UNIVERSITY OF BAGUIO COLLEGE OF NURSING GENERAL LUNA ROAD, BAGIUO CITY

A Delivery Write up In normal Spontaneous Delivery

Submitted to:

Mrs. Nellie Palgue, RN, MAN

Submitted my:

NMD-4

Denver Mani

Acknowledgement
The materialization of this delivery room right up wouldnt be possiblewithout the aid of the following folks: To the Almighty Father for the strength given in realizing andfulfilling the duties and the study; to beloved parents who have alwaysbeen supportive all throughout the start of the duty until the end, the toils and efforts . and to my groupmates for the overwhelming support, help, for being cooperative and idulging, that helped me in my learning and somehow sharpened my skills

T o o u r e v e r l e n i e nt c l i n i c a l i n st r u c t o r , M r s . N e l l i e P a l gu e , for simplifying What used to be incomprehensible, tricky andcomplicated concepts, for assisting us in the various procedures we haveperformed, and for being kind to us despite our immaturity

13 AREAS OF ASESSMENT
PHYSICAL ASSESSMENT Physical examination follows a methodical head to toe format in the Cephalocaudal assessment. This is done systematically using t h e techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer sphygmomanometer, tape measure and stethoscope and also the senses.During the procedure, we recognize and respect the p a t i e n t s f e e l i n gs a s w e l l a s t o p r o v i d e c o m f o r t m e a s u r e s an d f o l l o w appropriate safety precautions.

General Physical Assessment Patient is a 23 year old female, stands 54, with pulse rate of 82b e a t s p r e m i n u t e , r e s p i r a t o r y r a t e o f 2 1 b r e a t h e p e r m i n u t e a n d a tem perature of 37.3 C. She is conscious and coherent upon interaction but answers only the questions she is comfortable with. Most of the time,she is pacing inside the ward and appears withdrawn.

Assessment of the Head Head is round in shape. Hair is long, thick and coarse, straight andevenly distributed. Scalp is smooth and white in color, minimal lesions were noted. Dandruff and lice were seen.

Assessment of the Eyes H e r e ye s a r e s ym m e t r i c a l , b l a c k i n c o l or , a l m o n d s h a p e . P up i l s c o n s t r i c t s w h e n d i v e r t e d t o l i g h t a n d d i l a t e s w h e n s h e g a z e s a f a r , conju nctivas are pink. Eyelashes are equally distributed and skin aroundthe eyes is intact. The eyes involuntarily blink.

Assessment of the Ears E a r s a r e c l e a n , n o e a r w a x w a s n ot e d a nd a p p r ox i m at e l y o f t h e same size and shape. Patient can hear normally when spoken softly.

Assessment of the Nose With narrow nose bridge, there were discharges noted upon inspection. No swelling of the mucous membrane and presence of nasalhairs were seen.

Assessment of the Mouth She has a complete set of teeth with minimal dental caries noted.O r a l m u c o s a a n d gi n gi v a l a r e p i n k i n c o l o r , m oi s t a n d t he r e w e r e n o lesions nor inflammation noted. Tongue is pinkish and is free of swellingand lesions. Lips are symmetrical, appears pale without bits noted up on observation.

Assessment of the Neck Lymph nodes noted. Neck has strength that allows movement backand forth, left and right. Patient is able to freely move her neck.

Assessment of the Lungs and Thoracic Region No reports of pain during the inhalation and exhalation. Absence of adventitious sounds upon auscultation. Respiratory rate 21 breathes perminute from the normal range of 16-20 breaths per minute. Assessment of the Heart Patient has an audible heart sound. PMI is heard between 4 th -5 th intercostals space. Heart is pumping well with a pulse rate of 82 bpm fromthe normal rate of 60-100 beats per minute.

Assessment of the Abdomen Abdominal movement as with respiration, presence of peristalsisduring auscultation. Presence of rashes and lesions.

Assessment of the Upper ExtremitiesSkin W h i t e i n c o l o r ; n o p r e s e n c e o f m a r k s / s c a r s o f w o u n d s i n t h e arms, neck and legs. Skin is smooth, moist and soft to touch.

Hands M e d i u m i n si z e wi t h 5 f i n ge r n a i l s i n e a c h s i d e . N a i l s a r e short, small dusty particles are present.

Arms Able to move through active ROM. Able to extend a r m s in front or push them out to the side.

Assessment to the Lower Extremities Size of the feet is undefined with lines on the sole, presence of scarsand lesions. Ten fingers are present. Nails are clean and short. Patient isambulatory.

Assessment of the Genitourinary With episiotomy dry and intact, urinates 2 -4 times a day and hasnot defecated yet since her delivery.

Assessment of the Perineum With episiotomy intact, absence of lesions and swelling.

Neurological AssessmentBehavior P a t i e nt i s s i l e n t b ut i s c o ns c i o u s a n d co h e r e n t u p o n interaction. She sits and walks if she wants to.

Motor Functioning A b l e t o m o v e e x t r e m i t i e s t h r o u g h a c t i v e ROM. Able to extend arms front and resist activeas pushed down/up on his hands.

Reflexes R e f l e x e s w e r e p r e s e n t s u c h a s t h e b l i n ki n g r e f l e x a n d deep tendon reflex.

Sensory Functioning Patients sensory system is intact, she wasable to distinguish touch, pain, hot and cold.

TABLE OF CONTENT I. II. Patients Profile Pathophysiology

III.

Preparation of the Patient *Position *Skin preparation *Draping *Anesthesia

IV.

Discussion

V.

Instrumentation

PATIENTS PROFILE Name: X Age: 23 Sex: Female Civil status: Married Admitting diagnosis: G1p0 pregnancy uterine 39-40 weeks cephalic in labor. Past history: No previous hospitalization, no history of cervical cancer, Menarche: 11 years old, with regular menstruation Last menstrual cycle: march 8 2011 Number of pad used: 5 pads a day Day Cycle: 28-29 days

INTRODUCTION Pregnancy, the state of carrying a developing embryo or fetus within the female body. This condition can be indicated by positive results on an over-the-counter urine test, and confirmed through a blood test, ultrasound, detection of fetal heartbeat, or an X-ray. Pregnancy lasts for about nine months, measured from the date of the woman's last menstrual period (LMP). It is conventionally divided into three trimesters, each roughly three m o n t h s l o n g . When gestation has completed, it goes through a process called delivery, where the developed fetus is expelled from the mothers womb. There are two options of delivery: Cesarean section and NSVD or normal spontaneous vaginal delivery. A cesarean section is a surgical incision through the mothers abdomens and uterus to deliver one or more fetuses. NSVD or normal spontaneous vaginal delivery is the delivery of the baby through vaginal route. It can also be called NSD or normal spontaneous delivery, or SVD or spontaneous vaginal delivery, where the mother delivers the baby with effort and force exertion. Normal labor is defined as the gradual subjugation and dilatation of the uterine cervix as a result of rhythmic uterine contractions leading to the expulsion of the products of conception: The delivery of the fetus, membranes, umbilical cord, and placenta. Laboring cannot that be easy; thereby implicating that there are processes and stages to be undertaken to achieve spontaneous delivery. Through which, Obstetrics have divided labor into four (4) stages thereby explaining this continuous process.

PATHOPHYSIOLOGY Stages of labor 1st stage Phase I: latent, dilation= 0-3, duration/interval=20-40 sec. /5-30 minutes,mildtomoderate Phase II: active, dilation=4-7cm, duration/interval=40-60 sec. /3-5 minutes, moderatetostrong Phase III: transition, dilation=8-10cm, duration=60-90 sec. /2-3minutes,strong 2nd stage PhaseI:station=0to+2,contraction=2-3 minutesapart P h a s e I I : s t a t i o n = + t o + 4 , c o n t r a c t i o n = 2 t o 2 . 5 mi n u t e s . A p a r t with urgencytobear down Phase III: station= +4 to birth, contraction= to 2 minutes. Apart; fetalheadvisibleincreased.. Mechanisms of labor/cardinal movements

Engagement fetal presenting part (normally the head) as its widest d i a me t e r r e a c h e s t h e l e ve l o f t h e I s c h i a s p i n e s o f t h e pelvis Descent Downwardmovementofthebi parietaldiameterofthefetalheaduntilitreachesthepelvicinlet occurs because of pressure on the fetus by the uterine fundos Pressureofthefetalheadonthesacralnerveproducesa p u s h i n g s e n s a t i o n w h i c h i s e x p e r i e n c e d b y t h e m o t h e r i n labor Flexion Shortestheaddiameterpassesthroughthepelvis Fetal head reaches the pelvic floor; head bend forward into chest, presenting the smallest ante posterior diameter Internal rotation a l l o w s t h e l o n g e s t f e t a l h e a d d i a m e t e r s t o m a t c h t h e longestmaternal pelvicdiameter fetusentersthepelvicinlet Extension Internalrotationiscomplete F e t a l h e a d p a s s e s b e n e a t h t h e s y m p h y s i s p u b i s w h i l e i n flexion;thereisaresistancefrom tissuesofthepelvic f l o o r i n t h e f e t a l h e a d . F e t a l n e c k s t o p s a n d a c t a s a p i v o t . T h i s c o m b i n a t i o n c a u s e s t h e f e t a l h e a d t o m o v e anteriorly,or extend, while motherispushing External rotation allow the shoulders to rotate internally to fit the pelvis

Expulsion expulsion occurs first as the anterior and the posterior shoulderpassesunderthesymphysispubis Aftertheshoulderdelivery,restofthebodywillfollow

3rd stage Placental delivery =2phases (placental separation and placental expulsion) Suddengushofblood Lengtheningofthecord risingofthefundus globularuterus

4th stage Firstfourhoursafterdeliveryoftheplacenta.

StageI Latentphase Activephase Transitionphase StageII Engagement Descent

 Flexion Internalrotation Extension Externalrotation Expulsion StageIII Signsofplacentalseparation Suddengushofblood,lengtheningofthecord,calkinssign StageIV Expulsionoftheplacenta

PREPARATION OF THE PATIENT DRAPING THE PATIENT A. The procedure of covering a patient and surrounding areas w i t h a s t e r i l e b a r r i e r t o c r e a t e a n d m a i n t a i n a s t e r i l e f i e l d d u r i n g a s u r gi c a l p r o c e d u r e i s c a l l e d d r a p i n g. T h e p u r p o s e o f d r a p i n g i s t o e l i m i n a t e t h e p a s s a ge o f m i c r o o r ga n i s m s b e t w e e n o n s t e r i l e a n d n o n s t e r i l e a r e a s . D r a p i n g m a t e r i a l s m a yb e d i s p o s a b l e a n d u n d i s p o s a b l e . D i s p o s a b l e d r a p e s a r e ge n e r a l l y p a p e r o r p l a s t i c o r a c o m b i n a t i o n a n d ma y o r m a y not be absorbent. No disposable drapes are usually double thickness, drape must be sterile. B . S i n c e d r a p i n g i s v e r y i m p o r t a n t i n p r e p a r i n g a p a t i e n t f o r d e l i ve r y , i t must be done correctly. The entire team should be familiar with the draping procedure. The scrub must know the p r o c e d u r e p e r f e c t l y a n d b e r e a d y t o a s s i s t w i t h i t . D u r i n g t h e draping procedure, the circulator should stand by to direct the scrub as necessary and to watch carefully for breaks in sterile technique. ( 1 ) T h e f i r s t s t e p i n d r a p i n g i s t h e p l a c i n g o f a d r a p e s h e e t from the foot to the knees. The scrub will select the sheet and hand one end to the surgeon across the operating table, supporting the folds, keeping it high, and holding it taut until it is opened, then drop it (open fingers and release sheet). The second drape sheet is handled in the same manner. This sheet is placed below the site with the edge of the sheet just below thes i t e . T h i s d r a p i n g s h e e t p r o vi d e s e x t r a t h i c k n e s s o f material under the area from the mayo tray to the incision where instrument and s p o n ge s a r e p l a c e d . ( 2 ) W h e n d i s p o s a b l e d r a p e s a r e u s e d , t h e t o w e l s u s u a l l y h a ve a r e mo v a b l e strip with an adhesive on the folded edge. The third step in draping is placing the four sterile towels around t h e l i n e o f i n c i s i o n . T h e s c r u b u n f o l d s f i r s t t o w e l , p a s s e s t h e towel drape to the surgeon with the strip side facing the scrub, a n d t h e n r e m o v e s t h e a d h e s i v e s t r i p . T h e s u r g e o n p l a c e s t h e towel w i t h i n t h e s c r u b b e d a r e a o n t h e n e a r s i d e o f t h e l i n e o f incision, leaving only enough exposed skin for the incision. The second towel is placed in the same way, except the towel is placed on the upper side (toward feet) the line incision. The third towel is passed in same way, except the towel is placed on the upper side (toward head) the line of incision. The last towel is passed to the surgeon with the adhesive strip facing the surgeon and is placed on the far side of the line of site. The adhesive area holds the towel drapes in place. (3) Finally the scrub will select the surgical drape (lap s h e e t ) . T h i s l a p s h e e t h a s a f e n e s t r a t i o n ( o p e n i n g ) i n t h e d r a p e . The scrub places the opening directly over the skin area outlined by the drape towels and in the direction indicated for the foot or head of the table. The lap sheet will have an arrow orsomeotherindicationtoidentifythe headorfootportionof the drape. Drop the folds over the sides of the table, and

theno p e n i t d o w n w a r d o v e r t h e p a t i e n t ' s f e e t a n d u p w a r d o v e r t h e anesthetistscreen. Drapingprocedure: 1.Thesteriledrapeisplacedontheinstrumenttable. 2. The drape, without the pouch, is handed to the Circulating n u r s e , w h o p l a c e s t h e d r a p e o n t h e o p e r a t i n g r o o m t a b l e a n d securesitinplace byremovingtheadhesivebacking. 3. The clear envelope containing the sterile blue accordion drape must be at the end of the table, or the brake in the t a b l e , w h e n f i x i n g t h e r e ma i n d e r o f t h e d r a p e t o w a r d s t h e h e a d ofthepatient.

4 . T h e p a t i e n t i s p l a c e d o n t h e d r a p e w i t h t h e b u t t o c k s o n t h e clearportionoftheclosed envelope. 5. The patient is placed in stirrups and prepped, following w h i c h t h e p r o t e c t i ve c l e a r e n ve l o p e i s o p e n e d b y r e m o vi n g t h e perforatedstriplocatedonthe patient'sright. 6 . T h i s w i l l e x p o s e t h e s t e r i l e b l u e a c c o r d i o n p o l y , w h i c h i s pulledtoitsfullextentby pullingthecentertab. 7.Leggingsareappliedtothelowerextremities. 8.Theselfadhesivecatchpouchisappliedbythescrubnurseorsurgeonataconvenientlocation. 9. At the termination of the procedure, the dirty blue polydrap e i s r e m o v e d a l o n g i t s p e r f o r a t i o n , b e f o r e t h e t a b l e i s raisedbackintopositionto placethelegsonthetable.

DISCUSSION

NORMALSPONTANEOUS DELI VERY Delivery many obstetric units now use a combined labor, delivery, recovery, and postpartum room, so that the woman, support person, and neonate remain in the same room throughout their stay. Some unit use a traditional labor room and separate delivery suite, to which the woman is transferred when delivery is imminent. The father or other support person should be offered the opportunity to accompany her. In the delivery room, the perineum is washed and draped, and the neonate is delivered. After delivery, the woman may remain there or transferred to a post partum unit. Management of complications during delivery requires additional measures.

ANESTHESIA Anesthesia options include regional, local and general anesthesia. Local anesthesia and opoids are commonly used. These drugs pass through the placenta; thus, during the hour before delivery, such drugs should give in small doses to avoid toxicity in the neonate. Opoids used alone, do not provide adequate analgesia and so are most often used with anesthetic regional anesthesia: several methods are available. Lumbar epidural injection of local anesthetic is most common used method. Epidural injection is being increasingly used for delivery, including cesarean section, and has essentially replaced pudendal and para cervical blocks. The local anesthetics often used for epidural injection (bupivacaine, marcaine, sensorcaine), have a longer duration of action and slower onset than those used for pudendal block (lidocaine, xylocaine) Other methods include caudal injection (into the sacral canal), which is rarely used, and spinal injection (into the para spinal sub arachnoid space). Spinal injection maybe used for cesarean section, but it is used less often for vaginal deliveries because it is short lasting( preventing its use during labor) and has a small risk of spinal headache afterward. When the spinal injection is used, patient must be constantly attended, and vital signs must be checked every 5 minutes to detect and treat possible hypertension local anesthesia: methods include pudendal block, perineal inflammation and para cervical block. Pudendal block, rarely used because epidural injections are used instead, involves injecting a local anesthetic through the vaginal wall so that anesthetic bathes the pudendal nerve as it crosses the ischial spine. This block anesthetizes the lover vagina, perineum and posterior vulva; the anterior vulva, innervated by lumbar dermatomes, is not anesthetized. Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection

Infiltration of the perineum with anesthetic is commonly used, although with this method is not effective as a well administered pudendal block. Para cervical block is rarely appropriate for delivery because incidence of fetal bradycardia is greater than 15%. It is used mainly for 1st or early 2nd trimester abortion. The technique involves injecting 5 to 10 ml of 1% lidocaine some trade names, xylocaine at the 3 and 9 oclock positions; the analgesic response is not hazing General anesthesia because potent and volatile inhalation drugs( isoflurane) can cause marked depression in mother and fetus, general anesthesia is not recommended for routine delivery. Rarely, nitrous oxide 40% with oxygen maybe used for analgesia during vaginal delivery as long as verbal contact with the woman is maintained. Thiopental (pentothal, a hypnotic is commonly given IV with other drugs( succinylcholine or anectine, quelicin, nitrous oxide plus oxygen). Pentothal provides inadequate analgesia. With thiopental (pentothal), induction is rapid and recovery is prompt. It becomes concentrated in the fetal liver, preventing levels from becoming high in the CNS; this may cause neonatal depression. Increased interest in preparation for child birth has reduced the need for general anesthesia except for cesarean section. Delivery procedure, vaginal examination is done to determine position and stationof the fetal head; the head is usually the presenting part when effacement is complete and the cervix is fully dilated, the woman is told to bear down and strain with each contraction to move the head through the pelvis and progressively dilate the vaginalincission so that more and more of the head appears, when about 3 or 4 cm of the head is visible during a contraction in nulliparas , the following maneuvers can facilitate delivery and reduce risk of perennial laceration. * The clinician, if right-handed, places the left palm over the infants head during a contraction to control and, if necessary slightly slow progress * Simultaneously, the clinician places the curved fingers of the right hand against the dilating perineum, through which the infants brow or chin is felt. * To advance the head, the clinician can wrap hand in a towel and, with curved fingers, apply pressure against the underside of the brow or chin (modified Regin Maneuver) Thus, the clinician controls the progress of the head to effect a slow safe delivery forceps or a vacuum extractor is often used for vaginal delivery when the second stage of labors likely to be prolonged forcep or vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Indications for forcep and vacuum extractor are essentially the same. An episiotomy is not routine and is done only if the perineum does not stretch adequately and is obstructing delivery, usually only for first deliveries at term. A local anesthetic can be infiltrated if epidural analgesia is an adequate. Episiotomy prevents excessive stretching and possible tearing of the perineal tissues, including anterior tears. The incision is easier to repair than a tear. The most commonly type is a midline incision made from the midpoint of the fourchette directly backward the rectum. Extension in the rectal sphinter or rectum is risk, but in recognized promptly, the extension can be repaired successfully and heals well. Tears or extensions into the rectum can usually be prevented by keeping the infants head well flexed until the occipital prominence passes under the symphysis pubis. Another type of episiotomy is a medial lateral incision made from the midpoint of the fourchette at a 45angle laterally on either side. This type usually does not extend into the sphincter or rectum, but it can cause greater post operative pain and it takes longer to heal the midline episiotomy. Thus, for episiotomy a midline cut is preferred. However, use of episiotomy is decreasing because extension or tearing into the

sphincter or rectum is a concern. Episioprototomy (intentional cutting to the rectum is not recommended because recto vaginal fistula is a risk. When the head is delivered the clinician determines whether the umbilical cord is wrapped around the neck. If it is, the clinician should try to un wrap the cord; if the cord cannot be rapidly remove this way, the cord maybe clumped and cut. After delivery of the head, the infants body rotates so that the shoulder are in an antero posterior position; gentle downward pressure on the head delivers the anterior shoulder under this symphysis. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cord should be double clamped and cut between the clamps, and a plastic cord clip should applied about 2 to 3 cm distal from the cord insertion of the infant. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. An arterial pH > 7.15 to 7.20 is considered normal. The infant is thorough dried, the place it on the mothers abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet. After delivery of the infant, the clinician places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. The mother can usually help deliver the placenta by bearing down. If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward(caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to invert. If this procedure is not effective, the umbilical cord is held taut while a hand place on the abdomen pushes upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided because it may invert the uterus. If the placenta has not been delivered within 45 to 60 minutes of delivery, manual removal maybe necessary; the clinician insert an entire hand into the uterine a avity, separating the placenta from its attachment, they extracts the placenta. In such cases, an abnormally adherent placenta should be suspect. The placenta should be examined for completeness because fragments left in the uterus can cause hemorrhage or infection later. If the placenta in incomplete, the uterine cavity should be explored manually. Some obstetricians routinely explore the uterus after each delivery. However, exploration is uncomfortable and is not routinely recommender. Immediately after delivery of placenta, oxytocin drug 10 units IM or as an infusion of 20 units/1000 ml saline at 125ml/h is given to help the uterus contract firmly. Oxytocin should not be given as an IV bolus because cardiac arrhythmia may occur. The cervix and vagina are inspected for lacerations, which, if present are repaired, as is episiotomy if done. Then in the mother and infant are recovering normally, they can begin bonding. Many mothers wish to begin breast feeding soon after delivery, and this activity should be encouraged. Mother, infant, and father should remain together in a warm, private area for an hour or more to enhance parentinfant bonding. Then, the infant may be taken to the nursery or left with the mother depending on her wishes. For first hour after delivery, the mother should be observed closely to make sure the uterus is contracting and to check the bleeding, BP abnormalities, and general well-being. The time from delivery of the placenta to 4hour postpartum has been cancelled the 4th stage of labor; most complications, especially hemorrhage occur at this time, and frequent observation is mandatory.

Instrumentation
Mayo scissor- for cutting sutures

Rubber suction bulb suction oral nasal secretion of baby

Several sterile gauze use for dressing and protecting wound

Sterile towel- for infection control

Pair of gloves

Mayo table- where all instruments needed are placed

Metz-use to cut suture during episiorraphy

suture used to hold body tissues

Xylocaine 2%(5cc)- use as anesthesia during episiorraphy 6.1 syringe (5cc with g23 needle)

Scalpel -sharp bladed instrument used for surgery,

anatomical dissection

Curve Kelly and straight Great for grasping anything which would be inconvenient or impracticable to grasp with the fingers

Bob cock- Designed to hold a short length of intestine without compressing it

Alis forcep- used for grasping tissues

Debakey- surgical instruments designed for temporary occlusion of large blood vessels.

Thumb forcep- surgical instrument used to grasp soft tissue, especially while suturing

Tissue forcep- used for compressing or grasping tissues in surgical operations, handling sterile dressings, and other purposes

Foester forcep- Featuring oval tips with serrations, the Foerster is used to hold sponges used to clean the incision area during the procedure

Back house towel clip- use to hold towels

Learning insights
Ihavel e a r n e d t o b e p a t i e n t a n d c o n t r o l m y f e e l i n g s o f a n g e r o r a n n o y a n c e towards the patient; to respect and accept their beliefs and values without judging them; to communicate with them therapeutically; to be accurateand systematic when it comes to charting to avoid errors and reprimands.B a s i c a l l y , i t s t h e f e e l i n g o f c o n f i d e n c e y o u h a v e i n y o u r s e l f t h a t w i l l facilitate accomplishment and error-free implementation of nursing care. If you are confident enough to perform the procedures, then the client willdevelop trust and confidence to you. The nurse has a lot of responsibilitiesto take in, thus, confidence is a very important factor. The exposure wasnt centered mainly to rendering care. Itw a s a l s o f o c u s e d t o b u i l d i n g a n d d e v e l o p i n g i n t r a p e r s o n a l a n d interpersonal relationships. I call it, personal growth. To adjust and adapt with the environment is a humongous task! Its not that easy. But minglingwith other people helps you identify your strength and weaknesses, and itaids in modifying what is somehow negative in our attitudes. To sum thisall up, it was a SUCCESS! Thanks be to GOD. The next time that Ill render care and perform procedures, Iwill try to do my best to attain satisfaction and accomplishment