Professional Documents
Culture Documents
Neil PAKO
Neil PAKO
PERINEAL CARE:
Purpose:
- To remove perineal secretions and odors
- To promote client comfort
Assessment:
- Assess the presence of irritation, inflammation, swelling, excessive discharge, odor, pain
or discomfort, urinary or fecal incontinence, recent rectal or perineal surgery and
indwelling catheter
- Determine client’s perineal-genital hygiene practices and self-care abilities
Planning:
Assignment:
Perineal-genital care can be assigned to AP; however, if the client has recently had
perineal, rectal or genital surgery, the nurse needs to assess if it is appropriate for the AP to
perform the care
Equipment:
- Bath towel
- Bath Blanket
- Clean gloves
- Bath basin with warm water at 43 C to 46 C (110F to 115F)
- Soap
- Wash cloth
- Bedpan
- Perineal pad
Implementation:
Preparation
- Determine whether the client is experiencing any discomfort in the perineal-genital area
- Obtain and prepare the necessary equipment and supplies
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using
agency protocol. Explain to the client what you are going to do, why is it necessary and
how to participate, being particularly sensitive to any embarrassment displayed by the
client
2. Perform hand hygiene and observe other appropriate infection prevention procedures
3. Provide for client privacy by drawing the curtains around the bed or closing the door to
the room. RATIONALE: Hygiene is a personal matter
4. Prepare the client:
- Fold the top bed linen to the foot of the bed and fold the gown up to expose the
genital area
- Place the bath towel under the client’s hips. RATIONALE: The bath towel
prevents the bed from becoming soiled
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
5. Position and drape the client and clean the upper inner thighs and inguinal areas
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
- For menstruating women and clients with indwelling catheters, use clean wipes instead
of washcloths. Use a clean wipe for each stroke
- Rinse the area well. You may place the client on a bedpan and use peri-wash or a
solution bottle to pour warm water over the area. Dry the perineum thoroughly, paying
particular attention to the folds between the labia. RATIONALE: Moisture supports the
growth of many microorganisms
Evaluation:
- Compare current assessment to previous assessments
- Conduct appropriate follow ups such as prescribed ointments for excoriations
- Report any deviation from normal to primary care provider
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
BAG TECHNIQUE
Frequently called the PHN bag is a tool used by the nurse during home or community
visits
Purpose:
- Provide a receptacle for items needed for nursing care
- Helps the nurse in infection control
- Allows nurse to give care efficiently
- Supports the idea that the nurse must be prepared for a variety of situations while in the
field
- Serves as a reminder of the need for hand hygiene and other measures to prevent the
spread of infections
Assessment:
The content of the bag depends upon the agency policies and the type of services
expected of the nurse while he or she is in the community or in the client’s home. It was once
popularly used in practice particularly in anticipation of attending to a home delivery of a woman
in labor. Today it is rarely used since deliveries should be done in a healthcare facility.
Planning:
Assignment:
A PHN bag is a traditional tool used by the nurse during home visits and community
visits to be able to provide care safely and efficiently.
Equipment:
- Soap with soap dish
- Linen or paper towels
- Aprons
- Antiseptic solutions
- Thermometers
- Measuring tape
- Newborn weighing scale
- Glucometer
- Benedict’s test
- Medicine dropper
- Testube holder and testubes
- Alcohol lamp
- Dressings
- Cotton balls
- Cotton tip applicators
- Syringes (2 and 5cc)
- Surgical gloves
- Cord clamp
- Kidney basin
- Two pair of forceps (straight)
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Implementation:
Preparation:
- Obtain and prepare the necessary equipment and supplies
- Review client’s records if available
Performance:
1. Prior to performing the procedure, introduce yourself and verify the client’s identity using
agency protocol. Explain to the client what you are going to do, why it is necessary and
how to participate.
2. Upon arrival at the patient’s home, place the bag on the table lined with a clean paper.
The clean side must be out and the folded part, touching the table. RATIONALE: This
minimizes contact of contamination and cross-contamination
3. Ask for a basin of water or glass of drinking water if tap water is not available.
4. Open the bag and take out the towel and soap
5. Wash hands using soap and water. Wipe to dry
6. Take out the apron from the bag and put it on with the right side out
7. Put out all necessary articles needed for specific care. RATIONALE: This practice is
facilitated when the contents of the bag are arranged according to the nurse’s
convenience to avoid confusion and promote efficiency. Those that will not be used
should remain in the bag
8. Close the bag and put it in one corner of the working area. RATIONALE: Contents of the
bag will be protected from contact with any article in the patient’s home. Consider the
bag and its content clean or sterile while articles that belong to the patients as dirty and
contaminated
9. Proceed in performing the necessary nursing care and treatment
10. After giving the treatment, clean all things that were used and perform hand washing.
RATIONALE: This practice minimizes contamination inside the bag
11. Open the bag and return all things that were used in their proper places after cleaning
them.
12. Remove the apron, folding it away from the person, the soiled side in and the clean side
out. Place it in the bag.
13. Fold the lining. Place it inside the bag and close the bag.
14. Take the record and have a talk with the mother. Write down all the necessary data that
were gathered, observations, nursing care and treatment rendered. Give instructions for
care of patients in absence of the nurse.
15. Make appointment for the next visit (either home or clinic) taking note on the date and
time
16. Record all relevant findings about the client and members of the family
17. Take notes on the environmental factors which affect the client/family health
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Evaluation:
- Compare current assessment to previous assessments if available
- Conduct appropriate follow ups
- Report any deviation from normal to primary care provider
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Purpose:
- To reduce child mortality
Planning:
Equipment (Arranged in linear sequence)
- 2 pair sterile gloves
- Dry linen
- Bonnet
- Oxytocin injection
- Plastic clamp
- Instrument clamp
- Scissors
- 2 kidney basins
- Eye ointment (Erythromycin)
- Stethoscope
- Vitamin K
- Hepatitis B
- BCG vaccine
- Cotton balls
Implementation:
Prior to woman’s transfer to DR
● Ensure that mother is in her position of choice
● Ask the mother if she wishes to eat/drink or void
● Communicate with the mother. Inform her progress of labor, give reassurance and
encouragement.
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
15-90 minutes
30. Advise mother to observe for feeding cues (opening of mouth, tonguing, licking, rooting)
Support mother and instruct her on positioning and attachment.
31. After a complete breastfeeding, administer eye ointment, thorough physical exam, and then
do injection of Vitamin K, Hepatitis B, and BCG injections.
32. Advise optional /delayed bathing of baby. RATIONALE: Washing exposes to hypothermia,
removes the vernix, a protective barrier to bacteria such as E. coli and Group B Strep, Washing
removes the crawling reflex.
33. Complete all records.
A Must Know:
4 time-bound procedures
1. Immediate drying
2. Early uninterrupted skin-to-skin contact
3. Delayed cord clamping
4. Breastfeeding for the 1st hour of life
New Trends:
● Position: position of comfort
● No NPO; Light meals are allowed
● No IV unless CS
● No Shaving
● No fundal push/pressure
● No routine episiotomy
● Companion of choice during labor
● Mobility during labor (within reason)
● Nonpharmacologic pain relief before offering anesthesia
Unnecessary procedures:
● Suctioning
● Separation for observation
● Administration of pre-lacteals
● Water formula
● Foot printing
● Application of substances to the cord
Active Labor starts at 5cm, 2nd stage of labor At perineal bulging, with presenting part visible
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
APGAR SCORING
A scoring system that provides a numeric indicator of the baby’s physiologic capacities
to adapt to extrauterine life.
Purpose:
- To assess infant’s physiologic capacities after birth
Assessment:
APGAR rates heart rate, Respiratory efforts, Muscle tone, Reflex irritability and Color of
the newborn. Each of five signs is assigned a maximum score of 2, so the maximum score
achievable is 10. Apgar scoring is usually carried out 60 seconds after birth and is repeated in 5
minutes. A score under 7 suggests that the infant is having difficulty and a score under 4
indicates that the baby's condition is critical. There is a high correlation between low 5 minute
Apgar scores and neurologic illness. Infants with very low scores require special resuscitative
measures and care.
Planning:
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Implementation:
Heart rate:
Auscultating a newborn heart with a stethoscope is the best way to determine heart rate;
however, heart rate also may be obtained by observing and counting the pulsations of the
umbilical cord at the abdomen if the cord is still uncut
● Heart rate is more than 100 beats per minute = 2 points
● Heart rate is present, but less than 100 beats per minute = 1 point
● No heart rate = 0
Respiratory effort:
Respirations are counted by observing chest movements. A mature newborn usually cries and
aerates the lungs spontaneously at about 30 seconds after birth. By 1 minute the infant is
maintaining regular, although rapid, respirations. Difficulty with breathing might be anticipated in
a newborn whose mother received large amounts of analgesia or general anesthesia during
labor or birth
● Strong, vigorous cry = 2 points
● Weak cry, slow or difficult respirations = 1 point
● No respiratory effort = 0
Muscle tone:
Term newborns hold their extremities tightly flexed, simulating their intrauterine position. Muscle
tone is tested by observing their resistance to any effort to extend their extremities.
● Maintains a position of flexion with brisk movements = 2 points
● Minimal flexion of extremities = 1 point
● Limp and flaccid = 0
Color:
All infants appear cyanotic at the moment of birth. They grow pink with or shortly after first
breath, which makes the color of newborns correspond to how well they are breathing.
Acyanosis (cyanosis of the hand and feet) is so common in newborns that a s core of 1 in this
category can be thought of as a normal
● Body and extremities pink = 2 points
● Body pink, extremities blue - = 1 point
● Body and extremities are blue (cyanotic) or completely pale (pallor) = 0
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Evaluation:
- Compare current assessment to previous assessments after 5 mins interval
- Conduct appropriate follow ups
- Report any deviation from normal to primary care provider
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
BALLARD SCORING
Proposed by Dr. Jenne L. Ballard. A standard method that helps detect infants who were
thought to be term but actually a pre-term
Purpose:
- To assess infant’s gestational age
Assessment:
It assesses gestational age from 20 to 44 weeks. The process of rating the infant will be
completed shortly after birth, including 6 physical and neuromuscular signs of maturity. The total
score may range from -10 to 50. Premature babies have low scores. Babies born late have high
scores.
Planning:
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Implementations
NEUROMUSCULAR ACTIVITY
- Posture: How the baby holds his or her arms and legs.
Observe the posture. Handling the infant may improve the assessment. As maturational
progresses it increases the flexor tone
● Arms and legs are extended = 0
● Slight or moderate flexion of hips and knees = 2
● Legs flexed and abducted, arms slightly flexed = 3
● Full flexion or arms and legs = 4
- Square window: How far the baby's hands can be flexed toward the wrist.
Flex the hand at the wrist. Exert pressure sufficient to get as much flexion as possible. The
angle between the hypothenar eminence and the anterior aspect of the forearm is measured
and scored.
● Greater than 90 degrees = -1
● 90 degree = 0
● 60 degree = 1
● 45 degree = 2
● 30 degree = 3
● 0 degree = 4
- Arm recoil: How well the baby's arms spring back to a flexed position.
Fully flex the forearms with the hands at the shoulders for 5 seconds, then fully extend by
pulling the hands. Release as soon as the elbows are fully extended, and observe the recoil
(degree of flexion at the elbows). Random movements do not count.
● Remain extended or random movement = 0
● Incomplete or partial flexia = 2
● Brisk return to full extension = 4
- Popliteal angle: How well the baby's knees bend and straighten.
With infant supine and the pelvis flat on the examining surface, use one hand to bring the knee
onto the abdomen. With the other hand, gently push behind the ankle to bring the foot towards
the face.
● 180 degree = -1
● 160 degree - 0
● 140 degree = 1
● 120 degree = 2
● 100 degree = 3
● 90 degree = 4
● Less than 90 degree = 5
- Scarf sign: How far the elbows can be moved across the baby's chest.
Take the infant's hand and draw it across the neck and as far across the opposite shoulder as
possible, like a scarf. Assistance to the elbow is permissible by lifting it across the body. Score
according to the location of the elbow.
● Elbow reaches opposite anterior axillary line = 0
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
● Elbow between opposite anterior axillary line and midline of the thorax = 1
● Elbow at the midline of the thorax = 2
● Elbow does not reach midline of the thorax = 3
● Elbow at the proximal axillary line = 4
- Heel to ear: How close the baby's feet can be moved to the ears.
Hold the infant's foot with one hand and move it as near to the head as possible without forcing
it. The knee may slide down the side of the abdomen. Keep the pelvis flat on the examining
surface. Note the location of the heel where significant resistance is appreciated. Landmarks
noted in order of increasing maturity include resistance felt
● Ear = -1
● Nose = 0
● Chin = 1
● Nipple line = 2
● Umbilical area = 3
● Femoral crease = 4
PHYSICAL MATURITY
- Skin: Skin may be sticky, smooth, or peeling.
Inspect the skin of the newborn, noting what is seen.
● Sticky, friable, transparent = -1
● Gelatinous, red, translucent = 0
● smooth , pink, visible veins = 1
● Superficial peeling and few veins = 2
● cracking , pale areas, rare veins = 3
● Parchment deep, cracking, no vessels = 4
● Leathery, cracked and wrinkled = 5
- Lanugo: This is the soft downy hair on a baby's body. It's absent in premature babies.
It's present in full-term babies, but not in babies born late.
Inspects for the fine hair covering the body. Turn the newborn to one side. In extreme
immaturity, the skin lacks any lanugo. 24th -25th week: Fine hair begins to appear. 26th week:
Abundant hair across the shoulders and upper back. At term, most of the fetal back is devoid of
lanugo.
● None = -1
● Sparse = 0
● Abundant = 1
● Thinning = 2
● Bald areas = 3
● Mostly bald = 4
- Plantar creases: These are the creases on the soles of the feet. They range from
absent to covering the entire foot
Inspects for the plantar creases on both feet. 28 – 30 weeks – creases appear and cover the
anterior portion of the plantar surface of the foot. Creases extend toward the heel as the
gestational age increases. After 12 hours the sole creases are not valid indicator due to drying
of the skin
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Score Weeks
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
Interpretation:
Premature: < 34 weeks’ gestation
Late preterm: 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
Post term: 42 0/7 weeks and beyond
Post term: 42 0/7 weeks and beyond Postmature: > 42 weeks
Evaluation:
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
● Conduct appropriate follow ups. Report any deviation from normal to primary care
provider
NUTRITIONAL SCREENING
Adequate nutrition during pregnancy cannot guarantee a good pregnancy outcome, it
does make an important contribution because both the nutritional state a woman brings into
pregnancy and her nutrition during pregnancy have a direct bearing on her health and on fetal
growth and development. Good nutrition during pregnancy is recognized as so important that
the subject is addressed in 2020 National Health Goals.
A MUST KNOWS:
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
As a rule, the average woman should gain 11.3 to 15.8kg (25 to 35 lbs) during pregnancy. To
predict weight gain one must first calculate the body mass index (BMI) or the ratio of body fat to
weight and height.
BMI FORMULA:
Overweight 25-29.9
Weight gain in pregnancy occurs from both fetal growth and an accumulation of maternal stores
and increases by approximately 0.8kg (1.5lbs) per month during the first trimester and then
0.4kg (1lb) per week during the last two trimesters. A trimester minimum weight gain of 4.5,12
and 12 lbs respectively). Women can be assured most of the weight gained during pregnancy is
easily lost afterwards.
● To ensure adequate fetal nutrition advise women not to diet or lose weight during
pregnancy
● A woman who reaches midpoint of pregnancy and has gained less than 10lbs needs to
have her daily nutritional intake reevaluated as low weight gain is associated with fetal
growth restriction
● Even obese women need to gain minimum 0.4lbs per week or 11 ro 15 lbs total to help
ensure adequate fetal growth
● Weight gain will be higher for multiple pregnancy than for a single pregnancy. You can
encourage women who are multiple pregnant to gain at least 1lb per week for a total 37
to 54 lbs
● Sudden increase in weight suggest fluid retention or polyhydramnios (excessive amniotic
fluid) a loss of weight suggests illness and should also be carefully evaluated at prenatal
visits
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
NURSING INTERVENTION
UNDERWEIGHT WOMEN:
● Begin counseling by asking a woman for a 24-Hour nutrition recall
● Work with women to develop menus based on well planned meals rather than on quick
take out foods
● Suggest additional calories in the form of a concentrated formula such as an instant
liquid breakfast. Be certain a woman understand that this should not be a high-protein
drink used for high-protein diet regimen
● Religiously measure a woman’s weight in each visit and meticulously calculate the gain
otherwise excessive gain weight would do more harm than good
● Lack of nutrition accompanied by fatigue, advise woman to get enough rest so she can
feel sufficiently energetic to prepare nutritious meals
OVERWEIGHT WOMEN:
● Most obesity is caused by overeating; determine the cause of overeating such as
learned habit, stress coping, or physiological causes such as hypothyroidism
● Do not advise overweight women to go on diet during pregnancy as it will deprive the
growing infant of nutrition it needs for growth and development. Rather, educate a
woman about healthy food intake
● Educate a woman regarding nutrition; in terms of empty calorie versus nutritious food
may help her to eat less fatty and more protein rich foods
● Provide additional nutritional counseling in the postpartum period so she can prepare
more nutritious meals in the future for herself and for her growing family
● Encourage all women especially overweight women to engage in an exercise program,
such as walking, in conjunction with dietary changes
D Low birth weight, Aids calcium Fortified milk, eggs No standard, Not recommended
increased rates of absorptions, and salmon suggested 600 IU to improve
preeclampsia formation of teeth daily maternal or
and bones and perinatal outcomes
immune function by WHO; concern
for adverse
effects-fat-soluble
vitamins
A Tender gums or New cell growth, Dark green and In areas where Not recommended
tongues, cracks in health oral, skin and yellow vegetables vitamin A to improve
skin, mouth, poor visions and fruits, liver, mil, deficiency is a maternal or
night vision butter, cheese and severe public perinatal outcomes
eggs health problem: by WHO; concern
10,000-25,000 IU for overdose
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
daily effects-fat-soluble
vitamins
C Scurvy, easy Antioxidant and Fresh fruits and Suggest 85mg No benefit seen
bruising, swollen collagen formation vegetables daily with standard
and bleeding gums supplementation;
not recommended
to improve
maternal or
perinatal outcomes
by WHO
FOLIC ACID Megaloblastic Red-blood cell Fresh vegetables 400ug daily Clear evidence of
anemia, fetal formation that and fruits benefits, WHO
neural tube defects prevents neural tube recommends daily
defects supplementation
Iodine Thyroid gland Iodized salt, Suggest 250ug Strong evidence that populations without
function seafoods and daily where iodized iodized salt need supplementation
cranberries salt is less than
20%
Iron Fetal cell Organ meats, eggs, 30-60mg elemental Strong evidence supplementation
development, leafy greens, whole iron daily reduces maternal anemia; puerperal
prevents physiologic grains, enriched sepsis, low birth weight and preterm
anemia of pregnancy breads, dried fruits births
Fluoride Tooth development Fluoridated water Supplements only Lack of evidence suggesting routine
warranted in areas supplementation
without fluoridated
water
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
● Weight loss diet and supplements (women need additional nutrients, not less)
● Caffeine (excessive amounts may be a cause of miscarriage, although research still
ongoing)
PHYSICAL SCREENING:
Body experiences physiologic and anatomical changes during pregnancy. Most of these
changes are influenced by hormones of pregnancy, primarily estrogen and progesterone.
Purpose:
- To establish baseline data for pregnant women
Assessment:
Assessment of the pregnant woman is a specialty assessment. Performing a head-to-toe
assessment requires experience and familiarity with changes that naturally occur in pregnancy
and indicator of abnormal changes.
Planning:
Equipment:
- Stethoscope
- Sphygmomanometer
- Tape measure
- Gloves
- Weighing scale
- Pen light
- Thermometer
Implementation:
General Survey:
● Measure blood pressure:
BP range: systolic 90-134 mmHg and diastolic 60-89 mmHg. BP decreases during the
second trimester because of the relaxation effect on the blood vessels. By 32-34 weeks,
the client BP should be back to Normal
● Measure pulse rate
60-90 beats/min; may increase 10-15 beats per minute higher than pregnancy levels
● Take client’s temperature
97-98.6 F (36-37 C)
● Measure height and weight
Establish a baseline height and weight. The client with normal pregnancy weight should
gain 2-4lbs in the first trimester and approximately 11-12lbs in both the second trimester
and third trimester for a total weight gain 25-35 lbs
● Observe behavior
First trimester: Tired, ambivalent
Second trimester: Introspective, energetic
Third trimester: Restless, preparing for baby, labile moods (father may also experience
the same behaviors)
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Breast:
● Inspect and palpate the breast and nipples for symmetry and color: Venous
congestion is noted with prominence of veins. Montgomery tubercles are prominent.
Breast size is increased and nodular. Breasts are more sensitive to touch. Colostrum is
excreted especially in the third trimester. Hyperpigmentation of nipples and areolae is
evident
Heart:
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
● Auscultate the heart: Normal sinus rhythm; soft systolic are audible during pregnancy
secondary to the increased blood volume
Peripheral Vascular:
● Inspect face and extremities: Note color and edema
During the third trimester, dependent edema is normal, varicose veins may also appear
● Percuss deep tendon reflexes: Normal reflexes 1-2+ Clonus is absent
Abdomen:
● Inspect the abdomen: Ask the client to recline with a pillow under head and her knees
flexed. Note striae, scars, and the shape and size of abdomen
Striae and linea-nigra are normal. The size of the abdomen may indicate gestational
age. The shape of the uterus may suggest fetal representation and positions in later
pregnancy
● Palpate abdomen: Note organs and any masses.
The uterus is palpable beginning at 10-12 weeks of gestation
● Palpate for fetal movement after 24 weeks: Fetal movement should be felt by the
mother by approximately 18-20 weeks of gestation
● Palpate for uterine contractions: Note intensity, duration and frequency of
contractions
The uterus contract and feels firms to the examiner
● Palpate the abdomen: Notice the difference between the uterus at rest and during
contraction
Intensity of contraction may be mild, moderate, or firm to palpation
● Time the length of the contraction from the beginning to the end: Note the
frequency of contractions timing from the beginning of one contraction until the
beginning of the next. The frequency of contractions is timed from the start of one
contraction to the start of the next contraction. This allows the nurse to see the pattern of
occurrence. Timing from the end of one contraction to the beginning of another would tell
the amount of time between contractions but that would allow the nurse to see the
pattern of occurrence.
Contraction may last 40-60 seconds and occur every 5-6 minutes
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Assessment S U NP Comments
Implementation
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Evaluation
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
LEOPOLD’S MANEUVERS
Are systematic methods of observation and palpation to determine fetal presentation and
position are done as part of a physical examination.
Purpose:
- Systematically observe and palpate the abdomen to determine fetal presentation and
position
Procedure:
1. Prior to performing the procedure, introduce yourself and verify the client’s identity using
agency protocol.
2. Explain the procedure and instruct the woman to void, empty her bladder. RATIONALE:
Explanation reduces anxiety and enhances cooperation. An empty bladder promotes
comfort and allows for more productive palpation because fetal contour will not be
obscured by a distended bladder
3. Wash your hands using warm water. Provide privacy. RATIONALE: Hand Washing
prevents spread of infection. Using warm water aids in patient comfort and prevents
tightening of abdominal muscles during palpation
4. Position the woman supine with knees slightly flexed. Place a small pillow or rolled towel
under her left side. RATIONALE: Flexing the knees relaxes the abdominal muscles.
Using a pillow or towel tilts the uterus off the vena cava. Preventing supine hypotension
syndrome.
5. Observe the woman’s abdomen as to which is the longest diameter and where fetal
movement is apparent. RATIONALE: The longest diameter (axis) is the length of the
fetus. The location of activity most likely reflects the position of the feet
FIRST MANEUVER: Fundal Grip
Stand at the foot of the woman, facing her and place both hands flat on her abdomen. Palpate
the superior surface of the fundus. Determine consistency, shape and mobility. RATIONALE:
This maneuver determines whether the fetal head or breech is in the fundus. A head feels more
firm than a breech, is round and hard and moves independently of the body (the breech feels
softer and moves only in conjunction with the body)
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
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opposite side. RATIONALE: This maneuver locates the back of the fetus. The fetal back feels
like smooth ard 6and resistant surface; the knees and elbow of the fetus on the opposite side
feel more like a number of angular bumps or nodules
Purpose: to determine the back of fetus to hear the fetal heart sound
If smooth hard and resistant surface - FETAL BACK
If angular nodulations - KNEES AND ELBOWS
Purpose: to determine the degree of engagement by palpating the lower uterine segment
If the presenting part is movable: NOT ENGAGED
If the presenting part is immovable: ENGAGED
HARD: HEAD
SOFT, GLOBULAR, LARGE: BUTTOCKS
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Purpose:
- To determine if the fetus is responding well
- To provide confirmatory information about fetal position
Assessment:
Assess the first fetal position. A fetal doppler ultrasound device can be used after 10–12
weeks’ gestation to hear the fetal heartbeat. A fetoscope may also be used to hear the
heartbeat after 18 weeks’ gestation
Planning:
~ Equipment:
- Stethoscope
- Fetoscope
- Lube
- Clean gloves
- Doppler ultrasound/device
Implementation:
1. Do handwashing.
2. Gather the materials to be use.
3. Identify the patient and explain the procedure.
4. Instruct the patient to void first before the procedure.
5. Provide privacy in the entire procedure.
6. Place the patient in a supine position.
7. Locate for the fetal presentation.
● In a-vertex or breech presentation, fetal heart sounds are heard usually through the fetal
back
● In a face presentation, the back becomes concave so the sounds are best heard through
the more convex thorax
● In breech presentations, fetal heart sounds are heard most clearly high in the uterus, at
the woman’s umbilicus or above
● In cephalic presentations, they are heard loudest low in a woman’s abdomen
● In a right occiput anterior (ROA) position, sounds are heard best in the right lower
quadrant
● In a left occiput anterior (LOA) position, sounds are heard best in the left lower quadrant
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
● In posterior positions, left occiput posterior and right occiput posterior (LOP or ROP), a
heart sound may be loudest at a woman’s side
8. Locate for the fetal back.
9. Lubricate the Doppler or fetoscope.
10.Place the fetoscope at the fetal back.
11.Listen for the fetal heart tone.
12.Count the fetal heart rate.
● Fetal heart rate ranges from 120-160 beats per minute. During third trimester, the fetal
heart rate should accelerate with fetal movement
13.Remove excess lubricant and place the patient in a comfortable position.
14.Do handwashing.
15.Record the data gathered.
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Planning:
~Equipment
- Tape measure
Implementation:
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
Interpretation:
20-22nd week – reaches the level of the umbilicus
36th week – touches the xiphoid process
38th week – fetal head settles into the pelvis
McDonald’s Rule:
- Use to determine the age of gestation in weeks using fundic height measurement
Bartholomew’s Rule:
- Use to determine age of gestation by proper location of fundus at abdominal cavity
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
References:
○ Weber, J., & Kelley, J. (n.d.). Health Assessment in Nursing (6th ed.).
Wolters Kluwer.
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51
Property of Alfie Velasco
○ Berman, A., Snyder, S., & Frandsen, G. (n.d.). Kozier & Erb’s
○ Silbert-Flagg, J., & Pillitteri, A. (n.d.). Maternal & Child Health Nursing. In
Care of the Childbearing & Childrearing Family (8th ed., Vol. 1). Wolters
Kluwer.
And you know damn well for you, I would ruin myself a million little times
~St. Taylor Swift from the book of “folklore” 2:39-51