Cardiac Disease

Classes:
I - ALL ACTIVITIES ARE ALLOWED!
II - SYMPTOMATIC WITH HEAVY PHYSICAL ACTIVITY EX. CLEANING THE
HOUSE,STAIRS
III – SYMPTOMATIC WITH ORDINARY ACTIVITY EX. EATING
IV - SYMPTOMATIC WITH ALL ACTIVITY!NO BATHROOM PRIVE! EX. SLEEPING/REST

DIABETES MELLITUS
- INCREASE INSULIN IN 2NDTRI D/T HPL

- ASSESSMENT

- POLYDIPSIA,POLYPHAGIA,POLYURIA,WT. LOSS

- GLYCOSYLATED HEMOGLOBIN –MEASURES CONTROL OF GLUCOSE

- IF COLD AND CLAMMY – NEED SOME CANDY (HYPOGLYCEMIA)

COCAINE
- EFFECT S ARE :

- 1. ABRUPTUIO PLACENTA

- 2. Low birth weight

HIV/AIDS
- COMMON WITH UNPROTECTED SEX
-ELISA – SCREENING
- WESTERN BLOT- CONFIRMS

NURSING INTERVENTION! PREVENT OPPORTUNISTIC INFECTION! (MOST COMMON IS

PCP - Pneumocystis carinii pneum caused by Pneumocystis jirovecii.

HELPER CELLS ARE ATTACKED!

1987- 1ST DUG: ZIDOUVINE
1984- 1ST CASE IN PHILIPPINES
DOLZURA CORTEZ – 1ST TO PUBLICLY ADMIT TO HAVE AIDS (NOT SARAH SALAZAR!)
NO BREASTFEEDING !

- RA 8504 AIDS PREVENTION AND CONTROL ACT OF 1988

- CONFIDENTIALITY IS IMPORTANT

RH SENSITIZATION
- RHOGAM IS GIVEN TO RH (-) MOTHERS WITHIN 72 HOURS TO PREVENT
SENSITIZATION OR ANTIBODY FORMATION TO THE NEXT RH POSITIVE CHILD

- ALSO CALLED ERYTHROBLASTOSIS FETALIS AND CURSE OF THE 1ST CHILD

- COOMB’S TEST: USE TO CHECK ANTIBODY FORMATION

- IF (-) GOOD! NO ANTIBODY FORMATION

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 - IF (+) BAD! GIVE RHOGAM WITHIN 72 HOUES

ANEMIA
- ANEMIC IF IRON IS BELOW 11MG/ML

- NURSING DIAGNOSIS: ACTIVITY INTOLERANCE

- GIVE WITH ORANGE JUICE! ENHANCES ABSORPTION! OR GUAVA JUICE! HIGH IN

VITAMIN C!

- IRON HAS NO EFFECT ON SICKLE CELL ANEMIA! DO NOT TAKE! WILL NOT HELP!

- SOURCES:

- 1. LIVER,ORGAN MEATS,LEGUMES,PROTEIN VEGETABLES, GREEN LEAFY

VEGETABLES!

- USE WITH STRAW

- IF IM , USE ZTRACK TECHNIQUE

- FOLIC ACID (B9) PREVENTS NEURAL TUBE DEFECTS

HYPEREMESIS GRAVIDARUM
- ASSOCIATED WITH INCREASED HCG LEVEL

- LOW FAT OODS!

- PREVENT ELECTROLYTE IMBALANCE!

ECTOPIC PREGNANCY
- MOST COMMON: TUBAL

- SPECIFICALLY AT THE AMPULLA

- MOST DANGEROUS : INTERSTITIAL

IF RUPTURED – SHARP KNIFE LIKE PAIN WITH CULLEN’ SIGN ( BLUISH

DISCOLORATION)

GESTATIONAL TROPHOBLASTIC DISEASE

- OR HYDATIDIFORM MOLE

- VERY HIGH HCG AND HIGH FUNDIC HEIGHT FOR GESTATIONAL AGE

- XRAY- “SNOWSTORM PATTERN” OR GRAPELIKE CLUSTER

- AVOID PREGNANCY FOR 1 YEAR BECAUSE HCG WILL BE MONITORED

- GIVE METHOTREXATE! TO PREVENT CHORIOCARCINOMA!

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 SPONTANEOUS ABORTION

THREATENED

- WITH BLEEDING BUT CLOSE CERVIX

- BEDREST/AVOID SEX FOR 2 WEEKS

INEVITABLE/IMMINENT

- WITH BLEEDING AND OPEN CERVIX

-D & C

MISSED

- DEATH IN THE UTERO!

- MONITOR FOR DIC, INFECTION

HABITUAL

- 3 OR MORE CONSECUTIVE!

- D/T INCOMPETENT CERVIX

- CERCLAGE ( ENCIRCLING CERVIX WITH SUTURE) FOR MANAGEMENT:

- MCDONALD- TEMPORARY

- SHIRODKAR – PERMANENT

PLACENTA PREVIA

- IMPROPER IMPLANTATION CAN BE TOTAL,PARTIAL OR MARGINAL

- PAINLESS BRIGHT RED!

- DOUBLE SET UP!

- APT OR KEIHAUER BETKE TEST – DETERMINES IF BLOOD IS FROM MOTHER OR

FETUS

ABRUPTIO PLACENTA
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- PREMATURE SEPARATION

- PAINFUL DARK RED

- BOARD LIKE RIGIDITY

- (+) COUVELAIRE UTERUS OF UTEROPLACENTAL INSUFFICIENCY

-IF FOR BT, FIRST DETERMINE BLOOD COMAPTIBILITY!

• IN BOTH PLACENTA PREVIA AND ABRUPTIO PLACENTA!

ALWAYS PRIORITIZE THE FETAL HEART TONE!

PREMATURE RUPTURE OF MEMBRANE

- RISK FOR INFECTION!

- IF THERE IS GUSH OF FLUID, NURSE SHOULD CHECK FOR PH

- AMNIOTIC IS ALKALINE (BLUE)

PIH

- ALSO CALLED TOXEMIA

- PROTEINURIA, EDEMA, HYPERTENSION

- BASIS IS VASCULAR SPASM LEADNG TO HYPERTENSION

- GIVE MAGNESIUM SULFATE : PREVENTS CONVULSIONS/SEIZURES

- THERAPEUTIC MAG IS : 5-8MG/100ML

- ANTIDOTE: CALCIUM GLUCONATE

- ASSESS FOR : DEEP TENDON REFLEXES (PATELLAR)

FETAL IN OCCIPUT POSTERIOR

- USE COUNTER PRESSURE!

- VERY PAINFUL!

BREECH PRESENTATION

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 - BUTTOCKS FIRST

- CS IN PRIMI MAY BE REQUIRED

- FETUS: MORTALITY, ASPHYXIA,TRAUMA LIKE BACHIAL PALSY AND FRACTURE!

- IF NSD, USE PIPER FORCEPS

PROLAPSED CORD

- FHT WILL SHOW VARIABLE DECELEARTION OR BRADYCARDIA

- RELIEVED CORD BY GLOVED HAND WITH GAUZE WITH STERILE SALINE

- POSITION: TRENDELENBERG,MODIFIED SIM,OR KNEECHEST

- PRIOTITY: FHT

CPD
 Disproportion between size of normal fetal head to the
pelvic diameters. It causes failure to progress in labor.
 Inlet contraction - ordinarily due to rickets early in life
or an inherited small pelvis.
- narrowing of the anteroposterior diameter to less than 11
cm or a maximum transverse diameter of 12 cm or less.
 Assessment:
- When engagement does not occur in primigravidas
(normally, it occurs at 36-38 weeks of pregnancy), suspect
either a fetal head abnormality (larger than usual heads) or a
pelvic abnormality (smaller than usual pelvis).
- All primis must have pelvic measurements before 24
weeks.
- Check trial labor - if the woman has a borderline inlet
measurement, and the fetal lie and position are good, a trial
labor may be allowed to see if labor may proceed normally.
This may be continually allowed as long as there is

5
progressing descent of presenting part and cervical
dilatations.
 Management:
- closely monitor maternal and fetal well-being.
- emotional support, emphasize that trial labor is best for
both mother and child.
-

DYSTOCIA

- DIFFICULT PROLONG PAINFUL LABOR

PREMATURE LABOR

- AFTER 20TH WEEK BUT BEFORE 37TH WEEK

- USE TOCOLTYTICS

- RITODRINE,TERBUTALINE,MAGSO4, INDOMETHACIN,RIFEDIPINE

- BETHAMETHASONE 24 TO 48 HOUS BEFORE BIRTH FOR LUNG MATURITY !

PRECIPITATE LABOR AND DELIVERY

- LESS THAN 3 HOURS

- HAZARDS: MOTHER: LACERATION/HEMORRHAGE

- INFANT:ANOXIA,INTRACRANIAL HEMORRHAGE

POSTPARTAL HEMORRHAGE

- MORE THAN 500 ML IN 24 HOURS

UTERINE ATONY

-RELAX

- RISK FOR HEMORRHAGE MON V/S HYPOVOLEMIC SHOCK IS COMMON

(HYPOTENSION, TACHYCARDIA,TACHYPNEA)

-NURSE SHOULD MASSAGE,ICE PACK COUNT PADS

6
 DIC

- COMPLICATION : RENAL FAILURE AS MANIFESTED BY DECREASED URINE OUTPUT

- CLOTTING CASCADE IS ACTIVATED RESULTING IN THE FORMATION OF CLOTS

CAUSING PLATELET DEPLETION

PETECHIAE AND ECCYMOSIS IS COMMON!

The Royal Pentagon Review Specialist, Inc. Maternity Nursing

Human Sexuality

a. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes and
emotions and preferences that is related to sexual self and eroticism
2. Sex is basic and dynamic aspect of life

7
 3. During reproductive years, the nurse performs as resource person on human
sexuality
15 – 44 y.o. – age of reproductivity CBQ

b. Definitions related to sexuality

Gender Identity – sense of feminity and masculinity – developed @age 3 or 2 -4 y.o.
Role Identity – attitudes, behaviours and attitudes that differentiate roles
Sex – biologic male or female status. sometimes referred to as specific sexual behavior
such as sexual intercourse
Sexuality - behavior of being a girl or boy and is identity subject to a lifelong dynamic
change

II. Sexual Anatomy and Physiology

a. Female Reproductive System

1. External – Vulva/ Pudenda
a. Mons pubis/ veneris – mountain of venus, a pad of fatty tissues that lies
over the symphysis pubis covered by skin and at puberty covered by pubic
hair that serves as a cushion or protection to the symphysis pubis

Stages of Pubic Hair Development (Tool Used: Tanner’s Scale/ Sexual Maturity Rating)

Stage 1 – Pre adolescence

• no pubic hair, fine body hair
Stage 2 – Occurs bet. 11 – 12 y.o
• sparse, long, slightly pigmented and curly that develop along labia
Stage 3 – Occurs bet. 12 – 13 y.o.
• hairs become darker and curlier develops along pubis symphysis
Stage 4 – 13 – 14 y.o.
• hair ssumes normal appearance of an adult but is not so thick and
does not appear to the inner aspect of the upper thigh
Stage 5 – Sexual Maturity
• assumes the normal appearance of an adult, appears at the inner
aspect of thigh

b. Labia Majora – large lips latin, longitudinal fold from perenium to pubis
symphysis
c. Labia Minora – aka Nymphae, soft and thin longitudinal fold created between
labia majora
• Clitoris – “key”, pea – shaped erectile tissue composed of sensitive
nerve endings; sight of sexual arousal in females
• Fourchet – tapers posteriorly of the labia majora. Site for episotomy
- sensitive to manipulation, torn during pregnancy
d. Vestibule – almond shaped area that contains the hymen, vaginal orifice and
batholene’s gland
• Urinary Meatus – small opening of urethra/ opening for urination
• Skene’s Gland – aka Paraurethral Gland, 2 small mucus secreting
glands for
lubrication
• Hymen – membranous tissue that covers the vaginal orifice
• Vaginal Orifice – external opening of the vagina
• Bartholene’s Gland – paravaginal gland, secretes alkaline
substance, neutralizes acidity of the vagina
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 o Doderleins Bacillus – responsible for vaginal acidity
o Parumculae Mystiformes – healing of a hymen
e. Perenium – muscular structure in between lower vagina and anus

2. Internal
a. Vagina – female organ for ovulation, passageway of menstruation, ¾ inches
8 – 10 cm long containing rugae
o Rugae – permits considerable stretching withouit tearing
during delivery CBQ
b. Uterus – hollow muscular organ, varies in size, weight and shape, organ of
menstruation
Size : 1 x 2 x 3
Shape : pear shaped, pregnant - ovoid
Weight : Uterine involution CBQ
Non pregnant : 50 – 60 g
Preganant : 1000 g
4th stage of Labor : 1000 g
2nd week after of Delivery : 500 g
3rd weeks after delivery : 300 g
5 – 6 Weeks after delivery: 50 – 60 g
Three Parts of Uterus
• Fundus – upper cylindrical layer
• Corpus/ Body – upper triangular layer
• Cervix – lower cylindrical layer
Isthmus – lower uterine segment during pregnancy

Muscular Composition: 3 main Muscles making possible expansion in all direction

a. Endometrium  muscle layer for menses
o Lines the non-pregnant uterus
o Volumes the non pregnant uterus
o Decidua – slouching off of endometrium during menstruation
o Endometriosis
 Ectopic Endometrium
 Common site is ovaries
 Proliferation of abnormal growth of lining of outer part
 Persistent dysmenorrhea, low back pain
 Dx Exam: biopsy,laparoscopy
 Tx: Lupron (luprolide)  inhibits FSH & LH
 Tx: Danazol (Danacrine) DOC
Inhibits ovulation
stop menstruation
b. Myometrium
o Power of labor
o Smooth muscles is considered to be LIVING LIGATURE
(muscles of delivery, capable of closing) of the body
o Largest portion of the uterus
c. Peremetrium
o Protects the entire uterus
c. Ovaries
• 2 female sex gland
• almond shape
• Fxn: Ovulation,production of 2 hormones( estrogen and progesterone)
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 d. Fallopian Tube
• 2 – 3 inches long that serves as a passageway of the sperm from the
uterus to the ampulla or the passageway of the mature ovum or fertilized
ovum from the ampulla to the uterus
• 4 significant segments
o Infundibulum – most distal part, trumpet shape, has fimbrae
o Ampulla – outer 3rd or 2nd half, site of fertilization, common site for
ectopic preg.
o Isthmus – site for sterilization, site for BTL
o Interstitial – most dangerous site for ectopic pregnancy

b. Male Reproductive System

1. External
• Penis
• The male organ of copulation and urination
• Contains of a body or shaft consisting of 3 cylindrical layers and erectile
tissues
o 2 corpora cavernosa
o 1 corpus spongiosum
• At the tip is the most sensitive area comparable to clitoris = glans penis
• Scrotum
• Pouch hanging below the pendulous penis, with medial septum deviding
into 2 sacs each containing testes
• Requires 2 degrees celcius for continuous spermatogenesis
• Cooling mechanism of testes
2. Internal
The Process of Spermatogenesis

Testes
(900 coiled seminiferous tubules)
↓
epididymis
(site of maturation of sperm 6 m)
↓
Vas Deferens
(conduit pathway of sperm)
↓
Seminal Vesicle
(secreted: fructose form of glucose, nutritative value
Prostaglandin: causes reverse contraction of uterus)
↓
Ejaculatory Duct
(conduit of semesn)
↓
Prostate Gland
(release alkaline substances)
↓
Cowpers Gland
(release alkaline substance)
↓
Urethra
Hypothalamus GNRH
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 ↓
APG
↓
FSH – maturation of sperm
LH – testosterone production
Leydig Cells – releases testosterone

Male & female Homologues

Male Female
Penile Glans Clitoris
Penile Shaft Clitoral shaft
Testes Ovaries
Prostate Skene’s gland
Cowper’s Glands Bartholin’s Gland
Scrotum Labia Majora

III. Basic Knowledge on Genetics and Obstetrics

1. DNA – Deoxyribonucleic Acid – carries genetic code

2. Chromosomes – threadlike structure of hereditary material known as the DNA
3. Normal amount of ejaculated sperm – 3 – 5 cc/ 1 teaspoon
4. Ovum is capable of being fertilized within 24 – 36 hours after ovulation.
5. Sperm 48 – 72 days viability
6. Reproductive cells divide by the process of MEIOSIS (haploid number)
• Spermatogenesis – process of maturation of sperm
• Oogenesis – process of maturation of ovum
o 30 weeks AOG – 6 million immature ovum
o @ birth – 1 million immature oocytes
o @ puberty – 300 – 400 immature oocytes
o @ 13 y/o – 300 – 400 mature oocytes
o @ 23 y/o – 180 – 280 mature ovum
o @ 33 y/o – 60 – 160 mature ovum
o @ 36 y/o – 24 – 124 mature ovum
o @46 y/o – 4 mature ovum
• Gametogenesis – process of formation of two haploid into diploid
7. Age of reproductivity – 15 – 44 y/o childbearing age – 20 – 35 y/o
High risk  <18 & >35 y.o. With Risk  18 – 20; 30 – 35
8. Menstruation
• Menstrual Cycle – beginning of menstruation to the beginning of the next
menstruation
• Average menstrual cycle – 28 days
• Average menstrual period – 5 days
• Normal blood loss – 50 cc/ ¼ cup accompanied by FIBRINOLYSIS – prevents
clot formation
• Related terminologies
o Menarche – 1st menstruation
o Dysmenorrhea – painful menstruation
o Metrorrhagia – bleeding in between menstruation
o Menorrhagia – Excessive bleeding during menstruation
o Amenorrhea – absence of menstruation
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 o Menopause – cessation of menstruation (Average Age- 51 y.o.)
 Tofu – has isoflavone – estrogen of plant that mimics the estrogen
with a woman
9. Functions of Estrogen and Progestin
• ESTROGEN – hormone of woman
o Primary function
 Responsible for the development of secondary characteristics in
females
 inhibit production of FSH
o Other function
 Hypertrophy of the myometrium
 Spinnbarkeit and Ferning Pattern (Billings Method)
 Ductile structure of the breast
 Osteoblastic bone activity (causes increased in height)
 Early closure of the epiphysis of the bone
 Sodium retention
 Increased sexual desire
 Responsible for vaginal lubrication
• PROGESTERONE – Hormone of the mother
o Primary function – prepares the endometrium for implantation making it
thick and tortous
o Secondary Function – inhibit uterine contractibility
o Others
 Inhibit LH (hormone of ovulation) production
 ↓ GI motility
 ↑ Permeability of kidneys to lactose and dextrose causing + 1 sugar
in urine
 Mammary gland development
 ↑ BBT
 Mood swings

10. Menstrual Cycle

4 phases of menstrual cycle
1. Proliferative
2. Secretory
3. Ischemic
4. Menses

1. On the initial phase of menstruation, the estrogen level is ↓, this level stimulates
the hypothalamus to release GnRH/ FSHRF
2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH
• FSH Function
o Stimulate ovaries to release estrogen
o Facilitate the growth of primary follicle to become
GRAAFIAN FOLLICE  structure that secretes large amount of
estrogen that contain mature ovum
3. Proliferative Phase (↑estrogen)
Follicular Phase – responsible for the variation and irregularity of mense
Postmenstrual Period – after menstruation
Preovulatory Phase – happen before menstruation

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 4. 13th day of menstruation, estrogen level is PEAK while progesterone is ↓, these
stimulates the hypothalamus to release GnRH/ LHRF
5. GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH
• Functions of LH
o Stimulates the release of progesterone
o Hormone for ovulation
6. 14th day estrogen level is ↑ while progesterone level is ↑
• S/S
o Rupture of the graafian follicle - OVULATION
o Mittelschsmerz – slight abdominal pain lower right
quadrant
7. 15th day, after ovulation day, graafian follicle starts to degenerate, estrogen level
↓, progesterone ↑, causing degeneration of the graafian follicle becoming yellowinsh
known as CORPUS LUTEUM – secretes large amount of progesterone
8. Secretory Phase
Lutheal Phase (↑progesterone)
Postovulatory phase
Premenstrual Phase
9. 24th day – Corpus Albicans (whitish) corpus luteum degenerates and becomes
white
10. 28th day – if no sperm united the ovum, the uterine begins to slough off to have
the next menstruation
Note:
• if there is no fertilization, corpus luteum continues functioning
• Ovarian Cycle – from primary follicle – corpus albicans
• Stages:
o 1 – 5 days – menses
o 6 – 14 – proliferative
o 15 – 26 – secretory
o 27 – 28 – ischemic

11. Stages of Human Sexual Response

Initial Response:
VASOCONGESTION – constriction of blood vessels
MYOTONIA – increased muscle tension
• Excitement Phase
• ↑ muscle tension, moderate VS
• erotic stimuli causing ↑ sexual tension, may last from minutes to hours
• Plateu Phase
• ↑ and sustained tension near orgasm
• may last 30 sec – 30 minutes
• Orgasm
• Involuntary release of sexual tension accompanied by physiologic and
psychologic release,
• immeasurable peak of experience 2 – 3 seconds
• Resolution
• Return to normal state
• VS return to normal

REFRACTORY PERIOD – only period present in male, wherein he cannot restimulated for
about 10 – 15 minutes
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IV. Wonders of Fertilization
a. Fertilization
1. Phonones – song of sperm
2. Capacitation – ability of sperm to release proteolytic enzyme and penetrate the
ovum
b. Stages of Fetal Growth and Development
1. Pre Embryonic Stage
I. Zygote  fertilized ovum (3 – 4 days travel, 4 days floating)> from fertilization
II. Morula  mulberry-liked ball containing 16 – 50 cells
III. Blastocyst  enlarging cell forming a cavity that later becomes the embryo covered by
thropoblast which later becomes the placenta and membrane
IV. Implantation  7 – 10 days after fertilization
• Thropoblast – covering of blastocyst that become placenta
• S/Sx of Implantation  Slight pain, Slight Vaginal Spotting
• 3 Processes
o Apposition
o Adhesion
o Invasion
2. Embryonic Stage
Zygote – fertilization to 14 days
Embryo – 15th – 2 mos/ 8 weeks
Fetus – 2 mos to birth
c. Decidua – thickened endometrium, latin word for “falling off”
1. Basalis – located directly under the fetus where placenta developed
2. Caspularis – encapsulates the fetus
3. Vera – remaining portion of and endometrium
d. Chorionic Villi – 10 – 11 weeks
1. Chorionic Villi Sampling (CVS) – removal of tissue from the fetal postion of the
developing placenta
• For genetic screening
• Fetal limb defects, missing digits of toes
e. Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the fetus against syphilis
(24 weeks/ 6 months)
f. Synsitiotrophoblast – syncitial layer – responsible for hormone production
1. Amnion – inner most layer 2. Chorion
I. Umbilical cord (Funis) – whitish gray (50 – 60 cm)
• Short  abruptio placenta, uterine inversion
• Long  cord prolapse, cord coil
• 3 vessels (AVA) – Artery Vein Artery
• Wharton’s Jelly – protects the umbilical cord
II. Amniotic fluid  bag of water  clear color, musty/mousy odor
• With crystallized forming pattern, slightly alkaline
• 500- 1000 cc Normal
o Oligohydramnios – kidney malformation
o Hydramnios – GIT , TEF/ TEA
• Functions
o Cushion the fetus against sudden blow or trauma
o Maintains temperature
o Facilitate muscuskeletal development
o Prevents cord compression

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 o Helps in development process

Diagnostic Test for Amniotic Fluid  Amniocentesis

• Purpose: obtain sample of amniotic fluid by inserting a needle
hrough the abdomen into the amniotic sac
• Fluid is tested for:
• Genetic screening
• Determination of fetal maturity primarily by evaluating factors
indicative of lung maturity
• Done with empty bladder
• Complication
> Most common side effect : INFECTION
> Late : pre term labor
> Early : spontaneous abortion
• Indication for Amniocentesis:
> Early in Pregnancy Advance Maternal Age
> Later in Pregnancy Diabetic Mothers
• ↑ - down syndrome
• ↓ - neural tube defect, spina befida
• L/S ratio : 2:1 (Lecitin/ Spingomyelin)
• Definitive test = Phosphatiglycerol: PG +  best Answer
• Greenish – Meconium Stains (Fetal Distress)
• Yellowish – jaundice, hyperbilirubinemia
• Cloudy – Infection
• Most Important Consideration  Needle insertion site
• Amnioscopy – direct examination through intact fetal membrane
via ultrasound
• Fern Test – a test determining if bag of water has rupture or not
• Nitrazine Paper Test – differentiate amniotic fluid and urine
Blue geen  + rupture of bag of H2O

2. Chorion – outermost layer

a. Placenta – AKA Secundines  chorionic Villi and basalis
• Pancake in latin
• 500 grams in weight
• 15 – 28 cotyledons
• 15 – 20 cm in diameter and 2 – 3 cm in depth
• Functions
o Respiratory  02 – CO2 exchange via simple diffusion
o GIT  glucose transport via facilitated diffusion
o Excretory  via 2 arteries, carries unoxygenated blood
then detoxify by maternal liver
o Circulatory  fetoplacental circulation by SELECTIVE
OSMOSIS
o Endocrine
 HCG – primary maintain corpus luteum/
secondary basis of pregnancy test
 Human Placental Lactogen – aka
Somatomammothrophin
• Responsible for the development of
mammary gland
15
 • Diabetogenic Effect – insulin antagonist
 Relaxin – softening of maternal joints and bones
o Serves as protective barrier against some microorganism
 Can pass: HIV CMV Rubella
 PINOCYTOSIS – transport of virus

Pregnancy – 266 – 288 days/ 37 – 42 weeks

FETAL STAGE: Fetal Growth and Development

First Trimester : Period of organogenesis, most critical period

First Month
FHT, CNS Develops, GIT and Respi Tract remains as single tube
Differentiation of Primary Germ Layer
• Endoderm
o Thyroid – responsible for basal metabolism
o Thymus – immunity
o Liver
o GIT
o Linings of Upper GI Tract
• Mesoderm
o Heart
o Musculoskeletal
o Reproductive Organ
o Kidney
• Ectoderm
o Brain
o CNS
o Skin
o 5 senses
o Hair, nails
o Anus
o Mouth
Second Month
• Life span of corpus luteum ends
• All vital organs are formed
• Placenta is developed
• Sex organ is developed
• Meconium is present
Third Month
• Placenta is complete
• Kidneys are functional
• Fetus begins to swallow amniotic fluid
• Buds of milk appear
• Sex is distinguishable
• FHT audible via dopples @ 10 – 12 weeks
Terratogens – any drug or irradiation, the exposure to which may cause damage to the fetus
• DRUGS
o Streptomycin – anti – TB – (quinine) damage to the 8th cranial nerve  poor learning
and deafness/ ototoxic
o Tetracycline – stoning the tooth enamel, inhibits long bone growth
o Vitamin K – hemolysis, destruction of RBC, jaundice, hyperbilirubenemia
16
 o Iodides – enlargement of thyroid and goiter
o Thalidomides – anti-emetics  Amelia or Pocomelia  absence of distal part of
extremities
o Steroids – cleft lip or palate and even abortion
o Lithium – congenital maformation
• ALCOHOL – LBW, fetal alcohol syndrome ( characterized by microcephaly)
• SMOKING – LBW
• CAFFEINE – LBW
• COCCAINE – LBW, abruptio placenta
• TORCH – group of infections that can cross the placenta or ascend through the birth canal
and adversely effect fetal growth
o Toxoplasmosis – cat lovers
o Others - Hepa AB, HIV, Syphillis
o Rubella – CHD,
 Rubella Titer – N @ 1:10 or ↓ = immunity to rubella = notify doctor
 Rubella vaccine after delivery for 3 mos. No pregnancy for 3 mos.
o Cytomegalo virus
o Herpes Simplex virus

Second Trimester : continuous growth and development (focus  lengh of fetus)

Fourth Month
• Lanugo begins to appear
• Buds of permanent teeth appear
• FHT audible via Fetuscope @ 18 – 20 weeks
Fifth Month
• Quickening : 1st fetal movement Primi: 18 – 20, Nulli - 16 - 18
• Lanugo covers the body
• FHT audible via stethoscope or w/out instrument
• Actively swallow amniotic fluid
• Fetus : 19 – 25 cm
Sixth Month
• Skin is red and wrinkled
• Vernix caseosa covers the skin
• Eyelids open
• Exhibits startle reflex
rd
3 Trimester : period of most rapid growth and development Focus: weight
Seventh Month
• Surfactant development
• Male: the testes begins to descent into the scrotal sac
• Female : clitoris is prominent and labia majora are small doesn’t cover the minora
Eight Month
• Active moro reflex
• Lanugo begins to disappear
• Sub q fats deposits, steady weight gain, nails to fingers
Ninth Month
• Lanugos and vernix caseosa is evident in body fold
• Birth position assumed
• Amniotic fluid somewhat decrease
• Sole of the foot has few creases
Tenth Month
• Bone ossification in the fetal skull
17
 • Vernix caseosa is evident in body

PHYSIOLOGIC ADAPTATION TO PREGNANCY

Systemic Changes
1. Cardiovascular System
• ↑ blood volume 30 – 50%
• 1500 cc; additional 500 cc for multiple pregnancy
• ↑ plasma volume
• ↑ cardiac workload – easy fatigability/ slight ventricular hypertrophy
• Epistaxis due to hyperemia of nasal membrane
• Palpitation due to SNS stimulation
• Physiologic Anemia/ pseudoanemia in pregnacy
o Normal Value
Hct : 32 – 42%
Hgb: 10.5 – 14 g/dl
o Criteria
1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl
2nd Trimester : Hct > 32% Hgb > 10.5 g/dl
o Pathologic Anemia
 Iron Defficiency Anemia is the most common hematologic disorder. It
affects 20% of pregnant women
 Assesment reveals:
• Pallor
• Slowed capillary refill = Normal = 2 – 3 sec
• Concave fingernails (late sign of progressive anemia) – clubbing
= chronic tissue hypoxia
• constipation
 Nursing care
• Nutritional instruction
o Source of iron
 Kangkong
 Liver = best source due to FERRIDIN Content
 Red and lean meat
 Green Leafy Vegetables
• Parenteral Iron (Imferon)
o Z tract IM
o incorrect causes hematoma
o best given 1 hour before meals (causes GI irritation)
o Maybe given 2 hours after meal (results to poor
absorption)
 Given with orange juice to ↑ absorption
• Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a day)
• Monitor for hemorrhage
 Alert
• Iron from red meat is better absorbed iron from other sources
• Iron is better absorbed when taken with foods high in Vitamin C
such as orange juice
• Higher iron intake is recommended since circulating blood
volume is increased and heme is required from production of
RBCs

18
 • Edema
o Impeded venous return due to the gravid uterus
o Nursing Intervention
 Elevate legs above the hips level
• Varicosities
o Wear support stockings
o Elevate legs
• Vulvar Varicosities
o D/t pressure of gravid uterus
o Side –lying with pillow under the hips
o Modified knee – chest position
• Thrombophlebitis
o Presence of thrombus in inflamed blood vessels
o + Homan’s Sign – pain on the calf upon dorsiflexion
o Medical Management
 Anticoagulant/ HEPARIN
• Does not cross the placental barrier
• Monitor APTT
• Antidote: PROTAMINE SULFATE
• No aspirin
• Milk Leg/ Plagmasia Alba Dolens
o Shiny white legs due to stretching of skin & hyperfibrinogenemia
o Nursing intervention
 Check dorsalis pedis pulse (compare both)
 Never massage
 Assess for Homan’s sign only once

2. Respiratory System
• Shortness of Breath d/t gravid uterus
• Nursing intervention: Side-lying – lateral expansion of the lungs

3. Gastrointestinal System
• Nausea and vomiting
• Morning Sickness
o Due to ↑ HCG levels
o Crackers 30 min before arising
o AM – Carb diet 30 mins
o PM – small frequent meal
• Constipation
o Due to PROGESTERONE = ↑ fluid reabsorption due to ↓ GIT motility
o Nursing intervention
• ↑ Fluid
• ↑ Fiber
• Exercise
• Flatulence
o Due to increased progesterone
o Avoid gas forming foods
• Heartburn (pyrosis)
o Reflux of stomach content into esophagus
o Nursing Intervention
• Small frequent meals
19
 • Sips of milk
• Avoid fatty and spicy foods
• Proper body mechanics
o Waist Above – Acid
o Waist Below – Base
• Hemorrhoids
o Due to gravid uterus
o Hot sitz bath for comfort
• Ptyalism
o ↑ salivation
o Mouthwashes to relieve
4. Urinary System
• Normal = + 1 sugar due to Progesterone via BENEDICT’S TEST
• First Trimester - Frequency
• Second Trimester - normal
• Third Trimester - Frequency
5. Muscoloskeletal
• Calcium sources
o Milk - ↑ Ca ↑ P – 1 pint/ day or 3 – 4 servings/ day
o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli
• Lordosis
o Pride of Pregnacy
• Waddling Gait
o Awkward gait while walking due to relaxin
o Prone to accidental falls
 Wear low healed shoes
• Leg Cramps
o Ca – P Imbalance during pregnancy
o Lumbo-sacral nerves by pressure of gravid uterus during labor
o Over sex
o Dorsiflex the foot affected
o 3-4 servings/ 4 cups/day sa milk, sardines, dilis

A. Local Chnages

• Vagina
o Chadwick’s Sign – bluish discoloration
o Leukorrhea – whitish gray, moderate in amount, mousy odor
• Cervix
o Goodel’s Sign – change in consistency of uterus
o Operculum – mucus plug to seal bacteria/ progesterone
• Uterus
o Hegar’s Sign – change in consistency

Vagina Chadwick’s
Cervix Goodel’s
Uterus Hegar’s

Problems related to the changes of Vaginal Environment

a. Vaginitis - AVOCADO
• Trichomonas Vaginalis

20
 o Flagellated protoxzoan, Loves alakaline environment
• Signs and Symptoms
o Greenish, cream, colored, frothy, irritably itchy, foul smelling vaginal discharge
o Vaginal edema
• Management
o Drug of choice: METRONIDAZOLE (Flagyl)
 Antiprotozoan
 Carcinogenic
 Not given in 1st trimester
• vaginal douche as substitue
o 1 qt Water = 1 tbsp white vinegar
Treat partner as well to prevent reinfection
No alcohol – due to antabuse effect
b. Moniliasis - CHEESE
• Candida Albicans
• Transvaginal transfer in fetus – Oral Trush
• Signs and Symptoms
o White Cheeselike patches that adheres to the walls of the vagina
• Management
o Antifungals
 Mycostatin
 Contrimazole – Canisten
 Gentian Violet

1. Abdominal Changes
• Striae Gravidarum
o Due to destruction of the subcutaneous tissue by the enlarge uterus

2. Skin Changes
• Melasma/ Chloasma
o White light brown pigmentation related to ↑ melanocytes
• Linea Nigra
o Brown pinkish line from symphysis pubis to umbilicus

3. Breast Changes
• Due to hormonal changes
• Change in color and size of nipple and areola
• Precolostrum – 6 weeks
• Colustrum – 3rd trimester
• Supine with pillow under the back
4. Ovaries – rest period, no ovulation
5. Signs and Symptoms of Pregnancy
Presumptive Probable Positive
S/sx felt and observed by the Signs observed by Undeniable signs confirmed
mother but does not confirm the members of the by the use of instrument
the diagnosis of pregnancy health care team
First Breast changes Goodel’s sign Ultrasound Evidence
trimester Urinary changes Chadwick’s sign
Fatigue Hegar’s sign
Amenorrhea Elevated BBT
Morning sickness Positive HCG
Enlarge uterus
21
 Second Chloasma Ballotement
Trimester Linea Nigra Enlarge Abdomen etal Heart Tone
Increase Skin Pigmentation Braxton Hicks etal movement
Striae gravidarum Contraction etal outline
Quickening etal parts palpable

CBQ Cancer of the Breast  quadrant B

Mamography 35 and above  1/ year
Ballotement  bouncing of the fetus
 may be present in uterine myoma
Transvaginal Ultrasound – empty bladder
Abdoiminal ulrasound – full bladder

Placenta Grading System

• Grade 0 – immature
• Grade 1 – slightly mature
• Grade 2 – moderately mature
• Grade 3 – fully mature
• What is deposited?  calcium

VI. Psychological Adaptation to Pregnancy – Reva Rubin

First Trimester
• No tangible s/sx
• Feeling of surprise
• Ambivalence
• Denial of pregnancy  maladaptation
• Developmental Task: Accept biological facts of pregnancy
• Health Teaching: Body changes of pregnancy and Nutrition

Second Trimester
• Tangible s/sx
• Mother identifies fetus as separate entity due to quickening
• Fantasy
• Developmental Task: Accept growing fetus as a baby to nurture
• Health Teaching: Growth and development of fetus

Third Trimester
• Mother has personally identifies with the appearance of the baby
• Developmental Task: Prepare child birth and parenting the child
• Health Teaching: responsible parenthood, prepare baby’s layette, Lamaze Class
• Address Mother’s fear  let she hear the FHT

VII. Pre – Natal Visit

Basic Consideration
1. Frequency of Visit
• 1 – 7th mos.  once a month
• 8 – 9th mos.  twice per month
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 • 10th month  every week
2. Personal Data
• Home Based Mother’s Record/ HBMR  determines high risk pregnancy
• Pseudocyesis  false pregnancy  appearance of presumptive & probable signs
• Comade Syndrome  psycosomatic disorder, father experience what the mother
goes through
3. Diagnosis of Pregnancy
• Urine Exam HCG  40 – 100th day; peak 60 – 70th day
• ELISA  beta subunits of HCG is detected as early as 7 – 10th day
• RIA  beta subunits of HCG is detected as early as 8th day
• Home Pregnancy Kit
4. Baseline Data
• Roll – Over Test  test of pre-eclampsia by the use of BP
• Weight monitoring
Normal Weight Gain
1st Trimester = 1.5 – 3 lbs  1 lb/ mo
2nd Trimester = 10 – 12 lbs  4 lbs/mo
3rd Trimester = 10 – 12 lbs  4 lbs/mo

Minimum allowable weight gain  20 – 25 lbs

Optimal weight gain  25 – 35 lbs

5. Obstetrical Data

a. Gravida  no. of pregnancy

b. Para  no. of viable pregnancy

Viability  the ability of the fetus to live outside the uterus at the earliest possible gestational age

1 abortion 1 39TH Week, 1 miscarriage, 1 still birth, 1 2nd mo. preg

1 pregnancy 3rd mos. G4P2 G4 T1 P1 A1 L1

G2P0 G2 T0 P0 A1 L0

c. Important Estimates
1. Nagele’s Rule
• Use to determine expected date of delivery
• Jan – Mar  +9 months +7 days
• Apr – Dec  -3 months +7 days + 1 year

2. McDonald’s Rule
• Determines age of gestation in weeks
• Fundic Height x 7/8 = AOG in weeks
3. Bartholomew’s Rule
• Determines age of gestations
o 3 mos – above pubis symphysis
o 5 mos – level of umbilicus
o 9 mos – below xiphoid process
o 10 mos – level of 8th mos

4. Haases Rule
• Determines the length of fetus in cm.
23
 • 1st half  square each month
• 2nd half  month x 5

d. Tetanus Immunization
• TT1 – anytime or early during pregnancy
• TT2 – 1 month after TT1  3 years protection
• TT3 – 6 months after TT2 – 5 years of protection
• TT4 – 1 year after TT3  10 years of protection
• TT5 – 1 year after TT4  lifetime protection

5. Physical Examinations
a. Danger Signs of Pregnancy
Chills & Fever
Cerebral Disturbances
Abdominal Pain  epigastric pain  auro of impending convulsion
Boardlike Abdomen  Abruptio placenta
Blurred Vission  pre eclampsia
Bleeding  abortion/ ectopic pregnancy – 1st trimester
 H Mole/ Incompetent Cervix – 2nd trimester
 Placental Anomalies – 3rd Trimester
BP ↑
Swelling
Scotoma – spots in the eye
Sudden gush of fluid – PROM – premature rupture of membrane

6. Pelvic Examination
 Pelvic examination or IE – empty bladder, precaution
 1st visit – Chadwicks, Goodle’s sign, etc.
 Position : dorsal recumbent, lithotomy
 Pap smear – done 1st visit
 Cytological exam – determine presence of cancer cells.
 Result :
o Class I – normal
o Class II A – cytology without evidence of malignancy
B – suggestive of inflammation
o Class III – cytology suggestive of malignancy
o Class IV – cytology suggestive og malignancy
o Class V – conclusive for malignancy
 Most common cancer report organ : cervical cancer
 Most common site for pap smear – external OS of cervix (squamocolumnar tissue)
 Common site of cervical cancer. maternal – speculum (open)
 Stages of cervical cancer
o 0 – carcinoma in situ
o 1 – Ca strictly confined to cervix
o 2 – from cervix extends to the vagina
o 3 – pelvic metastasis
o 4 – affectation to bladder & rectum

7. Leopolds Maneuver
 Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of
descent an estimate of the size, and no. of fetuses

24
  Procedure
1. 1st maneuver
o place patient in supine position with knees slightly flexed. Put towel under head and
right hip. With both hands palpate uppe4r abdomen and fundus. Assess size, shape,
movement and firmness of the part
o determine the presenting parts:
2. 2nd maneuver
o with both hands moving down, identify the back of the fetus where the ball of the
stethoscope is placed to determine FHT.
o PR of mother : uterine soufflé – MHR
o fundic soufflé – FHR
3. 3rd maneuver
o using the right hand, grasp the symphysis pubis part using the thumb and fingers.
o Assess whether the presenting part is engaged in the pelvis.
o Alert! If the head is engaged it will not be movable
4. 4th maneuver
o the examiner changes the position by facing the patient’s feet. With two hands, assess
the descent of the presenting part by locating the cephalic prominence or brow.
o When the brow is on the same side as the back, the head is extended. When the brow
is on the same side as the small parts, the head 8is flexed and vertex presenting.
 Attitude – relationship of fetus to one another.
 Full Flexion – when the chin touches the chest

8. Assessment of Fetal Well-being

a. Daily fetal Movement Counting (DFMC)

 Done starting 27th week
 Consideration
 fetal sleep wake pattern
 maternal food intake
 drug-nicotine use
 environmental stimuli
 maternal dose
 Cardiff count to 10 method – one method currently available
o begin at the same time each day (usually in the morning after breakfast ) and
count each fetal movement, noting how long it takes to count 10 fetal
movements (FMs)
o expected findings – 10 movements in 1hrs or less
o warning signs – 10-12 movements in 1hr or less
 more than 1hr to reach 10 movements
 less than 10 movements in 12hrs
 longer time to reach 10 FMs than on previous days.
 movements are becoming weaker, less vigorous
 movement alarm signal <3 FMs in 12hrs
o warning signs should be reported to healthcare provider immediately; often
require further testing. Eg. Non stress test (NST), biophysical profile (BPP)

b. Nonstress Test
o to determine the response of the fetal heart rate to the stress to activity.
o Indications – pregnancies at risk for
o placental insufficiency
o Postmaturity
25
 • pregnancy induced hypertension (PIH), diabetes
• warning signs noted during DFMC
• maternal history of smoking, inadequate nutrition
o Procedure :
• Done within 30mins wherein the mother is in semifowlers position; external
monitor is applied to document fetal activity; mother activates the “mark button”
on the electronic monitor when she feels fetal movement. Attach external
noninvasive fetal monitors
• tocotransducer over fundus to detect uterine contractions and fetal movements
(FMs)
• ultrasound transducer over abdominal site where most distinct fetal heart
sounds are detected
• monitor until at least 2 FMs are detected in 20mins.
o if no FM after 40mins provide women with a light snack or gently stimulate fetus through
abdomen
o If no FM after 1hr further testing may be indicated, such as a CST
o Result :
• Noncreative Nonstress Not Good
• Reactive Response is Real Good
o Interpretation of results
• Reactive result – real good
 baseline FHR between traction beteen 120 and 160 beats per min.
 at least two accelerations of the FHR of at least 15 beats per min., lasting
at least 15secs in a 10 to 20 min period as a result of FM
 good variability – normal irregularity of cardiac rhythm representing a
balanced interaction between the parasympathetic (↓ FHR) and
sympathetic (↑ FHR) nervous system; noted as an uneven line on the
rhythm strip
 result indicates a healthy fetus with an intact nervous system
o Nonreactive result – not good
 stated criteria for a reative result are not met
 could be indicative of a compromised fetus requires further evaluation
with another NST, biophysical profile, (BPP) or contraction stress test
(CST)

9. Health Teachings
o do nutritional assessment
o daily food intake
o determine habit
o if ↓ folic acid – lead to spina bifida/open neural tube defect
o HIGH RISK MOTHERS
• pregnant teenagers – poor compliance to health regimen
• extremes in wt – underwt – eg. Elite models overwt – eg. DM/HPN
• low social economic status. Refer to OSWD
• vegetarian mothers because ↓ intake of vit B12 (Cyanocobalamin) – formation
of folic acid (cell DNA & RNA formation)
• types :
 strict vegetarian – prone to develop anemia
 lacto vegetarian – milk
 lacto-ovo vegetarian – milk & egg

a. Recommended Nutrient Requirement that Increases During Pregnancy

26
Nutrients
Calories
Essential to supply energy for
↑metabolic rate
Utilization of nutrients
• Protein sparing so it can be
used for :
growth of fetus
o development of
structures requires
for pregnancy
including placenta,
amniotic fluid, tissue
growth
Protein
Essential for
• fetal tissue growth
• maternal tissue growth
including uterus and
breasts.
• Development of essential
pregnancy structures
• Formation of RBC and
plasma proteins
Inadequate protein intake has
been associated with onset of
pregnancy induced
hypertension (PIH)
Calcium-Phosphorous
Essential for
• Growth and development of
fetal skeleton and tooth
buds
• Maintenance of
mineralization of maternal
bones and teeth
• Current research is
demonstrating an
association between
adequate calcium intake
and the prevention of
pregnancy induced
hypertension
Iron
Essential for
Requirements
300 calories/day above the
prepregnancy daily requirement
to maintain ideal body weight
and meet energy requirement of
activity level
• begin ↑ in 2nd Trimester
• use wt-gain pattern as an
indication of adequacy of
calories intake
• failure to meet caloric
requirements can lead to
ketosis as fat & protein are
used for energy, ketosis has
been associated with fetal
damage.
Non pregnant: 2200 calories
Pregnant: 2500 calories
2200+500 @ lactation=2700 cal
60mg/day or an ↑ of 10% above
daily requirements for age
group
Adolescents have a higher
protein requirement than mature
women since adolescents must
supply protein for their own
growth as well as protein to
meet the pregnancy
requirement
Calcium ↑ of
• 1200mg/day representing an
↑ of 50% above pre
pregnancy daily requirement
• 1600mg/day is recommended
for adolescent
• 10mcg/day of vitamin D is
required since it enhances
absorption of both calcium
and phosphorous
Non Pregnat:15mg/day
Food sources
Caloric ↑ should reflect
• foods of high nutrient value
such as protein, complex
carbohydrates (whole grains,
vegetables, fruits)
• variety of foods representing
food sources for the nutrients
required during pregnancy
• no more than 30% fat
Na – 3gms/day – eat in
moderation
CHON x 4K Cal
CHO x 4K Cal
Fats x 9K Cal
Protein ↑ should reflect
• Lean meat, poultry, fish
• Eggs, cheese, milk
• Dried beans, lentils, nuts
• Whole grains
Vegetarians must take note of
the amino acid content of
CHON foods consumed to
ensure ingestion of sufficient
quantities of all amino acids
Calcium ↑ should reflect
• Dairy products, milk, yogurt,
ice cream, cheese, egg yolk
• Whole grain, tofu
• Green leafy vegetables
• Canned salmon & sardines
with bones
• Ca fortified foods such as
orange juice
• Vitamin D sources fortified
milk, margarine, egg yolk,
butter, liver, seafood
27
• Expansion of blood volume &
RBC formation
• Establishment of fetal iron
stores for first few months of life
Zinc
Essential for
• the formation of enzymes
• maybe be important in the
prevention of congenital
malformation of the fetus
Folic acids, folacin, folate
Essential for
• Formation of RBC &
prevention of anemia
• DNA synthesis & cell
formation; may play a role in
the prevention of neural
tube defects (spina bifida),
abortion, abruption placenta
Additional requirements
Minerals
• Iodine
• Magnesium
• selenium
Pregnant : 30mg/day
- representing a doubling
of the prepregnant daily
requirement
• Begin supplementation at
30mg/day in second
trimester, since diet alone is
unable to meet pregnancy
requirement
• 60 – 120mg/day along with
copper and zinc
supplementation for women
who have low Hgb values
prior to pregnancy or who
have iron deficiency anemia
• 70mg/day of vitamin C which
enhances iron absortion
o Inadequate iron intake
results in maternal effects
anemia, depletion of iron
stores, ↓ energy and
appetite, cardiac stress
especially during labor &
birth
o fetal effects ↓ availability
of oxygen thereby
affecting fetal growth
• iron deficiency anemia is the
most common nutritional
disorder of pregnancy
15 g/day representing an ↑ of
3mg/day over prepregnant daily
requirement
400mcg/day representing an ↑
of more than 2x the daily
prepregnant requirement
300mcg/day supplement for
women with low folate levels or
dietary deficiency
175mcg/day
320mg/day
65mcg/day
Iron ↑ should reflect
• liver, red meat, fish, poultry,
eggs
• enriched, whole grain cereals
& breads
• dark green leafy vegetables,
legumes
• nuts, dries fruits
• vitamin C sources: citrus
fruits & juices, strawberries,
cantaloupe, tomatoes, green
peppers, broccoli or
cabbage, potatoes
• iron form food sources is
more readily absorbed when
served with foods high in vit
C
Zinc ↑ should reflect
• liver, meats
• shell fish
• ↑grains, legumes, nuts
↑ should reflect
Liver. Kidney, lean beek, veal
• Dark, green leafy vegetables,
broccoli, asparagus,
artichokes, legumes
Whole grains, preanuts
↑ requirements of pregnancy
can easily be met with a
balanced diet that meets the
requirement for calories and
includes food sources high in
the other nutrients needed
28
 during pregnancy
Vitamins
E 10mg/day
Thiamine 1.5mg/day
Riboflavin 1.6mg/day
Pyridoxine (B6) 2.2mg/day
B12 2.2mcg/day
Niacin 17mg/day

b. Sexual Activity
• Principles of sex in Pregnancy
o Should be done in moderation
o Should be done in a private place
o That the mother should be placed in a comfortable position
o It must be avoided 6 weeks prior to EDD
o Avoid blowing of air during cunnilingus
• Contraindication in sex:
o vaginal spotting – 1st tri
o incompetent cervix – 2nd tri
o placenta previa, abruption placenta – 3rd tri
o pre-term labor R: prostaglandin – oxytocin – contraction
o PROM – infection
• Changes in sexual appetite during pregnancy:
o 1st tri - ↓
o 2nd tri - ↑
o 3rd tri - ↓

c. Exercise
• strengthen muscle to be used during the delivery process
• Walking – best form of exercise
• Squatting – strengthen perineum & ↑circulation to the perineum (raise the buttocks before head
to prevent postural hypotension)
• Tailor sitting – same purpose with squatting
• Kegel exercise – strengthen pubococcygeal muscle
• Abdominal exercise – muscle of the abdomen ( done as if blowing a candle)
• Shoulder circling exercise – strengthen muscle of the chest
• Pelvic rocking exercise or pelvic tilt – relieve low back pain & maintain good posture (arching
back for 3 sec)
• Principles of exercise
o must be done in moderation
o must be individualized

d. Childbirth Preparation
• Overall goal: To prepare patents physically & psychologically while promoting wellness
behavior that can be used by parents & family thus, helping them achieved a satisfying &
enjoying childbirth experiences.

• Psychological
o Bradley Method – Dr. Robert Bradley – discoverer

29
  advocated active participation of husband during labor & delivery to serve as
coach, based on “imitation of nature”
 Features:
• darkened room
• quiet & calm environment
• relaxation technique
• close eyes
o Grantly Dick Read Method
 fear can lead to tension while tension can lead to pain. (break cycle by
removing the fear-by abdominal breathing exercises & relaxation technique)
• Psychosexual
o Kitzinger Method – Dr. Shiella Kitzinger
 pregnancy, labor & birth & the care of the newborn is an important turning point
in a woman’s life cycle. “flowing with contractions rather than struggle with
contractions”
• Psychoprophylaxis
o Lamaze – Dr. Ferdinand Lamaze
 Prevention of pain thru mind & requires discipline, conditioning & concentration
with the husband’s help.
 Features:
• conscious relaxation
• cleansing breathe – inhaling thru nose & exhaling thru mouth
• effleurage – gentle circular massage
• over abdomen to relieve pain
• imaging
• Different methods of delivery
o birthing chain – semi-fowlers – mother
o bathing bed – dorsal recumbent
o squatting – position relieve on back pain & maintain good posture
o Leboyer’s method
 features :
• darkly lighted room
• quiet & calm environment
• room temp.
• soft music
o Birth under water

IX. INTRAPARTAL NOTES

A. Admitting the laboring Mother
• Personal data
• Baseline data
• Obstetrical data
• Physical exams
• Pelvic exams
B. Basic knowledge in intrapartum
• Theories of the Onset of Labor
o Uterine Stretch Theory – any hollow organ once stretched to its maximum potential
will always contract & expel its content
o Oxytocin Theory – released by PPG, contraction effect
o Prostaglandin Theory – stimulation by Arachidonic acid, causes contraction of uterus

30
 o Aging Placenta – 42wks (lifespan) by 36wks placenta begins to degenerate causes
contraction
o Progesterone deprivation theory - ↓ level of progesterone will facilitate contraction of
the uterus
• The 4 Ps of Labor
o Passenger – fetus
 fetal head
• is the largest presenting part
• ¼ of its length
• Bones – 6 bones (sphenoid, temporal, ethmoid) Frontal, occipital & 2
parietal bones
• Sutures/intermembranous spaces – allows molding
• Molding – the overlapping of the sutures of the skull to permit passage
of the head to the pelvis
o Sagittal bones – connect to parietal bones
o Cororontal bones – connect to parietal & frontal bones
o Lambdoidal bones – connect to parietal & occipital bones
• Fontanels
o 6 fontanels only 2 palpable
 anterior fontanel/Bregma
• diamond in shape
• 3cm x 4cm size
• close 12-18 mos post delivery
• ↑ 5cm – hydrocephalus
 posterior fontanel/lambda
• triangular in shape
• 1 x 1cm size
• close 2-3mos post delivery
• Measurements of fetal head :
o transverse diameter
 Bi-parietal - largest transverse diameter- 9.25cm
 Bi-temporal - 8cm
 Bi-mastoid - smallest transverse diameter - 7cm
o AP diameter
 Suboccipitobregmatic – complete flexion
 Occipitofrontal – partial flexion - 12cm
 Occipitotemporal – largest AP diameter; hyperextended
(13.5cm)
 Submentobrgmatic - face presentation; poor flexio
o Passageway – vagina & pelvis
 Pelvis
• 4 main pelvic types
o gynecoid – round, wide, deeper, most suitable for pregnancy
o android – heart shape “male pelvis” – anterior pointed post part
– shallow
o Anthropoid – oval “ape-like pelvis“ AP wider transverse narrow
o Platypelloid – flat transverse oval AP narrow transverse – wider
– c/s for delivery
• Problem :
o mother who encounter accident

31
 o ↓ 4’9”
o ↓ 18y/o – R: pelvis not achieve its full pelvic growth
 Bones of pelvis
• 4bones
o 2 hips (2 innominate bones)
 3parts of 2 innominate bones
• Ileum – lateral/side of hips
o Iliac crest – flaring superior border that
forms prominence of hips; common site
for bone marrow aspiration
• Ischium – inferior portion
o Ischial tuberosities of the area where we
o Sit; basis in getting external measurement
of pelvis
• Pubis – anterior portion
o Symphysis pubis – junction in between
o sacrum – posterior portion
 Sacral prominence – basis internal measurement of
pelvis
o 1 coccyx - 4 small bones that compresses during vaginal
delivery
• universal precaution in measurement of pelvis is to empty bladder first
• Important Measurements
o Diagonal Conjugate
 measure between Sacral promontory & inferior margin of
the symphysis pubis
 Measurement 11.5-12.5 cm
 Basis in getting the true conjugate.
o True Conjugate/Conjugate Vera
 Measure between the anterior surface of the sacral
promontory & superior margin of the symphysis pubis.
 Measurement: 11.0 cm
 Diagonal conjugate: 1.5 cm = true conjugate.
o Obstetrical Conjugate
 smallest AP diameter of the pelvis measuring 10cm or
more.
o Tuberoischii Diameter
 transverse diameter of the pelvic outlet.
 Approx by a fist- 8cm & above.
o Power
 the forces acting to expel the fetus & placenta
• involuntary contractions
• voluntary bearing down efforts
• characteristics: wave like
• timing: frequency, duration, intensity
 myometrium – power of labor
o Psyche/person
 psychological stress exist when the mother is fighting the labor experience.
• cultural interpretation preparation
• past experience

32
 • support system
• Pre-eminent signs of labor
o Preeminent Signs
 lightening
• settling of the presenting part into the pelvis brim (shooting pain
radiating to the legs, urinary frequency)
• primi- early 2 weeks prior to EDD
• engagement – settling of presenting part into pelvic inlet (not signs of
labor)
 Braxton Hicks Contractions – painless irregular contractions
 Increase Activity of the Mother – Nesting
• Instinct (mgt: save energy)
• epinephrine production (hormone that ↑ the activity of the mother)
 Ripening of the cervix –butter softness
 Decrease in weight – 1.5-3 lbs.
 Bloody show
• pinkish vaginal discharge (blood + leucorrhea + operculum = pink in
color)
 Rupture of membranes
• check FHT
• IE check for cord prolapse
• after several hrs – check temp.
o Premature Rupture of Membranes (PROM)
 contraction drop in intensity even though very painful
 contraction drop in frequency
 uterus tense &/or contracting between contractions
 abdominal palpitations
 Nursing Care:
• administer analgesics (morphine)
• attempt manual rotation for ROP or LOP
• bear down with contractions
• adequate hydration
• sedation as ordered
• cesarean delivery may be required, especially if fetal distress is noted
o Cord Prolapse
 a complication when the umbilical cord falls or is washed through the cervix
into the vagina.
 Danger Signs:
• PROM
• Presenting part has not yet engaged
• Fetal distress
• Protruding cord from vagina – cerebral palsy – ↑ 5 mins., irreversible
brain damage mgt: CS
 Nursing Care
• Positioning – knee chest or trendelenberg, place wet sterile gauze R: to
make it slippery
• Observe for fetal distress
• Provide emotional support
• Prepare for cesarean section

33
• Difference Between True and False Contraction
True False
• No in intensity • There is an in intensity
• Pain confined in the abdomen • Pain begins @ the lower back
• Pain is relieved by walking to abdomen
• No cervical changes • Pain is intensified by walking
• Cervical effacement (thinning of
the cervix, measured thru %) &
dilatation (widening of the
cervix, measurement thru cm)
*best/major sign of true labor

• Duration of Labor
o Primipara – 14 hrs but not more than 120 hrs
o Multipara – 8 hrs but not more than 14 hrs
• Nursing Interventions in Each Stage of Labor
o First Stage: onset of contractions to full dilatation & effacement of the cervix
o stage of effacement & dilatation
 Latent Phase:
• Assessment:
o Dilatations 0-3 cm
o Frequency 5-10 mins
o Duration 20-40 mins
o Intensity mild
o Mother is excited, apprehensive but can communicate
• Nursing Care:
o Encourage walking : shortens 1st stage of labor
o Encourage to void q 2-3 hrs : full bladder inhibits uterine
contraction
o breathing (chest breathing technique)
 Active Phase:
• Assessment:
o Dilatations 4-8 cm
o Frequency q 3-5 mins lasting for 30-60 secs
o Duration 30-60 secs
o Intensity moderate
• Nursing Care:
o M – edications – have meds ready
o A – ssessment include: v/s, cervical dilatation & effacement,
fetal monitor, etc
o D – ry lips – oral care (ointment), dry linens
o Breathing – abdominal breathing
 Transitional Phase:
• Assessment:
o Dilatations 8-10cm
o Frequency q 2-3 mins contractions
o Duration 45-90 sec
o Intensity strong
o Mood of mother suddenly change accompanied by
hyperesthesia (hypersensitivity of mother to touch) of the skin
• Management

34
 o sacral pressure, cold compress
• Nursing care:
o T – tires
o I – inform of progress (to relieve emotional support)
o R – restless support her breathing technique
o E – encourage & praise
o D – discomfort
o Pelvic Exams
 Effacement & Dilatation
• Station – relationship of the presenting part to the ischial spine
o 5 - -1 = the presenting part is above the ischial spine
o Engagement 10 = the presenting part is in line with the ischial
spine
o (-) fetus is floating
o (+) below the ischial spine
• Presentation
o the relationship of the long axis of the fetus to the long axis of
the mother.
o spine relationship of the spine of the mother & the spine of the
fetus

o Two Types
 Longitudinal Lie (Parallel)/ Vertical
• Cephalic – when the fetus is completely flexed
o Vertex
o Face
o Brow
o Chin
• 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
 Transverse Lie (Perpendicular)/Horizontal lie
• Position – relationship of the fetal presenting part
to specific quadrant of the mother’s pelvis.
o ROA/LOA
 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

35
 o ROP/LOP – most painful mgt: pelvis
squatting

o Breech – sacro
 place the stethoscope above the
umbilicus
o Chin – mentum
o Shoulder – acromnio dorso
 Monitoring the contractions & fetal heart tone
• spread the finger lightly over the fundus to monitor the contraction
• Increment/Cresendro - beginning of contraction until it increases
• Apex/Acne – height of contraction
• Decrement/Decresendro – from height of contraction until it decreases
• Duration – beginning of contraction to the end of the same contraction
• Interval – from end of contraction to the beginning of the next
contraction
• Frequency – from the beginning of 1 contraction to the beginning of
next contraction
• Intensity – strength of contraction
• if contract – blood vessel constricts; the fetus will get the oxygen on the
placenta reserve which is capable of giving oxygen to the fetus up to
1min.
• Duration of placenta to the fetus should not exceed 1min.
• Significance During active phase, if ↑ to 1min should notify the AMD
• ↑ BP; ↓ FHT : best time to get BO & FHT just after a contraction

NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR

 Bath is necessary
 Monitor VS especially BP
o Same BP = rest
o Elevated = notify the physician
 NPO
o Prevent aspiration  chemical pneuminitis
 Enema (per hospital policy)
o Purpose
 Cleanse the bowel
 Prevent infection
o 12 – 18 inches normal length of tube
o 18 inches optimal length
o Lateral sims position
o If there is contraction  clump the tube
o If there is resistance  slowly remove
o Before and after administration: check FHT (120 – 160) and contractions
 Encourage mother to void
 Perennial preparation (rule of 7)
 Rest on left side lying position
o Prevent supine vena cava syndrome or supine hypotension
 If membrane doesn’t rupture  amniotomy
 FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen
 For Pain

36
 o Systemic analgesic
 DEMEROL (Meperidine HCl)
• Narcotic and antispasmonic
• Don’t give during latent phase
• Given @ 6-8 cm dilated
• WOF : Respiratory depression
• Narcan (Naloxone, nalorfan, nalline)
o Antidote for toxicity
o Injected on the baby
 Epidural Anesthesia
• WOF : Hypotension
• Prehydrate the client to prevent hypotension
• In case of Hypotension
o Elevate leg
o Fast Drip IV

SECOND STAGE OF LABOR (FETAL STAGE)

 Complete dilatation and effacement to birth
 Crowning occurs
 PRIMI – transfer to DR @ 10 cm dilatation
 MULTI – transfer to DR @ 7 – 8 cm dilatation
 Position in lithotomy both legs at the same time
 BULGING OF PERENIUM  surest sign of delivery initiation
 PANT & BLOW Breathing, fetal pushing should be done on an open glottis
 Respiratory alkalosis
o Due to incorrect breathing
o Hyperventilation
o S/sx
 ↑ RR
 Lightheadedness
 Tingling sensation
 Carpopedal spasm
 Circumoral numbness

Episiotomy
 Prevent laceration
 Widen the vaginal canal
 Shortens the 2nd stage of labor
 2 types
o MEDIAN
 Less bleeding
 Less pain
 Easy repair
 Possible urethroanal fistula  major disadvantage
o MEDIOLATERAL
 More bleeding
 More pain
 Hard to repair and slow healing
 Ironing the Perenium  prevent laceration

Mechanism of Labor (ED FIRE ERE)

37
  Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion

PELVIS
 3 Parts
o Inlet – AP diameter narrow, transverse wider
o Cavity – between inner and outer
o Outlet – AP diameter wider, transverse narrow
 LINEA TERMINALES

Nursing Care

 MODIFIED RIGEN’S MANEUVER

o Done by supporting the perenium with a towel during delivery
o Facilitates complete flexion
o Avoids laceration
 First intervention: Support the head and suction secretion
 Do not milk the cord, wait for pulsation to stop before cutting
o Milking may cause too much blood going to the baby that may cause cardiac overload
 When there is still birth, let the mother see the baby to accept the finality of death

THIRD STAGE OF LABOR (PLACENTAL STAGE)

 3 – 10 minutes after child birth
 1st sign  Fundus rises  CALKIN’S SIGN
 Signs of Placental Separation
o Fundus becomes globular and rises  calkin’s sign
o Lengthening of the cord
o Sudden gush of blood
 BRANT – ANDREW’S MANEUVER
o slowly pulling the cord and wind at the clamp
o rapidly  may cause uterine inversion

Types Placental Delivery

 SHULTZ (Shiny)
o From center to the edges
o Presenting fetal side
 DUNCAN (Dirty)
o Form edges to center
o Presenting the maternal side

Nursing Considerations during placental delivery

 Check placental completeness
o Should be 500 g
 Check Fundus – Massage if Boggy
 BP Check
 Methergine, methylergonovine mallate (IM)
38
  Oxytocin (IV) if methergine is not present
 Check perenium for lacerations
 Assist in episioraphy
 Vaginoplasty/ Vaginal Landscape – Virgin again

FOURT STAGE OF LABOR (Recovery Stage)

 First 1 – 2 hours after delivery of placenta
 Maternal observation – body system stabilize
o 1st hour – q15 min 2nd hour - q 30 min
 Placement of fundus
o In between umbilicus and pubis symphysis
o Check bladder, assist in voiding, May lead to uterine atony  hemorrhage
 Lochia
 Perineum
o Check REEDA
 R edness
 E dema
 E cchymosis
 D ischarge
 A pproximation
o Fully saturated – 30 – 40 cc
o Weighing – 1 cc = 1 gram Common Board Question

Nursing Consideration during Recovery

 Flat on bed to prevent dizziness
 If with Chills  give blanket due to dehydration
 Give nourishment (progression of meal)
o Clear liquids – gatorade, ginger juice, gelatins
o Full liquid – milk, ice cream
o Soft diet
o Regular diet
 Check VS/ Pain
 Pychic State
 Bonding – interaction between mother and newborn
o Strict – 24 hours with mother
o Partial – morning with mother, night nursery

COMPLICATIONS OF LABOR

Dystocia
 Difficult labor related to mechanical factor
 Primary cause is Uterine Inertia

Uterine Inertia
 Sluggishness of contraction
 Types
o Primary/ Hypertonic
 Intense contraction resulting to ineffective pushing
 Management : Sedation
o Secondary/ Hypotonic
 Slow, irregular contraction resulting to ineffective pushing
39
  Management : Oxytocin Augmentation
Prolonged Labor
 > 20 H for primi
 > 14 H for multi
 proper pushing should be encourage if inappropriate:
o may cause fetal distress
o caput succedaneum
o cephalhematoma
o maternal exhaustion
 monitor contractions and FHT

Precipitate Labor
 labor less than 3 hours
 causes excessive laceration leading to profuse bleeding  hypovolemic shock
 s/sx of hypovolemic shock HYPO TACHY TACHY
o HYPOtension
o TACHYpnea
o TACHYcardia
o Cold clammy skin
o Management
 Modified trendelenburg
 Fast Drip IV

Inversion of Uterus
 Situation in which uterus is turn inside out due to:
o Short cord
o Hurrying of placental delivery
o Ineffective fundal push
 Cause profuse bleeding  hypovolemic
 Hysterectomy

Uterine Rupture
 Rupture of uterus
 Caused by
o Previous classical CS
o Very large baby
o Improper use of oxytocin
 S/sx
o Sudden pain
o Profuse bleeding
 Prepare fore TAHBSO
Physiologic Retraction Ring  boundary between upper and lower uterine segment
Bandl’sPathologic Ring  suprapubic depression sign of uterine rupture

Amniotic Fluid/ Placental Embolism

 Anaphylactic syndrome of pregnancy
 Situation in which placental fragment and amniotic fluid enters maternal circulation
 S/Sx
o Dyspnea
o Chest Pain
o Frothy Sputum

40
 o End Stage – DIC
 Prepare for CPR, Suction and emergency etc

Trial Labor
 Fetal head measurement = measurement of pelvis
 6 hours labor allowance given to mother
 monitor FHT and contractions

Preterm Labor
 labor after 20 weeks and before 37 weeks
 Triad signs
o Premature conditions every 10 minuets
o Effacement of 60 – 80%
o Dilatation of 2 – 3 cm
 Home Management
o CBR
o Avoid Sex
o Empty bladder
o Drink 3 – 4 Glasses of H2O
 Full bladder inhibit contraction
 Hospital Management
o If Cervix Close (Criteria: cervix is closed if it is 2 – 3 cm dilated only)
 2 – 3 cm dilated, pregnancy can be saved
 Tocolytic Therapy
• Yutupar (Ritodine HCl)
o Side effect maternal BP < 90/60
o Check Impt. Presence of crackles
• Brethine (terbutaline) Bricanyl
o DOC
o Side effect: sustained tachycardia
o Antidote: propanolol/ inderal
• Mg SO4
o If cervix is dilated ( > 4cm)
 Give steroid dexamethasone
• Promote surfactant maturation
• Immediately cut the cord after delivery to prevent jaundice/
hyperbilirubinemia

POSTPARTAL PERIOD

Puerperium – 5th stage of labor, 1st 6 weeks post partum

Characterize by involution
Involution - return to the normal stage of reproductive organ after pregnancy

Return to Normal Healing

Physiologic Changes
Systemic Changes
 Cardiovascular System
o ↑plasma volume
o sudden ↓ in blood volume
o elevated WBC’s up to 30, 000 mm3
o hyperfibrinogenemia
41
 o orthostatic hypertension can be possible
o early ambulation prevents thrombos formation
 steps in ambulation
• Flat
• Semifowlers
• Fowlers with dangling
• Walk with assist

 Genital Tract
o Fundus
 goes down 1 finger breadth a day
 10th day – non palpable behind the symphysis pubis
 Subinvolution
• delayed healing of uterus containing quarters or clots of blood
• may lead to puerperal sepsis
• Management : D&C
o After Pains
 After birth pains
 Multiparous breastfeeding – most common to develop
 Position = prone
 Cold compress
 Mefenamic acid
o Lochia
 Components
• Blood
• Deciduas
• WBC
• Microorg
 3 types
• Rubra – 1 – 3 days, musty, moderate amount
• Serosa – 4 – 10th day, pink or brown
• Alba – 10 – 21th day, crème white, ↓ amount

 Urinary Tract
o Urinary Frequency – due to urinary retention with overflow
o Dysuria
 Damage to trigone of the bladder
 Urine collection for culture and sensitivity
 Stimulate navel to urinate
 Palpate bladder
 Running water listening
 Pull pubic hair - stimulate cremasteric reflex

 Colon
o Constipation
 Due to NPO
 Bearing down may cause pain
 Perenium
o Pain relieved by sim’s position
o Cold compress 1st 24 hours if there is pain at episioraphy followed by warm

42
EMOTIONAL SUPPORT

1. Taking phase
• 1st 3 days
• dependent phase
• passive, can’t make decision
• tells about childbirth experience
• focus on: Hygiene
2. Taking Hold
• 4 – 7th day
• dependent to independent phase
• active, decides actively
• focus: care of newborn
• health teaching : Family planning
3. Letting Go
• Interdependent phase
• Redefines goals, new roles as parents
• May extend till the child grows

Post Partum Blues

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

Postpartal Complications

Hemorrhage
 bleeding within 24 hours postpartum

Early Pospartal Hemorrhage

1. Uterine Atony
 boggy fundus
 profuse bleeding
 interventions
o massage the uterus
o cold compress
o modified trendelenburg
o fast drip IV
o breastfeeding – to release oxytocin

2. Laceration
 well contracted uterus with profuse bleeding
 assess perenium for laceration
 degrees of laceration
o 1st degree – vaginal skin and mucus membrane
o 2nd degree – 1st degree + muscles
o 3rd degree – 2nd degree + external sphincter of rectum
o 4th degree – 3rd degree + mucus membrane of rectum
43
 3. Hematoma
 bluish discoloration of subQ tissues of vagina or perenium
 candidates
o delivery of very large babies
o pudendal block
o excessive manipulation due to excessive IE
 intervention
o cold compress 10 – 20 min then allow 30 minutes rest period for 24 h

4. DIC – disseminated intravascular coagulation

 Consumption of pregnancy (otherterm)
 Failure to coagulate
 Bleeding in the eyes, ears, nose
 Oozing blood
 Seen in cases with
o Abruptio placenta
o Still birth / IUFD
 Management
o Blood transfusion of cryoprecipitate or fresh frozen plasma
o hysterectomy

Late Postpartum Hemorrhage

Retained placental fragments

 manual extraction of fragments is done
 uterine massage
 D&C except for cases of
o Placenta Acreta – umusual attachment of the placenta to the myometrium
o Placenta Increta – deeper attachment of placemat to the myometrium
o Placenta Percreta – invasion of placenta to the perimetrium
 Candidates of these disorders are
• Grand multiparous
• Post CS
 All these requires hysterectomy

Infection
 Sources
o Endogenous – from normal flora of the body
o Exogenous – from the health care team
 Most common – Anaerobic Streptococci
 Management
o Supportive care
o ↑ Fluid intake
o TSB if there is fever/ cold compress + paracetamol may also be given
o Analgesics
 Given on time to achieve maximum effect
o Culture and sensitivity

Perenial Infection
Same s/ sx with infection
2 – 3 stitches are dislodges
44
with purulent drainage
Tx – resuturing

Endometritis
 Inflammation of the endometrium
 Gen s/sx of infection + abdominal tenderness
 Management
o High fowler’s – facilitates drainage & localize infection
o Administer oxytocin

FAMILY PLANNING METHOD

Guiding Principles
1. determine your own beliefs first
2. never advise a permanent method of family planning
3. informed concent
4. the method is an individual decision

Natural Method – accepted by the church

Billing’s/ Cervical Mucus/ Spinnbarkeit

clear watery & stretchable
13th day – longest due to estrogen
Basal Body Temp – in the morning before arising/ 13th – 14th day due to peak of progesterone
LAM – Lactational Amenorrhea Method
 prolactin – inhibits ovulation
 breastfeeding – 4 – 6 months no menstrual cycle
 bottle fed – 2 – 3 months
Sympthothermal – combination of Billings and BBT – most effective method

Social Methods

Coitus Interuptus
 withdrawal
 least effective method
Coitus Reservatus
 sex w/o ejaculation
Coitus interfemora
 between femor
Calendar Method
 14 days before menstrual cycle – ovulation day (regular)
 - 4, + 4 days – unsafe period
Origoknause Formula ( irregular menstrual cycle)
 get the longest and shortest cycle
 subtract 18 to shortest
 11 to the longest
 the difference is the unsafe period

PILLS
 combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland
roduction of FSH and LH which are essential for he maturation and rupture of a follicle.
 Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH
which is responsible for ovulation.
45
  contains estrogen that inhibits FSH and progesterone that inhibit LH
 99.9% effective
 21 day feel on the 5th day of mense start taking
 28 day – 1st day of mense
 if forgotten, take 2 tablets the following day
 adverse effect : breakthrough bleeding
 if mother wants to get pregnant
o wait 3 monts
o another 3 months if unsuucessful before consulting gyne
 contraindications
o chain smoking
o Hypertension
o DM
o Extreme obesity
o Thrombophlebitis
 Side effects (ressembles Hypertension)/ Immediate Discontinuation
o Abdominal paon
o Chest pain
o Headache
o Eye problem
o Severe leg cramp
 Alerts on oral contraceptives :
o In case a Mother who is taking an oral contraceptive for almost a long time and plans
to have a baby, she would wait for at least 3mos before attempting to conceive to
provide time for estrogen and progesterone levels to return to normal. If after 6months
the mother did not get pregnant, consult AMD.
o If a new oral contraceptive is prescribed, the mother should continue taking the
previously prescribed contraceptive and begin taking the new one on the first day of
the next menses.
o Discontinue oral contraceptive if there is signs of severe headache as this are an
indication of hypertension associated with increase incidence of CVA and
subarachnoid hemorrhage.
o If forget to drink pill for 1 day, take 2 pills the next day. If forget to drink pills for 2days,
stop the pill and wait for the next mens.
 Adverse reaction : breakthrough bleeding

DMPA – Depoprovera
 Contains progesterone
 Depomedroxy progesterone Acetate
 IM q 3 months – never massage the site  may decrease effectiveness

NORPLANT
 6 match stick like capsules/ rod
 contain progesterone
 sub Q planted
 good for 5 years

Mechanical Device
IUD
 prevent implantation
 alters mobility of sperm and ovum
46
  99.7% effective
 best inserted after delivery and during menstruation
 Common complication – EXCESSIVE MENSTRUAL FLOW
 Common problem – EXPULSION OF THE DEVICE
 No protection against STD
 Side effects include
o Uterine infection
o Uterine perforation
o Ectopic pregnacy
 Major indication for the use is PARITY
 HT: monthly check up and regular pap smear

CONDOM
 Made up of latex
 Put in erected penis or lubricated vagina
 Prevents sperm to enter the uterus
 FEMALE CONDOM – higher protection than that of male

DIAPRAGHM
 Dome shaped rubberied material inserted at the cervix to prevent sperm getting inside the
uterus
 Reusable
 HT : Proper hygiene
o Check for holes
o Must be refitted in case of weight gain of 15 lbs - - board question
o Kept in place for about 6-8 Hours – Board question
 Contraindicated to
o Frequent UTI

CERVICAL CAP
 More durable than the diaphram
 Could stay on place for more than 24 hours
 No need to apply spermicides
 Contraindicated to – abnormal papsmear

CHEMICAL
SPERMICIDES
 FOAMS – most effective
 Jellies
 Creams
 These may cause toxic shock syndrome

SURGICAL METHOD
 Bilateral tubal Ligation
o @ isthmus
o 20% probability of reversal
 Vasectomy
o Vas deferens is cut
o More than 30 x or 0 sperm count or 2 x negative sperm count before it could be
consider safe sex

47
HIGH RISK PREGNANCY
HEMORRHAGIC DISORDERS

General management
 CBR
 Avoid sex
 Prepare ultrasound – determine the sac integrity
 Assess bleeding and approximation
 Assess hypovolemia
 Save discharge for histopathology
o Determine whether the product of labor has been expelled

First Trimester Bleeding

Abortion – termination of labor before age of viability
 SPONTANEOUS
o AKA miscarriage
o Causes
1. Chromosomal aberrations due to advanced maternal age
2. Blighted ovum
3. germ plasm defect
o Natures way of expelling defective babies
o Classifications :
1. Threatened
• pregnancy is jeopardized by bleeding and cramping but the cervix is
closed and can be saved.
2. Inevitable
• moderate bleeding, cramping, tissue protrudes from the cervix and the
cervix is open.
o Types :
1. Complete
• all products of conception are expelled.
• Mgt : emotional support
2. Incomplete
• placenta and membranes retained.
• Mgt : D&C
 HABITUAL
o 3 or more consecutive pregnancies result in abortion usually related to incompetent
cervix.
o Management (suture of cervix)
1. McDonald procedure
• Temporary circlage
• Side effect – infection
• May have NSD
2. Shirodkar
• CS delivery
 MISSED
o fetus dies; product of conception remain in uterus 4 weeks or longer
o signs of pregnancy cease

48
 1. (-) pregnancy test
2. Dark brown
3. Scanty bleeding
o Mgt : induction of labor/ vacuum extraction

 INDUCED
o Therapeutic abortion  principle of 2 fold effect
1. Done when mother has class 4 heart disease

Ectopic Pregnancy
• occurs when gestation is location outside the uterine cavity
• Common site : Ampulla or Tubal
• Dangerous site: Interstitial
Unruptured
• Missed period
• Abdominal pain within 3- 5wks of
missed period (maybe generalized
of one sided)
• Scant, dark brown vaginal bleeding
• Vague discomfort
Ruptured
• sudden, sharp severe unilateral
pain, knife like
• shoulder pain (indicative of
intraperitoneal bleeding that extends
to diaphragm & phrenic nerve)
• (+) Cullen’s sign – bluish tinged
umbilicus
• syncope/fainting

• Nursing Care :
o vital signs
o administer IV fluids
o monitor for vaginal bleeding
o monitor I&O
o prepare for culdocentesis to determine
o hemoperitoneum
• Mgt : non-surgical Methotrexate

SECOND TRIMESTER BLEEDING

Hydatidiform Mole / “bunch of grapes”
• Gestational Trophoblastic Disease – 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 chronic 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 :
o Early signs
 vesicles passed thru the vagina
 Hyperemesis gravidarum due to ↑ HCG
 Fundal height
 Vaginal bleeding (scant or profuse)
o Early in pregnancy
 high levels of HCG
 Pre ecclampsia at about 12wks
 Vesicles look like a “snowstorm” on sonogram
 Anemia
 Abdominal cramping
49
 o Serious late complications
 Hyperthyroidism
 Pulmonary embolus
• Nursing care :
o prepare for D&C
o do not give oxytocin drugs due to proneness to embolism
o 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 Management:

• McDonald procedure
o temporary circlage of incompetent cervix.
o Delivery : NSVD
o SE: infection
o Health teaching
 observe for signs of infection
 signs of labor
• Shhirodkar procedure
o permanent procedure.
o Delivery : caesarian section required.

THIRD TRIMESTER BLEEDING “PLACENTAL ANOMALIES”

Placenta Previa
• it occurs when the placenta is improperly implanted in the lower uterine segment, sometime
covering the cervical os.
• Assessment
o Outstanding sign : frank, bright red, painless bleeding
o enlargement (usually has not occurred)
o fetal distress
o abnormal presentation
• Nursing care :
o Initial mgt : NPO candidate for CS
o Bedrest
o prepare to induce labor if cervix is ripe
o administer IV
o No IE, No Sex, No enema – complication : Sudden fetal blood loss
o 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:
o Cocaine user
o Severe PIH
o Accident
• Assessment:

50
 o Outstanding sign : dark red & painful bleeding
o concealed hemorrhage (retroplacental)
o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
o rigid boardlike abdomen
o severe abdominal pain
o dropping coagulation factor (a potential for DIC)
o sx : bleeding to any part of the body. Mgt : for hysterectomy
• General Nursing care :
o infuse IV, prepare to administer blood
• type and crossmatch
o monitor FHR
o insert Foley catheter
o measure bllod loss; count pads
o report s/s of DIC
o monitor v/s for shock
o strict I&O

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

Placenta Bipartita – placenta divided into 2 lobes

HYPERTENSIVE DISORDER

Pregnancy Induced Hypertension

o HPN after 24wks resolved 6wks postpartum which cause pregnancy.
o Types :
o Gestational HPN
 HPN without edema & proteinuria.
 Mgt : monitor BP
o Pre-eclampsia – triad
o sx : HPN with edema, proteinuria or albuminuria (HEP/A) which cause is unknown or
idiopathic but multifactoral
 primis d/t 1st exposure to chorionic villi
 multiple pregnancies due to ↑ exposure to chorionic villi
 Mothers of low socio-economic status due to ↓ protein intake
 Teenagers d/t low compliance to protein intake
o HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

Transitional Hypertension – HPN between 20-24wks

Chronic or Pre-existing Hypertension
o HPN before the 20th wk not resolved 6wks postpartum
o 3 types of pre-eclampsia
o Sign of pre-eclampsia :
o > 30mmHg systolic
o > 15mmHg diastolic
o Roll over test
 10-15min side lying
 Then supine
 Then take BP
o mild pre-ecclampsia
 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt, inability to wear
wedding ring due to developing edema
51
  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
o 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
o 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
o Eclampsia – with seizure
 ↑ BUN – sign of glumerular damage

52
53
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
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

Heart Disease
o Classification :
o I – no limitation
o II – Slight limitation, ordinary activity causes fatigue
 good prognosis can deliver vaginally
 Mgt : sleep of 10hrs/day, rest 30mins after meals
o III – moderate limitation, less than ordinary activity causes discomfort
 poor prognosis. Good for vaginal delivery
 Mgt : early hospitalization by 7-8mos
o IV – marked limitation of physical activity for even at rest there is fatigue
 poor prognosis. Good for vaginal delivery only with regional anesthesia.
 Low forceps delivery when unable to push & to shorten the stage of labor
 Mgt :
54
 • therapeutic abortion, high semi- fowlers position, left side lying, no
valsalva maneuver - may trigger cardiac arrest, heparin therapy
required, antibiotic therapy for prevention of sub acute bacterial
endocarditis

INTRAPARTAL COMPLICATIONS

Cesarean Delivery
• Indications
a. multiple gestation
b. diabetes
c. active herpes II
d. severe toxemia
e. placental previa
f. abruption placenta
g. prolapse of the cord
h. cephalo pelvic disproportion and primary indication
i. breech presentation
j. transverse lie
• procedure :
o classical – vertical incision
o low segment – “bikini”, for aesthetic purposes. Can have vaginal birth after c/s

Genotype – genetic make-up

Phenotype – Physical appearance
Karyotype – pictorial analysis of individual chromosome for detecting chromosomal abnormalities
Autosomal Dominant
• huntington’s chorea
• retinoblastoma
• achondroplasia
• polydactyl
Autosomal Recessive
• sickle cell
• Cystic fibrosis
• Celiac
• PKU
• Galactosemia
X- Linked Recessive
• Hemophilia
• Duchenne’s muscular dystrophy
• Color blindness
X – Linked Dominant
• Rickette’s

COMMUNICABLE DISEASE NURSING COMMUNICABLE DISEASE

Infectious Agent or its toxic products - AGENT

Directly or Indirectly - MODE OF TRANSMISSION
Person, Animal or Intermediate Vector – HOST
Environment - ENVIRONMENT

ECOLOGIC TRIAD OF DISEASE

55
Agent – element, substance, animate or inanimate that may serve as stimulus to initiate a
disease process
Host – organism that provides nourishment for another organism
Environment – physical (climate), biological (plants & animals)

CONTAGIOUS VS. INFECTIOUS

Contagious
Diseases that are easily spread directly transmitted from person to person (direct contact)
through an intermediary host
Infectious
Diseases that caused by a pathogen not transmitted by ordinary contact but require a direct
inoculation through a break in the skin or mucous membrane.
NOTE: ALL CONTAGIOUS DISEASE ARE INFECTIOUS BUT INFECTIOUS DISEASE IS NOT ALWAYS
CONTAGIOUS

What is Infection?
INFECTION - "the state or condition in which the body or part of the body is invaded by a
pathogenic agent ( bacteria, virus, parasites etc.) which under favorable conditions multiplies and
produces effects which are injurious…"

Infectious Agent
A. RESIDENT ORGANISMS
deeply seated in the epidermis, not easily removed by simple handwashing,
Ex: Staphylococci

B. TRANSIENT ORGANISM
represent recent contamination,
survive for a limited period of time, acquired during contact with the infected colonized patient or
environment,
easily removed by good handwashing
Ex: ( Klebsiella & Pseudomonas)

Infectious Agent
Bacteria – heama organism, systemic
Virus – nuero organism, systemic
Fungi – skin organism, local
Protozoa – GI organism, local
Infectious Agent

FACTORS THAT AFFECTS THE AGENT TO DEVELOP A DISEASE

Pathogenicity – ability to cause a disease
Infective dose – no of organism to initiate infection
Virulence – ability to enter or move through tissues
Specificity – ability of the organism to develop antigens

STAGES OF INFECTIOUS PROCESS

Means of Transmission
1. CONTACT - most common means of transmitting microorganisms from one person to another.
A. Direct Contact (person to person)
occurs when one person touches another
best vehicle is the Hands especially those of the Health Care workers

Indirect Contact (inanimate object)

- occurs when a person touches an inanimate object contaminated by an infected patient

56
2. AIRBORNE
- droplet, dust, organisms in env.
3. VECTOR - insects or animals
4. VEHICLE
- food (salmonella), water (shigellosis), blood (Hepa B), medication ( contaminated infusion)

PREVENTION OF
COMMUNICABLE DISEASE
Prevention is worth a pound than cure
PREVENTION OF
COMMUNICABLE DISEASE
Health Education – primary role of the nurse
Specific Protection- handwashing, use of protective devices
Environmental Sanitation – clean and conducive for health
Definition of Prevention
“Actions aimed at eradicating, eliminating, or minimizing the impact of disease and disability. The
concept of prevention is best defined in the context of levels, traditionally called primary,
secondary, and tertiary prevention”

A Dictionary of Epidemiology, Fourth Edition

by John M. Last

Prevention of Needlestick Injuries

Dispose Used Needles in Puncture Proof Needle Containers
Don’t Recap Needles (Unless using the One-handed Technique)
Use Gloves When Handling Needles (Won’t Prevent Injuries but May Lessen Chance of
Transmitting Diseases)

CONTROL OF C0MMUNICABLE DIESEASE

1. Notification
2. Epidemiological Investigation
3. Case finding; early dx and prompt treatment
4. Isolation and Quarantine
5. Disinfection; disinfestation
6. Medical Asepsis
a. Handwashing
b. Concurrent disinfection
c. Personal protective equipments (PPEs)
d. Barrier Cards/Placarding
Objectives of CCD
Restoration of health, reduce deaths and disability
Interpretation of control measures to IFC for practice to prevent spread of CD.
Promotion of health and prevention of spread of CD

Diseases that require weekly monitoring:

1. Acute flaccid paralysis (AFP) polio
2. Measles
3. Severe acute diarrhea (SAD)
4. Neonatal tetanus
5. AIDS

Diseases that require reporting w/in 24 hrs

1. Acute flaccid paralysis (AFP) polio
2. Measles

57
Diseases targeted for eradication
1. Acute flaccid paralysis polio
2. Neonatal tetanus
3. Measles
4. Rabies
Epidemiology
Study of the occurrence and distribution of diseases in the population

Patterns of occurrence of disease –frequency of disease occurrence

Sporadic
On and off occurrence of the disease
Most of the time it is not found in the community
One or two cases that occur are not related
Endemic
Persistently present in the community all year round
Ex: malaria in Palawan
Epidemic
An unexpected increase in the number of cases of disease
Pandemic
Epidemic of a worldwide proportions
Time Related Patterns of Occurrence
cyclical variation
a periodic increase in the number of cases of a disease
a seasonal disease, an increase is expected or there is usual increase- dengue fever during rainy
seasons are increased but it is not considered an epidemic because it is expected to rise at this
particular time
hot spot-a rising increase that may lead to an epidemic

Time Related Patterns of Occurrence

Short time fluctuation
A change in the frequency of occurrence of a disease over a short period of time
Maybe (+) or (-)
Secular variation
A change in the frequency of occurrence of a diseae taking place over a long period of time
Ex: a.) the change in the pattern of occurrence of polio after being eradicated in 2000, then
sudden repport of cases in 2001 due to mutant restraints.
b.) small pox virus-eradicated in 1979 (last case reported) and no another incidence as of today
Types of Epidemiology
Descriptive Epidemiology - concerned with disease frequency & distribution
Analytic Epidemiology
Is a study of the factors affecting occurrence and distribution of the disease.
Ex. Epidemiologic investigation
Therapeutic/Clinical
Study of the efficacy of a treatment of a particular disease
Ex. Clinical trial of a newly proposed therapeutic regimen
Evaluation Epidemiology
Study of the over-all effectiveness of a total/ comprehensive public health program.
Ex. Evaluation of the under five clinic

Note: We make use of the epidemiology in CHN in order to come up a community diagnosis and
also to determine the effectiveness of a particular treatment
Types of Epidemiologic Data
Demographic data
Demography is the study of population groups
Ex. Population size and distribution
Vital Statistics

58
Environmental data
Health services data
Ex. Ratio between nurse and the population being served
Ex. Degree of utilization of health facility/ service
Epidemiologic Investigation

1st step- Statement of the problem

2nd step- Appraisal of facts – describing the epidemic in terms of time, place, person.
3rd step- formulation of hypothesis
4th step-Testing the hypothesis
5th step- Conclusion and recommendation

TERMS
Disinfection – pathogens but not spores are destroyed

Disinfectant – substance use on inanimate objects

Concurrent disinfection – ongoing practices in the care of the patient to limit or control the spread
of microorganisms.

Terminal disinfection – practices to remove pathogens from the patient’s environment after his
illness is no longer communicable

FACTORS AFFECTING ISOLATION

Mode of Transmission
Source
Status of the client’s defense mechanism
Ability of client to implement precautions
ISOLATION
EPI
Launched by DOH in cooperation with WHO and UNICEF last July 1976
Objective – reduce morbidity and mortality among infants and children caused by the six
childhood immunizable diseases
PD No. 996 (Sept. 16, 1076) – “ Providing for compulsary basic immunization for infants and
children below 8 y/o
PP No. 6 (April 3, 1996) – “ Implementing a United Nations goal on Universal Child Immunization
by 1990”
RA 7846 (Dec. 30, 1994) – immunization hepa B
PD No. 4 (July 29, 1998) – “Declaring the period of September 16 to October 14, 1998 as Ligtas
Tigdas Month and launching the Phil Measles Elimination Campaign”

Legislation, Laws affecting EPI

Proclamation No. 46 – “polio eradication project”

Proclamation No. 1064 – AFP surveillance
Proclamation No. 1066 – National Neonatal Tetanus Elimination Campaign

EPI
BCG - TB
DPT – Diptheria, Pertussis, Tetanu
OPV - Poliomyletis
Hepatitis B
Measles
Immunization
Contraindications

59
-conditions that require hospitalization
For DPT 2 and 3 – history of seizures/ convulsions within 3 days after the first immunization with
DPT
Nursing responsibility: ask how the child reacts to the first dose
For infant BCG – clinical AIDS
The following conditions are NOT contraindications:
Fever up to 38.5 ºC
Simple or mild acute respiratory infection
Simple diarrhea without dehydration
Malnutrition (it is indication for immunization)

Schedule of immunization
Infant BCG
0 to 11 months or 0 to 1 year
at birth
0.05 ml (dose) – ID, right arm
School entrance BCG
When the child enters Grade 1 with or without scar on the right arm then still go on with the
vaccination except if he is repeating Grade 1

Schedule of immunization
DPT
3 doses, 4 weeks or 1 month interval
Target age: 1 ½ to 11 months but child is eligible up to 6 years
If 7 years old and above DT only not P
0.5 ml, IM, vastus lateralis

Schedule of immunization
OPV
3 doses, 4 weeks/1 month
Target population: same as above, eligibility until Grade 6
2-3 drops, oral route
*Feb 8-March 8: Oplan Polio Revival Drive
No side effect, but advise the mother to avoid feeding the child for 30 minutes after the vaccine,
if vomits within the 30 minute period, repeat the vaccination

Schedule of immunization
Hepa B
3 doses, 4 weeks
Can be given at birth
Target age 1 ½ to 11 months
0.5 ml, IM, vastus lateralis
Patient may experience local tenderness
Schedule of immunization
Measles
9 to 11 months
Most babies have protection because of maternal antibodies thus this vaccine is given at 9
months because the time where the maternal antibodies wear off, other virus if it still active it
will kill the vaccine
0.5 ml, subcutaneous, any arm
Measles
Fever and measles rash lasting for 1 to 3 days within 2 weeks after immunization (modified
measles)

60
Immunization
Fully Immunized Child
when he received all the antigens that should be given in the first year of life (1 dose BCG, MV; 3
doses DPT, OPV, HB)
Completely Immunized Child
All vaccines given but went beyond 0ne year of age

COMMUNICABLE DISEASE
 Disease caused by an infectious agent that are transmitted directly or indirectly to a well person through an agency, vector
or inanimate object

CONTAGIOUS DISEASE
 Disease that is easily transmitted from one person to another
INFECTIOUS DISEASE
 Disease transmitted by direct inoculation through a break in the skin

INFECTION
-Entry and multiplication of an infectious agent into the tissue of the host
INFESTATION
- Lodgement and development of arthropods on the surface of the body

ASEPSIS
- Absence of disease – producing microorganisms
SEPSIS
- The presence of infection

MEDICAL ASEPSIS
- Practices designed to reduce the number and transfer of pathogens
- Clean technique
SURGICAL ASEPSIS
- Practices that render and keep objects and areas free from microorganisms
- Sterile technique

 CARRIER – an individual who harbors the organism and is capable of transmitting it without showing manifestations of the
disease
 CASE – a person who is infected and manifesting the signs and symptoms of the disease

 SUSPECT – a person whose medical history and signs and symptoms suggest that such person is suffering from that
particular disease
 CONTACT – any person who had been in close association with an infected person

HOST
- A person, animal or plant which harbors and provides nourishment for a parasite
RESERVOIR
- Natural habitat for the growth, multiplication and reproduction of microorganism

ISOLATION
- The separation of persons with communicable diseases from other persons
QUARANTINE
- The limitation of the freedom of movement of persons exposed to communicable diseases

 STERILIZATION – the process by which all microorganisms including their spores are destroyed
 DISINFECTION – the process by which pathogens but not their spores are destroyed from inanimate objects
 CLEANING – the physical removal of visible dirt and debris by washing contaminated surfaces

CONCURRENT
- Done immediately after the discharge of infectious materials / secretions
TERMINAL
61
- Applied when the patient is no longer the source of infection

BACTERICIDAL
- A chemical that kills microorganisms
BACTERIOSTATIC
- An agent that prevents bacterial multiplication but does not kill microorganisms

CHAIN OF INFECTION

INFECTIOUS AGENT
 Any microorganism capable of producing a disease
RESERVOIR
 Environment or object on which an organism can survive and multiply
PORTAL OF EXIT
 The venue or way in which the organism leaves the reservoir
MODE OF TRANSMISSION
 The means by which the infectious agent passes from the portal of exit from the reservoir to the susceptible host
PORTAL OF ENTRY
 Permits the organism to gain entrance into the host
SUSCEPTIBLE HOST
 A person at risk for infection, whose defense mechanisms are unable to withstand invasion of pathogens

STAGES OF THE INFECTIOUS PROCESS

 Incubation Period – acquisition of pathogen to the onset of signs and symptoms
 Prodromal Period – patient feels “bad” but not yet experiencing actual symptoms of the disease
 Period of Illness – onset of typical or specific signs and symptoms of a disease
 Convalescent Period – signs and symptoms start to abate and client returns to normal health

MODE OF TRANSMISSION
CONTACT TRANSMISSION
 Direct contact – involves immediate and direct transfer from person-to-person (body surface-to-body surface)
 Indirect contact – occurs when a susceptible host is exposed to a contaminated object
DROPLET TRANSMISSION
 Occurs when the mucous membrane of the nose, mouth or conjunctiva are exposed to secretions of an infected person
within a distance of three feet
VEHICLE TRANSMISSION
 Transfer of microorganisms by way of vehicles or contaminated items that transmit pathogens
AIRBORNE TRANSMISSION
 Occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens
VECTOR-BORNE TRANSMISSION
 Transmitted by biologic vectors like rats, snails and mosquitoes

TYPES OF IMMUNIZATION
 ACTIVE – antibodies produced by the body
 NATURAL – antibodies are formed in the presence of active infection in the body; lifelong
 ARTIFICIAL – antigens are administered to stimulate antibody production
 PASSIVE – antibodies are produced by another source
 NATURAL – transferred from mother to newborn through placenta or colostrum
 ARTIFICIAL – immune serum (antibody) from an animal or human is injected to a person

62
SEVEN CATEGORIES OF ISOLATION
 STRICT- prevent highly contagious or virulent infections
 Example: chickenpox, herpes zoster
 CONTACT – spread primarily by close or direct contact
 Example: scabies, herpes simplex
 RESPIRATORY – prevent transmission of infectious distances over short distances through the air
 Example: measles, mumps, meningitis
 TUBERCULOSIS – indicated for patients with positive smear or chest x-ray which strongly suggests tuberculosis
 ENTERIC – prevent transmission through direct contact with feces
 Example: poliomyelitis, typhoid fever
 DRAINAGE – prevent transmission by direct or indirect contact with purulent materials or discharge
 Ex. Burns
 UNIVERSAL – prevent transmission of blood and body-fluid borne pathogens
 Example: AIDS, Hepatitis B

CENTRAL NERVOUS SYSTEM

ENCEPHALITIS MENINGITIS MENING

COCCE
MAIN PROBLEM
- Acute infect
- Inflammation of - Inflammation of the bloodstre
the brain the meninges developing va
ETIOLOGIC AGENT - Streptococcus
SIGNS AND SYMPTOMS
- Arboviruses OF ENCEPHALITIS
- Staphylococcus
- Pneumococcus
Virus enters neural
- Tubercle bacillus cells

INCUBATION PERIOD - Neisseria meningitides

5-15 days in
Disruption 1-10 days
Perivascular 3-4 day
Inflamm
cellular
MODE OF TRANSMISSION congestion reaction
Bite of infected
functioning
mosquito Respiratory droplets

Lethargy Headache Fever

Convulsions Photophobia Sore
63
t
Seizures Vomiting
 SIGNS AND SYMPTOMS OF MENINGITIS

THREE SIGNS OF MENINGEAL IRRITATION

OPISTHOTONUS
State of severe hyperextension and spasticity in which an individual’s head, neck and spinal column enter into a complete arching
position
BRUDZINSKI’S SIGN
Place the patient in a dorsal recumbent position and then put hands behind the patient’s neck and bend it forward.
If the patient flexes the hips and knees in response to the manipulation, positive for meningitis
KERNIG’S SIGN
Place the patient in a supine position, flex his leg at the hip and knee then straighten the knee; pain and resistance indicates
meningitis

SIGNS AND SYMPTOMS OF MENINGOCOCCEMI

DIC
URTI: Micr
ENCEPHALITIS Vasculitis:
MENINGITIS MENING
cough, sore thromb
petechial COCCE
throat,
rash in the Purp
fever,
SIGNS AND SYMPTOMS trunk and Vasculitis
headache, Hypote
Stiff neckand extremities
nausea Nuchal rigidity Waterhou
vomiting Sho
Photophobia
DIAGNOSTIC EXAM Opisthotonus Friderichs
Dea
 Informed consent
 Empty bowel and bladder
syndrome
Lethargy Brudzinski’s
64

Petechiae
  Fetal, shrimp or “C” position
 Spinal canal, subarachnoid space between L3-L4 or L4- L5
 After: bedrest
 Flat on bed to prevent spinal headache

ENCEPHALITIS MENINGITIS MENING

COCCE
TREATMENT MODALITIES

Dexamethasone Ceftriaxone

Mannitol Penicillin
ENCEPHALITIS MENINGITIS MENING
Anticonvulsants Chloramph
COCCE
Antipyretics
NURSING MANAGEMENT
1. Side board
1. Comfort: quiet, 1. Respiratory
2. Close conta
well-ventilated
PREVENTION isolation 24-72
room hours after onset H – ouse
1.
2.
Japanese
Skin care: 1.ofHiB
antibiotic
vaccine I Rifampicin
– nfected pe
POLIOMYELITIS
encephalitis RABIES
therapy TETAN
cleansing bath, kissing
Ciprofloxa
VAX
change in 2. Room protected S – ame dayc
position
MAIN PROBLEM against bright center
Acute infection of lightsviral disease
Acute Acute infectio
3. Eliminate S – hare mou
themosquito
CNS – muscle of the CNS – by disease with s
instrument
spasm, paresis and 3. Safety:
saliva side-lying
of infected neuromuscula
breeding sites:
paralysis position and
animals 3. Antibiotics
effects
CULEX
raised side rails prophylaxi
mosquito
ETIOLOGIC AGENT Rhabdovirus Clostridium
65
Legio debilitans Bullet-shaped Anaerobic
Affinity to CNS
 POLIOMYELITIS RABIES TETAN

INCUBATION PERIOD
2-8 weeks
7-21 days Distance of bite to Adult: 3 day
brain weeks
Extensiveness of the Neonate: 3-3
bite RABIES TETAN
POLIOMYELITIS
Resistance of the
host
SIGNS AND SYMPTOMS R – isus sard
MODE OF TRANSMISSION
1. Abortive type
- Direct contact with
1. Prodromal / O – pistotho
Biteinvasion
infected feces
2. Pre-paralytic of an infected Direct inocul
- Direct contact with phase
animal Tthrough
– rismusa br
or meningetic
POLIO
respiratory
ABORTIVE TYPE secretions
 Does not invade the CNS
skin
typewith soiled
 Headache
- Indirect
 Sore throat
2. Excitement / C – onvulsio
 linens and articles
Recovery within 72 hours and the disease passes by unnoticed
PRE-PARALYTIC OR MENINGETIC TYPE
neurological
3. Paralytic type
 Slight involvement of the CNS
 Pain and spasm of muscles
H – eadache
 Transient paresis
 (+) Pandy’s test (increased protein in the CSF) phase
PARALYTIC TYPE
 CNS involvement


Flaccid paralysis
Asymmetric 3. Terminal / I – rritabilit
 Affects lower extremities
 Urine retention and constipation
paralytic type
L – aryngea
 (+) HOYNE’S SIGN (when in supine position, head will fall back when shoulders are elevated)

spasm
RABIES
PRODROMAL/INVASION PHASE
 Fever
 Anorexia
 Sore throat

66
  Pain and tingling at the site of bite
 Difficulty swallowing
EXCITEMENT OR NEUROLOGICAL PHASE
 Hydrophobia (laryngospasm)
 Aerophobia (bronchospasm)
 Delirium
 Maniacal behavior
 Drooling
TERMINAL OR PARALYTIC PHASE
 Patient becomes unconscious
 Loss of urine and bowel control
 Progressive paralysis
 Death

POLIOMYELITIS RABIES TETAN

COMPLICATION

Paralysis of RESPIRATORY
DEA
respiratory muscles FAILURE

POLIOMYELITIS
DIAGNOSTIC PROCEDURES
RABIES TETAN
1. Throat washings 1. Blood exam
1. Stool culture
TREATMENT MODALITIES
2. Flourescent rabies 1. Tetanus im
2. CSF culture antibody (FRA) globulin (T
1. Analgesics 1. Local
3. Negri bodies
treatment of 2. Tetanus an
2. Morphine (TAT)
ISOLATION PRECAUTION wound
3.Enteric
Moist isolation
heat Respiratory 3. Penicillin G
2. Active
application isolation
immunization 4. Tetracycli
4. Bed rest 5. Diazepam
Lyssavac
5. Rehabilitation Imovax 6. Phenobarb
7. Tracheosto
67
Antirabies vax
8. NGT feedi
 POLIOMYELITIS RABIES TETAN

NURSING MANAGEMENT
1. Enteric isolation 1. Isolation 1. Adequate

2. Proper disposal 2. Optimum 2. Quiet, sem

of secretions
POLIOMYELITIS comfort
RABIES environm
TETAN
3. Moist hot packs 3. Restful 3. Avoid sud
PREVENTION
4. Firm / environment 1. stimuli
Aseptican
1. If the dog is
nonsagging
Salk vaccine bed 4. healthy
Emotional handling
5. Suitable body 2. Ifsupport
the dog dies or umbilica
- Inactivated
alignment 5. shows signs
Concurrent 2. Tetanus
polio vaccine suggestive of
RESPIRATORY SYSTEM
6. Comfort and and terminal immuniz
rabies
- safety
Intramuscular disinfection
3. If dog is not 3. Antibiot
Sabin vaccine available for prophyla
observation
- Oral polio - Penicillin
vaccine 4. Have domestic
dog 3 months to - Erythromy
- Per orem 1 year old
immunized - Tetracycli

68
 BIRD FLU SARS
MAIN PROBLEM

Flu infection in birds that A new type of atypical pn

affects humans that infects the lungs

ETIOLOGIC AGENT

BIRD FLU
Avian influenza virus, H5N1 SARS
Corona virus

SIGNS AND SYMPTOMS

INCUBATION PERIOD

Body weakness or muscle

3-5 days 2-8 days
pain
MODE OF TRANSMISSION

BIRD
Cough
Inhalation
FLU
of feces and
SARS
Respiratory drople
discharge of an infected bird
Difficulty breathing
COMPLICATIONS
Severe vira
Episodes of sore throat
Severe viral pneumonia
pneumonia
Acute respiratory distress
Fever
syndrome
Hypoxemia
Fluid accumulation in High fever >38’Cels
alveolar sacs
Chills
Respiratory fa
Severe breathing difficulties
69
 BIRD FLU SARS
TREATMENT MODALITIES
1. Amantadine/Rimantadine 1. No definitive treatm
for SARS
- Generic flu drugs
- H5N1 developed resistance 2. Antiviral drugs
BIRD FLU (normally
SARSused to t
2. Oseltamivir (TAMIFLU) AIDS)
Zanamavir
PREVENTION (RELENZA)
- RIBAVIRIN
- Primary treatment
1.Culling – killing of 1.Quarantine
- Within 2 days at onset of 3. Corticosteroids
sick or exposed
symptoms
birds 2. Isolation
- 150 mg BID x 2 days
NURSING MANAGEMENT
BIRD FLU
WHAT TO DO WITH A PERSON SUSPECTED TO HAVE BIRD FLU

2. Banning of
•
•
•
Isolation
Face mask on the patient
Caregiver: use a face mask and eye goggles/glasses
3. WHO aler
importation of
•
•
Distance of 1 meter from the patient
Transport the patient to a DOH referral hospital
on SARS
birds (Executive
REFERRAL HOSPITALS
•
•
order # 280)
•
Luzon – San Lazaro Hospital (Quiricada St., Sta. Cruz, Manila)
Visayas – Vicente Sotto Memorial Medical Hospital (Cebu City)
(March 12,
National Referral Center – Research Institute for Tropical Medicine (RITM) (Alabang, Muntinlupa)

SARS
• Mindanao – Davao Medical Center (Bajada, Davao City)

SUSPECT CASE
2003)
3. Cook chicken
1. A person presenting after 1 November 2002 with a history of:
 High fever >38 0C AND
 Cough or breathing difficulty AND

thoroughly
One or more of the following exposures during the 10 days prior to the onset of symptoms:
 Close contact, with a person who is a suspect or probable case of SARS
 History of travel, to an area with recent local transmission of SARS
 Residing in an area with recent local transmission of SARS
2. A person with an unexplained acute respiratory illness resulting in death after 1 November 2002, but on whom no autopsy
has been performed :
AND
70
  One or more of the following exposures during the 10 days prior to the onset of symptoms:
 Close contact, with a person who is a suspect or probable case of SARS
 History of travel, to an area with recent local transmission of SARS
Residing in an area with recent local transmission of SARS
PROBABLE CASE
1. A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome on Chest x-
ray.

2. A suspect case of SARS that is positive for SARS coronavirus by one or more assays.

3. A suspect case with autopsy findings consistent with the pathology of SARS without an identifiable cause.

DIPHTHERIA PERTUSSIS
MAIN PROBLEM
Acute bacterial disease Repeated attacks of spasm
characterized by the elaboration coughing
of an exotoxin
ETIOLOGIC AGENT
DIPHTHERIA
Corynebacterium diphtheriae or PERTUSS
Bordetella pertussis
Klebs-Loeffler bacillus
SIGNS AND SYMPTOMS
INCUBATION PERIOD

Types:
2-5 days Stages:
7-14 days
1.Nasal
MODE OF TRANSMISSION
NASAL DIPHTHERIA
1. Catarrhal
• Bloody discharge from the nose

2.Tonsilopharyngeal
•
1. Respiratory droplets
Excoriated nares and upper lip

2. Paroxysmal
TONSILOPHARYNGEAL DIPHTHERIA
• Low grade fever
• Sore throat
• 2. Direct contact with respiratory secretions
•3.Laryngeal
Bull-neck appearance

3.with
Convalescent
Pseudomembrane- Group of pale yellow membrane over tonsils and at the back of the throat as an inflammatory
response to a powerful necrotizing toxins

4.Wound or 3. Indirect contact articles

LARYNGEAL DIPHTHERIA
• Hoarseness
• Croupy cough
• Aphonia
•
• cutaneous
Membrane lining thickens  airway obstruction
Suffocation, cyanosis or death
WOUND OR CUTANEOUS DIPHTHERIA
• Yellow spots or sores in the skin

PERTUSSIS
CATARRHAL STAGE
• Lasts for 1 to 2 weeks

71
 • Most communicable stage
• Begins with respiratory infection, sneezing, cough and fever
• Cough becomes more frequent at night
PAROXYSMAL STAGE
• Lasts for 4 to 6 weeks
• Aura: sneezing, tickling, itching of throat
• Cough, explosive outburst ending in “whoop”
• Mucus is thick, ends in vomiting
• Becomes cyanotic
• With profuse sweating, involuntary urination and exhaustion
CONVALESCENT STAGE
• End of 4th-6th week
• Decrease in paroxysms

DIPHTHERIA PERTUSSIS
DIAGNOSTIC PROCEDURES
 SCHICK’S TESTS  CBC– increase in
- Susceptibility and immunity to lymphocytes
diphtheria
-ID of dilute diphtheria toxin (0.1
cc) DIPHTHERIA PERTUSSIS
(+) local circumscribed area of
COMPLICATIONS
redness, 1-3 cm Convulsions (bra
Toxins inTEST
MALONEY’S the bloodstream
damage from
-Determines hypersensitivity to asphyxia)
diphtheria anti-toxin
Myocarditis Peripheral Broncho-
-ID(epigastric
of 0.1 cc fluidparalysis
or chestDIPHTHERIA
toxoid
(tingling,
pneumonia
(fever,
Otitis media
PERTUSSIS
-(+) area
pain) of erythema in 24 hourscough)
numbness, (invading
TREATMENT paresis) MODALITIES organisms)
1. Diphtheria anti-toxin 1. Erythromycin – drug
Heart Respirat Bronchopneumo
- failure Decreased
Requires skin testing choice
in ory
(most dangerous
arrest2. Ampicillin – if resista
- Early administration
respiratory
rate
aimed at neutralizing the complication)
to erythromycin 72

toxin present in the 3. Betamethasone

DEATH
circulation before it is
 DIPHTHERIA PERTUSSIS
NURSING MANAGEMENT
1. Isolation: 4-6 weeks fr
1. Isolation: 14 days (until onset of illness
2-3 cultures, 24 hours
apart) 2. Supportive measures
(bedrest, avoid
2. Bedrest for 2 weeks
MUMPS
MAIN PROBLEM excitement, dust, smok
An acute contagious disease, with swelling of one or both of the parotid glands

3. Care for nose and

ETIOLOGIC AGENT
Filterable virus of paramyxovirus group and warm baths)
INCUBATION PERIOD
throat (gentle swabbing)
12-26 days
MODE OF TRANSMISSION
3. Safety (during
Respiratory droplets

paroxysms, patient
PERIOD OF COMMUNICABILITY
4. Ice collar (decrease pain
6 days before and 9 days after onset of parotid swelling
SIGNS AND SYMPTOMS

of sore throat)
PRODROMAL PHASE should not be left alon
F-ever (low grade)
H-eadache

5. Diet (soft food, small

M-alaise
4. Suctioning (kept at
bedside for emergency
PAROTITIS
frequent feedings)
F-ace pain
E-arache
S-welling of the parotid glands
use)
COMPLICATIONS
• Orchitis – the most notorious complication of mumps
• Oophoritis – manifested by pain and tenderness of the abdomen
• CNS involvement – manifested by headache, stiff neck, delirium, double vision
• Deafness as a result of mumps
NURSING MANAGEMENT
1. Prevent complications
− Scrotum supported by suspensory
− Use of sedatives to relieve pain
− Treatment: oral dose of 300-400 mg cortisone followed by 100 mg every 6 hours
− Nick in the membrane
2. Diet
- Soft or liquid diet
- Sour foods or fruit juices are disliked
3. Respiratory isolation
4. Comfort: ice collar or cold applications over the parotid glands may relieve pain
5. Fever: aspirin, tepid sponge bath
6. Concurrent disinfection: all materials contaminated by these secretions should be cleansed by boiling
7. Terminal disinfection: room should be aired for six to eight hours

GASTROINTESTINAL TRACT

73
 AMOEBIASIS SHIGELLOS
MAIN PROBLEM

Protozoal infection of the large Acute infection of the li

intestine of the small intestine

ETIOLOGIC AGENT
AMOEBIASIS
Entamoeba histolytica SHIGELLOS
Shigella group
SIGNS ANDinSYMPTOMS
- Prevalent areas with ill 1. Shigella flesneri – m
sanitation
1. Acute amoebic dysentery common in the Philip
-Acquired by swallowing
Fever
2. Shigella connei
- Diarrhea alternated with
constipation vegetative form
- Trophozoites: Abdominal
3. Shigella boydii pa
AMOEBIASIS
-- Cyst
Tenesmus
: infective stage SHIGELLOS
4. Shigella dysenterae –
- Bloody mucoid
DIAGNOSTIC stools
TESTS
Diarrhea and
infectious type

2. Chronic amoebic 1. Stool exam tenesmus

dysentery
- Enlarged liver
2. Blood exam Bloody mucoid
3. Sigmoidoscopy
- Large sloughs of intestinal stool
tissues accompanied by
TREATMENT
hemorrhage MODALITIES

1. Metronidazole – drug 1. Cotrimoxazole – d

of choice of choice
74

2. Tetracycline
 AMOEBIASIS SHIGELLOS
NURSING MANAGEMENT

1. Enteric isolation
2. Boil water for
drinking
CHOLERA3. Handwashing
TYPHOID FEV
MAIN PROBLEM 4. Sexual activity
Acute bacterial disease of the An infection affecting t
5. Avoid
GIT characterized by profuse
eating
Peyer’s patches of the s
secretory diarrhea uncooked leafy
intestines
ETIOLOGIC AGENT
vegetables
CHOLERA
Vibrio cholerae
TYPHOID FEV
Salmonella typhi
SIGNS AND SYMPTOMS
INCUBATION PERIOD Fever (ladder-like
Rice-water stool
1 to 3 days 1 to 3 weeks
Rose spots
Abdominal cramps
MODE OF TRANSMISSION
Diarrhea
Vomiting 1. Fecal-oral transmission
TYPHOID STAT
2. 5 F’s
Intravascular Sordes
Dehydration 75
Subsultus Tendin
Shock
 CHOLERA TYPHOID FEV
TREATMENT MODALITIES
1.Chloramphenic
1.Lactated Ringer’s drug of choice
solution
2. Ampicillin/
2. Oral rehydration AmoxicillinFEV
– fo
CHOLERA
therapy TYPHOID
typhoid carrier
NURSING MANAGEMENT
3. Antibiotic therapy
3. Cotrimoxazole
1. Maintain and restore the fluid
- Tetracycline – drug severe cases wit
and electrolyte balance
of choice relapses
2. Enteric isolation
- Cotrimoxazole
INTEGUMENTARY SYSTEM

CHICKENPOX3. Sanitary disposal

- Chloramphenicol of excretaZOS
HERPES
MAIN PROBLEM
4. Adequate provision of safe
drinking water
A highly contagious disease An acute viral infec
characterized by vesicular the sensory nerve
5. Good personal
eruptions on the skin and hygiene
mucous membranes
ETIOLOGIC AGENT
Varicella zoster virus
INCUBATION PERIOD 76

10-21 days 13-17 days

 CHICKENPOX HERPES ZOS
PERIOD OF COMMUNICABILITY

One day before eruption

One day before erup
of 1st lesion and five days
of 1st rash and five t
after appearance of last
days after the last cr
cropCHICKENPOX HERPES ZOS
SIGNS AND SYMPTOMS • Rashes
SIGNS AND SYMPTOMS
PRODROMAL -Unilateral, band-lik
• Rashes : Centrifugal
PERIOD distribution
distribution -Dermatomal
- Fever (low-grade)
•Rash stages: macule - Erythematous base
CHICKENPOX - HeadacheHERPES ZOS
papule vesicle - Vesicular, pustular
pustule crust - Malaise crusting
COMPLICATIONS
RAMSAY-HUNT
•Regional
SYNDROME - Involvem
SCARRING – most common lymphadenopathy
•complication;
Pruritus associated with the facial nerve in herpes
with facial paralysis, hea
•Pruritus
staphylococcal or streptococcal
loss, loss of taste in half
infections from scratching •Pain
tongue– stabbing or
NECROTIZING FASCIITIS – burning
GASSERIAN
most severe complication GANGLIONITIS –
REYE SYNDROME – Involvement of the optic
77
abnormal accumulation of fat in resulting to corneal anest
the liver plus increase of
 CHICKENPOX HERPES ZOS
TREATMENT MODALITIES

1. Antihistamines – 4. Corticosteroids – ant

symptomatic relief of itching inflammatory and decr
pain
Ex. Diphenhydramine
(Benadryl) Ex. Prednisone
CHICKENPOX HERPES ZOS
2. Analgesics and antipyretics
NURSING MANAGEMENT
Ex. Acetaminophen
Strict isolation
3. Antiviral agents – for patient to
Prevent secondary infection (cut less pain and faster
experience
fingernails short, wear mittens)
resolution of lesions when used withi
MEASLES
Eliminate GERMAN
48 hours of rash
itching: calamine onset MEA
lotions, warm baths, baking soda
Ex. Acyclovir (Zovirax)
pastePROBLEM
MAIN

A contagious
Encourage notexanthematous
going to school: A benign communicabl
disease
usually 7with
dayschief symptoms to exanthematous disease
the upper respiratory tract by rubella virus
Disinfection
ETIOLOGIC of clothes and linen
AGENT
with nasopharyngeal discharges
Filterable virus of Rubella virus
by sunlight or boiling
paramyxoviridae
INCUBATION PERIOD
78
10-12 days 14-21 days
MODE OF TRANSMISSION
 MEASLES GERMAN MEA
PERIOD OF COMMUNICABILITY

4 days before and 5 days after One week before and fo

the appearance of rashes after the appearance of

SIGNS AND SYMPTOMS

KOPLIK’S SPOT (Rubeola)
- Bluish white spots surrounded by a red halo
- Appear on the buccal mucosa opposite the premolar teeth
PRE-ERUPTIVE STAGE
FORCHEIMER’S SPOTS (Rubella)
- small, red lesions
PRE-ERUPTIVE STAG
Cough MEASLES Fever GERM
Coryza Headache
Conjunctivitis SIGNS AND SYMPTOMS
Malaise ERUPTIV
2. ERUPTIVE STAGE 1. Rash
Fever (high-grade) Coryza
Rashes - pinkish
Photophobia - Elevated papules Conjunctivitis
- Soft palate to mucus membrane - Begins
- Begin on the face and behind
MEASLES the ears GERMAN- MEA Spread
- Spread to trunk and
extremities - No pigm
COMPLICATIONS 1. Encephalitis desqua
Color: Dark red – purplish hue
– yellow brown 2. Congenital rubella
2. Posterio
syn
P
neumonia3. Stage of Convalescence subocci
- Spontaneous abortion
lympha
- Desquamation - Intrauterine growth reta
O
titis media
- Rashes fade from the(IUGR)
face
downwards - Thrombocytopenia pur
Severe diarrhea (leading “blueberry muffin ski
- Cleft lip, cleft palate, clu
to dehydration) 79
- Heart defects (PDA, VS
Encephalitis - Eye defects (Cataract,
 MEASLES GERMAN MEA
TREATMENT MODALITIES

1.Vitamin A – helps 1.Aspirin – help r

prevent eye damage inflammation an
and blindness fever
MEASLES
2. Antipyretics – for GERMAN MEA
fever
NURSING MANAGEMENT
3. Penicillin – given
only when1.secondary
Darkened room to relieve photophobia
infection sets inshould be liquid but nourishing
2. Diet:

SCABIES
3. Warm saline solution for eyes to relieve
MAIN PROBLEM eye irritation
Infestation of the skin produced by the burrowing action of a parasite mite resulting in skin irritation and formation of vesicles and
pustules
ETIOLOGIC AGENT
Sarcoptes scabiei 4. For fever: tepid sponge bath and anti-
INCUBATION PERIOD
Within 24 hours pyretics
MODE OF TRANSMISSION
Direct contact
Indirect contact
5. Skin care: during eruptive stage, soap is
Sarcoptes scabiei
1. Yellowish white in color omitted; bicarbonate of soda in water or
2. Barely seen by the unaided eye
lotion to relieve itchiness
3. Female parasite burrows beneath the epidermis to lay eggs
4. Males are smaller and reside on the surface of the skin
SIGNS AND SYMPTOMS
•
•
6. Prevent spread of infection: respiratory
Thin, pencil-mark lines on the skin

Rashes and abrasions on the skin isolation

Itching, especially at night
•
PRIMARY LESIONS
NODULAR LESIONS
SECONDARY LESIONS
TREATMENT MODALITIES
• SCABICIDE : Eurax ointment (Crotamiton)
• PEDICULICIDE : Kwell lotion (Gamma Benzene Hexachloride) – contraindicated in young children and pregnant women
• Topical steroids
• Hydrogen peroxide : cleanliness of wound
• Lindane Lotion

80
NURSING MANAGEMENT
• Apply cream at bedtime, from neck to toes
• Instruct patient to avoid bathing for 8 to 12 hours
• Dry-clean or boil bedclothes
• Report any skin irritation
• Family members and close contact treatment
• Good handwashing
• Terminal disinfection

SEXUALLY TRANSMITTED DISEASES

AIDS SYPHILIS

MAIN PROBLEM
Final and most serious stage Infectious disease ca
of HIV disease, which causes
severe damage to the immune
by a spirochete
system AIDS SYPHILIS
ETIOLOGIC AGENT
MODE OF TRANSMISSION
Retrovirus – Human T-cell
• Sexual
lymphotropic virus III contact – oral, anal orpallid
Treponema
(HTLV-3) vaginal sex
AIDS
INCUBATION PERIOD SYPHILIS
•Blood transfusion
3 to 6 months to 8 to 10 years 10-90 days
SIGNS AND •Mother
SYMPTOMS -to-child
OPPORTUNISTIC INFECTIONS
•Indirect contact through soiled
1. Pneumocystis carinni
pneumoniaarticles
2. Oral candidiasis 81

3. Toxoplasmosis
 AIDS SYPHILIS

SIGNS AND SYMPTOMS 1. PRIMARY SYPHILI

- CHANCRE: small, p
pimple-like ulceration
penis, labia majora, m
and lips
AIDS SYPHILIS
- May erupt in the geni
anus, nipple, tonsils o
SIGNS AND SYMPTOMS 2. SECONDARY SYPH
- Lymphadenopathy
- Skin rash
- Mucous patches

AIDS SYPHILIS
- Hair loss
- CONDYLOMATA L
SIGNS AND SYMPTOMS coalescing papules
3. TERTIARY SYPHIL wh
form a gray-white pla
- 1frequently
to 10 yearsinafter
skin infe
fold
- Appear on the skin, b
mucus membrane, UR
and stomach
- GUMMA: chronic, su
nodule or deep
granulomatous82lesion
solitary, painless, ind
 AIDS SYPHILIS
DIAGNOSTIC PROCEDURES

1.ELISA 1.Dark Field

Illumination t
2. Western blot
AIDS SYPHILIS
2. Flourescent
3. RIPA
TREATMENT MODALITIES Treponemal
1. Penicillin G Benzath
4.
1. PCR
Antivirals Antibody
- Disease < 1 year: 2.4
Absorption
once Te
in two injection
- Shorten the clinical
- Disease > 1 year: 2.4
course, prevent 3.inVDRL
2 injection sites x 3
complications, prevent
development of 2. Doxycycline – if aller
penicillin
latency, decrease
3. Tetracycline
transmission
- if allergic to penicilli
- Example: Zidovudine - Contraindicated for
(Retrovir) pregnant women

83
 CHLAMYDIA GONORRHE

MAIN PROBLEM

Sexually transmitted disease caused by a bacte

Purulent inflammation of m
membrane surfaces
CHLAMYDIA
ETIOLOGIC AGENT GONORRHE
Chlamydia trachomatis Neisseria gonorrhea
SIGNS AND SYMPTOMS Women
INCUBATION PERIOD
Women Bleeding after intercourse
2-3 weeks (males)
Abdominal or pelvic pain 2-10 days
Burning sensation during
Asymptomatic
Bleeding after intercourse urination
and (females)
in-between
MODE menses
OF TRANSMISSION Yellow or bloody vaginal
Unusual vaginal discharge discharge
Sexual contact: Oral, vaginal or anal sex
Men
Burning with urination
Swollen, painful testicles
White, yello
Discharge from the penis green pus fr
penis

84
 CHLAMYDIA GONORRHE
COMPLICATIONS
Women
Pelvic inflammatory
disease
Ectopic pregnancy

CHLAMYDIA Sterility GONORRHE

TREATMENT MODALITIES
Men
1. Cefixime
Epididymitis
1. Azithromycin
(Zithromax)
Newborn - Drug
Sterility of choice
Conjunctivitis because
Newborn of oral
CANDIDIASIS
-Otitis
Drug of choice because
media HERPES
efficacy, SIMP
single
Gonococcal ophthalmia
of single-dose treatment
Pneumonia
effectiveness and lower 2. Ciprofloxacin
MAIN costPROBLEM
A viral disease
3. Ceftriaxone
characterized by the
2. Doxycycline
Mild superficial fungal
appearance of sores
infection
- Secondary drug of 4. Erythromycin
blisters on the skin
choice
ETIOLOGIC AGENT
Herpes simplex vi
Candida albicans types 1 and 285
INCUBATION PERIOD
 CANDIDIASIS HERPES SIMP

MODE OF TRANSMISSION
1. Rise in glucose as in TYPE 1
diabetes mellitus - Respiratory dropl
2. Lowered body
SIGNS AND SYMPTOMS (Candidiasis)
ONYCHOMYCOSIS
• Red, swollen darkened nailbeds - Direct exposure to
resistance as in cancer
• Purulent discharge
• Separation of pruritic nails from nailbeds
DIAPER RASH
• Scaly, erythematous, papular rash
infected saliva
• Covered with exudates

3. Increase in estrogen
•
THRUSH
•
Appears below the breasts, between fingers, axilla, groin and umbilicus

Cream-colored or bluish-white patches on the tongue, mouth or pharynx

- Kissing and sharin
•
level in pregnant women
Bloody engorgement when scraped
MONILIASIS
• White or yellow discharge
utensils
• Pruritus
• Local excoriation
4. Broad-spectrum
• White or gray raised patches on vaginal walls with local inflammation
TYPE 2
CANDIDIASIS
antibiotics are used HERPES SIMP
- Sexual or genital
TREATMENT MODALITIES contact

1. Antifungals 1. Antivirals
- Fluconazole (Diflucan) - Acyclovir (Zovirax
- Ketoconazole (Nizoral)
- Imidazole (Nystatin)
- Used for oral thrush
- 48 hours until 86
symptoms disappear
VECTOR-BORNE DISEASES

DENGUE MALARIA

MAIN PROBLEM

An acute febrile disease An acute and chronic par

disease
The most DENGUE
common arboviral MALARIA
The most deadly vector-b
illness transmitted globally
disease in the world
ETIOLOGIC AGENT
INCUBATION PERIOD P. Falciparum – 12 days
Dengue virus types 1, 2, 3 and 4 Plasmodium falciparum
3-14 days P. Vivax – 14 days
Chikungunya virus Plasmodium vivax
P. Ovale – 14 days
O’nyong’nyong virus Plasmodium ovale
P. Malariae – 30 days
West Nile
MODE virus
OF TRANSMISSION Plasmodium malariae

Bite of an infected mosquito

Blood transfusion, contam

syringe or needle

Trans-placentally

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 DENGUE MALARIA

VECTOR

Aedes aegypti Anopheles flaviros

(Aedes albopictus)
DENGUE MALARIA
White stripes on the back and Brown in color
legs (Tiger mosquito)
SIGNS AND(2SYMPTOMS
Day biting hours after sunrise
Night biting (9 PM-3 AM
and 2 hours before sunset) FEVER
FEVER
Breeds on clear stagnant water Breeds on clear, flowing
HEADACHE shaded streams
CHILLS
DENGUE MALARIA
MALAISE
Urban-based PROFUSE SWEAT
Rural-based

RASH
DIAGNOSTIC PROCEDURES 1. CLINICAL DIAGNOSIS

1. TORNIQUET TEST - Based on triad symptoms, 5

EPISODES OF
- Screening test for dengue
BLEEDING
- A test for the tendency for blood
capillaries to break down or produce
petechial hemorrhage
- Performed by examining the skin of
the forearms after the arm veins
have been occluded for 5 minutes
- To detect unusual capillary fragility
accuracy
2. BLOOD SMEAR
- Definitive diagnosis of infe
based on demonstration of
parasites in blood film
3. RAPID DIAGNOSTIC TE
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- Uses immunochromatograp
methods to detect Plasmodi
specific antigens
 DENGUE MALARIA

TREATMENT MODALITIES 1. Chloroquine

1. Analgesics and antipyretics
2. Primaquine
- acetaminophen
3. Pyrimethamine
SCHISTOSOMIASIS
2. Volume expanders
LEPTOSPIRO
4. Sulfadoxine
- Used in the treatment of
intravascular volume deficits
5. Quinine
- Example:
MAIN Lactated Ringers
PROBLEM
6. Quinidine
3. Blood transfusion – for severe
A slowly progressive disease A zoonotic infectious dis
bleeding
caused by a blood fluke
4. Oxygen therapy
SCHISTOSOMIASIS
ETIOLOGIC AGENT LEPTOSPIRO
5. Sedatives
1. SCHISTOSOMA JAPONICUM Leptospira interrogans
- Intestinal tract, endemic in the
INCUBATION
Philippines PERIOD

At least 2 months
2. SCHISTOSOMA MANSONI 7 to 19 days
- Africa
MODE OF TRANSMISSION
3. SCHISTOSOMA HAEMATOBIUM
- Middle East countries likeIngestion
Iran and Iraq

Skin penetration
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Contact with the skin

SCHISTOSOMIASIS LEPTOSPIRO

VECTOR

Oncomelania quadrasi
1. Thrives in fresh water
SCHISTOSOMIASIS
stream LEPTOSPIRO
2. Clings to grasses and leaves
SIGNS AND SYMPTOMS
3. Greenish brown in color Septic or Leptospiremic
ACUTE
4. Size isSTAGE
as big as the smallest F – ever (remittent
grain of palay
1. Cercarial dermatitis H – eadache
(swimmer’s itch)
M – yalgia
2. Katayama syndrome
N – ausea
C - ough
V – omiting
H – eadache and fever
C – ough
A – norexia and lethargy
C – hest pain
R – ash
M - yalgia

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 SCHISTOSOMIASIS LEPTOSPIRO

SIGNS AND SYMPTOMS Immune or Toxic Stage

CHRONIC STAGE - Lasts for 4 to 30 days
1. Hepatic: pain, abdominal - Iritis, headache, meni
SCHISTOSOMIASIS
distension, hematemesis, melena LEPTOSPIRO
manifestations
2. Intestinal: fatigue, abdominal pain,
- Oliguria, anuria with
dysentery
failure
DIAGNOSTIC PROCEDURES
3. Urinary: dysuria, urinary
frequency, hematuria
1. Fecalysis - Shock, coma and cong
heart failure
4. Cardiopulmonary: palpitations,
dyspnea
2. on exertion
Kato-Katz Technique
SCHISTOSOMIASIS
5. CNS: seizures, headache, back
LEPTOSPIRO
3. Cercum
pain ova precipitin test
and paresthesia
(COPT)
TREATMENT MODALITIES
- Confirmatory test for 1st line drugs
1. Praziquantel (Biltricide)
schistosomiasis
1. Penicillin G – drug o
- Taken for 6 months
FILARIASIS
MAIN PROBLEM
A parasitic disease caused by an African eye worm
ETIOLOGIC AGENT
2. Doxycycline
- 1 tablet BID for 3 months
Wuchereria bancrofti
Brugia malayi
Brugia timori
INCUBATION PERIOD 2nd line drugs
- 1 tablet OD for 3 months
8 to 16 months
MODE OF TRANSMISSION
Person-to-person by mosquito bites
ACUTE STAGE 3. Ampicillin
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4. Amoxicillin
 • Lymphadenitis (inflammation of lymph nodes)
• Lymphangitis (inflammation of lymph vessels)
• Male genitalia affected leading to funiculitis, epididymitis and orchitis (redness, painful and tender scrotum)
CHRONIC STAGE
• Develop 10-15 years from onset of first attack
• Hydrocele (swelling of the scrotum)
• Lymphedema (temporary swelling of the upper and lower extremities)
• Elephantiasis (enlargement and thickening of the skin of the upper and lower extremities, scrotum and breast

LABORATORY EXAMINATIONS
• Nocturnal blood examination (NBE) – taken at patient’s residence/hospital after 8PM
• Immunochromatographic test (ICT) – rapid assessment method; an antigen test done at daytime
TREATMENT
• Diethylcarbamazine Citrate (DEC) or HETRAZAN – an individual treatment kills almost all microfilaria and a good
proportion of adult worms.
PREVENTION AND CONTROL
• Measures aimed to control vectors
• Environmental sanitation such as proper drainage and cleanliness of surroundings
• Spraying with insecticides
PREVENTION AND CONTROL
• Measures aimed to protect individuals and families:
• Use of mosquito nets
• Use of long sleeves, long pants and socks
• Application of insect repellants
• Screening of houses

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