2012 Midwifery Licensure Exams FUNDAMENTALS OF HEALTH CARE Weight: 20 %

Subject Coverage and Competencies Based on Board of Midwifery CMO No. 33 1. PRENATAL a. Assessment of major discomforts and relief measures b. Performs Leopold's maneuvers c. Performs auscultation d. Compute for EDC and AOG e. Administer tetanus toxoid f. Conducts health education/counselling in relation to: hygiene, diet, exercise, and preparation for delivery 2. LABOR AND DELIVERY a. Monitor the progress of labor b. Recognize early detection of abnormality c. Performs a) Catheterization b) Hand washing c) Gloving and draping d) Internal examination e) Suturing f) IVF insertion d. Administers oxytocin in labor e. Early detection of minor and serious complications during delivery a) Monitor and evaluate outcome of pregnancy b) Refers urgently any complication identified 3. POSTPARTUM a. Monitor and evaluate mothers condition b. Perform postpartum care c. Conduct health teaching and counselling on: a) Breastfeeding, family planning, diet, exercise, and hygiene b) Plans and conducts home visits following proper protocol 4. MIDWIFERY PROCEDURES a. Health Care Process a) Collect data b) Take OB history and medical history c) Asses patients condition d) Refer for laboratory examination b. Vital Signs a) Take temperature b) Take pulses c) Observe and count respiration d) Take blood pressure

e) Observe level of consciousness c. Drug Administration a) Discuss classification of drugs b) Identify names and uses of drugs c) Follow types of medication orders d) Administer drugs through proper routes e) Discuss actions/effects of drugs f) Identify proper abbreviation g) Identify commonly used drugs during pregnancy d. Preventive and comfort measures a) Give appropriate bed bath b) Prepare bed for the patient c) Perform perineal care d) Give health teaching on rest, sleep, personal hygiene, and position. e) Conduct health education on proper nutrition and elimination f) Perform hot and cold application g) Perform cord care h) Perform aseptic technique e. Common Emergency Measures a) Manage minor bleeding/hemorrhage b) Give comfort measures to fracture/sprain c) Give first aid to wounds and burns d) Manage shock and unconsciousness e) Give first aid during convulsion during labor f. Principles of Bacteriology a) Defines vocabulary word b) Identify principal group of microorganism c) Identify diseases caused by microorganism _____________________________________________________ Focused Antenatal Care Is based on the premise that every pregnancy is at risk for complications All women should receive the same basic care including identifying complications Involves a minimum of 4 visits in normal or uncomplicated pregnancies It stresses quality rather than number of visit & has essential goal-directed elements including screening for diseases that complicate pregnancy (pre-eclampsia & anemia) It also reduces cost, lessens workload & provides more time to interact with patients thereby improving quality of care

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Focused Antenatal Care Components 1. General Assessment of the Pregnant Woman 2. Screening for diseases that complicate pregnancy: hypertension, anemia, syphilis 3. Preventive measures: tetanus immunization, iron, folic acid supplementation 4. Health Education: self-care, nutrition & danger signs of pregnancy 5. Birth Plan Objectives: 1. Detection of diseases which may complicate pregnancy. 2. Education of women on danger & emergency signs & symptoms 3. Preparation of the woman & her family for childbirth Steps to follow: I. IMMEDIATE ASSESSMENT for emergency signs (QUICK CHECK): Unconscious/Convulsing Vaginal bleeding Severe abdominal pain Looks very ill Severe headache with visual disturbance Severe difficulty in breathing Fever Severe vomiting II. Make the woman comfortable Greet her, make sure she is comfortable & ask how she is feeling If first visit, register the woman & issue a Mother & Child Book/Home Based Maternal Record III. Assess the pregnant woman First Visit: How old is patient? Past medical history? Obstetrical history: Gravidity? LMP? AOG? Ask about or check record for prior pregnancies: convulsion, stillbirth or death in the first day, heavy bleeding during or after delivery, prior cesarean section, forceps or abortion ON ALL VISITS: Check duration of pregnancy (AOG)

Ask for bleeding/danger signs during this pregnancy Check record for previous treatments received during this pregnancy Prepare birth & emergency plan Ask patient if she has other concern Give education & counseling on family planning THIRD TRIMESTER Leopolds exam, fetal heart beat Give education & counseling on family planning Remember: Do not perform vaginal exam as a routine prenatal care procedure. Always record findings. All pregnancies are at risk. Encourage all pregnant women to deliver in the facility. Refer patients with abnormal findings to the doctor or to higher facility. IV. Get the baseline laboratory information of the woman on the first or following the first visit. Hemoglobin, blood type Urinalysis Screen for diseases that may complicate pregnancy: check for pallor or anemia Ask about getting tired easily or shortness of breath during routine work, drowsiness, palpitations, headaches these may indicate anemia

V.

First visit: o Check hemoglobin & blood type [normal Hb cut-off level for pregnant woman is 11g/dl. o if <8g/dl, refer to doctor for work-up & treatment for anemia Subsequent visit: Look for conjunctival pallor Look for palmar pallor. If pallor: Is it severe pallor? Some pallor? Count number of breaths in one minute VI. Check for hypertension/pre-eclampsia Measure BP in sitting position. If BP is above 140/90 early in pregnancy, she is suffering from chronic hypertension & should be referred to the doctor
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If diastolic BP is 90mmHg or higher repeat measurement after 1 hour rest If diastolic BP is still 90mmHg or higher ask the woman if she has: 1. Severe headache 2. Blurred vision 3. Epigastric pain Check urine for protein Diastolic BP >90mmHg, especially if with severe headache, blurred vision & epigastric pain & urine protein signs of severe pre-eclampsia REFER IMMEDIATELY! Screen for diseases that may complicate pregnancy: Check for gestational diabetes ASK ABOUT: Family history (1st degree) of diabetes & history of obesity Past pregnancy for difficult labor, large babies, congenital malformation & unexplained fetal death LOOK FOR: Signs of maternal overweight or obesity Polyhydramnios Signs of large baby or fetal abnormality Vaginal infection

500 mg single dose once in 6 months after 1st trimester Give iron & folate supplementation to prevent anemia & neural tube defects: Ferrous sulfate 320 mg (60 mg elemental iron) & 250 mcg folate If Hgb <80 gm/dl double the dose of iron. Refer to doctor for work-up of anemia

XI.

VII.

Give preventive intermittent for falciparum malaria (if area is endemic) XIII. Provide health information, advice & counsel on danger signals. a. Health Information a. Nutrition b. Self-care during pregnancy c. Effect of tobacco, alcohol and drugs d. Breastfeeding e. Birth and emergency situations f. Schedule of appointment b. Danger Signs a. Vaginal bleeding b. Convulsions c. Severe headache d. Severe abdominal pain e. Fast or difficult breathing f. Fever g. Burning feeling during urination XIV. Encourage the woman to come back for return visits. At least 4 routine antenatal visits: 1st visit: before 4 months 2nd visit: 6 months 3rd visit: 8 months 4th visit: 9 months return if undelivered within 2 weeks after EDC. Pregnant women who do not come for prenatal care should be visited at home.

XII.

REFER FOR GLUCOSE TEST AT 24-28 WEEEKS FOR LOW RISKS OR IMMEDIATELY IF HIGH RISK. VIII. Check for fever, burning sensation on urination & abnormal vaginal discharge: Ask about episodes of fever or chills & take temperature Ask about pain or burning sensation on urination Ask about presence of abnormal vaginal discharge, itching at the vulva if partner has a urinary problem Give preventive measures: IMMUNIZE AGAINST TETANUS To be protected, a pregnant mother must receive at least 2 doses of TT. The last dose should be given at least 2 weeks before delivery. Give preventive measures: Give MEBENDAZOLE: to treat intestinal parasites;

IX.

X.

The Birth A written document prepared during the first prenatal consultation. Plan may change anytime during pregnancy if abnormality develops. Discussed by the patient with the skilled birth attendant Contains information on: Womans condition during pregnancy Preferences for her place of delivery & choice of birth attendant. Discuss why facility delivery vs. home delivery with skilled attendant is recommended
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Available resources (transportation, companion, money) for her childbirth & newborn baby Preparation needed (blood donor, referral center) should an emergency situation arise during pregnancy, childbirth & postpartum

Contraceptive presently being used; types in the past Breast Health Any abnormality; any breast surgery; if she has breastfed a child

The Emergency Plan Discuss how to prepare for an emergency in pregnancy: Advise on danger signs, signs of labor Where to go? How to go? What to bring? With whom will you go? How much will it cost? Who will pay? How will you pay? Start saving for these possible cost now Who will care for your home & other children when you are away? PRENATAL CARE ASSESSMENT Past Medical History Disease experienced in the past Childhood illnesses Immunizations Drug sensitivities Past surgical procedures Smoking and alcohol consumption history Intake of over-the-counter drugs Gyneologic History Shows the womans past experiences with childbearing, labor, and delivery Menstrual Hx Age of menarche. Frequency and duration of menstruation, amount of menstrual flow, discomforts (dysmenorrhea), premenstrual syndrome Reproductive Tract Health Hx Vaginal discharges (characteristics), vaginal pruritus, odor, or any surgery Sexual Hx STD; if currently sexually active, discomforts during coitus; concerns about sexual intercourse Contraception Hx

Obstetric History Past pregnancies (number, sex of the child, date and place of birth, whether all pregnancies were planned, any complications, surgery, medications, prenatal care, duration of pregnancy or labor, type of delivery, infants birth weight, infants condition at birth, any abortions. Determine the gravida and para Obstetrical scoring: T-P-A-L

T-P-A-L T the number of full term infants born (37 weeks or after) P the number of preterm infants born (before 37 weeks) A the number of spontaneous or induced abortions L the number of living children Present pregnancy LMP (last menstrual period); duration of pregnancy or age of gestation. The Weeks of gestation is the clinically appropriate unit of measure for the duration of pregnancy. Early signs of pregnancy; minor discomforts; her feelings about her present pregnancy; any medications prescribed or OTC; danger signs of pregnancy. Compute for the EDC using Naegeles rule: Determine the LMP, count back 3 d months and add 7 days Physical Examination Techniques: Inspection, Percussion, Palpation, Auscultation Provide privacy; examining room temperature must be comfortable. Ask to empty bladder (except with UTZ) Initial data of VS must be taken especially BP and weight Include general appearance first, then each body parts must be examined (head to foot)
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During PE, observe the normal physiologic changes or other abnormalities. Important: PE must be focused on the reproductive tract. Cervix is visualized using a speculum in order to identify cytological abnormalities (Pap smear). Vaginal secretions: Normal moderate amount of white mucoid discharge Trichomonas foamy yellow liquid Candida presence of curdl-ike discharge For digital pelvic examination, special attention is given to the consistency, length, and dilatation of the cervix; Note the presenting part, bony architecture of the pelvis, and any abnormalities of the vagina and perineum. The vulva and other nearby structures are also carefully inspected. Pelvic or cervical examination must be done with caution especially if there is history of bleeding because this might aggravate the problem. Between 18 to 32 weeks, there is a good correlation between the gestational age of the fetus in weeks and the height of the uterine fundus in centimetres. Fundic height is measured as the distance over the abdominal wall from the top of the symphysis pubis.

The midwife stands at the foot of the client, facing her, and place both hands flat on the abdomen. A head is round and hard; the breech is less well defined. 2nd Maneuver: To locate the back of the fetus The health worker faces the client and places the palms of each hand on either side of the abdomen. The back is the smooth, hard, resistant surface On the opposite, a number of angular nodulations (the knees and the elbows) will be felt, indicating the front side of the fetus. 3rd Maneuver: Determine the part of the fetus at the inlet and its mobility. Grasp the lower portion of the abdomen just above the symphysis pubis between the thumb and the index finger together. Determine any movement and whether the part is firm or soft. If the presenting part moves upward, the presenting part is not yet engaged. If the part is firm, it is the head; if soft, then it is breech. th Maneuver: 4 Determines the fetal attitude and degree of fetal extension into the pelvis. Done only if the fetus is in cephalic presentation. Summary of PE Measure clients height and weight Vital signs Head-to-toe examination Special attention to the heart, lungs, pelvis, breasts, and nipples Pelvic exam is performed last External genitalia are examined for scars, lesions, or infection Pap smear for cervical cancer and gonorrhea is usually obtained Leopolds maneuvers Pelvic size for adequacy After taking the Hx, PE, and lab tests, analysis is done in order to estimate whether the pregnancy will continue with a good outcome or if is one that has the potential to end before term or with an unfavorable fetal or maternal outcome. Danger Signals/Signs of Pregnancy Any vaginal bleeding Swelling of the face and fingers Severe or continuous headache
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Ultrasound: Can be prescribed as early as 5 to 6 weeks after LMP Shows fetal heartbeat at 9-10 weeks gestation 12 -13 weeks can show the biparietal diameter of the fetal skull Fetal heartbeat Generally heard by 10-12 weeks with Doppler device Heard using a stethoscope at 18-20 weeks Quickening Fetal movement usually felt by the mother at 20 weeks gestation Usually detected in 2nd pregnancy than with a first Leopolds maneuvers Purpose: Systematically observing and palpating the abdomen to determine fetal presentation and position. 1st Maneuver: determine whether fetal head or breech is in the fundus.

Dimness or blurring of vision Abdominal pain Marked change in intensity or frequency of fetal movement Persistent vomiting Chills or fever Dysuria Escape of fluid from vagina

Neck rotation Shoulder rotation Swim thigh shift Leg shake Ankle rotation

Tetanus Toxoid Basis: Number of Pregnancies that will terminate in live births (3% of total population) plus number of other pregnancies that may not terminate in live births (0.5% of the total population) = 3.5% of the total population. Formula: Population x 3.5% Wastage allowance: TT 25% Annual Dose: TT 2/year Number of dose in every ampule or vial: TT 20 Nutrition during Pregnancy Nutritional status of the mother is likely to be compromised in any of the following circumstances: Under 16 years of age Economically deprived Pregnant for the 3rd time in 2 years Past reproductive performance has been poor Consumes a therapeutic diet in the course of management of some preexisting diseases Food faddist Smokes, drinks, or uses hard drugs Appreciably underweight at the outset Hematocrit drops much below 11gm/dl Weight for any month during the 2nd and 3rd trimester is less than 2 pounds General Instructions for Pregnant Mothers Exercise o It is not necessary for a pregnant woman to limit exercise, provided she does not become excessively fatigued or risk injuring herself or the fetus. o Contraindication: women who have pregnancy complications like PIH; multiple gestation; or suspected of having growth retarded fetus Recommended Exercise During Pregnancy o Stretching Exercises for Pregnancy

Kegels Exercise Strengthen the muscles that support the bladder, uterus, and bowels. By strengthening these muscles, the pregnant woman can develop the ability to relax and control the muscles in preparation for labor and birth. Also recommended during the postpartum period to promote healing of the perineal tissues, increase the strength of the pelvic floor muscles, and also increase urinary control. Coitus For healthy pregnant women, sexual intercourse usually does no harm before the last four weeks or so of pregnancy. Should be avoided whenever abortion or preterm labor threatens. Position: Woman on top or side lying. Care of the Breast and the Abdomen Pregnant women should wear a brassiere that is well-fitted to support the breast in a normal uplift position. This is conducive to good posture and helps prevent backache. Flat or inverted nipple: special care is needed. Abdominal Support A properly fitted maternity girdle gives the needed support to keep the mother from becoming fatigued. The purpose of the garment is support and comfort (prevents backache) Care of the teeth Good dental care is necessary because the teeth are important for mastication of food. Dental carries should be treated during pregnancy and oral hygiene must be emphasized. Smoking Contraindicated during pregnancy. Will result in LBW infants. Alcohol Excessive ingestion or chronic alcoholism can lead to fetal maldevelopment. Can result to growth restriction, facial abnormalities, and CNS dysfunction.
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Advise woman not to consume alcohol. Caffeine Decreases uterine blood flow by 5 to 10 %. Advise woman to limit caffeine intake. Hard drugs/Addicting drugs Opium derivatives, barbiturates, amphetamine in large doses are harmful to the fetus. This causes intrauterine distress, LBW, and serious compromise. The infant will have symptoms of drug withdrawal. Addicting drugs must be avoided. Medication With rare exceptions, any drug that exerts a systemic effect in the mother will cross the placenta to reach the embryo and fetus. Medication must always be prescribed. Immunization The following vaccines are contraindicated during pregnancy: Measles Mumps Poliomyelitis Rubella Yellow fever

Constipation - Difficulty in passage of hard stools Diarrhea - Passage of 3 or more soft, watery stools Fecal impaction Normal Characteristics of Stools Color - yellow or golden brown (d/t stercobilin) Odor - aromatic upon defecation (d/t skatole & indole) Amount - depends on bulk of food intake Alterations in Characteristic of Stools Melena -passage of black tarry stools d/t upper GI bleeding Acolic - gray, pale or clay colored stools d/t biliary obstruction Hematochezia - stool with bright red blood d/t lower GI bleeding Steatorrhea - greasy, bulky, foul smelling stools d/t hepato-pancreatic obstruction Independent Measures to Promote Normal Defecation Positioning - thighs flexed while sitting to increase intra-abdominal pressure Assist client to bed pan High fiber diet Adequate fluid intake (8-10 glasses/day) Provide client privacy Exercise Dependent Nursing Measures Inserting a rectal tube Enema Administering Enema The introduction of a solution into the GIT through the rectum for various purposes Relieve constipation Relieve flatulence Administer medication Lower body temperature Evacuate feces in preparation for surgery or diagnostic procedures Types of Enema Non-retention Enemas (to be expelled) Cleansing - cleanses bowel prior to surgery or diagnostic procedure. Solution used: tap water, soap suds, NSS (500-1000 mL)

ENSURING BOWEL ELIMINATION Bowel Elimination - basic needs to remove solid wastes from the body usually through defecation Defecation - The expulsion of the feces from the rectum. Factors Hindering Normal Bowel Elimination Accumulation of flatus (gas) Accumulation of fluid or feces d/t decreased peristalsis Surgical procedures (colostomy) Head or spinal cord injury Immobility Change in diet Environment Signs of Interference in Bowel Elimination Decreased bowel sounds Flatulence/adbominal distention accumulation of gas in the stomach/intestines Vomiting - expulsion of gastric contents

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Antihelminthic - to expel worms. Quassia solution Astringent - control or check bleeding Carminative Expel flatus or gas Milk and molasses solution Introduce 60-180 mL Fleet enema: 100-130 mL

Lubricate tip and insert 3-4 inches, with tip towards the umbilicus in rotating motion. Instruct patient to breath through mouth Do not administer more than three times at one time If abdominal cramps occur, clamp tubing & temporarily stop solution until peristalsis relaxes. Lower level of solution Not to be given to patient suspected having bowel obstruction and appendicitis

Enema to be Retained (retention enema) Diagnostic Outline colon for x-ray Barium sulfate Emollient Coat membranes to relieve irritation Starch solution Lubricating To soften stools Olive oil, mineral oil, or cottonseed oil Introduce 90-120 mL of solution Nutrient To give nourishment Dextrose solution Sedative Induce sleep Paraldehyde solution Stimulating Stimulate body processes Black coffee Special Considerations Retention enemas Hang solution 12 inches from buttocks Solution temperature: 105-110 F Hold solution for 1-3 hours Non-retention enemas Hang solution 12 inches from buttocks Solution temperature: 115-125 F Retain solution for 1-3 hours Position adult patient in sims/left lateral Infants and children on dorsal recumbent Use Fr # 22-30 catheter for adults Use Fr # 12-18 catheter for children Allow solution to flow through tube first to expel air Stool Examination Routine fecalysis Stool c/s Stool specimen in a sterile test tube Guaiac Test Test for occult/hidden blood Hemoglobin free diet x 3 days No meat, avoid dark colored foods Discontinue Iron Positive result: gastric cancer, peptic ulcer, colon cancer Insertion of Rectal Tube Purpose - remove flatus and relieve abdominal distention Position - left side lying Length of tube to be inserted - 4-6 Duration - 15-20 minutes Indicator of effectiveness - bubbling in kidney basin Common Problems in Bowel Elimination Constipation passage of hard, dry stools Fluids High fiber diet Regular bowel elimination Exercise Reduce stress Administration of laxatives Fecal Impaction - mass or collection of hardened stools in folds of rectum S/Sx: - Hardened fecal mass - Anorexia - Nausea and vomiting - Abdominal distention Interventions - Digital (manual) extraction - Increase oral fluids - High fiber diet - Activity and exercise
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 Diarrhea - increased frequency and passage of soft to liquid stools Rest Oral rehydration Low fiber diet BAR diet banana, apple, rice AM Avoid excessive hot or cold drinks Anti-diarrheals, absorbents, astringents Flatulence - excessive gas in the intestines Avoid gas forming food Knee-chest position

ENSURING URINARY ELIMINATION Urination - Also termed Voiding or Micturition - Occurs when the bladder contains 250-300 mL (adults) and 50-200 mL (children) of urine. - The pair of kidneys normally produces 30 mL/hour of urine. Characteristics of Normal Urine CLEAR - amber/straw colored ODOR -aromatic upon voiding pH - slightly acidic (4.6-8/average: 6) SPECIFIC GRAVITY - 1.015 1.025 AMOUNT - 1500 2000 mL/day Abnormal Characteristics & Alterations in Patterns of Voiding Turbid, cloudy Abnormal color tea colored or bloody Hematuria blood or RBC in the urine Albuminuria albumin in the urine Glycosuria sugar in the urine Pyuria pus in the urine Bacteuria bacteria in urine Proteinuria protein in the urine Clinduria presence of casts Ketonuria ketones in the urine Dysuria painful urination Polyuria voiding of abnormally large amounts of urine (more than 2000 ml/day) Oliguria voiding of less than 500 mL per day Anuria absence of urine or voiding of less than 200 mL per day Incontinence involuntary emptying of the bladder, loss of control in voiding. Stress incontinence leakage of less than 50 mL of urine as a result of sudden

increase in intra-abdominal pressure as when one coughs, sneezes, laughs, or exerts physically. Urge incontinence - feels strong desire to urinate and leads to involuntary detrusor contraction. Functional incontinence involuntary unpredictable passage of urine. Reflex incontinence involuntary loss of urine occuring at somewhat predictable intervals. Retention accumulation of urine in the bladder caused by inability to urinate. Dribbling (retention with overflow) frequent voiding of small amounts of urine while the bladder remains distended. Nocturia increased frequency of voiding at night. Frequency voiding at frequent intervals Urgency strong feeling or desire to void Hesitancy difficulty in initiating voiding Enuresis repeated involuntary voiding beyond 4-5 years of age (bedwetting) Pollakuria frequent, scanty urination.

Measures to Promote Urinary Elimination Independent Functions - Encouraging fluid intake - Running tap water within the clients hearing - Pouring water over the patients perineum - Alternate warm and cold compress over hypogastrium - Assist to toilet or bed pan Dependent Funtions - Obtaining urine specimens for laboratory examination - Catheterization Fluid Monitoring Measuring fluid intake and output (I & O) refers to measuring all fluid that enters and exits from the body. Intake - All food and fluids that liquify at room temperature (ice cream, gelatin) - Parenteral fluids (IVF) - Fluids introduced through tubes (NGT) Output - Urine - Vomitus - Diarrhea - Drainage from suctioning - Fluid in feces
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Purpose of Fluid Monitoring Monitor clients fluid intake and output Monitor renal function. Urine Specimen Collection Clean Cath, Midstream urine specimen (for routine Urinalysis (U/A), C & S - Catch first voided specimen - Perineal care prior to collection - Discard first flow and catch 30-50 mL midstream - Discard the last flow 24 Hour Specimen - Discard first voided specimen - Collect all specimen thereafter until the same time the following day - Soak specimen container in ice or put in refrigerator Sterile Urine Specimen - Obtained through catheterization Urinalysis Benedicts Test to determine prescence of sugar in the urine. - Collect specimen before meals - Put 5 mL of Benedicts Solution into the test tube - Add 8 10 drops of urine - Heat Benedicts Solution with urine - Blue (-) - Green (+) - Yellow (++) - Orange (+++) - Red (++++) Clinitest to determine sugar in the urine - Put one clinitest tablet in test tube - Add 5 drops of urine - Add 10 drops of water - Wait for reaction to occur and compare with standard chart Heat and Acetic Acid Test - Collect urine specimen before meals - Imaginary divide test tube into three parts - Put 2/3 parts of acetic acid in test tube - Add 1/3 part urine - Heat and observe for CLOUDINESS which indicates Albuminuria Catheterization - insertion of a catheter into the urethra and bladder Purposes: - Relieve retention - Obtain a sterile urine specimen

Measure residual urine Instill medications in the bladder Irrigate the bladder (treat infections) Measure hourly urine output Maintain continence

Special Considerations - Provide privacy - Practice strict asepsis - Catheter size: French # 8-10 (Children) French # 14-16 (adult female) French # 18 20 (adult male) - Types of catheter Foley for indwelling catheters, balloon tipped Straight for intermittent catheterization - Position patient in DORSAL RECUMBENT - Perineal care before catheterization - Drape DIAGONALLY - Insert catheter 2-3 inches in females and 7-9 inches in males in gently rotating motion. - Let patient take deep breaths to relax sphincter. - Inflate with sterile water of PNSS (0.9 NaCl) (Check label for quantity required). - Limit emptying of bladder to 700-1000 mL only to allow for gradual decompression and prevent shock - Anchor indwelling catheter in inner aspect of thigh. PROMOTING HYGIENE AND COMFORT - Measures to promote personal cleanliness and grooming - Maintain clients well-being and selfesteem. - Infection control. Determining Factors - Culture - Socioeconomic status - Religion - Developmental level - Health status - Personal preference Bathing a. Cleansing Bath - Complete bath washes the entire body - Partial bath cleanses some body parts only - Tub/Shower bath entire body
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b. Therapeutic Bath - Sitz reduce inflammation and clean perineal and perianal area. - Tepid Sponge Bath reduce fever/temperature - Medicated tub bath relieve skin irritation Cleansing Bed Bath - Cleanse the skin - Comfort and relaxation - Stimulate circulation - Remove secretion and excretions - Assessment of client - Inspection for skin breakdown Special Considerations - Water temperature 109 F 115 F (43-45 degree Celsius) - Fold washcloth into a mitt - Wipe eyes from inner to outer canthus - Use S-motion when wiping face - Use long strokes from fingers to axilla (distal to proximal), ankle to knee and knee to thigh. - Wash perineum last (finishing the bath). Perineal care - Promote comfort and cleanliness - Prevent infection - Promote healing - Remove perineal secretions and odor Special Considerations - Water temperature 109 F 115 F (43-45 degree Celsius) - Position patient in dorsal recumbent position - Apply diagonal draping - Clean from labia majora, labia minora, vagina to pubis to rectum - Grasp cotton ball with forceps using one downward stroke with each cotton ball - Drape patient diagonally with one tip/corner if blanket in between the patients thighs to cover perineum Back rub - Consists of massaging the back, shoulder, and lower neck - Done after a bath or bedtime - Relaxation - Relieve muscle tension - Stimulate circulation - Assessment of client skin Techniques - Effleurage - Stroking skin with the use of the palms in long or circular strokes.

Petrissage - kneading, lifts up portion of the skin - Tapotement - quick hacking motion using the side of the hand Special Considerations - Rub in circular motion over sacral and scapular area - In effleurage, use long strokes upward along center of patients back from buttocks to shoulder - Move downward alongside of back of iliac crest - Repeat strokes for 3-5 minutes Bed Making - Types of Bed o Closed/Unoccupied bed with no patient in it and is covered to the top. o Open bed with top sheet fan folded or folded diagonally ready for a newly admitted client o Post op or surgical bed bed ready to admit a client recovering from anesthesia o Occupied bed made with the client on it. Purposes - Provide a clean and neat environment - Promote client comfort - Reduce the transmission of organisms Special Considerations - Practice good body mechanics - Strip one bed linen/sheet at a time and do not shake soiled linens. - Apply bed sheets from bottom to top in the following order: bottom sheet, rubber sheet, draw sheet, top sheet and blanket, pillowcase - Fold bottom sheet wrong side out and top sheet right side out. - Place hem of bottom sheet even with the bottom of the mattress and pull towards the head part. Miter corner and tuck in at head part. - Place hem of top sheet even at the top of bed and pull towards bottom (foot part) of the bed. Miter corner and tuck in at foot part. - Place draw sheets about 15 18 from top to bed. - Place pillow case on head part of the bed with open end facing away from the door. - For close beds, draw top sheet and fold about 12-15 from top of bed. Place pillow and then draw over pillow to cover.
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Fanfold or fold top sheet diagonally when making an open bed. Finish one side of bed at a time to save time and conserve energy.

Postoperative/Surgical Bed - Top linens are folded a quarter from head and bottom of bed - Fanfold top sheets towards the center of bed - Place pillow against head board - Keep bed in high position to facilitate transfer Prepare at the bed side: IV pole, emesis basin, BP and suction apparatus, Oxygen device. Medication Administration Medications administered to clients are used, almost exclusively, to prevent, diagnose, or treat disease.

Types of medication action Therapeutic effects: The expected or predictable physiological response a medication causes. Each medication has a desired therapeutic effect for which it is prescribed. Side effects Are the unintended, secondary effects a medication predictably will cause. Side effects may be harmless or injurious. If the side effects are serious enough to negate the beneficial effects of a medications therapeutic action, the prescriber may discontinue the medication. Clients usually stop taking medications because of the side effects. Adverse effects Generally considered severe responses to medication. For example: a client may become comatose when a drug is ingested. When adverse responses to medications occur, the prescriber must discontinue the medication immediately. Some adverse effects are unexpected effects that were not discovered during drug testing.

Routes of administration Depends on the medications properties and desired effect and on the clients mental and physical condition. Oral routes Easiest and most commonly used Given by mouth and swallowed with fluid Have slower onset of action and a more prolonged effect than parenteral medications. Most preferred route. Sublingual Readily absorbed after being placed under the tongue to dissolve Should not be swallowed, or the desired effect will not be achieved. Nitroglycerine is an example Buccal Placing the solid medication in the mouth and against the mucous membranes of the cheek until the medication dissolves Client must alternate between cheeks to prevent irritation Do not chew or swallow medication or take any liquids with it. Parenteral routes Involves injecting a medication into body tissues. Intradermal into the dermis just under the epidermis Subcutaneous into tissues just below the dermis of the skin Intramuscular into a muscle Intravenous into a vein Topical administration Medications applied to the skin and mucous membranes and generally have local effects Systemic effects may occur if the skin of the client is broken down Includes ointments, eye drops, gargles, suppository Inhalation Medications administered through the nasal passages, oral passages, or endotracheal or tracheostomy tubes. Readily absorbed and work rapidly because of the rich vascular alveolar capillary network available
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Can either have local or systemic effects

Ways to prevent medication errors Read medication labels carefully Question administration of multiple tablets or vials for single dose Be aware of medications with similar names Check decimal point Question abrupt and excessive increase in dosages When new or unfamiliar medication is ordered, check a reference Do not administer medication ordered by nickname or unofficial abbreviation Do not attempt to decipher illegible handwriting Know clients with the same last names. Also, have clients fully state their names and check bands carefully. Do not confuse equivalents Avoiding Medication Errors 1. RIGHT DRUG - ensure that the medication order is properly composed and includes; - Patients full name - Drug name - Dosage form - Dose amount - Administration route - Time schedule - Practitioners signature - Date and Time of order Check the medication order against drug label THREE TIMES (3X) Know why the patient is receiving the specific drug at this time. Do not administer a medication someone else has prepared If using a unit dose system, do not open the packaging until you are at the client's bedside Never leave a medication unattended 2.) RIGHT ROUTE Check the order and medication supplied Oral (by mouth or gastric tube) Parenteral ( ID, Subcutaneous, IM, IV) Topical Otical Opthalmic Mucous membrane ( sublingual, buccal, vaginal, rectal, intranasal, transdermal, inhalation) 3.) RIGHT DOSE- perform dosage calculation

always use the appropriate measuring device and read it correctly ( measure liquid for oral administration at the meniscus) shake all suspensions and emulsions when measuring drops of medication with a dropper, always hold the dropper vertically and close the medication cup when removing a drug from a multiple dose vial, inject an amount of air equal to the amount of fluid to be withdrawn do not attempt to divide unscored tablets and do not administer tablets that have been broken unevenly along the scoring 4.) RIGHT TIME verify the frequency of dosage with the medication order 5.) RIGHT PATIENT check the tag on the client's bed check the client's identification band ask the client to state his name ask the parents to state the name of their child always check a prescription that the client questions 6.) RIGHT DOCUMENTATION Make sure that the practitioners order is clear and complete Compare the original order with the medication label to ensure accuracy Record the medication in the patients chart immediately after administering it If the patient doesnt take the medication, document that the drug was not given, why; notify the practitioner if appropriate. 7.) RIGHT EDUCATION Teach your patient about the drug he is receiving 8.) RIGHT DRUG HISTORY take a complete patient drug history (there is a risk of adverse drug reactions when a number of drugs are taken or when patient is taking alcohol drinks) 9.) RIGHT TO REFUSE be sure to assess the client's reason for refusing the medication

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 document if client refuses medication, client's reason and reporting of refusal to healthcare provider Do not forget to assert client education as to why is the medication prescribed, what the medication does, and importance of medication for treatment of client's health alteration. VITAL SIGNS - A.k.a cardinal signs - Includes temperature, pulse, respiration, blood pressure and pain - Measurement provides data to determine the clients usual state of health - Change in v/s can indicate change in physiologic function - Assessment of v/s will enable the HW to: Identify the problem precisely Plan for the right intervention - Techniques: a. Inspection b. Palpation c. auscultation BODY TEMPERATURE - The balance between the heat produced and the lost from the body - Measured in degrees KINDS: a. CORE TEMPERATURE - Temperature of the deep tissues of the body (abdominal & pelvic cavity) - Remains relatively constant within the range of 36.0C to 37.5C b. SURFACE TEMPERATURE - Temperature of the skin, subcutaneous tissue & fat - Rises & fails in response to the environment FACTORS OF HEAT PRODUCTION - Basal metabolic rate - Muscle activity - Shivering - Thyroxin output - Sympathetic stimulation Four Processes of Heat Loss - Radiation - Convection - Evaporation - Conduction ALTERATIONS IN BODY TEMPERATURE - Pyrexia or hyperthermia - Hyperpyrexia

- Hypothermia - Febrile - Afebrile TYPES OF FEVER - Intermittent - Remittent - Relapsing - Constant SITES OF TEMPERATURE TAKING - Oral - Rectal - Axilla - Tympanic membrane An elevation of body temperature above normal is labelled FEVER or HYPERTHERMIA A patient who has a temperature of 36.5C is known to be AFEBRILE A condition wherein the body temperature falls below 35C is called HYPOTHERMIA Cooling the body with the use of an electric fan is an example of heat loss by CONVECTION Your patients temperature records 40C. This condition is called HYPERPYREXIA PULSE - Palpable bounding of blood flow noted at various points on the body - Serves as indicator of circulatory status - Can be assessed by: a. Palpation b. Auscultation SITES FOR ASSESSING PULSE - Temporal - Carotid - Apical - Brachial - Radial - Femoral - Popliteal - Posterior tibia - Dorsalis pedis RATE - Tachycardia excessively fast heart rate - Bradycardia heart rate lower than normal TACHYCARDIA a pulse rate of 120 bpm in an adult female BRACHIAL used in cases of cardiac arrest for infants

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BRADYCARDIA a pulse rate of 70 bpm in a newborn FEMORAL used to determine circulation to the lower extremities BOUNDING PULSE a forceful blood volume that is obliterated only with difficulty

APNEA cessation of respiration for several seconds

BLOOD PRESSURE Refers to the force of blood against arterial walls BP measures: - SYSTOLIC PRESSURE The pressure of the blood as a result of contraction of the ventricles - DIASTOLIC PRESSURE The pressure when the ventricles are at rest. - PULSE PRESSURE Difference between the systolic & diastolic pressure BP - measured in millimeters of mercury (mmHg) - Recorded as a fraction - Numerator: systolic pressure - Denominator: diastolic pressure HYPERTENSION - A BP that is persistently above normal - Usually asymptomatic; predisposing factor to myocardial infarction - Types: a. Essential HPN b. Secondary HPN HYPOTENSION - A BP that is below normal - Causes: Analgesics Bleeding Severe burns Dehydration - Orthostatic hypotension pressure falls when the client changes position; results from peripheral vasodilatation CONSIDERATIONS IN TAKING THE BP - BP reading should be made with the eye at the level of the rounded curve (meniscus) of the manometer - BP cuff should be of accurate size: Width of cuff = 40% of arm circumference 2/3 of the arms length - Patients arm should be supported and positioned at the level of the heart Bladder cuff that is too narrow false high BP Bladder cuff that is too wide false low BP

RESPIRATIONS - The act of breathing - Involves several physiologic events: Pulmonary ventilation External respiration Internal respiration ASSESSING RESPIRATIONS - Normally, breathing is carried out automatically and effortlessly - Respirations are assessed while the client is relaxed - Before assessing a clients respiration, check for: a. The clients normal breathing pattern b. Influence of clients health problems on respirations c. Medications or therapies that might affect respirations d. The relationship of the clients respiration to cardiovascular function RESPIRATORY RATE - Normally described in breaths per minute or cycles per minute Described as: Eupnea normal breathing Bradypnea Tachypnea BREATH SOUNDS: Wheeze continuous high-pitched musical squeak or whistling sound occurring on expiration & sometimes on inspiration when air moves through a narrowed or partially obstructed airway Stridor a shrill, harsh sound heard during inspiration with laryngeal obstruction Stertor snoring respiration due to partial obstruction of the upper airway Bubbling gurgling sounds heard as air passes through moist secretions in RT 12 20 cpm normal respiratory rate in adults. - EUPNEA normal respiratory rate & depth. - ORTHOPNEA ability to breathe only in upright sitting or standing position. - HEMOPTYSIS presence of blood in sputum.

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Family Planning How to determine that a woman is NOT pregnant? Has not had intercourse since last normal menses, or Has been correctly and consistently using another reliable method, or Is within the first 7 days after normal menses, or Is within 4 weeks postpartum (for nonlactating women), or Is within the first 7 days post abortion, or Is fully breastfeeding, amenorrheic, and less than 6 months postpartum If the client answered NO to all of the questions, pregnancy cannot be ruled out. The client should await menses or use a pregnancy test. If the client answered YES to at least one of the questions and she is free of signs or symptoms of pregnancy, provide client with desired method. FERTILITY AWARENESS-BASED METHODS (FAB) & LAM FAB Methods- are family planning methods that focus on the awareness of the beginning & end of the fertile time of a womans menstrual cycle. Effectiveness depends on the couples ability to identify fertile & infertile periods & motivation to practice abstinence when required.

Basal Body Temperature (BBT) - It is based on a womans resting body temperature (body temp. after 3 hours of continuous sleep) which is lower before ovulation until it rises to a higher level beginning around the time of ovulation. - Her infertile days begin from the fourth day of the high temperature reading to the last day of the cycle - All days from the start of the menstrual cycle up to 3rd high temp.reading are considered FERTILE DAYS. - Perfect use:99% - Typical use: 80% Symptothermal Method (STM) - Combined technology of the BBT & BOM which indicate that the woman is fertile or infertile. - 98% effective as correctly used. Standard Days Method (SDM) - Is based on a calculated fertile & infertile period for menstrual cycle lengths that are 26-32 days. - Women who are qualified to use this method are counseled to abstain from sexual intercourse on days 8-19 to avoid pregnancy. - Couples use the device called the color coded cycle beads. Women with special consideration - Contraceptive shifters may also use SDM provided the following criteria are met; - Menstrual cycles were within 26-32 days before pill use - Expect current cycle to be within 26-32 days Advantage of FABM (Fertility Awareness Based Methods) Effective when used correctly & consistently No physical SE No prescription required Inexpensive; no medication involve No follow-up medical appointments required Better understanding of the couple about their sexual physiology & reproductive function. Encouraged shared responsibility for FP Foster better communication between partners. Disadvantage
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Signs of Fertility 1. Changes in the cervical mucus: cervical mucus can be used to determine the beginning & end of the fertile period. 2. Changes in the basal body temperature: BBT can be used to determine when ovulation has passed & the fertile days have ended. Billings ovulation method (BOM) - Based on the daily observation of what a woman sees & feels at the vaginal area throughout the day. - Cervical mucus changes indicate whether days are fertile or infertile & can be used to avoid or achieved pregnancy. - With perfect use, this method is 97% effective. - Typical use: 80% effectiveness

May inhibit sexual spontaneity Except for SDM, need extensive trainingtakes about 2-3 cycles to accurately identify the fertile period & how to effectively use it. Requires consistent & accurate record keeping & close attention to body changes. Required periods of abstinence from sexual intercourse, which may be difficult for some couples. Required rigid adherence to daily routine of awakening at a fixed time, without enduring any disturbances before taking the temp. Can be used only by women whose cycles are within 26-32 days (SDM). Offer no protection against STI, HIV & AIDS.

temporarily prevents the release of the natural hormones that cause ovulation. Effectiveness 99.5% effectiveness if the 3 criteria are consistently followed. 98% typically use Mothers should initiate BF as soon as possible after birth, & avoid separation from the baby as much as possible. BF on demand day & night, with no more than a 4 hour interval between any 2 daytime feeds & no more than a 6 hour interval between any 2 night time feeds. Advantages of LAM It can be started immediately after delivery It is recommended & easily available It does not require an Rx. No action is required at the time of intercourse There are no SE or precautions to its use No commodities/supplies are required for clients or for the FPP. Fosters mother-child bonding It serves as a bridge to using other methods because LAM is used for a limited time only It is consistent with religious & cultural practices. Disadvantages of LAM Effectiveness after 6 months is not certain. Frequent breastfeeding may be inconvenient or difficult for some women, especially working mothers. No protection against sexually transmitted diseases (STDs) including HIV/AIDS. If the mother has HIV (the virus that causes AIDS), there is a small chance that breast milk will pass HIV to the baby. Categories of Choice of FP methods for Postpartum and Breastfeeding women 1st choice; Non-hormonal methods other than LAM - IUD, condom, BTL, NFP, vasectomy 2nd choice: Progestin-only pills - DMPA & POI ( can be initiated after 6 weeks PP) 3rd choice: Methods containing estrogen (only after 6 months) KEY POINTS FOR PROVIDERS AND CLIENTS Take one pill every day. For greatest effectiveness a woman must take pills
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Lactational Amenorrhea Methods (LAM) LAM is a method that relies on the condition of infertility that results from specific BF patterns. Use of BF as a temporary FP method. Lactational means breastfeeding Amenorrhea means not having a menstrual bleeding. 3 criteria that must be met to use LAM 1. Woman fully or nearly fully breastfeeds her infants. Fully/ Nearly Fully maybe interpreted as; - Fully (exclusive) means no supplements of any sort are given. Infants receive no other liquid or food, not even water in addition to breast milk. - Nearly fully means very small amount of water, vitamins or ritual foods are given not more than once per day. For LAM to remain effective, 85% or more of feedings must be breastfeeds. - Simply put, the woman should use both breasts to breastfeed her baby on demand with no more than a 4 hour interval between any 2 daytime feeds & no more than a 6 hour interval between any two night time feeds. 2. Amenorrhea- mothers monthly bleeding has not returned. In the first 6-8 weeks PP. 3. 3. Infant is less than 6 months old. IF ANY OF THE CRITERIA IS NOT MET, LAM IS NOT APPLICABLE Mechanisms of Action (LAM) Works primarily by preventing the release of eggs from the ovaries. Frequent BF

daily and start each new pack of pills on time. Bleeding changes are common but not harmful. Typically, irregular bleeding for the first few months and then lighter and more regular bleeding. Take any missed pill as soon as possible. Missing pills risks pregnancy and may make some side effects worse. Can be given to women at any time to start later. If pregnancy cannot be ruled out, a provider can give her pills to take later, when her monthly bleeding begins.

How Effective? Effectiveness depends on the user: Risk of pregnancy is greatest when a woman starts a new pill pack 3 or more days late, or misses 3 or more pills near the beginning or end of a pill pack. Who Can and Cannot Use Combined Oral Contraceptives? - Safe and Suitable for Nearly All Women - Nearly all women can use COCs safely and effectively, including women who: Have or have not had children Are not married Are of any age, including adolescents and women over 40 years old Have just had an abortion or miscarriage Smoke cigarettesif under 35 years old Have anemia now or had in the past Have varicose veins Are infected with HIV, whether or not on antiretroviral therapy, unless that therapy includes ritonavir (see Combined Oral Contraceptives for Women With HIV, p. 9) 2 types of pills packets 28 pills - 21 active pills containing hormones - 7 inactive or reminder (does not contain hormones) Mechanism of Action Low dose COC prevents ovulation by suppressing FSH & LH. It also causes thickening of the cervical mucus, which makes it difficult for sperm to pass through. Perfect use: 99.7 % Factors affecting effectiveness Correct & consistent use Low dose COC must be taken daily, preferably at the same time of the day or night.

Low dose COC should be started within the 1st seven days of the menstrual cycle. Proper storage, observance of shelf life & expiration date Vomiting/diarrhea If vomits within 2 hours after taking a pill, she should take another pill from her pack as soon as possible, then keep taking pills as usual. Drug interaction Effectiveness lowered when taken with certain drugs: rifampicin, anticonvulsants Advantage of COC Safe as proven by extensive studies Reversible, rapid return of fertility Convenient, easy to use, no need to do anything at the time of sexual intercourse Has significant non-contraceptive benefits; - Monthly periods regular & predictable - Reduce symptoms of gyne conditions - Decrease risk of iron-deficiency anemia - Can be used at any age from adolescence to menopause - Will not affect a womans lactation after it is well-established. Disadvantage Requires regular & dependence supply Client- dependent Offers no protection against STI/HIV Not most appropriate choice for lactating women as it can suppress lactation Effectiveness maybe lowered when taken with certain drugs Possible Side Effects & Management Possible SE which are common during the first 3 months of use of the COC - Spotting - Amenorrhea - Nausea - Breast tenderness - Headaches - Depression Warning Signs o J-jaundice o abdominal pain (severe) o chest pain o H- headaches (severe) o E- eye problems such as acute loss of vision in one eye, seeing flashes o S- severe leg pains When is the best time to start low-dose COC? It is best for the woman to start taking low-dose COC within the first 5 days of the menstrual period.
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When can low dose COC be started Postpartum? Be sure a client is not pregnant If not BF =start at 3 weeks after deliver May low dose COC be started immediately postabortion? Begin immediately No back up contraceptives is needed if she begins within the first 5 days following abortion. Progestin Only Pills (POP) Contain a small amount of progestin which is similar to the womans hormone, progesterone. They do not contain estrogen. 0.5mg lynestrenol (exluton, daphne) 75ug desogestrel Mechanism of Action Prevents ovulation in about half of menstrual cycles Causes thickening of the cervical mucus, which it make more difficult for sperm to pass through. Effectiveness Perfect use 99% Typical use 99.5% Family Planning Counseling: Principles Focuses on individual clients needs and situation by assuring: Confidentiality Voluntary choice Informed consent Clients rights Empowerment In serving clients, it is important to remember that they have: The right to decide whether or not to practice family planning, The freedom to choose which method to use, The right to privacy and confidentiality, The right to complete and accurate information, The right to form/express their own opinions, and The right to refuse any type of examination. Counseling can be divided into three major phases: initial counseling or education at reception, individual counseling prior to and immediately following service provision, and Follow-up counseling.

An effective counselor: Understands and respects the clients rights Earns the clients trust Understands the benefits and limitations of all contraceptive methods Understands the cultural and emotional factors that affect a womans (or a couples) decision to use a particular contraceptive method Encourages the client to ask questions Be brief (most important information only) First things first Use simple words and short sentences Repeat most important information Organize information Be specific Counseling should be part of every interaction with the client. MYTHS AND MISCONCEPTIONS THE MORAL Contraception is EVIL! THE LEGAL Emergency contraception is allowed in the Philippines. THE SEXUAL Contraception makes one a sex maniac THE PERSONAL Contraception cannot be used by single or unmarried women or even by adolescents. THE MEDICAL Contraception has no health benefits. THE SOCIAL Contraception promotes promiscuity and rise in STIs. THE RIDICULOUS IUD can travel and reach the brain. THE MORBID Contraception can cause illnesses (e.g. Cancers) and can KILL! Most popular and most effective method is through COUNSELING! Adherence to the Principle of Informed Choice

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