HANDLING AND

ASSISTING
DELIVERIES

PREPARED BY: MS. MARITES C. TARUCAN

M.A.N., R.N., L.P.T
• After the discussion and demonstration,
the BSN 2 students will able to develop
positive attitude, acquire basic knowledge
and skills in handling and assisting
deliveries.
The BSN 2 Students will be able to:
1. Recognize the importance of assisting and handling safe
delivery to prevent maternal and child morbidity and
mortality.
2. Define related terminologies correctly.
3. Arrange instruments needed in handling and assisting
deliveries according to its use.
4. Practice the procedure at home following the steps
written in RLE Manual.
5. Prepare the materials needed in Handling and Assisting
Deliveries before a procedure.
6. Return Demonstrate Handling and Assisting Deliveries
utilizing the steps written in RLE Manual.
• Handling delivery- is the actual handling
of the delivery of the fetus
• Assisting delivery- handling the
instruments to the one handling the delivery
• Episiotomy- a surgical incision of the
perineum made to prevent tearing of the
perineum with birth and to release pressure of
the fetal head during delivery.
• Episiorraphy- repair tear of the episiotomy
with the use of sutures.
• Laceration- refers to the tearing of the
vulvar, vagina and sometimes rectal tissue
during birth.
 CARDINAL MOVEMENTS
• ENGAGEMENT- occurs when the widest part of the fetal
head has passed below the maternal pelvic
inlet.Essentially, the baby's head has officially entered its
mother's pelvis.

• DESCENT- downward movement of the biparietal diameter

of the fetal head to within the pelvic inlet.

– Floating- fetal presenting part is not engaged in pelvic

inlet
– Fixed- fetal presenting part has entered pelvis
– Engagement – fetal presenting part
(usually biparietal diameter of fetal
head) has passed through pelvic inlet
– Station 0- presenting part has reached
level of ischial spines
– Stations -1,-2,-3- presenting part is 1,2,3
above the level of ischial spines
– Stations +1, +2, +3- presenting part is
1,2,3 below level of ischial spines. A
station of +4 indicates that presenting is
on the pelvic floor.
FLEXION- baby moves further downward and then head meets
obstruction at the pelvic floor causing flexion.
-while descending through the pelvis, the fetal head flexes so
that the fetal chin is touching the fetal chest. This functionally creates a
smaller structure to pass through the maternal pelvis. When flexion
occurs, the occipital (posterior) fontanel slides into the center of the
birth canal and the anterior fontanel becomes more remote and difficult
to feel. The fetal position remains occiput transverse
INTERNAL ROTATION- in accommodating the birth canal, the fetal
occiput rotates anteriorly from its original position toward the
symphysis. The movement results from the shape of the fetal head,
space available in the midpelvis and contour of the perineal muscles.
The ischial spines project into the midpelvis causing the fetal head
to rotate enteriorly to accommodate to the available space.

With further descent, the occiput rotates anteriorly and the fetal
head assumes an oblique orientation. In some cases, the head may
rotate completely to the occiput anterior position.
EXTENSION- as the fetal head descends further it meets
resistance from the perineal muscles and is forced to extend.
The fetal head becomes visible at the vulvova ring; its largest
diameter is encircled (crowning) and the head then emerges
from the vagina.
The curve of the hollow of the sacrum favors extension of the
fetal head as further descent occurs. This means that the fetal
shin is no longer touching the fetal chest.
•EXTERNAL ROTATION/RESTITUTION- When head emerges, the
shoulders are undergoing internal rotation as they turn in the
midpelvis to accommodate to the projection of the ischial
spines. The head, now born, rotates the shoulders undergo this
internal roatation
The shoulders rotate into an oblique or frankly anterior-
posterior orientation with further descent. This encourages the
fetal head to return to its transverse position.
EXPULSION- Following delivery
of the infant’s head and internal
rotation of the shoulders, the
anterior shoulder rests beneath
the symphysis pubis. The
posterior shoulder is born,
followed by the anterior shoulder
and the rest of the body.
 STAGES OF LABOR:

FIRST STAGE OF LABOR

(Stage of DILATATION)
-Onset of true labor to full
cervical dilatation
•LATENT PHASE- The first phase of the first stage of labor when contractions
are becoming more frequent (usually 5 to 20 minutes apart) and somewhat stronger.The
cervix dilates (open approximately three or four centimetres and effaces (thins out).Is usually
the longest and least intense phase of labor.

•ACTIVE STAGE- the second phase of the first stage is signalled by dilatation of
the cervix from 4 to 7 cms. Contractions become longer, more severe, and frequent (usually 3
to 4 mins. Apart)

•TRANSITION PHASE- the third phase and the last phase. Cervix dilates
from 8 to 10 cms. Contractions are usually very strong lasting 60-90 seconds and occurring
every few minutes.
SECOND STAGE OF LABOR
( stage of EXPULSION)
Complete dilatation to expulsion
of the baby
Ritgen’s Maneuver
1.Denotes extracting the fetal head, using
one hand to pull the fetal chin from between
the maternal anus and the coccyx, and the
other on the fetal occiput to control speed of
delivery. It is perform during the uterine
contraction.
2.Palpate for cord coil.

•Suction baby’s mouth and nose using bulb syringes.

•Deliver the shoulder, wait for the external rotation where

one shoulder is up and the other shoulder is down.

•With one hand at the back of the neck, the other one grasping
the extremities and put the baby in the mothers abdomen
and suction secretions.
 THIRD STAGE (PLACENTAL
STAGE)
-Birth of the baby-expulsion of the placenta
-This stage of labor is the period from birth of the baby through delivery of
the placenta.
-This is considered a dangerous time because of the possibility of
hemmoraging
Placental separation

Calkin’s sign
1.1.The uterus becomes globular in shape and firmer, discoid to avoid,
indicating placental separation from the uterine wall.

1.2.Gushing of blood
-2nd sign
-or sudden glush of blood

1.3. Lengthening of the cord

-3rd sign
-the umbilical cord descends three (3) inches or more further
out of the vagina

1.4..The uterus rises in the abdomen

 Crede’s Maneuver
A method of expressing the
placenta in which body uterus is
vigorously squeezed in order to
produce placental separation
Placental Expulsion
Brandt- Andrews Maneuver- a method of expressing the
placenta by grasping the umbilical cord with one hand and
placing the other hand on the abdomen, application of the
traction on the cord by moving the forcep up, down, left,
right.

Schultze’s mechanism- Shiny (fetal side)- a mechanism or

technique for the delivery with the fetal rather than the
maternal side surface presenting the shiny and glistening
side of the fetal membrane

Duncan mechanism- dirty or rough (maternal side)- a

mechanism or technique for delivery with the maternal
rather than the fetal side surface presenting the dirty or
rough side.
FOURTH STAGE
(stage of PHYSICAL
RECOVERY)
- Delivery of the
placenta up to 1-4 hrs.
After delivery
 – Digital thermometer
– 3 gowns – Adult diaper
– 2 leggings – Sterile gloves
– 3 drapes – 1 bottle of 70% alcohol
– 1 perineal support – 1 bottle Betadine
solution
– Pack cotton ball
– Baby diaper
– Bonnet
– ID bracelet ( white and
pink / blue)
CONTENTS OF INSTRUMENT SET

– 1 bandage scissor -1 bandage scissor

-1 surgical scissor
– 1 kelly curve
-1 kelly curve/straight forcep
– 1 kelly straight - 1 needle holder
– 1 surgical scissor -1 tissue forcep with
teeth/without teeth
– 1 needle holder -1 tray
– 1 tissue forcep 10cc disposable syringe for
lidocaine hcl 2% (to be added)
– 1 placental bowl
– Needle and Suture (to be
added)
– Sterile 4x4 OS 5-10 pcs. (to
be added)
– 4 sterile OP towel
– 2 leggings (optional)
CONTENTS OF INSTUMENT SET

-1 bandage scissor
-1 kelly curve/straight forcep
- 1 needle holder
-1 tissue forcep with teeth/without teeth
-1 tray
-10cc disposable syringe for 2 % lidocaine hcl
(to be added)
– Needle and Suture
(to be added)
– Sterile 4x4 OS 5-10 pcs. (to be added)
– 2 leggings (optional)
 INSTRUMENTS
• 10cc disp. Syringe with lidocaine anesthesia + bandage
scissors are used during episiotomy.
• 2 kelly forceps – used to clamp the umbilical cord of the
baby
• Umbilical cord scissor- used to cut the umbilical cord.
• surgical scissors used to cut the umbilical cord.
• needle holder used to hold the round needle with suture.
• 1 tissue forceps with teeth used to hold the soft tissues
in the perineal area during episiorraphy
STEPS IN HANDLING DELIVERY
PROCEDURE
PREPARATION

a. Do medical and surgical hand washing

b. Perform gowning (per institution protocol) and gloving
(per institution protocol)
c. Do draping (per institution protocol)
ACTION:
1. DRAPE the patient accordingly.

a. Leggings (left and right)

b. Abdominal drape
c. Perineal drape
d. Baby drape
e. perineal support
2. Encourage the woman to push/ bear down once uterus is at
the height of its contraction and to do breathing exercises when it is not.
When the birth opening is stretching and the head of the
baby is crowning:
3.Ensure controlled delivery of the head of the baby.
4. Keep one hand on the head as the head of the baby
advances.
-To keep the head from coming out too quickly.
5. Support the perineum with the other hand.
-To prevent perineal lacerations.
6. Discard the pad when soiled.
-To prevent infection
7. During the delivery of the head encourage the
woman to stop pushing and breath rapidly with
mouth open.
Delivering the baby:
8. Sliding your hands into the neck of the
baby, gently feel if the cord is around the
neck.
-If it is loosely around the neck, slip it over
the shoulders or the head
-If it is tight, place a finger into the cord,
clamp and cut the cord, and unwind it from
around the neck.
When the face and head of the baby is delivered:
9. Gently wipe the baby’s mouth and nose with clean gauze.
10. Wait for external rotation (within 1-2 min) the head of
the baby will turn sideways bringing one shoulder just
below the symphysis pubis and the other facing the
perineum
11. Apply downward pulling motion to deliver the top
shoulder then lift the baby up to deliver the lower
shoulder. Gently deliver the rest of the baby.
12. Place the baby to the mother’s abdomen in prone
position.
13. Cover the baby with dry towel. Thoroughly dry the baby
immediately. Wipe the baby’s eyes.
14. Discard wet cloth.
15. Put the baby in prone position, in skin-to-skin contact
on the mother’s abdomen. Keep the baby warm.
16. Palpate mother’s abdomen to determine if there is a
second baby.
17. Remove gloves (first set of gloves) or change to new
ones.
18.

Make sure
the bladder
is empty.

19.
7. Once delivered, place the placenta on the
bowl and inspect for completeness of its
parts.
8. Document the placental presentation.
Assisting
Delivery
PREPARATION:

a. Do medical and surgical hand washing

b. Perform gowning (per institution protocol) and gloving
(per institution protocol)
c. Prepare the materials, ob pack and instruments set to be used in
the delivery.
*materials include: to be obtained from the accompanying
-maternity duster (per institutional policy)
-adult and newborn (per institutionall policy)
-baby clothes and flannel (per institutional policy)
* instruments set needs to be anticipated whether to use
primi/multi set (per institutional policy)
d. Anticipate the amount of anesthetic agent to be use. Prepare the
agent in the syringe.

ACTION:
1. Serve the instruments to be used to the physician in appropriate manner.
2. Assist in suturing the episitomy. Anticipate doctor’s need during suturing
3. After suturing of the perineum is done, flush the
operative site with normal saline.
4. Apply betadine antiseptic solution,sanitary pad/adult
diaper and clean maternity duster.
5. Do after care:
-position the mother comfortably- closed legs
-removed stained drapes
-take vital signs immediately
-Check the instruments if complete
-wash the instruments if complete and let it dry
-pack clean equipment and auto-clave
 Basic Emergency Obstetric and Newborn
Care (BEmONC ) or Comprehensive
Emergency Obstetric and Newborn Care
(CEmONC) Site Supervision Checklist

• This is a supervision checklist for Emergency

Obstetric and Newborn Care sites to help
monitor: (1) the infrastructure and environment,
(2) the equipment and material, (3) the
mananagement of antenatal care clients,
patients during labor and delivery, as well as
postnatal mothers and babies, (4) family
planning, and (5) postabortion care.
 Introduction
• Approximately 15% of expected births worldwide will
result in life-threatening complications during pregnancy,
delivery, or the postpartum period [1]. The concept of
emergency obstetric and newborn care (EmONC) was
introduced by WHO, UNICEF, and UNFPA in 1997 as an
organizing framework for the delivery of evidence-based
clinical services, as a critical component of any program
to reduce maternal and newborn mortality [2]. Skilled
birth attendants (SBAs) [3] provide EmONC services
within the context of community-focused and facility-
based health systems, enabling timely prevention of and
intervention for these complications and saving the lives
of mothers and newborns.
Universal access to EmONC is considered essential
to reduce maternal mortality and requires that all
pregnant women and newborns with complications
have rapid access to well-functioning facilities that
include a broad range of service delivery types and
settings A set of seven key obstetric services, or
“signal functions,” has been identified as critical to
basic emergency obstetric and newborn care
(BEmONC): administration of parenteral antibiotics;
administration of parenteral anticonvulsants;
administration of parenteral uterotonics; removal of
retained products (manual vacuum aspiration);
assisted vaginal delivery; manual removal of the
placenta; and resuscitation of the newborn [5].
Comprehensive emergency obstetric and newborn care
(CEmONC) includes all BEmONC services and adds surgical
capacity and blood transfusion. This set of life-saving services
defines a health facility with regard to its capacity to treat
obstetric and newborn emergencies [4]. The decision to include
these functions in a package of emergency obstetric and
newborn care services was based on evidence from numerous
quasi-experimental or experimental studies and is summarized
in various systematic reviews [6], [7], [8], [9]. Recent global
discussions have centered on expansion of the original seven
signal functions to encompass activities related to routine care
for mothers and newborns because they enable prediction,
prevention, and early intervention to mitigate life-threatening
complications [10].
 These expanded functions include such
services as: infection prevention and
management for both mothers and infants;
monitoring and management of labor using
the partograph; active management of the
third stage of labor; and infant thermal
protection, feeding, and HIV prevention.
IMMEDIATE NEWBORN
CARE
After the discussion and demonstration, the
BSN 2 students will able to develop positive
attitude, acquire basic knowledge and skills
in immediate newborn care.
The BSN 2 Students will be able to:
1. Recognize the importance of
immediate newborn care.
2. Define related terminologies
correctly.
3. Arrange instruments needed in
immediate newborn care
according to its use.
4. Practice the procedure at home
following the steps written in RLE
Manual.
5. Prepare the materials needed in
immediate newborn care before a
procedure.
6. Return Demonstrate immediate
newborn care utilizing the steps written
in RLE Manual.
Related Terminologies
 Apgar Scoring Acrocyanosis

-method of evaluating/ -bluish

monitoring cardiovascular discoloration
adaptation of the baby. of body and
The Apgar score is a test extremities.
given to newborns soon after
birth. This test checks a baby's
heart rate, muscle tone, and
other signs to see if extra
medical care or emergency
care is needed. The test is
usually given twice: once at 1
minute after birth, and again
at 5 minutes after birth.
 Harlequin’s
Sign

– dependence sign;
reddish on one side of
the baby. Harlequin
colour change appears
transiently in
approximately 10% of
healthy newborns. 
This distinctive
phenomenon presents
as a well-demarcated
colour change, with
one half of the body
displaying erythema
and the other half
pallor.
 Mottling
Milia

The hue and color patterns of

-pinpoint whitish
a newborn's skin may be startling to
structures on baby’s nose, some parents. Mottling of the skin, a
forehead and chin lacy pattern of small reddish and pale
areas, is common because of
the normal instability of the blood
circulation at the skin's surface.
 Lanugo
– downy hair
of newborn;
anterior
shoulder,
buttocks,
scapular
region,
forehead.
Mongolian Spots

– bluish discoloration in These birthmarks are noncancerous and

lumbar region and buttocks.
Mongolian blue spots, also
known as slate gray nevi,
are a type of
pigmented birthmark.
They’re formally called
congenital dermal
melanocytosis.
present no health danger. However,
your child’s pediatrician should examine
the marks to confirm the diagnosis.
There’s no recommended treatment for
Mongolian blue spots. They usually fade
before adolescence.

These marks are flat and

blue-gray. They typically
appear on the buttocks or
lower back, but may also be
found on the arms or legs.
They’re generally present at
birth or develop soon after.
 Vernix Caseosa

 also known as vernix,

is the waxy or cheese-
like white substance
found coating the skin
of newborn human
babies. It is produced
by dedicated cells and
is thought to have
some protective roles
during fetal
development and for a
few hours after birth.
 New Born Care

-the care is performed

immediately after birth
through the first 28 days of
life, making the transition
to extra uterine life
smoothly easy in promoting
the physical well-being of
the newborn and supporting
the establishment of a well-
functioning family unit.
NEONATAL TRANSITION PERIOD
§ The newborn’s
transition from
intrauterine to
extrauterine life is
marked by a series
of rapid and
complex
physiologic
changes.
§ Your assessment of
these changes
begins in the
delivery room
and continues
through the infant’s
hospital stay.
 During the birth
process, fluid is
squeezed from the
fetal lungs.
 As the chest emerges,
most healthy
newborns will take
their first breaths
spontaneously.
 The onset of
respiration stimulates
a series of
cardiopulmonary
changes as the infant
makes the transition
from fetal to neonatal
circulation.
Vital statistics
Newborns may look alike, The weight of
but each has their own newborns varies
physical attributes and according to their race,
personalities. Some genetics, and
newborns are fat and short nutritional factors.
while some are long and
thin. There are newborns
who never give a fuss
whenever they are changed
or cuddled, but some can
cry in high decibels
whenever you lift them
from their cradles.
 Parameter Average

Weight 6.5 to 7.5 lbs (2.9 kg to 3.4 kg)

Length 50 cm (20 in)

Head circumference 33 to 35 cm (13  to 13.7 in)

31 to 33 cm or
Chest circumference
2cm less than head circumference

Abdominal circumference 31 to 33 cm
 Vital Sign Immediately At Birth After Birth

Temperature 36.5 to 37.2 Celsius

120-140 beats/minute
Pulse 180 beats/minute
ave.

Respiration 80 breaths/minute 30-50 breaths/minute

100/50 mmHg (by

Blood Pressure 80/46 mmHg
10th day)
 2.5KGS TO 3.4KGS NORMAL WEIGHT
Male

 Weight (whites)
 3.5 kg (7.7 lbs)
 Other races:
 0.5 lb less

Female

 Weight (whites)
 3.4 kg (7.5 lbs)
The infant is weighed
nude at approximately
the same time each day.
Newborn loses 5% to
10% of birth weight
days after birth due to:

No longer under the

influence of salt-fluid
retaining maternal
hormones
Adjustment in
breastfeeding
A. Head For accurate measurement the tape is
circumference - placed over the most prominent part of
the occiput and brought to just above
proceeds from the eyebrows. The circumference of the
cephalocaudal newborn’s head is approximately 2 cm
principle: head longer greater than the circumference of the
than the rest of the newborn’s chest at birth.
body; head: 33-35 cm
using a tape.
Measurement above
head just above
eyebrows and pina
ears, resting on
occipital regions. If
above 33-35 cm-
suspect
hydrocephalus.
Chest Circumference :
Chest circumference should be taken
with the tape measure at the lower edge
of the scapulas and brought around
anteriorly directly over the nipple line.
Length :
The length of the newborn is difficult to measure because the
legs are flexed and tensed. To measure length ,start from the
crown of the newborn’s head following the conjunction of the
spine /back then the buttocks ,thigh down to the heel of the
foot.
Other way of measuring the length ,the nurse should place the
newborn’s flat on their backs with legs extended as much as
possible.
Vital Signs

 Temperature
 37.2ºC (99ºF) at birth
 It will fall immediately below normal
due to heat loss, temperature of
birthing room, immature
thermoregulating mechanism and less
subcutaneous fat.

 Newborn lose heat by 4

mechanisms:
1. CONVECTION
Ø Flow of heat
from
Newborn’s
body to cooler
surrounding
air
Ø Prevention:

§ Eliminate
drafts from
windows/air
conditioners
2)RADIATION

Ø Transfer of body
heat NOT IN
CONTACT with the
baby such as a cold
window or air
conditioner
Ø Prevention:

§ Move the infant as

far from the cold
surface as possible.
3) CONDUCTION

Transfer of body heat

to a cooler
solid object in contact
with the baby.
 4) EVAPORATION

-is loss of heat through

conversion of a liquid to a
vapor.
- drying the infant’s face
and hair effectively
reduces evaporation
because the head which is
a large surface area in a
newborn, can be
responsible for a great
amount of heat loss so
cover the hair with a cap
after drying.
 If the newborn’s temperature does not stabilize
shortly after birth, the cause needs to be
investigated to rule out infection.
 PULSE
 Transient murmurs
 Result from incomplete
closure of fetal
circulation shunts
 During crying
 May rise to 180 bpm
 During sleep
 90 – 110 bpm
v Palpate for femoral
pulses
Ø Absence suggests
coarctation
(narrowing) of the
aorta.
 RESPIRATION
 Coughing & sneezing
present to clear the airway.
 Maybe as high as
90breaths per minute
right after birth but will
settle to an average 0f
30- 60 breaths per minute
 NBs are obligate nose-
breathers
 Show signs of distress if
nostrils become obstructed.
 Blood Pressure
 At birth:
 80/46 mmHg
 By 10th day:
 100/50 mmHg
§ Crede’s
prophylaxis and
apply terramycin
eye ointment on
both eyes

§ Retract lower
eyelid outward to
instill ¼ inch
strand of ointment
along the
conjunctival
surface.
NEONATAL REFLEXES
Ø Also known as developmental, primary, or
primitive reflexes.
Ø They consist of autonomic behaviors that do

not require higher level brain functioning.

They can provide information about lower
motor neurons and muscle tone.
Ø They are often protective and disappear as

higher level motor functions emerge.

  NEUROMUSCULAR
SYSTEM
1. Blink reflex
§ May be elicited by shining a
strong light on an eye.
§ To protect eyes from any object
coming near it.

2. Rooting reflex
§ Serves to help the NB find food.
§ When cheek is stroked near the
corner of the mouth, a NB will
turn the head in
that direction.
§ Reflex disappears 6 wks. of life
§ At this time, NB eyes can
focus steadily
so food source can be seen.
3. Sucking reflex
§ This reflex helps the NB
find food.
§ When a NB’s lips are
touched, the baby makes
a sucking motion.
§ Begins to diminish at 6
months of age.
4. Swallowing reflex
§ Food that reaches the
posterior portion of the
tongue is automatically
swallowed.
5. Extrusion reflex
§ Prevents swallowing of
inedible substances.
§ Disappears in 4 months
§ Extrudes any substance
placed on anterior
portion of the tongue.
6. Palmar grasp
§ Disappears: 6 wks. - 3
months

§ Elicited by the examiner

placing his finger on the
palmar surface of the infant’s
hand and the infant’s hand
grasps the finger.

§ Attempts to remove the finger

result in the infant tightening
the grasp.

§ Grasps meaningfully at 3
months of age.
7. Step (Walk)-in-Place
§ NBs who are held in a
vertical
position with their feet
touching
a hard surface will take a
few quick,
alternating steps.
§ Disappears by 3 months of
age
8. Placing reflex
§ Similar to step-in-place
reflex
§ Elicited by touching the
anterior surface of the lower
part of the NB’s leg against
a hard surface.
Ø Edge of table or bassinet
8. Plantar grasp
§ When an object touches the sole of
a NB’s foot at the base of the toes,
the toes grasp in the same manner
as do the fingers.
§ Disappears at 8 – 9 months of age
in preparation for walking.
9. Tonic neck (Fencing
posture)
§ Elicited by rotating the infants
head from midline to one
side. The infant should
respond by extending the arm on
the side to which the
head is turned and flexing the
opposite arm. The lower
extremities respond similarly.
§ Disappears between 2 – 3 months
of life.
 10. Moro Reflex
The examiner holds the infant so that
§
one hand supports the head and the
other supports the buttocks. The
reflex is elicited by the sudden
dropping of the head in her hand. The
response is a series of movements: the
infant’s hands open and there is
extension and abduction of the upper
extremities. This is followed by
anterior flexion of the upper
extremities and audible cry.
§ Their fingers assume a typical
“C” position.
§ Fades by end of 4-5 months.

 An absent or inadequate Moro

response on one side :
 hemiplegia, brachial plexus palsy, or a
fractured clavicle
 Persistence beyond 5 months of age :
 indicate severe neurological defects.
11. BABINSKI REFLEX
§ Elicited when the sole of the foot is stroked in
an inverted “J” curve from the heel upward.
The infant responds by plantar flexion and
either flexion or extension of the toes (fans the
toes).
§ Remains positive until 3 months of age.
12. MAGNET REFLEX
§ If pressure is applied to
the sole of the feet of the
NB lying in supine
position, he/she pushes
back against the pressure.

13. CROSSED
EXTENSION REFLEX
§ If one leg of the NB lying supine
is extended, and the sole of that
foot irritated by being rubbed
with a sharp object (thumbnail),
the infant raises the other leg
and extends it, as if trying to
push the hand away.
14. TRUNK
INCURVATION
§ When NB lie in
prone and is touched
along the
paravertebral area
by a probing finger,
they flex their trunk
and swing their
pelvis toward the
touch.

15. LANDAU
REFLEX
§ A NB who is held in
prone position with a
hand underneath
supporting the trunk,
should demonstrate
some muscle tone
 MUSCLE TONES

Muscle toned is determined by

evaluating the degree of flexion and
resistance of the extremities.
1. The square window 2. Arm Recoil
sign is elicited by gently
flexing the newborn’s is elicited when the
hand towards the ventral newborn is in supine
forearm until resistance position , the forearm
is fully flex for 5
is felt. The angle formed
seconds the fully
at the wrist is measured. extend by pulling the
hands and release.
3. The popliteal angle
(degree of knee
flexion) is determined
with the newborn flat on
his or her back. Flex the
thigh on the abdomen and
chest, place the index
finger of the other hand
behind the newborns
ankle to extend the lower
leg until resistance is met,
and measure the angle
form. Results vary from
no resistance in the very
immature newborn to an
80 degree angle in a term
newborn.
 4. The scarf sign is elicited
by placing the newborn
supine and drawing an arm
across the chest toward the
newborns opposite shoulder
until resistance is met. Note
the location of the elbow in
relation to the midline of the
chest.
 5. The heel – to – ear
extension is performed by
placing the newborn in a
supine position and then
gently drawing the foot
toward the ear on the same
side until resistance is felt.
Allow the knee to bend during
the test.
6. Ankle dorsiflexion is determined by flexing the
ankle on the shin. Use a thumb to push on the sole
of the newborns foot while the fingers support the
back of the leg. Then measure the angle form by
the footand the interior leg. Intrauterine position
and congenital deformities can influence the sign.
7. Head Lag (neck flexor) is measured by pulling the
newborn sitting position and noting the degree of head lag.
Total lag is common in newborns up to 43 weeks gestation,
whereas post term newborn (42+weeks) hold their heads in
front of their body lines. Full – term newborn can support
their heads momentarily.
8. Ventral suspension (horizontal position)
is evaluated by holding the newborn prone on the hand and
noting the position of the head and the back and degree of
flexion and the arms and legs.
 NEWBORN CARE COMPETENCIES

§ Dry the baby for at least

30seconds, wipe eyes,
face, head, front, back,
arms and legs
§ Remove the wet cloth
§ Check breathing, do not
ventilate unless not
breathing and do not
suction unless with
secretions but first
suction the mouth first
§ Do APGAR scoring
immediately then after 5
minutes
§ If the baby is breathing and
crying, position the baby
prone on the mothers
abdomen then cover with
cloth, cover the head with
bonnet and place ID band on
ankle
§ Remove the first set of gloves
then when the umbilical
pulsation is gone, clamp the
cord using sterile clamp at
2cm from the umbilical base
then clamp again at 5cm
from the base then cut the
cord close to the clamp.
§ Check for presence of 2
arteries and one vein
Then allow skin to skin contact with the mother, observe
feeding cues and encourage the mother to feed the baby
through her breast.
After the first full breastfeeding, proceed to
weighing, eye care, injection of Vitamin K and
examination. Check temperature per rectum for
patency

Eye Care/ Crede’s Prophylaxis

§ Do Crede’s prophylaxis and apply terramycin eye
ointment on both eyes.

§ Retract lower eyelid outward to instill ¼ inch

strand of ointment along the conjunctival surface.
§ Record observation done and medications
given.
§ Report for any abnormalities noted.
 INJECTION OF
VITAMIN K
-is synthesize through
the action of intestinal
flora and is responsible
for the formation of
clotting factors.
- Newborn have less
coagulation ability so
vitamin K is usually
administered to prevent
from bleeding.
- Single dose of 0.5 mg
(for premature) – 1.0
mg (for FT), IM 1st hr. of
life
INJECTION OF VITAMIN K ON THE
VASTUS LATERALIS

§ Cleanse the area thoroughly

with alcohol swab and allow
skin to dry. Bunch the tissue
of the upper thigh (vastus
lateralis muscle) and
quickly insert a 25G 5/8 inch
needle at 90 degrees angle
to the thigh .Aspirate and
then slowly inject
the solution to distribute the
medication evenly. Remove
the needle and do not
massage the site.
Hepatitis B vaccine
§ Vaccine must be given within 12 hrs. after birth
§ 2nd dose at 1 month
§ 3rd dose at 6 months
§ Infants with mothers positive for HepB surface antigen
(HBsAg) should also receive Hep B immunuglobulin
(HBIG)
PROCEDURE:
1.Prepare all equipment.
 
§ Cebu Puericulture Center and Maternity Inc. (CPCMHI)
§ Cord clamp
§ Sterile OC (3-4 pcs)
§ Sterile cotton balls (2-3 pcs)
§ Mayo Scissors
§ Bulb Syringe
§ Tape measure
§ Vitamin K ampule
§ Terramycin eye ointment tube
§ ICC Syringe
§ Baby diaper
§ ID band – Blue (male), Pink (female)
§ Receiving blanket
§ Digital Thermometer
§ Baby’s cap
§ Weighing scale
§ Goose neck lamp
 § Vicente Sotto Memorial Medical Center (VSMMC)
§ Cord Clamp
§ Sterile OS (3-4 pcs)
§ Sterile Cotton balls (2-3 pcs)
§ Cord cuter
§ Tape measure
§ Vitamin K ampule
§ Terramycin eye ointment tube
§ ICC Syringe
§ Baby diaper
§ ID band – Blue (male), Pink (female)
§ Receiving blanket
§ Digital Thermometer
§ Baby’s clothes
§ Baby’s blanket
§ Weighing scale and goose neck lamp
2. Prepare the room temperature of the delivery room. Room
temperature should be 25-28 C.
3. Notify appropriate staff.
4. Arrange needed supplies in linear fashion.
5. Check resuscitation equipment.
6.Wear face mask and bonnet properly.
7. Wash hands with clean water and soap.
8.Don’t double glove just before delivery.
9. Within first 30 second;
§ Dry the newborn thoroughly for at least 30 seconds.
§ Do a quick check of breathing while drying. (do not suction
unless the mouth/nose are blocked with secretions or other
materials)
§ Wipe the eyes, face, head, front and back, arms and legs.
(DO NOT wipe off the vernix caseosa)
§ Remove the wet cloth.
10. After 30 seconds, if newborn is breathing and crying,
§ Position the newborn prone on the mother’s abdomen or
chest.
§ Cover the newborn’s back with a dry blanket.
§ Cover the newborn’s head with a bonnet/cap.
11. After 1-3 minutes, properly time cord clamping.
§ Remove the first set of gloves.
§ After the umbilical pulsations have stopped, lamp the
cord using a sterile plastic clamp at 2cm from the
base.
§ Do not milk the cord towards the baby.
§ Clamp again at 5 cm using Kelly forceps from the base.
§ Cut the cord close to the plastic clamp.

12. Place the identification band on ankle (not wrist) of

corresponding gender.
§ CPCMHI – left ankle
§ VSMMC – both ankles
§ Leave the newborn in skin-to-skin contact.
§ Observe for feeding cues, including tonguing, licking,
rooting.
§ Point these out to the mother and encourage her to
nudge.
§ 14. After 90 minutes, remove the newborn from
mother’s abdomen.
15. Transfer the newborn to the work table.
16. Weigh the newborn to the work table.
17. Perform physical assessment of the newborn
and do APGAR scoring.
§ Perform Anthropometric measurement

§ Head circumference

§ Chest circumference

§ Mid-arm

§ Body length

19.Take the rectal temperature

20. Inject Vitamin K
§ CPCMHI – left thigh

§ VSMMC – right thigh

21. Apply eye prophylaxis.
22. Put on baby’s clothes.
23. Wrap the baby with baby’s blanket
24. Obtain heart rate and respiratory rate.
25. Show the baby to the mothers. Latch on the baby
to the mother’s breast.
26. Documentation immediately after cord care and
latch on.
27. Do after care.
 After the discussion and demonstration, the
BSN 2 students will be able to develop
positive attitude, acquire basic knowledge
and skills on APGAR and Ballard Scoring.
The BSN 2 Students will be able
to:

1. Recognize the importance of 3. Measure vital

APGAR SCORING to determine statistics of
how well the baby tolerated the newborn
birthing process. accurately.
2. Recognize the importance of
providing immediate newborn 4. Describe the
care to minimize risk of illness neonatal transition
and maximize growth and period on time.
development.
5. Recognize the 7. Prepare the materials
importance of “Unang needed in Immediate
Yakap”. newborn care, bathing
and burping the baby
6. Practice the before a procedure.
procedure at home
following the steps
found in RLE Manual. 8. Return Demonstrate
Immediate newborn
care, bathing and
burping the baby
utilizing the steps found
in RLE Manual.
APGAR is a quick test performed
on a baby at 1 and 5 minutes after
birth. The 1-minute score determines
how well the baby tolerated the
birthing process. The 5-minute score
tells the health care provider how
well the baby is doing outside the
mother's womb.
In rare cases, the test will be done 10
minutes after birth.

Virginia Apgar, MD (1909-1974)

introduced the Apgar score in 1952.
How the Test is
Performed?
The Apgar test is done by a doctor, midwife,
or nurse. The provider examines the baby's:

§ Breathing effort
§ Heart rate
§ Muscle tone
§ Reflexes
§ Skin color

Each category is scored with 0, 1, or 2,

depending on the observed condition.
Breathing effort:

§ If the infant is not breathing, the

respiratory score is 0.
§ If the respirations are slow or irregular,
the infant scores 1 for respiratory effort.
§ If the infant cries well, the respiratory
score is 2.
Heart rate is evaluated by stethoscope.
This is the most important assessment:

§ If there is no heartbeat, the infant scores 0

for heart rate.
§ If heart rate is less than 100 beats per
minute, the infant scores 1 for heart rate.
§ If heart rate is greater than 100 beats per
minute, the infant scores 2 for heart rate.
Muscle tone:

§ If muscles are loose and floppy, the infant

scores 0 for muscle tone.
§ If there is some muscle tone, the infant
scores 1.
§ If there is active motion, the infant scores 2
for muscle tone.
Grimace response or reflex irritability is a
term describing response to stimulation, such
as a mild pinch:

§ If there is no reaction, the infant scores 0 for

reflex irritability.
§ If there is grimacing, the infant scores 1 for
reflex irritability.
§ If there is grimacing and a cough, sneeze, or
vigorous cry, the infant scores 2 for reflex
irritability.
Skin color:

§ If the skin color is pale blue, the infant

scores 0 for color.
§ If the body is pink and the extremities are
blue, the infant scores 1 for color.
§ If the entire body is pink, the infant scores
2 for color.
 Apgar scores of 0-3 are critically low, especially in term and late-preterm infants
 Apgar scores of 4-6 are below normal, and indicate that the baby likely requires medical
intervention
 Apgar scores of 7+ are considered normal
1.You’re collecting the 1
minute APGAR on a male
newborn.You note the
HR:140bpm. The baby’s
cry is strong, body is pink
with slightly blue hands
with some flexion of arms
and legs and With MORO
reflex:

 A=
 P=
 G=
 A=
 R
2. HR 97 PBM. NO
RESPONSE TO
STIMULATION,
FLACCID,ABSENT
RESPIRATION,
CYANOTIC
THROUGHOUT.

 A-
 P-
 G-
 A-
 R-
 qBALLARD
SCORING

- The process of
rating the infant’s
physical and
neuromuscular
maturity.
Newborn physical examination
findings also allow clinicians to
estimate gestational age using the
new Ballard score.
The Ballard score is based on the
neonate's physical and
neuromuscular maturity and can be
used up to 4 days after birth (in
practice, the Ballard score is usually
used in the first 24 hours).
The neuromuscular components are
more consistent over time because
the physical components mature
quickly after birth.
However, the neuromuscular
components can be affected by
illness and drugs (eg, magnesium
sulfate given during labor).
Because the Ballard score is
accurate only within plus or
minus 2 weeks, it should be used
to assign gestational age only
when there is no reliable
obstetrical information about the
estimated date of confinement or
there is a major discrepancy
between the obstetrically defined
gestational age and the findings on
physical examination.
Based on gestational age, neonates
are classified as:

§ Premature: < 34 weeks gestation

§ Late pre-term: 34 to < 37 weeks
§ Early term: 37 0/7 weeks through
38 6/7 weeks
§ Full term: 39 0/7 weeks through 40
6/7 weeks
§ Late term: 41 0/7 weeks through
41 6/7 weeks
§ Postterm: 42 0/7 weeks and
beyond
§ Postmature: > 42 weeks
ASSESSMENT for Well-being
UNANG YAKAP
 Unang Yakap is a simple
and evidence-based
interventions that may help
in ensuring the survival of all
newborns and young infant.
This compasses
interventions such as
ensuring warmth,
breastfeeding, love and safety
and infection control. This
protocol is now practiced in
birthing centers and
hospitals.
Clear instructions that EINC
(Essential Intrapartum
Newborn Care)  protocol
will be performed
immediately after the
delivery must be given by the
mother prior to giving birth.
Within 48 hours of
delivery until the first
week of baby, series of
measures are performed
in order to give safe and
quality care:

ü First, the newborn baby

must be immediately
and thoroughly dried.
This may prevent low
body temperature and
stimulate the newborn’s
breathing. Baby’s natural
reflex to root the
mother’s breast may be
hindered when the baby
is bath too early. 
ü Second, skin-to-skin
contact between the
newborn and mother
must be done for at
least six hours. This is
done to keep the baby
warm, prevent
complications such as
hypothermia, infection
and hypoglycemia, and
initiate breastfeeding
within one hour after
birth. Usually, baby’s
distress is caused by
her separation from the
mother. 
ü Third, appropriately
timed clamping and
cutting of the umbilical
cord. The umbilical cord
of the baby must be
clamped for 1-3 minutes,
or when the pulsation
stops. The appropriate
timing of cutting is
important in preventing
the newborn’s brain from
bursting a blood vessel
and bleeding. Also, it may
help increase the blood
volume and birth iron
stores of the baby. Proper
cord care must also be
observed to prevent
entry of infection through
the umbilicus.
ü Lastly, early
breastfeeding is
implemented to the
newborn. During early
breastfeeding, a mother
produces a substance
called colostrum which
helps in boosting the
immunity of the baby
against diseases. Also,
breast milk ensures that
the newborn receives
all the nutrients needed
by his/her body.
Newborn
Screening
A newborn baby should also
undergo newborn screening
(NBS) within 24 hours from
birth.
NBS is a practice of testing
babies to determine if they
have congenital metabolic
disorder that may affect their
mental ability, hinder their
development, and worst may
cause death. It helps health
professionals identify and treat
these conditions to prevent
consequences that may harm
the growth of the baby.
Metabolic conditions that
can be determined in
newborn screening are the
following:
ü Congenital
Hypothyroidism
ü Congenital Adrenal
Hyperplasia
ü Galactosemia
ü Phenylketonuria
ü Maple Syrup Urine
Disease
ü Glucose-6-Phosphate
Dehydrogenase
deficiency
 Congenital Hypothyroidism

-is a severe deficiency of thyroid hormone in newborns. It

causes impaired neurological function, stunted growth, and
physical deformities.
 ü Congenital Adrenal Hyperplasia

Congenital adrenal hyperplasia is

an inherited condition caused by
mutations in genes that code for
enzymes involved in making steroid
hormones in the adrenal glands.
The most common enzyme defect, 21-
hydroxylase deficiency, leads to excess
amounts of male hormones being
produced by the adrenal glands.
An excess of the male sex
hormones can result in short height
and early puberty for both boys and
girls. Signs and symptoms of
classic CAH in children and adults
include: Appearance of pubic hair at a
very early age. Rapid growth during
childhood, but shorter than average
final height.
 ü Galactosemia

Galactosemia, which means

“galactose in the blood,” refers
to a group of inherited
disorders that impair the
body's ability to process and
produce energy from a sugar
called galactose.
When people
with galactosemia injest
foods or liquids containing
galactose, undigested sugars
build up in the blood.
ü Phenylketonuria

Phenylketonuria (PKU)
is an inborn error of
metabolism that results in
decreased metabolism of
the amino acid
phenylalanine.
Untreated, PKU can lead to
intellectual disability,
seizures, behavioral
problems, and mental
disorders. It may also result
in a musty smell and lighter
skin.
 ü Maple Syrup Urine
Disease
Maple syrup urine
disease (MSUD) is an
autosomal recessive
metabolic disorder affec
ting branched-chain
amino acids. It is one
type of organic acidemia.
The condition gets its
name from the distinctive
sweet odor of affected
infants' urine,
particularly prior to
diagnosis and during
times of acute illness.
ü Glucose-6-Phosphate Dehydrogenase deficiency

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a
condition in which red blood cells break down when the body is exposed
to certain drugs or the stress of infection. It is hereditary, which means it is
passed down in families.
BATHING
THE NEW
BORN
 BATHING

is the immersion of the body in a fluid

usually water or an aqueous solution
in order to clean babies’ skin.

Purposes of bathing :
ü Getting clean
Babies need regular baths to clean
their skin and hair more consistently
than being wiped with a cloth after
eating or during a diaper change.
Baths control excess oil in the hair ,
clean the baby’s skin from too much
moisture and dry areas between skin
fold.
ü Staying Healthy
Baths are important for babies to protect the health
o f t h e i r s k i n . A b a by ’s s k i n c a n b e f r ag i l e a n d
protecting it by using soap made specifically for babies
instead of products designed for adults preserves the
softness of skin. A bath is also a time to check the
baby’s body for rashes or areas of dr y skin and
m a s s ag i n g t h e i r a r m s a n d l e g s w h i l e c l e a n i n g
promotes circulation in their extremities.
ü Emotional benefits
With a little practice a bath an
become a relaxing and time
between parents with their babies.
Bathing a baby teaches them the
importance of touch and gives her
the feeling of skin contact. Being
face to face with a baby while
bathing them promotes eye
contact and provides a positive
interaction between parent and
child. Wrapping them in a soft
towel and gently drying them after
the bath allows her to feel warm
and safe.
ü Play time
Beyond the health and emotional benefits ,
bath time can also be a play time for babies.
Splashing and playing allow the baby to learn
about the consistency of water.
Baby’s toys and bubbles teach hand –eye
coordination and are fun to play with in the
tub. Singing songs and pointing out body parts
are fun ways that babies can enjoy a bath while
getting clean at the same time.
 a by
b
t he
i n g
t h
in ba
ep s
St
1.First, undress baby -- cradling the
head with one hand.

2.Leave the diaper on (wash that

area last). Wrap baby in a towel,
exposing only those areas that you
are washing.
3.Using a baby bath sponge or
wash cloth, cleanse one area at a
time.
ü Start behind the ears, then
move to the neck, elbows,
knees between fingers and toes.
ü Pay attention to creases under
the arms, behind the ears,
around the neck.
ü The hair comes toward the end
of bath time so baby doesn't get
cold.
ü While newborns don't have
much hair, you can sponge the
few wisps that are there.
4. To avoid
getting eyes wet,
tip the head back
just a little.
There's no need
for shampoo; just
use water.
5.Now it's time to remove the diaper
and sponge baby's belly, bottom, and
genitals.
ü Wash little girls from front to back.
If there's a little vaginal discharge,
don't worry and don't try to wipe
it all away.
ü If a little boy is uncircumcised,
leave the foreskin alone.
ü If circumcised, don't wash the head
of the penis until it's healed.
ü Gently pat baby dry.
ü Rubbing the skin will irritate it.
ü Bath time is over, and your fresh
little baby is ready for a clean
diaper and clothes!
 T
N
FA
IN
N
A
G
I N
RP
BU
Burping is the release of gas from the
digestive tract (mainly esophagus and
stomach)through the mouth. It is
usually accompanied with a typical
sound and at times an odor.

Babies are particularly subject to

accumulation of gas in the stomach
while feeding and this can cause
considerable agitation and or
discomfort to the child unless it is
burped.

The act of burping an infant involves

placing the child in a position
conducive to gas expulsion(for example
holding the infant up to the adult’s
shoulder with the infant’s stomach
resting on the adult’s chest) then lightly
patting it on the lower back so that it
burps.
Because burping can cause
vomiting in infants the burp
cloth or burp pad is
sometimes employed on
the shoulder to protect the
adult’s clothing.
 Purposes of Burping

ü Burping helps to get rid

of some of the air that
babies tend to swallow
during feeding
ü Prevents colic
ü A lot of disturbances
and irritability of
infants could be kept
away
 es
qu
ni
ch
Te
ng
pi
ur
B
1.Over the hand burp.

Sit baby on your lap and

place the heel of your hand
against her tummy with her
chin resting on the top of
your hand. Lean baby
forward resting most of her
weight against the heel of
your hand to provide
counter pressure on her
tummy and pat her on the
back to move up the air
bubbles.
2. Over the shoulder burp.

Drape baby way up over your

shoulder so that your shoulder
presses against her tummy right
hand then rub or pat her back.
Hold baby securely by hooking
your thumb under her armpit. If
she’s on your right shoulder ,do
this holding with your right
hand.
3. Over the lap
burp.

Drape baby over

one thigh (legs
crossed or
spread)so that it
presses upward
against her tummy.
Support baby’s
head with one hand
while you pat or
rub her back with
the other hand.
4. Sling burping.

If the air just won’t

come up, place
baby upright against
your chest and
wear her in a sling
until the air comes
up.
5.Burp and switch.

Some babies are

more comfortable if
they burp when
changing sides.
Getting the air up
makes room for
more milk.
This can help avoid
large spit-ups when a
bubble gets trapped
under the milk.
6. Knee to chest burp.

Sometimes babies need help not

only getting air out to the top
end, but also out the bottom.
The knee chest position (flexing
baby’s knees up against her
chest )helps baby pass excess
gas.
GENERAL OBJECTIVES:

After the discussion and

demonstration, the BSN 2 students
will able to develop positive attitude,
acquire basic knowledge and skills in
IV therapy.
Specific Objectives

 The BSN 2 students will be able to:

 1. Recognize the importance of IV therapy in fluid and
electrolyte replacement and IV medication access.
 2. Define related terms correctly.
 4. Practice the procedure at home following the steps written
in RLE Manual.
 5. Prepare the materials needed in Assisting IV Insertion
completely.
 6. Return Demonstrate the procedure utilizing the correct
steps written in RLE Manual.
 DEFINITION OF TERMS

1. Intravenous Therapy
-

 
2. Parenteral
-
3. Parenteral fluids
-

 
4. IV pole
-
5. Drip chamber

6. Regulator
8. Injection port
-

 
9. IV catheter
-
 Because intravenous
(IV) medications enter
the client’s blood
stream directly by the
way of a vein, they are
appropriate when a
rapid effect is required.
This route is also
appropriate when
medications are too
irrititating to tissues to
be given by other routes.
When an intravenous
line is already
established, this
route is desirable
because it avoids the
discomfort of other
parenteral routes.
Following are
methods
To administer
medications
intravenously:
ü Large volume infusion
of intravenous fluid
ü Intermittent
intravenous infusion
(piggyback or tandem
setups)
ü Volume controlled
infusion (often used in
children)
ü Intravenous push or
bolus
ü Intermittent injection
ports
 With all IV medication
administration, it is very
important to observe
clients closely for signs of
adverse reactions. Because
the drug enters the
bloodstream directly and
acts immediately, there is
no way it can be withdrawn
or its action terminated.
Therefore the nurse must
take special care to avoid
any errors about the
preparation of the drug and
the calculation of the
dosage. When the
administered drug is
particularly potent, an
antidote of the drug should
be available. In addition,
assess the vital signs before,
during and after infusion of
the drug.
Large volume infusions

Mixing a medication into large

volume IV container is the safest
and easiest way to administer a
drug intravenously. The drugs
are diluted in volumes of 1000mL
or 500mL of compatible fluids.
Fluids such as IV normal saline
or Ringers are frequently used.
Commonly added drugs are
potassium chloride and vitamins.
The main danger of infusing
large volume of fluids is
circulatory overload.
Intermittent Intravenous
Infusions

A method of administering a
medication mixed in a small
amount of IV solution, such
as 50 or 100 mL. The drug is
administered at regular
intervals, such as every 4
hours with the drug being
infused for a short period of
time such as 30 to 60 minutes.
Two commonly used additive
or secondary IV setups are the
tandem and the piggyback.
Tandem setup, a second
container is attached to the
line of the first container at
the lower, secondary port.
It permits medications to
be administered
intermittently with the
primary solution.
Piggyback, a second set
connects the second
container to the tubing of
the primary container at the
upper port. Traditionally the
tubing of the secondary set
has been attached to ports
of the primary infusion by
inserting a needle through
port and taping it in place.
 Needleless systems
are now available.
These needleless
system are can be use
threaded lock or lever
lock cannulae to
connect the secondary
set to ports of the
primary infusion. This
design prevents
needlestick injuries
and also prevents
touch contamination
at the IV connection
site.
Needleless injection port
Injection port (requires needle)
Volume Control Infusions

These are small fluid containers (100 to 150 mL in size)

attached below the primary infusion container so that
the medication is administered through the client’s IV
line. Frequently used to infused solutions into children
and older clients when the volume administered is
critical and must be carefully monitored.
Intravenous Push

IV Push (Bolus) is the

intravenous
administration of an
undiluted drug directly
into the systemic
circulation. It is used
when a medication
cannot be diluted or in
an emergency.
 Intermittent Infusion
Devices

May be affixed to an
intravenous catheter or needle
to allow medications to be
administered intravenously
without requiring repeated
needlesticks or a continuous
intravenous solutions. May
have either a resealable latex
injection site for needleless
access or port that allows a
syringe or a needleless adapter
to be connected for
administering medications.
 Needleless systems are
preferred because
significantly reduce the
risk of needlestick
injuries among
healthcare workers.
Intermittent injection
ports may be flushed
with sterile saline prior to
and after medication.
 First, let’s get familiar
with the cell and how
tonicity works through
osmosis.The cell is
divided into two parts:
(intracellular and
extracellular). Each
part is made up of a
solution and depending
on the tonicity of the
fluid you can have
shifting of fluids from
outside of the cell to the
inside via osmosis.
 Osmosis allow molecules
of the solvent to pass
through a semipermeable
membrane from less
concentrated solution to a
higher concentrated
solution. The key thing to
remember here is that
everything will move from
a LOW concentration to a
HIGH concentration.
 The cell loves to be in
an isotonic state and
when something
happens to make it
unequal (like with
hypotonic or hypertonic
conditions) it will use to
try to equal it out.
1.Hypotonic Solution
ü lowers osmotic pressure and makes
fluid move into cells

ü used to treat cellular dehydration and

established renal function
ü HYPO: under/beneath
ü Tonic: concentration of a solution

üT h e c e l l h a s a l o w a m o u n t o f s o l u t e
extracellulary and it wants to shift inside the
cell to get everything back to normal via
osmosis. This will call cell swelling which can
cause the cell to burst or lyses.
Hypotonic solutions:

ü 0.45% Saline
ü 0.22% Saline
ü 0.33% saline
Hypotonic solutions
are used when the cell
is dehydrated and
fluids need to be put
back intracellularly.
This happens when
patients develop
diabetic ketoacidosis or
hyperosmolar
hyperglycemia.
0.45 % NaCl
 Use: raises total fluid
volume
 Miscellaneous: Useful
for daily maintenance of
body fluid, but is less
value for replacement of
NaCl deficit.
ü Helpful for establishing
renal function.
ü Fluid replacement for
clients who don’t need
extra glucose
(Diabetics)
Important: Watch out
for depleting the
circulatory system of
fluid since you are
trying to push
extracellular fluid into
the cell to rehydrate it.
Never give hypotonic
solutions to patient who
are at risk for increased
cranial pressure (can
cause fluid to shift to
brain tissue), extensive
burns, trauma because
you can deplete their
fluid volume.
2. Isotonic Solution
- increases only extracellular
fluid volume
Iso: same/equal
Tonic: concentration of a solution

The cell has the same concentration on the

inside and outside which in normal
conditions the cell’s intracellular and
extracellular are both isotonic.
Isotonic:

ü 0.9 % saline
ü 5% dextrose in water
ü Lactated Ringer
ü 0.9% NaCl (Normal Saline)

Use: increases circulating plasma

volume when blood cells are
adequate
Miscellaneous:
ü Replace losses without
altering fluid concentrations
ü Helpful for sodium
replacement
ü Lactated Ringer’s Solution

Description: Normal Saline with

electrolytes and buffer
Use: replaces fluid and buffers
pH
Miscellaneous:
ü Normal saline with Potassium,
Calcium and lactate (buffer)
ü Often seen with surgery
ü D5W (Dextrose in 5%
Water)

Use: Raises total fluid

volume. Helpful in
rehydrating and
excretory purposes.
Miscellaneous: Provides
17—200 calories/1,000 cc
for energy
 Isotonic solutions
are used: to increase
the EXTRACELLULAR
fluid due to blood loss.
Surgery. Dehydration,
Fluid loss that has
been loss
extracellularly.
3. Hypertonic Fluid
- increases osmotic pressure and draws
fluid from the cells
Hyper: Excessive
Tonic: concentration of a solution

The cell has an excessive amount of solute

extracellularly and osmosis is causing water
to rush out of the cell intracellularly to the
extracellularly area which will cause the cell
to shrink.
ü D5NaCl

Use: replaces fluid

sodium, chloride and
calories.
ü D5LR

(Dextrose 5% in Lactated
Ringer)
Use: same as LR plus
provides about 180 calories
per 1 Liter
D5 0.45% NaCl

Use: Useful for daily

maintenance of body
fluids, nutrition and for
rehydration.

Miscellaneous:
Most common
postoperative fluid
ü Volume control chamber – a special control chamber
that is used to regulate the fluid amount administered in
a specific time
Spike

IV Tubing

Drip Chamber
Y – Port /
Injection Port
Needle

Regulator
IV CATHETERS/ IV CANNULAS
3. Intracathether- refers to
a plastic tube inserted into
a vein
ü Catheters (needles) are
sized by their diameter,
which is called gauge
ü The smaller the diameter,
the larger the gauge
ü The greater the
diameter, the more
fluid can be delivered
ü To deliver a large
amounts of fluids, you
should select a large
vein and use a 14-16
gauge catheter
Sites for IV Cannulation
Lower extremities
Problems
with IV
Therapy
 Systemic Complications:

is an abnormal increase in
blood volume caused by an infusion rate more
than the patient’s system can accomodate .
Local Complications:
- inflammation of the vein
 – the catheter is dislocated to the surrounding
tissues rather that directly to the vein
Extravasation
Nursing Responsibilities of IV
complications:
 Remove the device
 Elevate the extremity with infiltrated site
 Prepare for possible reinsertion in the opposite arm if
applicable
 Notify the doctor if severe or there is a need to
continue IV therapy
 Assess circulation
 Monitor patient’s status for signs of infection
 Document
PREVENTION:
 Check site frequently
 Instruct patient to report signs of IV complications
such as discomfort, pain and swelling
 Anchor cannular securely
 Use maximal sterile barrier precautions during
insertion
 Practice good hand hygiene before palpating, inserting,
replacing , or dressing any vascular site.
 If any part of the system is disconnected, don’t rejoin it.
 Remove at first sign of infection
 Replace site, tubings or bags per institution policy

Example:
Change set= 72 hours
For TPN or antibiotic IV bags = 24hours
 Careful monitoring of IV flow rate, maintain
prescribed rate.
 Know the actions and side effects of the drug being
administered.
 Use IV infusion machine when indicated
Sites should be avoided during IV
cannulation:
ROLES OF NURSES
 PROCEDURE:

ASSISTING AN IV INSERTION
REMOVING PERIPHERAL IV LINE
PREPARE THE MATERIALS NEEDED
Materials used in IV therapy
1. Infusion set
2. Container of sterile parenteral solution
3. IV pole
4. Adhesive or hypoallergenic tape
5. Clean gloves
6. Tourniquet
7. Antiseptic swabs
8. Antiseptic ointment, such as povidone-iodine
9. Intravenous catheter
10. Sterile gauze dressing or transparent occlusive
dressing
11. Arm splint, if required
Key Points Prior to Initiation of IV Therapy
1. Physician’s prescribed
treatment.
ü Patient’s name
ü Type and amount of solution
ü The flow rate
ü The type, dose and frequency of
medications to be
incorporated/pushed
ü Others affecting the procedures
(X-rays, treatment to the
extremities, etc.)
2. Patient Assessment
ü Patient’s diagnosis
ü Patient’s age
ü Dominant –arm
ü Condition of the vein/skin:
a. use of distal veins of arms first
b. select a vein that is the most easily
palpated and feels soft and full
c. select a vein large amount enough
to allow adequate circulation
around the catheter
d. select a vein naturally splinted by
a bone
e. avoid veins that are previously
used and damaged
f. avoid veins of a surgically
compromised or injured extremity
3. IV set and equipment
preparation
ü Check for expiry date
ü Check for clarity; any presence of
holes on plastic cover (packaging);
plastic container (bag) presence of
sediments or insects
ü Check label against the physician’s
written prescription
ü Label for any medication that are
added: date, time, dose of
medication and amount,
compatibility of drug with the
solution
ü Functionality of Infusion Pump
ü Peripheral IV cannulas and the site
are routinely aseptically or re-sited
every 48-72 hours or when
necessary
Steps in Assisting IV Insertion
 Wash Hands
 Prepare Equipments
 Check the information label of the IV solution
container, including the patients name and room
number, type of solution. The time and date of it’s
preparation, the preparer’s name and ordered
transfusion rate.
 Compare the solution label with the doctor’s order.
 Remove the protective cap of the solution bottle.
 Take out the IV set from the package.
 Remove the protective cap of the IV set
needle of puncture device.
 Close the clamp of the IV tubing.
 Insert the IV set needle/ puncture device
into the rubber port of the solution bottle.
 Fill the drip chamber with IV solution by
pressing lightly on it.
 Open the IV tubing clamp and fill tubing
completely with solution , purging air out.
 Bring the equipment together with the prepared
I.V. solution at the patient’s bedside.
 Check patient’s identity.
 Explain the procedure.
 Wash hands.
 Place the patient in a comfortable reclining
position leaving the arm in dependent position
to increase capillary refill of the lower arm and
hand.
 If the patient’s arm is cold, warm it by rubbing
and stroking the arm to cover the entire arm
with warm packs for 5 to 10 minutes.
 Clean the IV insertion site with povidone-
iodine or alcohol in a circular motion from
inside to out.
 Do not touch the cleaned area and instruct the
patient to do the same.
 Place the IV pole in the proper slot in the
patient’s bed frame or if using a portable IV pole,
position it close to the patient.
 Hang the IV bottle on the IV pole with attached
primed administration set.
 After insertion of the IV catheter by the doctor
or trained IV therapy nurse, dispose the
needles/ stylet in a sharp container.
 Regulate the flow rate.
 Secure the device with transparent
semipermeable dressing or by the use of an
adhesive bandage.
 Adjust the flow rate as ordered.
 If puncture site is near a movable joint, secure it
with a roller gauze or tape to provide stability.
 Label the last piece of tape with the type,
gauge of needle, and length of the cannula;
date and time of insertion and your initials.
 Wash hands .
 Document procedure.
DOCUMENTATION
Removing Peripheral IV Line
 Check the doctor’s order and verify the patient’s name
and room number.
 Prepare the equipment.
 Bring equipment to bedside.
 Explain the procedure.
 Clamp the IV tubing to stop the flow solution.
 Gently remove the transparent dressing and all tape
from the skin if possible, use alcohol or acetone to
disable adhesive.
 Using the aseptic technique, open the gauze
pad and adhesive tape and place it within
reach.
 Put on gloves.
 Hold the sterile gauze pad over the puncture
site with one hand and use your other hand
to withdraw the cannula slowly and
smoothly, keeping it parallel to the skin.
 Using the gauze pad, apply firm pressure on the
site for 11- 2 minutes after removal or until the
bleeding has stopped.
 Clean the site and apply the adhesive bandage
or if blood oozes, apply a pressure bandage.
 Instruct the patient to restrict activity for about
10minutes and to leave the dressing in place for
at least an hour.
 Do after care.
 Wash hands
 Document procedure.
IVF CALCULATION
1. Flow rate= total volume of IVF x drop(gtts) factor
no. of hours to infuse x 60

DROP FACTOR:
Macro drip (gtt) = 15 gtts/ml
Micro drip (ugtt) = 60 ugtts/ml
Example: Compute the rate of flow of D5 0.3 NaCl 250
ml to be consumed in 8 hours
2. VOLUME PER HOUR

Volume per hour = Total vol. of IVF in ml/cc

no. of hours to consume

Example: 250 cc = 31.25 cc/hour

8 hours
3. NUMBER OF HOURS TO CONSUME

Number of hours = Total vol. of IVF

ml/ hour
Example: 250 cc = 8 hours
31 cc/hour
4.Volume per hour(ml/hour) to
flow rate
Formula:

Volume per hour x drip factor /60

120ml/ hour to be converted to flow rate?

120ml/hour x drip factor(15gtt/ml or

60gtt/ml) /60
Calculating Continuous Infusions
1. To calculate gg/hr (gtts/min)
Solution cc x 60min/ hr x kg x mcg/kg/min = cc/ hour
Drug mcg
Example: Dopamine 400mg/ 250cc D5W to start at 5
mcg/kg/min

=250cc x 60min x 86.4kgs x 5mcg / min

400, 000mcg 1 hour kg
= 16. 2cc/ hour
 2. mcg/ kg/min
Drug mcg x cc/hour = mcg/kg/min
Solution cc x 60min/ hour x kg

Example: Nipride 100mg/ 250cc D5W was ordered to decrease patient’s blood
pressure. The patient weight is 143lbs and the IV pump is set at 25cc/hour. How
many mmcg/kg/min of Nipride is the patient receiving?

Convert 100mg to mcg= 100, 000mcg

Convert 143 lbs to kgs = 65kgs

=100, 000mcg x 25cc /hour

250cc x 60mins/hour x 65 kg

= 2. 56mcg/min/kg
Common conversions
1 liter = 1000 ml
1 gram = 1000 mg
1 mg = 1000 mcg
1 kg = 2.2 lbs
 : D5LR 1 liter to be infused in 10
hours
a. Compute to rate of low in macro drops
b. Compute the flow of rate in micro drops
c. Compute for the volume per hour
1. MACRO DROPS

1000 mlx 15 = 15000 = 25 gtts/min

10 hours x 60 600
2. MICRO DROPS

1000 cc/ml x 60 = 60000 = 100 ugtts/min.

10 x 60 600
3. Volume per hour

1000 cc = 100 cc/hour

10 hours
4. NUMBER OF HOURS TO CONSUME

1000 cc = 10 hours
100 cc/hour
 Time Taping
Hourly rates of infusion can be calculated by
dividing the total infusion volume by the total
infusion time in hours.
 SAMPLE IVF FLUID TIME TAPE
Cebu (VELEZ) General Hospital
Name of patient: ________ Date: _______
Ward/RM/ Bed no: ____________________
Venoclysis: ____________________________
Additives: _____________________________
Rate of flow per minute: ________________
No. of hours to consume: _______________
Vol. / hour: _____________________________
TIME FLUID LEVEL
7 am 250 ml
8 am 219 ml
9 am 188 ml
10 am 157 ml
11 am 126 ml
12 nn 95 ml
1 pm 64 ml
2 pm 33 ml
3 pm 2 ml
 TIME FLUID LEVEL

12 NOON 1000 ml
1 PM 900 ml
2 PM 800 ml
3PM 700 ml
4PM 600 ml
5PM 500 ml
6PM 400 ml
7PM 300 ml
8PM 200 ml
9PM 100 ml
10 PM 0 ml
MEASURING INTAKE
AND OUTPUT
Equipment:
-Calibrated glass or cup
-Intake and output bedside
form with fluid conversions
-Intake and output record
chart
-Commode/ bedpan/ urinal
for urine and other output
measurements
-Clean gloves
Guidelines:
1. Assess if strict measurement of intake
and output is ordered
2. Assess patient’s ability to assist in
keeping intake and output record.
3. Instruct patient to keep record of all
fluids taken orally. Keep an I&O record
at the bedside for patient to document
intake
4. Assess all potential sources of intake
(IVF, oral fluids, NGT) and output
( e.g.vomitus, stool, urine, drainage
from tubes)
5. Instruct patient to void into bedpan or
urinal, not into toilet
6. Instruct patient not to place toilet tissue
in bedpan or defecate in bedpan
7. Empty urinal, bedpan, or Foley drainage
bag into measuring container
8. Record time and amount of output on
bedside I&O record. Record all urine,
drainage from nasogastric tubes,
drainage tubes, etc.
9. Observe color, clarity, and odor of urine
10. Determine all forms where
documentation of I&O occur
11. Assess for signs of dehydration or
overhydration
12. Evaluate weight changes
13. Record all forms of fluid intake except
blood and blood products in the total
amount column of the 24 hour record
(IVFs and Oral fluids). These are
recorded separately
13. Transfer all intake and output to
graphic sheet or 24 hour I&O record
14. Complete 24 hour output record by
adding together all three intake and
output totals and place total on graphic
sheet
15. Use clean gloves in transferring and
measuring the intake and output
16. Accurately measure all sources of fluid
intake and output
 Input
Shift IVF Oral Total

7-3

3-11

11-7
Intake
Fluids taken in the body can be via mouth, tube or IV

Examples:
Juice
Water
Ice chips(melt to half its volume)
Drinks
Gelatin
Milk
Coffee
IV fluids
IV flushing
Output
 Urine
 Emesis
 Liquid Stool
 Wound Drainage(drains, tubes
 Suction(gastric, respiratory
 Patient A was admitted because of acute renal failure and
the doctor ordered for absolute intake and output
monitoring.

 At around 6:30am, he drunk 100ml of neprocan,

consumed about 1 cup of porridge at 8am, and his IVF was
at 10ml/ hour up to 2pm and with IV medication drip
diluted with 50ml in the soluset.

 At around 9am he vomitted about 5ml of saliva, with

urine output of 20ml from 6am to 2pm. What is the
intake and output of the patient from 6am to 2pm?
Practice Test
1. Doctors says : Infuse 1500ml of Lactated Ringers over 12hours”.
Drip factor is 15gtt/ml.Compute for the flow rate.

2. Infuse 2 liters of D5LR with 50meq Potassium Chloride over 48

hours. Compute for the volume per hour.

3. D5LR 1 liter is to be infused at 120ml/hour at 7am.How many

hours will this IV fluid will last? At what hour the nurse will
hook another bottle of fluid?

4. D5IMB 500ml to be infused at 50cc/ hour around 6am.How

many drops per minute will the nurse regulate using a drip factor
of 15gtts/ml? using 60ugtts/ml?
My child there is something else to watch out
for. There is no end to the writing of books, and
too much study will wear you out.

After all this, there is only one thing to say:

Have reverence for God, and obey His
commands, because this is all that we were
created for.

Ecclesiastes 12: 11-12

 B LO O D T R A N S F U S I O N
A SSI ST I N G
 GENERA L O BJ E C T IV E
ND
• A FT E R T H E D IS C U S S IO
H
N
E B
A
S N 2 S T U D E N TS
DEMONSTRATION , T
T O D E V E LO P P O S IT IVE
WILL BE ABLE
U IR E B A S IC K N OW L E D GE
ATTITUDE, ACQ
S IN A S S IS T IN G B LO O D
AND SKILL
TRANSFUSION.
 SPECIFIC O BJ E C T IV E S
TS W ILL B E ABLE TO:
• THE BSN 2 S TU D EN
D T R A N S FU S ION IN SAVING
PORTANCE O F B LO O
• 1. RECOGNIZE THEAIM MITING TH E C O M P LIC A T IO N S OF SEVERE
A PATIENT’S LIFE ND LI
BLOOD LOSS.
TER M S CO RRECTLY.
• 2. DEFIN E REL A TED
FO LL O W IN G T HE STEPS
T H O M E
• 4. PRACTICE THE PRANOUCAEDL.URE A
WRITTEN IN RLE M
N EE D ED IN A S S IS TIN G BLOOD
IALS
• 5. PREPARE THE MOACTER ED U RE C O MPLETELY.
TRANSFU S IO N P R
P R O C ED U R E U T ILIZ IN G THE
• 6. RETURN DEMONWSRTITRATTENE TINHERLE MANUAL.
CORRECT STEPS
 BLOOD TRANSFUSION
• THE TRANSFER OF BLOOD OR BLOOD
PRODUCTS FROM ONE PERSON (DONOR)
INTO ANOTHER PERSON'S
BLOODSTREAM (RECIPIENT). 

• A ROUTINE MEDICAL PROCEDURE IN WHICH

DONATED BLOOD IS PROVIDED TO YOU
THROUGH A NARROW TUBE PLACED WITHIN A
VEIN IN YOUR ARM.
• HELP REPLACE BLOOD LOSS DUE TO
SURGERY , TRAUMA , OR ILLNESS.
 D Y O U N E E D A B LO O D
WHY WOUL
TRANS F U S IO N

ME
• RESTO R E B LO O D V O L U
IO U S
R SU RG E R Y O R A S E R
- YOU'VE HAD A MAJO ST
E E D TO R E P L AC E LO
INJURY AND YOU N
BLOOD.
E E D IN G IN YOUR
• YOU'VE EXPER IE N C E D B L
A N U LC E R O R OT H ER
M
DIGESTIVE TRACT FRO
CONDITION.
 E L E U K E M IA
•YOU HAVE AN IL L N E S S L IK
C A U S E S
EA S E T H A T
OR KIDNEY DIS
U G H H E A LT H Y R E D
ANEMIA (NOT ENO
BLOOD CELLS)
• Platelets
are tiny cells in the blood that help you stop the
bleeding. A platelet transfusion is used if your
body does not have enough of them , possibly
because of cancer or cancer treatments. Platelets
LO O D
used to treat thrombocytopenia and platelet B E N T S
P O N
M
dysfunction.
• Fresh frozen plasma transfusion CO
helps replace the proteins in your body that help
it clot. It maybe needed after severe bleeding or if
you have liver disease. It contain no platelets.
• Albumin
is prepared from plasma protein . it is used to
treat shock and hypoproteinemia

LO O D
B E N T S
• Whole blood P O N
CO M
refers to blood that has all of them. In some
cases, you may need to have a transfusion
that uses whole blood, but its more likely that
you will need a specific component.
•Packed red blood cells
A concentrated preparation that is
LO O D
obtained from whole blood by B E N T S
P O N
removing the plasma (as by CO M
centrifugation) and is used in
transfusion
 DIFFERENT BLOOD TYPES:
RECIPIENT DONOR

O A B AB
AB / / / /
B / /
A / /
O /
• THAT'S WHY BLOOD BANKS SCREEN FOR
BLOOD TYPE , RH-FACTOR (POSITIVE OR
NEGATIVE) AS WELL AS THAT CAN CAUSE
INFECTION.

• ABOUT 40% PEOPLE HAVE TYPE O BLOOD,

YOU ARE CALLED A UNIVERSAL DONOR.
•IF YOU HAVE TYPE AB BLOOD, YOU
CAN RECEIVE ANY TYPE OF BLOOD
AND YOU ARE CALLED UNIVERSAL
RECIPIENT . IF YOU HAVE RH-
NEGATIVE BLOOD , YOU CAN ONLY
RECEIVE RH-NEGATIVE BLOOD.
 N S A N D
A U TIO S
PR E C ILIT IE
O N S IB • N ORM AL S A L IN E S H O U L D B E R EADILY
RE S P P N S S O R
O R IT W IL L SERV E A S T H E M A IN L IN E .
A VA IL A B L E
A D D E D T O BLOOD
• MEDICATIONS AR E N E V E R

COMPONENT.
LO O D S H O U L D NOT
• INFUSION OF 1 UNIT
O F B

EXCEED 4 HOURS.
E D C O N S E N T H A S B EEN
• ENSURE THAT AN INF
OR M

OBTAINED.
 N S A N D
A U TIO S
PRE C ILIT IE
O N S IB t p ra c ti c e BT.
P d o e s n o
RES
o n
• S o m e re li g io u s organizati
th e p h y s ic ian’s
es need to c h e c k
• T w o re g is te re d n u rs
entity , and the client
’s
order , the client ’s id n b ra c e let and
r ide n ti fi ca ti o
identification band o e n a m e a n d the
ifyin g th a t th
hospital number. Ver b a g c o m p onent.
on th e b lo o d
number are identical
fo r th e ex p ira ti o n d ate.
od bag
• Always check the blo
ir n a m e , the
to s ta te th e
• The nurse asks the cli
e
a
n
m
t
e w it h th e id b a n d .
nurse compares the n
 N S A N D
A U TIO
PREC NSIBILITIES • The nurse checks the bsloureodthat ABO and the rh type is
b a g ta g la be l , the blood

RE SP O re q u is it io n fo rm to en
ble.
compati
te n c ie s w h e n v e r if y ing the
consis
• If the n u rs e n o te s a n y
mpatib il it y, th e n u rs e n o ti fi es the
client identity and co
ly
blood bank immediate
o lo r, c lo ts a n d b u b bles
• Inspect leaks, abnorm
a l c
a s p o s s ib le (w it hin
red as s o o n
• Bloo d m u st b e a d m in is
it
te
s being re c e ive d a t th e b lo o d blank,
20-3 0 m in u te s ) fro m
ow a b le ti m e o u t o f storage
l all
as this is the maxima
 N S A N D
A U TIO S is e le va te d ,
C
re
PRE NSIBILITI E • C he c k th e v ita l s ig ns, if tem p e
e
ratu
b e g in n in g the
O e fo re th
RESP
n o ti fy th e physician b
transfusion
e v ita l s ig n s a n d a s se ss
asure th
•T h e n u rs e s h o u ld m e
e tran s fu s io n a n d a g a in a fter
lung sounds before th r a fte r the
a n d e v e r y h o u
the first 15 minutes
ted.
transfusion is comple
re fr ige ra to rs o th er than
• Never refrigerate blo
o
a
d
n
in
ks ; if th e b lo o d is not
those used in blood b s , re tu rn it to blood
20-30 m inu te
administered within
bank.
 N S A N D
A U TIO
PRE NSIBILITIES
C
RE SP O
sion
Prior to blood transfu
blood
• Check v ita l s ig n s – g e t th e
n
During the transfusio
• Check the vitals signs
th e v ita l signs
• First 15 mins c h e c k a ga in
l signs
g a in th e v ita
• Another 15 mins c h e c k a
th e v ita l signs
• 30 mins after c h e c k a g a in
signs
• Eve r y h o u r c h e c k v it a l
 N S A N D
A U TIO S muscle
C E n g ,
I
ti
E sw e a
T v y
R e a
I , h
P IB IL • If a re a c ti o n o c curs (ch il ls
elling,
S P O N S c h e st pain , ra s h e s , itc h in g , s w
E c k pa in ,
R a c h e s , b a ll o r, c ya n o s is ,
, co u g h, whee z in g , p a
rapid p u ls e , d y s p n e a
h e , n a u s e a a n d v o m iting,
apprehension heada c
h e a ), S T O P th e tr a n s fusion,
diarr
abdominal cramping, IV s ite , k e e p the IV
dow n to th e
change the IV tubing fy th e p h ys ic ia n a n d
it h n o rm a l s aline, no ti
line o pe n w bing to
e blo o d b a g a n d tu
rn th
blood bank, and retu
the blood bank. nt
n d m o n ito r th e c li e
a lone, a
• Do no t le av e th e p ati
in
e n
g
t
sy m p to m s.
for any life-t h re ate n
 E M E M B E R :
T H IN GS T O R
a n d c ro s s m a tched
• 1. Blood should be ty p e d
re th e a d m in istr a ti o n.
befo
m in a ti o n to d ete rm ine
• Typing is a laboratory
exa
p e rs o n ’s b lo o d ty p e .
a
s s o f d e te rmining
• Crossmatching is th e p ro c e
o d ty p e s.
b e tw e e n b lo
compatibility
c o m p a ti b le w it h e ac h
• 2.Not all blood types
a re
other
•
3 . B lo o d d o n o r s m u st b e
g
c a re a c c o r d i n
c h o s e n w it h
l o w i n g c r i te r i a :
to the fol
 e s s uc h a s t yp e A or
• Must be free from disea s
type B hepatitis
s or a h is to r y o f
• Must be free from all e rg ie
chronic diseases
u n ize d r e c e n t ly to
• Must not have bee ic reaction to the blood
n im m
avoid possible allerg
b lo od c o u n t,
• Heart and chest and respiratory rate ,
so un d s ,
temperature , pulse in n or m al
ho u ld b e w it h
and blood pressure s
range
• SECURE AND TRANSFUSE 1 UNIT OF PRBC OF PATIENT’S BLOOD TYPE PROPERLY SCREENED
AND CROSSMATCHED TO TRANSFUSE IN 4 HOURS
• SECURE AND TRANSFUSE 2 UNITS OF PRBC OF PATIENT’S BLOOD TYPE PROPERLY
SCREENED AND CROSSMATCHED TO BE TRANSFUSE IN 4 HOURS WITH 4 HOURS INTERVAL
• SECURE AND TRANSFUSE 1 UNIT OF PRBC DIVIDED INTO 2 ALIQUOTS OF PATIENT’S BLOOD
TYPE PROPERLY SCREENED AND CROSSMATCHED TO BE TRANSFUSE IN 4 HOURS WITH 2
HOURS INTERVAL
• SECURE 3 UNITS OF PRBC PROPERLY SCREENED AND CROSSMATCHED OF PATIENTS
BLOOD TYPE. TRANSFUSE THE AVAILABLE 1 UNIT PRBC PROPERLY SCREENED AND
CROSSMATCHED OF PATIENT’S BLOOD TYPE TO BE INFUSED IN 4 HOURS.
 MATERIALS NEEDED:

BLOOD CONSENT FORM

BLOOD REQUEST FORM
BLOOD TRANSFUSION
REACTION FORM
1. BLOOD SET
2. PLATELET SET (FOR
PLATELET TRANSFUSION
OPTIONAL
 PROCEDURE IN ASSISTING BLOOD
TRANSFUSION

1. Store 2. Check 3. Make

Store the Check the Make sure
blood in the expiration that the date
blood bank , date of the
not in the unit administration
is not past the
date of
expiration
 DO NOT USE BLOOD IF
GAS BUBBLES ARE
PRESENT OR IF BLOOD IS
DISCOLORED
• 4. Identify the recipient with
extreme care. Check blood label
information with the patient's
chart

• Identify the recipient by asking

them to state their names or by
checking the identification band
with the chart
• 5. Begin blood administration
within 30 minutes after the
blood leaves the blood bank.

• Do not use blood that has been

left unrefrigerated more than
one hour unless administration
is already in progress.
•
6. Administer with a
filter set.

•
Make sure that the
filter set is in a sterile
package.
•7. Use G16, G18, G19 needle
or catherter for
administration.

•Make sure that the needle or

catheter is in sterile package.
• 8. When agency policy
permits, NSS is used for
establishing the infusion.
The saline may be added in a
piggyback manner.

• Make sure that connectors

are clean.
•9. Use venipuncture
technique and select a
vein large enough to
accommmodate a big
needle or catheter.
• 10. After starting the infusion with
saline begin the blood flow. Blood
should be administered slowly.
(10-20 gtts/min) during the first 15
minutes.

• Let the patient report any

symptoms on or any possible
transfusion reaction immediately.
• 11. Stay with the patient for
he first 15 minutes

• Monitor the patient regularly

and frequently, at least every
6-10 minutes.
•12. If no signs and
symptoms of a transfusion
reaction occur, the rate is
increased according to the
prescribed rate.
•13. Do not administer
medications through
out the blood line.
 BLOOD
TRANSFUSION
REACTION
REACTION SIGNS AND NURSING
SYMPTOMS INTERVENTION
1. Allergic Hives, Itching,
Reaction anaphylaxis
2. Febrile Reaction Fever, Chills,
Headache
3. Hemolytic Immmediate onset
Transfusion Reaction facial flushing, chills,
hhe, low back pain,
shock

4. Circulatory Dyspnea, Dry cough,

Overload Pulmonary edema

5. Bacterial Reaction Fever, Hypertension,

Dry Flushed Skin,
Abdominal Pain
 REFERENCES
• HTTPS://WEBSTOCKREVIEW.NET/IMAGE/GOAL-CLIPART-AIMS/2759702.HTML

• HTTPS://BLOG.PDCHEALTHCARE.COM/ARTICLES/PATIENT-SAFETY/BLOOD-TRANSFUSION-SAFETY-AT-THE-POINT-OF-CARE/

• HTTPS://WWW.THELANCET.COM/JOURNALS/LANRES/ARTICLE/PIIS2213-2600(20)30173-9/FULLTEXT

• HTTPS://WWW.CLIPARTMAX.COM/MIDDLE/M2I8D3Z5I8I8B1A0_QUESTION-MARK-ANIMATION-CLIP-ART-QUESTION-MARK-ANIMATION/

• HTTPS://PIXELS.COM/FEATURED/1-BAG-OF-BLOOD-USED-FOR-TRANSFUSION-WITH-AN-IV-DRIP-ALEX-BARTELSCIENCE-PHOTO-LIBRARY.HTML

• HTTPS://WWW.WALLPAPERBETTER.COM/OTHER-WALLPAPER/BLOOD-CELLS-3731

• HTTPS://CANVAS.BHAM.AC.UK/COURSES/30592/PAGES/BLOOD-TRANSFUSION

• HTTPS://FREEPNGIMG.COM/PNG/72547-THINKING-PHOTOGRAPHY-QUESTION-MARK-MAN-STOCK

• HTTPS://WWW.PINTEREST.PH/PIN/371054456775454546/

• HTTPS://WWW.123FREEVECTORS.COM/RED-AND-WHITE-ABSTRACT-BACKGROUND-VECTOR-ILLUSTRATION-107658/

• HTTPS://THENERDYNURSE.COM/17-INSPIRATIONAL-EMPOWERING-NURSE-QUOTES/
 THANK
YOU!!!!!!!
IV FLOW RATE/ DRIP RATE
 the RATE OR SPEED at which the amount of IV solution/fluid flows and
infuses into the vein of the patient and it is expressed in volume over time.
 It is measured in terms of:
 gtts/min
 cc/hr

Drop Factor
 The number of drops it takes to make up one ml of fluid.
 Macro drip (gtt) = 15 gtts/ml
 Micro drip (ugtt) = 60 ugtts/ml
FORMULA: IVDF = FRT
 IN WHICH: IV – TOTAL VOLUME OF IVF
DF – DROP FACTOR
FR – FLOW RATE
T- TIME

TIME – TAKE NOTE IF THE ONE

BEING ASKED IS MINS OR
HOUR

REMEMBER: 1 HOUR = 60 MINS

COMPUTE FOR IV FLOW RATE/ DRIP
RATE
 Compute the rate of flow of D5 0.3
NaCl 250 ml to be consumed in 8
hours.
 1. IN MACRO DRIP
 2. IN MICRO DRIP
 3. IN VOLUME PER HOUR (CC/HR)
 4. HOURS TO LAST
MACRO DRIP
MICRO DRIP
VOLUME PER HOUR
Number of hours to consume
Number of hours to consume

IF DROP FACTOR IS GIVEN

REMEMBER: 1 HOUR = 60 MINS

PRACTICE TEST