Reviewer para Maging Kumadrona

Property of Alfie Velasco
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
5. Position and drape the client and clean the upper inner thighs and inguinal areas
FOR FEMALE CLIENTS

- Position the client in a back-lying position with the knees flexed and spread well apart
(lithotomy)
- Cover the body and legs with a bath blanket positioned so a corner is at her head, the
opposite corner at her feet and the other two on the sides. Drape the legs by tucking the
bottom corners of the bath blanket under the inner sides of the legs. RATIONALE:
Minimum exposure lessens embarrassment and helps provide warmth. Bring the middle
portion of the base of the blanket up and then over the pubic area
- Apply gloves. Wash and dry the upper inner thighs and inguinal areas
FOR MALE CLIENTS

- Positions the male client in a supine position with knees slightly flexed and hips slightly
externally rotated
- Drape him by placing a towel or bath blanket over his abdomen and covering his legs
with a sheet or towel. RATIONALE: Minimum exposure lessens embarrassment and
helps provide warmth. When ready to begin care, fold the sheet or towel back to expose
the penis and perineal area.
- Apply gloves and wash and dry the upper inner thighs and inguinal areas
6. Inspect the perineal area

- Note particular areas of inflammation, excoriation or swelling, especially between
the labia in females and the scrotal folds in males
- Also note excessive discharges or secretions from the orifices ad the presence of
odors
7. Wash and dry the perineal-genital area
FOR FEMALE CLIENTS

- Clean the labia majora and perineum from the front to back, from pubis to the rectum.
Use a seperate clean area of the washcloth for each area or a new washcloth for each
stroke. RATIONALE: Using separate quarters of the washcloth or new wipes prevents
the transmission of microorganisms from one area to another. Wipe form the area of
least contamination (the pubis) to that of greatest (the rectum). Do not place the
washcloth in the basin. RATIONALE: this prevents cross-contamination (the movement
of microorganisms from one client to another)
- Separate the labia with one hand to expose the urethra and vaginal opening. Using a
different washcloth, wash the labia minora from the front to back on one side. Take a
separate clean area of the washcloth or a new cloth and wash the other side from top to
bottom. RATIONALE: Secretions that tend to collect around the labia minora facilitates
bacterial growth
- Using a separate clean area of the washcloth or a new washcloth, wash the urethra from
front to back, in a downward motion. RATIONALE: Thi actions uses the principle of
washing from clean to dirty area to prevent a urinary tract infection
- 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
FOR MALE CLIENTS

- If the client is uncircumcised, retract the prepuce (foreskin) to expose the glans penis
(the tip of the penis) for cleaning. Replace the foreskin after cleaning and drying the
glans penis. RATIONALE: Retracting the foreskin is necessary to remove the smegma
(thick, cheesy secretions) that collects under the foreskin and facilitates bacterial growth.
Replacing the foreskin prevents constriction of the penis which may cause edema
- Hold the shaft of the penis gently and securely in one hand
- Clean the tip of the penis at the urethral meatus in a circular motion from the center
outward and wash down the shaft with soap and water. Use a clean area of the
washcloth or a new washcloth when washing a new area. RATIONALE: This prevents
cross contamination
- Rinse and dry with new washcloth
- Wash and dry the scrotum. The posterior fold of the scrotum may need to be cleaned
when the buttocks are cleaned. RATIONALE: the scrotum tends to be more soiled than
the penis because of its proximity to the rectum; thus it is usually cleaned after the penis.
This follows the principle of cleaning from the least contaminated to that of the greatest
8. Inspect perineal orifices for intactness.

- Inspect particularly around the urethra in clients with indwelling catheters.
RATIONALE: A catheter may cause excoriations around the urethra
9. Clean between the the gluteal folds and the entire buttocks
- Assist the client to turn onto the side facing away from you
- Pay particular attention to the anal area and posterior folds of the scrotum in
males. Clean the anus with a wipe or toilet tissue before washing it. If necessary.
- Dry the area well
- For post delivery or menstruating women, apply a perineal pad as needed from
the front to back. RATIONALE: This prevents contamination of the vagina and
urethra from the anal area
10. Remove and discard gloves
11. Perform hand hygiene
12. Document any unusual findings such as redness, excoriations, skin breakdown,
discharge or drainage and any localized area of tenderness
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
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)
- Adhesive tapes and bandages

- Paper lining for soap dish
- Paper receptacle
- Stethoscope and Sphygmomanometer (carried separately)
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
18. Include quality of nurse patient relationship

19. Assess effectiveness of nursing care provided
Evaluation:
- Compare current assessment to previous assessments if available
- Conduct appropriate follow ups
ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)

Series of time bound chronologically ordered, standard procedures that a baby receives
from birth.
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.
Woman already in the DR – Preparing for delivery

1. Check the temperature in the DR area. It should be 25-28 degree Celsius
2. Ask woman if she is comfortable in semi-upright position
3. Ensure the woman’s privacy
4. Remove all jewelry, wash hands (observing the WHO 1-2-3-4-5 procedure). RATIONALE:
Jewelry can harbor microorganisms.
5. Prepare a clear, clean newborn resuscitation area. Check if equipment is clean, functional,
and within easy reach.
6. Arrange materials/supplies in linear sequence. RATIONALE: Promotes efficiency and avoids
confusion
7. Clean the perineum with antiseptic solution
8. Wash hands and put on 2 pairs of sterile gloves aseptically (if the same worker handles
perineum and cord.)
At the time of delivery

9. Encourage woman to push as desired.
10. Drape the clean, dry linen over the mother’s abdomen or arms in preparation for drying the
baby.
11. Apply perineal support and control delivery of the head
12. Call out the time of birth and gender of the baby. RATIONALE: for proper documentation
Inform the outcome to the mother.
First 30 seconds – After delivery

13. Thoroughly dry the baby for at least 30 seconds, starting from the face and head, going
down to the trunk and extremities while performing a quick check for breathing. RATIONALE:
Stimulates breathing and provides warmth
1-3 minutes- After delivery

14. Remove wet cloth
15. Place the baby in skin-to-skin contact on the mother’s abdomen or chest. RATIONALE:
Promotes warmth, bonding, prevent infection (by colonization of maternal normal flora) and
hypoglycemia.
16. Cover the baby with a dry cloth and the baby’s head with a bonnet. RATIONALE: Provides
warmth and prevents hypothermia
17. Use wet cloth to wipe the soiled gloves, then dispose wet cloth properly
18. Remove the first set of gloves and decontaminate them properly (0.5 % chlorine solution for
at least 10 minutes). RATIONALE: To maintain sterility when handling umbilical cord
19. Palpate umbilical cord to check for pulsations. After pulsations stopped, clamp the cord
using plastic clamp or cord tie 2cm from the base. RATIONALE: To reduce anemia,
intraventricular hemorrhages (IVH), and transfusion in preterm
20. Place the instrument clamp 5 cm from the base and then clamp.
21. Cut near plastic clamp (not midway)
22. Perform the remaining steps of the AMTSL (Wait for strong uterine contraction then apply
controlled cord traction and counter traction on the uterus, continue until placenta was delivered.
Massage the uterus until it is formed). NOTE: DO NOT PULL the placenta as it can pull the
uterus along with it.
23. Inspect the lower vagina and perineum for laceration
24. Examine the placenta for completeness and abnormalities. RATIONALE: Some genetic
abnormalities can be attributed to the deviations of placenta or umbilical cord
25. Clean the mother.
26. Check baby’s color and breathing. Check if mother is comfortable and uterus is contracted.
27. Dispose the placenta in a leak proof container/ plastic bag.
28. Decontaminate (0.5% chlorine solution) instruments before cleaning and decontaminate a
second pair of gloves before disposal.
29. Advice mother to maintain skin to skin contact. Baby should be prone on the mother's chest
or in between the breasts with the head turned to one side. RATIONALE: For easier facilitation
of initiation of breastfeeding.
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
Non time-bound procedure:

● Immunization
● Eye care (Crede’s prophylaxis)
● Vitamin k administration
● Weighing
● Washing/bathing (postponed up to 6 hrs)
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
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:
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
Reflex irritability (Grimace response):

Response to a suction catheter in the nostril or response to having the soles of the feet slapped.
A baby whose mother was heavily sedated for birth will probably demonstrate a low score in this
category
● Cries and sneezes when stimulated = 2 points
● Grimaces when stimulated = 1 point
● No response to stimulation = 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
Record your findings/scores
Evaluation:
- Compare current assessment to previous assessments after 5 mins interval
- Conduct appropriate follow ups
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:
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.
● Less 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
● 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
● Heel-Toe 40-50mm = -1 ; Less than 40mm = -2
● More than 50mm or no crease = 0

● Faint red marks = 1
● Anterior transverse crease only = 2
● Creases anterior ⅔ = 3
● Creases on the entire sole = 4
- Breast: The thickness and size of the breast tissue and the areola (the darkened area
around each nipple) are assessed.
Inspect for the appearance and the estimated size of the areola.
● Imperceptible = -1
● Barely perceptible = 0
● Flat areola, no bead = 1
● Stippled areola, 1-2mm bead = 2
● Raised areola, 2-4mm bead = 3
● Full areola, 5-10mm bead = 4
- Eyes and ears: Eyelids are checked to see if they are open or fused shut (more likely in
a premature baby). The amount of cartilage and stiffness of the ear tissue are also
noted.
Inspects the eyelids. Place the thumb and forefinger on the upper and lower eyelids gently
move them apart to separate them
Inspects the appearance of the pinna of the ears. Palpate the pinna of the ears for recoil/
presence of cartilage.
● Lids fused: Loosely = -1 ; tightly fused = 2
● Lids are open, pinna flat but remain folded = 0
● Slightly curved pinna,soft and slow recoil = 1
● Well curved pinna, soft but ready recoil = 2
● Formed and firm, instant recoil = 3
● Thick cartilage and ear stiff = 4
- Genitals (Male): The presence of testes and the look of the scrotum, from smooth to
wrinkled, is verified.
Inspects the scrotal skin and note for the rugae.
● Scrotum flat and smooth = -1
● Scrotum is empty, rare rugae = 0
● Testes upper canal, faint rugae = 1
● Testes descending, few rugae = 2
● Testes is down, good rugae = 3
● Testes pendulous, deep rugae = 4
- Genitals (Female): The appearance and size of the clitoris and the labia are noted
Inspects the presence/absence of the clitoris, labia minora and labia majora. In extreme
prematurity, the labia are flat, and the clitoris is very Prominent and may resemble the male
phallus. As maturation progresses, the clitoris becomes less prominent and labia minora
become more prominent. Nearing term, both clitoris and labia minora recede and are Eventually
enveloped by the enlarging labia majora
● Clitoris is prominent, labia flat = -1
● Prominent clitoris, small labia minora = 0
● Prominent clitoris, enlarging labia minora = 1

● Majora and minora are equally prominent = 2
● Majora large, minora small = 3
● Majora covers the clitors and minora small = 4
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
Document your finding/score
Evaluation:
● 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.
Nursing Process Overview

~Assessment:
Assessment begins with a woman’s preconception of nutrition patterns. Evaluate any cultural,
environmental or social lifestyle that could affect eating habits
~Nursing Diagnosis
Related to the nutritional status of a pregnant woman. Example diagnosis are:
● Imbalanced nutrition, less than body requirements related to increased physiologic
needs
● Imbalanced nutrition, less than body requirements related to nausea every morning
● Health-seeking behaviors related to determining best food choices in pregnancy
● Imbalanced nutrition, more than body requirements related to overeating or poor food
choices
● Deficient knowledge related to need for increased intake of nutrients and calories during
pregnancy
~Implementation
Begin by emphasizing the physiologic basis for nutritional needs in pregnancy. Based on this,
explain what nutritional deficits you have identified and then show the woman how to change
her nutritional pattern to improve the situation. Pregnant women are usually highly motivated to
adopt health behaviors for the sake of their baby’s health, although they still need support and
encouragement because this can involve major life changes.
~Outcome Evaluation
When evaluating whether a woman’s nutritional pattern has been improved, rely on the most
important assessments; weight, energy level, general appearance, bowel function, hydration
status, and when available, hemoglobin and urinalysis findings. Example of improved nutrition
includes:
● Patient demonstrates weekly menus that include three main meals and two snacks a day
● Patient verbalizes correct information about calcium needs during pregnancy
● Patient describes pattern she is using to drink at least eight glasses of water daily
A MUST KNOWS:
Weight Gain in Pregnancy:

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:
Prepregnancy BMI BMI
Underweight Less than 18.5
Normal weight 18.5-24.9
Overweight 25-29.9
Obese More than 30
Recommended weight gain by WHO

● Underweight women should gain 28-40 pounds
● Overweight women should gain 15-20 pounds
● Obese women should gain 11-20 pounds
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.lbs oer 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
VITAMINS NEEDS FOR THE PREGNANT WOMAN

VITAMINS SIGNS OF ESSENTIAL RELEVANT FOODS RECOMMENDED EVIDENCED

DEFICIENCY FUNCTION AMOUNT BASED EVAL
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
immune function outcomes 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
eggs health problem: outcomes by
10,000-25,000 IU WHO; concern for
daily overdose
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
MINERAL NEEDS FOR PREGNANT WOMAN
MINERALS ESSENTIAL RELEVANT FOODS RECOMMENDED EVIDENCED BASED EVAL

FUNCTION AMOUNT
Calcium Calcification of fetal Milk, cheese, yogurt, Adolescents = Supplementation is recommended to

bones (as early as 8 leafy greens and 1,300mg reduce the risk of preeclampsia
weeks) almonds Adults = 1,000mg
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
Zinc Immunity Oysters, red meat, Supplementation No standard recommended by WHO

poultry, beans, nuts, only in context of given lack of evidence
whole grains, dairy research
products
FOODS TO AVOID OR LIMIT IN PREGNANCY

● Raw eggs and undercook chicken (danger of salmonella)
● Soft unpasteurized cheese (can harbor Listeria bacteria)
● Raw milk
● Raw seafood and sushi (can harbor hepatitis A virus)
● Cold cuts (deli meats should be heated until steaming to kill bacterias)
● Alcoholic beverages (known to cause fetal alcohol spectrum disorder)
● Saccharin (has a long half-life and so can reach toxic levels in a fetus )
● Fish with high mercury content such as mackerel and swordfish
● 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)
Skin, Hair, and Nails:

● Inspect skin: Note hyperpigmented areas associated with pregnancy
Linea nigra, striae, gravidarum, chloasma and spider nevi may be present
● Observe skin for vascular markings associated with pregnancy: Angiomas and
palmar erythemas are common
● Inspect the hair and nails: Hair and nails tend to increase in growth; softening and
thinning are common
Head and Neck:

● Inspect and palpate the neck. Assess the anterior and posterior cervical chain lymph
nodes. Also palpate the thyroid gland
Smooth, nontender, small cervical nodes may be palpable. Slight enlargement of the
thyroid gland may be noted during pregnancy
● Inspect eyes: Examine cornea, lens, iris, and pupil.
Pupils are equal and round, reactive to light and accommodation
Mouth, Throat and Nose:

● Inspect mouth: Pay particular attention to the teeth and the gingival tissues which may
normally appear swollen and slightly reddened
Hypertrophy of gingival tissues is common. Bleeding may occur due to brushing teeth or
dental examinations
● Inspect the throat: Throat is pink, no redness or exudates
● Inspect the nose: Nasal mucosal swelling and redness may result from increased
estrogen production. Epistaxis is a common variations because of the increased
vascular supply to the nares during pregnancy
Thorax and Lungs:

● Inspect, palpate, percuss and auscultate the chest: Normal findings include
increased anteroposterior diameter, thoracic breathing, slight hyperventilation; shortness
of breath in late pregnancy. Lung sounds are clear to auscultation bilaterally
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:
● 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
SAMPLE CHECKLIST FOR NUTRITIONAL AND PHYSICAL EXAMINATION
Assessment S U NP Comments
1. Identify patients using at least two

identifiers
2. Asked patient to report usual body

weight noted, recent changes in weight,
asked if any loss was intentional
3. Performed hand hygiene, measured

actual body weight properly
4. Measured actual height properly
5. Calculated ideal body weight properly
6. Calculated BMI properly
7. Obtained dietary information, including

history, cultural or religious restrictions
and medications and supplements
8. Performed physical assessment noted

physical changes reflecting nutritional
deficiencies
9. Review relevant laboratory tests
10. Determined patient’s ability to

manipulate eating utensils and self-feed
11. Completed a nutritional screening tool if

required
12. Explained to patient that nutritional

assessment was complete and how
information will be applied to patient
care
Implementation
1. Provided patient help with feeding

based on assessment findings
2. Instituted aspiration precautions
Evaluation
1. Reviewed history and physical findings

noted abnormal finding pr areas of
concern
2. Compared patient’s weight for height

with IBW, compared BMI with
recommended BMI
3. Compared normal laboratory test levels

with patient’s level
4. Computed any score on nutritional

screening tool
5. Asked patient to describe what the

screening will determine
6. Identified unexpected outcomes
Recording and Reporting
1. Documented assessment results in

appropriate log
2. Documented evaluation of patient or

caregiver learning
3. Notified health care provider of

abnormal findings
4. Make referral to the RD
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)
Purpose: to determine the fetal presentation/lie through fundal palpation

If palpated a round, hard and movable – BREECH presentation
If palpated round, soft and immovable - HEAD/CEPHALIC presentation
SECOND MANEUVER: Umbilical/Lateral Grip

Face the woman, hold the left hand stationary on the left side of the uterus while you palpate
with the right hand on the opposite side of the uterus top to bottom. Repeat palpations using the
opposite side. RATIONALE: This maneuver locates the back of the fetus. The fetal back feels
like smooth ard and 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
THIRD MANEUVER: Pawlick’s Grip

Gently grasp the lower portion of the abdomen just above the symphysis pubis between the
thumb and fingers and try to press the thumb and finger together. Determine any movement and
whether the part feels firm or soft. RATIONALE: This maneuver determines which part of the
fetus is at the inlet and its mobility. If the presenting part moves upward so your fingers and
thumb can be pressed together, the presenting part is not engaged (not firmly settled into the
pelvis). If the part is firm, it is the head; if its soft, then it is breech
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
FOURTH MANEUVER: Pelvic Grip

Place fingers on both sides of the uterus approximately 2 inches above the inguinal ligaments,
pressing downward and inward in the direction of the birth canal. Allow fingers to be carried
downward. RATIONALE: This maneuver is only done if the fetus is in a cephalic presentation
because it determines fetal attitude and degree of fetal extension into the pelvis. The fingers of
one hand will slide along the uterine contour and meet no obstruction, indicating the back of the
fetal neck. The other hand will meet an obstruction an inch or so above the ligament–this is the
fetal brow. The position of the fetal brow should correspond to the side of the uterus that
contains the elbows and knees of the fetus. If the fetus is in a poor attitude, the examining
fingers will meet an obstruction on the same side as the fetal back; that is, the fingers will touch
the hyperextended head. If the brow is very easily palpated (as if it lies just under the skin) the
fetus is probably in a posterior position (occiput is pointing toward the woman’s back)
Purpose: to determine the fetal attitude –relationship of fetus to each part or

degree of flexion by grasping the lower quadrant of abdomen. It is done only if the fetus
is in cephalic presentation.
Full Flexion if the fetal chin touches chest
6. After the maneuvers are done, record your findings
VISUAL SUMMARY OF LEOPOLD’S MANEUVER
FETAL HEART TONE

Fetal heart sounds are transmitted best through the convex portion of a fetus because
that is the part that lies in closest contact with the uterine wall.
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
● 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.
FUNDAL HEIGHT MEASUREMENT:

Fundal height varies depending on the week of pregnancy.
Planning:
~Equipment
- Tape measure
Implementation:
1. Identify the client and explain the procedure.
2. Gather the equipment to be use.
3. Provide privacy for the client.
4. Place the client in a supine position.
5. Instruct the client to relax.
6. Place one hand on each side of the abdomen and walk hands up the sides of the uterus until
you feel the uterus curve; hands should meet.
7. Take a tape measure and place the zero point on the symphysis pubis and measure to the
top of the fundus
8. Measure the fundic height using the centimeter side of the tape measure.
9. Note the measurement.
● Uterine size should approximately equal the number of weeks of gestation.
Measurements may vary by about 2cm and examiners’ techniques may vary but
measurements should be about the same
10.Place the patient in a comfortable position.
11.Wash hands.
12.Document the procedure done.
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
Age of Gestation in Weeks = fundic height x 8 / 7

Age of Gestation in Months = fundic height x 2 / 7
Bartholomew’s Rule:
- Use to determine age of gestation by proper location of fundus at abdominal cavity
● Less than 12 weeks = not palpable/pelvic cavity
● 3 months = above symphysis
● 5 months = level of umbilicus
● 7 months = between umbilicus and xiphoid process
● 9 months = touching/below xiphoid process
● 10 months = level of 9 months due to lightening about 4cm
References:
○ Weber, J., & Kelley, J. (n.d.). Health Assessment in Nursing (6th ed.).
Wolters Kluwer.
○ Berman, A., Snyder, S., & Frandsen, G. (n.d.). Kozier & Erb’s
Fundamentals of Nursing. In Concepts, Process and Practice (11th ed.,
Vol. 1). Pearson.
○ Silbert-Flagg, J., & Pillitteri, A. (n.d.). Maternal & Child Health Nursing. In
Care of the Childbearing & Childrearing Family (8th ed., Vol. 1). Wolters
Kluwer.
DO NOT BASE SOLELY ON THIS REVIEWER PLEASE DO STILL

STUDY OUR LESSONS IN CANVAS AND ON DIFFERENT
RESOURCES SUCH AS YOUTUBE. THIS WILL ONLY SERVE AS
YOUR STUDY GUIDE :))))
Padayon future RNs

Let me share a wise word from Sister Taylor Swift
"I know I’m probably better off all alone than needing a man who
could change his mind at any given minute." from the book of Red (Taylor
Swift Version) 1:37-47

Reviewer para Maging Kumadrona

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FOR FEMALE CLIENTS

FOR MALE CLIENTS

6. Inspect the perineal area

FOR FEMALE CLIENTS

FOR MALE CLIENTS

8. Inspect perineal orifices for intactness.

- Adhesive tapes and bandages

18. Include quality of nurse patient relationship

ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)

Woman already in the DR – Preparing for delivery

At the time of delivery

First 30 seconds – After delivery

1-3 minutes- After delivery

Non time-bound procedure:

Reflex irritability (Grimace response):

Record your findings/scores

● Elbow at the midline of the thorax = 2

● More than 50mm or no crease = 0

● Prominent clitoris, enlarging labia minora = 1

Document your finding/score

Nursing Process Overview

Weight Gain in Pregnancy:

Prepregnancy BMI BMI

Underweight Less than 18.5

Normal weight 18.5-24.9

Obese More than 30

Recommended weight gain by WHO

VITAMINS NEEDS FOR THE PREGNANT WOMAN

VITAMINS SIGNS OF ESSENTIAL RELEVANT FOODS RECOMMENDED EVIDENCED

MINERAL NEEDS FOR PREGNANT WOMAN

MINERALS ESSENTIAL RELEVANT FOODS RECOMMENDED EVIDENCED BASED EVAL

Calcium Calcification of fetal Milk, cheese, yogurt, Adolescents = Supplementation is recommended to

warranted in areas supplementation

Zinc Immunity Oysters, red meat, Supplementation No standard recommended by WHO

FOODS TO AVOID OR LIMIT IN PREGNANCY

Skin, Hair, and Nails:

Head and Neck:

Mouth, Throat and Nose:

Thorax and Lungs:

SAMPLE CHECKLIST FOR NUTRITIONAL AND PHYSICAL EXAMINATION

1. Identify patients using at least two

2. Asked patient to report usual body

3. Performed hand hygiene, measured

4. Measured actual height properly

5. Calculated ideal body weight properly

6. Calculated BMI properly

7. Obtained dietary information, including

8. Performed physical assessment noted

9. Review relevant laboratory tests

10. Determined patient’s ability to

11. Completed a nutritional screening tool if

12. Explained to patient that nutritional

1. Provided patient help with feeding

2. Instituted aspiration precautions

1. Reviewed history and physical findings

2. Compared patient’s weight for height

3. Compared normal laboratory test levels

4. Computed any score on nutritional

5. Asked patient to describe what the

6. Identified unexpected outcomes

Recording and Reporting