BRYNDYLL S NOTES ꒱࿐ ˚.

*ೃ

1ST ROT: IMCI

 BRYNDYLL S NOTES ꒱࿐ ˚.*ೃ

OBJECTIVES OF IMCI
o To reduce significantly global morbidity and
INTEGRATED MANAGEMENT OF CHILDHOOD
mortality
ILLNESS
o To contribute to a healthy growth and
development of children
TIMELINE
1995: IMCI was developed by WHO-UNICEF to all
MAJOR COMPONENTS OF IMCI
developing countries
o Improving case management skills of health
1997: IMCI was brought to the Philippines thru the
worker and health facilities
DOH
o Improving the health systems to deliver IMCI
2001: integration of IMCI to nursing and midwifery
- Ensuring the availability of essential
curriculum (attended by the academe from
drugs and other supplies
different nursing and midwifery school)
- Improving the organization of work at
the health facility level
EDUCATIONAL INSTITUTION: PILOT SCHOOLS
- Improving and monitoring and
(INITIAL)
supervision
o Improving family and community health
1. NURSING EDUCATION practices
o MINDANAO: san pedro college, davao city
o VISAYAS: st. paul college, Iloilo city
IMPORTANT ELEMENTS FOR IMPROVING CHILD
o NCR: university of sto. Tomas, manila baliuag
HEALTH
university, baliuag, bulacan
o Improve case management of sick children
o Improve nutrition
REASONS FOR DEVELOPING IMCI
o Ensure immunization
o Curative care o Prevent injuries
o Aspect of nutrition o Prevent other diseases
o Immunization o Improve psychosocial support and
o Disease prevention stimulation
o Health promotion
IMCI CASE MANAGEMENT PROCESS
IMCI 1. Assess
IS AN INTEGRATED APPROACH TO CHILD HEALTH 2. Classify
THAT FOCUSES ON THE WELL-BEING OF THE WHOLE 3. Identify treatment
CHILD 4. Treat
o A strategy for reducing mortality and 5. Counsel the mother
morbidity associated with major causes of
childhood illness STEPS IN CASE MANAGEMENT PROCESS
o A joint WHO/UNICEF initiative since 1992
o Currently focused on first level health facilities
1. ASSESS the child or young infant
o Comes as a generic guideline for
- Taking a history and doing a physical
management which have been adapted to
examination
each country
2. CLASSIFY the illness
- Making a decision on the severity of the
illness
3. IDENTIFY treatment
- The charts recommend appropriate
treatment for each classification
4. TREAT the child
- Giving treatment in health center,
prescribing drugs or other treatments to
be given at home, and also teaching
the mother how to carry out the
treatment
 BRYNDYLL S NOTES ꒱࿐ ˚.*ೃ

- If in doubt, offer the child water

ASSESS AND CLASSIFY COUGH OR DIFFICULT

BREATHING
o COMMON CAUSES OF PNEUMONIA
- Streptococcus pneumoniae
o CAUSE OF DEATH
- HYPOXIA: too little oxygen
- SEPSIS: generalized infection

MAIN SYMPTOMS
o Cough or difficulty in breathing
o Diarrhea
o Fever
o Ear problem

PNEUMONIA
- Is inflammation of the airspaces in the lungs,
AGE BRACKET most commonly due to an infection
o 1 WEEK 2 MONTHS: sick young infant - Pneumonia may be caused by viruses,
o 2 MONTHS 5 YEARS: sick child bacteria, or fungi; less frequently by other
causes
ASSESSMENT - S/S: fever, chills, cough, shortness of breath,
1. DETERMINE WHICH AGE GROUP THE CHILD and fatigue
BELONGS:
o Birth up to 2 months ASSESS COUGH OR DIFFICULT BREATHING
o 2 months up to 5 years o How long the child has had cough or difficult
2. ECO D HE CLIEN DA A: breathing
- Name, age in months, weight in kg, o Fast breathing
temperature, etc. o Chest indrawing
3. A K HE MO HE HA HE CHILD P OBLEM o Stridor in calm child
ARE:
- Listen carefully to what the mother tells NOTE:
you 1. If the child is asleep and has cough or
- Use words the mother understands difficult breathing, count the number of
- Give the mother time to answer the breaths first before you try to wake the child
questions 2. If there is any general danger sign, complete
- Ask additional questions when the the assessment and any pre-referral
mother is not sure about her answer treatment immediately so referral is not
4. DETERMINE IF THIS IS AN INITIAL VISIT OR delayed
FOLLOW-UP VISIT: 3. A child with any general danger signs needs
o INITIAL VISIT: 1st visit for this episode of an URGENT attention: complete the assessment
illness or problem and any pre-referral treatment immediately
o FOLLOW-UP VISIT: the child has been so referral is not delayed
seen a few days ago for the same illness o DOES THE CHILD HAVE COUGH OR
DIFFICULT BREATHING?
GENERAL DANGER SIGNS - Yes/no
o Not able to drink of breastfeed o FOR HOW LONG?
o Vomits everything o COUNT THE BREATHS IN 1MINUTE
o Convulsions - Cut-off for fast breathing
o Lethargic or unconscious 2 MONTHS UP TO 12 MONTHS
o Convulsing now MORE: 50 breaths per minute
12 MONRHS UP TO 5 YEARS: 40
CHECK FOR GENERAL DANGER SIGNS breaths per minute
o NOT BEING ABLE TO DRINK OR BREASTFEED THE CHILD WHO IS EXACTLY 12
- Too weak to drink and is not able to MONTHS OLD HAS FAST BREATHING
suck or swallow when offered a drink or IF YOU COUNT 40 breaths per
breastmilk minute or more
o VOMITS EVERYTHING o LOOK FOR CHEST INDRAWING
- A child is not able to hold anything
down at all
 BRYNDYLL S NOTES ꒱࿐
- The lower ribs on both sides of the
chest are pulled in when the child
breathes in
- Lower chest walls goes IN when the
child breathes IN
- It must be clearly visible and
present all the time
o LOOK AND LISTEN FOR STRIDOR
- A harsh noise made when the child
breathes IN
- Put your ear near he ch d h
because stridor can be difficult to
hear
- WHEEZING: harsh noise while
breathing OUT; not stridor
- Look and listen for stridor when the
child is calm
THE CLASSIFICATION
- The classification table on the assess and
classify have 3 rows
- COLORS of the ROWS helps to IDENTIFY
RAPIDLY whether the child has a SERIOUS
DISEASE requiring URGENT ATTENTION
COLOR CODING
PINK: urgent pre-referral treatment and referral
YELLOW: specific medical treatment and advice
GREEN: simple advice on home arrangement
*the child is classified only once in each
classification table
˚.*ೃ
*chest indrawing belongs in the YELLOW
category
DIARRHEA
- Defines as 3 or more loose or watery stool in a
24-hour period. More water than normal
TYPES:
o ACUTE DIARRHEA: diarrhea lasts less than 14
days
o PERSISTENT DIARRHEA: diarrhea lasts 14 days
or more
o DYSENTERY: diarrhea with blood in the stool,
with or without mucus. Shigella bacteria
*red stool: lower git problems
*black, tarry stool: upper git problems
ASSESS FOR:
o How long the child has had diarrhea
o Blood in the stool to determine if the child
has dysentery
o Signs of dehydration
o ASK:
- Does the child have diarrhea?
- For how long?
- Is there blood in the stool?
o L a he ch d ge e a c d
- If the child is lethargic or unconscious
- A child has the sign restless and irritable
o Look for sunken eyes
 BRYNDYLL S NOTES ꒱࿐
o Offer the child fluid
- NOT ABLE TO DRINK: if he is not able to
take fluid in his mouth and swallow it
- DRINKING POORLY: if the child is weak
and cannot drink without help
- DRINKING EAGERLY, THIRSTY: reaches out
for the cup or spoon when you offer
water. Wants to drink more
o Pinch the skin of the abdomen
- L ca e he a ea he ch d
abdomen halfway between the
umbilicus and the side of the abdomen
VERY SLOWLY: longer than 2 seconds
SLOWLY: skin stays up even for a brief
instant
IMMEDIATELY
FEVER
MALARIA
- Malaria is an infectious disease caused by a
parasite, plasmodium (causative agent)
- Mosquito borne infectious disease:
anopheles mosquitoes
- Four species of plasmodia: PLASMODIUM
FALCIPARUM (most common)
o P. VIVAX
o P. OVALE
o P. MALARIAE
- Fever is the main symptom of malaria
˚.*ೃ
DECIDING MALARIA RISK
- Child lives in malarious area or
- Has been in a malaria risk area in the past 4
weeks
- PD ORDER 123-S 2002 all the provinces in the
country are categorized according to
malaria situation
- CATEGORY A provinces with no significant
improvement in malaria situation worsened in
the late 5 years, average number of cases of
more than 1000 in the last 10 years
o Davao del sur/norte/oriental, agusan del
norte/del sur, sulu, palawan, Bukidnon,
Cagayan, Zamboanga del sur, tawi-tawi,
misamis oriental, saranggani, basilan
MEASLES
- Rubeola
- Measles is a highly contagious viral disease
that can be fatal
- Is an infection of the respiratory system
ca ed b a PARAMYXOVIRUS
- Fever and a generalized rash are the main
signs of measles
- Most cases occur in children between 6
months and 2 years of age
- Complications of measles occur in about
30% of all cases. The most important are:
o Diarrhea (including dysentery and
persistent diarrhea)
o Pneumonia
o Stridor
o Mouth ulcers
o Ear infection
o Severe eye infection (which may lead to
corneal ulceration and blindness)
o 3CS
Cough
Coryza
Conjunctivitis
o Pa h g c g : KOPLIK S SPOT
- They are small, white spots (often
on a reddened background) that
occur on the inside of the cheeks
early in the course of measles
DENGUE HEMORRHAGIC FEVER
- Dengue is a mosquito-borne viral infection
- Primary vector: AEDES AEGYPTI mosquito
- Causes flu-like illness, and occasionally
develops into a potentially lethal
complication called severe dengue
SYMPTOMS:
o Headache, muscle and joint pain, petechiae
(small red spots that do not disappear when
the skin is pressed, which are caused by
broken capillaries)
 BRYNDYLL S NOTES ꒱࿐
o Children may bleed from the mouth or nose
or may vomit black fluid or may pass black
stools
*if may dysentery, automatic na red na siya
bc may bleeding sa dengue
o The most severe signs of DHF often occur in
the 2 days after the fever has disappeared
TREATMENT:
- There is no specific treatment for
dengue/severe dengue, but early detection
and access to proper medical care lowers
fatality rates below 1%
- Dengue prevention and control solely
depends on effective vector control
measures
ASSESS FEVER
o ASK: does the child have fever?
- Check to see if the child has a history of
fever, feels hot or has a temp. of 37.5C
or above
o DECIDE THE MALARIA RISK
- To classify and treat children with fever,
you must know the malaria risk in your
area
o ASK: for how long? If more than 7 days, has
fever been present every day?
- Fever present every day for more than 7
days may indicate severe disease such
as thypoid
o ASK: has the child had measles within the last
3 months?
- May have an infection due to
complications of measles such as an
eye infection
o LOOK OR FEEL FOR STIFF NECK
- A child with fever and stiff neck may
have meningitis
o LOOK FOR RUNNY NOSE
- A runny nose in a child with fever may
mean that the child has a common
cold
˚.*ೃ
o LOOK FOR SIGNS SUGGESTING MEASLES
- Asses a child with fever to see if there
are signs suggesting measles. Look for a
generalized rash and for one of the ff
signs: cough, runny nose, or red eyes
o LOOK FOR MOUTH ULCERS. Are they deep
and extensive?
o LOOK FOR PUS DRRAINING FROM THE EYE
o LOOK FOR CLOUDING OF THE CORNEA
ASSESS DENGUE
o Has the child had any bleeding from the
nose or gums, in the vomitus or in the stool
since the present illness started?
o Has the child had black vomitus in this illness?
o Has the child had black stools?
o LOOK and FEEL for signs of bleeding
- Bleeding manifestations (bleeding from nose
and gums. Dried blood in the nostrils)
- Skin petechiae
o Look and feel for signs suggesting shock
o Cold clammy extremities
o Slow capillary refill
TORNIQUE TEST
- This gives a good indication for assessing the
blood vessels and whether it will lead to
Dengue Shock Syndrome (DHS) Or Dengue
Hemorrhagic Fever (DHF). This test involves
checking what are known as petechiae
- CRITERIA
o Child is not in shock
o Has no signs of bleeding
o Has no abdominal pain
o And 6 months older and has fever for
more than 3 days
- PROCEDURE
o Pump up a blood pressure cuff on one
of the arm to more than venous pressure
o 70 mmHg
o Keep it for 5 minutes and then ease the
pressure
o Examine the extremity of the pressure for
petechiae
 BRYNDYLL S NOTES ꒱࿐ ˚.*ೃ

o If there are more than 20 petechiae, the o KWASHIORKOR: protein malnutrition

test is POSITIVE predominant
o MARASMUS: deficiency in both calorie and
EAR PROBLEMS protein nutrition
o MARASMIC KWASHIORKOR: marked protein
CLINICAL ASSESSMENT deficiency and marked calorie insufficiency
o Tender swelling behind the ear signs present, sometimes referred to as the
o Ear pain most severe form of malnutrition
o Ear discharge or pus
MARASMUS
CLASSIFICATION - THE CHILD IS JUST SKIN AND BONES. This child
o MASTODITIS: Is usually caused by a middle needs more food especially energy foods
ear infection (acute otitis media). The
infection may spread from ear to the mastoid
bone of the skull
o ACUTE EAR INFECTION: Pus draining from the
ear and discharge has been present for less
than 2 weeks

KWASHIORKOR
- THE CHILD IS SKIN, BONES, AND WATER
- This child needs more food more often a lot
of foods rich in energy, and some foods rich
in protein

MALNUTRITION
- Is the condition that results from taking an
unbalanced diet in which certain nutrients
are lacking
- PROTEIN-ENERGY MALNUTRITION (or protein-
calorie malnutrition) refers to a form of
malnutrition where there is inadequate
protein intake LOOK FOR PALMAR PALLOR
- Unusual paleness of the skin
TYPES
 BRYNDYLL S NOTES ꒱࿐ ˚.*ೃ

o SOME PALMAR PALLOR: if the skin of the - Give every child a dose of vitamin A every 6
ch d a ae months from the age of 6 months. Record
o PALMAR PALLOR: if the skin of the palm is he d e he ch d cha
very pale so that it looks white *compare the
hand with your own, or with a bond paper ROUTINE DEWORMING
- Give every child MEBENDAZOLE or
LOOK AND FEEL FOR EDEMA OF BOTH FEET ALBENDAZOLE every 6 months from the age
- A child with edema of both feet may have of one year
kwashiorkor. Other common signs of
kwashiorkor include thin, sparse and pale hair ORAL HEALTH
that easily falls out; dry, scaly skin especially - Advice mother to bring the child to a dentist
on the arms and legs; and a puffy or every 6 months for dental check-up from the
face age 6 months
- Use your thumb to press gently for a few
seconds on the top side of each foot, the IMMUNIZATION SCHEDULE
child has edema if a dent remains in the
ch d f he f h b

DETERMINE WEIGHT FOR AGE

- Look at the weight for age chart in the IMCI
chart booklet. To determine weight for age:
1. Ca c a e he ch d age h
2. Weigh the child f he has not already
been weighed today
3. Use the weight for age chart to
determine weight for age
4. Decide if the point is ABOVE, ON, or
BELOW the bottom curve
a. if the point is BELOW THE BOTTOM
CURVE, the child is NOT VERY low GOLDEN RULE
weight for age - There are no contraindications to
immunization of a sick child if the child is well
CHECK FOR ACUTE MALNUTRITION enough to go home
LOOK AND FEEL - If a child is going to be referred, do not
o look for signs of acute malnutrition immunize the child before referral. The
o look for edema of both feet hospital staff at the referral site should make
o determine WFH/L___ z-score the decision about immunizing the child
o measure MUAC ___mm in a child 6 months or when the decision about immunizing the
older child when the child is admitted. This will
avoid delaying referral

CONTRAINDICATIONS TO IMMUNIZATION
o Do not give BCG to a child known to have
AIDS
o Do not give DPT 2 or DPT 3 to a child who has
had convulsions or shock within 3 days of the
most recent dose
o Do not give DPT to a child with recurrent
convulsions or another active neurological
disease of the central nervous system
o Children with diarrhea who are due for OPV
should receive a dose of OPV (oral polio
vaccine) during this visit. However, do not
count the dose. The child should return when
the next dose for OPV is due for an extra
dose of OPV
CHECK THE IMMUNIZATION, VITAMIN A,
DEWORMING STATUS, AND ORAL HEALTH

VITAMIN A SUPPLEMENTATION
 BRYNDYLL S NOTES ꒱࿐ ˚.*ೃ

COUNT THE BREATHS IN ONE MINUTE.

REPEAT THE COUNT IF ELEVATED
LOOK FOR SEVERE CHEST INDRAWING
- Severe chest indrawing is very
deep and easy to see
- Severe signs of chest indrawing is a
sign of pneumonia and is serious in
a young infant *because
sometimes if infants cry there might
be chest indrawing bc their chest
wall is still soft; thus, in checking, we
need to calm the infant down
LOOK AT THE UMBILICUS IS IT RED OR
DRAINING IN PUS? DOES THE REDNESS
EXTEND TO THE SKIN?
- There may be some redness of the
end of the umbilicus or the
umbilicus may be draining pus
- If the redness extends to the skin of
the abdominal wall, it is a serious
infection

NUTRITIONAL STATUS

CLINICAL ASSESSMENT
o Edema of both feet
o Weight for age
o Palmar pallor
SICK YOUNG INFANT *cord usually drops around 1 week = 10 days
BIRTH TO 2 MONTHS
o FEEL: MEASURE THE TEMPERATURE (OR FEEL
ASSESS AND CLASSIFY FOR FEVER OF LOW BODY TEMPERATURE)
o Check for signs of possible bacterial - Fever (axillary temperature more than
infections 37.5℃ or rectal temperature more than
o Classify jaundice 38.0℃)
o Ask about the diarrhea (dehydration and - If a young infant has fever, this may
persistent diarrhea) mean the infant has a serious bacterial
o Check for feeding problem or low weight infection
o Chec he g fa a a - If you do not have a thermometer, feel
and vitamin A status he fa ach a a ( de a )
o Assess any other problems and determine if it feels hot or unusually
cool
POSSIBLE BACTERIAL INFECTION o LOOK:
*bacterial = low grade fever LOOK FOR SKIN PUSTULES. ARE THERE
*viral = high grade fever MANY OR SEVERE PUSTULES?
- are red spots or blisters that contain
*infants s all don t ha e fe er if ma infection pus

o ASK: is the infant having difficulty in feeding?

HAS THE INFANT HAD CONVULSIONS?
o LOOK:
 BRYNDYLL S NOTES ꒱࿐
LOOK AT THE YOUNG INFANT S
MOVEMENTS. ARE THEY LESS THAN
NORMAL?
- Does the infant move on his/her
own?
- Does the infant not move at all?
*how to wake up an infant: move or touch the
arms or legs of infant; slowly and gently turn head
several times; pikpik
JAUNDICE
- I a e d c a a e b bab
skin and eyes. Infant jaundice occurs
beca e f he bab b d contains an
excess of bilirubin
*incubate baby if may jaundice
CLASSIFICATION
o PHYSIOLOGIC: jaundice occurs more than 24
hours after both *normal
o PATHOLOGIC: jaundice occurs less than 24
hours after birth *may infection si infant
possibly
ASK:
- Is the infant breastfed? If yes, how many
times in 24 hours?
- Does the infant usually receive any other
foods or drinks? If yes, how often?
- What do you use to feed the infant? *utensils
should be INFANT-FRIENDLY
*infant should be EXCLUSIVELY breastfed for 6
months; meaning no other intake of food or
water
FEEDING PROBLEM OR LOW WEIGHT
2 PART ASSESSMENT
1. Determine difficulty feeding the infant, what
the young infant is fed and how often *cleft
lip = bungi; may cause bloating of stomach
2. Any problems with breastfeeding or is low
weight for age
˚.*ೃ
ASSESS BREASTFEEDING
o DO NOT assess breastfeeding:
- If the infant is exclusively BF without
difficulty and is not low weight for age
- If the infant is not breastfed at all
- If the infant has a serious problem
requiring urgent referral to a hospital
o Is the infant able to attach?
Not well attached
Good attachment
SIGNS OF GOOD ATTACHMENT
- Chin touching breast
- Mouth wide open
- Lower lip turned outward
- More areola visible above than below the
mouth
o Is the infant sucking effectively?
Not sucking effectively *rapid, shallow
sucks; indrawing of cheeks
Sucking effectively *slow, deep sucks,
sometimes pausing
o Clear a blocked nose if it interferes with BF
o Look for ulcers or white patches in the mouth
- Thrush milk curds on the side of the
cheek or thick white coating of the
tongue
INFAN IMM NI A ION A
*recommended by WHO to improve maternal
health status; vitamin A is injected to the mother
IDENTIFY TREATMENT
o Determining if urgent referral is needed
o Identifying treatments needed
o For patients who need urgent referral:
Identifying the urgent pre-referral
treatment
- Explaining the need for referral to
the mother
- Writing the referral note
REFERRAL NOTE
o Date and time of referral
o Name and age of the child
o De c f ch d be
o Reason for referral
o Treatments that was given
 BRYNDYLL S NOTES ꒱࿐
o Name, name of the health center and
address
TREAT
1. GIVE AN APPROPRIATE ORAL ANTIBIOTIC
o General danger sign
o Severe pneumonia or very severe
disease
o Pneumonia
o Severe dehydration
o Dysentery
o Very severe febrile disease / malaria
o Very severe febrile
o Severe complicated measles
o Mastoiditis
o Acute ear infection
o Sick young infant: local bacterial
infection
*cotrimoxazole are not given to infants bc it has
too many components. Infants have immature
and sensitive liver thus it is hard for them to break
down cotrimoxazole and cause brain damage
due to high bilirubin levels
2. GIVE ORAL ANTI-MALARIA
- FIRST LINE: Artemether-Lumefantrine
- SECOND LINE: Chloroquine, Primaquine,
Sulfadoxine, Pyrimethamine
o CHLOROQUINE: given for 3 days, itching
is the possible side effect
o SULFADOXINE, PYRIMETHAMINE: give a
single dose 2 hours before intake of
Chloroquine
˚.*ೃ
o PRIMAQUINE: give single dose on day 4
for P. falciparum, not given to children
under 12 months of age
o QUININE for severe malaria: 1st dose IM
Quinine for children with very severe
febrile disease / malaria; NO to a child
less than 4 months of age
3. PARACETAMOL FOR HIGH FEVER (38.5 OR
MORE) OR EAR PAIN
o Lowers fever and reduces pain
o Every 6 hours until high fever or ear pain
is gone
4. GIVE VITAMIN A
o Severe pneumonia
o Very severe disease
o Severe persistent diarrhea
o Persistent diarrhea
o Measles
o Severe malnutrition very low weight
- Helps resist the measles virus infection as well
as in the layers of cells that line the lungs
- Prevents progress to blindness
6 MONTHS TO 12 MONTHS: 100,000 IU
12 MONTHS UP TO 5 YEARS OLD: 200,000
IU
5. GIVE IRON
- A child with some palmar pallor
o 12 MONTHS OF AGE: syrup/drops
o 12 MONTHS OLDER: iron folate tablets
o Give 1 dose for 14 days
- NOTE: if a child with some palmar pallor is
receiving sulfadoxine pyrimethamine
(fansidar), do not give iron/folate tablets until
the follow up visit in 2 weeks
6. GIVE MEBENDAZOLE / ALBENDAZOLE
o Routine worm treatment
o Hookworm or whipworm, anemic child
who is 1 year of age or older
o Give 500mg mebendazole (or 400mg
albendazole) as a single dose in the
health center if the child is 12 months up
to 59 months and has not had a dose in
the previous 6 months
7. GIVE MULTIVITAMINS AND MINERALS
o For persistent diarrhea
o With RENI (folate, vitamin A, zinc,
magnesium, and copper)
o Every day for 2 weeks
8. GIVE SALBUTAMOL
o For wheezing *if the child is having cough
and fast breathing, this is given for every
15 mins. If Nawala, pwede siya hindi I
classify as pneumonia
TEAT LOCAL INFECTIONS AT HOME
1. TREATMENT EYE INFECTIONS WITH
TETRACYCLINE OINTMENT
o For severe complicated measles
(clouding of the cornea)
o Treat until redness is gone
 BRYNDYLL S NOTES ꒱࿐ ˚.*ೃ

o Both eyes should be treated to prevent

damage to the eyes
o Slightly sting the eyes
o TELL THE MOTHER TO:
- Wash her hands before and after
treating the eye
- C ea he ch d e e
- Apply 3x a day
o SHOW THE MOTHER TO:
- Pull the lower lid of the eye
- Have someone to hold the child still
- Make sure the mother sees where to
apply the ointment and the amount
2. DRY THE EAR BY WICKING AND INSTILL
QUINOLONE DROPS
o Dry the ear at least 3x a day
o Instill quinolone after dry wicking, 2-3
drops 3x a day for 2 weeks (aka otic
drops)
3. TREAT MOUTH ULCERS WITH GENTIAN VIOLET
o Measles with mouth complications
o Treating will control infection and help
child to eat
o Pain GV 2x a day for 5 days

*gv is also yung ginagamit for mumps noon

4. SOOTHE THE THROAT, RELIEVE THE COUGH

WITH SAFE REMEDY
o RECOMMENDED:
Breastmilk for exclusively breastfed
infants
Calamansi juice, tamarind, ginger
(SLK)
o HARMFUL REMEDIES:
Codeine cough syrup
Other cough syrup
Oral and nasal decongestants
 BRYNDYLL S NOTES ꒱࿐ ˚.*ೃ

2 ROT:
ND PEDIA
 HIGH I K NE BO N

P OBLEM ELA ED O MA I

E E M NE B N
De crip ion: A neona e born before 37 eek of ge a ion
Primar concern rela e o imma ri of all bod em
Ca e: nkno n
Ma ernal fac or : age, moking, poor n ri ion, Placen al problem , Preeclamp ia/ eclamp ia
Fe al fac or : m l iple pregnanc , infec ion
O her fac or : poor ocioeconomic a , en ironmen al e po re o harmf l b ance

A e men
Re pira ion are irreg lar i h period of apnea
Bod empera re i belo normal
Skin i hin, i h i ible blood e el and minimal bc aneo fa pad , ma appear
ja ndiced (Poikilo hermic-ea il ake on he empera re of he en ironmen )
Poor cking and allo ing refle e
Bo el o nd are dimini hed

Common or pecial problem of pre erm neona e

1. Re pira or Di re S ndrome
H aline membrane di ea e
d e o l ng imma ri ; deficien in rfac an
2. H perbilir binemia
high le el of bilir bin in he blood,
neona e become ja ndice d e o imma ri of he li er
Kernic er aining of brain cell i h bilir bin, ca ing irre er ible brain damage
3. Infec ion - no able o recei e IgG glob lin
4. Cold re - le bc aneo i e, poikilo hermic
5. Anemia le iron ore

Managemen
1. Impro ing re pira or f nc ion- O gen herap , Mechanical en ila or
2. Main aining bod empera re- I ole e main ain ideal empera re, h midi and o gen
concen ra ion i ola e infan from infec ion, Kangaroo Care
3. Pre en ing infec ion- Hand a hing
4. Promo ing n ri ion- Ga age feeding, Milk feeding
5. Promo ing Sen or im la ion- Gen le o ch, peaking gen l and of l , m ic bo or
lo ned radio

N r ing In er en ion
1. Moni or i al ign e er 2 o 4 ho r
2. Admini er o gen and h midifica ion a pre cribed.
3. Moni or in ake and o p
4. Moni or dail eigh .
5. Main ain ne born in a arming de ice.
6. Repo i ion e er 1 o 2 ho r ,and handle ne born caref ll
7. A oid e po re o infec ion .
8. Pro ide ne born i h appropria e im la ion, ch a o ch
9. S c ioning of ecre ion a needed
10. Moni or for ign of infec ion
11. Pro ide kin care
12. Pro ide comple e e plana ion for paren

- E M NE B N
 De crip ion: Neona e born af er 42 eek of ge a ion
Abo 12% of all infan are po - erm
Ca e of dela ed bir h i nkno n
Ma ernal fac or : Fir pregnancie be een he age 15 o 19 ear
Woman older han 35 ear
M l ipari
Fe al fac or : Fe al anomalie ch a anencephal

A e men
Deple ed bc ane o fa : old looking old man facie
Parchmen -like kin (dr , rinkled and cracked) i ho lan go
Fingernail long and e ended o er end of finger
Ab ndan calp hair
Long and hin bod
Sign of meconi m aining
Nail and mbilical cord ( ello o green)

COMPLICATIONS OF POST MATURITY

1. The placen a begin o aged o ard he end of pregnanc , and ma no f nc ion a
efficien l a before.
2. The failing placen al f nc ion ill place infan a ri k for in ra erine h po ia d ring labor and
deli er .
3. MECONIUM ASPIRATION SYNDROME
4. HYPOGLYCEMIA - FROM NUTRITIONAL DEPRIVATION AND POOR STORAGE OF
GLYCOGEN AT BIRTH
5. POLYCYTHEMIA- increa e RBC

Managemen
1. Ul ra o nd i done o e al a e fe al de elopmen , amo n of amnio ic fl id and he placen a
ign of aging
2. To red ce he chance of meconi m a pira ion, pon deli er of ne born head and j
before he bab ake hi fir brea h c ioning of he mo h and no e i done

N r ing managemen
1. Clo el moni or he ne born cardiop lmonar a
2. Admini er pplemen al o gen herap a needed
3. Freq en moni oring of blood gar; a e for ign of h pogl cemia
4. Pro ide hermoreg la ed en ironmen e of i ole e or radian hea armer
5. Moni or for ign of meconi m a pira ion ndrome

DIFFERENCES PRETERM FULL TERM

Po re Rela ed a i de limb more e ended More fle ed a i de
Ear Ear car ilage are poorl de eloped, ma Well formed car ilage
fold ea il
Sole Onl fine rinkle Well and deepl crea ed
Female geni alia Cli ori i prominen ; labia majora poorl Cli ori i no a prominen ; labia
de eloped majora f ll de eloped
Male geni alia Scro m i nder de eloped and no Scro m i f ll de eloped,
pend lo , i h minimal r gae pend lo , r ga ed
Scarf ign Elbo i ea il bro gh acro he che Wi h re i ing a emp hen elbo
i h li le or no re i ance i bro gh o he midline of he
che
Gra p refle Weak S rong, allo ing he infan o be
lif ed p from he ma re
P OBLEM ELA ED O GE A IONAL EIGH

MALL F GE A I NAL AGE

(SGA) babie are ho e ho e bir h eigh lie belo he 10 h percen ile for ha ge a ional
age
SGA babie ma be:
o prema re (born before 37 eek of pregnanc ),
o f ll erm (37 o 41 eek ), or
o po erm (af er 42 eek of pregnanc )
In ra erine gro h re ric ion (IUGR) - i he mo common nderl ing condi ion leading o
SGA ne born
Some fac or ha ma con rib e o SGA are he follo ing:
o Ma ernal fac or :
high blood pre re
chronic kidne di ea e
ad anced diabe e
hear or re pira or di ea e
maln ri ion, anemia
infec ion
b ance e (alcohol, dr g )
cigare e moking
Placen al anomal i he mo common ca e of IUGR
o Fac or rela ed o he fe
m l iple ge a ion ( in )
infec ion
chromo omal abnormali
A e men
o Re pira or di re - h po ic epi ode
o Loo e and dr kin ,li le fa , li le m cle ma
o Wa ed Appearance
o Small li er
o Head i larger compared o bod
o Wide k ll re
o Poor kin rgor
o S nken abdomen
Babie i h SGA ma ha e problem a bir h ch a :
o Re pira or di re (a ph ia)
o Meconi m a pira ion
o H pogl cemia
o Diffic l main aining normal bod empera re
o Pol c hemia oo man red blood cell
N r ing In er en ion
o Ob er e for ign of re pira or di re
o Main ain bod empera re
o Moni or for infec ion and ini ia e mea re o pre en ep i
o Moni or blood gl co e le el and for ign of h pogl cemia
o Ini ia e earl feeding and moni or for ign of a pira ion.
o Pro ide im la ion, ch a o ch and c ddling

LA GE F GE A I NAL AGE
1. De crip ion: Neona e ho i plo ed a or abo e he 90​ h percen ile on he in ra erine gro h
c r e
2. Weigh more han 4,000 gram
 3. Ca e nkno n (gene ic fac or and ma ernal condi ion )
4. Ma ernal diabe e i he mo idel kno n con rib ing fac or
5. Increa e in lin ac a a fe al gro h hormone
6. Macro omia an n all large ne born i h bir h eigh of more han 4500gram

A e men
7. large, obe e
8. Le hargic and limp
9. Ma feed poorl
10. Sign and mp om of bir h ra ma
Br i ing
Broken cla icle
E idence of molding
Cephalhema oma
Cap ccedane m

Problem of LGA babie

1. H pogl cemia (lo blood gar) of bab af er deli er
2. Re pira or di re
3. H perbilir binemia
4. Po en ial complica ion rela ed o increa e in bod i e:
a. Leading ca e of breech po i ion and ho lder d ocia
b. Frac red k ll, cla icle , cer ical or brachial ple inj r
and erb pal

Managemen
Ro ine ne born care i h pecial empha i on he follo ing:
a) Moni or i al ign freq en l , e peciall re pira or a .
b) Moni or blood gl co e le el and for ign of h pogl cemia
c) Ini ia e earl feeding
d) No e an ign of bir h ra ma or inj r
e) Moni or for infec ion and ini ia e mea re o pre en ep i
f) Pro ide im la ion, ch a o ch and c ddling.

COMMON AC E CONDI ION OF NE BO N

E I A DI E ND ME ( D )
De crip ion: Serio l ng di order ca ed b imma ri and inabili o prod ce rfac an ,
re l ing in h po ia and acido i
S rfac an a biochemical compo nd ha red ce rface en ion in ide he air ac
Decrea e in rfac an re l o l ng collap e, h grea l red cing infan i al ppl of
o gen
Damaged l ng cell combine i h o her b ance pre en in he l ng o form fibro
b ance called h aline membrane (H aline membrane di ea e)
hi membrane line he al eoli and block ga e change in he al eoli
 A e men
1. E pira or gr n ing major- i he bod ' a of r ing o keep air in he l ng o he ill
a open
2. Tach pnea
3. Na al flaring
4. Re rac ion
5. See a like re pira ion (che all re rac and he abdomen pro r de )
6. Decrea ed brea h o nd
7. Apnea
8. Pallor and c ano i
9. H po hermia
Managemen
a) O gen herap - hood, na al prong, ma k, endo racheal be , CPAP (Con in o
Po i i e Air a Pre re) or PEEP (Po i i e End E pira or Pre re) ma be ed
b) M cle rela an Panc roni m (Pa lon)
Red ce m c lar re i ance
Pre en pne mo hora
Prepare A ropine or Neo igmine Me h l lfa e
c) Liq id Ven ila ion- U e perfl orocarbon b ance ed in ind r o a e leak
d) Ni ric Acid- Ca e p lmonar a odila ion increa e blood flo o he al eoli
N r ing In er en ion
1. Moni or color, re pira or ra e, and degree of effor in brea hing.
2. S ppor re pira ion a pre cribed
3. Moni or ar erial blood ga e and o gen a ra ion le el (ar erial blood ga e from
mbilical ar er ). o ha o gen admini ered o he ne born i a he lo e po ible
concen ra ion nece ar o main ain adeq a e ar erial o gena ion.

E IN A H F EMA I
Va c lar di order in ol ing grad al replacemen of re ina b fibro i e and blood e el
Primaril ca ed b prema ri and e of pplemen al o gen (longer han 30 da )
O gen admini ra ion ho ld ne er be more han 40% nle h po ia i doc men ed
An prema re ne born ho req ired o gen ppor ho ld be ched led for an e e
e amina ion before di charge o a e for re inal damage.
Bronchop lmonar D pla ia- o er e panded l ng prolonged e of O2
Managemen :
a) S c ion e er 2 ho r or more of en a nece ar .
b) Prepare o admini er rfac an replacemen herap (in illed in o he endo racheal
be)
c) Admini er re pira or herap (perc ion and ibra ion)
 d) Pro ide n ri ion
e) S ppor bonding
f) Enco rage a m ch paren al par icipa ion in ne born' care a condi ion allo .

H E BILI BINEMIA
De crip ion: i an abnormall high le el of Bilir bin in he blood; re l o ja ndiced
In ph iologic ja ndiced:
occ r on he econd da o e en h da
a erage increa e of 2mg/dl; no e ceeding 12mg/dl
Pa hological Ja ndice of Neona e
An of he follo ing fea re charac eri e pa hological ja ndice:
Clinical ja ndice appearing in he fir 24 ho r .
Increa e in he le el of o al bilir bin b more han 12 mg/dl
Therap i aimed a pre en ing Kernic er , hich re l in permanen ne rological damage
re l ing from he depo i ion of bilir bin in he brain cell .
Ca e :
a) Imma ri of he li er
b) Rh or ABO incompa ibili
c) Infec ion
d) Bir h ra ma
e) Ma ernal diabe e
f) Medica ion
A e men
Ja ndice
Dark concen ra ed rine
Enlarged li er
Poor m cle one
Le harg
Poor cking refle
Managemen
1. Pho o herap
-i e of in en e flore cen ligh o red ce er m bilir bin le el
-The e of bl e ligh o erhead or in blanke de ice rapped aro nd infan
-i e of in en e flore cen ligh o red ce er m bilir bin le el in he ne born
- Inj r from rea men , ch a : e e damage, deh dra ion, or en or depri a ion
- Po ible complica ion of pho o herap : e e damage, deh dra ion, en or depri a ion
- Wallab blanke -a blanke hich, hen rapped aro nd he infan or o, deli er
effec i e herap o ja ndiced babie
- no need o co er he bab e e a all ligh rea men i deli ered hro gh he blanke
2. E change blood ran f ion ia mbilical ca he er-for er e ere ca e
infan blood remo e = 5 / 10ml a a ime
N r ing In er en ion
1. E po e a m ch of he ne born' kin a po ible.
2. Co er he geni al area, and moni or he geni al area for kin irri a ion or breakdo n.
3. Co er he ne born' e e i h e e hield or pa che ; make re ha e elid are clo ed
hen hield or pa che are applied.
4. Remo e he hield or pa che a lea once per hif (d ring a feeding ime) o in pec
he e e for infec ion or irri a ion and o allo e e con ac and bonding i h paren .
5. Moni or kin empera re clo el .
6. Increa e fl id o compen a e for a er lo .
7. E pec loo e green ool and green rine.
8. Moni or he ne born' kin color i h he fl ore cen ligh rned off, e er 4 o 8 ho r .
9. Moni or he kin for bron e bab ndrome- a gra i h-bro n di colora ion of he kin.
10. Repo i ion ne born e er 2 ho r .
11. Pro ide im la ion.
 12. Af er rea men , con in e moni oring for ign of h perbilir binemia, beca e rebo nd
ele a ion are normal af er herap i di con in ed.
13. T rn off pho o herap ligh before dra ing blood pecimen for er m bilir bin le el and
a oid allo ing blood pecimen o remain nco ered nder fl ore cen ligh ( o pre en
he breakdo n of bilir bin in he blood pecimen).
14. Moni or for he pre ence of ja ndice; a e kin and clera for ja ndice.
15. E amine he ne born' kin color in na ral ligh .
16. Pre finger o er a bon prominence or ip of he ne born' no e o pre o capillar
blood from he i e .
17. Ja ndice ar a he head fir , pread o he che , abdomen, and hen he arm and
leg , follo ed b he hand and fee
18. Keep ne born ell h dra ed o main ain blood ol me.
19. Facili a e earl , freq en feeding o ha en pa age of meconi m and enco rage
e cre ion of bilir bin.
20. Repor o he ph ician an ign of ja ndice in he fir 24 ho r of life and an
abnormal S&S
21. Prepare for pho o herap , and moni or he ne born clo el d ring he rea men .

MEC NI M A I A I N ND ME (MA )
occ r hen infan ake meconi m in o heir l ng d ring or before deli er
Occ r in erm or po - erm infan
D ring fe al di re here i increa e in e inal peri al i , rela ing he anal phinc er and
relea ing meconi m in o he amnio ic fl id.
A pira ion can occ r in ero or i h he fir brea h.
Meconi m can block he air a par iall or comple el and can irri a e he ne born air a ,
ca ing re pira or di re
A e men :
1. Re pira or di re i pre en a bir h:
- ach pnea,
- c ano i ,
- re rac ion ,
- na al flaring,
- gr n ing,
- crackle , and rhonchi ma be pre en .
- infan ' nail , kin, and mbilical cord ma be ained a ello -green color.
CAUSES and RISK FACTORS:
1. Common o po ma re
2. Ma ernal hi or of diabe e
3. H per en ion
4. Diffic l deli er
5. Poor in ra erine gro h
Managemen
a) S c ioning m be done immedia el af er he head i deli ered before he fir brea h i
aken;
b) Vocal cord ho ld be ie ed o ee if he air a i clear before im la ion and cr ing
E racorporeal membrane o gena ion (ECMO)- Cardiop lmonar b pa o ppor ga
e change allo he l ng o re
N r ing in er en ion
1. Ob er ing neona e re pira or a clo el
2. En ring adeq a e o gena ion
3. Admini ra ion of an ibio ic herap
4. Main ain hermoreg la ion

E I
De crip ion: Generali ed infec ion re l ing from he pre ence of bac eria in he blood
Major common ca e i gro p B be a- hemol ic rep ococci
 Con rib ing fac or :
1. Prolonged r p re of membrane
2. Prolonged or diffic l labor
3. Ma ernal infec ion
4. Cro -con amina ion
5. A pira ion
A e men finding of en doe no ha e pecific ign of illne
1. Poor feeding
2. Irri abili
3. Le harg
4. Pallor
5. Tach pnea
6. Tach cardia
7. Abdominal di en ion
8. Tempera re in abili diffic l keeping empera re i hin normal range
Diagno i :
1. Blood, rine, and cerebro pinal fl id c l re
2. Ro ine CBC, rinal i , fecal i
3. Radiographic e
Managemen
1. In en i e an ibio ic herap
2. IV fl id
3. Re pira or herap
N r ing in er en ion - Ro ine ne born care i h pecial empha i on he follo ing:
1. Moni or i al ign , a e for period of apnea or irreg lar re pira ion ..
2. Admini er o gen a pre cribed
3. Pro ide i ola ion a nece ar - Moni or and limi i i or
4. Hand a hing before af er handling neona e

DDEN INFAN DEA H ND ME

S dden dea h of an o ng child ha i ne pec ed b hi or and hich horo gh po mor em
e amina ion fail o demon ra e adeq a e ca e of dea h
U all occ r d ring leep
Diagno i i made af er a op
High incidence in pre erm infan , infan i h abnormali ie in re pira ion
Unkno n ca e : ma be rela ed o a brain em abnormali in he ne rological reg la ion of
cardio-re pira or con rol
N r ing Role:
1. Care i direc ed a ppor ing paren /famil
2. Pro ide a room for he famil o be alone
3. Reinforce ha dea h a no heir fa l
4. Pro ide appropria e ppor referral
5. E plain ho paren can recei e a op re l
Pre en ion:
1. Infan ho ld be placed in he pine po i ion for leep.
2. Sof moldable ma re e and bedding, ch a pillo or q il , ho ld no be ed for
bedding.
3. S ffed animal ho ld be remo ed from he crib hile he infan i leeping.
4. Di co rage bed haring ( leeping i h an ad l ).
5. Home apnea moni or o infan i h near mi SIDS
 HIGH I K I FA ( 1)

C MM HEAL H BLEM D I G I FA C
FAIL RE O HRI E
A condition in hich a child fails to gain eight and is persistentl less than the fifth percentile on
standard gro th chart
Persistent de iation from established gro th cur e.
Dela in ph sical gro th and eight gain might lead to cogniti e impairment or e en death
4 principal factors for human gro th:
1. Food
2. Rest and acti it
3. Adequate secretions of hormones
4. Satisfactor relationship ith care gi er
Classified as:
1. Organic (OFTT) - due to pathologic condition such as problem in absorption and
hormonal d sfunction
2. Nonorganic (NFTT) due to ps chosocial factor disrupted maternal child relationship
3. Idiopathic(IFTT) - Une plained b the usual organic and en ironmental etiologies but
usuall classified as NFTT
A thorough histor is the best guide to establishing the etiolog of the failure to thri e:
Po ert ​ ​is the greatest single risk factor orld ide and in​ ​the United States
Nutritional deficienc is the fundamental cause
Assessment findings
Poor muscle tone, loss of subcutaneous fats, skin breakdo n
Rumination common characteristic; oluntar regurgitation
Lethargic- unresponsi e
Positi e dela in gro th and de elopment
Signs of disturbed maternal child interaction
Diminished or none istent cr ing
Radar ga e - ide-e ed ga e and continual scan of en ironment
Characteristics of the indi idual pro iding care:
1. Difficult percei ing and assessing the infant s needs
2. Frustrated and angered at the infant s dissatisfied response
3. Frequentl under stress and in crisis, ith emotional, social and financial problems
All children ith failure to thri e need additional calories for catch-up gro th :
Treatment depends on the cause
Medical disorder - specific treatment is gi en Parent-child relationship - Famil
counseling
Nutritious, high-calorie feedings
Nursing Inter entions
Pro ide consistent caregi er.
Pro ide sufficient nutrients.
Make feeding a priorit inter ention.
Keep an accurate record of intake.
Weigh dail .
Introduce positi e feeding en ironment
Establish a structured routine
Hold the oung child for feeding
Maintain e e-to-e e contact
Maintain a calm, e en temperament
Pro ide a quiet, non stimulating en ironment
Talk to child gi ing appropriate directions and praise for eating
Increase stimulation appropriate to the child s present de elopmental le el.
Pro ide the parent an opportunit to talk.
When necessar , relie e the parent of childrearing responsibilities until able and
read emotionall to support the child.
 Demonstrate proper infant care b e ample, not lecturing.
Suppl the parent ith emotional support ith fostering dependenc .
Promote the parent s self-respect and confidence b praising achie ements ith
child.

H DROCEPHAL
Description: An imbalance of cerebrospinal fluid (CSF) absorption or production caused b :
malformations, tumors, hemorrhage, infections, or trauma
Results in head enlargement and increased ICP
T pes:
COMMUNICATING- occurs as a result of impaired absorption ithin the subarachnoid
space.
NONCOMMUNICATING- blockage in the entricular s stem that pre ents CSF from
entering the subarachnoid space
Assessment:
1. Increased head circumference
2. Thin, idel separated bones of the head that produce a cracked pot sound (Mace en's
sign) on percussion
3. Anterior fontanel tense, bulging, and nonpulsating
4. Dilated scalp eins
5. Sunsetting e es
6. Beha ior changes, such as irritabilit and letharg
7. Headache on a akening
8. Nausea and omiting
9. Ata ia- lack of coordination of muscle mo ement
10. N stagmus- in oluntar mo ement of the e es
11. Late signs: High, shrill cr and sei ures.
Diagnostic Test: CT scan, MRI, Skull X-ra
Transillumination- holding a bright light such as a flashlight or speciali ed light (Chun
gun) against the skull in a darkened room; a skull filled ith fluids rather than solid brain
substance
Management - treatment depends to cause
Surgical inter entions
GOAL: Pre ent further CSF accumulation b b passing the blockage and
draining the fluid from the entricles to a location here it ma be reabsorbed.
a) Ventriculoperitoneal shunt -the CSF drains into the peritoneal ca it
b) Atrio entricular shunt -CSF drains into the right atrium of the heart
c) Aceta olamide (diamo )- promote the e cretions of e cess fluids
Preoperati e inter entions
a) Gi e small frequent feedings as tolerated until a preoperati e NPO status
is prescribed.
b) Reposition head frequentl and use an egg crate mattress under the
head to pre ent pressure sores.
c) Prepare the child and famil for diagnostic procedures and surger
Postoperati e inter entions
a) Monitor ital signs and neurological signs.
b) Position the child on the unoperated side
c) Obser e for signs of increased ICP
d) ele ate head 15-30 degrees
e) Monitor for signs of infection
f) Measure head circumference.
g) Pro ide comfort measures; e pected le el of functioning
h) Administer medications as prescribed, diuretics, antibiotics, or
anticon ulsants.
i) Instructions on parents re: ound care, shunt re ision
j) A ailabilit of support groups; communit agencies
 k) Instruct the parents on ho to recogni e shunt infection or malfunction
o In an infant- irritabilit , letharg , and feeding poorl
o In a toddler- headache and a lack of appetite
o In older children- an alteration in the child's le el of
consciousness.
PINA BIFIDA
Description: A central ner ous s stem defect results from failure of the neural tube to close
during embr onic de elopment generall in the lumbosacral region
Causes:
Actual cause is unkno n; multiple factors
Genetic if a sibling has had neural tube defect
En ironmental factors
Medications , iral infection and radiation
T pes:
1. Spina bifida occulta- Posterior ertebral arches fail to close in the lumbosacral area.
Spinal cord and meninges remains in the normal anatomic position
Defect ma not be isible dimple or a tuff of hair on the spine
As mptomatic ma ha e slight neuromuscular deficits
No treatment if as mptomatic aimed at specific s mptoms
2. Spina bifida c stica- Protrusion of the spinal cord and/or its meninges ith ar ing degrees of
ner ous tissue in ol ement.
a) Meningocele
part of spinal protrudes through opening in the spinal canal
sac is co ered ith thin skin no ner e roots in ol ed
no motor or sensor loss Good prognosis after surger
b) M elomeningocele (meningom elocele)
ith spinal ner es roots in the sac
ha e sensor or motor deficit
belo site of the lesion
80% ha e multiple handicaps
Assessment- Depends on the spinal cord in ol ement
1. Visible spinal defect
2. Motor/sensor in ol ement
a) Flaccid paral sis of the legs
b) Altered bladder and bo el function
c) Hip and joint deformities
d) H drocephalus

Diagnostics:
Prenatal- ultrasound, amniocentesis
Postnatal
ra of spine
ct scan
m elogram-uses a special d e and an X-ra (fluoroscop ) to pro ide a er
detailed picture of the spinal cord and spinal column
encephalogram
urinal sis, BUN, Creatinine clearance
Management:
1. Surger - closure of sac ithin 48 hours, shunt, orthopedic
2. Drug therap - Antibiotic, Anticholinergic

Nursing Management:
1. Pre ent trauma to the sac
a) co er ith a sterile, moist (normal saline), non adherent dressing
b) change the dressing e er 2 to 4 hours as prescribed, keep area free from
contamination
 c) place in a prone position to minimi e tension on the sac
d) head is turned to one side for feeding
e) Administer meds
2. Pre ent Complication
a) Use aseptic technique to pre ent infection.
b) Assess the sac for redness, clear or purulent drainage, abrasions, irritation, and
signs of infection.
c) Clean intermittent catheteri ation
d) Perform neurological assessment
e) Assess for ph sical impairments such as hip and joint deformities
3. Pro ide adequate nutrition
4. Pro ide sensor stimulation
5. Pro ide emotional support to parents and famil
6. Pro ide discharge teachings
ound care
ROM, PT
signs of complications
medication regimen
positioning feeding ,diaper change

MENINGI I
Description: inflammations of meninges of the brain and spinal cord
Cause b bacteria, iruses, other microorganism
as a primar disease or as a result of complications of neurosurger , trauma, infection of the
sinus or ears, or s stemic infections.
H Influen ae Meningitis the most common form; bet een 6 to 12 months
Bacterial meningitis - Haemophilus influen a t pe B, Streptococcus pneumoniae, or
Neisseria meningitidis
Viral meningitis is associated ith iruses such as mumps, herpes irus, and entero irus.
Assessment
Fe er, chills, headache,
high-pitched cr , irritabilit
Vomiting, Poor feeding or anore ia
Bulging anterior fontanel in the infant
Signs of meningeal irritations
Nuchal rigidit stiff neck
Positi e Kernig sign- Se ere stiffness of the hamstring muscle causes an inabilit
to straighten the leg hen the hip is fle ed to 90 degrees.
Opisthotonos
a) arching of the back
b) head and heels bent back ard
c) and bod arched for ard
Brud inski sign - Fle ion at the hip in response to for ard fle ion of the neck
Inter entions
1. Pro ide isolation and maintain it for at least 24 hours after antibiotics are initiated.
2. Administer antibiotics and antip retics as prescribed.
3. Perform neurological assessment and monitor for sei ures and complications
4. Assess for changes in le el of consciousness and irritabilit .
5. Monitor intake and output.
6. Assess nutritional status.
7. Determine close contacts of the child ith meningitis because the contacts ill need
proph lactic treatment.
8. Meningococcal accine is recommended to protect against meningitis.
 HIGH RISK INFANT (PART II)

❖ SEI URES
D
Rec en dden change in con cio ne , beha io , en a ion and o m c la ac i i ie
be ond ol n a con ol ca e b e ce ne onal di cha ge
No mall he ne on end o me age in elec ical imp l e pe iodicall and he fi ing
indi id al ne on i eg la ed b an inhibi o feedback loop mechani m
Wi h ei e man mo e ne on han no mal fi e in a nch on fa hion in a pa ic la a ea of
he b ain; he ene g gene a ed o e come he inhibi o feedback mechani m

FEBRILE SEI URES

D
Common in child en be een 6mo 3 old
Common in 5% of pop la ion nde 5 ea old, familial
Nonp og e i e, doe no gene all e l in b ain damage
Commonl a ocia ed i h high fe e 38.9 o 41.1 Cel i
Some appea o ha e a lo ei e h e hold and con l e hen a fe e of 37.8 o 39.8
C :
1. Pa ial ei e
a. Simple locali ed mo o ac i i
- haking of a m o leg
- limi ed o one ide of he bod
b. Comple p chomo o ei e
- memo lo and a ing
- non p po ef l mo emen
AURA en a ion ha ignal an a ack
Af e leep o conf e; na a e of he ei e
2. Gene ali ed
a. Tonic clonic
p od omal
AURA
onic
po ic al
b. Ab ence - a el 20 econd
ae aigh , doe no fall
Sa Eplilep ic
C :
1. In ac anial infec ion
2. Space occ p ing le ion
3. CNS defec
A
1. Re le ne /i i abili
2. Bod iffen and lo of con cio ne
3. Clonic mo emen q ick, je king mo emen of a m , leg , and facial m cle
4. P pil dila e and oll p
D T :
Blood die
- o le o lead poi oning,
- h pogl cemia
- infec ion
- Elec ol e imbalance
EEG o de ec abno mal a e
T :
1. D g The ap
a. Dia epam
 b. Phenoba bi al
c. Dilan in
2. S ge fo mo and hema oma
I
1. Red ce fe e i h an ip e ic .
2. Gi e p e c ibed medica ion
3. Gene ali ed ei e p eca ion
4. Do no e ain; pad c ib ail ; do no e ong e blade
5. Ob e e and eco d he ime of ei e, d a ion, and bod pa in ol ed.
6. S c ion and admini e o gen af e he ei e a eq i ed.
7. Ob e e he deg ee of con cio ne and beha io af e ei e
8. P o ide e af e he ei e.

❖ OTITIS MEDIA
D
Bac e ial o i al infec ion of he middle ea
Common in infan and p e choole
E achian i ho e , ide , and aigh e he eb , allo ing na opha ngeal ec e ion o en e
middle ea mo e ea ilY
​A F
1. Beha io ha o ld indica e pain e le and epea edl hake he head
- f eq en l p ll o g a affec ed ea
2. I i abili , co gh, na al conge ion, fe e
3. Hea ing impai men
4. P len di cha ge
D
1. E amina ion of ea i h o o cope e eal b igh ed b lging ea d m
2. C l e and en i i i of ea di cha ge
P C -​pe manen hea ing lo
​- ma oidi i
M
1. An ibio ic , analge ic
2. M ingo om inci ion in o he mpanic memb ane o elie e p e e and d ain he fl id
i h / i ho be
- Po ope a i e In e en ion
1. Wea ea pl g hile ba hing, hampooing, and imming,
2. Di ing and bme ging nde a e a e no allo ed.
3. Child ho ld no blo hi o he no e fo 7 o 10 da af e ge .
​I
1. Enco age fl id in ake.
2. Teach he pa en o feed infan in p igh po i ion, o p e en efl .
3. In c he child o a oid che ing a m ch a po ible d ing he ac e pe iod beca e che ing
inc ea e pain.
4. P o ide local hea and ha e he child lie i h he affec ed ea do n.
5. In c he pa en in he app op ia e p oced e o clean d ainage f om he ea i h e ile co on
ab .
6. In c he pa en in:
⚫ Admini a ion of analge ic o an ip e ic
⚫ Admini a ion of he p e c ibed an ibio ic , empha i ing ha he 10- o 14-da pe iod i
nece a o e adica e infec i e o gani m .
⚫ Sc eening fo hea ing lo ma be nece a .
⚫ Admini e ing ea medica ion .
- Yo nge han age 3, p ll he lobe do n and back.
- Olde han 3 ea , p ll he pinna p and back.

❖ CLEFT LIP AND CLEFT PALATE

 D
Non nion of he i e and bone of he ppe lip and ha d/ of pala e d ing emb onic
de elopmen
Fail e of he ma illa and p ema illa p oce e o f e d ing fe al de elopmen
​E ​ p ima il gene ic
- en i onmen al fac o
- i al infec ion
- e po e o adia ion
- Folic acid deficienc
- e a ogenic fac o
​A F
1. Facial abno mali
2. Diffic l cking and allo ing
3. Milk e cape h o gh no e
​ A
Clef lip
- can ange f om a ligh no ch o a comple e epa a ion f om he floo of he no e.
Clef pala e
- na al di o ion
- midline o bila e al clef
- a iable e en ion f om he la and of and ha d pala e.
A P
1. Feeding p oblem
2. URTI
3. Ea infec ion
4. Speech defec , den al malfo ma ion
5. Bod image
M
1. S gical co ec ion (R le of Ten)
✔ Cheilopla Co ec ion of clef lip
✔ Pala opla Clef pala e ge
- Done befo e peech de elopmen
- Allo fo pala al change
Logan ba / e i ip - o ake he en ion off he e
2. Team App oach The ap Den i and o hodon i
- A diologi
- Speech The api
- Pedia ician
​N I (P - C L )
1. Feed in p igh po i ion in mall f eq en feeding
2. B p f eq en l
3. U e la ge-holed nipple
4. U e bbe - ipped inge if nable o ck
5. Ga age feeding a o de ed
6. Fini h feeding i h a e
7. P o ide emo ional ppo fo pa en and famil
N I (P - C L )
1. Main ain pa en ai a
2. A e colo ; moni o fo f eq en allo ing
3. Do no place in p one po i ion
4. A oid aining e line
5. U e elbo e ain
6. Re me feeding a o de ed (Habe man feede )
7. P o ide pain con ol a o de ed
N I (P - C P )
1. P epa e pa en o ca e fo child af e ge
 2. In c conce ning feeding me hod and po i ioning
N I (P - C P )
1. S c ion m c and ali a gen l and do no o ch he e
2. Inci ion ca e
3. Clean e i h e ile co on ab i h half eng h h d ogen pe o ide follo ed b aline
4. Appl an ibio ic oin men
5. Do no di place Logan ba
6. Do no place in p one po i ion, Place in ide l ing po i ion
7. Keep poon , pacifie , a , a a f om child mo h fo 7 o 10 da po op
8. Elbo ain
9. Special feede inge i h bbe bing in o ide of mo h, B eck feede
❖ ESOPHAGEAL ATRESIA/TEF
D
The e ophag e mina e befo e i eache he omach, ending in a blind po ch, and/o a
fi la i p e en ha fo m an nna al connec ion i h he achea.
⚫ T pe I/A - lo e egmen of he e ophag a e blind;
⚫ T pe II/ B ppe end of e ophag open in o he achea; blind lo e egmen
⚫ T pe III/ C ppe end blind; lo e end connec in o achea
C M
1. E ce i e amo n of ec e ion con an d ooling la ge ec e ion f om he no e
2. In e mi en / ne plained c ano i
3. Co gh and choke
4. Fl id e n h o gh no e and mo h
5. Reg gi a ion & omi ing
6. Abdominal di en ion
7. Inabili o pa a mall ca he e h o gh
8. The mo h o no e in o he omach.
​D E
1. X- a of abdomen and Che X- a
2. X- a i h adiopaq e ca he e
3. In e ion of a ca he e
M
Incl de main enance of :
- a pa en ai a
- p e en ion of a pi a ion pne monia
- ga ic o blind po ch decomp e ion
- ppo i e he ap
- gical epai
1. D g The ap
An ibio ic fo e pi a o infec ion
2. S ge
✔ P ima epai e ophageal ana omo i
✔ Ga o om - feeding
✔ E ophago om - d ain ec e ion
P e- e a i e In e en i n
1. The infan ma be placed in an inc ba o o adian a me i h high h midi (in ba ion and
mechanical en ila ion ma be nece a if e pi a o di e occ ).
2. Up igh po i ion
3. Main ain an NPO a .
4. Reg la c ioning
5. Main ain IV fl id o h pe alimen a ion a p e c ibed.
6. Ob e e clo el fo :
- i al ign ; e pi a o beha io
- amo n of ec e ion
- abdominal di en ion
- kin colo
 P - e a i e In e en i n
1. Moni o e pi a o a .
2. Main ain pa en ai a ; con in ed e of inc ba o
3. S c ion a needed, change po i ion f eq en l ; a oid h pe e en ion of neck
4. Main ain IV fl id , an ibio ic , and pa en e al n i ion a p e c ibed.
5. Main ain adeq a e n i ion ga o om
6. Moni o ic in ake and o p .
7. Moni o dail eigh .
8. In pec he gical i e fo ign and mp om of infec ion.
9. Moni o fo ana omo ic leak a e idenced b p len d ainage f om he che be, inc ea ed
empe a e, and inc ea ed hi e blood cell co n .
10. Ob e e fo ign of ic e a he ana omo i i e (e.g., poo / ef al o feed, d phagia,
d ooling, eg gi a ed ndige ed food).

❖ H PERTROPHIC P LORIC STENOSIS

D
Congeni al h pe oph of he ci c la m cle of he p lo in he omach; he m cle
become p og e i el hickened and elonga ed i h na o ing of he p lo ic canal.
The eno i all de elop in he fi fe eek of life, ca ing p ojec ile omi ing,
deh d a ion, me abolic alkalo i , and fail e o h i e.
​A
1. Vomi ing ha p og e e f om mild eg gi a ion o fo cef l and p ojec ile omi ing
2. Vomi con ain ga ic con en ch a milk o fo m la, ma con ain m c , ma be
blood- inged, and doe no all con ain bile.
3. E hibi h nge and i i abili .
4. Pe i al ic a e a e i ible f om lef o igh ac o he epiga i m d ing o immedia el
follo ing a feeding.
5. Oli e- haped ma i in he epiga i m j igh of he mbilic .
6. On ba i m enema, ing ign can be een
7. Deh d a ion and maln i ion can occ .
8. Elec ol e imbalance can occ .
​M
F ede -Ram ed P lo om o om
- pli he h pe ophic p lo ic m cle do n o he bm c a ,allo ing
p lo o e pand o ha food ma pa
​N I
1. Moni o i al ign .
2. Moni o ic in ake and o p .
3. Ob ain dail eigh .
4. Moni o fo ign of deh d a ion and elec ol e imbalance .
5. Feed b ga age
- Thickened feeding
- Slo l p igh
- B p f eq en l
6. P epa e he child and pa en fo ge if p e c ibed.
P
P
- Moni o h d a ion a
- Co ec F/E imbalance
- NPO
- Moni o cha ac e of ool
- NGT
P
- Moni o in ake and o p
- S a SFF
- Feed lo l , p igh
 - Moni o fo abdominal di en ion
- Moni o fo ign of infec ion
- In c pa en on o nd ca e and feeding

❖ HIRSCHSPRUNG S DISEASE (AGANGLIONIC MEGACOLON)

D
Ab ence of ganglion cell in a po ion of he la ge in e ine
I a pa a mpa he ic ne e cell ha eg la e pe i al i in he in e ine
The ab ence of he ganglion cell o ld e l o ab ence pe i al i and affec ed colon
become dila ed and filled i h fece and ga
The di ea e ma be a familial congeni al defec o ma be a ocia ed i h o he anomalie ,
ch a Do n nd ome and geni o ina abno mali ie .

​A F
Ne bo n
Fail e o pa meconi m ool
Ref al o ck
Abdominal di en ion
Bile- ained omi
Child en
Fail e o gain eigh and dela ed g o h
Abdominal di en ion
Vomi ing
Con ipa ion al e na ing i h dia hea
Ribbon-like and fo l- melling ool
D S ​ Rec al biop
M
S ge
✔ Tempo a colo om
- A po ion of he la ge in e ine i b o gh h o gh he abdominal all o ca ool o of he bod
✔ Bo el epai
- Di ec ion and emo al of he affec ed ec ion i h ana omo i of in e ine
- Abdominal pe ineal p ll h o gh
N M
1. Admini e enema a o de ed i h I o onic ol ion onl
2. Do no ea loo e ool child i con ipa ed
3. Admini e TPN
4. In c pa en on colo om ca e, co ec die
❖ INTUSSUSCEPTION
D
In agina ion o ele coping of a po ion of he mall in e ine in o a mo e di al egmen of he
in e ine
 3 ime mo e likel in bo han gi l and he common ca e of in e inal ob c ion in childhood
Ca e i nkno n
​F
1.H pe pe i al i and n al mobili of cec m and ile m
2. Le ion ch a pol p and mo
I i con ide ed a ​ ​ in child en
Mechanical Bo el Ob c ion Occ :
in e inal all p e again each o he ca ing inflamma ion, edema and dec ea ed
blood flo .
Ma p og e o nec o i , pe fo a ion and pe i oni i .
Gang ene of he bo el
C P
1. S dden on e of abdominal pain (in a heal h bab )
2. Infan c ie o ha pl and d a knee p o abdomen
3. Vomi ing occ and inc ea e o e ime (Bile ained omi )
4. C an jell ool
5. Sign of hock
6. (+) fo Occ l blood in ool
7. Sa age- haped ma in RLQ
​D
Of en ba ed on hi o and ph ical e amina ion alone
1. Ba i m enema
- I defini i e (in 75% of ca e )
- I i he ape ic and c a i e in mo ca e i h le han 24-ho d a ion
2. Digi al ec al e am
- e eal m co , blood
​I T
- IV fl id
- NPO a
- Diagno ic ba i m enema
S ge man al ed c ion of in agina ion
- e ec ion i h ana omo i
- po ible colo om (gang eno )
N M
1. P o ide o ine p e- and po -ope a i e ca e fo abdominal ge
2. Moni o fl id and elec ol e a
3. Main ain n i ion and h d a ion
4. Re me feeding 24 ho po ope a i e

❖ IMPERFORATE ANUS
D
Congeni al malfo ma ion in hich he e i no anal opening o he e i ic e of he an
E iolog i nkno n
An a e in emb onic de elopmen on 7​ h​ o 8​ h​ eek of in a e ine life
A memb ane emain and block he nion be een he ec m and he an
Blind ec al po ch i h no mal an
​C P
1. No ool pa age i h in 24 ho af e bi h
2. Meconi m ool f om o he o ifice
3. Onl a dimple indica e he i e of he an
4. Inabili o in e he mome e
​D ​ Digi al ec al e am
- Ul a o nd
 - Abdominal X- a
​M
1. M
2. S
. A
. T
3. A

N
1. If pec ed, do no ake ec al empe a e
2. P e-ope a i e ca e
- Moni o fo he p e ence of ool in he ine and agina (indica e a fi la) and epo
immedia el .
- Admini e IV fl id a p e c ibed
- P epa e he child and pa en fo he gical p oced e , incl ding he po en ial fo colo om .
3. Po -ope a i e Ca e
- E po e pe ine m o ai
- Check bo el o nd
- NGT fo ga ic decomp e ion
- Change po i ion f eq en l
- O al feeding a ed g ad all a oon a pe i al i f nc ion e ned
- In c he pa en o e onl a a e - ol ble l b ican and o in e he dila o no mo e han 1
o 2cm

❖ DISPLACED URETHRAL OPENINGS

✔ H POSPADIAS
Male : e h a open on he lo e face of he peni
Female : e h a open in o he agina
✔ EPISPADIAS
⚫ Onl in male
⚫ U e h a open on he do al face of he peni
⚫ Congeni al ab ence of he ppe all of he e h a
P oc ea ion ma be in e fe ed i h in e e e ca e
Inc ea ed i k of ina ac infec ion
MANAGEMENT
1. Ci c mci ion i dela ed n il gical epai
2. S gical epai
⚫ Mea o om

❖ DO N S NDROME
D
Ch omo omal di o de ca ed b he p e ence of all o pa of an e a 21 ch omo ome.
I i named af e John Langdon Do n, he B i i h doc o ho de c ibed he nd ome in 1866.
The di o de a iden ified a a ch omo ome 21 i om
​A F
1. Small head, fla facial p ofile
2. Lo - e ea
3. Simian c ea e
4. 40% congeni al hea defec
5. Wi h mode a e e a da ion
6. Wide pace be een 1​ ​ 2​nd​ oe
7. La m cle one
M
1. P e en e pi a o infec ion
- Clea ing he no e
- Cool mi apo i e
 - Che ph io he ap
- Hand a hing and a oiding e po e o infec ion.
2. When feeding infan and o ng child en, e a mall, aigh -handled poon o p h food
o he ide and back of he mo h.
3. Enco age fl id and food ich in fibe .
4. Con ipa ion e l f om dec ea ed m cle one, hich affec ga ic mo ili .
5. P o ide good kin ca e beca e he kin i d and p one o infec ion.
6. Famil ed ca ion co n eling
7. - de elopmen al p og e

❖ AUTISM
D
Se e e men al di o de beginning in infanc o oddle hood
Pe a i e de elopmen al di o de
Di o de appa en o he pa en befo e he child i 3 ea old
Cha ac e i ed b :
- Se e e defici in lang age,
- pe cep al and mo o de elopmen
- Defec i e eali e ing
- Inabili o f nc ion in ocial e ing
The ca e i nkno n and he p ogno i ma be poo .
​P
1. Un a i fac o mo he -child ela ion hip
2. CNS abno mali ie
Diagno i i e abli hed ba ed on mp om and he e of peciali ed a i m a e men
ool .
C
1. Inabili o ela e i h o he
2. Inabili o comm nica e
3. Ob io limi ed ac i i ie /in e e
C
1. Infan no e pon i e o c ddling
2. No e e con ac o facial e pon i ene
3. Impai ed/no e bal comm nica ion
4. Echolalia
5. Inabili o ole a e change
6. Fa cina ion i h mo emen
7. Labile mood
​A
1. Bi a e e pon e o he en i onmen
In en e eac ion o mino change
A achmen o objec
In en el p eocc pied o mo ing objec
2. Self-ab o bed and nable o ela e o o he .
3. Repe i i e hand mo emen , ocking, and h hmic bod mo emen
4. Hi ing, head banging, and bi ing
5. M ic of en hold a pecial in e e fo hem
6. No del ion , hall cina ion , o incohe ence
7. E cellen long- e m memo
8. Ma pla happil alone fo ho b ha e empe an m if in e p ed.
N
1. P o ide pa en /famil i h ppo and info ma ion abo he di o de
2. A i child i h ADL
3. P omo e eali e ing
4. Enco age he child o de elop ela ion hip i h ano he pe on
 5. Main ain eg la ched le of ac i i ie
6. P o ide con an o ine fo child
7. P o ec f om elf inj
8. P o ide afe en i onmen
9. P o ide ei e p eca ion

❖ ATTENTION DEFICIT H PERACTIVIT DISORDER

D
De elopmen al di o de cha ac e i ed b inapp op ia e deg ee of ina en ion, o e ac i i , and
imp l i i
One of he mo common ea on fo efe al of child en o men al heal h e ice
Childhood p oblem incl de lo e ed in ellec al de elopmen , ome mino ph ical
abno mali ie , leeping di bance , beha io al o emo ional di o de , and diffic l in ocial
ela ion hip .
​D
E abli hed on:
- pa en and eache epo
- p chological a e men
Diagno able b 36 mon h
3 majo cha ac e i ic e ealed befo e 7 ea of age
​A
1. Fidge i h hand o fee o q i m in he ea
2. Ea il di ac ed i h e e nal o in e nal im li
3. Diffic l i h follo ing h o gh on in c ion
4. Poo a en ion pan
5. Shif ing f om one ncomple ed ac i i o ano he
6. Talking e ce i el
7. In e p ing o in ding on o he
8. Engaging in ph icall dange o ac i i ie i ho con ide ing he po ible con eq ence
T M
En i onmen con c ion of able en i onmen
- pecial in c ion f ee f om di ac ion
- fai b fi m and e con i en limi
Medica ion
- con ol e ce i e ac i i
- leng hening he a en ion pan
- dec ea ing he di ac ibili
I
1. P o ide en i onmen al and ph ical afe mea e .
2. Enco age ppo g o p fo pa en .
3. Admini e p e c ibed medica ion; ome commonl p e c ibed medica ion ha incl de:
- me h lphenida e h d ochlo ide (Ri alin),
- pemoline (C le ), and
- de oamphe amine lfa e (De ed ine).
4. Info m he child and pa en ha po i i e effec of he medica ion ma be een i hin 1 o 2
eek
 HIGH RISK TODDLER
❖ BURNS
D
I i he mo e ere form of ra ma o he in eg men ar em
T :
✔ Thermal​ - Ca ed b flame , fla h,​ a ( )​, con ac o ho me al, grea e
✔ Chemical​ - Inhala ion or inge ion of acid , alkaline , or e ican
✔ Smoke inhalation ​- Fire, ga e , perhea ed air moke ca e re pira or i e
damage
✔ Electrical burn​ - Damage of ner e and e el d e o elec ric c rren
Ca a a . :
✔ Par ial hickne
a. S perficial par ial hickne Epidermi
- painf l er hema
- no e icle
b. Deep par ial hickne Epidermi /dermi
- Ver painf l
- Fl id filled e icle
- Red, hin , e
✔ F ll hickne - All kin la er and ner e ending ; ma in ol e he m cle , endon , and
bone
- li le or no pain
- o nd i dr , hi e lea her
E a ​- he o gh, lea her cab ha form o er modera e or e ere b rn area
P a /S a B
1. Emergen Pha e
a. Remo e he per on from he o rce of b rn
T a​ mo her b rn beginning i h he head
S aa ​ en re pa en air a
C a ​ remo e clo hing
E a ​ main ain air a , iden if en r and e i ro e
b. Wrap in dr , clean hee
c. A e ho and hen b rn occ rred
d. Pro ide IV ro e if po ible
e. Tran por immedia el
2. Shock Pha e - Fl id hif from pla ma o in er i ial ca ing h po olemia
A e men Finding - Sign of deh dra ion, BP, ach cardia, rine o p , hir
Diagno ic Te - h pona remia, h popro einemia, h perkalemia
3. Di re ic Pha e/Fl id remobili a ion - In er e ial fl id re rn o he a c lar pace
A e men Finding ele a ed BP, increa e rine o p
4. Con ale cen Pha e o nd healing
A F
1. E en of inj r R le of 9
- L nd and Bro der
2. Se eri of B rn cla ifica ion:
Mi
✔ par ial hickne (1​ ​ /2​nd​ degree); le han 10 -15% of bod rface
rd​
✔ f ll hickne (3​ degree); le han 2% of bod rface
✔ No b rn on area of face, fee , hand , or geni alia

M de a e
✔ par ial hickne (2​nd​ degree) be een15-25% of bod rface
✔ f ll hickne le han 10%
✔ moke inhala ion
Ma
✔ par ial hickne grea er han 25% of bod rface
 ✔ f ll hickne grea er han or eq al o 10%
Ba B T a
1. Mi b
- An ibio ic
- Analge ic oin men
- Ga e bandage
2. M de a e b
- do no r p re bli er
- analge ia/an ip re ic oin men
- arm a er and mild oap
- b rn dre ing b lk dre ing
3.​ ​Se e e b
a. S ppor i e Therap ; Fl id Managemen
- Cr alloid ol ion : Lac a ed Ringer
- Colloid ol ion ch FFP
- Ca he eri a ion
b. Wo nd Care open or clo ed b rn herap , h dro herap
c. Dr g Therap
- Topical an ibio ic (Sil er S lfadia ine)
- S emic an ibio ic
- Te an o oid/HTIG
- Analge ic morphine lfa e
d. Ph ical Therap o pre en di abili ca ed b carring, con rac re
e. S rger E charo om
- Debridemen
- Skin graf ing

Parame er ch a i al ign (hear ra e), rine o p , adeq ac of capillar

filling, and en ori m a de ermine adeq ac of fl id re ci a ion

C a O a C B T a
METHOD DESCRIPTION ADVANTAGE DISADVANTAGE
OPEN E po ed o air; for perficial or Allo freq en - Req ire i ola ion
bod par prone o infec ion in pec ion of i e - Area ma crape
and bleed ea il

CLOSED B rn i co ered i h nonadheren Pro ide be er Changing dre ing i

ga e; for modera e and e ere pro ec ion from inj r ; painf l; po ibili of
ea ier o rn and infec ion
po i ion child; allo
more freedom o pla

O C a T a B :
1. Hand inj rie - each indi id al finger ho ld be dre ed and mo emen enco raged
2. Facial b rn - open echniq e i h oin men e onl
3. Topical an imicrobial - il er lfadia ine and lfam lon - ed onl for major b rn and ho ld
no be ed in o pa ien
4. An b rn ha doe no heal in a mon h ho ld be referred o a b rn rgeon

Pa a F a
LR
4cc W in kg o al BSA%
(deliver over first 8hrs; then other over the ne t 16hrs)

FFP
 0.5cc W in kg o al BSA%
(deliver over the ne t four hours following fluids)

MAINTENANCE (D5W)
1cc W in kg o al BSA%

N I
1. Pro ide relief or con rol of pain
2. Moni or al era ion in fl id and elec rol e
3. Promo e ma im m n ri ional a
4. Pre en o nd infec ion
5. Pre en GI complica ion
6. Pro ide heal h eaching

❖ CEREBRAL PALSY
D
Ne rom c lar di order charac eri ed ​b a a ​ re l ing from an
abnormali in he e rap ramidal or p ramidal mo or em
CP i ca ed b damage o he mo or con rol cen er of he de eloping brain and can occ r d ring:
- Pregnanc -abo 75 percen
- Childbir h 5 percen
- Af er bir h -15 percen p o abo age hree
E
a. Prena al gene ic, mo her i h r bella, acciden , PIH
b. Perina al dr g a deli er , precipi a e deli er , breech deli erie
c. Po na al kernic er ,head r ma (fall o of crib, car acciden )
T C b a Pa
✔ Spa ic en e, con rac ed m cle (mo common pe of CP)
✔ A he oid con an , ncon rolled mo ion of limb , head and e e
✔ A a ic poor en e of balance, of en ca ing fall and mble
✔ Rigidi igh m cle ha re i effor o make hem mo e
✔ Tremor ncon rollable haking, in erfering i h coordina ion
C P b
- i al defec ( rabi m , n agm , refrac or error ),
- hearing lo
- peech or lang age dela
- ei re
- men al re arda ion
Pa Ca Ma a
1. Promo ion of op imal rehabili a ion in he area of locomo ion, comm nica ion, and he ac i i ie
of dail li ing.
2. Correc ion of a ocia ed di abili ie
M a Ma a
1. Dr g herap
- an ian ie
- kele al m cle rela an
- local ner e block
2. Speech/ a dio herap
3. Ph ical/occ pa ional herap
S rgical in er en ion are re er ed for he child ho doe no re pond o more
con er a i e mea re or for he child ho e pa ici ca e progre i e deformi .
N I
The goal of managemen i earl recogni ion and in er en ion o ma imi e he child'
abili ie
1. A m l idi ciplinar eam approach
2. A e he child' de elopmen al le el and in elligence.
3. Enco rage earl in er en ion and par icipa ion in chool program .
4. Prepare for ing mobili ing de ice .
5. Enco rage comm nica ion and in erac ion i h he child on hi or her de elopmen al le el ra her
han chronological age le el.
6. Pro ide a afe en ironmen
7. A i in ADL
8. Pro ide afe appropria e o for he child' age and de elopmen al le el.
9. Po i ion he child prigh af er meal .
10. Admini er medica ion a pre cribed o decrea e pa ici .
11. Therap

❖ INGESTION OF POISONS
Poi on an b ance ha i harmf l o he bod
- Inge ion of o ic b ance
Common agen in childhood oap , co me ic , de ergen or cleaner and plan
M
- inge ion
- inhala ion
- pra
S a S
1. GI di rbance - Vomi ing, abdominal pain, anore ia, di inc i e odor
2. Re pira or /circ la or di rbance - collap e , hock, ne plained c ano i
3. CNS manife a ion
- conf ion
- di orien a ion
- dden lo of conc
- con l ion
G a M a T a
1. Elimina ion of poi on
2. An ido e admini ra ion
3. General ppor i e mea re
G a I
1. S abili e child condi ion - pa en air a
2. Pre en ab orp ion
a. De ermine he pe of b ance inge ed
b. Ind ce eme i e cep ca ic ma erial inge ion, coma o e, ac i e ei re or lacking gag
refle
c. S r p of ipecac
d. Ga ric la age
e. Ca har ic
3. Pro ide rea men and pre en ion informa ion o paren
4. Incorpora e an icipa or g idance rela ed o he de elopmen al age of he child
5. Di c general fir aid mea re i h paren
M P
1. Child proofing he en ironmen
2. Ed ca ing paren and child
3. An icipa or g idance
4. Under anding and appl ing he principle of G/D
S P
1. Salic la e poi oning = a pirin, oil of in ergreen,
To ici begin a do e of 150 - 200 mg/kg.
S/S​ CNS depre ion
- omi ing
- re pira or fail re
2. Ace aminophen poi oning = commonl ed analge ic
 ri k li er damage
A ​ m com (​N​-Ace lc eine)
S/S​ omi ing,li er enderne , abdominal pain
3. Lead Poi oning (Pl mbi m) common in oddler and pre chooler
Lead in erfere i h RBC f nc ion
Lead al e of 15 g/dl heal h ha ard
S mp om appear hen lead le el i 70 g/dl
Mo erio effec : Lead encephali i
Air, oil, a er, ho e , ceramic cook are, older ed in me al can and pipe
S/S:
Abdominal complain colick pain
- con ipa ion
- omi ing
Pallor
Irri abili
Lo of coordina ion
Encephalopa h
(+ lead in he blood
N A
1. Admini er chela ing agen
dimercaprol (BAL in Oil) - no gi en if allerg / pean (prepared in pean oil
ol ion
eda a e calci m di odi m (calci m EDTA)
2. Pro ide n ri ional co n eling
3. Aid in elimina ing en ironmen al condi ion ha led o lead inge ion

❖ INGESTION OF POISON
A. LEAD
D
When lead en er he bod , i affec he er hroc e , bone and ee h, and organ and i e ,
incl ding he brain and ner o em; he mo erio con eq ence are he effec on he
cen ral ner o em.
Common ro e i hand o mo h from con amina ed objec or from ea ing loo e pain chip ,
cra on , or po er ha con ain lead.

C a T a
- remo e lead from he circ la ing blood and from ome organ and i e .

B a : ​U ed f c ee i g a d diag i
LEVEL INTERVENTION

Le han 10 mcg/dL Rea e or re creen in 1 ear or ooner if e po re a change .

10 o 14 mcg/dL Pro ide famil lead ed ca ion, follo - p e ing, and ocial er ice referral if
nece ar .

15 o 19 mcg/dL Pro ide famil lead ed ca ion, follo - p e ing, and ocial er ice referral if
nece ar ; on follo - p e ing, ini ia e ac ion for blood lead le el of 20 o 44
mcg/dL.

20 o 69 mcg/dL A blood lead le el grea er han 20 mcg/dL i con idered ac e; pro ide
coordina ion of care, clinical managemen , incl ding rea men , en ironmen al
in e iga ion, and leadha ard con rol ( he child m no remain in a
lead-ha ardo en ironmen if re ol ion i nece ar ).
70 mcg/dL or grea er Medical rea men i pro ided immedia el , incl ding coordina ion of care, clinical
managemen , en ironmen al in e iga ion, and lead-ha ard con rol.

B. CAUSTIC POISONING
D
Inge ion of rong alkali
Ma ca e b rn and i e necro i in he mo h, e ophag , omach
Phar ngeal edema ma ca e air a ob r c ion in ba ion migh be nece ar

❖ CHILD ABUSE
D
Child ab e in ol e emo ional or ph ical ab e or neglec , a ell a e al e ploi a ion or
mole a ion b care aker or o her indi id al .
Problem rela ed o paren limi ed abili o cope or rela e o he child
Al o ic im of ab e
✔ E a Ab
o Speech di order
o Habi di order ch a cking, bi ing, and rocking
o P chone ro ic reac ion
o Learning di order
o S icide a emp
✔ S a Ab
o Torn, ained, or blood nderclo hing
o Pain, elling, or i ching of he geni al
o Br i e , bleeding, or lacera ion in he geni al or anal area
o Diffic l alking or i ing
o Un illingne o change clo he or n illingne o par icipa e in g m ac i i ie
Poor peer rela ion
✔ P a Ab
o Une plained br i e , b rn , or frac re
o bald po on he calp
o Apprehen i e child
o E reme aggre i ene or i hdra al
o Fear of paren
o Lack of cr ing (older infan , oddler, or o ng pre chool child) hen approached
b a ranger
✔P a N
o Inadeq a e eigh gain
o Poor h giene
o Con i en h nger
o Incon i en chool a endance
o Con an fa ig e
o Repor of lack of child per i ion
o Delinq enc
G a Ca
1. Clien ill be afe
2. Child ill par icipa e i h n r e for emo ional ppor
3. Paren ill par icipa e in herap
N I
1. A end o he need of he child
2. Repor pec ed child ab e ca e o appropria e agenc
3. Pro ide role model for paren
4. Enco rage paren o be in ol ed in child care
 5. Enco rage paren o e pre heir feeling
6. Pro ide famil ed ca ion
7. Ini ia e referral for long erm follo - p
I
1. S ppor he child d ring a horo gh ph ical a e men .
2. A e inj rie .
3. Repor ca e of pec ed ab e; n r e are legall req ired o repor all ca e of pec ed
ab e o he appropria e local/ a e agenc .
4. Place he child in an en ironmen ha i afe, hereb pre en ing f r her inj r .
5. Doc men informa ion rela ed o he pec ed ab e​ ​in an objec i e manner.
6. A e paren ' reng h and eakne e , normal coping mechani m , and pre ence or
ab ence of ppor em .
7. A i he famil in iden if ing re or , ppor em , and re o rce .
8. Refer he famil o appropria e ppor gro p .
9. If haken bab ndrome i pec ed, moni or he infan ' le el of con cio ne .

❖ IRON DEFICIENCY ANEMIA

D
Iron ore are deple ed, re l ing in a decrea ed ppl of iron for he man fac re of
hemoglobin in RBC
Ca e : blood lo , increa ed me abolic demand , ndrome of GI malab orp ion, die ar
inadeq ac
More common in:
- Child bearing omen
- Poor iron in ake
- Infan and children in rapid gro h
- Pregnan /lac a ing mo her
A
1. Compen a or ach cardia
2. Pallor
3. Weakne , fa ig e, irri abili
4. Lab re l
Ma a
1. Food choice : mea , dark green & leaf ege able , egg olk , li er, kidne bean , iron-enriched
form la & cereal
2. Admini er iron pplemen a pre cribed
3. Teach paren o admini er iron pplemen :
Be een meal
Gi e i h Vi C
Do no gi e i h an acid or milk
Oral care
Side effec
4. Moni or ign and mp om of bleeding
5. Adeq a e re period
6. E plana ion of all diagno ic e

❖ CYSTIC FIBROSIS
D
Thi i a chronic m l i em di order (a o omal rece i e rai di order) charac eri ed b
e ocrine gland d f nc ion.
 The m c prod ced b he e ocrine gland i abnormall hick, enacio , and copio , ca ing
ob r c ion of he mall pa age a of he affec ed organ , par ic larl in he re pira or ,
ga roin e inal, and reprod c i e em .
CF i a fa al gene ic di order and re pira or fail re i he mo common ca e of dea h.
There i al o a marked elec rol e change in he ecre ion of ea gland
The mo common mp om are pancrea ic en me deficienc ca ed b d c blockage,
progre i e chronic l ng di ea e a ocia ed i h infec ion, and ea gland d f nc ion re l ing
in increa ed odi m and chloride ea concen ra ion .
4S Sa W C a D a
✔ maln ri ion
✔ pro beran abdomen
✔ ea orrhea
✔ fa - ol ble i amin deficienc

S
A. Re pira or
1. Whee ing and dr nonprod c i e co gh
2. D pnea
3. C ano i
4. Cl bbing of he finger and oe
5. Barrel che
6. Repea ed epi ode of bronchi i and pne monia
B. Ga roin e inal
1. Meconi m ile in he neona e
2. In e inal ob r c ion (pain, abdominal di en ion, na ea, and omi ing)
3. S ea orrhea (fro h , fo l- melling ool )
4. ea br i ing and anemia
5. Maln ri ion and fail re o hri e
6. Generali ed edema (d e o h poalb minemia)
7. Rec al prolap e (d e large, b lk ool and lack of he ppor i e fa pad aro nd he rec m)
C. In eg men ar
1. Abnormall high concen ra ion of odi m and chloride in ea
 2. Paren repor ing ha he infan a e ​ a ​ hen ki ed
3. Deh dra ion and elec rol e imbalance , e peciall d ring h per hermic condi ion
D. Reprod c i e
1. Dela p ber in girl .
2. Infer ili (highl i co cer ical ecre ion )
3. S erili (ca ed b he blockage of he a deferen b abnormal ecre ion or b fail re of
normal de elopmen of d c r c re .
Da T
1. Q an i a i e ea chloride e he mo reliable diagno ic e
✔ Pilocarpine​ ​ a cholinergic dr g ha im la e prod c ion of ea
- he ea i collec ed, and he ea elec rol e are mea red
✔ Normal - if ea chloride concen ra ion i 20 meq/L or lo er han 40mEq/L.
✔ Chloride concen ra ion of 50 o 60 mEq/L are highl gge i e of c ic fibro i and
req ire a repea e .
✔ A chloride concen ra ion higher han 60 mEq/L i a po i i e e re l .
2. Che -ra film re eal a elec a i and ob r c i e emph ema.
3. P lmonar f nc ion e pro ide e idence of abnormal mall air a f nc ion.
4. S ool, fa , en me anal i : A 72-ho r ool ample i collec ed o check he fa and/or en me
( r p in) con en (food in ake i recorded d ring he collec ion).
5. D odenal anal i na oga ric be i in er ed o a pira e d odenal ecre ion
T a Ma a
1. Re pira or S em
Goal of rea men incl de pre en ing and rea ing p lmonar infec ion b impro ing aera ion,
remo ing ecre ion , and admini ering an imicrobial medica ion .
a. Che ph io herap
b. Aero ol Therap
- Bronchodila or
- An imicrobial
- M col ic
c. U e of a Fl er M c Clearance De ice (a mall, hand-held pla ic pipe i h a ainle
eel ball on he in ide)
d. U e of a ThAIRap e de ice ha pro ide high-freq enc che all o cilla ion o help
loo en ecre ion
2. Ga roin e inal S em
The goal of rea men for pancrea ic in fficienc i o replace pancrea ic en me
The amo n of pancrea ic en me admini ered i adj ed o achie e normal gro h and a
decrea e in he n mber of ool o o or hree dail .
a. En eric-coa ed pancrea ic en me ho ld no be cr hed or che ed.
b. Pancrea ic en me ho ld no be gi en if he child i NPO.
c. Enco rage a ell-balanced, high-pro ein, high-calorie die ; m l i i amin and i amin A, D,
E, and K are al o admini ered.
d. A e eigh and moni or for fail re o hri e.
e. Moni or for con ipa ion and in e inal ob r c ion.
f. En re adeq a e al in ake and fl id ha pro ide an adeq a e ppl of elec rol e
d ring e remel ho ea her and if he child ha a fe er.
H a
1. In r c he child and famil abo he pre cribed rea men mea re and heir impor ance.
2. In r c he paren and caregi er o be re imm ni a ion are p o da e.
3. Inform he paren and caregi er ha he child ho ld be accina ed earl for infl en a;
pne mococc accine ma al o be pre cribed.

❖ CELIAC DISEASE (G -I E a )
D
Malab orp ion S ndrome
 I a en i i i or imm nologic re pon e o pro ein, par ic larl he gl en fac or of pro ein fo nd
in grain of hea , barle , r e, and oa
Re l in he acc m la ion of he amino acid - gl amine, hich i o ic o in e inal m co al
cell .
In e inal illi a roph occ r , hich affec ab orp ion of inge ed n rien .
A
1. Ac e or in idio diarrhea
2. S ea orrhea
3. Anore ia
4. Abdominal pain and di en ion
5. M cle a ing, par ic larl in he b ock and e remi ie
6. Vomi ing
7. Anemia
8. Irri abili
C a C
Precipi a ed b infec ion, fa ing, inge ion of gl en
E reme and ac e prof e a er diarrhea and omi ing occ r
Can lead o elec rol e imbalance, rapid deh dra ion, e ere acido i
In en i e herap o replace fl id and elec rol e i req ired
I
1. Main ain a gl en-free die , b i ing corn, rice, and mille a grain o rce .
2. In r c paren and child abo lifelong elimina ion of gl en o rce ch a hea , r e, oa , and
barle .
3. Admini er mineral and i amin pplemen , incl ding iron, folic acid, and fa - ol ble pplemen A,
D, E, and K
4. Teach he child and paren abo a gl en-free die and abo reading food label caref ll for hidden
o rce of gl en
5. In r c he paren in mea re o pre en celiac cri i .
Ba aG -F D
✔ FOODS ALLOWED
Mea ch a beef, pork, and po l r and fi h, egg , milk and dair prod c , ege able , fr i , rice, corn,
gl en-free hea flo r, p ffed rice, cornflake , cornmeal, and precooked gl en-free cereal
✔ FOODS PROHIBITED
Commerciall prepared ice cream, mal ed milk, prepared p dding ,grain , incl ding an hing made from
hea , r e, oa , or barle , ch a bread , roll , cookie , cake , cracker , cereal, paghe i,
macaroni noodle & beer
P
✔ Die ar a oidance of gl en re l in impro emen of mp om in 70% of pa ien i hin 2
eek
✔ Serologic an ibod i er decrea e on a gl en-free die
- Af er 3-6 mon h an ibod le el ma become nde ec able
- Comple e hi ological re ol ion of mall bo el inflamma ion ma ake p o 2 ear
 HIGH I K E CH LE

B ONCHIAL A HMA
it is an obstructi e disease of the lo er respirator tract
often cause b an allergic reaction to an en ironmental allergen
allergic reaction results in histamine release - air a responses
Allergic reaction results to 3 main air a responses
a. Edema of mucous membrane
b. Spasm of the smooth muscles
c. accumulation of secretions
Risk Factor
a. Famil histor of allergies and asthma
b. Client histor of ec ema
Clinical manifestations
a. E pirator hee e
b. Cough
c. Thick tenacious
d. Barrel chest if chronic
e. Se ere attack
f. Shortness of breath
g. Use of accessor muscles
h. Retractions
i. Nasal flaring
j. Irritabilit ( earliest sign h po ia)
k. Diaphoresis
Diagnosis
a. ABG respirator acidosis
b. Peak flo meter- An objecti e a to measure air a obstruction
The most reliable earl sign of an asthma attack is a drop in the in the child peak
e pirator flo rate
Medical management
a. Drug therap
Brochodilators - Beta-2-agonist bronchodilator, anthine deri ati e
Antiasthma- Corticosteroids, Mast cell stabili er , leukotriene inhibitors
Antibiotics
b. H posensiti ation
c. E ercise aimed to increased e pirator function
Nursing inter entions
1. Place client in high fo ler s position
2. Administer o gen as ordered
3. Administer medications as ordered
4. Pro ide good h dration
5. Pro ide chest ph siotherap
6. Promoting energ conser ation
7. Monitor respirator function
8. Pro ide famil health teachings

ILM MO
Nephroblastoma
A large malignant tumor that de elops in the renal parench ma
Arises from bits of embr onic tissue that remains after birth
It accounts for 20% of solid tumors in childhood
Tumor is rarel disco ered until it is large enough to be palpated
Assessment
Palpable mass
Hematuria
 H pertension
Anemia
Lo grade fe er
Diagnostic tests
Sonogram
CT scan
IVP- intra enous p elogram
Staging of Nephroblastoma
a. stage 1: limited to kidne
b. stage II: tumor e tends be ond kidne but completel encapsulated
c. stage III: tumor confined to abdomen
d. stage IV: tumor has metastasi ed to lung, li er, bone or brain
e. stage V : bilateral renal in ol ement
Management : Post a isible sign NO ABDOMINAL PALPATION
1. Surger - nephrectom
2. Radiation therap
3. Chemotherap
Nursing inter ention
PRE OPERATIVE POST OPERATIVE
1. Do not palpate the abdomen 1. Assess the respirator , circulator , fluid and
2. Handle the child carefull electrol tes status
3. Monitor BP, Intake and output 2. Monitor patenc and adequac of urinar output
4. Pro ide routine preoperati e care 3. Obser e for an post operati e complications
4. Pro ide care for child recei ing radiation and
chemotherap

INA AC INFEC ION

It is a bacterial in asion of the kidne s or bladder
E. Coli accounts for about 80% of acute episodes
Predisposing factors: Poor h giene, Irritation from bubble
Assessment findings
1. Lo grade fe er
2. Abdominal pain lo er region
3. Burning pain upon urination
4. Hematuria
5. Foul-smelling
6. Urinar frequenc
7. Enuresis common sign for preschooler
Diagnostic test: Urine anal sis presence of pus cells
Treatment: Antibiotic, Analgesic and antispasmodic and Increase fluid intake
Nursing inter ention
1. Administer antibiotics as ordered
2. Pro ide arm baths and allo to oid in ater
3. Force fluids
4. Encourage measures to acidif urine
5. Pro ide health teaching:
A oidance of tub bath
A oidance of bubble bath
For girls to ipe perineum from front to back

GL ME ONEPH I I
Refers to a group of kidne disorders characteri ed b inflammator injur in the glomerulus, most of
hich are caused b an immunological reaction.
Causes:
1. Immunological diseases
 2. Autoimmune diseases
3. Antecedent group A beta-hemol tic streptococcal infection of the phar n or skin
4. Histor of phar ngitis or tonsillitis 2 to 3 eeks before s mptoms
T pes
1. Acute: Occurs 2 to 3 eeks after a streptococcal infection
2. Chronic: Can occur after the acute phase or slo l o er time
Assessment
1. Periorbital and facial edema that is more prominent in the morning
2. Anore ia, h pertension
3. Decreased urinar output
4. Cloud , smok , bro n-colored urine (hematuria)
5. Pallor, irritabilit , letharg
6. In the older child, headaches, abdominal or flank pain, d suria
7. Proteinuria that produces a persistent and e cessi e foam in the urine
8. A otemia
9. Increased blood urea nitrogen and creatinine le els
10. Increased antistreptol sin O titer (used to diagnose disorders caused b streptococcal
infections)
Inter entions
1. Monitor ital signs, eight, intake and output, and the characteristics of urine.
2. Limit acti it ; pro ide safet measures.
3. Pro ide high-qualit nutrient foods.
a. Restrictions depend on the stage and se erit of the disease, especiall the e tent of the
edema.
b. In uncomplicated cases: Regular diet is permitted but sodium is restricted to a no added
salt to foods diet.
c. Moderate sodium restriction: H pertension or edema.
d. Foods high in potassium are restricted during periods of oliguria.
e. Protein is restricted if the child has se ere a otemia resulting from prolonged oliguria.
4. Monitor for complications
5. Administer diuretics, antih pertensi es, and antibiotics as prescribed.
6. Instruct the parents to report signs of blood urine, headache, or edema.
7. Instruct the parents that the child needs to obtain appropriate adequate treatment for infections,
specificall infections.

NEPH O IC ND OME
is a kidne disorder characteri ed b massi e proteinuria, h poalbuminemia, h perlipidemia, and
edema.
Autoimmune process
The primar objecti e of therapeutic management is to reduce the e cretion of urinar protein and
maintain protein-free urine.
Assessment
a. Periorbital and facial edema is most prominent in the morning.
b. Leg, ankle, labial, or scrotal edema occurs.
c. Urine output decreases; urine is dark and froth .
d. Ascites (fluid in the abdominal ca it )
e. Blood pressure is normal or slightl decreased.
f. Massi e proteinuria is seen.
g. Decreased serum protein (h poproteinemia) and ele ated serum lipid le els occur.
Inter entions
1. Monitor ital signs, intake and output, and dail eights.
2. Monitor urine for specific gra it and albumin.
3. Monitor for edema.
4. Nutrition: A regular diet ithout added salt is prescribed if the child is in remission; sodium is
restricted during periods of massi e edema.
 5. Corticosteroid therap is prescribed as soon as the diagnosis has been determined; monitor
the child closel for signs of infection.
6. Immunosuppressant therap (reduce the relapse rate and induce long-term remission)
7. Diuretics ma be prescribed to reduce edema.
8. Plasma e panders such as salt-poor human albumin ma be prescribed for the se erel
edematous child.
9. Instruct the parents regarding the signs of infection and the need to a oid contact ith other
children ho ma be infectious.

Comparison of features of acute glomerulonephritis and nephrotic s ndrome

Assessment Factor Acute Glomerulonephritis Nephrotic s ndrome

Cause Immune reaction to group A -hemol tic Idiopathic; possibl

streptococcal infection h persensiti it

Onset abrupt insidious

Hematuria Grossl blood rare

Edema mild mild

Peak age 5 10 ears 2-3 ears old

Diet No added salt if child is h pertensi e High protein, lo salt

Inter ention Limited acti it ; antih pertensi es as Bed rest during edema stage;
needed corticosteroid;

LE KEMIA
(refers to cancers of the hite blood cells)
proliferation of abnormal hite blood cells that do not mature be ond the blast phase
In the bone marro , blast cell cro d out health hite blood cells, red blood cells, and platelets,
leading to bone marro depression
Blast cells also infiltrates other organs, most commonl the li er, spleen, kidne s, and l mph tissue
T pes:
1. Acute L mphoc tic Leukemia
a. Primaril strikes children and oung adults
b. 80 85 % of childhood leukemia
c. the malignant cell in ol ed is the l mphoblast
2. Acute M eloid Leukemia
a. Also kno n as Acute nonl mphoc tic Leukemia
b. Cells in ol ed is the granuloc tes

Classified:
1. Acute (rapidl de eloping)
2. Chronic (slo l de eloping) forms.
Assessment Findings
1. Anemia ( eakness , pallor, d spnea)
2. Bleeding (petechiae, bruise
3. Infection (fe er, chills, malaise)
4. Enlarged l mph nodes
5. Enlarged spleen and li er( splenomegal and hepatomegal )
6. Abdominal pain
 7. Bone and joint pain
Diagnosis:
blood studies
bone marro aspiration
Lumbar tap
Xra of bone
Management : Goal of care: complete cure
1. Chemotherap
a. Treatment Phase:
Induction achie ing complete remisssion or absence of leukemic cells
Consolidation / Sanctuar - pre enting leukemic cells from in ading or
gro ing in the CNS
Maintenance - aims to eliminate completel an remaining leukemic cells; or
maintaining remission
o Intensifies the assault against leukemic cells using chemotherap
o Gi en for 2 to 3 ears
b. T o additional phases are instituted for children ho e perience relapse
Reinduction- Administration of the drugs pre iousl used plus additional
drugs
Bone marro transplant- Usuall recommended after the second remission
in children
Nursing inter ention
1. Pre enting infection
2. Reducing pain
3. Promoting energ conser ation and relie ing an iet
4. Promoting normal gro th and de elopment
5. Promoting a positi e bod image
6. Promoting famil coping

ON ILLI I AND ADENOIDI I

Tonsillitis refers to inflammation and infection of the tonsils.
Adenoiditis refers to inflammation and infection of the adenoids.
Assessment
a. Persistent or recurrent sore throat
b. Enlarged, bright red tonsils that ma be co ered ith hite e udate
c. Difficult in s allo ing
d. Mouth breathing and an unpleasant mouth odor
e. Fe er
f. Cough
g. Enlarged adenoids ma cause nasal qualit of speech, mouth breathing, hearing difficult ,
snoring, and/or obstructi e sleep apnea.
Preoperati e inter entions
1. Assess for signs of acti e infection.
2. Assess bleeding and clotting studies because the throat is ascular.
3. Prepare the child for a sore throat postoperati el , and inform the child that he or she ill
need to drink liquids.
4. Assess for an loose teeth to decrease the risk of aspiration during surger .
Preoperati e inter entions
1. Position the child prone or side-l ing to facilitate drainage.
2. Ha e suction equipment a ailable, but do not suction unless there is an air a obstruction.
3. Monitor for signs of hemorrhage (frequent s allo ing ma indicate hemorrhage); if
hemorrhage occurs, turn the child to the side and notif the ph sician.
4. Discourage coughing or clearing the throat.
5. Pro ide clear, cool, non citrus and noncarbonated fluids.
6. A oid milk products initiall because the ill coat the throat.
7. A oid red liquids, hich simulate the appearance of blood if the child omits.
 8. Do not gi e the child an stra s, forks, or sharp objects that can be put into the mouth.
9. Administer acetaminophen (T lenol) for sore throat as prescribed.
10. Instruct the parents to notif the ph sician if bleeding, persistent earache, or fe er occurs.
11. Instruct the parents to keep the child a a from cro ds until healing has occurred.

KA A AKI DI EA E
is kno n as mucocutaneous l mph node s ndrome and is an acute s stemic inflammator illness.
The cause is unkno n but ma be associated ith an infection from an organism or to in.
Cardiac in ol ement is the most serious complication; aneur sms can de elop.
Assessment
ACUTE STAGE SUBACUTE STAGE CONVALESCENT STAGE
Fe er Cracking lips and fissures Child appears normal but signs of
Conjuncti al h peremia Desquamation of the skin on the inflammation ma be present.
Red throat tips of the fingers and toes
S ollen hands, rash, and Joint pain
enlargement of the cer ical Cardiac manifestations
l mph nodes Thromboc tosis

Diagnosis
o fe er 3/5da s
o + 4/5 diagnostic criteria
1. er thema
2. rash on trunk
3. s elling of hands or feet
4. red e es
5. s ollen l mph nodes
Inter entions
a. Monitor temperature frequentl .
b. Assess heart sounds, rate, and rh thm.
c. Assess e tremities for edema, redness, and desquamation.
d. E amine e es for conjuncti itis.
e. Monitor mucous membranes for inflammation.
f. Monitor strict intake and output.
Medication: IVIG, aspirin, steroids
Parent education
1. Follo -up care is essential to reco er .
2. The signs and s mptoms of Ka asaki disease include the follo ing:
3. Irritabilit ma last up for up to 2 months after the onset of s mptoms.
4. Peeling of the hands and feet ma occur.
5. Pain in the joints ma persist for se eral eeks.
6. Stiffness in the morning, after naps, and in cold temperatures ma occur.
7. Record the temperature until child has been afebrile for se eral da s.
8. Notif the ph sician if the temperature is 101 F or higher.
9. Salic lates such as acet lsalic lic acid (aspirin) ma be gi en.
10. Signs of aspirin to icit include tinnitus, headache, ertigo, bruising; do not administer
aspirin or aspirin-containing products if child has been e posed to chickenpo or the flu.
11. S/s of bleeding: epista is, hemopt sis, hematemesis, hematuria, melena, and bruises
on bod .
12. S/s of cardiac complications chest pain or tightness (older children), cool and pale
e tremities, abdominal pain, nausea and omiting, irritabilit , restlessness, and
uncontrollable cr ing.
13. Child should a oid contact sports, if age appropriate, if taking aspirin or anticoagulants.
14. A oid administration of MMR or aricella accine to the child for 11 months
post intra enous immune globulin therap , if appropriate.
 COMMON HEALTH PROBLEMS IN SCHOOLAGE CHILDREN

PEDICULOSIS
Description
Head lice
Parasitic Infection
Spread by close physical contact
Occurs in school age, particularly with long hair

Findings
White eggs firmly attached to base of hair shafts
Pruritus of scalp

Management
Special shampoos
Fine tooth comb

Nursing Intervention
1. Institute skin isolation precautions
- Head covering
- Gloves
2. Use specific shampoo/comb
3. Provide health teachings on treatment and prevention
- Check on other family members
- Washing of bed linens
- No sharing of combs and hats

IMPETIGO
Description
Superficial bacterial infection of the outer layers of the skin
Etiology: Staphylococcus aureus/ Beta H. streptococcus
Incubation period 2 to 5 days;
Period of communicability outbreak of lesion until healed
Mode of transmission direct contact

Assessment Findings
Well demarcated lesions
Macules,vesicles, papule that rupture - moist erosion
Once most area dries; honey colored crust
Pruritus

Management
Topical antibiotic bactroban
Systemic antibiotic - penicillin or erythromycin

Nursing Management
1. Implement skin isolation techniques
2. S f e ki a d c ihb l i ; he e e c l l
3. Cover lesion to prevent spread of infection
4. Remove crust gently
5. Administer antibiotics as ordered
6. Health teachings

SCABIES (THE ITCH)

Description
A contagious skin infestation caused by the scabies mite Sarcoptes scabiei
Characterized by :
- superficial burrows
- intense pruritus(itching)
- Papular rash
Mites are small eight-legged parasites,they are tiny (not visible with the naked eye), and burrow
into the skin to produce intense itching, which tends to be worse at night.
Scabies may involve:
webs between the fingers,
wrists
Elbows
knees,
waist
umbilicus,
axillary folds,
around the nipples,
sides and backs of the feet,
genital area, and the buttocks.

Management
Medication (SCABICIDES) - Permethrin cream / Lindane lotion
- Lindane should not be used in children younger than 2 years because of the risk of
neurotoxicity and seizures.
Instruction:
body is scrubbed with soap
and water before application
left on the skin for 8 14 hours
then completely washed with warm water
Stress importance of proper hygiene

Interventions
When permethrin is used, the cream is massaged thoroughly and gently into all skin surfaces
from the head to the soles of the feet; care should be taken to avoid contact with the eyes.
Household members and contacts of the infected child need to be treated at the same time.

RHEUMATIC FEVER
Description
An inflammatory disorder that may involve the connective tissue of heart, joints,lungs and brain
Is an autoimmune disease that occurs as a reaction to a group A beta-hemolyticstreptococcal
infection
It is precipitated by streptococcal infection which is undiagnosed and untreated
Antigenic markers for streptococcal toxin closely resemble markers of the heart valves; this
resemblance causes antibodies made against the streptococcal to also attacks the heart valve

Assessment Findings
Divided to major and minor symptoms according to Jones criteria
5 major symptoms/criteria
1. Carditis - inflammation of the heart muscle around
- hea al e ; a ch ff d le
2. Polyarthritis/Migratory Polyarthritis a temporary migrating inflammation of the large joints
3. Chorea S de ha ch ea; S . Vi da ce
- A CNS disorder characterized by abrupt, purposeless involuntary movement
4. Subcutaneous nodules painless, firm collections of collagen fibers over bones or tendons
5. Erythema marginatum transient, non pruritic rash (resembles giraffe spots)
 Minor symptoms/criteria
Clinical findings
Arthralgia
Fever
Laboratory findings
Erythrocyte sedimentation rate
C-reactive protein
antistreptolysin O (ASO) titer
ECG - Prolonged PR interval
leukocytosis
Evidence of previous group A streptococcal infection
(+) Throat culture or rapid streptococcal antigen test

Two of the major criteria, or one major criterion plus two minor criteria, are present along
with evidence of streptococcal infection.
Exceptions are chorea and indolent carditis each of which by itself can indicate rheumatic
fever.

Medical management
1. Drug therapy
a. Penicillin used in acute phase
- given as prophylactic until age 20 or for 5 years
- Erythromycin as substitute
b. Salicylates analgesics, anti-inflammatory, antipyretic effect
c. Steroids anti-inflammatory effect
2. Bed rest is essential during the active process of rheumatic fever to reduce cardiac workload
- 1 week to 6 months

JUVENILE RHEUMATOID ARTHRITIS

Description
Systemic, chronic disorder of connective tissue resulting from an autoimmune reaction
Primarily involves joints
results in eventual joint destruction
affected by stress, climate
genetic predisposition may increase the risk in some people
More common in girls; peak age 1 to 3 years and 8 to 12 years

Types
1. Monoarticular / pauciarticular - involving 4 joints or less joints usually large joints affected,
such as knee, ankles or elbow of one side of body (asymmetric)
- generally mild signs of arthritis
- mild fever
- Other symptoms such as:
- Iridocyclitis (eye inflammation)
- Uveitis (inflammation of the iris, ciliary body, choroid mebrane)
- Painless joint swelling with little redness

2. Polyarticular
- multiple joints affected (five or more)
- usually small joints of finger and hands are affected also possibly weight-bearing
joints often same joint on both sides of the body(symmetrical) disability may be mild
or severe with periods of remission and exacerbations
- low grade fever
- Other symptoms such as:
- stiffness and minimal joint swelling limited motion
 - rheumatoid nodules

3. Systemic Disease with Polyarthritis (S i Di ea e)

- any joints might be affected
- begins with high fever associated with macular rash on chest, thigh
- Other symptoms included are:
- anemia
- anorexia
- weight loss
- splenomegaly, hepatomegaly, lymphadenopathy

Assessment Findings
Painful joints, warm and swollen
Muscle weakness
Affected area has limited motion
Crippling deformity due to reversible changes in joint cartilage due to inflammation
Fatigue, anorexia, malaise, weight loss

Diagnostic Tests
X-ray
CBC
Erythrocyte sedimentation rate (ESR)
C-reactive protein
ANA
Rheumatoid Factor

Medical management
To relieve pain, restore function and maintain joint mobility

1. Drug Therapy
Aspirin analgesic and anti-inflammatory effect
NSAIDS (nonsteroidal anti-inflammatory drugs)
Gold compounds (Chrysotherapy)
Corticosteroids
Methotrexate

2. Physical Therapy/exercise to minimize joint deformity

3. Surgery to remove severely damaged joints
- Total hip replacement
- Knee replacement
4. Heat application splinting

Gold Therapy - It is believed that gold attaches itself to certain proteins (albumin). Once
absorbed into the cell, it is then purported to kill particular cells in order to affect the
inflammation and erosion of joints. It does not necessarily act as a cure, but is rather believed
to merely relieve symptoms of joint disease.

Nursing Interventions
1. Assess joints for pain, swelling, tenderness, or limitationof motion
2. Promote maintenance of joint mobility
3. Change position frequently
4. Promote comfort and relief of pain
5. Ensure bed rest
6. Provide heat treatments
7. Provide cold treatments as ordered acute
8. Provide psychologic support and encourage to verbalize feelings
 DIABETES MELLITUS
Description
Is a condition resulting from dysfunction of the beta (insulin- secreting) cells of islet of Langerhans in
the pancreas
There is a lack pancreatic hormone INSULIN which is essential for carbohydrate metabolism and
is important to the metabolism of fats and protein

Hyperglycemia
Excessive accumulation of sugar in the bloodstream
2 major types:
1. DM Type I
- formerly called Insulin Dependent Diabetes (IDDM)
- Juvenile diabetes
- common in children; affect 1 in 1500 below 5 years and increases to 1 in every 350
children by age 16
- due to destruction of beta cells in the Islets of Langerhans
2. DM Type II
- Formerly called non insulin dependent
- occurs in adults / obese individual
- may result from partial deficiency of insulin production and insulin resistance

Assessment Type I Type II

Age of onset 5 7 yr / puberty Increasingly occurring in

younger children
Type of onset abrupt Gradual
Weight Marked wt loss Associated with obesity
changes

Other Polydipsia Polydipsia

symptoms Polyuria Polyuria
Polyphagia Fatigue
Fatigue Blurred vision
Blurred vision Glycosuria
Glycosuria Pruritus
Pruritus
therapy insulin Diet
Diet Regular exercise
Regular exdercise Hypoglycemic agent
Foot care Skin and foot care

Period 1-12 months after initial Not demonstrable

of remission diag i h e
ei d

DIABETIC KETOACIDOSIS (DKA)

Description
Is a potentially life-threatening complication in patients with diabetes mellitus type I
Ketones bodies, the acid end-product of fat breakdown, begin to accumulate in the blood stream and
spill into the urine
Characterized by drowsiness, dry skin, flushed cheeks,and cherry red lips, acetone breath with fruity
smell and Kussmaul breathing( abnormal increase in the depth and rate of the respiratory
movement)

Risk Factors for Type 1 Diabetes

Autoimmunity
Inherited (or genetic) factors
Environmental
- A virus or chemical
- Injuring the pancreatic cells

Diagnosis
Fasting blood sugar 126 mg/dl
Random blood sugar 200 mg/dl
2 hours oral glucose tolerance test (OGTT) 200 mg/dl or greater
Glycosylated hemoglobin ide i f a i ab ha he child gl c e le el ha e bee
during the preceding 3 to 4 months

Management for Type I Diabetes

Goal: to keep your blood sugars as close to normal as possible to prevent the complications
of diabetes
1. Insulin Therapy
- Dosage of insulin is adjusted according to blood glucose level
- A short acting and intermediate acting insulin is usually given (70/30 insulin)
- Adverse effect: insulin reaction (insulin shock or hypoglycemia)
- Glucose monitoring
- Rotate site to prevent lipodystrophy/lipohypertrophy
2. Meal planning
- Calories should be made up of 50-60% carbohydrates,15 -20% protein, and no more
30% 0f fats
- Avoid simple sugar; serve complex carbohydrates
- Make sure the child would not skip meals
- Teach child about food plan so that he can independently choose food selection
3. Exercise
- Exercise decrease the blood glucose level because carbohydrates are being burned
for energy
4. Stress management
5. Blood glucose and urine ketone monitoring

Nursing Intervention
1. Provide special diet diabetic diet
2. Monitor urine sugar or blood sugar levels
3. Observe for signs of hypoglycemia and hyperglycemia
4. Provide meticulous skin care
5. Monitor Intake and Output every shift, weigh daily
6. Provide emotional support
7. Observe for complications
 NCM 102
HIGH RISK Children
HIGH RISK ADOLESCENT

COMMON HEALTH PROBLEMS IN ADOLESCENT

SCOLIOSIS
a lateral curvature of the spine
five times more common in girls and has peak incidence at 8 to 15yrs
Majority (75%) - idiopathic has a familial pattern (30% of children with scoliosis)
associated with other neuromuscular disorders
Forms :
Structural / Progressive form
S cur e of the spine
usually idiopathic
does not disappear with position changes needs more aggressive treatment
Functional/ Postural/Non structural
C cur e of the spine
cause by poor posture, muscle spasm due to trauma, or unequal length of legs
disappears when child lies down can be treated with posture exercise
Assessment findings
Uneven shoulders
Uneven hips
Asymmetry of rib cage
Unequal length of bra strap
Bump or rib hump on one side of the spine
Diagnosis
For ard bend test/ Adam s bend test
a test used most often in schools and doctor's offices to screen for scoliosis
Scoliometer a commercial device used to document the extent of spinal curve
Radiograph (X-ray)- assess the angle of the curve and determine extent of deformity
Management - Depends on the maturity of the skeleton and on the degree of curvature
Spinal curve of less 20 degree
no therapy
observation until 18years of age
Spinal curve greater than 20 degree
conservative, nonsurgical approach
braces
traction
Plaster jacket cast
Spinal curve of more than 40 degree surgery
Spinal fusion with insertion of Harrington rod
Electrical stimulation
Use as an alternative for braces
Electrodes are applied to the skin or surgically implanted
Electrical stimulation is usually employed at night, during sleeping hours
To stimulate muscle to contract to straighten the spine
Stretching exercises of the spine for non structural changes
Nursing intervention
1. Provide care for child with brace
a. Teach the child to wear it constantly, except when bathing
b. wear over a t-shirt to protect the skin
c. report if there is rubbing
d. encourage exercise as prescribed
2. Provide cast or traction care
 a. Frequent cleansing on the pin sites
b. Provide diversional activities
c. Monitor for signs of complications
3. Provide preoperative and post operative nursing care
a. Deep breathing exercise
b. Use of incentive spirometry
c. Log roll; do not raise the head of the bed
4. Stress correct body mechanics
a. Promoting mobility, positive body image and compliance with therapy
b. Preventing injury and
c. Preventing skin irritation

BONE TUMORS
a. Sarcoma tumors arising from connective tissue, such bones and cartilage, muscle, blood vessels or
lymphoid tissue
b. common neoplasm in adolescent
c. Arise during adolescent because of rapid bone growth
d. Two most frequently occuring types of bone cancer:
a. Osteogenic Sarcoma
A malignant tumor tumor of long bone involving rapidly growing bone tissue (
mesenchymal matrix forming cells)
characterized by formation of osteoid (immature bones)
Common sites of occurrence
a. distal femur 50%
b. Proximal tibia 20%
c. Proximal humerus 10 to 15%
High incidence in children expose to radiation and with retinoblastoma
Lungs common site of metastasis
Assessment
a. pain
b. Swelling, redness
c. Tender mass, warm to touch
d. Limitation of movement
e. Pathologic fracture
Diagnosis
a. Bone Biopsy
b. Ct scan
c. Bone scan
Management
1. Surgery
a. Limb salvage procedures
b. Bone or skin grafts
c. Amputation
d. Reconstructions
e. Resections of metastases
2. Radiation therapy
3. Chemotherapy
4. Rehabilitation
a. physical and occupational therapy
b. psychosocial adapting
c. prosthesis fitting and training
d.
Nursing management
a. Provide routine preoperative care
b. Offer support or encouragement and accept client s response of anger and
grief
 c. Discuss to patient and family
a. rehabilatation program and use of prosthesis
b. crutch walking
c. phantom limb sensation as normal recurrence
d. Prevent hip and knee contractures prone position several times a day (unless
otherwise ordered)
e. Provide stump care
b. E ing s Sarcoma
Malignant tumor arising most often in the bone marrow of the diaphysis area
(midshaft) of long bones
The diaphyses of the femur are the most common sites, followed by the tibia and the
humerus
Lungs is the most frequent site of metastasis
Clinical Findings
a. Pain and swelling on affected part
b. Palpable mass
c. Tender and warm to touch
d. 15- 35% of clients have metastasis at time of diagnosis
Management
a. High doses of radiation therapy
b. Chemotherapy
c. Surgery
Diagnosis
X-ray
Bone scan
Biopsy
Bone marrow aspiration
Nursing intervention
Caution adolescent to continue to be careful and avoid activities that may
cause added stress to affected limb such as football and weight lifting

SEXUALLY TRANSMITTED DISORDERS

are those disease spread through sexual contact
A. Gonorrhea
Causative agent Neisseria Gonorrhea
Signs & symptoms: often asymptomatic in females purulent yellow-green vaginal
discharge
May cause ophthalmia neonatorum and sepsis to newborn
Treatment:
a) Penicillin
b)Erythromycin
c) Ceftriaxone
d)Doxycycline

B. Chlamydia
Chlamydia trachomatis
Most common STD
Signs & symptoms:
i. watery, gray-white vaginal discharge
ii. vulvar itching
May causes ophthalmia neonatorum, sterility in female or male, tubal pregnancy
Drug: doxycycline or tetracycline, azithromycin,
C. Syphilis
Treponema pallidum (spirochete)
Crosses placenta after 16 week of pregnancy
Manifestation
 i. Primary cardinal sign CHANCRE - a hard red painless lesion @ the point of
infection site disappear without treatment in 4-6 weeks
ii. Secondary - rash, malaise, alopecia
iii. Tertiary
iv. effect any organ system cardiovascular, neurovascular system
Treatment : penicillin or erythromycin
D. Trichomoniasis
Trichomonas vaginalis - a single-cell protozoan
Sign & symptoms: thin, irritating, frothy gray- green discharge, strong odor, itching to
genitalia
Treatment:
i. Metronidazole
ii. douche with weak vinegar solution to reduce pruritus
E. Candidiasis
Candida Albicans - fungus
Caused by a yeast transmitted from GI tract to vagina
Sign & symptoms thick , white cheese-like vaginal discharges, vulvar reddening and
pruritus
Treatment:
i. topical application or suppositories of antifungal drug such as:
clotrimazole , nystatin, miconazole, diflucan, gentian violet
ii. Bathing with diluted sodium bicarbonate solution to reduce pruritus

ANOREXIA NERVOSA
A disorder characterized by refusal to maintain a minimally normal body weight because of a
disturbance in perception of the size or appearance of the body
an eating disorder characterized by extremely low body weight, body image distortion and
an obsessive fear of gaining weight.
May be manifested as severe weight restriction controlled by:
a. limiting food intake
b. excessive exercise
c. binge eating/purging
Clinical findings and diagnosis(The American Psychiatric Association Criteria for Diagnosis)
body mass index less than 85% of expected weight
intense fear of getting fat or gaining weight even though underweight
severely distorted body image
refusal to acknowledge seriousness of weight loss
amenorrhea
Manifestation
Almost skeleton-like appearance
Sexually immature
Dry skin, brittle nails
Presence of lanugo
Constipation, hypothermia, bradycardia, low blood pressure
Anemia
Depression, social withdrawal and poor individual coping
Management
1. Nutritional therapy
a. Total parenteral nutrition
b. Enteral tube feeding
2. Behavior modification
3. Medication - antidepressant
4. Counselling
a. Individual therapy
b. Group therapy
c. Family therapy
BULIMIA NERVOSA
Bulimia refers to recurrent and episodes binge eating and purging
accompanied by an awareness that eating pattern is abnormal but not being able to stop
Bulimic person is of normal of weight or slightly overweight or underweight
may abuse purgative, laxatives and diuretic to aid in weight control
Clinical manifestation and Diagnosis
Dental caries and erosion
Throat irritation
Electrolytes imbalance- hypokalemia
Behavior problem
drug abuse
alcoholism
stealing
impulsive activities
American Psychiatric Association the criteria for bulimia are:
Recurrent episodes of binge eating
A feeling of lack of control over behavior during binges
Self-induced purging; use of laxatives, diuretics, enemas
Average of at least two binge-eating episodes a week during 3 months period
Obsessiveness regarding body weight and shape
Management
Pharmacology antidepressant
Psychotherapy
Nursing intervention
1. Monitor vital signs
2. Monitor intake and output
3. Record food intake
4. Monitor weight
5. Encourage client to express feelings
6. Help client to set realistic goal for self
7. Help client identify interest and positive aspect of self

OBESITY
An excessive accumulation of fat that increases body weight by 20% or more
Obesity is now among the most widespread medical problems affecting children and adolescents
living in the United States and other developed countries.
Obesity increases the child's risk of of serious health problems such as heart disease, DM type 2
and stroke
Causes
Many different factors contribute to this imbalance between calorie intake and
consumption
Genetic factors- Obesity tends to run in families
Dietary habits
fast food, processed snack foods, and sugary drinks
use food as means of satisfying emotional needs
Indulging in late night eating
Physical inactivity- The popularity of television, computers, and video games
results into an increasingly sedentary lifestyle
Management
Lifestyle modification,
Physical activity,
Nutrition education
Ways to manage obesity in children and adolescents include:
1. Start a weight-management program
 2. Change eating habits (eat slowly, develop a routine)
3. Plan meals and make better food selections
4. Increase physical activity and have a more active lifestyle
5. Know what your child eats at school
6. Do not use food as a reward
7. Limit snacks
8. Attend a support group (e.g., Overeaters Anonymous)

SUBSTANCE ABUSE
is the misuse of an addicti e substance that changes the user s mental state
refers to the use of chemicals to improve a mental state or induce euphoria
Commonly abuse substance alcohol, tobacco and illicit drugs
Cause/Reasons: a means of relieving the tension and pressure of their lives
Adolescent : a desire to feel more confident and mature due to peer pressure as a form of rebellion
Children at greatest risk
1. have family in which alcohol or drug abuse is present
2. suffer from abuse, neglect
3. have behavior problems aggressiveness and excessively rebelious
4. slow learners
5. have problems with depression and low-self esteem
Stages of substance abuse
STAGE O STAGE 1 STAGE 2 STAGE 3 STAGE 4
Pre abuse or Experimental Early Regular Late Regular End Stage or
Curiosity Stage (Learning Use (Seeking the Use Burn Out
Stage the Euphoria) Euphoria) (Preoccupation
with the
Euphoria)

Describes the Adolescents have The adolescent Dependent on Adolescent needs

adolescent with already made a now actively substance abuse drugs just to feel
an increased decision to tr seeks the drug- normal and to
potential for drugs and begun induced mood Deterioration of avoid the profound
substance learning the drug swing behavior such as and nearly
abuse induced mood fighting, lying, constant
swing or Use drugs to stealing, dysphoria.
Need for peer euphoria. seeks relief from Prostitution often
acceptance; everyday stress depressed, Depression,guilt,
anger and Drug use is suicidal ideation, shame, and other
boredom confined to social Changes in dress, self-destructive remorse may be
situations decline in and risk-taking overwhelming,
There are few personal hygiene, behavior and suicidal
behavioral deterioration in ideation becomes
changes other school more common
than l ing Performance, loss
of previous Paranoia, angry
interest in extra outbursts, and
curricular aggression are
activities common

Adolescent
exhibits more
mood swings,
engages in
regular lying
 Common Assessment findings
1. Failure to complete assignments in school
2. Demonstration of poor reasoning ability
3. Decreased school attendance
4. Frequent mood swings
5. Deteriorating physical appearance
6. Recent change in peer group
7. Expressed negative perceptions of parents
Treatment
1. Prevention is the most effective and least expensive treatment for substance abuse
2. Medication, -nicotine patches and methadone
3. Rehabilatation, counseling, social support, family support

SUICIDE
Is a deliberate self- injur ith the intent to end one s life.
successful suicide occurs more frequently in male than females
third cause of cause of death between 15 19 years of age
Suicide as viable solution to life problems
Risk Factors
1. Previous suicide attempts
2. Close family member who has committed suicide.
3. Past psychiatric hospitalization
4. Recent losses: death of a relative, a family divorce or a breakup with a girlfriend
5. Social isolation
6. Drug or alcohol abuse
7. Exposure to violence in the home or the social environment
Warning Signs for Suicide
1. Suicidal talk
2. Preoccupation with death and dying
3. Signs of depression
4. Behavioral changes
5. Giving away special possessions and making arrangements to take care of unfinished
business
6. Difficulty with appetite and sleep
7. Taking excessive risks
8. Increased drug use
9. Loss of interest in usual activities
Tips for Parents
1. Know the warning signs!
2. Do not be afraid to talk to your child- The message is, Suicide is not an option, help is
available."
3. Suicide-proof your home- Make the knives, pills and firearms inaccessible.
4. Utilize school and community resources- school psychologist, crisis intervention
personnel
5. Take immediate action. If your child indicatescontemplating suicide
6. Do not leave your child alone
7. Seek professional
8. Listen to our child s friends. They may give hints.
9. Be open. Ask questions.
Three steps teens can take
1. Take your friend's actions seriously
2. Encourage your friend to seek professional help, accompany if necessary
3. Talk to an adult you trust. Don't be alone in helping your friend.
 HEAD INJURIES
Types:
1. Concussion severe blow to the head jostles brain, causing it to strike the skull and results in
temporary neural dysfunction
S/S: headache, transient loss of consciousness, nausea, vomiting, dizziness, irritability
2. Contusion results from more severe blow that bruises the brain and disrupts neural function
S/S: neurologic deficits depend on site and extent of damage
dec LOC,sensory deficits,hemiplegia
3. Hemorrhage
a. Epidural blood between dura matter and skull
laceration of middle meningeal artery during skull fracture blood accumulates rapidly
S/S: brief loss of conc, severe headache, vomiting, possible seizures
b. Subdural blood in the dura and arachnoid venous bleeding that form slowly
acute, sub acute or chronic
S/S: alteration in LOC,headache,
c. Subarachnoid bleeding in subarachnoid space
d. Intracerebral accumulation of blood in the cerebrum
S/S: headache, dec LOC, pupillary dilatation
4. Fractures- linear, depressed, comminuted, compound
S/S: leakage of CSF from nose or ear
Diagnostics:
1. Skull x ray
2. CT scan

Nursing Interventions
1. Maintain a patent airway and adequate ventilation
2. Monitor VS and NVS
3. Observe for CSF leakage
4. Prevent complications of immobility
5. Prepare client for surgery if indicated
6. Provide psychologic support to client and family
7. Client teachings: rehabilitation

INTRACRANIAL SURGERY
Types:
1. Craniotomy surgical opening of skull to gain access to intracranial structures removal of tumor,
evacuate blood clots, control hemorrhage relieve increased ICP
2. Craniectomy excision of a portion of a skull use for decompression
3. Cranioplasty repair of a cranial defect with a metal or plastic plate
Nursing Intervention:
PRE OPERATIVE POST OPERATIVE
1. Routine pre op care 1. Maintain a patent airway
2. Provide emotional support 2. Check VS and NVS
3. Shampoo the scalp and check for signs of 3. Monitor fluid and electrolytes
infection 4. Assess dressing frequently and report for
4. Shave hair any abnormalities
5. Evaluate and record baseline vital signs 5. Administer medications as ordered
and neuro checks 6. Apply ice to swollen eyelids, lubricate lids
6. Avoid enema with petroleum jelly
7. Give pre op steroids as ordered to 7. Refer for rehabilitation
decrease brain swelling
8. Insert FBC as ordered
SPINAL CORD INJURY
Common in males
Ages 15 to 25
Causes: motor vehicle, diving in shallow water, falls, industrial accidents, sports injuries
Non traumatic tumors, spina bifida, aneurysms
Classification
Extent of injury
may affect vertebral column: fracture, dislocation
anterior/posterior ligaments compression of spinal cord
spinal cord and its roots
S/S:
Complete cord transection loss of all voluntary movements and sensation
below the level of injury
Incomplete will depend on damaged neurological tracts
Level of injury
a. cervical C1 C8 ( quadriplegia)
paralysis of all four extremities
respiratory paralysis C6
b. thoracic lumbar T1 L4
paraplegia
paralysis of the lower half of the body involving both legs
Mechanisms of injury
hyperflexion
hyperextension
axial loading diving accidents
penetrating wounds
Spinal shock occurs immediately
insult to the CNS
several days to 3 months
absence of reflexes below the level of the lesion
Management : immobilization and maintenance of normal spinal alignment to promote fracture healing
1. Horizontal turning frames- Stryker frame
2. Skeletal traction
a. cervical tongs
b. halo traction
3. Surgery
a. decompression
b. laminectomy
c. spinal fusion
Nursing intervention emergency care
1. Assess ABC
2. Quick head to toe assessment
3. Immobilize client
Acute care
1. Maintain optimum respiratory function
2. Maintain optimum cardiovascular function
3. Maintain fluid and electrolyte balance and nutrition
4. Maintain immobilization and spinal alignment always
5. Prevent complication of immobility
6. Maintain urinary and bowel elimination
7. Monitor temp control
8. Observe for and prevent infection
9. Observe for and prevent stress ulcer
 CONGENITAL HEART DEFECT

ACYANOTIC TYPE
A. ATRIAL SEPTAL DEFECT
A
U
S/S​: -
-
+
M ​: S 2 4
B. VENTRICULAR SEPTAL DEFECT
O ,
S VSD
L /
S/S:​
F
+ @
C -
M : ​S
C. PATENT DUCTUS ARTERIOSUS
C
S/S:​ + @

M :​ I
S e ​
D. COARCTATION OF AORTA
N
S
B
S/S:​ BP /
H

M :​
E. VALVULAR DEFECTS
.

S/S​:
P
E
,
M :​ ​S e ​ ,

CYANOTIC TYPE
A. TRANSPOSITION OF GREAT VESSELS
✔ A ,

✔ ,

S/S:
⦿ B
3RD ROT: OB
NCM 209 11. FAMILY PLANNING
Care of Mother, Child, and Population Group at Risk or 12. POSTPARTUM CARE
with Problems

PRENATAL CARE
THE PURPOSE OF PRENATAL CARE IS TO ENSURE AN High Risk Mom
UNCOMPLICATED PREGNANCY AND THE DELIVERY OF A
LIVE AND HEALTHY INFANT. What is High Risk Pregnancy?
poor maternal or fetal outcome due to :
BALANCE OF FORCES IN PREGNANCY medical
FETAL SURVIVAL reproductive
MATERNAL SURVIVAL Psychosocial
5 Branches of Maternal Health Obstetrical
• Nutrition SCREENING
• Prenatal Care Diagnostic and Laboratory Examinations
• Safe Delivery Complete Blood Count
• Breastfeeding Hemoglobin
• Family Planning Hematocrit
Prenatal Care Leukocyte
• Regular prenatal care increases the chances of a Thrombocytes
healthy mother and child after birth. Blood Typing
• Early detection of congenital & birth defects Rhesus Factor
• Prenatal immunizations can prevent mother-to- URINALYSIS
child-transmission and infection. Pus cells
DOH STANDARDS OF PRENATAL CARE Bacteria
1. WEIGHT Protein/albumin
2. HEIGHT Sugar
3. BLOOD PRESSURE Squamous epithelial cells
4. FHT PAP SMEAR
5. FUNDIC HEIGHT ULTRASONOGRAPHY
• 5th month = 20 cm Transabdominal
• 6th month = 21-24 cm TRANSVAGINAL ULTRASOUND
• 7th month = 25-28 cm BLOOD GLUCOSE TEST
• 8th month = 29-30 cm FBS
• 9th month = 30-34 cm HGT/CBG
6. LEOPOLD’S MANEUVER OGTT
OGCT
2 HRS. POST PRANDIAL
AMNIOCENTESIS
Maternal Alpha-Feto Protein
Fetal neural tube defect:
anencephaly
gastroschisis
spina bifida
DOPPLER VELOCIMETRY
PERCUTANEOUS UMBILICAL BLOOD SAMPLING
BIOPHYSICAL SCORING
30 minutes observation by USD
5 markers:
non stress test
fetal breathing
amniotic fluid
7. TT IMMUNIZATION fetal body movement
TETANUS TOXOID WHEN TO GIVE fetal tone
TT 1 ANYTIME DURING BPS RESULT INTERPRETATION
PREGNANCY 8 – 10 - Normal fetus
TT 2 4 WEEKS AFTER TT 1 6 - chronic asphyxia
TT 3 6 MONTHS AFTER TT 2 - repeat the procedure after 24 hours
TT 4 1 YEAR AFTER TT 3 4 - abnormal result
TT 5 1 YEAR AFTER TT 4 2 - ill fetus, terminate pregnancy
Non Stress Test (NST)
8. DIET 2 - 2 or more FHT acceleration
9. DANGER SIGNS OF PREGNANCY per movement
10. BREASTFEEDING 1 - <2 accelerations
 per movement
0 - no acceleration
Fetal Breathing
2 - 1 episode/30 minutes lasting 30 seconds
0 - no episode
- more than 30 minutes
- not lasting 30 seconds

AMNIOTIC FLUID INDEX

2 - fluid filled pocket of 1 cm or more
0 - no amniotic fluid or less than 1 cm in every
pocket
FETAL BODY MOVEMENT
2 - 3 or more discrete movement of limbs and
body in 30 minutes
1 - less than 3 movements
0 - no movements
FETAL TONE
2 - 1 or more episodes of active extension with
return to flexion of limbs and trunk
1 - slow extension with return to flexion
0 - no movements
HEPATITIS B DETERMINATION ATRIAL SEPTAL DEFECT
1 Hepatitis B Antigen (HBSAg) asymptomatic
2 reactive - positive increase pulmonary blood flow
3 non-reactive – negative pulmonary hypertension
4 Hepatitis B Antibiodies (HBSAb) VENTRICULAR SEPTAL DEFECT
qualitative left ventricular hypertrophy
quantitative pulmonary hypertension
CONTRACTION STRESS TEST (CST) biventricular hypertrophy
done after 32 weeks AOG PATENT DUCTUS ARTERIOSUS
Negative - normal; no fetal heart rare
deceleration early surgical repair
Positive - abnormal; with deceleration similar with VSD
FETOSCOPY RHEUMATIC HEART DISEASE
- Direct visualization of the fetus through a scope Group A Beta Hemolytic Streptococcus
- Obtain sample tissues or blood Inflammatory process
- May perform intrauterine fetal surgery Autoimmune disease
FETAL MOVEMENT COUNTING Scarring of the valves
- Done after 27 weeks AOG SIGNS AND SYMTOMS OF CARDIAC DISEASES
- Twice daily for 20-30 minutes Shortness of breath
- Normal – 5-6movements in 20-30 minutes Palpitations
- Abnormal – less done 3 movements in 1 hour Orthopnea
Expectoration of blood
Cyanosis
MEDICAL COMPLICATIONS DURING PREGNANCY Murmur
CARDIOVASCULAR DISORDERS Heart enlargement
PREGNANCY FUNCTIONAL CLASSIFICATIONS OF CARDIAC
Increase blood volume 40 50% DISEASES
Increase cardiac output
Decrease B during first trimester CLASS 1 - asymptomatic
Increase size of ventricular chamber CLASS II - symptomatic but with
LEFT TO RIGHT SHUNTING normal activities
CLASS III - symptomatic and with less
than normal activities
CLASS IV - symptomatic and at rest
Judgment of safety of pregnancy
• Conception should be prevented if:
1. Severe heart disease
2. Functional classification: class III-IV
3. History of heart failure
 4. Pulmonary hypertension ORAL GLUCOSE CHALLENGE TEST
5. Right to left shunting fasting post midnight
6. Severe arrhythmia blood and urine specimen are obtained
7. rheumatic fever 50 grams glucose intake
8. Combined valve disease after 1 hour, blood and urine specimen is
9. Acute myocarditis
obtained
A value above 130 140 gms/l one hour after
MANAGEMENT OF CARDIAC DISEASES
o termination of pregnancy by CS is used as threshold for performing a 3-hour
Weight reduction OGTT.
Rest Prerequisites of OGTT:
prevent infection Normal diet for 3 days before the test.
Digoxin No diuretics 10 days before.
Diuretics At least 10 hours fast.
NURSING CARE OF CARDIAC DISEASES Test is done in the morning at rest.
Vital signs CRITERIA FOR OGTT
Provide rest The maximum blood glucose values during pregnancy:
Emotional support • fasting 90 mg/dl
I & O monitoring • one hour 165 mg/dl
Proper nutrition • 2 hours 145 mg/dl
Carry out medical orders • 3 hours 125 mg/dl
MANAGEMENT OF GDM
Insulin
Diet
Exercise

Substance Abuse During Pregnancy

TERATOGEN
GESTATIONALDIABETES MELLITUS Any agents that interferes with normal
RISK FACTORS CAUSING GDM embryonic development
Obesity ALCOHOL
Family history CNS Depressant
Personal history Reduce Anxiety
Sedentary lifestyle Sedation
Improper diet Respiratory Depressant
(PATHOPHYSIOLOGY NOT INCLUDED) ALCOHOL EFFECTS ON FETUS
Fetal Alcohol Syndrome (FAS)
FETAL/NEONA TAL COMPLICATIONS OF GDM
Fetal hyperglycemia
Fetal Hyperinsulinemia
Macrosomia
Prematurity
Respiratory Distress
Neonatal Hypoglycemia
MATERNAL COMPLICATIONS OF GDM
Preeclampsia
Polyhydramnious
Infection
Dystocia
Postpartum Bleeding
Birth canal trauma
Caesarean delivery

Fasting & 2 hours postprandial venous plasma sugar Intrauterine Growth Restriction
during pregnancy. Preterm Delivery

FASTING 2HRS POST RESULT CNS Depressants:

PRANDIAL Morphine,
<100 mg/dl < 145mg/ dl. Not diabetic Heroin,
Methadone
>125 mg/ dl >200 mg/ dl. Diabetic Analgesics
STIMULANTS
 Cocaine White spots in the mouth or throat
Amphetamine Chronic diarrhea
Ecstacy A cough that won’t go away
Caffeine Short-term memory loss
EFFECTS OF STIMULANTS Fact or Fiction?
Increase Concentration You can get AIDS from a mosquito bite
Alertness Fact or Fiction?
Paranoia You can get AIDS by having oral sex with an infected
Hypertension person
Psychosis Fact or Fiction?
STIMULANTS EFFECTS ON FETUS HIV survives well in the environment, so you can get it
Preterm labor from toilet seats and door knobs
Spontaneous abortion Fact or Fiction?
Placental abruption You can get AIDS by hugging a person with HIV who is
Fetal hypertension sweating
PREGNANCY SMOKING Fact or Fiction?
Higher rates of spontaneous abortion, placenta You can get AIDS by kissing someone who is HIV
previa, infected
Preterm labor Fact or Fiction?
Low birth weight infant Condoms aren't really effective in preventing HIV
Fetal hypertension transmission
MARIJUANA Fact or Fiction?
Relaxant There is a connection between other STDS and HIV
Hallucination infection
Short term Memory loss
Low birth weight Infant How A Healthy Immune System Works
Lifetime Effects of Substance Abuse Physical Barriers:
Physical deformities Innate Immune System:
Mental Retardation Acquired Immune System:
Developmental Problem How does HIV interrupt the Normal Functioning of the
Immune System?
(END OF FIRST PRESENTATION) HIV infects T-cell
Phases of HIV/AIDS
1. Infection
2. Window period
3. Seroconversion
4. Asymptomatic period
5. HIV/AIDS - related illness
6. AIDS
CD4 counts
Number of CD4 cells in blood provides a
measure of immune system damage
CD4 count reflects phase of disease
CD4 count:
500 – 1200: Normal
200 – 500: Beginning of HIV illness
< 200: AIDS
Window period
ACQUIRED IMMUNODEFFICIENCY SYNDROME Time between infection & enough antibodies
Caused by HIV Duration: approximately 3 months
Transmitted through blood, blood products, No symptoms or signs of illness
semen, vaginal fluid, breast milk HIV test is negative
Diagnosed by enzyme-linked immunosorbent Virus is multiplying rapidly - viral load is high
assay (ELISA) Person is very infectious
Confirmed by western blot test Seroconversion
Point at which HIV test becomes positive
SYMPTOMS OF AIDS Body starts making antibodies to HIV a few
Extreme weakness and fatigue weeks after infection
Rapid weight loss HIV test becomes positive
Frequent fevers with no explanation Person may have a mild flu-like illness, lasting a
Heavy sweating at night week or two
Swollen lymph glands Afterwards, the person is well again
Minor infections that cause skin rashes and Asymptomatic period
mouth, genital, and anal sores.
 Time period between seroconversion and onset Anti-retrovirals
of HIV/AIDS-related illness Zidovudine (ZDV):
Duration variable: < 1 year to > 15 years o Long course
Most people remain healthy (asymptomatic) for o Short course
about three years Nevirapine
Duration may depend on socio-economic ZDV/lamivudine (ZDV/3TC)
factors Obstetric Procedures to be avoided
The CD4 count is above 500 cells/ml Amniotomy
HIV/AIDS-Related Illness Fetal scalp electrode/sampling
Time period between onset of illness & Forceps/vacuum extractor
diagnosis of AIDS Episiotomy
Duration is variable: average about 5 years Vaginal tears
Illnesses initially mild, with gradual increase in Intrapartum Management
frequency and severity Goal is to minimize duration of labor ,
CD4 count is between 500 & 200 cells/ml Do not rupture membranes
AIDS Avoid invasive monitoring
Final phase of HIV/AIDS Avoid episiotomy or instrumental delivery when
Duration: without antiretroviral drugs, less than possible
2 years with antiretrovirals, potentially many Delivery: Cesarean vs. Vaginal Birth
years Cesarean section before labor and/or rupture of
CD4 count is below 200 cells/ml membranes reduces risk of mother-to-child
Viral loads are high & the person is very transmission by 50–80%
infectious Cesarean section, however, increases morbidity
Important Facts and possible mortality to mother
Duration of different phases of HIV/AIDS will Give antibiotic prophylaxis for cesarean section
vary in different people in HIV-infected women
Factors affecting the course of HIV/AIDS include Recommended Infection Prevention Practices
nutrition, emotional stress, and access to health Needles:
care o Take care! Minimal use
People infected with HIV can infect others at o Suturing: Use appropriate needle and
any phase of the disease holder
Mother-to-Child Transmission o Care with recapping and disposal
25–35% of HIV positive pregnant mothers will Wear gloves, wash hands with soap
pass HIV to their newborns immediately after contact with blood and body
30% of transmission in utero fluids
70% of transmission during the delivery Cover incisions with watertight dressings for
14% transmission with breastfeeding first 24 hours
Interventions to Reduce Mother-to-Child Transmission Use:
HIV testing in pregnancy Plastic aprons for delivery
Antenatal care Goggles and gloves for delivery and surgery
Antiretroviral agents Long gloves for placenta removal
Obstetric interventions Dispose of blood, placenta and waste safely
o Avoid amniotomy PROTECT YOURSELF!
o Avoid procedures: Forceps/vacuum Newborn
extractor, scalp electrode, scalp blood Wash newborn after birth, especially face
sampling Avoid hypothermia
o Restrict episiotomy Give antiretroviral agents, if available
o Elective cesarean section
o Remember infection prevention Breasfeeding Issues
practices Warmth for newborn
Newborn feeding: Breastmilk vs. formula Nutrition for newborn
Antenatal Care Protection against other infections
Watch for signs/symptoms of AIDS and Safety – unclean water, diarrheal diseases
pregnancy-related complications Risk of HIV transmission
Unless complication develops, no need to Contraception for mother
increase number of visits Cost
Treat STDs and other coinfections Breastfeeding Recommendations
Counsel against unprotected promote exclusive breastfeeding for 6 months
intercourse counsel on the safe and appropriate use of
Avoid invasive procedures formula
and external cephalic version HIV-positive and chooses to breastfeed,
Give antiretroviral agents promote exclusive breastfeeding for 6 months
Counsel about nutrition Rh Incompatibility
Rh mother and Rh+ father
 mostly on the second pregnancy Progress diet – clear liquid, full liquid, soft, small
during placental accidents frequent, full diet
Midnight snacks
(NOT IN THE HANDOUTS) Parenteral vitamins and electrolyte

TYPES OF ANEMIA NURSING DIAGNOSIS OF HYPEREMESIS GRAVIDARUM

Iron Deficiency Anemia Actual/Potential Fluid Volume Deficit
Megaloblastic Anemia Imbalance Nutrition; less than Body
Pernicious Anemia Requirements
Folic Acid Deficiency Anemia Fatigue
Aplastic Anemia Ineffective Coping
Hemolytic Anemia Anxiety
Sickle Cell Anemia Bleeding Complications of Pregnancy
Physiologic Anemia ABORTION
Pathologic Anemia - Termination of pregnancy before the age of
SIGNS AND SYMPTOMS OF ANEMIA viability
Pallor Spontaneous Abortion
Fatigue Threatened Abortion
Shortness of breath Imminent Abortion
Hypotension Complete abortion
Asymptomatic Incomplete Abortion
DIAGNOSTIC EXAMINATIONS OF ANEMIA Missed Abortion
Hemoglobin count......... 12 – 14 grams/dl Recurrent/Habitual abortion
Iron .............................. 50 – 150 grams/dl Septic Abortion
Transferin ......................250 – 430 mg/ml Induced Abortion
Ferritin...........................11 – 20 g/ml Therapeutic Abortion
Folate.............................7 – 20 g/ml Eugenic Abortion
Vit B12...........................200 – 800 g/ml Secondary Abortion
MANAGEMENT OF PHYSIOLOGIC ANEMIA
Rest Signs and Symptoms of Abortion
Fe Supplement Bleeding
O2 Therapy Abdominal cramping
Nutrition Passage of watery vaginal discharges
Blood Transfusion Passage of product of conception
NURSING DIAGNOSIS OF ANEMIA Management of Threatened Abortion
Altered Tissue Perfusion Bed rest
Altered Nutrition Less Than Body Requirements Tocolytic medications
Activity Intolerance Treat underlying factors
HYPEREMESIS GRAVIDARUM No sexual activity
Excessive vomiting that persists beyond 1st Fetal monitoring by ultrasound
trimester Avoid stress
contains: Management of Other Type Of Abortion
previous food intake Hospitalization
mucus Oxytocin administration
bile Completion curettage
finally blood Prophylactic antibiotic
Predisposing Factors Analgesics
Pancreatitis Fluid/blood replacement
Biliary tract dse Emotional support
Decrease Vit B6 NURSING DIAGNOSIS
Psychological Alteration in comfort; Pain
Drug toxicity Anticipatory Grieving
Risk for Fluid Volume Deficit
Precipitating Factors Ectopic Pregnancy
Pregnancy
Multiple pregnancy Factors Causing Ectopic Pregnancy
Pelvic Inflammatory Diseases
Hydatidiform mole
Heredity Previous Ectopic Pregnancy
Female Tubal/Uterine Surgery
Intrauterine Device
MANAGEMENT OF HYPEREMESIS GRAVIDARUM
May need hospitalization
IVF infusion
Parenteral nutrition
Antiemetics
 Vaginal bleeding
Uterine enlargement is bigger than usual
pregnancy
Increase HCG
Hyperemesis gravidarum
No FHT/fetal movement
Management of H Mole
Suction evacuation
Dilatation and Curettage
Hysterectomy
Methotrexate
Placenta Previa
Implantation of the placenta at the lower
uterine segment
Risk Factors of Placenta Previa
Signs and Symptoms of Ectopic Pregnancy > discovered @ 20 Advance maternal age > 35
Symptoms of bleeding wks USD Multiparity
Bleeding into the uterine cavity > repeat USD @ 32 Previous uterine surgery (cs, fibroid removal)
Sharp one sided abdominal pain wks (marginal.partial)
Breech and Transverse position
Syncope Signs and Symptoms of Placenta Previa
Referred shoulder pain Painless bright red bleeding
Lower abdominal pain Recurrent and heavier as pregnancy progress
*placenta cannot grow due to
Vaginal bleeding low blood supply because it is No uterine contraction
Abdominal tenderness outside of the implantation ABRUPTIO PLACENTA
Low HCG hormone site Risk Factors Causing Abruptio Placenta
Maternal age
Previous history of abruptio placenta
Multiparity
Smoking
Maternal hypertension
Abdominal trauma
Signs and Symptoms of Abruptio Placenta
Concealed or visible bleeding
Painful bleeding
Dark red bleeding
Board like abdomen
Fetal distress
Tetanic contraction
Management of Abruptio Placenta
Bed rest
Diagnostic Examinations of Ectopic Pregnancy Tocolytic
Transvaginal ultrasound Steroids
Physical examination Immediate Delivery
Pregnancy test Fluid and blood replacement
HCG Nursing Diagnosis of Abruptio Placenta
Pelvic examinations Altered Tissue Perfusion
Management of Ectopic Pregnancy Fluid Volume Deficit
Methotrexate Risk for Infection
Salphingostomy via laparoscope Anxiety/Fear
Laparoscopic salphingectomy Acute pain
Nursing Diagnosis Complications of Abruptio Placenta
Alteration in Comfort; pain Hypovolemic shock
Anticipatory grieving Intrauterine growth restriction
Fluid volume deficit Placenta accreta
Hydatidiform Mole (H-MOLE/MOLAR PREGNANCY) Maternal Mortality
Partial Mole Fetal Mortality
egg cell + 2 sperm cells Congenital Anomalies
Abnormal first meiotic division
With fetus PRETERM LABOR
Complete Mole - Labor that begins after 20 weeks
Empty egg + normal sperm gestation and before 37 weeks
Embryo dies at very early age gestation
No embryonic tissues Etiology of Preterm Labor
Signs and Symptoms of H- Mole Premature rupture of membrane
 Preeclampsia infection
Hydramnios PATHOPHYSIOLOGY: (NOT INCLUDED)
Placenta previa DIAGNOSIS:
Abruptio Placenta • Dilators or balloons
Incompetent cervix • hysterosalpingograms
Tauma • Digital examination of the cervix
Uterine structual anomalies • Sonography
Multiple gestation MANAGEMENT:
Infection • Tocolytics
Fetal death • Bed rest
Maternal factors • Hydration
MANAGEMENT OF PRETERM LABOR • Progesterone
Bed rest • Trendelenburg position
Avoid sexual contact • Antibiotics
Limit abdominal handling NURSING DIAGNOSIS:
Increase fiber in the diet • Anxiety
Treat underlying factors • Risk for maternal injury
Tocolytic medications • Risk for fetal injury
Steroid • Knowledge Deficit
SIGNS AND SYMPTOMS • Anticipatory grieving
Low back pain
Suprapubic pressure HYPERTENSIVE DISORDERS OF PREGNANCY
Vaginal pressure RISK FACTORS:
Rhythmic uterine contraction FIRST PREGNANCY
Cervical changes MULTIPLE GESTATION
Possible rupture of membrane POLYHYDRAMNIOS
Expulsion of cervical mucus plug HYDATIDIFORM MOLE
Bloody show MALNUTRITION
FAMILY HISTORY
Missed Abortion: VASCULAR DISEASE
Retention of the conceptus in the uterus for a TYPES OF PREGNANCY INDUCE HYPERTENSION
clinically appreciable time after death of the Gestational Hypertension
embryo or fetus. Preeclampsia
Eclampsia
(END OF SECOND PART) Chronic Hypertension
Superimposed Preeclampsia
Second and third trimester disorders Gestational Hypertension
* increased blood pressure
Cervical Incompetence - systolic pressure of more than 130mm/Hg
- the inability of the cervix to support a or +30mmHg from baseline
pregnancy to term due to structural and or - diastolic pressure of more than 90mmHg
functional weakness. or +15mmHg from baseline
- painless and bloodless cervical dilatation * edema
- premature cervical dilatation between 16 – 22 PREECLAMPSIA
weeks Hypertension or PIH
Factors Causing IC Proteinuria
FUNCTIONAL: Edema (wt gain)
premature triggering of the normal mechanism MILD PREECLAMPSIA
of cervical dilatation and effacement. HYPERTENSION (140/90)
Induction of ovulation PROTEINURIA>300mg/24 hrs
3 or more prior fetal losses during the 2nd MILD EDEMA,signaled by wt gain
trimester (>2 lb/week or >6 lb/month)
CONGENITAL URINE OUTPUT>500ml/24hrs
congenital or acquired SEVERE PREECLAMPSIA
Congenital: Any of the following symptoms:
Weakness of the internal os BP>160/110 (2X, 6hrs apart, bedrest)
Short hypoplastic cervix Proteinuria.5g/24 hours (3+ or 4+ dipstick)
Bicornuate uterus Massive edema
Septate uterus Oliguria <400ml/24 hrs
overzealous dilatation and curettage IUGR in fetus
cone biopsy Systemic symptoms
cervical amputation SYSTEMIC SYMPTOMS:
difficult delivery Pulmonary edema
instrumentation headache
 visual changes depression
RUQ pain Treatment
Liver Enzymes fetal surveillance
Thrombocytopenia NST, CST, BPP Q wk
ECLAMPSIA: mom monitors mvmt
Hypertension Induction
Proteinuria Pitocin (10-20U/L) @ 1-2
Edema mU/min every 20-60 min
Seizure DISORDERS OF AMNIOTIC FLUID:
CHRONIC HYPERTENSION SUPERIMPOSED Polyhydramnios
PREECLAMPSIA S&S
hypertensive disorders before pregnancy uterine dist
that progresses to preeclampsia dyspnea
(NOT INCLUDED) edema of lower extr
Treatment
LABORATORY WORK-UPS: therapeutic amniocentesis
Blood--CBC, electrolytes, BUN, Creatinine Oligohydramnios
Liver function studies Risks
Coagulation studies cord compression
24hr Urine musculoskeletal deformities
HELLP syndrome pulmonary hypoplasia
Hemolysis Treatment
Elevated Liver function tests amnioinfusion
Low Platelet count
COMPLICATIONS: PREMATURE RUPTURE OF MEMBRANES:
Eclamptic seizures Premature rupture of membranes (PROM) is a
HELLP syndrome rupture (breaking open) of the membranes
Hepatic rupture (amniotic sac) before labor begins. If PROM
DIC occurs before 37 weeks of pregnancy, it is called
pulmonary edema preterm premature rupture of membranes
renal failure (PPROM).
placental abruption WHAT CAUSES PREMATURE RUPTURE OF
cerebral hemorrhage MEMBRANES?
fetal demise RUPTURE OF THE MEMBRANES NEAR THE END
MANAGEMENT OF PIH: OF PREGNANCY (TERM) MAY BE CAUSED BY A
bed rest with or without BRP NATURAL WEAKENING OF THE MEMBRANES OR
BP monitoring FROM THE FORCE OF CONTRACTIONS. BEFORE
weight and urine checks TERM, PPROM IS OFTEN DUE TO AN INFECTION
NST’s early IN THE UTERUS.
US for IUGR OTHER FACTORS THAT MAY BE LINKED TO
IVF PROM INCLUDE THE FOLLOWING:
Check for reflexes o LOW SOCIO ECONOMIC CONDITONS
Antihypertensive drugs o SEXUALLY TRANSMITTED INFECTIONS:
Anticonvulsant drugs CHLAMYDIA AND GONORRHEA
Steroids o PREVIOUS PRETERM BIRTH
Delivery of the baby o VAGINAL BLEEDING
MGSO4 THERAPHY o CIGARETTE SMOKING DURING
Loading dose IV 4-6 g/20min PREGNANCY
continued at 2 g/hr o UNKNOWN CAUSES
check for adverse effects In addition to a complete medical history and physical
Respiratory rate<12/minute examination, PROM may be diagnosed in several ways,
DTR of <1 including the following:
Urine output<30cc/hour an examination of the cervix
POST-TERM PREGNANCY: testing of the pH (acid or alkaline) of the fluid
S&S looking at the dried fluid under a microscope
Wt loss ultrasound - a diagnostic imaging technique
uterine size which uses high-frequency sound waves and a
Meconium in AF computer to create images of blood vessels,
Risks tissues, and organs. Ultrasounds are used to
fetal mortality view internal organs as they function, and to
cord compression assess blood flow through various vessels.
mec asp Possible Nursing Diagnoses:
LGA shoulder dystocia CS Risk for infection related to preterm rupture of
episiotomy/laceration membranes without accompanying labor.
 Knowledge deficit. FACTOR MATERNAL FETAL OR NEONATAL
Anxiety related to outcome of labor. IMPLICATIONS IMPLICATIONS
Risk for fetal injury related to preterm birth.
Management:
bed rest either in the hospital or at home Social and Poor antenatal Low birth weight
setting Personal care Intrauterine growth
monitor for signs of infection such as fever, Low income Poor nutrition restriction (IUGR)
pain, increased fetal heart rate, and/or level and/or risk
laboratory tests. low preecalmpsia
giving the mother corticosteroids that may help educational
mature the lungs of the fetus. level
avoid vaginal exams to prevent introduction of
microorganisms Poor diet Inadequate Fetal malnutrition
administer antibiotics nutrition Prematurity
administer tocolytics to stop preterm labor. risk anemia
prepare for possible immediate delivery. risk of
Premature Rupture of Membrane (PPROM before 37 preeclampsia
weeks)
Spontaneous ROM prior to onset of labor at the Living at high hemoglobin Prematurity
end of 37 weeks [high risk] altitude IUGR
Full term = PROM [38 weeks] hemoglobin
S&S (polycythemia)
o contractions
o cramps
o backache Factor Maternal Fetal & Neonatal
o diarrhea Implications Implications
o vag d/c
o ROM

Treatment Multiparity risk antepartum Anemia

o Tocolytics >3 or postpartum Fetal death
o IV hydration hemorrhage
o bedrest
o steroids, if needed Weight Poor nutrition IUGR
o abx, if needed <45.5 kg Cephalopelvic Hypoxia associated
NURSING CARE: (100 lb) disproportion with difficult labor &
Assessment Prolonged labor birth
Thorough hx
bleeding Weight risk fetal nutrition
ROM >91 kg hypertension risk macrosomia
BPP (for PROM) (200 lb) risk
Teaching cephalopelvic
Infection Control disproportion
FMC risk diabetes
Fetal Risk: Pre-maturity, infection
*Prevention of infection
Monitor temp Age <16 Poor nutrition Low birth weight
Monitor amniotic fluid, you want white and Poor antenatal fetal demise
sticky – not black, green, smelly care
Antibiotic within 24 hours and have c-sect risk
MANAGEMENT: preeclampsia
Hospitalized – pre term, NICU, lungs, intubation risk
(will be in NICU until Mother’s expected date of cephalopelvic
delivery) disproportion
Limit sterile vaginal exam Age >35 risk risk congenital
Antibiotics preeclampsia anomalies
Bed rest risk cesarean chromosomal
Trendelenberg position- to get pressure off birth aberrations
perineum
Daily CBC
Factor Maternal Fetal/Neonatal Hypertension vasospasm placental
Implications Implications risk central perfusion
nervous system low birth
irritability weight
Smoking one risk placental convulsions Preterm birth
pack/day or hypertension perfusion O2 risk
more risk cancer and nutrients cerebrovascular
available accident
Low birth weight risk renal
IUGR damage
Preterm birth Thyroid disorder infertility
spontaneous
Use of risk poor risk congenital abortion
addicting nutrition anomalies
Hypothyroidism basal risk
drugs risk of risk low birth
metabolic rate, congenital
infection with IV weight
goiter, goiter
drugs Neonatal withdrawal
myxedema
risk HIV, Lower serum
hepatitis C bilirubin Hyperthyroidism risk Mental
postpartum retardation
Excessive risk poor risk fetal alcohol
hemorrhage cretinism
alcohol nutrition syndrome
risk incidence
consumption Possible hepatic
preeclampsia congenital
effects with
Danger of anomalies
long-term
thyroid storm
consumption
incidence
Preexisting risk Low birth weight preterm birth
Medical preeclampsia, Macrosomia tendency to
Disorders hypertension Neonatal thyrotoxicosis
Diabetes Episodes of hypoglycemia
mellitus hypoglycemia risk congenital
and anomalies
hyperglycemia risk respiratory Factor Maternal Fetal/Neonatal
risk cesarean distress syndrome Implications Implications
birth
Cardiac Cardiac risk fetal demise
Renal disease risk renal risk IUGR
disease decompensation prenatal mortality
(moderate to failure risk preterm
Further strain
severe) birth
on mother’s
body
maternal Diethylstilbestrol infertility, spontaneous
death rate (DES) exposure spontaneous abortion
abortion risk preterm
cervical birth
Factor Maternal Fetal/Neonatal incompetence
Implications Implications
Obstetric emotional or risk IUGR
Considerations psychological risk preterm
Previous distress birth
Anemia: Iron-deficiency Fetal death Pregnancy
hemoglobin <9 anemia Prematurity Stillborn
g/dL (white) Low energy Low birth
<29% level weight
Habitual emotional or risk abortion
hematocrit oxygen-
abortion psychological
(white) carrying
distress
<8.2 g/dL capacity
possibility
hemoglobin
diagnostic
(black)
workup
<26%
hematocrit
(black)
Cesarean birth possibility risk preterm Factor Maternal Fetal/Neonatal
repeat cesarean birth Implications Implications
birth risk
respiratory
Syphilis incidence fetal demise
distress
abortion Congenital
syphilis
Factors Maternal Fetal/Neonatal
Implications Implications
Abruptio risk Fetal or
Rh or blood financial Hydrops fetalis placenta and hemorrhage neonatal
group expenditure for Icterus gravis placenta previa Bed rest anemia
sensitization testing Neonatal anemia Extended Intrauterine
Kernicterus hospitalization hemorrhage
Hypoglycemia fetal demise
Large baby risk cesarean Birth injury
birth Hypoglycemia Preeclampsia or See placental
risk eclampsia hypertension perfusion
gestational low birth
diabetes weight

Current Congenital heart Multiple risk risk preterm

Pregnancy disease gestation postpartum birth
Rubella (first Cataracts hemorrhage risk fetal
trimester) Nerve deafness risk preterm demise
Bone lesions labor
Prolonged virus
shedding Elevated Increased Fetal death rate
hematocrit viscosity of 5 times normal
Rubella (second Hepatitis
>41% (white) blood rate
trimester) Thrombocytopenia
>38% (black)
Cytomegalovirus IUGR
Encephalopathy Spontaneous uterine risk preterm
premature infection birth
Herpes virus Severe Neonatal herpes rupture of membranes
type 2 discomfort virus type 2
Concern about 2% hepatitis with
possibility of jaundice
cesarean birth, Neurologic
fetal infection abnormalities MONITORING FETAL WELL-BEING
• Early US for accurate gestational dating
• US if macrosomia is suspected
• amniocentesis for fetal lung maturity
• antepartum NST weekly p. 34 wks
PREGNANCY CATEGORY OF MEDICATIONS:
• Category A--safe (vitamins)
• Category B--no animal effects (penicillin)
• Category C--no studies available
• Category D--evidence of risk but benefits
outweigh the risks
• Category X--risks outweigh benefits

(END OF 3RD PRESENTATION)

NURSING CARE OF THE CLIENT WITH HIGH RISK LABOR

& DELIVERY AND HER FAMILY

ESSENTIAL FACTORS IN LABOR:

1. PASSENGER
a. FETUS-
b. PLACENTA
2. PASSAGEWAY
3. POWERS
 a. primary power
b. secondary power
4. POSITION OF THE MOTHER
5. PSYCHE

PROBLEMS WITH THE PASSENGER

PASSENGER:
• FETUS
o fetal skull
o fetal body size
o fetal presentation THE FONTANELLES
o fetal position
o fetal lie

MOULDINGS:

ANTEROPOSTERIOR DIAMTERE:

MEMBRANE SPACES
Synclitism & Asynclitism:
• Asynclitic refers to a fetal head that is not
parallel to the anteroposterior plane of the
pelvis.
• The head is synclitic when the sagittal suture
lies midway between the symphysis pubis and
the sacral promontory.
FETAL MALPOSITION
Persistent Occiput Posterior
fetus enters the birth canal, descends, and is
delivered in occiput posterior position
fetus is facing up instead of facing down as it
enters the vagina
Transverse Occiput Arrest
baby is head-down but the head is turned
completely sideways towards the mother’s
hipbone, causing baby to ‘arrest’ (get stuck)
because it doesn’t fit well.
Factors Causing POP
lack of rotation due to poor contraction
abnormal flexion of the head
incomplete rotation
inadequate maternal pushing effort
epidural anesthesia
large baby
Risk of Fetal Malposition
prolonged labor
third to fourth degree perineal lacerations
extension of midline episiotomy
forceps/vacuum assisted or caesarean delivery
Management of Fetal Malposition
monitoring on fetal and maternal status
cesarean birth if necessary
Scanzoni’s maneuver
Forceps assisted
Vacuum assisted
Regional anesthesia
FETAL MALPRESENTATION
VERTEX MALPRESENTATION
1. BROW PRESENTATION
2. FACE PRESENTATION
Risk of Brow Presentation
longer labor
ineffective contraction
slow or arrest fetal descent
cesarean delivery
neonatal neck and cerebral compression
damage to the neonatal larynx and trachea
neonatal facial edema and bruises
Management of Brow Presentation many of the same symptoms as other
monitor for CPD malpositions.
left or right mediolateral episiotomy • One other variation of this is when the baby's
cesarean delivery arm or elbow is across its face ('nuchal arm'),
Risk of Face Presentation which can cause intense pain.
increase risk of CPD • A baby can be born with a nuchal hand
prolongation of labor alongside its head, although the process is
increase risk of infection usually slow.
Cesarean birth VERSION:
neonatal cephalhematoma • Turning of the fetus.
edema of neonatal face and throat • is a procedure used to change the fetal
pronounced molding presentation by abdominal or intrauterine
Management of Face Presentation manipulation.
vaginal birth may be anticipated if not CPD, External Cephalic Version (ECV)
reassuring fetal heart pattern, and labor pattern most common wherein the fetus is changed
is effective from a breech to a cephalic presentation
cesarean birth if mentum remains posterior Podalic Version-
Risk of Breech Presentation less common type
higher perinatal morbidity and mortality rate used only with the 2nd fetus during a vaginal
cord prolapsed twin birth and only if the twin does not descend
neonatal cord injury due to hyperextension readily or if the heart rate is non-reassuring.
birth trauma especially the head medication is used to relax the uterus
Management of Breech Presentation The OB places a hand inside the uterus, grabs
external cephalic version at 36 – 38 weeks or the fetus’s feet and draws them down thru the
prior to labor cervix.
method of delivery depends on: Contraindications of Versions:
gestational age 3rd trimester bleeding
presence of other fetuses uterine anomalies
EFW ROM, oligohydramnios
types of breech presentation need for CS for other reasons (placenta previa,
and physician’s preferences contracted pelvis, hyperextended head)
Shoulder Presentation indicated vaginal delivery (fetal death)
Fetus is in a transverse lie
ETIOLOGY OF FLUPP (END OF 4TH PART)
Fetal
prematurity FETAL DISTRESS
multiple Compromise of the fetus during the antepartum
anomalies: often those that restrict the ability period or intrapartum period
of the fetus to assume a vertex presentation Fetal hypoxia
major malformation:hydrocephaly,
anencephaly, meningomyemocoele Criteria in Determining Signs of Fetal Distress
most common malformation:congenital Fetal Heart Rate:
dislocation of the hip Baseline rate
Liquor Variability
oligohydramnios/polyhydramnios Accelerations of Fetal Heart rate Decelerations
Uterine Fetal Movements/Activities
anomalies (bicornuate, fibroid) Meconium Staining
Placenta Fetal Stimulation
Previa Fetal Scalp Blood Sampling
Pelvis Fetal Oxygen Saturation
contracture, pelvic tumors obstructing birth Fetal Heart Rate
canal A. Baseline Rate
Management of Shoulder Presentation average FHR observed during a 10-minute
expectant – fetus may change presentation period of monitoring
without intervention if discovered before term normal rate ranges from 110 – 160 bpm
external cephalic version if evident at 37 weeks two abnormal baseline:
cesarean delivery if unsuccessful o Fetal tachycardia
Compound Presentation o Fetal Bradycardia
There are two presenting part Fetal Tachycardia
COMPOUND: early fetal hypoxia
• baby's hand presents alongside its head Maternal fever
(sometimes called a 'nuchal hand'), making a Maternal Dehydration
larger size that has to go through the pelvis; Beta-sympathomimetic drugs
 Amnionitis applying pressure to fetal scalp by
Maternal Hyperthyroidism gently stroking or massaging it for 15
Fetal Anemia seconds while doing vaginal
Fetal Bradycardia examination
late/profound fetal hypoxia o Vibroaccoustic stimulation
Maternal Hypotension
Umbilical cord compression Fetal Blood Scalp Sampling
Vagal Stimulation acid-base status of fetus
Fetal Arrhythmia must be done when:
Uterine hyperstimulation o RBOW
o 2-3 cms cervical dilatation
Abruptio Placenta
o station -2 and below
Uterine Rupture
must not done when:
Variability
o FHR pattern are ominous
a measure of interplay (push-pull effect)
o acute emergencies
between the sympathetic and parasympathetic
o vaginal bleeding
nervous system
normal during labor is above 7.25 pH
two abnormal variability:
pH 7.2 – 7.25 is borderline
Decreased variability below 7.2 is non reassuring and necessitate
Increased variability birth
Decreased Variability Fetal Oxygenation Saturation (FSpO2)
Hypoxia 40% - 70% are considered reassuring
Acidosis 30% - 40% mild acidosis and requires
CNS depressant agents continuous monitoring
Fetal sleep below 30% indicates hypoxia and requires
< 32 weeks fetus immediate birth
Fetal anomalies Factors Causing Fetal Distress
Previous neurologic insult Breathing problems
Tachycardia Abnormal position and presentation of the
Increased Variability fetus
Early mild hypoxia Multiple births
Fetal stimulation or activity Shoulder dystocia
Alteration in placental blood flow Umbilical cord prolapse
Fetal Heart Acceleration Nuchal cord
tansient increase of FHT normally caused by Placental abruption
fetal movements Premature closure of the fetal ductus
indicates fetal well being arteriosus
no accelerations is an ominous sign Fetal Distress Management
Fetal Heart Deceleration continuous fetal monitoring
periodic decrease of FHT from its baseline rate Oxytocin if indicated
three types: discontinue oxytocin if with prolonged late
o Early deceleration decelerations
o Late deceleration intrauterine fetal resucitations:
o Variable deceleration left lateral position
(NOT INCLUDED) – 3 types Oxygen administration
Hydration
Fetal Movements fetal stimulation
at least 10x in 3 hours prepare for immediate delivery
affected by: NURSING DIAGNOSIS:
o fetal sleep Decreased Cardiac Output (fetal)
o sound Impaired Gas Exchange (fetal)
o time of day Ineffective Tissue Perfusion (fetal)
o blood glucose level Risk for fetal injury
o cigarette smoking Anxiety (maternal)
o Drugs Deficient Knowledge (maternal)
o Oxygenation status UMBILICAL CORD PROLAPSE
less than 10 movements in 3 hours or absent A rare, obstetrical emergency that occurs when
movement are ominous the umbilical cord descends alongside or
(MECONIUM STAINING – NOT INCLUDED) beyond the fetal presenting part.
TYPES OF UMBILICAL CORD PROLAPSE:
Fetal Stimulation Overt Prolapse
fetus should response by fetal heart Refers to protrusion of the cord
accelerations in advance of the fetal
o Fetal scalp stimulation presenting part, often through
 the cervical os and into or To prevent cord compression, the presenting part MUST
beyond the vagina. BE elevated:
Occult Prolapse • knee chest position or head-down
Occurs when the cord descends • tilt (preferably in left-lateral position).
alongside, but not past, the • Tocolysis
presenting part. Optimal mode of delivery with cord prolapse:
• category 1 caesarean section
• Category 2 caesarean section
Vaginal birth, in most cases operative,
can be attempted at full dilatation
A practitioner competent in the
resuscitation of the newborn should
attend all deliveries with cord
prolapse.
Management in community setting:
• assume the knee–chest face-down position
while waiting for hospital transfer.
• Transport woman to nearest consultant-led
institution
• Left lateral position during transport
SIGNS: • Elevate presenting part
Ill-fitting or non-engaged presenting UMBILICAL CORD ABNORMALITIES
part • Velamentous insertion of the cord
Prolapsed umbilical cord • Umbilical cord compression
umbilical cord visualized in • Umbilical cord prolapse
vagina or at vulva • Hypercoiling of the cord
umbilical cord palpated on • Cord Coil
pelvic exam Velamentous Insertion of the Cord
Fetal distress on Fetal Heart Tracing • Condition where the umbilical cord joins the
May follow rupture of placenta at the edge, rather than the typical
membranes insertion in the center.
PROGNOSIS:
High perinatal mortality for delayed delivery
>40 min
PROBLEMS WITH THE PASSAGEWAY
RISK FACTORS:
Premature rupture of the amniotic sac
CEPHALOPELVIC DISPROPORTION
Polyhydramnios
Disproportion of fetal head and mother’s pelvis
Long umbilical cord
CAUSES:
Fetal malpresentation
increased fetal weight
Multiparity
fetal position
Multiple gestation
problems with the pelvis
Placenta previa
problems with the genital tract
Intrauterine tumors
S/S:
A small fetus
• the delivery of the baby is obstructed
CPD
• The labor is prolonged
DIAGOSTICS:
(PATHOPHYSIOLOGY NOT INCLUDED)
A pelvic examination can also be conducted by a
DIAGNOSTICS:
physician and may see the prolapsed cord, or
Estimation of the size of the pelvis:
palpate (feel) the cord with the fingers.
Clinical Pelvimetry
Cardiotocograph ( Electronic Fetal Monitoring)
Radiologic Pelvimetry
Ultrasound
Estimation of fetal size
(PATHOPHYSIOLOGY – NOT INCLUDED)
MANAGEMENT:
NURSING DIAGNOSIS:
CESAREAN SECTION
Impaired Gas Exchange (fetal)
NURSING DIAGNOSIS:
Risk for Injury (fetal)
• Anxiety
Fear (maternal)
• Fatigue
Anxiety (maternal)
• Risk for fetal injury
Deficient Knowledge (maternal)
• Risk for impaired skin integrity
Umbilical Cord Prolapse Management
• Situational low self- esteem
Initial management of cord prolapse in hospital
INTERVENTIONS:
setting:
• Monitor heart sounds and uterine contractions
• immediate delivery
continuously, if possible, during trial labor.
• minimal handling of loops of cord lying outside
• Urge the woman to void every 2 hours s
the vagina.
• Assess FHR carefully
 • Establish a therapeutic relationship, conveying B.) Secondary: efficient pattern that changes to efficient
empathy and unconditional positive regard or stops; may occur in any stage.
• Instruct in methods to conserve energy Assessment findings:
• Massage bony prominences gently and change Progress of labor is slower than expected rate of
position on bed in a regular schedule dilatation, effacement, descent for specific
• Convey confidence in client’s ability to cope client.
with current situation Length of labor prolonged; prolonged latent
SHOULDER DYSTOCIA: phase (>20 hrs in nullipara pt. or >4 h in a
Incidence: about 0.2–1%. multipara pt), protacted active phase dilatation
This is one of the most frightening obstetric np. <1-2cm, mp <1.5cm; protacted descengt <1
emergencies cm per hr change in station in the nullipara pt.
It occurs when the fetal shoulders fail to negotiate or <2 cm per hour in the mp pt.
the pelvic inlet Maternal exhaustion/ distress
Prompt (but not forcible) action is required to Fetal distress
prevent fetal Arrest of descent: no progress in fetal station
morbidity or mortality (see Stirrat and Taylor in greater than 1 hour
‘Further reading’) Nursing intervention:
Antenatal risk factors Individual as to cause
• Mother’s birthweight 90th centile Provide comfort measures for client
• Maternal obesity or massive weight gain Provide client, supportive descriptions of all
• Diabetes mellitus—can be despite seemingly actions taken
good blood sugar Administer analgesia if ordered
control Monitor mother/ fetus continuously
• Prolonged pregnancy (beyond 42 completed Pathophysiology: (DIAGRAM NOT INCLUDED)
weeks)
• Previous shoulder dystocia (10% risk of PREDISPOSING FACTORS:
recurrence) or large baby • Genetic
• Recognized macrosomia this pregnancy. • Overweight
• Multiple gestation
• Hydramnios
PROBLEMS WITH THE POWERS • Maternal fatigue
• Pelvic malformation
DYSTOCIA: • Inappropriate timing of analgesic and
General information: anaesthetic administration
Any labor or delivery that is prolonged and • Gestational DM
difficult. • STDs
Usually results form a change in the • Other diseases
interrelationships among the PRECIPITATING FACTORS:
5 Ps (factors in labor and delivery): • Malpresentation and malposition of the fetus
>passenger • Congenital malformation of the uterus
>passage • Over stimulation with oxytocin
>powers • CPD
>placenta • Fetal anomalies such as neural tube defects,
>psyche of mother. large tumor, and gross ascites
Cesarean birth is needed if disproportion is Signs/ symptoms:
great. Pain
Problems with presentation: any Increase heart rate, pulse, body temp.
presentation unfavorable for delivery (e.g. Increased BP
breech, shoulder , face, transverse lie. Diaphoresis
Posterior presentation that does not rotate Body weakness
or cannot be rotated with ease. Exhausted appearance
1. Problems with maternal soft tissue SOB
A full bladder may impede the progress of labor, Nasal flaring
as can myomata uteri, cervical edema, scar Anxiety
tissue, and congenital anomalies. Restlessness
Emptying the bladder may allow labor to Vaginal hemorrhage
continue; the other conditions may necessitate Medical Management:
caesarean birth. 1. Treatment for contraction abnormalities
2. Dysfunctional uterine contractions involves stimulation of labor through the use of
Contraction may be too weak, too short, too far oxytocin. An intrauterine pressure catheter may
apart, ineffectual be used.
Classification 2. Management for maternal passageway or fetal
A.) Primary: inefficient pattern present from passage problems involves delivery in the safest
beginning of labor; usually prolonged latent phase. manner for the mother and fetus.
 If the problem is related to the inlet or • Vaginal discharge.
midpelvis, a CS delivery is indicated. GOAL = to minimize physical/psychological stress during
If the size of the outlet is the problem, a labor/birth. Emotional support.
forceps or vacuum extraction maybe
perform. DYSFUNCTIONAL LABOR PATTERN:
Surgical Management: • Hypertonic labor
1. Caesarean in necessary for delivery of the fetus • Hypotonic labor
• Precipitate labor level
NURSING DIAGNOSIS: HYPERTONIC DYSFUNCTION:
Acute pain related difficulty in labor. • Increased resting tone of uterine myometrium;
Promoting comfort: diminished refractory period; prolonged latent
Relaxation technique such as breathing phase.
techniques during labor • Nullipara: more than 20 hours.
Changing position • Multipara: more than 14 hours.
Support person • Etiology: unknown. Theory – ectopic initiation
Pain medications of incoordiante uterine ctx.
Anxiety related to threat of change in health status of • Assessment:
self and fetus. • Onset (early labor)
Decreasing anxiety: • Contractions:
Give brief explanation to the women about the • Continuous fundal tension,
nature of contraction associated with induce incomplete relaxation.
labor • Painful.
Provide anticipatory guidance regarding use of • Ineffectual – no effacement or
meds, procedures and equipment. dilation.
Prepare for caesarean if necessary • Signs of fetal distress:
• Meconium-stained fluid.
• FHR irregularities.
Powerlessness • Maternal VS.
Provide rest period • Emotional status.
Relaxation technique • Medical evaluation: to rule out CPD.
Support person • Vaginal examination, x-ray
Deficient knowledge related to measures that can be pelvimetry, ultrasonography.
used to enhance labor and facilitate birth. INTERVENTIONS:
Teach proper breathing techniques used during • Short-acting barbiturates (to encourage rest,
labor relaxation).
Educate about the complication of the delivery • IV fluids (to restore / maintain hydration &
Explain client that caesarean is necessary due to fluid-electrolyte balance).
difficult labor. • If CPD – c/s.
Ineffective individual coping related to inadequate • Provide emotional support.
support system. • Provide comfort measures.
Support mechanism: • Prevent infection (strict aseptic technique).
Stay with the patient during labor process • Prepare patient for c/s if needed.
Encourage patient to discuss about her
condition HYPOTONIC DYSFUNCTION:
• After normal labor at onset, ctx diminish in
DYSFUNCTIONAL LABOR: frequency, duration, & strength.
• Possible Causes: • Lowered uterine resting tone; cervical
• Catecholamines (response to effacement & dilation slow / cease.
anxiety/fear), increase • Etiology:
physical/psychological stress, leads to • Premature or excessive analgesia /
myometrial dysfunction; painful & anesthesia (epidural, spinal block).
ineffective labor. • CPD.
• Premature or excessive analgesia, • Overdistention (hydramnios, fetal
particularly during latent phase. macrosomia, multifetal pregnancy).
• Maternal factors. • Fetal malposition / malpresentation.
• Fetal factors. • Maternal fear / anxiety.
• Placental factors. • Assessment:
• Physical restrictions (position in bed). • Onset (latent phase & most common in
ASSESSMENT: active phase).
• Antepartal history. • Contractions - normal previously, will
• Emotional status. demonstrate:
• Vital signs, FHR. • Decreased frequency.
• Contraction pattern (frequency, duration, • Shorter duration.
intensity).
 • Diminished intensity (mild to
moderate).
• Less uncomfortable.
• Cervical changes – slow or cease.
• Signs of fetal distress – rare.
• Usually late in labor d/t
infection secondary to
prolonged ROM.
• Tachycardia.
• Maternal VS (elevated temperature) –
may indicate infection.
• Medical diagnosis – procedures: vaginal
examination, x-ray pelvimetry,
ultrasonography. To rule out CPD (most
common cause).
• Management:
• Amniotomy (artificial ROM).
• Oxytocin augmentation of labor.
• If CPD, prepare for c/s.
• Emotional support, comfort measures,
prevent infection.
PRECIPITATE LABOR:
• Labor that progresses rapidly and ends with the
delivery occurring less than 3 hours after the
onset of uterine activity.
• Rapid labor and delivery.
PRETERM LABOR:
-Labor that occurs before the end of the thirty-
seventh week of gestation. It occurs
approximately 9%- 11% of pregnancies. Any
woman having persistent uterine contractions
(4 very 20 min) should be considered to be in
labor. A woman is documented as being in
actual labor rather than having false labor
contractions if she is having uterine
contractions that cause cervical effacement
over 80% and dilation over 1cm.
-Preterm labor is always serious because if it
results in infant’s birth, the infant may be
immature.
ASSESSMENT:
During tocolytic therapy, assess the following:
• Fetal status by electronic fetal monitoring
• Uterine activity pattern
• Respiratory status
• Muscular tremors
• Palpitations
• Dizziness
• Lightheadedness
• Urinary output
• Patient education to S/Sx of PTL
• Patient education to S/Sx of infection
RISK FACTORS:
• Race: African-American women
• Age: Adolescents
• Those with inadequate prenatal care
• Those who continue to work at strenuous jobs
during pregnancy
• Those who have shift works that leads to
extreme fatigue
Signs and Symptoms:
• Persistent, dull, low backache
• Vaginal spotting
• A feeling of pelvic pressure (abdominal
tightening)
• Menstrual-like cramping
• Vaginal discharges
• Uterine contractions
• Intestinal cramping
• Feeling that baby is “pushing down” or that
“something” is in the vagina
Nursing Diagnosis & Interventions:
Anxiety r/t medication and fear of outcome of
pregnancy
Know the C/I and potential complications of
tocolytic therapy
Explain the purpose and common A/E of
tocolytic therapy
Provide accurate information on the status of
the fetus and labor (contraction pattern).
Allow the woman and her support person to
verbalize their feelings regarding the episode of
PTL and the treatment.
If a private room is not used, do not place the
woman in a room with a woman who is in labor
or who has lost an infant.
Situational Low Self-Esteem r/t Inability to carry
pregnancy
Provide support persons because she is apt to
be more concerned than the average person
about labor.
Encourage expression of feelings and anxieties
to facilitate coping with actual situation.
Provide frequent assurance during labor that
she is breathing well with contractions and
continue until postpartum period because she
may not be mentally prepared for the labor
because it has come unexpectedly.
Comment on strengths of the family unit.
Convey confidence in client’s ability to cope
with current situation.
Risk for Fetal Injury r/t Preterm Birth
Monitor fetal status and labor problems.
Assess WBC count frequently. A count of
18,000-20,000/mm3 suggests infection.
Reassure misconceptions about difficulty of
labor after preterm rupture of the membranes
(dry labor) since amniotic fluid is always being
formed so there is no such thing as dry labor
Encourage the woman to assume positions that
will enhance placental perfusion.
Assist with delivery of infant as needed.
Risk for Injury Secondary to Tocolytic therapy
Maintain accurate I/O at least every hour. Limit
intake to 2,500mL/day.
Assess maternal VS.
Notify Physician if maternal pulse is greater
than 120 bpm.
Assess for S/Sx of pulmonary edema.
Educate woman on tocolytic therapy, explaining
the purpose and common A/E.
Compromised Family Coping Secondary to
Hospitalization
Encourage private time for woman and partner.
Encourage family members to verbalize feelings
openly and clearly.
 Allow visitation with other children as tolerated
by the woman.
Comment on strengths of the family unit.
Promote assistance of family in providing client
care as appropriate.
Medical Management:
• Antibiotics
• Prostaglandin Inhibitors
Indomethacin (Indocin)
• Calcium Channel Blockers
Nifepidine (Procardia)
• Corticosteriods
Betamethazone 12 mg IM q 24 hrs 2
doses
Dexamethazone 6 mg IM q 12 hrs 4
doses
• Magnesium sulfate
• Beta-sympathomimetic drugs
Ritodrine hydrochloride (yutopar)
Terbutaline (brethine)
Surgical Management:
Cesarean Section
NURSING MANAGEMENT:
• Hydration (Oral or IV)
• Bedrest (Home or Hospital), usually left side
lying
• Medications to stop labor (Magnesium sulfate,
brethine, terbutaline, etc.)
• Medication to help prevent infection (More
likely if your membranes have ruptured or if the
contractions are caused by infection)
• Evaluation of your baby. Biophysical profile,
non-stress or stress tests
• Medications to help your baby's lung develop
more quickly
Preconception Care
Baseline assessment of health and risks with
advice to decrease the risks attributable to
preterm labor/PTB.
Pregnancy planning and identification of
barriers to care.
Adjustment of prescribed and OTC that may
pose a threat to the developing fetus.
Advise to improve maternal nutrition.
Screening for and treatment of diseases.
Genetic counseling for those with a history of
genetic disease/ a previously affected
pregnancy.
Antepartum Treatment
Educate mother regarding S/Sx of PTL.
Instruct mother and provide resources for
lifestyle modifications.
o If mother smokes, encourage smoking
cessation classes.
o Ensure mother has a healthy diet and
adequate maternal weight gain during
pregnancy.
Initial treatment for a patient who is at risk for
PTL is the use of bed rest in a left lateral
position with continuous monitoring of fetal
status and uterine activity.
Hydration with IV fluids, with careful
assessment of I/O and auscultation of lungs to
assess for the development of pulmonary
edema.
If this stops the contractions, tocolytic therapy
is not needed.
(PATHOPHYSIOLOGY NOT INCLUDED)
UTERINE PROLAPSE (Uterine Prolapse/Pelvic
relaxation/Pelvic floor hernia)
• a descent or herniation of the uterus into or
beyond the vagina
• considered under the broader heading of
"pelvic organ prolapse" which also includes
cystocele, urethrocele, enterocele, and
rectocele.
• anatomically, the vaginal vault has 3
compartments:
an anterior compartment (consisting of the
anterior vaginal wall)
- a middle compartment (cervix)
posterior compartment (posterior vaginal
wall).
• UP involves the middle compartment
Four stages of uterine prolapse are defined:
stage I - descent of the uterus to any point in
the vagina above the hymen
stage II - as descent to the hymen
stage III - as descent beyond the hymen
stage IV - as total eversion or procidentia
Uterine prolapse always is accompanied by
some degree of vaginal wall prolapsed.
ASSESSMENT:
• A complete pelvic examination is required,
including a rectovaginal examination to assess
sphincter tone.
• A Sims speculum or a standard bivalve
speculum with the anterior blade removed may
facilitate diagnosis.
• Physical findings may be enhanced by having
the patient strain during the examination or by
having her stand or walk prior to examination.
Standing with an empty bladder may result in a
1-2 stage difference in the degree of prolapse
noted on examination when compared to a
supine position with a full bladder.
• Mild uterine prolapse may be recognized only
when the patient strains during the bimanual
examination.
• Evaluate all patients for estrogen status.
• Signs of decreased estrogens
• Loss of rugae in the vaginal
mucosa
• Decreased secretions
• Thin perineal skin
• Easy perineal tearing
• Physical examination should also be directed
toward ruling out serious conditions that may
rarely be associated with uterine prolapse, such
as infection, urinary outflow obstruction with
renal failure, and hemorrhage.
• If urinary obstruction is present, the
patient may exhibit suprapubic
tenderness or a tympanitic bladder.
 • If infection is present, purulent cervical • preoperative nursing care:
discharge may be noted. Thorough explanation of procedure,
LABORATORY STUDIES: expectation and effect on future sexual
• Laboratory studies are unnecessary in f(x)
uncomplicated cases . Laxative and cleansing edema
• Cervical cultures - cases complicated by (rectocele) – independently, at home a
ulceration or purulent discharge day prior procedure
• Papanicolaou test (Pap smear cytology) or Perineal shave prescribed also
biopsy - in rare cases of suspected carcinoma Lithotomy position for surgery
• BUN and creatinine measurement - if PE • postop nursing care:
findings suggest urinary obstruction Pt. is to void few hours after surgery;
IMAGING STUDIES: catheter if unable (after 6 hrs)
• Pelvic ultrasound examination NURSING DIAGNOSIS:
• Ultrasonography PAIN
• MRI - to grade pelvic organ prolapse o Administer analgesic as prescribed.
SIGNS AND SYMPTOMS: o Provide comfort measures such as backrub.
• Pelvic heaviness or pressure o Provide diversional activities such as guided
• Protrusion of tissue: A patient who reports of a
imagery and socialization.
"bulge" has been found to be a valuable
screening tool for the detection of pelvic organ CONSTIPATION
o Administer stool softeners/laxatives as
prolapse (81% PPV, 76% NPV).
prescribed.
• Pelvic pain
• Sexual dysfunction, including dyspareunia, o Encourage increase in fluid and fiber intake.
decreased libido, and difficulty achieving o Encourage early ambulation.
orgasm
• Lower back pain URINARY INCONTINENCE
• Constipation o Determine if client is aware of incontinence.
Developmental issues/ medical conditions
• Difficulty walking
that can impair patient’s awareness and
• Difficulty urinating
• Urinary frequency sensory perception of voiding.
• Urinary urgency o Determine patient’s particular symptoms
(e.g. continuous dribbling).
• Urinary incontinence
• Nausea o Implement bladder training for
• Purulent discharge (rare) incontinence management by providing
ready acces to bathroom or commode,
• Bleeding (rare)
encouraging adequate fluid intake, and
• Ulceration (rare)
(PATHOPHYSIOLOGY NOT INCLUDED) establishing voiding/bladder emptying.

SEXUAL DYSFUNCTION
COMPLICATIONS:
• Urinary retention o Provide factual information about individual
• Constipation condition involved to promote informed
decision making.
• Hemmorhoids
o Provide for ways to obtain privacy to allow
• Cervical ulceration
• Infection (possible) for sexual expression for individual and/or
• Cystitis between partners with out embarrassment
and/or objection of others.
TREATMENT/MEDICAL MANAGEMENT:
• Pessaries o Establish therapeutic nurse-client
o + fitted into the vagina to hold the relationship to promote treatment and
facilitate sharing of sensitive information.
uterus in place
RISK FOR INFECTION
o + temporary or permanent form
o + fitted individually for each woman o Observe for localized signs of infection.
o Note for signs and symptoms for sepsis.
o + attaining and maintaining optimal
o Stress proper hand hygiene.
weight is recommended
• Surgery
o + uterus sutured back into place & UTERINE RUPTURE
spontaneous or traumatic rupture of the uterus
o + colpopexy - involves the use of
ie., the actual separation of the uterine
surgical mesh for supporting the uterus
o + hysterectomy – removal of uterus myometrium/ previous uterine scar, with
rupture of membranes and extrusion of the
NURSING MANAGEMENT:
fetus or fetal parts into the peritoneal cavity.
• preventive measures:
Early visits to HC provider = early Dehiscence - partial separation of the old
detection uterine scar;
Teach Kegel’s exercises during PP
period
 - the fetus usually stays inside the uterus and
the bleeding is minimal when dehiscence
occurs.
RISK FACTORS:
• Women who have had previous surgery on the
uterus (upper muscular portion)
• Having more than five full-term pregnancies
• Having an overdistended uterus (as with twins
or other multiples)
• Abnormal positions of the baby such as
transverse lie.
• Use of Pitocin (oxytocin) and other labor-
induced medications (prostaglandin)
• Rupture of the scar from a previous CS
delivery/hysterectomy.
• Uterine/abdominal trauma
• Uterine congenital anomaly
• Obstructed labor; maneuvers within the uterus
• Interdelivery interval (time between deliveries)
(PATHOPHYSIOLOGY NOT INCLUDED)
ASSESSMENT:
evaluate maternal vital signs
note an increase in rate and depth of
respirations, an increase in pulse , or a drop in
BP indicating status change
assess fetal status by continuous monitoring
speak with family, and evaluate their
understanding of the situation
observe for signs and symptoms of impending
rupture
-lack of cervical dilatation
-tetanic uterine contractions
restlessness
anxiety
severe abdominal pain
fetal bradycardia
late or variable decelerations of the
FHR)
SIGNS AND SYMPTOMS:
CLINICAL MANIFESTATIONS:
Developing Rupture
Abdominal pain and tenderness
Uterine contractions will usually continue but
will diminish in intensity and tone.
Bleeding into the abdominal cavity and
sometimes into the vagina.
Vomiting
Syncope; tachycardia; pallor
Significant change in FHR characteristics –
usually bradycardia (most significant sign)
Violent Traumatic Rupture
Sudden sharp abdominal pain during or
between contractions.
Abdominal tenderness
Uterine contractions may be absent, or may
continue but be diminished in intensity and
cord
bleeding vaginally, abdominally, or both
Fetus easily palpated in the abdominal with
shoulder pain
Tenses, acute abdominal with shoulder pain
Signs of shock
Chest pain from diaphragmatic irritation due to
bleeding into the abdomen.
NURSING DIAGNOSIS WITH INTERVENTIONS:
DEFICIENT FLUID VOLUME:
Start or maintain an IV fluid as prescribed. Use a
large gauge catheter when starting the IV for
blood and large quantities of fluid replacemnt.
Maintain CVP and arterial lines, as indicated for
hemodynamic monitoring.
Maintain bed rest to decrease metabolic
demands.
Insert Foley catheter, and moniter urine output
hourly or as indicated.
Obtain and administer blood products as
indicated.
FEAR
Give brief explanation to the woman and her
support person before beginning a procedure.
Answer questions that the family or woman
may have.
Maintain a quiet and calm atmosphere to
enhance relaxation.
Remain with the woman until anesthesia has
been administered; offer support as needed.
Keep the family members aware of the situation
while the woman is in surgery and allow time
for them to express feelings.
DECREASED CARDIAC OUTPUT
Administer supplemental oxygen, blood/fluid
replacement, antibiotics, diuretics, inotropic
drugs, antidysrhythmics, steroids,
vassopressors, and/or dilators as ordered.
Position HOB flat or keep trunk horizontal while
raising legs 20 to 30 degrees in shock situation
Activities such as isometric exercises, rectal
stimulation, vomiting, spasmodic coughing
which may stimulate Valsalva response should
be avoided; administer stool softener as
indicated.
INEFFECTIVE TISSUE PERFUSION
Administer O2 using a face mask at 8-12 L/min
or as ordered to provide high oxygen
concentration.
Apply pulse oximeter, and monitor oxygen
saturation as indicated.
Monitor ABG levels and serum electrolytes as
indicated to assess respiratory status, observing
for hyperventilation and electrolyte imbalance.
Continually monitor maternal and fetal vital
signs to assess pattern because progressive
changes may indicate profound shock.
RISK FOR INFECTION
Observe for localized signs of infection.
Cleanse incision or insertion sites daily and PRN
with povidone iodine or other appropriate
solutions.
Change dressings as needed or indicated.
Encourage early ambulation, deep breathing,
coughing and position changes.
Maintain adequate hydration and provide.
Provide perineal care.
MEDICAL MANAGEMENT:
 • Immediate stabilization of maternal Culture
hemodynamics and immediate caesarean A woman’s culture influences and
delivery defines
• Oxytocin is given to contract the uterus and the The childbirth experience
replacement . Shameful versus joyful
• After surgery, additional blood, and fluid Superstitions and beliefs about pregnancy and birth
replacement is continued along with antibiotic Prescribed behaviors and taboos during
theory. the intrapartum period
Relationships
SURGICAL MANAGEMENT: Interpersonal interactions
• Caesarean Section Parent–infant interactions
• Laparotomy Role expectations of family members
• Hysterectomy Support person involvement
NURSING MANAGEMENT:
• Continually evaluate maternal vital signs;
especially note an increase in rate and depth of
respirations, an increase in pulse , or a drop in
BP indicating status change.
• Assess fetal status by continuous monitoring.
• Speak with family, and evaluate their
understanding of the situation.
• Anticipate the need for an immediate caesarean
birth to prevent rupture when symptoms are
present.
• Provide information to the support person and
inform him or her about fetal outcome, the
extent of the surgery and the woman’s safety.
• Let the pt express her emotion without feeing
threatened.

PROBLEMS WITH THE PSYCHE

Factors that may affect the woman s psyche during
labor include the woman s:
Current pregnancy experience
Unplanned versus planned pregnancy
Amount of difficulty conceiving
Presence of risk factors
Complications of pregnancy
Previous birth experiences
Complications of delivery
Mode of delivery (cesarean versus vaginal)
Birth outcomes (e.g., fetal demise, birth defects)
Expectations for current birth experience
View of labor as a meaningful or a stressful
event
Realistic and attainable goals versus
idealistic views that conflict with reality (a
situation that can lead to disappointment)
Preparation for birth
Type of childbirth preparation
Familiarity with institution and its policies
and procedures
Type of relaxation techniques learned and
practiced
Support system
Presence and support of a birth companion
Husband
Mother
Lesbian partner
Friend
Doula
Pain
Meaning and context of pain
Acceptable responses to pain
The significance of touch Oligohydramnios Maternal fear Incidence of
Soothing versus intruding of “dry birth” congenital anomalies
May be a symbol of intimacy Incidence of renal
lesions
Risk of IUGR
SUMMARY
Risk of fetal
INTRAPARTAL HIGH RISK FACTORS
acidosis
Risk of cord
Factor Maternal Fetal-Neonatal compression
Implications Implications Postmaturity
Meconium staining Risk of fetal
Abnormal Incidence of Incidence of of amniotic fluid Psychologic asphyxia
presentation cesarean birth placenta pre stress due to Risk of meconium
Incidence of Prematurity fear for baby aspiration
prolonged labor Risk of congenital Risk of pneumonia
abnormality due to aspiration of
Neonatal physical meconium
trauma
Risk of intrauterine Premature rupture Risk of Perinatal
growth restriction of membranes infection morbidity
(IUGR) (chorioamnio Prematurity
via nitis) Birth weight
Risk of Risk of respiratory
preterm labor distress syndrome
Multiple Uterine Low birth weight Anxiety Prolonged
gestation distention risk Prematurity Fear for the hospitalization
of postpartum Risk of baby
hemorrhage congenital Prolonged
Risk of cesarean anomalies hospitalizatio
birth Feto-fetal n
Risk of preterm transfusion Incidence
labor of tocolytic
therapy
Induction of labor Risk of Prematurity if
Hydramnios Discomfort Risk of hypercontrac gestational age not
Dyspnea esophageal or tility of assessed correctly
Risk of preterm other high- uterus Hypoxia if
labor alimentary-tract Risk of hyperstimulation
atresias uterine occurs
Risk of CNS rupture
anomalies Length of
(myelocele) labor if cervix
Edema of lower not ready
extremities Anxiety
Abruptio Hemorrhage Perinatal
placentae/placenta Uterine atony mortality
previa Incidence Fetal
of cesarean hypoxia/acidosis
birth Fetal exsanguination
Failure to Maternal Fetal Precipitous labor Perineal, vaginal, Tentorial tears
progress in labor exhaustion hypoxia/acidosis (<3 hours) cervical
Incidence of Intracranial birth lacerations
augmentation of injury Risk of
labor postpartum
Incidence of hemorrhage
cesarean birth
Prolapse of Fear for baby Acute fetal B reasts
umbilical cord Cesarean birth hypoxia/acidosis U terus
B ladder
B owel
Fetal heart Fear for baby Tachycardia, L ochia
aberrations Risk of chronic asphyxic E pisiotomy/Episiorrhapy
cesarean birth, insult, H oman s sign
forceps, vacuum bradycardia, E motions
Continuous acute R hogam
electronic Asphyxic insult
monitoring and Chronic hypoxia
intervention Congenital heart
in labor block

Uterine rupture Hemorrhage Fetal anoxia

Cesarean birth Fetal
for hysterectomy hemorrhage
Risk of death Neonatal
morbidity and
mortality

Postdates Anxiety Postmaturity

(>42 weeks) Incidence of syndrome
induction of labor Risk of fetal-
Incidence of neonatal mortality
cesarean birth and morbidity
Use of Risk of
technology to antepartum fetal
monitor fetus death
Risk of Incidence or
shoulder dystocia risk of large baby
Diabetes Risk of Risk of
hydramnios malpresentation
Risk of Risk of
hypoglycemia or macrosomia
hyperglycemia Risk of IUGR
Risk of Risk of
preeclampsia- respiratory
eclampsia distress syndrome ASSESSMENT OF THE GENERAL APPEARANCE
Risk of Assessment Normal Abnormal
congenital Technique Assessment Assessment
anomalies Findings Findings
Preeclampsia- Risk of seizures Risk of small- Inspection/ Exhaustion Extreme
eclampsia Risk of stroke for-gestational-age Observation Fatigue exhaustion,
Risk of HELLP baby Sleep hunger Weakness, and
Risk of preterm depression at the
birth end of 6th week
Risk of mortality Pallor
AIDS/STI Risk of Risk of Anxiousness and
additional transplacental restlessness
infections transmission Dizziness
Fainting

(END OF 5TH PART)

COMMON POSTPARTUM COMPLICATIONS

POST PARTUM ASSESSMENT:

A pperance
V ital Signs
ASSESSMENT OF THE VITAL SIGNS ASSESSMENT OF THE UTERUS
VITAL SIGNS NORMAL ABNORMAL ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Blood 90/60 – 130/80 Below 90/60 Inspection • Weight 1000 • No weight

Pressure 40 – 80 bpm 130/90 & above gms changes
Pulse Rate Tachycardia immediately • Visible cervix or
Weak Thready after birth uterus
Palpitations • 500 gms at • Severe
the end of abdominal pain
first week and tenderness
NORMAL ABNORMAL • 50 grms at 6th • Lateral
week displacement
Respiratory 16 -24 Tachypnea • After pains of the uterus
Rate breaths/cycle Shallow & Irregular during
Dyspnea contractions

Measurement of descent of fundus for the woman with

vaginal birth. The fundus is located two finger-breadths
NORMAL ABNORMAL
below the umbilicus. Always support the bottom of the
uterus during any assessment of the fundus.
Temperature 36.2 – 38 C on the 38 C and above in
first 24 hours any or two
Occasionally consecutive 24-hour
febrile on the 3rd period (excluding
to 4th day the first 24 hours)

ASSESSMENT OF THE BREAST

ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Inspection Increase in size • Localized

Colostrum • swelling
Milk changes • Localized Pain
from thin • Redness
watery to • Purulent
bluish white discharges
Becomes • Cracked and
heavier irritated
Veins become nipples
apparent

The uterus becomes displaced and deviated to the right

ASSESSMENT NORMAL ABNORMAL when the bladder is full.
TECHNIQUE

Palpation Warm and firm Localized mass

Engorged
ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Palpation • Contracted • Boggy

uterus
• Cervix is soft
and malleable • Board-like
• Cervical os is abdomen
narrowed

ASSESSMENT OF THE BLADDER

ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Inspection • Temporary • Burning

difficulty of sensation
voiding • Hematuria
• Void within • Inability to void
6 to 8 hours more than 10
postpartum hours
• 3Liters • Oliguria
urinary • Severe
output/day proteinuria
• Zero-trace • Glycosuria
protein
• Zero-trace
sugar
• Urinary
stasis

ASSESSMENT NORMAL ABNORMAL

TECHNIQUE
TYPES OF NORMAL ABNORMAL
• Palpation • Cannot be • Hard and firm LOCHIA
• Percussio palpated • Resonant
n • Dull, Lochia 2 to 3 days Large
thudding Rubra postpartum clots
Dark Red in
color
ASSESSMENT OF THE BOWEL: Contains blood
ASSESSMENT NORMAL ABNORMAL and fragments of
TECHNIQUE the deciduas and
mucus
Inspection • Constipation • Passage of
• Decrease stool out
TYPES OF NORMAL ABNORMAL
flatus from the
LOCHIA
• Abdominal vaginal orifice
distention Lochia • 3 to 10 days • Reappearanc
• Decrease Serosa postpartum e of bright
bowel • Pink in color red colored
movement • Contains blood, lochia
• mucus, and • Foul-smelling
Hemorrhoids invading
leukocytes
Auscultation • decrease • Absent
bowel bowel
sound sound

ASSESSMENT OF LOCHIA
TYPES OF NORMAL ABNORMAL Subinvolution
LOCHIA Dessiminated Intravascular Coagulation

UTERINE ATONY
LOCHIA ALBA 10 to 14 days Reappearance
SIGNS AND SYMPTOMS:
postpartum of bright red
Boggy uterus
color
Large Uterus
Expulsion of large clots
Contains Foul-smelling Bright red bleeding
mucus, whitish Hypovolemic shock
FACTORS CAUSING UTERINE ATONY
Multiple Gestation
Hydramnios
Large baby
Uterine Myoma
Anestheia
Oxytoxic drugs
Multiparity
Advanced maternal age
Prolonged tocolytic agents
Dystocia
Previous Uterine surgery
Chorioamnionitis
Full bladder
MANAGEMENT OF UTERINE ATONY
Promote Uterine Contraction
Stop Bleeding
ASSESSMENT OF EPISIOTOMY/EPISSIORRHAPY Prevent Complications:
ASSESSMENT NORMAL ABNORMAL Hypovolemic Shock - Death
TECHNIQUE MEDICAL MANAGEMENT OF UTERINE ATONY
Intravenous Fluid
Oxytoxic Medications:
Oxytocin
Inspection • Redness, • Hematomas Maleate
edema, and • 1 or 2 stitches Cytotec
bruises on sloughed away Antibiotics
the • Large Blood Transfusion
perineum lacerations Catheterization
• Slight • Purulent Oxygen Administration
separation discharges SURGICAL MANAGEMENT OF UTERINE ATONY
of wound Ligation of Uterine Arteries
edges Hysterectomy
• 1st degree NURSING DIAGNOSIS & MANAGEMENT OF UTERINE
laceration ATONY
Actual/Potential Fluid Volume Deficit
Inspect the perineum for fundal massage
episiotomy/lacerations with REEDA assessment ice pack application on fundus
Inspect C/S abdominal incisions for REEDA encourage voiding
R = redness (erythema) administer oxytocics as ordered
E = edema regulate IVF and BT
E = ecchymosis Altered Tissue Perfussion
D = drainage, discharge assess VS, NVS, CRT
A = approximation assess skin color and turgor
Postpartum Hemorrhage trendelenburg position
oxygen administration as ordered
POSTPARTUM HEMORRHAGE Anxiety
1. EARLY POSTPARTUM HEMORRHAGE emotional support
Uterine Atony give factual information about the condition
Lacerations explain the procedures
Hematomas provide calm environment
Uterine Rupture
Uterine Inversion
2. LATE POSTPARTUM HEMORRHAGE
Retention of Fragments
LACERATIONS Varicosities
Vaginal : Episiorrhaphy
anterior Lacerations
posterior MANAGEMENT OF HEMATOMAS
lateral wall MEDICAL MANAGEMENT:
Perineal: Analgesics
first degree – skin Cold Compress
second degree – muscles SURGICAL MANAGEMENT:
third degree – external anal sphincter Incision and drainage
fourth degree – rectal sphincter and Removal of sutures
rectal mucus membrane Packing
Cervical: Ligation of vessels
lateral NURSING DIAGNOSIS AND INTERVENTIONS
SIGNS AND SYMPTOMS OF LACERATIONS Alteration in comfort; Pain
Firm and Contracted Uterus proper referral
Bright red Bleeding ice pack application on the perineum
Tear in the birth canal, and perineum analgesics as ordered
FACTORS CAUSING LACERATIONS: assist for surgical intervention
Precipitate labor
Dystocia UTERINE RUPTURE
Malpresentation COMPLETE
Large babies involves endometrium, myometrium
Instrumentation and perimetrium
Lithotomy position INCOMPLETE
Rapid cervical dilatation intact peritoneum
Primigravida SIGNS AND SYMPTOMS OF UTERINE RUPTURE
MANAGEMENT OF LACERATIONS: Localized abdominal pain
Surgical Repair Abdominal tenderness
Cessation of bleeding Tearing feeling
Prevent Infection Hypovolemic shock
Alleviate pain Concealed bleeding
MEDICAL MANAGEMENT Change in abdominal contour
o Vaginal pack FACTORS CAUSING UTERINE RUPTURE
o Analgesics Difficult Vaginal Delivery
o Antibiotics Weak uterine operative site
o Stool softener vertical uterine scar from previous CS
SURGICAL MANAGEMENT OF LACERATIONS Faulty presentation
Surgical Repair Multiple gestation
Regional anesthesia Traumatic manuevers using instruments
NURSING DIAGNOSIS AND MANAGEMENT OF for delivery
LACERATIONS Injudicious use of oxytoxic agents
Alteration in Comfort; Pain Obstructed Labor
cold compress on the perineum GOAL OF MANAGEMENT OF UTERINE RUPTURE
perineal douch Repair of tear or laceration
high fiber diet Prevent Hemorrhage
increase OFI Prevent Hypovolemic shock
NSAIDS as ordered Prevent Infection
Potential for infection Prevent Death
pat dry the perineum MEDICAL MANAGEMENT OF UTERINE RUPTURE
frequent change of gowns and perineal pads Intravenous fluid
proper nutrition Blood Transfusion
increased OFI Antibiotics
prophylactic antibiotic as ordered Oxytoxics
SURGICAL MANAGEMENT OF UTERINE RUPTURE
HEMATOMA Laparotomy
SIGNS AND SYMPTOMS OF HEMATOMA Tubal ligation
severe perineal and pelvic pain not relieved by Hysterectomy
analgesia NURSING DIAGNOSIS AND INTERVENTIONS OF
bluish bulging under the skin UTERINE RUPTURE
tenderness Fluid Volume Deficit
firm to palpate Altered Cardiac Output
minor bleeding Altered Tissue Perfusion
FACTORS CAUSING HEMATOMA Monitor VS every 15 minutes
Rapid Spontaneous birth Evaluate blood loss
 IVF and BT Administer oxygen by face mask
Administer oxygen as ordered Anxiety
Dysfunctional Grieving Emotional support
Anxiety Stay with the client
Fear Listen
o Obtain consent for surgery Give factual informations
o Give factual informations Risk for infection
o Explain procedures Aseptic technique
o Do not give reassurance Administer prophylactic antibiotics
o Emotional support
LATE POSTPARTUM HEMORRHAGE
UTERINE INVERSION Retained Placental Fragments
DEGREE OF INVERSION Subinvolution
First-degree - the inverted fundus extends to, Endometritis
but not through, the cervix. RETAINED PLACENTAL FRAGMENTS
Second-degree - the inverted fundus extends Signs and Symptoms:
through the cervix but remains within the Incomplete placental delivery
vagina. Uterus remains large
Third-degree - the inverted fundus extends Bright red bleeding
outside the vagina. + HCG in the blood
Total inversion - the vagina and uterus are + ultrasound result
inverted. FACTORS CAUSING RETAINED PLACENTAL FRAGMENTS
SIGNS AND SYMPTOMS: Failure to inspect after placental delivery
Visualization of protruded uterus Placenta accreta
Sudden gush of large amount of blood MEDICAL MANAGEMENT OF RETAINED PLACENTA
Hypovolemic shock after 10 minutes Oxytoxin administration
FACTORS CAUSING UTERINE INVERSION Methotrexate
Pulling the umbilical cord before placental IVF
separation SURGICAL MANAGEMENT OR RETAINED PLACENTA
Extreme pushing of the fundus Dilatation and Curettage
Fundal implantation of the placenta Hysterectomy
GOAL OF CARE OF UTERINE INVERSION NURSING DIAGNOSIS AND MANAGEMENT
Prevent Hemorrhage Fluid Volume Deficit
Jhonson’s Maneuver Decreased cardiac Output
Prevent Shock Altered Tissue Perfusion
Prevent Infection Risk for infection
Prevent Death Anxiety
MEDICAL MANAGEMENT
Initially: SUBINVOLUTION OF THE UTERUS
Tocolytic Signs and Symptoms:
General anesthesia Uterus remains large
Nitroglycerine Lochia is profused
Oxytocic agents Altered pattern of lochia
Double intravenous fluid FACTORS CAUSING UTERINE SUBINVOLUTION
Oxygen administration Retained Placental fragments
Ready for CPR Endometritis
Antibiotics Uterine Myoma
Blood Transfusion MEDICAL MANAGEMENT OF UTERINE SUBINVOLUTION
SURGICAL MANAGEMENT Oxytocin
Jhonson’s Maneuver Maleate
Surgical Replacement IVF
Hysterectomy SURGICAL MANAGEMENT OF UTERINE
Laparotomy SUBINVOLUTION
General Anesthesia Hysterectomy
NURSING DIAGNOSIS AND INTERVENTION NURSING DIAGNOSIS AND MANAGEMENT
Fluid Volume Deficit Fluid Volume Deficit
Altered Cardiac Output Altered Cardiac Output
Altered Tissue Perfusion Altered Tissue Perfusion
Determine the degree of inversion Alteration in thermoregulation; hyperthermia
Assess VS, NVS, and CRT Anxiety
Evaluate blood loss Fear
Use large needles/cannula for
intravenous fluid
Regulate IVF and BT as ordered
DISSEMINATED INTRAVASCULAR COAGULATION heat
Signs and Symptoms: pressure on the perineum
Mild oozing of venipuncture site one or two stitches slough off
Petechiae purulent discharges from suture line
FACTORS CAUSING DIC may be afebrile unless systemic
PIH Management of the Infection of the Perineum
Abruptio Placenta systemic or topical antibiotics
Incomplete Abortion analgesics
Septic Abortion hot sitz bath
Prolonged retention of dead fetus warm compress
Amniotic fluid Embolism perineal sutures may be removed to allow
Hypertonic labor drainage
Sepsis packing with gauze
GOAL OF MANAGEMENT OF DIC
Treat underlying conditions PERITONITIS
Stop Clotting an infection of the peritoneal cavity
Restore normal clotting functions usually an extension of endometritis
MEDICAL MANAGEMENT OF DIC gravest of postpartum complications
Heparin common cause of mortality death from
Blood Replacement puerperal infection
Fresh Frozen Plasma Signs and Symptoms of Peritonitis
Platelet Replacement rigid abdomen with guarding behavior
NURSING DIAGNOSIS AND INTERVENTIONS abdominal pain
Actual/Potential Fluid Volume Deficit high fever
Frequent monitoring rapid pulse
Evaluate blood loss vomiting
Gentle handling of patient appearance of acutely ill
Frequent turning to sides Management of Peritonitis
large dose of antibiotics
PUERPERAL INFECTION NGT to relieve vomiting and rest the bowel
Infection of the genital tract during postpartum IVF
TYPES OF INFECTION parenteral feeding
Endometritis analgesics
Infection of the Perineum antipyretics
Peritonitis
Mastitis MASTITIS
Endometritis infection of the breast tissues
an infection of the inner lining (endometrium) occurs as early as 7 days postpartum or not
of the uterus until the baby is weeks or months of age
bacteria may gain access from the vagina into ETIOLOGY:
the uterus maybe during delivery process Staphylococcus
Signs and Symptoms of Endometritis Streptococcus
fever for 2 consecutive 24 hours usually on the Eschericia
3rd or 4th day excluding the first 24 hours Signs and Symptoms of Mastitis
postpartum localized pain, swelling, and redness
chills fever
loss of appetite body malaise
general malaise rapid pulse
abdominal tenderness scanty breast milk
uterine atony Management of Mastitis
strong afterpains broad spectrum antibiotics
dark brown foul smelling lochia analgesics
Management of Endometritis antipyretics
antibiotics warm or cold compress
oxytocic supportive bra
analgesics constant emptying
antipyretics incision and drainage
Infection of the Perineum Nursing Diagnosis of Puerperal Infection
very rare because of improved aseptic Actual/potential for infection
technique Alteration in thermoregulation; hyperthermia
occurs at the suture line or repair of lacerations Alteration in comfort; pain
Signs and Symptoms of Infection of the Perineum Social Isolation
pain on the perineum
swelling
THROMBOPHLEBITIS proper nutrition
It is the inflammation of the lining of the avoid gatch or pillow under the knee
vessel in which a clot attaches to the vessel Risk for Injury (bleeding) related to therapy
wall. btain baseline coagulation
May not appear until 10-20 days after avoid IM injection of other drugs
delivery rotate injection site
THREE MAJOR CAUSES: inject heparin subcutaneously, do not
venous stasis massage
hypercoagulability prepare Protamin Sulfate ( antidote of
damage of the intima of the blood vessels Heparin)
Other Factors: prepare Vitamin K ( antidote of Warfarin)
varicosities How to prevent thrombophlebitis?
obesity avoid wearing constricting clothings
history of thrombophlebitis rest while feet elevated
oral contraceptives ambulate daily during pregnancy
age >35 years old limit woman in lithotomy position
multiparity aseptic technique in invasive procedures
diabetes millitus if with varicose veins, wear support
smoking stockings
first 2 weeks postpartum
Classifications of Thrombophlebitis according to the avoid in 1 position for long period of time
depth avoid leg crossing
a) Superficial venous thrombosis increase oral fluid intake
limited to the calf only early ambulation after pregnancy
swelling of extremity, redness, if cannot ambulate, PROM exercises
tenderness, and warm, pain while avoid pillows under the knees
walking don’t smoke
b) Deep vein thrombosis EMOTIONAL AND PSYCHOLOGICAL POSTPARTAL
often absent or diffused signs COMPLICATIONS
swelling, erythema, edema, heat, Phases of Puerperium:
tenderness 1. Taking-in Phase
phlegmasia This is the time of reflection for a woman.
Classifications of Thrombophlebitis according to The woman is passive letting other people
location (husband, nurse, etc.) do things for her and
a) Femoral make decisions for her.
fever, chills, pain, redness, 2. Taking-hold Phase
swelling of extremeties, This is the phase where the woman begins to
White - stretched skin, initiate action herself.
+ homan’s sign shows a woman with great interest on caring
b) Pelvic for the baby.
ovarian, uterine, hypogastric vein 3. Letting-go
high fever The woman finally defines her new role.
chills She gives up the fantasized image of her child
body malaise for the real one.
Management of Thrombophlebitis POSTPARTUM BLUES
Anticoagulant (Warfarin, Heparin) It is a maternal adjustment reaction
Thrombolytic (Streptokinase, Urokinase)
Analgesics ( except aspirin) accompanied by irritability, anxiety, and a mild
laparotomy – locate and incise to remove let-down feeling
affected veins usually occurring between the 2nd to 3rd
monitoring of prothrombin time postpartum day through the 1st to 2nd
Nursing Diagnosis and Management of postpartum week.
Thrombophlebitis Signs and symptoms of Postpartum Blues
Alteration in Comfort; pain Insomnia
rest Depressed mood
elevate legs Headache
antiembolic stockings Poor concentration
avoid standing for long period of time Tearfulness
moist heat application Confusion
DO NOT MASSAGE Mood labile
Altered Tissue Perfusion Factors causing Postpartum Blues
constantly check the skin sudden drop of hormone at about 72
passive range of motion exercise hours postpartum
prevent skin ulcerations disappointments of body changes
 extreme disappointments of labor and antipsychotic drugs
birth hospitalization
inadequate emotional support from woman must be observed during her
partner interaction with her child
extreme stress from mothering role Nursing Diagnosis and Management of Postpartum
Management of Postpartum Blues Emotional Disturbances
allow woman to talk and cry Risk for/Actual Ineffective coping
work through their feelings Convey a caring attitude
encourage family support Acknowledge that the woman feels
depressed
POSTPARTUM DEPRESSION Assure that it is not her fault
It is a mood disturbance that is characterized by encourage support from family
feelings of sadness, despair, apathy, and members
discouragement caused by loss in the person’s Adequate rest and nutrition
life or by neurobiological imbalance of INFERTILITY
neurotransmitters. The inability to conceive after at least 1 year of
It occurs 30 days to 6 months after birth sexual intercourse at least 4 times a week
SIGNS AND SYMPTOMS OF POSTPARTUM DEPRESSION without contraception.
Excessive crying Normally .
Feeling of inadequacy 50% of couples conceive within 6
Low self-esteem months
Inability to cope 35% conceive within 12 months
Anorexia Primary infertility
Insomnia no previous history of conception
Psychosomatic symptoms Secondary Infertility
Depressive or manic mood fluctuation inability to conceive after previous successful
Social withdrawal pregnancy
Etiology of Female Infertility
Vaginal problems:
vaginal infections
Factors causing Postpartum Depression anatomic abnormalities
history of depression sexual dysfunction
troubled childhood highly acidic vaginal environment
stress in the home or at work
lack self-esteem
lack of support system Cervical:
Management of Postpartum Depression changes during ovulation
Nurse-patient relationship cervical incompetence
- therapeutic relationship Etiology of Female Infertility
Psychopharmacologic
- antidepressive drugs Uterine
Milleu therapy functional
– forceful manipulation of the environment structural
Tubal
POSTPARTUM PSYCHOSIS scarring
It is a disrupted mental state in which an PID
individual struggles to distinguish the external endometriosis
world from his internally generated Ovarian
perceptions. anovulation
The disorder may become apparent 2 to 3 oligo-ovulation
weeks after birth to as long as 6 to 12 months. Etiology of Male Infertility
Factors causing Postpartum Psychosis Congenital
major life crisis absence of vas deferens and testes
previous mental illness Ejaculatory
family history of mental illness retrograde ejaculation
hormonal changes Sperm abnormalities
Signs and Symptoms of Postpartum Psychosis oligospermia
suicidal and infanticidal thoughts aspermia
dissociated inadequate maturation
delusional inadequate motiliy
confused inability to deposit sperm into the vagina
distortion of reality blockage of sperm
Management of Postpartum Psychosis Testicular
professional psychiatric counselling orchitis
 cryptorchidism sperm that aren't strong enough to swim
trauma through the cervix and up into the fallopian
radiation tubes.
Coital option for women who have endometriosis or
obesity abnormalities of any of their reproductive
nerve damage organs.
impotence PROCESS:
Drugs washing the sperm
Methotrexate liquefying the sperm at room temperature for
Amebicides 30 minutes
Other factors: harmless chemical is added to separate out the
STD most active sperm.
stress centrifuge is used to collect the best sperm.
inadequate nutrition sperm are then placed in a thin tube called a
alcohol & nicotine catheter and introduced through the vagina and
Interactive Problems cervix into the uterus
Insufficient frequency of SI cramping during the procedure and
Poor timing of intercourse light bleeding afterward
Development of antibodies Immediately after the procedure, your doctor
against partner’s sperm will probably have you lie down for about 15 to
Use of spermicidal lubricants 45 minutes to give the sperm a chance to get to
Inability of the sperm to work.
penetrate the egg you can resume your usual activities.
Diagnostic Studies
Semen Analysis after 48 72 hours of Success rates for artificial insemination vary. Factors
abstinence that lessen your chance of success include:
Older age of the woman
Cervical Mucous assessment Poor egg quality
o fern test Poor sperm quality
o spinnbarkeit test Severe endometriosis
Postcoital Test Severe damage to fallopian tubes (usually from
o SI at presumed ovulatory state chronic infection)
o after48 hour abstinence Blockage of fallopian tubes (IUI will usually not
o Check cervical mucus work in this case)
Basal Body Recording IN VITRO FERTILIZATION
o oral temp when awakening is a process by which an egg is fertilized by
o increase temp 12-14 days sperm outside the body in a laboratory.
o before menses- ovulation The fertilized egg (zygote) is then transferred to
the patient's uterus.

MANAGEMENT OF INFERTILITY
1. Management of underlying problems
douche with alkaline solution 30 minutes
before intercourse
surgery IVF may be an option if you or your partner have been
medications diagnosed with:
antibiotic Endometriosis
testosterone Low sperm counts
estrogen Problems with the uterus or fallopian tubes
sexual therapy Problems with ovulation
2. Assisted Reproductive Techniques Antibody problems that harm sperm or eggs
artificial insemination The inability of sperm to penetrate or survive in
In vitro fertilization the cervical mucus
Surrogate embryo transfer An unexplained fertility problem
Surrogate mothering Surrogate embryo transfer
ARTIFICIAL INSEMINATION embryos are placed into the uterus of a female
The process by which a woman is medically with the intent to establish a pregnancy.
impregnated using semen from her husband or embryos are typically transferred 3 days
from a third-party donor. after fertilization.
Injecting collected semen into the woman's PROCESS:
uterus and is performed under a physician's After the follicles are aspirated from the
supervision. Intended Mother or Egg Donor they will be
INDICATION examined and mixed with the intended father
men who have very low sperm counts. or a donors sperm.
 They are then incubated for 3 - 5 days to allow
fertilization to occur.
The gestational surrogate, intended parents and
reproductive physician will have a consult to
determine the number of embryos to transfer.
Then, the embryos will be placed in the
surrogates uterus via invitro fertilization
the embryo transfer procedure will take place in
a sterile, surgical room within the fertility clinic
or hospital.
The process does not cause discomfort and
requires no medication or anesthesia. .
The process usually takes approximately ten-
fifteen minutes.
surrogates will be required to remain at the
clinic for at least one-two hours after the
completion of the transfer procedure to rest .
Surrogates will be required to rest with activity
restrictions for two-three days following the
transfer procedure.
SURROGATE MOTHER
A woman who bears a child for another person,
often for pay.
A substitute mother
TWO KINDS OF SURROGATE MOTHER
Traditional surrogates
is a woman who is artificially inseminated with
the father's sperm.
She then carries the baby and delivers it for the
parents to raise.
is the baby's biological mother. That's because it
was her egg that was fertilized by the father's
sperm. Donor sperm can also be used for a
traditional surrogacy.
GESTATIONAL SURROGATES
has no genetic ties to the child. That's because it
wasn't her egg that was used.
is called the "birth mother.
more common than a traditional surrogate
WHO USES SURROGATES:
Those with medical problems with her uterus.
hysterectomy
conditions that make pregnancy impossible or
medically risky, such as severe heart disease.
OTHER REASONS:
age
marital status
sexual orientation

CHOOSING A SURROGATE:
1. Is at least 21 years old
2. Has already given birth to at least one healthy
baby
3. Has passed a psychological screening by a
mental health professional
4. Willingly signs a contract agreeing to her role
and responsibilities in the pregnancy
5. have a complete medical evaluation and
pregnancy history to assess the likelihood of a
healthy, full-term pregnancy.

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