NURS 55: CARE OF MOTHER, CHILD, FAMILY AND POPULATION GROUPS AT-RISK OR WITH PROBLEMS

This course deals with the concept of disturbances & pre-existing health problems of pregnant women and the pathologic changes during intrapartum and post partum periods. This course further deals with the common problems occurring during infancy to adolescence stage.
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 Estimated date of delivery Current gestational age Complications in pregnancy Results of laboratory tests and ultrasounds Medications used in pregnancy Presence of vaginal discharge or bleeding Amniotic fluid status Presence of fetal movement Onset and pattern of contractions 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 Descriptive term Gravida (G) Term (T) Preterm (P) Definition Number of pregnancies Number of deliveries after 37 weeks Number of deliveries after 20 weeks but before 38

weeks Abortion (A) Living (L) Number of deliveries before 20 weeks, either spontaneous or induced 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. G: 5 (currently pregnant, 3 children at home, one abortion) T: 1 (her son was born on his due date) P: 2 (her daughters were each born a month early) A: 1 (she lost a pregnancy at approximately 8 weeks) L: 3 (reports three children at home) Document as G5-1213 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

 Collect urine specimen for protein and glucose Assess for presence of edema Assess deep tendon reflexes Perform Leopolds 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 (0100%) Station (Level of presenting fetal part in relation to the ischial spines of the maternal pelvis

Note presence, color, and amount of bloody show Check status of amniotic membranes Intact Bulging Ruptured (note color, amount, and odor) 2. Screening procedures Cervical screen
According to the guidelines of the American College of Obstetrician and

Gynecologists (ACOG) and the American Cancer Society (ACS), initial cervical screen for cancer should begin 3 years after first sexual intercourse or by age 21, whichever comes first However, ACOG recommends that a visit to an obstetrician/gynecologist occur before that time for health guidance, screening, and prevention Follow-up cervical screen for low-risk women less than 30 years of age

ACOG Guidelines ACS

Annually 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 23 years

Sexually Transmitted Infections 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 longterm 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

Infection Gonorrhea

Symptoms (may be asymptomatic) Yellow-green vaginal discharge dyspareunia abdominal pain dysuria Mucopurulent discharge post coital bleeding dyspareunia abdominal pain dyuria Frothy malodorous vaginal discharge dyspareunia vaginal itching/ irritation dysuria Fatigue dark urine clay-colored stool jaundice/ abdominal pain Many subtypes exist, some associated with cervical

Detection Endocervical culture urine test

Chlamydia

Endocervical culture urine test

Trichomoniasis

Saline wet amount of vaginal discharge viewed under microscopy

Hepatitis

Serological testing

Human Papilloma Virus (HPV)

Serological testing

dysplasia Syphilis Primary chancre (painless red ulcer) Secondary Skin rash, lymphadenopathy Latent Lack clinical manifestations Tertiary Cardiac, ophthalmic, auditory involvement HIV Fever Malaise Lymphadenopathy Skin rash Serological testing Nontreponemal (RPR, VDRL) Reported quantitatively (titers) Four-fold change in titers clinically significant Effective treatment will result in falling titers False-positive possible; verify with treponemal test Treponemal (FTA-ABS) Reported as positive or negative Serological testing (Pretest and posttest counseling with informed consent required) Positive screen must be confirmed by more specific test (Western blot) Viral culture with DNA probe

Herpes Simplex Virus (HSV)

Painful, recurrent vesicular lesions Fever, malaise Enlarged lymph nodes

TORCH test series T O R Oxoplasmosis (protozoa) Thers: syphilis, varicella/ shingles, hepatitis B, hepatitis A, AIDS Ubella Avoid eating uncooked meat and handling cat litter box Rx: Zoster Immune Globulin, Penicillin Effect: if contracted early, slows down cell division during organogenesis causing congenital defects newborn can carry and transmit the virus about 12-24 months after birth DNA virus

C H

Ytomegalovirus Erpes type 2

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

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 2040) during a physical exam by a health professional; yearly after age 40 Annual mammogram starting at age 40 Instructions for Breast Self Exam (BSE) Step 1: Inspection 1. Visually inspect the breasts, looking for dimpling, lumps, skin irregularities, symmetry 2. Visually inspect in several positions; may accentuate an abnormality Hands at the side Hands above the head Hands pressed onto hips Leaning over

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 3. Diagnostic tests and laboratory exams

Diagnostic Testing during Early Pregnancy Diagnostic test Ultrasound Performed throughout pregnancy Clinical Application: - confirm and date pregnancy - verify pregnancy location - detect fetal cardiac activity - measure fetal growth - detect fetal anomalies - measure amniotic fluid index - determine fetal position - determine placental position - measure cervical length - adjunct to invasive procedures Chorionic villi sampling (CVS) Performed at 10 -12 weeks Clinical Application: Chromosomal analysis Amniocentesis Performed throughout pregnancy Clinical Applications: Chromosomal analysis is desired Measure AFP Measure bilirubin level Determine lung maturity Lecithin/Sphingomyelin Ratio (L/S Ratio) Phosphatidylglycerol (PG) L/S Ratio of 2:1 and positive PG indicative of fetal lung maturity Review blood type, Rh and antibody status Administer Rh (D) immune globulin if indicated Monitor patient for postprocedure cramping or bleeding Monitor fetal heartbeat Nursing consideration Position to avoid supine hypotension; folded towel under right hip if supine

Maternal Serum Triple Screen (tests maternal Results adjusted according to documented serum for AFP, hCG, and estriol) gestational age, maternal age, race, and weight, Performed at 1518 weeks presence of diabetes/multiple gestation; the nurse must accurately document these variables on the Clinical Applications: laboratory requisition Serum screen for neural tube defects/ Down syndrome Interpretation of Results Defect Risk for open neural tube Risk for Down Syndrome

AFP Increased Decreased HCG WNL Increased Estriol WNL Decreased

Diagnostic Test for First Prenatal Visits Common Laboratory Tests Expected Finding in Pregnancy

HIV * check state laws regarding HIV testing in Negative pregnancy Blood Type Rh factor Antibody screen Hemoglobin Hematocrit Platelets WBC RPR Hepa B antigen Rubella titer Hemoglobin electrophoresis Chlamydia culture Gonorrhea culture Pap smear A, B, AB, O negative/positive Negative > 11.5 mg/dl > 33% 150,000-400, 000 cmm 5,000 -12,000 cmm Negative Negative 1:8 immune AA, unaffected Negative Negative Normal cytology

Diagnostic Test for Return Prenatal Visits (Second / Third Trimester)

Diagnostic tests 1-hour glucose screen

Nursing Consideration Administer 50 g glucose load

Performed at 2428 weeks Clinical Application Detection of gestational diabetes

Patient should not eat, drink, or smoke during the test Serum sample drawn in 1 hour EXPECTED RESULT 140 mg/dL Explain test to patient Collect vaginal/rectal specimen EXPECTED RESULT Negative

Group B vaginal culture Performed between 3537 weeks Clinical Application Positive culture treated with antibiotics in labor to prevent newborn transmission Fetal fibronectin (fFN) Performed between 22 and 35 weeks in women at high risk for preterm labor Clinical Application Negative predictive value for preterm labor Antibody screen Performed at 28 weeks in Rh negative women Clinical Application Detects presence of positive antibodies in serum of Rh negative women

NO intercourse 24 hours prior to exam Cervical/posterior fornix specimen EXPECTED RESULT Negative

Administer Rh (D antigen) immune globulin at 28 weeks to prevent antibody formation if Rh negative and antibody screen negative EXPECTED RESULT Negative

Diagnostic Test during Postpartum Examine postpartum laboratory findings and compare to prenatal levels (usually drawn at 24 hours postpartum) Hemoglobin/hematocrit White blood cell count Platelet count If mother is RH negative check Rh status of infant Mother Negative Negative Infant negative Positive Rho (D) immune globulin (300 micrograms) No treatment needed Administer within 72 hours of birth

b. Pre-gestational conditions such as rheumatic heart disease, diabetes mellitus, substance abuse, HIV/AIDS, Rh Sensitization, anemia

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 Signs and Symptoms: Heart murmur due to increased cardiac volume Cardiac output decreased--> nutritional and oxygen requirement not met Incomplete emptying of the left side of the heart--> Pulmonary edema and hypertension (moist cough in gravidocardiacs--> danger sign) 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 Management (depends on cardiac functional capacity) a. bed rest- especially after 30th week of gestation b. diet- gain enough (consider effect on cardiac workload) c. medications: digitalis, iron preparations d. avoid lithotomy position to avoid increase in venous return, place in semi- sitting positioning e. not allowed to bear down; birth is via low forceps or CS f. anesthetic choice- caudal anesthesia g. ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral contraceptives h. contraindicated--> can cause fluid retention and promote thromboembolism I. most critical period: immediate postpartum period when 30-50% increased blood volume j. is reabsorbed back in 5-10 minutes and the weak heart needs to adjust

DIABETES MELLITUS
o o o

cause by absent & lack of Insulin Action of Insulin is to facilitate transfer of glucose into the cell Dx test : 50gm 1hr Glucose Tolerance Test o 130 hyperglycemia o 70 hypoglycemia o 80-120 euglycemia o if > 130mg/dl, the Mother needs to undergo a 3hr GTT

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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 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 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 Substances Commonly Abused 1. Tobacco 2. Alcohol- most abused substance

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3. 4. 5. 6. 7.

Marijuana / cannabis- most frequently used illicit drug Cocaine Heroin- most abused opioid Methampethamine (shabu, crystal, ice) ampethamine of choice and is taken intranasally 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 Problems associated with Substance Abuse Pregnancy complications (low birthweight, miscarriage, preterm delivery), increased asthma risk in children, other respiratory problems Cervical dysplasia Increased risk for cancer (esophageal, bladder, kidney, pancreatic, leukemia, breast, gynecologic) Gastric and duodenal ulcers Premature wrinkling of the skin Decreased bone density, osteoporosis, fractures Impotence and fertility problems Lung disease Liver disease Decreased HDL Peripheral vascular disease Periodontal and dental diseases; oral cancers Depression Early menopause Barriers to Substance abuse A. Physical dependence 1. Withdrawal symptoms a. Depressed mood b. Insomnia c. Irritability d. Difficulty concentrating e. Increased appetiteweight gain f. Anger g. Restlessness h. Frustration i. Increased heart rate

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B. Psychological dependence 1. Behaviors associated with substance use become integrated into a persons routine 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? B. What the patient may present with Nagging, chronic cough Sinus congestion Shortness of breath Fatigue Elevated blood pressure Inability to meet physical challenges (run for a bus, play with young children) Decreased fertility Osteoporosis, decreased bone density Premature wrinkling Gum disease C. Additional questions to be asked Pregnancy complications History of abnormal Pap smears History of, or presently existing, cancer Fractures Cataracts/glaucoma Problems with cold hands or feet or leg pain Diabetes Gastric or duodenal ulcer Current medicines including herbals, homeopathics, vitamins 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

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ENT
o

dental cavities, stained teeth, tongue or buccal lesions, gum disease, foul breath

Lungs
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,

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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 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 B. Additional information to be considered 1. Sexual history a. Homosexual encounters; anal penetration b. Use of condoms, other methods of contraception, anal intercourse as contraception c. High-risk partners d. High-risk sexual practices e. History of previous sexually transmitted disease f. Contact with prostitute g. Multiple partners or partner with multiple partners 2. Use of injectable drugs by self or partner 3. High-risk occupation 4. History of blood transfusions or recipient of blood products particularly from 19801985 5. Duration and frequency of any presenting symptoms 6. Reason for fear of exposure to AIDS 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

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f. Recurrent, recalcitrant vaginal candidiasis g. External condyloma unresponsive to treatment h. Existing pregnancy i. Anal discharge j. Pelvic, abdominal pain 8. Travel outside the United States, especially to West Africa IV. Physical Examination A. As appropriate to presenting complaint V. Laboratory Examination A. Per protocol for presenting complaint, symptoms, risk status, exposure. B. HIV testing if indicated or requested; if setting offers testing, resources must be in place for both pretest and posttest counseling for positive or negative results and follow-up; retest as needed. C. CDC recommends HIV testing for all persons seeking evaluation for STDs; consider rapid testing if patients unlikely to return for results. D. All pregnant women should have HIV screening and encourage for women planning a pregnancy (per new CDC guidelines, 2006). E. Workplace exposures. F. Consider other bloodborne screening including HAB, HAC. 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). b. Decreased number of sexual partners; mutual monogamy; abstinence. 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. f. Empowering women to maintain equal decision-making power in their relationship(s). 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.

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VIII. Complications A. Opportunistic infections. B. AIDS may be fatal to some of its victims within two years of diagnosis. C. Transmission to unborn child (infants true HIV status based on antibody testing will not be accurate until 610 months); for a child < 18 months, definitive tests include evidence of HIV in blood or tissues by culture, nucleic acid, or antigen detection. IX. Consultations and Referral A. All patients falling into high-risk groups in need of testing for presence of HIV virus unless setting offers testing and counseling. B. Referral for all patients testing positive to HIV antibody for appropriate treatment. C. Referral per guideline for all occupational exposures. 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 Coombs test Maternal serum mixed with Rh(+) RBC In mother with Rh (-): clumping (+) result Direct Coombs test Neonatal cord blood washed and mixed with Coombs serum Fetus with Rh (-): clumping (+) result Preventive vaccine: Rho gam IM 1. Given to Rh(-) mother, NEVER TO BABY, at 28 wks AOG and within 72 hrs post delivery, BT, amniocentesis, chorionic villi sampling, D & C, abortion 2. Purpose: to destroy fetal Rh (+) RBC and prevent sensitization 3. S/E: fever, pain at injection site 4. CI: allergy to human Ig

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ABO INCOMPATIBILITY Happens when: Mother blood type O Fetus: A, B, AB O-A most common O-B most severe 1st child can be severely affected

Blood RBC Group Ag

Upon uterine contraction: start of hemolysis Fetus: Hydrops fetalis Edematous, lethal state with pathologic jaundice Management No breastfeeding Has Pregnanediole: delays action of glucoronyl transferase (liver enzyme that converts indirect to direct bilirubin) otherwise, complication: Kernicterus (irreversible brain death) Use of Phototherapy Exchange Transfusion for Rh or ABO affectations cause continuous in Hgb during the first 6 months because the BM fails to produce erythrocytes in response to continuing hemolysis

IRON DEFICIENCY ANEMIA

iron stores needed for Hgb production Caused by blood loss, metabolic demands, GI malabsorption, iron in diet

AB

A, B
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 S/Sx: pallor, weakness & fatigue, irritability\ iron diet (dark, green leafy vegies, breads, cereals, egg yolk, kidney beans, liver, meat, raisins) Administer iron supplements as ordered In between meals With Vit. C/citrus juice: absorption Milk/antacids: absorption Liquid iron: Taken with straw or medicine dropper at the back of mouth S/E: foul aftertaste, melena, constipation c. Gestational condition such as hyperemesis gravidarum, ectopic pregnancy, gestational trophoblastic disease (Hmole), incompetent cervix, spontaneous abortion, placenta previa, abruptio placenta, premature rupture of membranes, pregnancy-induced hypertension

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

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 Dangerous site: Interstitial

Unruptured Ruptured Missed period sudden, sharp severe unilateral pain, Abdominal pain knife like within 3- 5wks of shoulder pain (indicative of missed period (maybe intraperitoneal bleeding that extends to generalized of one diaphragm & phrenic nerve) sided) (+) Cullens 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

GESTATION TROPHOBLASTIC DISEASE (HYDATIFORM MOLE)

progressive degeneration of chorionic villi gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed from the swelling of the chorionic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46xx. It grows and enlarges the uterus very rapidly Cause: unknown Assessment: Early signs vesicles passed thru the vagina hyperemesis gravidarum due to increased HCG Fundal height? Vaginal bleeding (scant or profuse) Early in pregnancy high levels of HCG Preecclampsia at about 12 weeks vesicles look like snowstorm on sonogram anemia abdominal cramping serious late complication hyperthyroidism pulmonary embolus nursing care prepare for D&C do not give oxytocin drugs due to proness to embolism health teaching: return for pelvic exams as scheduled for one year to monitor HCG and assess for

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enlarged uterus and rising titer could be indicative of choriocarcinoma avoid pregnancy for at least one year methotrexate therapy

INCOMPETENT CERVIX
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

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 Temporary circlage Side effect infection May have NSD Shirodkar CS delivery MISSED fetus dies; product of conception remain in uterus 4 weeks or longer 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

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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 measure bllod loss; count pads report s/s of DIC monitor v/s for shock strict I&O

PREMATURE RUPTURE OF MEMBRANES

Rupture of the amniotic sac before the onset of true labor, regardless of length of gestation. Preterm Premature Rupture of Membranes Earlier than end of 37th week Causative Factors Vaginal or cervical infections gonorrhea Chorioamnionitis Incompetent cervix Fetal abnormalities or malpresentation Hydramnios Amniotic sac with a weak structure Recent sexual intercourse Nutritional deficiencies Management Prevent complications Oxytocin induction or caesarean birth Nursing considerations No coitus or douching Avoid breast stimulation Monitor temperature (> 37.8 degrees celcius) Maintain bed rest (50 % effective)

PREGNANCY INDUCED 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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Transitional Hypertension HPN between 20-24wks Chronic or Pre-existing Hypertension HPN before the 20th wk not resolved 6wks postpartum 3 types of pre-eclampsia Sign of pre-eclampsia : > 30mmHg systolic > 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, 1 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 Management for Eclampsia a. digitalis (with heart failure) increase the force of contraction of the heart--> decrease heart rate nursing considerations: check HR prior administration (do not give if HR < 60/min) b. potassium supplements- prevent arrhythmias c. barbiturates-- sedation by CNS depression d. Analgesics: antihypertensives, antibiotics, anticonvulsants, sedatives e. Magnesium sulfate drug of choice Action: CNS depressant; vasodilator Antidote: calcium gluconate- given 10% IV to maintain cardiac and vascular tone Earliest sign of MgSO4 toxicity--> disappearance of knee jerk/ patellar reflex Method of delivery- preferably vaginal but if not possible CS Prognosis: the danger of convulsions is present until 48 hours postpartum 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)

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Check first the ff. before administration 1. deep tendon reflexes are presentation 2. RR = 12 3. UO= at least 100 ml/ 6 hrs Nursing Intervention: 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 Post delivery PIH with disseminated intravascular coagulation anticoagulant therapy monitor blood pressure for 48 hour Diagnosis: Roll-over test: Assess the probability of developing toxemia when done between the 28th and 32nd week of pregnancy Procedure on Roll-over test: patient in lateral recumbent position for 15 minutes until BP stable rolls over to supine position BP taken at 1 minute and 5 minutes after roll over interpretation: if diastolic pressure increases 20 mmHg or more, patient is prone to toxemia Management: same as eclampsia

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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

28

< 1 cm normal size/location Triangular in shape Closes 2 3 months Measurements Transverse diameter Biparietal largest at 9.5 cm 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

Fetal Accommodation to the Passageway Fetal Lie Transverse Longitudinal Oblique Presentation Cephalic Vertex head is completely flexed, chin touching chest Sinciput anterior fontanel is the presenting part Brow head is bent back causing the occipitomental diameter Face presentation Chin presentation Breech / buttock / lower extremities presentation Frank - thighs flexed, legs extended on anterior body surface, buttocks presenting Full or complete squatting presentation Footling one or both Shoulder / horizontal / transverse presentation Compound presentation Presentation occurs when there is prolapsed of the fetal head alongside the vertex, breech or shoulder. Position Relationship of the landmark on the presenting part to the front, side, and back of the maternal pelvis. Maternal side 1st refer to the side of the maternal pelvis in which the part is found right or left. Fetal presentation side Occiput (O) vertex or military Frontum/ brow (FR) brow Mentum / chin (M) face Sacrum (S) breech Scapula (Sc) shoulder Maternal quadrant Side of the maternal pelvis which the reference point is found. Anterior front of the pelvis Posterior back Transverse side

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Most common positions LOA favorable delivery position Facing the lower left abdomen

ROA fetal occiput on maternal side 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

PASSAGEWAY STRUCTURES

OR

PELVIC

BONES

AND

OTHER

PELVIC

Maternal pelvis False pelvis part of the bony passageway True pelvis Landmark: inlet (entrance to the midpelvis); outlet (exit point) Measurements estimate size of true pelvis Obstetric conjugate smallest diameter of the inlet where fetus must pass 1.5 2 form diagonal conjugate for approximation. 11 cm adequate to accommodate delivery Diagonal conjugate distance from the promontory of the sacrum to the lower. Pelvic shapes Android Anthropoid Gynaecoid Platypeloid

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POWERS OR UTERINE CONTRACTIONS

Forces that cause the cervix to open and propel the fetus through the birth canal. Uterine contraction Primary power of labor o Characteristics Involuntary contraction Spontaneous contraction o Cervix dilatation and effacement of the cervix during the 1st 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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CLIENTS PSYCHE OR PSYCHOLOGIC STATE

Factors that may increase a woman's chance of depression history of depression or substance abuse little support from family and friends anxiety about the fetus problems with previous pregnancy or birth marital or financial problems young age of mother Signs and symptoms of post partum depression feeling restless or irritable feeling sad, hopeless, and overwhelmed having no energy or motivation eating too little or too much sleeping too little or too much trouble focusing, remembering, or making decisions feeling worthless and guilty loss of interest or pleasure in activities withdrawal from friends and family having headaches, chest pains, heart palpitaions (heart beating fast and feeling like it is skipping beats), or hyperventilation (fast and shallow breathing) Physical preparation of childbirth Three Categories Psychophysical Bradleys method presence of husband Dick Read method fear produces tension, pain Psychosexual Ketzingers method states that pregnancy, labor, birth, and care of newborn are an important turning point in womans cycle. Psychoprophylactic Lamaze requires discipline, conditioning and concentration Prevention of pain Features: Conscious relaxation Cleansing birth inhaling to the nose and mouth exhaling Effleurage light abdominal massage

2. Problems of the Passenger

FETAL MALPOSITIONS
1. Types of fetal malposition 2. Nursing care 3. Medical Management Position = relationship of the fetal presenting part to specific quadrant of the mother's pelvis ** the pelvis is divded into four quadrants

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** right anterior ** right posterior ** left anterior ** left posterior ** posterior positions results in more backaches because of pressure of fetal part on the maternal sacrum ** points of direction in the fetus ** occiput vertex presentatons ** chin (mentum) in face presentations ** sacrum in breech presentation **scapula (acromio) in horizontal presentation ROA/LOA

presenting

o o o o o o o
umbilicus

left occipito anterior most common & favorable position ROT/LOT left occipito transverse ROP/LOP left occipito posterior L/R- side of maternal pelvis Middle presenting part ROP/ROT most common malposition ROP/LOP most painful mgt: pelvis squatting Breech sacro place Chin mentum Shoulder acromnio dorso the stethoscope above the

o o

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 Longitudinal Lie (Parallel)/ Vertical

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A. Cephalic when the fetus is completely flexed 1. Vertex 2. Face 3. Brow 4. Chin B. Breech 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 Transverse Lie (Perpendicular)/Horizontal lie 4) Nursing care of client with malpresentation

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 Signs and Symptoms: Decreased movement nonreassuring or ominous FHR patterns Meconium in the amniotic fluid (unless fetus is in breech presentation) 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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NURSING RESPONSIBILITY IN FETAL MONITORING Position patient to avoid supine hypotension Assess FHR and interpret findings Compare FHR to maternal pulse to ensure monitoring of fetal heart and not maternal rate Implement nursing interventions for nonreassuring patterns of FHR Evaluate effectiveness of nursing interventions for nonreassuring patterns Update primary health-care provider with FHR status Document findings and interventions Assessment of the FHR may be intermittent or continuous

Intermittent Auscultation

Count FHR between, during, and immediately following a contraction Note both rate and rhythm of FHR Frequency of auscultation based on: Phase/stage of labor Hospital protocol Risk status Labor interventions Physician orders

Stage / Phase of Labor Stage 1: Latent phase Stage 1: Active phase Stage 1: Transition Stage 2
Continuous Fetal Monitoring

Frequency of FHR Monitoring Every 30-60 minutes Every 15-30 minutes Every 5-15 minutes Every 5-15 minutes

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Monitored with external or internal fetal monitoring External Fetal Monitoring (EFM) Encourage patient to void before applying EFM Test internal circuitry of EFM Place ultrasound transducer over fetal back Place toco transducer over uterine fundus Monitor for 2030 minutes on admission 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 515 mmHG Contraction tone of uterus averages 5085 mmHG Evaluating the Baseline Fetal Heart Rate Normal baseline FHR is 110160 BPM Evaluated between contractions over 10 minutes Documented as a range Does not include accelerations or decelerations Influences on the fetal heart rate Central nervous system Fetal sleep variability of FHR Fetal movement variability of FHR Autonomic nervous system Sympathetic branch ( FHR) Parasympathtic branch ( FHR) Baroreceptors respond to blood pressure with subsequent FHR Chemorecptors sense oxygen and FHR

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Figure: Normal fetal heart rate (Left:contractions, right: fetal heart rate) Changes to Baseline Fetal Heart Rate 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

Long term variability

Possible cause 37

Absent (0-2 BPM) Minimal (3-5 BPM) Average (6-10 BPM) Moderate (11-25 BPM) Marked (> 25 BPM)

Maternal medication Fetal sleep Fetal hypoxia Adequate fetal oxygenation Early sign of mild fetal hypoxia Fetal stimulation

Changes in Fetal Heart Rate The nurse interprets changes to baseline FHR as reassuring or nonreassuring The nurse must act on nonreassuring FHR patterns ACCELERATIONS Sudden increase of fetal heart rate over baseline Indication of fetal well-being Reassuring pattern Possible cause: Fetal movement/stimulation

Acceleration (Top: Fetal Heart Rate, Bottom: Contractions)

DECELERATIONS (Early, Late, Variable) EARLY DECELERATION Decrease in FHR occurring with contractions Onset occurs before the contraction peak Recovery to baseline rate occurs by contraction end Commonly seen in active phase of first stage of labor Mirrors the contraction Usually benign finding Continue to monitor FHR pattern for nonreassuring patterns Possible cause: Fetal head compression

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Acceleration (Top: fetal heart rate; bottom: contractions)

DECELERATIONS (Early, Late, Variable) EARLY DECELERATION Decrease in FHR occurring with contractions Onset occurs before the contraction peak Recovery to baseline rate occurs by contraction end Commonly seen in active phase of first stage of labor Mirrors the contraction Usually benign finding Continue to monitor FHR pattern for nonreassuring patterns Possible cause: Fetal head compression

Early deceleration: (Top: fetal heart rate; bottom: contractions) LATE DECELERATIONS Decrease in FHR occurring with contractions Onset with or after the peak of contraction Recovery to baseline rate occurs after contraction ends Repetitive pattern Nonreassuring requiring intervention INTRA

39

Late deceleration: (Top: fetal heart rate; bottom: contractions) Etiology: decreased uteroplacental blood flow/oxygen delivery related to maternal supine hypotension hyperstimulation of uterus preeclampsia chronic maternal disease hypertension diabetes anemia VARIABLE DECELERATIONS 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

40

Variable deceleration: (Top: fetal heart rate; bottom: contractions) Nursing Interventions for Non-Reassuring FHR Patterns Turn patient to side-lying position Shifts weight of gravid uterus off the inferior vena cava Allows for improved uteroplacental blood flow O2 per mask at 810 L/min Improve oxygen delivery to fetus Discontinue IV Oxytocin Decreases uterine contractions, thus improving uteroplacental blood flow Hydrate patient as indicated Corrects identified maternal hypotension Notify primary health-care provider Document findings Document baseline FHR (baseline FHR should be between 110 and 160 BPM) Describe variability Note changes in FHR in relation to contractions Document nursing interventions, effectiveness of interventions and notification of primary health-care provider Monitoring Contractions Frequency Beginning of one contraction to the beginning of the next contraction Documented as range, for example, every 25 minutes Duration Beginning of the one contraction to the end of the same contraction Documented as a range, for example, lasting 6090 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) Intensity Mild Palpated by Nurse Fundus easily palpated

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Moderate Strong

Requires more pressure to indent fundus Unable to indent fetus

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. 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 womans anxiety. Simple explanation of the condition. Include the family (decision making). 4. Problems with the Powers Powers the forces acting to expel the fetus & placenta involuntary contractions voluntary bearing down effects

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 characteristics: wavelike timing: frequency, duration, intensity myometrium- power of labor

DYSTOCIA
broad term for abnormal or difficult labor and delivery Uterine Inertia = sluggishness of contractions Causes: a. inappropriate use of analgesics b. pelvic bone contractions c. poor fetal position d. overdistention due to multiparity, multiple pregnancy, polyhydramnios or prematurely large fetus Types: Hypertonic uterine dysfunction = relaxations are inadequate and mild, thus are ineffective. Since uterine muscles are in a state of greater than normal tension, latent phase of the first stage of labor is prolonged. Treatment: sedate the patient Hypotonic uterine dysfunction = contractions have been good but gradually become infrequent and of poor quality and dilatation stops Treatment: stimulation of labor either by oxytocin administration or amniotomy

ABNORMAL PROGRESS OF LABOR

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

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Bandl's Pathologic ring--> suprapubic depression sign of uterine rupture

PREMATURE LABOR
labor after 20 weeks and before 37 weeks Triad signs premature conditions every 10 minutes effacement of 60-80% Home management CBR avoid sex empty bladder drink 3-4 glasses of water- full bladder inhibit contraction Hospital management if cervix is close (criteria: cervix is closed if it is 2-3 cm dilated only) Tocolytic therapy Yutupar (Ritodine Hcl)\ Side effect maternal BP < 90/60 check important presence of crackles Brethine (terbutaline) Bricanyl DOC Side effect: sustained tachycardia Antidote: propanolol/inderal if cervix is dilated (> 4cm) give steroid dexamethasone promote surfactant maturation immediately cut the cord after delivery to prevent jaundice/ hyperbilirubinemia

PRECIPITATE LABOR/ BIRTH

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

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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 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
it is the premature separation of the placenta from the implantation site it usualy occurs after the twentieth week of pregnancy cause: cocaine user severe PIH accident

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 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 measure blood loss; count pads report s/sx of DIC monitor v/s for shock strict I&O Placental Succenturiata- 1 or 2 lobes are connected to the placenta by a blood vessel Placenta Bipartita- placenta divided into 2 lobes 6. Problems with the psyche factors 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 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

INABILITY TO BEAR DOWN

can cause exhaustion

Causes: improper bearing down anxiety uncoordinated / weak contractions Nursing diagnoses: Energy field disturbance r/t slowing or blocking of energy flow secondary to labor

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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 C. Nursing Care of the High-Risk Postpartal Client 1. Postpartal hemorrhage a. Early postpartal hemorrhage b. Late postpartal hemorrhage subinvolution 2. Postpartal puerperal infection a. Endometritis b. Wound infection 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 Early postpartum hemorrhage bleeding during the first 24 hours postpartum 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

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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 4. DIC- dissemination intravascular coagulation - consumption of pregnancy (other term) - failure to coagulate - bleeding in the eyes, ears, nose - oozing blood - seen in cases with a) abruptio placenta; b.) still birth/IUFD - Management: - blood transfusion of cryoprecipitate or fresh frozen plasma - hysterectomy Late postpartum hemorrhage Retained Placental Fragments manual extraction of fragments is done uterine massage D&C except in cases of placenta acreta= unusual attachment of the placenta to the myometrium placenta increta = deeper attachment of placenta to the myometru placenta precreta = invasion of placenta to the perimetrium Candidates of these disorders are grand multiparous post CS all these requires hysterectomy Hematoma due to the injury to blood vessels during delivery

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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

POSTPARTAL PUERPERAL INFECTIONS

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 Mastitis (breast infection) Contributing factors Alteration in nipple integrity Delayed emptying of breast milk Clinical findings Unilateral breast pain, warmth and redness Malaise and flu-like symptoms 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

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 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, cant make decision tells about childbirth experience 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

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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 312 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 D. Care of couple with problems of infertility

INFERTILITY
Definition Etiology A. Factors in male infertility: 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 spermanti-spermatozoa antibodies B. Factors in female infertility: blocked fallopian tubes inability to conceive after 1 year or more of unprotected intercourse

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anovulatory cycles anatomical anomalies hormonal imbalance polycystic ovary syndrome (PCOS) obstruction of vaginal, cervical, and/or uterine cavity hostile cervical mucus ovarian cyst or tumor pituitary tumor endometriosis previous STDs vaginitis vaginosis PID septic abortion history of and drug treatment for thyroid disease, depression, asthma lifestyle factors (alcohol, smoking, street drugs, etc.)

C. Factors in couple infertility: improper technique for intercourse; infrequent intercourse; emotional state; male and female factors contributing to infertility History What the patient presents with History of failure to conceive for period of time with no use of contraception Desire for pregnancy Additional information to be obtained Complete medical and surgical history including immunizations; family history Complete menstrual history including menarche, character of menses, frequency, duration, last menstrual period, postmenarche amenorrhea Gynecologic history: anomalies; problems; infections; surgery including LEEP, LOOP; DES exposure; endometriosis; fibroids; abnormal Papanicolaou smears; previous treatment for menstrual disorders related to polycystic ovarian syndrome Contraceptive history to the present including postmethod amenorrhea Obstetrical history: any previous conceptions number of children, abortions, stillbirths; complications Partners 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

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B. Complete physical examination; observation of secondary sex characteristics; signs/symptoms of PCOS

C. External examination (careful observation for signs of infection, lesions, or anomalies) 1. Clitoris 2. Labia 3. Skenes glands 4. Bartholins glands 5. Vulva 6. Perineum D. Pelvic examination 1. Length of vagina 2. Position and character of cervix 3. Any anomalies E. Bimanual examination (examine for palpable masses, tenderness, anomalies, signs of trauma) 1. Uterus 2. Ovaries 3. Adnexa 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 2123 of cycle 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 testserial if antispermatozoa antibodies 4. Cervical mucus test; sperm antibody level; sperm agglutination test; sperm immobilization test; endometrial biopsy 23 days before menstruation 5. Hysterosalpingogram after menses, before ovulation 6. Hormonal assay (serum) such as FSH, LH, prolactin, estrogen DHEA-S, testosterone, urinary LH 45 days at midcycle 7. Tuboscopy 8. Ultrasound

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9. Laparoscopy with chromotubation, hydrotubation; hysteroscopy; salpingoscopy B. Work-up of partner involving tests done by specialist C. For complete work-up, referral may be in order Complications A. Risks associated with certain tests; costs of testing B. Persistent infertility, discovery of sterility C. Effects on couples 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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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:

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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 2. are poikilothermic (= easily take temperature of the environment) Temperature stabilizes at a lower rate: 35-36C. Take the axillary, not the rectal, temperature becrying will mean increased energy expenditure (Important: A special consideration in the care of premature babies is conservation of energy for growth and development) 3. Physiologic weight loss is exaggerated. 4. General activity is more feeble and weak; they often assume frog-like position; extremities have less muscle tone (scarf sign = elbow passes midline of the body; square window wrist = wrist at 90 deg angle) 5. CNS centers for respiration are underdeveloped, which results in irregular breathing with short periods of apnea. Oxygen administered should never be more than 40% because it can lead to retrolental fibroplasia (overgrowth of retinal blood vessels causing blindness) 6. nutritional requirements are high in order to maintain rapid growth appropriate for the developmental stage. Birth weight, kidney and GIT functioning should be considered in determining nutritional requirements of the preemies a. method of feeding- basically by NGT Rationale: ** premature often have ineffective sucking which is not coordinated with swallowing and therefore may aspirate ** minimal handling is necessary in order to conserve energy 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 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

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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 2. Problems related to gestational weight a. Small for gestational age (SGA) = birth weight is less than expected for the specific gestational age. Eg. Baby born on the 3 b. Large for gestational age (LGA) 3. Acute conditions of the neonates such as:

RESPIRATORY DISTRESS SYNDROME

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 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

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proper positioning; NPO; IV;NGT care oxygen; high humidity; warmth; CPAP Suction PRN Prevent complications sodium bicarbonate- for acidosis

MECONIUM ASPIRATION SYNDROME

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, 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 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

HSV,

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No chronic disease 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 o

Antibiotic Treatment of Serious Bacterial Infections Neonate Pathogens: GBS, E. coli, Listeria, S. aureus

1-3 months Same pathogens as above and below > 3 months Pneumococcus, H. influenzae type b (> 5 years)*

ampicillin + gentamicin Or Ampicillin + cefotaxime +/- cloxacillin if risk of S. aureus ampicillin + cefotaxime +/- cloxacillin if risk of S. aureus cefuroxime ceftriaxone or cefotaxime, if risk of meningitis vancomycin, if penicillin/ cephalosporinresistant pneumococci

* Hib has dramatically decreased since introduction of Hib vaccine

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 Hyperbilirubenemia More than 12mg of indirect bilirubin among full terms Normal Indirect Bilirubin Level: 0 3 mg/dl Kernicterus/ Bilirubin Encephalopathy Irreversible brain damage > 20 mg/dl of indirect bilirubin among full terms > 12 mg/ dl of indirect bilirubin among preterm because of immaturity

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Physiologic Jaundice Pathologic Jaundice Normal Within 24 hours Within 48 72 hours Yellow upon birth Mx: Expose to early morning Possible Rh/ sunlight incompatibility Assessment of Jaundice blanching of forehead, nose and sternum yellow skin, sclera light stool dark urine

Breastfeeding Jaundice Within 6th 7th day Due to glucoronyl transferase ABO

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

SUDDEN INFANT DEATH SYNDROME (SIDS)

Sudden and unexpected death of an infant < 12 months of age in which the cause of death cannot be found by history, examination or a thorough postmortem 0.5/1,000 (leading cause of death between 1-12 months of age) Frequency varies widely in different populations Most common in children placed in prone position Number of deaths peak at age 2 months Most deaths occur between midnight and 8:00 am More common in prematurity, if smoking in household, minorities, socially disadvantage 3:2 male predominance Risk of SIDS is increased 3-5 times in sibling of infants who have died of SIDS

Prevention: Place infant on back, NOT in prone position 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

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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. Signs and symptoms Acute paroxysmal abdominal pain Currant jelly stool caused by inflammation and bleeding Sausage shaped mass Peritonitis danger of intussusception Emergency for URT epiglotitis Emergency for GIT peritonitis Non congenital Caused by fast eating and positioning
o o o

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: WEIGHT, sometimes height that falls below 5th percentile for childs 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. Approach to a child with FTT History o Duration of problem o Detailed dietary and feeding history, appetite, behavior during feeds o Pregnancy, birth and postpartum history; developmental and medical history, including medications; social and family history (parental height and weight)

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Assess 4 areas of functioning: childs temperament, child-parent Interaction, feeding behavior and parental psychosocial stressors History Findings in Failure to Thrive
o

Poor caloric intake breastfeeding mismanagement lactation failure improper formula preparation maternal stress, poor diet, illness eating disorders aberrant parental nutritional beliefs food faddism diaphoresis or fatigue while eating poor suck, swallow vomiting, hyperkinesis billous vomiting recurrent pneumonias, steatorrhea

Diarrhea, dysentery, fever inflammatory bowel disease radiation, chemotherapy hypogeusia, anorexia recurrent infections rash, arthritis, weakness jaundice polyuria, polydipsia, polyphagia irritability, constipation mental retardation, swallowing difficulties intrauterine growth delay

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

Physical Findings in Growth Deficiency

Cleft lip and palate Short stature poor suck, swallow cachexia, mass bulging fontanelle, papilledema rash, joint erythema, tenderness, weakness nystagmus, ataxa jaundice, hepatomegaly abdominal distention ambiguous genitalia fever irritability clubbing perianal skin tags 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

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Inborn errors of metabolism 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
o o

B. Nonorganic Failure to Thrive (NFTT)- Unrelated to disease; Result of psychosocial factors

Noted by 6-12 months Often due to malnutrition, inadequate nutrition, poor feeding technique, errors in making formula These children are often picky, poor eaters with poor emotional support at home May have delayed psychomotor, language and personal / social development Emotional deprivation, poor parent-child interaction, dysfunctional home Child abuse and/or neglect Parent psychosocial stress, childhood abuse and/or neglect Treatment: most are managed as outpatients with multidisciplinary approach o Primary care physician, nurse, dietician, psychologist, social work, child protection services

C. Idiopathic Failure to Thrive unexplained by usual organic and environmental etiologies but may also be classified as NFTT.

DOWN SYNDROME (TRISOMY 21)

A generalized syndrome1:800 to 1:1000 live births Etiology unclear 90% + cases attributable to an extra chromosome 21 (trisomy 21) 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

Clinical manifestations of Down syndrome

Intelligence varies from severely affected to near-normal intelligence Social: 2-3 years behind mental age, especially in childhood Congenital anomalies: 30-40% has a congenital heart disease, especially septal defects. May also have GI and ortho alterations.

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Respiratoryinfections very prevalent Due to hypotonia; swallowing muscles are weakprone to aspiration Growthrate reduced in height and weight as children; but often overweight as teens/adults Sexual developmentmay be delayed, incomplete, or both

Physical manifestations

Headseparated sagital suture Face: flat profile Eyes: upward, outward slant Nose: small and depressed Ears: small, sometimes low set Mouth: high-arched palate, downward curve, especially when crying Hands: broad, short, transverse palmar crease (simian line) Feet: wide space between great and first toes, plantar crease between great and second toes. Hypotonia

Prognosis with Down syndrome

Improved in recent years Significantly lower than for the general population Survival at one year with CHD: 76%; at 20 years of age: 53% Survival at one year without CHD: 91%; at 20 years of age: 82% Dramatic increase in mortality after the age of 44, virtually all have neuro changes similar to Alzheimers disease

Possible nursing diagnoses for DS

Potential for infection related to hypotonia, increased susceptibility to respiratory infection Impaired swallowing related to hypotonia, large tongue, cognitive impairment Altered family processes related to having a child with Down syndrome Altered growth and development related to impaired cognitive functioning Potential for injury due to hypotonia/cognitive impairments high risk for falls

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)

Associated Nursing Diagnoses for Cleft lip and palate 5. Risk for fluid volume deficit

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6. Risk for altered nutrition; less than body requirements 7. Risk for aspiration

Treatment for cleft lip and palate Special nipples before surgery and while recovering Cleft lip surgery is usually done between birth and 10 months of age Cleft palate repairs are done at 18-24 months, so that anatomic changes in the palate contour are complete. Recovery is usually excellent Remember, these are typically stages surgeries

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 o Frequent URTI and otitis media Post cheilo prone Nutrition use paper cup/ plastic cup/ soup spoon Condition to consider for suspension of operation If child has a cold/ nasopharyngitis may lead to general septicemia General management Maintenance of patent airway Proper nutrition o NPO 4 hours post op

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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 o

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 C. Signs and symptoms 1. no anal opening 2. temporary colostomy if poor surgical risk (very young baby; malnourished; high agenetic or atretic type) 3 Surgery a. anoplasty b. abdominoperineal pull-through 4 Post operative care expose perineum to air by putting infant on supine with legs suspended straight up or on prone position check bowel sounds frequently

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 NGT for gastric decompression change position from side to side to decrease tension on suture line oral feedings resumed 1-2 days post-op when peristalsis has resumed (fluids are retained; stools/ flatus passed)

HIRSCHPRUNGS MEGACOLON)

DISEASE

(CONGENITAL

AGANGLIONIC

Absence of ganglionic innervation to a portion of the bowel Peristalsis does not occur in non-innervated bowel areas Patients have chronic constipation or ribbon-like stools

Treatment of Hirschsprungs disease

Surgery to remove the agangilionic colon segment May be done in 2 stages, with a temporary colostomy for 6-8 months to allow bowel to rest.

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 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

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4. urinary and bowel problems a. inefficient bladder causes constant urinary dribbling b. stasis or urine causes UTI c. possible renal destruction d. fecal incontinence or retention due to poor innervation of the anal sphincter and bowel musculature C. Preoperative management/conservative treatment 1. careful handling to avoid rupture, pressure, irritation or leakage from the protruding mass by putting child on prone position, with the hips abducted 2. meticulous skin hygiene to prevent irritation sterile donut ring over the lesion 3. watch for signs of increased intracranial pressure a. anterior fontanelle for tenseness, fullness and bulging b. shrill, high-pitched cry c. measure head circumference for any significant increase d, vomiting, irritability e. increasing BP, decreasing PR and RR and widening pulse pressure 4. passive range of motion (ROM) exercise to impaired lower extremities 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: * 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

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Clinical manifestations Meningeal sac (can be transilluminated) Ultrasound prenatally

Care of the myelomeningocele sac

Evaluate the sac and measure the lesion Protect the sac; cover with a sterile, moist (normal saline) dressing. May include an antibiotic in the solution. Change every 2-4 hours. Device to maintain body temperature without clothing or covers that irritate the sac. Place in prone position to minimize tension on the sac and the risk of trauma; the head is turned to one side for feeding. Assess for early signs of infection; elevated temperature, irritability, lethargy, nuchal rigidity.

Associated Nursing Diagnoses 4. Potential for infection related to presence of infective organisms, nonepithelialized meningeal sac 5. Potential for trauma r/t delicate spinal lesion 6. Potential for impaired skin integrity r/t paralysis, continual dribbling of urine or feces 7. Potential for trauma r/t impaired cerebrospinal circulation 8. Potential for injury r/t neuromuscular impairment

HYDROCEPHALUS

Caused by imbalance in production and absorption of CSF CFS accumulates within ventricular system of brain, producing dilation of ventricles.

Mechanisms of Fluid imbalance in 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 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

Clinical manifestations of hydrocephalus

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Influenced by acuity of onset and presence of pre-existing structural lesions In infancy, head grows at an abnormal rate Anterior fontanel tense, bulging, dilated scalp veins (due to the skin stretching)

Manifestations of Hydrocephalus in childhood

Caused by increased ICP Headache upon awakening with improvement following emesis or upright posture Papilledema (edema and inflammation of optic nerve) Strabismus Ataxia Irritability/lethargy Confusion Incoherence

Diagnosis 3. 4. 5. 6. Head circumferences Associated Neuro signs CT, MRI, skull x-ray Dye inserted into ventricle through anterior fontanelwill 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

Direct removal of obstruction if present (cyst, neoplasm, Hematoma) A shunt is inserted under the skin the drain ventricles, may include a reservoir to add medications and remove fluid.

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.)

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Complications of shunts

Mechanical obstruction within ventricles from tissue or exudates, displacement related to growth, thrombus (clot) Often presents as an emergency; increased ICP and worsening of neuro status Infectionthe most serious complication. May occur at any time but the greatest risk is 1-2 months after placement. (tubing colonized with bacteria)

Postoperative care after shunt placement

Position on un-operated side May need to keep flat to avoid too rapid reduction of intracranial fluid Observe for signs of increased ICP o If increased ICP occurs, elevated the HOB to 15-30 degrees to enhance gravity flow through the shunt Monitor I & Os carefully, may be on a fluid restriction Presence of bowel sounds determined before feeding infant with VP shunt (in case the bowel was perforated at the time of placementdo not want shit leaking into the tube)

Signs of CSF infection

Elevated vital signs Poor feeding Decreased LOC Seizures

Associated nursing diagnoses

Potential for injury related to increased ICP Potential for infection related to presence of mechanical drainage system Altered family processes related to having a child with a chronic illness

OTITIS MEDIA

Inflammation of the middle ear Common to children due to wider and shorter Eustachian tube

Predisposing factors Bottle propping Cleft lip/ palate

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Signs and symptoms During otoscopic exam, reveals bulging tympanic membrane Observe for passage of purulent, foul smeeling odor discharge 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) 4. 90% of cases are between 1 month and 5 years 5. Peak incidence is in the winter. 6. Causative organisms (95% of cases) 1. H. Influenzae (type B) 2. Streptococcus pneumoniae 3. Neisseria meningitis- epidemic form; droplet from nasophargeal secretions 1. MUST be put on droplet isolation

Pathophysiology of Bacterial meningitis

Pathologic organism spreads to the meninges from upper respiratory tract or by lymphatic drainage from the sinuses. 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

Clinical signs in Children and Adolescents 4. Usually have 2-3 days of a cold, upper respiratory infection and occasionally and ear infection.

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5. 6. 7. 8.

Become VERY irritable due to headache May have convulsions photophobia As the disease progresses, more signs of meningeal irritability occurs: 1. Positive Brudzinskis (image on page 674) 1. When childs head is flexed forward (while laying on back), both hips, knees and ankles flex. This shows meningeal irritation 2. Positive Kernigs (image on page 674) 1. Flex childs hips and knee (while laying on back) 2. Then extend legthis will cause pain, resistance and spasm which indicate irritation. 3. Nuchal rigidity occurs (neck stiffness) 4. In the newbornpoor sucking, weak cry, lethargy

Diagnostic EvaluationLumbar Puncture

Obtained by history and analysis and CSF via Lumbar puncture o Culture and gram stain identify causative organism Blood cell countWBC elevated Lowered glucose o Increased metabolic rate due to the body and brain trying to fight off infection; draws glucose out of blood for energy. Protein content increased o Due to extra cells and metabolism occurring in the CNS

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

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 childs life

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Seizure activity

Seizure usually lasts 15-20 seconds Shows an active tonic-clonic pattern (alternately contracting and relaxing the muscles) EEG tracing usually normal Usually a family history Seizures subside once the fever is gone

Prevention of Febrile convulsions

Give Tylenol to keep fever below 101 Often fever develops during the night when parent/caregiver is not with child If child has one febrile seizure, no further treatment given other than to advise parents to administer Tylenol to keep fever below 101 If more than one seizure, child may be put on Phenobarbital (controversial)

Therapeutic management of seizures

Teach parents that after the seizure subsides, they should: o Sponge the child with tepid water Do not put child in bathtub Do not use rubbing alcohol or cold water Do not give Tylenol right after the seizure (not awake enough to swallow) If unable to decrease temperature by sponging, advise parents to: o Put a cool washcloth on childs forehead, axillary, and groin areas (which are temperature receptors)

Healthcare facility will:

Determine underlying cause Lumbar puncture to rule out meningitis Antipyretic drugs Antibiotic therapy if needed Assure parents that febrile convulsions do not lead to brain damage and child will be well.

C. Health problems common in toddlers

BURN TRAUMA
Injury to body tissues caused by excessive heat HIGH RISK BURN VICTIM: CHILD

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Higher proportion of body fluid to smaller muscle & fat mass, thinner skin Higher mortality r/t Fluid & heat loss Dehydration Metabolic acidosis Cardiovascular collapse Protein & calorie deficiency Infection MODIFIED RULE OF NINES ASSESSMENT OF EXTENT (INFANTS)

PARTSANTERIORPOSTERIORHead9.59.5Neck 11Upper Arm22Lower Arm1.51.5Hand1.251.25Trunk13-Back13-Genital1-Each Buttock2.5Thigh2.752.75Leg2.52.5Foot1.751.75 5-9 YEARS PARTSANTERIORPOSTERIORHead6.56.5Neck 11Upper Arm22Lower Arm1.51.5Hand1.251.25Trunk13-Back13-Genital1-Each Buttock2.5-Thigh44Leg33Foot1.751.75 Characteristic 1st Degree Partial Thickness 2nd Degree Partial Thickness 3rd Degree Full Thickness Involves only the superficial epidermis characterized by erethema, dryness and pain Ex: Sunburn heals by regeneration in 1 10 weeks Involves the entire epidermis, and portion of the dermis, characterized by erythema, blistered and moist from exudates which is extremely painful Ex: Scalds Involves skin layers, epidermis and dermis, may involve adipose 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:
o o o o o o o o o o

First Aid Put out the flames by rolling the child on a blanket Immerse the burned part on cold water Removed burned clothing (sterile material) Cover burned part with sterile dressing Maintainance of patent airway Suction PRN O2 administration with humidity Endotracheal Intubation Tracheostomy Prevention of shock and flued and electrolyte imbalances Colloids to expand blood volume Isotonic saline to replace electrolyte

FLUID RESUSCITATION: PARKLAND FORMULA Plain LR 4ml X body wt (kg) X TBSA burned of total: 1st 8hrs post burn of total: 2nd & 3rd 8hrs post burn

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Goal: U.O.= 1ml/kg/hr Dextrose in water to provide calories Booster dose of Tetanus Toxoid Relief pain such as IV analgesic (morphine sulfate) Prevention of wound infection o Cleaning and debriding the wound o Open or close method of wound care o Whirl pool therapy Skin grafting o 3rd degree burn o get skin from buttocks or pig skin (xenograft) or from frozen cadaver Diet CHON and calories
o

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 hypochromic Microcytic Anemia Destroys Kidney Function Accumulation of ammonia Leading to Encephalitis (Late stage)

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 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

Toxic dose: >150mg/kg Signs & Symptoms 1st 2-4hrs: malaise, N/V, sweating, pallor, weakness Latent period 24-36hrs: child improves Hepatic involvement: up to 7days & may be permanent; RUQ pain, jaundice, confusion, stupor, liver enzymes, bilirubin, Pro time Management: N-Acetylcysteine (Antidote) Dilute in juice/soda to remove offensive odor

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

CHILD ABUSE AND NEGLECT

Definition An act of commission or omission (physical, sexual, or emotional) by another person that

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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

Legal Duty to Report duty to report overrides patient confidentiality, physician is protected against liability ongoing duty to report: if there are additional reasonable grounds to suspect abuse and/ or neglect, a further report to the CAS must be made 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 - 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

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recurrent UTIs, pregnancy, STDs, vaginitis, vaginal bleeding, genital injury

RED FLAGS Presentation of neglects failure to thrive, developmental delay inadequate or dirty clothing, poor hygiene child exhibits poor attachment to parents, no stranger anxiety Management of Child Abuse and Neglect history: interview parents and child separately for children, use age appropriate toys to encourage child to tell what happened if one parent inflicts injury, the other parent is unable to protect physical exam head to toe (do not force) emotional state development document and/or photograph all injuries: type, location, size, shape, color, pattern laboratory may include STD workup, bone scan, CT/MRI report all suspicions to child abuse services (Bantay Bata 163) acute medical care: hospital if indicated or if concerns about further or ongoing abuse arrange consultation to social work and appropriate follow-up discharge child directly to CAS (child abuse services) or to responsible guardian under CAS supervision

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

Incidence and Causes of CP

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) 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 havent been fully developed CP has increased over the past decade due to: o Preemies are living longer o Multiple births from artificial reproductive technologies

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Prenatal technology

Types of CP

Two main categories based in type of neuromuscular involvement o Pyramidal or spastic (50-70% of children with CP) o Extrapyramidal (outside of the pyramidal tracts of the CNS) Ataxic (awkward, unsteady gait) Dyskinetic (defect in ability to perform voluntary movement) Athetoid (slow, irregular, twisting, snakelike movements occur in the upper extremities, esp. in the hands and fingers) Mixed

Spastic or pyramidal CP Pyramidal system: conveys nerve impulses that create voluntary movements Problems in this area result in: o Hypertonicity: excessive tone in the voluntary muscles o Abnormal clonus: rapidly alternating involuntary contraction of skeletal muscle o Exaggeration of deep tendon reflexes Abnormal reflexes such as a positive Babinski reflex Continue to have neonatal reflexes past usual age (tonic neck reflex) Arch their back and extend arms/legs abnormally when held in a ventral suspension position Fail to do a parachute reflex if lowered suddenly (do not extend arms/hands in front of self) Assume a scissors gait due to tight adductor thigh muscles which cause their legs to cross when held upright. May have tightening of heel cord which causes the child to walk on toes; unable to stretch heel to touch the ground. Spastic involvement may affect: o Both extremities on one side (hemiplegia) o All four extremities (Quadriplegia) o Primarily lower extremities (paraplegia or diplegia) Children with quadriplegia: o Usually have impaired speech o Swallowing is difficultdrool, problems eating o May have cognitive impairment

Extrapyramidal CP

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)

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Athetoidwormlike 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

Diagnostic evaluation for diagnosis of CP 3. 4. 5. 6. 7. Neurological exam Historyespecially born prematurely Ultrasound of brain CT scan MRI

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Physical findings that may suggest CP

Delayed motor development Abnormal head circumference (head is typically larger) Abnormal postures Abnormal reflexes Abnormal muscle performance and tone 25-75% of children have cognitive defects may have visual problems

Medical management of CP
o o o o o o o

Overall goaldevelop a rehabilitation plan to promote optimum function Multidisciplinary teams o OT, PT, Speech As child grows, would include therapeutic exercises, splints, braces Antispasmodic drugs may also be used (Baclofen), but may have little effect Surgery to lengthen heel tendons may be done Wheeled walkers or scooter boards Cerebellar pacemakers may decrease spasticity in some children o Also called Baclofen pumps

Nursing Diagnoses

Altered growth and development Impaired physical mobility Self-care deficits (bathing/toileting/dressing) Self-esteem disturbance Impaired social interactions

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General interventions 5. Promote maximal functioning of joints 6. Provide adaptive equipment for activities of daily living 1. Modified utensils for eating 2. Push panels for computer 3. Electric switches for battery operated toys 7. Position to prevent contractures 1. Perform active and passive ROM exercises, must be done daily 8. Provide adequate nutritionoften have difficulty swallowing 9. Encourage verbalization of feelings about altered body image 10. Encourage social interaction with peers 11. Teach patient and family how to maintain independence 12. Identify support groups

Long term care for CP

Sometimes children are not diagnosed with CO until 2-4 years later. This can be upsetting to parents. Will need much support and education.

Bells palsy/ Facial Nerve Paralysis 7th CN injury usually related to forceps delivery risk for URTI Signs and symptoms Continuous drooling of saliva Inability to open one eye and close the other Management Artificial tear Self limiting Refer to PT for rehabilitation

D. Health problems common In preschooler Example: leukemia, wilm's tumor (nephroblastoma), asthma, urinary tract infection (UTI)

LEUKEMIA

Group of malignant disease characterized by rapid proliferation of immature RBC Ratio is 500 RBC : 1 WBC The client is immunocompromised Classification of Leukemia o Lympho affects the lymphatic system o Myelo affects the bone marrow

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o o

Acute/ Blastic affects the immature cells Chronic/ cystic affects the mature cells

Acute Lymphocytic Leukemia Most common in children Increase immature WBC Signs and Symptoms Infection Fever Poor wound healing Bone weakness and causes fractures Signs of bleeding Blood in the urine Emesis Petechiae Epistaxis Signs of anemia Pallor Body malaise constipation Invasion of the organs Hepatomegaly abdominal pain Splenomegaly 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

4. Bone Marrow Aspiration Determines the presence of blast cells Site of bone marrow aspiration iliac Crest post op : prevent hemorrhage Lie on affected site

5. Bone Scan determines the degree of bone involvement 6. CT Scan determine the degree of organ involvement
Management Triad Surgery Irradiation Chemotherapy Bone marrow transplant Levels of Chemotherapy

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 Induction Sanctuary To treat the Drugs Irradiation

To achieve remission Drugs IV Vincristine L Asparagine Oral Prednisone

leukemic cells that has invaded the testes and CNS intrathecal methotrexate via spine cytocine arabinase steroids

Maintenance Reinduction

To continue remission Drugs oral methotrexate oral 6-mecaptopurine cytarabine 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 childs preference Alopecia temporary side effect of chemotherapy

NEPHROBLASTOMA (Wilms Tumor)

Tumor of the kidney (uni- or bilateral) with metastasis to other organs Peak incidence: 3 y/o Treatment: Partial to total nephrectomy & chemotherapy with or withour radiation

Signs & Symptoms Mass within abdomen (firm, nontender, confined to 1 side & deep within the flank) Abdominal pain

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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 acute O2: to keep O2 saturation > 92% fluids: if dehydration

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 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)

URINARY TRACT INFECTION (UTI)

newborns - more common in males (especially if uncircumcised) children - more common in females due to straight short urethra 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 E. Health problems most common in school aged children example: diabetes mellitus, rheumatic fever, rheumatic arthritis, scabies, pediculosis, impetigo

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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 -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

RHEUMATIC HEART DISEASE

Inflammatory disease following an infection caused by Group A Beta Hemoilytic Streptococcus Affected body parts o Musculoskeletal o Cardiac muscle o Integumentary system o CNS Tonsillitis due to love of sweets with no oral hygiene serving a good medium for bacterial growth causing inflammation 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

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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: JONES CRITERIA Major Minor Polyarthritis multi Low grade fever joint pain Athralgia joint pain Diagnostic Exams CHOREA/ Antibody Sydenhamms 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: Reyes Syndrome encephalopathy accompanied by fatty infiltration of the organs such as the heart and liver

JUVENILE RHEUMATOID ARTHRITIS (JRA)

a heterogenous group of conditions characterized by a persistent arthritis in childhood diagnosis arthritis in at least one joint lasts for at least 6 weeks onset before the age of 16 other causes of arthritis excluded classification defined by features/number of joints affected in the first 6 months of onset systemic onset - fever at onset with arthritis appearing later pauciarticular - 4 or less joints involved polyarticular - 5 or more joints involved prognosis: worst prognosis with systemic onset and polyarticular course outcome of most children is favourable best prognosis in young female with pauciarticular disease

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Systemic (Still's Disease) high spiking fever (= 38.5C) 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 mature & complete life cycle Contagious during course of infestation via direct contact

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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

PEDICULOSIS CAPITIS (HEAD LICE)

Infestation of hair and scalp with lice Sites affected: occipital area, behind ears, nape, eyebrows & lashes Transmitted by direct and indirect contact (sharing brushes, hats, towels & bedding) All contacts should be treated Signs & Symptoms Intense pruritus (+) adult lice (gray specks crawling fast) (+) silver/gray specks firmly attached to hair shaft Management Pediculicide shampoo & repeat after 7days Permethrin (Nix) rinse Apply to washed, towel-dried hair, leave for 10 mins, rinse Remove nits with fine-toothed comb Change bedding & clothing OD, wash in hot water with detergent, hot dryer for 20mins Seal non-essential bedding, clothing, unwashable toys in plastic bag for 2wks Discard hairbrushes/combs or soak in hot water No sharing of bedding, clothing, headwear, hairbrush/comb Vacuum furniture & carpets frequently

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 localized erythema becoming purulent and ooze, forming a honey-colored crust Cx: AGN Management

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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)

F. Health problems common in adolescent example: scoliosis, bone tumors, accidents (trauma/injury), STD, amenorrhea, dysmenorrhea, obesity, anorexia nervosa, substance abuse, suicide

SCOLIOSIS

Lateral (sideways) curvature of the spine May involve all or only a portion of the spinal column 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

Types

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: 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.

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SEXUALLY TRANSMITTED DISEASES (STD)

SYPHILIS Other names: Sy, bad blood, the pox, lues venereal, morbus gallicus Causative Agent: Treponema pallidum (a spirochete) Incubation Period: 10 to 90 days (3 months); average of 21 days Mode of Transmission: Direct contact Transplacental (after 16th week AOG) Indirect contact with contaminated articles Signs and Symptoms: Primary stage (4-6 weeks); painless chancre at site of entry of germ with serous exudates Secondary syphilis (6-8 weeks): generalized rushes, generalized tender discrete lymphadenopathy, mucous patches, flu-like symptoms, condylomata, patchy alopecia Tertiary stage (one to 35 years): Gumma, syphilitic endocarditis and meningitis Latent stage (one to two to 50 years): non-infectious 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 Other names: GC, Clap, Drip, Stain, Gleet, Flores Blancas 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 Incubation: 2 to 10 days. Symptoms can occur 3 to 30 days after sexual contact; average is 2 to 5 days after exposure. Usual Signs and Symptoms A. Females 1. Up to 80% have no symptoms 2. Abnormal, thick green (or yellow) vaginal discharge

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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. 410% 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 Diagnosis (for Both Sexes) A. History of sexual contact with a person known to be infected with gonorrhea B. Smears and cultures taken from infected areas (cervix, penis, rectum, and throat) Treatment for Males and Females Antibiotics: Drug of choice Penicillin. Be sure to tell your clinician if you are allergic to any antibiotic. 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. Patient Education (for Both Sexes) A. All medication must be taken as directed. Prevention of gonococcal ophthalmia is done through the prophylactic use of ophthalmic preparations with erythromycin or tetracycline. B. No intercourse until treatment of self and partner(s) is completed. ABCs: abstinence, be faithful and condom C. Return to the clinician for reevaluation if symptoms persist or new symptoms occur after treatment is complete. D. Important: The responsible lover informs all partners immediately upon finding out about exposure to sexually transmitted disease so that all persons involved can be evaluated adequately and treated immediately. TRICHOMONIASIS Other names: Vaginitis, trich Mode of Transmission: direct contact

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Incubation period: 4-20 days, average of 7 days Signs and Symptoms: Females: white or greenish-yellow odorous discharge vaginal itching and soreness painful urination Males: slight itching of penis painful urination clear discharge from penis Diagnosis: culture Treatment: Drug of choice: Metronidazole (Flagyl) Prevention: ABC, personal hygiene CHLAMYDIA TRACHOMATIS Causative Agent: Chlamydia trachomatis Transmission Sexual contact with 2 to 3 week incubation period before symptoms present Signs and Symptoms A. In the female 1. Often no symptoms 2. Possibly, increased vaginal discharge with fishy odor 3. Cervicitis or an abnormal Papanicolaou smear 4. Possibly, frequent uncomfortable urination 5. Advanced symptoms include those of pelvic infection B. In the male 1. Possibly, thick and cloudy discharge from the penis 2. Possibly, burning pain in urination and/or frequent urination; itching of urethral opening 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 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

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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. CANDIDIASIS (MONILIA) YEAST INFECTION Other names: moniliasis, candidiasis Causative agent: Candida albicans 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. Signs and Symptoms A. In the female 1. Vaginal discharge: thick, white, and curd-like 2. Vaginal area itch and irritation with occasional swelling and redness 3. Burning on urination 4. Possibly, pain with intercourse B. In the male 1. Itch and/or irritation of penis 2. Cheesy material under foreskin, underside of penis 3. Jock itch; athletes foot Diagnosis A. Female evaluation may include vaginal examination to check for candida and rule out trichomoniasis, bacterial vaginosis, Chlamydia, and gonorrhea. B. Male evaluation may include: 1. Examination of penis to check for irritation and/or cheesy materials 2. Culture for ruling out gonorrhea and Chlamydia 3. Urinalysis Treatment Nystatin for oral thrush Cotrimazole, fluconazole for mucous membranes and vaginal infection Fluconazole or amphotericin for systemic infection 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) 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

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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). D. Over-the-counter medication. Many women choose to try an over-the-counter preparation before seeking an examination. If symptoms do not subside after 1 course of treatment (1 tube or 1 set of suppositories), having an examination for diagnosis is recommended.

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. Ashermans syndrome 14. Cervical stenosisoutfl ow tract anomaly 15. Medications including psychotropics 16. Chronic illness 17. Tuberculosis History A. What the patient presents with 1. Absence of menstruation 2. Possible breast discharge 3. Other symptoms secondary to underlying etiology

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B. Additional information to be considered 1. Careful menstrual history; pregnancy history 2. Sexual history 3. Contraceptive history 4. MedicationsOTC, 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 disordercurrent 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. Cervixscarring, stenosis 3. Adnexa: ovaries may be enlargedcystic 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) 510 mg per day 510 days. 1. If no withdrawal bleed in 37 days after progestin, consider follicle stimulating hormone and luteinizing hormone assays 2 weeks after Provera. Try oral estrogen 1.252.5 mg to prime the endometrium (estropipate) daily for 2125 days; if no bleeding, add progestin during last 510 days of estrogen. If no withdrawal bleed,

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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 d. Polyps 1) Endometrial 2) Cervical

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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 B. Additional information to be elicited by asking the following questions: 1. Relationship to menarche 2. When does pain begin? 3. How long does it last? 4. Does anything make it feel better? 5. Last menstrual period 6. Birth control method(s) used 7. Any relationship to intercourse? 8. Any vaginal discharge? 9. Any fever related to pain? 10. What is menstrual flow like? 11. Is this new; is this a change in pattern? 12. Sensitivity to aspirin; nonsteroidal anti-inflammatories 13. History of chronic illness (kidney disease) 14. Current medications (prescription and over-the-counter) 15. Postcoital bleeding 16. Home remedies and/or folk remedies tried; use of complementary and alternative therapies 17. STD history, vaginitis/vaginosis 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 B. Gonorrhea culture (same as Chlamydia) C. Wet mount

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Treatment A. Medication 1. Ibuprofen (Motrin) 400 mg 4 times a day, 200400 mg every 46 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 68 hours (no more than 5 tabs 1.375 grams per day); Aleve 200 mg every 812 hours 4. Naprosyn 500 mg every 12 hours or 250 mg every 68 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 12 tablets every 4 hours as needed 7. lbuprofen (Advil) 200 mg, 2 tablets every 46 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 ideation high levels of stress and poor coping are related to suicide

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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 Patient may present: feelings of sadness guilt hopelessness helplessness reasons that the patient has to wish to go on living\Did the patient believe that he would succeed in suicide? Is the patient upset that he is still alive?

Past History previous suicide attempts or threats antidepressant use Family history of depression, suicide, psychiatric disease, family supporting 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 HEALTH TASKS OF THE FAMILY 1. recognizing interruptions of health or development 2. seeking health care 3. managing health and non-health crises 4. providing nursing care to the sick, disabled and dependent member of the family 5. maintaining a home environment conducive to health and personal development 6. maintaining a reciprocal relationship with the community and health institutions FAMILY NURSING PROBLEM arises when the family cannot effectively perform its health tasks Nursing Assessment first major phase of the nursing process. - 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. Nursing Assessment includes: Data collection Data analysis or interpretation Two Phases: a. FIRST- LEVEL ASSESSMENT is a process whereby existing and potential health conditions or problems of the family are determined. TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE classification system of family nursing problems. Family structure, characteristics, and dynamics and relationship to the head of the family Members of the household and relation to the head of the family Demographic data- age, sex, civil status, position in the family

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Place of residence of each member- whether living with the family or elsewhere Type of family structure eg matriarchal or patriachal, nuclear or extended Dominant family members in terms of decision-making especially in matters of health care General family/ relationship/ dynamics- presence of any readily observable conflict between members; characteristics communication patterns among members Socioeconomic and cultural characteristics occupation, place of work and income of each family members adequacy to meet basic necessities who makes decisions about money and how it is spent Educational attainment of each other Ethnic background and religious affiliation 1. significant others- role (s) they play in family life 2. relationship of the family to larger community- nature and extent of participation of the family in community activities Home and Environment Housing adequacy of living space sleeping arrangement presence of breeding or resting sites of vectors of diseases presence of accident hazards food storage and cooking facilities water supply- source, ownership, portability toilet facility- type, ownership, sanitary condition drainage system- type, ownership, sanitary condition 1. kind of neighborhood: congested, slum, etc. 2. social and health facilities available 3. communication and transportation facilities available Health status of each family member 2. Medical and nursing history indicating current or past significant illnesses or beliefs and practices conducive to health and illness 3. Nutritional assessment - anthropometric data: measures of nutritional status, weight, height, mid-upper arm circumference, waist hip ratio dietary history specifying quality and quantity of food/nutrient intake per day eating/feeding habits/ practices Developmental assessments of infants, toddlers, and preschoolers- Metro Manila 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 Physical assessment indicating presence of illness states Results of laboratory/ diagnostic and other screening procedures supportive of assessment findings

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Values, habits, practices on Health promotion, maintenance, and disease prevention 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 familys assumption of the tasks. I. Inability to recognize the presence of the condition or problem. 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. V. Failure to utilize community resources for health care. 2. Family health problem identification a. Determination of categories of family health problems Health deficits- instances of failure in health maintenance (disease, disability, developmental lag) Health threats- conditions that are conducive to disease, accident or failure to realize ones health potential Foreseeable crisis/stress points - anticipated periods of unusual demand on the individual or family in terms of adjustment or family resources Enhanced capability for health promotion is a nursing judgment related with the clients capability for wellness. 3. Definition of contributing risk factors From PROCEED- PRECEDE MODEL

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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

4. Criteria of setting priorities among family health problems:

Nature of the problem Health deficit Health threat Foreseeable Crisis Preventive potential High Moderate Low Modifiability Easily modifiable Partially modifiable Not modifiable

Salience (needs immediate attention, not immediate, not perceived as problem)

5. Tool of analysis Social determinants of health

B. Planning of individual & family health nursing care

1. Concepts, principles, phases and components in planning family health interventions 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. DESIRABLE QUALITIES OF A NURSING CARE PLAN 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. THE IMPORTANCE OF PLANNING CARE

They individualize care to clients. The nursing care plan helps in setting priorities by providing information about the client as well as the nature of his problems. The nursing care plan promotes systematic communication among those involved in the health care effort. Continuity of care is facilitated through the use of nursing care plans. Gaps and duplications in the services provided are minimized, if not totally eliminated. Nursing care plans, facilitate the coordination of care by making known to other members of the health team what the nurse is doing.

STEPS IN DEVELOPING A FAMILY NURSING CARE PLAN

The prioritized condition/s or problems based on: nature of condition or problem modifiability preventive potential salience The goals and objectives of nursing care. Expected Outcomes: conditions to be observed to show problem is prevented, controlled, resolved or eliminated. Client response/s or behavior > Specific, Measurable, Client-centered Statements/Competencies The plan of interventions. Decide on: Measures to help family eliminate: . barriers to performance of health tasks . underlying cause/s of non-performance of health tasks Family-centered alternatives to recognize/detect, monitor, control or manage health condition or problems Determine Methods of Nurse-Family Contact Specify Resources Needed

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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: National Tuberculosis Program Direct Observed Short Course Treatment (NTP-DOTS) Integrated Management of Childhood Illness (IMCI) Control of Diarrheal Diseases (CDD) DOH DOH Major Functions hospital services direct hospital service delivery hospital development services Public health services public health policy development and assistance services - local health systems development Health regulation services and administration regulation of food, drugs, health facilities & development health financing systems administration DOH Priority Programs

National TB Control Program

major public health threat 3.1/1000 population is sputum positive (1997) males are affected age group at risk is 30-59 years

Vision: A country where TB is no longer a public health problem Mission: Ensure that TB DOTS Services are available, accessible, and affordable to the communalities in collaboration with LGUs and others 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 Objectives: 1. Improve access to and quality of services 2. Enhance stakeholder's health-seeking behavior 3. Increase and sustain support for TB control activities 4. Strengthen management of TB control activities at all levels 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 DOTS Strategy internationally-recommended TB control strategy Five Elements of DOTS: (RUSAS) Recording & reporting system enabling outcome assessment of all patients Uninterrupted supply of quality-assured drugs Standardized SCC for all TB cases Access to quality-assured sputum microscopy Sustained political commitment 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

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 hemoptysis or blood streaking at any time 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 TREATMENT: SCC/Short Course Chemotherapy, Direct observed treatment short course/DOTS; Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S)

CATEGORY 1: 6 months SCC Indications: > new (+) smear > (-) smear PTB with extensive parenchymal lesions on CXR > Extrapulmonary TB > severe concominant HIV disease Intensive Phase: 2 months R&I : 1 tab each; P&E 2 tabs each Continuation Phase:

CATEGORY 2: 8 months SCC Indications: > treatment failure > relapse > return after default Intensive Phase:3 mos R&I 1 tab each; P&E 2 tabs each Streptomycin 1 vial/day IM for first 2 months = 56 vials (if given for > 2mos can cause nephrotoxicity Continuation Phase: 5 months

CATEGORY 3: 6 months SCC Indications: > new (-) smear PTB with minimal lesions on CXR Same meds with Category 1 Intensive Phase: 2 months R&I 1 tab each; P&E 2 tabs each Continuation Phase: 4 months R&I 1 tab each CATEGORY 4:

SIDE EFFECTS: Rifampicin body fluid discoloration hepatotoxic permanent discoloration of contact lenses Isoniazid Peripheral neuropathy (Give Vit B6/Pyridoxine) Pyrazinamide hyperuricemia /gouty arthritis

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4 months R&I : 1 tab each

R&I : 1 tab each E : 2 tabs

Chronic (*Referral needed)

(increase fluid 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 MANAGEMENT OF CHILDREN WITH TUBERCULOSIS Prevention: BCG immunization to all infants (EPI) Casefinding: - cases of TB in children are reported and identified in 2 instances: (a) patient was screened and was found symptomatic of TB after consultation (b) patient was reported to have been exposed to an adult TB patient - ALL TB symptomatic children 0-9 y.o, EXCEPT sputum positive child shall be subjected to Tuberculin testing (Note: Only a trained PHN or main health center midwife shall do tuberculin testing and reading which shall be conducted once a week either on a Monday or Tuesday. Ten children shall be gathered for testing to avoid wastage. - Criteria to be TB symptomatic (any three of the following:) * cough/wheezing of 2 weeks or more * unexplained fever of 2 weeks or more * loss of appetite/loss of weight/failure to gain weight/weight faltering * failure to respond to 2 weeks of appropriate antibiotic therapy for lower respiratory tract infection * failure to regain previous state of health 2 weeks after a viral infection or exanthem (e.g. measles) -Conditions confirming TB diagnosis (any 3 of the following:) * (+) history of exposure to an adult/adolescent TB case * (+) signs and symptoms suggestive of TB

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* (+) tuberculin test * 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 - for TB symptomatic children *a TB symptomatic child with either known or unknown exposure to a TB case shall be referred for tuberculin testing * (+) contact but (-) tuberculin test and unknown contact but (+) tuberculin test shall be referred for CXR examination *(-) CXR, repeat tuberculin test after 3 months * INH chemoprophylaxis for three months shall be given to children less than 5y.o. with (-) CXR; after which tuberculin test shall be repeated Treatment (Child with TB): Short course regimen PULMONARY TB Intensive: 3 anti-TB drugs (R.I.P.) for 2 months Continuation: 2 anti-TB drugs (R&I) for 4 months EXTRA-PULMONARY TB Intensive: 4 anti-TB drugs (RIP&E/S) for 2 months Continuation: 2 anti-TB drugs (R&I) for 10 months PERIOD OF COMMUNICABILITY OF TUBERCULOSIS: long as bacillus is contained in the sputum as Primary complex in children is NOT contagious Good compliance to regimen renders person not contagious 2-4 weeks after initiation of treatment

IMCI Integrated Management for Childhood Illnesses

used in countries with limited resources symptom based approach allows classification of disease in children under five integrates management of most common child hood problems (diarrhea, pneumonia, measles, malnutrition, DHF, malaria) Involves family members and community in the health care process for physical growth and mental development and disease prevention

Three components of IMCI upgrading the case management and counseling skills of health care providers strengthening the health system for effective management of childhood diseases improving family and community practices related to child health and nutrition IMCI: CASE MANAGEMENT PROCESS 1. Assess the child or young infant by checking first the danger signs (or possible bacterial infection in

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young infant) 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) 2. Classifying the illness- severity of illness 3. Identifying treatment. - classification chart 4. Treating the child- giving treatment. In health centers, prescribed drugs & teaching mothers how to carry out treatment. 5. Counseling the mother- child feeding, foods and fluids to give & when to bring the child back to the health center 6. Giving of follow-up care GENERAL DANGER SIGNS

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inability to drink or breastfeed convulsions 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 I. Cough or Difficulty in Breathing Assess for danger signs. This child may have pneumonia or another severe respiratory infection. After checking for danger signs, it is essential to ask the child's caretaker about this main symptom 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 Cough or Difficulty in breathing

Child's Age 2 months up to 12 months 12 months to 5 years

Cut-off rate for fast breathing 50 breaths per minute or more 40 breaths per minute or more

Lower chest wall indrawing: the bony structure of the chest wall with inspiration is a useful indicator of severe pneumonia. 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.

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Agitation, a blocked nose or breastfeeding can all cause temporary chest indrawing. 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) Classification of Cough or Difficulty in Breathing

SIGNS (+) danger sign or chest indrawing or stridor in a calm child

CLASSIFY AS

TREATMENT

Severe pneumonia or very severe Give first dose of appropriate pneumonia antibiotic: Cotrimoxazole and Amoxicillin. If the child cannot take an oral antibiotic give the first dose of IM Chloramphenicol (40 mg/kg)/ Benzylpenicillin/ Ceftriaxone. 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 If coughing for > 30 days, refer for assessment soothe the throat and relieve the cough with a safe remedy advice the mother when to return immediately follow-up in five days if not improving

No signs of pneumonia or very severe disease

No pneumonia

Fever

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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 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 - stiff neck

Very severe febrile disease

- fever (by history or feels hot or Malaria temperature 37.5 C or above

- give first dose of quinine - give first dose of appropriate antibiotic - treat the child to prevent low

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- NO runny nose and NO measles and NO other causes of fever

Malaria

- runny nose PRESENT or - Measles PRESENT - Other causes of fever PRESENT - obvious causes of fever - NO obvious causes of fever

FEVER malaria unlikely

blood sugar - treat the fever - REFER IMMEDIATELY to the nearest hospital - Advise follow-up in two days - if fever > 7 days REFER - Treat the fever - advice mother when to return - advise mother to return in two days if fever persists

Possible bacterial infection 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 deaths occur form: a. pneumonia b. laryngotracheitis (67 percent) c. diarrhea (25 percent) d. measles alone e. and a few from encephalitis 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

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measles) Measles: etiology: Measle virus (Paramyxovirus) Clinical manifestations: fever cough coryza 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 - clouding of cornea - deep/ extensive mouth ulcers SEVERE COMPLICATED MEASLES

Management - Give vitamin A - give first dose of appropriate antibiotic - clouding of cornea or pus draining, apply tetracycline - REFER IMMEDIATELY to the nearest hospital - give vitamin A - apply tetracycline if pus draining from eye - apply gentian violet for mouth ulcers - follow-up in 2 days - give vitamin A - Follow-up in 2 days

- pus draining from the eye - mouth ulcers

MEASLES WITH EYES OR MOUTH COMPLICATIONS

- measles now or within the last 3 months

MEASLES

Before classifying fever, check for the other obvious causes of fever (e.g. ear pain, burn, abscess ,

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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. Dengue hemorrhagic fever 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 Gr. IV: Gr. III + profound shock Signs of Shock: Cold clammy extremities Slow capillary refill Other diagnostic aids: Tourniquet test 1. MAP 2. Inflate cuff for 5 mins 3. Draw 1 in. sized square 4. > petechiae/ square inch Typhoid Fever Etio: S. typhi S. paratyphi Clinical Manifestation: Fever Constipation/ diarrhea

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Abdominal pain Anorexia Vomiting Headache Hepatosplenomegaly- 2nd week Rose spots Malnutrition and Anemia 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 Edema of both feet kwashiorkor nephrotic syndrome Classification of Nutritional Status and Anemia Severe Malnutrition or Severe Anemia visible severe wasting severe palmar pallor edema of both feet Anemia or Low (or very low) weight for age some palmar pallor (very) low weight for age No anemia and Not very Low Weight not (very) low weight for age no other signs of malnutrition 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

Assessing Childs feeding breastfeeding frequency & night feeds types of complimentary foods or fluids, frequency of feeding & whether feeding is active

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feeding patterns during the current illness

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 9 months- measles Checking immunization status 4 common situations that are contraindications to immunization of sick children - children who are being referred urgently to the hospital - live vaccines should not be given to children with immunodeficiency diseases or those who are immunosuppressed due to malignant disease, therapy with immunosuppressive agents or irradiation - DPT2/DPT3 should not be given to those who had convulsions or shock within 3 days of a previous dose of DPT - DPT should not be given to those with recurrent convulsions or another active neurological disease of the CNS

CDD (CONTROL OF DIARRHEAL DISEASES)

MANAGEMENT OF THE PATIENT WITH DIARRHEA 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 THREE RULES FOR HOME TREATMENT 1. Give the child more fluids than usual use home fluid such as cereal gruel give ORESOL, plain water 2. Give the child plenty of food to prevent undernutrition - continue to breastfeed frequently - if child is not breastfeed, give usual milk - if child is less than 6 months and not yet taking solid food, dilute milk for 2 days - if child is six months or older and already take solid food, give cereal and other starchy food mixed with vegetables, meat or fish; give fresh fruit juice or mashed banana to provide potassium; feed child at least 6 times a day. After diarrhea stops, give an extra meal each day for two weeks 3. Take the child to the health worker if the child does not get better in 3 days or develops any of the following: - many watery stools repeated vomiting marked thirst eating of drinking poorly fever

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blood in the stool ORESOL TREATMENT

Age < 24 months 2-10 years 10 years up

Amount of ORS to give after each loose stool 50- 100 ml 100-200 ml As much as wanted

Amount of ORS to provide for use at home 500 ml/day 1000 ml/day 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 APPROX. AMT OF ORS- To give in 1st 4 hrs

Age 4 mos 4-11 mos. 12-23 mos. 2-4 yrs 5-14 yrs 15 yrs up

Weight kg 5 w 5- 7.9 - 8-10.9 - 11-15.9 - 16- 29.9 30 up

ORS ml 200-400 400-600 600- 800 800-1200 1200-2200 2200- 4000

1. if the child wants more ORS shown, give more 2. Continue breastfeeding 3. For infants below 6 months, who are not breastfeeding, give 100-200 ml clean water during the period 4. For a child less than 2 years give a teaspoonful every 1-2 mins 5. If the child vomits, wait for 10 min, then continue giving ORS, 1 tbsp/2-3 min 6. If the child's eyelid become puffy, stop ORS, give plain water or breastmilk, resume ORS when puffiness is gone 7. If (-) signs of DHN- shift to Plan A Use of Drugs during diarrhea Antibiotics should only be used of dysentery and suspected diarrhea antiparasitic drugs should only be used for amoebiasis and giardiasis C. SEVERE DEHYDRATION

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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. 2. 3. 4. Bring pt to hospital IVF- lactate Ringers solution or normal saline Reassess pt every 1-2 hrs Give ORS as soon as the pt can drink

ROLE OF BREASTFEEDING IN THE CONTROL OF DIARRHEAL DISEASES 1. Two problems in CDD high child mortality due to diarrhea high diarrhea incidence among under fives Highest incidence in age 6- 23 months highest mortality in the first 2 years of life Main causes of death in diarrhea dehydration malnutrition 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 Summary of WHO-CDD recommended strategies to prevent diarrhea 1. improved nutrition - exclusive breastfeeding for the first 4-6 months of life and partially for at least one year 2. Use of safe water

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- collecting plenty of water from the cleanest source - protecting water from contamination at the source and in the home 3. Good and personal domestic hygiene - handwashing - use of latrines - proper disposal of stools of young children 4. Measles immunization Nursing that considers the health of the family as a unit in th, values and productivity of individual family members. 3. Identification of goal of care for priority problems 4. Parameters for selecting nursing interventions: a. Applicable, appropriate and available to the home community setting b. Promotes client safety, comfort & hygiene c. Standards of care & interventions that address acute and chronic illness 5. Principles of collaboration and advocacy to be considered to ensure continuity of care

C. Implementation of Individual & Family Health Nursing Care

1. Component of care in acute and chronic illness Acute Illness has a rapid onset of symptoms that lasts for a limited and relatively short period of time e.g. typically less than six months 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 characterized by periods of remission and exacerbation remission symptoms disappear exacerbation symptoms reappear

a. Health promotion not disease oriented, motivated by personal, positive approach to wellness seeks to expand positive potential for health Levels of health promotion individual wellness family wellness community wellness

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environmental wellness societal wellness Incorporates the following identification of health risks reduction of health risks preventive measures screening tests 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 Behaviors associated with health promotion stop smoking or do not start smoking avoid over exposure to the sun support antipollution legislation practice safe sex, monogamy, or abstinence obtain genetic counseling for family-linked disorders design and follow a regular exercise plan maintain ideal body weight maintain a low cholesterol, low-fat, high fiber nutrients wear seat belt and helmet identify and eliminate stressors limit alcohol intake, and never drink and drive have regular dental care 6-8 hours of sleep 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 Primary level of disease prevention / health protection through people

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environmental control Provided at health care/ RHU Brgy, Health stations main health center community hospital and health center private and semi-private agencies 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 e. Rehabilitative/ restorative/ third level of disease prevention- assisting/restoring the individual with a handicap to realize his or her particular goals, physically, mentally, socially and economically; helps client to recover emphasis on existing abilities encourages independence promotes productive lifestyle Goals

prevention of complications/ disabilities, etc. restraining in lost skills learning new skills when highly-specialized medical care is necessary referrals are made to hospitals and medical center such as PGH, PHC, POC, National Center for Mental Health and other government and private hospitals at the municipal level

Functional losses cause: resentment anger frustration withdrawal depression grief Basic nursing care:

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bowel/bladder retraining adaptive devices for assisting with activities of daily living ambulation devices and transfer aids ROM prosthetic devices body mechanics cast care 2. Bio-behavioral interventions and holistic care for individuals & Family with specific problems in oxygenation, fluid and electrolyte balance, metabolic and endocrine function FOR PROBLEMS IN OXYGENATION 1. Promoting proper breathing and lung expansion inhale through the nose, exhale through the mouth hourly or 4x/ day while awake 2. Pursed lip breathing rationale- to prolong expiration, slow RR thereby increasing ventilation, and therefore decrease work of breathing indication- COPD, dyspneic and anxious patients positioning- sit upright technique- inhale via nose for 3 counts, exhale through purse lips for 7-8 counts 3. Abdominal/ Diaphragmatic Breathing rationale- decrease air trapping and work of breathing; e.g. COPD, thoracic surgery/ injury, women in labor to promote relaxation and provide pain control position- initially supine, then practice while sitting or standing technique- one hand on abdomen and other on middle chest often used with pursed lip breathing (Drawings of chest tube drainage) 1. Incentive spirometry rationale- to provide visual feedback about inspiratory volume indications- postoperative patients Types: flow-oriented: elevated balls with inspiration as long as possible volume-oriented 2. Blow bottles transfer fluids from one container to another by air pressure using exhalation disadvantage provide feedback only about exhalation; benefit only deep breath has taken before blowing may be used for children (?) 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 Promoting effective coughing

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1. Proper coughing technique position- upright technique- take 2 slow, deep breaths, hold breath on 3rd breath for 3 counts, and cough full 2-3 times frequency- 2-3x every 2 hours while awake esp. for post-operative patients; teach pre-operatively 2. Cascade Cough 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 Mobilization of Pulmonary Secretions 1. Hydration 2. Humidification- process of adding water to gas keeps airways moist and lessens/mobilizes pulmonary secretions routinely used with oxygen therapy to prevent drying of airways 3. nebulization- process of adding moisture or medications to inspired air by mixing particles of varying sizes with the air (aerosol principle) Major types: jet-aerosol nebulizer- uses gases under pressure ultrasonic nebulizer- uses high frequency vibrations to break up water or medications into fine drops or particles; produces smaller size droplets than jet nebulizers 4. Chest Physiotherapy a. chest percussion: Contraindication: chest injury, bleeding disorders, TB with bullae b. vibration - applied on exhalation - contraindicated in children and infants c. coughing or suctioning d. oral care 5. Postural drainage 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

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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 o low-flow- affected by the pattern of breathing hypoxic drive- will stimulate breathing of people with COPD

Maintenance of a Patent Airway 1. Proper Positioning 2. Coughing 3. Suctioning Rationale: when client is unable to clear respiratory tract secretions with coughing Routes: o Oropharyngeal and nasotracheal suctioning: client can cough but cannot expectorate or swallow secretions o Orotracheal and nasotracheal suctioning- client cannot cough at all o Suctioning on artificial airway A sterile technique Suction oropharynx and trachea first before the mouth (from sterile to clean) Not more than 15 seconds Allow patient to rest between passes of catheter; if with oxygen or ventilator. Replace cannula, mask, tube right away Artificial Airways: Emphasize roles of nurses in making sure these adjuncts are in place and patent Oral airway (S tube): Insert with curve toward cheek then turn downwards Flange (flat part) should rest against clients teeth NURSING PROCESS AND FLUID, ELECTROLYTE AND ACID BASE BALANCE Assessment identify any presence of alterations and extent to which body systems are involved determine the effectiveness of therapies as well as adverse reactions to treatment anticipate needs for nursing care 1. Nursing History: identify potential or actual risk factors that increase the client's chances of fluid, electrolyte and acid-base imbalances

conditions that lead to inadequate oral intake excessive fluid loss stress chronic illness

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surgery pregnancy

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: 1. maintain an approximate balance between fluid intake and output 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 When an imbalance exists: 1. client's fluid, electrolyte and acid-base balance are restored and maintained 2. causes of imbalance are identified and corrected 3. client has no complications from therapies needed to restore balance

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: Fluid volume deficit related to loss of plasma associated with burns vomiting failure of regulatory mechanisms Fluid volume excess related to: sodium retention compromised regulatory mechanisms High risk for fluid volume deficit changes in mental status (occur with changes in serum osmolality) changes in vital signs (RR and depth, HR and rhythm, postural PR and BP) abnormal tissue hydration (poor skin turgor, edema) + 2mm just perceptible ++ 4-6mm moderate +++ } ++++ severe

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pitting edema: skin indentation remains for 15-30 seconds; not apparent until there is approximately 10% increase in the body weight ascites- measure abdominal circumference

abdominal muscle tone or sensation (neuromuscular excitability, irritability, muscle weakness, twitching, cramping) neck veins central venous pressure: pressure in the right atrium or vena cava; normal pressure is approximately 4-11 cm of water

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

3. Strategies in meeting health problems of family a. Promoting behavior change b. Creating a supportive environment towards healthy lifestyle 4. Principles of behavior change Behavior Changes in Stages (from Transtheorethical Model) 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)

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5. Referral system 6. Concept & principles of collaboration & advocacy

D. Evaluation of progress and outcome of care

1. Methods & tools in evaluating effectiveness of family health interventions 2. Sources of evaluative data 3. Alternative strategies & approaches for specific problems & objectives

E. Ensuring a well organized & accurate documentation & reporting

1. Standard format 2. Legal principles involved in documentation

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