Example: Tetanus toxoid – prevent preterm

birth or infection
MCN CONCEPT
12 DOH STANDARDS OF PRENATAL CARE
PRENATAL CARE
According to DOH, it is recommended before to
THE PURPOSE OF PRENATAL CARE IS TO have at least 4 visits, now, it should be at least 8
ENSURE AND UNCOMPLICATED PREGNANCY visits because statistics says…
AND THE DELIVERY OF A LIVE AND HEALTHY
INFANT Back in 2015, 303,000 pregnant women died, 2.7M
babies died, and 2.5M babies are pre-mature who
BALANCE OF FORCES IN PREGNANCY died.

BALANCE BETWEEN: RECOMMENDED VISITS

● FETAL SURVIVAL DOH advises at least 8 visits…

● MATERNAL SURVIVAL
1ST Visit – first 12 weeks (1st Trimester)
5 BRANCHES OF MATERNAL HEALTH
2nd – 20 weeks
● Nutrition
3rd – 26 weeks
Kcal requirement for a normal adult is 2,200 kcal, if
pregnant woman add 300 kcal, making it a total of 4th – 30 weeks
2,500 kcal.
5th – 34 weeks
➢ Promote health of mother
6th – 36 weeks
➢ Promote adequate weight gain through
sufficient balance of nutrient and protein 7th - 38 weeks
intake (44-50g CHON)
8th – 40 weeks
➢ Promote consistent & continued use of
micronutrient supplements. E.g. Folic Acid, But the most IDEAL ONE are….
etc.
1 month – 28 weeks; 4 – 28 weeks OR 1 month to
7 months à every 4 weeks or once in a month
● Prenatal care
● Safe delivery 28 – 36 weeks OR 7 – 9 months à once in every 2
● Breastfeeding weeks or twice a month
● Family planning
36 – 42 weeks OR more than 9 months à every
PRENATAL CARE week or once in a week
★ Regular prenatal care increases the
chances of a healthy mother and child after 1. Weight
birth
Example: Giving schedules when to visit to ● 20-25 lbs. - normal weight gain of a
the obgyne pregnant woman; 11.2 – 15.9 kg; some says
25-30 lbs. à Max. 1 kg/month (?)
★ Early detection of congenital & birth
defects; monitor fetal and maternal status ● If beyond or below the normal value it can
Example: 4D fetal profile can help identify be considered to have complication (e.g.
birth defect and congenital anomaly that GDM, intrauterine growth constriction)
we could prevent and lessen the risk
2. Height
★ Prenatal immunizations can prevent
mother-to-child-transmission and infection ● Determined with BMI
 ● Height matters especially when the baby is
big and the mother is short, the pressure in
the lower extremities like edema which
compromises the oxygenation. This is why
the mother needs to regulate nutrition.

3. Blood pressure

● Very important to prevent pregnancy

induced hypertension (PIH).

● However, all VS parin ang imonitor but

highlight ang BP.

4. FHT

● 120 – 160 – normal FHT

5. Fundic height
● use tape measure
A. start at the symphysis pubis to
fundus

➔ 5th month = 20 cm
➔ 6th month = 21-24 cm
➔ 7th month = 25-28 cm
➔ 8th month = 29-30 cm
➔ 9th month = 30-34 cm

6. Leopold’s maneuver

● Check for presentation, fetal back,

engagement, flexion

● Warm hands

● Urinate prior to assessment

● Lying down position

C – Pawlik’s Grip (Engagement)

● If it is in line with the ischial spine.

● If mulihok, ENGAGED; if dili mulihok, NOT

ENGAGED.

D – Pelvic Grip (Attitude)

● Degree of flexion of fetal head.

A – Fundal Grip (Presentation) 7. TT immunization

● Comes in contact with the cervix.

TETANUS WHEN TO GIVE IMMUNITY
TOXOID
B – umbilical Grip (Position)
TT1 Anytime during None
● Maternal presentation in relation to the
maternal quadrant pregnancy

TT2 4 weeks after TT1 1-3 years

TT3 6 months after 5 years

TT2
 TT4 1 year after TT3 10 years
● Leukocyte
➔ WBC or leukocytes
TT5 1 year after TT4 lifetime
➔ Are cells of the immune system
involved in defending the body
8. Diet against both infectious disease and
foreign materials
9. Danger signs of pregnancy
● Thrombocytes (platelet)
● For Fetus: absence of movement (as the
➔ Cells that play a key role in blood
fetus could possibly be dead)
clotting
10. Breastfeeding
➔ Low = bleeding can occur
11. Family planning
➔ Too high = blood clots can form
12. Postpartum care – as early as prenatal check thrombosis which may obstruct blood
pa, gina ingon nan isa buntis vessels and result in such events as
a stroke
- For 6 weeks, or once the incision is healed or
lochia is absent or gone. ➔ Thrombocytopenia – blood platelet
count falls below normal
HISH RISK MOM
● Blood Typing
What is High Risk Pregnancy? ➔ Type A blood = can only receive
types A and O blood
● Poor maternal or fetal outcome due to:
➔ Type B blood = can only receive
➢ Medical (nasakit before or prior to types B and O blood
pregnancy)
➔ Type AB blood = can receive types
➢ Reproductive (uterus can be too small A, B, AB, and O blood
to accommodate a growing fetus;
Bicornuate uterus; deformities involve in ➔ Type O blood = can only receive O
pregnancy; incompetence cervix; fetal
blood
complication can also occur)

➢ Psychosocial (postpartum depression,

psychosis)
● Rhesus Factor
➢ Obstetrical (related to reproductive; ➔ Is an antigen found in RBCs
irregular menstruation)
➔ If the mother is found Rh (-) and
SCREENING: DIAGNOSTIC AND LAB
EXAMINATIONS ➔ If the father is Rh (+) blood, the
mother needs to receive a treatment
COMPLETE BLOOD COUNT to help prevent the development of
substances that may harm the
● Hemoglobin unborn baby
➔ Is a protein in red blood cells that
carries oxygen ➔ RhoGAM – medication to prevent

➔ Female: 12.1 to 15.1 gm/Dl

URINALYSIS
(Alternative Names Hgb; Hb)
Standard operating procedure in admitting a client
● Hematocrit who is pregnant
➔ Aka Ht or HCT, or erythrocyte
❖ Pus cells – infection or bacteria
➔ Is the volume percentage (%) of red
blood cells in blood ❖ Bacteria

➔ It is normally about 45% for men and ❖ Protein/albumin (for GDM) – PIH,
40% for women preeclampsia

➔ Example: 25% - in 100 mL of blood, ❖ Sugar (UTI)

there is 25 mL of RBC
 ❖ Squamous epithelial cells (example lab ★ abnormal findings on a physical
result: +++) - Represent possible exam, such as cysts, fibroid tumors,
contamination of the specimen with skin or other growths
flora;
★ abnormal vaginal bleeding and
galing ito sa vaginal tissues kaya dapat if menstrual problems
mag ihi, midstream clean catch ang iapply
★ certain types of infertility
para walang epithelial cells, as it could
indicate false positive results. ★ ectopic pregnancy (sa fallopian tube
mag grow)
PAP SMEAR
★ pelvic pain
● Papanicolaou Smear
BLOOD GLUCOSE TEST
● Is done to screen for the presence of cellular
anomalies of the cervix and endocervical Types:
canal
● FBS
● A screening test that tests for precancerous ❖ FASTING BLOOD SUGAR
or cancerous cells in the cervix.
❖ Measures blood glucose after NPO
● Empty your bladder just before the test for at least 8 hours
● Done every 3 years ❖ It is often the first test done to check
for prediabetes and diabetes
● 3 negative results = every 5 years
● HGT/CBT
● Normal result = means there are no ❖ HEMAGLUCOTEST/CAPILLARY
abnormal cells present BLOOD GLUCOSE

❖ Measure the glucose (sugar)

content in the blood

❖ Is done on a regular basis in

ULTRASONOGRAPHY diabetes patients to determine their
glucose level
TRANSABDOMINAL
❖ Normal = 90-120
● Patient is lying down
❖ Use to check if medication is
● Using a transducer with a lubricant to hear effective or not.
the heartbeat and see the baby
❖ Fasting can be done at least 2 hours.
● Help detect or check fetal health and
❖ NORMAL is around 80 – 120 mg/dL;
physical appearance.
60 – 120 mg/dL
TRANSVAGINAL ● OGCT
❖ ORAL GLUCOSE CHALLENGE
● Usually during 1st Trimester; to confirm if
TEST
nitubo sa uterus or sa endometrium
❖ NPO or not, drink grams of glucose,
● is a test used to look at woman’s
after 1 hour blood sample is taken
reproductive organs, including the uterus,
ovaries, and cervix ❖ If positive proceed to OGTT
● empty or half-filled bladder ● OGTT
● done to identify fetal abnormalities. Between ❖ ORAL GLUCOSE TOLERANCE
18 and 40 weeks gestation TEST

❖ NPO 6-8 hrs

● may be done for the following problems:
❖ Taken after drinking a sweet liquid
that contains glucose
 ❖ Inform medtech for blood test X3 ❖ Gastroschisis
(1HR.2HR.3HR.) ❖ Spina bifida

❖ Mas mag take time ito kasi may ● It is a screening test not diagnostic test
fasting; 3 takes
● It only signals that further testing should be
❖ 75g Glucose done

❖ Dapat hutdon ang drink in 1 sitting! ● Most accurate during the 16th to 18th week

● Done between 15 – 20 weeks

NOTES: WHEN TO TAKE OR THE NUMBER OF ● NORMAL: 10 – 150 ng/mL; if GREATER

TAKES THAN 150, there is neural tube defect; if
LESS THAN 10, indicates abnormality like
1. NPO - inom ng Glucose after; Example: 8 Trisomy 21 (down syndrome)
AM
2. 1 hour after Glucose drink; Example: 9 AM ● The Alpha-Feto Protein is found n the
3. 2 hours after garbage drink; Example: 10 LIVER.
AM (?)
● Especially recommended for:
According to the American Diabetic
Association… ➔ Women who have family history of
birth defects
1. BEFORE MEALS – 95 mg/dL ➔ Women who are 35 years or older
2. 1 HOUR AFTER – 140 mg/dL or lesS ➔ Women who used possible possible
3. 2 HOURS AFTER – 120 mg/dL or less harmful medications or drugs during
pregnancy
● 2 HOURS POST PRANDIAL ➔ Women who have diabetes
❖ Measures blood glucose exactly 2
hours after you start eating a meal ANENCEPHALY
AMNIOCENTESIS
● a fetal congenital disorder where the cranial
● Check for chromosomal abnormalities, bones are undeveloped
infection and fetal sex
● is the absence of major portion of the brain,
● Risk = miscarriage skull, and scalp that occurs during
embryonic development
● Anesthesia – abdominal wall – uterus –
amniotic sac ● it is a cephalic disorder that results from a
neural tube defect that occurs when the
● Guided by an ultrasound! rostral (head) end of the neural tube fails to
close, usually between the 23rd and 26th
● Done during the 14th to 16th week day of conception (ovulation to implantation)
CHORIONIC VILLI SAMPLING ● dies after an hour

● Done late in the first trimester, @ 10th and ● absence of fetal blood
12th weeks. Or 15-20 wks
GASTROSCHISIS
● To check chromosomal defect, genetic
disorder especially if woman is 35 year old
and above ● a fetal complication of teratogens where fetal
abdominal cavity fails to close
❖ Down syndrome
❖ Neural tube defect ● represents a congenital defect characterized
by a defect in the anterior abdominal wall
● 8 – 10 weeks pa si placenta through which the abdominal contents freely
protrude
MATERNAL SERUM ALPHA-FETO PROTEIN
● abdomen did not close
● High levels of AFP = fetal neural defect:
❖ Anencephaly ● related factors:
 ★ infection (deprivation of oxygen) ➢ Genetic studies
★ young maternal age ➢ Rh incompatibility
★ Smoking ➢ Hydrops fetalis
★ drug abuse
★ low birth/gestational age (early labor ● Blood from the umbilical cord
= premature baby)
BIOPHYSICAL SCORING
SPINA BIFIDA
● 30 minutes observation by USD

● Is a prenatal ultrasound evaluation of fetal

● birth defect in which bones of the spine well-being involving a scoring system, with the
(vertebrae) do not form properly around the score being termed Manning’s score
spinal cord
● DONE IF NST IS NON REACTIVE & OTHER OB
● also known as “spilt spine” INDICATION

● incomplete closing of embryonic neural tube ● 24 – 28 weeks AOG

● bottom part of the spinal column ● 5 MARKERS:

DOPPLER VELOCIMETRY ➢ Non Stress Test

➢ Fetal breathing
● Aka – Umbilical Velocimetry ➢ Amniotic fluid index
➢ Fetal body movement
● Helpful in assessing uteroplacental ➢ Fetal tone
insufficiency before asphyxia occur Could
be: EXAMPLE: All markers are scored 2 as it is the normal
count, garnering a total of 8 – 10. Ginatan-aw ang FETAL
TONE sa ultrasound.
● Umbilical compression
BIOPHYSICAL SCORING (BPS)
● Head compression
INTERPRETATION
● Non-invasive – USD

● Assess placental function SCORE INTERPRETATION

● A Doppler-handheld device directed to artery

reflected to RBC’s creating waveform 8 – 10 Normal Fetus

● Can determine whether flow rates are

adequate in the uterine artery, placenta and 6 Chronic asphyxia
umbilical cord vessels.
(repeat the procedure
● Checks the blood flow from placenta to baby
after 24 hours)
● Not performed with low risk

● IUGR – Intrauterine Growth Restrictio 4 Abnormal result

● Preeclampsia
2 Ill fetus, terminate
NOTES!!! DIFFERENCE BETWEEN NON
STRESS TEST (NST) and CONTRACTION pregnancy
STRESS TEST (CST)
Note: Ask permission to the mother of
- NST checks the acceleration termination or observe more if it has low score!
- CST checks the deceleration NON STRESS TEST (NST)
PERCUTANEOUS UMBILICAL BLOOD ● Determines the response of the fetal heart
SAMPLING rate to fetal movements @ 28 weeks

● blood technique used for obtaining rapid

chromosomal diagnosis such as:
 ● Normal = 8-18 cm
SCORE INTERPRETATION
● Moderate 14cm @ 20-35 weeks

● 36 weeks onwards – AF is decreasing

2 2 or more FHT
acceleration per ❖ OLIGOHYDRAMNIOS = < 5 - 6cm
movement (normal is ❖ POLYHYDRAMNIOS = > 20 - 24cm
REACTIVE)
FETAL BODY MOVEMENT

1 < or less than 2 ● Instruct mother to press on the marker if

accelerations per there is fetal movement

● Usually use vas to awaken the baby

0 No accelerations

SCORE INTERPRETATION
FETAL BREATHING

● Checks movement of baby’s diaphragm 2 With 3 or more discrete

movement of limbs and
body in 30 mins
SCORE INTERPRETATION

1 Less than 3 movements

2 1 episode within 30
minutes monitoring
lasting 30 seconds 0 No movements

0 No episode more than FETAL TONE

30 minutes

Not lasting 30 seconds SCORE INTERPRETATION

2 1 or more episodes of
active extension with
AMNIOTIC FLUID INDEX return to flexion of limbs
and trunk
● Anteroposterior diameter

SCORE INTERPRETATION 1 Slow extension with

return to flexion

2 Fluid filled pocket of 1

cm or more 0 No movements

0 No amniotic fluid or less

than 1 cm in every
pocket HEPATITIS B DETERMINATION

(2 – 8 cm each pocket); ❖ Hepatitis B surface Antigen (HBsAg)

movement (7 – 25 cm) ● Reactive = positive (can infect using
blood)
● Non-reactive = negative (good result)
● AFI is the score (expressed in cm)

● 4 quadrant technique
Note: if positive, there is an option to take the
FETAL MOVEMENT COUNTING
patient’s case; then do double gloving, soak
instrument separated from those with non-hep B ● done after 27 weeks AOG
patients; 30 mins:non for positive then it takes 1
hour for disinfection of instruments) ● (viable na man ang 28 weeks so justifiable
na dapat ganito na talaga ang number of
❖ Hepatitis B surface Antibodies (HBsAb) movement
● The test that looks for antibodies that ● twice daily for 20-30 minutes
your immune system makes in
response to the surface protein of the NORMAL = 5-6 movements in 20-30 minutes
hepatitis B virus,

● Qualitative (either – or +) ABNORMAL = less done 3 movements in 1 hour

● Quantitative (eg. <10 mIU/ml)

CONTRACTION STRESS TEST (CST) MEDICAL COMPLICATIONS DURING

PREGNANCY
● Done after 32 weeks AOG (check how well
the fetus cope with the stress of uterine
contraction)
CARDIOVASCULAR DISORDERS
★ is performed near the end of
pregnancy to determine how well the PREGNANCY
fetus will cope with the contractions
of childbirth ● increase blood volume 40 - 50%
★ how to know if able to cope with the
uterine contraction: no decelaration; ● increase cardiac output
normal
(normally mag increase talaga ang blood volume
● 32 weeks and beyond: there is always during pregnancy. It is normal because of the fetal
contraction demand, blood loss, gina anticipate ang return of
blood going back to the heart. )
● Negative = normal; no fetal decelartion
● decrease BP during the first trimester
● Positive = abnormal; with FHT

(normal because of the fetal demand)

FETOSCOPY
● increase size of ventricular chamber
● direct visualization of the fetus through a (because to accommodate the larger amount of
scope blood that increases due to pregnancy)
● is an endoscopic procedure during ATRIAL SEPTAL DEFECT (ASD)
pregnancy to allow access to the fetus, the
amniotic cavity, the umbilical cord, and the (atrial - upper, septal - septum the one that divides)
fetal side of the placenta.
● Asymptomatic
(fetal side - shiny schultz, clean part of the placenta) ● increase pulmonary blood (kay naa may
butas)
● obtain sample tissues or blood
● pulmonary hypertension (because
● may perform intrauterine fetal surgery constricted ang mga vessel so ang pressure
increased)
● EVALUATE, TREATMENT DURING
PREGNANCY VENTRICULAR SEPTAL DEFECT (VSD)

● left ventricular hypertrophy

● pulmonary hypertension
● biventricular hypertrophy
(mag increase ang tissues diri sa ventricles. and (the higher the classification mas severe na ang
pag increase ang tissues mahirapan sya mag heart problem)
pump og blood so less ang iya ma pump nga
blood to the lungs and that is not enough. basta
gani dili good ang anatomical structure, mag
create jud na sya og problem kay dili na man JUDGEMENT OF SAFETY IN
good ang blood flow) PREGNANCY
PATENT DUCTUS ARTERIOSUS (PDA)
CONCEPTION SHOULD BE PREVENTED IF:
● Rare
1. Severe heart disease
● early surgical repair
● similar symptoms with VSD 2. Functional classification: class III-I
RHEUMATIC HEART DISEASE (RHD) 3. History of heart failure

● caused by Group A Beta Hemolytic 4. Pulmonary hypertension

Streptococcus (untreated na mga tonsillitis
pwede mag resort to this condition) 5. Right to left shunting
● Inflammatory process 6. Severe arrhythmia
● autoimmune disease
7. rheumatic fever
● scarring of the valves (scarring of the valves
8. combined valve disease
would also somewhat contribute to the
malfunctioning of the heart) 9. acute myocarditis

SIGNS AND SYMPTOMS OF CARDIAC

DISEASES MANAGEMENT OF CARDIAC DISEASE
● shortness of breath ● Rest

● Palpitations ● termination of pregnancy by CS

● orthopnea (shortness of breath when lying ● weight reduction

flat)
● prevent infection
● expectoration of blood
● digoxin (decreases HR)
● cyanosis (discoloration due to lack of
oxygen)
● diuretics (promotes urination)
● murmur (abnormal heart sound)
NURSING CARE OF CARDIAC DISEASE
● heart enlargement (due to di na maka pass
through ang blood to the heart) ● Vital signs monitoring

FUNCTIONAL CLASSIFICATION OF CARDIAC ● Provide rest

DISEASES
● Emotional support (empathize with the
patient, understand the feeling of the patient
● Class I - asymptomatic
rather than feeling their feelings)
(naa syay heart problem pero walay symptoms)
● I & O monitoring
● Class II - symptomatic but with
normal activities ● Proper nutrition (avoid fats in the diet)

(makabuhat gihapon og chores pero maka ● Carry out medical orders

feel na sya ng mga palpitations)
● Class III - symptomatic and with less
than normal activities
● Class IV - symptomatic and at rest
 GESTATIONAL DIABETES MELITUS Explanation: During pregnancy, there is formation
of placenta and this is present, HPL or human
● Common topic in DR chorionic somatomammotropin. This hormone can
● GDM is usually “not payat” decrease insulin sensitivity. Insulin = usherette of
● DM can happen even if the patient is not glucose to cells. If there is decrease insulin
pregnant, but when the patient is pregnant it sensitivity, insulin is not performing their functioning
is called Gestational Diabetes Mellitus to carry glucose to cells, so glucose will stay in the
blood.

RISK FACTORS CAUSING GDM: Increase level of glucose in the blood will cross the
placenta (macrosomic baby), so the baby will also
● Obesity (usually walang payat na diabetic) have hyperglycemia. And since the baby does not
have decreased sensitivity to insulin then it will have
● Family History
an increase in insulin, which will result to
● Personal History hyperinsulinemia. This will convert into growth
● Sedentary Lifestyle hormone which will result to big babies or
macrosomic babies. The increase level of glucose
● Improper Diet (sweet, salty and fatty foods) which will also increase the energy in cell
(adenotricosphate) that will lead to macrosomia.
PATHOPHYSIOLOGY OF GDM
FETAL/NEONATAL COMPLICATIONS OF GDM
Human Placental Lactogen
(Human Chorionic somatomammotropin) ● Fetal- naa sa sulod si baby (inside)

● Neonatal – naa na sa gawas (outside)

● Fetal hyperglycemia
Decrease Insulin sensitivity ● Fetal hyperinsulinemia

● Macrosomia (conversion of growth

hormone;it will put a lot of pressure in the
gravid uterus which will result in the opening
Hypeglycemia (hyper- increase; lglycemia- glucose in of cervix prematurely
the blood) ● Prematurity

● Respiratory Distress

Crosses Placental ● Neonatal Hypoglycemia (no increased

supply of glucose after delivery; MGT:
monitor the blood glucose (HGT) in the heel
of the foot of the baby)
Fetal hyperglycemia
MATERNAL COMPLICATIONS OF GDM

● Preeclampsia

Increase insulin ● It is when the blood pressure of the mother

increases
● the blood vessels become narrowed
Fetal hyperinsulinemia ● it is not good that glucose only stays in the
blood, it should travel throughout our body
continuously. However, hypoglycemia occurs
in the case of diabetes
Growth hormone
● one complication must be prevented for it
Increase ATP in cells can lead to another complication
● Polyhydramnios (increase ang thirst due
to increase glucose; POLYDIPSIA –
increase thirst; increase fluid then
Macrosemia increase in AFI)
- Infection (bacteria loves sugar)
 ● Dystocia (difficult labor; imbalance CRITERIA FOR OGTT
between passageway and passenger)
● Postpartum Bleeding (episiotomy and risk
for laceration or early detachment due to The maximum blood glucose values during
weight of baby, birth canal trauma) pregnancy:
● Birth canal trauma ● Fasting: 90 mg/dl
● One hour: 165 mg/dl
● Cesarean delivery (fetal distress;
cephalopelvic disproportion- head is too ● 2 hours: 145 mg/dl
big to pass through the pelvic) ● 3 hours: 125 mg/dl
Fasting and 2 hours Postprandial venous
plasma sugar during pregnancy MANAGEMENT OF GDM

INSULIN > DIET > EXERCISE

● Non-stress testing is performed weekly

FASTING 2 HRS POST RESULT
until 32 weeks gestation
PRANDIAL
★ If the mother is diabetic, the result
of the NST
< 100 mg/dl < 145 mg/dl Not diabetic
★ NST should be monitored
★
100 - 125 125 - 200 Borderline
mg/dl indicates
glucose SUBSTANCE ABUSE DURING
tolerance test PREGNANCY

> 125 mg/dl > 200 mg/dl Diabetic TERATOGEN

● Any agents that interferes with normal

embryonic development
ORAL GLUCOSE CHALLENGE TEST (OGTT)
● substances that can pass through the
● fasting post-midnight placental barrier and will alter the normal
fetal development
● After 1 hr, blood and urine specimen are
➢ nicotine has a teratogenic effect
obtained

● 50 grams glucose intake ALCOHOL

● after 1 hour, blood and urine specimen is ● CNS Depressant

obtained b - this is to check the presence of
glucose it disrupts the normal activity of the brain
● Reduce Anxiety
● a value above 130-140 gms/I one hour after
us used as threshold for performing a 3-hour ● Sedation
OGTT
● Respiratory Depressant
PREREQUISITES OF OGTT
> CNS DEP=INHIBIT BRAIN ACTIVITY
(DECREASE VS = can affect the fetal status)
● Normal diet for 3 days before the test

● No diuretics 10 days before —> it can affect the ALCOHOL EFFECTS ON FETUS
result
● Fetal Alcohol Syndrome (FAS)
● At least 10 hours fasting —> there should be
a particular time in performing this to avoid
● Intrauterine Growth Restriction
delayed procedure
● Preterm Delivery
● Test is done in the morning OPIOIDS

● Morphine

● Heroin
 ● Methadone LIFETIME EFFECTS OF SUBSTANCE
ABUSE
● Analgesics (prescription is necessary for
pregnant women) ● Mental retardation
● Physical deformities (FAS)
STIMULANTS ● Developmental problems
IUGR or Intrauterine growth restriction
● Cocaine
● Amphetamine Gastroschisis is a factor for this
● Ecstasy
● Caffeine
ACQUIRED IMMUNODEFICIENCY
EFFECTS OF STIMULANTS SYNDROME (AIDS)

● Increase Concentration ● Caused by HIV

● Alertness ● Transmitted through:
● Paranoia ➢ Blood
● Hypertension ➢ blood product
● Psychosis ➢ Semen
➢ vaginal fluid
STIMULANTS EFFECTS OF PREGNANCY ➢ breast milk

● Preterm labor It is important to know the mode of transmission

● Palpitation since we are handling bloods and secretions in the
● Spontaneous abortion hospital. We have to be mindful and keep ourselves
● Placenta abruption protected.
● Fetal hypertension - there is a possibility for
blood vessels to narrow Wear goggles or glasses to protect the mucus
membrane in the eyes
NICOTINE
Diagnosed by enzyme-linked immunosorbent assay
● cigarettes (ELISA) detect HIV antibodies

PREGNANCY SMOKING (X2 ELISA +) = Confirmed by western blot test

this is done after the diagnostic test for AIDS
● Higher rates of spontaneous abortion,
placenta previa SYMPTOMS OF AIDS

● Preterm labor ● Extreme weakness and fatigue

● Low birth weight infant ● Rapid weight loss

● Frequent fevers with no explanation

● Fetal pulmonary hypertension
● Heavy sweating at night
MARIJUANA
● Swollen lymph glands
In other countries, marijuana is useful for seizures.
● Minor infections that cause skin rashes and
In the Philippines, it is not used as a medication for mouth, genital, and anal sores.
seizures.
● White spots in the mouth or throat
● Relaxant
● Hallucination ● Chronic diarrhea
● Short term memory loss
● A cough that won’t go away
● Low birth weight infant
● Short-term memory loss
 FACT OR FICTION HOW A HEALTH IMMUNE SYSTEM WORKS

1. You can get AIDS from a mosquito bite

FICTION HOW A HEALTHY IMMUNE SYSTEM

WORKS
- HIV is not transmitted by insects

2. You cannot get AIDS by having oral sex with

an infected person PHYSICAL BARRIERS

FACT ● These barriers provide a physical block

against pathogens from entering the immune
- Any type of sexual activity (where bodily system
fluids are exchanged) with an infected
person is a risk of HIV transmission ● SKIN
3. HIV survives well in the environment, so you can
get it from toilet seats and door knobs Avoid having your body hair removed for it
has a significant purpose in our body
FICTION
INNATE IMMUNE SYSTEM
- Scientists and medical authorities agree that
HIV does not survive well in the environment ● Immune system cells that attack foreign cells
- so forget about those toilet seats
in the body occur naturally due to genetic
4. You can get AIDS by hugging person with HIV factors or physiology
who is sweating ● WBC - it increases whenever they sense a
FICTION foreign body or an infection

- Contact with saliva, tears, or sweat has ACQUIRED IMMUNE SYSTEM

never been shown to result in
transmission of HIV ● (adaptive or specific) immunity is not
present at birth
5. You can get AIDS by kissing someone who is ● Vaccines
HIV infected

FICTION
HOW DOES HIV INTERRUPT THE
- It would be extremely unlikely to get HIV NORMAL FUNCTION OF THE IMMUNE
from kissing, even open-mouth deep kissing. SYSTEM?
HIV is transmitted through blood, semen,
vaginal fluids, and breast milks and these HIV INFECTED T-CELL
fluids are not usually present during kissing.
● HIV infects a type of white blood cell in the
6. Condoms are really effective in preventing
HIV transmission body’s immune system called a T-helper cell
(also called a CD4 cell).
FACT
● These vital cells keep us healthy by fighting
- Latex condoms have pores measuring off infections and diseases.
.5mm3, while HIV virus measures only
.005mm3. if the CD4 cells are low in amount, the person is
7. There is a connection between other STD’s
and HIV infection most likely susceptible to infection

FACT CD4 COUNTS

- Having a sexually transmitted disease (STI) ● A measure of the number of helper T-cells
can increase a person’s risk of becoming
per cubic millimeter of blood, used to
infected with HIV up to 10x
analyze the prognosis of patients infected
 with HIV. - the patient has to undergo frequent IV. ASYMPTOMATIC PERIOD
monitoring of CD4 cells
● Time period between seroconversion
● Number of CD4 cells in the blood provides a and onset of HIV/AIDS-related illness
measure of immune system damage ● Duration variable: < 1 year to > 15
years
● CD4 count reflects phase of disease
● Most people remain healthy
(asymptomatic) for about three years
CD4 count: this is where AIDS can be determined
● Duration may depend on
★ 500-1200: normal socio-economic factors
★ 200-500: beginning of HIV illness
● The CD4 count is above 500 cells/ml
★ <200: AIDS V.

PHASES OF HIV/AIDS

1. Infection V. HIV/AIDS-RELATED ILLNESS

2. Window period ● Time period between onset of illness
3. Seroconversion & diagnosis of AIDS
4. Asymptomatic period
5. HIV/AIDS – related illness ● Duration is variable: average about
6. AIDS 5 years
● Illnesses initially mild, with gradual
increase in frequency and severity
I. INFECTION ● CD4 count is between 500 & 200
● HIV invades the system cells/ml

● During this time, large amounts of the virus VI. AIDS

are being produced in the body
● Final phase of HIV/AIDS
II. WINDOW PERIOD
● Duration: without antiretroviral drugs less
● Time between infection and enough than 2 years. with antiretrovirals potentially
antibodies many years
● Duration: approximately 3 months ● CD4 count is below 200 cells/ml
● No symptoms or signs of illness
● Viral loads are high and the person is very
● HIV test is negative infectious
● Virus is multiplying rapidly – viral load is high
IMPORTANT FACTS:
● Person is very infectious
III. SEROCONVERSION ★ Duration of different phases of HIV/AIDS
will vary in different people (because of
● Points at which HIV test becomes positive the status)

● Body starts making antibodies to HIV a few ★ Factors affecting the course of HIV/AIDS
include nutrition, emotional stress, and
weeks after infection access to health care
★ People infected with HIV can infect
● HIV test becomes positive
others at any phase of the disease

● Person may have a mild flu-like illness, MOTHER-TO-CHILD TRANSMISSION

lasting a week or two
● 25-35% of HIV positive pregnant mothers
will pass HIV to their newborns = from
● Afterwards, the person is well again maternal to fetal circulation

● 30% of transmission in uterus

 ● 70% of transmission during Labor & Delivery
= greater chance of mixture of maternal and Obstetric Procedures to be avoided
fetal blood
● Amniotomy
● 14% transmission with breastfeeding
● Fetal scalp electrode/sampling
INTERVENTION TO REDUCE
MOTHER-TO-CHILD TRANSMSSION ● Forceps/vacuum extractor

● HIV testing in pregnancy ● Episiotomy

● Vaginal tears
● Antenatal care

● Antiretroviral agents INTRAPARTUM MANAGEMENT DURING

LABOR AND DELIVERY
● Obstetric intervention
Intrapartum Management during Labor and
● Avoid amniotomy Delivery

❖ Avoid procedures: Forceps/vacuum ● Goal is to minimize duration of labor =

extractor, scalp electrode, scalp because kung longer ang labor mas daghan
blood sampling ang procedure and ma expose to a lot of
infection
❖ Restrict episiotomy
● Do not rupture membranes = because it
❖ Elective cesarean section
gives way for the virus or any infection to
❖ Remember infection prevention ascend
practices
● Avoid invasive monitoring
● Newborn feeding: Breastmilk vs. Formula
● Avoid episiotomy or instrumental delivery
when possible
ANTENATAL CARE
DELIVERY: CESAEREAN VS. VAGINAL
● Watch for signs and symptoms of AIDS BIRTH
and pregnancy-related complications
● Unless complication develops, no need to ● Cesarean section before labor and/or
increase number of visits rupture of membranes reduces risk of
● Treat STDs and other co infections mother-to-child transmission by 50-80%
● Counsel against unprotected intercourse
● Cesarean section, however, increases
● Avoid invasive procedures and external morbidity and possible mortality to mother
cephalic version
● Give antiretrovirals agents ● Give antibiotic prophylaxis for cesarean in

● Counsel about nutrition HIV-infected women

ANTI-RETROVIRALS RECOMMENDED INFECTION PREVENTION

● Zidovudine (ZDV) PRACTICES
❖ Long course - 14 weeks to
postpartum (no BF); 300 mg ● Needles (handling of sharps)
❖ Short course - 1 TAB 300 mg 2x a ➢ Take care!
day 36 wks start
● Nevirapine ➢ Minimal use

● ZDV/lamivudine (ZDV/3TC) ● Suturing: Use appropriate needle and holder

(dili kinamuton ang mga needles, even aftr
 care, use forceps in order to transfer the Q: Kailan binibigay ang antiretroviral sa newborn
needle in sharp container) and saan part?

● Care with recapping and disposal

A: Wala tayo information about giving antiretroviral
● Wear gloves, wash hands with soap
drugs sa newborn because it is not our scoop sa
immediately after contact with blood and
ating practice sa clinical setting. Dili kita ang naga
body fluids (double gloving
administer ana.
● Use:
RH INCOMPATIBILITY
★ Plastic aprons for delivery (available
in the delivery room)
● Rh (-) mother and Rh (+) father
★ Goggles and gloves for delivery and
surgery ● Mostly on the second pregnancy (kasi
ang mother nakaform na ng antibodies
★ Long gloves for placenta removal sa first pregnancy nya. Naka detect na
● Dispose of blood, placenta and waste
siya ng foreign body which is the Rh
safety (very important during the first day posiive. Now, complication mostly
of duty sa area na naay physical happen on the second kasi mas early
orientation set up, asa dapit ilabay ang ang exposure nang fetus sa maternal
mga blood and naay placenta container) circulation.
● PROTECT YOURSELF! ● During placental accidents
NEWBORN PATHOPHYSIOLOGY OF Rh INCOMPATIBILITY
● Wash newborn after birth, especially face Rh (+) fetus (ang screening nito is not only
(wash newborn after 6hrs of birth but if born blood typing but also resist factor)
with infected mother, wash the newborn after
birth especially the face kay naa dira ang ↓
mga open mucus membrane)
Rh (-) mother
● Avoid hypothermia
↓
● Give antiretroviral agents, if available
Antibodies against Rh(+)
BREASTFEEDING ISSUES
↓
● Warmth for newborn (provide good swaddle)
● Nutrition for newborn Attack Fetal RBC (RBC is carrier of oxygenated
blood)
● Protection against other infections
↓
● Safety- unclean water, diarrheal diseases
Hemolysis (break down of RBC)
● Risk of HIV transmission (very high kasi
infected ang mother)
↓
● Contraception for mother (habang naga pa
breastfeed) Fetal Anemia (because there is no oxygen carrier)

BREASTFEEDING RECOMMENDATIONS ↓

● Promote exclusive breastfeeding for 6 Hypoxia (Lack of oxygen)

months
↓
● Counsel on the safe and appropriate use of
formula (mix with clean water) Erythropoiesis (RBC production)

● HIV-positive and chooses to breastfeed, ↓

promote exclusive breastfeeding for 6
months Increase RBC production

↓
Increase Hemolysis

↓ A: Yes, all invasive procedures kay naa jud

Hyperbilirubinemia (hyper=increase; risk. That is why ang naga perform lang ana kay
bilirubin=in the blood, also I breakdown sa katong mga trained individual lang.
liver)

ANEMIA IN PREGNANCY
● Jaundice (discoloration/yellowish of skin)
Nutritional Influence of RBC Production
● Kernicterus (a medical term wherein ang
increase amount of bilirubin in the blood
will accumulate in the brain kay dili na ● Folic Acid
siya enough nga didto lang siya mag ● Vitamin B12 or cobalamin
stay ang bilirubin sa blood, maad na siya
kay ang blood maabot mana siya sa ● Iron
brain; if ang baby increase kaaayo ang
amount ng bilirubin sa brain would Increased Blood Volume 40-50% (Meet
experience seizure) increased demand, Protect from impaired
venous return, Prepare for blood loss) →
● Hydrops Fetalis (this is due to the
increase amount of bilirubin; a fetal Decrease hemoglobin concentration →
complication na magkaroon ng PHYSIOLOGIC ANEMIA
accumulation of fluid in the fetal
circulation) Signs and Symptoms of Anemia

● Utilizes immature RBC (walang choice 1. Pallor

ang baby kundi to utilize the immature
red blood cells to have oxygen) 2. Fatigue

↓ 3. Shortness of breath
4. Hypotension
● Erythroblastosis Fetalis (severe
hemolytic disease) (sobrang baba na ng 5. Asymptomatic
RBC; anemic na masyado ang baby)
Management of Physiologic Anemia
MANAGEMENT OF Rh INCOMPATIBILITY
● Intrauterine Fetal Blood transfusion (perform at ● Rest
28 weeks; guided by ultrasound) ● Iron supplement
● Replace fetal RBCs ● Oxygen therapy
● Keep the fetus healthy until he or she is ● Nutrition
mature enough to be delivered ● Blood transfusion- severe type of anemia
● Phototherapy
Priority Nursing Diagnosis of Anemia
★ Aka light therapy to treat jaundice
★ Exposure to light using ● Altered tissue perfusion
LED/polarized light at a specific time ● Altered Nutrition less than body
of the day requirements
● RhoGAM (very known medication) ● Activity intolerance
★ Anti D Immunoglobulin
★ After 28 weeks AOG Iron → Transferrin (stored by the stomach)
★ Within 72 hours after birth →Ferritin (absorbed by the intestine)
★ Suppress immune system of mother
not to produce antibodies (MOA)

Q: Sa paghatag ug RBC sa fetus, since

invasive siya, naay risk sad?
Types of Anemia · Drug toxicity

1. Iron Deficiency Anemia- d/t insufficient

dietary intake
Precipitating Factors
2. Megaloblastic Anemia- large RBC produce
fewer cell & die
Factors that cannot be changed
3. Pernicious Anemia- same as megaloblastic
anemia ● Pregnancy- interplay of hormone like
progesterone and estrogen
4. Folic Acid Deficiency Anemia- lack of
folate/B9 that makes RBCs

- Folate are those who make the RBC

● Multiple pregnancy- due to a lot of fetuses
5. Aplastic Anemia- bone marrow defect; inside can put pressure, can affect the
can't make enough RBCs digestion

6. Hemolytic Anemia-d/t RBCs destruction -

· Hydatidiform mole
Okay ang size, okay ang production but
there is a destruction due to disease · Heredity
7. Sickle Cell Anemia- abnormal shaped · Female
RBCs d/t organ damaged

8. Physiologic Anemia- low hgb level from Management of Hyperemesis Gravidarum

6-8 weeks (newborn) - Jaundice and
decrease hemoglobin level ● May need hospitalization- for IVF infusion
● IVF infusion
9. Pathologic Anemia- low erythrocytes d/t
bleeding ● Parenteral nutrition
● Antiemetics
Hyperemesis Gravidarum
● Progress die t- clear liquid, full liquid,
● soft, small frequent, full diet
● Increase vomiting ● Midnight snacks
● Excessive vomiting that persists ● Parenteral vitamins and electrolyte
beyond 1st trimester ● ·Increase OFI-

● Contains: previous food intake,

very important pag dehydration
mucus, bile, finally blood -
Nursing Diagnosis of Hyperemesis Gravidarum
We need to replenish the fluid na
nawala kasi excessive ang vomiting ● actual/potential fluid volume deficit
sa patient; ● Imbalanced nutrition; less than body
requirements
Needs rehydration, give IVF
● Fatigue

Predisposing factors ● Ineffective coping

● Anxiety
Factors that can be changed/prevented
Bleeding Complications of Pregnancy
● Pancreatitis- inflammation of the pancreas
due to obstruction
1. Abortion
· Biliary tract disease 2. Ectopic pregnancy- outside uterus ang
implantation
· Decrease Vit B6 - metabolism
3. Placenta previa- detaches early before term
· Psychological- stressful environment
Abruptio placenta- nauna yung placenta kaysa baby
conception • Abdominal cramping
Hydatidiform mole- trophoblastic disease
Preterm labor- before 38 weeks
Missed abortion
Abortion
● Is a miscarriage in which fetus didn’t form or
- Termination of pregnancy before the age of
viability (<28 weeks) has died, but the placenta and embryonic
tissues are still in the uterus
● Aka missed miscarriage or silent miscarriage
Spontaneous Abortion (no uterine contraction)
● Retention of the conceptus in the uterus
● Before 20 weeks na termination of
after death of the embryo or fetus (fetal
pregnancy
death in the utero)
● Refers to naturally occurring events

o Not induced abortion Recurrent/habitual abortion

● Not to medical abortions or surgical ● Recurrent miscarriage

abortions ● Also called recurrent pregnancy loss or
habitual abortion
Types of Spontaneous Abortion ● Occurs when a woman has two or
● more consecutive clinical pregnancy losses
● Threatened abortion
Septic abortion
o Is vaginal bleeding that occurs in
the first 20 weeks of pregnancy
● Serious uterine infection during or shortly
o The bleeding is sometimes
accompanied by abdominal before or after an abortion
cramps ● Usually result from induced abortions done
by untrained practitioners using nonsterile
● Imminent abortion techniques
● They are much more common when induced
o Aka impending abortion
abortion is illegal. Di gusto ng patient
characterized by bleeding and
colicky pains (spasm-like) mapunta sa hospital

o The cervix is usually effaced

and expanded Induced Abortion

o Effacement- thinning of the

cervix, measured by percentage
Therapeutic Abortion
● Complete abortion
● When pregnancy causes harm or threat to
Occurs when all of the products of a pregnancy mother
have been removed. ● Done to save the life of the mother
● Done 6-10 weeks

● Incomplete abortion Eugenic Abortion

➔ Involves vaginal bleeding, cramping
(contractions), cervical dilatation, and ● To prevent birth of a potentially defective
child
● Elimination of those that are deemed
Signs and Symptoms of Abortion
“deficient”

incomplete passage of the products of •

Bleeding
Eg. Aborting a child with dwarfism or down’s would
certainly qualify as eugenic. o To save the life of a mother (you
have to expel the retained
Signs and Symptoms of Abortion products by giving oxytocin)

● Bleeding
● Completion curettage
● Abdominal cramping
● Prophylactic antibiotic
● Passage of watery vaginal discharges
● Passage of product of conception o Anticipate for infections

Management of Threatened Abortion ● Analgesics

● Bed rest- i wheel talaga ang patient o pain reliever

● Tocolytic medications (isoxilan drip)
● Fluid/blood replacement
● Treat underlying factors
● No sexual activity
● Emotional support
● Fetal monitoring by ultrasound
● Avoid stress o because of loss

Management of Threatened Abortion Nursing Diagnosis

● Bed Rest 1. Alteration in comfort; pain

● Tocolytic medications (isoxilan drip)
o Because it is really painful to undergo mthat
- Oxytocin is a type of drug would stop uterine
condition
contractions
- Classification of oxytocin is “oxytocic” 2. Anticipatory Grieving
● Treat underlying factors
● No sexual activity o Because of the loss
- Because uterine contraction will happen
3. Risk for Fluid Volume Deficit
during sexual intercourse (kay magkaroon
ng “spasm” so nay tendency ang uterus ECTOPIC PREGNANCY
mag contract)
● Fetal monitoring by ultrasound (bleeding complication) = any pregnancy that is
outside the uterus is considered Ectopic pregnancy
The patients need pre-natal (Kung
daghan kag complication or frequent ang imong Common sites: fallopian tube
visit sa OB para ma monitor ang fetal status
Ectopic Pregnancy: possible ma survive ang child
● Avoid Stress
Factors Causing Ectopic Pregnancy
- a big factor for a woman to
experience like: bleeding
● Pelvic Inflammatory Diseases - scaring
formation, deformation of structure
Management of Other Type of Abortion ● Previous Ectopic Pregnancy - history of the
● Hospitalization patient having ectopic pregnancy
● Tubal/Uterine Surgery
o Like if nay bleeding
● Intrauterine Device

● Oxytocin administration
(incomplete abortion)
Signs and Symptoms of Ectopic Pregnancy TUBAL PREGNANCY

● Symptoms of bleeding
● Bleeding into the uterine cavity: in the
implantation site kasi doon dadaan ang
blood kahit dito nag implant sa may fallopian
tube
● Sharp one-Sided abdominal pain: the area
where in the implantation happens
● Syncope or fainting: blood loss
● Referred shoulder pain (ruptured EP)
● tower abdominal pain
● Vaginal bleeding
● Abdominal tenderness
● Low HCG hormone

Diagnostic Examinations of Ectopic Pregnancy

● Transvaginal ultrasound
● Physical examination: to perform head to toe
OVARIAN PREGNANCY
assessment
● Pregnancy test
● HCG: level of placental hormone
● Pelvic examinations: includes internal exam

Management of Ectopic Pregnancy

● Methotrexate: drug of choice for ectopic

pregnancy, also drug for cancer; Stops
growth and dissolves existing cells
● Salpingostomy via laparoscope Nursing Diagnosis
● - is a procedure in which the contents of the
● Alteration in comfort; pain - Especially when
fallopian tubes are removed by making an
ruptured
opening
● Anticipatory grieving - Hindi na buo yung
● Laparoscopic salpingectomy
pregnancy
Is the surgical removal of one (unilateral) or ● Fluid Volume Deficit
both (bilateral) fallopian tubes.
Hydatidiform Mole (H-mole / Molar
Pregnancy)

● Is a growing mass of tissue inside the womb

(uterus) that will not develop into a baby.
● Is a pregnancy/conceptus in which the
placenta contains grapelike vesicles (small
sacs) that are usually visible with the naked
eye.
● It results from an abnormal meiotic division
of a zygote from 2 sperm cells and 1 egg
cell.
 ● Implantation of the placenta at the lower
uterine segment
Types:
RISK FACTORS OF PLACENTA PREVIA
Partial mole ● Advance maternal age-
● Multiparity A.k.a. Multiple Births
➔ 1 egg cell + 2 sperm cells ● Previous uterine surgery
➔ Abnormal first meiotic division ● Breech and Transverse Position

SIGNS AND SYMPTOMS

Complete mole
● Painless bright red bleeding
● Recurrent and heavier as pregnancy
progress
➔ Empty egg + normal sperm ● No uterine contraction
➔ Embryo dies at very early age
➔ No embryonic tissues ABRUPTIO PLACENTA

RISK FACTORS CAUSING ABRUPTIO

PLACENTA
● Maternal Age
● Previous history of abruptio placenta
● Multiparity
● Smoking
● Maternal hypertension
● Abdominal Trauma

SIGNS AND SYMPTOMS OF ABRUPTIO

If they remove the mole, they are going to measure PLACENTA
it in centimeter kasi sa biopsy kailangan ng ● Concealed or visible bleeding
measurement, whatever specimen that is out from ● Painful Bleeding
the human body ireserve mo yun kung ikaw yung ● Dark red bleeding
nag assist kasi hahanapin yan later for biopsy or ● Board like abdomen
ipakita sa watcher (which serves a proof that the ● Fetal distress
mole is removed) ● Tetanic contraction

MANAGEMENT OF ABRUPTIO PLACENTA

Signs and Symptoms of H-mole
● Bed rest
● Tocolytic
● Vaginal bleeding
● Steroids
● Uterine enlargement is bigger than usual ● Immediate Delivery
pregnancy ● Fluid and blood replacement
● Increase HcG
NURSING DIAGNOSIS OF ABRUPTIO
● Hyperemesis gravidarum PLACENTA
● No FHT/fetal movement ● Altered tissue perfusion
● Fluid volume deficit
Management of H Mole ● Risk for infection
● Suction evacuation ● Anxiety/Fear
● Dilation and Curettage ● Acute pain
● Hysterectomy
● Methotrexate COMPLICATIONS OF ABRUPTIO PLACENTA
● Hypovolemic shock
SIGNS AND SYMPTOMS ● Intrauterine growth restriction
● Vaginal bleeding ● Placenta accreta
● Uterine enlargement is bigger than usual ● Maternal Mortality
pregnancy ● Fetal Mortality
● Increase HcG ● Congenital Anomalies
● Hyperemesis gravidarum
● No FHT/fetal movement PRETERM
● Labor that begins after 20 weeks gestation
PLACENTA PREVIA and before 37 weeks of gestation
ETIOLOGY OF PRETERM LABOR
● Premature rupture of membrane MANAGEMENT
● Preeclampsia ● Tocolytics
● Hydramnios ● Bed rest
● Placenta Previa ● Hydration
● Abruptio Placenta ● Progesterone
● Incompetent cervix ● Trendelenburg position
● Trauma ● Antibiotics
● Uterine Structural anomalies
● Multiple gestation NURSING DIAGNOSIS
● Infection ● Anxiety
● Fetal Death ● Risk for maternal injury
● Maternal Factor ● Risk for fetal injury
● Knowledge Deficit
MANAGEMENT OF PRETERM LABOR ● Anticipatory grieving
● Bed Rest
● Avoid Sexual Contact HYPERTENSIVE DISORDERS OF PREGNANCY
● Limit abdominal handling RISK FACTORS:
● Increase fiber in the diet ● First pregnancy
● Treat underlying factors ● Multiple gestation complications
● Tocolytic ● Polyhydramnios
● Medications ● Hydatidiform mole
● Steroid ● Malnutrition
● Family history
SIGNS AND SYMPTOMS OF PPRETERM LABOR ● Vascular disease
● Low back pain
● Suprapubic pressure (over Bladder) TYPES OF PREGNANCY INDUCE
● Vaginal Pressure HYPERTENSION
● Rhythmic Uterine contraction(wavelike) ● Gestational Hypertension
● Cervical changes ● Preeclampsia
● Possible rupture of membrane ● Eclampsia
● Expulsion of cervical mucus plug ● Chronic Hypertension
● Bloody show ● Superimposed Preeclampsia

MISSED ABORTION GESTATIONAL HYPERTENTION

● Retention of the conceptus in the uterus for ● increased blood pressure
clinically appreciable time after death of the ○ systolic pressure of more than
embryo or fetus 130mm/Hg or +30mmHg from
baseline
SECOND AND THIRD TRIMESTER DISORDERS ○ diastolic pressure of more than
90mmHg or + 15 mmHg from
Cervical Incompetence baseline
● The inability of the cervix to support a ● edema
pregnancy to term due to structural and or
functional weakness. PREECLAMPSIA
● Painless and bloodless cervical dilation ● Hypertension or PIH
● Premature cervical dilation between 16-22 ● Proteinuria (not seen in gestational
weeks hypertension) presence of protein in urine
● Edema (wt gain) >2lbs/week
FACTORS CAUSING IC
● Functional MILD PREECLAMPSIA
○ Premature triggering of the normal ● HYPERTENSION (140/90)
mechanism of cervical dilation and ● PROTEINURIA >300mg/24 hrs (>+1)
effacement ● MILD EDEMA signalled by wt gain (>2
○ 3 or more prior fetal losses during the lb/week or >6 lb/month)
2nd trimester ● URINE OUTPUT >500mI/24hrs
● Congenital: ● Dipstick result is more than +1
○ Weakness of the internal os ● Urine output is less than 30 cc/hour
○ Short hypoplastic cervix(<2mm) ● Our bladder can hold urine up to 4 hours
○ Bicornuate uterus
SEVERE PREECLAMPSIA
PATHOPHYSIOLOGY ● BP>160/110 (2X, 4 - 6 hrs apart, bedrest)
● Dilators or ballooons ● Proteinuria 5g/24 hours (3+ or 4+ dipstick)
 ● Oliguria <400mI/24 hrs ● cerebral hemorrhage
● IUGR in fetus ● fetal demise(fetal death in the uterus)
● Systemic symptoms
○ Pulmonary edema - when protein MANAGEMENT OF PIH
goes out in the body, the water sets ● bed rest with or without BRP
in ● BP monitoring
○ Headache - irritability in the nervous ● weight and urine checks
system, if brain is affected it causes ● NST's early
seizure and convulsion ● Monitor for IUGR
○ Visual changes - d/t increased blood ● IVF
pressure ● Check for reflexes
■ Can result to seizure and ● Antihypertensive drugs (magnesium sulfate)
convulsion, changes in vision ● Anticonvulsant drugs (diazepam)
■ Seizure - visual changes, ● Steroids (betamethasone)
fatigue, weakness ● Delivery of the baby
■ Convulsion is uncontrollable MGSO4 THERAPY
shaking of the muscle ; it is ● Placed in an ampule
also a type of seizure ● Loading dose IV 4-6 g/20 min
■ Epilepsy is a brain disorder ● continued at 2 g/hr
where there is a recurrent ● check for adverse effects
seizure ○ Respiratory rate <12/minute
○ DTR of <1
● RUQ pain - because of the location ○ Urine output <30cc/hour
of the liver (abdominal right upper
quadrant pain) POST-TERM PREGNANCY
● ↑ Liver Enzymes (put more stain to ● S&S
liver) - ○ Wt loss
● Thrombocytopenia (low platelet) ○ ↓ uterine size
○ Meconium in AF
ECLAMPSIA ● Risk
● Hypertension ○ ↑ fetal mortality
● Proteinuria ○ cord compression (due to low
● Edema amniotic fluid)
● Seizure ○ meconium aspiration
○ Large for Gestational Age (LGA) →
CHRONIC HYPERTENSION SUPERIMPOSED shoulder dystocia → CS -shoulder is
PREECLAMPSIA trapped, cannot pass through the
● hypertensive disorders before pregnancy pelvic cavity episiotomy/laceration
that progresses to preeclampsia depression
● CHRONIC - HIGH BP BEFORE <20 ● Treatment
WEEKS - TILL 12 WEEKS POSTPARTUM ○ fetal surveillance
● SUPER - COMPLICATE PREECLAMPSIA ○ Induction
WITH ANOTHER CAUSE LIKE GDM, SLE,
KIDNEY DISEASE DISORDERS OF AMNIOTIC FLUID
● Polyhdramnios
LABORATORY WORK-UPS/STUDIES ○ S&s
● Blood-CBC, electrolytes, BUN, Creatinine ■ uterine distention
● Liver function studies ■ Dyspnea
● Coagulation studies ■ edema of lower extremities
● 24 hr Urine ○ Treatment
● HELLP syndrome ■ therapeutic amniocentesis
○ Hemolysis ○ Oligohydramnios
○ Elevated Liver function tests ■ Risk
○ Low Platelet count ● Cord compression
● musculoskeletal
COMPLICATIONS deformities
● Eclamptic seizures ● pulmonary hypoplasia
● HELLP syndrome
● Hepatic rupture PREMATURE RUPTURE OF MEMBRANES:
● DIC
● pulmonary edema What causes premature rupture of membranes?
● renal failure ● Natural weakening of the membranes
● placental abruption ● From the force of contractions. Oxytock
 ● Before term, infection in the uterus ○ S
● Other factors that may be linked to prom ○ S
include the following: NURSING CARE:
○ Low socioeconomic conditions ● Assessment
○ Sexually transmitted infections such ○ Through hx
as (chlamydia and gonorrhoea) ○ Bleeding
○ Previous preterm birth ○ ROM
○ Vaginal bleeding ○ BPP (for PROM)
○ Cigarette smoking during pregnancy ● Teaching
○ Unknown cause (idiopathic) ○ Infection control
○ FMC
In addition to a complete medical history and ● Fetal Risk: Pre-maturity, infection
physical examination, PROM may be diagnosed in ○ Prevention of infection
several ways, including the following: ○ F
○ Monitor amniotic fluid, you want
● an examination of the cervix white and sticky- not black, green,
● testing of the pH (acid or alkaline) of the fluid smelly
● looking at the dried fluid under a microscope ○ D
● ultrasound - a diagnostic imaging technique MANAGEMENT
which uses high•frequency sound waves ● Limit sterile vaginal exam
and a computer to create images of blood ● Antibiotics
vessels, tissues, and organs. Ultrasounds ● Bed rest
are used to view internal organs as they ● S
function, and to assess blood flow through ● Daily CBC
various vessels.

POSSIBLE NURSING DIAGNOSES:

FACTOR MATERNAL FETAL OR
● Risk for infection related to preterm rupture
IMPLICATION NEONATAL
of membranes without accompanying labor.
S IMPLICATION
● Knowledge deficit.
S
● Anxiety related to outcome of labor.
● Risk for fetal injury related to preterm birth. Social and Poor antenatal Low birth
Personal Low care Poor weight
MANAGEMENT: income level nutrition ↑ risk Intrauterine
● bed rest either in the hospital or at home and/or low preecalmpsia growth
setting educational restriction
● monitor for signs of infection such as fever, level (IUGR)
pain, increased fetal heart rate, and/or
laboratory tests. Poor diet Inadequate Fetal
● giving the mother corticosteroids that may nutrition malnutrition
help mature the lungs of the fetus. ↑ risk anemia Prematurity
● avoid vaginal exams to prevent introduction ↑ risk of
of microorganisms preeclampsia
● administer antibiotics
● administer tocolytics to stop preterm labor. Living at high ↑ hemoglobin Prematurity
● prepare for possible immediate delivery. altitude IUGR ↑
hemoglobin
PREMATURE RUPTURE OF MEMBRANE (polycythemia)
(PRROM- before 37 weeks)
● Spontaneous ROM prior to inset of labor at
the end of 37 weeks (high risk)
● Full term = PROm (38 weeks) FACTOR MATERNAL FETAL OR
● S&S IMPLICATION NEONATAL
○ Contractions S IMPLICATION
○ Cramps S
○ Diarrhea
○ D Multiparity >3 ↑ risk Anemia Fetal
○ D antepartum or death
○ ROM postpartum
● Treatment hemorrhage
○ Tocolytic
○ A Weight <45.5 Poor nutrition IUGR Hypoxia
○ Bedrest
kg (100 lb) Cephalopelvic associated Disorders hypertension Macrosomia
disproportion with difficult Diabetes Episodes of Neonatal
Prolonged labor & birth mellitus hypoglycemia hypoglycemia
labor and ↑ risk
hyperglycemia congenital
Weight >91 kg ↑ risk ↓ fetal nutrition ↑ risk anomalies ↑
(200 lb) hypertension ↑ risk cesarean birth risk respiratory
↑ risk macrosomia distress
cephalopelvic syndrome
disproportion
↑ risk diabetes Cardiac Cardiac ↑ risk fetal
disease decompensati demise ↑
Age <16 Poor nutrition Low birth on Further prenatal
Poor antenatal weight strain on mortality
care ↑ fetal demise mother’s body
↑ risk ↑ maternal
preeclampsia death rate
↑ risk
cephalopelvic
disproportion
FACTOR MATERNAL FETAL OR
Age >35 ↑ risk ↑ risk IMPLICATION NEONATAL
preeclampsia congenital S IMPLICATION
↑ risk anomalies S
cesarean birth ↑
chromosomal Anemia: Anemia: Fetal death
aberrations hemoglobin <9 hemoglobin <9 Prematurity
g/dL (white) g/dL (white) Low birth
<29% <29% weight
hematocrit hematocrit
FACTOR MATERNAL FETAL OR (white) <8.2 (white) <8.2
IMPLICATION NEONATAL g/dL g/dL
S IMPLICATION hemoglobin hemoglobin
S (black) <26% (black) <26%
hematocrit hematocrit
Smoking one ↑ risk ↓ placental (black) (black)
pack/day or hypertension ↑ perfusion →↓
more risk cancer O2 and Hypertension ↑ vasospasm ↑ ↓ placental
nutrients risk central perfusion→
available nervous low birth
Low birth system weight
weight IUGR irritability → Preterm birth
Preterm birth convulsions ↑
risk
Use of ↑ risk poor ↑ risk cerebrovascul
addicting nutrition congenital ar accident ↑
drugs ↑ risk of anomalies risk renal
infection with ↑ risk low birth damage
IV drugs weight
↑ risk HIV, Neonatal Thyroid ↑ infertility ↑ spontaneous
hepatitis C withdrawal disorder abortion
Lower serum
bilirubin Hypothyroidis ↓ basal ↑ risk
m metabolic rate, congenital
Excessive ↑ risk poor ↑ risk fetal goiter, goiter
alcohol nutrition alcohol myxedema
consumption Possible syndrome
hepatic effects Hyperthyroidis ↑ risk Mental
with long-term m postpartum retardation →
consumption hemorrhage ↑ cretinism ↑
risk incidence
Preexisting ↑ risk Low birth preeclampsia congenital
Medical preeclampsia, weight
 Danger of anomalies Current Congenital
thyroid storm ↑ Pregnancy heart disease
incidence Rubella (first Cataracts
preterm birth ↑ trimester) Nerve
tendency to deafness Bone
thyrotoxicosis lesions
Prolonged
virus shedding

FACTOR MATERNAL FETAL OR Rubella Hepatitis

IMPLICATION NEONATAL (second Thrombocytop
S IMPLICATION trimester) enia
S
Cytomegalovir ↑ possibility IUGR
Renal disease ↑ risk renal ↑ risk IUGR ↑ us repeat Encephalopath
(moderate to failure risk preterm cesarean birth y
severe) birth thyroid storm ↑
incidence
Diethylstilbestr ↑ infertility, ↑ spontaneous preterm birth ↑
ol (DES) spontaneous abortion ↑ risk
exposure abortion ↑ preterm birth Herpes virus Severe Neonatal
cervical type 2 discomfort herpes virus
incompetence Concern about type 2 2%
possibility of hepatitis with
Obstetric ↑ emotional or ↑ risk IUGR cesarean birth, jaundice
Considerations psychological ↑ risk preterm fetal infection Neurologic
Previous distress birth abnormalities
Pregnancy
Stillborn

Habitual ↑ emotional or ↑ risk abortion FACTOR MATERNAL FETAL/

abortion psychological IMPLICATION NEONATAL
distress ↑ S IMPLICATION
possibility S
diagnostic
workup Syphilis ↑ incidence ↑fetal demise
abortion Congenital
Cesarean birth ↑ possibility ↑ risk preterm syphilis
repeat birth ↑ risk
cesarean birth respiratory Abruptio ↑ risk Fetal or
thyroid storm ↑ distress placenta and hemorrhage neonatal
incidence placenta Bed rest anemia
preterm birth ↑ previa Extended Intrauterine
hospitalization hemorrhage
↑fetal demise
FACTOR MATERNAL FETAL OR
IMPLICATION NEONATAL Preeclampsia/ See ↓placental
S IMPLICATION eclampsia hypertension perfusion
S →low birth
weight
Rh or blood ↑ financial Hydrops fetalis
group expenditure for Icterus gravis Multiple ↑ risk ↑risk preterm
sensitization testing Neonatal gestation postpartum birth
anemia hemorrhage ↑risk fetal
Kernicterus ↑ risk preterm demise
Hypoglycemia labor

Large baby ↑ risk Birth injury Elevated Increased Fetal death

cesarean birth Hypoglycemia hematocrit viscosity of rate 5 times
↑ risk >41% (white) blood normal
gestational >38%(black)
diabetes
Spontaneous ↑uterine ↑risk preterm
 premature infection birth of lies midway between the symphysis pubis and
rupture membranes the sacral promontory.

FETAL MALPOSITION
MONITORING FETAL WELL-BEING
Persistent Occiput Posterior
-fetus enters the birth canal, descends, and is
• Early US for accurate gestational dating delivered in occiput posterior position.
• amniocentesis for fetal lung maturity -fetus is facing up instead of facing down the
• ultrasound if macrosomia is suspected vagina.
• antepartum newborn screening test post 34
weeks Transverse Occiput Arrest
-baby is head-down but the head is turned
PREGNANCY CATEGORY OF completely sideways towards the mother’s
MEDICATIONS: hipbone, causing baby to ‘arrest’ (get stuck)
because it doesn’t fit well.
Factors Causing POP
• Category A--safe (vitamins)
- lack of rotation due to poor contraction
• Category B-- no animal effects (penicillin)
-abnormal flexion of head
• Category C--no studies available
-incomplete rotation
• Category D--evidence of risk but benefits
-inadequate
outweigh the risks
-epidural anesthesia
• Category X-- risks outweigh benefits
-large baby

Risk of Fetal Malposition

NURSING CARE OF THE CLIENT WITH - prolonged labor
HIGH RISK LABOR & DELIVERY AND HER -third to fourth degree perineal laceration
FAMILY - extension of midline episiotomy
-forceps or vacuum or caesarianØ
ESSENTIAL FACTORS IN LABOR:
1. PASSENGER Management of Fetal Malposition
a. FETUS- -monitoring on fetal and maternal status (EFM)
b. PLACENTA -cesarean birth if necessary
2. PASSAGEWAY -Scanzoni’s maneuver- changing a posterior
3. POWERS presentation into an anterior one required the
a. primary power use of forceps twice in the process of delivery.
b. secondary power -Forceps assisted
4. POSITION OF THE MOTHER -Regional anesthesia (epidural)
5. PSYCHE

PROBLEMS WITH THE PASSENGER FETAL MALPRESENTATION

PASSENGER:
VERTEX MALPRESENTATION
• FETUS 1. BROW PRESENTATION
o fetal skull 2. FACE PRESENTATION- head
o fetal body size hyperextended
o fetal presentation
o fetal position Risk of Brow Presentation
o fetal lie -longer labor
o fetal attitude -ineffective contraction
Synclitism & Asynclitism: - slow or arrest fetal descent
• Asynclitic refers to a fetal head that is not -Cs delivery
parallel to the anteroposterior plane of the -neonatal neck and cerebral expression
pelvis. -damage to neonatal larynx and trachea
• The head is synclitic when the sagittal suture
Management of Brow Presentation
-monitor for CPD (Cephalopelvic disproportion) anomaly, or any anomaly wherein the baby
-left/right mediolateral episiotomy dont have the choice to be in position with the
-cesarean delivery normal cephalic position because the
environment will not allow it kay may structural
Risk of Face Presentation
-increase risk of CPD defect)
- prolongation of labor - Major malformation: hydrocephaly,
-increase risk of infection anencephaly, meningomyelocele (so dili
-Cesarean birth comfortable ang baby to position vertically
-neonatal cephalhematoma kay naa syay deformities mas favorable
-edema of neonatal face and throat saiyaha ang shoulder presentation because of
- pronounced molding the portion of their body parts)
- Most common malformation: congenital
Management of Face Presentation dislocation of the hip (mag depend sya kay it
-cesarean birth if mentum remains posterior favors to their condition kay feel nila naga lie
-vaginal birth may be anticipated if not CPD, sila kay mura sila naga stand kung vertica)
reassuring FHT, labor pattern is effective.
Liquor
Risk of Breech Presentation -oligohydramnios/ polyhydramnios (refers to the
-higher perinatal morbidity and mortality rate. amniotic fluid if it is less or more)
-cord prolapsed Uterine
-neonatal cervical cord injury due to -Anomalies (bicornuate, fibroid) (abnormal
hyperextension. structure of the uterus, walay choice ang baby
-birth trauma especially the head. kundi iposition iyang self sa shoulder position).

Management of Breech Presentation Placenta

-external cephalic version at 36 – 38 weeks or -Previa (nauna man ang placenta, since
prior to labor. connected sya kay baby so ma pull down niya
-depends on: so mas favorable kay baby na mag position into
→gestational age shoulder)
→presence of other fetus
→Weight Pelvis
→types of breech and doctor’s -Contracture, pelvic tumors obstructing birth
preferences. canal (same lang gyapon ang principle kung
naay mga abnormal growth or malformation
Shoulder Presentation within the uterus that would not favor the fetus
-Fetus is in a transverse lie to stay upright mas favorable na mag shoulder
sya due to the growth of that tumor.)
ETIOLOGY OF FLUPP
Management of Shoulder Presentation
-expectant – fetus may change presentation
Fetal without intervention if discovered before term.
-Prematurity (premature fetus can assume a -external cephalic version if evident at 37 wks.
transverse lie kay gamay ra sila) -CS delivery if unsucessful.
- Multiple (pwede sila ma push sailahang
kauban na baby or wala silay choice bisag dili Compound Presentation
sila gusto mo assume of transverse lie but There are two presenting part
because of the other babies ma butang sila ing COMPOUND: baby’s hand presents alongside
ana na position) the head (nuchal hand)
- Anomalies: often those that restrict the fetus :process is slow
to assume a vertex presentation (uterine VERSION:
• Turning of the fetus. 2 Abnormal baseline:
External Cephalic Version (ECV) A. Fetal tachycardia
-wherein when fetus is changed from breech to B. Fetal bradycardia
cephalic.
Fetal Tachycardia
Podalic Version -early fetal hypoxia
-less common type -maternal fever, dehydration, and
-used only 2nd fetus durinh vaginal twin birth. hyperthyroidism
-medication is used to relax the uterus -beta-sympathomimetic drugs
-OB places hand inside the uterus, grab fetus’ -amnionitis
feet and draws down the cervix. -fetal anemia

Contraindications of Versions: Fetal Bradycardia

-3rd trimester bleeding - late/profound fetal hypoxia
-Vaginal uterine anomalies -Maternal hypotension
-ROM, oligohydramnios -umbilical cord compression
-need for CS (placenta previa, contracted pelvic -vaginal stimulation
etc.) -fetal arrhythmia
-indicated vaginal delivery (fetal death, -uterine hyperstimulation
anomaly). -abruptio placenta
-uterine rupture
FETAL DISTRESS -fluctuations
-Compromise of the fetus during the
antepartum period or intrapartum period Variability
-Fetal hypoxia -a measure of interplay (push-pull effect)
between the sympathetic and parasympathetic
nervous system
Criteria in Determining Signs of Fetal (2 Abnormal variability:)
Distress Decreased Variability
-Hypoxia
- Acidosis
-Fetal Heart Rate: CNS depressed agents
-Baseline rate -fetal sleep
-Variability -<32 wks fetus
-Accelerations of fetal heart rate -fetal anomalies
-Decelerations -previous neurologic insult
-Meconium Staining -tachycardia
-fetal movement Increased Variability
-fetal scalp blood samplingØ -Early mild hypoxia
-meconium -Alteration in placental blood flow
-fetal stimulation -fetal stimulation/activity
-fetal oxygen
Fetal Heart Acceleration
Fetal Heart Rate -transient increase of FHT normally caused by
A. Baseline Rate fetal movements
- average FHR observed during a 10-minute -indicates fetal well being
period of monitoring. -no acceleration is an omnious sign
-normal rate ranges from 110-160 bpm
/120-160. Fetal Heart Deceleration
-periodic decrease of FHT from its baseline
rate. -Nuchal cord
3 Types: -Placental abruption
-Early deceleration -premature closure of the fetal ductus
-Late deceleration arteriosus
-Variable decelerationh
Fetal Movements
-at least 10x in 3 hours Fetal Distress Management
-affected by: -continuous fetal monitoring
o fetal sleep -discontinue oxytocin if with prolonged late
o sound decelerations
o time of day -oxytocin if needing
o blood glucose level -immediate delivery
o cigarette smoking -intrauterine fetal resucitations: left lateral
o Drugs position, oxygen administration, hydration, fetal
o oxygenation status stimulation
Ø- less than 10 movements in 3 hours or
absent movement are ominous
NURSING DIAGNOSIS:
Fetal Stimulation
-fetus should response by fetal heart
Accelerations. Ø →Decreased Cardiac Output (fetal)
Ø → Impaired Gas Exchange (fetal)
Fetal Blood Scalp Sampling Ø →Ineffective Tissue Perfusion (fetal)
-acid-base status of fetus Ø →Risk for fetal injury
-pH 7.2 – 7.25 is borderline Ø →Anxiety (maternal)
-below 7.2 is non reassuring and necessitate Ø →Deficient Knowledge (maternal)
birth.
UMBILICAL CORD PROLAPSE
Must be done: -A rare, obstetrical emergency that occurs
-RBOW when the umbilical cord descends alongside or
-2-3 cervical dilation beyond the fetal presenting part.
-station -2 and below TYPES OF UMBILICAL CORD PROLAPSE:
-FHT pattern is omnious ×Overt Prolapse (nakagawas)-refers to
-acute emergencies protrusion of cord in advance of the fetal
-vaginal bleeding presenting part.
×Occult Prolapse (naa ra sa ulo dapit)-occurs
Fetal Oxygenation Saturation (FSpO2) when the cord descends alongside the head.
- 40% - 70% are considered reassuring
-30%-40% mild acidosis and requires SIGNS:
continuous monitoring √ Ill-fitting or non-engaged presenting part
-below 30% indicates hypoxia and requires √ Prolapsed umbilical cord -visualized in
immediate birth vulva/vagina. Palpated on pelvic exam.
√ Fetal distress on Fetal Heart Tracing
Factors Causing Fetal Distress
-Breathing problems PROGNOSIS:
-Abnormal position and presentation of the -High perinatal mortality for delayed delivery
fetus >40 min
-multiple births
-Shoulder dystocia RISK FACTORS:
-umbilical cord prolapse →Premature rupture of the amniotic sac
→Polyhydramnios • Cord Coil
→Multiparity
→Placenta previa Velamentous Insertion of the Cord
→A small fetus -condition where the umbilical cord joins
the placenta at the edge, rather than the
DIAGOSTICS: typical insertion in the center.
-A pelvic examination- conducted by physician § the substance that typically surrounds
palpated with fingers. them (Wharton's jelly) is missing.
-Cardiotocograph
-Ultrasound

NURSING DIAGNOSIS: PROBLEMS WITH THE PASSAGEWAY

→Impaired Gas Exchange (fetal) CEPHALOPELVIC DISPROPORTION
→Fear (maternal)
→Anxiety (maternal) - Disproportion of fetal head and mother’s
→Risk for injury (fetal) pelvis
→deficient knowledge (maternal) - Also known as CPD
- Indication for CS
Umbilical Cord Prolapse Management CAUSES:
Ø- Initial management of cord prolapse in üo Increased fetal weight
hospital setting: § macrosomic = Malaki ang fetal head
→immediate delivery § GDM = risk for CS because of CPD
→minimal handling of loops of cord o Fetal position
→knee-chest position o Problems with the pelvis
→tilt/left lateral position § Passageway is too short for the baby to
→tocolysis pass
-To prevent cord compression, the presenting o Problems with the genital tract
part MUST BE elevated: § Problem of the passageway
§ May history of infection before and
Optimal mode of delivery with cord then na treat na sya. After treatment
prolapse: maybe ang treatment is for example
• category 1 caesarean section surgery or medications that can cause
• Category 2 caesarean section against scarring formation of that
-vaginal birth, in most cases operative, can be structure that would also cause
attempted at full dilation. problem during pregnancy because of
-a practitioner competent in the resuscitation of the passenger
the newborn shouldn’t attend all deliveries.
S/S:
Management in community setting: The delivery of the baby is obstructed
• assume the knee–chest face-down § Presence of tumor
position § Whatever unusualities in the
• Transport woman to nearest consultant-led anatomical organ involved
institution - The labor is prolonged
• Left lateral position during transport CPD does not talk only about the bladder
• Elevate presenting part
UMBILICAL CORD ABNORMALITIES DIAGNOSTICS:
•velamentous insertion of cord - Estimation of the size of the pelvis:
• Umbilical cord compression o Pelvimeter – it measures the diameter of
• Umbilical cord prolapse pelvis
•hypercoiling of cord o Prior to deliver
- Clinical Pelvimetry weeks)
o That diagnose na mas smaller ang diameter • Previous shoulder dystocia (10% risk of
ng pelvis compared to the presenting part recurrence) or large baby
- Radiologic Pelvimetry • Recognized macrosomia this pregnancy.
- Estimation of Fetal Size – that can be seen at
the ultrasound PROBLEMS WITH THE POWERS
MANAGEMENT: DYSTOCIA:
Ø CESAREAN SECTION
NURSING DIAGNOSIS:
- Anxiety – prolong ang labor,ma anxious si any labor/delivery that is prolonged and difficult
mother
- Fatigue – prolong stay in the hospital 5 Ps (factors in labor and delivery):
- Risk for fetal injury – because of prolong Ø >passenger
labor (fetal distress) Ø>power
- Risk for impaired skin integrity – possible for Ø>passage
laceration (maternal problem) Ø >placenta
- Situational low self-esteem – comparing Ø >psyche of mother.

INTERVENTIONS: 1. Problems with maternal soft tissue

• Monitor heart sounds and uterine contractions -A full bladder may impede the progress of
continuously labor,
• Urge the woman to void every 2 hours -Emptying the bladder
• Assess FHR -posterior presentation that does not rotate.
• Establish a therapeutic relationship 2. Dysfunctional uterine contractions
•Massage bony prominences gently and -Contraction may be too weak, too short, too
change position far, too apart, ineffectual
• Massage bony prominences on bed in a ü Classification
regular schedule A.) Primary: inefficient pattern present from
- Establish a therapeutic relationship, beginning of labor
conveying empathy and unconditional B.) Secondary: efficient pattern that changes to
positive regard efficient or stops; may occur in any stage.
- Instruct in methods to conserve energy
o Conserve energy – relax, rest etc. Assessment findings:
-Progress of labor is slower than expected rate.
SHOULDER DYSTOCIA: -Length of labor prolonged;
Incidence: about 0.2–1%. -1.5 cm ; prolacted descent <1 cm per hour
-This is one of the most frightening obstetric change in station
emergencies -Fetal distress
- It occurs when the fetal shoulders fail to -Arrest of descent
negotiate the pelvic inlet
-Prompt (but not forcible) action is required to Nursing intervention:
prevent fetal morbidity or mortality (see Stirrat -Individual as to cause
and Taylor in ‘Further reading’) -Provide comfort measures
-provide client, supportive descriptions of all
Antenatal risk factors actions taken
• Mother’s birthweight >90th centile -Monitor mother/ fetus continuously
• Maternal obesity or massive weight gain
• Diabetes mellitus—can be despite seemingly PREDISPOSING FACTORS:
good blood sugar control • Genetic
• Prolonged pregnancy (beyond 42 completed • Overweight
• - Downward and lateral to release anterior
• Hydramnios shoulder
• Maternal fatigue Enlarge vaginal opening with episiotomy to facilitate
• extra maneuvers
• Gestational DM
• Maneuversf
● Delivery of posterior arm
• Other diseases ● Pressure against baby’s posterior should
either anteriorly or posteriorly and anterior
rotation (woods corkscrew or rubin
maneuvers
● Mother on hands and knees
○ “All fours” (Gaskin maneuver)
PRECIPITATING FACTORS: ● Replacement of baby’s head to vagina
• Malpresentation and malposition of the fetus followed by cesarean delivery (Zavanelli
• Congenital malformation of the uterus maneuver)
Signs/ symptoms:
-Pain NURSING DIAGNOSIS:
-increased heart rate, pulse, body temp
-Increased BP 1. Acute pain related difficulty in labor
Promoting comfort:
-Diaphoresis ● Relaxation technique such as
-body weakness breathing techniques during labor
-Exhausted appearance ● Changing position
-SOB ● Support person
● Pain medications
-nasal flaring
-anxiety
-restlessnes 2. Anxiety related to threat of change in
health status of self and fetus.
-vaginal bleeding
Decreasing anxiety:
● Give brief explanation to the women
Medical Management: about the nature of contraction
1. Treatment for contraction abnormalities. associated with induce labor
● Provide anticipatory guidance
2. Management for maternal passageway or
regarding use of meds, procedures
fetal passage and equipment
√ If the problem is related to the inlet or ● Prepare for cesarean if necessary
midpelvis- CS delivery
√ If the size of the outlet is the problem -
3. Powerlessness
forceps or vacuum extraction ● Provide rest period
● Relaxation technique
Surgical Management ● Support person
● Cesarean in necessary for delivery of the
fetus
4. Deficient knowledge related to measures
Management of Shoulder Dystocia (BE CALM) that can be used to enhance labor and
facilitate birth.
Breath, do not push lower head of the bed ● Teach proper breathing techniques
● Educate about the complication of
Elevate legs into McRoberts position the delivery
- Sharp hip flexion while in supine position ● Explain client that cesarean is
necessary

Call for help 5. Ineffective individual coping related to

- Nurse, anesthesiologist, pediatrician, inadequate support system.
another physician ● Support Mechanism:
● Stay with the patient during labor
Apply suprapubic pressure process
 ● Encourage patient to discuss about Interventions:
her condition ● Short-acting barbiturates (to encourage rest,
relaxation)
● IV fluids (to restore/maintain hydration and
fluid-electrolyte balance)
DYSFUNCTIONAL LABOR
● If CPD – c/s.
Possible Causes: ● Provide emotional support.
● Catecholamines (response to anxiety/fear), ● Provide comfort measures
increase physical/psychological stress, leads ● Prevent infection (strict aseptic technique)
to myometrial dysfunction; painful and ● Prepare patient for c/s if needed
ineffective labor
● Premature or excessive analgesia,
particularly during latent phase.
● Maternal Factors (ex. Uterine anomaly,
history of prolonged labor)
● Fetal Factors
● Placental factors
● Physical restrictions (position in bed)
○ Sims position

Assessment: Hypotonic Dysfunction

● Anterpartal
● Emotional status ● After normal labor at onset, contraction
● Vital signs, FHR (Fetal Heart Rate) diminish in frequency, duration, and strength
● Contraction pattern (Frequency, Duration, ● Lowered uterine resting tone; cervical
Intensity, Interval) effacement & dilation slow / cease.
● Vaginal discharge ● Etiology:
○ Premature or excessive analgesia/
GOAL = to minimize physical/psychological stress anesthesia (epidural, spinal block)
during labor/birth ■ Epidural = Epidugay
○ CPD
○ Overdistention (hydramnios, fetal
DYSFUNCTIONAL LABOR PATTERN: macrosomia, multifetal pregnancy)
● Hypertonic labor ○ Fetal malposition / malpresentation.
● Hypotonic labor ○ Maternal Fear / Anxiety
● Precipitate labor
● Assessment:
○ Onset (latent phase & most common
Hypertonic Dysfunction in active phase).
● Uncoordinated contractions ○ Contractions - normal previously, will
● Increased resting tone of uterine demonstrate:
myometrium; diminished refractory period; ■ Decreased frequency
prolonged latent phase ■ Shorter duration.
- Nullipara: More than 20 hours ■ Diminished intensity (Mild to
Multipara: More than 14 hours moderate)
■ Less uncomfortable
● Etiology: unknown
● Assessment: ○ Cervical changes - slow or cease
○ Onset (early labor) ○ Signs of fetal distress – rare.
○ Contractions: ■ Usually late in labor d/t
■ Continuous fundal tension infection secondary to
■ Painful. prolonged ROM
● Intellectual - no effacement or dilation ■ Tachycardia
● Signs of fetal distress: ■ Maternal VS (elevated
○ Meconium-stained fluid. temperature) - may indicate
○ FHR irregularities. infection
● Maternal VS. ■ Medical diagnosis -
● Emotional status. procedures: vaginal
● Medical evaluation: to rule out CPD examination, x-ray pelvimetry,
(Cephalopelvic Disproportion) ultrasonography. To rule out
● Vaginal Examination, X ray pelvimetry, CPD (most common cause).
Ultrasonography ■ Management:
 ● Amniotomy (artificial ● Those who continue to work at strenuous
ROM) jobs during pregnancy
● Oxytocin ● Those who have shift works that leads to
augmentation of labor extreme fatigue
● If CPD, prepare for c/s
● Emotional support, Signs and Symptoms:
comfort measure, ● Persistent, dull, low backache
prevent infection ● Vaginal spotting
● A feeling of pelvic pressure (abdominal
tightening)
● Menstrual-like cramping
● Vaginal discharges
● Uterine contractions
● Intestinal cramping
● Feeling that baby is “pushing down’ or that
“something” is in the vagina

Precipitate Labor Nursing Diagnosis & Interventions:

❖ Anxiety r/t medication and fear of
● Labor that progresses rapidly and ends with outcome of pregnancy
the delivery occurring less than 3 hours after ➢ Know the Contraindication and
the onset of uterine activity potential complication of tocolytic
● Rapid labor and delivery. therapy
➢ Explain the purpose and common
A/E of tocolytic therapy
PRETERM LABOR ➢ Provide accurate information on the
status of the fetus and labor
● Labor that occurs before the end of the
(contraction pattern)
thirty seventh week of gestation.
➢ Allow the woman and her support
● It occurs approximately 9% - 11% of
person to verbalize their feelings
pregnancies.
regarding the episode of PTL and the
● Any woman having persistent uterine
treatment
contractions (4 very - 20 min) should be
➢ If a private room is not used, do not
considered to be in labor
place the woman in a room with a
● A woman is documented as being in actual
woman who is in labor or who has
labor rather than having false labor
lost an infant
contractions if she is having uterine
contractions that cause cervical effacement
❖ Situational Low Self-Esteem r/t Inability
over 80% and dilation over 1cm
to carry pregnancy
● Preterm labor is always serious because if it
➢ Provide support persons because
results in infant’s birth, the infant may be
she is apt to be more concerned than
immature
the average person about labor
➢ Encourage expression of feelings
ASSESSMENT:
and anxieties to facilitate coping with
● During tocolytic therapy, assess the
actual situation
following:
➢ Provide frequent assurance during
○ Fetal status by electronic fetal
labor that she is breathing well with
monitoring
contractions and continue until
○ Uterine activity pattern
postpartum period because she may
○ Respiratory status
not be mentally prepared for the
○ Muscular tremors
labor because it has come
○ Palpitations
unexpectedly
○ Dizziness
➢ Comment on strengths of the family
○ Lightheadedness •
unit.
○ Urinary Output
➢ Convey confidence in client’s ability
○ Patient education to S/Sx of PTL
to cope with current situation.
○ Patient education to S/sx of infection
❖ Risk for Fetal Injury r/t Preterm Birth
RISK FACTORS:
➢ Monitor fetal status and labor
● Race: African-American women
problems.
● Age: Adolescents
➢ Assess WBC count frequently. A
● Those with inadequate prenatal care
count of 18,000-20,000/mm3 suggest
infection
 ➢ Reassure misconceptions about ● Medication to help prevent infection (more
difficulty of labor after preterm likely if your membranes have ruptured or if
rupture of the membranes (dry labor) the contractions are caused by infection)
since amniotic fluid is always being ● Evaluation of your baby. Biophysical profile,
formed so there is no such thing as non-stress or stress tests
dry labor ● Medications to help your baby’s lung
➢ Encourage the woman to assume develop more quickly
position that will enhance placental
perfusion Preconception Care
➢ Assist with delivery of infant as I. Baseline assessment of health and risks
needed. with advice to decrease the risks attributable
to preterm labor/PTB
❖ Risk for Injury to Tocolytic therapy II. Pregnancy planning and identification of
➢ Maintain accurate I/O at least every barriers to care
hour. Limit intake to 2500 ml/day III. Adjustment of prescribed and OTC that may
➢ Assess maternal VS. pose a threat to the developing fetus
➢ Notify Physician if maternal pulse is IV. Advise to improve maternal nutrition
greater than 120 bpm V. Screening for and treatment of diseases
➢ Assess for S/Sx of pulmonary VI. Genetic counseling for those with a history
edema. of genetic disease/ a previously affected
➢ Educate women on tocolytic therapy, pregnancy
explaining the purpose and common
A/E ANTEPARTUM TREATMENT
● Educate mother regarding S/Sx of PTL
❖ Compromised Family Coping ● Instruct mother and provide resources for
➢ Encourage private time for woman lifestyle modifications
and partner. ○ If mother smokes, encourage
➢ Encourage family members to smoking cessation classes
verbalize feelings openly and clearly ○ Ensure mother has a healthy diet
➢ Allow visitation with other children as and adequate maternal weight gain
tolerated by the woman. during pregnancy
➢ Promote assistance of family in ● Initial treatment for a patient who is at risk
providing client care as appropriate for PTL is the use of bed rest in a left lateral
➢ position with continuous monitoring of fetal
status and uterine activity
MEDICAL MANAGEMENT: ● Hydration with IV fluids with careful
● Antibiotics assessment of I/O and auscultation of lungs
● Prostaglandin Inhibitors to assess for the development of pulmonary
○ Indomethacin (Indocin) edema
● If this stops the contraction, tocolytic therapy
● Calcium Channel Blockers is not needed
○ Nifedipine (procardia)
PATHOPHYSIOLOGY
● Corticosteroids
○ Betamethazone 12 mg IM q 24 hrs 2
doses
○ Dexamethasone 6 mg IM q 12 hrs 4
doses
● Magnesium sulfate
● Beta-sympathomimetic drugs
○ Ritodrine hydrochloride (yutopar)
○ Terbutaline (brethine)

Surgical Management:
● Cesarean Section

NURSING MANAGEMENT:
● Hydration (Oral or IV)
● Bedrest (Home or Hospital), usually left side
lying
● Medications to stop labor (MgS04, brethine,
terbutaline, etc.)
 ASSESSMENT:
● A complete pelvic examination is required,
including a rectovaginal examination to
assess sphincter tone
● A Sims speculum or a standard bivalve
speculum with the anterior blade removed
may facilitate diagnosis.
● Mild uterine prolapse may be recognized
only when the patient strains during the
bimanual examination
● Evaluate all patients for estrogen status.
UTERINE PROLAPSE ○ Signs of decreased estrogens
■ Loss of rugae in the vaginal
● Uterine Prolapse/Pelvic Relaxation/Pelvic mucosa
floor hernia ■ Decreased secretions
● a descent or herniation of the uterus into or ■ Thin perineal skin
beyond the vagina ■ Easy perineal tearing
● Considered under the broader heading of
“pelvic organ prolapse” which also include ● If urinary obstruction is present, the patient
cystocele, urethrocele, enterocele, and may exhibit suprapubic tenderness or a
rectocele tympanitic bladder.
● anatomically, the vaginal vault has 3 ● If infection is present, purulent cervical
compartments: discharge may be noted.
○ an anterior compartment
(consisting of the anterior vaginal
wall) Lab Studies Imaging Studies
○ a middle compartment (cervix)
● Laboratory ● Pelvic
○ posterior compartment (posterior
studies are ultrasound
vaginal wall).
unnecessary in examination
○ UP involves the middle compartment
uncomplicated ● Ultrasonograph
cases y
Four stages of uterine prolapse are defined:
● Cervical ● MRI- to grade
● stage I - descent of the uterus to any point
cultures - pelvic organ
in the vagina above the hymen
cases prolapse
● stage II - descent to the hymen
complicated by
● stage III - as descent beyond the hymen
ulceration or
● stage IV - total eversion or procidentia
purulent
discharge
Uterine prolapse always is accompanied by some
● Papanicolaou
degree of vaginal wall prolapse
test (Pap
smear
cytology) or
biopsy - rare
cases of
suspected
carcinoma
● BUN and
creatinine
measurement -
if PE findings
 suggest urinary
obstruction

SIGNS AND SYMPTOMS:

● Pelvic heaviness or pressure
● Protrusion of tissue: a patient who report of
a “bulge” has been found to be valuable
screening tool for the detection of pelvic
organ prolapse (81% PPV, 76% NPV)
● Pelvic pain
● Sexual dysfunction, including dypareunia,
decreased libido, and difficulty achieving
orgasm
● Lower back pain
● Constipation
● Difficulty walking
● Difficulty urinating
● Urinary frequency
● Urinary urgency
● Urinary incontinence
● Nausea •
● Purulent discharge (rare) COMPLICATIONS:
● Bleeding (rare) ● Urinary retention
● Ulceration (rare) ● Constipation
● Hemorrhoids
PATHOPHYSIOLOGY ● Cervical ulceration
● Infection
● Cystitis

TREATMENT/MEDICAL MANAGEMENT:
● Pessaries
○ fitted into the vagina to hold the
uterus in place
○ Temporary or permanent form
○ fitted individually for each woman
○ Attaining and maintaining optimal
weight is recommended

● Surgery
○ uterus sutured back into place
○ colpopexy - involves the use of
surgical mesh for supporting the
uterus
○ Hysterectomy - removal of uterus
 ○ Provide factual information about
individual condition involved to
promote informed decision making
○ Provide for ways to obtain privacy to
allow for sexual expression for
individual and/or between partners
without embarrassment and/or
objection of others

● RISK FOR INFECTION

NURSING MANAGEMENT: ○ Observe for localized signs of
● Preventive measures: infection
○ Early visits to HC provider = early ○ Note for signs and symptoms for
detection sepsis
○ Teach Kegel’s exercises during PP ○ Stress proper hand hygiene
period
UTERINE RUPTURE
● Preoperative nursing care:
○ Thorough explanation of procedure, ● Spontaneous or traumatic rupture of the
expectation and effect on future uterus ie., the actual separation of the
sexual f(x) uterine myometrium/ previous uterine scar,
○ Laxative and cleansing edema with rupture of membranes and extrusion of
(rectocele) - independently, at home the fetus or fetal parts into the peritoneal
a day prior procedure cavity
○ Perineal shave prescribe also ● Dehiscence
○ Lithotomy position for surgery ○ Partial separation of the old uterine
scar;
● Post Op nursing care: ○ The fetus usually stays inside the
○ Pt. is to void few hours after surgery; uterus and the bleeding is minimal
catheter if unable (after 6 hrs) 4-6 hrs when dehiscence occurs

NURSING DIAGNOSIS: Ruptured Uterus

● PAIN
○ Administer analgesic as prescribed
○ Provide comfort measures such as
backrub
○ Provide diversional activities such as
as guided imagery and socialization

● CONSTIPATION
○ Administer stool softeners/laxatives
as prescribed
○ Encourage increase in fluid and fiber
intake
○ Encourage early ambulation RISK FACTORS:
● Women who hace had previous surgery on
● URINARY INCONTINENCE the uterus (uupper muscular portion)
○ Determine if client is aware of ● Having more than five full-term pregnancies
incontinence. Developmental issus/ ● Having overdistended uterus (as with twins
medical conditions that can impair or other multiples)
patient’s awareness and sensory ● Abnormal positions of the baby such as
perception of voiding transverse lie
○ Determine patient’s particular ● Use of Pitocin (oxytocin) and other
symptoms (e.g continus dribbling) labor-induced medication (prostaglandin)
○ Implement bladder training for ● Rupture of the scar from a previous CS
incontinence management by delivery
providing ready access to bathroom ● Uterine/abdominal trauma
or commode, encouraging adequate ● Uterine congenital anomaly
fluid intake, and establishing ● Obstructed labor; maneuvers within the
voiding/bladder emptying uterus
● Interdelivery interval (time between
● SEXUAL DYSFUNCTION deliveries)
PATHOPHYSIOLOGY

ASSESSMENT:
● Evaluate maternal vital signs
● Note an increase in rate and depth of
respirations, an increase in pulse, or a drop
in BP indicating status change
● Assess fetal status by continuous monitoring
● Speak with family, and evaluate their
understanding of the situation
● Observe for signs and symptoms of
Impending rupture
○ Lack of cervical dilaition
○ Tetanic uterine contraction = nonstop
○ Restlessness
○ Anxiety
○ Severe abdominal pain
○ Fetal bradycardia
○ Late or variable deceleration of the
FHR

SIGNS AND SYMPTOMS:

Clinical Manifestation:
● Developing Rupture
○ Abdominal pain and tenderness
○ Uterine contractions will usually
continue but will diminish in intensity
and tone.
○ Bleeding into the abdominal cavity
and sometimes into the vagina
○ Vomiting
○ Syncope;tachycardia; pallor
○ Significant change in FHR
characteristics - usually bradycardia
(most significant sign)

● Violent Traumatic Rupture

○ Sudden sharp abdominal pain during
or between contraction
○ Abdominal tenderness
○ Uterine contractions may be absent,
or may continue but be diminished in
intensity and tone
○ Bleeding vaginally, abdominally, or
both
 ○ Fetus easily palpated in the ○ Administer 02 using a face mask at
abdominal with shoulder pain 8-12 L/min or as ordered to provide
○ Tenses, acute abdominal with high oxygen concentration
shoulder pain ○ Apply pulse oximeter, and monitor
○ Signs of shock oxygen saturation as indicted
■ Hypovolemic = hypoterm, ○ Monitor ABG labels and serum
tachycardia, tachypnea electrolytes as indicated to assess
○ Chest pain from diaphragmatic respiratory status, observing for
irritation due to bleeding into the hyperventilation and electrolyte
abdomen imbalance
○ Continually monitor maternal and
NURSING DIAGNOSIS WITH INTERVENTIONS: fetal vital signs to assess pattern
● DEFICIENT FLUID VOLUME because progressive changes may
○ Start or maintain an IV fluid as indicate profound shock
prescribed. Use a large gauge
catheter when staring the IV for ● FOR INFECTION MEDICAL
blood and large quantities of fluid MANAGEMENT:
replacement ○ Observe for localized signs of
○ Maintain CVP and arterial lines, as infection
indicated for hemodynamic ○ Cleanse incision or insertion sites
monitoring daily and PRN with providone iodine
○ Maintain bed rest to decrease or other appropriate solution
metabolic demands ○ Change dressings as needed or
○ Insert foley catheter, and monitor indicated
urine output hourly or as indicated ○ Encourage early ambulation, deep
○ Obtain and administer blood breathing, coughing and position
products as indicated changes
○ Maintain adequate hydration and
● FEAR provide
○ Give brief explanation to the woman ○ Provide perineal care
and her support person before
beginning a procedure
Medical Management Surgical Management
○ Answer question that the family or
woman may have ● Immediate ● Cesarean
○ Maintain a quiet and calm stabilization of section
atmosphere to enhance relaxation maternal ● Laparotomy
○ Remain with the woman until hemodynamics ● Hysterectomy
anesthesia has been administered; and immediate
offer support as needed cesarean
○ Keep the family members aware of delivery
the situation while the woman is in ● Oxytocin is
surgery and allow time for them to given to
express feeling contract the
uterus and the
● DECREASED CARDIAC OUTPUT replacement
○ Administer supplemental oxygen, ● After surgery,
blood/fluid replacement, antibiotic, additional blood,
diuretic, inotropic drugs, and fluid
antidysrhythmics, steroids, replacement is
vasopressors, and/or dilators as continued along
ordered with antibiotic
○ Position HOB flat or keep trunk theory
horizontal while raising legs to 20-30
degrees in shock situation
○ Activities such as isometric exercise,
rectal stimulation, vomiting,
spasmodic coughing which may Nursing Management
stimulate valsalva response should
be avoided; administer stool softener ● Continually evaluate maternal vital signs
as indicated ● Assess fetal status
● Speak with family, and evaluate
● INEFFECTIVE TISSUE PERFUSION RISK understanding of the situation
 ○ A woman’s culture influences and
● Anticipate the need for an immediate
defines
cesarean birth to prevent rupture when
○ The childbirth experience
symptoms are present
■ Shameful versus joyful
● Provide information to the support person
○ Superstitions and beliefs about
and inform him or her about fetal
pregnancy and birth
outcome, the extent of the surgery and the
○ Prescribed behavior and taboos
woman’s safety
during the intrapartum period
● Let the pt express her emotion without
○ Relationships
feeling threatened
■ Interpersonal interactions
PLACENTAL PROBLEMS ■ Parent-infant interaction
● Placenta previa ■ Role expectations of family
● Abruptio placenta members
■ Support person involvement
● Pain
PROBLEMS WITH THE PSYCHE ○ Meaning and context of pain
○ Acceptable responses to pain
○ The significance of touch
Factors that may affect the woman’s psyche during ○ Soothing versus intruding
labor include the woman’s: ○ May be a symbol of intimacy
● Current pregnancy experience
○ Unplanned versus planned SUMMARY
pregnancy INTRAPARTAL HIGH RISK FACTORS
○ Amount of difficulty conceiving
○ Presence of risk factories
○ Complications of pregnancy FACTOR MATERNAL FETAL-NEONATAL
IMPLICATIONS IMPLICATIONS
● Previous birth experiences
abnormal ↑ Incidence of ↑ Incidence of
○ Complications of delivery
presentation cesarean birth placenta pre
○ Mode of delivery (cesarean versus
Prematurity
vaginal)
↑ Incidence of
○ Birth outcomes (e.g., fetal demise,
prolonged labor ↑ Risk of congenital
birth defects)
abnormality
Neonatal physical
● Expectation for current birth experience
trauma
○ View of labor as meaningful or a
stressful event
↑ Risk of
○ Realistic and attainable goals versus
intrauterine growth
idealistic views that conflict with
restriction (IUGR)
reality (a situation that can lead to
via
disappointment)
Multiple ↑ Uterine low birth weight
● Preparation for birth gestation distention→↑risk Prematurity
○ Type of childbirth preparation of postpartum
○ Familiarity with institution and its hemorrhage ↑ Risk of congenital
policies and procedures anomalies
○ Type of relaxation techniques ↑ Risk of Feto-fetal
learned practiced cesarean birth transfusion
● Support system
○ Presence and support of a birth ↑ Risk of
companion preterm labor
■ Husband
■ Mother Hydramnios ↑Discomfort ↑ Risk of
■ Lesbian partner esophageal or other
■ Friend ↑ Dyspnea highalimentary-tract
■ Doula - a woman, typically atresias
without formal obstetric ↑ Risk of
training, who is employed to preterm labor ↑ Risk of CNS
provide guidance and support anomalies
to a pregnant woman during
(myelocele) Edema
labor
of lower extremities
● Culture
Failure to Maternal Fetal ↑ Incidence of
progress in exhaustion hypoxia/acidosis tocolytic therapy
labor Intracranial birth
↑ Incidence of injury Induction of ↑ Risk of Prematurity if
augmentation of labor hypercontractilit gestational age not
labor y of uterus assessed correctly
Hypoxia if
↑ Incidence of ↑ Risk of uterine hyperstimulation
cesarean birth rupture Length occurs
of labor if cervix
Precipitous Perineal, Tentorial tears not ready
labor (<3 vaginal, cervical
hours) lacerations ↑ Anxiety

↑ Risk of Abruptio Hemorrhage ↑ Perinatal mortality

postpartum placentae/pl Uterine atony
hemorrhage acenta Fetal
previa ↑ Incidence of hypoxia/acidosis
Prolapse of ↑ Fear for baby Acute fetal cesarean birth
umbilical Cesarean birth hypoxia/acidosis Fetal
cord exsanguination

Oligohydra Maternal fear of ↑ Incidence of Fetal heart ↑ Fear for baby Tachycardia,
mnios “dry birth” congenital aberrations chronic asphyxic
anomalies ↑ Risk of insult, bradycardia,
cesarean birth, acute Asphyxic
↑ Incidence of renal forceps, vacuum insult Chronic
lesions Continuous hypoxia Congenital
electronic heart block
↑ Risk of IUGR monitoring and
intervention in
↑ Risk of fetal labor
acidosis
Uterine Hemorrhage Fetal anoxia
↑ Risk of cord rupture Cesarean birth
compression for hysterectomy Fetal hemorrhage
Postmaturity
↑ Risk of death ↑ Neonatal
Meconium ↑ Psychologic ↑ Risk of fetal morbidity and
staining of stress due to asphyxia mortality
amniotic fear for baby
fluid ↑ Risk of meconium
aspiration

↑ Risk of
pneumonia due to
PAGES 18-21
aspiration of
meconium
Postdates ↑ Anxiety Postmaturity
Premature ↑ Risk of ↑ Perinatal (>42 weeks) ↑ Incidence of syndrome
rupture of infection morbidity induction of ↑ Risk of
membranes (chorioamnio Prematurity labor fetal-neonatal
nitis) ↑ Incidence of mortality and
↑ Birth weight cesarean birth morbidity
↑ Risk of ↑ Use of ↑ Risk of
preterm labor ↑ Risk of respiratory technology to antepartum
distress syndrome monitor fetus fetal death
↑ Anxiety Fear Prolonged ↑ Risk of ↑ Incidence or
for the baby hospitalization shoulder risk of large
Prolonged dystocia baby
hospitalization
Diabetes ↑ Risk of ↑ Risk of
 hydramnios malpresentatio Assessment Normal Abnormal
↑ Risk of n Technique Assessment Assessment
hypoglycemia ↑ Risk of Findings Findings
or macrosomia
hyperglycemia ↑ Risk of IUGR Inspection/ ● Exhaustion ● Extreme
↑ Risk of ↑ Risk of Observation ● Fatigue exhaustion
preeclampsia respiratory ● Sleep ,
eclampsia distress hunger weakness,
syndrome and
↑ Risk of depression
congenital at the end
anomalies of 6th
week
Preeclampsia - ↑ Risk of ↑ Risk of small ● Pallor
eclampsia seizures for-gestational- ● Anxiousne
↑ Risk of age baby ss and
stroke ↑ Risk of restlessne
↑ Risk of preterm birth ss
HELLP ↑ Risk of ● Dizziness
mortality ● Fainting

AIDS/STI ↑ Risk of ↑ Risk of

additional transplacental ASSESSMENT OF THE VITAL SIGNS
infections transmission
Vital Signs Normal Abnormal

COMMON POSTPARTUM COMPLICATIONS ● Blood ● 90/60 – ● Below 90/60

Pressure 130/80 130/90 &
● Postpartum Assessment: ● Pulse ● 40 – 80 above
Rate bpm ● Tachycardia
A appearance ● Weak
V ital Signs Thready
B reasts Palpitations
U terus
B ladder ● Respirator ● 16 -24 ● Tachypnea
B owel y Rate breaths/cy ● Shallow &
L ochia cle Irregular
E pisiotomy/Episorrhapy Dyspnea
H oman’s Sign
E motions ● Temperatur ● 36.2 – 38 C ● 38 C and
R hogan e on the first above in any
24 hours or two
PATHOPHYSIOLOGY OF POSTPARTUM ● Occasionall consecutive
● Involution - rapid reduction in size of uterus y febrile on 24-hour
and return to prepreganant state the 3rd to period
● Subinvolution - failure to descent 4th day (excluding
● Uterus is at level of umbilicus within 6 to 12 the first 24
hours after childbirth - decreases by one hours)
finger breath per day
● Exfoliation - allows for healing of placenta
site and is important part of involution - may
take up to 6 weeks ASSESSMENT OF THE BREAST
● Enhanced by:
○ Uncomplicated labor and birth
○ Complete expulsion of placenta or Assessment Normal Abnormal
membranes Technique
○ Breastfeeding
○ Early ambulation Inspection ● Increase in ● Localized
size ● swelling
ASSESSMENT OF THE GENERAL ● Colostrum ● Localized
APPEARANCE ● Milk Pain
changes ● Redness
 from thin ● Purulent ● Zero-trace
watery to discharge sugar
bluish ● Cracked ● Urinary
white and stasis
● Becomes irritated
heavier nipples ● Palpation ● Cannot be ● Hard and
● Veins ● Percussion palpated firm
become ● Dull, ● Resonant
apparent thudding

Palpation ● Warm and ● Localized

firm mass
ASSESSMENT OF THE BOWEL
Engorged

Assessment Normal Abnormal

ASSESSMENT OF THE UTERUS
Technique
Assessment Normal Abnormal
Technique Inspection ● Constipatio ● Constipatio
n n
Inspection ● Weight ● No weight ● Decrease ● Decrease
1000 gms changes flatus flatus
immediatel ● Visible ● Abdominal ● Abdominal
y after birth cervix or distention distention
● 500 gms at uterus ● Decrease ● Decrease
the end of ● Severe bowel bowel
first week abdominal movement movement
● 50 grms at pain and ● Hemorrhoi ● Hemorrhoi
6th week tenderness ds dsa
● After pains ● Lateral
during displacem
contraction ent of the Auscultation ● decrease ● Absent
s uterus bowel bowel
sound sound
Palpation ● Contracted ● Boggy
● Cervix is uterus
soft and ● Board-like
ASSESSMENT OF LOCHIA
malleable abdomen
● Uterus rids itself of debris remaining after
● Cervical os
birth through discharge called lochia
is
● Lochia changes:
narrowed
○ Bright red at birth
○ Rubra - dark red (2-3 days after
delivery)
○ Serosa - pink (day 3 - 10 after
ASSESSMENT OF THE BLADDER delivery)
○ Alba - white
○ Clear
Assessment Normal Abnormal
● If blood collects and forms clots within
Technique
uterus, fundus rises and becomes boggy
Inspection ● Temporary ● Burning (uterine atony)
difficulty of sensation
voiding ● Hematuria LOCHIA - RUBRA ASSESSMENT
● Void within ● Inability to ● Lochia - blood mucus, tissue vaginal
6 to 8 void more discharge
hours than 10 ● Assess amount, color, odor, clots
postpartum hours ● If soaking 1 or > pads / hour, assess uterus,
● 3 Liters ● Oliguria notify health care provider
urinary ● Severe ● Total volume - 240 to 270 ml
output/day proteinuria ● Resume menstrual cycle within 6 - 8 weeks,
● Zero-trace ● Glycosuria breast feeding may be 3 months
protein
TYPES OF NORMAL ABNORMAL separation of ● Large
LOCHIA wound lacerations
edges ● Purulent
Lochia Rubra ● 2 to 3 days ● Large clots ● 1st degree discharges
postpartum laceration
● Dark Red in
color
● Contains ● Inspect the perineum for
blood and episiotomy/lacerations with REEDA
fragments assessment
of the ● Inspect C/S abdominal incisions for REEDA
deciduas ○ R = redness (erythema)
and mucus ○ E = edema
○ E = ecchymosis
Lochia Serosa ● 3 to 10 days ● Reappeara ○ D = drainage, discharge
postpartum nce of ○ A = approximation
● Pink in color bright red
● Contains colored
blood, lochia POSTPARTUM HEMORRHAGE
mucus, and ● Foul-smelli
invading ng 1. Early Postpartum Hemorrhage
leukocytes ○ Uterine Atony
○ Lacerations
Lochia Alba ● 10 to 14 ● Reappeara ○ Hematomas
days nce of ○ Uterine Rupture
postpartum bright red ○ Uterine Inversion
● Contains color 2. Late Postpartum Hemorrhage
mucus, ● Foul-smelli ○ Retention of Fragments
whitish ng ○ Subinvolution
○ Disseminated Intravascular
Coagulation

UTERINE ATONY
OVULATION AND
MENSTRUATION/LACTATION SIGNS AND SYMPTOMS
● Boggy Uterus
● Large Uterus
● Return of ovulation and menstruation varies ● Expulsion of large clots
for each postpartal woman ● Bright red bleeding
○ Menstruation returns between 6 and ● Hypovolemic shock
10 weeks after birth in nonlactating
mother - ovulation returns within 6 FACTORS CAUSING UTERINE ATONY
months ● Multiple Gestation
○ Return of ovulation and menstruation ● Hydramnios
in breastfeeding mother is prolonged ● Large baby
related to length of time ● Uterine Myoma
breastfeeding continues ● Anestheia
● Breast begin milk production ● Oxytoxic drugs
○ A result of interplay of maternal ● Multiparity
hormones ● Advanced maternal age
● Prolonged tocolytic agents
ASSESSMENT OF EPISIOTOMY/EPISSIORRAPY ● Dystocia
● Previous Uterine surgery
Assessment Normal Abnormal ● Chorioamnionitis
Technique ● Full bladder

Inspection ● Redness, ● Hematomas MANAGEMENT OF UTERINE ATONY

edema, and • 1 or 2 ● Promote Uterine Contraction
bruises on stitches ● Stop Bleeding
the perineum sloughed ● Prevent Complications
● Slight away ○ Hypovolemic Shock - Death
MEDICAL MANAGEMENT OF UTERINE ATONY ● Primigravida
● Intravenous Fluid
● Oxytoxic Medications: MANAGEMENT OF LACERATIONS
○ Oxytocin ● Surgical Repair
○ Maleate ● Cessation of bleeding
○ Cytotec ● Prevent Infection
● Antibiotics ● Alleviate pain
● Blood Transfusion
● Catheterization MEDICAL MANAGEMENT
● Oxygen Administration ● Vaginal pack
● Analgesics
SURGICAL MANAGEMENT OF UTERINE ATONY ● Antibiotics
Ligation of Uterine Arteries ● Stool softener
Hysterectomy
SURGICAL MANAGEMENT OF LACERATIONS
NURSING DIAGNOSIS & MANAGEMENT OF ● Surgical Repair
UTERINE ATONY ● Regional anesthesia
● Actual/Potential Fluid Volume Deficit
○ fundal massage NURSING DIAGNOSIS AND MANAGEMENT OF
○ ice pack application on fundus LACERATIONS
○ encourage voiding ● Alteration in Comfort; Pain
○ administer oxytocics as ordered ○ cold compress on the perineum
○ regulate IVF and BT ○ perineal douch
● Altered Tissue Perfussion ○ high fiber diet
○ assess VS, NVS, CRT ○ increase OFI
○ assess skin color and turgor ○ NSAIDS as ordered
○ trendelenburg position ● Potential for infection
○ oxygen administration as ordered ○ pat dry the perineum
● Anxiety ○ frequent change of gowns and
● emotional support perineal pads
● give factual information about the condition ○ proper nutrition
● explain the procedures ○ increased OFI
● provide calm environment ○ prophylactic antibiotic as ordered

LACERATIONS HEMATOMA
Vaginal: SIGNS AND SYMPTOMS OF HEMATOMA
● anterior ● severe perineal and pelvic pain not relieved
● posterior by analgesia
● lateral wall ● bluish bulging under the skin
Perineal: ● tenderness
● first degree – skin ● firm to palpate
● second degree – muscles ● minor bleeding
● third degree – external anal sphincter
● fourth degree – rectal sphincter and rectal FACTORS CAUSING HEMATOMA
mucus membrane ● Rapid Spontaneous birth
Cervical: ● Varicosities
● lateral ● Episiorrhaphy
● Lacerations
SIGNS AND SYMPTOMS OF LACERATIONS
● Firm and Contracted Uterus MANAGEMENT OF HEMATOMA:
● Bright red Bleeding MEDICAL MANAGEMENT
● Tear in the birth canal, and perineum ● Analgesics
● Cold Compress
FACTORS CAUSING LACERATIONS
● Precipitate labor SURGICAL MANAGEMENT
● Dystocia ● Incision and drainage
● Malpresentation ● Removal of sutures
● Large babies ● Packing
● Instrumentation ● Ligation of vessels
● Lithotomy position
● Rapid cervical dilatation NURSING DIAGNOSIS AND INTERVENTIONS
 ● Alteration in comfort; Pain ○ Administer oxygen as ordered
○ proper referral ● Dysfunctional Grieving
○ ice pack application on the perineum ● Anxiety Fear
○ analgesics as ordered ○ Obtain consent for surgery
○ assist for surgical intervention ○ Give factual informations
○ Explain procedures
○ Do not give reassurance o Emotional
support
UTERINE RUPTURE
COMPLETE
UTERINE INVERSION
● involves endometrium, myometrium and
perimetrium DEGREE OF INVERSION
● First-degree - the inverted fundus extends
INCOMPLETE to, but not through, the cervix.
● intact peritoneum ● Second-degree - the inverted fundus
extends through the cervix but remains
SIGNS AND SYMPTOMS OF UTERINE RUPTURE within the vagina.
● Localized abdominal pain ● Third-degree - the inverted fundus extends
● Abdominal tenderness outside the vagina.
● Tearing feeling ● Total inversion - the vagina and uterus are
● Hypovolemic shock inverted.
● Concealed bleeding
● Change in abdominal contour SIGNS AND SYMPTOMS
● Visualization of protruded uterus
FACTORS CAUSING UTERINE RUPTURE ● Sudden gush of large amount of blood
● Difficult Vaginal Delivery ● Hypovolemic shock after 10 minutes
● Weak uterine operative site
● vertical uterine scar from previous CS FACTORS CAUSING UTERINE INVERSION
● Faulty presentation ● Pulling the umbilical cord before placental
● Multiple gestation separation
● Traumatic maneuvers using instruments for ● Extreme pushing of the fundus
delivery ● Fundal implantation of the placenta
● Injudicious use of oxytoxic agents
● Obstructed Labor GOAL OF CARE OF UTERINE INVERSION
● Prevent Hemorrhage
GOAL OF MANAGEMENT OF UTERINE ● Jhonson’s Maneuver
RUPTURE ● Prevent Shock
● Repair of tear or laceration ● Prevent Infection
● Prevent Hemorrhage ● Prevent Death
● Prevent Hypovolemic shock
● Prevent Infection MEDICAL MANAGEMENT
● Prevent Death ● Initially:
○ Tocolytic
MEDICAL MANAGEMENT OF UTERINE ○ General anesthesia
RUPTURE ○ Nitroglycerine
● Intravenous fluid ● Oxytocic agents
● Blood Transfusion ● Double intravenous fluid
● Antibiotics ● Oxygen administration
● Oxytoxics ● Ready for CPR
● Antibiotics
SURGICAL MANAGEMENT OF UTERINE ● Blood Transfusion
RUPTURE
● Laparotomy SURGICAL MANAGEMENT
● Tubal ligation ● Jhonson’s Maneuver
● Hysterectomy ● Surgical Replacement
● Hysterectomy Laparotomy
NURSING DIAGNOSIS AND INTERVENTIONS OF ● General Anesthesia
UTERINE RUPTURE
● Fluid Volume Deficit NURSING DIAGNOSIS AND INTERVENTION
● Altered Cardiac Output ● Fluid Volume Deficit
● Altered Tissue Perfusion ● Altered Cardiac Output
○ Monitor VS every 15 minutes ● Altered Tissue Perfusion
○ Evaluate blood loss IVF and BT ○ Determine the degree of inversion
 ○ Assess VS, NVS, and CRT ● Retained Placenta fragments
○ Evaluate blood loss ● Endometritis
○ Use large needles/cannula for ● Uterine Myoma
intravenous fluid
○ Regulate IVF and BT as ordered MEDICAL MANAGEMENT OF UTERINE
○ Administer oxygen by face mask SUBINVOLUTION
● Anxiety ● Oxytocin
○ Emotional support ● M. Malate
○ Stay with the client ● IVF
○ Listen
○ Give factual informations SURGICAL MANAGEMENT OF UTERINE
● Risk for infection SUBINVOLUTION
○ Aseptic technique ● Hysterectomy
○ Administer prophylactic antibiotics
NURSING DIAGNOSIS AND MANAGEMENT
● Fluid
LATE POSTPARTUM HEMORRHAGE
● Volume Deficit
Occurs between 24 hrs and 6 weeks postpartum ● Altered Cardiac Outout
● Altered Tissue Perfusion
● Retained Placental Fragments ● Alteration in thermoregulation; hyperthermia
● Subinvolution – “Opposite of involution, ● AnxIety
Lumaki ang uterus even after panganak” ● Fear
● Endometritis

RETAINED PLACENTAL FRAGMENTS DISSEMINATED INTRAVASCULAR

SIGNS AND SYMPTOMS COAGULATION
● Incomplete placental delivery Signs and Sumptoms:
● Uterus remain large ● Mild oozing of venipuncture site
● Bright red bleeding ● Petechiae
● +HCG in the blood
● +ultrasound result FACTORS CAUSING DIC
FACTORS CAUSING RETAINED PLACENTAL ● Abruptio placenta
FRAGMENTS ● Incomplete Abortion
● Failure to inspect after placental delivery ● Septic abortion
● Placental accreta - in the myometrium ● Prolonged retention of dead fetus
instead of endometrium ● Amniotic fluid embolism
● Hypertonic labor
MEDICAL MANAGEMENT OF RETAINED ● Excessive bleeding
PLACENTA
● Oxytocin administration GOAL OF MANAGEMENT OF DIC
● Maleate intramuscular ● Treat underlying conditions
● IVF ● Stop Clotting
● Resture normal clotting functions
SURGICAL MANAGEMENT OR RETAINED
PLACENTA MEDICAL MANAGEMENT OF DIC
● Dilatation and Curettage ● Heparin - anti coagulant
● Hysterectomy ● Blood replacment
● Fresh Frozen Plasma
NURSING DIAGNOSIS AND MANAGEMENT ● Platelet replacement
● Fluid Volume Deficit
● Decreased cardiac Outnut NURSING DIAGNOSIS AND INTERVENTIONS
● Altered Tissue Perfusion Actual/Potential Fluid Volume Deficit
● Risk for infection
● Anxiety ● Frequent monitoring
● Evaluate blood loss
SUBINVOLUTION OF THE UTERUS ● Gentle handling of patient
Signs and Symptoms: ● Frequent turning to sides
● Uterus remains large
● Lochia is perfused
PUERPERAL INFECTION
● Altered pattern of lochia
- Infection of the genital tract during
FACTORS CAUSING UTERINE SUBINVOLUTION postpartum
 ● vomiting
TYPES OF INFECTION ● appearance of acutely ill
● Endometritis
● mfection of the penium Management of Peritonitis
● Petritonitis ● large dose of antibiotics
● Mastitis ● NGT to relieve vomiting & rest the bowel
● IVF
ENDOMETRITIS ● Parenteral feeding
- an infection of the inner lining (endometrium) ● analgesics
of the uterus ● Antipyretics

Signs and Symptoms of Endometritis

● fever for 2 consecutive 24 hours usually on
MASTITIS
the 3rd or 4th day excluding the first 24
hours postpartum - infection of the breast tissues
● chills
● lost of appetite ETIOLOGY:
● general malaise ● Staphylococcus
● abdominal tenderness ● Streptococcus
● uterine atony ● Escherichia coli
● Strong afterpains
● dark brown foul smelling lochia Signs and Symptoms of Mastitis
● Localized pain, swelling, & redness
MANAGEMENT OF ENDOMETRITIS ● fever
● antibiotics ● body malaise
● oxytoxic ● rapid pulse
● analgesics ● scanty breastmilk
● Antipyretic
Management of Mastitis
INFECTION OF THE PERINEUM ● antibiotics
- very rare because of improved aseptic ● analgesics
technique ● antipyretics
Signs and Sumntoms of Infection of the ● warm or cold compress
Perineum ● supportive bra
● pain on the perineum ● constant emptying
● swelling ● incision and drainage
● heat
● pressure on the penneum Nursing Diagnosis of Puerperal Infection
● one or two stitches slough off ● Actual/potential for infection
● purulent discharges fm suture line ● Alteration in thermoregulation; hyperthermia
● may be febrile unless systemic ● Alteration in comfort; pain
● Social Isolation
Management of the Infection of the Perineum
● systemic or topical antibiotics THROMBOPHLEBITIS
● analgesics
● hot sitz bath
● warm compress - It is the inflammation of the lining of the
● perineal sutures may be removed to allow vessel in which a clot attaches to the vessel
drainage wall.
● packing with gauze
THREE MAJOR CAUSES:
● venous stasis
● Hypercoagubility
PERITONITIS ● damage of the intima of the blood vessels
- an infection of the peritoneal cavity
- common cause of mortality death from Other Factors:
puerperal infection ● varicosities
● obesity
Signs and Symptoms of Peritonitis ● history of thrombophlebitis
● rigid abdomen with guarding behavior ● oral contraceptives
● abdominal pain ● age > 35 yo
● high fever ● diabetes mellitus
● rapid pulse ● Smoking
 ● aseptic technique in invasive procedures
Classifications of Thrombophlebitis according ● then bud in
to the DEPTH ● irtrin apers)
● position dr lag period of
a) Superficial venous thrombosis ● Avoid in I perition for long penod of time
- limited to the calf only ● avoid leg crossing
- swelling of extremity, redness, tenderness, and ● increase oral fluid intake
warm; pain while walking ● early ambulation aft, pregman
● if cannot ambulat, prom exercises
b) Deep vein thrombosis ● avoid pillows under the knees
- often absent or diffused signs ● V dont smola
- swelling of erythema, edema, heat, tenderness

Classifications of Thrombophlebitis according

EMOTIONAL AND PSYCHOLOGICAL
to LOCATION
POSTPARTAL COMPLICATIONS
a) Femoral
● fever, chills, pain, redness, Phases of Puerperlum:
● swelling of extremeties, 1. Taking-In Phase
● White -stretched skin - This is the time of reflection for a woman.
● + homan's sign 2. Taking-hold Phase
- This is the phase where the woman begins
b) Pelvic to initiate action herself.
● ovarn, uterine, hypogastric vein 3. Letting-go
● high fever - The woman finally defines her new role.
● chills
● body malaise
POSTPARTUM BLUES
Management of Thrombophlebitis
● Anticoagulant
● Thrombolytic - It is a maternal adjustment reaction usually
● Analgesics occurring between the 2nd to 3rd
● laparotomy postpartum day through the 1st to 2nd
● monitoring or prothrombin time postpartum week.

Nursing Diagnosis and Management of Signs and symptoms of Postpartum Blues

Thrombophlebitis ● Insomnia
● Depressed mood
Alteration in Comfort; pain ● headache
- rest ● poor concentration
- elevate legs ● Tearfulness
- avoid standing to long period of time ● confusion
- antiembolic stockings ● Mood labile
- moist heat application
Factors causing Postpartum Blues
Altered Tissue Perfusion - sudden drop of hormone at about 72 hours
- constantly check skin postpartum
- passive ROM - disappointments of body changes
- previous skin ulceration - extreme disappoinments of labor and birth
- proper nutrition - inadequate emotional support from partner
- DO NOT MASSAGE - extreme stress from mothering role
- avoid pillow under the back
Management of Postpartum Blues
Risk for Injury (bleeding) related to therapy - allow woman to talk and cry
- work through their feelings
How to prevent thrombophlebitis? - encourage family support

● avoid wearing constricting clothings POSTPARTUM DEPRESSION

● rest while feet eluated
● ambulate daily during pregnancy
● limit - It is a mood disturbance that is characterized
● woman in by feelings of sadness, despair, apathy, and
● lithotorny position discouragement caused by loss In the
 person's life or by neuroblological imbalance ● Acknowledge that the woman feels
of neurotransmitters. depressed
● Assure that it is not her fault
SIGNS AND SYMPTOMS OF POSTPARTUM ● Encourage support from family members
DEPRESSION ● adequate rest and nutrition
● Excessive crying
● feeling of inadequacy
INFERTILITY
● Low self-esteem
● inability to cope - The inability to conceive after at least 1 year
● Anorexia of sexual intercourse at least 4 times a week
● insomnia without contraception.
● Psychosomatic symptoms
● deprusive or manic mood flactuation Normally...
● Social withdrawal .
● 50% of couples conceive within 6 months
Factors causing Postpartum Depression ● 35% conceive within 12 months
● history of depression
● troubled childhood Primary infertility
● Stress > no previous history of conception
● lack of support system
Secondary Intertility
Management of Postpartum Depression > Inability to conceive after previous successful
● Nurse-patient relationship pregnancy
- therapeutic relationship
● Psychopharmacologic Etiology of Female Infertility
- antidepressive drugs Vaginal problems:
● Milleu therapy ● vaginal infections
- forceful manipulation of the environment ● Anatomic abnormalities
● sexual dysfunction
● highly acidic vaginal ervinnnent
POSTPARTUM PSYCHOSIS
- it is a disrupted mental state in which an Cervical:
individual struggles to distinguish the - changes during ovulation
external world from his internally generated > cervical incompetence
perceptions.
Etiology of Female Infertility 70%
Factors causing Postpartum Psychosis ● Uterine
● major life crisis - functional
● previous mental illness - structural
● Family history of mental illness ● Tubai (F. Tube)
● Hormonal changes - Scarring
- PID
Signs and Symptoms of Postpartum Psychosis - Endometriosis
● suicidal & infanticidal thoughts - do not leave ● Ovarian
patient alone - Anovulation (di naga ovulate)
● dissociated - Oligo-ovulation (less ovulation)
● delusional
● confused Etiology of Male Infertility 30%
● distortion of reality ● Congenital
- absence of vas deferens and testes
Management of Postpartum Psychosis ● Ejaculatory
● professional psychiatric counselling - Retrograde ejaculation
● antiesychoticaras ● Sperm abnormalities
● hospitalization - oligospermia
● woman must be observed during her - aspermia
interaction with her child - inadequate maturation
- inadequale motility
Nursing Diagnosis and Management of - inability to deposit sperm into the vagina
Postpartum Emotional Disturbances (erectile dysfunction)
- blockage of sperm
• Risk for/Actual Ineffective coping ● Testicular
● convey caring attitude - orchitis: inflammation of the testes
 - cryptorchordism: undescended testes - The process by which a woman is medically
- trauma impregnated using semen from her husband
- radiation or from a third-party donor.
● Coital - Injecting collected semen into the woman's
- obesity uterus and is performed under a physician's
- nerve damage supervision.
- Impotence
● Drugs INDICATION
- Methotrexate - men who have very low sperm counts.
- Amebicides - sperm that aren't strong enough to swim
● Other factors: through the cervix and up into the fallopian
- STD tubes.
- stress
- alcohol & nicotine PROCESS:
● washing the sperm
Interactive Problems ● liquefying the sperm at room temperature for
● Insufficient frequency of sex intercourse (4x 30 minutes
a week) ● centrifuge is used to collect the best sperm.
● Poor timing of intercourse ● you can resume your usual activities
● Development of antibodies against partner’s
sperm Success rates for artificial Insemination vary.
● Use of spermicidal lubricants Factors that lessen your chance of success
● Inability of the sperm to penetrate the egg include:
● Older age of the woman
Diagnostic Studies ● Severe endometriosis
● Semen Analysis after 48 - 72 hours of ● Blockage of fallopian tubes
abstinence
● Cervical Mucous assessment IN VITRO FERTILIZATION
- fern test - is a process by which an egg is fertilized by sperm
- Spinnbarkei test outside the body in a laboratory.
● Postcoital Test
- SI at presumed ovulatory state IVF may be an option if you or your partner have
- after 48hrs of abstinence been
- Check cervical mucus diagnosed with:
● Basal Body Recording ● Endometriosis
- oral temp when awakening ● Low sperm counts
- Increase temp. 12-14 days ● Problems with ovulation
- Before menses-ovulation ● An unexplained fertility problem
● Serum Progesterone Test
● Endometrial Biopsy Surrogate embryo transfer
● Hysterosalpinography - embryos are placed into the uterus of a
● Ultrasound imaging female with the intent to establish a
pregnancy.
MANAGEMENT OF INTERTILITY
1. Management of underlying problems PROCESS:
- douche with alkaline solution 30 minutes - After the follicles are aspirated from the
before intercourse intended Mother or Egg Donor they will be
- renew environmental hazards examined and mixed with the intended
- Surgery father or a donors sperm.
- medications - They are then incubated for 3 - 5 days to
>antibiotic allow fertilization to occur.
>testosterone - Then, the embryos will be placed in the
>estrogen surrogates uterus via invitro fertilization
- sexual therapy - talk therapy - The process does not cause discomfort and
2. Assisted Reproductive Techniques requires no medication or anesthesia.
- artificial insemination - The process usually takes approximately
- in vitro fertilization ten-fifteen minutes.
- gamete intrafallopian transter (GIFT) - Surrogates will be required to rest with
- Surrogate mothering activity restrictions for two-three days
- zygote intrafallopian transfer (ZIFT) following the transfer procedure.

ARTIFICIAL INSEMINATION SURROGATE MOTHER

 - A woman who bears a child for another
person, often for pay.

TWO KINDS OF SURROGATE MOTHER

Traditional surrogates
- is a woman who is artificially inseminated
with the father's sperm.
- She then carries the baby and delivers it for
the parents to raise.

Gestational surrogates
- has no genetic ties to the child. That's
because it wasn't her egg that was used.
- more common than a traditional surrogate

WHO USES SURROGATES:

- Those with medical problems with her uterus.
Hysterectomy

OTHER REASONS:
- age
- sexual orientation

CHOOSING A SURROGATE:
1. Is at least 21 years old
2.
3. Has passed a psychological screening by a
mental health professional
4.
5. have a complete medical evaluation and
pregnancy history to assess the likelihood of a
healthy, full-term pregnancy.
 implanted on the vaginal OS which causes
bleeding which can lead to preterm labor.
PEDIA Concept
● Placental Aging is due to the aging of the
placenta. Not enough nutrients are provided
HIGH RISK NEWBORN to the baby since the placenta is unable to
supply oxygen and nutrients to the baby
from the mother
PROBLEMS RELATED TO MATURITY: E. PREECLAMPSIA/ECLAMPSIA
PRETERM ● Increase blood pressure (hypertension)
during gestational age causes
vasoconstriction, which leads to decrease in
● Preterm is a neonate born before 37 weeks oxygen supply and nutrients to the baby,
of gestation which can cause prematurity.
○ 36 weeks and 6 days/7 is still
considered as preterm but, termed
as borderline preterm FETAL FACTORS
● Primary concern: relates to immaturity of all
body system A. MULTIPLE PREGNANCY
● Cause: unknown ● Most common factor
● Ex. twins, triplets, etc. which can be
MATERNAL FACTORS hereditary
● Uterine Stretch Theory – when a uterus
reaches its maximum capacity to stretch, it
A. AGE will initiate contraction which leads to
● The younger the mother, the more prematurity.
predispose to develop a preterm infant. ○ Ex. triplets: mas mudako ug maayo,
Example, teens aged 13-15 yrs old doesn’t ma reach ang maximum capacity to
have a fully developed body system to bear stretch so mag initiate ug contraction
a child maong madeliver ang babies even
● Mothers beyond 35 years old are not able to though preterm pa..
bear a baby due to their body system not
being normal which can most likely cause a B. INFECTION
premature baby ● Presence of infection warrants prematurity
● Once the baby has an infection, the fetus
experiences respiratory distress so the baby
has to be delivered, which can cause
prematurity
● The baby can still be delivered normally
depending on its condition and if the baby
responds to the meds

OTHOTHER FACTORS

A. POOR SOCIOECONOMIC STATUS

● Equates with lesser financial status.
● Family cannot afford to provide a nutritious
meal to the mother
B. SMOKING
● Nicotine can cause vasoconstriction which B. ENVIRONMENTAL EXPOSURE TO
leads to decrease blood flow to the placental HARMFUL SUBSTANCES
which decreases oxygenation and nutrients ● Emission smoke or any chemical
to the baby and can cause prematurity substances the mother is exposed to most
C. POOR NUTRITION especially related to smoke can lead to
● It can lead to a decrease in nourishment prematurity.
delivered by the placenta to the baby, ● Harmful substances what affects the mother
resulting in the newborn not getting enough most especially is the respiratory system
nutrients which causes prematurity. which the mother will have a compromised
● Body system cannot develop properly blood circulation and oxygen
because of lack of sufficient nutrition.
D. PLACENTAL PROBLEM
● Placenta Previa is the abnormal
implantation of the placenta, usually
 exhaling.
ASSESSMENT
2. HYPERBILIRUBINEMIA
● High level of bilirubin in the blood, neonate
● Extremities are thin with minimal creasing on become jaundice due to immaturity of the
soles and palms. Subcutaneous fats are not liver.
fully developed. ● This is associated with skin discoloration
● Extension of extremities and does not (yellowish) as a result of increasing high
maintain flexion. levels.
● Abundance of lanugo hair ● Bilirubin is not conjugated properly because
● Labia are narrow in girls of its high levels, resulting in bilirubin
● Testes are undescended in boys accumulation in the blood
● Extension of extremities and does not ● Kernicterus staining of brain cells with
maintain flexion bilirubin, causing irreversible brain damage.
Blood with accumulated bilirubin travels to
the brain, which stains the brain.
○ If untreated, hyperbilirubinemia can
result to kernicterus or the deposition
of bilirubin in the brain.
○ Usually occurs in the bilirubin levels
are 25mg/dl or higher in term infants
○ Toxicity starts at 8-12 mg/dl in sick or
low birth weights
● Square window wrist. Bones are not fully
developed, they are only cartilages.
TWO TYPES OF JAUNDICE

Physiologic Jaundice Pathologic Jaundice

● Appears after 24 ● Underlying

hours of birth disease process
● Normal ● Appears within 24
● Cause: hours
Breakdown of ● Not normal
RBCs (72 hrs ● ABO
● Scarf sign – bring the arms of the infant lifespan) incompatibility
across the neck can be a factor

KEY TERMS: INFANT JAUNDICE

Bilirubin When the liver breaks

down old red blood
cells, bilirubin is
produced in the body.
Without proper
treatment high bilirubin
levels in newborns can
cause permanent brain
COMMON OR SPECIAL PROBLEM OF injury and disability.
PRETERM NEONATES
Hyperbilirubinemia An abnormally high
level of bilirubin in the
1. RESPIRATORY DISTRESS SYNDROME blood demonstrated by
(HYALINE MEMBRANE DISEASE) jaundice and lethargy,
● Due to lung immaturity; deficient in and associated with
surfactant. liver and hemolytic
● Surfactant is a fluid-like substance that can disease.
help with alveoli tension in order for it not to
collapse. Lack of surfactant means the lungs Jaundice An excess of bilirubin in
will not expand properly when inhaling and it the blood, which
will not maintain its deflated size when
 5. Promoting Sensory stimulation - Gentle
causes yellow
touch, speaking gently and softly, music
coloration of the eyes
box or low tuned radio
and skin. Medical staff
must quickly diagnose
and treat infant NURSING INTERVENTIONS
jaundice in order to
avoid kernicterus and
1. Monitor vital signs every 2 to 4 hours
permanent brain injury.
2. Administer oxygen and humidification as
Kernicterus A severe condition that prescribed.
occurs when bilirubin ● Mothers are given tocolytics that can
levels are so high that hasten fetal lung maturity of the
they move from the baby.
blood and into brain 3. Monitor intake and output
tissues. Kernicterus 4. Monitor daily weight.
can cause brain ● Essential aspect
damage and ● Should be taken at the same time,
permanent injury if not the newborn should be naked to get
diagnosed and treated the accurate weight. (The night shift
in a timely manner. nurse usually gets the weight of the
baby)
● Patients attached to many devices
3. INFECTION have a certain machine that displays
● Not able to receive IgG globulins the patient’s current weight. Nurse
should take note of the weight at the
4. COLD STRESS same time everyday
● Less subcutaneous tissue, poikilothermic 5. Maintain a newborn in a warming device.
● Warming device – maintain
5. ANEMIA thermoregulation, maintain newborn
● Less iron stores temp 35.5 to 36.5
● There are premature babies that are
6. HYPOTHERMIA not in the incubator because they are
● Can also lead to other problems able to regulate their temperature
● The baby should be in an open crib
MANAGEMENT with a double drop light or Swaddle.
6. Reposition every 1 to 2 hours, and handle
1. Improving respiratory function - Oxygen newborn carefully
therapy, mechanical ventilator ● Repositioning helps increase blood flow. If
● Mechanical Ventilator are needed the newborn isn’t repositioned it can cause
when the baby cannot sustain to pressure ulcers. Reposition the newborn
breathe on her own carefully
2. Maintaining body temperature - Isolette – ● Handle newborn carefully because they are
maintains ideal temperature, humidity and very fragile
oxygen concentration isolates infant from 7. Avoid exposure to infections.
infection, Kangaroo Care ● Handwasing
● Kangaroo Care= Skin to skin contact 8. Provide newborn with appropriate stimulation,
3. Preventing infection – Handwashing such as touch
● Make sure to do Hand washing when 9. Suctioning of secretions as needed
handling one patient from another or 10. Monitor for signs of infection
entering one room from another. ● Cardinal signs of infection
4. Promoting nutrition - Gavage feeding, Milk ○ Rubor - redness
feeding ○ Calor - increase body temp
● Gavage Feeding- OGT (Orogastric ○ Loss of function
Feeding) we also have NGT ○ Swelling
(Nasogastric tube) ○ Pain
● Babies use OGT when feeding for ● Decrease in body temp = decrease
they are obligate nasal breathers. of respiratory rate = apnea (one
NGT may cause partial nasal factor gitugnaw)
obstruction that can cover the other 11. Provide skin care
nose and hinder them to breathe. ● Babies in the incubator should not
● Babies learn to use their mouth to take a bath for it might decrease their
breathe when they reach 3 months body temperature or have an apneic
episodes. However, when it is
 transfer in an open crib the baby is
COMPLICATIONS OF POST MATURITY
already allowed to take a bath since
they are able to maintain their body
temperature. 1. The placenta begins to age toward the end
12. Provide complete explanations for parents of pregnancy, and may not function as
● Always keep the parents informed efficiently as before
and updated ● Placental age – normal term of AOG
● Placental aging – decrease
oxygenation and nutrients which
PROBLEMS RELATED TO MATURITY: POST
leads to deprivation, resulting in post
TERM
maturity

● Neonate born after 42 weeks of gestation 2. The failing placental function will place infant
● About 12% of all infants are post-term at risk for intrauterine hypoxia during labor
● Causes of delayed birth is unknown and delivery.
● Hypoxia – respiratory distress Fig 7.
Post term baby
MATERNAL FACTORS
● If the baby is experiencing distress, it
facilitates relaxation of rectal
A. First pregnancies between the ages 15 to muscles, which releases meconium.
19 years are unexpected pregnancies, they Meconium then floats around the
tend to hide their pregnancies. amniotic sac which the baby can
○ As a result, dili iingon na nag labor or drink which would lead to meconium
start na ang labor so ma extend ang aspiration syndrome once the baby is
labor delivered.
B. Woman older than 35 years
C. Multiparity with small babies so dili mafeel so 3. MECONIUM ASPIRATION SYNDROME
the uterine won’t reach its maximum capacity ● Crying is a baby’s first reaction. If the
which can lead to post term babies. baby swallowed its meconium, matuk
an ang baby then ang meconium
pwede muadto sa lungs.
FETAL FACTORS
4. HYPOGLYCEMIA - from nutritional
deprivation and poor storage of glycogen at
A. Fetal anomalies such as anencephaly birth
● Anencephaly – baby’s brain didn’t develop. ● Placental aging – decrease oxygen,
Life can be sustained but can’t live longer. nutrients which would lead to low
Death depends on the severity (most blood glucose, resulting in lethargy
common is 3 hours)
5. POLYCYTHEMIA- increase RBC (from both
mother and baby)
ASSESSMENT ● Manifestation: reddish

● Depleted subcutaneous fat: old looking “old

man facies” MANAGEMENT
● Parchment-like skin (dry, wrinkled and
cracked) without lanugo 1. Ultrasound is done to evaluate fetal
○ Inadequate amniotic fluid (because development, amount of amniotic fluids and
of placental aging, LBOW, RBOW) the placenta signs of aging
● Fingernails long and extended over ends of ● 1 st trimester ultrasound - confirm
fingers pregnancy
○ Provide mittens to avoid scratches • ● 2nd trimester ultrasound – congenital
Abundant scalp hair scan to determine congenital
● Long and thin body anomalies
● Sign of meconium staining ● 3rd trimester ultrasound – evaluate
○ Meconium – first transitional stool fetal development, amount of
○ Amniotic is green and foul-smelling amniotic fluid, etc.
● Nails and umbilical cord 2. Suctioning of the mouth and nose is done
○ Umbilical cord should be white to reduce the chance of meconium aspiration.
○ Yellow to green umbilical cord is a Suction upon delivery of newborn’s head and
sign of meconium staining just before the baby takes his first breath
● Suction mouth and nose to remove
the secretions (meconium). Suction
 mouth before nose. Clear the mouth
Grasp reflex Wreak Strong,
first since a baby’s first breath is
allowing the
through the mouth (by crying)
infant to the
● Cut ang cord = blood flow initiates
lifted up from
the baby to cry. Pag cry, mulanghap
the mattress
ug air which is through the mouth. If
naay secretions pwede maadto sa
lungs which is a foreign body so, dili PROBLEMS RELATED TO GESTATIONAL
maka work ug tarong ang alveoli WEIGHT: SGA
because of the meconium in the
lungs. ● SMALL FOR GESTATIONAL AGE (SGA)
● (SGA) babies are those whose birth weight
lies below the 10th percentile for that
NURSING MANAGEMENT gestational age
● SGA babies may be:
1. Closely monitor the newborn cardiopulmonary ○ premature (born before 37 weeks of
status pregnancy),
● Check vital signs ■ Ex. expected weight for baby’s age is
2. Administer supplemental oxygen therapy as 900 grams pero and weight sa baby is
needed 700 grams = SGA
● Depending on meconium stain ○ full term (37 to 41 weeks), or
3. Frequent monitoring of blood sugar; assess ■ Ex. 38 wks. expected is 2.5 kg then
for sign of hypoglycemia ang weight is 2.3 kg = SGA
4. Provide thermoregulated environment – use of ○ post term (after 42 weeks of pregnancy)
isolette or radiant heat warmer ■ Ex. 43 wks. weight is 2.4 kg = SGA
● Decrease in body temp happens ● Intrauterine growth restriction (IUGR) - is
when the baby is not the most common cause and underlying
thermoregulated which can cause condition leading to SGA newborn
apneic episodes
5. Monitor for signs of meconium aspiration
syndrome MATERNAL FACTORS

A. HIGH BLOOD PRESSURE

● preeclampsia/eclampsia = vasoconstriction
B. CHRONIC KIDNEY DISEASE
DIFFERENCES PRETERM POST TERM ● Not advised to get pregnant because
kidneys don’t function well, which increases
Posture “Relaxed More flexed
accumulation of metabolic waste products,
attitude” limbs attitude
resulting in problems with blood circulation
more extended
that can affect the baby
Sole Only fine Well and
wrinkles deeply creased C. ADVANCED DIABETES
● Decrease blood flow leads to decrease in
Female genitalia Clitoris is Clitoris is not oxygen and nutrients, which causes
prominent; as prominent; deprivation
labia majora labia majora
poorly fully developed D. HEAT OR RESPIRATORY DISEASE
developed ● Restricted activity and on a diet, which
causes deprivation of nutrients and oxygen
Male genitalia Scrotum is Scrotum is fully to the baby
underdevelope developed.
d and not pendulous, E. MALNUTRITION, ANEMIA
pendulous, with nugated
minimal rugae F. INFECTION
● Baby can be affected, especially during the
Scarf sign Elbow is easily With resisting 3rd trimester
brought across attempt when ● 1st trimester: oogenesis so if the mother has
the chest with elbow is an infection, it could lead to congenital
little or no brought to the anomaly
resistance midline of the ● 3rd trimester: the baby can also be affected
chest if the mother has UTI during this stage
G. SUBSTANCE USE (ALCOHOL, DRUGS)
COMMON COMPLICATIONS SGA
● vasoconstriction
● Respiratory distress (asphyixia)
H. CIGARETTE SMOKING ○ Preterm SGA
● vasoconstriction ● Meconium aspiration - Post term SGA
● Difficulty maintaining normal body temp
I. PLACENTAL ANOMALY ○ Preterm SGA
● The most common cause of IUGR ○ Fats helps baby thermoregulate, if
● Placenta is detached from the uterine wall, the baby is SGA it has difficulty
which could lead to deprivation of oxygen maintaining body temp due to
and nutrients. This isn’t easily detected decrease muscle mass
because the bleeding is concealed. ● Polycythemia
○ Post term SGA

NURSING INTERVENTIONS
1. Observe for signs of respiratory distress

2. Maintain body temperature

● thermoregulate

3. Monitor for infection and initiate measures to

prevent sepsis

4. Monitor blood glucose levels and for signs of

hypoglycemia

FETAL FACTORS 5. Initiate early feedings and monitor for signs

of aspirations
● Early feedings to help increase blood
A. MULTIPLE GESTATION glucose level
● Twins, triplets, quadruplets, etc. 6. Provide stimulation, such as touch and
● Identical twins share the same placenta, so cuddling
they also share oxygen and nutrients, which *Note: go back to s/sx during an intervention to
could lead to intrauterine growth restriction know what the appropriate interventions are*
● Fraternal twins different placenta so each
baby has their own source of oxygen and
nutrients
PROBLEMS RELATED TO GESTATIONAL
B. INFECTION WEIGHT: LGA
● Amnionitis is the most common infection.
Amniotic fluid infection ● LARGE FOR GESTATIONAL AGE (LGA)
● Neonate who is plotted at or above the 90th
C. CHROMOSOMAL ABNORMALITY percentile on the intrauterine growth care
● Weigh more than 4,000 grams
● Cause: Unknown

ASSESSMENT
● Respiratory distress MATERNAL FACTOR
○ SGA associated with prematurity
● Loose and dry skin, little fat, little muscle mass ● Maternal DM – the most widely known
● Wasted Appearance (payat) contributing factor, increase insulin acts as a
● Small liver fetal growth hormone
● Head is larger compared to body ● The baby is inside the mother with Diabetes
● Wide skull sutures Mellitus
● Poor skin turgor ● Maraming sugar sa loob ng mother so the
● Sunken abdomen doctor prescribed her with synthetic insulin
○ Decrease abdominal muscle ● Glucose goes inside the baby’s body since it is
a nutrient and it’s able to pass through the
placental barrier
● The baby then produces its own insulin to
compensate sa daghan na glucose na
makuha ni baby from mommy.
○ Insulin from the mother cannot pass
through the placental barrier since
malaki ang molecule ng insulin
● Since sige produce and baby ng insulin,
managhan na ang insulin
○ Aside sa pang store ug glucose, fetal
growth hormone din ang insulin
maong mudako ang baby
● Once ma cut ang cord after delivery, pa cut din
ang glucose supply pero maretain parin ang
glucose na naa na sa body ng baby
● It would take time for the baby’s body to adjust
na hinayan na ang pag produce ng insulin
○ Mag decrease ang blood glucose
levels ni baby since na cut off naman
iyang supply, as a result mas daghan
na ang insulin compared sa glucose,
which causes hypoglycemia

FETAL FACTORS
● Increase insulin acts as a fetal growth
hormone - Hypoglycemia
● Macromia - an unusual large newborn with a
birth weight more than 4500 grams or 4kgs

ASSESSMENT
● Large, obese
● Lethargic and limp = hypoglycemia
● May feed properly because of lethargy
● Signs and symptoms of birth trauma (if NSVD)
○ Bruising
○ Broken clavicle
■ Pelvic disproportion (mother’s PROBLEMS OF LGA BABIES
pelvic is proportion but since 1. Hypoglycemia (low blood sugar) of baby after
the baby is too big and the delivery
shoulder is broader, doctors 2. Respiratory distress
intentionally break the clavicle ● Due to prolonged labor
in order to deliver the baby. 3. Hyperbilirubinemia
○ Evidence of molding ● Increase bilirubin level
■ Resulting from pressure on 4. Potential complications related to increase in
the baby’s head during body size:
childbirth ● Leading cause of breech position and
○ Cephalhematoma shoulder dystocia
■ Presence of blood clots, ● Fractured skull, clavicles, cervical or brachial
accumulation of blood plexus injury, and Erb’s palsy
○ Caput succedaneum ○ Shoulder dystocia – difficulty
■ Cranial trauma delivering the shoulder
○ Erb’s palsy – naipit ang part ng facial
nerves •
● Generally, there is no treatment other than
lifting the child gently to prevent discomfort.
Occasionally, the arm on the affected side
may be immobilized (movement is restricted
by applying restraints)
 COMMON ACUTE CONDITIONS OF NEWBORN

RESPIRATORY DISTRESS SYNDROME (RDS)

● Serious lung disorder caused by immaturity
and inability to produce surfactant, resulting in
hypoxia and acidosis
● Surfactant- a biochemical compound that
reduces surface tension inside the air sac
● Decrease in surfactant results to lung
collapse, thus greatly reducing infant’s vital
supply of oxygen CIRCUMORAL CYANOSIS
● Damaged lung cells combines with other
● Bluish discoloration around the mouth denotes
substance present in the lungs to form fibrous
that the baby is experiencing hypoxia or baby
substance called Hyaline Membrane (Hyaline
is not thermoregulated/hypothermic = apneic
Membrane Disease)
episode
Additional Notes:
● Low/poor surfactant leads to lung collapse
● There’s diffusion of O2/CO2 due to the poor
surfactant MOTTLED SKIN
● Lung collapse may cause difficulty of
● Hypothermia or initial sign of compromised
breathing
oxygenation

MANAGEMENT
A. OXYGEN THERAPY
● Hood nasal prong, mask, endotracheal tube,
CPAP (Continuous positive airway pressure)
or PEEP (Positive and expiratory pressure)
may be used)

● Hypoxic Spells leads to increase capillary

permeability
● Sounds during expiration is grunting
● Hypothermia- effect of acidosis ● SURFACTANT REPLACEMENT THERAPY
● EXTRACORPOREAL MEMBRANE
OXYGENATION (ECMO)
○ Treatment that uses a pump to
ASSESSMENT
circulate a blood through an artificial
● Expiratory grunting-major- is the body’s way of lung back in the blood stream
trying to keep air in the lungs so they will stay ○ Inserted through the extrajugular
open. vein, serves as an artificial lung,
● Tachypnea used in extreme cases.
● Nasal Flaring
● Retractions
● Seesaw- like respirations (chest wall retracts
and the abdomen protrudes)
● Decreased breath sounds
● Apnea
● Pallor and cyanosis
● Hypothermia
Additional Notes:
● Decreased breath sounds due to lung
collapse B. MUSCLE RELAXANTS
● Apnea – absence of breathing ● Pancronium (Pavulon)
● Pallor (initial na Makita) and cyanosis ● Reduces muscular resistance
(hypoxia) ● Prevents pneumothorax
● Sounds during expiration is grunting ● Prepare atropine or neostigmine
methysulfate
 ○ Nurses are allowed to administer
C. LIQUID VENTILATION oxygen athte safest level without
● Uses perfluorocarbons - substance used in doctor’s order
industry to assess leaks ■ Safest level to administer
D. NITRIC ACID oxygen is 1LPM
● Causes pulmonary vasodilation- increases ○ Any premature newborn who require
blood flow to the alveoli oxygen support should be scheduled
Additional notes: for an eye examination before
● PEEP & ECMO- for severe cases discharge to assess for retinal
damage.
■ Eye examination – doctor’s
NURSING INTERVENTION
order for premature babies
1. Monitor vital color, respiratory rate (RR) and that are candidate for
degree of effort in breathing graduation to assess for
2. Support respirations as prescribed retinal damage
3. Monitor arterial blood gases (ABG) and O2
saturation levels (ABG from umbilical artery)
● So that oxygen administered to the
ASSOCIATED COMPLICATION
newborn is at the lowest possible
concentration necessary to maintain Bronchopulmonary Dysplasia (BPD)
adequate arterial oxygenation ● Over expanded lungs because of prolonged
Additional notes: use of oxygen
● Color of the baby signifies hypoxia ● In a normal breathing, once an individual
● Support respirations by providing oxygen breathes in and out are, there will be an
therapy easy delivery of air into the air sacs in the
● Arterial blood gases determine the oxygen alveoli; easier diffusion
level in the blood of the patient; specimen is ○ Patient with BDP - because of
extracted from umbilical artery, if nag fall off prolonged use of oxygen, the lung
na then sa artery na sa newborn magkuha tissue becomes stiff because they
don’t have the normal capacity to
push air in and out, resulting in
RETINOPATHY OF PREMATURITY (ROP)
overdistention, which leads to
● Vascular disorder involving gradual difficulty in delivery of oxygen
replacement of retia by fibrous tissue and
blood vessels
● Retrolental Fibroplasia
Additional Notes:
● Vascular disorder that causes blindness
● Deliver oxygen at the maximum level
prescribed by the physician and not at a
longer period of time. If the baby is exposed
to too much oxygen = increased rate =
increase pressure = oxygen is delivered in
the blood which includes minute capillaries
which can be seen in the eyes = blindness
Management
● Increased O2 concentration and Increased
a) Suction every 2 hours or more often as
Pressure causes blindness
necessary
● Only suction if there are discharges
because these can impede breathing
CAUSE pattern
● PREMATURITY b) Prepare to administer surfactant replacement
○ Immature body system and minute therapy (instilled into the endotracheal tube)
capillaries in the eyes ● Premature client
● USE OF SUPPLEMENTAL OXYGEN c) Administer respiratory therapy (percussion
○ o Most common cause and vibration)
○ Premature infants are more prone to ● Device used by pediatrics
ROP because they have immature (rubber-like cuff) during percussion
lungs, which makes them dependent and vibration so it doesn’t put too
with supplemental oxygen much pressure
○ Oxygen administration should never d) Provide nutrition
be more than 40% unless hypoxia is ● Breastmilk through OGT
documented ● Formula milk is hard to digest
 ● Breastmilk is good up to 6 months if
affected. Mother’s affected. The mother’s
inside the freezer
immune system will immune system will
● Breastmilk banking – first in, first out
react and make view it as a foreign
e) Support bonding
antibodies against object (baby is A-, it
● Kangaroo mother care
baby’s RBC and will should be A+), so the
f) Encourage as much parental participation in
attack causing a body will make
newborn's care as condition allows.
breakdown of RBC, antibodies. If the same
Additional Notes:
resulting in problem is encountered
● O2 hood is safer if oxygen is administered at
hyperbilirubinemia during the second
6-10 LPM
pregnancy, the
● O2 cannula/cone up to 5LPM
antibodies will attack
the baby

HYPERBILIRUBINEMIA
c) Infections
● is an abnormally high level of Bilirubin in the d) Birth trauma
blood; results to jaundiced e) Maternal diabetes
○ RBC starts to breakdown (hemi into f) Medications
globin). Globin is further broken ● There are certain medications that can lead
down which results to bilirubin and to conjugation of bilirubin
needs to be conjugated. Additional Notes:
○ Unconjugated bilirubin in the liver ● Mixing of maternal and fetal blood happens
results as a waste product during delivery
○ Conjugated bilirubin becomes ○ Placenta is detached from the
water soluble which gives color to the abdominal wall resulting in small
urine and stool openings or wounds on the wall =
● In physiologic jaundiced: mixing of maternal and fetal blood
○ occurs on the second day to seventh
day (sometimes extends to 10 days) ● No mixing of maternal and fetal blood
○ average increase of 2mg/dl; not during the pregnancy
exceeding 12mg/dl ○ Placenta is attached on the
● Pathological Jaundice of Neonates abdominal wall. Oxygen, nutrients,
○ Any of the following features etc. are transferred from the mother
characterizes pathological jaundice: and baby through Facilitated
■ Clinical jaundice appearing in Diffusion and Active Transport.
the first 24 hours.
■ Increases in the level of total
bilirubin by more than 12
ASSESSMENT
mg/dl
● Therapy is aimed at preventing Kernicterus,
which results in permanent neurological
damage resulting from the deposition of
bilirubin in the brain cells.

CAUSES
a) Immaturity of the liver
● Cannot facilitate bilirubin conjugation
b) Rh or ABO incompatibility
● Blood factors

ABO Rh

Blood type of mother Rhesus factor is

and baby are incompatible
incompatible ● Jaundice
● Dark concentrated urine
More common, less Less common, more ○ Dark yellow
severe severe ● Enlarged liver
● Poor muscle tone
First pregnancy is Second pregnancy is ○ lethargic
● Lethargy
● Poor sucking reflex
○ Poor sucking reflex (along with
nausea and vomiting) are first signs
of infection

MANAGEMENT
1) Phototherapy (Bililight)
● is use of intense florescent lights to reduce
serum bilirubin levels
● The use of blue lights overhead or in blanket 2) Exchange blood transfusion via umbilical
– device wrapped around infant catheter-for very severe cases
● Injury from treatment, such as: eye damage, ● infants blood – remove = 5 / 10ml at a time
dehydration, or sensory deprivation ● infused with PlainNSS
○ Eye damage – too much exposure to ● draw blood from artery, infuse blood in the
UV light; provide eye shield to vein
prevent eye damage
○ Dehydration – init ang light
○ Sensory deprivation – baby isn’t
carried if it is undergoing
phototherapy
● Possible complication of phototherapy: eye
damage, dehydration, sensory deprivation
● Wallaby blanket - a blanket which, when
wrapped around the infant’s torso, delivers
effective therapy to jaundiced babies
○ no need to cover the baby’s eyes as
all light treatment is delivered
through the blanket NURSING INTERVENTIONS
● Physiologic jaundice can disappear if the
1. Expose as much of the newborn's skin as
baby is exposed to sunlight because of the
possible.
UV rays
● Undress the baby
2. Cover the genital area, and monitor the
genital area for skin irritation or breakdown.
● Do not remove the diaper
3. Cover the newborn's eyes with eye shields
or patches; make sure that eyelids are closed
when shields or patches are applied.
4. Remove the shields or patches at least
once per shift (during a feeding time) to
inspect the eyes for infection or irritation and
to allow eye contact and bonding with parents.
5. Monitor skin temperature closely.
● Body temp increases because of
exposure to light Ioff if init na kaayo
si baby
6. Increase fluids to compensate for water loss
○ Increase fluid through IVF Letting
the baby drink water can lead to
water intoxication.
○ Increase fluid through IVF Letting
the baby drink water can lead to
water intoxication
7. Expect loose green stools and green urine
8. Monitor the newborn's skin color with the
fluorescent light turned off, every 4 to 8 hours.
● Check for progress
9. Monitor the skin for bronze baby syndrome
- a grayish-brown discoloration of the skin.
● Too much exposure
 ● Continuous phototherapy – not ● Rh: mother (-) – pinoy, father (usually
turned off for 24 hours. Only turned +) – foreigner = expect
off if diaper needs to be changed or hyperbilirubinemia
for feeding. (more severe = longer 20. Prepare for phototherapy, and monitor the
exposure) newborn closely during the treatment
● Intermittent phototherapy – has a
schedule. Usual order is 6 hours on
and 6 hours off (ex. 7am on, 1pm off,
7pm on, 1am off)
10. Reposition newborn every 2 hours.
● Provide ample time for exposure
● Prevent ulceration
11. Provide stimulation.
12. After treatment, continue monitoring for
signs of hyperbilirubinemia, because
rebound elevations are normal after therapy is
discontinued.
13. Turn off phototherapy lights before
drawing blood specimen for serum bilirubin
levels and avoid allowing blood specimen to
remain uncovered under fluorescent lights (to
prevent the breakdown of bilirubin in the
blood specimen).
● Blood specimen exposed under the
light gives a false result. Cannot get
actual serum bilirubin level since the
blood is exposed under the light so
mag continue ug breakdown
14. Monitor for the presence of jaundice;
assess skin and sclera for jaundice
● Assessment is crucial within the first
24 hours MECONIUM ASPIRATION SYNDROME (MAS)
● Apply blanch pressure then slowly ● Occurs when infants take meconium into their
release. When you are going to lungs during or before delivery
blanch, the skin turns white and ● Occurs in term or post-term infants
slowly turns to pink after you release. ● During fetal distress there is increases
If jaundice is present, the skin slowly intestinal peristalsis, relaxing the anal
turns to yellow once you release sphincter and releasing meconium into the
pressure. amniotic fluid.
● The more severe, the more it will ● Aspiration can occur in utero or with the first
appear on the eyes breath.
● Dark skin – check inner arm, sclera, ● Meconium can block the airway partially or
or inner lip completely and can irritate the newborn’
15. Examine the newborn's skin color in natural airway, causing respiratory distress
light.
16. Press finger over a bony prominence or tip
of the newborn's nose to press out capillary CAUSES AND RISK FACTORS
blood from the tissues. 1. Common to post mature
● Jaundice starts at the head first, 2. Maternal history of diabetes
spreads to the chest, abdomen, and 3. Hypertension
then the arms and legs, followed by 4. Difficult delivery
the hands and feet 5. Poor intrauterine growth
● Checking severity of jaundice
17. Keep newborn well hydrated to maintain
blood volume.
● IVF flow rate should correct ASSESSMENT
18. Facilitate early, frequent feeding to hasten Respiratory distress is present at birth:
passage of meconium and encourage ● tachypnea,
excretion of bilirubin ● cyanosis,
19. Report to the physician any signs of ○ ineffective breathing pattern can lead
jaundice in the first 24 hours of life and any to
abnormal S&S ○ ineffective oxygenation that can lead
to hypoxia which leads to cyanosis
 ● retractions, ruptures, the baby is already exposed which
○ due to the effort of the baby’s puts the baby at risk for infection
breathing pattern 2. Prolonged or difficult labor
○ subcoastal or substernal ● can develop ascending infection because of
● nasal flaring, internal examination
● grunting, 3. Maternal infection
● Crackles, and rhonchi may be present. ● Once the mother is sick, it can be passed on
● Infant’s nails, skin, and umbilical cord may to the baby, especially during the 3rd
be stained a yellow-green color. trimester
4. Cross contamination
5. Aspiration
● Aspiration of meconium
● Aspiration of milk
● Aspiration pneumonia – when food, saliva,
liquids, etc. is breathed into the lungs. Since
these are foreign bodies, it could put the
baby at risk for infection

ASSESSMENT FINDINGS
Often does not have specific sign of illness
1. Poor feeding
MANAGEMENT ● most common problem assessed if the
a) Suctioning must be done immediately after patient is experiencing sepsis
the head is delivered before the first breath 2. Irritability
is taken; 3. Lethargy
● No need to suction if amniotic fluid is 4. Pallor
clear because there is no meconium 5. Tachypnea
staining 6. Tachycardia
b) Vocal cords should be viewed to see if the 7. Abdominal distention
airway is clear before stimulation and crying ● Assessed by getting abdominal girth
● Extracorporeal membrane 8. Temperature instability - difficulty keeping
oxygenation (ECMO)- temperature within normal range
● Cardiopulmonary bypass to support
gas exchange allows the lungs to DIAGNOSIS
rest
1. Blood culture, urine culture, and
cerebrospinal fluid cultures
NURSING INTERVENTIONS 2. Routine CBC, urinalysis, fecalysis
1. No need to suction if amniotic fluid is clear 3. Radiographic test
because there is no meconium staining Additional Notes:
● Monitor vital signs ● Urinalysis – determine if there is infection
2. Ensuring adequate oxygenation but cannot determine the type of bacteria
3. Administration of antibiotic therapy ● Urine Culture - dili pwede mag diretso
● Given immediately; don’t wait for signs of unless sure na naa nay infection. Urine
infection = prophylaxis (prevention) culture determine the type of bacteria
4. Maintain thermoregulation present in urine
○ To be certain what causes the
infection
● Urine culture and sensitivity - test the type of
SEPSIS bacteria that is sensitive in a particular
● Generalized infection resulting from the medication
presence of bacteria in the blood
● Major common cause is group B beta- MANAGEMENT
hemolytic streptococci
1. Intensive antibiotic therapy
● Depending on the type of bacteria present
CONTRIBUTING FACTORS (common: Amoxicillin, gentamicin, amikacin)
1. Prolonged rupture of membranes 2. IV fluids
● Amniotic sac serves as a shield to protect 3. Respiratory therapy
the baby from infection. Once the membrane ● includes oxygenation, percussion, vibration
(help loosen secretions)
 NURSING INTERVENTIONS FETAL CIRCULATION
Routine newborn care with special emphasis on the
following:

1. Monitor vital signs, assess for periods of

apnea or irregular respirations.
2. Administer oxygen as prescribed
3. Provide isolation as necessary- Monitor and
limit visitors
● Can put at risk other babies for cross
contamination
● Isolation room – septic room (babies
with +culture); not allowed for
viewing
● Mothers are the only visitors allowed
in the septic room for stimulation, if
namatay then pwede musulod ang
father. If wala ang father, the nearest
kin (grandmother). If preterm or
kamatyonon – both parents are
allowed to visit
4. Handwashing before after handling neonate
BLOOD FLOW TO THE HEART

SUDDEN INFANT DEATH SYNDROME

● Sudden death of any young child that is
unexpected by history and which thorough
postmortem examination fails to demonstrate
adequate cause of death
● Usually occurs during sleep
● Diagnosis is made after autopsy
● High incidence in preterm infants, infants with
abnormalities in respiration
● Unknown cause: may be related to a
brainstem abnormality in the neurological
regulation of cardiorespiratory control
Additional Notes:
● 3 shunts (opening):
○ Ductus venosus: connects umbilical
NURSING ROLE
vein to IVC
1. Care is directed at supporting parents/family ○ Ductus arteriosus: between the aorta
2. Provide a room for the family to be alone and pulmonary artery
● Do post mortem care to make the ○ Foramen ovale: between the right
baby look presentable pero dili ibalot and the left atrium
● Bodies aren’t allowed to stay in the ○ These shunts are important since the
room for more than 2 hours baby’s lungs aren’t functioning, the
3. Reinforce that death was not their fault placenta serves as the baby’s lungs.
4. Provide appropriate support referrals Fetal lungs are collapsed, lungs
● Counsellors expand as baby takes its first breath
5. Explain how parents can receive autopsy ○ High Pulmonary Vascular Resistance
results - collapsed lungs
○ Cord clamp - cessation of blood flow
= expansion of lungs = abrupt
CONGENITAL HEART DEFFECT
changes in hemodynamics.
● Are present at birth and can affect the ○ As baby takes it first breath, shunts
structures of a baby’s heart and the way it start to close slowly. Failure to close
works. They can affect how blood flows leads to congenital heart defect.
through the heart and out to the rest of the
body
 ● Large – hypertrophy and/or failure of right
ACYANOTIC TYPE
ventricle
A. ATRIAL SEPTAL DEFECT ○ Hypertrophy – enlargement of left
ventricle
● Abnormal opening in the septum between left ■ There is blood coming to the
and right atria left ventricle from both the
● Usually detected after neonatal period lungs and the right ventricle
● Atrial (between the atrium) Septal (septum) ● More blood coming from the left going to the
Defect right because the left ventricle has more
● Foramen ovale failed to close pressure
● S/S: - decrease activity tolerance ● Most common heart defect
○ Dyspnea ● S/S: increase respiratory effort
○ + murmur – upper left sternal border ○ Frequent respiratory infection
○ Mgt: Surgery – 2 and 4 yrs of age ○ + murmur – heard best @ lower left
Neonates cannot cope with heart sternal border
surgery Gives time for the opening ○ Congestion in the pulmonary area
to close ● Mgt: Surgery

Additional Notes: Additional Notes:

● Secundum atrial septal defect – most ● A ventricular septal defect or VSD is abirth
common type of ASD defect where there is an abnormal connection
● Opening usually closes shortly after birth between the two ventricles of the heart.
● This opening allows blood to move between ● The left ventricle pumps at a higher pressure
the upper chambers which increases blood than the right ventricle so any hole in the
flow to the lungs septum results in blood pumping from the left
● If the hole is large enough, the increased ventricle to the right ventricle this causes the
blood flow leads to enlargement of the heart blood to mix
and can also damage the blood vessels in ● VSDs most common type of congenital heart
the lungs. It can also lead to abnormal heart defect that can be associated with other heart
rhythm due to injury to the heart muscle. defects
● Symptoms: most have none ● Most common symptoms: shortness of
○ Large defect – slow growth breath, failure to gain weight, sweating while
○ Rare – congestive heart failure being fed, frequent respiratory infections
● Definitive treatment – cardiac catheterization
or surgery
C. PATENT DUCTUS ARTERIOSUS

B. VENTRICULAR SEPTAL DEFECT ● Connects pulmonary trunk to aorta

● Patent – opening of the ductus arteriousus
● Opening in the septum between ventricles, ● Most common type of acyanotic heart defect
causing a left to right shunt ● S/S: + murmur – machinery type @ middle to
● Small VSD – asymptomatic upper left sternal border
 ○ poor feeding ● Coarctation can sometimes be detected by
○ tiring easily differences in the blood pressure in the arms
● Mgt: Indomethacin Facilitates closure of and legs
ductus arteriosus ● The degree of the narrowing determines
● Surgery – ligation how soon intervention is needed
● Severe coarctation of the aorta is often
found in the first few weeks of life. However,
a less severe coarctation may go
undiscovered for years
● The less severe, less manifestation,
● More severe, more profound manifestations

E. VALVULAR DEFECTS
a) right side – tricuspid (separates R & L
ventricle)
b) left side – mitral / biscuspid

● S/S: palpitations
D. COARCTATION OF AORTA ○ once blood enters into a certain
chamber, the valve should close.
● Narrowing of the aorta Since sira ang tricuspid valve, mag
● Significant decrease in blood flow to abdomen flutter siya = palpitations
and legs ○ Pain
○ Decrease in blood flow because of ○ Edema
the narrowing ■ Sobra congest
● Blood shunted to head and arms ○ Weakness, dizziness
● S/S: BP /pulse – higher in arms than legs ■ Kulang ang oxygenated blood
○ High pulse pressure in carotid and to be distributed to other parts
radial pulse of the body
■ Bounding carotid and radial ● Mgt: Surgery – valvotomy, valvuloplasty
pulse valve replacement
○ Warm upper body ○ Valvotomy – repair
■ More blood ○ Valvuloplasty – replace (usually pig)
○ Cold and clammy lower extremities
due to compromised blood flow
● Mgt: surgery – angioplasty – repaired of
narrowed vessel

Additional Notes:
● Coarctation of the aorta refers to a
narrowing of the main blood vessel carrying
oxygen-rich blood from the heart to the body
 throughout the body maong kulang ang
CYANOTIC TYPE
oyxgen
A. TRANSPOSITION OF GREAT VESSELS ● Pulmonary artery and aorta are switched from
their normal positions
● Aorta arises from right ventricle, pulmonary ● Deoxygenated bloods goes to the body
artery arises from left ventricle oxygenated instead of the lungs.
blood therefore circulates through left side of ● Oxygenated blood returns from the lungs and
heart to lungs and back to left side goes right back to the lungs again instead of
● Unoxygenated blood enters the right atrium to the body
from body, goes back to right ventricle and ● Mustard operation – corrects the problem by
back to circulation without being oxygenated using a synthetic material creating baffles to
● S/S: direct deoxygenated blood to the lungs and
○ Cyanotic appearance oxygenated blood to the body.
○ Shortness of breath
○ Poor feeding
○ Clubbing of the fingers or toes – B. TETRALOGY OF FALLOT
very evident manifestation of heart ● This condition is characterized by the following
problems four defects:
○ peripheral hypoxemia - ex. cold, ○ Ventricular Septal Defect - an
clammy skin, slow pulse abnormal opening, or ventricular
○ Severe progressive pulmonary septal defect, that allows blood to
hypertension. pass from the right ventricle to the
● Complications: left ventricle without going through
○ Arrythmias the lungs
○ Heart failure ○ Pulmonary Stenosis - a narrowing
● Mgt: Balloon Atrial Septostomy (Rashkind (stenosis) at or just beneath the
Procedure) pulmonary valve that partially blocks
the flow of blood from the right side
of the heart to the lungs
○ Right Ventricular Hypertrophy - the
right ventricle is more muscular
than normal
■ Since nag narrow ang
pulmonary valve, mas
maraming blood maiwan sa
right ventricle
■ Compensatory mechanism:
mag expand
○ Overriding Aorta - the aorta lies
directly over the ventricular septal
defect
■ Blood from the right ventricle
and left ventricle goes to the
aorta
● Tetralogy of Fallot results in cyanosis (bluish
color of the skin and mucous membranes due
to lack of oxygen)
Additional Notes: ○ There is lack of oxygen because
● Override between the two great vessel: deoxygenated blood didn’t go to the
Pulmonary artery & Aorta lungs which was supposed to be
● Normal: Pulmonary artery is connected oxygenated by the lungs
directly to distribute deoxygenated blood to ● Cyanosis develops within the first few years of
the lungs life.
● Normal: Aorta receives blood coming from the ● First presentation may include poor feeding,
left ventricle to distribute to the body fussiness, tachypnea, and agitation
● Transposition: pulmonary artery is directly ○ Poor feeding – lack of oxygen
connected to the aorta. Deoxygenated blood because feeding entails oxygenation
directly goes into the circulation without going ● Cyanosis occurs and demands surgical repair.
through the lungs ● Dyspnea on exertion is common.
● Ang deoxygenated blood sa pulmonary artery ● Hypoxic "tet" spells are potentially lethal,
kay niadto sa aorta na dapat sa lungs. Since unpredictable episodes that occur even in
niadto man sa aorta, ma dispense ang blood noncyanotic patients with TOF. These spells
 can be aborted with relatively simple
procedures
○ Mukalit lang lagom ang bata
● Birth weight is low.
● Growth is retarded.
● Development and puberty may be delayed.
● Right ventricular predominance on palpation
● May have a bulging left hemithorax
● Systolic thrill at the lower left sternal border
● Single S2 - Pulmonic valve closure not heard
● Systolic ejection murmur
● Cyanosis and clubbing – Variable
● Squatting position
○ Facilitate return of blood going to the
circulation
● Scoliosis
○ Common associated problem with
TOF
● Retinal engorgement
○ More blood going to the upper
extremities
● Hemoptysis
○ Coughing out blood
○ Ma irritate and bronchial artery since
kulang ang oxygen sa lungs. Once
ma irritate, it causes blood and once
mag ubo, ma spit out ang blood
● Mgt: Tet Spells
○ Knee-chest position:- This provides a
calming effect, reduces systemic
venous return.
○ Oxygen therapy
○ Morphine sulfate - decrease systemic
venous return.
○ Surgery: Blalock Taussig Shun
 A thorough history is the best guide to establishing
the etiology of the failure to thrive:
HIGH RISK INFANT
● Poverty is the greatest single risk
factor worldwide and in the United
COMMON HEALTH PROBLEMS DURING States
INFANCY ● Nutritional deficiency is the
fundamental cause

FAILURE TO THRIVE ASSESSMENT FINDINGS

● Poor muscle tone, loss of subcutaneous
● A condition in which a child fails to gain fats, skin breakdown
weight and is persistently less than the fifth ● Rumination - common characteristic
percentile on standard growth chart. voluntary regurgitation
● Persistent deviation from established growth ● Lethargic - unresponsive
curve. ● Positive delay in growth and development
● Delay in physical growth and weight gain ● Signs of disturbed maternal - child
might lead to cognitive impairment or even interaction
death ● Diminished or nonexistent crying
● Main problem is with nutrition ● Rader gaze - wide-eyed gaze and continual
scan of environment
4 Principal Factors for Human Growth
1. Food Skin breakdown
- This is a main factor why an infant - seen on bony prominence like in the
experiences failure to thrive sacral bone
- Gives nourishment to the child - no tissues to pad because there is lesser
subcutaneous fats so there is more
2. Rest and Activity pressure from the sacral bone going to
- This facilitates growth and should be the skin that creates the skin breakdown
balance (ex. rashes, wounds, etc.)

3. Adequate Secretion of Hormones Regurgitation

- Normal secretion of growth - backflow of previously eaten food to the
hormones to facilitate normal growth mouth or throat
and development of the child - Children with failure to thrive voluntarily

4. Satisfactory Relationship with Caregiver Regurgitates = Rumination

- Facilitates human growth - Walay ginakaon pero mag sigeg nguya

Classified as: • Positive delay in growth and development

● Organic (OFTT) • Signs of disturbed maternal–child interaction
- due to pathologic condition such as • Diminished or nonexistent crying - wala nay
problem in absorption and hormonal energy mag
dysfunction cry
- Has underlying disease • Radar gaze - wide-eyed gaze and continual scan
of environment using the eyes only
● Nonorganic (NFTT)
- due to psychosocial factor disrupted CHARACTERISTICS OF THE INDIVIDUAL
maternal child relationship PROVIDING CARE:
- - Infants are very helpless and
dependent with their caregiver 1. Difficulty perceiving and assessing the infant’s
needs
Ex. the mother is a rape victim. There is a disrupted 2. Frustrated and angered at the infant’s dissatisfied
maternal-child relationship because there is a response
tendency that the mother would resent the baby. As 3. Frequently under stress and in crisis, with
a result, the mother won’t feed or disregard the emotional, social and financial problems
baby, which could be a factor of the nonorganic type
of failure to thrive because the mother’s disregard All children with failure to thrive need additional
towards the baby could lead to malnourishment. calories for catch-up growth:
● Treatment depends on the cause
● Idiopathic (IFTT) - Unexplained by the ● Medical disorder - specific treatment is given
usual organic and environmental etiologies ● Parent-child relationship - Family counseling
but usually classified as NFTT ● Nutritious, high-calorie feedings
Nursing Interventions: ● Behavior changes, such as irritability and
1. Provide consistent caregiver lethargy
2. Provide sufficient nutrients ● Headache on awakening
- Make feeding a priority intervention ● Nausea and vomiting
- Keep an accurate record of intake ● Ataxia - Lack of coordination of muscle
- Weigh daily movement
3. Introduce positive feeding environment ● Nystagmus - involuntary movement of the
- Establish a structured routine eyes
- Hold the young child for feeding
- Maintain eye-to-eye contact LATE SIGNS: High, shrill cry and seizures
- Maintain a calm, even temperament
- Provide a quiet, non stimulating DIAGNOSTIC TEST:
environment ● CT Scan
- Talk to child giving appropriate ● MRI
directions and praise for eating ● Skull X-ray
4. Increase stimulation appropriate to the ● Transillumination
child’s present developmental level ○ Holding a bright light such as
5. Provide the parent an opportunity to talk flashlight or specialized light (Chun
6. When Necessary,, Relieve the parent of gun) against the skull in a darkened
child rearing responsibilities until able and room
ready emotionally to support the child ○ A skull filled with fluids rather than
7. Demonstrate proper infant care by example, solid brain substance
not lecturing
8. Supply the parent with emotional support Management: Treatment depends on the cause
with fostering dependency
9. Promote the parent’s self-respect and Surgical Interventions:
confidence by praising achievements with ● GOAL: Prevent further CSF accumulation by
child bypassing the blockage and draining the
fluid from the ventricles to a location where it
may be reabsorbed
HYDROCEPHALUS
● An imbalance of cerebrospinal fluid (CSF) Ventriculoperitoneal Shunt
absorption or production - The CSF drains into the peritoneal cavity
● Results in head enlargement and increase
ICP Atrioventricular shunt
- CSF drains into the right atrium of the heart
Caused by: - Acetazolamide (diamox)
● Malformations, tumors, hemorrhage, - Promote the excretions of excess
infections, or trauma fluids

Types: ~~~~~PIC TO INSERT~~~~~~~~~~

● Communicating
- Occurs as a result of impaired PREOPERATIVE INTERVENTIONS
absorption within the subarachnoid 1. Give small frequent feedings as tolerated
space until a preoperative NPO status is prescribed
2. Reposition head frequently and use an egg
● Non Communication crate mattress under the head to prevent
- Blockage in the ventricular system pressure sores
that prevents CSF from entering the 3. Prepare the child and family for diagnostic
subarachnoid space procedures and surgery

ASSESSMENT: POSTOPERATIVE INTERVENTIONS

● Increase head circumference 1. Monitor vital signs and neurological signs
● Thin, widely separated bones of the head 2. Position the child on the unoperated side
that produce a cracked pot sound 3. Observe for signs of increased ICP
(Macewen’s sign) on percussion 4. Elevate head 15-30 degrees
● Anterior fontanel tense, bulging, and non 5. Monitor for signs of infection
pulsating 6. Measure head circumference
● Dilated scalp veins 7. Provide comfort measures; expected level of
● Sunsetting eye functioning
8. Administer medications as prescribed,
~~~~~~~~PIC TO INSERT ~~~~~~~~~~~ diuretics, antibiotics, or anticonvulsants
 9. Instructions on parents re: wound care, - 80% have multiple handicaps
shunt revision
10. Availability of support groups; community
agencies
11. Instruct the parents on how to recognize
shunt infection or malfunction
● In an Infant
○ Irritability, lethargy, and
feeding poorly
● In a toddler
○ Headache and a lack of
appetite
● In older children
○ An alteration in the child’s
level of consciousness

SPINA BIFIDA Assessment - Depends on the spinal cord

involvement
● A central nervous system defect results from 1. Visible spinal defect
failure of the neural tube to close during 2. Motor/sensory involvement
embryonic development generally in the a. Flaccid paralysis of the legs
lumbosacral region b. Altered bladder and bowel function
● Taking folic acid decrease incidence of c. Hip and joint deformities
neural tube defect d. Hydrocephalus
Causes:
● Actual cause is unknown; multiple factors Diagnostics:
● Genetic - if a sibling has had neural tube ● Prenatal - ultrasound, amniocentesis
defect ● Postnatal
● Environmental factors ○ x-ray of spine
● Medications, viral infection and radiation ○ ct scan
○ myelogram-uses a special dye and
Types: an X-ray (fluoroscopy) to provide a
1. Spina bifida occulta very detailed picture of the spinal
- Posterior vertebral arches fail to cord and spinal column
close in the lumbosacral are ○ Encephalogram
- Spinal cord and meninges remains in ○ urinalysis, BUN, Creatinine clearance
the normal anatomic position
- Defect may not be visible Management
- Dimple or a tuff of hair on the spine 1. Surgery - closure of sac within 48 hours,
- Asymptomatic may have slight shunt, orthopedic
neuromuscular deficits
- No treatment if asymptomatic aimed 2. Drug therapy - Antibiotic, Anticholinergic
at specific symptoms
Nursing Management
2. Spina bifida cystica 1. Prevent trauma to the sac
- Protrusion of the spinal cord and/or a. cover with a sterile, moist (normal
its meninges with varying degrees of saline), non adherent dressing
nervous tissue involvement. b. change the dressing every 2 to 4
hours as prescribed, keep area free
a. Meningocele from contamination
- Part of spinal protrudes through c. place in a prone position to minimize
opening in the spinal canal tension on the sac
- Sac is covered with thin skin no d. head is turned to one side for
nerve roots involved feeding.
- No motor or sensory loss e. Administer meds
- Good prognosis after surgery 2. Prevent Complication
a. Use aseptic technique to prevent
b. Myelomeningocele (meningomyelocele) infection.
- with spinal nerves roots in the sac
- have sensory or motor deficit
- below site of the lesion
 b. Assess the sac for redness, clear or ● Bulging anterior fontanel in the infant
purulent drainage, abrasions,
irritation, and signs of infection.
c. Clean intermittent catheterization Signs of meningeal irritations
d. Perform neurological assessment ● Nuchal rigidity - Stiff neck
e. Assess for physical impairments ● Positive Kernig Sign - severe stiffness of
such as hip and joint deformities the hamstring muscle causes an inability to
3. Provide adequate nutrition straighten the leg when the hip is flexed to
4. Provide sensory stimulation 90 degrees
5. Provide emotional support to parents and
family
6. Provide discharge teachings
● wound care
● ROM, PT
● signs of complications
● medication regimen
● positioning – feeding, diaper change

MENINGITIS
● inflammation of meninges of the brain and ● Opisthotonos - arching of the back head
spinal cord and heels bent backward and body arched
● Cause by bacteria, viruses, other forward
microorganism
● as a primary disease or as a result of
complications of neurosurgery, trauma,
infection of the sinus or ears, or systemic
infections.
● H Influenzae Meningitis
○ the most common form; between 6 to
12 months
○ Bacterial meningitis - Haemophilus
influenza type B, Streptococcus
pneumoniae, or Neisseria ● Brudzinski sign - Flexion at the hip in
meningitidis response to forward flexion of the neck
○ Viral meningitis is associated with
viruses such as mumps, herpesvirus,
and enterovirus.

Diagnosis
- CSF testing obtained by lumbar puncture
- The fluid is cloudy with increased pressure,
increased white blood cell count and
elevated protein and decreased glucose
levels
Interventions:
1. Provide isolation and maintain it for at least
24 hours after antibiotics are initiated.
2. Administer antibiotics and antipyretics as
prescribed.
3. Perform neurological assessment and
monitor for seizures and complications
4. Assess for changes in level of
consciousness and irritability
5. Monitor intake and output
LUMBAR TAP 6. Assess nutritional status.
7. Determine close contacts of the child with
meningitis because the contacts will need
Assessment prophylactic treatment
● Fever, chills, headache, 8. Meningococcal vaccine is recommended to
● high-pitched cry, irritability protect against meningitis
● Vomiting, Poor feeding or anorexia
 and return to baseline
condition
SEIZURES
- Pahumanay na
● Recurrent sudden changes in b. Absence - rarely 20 seconds, stares
consciousness, behavior, sensations and or straight, does not fall
muscular activities beyond voluntary control
cause by excess neuronal discharge ➢ Status Epilepticus - continuous seizure,
● Normally the neuron sends out messages in cause by a tumor or blockage
electrical impulses periodically and the firing
individual neuron is regulated by an Contributing Factors (Seizure Disorder)
inhibitory feedback loop mechanism 1. Intracranial infection - common in meningitis
● With seizures many more neurons than or hydrocephalus
normal fire in a synchronous fashion in a 2. Space occupying lesion
particular area of the brain; the energy 3. CNS defects
generated overcomes the inhibitory
feedback mechanism Assessment Findings
1. Restlessness/irritability
2. Body stiffens and loss of consciousness
Febrile Seizures 3. Clonic movements - quick, jerking
movements of arms, legs, and facial muscle
● Common in children between 6 mos – 3 yrs 4. Pupils dilate and roll up
old
● Common in 5% of population under 5 years Treatment
old, familial 1. Drug Therapy
○ *familial = if a member in the family a. Diazepam
has a history of disease, the offspring b. Phenobarbital
may manifest the disease *threshold c. Dilantin
varies between patients, some pt.
may have a seizure triggered by a 2. Surgery
temp. of 39.1 C a. Tumor
● Non Progressive, does not generally result b. Hematoma
in brain damage
● Commonly associated with high fever – 38.9 Diagnostic Test
to 41.1 Celsius ● Blood studies
● Some appear to have a low seizure ○ to rule out lead poisoning,
threshold and convulse when a fever of 37.8 ○ Hypoglycemia
to 39.8 ○ Infection
○ Electrolytes imbalance
Classification
1. Partial Seizure ● EEG – to detect abnormal wave
- - Putting nodes to check brain activity
a. Simple - localized motor activity,
shaking of arm or leg, limited to one Interventions
side of the body 1. Reduce fever with antipyretics.
2. Give prescribed medication
b. Complex - psychomotor seizure, 3. Generalized seizure precautions
memory loss and staring, non 4. Do not restrain; pad crib rails; do not use
purposeful movements tongue blade
5. Observe and record the time of seizure,
➢ AURA – sensation that signals an attack duration, and body parts involved.
➢ After – sleep or confuse; unaware of the 6. Suction and administer oxygen after the
seizure seizure as required.
7. Observe the degree of consciousness and
2. Generalized behavior after seizure
a. Tonic - Clonic 8. Provide rest after the seizure
➢ Prodromal - maluya; early
symptoms Seizure Precautions
➢ AURA - naay makita na lights ● Keep the head elevated
and other feels na murag ● Oxygen on standby - hook pt. During
padulungay na mag seizure seizure, do not give via nasal cannula above
➢ Tonic - bubbles in the mouth 4L of O2
➢ Post ictal - occurring between ● Medication located at nurse’s station
the end of an epileptic seizure
 ● Take note of the time of the seizure and ● Administration of the prescribed
when it ends antibiotics, emphasizing that the 10-
● Suction equipment on standby at bedside in to 14-day period is necessary to
case of choking eradicate infective organisms.
● Screening for hearing loss may be
necessary.
OTITIS MEDIA
● Administering ear medications.
● Bacterial or viral infection of the middle ear ○ Younger than age 3, pull the
● Common in infants and preschoolers lobe down and back.
● Eustachian is shorter, wider, and straighter ○ Older than 3 years, pull the
thereby, allowing nasopharyngeal secretion pinna up and back.
to enter middle ear more easily
CLEFT LIP AND PALATE
Assessment Findings
1. Behavior that would indicate pain ● Non-union of the tissue and bone of the
- restless and repeatedly shakes the upper lip and hard/soft palate during
head embryonic development
- frequently pulls or tugs at affected ● Failure of the maxillary and premaxillary
ear processes to fuse during fetal development
2. Irritability, cough, nasal congestion, fever
3. Hearing impairment Etiology - primarily genetic environmental factors
4. Purulent discharges ● Viral infection
● Exposure to radiation
Diagnosis ● Folic acid deficiency
1. Examination of ear with otoscope ● Teratogenic factors
- reveals bright red bulging eardrum
2. Culture and sensitivity of ear discharges Assessment Findings
1. Facial abnormality
Possible Complication 2. Difficulty sucking and swallowing
- permanent hearing loss 3. Milk escapes through nose
- mastoiditis - inflamed mastoid, bacteria
migrates to area

Management
1. Antibiotics, analgesics
2. Myringotomy
- Incision into the tympanic membrane
to relieve pressure and drain the fluid
with/without tube

Post-operative Interventions
1. Wear earplugs while bathing, shampooing,
and swimming,
2. Diving and submerging under water are not
allowed.
3. Child should not blow his or her nose for 7 to
10 days after surgery
Assessment
Interventions ● Cleft lip
1. Encourage fluid intake. ○ can range from a slight notch to a
2. Teach the parents to feed infants in upright complete separation from the floor of
position, to prevent reflux. the nose
3. Instruct the child to avoid chewing as much ● Cleft palate
as possible during the acute period because ○ nasal distortion
chewing increases pain. ○ midline or bilateral cleft
4. Provide local heat and have the child lie with ○ variable extension from the uvula
the affected ear down. and soft and hard palate.
5. Instruct the parents in the appropriate
procedure to clean drainage from the ear Associated problems
with sterile cotton swabs. 1. .Feeding problems
6. Instruct the parents in: 2. URTI - milk may enter the lungs if inhaled
● Administration of analgesics or 3. Ear infection
antipyretics 4. Speech defect, dental malformation
 5. Body image stomach
Management (Rule of ten) Gastrostomy – creation
1. Surgical Correction of an opening directly
● Cheiloplasty - Corrections of cleft into the stomach
lip, done - 2 months old
● Palatoplasty - Cleft palate surgery Fig. 23 Client who
○ Done - before speech underwent gastrostomy
development
○ Allow for palatal changes that Gastrostomy
take place with in 12-18 tube
months Create a balloon
● Logan bar/steri strips - to take the to anchor; para
tension off the sutures dili matanggal
For the food
Con’t Management (OF)
2. Team approach therapy Stoma
● Dentist and orthodontist
● Audiologist Stricture – narrowing of the area because of the
● Speech therapist scarring from the infection
● Pediatrician
NURSING INTERVENTION PRE OPERATIVE-
Nursing Intervention (PRE OP CLEFT LIP) LEFT CLEFT PALATE
1. Feed in upright position’ in small frequent ● Prepare parents to care for child after
feedings surgery
2. Burp frequently - feeding lasting 5 - 10 min. ● Instruct concerning feeding methods and
Then immediately burp positioning
3. Use large-holed nipples ○ Feed upright, use large-holed nipples
4. Use rubber-tipped syringe – if unable to suck
5. Gavage feeding as ordered NURSING INTERVENTION POST
6. Finish feeding with water OPERATIVE-LEFT CLEFT
7. Provide emotional support for parents and ● Suction mucus and saliva gently and do not
family touch the sutures
● Incision care
Nursing Intervention (POST OP CLEFT LIP) ● Clean suture with sterile cotton swab with
1. Maintain patent airway half strength hydrogen peroxide followed by
2. Assess color; monitor for frequent saline
swallowing ● Apply antibiotic ointment
3. Do not place in prone position ● Do not displace logan bar
4. Avoid straining suture lines ● Do not place in prone position, place in side
5. Use elbow restraints - prevent scratching the lying position
site with hands ● Keep spoons, pacifier, straws, away from
6. Resume feedings as ordered (Haberman child’s mouth for 7-10 days post op
feeder) ● Elbow restrain
7. Provide pain control as ordered ● Special feeder - syringe with rubber tubing
into side of mouth, breck feeder
Additional Notes: ● Monitor respiratory status.
✓ Death is likely to occur without surgical ● Maintain patent airway; continued use of
intervention incubator if indicated
- Especially if it is tracheoesophageal since ● Suction as needed, change position
there is no intake of food frequently; avoid hyperextension of neck
○ Hyperextension of neck can stretch
✓ Urgency of surgery depends on the severity of the esophagus and trachea as well
condition na wala pa nagheal ang site
● Maintain IV fluids, antibiotics, and parenteral
Fig. 22 Gastrostomy nutrition as prescribed.
● Maintain adequate nutrition – gastrostomy
Fig. 24 Esophageal ○ NPO – to allow continuous healing
Anastomosis on the post- operative site
● Monitor strict intake and output. Determine
Esophageal anastomosis client’s nutrition
– creating a connection to ● Monitor daily weight.
make an opening from the ○ Reflection of client’s progress (weight
esophagus directly into the should increase)
 ● Inspect the surgical site for signs and ● TYPE III/ C
symptoms of infection. ○ upper end blind; lower end connects
● Monitor for anastomotic leaks as evidenced into trachea
by purulent drainage from the chest tube, ○ esophagus has a blind pouch
increased temperature, and increased white ○ trachea is connected directly to the
blood cell count. stomach
○ Anastomotic leaks – starts once ■ Air enters the stomach, which
infection sets in; formation of leads to bloating. Some of the
purulent discharges (pus gastric juices can go to the
trachea which could lead to
● Observe for signs of stricture at the aspiration
anastomosis site (e.g., poor/refusal to feed,
dysphagia, drooling, regurgitated undigested ● TYPE IV/D
food). ○ Both the trachea and esophagus has
an opening to the stomach
○ There is a risk for aspiration since
the esophagus has an opening in the
ESOPHAGEAL ATRESIA/TEF
trachea
■ Although food is able to go to
the stomach, food could still
● The esophagus terminates before it reaches enter the trachea which could
the stomach, ending in a blind pouch, and/or reach the lungs
a fistula is present that forms an unnatural
connection with the trachea. ● TYPE V/E
○ Fistula – abnormal connection ○ Esophagus is connected to the
between two body parts; mag stomach but still has an opening
reconnect siya sa lain body part connected to the trachea
○ Atresia – no opening connection; ■ could lead to bloating
wala nag connect sa organ (because of air from the
● Congenital anomaly trachea) and/or aspiration
(because of the food)
Types TEA/TEF
CLINICAL MANIFESTATION
● TYPE I/A
○ lower segments of the esophagus 1. Excessive amount of secretions constant
are blind drooling large secretion from the nose
○ air is directly connected to the lungs 2. Intermittent/unexplained cyanosis
○ closed esophagus – food isn’t a. Compromised oxygenation/aspiration
digested because it doesn’t reach the 3. Coughs and chokes
stomach so the patient vomits a. Aspiration
○ mubalik ra ang food sa taas since 4. Fluids returns through nose and mouth
wala man siyay padulngan = a. Saliva returns upward since there is
vomiting no opening in the esophagus
5. Regurgitation & vomiting
6. Abdominal distention
● TYPE II/ B a. If trachea is connected to the
○ upper end of esophagus opens into stomach
the trachea; blind lower segment b. Bloating
○ combination of fistula and atresia 7. Inability to pass a small catheter through the
○ esophagus has a connection to the mouth or nose into the stomach
trachea, but the esophagus also has a. Catheter returns upward since there
a blind pouch so it isn’t connected to is a blind pouch, wala nay maadtuan
the stomach ang catheter
■ Instead of the stomach, food
is diverted inside the trachea
which is connected to the DIAGNOSTIC EVALUATION
lungs, which could cause
aspiration ● Maternal history of polyhydramnios
● X-ray of abdomen and Chest X-ray
○ To determine the type of fistula
● X-ray with radiopaque catheter
 ○ Insertion of catheter with a dye. The increased temperature, and increased white
dye serves as a guide. blood cell count
○ Subayon sa dye 10. Observe for signs of stricture at the
● Insertion of a catheter
anastomosis site (e.g., poor/refusal to feed,
Management dysphagia, drooling, regurgitated undigested
food).
Includes maintenance of :
● a patent airway
● prevention of aspiration pneumonia ○ gastric Hypertrophic Pyloric Stenosis
or blind pouch decompression
● supportive therapy
● Congenital hypertrophy of the circular
● surgical repair
muscles of the pylorus in the stomach; the
muscle becomes progressively thickened
1. Drug Therapy
and elongated with narrowing of the pyloric
● Antibiotics – for respiratory infection
canal.
● The stenosis usually develops in the first few
2. Surgery
weeks of life, causing projectile vomiting,
● Primary repair – esophageal anastomosis
dehydration, metabolic alkalosis, and failure
● Gastrostomy - feeding
to thrive.
● Esophagostomy - drain secretions

Assessment
Pre-operative Interventions

1. Vomiting that progresses from mild

1. The infant may be placed in an incubator or
regurgitation to forceful and projectile
radiant warmer with high humidity (intubation
vomiting
and mechanical ventilation may be
2. Vomitus contains gastric contents such as
necessary if respiratory distress occurs).
milk or formula, may contain mucus, may be
2. Upright position
bloodtinged, and does not usually contain
3. Maintain an NPO status.
bile. *bile is found in the small intestine
4. Regular suctioning
3. Exhibits hunger and irritability.
5. Maintain IV fluids or hyperalimentation as
4. Peristaltic waves are visible from left to right
prescribed.
across the epigastrium during or
6. Observe closely for:
immediately following a feeding.
● vital signs; respiratory behavior
5. Olive-shaped mass is in the epigastrium just
● amount of secretions
right of the umbilicus.
● abdominal distention
6. On barium enema (x-ray), string sign can be
● skin color
seen - String sign: in an x-ray, there is a faint
string seen by the pylorus
Post-operative Interventions
7. Dehydration and malnutrition can occur.
8. Electrolyte imbalances can occur.
1. Monitor respiratory status.
2. Maintain patent airway; continued use of
incubator
Management
3. Suction as needed, change position
frequently; avoid hyperextension of neck
Fredet-Ramstedt Pyloromyotomy
4. Maintain IV fluids, antibiotics, and parenteral
● splits the hypertrophic pyloric muscle down
nutrition as prescribed.
to the submucosa ,allowing pylorus to
5. Maintain adequate nutrition – gastrostomy
expand so that food may pass
6. Monitor strict intake and output.
7. Monitor daily weight.
Nursing Interventions
8. Inspect the surgical site for signs and
symptoms of infection.
1. Monitor vital signs.
9. Monitor for anastomotic leaks as evidenced
2. Monitor strict intake and output. - must stay
by purulent drainage from the chest tube,
fairly equal
 3. Obtain daily weights. Assessment Findings
4. Monitor for signs of dehydration and
electrolyte imbalances. - imbalance Newborn
increases bleeding risk and complications ● Failure to pass meconium stool
5. Feed by gavage ● Refusal to suck
● thickened feedings ● Abdominal distention
● Slowly upright ● Bile-stained vomitus
● Burp frequently
6. Prepare the child and parents for surgery if Children
prescribed. ● Failure to gain weight and delayed growth
● Abdominal distention
● Vomiting
Pyloromyotomy ● Constipation alternating with diarrhea
● Ribbon-like and foul-smelling stools
Pre operative
● Monitor hydration status
● Correct F/E imbalances Diagnostic Studies
● NPO ● Rectal biopsy
● Monitor character of stools ○ taking a tissue sample by inserting
● NGT through the rectum

Post operative Management

● Monitor intake and output ● Temporary colostomy
● Start SFF - small frequent feeding ○ A portion of the large intestine is
● Feed slowly, upright brought through the abdominal wall
● Monitor for abdominal distention - if there is to carry stool out of the body
presence of AD, wala na digest ug tarong
● Monitor for signs of infection ● Bowel repair
● Instruct parents on wound care and feeding ○ Dissection and removal of the
affected section with anastomosis of
intestine
○ Abdominal – perineal pull through
Hirschsprung’s Disease
“Aganglionic Megacolon” Nursing Management

● Absence of ganglion cells in a portion of the 1. Administer enema as ordered with Isotonic
large intestine solution only
● Is a parasympathetic nerve cells that 2. Do not treat loose stools – child is
regulates peristalsis in the intestine constipated
● The absence of the ganglion cells would 3. Administer TPN - Total Parenteral Nutrition
result to absence peristalsis and affected allows gastric rest, or allows the stomach to
colon becomes dilated and filled with feces relax
and gas 4. Instruct parents on colostomy care, correct
● The disease may be a familial congenital diet; feed pt. 24 hrs post-operation
defect or may be associated

Intussusception

● Invagination or telescoping of a portion of

the small intestine into a more distal
segment of the intestine
● 3 times more likely in boys than girls and the
common cause of intestinal obstruction in
childhood
 ● Cause is unknown\

Factors
Imperforate Anus
1. Hyperperistalsis and unusual mobility of ● Congenital malformation in which there is no
cecum and ileum anal opening or there is stricture of the anus
2. Lesion such as polyp and tumor ● Etiology is unknown
a. It is considered a surgical abdominal ● An arrest in embryonic development on 7th
emergency in children to 8th week of intrauterine life
b. Mechanical Bowel Obstruction ● A membrane remains and blocks the union
Occurs: intestinal walls press against between the rectum and the anus
each other causing inflammation, ● Blind rectal pouch with normal anus
edema and decreased blood flow.
c. May progress to necrosis, perforation Clinical Presentation
and peritonitis. ● No stool passage with in 24 hours after birth
d. Gangrene of the bowel ● Meconium stool from other orifice
● Only a dimple indicates the site of the anus
Clinical presentation ● Inability to insert thermometer
Diagnosis
1. Sudden onset of abdominal pain (in a ● Digital rectal exam
healthy baby) ● Ultrasound
2. Infant cries out sharply and draws knees up ● Abdominal X-rays
to abdomen Management
3. Vomiting occurs and increases overtime ● If suspected, do not take rectal temperature
(Bile stained vomitus) ● Pre-operative care
4. Currant jelly stool ○ Monitor for the presence of stool in
5. Signs of shock the urine and vagina (indicates a
6. (+) for Occult blood in stools fistula) and report immediately.
7. Sausage-shaped mass in RLQ ○ Administer IV fluids as prescribed
○ Prepare the child and parents for the
surgical procedures, including the
Diagnosis potential for colostomy
Often based on history and physical examination
alone ● Post-operative Care
○ Expose perineum to air
● Barium enema ○ Check bowel sounds
○ Is definitive (in 75% of cases) ● It is ○ NGT for gastric decompression
therapeutic and curative in most ○ Change position frequently
cases with less than 24-hour duration ○ Oral feeding started gradually as
soon as peristalsis function returned
● Digital rectal exam ○ Instruct the parents to use only a
○ reveals mucous, blood water-soluble lubricant and to insert
Immediate Treatment the dilator no more than 1 to 2 cm
● IV fluids
● NPO status
● Diagnostic barium enema
Displaced Urethral Openings
● Surgery – manual reduction of invagination
○ resection with anastomosis HYPOSPADIAS
○ possible colostomy (gangrenous) ● Males: urethra opens on the lower surface of
Nursing Management the penis
● Provide routine pre- and post-operative care ● Females: urethra opens into the vagina
for abdominal surgery
● Monitor fluid and electrolyte status EPISPADIAS
● Maintain nutrition and hydration ● Only in males
● Resume feedings 24 hours post operative
 ● Urethra opens on the dorsal surface of the ○ Handwashing and avoiding exposure
penis to infection.
● Congenital absence of the upper wall of the
urethra ● When feeding infants and young children,
● Procreation may be interfered with in severe use a small, straight-handled spoon to push
cases food to the side and back of the mouth.
● Increased risk of urinary tract infection ● Encourage fluids and foods rich in fiber.
Management ● Constipation results from decreased muscle
● Circumcision is delayed until surgical repair tone, which affects gastric motility.
● Surgical repair ● Provide good skin care because the skin is
○ Meatotomy - moving the meatus to dry and prone to infection.
the tip of the glans penis or the ● Family education – counseling
orifice to be in front of the vaginal developmental progress
opening

Down Syndrome Autism

● Chromosomal disorder caused by the ● Severe mental disorder beginning in infancy
presence of all or part of an extra 21st or toddlerhood
chromosome. ● Pervasive developmental disorder
● It is named after John Langdon Down, the ● Disorder apparent to the parents before the
British doctor who described the syndrome child is 3 years old
in 1866. ● Characterized by :
● The disorder was identified as a ○ Severe deficit in language,
chromosome 21 trisomy ○ perceptual and motor development
Assessment Findings ○ Defective reality testing
● Small head, flat facial profile ○ Inability to function in social setting
● Low- set ears ● The cause is unknown and the prognosis
● Simian creases - straight line on palm may be poor.
● 40% - congenital heart defects
● With moderate retardation Possible Causes
● Wide space bet 1st – 2nd toes ● Unsatisfactory mother-child relationship
● Lax muscle tone ● CNS abnormalities
○ Diagnosis is established based on
symptoms and the use of specialized
autism assessment tools.
Categories
● Inability to relate with others
● Inability to communicate
● Obvious limited activities/interest
Clinical Presentation
● Infant not responsive to cuddling
● No eye contact or facial responsiveness
● Impaired/non verbal communication
○ Normal: at 4 - 5 mo., a child is able
to babble to communicate
● Echolalia - repeats words
● Inability to tolerate change
● Fascination with movement
● Labile moods - easily altered mood
Management Assessment
● Prevent respiratory infections ● Bizarre responses to the environment
○ Clearing the nose ○ Intense reaction to minor changes
○ Cool mist vaporizer ○ Attachment to objects
○ Chest physiotherapy
 ○ Intensely preoccupied to moving ● Shifting from one uncompleted activity to
object another
● Self-absorbed and unable to relate to others. ● Talking excessively
● Repetitive hand movement, rocking, and ● Interrupting or intruding on others
rhythmic body movement ● Engaging in physically dangerous activities
● Hitting, head banging, and biting without considering the possible
● Music often holds a special interest for them consequences
● No delusions, hallucinations, or incoherence Therapeutic Management
● Excellent long-term memory ● Environment
● May play happily alone for hours but have ○ construction of stable environment
temper tantrums if interrupted. ○ special instruction free from
Nursing Intervention distractions
● Provide parents /family with support and ○ fair but firm and set consistent limits
information about the disorder
● Assist child with ADL ● Medications
● Promote reality testing ○ controls excessive activity
● Encourage the child to develop relationship ○ lengthening the attention span
with another person ○ decreasing the distractibility
● Maintain regular schedule of activities Interventions
● Provide constant routine for child ● Provide environmental and physical safety
● Protect from self injury measures.
● Provide safe environment ● Encourage support groups for parents.
● Provide seizure precaution ● Administer prescribed medication; some
Management commonly prescribed medications that
include:
○ methylphenidate hydrochloride
Attention Deficit Hyperactivity Disorder
(Ritalin),
(ADHD)
○ pemoline (Cylert), and
● Developmental disorder characterized by ○ dextroamphetamine sulfate
inappropriate degrees of inattention, (Dexedrine).
overactivity, and impulsivity ● Inform the child and parents that positive
● One of the most common reasons for effects of the medication may be seen within
referral of children to mental health services 1 to 2 weeks
● Childhood problems include lowered
intellectual development, some minor
physical abnormalities, sleeping
disturbances, behavioral or emotional
disorders, and difficulty in social
relationships
Diagnosis
● Established on: - parent and teachers
reports - psychological assessments
● Diagnosable by 36 months
● 3 major characteristics revealed before 7
years of age

Assessment
● Fidgets with hands or feet or squirms in the
seat
● Easily distracted with external or internal HIGH RISK TODDLER
stimuli
● Difficulty with following through on
instructions
● Poor attention span BURNS
- an injury to body tissue caused by
excessive heat
- most severe form of trauma to the
integumentary system

TYPES OF BURNS

1. Thermal - caused by flames, flash, scalding

(hot liquid), contact to hot metal, grease
2. Chemical - inhalation or ingestions of acids, 2. FULL THICKNESS
alkalines, or vesicant - All skin layers and nerve endings; may
3. Smoke inhalation - fire, gases, involve the muscles, tendons, and bones
superheated air – smoke causes respiratory - Little or no pain
tissue damage - Wound is dry, white leathery, or hard
4. Electrical burn - damage of nerves and Eschar - the tough, leathery scab that form over
vessels due to electric current moderate or severe burn area

CLASSIFICATIONS ACCORDING TO DEPTH

1. PARTIAL THICKNESS

a. Superficial partial thickness

- Epidermis
- Painful erythema
- No vesicles

PHASES/STAGES OF BURNS

1. EMERGENT PHASE

a. remove the person from the source of burn

b.
c. Deep partial thickness Thermal – smother burn beginning with the head
- epidermis / dermis Smoke inhalation – ensure patent airway
- Very painful Chemicals – remove clothing
- Fluid filled vesicles
- Red, shiny, wet
Electrical – maintain airway, identify entry and exit
route

b. wrap in dry, clean sheet

c. assess how and when burn occurred
d. provide IV route if possible
e. transport immediately

2. SHOCK PHASE
- fluid shift from plasma to interstitial causing
hypovolemia

ASSESSMENT FINDINGS

● dehydration - because of fluid shifting

● decrease BP - because of decrease in blood
volume
● tachycardia - first manifestation
- Compensatory mechanism
- Compensates due to the decrease in BP 2. Severity of burn
and low blood volume - Classification
● decrease urine output, thirst - dehydration
● Diagnostic test – hyponatremia, MINOR
hypoproteinemia, hyperkalemia - partial thickness (1st /2nd degree)
less than 10 -15% of body surface
3. DIURETIC PHASE/FLUID REMOBILIZATION - full thickness (3rd degree)
- intertesial fluids returns to the vascular less than 2% of body surface
space - No burn on area of face, feet, hands,
or genitalia
ASSESSMENT FINDINGS
MODERATE
● Elevated BP, increase urine output - partial thickness ( 2nd degree)
between15-25% of body surface
4. CONVALESCENT - Full thickness less than 10%
- wound healing - Smoke inhalation

ASSESSMENT FOCUS: MAJOR

- Partial thickness
1. Extent of injury - Greater than 25% of body surface
- rule of nine (adults) - Full thickness
● Divided into multiples of - Greater than or equal to 10
- Lund and bowder (pediatrics)
Additional Notes:
✓ No burn on area of face, feet, hands, or genitalia
- Considered as moderate to major
- Facial burn – moderate or major
- entrance of respiratory area
- respiratory distress, laryngospasm
that can lead to death
- Genitalia – unable to urinate

BASIC BURN TREATMENT

Minor Burns
• Antibiotic
- prophylaxis
- Predispose to develop infection because of skin
Breakdown

• Analgesic ointment
- to relieve pain - Taking healthy skin from one part of the
body and transplant (move) it to cover skin
• Gauze bandage that's damaged or missing
- prevent exposure to environment - Auto graft - self; skin used for grafting is
- Decrease incidence of infection from the patient itself
- Skin used is usually from the buttocks and
Moderate Burns abdomen
• do not rupture blisters - Tilapia skin is also used for skin grafting to
- prone to develop infections because of skin lessen or prevent scarring while promoting
breakdown wound healing
• analgesia/antipyretic ointment
• warm water and mild soap
• burn dressing – bulky dressing Additional Notes:
- magtubig if blisters break causing the fluids to ✓ Treatment depends on severity
leak. Gauze can quickly dampen if the dressing ✓ Severe burns if left untreated after 24 hours will
is thin lead
to death (because of fluid shifting, hypovolemic
shock)
✓ NOTE: Parameters such as vital sign (heart
rate),
urine output, adequacy of capillary filling, and
sensorium status determine adequacy of fluid
resuscitation
Fig. 9 Antibiotic Fig. 10 Bulky dressing
✓ Discourage the use of toothpaste. Toothpastes
Severe Burns only have a cooling effect.
- Can worsen the burn
a. Supportive Therapy; Fluid Management - Can make the burn more
● Can lessen the occurrence of hypovolemic
shock if done right away COMPARING OPEN AND CLOSED BURN
● Crystalloid solutions: Lactated Ringer THERAPY
- - Most common
● Colloid solutions: such FFP
- dextran is commonly used
- faster action
● Catheterization
- Monitoring and assessing the condition of
client for hypovolemic shock and
remobilization
b. Wound Care
● open or closed burn therapy, hydrotherapy
● Hydrotherapy – submerging patient in a
whirlpool/bath tub to prepare for
debridement (facilitates skin softening)
c. Drug Therapy
● Topical antibiotic (Silver Sulfadiazine)
● Systemic antibiotics – prevent infection
● Tetanus toxoid/HTIG - SOP OTHER CONSIDERATIONS IN THE
● Analgesic – morphine sulfate TREATMENT OF BURN
d. Physical Therapy
● to prevent disability caused by scarring,
contracture 1. Hand injuries
● Contracture - permanent tightening of the - each individual finger and toes should be dressed
muscles, tendons, skin, and nearby tissues and movement encouraged
that causes the joints to shorten and - to prevent contractures
become very stiff. - creates tissue scarring in-between the fingers or
e. Surgery toes resulting in webbed hands or feet
● Escharotomy 2. Facial burns
- Surgical removal of eschar - open technique with ointment use only
● Debridement open technique – eyes, mouth, and nose
- Removal of dead tissue are left open
● Skin grafting ointment – keeps area moist
3. Topical antimicrobials
- silver sulfadiazine and sulfamylon - used only
for major burns and should not be used in 2. Monitor alterations in fluid and electrolytes
outpatients 3. Promote maximum nutritional status
silver sulfadiazine – if patient is still 4. Prevent wound infection
admitted (needs skill, wrong application 5. Prevent GI complications
can cause irritation) sulfamylon – once patient is ● Curling’s ulcer – common burn
discharged complication
4. Any burn that does not heal in a month - Burn patients undergoes stress. Stress
should be referred to a burn surgeon promotes the GI tract to produce more acids.
If client has no intake, this will lead to
erosion of the mucosa, resulting in curling’s
ulcer
● Patients are usually given antacids
6. Provide health teachings

Fig. 11 Correct hand dressing

CEREBRAL PALSY

● Neuromuscular disorder characterized by

impaired
movement and posture resulting from an
abnormality in
the extrapyramidal or pyramidal motor system
● Has distinct manifestations in every age
group.
● Differently abled
● CP is caused by damage to the motor
control centers of
the developing brain and can occur during:
● Pregnancy - about 75 percent (congenital)
Fig. 12 Open technique for facial burns ● Childbirth – 5 percent
● After birth -15 percent up to about age
three

ETIOLOGY

a. Prenatal – genetic, mother with rubella,

accidents, PIH
b. Perinatal – drugs at delivery, precipitate delivery,
breech
deliveries
Fig. 13 silver sulfadiazine
● Precipitate delivery - extremely rapid labor
anddelivery’ immediate expulsion of baby
- Incorrect or unknown (for healthcare
PARKLAND FORMULA workers) positioning of the mother, baby’s
head may be bumped
LR (Lactated Ringer) ● Breech NSVD can cause damage to the
4cc x Wt in kg x total BSA% nerve that causes CP
(deliver ½ over first 8hrs; then other ½ over the next c. Postnatal – kernicterus, head trauma (falls out of
16hrs) crib, car accidents) = Brain damage
Example: 4cc x 11 kg = 44
44 x 9 (BSA) = 396 Additional Notes:
396/2 = 198 ✓ Brain damage occurs of there is more than 20
198cc –first 8 hrs; 198cc –next 16 hrs secs
of oxygen deprivation
FFP (Fresh Frozen Plasma)
0.5cc x Wt in kg x total BSA%
(deliver over the next four hours following fluids) TYPES OF CEREBRAL PALSY
MAINTENANCE (D5W)
1cc x Wt in kg x total BSA% ● SPASTIC
- tense, contracted muscles (most common
NURSING INTERVENTIONS type of CP)
1. Provide relief or control of pain
 - occipital area
● ATHETOID
- constant, uncontrolled motion of limbs, head
and Eyes
- frontal area
● ATAXIC
- poor sense of balance, often causing falls
and stumbles
- occipital area
- confined to a wheelchair
● RIGIDITY
- tight muscles that resist effort to make them
move
- temporal area
- usually confined to a wheelchair
● TREMOR
- uncontrollable shaking, interfering with
coordination
- occipital area

Additional Notes:
✓ Athetoid and tremor are likely the same except
that Athetoid can still provide balance while tremor
has no balance at all.
✓ Cerebral Palsy entails Paralysis and Weakness.

TYPES OF PARALYSIS

COMMON PROBLEMS
Depends on affected area

* visual defects (strabismus, nystagmus, refractory

errors)
• hearing loss
• speech or language delay
• seizures
• mental retardation

PATIENT CARE MANAGEMENT

1. Promotion of optimal rehabilitation in the areas of

locomotion, communication, and the activities of
daily
living.
- Nurses should give only ASSISTANCE and
not take full responsibility for resident’s ADL
for them to feel purposeful

2. Correction of associated disabilities

Additional Notes:
✓ People with cerebral palsy inside rehabilitation
Facilities are called “Residents” because they live
in that area with a purpose.
✓ They are physically challenged or physically
handicapped because they are able; they only have
problems in certain areas.

MEDICAL MANAGEMENT
1. Drug therapy PT, speech therapy, audiotherapy, OT, etc.
Antianxiety – given when patient is anxious 2. Assess the child's
skeletal muscle relaxants – for stiff muscles developmental level and
local nerve block intelligence.
2. Speech/audiotherapy Mental retardation
3. Physical/occupational therapy 3. Encourage early intervention and participation
Physical - ADL, Paralympics in
Occupational – taught how to make a living school programs.
NOTE: Surgical interventions are reserved for the 4. Prepare for using mobilizing devices.
child Teach the client the different techniques in using
who does not respond to more conservative the mobilizing devices
measures 5. Encourage communication and interaction with
(PT) or for the child whose spasticity causes the
progressive child on his or her developmental level rather than
Deformity. chronological age level.
6. Provide a safe environment
7. Assist in ADL
8. Provide safe appropriate toys for the child's age
NORMAL DEVELOPMENT VS. CEREBRAL
and
PALSY
developmental level.
9. Position the child upright after meals.
10. Administer medications as prescribed to
decrease
spasticity.
11. Therapy

INGESTION OF POISONS

• Poison – any substance that is harmful to the body

• Ingestion of toxic substance
• Common agent in childhood – soaps, cosmetics,
detergents or cleaner and plants
Modes of Exposure
• Ingestion
• Inhalation
• Spray

Fig. 16 Normal Development vs Cerebral Palsy A SIGNS AND SYMPTOMS

1. GI disturbances – Vomiting, abdominal pain,
anorexia,
distinctive odor
2. Respiratory/circulatory disturbances – Collapse,
shock,
unexplained cyanosis
3. CNS manifestation – Confusion, disorientation,
sudden
loss of consciousness, convulsion

GENERAL MEDICAL TREATMENT

1. Elimination of poisons
● Childproof; use symbols in teaching children
about poisonous substances
2. Antidote administration
3. General supportive measures
Fig. 17 Normal Development vs Cerebral Palsy B
GENERAL INTERVENTIONS
1. Stabilize child’s condition by maintaining patent
NURSING INTERVENTIONS
airway
2. Prevent absorption
NOTE: The goal of management is early recognition
a. Determine the type of substance ingested
and
b. Induce emesis – except caustic material
interventions to maximize the child's abilities
ingestion,
comatose, active seizure or lacking gag reflex
1. A multidisciplinary team approach
Pasukahon ang client
Don’t induce emesis if it’s a corrosive substance. It 1. Administer chelating agents – for lead poisoning
may cause ulcers and injury in the mucosa since dimercaprol (BAL in Oil) - not given if allergy w/
mabalik man ang substance and makapaso. At peanuts (prepared in peanut oil solution)
least the affected area can be localized edatate calcium disodium (calcium EDTA)
c. Syrup of ipecac – prevent absorption 2. Provide nutritional counseling
d. Gastric lavage – if corrosive PICA – loves eating nonedible objects
e. Activated charcoal – facilitate absorption 3. Aid in eliminating environmental conditions that
f. Cathartic led to
3. Provide treatment and prevention information to lead ingestion
parents
4. Incorporate anticipatory guidance related to the A. LEAD POISONING
developmental stage of the child - childproofing • When lead enters the body, it affects the
5. Discuss general first aid measures with parents erythrocytes,
bones and teeth, and organs and tissues, including
METHODS OF PREVENTION the
brain and nervous system; the most serious
Child proofing the environment consequences are the effects on the central
Most important nervous
Place all the medicines far from their reach or top system.
shelves • Common route is hand to mouth from
2. Educating parents and child contaminated
Teaching the children to look for the poison sign objects or from eating loose paint chips, crayons, or
or alike in the medicine labels pottery that contains lead.
3. Anticipatory guidance • Chelation Therapy - removes lead from the
4. Understanding and applying the principles of G/D circulating
blood and from some organs and tissues.
SPECIFIC POISONING

1. Salicylate poisoning
• aspirin, oils of wintergreen
• decrease RR
• Toxicity begins at doses of 150 - 200 mg/kg.
• S/S – CNS depression
- Vomiting (initial manifestation)
- respiratory failure
2. Acetaminophen poisoning
• commonly used analgesics
• risk for liver damage
• Antidote – mucomyst (N-Acetylcysteine)
• S/S – vomiting, liver tenderness, abdominal pain Fig. 18 Photo of Lead Poisoning
3. Lead Poisoning (Plumbism)
• common in toddlers and preschoolers Blood Lead Level Test
• Prevention: Lead-free •Used for screening and diagnosis
• Lead interferes with RBC function •Intervention depends on the level of lead in the
• Lead value of 15ug/dl – health hazard body
• Symptoms appear when lead level is – 70ug/dl
• Most serious effect: Lead encephalitis
• Air, soil, water, houses, ceramic cookware, solder
used in
metal cans and pipes
- Toys also contains lead
- The brighter the color, the higher the lead
content
• S/S:
Abdominal complaints – colicky pain,
Constipation, vomiting
Pallor – this concerns the RBC
Irritability
Loss of coordination
Encephalopathy
(+) lead in the blood

NURSING ACTION
 OTHER SYMPTOMS

B. CAUSTIC POISONING ● Generalized shock

• ● Renal Failure
Ingestion of strong alkali or acidic substance ● Leukocytosis
•
May cause burns and tissue necrosis in the mouth, TREATMENT
esophagus, stomach
Symptoms and treatment are similar for inorganic FOR RESPIRATORY DEPRESSION:
acids and alkalis 100% oxygen supply
• Cricithyroidotomy
Pharyngeal edema
may cause airway obstruction – intubation might be DECONTAMINATION:
necessary
Because of the trauma into the tissues If ingested:
Respiratory distress -Water/milk: 120-240 ml
-30min after ingestion
If dermal exposure
-Remove clothes
-Apply silver sulfadiazine
If ocular exposure
-Irrigate with saline/water for 15-30mins
FOR PAIN:
Morphine can be given

Fig. 20 Photo of Caustic Poisoning

Fig. 21 Symptoms and Treatment of Caustic
CAUSTIC Poisoning
● Any substance capable of producing:
Corrosive, Burning effects
ALKALIS CHILD ABUSE
● Ammonia
● Carbonates: Sodium, potassium
● Sodium hypochlorite •Child abuse involves emotional or physical abuse
HYDROXIDES OF: or neglect, as well as sexual exploitation or
● Sodium molestation by caretakers or other individuals.
● Calcium •Problem – related to parents’ limited ability to
● Potassium cope or relate to the child
SYMPTOMS AND TREATMENT OF CAUSTIC Parent/s are also victims of abuse
POISONING
● If ingested, the major affected system is GIT Emotional Abuse
- Intense thirst •Speech disorders
- Chalky white teeth •Habit disorders such as sucking, biting, and
- Erosion of teeth due to the acid rocking
- Drooling saliva •Psychoneurotic reactions
- Brownish vomit •Learning disorders
- due to the blood mixed with acid •Suicide attempts
- Swollen tongue - Especially if child has a very low coping
- Severe abdominal pain index
- Dysphagia
- Perforation of stomach and duodenum Sexual Abuse
• Torn, stained, or bloody underclothing
•Pain, swelling, or itching of the genitals 4. Encourage parents to be involved in child’s care
•Bruises, bleeding, or lacerations in the genital or 5. Encourage parents to express their feelings
anal area 6. Provide family education
•Difficulty walking or sitting 7. Initiate referrals for long term follow-up
•Unwillingness to change clothes or unwillingness to 8. Support the child during a thorough physical
participate in gym activities assessment.
•Poor peer relations Support the child because they are become
- Because of the abuser’s threats that leads to hesitant because of the trauma and fear
the child’s impaired socialization 9. Assess injuries.
10. Report case of suspected abuse; nurses are
Physical Abuse legally
•Unexplained bruises, burns, or fractures required to report all cases of suspected abuse to
Comes in different stages of healing the
•Bald spots on the scalp appropriate local/state agency.
•Apprehensive child 11. Place the child in an environment that is safe,
•Extreme aggressiveness or withdrawal thereby
•Fear of parents preventing further injury.
•Lack of crying (older infant, toddler, or young 12. Document information related to the suspected
preschool child) when approached by a stranger abuse in
an objective manner.
Physical Neglect 13. Assess parents' strengths and weaknesses,
•Inadequate weight gain normal
•Poor hygiene coping mechanisms, and presence or absence of
•Consistent hunger support
- Failure to thrive systems.
•Inconsistent school attendance 14. Assist the family in identifying stressors, support
•Constant fatigue systems,
•Reports of lack of child supervision and resources.
•Delinquency 15. Refer the family to appropriate support groups.
16. If shaken baby syndrome is suspected, monitor
the infant's level of consciousness.
Shaken baby syndrome - occurs when a parent or
caregiver severely shakes a baby or toddler due
to frustration or anger.
- If a baby is forcefully shaken, their fragile brain
moves back and forth inside the skull. This causes

IRON DEFICIENCY ANEMIA

RACOON EYE •Iron stores are depleted, resulting in a decreased

- A sign of intracranial bleeding supply of iron for the manufacture of hemoglobin in
- intracranial bleeding is RBC
manifested in the
periorbital region Causes: blood loss, increased metabolic demands,
syndromes of GI malabsorption, dietary inadequacy
Blood loss due to hemorrhage or early
GOAL OF CARE menstruation (school-age)
1. Client will be safe Increased metabolic demands because of active
Ensure safety by making referrals, like DSWD lifestyle
2. Child will participate with nurse for emotional Dietary inadequacy is common during preschool
support because they are picky-eaters
3. Parents and/or primary caregiver will participate
in Common in:
therapy • Child bearing women
Regardless if the patient is the abuser or not Increasing demand of iron in the body
•Poor iron intake
NURSING INTERVENTION •Infants and children in rapid growth
1. Attend to the needs of the child •Pregnant/lactating mothers
2. Report suspected child abuse case to appropriate
agency ASSESSMENT
3. Provide role models for parents 1. Compensatory tachycardia
Less circulatory blood volume because of in serious health conditions, such as dehydration,
inadequate RBC decrease BP, stroke, and rarely death.
2. Pallor ✓ Although people with the disorder require daily
Lips, conjunctivae, nailbeds care,
3. Weakness, fatigue, irritability they can still live a normal life.
4. Lab results ✓ There is no cure for cystic fibrosis. People with
CF will not live longer lives because complications
MANAGEMENT will appear over time.
1. Food choices: meats, dark green & leafy ✓ Most common among white people; less
vegetables, egg yolks, liver, kidney beans, common
iron-enriched formula & cereal in Asians
2. Administer iron supplements as prescribed ✓ Caused by a defect in the cystic fibrosis
3. Teach parents to administer iron supplements: transmembrane conductance regulator gene
Between meals (CFTR gene)
- Full stomach ✓ In order to have cystic fibrosis, a child must
- Give with Vit C inherit a faulty gene from each parent. Children
To facilitate iron absorption who inherit one normal and one faulty gene will be a
- Do not give with antacids or milk carrier of the defective gene and may not usually
Can impair absorption develop CF. However, they may pass the defective
- Oral care gene on their own children.
- Side effects ✓ A genetic test or blood test is used for newborn
4. Monitor signs and symptoms of bleeding screening
5. Adequate rest periods ✓ Goals of treatment are to prevent and control
6. Explanation of all diagnostic test infections that occur in the lungs
-
To loosen the mucus in the lungs
-
CYSRIC FIBROSIS
To treat and prevent intestinal blockages
-
This is a chronic multisystem disorder (autosomal To provide adequate nutrition
recessive trait disorder) characterized by -
exocrine gland dysfunction. To prevent dehydration
•The mucus produced by the exocrine glands is
abnormally thick, tenacious, and copious,
causing obstruction of the small passageways of the
affected
organs, particularly in the respiratory,
gastrointestinal,
and reproductive systems.
•CF is a fatal genetic disorder and respiratory failure
is the most common cause of death.
•There is also a marked electrolytes change in the
secretion of sweat glands

SYMPTOMS
Additional Notes:
✓ Cystic fibrosis affects the cells that produce
sweat,
mucus, and digestive enzymes Fig. 24 Areas affected by Cystic Fibrosis A
✓ Thick mucus may build up in the lungs and
block
the airways, which makes it ideal of bacterial
growth and may lead to lung infections
-
Bacteria thrives in thick, tenacious
secretions
✓ The fluid can also block tubes in the pancreas,
this
may hinder the digestive enzymes. This can cause
malnutrition and vitamin deficiency
✓ Sweat can also become very salty. Thus, a large
amount of salt is lost when sweating. This can upset
the mineral balance in the blood, which may result
 growth and may lead to lung infections
-
Bacteria thrives in thick, tenacious
secretions
✓ The fluid can also block tubes in the pancreas,
this
may hinder the digestive enzymes. This can cause
malnutrition and vitamin deficiency
✓ Sweat can also become very salty. Thus, a large
amount of salt is lost when sweating. This can upset
the mineral balance in the blood, which may result
in serious health conditions, such as dehydration,
decrease BP, stroke, and rarely death.
✓ Although people with the disorder require daily
care,
they can still live a normal life.
✓ There is no cure for cystic fibrosis. People with
CF
will not live longer lives because complications will
appear over time.
✓ Most common among white people; less
common
Fig. 25 Areas affected by Cystic Fibrosis B in Asians
✓ Caused by a defect in the cystic fibrosis
transmembrane conductance regulator gene
(CFTR gene)
✓ In order to have cystic fibrosis, a child must
inherit
a faulty gene from each parent. Children who
inherit one normal and one faulty gene will be a
carrier of the defective gene and may not usually
develop CF. However, they may pass the defective
gene on their own children.
✓ A genetic test or blood test is used for newborn
screening
✓ Goals of treatment are to prevent and control
infections that occur in the lungs
-
Fig. 26 Example Inheritance Pattern To loosen the mucus in the lungs
of Cystic Fibrosis -
To treat and prevent intestinal blockages
-
To provide adequate nutrition
-
To prevent dehydration
Increase bacterial
invasion•
The most common symptoms are pancreatic
enzyme deficiency caused by duct blockage,
progressive chronic lung disease associated with
infection, and sweat gland dysfunction resulting in
increased sodium and chloride
sweat concentrations.
Fig. 27 Cystic Fibrosis
4 Symptoms Same With Celiac Disease
SYMPTOMS •Malnutrition
Additional Notes: •protuberant abdomen
✓ Cystic fibrosis affects the cells that produce •steatorrhea
sweat, •fat-soluble vitamin deficiency
mucus, and digestive enzymes
✓ Thick mucus may build up in the lungs and A. RESPIRATORY
block 1. Wheezing and dry nonproductive cough
the airways, which makes it ideal of bacterial 2. Dyspnea
3. Cyanosis Normal - if sweat chloride concentration is 20
Poor diffusion of oxygen meq/L or
4. Clubbing of the fingernails and toes lower than 40mEq/L.
Determine the length of oxygen deprivation •Chloride concentrations of 50 to 60 mEq/L are
5. Barrel chest highly
Result of compensatory mechanism of the suggestive of cystic fibrosis and require a repeat
respiratory area test.
6. Repeated episodes of bronchitis and pneumonia •A chloride concentration higher than 60 mEq/L is
Complications of CF that causes death a Positive result

B. GASTROINTESTINAL
1. Meconium ileus in the neonate
2. Intestinal obstruction
● Pain
● abdominal distention
● severe constipation
● nausea and vomiting
3. Steatorrhea (frothy, foul-smelling stools) easy
bruising and anemia
4. Malnutrition and failure to thrive
5. Generalized edema due to hypoalbuminemia
albumin is responsible to maintain oncotic pressure
para dili basta basta mag transfer ang fluids and
other electrolytes to other compartment. If wala na,
this would lead to shifting of bodily fluids, resulting
in generalized edema (ex. ascites) Fig. 28 Quantitative Sweat Chloride Test
6. Rectal prolapse
due to large, bulky stools and lack of the 2. Chest x-ray
supportive fat pads around the rectum •Film reveals atelectasis (lung collapse) and
obstructive
C. INTEGUMENTARY emphysema.
1. Abnormally high concentrations of sodium and 3. Pulmonary function tests
chloride in sweat •Provide evidence of abnormal small airway
2. Parents reporting that the infant tastes “salty” function.
when kissed 4. Stool, fat, enzyme analysis:
3. Dehydration and electrolyte imbalances, • A 72-hour stool sample is collected to check the
especially during hyperthermic conditions fat and/or enzyme (trypsin) content
Hyperthermic conditions = due to excessive •Food intake is recorded during the collection
sweating during -Can give an explanation about the fat content in
the client’s stool
D. REPRODUCTIVE 5. Duodenal analysis
1. Delay puberty in girls. •nasogastric tube is inserted to aspirate duodenal
2. Infertilityhighly viscous cervical secretions secretions
3. Sterility •to check if GI area is affected
caused by the blockage of the vas deferens by
abnormal secretions or by failure of normal THERAPEUTIC MANAGEMENT
development of duct structures. 1. RESPIRATORY SYSTEM
•Goals of treatment include preventing and
Additional Notes: treating pulmonary infection by improving aeration,
✓ Respi, GI, and Repro have increase mucus removing secretions, and administering
production if patient has CF antimicrobial medications.

a. Chest physiotherapy
DIAGNOSTIC TESTS - chest tapping
1. Quantitative Sweat Chloride Test b. Aerosol Therapy - nebulization
• the most reliable diagnostic test Bronchodilator
Pilocarpine – a cholinergic drug that stimulate Antimicrobial
production of sweat Mucolytic – loosen mucus
-the sweat is collected, and the sweat c. Use of a Flutter Mucus Clearance Device
electrolytes are measured -
- a device is placed on a child to collect the a small, hand-held plastic pipe with a stainless
sweat steel ball on the inside
•
- ✓ Malabsorption can lead to permanent intestinal
chest physiotherapy damage
- -
can loosen secretions In children, malabsorption can lead to
d. Use of a ThAIRapy vest device abnormal growth and development
- ✓ Some gene variation may increase the risk of
provides high-frequency chest wall oscillation to developing the disease
help loosen secretions ✓ Celiac disease may be triggered or become
active for the first time after surgery, emotional
2. GASTROINTESTINAL SYSTEM stress, viral infections, pregnancy, and childbirth
a. The goal of treatment for pancreatic insufficiency ✓ Factors that may predispose a person to celiac
is to replace pancreatic enzymes disease are Type 1 diabetes, Down syndrome,
b. The amount of pancreatic enzymes administered Autoimmune thyroid disease, and Rheumatoid
is adjusted to achieve normal growth and a arthritis
decrease in the number of stools to two or three ✓ Doctors recommend gluten-free mineral and
daily. vitamin supplements for chronic nutritional
c. Enteric-coated pancreatic enzymes should not be deficiency
crushed or chewed. ✓ Doctors recommend steroids for severe intestinal
d. Pancreatic enzymes should not be given if the damage to control inflammation
child isNPO. ✓ Inflammation in the small intestine starts to
e. Encourage a well-balanced, high-protein reduce
(hypoalbuminemia), high-calorie diet; multivitamins once gluten has been removed from diet
and vitamins A, D, E, and K are also administered. -
F. Assess weight and monitor for failure to thrive Regrowth and complete healing of the villi
(due to weight loss). may take several months to years
g. Monitor for constipation (increase mucus) and
intestinal obstruction.
h. Ensure adequate salt intake and fluids that
provide an adequate supply of electrolytes during
extremely hot weather and if the child has a fever.
Children with cystic fibrosis are easily dehydrated
because of increased perspiration

HOME CARE

1. Instruct the child and family about the prescribed

treatment measures and their importance.
2. Instruct the parents and caregivers to be sure
immunizations are up to date.
Prone to develop infections
3. Inform the paren’ts and caregivers that the child
should be vaccinated yearly for influenza (annual);
pneumococcus vaccine (q3 or q5) may also be
prescribed.
CELIAC DISEASE
•Gluten-Induced Enteropathy
ASSESSMENT
•Malabsorption Syndrome- Is a sensitivity or
1. Acute or insidious diarrhea
immunologic response to protein, particularly the
2. Steatorrhea
gluten factor of protein found in grains of wheat,
3. Anorexia
barley, rye, and oats
4. Abdominal pain and distention
•Results in the accumulation of the amino acid -
Irritation of toxins in the villi
glutamine, which is toxic to intestinal mucosal cells.
5. Muscle wasting, particularly in the buttocks and
•Intestinal villi atrophy (shrinks) occurs, which
extremities
affectsabsorption of ingested nutrients
6. Vomiting
(malabsorption).
7. Anemia
Impaired nutrient absorption
Additional Notes:
8. Irritability
✓ Celiac disease is a long-term autoimmune
disorder that is characterized by an inflammation in
SYMPTOMS
the small intestine due to an exposure to gluten
•
✓ If a person with celiac disease eats gluten, the
Adults
immune system responds by creating toxins that
damages the villi
-Diarrhea, fatigue and headaches, abdominal pain,
constipation, nausea, anemia, itchy blistery skin BASICS OF A GLUTEN-FREE DIET
rash, loss of bone density, numbness and tingling in
hands and feet, heartburn, and acid reflux. FOODS ALLOWED
•Children under two years old Meat such as beef, pork, and poultry and fish, eggs,
-chronic diarrhea, FTT, poor appetite and milk and dairy products, vegetables, fruits, rice,
distended abdomen, and vomiting corn, gluten-free wheat flour, puffed rice, cornflakes,
•Older children cornmeal, and precooked gluten free cereals
-include constipation, weight loss, irritability,
stunted growth, and delayed puberty FOODS PROHIBITED
Commercially prepared ice cream, malted milk,
DIAGNOSIS prepared puddings, grains, including anything made
1. Serology test that look for certain antibodies in from wheat, rye, oats, or barley, such as breads,
the blood. rolls, cookies, cakes, crackers, cereal, spaghetti,
A high level of certain antibody protein may indicate macaroni noodles & beer
an
immune reaction to gluten PROGNOSIS
2. Generic test to look for human leukocyte antigens •Dietary avoidance of gluten results in improvement
to rule of symptoms in 70% of patients within 2 weeks
out celiac disease •Serologic antibody titers decrease on a gluten-free
diet
Additional Notes: After 3-6 months antibody levels may become
✓ Doctors may request an endoscopy if positive for undetectable
celiac disease to view the small intestine and take a Complete histological resolution of small bowel
little bit of tissue to see if it’s damaged inflammation may take up to 2 year

CELIAC CRISIS

•Precipitated by infection, fasting, ingestion of

gluten
•Extreme and acute (sudden) profuse watery
diarrhea and vomiting occurs
•Can lead to electrolyte imbalance, rapid
dehydration, and severe acidosis.
•Intensive therapy to replace fluids and electrolytes
is required

INTERVENTIONS
1. Maintain a gluten-free diet, substituting corn, rice,
and COMMON HEALTH PROBLEMS IN
millet as grain sources. PRESCHOOL AGE
Gluten can be found in preservatives, vitamin
supplements, herbal supplements, toothpaste and
mouthwash, hair and skin products, and lipstick BRONCHIAL
2. Instruct parents and child about lifelong
elimination of ● it is an obstructive disease of the lower
gluten sources such as wheat, rye, oats, and barley. respiratory tract
3. Administer mineral and vitamin supplements, ● often cause by an allergic reaction to an
including environmental allergen
iron, folic acid, and fat-soluble supplements A, D, E, ● allergic reaction results in histamine release
and ○ airway responses causes inflammation,
K constriction, obstruction
4. Teach the child and parents about a gluten-free
diet and Allergic reaction results to 3 main airway
about reading food labels carefully for hidden responses
sources of a. Edema of mucous membrane
gluten ● Presence of inflammation
5. Instruct the parents in measures to prevent celiac b. Spasm of the smooth muscles
crisis. ● Smooth muscles are tightened
Prevent exposure from any other infection because of the reaction of the
Small frequent feeding histamine release, creating a narrow
 airway, which causes constriction ● Chronic - more than 6 months, long
and obstruction period of time
c. . Accumulation of secretions
● The release of histamine thickens the Severe attack
wall which releases secretions a. Shortness of breath
b. Use of accessory muscles
c. Retractions
d. Nasal flaring
e. Irritability (earliest sign hypoxia)
f. Diaphoresis

DIAGNOSIS
a. ABG – respiratory acidosis
b. Peak flow meter - An objective way to
Additional Notes: measure airway obstruction
● Compromised air exchange because of the ● The most reliable early sign of an asthma
secretions and the spasm. The air in the attack is a drop in the in the child peak
alveolus becomes trapped creating the expiratory flow rate
wheezing sound

MEDICAL MANAGEMENT
a. Drug therapy
RISK FACTOR ● Bronchodilators - Beta-2-agonist
bronchodilator, xanthine derivative
a. Family history of allergies and asthma
● Antiasthma - Corticosteroids, Mast cell
b. Client history of eczema
stabilizer , leukotriene inhibitors
- Contact dermatitis/eczema
● Antibiotics
inflammation of skin that cause ○ Prophylaxis treatment since there is
allergens increase production in mucus,
increasing the chance of bacterial
growth
CLINICAL MANIFESTATIONS
b. Hyposensitization – limit allergens
a. Expiratory wheeze c. Exercise – aimed to increased expiratory
● Narrow bronchial airways function
b. Cough d. Incentive Spirometer – alternative to
c. Thick tenacious secretions exercise
d. Barrel chest - if chronic ● Used daily
● Narrow bronchial airways ● Measures the amount and rate a person
● Acute - within 6 month breathes in order to diagnose illness or
period/temporary determine progress of treatment
● Pia (24 hr period)
 * From the word “nephro” it affects the kidney
*Before its enlargement, manifestations are
asymptomatic.

NURSING INTERVENTIONS
1. Place client in high fowler’s position
● Facilitates lung expansion ASSESSMENT
2. Administer oxygen as ordered
● Low flow if there’s no doctor’s order since ● Palpable mass
the airways are constricted. If the airways ● Hematuria
are constricted, there is impaired diffusion ● Hypertension
of gasses so pwede mag pundo if dili ● Anemia
maapas ug pagawas ang gas ● Low grade fever
3. Administer medications as ordered
4. Provide good hydration
● Can facilitate proper expulsion of secretions
5. Provide chest physiotherapy
6. Promoting energy conservation
7. Monitor respiratory function
8. Provide family health teachings
● Include what triggers asthma attack
● Allergy-causing foods

Additional Notes:
* The kidneys are responsible for removing wastes
from the body, regulating electrolyte imbalance and
blood pressure, and stimulating red blood cell
production
* As there’s irritation with the renal parenchyma,
hematuria manifests
* Regulator of blood is affected, thus, hypertension
* Numbers 4 and 5 helps with loosening secretions follows
WILM’S TUMOR * Anemia happens as blood circulation has been
affected
● Nephroblastoma
● A large malignant tumor that develops in the
renal parenchyma DIAGNOSTIC TESTS
● Arises from bits of embryonic tissue that ● Sonogram
remains after birth ● CT Scan
● It accounts for 20% of solid tumors in childhood ● IVP - intravenous pyelogram
● Tumor is rarely discovered until it is large ○ Introduction of dye to determine the
enough to be palpated affected part or the area of the mass

Additional Notes
 4. Provide routine preoperative care
STAGING OF NEPHROBLASTOMA
POSTOPERATIVE
STAGE 1 ● Limited to kidney 1. Assess the respiratory, circulatory, fluid and
● Not easily electrolyte status
diagnosed 2. Monitor patency and adequacy of urinary
status
STAGE 2 ● Tumor extends 3. Observe for any postoperative complications
beyond kidney but (signs of infection)
completely 4. Provide care for child receiving radiation and
encapsulated chemotherapy

STAGE 3 ● Tumor confined to Additional Notes:

abdomen Post operative
* After the abdominal surgery, circulatory function is
STAGE 4 ● Tumor has compromised. DO splint, put a pillow on the
metastasized to abdomen to alleviate the pain
lung, liver, bone or * After the surgery, the fresh wound may be
brain susceptible for high risk of bacterial growtn

STAGE 5 ● Bilateral renal

URINARY TRACT INFECTION
removal
● It is a bacterial invasion of the kidneys or
bladder
● E. Coli accounts for about 80% of acute
episodes
● Predisposing factors: Poor hygiene, Irritation
MANAGEMENT from bubble (bubble bath)
● Post a visible sign “NO ABDOMINAL
UTI Different Types
PALPATION”
1. Urethritis: Urethra infection
○ Palpation can rupture the tumor
● S/Sx: Dysuria
capsule, resulting in metastasis
○ dribbling of urine
1. Surgery - nephrectomy
2. Cystitis: Bladder infection
● Removal of the affected part of the
● S/Sx: pelvic pain
kidney
3. Pyelonephritis: due to the ascending
2. Radiation therapy
infection, it results to inflicting the kidney
3. Chemotherapy
● S/Sx: flank pain

Additional Notes:
* Its different types depend on the location
* Common manifestations are frequent urination,
painful urination and dysuria
* Not all manifestations are present to people with
UTI as it depends on the infected

ASSESSMENT FINDINGS
1. Low grade fever
2. Abdominal pain - lower region
3. Burning pain upon urination (dysuria)
4. Hematuria
5. Foul-smelling
6. Urinary frequency (polyuria)
NURSING INTERVENTION 7. Enuresis - common sign for preschooler
PREOPERATIVE a. Cannot withhold urine
1. Do not palpate the abdomen
2. Handle the child carefully DIAGNOSTIC TEST
a. Do not place in prone position to
avoid rupturing of the capsule ● Urine analysis - presence of pus cells and
3. Monitor BP, Intake, and Output bacteria
a. Include the VS as well ○ Clean catch
○ WBC count is increased
 TYPES
TREATMENT
1. Acute: Occurs 2 to 3 weeks after a
● Antibiotic streptococcal infection
● Analgesic - for the pain 2. Chronic: Can occur after the acute phase or
● Antispasmodic - to relieve spasm slowly over time
● Increase fluid intake a. Manifestations usually extend
○ Facilitate passage of bacteria beyond 6 months

NURSING INTERVENTION ASSESSMENT

1. Administer antibiotics as ordered 1. Periorbital and facial edema that is more
2. Provide warm baths and allow to void in water prominent in the morning
3. Force fluids a. Child is laid flat on the bed, resulting
4. Encourage measures to acidify urine in fluid accumulation in the head part
5. Provide health teaching 2. Anorexia, hypertension
a. Avoidance of tub bath 3. Decreased urinary output
b. Avoidance of bubble bath 4. Cloudy, smoky, brown-colored urine
c. For girls to wipe perineum from front (hematuria)
to back 5. Pallor, irritability, lethargy
6. In the older child, headaches, abdominal or
Additional Notes: flank pain, dysuria
Common misconception: 7. Proteinuria that produces a persistent and
* Increased intake of soda/ too much junk or salty excessive foam (bubbles) in the urine
foods does not immediately result to UTI. However, 8. Azotemia
excessive amount of acid and sodium may result to a. Kidneys are no longer able to get rid
altering the pH balance that encourages or allow of enough nitrogen waste
bacteria to thrive. b. CNS complication
9. Increased blood urea nitrogen and creatinine
levels
GLOMERULONEPHRITIS
10. Increased antistreptolysin O titer
● Refers to a group of kidney disorders a. Blood test to measure antibodies
characterized by inflammatory injury in the against streptolysin O (a substance
glomerulus, most of which are caused by an produced by group A streptococcus
immunological reaction bacteria)
● Can also be caused by untreated UTI b. used to diagnose disorders caused
by streptococcal infections

INTERVENTIONS
1. Monitor vital signs, weight, intake and output,
and the characteristics of urine (color and
CAUSES foam).
a. Fluid retention can cause an
1. Immunological diseases increase in weight
2. Autoimmune diseases b. I/O for fluid retention and Oliguria
3. Antecedent group A beta-hemolytic 2. Limit activity; provide safety measures.
streptococcal infection of the pharynx or skin 3. Provide high-quality nutrient foods
4. History of pharyngitis or tonsillitis 2 to 3 weeks a. Restrictions depend on the stage and
before symptoms severity of the disease, especially the
extent of the edema (LSLF).
 b. In uncomplicated cases: Regular diet
is permitted but sodium is restricted
to a “no added salt to foods” diet.
(bland diet)
c. Moderate sodium restriction:
Hypertension or edema. Increase in
sodium attracts more water which
can increase BP
d. Foods high in potassium are
restricted during periods of oliguria.
e. Protein is restricted if the child has
severe azotemia resulting from
prolonged oliguria.
4. Monitor for complications
a. Azotemia
b. Dialysis (if chronic)
5. Administer diuretics, antihypertensive, and INTERVENTIONS
antibiotics as prescribed 1. Monitor vital signs, intake and output, and daily
6. Instruct the parents to report signs of bloody weights.
urine, headache (increase BP), or edema 2. Monitor urine for specific gravity and albumin.
(progression). 3. Monitor for edema.
7. Instruct the parents that the child needs to 4. Nutrition: A regular diet without added salt is
obtain appropriate adequate treatment for prescribed if the child is in remission; sodium is
infections, specifically infections. restricted during periods of massive edema.
5. Corticosteroid therapy is prescribed as soon as
NEPHROTIC SYNDROME the diagnosis has been determined; monitor
the child closely for signs of infection.
● Increase permeability to plasma
a. Patient becomes
(protein-albumin)
immunocompromised
● Is a kidney disorder characterized by massive
6. Immunosuppressant therapy - reduce the
proteinuria, hypoalbuminemia
relapse rate and induce long-term remission
(hypoproteinemia), and edema.
7. Diuretics may be prescribed to reduce edema.
● Autoimmune process
8. Plasma expanders such as salt-poor human
● The primary objective of therapeutic
albumin may be prescribed for the severely
management is to reduce the excretion of
edematous child.
urinary protein and maintain protein-free urine
9. Instruct the parents regarding the signs of
● Patho: plasma enters the renal tubules –
infection and the need to avoid contact with
excreted in the urine = proteinuria Protein shift
other children who may be infectious.
causes altered oncotic pressure (swelling)

COMPARISON OF FEATURES OF ACUTE

ASSESSMENT
GLOMERULONEPHRITIS AND NEPHROTIC
a. Periorbital and facial edema is most prominent SYNDROME
in the morning.
b. Leg, ankle, labial, or scrotal edema occurs.
c. Urine output decreases; urine is dark and Assessment Acute Nephrotic
frothy. Factor Glomerulonep Syndrome
d. Ascites (fluid in the abdominal cavity) hritis
e. Blood pressure is normal or slightly decreased.
f. Massive proteinuria is seen. Cause Immune Idiopathic
g. Decreased serum protein (hypoproteinemia) reaction to (unknown);
and elevated serum lipid levels occur. group A possibly
β-hemolytic Hypersensitivit
streptococcal y
infection (autoimmune)

Onset abrupt insidious

Hematuria Grossly bloody rare

Edema mild mild

Peak age 5 – 10 years 2 – 3 years old

 1. Treatment Phase:
Diet No added salt High protein,
a. Induction - achieving complete
if child is low salt
remission or absence of leukemic
hypertensive
cells
Intervention Limited Bed rest b. Consolidation / Sanctuary -
activity; during edema preventing leukemia cells from
antihypertensi stage; invading or growing in the CNS
ve as needed corticosteroid c. Maintenance - aims to eliminate
completely any remaining leukemic
cells; or maintaining remission
Additional Notes: d. Intensifies the assault against
* Nephrotic syndrome disappears as the child grows leukemic cells using chemotherapy
older, whereas untreated acute glomerulonephritis e. Given for 2 to 3 years
progresses to chronic renal failure 2. Two additional phases aer insulted for children
* Nephrotic syndrome BP is normal, whereas who experience relapse
glomerulonephritis has a high BP a. Reinduction - Administration of the
drugs previously used plus additional
LEUKEMIA drugs
b. Bone marrow transplant - Usually
● Refers to cancers of the white blood cells recommended after the second
● Proliferation of abnormal white cells that do not remission in children
mature beyond the blast phase
● In the bone marrow, blast cell crowd out healthy
white blood cells, red blood cells, and platelets, NURSING INTERVENTION
leading to bone marrow depression
● Blast cells also infiltrate other organs, most ● Preventing infection
commonly the liver, spleen. Kidneys, and lymph ● Reducing pain
tissue ● Promoting energy conservation and relieving
● In children, about 98% of leukemia are acute ● Promoting normal growth and development
● Promoting family coping

CLASSIFIED
1. Acute (rapidly developing) TONSILLITIS AND ADENOIDITIS
2. Chronic (slowly developing)
Tonsillitis refers to inflammation and infection of the
tonsils.
TYPES
Adenoiditis refers to inflammation and infection of the
1. Acute Lymphocytic Leukemia adenoids.
a. Primarily strikes children and young
adults Assessment
b. 80 - 85 % of childhood leukemia
c. The malignant cells involved is the ● Persistent or recurrent sore throat
lymphoblast ● Enlarged, bright red tonsils that may be covered
2. Acute Myeloid Leukemia with white exudate
a. Also known as - acute ● Difficulty in swallowing
nonlymphocytic leukemia ● Mouth breathing and an unpleasant mouth odor
● Fever
b. Cells involved as the granulocytes
● Cough
● Enlarged adenoids may cause nasal quality of
ASSESSMENT FINDINGS speech, mouth breathing, hearing difficulty,
snoring, and/or obstructive sleep apnea.
1. Anemia (weakness, pallor, dyspnea)
2. Bleeding (petechiae, bruise) Preoperative interventions
3. Infection (fever, chills, malaise)
4. Enlarged lymph nodes ● Assess for signs of active infection.
5. Enlarged spleen and liver (splenomegaly and ● Assess bleeding and clotting studies because
hepatomegaly) the throat is vascular.
6. Abdominal pain ● Prepare the child for a sore throat
postoperatively and inform the child that he or
7. Bone and joint pain she will need to drink liquids.
● Assess for any loose teeth to decrease the risk
of aspiration during surgery.
DIAGNOSIS
Goal of care: complete cure Interventions postoperatively
 ● Position the child prone or side-lying to facilitate 4. red eyes
drainage.
● Have suction equipment available, but do not 5. swollen lymph nodes
suction unless there is an airway obstruction.
● Monitor for signs of hemorrhage (frequent Interventions
swallowing may indicate hemorrhage); if
hemorrhage occurs, turn the child to the side and ● Monitor temperature frequently.
notify the physician. ● Assess heart sounds, rate, and rhythm.
● Discourage coughing or clearing the throat. ● Assess extremities for edema, redness, and
● Provide clear, cool, noncitrus and noncarbonated desquamation.
fluids. ● Examine eyes for conjunctivitis.
● Avoid milk products initially because they will ● Monitor mucous membranes for inflammation.
coat the throat. ● Monitor strict intake and output.
● Avoid red liquids, which simulate the appearance
of blood if the child vomits. MEDICATION
● Do not give the child any straws, forks, or sharp
objects that can be put into the mouth. ★ IVIG
● Administer acetaminophen (Tylenol) for sore ★ Aspirin
throat as prescribed. ★ steroids
● Instruct the parents to notify the physician if
bleeding, persistent earache, or fever occurs.
PARENT EDUCATION
● Instruct the parents to keep the child away from
crowds until healing has occurred.
● Follow-up care is essential to recovery.
● The signs and symptoms of Kawasaki disease
include the following:
KAWASAKI DISEASE
Ø Irritability may last up for up to 2
● Kawasaki disease is known as mucocutaneous months after the onset of symptoms.
lymph node syndrome and is an acute systemic
inflammatory illness. Ø Peeling of the hands and feet may
● The cause is unknown but may be associated occur.
with an infection from an organism or toxin.
● Cardiac involvement is the most serious Ø Pain in the joints may persist for
complication; aneurysms can develop. several weeks.
Assessment Ø Stiffness in the morning, after naps,
and in cold temperatures may occur.
Acute stage
● Record the temperature until child has been
● Fever afebrile for several days.
● Conjunctival hyperemia ● Notify the physician if the temperature is 101° F
● Red throat or higher.
● Swollen hands, rash, and enlargement of the ● Salicylates such as acetylsalicylic acid (aspirin)
cervical lymph nodes may be given.
● Signs of aspirin toxicity include tinnitus,
Subacute stage headache, vertigo, bruising; do not administer
aspirin or aspirin-containing products if child has
● Cracking lips and fissures been exposed to chickenpox or the flu.
● Desquamation of the skin on the tips of the ● S/sx of bleeding: epistaxis, hemoptysis,
fingers and toes hematemesis, hematuria, melena, and bruises
● Joint pain on body.
● Cardiac manifestations ● S/sx of cardiac complications chest pain or
● Thrombocytosis tightness (older children), cool and pale
extremities, abdominal pain, nausea and
Convalescent stage: Child appears normal but signs of vomiting, irritability, restlessness, and
inflammation may be present. uncontrollable crying.
● Child should avoid contact sports, if age
appropriate, if taking aspirin or anticoagulants.
DIAGNOSIS ● Avoid administration of MMR or varicella vaccine
to the child for 11 months post–intravenous
● fever x 3/5days immune globulin therapy, if appropriate.
● + 4/5 diagnostic criteria

1. erythema

2. rash on trunk

3. swelling of hands or feet

 COMMON HEALTH PROBLEMS IN SCHOOL AGE
CHILDREN
2. Soften skin and crust with burrow’s solution;
then removes crust slowly
PEDICULOSIS 3. Cover lesion to prevent spread of infection
4. Remove crust gently
5. Administer antibiotics as ordered
● Head lice
● Parasitic Infection 6. Health teachings (important: handwashing)
● Spread by close physical contact
● Occurs in school age, particularly with long hair
SCABIES (THE ITCH)
FINDINGS
● A contagious skin infestation caused by the
● White eggs firmly attached to base of hair shafts scabies mite: Sarcoptes scabiei
● Pruritus of scalp
● From bite of head lice ● Characterized by :

MANAGEMENT superficial burrows

● Special shampoos intense pruritus (itching) Papular rash

● Fine tooth comb

NURSING INTERVENTION
● Mites are small eight-legged parasites, they
are tiny (not visible with the naked eye), and
1. Institute skin isolation precautions burrow into the skin to produce intense
★ Head covering itching, which tends to be worse at night
★ Gloves ● Scabies attack at night
2. Use specific shampoo/comb
3. Provide health teachings on treatment and prevention
● Scabies may involve:
★ Check on other family members ➔ webs between the fingers,
★ Washing of bed linens ➔ wrists
★ No sharing of combs and hats ➔ Elbows
➔ knees,
➔ waist
IMPETIGO ➔ umbilicus,
➔ axillary folds,
➔ around the nipples,
● Superficial bacterial infection of the outer ➔ sides and backs of the feet,
layers of the skin ➔ genital area, and the buttocks.
● Etiology: Staphylococcus aureus/ Beta H.
streptococcus MANAGEMENT
● Incubation period – 2 to 5 days
● Period of communicability – outbreak of ● Medication (SCABICIDES) - Permethrin
lesion until it’s healed cream / Lindane lotion
● Mode of transmission direct contact ● Scabicides – meds to treat scabies
● Very contagious ● Lindane should not be used in children
younger than 2 years because of the risk of
ASSESSMENT FINDINGS neurotoxicity and seizures.
● Because it’s easily absorbed in the skin
● Well demarcated lesions
● Macules, vesicles (fluid), papule (pus) that Instruction:
rupture = moist erosio
● Once most area dries, scab is honey colored body is scrubbed with soap and water before
crus application
● Pruritus
leave on the skin for 8 – 14 hours
MANAGEMENT
then completely washed with warm water
● Topical antibiotic – bactroban
● Systemic antibiotic - penicillin or ● Stress importance of proper hygiene
erythromycin
INTERVENTIONS
NURSING MANAGEMENT
● When permethrin is used, the cream is
1. Implement skin isolation techniques massaged thoroughly and gently into all skin
surfaces from the head to the soles of the
Including child’s things
 feet; care should be taken to avoid contact antistreptolysin O (ASO) titer
with the eyes.
● Household members and contacts of the ECG - Prolonged PR interval
infected child need to be treated at the same
time. leukocytosis

Evidence of previous
RHEUMATIC FEVER (RF)
group A streptococcal infection

● An inflammatory disorder that may involve + Throat culture or rapid streptococcal antigen test
the connective tissue of heart, joints, lungs
and brain
● Is an autoimmune disease that occurs as a two of the major criteria, or one major criterion plus
reaction to a group A two minor criteria, are present along with evidence
beta-hemolyticstreptococcal infection of streptococcal infection.
● It is precipitated by streptococcal infection
which is undiagnosed and untreated
● Antigenic markers for streptococcal toxin Exceptions are chorea and indolent carditis each
closely resemble markers of the heart of which by itself can indicate rheumatic fever.
valves; this resemblance causes antibodies
made against the streptococcal to also
attacks the heart valve MEDICAL MANAGEMENT

ASSESSMENT FINDINGS 1. Drug therapy

a. Penicillin – used in acute phase
● Divided to major and minor symptoms
according to Jones criteria given as prophylactic until age 20 or for 5 years

5 major symptoms/criteria Erythromycin as substitute

1. Carditis - inflammation of the heart muscle b. Phenobarbital – reduce chorea

around the heart valves; aschoff’s nodules c. Digoxin, diuretics – CHF
2. Polyarthritis/Migratory Polyarthritis – a d. Salicylates – analgesics,
temporary migrating inflammation of the anti-inflammatory, antipyretic effect
large joints e. Steroids – anti-inflammatory effect
3. Chorea – Sydenham’s chorea; St. Vitus’
dance

A CNS disorder characterized by abrupt, 2. Bed rest – is essential during the active process
purposeless involuntary movement of rheumatic fever to reduce cardiac workload

4. Subcutaneous nodules – painless, firm - 1 week to 6 months

collections of collagen fibers over bones or
tendons
5. Erythema marginatum – transient, non SELECTED NURSING DIAGNOSIS
pruritic rash (resembles giraffe spots)
Acute pain related to inflammatory process
Deficient diversional activity related to
Minor symptoms/criteria prescribed bed rest
Activity intolerance related to pain and
Clinical findings fatigue
Risk for injury related to involuntary
Arthralgia movement
Risk for noncompliance with prophylactic
Fever drug therapy related to financial or emotional
burden of lifelong therapy
Laboratory findings Whenever the child is to have oral surgery,
including dental work, extra prophylactic
Erythrocyte sedimentation rate precaution should be taken, even in
adulthood
C-reactive protein
 ● splenomegaly, hepatomegaly,
lymphadenopathy
JUVENILE RHEUMATOID ARTHRITIS (JRA)

● Systemic, chronic disorder of connective ASSESSMENT FINDINGS

tissue resulting from an autoimmune
reaction ● Painful joints, warm and swollen
● Primarily involves joints ● Muscle weakness
● results in eventual joint destruction affected ● Affected area has limited motion - pain
by stress, climate ● Crippling deformity – due to irreversible
● genetic predisposition may increase the risk changes in joint cartilage due to
in some people inflammation
● More common in girls; peak age 1 to 3 years ● Fatigue, anorexia, malaise, weight loss
and 8 to 12 years

TYPES Diagnostic Tests

● X-ray – determine deformity

1. Monoarticular / pauciarticular ● CBC
● Erythrocyte sedimentation rate (ESR)
● involving 4 joints or less joints usually large Indicative if
joints affected, such as knee, ankles or ● C-reactive protein there are
elbow of one side of body (asymmetric) ● ANA inflammations
● generally mild signs of arthritis ● Rheumatoid Factor – diagnostic findings that
● mild fever can really identify that the patient has
● Other symptoms such as: rheumatoid arthritis

Iridocyclitis (eye inflammation)

MEDICAL MANAGEMENT
Uveitis (inflammation of the iris, ciliary body, choroid
mebrane) To relieve pain, restore function and maintain joint
mobility
Painless joint swelling with little redness 1. Drug Therapy

2. Polyarticular Aspirin – analgesic and anti-inflammatory effect

NSAIDS (nonsteroidal anti-inflammatory drugs)
● multiple joints affected (five or more) Gold compounds (Chrysotherapy)
● usually small joints of finger and hands are
affected Corticosteroids Methotrexate
● also possibly weight-bearing joints often
same joint on both sides of the body 2. Physical Therapy/exercise – to minimize
(symmetrical) joint deformity
● disability may be mild or severe with periods 3. Surgery – to remove severely damaged
of remission and exacerbations joints Total hip replacement
● low grade fever Knee replacement
● Other symptoms such as: 4. Heat application splinting – relieve pain
5. Gold Therapy - It is believed that gold
stiffness and minimal joint swelling – limited motion attaches itself to certain proteins (albumin).
Once absorbed into the cell, it is then
synovial fluids are affected which helps in range of purported to kill particular cells in order to
motion affect the inflammation and erosion of joints.
It does not necessarily act as a cure, but is
rheumatoid nodules rather believed to merely relieve symptoms
of joint disease.
3. Systemic Disease with Polyarthritis (Still’s
Disease) NURSING INTERVENTIONS

● any joints might be affected 1. Assess joints for pain, swelling, tenderness,
● begins with high fever associated with or limitation of motion
macular rash on chest, thigh 2. Promote maintenance of joint mobility
● Other symptoms included are: Anemia (passive ROM exercise)
● Anorexia weight loss 3. Change position frequently
 4. Promote comfort and relief of pain
Other Polydipsia Polydipsia
5. Ensure bed rest
symptoms Polyuria Polyuria
6. Provide heat treatments
Polyphagia Polyphagia
7. Provide cold treatments as ordered – acute
Fatigue Fatigue
8. Provide psychologic support and encourage
Blurred vision Blurred vision
to verbalize feelings
Glyocosuria Glyocosuria
pruritus pruritu

DIABETES MELLITUS (DM) therapy Insulin Diet

Diet Regular
Regular exercise
● Is a condition resulting from dysfunction of
exercise Hypoglycemic
the beta (insulin - secreting) cells of islet of
Fast care magnet
Langerhans in the pancreas
Skin and foot
● There is a lack pancreatic hormone –
care
INSULIN which is essential for carbohydrate
metabolism and is important to the
Period of 1-12 months Not
metabolism of fats and protein
remission after initial demonstrable
diagnosis,
“honeymoon
Hyperglycemia
period”
● Excessive accumulation of sugar in the
bloodstream
● Manifestation of diabetes mellitus DIABETIC KETOACIDOSIS (DKA)

2 MAJOR TYPES ● Is a potentially life-threatening complication

in patients with diabetes mellitus type I
1. DM Type I ● Ketones bodies, the acid end-product of fat
breakdown, begin to accumulate in the blood
formerly called Insulin Dependent Diabetes stream and spill into the urine
(IDDM) ● If ketones bodies are not excreted and
continue to break down fats, they can enter
Juvenile diabetes - common in children; affect 1 in the CNS.
1500 below 5 years and increases to 1 in every 350 ● Characterized by drowsiness, dry skin,
children by age 16 flushed cheeks, and cherry–red lips, acetone
due to destruction of beta cells in the Islets of breath with fruity smell and Kussmaul
breathing (abnormal increase in the depth
Langerhans (responsible for insulin release) insulin and rate of the respiratory movement)
is for life

2. DM Type II RISK FACTORS FOR TYPE 1 DIABETES

Formerly called non-insulin dependent (NIDM) ● Autoimmunity

occurs in adults / obese individual ● Inherited (or genetic) factors
● Environmental
may result from partial deficiency of insulin ● A virus or chemical that predisposes an
production and insulin resistance individual to DM
● Injuring the pancreatic cells

DIAGNOSIS
Assessment TYPE 1 TYPE 2
● Fasting blood sugar – 126 mg/dl or greater
Age of onset 5 – 7 yr / Increasingly ● Random blood sugar – 200 mg/dl or greater
puberty ● With CBG and HGT
● 2 hours oral glucose tolerance test (OGTT) –
Type of Onset abrupt gradual
200 mg/dl or greater
Weight Marked weight Assessment ● Done together with FBS. Baseline data is
changes loss with obesity FBS result. Right after FBS, patient drinks
glucose (8oz) then blood is checked 2 hrs
after drinking.
 ● Glycosylated hemoglobin – provide
information about what the child’s glucose 5. Monitor Intake and Output every shift, weigh
level have been during the preceding 3 to 4 daily
months 6. Provide emotional support
7. Observe for complications

MANAGEMENT FOR TYPE I DIABETES DKA if type I = CNS complications = check level of
consciousness
Goal: to keep your blood sugars as close to normal
as possible to prevent the complications of diabetes

1. Insulin Therapy

Dosage of insulin is adjusted according to blood

glucose level

A short acting and intermediate acting insulin is

usually given (70/30 insulin)

Adverse effect: insulin reaction (insulin shock or

hypoglycemia = cold-clammy, sweaty, drowsiness)

Glucose monitoring – self-monitoring

Rotate site to prevent lipodystrophy/lipohypertrophy

2. Meal planning

Calories should be made up of 50-60%

carbohydrates, 15 -20% protein, and no more 30%
of fats

Avoid simple sugar; serve complex carbohydrates

Make sure the child would not skip meals

Teach child about food plan so that he can

independently choose food selection

3. Exercise

Exercise decrease the blood glucose level because

carbohydrates are being burned for energy

4. Stress management
5. Blood glucose and urine ketone
monitoring

NURSING INTERVENTION

1. Provide special diet – diabetic diet

(individualized)
2. Monitor urine sugar or blood sugar levels
(HGT/CBG)

Urine sugar – if sa bahay lang, amigason ang

underwear or urine

3. Observe for signs of hypoglycemia

(cold-clammy) and hyperglycemia (warm)
4. Provide meticulous skin care Poor healing
time
Thoroughly inspect feet and keep them clean
 COMMON HEALTH PROBLEMS IN ADOLESCENT ASSESSMENT FINDINGS
● Uneven shoulders
● Uneven hips
OUTLINE ● Asymmetry of rib cage
I.Scoliosis ● Unequal length of bra strap
II.Bone Tumors ● Bump or rib hump on one side of the spine
III.Sexually Transmitted Infection
IV.Anorexia Nervosa
V.Bulimia Nervosa
VI.Obesity
VII.Substance Abuse
VIII.Suicide

SCOLIOSIS

● a lateral curvature of the spine

● five times more common in girls and has
peak incidence at 8 to 15yrs
● Majority (75%) – idiopathic has a familial
pattern (30% of children with scoliosis) but
not genetic Idiopathic – unknown cause
● associated with other neuromuscular
disorders

FORMS
1. Structural / Progressive form
-“S” curve of the spine
-usually idiopathic
-does not disappear with position changes
-needs more aggressive treatment

2. Functional/ Postural/Non structural

DIAGNOSIS
-“C” curve of the spine
-cause by poor posture, muscle spasm due to ● Forward bend test/ Adam’s bend test
trauma, or unequal length of legs ○
a test used most often in schools and
-disappears when child lies down doctor's
-can be treated with posture exercise ○ offices to screen for scoliosis
-the earlier the management, the better ○ Scoliometer – a commercial device used to
○ document the extent of spinal curve
○ Cobb angle – standard method for
assessing the
○ curvature qualitatively
● Radiograph (X-ray)
○ assess the angle of the curve and determine
○ extent of deformity
Using a Scoliometer
1. Ask the child to slowly bend forward until the
shoulders are level with the hips
2. Adjust the bending position height so the
deformity of the spine is most pronounced.

* A scoliosis brace us usually worn under clothing and is one

method to try to improve the exaggerated curvature of the spine
as seen in scoliosis

3. Gently lay the scoliometer across the

deformity at right angles to the body, with the
marking centered over the curve.

General Rule: refer to a physician with a

scoliometer reading of seven degrees or greater.
The greater the degree of the curvature, the greater
the extent of the severity.

MANAGEMENT

● Depends on the maturity of the skeleton and

on the degree of curvature
● Spinal curve of less 20 degree no therapy
NURSING INTERVENTION
observation until 18 years of age
● Spinal curve greater than 20 degree 1. Provide care for child with brace
conservative, nonsurgical approach a. Teach the child to wear it
○ braces constantly, except when bathing
○ traction b. wear over a t-shirt to protect the skin
○ Plaster jacket cast c. report if there is rubbing
● Spinal curve of more than 40 degree d. encourage exercise as prescribed
○ Surgery 2. Provide cast or traction care
○ Spinal fusion with insertion of a. Frequent cleansing on the pin sites
○ Harrington rod ● Dress with gauze covered on betadine
● Electrical stimulation to prevent bacterial infection
○ Use as an alternative for braces b. Provide diversional activities
○ Electrodes are applied to the skin or 3. Provide preoperative and post-operative
surgically implanted nursing care
○ Electrical stimulation is usually employed a. Deep breathing exercise
at night, during sleeping hours ● To prevent complications
○ To stimulate muscle to contract to (ex.pneumonia)
straighten the spine b. Use of incentive spirometry
● Stretching exercises of the spine for ● Encourages lung expansion to
non-structural changes. Prevent complications
c. Log roll; do not raise the head of the bed
4. Stress correct body mechanics
Milwaukee brace a. Promoting mobility, positive body image
- 23 hrs/day for 3 yrs to And compliance with therapy
correct curvature
b. Preventing injury
c. Preventing skin irritation

BONE TUMORS

● Sarcoma – tumors arising from connective

tissue, such bones and cartilage, muscle,
blood vessels or lymphoid tissue
○ common neoplasm in adolescent
 ○ Arise during adolescent because of ○ a certain cause that can be identified
rapid bone growth that is associated with a certain
○ Two most frequently occurring disease condition
types of bone cancer: ● because of the presence of sarcoma,
■ a. Osteogenic Sarcoma individuals are predisposed to fractures
■ b. Ewing’s Sarcoma
DIAGNOSIS
a. Bone Biopsy
● SOP if tumor is suspected
● Determine whether tumor is benign or
malignant
● Malignancy predisposed an individual to
cancer
b. Ct scan
c. Bone scan

A. OSTEOGENIC SARCOMA

● A malignant tumor of long bone involving

rapidly growing bone tissue (mesenchymal
matrix forming cells)
● characterized by formation of osteoid
(immature bones) MANAGEMENT
● High incidence in children expose to radiation
and with retinoblastoma 1. Surgery
● Lungs – common site of metastasis a. Limb salvage procedures
b. Bone or skin grafts
Common sites of occurrence c. Amputation
a. distal femur – 50% (most common form) d. Reconstructions
b. Proximal tibia – 20% ● Steels
c. Proximal humerus – 10 to 15% ● Artificial leg
e. Resections of metastases
2. Radiation therapy
3. Chemotherapy
● Group of drugs used in combination
to treat a certain condition Is not
always associated with cancer
4. Rehabilitation
a. physical and occupational therapy
b. psychosocial adapting
c. prosthesis fitting and training
● done after surgical site has healed

NURSING MANAGEMENT
a. Provide routine preoperative care
● NPO, IVF, VS
Additional Notes:
✓ Malignancy – rapid growth in a bone tissue
● Client and family should undergo counseling
before and after amputation
b. Offer support or encouragement and accept
client’s response of anger and grief
ASSESSMENT c. Discuss to patient and family
● rehabilitation program (pre-op) and use of
a. Pain prosthesis
b. Swelling, redness ● crutch walking
c. Tender mass, warm to touch ● phantom limb sensation as normal
d. Limitation of movement recurrence
○ Associated with the swelling and pain ○ When you “feel” the amputated body
e. Pathologic fracture part.
○ a break in a bone that is caused by ○ It is often painful normal occurrence
an underlying disease especially after amputation
 ○ common struggle after amputation NURSING INTERVENTION
d. Prevent hip and knee contractures prone position
several times a day (unless otherwise ordered) ● Caution adolescent to continue to be careful
e. Provide stump care and avoid activities that may cause added
● Prone to infection stress to affected limb such as football and
weight lifting
○ Can cause pathologic fractures since
bones become fragile

SEXUALLY TRANSMITTED INFECTION

● are those disease spread through sexual
contact(depends on representation of
findings)
B. EWING’S SARCOMA
Additional Notes:
● Malignant (cancerous) tumor arising most ✓ CONTACT TRACING – identifying the source
often in the bone marrow of the diaphysis of infection
✓ ALL SEXUAL CONTACTS MUST BE TREATED!
area (midshaft) of long bones
● The diaphyses of the femur are the most
common sites, followed by the tibia and the Signs & symptoms
humerus ● often asymptomatic in females (carrier)
● Lungs is the most frequent site of ● purulent yellow-green vaginal discharge
metastasis (+
● gonorrhea) (advance stage)
● Treatment:
a. Penicillin (most common)
b. Erythromycin
c. Ceftriaxone
d. Doxycycline

Additional Notes:
✓ TERRAMYCIN – prophylaxis ointment to prevent
ophthalmia neonatorum caused by STI

B. CHLAMYDIA
CLINICAL FINDINGS
● Chlamydia trachomatis
a. Pain and swelling on affected part
● Most common STI
b. Palpable mass (tumor)
● May causes ophthalmia neonatorum, sterility in
c. Tender and warm to touch (swelling)
female or male, tubal pregnancy (ectopic
d. 15- 35% of clients have metastasis (invade other
pregnancy)
parts of body) at time of diagnosis
● Ewing’s sarcoma has poor
Signs & symptoms
prognosis compared to
● watery, gray-white vaginal discharge
osteosarcoma.
● vulvar itching

MANAGEMENT Treatment
● doxycycline
1. High doses of radiation therapy ● tetracycline
● Treatment should be aggressive ● azithromycin (most common)
because of the poor prognosis
2. Chemotherapy
3. Surgery C. SYPHILIS
● Crosses placenta after 16 week of pregnancy
DIAGNOSIS (dangerousfor oogenesis)

● X-ray Treatment: penicillin or erythromycin

● Bone scan
● Biopsy Manifestation
● Bone marrow aspiration ● Primary cardinal sign – CHANCRE - a hard
red painless lesion @ the point of infection
site
 ○ disappear without treatment in 4-6 ● Bathing with diluted sodium bicarbonate
weeks solution to reduce pruritus
● Secondary - rash, malaise, alopecia
● Tertiary - affect any organ system (if left
untreated) –cardiovascular, neurovascular
system

Additional Notes:
✓ SYPHILIS is dangerous when pregnant especially at
16 weeks due to Oogenesis (formation of organs)
because the bacteria can cross to the placenta that
can affect the growth of the baby
F. GENITAL WARTS

● Genital warts is seen in the perineal area or

vulva
● Genital warts has the same presentations as
the wartsseen throughout the body
● If assigned in the DR, be cautious when
shaving becausethe warts can be hidden by
the pubic hair

D. TRICHOMONIASIS

● Trichomonas vaginalis - a single-cell

protozoan

Sign & symptoms: thin, irritating, frothy gray -

green discharge, strong odor, itching to genitalia

Treatment
● Metronidazole ANOREXIA NERVOSA
● douche with weak vinegar solution to reduce
pruritus ● A disorder characterized by refusal to maintain
a minimally normal body weight because of
a disturbance in perception of the size or
appearance of the body
● An eating disorder characterized by extremely
low bodyweight, body image distortion and an
obsessive fear of gaining weight.
● Eating disorder associated with mental
disturbance
○ Needs psychiatric evaluation if
○ client is suspected with anorexia nervosa

May be manifested as severe weight restriction

controlled by:
● limiting food intake
● excessive exercise
E. CANDIDIASIS ● binge eating/purging
● Candida Albicans – fungus
● Caused by a yeast transmitted from GI tract to
vagina CLINICAL FINDINGS AND DIAGNOSIS
Sign & symptoms – thick , white cheese-like The American Psychiatric Association Criteria
vaginaldischarges, vulvar reddening and pruritus ● Diagnosis
○ body mass index – less than 85% of
Treatment expected weight
● topical application or vaginal suppositories of ○ intense fear of getting fat or gaining
antifungal drug such as: clotrimazole , weight even though underweight
nystatin, miconazole, diflucan, gentian violet ○ severely distorted body image
 ○ refusal to acknowledge seriousness ○ impulsive activities
of weight loss
○ amenorrhea American Psychiatric Association the criteria for
bulimia are:
● Recurrent episodes of binge eating
MANIFESTATION
● A feeling of lack of control over behavior
● Almost skeleton-like appearance during binges
● Sexually immature ● Self-induced purging; use of laxatives,
○ Associated with amenorrhea diuretics, enemas
● Dry skin, brittle nails ● Average of at least two binge-eating episodes
● Presence of lanugo a week during 3 months period
● Constipation, hypothermia, bradycardia, low ○ History taking
blood ● Obsessiveness regarding body weight and
● Pressure shape
○ Hypothermia – lack of subcutaneous fats
● Anemia MANAGEMENT
● Depression, social withdrawal and poor
individual coping ● Pharmacology – antidepressant
● Psychotherapy

NURSING INTERVENTION
1. Monitor vital signs
2. Monitor intake and output
i. Fluid and electrolyte imbalance
3. Record food intake
4. Monitor weight
5. Encourage client to express feelings
6. Help client to set realistic goal for self
MANAGEMENT
7. Help client identify interest and positive aspect
1. Nutritional therapy of self
a. Total parenteral nutrition - Intravenous
b. Enteral tube feeding - NGF = OF
2. Behavior modification - Psychiatrist) Additional Notes:
3. Medication – antidepressant ✓ Difference between the two eating disorders is their
4. Counseling perception
Anorexia nervosa – payat pero feeling niya
a. Individual therapy taba
b. Group therapy -Prefers not to eat
c. Family therapy Bulimia – either no perception but has ideal
body shape/weight
-Cannot control food intake
BULIMIA NERVOSA
OBE
● Bulimia – refers to recurrent and episodes binge OBESITY
eating and purging
● accompanied by an awareness that eating ● An excessive accumulation of fat that
pattern is abnormal but not being able to stop increases body weight by 20% or more (IBW)
● Bulimic person is of normal of weight or slightly ○ Obesity is now among the most widespread
overweight or underweight medical problems affecting children and
● may abuse purgative, laxatives and diuretic to adolescents living in the United States and
aid in weight control other developed countries.
○ Obesity increases the child's risk of of
serious health problems such as heart
CLINICAL MANIFESTATION AND DIAGNOSIS
disease, DM type 2 and stroke
● Dental caries and erosion ○ It can also create emotional and social
● Throat irritation problems
● Electrolytes imbalance – hypokalemia ○ Often feels isolated from the peer group
○ Associated with the use of laxatives (insecurities)
○ And Diuretics ○ Embarrassed to participate in sports
● Behavior problem ○ Adolescents may have difficulty
○ drug abuse achieving a sense of identity if they are
○ alcoholism always excluded from group and if they
○ stealing don’t like their image in the mirror
 ○ BMI – most accurate method of ● mature due to peer pressure - a form of
assessment rebellion
■ Indicates relationship between height ● Children at greatest risk
and weight 1. have family in which alcohol or drug
abuse is present
Causes 2. suffer from abuse, neglect (feels
● Many different factors contribute to this euphoria)
imbalance 3. have behavior problems –
● between calorie intake and consumption aggressiveness and excessively
● Genetic factors- Obesity tends to run in rebellious
families 4. slow learners
● Dietary habits 5. have problems with depression and
○ fast food, processed snack foods, low-self esteem
○ and sugary drinks
○ use food as means of satisfying emotional
STAGES OF SUBSTANCE ABUSE
needs
○ indulging in late – night eating
● Physical inactivity- The popularity of television, Stage 0: Pre abuse or Curiosity stage
● computers, and video games results into an ● Describes the adolescent with an increased
increasingly sedentary lifestyle potential for substance abuse
● Need for peer acceptance; anger and
boredom

Stage 1: Experimental Stage

● Learning the Euphoria
● Adolescents have already made a decision
to “try” drugs and begun learning the drug
induced mood swing or euphoria.
● Drug use is confined to social situations
● There are few behavioral changes other
than “lying”
MANAGEMENT
Stage 2: Early Regular Use
● Lifestyle modification, ● Seeking the Euphoria
● Physical activity, ● The adolescent now actively seeks the
● Nutrition education drug-induced mood swing
● Use drugs to seeks relief from everyday
Ways to manage obesity in children and stress
adolescentsinclude: ● Changes in dress, decline in personal
1. Start a weight-management program hygiene, deterioration in school
2. Change eating habitseat slowly, develop a ● Performance, loss of previous interest in
routine extracurricular activities
3. Plan meals and make better food selections ● Adolescent exhibits more mood swings,
4. Increase physical activity and have a more engages in regular lying
active lifestyle
5. Know what your child eats at school Stage 3: Late Regular Use
6. Do not use food as a reward ● Preoccupation with the Euphoria
7. Limit snacks ● Dependent on substance abuse
8. Attend a support group ● Dependence – compulsive need to use a
a. e.g., Overeaters Anonymous substance for its satisfying effect
SUBSTANCE ABUSE ● Deterioration of behavior such as fighting,
SUBSTANCE ABUSE lying, stealing, prostitution, often depressed,
● is the misuse of an addictive substance that suicidal ideation (hallucinations),
changes the user’s mental state self-destructive, and risk-taking behavior
● refers to the use of chemicals to improve a
mental stateor induce euphoria Stage 4: End stage or “Burn Out”
● Commonly abuse substance – alcohol, ● Adolescents need drugs just to feel normal
tobacco and illicit drugs and to avoid the profound and nearly
● Cause/Reasons: a means of relieving the constant dysphoria.
tension and pressure of their lives ● Depression, guilt, shame, and other remorse
● Adolescent: a desire to feel more confident may be overwhelming, and suicidal ideation
and becomes more common
 ● Paranoia, angry outbursts, and aggression 7. Taking excessive risks
are common 8. Increased drug use
E.g. sleeping pills
9. Loss of interest in usual activities
COMMON ASSESSMENT FINDINGS
1. Failure to complete assignments in school
2. Demonstration of poor reasoning ability TIPS FOR PARENTS
3. Decreased school attendance
4. Frequent mood swings
5. Deteriorating physical appearance 1. Know the warning signs!
6. Recent change in peer group 2. Do not be afraid to talk to your child- TheN
7. Expressed negative perceptions of parents message is, “Suicide is not an option, help is
available."
3. Suicide-proof your home- Make the knives, pills
and firearms inaccessible.
Additional Notes:
✓ Important: Therapeutic communication and non 4. Utilize school and community resources- school
judgmental psychologist, crisis intervention personnel
5. Take immediate action. If your child indicates
contemplating suicide
TREATMENT 6. Do not leave your child alone
7. Seek professional
1. Prevention is the most effective and least 8. Listen to your child’s friends. They may give
expensive treatment for substance abuse hints.
2. Medication, - nicotine patches (cigarette) and 9. Be open. Ask questions.
methadone
3. Rehabilitation, counseling, social support,
family support
THREE STEPS TEENS CAN TAKE
SUICIDE
1. Take your friend's actions seriously
● Is a deliberate self- injury with the intent to end 2. Encourage your friend to seek professional help,
one’s life. accompany if necessary
● Successful suicide occurs more frequently in 3. Talk to an adult you trust. Don't be alone in
male than females helping your friend
● third cause of cause of death between 15 – 19
years of age
● Suicide as viable solution to life problems
ACCIDENTS AND INJURY
RISK FACTORS
Types
1. Previous suicide attempts 1. Concussion - severe blow to the head ,
-Denotes suicide jostles, brain causing to strike and result s in
2. Close family member who has committed suicide. temporary neural dysfunction
3. Past psychiatric hospitalization
-Mentally ill, hallucinations
Very minor
4. Recent losses: death of a relative, a family
divorce or a breakup with a girlfriend
5. Social isolation s/s-headache, nausea, transient loss of
6. Drug or alcohol abuse consciousness- temporary, nausea and vomiting,
7. Exposure to violence in the home or the social dizziness and irritability
environment

WARNING SIGNS FOR SUICIDE

1. Suicidal talk
2. Preoccupation with death and dying
3. Signs of depression
4. Behavioral changes
5. Giving away special possessions and making
arrangements to take care of unfinished business
6. Difficulty with appetite and sleep
 NUrsing intervention
1. Maintain a patent airway and adequate
If left untreated - you would loss him
ventilation
- *the lower the GCS, the more the
Citicoline
patient has arrested breathing; very
low GCS = intubate
2. Contussion - results from more severe
2. Monitor VS and NVS
blow that bruises the brain and disrupts
3. Observe for CSF leakage
neural function
4. Prevent complications of immobility
5. Prepare a client for surgery if indicated
S/S: Neurologic deficits depend on site and extent
6. Provide psychological support to client and
of damage LOC, sensory deficits, hemiplegia
family
(paralyzed half of body)
7. Client teachings: rehabilitation
3. Hemorrhage

Diagnostic Test
a. Epidural - blood between dura mater and skull
1. Skull x ray
laceration of middle meningeal artery during skull
2. CT scan
fracture blood accumulates rapidly

S/s: brief LOC, severe headache, vomiting possible

seizure INTRACRANIAL SURGERY

b. Subdural- blood in the dura and arachnoid Intracranial Surgery

venous bleeding that form slowly (acute, chronic) Types
S/S: alteration in LOC, headache 1. Craniotomy - surgical opening of skull to
gain access to intracranial structures
c. Subarachnoid - bleeding in subarachnoid space removal of tumor, evacuate blood clots,
control hemorrhage relive increase ICP
D. Intracerebral - accumulation of blood in the
cerebrum 2. Craniectomy- excision of a portion of a skull
S/s: headache, dec LOC, pupillary dilation use for decompression.

4. Fractures
Types of fractures 3. Cranioplasty - repair of cranial defect with a
- Linear metal or plastic plate
- Depressed
- Comminutes PREOPERATIVE NURSING INTERVENTION
- Compound (combination of both)
S/s: leakage of CSF from nose or ear 1. Routine pre op care
CSF - very clear and watery ang consistency 2. Provide emotional support
3. Shampoo the scalp and check for signs of
infection
4. Shave hair
 5. Evaluate and record baseline vital signs and ● ● Penetrating wounds
neuro checks ● ● Spinal shock – occurs immediately
6. Avoid enema - ○ Insult to the CNS
7. Give pre op steroid as ordered - to ○ Several days to 3 months
decrease brain swelling ○ Absence of reflexes below the level
of the lesion
POST OPERATIVE NURSING INTERVENTION Management
1. Maintain a patent airway - - immobilization and maintenance of normal
2. Check VS and NVS spinal alignment to promote fracture healing
3. Monitor fluid and electrolytes - because we
are drawing fluids 1. Horizontal turning frames - Stryker frame
4. Assess dressing frequently and report for 2. Skeletal traction
any abnormalities a. Cervical tongs
5. Administer medications as ordered b. Halo traction
6. Apply ice to swollen eyelids, lubricate lids 3. Surgery
with petroleum jelly a. Decompression b.
7. Refer for rehabilitation b. Laminectomy
c. Spinal fusion

SPINAL CORD INJURY Nursing intervention - emergency care

1. Assess ABC
2. Quick head to toe assessment
- common in males 3. Immobilize clien
- Ages 15 to 25
- Causes: motor, vehicle, diving in shallow
water, iIndustrial accidents, sports injuries. Acute care (AQI)
- Non traumatic - tumors, spina bifida, A- airway
aneurysms (ruptured of blood vessel) Q - Quick assessment
I - immobilized client
Classification 1. Maintain optimum respiratory function
2. 2. Maintain optimum cardiovascular function
1. Extent of Injury 3. . Maintain fluid and electrolyte balance and
● May affect of vertebral column: nutrition
fracture, dislocation 4. 4. Maintain immobilization and spinal
● anterior/posterior ligaments- alignment always
compression of spinal cord 5. 5. Prevent complication of immobility
● Spinal cord and its roots 6. Maintain urinary and bowel elimination
S/S: 7. Monitor temp control
● Complete cord transection – loss of all 8. Observe for and prevent infection
voluntary movements and sensation below 9. Observe for and prevent stress ulcer
the level of injury
● Incomplete – will depend on damaged
neurological tracts

2. Level of injury
a. Cervical
- C1-CB (quadriplegia)
- Paralysis of all four
extremities
- Respiratory paralysis- C6

3. Mechanisms of injury
● Hyperflexion
● Hyperextension
● Axial loading – diving accidents