information and advice.
 Advice that exclusive breastfeeding is the best contraceptive in the 1st six
months.
 Help her to choose the most appropriate method for her and her partner.
12. Inform, teach and counsel the woman on important MCH messages.
 Talk to the woman when she is rested and comfortable.
 Also give important information and advice to her companion.
13. Discharge the woman and her baby.
 The woman and her baby may be discharged 24 hours after delivery.
 Ensure that the woman is able to breastfeed successfully before discharge.
 Repeat important health information.
 Check understanding and arrange follow-up.

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POSTPARTUM NURSING INTERVENTIONS
Monitor Vital Signs
 NOTE: Maternal temperature during the first 24 hours following delivery may rise
to 100. 4` F (38`C) as a result of dehydration. The nurse can reassure the new
mother that these symptoms are normal.
 Postpartum Exercise
 Supine Position with the knee’s flexed, and then inhale deeply while allowing the
abdomen to expand and exhale while contracting the abdominal muscles. The
purpose of this exercise is to strengthen the abdominal muscles. Examples are
reaching for the knees; push ups and sits ups on the first postpartum day.
 Assess height, consistency, and location of the fundus
 Monitor color, amount, and odor of lochia
 Assess lochia and color volume
 Give RhoGAM to mother if ordered. RhoGAM promotes lysis of fetal Rh (+)
RBCs. Administer RhoGam as prescribed within 72 hours postpartum to
the Rh-negative client who has given birth to an Rh-positive neonate.
Rhogam (D) immune globulin is given by intramuscular injection
 Check episiotomy and perineum for signs of infection.
 Promote successful feeding.
 Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast
stimulation.
 Nursing woman- success depends on infant sucking and maternal
production of milk.
 “Postpartum Blues” (3-7 days) – Normal occurrence of “roller coaster”
emotions
 Sexual activities- abstain from intercourse until episiotomy is healed and
lochia ceased around 3-4 weeks. Remind that Assess height, consistency, and
location of the fundus breastfeeding does not give adequate protection.
 Assess breasts for engorgement
 Monitor episiotomy for healing ( assess dehiscence & evisceration)

61
 Assess incisions or dressings of cesarean birth client ( prone to infection)
 Monitor bowel status ( prone to constipation)
 Monitor I &0
 Encourage frequent voiding (prevent urinary retention which will predispose the
mother to uterus displacement & infection)
 Encourage ambulation ( to prevent thromboplebitis & paralytic ileus
 Assess bonding with the newborn infant ( to prevent failure to thrive)
NOTE:
 A positive bonding experience is indicated when the mother turns her face
toward the baby to initiate eye-to-eye contact. Observation of new mothers has
shown that a fairly regular pattern of maternal behaviors is exhibited at first
contact with the newborn. The mother follows a progression of touching activities
from fingertip exploration toward palmar contact to enfolding the infant with the
whole hand and arm. The mother also increase the time spent in the en face
position. The mother arranges herself or the newborn so that her face and eyes
are in the same plane as in her infant.
 III. POSTPARTUM DISCOMFORTS
A. Perineal discomfort
 Apply ice packs to the perineum during the first 24 hours to reduce swelling after
the first 24 hours, apply warmth by sitz baths
B. Episiotomy
 1. Instruct the client to administer perineal care after each voiding
 2. Encourage the use of an analgesic spray as prescribed
 3. Administer analgesics as prescribed if comfort measures are unsuccessful
 C. Breast discomfort
PREVENTION:
The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND
FREQUENTLY WITH FEEDINGS. The 2nd is EXPRESSING A LITTLE MILK BEFORE

NURSING, MASSAGING THE BREASTS GENTLY OR TAKING A WARM SHOWER
BEFORE FEEDING MAY HELP TO IMPROVE MILK FLOW.
Placing as much of the areola as possible into the neonate’s mouth is one method.
Other methods include changing position with each nursing so that different areas of the
nipples receive the greatest stress from nursing and avoiding breast engorgement,
which make I difficult for the neonate to grasp. In addition, nursing more frequently, so
that a ravenous neonate is not sucking vigorously at the beginning of the feedings, AND
FEEDING ON DEMAND to prevent over hunger is helpful. AIRDRYING THE NIPPLES
AND EXPOSING THEM TO THE LIGHT HAVE ALSO BEEN RECOMMENDED. Warm
Tea bags, which contain tannic acid also, will sooth soreness. WEARING A
SUPPORTIVE BRASSIERE DOES NOT PREVENT BREAST ENGORGEMENT.
APPLYING ICE and LANOLIN DOES NOT RELIEVE BREAST ENGORGEMENT.
INTERVENTION: Measures that help relieve nipple soreness in a breast-feeding client
include lubricating the nipples with a few drops of expressed milk before feedings,
applying ice compresses just before feedings, letting the nipples air dry after feedings,
and avoiding the use of soap on the nipples.
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NOTE: Specific nursing care for breast Engorgement
 Breastfeed frequently
 Apply warm packs before feeding
 Apply ice packs between feedings
NOTE: Specific Nursing Care for Cracked nipples
 Expose nipples to air for 10 to 20 minutes after feeding
 Rotate the position of the baby for each feeding
 Be sure that the baby is latched on to the areola, not just the nipple
NOTE: Do not use soap on the breasts, as it tends to remove natural oils, which
increases the chance of cracked nipples
 IV. POST PARTUM COMPLICATIONS
A. HEMORRHAGE
B. THROMBOPLEBITIS
Inflammation of the vein caused by a clot
The positive Homan’s sign indicate is possibility of thrombophlebitis or a deep
venous thrombosis that is present in the lower extremities.

When assessing for Homan’s sign ask the patient to stretch her kegs out with the
knee slightly flexed while dorsiflex the foot. A positive sign is present when pain
is felt at the back of the knee or calf. It is normal for a patient on magnesium
sulfate to feel tired because it acts as a central nervous depressant and often
makes the patient drowsy.
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C. INFECTION
D. MASTITIS
E. Postpartum Mood Disorders
 POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN
 Increased bleeding, clots or passage of tissue.
 Bright red vaginal bleeding anytime after birth.
 Pain greater than expected.
 Temperature elevation to 100.4º F.
 Feeling of full bladder accompanied by inability to void.
 Enlarging hematoma.
 Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness;
and visual disturbance.
 Pain, redness, and warmth accompanied by a firm area in the calf.
 Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension,
pale, cold, or blue skin color
 V. Psychological Adaptation
 Rubin's Postpartum Phases of Regeneration (POSTPARTUM
PSYCHOSOCIAL ADAPTATION)
“TAKING IN” PHASE (DEPENDENT) First 3 Days
 During this time, food and sleep are a major focus for the client. In addition, she
works through the birth experience to sort out reality from fantasy and to clarify
any misunderstandings. This phase lasts 1 to 3 days after birth. The primary
concern is to meet her own needs.

64
• Takes place 1-2 days postpartum
• Mother is passive and dependent; concerned with own needs.
• Verbalizes about the delivery experience.
• Sleep/food important.
• Mother focuses on her own primary needs, such as sleep and food
 Important for the nurse to listen and to help the mother interpret the events
of delivery to make them more meaningful
 Not an optimum time to teach the mother about baby care
“TAKING HOLD” PHASE (DEPENDENT/INDEPENDENT)
The client is concerned regarding her need to resume control of all facets of her
life in a competent manner. At this time, she is ready to learn self-care and infant
care skills.
• 3-10 days postpartum
• Mother strives for independence and begins to reassert herself.
• Mood swings occur. May cry for no reason.
• Maximal stage of learning readiness.
• Mother requires reassurance that she can perform tasks of motherhood.
• Begins to assume the tasks of mothering
• An optimum time to teach the mother about baby care.
“LETTING GO” PHASE (INTERDEPENCE)
• 10 to 6 weeks postpartum
• Realistic regarding role transition.
• Shows pattern of life-style that includes the new baby but still focuses on entire family
as a unit.
• Accepts baby as separate person.
 Mother may feel deep loss over separation of the baby from part of the body and
may grieve over the loss

 Mother may be caught in a dependent/independent role, wanting to feel safe and
65
secure yet wanting to make decisions
 Teenage mothers need special consideration because of the conflict taking place
within them as part of adolescence

66
Unang yakap
A program that been formulated by Department of Health to decrease the Newborn
Mortality Rate and improving Maternal Health. AO 25 (2009), it is a time bound
intervention. A protocol that must be carried out in a specific time.
Preparation:
3 Pairsof surgical glove
2 Warm blankets
1 Bonnet
Cordcare Set
Erythromycin
Vitamin K
Hepa. B Shot
Other requirements:
Breastfeeding
Delayed bathing until 6 hours of life
New born Screening
Steps
1. Immediate and thorough drying for 30 seconds to stimulate breathing after delivery
of the baby and prevent heat loss.
2. Early skin to skin contact maintaining a delivery room temperature of 25-28 degrees
centigrade andwrapping the newborn with clean, dry cloth. (To promote bonding and
prvent heat loss).
3. Properly timed clamping and cutting of umbilical cord 1-3 minutesoruntil cord
pulsation stops.(To reduce anemia or intraventricular hemorrage on pre-term
newborn).
4. Non separation of the newborn and mother for early breast-feeding. Immediate
latching on and initiation of breastfeeding within the firsthour after birth. (To provide
support for early breastfeeding and transfer of colostrum)

67
PERINEAL CARE
Assessment
 Check for the skin redness, inflammation,excoriation, irritation
 Excessive discharge
 Odor pain discomfort
 Urinary or fecal incontinence
 Recent rectal or perineal surgery
 An indwelling catheter
Determine:
 Perianeal genital practices
 Self care abilities
Assesmble equipment
Perineal genital care provided in conjunction with the bed bath:
 Bath towel
 Bath blanket
 Clean gloves
 Bath basin with water @ 43 degree to 46 degree
 Soap
 Washcloth
Special perineal genital care:
 Bath towel
 Bath blanket
 Clean gloves
 Cotton balls or swab
 Solution bottles, pitcher, or container filled with warm water or a prescribed solution
 Bedpan to receive rinse water
 Moisture resistant bag or receptacle for use cotton swabs
 Perineal pad
Procedure:
4. Introduce your self and verify the clients identity.explain to the client what is the
procedure are you going to do, why it is necessary, and how the client can
cooperate,being sensitive to any embarrassment felt by the client.
5. Perform hand hygiene and other appropriate infection control procedure.

68
6. Provide for client privacy by drawing the curtains and closing the door.
7. Prepare the client:
 Fold the top bedlinen to the foot of the bed the gown up to expose the genital area
 Place a bath towel under the clients hip
 Position and drape the client, and clean the upper inner thighs.
Females
 Position the female in back lying position with knees flexed and spread well a part.
 Cover her body and legs with the bath blanket drape the legs by tucking the bottom
corners of the blanket under the inside of the legs. Bring the middle portion of the
base of the blanket up over the pubic area.
 Put on gloves and wash and dry the under inner thighs.
For males
 Position the male client in a supine position with his knees are flexed and his hips
slightly externally rotated.
 Put on gloves, and wash and dry the upper inner thighs.
 Inspect the perineal area.
 Note particular areas of inflammation, excoriation,or swelling,especially between the
labia in females or the scrotal folds in male.
 Also note excessive discharge or secretion from the orifices, and the presence of
odors.
 Wash and dry the perineal genital area.
For female
 Clean the labia majora. Then spread the labia to wash the folds between the labia
majora and the labia minora.
 Use separate quarter of the wash cloth of the wash cloth for each stroke, and wipe
from the pubis to the rectum. For menstruating woman and clients with indwelling
catheter,use clean wipes,cotton balls, or gauze.take a clean wipe for each stroke.
 Rinse the perineal area as well.
 Dry the perineum thoroughly.
For male
 Wash and dry the penis,using firm strokes.
 If the client is uncircumcised,retract the prefuce foreskinto expose the glans penis
for cleaning. Replace the foreskin after cleaning the glans penis.
 Wash and dry the scrotum. The posterior fold of the scrotum might need to be
cleaned in step 9, with the buttocks.
 Inspect perineal orifices for intactness.

69
 Inspect particularly around the urethra in clients with indwelling catheter.
 Clean between the buttocks.
 Pay particular attention to the anal area and posterior fold of the scrotum in
males.clean the anus with toilet tissue before washing it, if necessary.
 Dry the area well.
 For post delivery or menstruating females, apply the perineal pad as needed, from
front to back.
10. Clean the area and equipment.
11.Document the procedure done.
PERINEAL SHAVING
Assessment
 Check for the skin redness, inflammation,excoriation, irritation
 Excessive discharge
 Odor pain discomfort
 Urinary or fecal incontinence.
Determine:
 Perianeal genital practices
 Self care abilities
Assesmble equipment
Perineal genital care provided in conjunction with the bed bath:
 Bath towel
 Bath blanket
 Clean gloves
 Bath basin with water @ 43 degree to 46 degree
 Soap
 Cotton balls
 Shaving cream if necessary
 Shaving blade
 Straight forceps
Procedure:
 Introduce your self and verify the clients identity.explain to the client what is the

70
procedure are you going to do, why it is necessary, and how the client can
cooperate,being sensitive to any embarrassment felt by the client.
2.Perform hand hygiene and other appropriate infection control procedure.
3.Provide for client privacy by drawing the curtains and closing the door.
4.Prepare the client:
 Fold the top bedlinen to the foot of the bed the gown up to expose the genital area
 Place a bath towel under the clients hip
5. Position and drape the client, and clean the upper inner thighs.
Females
 Position the female in back lying position with knees flexed and spread well a part.
 Cover her body and legs with the bath blanket drape the legs by tucking the bottom
corners of the blanket under the inside of the legs. Bring the middle portion of the
base of the blanket up over the pubic area.
 Put on gloves and wash and dry the under inner thighs.
For males
 Position the male client in a supine position with his knees are flexed and his hips
slightly externally rotated.
 Put on gloves, and wash and dry the upper inner thighs.
6. Inspect the perineal area.
 Note particular areas of inflammation, excoriation,or swelling,especially between the
labia in females or the scrotal folds in male.
 Also note excessive discharge or secretion from the orifices, and the presence of
odors.
 Apply cotton balls with soap the perineum.
 Shave the perineum starts from the symphisis pubis down to the labia majora.
 Wash the genitals using the clean water.
 Dry the area well.
 Clean the area and equipment.
 Document the procedure done.

71
References:
American Academy of P ediatrics Policy Statement (2005) Breastfeeding and the use of
human milk. Pediatrics, 115, 496-505.
Jensen, D., et al . (1993) LA TCH: A breastfeeding charting system and doc umentation
Tool. JOGGN, 23 (1), 27-32.
Lawrence, R. M. & R. A. (2005). Breastfeeding: A guide f or the medical profession (6th
Ed.). St. Louis: C.V. Mosby.
Lawers, J., Swis her, A. (2000). Counseling the Nursing Mother (3rd Edition). Sudbury,
Massachusetts. Jones & Bartlett Publishers.
Lazaroy, M., Fedlman, A. WHO/UNIFCEF Ten Steps to Successful Breastfeeding,
United States Committee for UNICEF Annotated Bibliography for each step, 1995.
Riordan, J . (2005). Breastfeeding and Human Lactation (3rd Edition). Sudbury,
Massachusetts. Jones & Bartlett Publishers.
[Howard, C. R., et al. (1999). The effects of early pacifier use on breastfeeding
duration. Pediatrics, 103, 659.]
http://carolmelcher.com/assets/Assisting%20with%20Breastfeeding.pdf
Kozier & Erb's Fundamentals of Nursing
http://www.drugs.com/cg/how-to-give-an-intramuscular- injection.html
http://nurseslabs.com/hot-sitz-bath-nursing-interventions-procedure/
http://nursingreviewbyozlek.blogspot.com/2010/08/enema.html
http://labspace.open.ac.uk/mod/oucontent/view.php?id=452806&section=1.4

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