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9 • Normal weight gain is – 1lbs/month on first trimester, – 1lbs/week on second and third trimester • Underweight causes preterm labor and LBW • Overweight causes fetal death Calories (kcal) 2,200 2,500 Protein (g) 46-50 60
• • •
CALORIES • Increase calories for – fetal energy and placenta, – for elevated metabolism (thyroid function and increase workload due to increase weight) and milk production • Sources are from protein, CHON, fats • Decrease calories lead to ketoacidosis (causes fetal and neurologic disorder) • Indicator of adequate caloric intake: weight gain Protein • For fetus (growth, amniotic fluid, placenta) • For mother (uterus, mammary glands, RBC, plasma volume and protein, milk protein during lactation, uterus • Protein sources are meat, poultry, fish, legumes (beans, peas, peanuts) yogurt, eggs and milk. • Women with history of hypercholesterolemia should modify diet FATS • Can be consumed through food • Linoleic acid for new cell growth • Best sources are vegetable oils (corn, olive, peanut, cottonseed) Vitamins • Vitamin A for cell development and tooth bud and bone growth – Deep green, dark yellow vegetables and fruits, liver – Vitamin A toxicity can cause fetal malformation • Vitamin D for maternal-fetal bone density – Absorption of calcium and phosphorus – Milk, margarine, egg yolk, butter, liver, seafood • Vitamin E for antioxidant, prevents hemolysis of RBC – Vegetable oils, green vegetables, whole grains, liver • Vitamin C for tissue formation and iron absorption • Folic acid found in fruits, vegetables and liver necessary for RBC formation, decrease causes megaloblastic anemia, neural tube defect • Vitamin A, B and folic acid intake should be more for women who used oral contraceptives. • No mineral oil laxative inhibits Vit ADEK absorption • Megadoses of water soluble (Vitamin C) can cause scurvy Minerals • Calcium for skeletal (12 weeks) and teeth formation (8 weeks) – Maternal bone and tooth mineralization – Milk, cheese, yogurt, green leafy vegetables – Can take calcium supplement if not provided in diet or lactose intolerant (lactase enzyme) • Phosphorus for fetal skeleton and tooth bud formation. – Can be taken from protein sources – Milk, cheese, yogurt, meats, whole grains, nuts, legumes • Iodine for formation of thyroxine for increase thyroid function
Decrease iodine causes goiter can cause hypothyroidism in infant (mental retardation) and thyroid enlargement in infant can cause airway problem. – Iodine best source is seafood Iron for hemoglobin, 20 weeks fetus stores iron in liver for 3 months in life, to increase red cell volume for blood lost during delivery – Iron rich foods organ meat, green leafy vegetables, whole grains, enriched breads Fluoride for teeth formation. Can be found in water. Excessive fluoride causes brown stained teeth. Sodium causes water retention (increase heart strain and blood volume) Zinc for synthesis DNA and RNA. Usually on protein sources (meat, liver, eggs, milk, seafood), – antagonistic with iron and folic acid, causes fetal CNS malformation – Remove toxins 6 glasses for more
Fluid • • Fibers •
Common constipation due to decrease peristalsis from pressure • Vegetables • Lowers cholesterols and removes carcinogens Foods to Avoid • Caffeine is CNS stimulant (increase HR, urine production and stomach acid secretion) • > 8 cups causes stillbirth • Can be found in chocolates, softdrinks, tea • 120 mg (1 cup coffee) Common Problems • Nausea and Vomiting – r/t high Hcg, – high estrogen/progesterone, – low blood sugar, – lack Vit B6, – decrease gastric motility • Intense first 3 months, usually upon rising, smelling and preparing food • Small frequent meals, dry crackers upon rising. • Avoid skipping meals • Decrease intake of fatty foods • Avoid cooking odors • No antacids may cause fluid retention • Avoid excessive fluid early in the day or when nausea in present Hyperemesis gravidarium/ pernicious vomiting • More than 12 weeks causes dehydration, ketonuria, weight loss • Due to increase thyroid fxn, H.pylori • Shows elevated Hct (hemoconcentration) decrease fluid retention • Hypokalemic acidosis (vomiting) • Polyneuritis due to B deficiency • Ketones in urine • Can cause intrauterine growth restriction or preterm birth due to decrease fluid • IV fluid, antiemetic, NPO 24 hrs then clear fluid then cereals Cravings • Cravings or aversion are normal • Pica – abnormal nonfood cravings, supplement with iron. Pyrosis • Caused by decrease gastric motility causing slow gastric emptying and pressure on stomach by uterus. • Eat small frequent meal • Avoid fluid with meals but plenty of fluid between feedings • 2-3 pillows sleeping, do not lie down after eating
Expanded Program on Immunization Definition of Terms: 1) Immunization The protection of individuals from disease by vaccination Induction or introduction of specific protective antibodies in a susceptible person or production of cellular immunity in such a person Is the provision of an individual with antibodies, which possess the power to destroy or inactivate disease producing agent to neutralize its toxins 2) Immunity A condition of being able to or the capacity to resist a particular disease Is the resistance that an individual has against a disease A condition of being secure against any particular disease, particularly, the powers to which a living organism possesses to resist and overcome infection 3) Antibodies / Immunoglobulins Any of various body globulins that normally prevent or are produced in response to infection or administration of suitable antigens 4) Antigen A protein substance (as a toxin, enzyme, or any certain constituent of blood), that when introduced into the body stimulates the production of antibodies 5) Attenuated Refers to weakening, thinning or decreasing the pathogenicity (capability of causing a disease) or vitality of microorganisms A) PASSIVE IMMUNIZATION Is achieved by injecting a recipient with preformed immunoglobulins directed against an already present infection State of relative temporary protection produced by the injection of serum containing antibodies which have formed in another host. B) ACTIVE IMMUNIZATION Involves injection of modified or purified pathogens or their products, prompting the immune system to respond as if the body were being attacked by an intact infectious microorganism PASSIVE IMMUNITY Immunity transferred from another person ▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼ ▼▼▼▼▼ ▼▼▼▼▼ Natural Passive Immunity Artificial Passive Immunity Transferred by mother to child through Antibodies produced by another milk or through the placenta person or animal is injected Examples are gamma globulin, antitoxin and antiserum ACTIVE IMMUNITY Individual’s own system is the cause of the immunity ▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼ ▼▼▼▼▼ ▼▼▼▼▼ Natural Active Immunity Artificial Active Immunity Example is natural exposure Deliberately introduced in a vaccine Example is measles vaccine, DPT or Toxoids like Tetanus toxoid Formulations for Active Immunity Live Pathogens When live pathogens are used, they are attenuated to prevent clinical consequences of infection Killed Microorganisms Killed vaccines have the advantage over attenuated microorganisms in that they pose no risk of vaccine-associated infection Microbial Extracts
Instead of using whole organisms, vaccines can be composed of antigen molecules (often located on the surface of the microorganism) extracted from the pathogen or prepared by recombinant DNA techniques. Toxoids These are derivatives of bacterial exotoxins that can be produced by chemically altering the natural toxin, or by engineering bacteria to produce harmless variants of the toxin Six (6) EPI Diseases Poliomyelitis Measles Diphtheria Pertusis Tetanus Tuberculosis Coverage The three population of EPI consists of the following: Infants below one year old School entrants Pregnant Women Starts from the Manufacturer ▼▼▼▼▼ Airport ▼▼▼▼▼ Central Vaccine Store ▼▼▼▼▼ Regional Store ▼▼▼▼▼ District Hospital ▼▼▼▼▼ Health Center or Outreach Service ▼▼▼▼▼ Discrepancy ▼▼▼▼▼ Immunizing Staff or Mother and Child Vaccine TT1 TT2 TT3 TT4 TT5 Vaccine Dose/Route Baby 0.5 R 80% 0.5 L Protected 0.5 R Protected 90 % 5 yrs 0.5 L Protected 99% 10 yrs 0.5 R Protected 99% Lifetime Contents Form Mother 80% 3 yrs
Condition when exposed to Heat / Freezing
Live, attenuated bacterial vaccine; Bacillus Calmette and Guerin DPT Toxoid which is a Diphtheria weakened toxin Pertussis Killed bacteria Tetanus Toxoid which is a weakened toxin Polio Vaccine Live attenuated virus Measles Live attenuated virus
Freeze dried and Destroyed by reconstituted with heating, sunlight but a special diluent not by freezing Liquid Destroyed by freezing, heat Damaged by heat, freezing Damaged by heat Easily damaged by heat but not destroyed by freezing
Freeze dried and Easily damaged by reconstituted with heat but not a special diluent destroyed by freezing Liquid Liquid Damaged by heat, freezing Damaged by heat, freezing
Tetanus Toxoid Hepatitis B
Weakened toxin Plasma derived; RNA recombinant
METHODS ARTIFICIAL -Temporary Hormones Pills Estrogen/Progesterone Patch Implants DMPA Injections Barriers Spermicides Diaphragm Cervical Caps Female Condom Male Condom -Permanent Tubal Ligation Vasectomy -Natural Calendar (Rhythm) Method Basal Body Temperature Cervical Mucus (Billings) Method Symptothermal Method Lactation Amenorrhea Method Coitus Interruptus NATURAL FAMILY PLANNING METHOD Calendar (Rhythm) Method • Requires couple to abstain from coitus during menstrual cycle where conception is possible (3 days before or after ovulation) • Keep 6 months diary of menstrual cycle • Subtract 18 from shortest cycle (25 days) represents the first fertile day • Subtract 11 from longest cycle (29 days) represents last fertile day • Use contraceptive or avoid coitus on fertile days Basal Body Temperature • A day before ovulation the temp drops 0.5 F • On the ovulation day it rises to 1 F because of progesterone and is maintained throughout the cycle • Take the temperature every morning upon waking up before any activity • Refrain from sex for 3 days (life of ovum), once notices a slight drop and rise • Temperature can be affected by illness (fever), daily activity (metabolism rate) • Women working at night must take temperature once awake from longer sleep period, no matter what time of the day. Cervical Mucus (Billings) Method • Before ovulation, cervical mucus is thick, non stretchable. • Peak ovulation mucus becomes copious, thin, watery, and transparent. Feels slippery and stretches atleast 1 inch before it breaks (Spinnbarkeit properties). • Breast is also tender • 3 days after peak days or until mucus is copious is considered fertile days and avoid coitus. • Vaginal secretion after intercourse is unreliable and can give watery consistency because of the seminal fluid and can be mistaken as fertile. Symptothermal Method • Combination of cervical mucus and BBT • Abstain 3 days after rise of temperature or 4 days after peak of mucus change • Ovulation Kit • Detects Luteinizing Hormone in urine 12-24 hours before ovulation. • Expensive
Lactation Amenorrhea Method • As long as woman breastfeed, there is natural suppression to ovulation. • Must be exclusive breastfeeding (may ovulate without menstruate while breastfeeding) Coitus Interruptus • Man withdraws and sperm emitted outside the vagina • May fertilized during preejaculation fluid. ARTIFICIAL FAMILY PLANNING METHOD Pills / Oral Contraceptives/ Combination Oral Contraceptives • Combination of synthetic estrogen and progesterone • Estrogen suppress FSH and LH, suppressing ovulation • Progesterone decreases permeability of cervical mucus, prevents transport of ovum tubal transport and endometrial proliferation to prevent implantation. • Must be given only after Papanicolaou Smear and pelvic examination. • Not effective on first 7 days must take other contraceptive methods • Take 21 pills everyday at the same time then rest for 1 week (mense begins on 4th day) then start new 21 packs. Some have 28 pills (7 are placebo to prevent forgetting the gap) (menstrual flow begins on 7th day of placebo) • If woman does not want to have a menstrual flow, she can immediate take the new 21 day pill or do not take the 7 days placebo and start with 28 days pills immediately once the previous pills are consumed. • Decreases incidence of: • Dysmenorrhea (due to lack of ovulation) • Iron deficiency anemia (reduce menstrual flow) • Pelvic Inflammatory Disease (PID) and tubal scarring • Endometrial and ovarian cancer/cysts • Fibrocystic breast disease • Osteoporosis and uterine myomata • Colon cancer • Side effects • Weight gain (estrogen interferes with lipid metabolism lowers LDL and increase HDL) • Nausea (r/t estrogen) • Headache • Breast tenderness • Breakthrough bleeding (spotting outside mense period) • Monilial vaginal infections • Mild hypertension • Depression • Danger signs of myocardial or thromboembolic complication • Chest pain (MI/TE) • Shortness of breath (Pulmonary embolism) • Severe headaches (CVA) • Severe leg pain (thrombophlebitis) • Blurred vision (HPN, CVA) • Contraindications: • Breastfeeding/ < 6 weeks postpartum (weight loss in brestfeed infants, estrogen decreases breast milk) • >35 years old and smoker (>15 cigarettes/day) • Risk factor for arterial cardiovascular disease (old age,smoking, diabetes, hypertension) • HPN >160 mmHg systolic or 100 mmHg diastolic or higher • History of deep vein thrombosis or pulmonary embolism • Major surgery with prolonged immobilization • History of ischemic heart disease
Stroke Valvular heart disease Migraine with aura; migraine without aura but >35 years old • Current breast cancer • Diabetes with nephropathy, retinopathy, neuropathy, vascular disease (estrogen interferes with glucose metabolism) • Severe cirrhosis • Liver tumors Estrogen/Progesterone Patch • Transdermal (upper outer arm, upper torso-front and back, abdomen, buttocks) patches continuously release estrogen and progesterone applied once a week for 3 weeks. During week patchfree, menstrual flow resume. • Same as pills but less effective for women more than 90 kg • Does not need to remember daily, easy concealment, mild breast discomfort and irritation at the site. • Can be used bathing, swimming, shower. If becomes loose just replace (within 24 hours). But if unsure or more than 2 hours, woman should start a new 4 week cycle and use other contraceptive method for 1 week. Vaginal Rings • Silicone ring surrounding cervix (absorbed by mucous membrane of vagina avoiding first pass on the liver) and continuously releasing estrogen and progesterone left for 3 weeks then removed for 1 week. (fertility resumes immediately). • Menstrual bleeding occurs once ring free Emergency Postcoital Contraception. • Called morning after pills contains high level estrogen inhibiting progesterone and implantation • 2 dose within 72 hours after unprotected intercourse followed by 2 pills after 12 hours. • Used for rape, kit contains pregnancy test and 4 pills Subcutabeous Implants • Norplant is a nonbiodegradable silastic implants filled with levonorgestrel (synthetic progesterone) embedded under the skin of upper arm • Looks like small veins and release hormones, thickens cervical mucus (making endometrial implantation difficult) for 5 years. • Inserted during menses for first 7 days at the start of menstrual cycle to make sure woman is not pregnant. Can be inserted immediately after abortion or 6 weeks postpartum. • No effect on breastmilk • Return fertility after 3 months from removal. • Contraindicated to pregnancy (causes birth defects), uterine bleeding, Disadvantage – Costly – Weight gain – Irregular menstrual cycle (spotting, breakthrough bleeding, amenorrhea, prolonged periods) Intramuscular Injections • Single injection of medroxyprogesterone acetate (DepoProvera) inhibit ovulation, alter endometrium, change cervical mucus. • Contains only progesterone so safe for breastfeeding • Given every 3 months and fertility resume after 6-12 months • Side effects: – Irregular menstruation – Headache – Weight gain – Depression – Impair glucose tolerance (diabetes) – At risk osteoporosis (take calcium and weight bearing exercises) • • •
Intrauterine Device (IUD) • T shape plastic place in uterus via the vagina prevents sperm form reaching uterus and ovum • Must be inserted by MD, Nurse practitioner, nurse-midwife after pap smear and pelvic examination • Inserted after menstruation before coitus to ensure patient is not pregnant, and can be inserted after delivery • The T shape plastic with copper, a drug reservoir with progesterone (prevents endometrial proliferation and thickens cervical mucus) and a monofilament string • Effective 1, 5 or 10 years depending on the brand. • Once time insertion, no effect on sex, should have monthly check up to see if IUD is still in place after menstrual flow, and have yearly pelvic examination. • Side effect: – Spotting/ uterine cramping on first 2-3 weeks and should use other contraceptive. – High risk for PID (IUD + multiple partner) – Increase risk of STI (women with IUD and multiple partner) • Contraindicated – Distorted uterus – Severe dysmenorrheal – Menorrhagia (bleeding inbetween menstrual periods) – History of ectopic pregnancy – Valvular disease (PID increases bacterial endocarditis) – Anemia • If pregnant must remove to prevent infection and spontaneous abortion. (detected by ultrasound the placement and pregnancy) Spermicides • makes vagina acidic and kills sperms. Inserted 1 hour before coitus (foam, gel, cream, sponges, films, suppositories) and no douche 6 hours after coitus • contraindicated – acute cervicitis – bothersome • can be irritating to penile or vaginal mucous • does not cause birth defect or abortion if pregnant. Diaphragm • circular rubber disc inserted on cervix before intercourse prevents sperm • must check if weight gain/loss of 15 lbs, because change cervical contour. • Must be kept 6-24 hours after coitus. If left more than 24 hours may cause fluid stasis and cause urethral and cervical inflammation. • Reusable (wash soap and water and place on case) and can be reused for 2-3 years. • Side effects: – Increase UTI • Contraindications – History staph infection – Rubber/spermicide allergy – Recurrent UTI Cervical caps • Soft rubber shaped like a thimble and fitted on uterine cervix • Can be dislodged but can stay longer than diaphragm (bec does not put pressure on vaginal walls or urethra) but not >48 hours to prevent cervical infection. Female Condom • Latex sheath with spermicides • The inner ring (closed end) covers the cervix, outer ring (open end) rest against vaginal opening • One time use, inserted before and remove after coitus • Protect against conception and STI
• Difficult to use Male Condom • Latex rubber placed on erect penis before coitus • Contraindicated on latex allergy Vasectomy • Small incision on each side of scrotum. • Cut, cauterized or plugged vas deferens • Done ambulatory but doctor under local anesthesia • Sperm in vas deferens can last upto 6 months • Can resume coitus after a week surgery but must use other method until 2 negative sperm report (10-20 ejaculations) • Does not interfere with sperm production, can still have erection, can still ejaculate seminal fluid but without sperm. • Hematoma on site, 70-80% can be reanastemosed, can develop autoimmunity to sperm, can develop urolithiasis Tubal Ligation • Fallopian tubes are occluded by cautery, crushing, clamping (metal/plastic clips), or blocking • Done via laparoscopy/culdoscopy/colpotomy after menstrual flow and before ovulation. Make sure no contact before procedure to prevent ectopic pregnancy • Incision under umbilicus • Abnormal bloating after 24 hours (until carbon dioxide is absorbed) • Can resume coitus 2-3 days after, will still have menstrual flow, • Can be done 4-6 hours or 12-24 hoursafter delivery/abortion • No sexual effect Growth – means an increase in physical size of the whole body and parts, can be measured an quantified. Development – progressive increase in skills, capacity and functioning. General Principles of Growth and Development 1. 2. 3. Children are competent children resemble one another Each child is unique a. Heredity and constitutional make-up b. Social and national characteristics c. Sex d. Environment Growth and development are directional a. Cephalocaudal – growth is advanced near head gradually progresses down to the neck, trunks and extremities b. Proximo-distal – growth proceeds outward, from central axis of body to the periphery c. General to Specific d. Simple to Complex
Age Birth – 28 days 1 month – 1 year old 1 – 3 years 3 – 6 years 6 – 12 years Characteristics Behavior are reflective Rapid physical growth Motor development and increase psychosocial skills Increase social roles; slowed physical growth Preadolescent stage Increase peer influence Increase physical, cognitive, social development Physical growth fastest Nursing Implication Parental education and guidance Provision of physical and psychological needs Safety and growth Provide play and social activity Pursue school activity and hobbies Recognize and support achievements Develop coping
Young adulthood Middle adulthood Older adulthood Young old
20 – 40 years 40 – 65 years
Values are tested Increase stress and conflicts Develop personal lifestyles Builds relationships Changes in lifestyles
behaviors, conflict resolutions Adjustment relating to health caused by lifestyle Anticipated changes in life Identify risk factors Keep physical and social activity active Maintain peer interaction Coping with loss Safety measures
65 – 74 years
75 – 84 years
85 years and over
Retirement and changes in physical abilities Development of chronic illness Decline in speed movement, reaction time, senses Slight dependence on others Increase physical problems and dependence
Assists self care and maintain independence
Psychoanalytic Theories: Sigmund Freud Major Components of Freud’s theory a. b. c. Unconscious mind – contains memories, motives, fantasy, and fears that are not accessible to recall but directly affect behavior. Id – part of psyche concern with self-gratification Ego – conscious part of psyche; Mediator for id and supergo; contains intelligence, memory, problem solving, incorporation of learning and experiences. Develops by 1 years old. Superego – one’s conscience; represents rules and values. Age
Birth – 1 year
Pleasure Center: Mouth Sexual Activities: sucking, swallowing, chewing, biting Greatest need: Security Greatest fear: Anxiety Pleasure Center: Anus & Rectum Sexual Activities: Expulsion and retention of waste products Pleasure Center: Genitals Sexual Activities: Masturbation Pleasure Center: None Sexual Activities: None Pleasure Center: Genital Sexual Activities: Masturbation, Sexual intercourse, feelings for others
Develop Narcissistic – focus on self Fixation: Mistrust, nail bitting, drug abuse, smoking, overeating,
2 – 3 years
4 – 5 years
Develop Gender awareness & differences, experience Oedipus & Electra Complex
6 – 12 years 13 years and after
Stages of Growth and Development
Stage Neonatal Infancy Toddlerhood Preschool School age
Psychosocial Theory: Erik Erikson Stage Age Developmental Task
Infancy Toddler Preschool Birth – 1 year old 1-3 years old 3-6 years old Trust vs. Mistrust Autonomy vs. Shame & Doubt Initiative vs. Guilt
Task to be achieved
Gain trust in others Toilet train and self control Gain independence; Initiate spontaneous activities
12 – 20 years
6-12 years old 13-18 years old
Industry vs. Inferiority Identity vs. Role Confusion
Young adult Middle adult
Intimacy vs. Isolation Generativity vs. stagnation Ego integrity vs. despair
65 and over
Gain achievement and necessary social skills Integrate childhood experiences into personal identity; Gain new roles and self acceptance Make commitments to others and to life work (career) Establish a family and become productive; Share community and world Sense of fulfillment, meaning and purpose
Birth – 9 years old
Stage 1: Punishment and Obedience Orientation Stage 2: Instrumental relativist orientation
Based on intuitive thoughts; Right if not punished, Wrong if punished Right is defined as which is acceptable to and approved by self or when they satisfy one’s needs. Approval of others is sought through one’s actions. Authority is respected. Individual feels duty bound to maintain social order. Behavior is right when it conforms to the rules It is wrong to violate others’ rights The person understands the principles of human rights and personal conscience. Person believes that trust is the basis of relationships.
9-13 years old
Stage 3: Interpersonal Concordance (Good boy- good girl orientation) Stage 4: Law and Order Orientation
Cognitive Development: Jean Piaget Stage Age Sensorimotor 0 – 1 Stage 1: Use months reflex 1-4 Stage 2: Primary months Circular reaction 4-8 months Stage 3: Secondary Circular reaction Stage 4: Coordination of secondary schemata Stage 5: Tertiary circular reaction Stage 6: Invention of new means
8-12 months 12-18 months 18-24 months
Description Movements are reflexes Perceptions center around self; objects are extension of self Aware external environment; initiates act to change environment Differentiates goals and goal directed activities Develops rituals Uses mental imagery and uses fantasy to understand environment Emerging ability to think Thinking is egocentric; use symbols Unable to break down whole to parts; can classify objects according to traits. Manipulate tangible objects, can classify objects, starts logical reasoning, reversibility, relations between numbers Abstract thinking and deductive reasoning
13 and above
Stage 5: Social contract/ Utilitarian Orientation Stage 6: Universal ethical principle orientation
Faith Development: James Fowler Stage Age Intuitive-projective 3-7 years old Faith Mythical-Literal Faith 7-12 years old
2- 7 years old 2-4 years old 4-7 years old
Preconceptual Stage Intuitive Stage
13-18 years old
7 – 11 years old
Late adolescent and young adult Adult Adult
11 and above
Conjunctive Faith Universalizing Faith
Imitate religious gestures of parents without understanding Religious stories and existence of diety is accepted; Concept of reciprocal fairness Ideology emerged; questions god, values, morality and religious practices Search for self identity; assumes responsibilitiy for own attitudes and beliefs Integrates others viewpoints about faith into own truth Makes tangible values of love and justice for humankind.
Moral Development: Lawrence Kohlberg Stage Age HUMAN BEHAVIOR
The World Health Organization defines mental health as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”. It was previously stated that there was no one "official" definition of mental health. Cultural differences, subjective assessments, and competing professional theories all affect how "mental health" is defined.
MINIMAL MENTAL HEALTH OPTIMUM MENTAL HEALTH
the worth attributed to him by significant others on the basis of his own presentation to the world. (e.g.suicidal) Role performance – expression of self concept, totality of how one is known to others, one’s representation and public roles. 2. Growth, development, and self-actualization Individual seeks new experiences to more fully experience aspects of oneself. Maslows self actualization and Rogers fully functioning person. 3. Integration Balance between what is expressed and what is repressed, between outer and inner conflicts. Balance of ID, EGO and SUPEREGO Includes regulation of emotional responses and a unified philosophy in life. Can be measured by the person’s ability to withstand stress and cope with anxiety. Ego enables person to handle change and grow as a result. 4. Autonomy Self determination Balance between dependence and independence, and acceptance of the consequences of one’s action. Implies person is self-responsible for ones decisions, actions, thoughts and feelings. As a result person can respect autonomy and freedom in others.
MAXIMAL MENTAL ILLNESS OR DISORDER
MINIMAL MENTAL ILLNESS
HIGH WELL BEING
HIGH ILL HEALTH
LOW ILL HEALTH
5. Reality perception Individuals ability to test assumptions about world by empirical though. The mentally healthy person can change perceptions in light of new information. This criterion makes empathy or social sensitivity, a respect for the feelings and attitudes of others. 6. Environmental mastery Enables a mentally healthy person to feel success in an approved role in society. Deal effectively with world, work out personal problems, and obtain satisfaction from life. Can able to cope with loneliness, aggression, and frustration without being overwhelmed. Can respond to others, loved and be loved, and cope with reciprocal relationships. Can build new friendship and have satisfactory social involvement Influencing Factors for Mental Health Genes Depression and Mania Linking DNA markers on chromosome 11 to bipolar disorders and increased risk of disorder in familial descendants. Special case of depression “postpartum blues” due to sudden drop in hormones can range from mild to clinical depression to psychosis. Environmental factors may increase genetic vulnerability. Schizophrenia Children with 1 schizoprenic parents have 15% chance Children with 2 parents have 40% Only 2% in general population Personality, Conduct, Character Disorder Children of alcoholic parents diagnosed with depression, anxiety disorder, personality disorder.
LOW WELL BEING
Criteria for Mental Health 1. Positive attitude towards self Acceptance of self and self awareness. Must have objectivity about self and realistic aspirations that necessarily change with age. Must have a sense of identity, wholeness, belongingness, security, and meaningfulness. Self acceptance – regard for oneself with realistic concept of strengths and weaknesses. Depends on self concept Self awareness – involves noticing how the self feels, thinks and behaves at any given time. Different from introspection which involves evaluation or determining why the self reacts as it does. Self-concept – part of self that lies within conscious awareness. It represents collection of attitudes and ideas about the self. It is a product of life experiences. It encompasses all that a person perceives, knows and hold to be true about his/her identity. Four aspect of self-concept Body Image – physical dimension. How we present ourselves to others physically affects how others perceives us socially and emotionally as well as intellectually. (anorexia, bulimia Personal Identity – psychological aspect. Unconscious stratum/unaware. Perception of internal/external reality. It is the innerworld of the client encased by feelings, thoughts, previous learning. (personality disorder) Self-esteem – emotional component. Degree of value or worth ascribed to the self. It is based on the ability, attributes in interpersonal relationships. It represents an individual’s perception of
Environment Childhood Nurturing Life Circumstances Life Circumstances • Major Life Events • Life strains (definition) occurs in 4 Areas – Strife association with marital relations. – Parental challenges associated with teenage and young adult children. – Strains associated with household economics. – Overloads and dissatisfactions associated with the work overload. • Hassles – irritating, frustrating, or distressing incidents that occur in everyday life. Early Signs of Failing Mental Health 1.Sleep disturbances. 2. Dramatic weight fluctuations/changes in eating patterns. 3. Unexplained physical symptoms. 4. Difficulty managing anger or controlling your temper. 5. Compulsive/obsessive behaviors. 6. Chronic fatigue, tiredness, and lack of energy. 7. Memory problems. 8. Shunning social activity. 9. Loss of satisfaction. . 10. Mood swings and erratic behavior noticed by more than one person. Death and Dying • Grief – refers to the subjective emotions and affect that a normal response to the experience of loss. • Grieving/Bereavement – refers to the process by which a person experiences the grief. • Mourning – the outward expression of grief. Religious ceremonies. • Anticipatory Grieving – emotional work begun before the actual loss of a valued person, object or concept. It is an adaptive response to an expected loss and helps prepare both patients and families for the actual moment of death. • Disfranchised grief – grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially because: • a relationship has no legitimacy • the loss itself is not recognized • the griever is not recognized • Classification – Timely versus Untimely – Intentional versus Unintentional versus Subintentional STAGES OF DEATH AND DYING Denial and Isolation » A necessary and protective mechanism that may be present for a few minutes or months » Patient avoids confirmation Anger » Directed at self, God, and others who have a future and who do not face the loss of existence. Bargaining » The client attempts to postpone or reverse the dreaded movement of death. Pray to complete things, etc. » Make promises to alter lifestyle, be extra nice and charitable, etc. Depression Full effect of diagnosis and loss can no longer be delayed. » A therapeutic state that aids the client to detach from life and living thereby accepting death. » Different from pathologic depression. Necessary stage of growth rather than a regression. Acceptance » Complete unfinished business » Comfort who will be left behind
» Fear and needs company until the end Denial Reflecting feelings “This isnt happening” “You are wrong” Anger Understand and Support “Its your fault” Give what patient needs Listen and ventilate feelings Acceptance of anger Bargaining Depression Acceptance Act upon request if possible Listen Avoid reassuring cliches Therapeutic touch Crying Remain close to patient
• Attitude towards death Under 5 years old Does not understand concept of death Believes death is reversible, temporary departure or sleep Emphasizes immobility and inactivity as attributes of death Nursing approaches Utilize play to express feelings Explain death is final Permit choice to attend funeral Toddler (1-3) No concept of death Reacts more to pain and discomfort of illness Experience separation anxiety Assists parents to deal with feelings Encourage parents participation in child care • Preschooler (3-5) Death is sleep. Form of punishment May bury pets and request burials Play for expression of feelings Explain death is final not sleep Choice in attending funeral 5-9 year old » Understands death is final » Believes own death can be avoided » Associates death with aggression or violence » Believes wishes or unrelated actions can be related to death Nursing Approaches Accept regressive or protest behavior Encourage verbalization of feelings 9-10 years old » Understands death as inevitable end of life » Begins to understands own mortality, expressed as interest in afterlife or fear of death » Expresses ideas about death from parents/older adults Nursing approaches » Encourage verbalization of feelings » Respect need for privacy and personal expression of fear, anger, sadness School age (5-12) Death is personified Fears mutilation and punishment Anxiety alleviated by nightmares and superstitions Death as final process Accepts regressive/protest behavior Verbalization of feelings
Sibling relationship • The narrower the space between sibling the more the children influence one another, the wider the gap the more the parent influence. • Siblings of same gender and closer age are high access. • Eldest Achievement oriented More dominant Receive more physical punishment Show more aggression to siblings Stronger conscience, more self-disciplined, inner directed More socially anxious Prone to guilt feelings Identify more with parents than peers More conservative Have greater parental expectations Begin to speak early in life Demonstrate higher intellectual achievement Plan better and experience fewer frustrations. Middle child More demands for household help Praised less often Receive less of parents time Learn to compromise and be adaptable Less stimulated towards achievement More difficult to characterized due to varied Youngest child Are less dependent than firstborn. Less tense, more affectionate, more good-natured Identify more with peers than parents More flexible in thinking Popular with classmates Fewer demands in household help Only child Resembles first born More mature and cultivated • Greater parental pressure for mature behavior and achievements Superior in language facility Stereotyped as spoiled and selfish Enjoy a rich fantasy life due to isolation Separation and divorce effects Reaction of age groups: • Reaction 3-6 years old – Fear of abandonment – Blame self for divorce; decreases self-esteem – Becomes more aggressive in relationships with others (siblings, peers, etc) – Engage in fantasy to seek understanding of the divorce. – Establish a sense of stability – Assure child will not be deserted and left alone. – Inform and be specific on details of new life – Focus on reality • 6-8 years old Panic reactions Feel deprive – parent, attention, money, future Profound fear, depression, insecurity Difficulty expressing anger towards parents Intense desire for reconciliation of parents Decline school performance Loss appetite and sleep disturbances 9-12 years old Anger directed at one or both parents Divided loyalties Can express feelings of anger Feel the need for revenge Feel lonely, rejected, and abandoned Decline school performance Engage in aberrant behavior – stealing, lying
Temper tantrums Dictatorial attitude • Adolescent – Disengage from parental conflicts – Feel profound sense of loss – family, childhood – Anxiety – Worry about self, parents, siblings – May withdraw from family and friends – Disturbed concept of sexuality – Acting-out behaviors (violence, smoking alcohol delinquency) Inferiority complex/ inferior organ School age (Industry vs. Inferiority) All children will feel sense of inadequacy in performance of certain task Repeated failure may cause reluctance to try new skills Comparison to others (peers, siblings) Feelings of doubt and guilt Affects confidence and self esteem Adolescent risk taking behavior • Common reasons • Biologic • Results Risk factor to childhood psychopathology • Poverty and homelessness • Child abuse and neglect • Out of home placement • Children of alcoholics • Poverty • Two Types of Poverty (visible vs. invisible) • Present in urban and rural areas • Poor nutrition, no preventive health care, limited access to health services • High infant mortality rate • Health care least priority • Health problems: nutritional deficiency, growth retardation, dental problems, communicable disease (lack vaccine/decrease resistance) • Homelessness – Reasons for homelessness are physical/substance abuse, poor living conditions, parental mental illness, domestic conflict, economic crises. – Runaways are often physically/sexually abuse. Possible reasons also includes poor parent-child relationship, extreme family contact, feelings of alienation, inconsistency in supervision, unpredictability in discipline – Homelessness deprives children of basic needs – It disrupts friendship and schooling – Suffer from physical and mental illness. • Child neglect – Failure to provide basic needs and adequate level of care – Reason includes physical abuse, ignorance in child rearing – Includes physical and emotional neglect (rejection, isolation, terrorizing, ignoring, verbal assault, over pressure) • Child abuse Physical abuse Bruises and welts (in various stages of healing) Burns Fractures and dislocations Lacerations and abrasions Wariness of physical adult contact Fear or parent or going home Apprehensive when hearing other children cry Superficial relationships Acting-out (animal, playmate assault) Withdrawal behavior • Child abuse Sexual abuse
• • • • • • • • • • • • • • • • • • •
Bruises, bleeding, laceration (genital, mouth, anus, throat) Torn, stained, bloody underclothing Sexually transmitted disease Difficulty walking or sitting Recurrent UTI Pregnancy in young adolescent Withdrawn behavior Poor relationships with peers Excessive anger at mother (incest) Regressive behavior Phobias (men, dark places) Running away from home Substance abuse Poor school performance Suicidal attempts and ideation Poverty and homelessness Child abuse and neglect Out of home placement Children of alcoholics
a. This involves assessment of the knowledge of patient by checking the vocabulary and educational background of patients. The Dying patient’s Bill of Rights (American Journal of Nursing) sI have the right to be treated as a living human being until I die. I have the right to maintain a sense of hopefulness however changing its focus may be. I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this might be. I have the right to express my feelings and emotions about my approaching death in my own way. I have the right to participate in decisions concerning my care. I have the right to expect continuing medical and nursing attention even though "cure" goals must be changed to "comfort" goals. I have the right not to die alone. I have the right to be free from pain. I have the right to have my questions answered honestly. I have the right not to be deceived. I have the right to have help from and for my family in accepting my death. I have the right to die in peace and dignity. I have the right to retain my individuality and not be judged for my decisions which may be contrary to beliefs of others. I have the right to discuss and enlarge my religious and/or spiritual experiences, whatever these may mean to others. I have the right to expect that the sanctity of the human body will be respected after death. I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face death. POST MORTEM CARE Definition: Post mortem care refers to the care of the body after death. Purposes: 1. To keep the body clean and odor free. 2. To prepare the body for discharge from the health facility 3. To make the dead presentable for viewing by the significant others. Special Considerations: 1. Respect the family’s emotional state and their religious beliefs. 2. Start post mortem care only after the patient has been pronounced legally dead. 3. Requires a signed receipt from the next of kin who received the dead’s personal effects. 4. Follow the institutions policy as regards the following: 5. Always handle the body gently and apply tags loosely to prevent skin dents and discoloration. 6. Be sure the dead body is properly identified. 7. Provide privacy for the deceased and his relatives. Equipments and Supplies Shroud or extra bed sheet Identification tags (2) Roller bandage Bath towel Equipment for bed and perineal care Dressing tray Loin cloth Safety pins (2)
Communication – the process of transmitting thoughts, feelings, facts and other information, includes verbal and non-verbal behavior. Levels of Communication 1. Intrapersonal Communication – the message one sends to oneself, including self-talk, communication with one self. 2. Interpersonal Communication – process occurs between two people either face to face encounters, over the phone, or other media. 3. Public Communication – 3 or more people meet in face to face encounters or through another communication medium such as conference Elements of Communication: 1. Sender – generates the message; the source of information 2. Message – is a stimulus produced by a sender and responded to by a receiver. It may be verbal, nonverbal, written materials, and arts. 3. Channel – medium through which a message is transmitted. a. Visual channel – sight and observation b. Auditory channel – spoken words and cues c. Kinesthetic channel – experiencing sensations. 4. Receiver – the person who intercepts the sender’s message. 5. Referent - feedback 6. Variables Modes of communication 1. verbal 2. Nonverbal a. Kinesics b. Proxemics – is the study of the distance between people and object i. Intimate distance – 0-18 inches; vital signs, massage ii. Personal distance – 1.5 – 4 feet; teaching, counseling, interview iii. Social distance – 4 feet and beyond; rounds, class teaching Paralanguage Factors influencing communications 1. Development a. The nurse must know how to communicate with different age groups (children, adult, elderly) 2. Perception a. How the person interprets the information on their own words or understanding 3. Values a. Refers to the social norms, religion and moral standards of the person 4. Emotions a. Nurse be aware of own feelings and deal with patient in calm manner. 5. Socio-Cultural Backgrounds 6. Knowledge
PROCEDURE 1. Close the door, if in the private room, or pull a screen around the dying patient’s bed. 2. Assist in the religious ritual that may be done 3. As soon as the body is pronounced dead a. Elevate the head either on a pillow or on a low back rest b. Gently close the eyes and close the mouth by placing a small rolled towel under the chin. c. Depending on the institutions policy and the wishes of the family, dentures may or may not be replaced at this time d. Remove valuables, make an inventory and endorse to next of kin. e. Notify the following: Attending Physician, Nursing Supervisor, Admitting or Census Department, Appropriate Agency for Organ Procedures, Medical Examiner, Designated Mortician 4. Wash hands and gather equipments and put on clean gloves 5. Remove contraptions. a. Some contraptions are not pulled out completely; they are cut close to the skin. b. Contraptions may not be removed if the body is for autopsy. 6. With the dead body properly draped, clean the dirty parts. a. Wash peri-anal area with soap and water if soiled with feces. b. Change soiled dressing/bandages and ostomy bags. c. Pack/ plug draining orifices with disposable pads 7. Place arms along the side of the body in normal functional position. 8. Remove and put on another clean gloves 9. Put on under pants or a loin cloth and loose clean clothes or gown. Leave the identification band in place. 10. Attaches a properly accomplished identification tag on one wrist or leg (ankle or great toe) containing the following data: a. Full name of the deceased b. Sex and Age c. Date and time of death d. Name of AMD e. Name of health facility 11. Bind the legs together with
RATIONALE To provide privacy for the patient and significant others & protect the sensitivity of the other patients. To show respect for the family’s religious beliefs To prevent pooling of blood on the face that causes discoloration. To give the body a more peaceful and natural appearance. Some morticians prefer that the dentures be replaced by them for a better fit. To prevent possible legal problems later.
bandage applied loosely or provided with padding. 12. Cover the body with a shroud or mummify with a bed sheet. 13. Pin another name tag on the shroud or bed sheet. 14. Complete the patient’s record and send to the appropriate department of health facility 15. Have the dead body transported to the morgue. 16. Put away or dispose equipment and supplies used. 17. Wash hands 18. Accomplish discharge responsibilities and Document Post Mortem activities including: A. Time of cessation of Vital Signs. B. Persons notified and time of notification. C. List and documentation of valuable and personal effects. D. Time body removed from unit, destination and by whom removed. E. Other information required by faculty.
when the body is lifted for transport. Padding will prevent dents on the skin. To provide privacy during transport to the morgue To ensure proper identification in case one name tag is lost. The patient’s record will be the basis of death certificate Institutional policy may require that the body be transported to the morgue within 1-2 hours after death.
Contraptions impair the natural appearance of the body
Keep the body clean, odor free an presentable for viewing by significant others.
Rigor mortis is the state of partial contraction of muscles after death due to lack of ATP; myosin heads (cross bridges) remain attached to actin thus preventing relaxation. Cellular membranes becomes leaky calcium ions leak out of the sarcoplasmic reticulum into the cytosol and allows myosin heads to bind to actin. Begins 3-4 hours after death and last 24 hours then disappears as proteolytic enzymes from lysosomes digest the crossbridges
Crossing the arms over the chest makes their repositioning difficult when rigor mortis has set in. To provide privacy
To ensure proper indentification
To prevent dangling of a leg
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