 Inductive

ETHICS  Specific to general

 Moral philosophy  Descriptive to metaethics
 Love of wisdom for standards of
norms of what is right, what is wrong,
and what ought to be
Purpose of studying Ethics in Nursing: Approaches in applying ethical principles
 Part of becoming a professional
Teleological Deontological
 Provides guidelines for practice
(ethical principle) - “Utilitarianism” - “Kantianism”
 Protect and safeguard rights of - “telos” - result - “dentos” - action
patients - action of the nurse - ethical if nature of the
Brances of Ethics: is ethical if outcome action is good- means
1. Bioethics is good regardless of the
 All about life + environment + - better good / outcome
animals outcome regardless - “means justify the end”
 Application of ethical standards on of the means
situations about life “End justifies the
2. Healthcare means”
 Applicable to humans only
 Application of ethical standards on
situations concerning healthcare (In choosing ethical principles, it will be a
delivery win-lose situation)
3. Nursing Ethics
 Application of ethical standards on Principles of Ethics
situations about nursing  Ethical principles: Normative
 Guides the nurse in decision making
Metaparadigm of Ethics and acting
 A general view that help nurse better 1. Autonomy
understand branches of ethics.  Self determination / without external
4 elements: control
a. Metaethics  Foundation: respect right of patient
 Vocabulary of ethics  Subjective to mental capacity, age
 Definition of terms  Diminished autonomy: comatose,
 Ex. “truth” - good - telling facts mentally ill
b. Normative ethics  Best shown:
 Standards; followed by everyone Informed consent 
 Establishment of principles  process of obtaining permission
 Ex. “tell the truth” 2 steps: 
c. Applied ethics  Full disclosure - risks, benefits,
 Branches of ethics indications, alternative, right to refuse
 Application to real life situations  Consent proper - nurses can obtain
 Ex. practical use for independent procedures
d. Descriptive ethics example for MCN:
 Uses a bottom to up approach  Sterilization procedure
 Definition does not come from a (contraceptive)
specific source but from society itself o If married - both should
consent
o If unmarried - patient only
example for CHN:
 Deductive   Courtesy call
 General to specific  Immunization
 Metaethics to normative to example for PSYCH:
applied 
  Voluntary: patient consents; with 2. Beneficence vs Non-maleficence
right to refuse treatment  Therapeutic abortion
 Involuntary: no right to DAMA  Euthanasia - active/passive
example for RESEARCH: 3. Beneficence vs. Justice
 If respondent withdraws, let them   Human organ donation (RA 7170)
Donor: live or cadaver
2. Veracity Recipient:
 Telling the truth  Willed: secured
3 forms of lying:  non-willed: fall in line
 Intentional or deliberate lying 4. Beneficence vs Veracity
 Incomplete information  Placebo
 Omission - not telling
anything at all (worst) Solving an Ethical Dilemma
3. Beneficence - do good 1. Gather all relevant data about the dilemma
4. Non-maleficence - do no harm; prevention (ASSESS)
of harm 2. Establish the ethical dilemma
5. Fidelity - loyalty; keeping true to promises 3. Perform values clarification
made  Process of self awareness
6. Justice - fairness and equality;   C - choosing the value
 promotes justice: TRIAGE  P - prizing; cherishing the value
Violations of justice:  A - acting based on the value
 Discrimination 4. Recommend actions
 Racism - color 1. Evaluate if recommendations are
 Sexism - gender effective
 Ageism - elderlies
 Ethnocentrism - beliefs / culture is Other resources in solving ethical dilemma:
superior 1. Self first
7. Confidentiality 2. Superiors
 Honoring privacy (data, solitude) 3. Ethics committee
8. Solidarity  Prerequisite in all medical
 Unity, cooperation, teamwork and academic facilities
9. Totality  Handle complicated ethical
 Preservation of the human body as a dilemma
whole
 amputation LAW
10. Stewardship  The rule of the bad
 Caretaker of God’s creation  Purpose: to keep peace and order
Why nurses study the law:
Ethical Dilemma 1. Ignorance of the law excuses no one
 A universal situation wherein the 2. To protect the rights of our patients
nurse is torn between two or more 3. To protect ourselves
ethical beliefs
 Intrapersonal conflict Classifications of the Law:
 Win-lose situation a. Divine Law
 First resource: self  Coming from omnipotent and
omniscient being
b. Human Law
Ethical Dilemmas:   Created by human beings to human
1. Autonomy vs. Beneficence beings
 Medical paternalism Classification of Law According to Statute: 
- nurse acts as a parent (Man-made)
- behavior of the nurse where the a. 1987 Philippine Constitution
nurse coerces the patient to follow  Highest form of law in the Philippines
his or her advice
  Preamble: opening statement of  Illegal detention
authors - wrong prevention of discharge of
b. Enacted / Statutory Laws the patient
 Republic acts - violation of the right to Habeas
 National level Corpus
c. Regulatory / Administrative Laws
 Regional level ii. Unintentional Torts
 City ordinance (CO)  Without intent but results ro harm,
 Implemented by DOH: AO 2004 injury, or death
0025   Based on “culpa” - fault
 Lowest form of law Examples:
Classification of Law According to  Negligence
Relationships Governed: - failure of the nurse to act in the
a. Civil Law same way a prudent nurse would
 Governs private relations of an which resulted in injury.
individual to others - carelessness
 RA 386 - civil code of the Philippines - “the act”
Tort  Malpractice
 “Civil wrong” - overstepping beyond one’s job
 Violation of the civil code which description resulting to injury
destroys relation of an individual to - inability to perform job description
another individual - the “lawsuit” / liability
 Civil penalty: Php 200,000 
 Revocation of the license 4Ds:
 Community work 1. Duty: job description
i. Intentional Torts 2. Dereliction: breech
 With malevolent intent 3. Damage: harm
 Based on “dolo” or deceit 4. Direct causation: proximate cause
Examples:
 Assault  Incidence Report:
- actual threat that results to fear or  Internal risk management
anxiety  Deadline: 24 hours
- verbal or non-verbal  Content: facts, no assumptions
 Battery  Goes to the employee’s permanent
- actual physical contact resulting to record (401 file)
harm Purpose:
- no consent  Prevention of future incidence
 For legal documentation
False imprisonment  Audit
- form of battery which transpires  Research - problem
when the nurse isolates and
restraints without proper purpose.  b. Criminal Law
To prevent assault and battery:   Violation of the law of the land
ASK CONSENT: “damnun absque injuria”  Destroys one relationship to the state
meaning “although there is physical injury,
 Enemy of the state
there is no liability:
2 basic elements:
 Mens rea - criminal intent
 Actus reus - criminal act
 Defamation 3 degrees of a crime:
- character assasination  i. Consummated crime
Slander: oral, speech,needs witness  known, discovered, and fulfilled (act)
Libel: written  Highest degree of a crime
 Fraud  Mens and actus reus performed
- forgery, plagiarism ii. Frustrated crime
  Known and discovered but almost  Opportunistic
fulfilled
 Mens rhea: known Litigation Process in the Philippines
Actus reus: done but unsuccessful 1. Filing of the complaint
(almost)  Plaintiff - one who filed
iii. Attempted crime o Individual if civil case
 Known but action stopped o State is the plaintiff if criminal
(unfulfilled)  case
 Mens rea: discovered  Defendant - one named in the lawsuit
Actus reus: stopped; not done 2. Issuance of summon 
 Subpoena
Examples of a Crime:  3. Discovering
 Murder - MR: to kill 4. Pre-trial
 Homicide - MR: to hurt, injure  Presentation of evidence
 Parricide - kill own blood-related  Can be dismissed if: (1) lack of
individual evidence and (2) settlement
 Infanticide - kill infant >3 days old 5. Trial
 Abortion - kills fetus (worst murder)
 Rape - no consent
o Carnal knowledge (mens
rhea)
o Attempt or actual penetration
of an orifice
o Grave coercion
o Either consummated or
attempted rape only
 Simulation of birth
 Arson - burning of private properties

Conspiracy of a Crime:
 More than 1 person involved
 Example: Abortion
1. Principal - mother (mastermind)
2. Accomplice - nurse (partner in crime;
assistant)
3. Accessory - abortionist (to eliminate body
or hide)

Circumstances that affect criminal liability:

1. Justifying
 Self defense 
 No care
2. Exempting
 Minor
 Old age
 No case in this one
3. Mitigating
 Decreases liability
 Provoking someone
 Admits being guilty
4. Aggravating
 Public official
 Higher punishment
 1. Menstrual Phase
 Slough off
 Thinning of endometrium
 Bleeding
MATERNAL AND CHILD NURSING 2. Proliferative Phase
 Increase of estrogen causes
Female Hormones thickening of endometrium
Estrogen Progesteron  Most fertile phase
e  Only phase where you can
get pregnant
Stimulatin FSH LH 3. Secretory Phase
g Function  Corpus luteum  causes
hormone secretion
Main Secondary reproduction (progesterone)
function sexual 4. Ischemic
characteristic  If no fertilization takes place
s
The Menstrual Cycle
Muscle Slight Increased
and bones contraction of muscle
muscles relaxation
(increases (osteoblast)  1-5th day: menstrual phase
osteoclast)  Day 5-14: Follicular
 Day 14-28: Luteal 

Menstrual Cycle
 Monthly period
 Average length: 28 days
 No. of days of menses: 5-7 days
 Usual amount of bleeding: 20-
80mL/month
 Menses: flesh smelling
 Infection: foul smelling (bacterial
vaginosis=G. vaginalis)
 Menarche: first menses
 <12: early menarche
 >18: late menarche
 Timing of menarche (risk for breast
cancer)  functions to thicken the endometrium
 In the first 5 days (menstrual phase),
there is low estrogen and
progesterone which stimulates GnRH
 GnRH signals the APG to secrete
FSH, which in turn increases the
estrogen hormone
 The APG will then secrete LH, which
in turn increases progesterone
 During the 14th day, the ovum is
released and leaves a shell called
the corpus luteum, which is a gland
that secretes progesterone that

↑ estrogen - food for the cancer Deviations from the Normal Menstrual
 High risk for breast cancer Cycle
 Early menarche 1. Amenorrhea
 absence of menstruation
Processes in the Menstrual Cycle: a. No onset of menarche after 18 years
1. Hypothalamic pituitary cycle old
a. Follicular  b. 3 consecutive months of no menses
b. Luteal Two types:
2. Ovulatory cycle  a. Primary amenorrhea
a. Day 1-14: preovulatory   Idiopathic (unknown)
b. Day 14: ovulatory b. Secondary amenorrhea
c. >day 14: postovulatory  Underlying condition
3. Endometrial  Pregnancy (no. 1
Phases of the Menstrual Cycle: cause)
 2. Menorrhagia  No stimulation of
 Increased amount of endometrium to
menstruation thicken
 >100ml of menses o Testosterone
3. Metrorrhagia  Parenteral for 1-3
 Increased frequency of months
menstruation  May cause hirsutism
 Bleeding in between menses b. Surgical treatment
4. Hypomenorrhea o Laparoscopic removal 
 Decreased amount (spotting) o Ablative
 Caused by: shirodkar  Salpingectomy (fallopian
cerclage, obstruction tube)
5. Oligomenorrhea  Oophorectomy (ovaries)
 Decreased frequency  Hysterectomy (uterus)
 TAHBSO/Panhysterectomy
Take note:
 Athletes 
o Hyperactive: hypo/oilgo ANTEPARTUM
o Super active: amenorrhea
 Obese
o meno/metro  PREGNANCY
 Eating disorder  antepartum/gestation
o Amenorrhea  Happens after two processes
1. Fertilization (Conception) 24-
Endometriosis 72 hrs
 Abnormal implantation of the 2. Implantation (Nidation) 7-10
endometrium  days after fertilization
 Leading cause of infertility   Full term:
 Idiopathic, but leading theory/cause o 10 lunar months
is retrograde menstruation o 9 calendar months
 Once implanted, hormones will o 38-40 weeks
continue to stimulate it o 280 days
 Will continue sloughing off despite  Trimester
abnormal implantation o 1st: 3 months / 12 weeks
 Normal site: uterus (innermost) o 2nd: next 3 months / 24
 Abnormal site: fallopian tube (most weeks
common), ovaries, cervix, peritoneal o 3rd: third 3 months / 38
cavity, rectum weeks
Manifestation:
 Increased bleeding A. First trimester
 Increased pain  Period of organogenesis (8th week)
 Dysmenorrhea  Heart, brain, liver, kidneys 
 Dyspareunia  Harmful to teratogens
 Dyschezia 3 primordial germ layers:
 Abdominal pain (rebound 1. Ectoderm - integumentary and
tenderness) nervous
 Dehydration  2. Mesoderm - cardiovascular,
Treatment: reproductive, musculoskeletal
a. Medical treatment (hormonal 3. Endoderm - endocrine, digestive, GU
medication)  Lungs - last to develop (both meso
o OCP (estrogen, and endo)
progesterone) Teratogens:
a. TORCH
i. Toxoplasmosis
 ii. Other STD
iii. Rubella (German)
iv. Cytomegalovirus
v. Herpes Simplex
b. Alcohol
c. Smoking, drugs (thalidomide)
d. Radiation
Health teaching: danger signs of pregnancy
to fetal development
B. Second trimester
 Most comfortable period of
pregnancy, because:
 Plateau hormones
 Uterus is an abdominal organ -> no
compression -> no urinary frequency
and SOB
C. Third trimester
 Most popular fetal development
Physiological Changes and Discomfort
A. Reproductive System
 Enlarging uterus
 Hyperstimulated ovaries (↑estrogen,
progesterone more)
 Increased vascularity of cervix and
vaina
⤷ Discoloration (Chadwick’s)
⤷ d/t more blood flow
 Softening cervix (Goodel’s) 
 Softening of the Uterus
 Inner uterine segment
(Hegar’s)
 Posterior (Piskacek)
 Anterior (Vonbraun
Fernwald) 
 Leukorrhea: high level of estrogen;
white menses
B. Integumentary System
 Increased melanin due to ↑ estrogen
 Darkening of the skin
 Melasma (mask of
pregnancy)
 Linea nigra
 Striae gravidarum   Do not massage legs (dislodge clots)
Discomfort: 
a. pruritus gravidarum d/t:
 Increase histamine because
of estrogen
 Increased level of bile salts
in the epidermis
Management:
 Avoid scratching, put mittens
 Cut fingernails
 Dilute bile (increase O.F.I)
 Topical antihistamine
(calamine lotion)
 Cool batch causes
desensitization of nerve
endings mixed with baking
soda (antipruritic effect)
C. Cardiovascular System
 Cardiac output increased
➣ pre-pregnant: 4-6L/min
➣ pregnant: 6-10L/min
 Increased plasma, RBC, WBC,
platelets, clotting factors
 BP: systolic = ↓ 130
2 problems:
1. Pregnancy-induced anemia
 d/t hemodilution (liquid plasma, solid
blood)
 most common in 3rd trimester (BV
higher)
 fatigue because of low RBC,
decreased oxygen, pallor
Management:
 Provide rest
 Iron (Ferrous Sulfate)
 30-60mg/day morning
 Black tarry stool
 With orange juice
2. Deep Vein Thrombosis (Homan’s Sign)
 Caused  by increased level of
estrogen
 Increased fibrin
 Confirmatory: doppler
2 types of DVT:
 Phlegmasia alba dolens - milk, pale
 Phlegmasia cerulea dolens - blue
legs, circulation but low
Management:
 Elevate legs (improve venous return)
(2-3 firm pillows)
 Promote ambulation
 Wear elastic compression stockings
(thigh level)
 Anticoagulant (prevent clot) ->
HEPARIN does not cross placental
barrier
 Thrombolytics (dissolve)
 Warm compress (blood circulation)
D. Respiratory System
 Increased shortness of breath
especially 3rd trimester d/t
compression of diaphragm
  Increased tidal volume  1st 7 months: up to end of 28th week
E. Gastrointestinal System = once a month
 Decreased peristalsis d/t gravity of  7-8 months: end of 28 to end of 32nd
the uterus week = twice a month (q 2 weeks)
 Progesterone  8th-9th month: end of 32nd week to
 Constipation (stool softeners) end of 36th week = once q week
 Hemorrhoids (prolapse of vein)
 Hot sitz bath: (1) bedside
commode and (2) potty for Activities
adults 1. Obstetrical history/ Birth history
 Avoid sitting (GTPAL)
 Witchhazel solution (put 2. Estimates of Pregnancy
cotton ball for 8 hours then a. EDC/EDD
remove) i. Naegele’s Rule: (-3 +7 +1)
Note: Do not perform enema if woman is ii. Mittendorf Rule
pregnant since it increases peristalsis -> 1. White caucasian:
increases premature uterine contraction -> (+15 days +3 months)
preterm labor 2. Nonwhite: (+10 days
+3 months)
F Genitourinary System b. AOG
 Compressed bladder (1st and 3rd) i. Mcdonald’s Rule
 ↑ GFR d/t ↑ renal blood flow  (Height of fundus
 Urinary frequency cm) x (2/7) = AOG in
G. Endocrine System months
 Increased gland function (↑  (Height of fundus
secretions all) cm) x (8/7) = AOG in
weeks
 Additional gland: placenta
c. Estimate fetal weight (grams)
a. Morning sickness
i. Johnson’s Rule
 ↑  estrogen, HCG, P
 If engaged (FH-11) x
↳fatigue, nausea, and vomiting
155
 Give dry crackers / 
 If unengaged (FH-
 Pregnant women has
12) x 155
“ptyalism” so water cause d. Estimate fetal length (cm)
vomiting i. Haase’s rule 
 Source of carbohydrate /  1st 5 months: (AOG
hunger exacerbates nausea months)2
and vomiting
 After 5 months (AOG
 Promote rest
months)(5)
 Avoid noxious stimuli Diagnostic Tests
 Fluid in between meals (small freq.)  Ultrasound: visualization of the
contents of the uterus
PRENATAL ASSESSMENT CARE  Indications
 Purpose: preparation
 Priority: safety of mother and fetus
Two methods: First  Confirmation of
Trimester pregnancy
Clinic Visit  Miscarriage
 Ectopic pregnancy
 Pregnant woman goes to the clinic
 Unstable pregnancy Second  Identification of sex (>12
Virtual Visit: third type of prenatal via Trimester wks)
the use of internet  H. mole
Schedule of Prenatal Assessment Care  AOG
  Multigravidit
Third  Fetal position (ROA, y (↑5)
Trimester LOA)  Multiple
 Placental location gestation
 A.F. index  Previous hx
of
chromosom
al
 2 Methods of UTZ abnormality
 Procedure
1. Position client
Transabdominal Transvaginal
supine
2. Apply topical
 Noninvasive  Invasive
anesthetic as
 Anytime during  Early and late
prescribed
pregnancy pregnancy
3. Assist the OB in
 CI: morbid obesity  CI: vaginal performing
 Full bladder bleeding procedure by holding
o Lift bladder  Empty bladder on the UTZ
o Echolucent  Lubricant/KY Jelly 4. Observe while F 12-
   Lithotomy 14 catheter is
 Conductive gel inserted in the
 Supine (w/ edge abdomen
under the R hip) Bladder status:
 If
<20wks=full
bladder
 Amniocentesis  If
 Aspiration of amniotic fluid for >20wks=em
specimen submission pty bladder
 Earliest time: 2nd trimester (>14 wks)  Lab Tests
 Invasive: requires physician’s order 1. Quad screen: HCG,
and formal consent AFP, estriol, inhibin
 Role of nurse: assist OB A
 Usual amount of amniotic fluid to 2. CVS (chorionic villus
obtain: 10-20mL sampling)
 Amniotic Fluid: 3. Fetal lung maturity
 Normal characteristics:  L/S maturity
 clear with white a. 2:1 (normal
specs floating pregnancy)
 pH: alkaline (↑) b. 3:1 (GDM)
c. 1:2
 amount: 500ml-
(Immature)
100ml
4. Phosphatidylglycerol
 ↓300mL:
(PG)
oligohydram
 Lung
nios
surfactant
 ↑1200mL:
 3rd trimester
polyhydramn
ios  Adverse effect of
Amniocentesis
 Indications
o Excessive bleeding
High risk
pregnancy:  o Infection
 Age ↑35 (Choriocentesis)
years old o PROM
o Fetal Injury
Lab Tests during Pregnancy o Milk based product,
1. Urinalysis GLV
 Clean catch/midstream (5-  Iron: fetal brain development
10mL) o Rec: 30-60mg/day
 Assess for UTI  Iodine: fetal brain development
 Assess for glucose, ketones, o Rec: 220mcg
protein (-) o Shellfish
2. CBC  Choline: fetal brain
 Hemoglobin: 10-12 g/dl development
 Hematocrit:  o Rec: 450mg
Normal: 35-45  Folic acid (B9): fetal brain
Expected: 32-35 development
o Rec: 600-700mcg
 WBC o Red meat, GLV
Expected: 11000-15000 U
 Pyridoxine (B6): fetal nerve
Labor: 15000-21000
development
Pregnancy Tests
o Rec: 1.9mg
 Hormone HCG
 Cyanocobalamin (B12): fetal
 2 specimen:
RBC development
o Urine: homebased
o Rec: 2.6 mcg
o Blood: clinic based
 Vitamin C (Ascorbic A.): fetal
 Proper timing: early in the morning immune development
 Date of test: 10-14 days after  Retinol: fetal eye
unprotected coitus development/vision
 False positive: anticonvulsant o Rec: 770 mcg
 False negative: diuretics/beta o Limit: 3,000 mcg
blockers 
(120,000 IU)
c. Hydration
Health Promotion and Maintenance of the  Mainly water
Pregnant Woman  Rec: 2-3L/day
1. Maternal Nutrition  Prevents dehydration that
 Significant for fetal leads to uterine contraction
nourishment  Avoid: coffee, sugary drinks,
 Adequate maternal nutrition alcohol
results to adequate fetal 2. Maternal Activity 
growth and development a. Exercise
 Most stable parameter:  Priority: safety
weight gain  Type of exercise usually
 Expected weight gain pattern recommended:
o 1st tri: 1 lb/month o Isotonic
o 2nd & 3rd tri: o Isometric
1lb/week  Schedule: 4-5/week, 30
mins/day
Specific Recommendation for Nutrient Intake  Most convenient form of
a. Calories exercise: leisure walking
 Pregnant: add 200 kcal on top b. Sexual intercourse
of RDA  Increased motivation d/t
 Lactating: add 500 kcal on top increased libido 
of RDA  Safe for as long as: 
b. Micronutrients o Intact BOW (bag of
 Calcium: fetal bone and water)
muscle growth and o No complication
development
 Reminders:
o Rec: 1,300mg/day
 1. Assume comfortable
position: spooning,
on four points
2. Counsel both couple
3. Report any vaginal
bleeding
4. Void after sex
c. Exercises to prevent pain sensation
1. Pelvic rock/tilt: patients with
lower back pain
2. Tailor sit: patients with weak
muscles of the perineum
3. Dorsiflexion of foot: patients
with leg cramps
d. Sleep and Rest
 6-8 hours
 Position left side lying to
prevent reflux of gastric
content
 To enhance sleep:
o Minimize noise
o Cool room
temperature
o Chamomile
tea/Warm glass of
milk
o Avoid co-sleeping
o Provide midnight
snack
INTRAPARTUM
Labor and delivery
 “Parturition” 
Theories
a. Aging Placenta Theory
 Promotes detachment and descent
of the fetus (37th week)
b. Progesterone Deprivation Theory
 Decrease in progesterone which
could lead to labor
c. Oxytocin Release Theory
 Caused by decrease of progesterone
 Uterine contraction
Minor
d. Prostaglandin Rise Theory
 Cervical ripening leads to effacement
Signs of Impending Labor
1. Energy surge
 “Nesting syndrome”
 Adrenaline (epi-norepi) rush
2. Lightening 
 Fetal descent resulting to less
compression of the diaphragm
 As early as 34-36 weeks of gestation
3. Rupture of bag of water
 SROM (spontaneous rupture of
membrane)
 Can happen anytime during labor
Scenarios:
 BOW intact: go home
 BOW intact with dilation of cervix: go
home
 BOW ruptures but no dilation: admit
d/t increased risk for infection
4. Bloody show
 Increased vaginal discharge d/t the
release of operculum
5. True labor contractions
 True onset of labor which progresses
dilation 
True contraction
- regular - irregular
- progressive - erratic 
- stronger in the long run - weak in th
- hydration has no effect - relieved b
- increased by ambulation - relieved b
Origin: Origin:
- lower back to front - starts at th
Progressive dilation Little or no
Primary power of woman “Braxton-hic
5Ps of Labor
1. Passageway
 Maternal pelvis (inlet and outlet)
Inlet: true maternal pelvis
Outlet: false pelvis
 Molding: head of baby adjusts to the
smaller maternal pelvis; cranial
sutures allow molding of the skull 
 Pelvimetry: xray before pregnant
Shapes: 4D 
 Gynecoid (Round): preferred shape
of delivery
 Android: heart
 Anthropoid: oblong
 Platypelloid: flat 
 a. Station 0: engagement
2. Passenger (3) b. Positive station: favorable
i. Bag of water station
 PROM iii. Placenta 
 SROM  Comes out at the third stage of labor
 AROM (Amniotomy)  Function: blood flow, lungs of the
 Can be done until transitional fetus
phase (1st stage)  #1 nutrient supplied to placenta:
ii. Fetus glucose
 Fetal Presentation   Hormones: estrogen, progesterone,
- first part of the fetus that enters the HCG, HPL
maternal pelvis
a. Cephalic (Vertex) Two methods of placental delivery:
Types: a. Schultz
*Mentum: chin; largest - shiny side
diameter - fetal aspect first
*Brow: - intact cotyledons
*Occiput: mos preferred b. Duncan
since smallest diameter - dirty
b. Breech - common - maternal aspect
malpresentation of the fetus - exposed cotyledons
 Fetal Lie - higher risk for PPH
- relationship of fetal axis to maternal
axis 3. Powers
a. Transverse - perpendicular  Forces that promotes descent and
 CS dilation
b. Longitudinal - parallel a. Primary - true contraction
 Favored fetal lie b. Secondary - maternal pushing
 Fetal Attitude  2nd stage of labor (mother
- relationship of fetal parts to center encouraged to push)
of the body 4. Position
a. Full flexion - preferred fetal  Encourage woman to shift positions
attitude; cephalic-occiput from time to time = encourages
comfort, intensity, and fetal descent
 Avoid supine which cause vena cava
 Fetal Position compression -> hypotension
a. First letter - Location of the  NSVD: lithotomy
fetal back  CS: Supine (with wedge pillow under
b. Second letter - depends on the right hip)
the presenting part  Home birth: dorsal recumbent
 O is preferred 5. Psyche
c. Third letter - anterior or  Emotional status of the woman
posterior; orientation of fetus  Anxiety
r/t maternal ischial spine Mgmt: 
 Anterior is  lower down anxiety
preferred (less  Relaxation exercises (DBE)
lower back pain)  Distract the woman, talk, let
*NSVD: ROA/LOA watch tv or listen music
 Best support person:
MOTHER 
 Fetal Station
- location of the fetal presenting part Stages of Labor
with regards to the level of the Stage 1: Cervical Stage
maternal spine
  onset of true contraction to full 3. Establish baseline data: VS, FHR,
cervical dilation Urinalysis (Glucose, Keto, Urine), CBC
 Basis is the dilation (Hemoglobin, Hematocrit), Cervical dilation,
a. Latent, Active, Transitional VDRL
Primi Multi
Progress of Labor: (depends on the
dilation) - Longer, slower - Shorter, faster
labor labor
Stages Dilatio Effacemen Statio - prolonged - precipitate
n t n - more blood loss - less blood loss

Latent 0-3cm 0-30% -3 to - 4. Perform Leopold’s Maneuver

0
 Abdominal palpation of the pregnant
woman
Active 4-7cm 40-70% -2 to
+2  Done at 3rd trimester and during 1st
stage of labor
Transitiona 8-10 80-100% 0 to a.  L1 (Fundal Grip)
l +3  Establishes fetal lie
 Nurse stands beside the
patient
b. L2 (Lateral Grip)
Uterine Contractions
 Establishes fetal position
Stages Duratio Frequenc Intensity  Palpate left and right
n y  Nurse stands at the side or
head part
Latent 30-45 every 5- mild c. L3 (Pawlik’s Grip)
sec 30 min  Establishes fetal
presentation
Active 45-70 every 3-5 moderat  Palpate symphysis pubis
sec min e d. L4 (Pelvic Grip)
 Establishes fetal attitude 
Transition 60-90 every 2-3 strong
al sec min Nursing considerations in LM:
 Have woman empty bladder
 Explain procedure (non-
Length of labor invasive)
 Position client supine
Latent Active Transitional  Expose the abdomen
 Warm hands by rubbing
Primi 12 to 18 2 to 4 hours 40 min to 1 5. Perform perineal care
(12 to 20 hours hour  Labor increases peristalsis =
hours) defecate
 Provide bed pan
Multi 6 to 9 40 minutes 20 to 30
 Avoid douching
(8 to 12 hours to 2 hours minutes
hours)  Avoid enema
 Wipe front to back
 Clean tap water
Management:  6. Provide pain relief
1. Admit woman in LR  Nonpharmacologic: all phases of
 Primary check: ROM labor
2. Help woman change gown and make feel  Pharmacologic: ACTIVE PHASE
comfortable Anesthetic is best: 
 Pudendal
  Epidural and Spinal: hypotension   Perineal pressure 
 Spinal: CSF leakage -> spinal  Done during crowning
headaches  How is it done?
 Supine, flat on the back 1. Get a clean towel
 Increase fluid intake    2. Put towel on the perineum while
7. Use WHO Partograph putting pressure 
 Monitoring sheet for progress of Management:
labor 1. Prepare DR: 20 to 25 degrees
 Used in active phase of labor 2. Contact NICU
(Stay with the woman at this stage)
Stage 2: Fetal Stage
 From full dilation (Crowning) to Stage 3: Placental Stage
delivery of fetus  Delivery of fetus to delivery of
 Onset: crowning placenta 
 Appearance of presenting  5 to 30 minutes only
part in vaginal introitus Signs of impending placental delivery:
 Sign: bulging of the  Lengthening of the cord
perineum  Sudden gush of blood (tissue
Details:  tearing)
 Dilation: full (10cm)  Calkin’s sign (Globular shaping of the
 Effacement: 100% fundus)
 UC length: 60-90 sec
 UC frequency: q 2-3 mins (AMTSL) Active Management in the Third
 UC intensity: strong to very strong Stage of Labor: 
 Primi: 30mins - 2 hrs  Purpose is to prevent hemorrhage
 Multi: 20-30 mins 1. Fundal massage 
Proper timing: push when UC is at peak  Fingertips on fundus in a clawing
Tocotransducer motion
Four measurements:  Promotes uterine contraction
1. Length/duration: start of the UC to 2. Oxytocin Release 
the end of the same UC  nipple stimulation and breastfeeding
2. Frequency: how often contraction  10 IU parenteral: IM or IV piggyback
happens; start of the first UC to start or diluted with isotonic solution
of the next UC 3. CCT (Control Cord Traction)
3. Interval: resting period; end of the  Brandt Andrews Maneuver
first UC to start of the next UC
4. Intensity: based on peak of UC Stage 4: Recovery Stage
 Delivery of placenta to maternal
recovery
Management:
1. monitor woman, check VS
2. Check blood loss: NSVD <500ml,
Cardinal Movements of Labor
CS: <1000ml
“EDFIREEE”
 E- engagement (-)
Vital Signs: 
 D- descent (+)
1st hour: q14 x 5
 F- flexion
2nd hour: q30 x 2
 IR - Internal rotation (180 degrees); Succeeding hours: qhr
rotation to advance/forward 
 Temp: elevated
 E - extension
 RR: slightly increased or normal
 E - external rotation
 BP: slightly decreased
 E - expulsion (baby out)
 PR: elevated
Ritgen’s Maneuver
POSTPARTUM
  “puerperium”  GH
 onset: 4th stage of labor (recovery (somatoma
stage) mmotropin)
 Up to 6 weeks since menses may  MSH
occur  TSH
 woman starts to return to pre  ACTH
pregnant state Care:
 woman goes through psychological o Promote BF
adaptation o Wear well supportive bra
Reva Rubin's Stages of Postpartum o Warm compress if
Psychological Adjustment: breastfeeding
1. Taking In o Cool compress if bottle
 onset: first 24 hours after feeding
birth Possible problems:
 focus: rest o Mastitis 
o Mother is physically  Inflammation of the breast
and mentally tissue
exhausted  onset:48-72 hrs after birth
 nurse’s role  Local infection
o Provide comfort  Risk factor: poor breast
measures such as and hand hygiene
talking to the mother;  staphylococcus aureus
topic should be Manifestations: rubor, dolor, calor
about labor; don’t Care: continue BF using unaffected breast,
talk about the baby administer antibiotic (amoxicillin:
2. Taking Hold PO/topical, 5-7days)
 onset: few days afterPreventive
giving measures: handwashing, breast hygiene, regular
birth changing of breast pads
 focus: infant care 2. UTERUS
 educate on infant care  Expectation: involution
 monitor breastfeeding o Normal return of the
3. Letting Go uterus to
 onset: after discharge prepregnant state
 focus: she and her baby are o Location of uterus
separate entities (fundus)
 baby needs to be integrated  Right after giving birth:
into the family through umbilicus
introduction to the members  Rate of descent: 1cm/day
of the family and mother will  Duration: 10-14 days
be able to accept Possible problems:
Postpartum Assessment a. Uterine atony
“BUBBLESHE”  Lack or absence of tone d/t
1. BREAST inability to contract
 Expectation: engorgement  Leading cause of postpartum
(due to estrogen and hemorrhage
prolactin) Risk factors: displacement;
 PPG decreased level of oxytocin
 Vasopressin Care: empty the bladder, massage the
(ADH) fundus, nipple stimulation,
 oxytocin breastfeeding, 10 IU of oxytocin
 APG b. Subinvolution
 FSH  Delayed return of the uterus
 LSH  Care is the same as uterine
 Prolactin  atony
  Cutting of the
fourchette/levator ani muscle
3. BLADDER  Promote laceration resulting
 Expectation: full/distended, to bleeding
dull upon auscultation, within  EBP discourages use of
first 4 hours episiotomy 
Possible problems:  Possible problems
 Urinary retention a. Perineal hematoma
Care: Assist to cr, bed pan, straight  Swelling of
catheter, crede’s maneuver (manual one side of
bladder palpation) the
4. Bowel perineum
 Expectation: low peristalsis,  asymmetrica
decreased bowel sounds l perineum
Possible problems:  Also results
 Ileus from birth
 Decreased peristalsis d/t trauma
high levels of progesterone (macrosomi
Care: promote ambulation, NPO until return a, multiple
of bowel sound gestation,
5. Lochia forceps
 Post partum discharge deliver,
vacuum,
 Schedule:
precipitate)
o Day 1-3: Rubra
Care: ice/cold compress
 Flow: heavy 
over the perineum, peri light
 Color: red
exposure (20-30 mins)
o Day 4-7: Serosa
7. SKIN
 Flow:  Expectation: 
moderate o Diaphoresis
 Color:
pinkish  excessive
o Day 8-return of sweating d/t
compensatio
menses
n of
 Flow:
eliminating
mild/spotting
body fluids
 Color:
Care: change gown from
white/light
time to time
yellow
 Possible problem
 Measuring postpartum
o Pruritus: wear loose
discharge/bleeding through
weighing napkins fitting clothes
o Light: spotting
o Mild: spots sized at
less than 5cm 8. HOMAN’S SIGN
o Moderate: spots  Screening assessment for
sized between 5- DVT
10cm  Calf pain upon dorsiflexion of
o Severe: saturated the foot
within 30 mins  Confirm using doppler blood
o Profuse: saturated flow analysis
within 5 mins  Care: 
6. Episiotomy o Avoid massage
 Perineotomy  o Promote ambulation
 o
Elevate legs at least  Fetal demise before reaching age of
30 mins/day (2 viability 
pillows under thigh, Causes: 
3 pillows under leg)  (Main) Chromosomal abnormalities
o Don elastic  Teratogenic exposure
compression  Trauma
stockings upon  Domestic violence
arising from the bed  Poor nutrition
o Take thrombolytics   Advancing age
o Take anticoagulants Categories of Spotaneous Abortion:
9. EMOTIONAL STATUS a. Threatened abortion
 Expectation: postpartum  Baby is salvageable 
blues  Reversible since cervix is closed
o reason: d/t preventing the baby from being
fluctuation hormones aborted
o Affect: sad, lonely, Management:
melancholic  Bed rest
o Care: promote  Given hormones (progesterone,
verbalization estrogen)
o Length: less than 6  Lower down stress
months after giving b. Inevitable/Imminent abortion
birth  Difficult to save baby
 Possible problem: Management:
a. Postpartum  Full Dilatation and Curettage 
depression c. Incomplete abortion
 Neurotic   Most painful type of abortion
 Classified as Management:
a major  D&C
depressive  Differential diagnosis: Ectopic
disorder pregnancy (OB), Appendicitis (MS)
(MDD) d. Complete abortion
 Prozac  No more products left
(SSRI): 2-4 Management:
weeks to  Save and submit product of
take effect conception or discharge
b. Postpartum  TVS (transvaginal sonography)
psychosis e. Missed abortion
 Psychotic /  Did not notice or feel anything
 Hallucination  Not aware that they are pregnant
: sensation  Painless form of missed abortion 
alteration Management:
(auditory)
 D & C; can be delayed up to 6 weeks
 Delusion: f. Septic abortion
thought
 Infection 
alteration
Management:
 Antibiotic therapy (7 days)
Bleeding Disorders of Pregnancy  If infection free, D & C
Note: any form of vaginal bleeding needs to
be reported
Universal management for all types of
abortion:
 Emotional support
1st trimester:
 Contact support system
1. Spontaneous abortion
 Promote bed rest 
 “Miscarriage”
  Do not encourage to have a baby  Abnormal implantation of the zygote
again  outside of the uterus
 Guide when going to nursery (CODE  Incomplete abortion
PINK if a baby is missing)  Pain on one side (unilateral)
 Common in prostitution 
Blighted ovum Causes:
 Anembryonic pregnancy  PID 
 Positive fetal sac but no fetal heart  STD/STI that is recurrent and
tone since no baby untreated: Gonorrhea, syphilis,
 D&C chlamydia
 IUD - scar tissue in the uterus
 DES - fertility drug
Type of Cervic Bleedin Abdomi Diagnosis:
Abortion al g nal  UTZ - first choice
dilation crampi  Culdocentesis - aspiration of blood in
ng the pouch of Douglas (space
between rectum and vagina)
Threatened  Closed Spottin Mild
Treatment:
g
 Termination / Therapeutic abortion
o Medical abortion:
Inevitable/ Open Modera Modera
Imminent te and te and Misoprostol (Cytotec),
increasi increasi Mifepristone, Methotrexate 
ng ng o Surgical abortion:
amount Salphingostomy 

Incomplete Open Severe Severe

with
passa 2nd trimester:
ge of 1. Hydatidiform Mole
produc  Also called: Molar pregnancy or
ts of Gestational Trophoblastic Disease
conce  Proliferation of immature
ption trophoblastic tissue causing bleeding
 ↑ HCG is 1-2million units
Complete Closed Spottin Mild to
Possible causes:
after g none
 Previous history of H-mole
passa
ge of  Low protein (vegan)
all Pathognomonic sign:
conten  Hyperemesis gravidarum
ts - excessive vomiting during 2nd
trimester
Missed Closed Spottin Painles -Results to: Metabolic Alkalosis
g s Other manifestations:
 Bleeding - prune color 
Septic May or Malodo Malodo  Hypertension
may rous rous  Abdominal enlargement
not be vaginal crampi  FH: higher by at least 2inches (25-28
dilated bleedin ng inches)
g  No FHT
Diagnostic:
 Transabdominal Ultrasound: no fetal
2. Ectopic pregnancy
outline, no fetal sac, only grape-like
 “Tubal pregnancy”  clusters or snowstorm pattern
Treatment: 
  D&C Discharge teaching: 
 D & S (Suction)  Promote bed rest
Management:  Avoid heavy lifting, long
 Not give antiemetic because it will standing, hyperstimulation,
not solve problem of increased HCG breastfeeding
 Provide rest
3rd trimester:
Complication of Repetitive H-mole:
 Choriocarcinoma - worst type of
Placenta previa Abruptio placenta
cancer as it easily metastasizes 
Discharge teaching:
- painless bleeding  - painful bleeding /
 Advise them to use effective - abnormal Sharp sudden
method of contraception for implantation of the abdominal pain
at least 1 year placenta (low in the - abnormal
 Get HCG levels checked in uterus, closer to detachment /
the clinic before deciding to cervix) premature
get pregnant again removal of the
placenta from the
2. Incompetent cervix / “Cervical original site of
insufficiency” implantation
 Painless cervical dilation during
the late second trimester resulting to Causes: Fetus Causes: Maternal
miscarriage   Fetal  Maternal
 Dilates with or without contraction presentatio trauma
Causes: n (breech) (accident,
 Short cervix  Multiple violence)
- normal length: 20mm  gestation  Cocaine
 Short stature  - one (downer) 
 Cervical trauma placenta is  Pre-
- recurrent D&C correct, one eclampsia 
 Multigravida is abnormal  Smoking 
 Rape victims  Abnormal
 Heavy lifting (behavioral) = athletes length of
Manifestation: umbilical
 Painless bleeding cord
 Mild to moderate bleeding  Macrosomi
Complications: c (not
 Habitual abortion (3 consecutive enough
abortions) space)
Management:   Fertility
 Cervical cerclage drugs
- application of a strong suture
material to surgically close the cervix
a. Shirodtkar - gives birth via CS Other Other
- can carry full term manifestations: manifestations:
b. Mcdonalds - gives birth (Abdomen) (Abdomen)
either CS or NSVD  Soft  Hard
- preferable since temporary abdomen abdomen
- premature birth (36 weeks  Less (board-
latest) abdominal like
- cerclage is temporary so it cramping rigidity)
can only bear specific  More  More
amount of weight vaginal abdominal
Position of woman: lithotomy discharge cramping
 3 Types:
(placenta is  Less a. Partial apparent bleeding abruptio
near discharge placenta
cervical os) (placenta - since edge of placenta is detached
is far) b. Partial concealed bleeding abruptio
placenta
- intact edges but center part is
Management: detached
 Bed rest until delivery - blood goes to peritoneum
 Decrease stress by providing -  can manifest “Cullen’s sign” ->
comfort measures bluish color in the umbilicus 
 Blood transfusion: PRBC c. Complete concealed bleeding 
 Method of delivery: CS - more bleeding, more pain
 Administer antenatal - more 
corticosteroid 
￫ Purpose: fetal lung maturity by 3. Preterm labor
increasing surfactants (gas  Onset of true labor contractions
exchange)  promoting cervical dilation before
￫ Route: IM term (38 weeks of gestation)
￫ Site: ventrogluteal  Leading cause: maternal infection
￫ Dosage: 6mg (2x/day) or 12mg (UTI)
(once/day)  Other causes: dehydration, GDM,
￫ Give >28th week of gestation preeclampsia, PROM, multiple
￫ Note: Both drugs are gestation, stress, trauma, advancing
dangerous as they cross PBB age, poor nutrition
and fetal BBB  Manifestations: 
o Betamethasone - does o Backache
not cause periventricular o Increased vaginal discharge
leukomalacia
o Anxiety
(intracranial bleeding)
o Abdominal cramping and pain
o Dexamethasone -
o nauseous  and vomiting
causes periventricular
leukomalacia  Goal: Stop the uterine contractions
Avoid ff: 1. Tocolytics
 NPVagina: IE, TVS, vaginal a. Magnesium sulfate 
intercourse, tampon  b. Hydralazine 
c. Nifedipine
d. Terbutaline
1. Placenta previa  Nursing Care:
3 types: 1. Lateral position (L)
a. Marginalis 2. Promtoe bed rest
- tip of placenta is right off the edge 3. Decrease stimulation
of cervical os  4. Fetal monitoring
- can be pregnant and NSVD but can 5. Adequate hydration
cause bleeding Complications of Pregnancy 
b. Partialis
- 50% of cervical os is covered
- CS Type 1 DM Type 2 DM
c. Totalis
- cervical os is totally covered by  Juvenile  Adult
placenta onset onset
- will cause most amount of bleeding  Insulin  NIDDM
2. Abrutio placenta dependent  Insulin
(IDDM) resistant
 Destruction of
 6. Take 3rd CBG after 1 hour from the
beta cells
2nd CBG
 Genetic / 7. Compare findings
autoimmune Carpenter Coustan: at least 2
abnormal findings = GDM
1. Gestational Diabetes Mellitus FBS: <90mg/dL
 Impaired glucose tolerance induced First hour: <180mg/dL
by pregnancy  2nd: <155 mg/dL
3rd: <140mg/dL
 50% of women with GDM develop
Type 2 DM within 10 years  OHA: Insulin given parenterally to
 Happens only when a woman GDM clients (However, teratogenic
here in the Philippines) still answer
becomes diabetic DURING
insulin in the boards haha
PREGNANCY
 Subcu (arm) if pregnant 
 Onset: as early as late 2nd trimester
Collaborative Management
and late as early 3rd trimester (24-
1. Medications
28-32)
a. OHA (Type 2)
 Biguanides (Metformin)
Pathophysiology: b. Insulin (Type 1)
Pregnancy → increased hormones in the
 Parenteral
blood (HPL) → hyperglycemia → insulin
Preferred Site for p.
resisted by the blood
woman: Arm
Preferred: Abdomen
Negative effects of GDM:  Heat sensitive
a. Maternal  Short acting and
 Hyperglycemia Intermediate acting
 Infection  Needed more during the 3rd
o UTI trimester
o Candidiasis / Moniliasis  2. Diet/Nutrition
 PIH (pregnancy induced  Meal schedule: SFF (6
hypertension) meals a day)
 Placenta previa  Diet filled with more fruits
 Polyhydramnios and vegetables
 DKA  3. Activity/Exercise
B.  Fetal  Recommended to exercise
 Macrosomia when sugar is normal 
 Hyperglycemia  Lowers blood sugar
 Fetal distress 2. Pregnancy Induced Hypertension (PIH)
 Preterm birth   “Gestational Hypertension”
 Malpresentation of the fetus (breech)  Elevated blood pressure
 Cord compression  Expected BP: <130/90 mmHG
 A continuum of conditions involving
Note: OGTP; 3 hour; fasting bc FBS; 1st the adverse effects of having
thing in the morning; fast 6-8hrs during elevated blood pressure
midnight; after OGTP drink sugar water  Evolves from PIH to pre-eclampsia
(glucola 100g). After 1hr CBG, get the 2nd (mild/severe) severe leads to
hour CBG eclampsia (toxemia)
Continuum of conditions of PIH
Confirmation of GDM: 3-hour OGTT   Pre-eclampsia 
1. Fasting for 8 hours (after midnight) o Only known cure: delivery of
2. Take blood for FBS the fetus through cesarean
3. Give 100 gram of sugar (Glucola) section by preterm
4. Take first CBG after 1 hour o Limit of gestation is 5 with hx
5. Take 2nd CBG after 1 hour from first of preeclampsia
CBG
 Hypotonic Uterine Hypertonic Uterine
Inertia Inertia

 Weak  Strong and

contractions painful uterine
 Slow progress contractions
of labor  Rapid progress 4. Promote adequate
 Prolonged labor of labor <6 hrs hydration
 Most common  Precipitate  HELLP Syndrome
among labor  Systemic effect of PIH
primigravida  Most common  May cause DIC
 Given oxytocin among o Hemolysis: destruction of
or Methergine  multigravida RBC
 No tocolytics o Elevated liver enzymes
(ALT)
Mild  Severe o Low platelets
 
 Excessive weight gain (↑2  All symptoms of 3. Intrapartal / Labor Problems
lbs/week) mild
 Proteinuria (+1,+2)  Increasing deep
 Upper body edema: tendon reflexes
Periorbital edema, facial (DTR)
edema, hand edema  Severe headaches
 Blurring of vision
 Eclampsia (toxemia): grand 
o Seizures (grand
mal/general/izedtonic clonic)
 Causes low 02 to the fetus
known as UPI which leads to
fetal distress 4. Dystocia
 4-6 mins without 02 in the  Difficult labor
brain will lead to irreversible  Attributed to the 5Ps of labor
damage Problems:
o Magnesium sulfate (Drug of a. Passageway - small diameter and
choice) abnormal shape; CPD
 Antidote: calcium gluconate b. Passengers - intact ROM, transverse
 Anti convulsant/CNS fetal lie, extension fetal attitude,
depressant/Tocolytic breached  fetal presentation,
 Action: supresses electrical posterior fetal position, placenta
impulse delivery; prevents previa
seizures c. Powers- hypotonic UC, inability to
 Given during mild pre- push
eclampsia d. Position - incorrect maternal position
 Therapeutic serum level: 4- e. Psyche -  increased anxiety
7meq/L
 Signs of toxicity Goal: treat underlying problem/suggest
 Herald: absent patellar alternative
reflex 1. Amniotomy (AROM): resolves issue
 Others: ↓RR, ↓BP, ↓PR, of intact BOW
↓LOC, oliguria, cool 2. Cephalic version: manual
clammy skin manipulation of presentation of the
 Preventive measures of fetus by the OB
toxicity: 3. Surgical assistive deliveries:
1. Administer MGSO as
diluted in PNSS 100mL
per IV Forceps delivery  Vacuum
2. Use an infusion pump 
3. Monitoring for levels of  Application  of  Application of
serum magnesium traction to the suction
head via (negative
  Rapid growth and
forceps pressure) for
development
around 5-20
Developmental Milestone
minutes of
INFANCY
suction
Month1: Head lags/sags
pressure
Month 2: Social smile 
Month 3:Sidelying to front 
Month 4: Front to back
Month 5: Rollover
Month 6: Sits with support
Month 7: Transfer object from hand to hand
Month 8: Sits without support
Month 9: “Mama” “Dada”, pincer grasp, creep crawl
Month 10: Bring hands together, peekaboo, object
permanence
Month 11: Cruising
Month 12: Stands alone and walks with assistance,
“Mama, dada” plus 2 words,can drink from a
Pediatric Nursing cup
Month 15: : stands alone

GROWTH AND DEVELOPMENT Mild mental retardation: late walking

Growth: measurement, quantity TODDLER

Development: Maturation, quality
Theories of Growth and Development
1. Cephalo-caudal
 Head to toe
2. Proximo-distal
 Center to peripheral
3. Gross to fine motor skills
4. General to specific
 Deductive
5. Nature vs. Nurture
 Nurture: environment
 Nature: genetics
6. We do have the same pattern but
with different rate and time
Growth and Development
1. Infancy (0-1)
a. Neonate: first 28 days
b. Formal Infancy: 29th day-1
y.o.
 Most rapid growth and
developement
2. Toddler (1-3)
 Slow
3. Pre-schooler (3-6)
 Alternating growth and
development
4. School Age (6-12)
 Slower  2. Despair: sad and
5. Adolescent (12-18)
“TIRNS”
1. Toddler, Temper tantrums Toilet training
Toilet training has the ability to:
1. Sit, stand, walk, squat
2. Communicate with others
3. Maintain dryness every 2 hours
4. Readiness of the child
Additional:
 Bowel training is achieved first then
bladder training
 Day time training  (2 y.o) first then
night time bladder control (3 y.o.)
 Enuresis vs encopresis
2. Independence
3. Ritual, Ritualistic behavior, Regression
 Offer choices
4. Negativism, Nutrition: food jags
 Food jags aka physiological
anorexia
 Picky eaters
5. Security blanket, Stranger anxiety
before separation anxiety
 Stranger anxiety peaks at 8th
month
 Separation anxiety peaks at 18th
month
o Stages of separation anxiety
1. Protest: crying
withdrawn
 3. Denial/Detachment: stays  Opposite sex relationship
with someone else “I  Identity vs. role confusion
don’t believe”  Growth spurt: sudden increase or
Play change in the size of the body
 Universal language of a child  Women
1. Solitary Play (Infancy) o Increased size of the breast
 alone, solo play  Thelarche
 Pacifier is usually given o Widening of the hips
 Child uses their senses o Appearance of axillary and
 Food: oral gratification pubic hair
 Always think of the safety of  Adrenarche
the patient o Menstruation
2. Parallel Play (Toddler)  Menarche
 “Mirror”: side by side, same  Men
set of toys, withou o Increased in the size of penis
communication o Deepening of the voice
 Push-pull toys o Development of voice
3. Associative Play (Pre-schooler) o Appearance of axillary and
 They associate themselves pubic hair
as someone o Production of viable sperm
 ‘Imaginative play’
4. Competitive Play (School Age)
 ‘Competition
 Sports 

PRE-SCHOOL DEATH AND DYING

 Sibling rivalry  Pre-schooler
 Fear of Castration/ fear of mutilation o Death is temporary and
 Imaginary friend: present reality to reversible and brought about
the child by separation
 They love to ask why: answer  Schooler
questions of the child o Death is permanent,
 Fear of the child: ghost etc. irreversible
 Masturbation is common: divert the  Adolescent 
attention and provide hand held o Undergo grieving process
activities (DABDA)
 Exploration of his/her body
 Initiative vs. guilt Priority Needs on the first 24 hours of life
 Phallic  1. Airway and Breathing 
SCHOOL AGE  Suctioning 
 Slower growth and development o Mouth before nose 
 Same sex relationship; homosexual  Rule of five: 5-10s 10-15s
is common 20-30s 5mins
 Gang age o Before inserting
 School phobia (fear of bullying, suction, the port is
failure): desensitization/ orient child open
to the new environment  Signs and symptoms of
 Industry vs. Inferiority hypoxia:
 Concrete stage 7-11 years old o Feeding difficulties
(Cognitive theory) o Inspiratory stridor
o Classify, cohort and collect o Nasal flaring
o Conservation is positive o Expiratory grunting
o Seesaw respiration
ADOLESCENT (12-18 y.o)
 o Sternal border  ductus venosus
retraction - carries oxygenated or clean blood
Respiratory Distress Syndrome (RDS) - bypasses liver and inferior vena
 Also known as hyaline membrane cava
disease Note: Arteriosus, venosus, and
 Common in pre-term infants foramen ovale close immediately at
 Risk factor: amniocentesis  birth after you initiate crying. 
How to initiate crying:
Signs and symptoms of RDS:  Foot or sole slapping
 Retraction (earliest sign)  Suctioning
 Expiratory grunting  Immediate drying facilitates crying
 Cyanosis (Last sign)  Normal fetal cry: Loud lusty cry
 Abnormal fetal cry: 
o Hoarse cry
Score: 1-10
o High-pitched cry: Increased
 APGAR: High = bad; low = good
ICP, Hypoglycemia
 Silverman-Anderson: High = good
o Stable with bulging
(NO RDS); low = bad
RDS - abundant lanugo fontanelle
o Crying with bulging
fontanelle
LaryngotracheoBronchitis
 Inflammation of larynx, trache, and
bronchi SHOCK INCREASED
Signs and Symptoms ICP
 Crow-like cough
 Barking cough bleeding Normal ICP: 0-
 Hoarse cry 15 
 Inspiratory stridor (prominent at
night) Late Hypotension Hypertension
Nursing Management signs Tachycardia Bradycarida
Goal: Open the airway Tachypena  Bradypnea
 Bring the baby to bathroom and
provide warm shower
Epiglottitis Early Decreased Decreased
 If inflamed, it affects the whole upper sign LOC LOC
respiratory system
Manifestations - high pitched
S/S the same as tonsillitis cry
 Difficulty swallowing (dysphagia)
 Drooling of saliva
Management Position Trendelenburg Semi-
 Tripod position: Tongue out and fowlers(30-45)
lean forward
 Examination of the throat is
contraindicated Signs and symptoms:
Bedside   Projectile vomiting
 Tracheostomy set  Nursing management for Cord Care: 
 Cord is cry 
2. Circulation  Slough off in 7-10 days
 Cord care/ Fetal Circulation  Clean with 70% alcohol
Problems
 AVA (2 arteries, 1 vein)
1. Omphalitis: infection
Fetal Circulation
2. Ompholagia: bleeding
 Ductus arteriosus
3. Hemophilia: excessive bleeding
- carries oxygenated or dirty blood
(>30ml) problem in the clotting factor 
 a. Hemophilia A: Clotting factor 8
with a
(VIII)
period
b. Hemophilia B: Clotting factor 9
of
(IX)
apnea
c. Hemophilia C: Clotting factor 11
not
(XI)
lasting
3. Thermoregulation
for 15
 Heat loss is present which will lead to
second
cold stress
s
 Immature thermoregulation in
children which could lead to
metabolic acidosis, hypoglycemia,
and respiratory distress. Nursing Management:
 APGAR - 1st min, 5th min, 10th min  Cover the head first
 If severely depressed, perform CPR
Newborn Cardiopulmonary Resuscitation
 Suctioning plus additional oxygen
continue monitoring
 Brachial pulse if children
 Do not give too much oxygen to
prevent:
 retrolental fibroplasia
Normal Abno  retinopathy of prematurity
rmal (ROP) 
 Blindness
Appear Acrocya
ance nosis 4. Nutrition (Breastfeeding)
EO 51: Milk Code
*caused RA 10028: Expanded Breastfeeding Act
by  10 minutes each breast
sluggish  If feeding is stopped <10 mins,
circulati continue feeding on last breast to
on empty the breast
 Type of immunity: Natural Passive
Pulse 120 - IgA
160  Prolactin: stimulates aciner cells to
bpm produce milk 
 Gold: color of baby’s feces when
*180: breastfed
active
crying ADD ISA
*100: if
baby is
sleepy Cystic Fibrosis
 Exocrine gland disease
Grimac  Mucoviscidosis
e
Organs affected:
Activity a. Bronchioles
 Viscous mucus in bronchi
Respir 30-60 (obstruction)
ation bpm  There is an obstruction of the
bronchioles which could lead to lung
*regular collapse (atelectasis)
Management:
  Perform x-ray (atelectasis)
Colostru Transitiona Mature milk
b. Pancreas
m l milk
 Obstruction in pancreas which inhibit
release of pancreatic enzyme Da 1-4 days 4-14 days >14 days 
 related to Diabetes Mellitus (Type 1) y
Management:
 Give pancrelipase in a form of Protein La way?? FatCho
capsule for better absorption
 Can be given before meals Fat Lactose Fat
(ac) soluble consumptio
 Can be given WITH meals vitamins n
 (Vit.
A,D,E,K)
c. Small Intestine
 Obstruction which inhibits absorption IgA  Water
of fats (steatorrhea) and proteins Protein soluble 
(weight loss)
Management:
Reflexes to Assess CNS Integrity
 Monitor weight 
 Tonic neck reflex/ Fencing reflex
example. Infant with sunken fontanelle
(dehydration) → management. Monitor  Rooting reflex
weight  Anterior: Protrusion/extrusion reflex
 Give fat soluble vitamins (ADEK)  Posterior: Swallowing reflex
 For steatorrhea: 72-hour fecal fat  Middle: Sucking reflex
diet analysis  Moro/Startle reflex
Nutrition:  Palmar grasp reflex
 Increase caloric intake  Boxing reflex
 Increase protein  Tango reflex
 Increase sodium Foot Reflexes
 Moderate fat  Babinski reflex
Manifestation:  Plantar grasp reflex
 Salty sweat Disappear or will start to disappear:
Diagnostic test:  4 months: Palmar/ Sucking/Rooting
 Sweat chloride test: >60 mEq/L 5 months: Babinski
 Prenatal DNA analysis 6 months: Moro/Tonic neck reflex

Cystic Fibrosis and Celiac Disease Note: Exclusive breastfeeding up to 6 months

Both are:
 autosomal recessive Solid food:
 malabsorption disease 1. Rice cereals 
 Lifetime dietary modification 2. Fruits and vegetables 
3. Meat
 steatorrhea
4. Honey (1 y.o)
5. Egg yolk
Celiac Disease
 Gluten food sensitivity disorder
Nursing Management in Introducing Solid
 Can be given rice and corn Food:
Allergic to: DO NOT OFFER
 Introduce solid food one at a time
 B - barley with at least 1 week interval
 R - rye  Do not give Hepa A vaccine if child is
 O - oats allergic to aluminum hydroxide
W - wheatMILK  Do not give Hep B vaccine if child is
allergic to baker's yeast
  Do not give influenza and measles o pyloromyotomy: surgical
vaccine if child is allergic to egg procedure to repair pylorus
white  Intussusception: telescoping of the
colon; currant jelly-like stool,
5. Elimination sausage shaped mass
a. Meconium Note: megacolon and intussusception
 first stool of the newborn management is colonoscopy
 Blackish, greenish stool Management:
 Problem: Meconium Aspiration 1. Constipation is present thus barium
Syndrome enema will be done
o At risk: cephalic, post term 2. Position patient in left sim’s sidelying 
(>42 wks)
o Prepare suction at bedside Phototherapy
Preterm  Facilitate or speeds up maturation of
 20-36 weeks the liver
 Lanugo at 20 wks (fine downy hair)  Done since the baby has jaundice
 Absence of muscle tone  Pregnanediol: component of
 Frog leg breastfeeding that causes jaundice
 + Square window sign 90 degrees (expected)
angle  Stool: bright green
 Scarf sign  Direct sunlight
 + heel to ear extension Jaundice:
Post term  Pathological jaundice - first 24 hours;
 >42 weeks unexpected
 Old man’s face  Physiological jaundice - next 24
hours; expected
 Widened eyes
a. Indirect bilirubin - fat soluble
 Long brittle fingernails
b. Direct bilirubin 
 Desquamation (Glucuronyl transferase: converts
 Wrinkled skin indirect to direct bilirubin)

b. Bottle Feeding: Pale yellow stool
c. Hirschsprung disease: ribbonlike
stool
d. Intussusception: currant jelly like
stool
e. Cystic fibrosis and Celiac disease:
steatorrhea, fatty bulky stool
Gastric Motility Disorders
 Hirschsprung Disease
o Megacolon: large sigmoid
colon
o Anganglion: absence of
ganglion cells
 Pyloric stenosis
o between esophagus and
small intestine (narrowing of
pylorus)
o Left to right peristaltic
movement with olive shaped
mass in the RUQ
o causes: projectile vomiting
(nonbile/nonbilious vomiting)
Nursing management:
 Cover the eyes and the genitals
 Undress the child
 Turn child every 2 hours 
 Give IV fluids
 Do not give oil and lotion to prevent
burns
 Light placed 18-20 inches from the
baby
6. Prevention of Infection
PD 996 / RA 10152: Immunization
At birth: Hep B. and BCG
Vit K.: vastus lateralis
Heat sensitive: measles, OPV, BCG
Intradermal: 15 degrees, BCG, no massage,
no aspiration
IM: 90 degrees, hep b, DPT
Subq: measles, 45 degrees
Insulin: Subcu but in obese 90 degree angle
7.  Mother and Infant Relationship
RA 7600: Rooming In 
  Step 4: promote breastfeeding  Weight: 5.6-7.8 lbs (2500-3500g)
o Doubles in 6 months
8. Mental Stimulation and Rest o Triples during 1 year old
RA 9288: Newborn Screening Test o Quadruples during 2 years
- Secondary level of prevention old
- done next 24 hours; 48-72 hours At birth: 6lbs
- Heel prick test 6 months: 12 lbs
 Nurse SGA: below 10% percentile rank
- Primary prevention  AGA: above 90% percentile rank
Expected: physiological weight loss: loses 5-
Newborn Screening Diseases 10% of birth weight after 5-10 days in
a. PKU extrauterine life
 Phenylalanine cannot be
converted to tyrosine since Growth
PHT is missing  First 6 months: 1 inch/month
 At risk for mental retardation  Next 6 month: ½ inch per month
S/S:  Head
 blonde hair, blue eyes, fair
complexion Hydrocephalus
Mgmt:   Imbalance of CSF due to:
 Low phenyla formula o Malabsorption
b. Galactosemia o Obstruction
 Galactose in the blood  Normal CSF: 75-150cc
 GUPT is missing   Due to folic insufficiency 
Mgmt:  o Increased AFP may cause
 Give soya milk neural tube defects (spina
c. G6PD bifida)
 At risk for hemolytic anemia  Meningocele and
that may lead to death myelomeningocele
d. Congenital adrenal hyperplasia will lead to arnold-
 Increased male hormones chiari malformation
 At risk for mental retardation Two types of Hydrocephalus
S/S: 1. Communicating: Imbalance of CSF
 Dehydration is common due to malabsorption
 Sweating: Increased sodium 2. Non-communicating: imbalance of
loss CSF due to obstruction
e. Congenital hypothyroidism Signs and Symptoms
 Affects metabolism 1. Head circumference >35 cm
 Weight gain  2. Increased ICP 
 All are decreased except a. High pitched cry
weight and menstruation b. Hypertension
f. Maple Syrup Urine Disease  c. Bradypnea
d. Bradycardia
3. Projectile vomiting
4. Bossing sign
Cephalocaudal Assessment with Deviation 5. Sun set eyes
from the Normal 6. Upon percussion, cracked-pot sound
(Macewen’s sign)

Anthropometric Measurement Average Management/Intervention

 Head circumference: 34 cm 1. Preoperative: hyperventilate the child
 Chest Circumference: 32 cm 2. Ventriculoperitoneal Shunt “Shifting”
 Abdominal Circumference: 32 cm 3. Postoperative: Position child on
 Length average: 50 cm unoperative side (Supine)
 4. Give osmotic diuretics (mannitol)
Mouth Disorders
Fontanelles
Expected:  Disorders with the same causative agent
 Anterior fontanelle: bregma (GAHBS): Tonsillitis, RHF and AGN
o Closes after 12-18 months
 Posterior fontanelle: lambda 1. Tonsillitis 
o Closes after 2-3 months
 Inflammation of the tonsils 
 Caput succedaneum: crosses the Signs and symptoms:
suture line  Dysphagia
Eyes  Drooling
Expected:
 Reddened tonsils
 Subconjunctival hemorrhage
Tonsillectomy: removal of tonsils
o Brought about by tiny
Post tonsillectomy
bleeding in the capillaries  Prone or side lying position
Management:
 Assess frequent swallowing
 Crede’s maneuver
 Do not offer:
 Give Erythromycin (eye ointment)
o hot drinks/food 
from inner to outer canthus 
o color red/dark food
o citrus juices
o Anticoagulants
 Conjunctivitis  Best 1st thing to offer: clear liquid
o Red eye, pink eye, sore eyes diet, then gelatin 
Management:  After: cold drinks/ food
 Give cold compress

Nose
2. Rheumatic heart fever (acquired)
 Nose obligatory breathers
 Jones Criteria: used to assess for
Ears 
RHF
Pulling the pinna:
o Major criteria:
 Below 3 y.o: pull pina down and up
 Polyarthritis
 Above 3 y.o: pull up and back  Erythema marginatum
 Otitis media  Carditis
o Inflammation of the middle  Chorea
ear  Subcutaneous nodules
o Children more at risk since o Minor criteria:
short and wider eustachian  Arthralgia
tube (horizontal)  Increased WBC
o To assess: pull the affected  Increased ASO
ear   Increased ESR
o To assess ear pain: Wong  Question to ask mother: did the child
and Baker’s Scale have tonsillitis/sore throat  2 weeks
Management: ago?
 7 days full course antibiotic therapy
3. Acute glomerulonephritis 
 Kidneys are affected
Mouth Characteristics of child urine
Teeth  Tea colored urine
 6 months: 2 lower central incisor   Smoky urine
 7 months: 2 upper central incisor Signs and symptoms:
 9 months: 2 upper lateral incisor  Proteinuria
 11 months: 2 lower lateral incisor  Edema (Upper extremities)
 6 y.o: permanent teeth erupts o Puffy eyelids
 o Periorbital edema 1. Atrial septal defect:
 Hypertension >140/90  failure of the foramen ovale to close
 POH: proteinuria, hematuria, oliguria  Systolic murmur on the upper border
of the heart
4. Cleft lip/ Cleft Palate  Right atrium hypertrophy will occur
 Not all who have CL has CP, but all 2. Ventricular septal defect 
CP have CL  Systolic murmur on the lower border
 CL is done first before CP of the heart
 Repair is usually before on 6 months  Right ventricular hypertrophy will
since introduction of food is on 6 occur
months  Most common coronary heart
 Cleft Lip disease
o usually male  Most common manifestation: growth
o Cheiloplasty and retardation
Management:  Dacron patch
 Goal: avoid tension in the 3. Coarctation of the aorta
suture line  Aortic bypass graft with balloon stem
 Supine
 Cleft Palate:  Extremitie BP Temp. Pulse Bleeding
o usually female s
o palatoplasty/uranoplasty
Upper Hig Warm Boundin epistaxis
o “Bawal tuslokon” h g pulse
Management:
 Goal: avoid tension in the Lower Low Cold With or Vaginal
suture line absent bleeding
femoral
 Prone or side lying pulse 
Nutrition Preoperatively:
 Enlarge nipple of the bottle
 Stimulate sucking reflex 4. Patent Ductus Arteriosus: failure to
 Swallow then close
 Rest Signs and Symptoms:
 Acyanotic
 Radial pulse is prominent 
LIP PALATE  Machinery murmur like
Drug of choice: Indomethacin 
When 1-2 months On or before 6
months  Cyanotic Disorder
 Right to left shunting: does not pass
At risk Abdominal colic aspiration the lungs so cyanotic
Tetralogy of Fallot
Save Sucking ability speech 1. Pulmonary arterial stenosis: blood
returns
Food breastfeeding Solid food  2. Right ventricular hypertrophy:
enlargement
Used to Rubber tipped Paper cup or
3. Overriding of the aorta: blood exits
feed syringe soup spoon
heart
4. Ventricular septal defect: flow of
Cardiac Disorder blood goes to the left 
 Left to right shunting: passes the 5.
lungs so acyanotic; right  Signs and Symptoms:
hypertrophy will occur  Blue spells
 Right to left shunting: does not pass  Clubbing of fingers
the lungs so cyanotic  Polycythemia vera 
Acyanotic Disorders  Blalock-taussig Procedure
Management
 Infant: knee chest position
 Older child: squatting position

Genito-urinary Disorder

Cryptorchidism: 
 undescended testes
 Normal descent: 7 months
 Operation: Orchiopexy/orchidoplasty
 Wait until 1 year old
o Testes may descend into the
scrotum by this period
o Purpose of repair: to prevent
sterility
 Lateral curvature of the penis:
chordee

Hypospadia: opening on the ventral side

Epispadia: opening on the dorsal side

Management:
 Do not circumcise as the foreskin will
be used as a patch

Test Taking Strategies:

KAPMAN
K=keywords
A=assessment vs Implementation
P=physical vs psychosocial
M=maslow’s hierarchy of needs
A=ABC
N=need to evaluate your answer first
S=smart/Safety

Law of Prioritization:
1. Physical vs psychosocial
2. Unstable vs stable patient
3. Unexpected vs expected
4. Acute vs. Chronic
5. Triage (Life threatening situation)