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Course Credit: 5 units lecture, 6 units RLE [1 unit skills lab/5 units clinicals]
MOTHER
A. High-Risk Prenatal Client
a. Identifying Clients at Risk
1. Assessment of risk factors
Prenatal History
Obstetrical History
Type of births
■ Vaginal
■ Instrumentation
■ Episiotomy
■ Length of labor
■ Cesarean
■ Reason for cesarean
■ Document type of incision
• Low-transverse
• Classical
■ Complications of birth
■ Neonatal outcomes
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weeks
Abortion (A) Number of deliveries before 20 weeks, either
spontaneous or induced
Living (L) Number of living children
Documentation 1: three children at home. She reports that her son was born on his due date, but her
daughters were both born a month early. She states that she lost a baby in her second month.
Documentation Example 2: The same prenatal client may also be described as G5 (5 pregnancies)
P3 (number of live births); pregnancies ended before 20 weeks are not counted as “P” in this method.
Medical History
Chronic health problems
■ Current medications
■ Time and description of last oral intake
■ Allergies to food/medicine'
Surgical History
■ Complications with anesthesia
■ Date/reason for surgery
Sexual history
■ Number of sexual partners
■ Sexually transmitted infections
■ Sexual abuse
■ Methods of contraception
■ Condom use
Social history
■ Use of recreational drugs
■ Smoking
■ Domestic abuse
■ Educational level/ability to read
■ Economic status
■ Type of health insurance
■ Need for community referrals
• Transportation
• Nutrition
• Medications
Physical Examination
■ Assess maternal vital signs
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■ Collect urine specimen for protein and glucose
■ Assess for presence of edema
■ Assess deep tendon reflexes
■ Perform Leopold’s maneuver to determine fetal position
■ Assess fetal heart rate (FHR)
■ Measure fundal height
■ Determine the frequency, duration, and intensity of contractions
■ Determine the stage and phase of labor
■ Assess cervical changes
■ Dilation (0 to 10 cm)
■ Effacement (0–100%)
■ Station (Level of presenting fetal part in relation to the ischial
spines of the maternal pelvis
2. Screening procedures
Cervical screen
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ACOG Guidelines Annually
ACS Annually with conventional Pap smear
every 2 years with liquid based cytology
Women 30 years of age and older, with three consecutive negative cervical screens, are
recommended to have repeat exams every 2–3 years
Abstinence from sexual activity (both oral and genital) is the only 100% effective
method of STI prevention
Consistent and proper use of condoms during sexual intercourse will decrease the
incidence of STIs
STIs transmitted via skin contact (human papillomavirus [HPV], herpes simplex virus
[HSV]) may still be transmitted with use of latex condoms
Sexual partners should be tested and treated when an STI is identified; sexual activity
should be avoided until treatment regimen completed
Patients diagnosed with a viral STIs should consult their health-care provider for long-
term management
Reportable STIs must be forwarded to the local health department along with treatment
rendered
Encourage immunization against hepatitis B
Visit CDC Web site www.cdc.gov for latest treatment guidelines for STIs
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dysplasia
Syphilis Primary Serological testing
chancre (painless red ulcer) Nontreponemal (RPR, VDRL)
■ Reported quantitatively
Secondary (titers)
Skin rash, lymphadenopathy ■ Four-fold change in titers
clinically significant
Latent ■ Effective treatment will result
Lack clinical manifestations in falling titers
Tertiary ■ False-positive possible; verify
Cardiac, ophthalmic, auditory with treponemal test
involvement Treponemal (FTA-ABS)
Reported as positive or negative
HIV Fever Serological testing
Malaise (Pretest and posttest counseling
Lymphadenopathy with informed consent
Skin rash required)
Positive screen must be
confirmed by more specific
test (Western blot)
Herpes Simplex Painful, recurrent vesicular Viral culture with DNA probe
Virus (HSV) lesions
Fever, malaise
Enlarged lymph nodes
Group of maternal systemic infections that can cross the placenta or by ascending
infection (after rupture of membranes) to the fetus
Infection early in pregnancy may produce fetal deformities, whereas late infections may
result in active systemic disease and/ or CNS involvement causing severe neurological
impairment or death of newborn
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Breast Exam
■ Monthly breast self-exam, starting at age 20, instructed to woman as an optional tool for
identifying and reporting breast changes
■ Clinical breast exam at least every 3 years (age 20–40) during a physical exam by a health
professional; yearly after age 40
■ Annual mammogram starting at age 40
Step 2: Palpation
1. Feel the breast tissue and lymph node chain for lumps or thickening by using three
finger pads while exerting light, medium, and deep pressure in a systematic
fashion
2. Begin by lying down on a flat surface with arm raised and a folded towel under the back of the
breast being examined
3. After examining breast tissue, bring arm toward body and feel the axilla and the skin above as well
as below the collar bone
4. Repeat technique on the other side
5. Report lumps, thickening, nipple discharge or any suspicious findings to health-care provider
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Diagnostic Testing during Early Pregnancy
Clinical Application:
Interpretation of Results
Defect
Risk for open neural tube
Risk for Down Syndrome
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AFP
Increased
Decreased
HCG
WNL
Increased
Estriol
WNL
Decreased
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Performed at 24–28 weeks Patient should not eat, drink,
Clinical Application or smoke during the test
Detection of gestational Serum sample drawn in
diabetes 1 hour
EXPECTED RESULT
140 mg/dL
Group B vaginal culture Explain test to patient
Performed between Collect vaginal/rectal
35–37 weeks specimen
Clinical Application EXPECTED RESULT
Positive culture treated Negative
with antibiotics in labor
to prevent newborn
transmission
Fetal fibronectin (fFN) NO intercourse 24 hours
Performed between 22 prior to exam
and 35 weeks in women Cervical/posterior fornix
at high risk for preterm specimen
labor EXPECTED RESULT
Clinical Application Negative
Negative predictive value
for preterm labor
Antibody screen Administer Rh (D antigen)
Performed at 28 weeks in immune globulin at 28
Rh negative women weeks to prevent antibody
Clinical Application formation if Rh negative
Detects presence of positive and antibody screen
antibodies in serum of Rh negative
negative women EXPECTED RESULT
Negative
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HEART DISEASE
Classification:
Class I: no physical limitation
Class II: slight limitation of physical activity
Class III: ordinary activity cause fatigue, palpitation, dyspnea or angina; less than ordinary activity
causes fatigue
Class IV: unable to carry on any activity without experiencing discomfort
Prognosis
Class I & II- normal pregnancy & delivery
Class III & IV- poor candidates
rheumatic heart disease – condition in which heart valves are damage by rheumatic fever-->
obstruction, abnormal opening--> incomplete emptying
congestion of liver and other organs due to inadequate venous return--> increased venous pressure
--> fluid escapes through the walls of engorged arteries and cause edema and ascites CHF is a high
probability due to increased CO during pregnancy--> dyspnea, exhaustion, edema, pulse irregularities,
chest pain on exertion and cyanotic nailbeds are obvious
DIABETES MELLITUS
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o Maternal Effects :
o hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus
yung glucose ng nanay.
o Hyperglycemia during the 2nd & 3rd trimester
HPL effect Mgt : give insulin. OHA are teratogenic.
1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum – drop suddenly
Frequent infections eg. Moniliasis
Polyhydramnios
Dystocia
o Fetal Effects :
o hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd
trimester thru facilitated diffusion
o Macrosomia/LGA .4000gms
o IUGR due to prolonged DM
o Preterm birth promote still birth
o Newborn Effects :
o Hyperinsulinism and Hypoglycemia
40mg/dl
Normal : 45-55mg/dl
Borderline : 40mg/dl
Sx : ↑ pitched shrill cry, tremors, jitteriness
Dx test : heel stick test to check glucose levels
o Hypocalcemia
< 7mg/dl
Calcemic tetany
Tx : Ca gluconate
SUBSTANCE ABUSE
Definition
substance abuse that leads to:
loss of control of substance abuse
monopolization of time by substance abuse
individual spends his time obtaining or using drugs, recovering from drug use and discussing
drugs
presence of adverse medical, social or emotional consequences from drug abuse, including
tolerance and withdrawal
Prevalence in the Philippines
Mean Age: 29 years
Male to female ratio 9:1
mostly from those with low total family earnings, single and attained High school
Causes maternal and fetal risks
maternal: pregnancy complications
fetal: fetal alcohol syndrome, growth retardation
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4. Cocaine
5. Heroin- most abused opioid
6. Methampethamine (shabu, crystal, ice) – ampethamine of choice and is taken intranasally
7. prescription dugs (cough syrup, etc.)
Risk Factors
1. Family Factors:
parent and sibling drug use
family conflict
family social and economic disadvantage
spouse abuse, child abuse
2. Environmental Factors:
peer pressure, social isolation
3. Psychiatric Disturbances:
mood disorders, psychosis, anxiety disorders
B. Psychological dependence
1. Behaviors associated with substance use become integrated into a person’s routine
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2. Substance use once integrated into routine becomes associated with pleasure and enjoyment
3. Substance use may also be used to cope with stress or lessen negative emotions
History
A. Risk assessment
CAGE: Affirmative answered to 2 of the following questions (or to the last question alone) are
suggestive of alcohol abuse
1. Have you ever felt that you should cut down your drinking?
2. Have you ever felt annoyed by others criticizing your drinking?
3. Have you ever felt guilty about your drinking?
4. Have you ever had a morning drink (Eye-opener) after hang-over?
Physical Examination
General Survey
o poor hygiene, poor nutrition
Vital signs- may reflect substance intoxication and withdrawal
o Temperature
o Pulse, respirations
o Blood pressure
Skin
o color, tone, and premature wrinkling
o needle marks or skin infections, self-inflicted injuries or accidents
ENT
o dental cavities, stained teeth, tongue or buccal lesions, gum disease, foul breath
Lungs
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o adventitious sounds (wheezes, rales, crackles)
Breast examination
Abdominal examination
Gynecologic examination (Pap, cultures, bimanual)
Extremities
o signs of circulatory, peripheral vessel involvement, pulses, pedal edema
Laboratory Examination
CBC (elevated hematocrit, WBC, platelets, decreased leukocytes)
Lipid level (decreased HDL)
SGGT. SGOT, SGPT, LDH
Intravenous drug abuse work-up
HIV, Hepatitis B, Hepatitis C and TB
Consider
o Vitamin C level (decreased)
o Serum uric acid (decreased)
o Serum albumin (decreased)
o Pulmonary function tests
Consider: anxiety, mood disorders, history of abuse, peer pressure or social isolation
Treatment
A. Group psychotherapy
alcoholic anonymous, nicotine anonymous
B. Patient education
a. Personalize the risks to each individual. Relate her current health problems or findings on physical
examination to the effects of substance abuse.
b. Emphasize how quitting can reward the individual.
c. If the patient indicates a willingness to quit, form a contract for a quit date.
C. Medications
a. for alcoholism: disulfiram (aldehyde dehydrogenase inhibitor) causes unpleasant reaction when
alcohol is ingested
b. for opioid abuse: naltrexone- blocks pleasurable effects of opioids (including alcohol); methadone
and long-acting opioid antagonists
c. for smoking abuse: bupropion, nicotine replacement drugs
HIV/ AIDS
I. Definition
AIDS is the commonly used acronym for acquired immune deficiency syndrome, which is the name for
a complex of health problems first reported in 1981.
II. Etiology
Caused by the human immune deficiency virus (HIV); infection mainly by sexual contact (anal, vaginal,
oral); contaminated blood and blood products, including needle and syringe sharing; contaminated
semen used for artificial insemination; intrauterine acquisition (baby of woman with AIDS); and rarely
breast milk. Majority of cases in the United States are
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HIV-1; HIV-2 infection is endemic in West Africa.
III. History
A. What the patient may present with
1. Rapid weight loss without known factor (> 10%)
2. Extreme fatigue; unexplained, increasing tiredness
3. Chronic diarrhea (> 1 month)
4. Persistent dry cough, shortness of breath, dyspnea on exertion
5. Prolonged fever, soaking night sweats, shaking chills
6. Loss of appetite
7. Purple or pink flat or raised lesions on skin or under skin, inside mouth, nose, eyelids, anus
8. Changes in neurological and/or cognitive function
9. Generalized adenopathy
10. Chronic herpes simplex
11. Recurrent herpes zoster
12. Generalized dermatitis pruritic
13. Oral and pharyngeal candidiasis; fungal infection of nails
14. Persistent muscle pain
15. Vaginal Discharge, Vaginitis, Vaginosis, STDs 103
16. Fear of exposure to AIDS through sexual partner or high risk behavior or work-related accident
(needlestick, contact with infected blood)
17. Chronic sinusitis
18. History of abnormal Papanicolaou smears
19. Persistent vulvar, vaginal, and anal condyloma
7. Gynecological history
a. Recurrent sexually transmitted diseases, vaginitis, vaginosis
b. Widespread molluscum contagiosum 100 or more lesions
c. Infected with several sexually transmitted diseases concurrently (may include gonorrhea, syphilis,
Chlamydia)
d. Rapidly progressing cervical dysplasia
e. Papillomavirus on Papanicolaou smear
f. Recurrent, recalcitrant vaginal candidiasis
g. External condyloma unresponsive to treatment
h. Existing pregnancy
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i. Anal discharge
j. Pelvic, abdominal pain
8. Travel outside the United States, especially to West Africa
VII. Treatment
A. General measures
1. Counseling to avoid or minimize high-risk behaviors
a. Instruction and counseling regarding safer sexual practices to protect self and partner from
exchange of body fluids (e.g., by using latex condoms, female condoms, dental dams, Saran
WrapTM); by avoiding anal intercourse and oral-genital contact; avoiding sharing sex toys
such as vibrators and dildos (or clean them with bleach or alcohol).
c. Discourage use of injectable drugs; if patient is using injectable drugs, stress the need to avoid
needle, works, or cooker sharing; offer resources on drug rehabilitation programs.
d. Avoid unsafe sexual contact with persons who are injectable drug users or fall into other high-risk
groups.
e. Sexual activities with partner with AIDS that do not involve direct passage of body fluids, such as
light kissing, caressing, mutual masturbation.
g. Avoid sharing razors, toothbrushes, nail files and clippers, and other items that could be
contaminated with blood.
B. Specific treatment
1. Per guideline for specific presenting complaint.
2. Refer those patients falling into high-risk groups for further counseling and appropriate testing and
follow-up if setting does not offer such services.
3. Referral for exposure so prophylactic therapy can be instituted.
VIII. Complications
A. Opportunistic infections.
B. AIDS may be fatal to some of its victims within two years of diagnosis.
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C. Transmission to unborn child (infant’s true HIV status based on antibody testing will not be accurate
until 6–10 months); for a child < 18 months, definitive tests include evidence of HIV in blood or tissues
by culture, nucleic acid, or antigen detection.
X. Follow-up
A. Per referral
B. Contraceptive and gynecological services for women with AIDS
RH INCOMPATIBILITY
Or Isoimmunization
Rh (Rhesus factor)- 85% of population: foreign body: Antigen: protein factor
Happens if:
Mother Rh (-)
Father/Fetus Rh (+)
4th child is severely affected r/t degree of sensitization to Rh (+) RBC
Fetus: Erythroblastosis fetalis
IUGR due to hemolysis
Pathologic jaundice within 24hrs
Hemolytic anemia (¯ O2-carrying capacity):
Cardiac decompensation
Hydrothorax
Hepatosplenomegaly
Edema, ascites
Diagnostic Tests
Indirect Coomb’s test
Maternal serum mixed with Rh(+) RBC
In mother with Rh (-): clumping (+) result
Direct Coomb’s test
Neonatal cord blood washed and mixed with Coomb’s serum
Fetus with Rh (-): clumping (+) result
ABO INCOMPATIBILITY
Happens when:
Mother blood type O
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Fetus: A, B, AB
O-A most common
O-B most severe
1st child can be severely affected
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Milk/antacids: ¯absorption
Liquid iron: Taken with straw or medicine dropper at the back of mouth
S/E: foul aftertaste, melena, constipation
HYPEREMESIS GRAVIDARUM
Persistent uncontrollable vomiting during pregnancies.
Excessive vomiting of pregnant women
Causative Factors
Hormonal changes
■ Increased HCG, estrogen and progesterone [delay GIT motility]levels (salivation)
Psychological factors
Complications
Weight loss
Dehydration
Vitamin deficiency
Diagnostic
Laboratory studies (HGB & HCT; serum electrolytes)
Management
IV rehydration
■ TPN as necessary
Antiemetic drugs
Nursing considerations
Reducing nausea and vomiting
■ Dry crackers or toast
■ Rise slowly from bed
■ Small frequent feeding
■ Drink fluids in between meals
■ Avoid greasy or spicy foods
Maintaining nutrition and fluid balance
■ IVF and TPN as directed
■ Increase K and Mg intake
■ Clear fluids are started as N&V subside.
Providing emotional support
ECTOPIC PREGNANCY
occurs when gestation is location outside the uterine cavity
Common site : Ampulla or Tubal
Dangerous site: Interstitial
Unruptured Ruptured
Missed period sudden, sharp severe unilateral pain,
Abdominal pain within knife like
3- 5wks of missed shoulder pain (indicative of
period (maybe intraperitoneal bleeding that extends to
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generalized of one diaphragm & phrenic nerve)
sided) (+) Cullen’s sign – bluish tinged
Scant, dark brown umbilicus
vaginal bleeding syncope/fainting
Vague discomfort
Nursing Care
vital signs
administer IV fluids
monitor for vaginal bleeding
monitor I&O
prepare for culdocentesis to determine
hemoperitoneum
Mgt : non-surgical Methotrexate
INCOMPETENT CERVIX
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Incompetent Cervix Management:
McDonald procedure
temporary circlage of incompetent cervix.
Delivery : NSVD
SE: infection
Health teaching
observe for signs of infection
signs of labor
Shhirodkar procedure
permanent procedure.
Delivery : caesarian section required.
ABORTION
Termination of labor before age of viability
SPONTANEOUS
AKA miscarriage
Causes
Chromosomal aberrations due to advanced maternal age
Blighted ovum
germ plasm defect
Natures way of expelling defective babies
Classifications :
Threatened
■ pregnancy is jeopardized by bleeding and cramping but the cervix is closed and can be
saved
Inevitable
■ moderate bleeding, cramping, tissue protrudes from the cervix and the cervix is open.
Types :
Complete
■ all products of conception are expelled.
■ Mgt : emotional support
Incomplete
placenta and membranes retained.
Mgt : D&C
HABITUAL
3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
Management (suture of cervix)
McDonald procedure
■ Temporary circlage
■ Side effect – infection
■ May have NSD
Shirodkar
CS delivery
MISSED
fetus dies; product of conception remain in uterus 4 weeks or longer
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signs of pregnancy cease
(-) pregnancy test
Dark brown
Scanty bleeding
Mgt : induction of labor/ vacuum extraction
INDUCED
Therapeutic abortion principle of 2 fold effect
Done when mother has class 4 heart disease
PLACENTA PREVIA
it occurs when the placenta is improperly implanted in the lower uterine segment, sometime
covering the cervical os.
Assessment
Outstanding sign : frank, bright red, painless bleeding
enlargement (usually has not occurred)
fetal distress
abnormal presentation
Nursing care :
Initial mgt : NPO candidate for CS
Bedrest
prepare to induce labor if cervix is rip
administer IV
No IE, No Sex, No enema – complication : Sudden fetal blood loss
prepare Mother for double set –up –DR is converted to OR
ABRUPTIO PLACENTA
it is the premature separation of the placenta from the implantation site.
It usually occurs after the twentieth week of pregnancy
Cause:
Cocaine user
Severe PIH
Accident
Assessment:
Outstanding sign : dark red & painful bleeding
concealed hemorrhage (retroplacental)
couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
rigid boardlike abdomen
severe abdominal pain
dropping coagulation factor (a potential for DIC)
sx : bleeding to any part of the body. Mgt : for hysterectomy
General Nursing care :
infuse IV, prepare to administer blood
■ type and crossmatch
monitor FHR
insert Foley catheter
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measure bllod loss; count pads
report s/s of DIC
monitor v/s for shock
strict I&O
ED HYPERTENSION
hypertension for 24wks resolved 6weeks postpartum which cause pregnancy
types:
gestational HPN
■ HPN without edema & proteinuria
preeclampsia: triad
■ sx: HPN with edema, proteinuria or albuminura (HEP/A) which
cause is unknown or idiopathic but multifactorial
■ primis d/t 1st exposure to chorionic villi
■ multiple pregnancies due to inc. exposure to chorionic villi
■ mothers of low socio-economic status due to dec. protein intake
■ teenages d/t low compliance to protein intake
HELLP syndrome
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> 15mmHg diastolic
Roll over test
■ 10-15min side lying
■ Then supine
■ Then take BP
mild pre-ecclampsia
■ 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt, inability to wear wedding ring
due to developing edema
■ Signs present
cerebral & visual disturbances, epigastric pain to liver edema and oliguria usually
indicates an impending convulsion
Before convulsion : if you see sign of epigastric pain, 1º mgt is to place tongue
depressor and put the side rales up
During convulsion : observe the Mother for safety
After convulsion – turn to side to facilitate drainage
Severe pre-ecclampsia
■ 160/110, +3 or +4, proteinuria, visual disturbances
■ Nursing care
P – promote bedrest
Prevent convulsions by nursing measures
to ↑ O2 demand & facilitate Na excretion
Management: quiet & calm environment, minimal handling, avoid moving the
bed
Heat Acetic Acid – determine protein in the urine
Prepare the following at bedside
■ tongue depressor, Suction machine & O2 tank
E – ensure high protein intake (1g/kg/day)
Na in moderation
A – antihypertensive drug with hydraluzine
C – CNS depressant with Mg Sulfate for anti-convulsion
Mgt : evaluate for hypermagnesiumenimia
E – evaluate physical parameters for Magnesium Sulfate toxicity :
B – BP ↓
U – Urine output ↓
R – RR ↓
P – Patellar reflex is absent
Antidote : Ca gluconate
Eclampsia – with seizure
↑ BUN – sign of glomerular damage
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Immediate Intervention for eclampsia:
a. maintain IV line with large bore needle
b. monitor fluid balance
c. minimize stimuli
d. have airway and oxygen available
e. give medications as orders (magnesium sulfate, apresoline, valium)
f. prepare for possible delivery of fetus
g. monitor fetal status
h. type and cross match for blood
I. postpartum- monitor vital signs and watch for seizure
f. cathartic- cause shift of fluid from the extracellular spaces into the intestines from where the fluid can
be excreted
Dosage: 10 gms initially-- either by slow IV push over 5-10 min or deep IM
5 gms / buttock, then an IV drip of 1 gm per hr (1 gm/100ml D10W)
Nursing Intervention:
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a. advised bedrest, left lateral
b. encourage a well-balanced diet
c. weigh daily, keep daily log
d. education on self-management
e. diversion
f. family support
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B.Nursing Care of the client with high-risk labor & delivery & her Family
1. High-Risk factors:
(may happen at anytime during the course of labor to a client who has been otherwise been healthy
throughout her pregnancy & may be related to stress/stressor; adaptive process):
PASSENGER/ FETUS
Refers to the fetus plus the membranes and placenta
Fetal skull and fetal accommodation to passageway affects the labor progress.
Indication of fetal head
Largest part of the body
■ Common presenting part
■ Least compressible fetal part
■ Cranial bones
Frontal – 1
Parietal – 2
Temporal – 2
Occipital – 1
Sphenoid – 1
Ethmoid – 1
■ Suture line
Intermembranous spaces
Allows molding – overlapping of the sutures
Sagittal – 2 parietal
Coronal – parietal and frontal
Lamboidal – parietal and occipital
■ Fontanels
Anterior fontanel
4 cm in any direction – normal size
Diamond in shape
Closes at 12 – 18 months
Posterior fontanel
< 1 cm – normal size/location
Triangular in shape
Closes 2 – 3 months
■ Measurements
Transverse diameter
Biparietal – largest at 9.5 cm
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Bitemporal – 8 cm
Bimastoid – smallest at 7 cm
Antero-posterior diameter
Sub-occipito bregmatic – 9.5 cm
Occipito – frontal – 12 cm
Occipito – mental – 13.5 cm
Submento bregmatic – face presentation
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■ LOP – maternal side and toward back, face is up
Labor is slowed and much back discomfort on mother during labor.
ROT – occiput is facing the right side and looking toward the left side.
Attitude or Habitus
Describes the degree of flexion a fetus assume during labor or the
relationship of fetal part to each other
■ Full flexion (Vertex) – good attitude – normal fetal position
Presents the smallest anterior diameter
Moderate flexion (sinciput)
■ Chin not touching the chest (military)
Partial extension (Brow) – brow of head to the birth canal
Complete extension (face)
Station
Descent of the fetal presenting part in relationship to the level of the
ischial spine
■ 0 – level of ischial spine
■ -3 to -1 – above the ischial spine
■ +1 to +3 – below the ischial spine
Engagement
Settling of the presenting part of a fetus far enough into the pelvis to
determine the level of ischial spine
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o Characteristics
Involuntary contraction
Spontaneous contraction
o Cervix dilatation and effacement of the cervix during the 1 st stage
of labor
o Phases: Increment (gain strength). Acme (peak), Decrement
(letting go)
Intermittent Contraction
o Description
Frequency
Duration
Intensity
Regularity
Maternal Push
Voluntary beating down efforts
After full dilatation of the cervix
Efforts similar to those of defecation
Contraction of levator ani muscle
PLACENTA
■ Power: Strong uterine contractions cause the placenta to detach from the uterine wall
■ Psyche: Patient may be exhausted; encourage bonding with baby
■ Signs of placental separation
■ Sudden gush or trickle of blood from vagina
■ Lengthening of visible umbilical cord at introitus
■ Contraction of the uterus
■ Nursing considerations
■ Instruct patient to push when appropriate
■ Note time of placenta delivery
■ After placenta expelled:
• Monitor amount of bleeding
• Monitor vital signs
• Assess fundus
– Height
– Location
– Tone
■ Administer oxytocic medication as ordered
• Stimulates uterus to contract
• Prevents hemorrhage
■ Cleanse and apply ice pack to the perineum
■ Provide clean linen under patient
■ Provide warm blanket: patients often tremble/shiver immediately after the birth
■ Assess level of consciousness/comfort
■ Place newborn in arm of mother, encouraging skin-to-skin contact
■ Assist with positioning for breastfeeding and bonding
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little support from family and friends
anxiety about the fetus
problems with previous pregnancy or birth
marital or financial problems
young age of mother
FETAL MALPOSITIONS
Position = relationship of the fetal presenting part to specific quadrant of the mother's pelvis
** the pelvis is divded into four quadrants
** right anterior
** right posterior
** left anterior
** left posterior
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** posterior positions results in more backaches because of pressure of fetal presenting
part on the maternal sacrum
o Breech – sacro
place the stethoscope above the umbilicus
o Chin – mentum
o Shoulder – acromnio dorso
FETAL MALPRESENTATIONS
1) Vertex malpresentation
a) brow presentation
b) face presentation
c) sincipital presentation
2) Breech presentation
a) types
b) maternal risks
c) vaginal evolving of breech
d) external/podalic version
Presentation - the relationship of the long axis of the fetus to the long axis of the mother. spine
relationship of the spine of the mother & the spine of the fetus
Two Types
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B. Breech
o Complete breech – thigh rest on abdomen while legs rest on thigh
o Incomplete breech
Frank – thigh resting on abdomen while legs extend to the head
Footling
Kneeling
C. Shoulder presentation
D. Compound presentation
FETAL DISTRESS
Causes:
pregnancy induced hypotension
diabetes mellitus
uterine hypertonus
hemorrhage
maternal hypotension
umbilical cord prolapse
oligohydramnios
abruptio placenta
premature closure of fetal ductus arteriosus
anemia
preterm or IUGR fetus
Nursing interventions
monitor FHR q 15 minutes during 1st stage and q 5 mins during 2nd stage of labor
assess color, amount and odor of amniotic fluid
assess for vaginal bleeding
discontinue oxytocin if fetal distress
maternal BP P, R on same schedule and temp q2h
position on left side
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■ Update primary health-care provider with FHR status
■ Document findings and interventions
■ Assessment of the FHR may be intermittent or continuous
Intermittent Auscultation
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Internal Fetal Monitoring
Indicated when EFM not providing adequate FHR or contraction
tracing
May be implemented only after amniotic sac is ruptured
FHR measured by spiral electrode attached to presenting part
Uterine tone measured by intrauterine pressure catheter (IUPC)
Resting tone of uterus averages 5–15 mmHG
Contraction tone of uterus averages 50–85 mmHG
Figure: Normal fetal heart rate (Left:contractions, right: fetal heart rate)
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TACHYCARDIA
FHR greater than 160 BPM for 10 minutes
Possible cause:
• Infection/hyperthermia
• Fetal hypoxia
• Maternal medications (ex. terbutaline, albuterol)
BRADYCARDIA
FHR less than 110 BPM for 10 minutes
Possible cause:
• Vagal stimulation
• Hypoxia
• Anesthetic agents
VARIABILITY
Fluctuations in FHR over time
Important indicator of fetal well-being
Sensitive to hypoxia and changes in Ph
Short-term variability (STV)
• Beat-to-beat changes in FHR
• Documented as present or absent
• Most accurate with internal FHR monitoring
Long-term variability (LTV)
• Pattern of fluctuations in FHR baseline
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Acceleration (Top: Fetal Heart Rate, Bottom: Contractions)
38
• Usually benign finding
• Continue to monitor FHR pattern for nonreassuring patterns
• Possible cause: Fetal head compression
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• Decrease in FHR occurring without regard to contractions
• Can range from mild to severe
• May be persistent or occasional
• Shaped like a “V” or “W”
• Onset variable
• Nonreassuring variable decelerations
– Repetitive and/or deep decrease in FHR
– Associated with minimal variability
– Prolonged with slow return to baseline FHR
• Possible causes:
– Cord prolapse
– Umbilical cord compression
• Intervention: AMNIOINFUSION may be performed to try to
relieve cord compression
– Infusion of warmed normal saline into uterus via sterile
catheter
– Monitor FHR, contraction status, and maternal temperature
Verify that fluid is exiting uterus
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primary health-care provider
Monitoring Contractions
Frequency
Beginning of one contraction to the beginning of the next contraction
Documented as range, for example, “every 2–5 minutes”
Duration
Beginning of the one contraction to the end of the same contraction
Documented as a range, for example, “lasting 60–90 seconds”
Intensity
Palpate uterus both during and after contraction
Resting tone palpated between contractions
Document intensity of uterine contractions (findings subjective unless monitored
with IUPC)
PROLAPSED CORD
Occurs when the cord passes out of the uterus ahead of the presenting part.
Risk Factors:
A very small fetus
Breech presentation
Transverse lie
Hydramnios
Long cord
Placenta previa
Clinical Manifestation:
Completer prolapse – visible on the vulva
Occult prolapse – cord slips alongside with the head or shoulder of fetus
Changes in FHR (bradycardia)
Nursing Diagnoses:
Impaired Fetal Gas Exchange r/t insufficient oxygen delivery secondary to cord compression
Fear/Anxiety r/t perceived grave danger to fetus and self from obstetric emergency\
Management:
Focus: to relieve pressure on the cord to restore blood flow through it until delivery.
Position the woman hip higher than her head to shift the fetal presenting part toward her
diaphragm.
■ Knee chest
■ Trendelenburg
■ Hips elevated with pillows, with side lying position maintained.
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With gloved hand, push the fetal presenting part upward.
Oxygenation at 8 – 10 LPM via face mask.
Tocolytic drug, terbutaline (inhibit contraction; increase placental blood flow)
Warm saline – moistened towels retard cooling and drying of cord.
Nursing considerations
The nurse must remain calm and acknowledge the woman’s anxiety.
Simple explanation of the condition.
Include the family (decision making).
Powers
the forces acting to expel the fetus & placenta
involuntary contractions
voluntary bearing down effects
characteristics: wavelike
timing: frequency, duration, intensity
myometrium- power of labor
DYSTOCIA
broad term for abnormal or difficult labor and delivery
Causes:
Types:
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refers to labor dystocia with a lack of progressive cervical dilataion and or fetal descent
discrepancy between fetal size or position (passenger) and the pelvis (passageway) may
inhibit fetal descent (CPD)
maternal anxiety (psyche) and maternal positioning may also interfere labor progress
Medical care:
evaluation of fetal size, presentation, position, and pelvic adequacy
AROM or oxytocin augmentation may be initiated if uterine hypotonus is diagnosed and CPD
ruled out
forceps or vacuum extraction may be tried if the problem develops in the second stage
CS for CPD
RETRACTION RINGS
Physiologic retraction ring--> boundary between upper and lower uterine segment
Bandl's Pathologic ring--> suprapubic depression sign of uterine rupture
PREMATURE LABOR
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labor and delivery that is completed in less than 3 hours after the onset of true labor pains;
probably due to multiparity or following oxytocin administration or amniotomy. Dangers
imposed by precipitate delivery: extensive lacerations; abruptio placenta; or hemorrhage due to
sudden release of pressure, leading to shock
s/sx of shock: hypotension, tachycardia, tachypnea, cold clammy skin
Management: modified trendelenburg, fast drip IV
UTERINE INVERSION
fundus is forced through the cervix so that the uterus is turned inside out
causes:
a. insertion of placenta at the fundus so that as fetus is rapidly delivered, especially if
unsupported, the fundus is pulled down
b. strong fundal push when mother fails to bear down properly
c. attempts to deliver the placenta before signs of placental separation appear
UTERINE RUPTURE
occurs when the uterus undergoes more strain that it is capable of sustaining
Causes:
scar from a previous classic caesarian section
improper use of oxytocin
very large baby (overdistention)
faulty presentation or prolonged labor
Signs/symptoms:
sudden, severe pain
hemorrhage and clinical signs of shock (restlessness, pallor, hypotension, tachycardia,
tachypnea)
change in abdominal contour, with two swellings on the abdomen, the retracted uterus and the
extrauterine fetus
5. Placental problems
PLACENTA PREVIA
occurs when the placenta is improperly implanted in lower uterine segment, sometime covering
the uterine os
Assessment
outstanding sign: frank, bright red, painless bleeding
enlargement (usually has not occurred)
fetal distress
abnormal presentation
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Nursing care
initial management: NPO--> candidate for CS
Bed rest
prepare to induce labor if cervix is ripe
administer IV
No IE (internal exam), no enema-- complication: sudden fetal blood loss
prepare mother for double set up- DR is converted to OR
ABRUPTIO PLACENTA
Psychological Changes
Latent Phase: may be talkative and excited that labor has started
Active Phase: becomes more serious and focused on contractions; concerned about ability to cope
with discomfort
Transition Phase: Client becomes more irritable and may lose control during contractions; convinced
that she can't do it; very introverted or sleeping between contractions
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2nd Stage: works hard at pushing and sleeps or appears exhausted between contractions
3rd.Stage: Client is usually elated with birth of the baby and pushes on request to deliver placenta
4th Stage: client is alert and ready to bond or breastfeed her baby; may be talkative and hungry
Causes:
improper bearing down
anxiety
uncoordinated / weak contractions
Nursing diagnoses:
Energy field disturbance r/t slowing or blocking of energy flow secondary to labor
Anxiety
Nursing intervention:
psychoprophylactic interventions such as lamaze
relaxation / breathing techniques
therapeutic touch/ effleurage
ANXIETY/FEAR
Causes:
Client perceives threat to fetal well-being
invasive procedures (CS)
Defining characteristics:
verbalizations: “I'm nervous, frightened, tense”
trembling
crying
increased P, BP
Nursing interventions:
acknowledge anxiety
inform about fetal status
explain procedures
include family
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c. UTI
3. Thromboembolic disorders
4. Postpartal psychiatric disorder
POSTPARTAL HEMORRHAGE
blood loss of more than 500 cc (blood loss during labor and delivery is 250-350 cc); leading
cause of mortality associated with childbearing
1. uterine atony= uterus is not well contracted, relaxed or boggy; most frequent cause
intervention
a. massage the uterus- first nursing action
b. ice compress
c. modified trendelenburg
d. fast drip IV
e. breastfeeding- to release oxytocin
f. oxytocin administration
g. emptying the bladder
h.bimanual compression to explore retained placental fragments
I. hysterectomy- last resort
2. lacerations
- well contracted with profused bleeding
- assess perineum for laceration
- degrees of laceration
- 1st degree- vaginal skin and mucous membrane
- 2nd degree- 1st degree + muscles
- 3rd degree - 2nd degree + external sphincter of rectum
- 4th degree- 3rd degree + mucous membrane of rectum
3. hematoma
- bluish discoloration of subQ tissues of vagina or perenium
- candidates
- delivery of very large babies
- pudendal block
- excessive manipulation due to excessive IE
- intervention
cold compress 10- 20 mins then allow 30 minutes rest period for 24 hours
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Late postpartum hemorrhage
Hematoma
due to the injury to blood vessels during delivery
1, Incidence: commonly seen in precipitate delivery and those with perineal varicosities
2. treatment:
ice compress during the first 24 hours
oral analgesics, as ordered
site is incised and bleeding vessel is ligated
Endometritis
inflammation/ infection of the lining of the uterus
Specific s/sx
abdominal tenderness
uterus not contracted and painful to touch
dark brown, foul smelling lochia
Management
High fowler's- to drain lochia and prevent pooling of infected discharge
oxytocin
Wound Infection
Specific symptoms:
pain, heat and feeling of pressure in the perineum
inflammation of the suture line, with 1 or 2 stitches slough off
with or without elevated temperation
Tx suturing (usually done by doctor), hot Sitz bath
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Incisional infection
■ Contributing factors
• Inadequate care of incision
• Operative delivery
• Laceration
■ Clinical findings
• Incision not well approximated
• Incision red with purulent drainage
UTI
■ Contributing factors
• Catheterization of bladder
• Retention of urine in bladder
■ Clinical findings
• Dysuria
• Frequency of urination
• Flank pain
THROMBOEMBOLITIC DISORDERS
infection of the lining of the blood vessels with formation of clots; usually an extension of
endometritis
Specific symptoms:
pain, stiffness, and redness in the affected part of the leg
leg begins to swell below the lesion because venous circulation has been blocked
skin is stretched to a point of shiny whiteness, called milk leg = phlegmasia alba dolens
Positive Homan's sign = pain in the calf when the foot is dorsiflexed
Specific Management
bed rest with affected leg elevated
anticoagulants, e.g. Decumarol or heparin to prevent further clot formation or extension
of a thrombus
side effects: hematuria and increased lochia
Considerations:
discontinue breastfeeding
monitor prothrombin time
always have Promtamine sulfate or vitamin K at bed side to counteract
toxicity
analgesics are given but never aspirin because it inhibits prothrombin
formation; since patient is already receiving an anticoagulant, bleeding may occur
EMOTIONAL SUPPORT
1. Taking phase
1st 3 days
dependent phase
passive, can’t make decision
tells about childbirth experience
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focus on: Hygiene
2. Taking Hold
4 – 7th day
dependent to independent phase
active, decides actively
focus: care of newborn
health teaching : Family planning
3. Letting Go
Interdependent phase
Redefines goals, new roles as parents
May extend till the child grows
POSTPARTUM BLUES
4th – 5th days
overwhelming feeling of depression, inability of sleep and lack of appetite
50 – 80% incidence rate
cause by sudden hormonal change – progesterone suddenly decreases
allow crying: therapeutic
may lead to postpartum psychosis/ depression
POSTPARTUM DEPRESSION
■ Risk factors
■ History of depression or anxiety disorder
■ Prenatal depression
■ Inadequate social or partner support
■ Large number of life stressors
■ Clinical findings
■ Symptoms extend beyond 2 weeks postpartum; may occur 3–12 months after birth
■ Extreme or unswerving sadness
■ Compulsive thoughts
■ Feelings of inadequacy
■ Inability to care for infant and/or self
■ Suicidal thoughts
■ Interventions
■ Psychotherapy
■ Medications
INFERTILITY
Definition
■ inability to conceive after 1 year or more of unprotected intercourse
Etiology
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faulty sperm production
reproductive tract anomaly
physical and chemical agents (coal tar, radioactive substance, orchitis, other infection, etc.);
endocrine disorders
general state of health
blocked vas deferens
testicular infection
injury to reproductive organs/tract
nerve damage
impotence
lifestyle factors (smoking, alcohol, street drugs, etc.)
incompatible immunologic factors for sperm—anti-spermatozoa antibodies
C. Factors in couple infertility: improper technique for intercourse; infrequent intercourse; emotional
state; male and female factors contributing to infertility
History
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Partner’s reproductive history; medical, surgical history
Employment history: exposure to radiation, viruses, other
substances known to cause sterility; teratogens
Sexual history: techniques, frequency and timing of intercourse in relation to the menstrual
cycle; use of lubricants, douches, sex stimulants, or toys; trauma
Report of any previous infertility testing, work-ups; diagnoses; interventions; genetic evaluation
Lifestyle history: use of recreational (street) drugs, prescription drugs, alcohol, tobacco,
caffeine, eating habits, saunas or hot tubs, exercise (including biking and running); stress
Age of patient/partner may determine timing of intervention
Physical Examination
A. Vital signs
1. Temperature
2. Pulse
3. Blood pressure
D. Pelvic examination
1. Length of vagina
2. Position and character of cervix
3. Any anomalies
Laboratory
A. Papanicolaou smear, maturation index; mammogram as appropriate
B. N. gonorrhea culture; RPR status (syphilis), TB status, HIV, hepatitis status, Rubella titre, varicella
titre
C. Chlamydia smear
D. Pregnancy test in amenorrhea
E. Complete blood count; erythrocyte sedimentation rate
F. Mycoplasma and ureaplasma culture
G. Endometrial biopsy during luteal phase
H. Serum progesterone level days 21–23 of cycle
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I. Wet mounts, vaginal cultures
J. Prolactin level, FSH, LH, TSH, Rh factor, blood type
Treatment
A. Infertility work-up for the woman
1. Basal body temperature charts, may use test for LH surge instead
2. Commercially available ovulation tests or devices and fertility monitoring devices
3. Postcoital test—serial if antispermatozoa antibodies
4. Cervical mucus test; sperm antibody level; sperm agglutination test; sperm immobilization test;
endometrial biopsy 2–3 days before menstruation
5. Hysterosalpingogram after menses, before ovulation
6. Hormonal assay (serum) such as FSH, LH, prolactin, estrogen DHEA-S, testosterone, urinary LH
4–5 days at midcycle
7. Tuboscopy
8. Ultrasound
9. Laparoscopy with chromotubation, hydrotubation; hysteroscopy; salpingoscopy
Complications
A. Risks associated with certain tests; costs of testing
B. Persistent infertility, discovery of sterility
C. Effects on couple’s relationship
Consultation/Referral
To gynecologist or infertility specialist; reproductive technology centers;
genetic counseling
Follow-up
Long-term process for work-up that is staged, so patient would be asked to return for next phase of
testing if conception not achieved.
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54
CHILD
A. Nursing care of the high-risk newborn to maturity
1. Problems related to maturity
PREMATURITY
premature babies= born before the 38th week of gestation
1. have underdeveloped subQ tissues and less fat to act as insulation. Are thin-skinned. This is
the reason why rapid drying and warming inside incubators are important
Characteristics:
in incubator care:
a. temperature- 92-94 F (33.3- 34.4C)
b. humidity – 55- 65%
c. frequent positioning on the right side will favor closure of the foramen ovale because of the
increased pressure on the left ventricle
Procedure
** determine the distance to which the NGT is to be inserted by measuring from the ear lobe to the
nose to the distal end of the sternum
** Procedure
determine the distance to which the NGT is to be inserted
check the location after NGT has been inserted:
submerge tip of the NGT in a glass of water; if bubble appear, it is inside the lungs
inject 5 cc of air, then auscultate. If no sound is heard as air is injected, it means that the NGT
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is not in the stomach but in the lungs
aspirate contents; if acids are aspirated, the NGT is in the stomach
determine amount of residual milk or undigested milk and subtract the same amount from
the next feeding because this means that the baby is not able to digest all the milk that is given to
him. Be sure to put back the residual milk since it contains acids and the baby can develop
metabolic alkalosis if not given back to the baby
keep the NGT always closed to avoid abdominal distention
fill syringe with formula before opening NGTl let formula flow by gravity
POSTMATURITY
postterm/ postmature babies = born after the 42nd week of gestation
A. Classic signs: “old man facies”; evidence of intrauterine weight loss, dehydration and chronic
hypoxia
1. long and thin
2. cracked skin which is loose, wrinkled and stained greenish-yellow, with no vernix nor lanugo
3. long nails; firm skull
4. wide eyed alertness of a one month old baby
B. Management
1. monitor VS
2. IV as ordered
C. Outlook: reasonable
Respiratory Distress Syndrome or Hyaline Membrane Diseases- the disease specific for premature
babies
DECREASE PULMONARY SURFACTANT ==> increased surface tension-- > alveolar walls will not
separate--> lack of expansion of affected alveoli ---> decreased alveolar ventilation ---> inadequate
exchange of oxygen and carbon dioxide ----> HYPOXIA ----> increased capillary permeability which
causes effusion from the pulmonary capillaries into the alveoli and terminal bronchioles -----> HYALIN
LIKE MEMBRANE found in the alveoli and bronchioles composed mainly of fibrin -----> ATELECTASIS
a. Pathophysiology:
the main problem is decreased pulmonary surfactants, substances responsible for maintaining
the expansion of the alveolar walls after initial respiration
the lack of expansion of affected alveoli decreases alveolar ventilation
this results in inadequate exchange of oxygen and carbon dioxide, leading to hypoxia.
Hypoxia increases capillary permeability, causing effusion from the pulmonary capillaries into
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the alveoli and terminal bronchioles
Hyaline-like membrane forms around the alveoli and bronchioles causing further hypoxia
atelectasis, the chief lesion of RDS, thus occur
b. signs and symptoms:
respiratory grunting-- major symptom
increased respiratory rate
flaring alae nasi
cyanosis; retractions; rales
respiratory acidosis
blood values low pH level (N= 7.35- 7.45); low pO2 level (N = 40- 60 mm Hg); High pO2 level
(N = 35-45)
c. Management
monitor VS, ABGs, skin color, muscle tone
proper positioning; NPO; IV;NGT care
oxygen; high humidity; warmth; CPAP
Suction PRN
Prevent complications
sodium bicarbonate- for acidosis
10-15% of all infants are meconium stained at birth, ~5% of meconium stained infants get MAS
usually associated with fetal distress in utero, or postterm infant
high incidence of MAS with thick meconium
respiratory distress within hours of birth
tachypnea, increased PCO2, small airway obstruction, chemical pneumonitis
complications: hypoxemia, acidosis, persistent pulmonary hypertension (PPHN),
pneumothorax, respiratory failure, death
treatment: supportive care and ventilation, may benefit from surfactant replacement (surfactant
function is inhibited by meconium)
prevention: careful in utero monitoring, suction naso/oropharynx at perineum, then intubate
and suction below cords at birth
NEONATAL SEPSIS
Early Onset (birth- 8 days) Late onset (8- 28 days)
begins in utero Acquired after birth
Risk factors: Usually healthy, full-term
Maternal UTI, GBS positive, primary maternal Same pathogens plus:
infection, maternal fever/ leukocytosis/ Pneumococcus, meningococcus, HSV,
chorioamnionitis, prolonged rupture of staphylococcus
membrane, prematurity, large inoculum
GBS, E. coli, listeria, klebsiella
Signs of Sepsis
Respiratory distress, cyanosis, apnea
Tachycardia/ bradycardia
Lethargy, poor feeding
Hypotonia, seizures, bulging fontanelle
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Jaundice
Temperature instability (hypo/hyperthermia)
Rochester Criteria: for determining risk of febrile infant of having a serious bacterial infection
Risk < 1% if
o past health
Born at (37 weeks gestation)
Home with or before mother
No subsequent hospitalizations
No perinatal, postnatal or current antibiotics
No treatment for unexplained hyperbilirubinemia
No chronic disease
o Physical exam
Rectal temperature > 38.0C
Appears generally well (no evidence of infection)
o Laboratory
Total WBC 5-15 x 10(9)/L
Bands < 1.5 x 10 (9)/L
Urine > 10 wbc/hpf
Stool (if diarrhea) > 5 WBC/ hpf
If criteria are met, may observe on out-patient basis without specific antibacterial treatment
If F/U is a problem, observation should be done in hospital
HYPERBILIRUBINEMIA
because of the immaturity of the liver, kernicterus (= staining of brain damage or even death) appears
to occur at a lower bilirubin level. Management: phototherapy= photooxidation by the use of artificial
blue light in order to convert bilirubin into an excretable form. Nursing responsibilities in phototherapy
care:
expose all areas of the body to light by turning the infant every 2 hours
cover eyes and genitalia
give plenty of fluids to prevent dehydration
check the loose stools and increased body temperature
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Hyperbilirubenemia
More than 12mg of indirect bilirubin among full terms
Normal Indirect Bilirubin Level: 0 – 3 mg/dl
Assessment of Jaundice
blanching of forehead, nose and sternum
yellow skin, sclera
light stool
dark urine
Management
Phototherapy/ Photooxygenation
o Nursing Responsibilities
Cover the eyes – prevents retinal damage
Height of light from baby – 18 – 20 inches
Increase Fluid intake
Cover genetalia – prevent priapism ( painful continuous erection
Change position
Avoid lotion and oils
Monitor I&O – best way is to weigh the baby
Monitor VS
Prevention:
Place infant on back, NOT in prone position
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Alarm/other monitors not recommended- increase anxiety and do not prevent life-threatening
event
Avoid overheating and overdressing
Appropriate infant bedding
B. Common health problems that develop during infancy example: intussusception, failure to thrive,
sudden infant death syndrome, colic, trisomy 21, cleft palate, imperforated anus, hirchsprung's
disease, spina bifida, hydrocephalus, otitis media, meningitis, febrile seizures, autism/ADHD
INTUSSUSCEPTION
Invagination of one portion of the intestine to another (telescoping is a good synonym for it)
Generally occurs at 6-12 months
Typically idiopathic in patients under 12 months
May be related to another disorder in patients over 12 months.
Treatment of intussusception:
Surgery - anastomosis
Reduction by fluid/air/barium (done in radiology)
FAILURE TO THRIVE
sign of inadequate growth resulting from inability to obtain or use calories required growth
No universal definition
Energy requirements
0-10 kg: 100 cal/kg/day
10-20 kg: 1000 cal + 50/kg/day for each kg> 10
20 kg +: 1500 + 20 cal/kg/day for each kg> 20
May have other nutritional deficiencies, eg. Protein, iron, vitamin D
Common parameter:
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WEIGHT, sometimes height that falls below 5th percentile for child’s age
Weight for age (height) z value of less than -2.0
Weight curve (loss) that crosses >2 percentile lines on National Center for Health Statistics
(NCHS) growth after previous achievement of a stable growth pattern.
Physical examination
o Height, weight, head circumference, arm span,
o Assessment of nutritional status, dysmorphism, pubertal status, evidence of chronic
disease
o Observation of a feeding session and parent-child interaction
o Signs of abuse and neglect
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3 General Categories
A. Organic Failure to Thrive - Physical Cause
Inadequate intake
o Insufficient breast milk production
o Inappropriate feeding practices
o CNS, neuromuscular, mechanical problems with swallowing, sucking
o Anorexia (associated with chronic disease)
Inadequate absorption
o Malabsorption: celiac disease, cystic fibrosis (CF), pancreatic insuffiency
Inappropriate utilization of nutrients
o Renal loss: e.g. tubular disorders
o Loss from GI tract: chronic diarrhea, vomiting
o Inborn errors of metabolism
o Endocrine: type 1 diabetes, diabetes insipidus (DI), hypopituitarism
Increased energy requirements
o Pulmonary disease: CF
o Cardiac disease
o Endocrine: hyperthyroidism, DI, hypopituitarism
o Chronic infections
o Inflammatory: systemic lupus erythematosus (SLE)
Decreased growth potential
o Specific syndromes, chromosomal abnormalities
o Intrauterine insults: fetal alcohol syndrome (FAS)
Treatment: cause specific
C. Idiopathic Failure to Thrive – unexplained by usual organic and environmental etiologies but may
also be classified as NFTT.
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Statistically greater risk if mother is over 35, but 80% born to women under the age of 35.
Paternal age may also be a factor
Degree of physical and cognitive development impairment related to the percentage of cells
with abnormal chromosomal makeup
Physical manifestations
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CLEFT LIP AND PALATE
1. Cleft lip occurs when there is a failure of the fusion of the maxillary and median nasal
processes.
2. Cleft palate occurs when there is a failure of the fusion of the palatal process (roof of the
mouth)
Cleft Lip
Failure of the median maxillary nasal process to fuse
Common to boys
Surgery – cheiloplasty
o Done w/in 1 – 3 months
o To save sucking reflex
Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common
o Frequent URTI and otitis media
Post cheilo – sidelying
Nutrition – use rubber tip syringe
Cleft Palate
Failure of the palate to fuse
Common to girls
Surgery – Uranoplasty
o Done w/in 4 – 6 months
o To save speech
Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common
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o Frequent URTI and otitis media
Post cheilo – prone
Nutrition – use paper cup/ plastic cup/ soup spoon
General management
Maintenance of patent airway
Proper nutrition
o NPO 4 hours post op
o Clear liquid
Popsicle except red and brown in color
Flavore gelatin
No ice cream
Observe for bleeding
o Frequent swallowing
Protect suture lines specially LOGAN BAR
o Clean using hydrogen peroxide, bubbles traps microorganism, more bubbles more
microorganism trapped
o Prevent crying by attending to needs
Therapeutic Management
Emotional support
Proper Nutrition
Cleft lip nipple (long tip, made by silicon)
Prevent Colic
o Burp frequently
o One at the middle of the feeding
o Another at the end of the feeding
o Upright sitting position
o Pat at the back – lower to upper
o Prone position
o Right – sidelying position – facilitates gastric emptying
Educate parents
Apply elbow restraints so the baby can easily adjust post –op
IMPERFORATE ANUS
A. unknown etiology- arrest in embryonic development at 8 weeks of intrauterine life
B. Types
a. type I- stenosis
b. type II- membranous
c. type III- agenesis (low and high)
low – distance less than 1.5 cm
high – distance greater than 1.5 cm
d. type IV – atretic
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atretic type)
3 Surgery
a. anoplasty
b. abdominoperineal pull-through
SPINAL BIFIDA
congenital problem in which there is a defective closure of the spinal column
A. Classification
1. Occulta- L5 and S1 are usually affected, with no protrusion of spinal contents. Skin over the
defect may reveal a dimple, a small fatty mass or a tuft of hair
2. cystica
a. meningocoele
b. myelomeningocoele= congenital failure of the arches of one or more vertebrae to unite at
the center of the back, so that the bony wall normally surrounding the spinal canal at that place
is missing. There is external protrusion, through a transparent sac, containing spinal fluid,
meninges, spinal cord and/or nerve roots. It is the most severe of the spinal deformities
B. Associated clinical problems – depend on the location; all body parts below the lesion are affected
1. Motor function:
a. feet may be deformed
b. joints of ankles, knees or hips may be immobile
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c. variable degrees of weakness in lower extremities
d. spontaneous and induced movements are decreased or absent
2. Sensory function:
a. sensations usually absent below the level of the defect
b. ulcerations of the skin are common
3. impaired functioning of the autonomic nervous system
a. skin is dry and cool
b. sweating ability is impaired
Surgical correction:
1. early excision of the sac if it is small and primary closure is done
2. if base of the defect is too large for primary closure, conservative treatment is carried out first
while waiting for epithelialization to take place and then closure is done at a later time
Postoperative care
1. keep on prone position
2. monitor urine output- bladder injury is a high possibility in operations involving the spinal
column
3. measure head circumference daily
4. monitor movement of lower extremities
Complications
1. meningitis
2. severe neurologic deficits
3. hydrocephalus
a. Types:
** noncommunicating = blockage within the ventricles which prevents CSF from entering the
subarachnoid space
** communicating = obstruction in the subarachnoid cistern at the base of the brain and / or
within the subarachnoid space
b. Management:
67
* 1.5- 2 Gms. Mannitol 20%/KBW over 10-15 minutes- since mannitol is a diuretic, an
indwelling catheter should be inserted for accurate recording of intake and output
ventriculo-peritoneal/ ventriculo-atrial shunt – to bring CSF to an area from where it can be
excreted from the body. After the procedure, the child should be positioned on the side
where the shunt is to prevent sudden decrease in intracranial pressure
Diagnostic evaluation
Clinical manifestations
Meningeal sac (can be transilluminated)
Ultrasound prenatally
HYDROCEPHALUS
Tumor of choroid plexus (the area that produces CSF in brain) may cause increased secretion
of CFS.
Choroid tumors are rare, but structural malformations may cause impaired absorption or
obstruction to outflow of CSF.
Imbalance of secretion and absorption of CFS causes CFS to accumulate in the ventricles,
which dilate and compress against cranium
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Skull also enlarged
Most are a result of developmental malformations (in ventricular system)
Usually presents in infancy, but can also be up to early childhood
Other causes: infections, neoplasms, trauma, brain damage
Diagnosis
3. Head circumferences
4. Associated Neuro signs
5. CT, MRI, skull x-ray
6. Dye inserted into ventricle through anterior fontanel—will not appear in CSF from lumbar
puncture if non-communicating
Therapeutic management
Relief of hydrocephalus
Treatment of complications
Management of issues related to psychomotor alterations
Surgical treatment
69
More on Shunts…
Valves open at a predetermined intraventricular pressure and close when the pressure falls below
that level (prevents backflow)
Ventriculo-Peritoneal (VP) shunt is preferred for infants and young children
Ventriculo-Atrial (VA) shunt (ventricle to right atrium) reserved for older children who have attained
most of their growth and for children with abdominal pathology (perforation of bowel, etc.)
Complications of shunts
70
OTITIS MEDIA
Inflammation of the middle ear
Common to children due to wider and shorter Eustachian tube
Predisposing factors
Bottle propping
Cleft lip/ palate
Management
Positioning – sidelying on the affected side
Supportive care
Medical management
Massive dosage of antibiotics
Mucolytics
Ear drops
< 3 y/o – down and back
>3 y/o – up and back
Surgery
Myringectomy – slight incision of tympanic membrane to prevent hearing loss
Side effect – bacterial meningitis
BACTERIAL MENINGITIS
Infections or inflammation of the cerebral meninges (the membranes covering the brain and
spinal cord)
Pathologic organism spreads to the meninges from upper respiratory tract or by lymphatic
drainage from the sinuses.
71
Once pathogen enter the meningeal space, they spread rapidly
Produces an inflammatory effect that leads to thick exudates that blocks CSF flow.
Brain becomes edematous, covered with purulent exudate.
Spreads VERY quickly through CNS
4. Usually have 2-3 days of a cold, upper respiratory infection and occasionally and ear infection.
5. Become VERY irritable due to headache
6. May have convulsions
7. photophobia
8. As the disease progresses, more signs of meningeal irritability occurs:
1. Positive Brudzinski’s (image on page 674)
1. When child’s head is flexed forward (while laying on back), both hips, knees and ankles
flex. This shows meningeal irritation
2. Positive Kernig’s (image on page 674)
1. Flex child’s hips and knee (while laying on back)
2. Then extend leg—this will cause pain, resistance and spasm which indicate irritation.
3. Nuchal rigidity occurs (neck stiffness)
4. In the newborn—poor sucking, weak cry, lethargy
Therapeutic Management
Medical emergency!
Directly put on droplet isolation precautions
IMMEDIATE antimicrobial therapy
Hydration
Ventilation (not in all cases)
Reduction of increased ICP
Management of shock and Disseminated intravascular coagulation (DIC)
Tidbits on DIC: Normally, when you are injured, certain proteins are turned on and travel to
the injury site to help stop bleeding. However, in persons with DIC, these proteins are
abnormally active. Small blood clots form throughout the body. Overtime, the clotting
proteins become "used up" and are unavailable during times of real injury
This disorder can result in clots or, more often, bleeding. Bleeding can be severe.
Control of seizures, temperature
72
FEBRILE CONVULSIONS
1. Seizures associated with high fever (102-104 degrees F)
2. Most common in preschool children or between 5 months and 5 years of age
3. Usually no more than 5-7 of these episodes occur in a child’s life
Seizure activity
73
C. Health problems common in toddlers
BURN TRAUMA
Injury to body tissues caused by excessive heat
Characteristic
1st Degree Involves only the superficial epidermis characterized by erethema,
Partial dryness and pain
Thickness Ex: Sunburn – heals by regeneration in 1 – 10 weeks
2nd Degree Involves the entire epidermis, and portion of the dermis,
Partial characterized by erythema, blistered and moist from exudates which
Thickness is extremely painful
Ex: Scalds
3rd Degree Involves skin layers, epidermis and dermis, may involve adipose
Full Thickness tissue, fascia, muscle and bone. It appears to be leathery, white or
black, not sensitive to pain since nerve ending had been destroyed
Ex: Lava Burn
Management:
First Aid
o Put out the flames by rolling the child on a blanket
o Immerse the burned part on cold water
o Removed burned clothing (sterile material)
o Cover burned part with sterile dressing
Maintainance of patent airway
o Suction PRN
o O2 administration with humidity
o Endotracheal Intubation
o Tracheostomy
Prevention of shock and flued and electrolyte imbalances
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o Colloids to expand blood volume
o Isotonic saline to replace electrolyte
POISONING
Common accident in toddlers – poisoning
Common accident in infants – falls
Principles
o Determine the substance taken and assess LOC
o Unless poisoning was corrosive, caustic (strong alkali, such as lye) or hydrocarbon,
vomiting is the most effective way to remove the poison from the body
Strong acid poisoning – give weak acid to neutralize strong acid
o Syrup of ipecac – oral antiemetic to cause vomiting after drug overdose or poisoning
15 ml – adolescent, school age and preschool
10 ml – infant
o Universal Antidote
Activated charcoal
Milk of magnesia
Burned toast
Charcoal absorbs toxic substance
o Never administer the charcoal before ipecac because giving charcoal first will absorb
the effect of ipecac
o Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst)
o Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and prevent poison
absorption
Tracheostomy set will be at bed side
Lead Poisoning
Pencil, paint, crayon Lead
↓
Destruction of RBC Functioning
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↓
hypochromic Microcytic Anemia
↓
Destroys Kidney Function
↓
Accumulation of ammonia
↓
Leading to Encephalitis (Late stage)
↓
Severe mental retardation
Assessment
o Beginning symptoms of lethargy
o Impulsiveness and learning difficulty
o As lead ↑, severe encephalopathy with seizure and permanent mental retardation
Diagnostic procedure
o Blood smear
o Abdominal x-ray
o Lone bone
Management
o Chelation – binds with the lead and excreted via kidneys
o Ca EDTA/ BAL/ Dimercapro
Nephrotoxic
Food poisoning
Staphylococcus
Clostridium perfringens
Clostridium botulinum
Acetaminophen poisoning
Aspirin poisoning
Toxic dose: Acute ingestion: 300-500mg/kg
Chronic ingestion:>100mg/kg/day X2days or more
Signs & Symptoms
N/V, thirst, hypoglycemia, ¯Na+, ¯K+, diaphoresis, oliguria, bleeding, dehydration, fever
Hyperpnea, confusion, tinnitus, seizure, coma, respiratory & circulatory failure
Management
Syrup of Ipecac, gastric lavage with activated charcoal
Administer as ordered: IVF, NaHCO3, electrolytes, volume expander, glucose, Vit. K
Prepare for dialysis if unresponsive to the therapy
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CHILD ABUSE AND NEGLECT
Definition
An act of commission or omission (physical, sexual, or emotional) by another person that
harms a child in a significant way
RA 7610
An act providing for stronger deterrence and special protection against child abuse,
exploitation and discrimination
child: anyone below 18 years old
Risk Factors
environmental factors
o social isolation
o poverty
o domestic violence
caregiver factors
o parents were abused as children
o psychiatric
child factors
o difficult child (temperament)
o disability, special needs (e.g. mental retardation)
o premature
Physical abuse
injury in an infant less than 12 months
repeated multiple injuries of a child at any age
distinctive marks: cuts, burns, rope mark, belt buckle
atypical patterns of injury: bruises on the face, abdomen, buttocks
altered mental status: head injury, poisoning
shaken baby syndrome
head trauma is the leading cause of death in child maltreatment
violent shaking of infant resulting in intracranial hematomas retinal hemorrhages and
sometimes fractures
diagnosis confirmed by head CT or MRI, ophthalmologic exam, skeletal survey/ bone scan
Sexual abuse
- prevalence: 1 in 4 females, 1 in 10 males
- peak ages at 2-6 and 12 -16 years
- most perpetrators are male and known to child
o most common: father, stepfather, uncle
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- diagnosis usually depends on child telling someone
- physical exam is often normal
- presentation
o specific or generalized fears, depression, nightmares
o social withdrawal, lack of trust, low self-esteem, school failure
o sexually aggressive behavior, advanced sexual knowledge, sexual preoccupation,
sexual preoccupation or play
o recurrent UTIs, pregnancy, STDs, vaginitis, vaginal bleeding, genital injury
CEREBRAL PALSY
A group of non-progressive disorders of upper motor neuron impairment that result in motor
dysfunction.
Can happen before, during, or after birth
Occurs 2:1000 births
Most common permanent disability of childhood
Most frequently associated with brain anoxia that leads to cell destruction
o Symptoms can range from very mild to quite severe, depending on the extent of brain
damage
Also can be caused by:
o Kernicterus (a form of jaundice from hyerbilirubinemia; staining of the brain with
bilirubin)
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o Meningitis (viral is the most common)
Occurs most frequently in very low weight infants (born prematurely), or those small for their
age.
o Their lungs haven’t been fully developed
CP has increased over the past decade due to:
o Preemies are living longer
o Multiple births from artificial reproductive technologies
o Prenatal technology
Types of CP
Spastic or pyramidal CP
Extrapyramidal CP
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Extrapyramidal nerve tract conveys nerve impulses that effect autonomic movements:
o Help coordinate body movements
o Maintain skeletal muscle tone
o Play major role in equilibrium
Ataxia (defective muscular coordination)
Dyskinetic (a defect in the ability to perform voluntary movements)
Athetoid—“wormlike”
o Limp and flaccid muscles as an infant
o Later, child makes slow, writhing motions (in place of voluntary muscles)
o May involve all four extremities, face, neck, tongue
o Due to poor tongue and swallowing movements, child may have poor speech and
problems with drooling
Concerned about aspiration
o With emotional stress, involuntary movements may become irregular and jerky
Ataxic
o Children have an awkward, wide-based gait
o On neurologic exam, unable to touch finger-to-nose or due rapid, repetitive movements
Mixed
o Combination of more than one condition listed above
3. Neurological exam
4. History—especially born prematurely
5. Ultrasound of brain
6. CT scan
7. MRI
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Physical findings that may suggest CP
Medical management of CP
Nursing Diagnoses
81
Self-esteem disturbance
Impaired social interactions
General interventions
Sometimes children are not diagnosed with CO until 2-4 years later. This can be upsetting to
parents. Will need much support and education.
Management
Artificial tear
Self limiting
Refer to PT for rehabilitation
Example: leukemia, wilm's tumor (nephroblastoma), asthma, urinary tract infection (UTI)
LEUKEMIA
82
The client is immunocompromised
Classification of Leukemia
o Lympho – affects the lymphatic system
o Myelo – affects the bone marrow
o Acute/ Blastic – affects the immature cells
o Chronic/ cystic – affects the mature cells
Diagnostic examinations
1. Peripheral Blood Smear reveals immature WBC
2. CBC reveals anemia and thrombocytopenia; neutropenia
3. Lumbar Puncture
■ To determine CNS involvement
■ Fetal position without flexion of the neck because it will cause airway obstruction
■ C position or shrimp position
Management Triad
Surgery
Irradiation
Chemotherapy
83
Bone marrow transplant
Levels of Chemotherapy
Induction
To achieve remission
Drugs
■ IV – Vincristine
■ L – Asparagine
■ Oral Prednisone
Sanctuary
To treat the leukemic cells that has invaded the testes and CNS
Drugs
intrathecal methotrexate – via spine
cytocine
arabinase
steroids
Irradiation
Maintenance
To continue remission
Drugs
oral methotrexate
oral 6-mecaptopurine
cytarabine
Reinduction
Give anti-gout agent
To treat leukemic cells after relapse occurs
Treat hyperurecemic neuropathy
Allopurinol or zyloprene
Nursing Management
Assess for common side effects of chemotherapy – nausea and vomiting
Assess for stomatitis ulceration and abcess of oral mucosa
Oral care
Alcohol free mouthwash
Cotton piedgets
Diet – give food acoording to child’s preference
Alopecia – temporary side effect of chemotherapy
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Signs & Symptoms
Mass within abdomen (firm, nontender, confined to 1 side & deep within the flank)
Abdominal pain
Urinary retention, hematuria
Anemia (r/t tumor hemorrhage), pallor, anorexia, lethargy
HTN (r/t renin production by tumor)
Weight loss, T
Lung involvement: dyspnea, chest pain
Management
Monitor VS, esp. BP
Place a sign “DO NOT PALPATE ABDOMEN” at bedside
Measure abdominal girth
WOF abdominal distention, ¯bowel sounds because of risk of GI obstruction post op
ASTHMA
Characterized by airway hyperactivity, bronchospasm and inflammation, reversible small
airway obstruction
very common illness which presents most often in early adulthood
associated with other atopic diseases such as allergic rhinitis or eczema
Clinical Features
episodic bouts of
wheezing
cough: at night, early morning with activity
tachypnea
dyspnea
tachycardia
Triggers
URI (viral or Mycoplasma)
weather (cold exposure, humidity changes)
allergens (pets), irritants (cigarette smoke)
exercise, emotional stress
drugs (aspirin, beta blockers)
Classification
mild asthma
occasional attacks of wheezing or coughing (< 2 per week)
symptoms respond quickly to inhaled bronchodilator
moderate asthma
more frequent episodes with symptoms persisting and chronic cough
decreased exercise tolerance
severe asthma
daily and nocturnal symptoms
frequent ER visits and hospitalization
Management
85
acute
O2: to keep O2 saturation > 92%
fluids: if dehydration
beta agonists: salbutamol (ventolin) 0.03 cc/kg in 3 cc NS q 20 mins, mins by mask until
improvement, then masks q hourly if necessary
ipratropium bromide (Atrovent) if severe: 1 cc added to each of first 3 Ventolin masks
steroids: prednisone 2 mg/kg in ER, then 1 mg/kg po od x 4 days
■ in severe disease, give steroids immediately since onset of action is slow (4 hours)
indications for hospitalization
initial O2 saturation < 92%
past history of life threatening asthma (ICU admission)
unable to stabilize with q4 Ventolin masks
concern over environmental issues or family's ability to cope
chronic
education, emotional support, avoidance of environmental allergens or irritants,
development of an “action plan”
exercise program (e.g. Swimming)
monitoring of respiratory function with peak flow meter (improves compliance and allows
modification of medication)
patients with moderate or severe asthma will need regular prophylaxis in addition to
bronchodilators (e.g. Daily inhaled steroid, long-acting beta-agonist, anticholinergics,
sodium cromoglycate, theophylline)
Etiology
E. coli serotypes from bowel flora (most common)\
others: Klebsiella, Proteus, enterococci, S. saprophyticus
Risk Factors
female (after 2 years), neurogenic bladder, reflux, genitourinary (GU) tract abnormalities,
diabetes, immunocompromised, uncircumcised male
Complications
children 2 months to 2 years are at greatest risk of renal damage from UTI
Clinical Features
neonates: feeding difficulties, fever, vomiting, jaundice, FTT
preschool: fever, increased frequency, urgency, dysuria, abdominal pain, vomiting
school-age: fever, enuresis, increased frequency, urgency, dysuria, flank pain
Diagnosis
febrile infant < 2 months requires full septic work-up (see Infectious Diseases section)
unexplained fever in child 2 months to 2 years of age ––> consider UTI
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example: diabetes mellitus, rheumatic fever, rheumatic arthritis, scabies, pediculosis, impetigo
DIABETES MELLITUS
Type 1 Diabetes
❏ insulin dependent, most common type in childhood
❏ prevalence: 1 in 400-500 children under 18 years of age
❏ etiology: genetic predisposition and environmental trigger
• autoimmune destruction of ß-cells of the pancreas (antibodies directed towards glutamic acid
decarboxylase have been identified)
• a non-immune variation has been described
❏ classic presentation: polyuria, polydipsia, abdominal pain, weight loss, and fatigue
❏ 25% present in diabetic ketoacidosis (DKA)
Management of Uncomplicated Diabetes
❏ insulin, blood glucose monitoring
❏ young children more susceptible to CNS damage with hypoglycemia with fewer benefits from tight
control, hence target glucose range higher at 6-12 mmol/L (110-220 mg/dL)
❏ increasingly tighter control in older children, 4-8 mmol/L (70-140 mg/dL)
❏ meal plan, exercise, education, psychosocial support
Complications of Diabetes
❏ hypoglycemia
• cause: missed/delayed meals, excess insulin, increased exercise
• complications: seizures, coma
• must have glucagon kit for quick injections
❏ hyperglycemia
• cause: infection, stress, diet-to-insulin mismatch
• complications: risk of DKA, long-term end-organ damage
❏ DKA
• cause: new-onset diabetes, missed insulin doses, infection
• medical emergency: most common cause of death in children with diabetes (attributed to cerebral
edema)
❏ long-term complications (retinopathy, nephropathy, neuropathy)
• usually not seen in childhood (often begin 5 years after presentation or 3-5 years after puberty)
Type 2 Diabetes
❏ incidence increasing dramatically in children: up to 7.2 in 100,000
❏ especially prevalent among North American Aboriginals, Africans, Asians, Hispanics
Mature Onset Diabetes of the Young (MODY)
❏ autosomal dominant inheritance
87
Group A Beta Hemolytic Streptococcus will release toxin and enters circulation
Group A Beta Hemolytic Streptococcus is an anaerobic organism and will stay at the left side of
the heart or the mitral valve as an ASCHOFF BODIES
ASCHOFF BODIES – round nodules with multi nucleated cell and fibroblast that stays in the
miral valve
Left sided heart failure because of mitral stenosis due to increase in the size of Aschoff Bodies
Diagnostic Exam: JONE’S CRITERIA
Major Minor
Polyarthritis – multi Low grade fever
joint pain
Athralgia – joint pain Diagnostic Exams
CHOREA/ Antibody
Sydenhamm’s C reactive protein
Chorea/ St. Vitous ESR
Dance – involuntary, Anti Streptolysin Titer
purposeless
Carditis – signs of
tachycardia
Erythema
Marginatum –
macular rashes
Subcutaneous
nodules
Presence of 2 major or 1 major and 2 minor plus a history of
sore throat will confirm diagnosis
Management
o Bed rest
o Avoid contact sports
o Throat swab for C & S
o Antibiotics – purpose is to prevent recurrence
o Aspirin Therapy or salicylates – act as an anti-inflammatory agent in RHD
o Side effect: Reye’s Syndrome encephalopathy accompanied by fatty infiltration of the
organs such as the heart and liver
88
• outcome of most children is favourable
• best prognosis in young female with pauciarticular disease
Systemic (Still's Disease)
❏ high spiking fever (= 38.5°C) for at least 2 weeks
❏ extra-articular features: erythematous “salmon-coloured” maculopapular rash, lymphadenopathy,
hepatosplenomegaly, leukocytosis, thrombocytosis, anemia, serositis (pericarditis, pleuritis)
❏ arthritis may occur weeks to months later
Pauciarticular
❏ Type I
• most common subtype, peak age 2 years
• usually involves large joints: knee, ankle or elbow, rarely shoulder or hip
• often resolves without permanent sequelae
• prone to chronic iridocyclitis and uveitis, which, if untreated may lead to permanent visual damage
• slit lamp exam should be done early in child presenting with joint swelling and then every 3 months if
ANA positive
❏ Type II
• at onset, there is an asymmetrical peripheral arthritis usually confined to joints below the waist
(hip, knees, ankles, feet)
• enthesitis (inflammation at tendon insertion sites) of Achilles tendon, patellar tendon, plantar fascia
• seronegative spondyloarthropathy may develop later in life
• family history of spondyloarthropathy, IBD or psoriasis
Polyarticular
❏ RF Negative
• often involves small joints of hands and feet, temporomandibular joint, sternoclavicular joint,
distal interphalangeal joints (DIP), cervical spine
• patients who are ANA positive are prone to chronic uveitis
❏ RF Positive
• similar to the aggressive form of adult rheumatoid arthritis
• severe, rapidly destructive, symmetrical arthritis of large and small joints
• associated with rheumatoid nodules at pressure points (elbows, knees)
• unremitting disease, persists into adulthood
Management
❏ children may complain very little about their pain and disability
❏ night splints to prevent development of contractures secondary to guarding and disuse
❏ exercise to maintain range of motion (ROM) and muscle strength
❏ multidisciplinary approach with OT/PT, social work, orthopedics, ophthalmology, rheumatology
❏ first line drug therapy: NSAIDs
❏ other options
• methotrexate
• corticosteroids - intra-articular, systemic, or topical eye drops
• hydrochloroquine
• sulfasalazine
• gold
• new biologic agents (etanercept: anti-TNF)
SCABIES
Infestation of Sarcoptes scabiei (itch mite)
F mite burrows into epidermis, lay eggs & dies after 4-5 wksThe eggs hatch in 3-5 days, larvae
89
mature & complete life cycle
Contagious during course of infestation via direct contact
Signs & Symptoms
Intense pruritus esp. at night
(+) burrows (fine grayish red lines) on skin
Management
Topical scabicides:
Lindane cream (Kwell, Scabene) should not be used for <2 y/o: risk of neurotoxicity and
seizures; Crotamiton (Eurax)
Warm soap-and-water bath
Dry and cool skin
Apply scabicide lotion; leave for 8-14 hrs before rinsing
Permethrin 5% (Elimite): cream is massaged thoroughly and gently from head to soles;
avoid contact with eyes
Treat all household members & close contacts
Strict handwashing
Change all clothing & bedding OD, wash in detergent with hot water, hot dryer & iron before
reuse
Seal nonwashable toys & other items in plastic bag for 4 days
IMPETIGO
Highly infectious, caused by Group A b-hemolytic Streptococcus, possibly Staph aureus
Predisposing factor: heavy infestation of Pediculosis capitis then pick nose
Papulovesicular lesions (face, around mouth, hands, neck, extremities) surrounded by
90
localized erythema becoming purulent and ooze, forming a honey-colored crust
Cx: AGN
Management
Contact isolation (Communicable for 48hrs without treatment)
Skin care
■ Allow lesions to dry by air exposure
■ Daily bathing with antibacterial soap (pHisoHex)
■ Warm compress 2-3X/day to remove crusts
■ Use of skin emollients to prevent cracking
■ Proper hygiene
■ Strict handwashing
■ Use separate towels, linens, dishes (washed separately with detergent in hot
water)
■ Oral antibiotics (Penicillin)
■ Antibiotic ointment (Mupirocin)
SCOLIOSIS
Lateral (sideways) curvature of the spine
May involve all or only a portion of the spinal column
Types
Functional scoliosis (in response to another condition)
o Occurs as a compensatory mechanism
o Usually due to unequal leg lengths
o Created a pelvic tilt that is C-shaped
o Must correct the initial problem
A lift placed in one shoe
Remind the child to maintain good posture (walking with book on head 3 x daily
for 10 minutes)
Sit-ups and push-ups are good exercises
Structural scoliosis
o Permanent curvature of the spine with damage to the vertebrae
o Spine has an S-shaped appearance
o Usually there is a family history
o 5x more common in girls than boys
o Usually peaks between 8-15 years (school age)
o Diagnosis is made on physical exam by having the child bend forward
X-rays confirm diagnosis
Therapeutic management:
91
o If spinal curve is less than 20 degrees, no therapy except close observation until the
child reaches 18 years of age)
o If greater than 20 degrees, may use braces, traction, surgery, or combination.
Other names: Sy, bad blood, the pox, lues venereal, morbus gallicus
Mode of Transmission:
Direct contact
Transplacental (after 16th week AOG)
Indirect contact with contaminated articles
Primary and secondary sores will go even without treatment but the germs continue to spread
throughout the body. Latent syphilis may continue 5 to 20 + years with NO symptoms, but the person
is NO longer infectious to other people. A pregnant mother can transmit the disease to her unborn
child (congenital syphilis).
GONORRHEA
Causative agent:
Neiserria gonorrheae
Mode of Transmission:
Highest incidence in males between 20 and 24 y/o and in females between 18 and 24.
direct contact- genitals, anus, mouth
92
A. Females
1. Up to 80% have no symptoms
2. Abnormal, thick green (or yellow) vaginal discharge
3. Frequency, burning pain on urination
4. Urethral discharge
5. Rectal pain and discharge
6. Unilateral labial pain and swelling
7. Abnormal menstrual bleeding; increased dysmenorrhea (menstrual cramps)
8. Lower abdominal discomfort
9. Sore throat
B. Males
1. 4–10% have no symptoms
2. Frequency, pain on urination
3. Burning sensation in the urethra
4. Whitish discharge from the penis (early); may appear only as a drop during erection
5. Yellow or greenish discharge from the penis (late)
6. Sore throat
Complications
A. Females: If gonorrhea goes untreated, it may lead to pelvic inflammatory disease (PID). PID
involves severe abdominal
cramps, pelvic pain, and high fever that will lead to scarring and possible blockage of the fallopian
tubes, the risk of tubal pregnancy, and infertility.
B. Males: If gonorrhea goes untreated, scar tissue may form on the sperm passageway causing pain
and sterility.
C. Females and males: The infection may spread throughout the body causing arthritis, sometimes
with skin lesions.
TRICHOMONIASIS
93
Mode of Transmission: direct contact
Males:
slight itching of penis
painful urination
clear discharge from penis
Diagnosis:
culture
CHLAMYDIA TRACHOMATIS
Transmission
Sexual contact with 2 to 3 week incubation period before symptoms present
Diagnosis
A. Evaluation may include tests to rule out candidiasis, trichomoniasis, bacterial vaginosis, gonorrhea,
syphilis, and urinary tract infection
B. Vaginal and urethral smears/ culture are examined for the Chlamydia trachomatis organism
Treatment
Drug of choice: tetracycline
Patient Education
94
A. Any sexual contacts should be advised to seek evaluation and treatment.
B. Do not have intercourse until you and any sex partner(s) have completed treatment.
C. In an untreated male or female the disease may progress to further reproductive infection with
possible tissue scarring and infertility risks.
D. Wash all sex toys, diaphragm, cervical cap with soap and water or soak in rubbing alcohol or
betadine scrub. Be sure to rinse thoroughly.
Transmission
A. Usually nonsexual.
B. Some common causes of candida overgrowth are: use of hormonal contraceptives such as birth
control pills, the patch, ring, implant; antibiotics; diabetes; pregnancy; stress; deodorant tampons and
other such menstrual products.
Diagnosis
A. Female evaluation may include vaginal examination to check for candida and rule out
trichomoniasis, bacterial vaginosis, Chlamydia, and gonorrhea.
Treatment
Patient Education
A. No intercourse until symptoms subside.
B. Continue prescribed treatment even if menses occurs, but use pads rather than tampons.
C. Ways to prevent recurrent candida (yeast) infections:
1. Bathe daily (with lots of water and minimal soap)
95
2. To minimize the moist environment Candida favors, use:
a. Cotton-crotched or cotton underwear/pantyhose (or cut out crotch of pantyhose)
b. Loose-fitting slacks
c. No underwear while sleeping
d. Remember ABC: Abstain, be faithful and condom
3. Wipe the front first and then the back after toileting.
4. Avoid feminine hygiene sprays, deodorants, deodorant tampons/ minipads, colored or perfumed
toilet paper, tear-off fabric softeners in the dryer, etc., any of which may cause
allergies and irritation.
5. Some women have found that vitamin C 500 mg 2– 4 x each day helps or taking oral acidophilous
tablets 40 million to 1 billion units a day (1 tablet).
AMENORRHEA
Definition
A. Primary amenorrhea: failure of the menses to occur by age 15
B. Secondary amenorrhea: cessation of the menses for longer than 6 months in a woman who has
established menses at least 1 year after menarche
Etiology
A. Primary Amenorrhea
1. Gonadal failure
2. Congenital absence of uterus & vagina
3. Constitutional delay
B. Secondary Amenorrhea
1. Pregnancy; breastfeeding
2. Pituitary disease or tumor; disruption of hypothalamicpituitary axis
3. Menopause
4. Too little body fat (about 22% required for menses)
5. Excessive exercise (e.g., long-distance running, ballet dancing, gymnastics, fi gure skating)
6. Rapid weight loss
7. Cessation of menstruation following use of hormonal contraception
8. Recent change in lifestyle (e.g., increase in stress, travel)
9. Thyroid disease
10. Polycystic ovary syndrome
11. Anorexia nervosa or other eating disorders
12. Premature ovarian failure, ovarian dysgenesis, infection, hemorrhage, necrosis, neoplasm
13. Asherman’s syndrome
14. Cervical stenosis—outfl ow tract anomaly
15. Medications including psychotropics
16. Chronic illness
17. Tuberculosis
History
A. What the patient presents with
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1. Absence of menstruation
2. Possible breast discharge
3. Other symptoms secondary to underlying etiology
B. Additional information to be considered
1. Careful menstrual history; pregnancy history
2. Sexual history
3. Contraceptive history
4. Medications—OTC, prescription, homeopathic, herbal
5. Sources of emotional stress
6. Symptoms of climacteric
7. Any current acute illness
8. History of chronic illness
9. Present weight, weight 1 year ago
10. Amount of daily exercise
11. Recent D&C or abortion
12. History of tuberculosis
13. Eating disorder—current or history of
Physical Examination
A. Weigh patient
B. Neck: thyroid gland (look for nodes: palpable, enlarged)
C. Breast: discharge
1. Breast examination
2. Milky, clear, dark, light, bloody, thick, thin, color
D. Vaginal examination (speculum): vagina may be atrophic and there may be no cervical mucus
E. Bimanual examination
1. Uterus: may be enlarged
2. Cervix—scarring, stenosis
3. Adnexa: ovaries may be enlarged—cystic
4. Recto-vaginal examination
F. Measure ratio of body fat to lean mass; BMI
Laboratory Examination
A. Human chorionic gonadotropin (HCG) qualitative, quantitative
B. Prolactin level
C. Thyroid stimulating hormone
D. Follicle stimulating hormone, luteinizing hormone, Dehydroepiandrosterone sulfate (DHEAS), and
serum testosterone (if patient is hirsute); hemoglobin, erythrocyte sedimentation rate
E. Papanicolaou smear
F. Microscopic examination of cervical mucus
G. TB test if no history
H. Consider pituitary function assessment, ultrasound, CAT scan, MRI, hysterosalpingography,
hysteroscopy after consultation with a physician
I. GnRH stimulation test
Treatment
A. If breast discharge is present, do not wait: do work-up as per breast discharge protocol.
B. If human chorionic gonadotropin (HCG) and prolactin levels are within normal limits, pregnancy test
is negative, the nurse practitioner may give Medroxyprogesterone acetate (Provera®) 5–10 mg per
day × 5–10 days.
1. If no withdrawal bleed in 3–7 days after progestin, consider follicle stimulating hormone and
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luteinizing hormone assays
2 weeks after Provera. Try oral estrogen 1.25–2.5 mg to prime the endometrium (estropipate) daily for
21–25 days; if no bleeding, add progestin during last 5–10 days of estrogen. If no withdrawal bleed,
refer to physician.
2. If woman wishes to start oral or other hormonal contraceptive and has no withdrawal bleed from
Provera, repeat HCG if indicated and start oral contraceptives or other hormonal method the following
Sunday regardless of brand of hormonal contraceptive used. If no withdrawal bleed after first cycle,
consult with physician.
3. If woman wishes to start oral or other hormonal contraceptives and has withdrawal bleed from
Provera, start contraceptive after start of bleed; if Provera is not completed by that time, discontinue
and discard remainder (some clinicians have woman complete Provera).
4. If withdrawal bleed occurs with Provera, then no menses for 2 months following the bleed, possible
consult with physician, then give Provera 10 mg × 10 days every 2 months. If sexually active, an HCG
must be run prior to taking medication each time.
5. If woman has a history of uterine infection or trauma to the uterus through multiple curettages
(postpartum or postabortion), or if the work-up is negative and there is no response to Provera, referral
for further evaluation (hysterosalpingography; hysteroscopy to lyse adhesions; estrogen to restore
endometrium).
6. Instruct woman to complete 10 days of Provera even if withdrawal bleed begins, unless starting oral
or other hormonal contraceptive as indicated prior in 3.
Complications
A. Inability to conceive
B. Sequelae of underlying cause
DYSMENORRHEA
Definition
A. Primary dysmenorrhea is the occurrence of painful menses usually beginning within several years
of menarche and in the absence of any pelvic pathology but may occur at any time during childbearing
years.
B. Secondary dysmenorrhea is painful menstruation due to an identifiable pathologic or iatrogenic
condition, which may be readily identifiable on the basis of the history and the findings in a physical
examination.
Etiology
A. Primary dysmenorrhea
1. Caused by prostaglandins produced in the uterine lining and released into the bloodstream as the
lining is shed, causing smooth muscle contraction, nausea, and/or diarrhea
B. Secondary dysmenorrhea
1. Extrauterine causes
a. Endometriosis
b. Tumors
1) Subserosal leiomyomata
2) Malignancies
3) Pelvic tumors
c. Ovarian cysts
d. Pelvic inflammatory disease
2. Intrauterine causes
a. Adenomyosis
b. Endometriosis
c. Intramural leiomyomata
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d. Polyps
1) Endometrial
2) Cervical
e. Presence of an intrauterine device
f. Cervical stenosis
g. Endometritis
History
A. What the patient may present with
1. Regular, recurrent pain may occur monthly, prior to menses, or with menses
a. Abdominal pain
b. Pelvic pain
c. Severe backache
2. Nausea, diarrhea, or constipation
3. Weakness
4. Dizziness
5. Weight gain
6. Breast tenderness
7. Backache
Physical Examination
A. Vital signs
1. Blood pressure
2. Pulse
3. Temperature, if symptoms are present at time of visit
4. Weight
B. Vaginal examination (speculum): cervix, cervical pathology
C. Bimanual examination
V. Laboratory Examination
A. Chlamydia (if not done within 1 year or woman has a new sexual partner), or cervical picture
indicates, or if severity of symptoms has increased
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B. Gonorrhea culture (same as Chlamydia)
C. Wet mount
Treatment
A. Medication
1. Ibuprofen (Motrin®) 400 mg 4 times a day, 200–400 mg every 4–6 hours (max. 1.2 grams/day)
2. Mefenamic acid (Ponstel®) 250 mg, 2 tablets immediately and one every 6 hours
3. Naproxen (Anaprox®) 275 mg, 2 immediately and 1 every 6–8 hours (no more than 5 tabs 1.375
grams per day); Aleve® 200 mg every 8–12 hours
4. Naprosyn 500 mg every 12 hours or 250 mg every 6–8 hrs. (max. 1.25 grams 1st day then 1.0
grams/day)
5. Anaprox DS® 550 mg = one every 12 hours
6. Aspirin with codeine 1–2 tablets every 4 hours as needed
7. lbuprofen (Advil®) 200 mg, 2 tablets every 4–6 hours (max. 1.2 grams/day) (OTC),
8. Flurbiprofen (Ansaid®) 100 mg orally twice or three times a day
9. Meclofenamate (Meclomen®) 1 tab (100 mg) every 6 hours prn
10. Other OTC analogues
11. Oral or possibly other hormonal contraceptive (to produce anovulatory state)
B. Other measures
1. Reassurance
2. Refer to premenstrual syndrome guidelines for diet, exercise, and vitamin recommendations
3. Heating pad; microwave pad (fi lled with nonpopping corn or buckwheat)
Complications
May occur with failure to recognize presence of entity as described in differential diagnosis that results
in lack of appropriate treatment.
OBESITY
weight > 20% greater than expected for age and height
body mass index (BMI) tends to vary and increases with age; not used prior adolescence
history: diet, activity, family heights and weights, growth curves
physical examination: may suggest secondary cause such as Cushing syndrome
caliper determination of fat is more sensitive than weight
organic causes such as genetics, or endocrine are rare
complications:
association with hypertension, increased LDL, type 2 diabetes
Management
encouragement and reassurance
diet: qualitative changes; do not encourage weight loss but allow linear growth to catch up
increase activity, change meal patterns
refer to dietitian, counseling
SUICIDE
to end oneself
suicide is a psychiatric emergency
depressed individuals usually resort to suicide\associated with deterioration of functioning and
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ideation
high levels of stress and poor coping are related to suicide
History
time suicide was attempted and method
quantity of pills; motives for attempt
alcohol intake; where was substance obtained
precipitating factor for suicide (death, divorce, humiliating event)
further desire to commit suicide; is there a definite plan? Was the action impulsive or planned
Past History
previous suicide attempts or threats
antidepressant use
Social history: personal or family history of emotional, physical or sexual abuse; alcohol or drug abuse;
sources of emotional stress; availability of other dangerous medications or weapons
Physical Examination
level of consciousness, delirium, presence potentially dangerous objects (belts and shoe
laces)
hypotension, bradycardia are noted
signs of trauma, ecchymoses, pupil size and reactivity, mydriasis and nystagmus
abnormal respiratory patterns
arrhythmias, murmurs
decreased bowel sounds, tenderness
wounds and fractures
mental status exam, tremors, clonus
Laboratory: electrolytes, BUN, creatinine, glucose, Alcohol and acetaminophen levels, chest x-ray,
urine toxicology screen
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FAMILY
A. The family with health problems
1. Assessment of the family capability to perform health tasks
- involves a set of actions by which the nurse measures the status of the family as a client, its
ability to maintain itself as a system and functioning unit, its ability to maintain wellness, prevent,
control or resolve problems in order to achieve health and well-being among its members.
Two Phases:
is a process whereby existing and potential health conditions or problems of the family are
determined.
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Members of the household and relation to the head of the family
Demographic data- age, sex, civil status, position in the family
Place of residence of each member- whether living with the family or elsewhere
4. Risk factor assessment indicating presence of major and contributing factors and contributing
modifiable risk factors for healthy lifestyles, cigarette smoking, elevated blood lipids, obesity,
diabetes mellitus, inadequate fiber intake, stress, alcohol drinking and other substance abuse
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Physical assessment indicating presence of illness states
Results of laboratory/ diagnostic and other screening procedures supportive of assessment findings
Examples include:
immunization status of family members
healthy lifestyles
adequacy of:
rest and sleep
exercise
use of protective measures- e.g. adequate footwear in parasite-infested areas;
relaxation and other stress management activities
Use of promotive- preventive health services
b. SECOND-LEVEL ASSESSMENT
the nature or type of nursing problems that the family encounters in performing the health tasks with
respect to a given health condition or problem, and the etiology or barriers to the family’s assumption
of the tasks.
II. Inability to make decisions with respect to taking appropriate health action.
III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk
member of the family.
IV. Inability to provide a home environment conducive to health maintenance and personal
development.
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Predisposing factors -
personal preferences that a group or individual brings to a behavioral choice. Includes KAP
(Knowledge, Attitude, Practice), values, existing skills, perceived needs and abilities
Enabling factors
facilitate the performance of an action. Environmental conditions- availability, accessibility affordability
of resources. New skills needed to carry out a behavioral or environmental change
Reinforcing factors
positive and negative consequence of an action, including social support, peer influences, advice and
feedback of health care providers and physical consequences of behavior. The determine whether the
individual receives positive feedback for the behavior and is socially supported after behavior
5. Tool of analysis
Social determinants of health
THE FAMILY CARE PLAN – is the blueprint of the care that the nurse designs to systematically
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minimize or eliminate the identified health and family nursing problems through explicitly formulated
outcomes of care ( goals and objectives) and deliberately chosen of interventions, resources and
evaluation criteria, standards, methods and tools.
2. It should be based on clear, explicit definition of the problems. A good nursing plan is based on
a comprehensive analysis of the problem situation.
3. A good plan is realistic.
4. The nursing care plan is prepared jointly with the family. The nurse involves the family in
determining health needs and problems, in establishing priorities, in selecting appropriate
courses of action, implementing them and evaluating outcomes.
5. The nursing care plan is most useful in written form.
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The plan for evaluating.
Criteria/Outcomes Based on Objectives of Care
Methods/Tools
2. Programs and services that focus on primary & secondary prevention of communicable and
non-communicable diseases
a. Examples of DOH programs:
DOH
hospital services
direct hospital service delivery
hospital development services
Goal: To reduce prevalence and mortality from TB by half by the year 2015 (Millenium
Development Goal)
Targets: 1. Cure at least 85% of the sputum smear (+) patients discovered
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2. Detect at least 70% new sputum smear (+) TB cases
KEY POLICIES
Case Finding
DSSM shall be the primary diagnostic tool in NTP case finding
No TB Dx shall be made based on CXR results alone
All TB symptomatic shall be asked to undergo DSSM before treatment
Only contraindication for sputum collection is hemoptysis
PTB symptomatic shall be asked to undergo other tests (CXR and culture), only after three
sputum specimens yield negative results in DSSM
Only trained med techs / microscopists shall perform DSSM
Passive case finding shall be implemented in all health stations
*Treatment: Domiciliary treatment – preferred mode of care
DSSM – basis for treatment of all TB cases
*Hospitalization is recommended: massive hemoptysis, pleural effusion, military TB, TB meningitis,
TB pneumonia, & surgery is needed or with complications
*All patients undergoing treatment shall be supervised
*National & LGUs shall ensure provision of drugs to all smear (+) TB cases
*Quality of fixed-dose combination (FDC) must be ensured
*Treatment shall be based on recommended category of treatment regimen
Tuberculosis
Other names: Koch's disease, consumption, phthisis, weak lungs
Causative agent: Mycobacterium tuberculosis, TB bacillus, Koch's bacillus, M. bovis (rod-shaped)
Mode of Transmission
Airborne- droplet
Direct invasion through mucous membranes and breaks in the skin (very rare)
Incubation period: 4-6 weeks
Most hazardous period for development of clinical disease is the first 6-12 months
Sign and Symptoms
Any combination of the following symptoms are suggestive of TB:
cough for two weeks or longer
chest and back pains for one month or more
progressive loss of weight
fever for one month or more
hemoptysis or blood streaking at any time
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Diagnostic test:
· Sputum examination or the Acid-fast bacilli (AFB) / sputum microscopy
1. Confirmatory test
2. Early morning sputum about 3-5 cc
3. Maintain NPO before collecting sputum
4. Give oral care after the procedure
5. Label and immediately send to laboratory
6. If the time of the collection of the sputum isunknown, discard
· Chest X-ray is used to:
1. Determine the clinical activity of TB, whether it is inactive (in control) or active (ongoing)
2. To determine the size of the lesion:
a. Minimal – very small
b. Moderately advance – lesion is < 4 cm
c. Far advance – lesion is > 4 cm
· Tuberculin Test – purpose is to determine the history of exposure to tuberculosis
Other names:
Mantoux Test – used for single screening, result interpreted after 72 hours
Tine test – used for mass screening read after 48 hours
Interpretation:
0 - 4 mm induration – not significant
5 mm or more – significant in individuals who are considered at risk; positive for patients who
are HIV-positive or have HIV risk factors and are of unknown HIV status, those who are closecontacts
with an active case, and those who have chest x-ray results consistent with tuberculosis.
10 mm or greater – significant in individuals
who have normal or mildly impaired immunity
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R&I : 1 tab each E : 2 tabs needed) intake)
SIDE EFFECTS:
Ethambutol
· Optic neuritis
· Blurring of vision
(Not to be givento
children below 6 y.o.
due
to inability to complain
blurring of vision)
· Inability to recognize
green from blue
Streptomycin
· Damage to 8th CN
· Ototoxic
· Tinnitus
· nephrotoxic
PREVENTION
· Respiratory precautions
· Cover the mouth and nose when sneezing to avoid mode of transmission
· Give BCG
BCG is ideally given at birth, then at school entrance. If given at 12 months, perform tuberculin testing
(PPD), give BCG if negative.
· Improve social conditions
· Cover the mouth and nose when sneezing to avoid mode of transmission
· Give BCG BCG is ideally given at birth, then at school entrance. If given at 12 months, perform
tuberculin testing (PPD), give BCG if negative.
· Improve social conditions
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* abnormal CXR suggestive of TB
* Lab findings suggestive or indicative of TB
- for children with exposure to TB
* a child w/ exposure to a TB registered adult patient shall undergo physical exam and tuberculin
testing
* a child with productive cough shall be referred for sputum exam, for (+) sputum smear child, start
treatment immediately
* TB asymptomatic but (+) tuberculin test and TB symptomatic but (-) tuberculin test shall be referred
for CXR examination
1. Assess the child or young infant by checking first the danger signs (or possible bacterial infection in
young infant)
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Taking the history
Presenting Complaint: Why do you bring the child?
History of Present Illness: symptoms of the child, including the personal, family, social and
environmental history
include counseling / health education related to symptoms / problems identified
Informant: parent or caregiver
checking nutrition and immunization
Younger infants: history of pregnancy and birth
infant and younger child: feeding history
late childhood: milestones of development and behavior
checking for other problems
Physical examination
comprehensive examination
systematic approach
Points to remember during clinical examination:
do not upset the child unnecessary. If child is distressed, let the mother settle the child first or
ask her breastfeed child
leave the child in the arms of mother or carer
observe as many signs as possible before touching the child. These include
Is the child alert, interested and looking about?
does the child appear drowsy?
Is the child irritable?
is the child vomiting?
Is the child able to suck or breastfeed?
Is the child cyanosed or pale?
Are there signs of respiratory distress?
Does the child use auxillary muscles
is there lower chest wall indrawing?
Does the child appear to breathe fast?
Count the respiratory rate
Laboratory tests
are based on history and examination
examples are Hgb/ packed RBCs, blood smear (malaria), blood glucose, CSF, urinalysis, blood
typing and crossmatching, HIV testing, pulse oximetry, x-ray, blood cultures, fecalysis
bilirubin: sick newborns (<1 week)
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lethargy or unconsciousness
abnormally sleepy or difficulty to awaken
vomiting everything taken
A child with ANY of the Danger Signs has a serious problem needs URGENT referral to the
HOSPITAL
ASK: is the child able to drink or breastfeed?
◦ A child has this sign if he/she is too weak to drink and is not able to suck or swallow when
offered a drink. Look to see the child's response
◦ Breastfeeding children may have difficulty sucking when their nose is blocked, clear it first
ASK: Does the child vomit everything?
◦ A child who is not able to hold on anything down at all has the sign “vomits everything”
A child with ANY of the Danger Signs has a serious problem and needs URGENT referral to the
hospital
ASK: Has the child had convulsions?
◦ Use the term for convulsions like “fits”, “spasm”, or “jerky movements” which the mother
understands
LOOK: See if the child is abnormally sleepy or difficult to awaken
◦ an abnormally sleepy child is drowsy and does not show interest in what is happening
around him/her
◦ he does not look at his mother or watch your face when you talk
◦ he may stare blankly and does not notice what is going on around him
◦ he does not respond when she is touched, shaken or spoken to
Clinical Assessment
Three key clinical signs are used to assess a sick child with cough or difficult breathing
1. Respiratory rate, which distinguishes children who have pneumonia from those who do not;
2. lower chest wall indrawing, which indicates severe pneumonia; and
3. stridor, which indicates those with severe pneumonia who require hospital admission
It is more specific than “intercostal indrawing,” which concerns the soft tissue between the ribs without
involvement of the bony structure of the chest wall
Chest indrawing should only be considered present if it is consistently present in a calm child.
Agitation, a blocked nose or breastfeeding can all cause temporary chest indrawing.
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Stridor is a harsh noise made when the child inhales (breathes in). Children who have stridor when
calm have substantial risk of obstruction and should be referred.
Wheezing is heard when the child exhales (breathes out). This is not stridor. A wheezing sound is
often associated with asthma.
In some cases, especially when a child has wheezing when exhaling, the final decision on presence or
absence of fast breathing can be made after a test with a rapid acting bronchodilator (if available)
Give vitamin A
Treat the child to prevent low
blood sugar
refer urgently to hospital
Fast breathing Pneumonia Give an appropriate antibiotic for
5 days: cotrimoxazole/
amoxicillin
soothe the throat and relieve the
cough with a safety remedy
advice mother when to return
immediately
follow up in 2 days
All sick children should be check for fever. It may be caused by minor infections, but may also
be the most obvious sign of a life-threatening illness, particularly malaria (especially lethal
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malaria P. falciparum), or other severe infections, including meningitis, typhoid fever, or
measles
When diagnostic capacity is limited, it is important first to identify those children who need
urgent referral with appropriate pre-referral treatment (antimalarial or antibacterial)
Fever
Clinical Assessment
a. Body temperature should be checked
b. children are considered to have fever if their body temperature is above 37.5 C axillary (38 C
rectal)
c. In the absence of a thermometer, children are considered to have fever if they feel hot. Fever also
may be recognized based on a history of fever.
d. a child presenting with fever should be assessed for:
1. Stiff neck. A stiff neck may be a sign of meningitis, cerebral malaria or another very febrile disease.
If the child is conscious and alert, check stuffiness by tickling the feet, asking the child to bend his/her
neck to look down or by very gently bending the child's head forward. It should move freely.
2. Risk of malaria and other endemic infections. In situations where routine microscopy is not
available or the results may be delayed, the risk of malarial transmission must be defined.
A high malaria risk setting is defined as situation in which more than 5 percent of cases of febrile
disease in children age 2 to 59 months are malarial disease.
A low malarial risk setting is a situation where fewer than 5 percent of cases of febrile disease in
children age 2-59 months are malarial disease, but in which the risk is not negligible.
If malaria transmission does not normally occur in the area, and imported malaria is not uncommon,
the setting is considered to have no malaria risk.
Runny nose. When malaria is low, a child with fever and a runny nose does not need an antimalarial.
This child's fever is probably due to a common cold.
4. Duration of fever. Most fevers due to viral illness go away within a few days. A fever that has
been present everyday for more than five days can mean that the child has a more severe
disease such as typhoid fever. If the fever has been present for more than five days, it is
important to check whether the fever has been present every day.
5.
Classification of Fever
- any danger sign or Very severe febrile disease - give first dose of quinine
- stiff neck - give first dose of appropriate
- fever (by history or feels hot or Malaria antibiotic
temperature 37.5 C or above - treat the child to prevent low
blood sugar
- NO runny nose and NO Malaria - treat the fever
measles and NO other causes of - REFER IMMEDIATELY to the
fever nearest hospital
- Advise follow-up in two days
- if fever > 7 days REFER
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- Measles PRESENT - advice mother when to return
- Other causes of fever - advise mother to return in two
PRESENT days if fever persists
- obvious causes of fever Possible bacterial infection
- NO obvious causes of fever Uncomplicated fever
Treatment of malaria
Oral antimalarials
Oral anti-malarials vary by country.
Chloroquine and Sulfadoxine-pyrimethamine are the first-line and second-line drugs in many
countries. Chloroquine is given for three days.
The dose is reduced on the third day unless the child weighs less than 10 kg.
If this is a case, the child should be given the same dose on all three days.
5. Measles. Considering the high risk of complications and death due to measles, children with
fever should be assessed for signs of current or previous measles (within the last three
months).
Measles.
Other complications (usually nonfatal) include conjuntivitis, otitis media, and mouth ulcers. Significant
disability can result from measles including blindness, severe malnutrition, chronic lung disease
(bronchiectasis and recurrent infection), and neurologic dysfunction. (WHO. Technical basis for the
case management of measles. Document WHO/EPI/95. Geneva, WHO, 1995.
- Detection of acute (current) measles is based on: fever with a generalized rash.
Plus at least one of the following signs:
1. red eyes
2. runny nose or cough
3. cough
The mother should be asked about the occurrence of measles within the last three months (recent
measles)
Measles:
etiology: Measle virus (Paramyxovirus)
Clinical manifestations:
fever
cough
coryza
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conjunctivitis
erythematous maculopapular rash
koplik spots
Epidemiology:
direct contact with infectious droplets
Assess a child for possible complications: if the child has measles currently or within the last three
months.
Measles damages the epithelial surfaces and the immune system, and lowers vitamin A levels.
Despite great success in improving immunization coverage in many countries, substantial numbers of
measles cases and deaths continue to occur.
Although the vaccine should be given at 9 months of age, immunization does not take place (because
of false contraindications, lack of vaccine, or failure of cold chain), or is delayed. In addition, many
measles cases occur early in a child's life (between 6 and 8 months of age), especially in urban and
refugee populations).
Classification of Measles
Classify Management
- clouding of cornea SEVERE COMPLICATED - Give vitamin A
- deep/ extensive mouth ulcers MEASLES - give first dose of appropriate
antibiotic
- clouding of cornea or pus
draining, apply tetracycline
- REFER IMMEDIATELY to the
nearest hospital
- pus draining from the eye MEASLES WITH EYES OR - give vitamin A
- mouth ulcers MOUTH COMPLICATIONS - apply tetracycline if pus
draining from eye
- apply gentian violet for mouth
ulcers
- follow-up in 2 days
- measles now or within the last MEASLES - give vitamin A
3 months - Follow-up in 2 days
Before classifying fever, check for the other obvious causes of fever (e.g. ear pain, burn, abscess ,
etc)
Children with high fever, defined as an axillary temperature greater than 39.5 C or rectal greater tha 39
C should be given a single dose of paracetamol to combat hyperthermia.
If other endemic infections with public health importance for children under 5 are present in the area
(e.g. dengue hemorrhagic fever or relapsing fever), their risk should be also considered.
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etio: dengue virus (types 1-4)
Clinical manifestations:
fever (27 days)
+/- rash
hemorrhagic manifestation
> + torniquet test
> nose bleeding
> tarry stools
Myalgia
Polyarthritis
Grading:
Gr. I: Fever + non-specific constitutional S/Sx
Gr. II: Gr. I + spontaneous bleeding
Gr. III: Gr. II + circulatory failure
Rapid and weak pulse
Narrowing of pulse pressure
Hypotension
Cold and clammy skin
Restlessness
Signs of Shock:
Cold clammy extremities
Slow capillary refill
Typhoid Fever
Etio: S. typhi
S. paratyphi
Clinical Manifestation:
Fever
Constipation/ diarrhea
Abdominal pain
Anorexia
Vomiting
Headache
Hepatosplenomegaly- 2nd week
Rose spots
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2 main reasons for routine assessment of nutritional status in sick children
1. to identify children with severe malnutrition who are at increased risk of mortality and need urgent
referral to provide active treatment
2. to identify children with sub-optimal growth resulting from ongoing deficits in dietary intake plus
repeated episodes of infections and who may benefit from nutritional counseling and resolution of
feeding problems
Clinical Assessment
Visible severe wasting
- shoulders, arms, buttocks, legs, ribs
- marasmus
Anemia
- treated with oral iron
- child should be seen every 2 weeks (follow-up)
- no response after 2 months, referred hospital for further assessment
- in areas where there is evidence that hookworm, whipworm & ascaris are the main causes
of malnutrition, regular deworming with mebendazole at 500mg every 4-6 months is
recommended
Immunization
Birth – BCG
6 weeks after birth – DPT 1, OPV 1, Hep B 1
10 weeks after- DPT 2, OPV 2, Hep B 2
14 weeks after – DPT 3, OPV 3, Hep B 3
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9 months- measles
A. No dehydration
condition- well, alert
mouth and tongue- moist
eyes- normal
thirst- drinks normally, not thirsty
tears present
skin pinch- goes back quickly
TREATMENT PLAN A- home TTT
ORESOL TREATMENT
Age Amount of ORS to give after Amount of ORS to provide for
each loose stool use at home
< 24 months 50- 100 ml 500 ml/day
2-10 years 100-200 ml 1000 ml/day
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10 years up As much as wanted 2000 ml/day
B. SOME DEHYDRATION
Condition- restless, irritable
mouth and tongue- dry
eyes- sunken
thirst- thirsty, drinks eagerly
tears- absent
skin pinch- goes back slowly
WEIGH PT, TTT. Plan B
C. SEVERE DEHYDRATION
Condition – lethargic or unconscious; floppy
Eyes- very sunken and dry
Tears- absent
Mouth and tongue- very dry
Thirst- drinks poorly or not able to drink
Skin pinch- goes back very slowly
TTT PLAN C- ttt slowly
1. Bring pt to hospital
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2. IVF- lactate Ringers solution or normal saline
3. Reassess pt every 1-2 hrs
4. Give ORS as soon as the pt can drink
1. To prevent dehydration, give home fluids “am” as soon as diarrhea starts and if dehydration is
present, rehydrate early, correctly and effectively by giving ORS
2. For undernutrition, continue feeding during diarrhea especially breastfeeding
Interventions to prevent diarrhea
1. breastfeeding
2. improved weaning practices
3. use of plenty of water
4. handwashing
5. use of latrines
6. proper disposal of stools of small children
7. measles immunization
Risk of severe diarrhea 10-30x higher in bottle-fed infants than in breastfed infants
Advantage of breastfeeding in relation to CDD
1. Breastmilk is sterile
2. presence of antibodies protection against diarrhea
3. intestinal flora in BF infants prevents growth of diarrhea causing bacteria
Breastfeeding decreases incidence rate by 8-20% and mortality by 24-27% in infants under 6 months
of age
4-6 months- soft mashed foods 2x a day
6 months- variety of foods 4x a day
4. Measles immunization
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Nursing that considers the health of the family as a unit in th, values and productivity of individual
family members.
c. Standards of care & interventions that address acute and chronic illness
chronic illness
has a gradual onset of symptoms that lasts for an extended and relatively long period of time
e.g. typically six months or longer
a. Health promotion – not disease oriented, motivated by personal, positive approach to wellness
seeks to expand positive potential for health
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human development across lifespan
methods to prevent disease: immunization, screening when risk factors are present
early diagnosis and treatment
health promotion applies to all members of the family, with regard to the following
lifestyle behaviors
diet and exercise
sleep
weight
Nurses role
model healthy lifestyle
facilitate client involvement
teach self-care strategies
assist clients to increase levels of health
educate clients to be effective health care consumers
assist patients to develop and choose health promoting options
guide development of effective problem-solving and decision making
reinforce client's personal and family health promoting behaviors
advocate in the community for changes that promote a healthy environment
b. Disease prevention
. illness or injury specific
. motivated by avoidance of illness
seeks to thwart the occurrence of insults to health and well-being
Provided at-
health care/ RHU
Brgy, Health stations
main health center
community hospital and health center
private and semi-private agencies
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c. Curative/ Secondary level of disease prevention
prevention of complications thru early diagnosis and treatment
Screening methods:
mass screening
case-finding
contact tracing
multiphasic- screening
surveillance
Characteristics of an ideal screening test:
sensitivity
specificity
- when hospitalization is deemed necessary and referral is made to emergency (now district),
provincial or regional or private hospitals
Goals
prevention of complications/ disabilities, etc.
restraining in lost skills
learning new skills
bowel/bladder retraining
adaptive devices for assisting with activities of daily living
ambulation devices and transfer aids
ROM
prosthetic devices
body mechanics
cast care
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2. Bio-behavioral interventions and holistic care for individuals & Family with specific
problems in oxygenation, fluid and electrolyte balance, metabolic and endocrine function
3. Chest tubes
pressure of H2O is determined by the length of the tube immersed
2 bottle drainage- drainage bottle is segmented
works with gravity
2. Cascade Cough
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Take slow, deep breath and hold for 2-3 seconds, then open mouth and perform a series of
cough; through the breath
rationale- promotes airway clearance and a potent airway in clients with large volumes of
sputums
3. Huff Cough
while exhaling, opens the glottis by saying the word “huff”
rationale- stimulates a natural cough reflex effective only for clearing airway
4. Quad Cough
push abdominal muscles inward and upward towards the diaphragm while the client maximally
exhales causing cough
indication- for clients w/o abdominal muscle control e.g. Spinal cord injury
Oxygen therapy
highly combustible gas, tasteless, colorless, odorless; will not spontaneously burn or cause an
explosion but will cause a fire to ignite if it comes in contact with a spark
nursing implications- educate client about dangers; observe necessary precautions
o “no smoking” sign at room door and over the bed
o Avoid flames in the area
o Electrical equipment in room should be functioning correctly and properly grounded
o Avoid using oils in the area or in handling oxygen equipment; oil can ignite
spontaneously in the presence of oxygen
(Supply of oxygen)
o Tanks with regulators to control the amount of oxygen delivered; prime tank first before
connecting to regulator to remove dust and other particles
o Permanent wall piped system
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hypoxic drive- will stimulate breathing of people with COPD
Artificial Airways:
Emphasize roles of nurses in making sure these adjuncts are in place and patent
1. Nursing History: identify potential or actual risk factors that increase the client's chances of
fluid, electrolyte and acid-base imbalances
2. physical examination: identify manifestations of specific fluid, electrolyte and acid-base imbalances
Planning
in planning nursing care, client goals for a healthy adult client are the following:
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2. maintain a urine specific gravity within normal range
3. practice self-care behaviors to promote fluid, electrolyte and acid-base balance- maintain adequate
intake of fluid and electrolytes; respond appropriately to body signals of impending fluid, electrolyte or
acid-base imbalance
Arterial Blood Gases: Provide information on the status of acid-base balance and effectiveness
of ventilatory function
◦ PaCO2
◦ PaO2: measures partial pressure of oxygen in the arterial blood; 80-100 mm Hg
◦ SaO2: measures degree to which hemoglobin is saturated by oxygen; 95-99%
◦ Bicarbonate level
◦ pH
Nursing Diagnosis
Fluid and Electrolyte disturbance as the problem
when the assessment data point to fluid and electrolyte problems amenable to nursing therapy, they
can fall into three broad categories of nursing diagnosis:
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Interventions
giving full attention to whatever foods and fluids client is taking
selecting appropriate food and beverages
relaxation methods
weight managing techniques
washing hands before handling food
avoid using enemas or laxative
good hydration
maintaining rest / providing comfort
activity- avoid heavy lifting
breath sounds and ABGs
skin care
perineal exercise / bladder retraining
avoid caffeine
Precontemplation- no intention of changing behavior, and may not think they have a problem at all
Contemplation- awareness of problem, some thought of doing something about it within 6 months
Preparation- specific behaviors and thoughts involved in planning to change behavior
Action- overt change in behavior made
Maintenance- sustain behaviors and prevent relapse
Termination- copes without fear of relapse*
Relapse or Recycle
an opportunity to learn from experience and renew efforts to change
Different stages are affected by different factors, thus requiring different assistance to move to next
stage relapses part of the model-- to be expected
recognition of importance of decisional balance (pros and cons of maintaining risky behaviors vs
healthy behavior)
5. Referral system
6. Concept & principles of collaboration & advocacy
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E. Ensuring a well organized & accurate documentation & reporting
1. Standard format
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