NURS 55: CARE OF MOTHER, CHILD, FAMILY AND POPULATION

GROUPS AT-RISK OR WITH PROBLEMS

This course deals with the concept of disturbances & pre-existing health problems
of pregnant women and the pathologic changes during intrapartum and post
partum periods. This course further deals with the common problems occurring
during infancy to adolescence stage.

Course Credit: 5 units lecture, 6 units RLE [1 unit skills lab/5 units clinicals]

MOTHER
A. High-Risk Prenatal Client
a. Identifying Clients at Risk
1. Assessment of risk factors

Prenatal History

■ Estimated date of delivery

■ Current gestational age
■ Complications in pregnancy
■ Results of laboratory tests and ultrasounds
■ Medications used in pregnancy
■ Presence of vaginal discharge or bleeding
■ Amniotic fluid status
■ Presence of fetal movement
■ Onset and pattern of contractions

Obstetrical History
Type of births
■ Vaginal
■ Instrumentation
■ Episiotomy
■ Length of labor
■ Cesarean
■ Reason for cesarean
■ Document type of incision
• Low-transverse
• Classical
■ Complications of birth
■ Neonatal outcomes

Descriptive term Definition

Gravida (G) Number of pregnancies
Term (T) Number of deliveries after 37 weeks
Preterm (P) Number of deliveries after 20 weeks but before 38

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 weeks
Abortion (A) Number of deliveries before 20 weeks, either
spontaneous or induced
Living (L) Number of living children

Documentation 1: three children at home. She reports that her son was born on his due date, but her
daughters were both born a month early. She states that she lost a baby in her second month.

G: 5 (currently pregnant, 3 children at home, one abortion)

T: 1 (her son was born on his due date)
P: 2 (her daughters were each born a month early)
A: 1 (she lost a pregnancy at approximately 8 weeks)
L: 3 (reports three children at home)
Document as G5-1213

Documentation Example 2: The same prenatal client may also be described as G5 (5 pregnancies)
P3 (number of live births); pregnancies ended before 20 weeks are not counted as “P” in this method.

Medical History
Chronic health problems
■ Current medications
■ Time and description of last oral intake
■ Allergies to food/medicine'

Surgical History
■ Complications with anesthesia
■ Date/reason for surgery

Sexual history
■ Number of sexual partners
■ Sexually transmitted infections
■ Sexual abuse
■ Methods of contraception
■ Condom use

Social history
■ Use of recreational drugs
■ Smoking
■ Domestic abuse
■ Educational level/ability to read
■ Economic status
■ Type of health insurance
■ Need for community referrals
• Transportation
• Nutrition
• Medications

Physical Examination
■ Assess maternal vital signs

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■ Collect urine specimen for protein and glucose
■ Assess for presence of edema
■ Assess deep tendon reflexes
■ Perform Leopold’s maneuver to determine fetal position
■ Assess fetal heart rate (FHR)
■ Measure fundal height
■ Determine the frequency, duration, and intensity of contractions
■ Determine the stage and phase of labor
■ Assess cervical changes
■ Dilation (0 to 10 cm)
■ Effacement (0–100%)
■ Station (Level of presenting fetal part in relation to the ischial
spines of the maternal pelvis

■ Note presence, color, and amount of bloody show

■ Check status of amniotic membranes
■ Intact
■ Bulging
■ Ruptured (note color, amount, and odor)

2. Screening procedures

Cervical screen

 According to the guidelines of the American College of Obstetrician and

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

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ACOG Guidelines Annually
ACS Annually with conventional Pap smear
every 2 years with liquid based cytology

Women 30 years of age and older, with three consecutive negative cervical screens, are
recommended to have repeat exams every 2–3 years

Sexually Transmitted Infections

Abstinence from sexual activity (both oral and genital) is the only 100% effective
method of STI prevention
Consistent and proper use of condoms during sexual intercourse will decrease the
incidence of STIs
STIs transmitted via skin contact (human papillomavirus [HPV], herpes simplex virus
[HSV]) may still be transmitted with use of latex condoms
Sexual partners should be tested and treated when an STI is identified; sexual activity
should be avoided until treatment regimen completed
Patients diagnosed with a viral STIs should consult their health-care provider for long-
term management
Reportable STIs must be forwarded to the local health department along with treatment
rendered
Encourage immunization against hepatitis B
Visit CDC Web site www.cdc.gov for latest treatment guidelines for STIs

Infection Symptoms (may be Detection

asymptomatic)
Gonorrhea Yellow-green vaginal discharge Endocervical culture
dyspareunia urine test
abdominal pain
dysuria
Chlamydia Mucopurulent discharge Endocervical culture
post coital bleeding urine test
dyspareunia
abdominal pain
dyuria
Trichomoniasis Frothy malodorous vaginal Saline wet amount of vaginal
discharge discharge viewed under
dyspareunia microscopy
vaginal itching/ irritation
dysuria
Hepatitis Fatigue Serological testing
dark urine
clay-colored stool
jaundice/ abdominal pain
Human Papilloma Virus (HPV) Many subtypes exist, some Serological testing
associated with cervical

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

TORCH test series

T Oxoplasmosis (protozoa) Avoid eating uncooked meat and

handling cat litter box
O Thers: syphilis, varicella/ shingles, hepatitis B, hepatitis A, Rx: Zoster Immune Globulin,
AIDS Penicillin
R Ubella Effect: if contracted early, slows
down cell division during
organogenesis causing
congenital defects newborn can
carry and transmit the virus
about 12-24 months after birth
C Ytomegalovirus DNA virus
H Erpes type 2

Group of maternal systemic infections that can cross the placenta or by ascending
infection (after rupture of membranes) to the fetus

Infection early in pregnancy may produce fetal deformities, whereas late infections may
result in active systemic disease and/ or CNS involvement causing severe neurological
impairment or death of newborn

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Breast Exam

■ Monthly breast self-exam, starting at age 20, instructed to woman as an optional tool for
identifying and reporting breast changes
■ Clinical breast exam at least every 3 years (age 20–40) during a physical exam by a health
professional; yearly after age 40
■ Annual mammogram starting at age 40

Instructions for Breast Self Exam (BSE)

Step 1: Inspection
1. Visually inspect the breasts, looking for dimpling, lumps, skin irregularities, symmetry
2. Visually inspect in several positions; may accentuate an abnormality
◆ Hands at the side ◆ Hands above the head
◆ Hands pressed onto hips ◆ Leaning over

Step 2: Palpation
1. Feel the breast tissue and lymph node chain for lumps or thickening by using three
finger pads while exerting light, medium, and deep pressure in a systematic
fashion

2. Begin by lying down on a flat surface with arm raised and a folded towel under the back of the
breast being examined
3. After examining breast tissue, bring arm toward body and feel the axilla and the skin above as well
as below the collar bone
4. Repeat technique on the other side
5. Report lumps, thickening, nipple discharge or any suspicious findings to health-care provider

3. Diagnostic tests and laboratory exams

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Diagnostic Testing during Early Pregnancy

Diagnostic test Nursing consideration

Ultrasound Position to avoid supine hypotension; folded towel
Performed throughout pregnancy under right hip if supine

Clinical Application:

- confirm and date pregnancy

- verify pregnancy location
- detect fetal cardiac activity
- measure fetal growth
- detect fetal anomalies
- measure amniotic fluid index
- determine fetal position
- determine placental position
- measure cervical length
- adjunct to invasive procedures
Chorionic villi sampling (CVS) Review blood type, Rh and antibody status
Performed at 10 -12 weeks Administer Rh (D) immune globulin if indicated
Monitor patient for postprocedure cramping or
Clinical Application: bleeding
■ Chromosomal analysis Monitor fetal heartbeat
Amniocentesis
Performed throughout pregnancy
Clinical Applications:
■ Chromosomal analysis is
desired
■ Measure AFP
■ Measure bilirubin level
■ Determine lung maturity
■ Lecithin/Sphingomyelin
Ratio (L/S Ratio)
■ Phosphatidylglycerol (PG)
■ L/S Ratio of 2:1 and positive
PG indicative of fetal lung maturity
Maternal Serum Triple Screen (tests maternal Results adjusted according to documented
serum for AFP, hCG, and estriol) gestational age, maternal age, race, and weight,
Performed at 15–18 weeks presence of diabetes/multiple gestation; the nurse
must accurately document these variables on the
Clinical Applications: laboratory requisition
■ Serum screen for neural tube
defects/ Down syndrome

Interpretation of Results

Defect
Risk for open neural tube
Risk for Down Syndrome

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AFP
Increased
Decreased
HCG
WNL
Increased
Estriol
WNL
Decreased

Diagnostic Test for First Prenatal Visits

Common Laboratory Tests Expected Finding in Pregnancy

HIV * check state laws regarding HIV testing in Negative
pregnancy
Blood Type A, B, AB, O
Rh factor negative/positive
Antibody screen Negative
Hemoglobin > 11.5 mg/dl
Hematocrit > 33%
Platelets 150,000-400, 000 cmm
WBC 5,000 -12,000 cmm
RPR Negative
Hepa B antigen Negative

Rubella titer 1:8 immune

Hemoglobin electrophoresis AA, unaffected
Chlamydia culture Negative
Gonorrhea culture Negative
Pap smear Normal cytology

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

Diagnostic tests Nursing Consideration

1-hour glucose screen Administer 50 g glucose load

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Performed at 24–28 weeks Patient should not eat, drink,
Clinical Application or smoke during the test
Detection of gestational Serum sample drawn in
diabetes 1 hour
EXPECTED RESULT
140 mg/dL
Group B vaginal culture Explain test to patient
Performed between Collect vaginal/rectal
35–37 weeks specimen
Clinical Application EXPECTED RESULT
Positive culture treated Negative
with antibiotics in labor
to prevent newborn
transmission
Fetal fibronectin (fFN) NO intercourse 24 hours
Performed between 22 prior to exam
and 35 weeks in women Cervical/posterior fornix
at high risk for preterm specimen
labor EXPECTED RESULT
Clinical Application Negative
Negative predictive value
for preterm labor
Antibody screen Administer Rh (D antigen)
Performed at 28 weeks in immune globulin at 28
Rh negative women weeks to prevent antibody
Clinical Application formation if Rh negative
Detects presence of positive and antibody screen
antibodies in serum of Rh negative
negative women EXPECTED RESULT
Negative

Diagnostic Test during Postpartum

■ Examine postpartum laboratory findings and compare to

prenatal levels (usually drawn at 24 hours postpartum)
■ Hemoglobin/hematocrit
■ White blood cell count
■ Platelet count
■ If mother is RH negative check Rh status of infant

Mother Infant Rho (D) immune globulin (300 micrograms)

Negative negative No treatment needed
Negative Positive Administer within 72 hours of birth

b. Pre-gestational conditions such as rheumatic heart disease, diabetes mellitus, substance

abuse, HIV/AIDS, Rh Sensitization, anemia

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HEART DISEASE
Classification:
Class I: no physical limitation
Class II: slight limitation of physical activity
Class III: ordinary activity cause fatigue, palpitation, dyspnea or angina; less than ordinary activity
causes fatigue
Class IV: unable to carry on any activity without experiencing discomfort

Prognosis
Class I & II- normal pregnancy & delivery
Class III & IV- poor candidates

rheumatic heart disease – condition in which heart valves are damage by rheumatic fever-->
obstruction, abnormal opening--> incomplete emptying

Signs and Symptoms:

Heart murmur due to increased cardiac volume
Cardiac output decreased--> nutritional and oxygen requirement not met
Incomplete emptying of the left side of the heart--> Pulmonary edema and hypertension (moist cough
in gravidocardiacs--> danger sign)

congestion of liver and other organs due to inadequate venous return--> increased venous pressure
--> fluid escapes through the walls of engorged arteries and cause edema and ascites CHF is a high
probability due to increased CO during pregnancy--> dyspnea, exhaustion, edema, pulse irregularities,
chest pain on exertion and cyanotic nailbeds are obvious

Management (depends on cardiac functional capacity)

a. bed rest- especially after 30th week of gestation
b. diet- gain enough (consider effect on cardiac workload)
c. medications: digitalis, iron preparations
d. avoid lithotomy position to avoid increase in venous return, place in semi- sitting positioning
e. not allowed to bear down; birth is via low forceps or CS
f. anesthetic choice- caudal anesthesia
g. ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral contraceptives
h. contraindicated--> can cause fluid retention and promote thromboembolism
I. most critical period: immediate postpartum period when 30-50% increased blood volume
j. is reabsorbed back in 5-10 minutes and the weak heart needs to adjust

DIABETES MELLITUS

o cause by absent & lack of Insulin

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

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 o Maternal Effects :
o hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus
yung glucose ng nanay.
o Hyperglycemia during the 2nd & 3rd trimester
 HPL effect Mgt : give insulin. OHA are teratogenic.
 1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum – drop suddenly
 Frequent infections eg. Moniliasis
 Polyhydramnios
 Dystocia
o Fetal Effects :
o hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd
trimester thru facilitated diffusion
o Macrosomia/LGA .4000gms
o IUGR due to prolonged DM
o Preterm birth promote still birth
o Newborn Effects :
o Hyperinsulinism and Hypoglycemia
 40mg/dl
 Normal : 45-55mg/dl
 Borderline : 40mg/dl
 Sx : ↑ pitched shrill cry, tremors, jitteriness
 Dx test : heel stick test to check glucose levels
o Hypocalcemia
 < 7mg/dl
 Calcemic tetany
 Tx : Ca gluconate

SUBSTANCE ABUSE
Definition
 substance abuse that leads to:
 loss of control of substance abuse
 monopolization of time by substance abuse
 individual spends his time obtaining or using drugs, recovering from drug use and discussing
drugs
 presence of adverse medical, social or emotional consequences from drug abuse, including
tolerance and withdrawal
 Prevalence in the Philippines
 Mean Age: 29 years
 Male to female ratio 9:1
 mostly from those with low total family earnings, single and attained High school
 Causes maternal and fetal risks
 maternal: pregnancy complications
 fetal: fetal alcohol syndrome, growth retardation

Substances Commonly Abused

1. Tobacco
2. Alcohol- most abused substance
3. Marijuana / cannabis- most frequently used illicit drug

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 4. Cocaine
5. Heroin- most abused opioid
6. Methampethamine (shabu, crystal, ice) – ampethamine of choice and is taken intranasally
7. prescription dugs (cough syrup, etc.)

Risk Factors
1. Family Factors:
 parent and sibling drug use
 family conflict
 family social and economic disadvantage
 spouse abuse, child abuse

2. Environmental Factors:
 peer pressure, social isolation

3. Psychiatric Disturbances:
 mood disorders, psychosis, anxiety disorders

Problems associated with Substance Abuse

 Pregnancy complications (low birthweight, miscarriage, preterm delivery), increased asthma
risk in children, other respiratory problems
 Cervical dysplasia
 Increased risk for cancer (esophageal, bladder, kidney, pancreatic, leukemia, breast,
gynecologic)
 Gastric and duodenal ulcers
 Premature wrinkling of the skin
 Decreased bone density, osteoporosis, fractures
 Impotence and fertility problems
 Lung disease
 Liver disease
 Decreased HDL
 Peripheral vascular disease
 Periodontal and dental diseases; oral cancers
 Depression
 Early menopause

Barriers to Substance abuse

A. Physical dependence
1. Withdrawal symptoms
a. Depressed mood
b. Insomnia
c. Irritability
d. Difficulty concentrating
e. Increased appetite—weight gain
f. Anger
g. Restlessness
h. Frustration
i. Increased heart rate

B. Psychological dependence
1. Behaviors associated with substance use become integrated into a person’s routine

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 2. Substance use once integrated into routine becomes associated with pleasure and enjoyment
3. Substance use may also be used to cope with stress or lessen negative emotions

History
A. Risk assessment

CAGE: Affirmative answered to 2 of the following questions (or to the last question alone) are
suggestive of alcohol abuse
1. Have you ever felt that you should cut down your drinking?
2. Have you ever felt annoyed by others criticizing your drinking?
3. Have you ever felt guilty about your drinking?
4. Have you ever had a morning drink (Eye-opener) after hang-over?

B. What the patient may present with

 Nagging, chronic cough
 Sinus congestion
 Shortness of breath
 Fatigue
 Elevated blood pressure
 Inability to meet physical challenges (run for a bus, play with young children)
 Decreased fertility
 Osteoporosis, decreased bone density
 Premature wrinkling
 Gum disease

C. Additional questions to be asked

 Pregnancy complications
 History of abnormal Pap smears
 History of, or presently existing, cancer
 Fractures
 Cataracts/glaucoma
 Problems with cold hands or feet or leg pain
 Diabetes
 Gastric or duodenal ulcer
 Current medicines including herbals, homeopathics, vitamins

Physical Examination
 General Survey
o poor hygiene, poor nutrition
 Vital signs- may reflect substance intoxication and withdrawal
o Temperature
o Pulse, respirations
o Blood pressure
 Skin
o color, tone, and premature wrinkling
o needle marks or skin infections, self-inflicted injuries or accidents
 ENT
o dental cavities, stained teeth, tongue or buccal lesions, gum disease, foul breath
 Lungs

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 o adventitious sounds (wheezes, rales, crackles)
 Breast examination
 Abdominal examination
 Gynecologic examination (Pap, cultures, bimanual)
 Extremities
o signs of circulatory, peripheral vessel involvement, pulses, pedal edema

Laboratory Examination
 CBC (elevated hematocrit, WBC, platelets, decreased leukocytes)
 Lipid level (decreased HDL)
 SGGT. SGOT, SGPT, LDH
 Intravenous drug abuse work-up
 HIV, Hepatitis B, Hepatitis C and TB

 Consider
o Vitamin C level (decreased)
o Serum uric acid (decreased)
o Serum albumin (decreased)
o Pulmonary function tests

 Consider: anxiety, mood disorders, history of abuse, peer pressure or social isolation

Treatment
A. Group psychotherapy
 alcoholic anonymous, nicotine anonymous

B. Patient education
a. Personalize the risks to each individual. Relate her current health problems or findings on physical
examination to the effects of substance abuse.
b. Emphasize how quitting can reward the individual.
c. If the patient indicates a willingness to quit, form a contract for a quit date.

C. Medications
a. for alcoholism: disulfiram (aldehyde dehydrogenase inhibitor) causes unpleasant reaction when
alcohol is ingested
b. for opioid abuse: naltrexone- blocks pleasurable effects of opioids (including alcohol); methadone
and long-acting opioid antagonists
c. for smoking abuse: bupropion, nicotine replacement drugs

HIV/ AIDS
I. Definition
AIDS is the commonly used acronym for acquired immune deficiency syndrome, which is the name for
a complex of health problems first reported in 1981.

II. Etiology
Caused by the human immune deficiency virus (HIV); infection mainly by sexual contact (anal, vaginal,
oral); contaminated blood and blood products, including needle and syringe sharing; contaminated
semen used for artificial insemination; intrauterine acquisition (baby of woman with AIDS); and rarely
breast milk. Majority of cases in the United States are

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HIV-1; HIV-2 infection is endemic in West Africa.

III. History
A. What the patient may present with
1. Rapid weight loss without known factor (> 10%)
2. Extreme fatigue; unexplained, increasing tiredness
3. Chronic diarrhea (> 1 month)
4. Persistent dry cough, shortness of breath, dyspnea on exertion
5. Prolonged fever, soaking night sweats, shaking chills
6. Loss of appetite
7. Purple or pink flat or raised lesions on skin or under skin, inside mouth, nose, eyelids, anus
8. Changes in neurological and/or cognitive function
9. Generalized adenopathy
10. Chronic herpes simplex
11. Recurrent herpes zoster
12. Generalized dermatitis pruritic
13. Oral and pharyngeal candidiasis; fungal infection of nails
14. Persistent muscle pain
15. Vaginal Discharge, Vaginitis, Vaginosis, STDs 103
16. Fear of exposure to AIDS through sexual partner or high risk behavior or work-related accident
(needlestick, contact with infected blood)
17. Chronic sinusitis
18. History of abnormal Papanicolaou smears
19. Persistent vulvar, vaginal, and anal condyloma

B. Additional information to be considered

1. Sexual history
a. Homosexual encounters; anal penetration
b. Use of condoms, other methods of contraception, anal intercourse as contraception
c. High-risk partners
d. High-risk sexual practices
e. History of previous sexually transmitted disease
f. Contact with prostitute
g. Multiple partners or partner with multiple partners

2. Use of injectable drugs by self or partner

3. High-risk occupation
4. History of blood transfusions or recipient of blood products particularly from 1980–1985
5. Duration and frequency of any presenting symptoms
6. Reason for fear of exposure to AIDS

7. Gynecological history
a. Recurrent sexually transmitted diseases, vaginitis, vaginosis
b. Widespread molluscum contagiosum 100 or more lesions
c. Infected with several sexually transmitted diseases concurrently (may include gonorrhea, syphilis,
Chlamydia)
d. Rapidly progressing cervical dysplasia
e. Papillomavirus on Papanicolaou smear
f. Recurrent, recalcitrant vaginal candidiasis
g. External condyloma unresponsive to treatment
h. Existing pregnancy

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i. Anal discharge
j. Pelvic, abdominal pain
8. Travel outside the United States, especially to West Africa

IV. Physical Examination

A. As appropriate to presenting complaint
V. Laboratory Examination
A. Per protocol for presenting complaint, symptoms, risk status, exposure.
B. HIV testing if indicated or requested; if setting offers testing, resources must be in place for both
pretest and posttest counseling for positive or negative results and follow-up; retest as needed.
C. CDC recommends HIV testing for all persons seeking evaluation for STDs; consider rapid testing if
patients unlikely to return for results.
D. All pregnant women should have HIV screening and encourage for women planning a pregnancy
(per new CDC guidelines, 2006).
E. Workplace exposures.
F. Consider other bloodborne screening including HAB, HAC.

VII. Treatment
A. General measures
1. Counseling to avoid or minimize high-risk behaviors

a. Instruction and counseling regarding safer sexual practices to protect self and partner from
exchange of body fluids (e.g., by using latex condoms, female condoms, dental dams, Saran
WrapTM); by avoiding anal intercourse and oral-genital contact; avoiding sharing sex toys
such as vibrators and dildos (or clean them with bleach or alcohol).

b. Decreased number of sexual partners; mutual monogamy; abstinence.

c. Discourage use of injectable drugs; if patient is using injectable drugs, stress the need to avoid
needle, works, or cooker sharing; offer resources on drug rehabilitation programs.

d. Avoid unsafe sexual contact with persons who are injectable drug users or fall into other high-risk
groups.

e. Sexual activities with partner with AIDS that do not involve direct passage of body fluids, such as
light kissing, caressing, mutual masturbation.

f. Empowering women to maintain equal decision-making power in their relationship(s).

g. Avoid sharing razors, toothbrushes, nail files and clippers, and other items that could be
contaminated with blood.

B. Specific treatment
1. Per guideline for specific presenting complaint.
2. Refer those patients falling into high-risk groups for further counseling and appropriate testing and
follow-up if setting does not offer such services.
3. Referral for exposure so prophylactic therapy can be instituted.

VIII. Complications
A. Opportunistic infections.
B. AIDS may be fatal to some of its victims within two years of diagnosis.

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C. Transmission to unborn child (infant’s true HIV status based on antibody testing will not be accurate
until 6–10 months); for a child < 18 months, definitive tests include evidence of HIV in blood or tissues
by culture, nucleic acid, or antigen detection.

IX. Consultations and Referral

A. All patients falling into high-risk groups in need of testing for presence of HIV virus unless setting
offers testing and counseling.
B. Referral for all patients testing positive to HIV antibody for appropriate treatment.
C. Referral per guideline for all occupational exposures.

X. Follow-up
A. Per referral
B. Contraceptive and gynecological services for women with AIDS

RH INCOMPATIBILITY
 Or Isoimmunization
 Rh (Rhesus factor)- 85% of population: foreign body: Antigen: protein factor
 Happens if:
 Mother Rh (-)
 Father/Fetus Rh (+)
 4th child is severely affected r/t degree of sensitization to Rh (+) RBC
 Fetus: Erythroblastosis fetalis
 IUGR due to hemolysis
 Pathologic jaundice within 24hrs
 Hemolytic anemia (¯ O2-carrying capacity):
 Cardiac decompensation
 Hydrothorax
 Hepatosplenomegaly
 Edema, ascites

Diagnostic Tests
 Indirect Coomb’s test
 Maternal serum mixed with Rh(+) RBC
 In mother with Rh (-): clumping (+) result
 Direct Coomb’s test
 Neonatal cord blood washed and mixed with Coomb’s serum
 Fetus with Rh (-): clumping (+) result

Preventive vaccine: Rho gam IM

1. Given to Rh(-) mother, NEVER TO BABY, at 28 wks AOG and within 72 hrs post delivery,
BT, amniocentesis, chorionic villi sampling, D & C, abortion
2. Purpose: to destroy fetal Rh (+) RBC and prevent sensitization
3. S/E: fever, pain at injection site
4. CI: allergy to human Ig

ABO INCOMPATIBILITY
 Happens when:
 Mother blood type O

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  Fetus: A, B, AB
 O-A most common
 O-B most severe
 1st child can be severely affected

 Upon uterine contraction: start of hemolysis

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

IRON DEFICIENCY ANEMIA

 iron stores needed for Hgb production
 Caused by blood loss, metabolic demands, GI malabsorption, ¯ iron in diet
 S/Sx: pallor, weakness & fatigue, irritability\
 iron diet (dark, green leafy vegies, breads, cereals, egg yolk, kidney beans, liver, meat, raisins)
 Administer iron supplements as ordered
 In between meals
 With Vit. C/citrus juice: absorption

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  Milk/antacids: ¯absorption
 Liquid iron: Taken with straw or medicine dropper at the back of mouth
 S/E: foul aftertaste, melena, constipation

c. Gestational condition such as hyperemesis gravidarum, ectopic pregnancy, gestational

trophoblastic disease (Hmole), incompetent cervix, spontaneous abortion, placenta
previa, abruptio placenta, premature rupture of membranes, pregnancy-induced hypertension

HYPEREMESIS GRAVIDARUM
 Persistent uncontrollable vomiting during pregnancies.
 Excessive vomiting of pregnant women
 Causative Factors
 Hormonal changes
■ Increased HCG, estrogen and progesterone [delay GIT motility]levels (salivation)
 Psychological factors
 Complications
 Weight loss
 Dehydration
 Vitamin deficiency
 Diagnostic
 Laboratory studies (HGB & HCT; serum electrolytes)
 Management
 IV rehydration
■ TPN as necessary
 Antiemetic drugs
 Nursing considerations
 Reducing nausea and vomiting
■ Dry crackers or toast
■ Rise slowly from bed
■ Small frequent feeding
■ Drink fluids in between meals
■ Avoid greasy or spicy foods
 Maintaining nutrition and fluid balance
■ IVF and TPN as directed
■ Increase K and Mg intake
■ Clear fluids are started as N&V subside.
 Providing emotional support

ECTOPIC PREGNANCY
 occurs when gestation is location outside the uterine cavity
 Common site : Ampulla or Tubal
 Dangerous site: Interstitial
Unruptured Ruptured
 Missed period  sudden, sharp severe unilateral pain,
 Abdominal pain within knife like
3- 5wks of missed  shoulder pain (indicative of
period (maybe intraperitoneal bleeding that extends to

19
 generalized of one diaphragm & phrenic nerve)
sided)  (+) Cullen’s sign – bluish tinged
 Scant, dark brown umbilicus
vaginal bleeding  syncope/fainting
 Vague discomfort
 Nursing Care
 vital signs
 administer IV fluids
 monitor for vaginal bleeding
 monitor I&O
 prepare for culdocentesis to determine
 hemoperitoneum
 Mgt : non-surgical Methotrexate

GESTATION TROPHOBLASTIC DISEASE (HYDATIFORM MOLE)

 progressive degeneration of chorionic villi

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

INCOMPETENT CERVIX

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Incompetent Cervix Management:
 McDonald procedure
 temporary circlage of incompetent cervix.
 Delivery : NSVD
 SE: infection
 Health teaching
 observe for signs of infection
 signs of labor
 Shhirodkar procedure
 permanent procedure.
 Delivery : caesarian section required.

ABORTION
 Termination of labor before age of viability

SPONTANEOUS
 AKA miscarriage
 Causes
 Chromosomal aberrations due to advanced maternal age
 Blighted ovum
 germ plasm defect
 Natures way of expelling defective babies
 Classifications :
 Threatened
■ pregnancy is jeopardized by bleeding and cramping but the cervix is closed and can be
saved
 Inevitable
■ moderate bleeding, cramping, tissue protrudes from the cervix and the cervix is open.
 Types :
 Complete
■ all products of conception are expelled.
■ Mgt : emotional support
 Incomplete
 placenta and membranes retained.
 Mgt : D&C

HABITUAL
 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
 Management (suture of cervix)
 McDonald procedure
■ Temporary circlage
■ Side effect – infection
■ May have NSD
 Shirodkar
 CS delivery

MISSED
 fetus dies; product of conception remain in uterus 4 weeks or longer

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  signs of pregnancy cease
 (-) pregnancy test
 Dark brown
 Scanty bleeding
 Mgt : induction of labor/ vacuum extraction

INDUCED
 Therapeutic abortion  principle of 2 fold effect
 Done when mother has class 4 heart disease

PLACENTA PREVIA

 it occurs when the placenta is improperly implanted in the lower uterine segment, sometime
covering the cervical os.
 Assessment
 Outstanding sign : frank, bright red, painless bleeding
 enlargement (usually has not occurred)
 fetal distress
 abnormal presentation
 Nursing care :
 Initial mgt : NPO candidate for CS
 Bedrest
 prepare to induce labor if cervix is rip
 administer IV
 No IE, No Sex, No enema – complication : Sudden fetal blood loss
 prepare Mother for double set –up –DR is converted to OR

ABRUPTIO PLACENTA
 it is the premature separation of the placenta from the implantation site.
 It usually occurs after the twentieth week of pregnancy
 Cause:
 Cocaine user
 Severe PIH
 Accident
 Assessment:
 Outstanding sign : dark red & painful bleeding
 concealed hemorrhage (retroplacental)
 couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
 rigid boardlike abdomen
 severe abdominal pain
 dropping coagulation factor (a potential for DIC)
 sx : bleeding to any part of the body. Mgt : for hysterectomy
 General Nursing care :
 infuse IV, prepare to administer blood
■ type and crossmatch
 monitor FHR
 insert Foley catheter

22
  measure bllod loss; count pads
 report s/s of DIC
 monitor v/s for shock
 strict I&O

REMATURE RUPTURE OF MEMBRANES

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

ED HYPERTENSION
 hypertension for 24wks resolved 6weeks postpartum which cause pregnancy
 types:
 gestational HPN
■ HPN without edema & proteinuria
 preeclampsia: triad
■ sx: HPN with edema, proteinuria or albuminura (HEP/A) which
cause is unknown or idiopathic but multifactorial
■ primis d/t 1st exposure to chorionic villi
■ multiple pregnancies due to inc. exposure to chorionic villi
■ mothers of low socio-economic status due to dec. protein intake
■ teenages d/t low compliance to protein intake
 HELLP syndrome

Transitional Hypertension – HPN between 20-24wks

Chronic or Pre-existing Hypertension

 HPN before the 20th wk not resolved 6wks postpartum
 3 types of pre-eclampsia
 Sign of pre-eclampsia :
 > 30mmHg systolic

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 > 15mmHg diastolic
 Roll over test
■ 10-15min side lying
■ Then supine
■ Then take BP
 mild pre-ecclampsia
■ 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt, inability to wear wedding ring
due to developing edema
■ Signs present
 cerebral & visual disturbances, epigastric pain to liver edema and oliguria usually
indicates an impending convulsion
 Before convulsion : if you see sign of epigastric pain, 1º mgt is to place tongue
depressor and put the side rales up
 During convulsion : observe the Mother for safety
 After convulsion – turn to side to facilitate drainage
 Severe pre-ecclampsia
■ 160/110, +3 or +4, proteinuria, visual disturbances
■ Nursing care
 P – promote bedrest
 Prevent convulsions by nursing measures
 to ↑ O2 demand & facilitate Na excretion
 Management: quiet & calm environment, minimal handling, avoid moving the
bed
 Heat Acetic Acid – determine protein in the urine
 Prepare the following at bedside
■ tongue depressor, Suction machine & O2 tank
 E – ensure high protein intake (1g/kg/day)
 Na in moderation
 A – antihypertensive drug with hydraluzine
 C – CNS depressant with Mg Sulfate for anti-convulsion
 Mgt : evaluate for hypermagnesiumenimia
 E – evaluate physical parameters for Magnesium Sulfate toxicity :
 B – BP ↓
 U – Urine output ↓
 R – RR ↓
 P – Patellar reflex is absent
 Antidote : Ca gluconate
 Eclampsia – with seizure
 ↑ BUN – sign of glomerular damage

24
25
Immediate Intervention for eclampsia:
a. maintain IV line with large bore needle
b. monitor fluid balance
c. minimize stimuli
d. have airway and oxygen available
e. give medications as orders (magnesium sulfate, apresoline, valium)
f. prepare for possible delivery of fetus
g. monitor fetal status
h. type and cross match for blood
I. postpartum- monitor vital signs and watch for seizure

Management for Eclampsia

a. digitalis (with heart failure)
 increase the force of contraction of the heart--> decrease heart rate
 nursing considerations:
 check HR prior administration (do not give if HR < 60/min)
b. potassium supplements- prevent arrhythmias
c. barbiturates-- sedation by CNS depression
d. Analgesics: antihypertensives, antibiotics, anticonvulsants, sedatives
e. Magnesium sulfate – drug of choice
Action: CNS depressant; vasodilator
Antidote: calcium gluconate- given 10% IV to maintain cardiac and vascular tone

Earliest sign of MgSO4 toxicity--> disappearance of knee jerk/ patellar reflex

Method of delivery- preferably vaginal but if not possible CS
Prognosis: the danger of convulsions is present until 48 hours postpartum

f. cathartic- cause shift of fluid from the extracellular spaces into the intestines from where the fluid can
be excreted

Dosage: 10 gms initially-- either by slow IV push over 5-10 min or deep IM
5 gms / buttock, then an IV drip of 1 gm per hr (1 gm/100ml D10W)

Check first the ff. before administration

1. deep tendon reflexes are presentation
2. RR = 12
3. UO= at least 100 ml/ 6 hrs

Nursing Intervention:

26
a. advised bedrest, left lateral
b. encourage a well-balanced diet
c. weigh daily, keep daily log
d. education on self-management
e. diversion
f. family support

Post delivery PIH

 with disseminated intravascular coagulation – anticoagulant therapy
 monitor blood pressure for 48 hour
 Diagnosis: Roll-over test: Assess the probability of developing toxemia when done between
the 28th and 32nd week of pregnancy
 Procedure on Roll-over test:
 patient in lateral recumbent position for 15 minutes until BP stable
 rolls over to supine position
 BP taken at 1 minute and 5 minutes after roll over
 interpretation: if diastolic pressure increases 20 mmHg or more, patient is prone to toxemia
 Management: same as eclampsia

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B.Nursing Care of the client with high-risk labor & delivery & her Family
1. High-Risk factors:

(may happen at anytime during the course of labor to a client who has been otherwise been healthy
throughout her pregnancy & may be related to stress/stressor; adaptive process):

PASSENGER/ FETUS
 Refers to the fetus plus the membranes and placenta
 Fetal skull and fetal accommodation to passageway affects the labor progress.
 Indication of fetal head
 Largest part of the body
■ Common presenting part
■ Least compressible fetal part
■ Cranial bones
 Frontal – 1
 Parietal – 2
 Temporal – 2
 Occipital – 1
 Sphenoid – 1
 Ethmoid – 1
■ Suture line
 Intermembranous spaces
 Allows molding – overlapping of the sutures
 Sagittal – 2 parietal
 Coronal – parietal and frontal
 Lamboidal – parietal and occipital
■ Fontanels
 Anterior fontanel
 4 cm in any direction – normal size
 Diamond in shape
 Closes at 12 – 18 months
 Posterior fontanel
 < 1 cm – normal size/location
 Triangular in shape
 Closes 2 – 3 months
■ Measurements
 Transverse diameter
 Biparietal – largest at 9.5 cm

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  Bitemporal – 8 cm
 Bimastoid – smallest at 7 cm
 Antero-posterior diameter
 Sub-occipito bregmatic – 9.5 cm
 Occipito – frontal – 12 cm
 Occipito – mental – 13.5 cm
 Submento bregmatic – face presentation

Fetal Accommodation to the Passageway

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

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 ■ LOP – maternal side and toward back, face is up
 Labor is slowed and much back discomfort on mother during labor.
 ROT – occiput is facing the right side and looking toward the left side.
 Attitude or Habitus
 Describes the degree of flexion a fetus assume during labor or the
relationship of fetal part to each other
■ Full flexion (Vertex) – good attitude – normal fetal position
 Presents the smallest anterior diameter
 Moderate flexion (sinciput)
■ Chin not touching the chest (military)
 Partial extension (Brow) – brow of head to the birth canal
 Complete extension (face)

 Station
 Descent of the fetal presenting part in relationship to the level of the
ischial spine
■ 0 – level of ischial spine
■ -3 to -1 – above the ischial spine
■ +1 to +3 – below the ischial spine
 Engagement
 Settling of the presenting part of a fetus far enough into the pelvis to
determine the level of ischial spine

PASSAGEWAY OR PELVIC BONES AND OTHER PELVIC

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

POWERS OR UTERINE CONTRACTIONS

 Forces that cause the cervix to open and propel the fetus through the birth canal.
 Uterine contraction
 Primary power of labor

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 o Characteristics
 Involuntary contraction
 Spontaneous contraction
o Cervix dilatation and effacement of the cervix during the 1 st stage
of labor
o Phases: Increment (gain strength). Acme (peak), Decrement
(letting go)
 Intermittent Contraction
o Description
 Frequency
 Duration
 Intensity
 Regularity
 Maternal Push
 Voluntary beating down efforts
 After full dilatation of the cervix
 Efforts similar to those of defecation
 Contraction of levator ani muscle

PLACENTA
■ Power: Strong uterine contractions cause the placenta to detach from the uterine wall
■ Psyche: Patient may be exhausted; encourage bonding with baby
■ Signs of placental separation
■ Sudden gush or trickle of blood from vagina
■ Lengthening of visible umbilical cord at introitus
■ Contraction of the uterus
■ Nursing considerations
■ Instruct patient to push when appropriate
■ Note time of placenta delivery
■ After placenta expelled:
• Monitor amount of bleeding
• Monitor vital signs
• Assess fundus
– Height
– Location
– Tone
■ Administer oxytocic medication as ordered
• Stimulates uterus to contract
• Prevents hemorrhage
■ Cleanse and apply ice pack to the perineum
■ Provide clean linen under patient
■ Provide warm blanket: patients often tremble/shiver immediately after the birth
■ Assess level of consciousness/comfort
■ Place newborn in arm of mother, encouraging skin-to-skin contact
■ Assist with positioning for breastfeeding and bonding

CLIENT’S PSYCHE OR PSYCHOLOGIC STATE

Factors that may increase a woman's chance of depression
 history of depression or substance abuse

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  little support from family and friends
 anxiety about the fetus
 problems with previous pregnancy or birth
 marital or financial problems
 young age of mother

Signs and symptoms of post partum depression

 feeling restless or irritable
 feeling sad, hopeless, and overwhelmed
 having no energy or motivation
 eating too little or too much
 sleeping too little or too much
 trouble focusing, remembering, or making decisions
 feeling worthless and guilty
 loss of interest or pleasure in activities
 withdrawal from friends and family
 having headaches, chest pains, heart palpitaions (heart beating fast and feeling like it is
skipping beats), or hyperventilation (fast and shallow breathing)
 Physical preparation of childbirth
 Three Categories
 Psychophysical
 Bradley’s method – presence of husband
 Dick Read method – fear produces tension, pain
 Psychosexual
 Ketzinger’s method – states that pregnancy, labor, birth, and care of newborn
are an important turning point in woman’s cycle.
 Psychoprophylactic
 Lamaze – requires discipline, conditioning and concentration
 Prevention of pain
 Features:
 Conscious relaxation
 Cleansing birth inhaling to the nose and mouth exhaling
 Effleurage – light abdominal massage

2. Problems of the Passenger

FETAL MALPOSITIONS

1. Types of fetal malposition

2. Nursing care
3. Medical Management

Position = relationship of the fetal presenting part to specific quadrant of the mother's pelvis
** the pelvis is divded into four quadrants
** right anterior
** right posterior
** left anterior
** left posterior

32
 ** posterior positions results in more backaches because of pressure of fetal presenting
part on the maternal sacrum

** points of direction in the fetus

** occiput – vertex presentatons
** chin (mentum) – in face presentations
** sacrum – in breech presentation
**scapula (acromio) – in horizontal presentation

 left occipito anterior

 most common & favorable position
o ROT/LOT – left occipito transverse
o ROP/LOP – left occipito posterior

o L/R- side of maternal pelvis

o Middle – presenting part

o ROP/ROT – most common malposition

o ROP/LOP – most painful mgt: pelvis squatting

o Breech – sacro
 place the stethoscope above the umbilicus
o Chin – mentum
o Shoulder – acromnio dorso

FETAL MALPRESENTATIONS
1) Vertex malpresentation
a) brow presentation
b) face presentation
c) sincipital presentation
2) Breech presentation
a) types
b) maternal risks
c) vaginal evolving of breech
d) external/podalic version

Presentation - the relationship of the long axis of the fetus to the long axis of the mother. spine
relationship of the spine of the mother & the spine of the fetus

Two Types

Longitudinal Lie (Parallel)/ Vertical

A. Cephalic – when the fetus is completely flexed

1. Vertex
2. Face
3. Brow
4. Chin

33
B. Breech
o Complete breech – thigh rest on abdomen while legs rest on thigh
o Incomplete breech
 Frank – thigh resting on abdomen while legs extend to the head
 Footling
 Kneeling
C. Shoulder presentation
D. Compound presentation

Transverse Lie (Perpendicular)/Horizontal lie

4) Nursing care of client with malpresentation

FETAL DISTRESS
Causes:
 pregnancy induced hypotension
 diabetes mellitus
 uterine hypertonus
 hemorrhage
 maternal hypotension
 umbilical cord prolapse
 oligohydramnios
 abruptio placenta
 premature closure of fetal ductus arteriosus
 anemia
 preterm or IUGR fetus

Signs and Symptoms:

 Decreased movement
 nonreassuring or ominous FHR patterns
 Meconium in the amniotic fluid (unless fetus is in breech presentation)

Nursing interventions
 monitor FHR q 15 minutes during 1st stage and q 5 mins during 2nd stage of labor
 assess color, amount and odor of amniotic fluid
 assess for vaginal bleeding
 discontinue oxytocin if fetal distress
 maternal BP P, R on same schedule and temp q2h
 position on left side

NURSING RESPONSIBILITY IN FETAL MONITORING

■ Position patient to avoid supine hypotension

■ Assess FHR and interpret findings
■ Compare FHR to maternal pulse to ensure monitoring of fetal heart and not maternal rate
■ Implement nursing interventions for nonreassuring patterns of FHR
■ Evaluate effectiveness of nursing interventions for nonreassuring patterns

34
■ Update primary health-care provider with FHR status
■ Document findings and interventions
■ Assessment of the FHR may be intermittent or continuous

Intermittent Auscultation

Count FHR between, during, and immediately following a

contraction
Note both rate and rhythm of FHR
Frequency of auscultation based on:
Phase/stage of labor
Hospital protocol
Risk status
Labor interventions
Physician orders

Stage / Phase of Labor Frequency of FHR Monitoring

Stage 1: Latent phase Every 30-60 minutes
Stage 1: Active phase Every 15-30 minutes
Stage 1: Transition Every 5-15 minutes
Stage 2 Every 5-15 minutes

Continuous Fetal Monitoring

Monitored with external or internal fetal monitoring

External Fetal Monitoring (EFM)
Encourage patient to void before applying EFM
Test internal circuitry of EFM
Place ultrasound transducer over fetal back
Place toco transducer over uterine fundus
Monitor for 20–30 minutes on admission

35
Internal Fetal Monitoring
Indicated when EFM not providing adequate FHR or contraction
tracing
May be implemented only after amniotic sac is ruptured
FHR measured by spiral electrode attached to presenting part
Uterine tone measured by intrauterine pressure catheter (IUPC)
Resting tone of uterus averages 5–15 mmHG
Contraction tone of uterus averages 50–85 mmHG

Evaluating the Baseline Fetal Heart Rate

Normal baseline FHR is 110–160 BPM
Evaluated between contractions over 10 minutes
Documented as a range
Does not include accelerations or decelerations
Influences on the fetal heart rate
Central nervous system
Fetal sleep ↓variability of FHR
Fetal movement ↓variability of FHR
Autonomic nervous system
Sympathetic branch (↓FHR)
Parasympathtic branch (↓FHR)
Baroreceptors respond to ↓blood pressure with subsequent ↓FHR
Chemorecptors sense ↓oxygen and ↓FHR

Figure: Normal fetal heart rate (Left:contractions, right: fetal heart rate)

Changes to Baseline Fetal Heart Rate

36
TACHYCARDIA
FHR greater than 160 BPM for 10 minutes
Possible cause:
• Infection/hyperthermia
• Fetal hypoxia
• Maternal medications (ex. terbutaline, albuterol)
BRADYCARDIA
FHR less than 110 BPM for 10 minutes
Possible cause:
• Vagal stimulation
• Hypoxia
• Anesthetic agents
VARIABILITY
Fluctuations in FHR over time
Important indicator of fetal well-being
Sensitive to hypoxia and changes in Ph
Short-term variability (STV)
• Beat-to-beat changes in FHR
• Documented as present or absent
• Most accurate with internal FHR monitoring
Long-term variability (LTV)
• Pattern of fluctuations in FHR baseline

Long term variability Possible cause

Absent (0-2 BPM) Maternal medication
Minimal (3-5 BPM) Fetal sleep
Fetal hypoxia
Average (6-10 BPM) Adequate fetal oxygenation
Moderate (11-25 BPM)
Marked (> 25 BPM) Early sign of mild fetal hypoxia
Fetal stimulation

Changes in Fetal Heart Rate

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

37
 Acceleration (Top: Fetal Heart Rate, Bottom: Contractions)

DECELERATIONS (Early, Late, Variable)

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

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

DECELERATIONS (Early, Late, Variable)
EARLY DECELERATION
• Decrease in FHR occurring with contractions
• Onset occurs before the contraction peak
• Recovery to baseline rate occurs by contraction end
• Commonly seen in active phase of first stage of labor
• Mirrors the contraction

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• Usually benign finding
• Continue to monitor FHR pattern for nonreassuring patterns
• Possible cause: Fetal head compression

Early deceleration: (Top: fetal heart rate; bottom: contractions)

LATE DECELERATIONS
• Decrease in FHR occurring with contractions
• Onset with or after the peak of contraction
• Recovery to baseline rate occurs after contraction ends
• Repetitive pattern
• Nonreassuring requiring intervention
INTRA

Late deceleration: (Top: fetal heart rate; bottom: contractions)

• Etiology: decreased uteroplacental blood flow/oxygen delivery related to

 maternal supine hypotension
 hyperstimulation of uterus
 preeclampsia
 chronic maternal disease
 hypertension
 diabetes
 anemia
VARIABLE DECELERATIONS

39
• Decrease in FHR occurring without regard to contractions
• Can range from mild to severe
• May be persistent or occasional
• Shaped like a “V” or “W”
• Onset variable
• Nonreassuring variable decelerations
– Repetitive and/or deep decrease in FHR
– Associated with minimal variability
– Prolonged with slow return to baseline FHR
• Possible causes:
– Cord prolapse
– Umbilical cord compression
• Intervention: AMNIOINFUSION may be performed to try to
relieve cord compression
– Infusion of warmed normal saline into uterus via sterile
catheter
– Monitor FHR, contraction status, and maternal temperature
Verify that fluid is exiting uterus

Variable deceleration: (Top: fetal heart rate; bottom: contractions)

Nursing Interventions for Non-Reassuring FHR Patterns

Turn patient to side-lying position
Shifts weight of gravid uterus off the inferior vena cava
Allows for improved uteroplacental blood flow
O2 per mask at 8–10 L/min
Improve oxygen delivery to fetus
Discontinue IV Oxytocin
Decreases uterine contractions, thus improving uteroplacental blood flow
Hydrate patient as indicated
Corrects identified maternal hypotension
Notify primary health-care provider
Document findings
Document baseline FHR (baseline FHR should be between 110 and 160 BPM)
Describe variability
Note changes in FHR in relation to contractions
Document nursing interventions, effectiveness of interventions and notification of

40
 primary health-care provider

Monitoring Contractions
Frequency
Beginning of one contraction to the beginning of the next contraction
Documented as range, for example, “every 2–5 minutes”
Duration
Beginning of the one contraction to the end of the same contraction
Documented as a range, for example, “lasting 60–90 seconds”
Intensity
Palpate uterus both during and after contraction
Resting tone palpated between contractions
Document intensity of uterine contractions (findings subjective unless monitored
with IUPC)

Intensity Palpated by Nurse

Mild Fundus easily palpated
Moderate Requires more pressure to indent fundus
Strong Unable to indent fetus

PROLAPSED CORD
 Occurs when the cord passes out of the uterus ahead of the presenting part.

Risk Factors:
 A very small fetus
 Breech presentation
 Transverse lie
 Hydramnios
 Long cord
 Placenta previa

Clinical Manifestation:
 Completer prolapse – visible on the vulva
 Occult prolapse – cord slips alongside with the head or shoulder of fetus
 Changes in FHR (bradycardia)

Nursing Diagnoses:
 Impaired Fetal Gas Exchange r/t insufficient oxygen delivery secondary to cord compression
 Fear/Anxiety r/t perceived grave danger to fetus and self from obstetric emergency\

Management:
 Focus: to relieve pressure on the cord to restore blood flow through it until delivery.
 Position the woman hip higher than her head to shift the fetal presenting part toward her
diaphragm.
■ Knee chest
■ Trendelenburg
■ Hips elevated with pillows, with side lying position maintained.

41
  With gloved hand, push the fetal presenting part upward.
 Oxygenation at 8 – 10 LPM via face mask.
 Tocolytic drug, terbutaline (inhibit contraction; increase placental blood flow)
 Warm saline – moistened towels retard cooling and drying of cord.
 Nursing considerations
 The nurse must remain calm and acknowledge the woman’s anxiety.
 Simple explanation of the condition.
 Include the family (decision making).

4. Problems with the Powers

Powers
 the forces acting to expel the fetus & placenta
 involuntary contractions
 voluntary bearing down effects
 characteristics: wavelike
 timing: frequency, duration, intensity
 myometrium- power of labor

DYSTOCIA
 broad term for abnormal or difficult labor and delivery

Uterine Inertia = sluggishness of contractions

Causes:

a. inappropriate use of analgesics

b. pelvic bone contractions
c. poor fetal position
d. overdistention – due to multiparity, multiple pregnancy, polyhydramnios or prematurely large fetus

Types:

Hypertonic uterine dysfunction

= relaxations are inadequate and mild, thus are ineffective. Since uterine muscles are in a state of
greater than normal tension, latent phase of the first stage of labor is prolonged.

Treatment: sedate the patient

Hypotonic uterine dysfunction

= contractions have been good but gradually become infrequent and of poor quality and dilatation
stops
Treatment: stimulation of labor either by oxytocin administration or amniotomy

ABNORMAL PROGRESS OF LABOR

42
  refers to labor dystocia with a lack of progressive cervical dilataion and or fetal descent
 discrepancy between fetal size or position (passenger) and the pelvis (passageway) may
inhibit fetal descent (CPD)
 maternal anxiety (psyche) and maternal positioning may also interfere labor progress

Medical care:
 evaluation of fetal size, presentation, position, and pelvic adequacy
 AROM or oxytocin augmentation may be initiated if uterine hypotonus is diagnosed and CPD
ruled out
 forceps or vacuum extraction may be tried if the problem develops in the second stage
 CS for CPD

RETRACTION RINGS
Physiologic retraction ring--> boundary between upper and lower uterine segment
Bandl's Pathologic ring--> suprapubic depression sign of uterine rupture

PREMATURE LABOR

 labor after 20 weeks and before 37 weeks

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

PRECIPITATE LABOR/ BIRTH

43
  labor and delivery that is completed in less than 3 hours after the onset of true labor pains;
probably due to multiparity or following oxytocin administration or amniotomy. Dangers
imposed by precipitate delivery: extensive lacerations; abruptio placenta; or hemorrhage due to
sudden release of pressure, leading to shock
 s/sx of shock: hypotension, tachycardia, tachypnea, cold clammy skin
 Management: modified trendelenburg, fast drip IV

UTERINE INVERSION

 fundus is forced through the cervix so that the uterus is turned inside out
 causes:
a. insertion of placenta at the fundus so that as fetus is rapidly delivered, especially if
unsupported, the fundus is pulled down
b. strong fundal push when mother fails to bear down properly
c. attempts to deliver the placenta before signs of placental separation appear

UTERINE RUPTURE
 occurs when the uterus undergoes more strain that it is capable of sustaining

Causes:
 scar from a previous classic caesarian section
 improper use of oxytocin
 very large baby (overdistention)
 faulty presentation or prolonged labor

Signs/symptoms:
 sudden, severe pain
 hemorrhage and clinical signs of shock (restlessness, pallor, hypotension, tachycardia,
tachypnea)
 change in abdominal contour, with two swellings on the abdomen, the retracted uterus and the
extrauterine fetus

5. Placental problems

PLACENTA PREVIA

 occurs when the placenta is improperly implanted in lower uterine segment, sometime covering
the uterine os

Assessment
 outstanding sign: frank, bright red, painless bleeding
 enlargement (usually has not occurred)
 fetal distress
 abnormal presentation

44
Nursing care
 initial management: NPO--> candidate for CS
 Bed rest
 prepare to induce labor if cervix is ripe
 administer IV
 No IE (internal exam), no enema-- complication: sudden fetal blood loss
 prepare mother for double set up- DR is converted to OR

ABRUPTIO PLACENTA

 it is the premature separation of the placenta from the implantation site

 it usualy occurs after the twentieth week of pregnancy
 cause:
 cocaine user
 severe PIH
 accident
 Assessment
 outstanding sign: dark red & painful bleeding
 concealed hemorrhage (retroplacental)
 couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
 rigid boardlike abdomen
 severe abdominal pain
 dropping coagulation factor (a potential for DIC)
 sx: bleeding to any part of the body. Mgt: for hysterectomy

General Nursing Care

 infuse IV, prepare to administer blood
- type and crossmatch
 monitor FHR
 insert Foley catheter
 measure blood loss; count pads
 report s/sx of DIC
 monitor v/s for shock
 strict I&O

Placental Succenturiata- 1 or 2 lobes are connected to the placenta by a blood vessel

Placenta Bipartita- placenta divided into 2 lobes

6. Problems with the psyche factors

Psychological Changes

Latent Phase: may be talkative and excited that labor has started

Active Phase: becomes more serious and focused on contractions; concerned about ability to cope
with discomfort

Transition Phase: Client becomes more irritable and may lose control during contractions; convinced
that she can't do it; very introverted or sleeping between contractions

45
2nd Stage: works hard at pushing and sleeps or appears exhausted between contractions

3rd.Stage: Client is usually elated with birth of the baby and pushes on request to deliver placenta

4th Stage: client is alert and ready to bond or breastfeed her baby; may be talkative and hungry

INABILITY TO BEAR DOWN

 can cause exhaustion

Causes:
 improper bearing down
 anxiety
 uncoordinated / weak contractions

Nursing diagnoses:
 Energy field disturbance r/t slowing or blocking of energy flow secondary to labor
 Anxiety

Nursing intervention:
 psychoprophylactic interventions such as lamaze
 relaxation / breathing techniques
 therapeutic touch/ effleurage

ANXIETY/FEAR
Causes:
 Client perceives threat to fetal well-being
 invasive procedures (CS)

Defining characteristics:
 verbalizations: “I'm nervous, frightened, tense”
 trembling
 crying
 increased P, BP

Nursing interventions:
 acknowledge anxiety
 inform about fetal status
 explain procedures
 include family

C. Nursing Care of the High-Risk Postpartal Client

1. Postpartal hemorrhage
a. Early postpartal hemorrhage
b. Late postpartal hemorrhage subinvolution
2. Postpartal puerperal infection
a. Endometritis
b. Wound infection

46
c. UTI
3. Thromboembolic disorders
4. Postpartal psychiatric disorder

POSTPARTAL HEMORRHAGE
 blood loss of more than 500 cc (blood loss during labor and delivery is 250-350 cc); leading
cause of mortality associated with childbearing

Early postpartum hemorrhage

 bleeding during the first 24 hours postpartum

1. uterine atony= uterus is not well contracted, relaxed or boggy; most frequent cause
intervention
a. massage the uterus- first nursing action
b. ice compress
c. modified trendelenburg
d. fast drip IV
e. breastfeeding- to release oxytocin
f. oxytocin administration
g. emptying the bladder
h.bimanual compression to explore retained placental fragments
I. hysterectomy- last resort

2. lacerations
- well contracted with profused bleeding
- assess perineum for laceration
- degrees of laceration
- 1st degree- vaginal skin and mucous membrane
- 2nd degree- 1st degree + muscles
- 3rd degree - 2nd degree + external sphincter of rectum
- 4th degree- 3rd degree + mucous membrane of rectum

3. hematoma
- bluish discoloration of subQ tissues of vagina or perenium
- candidates
- delivery of very large babies
- pudendal block
- excessive manipulation due to excessive IE
- intervention
 cold compress 10- 20 mins then allow 30 minutes rest period for 24 hours

4. DIC- dissemination intravascular coagulation

- consumption of pregnancy (other term)
- failure to coagulate
- bleeding in the eyes, ears, nose
- oozing blood
- seen in cases with a) abruptio placenta; b.) still birth/IUFD
- Management:
- blood transfusion of cryoprecipitate or fresh frozen plasma
- hysterectomy

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Late postpartum hemorrhage

Retained Placental Fragments

 manual extraction of fragments is done
 uterine massage
 D&C except in cases of
 placenta acreta= unusual attachment of the placenta to the myometrium
 placenta increta = deeper attachment of placenta to the myometru
 placenta precreta = invasion of placenta to the perimetrium
 Candidates of these disorders are
 grand multiparous
 post CS
 all these requires hysterectomy

Hematoma
 due to the injury to blood vessels during delivery
1, Incidence: commonly seen in precipitate delivery and those with perineal varicosities
2. treatment:
 ice compress during the first 24 hours
 oral analgesics, as ordered
 site is incised and bleeding vessel is ligated

POSTPARTAL PUERPERAL INFECTIONS

Endometritis
 inflammation/ infection of the lining of the uterus
Specific s/sx
 abdominal tenderness
 uterus not contracted and painful to touch
 dark brown, foul smelling lochia

Management
 High fowler's- to drain lochia and prevent pooling of infected discharge
 oxytocin

Wound Infection
 Specific symptoms:
 pain, heat and feeling of pressure in the perineum
 inflammation of the suture line, with 1 or 2 stitches slough off
 with or without elevated temperation
 Tx suturing (usually done by doctor), hot Sitz bath

Mastitis (breast infection)

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

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Incisional infection
■ Contributing factors
• Inadequate care of incision
• Operative delivery
• Laceration
■ Clinical findings
• Incision not well approximated
• Incision red with purulent drainage

UTI
■ Contributing factors
• Catheterization of bladder
• Retention of urine in bladder
■ Clinical findings
• Dysuria
• Frequency of urination
• Flank pain

THROMBOEMBOLITIC DISORDERS

 infection of the lining of the blood vessels with formation of clots; usually an extension of
endometritis
 Specific symptoms:
 pain, stiffness, and redness in the affected part of the leg
 leg begins to swell below the lesion because venous circulation has been blocked
 skin is stretched to a point of shiny whiteness, called milk leg = phlegmasia alba dolens
 Positive Homan's sign = pain in the calf when the foot is dorsiflexed
 Specific Management
 bed rest with affected leg elevated
 anticoagulants, e.g. Decumarol or heparin to prevent further clot formation or extension
of a thrombus
 side effects: hematuria and increased lochia
 Considerations:
 discontinue breastfeeding
 monitor prothrombin time
 always have Promtamine sulfate or vitamin K at bed side to counteract
toxicity
 analgesics are given but never aspirin because it inhibits prothrombin
formation; since patient is already receiving an anticoagulant, bleeding may occur

EMOTIONAL SUPPORT

1. Taking phase
 1st 3 days
 dependent phase
 passive, can’t make decision
 tells about childbirth experience

49
  focus on: Hygiene
2. Taking Hold
 4 – 7th day
 dependent to independent phase
 active, decides actively
 focus: care of newborn
 health teaching : Family planning
3. Letting Go
 Interdependent phase
 Redefines goals, new roles as parents
 May extend till the child grows

POSTPARTUM BLUES
 4th – 5th days
 overwhelming feeling of depression, inability of sleep and lack of appetite
 50 – 80% incidence rate
 cause by sudden hormonal change – progesterone suddenly decreases
 allow crying: therapeutic
 may lead to postpartum psychosis/ depression

POSTPARTUM DEPRESSION
■ Risk factors
■ History of depression or anxiety disorder
■ Prenatal depression
■ Inadequate social or partner support
■ Large number of life stressors
■ Clinical findings
■ Symptoms extend beyond 2 weeks postpartum; may occur 3–12 months after birth
■ Extreme or unswerving sadness
■ Compulsive thoughts
■ Feelings of inadequacy
■ Inability to care for infant and/or self
■ Suicidal thoughts
■ Interventions
■ Psychotherapy
■ Medications

D. Care of couple with problems of infertility

INFERTILITY
Definition
■ inability to conceive after 1 year or more of unprotected intercourse

Etiology

A. Factors in male infertility:

50
  faulty sperm production
 reproductive tract anomaly
 physical and chemical agents (coal tar, radioactive substance, orchitis, other infection, etc.);
endocrine disorders
 general state of health
 blocked vas deferens
 testicular infection
 injury to reproductive organs/tract
 nerve damage
 impotence
 lifestyle factors (smoking, alcohol, street drugs, etc.)
 incompatible immunologic factors for sperm—anti-spermatozoa antibodies

B. Factors in female infertility:

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

C. Factors in couple infertility: improper technique for intercourse; infrequent intercourse; emotional
state; male and female factors contributing to infertility

History

What the patient presents with

 History of failure to conceive for period of time with no use of contraception
 Desire for pregnancy

Additional information to be obtained

 Complete medical and surgical history including immunizations; family history
 Complete menstrual history including menarche, character of menses, frequency, duration, last
menstrual period, postmenarche amenorrhea
 Gynecologic history: anomalies; problems; infections; surgery including LEEP, LOOP; DES
exposure; endometriosis; fibroids; abnormal Papanicolaou smears; previous treatment for
menstrual disorders related to polycystic ovarian syndrome
 Contraceptive history to the present including postmethod amenorrhea
 Obstetrical history: any previous conceptions
 number of children, abortions, stillbirths; complications

51
  Partner’s reproductive history; medical, surgical history
 Employment history: exposure to radiation, viruses, other
 substances known to cause sterility; teratogens
 Sexual history: techniques, frequency and timing of intercourse in relation to the menstrual
cycle; use of lubricants, douches, sex stimulants, or toys; trauma
 Report of any previous infertility testing, work-ups; diagnoses; interventions; genetic evaluation
 Lifestyle history: use of recreational (street) drugs, prescription drugs, alcohol, tobacco,
caffeine, eating habits, saunas or hot tubs, exercise (including biking and running); stress
 Age of patient/partner may determine timing of intervention

Physical Examination
A. Vital signs
1. Temperature
2. Pulse
3. Blood pressure

B. Complete physical examination; observation of secondary sex

characteristics; signs/symptoms of PCOS

C. External examination (careful observation for signs of infection,

lesions, or anomalies)
1. Clitoris
2. Labia
3. Skene’s glands
4. Bartholin’s glands
5. Vulva
6. Perineum

D. Pelvic examination
1. Length of vagina
2. Position and character of cervix
3. Any anomalies

E. Bimanual examination (examine for palpable masses, tenderness,

anomalies, signs of trauma)
1. Uterus
2. Ovaries
3. Adnexa

Laboratory
A. Papanicolaou smear, maturation index; mammogram as appropriate
B. N. gonorrhea culture; RPR status (syphilis), TB status, HIV, hepatitis status, Rubella titre, varicella
titre
C. Chlamydia smear
D. Pregnancy test in amenorrhea
E. Complete blood count; erythrocyte sedimentation rate
F. Mycoplasma and ureaplasma culture
G. Endometrial biopsy during luteal phase
H. Serum progesterone level days 21–23 of cycle

52
I. Wet mounts, vaginal cultures
J. Prolactin level, FSH, LH, TSH, Rh factor, blood type

Treatment
A. Infertility work-up for the woman
1. Basal body temperature charts, may use test for LH surge instead
2. Commercially available ovulation tests or devices and fertility monitoring devices
3. Postcoital test—serial if antispermatozoa antibodies
4. Cervical mucus test; sperm antibody level; sperm agglutination test; sperm immobilization test;
endometrial biopsy 2–3 days before menstruation
5. Hysterosalpingogram after menses, before ovulation
6. Hormonal assay (serum) such as FSH, LH, prolactin, estrogen DHEA-S, testosterone, urinary LH
4–5 days at midcycle
7. Tuboscopy
8. Ultrasound
9. Laparoscopy with chromotubation, hydrotubation; hysteroscopy; salpingoscopy

B. Work-up of partner involving tests done by specialist

C. For complete work-up, referral may be in order

Complications
A. Risks associated with certain tests; costs of testing
B. Persistent infertility, discovery of sterility
C. Effects on couple’s relationship

Consultation/Referral
To gynecologist or infertility specialist; reproductive technology centers;
genetic counseling

Follow-up
Long-term process for work-up that is staged, so patient would be asked to return for next phase of
testing if conception not achieved.

53
54
CHILD
A. Nursing care of the high-risk newborn to maturity
1. Problems related to maturity

PREMATURITY
 premature babies= born before the 38th week of gestation

1. have underdeveloped subQ tissues and less fat to act as insulation. Are thin-skinned. This is
the reason why rapid drying and warming inside incubators are important

Characteristics:
in incubator care:
a. temperature- 92-94 F (33.3- 34.4C)
b. humidity – 55- 65%
c. frequent positioning on the right side will favor closure of the foramen ovale because of the
increased pressure on the left ventricle

2. are poikilothermic (= easily take temperature of the environment)

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

a. method of feeding- basically by NGT

Rationale:
** premature often have ineffective sucking which is not coordinated with swallowing and therefore
may aspirate
** minimal handling is necessary in order to conserve energy

Procedure
** determine the distance to which the NGT is to be inserted by measuring from the ear lobe to the
nose to the distal end of the sternum
** Procedure
 determine the distance to which the NGT is to be inserted
 check the location after NGT has been inserted:
 submerge tip of the NGT in a glass of water; if bubble appear, it is inside the lungs
 inject 5 cc of air, then auscultate. If no sound is heard as air is injected, it means that the NGT

55
 is not in the stomach but in the lungs
 aspirate contents; if acids are aspirated, the NGT is in the stomach
 determine amount of residual milk or undigested milk and subtract the same amount from
the next feeding because this means that the baby is not able to digest all the milk that is given to
him. Be sure to put back the residual milk since it contains acids and the baby can develop
metabolic alkalosis if not given back to the baby
 keep the NGT always closed to avoid abdominal distention
 fill syringe with formula before opening NGTl let formula flow by gravity

POSTMATURITY
postterm/ postmature babies = born after the 42nd week of gestation

A. Classic signs: “old man facies”; evidence of intrauterine weight loss, dehydration and chronic
hypoxia
1. long and thin
2. cracked skin which is loose, wrinkled and stained greenish-yellow, with no vernix nor lanugo
3. long nails; firm skull
4. wide eyed alertness of a one month old baby
B. Management
1. monitor VS
2. IV as ordered

C. Outlook: reasonable

2. Problems related to gestational weight

a. Small for gestational age (SGA) = birth weight is less than expected for the specific gestational age.
Eg. Baby born on the 3
b. Large for gestational age (LGA)

3. Acute conditions of the neonates such as:

RESPIRATORY DISTRESS SYNDROME

Respiratory Distress Syndrome or Hyaline Membrane Diseases- the disease specific for premature
babies

DECREASE PULMONARY SURFACTANT ==> increased surface tension-- > alveolar walls will not
separate--> lack of expansion of affected alveoli ---> decreased alveolar ventilation ---> inadequate
exchange of oxygen and carbon dioxide ----> HYPOXIA ----> increased capillary permeability which
causes effusion from the pulmonary capillaries into the alveoli and terminal bronchioles -----> HYALIN
LIKE MEMBRANE found in the alveoli and bronchioles composed mainly of fibrin -----> ATELECTASIS
a. Pathophysiology:
 the main problem is decreased pulmonary surfactants, substances responsible for maintaining
the expansion of the alveolar walls after initial respiration
 the lack of expansion of affected alveoli decreases alveolar ventilation
 this results in inadequate exchange of oxygen and carbon dioxide, leading to hypoxia.
 Hypoxia increases capillary permeability, causing effusion from the pulmonary capillaries into

56
 the alveoli and terminal bronchioles
 Hyaline-like membrane forms around the alveoli and bronchioles causing further hypoxia
 atelectasis, the chief lesion of RDS, thus occur
b. signs and symptoms:
 respiratory grunting-- major symptom
 increased respiratory rate
 flaring alae nasi
 cyanosis; retractions; rales
 respiratory acidosis
 blood values low pH level (N= 7.35- 7.45); low pO2 level (N = 40- 60 mm Hg); High pO2 level
(N = 35-45)
c. Management
 monitor VS, ABGs, skin color, muscle tone
 proper positioning; NPO; IV;NGT care
 oxygen; high humidity; warmth; CPAP
 Suction PRN
 Prevent complications
 sodium bicarbonate- for acidosis

MECONIUM ASPIRATION SYNDROME

 10-15% of all infants are meconium stained at birth, ~5% of meconium stained infants get MAS
 usually associated with fetal distress in utero, or postterm infant
 high incidence of MAS with thick meconium
 respiratory distress within hours of birth
 tachypnea, increased PCO2, small airway obstruction, chemical pneumonitis
 complications: hypoxemia, acidosis, persistent pulmonary hypertension (PPHN),
pneumothorax, respiratory failure, death
 treatment: supportive care and ventilation, may benefit from surfactant replacement (surfactant
function is inhibited by meconium)
 prevention: careful in utero monitoring, suction naso/oropharynx at perineum, then intubate
and suction below cords at birth

NEONATAL SEPSIS
Early Onset (birth- 8 days) Late onset (8- 28 days)
 begins in utero  Acquired after birth
 Risk factors:  Usually healthy, full-term
Maternal UTI, GBS positive, primary maternal  Same pathogens plus:
infection, maternal fever/ leukocytosis/ Pneumococcus, meningococcus, HSV,
chorioamnionitis, prolonged rupture of staphylococcus
membrane, prematurity, large inoculum
 GBS, E. coli, listeria, klebsiella

Signs of Sepsis
 Respiratory distress, cyanosis, apnea
 Tachycardia/ bradycardia
 Lethargy, poor feeding
 Hypotonia, seizures, bulging fontanelle

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  Jaundice
 Temperature instability (hypo/hyperthermia)

Rochester Criteria: for determining risk of febrile infant of having a serious bacterial infection
 Risk < 1% if
o past health
 Born at (37 weeks gestation)
 Home with or before mother
 No subsequent hospitalizations
 No perinatal, postnatal or current antibiotics
 No treatment for unexplained hyperbilirubinemia
 No chronic disease
o Physical exam
 Rectal temperature > 38.0C
 Appears generally well (no evidence of infection)
o Laboratory
 Total WBC 5-15 x 10(9)/L
 Bands < 1.5 x 10 (9)/L
 Urine > 10 wbc/hpf
 Stool (if diarrhea) > 5 WBC/ hpf
 If criteria are met, may observe on out-patient basis without specific antibacterial treatment
 If F/U is a problem, observation should be done in hospital

Antibiotic Treatment of Serious Bacterial Infections

Neonate
Pathogens: GBS, E. coli, Listeria, S. aureus ampicillin + gentamicin
Or
Ampicillin + cefotaxime
+/- cloxacillin if risk of S. aureus
1-3 months ampicillin + cefotaxime

Same pathogens as above and below +/- cloxacillin if risk of S. aureus

> 3 months
Pneumococcus, H. influenzae type b (> 5 years)* cefuroxime
ceftriaxone or cefotaxime, if risk of meningitis
vancomycin, if penicillin/ cephalosporin-
resistant pneumococci

* Hib has dramatically decreased since introduction of Hib vaccine

HYPERBILIRUBINEMIA
because of the immaturity of the liver, kernicterus (= staining of brain damage or even death) appears
to occur at a lower bilirubin level. Management: phototherapy= photooxidation by the use of artificial
blue light in order to convert bilirubin into an excretable form. Nursing responsibilities in phototherapy
care:
 expose all areas of the body to light by turning the infant every 2 hours
 cover eyes and genitalia
 give plenty of fluids to prevent dehydration
 check the loose stools and increased body temperature

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Hyperbilirubenemia
 More than 12mg of indirect bilirubin among full terms
 Normal Indirect Bilirubin Level: 0 – 3 mg/dl

Kernicterus/ Bilirubin Encephalopathy

 Irreversible brain damage
 > 20 mg/dl of indirect bilirubin among full terms
 > 12 mg/ dl of indirect bilirubin among preterm because of immaturity

Physiologic Jaundice Pathologic Jaundice Breastfeeding Jaundice

Normal Within 24 hours Within 6th – 7th day
Within 48 – 72 hours Yellow upon birth Due to glucoronyl transferase
Mx:
Expose to early morning Possible Rh/ ABO
sunlight incompatibility

Assessment of Jaundice
 blanching of forehead, nose and sternum
 yellow skin, sclera
 light stool
 dark urine

Management
 Phototherapy/ Photooxygenation
o Nursing Responsibilities
 Cover the eyes – prevents retinal damage
 Height of light from baby – 18 – 20 inches
 Increase Fluid intake
 Cover genetalia – prevent priapism ( painful continuous erection
 Change position
 Avoid lotion and oils
 Monitor I&O – best way is to weigh the baby
 Monitor VS

SUDDEN INFANT DEATH SYNDROME (SIDS)

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

Prevention:
 Place infant on back, NOT in prone position

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  Alarm/other monitors not recommended- increase anxiety and do not prevent life-threatening
event
 Avoid overheating and overdressing
 Appropriate infant bedding

B. Common health problems that develop during infancy example: intussusception, failure to thrive,
sudden infant death syndrome, colic, trisomy 21, cleft palate, imperforated anus, hirchsprung's
disease, spina bifida, hydrocephalus, otitis media, meningitis, febrile seizures, autism/ADHD

INTUSSUSCEPTION
 Invagination of one portion of the intestine to another (telescoping is a good synonym for it)
 Generally occurs at 6-12 months
 Typically idiopathic in patients under 12 months
 May be related to another disorder in patients over 12 months.

 Signs and symptoms

o Acute paroxysmal abdominal pain

o Currant jelly stool caused by inflammation and bleeding
o Sausage shaped mass
 Peritonitis – danger of intussusception
 Emergency for URT – epiglotitis
 Emergency for GIT – peritonitis
 Non congenital
 Caused by fast eating and positioning

Treatment of intussusception:

 Surgery - anastomosis
 Reduction by fluid/air/barium (done in radiology)

FAILURE TO THRIVE

 sign of inadequate growth resulting from inability to obtain or use calories required growth
 No universal definition
 Energy requirements
 0-10 kg: 100 cal/kg/day
 10-20 kg: 1000 cal + 50/kg/day for each kg> 10
 20 kg +: 1500 + 20 cal/kg/day for each kg> 20
 May have other nutritional deficiencies, eg. Protein, iron, vitamin D

Common parameter:

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  WEIGHT, sometimes height that falls below 5th percentile for child’s age
 Weight for age (height) z value of less than -2.0
 Weight curve (loss) that crosses >2 percentile lines on National Center for Health Statistics
(NCHS) growth after previous achievement of a stable growth pattern.

Approach to a child with FTT

 History
o Duration of problem
o Detailed dietary and feeding history, appetite, behavior during feeds
o Pregnancy, birth and postpartum history; developmental and medical history, including
medications; social and family history (parental height and weight)
o Assess 4 areas of functioning: child’s temperament, child-parent
Interaction, feeding behavior and parental psychosocial stressors
History Findings in Failure to Thrive

Poor caloric intake Diarrhea, dysentery, fever

breastfeeding mismanagement inflammatory bowel disease
lactation failure radiation, chemotherapy
improper formula preparation hypogeusia, anorexia
maternal stress, poor diet, illness recurrent infections
eating disorders rash, arthritis, weakness
aberrant parental nutritional beliefs jaundice
food faddism polyuria, polydipsia, polyphagia
diaphoresis or fatigue while eating irritability, constipation
poor suck, swallow mental retardation, swallowing difficulties
vomiting, hyperkinesis intrauterine growth delay
billous vomiting
recurrent pneumonias, steatorrhea

 Physical examination
o Height, weight, head circumference, arm span,
o Assessment of nutritional status, dysmorphism, pubertal status, evidence of chronic
disease
o Observation of a feeding session and parent-child interaction
o Signs of abuse and neglect

Physical Findings in Growth Deficiency

Cleft lip and palate Short stature

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

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3 General Categories
A. Organic Failure to Thrive - Physical Cause
 Inadequate intake
o Insufficient breast milk production
o Inappropriate feeding practices
o CNS, neuromuscular, mechanical problems with swallowing, sucking
o Anorexia (associated with chronic disease)
 Inadequate absorption
o Malabsorption: celiac disease, cystic fibrosis (CF), pancreatic insuffiency
 Inappropriate utilization of nutrients
o Renal loss: e.g. tubular disorders
o Loss from GI tract: chronic diarrhea, vomiting
o Inborn errors of metabolism
o Endocrine: type 1 diabetes, diabetes insipidus (DI), hypopituitarism
 Increased energy requirements
o Pulmonary disease: CF
o Cardiac disease
o Endocrine: hyperthyroidism, DI, hypopituitarism
o Chronic infections
o Inflammatory: systemic lupus erythematosus (SLE)
 Decreased growth potential
o Specific syndromes, chromosomal abnormalities
o Intrauterine insults: fetal alcohol syndrome (FAS)
 Treatment: cause specific

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

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

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

DOWN SYNDROME (TRISOMY 21)

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

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  Statistically greater risk if mother is over 35, but 80% born to women under the age of 35.
 Paternal age may also be a factor
 Degree of physical and cognitive development impairment related to the percentage of cells
with abnormal chromosomal makeup

Clinical manifestations of Down syndrome

 Intelligence varies from severely affected to near-normal intelligence

 Social: 2-3 years behind mental age, especially in childhood
 Congenital anomalies: 30-40% has a congenital heart disease, especially septal defects. May also
have GI and ortho alterations.
 Respiratory—infections very prevalent
 Due to hypotonia; swallowing muscles are weak—prone to aspiration
 Growth—rate reduced in height and weight as children; but often overweight as teens/adults
 Sexual development—may be delayed, incomplete, or both

Physical manifestations

 Head—separated sagital suture

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

Prognosis with Down syndrome

 Improved in recent years

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

Possible nursing diagnoses for DS

 Potential for infection related to hypotonia, increased susceptibility to respiratory infection

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

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CLEFT LIP AND PALATE
1. Cleft lip occurs when there is a failure of the fusion of the maxillary and median nasal
processes.
2. Cleft palate occurs when there is a failure of the fusion of the palatal process (roof of the
mouth)

Associated Nursing Diagnoses for Cleft lip and palate

5. Risk for fluid volume deficit

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

Treatment for cleft lip and palate

 Special nipples before surgery and while recovering

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

Cleft Lip
 Failure of the median maxillary nasal process to fuse
 Common to boys
 Surgery – cheiloplasty
o Done w/in 1 – 3 months
o To save sucking reflex
 Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common
o Frequent URTI and otitis media
 Post cheilo – sidelying
 Nutrition – use rubber tip syringe

Cleft Palate
 Failure of the palate to fuse
 Common to girls
 Surgery – Uranoplasty
o Done w/in 4 – 6 months
o To save speech
 Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common

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 o Frequent URTI and otitis media
 Post cheilo – prone
 Nutrition – use paper cup/ plastic cup/ soup spoon

Condition to consider for suspension of operation

 If child has a cold/ nasopharyngitis – may lead to general septicemia

General management
 Maintenance of patent airway
 Proper nutrition
o NPO 4 hours post op
o Clear liquid
 Popsicle except red and brown in color
 Flavore gelatin
 No ice cream
 Observe for bleeding
o Frequent swallowing
 Protect suture lines specially LOGAN BAR
o Clean using hydrogen peroxide, bubbles traps microorganism, more bubbles more
microorganism trapped
o Prevent crying by attending to needs

Therapeutic Management
 Emotional support
 Proper Nutrition
 Cleft lip nipple (long tip, made by silicon)
 Prevent Colic
o Burp frequently
o One at the middle of the feeding
o Another at the end of the feeding
o Upright sitting position
o Pat at the back – lower to upper
o Prone position
o Right – sidelying position – facilitates gastric emptying
 Educate parents
 Apply elbow restraints so the baby can easily adjust post –op

IMPERFORATE ANUS
A. unknown etiology- arrest in embryonic development at 8 weeks of intrauterine life
B. Types
a. type I- stenosis
b. type II- membranous
c. type III- agenesis (low and high)
low – distance less than 1.5 cm
high – distance greater than 1.5 cm
d. type IV – atretic

C. Signs and symptoms

1. no anal opening
2. temporary colostomy – if poor surgical risk (very young baby; malnourished; high agenetic or

65
 atretic type)
3 Surgery

a. anoplasty
b. abdominoperineal pull-through

4 Post operative care

 expose perineum to air by putting infant on supine with legs suspended straight up or on prone
position
 check bowel sounds frequently
 NGT for gastric decompression
 change position from side to side to decrease tension on suture line
 oral feedings resumed 1-2 days post-op when peristalsis has resumed (fluids are retained;
stools/ flatus passed)

HIRSCHPRUNG’S DISEASE (CONGENITAL AGANGLIONIC

MEGACOLON)
 Absence of ganglionic innervation to a portion of the bowel
 Peristalsis does not occur in non-innervated bowel areas
 Patient’s have chronic constipation or ribbon-like stools

Treatment of Hirschsprung’s disease

 Surgery to remove the agangilionic colon segment

 May be done in 2 stages, with a temporary colostomy for 6-8 months to allow bowel to rest.

SPINAL BIFIDA
 congenital problem in which there is a defective closure of the spinal column

A. Classification
1. Occulta- L5 and S1 are usually affected, with no protrusion of spinal contents. Skin over the
defect may reveal a dimple, a small fatty mass or a tuft of hair
2. cystica
a. meningocoele
b. myelomeningocoele= congenital failure of the arches of one or more vertebrae to unite at
the center of the back, so that the bony wall normally surrounding the spinal canal at that place
is missing. There is external protrusion, through a transparent sac, containing spinal fluid,
meninges, spinal cord and/or nerve roots. It is the most severe of the spinal deformities

B. Associated clinical problems – depend on the location; all body parts below the lesion are affected

1. Motor function:
a. feet may be deformed
b. joints of ankles, knees or hips may be immobile

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 c. variable degrees of weakness in lower extremities
d. spontaneous and induced movements are decreased or absent

2. Sensory function:
a. sensations usually absent below the level of the defect
b. ulcerations of the skin are common
3. impaired functioning of the autonomic nervous system
a. skin is dry and cool
b. sweating ability is impaired

4. urinary and bowel problems

a. inefficient bladder causes constant urinary dribbling
b. stasis or urine causes UTI
c. possible renal destruction
d. fecal incontinence or retention due to poor innervation of the anal sphincter and bowel
musculature

C. Preoperative management/conservative treatment

1. careful handling to avoid rupture, pressure, irritation or leakage from the protruding mass by
putting child on prone position, with the hips abducted
2. meticulous skin hygiene to prevent irritation sterile donut ring over the lesion
3. watch for signs of increased intracranial pressure
a. anterior fontanelle for tenseness, fullness and bulging
b. shrill, high-pitched cry
c. measure head circumference for any significant increase
d, vomiting, irritability
e. increasing BP, decreasing PR and RR and widening pulse pressure
4. passive range of motion (ROM) exercise to impaired lower extremities

Surgical correction:
1. early excision of the sac if it is small and primary closure is done
2. if base of the defect is too large for primary closure, conservative treatment is carried out first
while waiting for epithelialization to take place and then closure is done at a later time

Postoperative care
1. keep on prone position
2. monitor urine output- bladder injury is a high possibility in operations involving the spinal
column
3. measure head circumference daily
4. monitor movement of lower extremities

Complications
1. meningitis
2. severe neurologic deficits
3. hydrocephalus
a. Types:
** noncommunicating = blockage within the ventricles which prevents CSF from entering the
subarachnoid space
** communicating = obstruction in the subarachnoid cistern at the base of the brain and / or
within the subarachnoid space
b. Management:

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 * 1.5- 2 Gms. Mannitol 20%/KBW over 10-15 minutes- since mannitol is a diuretic, an
indwelling catheter should be inserted for accurate recording of intake and output
 ventriculo-peritoneal/ ventriculo-atrial shunt – to bring CSF to an area from where it can be
excreted from the body. After the procedure, the child should be positioned on the side
where the shunt is to prevent sudden decrease in intracranial pressure

Diagnostic evaluation

 Clinical manifestations
 Meningeal sac (can be transilluminated)
 Ultrasound prenatally

Care of the myelomeningocele sac

 Evaluate the sac and measure the lesion

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

Associated Nursing Diagnoses

4. Potential for infection related to presence of infective organisms, nonepithelialized

meningeal sac
5. Potential for trauma r/t delicate spinal lesion
6. Potential for impaired skin integrity r/t paralysis, continual dribbling of urine or feces
7. Potential for trauma r/t impaired cerebrospinal circulation
8. Potential for injury r/t neuromuscular impairment

HYDROCEPHALUS

 Caused by imbalance in production and absorption of CSF

 CFS accumulates within ventricular system of brain, producing dilation of ventricles.

Mechanisms of Fluid imbalance in Hydrocephalus

 Tumor of choroid plexus (the area that produces CSF in brain) may cause increased secretion
of CFS.
 Choroid tumors are rare, but structural malformations may cause impaired absorption or
obstruction to outflow of CSF.
 Imbalance of secretion and absorption of CFS causes CFS to accumulate in the ventricles,
which dilate and compress against cranium

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  Skull also enlarged
 Most are a result of developmental malformations (in ventricular system)
 Usually presents in infancy, but can also be up to early childhood
 Other causes: infections, neoplasms, trauma, brain damage

Clinical manifestations of hydrocephalus

 Influenced by acuity of onset and presence of pre-existing structural lesions

 In infancy, head grows at an abnormal rate
 Anterior fontanel tense, bulging, dilated scalp veins (due to the skin stretching)

Manifestations of Hydrocephalus in childhood

 Caused by increased ICP

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

Diagnosis

3. Head circumferences
4. Associated Neuro signs
5. CT, MRI, skull x-ray
6. Dye inserted into ventricle through anterior fontanel—will not appear in CSF from lumbar
puncture if non-communicating

Therapeutic management

 Relief of hydrocephalus
 Treatment of complications
 Management of issues related to psychomotor alterations

Surgical treatment

 Direct removal of obstruction if present (cyst, neoplasm, Hematoma)

 A shunt is inserted under the skin the drain ventricles, may include a reservoir to add
medications and remove fluid.

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More on Shunts…

 Valves open at a predetermined intraventricular pressure and close when the pressure falls below
that level (prevents backflow)
 Ventriculo-Peritoneal (VP) shunt is preferred for infants and young children
 Ventriculo-Atrial (VA) shunt (ventricle to right atrium) reserved for older children who have attained
most of their growth and for children with abdominal pathology (perforation of bowel, etc.)

Complications of shunts

 Mechanical obstruction within ventricles from tissue or exudates, displacement related to

growth, thrombus (clot)
 Often presents as an emergency; increased ICP and worsening of neuro status
 Infection—the most serious complication. May occur at any time but the greatest risk is 1-2
months after placement. (tubing colonized with bacteria)

Postoperative care after shunt placement

 Position on un-operated side

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

Signs of CSF infection

 Elevated vital signs

 Poor feeding
 Decreased LOC
 Seizures

Associated nursing diagnoses

 Potential for injury related to increased ICP

 Potential for infection related to presence of mechanical drainage system

 Altered family processes related to having a child with a chronic illness

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

Predisposing factors
 Bottle propping
 Cleft lip/ palate

Signs and symptoms

 During otoscopic exam, reveals bulging tympanic membrane
 Observe for passage of purulent, foul – smeeling odor discharge

Management
 Positioning – sidelying on the affected side
 Supportive care

Medical management
 Massive dosage of antibiotics
 Mucolytics
 Ear drops
 < 3 y/o – down and back
 >3 y/o – up and back
 Surgery
 Myringectomy – slight incision of tympanic membrane to prevent hearing loss
Side effect – bacterial meningitis

BACTERIAL MENINGITIS

Infections or inflammation of the cerebral meninges (the membranes covering the brain and
spinal cord)

4. 90% of cases are between 1 month and 5 years

5. Peak incidence is in the winter.
6. Causative organisms (95% of cases)
1. H. Influenzae (type B)
2. Streptococcus pneumoniae
3. Neisseria meningitis- epidemic form; droplet from nasophargeal secretions
1. MUST be put on droplet isolation

Pathophysiology of Bacterial meningitis

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

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  Once pathogen enter the meningeal space, they spread rapidly
 Produces an inflammatory effect that leads to thick exudates that blocks CSF flow.
 Brain becomes edematous, covered with purulent exudate.
 Spreads VERY quickly through CNS

Clinical signs in Children and Adolescents

4. Usually have 2-3 days of a cold, upper respiratory infection and occasionally and ear infection.
5. Become VERY irritable due to headache
6. May have convulsions
7. photophobia
8. As the disease progresses, more signs of meningeal irritability occurs:
1. Positive Brudzinski’s (image on page 674)
1. When child’s head is flexed forward (while laying on back), both hips, knees and ankles
flex. This shows meningeal irritation
2. Positive Kernig’s (image on page 674)
1. Flex child’s hips and knee (while laying on back)
2. Then extend leg—this will cause pain, resistance and spasm which indicate irritation.
3. Nuchal rigidity occurs (neck stiffness)
4. In the newborn—poor sucking, weak cry, lethargy

Diagnostic Evaluation—Lumbar Puncture

 Obtained by history and analysis and CSF via Lumbar puncture

o Culture and gram stain identify causative organism
 Blood cell count—WBC elevated
 Lowered glucose
o Increased metabolic rate due to the body and brain trying to fight off infection; draws
glucose out of blood for energy.
 Protein content increased
o Due to extra cells and metabolism occurring in the CNS

Therapeutic Management

 Medical emergency!
 Directly put on droplet isolation precautions
 IMMEDIATE antimicrobial therapy
 Hydration
 Ventilation (not in all cases)
 Reduction of increased ICP
 Management of shock and Disseminated intravascular coagulation (DIC)
 Tidbits on DIC: Normally, when you are injured, certain proteins are turned on and travel to
the injury site to help stop bleeding. However, in persons with DIC, these proteins are
abnormally active. Small blood clots form throughout the body. Overtime, the clotting
proteins become "used up" and are unavailable during times of real injury
 This disorder can result in clots or, more often, bleeding. Bleeding can be severe.
 Control of seizures, temperature

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FEBRILE CONVULSIONS
1. Seizures associated with high fever (102-104 degrees F)
2. Most common in preschool children or between 5 months and 5 years of age
3. Usually no more than 5-7 of these episodes occur in a child’s life

Seizure activity

 Seizure usually lasts 15-20 seconds

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

Prevention of Febrile convulsions

 Give Tylenol to keep fever below 101

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

Therapeutic management of seizures

 Teach parents that after the seizure subsides, they should:

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

Healthcare facility will:

 Determine underlying cause

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

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C. Health problems common in toddlers

BURN TRAUMA
Injury to body tissues caused by excessive heat

HIGH RISK BURN VICTIM: CHILD

• Higher proportion of body fluid to smaller muscle & fat mass, thinner skin® Higher mortality r/t
– Fluid & heat loss
– Dehydration
– Metabolic acidosis
– Cardiovascular collapse
– Protein & calorie deficiency
– Infection

MODIFIED RULE OF NINES ASSESSMENT OF EXTENT (INFANTS)

PARTSANTERIORPOSTERIORHead9.59.5Neck 11Upper Arm22Lower

Arm1.51.5Hand1.251.25Trunk13-Back13-Genital1-Each Buttock2.5-
Thigh2.752.75Leg2.52.5Foot1.751.75
5-9 YEARS
PARTSANTERIORPOSTERIORHead6.56.5Neck 11Upper Arm22Lower
Arm1.51.5Hand1.251.25Trunk13-Back13-Genital1-Each Buttock2.5-Thigh44Leg33Foot1.751.75

Characteristic
1st Degree Involves only the superficial epidermis characterized by erethema,
Partial dryness and pain
Thickness Ex: Sunburn – heals by regeneration in 1 – 10 weeks
2nd Degree Involves the entire epidermis, and portion of the dermis,
Partial characterized by erythema, blistered and moist from exudates which
Thickness is extremely painful
Ex: Scalds
3rd Degree Involves skin layers, epidermis and dermis, may involve adipose
Full Thickness tissue, fascia, muscle and bone. It appears to be leathery, white or
black, not sensitive to pain since nerve ending had been destroyed
Ex: Lava Burn

Management:
 First Aid
o Put out the flames by rolling the child on a blanket
o Immerse the burned part on cold water
o Removed burned clothing (sterile material)
o Cover burned part with sterile dressing
 Maintainance of patent airway
o Suction PRN
o O2 administration with  humidity
o Endotracheal Intubation
o Tracheostomy
 Prevention of shock and flued and electrolyte imbalances

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 o Colloids to expand blood volume
o Isotonic saline to replace electrolyte

FLUID RESUSCITATION: PARKLAND FORMULA

• Plain LR 4ml X body wt (kg) X TBSA burned
– ½ of total: 1st 8hrs post burn
– ¼ of total: 2nd & 3rd 8hrs post burn
– Goal: U.O.= 1ml/kg/hr
o Dextrose in water to provide calories
 Booster dose of Tetanus Toxoid
 Relief pain such as IV analgesic (morphine sulfate)
 Prevention of wound infection
o Cleaning and debriding the wound
o Open or close method of wound care
o Whirl pool therapy
 Skin grafting
o 3rd degree burn
o get skin from buttocks or pig skin (xenograft) or from frozen cadaver
 Diet   CHON and calories

POISONING
 Common accident in toddlers – poisoning
 Common accident in infants – falls
 Principles
o Determine the substance taken and assess LOC
o Unless poisoning was corrosive, caustic (strong alkali, such as lye) or hydrocarbon,
vomiting is the most effective way to remove the poison from the body
 Strong acid poisoning – give weak acid to neutralize strong acid
o Syrup of ipecac – oral antiemetic to cause vomiting after drug overdose or poisoning
 15 ml – adolescent, school age and preschool
 10 ml – infant
o Universal Antidote
 Activated charcoal
 Milk of magnesia
 Burned toast
 Charcoal absorbs toxic substance
o Never administer the charcoal before ipecac because giving charcoal first will absorb
the effect of ipecac
o Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst)
o Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and prevent poison
absorption
 Tracheostomy set will be at bed side

Lead Poisoning
 Pencil, paint, crayon Lead
↓
Destruction of RBC Functioning

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 ↓
hypochromic Microcytic Anemia
↓
Destroys Kidney Function
↓
Accumulation of ammonia
↓
Leading to Encephalitis (Late stage)
↓
Severe mental retardation
 Assessment
o Beginning symptoms of lethargy
o Impulsiveness and learning difficulty
o As lead ↑, severe encephalopathy with seizure and permanent mental retardation
 Diagnostic procedure
o Blood smear
o Abdominal x-ray
o Lone bone
 Management
o Chelation – binds with the lead and excreted via kidneys
o Ca EDTA/ BAL/ Dimercapro
 Nephrotoxic

Food poisoning

 Staphylococcus
 Clostridium perfringens
 Clostridium botulinum

Acetaminophen poisoning

 Toxic dose: >150mg/kg

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

Aspirin poisoning
 Toxic dose: Acute ingestion: 300-500mg/kg
 Chronic ingestion:>100mg/kg/day X2days or more
 Signs & Symptoms
 N/V, thirst, hypoglycemia, ¯Na+, ¯K+, diaphoresis, oliguria, bleeding, dehydration, fever
 Hyperpnea, confusion, tinnitus, seizure, coma, respiratory & circulatory failure
 Management
 Syrup of Ipecac, gastric lavage with activated charcoal
 Administer as ordered: IVF, NaHCO3, electrolytes, volume expander, glucose, Vit. K
 Prepare for dialysis if unresponsive to the therapy

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CHILD ABUSE AND NEGLECT
Definition
 An act of commission or omission (physical, sexual, or emotional) by another person that
harms a child in a significant way
 RA 7610
 An act providing for stronger deterrence and special protection against child abuse,
exploitation and discrimination
 child: anyone below 18 years old

Legal Duty to Report

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

Risk Factors
 environmental factors
o social isolation
o poverty
o domestic violence
 caregiver factors
o parents were abused as children
o psychiatric
 child factors
o difficult child (temperament)
o disability, special needs (e.g. mental retardation)
o premature

Physical abuse
 injury in an infant less than 12 months
 repeated multiple injuries of a child at any age
 distinctive marks: cuts, burns, rope mark, belt buckle
 atypical patterns of injury: bruises on the face, abdomen, buttocks
 altered mental status: head injury, poisoning
 shaken baby syndrome
 head trauma is the leading cause of death in child maltreatment
 violent shaking of infant resulting in intracranial hematomas retinal hemorrhages and
sometimes fractures
 diagnosis confirmed by head CT or MRI, ophthalmologic exam, skeletal survey/ bone scan

Sexual abuse
- prevalence: 1 in 4 females, 1 in 10 males
- peak ages at 2-6 and 12 -16 years
- most perpetrators are male and known to child
o most common: father, stepfather, uncle

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 - diagnosis usually depends on child telling someone
- physical exam is often normal
- presentation
o specific or generalized fears, depression, nightmares
o social withdrawal, lack of trust, low self-esteem, school failure
o sexually aggressive behavior, advanced sexual knowledge, sexual preoccupation,
sexual preoccupation or play
o recurrent UTIs, pregnancy, STDs, vaginitis, vaginal bleeding, genital injury

RED FLAGS – Presentation of neglects

- failure to thrive, developmental delay
- inadequate or dirty clothing, poor hygiene
- child exhibits poor attachment to parents, no stranger anxiety

Management of Child Abuse and Neglect

 history: interview parents and child separately
for children, use age appropriate toys to encourage child to tell what happened
 if one parent inflicts injury, the other parent is unable to protect
 physical exam
 head to toe (do not force)
 emotional state
 development
 document and/or photograph all injuries: type, location, size, shape, color, pattern
 laboratory may include STD workup, bone scan, CT/MRI
 report all suspicions to child abuse services (Bantay Bata 163)
 acute medical care: hospital if indicated or if concerns about further or ongoing abuse
 arrange consultation to social work and appropriate follow-up
 discharge child directly to CAS (child abuse services) or to responsible guardian under CAS
supervision

CEREBRAL PALSY
A group of non-progressive disorders of upper motor neuron impairment that result in motor
dysfunction.
 Can happen before, during, or after birth
 Occurs 2:1000 births
 Most common permanent disability of childhood

Incidence and Causes of CP

 Most frequently associated with brain anoxia that leads to cell destruction
o Symptoms can range from very mild to quite severe, depending on the extent of brain
damage
 Also can be caused by:
o Kernicterus (a form of jaundice from hyerbilirubinemia; staining of the brain with
bilirubin)

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 o Meningitis (viral is the most common)
 Occurs most frequently in very low weight infants (born prematurely), or those small for their
age.
o Their lungs haven’t been fully developed
 CP has increased over the past decade due to:
o Preemies are living longer
o Multiple births from artificial reproductive technologies
o Prenatal technology

Types of CP

 Two main categories based in type of neuromuscular involvement

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

Spastic or pyramidal CP

 Pyramidal system: conveys nerve impulses that create voluntary movements

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

Extrapyramidal CP

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  Extrapyramidal nerve tract conveys nerve impulses that effect autonomic movements:
o Help coordinate body movements
o Maintain skeletal muscle tone
o Play major role in equilibrium
 Ataxia (defective muscular coordination)
 Dyskinetic (a defect in the ability to perform voluntary movements)
 Athetoid—“wormlike”
o Limp and flaccid muscles as an infant
o Later, child makes slow, writhing motions (in place of voluntary muscles)
o May involve all four extremities, face, neck, tongue
o Due to poor tongue and swallowing movements, child may have poor speech and
problems with drooling
 Concerned about aspiration
o With emotional stress, involuntary movements may become irregular and jerky
 Ataxic
o Children have an awkward, wide-based gait
o On neurologic exam, unable to touch finger-to-nose or due rapid, repetitive movements
 Mixed
o Combination of more than one condition listed above

Diagnostic evaluation for diagnosis of CP

3. Neurological exam
4. History—especially born prematurely
5. Ultrasound of brain
6. CT scan
7. MRI

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Physical findings that may suggest CP

 Delayed motor development

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

Medical management of CP

o Overall goal—develop a rehabilitation plan to promote optimum function

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

Nursing Diagnoses

 Altered growth and development

 Impaired physical mobility
 Self-care deficits (bathing/toileting/dressing)

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  Self-esteem disturbance
 Impaired social interactions

General interventions

5. Promote maximal functioning of joints

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

Long term care for CP

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

Bell’s palsy/ Facial Nerve Paralysis

 7th CN injury
 usually related to forceps delivery
 risk for URTI
 Signs and symptoms
 Continuous drooling of saliva
 Inability to open one eye and close the other

 Management
 Artificial tear
 Self limiting
 Refer to PT for rehabilitation

D. Health problems common In preschooler

Example: leukemia, wilm's tumor (nephroblastoma), asthma, urinary tract infection (UTI)

LEUKEMIA

 Group of malignant disease characterized by rapid proliferation of immature RBC

 Ratio is 500 RBC : 1 WBC

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  The client is immunocompromised
 Classification of Leukemia
o Lympho – affects the lymphatic system
o Myelo – affects the bone marrow
o Acute/ Blastic – affects the immature cells
o Chronic/ cystic – affects the mature cells

Acute Lymphocytic Leukemia

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

 Diagnostic examinations
1. Peripheral Blood Smear  reveals immature WBC
2. CBC  reveals anemia and thrombocytopenia; neutropenia
3. Lumbar Puncture
■ To determine CNS involvement
■ Fetal position without flexion of the neck because it will cause airway obstruction
■ C position or shrimp position

4. Bone Marrow Aspiration

■ Determines the presence of blast cells
■ Site of bone marrow aspiration  iliac Crest  post op : prevent hemorrhage
■ Lie on affected site

5. Bone Scan  determines the degree of bone involvement

6. CT Scan  determine the degree of organ involvement

Management Triad
 Surgery
 Irradiation
 Chemotherapy

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  Bone marrow transplant

Levels of Chemotherapy

 Induction
 To achieve remission
 Drugs
■ IV – Vincristine
■ L – Asparagine
■ Oral Prednisone

 Sanctuary
 To treat the leukemic cells that has invaded the testes and CNS
 Drugs
 intrathecal methotrexate – via spine
 cytocine
 arabinase
 steroids
 Irradiation

 Maintenance
 To continue remission
 Drugs
 oral methotrexate
 oral 6-mecaptopurine
 cytarabine

 Reinduction
 Give anti-gout agent
 To treat leukemic cells after relapse occurs
 Treat hyperurecemic neuropathy
 Allopurinol or zyloprene

Nursing Management
 Assess for common side effects of chemotherapy – nausea and vomiting
 Assess for stomatitis ulceration and abcess of oral mucosa
 Oral care
 Alcohol free mouthwash
 Cotton piedgets
 Diet – give food acoording to child’s preference
 Alopecia – temporary side effect of chemotherapy

NEPHROBLASTOMA (Wilm’s Tumor)

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

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Signs & Symptoms
 Mass within abdomen (firm, nontender, confined to 1 side & deep within the flank)
 Abdominal pain
 Urinary retention, hematuria
 Anemia (r/t tumor hemorrhage), pallor, anorexia, lethargy
 HTN (r/t renin production by tumor)
 Weight loss, T
 Lung involvement: dyspnea, chest pain

Management
 Monitor VS, esp. BP
 Place a sign “DO NOT PALPATE ABDOMEN” at bedside
 Measure abdominal girth
 WOF abdominal distention, ¯bowel sounds because of risk of GI obstruction post op

ASTHMA
 Characterized by airway hyperactivity, bronchospasm and inflammation, reversible small
airway obstruction
 very common illness which presents most often in early adulthood
 associated with other atopic diseases such as allergic rhinitis or eczema

Clinical Features
 episodic bouts of
 wheezing
 cough: at night, early morning with activity
 tachypnea
 dyspnea
 tachycardia

Triggers
 URI (viral or Mycoplasma)
 weather (cold exposure, humidity changes)
 allergens (pets), irritants (cigarette smoke)
 exercise, emotional stress
 drugs (aspirin, beta blockers)

Classification
 mild asthma
 occasional attacks of wheezing or coughing (< 2 per week)
 symptoms respond quickly to inhaled bronchodilator
 moderate asthma
 more frequent episodes with symptoms persisting and chronic cough
 decreased exercise tolerance
 severe asthma
 daily and nocturnal symptoms
 frequent ER visits and hospitalization

Management

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  acute
 O2: to keep O2 saturation > 92%
 fluids: if dehydration
 beta agonists: salbutamol (ventolin) 0.03 cc/kg in 3 cc NS q 20 mins, mins by mask until
improvement, then masks q hourly if necessary
 ipratropium bromide (Atrovent) if severe: 1 cc added to each of first 3 Ventolin masks
 steroids: prednisone 2 mg/kg in ER, then 1 mg/kg po od x 4 days
■ in severe disease, give steroids immediately since onset of action is slow (4 hours)
 indications for hospitalization
 initial O2 saturation < 92%
 past history of life threatening asthma (ICU admission)
 unable to stabilize with q4 Ventolin masks
 concern over environmental issues or family's ability to cope

 chronic
 education, emotional support, avoidance of environmental allergens or irritants,
development of an “action plan”
 exercise program (e.g. Swimming)
 monitoring of respiratory function with peak flow meter (improves compliance and allows
modification of medication)
 patients with moderate or severe asthma will need regular prophylaxis in addition to
bronchodilators (e.g. Daily inhaled steroid, long-acting beta-agonist, anticholinergics,
sodium cromoglycate, theophylline)

URINARY TRACT INFECTION (UTI)

 newborns - more common in males (especially if uncircumcised)
 children - more common in females due to straight short urethra

Etiology
 E. coli serotypes from bowel flora (most common)\
 others: Klebsiella, Proteus, enterococci, S. saprophyticus

Risk Factors
 female (after 2 years), neurogenic bladder, reflux, genitourinary (GU) tract abnormalities,
diabetes, immunocompromised, uncircumcised male

Complications
 children 2 months to 2 years are at greatest risk of renal damage from UTI

Clinical Features
 neonates: feeding difficulties, fever, vomiting, jaundice, FTT
 preschool: fever, increased frequency, urgency, dysuria, abdominal pain, vomiting
 school-age: fever, enuresis, increased frequency, urgency, dysuria, flank pain

Diagnosis
 febrile infant < 2 months requires full septic work-up (see Infectious Diseases section)
 unexplained fever in child 2 months to 2 years of age ––> consider UTI

E. Health problems most common in school aged children

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example: diabetes mellitus, rheumatic fever, rheumatic arthritis, scabies, pediculosis, impetigo

DIABETES MELLITUS
Type 1 Diabetes
❏ insulin dependent, most common type in childhood
❏ prevalence: 1 in 400-500 children under 18 years of age
❏ etiology: genetic predisposition and environmental trigger
• autoimmune destruction of ß-cells of the pancreas (antibodies directed towards glutamic acid
decarboxylase have been identified)
• a non-immune variation has been described
❏ classic presentation: polyuria, polydipsia, abdominal pain, weight loss, and fatigue
❏ 25% present in diabetic ketoacidosis (DKA)
Management of Uncomplicated Diabetes
❏ insulin, blood glucose monitoring
❏ young children more susceptible to CNS damage with hypoglycemia with fewer benefits from tight
control, hence target glucose range higher at 6-12 mmol/L (110-220 mg/dL)
❏ increasingly tighter control in older children, 4-8 mmol/L (70-140 mg/dL)
❏ meal plan, exercise, education, psychosocial support

Complications of Diabetes
❏ hypoglycemia
• cause: missed/delayed meals, excess insulin, increased exercise
• complications: seizures, coma
• must have glucagon kit for quick injections
❏ hyperglycemia
• cause: infection, stress, diet-to-insulin mismatch
• complications: risk of DKA, long-term end-organ damage
❏ DKA
• cause: new-onset diabetes, missed insulin doses, infection
• medical emergency: most common cause of death in children with diabetes (attributed to cerebral
edema)
❏ long-term complications (retinopathy, nephropathy, neuropathy)
• usually not seen in childhood (often begin 5 years after presentation or 3-5 years after puberty)
Type 2 Diabetes
❏ incidence increasing dramatically in children: up to 7.2 in 100,000
❏ especially prevalent among North American Aboriginals, Africans, Asians, Hispanics
Mature Onset Diabetes of the Young (MODY)
❏ autosomal dominant inheritance

RHEUMATIC HEART DISEASE

 Inflammatory disease following an infection caused by Group A Beta Hemoilytic Streptococcus

 Affected body parts
o Musculoskeletal
o Cardiac muscle
o Integumentary system
o CNS
 Tonsillitis due to love of sweets with no oral hygiene serving a good medium for bacterial
growth causing inflammation

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  Group A Beta Hemolytic Streptococcus will release toxin and enters circulation
 Group A Beta Hemolytic Streptococcus is an anaerobic organism and will stay at the left side of
the heart or the mitral valve as an ASCHOFF BODIES
 ASCHOFF BODIES – round nodules with multi nucleated cell and fibroblast that stays in the
miral valve
 Left sided heart failure because of mitral stenosis due to increase in the size of Aschoff Bodies
 Diagnostic Exam: JONE’S CRITERIA
Major Minor
Polyarthritis – multi Low grade fever
joint pain
Athralgia – joint pain Diagnostic Exams
CHOREA/  Antibody
Sydenhamm’s  C reactive protein
Chorea/ St. Vitous  ESR
Dance – involuntary,  Anti Streptolysin Titer
purposeless
Carditis – signs of
tachycardia
Erythema
Marginatum –
macular rashes
Subcutaneous
nodules
Presence of 2 major or 1 major and 2 minor plus a history of
sore throat will confirm diagnosis

 Management
o Bed rest
o Avoid contact sports
o Throat swab for C & S
o Antibiotics – purpose is to prevent recurrence
o Aspirin Therapy or salicylates – act as an anti-inflammatory agent in RHD
o Side effect: Reye’s Syndrome  encephalopathy accompanied by fatty infiltration of the
organs such as the heart and liver

JUVENILE RHEUMATOID ARTHRITIS (JRA)

❏ a heterogenous group of conditions characterized by a persistent arthritis in childhood

❏ diagnosis
• arthritis in at least one joint
• lasts for at least 6 weeks
• onset before the age of 16
• other causes of arthritis excluded
❏ classification
• defined by features/number of joints affected in the first 6 months of onset
• systemic onset - fever at onset with arthritis appearing later
• pauciarticular - 4 or less joints involved
• polyarticular - 5 or more joints involved
❏ prognosis: worst prognosis with systemic onset and polyarticular course

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• outcome of most children is favourable
• best prognosis in young female with pauciarticular disease
Systemic (Still's Disease)
❏ high spiking fever (= 38.5°C) for at least 2 weeks
❏ extra-articular features: erythematous “salmon-coloured” maculopapular rash, lymphadenopathy,
hepatosplenomegaly, leukocytosis, thrombocytosis, anemia, serositis (pericarditis, pleuritis)
❏ arthritis may occur weeks to months later

Pauciarticular
❏ Type I
• most common subtype, peak age 2 years
• usually involves large joints: knee, ankle or elbow, rarely shoulder or hip
• often resolves without permanent sequelae
• prone to chronic iridocyclitis and uveitis, which, if untreated may lead to permanent visual damage
• slit lamp exam should be done early in child presenting with joint swelling and then every 3 months if
ANA positive
❏ Type II
• at onset, there is an asymmetrical peripheral arthritis usually confined to joints below the waist
(hip, knees, ankles, feet)
• enthesitis (inflammation at tendon insertion sites) of Achilles tendon, patellar tendon, plantar fascia
• seronegative spondyloarthropathy may develop later in life
• family history of spondyloarthropathy, IBD or psoriasis

Polyarticular
❏ RF Negative
• often involves small joints of hands and feet, temporomandibular joint, sternoclavicular joint,
distal interphalangeal joints (DIP), cervical spine
• patients who are ANA positive are prone to chronic uveitis
❏ RF Positive
• similar to the aggressive form of adult rheumatoid arthritis
• severe, rapidly destructive, symmetrical arthritis of large and small joints
• associated with rheumatoid nodules at pressure points (elbows, knees)
• unremitting disease, persists into adulthood
Management
❏ children may complain very little about their pain and disability
❏ night splints to prevent development of contractures secondary to guarding and disuse
❏ exercise to maintain range of motion (ROM) and muscle strength
❏ multidisciplinary approach with OT/PT, social work, orthopedics, ophthalmology, rheumatology
❏ first line drug therapy: NSAIDs
❏ other options
• methotrexate
• corticosteroids - intra-articular, systemic, or topical eye drops
• hydrochloroquine
• sulfasalazine
• gold
• new biologic agents (etanercept: anti-TNF)

SCABIES
 Infestation of Sarcoptes scabiei (itch mite)
 F mite burrows into epidermis, lay eggs & dies after 4-5 wksThe eggs hatch in 3-5 days, larvae

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 mature & complete life cycle
 Contagious during course of infestation via direct contact
 Signs & Symptoms
 Intense pruritus esp. at night
 (+) burrows (fine grayish red lines) on skin
 Management
 Topical scabicides:
 Lindane cream (Kwell, Scabene) should not be used for <2 y/o: risk of neurotoxicity and
seizures; Crotamiton (Eurax)
 Warm soap-and-water bath
 Dry and cool skin
 Apply scabicide lotion; leave for 8-14 hrs before rinsing
 Permethrin 5% (Elimite): cream is massaged thoroughly and gently from head to soles;
avoid contact with eyes
 Treat all household members & close contacts
 Strict handwashing
 Change all clothing & bedding OD, wash in detergent with hot water, hot dryer & iron before
reuse
 Seal nonwashable toys & other items in plastic bag for 4 days

PEDICULOSIS CAPITIS (HEAD LICE)

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

IMPETIGO
 Highly infectious, caused by Group A b-hemolytic Streptococcus, possibly Staph aureus
 Predisposing factor: heavy infestation of Pediculosis capitis then pick nose
 Papulovesicular lesions (face, around mouth, hands, neck, extremities) surrounded by

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 localized erythema becoming purulent and ooze, forming a honey-colored crust
 Cx: AGN
 Management
 Contact isolation (Communicable for 48hrs without treatment)
 Skin care
■ Allow lesions to dry by air exposure
■ Daily bathing with antibacterial soap (pHisoHex)
■ Warm compress 2-3X/day to remove crusts
■ Use of skin emollients to prevent cracking
■ Proper hygiene
■ Strict handwashing
■ Use separate towels, linens, dishes (washed separately with detergent in hot
water)
■ Oral antibiotics (Penicillin)
■ Antibiotic ointment (Mupirocin)

F. Health problems common in adolescent

example: scoliosis, bone tumors, accidents (trauma/injury), STD, amenorrhea, dysmenorrhea, obesity,
anorexia nervosa, substance abuse, suicide

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

Types
 Functional scoliosis (in response to another condition)
o Occurs as a compensatory mechanism
o Usually due to unequal leg lengths
o Created a pelvic tilt that is C-shaped
o Must correct the initial problem
 A lift placed in one shoe
 Remind the child to maintain good posture (walking with book on head 3 x daily
for 10 minutes)
 Sit-ups and push-ups are good exercises

 Structural scoliosis
o Permanent curvature of the spine with damage to the vertebrae
o Spine has an S-shaped appearance
o Usually there is a family history
o 5x more common in girls than boys
o Usually peaks between 8-15 years (school age)
o Diagnosis is made on physical exam by having the child bend forward
 X-rays confirm diagnosis
 Therapeutic management:

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 o If spinal curve is less than 20 degrees, no therapy except close observation until the
child reaches 18 years of age)
o If greater than 20 degrees, may use braces, traction, surgery, or combination.

SEXUALLY TRANSMITTED DISEASES (STD)

SYPHILIS

Other names: Sy, bad blood, the pox, lues venereal, morbus gallicus

Causative Agent: Treponema pallidum (a spirochete)

Incubation Period: 10 to 90 days (3 months); average of 21 days

Mode of Transmission:
Direct contact
Transplacental (after 16th week AOG)
Indirect contact with contaminated articles

Signs and Symptoms:

 Primary stage (4-6 weeks); painless chancre at site of entry of germ with serous exudates
 Secondary syphilis (6-8 weeks): generalized rushes, generalized tender discrete
lymphadenopathy, mucous patches, flu-like symptoms, condylomata, patchy alopecia
 Tertiary stage (one to 35 years): Gumma, syphilitic endocarditis and meningitis
 Latent stage (one to two to 50 years): non-infectious

Primary and secondary sores will go even without treatment but the germs continue to spread
throughout the body. Latent syphilis may continue 5 to 20 + years with NO symptoms, but the person
is NO longer infectious to other people. A pregnant mother can transmit the disease to her unborn
child (congenital syphilis).

GONORRHEA

Other names: GC, Clap, Drip, Stain, Gleet, Flores Blancas

Causative agent:
Neiserria gonorrheae

Mode of Transmission:

Highest incidence in males between 20 and 24 y/o and in females between 18 and 24.
direct contact- genitals, anus, mouth

Incubation: 2 to 10 days. Symptoms can occur 3 to 30 days after

sexual contact; average is 2 to 5 days after exposure.

Usual Signs and Symptoms

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A. Females
1. Up to 80% have no symptoms
2. Abnormal, thick green (or yellow) vaginal discharge
3. Frequency, burning pain on urination
4. Urethral discharge
5. Rectal pain and discharge
6. Unilateral labial pain and swelling
7. Abnormal menstrual bleeding; increased dysmenorrhea (menstrual cramps)
8. Lower abdominal discomfort
9. Sore throat

B. Males
1. 4–10% have no symptoms
2. Frequency, pain on urination
3. Burning sensation in the urethra
4. Whitish discharge from the penis (early); may appear only as a drop during erection
5. Yellow or greenish discharge from the penis (late)
6. Sore throat

Diagnosis (for Both Sexes)

A. History of sexual contact with a person known to be infected with gonorrhea
B. Smears and cultures taken from infected areas (cervix, penis, rectum, and throat)

Treatment for Males and Females

Antibiotics: Drug of choice Penicillin. Be sure to tell your clinician if you are allergic to any
antibiotic.

Complications
A. Females: If gonorrhea goes untreated, it may lead to pelvic inflammatory disease (PID). PID
involves severe abdominal
cramps, pelvic pain, and high fever that will lead to scarring and possible blockage of the fallopian
tubes, the risk of tubal pregnancy, and infertility.
B. Males: If gonorrhea goes untreated, scar tissue may form on the sperm passageway causing pain
and sterility.
C. Females and males: The infection may spread throughout the body causing arthritis, sometimes
with skin lesions.

Patient Education (for Both Sexes)

A. All medication must be taken as directed. Prevention of gonococcal ophthalmia is done through the
prophylactic use of ophthalmic preparations with erythromycin or tetracycline.
B. No intercourse until treatment of self and partner(s) is completed. ABCs: abstinence, be faithful and
condom
C. Return to the clinician for reevaluation if symptoms persist or new symptoms occur after treatment
is complete.
D. Important: The responsible lover informs all partners immediately upon finding out about exposure
to sexually transmitted disease so that all persons involved can be evaluated adequately and treated
immediately.

TRICHOMONIASIS

Other names: Vaginitis, trich

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Mode of Transmission: direct contact

Incubation period: 4-20 days, average of 7 days

Signs and Symptoms:

Females:
white or greenish-yellow odorous discharge
vaginal itching and soreness
painful urination

Males:
slight itching of penis
painful urination
clear discharge from penis

Diagnosis:
culture

Treatment: Drug of choice: Metronidazole (Flagyl)

Prevention: ABC, personal hygiene

CHLAMYDIA TRACHOMATIS

Causative Agent: Chlamydia trachomatis

Transmission
Sexual contact with 2 to 3 week incubation period before symptoms present

Signs and Symptoms

A. In the female
1. Often no symptoms
2. Possibly, increased vaginal discharge with fishy odor
3. Cervicitis or an abnormal Papanicolaou smear
4. Possibly, frequent uncomfortable urination
5. Advanced symptoms include those of pelvic infection
B. In the male
1. Possibly, thick and cloudy discharge from the penis
2. Possibly, burning pain in urination and/or frequent urination; itching of urethral opening

Diagnosis
A. Evaluation may include tests to rule out candidiasis, trichomoniasis, bacterial vaginosis, gonorrhea,
syphilis, and urinary tract infection
B. Vaginal and urethral smears/ culture are examined for the Chlamydia trachomatis organism

Treatment
Drug of choice: tetracycline

Patient Education

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A. Any sexual contacts should be advised to seek evaluation and treatment.
B. Do not have intercourse until you and any sex partner(s) have completed treatment.
C. In an untreated male or female the disease may progress to further reproductive infection with
possible tissue scarring and infertility risks.
D. Wash all sex toys, diaphragm, cervical cap with soap and water or soak in rubbing alcohol or
betadine scrub. Be sure to rinse thoroughly.

CANDIDIASIS (MONILIA) YEAST INFECTION

Other names: moniliasis, candidiasis

Causative agent: Candida albicans

Transmission
A. Usually nonsexual.
B. Some common causes of candida overgrowth are: use of hormonal contraceptives such as birth
control pills, the patch, ring, implant; antibiotics; diabetes; pregnancy; stress; deodorant tampons and
other such menstrual products.

Signs and Symptoms

A. In the female
1. Vaginal discharge: thick, white, and curd-like
2. Vaginal area itch and irritation with occasional swelling and redness
3. Burning on urination
4. Possibly, pain with intercourse
B. In the male
1. Itch and/or irritation of penis
2. Cheesy material under foreskin, underside of penis
3. Jock itch; athlete’s foot

Diagnosis

A. Female evaluation may include vaginal examination to check for candida and rule out
trichomoniasis, bacterial vaginosis, Chlamydia, and gonorrhea.

B. Male evaluation may include:

1. Examination of penis to check for irritation and/or cheesy materials
2. Culture for ruling out gonorrhea and Chlamydia
3. Urinalysis

Treatment

Nystatin for oral thrush

Cotrimazole, fluconazole for mucous membranes and vaginal infection
Fluconazole or amphotericin for systemic infection

Patient Education
A. No intercourse until symptoms subside.
B. Continue prescribed treatment even if menses occurs, but use pads rather than tampons.
C. Ways to prevent recurrent candida (yeast) infections:
1. Bathe daily (with lots of water and minimal soap)

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2. To minimize the moist environment Candida favors, use:
a. Cotton-crotched or cotton underwear/pantyhose (or cut out crotch of pantyhose)
b. Loose-fitting slacks
c. No underwear while sleeping
d. Remember ABC: Abstain, be faithful and condom
3. Wipe the front first and then the back after toileting.
4. Avoid feminine hygiene sprays, deodorants, deodorant tampons/ minipads, colored or perfumed
toilet paper, tear-off fabric softeners in the dryer, etc., any of which may cause
allergies and irritation.
5. Some women have found that vitamin C 500 mg 2– 4 x each day helps or taking oral acidophilous
tablets 40 million to 1 billion units a day (1 tablet).

D. Over-the-counter medication. Many women choose to try an over-the-counter preparation before

seeking an examination. If symptoms do not subside after 1 course of treatment (1 tube or 1 set of
suppositories), having an examination for diagnosis is recommended.

AMENORRHEA
Definition
A. Primary amenorrhea: failure of the menses to occur by age 15
B. Secondary amenorrhea: cessation of the menses for longer than 6 months in a woman who has
established menses at least 1 year after menarche
Etiology
A. Primary Amenorrhea
1. Gonadal failure
2. Congenital absence of uterus & vagina
3. Constitutional delay

B. Secondary Amenorrhea
1. Pregnancy; breastfeeding
2. Pituitary disease or tumor; disruption of hypothalamicpituitary axis
3. Menopause
4. Too little body fat (about 22% required for menses)
5. Excessive exercise (e.g., long-distance running, ballet dancing, gymnastics, fi gure skating)
6. Rapid weight loss
7. Cessation of menstruation following use of hormonal contraception
8. Recent change in lifestyle (e.g., increase in stress, travel)
9. Thyroid disease
10. Polycystic ovary syndrome
11. Anorexia nervosa or other eating disorders
12. Premature ovarian failure, ovarian dysgenesis, infection, hemorrhage, necrosis, neoplasm
13. Asherman’s syndrome
14. Cervical stenosis—outfl ow tract anomaly
15. Medications including psychotropics
16. Chronic illness
17. Tuberculosis

History
A. What the patient presents with

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1. Absence of menstruation
2. Possible breast discharge
3. Other symptoms secondary to underlying etiology
B. Additional information to be considered
1. Careful menstrual history; pregnancy history
2. Sexual history
3. Contraceptive history
4. Medications—OTC, prescription, homeopathic, herbal
5. Sources of emotional stress
6. Symptoms of climacteric
7. Any current acute illness
8. History of chronic illness
9. Present weight, weight 1 year ago
10. Amount of daily exercise
11. Recent D&C or abortion
12. History of tuberculosis
13. Eating disorder—current or history of

Physical Examination
A. Weigh patient
B. Neck: thyroid gland (look for nodes: palpable, enlarged)
C. Breast: discharge
1. Breast examination
2. Milky, clear, dark, light, bloody, thick, thin, color
D. Vaginal examination (speculum): vagina may be atrophic and there may be no cervical mucus
E. Bimanual examination
1. Uterus: may be enlarged
2. Cervix—scarring, stenosis
3. Adnexa: ovaries may be enlarged—cystic
4. Recto-vaginal examination
F. Measure ratio of body fat to lean mass; BMI

Laboratory Examination
A. Human chorionic gonadotropin (HCG) qualitative, quantitative
B. Prolactin level
C. Thyroid stimulating hormone
D. Follicle stimulating hormone, luteinizing hormone, Dehydroepiandrosterone sulfate (DHEAS), and
serum testosterone (if patient is hirsute); hemoglobin, erythrocyte sedimentation rate
E. Papanicolaou smear
F. Microscopic examination of cervical mucus
G. TB test if no history
H. Consider pituitary function assessment, ultrasound, CAT scan, MRI, hysterosalpingography,
hysteroscopy after consultation with a physician
I. GnRH stimulation test

Treatment
A. If breast discharge is present, do not wait: do work-up as per breast discharge protocol.
B. If human chorionic gonadotropin (HCG) and prolactin levels are within normal limits, pregnancy test
is negative, the nurse practitioner may give Medroxyprogesterone acetate (Provera®) 5–10 mg per
day × 5–10 days.
1. If no withdrawal bleed in 3–7 days after progestin, consider follicle stimulating hormone and

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luteinizing hormone assays
2 weeks after Provera. Try oral estrogen 1.25–2.5 mg to prime the endometrium (estropipate) daily for
21–25 days; if no bleeding, add progestin during last 5–10 days of estrogen. If no withdrawal bleed,
refer to physician.
2. If woman wishes to start oral or other hormonal contraceptive and has no withdrawal bleed from
Provera, repeat HCG if indicated and start oral contraceptives or other hormonal method the following
Sunday regardless of brand of hormonal contraceptive used. If no withdrawal bleed after first cycle,
consult with physician.
3. If woman wishes to start oral or other hormonal contraceptives and has withdrawal bleed from
Provera, start contraceptive after start of bleed; if Provera is not completed by that time, discontinue
and discard remainder (some clinicians have woman complete Provera).
4. If withdrawal bleed occurs with Provera, then no menses for 2 months following the bleed, possible
consult with physician, then give Provera 10 mg × 10 days every 2 months. If sexually active, an HCG
must be run prior to taking medication each time.
5. If woman has a history of uterine infection or trauma to the uterus through multiple curettages
(postpartum or postabortion), or if the work-up is negative and there is no response to Provera, referral
for further evaluation (hysterosalpingography; hysteroscopy to lyse adhesions; estrogen to restore
endometrium).
6. Instruct woman to complete 10 days of Provera even if withdrawal bleed begins, unless starting oral
or other hormonal contraceptive as indicated prior in 3.

Complications
A. Inability to conceive
B. Sequelae of underlying cause
DYSMENORRHEA

Definition
A. Primary dysmenorrhea is the occurrence of painful menses usually beginning within several years
of menarche and in the absence of any pelvic pathology but may occur at any time during childbearing
years.
B. Secondary dysmenorrhea is painful menstruation due to an identifiable pathologic or iatrogenic
condition, which may be readily identifiable on the basis of the history and the findings in a physical
examination.

Etiology
A. Primary dysmenorrhea
1. Caused by prostaglandins produced in the uterine lining and released into the bloodstream as the
lining is shed, causing smooth muscle contraction, nausea, and/or diarrhea
B. Secondary dysmenorrhea
1. Extrauterine causes
a. Endometriosis
b. Tumors
1) Subserosal leiomyomata
2) Malignancies
3) Pelvic tumors
c. Ovarian cysts
d. Pelvic inflammatory disease
2. Intrauterine causes
a. Adenomyosis
b. Endometriosis
c. Intramural leiomyomata

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d. Polyps
1) Endometrial
2) Cervical
e. Presence of an intrauterine device
f. Cervical stenosis
g. Endometritis

History
A. What the patient may present with
1. Regular, recurrent pain may occur monthly, prior to menses, or with menses
a. Abdominal pain
b. Pelvic pain
c. Severe backache
2. Nausea, diarrhea, or constipation
3. Weakness
4. Dizziness
5. Weight gain
6. Breast tenderness
7. Backache

B. Additional information to be elicited by asking the following

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

Physical Examination
A. Vital signs
1. Blood pressure
2. Pulse
3. Temperature, if symptoms are present at time of visit
4. Weight
B. Vaginal examination (speculum): cervix, cervical pathology
C. Bimanual examination
V. Laboratory Examination
A. Chlamydia (if not done within 1 year or woman has a new sexual partner), or cervical picture
indicates, or if severity of symptoms has increased

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B. Gonorrhea culture (same as Chlamydia)
C. Wet mount

Treatment
A. Medication
1. Ibuprofen (Motrin®) 400 mg 4 times a day, 200–400 mg every 4–6 hours (max. 1.2 grams/day)
2. Mefenamic acid (Ponstel®) 250 mg, 2 tablets immediately and one every 6 hours
3. Naproxen (Anaprox®) 275 mg, 2 immediately and 1 every 6–8 hours (no more than 5 tabs 1.375
grams per day); Aleve® 200 mg every 8–12 hours
4. Naprosyn 500 mg every 12 hours or 250 mg every 6–8 hrs. (max. 1.25 grams 1st day then 1.0
grams/day)
5. Anaprox DS® 550 mg = one every 12 hours
6. Aspirin with codeine 1–2 tablets every 4 hours as needed
7. lbuprofen (Advil®) 200 mg, 2 tablets every 4–6 hours (max. 1.2 grams/day) (OTC),
8. Flurbiprofen (Ansaid®) 100 mg orally twice or three times a day
9. Meclofenamate (Meclomen®) 1 tab (100 mg) every 6 hours prn
10. Other OTC analogues
11. Oral or possibly other hormonal contraceptive (to produce anovulatory state)

B. Other measures
1. Reassurance
2. Refer to premenstrual syndrome guidelines for diet, exercise, and vitamin recommendations
3. Heating pad; microwave pad (fi lled with nonpopping corn or buckwheat)

Complications
May occur with failure to recognize presence of entity as described in differential diagnosis that results
in lack of appropriate treatment.

OBESITY
 weight > 20% greater than expected for age and height
 body mass index (BMI) tends to vary and increases with age; not used prior adolescence
 history: diet, activity, family heights and weights, growth curves
 physical examination: may suggest secondary cause such as Cushing syndrome
 caliper determination of fat is more sensitive than weight
 organic causes such as genetics, or endocrine are rare
 complications:
 association with hypertension, increased LDL, type 2 diabetes
 Management
 encouragement and reassurance
 diet: qualitative changes; do not encourage weight loss but allow linear growth to catch up
 increase activity, change meal patterns
 refer to dietitian, counseling

SUICIDE
 to end oneself
 suicide is a psychiatric emergency
 depressed individuals usually resort to suicide\associated with deterioration of functioning and

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 ideation
 high levels of stress and poor coping are related to suicide

History
 time suicide was attempted and method
 quantity of pills; motives for attempt
 alcohol intake; where was substance obtained
 precipitating factor for suicide (death, divorce, humiliating event)
 further desire to commit suicide; is there a definite plan? Was the action impulsive or planned

Patient may present:

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

Past History
 previous suicide attempts or threats
 antidepressant use

Family history of depression, suicide, psychiatric disease, family supporting

Social history: personal or family history of emotional, physical or sexual abuse; alcohol or drug abuse;
sources of emotional stress; availability of other dangerous medications or weapons

Physical Examination
 level of consciousness, delirium, presence potentially dangerous objects (belts and shoe
laces)
 hypotension, bradycardia are noted
 signs of trauma, ecchymoses, pupil size and reactivity, mydriasis and nystagmus
 abnormal respiratory patterns
 arrhythmias, murmurs
 decreased bowel sounds, tenderness
 wounds and fractures
 mental status exam, tremors, clonus

Laboratory: electrolytes, BUN, creatinine, glucose, Alcohol and acetaminophen levels, chest x-ray,
urine toxicology screen

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FAMILY
A. The family with health problems
1. Assessment of the family capability to perform health tasks

HEALTH TASKS OF THE FAMILY

1. recognizing interruptions of health or development
2. seeking health care
3. managing health and non-health crises
4. providing nursing care to the sick, disabled and dependent member of the family
5. maintaining a home environment conducive to health and personal development
6. maintaining a reciprocal relationship with the community and health institutions

FAMILY NURSING PROBLEM

arises when the family cannot effectively perform its health tasks

Nursing Assessment – first major phase of the nursing process.

- involves a set of actions by which the nurse measures the status of the family as a client, its
ability to maintain itself as a system and functioning unit, its ability to maintain wellness, prevent,
control or resolve problems in order to achieve health and well-being among its members.

Nursing Assessment includes:

Data collection
Data analysis or interpretation

Two Phases:

a. FIRST- LEVEL ASSESSMENT

is a process whereby existing and potential health conditions or problems of the family are
determined.

TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE – classification system of

family nursing problems.
Family structure, characteristics, and dynamics and relationship to the head of the family

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Members of the household and relation to the head of the family
Demographic data- age, sex, civil status, position in the family
Place of residence of each member- whether living with the family or elsewhere

Type of family structure – eg matriarchal or patriachal, nuclear or extended

Dominant family members in terms of decision-making especially in matters of health care

General family/ relationship/ dynamics- presence of any readily observable conflict between members;
characteristics communication patterns among members

Socioeconomic and cultural characteristics

occupation, place of work and income of each family members
adequacy to meet basic necessities
who makes decisions about money and how it is spent

Educational attainment of each other

Ethnic background and religious affiliation

1. significant others- role (s) they play in family life
2. relationship of the family to larger community- nature and extent of participation of the family in
community activities

Home and Environment

Housing
 adequacy of living space
 sleeping arrangement
 presence of breeding or resting sites of vectors of diseases
 presence of accident hazards
 food storage and cooking facilities
 water supply- source, ownership, portability
 toilet facility- type, ownership, sanitary condition
 drainage system- type, ownership, sanitary condition

1. kind of neighborhood: congested, slum, etc.

2. social and health facilities available
3. communication and transportation facilities available

Health status of each family member

2. Medical and nursing history indicating current or past significant illnesses or beliefs and
practices conducive to health and illness
3. Nutritional assessment
- anthropometric data: measures of nutritional status, weight, height, mid-upper arm circumference,
waist hip ratio
 dietary history specifying quality and quantity of food/nutrient intake per day
 eating/feeding habits/ practices
Developmental assessments of infants, toddlers, and preschoolers- Metro Manila

4. Risk factor assessment indicating presence of major and contributing factors and contributing
modifiable risk factors for healthy lifestyles, cigarette smoking, elevated blood lipids, obesity,
diabetes mellitus, inadequate fiber intake, stress, alcohol drinking and other substance abuse

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Physical assessment indicating presence of illness states
Results of laboratory/ diagnostic and other screening procedures supportive of assessment findings

Values, habits, practices on Health promotion, maintenance, and disease prevention

Examples include:
immunization status of family members
healthy lifestyles
adequacy of:
 rest and sleep
 exercise
 use of protective measures- e.g. adequate footwear in parasite-infested areas;
 relaxation and other stress management activities
Use of promotive- preventive health services

b. SECOND-LEVEL ASSESSMENT

the nature or type of nursing problems that the family encounters in performing the health tasks with
respect to a given health condition or problem, and the etiology or barriers to the family’s assumption
of the tasks.

I. Inability to recognize the presence of the condition or problem.

II. Inability to make decisions with respect to taking appropriate health action.

III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk
member of the family.

IV. Inability to provide a home environment conducive to health maintenance and personal
development.

V. Failure to utilize community resources for health care.

2. Family health problem identification

a. Determination of categories of family health problems

 Health deficits- instances of failure in health maintenance (disease, disability, developmental lag)
 Health threats- conditions that are conducive to disease, accident or failure to realize one’s health
potential
 Foreseeable crisis/stress points - anticipated periods of unusual demand on the individual or family
in terms of adjustment or family resources
 Enhanced capability for health promotion is a nursing judgment related with the client’s capability
for wellness.

3. Definition of contributing risk factors

From PROCEED- PRECEDE MODEL

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 Predisposing factors -
personal preferences that a group or individual brings to a behavioral choice. Includes KAP
(Knowledge, Attitude, Practice), values, existing skills, perceived needs and abilities

 Enabling factors
facilitate the performance of an action. Environmental conditions- availability, accessibility affordability
of resources. New skills needed to carry out a behavioral or environmental change

 Reinforcing factors
positive and negative consequence of an action, including social support, peer influences, advice and
feedback of health care providers and physical consequences of behavior. The determine whether the
individual receives positive feedback for the behavior and is socially supported after behavior

4. Criteria of setting priorities among family health problems:

 Nature of the problem Health deficit Health threat Foreseeable Crisis

 Preventive potential High Moderate Low

 Modifiability Easily modifiable Partially modifiable Not modifiable

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

5. Tool of analysis
 Social determinants of health

B. Planning of individual & family health nursing care

1. Concepts, principles, phases and components in planning family health interventions

THE FAMILY CARE PLAN – is the blueprint of the care that the nurse designs to systematically

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minimize or eliminate the identified health and family nursing problems through explicitly formulated
outcomes of care ( goals and objectives) and deliberately chosen of interventions, resources and
evaluation criteria, standards, methods and tools.

DESIRABLE QUALITIES OF A NURSING CARE PLAN

2. It should be based on clear, explicit definition of the problems. A good nursing plan is based on
a comprehensive analysis of the problem situation.
3. A good plan is realistic.
4. The nursing care plan is prepared jointly with the family. The nurse involves the family in
determining health needs and problems, in establishing priorities, in selecting appropriate
courses of action, implementing them and evaluating outcomes.
5. The nursing care plan is most useful in written form.

THE IMPORTANCE OF PLANNING CARE

 They individualize care to clients.

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

STEPS IN DEVELOPING A FAMILY NURSING CARE PLAN

 The prioritized condition/s or problems based on:

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

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  The plan for evaluating.
 Criteria/Outcomes Based on Objectives of Care
 Methods/Tools

2. Programs and services that focus on primary & secondary prevention of communicable and
non-communicable diseases
a. Examples of DOH programs:

 National Tuberculosis Program – Direct Observed

 Short Course Treatment (NTP-DOTS)
 Integrated Management of Childhood Illness
(IMCI)
 Control of Diarrheal Diseases (CDD)

DOH

DOH Major Functions

hospital services
 direct hospital service delivery
 hospital development services

Public health services

 public health policy development and assistance services

- local health systems development

Health regulation services and administration

 regulation of food, drugs, health facilities & development
 health financing systems
 administration

DOH Priority Programs

National TB Control Program

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

Vision: A country where TB is no longer a public health problem

Mission: Ensure that TB DOTS Services are available, accessible, and affordable to the communalities
in collaboration with LGUs and others

Goal: To reduce prevalence and mortality from TB by half by the year 2015 (Millenium
Development Goal)

Targets: 1. Cure at least 85% of the sputum smear (+) patients discovered

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2. Detect at least 70% new sputum smear (+) TB cases

Objectives: 1. Improve access to and quality of services

2. Enhance stakeholder's health-seeking behavior
3. Increase and sustain support for TB control activities
4. Strengthen management of TB control activities at all levels

KEY POLICIES
Case Finding
 DSSM shall be the primary diagnostic tool in NTP case finding
 No TB Dx shall be made based on CXR results alone
 All TB symptomatic shall be asked to undergo DSSM before treatment
 Only contraindication for sputum collection is hemoptysis
 PTB symptomatic shall be asked to undergo other tests (CXR and culture), only after three
sputum specimens yield negative results in DSSM
 Only trained med techs / microscopists shall perform DSSM
 Passive case finding shall be implemented in all health stations
*Treatment: Domiciliary treatment – preferred mode of care
DSSM – basis for treatment of all TB cases
*Hospitalization is recommended: massive hemoptysis, pleural effusion, military TB, TB meningitis,
TB pneumonia, & surgery is needed or with complications
*All patients undergoing treatment shall be supervised
*National & LGUs shall ensure provision of drugs to all smear (+) TB cases
*Quality of fixed-dose combination (FDC) must be ensured
*Treatment shall be based on recommended category of treatment regimen

DOTS Strategy – internationally-recommended TB control strategy

Five Elements of DOTS: (RUSAS)
Recording & reporting system enabling outcome assessment of all patients
Uninterrupted supply of quality-assured drugs
Standardized SCC for all TB cases
Access to quality-assured sputum microscopy
Sustained political commitment

Tuberculosis
Other names: Koch's disease, consumption, phthisis, weak lungs
Causative agent: Mycobacterium tuberculosis, TB bacillus, Koch's bacillus, M. bovis (rod-shaped)
Mode of Transmission
Airborne- droplet

Direct invasion through mucous membranes and breaks in the skin (very rare)
Incubation period: 4-6 weeks

Most hazardous period for development of clinical disease is the first 6-12 months
Sign and Symptoms
Any combination of the following symptoms are suggestive of TB:
 cough for two weeks or longer
 chest and back pains for one month or more
 progressive loss of weight
 fever for one month or more
 hemoptysis or blood streaking at any time

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Diagnostic test:
· Sputum examination or the Acid-fast bacilli (AFB) / sputum microscopy
1. Confirmatory test
2. Early morning sputum about 3-5 cc
3. Maintain NPO before collecting sputum
4. Give oral care after the procedure
5. Label and immediately send to laboratory
6. If the time of the collection of the sputum isunknown, discard
· Chest X-ray is used to:
1. Determine the clinical activity of TB, whether it is inactive (in control) or active (ongoing)
2. To determine the size of the lesion:
a. Minimal – very small
b. Moderately advance – lesion is < 4 cm
c. Far advance – lesion is > 4 cm
· Tuberculin Test – purpose is to determine the history of exposure to tuberculosis

Other names:
Mantoux Test – used for single screening, result interpreted after 72 hours
Tine test – used for mass screening read after 48 hours
Interpretation:
0 - 4 mm induration – not significant
5 mm or more – significant in individuals who are considered at risk; positive for patients who
are HIV-positive or have HIV risk factors and are of unknown HIV status, those who are closecontacts
with an active case, and those who have chest x-ray results consistent with tuberculosis.
10 mm or greater – significant in individuals
who have normal or mildly impaired immunity

TREATMENT: SCC/Short Course Chemotherapy, Direct –observed treatment short course/DOTS;

Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S)

CATEGORY 1: 6 CATEGORY 2: 8 CATEGORY 3: 6 SIDE EFFECTS:

months SCC months SCC months SCC Rifampicin
Indications: Indications: Indications: · body fluid
> new (+) smear > treatment failure > new (-) smear PTB discoloration
> (-) smear PTB with > relapse with minimal lesions · hepatotoxic
extensive > return after default on CXR · permanent
parenchymal lesions Intensive Phase:3 mos Same meds with discoloration of
on CXR R&I 1 tab each; P&E 2 Category 1 contact lenses
> Extrapulmonary TB tabs each Intensive Phase: 2 Isoniazid
> severe concominant Streptomycin – 1 months · Peripheral
HIV disease vial/day IM for first 2 R&I 1 tab each; P&E neuropathy
Intensive Phase: 2 months = 56 vials (if 2 tabs each (Give Vit
months given for > 2mos can Continuation Phase: B6/Pyridoxine)
R&I : 1 tab each; P&E cause nephrotoxicity 4 months Pyrazinamide
2 tabs each Continuation Phase: 5 R&I 1 tab each · hyperuricemia
Continuation Phase: months CATEGORY 4: /gouty arthritis
4 months R&I : 1 tab each Chronic (*Referral (increase fluid

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R&I : 1 tab each E : 2 tabs needed) intake)
SIDE EFFECTS:
Ethambutol
· Optic neuritis
· Blurring of vision
(Not to be givento
children below 6 y.o.
due
to inability to complain
blurring of vision)
· Inability to recognize
green from blue
Streptomycin
· Damage to 8th CN
· Ototoxic
· Tinnitus
· nephrotoxic

PREVENTION
· Respiratory precautions
· Cover the mouth and nose when sneezing to avoid mode of transmission
· Give BCG
BCG is ideally given at birth, then at school entrance. If given at 12 months, perform tuberculin testing
(PPD), give BCG if negative.
· Improve social conditions
· Cover the mouth and nose when sneezing to avoid mode of transmission
· Give BCG BCG is ideally given at birth, then at school entrance. If given at 12 months, perform
tuberculin testing (PPD), give BCG if negative.
· Improve social conditions

MANAGEMENT OF CHILDREN WITH TUBERCULOSIS

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

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* abnormal CXR suggestive of TB
* Lab findings suggestive or indicative of TB
- for children with exposure to TB
* a child w/ exposure to a TB registered adult patient shall undergo physical exam and tuberculin
testing
* a child with productive cough shall be referred for sputum exam, for (+) sputum smear child, start
treatment immediately
* TB asymptomatic but (+) tuberculin test and TB symptomatic but (-) tuberculin test shall be referred
for CXR examination

- for TB symptomatic children

*a TB symptomatic child with either known or unknown exposure to a TB case shall be referred
for tuberculin testing
* (+) contact but (-) tuberculin test and unknown contact but (+) tuberculin test shall be referred for
CXR examination
*(-) CXR, repeat tuberculin test after 3 months
* INH chemoprophylaxis for three months shall be given to children less than 5y.o. with (-) CXR; after
which tuberculin test shall be repeated
Treatment (Child with TB):
Short course regimen
PULMONARY TB
Intensive: 3 anti-TB drugs (R.I.P.) for 2 months
Continuation: 2 anti-TB drugs (R&I) for 4 months
EXTRA-PULMONARY TB
Intensive: 4 anti-TB drugs (RIP&E/S) for 2 months
Continuation: 2 anti-TB drugs (R&I) for 10 months

PERIOD OF COMMUNICABILITY OF TUBERCULOSIS:

 as long as bacillus is contained in the sputum
 Primary complex in children is NOT contagious
 Good compliance to regimen renders person not contagious 2-4 weeks after initiation of treatment

IMCI Integrated Management for Childhood Illnesses

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

Three components of IMCI

 upgrading the case management and counseling skills of health care providers
 strengthening the health system for effective management of childhood diseases
 improving family and community practices related to child health and nutrition

IMCI: CASE MANAGEMENT PROCESS

1. Assess the child or young infant by checking first the danger signs (or possible bacterial infection in
young infant)

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Taking the history
 Presenting Complaint: Why do you bring the child?
 History of Present Illness: symptoms of the child, including the personal, family, social and
environmental history
 include counseling / health education related to symptoms / problems identified
 Informant: parent or caregiver
 checking nutrition and immunization
 Younger infants: history of pregnancy and birth
infant and younger child: feeding history
 late childhood: milestones of development and behavior
 checking for other problems

Physical examination
 comprehensive examination
 systematic approach
 Points to remember during clinical examination:
 do not upset the child unnecessary. If child is distressed, let the mother settle the child first or
ask her breastfeed child
 leave the child in the arms of mother or carer
 observe as many signs as possible before touching the child. These include
 Is the child alert, interested and looking about?
 does the child appear drowsy?
 Is the child irritable?
 is the child vomiting?
 Is the child able to suck or breastfeed?
 Is the child cyanosed or pale?
 Are there signs of respiratory distress?
 Does the child use auxillary muscles
 is there lower chest wall indrawing?
 Does the child appear to breathe fast?
 Count the respiratory rate

 Laboratory tests
 are based on history and examination
 examples are Hgb/ packed RBCs, blood smear (malaria), blood glucose, CSF, urinalysis, blood
typing and crossmatching, HIV testing, pulse oximetry, x-ray, blood cultures, fecalysis
 bilirubin: sick newborns (<1 week)

2. Classifying the illness- severity of illness

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

GENERAL DANGER SIGNS

 inability to drink or breastfeed
 convulsions

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  lethargy or unconsciousness
 abnormally sleepy or difficulty to awaken
 vomiting everything taken

A child with ANY of the Danger Signs has a serious problem needs URGENT referral to the
HOSPITAL
 ASK: is the child able to drink or breastfeed?
◦ A child has this sign if he/she is too weak to drink and is not able to suck or swallow when
offered a drink. Look to see the child's response
◦ Breastfeeding children may have difficulty sucking when their nose is blocked, clear it first
 ASK: Does the child vomit everything?
◦ A child who is not able to hold on anything down at all has the sign “vomits everything”

A child with ANY of the Danger Signs has a serious problem and needs URGENT referral to the
hospital
 ASK: Has the child had convulsions?
◦ Use the term for convulsions like “fits”, “spasm”, or “jerky movements” which the mother
understands
 LOOK: See if the child is abnormally sleepy or difficult to awaken
◦ an abnormally sleepy child is drowsy and does not show interest in what is happening
around him/her
◦ he does not look at his mother or watch your face when you talk
◦ he may stare blankly and does not notice what is going on around him
◦ he does not respond when she is touched, shaken or spoken to

I. Cough or Difficulty in Breathing

Assess for danger signs. This child may have pneumonia or another severe respiratory infection.
After checking for danger signs, it is essential to ask the child's caretaker about this main symptom

Clinical Assessment
Three key clinical signs are used to assess a sick child with cough or difficult breathing
1. Respiratory rate, which distinguishes children who have pneumonia from those who do not;
2. lower chest wall indrawing, which indicates severe pneumonia; and
3. stridor, which indicates those with severe pneumonia who require hospital admission

Cough or Difficulty in breathing

Child's Age Cut-off rate for fast breathing
2 months up to 12 months 50 breaths per minute or more
12 months to 5 years 40 breaths per minute or more

Lower chest wall indrawing:

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

It is more specific than “intercostal indrawing,” which concerns the soft tissue between the ribs without
involvement of the bony structure of the chest wall

Chest indrawing should only be considered present if it is consistently present in a calm child.
Agitation, a blocked nose or breastfeeding can all cause temporary chest indrawing.

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Stridor is a harsh noise made when the child inhales (breathes in). Children who have stridor when
calm have substantial risk of obstruction and should be referred.

Wheezing is heard when the child exhales (breathes out). This is not stridor. A wheezing sound is
often associated with asthma.

In some cases, especially when a child has wheezing when exhaling, the final decision on presence or
absence of fast breathing can be made after a test with a rapid acting bronchodilator (if available)

Classification of Cough or Difficulty in Breathing

SIGNS CLASSIFY AS TREATMENT
(+) danger sign Severe pneumonia or very severe Give first dose of appropriate
or chest indrawing pneumonia antibiotic:

or Cotrimoxazole and Amoxicillin.

stridor in a calm child
If the child cannot take an oral
antibiotic give the first dose of
IM Chloramphenicol (40 mg/kg)/
Benzylpenicillin/ Ceftriaxone.

Give vitamin A
Treat the child to prevent low
blood sugar
refer urgently to hospital
Fast breathing Pneumonia Give an appropriate antibiotic for
5 days: cotrimoxazole/
amoxicillin
soothe the throat and relieve the
cough with a safety remedy
advice mother when to return
immediately
follow up in 2 days

No signs of pneumonia or very No pneumonia If coughing for > 30 days, refer

severe disease for assessment soothe the throat
and relieve the cough with a safe
remedy advice the mother when
to return immediately

follow-up in five days if not

improving
Fever

 All sick children should be check for fever. It may be caused by minor infections, but may also
be the most obvious sign of a life-threatening illness, particularly malaria (especially lethal

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 malaria P. falciparum), or other severe infections, including meningitis, typhoid fever, or
measles
 When diagnostic capacity is limited, it is important first to identify those children who need
urgent referral with appropriate pre-referral treatment (antimalarial or antibacterial)

Fever
Clinical Assessment
a. Body temperature should be checked
b. children are considered to have fever if their body temperature is above 37.5 C axillary (38 C
rectal)
c. In the absence of a thermometer, children are considered to have fever if they feel hot. Fever also
may be recognized based on a history of fever.
d. a child presenting with fever should be assessed for:
1. Stiff neck. A stiff neck may be a sign of meningitis, cerebral malaria or another very febrile disease.
If the child is conscious and alert, check stuffiness by tickling the feet, asking the child to bend his/her
neck to look down or by very gently bending the child's head forward. It should move freely.
2. Risk of malaria and other endemic infections. In situations where routine microscopy is not
available or the results may be delayed, the risk of malarial transmission must be defined.

A high malaria risk setting is defined as situation in which more than 5 percent of cases of febrile
disease in children age 2 to 59 months are malarial disease.

A low malarial risk setting is a situation where fewer than 5 percent of cases of febrile disease in
children age 2-59 months are malarial disease, but in which the risk is not negligible.

If malaria transmission does not normally occur in the area, and imported malaria is not uncommon,
the setting is considered to have no malaria risk.

Runny nose. When malaria is low, a child with fever and a runny nose does not need an antimalarial.
This child's fever is probably due to a common cold.

4. Duration of fever. Most fevers due to viral illness go away within a few days. A fever that has
been present everyday for more than five days can mean that the child has a more severe
disease such as typhoid fever. If the fever has been present for more than five days, it is
important to check whether the fever has been present every day.
5.
Classification of Fever
- any danger sign or Very severe febrile disease - give first dose of quinine
- stiff neck - give first dose of appropriate
- fever (by history or feels hot or Malaria antibiotic
temperature 37.5 C or above - treat the child to prevent low
blood sugar
- NO runny nose and NO Malaria - treat the fever
measles and NO other causes of - REFER IMMEDIATELY to the
fever nearest hospital
- Advise follow-up in two days
- if fever > 7 days REFER

- runny nose PRESENT or FEVER – malaria unlikely - Treat the fever

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- Measles PRESENT
- Other causes of fever
PRESENT
- obvious causes of fever
- NO obvious causes of fever
- advice mother when to return
- advise mother to return in two
days if fever persists
Possible bacterial infection
Uncomplicated fever

Treatment of malaria
Oral antimalarials
Oral anti-malarials vary by country.

Chloroquine and Sulfadoxine-pyrimethamine are the first-line and second-line drugs in many
countries. Chloroquine is given for three days.

The dose is reduced on the third day unless the child weighs less than 10 kg.

If this is a case, the child should be given the same dose on all three days.

5. Measles. Considering the high risk of complications and death due to measles, children with
fever should be assessed for signs of current or previous measles (within the last three
months).

Measles deaths occur form:

a. pneumonia
b. laryngotracheitis (67 percent)
c. diarrhea (25 percent)
d. measles alone
e. and a few from encephalitis

Measles.
Other complications (usually nonfatal) include conjuntivitis, otitis media, and mouth ulcers. Significant
disability can result from measles including blindness, severe malnutrition, chronic lung disease
(bronchiectasis and recurrent infection), and neurologic dysfunction. (WHO. Technical basis for the
case management of measles. Document WHO/EPI/95. Geneva, WHO, 1995.

- Detection of acute (current) measles is based on: fever with a generalized rash.
Plus at least one of the following signs:
1. red eyes
2. runny nose or cough
3. cough

The mother should be asked about the occurrence of measles within the last three months (recent
measles)

Measles:
etiology: Measle virus (Paramyxovirus)
Clinical manifestations:
fever
cough
coryza

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conjunctivitis
erythematous maculopapular rash
koplik spots

Epidemiology:
direct contact with infectious droplets

Assess a child for possible complications: if the child has measles currently or within the last three
months.
Measles damages the epithelial surfaces and the immune system, and lowers vitamin A levels.

Despite great success in improving immunization coverage in many countries, substantial numbers of
measles cases and deaths continue to occur.
Although the vaccine should be given at 9 months of age, immunization does not take place (because
of false contraindications, lack of vaccine, or failure of cold chain), or is delayed. In addition, many
measles cases occur early in a child's life (between 6 and 8 months of age), especially in urban and
refugee populations).

Classification of Measles
Classify Management
- clouding of cornea SEVERE COMPLICATED - Give vitamin A
- deep/ extensive mouth ulcers MEASLES - give first dose of appropriate
antibiotic
- clouding of cornea or pus
draining, apply tetracycline
- REFER IMMEDIATELY to the
nearest hospital
- pus draining from the eye MEASLES WITH EYES OR - give vitamin A
- mouth ulcers MOUTH COMPLICATIONS - apply tetracycline if pus
draining from eye
- apply gentian violet for mouth
ulcers
- follow-up in 2 days
- measles now or within the last MEASLES - give vitamin A
3 months - Follow-up in 2 days

Before classifying fever, check for the other obvious causes of fever (e.g. ear pain, burn, abscess ,
etc)
Children with high fever, defined as an axillary temperature greater than 39.5 C or rectal greater tha 39
C should be given a single dose of paracetamol to combat hyperthermia.

If other endemic infections with public health importance for children under 5 are present in the area
(e.g. dengue hemorrhagic fever or relapsing fever), their risk should be also considered.

Dengue hemorrhagic fever

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etio: dengue virus (types 1-4)

Clinical manifestations:
fever (27 days)
+/- rash
hemorrhagic manifestation
> + torniquet test
> nose bleeding
> tarry stools
Myalgia
Polyarthritis

Grading:
Gr. I: Fever + non-specific constitutional S/Sx
Gr. II: Gr. I + spontaneous bleeding
Gr. III: Gr. II + circulatory failure
Rapid and weak pulse
Narrowing of pulse pressure
Hypotension
Cold and clammy skin
Restlessness

Gr. IV: Gr. III + profound shock

Signs of Shock:
Cold clammy extremities
Slow capillary refill

Other diagnostic aids:

Tourniquet test
1. MAP
2. Inflate cuff for 5 mins
3. Draw 1 in. sized square
4. > petechiae/ square inch

Typhoid Fever
Etio: S. typhi
S. paratyphi

Clinical Manifestation:
Fever
Constipation/ diarrhea
Abdominal pain
Anorexia
Vomiting
Headache
Hepatosplenomegaly- 2nd week
Rose spots

Malnutrition and Anemia

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2 main reasons for routine assessment of nutritional status in sick children
1. to identify children with severe malnutrition who are at increased risk of mortality and need urgent
referral to provide active treatment

2. to identify children with sub-optimal growth resulting from ongoing deficits in dietary intake plus
repeated episodes of infections and who may benefit from nutritional counseling and resolution of
feeding problems

Clinical Assessment
Visible severe wasting
- shoulders, arms, buttocks, legs, ribs
- marasmus

Edema of both feet

- kwashiorkor
- nephrotic syndrome

Classification of Nutritional Status and Anemia

Severe Malnutrition or Severe Anemia

- visible severe wasting
- severe palmar pallor
- edema of both feet

Anemia or Low (or very low) weight for age

- some palmar pallor
- (very) low weight for age

No anemia and Not very Low Weight

- not (very) low weight for age
- no other signs of malnutrition

Anemia
- treated with oral iron
- child should be seen every 2 weeks (follow-up)
- no response after 2 months, referred hospital for further assessment
- in areas where there is evidence that hookworm, whipworm & ascaris are the main causes
of malnutrition, regular deworming with mebendazole at 500mg every 4-6 months is
recommended

Assessing Child’s feeding

- breastfeeding frequency & night feeds
- types of complimentary foods or fluids, frequency of feeding & whether feeding is active
- feeding patterns during the current illness
-

Immunization
 Birth – BCG
 6 weeks after birth – DPT 1, OPV 1, Hep B 1
 10 weeks after- DPT 2, OPV 2, Hep B 2
 14 weeks after – DPT 3, OPV 3, Hep B 3

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  9 months- measles

Checking immunization status

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

CDD (CONTROL OF DIARRHEAL DISEASES)

MANAGEMENT OF THE PATIENT WITH DIARRHEA

A. No dehydration
 condition- well, alert
 mouth and tongue- moist
 eyes- normal
 thirst- drinks normally, not thirsty
 tears present
 skin pinch- goes back quickly
 TREATMENT PLAN A- home TTT

THREE RULES FOR HOME TREATMENT

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

ORESOL TREATMENT
Age Amount of ORS to give after Amount of ORS to provide for
each loose stool use at home
< 24 months 50- 100 ml 500 ml/day
2-10 years 100-200 ml 1000 ml/day

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 10 years up As much as wanted 2000 ml/day

B. SOME DEHYDRATION
 Condition- restless, irritable
 mouth and tongue- dry
 eyes- sunken
 thirst- thirsty, drinks eagerly
 tears- absent
 skin pinch- goes back slowly
 WEIGH PT, TTT. Plan B

APPROX. AMT OF ORS- To give in 1st 4 hrs

Age Weight kg ORS ml

4 mos 5 200-400
4-11 mos. w 5- 7.9 400-600
12-23 mos. - 8-10.9 600- 800
2-4 yrs - 11-15.9 800-1200
5-14 yrs - 16- 29.9 1200-2200
15 yrs up 30 up 2200- 4000

1. if the child wants more ORS shown, give more

2. Continue breastfeeding
3. For infants below 6 months, who are not breastfeeding, give 100-200 ml clean water during the
period
4. For a child less than 2 years give a teaspoonful every 1-2 mins
5. If the child vomits, wait for 10 min, then continue giving ORS, 1 tbsp/2-3 min
6. If the child's eyelid become puffy, stop ORS, give plain water or breastmilk, resume ORS when
puffiness is gone
7. If (-) signs of DHN- shift to Plan A

Use of Drugs during diarrhea

Antibiotics should only be used of dysentery and suspected diarrhea
antiparasitic drugs should only be used for amoebiasis and giardiasis

C. SEVERE DEHYDRATION
Condition – lethargic or unconscious; floppy
Eyes- very sunken and dry
Tears- absent
Mouth and tongue- very dry
Thirst- drinks poorly or not able to drink
Skin pinch- goes back very slowly
TTT PLAN C- ttt slowly

1. Bring pt to hospital

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

ROLE OF BREASTFEEDING IN THE CONTROL OF DIARRHEAL DISEASES

1. Two problems in CDD
high child mortality due to diarrhea
high diarrhea incidence among under fives

Highest incidence in age 6- 23 months

highest mortality in the first 2 years of life
Main causes of death in diarrhea
 dehydration
 malnutrition

1. To prevent dehydration, give home fluids “am” as soon as diarrhea starts and if dehydration is
present, rehydrate early, correctly and effectively by giving ORS
2. For undernutrition, continue feeding during diarrhea especially breastfeeding
Interventions to prevent diarrhea
1. breastfeeding
2. improved weaning practices
3. use of plenty of water
4. handwashing
5. use of latrines
6. proper disposal of stools of small children
7. measles immunization

Risk of severe diarrhea 10-30x higher in bottle-fed infants than in breastfed infants
Advantage of breastfeeding in relation to CDD
1. Breastmilk is sterile
2. presence of antibodies protection against diarrhea
3. intestinal flora in BF infants prevents growth of diarrhea causing bacteria

Breastfeeding decreases incidence rate by 8-20% and mortality by 24-27% in infants under 6 months
of age
4-6 months- soft mashed foods 2x a day
6 months- variety of foods 4x a day

Summary of WHO-CDD recommended strategies to prevent diarrhea

1. improved nutrition
- exclusive breastfeeding for the first 4-6 months of life and partially for at least one year
2. Use of safe water
- collecting plenty of water from the cleanest source
- protecting water from contamination at the source and in the home
3. Good and personal domestic hygiene
- handwashing
- use of latrines
- proper disposal of stools of young children

4. Measles immunization

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Nursing that considers the health of the family as a unit in th, values and productivity of individual
family members.

3. Identification of goal of care for priority problems

4. Parameters for selecting nursing interventions:

a. Applicable, appropriate and available to the home community setting

b. Promotes client safety, comfort & hygiene

c. Standards of care & interventions that address acute and chronic illness

5. Principles of collaboration and advocacy to be considered to ensure continuity of care

C. Implementation of Individual & Family Health Nursing Care

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

chronic illness
has a gradual onset of symptoms that lasts for an extended and relatively long period of time
e.g. typically six months or longer

characterized by periods of remission and exacerbation

 remission
 symptoms disappear
 exacerbation
 symptoms reappear

a. Health promotion – not disease oriented, motivated by personal, positive approach to wellness
seeks to expand positive potential for health

Levels of health promotion

individual wellness
family wellness
community wellness
environmental wellness
societal wellness

Incorporates the following

 identification of health risks
 reduction of health risks
 preventive measures
 screening tests

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  human development across lifespan
 methods to prevent disease: immunization, screening when risk factors are present
 early diagnosis and treatment
 health promotion applies to all members of the family, with regard to the following
 lifestyle behaviors
 diet and exercise
 sleep
 weight

Behaviors associated with health promotion

 stop smoking or do not start smoking
 avoid over exposure to the sun
 support antipollution legislation
 practice safe sex, monogamy, or abstinence
 obtain genetic counseling for family-linked disorders
 design and follow a regular exercise plan
 maintain ideal body weight
 maintain a low cholesterol, low-fat, high fiber nutrients
 wear seat belt and helmet
 identify and eliminate stressors
 limit alcohol intake, and never drink and drive
 have regular dental care
 6-8 hours of sleep

Nurses role
 model healthy lifestyle
 facilitate client involvement
 teach self-care strategies
 assist clients to increase levels of health
 educate clients to be effective health care consumers
 assist patients to develop and choose health promoting options
 guide development of effective problem-solving and decision making
 reinforce client's personal and family health promoting behaviors
 advocate in the community for changes that promote a healthy environment

b. Disease prevention
. illness or injury specific
. motivated by avoidance of illness
seeks to thwart the occurrence of insults to health and well-being

Primary level of disease prevention / health protection

through people
environmental control

Provided at-
 health care/ RHU
 Brgy, Health stations
 main health center
 community hospital and health center
 private and semi-private agencies

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c. Curative/ Secondary level of disease prevention
 prevention of complications thru early diagnosis and treatment
 Screening methods:
 mass screening
 case-finding
 contact tracing
 multiphasic- screening
 surveillance
Characteristics of an ideal screening test:
 sensitivity
 specificity

- when hospitalization is deemed necessary and referral is made to emergency (now district),
provincial or regional or private hospitals

e. Rehabilitative/ restorative/ third level of disease prevention- assisting/restoring the individual

with a handicap to realize his or her particular goals, physically, mentally, socially and economically;
helps client to recover
 emphasis on existing abilities
 encourages independence
 promotes productive lifestyle

Goals
 prevention of complications/ disabilities, etc.
 restraining in lost skills
 learning new skills

 when highly-specialized medical care is necessary

 referrals are made to hospitals and medical center such as PGH, PHC, POC, National Center
for Mental Health and other government and private hospitals at the municipal level

Functional losses cause:

resentment
anger
frustration
withdrawal
depression
grief

Basic nursing care:

bowel/bladder retraining
adaptive devices for assisting with activities of daily living
ambulation devices and transfer aids
ROM
prosthetic devices
body mechanics
cast care

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2. Bio-behavioral interventions and holistic care for individuals & Family with specific
problems in oxygenation, fluid and electrolyte balance, metabolic and endocrine function

FOR PROBLEMS IN OXYGENATION

1. Promoting proper breathing and lung expansion

 inhale through the nose, exhale through the mouth
 hourly or 4x/ day while awake
2. Pursed lip breathing
 rationale- to prolong expiration, slow RR thereby increasing ventilation, and therefore decrease
work of breathing
 indication- COPD, dyspneic and anxious patients
 positioning- sit upright
 technique- inhale via nose for 3 counts, exhale through purse lips for 7-8 counts

3. Abdominal/ Diaphragmatic Breathing

 rationale- decrease air trapping and work of breathing; e.g. COPD, thoracic surgery/ injury,
women in labor to promote relaxation and provide pain control
 position- initially supine, then practice while sitting or standing
 technique- one hand on abdomen and other on middle chest
 often used with pursed lip breathing

(Drawings of chest tube drainage)

1. Incentive spirometry
 rationale- to provide visual feedback about inspiratory volume
 indications- postoperative patients
 Types:
 flow-oriented: elevated balls with inspiration as long as possible
 volume-oriented
2. Blow bottles
 transfer fluids from one container to another by air pressure using exhalation
 disadvantage – provide feedback only about exhalation; benefit only deep breath has taken
before blowing
 may be used for children (?)

3. Chest tubes
 pressure of H2O is determined by the length of the tube immersed
 2 bottle drainage- drainage bottle is segmented
 works with gravity

Promoting effective coughing

1. Proper coughing technique
 position- upright
 technique- take 2 slow, deep breaths, hold breath on 3rd breath for 3 counts, and cough full 2-3
times
 frequency- 2-3x every 2 hours while awake
 esp. for post-operative patients; teach pre-operatively

2. Cascade Cough

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  Take slow, deep breath and hold for 2-3 seconds, then open mouth and perform a series of
cough; through the breath
 rationale- promotes airway clearance and a potent airway in clients with large volumes of
sputums

3. Huff Cough
 while exhaling, opens the glottis by saying the word “huff”
 rationale- stimulates a natural cough reflex effective only for clearing airway

4. Quad Cough
 push abdominal muscles inward and upward towards the diaphragm while the client maximally
exhales causing cough
 indication- for clients w/o abdominal muscle control e.g. Spinal cord injury

Mobilization of Pulmonary Secretions

1. Hydration
2. Humidification- process of adding water to gas
 keeps airways moist and lessens/mobilizes pulmonary secretions
 routinely used with oxygen therapy to prevent drying of airways
3. nebulization- process of adding moisture or medications to inspired air by mixing particles of
varying sizes with the air (aerosol principle)
Major types:
 jet-aerosol nebulizer- uses gases under pressure
 ultrasonic nebulizer- uses high frequency vibrations to break up water or medications into fine
drops or particles; produces smaller size droplets than jet nebulizers
4. Chest Physiotherapy
a. chest percussion:
Contraindication: chest injury, bleeding disorders, TB with bullae
b. vibration
- applied on exhalation
- contraindicated in children and infants
c. coughing or suctioning
d. oral care
5. Postural drainage

Oxygen therapy
 highly combustible gas, tasteless, colorless, odorless; will not spontaneously burn or cause an
explosion but will cause a fire to ignite if it comes in contact with a spark
 nursing implications- educate client about dangers; observe necessary precautions
o “no smoking” sign at room door and over the bed
o Avoid flames in the area
o Electrical equipment in room should be functioning correctly and properly grounded
o Avoid using oils in the area or in handling oxygen equipment; oil can ignite
spontaneously in the presence of oxygen
(Supply of oxygen)
o Tanks with regulators to control the amount of oxygen delivered; prime tank first before
connecting to regulator to remove dust and other particles
o Permanent wall piped system

 low-flow- affected by the pattern of breathing

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  hypoxic drive- will stimulate breathing of people with COPD

Maintenance of a Patent Airway

1. Proper Positioning
2. Coughing
3. Suctioning
 Rationale: when client is unable to clear respiratory tract secretions with coughing
 Routes:
o Oropharyngeal and nasotracheal suctioning: client can cough but cannot
expectorate or swallow secretions
o Orotracheal and nasotracheal suctioning- client cannot cough at all
o Suctioning on artificial airway
 A sterile technique
 Suction oropharynx and trachea first before the mouth (from sterile to
clean)
 Not more than 15 seconds
 Allow patient to rest between passes of catheter; if with oxygen or
ventilator. Replace cannula, mask, tube right away

Artificial Airways:
 Emphasize roles of nurses in making sure these adjuncts are in place and patent

Oral airway (S tube):

 Insert with curve toward cheek then turn downwards
 Flange (flat part) should rest against client’s teeth

NURSING PROCESS AND FLUID, ELECTROLYTE AND ACID BASE BALANCE

Assessment
 identify any presence of alterations and extent to which body systems are involved
 determine the effectiveness of therapies as well as adverse reactions to treatment
 anticipate needs for nursing care

1. Nursing History: identify potential or actual risk factors that increase the client's chances of
fluid, electrolyte and acid-base imbalances

 conditions that lead to

◦ inadequate oral intake
◦ excessive fluid loss
 stress
 chronic illness
 surgery
 pregnancy

2. physical examination: identify manifestations of specific fluid, electrolyte and acid-base imbalances

Planning
in planning nursing care, client goals for a healthy adult client are the following:

1. maintain an approximate balance between fluid intake and output

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2. maintain a urine specific gravity within normal range
3. practice self-care behaviors to promote fluid, electrolyte and acid-base balance- maintain adequate
intake of fluid and electrolytes; respond appropriately to body signals of impending fluid, electrolyte or
acid-base imbalance

When an imbalance exists:

1. client's fluid, electrolyte and acid-base balance are restored and maintained
2. causes of imbalance are identified and corrected
3. client has no complications from therapies needed to restore balance

 Arterial Blood Gases: Provide information on the status of acid-base balance and effectiveness
of ventilatory function
◦ PaCO2
◦ PaO2: measures partial pressure of oxygen in the arterial blood; 80-100 mm Hg
◦ SaO2: measures degree to which hemoglobin is saturated by oxygen; 95-99%
◦ Bicarbonate level
◦ pH

Nursing Diagnosis
Fluid and Electrolyte disturbance as the problem

when the assessment data point to fluid and electrolyte problems amenable to nursing therapy, they
can fall into three broad categories of nursing diagnosis:

Fluid volume deficit related to

 loss of plasma associated with burns
 vomiting
 failure of regulatory mechanisms

Fluid volume excess related to:

 sodium retention
 compromised regulatory mechanisms

High risk for fluid volume deficit

 changes in mental status (occur with changes in serum osmolality)
 changes in vital signs (RR and depth, HR and rhythm, postural PR and BP)
 abnormal tissue hydration (poor skin turgor, edema)
 + 2mm just perceptible
 ++ 4-6mm moderate
 +++ }
 ++++ severe
pitting edema: skin indentation remains for 15-30 seconds; not apparent until there is approximately
10% increase in the body weight
ascites- measure abdominal circumference

 abdominal muscle tone or sensation (neuromuscular excitability, irritability, muscle weakness,

twitching, cramping)
 neck veins
 central venous pressure: pressure in the right atrium or vena cava; normal pressure is
approximately 4-11 cm of water

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Interventions
 giving full attention to whatever foods and fluids client is taking
 selecting appropriate food and beverages
 relaxation methods
 weight managing techniques
 washing hands before handling food
 avoid using enemas or laxative
 good hydration
 maintaining rest / providing comfort
 activity- avoid heavy lifting
 breath sounds and ABGs
 skin care
 perineal exercise / bladder retraining
 avoid caffeine

3. Strategies in meeting health problems of family

a. Promoting behavior change

b. Creating a supportive environment towards healthy lifestyle

4. Principles of behavior change

Behavior Changes in Stages (from Transtheorethical Model)

Precontemplation- no intention of changing behavior, and may not think they have a problem at all
Contemplation- awareness of problem, some thought of doing something about it within 6 months
Preparation- specific behaviors and thoughts involved in planning to change behavior
Action- overt change in behavior made
Maintenance- sustain behaviors and prevent relapse
Termination- copes without fear of relapse*

Relapse or Recycle
an opportunity to learn from experience and renew efforts to change

Different stages are affected by different factors, thus requiring different assistance to move to next
stage relapses part of the model-- to be expected
recognition of importance of decisional balance (pros and cons of maintaining risky behaviors vs
healthy behavior)

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

D. Evaluation of progress and outcome of care

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

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E. Ensuring a well organized & accurate documentation & reporting
1. Standard format

2. Legal principles involved in documentation

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