L4: NASOGASTRIC AND GASTROSTOMY ● Assess tube placement prior to

MEDICATIONS administration of medications.

● Before giving the medication, aspirate all
NASOGASTRIC TUBE OR GASTROSTOMY
the stomach contents and measure the
TUBE
- An alternative route for administering residual volume. Check agency policy if
medications. residual volume is greater than 100 ml.
- A nasogastric (NG) tube is inserted by
way of the nasopharynx and is placed into STEPS
the client’s stomach for the purpose of When administering the medications:
feeding the client or removing gastric 1. Remove the plunger from the syringe and
secretions.
connect the syringe to a pinch or kinked
- A gastrostomy tube is surgically placed
into the client’s stomach and provides tube.
another route for administering Rationale:
medications and nutrition. Pinching or kinking the tube prevents
excess air from entering to the stomach
PRACTICE GUIDELINES IN and causing distention.
ADMINISTERING MEDICATIONS BY NGT 2. Put 15 to 30 ml (5 to 10 ml for children)
OR GASTROSTOMY TUBE
of sterile water into the syringe barrel to
● Always check with the pharmacist to see
flush the tube before administering the
if the client’s medications come in a liquid
first medication. Raise or lower the barrel
form because these are less likely to cause
of the syringe to adjust the flow as needed.
tube obstruction.
Pinch or clamp the tubing before all the
● If medications do not come in liquid form,
water is instilled to avoid excess air
check to see if they may be crushed. (Note
entering the stomach.
that enteric-coated, sustained action,
3. Pour liquid or dissolved medication into
buccal, and sublingual medications should
the syringe barrel and allow it to flow by
never be crushed.)
gravity into the enteral tube.
● Liquid medication must be further diluted
4. If you are giving several medications,
with sterile water, especially if the liquid
administer each one separately and flush
form is viscous.
with at least 15 to 30ml (5 to 10 ml for
● Crush a tablet into a fine powder and
children) of tap water between each
dissolve in at least 30 ml of warm sterile
medication.
water. Cold liquids may cause client
5. When you have finished administering all
discomfort. Use only water for mixing and
medications, flush with another 15 to
flushing. Some medications are mixed
30ml (5 to 10 ml for children) of warm
with other fluids, such as normal saline, in
water to clear the tube.
order to maximize dissolution. Nurses are
6. If the tube is connected to suction,
encouraged to consult with a pharmacist.
disconnect the suction and keep the tube
● Sterile water is recommended for use in
adult and neonatal/pediatric clients before clamped for 20 to 30 minutes after giving
the medication to enhance absorption.
and after the medication administration
(American Society for Parenteral and
TROUBLESHOOTING THE NG TUBE
Enteral Nutrition, 2009) advises not to use
1. Leaky connections
tap water because it often contains
○ If the NG tube is leaking around
chemical contaminants that might interact
the connection site, try a new
with the drug.
connector OR a new NG tube.
● Read medication labels carefully before
○ If the caps on the tube are
opening a capsule. Open hard gelatin
stretched out and opening by
capsule and mix the powder with sterile
themselves, you can wrap them
water.
tightly in Coban to keep them
● Do not administer whole or undissolved
closed.
medications because they will clog the
○ Have a nurse look at the tube to
tube.
 help you decide how to fix the intracranial placement, pneumothorax, and
leaky connection. trachea bronchopleural placement are rare
2. Clogged NG Tube complications of NG tube placement.
○ As soon as you notice any
resistance flushing or giving
medicines, try flushing the NG
tube with 5 to 10 mL of warm L9: MEDICATION ADMINISTRATION
water.
DEFINITION OF TERMS
○ If you are not able to flush any ● Physician – legally responsible for
liquid into the tube, try pulling prescribing medications
back on your syringe to see if ● Medication – a substance administered for
you can get any liquid out. diagnosis, cure, treatment, relief or
○ If you can’t flush or withdraw prevention of disease. It is also called a
anything from the tube, call your drug.
home care nurse or doctor. ● Medication Administration – task of a
nurse; a nursing dependent action; an
Please call your doctor for any of important nursing function that involves
the following: skillful technique and consideration of the
● Unable to hear a “whoosh” or “gurgle” patient’s development and safety.
when injecting air. ● Pharmacology – is the study of the effect
● Unable to give for any reason of drugs on living organisms.
● Client is not tolerating feeds ● Pharmacy – is the art of preparing,
● Unable to flush the tube compounding and dispensing drugs; refers
● Questions about which medicines can be to the place where drugs are prepared and
given through a tube and whether a dispensed.
medicine can be compounded (the ● Pharmacy – is the art of preparing,
pharmacy crushes and mixes it for you) compounding and dispensing drugs; refers
to the place where drugs are prepared and
NGT DECOMPRESSION dispensed.
● By inserting a nasogastric tube, you are ● Prescription - the written direction for the
gaining access to the stomach and its preparation and administration of a drug.
contents. This enables you to drain gastric
contents, decompress the stomach, obtain
a specimen of the gastric contents, or
introduce a passage into the GI tract. This
will allow you to treat gastric immobility,
and bowel obstruction.

CHECKING NGT PATENCY

1. Syringe test or “whoosh test”
- checks the placement of the tube
by using a stethoscope to listen
for the whooshing sound as a
syringe instills a 30cc air bolus
into the patient's stomach.
2. pH test
- This method aspires to the NG
tube and checks the content by
using pH paper. ● Pharmacopoeia – is a book containing a
list of products used in medicine,with
COMPLICATIONS OF NG TUBE descriptions of the product chemical tests
● Esophageal perforation, inadvertent for determining identity and purity and
 formulas for certain mixtures.
● Formulary – is a collection of formulas 4 KINDS OF DRUG NAME/DRUG
and prescriptions NOMENCLATURE
● Pharmacodynamics – the process by A. Prescription name / Generic name
which drugs alter the cell physiology and - The name given to a drug before
cause the effects on the body it becomes official. It refers to
● Pharmacokinetics – the study of the action the chemical makeup of a drug
in the body and their movement through rather than to the advertised
the body systems during absorptions, brand name under which the drug
distribution, biotransformation and is sold. It refers to any drug
elimination, including the time required marketed under its chemical
for therapeutic or pharmacologic response name. (e.g. Acetaminophen for
to them. Tylenol, Paracetamol for
● Pharmacoanthropology – science that Biogesic , Ibuprofen for Advil)
deals with the study of the difference in B. Official name
the drug response in various ethic or racial - The name after which the drug is
groups. listed in one of the official
● Posology – the study of dosage or amount publications like BFAD; the
of drugs given in the treatment of diseases generic name is usually followed.
● Drug study/Summary – study of rugs C. Chemical Name
before giving medications - The name by which a chemist
● Nurse – person licensed to administer, names it; this name describes the
educate about, and evaluate the constituents of drugs precisely;
effectiveness of prescribed medications. used is the chemical name with
the highest constituent of the
DIFFERENT SKILLS REQUIRED IN THE drug; chemical composition; very
ADMINISTRATION OF MEDICATIONS significant to the pharmacist. (e.g
1. Cognitive skills – what to do; how to acetyl-para- aminophenol for
implement or execute orders or Tylenol)
interventions D. Brand Name
2. Technical skills – handling situations; - The name given to a drug by the
palpation techniques, use of equivalents; manufacturer. It is also called
technicalities trademark. (e.g.Tylenol,
3. Interpersonal skills – what they are, how Biogesic, Advil)
to improve the and how to apply them
4. Ethical and legal skills – medical ethics
involves examining a specific
problem,usually a clinical case, and using
values, facts, and logic to decide what the
best course of action should be

SOURCES OF DRUG INFORMATION

1. PIMS (Phil, Indec for Medical Specialists)
2. MIMS (Medical Index for Medical
Specialists)
3. PDR (Physician Drug Reference)
4. Pharmacology book Example:
5. RN magazines and Medical magazines ✓ Trade Name: Benadryl
6. Journals ✓ Chemical Name: 2
7. Nursing Drug Handbook (Diphenylmethoxy)-N,N-
8. Package Insert of the Drug dimethylethylamine
9. The physician who prescribes the drugs hydrochloride
 ✓ Chemical Structure: ● Drug Toxicity – Deleterious or dangerous
effects of a drug on an organism or tissue.
Results from over dosage or ingestion of a
drug intended for external use and buildup
of the drug in the blood because of
impaired metabolism or excretion
✓ Generic Name: diphenhydramine
(cumulative effect).
hydrochloride
● Drug Tolerance – Exists in a person who
has unusually low physiologic response to
PHARMACOKINETIC VS. a drug and who requires increased dosage
PHARMACODYNAMIC to maintain a given therapeutic effect.
Pharmacokinetics as the Basis of Medication ● Drug Interaction – Occurs when the
Action administration of one drug before, at the
● ✓Route: how enter the body same time as, or after another drug alters
✓ A – bsorption : from site into the effect of one or both drugs.
blood ● Cumulative Effect – It is the increasing
✓ D – istribution : from blood into response to the repeated doses of drug that
cells, tissues, or organs occurs when the rate of administration
● ✓Action: how a medication acts exceeds the rate of metabolism or
✓ M – etabolism : changed to excretion and produces TOXICITY.
prepare for excretion ● Iatrogenic Disease – Disease caused
✓ E – xcretion : how they exit the unintentionally by medical therapy or can
body be due to drug therapy. Hepatic toxicity
resulting in biliary obstruction, renal
Pharmacodynamics damage and malformations of the fetus as
- The process by which a drug changes the a result of specific drugs taken during
pregnancy are examples.
body. Such changes require that the drug
interact with specific molecules and
DRUG MISUSE
chemicals normally found in the body.
● Drug Abuse – inappropriate intake of a
Effects of Drugs substance, either continuously or
● Therapeutic Effect/Desired effect – periodically
expected or predicted physiological ● Drug Dependence – it is a person’s
response that a medication causes. It is the reliance to take a drug or substance.
primary effect intended, that is the reason Intense physical or emotional disturbance
is produced if the drug is withdrawn
the drug is prescribed.
● Addiction – it is due to biochemical
● Side effect – predictable and often
changes in body tissues, especially the
unavoidable secondary effects produced at
a usual therapeutic dose nervous system. These tissues come to
● Adverse effect – unintended, undesirable, require the substance for normal
and often unpredictable severe responses functioning. Also called physical
to medication dependence.
● Toxic effect – develop after prolonged ● Drug Habituation – it is the emotional
reliance on a drug to maintain a sense of
intake of a medication or when a
well being accompanied by feelings of
medication accumulates in the blood
need or cravings for the drug. It is also
because of impaired metabolism or
excretion. called psychological dependence.
● Idiosyncratic effect – Unpredictable. A ● Illicit Drugs (Street Drugs) – are those
patient overreacts or under reacts to a sold illegally.
medication or has a reaction different from 2 Types of Illicit Drugs:
normal ✓ Drugs unavailable for purchase
under any circumstances
 ✓ Drugs normally available with a - A severe allergic
prescription that are being reaction which usually
obtained through illegal channels. occurs immediately
*Often taken because of their mood following administration
altering effect, the person feels relaxed of the drug; life-
and happy. threatening
- Symptoms: (SAT)
ALLERGIC RESPONSES • Shortness of breath
Allergic reaction • Acute hypotension
- Unpredictable. Repeated administration • Tachycardia
the patient develops an allergic response
to it, its chemical preservatives, or a THERAPEUTIC ACTION OF DRUGS
metabolite.
- The immunologic or anaphylactic reaction
to the drug. Can occur anytime from a few
minutes to 2 weeks after the
administration of the drug. Allergic or
adverse reactions can either be mild or
severe.
1. Mild
- Occurs anytime from few hours
to 2 weeks after the
administration of the drug
Examples:
○ Skin rash (urticaria) –
generalized; intraepidermal
vesicle rash or a rash typified by
an urticarial wheal or macular
eruption
○ Pruritus – itching of the skin with
or without rash
○ Angioedema – due to increased
permeability of blood capillaries MEDICATION: FORMS
○ Rhinitis – excessive watery ● Capsule
discharge from the nose - Is a medication in a gelatine
○ Lacrimal tearing – excessive container
tearing - Advantage: mask the unpleasant
○ Nausea and Vomiting – taste of its contents.
stimulation of the center of the - The two main types of capsules
brain are:
○ Wheezing and Dyspnea – 1. Hard-shelled capsules –
shortness of breath and wheezing which are normally used
upon inhalation & exhalation due for dry, powdered
to accumulated fluids & swelling ingredients
of the respiratory tissues 2. Soft-shelled capsules –
○ Diarrhea – irritation of the primarily used for oils
mucosa of the large intestine and for active
2. Severe ingredients that are
- Usually occurs immediately after dissolved or suspended
the administration of the drug. in oil.
Example:
○ Anaphylactic reaction
● Caplet carbon dioxide.
- A smooth, coated, oval-shaped - They are intended to be dissolved
medicinal tablet in the shape of a or dispersed in water before use
capsule, and are called “caplets”. providing:
● Tablet a. Very rapid tablet
- Compressed powder dispersion and
● Enteric coated dissolution
- Dissolves in small intestine b. Pleasant tasting
● Lozenge carbonated drink
- It is a solid preparation consisting ● Suspension
of sugar and gum, the latter - Drug particles in a liquid
giving strength and cohesiveness medium; when left alone will
to the lozenge and facilitating settle in the bottom
slow release of the medicament. ● Solution
- It is used to medicate the mouth - Sterile preparation that contains
and throat for the slow water and one or more dissolved
administration of indigestion or compounds (IM, SQ or IV)
cough remedies. ● Paste
● Pastilles - Semisolid, but thicker than
- They are solid medicated ointment; slower absorption
preparations designed to dissolve ● Transdermal disk or patch
slowly in the mouth. They are - Semi-permeable membrane disk
softer than lozenges and their or patch with drug applied to the
bases are either glycerol and skin
gelatin, or acacia and sugar. ● Lotion
● Dental cones - Liquid suspension for skin
- A tablet form intended to be ● Ointment
placed in the empty socket - Semisolid
following a tooth extraction, for ● Suppository
preventing the local - Solid drug mixed with gelatin
multiplication of pathogenic inserted into body cavity to melt
bacteria associated with tooth (rectum or vagina)
extractions.
- The cones may contain an TYPES OF DOCTOR’S ORDER
antibiotic or antiseptic Medication Order
● Time release - Is a written directions provided by a
- Granules with different coatings, prescribing practitioner for a specific
or some tablets that dissolve medication to be administered to an
slowly individual.
● Elixir - The prescribing practitioner may also give
- Mixed with water or alcohol and a medication order verbally to a licensed
a sweetener person such as a pharmacist or a nurse.
● Syrup 1. Standing order
- Medication dissolved in a sugar - It is carried out until it is
solution discontinued by another
● Effervescent tablets order; it may or may
- Are uncoated tablets that have a termination date
generally contain acid substances - Ex.: Demerol 100 mg
(citric and tartaric acids) and 1M every 4 hrs × 5 days
carbonates or bicarbonates and 2. Single order
which react rapidly in the - It is carried out for one
presence of water by releasing time only; is for
 medication to be given a - Makes the drug order a legal
specified time request.
- Ex.: Seconal 100 mg hs
before surgery 3 STEPS IN PATIENT’S MEDICAL ORDER
3. STAT order 1. Medication ticket
- It is carried out at once 2. Medication sheet
or immediately 3. Nursing kardex
- Ex.: Demerol 100 mg
IM STAT PARTS OF A PRESCRIPTION
4. PRN order
- It is carried out as the
patient requires
- Ex.: Calcibloc 5 mg
PRN

7 ESSENTIAL PARTS OF A DRUG ORDER

1. Client’s full name
- The first and last names, middle
initials and names should always
be used to avoid confusions
between two clients who have the
same last name. Client’s
identification number, room
number and provider’s name for
further identification.
2. Date and time the order is written
- The day, the month and the year Legend:
the order is written. 1. Name of the (Doctor, Hospital or Clinic)
3. The name of the drug to be administered 2. Descriptive information about the client
- Must be clearly written. In some (name, address, age)
settings only generic names are 3. Date on which the prescription was
permitted, however trade names written
are widely used in hospital and 4. The Rx symbol meaning “take thou”
health agencies. 5. Medication name, dosage and strength
4. The dosage of the drug 6. Dispensing instructions for the
- Includes the name of the drug, pharmacist. E.g.: Dispense 30 capsules
route, amount, and the time. 7. Directions for administration ot be given
5. Frequency of administration to the client
- And in many instances the 8. Refill and or special labeling
strength. 9. Prescriber’s signature
- Ex.: tetracycline 250 mg
(amount) 4 times a day MEDICATION ABBREVIATIONS
(frequency) ● ANST - after negative skin test
6. Route of administration ● PRN - as needed, as necessary
- This part of the order, like other ● NPO - nothing per orem/nil per
parts, is frequently abbreviated. It os
is not unusual for a drug to have ● BID - twice a day
several possible routes of ● OD - once a day
administration, therefore, it is ● TID - three times a day
important that the route be ● QID - four times a day
included in the order. ● Ad lib - as desired
7. Signature of the primary care providers ● ac - before meals (ante
 cibum) - Give the medication by the
● pc - after meals (post-cibum) ordered route. Make certain that
● RTC - round the clock the route is safe and appropriate
● HS - hour of sleep for the client.
● QHS - every bedtime ● Right education
● HGT - Hemoglucose testing - Explain information about the
● OS - left eye medication to the client (ex.: why
● AS - left ear receiving, what to expect, any
● AD - right ear precautions)
● OD - right eye ● Right dose
● OU - both eyes - The dose ordered is appropriate
● AU - both ears to the client. Give special
● Rx - prescribe / take thou attention if the calculation
● Tx - treatment indicates multiple pills/tablets or
● @ - at a large quantity of a liquid
● Ṫ - 1 (one) medication. This can be an
● STAT - immediately indication that calculation is
● SQ - subcutaneous incorrect.
● IM - intramuscular ✓ Double check calculation that
● ID - intradermal may appear questionable.
● mL - milliliter ✓ Know the usual dosage range of
● mg - milligram the medication.
● gtts - drops ✓ Question a dose outside of the
● Tsp - teaspoon usual dosage range.
● Tbsp - tablespoon ● Right time
● q 4h - every 4 hours - Give the medication at the right
● qH - every hour frequency and at the time ordered
● OZ - ounce according to agency policy.
● Lbs - pounds ● Right to refuse
● qt - quart - Adult client has the right to
● KVO - keep vein open refuse any medication.
● KSS - keep set sterile - The nurse’s role is to ensure that
● FBC to UB - foley bag catheter to the client is fully informed of the
urobag potential consequences of refusal
● CBR with TP - complete bed rest with and to communicate the client’s
toilet privilege refusal to the healthcare provider.
● D/C - discharge/discontinue ● Right assessment
● ISA - injection site adaptor - Some medications require
● DAT - diet as tolerated specific assessments prior to
administration
- Medication orders may include
specific parameters for
administration
● Right client
- Medication is given to the
intended client.
- Check the client’s identification
band with each administration of
● Right medication a medication.
- The medication given was the - Know the agency’s name alert
medication ordered. procedure when client’s with the
● Right route same or similar last names are in
 the nursing unit. patient. Before administering a
● Right evaluation medication, use at least two patient
- Conduct appropriate follow up identifiers.
- Ex.: Was the desired effect ● Always consult the prescriber if an order
achieved or not? does not designate a route of
- Did the client experience any administration. Likewise, if the specified
side effects or adverse reactions? route is not the recommended route, alert
● Right documentation the prescriber immediately.
- Document medication ● You need to know why a medication is
administration after giving it, not ordered for certain times of the day, and
before. whether you are able to alter the time
- If time of administration differs schedule.
from prescribed time, note the ● A medication order is required for every
time in the MAR and explain the medication that you administer to a
reason and follow up through patient.
activities. ● Never document that you have given
- If the medication is not given, medication until you have actually given
follow the agency’s policy for it.
documenting the reason why. ● If any question arises about a medication
order because it is incomplete, illegible,
MEDICATION: NURSE ROLE vague, or not understood, contact the
✓ Follow 10 rights prescribing health care provider before
✓ Read labels 3× administering the medication.
✓ Use at least 2 patient identifiers
MEDICATION ERRORS
✓ Avoid interruption
● Report all medication errors.
✓ Double check calculations, verify with
● Patient safety is top priority when an error
another RN, follow policy
occurs.
✓ Question unusual doses ● Documentation is required.
✓ Record after medication given ● The nurse is responsible for preparing a
✓ Report errors, near-misses written occurrence or incident report: an
✓ Participate in programs designed to reduce accurate, factual description of what
error occurred and what was done.
✓ Patient education about medications ● Nurses play an essential role in
medication reconciliation.
● Because nurses play an essential role in ● A medication error can cause or lead to
preparing and administering medications, inappropriate medication use or patient
they need to be vigilant in preventing harm.
errors. ○ Errors include inaccurate
● Regardless of how the nurse receives a prescribing or administration, or
medication order, he or she compares the giving a drug via the wrong route
prescriber’s written orders with the or frequency.
medication administration record (MAR) ● It is important to feel comfortable in
or the electronic medication reporting an error and not fear
administration record (eMAR) when repercussions from managerial staff.
medication is initially ordered. ● Even when a patient suffers no harm from
● When performing medication calculations a medication error, the institution can still
or conversions, have another qualified learn why the mistake occurred and what
nurse check the calculated doses. can be done to avoid similar errors in the
● An important step in safe medication future.
administration is making sure that you ● When an error occurs, the nurse first
give the right medication to the right assesses and examines the patient’s
 condition and notifies the health care ● Using the wrong route
provider of the incident as soon as ● Giving at the wrong time
possible. ● Extra doses
● Once the patient is stable, the nurse ● Omission of scheduled dose
reports the incident to the appropriate ● Similar drug names (25%)
person in the institution (e.g., manager, ○ CeFAZolin vs. CefTRIAXone
supervisor). ● Limit verbal orders; follow all procedures
● The nurse is responsible for preparing a ● Use only approved abbreviations, symbols
written occurrence or incident report that ● OK to question, clarify, repeat
usually needs to be filed within 24 hours ● Occurrence report for errors: nurse’s
of the error. responsibility, MD informed, within 24
● The report includes patient identification hours, reflect, context, identify factors
information; the location and time of the ● Caution with transfers within and between
incident; an accurate, factual description facilities
of what occurred and what was done; and
the signature of the nurse involved. MEDICATION: ERROR PREVENTION
● The occurrence report is not a permanent ● Checking compatibility charts
part of the medical record and is not ● Checking kidney or liver function &
referred to anywhere in the record. allergies
● This legally protects the nurse and the ● Never administer drugs prepared or
institution. Agencies use occurrence documented by others
reports to track incident patterns and ● Never leave meds at bedside
initiate quality improvement programs as ● Open med at bedside – check medication
needed. sheet with ID band
● Nurses play an essential role in ● Some drugs require 2 nurses to check
medication reconciliation. (insulin, heparin, etc.)
● Whenever a nurse admits a patient to a ● Check expiration dates
health care setting, he or she compares the
medications that the patient took in the SYSTEMS OF MEASUREMENT
previous setting (e.g., home, another Metric system
nursing unit) with his or her current ● Devised by the French in the latter part of
medication orders. the 18th century , is the system prescribed
● When the patient leaves that setting for by law in most European countries and in
another setting (e.g., skilled care facility, Canada.
intensive care unit), the nurse ● Basic units of measurements are the
communicates the patient’s current meter, the liter, and the gram. Only the
medications to the health care providers in measurements of volume (liter) and
the new setting. weight (gram) are discussed because these
● The nurse also reconciles the patient’s are the measures used in medication
medications when he or she is discharged administration.
from an agency or is seen in an outpatient
setting. Apothecaries’ system
● Many agencies have computerized or ● It was brought to the United States from
written forms to facilitate the process of England during the colonial period. The
medication reconciliation. basic unit of weight in apothecaries’
● Advances in technology have helped to system is the grain (gr) and the basic unit
decrease the occurrence of medication of volume is minims, a volume of water,
errors. which means “the least”.
● The other units of weight are the dram,
How does it happen? scruple, the ounce, pound. The units of
● Inaccurate prescribing volume are the fluid dram, the fluid ounce,
● Giving the wrong medication the pint, the quart, and the gallon.
 & discolor teeth; drug can be
Household system aspirated by seriously ill patient;
● Included in household measures are drops, may irritate gastric mucosa
teaspoons, tablespoons, cups, and glasses. ● Sublingual
- Drug placed under the tongue
- Advantage: Drug is rapidly
absorbed into the bloodstream;
Medication should not be
swallowed; Drug can be
administered by local effects;
Ensures greater potency because
drugs directly enters the blood
and bypasses the liver
- Disadvantage: If swallowed, the
drug may be inactivated by
gastric juice; the drug must
remain under the tongue until
dissolved or absorbed.
● Buccal
- Means pertaining to the cheek. A
medication is held in the mouth
against the mucous membranes
of the mouth or systemically
when it is swallowed in the
saliva.
- Advantages: a medication is held
in the mouth against the mucous
membranes of the cheek until the
drug dissolves; Drug may act
locally on the mucous
membranes of the mouth or
systemically when it is
swallowed with the saliva
- Disadvantages: if swallowed,
drugs may be inactivated by
gastric juice; drugs must remain
under the tongue until dissolved
ROUTES OF ADMINISTRATION
and absorbed.
Enteral Medications
● Nasogastric tube
● Oral
- Liquid form; dissolve in 15-30
- The drug is swallowed. It is the
mL warm water
most common , and most
- Flush tube with 15-30 mL of
convenient route for most clients
water between medications
because the skin is not broken as
- Flush afterwards with 30- 60mL
it is for an injection . It’s a safe
● Nasal installation
method.
- May self administer
- Advantages: safest; most
- Check nares for irritation
convenient; safe; does not break
- Nasal packing for bleeding and
skin barrier; administration
certain surgeries may be used
usually does not cause stress
applied by provider
- Disadvantages: slower acting;
drug may have an unpleasant
taste or odor; drug may damage
Topical Medications sac
- Applied to a circumscribed surface area of ● Vaginal installation
the body. They only affect the area to - Use gloves
which they are applied. - Privacy
● Ear instillation (OTIC) - Patient may choose to self-
- Structures are very sensitive to administer
temperature. - May need a pad to collect any
- Use sterile solutions. drainage.
- Drainage may indicate eardrum - Solid, oval suppositories come
rupture. individually packaged in foil
- Never occlude the ear canal. wrappers and sometimes are
- Do not force medication into an stored in the refrigerator to
occluded ear canal prevent them from melting.
- Administration: - After a suppository is inserted
○ Adult: pull ear back and into the vaginal cavity, body
up temperature causes it to melt and
○ Child: pull ear back and be distributed and absorbed.
down for child under 3 - Vaginal medications are
years available as suppositories, foam,
● Skin (Ointment, Cream, Paste) jellies, or creams.
- Use gloves and applicators. - Foam, jellies, and creams are
- Use sterile technique if the administered with an applicator
patient has an open wound. inserter.
- Clean skin first—remove tissue - Because vaginal medications are
and crusting. often given to treat infection,
- Apply ointments and pastes discharge is usually foul
evenly. smelling. Follow aseptic
- Follow directions for each type technique, and offer the patient
of medication frequent opportunities to
● Intraocular route maintain perineal hygiene.
- Administered by applying a
clear, flexible, elliptical shaped
disk similar to contact lens to the
conjunctival sac to provide
continuous treatment of a disease
as open angle glaucoma
● Eye instillation
- Avoid the cornea.
- Avoid the eyelids with droppers
or tubes to decrease the risk of
infection.
- Use only on the affected eye.
- Never allow a patient to use ● Rectal instillation
another patient’s eye medication. - Gloves
- Elderly may have difficulty with - Lubricant rounded end to ease
drops administration
- Risk of transmitting infection - Privacy
from one eye to the other, do not - Patient may choose to self-
touch any part of the eye with administer
eye applicator - May need a pad to collect any
- Apply ointment along lower drainage.
eyelid, drops into conjunctival ● Rectal suppositories are thinner and more
bullet shaped than vaginal suppositories.
 The rounded end prevents anal trauma Parts of a Syringe
during insertion.
● Rectal suppositories contain medications
that exert local effects such as promoting
defecation.
● Rectal suppositories are often stored in the
refrigerator until administered. Sometimes
it is necessary to clear the rectum with a
small cleansing enema before inserting a ● Fill a syringe by pulling the plunger
suppository. outward while the needle tip remains
immersed in the prepared solution. Touch
Inhalation only the outside of the syringe barrel and
- Administered into the respiratory tract by the handle of the plunger to maintain
a nebulizer or positive pressure breathing sterility. Avoid letting any unsterile object
apparatus. touch the tip or inside of the barrel, the
● Aerosol spray, mist, or powder via hub, the shaft of the plunger, or the
handheld inhalers; needle.
- Used for respiratory “rescue” and
“maintenance” Parts of the Needle
- Pressurized metered-dose
inhalers (pMDIs)
- Need sufficient hand strength for
use
● Nebulization
- A nebulizer is a device that turns ● A needle has three parts: the hub, which
the liquid medicine into a mist fits onto the tip of a syringe; the shaft,
which is then inhaled through a which connects to the hub; and the bevel,
mouthpiece or a mask. or slanted tip.
● The tip of a needle, or the bevel, is always
ADMINISTERING INJECTIONS slanted. The bevel creates a narrow slit
Types of Syringes when injected into tissue that quickly
A. 5-mL syringe closes when the needle is removed to
B. 3-mL syringe prevent leakage of medication, blood, or
C. Tuberculin syringe serum
- Is calibrated in sixteenths of a ● Long beveled tips are sharper and
minimum and hundredths of a narrower, minimizing discomfort when
milliliter and has a capacity of 1 entering tissue used for subcutaneous or
mL. IM injection.
- Use a tuberculin syringe to ● Some needles come packaged in
prepare small amounts of individual sheaths to allow flexibility in
medications. A tuberculin syringe choosing the right needle for a patient,
is useful when small, precise whereas others are preattached to
doses are prepared for infants or standard-sized syringes.
young children. ● Most needles are made of stainless steel,
D. Insulin syringe and all are disposable.

Types of Needles
● Choose needle length according to the
patient’s size and weight and the type of
tissue into which the medication is to be
injected.
● Choose needle length according to the
 patient’s size and weight and the type of prevents deposit of medication
tissue into which the medication is to be into sensitive tissue. It is
injected. recommended that, when
● Choose needle length according to the administering IM injections, the
patient’s size and weight and the type of Z-track method be used to
tissue into which the medication is to be minimize local skin irritation by
injected. sealing the medication in muscle
tissue. The Z-track method for
Parenteral Medications IM injections protects
- Defined as other than through the subcutaneous tissues from
alimentary or respiratory tract that is by irritating parenteral fluids.
needle. 1. To use the Z-track method, put a
- Advantages: new needle on the syringe after
○ Parenteral route is rapid. preparing the medication, so no
○ It is useful for uncooperative solution remains on the outside
patients needle shaft.
○ It is useful for unconscious 2. Then select an IM site, preferably
patients. in a large, deep muscle such as
○ Bioavailability is 100%. the ventrogluteal muscle. Place
- Disadvantages: the ulnar side of the nondominant
○ Skill is required. hand just below the site, and pull
○ It is painful. the overlying skin and
○ This method is expensive. subcutaneous tissues
○ It is less safe. approximately 2.5 to 3.5 cm (1 to
Route for Administration 1 ½ inches) laterally or
– Time until effect – downward. Hold the skin in this
position until you administer the
injection.
3. After preparing the site with an
antiseptic swab, inject the needle
deep into the muscle. Grasp the
barrel of the syringe with the
thumb and index finger of the
● Subcutaneous (SQ) nondominant hand, and slowly
inject the medication at a rate of
- Into the subcutaneous tissue just 10 seconds per milliliter if no
below the skin. blood return is noted on
○ Outer posterior aspect of aspiration.
the upper arms, 4. The needle remains inserted for
○ Abdomen from below 10 seconds to allow the
the costal margins to the medication to disperse evenly
iliac crests rather than channeling back up
○ Anterior aspects of the the track of the needle. Release
thighs. the skin after withdrawing the
- The site most frequently needle. This leaves a zigzag path
recommended for heparin that seals the needle track where
injection is the abdomen. tissue planes slide across one
- The injection site chosen needs to another.
be free of skin lesions, bony - The medication cannot escape
prominences, and nerves. from the muscle tissue. Injections
using this technique result in less
Z-track Technique discomfort and decrease the
- Z-track method of injection
 occurrence of lesions at the the lateral aspect of the
injection site. upper arm
● Intramuscular (IM) ○ Vastus lateralis –
- Into the muscle usually thick and well
- Faster absorption than developed in both adults
subcutaneous route and children
- Many risks, so verify the - Ventrogluteal
injection is justified ○ Three Landmarks:
- Injection into the muscles; 90o Greater Trochanter,
angle Anterior iliac spine, iliac
- Route for irritating solutions, crest
potent and toxic agents, aqueous, ○ The ventrogluteal
suspension and solutions in oil muscle involves the
- Advantages: gluteus medius; it is
○ Pain from irritating situated deep and away
drugs is minimized from major nerves and
○ Can be administer larger blood vessels.
volume than ○ This site is the preferred
subcutaneous and safest site for all
○ Drug is rapidly absorbed adults, children, and
- Disadvantages: infants, especially for
○ Breaks skin barrier medications that have
○ Can be anxiety larger volumes and are
producing more viscous and
- Needle irritating. The
○ Very obese: 3 inches ventrogluteal site is
○ Thin: ½ to 1 inch recommended for
- Amounts volumes greater than 2
○ Adults: 2 to 5 mL can be mL.
absorbed ○ Locate the ventrogluteal
○ Children, older adults, muscle by positioning
thin patients: up to 2 mL the patient in a supine or
○ Small children and older lateral position. Flexing
infants: up to 1 mL the knee and hip helps
○ Smaller infants: up to to relax this muscle.
0.5 mL ○ Place the palm of your
- IM Sites: hand over the greater
○ Ventrogluteal – gluteus trochanter of the
medius muscle which patient’s hip with the
lies over the gluteus wrist perpendicular to
minimus; the femur. Use the right
○ Dorsogluteal – hand for the left hip, and
composed of thick use the left hand for the
gluteal muscle of the right hip.
buttocks ○ Point the thumb toward
○ Rectus femoris – the patient’s groin and
belongs to the the index finger toward
quadriceps muscle the anterior superior
group situated on the iliac spine; extend the
anterior aspect of the middle finger back
thigh along the iliac crest
○ Deltoid – is found on toward the buttock.
 ○ The index finger, the acromion process. The
middle finger, and the injection site is then
iliac crest form a V- three finger widths
shaped triangle; the below the acromion
injection site is the process.
center of the triangle. - Vastus Lateralis
- Deltoid ○ The vastus lateralis
○ Use this site for small muscle is another
medication volumes (2 injection site for adults
mL or less). Carefully and children.
assess the condition of ○ The muscle is thick and
the deltoid muscle, well developed, is
consult medication located on the anterior
references for suitability lateral aspect of the
of the medication, and thigh, and extends in an
carefully locate the adult from a
injection site using handbreadth above the
anatomical landmarks. knee to a handbreadth
○ Use this site only for below the greater
small medication trochanter of the femur.
volumes, when giving ○ Use the middle third of
immunizations. the muscle for injection.
○ When other sites are The width of the muscle
inaccessible because of usually extends from the
dressings or casts. midline of the thigh to
○ To locate the muscle, the midline of the outer
fully expose the side of the thigh.
patient’s upper arm and ○ With young children or
shoulder. cachectic patients, it
○ Do not roll up a helps to grasp the body
tightfitting sleeve. Have of the muscle during
the patient relax the arm injection to be sure that
at the side and flex the the medication is
elbow. The patient may deposited in muscle
sit, stand, or lie down. tissue.
○ Palpate the lower edge ○ To help relax the
of the acromion process, muscle, ask the patient
which forms the base of to lie flat with the knee
a triangle in line with slightly flexed or in a
the midpoint of the sitting position. The
lateral aspect of the vastus lateralis site is
upper arm often used for infants,
○ The injection site is in toddlers, and children.
the center of the ● Intradermal (ID)
triangle, about 3 to 5 cm - 15o angle
(1 to 2 inches) below the - Skin test, dermis layer of the
acromion process. skin, under the epidermis
○ You can also locate the - Syringe: 1 mL
site by placing four - Needle gauge: #25, #26, #27
fingers across the - Vaccines: BCG, TB testing (48
deltoid muscle, with the hrs), allergy testing (30 minutes);
top finger along the 0.1 (medication); 0.9 (distilled
 water) subcutaneous tissues. In this case,
- Criteria for ID site: test results will not be valid.
○ Hairless ● Intravenous (IV) – into a vein
○ Less pigmented area
○ Less vascularized Comparison of Angles of Insertion for Injections
○ Less keratinized
- Route for ID injection:
○ Inner lower arm
○ Upper chest
○ Back beneath the
scapula
- Used for skin testing (TB,
allergies)
- Slow absorption from dermis
- Skin testing requires the nurse to
be able to clearly see the
injection site for changes.
- Use a tuberculin or small
hypodermic syringe for skin Mixing Medications from Two Vials
testing.
- Angle of insertion is 5 to 15
degrees with bevel up
- A small bleb will form as you
inject; if it does not form, it is
likely the medication is in
subcutaneous tissue, and the
results will be invalid.
- Because these medications are ● In (A), the diagram shows injecting air
potent, they are injected into the into vial A.
dermis, where blood supply is ● B shows injecting air into vial B and
reduced and medication withdrawing dose.
absorption occurs slowly. ● C diagrams withdrawing medication from
Sometimes patients have a severe vial A.
anaphylactic reaction if the ● The medications are now mixed.
medications enter the circulation ● Use only one syringe with a needle or
too rapidly. needleless access device attached to mix
- Skin testing requires that the medications from two vials.
nurse be able to clearly see the ● Aspirate the volume of air equivalent to
injection sites for changes in the dose of the first medication.
color and tissue integrity. ● Inject the air into the vial, making sure
- Intradermal sites need to be that the needle does not touch the solution.
lightly pigmented, free of lesions, Withdraw the needle and aspirate air
and relatively hairless. The inner equivalent to the dose of the second
forearm and the upper back are medication.
ideal locations. ● Inject the volume of air into a vial.
- As you inject the medication, a Immediately withdraw the medication
small bleb resembling a mosquito from the vial into the syringe and insert
bite appears on the surface of the the needle back into the vial, being careful
skin. If a bleb does not appear, or not to push the plunger and expel the
if the site bleeds after needle medication within the syringe into the
withdrawal, chances are good vial.
that the medication entered ● Withdraw the desired amount of
medication from vial A into the syringe.
 ● After withdrawing the necessary amount, ● Essentially, the baby's head has officially
withdraw the needle and apply a new entered its mother's pelvis.
safety needle or needleless access device
Descent
suitable for injection.
● Downward movement of the biparietal
diameter of the fetal head to within the
DRUG COMPUTATION pelvic inlet.
Desired Dose × Quantity = Amount to ○ Floating – fetal presenting part is
Administer not engaged in pelvic inlet
Stock on Hand ○ Fixed – fetal presenting part has
● Problem 1: Erythromycin 500 mg is entered pelvis
○ Engagement – fetal presenting
ordered. It is supplied in a liquid form
part (usually biparietal diameter
containing 250 mg in 5 mL. To calculate of fetal head) has passed through
the dosage, the nurse uses the formula: pelvic inlet
500 mg × 5 mL = 10 mL ○ Station 0 – presenting part has
250 mg reached level of ischial spines
● Problem 2: MD writes an order for Xanax ○ Stations -1,-2,-3 – presenting
2 mg by mouth a day. Pharmacy dispenses part is 1,2,3 above the level of
ischial spines
you with 1 mg per tablet of Xanax. How ○ Stations +1, +2, +3 – presenting
many tablets do you administer per dose? part is 1,2,3 below level of ischial
Answer: 2 tablets/dose spines. A station of +4 indicates
● Problem 3: MD writes an order for that presenting is on the pelvic
Cytotec 0.1 gram by mouth daily for a floor
patient with peptic ulcer disease.
Pharmacy dispenses you with 100 mg per
tablet. How many tablets do you
administer per dose?
Answer: 1 tablet/dose

L14: HANDLING AND ASSISTING

DELIVERIES

● Handling delivery
- Is the actual handling of the
delivery of the fetus Flexion
● Assisting delivery ● Baby moves further downward and then
- Handling the instruments to the the head meets obstruction at the pelvic
one handling the delivery floor causing flexion.
● Episiotomy ● While descending through the pelvis, the
- A surgical incision of the fetal head flexes so that the fetal chin is
perineum made to prevent tearing touching the fetal chest. This functionally
of the perineum with birth and to creates a smaller structure to pass through
release pressure of the fetal head the maternal pelvis.
during delivery. ● When flexion occurs, the occipital
● Episiorrhaphy (posterior) fontanel slides into the center
- Repair tears of the episiotomy of the birth canal and the anterior fontanel
with the use of sutures. becomes more remote and difficult to feel.
● Laceration The fetal position remains occiput
- Refers to the tearing of the transverse
vulvar, vagina and sometimes
rectal tissue during birth. Internal Rotation
● In accommodating the birth canal, the
CARDINAL MOVEMENTS fetal occiput rotates anteriorly from its
Engagement original position toward the symphysis.
● Occurs when the widest part of the fetal ● The movement results from the shape of
head has passed below the maternal pelvic the fetal head, space available in the
inlet. midpelvis and contour of the perineal
 muscles. The ischial spines project into ○ Is usually the longest and least
the midpelvis causing the fetal head to intense phase of labor.
rotate anteriorly to accommodate the ● Active stage
available space. ○ The second phase of the first
● With further descent, the occiput rotates stage is signaled by dilatation of
anteriorly and the fetal head assumes an the cervix from 4 to 7 cms.
oblique orientation. ○ Contractions become longer,
● In some cases, the head may rotate more severe, and frequent
completely to the occiput anterior (usually 3 to 4 mins. apart)
position. ● Transition phase
○ The third phase and the last
Extension phase. Cervix dilates from 8 to
● As the fetal head descends further it meets 10 cm.
resistance from the perineal muscles and ○ Contractions are usually very
is forced to extend. strong lasting 60-90 seconds and
● The fetal head becomes visible at the occurring every few minutes.
vulva ring; its largest diameter is encircled
(crowning) and the head then emerges Second Stage of Labor (Stage of Expulsion)
from the vagina. - Complete dilatation to expulsion of the baby
● The curve of the hollow of the sacrum ● Ritgen’s Maneuver
favors extension of the fetal head as ○ Denotes extracting the fetal head,
further descent occurs. using one hand to pull the fetal
● This means that the fetal shin is no longer chin from between the maternal
touching the fetal chest. anus and the coccyx, and the
other on the fetal occiput to
External Rotation / Restitution control speed of delivery.
● When the head emerges, the shoulders are ○ It is performed during the uterine
undergoing internal rotation as they turn contraction.
in the midpelvis to accommodate the ● Palpate for cord coil
projection of the ischial spines. ○ Suction baby’s mouth and nose
● The head, now born, rotates the shoulders using bulb syringes.
undergo this internal rotation ○ Deliver the shoulder, wait for the
● The shoulders rotate into an oblique or external rotation where one
frankly anterior-posterior orientation with shoulder is up and the other
further descent. shoulder is down.
● This encourages the fetal head to return to ○ With one hand at the back of the
its transverse position. neck, the other one grasping the
extremities and putting the baby
Expulsion in the mothers abdomen and
● Following delivery of the infant’s head suction secretions.
and internal rotation of the shoulders, the
anterior shoulder rests beneath the Third Stage (Placental Stage)
symphysis pubis. ● Birth of the baby → expulsion of the
● The posterior shoulder is born, followed placenta
by the anterior shoulder and the rest of the ● This stage of labor is the period from birth
body. of the baby through delivery of the
placenta.
STAGES OF LABOR ● This is considered a dangerous time
First Stage of Labor (Stage of Dilatation) because of the possibility of hemorrhaging
- Onset of true labor to full cervical dilatation
● Latent phase ー Placental Separation
○ The first phase of the first stage 1. Calkin’s sign
of labor when contractions are ○ The uterus becomes globular in shape
becoming more frequent (usually and firmer, discoid to avoid,
5 to 20 minutes apart) and indicating placental separation from
somewhat stronger. the uterine wall.
○ The cervix dilates (open 2. Gushing of blood
approximately three or four cm ○ 2nd sign
and effaces (thins out). ○ Or sudden gush of blood
3. Lengthening of the cord
 ○ 3rd sign CONTENTS OF INSTRUMENT SET
○ The umbilical cord descends three (3) ● CPCMHI
inches or more further out of the ○ 1 bandage scissor
vagina ○ 1 kelly curve and 1 kelly straight
4. The uterus rises in the abdomen ○ 1 surgical scissor
○ 1 needle holder
○ 1 tissue forcep
○ 1 placental bowl
● VSMMC PRIMI SET
ー Placental Expulsion ○ 1 bandage scissor
● Crede’s Maneuver ○ 1 surgical scissor
○ A method of expressing the ○ 1 kelly curve/straight forcep
placenta in which body uterus is ○ 1 needle holder
vigorously squeezed in order to ○ 1 tissue forcep with teeth/without
produce placental separation teeth
● Brandt- Andrews Maneuver ○ 1 tray
○ A method of expressing the ○ 10cc disposable syringe for
placenta by grasping the lidocaine hcl 2% (to be added)
umbilical cord with one hand and ○ Needle and Suture (to be added)
placing the other hand on the ○ Sterile 4x4 OS 5-10 pcs. (to be
abdomen, application of the added)
traction on the cord by moving ○ 4 sterile OP towel
the forcep up, down, left, right. ○ 2 leggings (optional)
● Schultze’s mechanism ● VSMMC SET MULTI SET
○ Shiny (fetal side) ○ 1 bandage scissor
○ A mechanism or technique for ○ 1 kelly curve/straight forcep
the delivery with the fetal rather ○ 1 needle holder
than the maternal side surface ○ 1 tissue forcep with teeth/without
presenting the shiny and teeth
glistening side of the fetal ○ 1 tray
membrane ○ 10cc disposable syringe for 2 %
● Duncan mechanism lidocaine hcl (to be added)
○ Dirty or rough (maternal side) ○ Needle and Suture (to be added)
○ A mechanism or technique for ○ Sterile 4x4 OS 5-10 pcs. (to be
delivery with the maternal rather added)
than the fetal side surface ○ 2 leggings (optional)
presenting the dirty or rough side.
INSTRUMENTS
Fourth Stage (Stage of Physical Recovery) ● 10cc disp. Syringe with lidocaine
● Delivery of the placenta up to 1-4 hrs. anesthesia + bandage scissors – are used
after delivery during episiotomy.
● 2 kelly forceps – used to clamp the
CONTENTS OF OB PACK umbilical cord of the baby
● CPCMHI ● Umbilical cord scissor – used to cut the
○ 3 gowns umbilical cord.
○ 2 leggings ● Surgical scissors – used to cut the
○ 3 drapes umbilical cord.
○ 1 perineal support ● Needle holder – used to hold the round
● VSMMC ( OB KIT) needle with a suture.
○ Digital thermometer ● 1 tissue forceps with teeth used to hold the
○ Adult diaper soft tissues in the perineal area during
○ Sterile gloves episiorrhaphy
○ 1 bottle of 70% alcohol
○ 1 bottle Betadine solution STEPS IN HANDLING DELIVERY
○ Pack cotton ball PROCEDURE
○ Baby diaper Preparation
○ Bonnet ● Do medical and surgical hand washing
○ ID bracelet ( white and pink / ● Perform gowning (per institution protocol)
blue) and gloving (per institution protocol)
● Do draping (per institution protocol)
 - The Apgar score is a test given to
Action newborns soon after birth. This
● DRAPE the patient accordingly. test checks a baby's heart rate,
○ Leggings (left and right) muscle tone, and other signs to
○ Abdominal drape see if extra medical care or
○ Perineal drape emergency care is needed.
○ Baby drape - The test is usually given twice:
○ Perineal support once at 1 minute after birth, and
● Encourage the woman to push/ bear down again at 5 minutes after birth.
once the uterus is at the height of its ● Acrocyanosis
contraction and to do breathing exercises - Bluish discoloration of body and
when it is not. extremities.
● Harlequin’s Sign
ASSISTING DELIVERY - Dependence sign; reddish on one
Basic Emergency Obstetric and Newborn Care side of the baby. Harlequin color
(BEmONC ) or Comprehensive Emergency change appears transiently in
Obstetric and Newborn Care (CEmONC) Site approximately 10% of healthy
Supervision Checklist newborns.
● This is a supervision checklist for - This distinctive phenomenon
Emergency Obstetric and Newborn Care presents as a well-demarcated
sites to help monitor: color change, with one half of the
1. The infrastructure and body displaying erythema and the
environment, other half pallor.
2. The equipment and material ● Milia
3. The management of antenatal - Pinpoint whitish structures on
care clients, patients during labor baby’s nose, forehead and chin
and delivery, as well as postnatal ● Mottling
mothers and babies - The hue and color patterns of a
4. Family planning, and newborn's skin may be startling
5. Postabortion care. to some parents. Mottling of the
● Universal access to EmONC is considered skin, a lacy pattern of small
essential to reduce maternal mortality and reddish and pale areas, is
requires that all pregnant women and common because of the normal
newborns with complications have rapid instability of the blood
access to well-functioning facilities that circulation at the skin's surface.
include a broad range of service delivery ● Lanugo
types and settings. - Downy hair of newborn; anterior
● A set of seven key obstetric services, or shoulder, buttocks, scapular
“signal functions,” has been identified as region, forehead.
critical to basic emergency obstetric and ● Mongolian Spots
newborn care (BEmONC): - Bluish discoloration in lumbar
1. Administration of parenteral region and buttocks. Mongolian
antibiotics; blue spots, also known as slate
2. Administration of parenteral gray nevi, are a type of
anticonvulsants; pigmented birthmark. They’re
3. Administration of parenteral formally called congenital dermal
uterotonics; melanocytosis.
4. Removal of retained products - These marks are flat and blue-
(manual vacuum aspiration); gray. They typically appear on
5. Assisted vaginal delivery; the buttocks or lower back, but
6. Manual removal of the placenta; may also be found on the arms or
7. Resuscitation of the newborn. legs. They’re generally present at
birth or develop soon after.
L15: IMMEDIATE NEWBORN CARE - These birthmarks are
noncancerous and present no
● Apgar Scoring health danger. However, your
- Method of evaluating/ child’s pediatrician should
monitoring cardiovascular examine the marks to confirm the
adaptation of the baby. diagnosis. There’s no
recommended treatment for
 Mongolian blue spots. They
Weight 6.5 to 7.5 lbs (2.9 kg to 3.4
usually fade before adolescence.
kg)

Length 50 cm (20 in)

● Vernix Caseosa
- Also known as vernix Head 33 to 35 cm (13 to 13.7 in)
- Is the waxy or cheese-like white
circumference
substance found coating the skin
of newborn human babies. Chest 31 to 33 cm or 2cm less than
- It is produced by dedicated cells circumference head circumference
and is thought to have some
protective roles during fetal Abdominal 31 to 33 cm
development and for a few hours circumference
after birth.
● Newborn Care
- The care is performed Vital sign Immediately After Birth
immediately after birth through at Birth
the first 28 days of life, making
the transition to extrauterine life Temperatu 36.5 to 37.2
smoothly easy in promoting the re Celsius
physical well-being of the
newborn and supporting the Pulse 180 120-140
establishment of a well- beats/minute beats/minute ave.
functioning family unit.
Respiratio 80 30-50
NEONATAL TRANSITION PERIOD n breaths/minut breaths/minute
● The newborn’s transition from intrauterine e
to extrauterine life is marked by a series of
rapid and complex physiologic changes. Blood 80/46 mmHg 100/50 mmHg (by
● Your assessment of these changes begins Pressure 10th day)
in the delivery room and continues
through the infant’s hospital stay. PARAMETER ANTHROPOMETRIC
● During the birth process, fluid is MEASUREMENTS
squeezed from the fetal lungs. Weight
● As the chest emerges, most healthy ● 2.5 kg to 3.4 kg normal weight
newborns will take their first breaths ● Male
spontaneously. ○ Whites : 3.5 kg (7.7 lb)
● The onset of respiration stimulates a series ○ Other races : 0.5 lb less
of cardiopulmonary changes as the infant ● Female
makes the transition from fetal to neonatal ○ Whites : 3.4 kg (7.5 lb)
circulation. ● The infant is weighed nude at
approximately the same time each day.
VITAL STATISTICS ● Newborn loses 5% to 10% of birth weight
● Newborns may look alike, but each has days after birth due to:
their own physical attributes and ○ No longer under the influence of
personalities. Some newborns are fat and salt-fluid retaining maternal
short while some are long and thin. hormones
● There are newborns who never give a fuss ○ Adjustment in breastfeeding
whenever they are changed or cuddled,
but some can cry in high decibels Length
whenever you lift them from their cradles. ● The length of the newborn is difficult to
● The weight of newborns varies according measure because the legs are flexed and
to their race, genetics, and nutritional tensed. To measure length ,start from the
factors. crown of the newborn’s head following
the conjunction of the spine /back then the
buttocks ,thigh down to the heel of the
Parameter Average foot.
Anthropometric ● Another way of measuring the length ,the
Measurement nurse should place the newborn’s flat on
 their backs with legs extended as much as ● Also known as developmental, primary, or
possible. primitive reflexes.
● They consist of autonomic behaviors that
Head Circumference do not require higher level brain
● Proceeds from cephalocaudal principle: functioning. They can provide information
head longer than the rest of the body; about lower motor neurons and muscle
head: 33-35 cm using a tape. tone.
● Measurement above head just above ● They are often protective and disappear as
eyebrows and pina ears, resting on higher level motor functions emerge.
occipital regions. If above 33-35 cm
suspect hydrocephalus. Neuromuscular System
● For accurate measurement the tape is ● Blink reflex
placed over the most prominent part of the ○ May be elicited by shining a
occiput and brought to just above the strong light on an eye.
eyebrows. ○ To protect eyes from any object
● The circumference of the newborn’s head coming near it.
is approximately 2 cm greater than the ● Rooting reflex
circumference of the newborn’s chest at ○ Serves to help the NB find food.
birth. ○ When the cheek is stroked near
the corner of the mouth, a NB
Chest Circumference will turn the head in that
● Chest circumference should be taken with direction.
the tape measure at the lower edge of the ○ Reflex disappears 6 wks. of life
scapulas and brought around anteriorly ー At this time, NB eyes can
directly over the nipple line. focus steadily so food source
can be seen
VITAL SIGNS ● Sucking reflex
Temperature ○ This reflex helps the NB find
● If the newborn’s temperature does not food.
stabilize shortly after birth, the cause ○ When a NB’s lips are touched,
needs to be investigated to rule out the baby makes a sucking
infection motion.
○ Begins to diminish at 6 months of
Pulse age.
● Transient murmurs ● Swallowing reflex
○ Result from incomplete closure ○ Food that reaches the posterior
of fetal circulation shunts portion of the tongue is
● During crying automatically swallowed.
○ May rise to 180 bpm ● Extrusion reflex
● During sleep ○ Prevents swallowing of inedible
○ 90 – 110 bpm substances.
● Palpate for femoral pulses ○ Disappears in 4 months
○ Absence suggests coarctation ○ Extrudes any substance placed on
(narrowing) of the aorta. the anterior portion of the tongue.
● Palmar grasp
Respiration ○ Disappears: 6 wks. - 3 months
● Coughing & sneezing present to clear the ○ Elicited by the examiner placing
airway. his finger on the palmar surface
● Maybe as high as 90 breaths per minute of the infant’s hand and the
right after birth but will settle to an infant’s hand grasps the finger.
average of 30- 60 breaths per minute ○ Attempts to remove the finger
● NBs are obligate nose-breathers result in the infant tightening the
○ Show signs of distress if nostrils grasp.
become obstructed ○ Grasps meaningfully at 3 months
of age.
Blood Pressure
● At birth: 80/46 mmHg
● By 10th day: 100/50 mmHg ● Step (Walk)-in-Place
○ NBs who are held in a vertical
NEONATAL REFLEXES position with their feet touching a
 hard surface will take a few extension of the toes (fans the
quick, alternating steps. toes).
○ Disappears by 3 months of age ○ Remains positive until 3 months
● Placing reflex of age.
○ Similar to step-in-place reflex ● Magnet reflex
○ Elicited by touching the anterior ○ If pressure is applied to the sole
surface of the lower part of the of the feet of the NB lying in
NB’s leg against a hard surface. supine position, he/she pushes
■ Edge of table or bassinet back against the pressure.
● Plantar grasp
○ When an object touches the sole ● Crossed extension reflex
of a NB’s foot at the base of the ○ If one leg of the NB lying supine
toes, the toes grasp in the same is extended, and the sole of that
manner as do the fingers. foot irritated by being rubbed
○ Disappears at 8 – 9 months of with a sharp object (thumbnail),
age in preparation for walking. the infant raises the other leg and
● Tonic neck (Fencing posture) extends it, as if trying to push the
○ Elicited by rotating the infant's hand away
head from midline to one side. ● Trunk incurvation
○ The infant should respond by ○ When NB lie in prone and is
extending the arm on the side to touched along the paravertebral
which the head is turned and area by a probing finger, they
flexing the opposite arm. The flex their trunk and swing their
lower extremities respond pelvis toward the touch.
similarly. ● Landau reflex
○ Disappears between 2 – 3 months ○ A NB who is held in prone
of life. position with a hand underneath
● Moro Reflex supporting the trunk, should
○ The examiner holds the infant so demonstrate some muscle tone
that one hand supports the head
and the other supports the MUSCLE TONES
buttocks. The reflex is elicited by - Muscle toned is determined by evaluating the
the sudden dropping of the head degree of flexion and resistance of the
in her hand. extremities.
○ The response is a series of ● Square window sign
movements: the infant’s hands ○ Is elicited by gently flexing the
open and there is extension and newborn’s hand towards the
abduction of the upper ventral forearm until resistance is
extremities. This is followed by felt. The angle formed at the
anterior flexion of the upper wrist is measured.
extremities and audible cry. ● Arm Recoil
○ Their fingers assume a typical ○ Is elicited when the newborn is in
“C” position. supine position , the forearm is
○ Fades by the end of 4-5 months. fully flexed for 5 seconds then
○ An absent or inadequate Moro fully extended by pulling the
response on one side : hands and releasing.
■ Hemiplegia, brachial ● Popliteal angle (degree of knee flexion)
plexus palsy, or a ○ Is determined with the newborn
fractured clavicle flat on his or her back. Flex the
○ Persistence beyond 5 months of thigh on the abdomen and chest,
age : place the index finger of the other
■ Indicate severe hand behind the newborn's ankle
neurological defect to extend the lower leg until
● Babinski reflex resistance is met, and measure
○ Elicited when the sole of the foot the angle form.
is stroked in an inverted “J” ○ Results vary from no resistance
curve from the heel upward. in the very immature newborn to
○ The infant responds by plantar an 80 degree angle in a term
flexion and either flexion or newborn.
● Scarf sign
 ○ Is elicited by placing the
newborn supine and drawing an
arm across the chest toward the
newborn's opposite shoulder until
resistance is met.
○ Note the location of the elbow in
relation to the midline of the
chest
● Heel-to-ear extension
○ Is performed by placing the
newborn in a supine position and
then gently drawing the foot ● Remove the first set of gloves then when
toward the ear on the same side the umbilical pulsation is gone, clamp the
until resistance is felt. Allow the cord using sterile clamp at 2cm from the
knee to bend during the test. umbilical base then clamp again at 5 cm
● Ankle dorsiflexion from the base then cut the cord close to
○ Is determined by flexing the the clamp.
ankle on the shin. Use a thumb to ● Check for presence of 2 arteries and one
push on the sole of the newborn's vein
foot while the fingers support the ● Then allow skin to skin contact with the
back of the leg. Then measure the mother, observe feeding cues and
angle formed by the foot and the encourage the mother to feed the baby
interior leg. through her breast.
○ Intrauterine position and ● After the first full breastfeeding, proceed
congenital deformities can to weighing, eye care, injection of
influence the sign. Vitamin K and examination. Check
● Head lag (neck flexor) temperature per rectum for patency
○ Is measured by pulling the
newborn sitting position and Eye Care / Crede’s Prophylaxis
noting the degree of head lag. ● Eye prophylaxis; Erythromycin;
○ Total lag is common in newborns Ophthalmic Ointment, 0.5%, and
up to 43 weeks gestation, Tetracycline Ophthalmic Ointment, 1%
whereas post term newborn ● Action:
(42+weeks) hold their heads in ○ These antibiotic ointments are
front of their body lines. bacteriostatic and bactericidal.
○ Full – term newborn can support They provide prophylaxis against
their heads momentarily Neisseria gonorrhoeae and and
● Ventral suspension (horizontal position) chlamydia trachomatis.
○ Is evaluated by holding the ● Indication:
newborn prone on the hand and ○ These medications are applied to
noting the position of the head prevent ophthalmia neonatorum
and the back and degree of in newborns of mothers who are
flexion and the arms and legs. infected of gonorrhea and
conjunctivitis in newborn
NEWBORN CARE COMPETENCIES mothers infected with chlamydia.
● Dry the baby for at least 30 seconds, wipe ● Do Crede’s prophylaxis and apply
eyes, face, head, front, back, arms and legs terramycin eye ointment on both eyes
● Remove the wet cloth ● Retract lower eyelid outward to instill ¼
● Check breathing, do not ventilate unless inch strand of ointment along the
not breathing and do not suction unless conjunctival surface
with secretions but first suction the mouth ● Record observation done and medications
first given.
● Do APGAR scoring immediately then ● Report for any abnormalities noted.
after 5 minutes
● If the baby is breathing and crying, Injection of Vitamin K
position the baby prone on the mothers ● It synthesizes through the action of
abdomen then cover with cloth, cover the intestinal flora and is responsible for the
head with bonnet and place ID band on formation of clotting factors.
ankle
 ● Newborns have less coagulation ability so
vitamin K is usually administered to
prevent bleeding.
● Vitamin K:
○ Term: 0.1ml
○ Premature: 0.05ml

- 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
● 0.5ml
● 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 immunoglobulin (HBIG)

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 ▪ Gooseneck lamp
● Vicente Sotto Memorial Medical Center
(VSMMC)
○ Cord Clamp ▪ Sterile OS (3-4 pcs) ▪
Sterile Cotton balls (2-3 pcs) ▪ Cord
cutter ▪ 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
MATERIALS AND EQUIPMENT ○ This is used to drape the mother
HANDLING AND ASSISTING DELIVERIES in preparation for delivery. This
● 10 cc syringe / 10 mL syringe would create a sterile area for the
○ This is used during episiotomy baby to come out. There are three
and episiorrhaphy. The first 5 cc drapes to be used, the first is
will be used for episiotomy, this placed underneath the mother’s
is to aid in making an incision buttocks, the second is on the
during the delivery of the baby abdomen, and the third is still on
The last 5 cc will be used for the mother’s abdomen.
episiorrhaphy, which aids in ● Kelly curve
healing the incision. ○ This is used to clamp the baby’s
● Bandage scissor umbilical cord temporarily before
○ This is used during an cutting to prevent the baby from
episiotomy. The dull side of the bleeding. This is paired with the
scissors on the skin and the sharp Kelly Straight. Where the Kelly
one on the top prevent cutting Curve is used to clamp towards
immediately. This is given to the the placenta and the Kelly
doctor along with the os to Straight is used to clamp towards
prevent accidents. The sharps the baby.
should always be paired with os. ● Lidocaine
This is given to the doctor with a ○ This is used as an anesthetic for
clicking sound, indicating the the mother during episiotomy and
instrument is in their hands episiorrhaphy. This is inside the
already. The handle facing the 10cc syringe.
doctor and you holding the sharp ● Surgical leggings / leggings
end with an os. ○ This is used to cover the mother’s
● Bulb syringe legs in preparation for delivery.
○ This is used when the baby is out. This is to create a sterile
This is to suction the amniotic environment for the baby to
fluid out the baby’s body. First come out. This will cover the
from the mouth then next is the legs of the mother, her thighs,
nose. and the pedal she’s stepping on.
○ The rationale for why we suction ○ Covering the entire legs
the mouth first: This is to prevent ● Needle holder
the baby from swallowing any ○ This is used by the doctor to hold
possible dirt that may have gone the suture, and this is done during
inside their mouth. Especially if episiorrhaphy. To aid in putting
the mother accidentally let out the skin together after the
some stool. Also, to take out the incision. In the 3rd tooth, it is
amniotic fluid in their mouth as where the suture should be
well. placed to hold the needle.
● Cord clamp ● Placental bowl
○ This is used the moment the baby ○ This is where you place the
is out. However, you don’t put placenta after it is out.
the clamp on immediately. You ● DR gown
wait for the umbilical cord ○ This is worn by healthcare
pulsations to stop before placing workers to create a sterile area
the cord. This way there is a during an operation. This would
boost of hemoglobin and iron in help keep them safe from any
the baby. You clamp the cord harmful microorganism.
about 2 inches from the base. ● Sterile OS
● Face towel ○ This is used to cover the sharp
○ This is used by the handle nurse parts of sharp instruments. This
to support the mother’s perineum goes with the sharp instruments
after episiotomy. This is when when passing things to the
the handle nurse pushes the doctor. This would help prevent
mother’s perineum to prevent accidents and can also be used to
further laceration. wipe things off. This is paired
● Drapes with 10 sharps, namely:
● Surgical scissors
 ○ This is used to cut the suture. the baby’s weight, they need to
● Sterile gloves be naked during the process
○ This is used during delivery. This ● 1 cc syringe
serves as a protective equipment ○ This is used to inject the vitamin
for your hands. K needed by the baby. Which
● Sutures would aid in blood clotting
○ This is used along with the factors.
needle holder to aid the incision ● ID bands
made by the doctor on the ○ This is used to identify whether
woman’s perineum. the baby is a boy or a girl.
● Tissue forcep with teeth ● Mayo scissors / surgical scissors
○ This is used to hold the skin of ○ This is used to cut the suture.
the patient during suture. This can also be used to cut the
● Tissue forcep without teeth umbilical cord.
○ This is used to hold the skin ● Neck lamp
tissues of the patient during ○ This is used to keep the baby’s
suture. body temperature within the
● Umbilical cord cutter normal range during immediate
○ This is used to cut the baby’s newborn care. This is because the
umbilical cord after it has been babies cannot thermoregulate yet.
clamped ● Ophthalmic ointment
● Mayo table ○ This is used to prevent the baby
○ This is used to place all the from having Ophthalmia
materials needed during the Neonatorum from mothers
operation in handling and infected with gonorrhea and
assisting deliveries. It contains conjunctivitis and chlamydia.
sharps and not sharp instruments This is against Neisseria
to be able to make the operation gonorrhea and Chlamydia
possible. trachomatis.
● Sterile gauze
NEWBORN CARE ○ This is used to clean the inside of
● Baby’s diaper the mouth, gum, tongue, cheek,
○ This is used after performing the pouches, and teeth.
immediate newborn care. This is ● Receiving blanket
worn to the baby to catch urine ○ This is used by the nurse to wrap
and feces. the baby after doing the
● Baby’s cap anthropometric measurement and
○ This is used along with the immediate newborn care. This is
baby’s diaper. This is to keep the now making the baby ready for
temperature regulated by the the “unang yakap” and breastfeed
baby’s head. with the mother.
● Bulb syringe ● Tape measure
○ This is used to remove mucus ○ This is used to measure the
from the baby’s mouth or nose baby’s length and circumference.
● Umbilical cord cutter To see if it is within the normal
○ This is used to cut the umbilical range.
cord after it has been clamped ● Thermometer
● Cord clamp ○ This is used to measure the
○ This is used to help stop the baby’s temperature to see if it is
bleeding from the three blood within the normal range.
vessels in the umbilical cord - ● Vitamin K
two arteries and one vein ○ This is used to inject into the
● Cotton balls baby to help in the blood clotting
○ This is used to cover the skin factor
right after each injection given to ● Sterile gloves
the baby. ○ A double sterile glove is worn by
● Weighing scale the immediate newborn care
○ This is used to measure the nurse to maintain sterility. The
baby’s weight if it’s within the outer gloves would be used
normal range. While measuring during the cleaning of the baby.
 After you remove the first layer
of gloves, and inner gloves are
sterile already and will be used to
perform measurements and
newborn care.

1. Lidocaine - Anesthetic
2. Bandage Scissors -
Incision
3. Kelly Curve - Clamp
4. Kelly Straight - Clamp
5. Umbilical cord scissor -
Cord cutter
6. Needle holder - hold
suture
7. Forceps w/out teeth -
Hold the skin tissues
8. Forceps w/ teeth - Hold
the skin
9. Ovum holding forceps -
Used to get tissues inside the uterus like
the placenta