VITAL SIGNS

- indicate state of px essential fx; document on GRAPHIC CHARTS to monitor/plot pattern GRAPHIC CHART
consideration I. PATIENT’S INFORMATION SECTION
- make necessary reassessment of abn before recording
- follow agency protocol (7-3, 3-11, 11-7)
- ask permission before using px chart
- don’t tamper entries
BODY TEMP- balance between heat produced & heat lost from body (DEGREES)
- BLACK: px name, attending physician, room #, hospital #

oral
contraindication: infant; unconscious/irrational px; px who breathe in mouth
oral cavity disease/surgery on nose/mouth
px who just took cold/hot food/fluid
rectal: obtain 1st temp of newborn for rectal patency
check core temp of adult
CI: recent rectal surgery; diarrhea; rectal disease
cardiovascular alteration bc thermometer stimulate vagus nerve, causing bradycardia
leukemia (traumatize rectal mucosa, causing bleeding)

PULSE- rhythmical throbbing from blood wave passing in artery as heart contracts
- purpose: obtain estimate of quality of hearts action per minute
- temporal artery, carotid, brachial, apical, brachial, femoral, popliteal, posterior
tibial, pedal
normal PR/min
children adult: F = 70-80 bpm M = 80-90 bpm

RESPIRATION- exchange of O2 & CO2 in atmosphere & body cells initiated by breathing
- purpose: obtain RR per min & estimate of px respiratory status
infant = 30-40/min children = 20-25/min adult = 16-20/min

BLOOD PRESSURE- lateral force exerted by blood on arterial walls

- purpose: aid in diagnosis; observe changes in px condition
Brachial Artery BP CI
- breast, axilla, shoulder, arm, hand surgeries
- venous access device (AV shunt; in hemodialysis) / IVF in arm
- injury/disease to shoulder/arm (trauma, burn, bandage/cast)
infant = 50/40 – 80/50 mmHg children = 87/48 – 117/64 mmHg
adult = 110/70 – 130/90 mmHg

Recording
VITAL SIGN MASTER LIST- seen in station for VS docu in all px in ward w/o seeing chart
TPR SHEET- in station; include VS, frequency of urination & defecation; outside clipart
PATIENT’S CHART
GRAPHIC CHART/TPR GRAPHIC CHART- VS progress; attached in px chart
VITAL SIGNS SHEET- tabulated form; found in px chart
NURSES NOTES- VS in narrative form w/nurse’s notes

VS & Graphic chart- inside px chart

 INTAKE & OUTPUT SHEET
- BLUE/RED (name; room & bed #)

NURSING CARE PLAN

I. ASSESSMENT
1. Perform thorough head-to-toe assessment
2. Document all assessment findings
3. Verify, validate, double check data
4. Record subj data in CLIENT’S OWN WORDS
 data from SO & health prof may also be SUBJ if they’re opinions & perception
 you may not always be able to obtain SUBJ DATA
5. Cluster data by writing OBJ & SUBJ cues on Gordon pattern in separate sheet

6. Establish PRIORITY using MASLOW’S HIERARCHY OF NEEDS. Identify if

problem is HIGH, MEDIUM, LOW PRIORITY
` 7. Identify PX NEED based on Gordon’s Pattern
HIGH PRIORITY
- life threatening (difficulty of breathing, hemorrhage)
- need immediate attention (test preparation, discharge that’ll occur shortly)
- very important to px (pain, anxiety)
MEDIUM PRIORITY
- result unhealthy consequence (physical/emotional impairment) but not likely
to threaten life
LOW PRIORITY
- easily resolved (hypertension)
- health maintenance

II. DIAGNOSIS/NSG DIAGNOSIS

1. After identifying need, refer to NANDA I diagnosis classification
2. Identify type of nsg diagnosis
types of nsg diagnosis
a. Problem-focused- undesirable human response to health condition/life
process b. Risk- susceptibility for developing undesirable human response to condition
c. Health Promotion
parts of diagnostic label
Ineffective (Modifier) breathing pattern (focus of diagnosis)
Risk for constipation
diagnostic indicators
- to diagnose & differentiate 1 diagnosis from another
a. Defining characteristics
- observable cues that cluster as dx manifestations (signs & symptoms)
- assessment identifying presence of # of defining characteristics supports
accuracy of nsg diagnosis
b. Related factors- integral for ALL problem-focused dx
- etiology, circumstance, fact, influence w/relationship to dx
INTRAVENOUS FLUID SHEET c. Risk factors

III. OUTCOME IDENTIFICATION

- make goals & measurable outcome as basis for evaluating nsg dx (ANA, 2014)
- must be done BEFORE interventions are determined
1. Establish patient outcomes & outcome criteria
Px outcome- educated guess, broad statement on px state after interv is completed
 - directly address problem in nsg diagnosis goal
- behavioral - indicate desired state - achieve efficient commu of high-quality clinical info at any time when px care is transfer
- action verb + qualifier (description of outcome perimeter) indicating - to commu task-relevant info across shift changes/between teams, ensuring continuity
performance level to be achieved of safe & effective working
2. Determine whether: types
- short-term outcome can be met in short period (days/less than 1 week) GROUP- large group w/all nurses commencing shift OR smaller groups of nurses
- long-term outcome need more time (wks/months). It describe expected benefit/result BEDSIDE- direct px handover at px bedside; include px & parents/carer
seen after plan of care is implemented BREAK- between nurses w/responsibility for care & nurse assuming that responsibility
TRANSFER OF PX (for procedure, treatment, to another ward)
- all px transferred from 1 clinical area to other; documented (details of transfer time,
indicating transfer of professional responsibility & accountability)

components of clinical handover

OUTCOME CRITERIA- specific, measurable, realistic statement of goal attainment

- present info guiding eval phase of nsg process
- who, what, action, under what circumstance, how well, when
subject: who is person expected to achieve goal? Components of Nursing/Medical Plan
verb: what action person must do to achieve goal? 1. LAB & RADIOLOGIC WORKUP 2. MEDICATIONS (PRN, STAT, PRE-OP)
condition: under what circumstance person is to perform action? 3. GADGETS ATTACHED (ET, RC, Infusion pump, NGT/OT)
criteria: how well person is to perform action? 4. MONITORING FREQUENCY (VS, I/O. NVS) 5. REFERRALS
specific time- when is person expected to perform action? 6. SPECIAL PRECAUTION (refer for unusuality, LOC changes, bleeding, cyanosis)
ex: Patient (who) verbalizes (what action) 3 dietary modifications of low salt diet to his 7. RESTRICTIONS (CBR) (ADL allowed) 8. UNUSUALITIES OCCURRED (fever, DOB)
wife (under what circumstance) accurately (how well) after teaching session (when) 9. SPECIAL PROCEDURE (BT, surgery) 9. SPECIAL NSG PROCEDURE (CBB, NB care)
10. IV THERAPY
PLANNING- dev’t of nsg strategy to ameliorate px problem
- written plan of care developed to direct nsg care activities FLOW SHEET
purpose: direct px care activity; promote care continuity; focus charting requirement NARRATIVE
allow delegation of specific activity SOAP/SOAPIE/SOAPIER (Subject, Objective, Assessment, Plan, Reaction/Response of Px)
activity: 1. Plan nsg interv (determine appropriate ones for specific px) - problem-oriented; identify px problems during shift, list down concerns & interv
2. Write px plan of care - no “r/t”
Plan of Care Concepts FDAR (Focus Data Action Response)
- highlight major px problem
1. px centered
2. step-by-step: sufficient date collected to substantiate nsg diagnosis ex: F=: increased body temp A: paracetamol given; TSB rendered; for CXR as ordered
atleast 1 goal must be stated for each nsg diagnosis D= flushed skin, temp R:
outcome criteria identified for each goal
nsg interv specifically designed to meet identified goal NURSES’S NOTES
each interv supported by scientific rationale - be concise - “NOTE” actions once completed (chronological)
eval address if goal was completely met, partially, completely unmet - follow policy abbrev - NEVER leave white space - document immediately
- add new info - once entry is made, it CAN’T BE ALTERED
IV. IMPLEMENTATION- action phase; actual plan initiation components
activity: reassessment; set priority; perform nsg inter; record nsg action
- DATE/TIME/SHIFT - ASSESSMENT OF PX DESCRIBING PERTINENT
skills: intellectual, interpersonal, technical
- px NAME, WARD, ROOM # - PERTINENT NEGATIVE
- APPEARANCE (when entering px room - VS (only include unusuality, not all results)
V. EVALUATION - LAB & DIAGNOSTICS, SURGICAL PROCEDURE
- judgment of nsg care effectiveness to meet px goal based on px response
- EVAL OF HOW MEDICAL INTERV WORKED
- ONGOING all throughout nsg process; PLAN OF CARE = foundation of eval
- PX SUBJ DATA - INTERV - DOCTOR’S VISIT - INSTRUCTION/EDUC
activity: - FAM INTERACTION - RECOMMENDATION/OBSERVATION - NURSE NAME & SIGN
1. Review px goals & outcome criteria
- observe px behavior; use documentation of px response
- receive feedback (px, fam, health team)
2. Collect data
- obj & subj data (ex: goal: px will state that pain is relieved within 10 min after
positioning)
- px subj statement is needed to judge if goal is achieved
3. Measure goal/Outcome achievement
- make judgment on goal attainment by comparing px actual behavior response to
predicted response & predetermined outcome criteria in planning phase
4. Record judgment/measurement of goal attainment
- write subj & obj data; docu judgment about goal attainment
- avoid ambiguous terminology (inadequate, good, extremely well, normal)
5. Revise/modify plan of care
- reassessment; if there’s new diagnosis, write new plan of care

CLINICAL HANDOVER/ENDORSEMENT
- transfer of prof responsibility & accountability for some/all care aspects for px/group of
px to another prof group on temporary/permanent basis
 FNCP
- blueprint in care that nsg design to systematically minimize/eliminate identified health &
fam nsg problems through explicitly formulated outcomes of care (goal/objective) &
deliberately chosen set of interv, resource, & evaluation criteria, standards, & tool

PRENATAL SERVICES IN THE PHILIPPINES

I. MATERNAL HEALTH PROGRAM
objective: improve survival, health, wellbeing of mothers & unborn child
services
 Antenatal Registration- pregnant women can avail free prenatal service at health center
 Tetanus Toxoid Immunization- series of 2 doses tetanus toxoid vaccine 1 mo before
delivery & 3 booster doses after childbirth
 Micronutrient Supplementation- Vit A & Iron supplement for anemia & Vit A deficiency
 Treatment of Disease/Other Condition- women diagnosed under high risk pregnancy
ideal frequency of prenatal visits during pregnancy

every month: 1st 6 months twice a month: 7th month (2nd trimester) weekly: 9th month

II. MATERNAL, NEWBORN, CHILD HEALTH, NUTRITION/MATERNAL & CHILD CARE PROGRAM
Maternal Health- women health during pregnancy, childbirth, postnatal period
most common direct cause of maternal injury/death:
- excessive blood loss - unsafe abortion
- high blood pressure - obstructed labor
indirect cause: anemia, malaria, heart disease

III. MATERNAL CARE/SAFE MOTHERHOOD PROGRAM

Safe Motherhood- all women receive care to be safe & healthy in pregnancy & childbirth
- embodies “No women should die/be harmed by pregnancy/childbirth-
related causes” - target: pregnant women
- 810 women die everyday from preventable causes r/t pregnancy & childbirth

IV. PRENATAL CARE

services:
Physical Exam (FH, VS)
Lab Exam (CBC (Hemoglobin Determination) Urinalysis, Ultrasound, Blood Typing)
Giving of Iron & Ferrous Sulfate (add hemoglobin to px)
Tetanus Toxoid Immunization, Dental Checkup,
Counselling (hygiene, nutrition, prenatal/neonatal care, breastfeeding, psychosocial issue,
birth spacing)
importance of prenatal visists
- early assessment & detection of high risk factors
sterile technique- actions
- early prevention, monitoring, treatment of rh factors
surgical asepsis- absence of all microorg within invasive procedures
- ensure safe delivery & healthy baby
- get correct advice/proper care during pregnancy & delivery
when to prepare sterile field: when mother shows signs of SUBIRBA (imminent signs of
delivery) activities
- Ht & Wt - Demographic OB data - Leopold’s Maneuver - Health Teaching
- VS checking - Measure fundic ht - FHT - IE (PRN)
Laboratories: UA (protein/glucose), Ultrasound, Blood Typing, CBC (hemoglobin
determination)
giving of tetanus toxoid
common tests during pregnancy
- genetic screening - fetal monitoring - amniocentesis - glucose

TETANUS TOXOID IMMUNIZATION

neonatal tetanus- public health concern
- mother & child are protected against tetanus & neonatal tetanus
 series of 2 doses by woman: 1 month before delivery to protect baby from neonatal TT
 3 booster dose shots to complete 5 doses for full protection to mother & child
 after completing the dose: Fully Immunized Mother (FIM)
tetanus toxoid immunization: (0.5 cc)
1st dose- as soon as possible (no protection)
2nd dose- after 4 wks (protect for 3 yrs)
3rd dose- after 6 months (up to 5 yrs)
4th dose- 1 year after (up to 10 yrs)
 5th dose- a year after (up to lifetime)
:

95% BARTHOLOMEW’S RULE

- determine pregnancy duration by measuring FH
of uterus above pubic symphysis

Abortion- fetus expulsion from uterus before viability (< 27 wks)

Full Term- 38-42 wks Preterm- 28-37 wks

IMMUNIZATIONS
VIT A SUPPLEMENTATION EXPANDED IMMUNIZATION PROGRAM (EPI)
- crucial micronutrient for pregnant & fetus - 1976; ensure infant/children & mothers have access to routinely recommended
- for morphological & functional dev’t & for ocular integrity infant/childhood vaccines
- exerts systemic effects on fetal organs & fetal skeleton 6 vaccine-preventable diseases initially included:
- pregnant: 10,000 IU daily / 25000 IU weekly as oral liquid, oil-based preparation of - Tuberculosis - Diphtheria - Pertussis
retinyl palmitate/retinyl acetate - Poliomyelitis - Tetanus - Measles
 continued for min 12 wks during pregnancy until delivery Mandates
- Vit A Deficiency (VAD): leading cause of preventable blindness RA 10152: Mandatory Infants and Children Health Immunization Act of 2011”
HIGH RISK PREGNANCY Presidential Decree No. 996: September 16, 1976
- threatens health/life of mother & fetus “Providing for Compulsory Basic Immunization for Infants & Children below 8 years of age”
- require specialized care from specially-trained providers Fully Immunized Child (FIC)
risk factors - (1997) received 1 dose BCG, 3 doses HEPA, 3 doses OPV, 1 dose measles at right time &
 Existing health condition- hypertension, diabetes, HIV-positive interval before reaching 1 y/o
 Overweight & Obesity - (2013) 1 dose BCG, 3 dose Penta, 3 dose PCV, 3 dose OPV, 1 dose measles “ “ “
- ↑ risk of hypertension, preeclampsia, GDM, stillbirth, neural tube defect, caesarian Complete Immunization
- NICHD: obesity raise infant’s risk of heart problems at birth by 15% - 1 dose BCG, 3 dose DPT, 3 dose HEPA, 3 dose OPV, 1 dose measles but not on desired age
 Multiple Birth- ↑complications (preeclampsia, premature labor, preterm birth) & time
- twins/higher-order multiples Target Setting
- > ½ of all twins & 93% of triplets are born at < 37 wks gestation - Infants (0-12 mos) - School Entrants/Grade 1/7 y/o
 Young/Old Maternal Age- teens / >35 increase risk for preeclampsia & gestational - Pregnant & Postpartum Women
hypertension
COLD CHAIN LOGISTIC MANAGEMENT
FUNDAL HEIGHT- measured from symphysis pubis to fundus (cm) - vaccine distribution by cold chain ensures vaccine is maintained under proper env
condition until administration time
allowable timeframes: 6 months = Regional level 3 months = Provincial/District level
1 month = main health center (w/ref)
not more than 5 days = health centers using transport boxes
most sensitive to heat (-15 to -25oC); put in freezer
 oral polio vaccine (OPV)
sensitive to heat & freezing (body of ref +2 - +8oC)
 BCG  Measles  Rotavirus  Hepatitis B
 Tetanus Toxoid  MMR  Pentavalent
FEFO (First Expiry & First Out)
- all vaccines are utilized before expiry date
- proper arrangement/label w/expiry date to identify near to expire vaccines
VACCINE VIAL MONITORING (VVM)
- Thermo chromic label (color lilac): indicator that vaccine is kept at temp acc to potency
Schedule of Vaccination (< 1 y/o) Considerations
OPV- ask if px has fever/condition/illness; DON’T FEED baby 30 min after administration
- dependent on HC protocol  not given if px is on ANTIBIOTICS
- w/LBM: instruct px to return after 1 wk for another dose to complete dosage

Contraindications
1. Anaphylaxis/severe hypersensisitivty reaction to previous dose
2. Person/known allergy to vaccine component SHOULDN’T BE VACCINATED
3. Pentavalent vaccine/DPT to child w/recurrent convulsions/active neurological disease
4. Pentavalent 2 or 3 to child who has had convulsions within 3 days of most recent dose
5. Rotavirus vaccine if child has history of hypersensitivity to previous dose, intussuception,
intestinal malformation (AGE) (DOH, 2012)
6. Don’t give live vaccines (BCG) to immunosuppressed client
7. child w/ s/sx of severe dehydration
8. Fever of > 38.5oC

Sites of Injection
INTRAMUSCULAR
Vastus Lateralis- antero-lateral mid aspect of thigh (penta, hepa B, IPV, PCV)
- Pentavalent (ALWAYS given at right side)
ORAL- OPV
SUBCUTANEOUS- upper outer portion of arm (Measles & MMR)

1 inch needle:

½ inch needle: SQ = 90o

PENTAVALENT
BCG (for TB)- max of 0.1 cc
- 5 antigens: diphtheria, pertussis, tetanus, hepa B, haemophilius influenza type B
- if given RIGHT AFTER BIRTH: NO EFFECT/USELESS (since baby is STILL PROTECTED from
Immunization Card
mother’s own immunization
measles- rubeola (attack younger children) (booster: MMR; protect lifetime from rubella
mumps- german measles (rubella) (attack older children & adult)
considerations in vaccines
- right site - right dose - right route - right schedule
- right interval - proper utilization of cold chain (esp OPV)

OPV- orally (MORE ABSORBED IN MUCOSE WHERE POLIO CAN ATTACH IN GI TRACT)
- booster: IPV (intramuscularly)
IM- absorbed in muscles

HOME VISIT
- prof face contact by nurse to px/fam to give healthcare activities & attain objective
- family-nurse contact allow health worker to assess home & fam situation to give nsg
care
factors in determining Home Visit Frequency
- careful eval of past service to fam & how fam made use of nsg service
- px/fam ability to recognize own needs, knoweldge of available resource, ability to use
resources on own accord
Making a Home Visit
- bring watch, pen, notebook, umbrella
- before leaving clinic, have correct name & address of px (thru barangay hall)
- go to barangay health center (record of cases are reviewed as regards to previous
visits)
 ask for families w/pregnant women)
- go to the household. upon arrival, observe rules of courtesy - put waste receptacle OUTSIDE paper lining
- after being admitted, introduce self professionally. Explain purpose of visit. - get 1 biostix , place inside medicine glass
- nurse must sit down & talk w/px to obtain info -open urine container above waste receptacle. Dip biostix in urine for 1 min
- select most responsible member of fam to assist during visit & give care in between - wipe biostix on the brim to remove excess. Place urine container inside waste receptacle
visits - compare result in biostix to manual (no color change = negative)
- look for place to put down CHN bag (table/chair) 6 ft away from bedisde. Line table - record on notebook
w/newspaper before settling bag - do aftercare:
- get articles from bag using bag technique - Wash hands & dry using washcloth. Place washcloth on top of soapdish,
- make appointment for next visit wrapping it together in its remaining paper lining. Place inside cellophane. Place
on top of sterile field
courtesy call - put cottons inside medicine glass. pour 70% alcohol on it, placing medicine
- go to barangay hall acc to assigned site & ask permission glass on top of receptacle.
- using CB, clean biostix container & medicine glass
introduction: - (3rd open) place materials back into bag
introduce yourself (from what institution) - remove apron. fold so outside surface is inside. put in bag
give purpose/objective - fold towel (upper portion folded inside). place in bag
give thanks & give set date to come back - ask px where you can discard your waste. (take opportunity to assess their garbage
system)
BAG TECHNIQUE - talk px w/results, (protein presence = risk for hypertension); (glucose = GDM) & provide
health education
- if px is not yet ready for discussion, set another appointment
- slip bag into your arms. Crumple paper lining by grasping on center top portion)
- say thanks to px, ask when is another appointment for further discussions.

specific gravity, protein, sugar,

acetic test- protein (amino acid)
+2 slight cloudiness +3 thick cloudiness +4 egg white cloudiness
benedict test- for reducing sugar (glucose, fructose, sucrose)
blue = negative
dark blue +1
- paper lining greenish blue +2
- towel lining- placed on top of paper lining (“CLEAN FIELD”) yellowish green +3
- apron (protect oneself from contaminating anything) orange to red +4
- cotton ball packs
- soap dish & handwashing (double wrap together in paper lining & place in cellophane)HOME VISIT
(outer wrapper must be discarded after using before moving to another house) - gym (morning prayer chuchu), check paraphernalia (include black umbrella to shoo away
- kidney basin stray dogs & against sunlight)
- alcohol lamp (for boiling test tube for urine protein)
test tube holder DISTRICT C: POBLACION
- test tube (put urine inside) to boil above lamp Barangay 23-C  assigned area for rotation (muslim area)
- 2 droppers ( services:
- thermometers (axillary + rectal) mon: free checkup
- medicine glass tues: TB dots
- acetic acid (5 drops for testing urine) wed: vaccine/immunization
- benedict reagent (5 ml in test tube. boil. add 8 drops of urine. boil again for another 5thurs: prenatal
min) fri: cardiopulmonary (cardiovascular/hypertension service)
- 70% alcohol sat:
- sterile water
- denatured alcohol 0.1-0.90 ml/L = normal urine glucose
- hydrogen peroxide
- biostix ((dip into urine & it chanes color) to come up result
- syringe
- OS
- match
- cleaning materials

BAG TECHNIQUE- for ease to save time & effort

client: for gestational diabetes mellitus/pregnancy-indused hypertension

1. place bag on top of flat surface, criss crossing the straps on the bottom of the bag. Put
paper lining first. Opening of bag should be facing area where you put your materials

check bag 3 times: (close after every open) (reduce contamination of contents/maintain
sterility)
1st: take out soap dish (“maam, asa ko pwede manghugas?”) (at the same time, take
opportunity to check for drainage sys, water sys, (refer to fam assessment)
2nd: take out all materials only used for procedure
3rd: return materials inside the bag)

- (1st open) take out soap dish. put outer lining first, then fold cellophane and put it on top.
- dry hands using wash cloth
- (2nd open) take out materials to test urine for sugar & protein presence
- towel lining, apron, biostix, cotton ball, 70% alcohol, medicine glass, waste
receptacle, gloves
- wear apron
- wear working gloves RIGHT BEFORE GETTING THE URINE SAMPLE)
- call px if she has already collected urine (instruction: collect early in morning after waking
up, wash genitals first, then collect middle flow urine)