MCN Compre

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MCN – FINALS REVIEWER

QUIZ 1  Instillation of the preparation into the lungs


1. Which of the following is the most important concept through an endotracheal tube
associated with the high-risk newborn?
 Support the high-risk newborn's 9. Hypothermia is common in newborn because of their
cardiopulmonary adaptation by maintaining inability to control heat. The following would be an
adequate airway appropriate nursing intervention to prevent heat loss
EXCEPT
2. Which of the following nursing diagnoses would be  place the crib beside the wall
given priority in then care of a newborn one hour of age?
 Ineffective thermoregulation 10. A nurse is assessing a newborn who was born at 32
weeks gestation. Which of the following would the nurse
3. Which of the following manifestations in a six-month- most likely find? Select all that apply
old infant who was born prematurely would lead a nurse  Ruddy skin
to suspect that the infant has apnea?  high-pitched cry
 A lapse of spontaneous breathing for 20 seconds  copious vernix caseosa
or more
11. Therese has just given birth at 42 weeks' gestation.
4. After therapeutic interventions, a newborn When the nurse assesses the neonate, which physical
demonstrates adequate lung expansion. The amount of finding is expected?
pressure that would enable her to continue to reinflate  Desquamation of the epidermis
the alveoli of her lungs would be
 15-20 cm H20 12. The physical finding you would expect to be seen in
ljezie because of prematurity is
5. The reason nurse May keeps the neonate in a neutral  lack of sole creases on her feet
thermal environment is that when a newborn becomes
too cool, the neonate requires 13. An insulin dependent diabetic delivered a 10-pound
 more oxygen, and the newborn's metabolic rate male. When the baby is brought to the nursery, the
increases priority care is to
 check the baby's serum glucose level and
6. Heat regulation is the most critical factor for a administer glucose if <40mg/dl
newborn's survival next to establishing respiration.
Which of the following characteristics of newborns 14. Small for gestational age newborns are at risk for
predispose them to poor heat regulation? difficulty of maintaining body temperature due to
 Newborns cannot shiver yet  they do not have as much fat stores as do other
infants
7. Andrea has no spontaneous respirations at birth.
Suppose her amniotic fluid is heavily stained with 15. Heat regulation is the most critical factor for a
meconium. Which would be your best action? newborn's survival next to establishing respiration.
 Begin chest massage to force out meconium Which of the following characteristics of newborns
predispose them to poor heat regulation?
8. A nurse in the nursery is caring for a neonate. On  Newborns cannot shiver yet
assessment the infant is exhibiting grunting, tachypnea,
nasal flaring and grunting. Respiratory distress syndrome QUIZ 2
is diagnosed and the physician prescribes surfactant 1. You're caring for a 2-day-old infant with a large patent
replacement therapy. The nurse would prepare to ductus arteriosus. The mother of the infant is anxious
administer this therapy by
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MCN – FINALS REVIEWER
and asks you to explain her child's condition to her again.  Ostium Primum
Which statement below BEST describes this condition?
 The vessel connecting the aorta and pulmonary 8. You're caring for a 2-year-old patient who has a large
artery has failed to close at birth, which is leading atrial septal defect that needs repair. This defect is
to a left-to-right shunt of blood causing complications. These complications are arising
from an abnormal shunting of blood throughout the
2. While assessing a newborn's heart sounds you note a heart. As the nurse, you know that ___________ shunt is
loud murmur at the left upper sternal border. You report occurring in the heart due to the defect.
this to the physician who suspects the infant may have  left to right
patent ductus arteriosus. The physician asks you to
obtain a pulse pressure. If patent ductus arteriosus is 9. Martial septal defects can lead to a decrease in lung
present, the pulse pressure would be blood flow.
 wide  False

3. You're working on a unit that provides specialized 10. A nurse in the nursery is monitoring a preterm infant
cardiac care to the pediatric population. Which patient for respiratory distress syndrome. Which assessment
below would be the best candidate for Indomethacin signs if noted in the newborn would alert the nurse to
from the treatment of patent ductus arteriosus? the possibility of this syndrome
 A premature infant  Acrocyanosis and grunting

4. The family is caring for their youngest child Justin who 11. A nurse in the nursery is caring for a neonate. On
is suffering from Tetralogy of Fallot. Which of the assessment the infant is exhibiting grunting, tachypnea,
following are defects associated with this congenital nasal flaring and grunting. Respiratory distress syndrome
heart condition? is diagnosed and the physician prescribes surfactant
 Ventricular septal defect, overriding aorta, replacement therapy. The nurse would prepare to
pulmonic stenosis and right ventricular administer this therapy by
hypertrophy  Instillation of the preparation into the lungs
through an endotracheal tube
5. In a normal heart without any type of congenital heart
defect, the pulmonary vein carries oxygenated blood 12. MAS can be prevented by
away from the lungs to the left side of the heart.  Suctioning mouth, nose and posterior pharynx
 True just after the head is delivered.

6. A two-month-old is showing signs and symptoms of 13. Baby Nicks has surfactant administered at birth. The
heart failure. An echocardiogram is ordered. The test purpose of surfactant is to
shows the infant has a ventricular septal defect (VSD).  Prevent alveoli from collapsing on expiration
Which statement below best describes the blood flow in
the heart due to this congenital heart defect? 14. When developing the initial plan of care for a neonate
 “The blood in the heart is shunting from the left who was born at 41 weeks' gestation, was diagnosed
ventricle to the right ventricle, which is with meconium aspiration syndrome (MAS), and
increasing pulmonary blood flow.” requires mechanical ventilation, which of the following
should the nurse include
7. An echocardiogram shows that your patient has an  Care of an umbilical arterial line
atrial septal defect located at the bottom of the septum
near the tricuspid and mitral valves. As the nurse you 15. The Gi system plays a major role in maintaining fluid,
know this is what type of atrial septa defect (ASD)? electrolyte, and acid-base balance. The Gl system often

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MCN – FINALS REVIEWER
is involved with two severe acid-base imbalances which intake decreases in conjunction with a fluid loss increase.
is It occurs in a child with: Select all that apply
 metabolic acidosis and metabolic alkalosis  nausea (preventing fluid intake)
 fever (increased fluid loss through perspiration)
 profuse diarrhea - where there is a greater loss
16. Hypotonic Dehydration occurs when there is a of fluid than salt
disproportionately high loss of electrolytes relative to  renal disease - associated with polyuria such as
fluid lost. The plasma concentration of sodium and nephrosis with diuresis.
chloride will be low. This could result from all of the
following except? 23. Infants do not concentrate urine as well as adults
 excessive intake of salt associated with great because their kidneys are immature.
gain through intake  True

17. Fluid shifts from the blood stream to interstitial and 24. All of the following are included in the Assessment in
intracellular spaces (from areas of great Metabolic alkalosis. Select all the apply.
osmotic pressure to areas of lesser pressure)  The child will breathe slowly and shallowly
 False  pH will be elevated (near or above 7.45)
 HCO3 level will be near or above 28 mEg/L.
18. Overhydration is serious as dehydration because the
ECF overload can lead to cardiovascular overload and 25. Isotonic Dehydration is when a child's body loses
cardiac failure. All of the following are true about more water than it absorbs (as with diarrhea) or absorbs
overhydration except less fluid than it excretes (as with nausea and vomiting).
 The excess fluid in these instances is usually As a result, all of the following will occur. Select all that
intravascular and interstitial. apply
 there will be a decrease in the volume of blood
19. Metabolic acidosis may result from diarrhea. When plasma.
diarrhea occurs, a great deal of sodium is lost with stool.  the body compensates for this rapidly by shifting
This excessive loss of Na, in turn, causes the body to interstitial fluid into the blood vessels.
conserve ions in an attempt to keep the total number of
positive and negative ions in serum balanced. As a result, 26. Hypotonic Dehydration occurs when there is a
all of the following will occur except disproportionately high loss of electrolytes relative to
 arterial blood gas analysis will reveal an fluid lost. The plasma concentration of sodium and
increased pH chloride will be low. This could result from all of the
following except?
20. The level of bicarbonate (HCO3) in arterial blood is  excessive intake of salt associated with great
normally gain through intake
 22 to 26 mEg/L.
27. Select all the correct options that represent the
21. When diarrhea occurs, or when a child becomes pathophysiology of an asthma attack
diaphoretic because of fever, the fluid output can be  The mucosa lining experiences severe
markedly decreased inflammation
 False  The goblet cells within the mucosa lining
produce excessive amounts of mucous.
22. In Hypertonic Dehydration water is lost in a greater
proportion than electrolytes and it occurs when fluid 28. Which of the following are typical signs and
symptoms of pneumonia? Select-all-that-apply
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MCN – FINALS REVIEWER
 Coarse crackles 6. When assessing a child with Wilm's tumor, the nurse
 Oxygen saturation less than 90% should keep in mind that it is most important to avoid
 Elevated white blood cells which of the following?
 Tachypnea  palpating the child's abdomen

29. What is the interpretation of the ABG if the pH =7.60; 7. A child is diagnosed with Wilm's tumor. During
PaCO2 = 33’ HCO3 = 16? assessment, the nurse in charge expects to find
 respiratory acidosis partially compensated  an abdominal mass

30. Interpret the ABG's. pH = 7.36; PaCO2 = 55; HCO3 = 8. A 5-year-old is admitted to the hospital with
28 complaints of leg pain and fever. On physical
 respiratory acidosis fully compensated examination, the child is pale and has bruising over
various areas of the body. The physician suspects that
QUIZ 3 the child has ALL. The nurse informs the parent that the
1. Which of the following interventions must be included diagnosis will be confirmed by which of the following?
in the plan of care of a child with mumps?  Bone marrow aspirate
 apply an ice pack over the parotid glands
encourage the client to drink plenty of fluids 9. Causative agent of mumps
 give tamarind for the client not to be sleepy  myxovirus

2. A child is diagnosed with Wilm's tumor. In planning 10. What is the incubation period of mumps?
teaching interventions, what key points should the nurse  14-21 days
emphasize for the parents?
 Do not put pressure on the abdomen" 11. What is the drug of choice for treatment of mumps?
 no specific treatment available
3. A child with leukemia is being discharged after
beginning chemotherapy. What instructions will the 12. Which age group is mostly affected with mumps?
nurse include in the teaching plan for the parents of this  5 to 15 years
child?
 Avoid fresh vegetables that are not cooked 13. Which gender is mostly affected with mumps?
 equal involvement of male and female
4. While working in a pediatric clinic, you receive a
telephone call from a parent of a 10-year-old who is 14. Period of communicability of mumps
receiving chemotherapy for leukemia. The client's sibling  7 days to after 9 days of symptoms
has chicken pox. Which of these actions will you
anticipate taking next? 15. The following are signs and symptoms of pneumonia,
 Prepare the client for admission to a private select all that apply
room in the hospital  fever
 fast breathing
5. Parents are often unaware that their child is  widening of the nostrils
developing leukemia. What are the first signs commonly  crackles
seen in a child with acute lymphocytic leukemia (ALL)?
 Fatigue and bruising 16. It measures oxygen saturation, answers in small
letters
 pulse oximetry

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MCN – FINALS REVIEWER
17. A drug that is used to neutralize the effects of chemo
drugs, answer in small letters 2. What causes cerebral palsy? select all that apply
 leucovorin  brain damage that happened before, during or
immediately after birth
18. A drug that is used to reduce the formation of uric  an infection such as meningitis
acid, answer in small letters  head injury
 allopurinol  jaundice

19. David, age 15 months is recovering from surgery to 3. One of the goals of hydrocephalus is directed toward
remove Wilm's tumor. Which findings best indicates that the relief of ventricular pressure. Which of the following
the child is free from pain? is an inappropriate nursing intervention for an infant
 Increased interest in play after placement of ventriculoperitoneal shubt?
 positioning the infant carefully on the affected
20. Which of the following symptoms would a student side
nurse observes if the diagnosis of the child is ALL?
 bruises, fatigue, joint pain 4. Your patient undergone pacement of a chunt for
hydrocephalus. Wow ull you position the child after the
21. The cause of leukemia is unknown but the risk factors operation?
are the following, select all that apply  place in flat position and lying on the unoprated
 exposure to high amount of radiation side
 exposure to chemicals like benzene
 genetic problem like down syndrome 5. When asked by a mother of a child with cerebral palsy
 defect of proximal tubule leading to in what is the most common cause of this condition,
malabsorption f electrolytes which of the following is your BEST reply?
 it results from premature birth or very low birth
22. The following statement are TRUE about acute weight
lymphocytic leukemia. Select all that apply
 common among children ages 2 and 6 years of 6. Cerebral palsy may result from a variety of causes. It is
age known that the most common cause of CP is
 involves immature lymphocytes  prenatal brain abnormalities
 uses methotrexate
7. What occurrence results from obstruction within the
23. Undescended testes is termed as. answer in small ventricles of the brain or inadequate reabsorption of
letters cerebrospinal fluid? (answer in small letters)
 cryptorchidism  hydrocephalus

24. What is the major characteristic of pneumonia 8. A parent tells a nurse "My three-month-old infant has
 inflammation in the air spaces of the lungs passed several stools that resembled clumpy red jelly".
The nurse should suspect that the infant has developed
25. Mode of administration of methotrexate on the  intussusception
spinal cord
 intrathecal injection 9. Andrew's father reports that his son was constipated
until this morning Hirschsprung's disease can be a cause
QUIZ 4 of constipation in infants. This is
1. What are some symptoms of cerebral palsy?  lack of nerve endings in the sigmoid colon.
 all of the above
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MCN – FINALS REVIEWER
10. Situation: Cathy, 3 months old had cleft lip on the left
side of the mouth. She is scheduled for surgical 18. Which of the following should the nurse do first after
correction of the defect. All of the following nursing noting that a child with Hirschsprung disease has a fever
interventions are included in the care plan for Cathy who and watery explosive diarrhea?
has just undergone cleft lip repair. Which of the following  Notify the physician immediately
actions by the mother should NOT be allowed by the
nurse? 19. Baby RR is a 4-month-old infant with a tentative
 Position the infant in prone position. diagnosis of intussusceptions. Which procedure will
likely be ordered for the infant?
11. Which of the following is a priority nursing  barium enema
intervention for the infant with cleft lip?
 Monitoring for adequate nutritional intake 20. A child is diagnosed with intussusceptions. The nurse
performs an assessment on a child knowing that which
12. The following are risk factors for type 2 diabetes, of the following is a characteristic of this disorder?
SATA  Invagination of a section of the intestine into the
 diet distal bowel.
 weight
 PCOS 21. While assessing a newborn with cleft lip, the nurse
 age would be alert that which of the following will most likely
 preterm birth be compromised?
 Sucking ability
13. A nurse is preparing to care for a child with a
diagnosis of intussusceptions. The nurse reviews t child's 22. Mr. and Ms. Villanueva's child failed to pass
record and expects to note which symptom of this meconium within the first 24 hours after birth, this
disorder documented? may indicate which of the following?
 Bright red blood and mucus in the stools  Hirschsprung’s disease

14. The following are signs and symptoms of 23. Which assessment finding would be most likely found
intussusceptions EXCEPT on an infant diagnosed with Hirschsprung disease?
 Slow RR  Weight less than normal for height and age

15. A child is diagnosed with Hirschsprung's disease. 24. Which of the following interventions should NOT be
Mother asked the nurse about the cause of the disease. included in the care plan for a three-month-old infant
The nurse tells the mother that Hirschsprung disease who has just undergone cleft palate repair?
 results from the absence of special cells in the  Place the infant in supine position
rectum
25. The nurse is caring for an infant following a cleft lip
16. Julius is scheduled for surgical repair of his cleft repair. What are the postoperative
palate. A priority in the post-op plan of care for Julius intervention to be observe. Select all that apply
would include teaching the mother  maintain patent airway
 to use cup or wide bowl spoon for feeding  cleanse the suture line
 prevent the child from crying
17. For a child with a diagnosis of Hirschsprung's disease,  place the infant in supine position
you expect the child's stool to be
 ribbon like

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MCN – FINALS REVIEWER
NURSING CARE OF A FAMILY WITH A HIGH-RISK ✔ Blood circulates through a patent ductus
NEWBORN arteriosus left to right or from aorta to
Newborn priorities in first days of life pulmonary artery
1. Initiation and maintenance of respirations RESULT: newborn struggles to breathe and
2. Establishment of extrauterine circulation circulate blood uses available serum glucose
3. Control of body temperature hypoglycemic
4. Intake of adequate nourishment • Resuscitation is done for those newborns who
5. Establishment of waste elimination fails to take first breath
6. Prevention of infection
7. Establishment of an infant-parent relationship RESUSCITATION PROCESS
8. Developmental care or care that balances a. Establish and maintain an airway
physiologic needs and stimulation for best ✔ bulb syringe suction (mouth then nose)
development ✔ Rub the back (be sure that the baby is dry)
 If a newborn has to attempt to raise body
1. INITIATION AND MAINTENANCE OF RESPIRATIONS temperature because of chilling, this will
• Establish respiration immediately to prevent: increase the need for oxygen which the baby
a. Respiratory acidosis cannot supply because breathing has not yet
b. Falling of blood pH and bicarbonate initiated.
c. Cerebral hypoxia ✔ warmed, blow-by oxygen by face mask or
positive pressure mask may be administered
CAUSES OF ASPHYXIA/ACIDOSIS WHILE INSIDE THE • If meconium stained:
UTERO ✔ DO NOT stimulate an infant to breathe by
• Cord compression rubbing the back or administering air or oxygen
• Maternal anesthesia under pressure
• Placenta previa EFFECT: could push meconium down into an
• Abruptio placenta infant’s airway compromising respiration
✔ GIVE oxygen by mask without pressure
FACTORS PREDISPOSING INFANTS TO RESPIRATORY ✔ Wait for a laryngoscope to be passed and the
DIFFICULTY IN THE 1ST FEW DAYS OF LIFE trachea to be deep suctioned before giving
• Low birth weight oxygen under pressure
• Maternal history of diabetes • If for deep suctioning:
• Premature rupture of membranes ✔ Place an infant on the back and slide a folded
• Maternal use of barbiturates or narcotics close towel or pad under the shoulders to raise them
to birth slightly to the head is in a neutral position.
• Meconium staining ✔ Slide a catheter (French 8- French 12) over the
• Irregularities detected by fetal heart monitor infant’s tongue to the back of the throat
during labor ✔ Do not suction for longer than 10 seconds – to
• Cord prolapse avoid removing excessive air from an infant’s
• Lowered Apgar score (<7) AT 1-5 MINUTES lungs
• Post maturity ✔ Use a gentle touch
• Small for gestational age  bradycardia or cardiac arrhythmias can
• Breech birth occur because of vagus stimulation from
• Multiple birth vigorous suctioning
• Chest, heart or respiratory tract anomalies • An infant who still makes no effort at spontaneous
respiration requires immediate laryngoscopy to
RESUSCITATION open the airway.
• If breathing is ineffective --- circulatory shunts • Laryngoscope --- deep tracheal suctioning ---
(ductus arteriosus) fails to close because: endotracheal tube insertion --- Oxygen
✔ There is increase pressure in the left side administration by a positive pressure bag and mask
than at the right side of the heart with 100% oxygen at 40 to 60 breaths/minute
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MCN – FINALS REVIEWER
• Primary apnea – period of halted respiration • Narcan (narcotic antagonist) - Naloxone
- a pause in respiration longer than 20 seconds with ✔ injected into the umbilical vessel
an accompanying bradycardia (after 1 or 2 minutes) ✔ Or injected intramuscularly into a thigh
 Resuscitation attempts are generally • Relieves depression
successful • Dose: 0.01 to 0.1 mg/kg body weight
• Secondary apnea – respiratory effort will become
weaker, heart rate will fall, stops breathing OTHER DRUGS USED IN RESUSCITATION
 Resuscitation attempts become difficult and
ineffective Drug Use
• Size of laryngoscope: 0 – 1cm = newborn 1. Atropine • Reduces bronchial secretions
• Size of endotracheal tube: Infants under 100 g = • Reduces vagus nerve effects
2.5mm; Over 3000g = 4.0 mm • Relives bradycardia
2. Calcium • Increases heart contractility
RESUSCITATION PROCESS chloride
b. Lung expansion 3. Dopamine • Increases systemic blood
- Once an airway has been established, newborn’s perfusion by increasing blood
lungs need to be expanded pressure through beta agonist
- Lungs are inflated by the first breath action
- Cry – proof of lung expansion 4. Epinephrine • Strengthens or initiates
- 40 cm H20 = pressure to open the lung alveoli for cardiac contractions
the first time • Increases heart rate and blood
- 15-20 cm H2o – pressure to continue inflating pressure
alveoli 5. Lidocaine • Counteracts ventricular
• The levels of oxygen should not fluctuate effect: can arrhythmias
cause bleeding from immature cranial vessels 6. Sodium • Corrects metabolic acidosis
• No pressure above what is necessary bicarbonate / • Do not give this unless
Effect: excessive force can rupture lung alveoli tromethamine ventilation is adequate or
 To be certain that oxygen is reaching the acidosis can be increased by
lungs with resuscitation- monitor the retained CO2
newborn’s oxygen level with pulse
oximetry and auscultating the chest. RESUSCITATION PROCESS
• If air can be heard on only one side or sounds are not c. Ventilation Maintenance
symmetric - An increase respiratory rate in a newborn is the
Reason: the endotracheal tube is probably at the first sign of obstruction or respiratory
bifurcation of the trachea and blocking one of compromise.
the main stem bronchi. - If RR is increased = undress the baby’s chest and
• When oxygen is given under pressure, the stomach look for retractions
quickly fills with oxygen (causes vomiting and • Interventions:
aspiration of stomach contents)
✔ Places under a warmer and remove the
• If resuscitation continues for over 2 minutes,
clothing from the chest = this prevents
✔ insert an orogastric tube and leaving the distal acidosis
end open
✔ Place the infant in supine and elevate
Reasons:
the bed at 15 degrees = this allows the
• will help deflate the stomach
abdominal contents to fall away from
• decreases the possibility of vomiting and
the diaphragm, offering additional
aspiration of stomach contents from
breathing space.
overdistention
✔ Suction secretions
• Administration of narcotic (morphine or meperidine
✔ Monitor oxygen level
(Demerol) during labor causes respiratory
depression.
2. ESTABLISHMENT OF EXTRAUTERINE CIRCULATION
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MCN – FINALS REVIEWER
• If an infant has NO audible heartbeat or if the cardiac 4. REGULATING TEMPERATURE
rate is below 80 beats/minute • All high-risk infants have difficulty maintaining a
Action: closed chest massage should be started normal temperature.
✔ hold an infant with fingers supporting • Maintain a neutral temperature environment
the back and depress the sternum with • If the environment is TOO HOT, metabolism
two fingers decreases
✔ Depress the sternum approximately 1/3 • If the environment is TOO COLD, increases
of its depth (1 or 2 cm) at a rate of 100 metabolism
times/min. • The increased metabolism requires increased
✔ Lung ventilation at a rate of 30x/min oxygen
✔ Ratio: 1:3 • Without oxygen
• If heart sounds are not resumed above 80 bpm after --- hypoxic
30 seconds of combined positive pressure --- vasoconstriction of blood vessels occur
ventilation and cardiac compression --- decreased pulmonary perfusion (if prolong)
Action: spray epinephrine 0.1 to 0.3 ml/kg --- PO2 lever falls and PCO2 increases
(1:10,000) into endotracheal tube to stimulate --- Decrease PO2
cardiac function. effect: may open fetal right to left shunts
surfactant production may stop
3. MAINTAINING FLUID AND ELECTROLYTE BALANCE • To prevent newborn from becoming chilled after
• Lactated Ringers solution or 5% dextrose are birth:
commonly used to maintain fluid and electrolytes ✔ Wipe an infant dry
levels. ✔ Cover the head with a cap
• Sodium, potassium and glucose are needed. ✔ Place the baby immediately under a prewarmed
• Rate of fluid administration must be carefully radiant warmer or in a warmed incubator (97.8
monitored F/36.5C)
WHY? Can lead to patent ductus arteriosus or ✔ Skin-skin
heart failure
• Use of radiant warmer may increase in water loss 5. ESTABLISHING ADEQUATE NUTRITIONAL INTAKE
from convection and radiation. • Infants with severe asphyxia at birth receive IVF
Therefore: the newborn requires fluid than he or Reason: for them not to be exhausted from
she is placed in a double walled incubator. sucking or until necrotizing enterocolitis has
• Monitor urine output and specific gravity to been ruled out.
determine dehydration. • If RR is rapid and with NEC
 A Urine Output of <2ml/kg/hr. or a specific Action: gavage feeding preterm infants should
gravity >1 fluid intake.015 to 1.020 suggests be breastfed/ manually express breastmilk
inadequate  Expressed breastmilk should be stored
• If an infant has hypotension without hypovolemia, a in a non-shiny plastic bags or bottles to
vasopressor such as dopamine may be given to avoid the infant being exposed to
increase BP and improve cell perfusion. polycarbonate
• If hypovolemia is present, the cause is fetal blood
loss from placenta previa or twin-twin transfusion. 6. ESTABLISHING WASTE ELIMINATION
• If hypovolemia is present observe the ff: • Immature infants void within 24 hours of birth
✔ Tachypnea Reason: BP may not be adequate to optimally
✔ Pallor supply their kidneys
✔ Tachycardia • Immature infants pass stool late than term
✔ Decreased arterial blood pressure Reason: meconium has not yet reached the end
✔ Decreased central venous pressure of the intestine at birth
✔ Decreased tissue perfusion of peripheral tissue
✔ Metabolic acidosis 7. PREVENTING INFECTION

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MCN – FINALS REVIEWER
• Infection from prenatal, perinatal and postnatal – Women with systemic diseases - DM, PIH
causes – Mothers who smoke heavily or use narcotics
• PROM – Infants with intrauterine infections – rubella,
• pneumonia toxoplasmosis
• Skin lesions – Babies with chromosomal abnormalities
Viruses that causes infection
Early onset sepsis Late onset sepsis ASSESSMENT
Grp b Streptococcus Staphylococcus aureus 1. Prenatal Assessment
E. Coli Enterobacter • Fundal Height during pregnancy becomes
Klebsiella candida progressively less than expected
Listeria monocytogenes • A sonogram can demonstrate decrease in size.
• A biophysical profile, non-stress test, placental
Common viruses that affects grading and UTZ can provide additional
the utero information.
Cytomegalovirus 2. Appearance
toxoplasmosis - The infant has over all wasted appearance
• Small liver
8. ESTABLISHING PARENT-INFANT BONDING • poor skin turgor
• Be certain that the parents of a high-risk newborns • Appears to have large head
are kept informed • Skull sutures maybe widely separated from
• If an infant die despite newborns resuscitation lack of normal bone growth
attempts, parents need to see the infant without • Hair is dull and lusterless
being covered by a myriad of equipment • Abdomen may be sunken
• Cord – appear dry and stained–yellow
9. ANTICIPATING DEVELOPMENTAL NEEDS • Skull may be firmer
• High risk newborns need special care to ensure that • unusually alert and active for that weight.
the amount of pain they experience during the • Lack subcutaneous fat – less able to control
procedures is limited to the least amount possible’ body temperature
• Follow up of high-risk infants at home • Underdeveloped chest muscles – unable to
sustain the rapid RR of a normal newborn
• Impaired cognitive development – due to
PROBLEMS RELATED TO GESTATIONAL AGE
lack of oxygen and nourishment in the utero
• Small for gestational age (SGA)
• Large for gestational age (LGA)
LABORATORY FINDINGS
• High hematocrit level
SMALL FOR GESTATIONAL AGE (SGA)
• Increase in the total number of RBC (polycythemia)-
• SGA – weight below then 10th percentile on an
due to state anoxia during intrauterine life.
intrauterine growth curve for the age
• Polycythemia causes increase blood viscosity
• Preterm – infant is born before week 37 of gestation
• Acrocyanosis- blueness of hands and feet
• Term – between 37 and 42
• HYPOGLYCEMIA -
• Post term – infant is one who remained in the utero
• Birth Asphyxia -
past 42 weeks of pregnancy
• Decreased glycogen stores
• SGA infants are small for their age
• Infants have difficulty maintaining warmth
MANAGEMENT
• The infant may be preterm, term or post term
• Assess for the presence of meconium during labor
and delivery
CAUSES
• thoroughly suction airway immediately after delivery
– Mother’s nutrition
if present
– Pregnant adolescents have a high incidence of SGA
• Assess temperature and provide neutral thermal
infants
environment
– Placental damage
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MCN – FINALS REVIEWER
• Assess for signs of hypoglycemia 15. Diaphragmatic paralysis – because of cervical trauma
• Weigh daily and assess changes in weight as the head is bent sideways to allow for birth of
• Observe RR in the first few hours of life large shoulders
• Encourage parents to provide toys suitable for the 16. Have the size of a 2-month-old
child’s chronologic age, not physical size 17. Sucking is not effective
• Intravenous glucose to sustain blood sugar until they
are able to suck vigorously NURSING INTERVENTIONS
• Assess for signs of birth injury
PRIORITY NURSING DIAGNOSES • Assess for signs of hypoglycemia
• Hypothermia • Needs to be breastfeed immediately to prevent
• Risk for Injury hypoglycemia
• Imbalanced nutrition: less than body requirements • Encourage parents to treat the newborn as fragile
newborn who needs warm nurturing
LARGE FOR GESTATIONAL AGE (LGA) • Remind parents that an infant’s weight is not in
• Birthweight above 90th percentile correlation of the child’s projected adult size.

ETIOLOGY PRIORITY NURSING DIAGNOSES


Overproduction of growth hormone in utero – Primary • Risk for injury
cause: infant of diabetic mother (IDM) • Risk for imbalanced nutrition less than body
• Multiparous women requirements
• Transposition of great vessels, BECKWITH • Risk for impaired parenting related to high-risk
SYNDROME (a rare condition characterized by status of large gestational age infant
overgrowth)
• Congenital anomalies such as omphalocele PROBLEMS RELATED TO MATURITY
Increased risk of: • Prematurity
• Hyperbilirubinemia • Post maturity
• Birth injury: fractured clavicle, ERB-Duchenne
paralysis secondary to shoulder dystocia PRETERM INFANT
• live–born infant born before the end of week 37
ASSESSMENT gestation.
1. Immature reflexes • weight of less than 2,500g (5lb 8oz) at birth
2. Low scores on gestational age examinations in • Preterm infant deaths account for 80-90% of the
relation to their size infant mortality in the first year of life.
3. Extensive bruising • Low birth weight infants (LBW) – infants born
4. Birth injury such as broken clavicle/ERB-Duchenne weighing 1,500-2,500g
5. Head is large • Very low birth weight (VLBW) – 1,000-1,500g
6. Caput succedaneum, cephalohematoma, molding • Extremely (EVLBW) – very-low-birth – weight 500-
7. Signs of hyperbilirubinemia 1,000g
8. Polycythemia - Lack of surfactant makes them vulnerable to
9. If with cyanosis – sign of transposition of the great RDS.
vessel - hypoglycemia
10. Macrosomia (large body size and high birthweight) - intracranial hemorrhage
11. Signs of birth trauma related to cephalopelvic
disproportion (CPD) RISK FACTORS
12. Hypoglycemia, especially with an IDM – early hours • low socio-economic level
of life • Inadequate nutrition before and during pregnancy
13. Have difficulty establishing respirations at birth • Lack of prenatal care
because of birth trauma • Multiple pregnancy
14. Increased intracranial pressure • Prior previous early birth
• Cigarette smoking
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MCN – FINALS REVIEWER
• Age of the mother • Born after the 42nd week of pregnancy
• Closely spaced pregnancies • Fetus remains in the utero with a failing placenta
• Abnormalities of the mother’s reproductive system may die or develop Post term Syndrome
• Obstetric complications- Premature Rupture of • Dry cracked, almost leather like skin from lack of fluid
Membranes, Premature separation of placenta • Absence of vernix caseosa
• Lightweight from a recent weight loss that occurred
CHARACTERISTICS OF PREMATURE INFANT because of placental function.
1. Immature respiratory system • The amount of amniotic fluid may be less at birth
2. Temperature regulation than normal, may be meconium stained.
3. Low resistance to infection • Fingernails have grown well beyond the end of the
4. Immature liver fingertips.
5. Gastrointestinal – increased NEC • May demonstrate alertness much more like a 2-
6. Renal – unable to concentrate urine week-old baby than a newborn.
7. Neuromuscular
8. Physiologically immature ASSESSMENT
• Dry, cracked, leather-like skin = from lack of fluid
COMPLICATIONS (desquamation)
1. Anemia of prematurity • Absence of vernix
2. Kernicterus • Light weight- because of poor placental function
3. Persistent patent ductus arteriosus • Less amniotic fluid
4. RDS • Meconium stained
5. Retinopathy of prematurity • Fingernails have grown at the end of fingertips
6. NEC • Reduced subcutaneous tissue-loose skin, especially
of buttocks and thighs
NURSING INTERVENTIONS • Abundant scalp hair
• Keep the baby warm • Having the alert appearance of a 2- to 3-week old
• Give 100% oxygen neonate after delivery
• IVF within hours after birth via infusion pump • Difficulty establishing respiration
• Check infusion site frequently • Hypoglycemia
• Monitor weight • Polycythemia
• Monitor urine output and specific gravity – weigh • Elevated hematocrit – because of
diaper • polycythemia and dehydration
• Test urine for glucose and ketones (blood glucose
should range between 40-60mg/dl) INTERVENTION
• Check for blood in the stools to evaluate possible 1. Determine gestational age by physical examination.
bleeding from the intestinal tract Measure weight, length, and head circumference
• Fed by total parenteral nutrition and plot on Colorado intrauterine growth chart
• Chest radiograph before a first feeding 2. Determine blood sugar; below 40 mg/100 m
• Feed every 2-3 hours (1 or 2 ml) indicates hypoglycemia
• Offer pacifier during gavage feeding to strengthen 3. Assess for asphyxia neonatorum by APGAR score and
the sucking reflex blood gas analysis
• Administer vit K • Be alert for meconium aspiration
• Kept under radiant warmer /skin-skin contact • Thick meconium in amniotic fluid at delivery
• Linen and equipment used with preterm infants • Tachypnea, increasing signs of cyanosis;
must not be shared with other infants difficulty breathing with need for ventilation
• Handwashing • Tachycardia
• Monitor closely for respiratory or cardiac • Inspiratory nasal flaring and retraction of chest
complications • Expiratory grunting
• Increased anteroposterior diameter of the chest
POSTMATURITY • Palpable liver
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MCN – FINALS REVIEWER
• Crackles and rhonchi on chest auscultation cardiac chamber to a lower pressure, right sided
• Concomitant cerebral irritation-jitteriness, cardiac chamber.
hypotonia, seizures  Causes the heart to function as an ineffective pump
• X-ray- classic course, patchy, irregular and make the child prone to heart failure.
pulmonary infiltrates ranging in severity
• Additional signs: metabolic acidosis, VENTRAL SEPTAL DEFECT
hypotension, hypoglycemia, hypocalcemia  Most common type of congenital heart disease
• Provide supportive treatment for meconium  Opening is present in the septum between the two
aspiration ventricles
• Warmth  Pressure in the left ventricle is greater than in the
• Adequate oxygenation and humidification to right ventricles
maintain partial pressure of arterial oxygen at  This impairs the effort of the HEART
50-70mm Hg
• Respiratory support with ventilator
• Adequate administration of calories and fluid
• Accurate monitoring of intake and output
• Administration of antibiotics prophylactically
• Provide oral feedings or IV glucose after birth to
treat or prevent hypoglycemia

ALTERATIONS IN OXYGENATION
 Congenital heart disease ASSESSMENT
 Easy fatigue
CLASSIFICATION OF HEART DISEASE  Dyspnea
 Swelling of extremities
ACYANOTIC CYANOTIC HEARTDSS  Crackles
A. INCREASED A. DECREASED  Sweating
PULMONARY BLOOD PULMONARY BLOOD  Low growth rate
FLOW FLOW  Loud, harsh pansytolic murmur (left sterna border,
1. Ventral septal defect 1. Tricuspid atresia 3rd or 4th interspace)
2. Atrial septal defect 1. Tetralogy of Fallot  thrill (variation)
3. Patent ductus
arteriosus DIAGNOSIS
B. OBSTRUCTION OF B. MIXED BLOOD FLOW  Echocardiography with color flow Doppler
BLOOD FLOW 1. Transposition of the  MRI (reveals right ventricular hypertrophy and
LEAVING THE HEART Great arteries possibly pulmonary artery dilatation from the
A. Pulmonary stenosis 2. Total anomalous increased blood flow)
B. Aortic stenosis Pulmonary venous  ECG (reveal ventricular hypertrophy)
C. 3. Coarctation of aorta return
1. 3. Hypoplastic left THERAPEUTIC MANAGEMENT
heart syndrome  Cardiac catheterization (to close in moderate size)
 Open heart surgery (large/ >3mm)
ACYANOTIC HEART DISEASE/INCREASED PULMONARY  Digoxin
BLOOD FLOW  diuretics
 Moves blood from the arterial to the venous system
 oxygenated to unoxygenated blood or LEFT-RIGHT ATRIAL SEPTAL DEFECT
shunts).  Abnormal communication between the two atria,
 Indicates the presence of a defect that permits the allowing blood to shift from left to the right atrium.
passage of blood from the higher pressure, left sided  More common in girls than boys

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MCN – FINALS REVIEWER

TYPES  The shunted blood returns to the left atrium of the


 Ostium Premium (ASD1) – opening is at the lower heart, passes to the left ventricle out to the aorta and
end of the septum shunts back to the pulmonary artery
 Ostium secundum (ASD2) – opening is near the  -------EFFECT: increased pressure in the pulmonary
center of the septum circulation from the extra shunted blood LEADING to
right ventricular hypertrophy and ineffective heart
ASSESSMENT action
 Harsh systolic murmur over the 2nd or 3rd interspace  Extra blood to the lungs---stresses the lungs
(pulmonic area) overtime---creating increase pressure---Damaging
 WHY? Because of the extra amount of shunted blood the integrity of arteries of the lungs---narrowed-----
that crosses the pulmonic valve. leading to the fixed pulmonary hypertension
splitting of second heart sound  Risk for:
 Enlarged right side of the heart via echocardiography ✔ Decreased o2
 Increased pulmonary circulation ✔ Risk for lung infection
 Separation in the atrial septum ✔ Heart failure
 Increased oxygen saturation in the right atrium  Increase pressure --- damage lining of the heat ---
increase risk of bacteria --- endocarditis
DIAGNOSIS  Remains open due to the stimulation of
 Echocardiography prostaglandin (PGE1) from the placenta and low
 Cardiac catheterization oxygen level of fetal blood.
 Doppler  After birth, when the PGE1 level falls and the oxygen
level increases----the ductus arteriosus is stimulated
THERAPEUTIC MANAGEMENT to close.
 Surgery – to close the defect (the edges of the
septum are approximated and sutured with cardiac ASSESSMENT
catheterization technique if the defect is small)  Common in girls than boys
 Large defects may require open heart surgery and  Wide pulse pressure (difference between systolic
cardiopulmonary bypass—a Silastic or Dacron patch and diastolic blood pressure)
may be sutured into place to occlude the space  Low diastolic pressure (because of the shunt or run
 Done between 1 and 3 years of age off of blood which reduces resistance)
 Machinery murmur (heard at the upper left sterna
PATENT DUCTUS ARTERIOSUS border or under the clavicle in older children)
 Ductus arteriosus is an accessory fetal structure that  ECG is normal – but may show ventricle enlargement
connects the pulmonary artery to the aorta. if the shunt is large
 Closes begins with the first breath and usually
complete between 7- 14 days of age  C – cardiac (continuous machinery murmur;
 full closure occurs until 3 months endocarditis, Increase HR, low O2 level, wide pulse
 If it fails to close at birth, blood will shunt from the pressure (low diastolic pressure); heart failure,
aorta (oxygenated blood) to the pulmonary artery crackles
(deoxygenated blood) because of the increased  A – activity intolerance
pressure in the aorta
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MCN – FINALS REVIEWER
 L – lungs –risk for infections, feeding prob  EFFECT: blood crosses through the patent foramen
 L – loss of weight (burning calorie in order to breath) oval into the left atrium, bypassing the lungs.
 If the shunts are close---the infant will develop
DIAGNOSIS extreme cyanosis, tachycardia and dyspnea
 Echocardiography – provides good visualization of
patent ductus arteriosus.

THERAPEUTIC MANAGEMENT
 Indomethacin or Ibuprofen via IV (if does not close
spontaneously)
 Assess the following Effects:
✔ Reduced glomerular filtration
✔ Impaired platelet aggregation
✔ Diminished gastrointestinal and cerebral blood MANAGEMENT
flow  IV infusion of PGE1 to ensure that ductus remains
 Ibuprofen - drug of choice open
 Prophylaxis in preterm infants  Surgery – construction of a vena cava to pulmonary
 Insertion of Dacron –coated stainless steel coils by artery shunt which deflects more blood to the lungs
interventional cardiac catheterization----when child (Fontan procedure/ Glenn Shunt baffle)
is 6 months to 1 year of age (done if medical
management fails) TETRALOGY OF FALLOT
 Ductal ligation- this involves major surgery----  4 anomalies are present:
because opening the chest (Thoracotomy) and ✔ VSD
manipulating the great vessels are necessary. ✔ Dextroposition (overriding) of the aorta
 Prostaglandin inhibitors ✔ Hypertrophy of the right ventricle
✔ Pulmonary stenosis –
CYANOTIC HEART DISEASE DECREASED BLOOD  Because of pulmonary stenosis ---pressure builds up
FLOW in the right side of the heart-------blood shunts from
 Occurs when blood is shunted from the venous to this area of increased pressure into the left ventricle
the arterial system as a result of abnormal and the overriding aorta.
communication between the two system  The extra effort involved to force blood through the
(deoxygenated blood to oxygenated blood) or stenosed pulmonary artery causes the fourth
RIGHT-LEFT shunts. deformity---hypertrophy of the right ventricle.
 Indicates an abnormality that permits some of the
systemic venous return (unoxygenated blood) to
bypass the lungs and enter general circulation
directly.
 Decreased pulmonary blood flow that involves
obstruction in the pulmonary artery--------because of
the obstruction:
 Increases pressure in the right side of the heart
 Deoxygenated blood shunts from right to left
RESULTING in deoxygenated blood invading the ASSESSMENT
systemic circulation  Skin is cyanotic/bluish
 Polycythemia (an increase in RBC as the body
TRICUSPID ATRESIA attempts to provide enough RBC to supply oxygen to
 Extremely serious disorder because the tricuspid all body parts)
valve is completely closed allowing no blood to flow  EFFECT: causes the blood to become thick (increased
from the right atrium to the right ventricle. viscosity) and clots in blood vessels may occur.
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MCN – FINALS REVIEWER
 Complication: thrombophlebitis, embolism or ductus arteriosus) --- this will allow blood to leave
cerebrovascular accident the aorta and enter the pulmonary artery, oxygenate
 Severe dyspnea the lungs and return to the left side of the heart, the
 Growth restriction aorta and the body.
 Clubbing of the fingers  NO palpable pulse in the right arm because the
✔ The child assumes a SQUATTING/KNEE CHEST subclavian artery is used.
position when resting.  --- No taking of BP and venipuncture in the affected
✔ Squatting gives physiologic relief to an arm
overstressed heart by trapping blood in the  Brock procedure – repair that relieves pulmonary
lower extremities. stenosis, VSD and overriding aorta
 Syncope (fainting)  POSTOPERATIVELY: observe arrhythmias ----which
 Hyper cyanotic episodes (spells)---- caused by may result from any ventricular septal repair, edema
decreased blood and oxygen supply to the brain and conduction interference.
 Cognitive challenge
 Loud, harsh, widely transmitted murmur or a soft, MIXED BLOOD FLOW
scratchy localized systolic murmur in the left second,  Cardiac anomalies that involve mixing of blood from
third or fourth parasternal interspace may be the pulmonary and systemic circulation in the heart
present. chambers
 The mixing results in a relative deoxygenation of
DIAGNOSIS systemic blood flow, although a cyanosis is most
 Echocardiography shows the enlarged chamber of always visible.
the right
 ECG side of the heart; echocardiography shows TRANSPOSITION OF GREAT ARTERIES
 The decrease in the size of the pulmonary  The aorta arises from the right ventricle instead of
 Artery and the reduced blood flow through the lungs the left and the pulmonary artery arises from the left
 Cardiac catheterization- permit a definitive ventricle instead of the right.
evaluation of the:  Blood enters the heart from the vena cava to the
o Extent of the defect particularly the right atrium right ventricle out to the aorta to the
o pulmonary stenosis and the VSD. body completely deoxygenated returns to the vena
cava.
LABORATORY FINDINGS  A secondary source of blood enters the heart from
✔ Polycythemias the pulmonary veins left atrium left ventricle
✔ Increased hemoglobin pulmonary artery lungs to be oxygenated returns to
✔ Hematocrit left atrium
✔ Total RBC count  Atrial and ventricular septal defects occur in
✔ Oxygen saturation connection with transposition
 Occur in large newborns (9-10lbs)
THERAPEUTIC MANAGEMENT  Occur most often in boys
 Surgery – to connect the heart defects done at 1 to 2
years of age
 Administer oxygen
 Place the baby in a knee chest position (to trap blood
in the lower extremities and keep the heart from
being overwhelmed)
 Administer morphine sulfate
 Oral Propranolol (Inderal – a beta blocker) – to aid ASSESSMENT
pulmonary artery dilation
 Cyanotic from birth
 Blalock-Taussig procedure – create a shunt between
 Enlarged heart
the aorta and the pulmonary artery (creating a
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MCN – FINALS REVIEWER
 Heart changes  Balloon atrial septal pull-through- to enlarge a
 Low oxygen saturation foramen oval
 Maintain on a continuous IV infusion of PGE1 to help
DIAGNOSIS keep the ductus arteriosus
 Echocardiography – reveals enlarge heart
 ECG – reveals heart changes HYPOPLASTIC LEFT HEART SYNDROME
 Cardiac catheterization – reveals low oxygen  The left ventricle is nonfunctional.
saturation  Lacks adequate strength to pump blood into the
systemic circulation
THERAPEURIC MANAGEMENT  Causes the right ventricle to hypertrophy as it tries
 PGE1/prostaglandin – IF NO septal defect to maintain the entire heart action.
 To keep the ductus arteriosus patent  There may be accompanying mitral or aortic valve
 Balloon atrial septal pull-through operation atresia.
 A deflated balloon catheter is passed from the right
atrium through the foramen oval into the left atrium
 The balloon is then inflated and the catheter is
drawn back into the right atrium---enlarging the
opening of the foramen oval and creates an artificial
ASD.
 Done at week to 3 months of age
 Involves an arterial switch procedure in which the
major vessels are switched in position.
 Survival rate is 95% ASSESSMENT
 Mild to moderate cyanosis
TOTAL ANOMALOUS PULMONARY VENOUS RETURN  Deoxygenated blood is shunted across the foramen
 The pulmonary veins return to the right atrium or the oval because of the greater pressure on the right
superior vena cava instead to the left atrium
 For blood to reach the systemic circulation, it must THERAPEUTIC MANAGEMENT
shunt across a patent foramen oval or a PDA.  Ultrasound – prenatally
 Echocardiography
 Prostaglandin therapy – to maintain a PDA --- to
increase blood supply to the aorta
 Heart transplantation – to prolonged the child’s life

OBSTRUCTION OF BLOOD FLOW


 PULMONARY STENOSIS
 AORTIC STENOSIS
 COARCTATION OF AORTA
 A vessel or valve is narrower than usual.
 Pressure from blood flow increases prior to the
narrowing and decreases after the narrowing.
ASSESSMENT  They prohibit enough blood from reaching its
 Absent spleen intended size, the lungs or the rest of the body
 Mildly cyanotic  They threated or overwhelm the heart because
 Easily gets tired of back pressure

THERAPEUTIC MANAGEMENT PULMONARY STENOSIS


 Surgery – re-implanting the pulmonary veins into the  Narrowing of the pulmonary valve or the pulmonary
left atrium. artery just distal to the valve
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MCN – FINALS REVIEWER
 10% of congenital anomalies  Because the heart cannot force blood through the
 Inability of the right ventricle to evacuate blood by stricture valve increased pressure and hypertrophy
way of the pulmonary artery because of the of the left ventricle occur
obstruction leads to right ventricular hypertrophy  if the left ventricular pressure become acute-----
increase
 pressure in the left atrium pulmonary veins
 back pressure in pulmonary edema

ASSESSMENT
 Cyanosis – if narrowing is severe
 Due to inability of the blood to reach the lungs for
oxygenation or there is right-left shunting across the
foramen oval --- this happens because of the ASSESSMENT
increase pressure at the right side of the heart  Asymptomatic
 Systolic ejection murmur (grade IV or V crescendo  Murmur- can be transmitted to the right shoulder,
decrescendo in quality) loudest at the upper left clavicle and up the vessels of the neck, heart apex
sterna border radiating to the suprasternal border.
 Rough systolic sound heard loudest in the 2nd right
 Thrill – from the upper left sterna border or at interspace (aortic space)
suprasternal notch.
 Thrill – at spurs sterna notch
 Widely split of the 2nd heart sound --- because of
 Decreased cardiac output – If severe
late closure of the pulmonary valve.
 Faint pulses
 Hypotension
DIAGNOSIS
 Tachycardia
 ECG / echocardiography – reveal ventricular
 Inability to suck for long periods
hypertrophy
 Chest pain similar to angina
 Cardiac catheterization – used for interventional
enlargement of the stenosed valve  Because the coronary arteries receive inadequate
amount of oxygen needed by the heart muscle on
THERAPEUTIC MANAGEMENT exertion far exceeds what is available
 Balloon angioplasty – procedure of choice
DIAGNOSIS
 A catheter with an uninflated balloon at its tip is
ECG/echocardiography – reveal left ventricular
inserted and passed through the heart into the
hypertrophy
stenosed valve
 As the balloon is inflated, it breaks the valve
THERAPEUTIC MANAGEMENT
adhesions and relieves the stenosis.
 Beta-blocker/calcium channel blocker --- to reduce
 Children may have residual heart murmur
cardiac hypertrophy before the defect is corrected
 Can expect a normal life span
 Balloon valvuloplasty- treatment of choice
 Dividing the stenotic valve r dilating an
AORTIC STENOSIS
accompanying constrictive aortic ring
 Stenosis or stricture of the aortic valve prevents
 May lead to aortic valve insufficiency later in life —
blood from passing freely from the left ventricle of
further surgery may be needed
the heart into the aorta.
 Some children will need artificial valve replacement
for correction
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MCN – FINALS REVIEWER
 If prosthetic valve is used---- continue to receive  Cold feet
anticoagulation or antiplatelet therapy and  Muscle spasms
antibiotic prophylaxis against endocarditis  Pulse is weak, delayed or even absent
 Children need exercise testing before participating in  Collateral arteries enlargement
competitive sports if an artificial valve is in place.  Seen on the ribs as obvious nodules as the child
grows older
COARCTATION OF AORTA  Soft, moderately loud systolic murmur – from the
 Narrowing of the lumen of the aorta due to base of the heart and transmitted to the left
constricting interscapular area
 band  BP is higher in upper extremities---because of the
 Occurs most frequently in boys than in girls pull of gravity
 Leading cause of congestive heart failure in the first  Headache
few months of life.  Epistaxis
 2 locations:  Pulse in the upper extremities will be rapid and b
 Preductal – the constriction occurs between the
subclavian artery and the ductus arteriosus DIAGNOSIS
 Post ductal – constriction is distal to the ductus arte  BP in the arms will be at least 20mmHg higher than
 Difficult for blood to pass through the narrowed in the legs
lumen of the aorta  Echocardiography
 Blood pressure increases proximal to the coarctation  ECG = reveal left-sided heart enlargement from
decreases distal  MRI = back pressure and also notching of the
 Increased BP in the heart and upper portions of the  X-ray = ribs from the enlarge collateral vessels.
body as pressure in the subclavian artery
 Increases headache, vertigo epistaxis (nose bleed) THERAPEUTIC MANAGEMENT
cerebrovascular  Interventional angiography (balloon
catheter)/surgery
 he narrowed portion of the aorta is removed and the
new ends of aorta are anastomosed
 A graft of transplanted subclavian artery may be
necessary if the narrowed section is so extensive
than an anastomosis cannot be accomplished readily
 Digoxin given before the time of surgery
 Diuretics aims to reduce the severity of congestive
heart failure from hypertension
 PLANNING IS IMPORTANT: It would be ideal if
children could achieve the greater part of their adult
height before surgical correction, preventing strain
ASSESSMENT
on the incision site as they grow
 Absence of palpable femoral pulses- slight
 In terms of self-image – correction is best done
coarctation
before children begin to think of themselves as
 Always include evaluation of femoral pulses in all
chronically ill or before they develop complications
initial newborn assessment and admission
such as chronic hypertension.
inspections
 Girls must have the defect repaired before
 Absent brachial pulses – those with an obstruction
childbearing age – or the extra blood volume during
proximal to the left subclavian artery
pregnancy can cause heart failure
 Lower BP in the lower extremities
 Surgical repair is scheduled by 2 years of age
 Leg pain on exertion
 After operation – abdominal vessels receive more
 Because of diminished blood supply to the lower
blood resulting to abdominal pain or generalized
extremities
abdominal discomfort
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MCN – FINALS REVIEWER
 Some may have elevated upper body hypertension
after the repair
 Need continual treatment with antihypertensive
agents
 Some may require repeat balloon angioplasty at
adolescence to re-enlarge the aortic lumens and help
reduce this upper body hype

MECONIUM ASPIRATION SYNDROME

DEFINITION OF TERM
Meconium aspiration syndrome (MAS) is a respiratory  Aspiration of Meconium into the lungs of: fetus or
disorder caused by inhalation of amniotic fluid neonate
contaminated with meconium into the tracheobronchial  What is Meconium? – first stools
tree.  What are the contents of Meconium?
 Water – Desquamated epithelium (of gut)
AFFECTED AREAS  Amniotic fluid – Desquamated epidermis (of
Respiratory Distress in Neonates Infectious skin)
 Metabolic Hematological  Mucopolysaccharides – Vernix
 Metabolic  Bile salts
 Neurological  What makes Meconium pass? - Meconium-stained
 Cardiovascular amniotic fluid
 Respiratory --- Airways & Lungs  fetal stress (The older the fetus, the more the
 Abdominal meconium) esp. > 42 weeks of gestation
 Pharmacological  Near – term
 Full – term
SYMPTOMS
Respiratory Distress in Neonates
 Infectious
 Metabolic
 Hematological
 Neurological
 Cardiovascular
 Respiratory
o Airways
 Choanal atresia
 Pierre-Robin Sequence
 Vocal Cord Paralysis
 Laryngo-tracheomalacia
o Lungs
 Respiratory Distress Syndrome
 Transient Types of the Newborn
 Meconium Aspiration Syndrome
 Persistent: Pulmonary HTN of the
Newborn
 Abdominal
 Pharmacological

NRDS AND MAS

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MCN – FINALS REVIEWER
NRDS & MAS --- Anoxia --- Coma ALTERATIONS IN FLUIDS AND ELECTROLYTES,
Anoxia – Respiratory Distress ACID-BASE BALANCE
 Tachypnea
 Grunting INTRODUCTION
 Intercostal retraction  The GI system plays a major role in maintaining fluid,
 Cyanosis electrolyte, and acid-base balance.
 It is the main route by which substances are taken
into the body and can be a major source of loss if
vomiting or diarrhea occurs (Holliday, Ray, &
Friedman, 2007).
 Greater importance in the body chemistry of infants
than that of adults -because fluid constitutes a
greater fraction of the infant's total weight.
✔ In adults, body water accounts for approximately
60% of total weight.
✔ In infants, it accounts for as much as 75% to 80%
of total weight
✔ In children, it averages approximately 65% to
70%.

CONTINUATION
MANAGEMENT  Fluid is distributed in three body compartments:
 When the infant is not vigorous: a. intracellular (within cells), 35% to 40% of body
 Clear airways as quickly as possible. weight;
 Free flow O2. b. interstitial (surrounding cells and bloodstream),
20% of body weight
 Radiant warmer but drying and stimulation should
c. intravascular (blood plasma), 5% of body weight.
be delayed.
 Fluid is normally obtained by the body through oral
 Direct laryngoscopy with suction of the mouth and
ingestion of fluid and by the water formed in the
hypopharynx under direct visualization, followed by
metabolic breakdown of food.
Intubation and then suction directly to the ET tube.
 Fluid is lost from
 The process is repeated until either "little additional
meconium is recovered, or until the baby's heart rate ✔ urine and feces
Indicates that resuscitation must proceed without ✔ insensible losses due to evaporation occurs
delay". from: skin, saliva, lungs

TREATMENT CONTINUATION
 Ventilation strategies  Infants do not concentrate urine as well as adults
o Avoid air leak, check CXR with acute because their kidneys are immature.
deterioration RESULT: they have a proportionally greater loss
o Prevent pulmonary hypertension - generous of fluid in their urine.
O2 - HFOV if unable to maintain on  Fluid intake is altered when a child is nauseated and
conventional ver. unable to ingest fluid or is vomiting and losing fluid
 Steroids (no human data, controversial) that was ingested.
 ROS, Antibiotics (ampicillin, gentamicin) ✔ When diarrhea occurs, or when a child becomes
 Surfactant diaphoretic because of fever, the fluid output
 Inhaled Nitric Oxide can be markedly increased.
✔ Dehydration occurs when there is an excessive
 ECMO
loss of body water

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MCN – FINALS REVIEWER
FLUID IMBALANCES levels of sodium. Generally, when water is excreted from
the body, electrolyte (e.g., sodium) concentrations in the
blood increase.
 Losing more solution than solute. Decreased urine output.
Cells shrink.
Occur in a child with:
 Nausea (preventing fluid intake)
 Fever (increased fluid loss through perspiration,
fever will increase the respiratory rate and therefore,
 Dehydration occurs when the body loses more fluid water loss. Water intake is commonly decreased
than it takes in. This condition can result from illness; during a fever which will aggravate dehydration)
a hot, dry climate; prolonged exposure to sun or high  Overexposure to heat
temperatures, not drinking enough water, and  Profuse diarrhea – where there is a greater loss of
overuse of diuretics or other medications that fluid than salt
increase urination.  Renal disease – associated with polyuria such as
nephrosis with diuresis
 Diabetes insipidus – which occurs when the kidneys
cannot regulate bodily fluids, typically leads to
frequent urination and can cause hypertonic
dehydration
 The use of diuretics, medications used to increase
urine excretion, may also lead to dehydration.
 Water accounts for about 60% of a man's body
SYMPTOMS
weight it represents about 50% of a woman's weight
 Common are fatigue, dark urine, less frequent
 Young and middle-aged adults who drink when
urination, dry skin or lips.
they're thirsty do not generally have to do anything
 Severe dehydration symptoms are Low blood
more to maintain their body's fluid balance
pressure or hypotension, lightheadedness, muscle
 Children need more water because they expand
cramps, headaches or dizziness.
more energy, but most children who drink when they
are thirsty get as much water as their systems
MANAGEMENT
require
 Treatment of hypertonic dehydration is largely
focused on fluid replacement to return the individual
3 MAIN TYPES OF DEHYDRATION
to euvolemic, or a healthy fluid-electrolyte balance.
 Hypertonic (primarily loss of water, cell shrinks
 Mild dehydration can often be treated with oral
 Isotonic (equal loss of water and electrolytes)
rehydration therapy, the individual can tolerate oral
 Hypotonic (primarily a loss of electrolytes, cells intake.
swell)
 Individuals with dehydration requiring intravenous
fluids (i.e., NV fluids) Intravenous Ringer's lactate or,
if not available, normal saline, who have been
dehydrated for fewer than 24 hours, can usually
experience rapid correction of their electrolyte
levels

ISOTONIC DEHYDRATION
 It is a condition in which both water and sodium are
HYPERTONIC DEHYDRATION lost proportionally and the serum sodium
 Hypertonic dehydration, also known as concentration maintains normal serum osmolality.
hypernatremia, refers to an imbalance of water and
sodium in the body characterized by relatively increased
CAUSES OF ISOTONIC DEHYDRATION
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MCN – FINALS REVIEWER
Vomiting and Diarrhea o For thermal burns, apply antibiotic
 Severe watery diarrhea and vomiting can be life- cream and cover
threatening conditions, especially in children. A o lightly with gauze.
person with gastroenteritis may lose notable Second-Degree Burns
amounts of fluids and electrolytes within a short o Treatment for second-and first-degree
time and their oral replacement is limited due to burns is similar. Your healthcare
recurrent vomiting, which can result in severe provider may prescribe a stronger
dehydration. antibiotic cream that contains silver,
Management such as silver sulfadiazine, to kill
o Wash your hands with soap and water bacteria. Elevating the burned area can
frequently. Wash mouth area and practice reduce pain and swelling.
good oral hygiene. Third-Degree Burns
o Drink lots of clear fluids like water and get o Third-degree burns can be life-
plenty of rest threatening and often require skin
o Follow the BRAT diet, which consists of bland grafts. Skin grafts replace damaged
foods. BRAT stands for bananas, rice, tissue with healthy skin from another of
applesauce, and toast. the uninjured part of the person's body.
o Avoid foods that are greasy, spicy, or high in The area where the skin graft is taken
fat and sugar. from generally heals on its own.
o Avoid caffeine. NOTE:
o Antiemetic drugs such as Dramamine and  Drink plenty of fluids
Gravol which often contain the ingredient  Check wounds for signs of infection and other long-
dimenhydrinate. term issues
Burns
 In severe or widespread burns, fluid is lost through HYPOTONIC DEHYDRATION
the skin, and the person can become dehydrated.  Hypotonic dehydration, in contrast with hypertonic
Dehydration can lead to life-threatening shock. Fluid dehydration, refers to a decrease in electrolyte
loss starts immediately after the burn occurs, concentration in the extracellular fluid. In hypotonic
because heat damage increases the permeability of dehydration, the cells grow as water in the
the capillaries, which means that plasma is able to extracellular fluid moves toward the higher sodium
leak out of the blood circulation. This increase concentration inside the cells.
disrupts the normal exchange of blood plasma into  Losing more solute than solution. Increased Urine
the extracellular space at the site of injury. which output Cells swell. This could result from:
results in rapid fluid loss. ✔ Excessive loss of electrolytes by vomiting
✔ Low intake of salt associated with extreme losses
through diuresis
✔ In diseases ---- adrenocortical insufficiency or
diabetic acidosis.
✔ Renal failure

MANAGEMENT
 Treatment of the cause should always be considered
along with the treatment of symptoms and fluid
replacement. Urine output should be monitored in
hospitalized patients as an indicator of treatment
Management efficacy and renal function recovery.
First-Degree Burns  In severe dehydration, restoration of the blood
o Run cool water over the burn. Don't volume is the main goal and is achieved with a fluid
apply ice.
saline or Ringer's lactate. Adults can use oral fluids if
o For sunburns, apply aloe Vera gel. they are conscious and able to drink, otherwise,
23
MCN – FINALS REVIEWER
intravenous fluids should be used. Correction of  Fluid volume deficit (Hypovolemia) occurs when loss
electrolyte abnormalities should follow of ECF volume exceeds the intake of fluid.
 Treatment options include fluid replacement orally if o Clinical signs and symptoms include acute
the child is conscious and able to drink Water, fluids, weight loss, decreased skin turgor, oliguria,
and an oral rehydration solution can be used. In concentrated urine, orthostatic
severe cases, intravenous fluids should be used. hypotension, a weak, rapid heart rate,
 Breastfeeding and a normal diet should be flattened neck veins, increased
continued, as long as the treatment with fluid temperature, thirst, decreased or delayed
replacement prevents weight loss or developmental capillary refill, cool, clammy skin, muscle
delays in infants. weakness, and cramps.
 Fluid volume excess (Hypervolemia) refers to an
OVERHYDRATION isotonic volume expansion of the ECF caused by the
 Overhydration can occur when people drink much abnormal retention of water and sodium in
more water than their body needs. approximately the same proportions in which they
 People, particularly athletes, who drink excessive normally exist in the ECF.
water to avoid dehydration can develop o Clinical manifestations for FVE include
overhydration. People may also drink excessive edema, distended neck veins, and crackles.
water because of a psychiatric disorder called  Hyponatremia refers to a serum sodium level that is
psychogenic polydipsia. less than 135 mEq/L
 Overhydration is much more common among people o Signs and symptoms include anorexia,
whose kidneys do not excrete urine normally. nausea and vomiting, headache, lethargy,
 Overhydration may also result from the syndrome of dizziness, confusion, muscle cramps and
inappropriate antidiuretic hormone secretion. weakness, muscular twitching, seizures, dry
skin, and edema.
SYMPTOMS  Hypernatremia is a serum sodium level higher than
 When overhydration occurs slowly and is mild or 145 mEq/L.
moderate, brain cells have time to adapt, so only o The signs and symptoms are thirst, elevated
mild symptoms (if any) like distractibility and body temperature, hallucinations, lethargy,
lethargy may ensue. When overhydration occurs restlessness, pulmonary edema, twitching,
quickly, vomiting and trouble with balance develop. increased BP and pulse.
If overhydration worsens, confusion, seizures, or  Hypokalemia usually indicates a deficit in total
coma may develop potassium stores.
o Clinical manifestations are fatigue, anorexia,
TREATMENT muscle weakness, polyuria, decreased
 Regardless of the cause of overhydration, fluid intake bowel motility, paresthesia, ileus,
usually must be restricted (but only as advised by abdominal distention, and hypoactive
doctors), Restricting drinking to less than a quart of reflexes
fluids (about 0.9 liters) a day usually results in  Hyperkalemia refers to a potassium level greater
improvement over several days. than 5.0 mEq/L.
 If overhydration occurs with excess blood volume o Signs and symptoms include muscle
because of heart, liver, or kidney disease, restricting weakness, tachycardia, paresthesia,
the intake of sodium is also helpful because sodium dysrhythmias, intestinal colic, cramps,
causes the body to retain water abdominal distention, and anxiety.
 Doctors prescribe diuretics (drugs that increase the  Hypocalcemia are serum levels below 8.6 mg/dl.
excretion of sodium and water in the urine). o The signs and symptoms are numbness,
tingling of fingers, toes, and circumoral
CLASSIFICATION AND CLINICAL MANIFESTATIONS region, positive Trousseau's sign and
The following are the different alterations on Fluid and Chvostek's sign, seizures, hyperactive deep
Electrolytes and Acid-base balance: tendon reflexes, irritability, and
bronchospasm.
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MCN – FINALS REVIEWER
 Hypercalcemia is calcium level greater than 10.2 COMPONENTS OF ABG
mg/dl.  pH-measurement of how acidic or alkalotic your
o The signs and symptoms include muscle blood is. Normal value: 7.35 to 7.45. The
weakness, constipation, anorexia, nausea abbreviation "PH"== refers to two French words that
and vomiting, dehydration, hypoactive deep mean the "power of hydrogen."
tendon reflexes lethargy, calcium stones,  PaCO2-measurement of carbon dioxide. Normal
flank pain, pathologic fractures, and deep value: 35 to 45. PaCO2 or carbon dioxide is that it is
bone pain. being controlled by our lungs. It is connected with
 Hypomagnesemia refers to a below-normal serum the word: "acid".
magnesium concentration.  HCO3 -measurement of bicarbonate. Normal value:
o Clinical manifestations include 22 to 26. The bicarbonate is being controlled by your
neuromuscular irritability, positive kidneys. It is connected with the word "base".
Trousseau's and Chvostek's sign, insomnia,  PaO2- or oxygen. It is regulated by lungs, and the
mood changes, anorexia, vomiting, and Normal value: 80 to 100. Not really needed in
increased deep tendon reflexes. reading ABG but it helps to identify when the patient
 Hypermagnesemia are serum levels over 2.3 mg/dl. is having hypoxemia or not.
o Signs and symptoms are flushing,
hypotension, muscle weakness, drowsiness, ARTERIAL BLOOD GASES
hypoactive reflexes, depressed respirations, PH = acidosis < 7.4> alkalosis
and diaphoresis  PH 7.35-7.45
 Hypophosphatemia is indicated by a value below 2.5  PaCo2 35-45 = Respiratory
mg/dl.  HC03 22-26 = Metabolic
o Signs and symptoms include paresthesia, o R – Respiratory = PH ↑ PCo2 ↓ Alkalosis
muscle weakness, bone pain and o O – Opposite = PH ↓ PCo2 ↑ Acidosis
tenderness, chest pain, confusion, seizures, o M – Metabolic = PH ↑ HC03 ↑ Alkalosis
tissue hypoxia, and nystagmus. o E – Equal = PH ↓ HC03 ↓ Acidosis
 Hyperphosphatemia is a serum phosphorus level  Uncompensated: Co2 or HCo3
that exceeds 4.5 mg/dl in adults. normal
o Clinical manifestations are tetany,  Partially Compensated: Nothing is
tachycardia, anorexia, nausea and vomiting, normal
muscle weakness, and hyperactive reflexes.  Compensated: PH is normal (7.4
baseline/neutral)
ARTERIAL BLOOD GAS (ABG) ANALYSIS
 Arterial blood gases are simply the measurements of RESPIRATORY ACIDOSIS
the acidity or alkalinity of the arterial circulation. It  build up CO2 (Co2 retention) in the blood due to
also measures gases such as oxygen and carbon
dioxide. BRADYPNEA
 This test is used to check how well your lungs are  decrease Ph, increase PaCO2
able to move oxygen into the blood and remove  body compensates by releasing HCO3 to increase pH
carbon dioxide from the blood.  depress breathing

PURPOSES OF ABG ANALYSIS CAUSES


 Acid base status  D – drugs (Opioids, morphine, sedatives, fentanyl) –
 Degree of oxygenation of blood and adequacy of causes respiratory depression
alveolar ventilation  E – edema (extreme fluid in the lungs)
 Continuous arterial blood pressure monitoring in an  P – pneumonia – excessive mucus production
emergency  R – respiratory center f brain is damaged
 E – emboli
 S – spasm of bronchioles

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MCN – FINALS REVIEWER
 S – sac elasticity of alveoli is damaged (COPD, HCO3 <- 22 – 26 ->
emphysema)
METABLIC ALKALOSIS
S/S:  Body has experienced an excessive loss of acid
1. neuro (drowsy, confused, headache) (hydrogen ion)
2. RR<12  Increase HCO3 in the body
3. <BP  Body compensates by HYPOVENTILATION to
increase CO2 levels
INTERVENTION  RR < 12
1. administer O2  LAB VALUES:
2. watch potassium levels o pH > 7.45
3. administer antibiotics o HCO3 > 26
4. endotracheal intubation o PaC2 > 45

Acid Normal Base CAUSES


pH <- 7.35 – 7.45 ->  A – Aldosterone production is excessive
paCo2 <- 45 – 35 -> (hyperaldosteronism)
HCO3 <- 22 – 26 ->  L – Loop Diuretics (Lasix, Thiazides)
 K – alkaline ingestion (baking soda, antacid, milk)
RESPIRATORY ALKALOSIS  A – anticonvulsant
 Expelling too much CO2 due to TACHYPNEA  L – loss of fluids (Vomiting, Nasogastric suctioning)
 pH in blood is &gt;7.45  I – Increase Sodium bicarbonate administration
 PaCo2 &lt;35
 Kidneys compensate by increasing urination, S/S
decreasing HCO3  Bradypnea
 Kussmaul’s breathing
CAUSES  Hypokalemia (tremor, muscle weakness)
 T – temperature is elevated (fever)  RR < 12
 A – aspirin toxicity
 C – controlled mechanical ventilation NSG INTERVENTION
 H – hyperventilation Treat the cause
 Y – hYsteria - anxiety attacks, rapid breathing 1. Antiemetic – vomiting
 P – Pain 2. Stop suctioning
 N – Neurological injury 3. Stop diuretics
 E – embolism and edema in lungs 4. WOF potassium and chloride
 A – Asthma 5. Watch arterial blood gas

S/S METABOLIC ACIDOSIS


RR>20 - > HR  Increase acid in the body (DKA)
Tetany  DECREASE HCO3
muscle cramps -< Calcium and potassium  Decrease acid excretion
 Losing CO3 due to diarrhea
INTERVENTION  Respiratory system compensates –
1. teach breathing techniques HYPERVENTILATION to expel CO2 to Increase HCO3
2. WOF for K and Ca levels  Lab Values:
o pH < 7.35
Acid Normal Base o HCO3 < 22
pH <- 7.35 – 7.45 -> o PaCO2 < 35
paCo2 <- 45 – 35 ->

26
MCN – FINALS REVIEWER
Causes MODE OF TRANSMISSION
 A – Aspirin toxicity ✔ Direct by person to person contact
 C – Carbohydrates not metabolize ✔ Droplet
 I – insufficiency of kidneys ✔ Airborne
 D – diarrhea/ DKA ***portal entry===oropharynx
 – ostomy drainage
 T – fistula INCIDENCE
 I – intake of high fat diet  A childhood disease with the peak of age 5 and 15
 C – carbonic anhydrase inhibitor (Diamox) years old

S/S PERIOD OF COMMUNICABILITY


 Kussmaul’s breathing- blowing Co2. Deep and rapid  From 7 days before until 9 days after the parotid
 Confused glands swell
 Decrease BP  Recovery: 2 weeks
 Weak
 RR &gt;20 Pathogenesis
 Following entry of the virus through droplet
INTERVENTION infection, there is virema with primary multiplication
1. Watch for respiratory distress- intubation in the upper respiratory tract. At the same time,
2. WOF electrolytes (potassium) localization occurs in the salivary glands and other
3. Neuro status organs
4. I and O  The glands are edematous and hyperemic with
5. WOF diet occasional small hemorrhages in the capsule. The
6. Insulin, monitor blood sugar (DKA) ducts are obstructed by swelling of the lining. The
acinar cells may be necrosed but subsequently
Acid Normal Base regenerate without fibrosis
pH <- 7.35 – 7.45 ->
paCo2 <- 45 – 35 -> SYMPTOMS OF MUMPS
HCO3 <- 22 – 26 ->
CLINICAL MANIFESTATIONS
 Slight malaise with low grade fever but it may be
MUMPS
absent at times
 Is an acute viral infection of the salivary glands
 Headache and lassitude (lack of energy)
particularly the parotids with constitutional
 Pain below the ear, particularly on moving the jaws
manifestation of varying degrees
 An acute contagious disease, the characteristic  Parotid gland (70% cases) are swollen, painful,
figure of swelling of one or both of the parotid glans enlarged and tender in varying degrees (involvement
often bilateral)
ANOTHER NAME  Submaxillary and sublingual glands may also be
 Epidemic parotitis affected which may lead to anorexia and dysphagia
 Viral parotitis  In large swelling, the ear lobe may be pushed
upwards and outwards
 Infectious parotitis
DIAGNOSIS
ETIOLOGY
1. Blood examination- leukocytes count which shows
 Caused by an RNA containing mumps virus of the
leukopenia with relative lymphocytosis
paramyxovirus group
2. Viral culture- isolation of virus from saliva, mouth
 Sources:
swabs or urine and if associated with
✔ Discharges coming from nose and mouth of
meningoencephalitis. CSF
infected persons (saliva)
3. Viral serology

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MCN – FINALS REVIEWER
- Not recommended below 1 year of age
COMPLICATIONS 7. Control measures:
1. Meningoencephalitis a. Active immunization- live attenuated mumps
- primary infection of the neurons with the virus vaccine (given between 12 and 15 months
parotitis occurring at the same time or after the 2nd dose bet 4 and 6 years)
onset b. Disinfection of articles contaminated with saliva
2. Epididymo-orchitis or nasopharyngeal secretions
- May occur even without evident swelling of the
parotids NURSING INTERVENTION
- May last about 5 days 1. Isolation
- Incidence: 15%-30% of males before puberty and 2. Comfort of the patient
of those who develop orchitis 30% may have - Remains in bed for at least 4 days after the
atrophy disappearance of all swelling
Clinical manifestations: - For comfort of the patient- either hot or cold
✔ Hyperpyrexia application may be used on the swollen jaws to
✔ Chills alleviate the discomfort
✔ Headache - Diet: soft bland
✔ Nausea and vomiting 3. Encourage rest
✔ Lower abdominal pain- testes may be 4. Encourage increased fluid intake
swollen, painful and tender which is 5. Avoid acidic foods
generally unilateral
✔ Inflammation of ovary - female PNEUMONIA
3. Oophoritis- pelvic pain and tenderness without any  Occurs at a rate of 2 to 4 children in 100.
evidence of impairment of fertility  Common cause of death among infants younger than
4. Pancreatitis – epigastric pain, chills, vomiting 48 hours of life
5. Nephritis  Newborns who are born more than 24 hours after
6. Thyroiditis – diffuse, tender swelling of the thyroid rupture of membranes and birth are particularly
about a week after the onset of parotitis followed by prone in developing pneumonia in their first few
the production of antithyroid antibodies days of life
7. Myocarditis – precordial pain, bradycardia and
fatigue with depression of the ST segment in the ECG CAUSES
8. Mastitis  Bacterial origin (pneumococcal, streptococcal,
9. Deafness usually unilateral with complete and staphylococcal, chlamydial)
permanent hearing loss  Viral in origin (RSV)
 Aspiration of lipids or hydrocarbon
TREATMENT
1. Isolation precaution (contagious from the 2nd day of TYPES
swelling to its disappearance) 1. Hospital acquired - Pneumococcal or streptococcal
2. Analgesics (headache) 2. Community acquired (chlamydia, viral pneumonias)
3. Lumbar tap- to relieve headache
(meningoencephalitis) PNEUMOCOCCAL PNEUMONIA
4. Corticosteroids- to relieve pain (orchitis)  Infants – remain to be bronchopneumonia with poor
5. Support for comfort (orchitis) consolidation of exudate into the alveoli
6. Care of exposed persons  Older children- localize in a single lobe, consolidation
a. Before puberty: no prophylaxis indicated occur
b. After puberty: live attenuated mumps virus ✔ blood tinged sputum as an exudate and RBC
vaccine or attenuated vaccine invade the alveoli
Contraindications: with allergy to eggs, ✔ After 24-48 hours – the alveoli are no longer
administration of immunosuppressive drugs filled with RBC and serum but Fibrin, leukocytes
or the presence of immune deficiencies and pneumococci
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MCN – FINALS REVIEWER

ASSESSMENT MANAGEMENT
 High fever  Macrolide antibiotics - erythromycin
 Nasal flaring
 Retractions VIRAL PNEUMONIA
 Chest pain  Caused by viruses of upper respiratory tract
 Dyspnea infection: RSV’s, mycoviruses adenovirus
 Appear acutely ill
 Tachypnea ASSESSMENT
 Tachycardia  Low grade fever
*Pain - abdominal  Non-productive cough
 Breath sounds become bronchial (sound is  Tachypnea
transmitted from the trachea), air no longer or  Diminished breath sounds
poorly enters fluid-filled alveoli  Fine rales
 Crackles- due to fluid  Apnea
 Dullness on percussion due to total consolidation  chest x-ray shows diffuse infiltrated areas
 Chest x-ray –patchy diffusion
 Lab result - leukocytosis MANAGEMENT
 Rest
THERAPEUTIC MANAGEMENT  Antipyretic for fever
 Antibiotics – ampicillin or 3rd gen  IVF
- cephalosporin  Explain the difference of bacterial and viral infections
- amoxicillin clavulanate to parents
(Augmentin) - for penicillin resistant organisms
 Rest- to prevent exhaustion ACUTE LYMPHOCYTIC LEUKEMIA
 Turn and reposition the child frequently- to avoid  “Acute” means that the leukemia can progress
pooling of secretions quickly, and if not treated, would probably be fatal
 IV therapy within a few months.
 Antipyretic – acetaminophen  "Lymphocytic" means it develops from
 Humidified oxygen – to alleviate labored breathing early(immature) forms of lymphocytes, a type of
and prevent hypoxemia white blood cell.
 Assess oxygen saturation levels via pulse oximetry  B lymphocytes (B cells): B cells help protect the body
 Chest physiotherapy – encourages the movement of by making proteins called antibodies. The antibodies
mucus and prevents obstruction attach to germs (bacteria, viruses, and fungi) in the
 For older children – encourage to cough body, which helps the immune system destroy them.
 T lymphocytes (T cells): There are several types of T
CHLAMYDIAL PNEUMONIA cells, each with a special job. Some T cells can
 Most often seen in newborns up to 12 weeks of age destroy germs directly, while others play a role in
– because the chlamydial organism is contracted either boosting or slowing the activity of other
from the mother’s vagina during birth. immune system cells.
 Are neoplasms composed of immature T cells which
ASSESSMENT are referred as lymphocytes
 Nasal congestion  is a type of cancer of the blood and bone marrow
 Sharp cough  Involves the lymphoblasts or immature lymphocytes.
 Infants fail to gain back their birth weight == with the rapid proliferation of immature
 Tachypnea lymphocytes, the production of RBC and platelets
 Wheezing fall, the invasion of body organs by the rapidly
 Rales increasing WBC begins.
 Elevated level of Immunoglobulin (IgG and IgM)  Most common cancer in children

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MCN – FINALS REVIEWER
== between 2 and 6 years of age 1. Vincristine given at about 1 month
== prognosis: younger than 1 year old or older than 2. Prednisone
10-year-old at the first time of occurrence is not as 3. Asparaginase
good those between 2 and 10 years of age. 4. Doxorubicin
5. Methotrexate
CONTRIBUTORY FACTORS 6. ALLUPURINOL – to reduce the formation
1. Radiation of uric acid
2. Exposure to chemicals ***well hydrated helps maintain safe
3. Genetics uric acid excretion incidence
4. Down syndrome  B cell ALL peaks – about 3 years of age
5. Fanconi syndrome  Peak incidence of T cell is in adolescence

ASSESSMENT COMPLICATIONS
1. Pallor 1. Central nervous system involvement
2. Low grade fever - Blindness
3. Lethargy - Hydrocephalus
4. Petechiae - Recurrent seizures
5. Bleeding from oral mucous membrane **the meninges and the 6th and 7th cranial
6. Bruise easily (due to low thrombocyte CT) nerves are usually affected
7. Abdominal pain due to enlargement of - Nuchal rigidity
8. Vomiting spleen and liver - Headache
9. anorexia - Irritability
10. Bone and joint pain- due to abnormal lymphocytes - Vomiting
11. in the bone periosteum - papilledema
12. Headache invaded CNS  Lumbar puncture result: presence of blast
13. Unsteady gait cells in the CSF === will be treated with
14. painless, generalized swelling of lymph nodes intrathecal injections of methotrexate
especially in submaxillary or cervical nodes ***check if the child is not taking oral or IV
15. Variable leukocyte CT methotrexate at the same time = because
16. Low HCT and platelet some of the dose of intrathecal
17. 16 normocytic and normochromic RBC methotrexate is absorbed systemically and
could lead to toxic reaction.
DIAGNOSIS  Insertion silicon tubing into a cerebral
1. Bone marrow aspiration – to identify the type of ventricle and threading under the scalp
WBC involved/type of leukemia (Ommaya reservoir) provides easy access to
== if there are more than 25% blast cells=leukemia is the CSF for sampling or injection without the
established need for repeated lumbar puncture
== bone marrow is aspirated at iliac crest rather than 2. renal involvement
the sternum - Kidneys may enlarge and function may be
2. radiograph= may reveal lesions of the long bones impaired
3. Lumbar puncture- evidence of blast cells in CSF - Increase uric acid (due to breakdown of leukemic
cells during chemotherapy)
THERAPEUTIC MANAGEMENT - Plugging of renal tubules with uric acid, kidney
1. Chemotherapy failure may result
- Administered by central venous catheter= ***renal involvement may limit the use of
because administration of drugs into a major chemotherapeutic agents because they cannot
vessel helps prevent irritation to the vessel wall be excreted effectively because of kidney
- The access device can be clamped or trapped so damage.
the child can be ambulatory 3. Testicular involvement
 Drugs to initiate remission:
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MCN – FINALS REVIEWER
- Leukemic cells tend to invade the testes and - Evaluation/follow-up
cannot
- be destroyed with chemotherapy TREATMENT
- Once chemotherapy is halted, leukemic cells 1. Chemotherapy and radiotherapy
may a. Induction (remission induction)
- grow and proliferate - to kill the most of the tumor cells rapidly
- Testes will be irradiated—leads to sterilization - Drugs commonly used: vincristine,
**boy is past puberty- sperm banking before asparaginase, dexamethasone
chemo and radiation to preserve sperm b. Consolidation- high doses of multidrug
chemotherapy are used to eliminate the disease
NURSING DIAGNOSIS AND INTERVENTION or reduce tumor burden to very low level
1. Risk for infection related to nonfunctioning WBCs Drugs commonly used:
and immunosuppressive effects to therapy o Vincristine, cyclophosphamide,
- temp = lower than 98.6F (37 C) cytosine arabinoside, daunorubicin,
- Septicemia etoposide or mercaptopurine
- Pneumonia c. Maintenance therapy
- meningitis - Aims to eliminate completely any remaining
- When at home: parents must report signs of leukemic cells
infection such as low-grade fever or behavior - Given with daily oral mercaptopurine and
that does not seem typical for the child. once weekly oral methotrexate. (continued
- Prophylactic antibiotics for 2-3 years)
- Limit visitors - Leucovorin is given after systemic
- Leukocytes transfusion – to increase functioning methotrexate to neutralize its action and
leukocytes ct. (fever and chills are not true signs protect normal cells from the effects of
of transfusion reaction) drugs
2. Risk for deficient fluid volume related to increased - Blood values are monitored at least monthly
chance of hemorrhage from poor platelet - if still with leukemic cells- new induction
production phase will be initiated followed by a
- Prone to massive hemorrhage sanctuary, intensification, and maintenance
- Epistaxis (most common type of bleeding) phase
- Digital pressure is effective to stop epistaxis - Bone marrow transplantation or
- BT – platelet transfusion immunotherapy can be used for children
- Heparin lock/multi lumen central nervous who do not respond well to standard
catheters minimizing the need for repeated therapy
venipunctures
3. Pain related to invasion of leukocytes WILMS TUMOR/NEPHROBLASTOMA
- Due to vast number of RBC that invades the  Malignant tumor that rises from the metanephric
periosteum of the bone mesoderm cells of the upper pole of the kidney.
- Handle arms and legs gently  Occurs in association with congenital anomalies such
- Use of an alternating mattress or sheepskin as:
underneath bony joints helps to reduce skin a. anirida (lack of color in the iris)
irritation caused by always resting in the same b. Crptorchidism
position c. Hypospadias
- Give analgesia as needed d. Pseudohermaphrodism
4. Ineffective health maintenance related to long term e. Cystic kidneys
therapy for leukemia f. Hemangioma
- Report signs of infection g. Talipes disorder
- Ask the child’s school to notify them if any other h. Deletion of chromosome 11
child in the school develops chicken
pox==immune protection can be given SYNDROMES ASSOCIATED WITH WILM’S TUMOR
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MCN – FINALS REVIEWER
1. WAGR syndrome (Wilms tumor, aniridia, RULE
genitourinary tract abnormalities, mental  “NO abdominal palpation” to be place at the crib
retardation)
 Denys-Drash syndrome – THERAPEUTIC MANAGEMENT
pseudohermaphrodites  Staged according to the criteria of the National
 Frasier syndrome – kidneys are diseased Wilms’ tumor
 Beckwith-wiedemann syndrome – overgrowth
syndrome STAGE DESCRIPTION
 Without therapy: metastatic spread by the 1 Tumor confined to the kidney and
bloodstream....to the lungs, regional lymph completely removed surgically
nodes, liver, bone and brain 2 Tumor extending beyond the kidney but
completely removed surgically
PREDISPOSING FACTORS 3 Regional spread of disease beyond the
1. genetics kidney with residual abdominal disease
2. Age postoperatively
3. Race 4 Metastases to lung, liver, bone, distant
4. Gender lymph nodes or other distant sites
5. Birth defects (aniridia, hemihypertrophy, 5 Bilateral disease
cryptorchidism, hypospadias)
 Nephrectomy (excision of the affected kidney)
ASSESSMENT  Radiation therapy (omitted in stage 1 tumor)
 Discovered early in life (6 months to 5 yrs., peak at 3-  Chemotherapy with dactinomycin, doxorubicin or
4 yrs.) vincristine
 Arises from embryonic structure present in the child
before birth  Chemotherapy may be given in varying intervals for
 Firm, nontender abdominal mass as long as 15 months
 Hematuria  2nd surgical procedure may be scheduled after 2 or
 Low grade fever 3 months to remove any remaining tumor
 Anemic from lack of erythropoietin formation  If tumor is bilateral, small...both kidneys can be
 Hypertension – because of excessive renin removed leaving functioning kidney cells intact or
production only the kidney with a larger tumor may be removed
 Tumor sites are treated with both radiation and
ASSESSMENT chemotherapy.
 Constipation
 Loss of appetite SIDE EFFECTS OF CHEMO DRUGS
 Weight loss  Nausea
 Blood in the urine (hematuria)  Vomiting
 Frequent UTI  Loss of appetite
 Hair loss
DIAGNOSTIC TEST  Higher risk of infection
 CT scan/utz reveals the primary tumor
 Kidney function studies COMPLICATIONS
a. Glomerular filtration rate or blood urea nitrogen  Small bowel obstruction from fibrotic scarring
– to assess the function of kidneys before  Hepatic damage from radiation to the lesion
surgery  Nephritis
**** tumor metastasizes rapidly as a result of  Damage to the ovaries
large blood supply into the kidneys and adrenal  Interstitial pneumonia
glands  Scoliosis – spine radiation

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MCN – FINALS REVIEWER
HIRSCHSPRUNG DISEASE
✔ Otherwise known as a ganglionic megacolon or SURGERY
intestinal ganglionitis 1. Dissection and removal of the affected section with
✔ is the absence of ganglionic innervation to the anastomosis of the intestine (a pull through
muscle section of the bowel operation
Two staged surgery:
a. Temporary colostomy
b. Repair at 12 to 18 months of age
 If the anus is deprived of nerve endings == a a
permanent colostomy will be established.
 POST- OP
 NGT in place attached to low suction, an IV infusion
and IFC
 Observe for abdominal distention
CAUSES  Assess bowel sounds
 associated with a genetic mutation.  Observe for the passage of flatus and stools
 occurs when nerve cells in the colon do not form  As soon as peristalsis has returned approx. 24 hours
completely. ✔ remove NGT
 Full fluids --- soft diet – minimal residue diet ---
ASSESSMENT normal diet for age.
 Failure to pass meconium within the first
24 hours of life INTUSSUSCEPTION
 Chronic constipation  common cause of intestinal obstruction in children
 Abdominal distention between ages 3 months and 6 years
 Ribbon like stool  telescoping of one portion of the bowel into another
 Thin, undernourished portion which results in an obstruction to the
 Rectum is empty passage of intestinal contents
 Vomiting
 VIDEO on the assessment of Hirschsprung SIGNS AND SYMPTOMS
disease  Nausea, vomiting
 Abdominal pain (intermittent)
DIAGNOSIS  Currant jelly stool (bloody red)
 Abdominal X-ray.
 lethargic
 Contrast enema.
 Sausage shaped mass (Dance’s sign)
 Rectal biopsy.
 Cry, draw legs towards chest (15-20 min)
 Anorectal manometry
 fever
COMPLICATIONS  Hypoactive/hyperactive bowel sounds
 constipation,
 fecal incontinence. MANAGEMENT
 Enterocolitis and colonic rupture  Monitor fever, increased heart rate. LOC, BP and
respiratory distress
MANAGEMENT  Antibiotics
PRE-OP  IVF
a. Minimal residue diet = low in undigestible fiber,  NGT
connective tissue and residue.  Monitor for normal brown stool
b. omit foods like: highly seasoned foods  Hydrostatic reduction
c. Stool softeners  Barium enema (detailed part of lower intestine)
d. Daily enema  Ultrasound of the abdomen
e. IVF Normal saline  Rectal exam
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MCN – FINALS REVIEWER
***surgery- general anesthesia, part of  Belly (abdominal) pain
the intestine will be removed  Weakness and fatigue
 Irritability and mood changes
DIABETES MELLITUS  Serious diaper rash that does get better with
 Diabetes mellitus involves absence of insulin treatment
secretion (type 1) or peripheral insulin resistance  Fruity breath and fast breathing
(type 2), causing hyperglycemia.  Yeast infection in girls

RISK FACTORS DIAGNOSIS


 Weight. Being overweight is a strong risk factor for  Fasting plasma glucose – The blood is tested after at
type 2 diabetes in children least 8 hours of not eating.
 Inactivity. The less active children are, the greater  Random plasma glucose – The blood is tested when
their risk of type 2 diabetes there are symptoms of increased thirst, urination,
 Diet and hunger.
 Family history
 Race or ethnicity TREATMENT
 Age and sex  Daily injections of insulin
 Maternal gestational diabetes  Eating the right foods to manage blood glucose
 Low birth weight or preterm birth levels. This includes timing meals and counting
carbohydrates.
DIAGNOSIS  Exercise, to lower blood sugar
 A blood sample is taken at a random time. === A  Regular blood testing to check blood-glucose
blood sugar level of 200 milligrams per deciliter  levels
(mg/dL), or 11.1 millimoles per liter (mmol/L), or  Regular urine testing to check ketone levels
higher, along with symptoms, suggests diabetes.
 Glycosylated hemoglobin (A1C) test. This test COMPLICATIONS
indicates your child's average blood sugar level for 1. Ketoacidosis
the past 3 months.  blood sugar levels are very high and the body
starts making ketones.
TYPE 1 DIABETES MELLITUS  risk for diabetic coma. A child with a diabetic
- is a long-term (chronic) condition. coma loses consciousness because of brain
- a condition in which the child's body no longer swelling. The brain swells because of the very
produces an important hormone (insulin) - can develop high blood sugar levels.
at any time during childhood, even during infancy, but 2. Low blood sugar (hypoglycemia). This is also
it usually begins between ages 4 years and 6 years or sometimes called an insulin reaction. This occurs
between ages 10 years and 14 years. when blood glucose drops too low.
3. Eye problems
SYMPTOMS 4. Kidney disease
 High levels of glucose in the blood and urine when 5. Nerve damage
tested 6. Tooth and gum problems
 Unusual thirst 7. Skin and foot problems
 Dehydration 8. Heart and blood vessel disease
 Frequent urination (a baby may need more diaper  Symptoms develop quickly in type 1 diabetes, usually
changes, or a toilet-trained child may start wetting over several days to weeks, and tend to appear in a
his or her pants) typical pattern.
 Extreme hunger but weight loss  High blood glucose levels cause the child to urinate
 Loss of appetite in younger children excessively. Children may wet the bed or become
 Blurred vision unable to control their bladder during the day.
 Nausea and vomiting Children who are not toilet-trained may have an

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MCN – FINALS REVIEWER
increase in wet or heavy diapers. This fluid loss RISK FACTORS
causes an increase in thirst and the consumption of  Weight. Being overweight is a strong risk factor for
fluids. About half of children lose weight and have type 2 diabetes in children. The fattier tissue children
impaired growth. have — especially inside and between the muscle
 Some children become dehydrated, resulting in and skin around the abdomen — the more resistant
weakness, fatigue, and a rapid pulse. their bodies' cells become to insulin.
 Children may also have nausea and vomiting due to  Inactivity. The less active children are, the greater
ketones (by-products of the breakdown of fat) in their risk of type 2 diabetes.
their blood. Vision may become blurred. If the  Diet. Eating red meat and processed meat and
symptoms are not recognized as being caused by drinking sugar-sweetened beverages is associated
diabetes and treated, children may develop with a higher risk of type 2 diabetes.
 Family history. Children's risk of type 2 diabetes
TYPE 2 DIABETES increases if they have a parent or sibling with the
 is a chronic disease that affects the child's body disease.
processes sugar (glucose) for fuel  Race or ethnicity. Although it's unclear why,
 Without treatment, the disorder causes sugar to certain people — including Black, Hispanic, American
build up in the bloodstream, which can lead to Indian and Asian American people — are more likely
serious long-term consequences. to develop type 2 diabetes.
 occurs more commonly in adolescents/ adults  Age and sex. Many children develop type 2 diabetes
 called adult-onset diabetes. in their early teens, but it may occur at any age.
Adolescent girls are more likely to develop type 2
SYMPTOMS diabetes than are adolescent boys.
 Increased thirst  Age and sex. Many children develop type 2 diabetes
 Frequent urination in their early teens, but it may occur at any age.
 Increased hunger Adolescent girls are more likely to develop type 2
 Fatigue diabetes than are adolescent boys.
 Blurry vision  Maternal gestational diabetes. Children born to
 Darkened areas of skin, most often around the neck women who had gestational diabetes during
or in the armpits and groin pregnancy have a higher risk of developing type 2
 Unintended weight loss, although this is less diabetes.
common in children with type 2 diabetes than in  Low birth weight or preterm birth. Having a low
children with type 1 diabetes birth weight is associated with a higher risk of
 Frequent infection developing type 2 diabetes. Babies born prematurely
 Diabetes screening is recommended for children — before 39 to 42 weeks' gestation —have a greater
who have started puberty or are at least 10 years old, risk of type 2 diabetes.
who are overweight or obese, and who have at least  Maternal gestational diabetes. Children born to
one other risk factor for type 2 diabetes. women who had gestational diabetes during
pregnancy have a higher risk of developing type 2
CAUSES diabetes.
 family history  Low birth weight or preterm birth. Having a low
 genetics birth weight is associated with a higher risk of
 children with type 2 diabetes can't process sugar developing type 2 diabetes. Babies born prematurely
(glucose) properly. — before 39 to 42 weeks' gestation — have a greater
***Most of the sugar in the body comes from food. risk of type 2 diabetes
When food is digested, sugar enters the
bloodstream. Insulin allows sugar to enter the cells METABOLIC SYNDROME
— and lowers the amount of sugar in the blood.  When certain conditions occur with obesity, they are
associated with insulin resistance and can increase
the risk of diabetes and heart disease and stroke. A

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MCN – FINALS REVIEWER
combination of the following conditions is often COMPLICATIONS OF DIABETES IN CHILDREN AND
called metabolic syndrome: ADOLESCENTS
✔ High blood pressure  Diabetes can cause immediate complications and
✔ Low levels of high-density lipoproteins (HDL), the long-term complications. The most serious
"good" cholesterol immediate complication is diabetic ketoacidosis.
✔ High triglycerides  Long-term complications are usually due to social
✔ High blood sugar levels and psychologic issues or to blood vessel problems.
✔ Large waist size Although blood vessel problems take years to
develop, the better the control of diabetes, the less
POLYCYSTIC OVARY SYNDROME likely that complications will ever occur.
 Polycystic ovary syndrome (PCOS) affects young  If the fasting glucose level is 126 milligrams per
females after puberty. PCOS is caused by an deciliter (mg/dL—7.0 mmol/L) or higher on 2
imbalance of hormones, resulting in signs such as different occasions, children have diabetes.
weight gain, irregular menstrual periods, and excess  If the random glucose level is 200 mg/dL (11.1
face and body hair. People with PCOS often have mmol/L) or higher, children probably have diabetes
problems with metabolism that can result in insulin and should have their fasting glucose level tested to
resistance and type 2 diabetes. confirm.
 People whose hemoglobin A1C level is 6.5% or higher
COMPLICATIONS are considered to have diabetes. Hemoglobin A1C
 High cholesterol levels are more helpful in the diagnosis of type 2
 Heart and blood vessel disease diabetes in children who do not have typical
 Stroke symptoms.
 Nerve damage
 Kidney disease ORAL GLUCOSE TOLERANCE TEST
 Eye disease, including blindness - may be done in children who have no symptoms or
whose symptoms are mild or not typical.
PREVENTIION - In this test, children fast, have a blood sample taken
 Healthy-lifestyle choices can help prevent type 2 to determine the fasting glucose level, and then
diabetes in children. Encourage your child to: drink a special solution containing a large amount of
- Eat healthy foods – Offer your child foods low in glucose. Doctors then measure blood glucose levels
fat and calories. Focus on fruits, vegetables and 2 hours later. If the level is 200 mg/dL (11.1 mmol/L)
whole grains. Strive for variety to prevent or higher, children are considered to have diabetes.
boredom. This test is similar to the test that pregnant women
- Get more physical activity – Encourage your child have to look for gestational diabetes.
to become active. Sign up your child for a sports
team or dance lessons. MANAGEMENT
- Many children do not have any symptoms, and  Metformin by mouth (orally) for children and
doctors diagnose type 2 diabetes only when adolescents. It is started at a low dose and often
blood or urine tests are done for other reasons increased over several weeks to higher doses. It can
(such as during a physical before playing sports be taken with food to prevent nausea and abdominal
or going to camp). Symptoms in children with pain.
type 2 diabetes are milder than those in type 1  Liraglutide is an injectable drug that can be given to
diabetes and develop more slowly. Parents may children over 10 years of age who have type 2
notice an increase in the child’s thirst and diabetes. Liraglutide may lower hemoglobin A1C
urination or only vague symptoms, such as levels and may also reduce appetite and promote
fatigue. Children with type 2 diabetes are less weight loss. It may be given to children who are
likely to develop ketoacidosis or severe taking metformin but whose hemoglobin A1C level is
dehydration than those with type 1 diabetes. not in the target range or it can be given instead of
metformin to children who cannot tolerate that
drug.
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MCN – FINALS REVIEWER
 Other drugs used for adults with type 2 diabetes may - Openings on both sides of the lip that extend up
help some adolescents, but they are more expensive, into the nose and typically involve the gum ridge
and there is limited evidence for their use in children. and palate
 Insulin

CLEFT LIP AND PALATE

CLEFT LIP
● A cleft lip is a physical split or separation of the two
sides of the upper lip and appears as a narrow
opening or gap in the skin of the upper lip. This
separation often extends beyond the base of the
nose and includes the bones of the upper jaw and/or
upper gum.
● Deviation may be unilateral or bilateral PREOPERATIVE MANAGEMENT
● Nose is usually flattened === because the incomplete ● Feed in upright position
fusion of the upper lip has allowed it to expand in a ● Feed with soft large holed nipple or rubber tipped
horizontal dimension. syringe or cleft lip or palate nurse
● Prevalent among boys than girls ● Burp frequently because of swallowed air
● Have associated birth defects ● Teach parents to give water after each feeding to
cleanse the mouth
CAUSES ● Prevent infection from irritation of the lip
● Occurs as a familial tendency or occurs from the ● Restrain infant’s arm if needed
transmission of multiple genes ● Provide a pacifier to increase sucking pleasure
- teratogenic factors present during weeks 5 to 8
of intrauterine life POST OPERATIVE MANAGEMENT
● Viral infection ● Maintain patent airway
● Deficiency of folic acid ● Cleanse the suture line to prevent crust formation
and eventual scarring
TYPES OF CLEFT LIP ● Prevent crying – because of the pressure on the
1. Forme fruste or microform cleft lip suture line (encourage the parent to stay with the
2. Incomplete unilateral cleft lip infant)
3. Complete unilateral cleft lip ● Place the infant in SUPINE position with arm or
4. Incomplete bilateral cleft lip elbow restraints (change the position to the side or
5. Complete bilateral cleft lip sitting up to prevent hypostatic pneumonia; remove
restraints at least 3X a day only when supervised)
1. Forme fruste or microform cleft lip ● Support the parents by accepting and treating the
- A small indentation on one or both sides of the infant as normal
lip ● Suture line is held by a LOGAN BAR (A wire bow
2. Incomplete unilateral cleft lip taped to both cheeks
- An opening on one side of the lip that does not
extend into the nose THERAPEUTIC MANAGEMENT
3. Complete unilateral cleft lip ● Cleft lip – fetal surgery while still in the utero or
- An opening on one side of the lip that extends up repaired surgically shortly after === during hospital
into the nose and typically involves the gum stay or between 2-10 weeks of age
ridge and palate ● Nasal mold apparatus applied before surgery to
4. Incomplete bilateral cleft lip shape a better nostril
- Openings on both sides of the lip that do not ● Early repair helps infants enjoy the pleasure of
extend into the nose sucking
5. Complete bilateral cleft lip
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MCN – FINALS REVIEWER
● Gives a problem on facial contours === another o Maternal smoking severity is depending upon
surgery will be done when the child reaches 4-6 years the number of cigarettes smoked
=== Nasal rhinoplasty --- to straighten a deviated o Ingestion of drugs, e. G. Thalidomide,
nasal septum corticosteroids.
o Exposure to radiation during
CLEFT PALATE
● A cleft palate is a split or opening in the roof of the COMPLICATIONS
mouth.  Children with cleft lip with or without cleft palate
● A cleft palate can involve the hard palate (the bony face a variety of challenges, depending on the type
front portion of the roof of the mouth), and/or the and severity of the cleft.
soft palate (the soft back portion of the roof of the o Difficulty feeding. One of the most
mouth). immediate concerns after birth is feeding.
While most babies with cleft lip can breast-
TYPES OF CLEFT PALATE feed, a cleft palate may make sucking
1. Incomplete cleft palate difficult
2. Complete cleft palate o Ear infections and hearing loss. Babies with
3. Submucous cleft palate cleft palate are especially at risk of
developing middle ear fluid and hearing loss.
1. Incomplete cleft palate o Dental problems. If the cleft extends through
- Opening in the back of the mouth, called the soft the upper gum, tooth development may be
palate affected.
2. Complete cleft palate o Speech difficulties. Because the palate is
- Opening in the front and back of the mouth, or used in forming sounds, the development of
the soft and hard palates normal speech can be affected by a cleft
3. Submucous cleft palate palate. Speech may sound too nasal.
- Muscles within the soft palate are separated or o Challenges of coping with a medical
cleft but the skin or mucous membrane is closed. condition. Children with clefts may face
At times the uvula may be bifid social, emotional and behavioral problems
due to differences in appearance and the
INCIDENCE stress of intensive medical care.
 Cleft lip -1:750 births. Predominantly seen in males
 Cleft palate -1:2500 births, mostly seen in females CLINICAL MANIFESTATIONS
 If the sibling has disorders - 1 in 20 to 1 in 10 Cleft lip has the following manifestations:
 If parent has disorders - 1:30  A notched vermilion borders
 Monozygotic twins are more prone to get than the  Dental anomalies - supernumerary teeth extra
non-zygotic twins teeth, teeth may be absent
 Cleft lip and palate are higher in Asian and lowest in  Variably sized clefts that involve the alveolar
Africans, Americans ridge

ETIOLOGY CLINICAL MANIFESTATIONS


 Genetic factors - it has been estimated that the Cleft palate includes:
chances of a child having a cleft lip and cleft palate is  Opening in roof of the mouth felt with examiners
two percent when one of the parents has a cleft lip finger on palate
or cleft palate.  Nasal distortion
 Unfavorable maternal factors:  Breathing difficulty
o Illness especially viral infections during the fifth  Exposed nasal cavities
and twelfth weeks of gestation, e.g. Rubella  Recurrent ear and throat infection
o Anemia  Speech defects and psychological problems
o Hypoproteinemia  Feeding problems
o Maternal malnutrition
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MCN – FINALS REVIEWER
 Inability to coordinate breathing and feeding  Mother and family should be demonstrated, the
leads to inadequate nutrition various techniques of feeding the baby.
 Difficulty in feeding leads to anemia,  Explain to parents about the risk of aspiration
malnutrition and failure to thrive  Small bolus should be given from the corner of the
 Mouth breathing mouth
 Give baby sufficient time to swallow
DIAGNOSTIC EVALUATION  Burp the baby in between the feeds and after
 History collection - collect the history of a parent  feeding
with cleft and cleft palate, and antenatal check-up  The baby must be given all essential care including
 Prenatal ultrasonography enables many cleft lips and immunization, warmth, hygiene,
some cleft palates to be identified in utero  prevention of infection
 Physical examination cleft lip and palate is diagnosed  Explain about follow up to the parents
by inspection. Physical examination reveals the
anemia breathing difficulty speech defects and PREOPERATIVE MANAGEMENT
dental anomalies Nursing Management
 X-ray it shows the deformity of palatine bone Care for the baby before surgery
 MRI-to evaluate extent of abnormality before  Preoperative care:
treatment o Keep the infant NPO for 6 hours before surgery
 Dental imprecision's for expansion prosthesis o Administer premedication as per doctor’s order.
 Genetic evaluation to determine recurrence risk o Physical, physiological psychological and legal
preparation should be done.
SURGICAL MANAGEMENT
 Management is based on the severity of the defect POST OPERATIVE MANAGEMENT
 Management of cleft lip and cleft palate requires a Nursing Management
team effort involving: Care for the baby after surgery
o Pediatrician  Postoperative care:
o A plastic surgeon o Кееp the airway clears from accumulation of in
o Orthodontist the nose and mouth.
o Ent specialist o Mild sedation may be prescribed to prevent
o Speech therapist infant from crying.
o Psychologist and community health nurse o Careful positioning (never abdomen).
o Restraining the arms if necessary.
NURSING MANAGEMENT o The mother and father should be encouraged to
 Detected immediately after birth. remain with their child as much as possible.
 Avoid complications o The infant is fed with a medicine dropper.
 The defect evokes negative reaction and shock in o Clear fluids offer initially breast milk or formula
parents. The nurse must explain to the parents about can when tolerated.
the possibility of defect correction.
 Feeding: Reduces infants’ ability to suck. POST OPERATIVE MANAGEMENT
o Breast feeding is possible with the use of palatal Nursing Management
prosthesis (Palatal Obturator) Care for the baby after surgery
o If baby is unable to suck, expressed breast milk  Postoperative care:
may be given using syringe with a rubber tube. o The mouth should be rinsed with water before
 Long handled spoon or dropper or soft nipple with a and after feeding
large hole o Do not brush the teeth 1-2 weeks after the
 Cleft palate needs a 2-stage palate repair: surgery
 Soft palate repair at 3-6 months of age o The suture line must be cleaned gently with
 Hard palate repair at 15 -18 months of age cotton or gauze -tipped swab dipped in hydrogen
peroxide or saline solution and dried carefully
several times a day to ensure proper healing
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MCN – FINALS REVIEWER
o the parents are taught the ways by which injury 2. Obstructive hydrocephalus or intraventricular
to the palate can be prevented after discharge hydrocephalus – if there is a block to passage of
and prevention of upper respiratory tract fluids
infection.
o Speech therapy should be given. OTHER CLASSIFICATIONS
o Encourage the child to socialize with family 1. Congenital due to: maternal infection
members and others (toxoplasmosis) infant meningitis
2. Acquired - from an incident later in life
POST OPERATIVE MANAGEMENT  EXCESSIVE CSF due to
 When maintaining a patent airway, try to avoid use 1. Overproduction of fluid by the choroid
of suction that traumatizes the operative site plexus in the 1st and 2nd ventricle
o Place the child in prone Trendelenburg position 2. Obstruction of the passage of fluid:
to prevent aspiration and promote postural ✔ In the narrow aqueduct of sylvius
drainage (common cause)
o Avoid trauma to suture line by: ✔ Foramina of magendei and Luschka
 Telling the child not to rub tongue on roof of mouth (opening that allow the fluid to leave the
 Avoid the use of straw, spoon, toothbrush 4th ventricle)
o Provide liquid diet ***Obstruction occurs because of:
 No milk – because of curd formation on suture line a. Infection (meningitis, encephalitis)- that
o Recognize the need for emotional support of the leave adhesions behind the block fluid
parents since recovery is longer and the progress flow
is uncertain b. Hemorrhage (from trauma, tumor)
c. Arnold Chiari disorder (elongation of the
HYDROCEPHALUS lower brainstem and displacement of
 The term hydrocephalus is derived from the the 4th ventricle into the cervical canal)
 Greekwords "hydro" meaning water and "Cephalus" 3. Interference with the absorption of CSF from the
meaning the head. subarachnoid space if a portion of the subarachnoid
 A condition in which excess cerebrospinal fluid (CSF) membrane is removed
builds up within the fluid-containing cavities or
ventricles of the brain. ASSESSMENT
 CSF is formed in the 1st and 2nd ventricles of the 1. If obstruction is present
brain then passes through the aqueduct of sylvius ✔ Excessive fluid accumulates and dilates the
and the 4th ventricle to empty into the subarachnoid system above the point of obstruction
space of spinal cord where it is absorbed. 2. If atresia is in the aqueduct of sylvius
 Infant: cranial nerves are not yet firmly knitted --- the ✔ The 1st, 2nd and 3rd ventricles will dilate
excess fluid causes enlargement of the skull 3. If it is at the exit from the 4th ventricle
✔ All ventricles will dilate
4. If hydrocephalus is present prenatally
✔ Can be detected on a prenatal sonogram
❖ Infants fontanelles widen, appear tense
❖ Suture lines separate
❖ Head diameter enlarges
❖ as fluid accumulates: scalp becomes shiny
and scalp veins becomes prominent
❖ Brow bulges forward (bossing)
❖ Sunset eyes (sclera shows above the iris
because the upper lid retracts
CLASSIFICATION
1. communicating hydrocephalus or extra ventricular
hydrocephalus – If fluid reaches the spinal cord
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MCN – FINALS REVIEWER
❖ Increased intracranial pressure (decreased  Destruction of a portion of the choroid plexus
pulse and RR, increased temperature and ✔ Ventricular endoscopy
BP)  If tumor is the cause of overproduction of fluid
❖ hyperactive reflexes ✔ Remove tumor
❖ Strabismus
❖ Optic atrophy  If caused by obstruction:
❖ Failure to thrive, lethargic, irritable ✔ Laser surgery to reopen the route of flow or
❖ High pitched cry bypassing the point of obstruction by shunting
*** all children under 2 years old should have their head the fluid to another point of absorption
circumference be recorded and plotted ✔ Shunting procedure- threading a thin
***measure the head circumference of all infants within polyethylene catheter under the skin from the
an hour after birth and before discharge ventricles to the peritoneum
**note for any asymmetry - could suggest obstruction ***after insertion: bed is flat or raised only
***a skull that is enlarging anteriorly with a shallow about 30 degrees
posterior fossa suggest an obstruction in the aqueduct *** if raised excessively- CSF may flow too
or 3rd ventricle rapidly and decompression can occur too rapidly
leading to the possible tearing of cerebral
arteries
 A one-way valve is inserted in the shunt that opens
when CSF has accumulated to the extent that
pressure has increased.
 It closes when enough fluid has drained to reduce
the pressure.
 Infants lie on the unaffected side to prevent pressure
on the valve

 Infant’s motor function becomes impaired as the


head enlarges – because of both neurologic
impairment and atrophy caused by the inability to
move such as heavy head
 Children’s intelligence remains normal even those
with extremely large head but fine motor is affected

DIAGNOSIS
1. UTZ
2. Computed tomography
3. MRI
4. Skull x-ray - reveal separating of sutures and thinning
of the skull
5. Transillumination/chun gun – reveal that the skull is
filled with fluid rather than solid brain
***if non-communicating hydrocephalus – dye
inserted into a ventricle through the anterior
fontanelle will not appear in CSF obtained from a
lumbar puncture

THERAPEUTIC MANAGEMENT
 If caused by overproduction of fluid:
✔ Acetazolamide (diamox) – diuretic, to promote
the excretion of the excess fluid
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MCN – FINALS REVIEWER
 Note how the child sucks
 Observe for constipation – could cause increased
intracranial pressure
 Urge parentsto increase fluids and high roughage
diet

CEREBRAL PALSY
WHAT IS CEREBRAL PALSY?
● Cerebral palsy is a disorder of movement, muscle
tone or posture that is caused by damage that
occurs to the immature, developing brain, most
often before birth.
● Signs and symptoms appear during infancy or
preschool years.

SIGNS & SYMPTOMS


Signs and symptoms can vary greatly. Movement and
coordination problems associated with cerebral palsy
may include:
 Variations in muscle tone, such as being either
too stiff or too floppy
 Stiff muscles and exaggerated reflexes
 (spasticity)
 Stiff muscles with normal reflexes (rigidity)
 Lack of muscle coordination (ataxia)
 Tremors or involuntary movements
 Slow, writhing movements (athetosis)
POST OP MGT
 Delays in reaching motor skills milestones, such
 Assess signs of increased intracranial pressure (tense as pushing up on arms, sitting up alone or
fontanelle, increasing head circumference, crawling
irritability, lethargy, decreased lochia, poor sucking
 Favoring one side of the body, such as reaching
ability, vomiting and increase BP, increasing temp,
with only one hand or dragging a leg while
decreasing pulse and respiration
crawling
 Assess for symptoms of infection (increased temp,
 Difficulty walking, such as walking on toes, a
increased pulse rate, general malaise)
crouched gait, a scissors-like gait with knees
 Assess for symptoms of meningitis (stiff neck crossing, a wide gait or an asymmetrical gait
 and marked irritability)  Excessive drooling or problems with swallowing
 Assess if the child receives adequate pain mgt  Difficulty with sucking or eating
***crying elevated CSF pressure
 Delays in speech development or difficulty
 NPO until bowel sounds returned speaking
 Introduce fluid gradually in small quantities after  Difficulty with precise motions, such as picking
removal of the tube (NGT) up a crayon or spoon
 Held when being fed  Seizures
 support head when moving them to avoid strain on - The disability associated with cerebral palsy
the neck from their heavy head may be limited primarily to one side of the
 Hold their head with whole palm not just the body, or it may affect the whole body.
 fingertips However, muscle shortening and muscle
 Urge parents to use rocking chair with an armrest to rigidity may worsen if not treated
provide support for their arm while feeding the child. aggressively.

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MCN – FINALS REVIEWER
- Brain abnormalities associated with cerebral o Infant infections that cause inflammation in or
palsy also may contribute to other around the brain
neurological problems. People with cerebral o Traumatic head injury to an infantfrom a
palsy may have: motor vehicle accident or fall
 Difficulty with vision and hearing o Lack of oxygen to the brain (asphyxia) related to
 Intellectual disabilities difficult labor or delivery, although birth-related
 Seizures asphyxia is much less commonly a cause than
 Abnormal touch or pain perceptions historically thought
 Oral diseases
 Mental health (psychiatric) conditions RISK FACTORS
 Urinary incontinence MATERNAL HEALTH
 Certain infections or health problems during
SOME AGE-SPECIFIC SIGNS MAY INCLUDE: pregnancy can significantly increase cerebral palsy
INFANTS YOUNGER THAN 6 MONTHS OF AGE: risk to the baby. Infections of particular concern
 Cannot hold up their head when picked up from include:
lying on their back ✔ German measles (rubella). Rubella is a viral
 Stiff or floppy infection that can cause serious birth defects. It
 When picked up, their legs get stiff or cross can be prevented with a vaccine.
 When held, they may overextend their back and ✔ Cytomegalovirus. Cytomegalovirus is a common
neck, constantly acting as though they are virus that causes flu-like symptoms and may lead
pushing away from you to birth defects if a mother experiences her first
active infection during pregnancy.
INFANTS OLDER THAN 6 MONTHS OF AGE: ✔ Herpes. Herpes infection can be passed from
 Cannot roll over mother to child during pregnancy, affecting the
 Cannot bring their hands to their mouth womb and placenta. Inflammation triggered by
 Have a hard time bringing their hands together infection may then damage the unborn baby's
developing nervous system.
 Reach out with only one hand while holding the
✔ Toxoplasmosis. Toxoplasmosis is an infection
other in a fist
caused by a parasite found in contaminated
food, soil and the feces of infected cats.
INFANTS OLDER THAN 10 MONTHS OF AGE:
✔ Syphilis. Syphilis is a sexually transmitted
 Crawl in a lopsided way, pushing with one hand
and leg while dragging the opposite hand and leg bacterial infection.
✔ Exposure to toxins. Exposure to toxins, such as
 Scoot around on their buttocks or hop on their
methyl mercury, can increase the risk of birth
knees but do not crawl on all fours
defects.
 Cannot stand even when holding onto support
✔ Zika virus infection. Infants for whom maternal
Zika infection causes microcephaly can develop
CAUSES
cerebral palsy.
 Cerebral palsy is caused by an abnormality or
disruption in brain development, usually before a ✔ Other conditions. Other conditions may increase
the risk of cerebral palsy, such as thyroid
child is born. In many cases, the exact trigger isn't
known. Factors that may lead to problems with brain problems, intellectual disabilities or seizures.
development include:
INFANT ILLNESS
o Mutations in genes that lead to abnormal brain
development  Illnesses in a newborn baby that can greatly increase
o Maternal infections that affect the developing the risk of cerebral palsy include:
fetus ✔ Bacterial meningitis. This bacterial infection
o Fetal stroke, a disruption of blood supply to the causes inflammation in the membranes
developing brain surrounding the brain and spinal cord.

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MCN – FINALS REVIEWER
✔ ✓ Viral encephalitis. This viral infection similarly Dyskinetic Cerebral Palsy
causes inflammation in the membranes  Have trouble controlling their body movements.
surrounding the brain and spinal cord. The condition causes involuntary, unusual
✔ Severe or untreated jaundice. Jaundice appears movements in the arms, legs, and hands. It also
as a yellowing of the skin. The condition occurs affects the face and tongue. It is difficult for the
when certain byproducts of "used" blood cells affected person to sit, walk, swallow, or talk.
aren't filtered from the bloodstream. Ataxic Cerebral Palsy
 It is characterized by voluntary muscle
OTHER FACTORS OF PREGNANCY AND BIRTH movements that often appear disorganized,
 While the potential contribution from each is clumsy, or jerky. They may have difficulty
limited, additional pregnancy or birth factors walking and performing fine motor functions,
associated with increased cerebral palsy risk include: such as grasping objects and writing.
✔ Breech births. Babies with cerebral palsy are Hypotonic Cerebral Palsy
more likely to be in a feet-first position (breech  Causes diminished muscle tone and overly
presentation) at the beginning of labor rather relaxed muscles. The arms and legs move very
than headfirst. easily and appear floppy, like those of a rag doll.
✔ Complicated labor and delivery. Babies who As they grow older, they may struggle to sit up
exhibit vascular or respiratory problems during straight as a result of their weakened muscles.
labor and delivery may have existing brain
damage or abnormalities. MANAGEMENT
✔ Low birth weight. Babies who weigh less than 1. Assistive aids include:
5.5 pounds (2.5 kilograms) are at higher risk of  Eyeglasses
developing cerebral palsy. This risk increases as  Hearing aids
birth weight drops.  Walking aids
✔ Multiple babies. Cerebral palsy risk increases  Body braces
with the number of babies sharing the uterus. If  Wheelchairs
one or more of the babies die, the chance that 2. Medications
the survivors may have cerebral palsy increases.  Muscle relaxants are commonly used to treat the
✔ Premature birth. A normal pregnancy lasts 40 symptoms of spasticity. Relaxing the muscles
weeks. Babies born fewer than 37 weeks into the helps reduce pain from muscle spasms.
pregnancy are at higher risk of cerebral palsy.  Your doctor might prescribe:
The earlier a baby is born, the greater the 1. baclofen
cerebral palsy risk. 2. dantrolene (Dantrium)
✔ Rh blood type incompatibility between mother 3. diazepam (Valium)
and child. If a mother's Rh blood type doesn't 4. tizanidine (Zanaflex)
match her baby's, her immune system may not
tolerate the developing baby's blood type and OTHER TREATMENT
her body may begin to produce antibodies to ● speech therapy
attack and kill her baby's blood cells, which can ● occupational therapy
cause brain damage. ● physical therapy
● recreational therapy
TYPES OF CEREBRAL PALSY ● Counseling or psychotherapy
Spastic Cerebral Palsy ● social services consultations
 It causes weak or stiff muscles and exaggerated
reflexes, making it difficult to walk. SURGERY
Abnormalities include unintentionally crossing  Orthopedic surgery may be used to relieve pain and
their knees or making scissor-like movements improve mobility. It may also be needed to release
with their legs. tight muscles or correct bone irregularities caused by
spasticity.

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MCN – FINALS REVIEWER
✔ Make sure you're vaccinated. Vaccination
COMPLICATIONS against diseases such as rubella may prevent an
 Muscle weakness, muscle spasticity and infection that could cause fetal brain damage.
coordination problems can contribute to a number ✔ Take care of yourself. The healthier you are
of complications either during childhood or later heading into a pregnancy, the less likely you'll be
during adulthood, including: to develop an infection that may result in
o Contracture. Contracture is muscle tissue cerebral palsy.
shortening due to severe muscle tightening ✔ Seek early and continuous prenatal care.
(spasticity). Contracture can inhibit bone Regular visits to your doctor during your
growth, cause bones to bend, and result in joint pregnancy are a good way to reduce health risks
deformities, dislocation or partial dislocation. to you and your unborn baby. Seeing your doctor
✔ Malnutrition. Swallowing or feeding regularly can help prevent premature birth, low
problems can make it difficult for someone birth weight and infections.
who has cerebral palsy, particularly an ✔ Practice good child safety. Prevent head injuries
infant, to get enough nutrition. by providing your child with a car seat, bicycle
This may cause impaired growth and weaker helmet, safety rails on beds and appropriate
bones. Some children may need a feeding supervision.
tube for adequate nutrition.
✔ Mental health conditions. People with ADHD
cerebral palsy may have mental health (ATTENTION DEFICIT HYPERACTIVITY DISORDER)
(psychiatric) conditions, such as depression. What is ADHD?
Social isolation and the challenges of coping  A chronic condition that affects millions of children
with disabilities can contribute to and often continues into adulthood. Marked by an
depression. ongoing pattern of inattention and/or hyperactivity-
✔ Lung disease. People with cerebral palsy impulsivity that interferes with functioning or
may develop lung disease and breathing development.
disorders.
✔ Neurological conditions. People with PREVALENCE
cerebral palsy may be more likely to develop  3 to 5 percent of the population aged 0 to 14 years
movement disorders or worsened in the Philippines.
neurological symptoms over time.  388,000 children aged 2-5 years.
✔ Osteoarthritis. Pressure on joints or o million children aged 6-11 years. 3.3 million children
abnormal alignment of joints from muscle aged 12-17 years.
spasticity may lead to the early onset of  5.4 million children (8.4 percent) have a current
painful degenerative bone disease diagnosis of ADHD.
(osteoarthritis).
✔ Osteopenia. Fractures due to low bone TYPES OF ADHD
density (osteopenia) can stem from several
common factors such as lack of mobility, INATTENTIVE
nutritional shortcomings and antiepileptic  Falls to give close attention to detail or makes are
drug use. mistake
✔ Eye muscle imbalance. This can affect visual  Has difficulty sustaining attention
fixation and tracking; an eye specialist  Does not appear to listen
should evaluate suspected imbalances.  Struggles to follow instructions
 Has difficulty with organization
PREVENTION
 Avoid or dislikes tasks requiring sustained mental
 Most cases of cerebral palsy can't be prevented, but effort
you can lessen risks. If you're pregnant or planning to
 Loses things
become pregnant, you can take these steps to keep
 Is easily distracted
healthy and minimize pregnancy complications:
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MCN – FINALS REVIEWER
 Is forgetful in daily activities  Trouble coping with stress

HYPERACTIVE-IMPULSIVE COMPLICATIONS
 Fidgets with hands or feet or squirms in chair  Often struggle in the classroom, which can lead to
 Has difficulty remaining seated academic failure and judgment by other children and
 Runs about or climbs excessively; extreme adults
restlessness in adults  Tend to have more accidents and injuries of all kinds
 Difficulty engaging in activities quietly than do children who don't have ADHD
 Acts as if driven by a motor; adults will often feel  Tend to have poor self-esteem
inside as if they are driven by a motor  Are more likely to have trouble interacting with and
 Talk excessively being accepted by peers and adults
 Blurts out answers  Are at increased risk of alcohol and drug abuse and
behavior
COMBINED
 Meet the tea for both inattention and hyperactive- COEXISTING CONDITIONS
impulsive presentations  Characterized by imitability and problems tolerating
frustration = Disruptive red dyer disorder
CAUSE  Generally defined as a pattern of negative, defiant
 Genetics and hostile behavior toward authority figures =
 Environment Oppositional defiant disorder (ODD)
 Significant head injuries  Marked by antisocial behavior such as stealing,
 Problems with the central nervous system at key fighting destroying property, and harming people or
moments in development. animals = Conduct disorder

RISK FACTORS COEXISTING CONDITIONS


 Gender  Including drugs, alcohol and smoking = Substance
 Hereditary use disorders
 Age  Including problems with reading writing,
Maternal factors, such as: understanding and communicating = Learning
 Smoking during pregnancy disabilities
 Preterm labor  Which may cause overwhelming worry and
 Mental health conditions nervousness, and include obsessive compulsive
 Exposure to certain environmental toxins, disorder (OCD) = Anxiety Disorder
 High blood pressure
COEXISTING CONDITIONS
 Prematurity
 Autism disorder, a condition related to brain
SIGNS & SYMPTOMS development that impacts how a person perceives
Clinical Manifestations and socializes with others = Substance use disorders
 Impulsiveness  Including depression and bipolar disorder, which
includes depression as well manic behavior = Mood
 Disorganization and problem prioritizing
disorders
 Poor time management
 Disorders that involve repetitive movements or
 Problems focusing on a task
unwanted sounds (tics) that can't be easily
 Troubles multitasking
controlled = Tic disorder or Tourette syndrome
 Excessive activity or restlessness
Clinical Manifestations
ASSESSMENT
 Poor planning
 Soft neurologic signs
 Low frustration tolerance
 Mirroring
 Frequent mood swings
 Evidence of cerebellar difficulty
 Problems following through and completing tasks
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MCN – FINALS REVIEWER
 Abnormal responses to graphesthesia (ability to today?" is less effective than such as "Here is
recognize a shape that has been traced on the skin) your blue shirt to wear today"
 Abnormal stereognosis (ability to recognize an o Urge parents to make sure their child recognizes
object by touch) their anger is at the behavior not the child
 Choreiform movements (aimless movements) 1. ENVIRONMENTAL Q MODIFICATION
 Unilateral Babinski Reflex  Construction of a stable learning environment is
crucial for children with ADHD so instruction can
ASSESSMENT be free from the distractions of an entire class
 Assessments to tell a child has ADHD is by EDUCATIONAL MODIFICATION
o Observing interactions with peers in classroom  preferential seating
o Work setting  extended time for test taking
o During formal testing interviewing parents about  a written list of due dates and
speech and language develop assignments
 Interviewing parents about speech and language  note-taking support
develop: 2. FAMILY SUPPORT
o Does a child stutter?  Ask parents they are having difficulty managing
o Good Pronunciation? the challenge of raising a child with ADHD
o Evaluating the ability to explain or re-tell story  Help them understand the behavior is the best
o Assessing social communication skills their child can achieve.
 Organizations such as Children and Adults with
DIAGNOSIS A- Deficit/Hyperactivity Disorder (CHADO
 IQ testing – used to document intelligence Attention Deficit Disorder Association (ADDA),
 The Wechsler Intelligence Scale for Children (WISC) – and the Attention Deficit information Network
the test most often chosen consists of two portions: (AD-IN may have local, community chapters and
a verbal scale and a performance scale. may also be available online
 A child is given three final scores: verbal IQ,  Inform them that some children and teens with
performance IQ, and a combination or full-scale IQ. ADHD continue to experience problems with
 Children with ADHD shows a “scatter” pattern on impulsivity and in a mention into adulthood.
both performance and verbal portions doing well on They may need counseling to find a career that
some portions and poorly on others. fits with these behaviors
 Initial history 3. MEDICATION
 Physical assessment  Medication management is a proven treatment
 Completion of evidence-based rating scales for many individuals with ADHD, but not all
 For this reason, test results are more accurate if they children and teens with ADHD need to take
take IQ tests individually in rooms free of distractions medication. Those with milder forms may be
such as attractive toys for this same reason. successful with a structured environment and
firm, but fair types of discipline and reward.
THERAPEUTIC MANAGEMENT  Stimulants work by stimulating dopamine
 IT IS IMPORTANT TO: receptors so there is more regular nerve
o Encourage parents to be fair but fine and to set transmission, which results in increased
consistent limits to reduce arguments. attention span.
o Teach parents to give instructions slowly and to o Short-intermediate, and long-acting formula
make certain they have their child's attention o Methylphenidate transdermal (Daytrana) in
before giving instructions a patch form.
o Consequences need to be established and o Stimulant medications
discussed ahead of time and delivered o Amphetamines
immediately. If a child has duty making decisions Other medications that may be used for ACHD include:
because of easy distractibility, a question such as  Nonstimulant medications,
"Do you want to wear your red or your blue shit  Atomoxetine (Strattera),

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MCN – FINALS REVIEWER
 SNRIs, and centrally acting adrenergic
 Guanfacine (Intuniv, Tenex), and clonidine AUTISM
agents,  Complicated condition that includes problems with
 atomoxetine communication and behavior
 An involve a wide range of symptoms and skills
HOW TEACHERS AND PARENTS CAN HELP?  Diagnosed when the child is 2-3 years old
 Teachers can provide accommodations in the
classroom ASSESSMENT
o Preferential seating  Lack of eye contact
o Shorter assignments  Narrow range of interest
o Closer supervision and Clearer instructions  Hand flapping
o Help in getting started on assignments  Frequently walking on tiptoe
o Closer supervision of homework  Consistent fussiness or screaming in public places
o Frequent communication with parents/doctors  Repetitive head banging
o Allow time for movement  Excessive biting or aggressiveness
o Environment with fewer distractions during tests  Lack of response
 Not wanting to be cuddled
HOW TEACHERS AND PARENTS CAN HELP?
 Like repeating words/phrases
 Parents can help their child who has ADHD by doing
 Trouble adjusting to change in routine
the following:
 Not looking or listening to other people
o Take a disability perspective
 Highly sensitive to sounds, touch, smell and sight
o Use rewards and incentives more than
punishments  Decrease sensitivity to pain
o Work closely with the school
o Know what your child's responses are in school SIGNS OF AUTISM
o Provide close supervision for homework  Issues with communication. Child doesn't respond
o Help your child stay organized his/her name
o Monitor the child's performance and let doctors  Prefers to be alone
know  Trouble interpreting what others feel
o Find the things your child does well and  Repetitive movements or speech patterns
encourage them, Learn as much about ADHD as  Avoiding eye contact
you can  Sensitive to loud noises
o Maintain a good sense of humor  Eccentric way of moving

NURSING MANAGEMENT AUTISM EARLY SIGNS IN INFANT


 Accept the child or individual as what he is. Consider 1. Unusual visual fixations – unusually strong and
his condition and communicate with him as an equal. persistent examination of objects
 Approach the child at his current level of functioning. 2. Abnormal repetitive behaviors – spending unusually
Do not use baby nor direct him as to his long periods of time repeating an action, such as
chronological age; encourage him to express his looking at their hands or rolling an object
thoughts or emotions and respond to hire 3. Lack of age-appropriate sound development –
therapeutically. Delayed development of vowel sounds, such as
 Use simple and direct instructions. "mama, dada, tata"
 Implement scheduled routine every day. Make his 4. Delayed intentional communication – Neutral facial
routine predictable and something like ritualistic so tones and decreased efforts to gesture and gain
that it will only be easy for him to grasp for his parent attention
independent functioning. 5. Decreased interest in interaction – Greater interest
 Avoiding stimulating or distracting settings in object than people and difficult sustain face-to-
 Give positive reinforcements face interaction
 Encourage physical activity
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MCN – FINALS REVIEWER
DIAGNOSIS
 Developmental screening
✔ 9 months, 18 months, 24 months, 30 months of
age
✔ Common = 18 and 24 months
 Hearing and vision test/genetic test

TREATMENT/MGT
1. Behavioral and communication
a. Applied behavioral analysis
b. Occupational therapy
c. Sensory integration therapy
2. Medication

INTERVENTIONS
 Give advance notice before a transition is going to
occur.
 Use visual supports.
 Use structure and consistency.
 Use reduced language.
 Provide light praise for good transitions.
 Consistency.
 Have clear expectations. Set clear, attainable
expectations for your child and your family.
 Anticipate the next move.
 Never miss a chance to catch your child being good.
 Get measuring.
 Engage

POSITIVE BEHAVIOR SUPPORT


 Always be person-centered and promote autistic
people's dignity.
 Keep people safe, healthy and happy.
 Enable autistic people to do the things they love.
 Never try and make someone 'less autistic', which is
impossible anyway.
 Never use punishment.

49
QUIZ 1
1. Which of the following is the most important concept associated with the high-risk newborn?
• Support the high-risk newborn's cardiopulmonary adaptation by maintaining adequate airway

2. Which of the following nursing diagnoses would be given priority in then care of a newborn one hour of age?
• Ineffective thermoregulation

3. Which of the following manifestations in a six-month-old infant who was born prematurely would lead a nurse to
suspect that the infant has apnea?
• A lapse of spontaneous breathing for 20 seconds or more

4. After therapeutic interventions, a newborn demonstrates adequate lung expansion. The amount of pressure that would
enable her to continue to reinflate the alveoli of her lungs would be
• 15-20 cm H20

5. The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool,
the neonate requires
• more oxygen, and the newborn's metabolic rate increases

6. Heat regulation is the most critical factor for a newborn's survival next to establishing respiration. Which of the following
characteristics of newborns predispose them to poor heat regulation?
• Newborns cannot shiver yet

7. Andrea has no spontaneous respirations at birth. Suppose her amniotic fluid is heavily stained with meconium. Which
would be your best action?
• Begin chest massage to force out meconium

8. A nurse in the nursery is caring for a neonate. On assessment the infant is exhibiting grunting, tachypnea, nasal flaring
and grunting. Respiratory distress syndrome is diagnosed and the physician prescribes surfactant replacement therapy.
The nurse would prepare to administer this therapy by
• Instillation of the preparation into the lungs through an endotracheal tube

9. Hypothermia is common in newborn because of their inability to control heat. The following would be an appropriate
nursing intervention to prevent heat loss EXCEPT
• place the crib beside the wall

10. A nurse is assessing a newborn who was born at 32 weeks gestation. Which of the following would the nurse most
likely find? Select all that apply
• Ruddy skin
• high-pitched cry
• copious vernix caseosa

11. Therese has just given birth at 42 weeks' gestation. When the nurse assesses the neonate, which physical finding is
expected?
• Desquamation of the epidermis

12. The physical finding you would expect to be seen in ljezie because of prematurity is
• lack of sole creases on her feet
13. An insulin dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority care
is to
• check the baby's serum glucose level and administer glucose if <40mg/dl

14. Small for gestational age newborns are at risk for difficulty of maintaining body temperature due to
• they do not have as much fat stores as do other infants

15. Heat regulation is the most critical factor for a newborn's survival next to establishing respiration. Which of the
following characteristics of newborns predispose them to poor heat regulation?
• Newborns cannot shiver yet

QUIZ 2
1. You're caring for a 2-day-old infant with a large patent ductus arteriosus. The mother of the infant is anxious and asks
you to explain her child's condition to her again. Which statement below BEST describes this condition?
• The vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left-to-right
shunt of blood

2. While assessing a newborn's heart sounds you note a loud murmur at the left upper sternal border. You report this to
the physician who suspects the infant may have patent ductus arteriosus. The physician asks you to obtain a pulse
pressure. If patent ductus arteriosus is present, the pulse pressure would be
• wide

3. You're working on a unit that provides specialized cardiac care to the pediatric population. Which patient below would
be the best candidate for Indomethacin from the treatment of patent ductus arteriosus?
• A premature infant

4. The family is caring for their youngest child Justin who is suffering from Tetralogy of Fallot. Which of the following are
defects associated with this congenital heart condition?
• Ventricular septal defect, overriding aorta, pulmonic stenosis and right ventricular hypertrophy

5. In a normal heart without any type of congenital heart defect, the pulmonary vein carries oxygenated blood away from
the lungs to the left side of the heart.
• True

6. A two-month-old is showing signs and symptoms of heart failure. An echocardiogram is ordered. The test shows the
infant has a ventricular septal defect (VSD). Which statement below best describes the blood flow in the heart due to this
congenital heart defect?
• “The blood in the heart is shunting from the left ventricle to the right ventricle, which is increasing pulmonary
blood flow.”

7. An echocardiogram shows that your patient has an atrial septal defect located at the bottom of the septum near the
tricuspid and mitral valves. As the nurse you know this is what type of atrial septa defect (ASD)?
• Ostium Primum

8. You're caring for a 2-year-old patient who has a large atrial septal defect that needs repair. This defect is causing
complications. These complications are arising from an abnormal shunting of blood throughout the heart. As the nurse,
you know that ___________ shunt is occurring in the heart due to the defect.
• left to right
9. Martial septal defects can lead to a decrease in lung blood flow.
• False

10. A nurse in the nursery is monitoring a preterm infant for respiratory distress syndrome. Which assessment signs if
noted in the newborn would alert the nurse to the possibility of this syndrome
• Acrocyanosis and grunting

11. A nurse in the nursery is caring for a neonate. On assessment the infant is exhibiting grunting, tachypnea, nasal flaring
and grunting. Respiratory distress syndrome is diagnosed and the physician prescribes surfactant replacement therapy.
The nurse would prepare to administer this therapy by
• Instillation of the preparation into the lungs through an endotracheal tube

12. MAS can be prevented by


• Suctioning mouth, nose and posterior pharynx just after the head is delivered.

13. Baby Nicks has surfactant administered at birth. The purpose of surfactant is to
• Prevent alveoli from collapsing on expiration

14. When developing the initial plan of care for a neonate who was born at 41 weeks' gestation, was diagnosed with
meconium aspiration syndrome (MAS), and requires mechanical ventilation, which of the following should the nurse
include
• Care of an umbilical arterial line

15. The Gi system plays a major role in maintaining fluid, electrolyte, and acid-base balance. The Gl system often is involved
with two severe acid-base imbalances which is
• metabolic acidosis and metabolic alkalosis

16. Hypotonic Dehydration occurs when there is a disproportionately high loss of electrolytes relative to fluid lost. The
plasma concentration of sodium and chloride will be low. This could result from all of the following except?
• excessive intake of salt associated with great gain through intake

17. Fluid shifts from the blood stream to interstitial and intracellular spaces (from areas of great
osmotic pressure to areas of lesser pressure)
• False

18. Overhydration is serious as dehydration because the ECF overload can lead to cardiovascular overload and cardiac
failure. All of the following are true about overhydration except
• The excess fluid in these instances is usually intravascular and interstitial.

19. Metabolic acidosis may result from diarrhea. When diarrhea occurs, a great deal of sodium is lost with stool. This
excessive loss of Na, in turn, causes the body to conserve ions in an attempt to keep the total number of positive and
negative ions in serum balanced. As a result, all of the following will occur except
• arterial blood gas analysis will reveal an increased pH

20. The level of bicarbonate (HCO3) in arterial blood is normally


• 22 to 26 mEg/L.
21. When diarrhea occurs, or when a child becomes diaphoretic because of fever, the fluid output can be markedly
decreased
• False

22. In Hypertonic Dehydration water is lost in a greater proportion than electrolytes and it occurs when fluid intake
decreases in conjunction with a fluid loss increase. It occurs in a child with: Select all that apply
• nausea (preventing fluid intake)
• fever (increased fluid loss through perspiration)
• profuse diarrhea - where there is a greater loss of fluid than salt
• renal disease - associated with polyuria such as nephrosis with diuresis.

23. Infants do not concentrate urine as well as adults because their kidneys are immature.
• True

24. All of the following are included in the Assessment in Metabolic alkalosis. Select all the apply.
• The child will breathe slowly and shallowly
• pH will be elevated (near or above 7.45)
• HCO3 level will be near or above 28 mEg/L.

25. Isotonic Dehydration is when a child's body loses more water than it absorbs (as with diarrhea) or absorbs less fluid
than it excretes (as with nausea and vomiting). As a result, all of the following will occur. Select all that apply
• there will be a decrease in the volume of blood plasma.
• the body compensates for this rapidly by shifting interstitial fluid into the blood vessels.

26. Hypotonic Dehydration occurs when there is a disproportionately high loss of electrolytes relative to fluid lost. The
plasma concentration of sodium and chloride will be low. This could result from all of the following except?
• excessive intake of salt associated with great gain through intake

27. Select all the correct options that represent the pathophysiology of an asthma attack
• The mucosa lining experiences severe inflammation
• The goblet cells within the mucosa lining produce excessive amounts of mucous.

28. Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply
• Coarse crackles
• Oxygen saturation less than 90%
• Elevated white blood cells
• Tachypnea

29. What is the interpretation of the ABG if the pH =7.60; PaCO2 = 33’ HCO3 = 16?
• respiratory acidosis partially compensated

30. Interpret the ABG's. pH = 7.36; PaCO2 = 55; HCO3 = 28


• respiratory acidosis fully compensated

QUIZ 3
1. Which of the following interventions must be included in the plan of care of a child with mumps?
• apply an ice pack over the parotid glands encourage the client to drink plenty of fluids
• give tamarind for the client not to be sleepy
2. A child is diagnosed with Wilm's tumor. In planning teaching interventions, what key points should the nurse emphasize
for the parents?
• Do not put pressure on the abdomen"

3. A child with leukemia is being discharged after beginning chemotherapy. What instructions will the nurse include in the
teaching plan for the parents of this child?
• Avoid fresh vegetables that are not cooked

4. While working in a pediatric clinic, you receive a telephone call from a parent of a 10-year-old who is receiving
chemotherapy for leukemia. The client's sibling has chicken pox. Which of these actions will you anticipate taking next?
• Prepare the client for admission to a private room in the hospital

5. Parents are often unaware that their child is developing leukemia. What are the first signs commonly seen in a child
with acute lymphocytic leukemia (ALL)?
• Fatigue and bruising

6. When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most important to avoid which of
the following?
• palpating the child's abdomen

7. A child is diagnosed with Wilm's tumor. During assessment, the nurse in charge expects to find
• an abdominal mass

8. A 5-year-old is admitted to the hospital with complaints of leg pain and fever. On physical examination, the child is pale
and has bruising over various areas of the body. The physician suspects that the child has ALL. The nurse informs the
parent that the diagnosis will be confirmed by which of the following?
• Bone marrow aspirate

9. Causative agent of mumps


• myxovirus

10. What is the incubation period of mumps?


• 14-21 days

11. What is the drug of choice for treatment of mumps?


• no specific treatment available

12. Which age group is mostly affected with mumps?


• 5 to 15 years

13. Which gender is mostly affected with mumps?


• equal involvement of male and female

14. Period of communicability of mumps


• 7 days to after 9 days of symptoms

15. The following are signs and symptoms of pneumonia, select all that apply
• fever
• fast breathing
• widening of the nostrils
• crackles

16. It measures oxygen saturation, answers in small letters


• pulse oximetry

17. A drug that is used to neutralize the effects of chemo drugs, answer in small letters
• leucovorin

18. A drug that is used to reduce the formation of uric acid, answer in small letters
• allopurinol

19. David, age 15 months is recovering from surgery to remove Wilm's tumor. Which findings best indicates that the child
is free from pain?
• Increased interest in play

20. Which of the following symptoms would a student nurse observes if the diagnosis of the child is ALL?
• bruises, fatigue, joint pain

21. The cause of leukemia is unknown but the risk factors are the following, select all that apply
• exposure to high amount of radiation
• exposure to chemicals like benzene
• genetic problem like down syndrome
• defect of proximal tubule leading to malabsorption f electrolytes

22. The following statement are TRUE about acute lymphocytic leukemia. Select all that apply
• common among children ages 2 and 6 years of age
• involves immature lymphocytes
• uses methotrexate

23. Undescended testes is termed as. answer in small letters


• cryptorchidism

24. What is the major characteristic of pneumonia


• inflammation in the air spaces of the lungs

25. Mode of administration of methotrexate on the spinal cord


• intrathecal injection

QUIZ 4
1. What are some symptoms of cerebral palsy?
• all of the above

2. What causes cerebral palsy? select all that apply


• brain damage that happened before, during or immediately after birth
• an infection such as meningitis
• head injury
• jaundice

3. One of the goals of hydrocephalus is directed toward the relief of ventricular pressure. Which of the following is an
inappropriate nursing intervention for an infant after placement of ventriculoperitoneal shubt?
• positioning the infant carefully on the affected side

4. Your patient undergone pacement of a chunt for hydrocephalus. Wow ull you position the child after the operation?
• place in flat position and lying on the unoprated side

5. When asked by a mother of a child with cerebral palsy in what is the most common cause of this condition, which of
the following is your BEST reply?
• it results from premature birth or very low birth weight

6. Cerebral palsy may result from a variety of causes. It is known that the most common cause of CP is
• prenatal brain abnormalities

7. What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal
fluid? (answer in small letters)
• hydrocephalus

8. A parent tells a nurse "My three-month-old infant has passed several stools that resembled clumpy red jelly". The nurse
should suspect that the infant has developed
• intussusception

9. Andrew's father reports that his son was constipated until this morning Hirschsprung's disease can be a cause of
constipation in infants. This is
• lack of nerve endings in the sigmoid colon.

10. Situation: Cathy, 3 months old had cleft lip on the left side of the mouth. She is scheduled for surgical correction of the
defect. All of the following nursing interventions are included in the care plan for Cathy who has just undergone cleft lip
repair. Which of the following actions by the mother should NOT be allowed by the nurse?
• Position the infant in prone position.

11. Which of the following is a priority nursing intervention for the infant with cleft lip?
• Monitoring for adequate nutritional intake

12. The following are risk factors for type 2 diabetes, SATA
• diet
• weight
• PCOS
• age
• preterm birth

13. A nurse is preparing to care for a child with a diagnosis of intussusceptions. The nurse reviews t child's record and
expects to note which symptom of this disorder documented?
• Bright red blood and mucus in the stools

14. The following are signs and symptoms of intussusceptions EXCEPT


• Slow RR
15. A child is diagnosed with Hirschsprung's disease. Mother asked the nurse about the cause of the disease. The nurse
tells the mother that Hirschsprung disease
• results from the absence of special cells in the rectum

16. Julius is scheduled for surgical repair of his cleft palate. A priority in the post-op plan of care for Julius would include
teaching the mother
• to use cup or wide bowl spoon for feeding

17. For a child with a diagnosis of Hirschsprung's disease, you expect the child's stool to be
• ribbon like

18. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and
watery explosive diarrhea?
• Notify the physician immediately

19. Baby RR is a 4-month-old infant with a tentative diagnosis of intussusceptions. Which procedure will likely be ordered
for the infant?
• barium enema

20. A child is diagnosed with intussusceptions. The nurse performs an assessment on a child knowing that which of the
following is a characteristic of this disorder?
• Invagination of a section of the intestine into the distal bowel.

21. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be
compromised?
• Sucking ability

22. Mr. and Ms. Villanueva's child failed to pass meconium within the first 24 hours after birth, this
may indicate which of the following?
• Hirschsprung’s disease

23. Which assessment finding would be most likely found on an infant diagnosed with Hirschsprung disease?
• Weight less than normal for height and age

24. Which of the following interventions should NOT be included in the care plan for a three-month-old infant who has
just undergone cleft palate repair?
• Place the infant in supine position

25. The nurse is caring for an infant following a cleft lip repair. What are the postoperative
intervention to be observe. Select all that apply
• maintain patent airway
• cleanse the suture line
• prevent the child from crying
• place the infant in supine position
MIDTERMS QUIZZES (NCM 109)

QUIZ ON POWER, passage and psyche

1. The client’s past history reveals that a condition preventing the fetus to pass through the maternal pelvis is (1 point)
interpreted by the nurse as
⚪ contracted pelvis
⚪ cervical insufficiency
⚪ maternal disproportion
⚫ cephalopelvic disproportion

2. Therapeutic management for pathologic retraction ring/ Bandl’s ring include the following. Select all that (1 point)
apply
⬛ Administration of IV morphine sulfate or inhalation of amyl nitrite to relieve retraction ring.
⬛ Tocolytic agent to stop/halt contraction
⬜ Vaginal delivery
⬛ Manual removal of the placenta under general anesthesia if the retraction ring does not allow the placenta to
be delivered.

3. In incomplete uterine rupture the signs of rupture are less evident which include the following except (1 point)
⚪ experience only a localized tenderness and a persistent aching pain over the area of the lower uterine segment
⚪ fetal and maternal distress
⚪ lack of contractions
⚫ swellings will be visible on the woman’s abdomen
4. Which of the following is not a part in the nursing care management for inversion of the uterus? (1 point)
⚫ Replace an inversion because handling of the uterus may not increase the bleeding.
⚪ Never attempt to remove the placenta if it is still attached because this only creates a larger surface area for
bleeding.
⚪ Administer oxytocin after manual replacement helps the uterus to contract and to remain in its natural place
⚪ Antibiotic therapy because the woman’s endometrium is exposed, preventing infection

5. A nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed (1 point)
cord. The mother becomes anxious and frightened and says to the nurse, “Why are all of these people in
here? Is my baby going to be alright?” Which of the following nursing diagnoses would be most
appropriate for this client at this time?
⚫ fear
⚪ fatigue
⚪ powerlessness
⚪ ineffective coping

6. Pathologic retraction ring/ Bandl’s ring is a common type of contraction ring that occurs in early labor (1 point)
usually caused by uncoordinated contractions. Further, Bandl’s ring is characterized by the following. Select
all that apply
⬜ Appears usually at the 3rd stage of labor
⬛ Can be palpated as a horizontal indentation across the abdomen
⬛ Formed by excessive retraction of the upper uterine segment, the uterine myometrium is much thicker above
than below the ring.
⬛ In the pelvic division of labor it is caused by obstetric manipulation or by administration of oxytocin
⬛ Fetus and placenta are gripped and cannot advance
⬜ Identified by Leopold’s maneuver

7. Maternal complications of precipitate labor include which of the following? (1 point)


⚪ Intracranial hemorrhage
⚪ Erb Duchenne palsy
⚪ Injuries as a falling to the floor in unattended birth
⚫ Postpartum hemorrhage

8. Inversion of the uterus occur if (1 point)


⚫ traction is applied to the umbilical cord to remove the placenta
⚪ pressure is not applied to the uterine fundus when the uterus is not contracted.
⚪ if the placenta is not attached at the fundus and during birth the fetus pulls the fundus down
⚪ in no degrees

9. When giving narcotic analgesics to mother in labor, the special consideration to follow is (1 point)
⚪ the progress of labor is well established reaching the transitional stage
⚪ uterine contraction is progressing well and delivery of the baby is imminent.
⚪ cervical dilatation has already reached at least 8 cm and the station is at least (+) 2.
⚫ uterine contractions are strong and the baby will not be delivered yet within the next 3 hour

10. Causes of prolonged labor include the following. Select all that apply (1 point)
⬜ Small fetus
⬛ Hypotonic uterine contractions
⬛ Hypertonic uterine contractions
⬛ Uncoordinated Contractions

11. Predisposing factors of precipitate labor include all of the following except (1 point)
⚪ multiparity
⚫ small pelvis
⚪ Lax unresisting maternal tissue
⚪ Induction of labor-amniotomy and oxytocin administration

12. If the labor period lasts only for 3 hours, the nurse should suspect that the following conditions may occur (1 point)
Select all that apply
⬛ fetal anoxia.
⬛ laceration of the cervix
⬛ laceration of perineum
⬛ cranial hematoma in the fetus

13. A nurse is monitoring the client who is in the active stage of labor. The client has been experiencing (1 point)
contractions that are short, irregular and weak. The nurse documents that the client is experiencing which
type of labor dystocia?
⚫ hypotonic
⚪ precipitous
⚪ hypertonic
⚪ uncoordinated

14. A primigravida, the nurse would suspect cephalopelvic disproportion when (1 point)
⚪ the woman complains of an urge to push at 7cm dilatation.
⚪ the fetus descends in active labor at a rate of 1 cm per hour.
⚪ an unopened cervix fails to dilate after 20 hours of contractions.
⚫ the cervix remains unchanged for three hours with regular contractions and prior cervical dilatation

15. Treatment of uterine prolapse comprise lifestyle changes which include all of the following except (1 point)
⚪ Weight loss is recommended in obese women with uterine prolapse.
⚪ Heavy lifting should be avoided, because they can worsen symptoms.
⚪ Avoid straining
⚫ Vaginal hysterectomy .

16. Late in the first stage of labor, Mrs Krisha receives a spinal block to relieve discomfort. A short time later, (1 point)
her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What
do the client’s symptoms suggest?
⚪ Anxiety
⚪ dehydration
⚫ Anesthesia overdose
⚪ transition to the second stage of labor

17. Nursing care management for preterm labor include all of the following except (1 point)
⚪ Assess the frequency, intensity and duration of contractions
⚪ Evaluate cervical dilatation and effacement
⚪ Determine the status of membranes and check for bloody show
⚫ Administer oxytocin medication as ordered

18. Complications of uterine prolapse include the following. Select all that apply (1 point)
⬛ Ulceration and infection of the cervix and vaginal walls
⬛ Urinary tract infections
⬛ Constipation
⬛ hemorrhoids

19. A client has a midpelvic contracture from a previous pelvic injury due to motor vehicle accident as a (1 point)
teenager. The nurse is aware that this could prevent a fetus from passing through or around which
structure during childbirth?
⚪ pubic arch
⚫ ischial spines
⚪ sacral promontry
⚪ symphysis pubis

20. Mr Directo is monitoring the fetal heart rate of a client who is in labor. He is correct if he will report to his (1 point)
clinical instructor that the fetal heart rate is said to be in distress if, select all that apply
⬜ the FHT is 160bpm, weak and irregular
⬜ The FHT is less than 120 bpm or over 160 bpm
⬛ the FHT decreased during a contraction and persists even after the uterine contraction ends
⬛ the pre-contraction FHR is 130 bpm, FHR during contractions is 118 bpm and FHR after uterine contraction is
126 bpm.

21. A nurse has developed a plan of care for a client experiencing dystocia and includes several nursing (1 point)
interventions in the plan of care. Which of the following interventions will be included in the plan of care
to a client experiencing dystocia? Select all that apply
⬛ Providing comfort measures
⬛ Monitoring the fetal heart rate
⬛ changing the client’s position frequently
⬛ Keeping the significant other informed of the progress of labor

22. The following are causes of premature labor. Select all that apply (1 point)
⬛ Hydramnios
⬛ Placenta previa
⬛ Preeclampsia
⬛ Multiple gestation
⬛ Abruption placenta
⬛ Incompetent cervix

23. All of the following are predisposing factors of uterine rupture except (1 point)
⚫ Normal labor
⚪ Abnormal presentation
⚪ Multiple gestation
⚪ Obstructed labor

24. A woman you care for during labor is having contractions 2 minutes apart but rarely over 5ommHg in (1 point)
strength; the resting tone is high, 20-25 mmHg. She asks what she can do to make contractions more
effective. Your best response would be that
⚪ walking around will make her contractions more regular
⚫ she needs to rest because her contractions are hypertonic
⚪ her physician will order oxytocin to strengthen contractions.
⚪ hypotonic contractions of this kind will strengthen by themselves

25. Those who have prolonged labor are at risk of the following except (1 point)
⚪ Postpartal infection
⚪ Hemorrhage
⚪ Infant mortality
⚫ Brachial plexus palsy

26. Mrs. Maine Corpuz is in active labor. She is on oxytocin per IV infusion drip. Which of the following (1 point)
situations would require that the infusion be stopped?
⚪ Contractions occur every 3-5 minutes, last 50-60 seconds
⚪ the cervix is 8 cm dilated, contractions occur every 3-5 minutes
⚫ contractions occur at less than 2 minute interval or last for longer than 90 seconds
⚪ the cervix is 6 cm, partially effaced, duration of contractions is 50-60 seconds

27. Precipitate dilatation occurs with grand multiparity and after induction of labor by oxytocin or (1 point)
amniotomy. It is when
⚫ cervical dilatation is progressing at a rate of 5 cm or more per hour in nulliparas and 10 cm per hour in
multiparas
⚪ cervical dilatation is progressing at a rate of 3 cm or more per hour in nulliparas and 5 cm per hour in multiparas
⚪ when fetal descent is progressing at a rate of 5 cm per hour or more in nulliparas and 10 cm per hour or more in
multiparas.
⚪ when fetal descent is progressing at a rate of 3 cm per hour or more in nulliparas and 5 cm per hour or more in
multiparas.
28. Mc Robert’s maneuver may widen the pelvic outlet and help in letting the anterior shoulder be delivered. (1 point)
This maneuver is described as
⚪ a nurse will try to help by applying a fundal push.
⚫ asking the woman to flex her thighs sharply on her abdomen.
⚪ the physician or nurse midwife will apply pressure on the perineum.
⚪ the woman will pull on her thighs slowly as she gradually try to push.

29. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong (1 point)
enough to dilate the cervix. Which of the following would the nurse anticipate doing?
⚫ Obtaining an order to begin IV pitocin infusion
⚪ administer a light sedative to allow the patient to rest for several hour
⚪ preparing for a cesarean section for failure to progress
⚪ increasing the encouragement to the patient when pushing begins

30. Fetal complications of precipitate labor include which of the following? (1 point)
⚪ Laceration of birth canal and uterine rupture
⚫ Intracranial hemorrhage
⚪ Postpartum hemorrhage
⚪ Amniotic fluid embolism

Problems on Postpartum

1. The nurse caring for the PP woman understands that late postpartum hemorrhage is most likely caused by (1 point)
⚫ Subinvolution of the placental site
⚪ Defective vascularity of the decidua
⚪ Cerivical lacerations
⚪ Coagulation disorders

2. The nurse knows that a measure for preventing late postpartum hemorrhage is to (1 point)
⚪ Administer broad spectrum antibiotics
⚫ Inspect the placenta after delivery
⚪ Manualy remove the placenta
⚪ Pull on the umbilical cord to hasten the delivery of the placenta
3. A nurse is monitoring a new mother in the postpartum period for signs of hemorrhage .Which of the (1 point)
following signs, if noted in the mother, would be an early sign of excessive blood loss?
⚪ A temperature of 100F
⚪ An increase in the pulse rate from 88 to 102 bpm
⚫ An increase in the RR from 18-22 breaths/min
⚪ A BP change from 130/88 to 124/80 mmHg

4. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of (1 point)
the following would the nurse be alert?
⚪ Salpingitis
⚫ Endometritis
⚪ Endometriosis
⚪ Pelvic thrombophlebitis

5. To be considered a PPH, what would the estimated blood loss have to be for a C-section? (1 point)
⚪ < 550 ML
⚪ > 600 ML
⚫ > 1000 ML
⚪ <800

6. Which statement by a postpartal woman indicates that further teaching is not needed regarding thrombus (1 point)
formation?
⚪ I’ll stay in bed for the first 3 days after my baby is born.”
⚪ “I’ll keep my legs elevated with pillows
⚪ “I’ll sit in my rocking chair most of the time
⚫ “I’ll put my support stockings on every morning before rising.”

7. Which measure may preventmastitis in th breastfeeding mother? (1 point)


⚫ initiating early and frequent feedings
⚪ Nursing the infant for 5 minutes on each breast
⚪ Wearing a tight-fitting bra
⚪ Applying ice packs before feeding

8. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would (1 point)
the nurse Mica expect to administer if the client develops complications related to heparin therapy?
⚪ Calcium gluconate
⚫ Protamine sulfate
⚪ Methylegonovine (Methergine
⚪ Nitrofurantoin (macrodantin

9. Which measure would be least effective in preventing postpartum hemorrhage? (1 point)


⚪ Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered
⚪ Encourage the woman to void every 2 hours
⚫ Massage the fundus every hour for the first 24 hours following birth
⚪ Teach the woman the importance of rest and nutrition to enhance healing

10. If the nurse suspects a uterine infection in the postpartum client, she should assess the (1 point)
⚪ pulse and blood pressure
⚫ odor of the lochia
⚪ episiotomy site
⚪ abdomen for distention

11. The client who is being treated for endometritis is placed in fowler’s position because it (1 point)
⚪ Promotes comfort and rest
⚫ Facilitates drainage of lochia
⚪ Prevents spread of infection to the urinary tract
⚪ Decreases tension on the reproductive organs
12. Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? (1 point)
⚪ Cervical laceration
⚪ Clotting deficiency
⚪ Perineal laceration
⚫ Uterine subinvolution

13. A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000g (1 point)
infant. Her fundus is boggy, lochia is heavy and vital signs are unchmaged. The nurse has the woman void
and massages her fundus but her fundus remains difficult to find and the rubra lochia remains heavy. The
nurse should
⚪ Continue to masage the fundus
⚫ Notify the ohysician
⚪ Recheck vital signs
⚪ Insert foley catheter

14. Which option below is considered a positive Homan’s Sign for the assessment of a deep vein thrombosis (1 point)
(DVT)?
⚪ The patient reports pain when the foot is manually plantarflexed
⚫ The patient reports pain when the foot is manually dorsiflexed.
⚪ The patient experiences pain when the leg is extended
⚪ the patient experiences pain when the leg is flexed

15. The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is (1 point)
to
⚪ Call the woman's primary health care provider
⚪ Administer the standing order for an oxytocic
⚫ Palpate the uterus and massage it if it is boggy
⚪ Assess maternal blood pressure and pulse for signs of hypovolemic shock

16. Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated with blood within (1 point)
2 hours post partum, PR= 80 bpm, fundus soft and boundaries not well defined. The appropriate nursing
diagnosis is
⚪ normal blood loss
⚪ blood volume deficiency
⚫ hemorrhage secondary to uterine atony
⚪ inadequate tissue perfusion related to hemorrhage

17. Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period after a (1 point)
cesarean birth?
⚪ Roll a bath blanket and place it firmly behind the knees
⚪ Limit oral intake of fluids for the first 24 jours
⚫ Assits the client in performing leg exercises every 2 hours
⚪ Ambulate the client as soon as her vital signs are stable

18. One of the first symptoms of puerperal infection to assess for in the postpartum woman is (1 point)
⚪ Fatigue continuing for longer than 1 week
⚪ Pain with voiding
⚪ Profuse vaginal bleeding with ambulation
⚫ Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth

19. The most effective and least expensive treatment of puerprial infetion is prevention. What is important in (1 point)
this strategy?
⚪ Large doses of vitamin C durng pregnancy
⚪ Prophylactic antibotics
⚫ Strict aseptic technique inluding hanswashing, by all health care personnel
⚪ Lmited protein and fat intake

20. Celeste has a perineal hematoma. A common cause of this is (1 point)


⚪ a clotting defect from the interaction of epidural anesthesia
⚪ bruising of the perineum from a vertex presentation.
⚫ bleeding from the placing of perineal episiotomy sutures.
⚪ urine seeping into the perineum from the anterior bladder
21. Nurse Shiela asseses a client for evidence of postpartum hemorrhage during the third stage of labor. Early (1 point)
signs of this postpartum complication include
⚪ an increased pulse rate, decreased respiratory rate, and increased blood pressure
⚪ a decreased pulse rate, increased respiratory rate, and increased blood pressure
⚪ a decreased pulse rate, decreased respiratory rate, and increased blood pressure
⚫ an increased pulse rate, increased respiratory rate, and decreased blood pressure

22. The nurse should expect medical intervention for subinvolution to include (1 point)
⚫ Oral methyergonovine maleate for 48 hours
⚪ Oxytocin intravenous infusion for 8 hours
⚪ Oral fluids to 3000 ml/day
⚪ Intravenous fluid and blood replacement

23. The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by (1 point)
⚪ Washing the nipples and breasts with mild soap and water once a day
⚫ Using proper breastfeeding techniques
⚪ Wearing a nipple shield for the first few days of breastfeeding
⚪ Wearing a supportive bra 24 hours a day

24. Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? (1 point)
⚪ Hypertension
⚪ Cervical and vaginal tears
⚫ Urine retention
⚪ Endometritis

25. The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the (1 point)
woman is experiencing profuse bleeding. The most likely etiology for the bleeding is
⚫ Uterine atony
⚪ Uterine inversion
⚪ Vaginal hematoma
⚪ Vaginal laceration

26. Suppose Marites has a retained placental fragment that is causing extensive postpartal bleeding. What (1 point)
hormone test would you anticipate being ordered?
⚪ Systemic prolactin
⚪ Progesterone from the placenta
⚪ Placental and cord blood estrogen
⚫ Human chorionic gonadotropin hormone

27. Which temperature indicates the presence of postpartum infection? (1 point)


⚪ 99.6 F in the first 48 hours
⚪ 100F for 2 days postpartum
⚪ 100.4F in the first 24 hours
⚫ 100.8 F on the second and third postpartum days

28. A woman is one hour postpartum after vaginal delivery is experiencing heavy vaginal bleeding. Which of (1 point)
the following actions would a nurse take first?
⚪ Obtain vital signs
⚫ Massage the uterine fundus
⚪ Initiate a perineal pad count
⚪ Assess the location of the bladder

29. A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a (1 point)
⚪ 5 lb 2 oz infnat with outlet forceps
⚫ 6.6 lb infnat after a 2 hour labor
⚪ 7 lb infant after an 8 hour labor
⚪ 8 lb infnat after a 12 hour labor
30. A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse (1 point)
should explain that
⚪ the infant is protected from infection by immunoglobulins in the breast milk
⚪ the infant is not susceptible to the organisms that cause mastitis.
⚫ the organisms that cause mastitis are not passed to the milk
⚪ the organisms will be inactivated by gastric acid

Post-test on the problems of passenger

Analyze the statement carefully and tick the correct letter

1. Mc Robert's maneuver may widen the pelvic outlet and help in letting the anterior shoulder be (1 point)
delivered. This maneuver is described as
⚫ Asking the woman to flex her
thighs sharply on her
abdomen
⚪ The physician or nurse
midwife will apply pressure
on the perineum
⚪ The woman will pull in her
thighs slowly as she
gradually try to oush
⚪ A nurse will try to help by
applying fundal push

2. The student states the following reasons for breech presentation. She needs further instruction if (1 point)
she includes which of the following cause of breech presentation?
⚫ oligohydrannios allowing
free fetal movement
⚪ Pendulous abdomen
⚪ Any space occupying mass in
the pelvis
⚪ Multiple gestation

3. If a fetus is in breech position, it can be turned to a cephalic position by external cephalic version (1 point)
just before or during labor. An important assessment to make immediately following this would be

⚪ bladder emptying
⚪ rectal bleeding
⚫ fetal heart rate
⚪ abdominal contour

4. A laboring client has been dilated 9-10 cm for 2 hours. The fetal head has remained at zero station (1 point)
for 45 minutes despite adequate pushing efforts by the client. A sterile vaginal exam reveals a
position of occiput posterior. Which of the following actions by the nurse would be most
appropriate?

⚪ prepare the client for a


cesarean delivery
⚫ assist the client to a hands
and knees position
⚪ prepare the client for a
forcep rotation
⚪ assist the client to a supine
position

5. You assess that a fetus is in a breech presentation. Where would you auscultate for fetal heart (1 point)
sounds?
⚫ high in the abdomen
⚪ fetal heart portion of the
umbilicus
⚪ low in the abdomen
⚪ low lateral portion of the
abdomen

6. Mc Robert's maneuver may widen the pelvic outlet and help in letting the anterior shoulder be (1 point)
delivered. This maneuver is described as
⚪ The woman will pull in her
thighs slowly as she
gradually try to oush
⚪ The physician or nurse
midwife will apply pressure
on the perineum
⚫ Asking the woman to flex her
thighs sharply on her
abdomen
⚪ A nurse will try to help by
applying fundal push

7. The client's history reveals that a condition preventing the fetus to pass through maternal pelvis is (1 point)
interpreted as

⚪ Contracted pelvis
⚪ Maternal disproportion
⚫ Fetopelvic disproportion
⚪ Cervical insufficiency

8. If the fetus is large, which means the baby is at risk for shoulder dystocia. Which finding in the (1 point)
newborn would be most important to assess for following shoulder dystocia in labor?

⚪ bleeding at the cord site


⚪ open shoulder lesions
⚫ uncoordinated respirations
⚪ blue tinged toes and fingers

9. As a delivery room nurse you would expect that the nurse will do which of the following (1 point)
interventions to relieve the impacted fetal shoulders quickly?
⚫ suprapubic pressure
⚪ position the woman in a
lunge position
⚪ Ritgen's manuever
⚪ Fundal pressure

10. A student nurse is studying the different types of breech presentation. She came across an (1 point)
illustration in which the hips of the fetus are flexed and the knees are flexed, the elbows are flexed,
the buttocks alone present to the cervix. She is correct if she identified this as

⚪ footling breech
⚪ incomplete breech
⚫ complete breech
⚪ frank breech

11. Which of the following statements is true regarding asynclitism? (1 point)


⚪ The fetal buttocks
presenting at a different
angle than expected
⚪ An engagement of the head
is apparent
⚪ The vertex is the presenting
part
⚫ Face and brow presentation
are examples of this

12. The arc of rotation of the fetal head in a posterior position is longer than in the anterior position. (1 point)
The fetal head rotation against sacrum causes the intense pressure and pain in the lower back of
the woman. All of the following measures will alleviate the pain EXCEPT

⚫ maintaining a dorsal
recumbent position
⚪ lying on the opposite side of
the fetal back
⚪ providing back rub
⚪ applying heat or cold,
whichever is best

13. Situation: Mrs Favour, gravida 2 para 0010, is admitted to the labor and delivery area. Initial (1 point)
assessment reveals cervical dilatation of 4 cm; cervical effacement, 100%, station 0, contractions
moderately intense and occuring every 5-6 minutes and lasting 45-60 seconds. Fetal heart tones
are loudest in the left upper quadrant. When performing leopold's manuever, nurse Tina detects
a hard, round object at the level of the fundus.
Assessment findings for Mrs. Favour indicate that the fetus is in a

⚪ posterior position
⚪ cephalic
⚪ transverse lie
⚫ breech presentation

14. When he bag of water ruptures spontaneously the nurse should inspect the vaginal is for possible (1 point)
cord prolapsed. If here is part of the cord that has prolapsed into vaginal of the correct nursing
intervention is to

⚪ Push back he prolapsed cord


into the vaginal canal
⚪ Push back the cord into the
vagina and place the woman
in Sims position
⚫ Cover the prolapsed cord
with strike gauze wet with
sterile saline
⚪ Place the mother in semi-
fowlers position to improve
circulation

15. The woman is in active labor. The presentation of the fetus I left occiput posterior. Which of the (1 point)
following measures should be included when caring for the client?

⚪ Provide foods and fluids


⚪ Assist the client to ambulate
⚫ Provide back massage
⚪ Allow the client to sleep

16. Which of the following statements is true regarding asynclitism? (1 point)


⚪ The vertex is the presenting
part
⚪ The fetal buttocks
presenting at a different
angle than expected
⚪ An engagement of the head
is apparent
⚫ Face and brow presentation
are examples of this
17. The nurse understands that the fetal head is in which of the following positiins with a face (1 point)
presentation?
⚪ Completely flexed
⚫ Completely extended
⚪ Partially flexed
⚪ Partially extended

18. If a fetus is determined to be in face presentation. What would be most important to observe in (1 point)
the newborn after birth?
⚪ Corneal irritation
⚫ Signs of dehydration
⚪ Sinus congestion
⚪ Decreased hearing

19. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate (1 point)
would be most audible in which of the following areas?

⚪ in the lower right maternal


abdominal quadrant
⚪ in the lower-left maternal
abdominal quafrant
⚪ above the maternal
umbilicus and to the right of
midline
⚫ above the maternal
umbilicus and to the left of
midline

20. Shoulder dystocia is a birth problem that occurs when the fetal head is born but the shoulders are (1 point)
to broad to enter and be born through the pelvic outlet. This happens during

⚫ the second stage of labor


⚪ the transition phase
⚪ the first stage of labor
⚪ the active phase
Quiz #4 NCM 109 lec

Name: ____________________________ Score: __________


Section: ___________________________

CARE STUDY: A FAMILY WITH A SUBFERTILITY CONCERN

Amy Newman is a 37-year-old woman attending a subfertility clinic. She has been married for 5 years and has two boys,
3 and 5 years old. She and her husband, Ross (40 years), had planned on having three children. Because they were married
when they were both 32, they planned on having them close together. Amy has not been using a contraceptive for a year
and a half and is concerned because she is apparently unable to conceive a third child.

CHIEF CONCERN:
"I want to get pregnant again."

HISTORY OF CHIEF CONCERN:


Client and husband have been trying for a third child for 1½ years. Both are discouraged at the delay because Mrs. Newman
is 37. Coitus twice a week. Client uses no lubricants. She has had no STIs or vaginal infections to her knowledge.

Client visibly upset discussing her inability to have a third child. Asked, "Do you realize what a good mother I would be to
a girl? Why am I sterile like this? Don’t tell me I’ll have to do something like in vitro fertilization."

FAMILY PROFILE:
Client is independently employed as she owns a craft shop. Admits to long hours of standing to meet needs of customers.
Husband works at a desk job as a stock broker. She describes finances as “middle class.” They own their own home plus a
sailboat they use for weekend sailing and vacations.

HISTORY OF PAST ILLNESSES:


Client was born with a cleft lip; had this repaired at birth with good results. Ruptured appendix at 12 years. Diagnosed and
treated for tuberculosis at 16 years. "Bad" adolescent acne treated with tetracycline all during adolescence.

FAMILY HEALTH HISTORY:


Husband's father has hypertension; a mother's cousin has renal failure and is on dialysis waiting for a transplant.

GYNECOLOGIC HISTORY:
Menarche at 13 years; cycle 28 to 30 days, duration of flow 7 days. Had "terrible" dysmenorrhea before she had her first
child. Last menstrual period: 2½ weeks ago. Used vaginal foam as method of contraception up until a year and a half
ago. Papanicolaou smear negative as of 1 month ago. A hysterosalpingogram revealed normal patent tubes but a small
uterine myoma. Client takes her basal body temperature daily. She is scheduled to have an endometrial biopsy later this
month.

OBSTETRICAL HISTORY:
Therapeutic abortion at 18 years before she was married. A spontaneous miscarriage 6 years ago of female twins. Male,
7 pounds 13 ounces, born 4 years ago, vertex presentation, alive and well. Male, 8 pounds 3 ounces, born 3 years ago,
vertex presentation; alive and well. After membranes had been ruptured for 24 hours, labor was induced. Amy had a mild
endometritis treated with intravenous antibiotics for 4 days following birth.

DAY HISTORY:
Nutrition: 24-hour nutrition recall reveals a diet light in protein and possibly iron. Eats “fast foods” 2 nights a week so her
intake of trans fat is high. Drinks 6 cups of coffee daily; "occasional" wine; does not smoke.
Sleep: Client tries to sleep 6 hours a night. Has frequent episodes of insomnia that reduce actual sleep time to 4 hours per
night.
Recreation: Used to spend a lot of time “tacking” on sailboat for husband and family. Now spends most of her free time
preparing crafts for her shop. States, “My husband is a ‘craft widow’. Walks a city block from bus to craft shop work days.

REVIEW OF SYSTEMS:
Essentially negative; one urinary tract infection 5 years ago shortly after marriage. Has noticed an increased watery vaginal
discharge lately, enough to soil underwear on long periods of standing.

PHYSICAL EXAMINATION:
Height: 5’5”
Weight: 210 lbs (BMI 34.9 or obese).
General appearance: Mildly obese, distressed appearing Caucasian woman.
HEENT: Grossly negative; one "shotty" lymph node present on posterior cervical chain.
Chest: Normal breast development; soft to palpation. Lungs clear to auscultation. Heart sounds and rate normal.
Abdomen: Soft, no masses; uterus not palpable
Extremities: Mild varicose vein on medial aspect of left leg; full range of motion in all joints; deep tendon reflexes 2+
Pelvic exam: Cervical mucus thin and with spinnbarkeit properties but strong odor; uterus and tubes palpable; normal size
and shape.

LABORATORY RESULTS:
Thyroid activity normal
Hemoglobin 11.6 gm/dL
Urine: negative for protein and glucose
Husband’s sperm count: 25 million/mL

Amy is diagnosed as having a Chlamydia infection. She was prescribed doxycycline for this.

CARE STUDY QUESTIONS:

1. Amy talks as if her problem of temporary subfertility is unique. Subfertility actually affects what percentage of
couples who want to have children?
A. 1% to 5%
B. 10% to 15%
C. 35% to 40%
D. 55%
2. Amy and her husband have been trying for a year and a half to conceive a third child. What is the average time span
it takes a couple to conceive?
A. Pregnancy usually occurs within 1 year of unprotected coitus.
B. Three years is not an unusual for the average healthy couple.
C. Almost all couples become pregnant within 3 months.
D. The majority of couples become pregnant in 6 months.
3. What finding in Amy’s history is often associated with female subfertility?
A. Amy works at a job where she stands for a long time every day.
B. Amy had an endometritis following her last baby’s birth.
C. Amy’s last baby was a boy and weighed over 8 pounds.
D. Amy works at craft projects that could include applying glue.
4. What finding in Ross’ history is often associated with male subfertility?
A. He has a beer on Saturday nights.
B. He had rubella as a child.
C. He enjoys sailing on weekends.
D. He works at a desk job..
5. Ross brings a sperm sample into the fertility clinic for analysis. Which of the following is a question you would want
to ask him?
A. Was he certain to omit any spicy or pickled food for lunch?
B. Did he keep the sample at body temperature during transport?
C. Is he certain that his car does not emit carbon monoxide fumes?
D. Did he restrain from urinating for 4 hours before the sample?
6. Ross’ sperm count is estimated to be 25 million per mL. Your analysis of this is that this
A. is a very low sperm count so accounts for their subfertility.
B. is a normal sperm count for a 40-year-old male.
C. number suggests Ross’ sperm must be immobile.
D. number is meaningless without knowing the semen amount.
7. Amy refers to herself as sterile. Sterility is actually defined as a condition where
A. a couple has not conceived a child even though they want to.
B. the couple has a documented reason for not conceiving.
C. a woman has never birthed a child although she has tried.
D. people feel they will not ever be able to have children.
8. Which of the following would be the best nursing diagnosis for Amy?
A. Anxiety related to difficulty conceiving a third child
B. Guilt related to a previous therapeutic abortion.
C. Pain related to current monthly menstrual periods
D. Difficulty with fertility related to current lifestyle
9. Amy had a hysterosalpingogram. It is important that this test is scheduled
A. on the 14th day of the menstrual cycle.
B. after the midpoint of the cycle
C. immediately following a menstrual flow.
D. anytime; time of the month is unimportant.

10. Following a hysterosalpingogram, you would want to advise Amy that she might experience
A. nausea and vomiting from the large amount of water she has to drink.
B. sharp shoulder pain afterward from the carbon dioxide infusion.
C. pain in her leg from pressure on the sciatic nerve afterward.
D. dull nagging ovarian pain from introduction of the catheter.
11. Amy reports that she takes her basal body temperature (BBT) daily and it shows no fluctuations.
Which of the following techniques would you want to be certain she is using?
A. She takes her temperature immediately after every meal daily.
B. She takes her temperature before she has activity in the morning.
C. She is certain not to drink coffee with either breakfast or lunch.
D. She records her temperature every night before falling asleep.
12. If Amy is ovulating, you would expect a basal body temperature graph to show
A. first an increase, then a decrease, and then a second increase of temperature.
B. an increase of 5° temperature that remains increased for 3 days.
C. a decrease of at least 1° temperature that lasts 2 days.
D. a slight dip of 0.5° followed by a 1° increase.
13. Amy is prescribed the drug clomiphene citrate (Clomid). Clomid is a(n)
A. estrogen agonist that causes the pituitary to release FSH hormone.
B. corticosteroid that reduces ovarian inflammation and scarring.
C. mild analgesic that can reduce the pain of ovulation.
D. progesterone that stimulates follicle stimulating hormone.
14. A precaution you would want Amy to know before taking this drug is that she
A. should take it on an empty stomach or only with water.
B. should never take aspirin with it to avoid side effects.
C. needs to coordinate coitus with ovulation while on the drug.
D. needs to avoid both tomatoes and spinach while on the drug.
16. Amy has no history of pelvic inflammatory disease (PID). PID can cause subfertility because it
A. increases the rate of ova transport so the ova cannot meet sperm.
B. leaves a scarred uterine surface so implantation can not occur.
C. creates excessive cervical mucus that then “drowns” sperm.
D. can cause inflammation and scarring of fallopian tubes.
17. Amy is to have an endometrial biopsy later this month. The purpose of this test will be to
A. analyze how many follicles are still present in her ovaries.
B. examine if her fallopian tubes are of average length.
C. analyze the type of endothelium she has present.
D. inspect and test cervical mucus for white blood cell content.
18. Amy says she could never undergo in vitro fertilization. This is
A. transferring embryos from the left to right ovary to improve conception.
B. transferring an ovum from the ovary to the vagina so it can meet sperm.
C. encouraging sperm to enter the fallopian tubes through vacuum pressure.
D. transferring a woman’s fertilized ovum into her uterus for implantation..
19. A possible side effect of in vitro fertilization that women need to be cautioned may occur is
A. women may have multiple pregnancies with this intervention.
B. children born this way may be more prone to allergies than usual.
C. husbands may develop a bleeding defect following the procedure.
D. women may experience shortness of breath from the drug therapy.
20. An instruction you would want to be sure Amy understands before having an in vitro fertilization
procedure is
A. that it is an expensive procedure and the success rate is not 100%.
B. even though she is pregnant, a pregnancy test will not test positive.
C. the pregnancy will be shorter by one month than a usual pregnancy.
D. she may feel dull pain from ovarian stimulation throughout pregnancy.

CARE STUDY: AN ADOLESCENT WITH A POSTPARTAL COMPLICATION


Pamela Barth is a 17-year-old, GI PO woman transferred to the postpartal service following the birth of a
9 pound 4 ounce infant boy
CHIEF CONCERN:
“Should I be bleeding this much?”

HISTORY OF PRESENT CONCERN:


Client gave birth to a 9 pound 4 ounce boy under epidural anesthesia at 7:25 a.m. following a 14-hour
labor. Membranes had been ruptured for 26 hours. Modified Crede's maneuver used to deliver placenta.
Fifteen U pitocin in 500 mL of lactated Ringer’s administered intravenously following birth. Blood loss
from birth estimated at 750 mL. At present, client reports vaginal bleeding is so heavy she is saturating a
perineal pad every 20 minutes.

FAMILY PROFILE:
Lives with mother, two older sisters, five nieces and nephews in a three-bedroom house on a dairy farm.
Has “borrowed” supplies for baby from sisters. Father of child is said to be supportive but did not come
to be with her in labor.

HISTORY OF PAST ILLNESS:


Chickenpox at 5 years: facial acne since she was 12. No major illnesses; no hospitalizations.

GYNECOLOGIC HISTORY:
Menarche at 10 years; cycle duration: 29 days; menstrual flow duration: 5 days. No STIs. Not using a
contraceptive before present pregnancy.

OBSTETRICAL HISTORY:
No previous pregnancies. This pregnancy was not planned but not unwelcome. No complications during
pregnancy except for minimal edema formation; proteinuria of 2+ and blood pressure increase to 140/98
for last 2 weeks.

REVIEW OF SYSTEMS:
Neurologic: Treated for 5 years when younger for “small seizures.” No longer takes medication for this.
Mouth: Severe malocclusion treated with oral braces since age 14.
Breasts: Mild breast engorgement; pleased to be breastfeeding.

PHYSICAL EXAMINATION

General appearance: apprehensive-appearing, slender black woman. T: 98.6°F, BP: 100/60.


HEENT: Integument: approximately five black comedones present on forehead. Mouth: Full upper and
lower metal braces present. No ulcerations or abrasions on gumlines.
Chest: Heart rate: 100 beats per minute. No murmurs present. Lungs: rhonchi present in upper lobes.
Respiratory rate: 22 breaths per minute
Abdomen; Soft. Fundus palpated at 2F above umbilicus and boggy. Massaged and large firm clot 5 cm in
diameter was expelled vaginally. Fundus somewhat firmer following massage but height did not change.
Perineum: Midline episiotomy line intact; no hemorrhoids. Lochia: continuous bright red vaginal flow
present; no clots.

LABORATORY RESULTS
• Hemoglobin: 8.9 g/dl. • WBC: 25,000 mm3
.

Questions 1-14 refer to the case

1. Which factor in Pamela’s health history makes her high risk for hemorrhage during the postpartal
period?
A. Her placenta was implanted on the posterior uterus.
B. Her baby weighed more than 9 pounds.
C. Her family earns their living caring for dairy cows.
D. Pamela was in labor longer than 12 hours.
2. To estimate blood loss postpartally, you assess Pamela’s perineal pads. A saturated perineal pad
contains approximately how much blood?
A. 10 to 20 mL D. 250 mL
B. 25 to 50 mL
C. 100 mL
3. A common drug used to cause a uterus to contract postpartally to prevent or control bleeding is
A. Levodopa. C. Oxytocin.
B. Prilosec. D. Meperidine
4. Massaging a uterus is a measure to control postpartal bleeding. To do this, you would
A. use a light rapid effleurage technique for this.
B. place one hand in the vagina to steady the cervix.
C. always massage from side to side to decrease pain.
D. place one hand at the base of the uterus to anchor it.
5. Which factor in Pamela’s history puts her at high risk for postpartal infection of the uterus?
A. Birth from a lithotomy position C. Birth of a 9-pound male infant
B. Rupture of membranes over 24 hours D. Breastfeeding her infant on demand.
6. Postpartal infection of the uterus is termed
A. vaginitis. C. endometritis
B. cystitis. D. cervicitis.
7. Pamela has a perineal hematoma. A common cause of this is
A. a clotting defect from the interaction C. bleeding from the placing of perineal
of epidural anesthesia. episiotomy sutures.
B. bruising of the perineum from a vertex D. urine seeping into the perineum from
presentation. the anterior bladder
3
8. Pamela has a WBC of 25,000 mm . For a postpartal woman, you would assess this as
A. below average. D. normal if it consists of only
B. a normal count. lymphocytes..
C. an elevated count.
9. Which temperature best signals postpartal infection?
A. 101°F at 8 hours postpartum B. 102°F immediately after birth
C. 99°F at 2 weeks postpartum D. 101.2°F on the third postpartal day
10. All women in the postpartum period are at high risk for thrombophlebitis. This is because
A. placental toxins may lead to anticoagulation.
B. vaginal tears can lead to minimal infections.
C. fetal blood mixes with maternal blood at birth.
D. stasis of lower extremity vessels due to dilation.
11. If a woman develops a deep vein thrombus in the femoral vein, a common intervention would be to
A. keep her legs in a dependent position. C. apply moist heat over the site.
B. apply alcohol soaks to the site. D. use a sterile needle to aspirate the clot..
12. Warfarin (Coumadin) is a common drug prescribed for deep vein thrombus. Which factor in
Pamela’s history would make you question an order for this drug postpartally?
A. She is breastfeeding her newborn. C. She has no history of a previous blood
B. She is less than 25 years of age. clot.
D. She has been exposed to dairy cows.
13. The antidote for Warfarin (Coumadin) is
A. acetylsalicylic acid. C. Heparin.
B. vitamin K. D. serotonin.
14. Which of the following denotes the correct technique for fundal massage for a postpartum client
exhibiting a large amount of blood on the perineal pad?
A. Compressing the fundus on one side while supporting the other side of the uterus
B. Massaging above the symphysis pubis while one hand supports the uterine fundus
C. Pressing deeply into the abdomen while compressing the fundus with both hands
D. Supporting the fundus while massaging the uterus just above the symphysis pubis
15. When teaching a childbirth education class on infection prevention after delivery, the nurse would
instruct the woman to perform perineal care how often?
A. After each voiding or defecation
B. Every 8 hours
C. Once each day
D. When she has perineal pain

16. A client who is 24 hours postpartum has the following morning vital signs: Temperature 100° F; BP
124/78; P58; R16. The nurse should do which of the following?
A. Assess the vital signs hourly instead C. Retake the pulse rate after the
of every 4 hours. client ambulates.
B. Report the changes in vital signs to D. Recognize the client’s vital signs are
the physician. normal
17. A client begins preterm labor and the physician orders terbutaline sulfate (Brethine). After its
administration, the nurse assesses the client for the therapeutic effect of
A. Reduction of pain in the perineal area
B. Decrease in blood pressure from 120/80 to 90/60
C. Decrease in frequency and duration of contractions
D. Dilation of the cervix from 1 to 1.5 cm for every hour of labor.
18. The postpartum client is bleeding heavily 2 hours after delivery. The fundus of the uterus is firm;
uterus at the center of the abdomen. Which of the following actions should the nurse do next?
A. change perineal pads C. massage the uterus
B. notify the physician D. check perineum
19. Which of the following techniques during labor and delivery can lead to uterine inversion?
A. Fundal pressure applied to assist the mother in bearing down during delivery of the fetal head
B. Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation
C. Massaging the fundus to encourage the uterus to contract
D. Applying light traction when delivering the placenta that has already detached from the uterine
wall
20. Lochia normally disappears after how many days postpartum?

A. 5 days C. 18-21 days


B. 7-10 days D. 28-30 days
21. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is:
A. Encourage the mother to ambulate to relieve the pain in the leg
B. Instruct the mother to apply elastic bondage from the foot going towards the knee to improve
venous return flow
C. Apply warm compress on the affected leg to relieve the pain
D. Elevate the affected leg and keep the patient on bedrest ( to reduce inflammation)
22. Which of the following denotes the correct technique for fundal massage for a postpartum client
exhibiting a large amount of blood on the perineal pad?
A. Compressing the fundus on one side while supporting the other side of the uteru
B. Massaging above the symphysis pubis while one hand supports the uterine fundus
C. Pressing deeply into the abdomen while compressing the fundus with both hands
D. Supporting the fundus while massaging the uterus just above the symphysis pubis
23 Cefelita, 38 years old multipara is admitted with a tentative diagnosis of femoral thrombophlebitis. The
nurse assesses the patient with
A. burning sensation C. abdominal pain
B. leg pain D. increased lochial flow
24. In the immediate postpartum period the action of methyergonovine is to
A. cause sustained uterine contractions.
B. cause intermittent contractions.
C. relax the uterus.
D. induce sleep so the mother can rest after an exhausting labor.
25. Management of thrombosis and thrombophlebitis includes
A. Checking the homan’s sign
B. Monitoring signs of inflammation in the lower extremities.
C. Starting on anticoagulant therapy
D. A and B
E. All of the above
COLLEGE OF NURSING

PRELIM EXAMINATION
NCM 107- Care of Mother, Child and Family
FIRST SEMESTER, S.Y. 2022-2023

Direction: Select the letter of the best answer from the given choices and write it in a capital letter.
Leave one space every five numbers. No erasures

1. Which of the following are goals of maternal and child health nursing ?
A. That every child lives and grows up in a family unit with love and security
B. To ensure that every that every expected and nursing mother maintain good
health.
C. To ensure that every mother has a normal delivery and bears healthy children.
D. To achieve healthy sexual development and maturation.
A. 1,2,3 C. 1,2,4
B. 2,3,4 D. 1,2
2. The following are trends in Maternal and Child Health EXCEPT
A. single parents are increasing in number.
B. families are smaller in size than in previous decades.
C. an increasing number of women work outside the home.
D. improve the survival, health and well being of mothers and the unborn.
3. The Integrated Maternal, Neonatal and Child Health and Nutrition (MNCHN) Strategy is
formulated and implemented to improve the health condition of the pregnant mother
and her child with an ultimate goal of
A. Assisting and empowering LGUs about the DOH programs.
B. Rapidly reducing maternal and neonatal mortality in the country.
C. Improving and making positive changes in Local health system.
D. Developing various programs aimed at women, mothers and children.
4. Basic Emergency Obstetric and Newborn Care (BEmONC) facilities are capable of
performing 6 signal OB functions. Which among the conditions below is NOT a function
of the BEmONC?
A. Performance of assisted deliveries
B. Manual removal of retained placenta
C. Removal of retained products of conception
D. Management of low birth weight or premature babies
5. The order issued by the DOH implementing health reforms for rapid reduction of
maternal and neonatal mortality is
A. RA 7600 C. AO 0023
B. RA 9288 D. AO 2008-0029
6. The following are philosophies of Maternal and Child Nursing EXCEPT
A. Maternal and Child is family-centered and community centered.
B. Maternal and child nursing is based on research and evidenced based practice
C. Maternal and child health nurse serves as an advocate protecting the rights of the
healthteam
D. Maternal and child health nursing is a challenging role for a nurse and is a major
factor in promoting high-level wellness in families
7. Which of the following are goals of Maternal and child Nursing based from Department
of Health? Except
A. That every child belongs to a family with love and insecurity
B. That every child will receive adequate nutrition and health supervsion
C. To ensure that every expectant mother will deliver their baby via cesarian section
delivery.
D. To ensure that every expectant mother will maintain good health throughout the
course of pregnancy until after delivery
8. One theory of MCN in which it tries to view that the infant’s behavior is a subsystem of
functioning. This is
A. Synactive theory
B. Universe developmental care
C. The mother and child integrative developmental care
D. Barnard’s parent-child interacton model
9. This MCN theory recognizes the link between all developing systems and the caregiver
providing a practiccal basis in formulating individualized patient care. This is
A. Universe developmental care
B. Maternal Role attainment theory
C. Barnard’s parent-child interacton model
D. The mother and child integrative developmental care
10. A role of MCN is to give care to women to prevent them to have sexually transmitted
infections. This is being referred to as
A. Case manager
B. Nurse Practitioner
C. Certified nurse-midwide
D. Women’s health nurse practitioner
11. They are nurses who are responsible in monitoring the cliet from the day of their
admission until their discharfe. They are
A. Case Manager
B. Family Nurse practioner
C. Clinical nurse practitioner
D. Neonatal Nurse Practioner
12. Goal number 1 is about poverty. What is the aim of this goal?
A. Cut poverty in half by 2030
B. Reduce poverty by 75% by 2030
C. End poverty in all its forms everywhere
D. Help each nation make progress on reducing poverty
13. Which of the following is not part of the Sustainable Development Goals?
A. Promotion of decent jobs for all
B. Access to sustainable energy for all
C. Provision of internet services for all
D. Availability of water and sanitation for all
14. Which of the following parts of the female reproductive system is located bilateral to the
urinary meatus, supplies lubrication to external genitalia during coitus?
A. Clitoris
B. Forchette
C. Skene’s gland
D. Bartholin’s gland
15. The students of Benner knows that the term that refers to the externally visible
structure of the female reproductive system located from the symphysis pubis to the
perineum is the
A. labia majora. C. vestibule.
B. mons pubis. D. Vulva
16. After teaching a group of students about the structures associated with the female
reprodcutive system, the nurse determines that the teaching was successful when the
students identify which structures? Select all that apply
A. Ovaries
B. Labia minora
C. Vas deferens
D. Labia majora
E. Seminal vesicles
17. In which portion of the fallopian tube does fertilization occur
A. isthmus
B. Ampulla
C. Infundibulum
D. Intersritial segment
18. During the prenatal check-up, the nurse conducts health teachings regarding family
planning methods.One client asks about tubal ligation “what parrt of the fallopian tube is
being cut duing the proedure?” The best answer of the nurse is
A. Ampulla
B. Isthmus
C. Interstitial
D. infundibulum
19. Based on the anatomy of external male genital, which of the following is the most logical
cause of inability to achieve erection?
A. An undescended testicle C. Weakness or atrophy of the penile muscle
B. Poor circulation of the penis D. Decreased functioning of the seminiferous tubules.
20. The testes are suspended in the scrotum to
A. protect the sperm acidity of urine.
B. facilitate the passage of sperm through the urethra.
C. protect the sperm from high abdominal temperature.
D. facilitate their maturation during embryonic development.
21. A male client had noticed that his reproductive part undergoes changes related to change
in weather especially the scrotum. What changes can be expected to the scrotum when
there is cold weather?
A. It dlilates and moves towards the body
B. It shrinks and moves closer to the body
C. It dilates and moves away from the body
D. The scrotum shrinks and moves away from the body
22. Testosterone production is stimulated by
A. luteinizing hormone (LH). C. follicle- stimulating hormone (FSH).
B. human placental lactogen (HPL). D. gonodotropin- releasing hormone (GRH).
23. The male hormone testosterone, which maintains spermatogenesis, is synthesized and
released by
A. leydig’s cells . B. Seminiferous tubules. C. seminal vesicles. D. spermatogenic
cells.
24. An instructor is preparing a class for a group of students about the male reproductive
structures. The instructor is planning to descrive tthe secretion by the seminal vesicles as
bing high in which if the following? Select all that apply
A. Acids D. Electrolytes
B. Sugar E. Prostaglandin
C. Protein
25. During sexual intercourse, Edriko experiences 50% increase in testicular size. Into what
phase does this happen?
A. Excitement B. Orgasmic C. Plateau D. Resolution
26. Which of the following physiologic changes occurs during the plateau stage of
sexual response?
A. Lengthening of the vagina C. Retraction of the clitoris\
B. Pelvic muscle contraction D. Scrotal elevation
27. A woman tells you she has difficulty achieving orgasm. Orgasm in females results mainly
from which of the following?
A. Penile penetration C. Uterine stimulation
B. Clitoral stimulation D. Sensory arousal
28. Which of the following events would occur during the excitement phase of the sexual
response cycle?
1) Scrotal thinning 2) Vaginal widening
3) Testicular elevation 5) Increased clitoral size
4) Ejaculation of semen 6) Mucosal fluid on vaginal walls
A. 1,2,3,4,5,6 C. 2,3,5,6
B. 2,3,4,5,6 D. 3,5,6

29. Which of the following statement about resolution phase is CORRECT?


A. Refractory period occurs in males
B. It takes 30 seconds to reach this phase
C. Women can immediately proceed to another orgasm
D. The external and internal genital organs returns to arouse state
30. Increased activity of endometrial glands during the luteal phase of the female
reproductive cycle is stimulated by
A. progesterone. B. estrogen. C. glycogen. D. prolactin.
Situation: Alyssa, a 19 year old Filipino girl, is seen at the school clinic for her annual physical
check-up.
31. She asks about the interval between ovulation and menstruation. Which of the following
response of the nurse is TRUE? Approximately _____day
A. 21 B. 28 C. 30 D. 14
32. The nurse instructs Alyssa further into the process of ovulation. Which two statements
below are TRUE?
1) It occurs in unpredictable way
2) Before puberty, the primordial cells produce estrogen
3) Normally, only one ovum matures in each cycle
4) The process of ovulation occurs in a predictable way
A. 2 and 4 C. 1 and 2
B. 1 and 3 D. 3 and 4

33. A 19 year old nulligravid client visits the clinic for a routine examination.She asks the
nurse aout the cervical mucus changes that occur during the menstrual cycle. Which of
the following statements would the nurse expect to include in the client’s teaching plan?
A. As ovulation approaches , cervical mucus is abundant and clear
B. During ovulation, the cervix remains dry without any mucus production
C. About midway through the menstrual cycle, cervical mucus is thick and sticky
D. Cervical mucus disappears immediately after ovulation reuming with menses.
34. Which phase of the menstrual cycle is characterized by a surge in Luteinizing Hormone
(LH) from the pituitary gland
A. Proliferative D. Secretory
B. Menstruation
C. Ischemic
35. Which of the following are signs of ovulation?
A. Mittelschmerz
B. Spinnabarkeit
C. Thin watery cervical mucus
D. Elevated body temperature of 4.0 degrees centigrade

A. 1 & 2 B. 1, 2, & 3 C. 3 & 4 D. 1, 2, 3, 4

36. The nurse knows the client understands the changes in her basalbody temperature during
the luteal phase when she states
A. “ Thermal heat is not significant.”
B. “Estrogen level is at its peak when thereis tthermal heat.”
C. “ Luetenizing hormone causes the basal body temperature to dip slightly.”
D. “Progesterone hoemone causes the basal body temperature to dip slightly.”
37. The thickened endometrium in which the fertilized embryo implants is called
A. amnion. B. chorion. C. decidua. D. endoderm.
38. The corpus luteum acts as the placenta for the implanted ovum until
A. the first gestational month. C. the fifth gestational month.
B. the fourth gestational month. D. the end of the second gestational month.
39. When evaluating information taught about conception and fetal development, the client
verbalizes understanding about transportation time of the zygote through the fallopian
tube and into the cavity of the uterus with which statement?
A. “It will take 8 days for the egg to reach the uterus.”
B. “It will take at least 3 days for the egg to reach the uterus.”
C. “it will take 18 hours for the fertilized egg to implant in the uterus.”
D. “It will only take about 12 hours for the egg to go through the fallopian tube.”
40. Miroslav is at 20 weeks gestation. At this stage, the conceptus is at the stage of
A. ovum. C. zygote.
B. fetus. D. embryo
rd
41. As early as the 3 week of intrauterine life, fetal blood begins to exchange nutrients with
the maternal circulation across the chorionic villi. Fetal circulation differs from
extrauterine circulation in all but one of the following aspects.
A. Fetal oxygen in the blood is derived from the placenta while in an adult the oxygen
is from the lungs.
B. In fetal circulation, shunting of blood is present while in adult circulation there is
normally no shunting of blood.
C. The blood that enters the lungs is oxygenated in fetal circulation while it is
unoxygenated in an adult circulation.
D. The vein in the umbilicus of the fetus carries blood away from the heart and the
artery carries blood towards the fetus. In an adult, it is the vein that carries blood
towards the heart and the artery carries blood away from the heart.
42. Yssa, a primigravida client asks the nurse, “what are expected of my fetus regarding
his/her digestive system?” Jen, the nurse is correct when she says
A. “At 12th weeks, the meconium forms
B. At 28th weeks, sucking and swallowing reflexes matures”.
C. “At 4th week, the digestive tract is separated with the respiratory tract”.
D. “At 32nd week, the gastrointestinal tract has the ability to secrete enzymes
essential for CHO and CHON digestion.”
43. The fetus has body weight of 1800 grams, lanugo begins to diminished, additional fat are
deposited and turns into vertex presentation. How many weeks is the fetus?
A. 28 C. 36
B. 32 D. 40
44. During prenatal visit, nurse Audrey is teaching her client about fetal development. And
she is correct if she says that the baby will have meconium at what week?

A. 8 weeks C. 16 weeks
B. 12 weeks D. 24 weeks

45. Decy, a 32 weeks primigravida client asks the nurse “what are expected of my fetus at
this time? The best answer of the nurse is

A. there is the formation of lanugo.


B. passive antibody transfer will occur.
C. the baby learns how to swallows and sucks.
D. lung alveoli begins to mature with surfactant.
46. In evaluating he effect of prior teaching refarding the functions of the amniotic fluid, the
jurse recognizes that more teachings is required when the client states
A. “the fluid is responsible for oxygen exchange”.
B. “the fluid helps cushion the baby against harm”.
C. “” the fluid aids in muculoskeletal development.”
D. “the fluid helps maintain environmental temperature.”
47. A young couple in eager anticipation for their child’s birth asks, “When does the
rudimentary foundation of the baby system such as the brain and a heart are formed?
The nurse answers
A. first month.
B. second month.
C. third month.
D. fifth month

48. Claire about 8 weeks pregnant, asks the nurse when she will be able to hear the fetal
heartbeat. The nurse would respond by stating to the client that the fetal heartbeat can
be heard with Doppler ultrasound device when the gestation is as early as

A. 8-10 weeks.
B. 15 weeks.
C. 18 weeks.
D. 40 weeks
49. Mailanie delivered to a baby girl with no lower extremities. What possibly have caused her
baby’s limb defects?
A. Lead
B. Rubella
C. Thalidomide
D. Tetracycline

50. Which of the following is not true about syphilis as a teratogen?


A. Treatment with Benzathine Penicillin early in pregnancy rarely affects fetus.
B. It cannot cross the placenta and cause damage to the fetus early in pregnancy.
C. When the cytotrophoblast layer atrophies at 24th-28th week, the spirochete can
cross placenta and cause fetal damage
D. If left untreated beyond 18th week, it may lead to deafness, cognitive challenge,
osteochondritis and fetal death

51. A pregnant woman is concerned about the “ugly brown spots on her face”. The nurse
should teach her that
A. she should avoid wering make up until the areas fade.
B. these are temporary changes due to uncreased hormones.
C. unscented skin lotion may reduce the darkness of the areas.
D. iron supplememt sometimes cause temorary skin darkening.
52. The placenta produces hormones that are vital to the function of the fetus.What
hormone is primarily responsible for the maintenance of pregnancy?
A. Estrogen
B. Progesterone
C. Human placental lactogen
D. Human chorionic ginadotropin
53. Sudden increase in weight during pregnancy may suggest fluid retention or
polyhydramnos while loss of weight indicate illness. A pregnant mother gains 3 pounds
per week on her 2nd trimester. Which of the following statement is true?
A. The increased weight gain of 3 lbs. in the 2nd trimester is normal
B. The normal weight gain during tthe 2nd trimester would be 15-20 lbs.
C. The pregnant mother’s weight gain of 3 pounds in the trimester is abnormal
D. The pregnant mother’s weight gain is normalle expected during pregnancy
54. The main reason for an expected increased need for iron in pregnancy is
A. the mother may suffer anemia because of poor appetite.
B. the mother may have a problem of digestion bevause of pica.
C. the fetus has an increased need for rbc which the mother must supply.
D. the mother may have physiologic anemia due to increased need for red blood cell
as well as the fetus requires about 350-400 mg of iron to grow.
55. This is a pinkish or reddish streaks on abboinal wall that turns white or gray when the
skin becomes loose.
A. Chloasma C. Telangiectasis
B. Linea migra D. Striae gravidarum
56. A woman presents to the clinic because she missed her last menstrual period and thinks
she may be pregnant. She reports fatigue, breast tenderness and urinary frequency. The
health care provider will interpret these findings as which of the following signs of
pregnancy?
A. Positive C. Pregnant
B. Probable D. Presumptive

57. In using the Bartholomew’s rule, you wullbe guided by the 3 landmarks. Select all that
apply
A. Navel C. Xyphoid
B. Breast D. Symphysis pubis
58. On which of the following areas would te nurse expect to observe chloasma?
A. Breast, areola, nipples C. Abdomen, breast, thighs
B. Chest neck, arms, legs D. Cheeks, forehead, nose
59. Which among the following statements is NOT true about the placenta?
A. It grows parallel with the fetus
B. It arises from trophoblast tissue
C. It weighs 400-600 g, ¼ of the weight of the baby
D. It has a size of 15-20 cm in diameter and 2-3 cm in length
60. The pregnant client complains of shortness of breath in her last trimester. What is the
rationale how come this happens?
A. The client has a respiratory problem
B. The growing uterus pushes the lungs upward
C. Due to the weight of the growing fetus
D. Because she’s tired of preparing ger things
61. Lowee sometimes feels ambivalent about being pregnant. What is the psychological
task you’d like to see her complete during the first trimester of pregnancy?
A. Choose a name for the baby.
B. View morning sickness as tolerable.
C. Accept the fact that she is pregnant.
D. Accept the fact the baby is growing inside her
62. Noomie is aware that she’s been showing some narcissism since becoming
pregnant. Which of her actions best describe narcissism?
A. Her thoughts tend to be mainly about herself.
B. Her skin feels “pulled thin” across her abdomen.
C. She She feels a need to sleep a lot more than usual.
D. often feels “numb” or as if she’s taken a narcotic
63. A client suspects that she is pregnant, but because she is the only wage earner in her
family, she is ambivalent about continuing the pregnancy.The nurse recognizes that the
client is in crisis and also remembers that pregnancy and birth are considered crises
because
A. there are mood changes during pregnancy.
B. they are periods of change and adjustment to change.
C. there are hormonal and physiologic changes in the mother.
D. narcissism is the mother affects the husband wife relationshiship
64. A woman is 12 weeks pregnant. During prenatal visit, she tells the nurse she is worried
that her baby might not be normal. How should the nurse interpret this statement?
A. Concerns about fetal well being and normality are common during early
pregnancy.
B. It is unusual for women to have these feelings because they do not perceive the
baby as real
C. She may have underlying rejection of the fetus that is being expressed in this way.
D. Her image of the fetus is expected to be more realistic at this time.
65. You know that Ronah has achieved the first psychological task of pregnancy when she
verbalizes which statement?
A. I am 12 weeks pregnant.
B. I wonder what my baby will look like.
C. I am going to name my baby Denver
D. I am going to make some adjustments in my household chores schedule after I
deliver my baby.
66. On her next clinic visit, Ronah’s husband went with her to the clinic. The soon to be
father told you that his wife confuses her at times because there are days when Ronah
would tell her that she’s happy to be having a baby and on certain days would comment
that having a baby is not on her plans yet. You tell the husband that this emotional
reaction is typical among pregnant women and is called
A. introversion. C. mood swing.
B. ambivalence. D. uncertainty

67. Which of the following findings in a woman would be consistent with a pregnancy of two
months duration?
A. Weight gain of 6-10 lbs. and presence of striae gravidarum
B. Fullness of the breast and urinary frequency
C. Braxton Hicks contractions and quickening
D. Increased respiratory rate and ballottement
68. What event occurring in the second trimester helps the expectant mother to accept the
pregnancy?
A. Lightening C. Pseudocysis
B. Ballotment D. Quickening
69. Which of the following common emotional reactions to pregnancy would the nurse
expect to occur during the first trimester?
A. Introversion, egocentrism, narcissism
B. Awkwardness, clumsiness, and unattractiveness
C. Anxiety, passivity, extroversion
D. Ambivalence, fear, fantasies
70. During the client’s prenatal visit in the second semester, the nurse describes quickening
and asks to note the date carefully on which she first feels fetal movement. This
information is used primarily to help
A. determine fetal well being.
B. determine the lie of the fetus.
C. assess the growth of the fetus.
D. document the estimated date of delivery.
71. You want to perform a pelvic examination on one of your pregnant clients. You prepare
your client for the procedure by
A. asking her to void.
B. doing a vaginal prep.
C. giving the client a perineal care.
D. taking her vital signs and recording the readings.
72. When preparing the mother who is on her 4th month of pregnancy for abdominal
ultrasound, the nurse should instruct her to
A. observe npo from midnight to avoid vomiting
B. do perineal flushing properly before the procedure.
C. void immediately before the procedure for better visualization.
D. drink at least 2 liters of fluid 2 hours before the procedure and not void until
the procedure is done.
73. A client at 36 weeks’ gestation is schedule for a routine ultrasound prior to an
amniocentesis. After teaching the client about the purpose for the ultrasound, which of
the following client statements would indicate to the nurse in charge that the client
needs further instruction?
A. The ultrasound will help to locate the placenta
B. The ultrasound locates a pool of amniotic fluid
C. The test will determine where to insert the needle
D. The ultrasound identifies blood flow through the umbilical cord
74. Which of the following best characterizes the Contraction stress test?
A. The fetus is typically monitored for at least 40 minutes, then the entire
monitoring( or tracing) is analyzed.
B. Any abnormal or nonreactive stress test results require further evaluation
that same day.
C. It is the least invasive test of fetal well-being that involves using an electronic
fetal monitor
D. Three contractions within 10 minute must be elevated ideally, each
contraction should last 40 to 60 seconds.
75. Which of the following diagnostic tests would be most important to ascertain for a
primigravid client in the second trimester of her pregnancy?
A. Ultrasound testing
B. Alpha-fetoprotein testing
C. Chorionic villus sampling
D. Culdocentesis to detect abnormalities
76. Which of the following prenatal laboratory test values would the nurse consider as
significant?
A. Hematocrit 33.5%
B. Rubella titer less than 1:8
C. White blood cells 8,000/mm3
D. One hour glucose challenge test 110 g/dL
77. In a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats
during a period of fetal movement. The decelerations occur twice during the test and
lasts 20 seconds each. The nurse realizes these results will be interpreted as
A. negative test B. reactive test C. equivocal test D. non-reactive test
78. Mrs. Jintalan is pregnant for the first time. The physician schedules a maternal serum-
fetoprotein (MSAFP) screening because of history of neural tube defects in her family.
MSAFP screening should be performed
A. 6-10 weeks gestation. C. 11-14 weeks gestation.
B. 15-20 weeks gestation. D. 21-25 weeks gestation
79. Berna is at 37 3/7 weeks gestation. Her anternatal testing demonstrates a fetal heart rate
baseline of 150 with 3 contractions in 10 minutes, no deceleration and with acceleration
of 4 times in one hour. This test would be considered
A. a negative nonstress test.
B. a positive nonstress test.
C. a positive contraction stress test.
D. a negative contraction stress test.

Situation: Mrs Morena schedules an appointment at the prenatal clinic because she has missed
two menstrual periods.
80. From the initial interview, the nurse learns that Mrs Morena last menstrual period began
August 25, 2021. According to Naegel’s rule, her estimated date of confinement is
A. May 31, 2022. C. June 2, 2022.
B. June 1, 2022. D. November 30, 2022

81. The physician determines that Mrs Morena is approximately ten weeks
gestation. At this time, it is possible to assess all of the following signs of pregnancy
EXCEPT
A. palpation of fetal movements.
B. an increase in the size of the uterus.
C. a softening of lower uterine segment.
D. a bluish color of the vaginal mucous membranes.
82. When giving Marie’s obstetrical history, she, a pregnant client tells you that she
had 2 prior pregnancies. She had a miscarriage with her first pregnancy after 8 weeks. With
the second pregnancy she delivered twin girls at 34 weeks gestation, but the babies died
2 days after birth. The nurse should record that the client is
A. G2P3. C. G3P1.
B. G3P0. D. G3P2.
83. Kaye, a pregnant client tells you she had a miscarriage with her first pregnancy
after 11 weeks. With her second pregnancy, she delivered twin girls at 32 weeks gestation,
but the babies died 2 days after birth. Using the GPTPAL system to record her obstetrical
history, the nurse should write
A. G2 P0 T0 P1 A1 L0.
B. G2 P1 T0 P1 A1 L0
C. G3 P0 T0 P1 A1 L0.
D. G3 P1 T0 P1 A1 L0

84. A client attending the prenatal clinic for the first time tells the nurse that her last
menstrual cycle is February 7-11. The client’s expected day of delivery is calculated to be
A. May 14. C. November 4.
B. November 14. D. January 16.
85. From the 33rd week of gestation till full term, a healthy mother should have prenatal
check up every
A. Week. C. 3 weeks.
B. 2 weeks. D. 4 weeks
86. In the Batholonew’s rule of 4, when the level of the fundus is midway between the
umbilicus and xyphoid process the estimated age of gestation (AOG) is
A. 5th month. C. 7th month.
B. 6th month. D. 8th month.

87. Which of the following danger signs should be reported immediately during the
antepartum period?
A. Constipation
B. Nasal stuffiness
C. Breast tenderness
D. Leaking of amniotic fluid
88. Which of the following would the nurse include in a client’s teaching plan about the
danger signs of pregnancy?
A. Backache C. Edematous feet
B. Blurred vision D. Quickening
89. The nurse is instructing a pregnant client that she should come for prenatal check up
once a month for the first and second trimester, but if she feels any of the danger signs
she needs to seek consultation right away. The following are danger signs of pregnancy.
1) Abdominal pain 6) Edema of the feet in the
2) Blurred vision afternoon
3) Chills and fever 7) Sudden escape of fluid
4) Cerebral disturbances 8) Swelling
5) Eupnea

A. 1,2,5
B. 1,2,3,4,5,6
C. 1,2,3,4,7,8
D. 1,2,3,4,5,6,7,8

90. The client is on her 8 months pregnancy. She informs the nurse about feeling her heart
skipping a beat sometimes. The nurse recognizes this as heart palpitations and sets which
of the following goal criteria?
A. Plan a diet menu that includes high vitamin C content.
B. Demonstrate moving slowly from one position to another.
C. Verbalize intent to limit fluids to lower her heart’s workload.
D. Lie supine when sleeping to keep pressure on her vena cava.
91. Hazel is developing constipation from being on bed rest. What measures would you
suggest she take to help prevent this?
A. Drink eight full glasses of fluid such as water daily
B. Walk for at least half an hour daily to stimulate peristalsis
C. Eat more frequent small meals instead of three large one daily
D. Drink more milk, increased calcium intake prevents constipation
92. When a pregnant woman experiences leg cramps, the correct nursing intervention to
relieve the muscle cramps is
A. allow the woman to exercise.
B. let the woman walk for a while.
C. ask the woman to raise her legs.
D. let the woman lie down and dorsiflex the foot towards the knees.
93. In the later part of the 3rd trimester, the mother may experience shortness of breath.
This complaint maybe explained as
A. the woman maybe experiencing complication of pregnancy.
B. the fundus of the uterus is high pushing the diaphragm upwards.
C. a normal occurrence in pregnancy because the fetus is using more oxygen.
D. the woman is having allergic reaction to the pregnancy and its hormones.
94. Mrs Gagarin tells the nurse that she has been vomiting her breakfast nearly early
morning. Which of the following nursing measures would most likely help Mrs Gagarin
with early morning nausea and vomiting?
A. Drink only liquids for breakfast
B. Sip whole milk with breakfast
C. Eat some crackers before arising from bed
D. Drinks a carbonated beverage before arising from bed.
95. Claude manifests ankle edema by the end of each day. Which statement by her would
reveal that she understands what causes this?
A. “I know this is a beginning complication. I’ll call my doctor tonight. ”
B. “I understand this is from eating too much salt. I’ll restrict that more.”
C. “I’ll rest in Sim’s position to take pressure off lower extremity veins.”
D. “I walk for half an hour every day to relieve this, I will try walking more.
96. Which of the following should not be advised during pregnancy?
A. See the dentist regularly for routine exam and cleaning.
B. Include fresh fruits and vegetables like apples and carrots.
C. Suggests chewy candy because it stays longer in the mouth for a longer time.
D. A pregnant woman may have dental X-ray as long as the abdomen will be shielded
with lead apron.
97. Walking around about 10 minutes every at least 2 hours during long distance trip will
A. alleviate pressure on lower back.
B. impede lower extremity circulation.
C. put the weight of the fetus on the woman.
D. relieve stiffness and muscle aches and improve lower extremity circulation.
98. Intestinal motility is reduced in pregnancy as an effect of progesterone. Your pregnant
patient experiencing constipation and needs further teaching about ways in which to
overcome this discomfort when she states
A. “I must avoid eating cheese”.
B. “I need to avoid intake of sweets”.
C. “I need to stop taking my iron supplement”.
D. “I must do brisk walking of at least 1 mile per day”.

99. A pregnant woman is experiencing pyrosis. Which of the following instructions would be
most helpful? Select all that apply
A. Sleeping on her left side with two pillows
B. Avoiding the intake of oils, such as olive oil in the diet
C. Eating small more frequent mrals rather than larger ones
D. Waiting at least 2 hours after eating before attempting to lir down
100. Clara has been experiencing secvere constpation during her eight month of pregnancy.
An appropriaye goal of outcome for Clara would be to
A. consume a diet containing hgh fiber fruit and extra amount of fluid.
B. become accustomed to the constipation and accept it as unavoidable.
C. have a bowel movement every other day to avoid faily straining activity.
D. refrain from taking her iron supplement since it probably caused the problem.
COLLEGE OF NURSING
FIRST SEMESTER, S.Y. 2022-2023

NCM 107- Care of Mother, Child, and Adolescent (Well Clients) Lecture
MIDTERM EXAMINATION

INSTRUCTION: Read each question carefully and choose the best answer and click on the button below
for your answer. Each correct response will result in an appropriate score immediately at the above
front screen after submitting your exam. (100 points)
1. This is considered as the most acceptable theory. This states that when the uterine muscles get
stretched with fetal growth and increasing amniotic fluid, it results to irritability and contractions to
empty the contents of the uterus.
A. Oxytocin theory C. Theory of aging placenta
B. Uterine stretch theory D. Low progesterone theory
2. It is a theory of labor which states that the pressure of the fetal head on the cervix in late pregnancy
stimulates the posterior pituitary gland to secrete oxytocin which causes uterine contraction.
A. Oxytocin theory C. Low progesterone theory
B. Uterine stretch theory D. Progesterone deprivation theory
3. The exact cause of labor is unknown. Some of the theories that explain labor onset include ______.
Select all that apply.
A. Uterine stretch C. Decreased estrogen level
B. Oxytocin theory D. Increased progesterone level
4. There are several theories for the cause of the onset of labor. The theory that states the need for
inhibition of uterine contractility throughout pregnancy is known as the
A. oxytocin theory. C. prostaglandin theory.
B. deprivation theory. D. fetal endocrine control theory.
5. Labor is said to start when progesterone decreases, and uterine muscle stimulants increase in late
pregnancy which causes uterine contraction. This is known as the
A. oxytocin theory. C. theory of aging placenta.
B. prostaglandin theory. D. low progesterone theory.
6. During a prenatal class, the nurse explains the rationale for breathing techniques during preparation
for labor. Based on the understanding. breathing techniques are most important in achieving which of
the following?
A. Facilitate relaxation possibly reducing the perception of pain.
B. Eliminate pain and give the expectant parents something to do.
C. Eliminate pain so that less analgesia and anesthesia are needed.
D. Reduce the risk of fetal distress by increasing uteroplacental perfusion.
7. Childbirth education is vital for a successful and comfortable childbirth method. The first method that
includes the father as a support person while embracing the belief that childbirth is a neutral event
and with the right preparation most women can have spontaneous and unmedicated vaginal birth is
A. Bradley method. C. Leboyer method.
B. Lamaze method. D. Grantly Dick-Read method.
8. Before labor, a woman often experiences subtle signs that signal the onset of labor. Lightening is the
term referring to the descent of the fetal presenting part into the pelvis. Which of the following
statements is true regarding lightening?
A. It occurs approximately 5 to 7 days before the onset.
B. Lightening occurs earlier in multiparas as compared to primiparas because of their tight
abdominal muscles.
C. The mother may experience shooting pains, increased vaginal discharge and urinary
frequency during lightening.
D. The woman may have trouble of breathing and “catching her breath” due to the descent of
the fetal presenting part into the pelvis.
9. A pregnant client visits the Emergency Room because she thinks she is in labor. The nurse should
explain to the client that true labor can be differentiated for false labor by contractions that
A. are often irregular. C. achieve cervical dilatation.
B. may be felt abdominally. D. may disappear with ambulation.
10. In normal labor, as the uterine contractions become stronger, they usually also become
A. less painful. C. longer in duration.
B. less frequent. D. shorter in duration.
11. The surest sign that labor has begun is
A. lightening. C. productive uterine contractions.
B. presence of show. D. all the above.
12. Which of the following signs indicate that delivery is near? Select all that apply.
A. Perineum is bulging
B. Bloody show is increased
C. Verbalized her desire to defecate
D. Uterine contractions increased in frequency, duration, and intensity
13. A pregnant client asks Nurse Kathleen the characteristics of TRUE contractions. Which of the following
would be the nurse’s best response?
A. “True contractions decrease with activity.”
B. “True contractions begin in the lower abdomen.”
C. “True contractions are difficult to determine because they come and go.”
D. “True contractions have regularity and become more intense over time.”
14. Which one of the following is NOT a sign of impending labor?
A. Back pain C. Bloody show
B. Rupture of membranes D. Patterned and rhythmic contraction
15. Several factors affect labor. Which of the following factors refers to the passageway?
A. The structure of the maternal pelvis
B. The distance of the presenting part from the ischial spines
C. Size of the fetal head and its ability to mold to the maternal pelvis
D. The fetal attitude and the relationship of fetal parts to one another
16. Physiologic alterations in labor which are progressive, opening, widening of cervical opening and the
end of the first stage of labor are manifestation s of
A. dilatation. C. ripening.
B. effacement. D. rupture of BOW.
17. It was determined that Glyka had a platypelloid pelvis. You know that this pelvis is
A. an ape like pelvis with an oval inlet.
B. a typical female pelvis with rounded inlet.
C. a normal male pelvis with heart shaped inlet.
D. a flat female pelvis with a transverse oval inlet.
18. When measuring the pelvic inlet, it was found that the obstetric conjugate was 10 cm. This indicates
that the anteroposterior diameter is
A. considered to be marginal.
B. considered to be extremely large.
C. too narrow for normal vaginal delivery.
D. within normal limits for a normal vaginal delivery.
19. The doctor told the nurse that Mary has android pelvis. The nurse questioned if Mary may need to
have cesarean birth. The doctor would most accurately respond with
A. “Android is a flat pelvis.”
B. “There is no problem, she will have vaginal delivery.”
C. “Mary has a contracted pelvis so she must be prepared for cesarean birth.”
D. “Arrest of labor is frequent and requires forcep manipulation or cesarean birth.”
20. Estephanie, a 25-year-old multigravida, is admitted to the hospital in labor. Following examination,
the physician noted on the chart “left anterior face presentation.” The nurse explains to the nursing
student assigned to Estephanie that the landmark used to designate the fetal position in the pelvis is
A. acromion. B. mentum. C. occiput. D. sacrum.
21. Kheyziel, a 22-year-old primigravida, was admitted to the labor unit. Upon examination, the nurse
detects a breech presentation in the left anterior position. Which landmark is used to designate the
position in the pelvis of a breech presentation?
A. Acromion B. Mentum C. Occiput D. Sacrum
22. The student nurse asks, “What is the position of the fetal head in a face presentation?” In response,
the nurse would explain that the head is
A. “completely flexed.” C. “partially flexed.”
B. “completely extended.” D. “partially extended.”
23. With a left anterior breech presentation, where would the fetal heart rate be most audible?
A. In the lower left maternal abdominal quadrant
B. In the lower right maternal abdominal quadrant
C. Above the maternal umbilicus and to the left of midline
D. Above the maternal umbilicus and to the right of midline
24. When determining the position of the fetus in vertex presentation, the part of the fetus that the nurse
will use to orient to the maternal pelvis is the
A. acromion. B. mentum. C. occiput. D. sacrum.
25. The middle letter when describing the fetal position denotes the
A. fetal presenting part. C. location of sagittal suture.
B. side of maternal pelvis. D. portion of maternal pelvis.
26. When reviewing the client’s admission record, the nurse notes that the physician has determined the
station of the fetus as minus two. To develop a plan of care, the nurse should know that this term
describes the
A. height of the uterus.
B. anatomic position of the fetus.
C. placement of the uterine fundus.
D. degree of descent of the fetal head or presenting part.
27. During vaginal examination of TinTin who is in labor, the presenting part is at station plus two. Nurse,
correctly interprets it as
A. biparietal diameter is 2 cm above the ischial spines.
B. biparietal diameter is at the level of the ischial spines.
C. presenting part is 2 cm above the plane of the ischial spines.
D. presenting part in 2 cm below the plane of the ischial spines.
28. The doctor informed the woman that she is on station -1. Mrs. Armino asked the nurse, “What does a
station -1 mean?” The most appropriate response of the nurse is,
A. “Your baby is still floating or “ballotable.”
B. “It means that engagement has already occurred.”
C. “The presenting part of your baby is at the vulvar ring of your reproductive organ.”
D. “The presenting part of your baby is at the entrance of the true pelvis or the largest diameter
of the presenting part into the true pelvis.”
29. Monitoring contractions is very important during labor. To monitor uterine contractions, what should
the nurse do?
A. Offer ice chips to the woman.
B. Instruct the client take note of the duration of her contractions.
C. Spread the fingers lightly over the fundus to monitor the contraction.
D. Observe for the client’s facial expression to know that the contraction has started or stopped.
30. To monitor the frequency of the uterine contraction during labor, the right technique is to time the
contraction
A. from the beginning of ne contraction to the end of the same contraction.
B. from the end of one contraction to the beginning of the next contraction.
C. from the deceleration of one contraction to the acme of the next contraction.
D. from the beginning of one contraction to the beginning of the next contraction.
31. A laboring mother should be prepared for delivery if the nurse observes
A. the mother becoming irritable and not following instructions.
B. that the perineum is beginning to bulge with each contraction.
C. an increase in the amount of bloody discharge from the vagina.
D. the contractions are occurring every 2 to 3 minutes and lasting 60 seconds.
32. It is described as the phase of increasing or “building up” of uterine contraction. It is the first phase
and the longest phase of contraction.
A. Duration B. Increment C. Decrement D. Rupture of BOW
33. During labor, Amy greatly relies on her husband for support. They previously attended childbirth
education classes, and now he’s working with her on comfort measures. Which nursing diagnosis
would be appropriate for this couple?
A. Powerlessness related to pain
B. Ineffective family coping: Compromised related to labor
C. Ineffective role performance related to involvement with the pregnancy
D. Readiness for enhanced family coping related to participation in pregnancy and delivery
34. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She
states that she’s in labor and says she attended the facility clinic for prenatal care. Which question
should Nurse Oliver ask her first?
A. “Do you have any allergies?” C. “Who will be with you during labor?”
B. “What is your expected due date?” D. “Do you have any chronic illnesses?”
35. A 26-year-old primigravid, Mrs. Dulatre is admitted to the birthing unit. The nurse completes her
assessment and determines that Mrs. Dulatre is in the first stage of labor. Which of the following
instructions is appropriate to give Mrs. Dulatre?
A. “Remain flat on the bed.”
B. “Do not push with contractions.”
C. “Push before becoming fully dilated.”
D. “Breathe rapidly and deeply with contractions.”
36. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early
part of the first stage of labor. Her pain is likely to be MOST intense
A. at the perineum.
B. around the pelvic girdle.
C. around the perlvic girdle and at the perineum.
D. around the pelvic girdle and in the upper arms.
37. Chloe is in the first stage of labor enters the labor and delivery area. She seems anxious and tells the
nurse that she hasn’t attended childbirth education classes. Her husband, who accompanies her, is
also unprepared for childbirth. Which nursing intervention would be most effective for the couple at
this time?

A. Use hypnosis on the client and her husband.


B. Teach the client progressive muscle relaxation.
C. Teach the client and her husband about pain transmission.
D. Instruct the husband on touch, massage, and breathing patterns.
38. Dianne has been experiencing contractions every 5 minutes lasting about 60 seconds. Cervical
dilatation is 7 cm. What nursing care is appropriate at this stage?
A. Assist her to sit or lie on bed assuming a side-lying position.
B. Encourage the woman and assist with positioning as she pushes and bears down.
C. Provide client teachings and proper breathing techniques as well as time to practice these
techniques.
D. All except B
39. The multigravid mother with a history of rapid labor who is in active labor calls out to the nurse, “The
baby is coming!” Which of the following would be the nurse’s first action?
A. Inspect the perineum C. Contact the birth attendant
B. Time the contractions D. Auscultate the fetal heart rate
40. The nurse is caring for a primigravida client in active labor. The nurse should encourage the client to
void every 2 hours because a full bladder can result in
A. uterine rupture. C. urinary tract infections.
B. delayed fetal descent. D. prolonged contractions.
41. While caring a client in active labor whose cervix is dilated to 8 cm, the nurse detects an early
deceleration pattern for the fetal heart rate. The nurse should explain to the client that early
deceleration is associated with
A. fetal head compression. C. cephalopelvic disproportion.
B. uteroplacental insufficiency. D. pressure on the umbilical cord.
42. The clinical instructor is evaluating a student’s understanding of the partograph. When asked when to
start using the partograph, which of the following responses indicated that further teaching is
necessary? Use partograph when
A. each contraction lasts 20 seconds or more.
B. there are 2 contractions or more in 10 minutes.
C. labor is in latent phase (cervical dilatation is 2 cm).
D. labor is in the active phase (cervical dilatation is 3 cm or more).
43. The nurse is in charge in caring for a patient who is in the first stage of labor. What is the shortest
but most difficult part of this stage?
A. Latent phase C. Complete phase
B. Active phase D. Transitional phase
44. The management of a client in transition phase of labor is primarily directed toward
A. helping the client maintain control.
B. decreasing intravenous fluid intake.
C. reducing the client’s discomfort with medications.
D. having the client breathe simple breathing patterns during contractions.
45. A laboring mother should be prepared for delivery when the nurse observes
A. the mother becoming irritable and not following instructions.
B. that the perineum is beginning to bulge with each contraction.
C. an increase in the amount of bloody discharge from the vagina.
D. the contractions are occurring every 2 to 3 minutes and lasting for 60 seconds.
46. According to EINC, the recommended position for a client during delivery is
A. semi-upright. C. lithotomy position.
B. dorsal recumbent. D. trendelenburg position.
47. A patient is in the second stage of labor. During this stage, how frequent should the nurse in charge
assess her uterine contractions?
A. Every 5 minutes C. Every 30 minutes
B. Every 15 minutes D. Every 60 minutes
48. Mrs. Macayan has contractions growing stronger which lasts for 40-60 seconds and occur
approximately every 3-5 minutes. The doctor is about to perform an IE, the nurse expects that the
client’s cervical dilatation will be
A. 0-3 cm. B. 4-7 cm. C. 8-10 cm. D. 11-13 cm.
49. The history of Mrs. Macayan revealed that she is a multipara. When should the nurse transport the
client from the labor room to the delivery room?
A. When the cervical dilatation is 8 cm C. When the cervical dilatation is 10 cm
B. When the cervical dilatation is 9 cm D. When the client feels the urge to push
50. When a client states that her “water broke,” which of the following actions would be inappropriate
for the nurse to do?
A. Observing the pooling of straw-colored fluid
B. Checking vaginal discharge with nitrazine paper
C. Observing for flakes of vernix in the vaginal discharge
D. Conducting a bedside ultrasound for an amniotic fluid index
51. Mary who is in labor shouts to the nurse, “My baby is coming right now! I feel I have to push!” An
immediate nursing assessment reveals that the head of the fetus is crowning. After asking another
staff member to notify the physician and setting up for delivery, which nursing intervention is MOST
appropriate?
A. Gently pulling at the baby’s head as it’s delivered
B. Holding the baby’s head back until the physician arrive
C. Applying gentle pressure to the baby’s head as it’s delivered
D. Placing the mother in a trendelenburg position until the physician arrives
52. To prevent the fetal head from being expelled too rapidly, it should be delivered between
contractions. To accomplish this, you must instruct the mother to
A. push with contractions. C. push as hard as she can.
B. pant with contractions. D. perform long, sustained pushing.
53. The passage of the fetus through the birth canal involves a number of different position changes
called cardinal movements. Which of the following is the correct order of positions the fetus
assumes during movement through the birth canal?
A. Descent, flexion, extension, internal rotation, external rotation, expulsion
B. Descent, flexion, internal rotation, extension, external rotation, expulsion
C. Descent, internal rotation, flexion, extension, external rotation, expulsion
D. Engagement, descent, internal rotation, flexion, external rotation, expulsion
54. Nurse Blessy is caring for a client who’s in labor. The physician still isn’t present. After the baby’s
head is delivered, which nursing intervention would be most appropriate?
A. Assessing the baby for respirations
B. Placing antibiotic ointment in the baby’s eyes
C. Turning the baby’s head to the side to drain secretions
D. Checking for the umbilical cord around the baby’s neck
55. When shoulder appears under the symphysis, the fetus has achieved
A. flexion. B. expulsion. C. extension. D. external rotation.
56. Which of the following statements is NOT true regarding the third stage of labor?
A. The placenta is delivered approximately 5-15 minutes after delivery of the baby.
B. If the placenta separates first at the center and lasts at its edges, this is known as Schultze
placenta.
C. Care should be taken in the administration of bolus oxytocin because oxytocin causes
hypertension.
D. Signs of placental separation are lengthening of the umbilical cord, sudden gush of blood and
change in the shape of the uterus.
57. After the placenta is delivered, the nurse may have which of the following responsibilities?
A. Administering intramuscular oxytocin to facilitate uterine contractility
B. Pushing down on the relaxed uterus too aid in the removal of the placenta
C. Monitoring for blood loss greater than 60 cc indicative of gross hemorrhage
D. Noting if placenta makes a schultze presentation which is a sign of major complication
58. What are the important considerations that the nurse must remember after the placenta is
delivered? Select all that apply.
A. Check if the cord is long enough for the baby
B. Check if the umbilical cord has 3 blood vessels
C. Check if the cord has a meaty portion and a shiny portion
D. Check if the placenta is complete including the membranes
59. A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant.
In the immediate postpartum period, the nurse plans to take the woman’s vital signs
A. every hour for the first 2 hours and then every 4 hours.
B. every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.
C. every 30 minutes during the first hour and then every hour for the next two hours.
D. every 15 minutes during the first hour and then every 30 minutes for the next two hours.
60. A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4
hours ago. The nurse notes that the mother’s temperature is 100.2*F. Which of the following actions
would be most appropriate?
A. Notify the physician C. Retake the temperature in 15 minutes
B. Document the findings D. Increase hydration by encouraging oral fluids
61. The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client
complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions
would be most appropriate?
A. Elevate the mother’s legs
B. Obtain hemoglobin and hematocrit levels
C. Instruct the mother to request help when getting out of bed
D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the
feelings of light-headedness and dizziness have subsided
62. When examining a postpartum woman, the nurse should immediately report
A. a soft, spongy uterine fundus noted during the first hour postpartum.
B. a fundus that cannot be located by palpation on the ninth postpartum day.
C. red, bloody vaginal discharge on the perineal pad on the first day postpartum.
D. a fundus that is palpated 2 cm below the umbilicus on the second postpartum day.
63. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action
in performing this assessment is which of the following?
A. Ask the client to turn on her side
B. Ask the mother to urinate and empty her bladder
C. Massage the fundus gently before determining the level of the fundus
D. Ask the client to lie flat on her back with the knees and legs flat and straight
64. The nurse is assessing the lochia on a 1-day postpartum patient. The nurse notes that the lochia is red
and has a foul-smelling odor. The nurse determines that this assessment finding is
A. normal. C. indicates the need for increasing oral fluids.
B. indicates the presence of infection. D. indicates the need for increasing ambulation.
65. When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The
nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing
actions is most appropriate?
A. Notify the physician C. Reassess the client in 2 hours
B. Document the findings D. Encourage increased intake of fluids
66. A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia
drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never
exceed the need for ___ per day.
A. 1 peripad B. 2 peripads C. 3 peripads D. 8 peripads
67. Nurse Amalia is providing instructions to a woman after delivery of a healthy newborn infant. She
instructs the mother that she should expect normal bowel elimination to return
A. 3 days postpartum. C. on the day of the delivery.
B. 7 days postpartum. D. within 2 weeks postpartum.
68. Select all the physiological maternal changes that occur during the postpartum period.
A. Digestive processes slow immediately
B. Cervical involution ceases immediately
C. Fundus begins to descend into the pelvis after 24 hours
D. Cardiac output decreases with resultant tachycardia in the first 24 hours
69. A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following
signs, if noted in the mother, would be an early sign of excessive blood loss?
A. A temperature of 100.4*F
B. An increase in the pulse from 88 to 102 BPM
C. A blood pressure changes from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths per minute
70. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period.
When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the
following nursing interventions would be most appropriate initially?
A. Elevate the mother’s legs
B. Encourage the mother to void
C. Massage the fundus until it is firm
D. Push on the uterus to assist in expressing clots
71. A nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client
has cool, clammy skin, is restless, and excessively thirsty. The nurse prepares immediately to
A. begin hourly pad counts and reassure the client.
B. begin fundal massage and start oxygen by mask.
C. elevate the head of the bed and assess vital signs.
D. assess for hypovolemia and notify the health care provider.
72. A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm, but that bleeding
is excessive. The initial nursing action would be which of the following?
A. Record the findings C. Massage the fundus
B. Notify the physician D. Place the mother in the Trendelenburg’s position
73. A nurse is preparing a list of self-care instructions for a Postpartum client who was diagnosed with
mastitis. Select all instructions that would be included on the list. Select all that apply.
A. Wear supportive bra
B. Rest during the acute phase
C. Continue to breastfeed if the breasts are not too sore
D. Take the prescribed antibiotics until the soreness subsides
74. Methergine or pitocin is prescribed for a woman to treat postpartum hemorrhage. Before
administration of this medication, the priority nursing assessment is to check the
A. uterine tone. C. amount of lochia.
B. blood pressure. D. deep tendon reflexes.
75. Which of the following factors might result in a decreased supply of breast milk in a postpartum
mother?
A. An alcoholic drink C. Maternal diet high in vitamin C
B. Frequent feedings D. Supplemental feedings with formula
76. Which of the following interventions would be helpful to a breastfeeding mother who is experiencing
engorged breasts?
A. Applying ice
B. Applying a breast binder
C. Administering bromocriptine (Parlodel)
D. Teaching how to express her breasts in a warm shower
77. On completing a fundal assessment, the nurse notes the fundus is situated on the client’s left
abdomen. Which of the following actions is appropriate?
A. Ask the client to empty her bladder
B. Straight catheterize the client immediately
C. Call the client’s health provider for direction
D. Straight catheterize the client for half of her uterine volume
78. Which of the following findings would be expected when assessing the postpartum client?
A. Fundus 1 cm above the umbilicus 1 hour postpartum
B. Fundus 1 cm above the umbilicus on postpartum day 3
C. Fundus palpable in the abdomen at 2 weeks postpartum
D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2
79. Which of the following behaviors characterizes the postpartum mother in the taking in phase?
A. Passive and dependent
B. Striving for independence and autonomy
C. Curious and interested in care of the baby
D. Exhibiting maximum readiness for new learning
80. Which of the following physiological responses is considered normal in the early postpartum period?
A. Rapid diuresis C. Urinary urgency and dysuria
B. Decrease in blood pressure D. Increase motility of the GI system
81. During the 3rd postpartum day, which of the following observations about the client would the nurse
be most likely to make?
A. The client talks a lot about her birth experience.
B. The client sleeps whenever the neonate isn’t present.
C. The client requests help in choosing a name for the neonate.
D. The client appears interested in learning about neonatal care.
82. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding
woman who is one day postpartum. An expected finding would be
A. leakage of milk at let down.
B. soft, non-tender; colostrum is present.
C. a few blisters and a bruise on each areola.
D. swollen, warm, and tender upon palpation.
83. Following the birth of her baby, a woman expresses concern about the weight she gained during
pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the
expected pattern of weight loss, should begin by telling this woman that
A. the expected weight loss immediately after birth averages about 11 to 13 pounds.
B. return to prepregnant weight is usually achieved by the end of the postpartum period.
C. fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-pound weight loss.
D. lactation will inhibit weight loss since caloric intake must increase to support milk production.
84. Which of the following findings would be a source of concern if noted during the assessment of a
woman who is 12 hours postpartum?
A. Postural hypotension C. Bradycardia — pulse rate of 55 BPM
B. Temperature of 100.4°F D. Pain in left calf with dorsiflexion of left foot
85. The nurse examines a woman one hour after birth. The woman’s fundus is boggy, midline, and 1 cm
below the umbilicus. Her lochial flow is profused, with two plum-sized clots. The nurse’s initial action
would be to
A. call the physician.
B. massage her fundus
C. place her on a bedpan to empty her bladder.
D. administer methergine 0.2 mg im which has been ordered prn.
86. Mrs. Gumangan is 1 day postpartum. Her temperature is 38°C. You would evaluate this as

A. she must be developing a postpartum infection.

B. this is a normal finding for the first day postpartum.

C. she must be developing a toxic reaction to her newborn.

D. her temperature is subnormal for 24 hours post-delivery.

87. Mrs. Mosuela reports she is afraid to have a bowel movement because that may cause pain. You

would advise her that

A. she should ask her doctor for a prescription for a stool softener.

B. it would be very rare if a bowel movement caused pain after birth.

C. she should eat soft foods for the next 3 days to increase peristalsis.

D. it would be good to feel pain because that means nerves are not severed.

88. On the third day postpartum, Mrs. Cornell tells you her breasts feel warm and tender. It would be

best to tell her that

A. her infant must be draining too much milk at feedings.

B. she needs to drink more fluid to reduce inflammation.

C. this suggests a breast infection (mastitis) is developing.

D. this sounds like engorgement occurring, which is normal.

89. The nurse in planning to help a woman adjust to her baby, must consider which of the following?
A. The mother will require little assistance since parental love instinctive.
B. It may be natural for the mother to be hesitant initially when touching the child.
C. The more difficult the labor process, the stronger the mother’s bond with her child.
D. Holding the child immediately after birth is overwhelming to a new mother and should be
avoided.
90. Baby Johua, like all newborns are in danger of losing body heat by conduction. You are taking action
to ensure that baby Joshua’s body temperature is maintained in order to protect his health and
comfort. Under which condition is heat loss by conduction most apt to occur?
A. A fan is operating in the room.
B. He pulls off the cap you put on her head.
C. Baby Joshua is wet from amniotic fluid at birth.
D. You place her on a scale that has not been prewarmed.
91. A Moro reflex is the single best assessment of neurologic ability in a newborn. Unit protocols should
specify what action for eliciting a Moro reflex in Tess?
A. Make a sharp noise, such as clapping your hands.
B. Turn her onto her abdomen and see if she can turn her head.
C. Lift her head while she is supine and allow it to fall back 1 inch.
D. Gently shake Tess’ bassinette until she responds by flailing out her arms.
92. Aizel had Apgar scores of 6 at 1 minute and 8 at 5 minutes after birth. Which of the following are the
five areas assessed with Apgar scoring?
A. Heart rate, respiratory effort, muscle tone, reflex irritability, and color
B. Respiratory rate, abdominal tone, reflexes, color, and head circumference
C. Color, breathing rate, cry, amount of brown fat, and response to loud noise
D. Abdominal tone, persistence, reflexes, blood pressure, and response to pain
93. Kaye Novales has milia on her nose. What teaching point would constitute a safety risk?

A. “Try to gently scratch off these spots in a few days.”

B. “Make sure that you keep Carmen bundled warmly.”

C. “Wash Carmen the same way that the nurse first taught you.”

D. “These will disappear on their own, so you don’t need to take any action.”

94. Mrs. Delmendo is preparing to take her new daughter home and has asked a midwife when will the
umbilical cord fall off. You should confirm that the midwife has stated what time?
A. Day 1 B. Day 2 to 3 C. Day 6 to 10 D. Day 30
95. The nurse is performing the morning assessment of baby boy Lee born yesterday at 39 weeks gestation
and weighing 3500 g. In assessing the chest comparatively to the head, the nurse would expect
A. the chest and head circumference to be equal.
B. the chest circumference to be about 2 cm less than the head circumference
C. the head circumference to be about 2 cm less than the chest circumference.
D. the head circumference to be about 3 cm more than the chest circumference.
96. A neonate’s temperature is slightly subnormal 1 hour after birth. Which action would be most
appropriate?
A. Place a second stockinette on the infant’s head.
B. Place the infant under a radiant warmer or in a heated isolette.
C. Administer a warm bath with temperature slightly higher than usual.
D. Take the infant to the mother for bonding and transfer of body heat after mom rests for an
hour.
97. Jammil’s temperature at 1 hour after birth was 98.6°F (37°C). The temperature of the average
newborn immediately after birth is
A. 96°F (35.6°C). C. 101°F (38.4°C).
B. 99°F (37.2°C). D. 105°F (40.6°C).
98. Albert ’s hemoglobin is 18 g/dL. The usual hemoglobin value of newborns is
A. 7 to 11 gm/dL. C. 17 to 18 gm/dL.
B.1 1 to 12 gm/dL. D. 19 to 21 gm/dL.
99. Sean’s weighed 8 pounds 1 ounce at birth. Suppose on the third day of life, he weighs 7 pounds 8
ounces. You would assess this as a(n)
A. excessive newborn weight loss.
B. average weight loss for a newborn.
C. loss not consistent with breastfeeding.
D. loss is still normal but becoming dangerous.
100. At 20 hours after birth, Renel still has not voided. You would assess this as
A. he must need his breast milk intake supplemented.
B. he needs a referral for kidney and bladder structure.
C. this is an emergency that will require catheterization.
D. this is within normal parameters for a breastfed newborn.
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

NATIONAL HEALTH SITUATION OF MCN in 2022, according to data from the Philippine
Statistics Authority.
1. Increase maternal death and unintended ▪ The PSA said 468 maternal deaths have been
pregnancies related to following: recorded in the first 6 months of 2022, up from
a. Declining utilization of facilities for the 425 recorded in the same period last year.
antenatal check-up and delivery ▪ Lolito Tacardon, Executive Director of the
➢ Service disruption Commission for Population and Development
➢ Difficulty in commuting (POPCOM), said they are still investigating the
➢ Fear of having COVID uptick in maternal deaths in the country.
b. Poor access to modern contraception ▪ More Filipino mothers are dying at childbirth,
2. Increase teenage pregnancy new data says
▪ Teenage pregnancy affects about ▪ Pregnant women urged to give birth in health
6% of Filipino girls. facilities aftiroer 'sharp increase' in maternal
▪ An estimated 538 babies are born to mortality
Filipino teenage mothers EVERY
SINGLE DAY, according to the REASON/S delay in the referral, and of course
Philippine Statistical Authority from other
2017. service-related, pertaining in general
▪ 96,370 babies born each year to on the quality of the services being
teenage mothers in the Philippines! provided in the health facility,”
▪ Nearly 200,000 teenagers get STRATEGY together with the Department of
pregnant every year! Health, we’re in the process of
intensifying and developing multi-
▪ there are roughly 40 births each
sectoral comprehensive action plan for
year by girls who have not yet
the more intensified implementation of
reached the age of 13 reproductive health (measures) ANC,
3. Increase intimate partner violence 21 October 2022
4. Disrupted access to life-saving sexual and
reproductive health services
INTERNATIONAL
STATISTICS
▪ The high number of maternal deaths in some
Maternal mortality increase by 26% areas of the world reflects
Unintended pregnancies increase by 42% ✓ inequities in access to health
No use of contraception increase by 67% services, and highlights the gap
between rich and poor.
UNINTENDED PREGNANCY AND ABORTION RATES ▪ Maternal mortality is higher in women living in
rural areas and among poorer communities.
▪ In the PH, the unintended pregnancy rate ▪ Young adolescents face a higher risk of
declined 33% between 1990-1994 and 2015- complications and death as a result of
2019. During the same period, the abortion pregnancy than older women.
rate increased 51%. The share of unintended
pregnancies ending in abortion rose from 22%
to 51%

PREGNANCY OUTCOMES

▪ In the PH, in 2015-2019, there were a total


3,770,000 pregnancies annually. Of these,
1,930,000 pregnancies were unintended and
973,00 ended in abortion. Abortion is
prohibited in the Philippines.

YEAR 2022

▪ MANILA – Deaths due to complications from


childbirth in the Philippines are up 10 percent

1|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

GENETIC ASSESSMENT AND COUNSELLING ▪ Extensive prenatal history


• Number of children
Genetics a branch of biology concerned • How are they delivered
with the study of genes, genetic
• Problems encountered
variations and heredity in living
organism. during pregnancy, labor
Genetic is a process of communicating and postpartum
Counselling between two or more persons 2. Physical Assessment
who meet to solve a problem, ▪ Pay particular attention to the space
resource a curse or take decisions between the eyes, height, contour,
on various matters. It is not a oe shape of ears, number of fingers and
way process where in the toes, presence of webbing
counseling tells the client what to ▪ DERMATOGLYPHICS – study of
do nor it is a forum for surface markings of the skin
presentation of the counselor’s
value. 3. Diagnostic Testing
Karyotyping Sample of peripheral
Is the process of advising
venous blood or a
individuals and families affected
scraping of cells from
by or at risk of genetic disorders to
the buccal membrane
help them understand and adapt
is taken
to the medical, psychological and
familial implications of genetic
Cells are allowed to
contributions to disease.
grow until they reach
Phenotype refers to outward appearance of
metaphase- most
the expression of genes
easily observed phase
Genotype refers to actual gene composition
Genome complete set of genes present Cells are stained,
placed under a
normal genome = 46XX/ 46XY microscope and
Genetic disorder passed from one photographed
Disorder generation to the next
Chromosomes are
Occur in same ethnic group identified according
to
Occur at the moment an ovum and size, shape and stain
sperm fuse or even earlier in the Maternal serum Done at 15th week of
meiotic division phase of the ovum screening pregnancy
or sperm when the chromosome
count is halved from 46 to 23. Alphafetoprotein
(AFP) – a
glucoprotein
METHODS OF ASSESSMENT
produced by the fetal
1. History Taking liver
▪ Include any one related to the family
Peak is between 13th
▪ Maternal age (> 35 y/o) = mother
and 32nd week of
will be at high risk and can have a
pregnancy
defective gene.
▪ Paternal age (>55y/o) = father will RESULT:
be at high risk and can have a if elevated – it means
defective gene. spinal cord disease/
▪ AGE = factor that determines why neural tube defects
they have genetic disorders.
▪ Document parents if If below – it means
consanguineous/related to each Chromosomal
other disorder/Down
▪ Document ethnic background syndrome

2|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

PUBS Other name:


MSAFP (Maternal (Percutaneous Cordocentesis
Serum Umbilical Blood
Alphafetoprotein) Sampling) Removal of blood
CVS (Chorionic a diagnostic from the fetal
Villi Sampling) technique that umbilical cord at
involves the retrieval about 17 weeks using
and analysis of an amniocentesis
chorionic villi from technique
the growing placenta Fetal Imaging MRI and UTZ = used
for chromosome or to assess a fetus for
DNA analysis general size and
structure disorder of
Commonly done at 8- the internal organs,
10 weeks or 10-12 spine and limbs
weeks of pregnancy

May be done as early COMMON CHROMOSOMAL DISORDERS


as 5 weeks
Amniocentesis Locate first where is Most common characteristics of chromosomal disorder
the baby’s back; to = cognitively challenged and low set ears
know where to insert
Down syndrome/Trisomy 47XXY21/47XY21
the needle.
21
FHR should be CHARACTERISTICS
monitored before
• Late closure of fontanelle
and after the
✓ Anterior = 17-18 months
procedure.
✓ Posterior = 2 months
Withdrawal of • Slant eyes
amniotic fluid • Epicanthal fold = extra fold of tissue at the
through the inner cannula
abdominal wall for • Bushfield spots = iris with white specks
analysis • Large tongue
• Low set ears
Done between 14th- • Small mouth cavity
16th week of • Back of the head is flat
pregnancy = 11-15 • Neck is short
weeks, amniotic fluid • Extra pad of fat at the base of the head
is abundant causes the skin to lose
• Poor muscle tone ( rag-doll appearance)
A pocket of amniotic • Fingers are short and thick
fluid is located by • Little finger is often curved inward
ultrasound (UTZ) • Wide space between the 1st and 2nd
fingers and toes
A needle is inserted
• Palm- with one single horizontal simian
transabdominally
crease
• Small head
Aspirate 20 ml of
• Brain is not well developed
amniotic fluid
• IQ= 50-70
Client receives Rh • Prone for infection
immune globulin • Clinodactyly = little finger is curved inward
administration after • Abnormal dermatoglyphics
the procedure
(Rhogam) = to
prevent problems
after the procedure

3|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Fragile X Syndrome 46XY23q • With coarctation (stricture) of aorta and


CHARACTERISTICS
• Kidney disorder
• Severely cognitively challenge
• Common in males
• q = long arm of the chromosome
• Most common cause f cognitive challenge Klinefelter Syndrome 47XXY
in males
CHARACTERISTICS
• An X linked disorder in which 1 long arm of
an X chromosome is defective • Common on Males
• Before puberty: displays maladaptive • With an extra X chromosome
behavior such as hyperactivity and autism • Absence of secondary sex characteristics
• Bossing (prominent forehead) • Small testes- produces ineffective sperm
• Prominent lower jaw • Gynecomastia (enlarged breast size)
• Large hands • Increased risk of male breast cancer
• Marked deficit in speech and
mathematics/problem solving
• Large head Trisomy 13/ Patau 47XX13/ 47XY13
• Long face Syndrome
• Large protruding ears CHARACTERISTICS
• After puberty: enlarged testicles
• Has an extra chromosome 13 and
cognitively challenged
Trisomy 18 Syndrome / 47XY18/47XX18 • Most do not survive beyond early
Edward’s Syndrome childhood
• Microcephaly
CHARACTERISTICS • Clip lip and palate
• have copies of chromosome 18 • Low set ears
• do not survive beyond early infancy; until 1 • Multiple hair whorls
year only. • Wide set nipples
• Microcephaly = small head • Rocker bottom feet
• Severely cognitively challenges • Heart defects (ventricular septal defect)
• Small gestational age at birth • Abnormal genitalia
• Marked low set ears • Small eyes (microphthalmos)
• Small jaw
• Congenital heart defects
• Misshapen fingers and toes (index fingers GENETIC COUNSELING
• deviates or cross over other finger)
▪ Provide concrete, accurate information about
• Multiple hair whorls
the process of inheritance and inherited
disorder
Turner syndrome 45X0 ▪ Reassure people who are concerned that their
child may inherit a particular disorder that the
CHARACTERISTICS
disorder will not occur
• Common in females ▪ Allow people who are affected by inherited
• Has only 1 functional X chromosome disorder to make
• Can be identified with an UTz during ▪ informed choices about future reproduction
pregnancy because of the increase neck ▪ Offer support on people who are affected by
folds genetic disorder
• Low set hair line ▪ Observe data privacy
• Webbed neck ▪ Ideal time for counseling is before 1st
• Gonadal diagenesis pregnancy
• Short in structure
• Has only streak (small and nonfunctional) ROLE OF A NURSE IN GENETIC COUNSELING
• ovaries
• Sterile = cannot produce a child ▪ Guiding women or couple through prenatal
• Exception of pubic hair; secondary sex diagnosis
• characteristics do not develop at puberty ▪ Helping parents to make decisions in regards
• Newborns= edema on the hands and feet to abnormal prenatal diagnosis results
4|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

▪ Assisting parents with have hada child with a


birth defect to locate needed service and
support
▪ Providing support to help the family deal with
the emotional impact of a birth defect
▪ Coordinate services of other professionals
such as social workers, physical and
occupational therapists, psychologist,
dietician

IMPORTANCE OF GENETIC COUNSELLING

1. Aid in determining the risk of disease


2. Help in identifying a hereditary condition
3. Assist in whether genetic testing is
appropriate
4. Offer diagnosis and disease prevention and
management
5. Offer emotional and psychological support,
ethical guidance to help clients make well
informed autonomous health care decisions
and reproductive choices.

5|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

ASSESSMENT OF HIGH-RISK PREGNANCY CIRCUMSTANCES THAT CAUSE WOMEN TO BE HIGH-


RISK:
▪ When a woman enters pregnancy with a
chronic condition such as cardiovascular, or ✓ Poverty
kidney disease, both she and the fetus can be ✓ Lack of support people circumstances that
at risk for complications because either the ✓ Poor coping mechanisms causes women to be
pregnancy can complicate the disease or the ✓ Genetic inheritance
disease can complicate the pregnancy
affecting the baby or leaving a woman less ASSESSMENT OF RISK FACTORS
equipped to function in the future or undergo
DEMOGRAPHIC FACTORS
a future pregnancy
▪ In addition to pre-existing illnesses, the EFFECTS
pregnant woman like any person may develop Maternal Age (<18 or Less than 18: increased
new illness during pregnancy which can >35 years) risk for LBW and
adversely affect not only the woman but her preterm labor, PIH,
unborn child. anemia, Cesarean
▪ When accidents and illness occur despite Section for CPD.
precautionary measures, nursing care focuses
More than 35 years:
on
increased risk of
✓ Preventing such disorders from
chromosomal
affecting the health of the fetus abnormalities, PIH,
✓ Helping a woman regain her health placenta
as quickly as possible so she can previa , H- Mole, CHVD
continue a healthy pregnancy and Babies with
prepare herself psychologically and chromosomial
physically for labor and birth and the abnormalities
arrival of her newborn Poverty Associate with LBW,
✓ Helping a woman learn more about preterm infants
her chronic illness so she can Maternal Parity/ Hemorrhage, CS and
continue to safeguard her health multiparty ( >4 fetal loss/ abortion
during her childrearing years pregnancies)

HIGH RISK
PERSONAL-SOCIAL FACTORS
▪ Is one in which a concurrent disorder,
pregnancy related complication, or external EFFECTS
factor jeopardizes the health of the woman, Weight <100 lbs: associated with
LBW
the fetus or both.
▪ One in which some condition puts the mother,
>200 lbs: PIH, LGA
the developing fetus, or both at higher-than- infants, difficult labor,
normal risk for complications during or after CS due cpd
the pregnancy and birth. Height ( <5 feet) Increased risk for CS due
to CPD
CAUSES
Smoking LBW, preterm birth
✓ Related to the pregnancy itself when they Alcohol/ illegal drug use
exist in pregnancy ✓ Lifestyle and Congenital anomalies,
occupation fetal withdrawal
✓ Occurs because the woman has a medical
✓ What she syndrome, fetal alcohol
condition
consumes and syndrome
✓ Results from environmental hazards what she is
✓ Arise from maternal behavior or lifestyle exposed to can
✓ Past history of pregnancy complications seriously affect
✓ Should be seen more frequently for prenatal her pregnancy.
care Substance Abuse

6|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

OBSTETRIC FACTORS AND GYNECOLOGIC HISTORY Concurrent infection Severe fetal effects if
maternal disease
EFFECTS occurs in the first
Birth of previous infant Increased risk for CS, trimester
with weight >8.5 lbs/ birth injury, maternal
2 or more premature gestational diabetes and Increased risk for
deliveries/ abortions neonatal hypoglycemia spontaneous abortion
Previous stillbirth Increased risk of and
maternal psychological congenital anomalies
distress Seizure disorders Increased risk of fetal
Rh sensitization Increased risk for fetal malformation,
anemia, increased incidence of
erythroblastosis and cerebral palsy, seizure
kernicterus disorder and mental
Cervical insufficiency Associated with delivery retardation in offspring
/cervical incompetency of previable fetus Liver disease Preterm and stillbirths
Multiple gestations/ Associated with
pregnancies nutritional anemia,
preeclampsia, preterm ENVIRONMENTAL AGENTS
malposition labor, malpresentation,
Impair fertility, interfere
CS, postpartum
with normal
malpresentation hemorrhage
placental function and
may be toxic to the
previous dystocia
fetus leading to fetal
death
placental abnormalities

FACTORS THAT CATEGORIZES CLIENT TO BE HIGH-RISK


EXISTING MEDICAL CONDITIONS/
MATERNAL MEDICAL HISTORY PREPREGNANCY
EFFECTS PSYCHOLOGICAL SOCIAL PHYSICAL
Diabetes Miletus Increased risk of PIH. CS, History of drug Occupation Visual or
LGA, SGA , neonatal dependence involving hearing
hypoglycemia, fetal or (including handling of challenges
neonatal death, alcohol) toxic
congenital anomalies substances Pelvic
Hypothyroidism Increased risk of History of (radiation & inadequacy or
spontaneous abortion, intimate partner anesthesia misshape
congenital anomalies, abuse gases)
congenital Uterine
hypothyroidism History of Environmental incompetency,
Cardiac Disease Increased risk of fetal or mental illness contaminants position or
neonatal death at home structure
History of poor
Watch out for signs of coping Isolated Secondary
worsening heart mechanisms major illness
disease such as edema, Lower (heart disease,
crackles, activity Cognitively economic level diabetes m.,
intolerance, and challenged kidney d.,
irregular heart rate Poor access to hypertension)
Renal Disease Associated with Survivor of transportation Chronic
maternal renal failure, childhood sexual for care infection such
preterm delivery, abuse as
intrauterine growth High altitude (tuberculosis,
retardation hemopoietic
Highly mobile or blood dis.,
lifestyle malignancy.

7|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Poor housing Poor Decrease in self Disruptive Multiple


gynecologic or esteem family incident gestation
Lack of support obstetric
people History Drug abuse Conception less A bleeding
(alcohol, than 1 year disruption
History of cigarette after last
previous poor smoking) pregnancy Poor placental
pregnancy formation or
outcome Poor position
(miscarriage, acceptance of
stillbirth, pregnancy Gestational
intrauterine diabetes
fetal death)
Nutritional
History of child deficiency of
with congenital iron, folic acid,
anomalies or protein

Obesity (BMI Poor weight


>30) gain

Underweight Pregnancy-
(BMI <18.5) induced
hypertension
Pelvic
inflammatory Infection
disease
Amniotic fluid
History of abnormality
inherited
disorder Postmaturity

Small stature
LABOR AND DELIVERY
Potential of
PSYCHOLOGICAL SOCIAL PHYSICAL
blood
incompatibility Severely Lack of Hemorrhage
frightened by support
Younger than labor and birth person Infection
age 18 years or experience
older than 35 Inadequate Fluid and
years Inability to home for electrolyte
participate infant care imbalance
Cigarette because of
smoker anesthesia Unplanned
cesarean birth
Substance Separation of
abuser infant at birth Lack of access
to continued
Lack of health care
PREGNANCY separation for
labor Lack of access
PSYCHOLOGICAL SOCIAL PHYSICAL to emergency
Loss of support Refusal of or Fluid or Birth of infant personnel or
person neglected electrolyte who is equipment
prenatal care imbalance disappointing in
Illness of a family some way
member Exposure to Intake of
environmental teratogen Illness in
teratogens such as drug newborn
8|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

VULNERABLE GROUPS OF PREGNANT WOMEN done between 14-


16TH weeks
✓ Adolescent
✓ Mentally ill Invasive procedure
✓ 18 y/o and below for amniotic fluid
✓ Women over 40 y/o analysis to
✓ Physically and cognitively challenge assess fetal lung
✓ Woman who is a substance dependent maturity done after
14 weeks gestation
DIAGNOSTIC TESTS AND LABORATORY EXAMS AND NST Reactive test – 3
SCREENING PROCEDURES accelerations of FHR
15 beats/min above
UTZ Abdominal, baseline FHR lasting
transvaginal, doppler for 15 sec. Or more,
over 20 minutes
UTZ = 18-20 weeks
detect gross Non-reactive test –
anomalies no accelerations or
BIOPROFILE 36-38 weeks acceleration less
than 15 beats/
Biophysical profile = minute above
uses baseline FHR. May
ultrasonography and indicate fetal
NST to assess 5 jeopardy.
biophysical variables AFI (AMNIOTIC FLUID the sum of the
in determining fetal INDEX) amniotic fluid in the
well-being. quadrants of the
uterus
Performed during a KICK COUNT ASSESSMENT Sandovsky or Cardiff
30-minute time TOOL Method – usually
frame done after meal

NST – assessing for 10 movements per


FHR acceleration in hour
relation to fetal AFP (AMNIOTIC to detect neural tube
movements FETOPROTEIN) defects, done at 15-
20 weeks
Amniotic fluid index DIABETIC SCREENING Done at 24-28 weeks
– assessing for one or PERCUTANEOUS BLOOD
more pockets of SAMPLING/CORDOCENTESIS
amniotic fluid MSAFP Done between 16-18
measuring ¾ inch (2 weeks
cm) or more in 2
perpendicular maternal serum
planes. alpha fetoprotein –
done to detect
Gross fetal body neural tube defects
movements – one or or open
more episodes abdominal wall
lasting at least 30 defects
seconds.
SICLE CELL TEST done to detect
presence of sickle
Fetal muscle tone –
hemoglobin in at risk
one or more active
women.
extension with
GROUP B BETA (cervical and
return to flexion of
STREPTOCOCCUS pharyngeal
spine, hand or limbs.
swabs)
AMNIOCENTESIS for L/S ratio

9|N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

done to detect
carriers or active
group B beta
streptococcus.
BASIC LAB TEST To test for high risk
patient

Blood screening for


Rh actor

VDRL for sedone at


32 weeks

Urine testing/
Urinalysis

Pap’s smear for STD

Stool culture for ova


and parasites

DANGER SIGNS OF PREGNANCY

✓ Pain
✓ Persistent vomiting
✓ Sudden gush of fluid from the vagina
✓ Headache
✓ Vaginal bleeding
✓ Blurred vision
✓ Dizziness
✓ Chills and fever over 38C (100.4F)
✓ Painful urination

10 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

PRE-GESTATIONAL CONDITIONS ✓ Shortness of


Breath
ANEMIA ✓ Palpitation
▪ Decreased oxygen carrying capacity of the ✓ Weakness
blood ✓ Headache
▪ Normally, blood volume expands during ✓ Fast HB
pregnancy (pseudo anemia)= faster increase ✓ Unusual craving
of plasma volume than RBC production BUT in (Pica)
2nd trimester, RBC increases EFFECTS ✓ Low Birth Weight
▪ PSEUDO ANEMIA = FALSE ANEMIA ✓ Heart Disease
✓ Common also for teenagers because ✓ Preterm birth
✓ Pica (food
of foods they comsume
craving)
1st trimester Hemoglobin is less tab 11g/dl ✓ Delayed growth
2nd trimester Hematocrit less than 33% MANAGEMENT Women should take
Hgb less than 10.5 g/dl prenatal vitamins

3rd trimester Hct less than 32% Iron supplement of 60 mg


✓ take with vitamin
C
Anemic Less than 11 g/dl ✓ take with food to
Normal 15.1 – 17.1 g/dl prevent gastric
Hemoglobin irritation
Normal 33 – 45% ✓ increase
Hematocrit roughage diet to
prevent
constipation
TYPES OF ANEMIA Constipation = Increase h20
Color of stool = black
✓ Iron deficiency anemia
✓ Folic acid deficiency anemia Diet high in iron and
✓ Sickle cell anemia vitamins

IRON DEFICIENCY ANEMIA FOLIC ACID DEFICIENCY ANEMIA

▪ A microcytic (small red blood cells) ▪ Folic acid/folacin necessary for the normal
▪ Hypochromic (less hemoglobin than the formation of RBC in the mother
average) ▪ Associated in preventing neural tube defects
▪ Inadequate supply of iron or iron is in the fetus
unavailable ▪ FOLATE
▪ Most commo anemia in pregnancy ✓ aids in the production of red blood
▪ If iron deficiency is severe and with difficulty cells
with oral therapy, IM or IV dextran can be ✓ aids in the synthesis of DNA
prescribed ✓ works with B12 and vitamin C to
help the body digest and utilize
CAUSES Diet low in iron
proteins
▪ Megaloblastic anemia – enlarged RBC
Heavy menstrual flow
▪ Apparent during 2nd tri
Unwise weight reduction ▪ Contributory factor:
programs ✓ early miscarriage or premature
separation of the placenta
Pregnant less than 2years ▪ Occur in the 1st few weeks of fetal
development.
Low socio-economic levels ▪ Can cause Spina Bifida (Open Defect) to
SIGNS & SYMPTOMS ✓ Pallor babies
✓ Fatigue
✓ Dizziness
11 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

SIGNS & SYMPTOMS ✓ Extreme ▪ In pregnancy= blockage to the placental


tiredness circulation can directly compromise the fetus,
✓ a lack of energy. causing LBW and possibly death
✓ pins and needles ▪ Symptoms of sickle cell anemia do not become
(paraesthesia) apparent until an infant’s fetal hemoglobin
✓ a sore and red converts to a largely adult pattern ( in 3-6
tongue.
months)
✓ mouth ulcers.
▪ 3-6 months = fetal hemoglobin will convert to
✓ muscle
adult hemoglobin
weakness.
✓ disturbed vision. ✓ Fetal hgb= 2 alpha 2 gamma chains
✓ psychological ✓ Adult hgh= 2 alpha 2 beta chains
problems, which
What happens?
may include
depression and ✓ Decrease oxygen
confusion.
✓ Blood becomes viscid
HIGH RISK Multiple pregnancies
✓ Cells clump
= Because of the
✓ Vessel blockage
competitor regarding
nutrients/ increase fetal ✓ Decrease blood flow to organs (heart, lungs,
demand extremities)
✓ Hemolysis
With Secondary hemolytic ✓ Decrease # of RBC
illness ✓ Severe anemia
= Rapid distraction of
RBC and rapid production SIGNS & SYMPTOMS ✓ Fatigue and
decreased
Use of hydantoin hemoglobin
= ANTICUNVULSANTS ✓ Eye damage
✓ Bouts of pain
Using oral contraceptives ✓ Pulmonary and
= can alter the effect of heart diseases
folic acid ✓ Swelling and
inflammation of
Had gastric bypass fingers, toes,
MANAGEMENT PRE-PREGNANCY = 400 arthritis
microgram folic acid daily ✓ Thrombosis in the
spleen and liver
PREGNANCY= 600 ✓ Leg ulcer
microgram daily ✓ Bacterial
infections
Eat folacin food (green leafy MANAGEMENT *doesn’t need iron
vegetables, oranges and supplement in this type of
dried beans) anemia

Periodic exchange
transfusion throughout
SICKLE CELL ANEMIA pregnancy

▪ An inherited hemolytic anemia caused by the Oxygen administration


abnormal amino acid in the beta chain of
hemoglobin Increase fluid volume
▪ Majority of RBC are irregular /sickle shaped
(crescent shaped) Hospitalization
▪ sickle shape = cannot carry as much hbg
▪ Sickle cell anemia is a threat to life Electrophoresis of RBC
ASSESSMENT Monitor hemoglobin

Clean catch urine sample


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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Diet Returns to heparin during


the last month of pregnancy
Fluid Intake = 8 glasses of
water/day
LEFT SIDED HEART FAILURE

HEART DISEASE/ CARDIAC DISEASE ▪ Causes: mitral stenosis, mitral insufficiency,


aortic coarctation
▪ Has problems in the Ventricles and Mitral
4 CATEGORIES OF HEART FAILURE Valve
▪ The left ventricle cannot move the volume of
a. Class 1 – can experience normal pregnancy
blood forward = Pump going to the aorta is not
and birth
being observed, blood goes back.
b. Class 2 – can be pregnant but slightly
▪ Heart becomes overwhelmed and fails to
compromise
function
c. Class 3 – can still be pregnant, markedly
▪ Decrease CO
compromise (can complete pregnancy, in CBR)
▪ Increase pressure in pulmonary veins =
d. Class 4 – severely compromise (poor
backflow of the blood
candidate)
▪ Orthopneic position = difficulty of breathing
ASSESSMENT Thorough health history ▪ Cough = cough caused by the blood in the
✓ ask her level of alveoli
exercise ▪ Pulmonary edema = alveoli is surrounded by
performance fluid causing p. edema
✓ ask if she has a ▪ Women with pulmonary HPN are extremely
cough or edema high-risk for:
✓ instruct the ✓ spontaneous miscarriage
woman to report ✓ preterm labor
coughing during ✓ maternal death
pregnancy
▪ The placenta may not receive adequate blood
because of the decreased peripheral
Make comparison
assessment of nail bed circulation
▪ If complications result in impaired blood flow
Jugular venous congestion to the uterus this leads to:
a. Poor placental perfusion
Assess liver size b. Intrauterine growth restriction
✓ Echocardiography c. Fetal abnormality
✓ Chest radiograph ▪ Needs UTZ and nonstress test after 30-32
✓ ECG weeks of pregnancy

SIGNS OF HEART F. ✓ Edema D Dyspnea


✓ Irregular pulse R Rale (crackles)
✓ Rapid or difficult O Orthopnea
respirations W Weakness
✓ Chest pain on N Nocturnal paroxysmal dyspnea
exertion I Increase HR
DRUGS Heparin = drug of choice for N Nagging cough
early pregnancy G Gaining weight
✓ no teratogenic
effect
✓ does not cross the NURSING
placenta and the INTERVENTIONS Assess client’s symptoms
fetus
Assess client’s
Sodium warfarin responsiveness to
(Coumadin) = can be used medications (digoxin,
after week 12 diuretics, ACE and
betablockers)
13 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Monitor BP a. Digoxin – to slow


FHR
Monitor volume status b. Adenosine beta
blockers and
Assess weight daily angiotensin
convertine
Monitor potassium level enzyme ( ACE)
inhibitors- reduce
Monitor diet (low sodium Hypertension
/day; not 2-3 grams per
day) c. Nitroglycerin –

Assess edema of legs (shd Educate regarding the


be elevated) avoidance of infection
PREGNANCY WITH less blood going to the
High-fowlers position/ HEART FAILURE placenta
semi-upright

Safety- risk for falling when RIGHT-SIDED HEART FAILURE


shifting positions
▪ Occurs when the output of the RV is less than
Compliance for medication the blood volume received by the Raof the
vena cava
No smoking and limiting ▪ Distension of pulmonary veins
alcohol consumption ▪ Peripheral Edema
MANAGEMENT Anticoagulant ▪ Back pressure—congestion of the systemic
venous circulation
Antihypertensive drugs = ▪ Decrease CO to the lungs
ACE Inhibitors ▪ Less blood – BP decreases in the aorta -
Pressure is high in the vena cava
Diuretics = Loop diuretics
(removes fluid) S Swelling of hands and liver
W Weight gain
Beta blockers = slowing hR, E Edema (pitting)
prevents norepinephrine L Large neck vein
L Lethargic
Digoxin = increase heart
I Irregular HR
ability to contract
N Nocturnal (frequent urination)
stronger (above .2=
G Girth (abdomen), anorexia
toxicity)

Balloon valve angioplasty =


ASSESSMENT ✓ Jugular distention
inserts something into the
✓ Liver and spleen
mitral valve
become
FETAL ASSESSMENT LBW distended
✓ Liver
Preterm labor enlargement
✓ Distended
Immaturity abdominal
vessels
Infant may not respond to ✓ Peripheral edema
labor ( late deceleration) ✓ Ascites = shifting
OTHER Promote healthy nutrition of fluids
INTERVENTIONS
Take iron supplements

Educate regarding
medication

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

RHEUMATIC HEART DISEASE resistance combined


with relatively deficiency
▪ A beta hemolytic streptococcal infection in the production of
resulting in valve leakage (insufficiency) and or insulin
obstruction (narrowing/stenosis)
▪ MITRAL VALVE is affected Insulin Insufficiency,
▪ Clients will first have RHEUMATIC FEVER beta cells cannot
▪ UNTREATED RHEUMATIC FEVER can lead to produce insulin
RHEUMATIC HEART DISEASE Gestational Diabetes Common diabetes
▪ RHD can lead to maternal death, preterm during pregnancy
labor, and abortion
A condition of abnormal
MANAGEMENT Throat culture glucose metabolism that
arises during pregnancy
Penicillin- drug of choice ( 24th-28th weeks)

Rest RISK FACTORS:


✓ Obesity
NSAIDS ✓ Age over 25
years
✓ Hx of large
DIABETES MELLITUS babies ( 10 lb
▪ An endocrine disorder in which the pancreas or more)
cannot produce adequate insulin to regulate ✓ Hx of
body glucose levels. unexplained
▪ Pregnancy places demands on carbohydrate fetal or
perinatal loss
metabolism and causes insulin requirements
✓ Hx of
to change:
congenital
a. First trimester – decrease anomalies in
b. 2nd trimester – increase previous
c. After placental delivery- decrease pregnancies
▪ Not a good candidate for oral contraceptive = ✓ Hx of
it can prevent the function of insulin polycystic
▪ Not a candidate for using IUD = Risk for ovary
infection and inflammatory disease syndrome
✓ Family hx of
CLASSIFICATIONS OF DIABETES MELLITUS diabetes
✓ Member of a
TYPE DESCRIPTION population
Type 1 Formerly known as with a
insulin dependent ✓ high-risk for
diabetes mellitus diabetes
Impaired Glucose A state between normal
A state characterized by Homeostasis and diabetes in which
the destruction of the the body is no longer
beta cells in the pancreas using and secreting
that usually leads to insulin properly.
absolute insulin
dependency. a. Impaired fasting
glucose – a state
Problem in the when fasting plasma
production of insulin and glucose is at least 110
beta cells of pancreas but under 126mg/dl
Type 2 Formerly known as non-
insulin dependent DM b. Impaired glucose
tolerance – a state when
A state that usually rises the results of the oral
because of insulin
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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

glucose tolerance test Spontaneous abortion Can try to damage the


are at least 140 but development of baby
under 200mg/dl in the 2 FETAL
hour sample Macrosomia Glucose = growth
hormone
Congenital anomalies
CLINICAL PRESENTATION Stillbirth
Spontaneous
Polyuria Excessive urination
miscarriage
If glucose can’t be absorbed by
the body, it will use CHON, that DIAGNOSTIC TEST
can decrease CHON in the body
cells, and causes CELL DEATH, and Oral Glucose Challenge 50 g glucose challenge
eventually will release NA, and Test test
KETONES in the urine, and causes
POLYRURIA Done during the 1st
Polydipsia Excessive thirst prenatal visit and repeat
at 24-28 th weeks AOG
Because of weight loss, polydipsia
can be observed After the 50 g glucose
Polyphagia Excessive hunger load= a venous sample
ia taken for glucose
If glucose can’t be absorbed by determination after 60
the body, it will use CHON, that minutes
can cause CELL STARVATION, and
causes POLYPHAGIA To confirm:
Pruritus Itchiness Fasting Plasma Glucose
Weight Loss Because of HYPERGLYCEMIA, = 126 mg/dl above
kidneys begin to excrete glucose
(glycosuria), and exerts OSMOTIC Non-Fasting Plasma
PRESSURE that causes DHN Glucose = 200 mg/dl
WEIGHT LOSS above
Frequent UTI
Large Fetus Because of the high amount of 140 mg/dl above = do
glucose in the amniotic fluid oral glucose tolerance
test
Glucose = growth hormone of Oral Glucose Tolerance 100 g Glucose tolerance
babies Test test
▪ Increase ketones and lipids in the blood can
accumulate in the blood vessels = Done at 32- 34 weeks
ATHEROSCLOROSIS – affects blood circulation
▪ KETONES = can decrease pH of blood – If the serum glucose
METABOLIC ACIDOSIS level at 1 hour is more
than 140mg/dl, the
▪ Decrease blood volume = Decrease oxygen =
woman is scheduled for
Anerobic – more acidotic
a 100 g, 3 hour fasting
COMPLICATIONS glucose tolerance test

MATERNAL If 2 of the 4 blood


PIH (Pregnancy induced Increase bp, weight gain, samples collected for
hypertension) proteinuria, edema this test are abnormal or
Infection Immune system is low if the fasting value is
Polyhydramnios Excessive amount of above 95mg/dl diabetes
Amniotic Fluid is present

Large abdomen is Oral glucose challenge


observed in mother test values (fasting

16 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

plasma glucose values) Biophysical profile Can determine Fetal


for pregnancy well-being or general
✓ Fasting = 95 status of the baby
✓ 1 hour = 180
✓ 2 hours = 155 Monitor FHR, Breathing,
✓ 3 hours = 140 Amniotic Fluid, NST
Serum alpha- AFP (alpha-fetoprotein) Glycosylated Used to detect degree of
fetoprotein Level = altered in poorly Hemoglobin (HB1Ac) hyperglycemia
controlled diabetic
pregnant Done at 4-6 weeks

NV= 0ng/ml to 40 ng/dl Reflects the average


blood glucose levels over
UTZ Check the size, location the past 4-6 weeks ( the
and amount of amniotic time the RBC were
fluid picking up glucose)
Creatinine Clearance Each trimester Ophthalmic One effects of BM =
Test examination blindness c
NV= 0.8 – 1.4 mg/dl Urine Culture for UTI Checks for UTI

Low in creatinine if you


have DM THERAPEUTIC MANAGEMENT

Function of kidneys are Insulin Short acting insulin


affected (filtering of (regular) combined
waste) with an intermediate
type
Low creatinine =
associated with 2/3 is given in the
increased risk of morning
diabetes
1/3 is given in the
Diabetes can damage the evening
filtering system and
reduce ability to clean Administer 30 minutes
waste from blood, before meals
creatine accumulates in
the blood Self-administered 30 min
in a ratio of 2:1
Determine the (intermediate to regular)
status/conditions of the and again just before
kidneys dinner in a ratio of 1:1
Non-Stress Test Analyzing fetal
movement, fetal heart Oral hypoglycemic NOT
rate, acceleration of FHR RECOMMENDED for
pregnant because they
Normal F. Movement = cross the placenta and
10 fm potentially teratogenic
Normal FHR = 15 bpm to fetus.
Recording for Fetal
Movements Route: Subcutaneously
Lecithin/ Sphingomyelin Week 36
ratio Regular insulin (clear)
Surfactant is present in
the lungs, lungs of the If mixing insulin: draw
baby can be affected and clear (regular) then
can cause respiratory cloudy (intermediate)
problems

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Site: 2 inches from belly ✓ Lowers serum


button glucose and the need
Blood glucose Fingerstick technique – for insulin
monitoring use of glucose meter ✓ May cause
hypoglycemia- insulin
FBS= below 95-100 is released quickly
mg/dl ✓ Extreme exercise will
cause hypoglycemia
2-hour postprandial level and ketoacidosis
below 120 mg/dl Explain the
Insulin pump therapy An automatic pump importance of
about the size of mp3 continued
player evaluation even
during
A syringe of regular postpartum and
insulin is placed in the even when blood
pump chamber and a glucose levels are
small gauge needle is normal.
attached to a length of Encourage regular Frequency = 3-4x/week
thin polyethylene tubing exercise Duration = 15-30 minutes
and implanted into the HR = maintains between 130-
subcutaneous tissue of a 180 bpm
woman’s thigh or Ensure patient’s
abdomen. preparation for
intensive and
regular
NURSING CARE MANAGEMENT intrapartum
assessment
Complete patient Advise
database and contraception in
document test diabetic woman
results during
Monitor BP and
pregnancy
lipid levels
Educate both NUTRITION
Woman who is
patient and her ✓ 1800-2400 calorie
type 1 or 2 should
family regarding: diet divided into 3
meet with her OB
meals and 3 snacks
before she
✓ Reduced amount of
becomes
saturated fats and
pregnant
cholesterol,
increased dietary
fiber SIGNS AND SYMPTOMS OF HYPOGLYCEMIA AND
✓ 20% CHON, 40-50% HYPERGLYCEMIA
CHO, 30% fat
✓ IV supplementation Hypoglycemia Hyperglycemia
for those who cannot common in the 2nd and common in the 6th
eat due to N/V 3rd month month
✓ Final snack of the day Sweating Fatigue
one of CHON and Pallor, cold clammy skin Flushed, Hot skin
complex carbo to Disorientation, Dry mouth, excessive
allow slow digestion irritability thirst
during the night Headache Frequent Urination
✓ Weight gain at 25-30
Hunger Rapid, deep breathing,
lb
fruity breath odor
EXERCISE
Blurred Vision Depressed reflexes
✓ Most important
Nervousness Drowsiness, headache
management of DM
Shallow breathing but
✓ Done moderately
normal PR

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Urine (-) for glucose and c. Amniocentesis after 15 weeks – to check


ketones baby’s type and Rh factor and to look for
Blood glucose level problems
<60mg/dl

RH SENSITIZATION HIV
▪ USA – ¼ of nearly one million people in the US
▪ Occurs when Rh (-) mother carries a fetus with are infected- female
an Rh (+) blood type ▪ Leading cause of death in women 25-44 yrs of
▪ Rh= rhesus; an inherited protein found on the age
surface of RBC. It lacks protein ▪ 1% -2% of every woman giving birth
▪ If mother’s blood and baby’s blood mix = the ▪ Higher risk of developing toxoplasmosis and
mother’s body will start to make antibodies cytomegalovirus infections
that can damage the baby’s RBC ▪ HIV positive woman may invade the
▪ Maternal antibodies formed against the Rh (+) cerebrospinal fluid and cause extreme
blood are not formed during pregnancy but in neurologic involvement.
the first 72 hours after birth making them a ▪ Tuberculosis
threat to a 2nd pregnancy
▪ Rh (-) mother + Rh (-) father= Rh (-) baby RISK FACTORS Multiple sexual partners
▪ Rh (-) mother =Rh (+) father = Rh (+) baby of the individual or
▪ Previous miscarriage, abortion sexual partner
▪ Had ectopic pregnancy
Bisexual partners
▪ Didn’t receive Rh immune globulin to prevent
sensitization
Intravenous drug used
▪ Had amniocentesis or CVS by the individuals or
▪ The test could let your blood and baby’s blood sexual partner
mix
▪ Blood will mix during delivery ASSESSMENT – EARLY ✓ Fatigue
▪ 1st baby will not be affected ✓ Anemia
▪ 2nd baby will be affected ✓ Diarrhea
▪ The antibodies that is already in the mother’s ✓ Weight loss
blood could attack the baby’s RBC leading to: ✓ Flu-like
a. Anemia symptoms
b. Jaundice
c. More serious problems
STAGES OF HIV
Therapeutic Management 1. Initial invasion of the virus with mild,
flulike symptoms
1. Rh (D) immune globulin (RHOGAM) 2. Seroconversion = a woman converts from
▪ to prevent the formation of HIV serum negative to HIV serum positive
maternal antibodies 3. Asymptomatic period = disease-free
▪ given during: 28th weeks, 40 weeks, except for symptoms-weight loss, fatigued
within 72 hours after delivery ✓ The virus is replicating
▪ Rh immune globulin- given if at risk ✓ 3-11 yrs
4. Symptomatic period
of forming antibodies
✓ Presence of opportunistic
2. Intrauterine Transfusion
infection and malignancies
▪ injecting RBC via amniocentesis ✓ CD4 count : below 200 cells/mm3
directly to the fetal cord ✓ Toxoplasmosis
▪ blood type should be O (-) ✓ Oral and vaginal candidiasis
✓ GI illness
If the mother is Rh sensitized, she will have: ✓ Herpes simplex
✓ P carinii pneumonia
a. Regular blood test- check the level of
✓ Kaposi sarcoma
antibodies
b. Doppler UTZ – to check blood flow to the
baby’s brain (showing anemia and its severity)
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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

DIAGNOSTIC TEST therapy beginning with


1. ELISA (Enzyme Linked Immunoassay) birth and a follow- up of 6
▪ To detect antibodies in the blood weeks
▪ Antibody – is a protein produced ✓ advise not to be pregnant
by the body’s immune system b. Trimethoprim with sulfamethoxazole
when it detects harmful (bactrim)- with pneumonia
substances or antigens ✓ Teratogenic in early
(salmonella enterica and pregnancy
Escherichia coli strains c. Sulfamethoxazole (Gantanol)
2. Western Blot Analysis ✓ may lead to increase
▪ to separate and identify proteins bilirubin levels in newborn if
(a mixture of proteins is administered late in
separated based on molecular pregnancy
weight 4. Chemotherapy for those with Kaposi’s
sarcoma
▪ Contraindicated during early
MODE OF TRANSMISSION pregnancy because of potential
✓ Exposure to blood and body secretions for fetal injury but can be used
through sexual contact later in pregnancy to halt the
✓ Sharing of contaminated needles for malignant growth.
injection ▪ Kaposi’s sarcoma = disease in
✓ transfusion of contaminated blood which cancer cells are found in
✓ Breastfeeding the skin or mucous membranes
✓ Multiple sexual partners that line the gastrointestinal
tract, from mouth to anus
including stomach and intestines
Effects of HIV to Low birth weight 5. CS delivery
pregnancy to reduce the risk of mother-to-newborn
Preterm birth transmission
6. No amniocentesis
20-50% of infants will 7. No episiotomy
develop AIDS in the 8. 8. Use standard infection precaution
first yr of life P carinii pneumonia – trimethroprim with
Issues to be addressed Safer sex practices sulfamethoxazole (Bactrim) or Pentamidine (Pentam)
when HIV+ • Trimethoprim = teratogenic
testing of sexual contacts • Sulfamethoxazole = increased bilirubin if
administered late in pregnancy
Continuations or
termination of Kaposi’s sarcoma – skin cancer in AIDS; treated with
pregnancy chemotherapy late in pregnancy

Thrombocytopenia – platelet transfusion close to


THERAPEUTIC MANAGEMENT birth to restore coagulation ability ( poor candidate
1. HIV positive women are advised to avoid for epidural injection for anesthesia or episiotomy)
Pregnancy
2. Monitoring of the CD4 cell counts and viral Follow-up testing of newborns being treated with
load level zidovudine for the first 6 weeks
GOAL THERAPY
To maintain the CD4 cell count at greater than 500 2 (-) HIV culture at 4 mos of age: HIV infection is
cell/mm3 by administering oral ZVD + one or more excluded
protease inhibitors: ritonavir (Norvir) or indinavir
(Crixivan) in conjunction with NRTI (nucleoside
reverse transcriptase inhibitor drug. NURSING DIAGNOSES
3. Medications Risk for infection related to dysfunction of the
a. Zidovudine (ZVD) immune system secondary to invasion of HIV
✓ administered to the woman • Administer acyclovir (Zovirax) for Herpes
beginning with the 14th simplex, clotrimazole troches (Mycelex)
week of pregnancy and for oral thrush, pyrimethamine (Daraprim)
newborns receives antiviral and sulfadiazine for toxoplasmosis and
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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

trimethoprim w/ sulfamethoxazole d. Continued substance use despite having


(Bactrim) for PCP persistent or recurrent social or interpersonal
• Immunization against pneumonia, problems caused or exacerbated by the
influenza and hepatitis B effects of the substance (e.g., arguments with
• During labor – internal fetal monitor, scalp spouse about consequences of intoxication,
blood sampling, forceps and vacuum physical fights)
extraction are avoided to prevent bleeding
• At birth – episiotomy and breastfeeding are When he or she has
avoided withdrawal symptoms
• Educate that patient about the mode of HIV Following discontinuation of
transmission and safer sex practices the substance combined with
abandonment of important
Use standard infection precautions to protect against activities
the spread of
Spending increased time in
SUBSTANCE activities related to substance
SUBSTANCE ABUSE DEPENDENT use
▪ Inability to meet major role obligations, an
increase in legal problems or risk-taking Using substances for longer
behavior or exposure to hazardous situations time than planned
because of an addicting substance.
▪ 10%-20% of pregnant women use illegal drugs Continued use despite
▪ Use of cocaine, amphetamines, and multiple worsening problems because
drugs of substance use
Usually younger age group
▪ Adolescents have an increased rate of inhalant
abuse and binge drinking, also known as drug
MARK:
abuse
▪ refers to a maladaptive pattern of use of a Late in prenatal care because
substance she s afraid her drug use will
▪ occurs when an individual abuses be discovered and be
alcohol/drugs as away of reducing their stress SUBSTANCE- reported to authorities.
levels DEPENDENT
▪ Binge drinking = consuming 5 or more drinks WOMEN Cannot wait long at health
on an occasion for men or 4 or more drinks on care facility to be seen for an
an occasion for women appointment

SUBSTANCE ABUSE AS: Difficulty following


instructions for proper
A maladaptive pattern of substance use leading to nutrition
clinically significant impairment or distress, as
manifested by one (or more) of the following, occurring Prefer to buy drugs than food
within a 12-month period: Can’t wait long at a health
care facility
a. Recurrent substance use resulting in a failure
to fulfill major role obligations at work, May have difficulty following
school, or home (e.g., repeated absences or BEHAVIORAL prenatal instructions for
poor work performance related to substance INDICATIONS OF proper nutrition- lack money
use; substance-related absences, suspensions SUBSTANCE ABUSE to buy both drugs and
or expulsions from school; neglect of children nutritious food and choosing
or household) drugs over food makes her
b. Recurrent substance use in situations in nutrition inadequate
which it is physically hazardous (e.g., driving
May not have money for
an automobile or operating a machine when
supplemental vitamins or iron
impaired by substance use) preparations
c. Recurrent substance-related legal problems
(e.g., arrests for substance-related disorderly
conduct)
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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

EFFECTS OF DRUGS If there is vasoconstriction,


• Cross the placenta placental insufficiency
• Fetal abnormalities /Preterm birth premature of the placenta
• Hepatitis – if using injected drugs B or HIV preterm labor or fetal death
• Increased Risk of STD
OUTCOMES INFANT will suffer intracranial
• Have few effective support people hemorrhage and a withdrawal
• Require a multidisciplinary team approach syndrome of tremulousness,
not only from pregnancy HCP but irritability and muscle rigidity.
substance abuse treatment providers
Long term effects: learning
• Still using drug when labor begins infant
defects
will have drug withdrawal symptoms after
birth AMPHETAMINES Methamphetamine (speed)
• Nervousness
Effects are similar to cocaine
• Irritability/lethargy
• Possibly seizures
Smoked
• Breastfeeding is not encouraged because
drugs are being carried and excreted into
Newborns show jitteriness, poor
breast milk.
feeding at birth, growth
• Women receiving METHADONE as part of restricted.
their drug treatment can breastfeed as only
MARIJUANA Obtained from the hemp plant
a small amount of this drug is excreted in
AND HASHISH CANNABIS
breast milk
May be used in pregnancy to
counteract nausea but is not
COMMON SUBSTANCES ABUSED DURING
advised
PREGNANCY
When smoked produce
COCAINE Derived from Erythroxylum coca tachycardia and sense of well
being
A powerfully addictive stimulant
drug-increases levels of Associated with short term
dopamine, a brain chemical (or memory and increased
neurotransmitter) associated respiratory infection in adults
with pleasure and movement,
Frequent user may NOT be able
Crack is the street name given to to breastfeed because of
the form of cocaine that has reduced milk production and
been processed to make a rock the risk of the newborn from
crystal, which, when heated, excretion of the drug in the
produces vapors that are milk.
smoked. The term “crack” refers PHENCYCLIDINE An animal tranquilizer that is
to the crackling sound produced frequently used street drug in
by the rock as it is heated. polydrug abuse.

When sniffed-= absorbed in the Causes increased cardiac output


mucous membrane affecting the and sense of euphoria, long
central nervous system= term hallucination
vasoconstriction occurs.
(Flashback episodes)
RR, BP and HR increases rapidly
in response to vasoconstriction Injurious to the fetus

Immediate death may result Tend to leave the maternal


from cardiac failure circulation and concentrate in
fetal cells - injurious to a fetus.
NARCOTIC Pain reliever
AGONISTS
22 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Morphine sulfate, meperidine Withdrawal symptoms may


HCL and codeine (Cough begin as soon as 6 hours after
suppressant) the last drug
• Nausea
Potent analgesic and euphoric • Diarrhea
effect • Hypertension
• Shivering
Heroin – raw opiate – used • Body aches
recreationally to the point of • Vomiting
dependence • Abdominal pain
• Restlessness
Sedative effect • Insomnia
• Muscle jerks
PIH, phlebitis, subacute bacterial
endocarditis, hepatitis B and HIV
Effects of Opiates to Infant
infection
• SGA
HEROIN A raw opiate, short acting
• Meconium aspiration
narcotic
• Fetal distress
• Withdrawal symptoms
Inactive until it crosses the blood
after birth
brain barrier
Treatment
Administered ID, IV and
inhalation • Methadone
maintenance program
Produces a short-lived feeling of • Buprenorphine if not
euphoria followed by sedation. treated with
methadone
Pregnant Woman • Suboxone
• Results in fetal opiate (combination of
dependence and nalone and
severe withdrawal buprenorphine)- an
symptoms in the infant analgesic similar to
after birth morphine
• Infants tend to be
small for gestational NOTE: Because the fetus is
age and with exposed to drugs that must be
increased incidence of processed by the liver during
fetal distress and pregnancy, the fetal liver is
meconium aspiration forced to mature faster than
normally. Fetal lung tissue also
• Liver tends to mature
appears to mature from the
faster = rare
stress of intrauterine drug
hyperbilirubinemia
exposure, thus being born in
• Fetal lung tissue
preterm
appears to mature
INHALANTS Sniffing/huffing of aerosol drugs
more rapidly = rare
RDS
Can lead to respiratory and
cardiac irregularities
Complications
• Pregnancy Induced
Ex: airplane glue, cooking sprays,
Hypertension
and computer keyboard cleaner
• HIV
• Phlebitis
Contain freon as a propellant
• Subacute bacterial and can lead to severe
endocarditis, respiratory and cardiac
• Hepatitis B irregularities
ALCOHOL Detrimental to fetal growth

23 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Fetal alcohol syndrome –


significant facial features,
cognitive challenge and memory
deficit

Fetal Alcohol Syndrome Facial


Characteristics
• Small head
• Low nasal bridge
• Short eyelid opening
• Flat midface
• Epicanthal folds
• Short nose
• Flat midface
• Short nose
• Smooth philtrum
• Underdeveloped jaw

24 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

GESTATIONAL CONDITIONS • D&C/suction


curettage = empty
1ST TRIMESTER PROBLEM uterus
ABORTION • Transfusion = replace
▪ Other term = SPONTANEOUS ABORTION blood loss
▪ Medical term for any interruption of • Direct replacement of
pregnancy before a fetus is viable fibrinogen = increase
▪ ELECTIVE ABORTION = planned medical coagulation ability
termination of pregnancy
▪ MISCARRIAGE = interruption occurs Infection
spontaneously • Possibility of infection
▪ VIABLE FETUS – fetus of more than 20-24 wks is MINIMAL when
gestation; weighs 500 g pregnancy loss occurs
▪ EARLY MISCARRIAGE – occurs before 16th over a short time
• DANGER SIGNS =
week or 4 months
fever, abdominal pain,
▪ LATE MISCARRIAGE – occurs between 16th
foul vaginal discharge
and 24 weeks or 4-6 months
• FEVER = may be a
▪ 1st 6th week – developing placenta is systematic reaction to
tentatively attached to the decidua’s miscarriage process
▪ 6 weeks - 12 – a moderate degree of (100.4 ‘c/ 38.0’C)
attachment to the myometrium • Escherichia Coli =
▪ After 12 weeks – attachment is penetrating organism responsible
and deep for infection after
▪ Bleeding before 6 weeks – severe miscarriage
▪ Bleeding after week 12 – profuse
Septic abortion
CAUSES A – abnormal fetal development • Abortion that is
complicated by
B – bleeding due to implantation infection
abnormalities • May lead to
INFERTILITY =
O – ovary fails to produce uterine/fibrotic
progesterone scarring
• PROGESTERONE • Occurs frequently in
TERAPHY may be women who tries to
attempted self-abort
• SYMPTOMS = fever,
R – recurrent systemic infection crampy abdominal
pain, tender uterus
T – teratogenic drug • If left untreated =
ASSESSMENT Vaginal spotting = may notice in toxic shock syndrome,
the underwear septicemia, kidney
failure, death
Lower abdominal cramps = • OBTAINED = complete
contraction blood count, serum
electrolytes, serum
Fever and body malaise creatinine, blood type,
cross match, cervical,
Signs of infection vaginal and uterine
COMPLICATIONS Hemorrhage culture
• Monitor VS = detect • Foley Catheter =
possible hypovolemic monitor urine output
shock • Intravenous Fluid =
• Excessive vaginal restore fluid volume
bleeding = position • Pulmonary artery
flat, massage fundus catheter/ Central
venous pressure =

25 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

monitor lest atrial Curettage (raspa)


filling pressure and = cleaning and
hemodynamic status scraping the
uterus
NURSING CARE Perform the appropriate Imminent/ Cervical Bring underwear
MANAGEMENT management and prevent inevitable dilatation = tissue
complications Uterine and fragments to be
contraction examined
Monitor vital signs, bleeding and
pain Moderate Vacuum
Vaginal bleeding Extraction = if the
Document IVF, lab test and baby is confirmed
prepare for emergency surgical CERVIX IS OPEN nonviable
intervention
After discharged
Prepare administration of – ask the woman
RhoGAM to Rh (-) mother to assess vaginal
bleeding by
Advise iron supplement recording the
number of pads
Refraining from sexual she uses
intercourse until next menses
and advise use of barrier Monitor bleeding
contraception = esp the use of
SANITARY PADS
(6-8 pads daily)
TYPES S&S MANAGEMENT Complete The entire Dilation and
Threatened Scant vaginal Ask to come to products of Curettage = to
bleeding the clinic to have Conception make sure that all
FHT to be (fetus, parts was
Slight cramping checked or UTZ to membranes, delivered
evaluate the placenta) is
No cervical viability of fetus expelled
dilatation spontaneously
HCG test = should without
CERVIX is be doubled; if it resistance
CLOSED does not doubled
= poor placental
function Incomplete Part of the fetus D &C (dilation and
(usually the curettage) or
Avoid strenuous fetus) is suction curettage
activity for 24-48 expelled but the to evacuate the
hrs = REST membrane or remainder of
placenta is pregnancy
Complete bed retained in the
rest is not usually uterus
necessary Missed/earl Fetus die in the UTZ
y pregnancy uterus but is not
Once bleeding failure expelled Dilation and
stops, can resume Evacuation (D&E)
activity Discovered = removes baby
during prenatal from the uterys
Coitus is examination =
restricted for 2 Determine Prostaglandin
weeks = prevents when the fetus suppository or
further bleeding does not misoprostol
and infection increase in size, (cytotec) if
NO FHT
For dilation and
26 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Painless vaginal pregnancy is over 1ST TRIMESTER PROBLEM


bleeding 14 weeks, to ECTOPIC PREGNANCY
dilate the cervix ▪ Implantation occurs outside the uterine cavity
Fetus died at 4-6 either in the surface of the ovary or the cervix
weeks before Oxytocin ▪ Fertilized Egg grows outside the uterus =
the onset of stimulation of FALLOPIAN TUBE
miscarriage administration of ▪ Common is the fallopian tube
mifepristone
▪ Problem in IMPLANTATION
▪ 2nd most frequent cause of bleeding in early
Disseminated
Intravascular pregnancy
Coagulation (DIC) ▪ IUD’s = may slow the transport of the zygote
Recurrent Defective leading to tubal or ovarian implantation
pregnancy/ spermatozoa or ▪ FALLOPIAN TUBE = for FERTILIZATION only,
habitual ova because it cannot accommodate the growing
baby
Endocrine ▪ 95% = surface of the ovary/ cervix
Factors = LOW ▪ 80% in the ampulla = highest incidence of
(PBI, BEI, GBI) tubal pregnancy
▪ 12% in the isthmus
Deviation of the ▪ 8% in interstitial /fimbria = can cause severe
uterus such as
intraperitoneal bleeding
bicornuate
uterus = uterus Fimbria Catch mature egg cell
is divided by 2 at Infundibulum Use to hold fimbria
the center, Isthmus For tubal ligation/ part that is
shapes like a cut
horn, it prevents
Ampulla Fertilization takes place
delivery of the
Interstitial Near the uterus
baby

Resistance to ASSESSMENT Amenorrhea = no menstrual


uterine artery flow occurs
blood flow
Nausea and Vomiting
Chorioamnioniti
s = uterine HCG will be positive
infection
Sharp knife stabbing pain in
Autoimmune the lower abdominal quadrants
disorders = (RLQ / LLQ)
lupus
anticoagulant, Scant vaginal spotting
antiphospholipi
d antibodies Shock (rapid thready pulse,
rapid RR, decrease BP)
A age before viability
B bleeding is scant. Low abdominal Leukocytosis = elevated WBC,
cramps, fever related to trauma on
O observe for infection, hemorrhage reproductive sites
R record v/s, bleeding, pain and IVF
T toxic shock syndrome, septicemia, No gestational sac
kidney failure, death
Rigid abdomen = accumulation
I inject RhoGam, give iron supplement
of blood
O ovary fails to produce progesterone
N no sexual intercourse, notify HCP
Cullen’s sign = Umbilicus
develop a bluish tinge due to

27 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

accumulation of blood in the Treated until negative HCG titer


abdomen; MOST IMPORTANT is achieved
SIGN
Hysterosalpingogram or UTZ =
Extensive or dull vaginal and uses “die” to color the uterus or
abdominal pain fallopian tube; assess whether
the tube is fully patent
Movement of the cervix and
pelvis exam causes excruciating Mifepristone = abortifacient or
pain (cervical motion it destroys the product of
tenderness) conception ; causing sloughing
of the tubal implantation site
Shoulder pain = accumulation
of blood in the peritoneal
area/diaphragm, that irritates RUPTURED ECTOPIC
the PREMIC NERVE PREGNANCY
• Due also to DELAYED • Fallopian Tube is
REFERRAL damaged

Diagnosed = UTZ and MRI Blood sample is drawn


immediately (Hgb, typing, hcg
Leads to acute hemorrhage = level = can lead to profuse
lightheadedness, rapid pulse, bleeding
shock
Intravenous Fluid = decrease
Transvaginal UTZ = blood volume and liquid
demonstrates the ruptured
membrane & blood collecting Blood Test
in the peritoneum
Therapy: LAPAROSCOPY = to
Falling HCG/ Serum repair or remove damaged
progesterone level = pregnancy fallopian tube
has ended
RISK FACTOR Obstruction (adhesion in FT Laparoscopy & Culdoscopy =
from previous infection) visualize the fallopian tube

Congenital malformations = Ultrasonography = reveals a


abnormalities in the anatomy clear-cut diagnostic picture
of the fallopian tube
Rh (D) immune globulin
Scars from tubal surgery
Culdocentesis = aspirate blood
Uterine tumor = prevents from the posterior portion of
implantation, and tends to the ovary “CULDESAC”
occupy the fallopian tube
MANAGEMENT UNRUPTURED PREGNANCY • Consent
• Fallopian tube is still • Lithotomy position
intact • Prepare perineum
• Speculum is
Oral administration of introduced
methotrexate = folic acid • Spinal needle
antagonist chemotherapeutic directed to posterior
agents; has EXCLORATING portion of the cervix
EFFECT, it shrinks and absorbs RESULT If blood is present in the cul-de-
product of conception. sac = ruptured ectopic

Followed by LEUCOVORIN If non-clotting/laked blood =


ectopic pregnancy

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Measure I and O and amt of


If blood clots = maternal blood vomitus = frequency, amount,
color, record stool

E extrauterine pregnancy If no vomiting within 24 hrs=


C cullen’s sign may start small amount of clear
T tender, rigid, abdominal pain (LQ), liquids; SFF = SMALL FREQUENT
amenorrhea FEEDING
O observe for shock
P prepare for surgery (laparoscopy) Dry crackers, dry toast or cereal
I inject Rhogam and be added every 2 hours the
C care for the client soft diet

If vomiting returns = TPN is


used
NURSING CARE Ensure that the client has no
2ND TRIMESTER PROBLEM MANAGEMENT oral intake until vomiting stops
HYPEREMESIS GRAVIDARUM
▪ Pernicious or persistent vomiting due to Administer IVF
elevated HCG
▪ N/V that is prolonged, beyond 12 weeks Record I and O
▪ Severe dehydration, weight loss
▪ Associated with helicobacter pylori (causes Advise SFF once vomiting has
peptic ulcer) subsided

ASSESSMENT Severe N/V Administer antiemetics as


prescribed
Elevated hematocrit = due to
dehydration Attends to client’s emotional
and psychological needs
Low Na, K and chloride
E exaggerated N/V beyond 1st trimester
Hypokalemic = muscle M metabolic alkalosis, hypoproteinuria
weakness due to low potassium E electrolyte, fluid, vitamins and minerals
replacement and nutrition
Polyneuritis = numbness and S skin turgor and mucus membrane
tingling sensation of nerves assessment for dehydration
I ingest bland solid foods
Weight loss S strict hygiene and bedrest

Urine test (+) for ketones =


when fats broke down

Poor skin turgor 2ND TRIMESTER PROBLEM


GESTATIONAL TROPHOBLASTIC DISEASE/H-MOLE
If left untreated = associated ▪ Another name: Hydatidiform/ Molar
with intrauterine growth pregnancy
restriction, preterm ▪ An abnormal proliferation and degeneration
THERAPEUTIC Hospitalization = to receive of the trophoblastic villi
MANAGEMENT fluid replacement ▪ As the cells degenerate, they become filled
and appear as clear fluid filled, grape-sized
Withheld oral food and fluid
vesicles
▪ THROBOBLAST = outer layer of BLASTOCYST –
IVF (3000 mL Lactated Rangers
with added Vit B) = to replace that will become the PLACENTA later on
loss fluid and electrolytes ▪ EMBRYOBLAST = becomes the EMBRYO
▪ Risk for CHORIOCARCINOMA and
Antiemetic- metoclopramide PREECLAMPSIA

29 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

RISK FACTORS Low protein intake Serum test for HCG (every 2
weeks until normal then begin
Women older than 35 years old monthly testing for 6 months,
(Asian heritage) then every 2 months for a total
of 1 yr) = MONITOR FOR 1 YEAR
Blood Incompatibility = Blood Negative HCG for 6 months =
group A who marry group O theoretically free of risk for
men malignancy
ASSESSMENT Uterus tends to expand faster
than normally = proliferation of Negative HCG for 12 months =
the trophoblast cells occurs can plan a second pregnancy
rapidly
Discourage to be pregnant = to
+urine test of HCG ( 1-2 M); NV= monitor the HCG for a year
400,000IU = because HCG is
produces by the trophoblast Use oral contraceptive
cells that are overgrowing (progestin) should not be COC =
for 12 months
Marked N/V = high HCG level
Methotrexate- drug of choice
UTZ show dense growth for choriocarcinoma
(snowflake pattern) = no fetal
growth in the uterus; Dactinomycin- added regimen
CONFIRMS IF THE CLIENT HAS if metastasis occur
HMOLE; BEST WAY

(-) FHR TYPES


Complete Mole All trophoblastic villi swell and
If structure was not identified become cystic
by UTZ, it will identify by =
Vaginal bleeding (approx. 16 If embryo forms, it dies at 1 to
weeks); DARK BROWN 2 mm in size with no fetal blood
present in the villi
early s/s of preeclampsia/
pregnancy induced EMPTY OVUM- the sperm
hypertension enters empty egg and its
(proteinuria, edema, HPN) chromosome replicates
before 20th week
snowstorm
Clear Fluid-filled cysts = Partial Mole Some of the villi form normally
changes the diagnosis from
miscarriage to gestational Syncytiotrophoblastic layer of
trophoblastic disease villi is swollen and misshapen

Women who have one A macerated embryo of approx.


incidence of hmole have an 9 weeks gestation may be
increased risk for second molar present and fetal blood may be
pregnancy present in the villi
MANAGEMENT Suction curettage = removes
the grape sized vesicles/ Has 69 chromosomes = a
evacuate the mole triploid formation in which
there are three chromosomes
Pelvic exam = affected part is instead of two for every pair,
the uterus one set supplied by an ovum
that apparently was fertilized
Chest Xray = cancer can spread, by two sperm or an ovum
this is to check whether the fertilized by one sperm in which
cancer has spread meiosis or reduction division
did not occur
30 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Trauma to the cervix = related


Rarely lead to choriocarcinoma to repeated abortion. D&C can
= cancer that affects fetal affect the cervix
membrane TREATMENT Cervical cerclage –performed
between 14th-16th weeks
pregnancy = because there is
H HCG is elevated, uterus is large for no EFFACEMENT and
gestational age, persistent bleeding, DILATATION yet. SEWING the
N/V cervix to prevent the delivery of
M mole is detected by UTZ and removed baby
by vacuum aspiration and curettage
O observe for s/s of shock, prepare for BT Mc Donald- temporary ( NSD)
and IV • sewing the cervix and
L lower the risk by avoiding pregnancy removes suture at 37-
for at least 1 year 38th weeks to deliver
E educate on the need to monitor HCG the baby
for 1 year • Nylon sutures are
placed horizontally
and vertically to the
cervix

2ND TRIMESTER PROBLEM Shirodkar – permanent (CS)


INCOMPETENT CERVIX • suture will not be
▪ Premature cervical dilatation removed until the
▪ Inability of the cervix to support growing delivery is done; CS
weight of pregnancy associate with repeated DELIVERY
spontaneous 2nd trimester abortion • Sterile Tape is
▪ Painless dilatation of the cervix in the absence threaded in a purse
of uterine contractions string manner under
▪ No UTERINE CONTRACTION the submucous layer
▪ Only at the 2nd pregnancy that the doctor can
know that the client has an incompetent cervix Emergent Cerclage Sutures =
discovered to have cervical
ASSESSMENT Painless dilatation dilatation but membrane still
intact may do this procedure
Bloody show (PINK-stained NURSING Modified Trendelenburg
vaginal bleeding) = 1st MANAGEMENT position = because of the
symptom; BLOOD + MUCUS increase pressure at pelvic
area; Pelvic Part = UPWARD;
Increased pelvic pressure/low Head Part = DOWNWARD
abdominal pressure
Bedrest
Followed by rupture of
membranes Coitus is temporarily restricted
= it can lead to infection
Uterine contractions begins
and a short labor the fetus is Tocolytic drug (ritodrin,
born = Occurs approx. Week 20 terbutaline) = drugs used to
of pregnancy stop uterine contraction

Progressive dilatation of the


cervix I Inability of the cervix to support the
growing baby
Urinary frequency N No douching = cleaning of internal parts
RISK FACTORS Maternal age of the vagina; CAN LEAD TO INFECTION
C Cervical cerclage
Congenital structural defects O Occur at week 20, bloody show = pink

31 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

M maternal age, congenital structure Ferning = secretions placed in a


defects, trauma of cervix slides and let it dry, view it
P premature cervical dilation without under a microscope; Presence
uterine contraction of crystals = AF
E elevated pelvic pressure
T Trendelenburg (modified) UTZ = determine if there is
E encourage bed rest enough AMNIOTIC FLUID inside
N no coitus temporarily the utero
T tocolytic drug THERAPEUTIC Bed rest
MANAGEMENT
Corticosteroid = helps in the
maturity of the lungs

3RD TRIMESTER PROBLEM Antibiotics


PREMATURE RUPTURE OF THE MEMBRANE
▪ PROM IV penicillin/ampicillin
▪ Rupture of fetal membrane with loss of
amniotic fluid during pregnancy before 37th Tocolytic agent – if NO signs of
week infection
▪ Associated with infection of membranes
(chorioamnionitis) Amnioinfusion – to reduce
pressure on the fetus or cord ;
COMPLICATIONS Chorioamnionitis = infection of WARM NORMAL SALINE (200-
the membrane 500 mL) is infused in the uterus
to replace loss amniotic fluid;
Cord Prolapse = umbilical cord Prevents pressure in the
tends to leak/ comes out at the umbilical cord and Prevents
vagina; the small head of the fetal distress
baby allows the umbilical cord
to come out into the vagina,
“presence of space” P pH of more than 6.5 indicates alkaline
• Affects FHR = bc of amniotic fluid (nitrazine paper turns
cord compression, it blue)
decreases oxygen R refer for tocolytic therapy until fetal
and FHR lungs are
• Cord compression mature
can lead to variable R refrain from coitus and douching
deceleration or late O observe closely for s/s of infection
deceleration and M maintain strict bedrest
placental
insufficiency
C cover any exposed portion with sterile
Preterm Labor saline compress to prevent drying of
the cord
Infection 0 O2 therapy to improve oxygenation to
ASSESSMENT Sudden gush of clear fluid from the fetus
her vagina = monitor FHR; R relieve pressure on the cord by
position in knee-chest position elevating fetal head OFF the cord or by
to prevent pressure on cord placing the woman in a knee-
prolapse chest/trendelenburg position
D do not push cord back to the uterus,
Constant wetness of this may add to compression
underwear

Nitrazine paper
• blue- amniotic fluid
• yellow- urine

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

3RD TRIMESTER PROBLEM segment starts to differentiate


PLACENTA PREVIA from the upper segment late in
▪ is a condition of pregnancy in which the pregnancy (approximately
placenta is implanted abnormally in the week 30) and the cervix begins
uterus. (lower segment) to dilate
▪ Normal implantation = upper
portion/segment Many low-lying placentas
detected on early ultrasounds
▪ most common cause of painless bleeding in
migrate upward to a
the third trimester of pregnancy
noncervical position,
▪ occur whenever the placenta is forced to
spread to find an adequate exchange surface. Bleeding = results from the
▪ An increase in congenital fetal anomalies may placenta’s inability to stretch to
occur if the low implantation does not allow accommodate the differing
optimal fetal nutrition or oxygenation shape of the lower uterine
segment or the cervix.
PREDISPOSING Increased parity = number of
FACTORS delivery; alive/dead Abrupt, Painless, Bright Red
Bleeding = limited/ compressed
Advanced maternal age placenta causes injury

Past cesarean births Uterus = soft, non-tender,


relaxed
Past uterine curettage = done
during abortion Presenting Part = placenta, no
engagement of the baby
Multiple gestation = tend to
displace location of placenta ** there is less blood supply in
the lower segment thus
Male fetus = height and weight placenta tends to grow larger
is bigger = displace placenta that I would normally do
FOUR TYPES Low-lying placenta
• implantation in the Less oxygen, less nutrients =
lower rather than in less blood supply
the upper portion of
the uterus ** the placenta is forced to find
• NSD an adequate exchange surface

Marginal Implantation Placenta in Lower Segment of


• the placenta edge Uterus = not conducive for the
approaches that of placenta to grow; baby
the cervical opening grows=placenta grows
• NSD
COMPLICATIONS Endometritis = inflammation;
Partial placenta previa portal of entry of parasites to
• implantation that invade endometrium
occludes a portion of
the cervical opening; Hemorrhage = The site of
half is ocluded bleeding, the open vessels of
• NSD OR CS the uterine decidua (maternal
blood); Placenta does not
Total/ Complete Placenta contract effectively
Previa
• implantation that Congenital Fetal Anomaly =
totally obstructs the related to nutrition and oxygen
cervical opening problem; affects development ;
• CS If it does not allow the optimal
ASSESSMENT Bleeding with placenta previa fetal nutrients and oxygenation
begins when the lower uterine
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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

MANAGEMENT Because the client is


experiencing blood loss
Bed Rest place the woman immediately
on bed rest in a side-lying Using a large-gauge catheter =
position for atleast 72 hours = 18 GAUGE
to ensure adequate blood
supply Monitor urine output every
hour = indicator of blood
= allow good perfusion of the volume adequacy
uterus and placenta Assess establish baselines, detect a
Hemoglobin, possible clotting disorder, and
Ask the following • Duration of Hematocrit, ready blood for replacement if
pregnancy Prothrombin necessary.
• Time of bleeding time, Partial
began thromboplastin Preparation for blood
• Amount of bleeding = time, Fibrinogen, transfusion; Prevents profuse
ml or tbsp Platelet count, bleeding
• Accompanying pain Type and Cross-
• Color of the blood = match, and
red = Antibody screen
fresh/continuing Location of Previa under 30% = NSD
bleeding Placental UTZ
Previa over 30%; mature = CS
• What she has done
for the bleeding
essential to determine the
• Prior episodes of
placenta’s location as
bleeding during the
accurately as possible in the
pregnancy
hope that its position will make
• Prior cervical surgery vaginal birth feasible.
for premature
Double set-up Attempt to deliver the baby via
cervical dilatation
NSD first
Inspect the Observe external bleeding
perineum for Fingers are needed to be
bleeding Estimate the present rate of inserted at the vagina = IF IT
blood loss. CAUSE MORE BLEEDING =
sifting to CS
Weighing perineal pads before
Betamethasone A steroid that hastens lung
and after use and calculating
maturity
the difference by subtraction is
• Given to mother if
a good method to determine
fetus is less than 34
vaginal blood loss.
weeks
• Given 12-24 hours
Kleihauer-Betke test (test strip
before birth
procedures) = detect whether
• 12-12.5 mg via IM
the blood is of fetal or maternal
origin Avoid coitus Because there is bleeding
NO internal any agitation of the cervix when Have adequate Advice client to rest
examination, there is a placenta previa may rest
pelvic or rectal initiate massive hemorrhage, Call HCP for any
examination, possibly fatal to both mother signs of bleeding
enema and child.
Obtain VS determine whether symptoms
P Position is Side
of shock are present
lying/Trendelenburg/Lateral position.
Painless bight red bleeding
Maternal & Fetal VS = assess
R Refrain from internal exam, rectal and
every 5-15 minutes
pelvic exam, relaxed uterus, soft and
non-tender
**NORMAL FHT
IVF

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

E Encourage strict bed rest and oxygen Vasoconstriction from cocaine


(10 L via Face mask) as indicated, or thrombosis
episodes of bleeding • Smokers = risk for
V v/s monitoring, FHT and movement, vasoconstriction
and fetal lung maturity, visible bleeding ASSESSMENT Sharp stabbing pain high in the
I IV line available and prepare for blood uterine fundus = UPPER
transfusion, intercourse post bleeding QUADRANT
A Assessment of blood loss and
preventive measures, abnormal fetal Uterine tenderness
position
Heavy bleeding = Concealed
(internal) hemorrhage =
P Painless, Bright red bleeding CANNOT SEE BLOOD COMING
R Relaxed, Soft, Non-tender uterus OUT FROM THE VAGINA
E Episodes of bleeding • Blood accumulates in
V Visible bleeding the ABDOMEN
I Intercourse post bleeding • Give uterus that is
A Abnormal fetal position rigid, tense, hard,
couvelaire
• Give way to a dark
red bleeding

3RD TRIMESTER PROBLEM DARK RED Bleeding


ABRUPTIO PLACENTA
▪ Problem regarding separation or detachment Uterus = Rigid and Tense
of the placenta
▪ Premature separation of the placenta Abdominal rigidity =
▪ Placenta separates early = cannot support the COUVELAIRE uterus/
baby anymore; no more blood, oxygen, uteroplacental apoplexy (hard,
nutrients going to the baby board like uterus)
▪ Tries to leave a space that leads bleeding
▪ Normal separation of placenta = 3rd stage of Hypotension, Tachycardia,
Pallor = bc of heavy bleeding
labor
▪ 1st stage = Full cervical dilatation
Disseminated Intravascular
▪ 2nd stage = delivery of the baby Coagulation = problem in the
▪ 3rd stage = delivery of the placenta clotting factor
• Placenta is detached
PREDISPOSING High parity
in the uterine wall =
FACTORS
DAMAGED
Advanced maternal age
• Production of
THROMBOPLASTIN =
Short umbilical cord = tries to
added into the
pull the placenta
maternal blood =
• Normal length =
BLOOD CLOT
50cm
• Affects arteries and
blood vessels
Chronic Hypertensive Disease =
Vasoconstriction; Increase
Fibrinogen Level, Platelet,
pressure in the heart; Increases
Hemoglobin, Hematocrit =
BP = affects flow of blood going
LOW
to the placenta = contracts and
separates MANAGEMENT IVF = needle should be gauge
18, in preparation for blood
Pregnancy Induced transfusion
Hypertension
Oxygen by mask = 10 L
Direct trauma
Monitor FHT = irregular/absent

35 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Record maternal v/s every 5-15 P Position = lateral position


min T Total FHT and v/s monitoring
I IV line should be open for possible
Left side-lying / Lateral Blood transfusion
Position = allow perfusion to O Observe for s/s of hypovolemic shock
the uterus due to unseen bleeding

No abdominal, vaginal and


pelvic exam D Dark red bleeding

If placental grade is 2-3, E Extended fundal height


terminate the pregnancy =
fetus is not getting anymore T Tender uterus
nutrients
A Abdominal pain/ contraction
CS = birth of choice
C Concealed bleeding
IV administration of fibrinogen H Hard uterus
= decrease level of fib that E Experience DIC
causes bleeding problems D Distressed baby
Hysterectomy = if uterus is
greatly affected, remove uterus CHARACTERISTICS OF ABRUPTIO AND PLACENTA
PREVIA
GRADE OF PREMATURE SEPARTION OF THE PLACENTA CHARACTERISTIC ABRUPTIO PREVIA
Onset 3rd trimester 3rd trimester
▪ Guides the doctor what to do with the patient
Bleeding Concealed, Mostly
GRADE CRITERIA external dark external, small
0 No symptoms of separation; Placenta is hemorrhage, to profuse
not yet separating bloody bleeding,
1 Minimal separation, not enough to amniotic fluid Bright red
cause vaginal bleeding and changes in Pain and uterine Usually Usually
the maternal and vital signs, no fetal tenderness present, absent,
distress or hemorrhagic shock occurs PAINFUL, PAINLESS,
2 Moderate separation, there is irritable uterus is soft,
evidenced of fetal distress, the uterus is uterus. relaxed, non-
tense and painful on palpation Progresses to tender
3 Extreme separation, without board-like
immediate interventions, maternal consistency
shock (HYPOVOLEMIC SHOCK) and FHT May be Usually,
fetal death will result irregular or normal
absent
Presenting part Baby; Engaged Placenta; Not
A Abruptio placenta is premature Engaged
separation of the placenta from the Delivery Immediate Maybe
uterine wall characterized by PAINFUL delivery via CS delayed
DARK RED, non-clotting vaginal depending on
bleeding, abdominal pain and the size of the
tenderness fetus and
B Baseline fibrinogen (if bleeding is amount of
extensive, fibrinogen reserve may be bleeding
used in body’s attempt to accomplish Shock Moderate to Usually not
effective clot formation severe present unless
R Refrain from internal exam, rectal depending on bleeding is
exam, enema the extent of excessive
U Utilized oxygen therapy to limit fetal concealed,
anoxia

36 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

EXTERNAL PREECLAMPSIA
hemorrhage
A. MILD BP 140/90

Systolic elevated at 30 mmHg,


diastolic elevated at 15 mmHg
3RD TRIMESTER PROBLEM above pre pregnancy level
PREGNANCY INDUCED HYPERTENSION
▪ Condition in which vasospasm occurs during Proteinuria +1, +2 on a random
pregnancy in both small and large arteries sample
▪ Signs of hypertension, proteinuria, and edema
develop. Weight gain over 2 lb per week
▪ Also called toxemia = pictured a toxin of some in 2nd trimester and 1 lb /wk in
kind being produced by a woman in response 3rd trimester
to the foreign protein of the growing fetus, the • NV = 1st tri = 3p
toxin leading to the typical symptoms = 2nd tri = 1p/w

PREDISPOSING Multiple pregnancy Mild edema in upper


FACTORS extremities or face = shifting of
Primiparas fluids in interstitial spaces

Age younger than 20 and older B. SEVERE BP of 160/110


than 40
Proteinuria +3, +4 on a random
Low socio economic-poor sample
nutrition
Oliguria = decrease amount of
5 or more pregnancies urine (500 ml or less in 24 hrs)
• NV = 600 ml in 24
Hydramnios = overproduction hours
of amniotic fluid
Elevated serum creatinine
With underlying disease more than 1.2 mg/dl
ASSESSMENT Hypertension
Cerebral or visual disturbance
Proteinuria = presence of (headache, blurred vision)
protein in the urine
Pulmonary or cardiac
Edema = cerebral and involvement
pulmonary edema
Extensive pulmonary edema =
Vision changes SOB

Weight gain Cerebral edema- headache,


confusion, ankle clonus

CLASSIFICATIONS OF PIH Ankle clonus = dorsiflex the


foot, observe movement of the
GESTATIONAL Develops an elevated BP foot.
HYPERTENSION (140/90 mmHg) • Mild – 2 movements
• Moderate – 3-5
Systolic pressure elevates at movements
30mmHg, diastolic elevated at • Severe – over 6
15 mmHg movements
Hepatic dysfunction
BP returns to normal after birth
No proteinuria or edema. Thrombocytopenia = lowers
platelet
Develop after 20 weeks
37 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Epigastric pain = RUQ pain

Pitting edema NURSING CARE MANAGEMENT


• +1= slightly indented
Mild HPN/ Mild Monitor antiplatelet therapy
• +2 – moderately
Preeclampsia
indented
Promote bed rest- lateral
• +3 – deep indention
recumbent position
• +4 – so deep that it
remains after
Promote good nutrition – give
removal of the finger
little sodium
ECLAMPSIA Seizure or coma accompanied
by s/s of pre-eclampsia Provide emotional support
(proteinuria, hypertension,
Severe HPN/ Support bed rest
edema)
Severe
Preeclampsia Hospitalization
Happens late in pregnancy upto
48 hours after birth
a. NO visitors
b. Private room
Tonic Clonic Seizure
c. Raise side rails to
• Preliminary prevent injury
signal/aura d. Darken the room
• All muscles contract e. No shining of
• Back arches, her arms flashlight into the
and leg stiffen, jaw woman’s eyes
closes, RR stops
(because her thoracic Monitor for maternal well-
muscles are held in being
contraction) • BP
• Last 20 seconds • obtain blood studies
• Cyanotic • daily hct monitoring
• frequent plasma
During the 2nd Clonic stage: estriol levels
• Bladder and bowel • daily weights at the
contracts and relax same time each day
• Incontinence of urine wearing the same
and feces amount of clothing
• Begins to breathe but • insert IFC (shd be
not entirely effective 600/24 hrs)
• Remain cyanotic • 24-hour urine sample
• Last up to 1 minute
Monitor fetal well-being
During the 3rd stage of seizure
(prostictal state) • doppler with 4 hr
• Semicomatose interval
• Cannot be roused • FHT
except by painful • NST daily
stimuli for 1-4 hours • oxygen
• Close observation is administration to
important = can mother
cause premature • Support nutrition diet
separation of the
• high CHON and
placenta = labor BUT
moderate sodium
the woman will be
• IVF
unable to report
sensation of
Administer medications to
contractions.
prevent eclampsia

38 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

• Hydralazine
(apresoline) Assess FHT and uterine
contractions
• Labetalol (
normodyne) Check vaginal bleeding
• Nifedipine
• Magnesium SO4- Nursing care during the 3rd
drug of choice to stage of seizure
prevent eclampsia
- given first 1V for • Keep the woman on
15 min in bolus her side
dose • Give her nothing by
- anticonvulsant mouth
= anti-seizure • Limit conversation
• Continuously monitor
Before administering MG SO4 FHT
check the ff: • Check vaginal
bleeding every 15
a. Urine output shd be minutes
25-30 ml/hr • If pregnancy is >24
b. Specific gravity 1.010 weeks – decision will
or lower be made as soon as
c. RR should be above her condition
12 breaths/min stabilizes usually 12-
d. Ankle clonus should 24 hrs
be minimal • Terminate the fetus
e. DTR (+) coz it does not
f. Calcium Gluconate – continue to grow
antidote for MGSO4 • CS is more hazardous
for the fetus
Signs and symptoms- overdose • Woman with
of MgSO4: eclampsia is NOT a
• Decreased urine good candidate for
output • surgery
• Decreased RR • Vaginal – preferred
• Reduced birth
consciousness • If labor does not
• Decreased DTR begin spontaneously,
• Hyperreflexia (4+ ROM or induct labor
DTR) with oxytocin via IV
• flushing or feeling • If ineffective ---CS is
hot/warm (early) indicated because
ECLAMPSIA To maintain a patent airway the fetus is in danger

Administer oxygen by face


mask = to protect the fetus HELLP SYNDROME

Turn woman to her side = to H Hemolysis


prevent aspiration, and E elevated Liver enzymes (SGOT/ AST= serum
allow drainage glutamic oxaloacetic transaminase/
Aspartate aminotransferase; SGPT/ALT
Magnesium sulfate/diazepam – serum glutamic pyruvic transaminase/
(valium) via IV as an emergency alanine Transaminase)
measure L Low platelets

Assess oxygen saturation


SIGNS AND Proteinuria
Apply external heart monitor SYMPTOMS
Edema
39 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Hypertension

Nausea

Epigastric pain RUQ

General malaise
MANAGEMENT Needs close supervision
COMPLICATIONS 1. liver hematoma
2. hyponatremia
3. renal failure
4. hypoglycemia
EFFECTS TO THE Cerebral hemorrhage
MOTHER
Aspiration pneumonia

Hypoxic encephalopathy
FETAL EFFECTS Growth restriction
Preterm birth

40 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

FERTILITY ▪ When pregnancy has not occurred after at


least 1 year of engaging in unprotected coitus
▪ It is the natural capability of giving life ▪ 14% couples
FERTILE MALE TYPES OF INFERTILITY
▪ Functional reproductive organs Primary Infertility there has been no
• Testes must produce adequate previous conception
numbers of sperm
✓ NORMAL amt of sperm = 15 m- Secondary Infertility there has been a
200 m/ mL or more previous viable
• Unobstructed genital tract pregnancy but the
• Genital tract secretions must be couple is
normal unable to conceive at
✓ NORMAL amt of seminal fluid present
= 2.5 – 5ml/ 1 tsp Sterility inability to conceive
because of a
• Ejaculated sperm must reach cervix
known condition
= not deposited
Subfertility decreased ability to
FERTILE FEMALE conceive

▪ Cervical mucus must be favorable = THIN,


TRANSPARENT, SLIPPERY, WATERY RISK FACTORS
▪ Fallopian tubes must be patent ▪ Age = 35yo above
▪ Functional hypothalamic-pituitary axis = ▪ Tobacco smoking = can lead to miscarriage
Releases FHS and LH ▪ Alcohol use.
▪ Ovaries must produce and release ova in a ▪ Being overweight
regular, cyclic fashion ▪ Being underweight
▪ Endometrium must be prepared for ▪ Too much exercise = esp athletes
implantation of the blastocyst = no tumor, ▪ Caffeine intake
masses, congenital defect
▪ Adequate reproductive hormones must be DIAGNOSIS OF INFERTILITY
present = enough estrogen and progesterone
If lack of ovarian function Basal body temperature
FERTILITY HISTORY is suspected recording = every
monring
▪ Information about most fertile times for
intercourse Hormonal assessments
▪ Explanation of basic infertility workup = checks for the level of
▪ Basic assessments estrogen, progesterone,
• Ovarian function follicle stimulating
• Cervical mucus adequacy hormone, luteinizing
hormone
• Semen analysis
• Tubal patency
Endometrial biopsy =
• General condition of pelvic organs getting tissues from
▪ Complete physical examination of both endometrium to check;
partners Can also detect luteal
▪ Laboratory examination phase; 2-3 days before
• CBC menstruation
• UA
• Hormonal assays Transvaginal ultrasound
= inserted inside the
INFERTILITY uterus
If cervical problems are Ferning capacity of
▪ Inability to conceive a child, sustain pregnancy suspected cervical mucus
and childbirth If tubal or uterine Hysterosalpingography
problems are suspected = infusing a dye; 2-3 days

41 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

before the next • 20 M/ml of seminal fluid


menstruation; Side • 50M/ ejaculation
Effects: painful uterine • 50% are motile, 30% in normal
cramping, shoulder pain, shape and form
difficult breathing
• Anti-sperm antibodies. Antibodies
that target sperm and weaken or
Hysteroscopy = uses
hysteroscope disable them usually occur after
surgical blockage of part of the vas
Laparoscopy = uses deferens for male sterilization
laparoscope (vasectomy).
If male’s fertility is Semen analysis = checks 4. Obstruction or Impaired Sperm Motility
suspected the amount of semen Conditions
• Mumps orchitis – testicular
Screening for anti- inflammation and scarring due to
sperm antibodies = mumps virus
looks for special • Epididymitis – inflammation of the
proteins/antibodies that
epididymitis; s/s swollen, red, war,
fight against sperm in
scrotum, painful testicle
blood, vaginal fluids or
semen. • BPH – Benign Prostate hypertrophy;
uncomfortable urinary symptoms;
blocking the flow of urine
MALE INFERTILITY • Congenital stricture of spermatic
duct
Male infertility Factors
5. Improper Deposition of Sperm
▪ Disturbance in spermatogenesis (production • Cystic fibrosis - Men with cystic
of sperm cells) fibrosis often have missing or
▪ Obstruction in the seminiferous tubules, obstructed vas deferens.
ducts, or vessels preventing movement of • Hypospadias- urethral opening on
spermatozoa the ventral surface of the penis
▪ Qualitative or quantitative changes in the • Epispadias – urethral opening on the
seminal fluid preventing sperm motility dorsal
(movement of sperm) 6. Ejaculation Problems
▪ Development of autoimmunity that • Erectile dysfunction/Impotence
immobilizes the sperm secondary to debilitating conditions
▪ Problems in ejaculation or deposition and psychological problems
preventing spermatozoa from being placed • Premature Ejaculation
close enough to the woman’s cervix to allow • Retrograde ejaculation. Various
ready penetration and fertilization conditions can cause retrograde
ejaculation including diabetes,
CAUSES OF MALE INFERTILITY bladder, prostate or urethral
surgery, and the use of certain
1. Psychological issue (psychogenic infertility)
medications.
• Solution to the problem can include
7. Dyspareunia
psychological or sexual counseling
• Painful sexual intercourse
and may involve long-term care.
2. Premature ejaculation- Ejaculation before • Can be observed before, during or
penetration after the sexual int.
• May interfere with the proper DIAGNOSTIC TESTS
deposition of sperm. Another
problem often attributed to ▪ Semen analysis- Urinalysis
psychological causes. ▪ Blood Tests
3. Inadequate Sperm Count ▪ Sperm penetration assay – analyzes the ability
• Refers to the number of sperms in a of man’s sperm to bind or attach to the egg
single ejaculation membrane
▪ Anti sperm antibody testing
42 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

FEMALE INFERTILITY ** Agglutination occurs when the head or tail of one


sperm sticks to another sperm restricting the motility of
CAUSES: the sperm
1. Anovulation = most common cause of PSYCHOLOGICAL REACTIONS
infertility
• Genetic abnormality ▪ Development of lack of spontaneity of sexual
• Hormonal imbalance intercourse
• Ovarian tumors • Constant attention to temperature
• Decrease body weight / fat ratio less charts
than 10% (eg. Athletes, anorexic) • Instructions about their sex life from
• Polycystic Ovary Syndrome an outsider
✓ Signs and symptoms: Irregular ▪ Feelings of loss of control
menstrual cycles, lack of ▪ Feelings of reduced competency
regular ovulation, abnormal ▪ Loss of status and ambiguity as a couple -
facial hair growth, infertility, infertility often becomes central focus for role
obesity and polycystic ovaries identity
(enlarged, cystic ovaries). ▪ Sense of social stigma
2. Tubal Transport Problems • Feelings of guilt or shame
• Due to scarring of the FT secondary ▪ Stress on marital and sexual relationship
to chronic salpingitis (chronic PID), • Heighten feelings of frustration or
ruptured appendix and other anger between partners
infections ▪ Strained relationship with healthcare
• Chronic PID = caused by prolonged providers
used of IUD ▪ Tasks of the infertile couple
• Dx: hysterosalpingography,
MANAGEMENT OF INFERTILITY
hysteroscopy or laparoscopy
3. Uterine Problems Drugs that induce Clomiphene Citrate
• Fibromas/ Leiomyomas –tumors ovulation (Clomid, Serophene) =
block the FT MOST COMMON DRUG;
• Congenitally deformed uterine Monitor ovulation
cavity – limits implantation
• Poor secretion of Estrogen and Human Menopausal
Progesterone from the ovary Gonadotropins
(Pergonal, Humegon,
• Endometriosis – abnormal
Repronex)
implantation of
endometrium/nodules spreading Bromocriptine –
from uterus to outside the uterus decreases Prolactin
4. Cervical problems thereby enhances
• Infection or inflammation of cervix – production of FSH
results to thick mucus and LH
• Stenotic cervical os – cervical polyp
• Cervical scarring secondary to Oral Contraceptives –
surgery (D and C) Danazol
5. Vaginal Problems Procedures/Treatment Gamete intrafallopian
transfer (GIFT)
• Infection – acidic vagina which limits
sperm motility and survival
In vitro fertilization (IVF)
✓ pH of vagina should be
ALKALINE Artificial insemination
• Sperm agglutinating antibodies in (AI)
the vagina = can restrict
mobility/movement of the sperm Intracytoplasmic sperm
injection (ICSI)
** Sperm must be swimming freelu not stuck to each
other
43 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

PROBLEMS OF THE PASSANGER ▪ Be aware of how long the woman last ate
During labor, she may need an oral sports
drink or IV glucose to replace glucose stores
FETAL MALPOSITION used for energy.

= with an OP the is deflexion of the baby’s head and so MACROSOMIA/ OVERSIZED FETUS
there is a larger diameter to stretch the vaginal ▪ Wt >4000-4500g (9-10 lbs) – born with
entrance. diabetic mother
▪ IDEAL POSITION = Anterior Position (baby is in ▪ Associated with multiparity = slightly heavier
prone position, looking down) and larger than the one born just before
▪ May cause uterine dysfunction = it tends to
OCCIPITO POSTERIOR POSITION OVERSTRECHED the uterus = Hypotonic
Uterine Contraction = weak contractions;
▪ The baby’s spine is lying against mother’s should be strong to push the baby
spine and face is looking up at mother’s ▪ Wide shoulders — cause fetal pelvic
tummy disproportion or uterine rupture from
▪ One of the most common causes of prolonged obstruction
labor. ▪ CS- birth method
▪ During internal rotation the fetal head must
rotate 135 degrees/ 3/8 rotation SHOULDER DYSTOCIA
▪ IR takes time = compresses SACRAL NERVE =
causes SACRAL PAIN/ BACK PAIN ▪ Comes from the Greek words “dys,” meaning
▪ Occur in women with an android (heart difficult, and “tokos,” meaning birth
shaped pelvis), anthropoid (oval or shorter ▪ Occurs at the 2nd stage of labor when the
pelvic outlet) or contracted pelvis. infant’s head is born but the shoulders are too
▪ Normal Pelvis = GYNECOID PELVIS broad to enter and be delivered thru the pelvic
▪ Suggest a dysfunctional labor such as: outlet
• Prolonged active phase • Turtle sign = can only see the head of the baby
• Arrested descent • Hazardous to the mother
▪ Fetal heart sounds heard best at the lateral • Hazardous to the fetus
sides of the abdomen
Occur with diabetes
Change position women with:
multipara
▪ Can be aided by having the woman assume
• Hands and knees position post-dated pregnancies
• Squatting Risk for (baby) Brachial plexus injury =
paralysis of the arms/shoulder
• Lying on her side
✓ Left side if the fetus in the right
Brain injury = because of cord
occiput posterior compression/ chest
✓ Right side if the fetus is in left compression
occiput posterior
• Lunging = one leg is position forward Cord compression = decrease
with knees flex amt of oxygen to the baby’s brai
• Swinging her body from right to left
Chest compression =
NURSING CARE MANAGEMENT compressed chest =
uncoordinated respirations =
▪ Applying counter pressure on the sacrum by a DOB
back rub Risk for (mother) Maternal trauma (PPH
▪ Applying heat or cold compress and 3rd degree laceration)
▪ Lying on her side opposite the fetal back
▪ Maintain a hand and knees position may help
rotate the fetus
▪ Voids every 2 hrs = prevents the descent of the
baby
44 | N CM 109 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

MANAGEMENT: M = McRoberts Maneuver

Call for help A = anterior shoulder (suprapubic pressure)

Empty bladder to prevent discomfort P = posterior shoulder (rubin’s maneuver)


Suprapubic Mazzanti Maneuver
pressure S = Salvage
(anterior Compress anterior shoulder a. Posterior shoulder sling = use cord, place
shoulder) using the heal of the hand around axilla of the baby and pull upward
above the symphysis pubis and and downward
press downward b. Zavanelli maneuver = rotating and pushing
Mc Roberts Flex the legs of the patient, back
maneuver flatten sacrum to have wider c. Fracture clavicle = use thumb to fracture
area the clavicle; lungs should not be affected

Suprapubic and Mc Roberts =


DONE AT THE SAME TIME FETAL MALPRESENTATION
Deliver the Rubin’s Maneuver
posterior arm
Insert finger in the vagina.
VERTEX PRESENTATION
Touch the shoulder and rotate
until it is located in the chest BROW Rarest/most uncommon of all
Wood corkscrew Insert 2 fingers in anterior, 2 PRESENTATION presentations.
fingers in posterior and rotate
clockwise. Normal Presenting Part =
OCCIPUT
The obstetrician places a hand
on the anterior aspect of the Brow presentation is commonly
posterior fetal shoulder and unstable, it usually converts to
rotates the shoulder toward face or vertex extreme facial
the fetal back. edema

The goal is to attempt to rotate Occur in multipara/women


the fetal shoulder 180 degrees. with relaxed abdominal
This allows the fetus to descend muscles.
while the rotation is occurring.
Results in = OBSTRUCTED
Delivery of posterior shoulder LABOR
Gaskin Pulling the baby downward to FACE Occurs when the head is hyper
maneuver/roll deliver posterior shoulder PRESENTATION extended and the
onto all fours chin(mentum) is the presenting
Changes pelvic dimensions in a part.
similar way to McRoberts
Maneuver ASYNCLITISM – fetal head
presenting at the different
Apply downward traction to angle expected.
disimpact the posterior
shoulder Face and brow= common
Episiotomy To cut
Zavanelli Cephalic replacement by Chin= rare
maneuver reversing cardinal movements
of labor The back is difficult to outline =
concave
Fetal head is rotated to occiput
anterior position, flexed, If the fetal back ais extremely
rotated and pushed back up to concave = FHT be heard on the
the uterus side of the fetus where the feet
and arms be palpated.

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

A mature fetus can’t be


Confirmed in vaginal exam delivered vaginally from this
A fetus in a posterior position presentation
instead of flexing the head as Rupture membranes beginning
labor proceeds may extend the labor because there is no firm
head resulting in CHIN presenting part
presentation usually with
contracted pelvis/placenta The cord, arm may prolapsed
previa.
Shoulders may obstruct the
Also occur in a relaxed uterus of cervix
multipara, hydramnios, fetal
malformation. CS delivery = mature baby

If chin is anterior and the pelvic Causes:


diameter are within the normal ✓ Lax uterus and
limit, the infant may be abdominal muscles
delivered without difficulty but due to multiparity
with long stage of labor ✓ Contracted pelvis
because the face does not mold ✓ Fibroids and
well to make a snugly engaging congenital
part. abnormality of the
uterus
If the chin posterior – CS maybe ✓ Preterm fetus,
the choice of birth hydrocephalus
✓ Placenta previa
Results of chin /face ✓ Multiple pregnancy
presentation:
✓ Facial edema Management:
✓ Ecchymosis ✓ External cephalic
✓ Lip edema version = external
SHOULDER Occurs in women with: monitor, UTZ in the
PRESENTATION ✓ pendulous abdomen bedside
✓ uterine masses such ✓ CS = if ECV is not
as fibroid – obstruct effective
the lower segment
✓ contraction of the
pelvic brim BREECH PRESENTATION
✓ congenital
abnormalities of the ▪ Common in early pregnancy
uterus ▪ 38 weeks , the fetus normally turns to a
✓ Hydramnios cephalic presentation:
✓ May occur with infant ▪ Prolonged labor, Presence of meconium, No
who engagement
hydrocephalus/gross
abnormalities that CAUSES:
prevents the head
▪ Gestational age less than 40 weeks
from engaging.
▪ Abnormally in a fetus such as:
May occur in prematurity = • Anencephaly = no skull
when the infant has room for • Hydrocephalus = big head
free movement, multiple • Meningocele = spinal problem
gestation (particularly the 2nd • Hydramnios = allows free fetal
twin), short umbilical cord. movement, allowing the fetus to fit
within the uterus in any position
Can be detected by Leopold’s • Congenital anomaly of the uterus
Maneuver and confirm by UTZ
such as midseptum that trap the
fetus in a breech position

46 | N C M 1 0 9 RDA
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

▪ Any space occupying mass in the pelvis that PROLAPSED UMBILICAL CORD
does not allow the fetal head to present like:
• Fibroid tumor of the uterus ▪ Loop of the umbilical cord slips down in front
of the presenting fetal part.
• Placenta previa
▪ Occurs any time after the PROM
• Pendulous abdomen = abdominal
▪ Occurs if the fetal part is not fitted firmly to
muscle are lax allowing the uterus to
the cervix.
fall forward that the fetal head
comes to lie outside the pelvic brim Occur most often:
• Multiple gestation = the presenting
part cannot turn to a vertex position ▪ PROM
▪ Unknown factors ▪ Fetal presentation other than cephalic
▪ Placenta previa
ASSESSMENT ▪ Intrauterine tumors preventing the presenting
part from engaging
▪ FHT are heard high in the abdomen
▪ A small fetus
▪ Leopold’s and vaginal exam may reveal the
▪ CPD
presentation
▪ Hydramnios
▪ Breech is complete = gluteal muscles of the
▪ Multiple gestation
fetus may be mistaken as the head during
vaginal exam ASSESSMENT
▪ The cleft between the buttocks may be
mistaken as the sagittal suture line ▪ Presence of cord on palpation on vaginal
▪ If presentation is unclear --- UTZ to confirm examination during labor or ultrasound
▪ Always monitor FHR and uterine contractions ▪ Cord is visible at the vulva
= allows detection of fetal distress from a ▪ Assess FHT immediately after rupture
complication such as prolapsed umbilical cord
NURSING CARE MANAGEMENT
TYPES OF BREECH PRESENTATION
▪ Relieve pressure on the cord
1. Complete Breech = in sitting position ▪ Cord prolapsed leads to cord compression =
(meditating position, arms are crossed) ; PP= because the presenting part presses against
buttocks the cord at the pelvic brim.
2. Frank Breech = sitting position; PP = buttocks; ▪ A gloved hand on the vagina and manually
Legs = extended to chest elevating the fetal head off the cord.
3. Footling Breech = PP= feet ▪ Place the client in Trendelenburg
position/knee chest position = to cause the
Hazardous to a fetus than a cephalic presentation fetal head to fall back from the cord.
because there is higher risk of: ▪ Administer Oxygen at 10L/min facial mask = to
prevent hypoxia to the part of the fetus.
▪ Anoxia from a prolapsed cord = absence of
▪ Tocolytic agent = to reduce uterine activity
oxygen
▪ Amnioinfusion = to relieve pressure on the
▪ Traumatic injury to the after coming head
cord
(possibility of intracranial hemorrhage or
▪ Infuse initial amount of 500ml/IV (LR)
anoxia)
inserted to the cervix to supplement the
▪ Fracture of the spine or arm
amount of amniotic fluid
▪ Dysfunctional labor = prolonged labor
▪ Side lying position = to prevent supine
▪ Early rupture of the membranes because of
hypotension syndrome
the poor fit of the presenting part
▪ Solution should be warm
▪ The inevitable contraction of the fetal
▪ Practice aseptic technique to prevent
buttocks from cervical pressure causes
infection
meconium to be extruded in the amniotic fluid
▪ Continuously monitor FHT, Temp of the
before birth = may lead to meconium
woman
aspiration if the infant inhales the amniotic
▪ Change the linens frequently
fluid.
▪ If vaginal leakage stops = fetal head is firmly
engaged but it is dangerous = it may lead to
hydramnios = uterine rupture
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▪ Forceps delivery = if the cervix is fully dilated


and, to prevent hypoxia
▪ If the cervical dilatation is incomplete = apply
an upward pressure on the presenting part to
the vagina = to keep pressure of the cord until
CS is done

MULTIPLE GESTATION

▪ Multiple gestation may have difficulty


contracting as usual placing them at risk of
hemorrhage from uterine atony and uterine
infection.
▪ CS delivery = to decrease the risk of of the 2nd
baby to experience anoxia
▪ After the 1st infant is born = both ends of the
baby’s cord are tied or clamped permanently
rather than with cord clamps which could slip.
▪ Oxytocin is given after birth with a single
pregnancy = to contract the uterus to
minimize bleeding BUT if with multiple =
OXYTOCIN is not being given coz it can
compromise the circulation of the infant not
yet born.
▪ After the delivery of 2nd baby = OXYTOCIN IS
ADMINISTERED
▪ If the presentation of the 2nd infant is not in
vertex = EXTERNAL CEPHALIC VERSION is
done.
▪ If ECV is not effective = CS
▪ If infant will be born vaginally = Oxytocin
infusion is given to shorten the time, assisting
uterine contraction
▪ If relaxation is needed = give NITROGLYCERIN
(uterine relaxant)
▪ Placenta of the 1st baby separates before the
second fetus is born = expect a sudden
bleeding at the vagina. = the uterus cannot
contract coz it is full the 2nd twin.
▪ If there is separation of the 1st placenta = the
fetal heart sounds will register distress
immediately.

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

PROBLEMS OF POWER INVERSION OF UTERUS

▪ Refers to the uterus turning inside out with


either birth of the fetus or delivery of the
CONTRACTION RING / BANDL’S RING placenta ( 3rd stage of labor)
▪ A hard band that forms across the uterus at ▪ Occur if traction is applied to the umbilical
the junction of the upper and lower uterine cord to remove the placenta
segments and interferes with fetal descent. ▪ Occur if pressure is applied to the uterine
▪ Pathologic retraction ring/ Bandl’s ring= fundus when the uterus is not contracted.
common type of contraction ring ▪ Occur if the placenta is attached at the fundus
▪ Frequency of Uterine contraction = Happens and during birth the fetus pulls the fundus
every 2 minutes ; 3 uterine contraction for 10 down
min ▪ Occurs in degrees
▪ Uterine Contractions should be VOLUNTARY, ▪ The inverted fundus may lie within the uterine
STRONG, EFFECTIVE cavity or the vagina
▪ Duration of Uterine contraction = Starts from ▪ Total inversion it may protrude from the
one contraction to same contraction = vagina
seconds ASSESSMENT
▪ Appears at the 2nd stage of labor
▪ Can be palpated at a horizontal indentation ▪ Large amount of blood suddenly gushes from
across the abdomen the vagina
▪ A WARNING SIGN that severe dysfunctional ▪ If it continues: woman will show signs of blood
labor is occuring loss: hypotension, dizziness, paleness and
▪ Formed by excessive retraction of the upper diaphoresis
uterine segment, the uterine myometrium is ▪ Fundus is not palpable in the abdomen
much thicker above than below the ring ▪ Uterus is not contracting
▪ IF OCCURS IN EARLY LABOR = usually caused ▪ Bleeding continues
by uncoordinated contractions
▪ In the pelvic division of labor = caused by CLASSIFICATION
obstetric manipulation or by administration of a. 1st Degree – inverted fundus up to cervix
oxytocin b. 2nd Degree – body of uterus protrudes through
▪ Fetus and placenta are gripped and cannot cervix into vagina
advance c. 3rd Degree – prolapse of inverted uterus
▪ Identified by UTZ outside vulva
MANAGEMENT: d. 4th Degree – prolapse of inverted uterus and
vagina
▪ Administration of morphine sulfate = to
relieve contraction ring CLASSIFICATION – DEGREE DESCRIPTION
▪ inhalation of amyl nitrite = smooth muscle 1. FIRST (INCOMPLETE)
relaxant/facilitate uterine relaxation ▪ The inverted fundus extends to, but
▪ Tocolytic agent =to stop contraction not beyond, the cervical ring
▪ CS 2. SECOND (INCOMPLETE)
▪ Manual removal of the placenta under ▪ The inverted fundus extends
general anesthesia= if contraction ring does through the cervical ring but
not allow the placenta to be delivered. remains within the vagina
COMPLICATIONS: 3. THRID (COMPLETE)
▪ The inverted fundus extends down
▪ Uterine rupture = accumulation of pressure/ to the introitus
tends to burst or rupture 4. FOURTH (TOTAL)
▪ Neurologic damage to the fetus = hypoxia or ▪ The vagina is also inverted
anoxia
▪ Massive hemorrhage = because the placenta
is loosened but then cannot deliver preventing
the uterus from contracting
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NURSING CARE MANAGEMENT may be brief.

a. Never attempt to replace an inversion == CLASSIFICATION


b. because handling of the uterus may increase
the bleeding. Precipitate Dilatation When cervical dilatation is
c. Never attempt to remove the placenta if it is progressing at a rate of 5
cm or more per hour in
still attached = because this only creates a
nulliparas and 10 cm per
larger surface area for bleeding.
hour in multiparas
d. Start an IV fluid using a large gauge needle
Precipitate Descent when fetal descent is
e. Administer O2 via mask progressing at a rate of 5
f. Assess Vital signs cm per hour or more in
g. Be ready to give CPR = due to sudden blood nulliparas and 10 cm per
loss, heart will fail hour or more in multiparas.
h. Give general anesthesia, or possibly
nitroglycerin or a tocolytic drug to relax the
uterus PREDISPOSING FACTORS
i. Physician/midwife/nurse replaces the fundus
✓ Multiparity
manually
✓ Large Pelvis
j. Administer oxytocin after manual
✓ Lax unresisting maternal tissue
replacement helps the uterus to contract and
✓ Small baby in good position
to remain in its natural place
✓ Induction of labor-amniotomy and oxytocin
k. Antibiotic therapy = because the woman’s
administration
endometrium is exposed, preventing infection
✓ Absence of painful sensation and thus lack of
l. Informed her that CS will probably be
awareness of vigorous
necessary in any future pregnancy = to
prevent the possibility of future inversion ASSESSMENT

PRECIPITATE LABOR ▪ Similar to woman with normal labor pattern


but they appear suddenly without warning.
▪ Occur when uterine contractions are so strong
▪ Patient complains of a sudden, intense urge to
that a woman gives birth with only a few
push
rapidly occurring contractions.
▪ Sudden increase in bloody show
▪ Labor that is completed in fewer than 3 hours.
▪ Sudden bulging of the perineum
▪ Precipitate dilatation – cervical dilatation that
▪ Sudden crowning of the presenting part
occurs at a rate of 5 cm or more /hr in a
primipara or 10 cm or more /hr in a multipara COMPLICATIONS
▪ NORMAL = Primipara (1-1.2); Multipara (1.5)
▪ Occur with: MATERNAL Laceration of birth canal and
• grand multiparity = 4x and more uterine rupture
preg.
Postpartum hemorrhage
• after induction of labor by oxytocin
or amniotomy Amniotic fluid embolism
▪ Contractions are forceful that may lead to: FETAL Fetal- hypoxia
• premature separation of the
placenta Intracranial hemorrhage
• Hemorrhage
• Lacerations Erb Duchenne palsy
• Rapid labor also possesses a risk to
the fetus resulting to: Premature separation of
✓ subdural hemorrhage placenta
✓ Caution a multiparous
Injuries as a falling to the floor
woman by week 28 of
in unattended birth
pregnancy that because a
past labor was so brief,
her labor this time also

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NURSING CARE MANAGEMENT ▪ Perform measures to manage or stop labor


from proceeding
▪ adequate prenatal care ▪ Place client on lateral bed rest
▪ warn women with history of precipitate labor ▪ Prepare client for possible UTZ,
that rapid labor and delivery may happen amniocentesis, tocolysis and steroid therapy
again ▪ STEROID THERAPY = hazens lung maturity;
▪ If accelerated labor pattern occurs during given 12-24 hours before labor
oxytocin administration. Stop infusion right ▪ Give tocolytic medication as ordered
away and turn woman on her side (terbutaline, ritodrine)
PRETERM LABOR ▪ Watch out for side effects of tocolytic therapy
(hypotension, difficulty of breathing, chest
▪ Cervical change or effacement and uterine pain, fetal tachycardia)
contractions occurring after 20 weeks ▪ Discontinue tocolytic therapy if maternal
gestation and prior to 37 weeks of gestation pulse is >120beats/min
▪ Delivered after 20 wks or before 37 wks; early ▪ Give emotional and psychosocial support
delivery of the baby ▪ Educate the patient and her family.
▪ Can arise from any of the three main
CAUSES: components of the process: power , the
passenger, and the passageway
✓ PROM
✓ Hydramnios PROLONGED LABOR
✓ Placenta previa
✓ Preeclampsia ▪ Pregnancy which extends beyond 42 weeks
✓ Multiple gestation AOG
✓ Abruption placenta ▪ Post term
✓ Incompetent cervix
✓ Fetal death CAUSES
✓ Trauma ✓ Large fetus
✓ Intrauterine infection ✓ Hypotonic
✓ Maternal factors: stress, Urinary Tract ✓ Hypertonic
Infection, ✓ Uncoordinated contractions
✓ Dehydration
Those who have prolonged labor are at risk of
ASSESSMENT
✓ Postpartal infection
▪ Suprapubic pressure ✓ Hemorrhage
▪ Vaginal pressure ✓ Infant mortality
▪ Low back pain
▪ Regular uterine contractions ASSESSMENT
▪ Cervical dilatation and effacement
▪ Bloody show ▪ Weight loss and decreased uterine size
▪ Rupture of membranes ▪ Excessively large fetus
▪ Meconium stained amniotic fluid = common
NURSING CARE MANAGEMENT on postpartum
▪ Non-reassuring FHR pattern
▪ Assess the maternal status and check for signs
of labor NURSING CARE MANAGEMENT
▪ Obtain complete history
▪ Obtain blood and urine specimens for lab test ▪ Evaluate the fetus = DO NOT initiate crying
▪ Assess the frequency, intensity and duration when the baby is meconium stained = it can
of contractions block the airway = causing the baby not to
▪ Evaluate cervical dilatation and effacement breath. REMOVE THE MECONIUM FIRST
▪ Determine the status of membranes and ▪ Prevent birth complications
check for bloody show ▪ Give emotional and physical support
▪ Monitor the fetus and evaluate for distress, ▪ Educate the patient and her family
size, maturity and activity

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

UTERINE RUPTURE
fetal and maternal distress
▪ Occurs when a uterus undergoes more strain
than it is capable of sustaining. lack of contractions
▪ Occur most commonly when a vertical scar
from a previous CS or hysterectomy repair
tears. NURSING CARE MANAGEMENT
▪ Confirmed by Ultrasound
▪ Administer emergency fluid replacement
▪ An immediate emergency situation
therapy as ordered = use GAUGE 18 needle
PREDISPOSING FACTORS ▪ Anticipate the use of oxytocin to attempt to
contract the uterus and minimize bleeding
✓ Prolonged labor ▪ Prepare the woman for possible laparotomy
✓ Abnormal presentation as an emergency measure to control bleeding
✓ Multiple gestation and achieve a repair
✓ Unwise use of oxytocin ▪ Advised not to conceive again after a rupture
✓ Obstructed labor of the uterus = unless the rupture occurred in
✓ Traumatic maneuvers of forceps or tractions the inactive lower segment.
▪ Perform a caesarian hysterectomy (with
ASSESSMENT
consent) fear of the removal of the damaged
▪ Sudden, severe pain during a strong labor uterus or tubal ligation at the time of
contraction laparotomy = result in the loss of childbearing
▪ Tearing sensation ability.

TYPES DYSTOCIA

COMPLETE 3 layers are affected = ▪ Difficult labor


RUPTURE endometrium, myometrium ▪ Can arise from any of the three main
and peritoneum layers components of the process: power , the
passenger, and the passageway.
uterine contractions will
immediately stop I. INTERIA
▪ Time to denote sluggishness of contractions of
2 distinct swellings will be the force of labor
visible on the woman’s ▪ Weakness of uterine contraction
abdomen
▪ Dysfunctional labor
The retracted uterus CAUSES Inappropriate use of analgesia
(excessive or too early
Extrauterine fetus administration) = it prevents
cervix to dilate; Excessive amt =
Signs of shock: rapid weak problem in uterine contraction
pulse, falling BP, cold clammy
skin, dilatation of the nostrils, Pelvic bone contraction that
FHR fades and then are has narrowed the pelvic
absent. diameter = fetus cannot pass;
INCOMPLETE Endometrium and occur in a woman with rickets
RUPTURE Myometrium are affected =
leaving the peritoneum intact Poor fetal position (posterior
rather than anterior position) =
the signs of rupture are less normal = anterior; prolonged
evident labor = posterior

woman experience only a Attitude = Extension rather


localized tenderness flexion of the fetal head; degree
and a persistent aching pain of flexion; Ideal position =
over the area of the GOOD FLEXION
lower uterine segment

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Overdistention of the uterus as Normal Strength = 25 mmHg –


with multiple pregnancy, 40 mmHg to 80 mmHg – 100
hydramnios or an excessively mmHg
oversized fetus = leads to
UTERINE DYSFUNCTION Occur during:
✓ Active labor
Cervical rigidity (unripe) = ✓ Occur after the
cervix is not yet riped, not yet administration of
dilated; pt should not be analgesia esp. If the
pushing = causes CERVICAL cervix is not dilated to
EDEMA 3-4 cm
If the bowel or bladder
Presence of a full rectum or distention prevents descent or
urinary bladder that impedes firm engagement
fetal descent
Uterus that is overstretched by
Woman becoming exhausted multiple gestation
from labor = related to bearing
down or risk to hypertonic Larger than usual fetus

Primigravida status = they Hydramnios


don’t have the experience yet
CLASSIFICATION Primary = occurring at the Lax uterus from grand
onset of labor multiparity

Secondary = occurring late in ✓ Contractions are not


labor painful
✓ Lack of intensity
✓ A subjective
INEFFECTIVE UTERINE FORCE symptom
✓ Increase the length of
Contraction occurs because of: labor
✓ Uterus does not
a. The interplay of the contractile enzyme
contract
adenosine triphosphate ✓ Exhaustion
b. The influence of major electrolytes such as
calcium, sodium and potassium NURSING CARE
c. Specific contractile proteins (actin and MANAGEMENT
myosin) ✓ 1st hour after birth =
d. Posterior pituitary hormone (epinephrine and palpate the uterus
norepinephrine, oxytocin) (HARD)
e. Estrogen ✓ Assess the lochia =
f. Progesterone every 15 minutes to
g. Prostaglandin ensure that
postpartal
HYPOTONIC Contractions: low, infrequent contractions are not
CONTRACTIONS (not more than 2 or 3 in a 10- also hypotonic and
minute period) therefore,
inadequate to halt
Resting tone of uterus: bleeding
<10mmHg HYPERTONIC Resting tone: more than 15
CONTRACTIONS mmHg
Normal RT = 10-15 mmHg
Intensity: stronger
Strength: does not rise above
25 mmHg Seen in Latent phase

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

Occurs because the muscle Distended


fibers of the myometrium do bowel and
not repolarize or relax after a bladder
contraction thereby “wiping it
clean” to accept a new Overstretched
pacemaker stimulus uterus

Myometrium is continuous to Hydramnios


contract = Problems in blood
circulation; Blood going to Large fetus
uterus and placenta
Lax uterus
Occur because more than one
pacemaker is stimulating
contractions UNCOORDINATED CONTRACTIONS

More painful-because the ▪ More than 1 pacemaker may be initiating


myometrium becomes tender contractions
from constant lack of relaxation ▪ Receptor points in the myometrium may be
and the anoxia of uterine cell acting independently of the pacemaker
results ▪ Appear closely together that they don’t allow
good cotyledon
Woman is frustrated or ▪ The woman don’t have time to rest or to use
disappointed because she has breathing exercises with contractions
ineffective breathing exercises
MANAGEMENT:
Danger: lack of relaxation
between contractions-may not ▪ Apply a fetal and uterine external monitor
allow uterine artery filling (TOCODYNAMAMONITOR) assessing the
pattern, resting tone and fetal response to
CONTRACT – RELAX – contraction for at least 15 minutes reveals
CONTRACT = NORMAL abnormal pattern
▪ Oxytocin administration = regulate the
CONTRACT – CONTRACT – frequency of uterine contraction
CONTRACT = HYPERTONIC
II. DYSFUNCTION LABOR AND ASSOCIATED
COMPARISON OF HYPOTONIC AND HYPERTONIC STAGES OF LABOR
CONTRACTIONS
DYSFUNCTION AT THE FIRST STAGE OF LABOR
CRITERIA HYPOTONIC HYPERTONIC 1st stage = strong uterine contraction leading to full
Phase of labor Active Latent cervical dilatation
Symptoms Limited pain Painful
Contractions No contraction, Strong PARTOGRAPH = determines dysfunctional labor
weak
Intensity Weak Strong, a. Involves prolonged latent phase
frequently b. Protracted active phase
Resting tone of <10mmHg <15mmHg c. Prolonged deceleration phase
the uterus d. Secondary arrest dilatation
Medications Little value Helpful
used Oxytocin PROLONGED LATENT PHASE
Causes Uterus does Myometrium
not contract doesn’t relax ▪ Accdg to Friedman: Latent phase that is longer
than 20 hours in a nullipara and 14 hours in a
Early More multipara.
administration pacemaker ▪ It occurs if the cervix is not ripe at the
of analgesia stimulus beginning of labor
▪ May occur if there is excessive use of an
analgesic early in labor
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▪ The uterus tends to be hypertonic state PROLONGED DECELERATION PHASE


▪ Relaxation between contractions is
inadequate ▪ Related to abnormal head position
▪ Contractions are mild (less than 15 mmHg), ▪ Becomes prolonged when it extends beyond 3
ineffective hours in nullipara and 1 hour in a multipara
▪ One segment of the uterus may be contracting ▪ Often results from abnormal fetal head
with more than another segment. position
▪ CS is frequently required
MANAGEMENT:
SECONDARY ARREST DILATATION
✓ Involves the uterus to rest
✓ Providing adequate fluid for hydration = can ▪ Occurred if there is NO progress in cervical
cause DIAPHORESIS = DEHYDRATION; that dilatation for longer than 2 hours
can slow down labor, breast milk becoming ▪ CS is necessary
viscus, and can lead to thrombophlebitis
✓ Pain relief with a drug such as morphine
sulfate DYSFUNCTION AT THE SECOND STAGE OF LABOR
✓ Changing the linen and the woman’s gown
✓ Darkening room lights = cannot add more on
contraction of the uterus PROLONGED DESCENT
✓ Decreasing noise and stimulation
▪ Occurs if the rate of descent is less than 1.0
LENGTH OF PHASES AND STAGES OF NORMAL LABOR cm/hr in a nullipara 2 cm/hr in a multipara
IN HOURS
▪ Can ne suspected if the second stage lasts over
NULLIPARA 3 hours in a multipara
Phase Average Upper Normal ▪ Contractions become infrequent and poor
Latent phase 8.6 20 quality
Active phase 5.8 12 ▪ Dilatation stops
Second stage 1 1.5
Management:

✓ If faulty contractions, CPD and poor fetal


MULTIPARA
presentation has been r/o by UTZ ( rest and
Phase Average Upper Normal
fluid intake)
Latent phase 5.3 14
✓ If membranes have not ruptured (ruptured
Active phase 2.5 6
them)
Second stage 1.5 --
✓ Oxytocin/IV – to induce the uterus to contract
effectively
PROTRACTED ACTIVE PHASE ✓ Semi- fowler’s position, squatting, kneeling or
more effective pushing may speed descent
▪ SLOW / Prolonged Labor
▪ Associated with CPD or fetal malposition ARREST of DESCENT
▪ May reflect myometrial activity’
▪ Results when NO DESCENT has occurred for 1
▪ PROLONGED IF:
hour in a multipara or 2 hours in a nullipara
✓ Cervical dilatation does not occur at
▪ Expected when:
a rate of at least 1.2 cm/hr in a
✓ the descent of fetus does not begin
nullipara or 1.5 cm/hr in a multipara
✓ Engagement or movement beyond 0
✓ active phase lasts longer than
station has not occurred
o 12 hrs in a primigravida
✓ CPD = most likely cause for arrest of
o 6 hrs in a multigravida
descent
MANAGEMENT: ✓ CS is necessary
✓ If there is no contraindications to
✓ CS – if due to CPD that causes delay of vaginal birth, oxytocin may be used
dilatation to assist labor
✓ Oxytocin is given if CPD is not present

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CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

PROBLEMS OF PASSAGE ▪ Occur with women with diabetes, multipara,


post-dated pregnancies

ABNORMAL SIZE OR SHAPE OF THE PELVIS RISK FACTORS
▪ Narrowing of the passageway/birth canal ✓ Brachial plexus injury
▪ Happen in the inlet, outlet and midpelvis ✓ Brain injury- due to lacj of o2 r/t cord
▪ The narrowing causes: CPD and failure to compression of umbilical cord
progress in labor. ✓ Chest compression leading to the
TYPES OF PELVIS uncoordinated breathing

a. Gynecoid – ideal shape of pelvis MANAGEMENT


b. Anthropoid- oval inlet, ape (will still give good ✓ Mc Robert’s Maneuver- mother is sharply
prognosis) flexing her thighs on her abdomen
c. Android – male pelvis, heart shaped ✓ Suprapubic pressure
d. Platypelloid- compressed front-back, oval

PELVIS ANTEROPO TRANSV OBLIQUIE


STERIOR ERSE
Pelvic Inlet 11 13 12
Pelvic Cavity 12 12 12
Pelvic 13 11 --
Outlet

CEPHALOPELVIC DISPROPORTION/ CPD

▪ Is suggested by lack of engagement at the


beginning of labor, prolonged first stage and
finally poor fetal descent.
▪ A disproportion between the size of the fetal
head and the pelvic diameters. This result in
failure to progress labor.
▪ INLET CONTRACTION- Narrowing of the
anteroposterior diameter to less than 11 cm or
of the transverse diameter to 12 cmor less
▪ OUTLET CONTRACTION- Narrowing of the
transverse diameter at the outlet to less than
11 cm. This is the distance between the ischial
tuberosities, a measurement that is easy to
make during a prenatal visit.

CAUSES:

▪ Rickets in early life


▪ Small pelvis

SHOULDER DYSTOCIA

▪ Occurs at the 2nd stage of labor when the


infant head is born but the shoulders are too
broad to enter and be delivered thru the pelvic
outlet.
▪ Hazardous to the mother- can result in vaginal
cervical tear
▪ Hazardous to the fetus == cord compression

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PROBLEMS OF PSYCHE ✓ Mother is unable to pick up on cues from the


infant and fail to meet the infant’s needs
✓ Fear and anxiety ✓ Symptoms are consistently present to at least
✓ Stress 2 weeks
✓ Support systems
✓ Coping ability MANAGEMENT:

MANAGEMENT ✓ Promote emotional and psychological support


for the patient and family
✓ Assess support available and be there for the ✓ Maintain a helpful attitude, keeping in mind
patient that the mother feels depressed and that she
✓ Patient teaching – breathing/relaxation is not to blame for her condition
✓ Provide non-pharmacological measures = back ✓ Inform the patient that postpartum
massage, picture therapy, music therapy depression is an illness with a treatment and a
✓ Keep informed good diagnosis
✓ Provide quiet calm environment = bc it can ✓ Inform the attending physician of the patient’s
trigger vs symptoms to so that intervention can be made
POSTPARTUM BLUES easily
✓ Observe and instruct the mother when
▪ Mild depression following giving birth needed when she is provoking care to the
▪ A let down feeling which may be related to infant
hormonal changes experienced by new
mothers POSTPARTUM PSYCHOSIS
▪ Usually 1-10 days postpartum and last longer ▪ Occurs within 3 weeks of delivery
than 2weeks ▪ May occur as a bipolar with manic and
Clinical features: depressive episodes or as major depression
with manic episodes
✓ Cries easily ▪ Cause = Support system/ Genetics
✓ Irritable
✓ Overwhelming sadness Clinical features:

MANAGEMENT: ✓ Bipolar symptoms = bipolar disorder is a


serious brain disorder in which a person
✓ Prevent by providing the mother with experiences extreme variances in thinking,
adequate rest, food and comfort measures mood, and behavior. Bipolar disorder is also
✓ Reassure the mother that crying spells are sometimes called manic-depressive illness
normal or manic depression. People who
✓ Encourage her to express her feelings have bipolar disorder commonly go through
periods of depression or mania. In
POSTPARTUM DEPRESSION the manic phase of bipolar disorder, it's
▪ Underdiagnosed and unreported common to experience feelings of heightened
▪ Can affect either partner energy, creativity, and euphoria. If you're
▪ Observed 1-12 months experiencing a manic episode, you may talk a
mile a minute, sleep very little, and be
Clinical features: hyperactive. You may also feel like you're all-
powerful, invincible, or destined for greatness.
✓ Lack of interest in surroundings ✓ Irritability
✓ Loss of emotional response toward family ✓ Hyperactivity
✓ Unable to feel love or pleasure ✓ Euphoria
✓ Feelings of guilt, unworthiness and shame, ✓ Grandiosity
fatigue, difficulty concentrating, poor ✓ Minimal need for sleep
appetite, insomnia, panic attacks ✓ Poor insight to illness
✓ Mother is unable to care for the infant ✓ Poor judgment and confusion
✓ Feels that the infant is demanding and she is
incompetent as a mother

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Depression symptoms:

✓ Tearfulness
✓ Preoccupation with guilt
✓ Feelings of worthlessness
✓ Sleep and appetite disturbance
✓ Excessive concern for the infant’s health
✓ May have delusions that the child is
dead or defective

MANAGEMENT:

✓ Medical treatment
✓ Give lithium, antidepressant or antipsychotic
medications as ordered
✓ Suicide precautions
✓ Do not leave patient alone with the infant
✓ Give emotional support for the patient and
family
✓ Encourage patient to be involved in self-care
and reinforce healthy behavior
✓ Promote expression of feelings and concerns

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POSTPARTUM COMPLICATIONS TISSUE Presence of retained placental


tissues prevents full uterine
POST PARTAL HEMORRHAGE contractions resulting in failure to
seal off bleeding vessels
▪ Excessive blood loss during or after the third
stage labor. Preterm gestation especially in less
▪ Accepted normal average blood loss is 500 ml than 24 weeks gestation
in vaginal delivery and 1000 ml at CS
▪ The most dangerous time at which Abnormal adhesions such as
hemorrhage is likely to occur is during the first accreta, increta and percreta
hour post partum
▪ Blood loss more than 500 cc. (normal blood Site stop the oozing of blood
loss 250- 350 cc) vessels of the uterus
▪ Leading cause of maternal mortality TRAUMA 20% of postpartum hemorrhage is
associated with childbearing due to trauma anywhere in the
genital tract
INCIDENCE
Lacerations and episiotomy
▪ The overall incidence is 3-6% in all deliveries
▪ Vaginal delivery is associated with a 3.9% Hematoma
incidence of postpartum hemorrhage
▪ Cesarean delivery is associated with a 6.4% CS
incidence of postpartum hemorrhage.
▪ Delayed postpartum hemorrhage occurs in 1- Uterine rupture and uterine
2 % of patients. inversion

CAUSES Uterine perforation during forceps


application or curettage
The cause of postpartal hemorrhage can be THROMBOSIS clot formation and fibrin deposition
remembered easily by using the mnemonic 4T’s on the placental

TONE refers to the failure of the uterine Disorders of the coagulation system
myometrial muscle fibers to and platelets, whether preexistent
contract and retract or acquired can result in bleeding or
aggravate bleeding.
Overdistention = Macrosomnia,
hydramnios, multiple pregnancy Acquired disorders - HELLP
syndrome, DIC
Fatigue = prolonged labor,
precipitate labor, oxytocic drugs Preexistent coagulation disorder-
thrombocytopenic purpura
Infection = chorioamnionitis,
endomyometritis, septicemia
TYPES OF POSTPARTUM HEMORRHAGE
Uterine structural abnormality
EARLY POST-PARTUM occurs during the first 24
Hypoxia = due to hypoperfusion or HEMORRHAGE hrs after delivery
Couvelaire uterus
Causes of early postpartum
Placental site in the lower uterine hemorrhage:
segment
Uterine Atony – uterus is
Distention with blood before or not well contracted,
after placental delivery relaxed or boggy most
frequent cause)
Inhibition of contractions by drugs-
anesthetic agents, nitrates, NSAIDS, Lacerations of birth canal
Mg S04, nifedipine, beta-
sympathomimetics Inversion of the uterus

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Hypofibrinogenemia ✓ Uterine relaxing agents = anesthesia,


analgesia, terbutaline, magnesium sulfate,
Clotting defect nitroglycerine
✓ Oxytocin given during labor
** client bleeds = bc of ✓ High parity and advanced maternal age
UTERINE ATONY = apply ✓ Infection = amnionitis and chorioamnionitis
UTERINE MASSAGE ( above
✓ Presence of fibroid tumors that interfere with
symphysis pubis, anchor it.
uterine contractions
To prevent uterine
✓ Over massage of the uterus that results in very
inversion) = OXYTOCIN
NEXT strong uterine contractions and eventual
LATE POST-PARTUM Occurs from 24 hours after fatigue
HEMORRHAGE birth to 4 weeks ✓ Retained placental fragments
postpartum. ✓ Prolonged third stage of labor

Causes of late postpartal ASSESSMENT


hemorrhage:
▪ If the uterus suddenly relaxes, there will be
abrupt gush of blood from the placental site.
Retained Placental
Fragments ▪ Vaginal bleeding which is extremely large and
the client may exhibit symptoms of shock and
Subinvolution of the uterus blood loss.

THERAPEUTIC MANAGEMENT
Infection
✓ Intravenous infusion of oxytocin (pitocin) to
NURSING CARE MANAGEMENT help uterus maintain tone
✓ The usual dose is 10-40U per 1000ml of
✓ Fundal massage 5%dextrose solution
✓ Offer a bedpan or assist with ambulating to ✓ Intramuscular Methylergonovine ( methergin)
the bathroom at least every 4 hours to keep of ✓ Bimanual massage
the woman’s bladder empty ✓ Prostaglandin administration
✓ If a woman is experiencing respiratory distress ✓ Blood replacement
from decreasing blood volume, mask ✓ Hysterectomy
administer oxygen by face mask of 4 L/min
rate
✓ Supine position to allow adequate blood flow RETAINED PLACENTAL FRAGMENTS
to her brain and kidneys.
✓ Obtain vital signs frequently ▪ The most common cause of post partal
hemorrhage.
▪ Have increased risk of recurrence of retained
UTERINE ATONY placental fragments in subsequent deliveries.
▪ Failure of the uterus to contract continuously ▪ Incidence: occurs in 6% of vaginal deliveries.
after delivery. ▪ Experienced after 24 hours; bleeding at home
▪ It is the most common cause of Postpartal ▪ Uterus will no contract = uterus is SOFT =
hemorrhage and often occurs following profuse bleeding
delivery of the baby and up to 24 hours after ▪ Positive HCG Result = confirms retained
the delivery of the placenta., placental fragments
▪ Relaxation of the uterus CAUSES
CAUSES ✓ Partial separation of a normal placenta
✓ Overdistention = hydramnios, multiple ✓ Manual removal of placenta
pregnancy, macrosomia ✓ Abnormal adherent placenta- accreta, increta
✓ Complication of labor = Precipitate , ore perceta
prolonged labor ✓ Abnormal placental adhesion

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SUBINVOLUTION OF THE UTERUS POSTPARTAL PUERPERIAL INFECTION

▪ Occurs when there is a delay in the return of ▪ Reproductive tract infection developing after
the prepregnant size, shape and function delivery
▪ May spread to the peritoneum (peritonitis) or
CAUSES the circulatory system (septicemia)
▪ Retained placental fragments ▪ Most common route of microorganisms =
▪ Infection- endometritis episiotomy site/ lacerations
▪ Uterine tumors RISK FACTORS
NORMAL UTERUS ▪ Rupture of the membrane more than 24 hours
▪ Uterus = above symphysis pubis before birth = check body temperature
▪ After 1-12 hours = at the umbilicus ▪ Placental fragments retained within the uterus
▪ 24 hours = above the umbilicus = the tissue necroses and serves as an
▪ After 24 hours = descend in 1 finger breaths excellent bed for bacterial growth
▪ 48 hours = descend in 2 finger breaths ▪ Postpartal hemorrhage = the woman’s general
▪ 9th-10th day = can no longer palpate the uterus condition is weakened
▪ Pre-existing anemia = the body’s defense
ASSESSMENT against infection is lowered
▪ Prolonged and difficult labor, particularly
▪ Enlarged and boggy uterus = NOT instrument births = trauma to the tissue may
CONTRACTING leave lacerations or fissures for easy portals of
▪ Prolonged or reversal pattern in lochial entry for infection
discharge ▪ Internal fetal heart monitoring=
▪ Foul odor in lochia if caused by infection = dark contamination may have been introduced in
brown in color with general malaise the placement of the scalp electrode
▪ Backache ▪ Local vaginal infection was present at the time
THERAPEUTIC MANAGEMENT of birth = direct spread of infection has
occurred
✓ Initially the physician may order Ergonovine = ▪ The uterus was explored after birth for a
stimulate uterine contraction and prevent retained placenta or abdominal bleeding site =
bleeding infection was introduced with exploration
✓ Maleate .2mg to stimulate uterine
ASSESSMENT
contractions for 2 weeks. If bleeding continues
after 2 weeks, D and C is performed ▪ localized in the vagina, vulva, perineum
✓ Treating the cause ▪ Pain
✓ Removal of uterine tumors and antibiotics for ▪ Fever
infection ▪ Edema
✓ Evacuation of the retained placental ▪ Redness
fragments by D and C ▪ Firmness
NURSING CARE MANAGEMENT ▪ Tenderness
▪ Burning on urination
✓ Uterine Massage – initial/ first nursing action ▪ Wound discharge
✓ Ice compress = can minimize bleeding ▪ Temperature >100.4 (38C) after 1st 24 hours
✓ Oxytocin administration = initiates uterine on any of the first 10 postpartum days.
contraction ▪ Elevated body temperature on the first day/
✓ Empty bladder first 24 hours of PP = NORMAL
✓ Bimanual compression = to explore retained ▪ general malaise
placental fragments ▪ Loss appetite
✓ Hysterectomy = last alternative/resort ▪ Lochia = dark brown, foul odor; can also be
scant or absent
▪ Chills

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PREVENTION ▪ Strong afterpains


▪ Lochia is dark brown, foul odor
✓ Use sterile gloves, instruments during labor, ▪ if accompanied with high fever = lochia may be
birth and postpartal period. scant or absent
✓ Proper perineal care by the client, (front-back) ▪ Placental fragments confirmed by UTZ
✓ Handwashing
✓ The client should have her own bedpan and DANGER OF ENDOMETRITIS
perineal supplies and should not share them.
✓ Antibiotics (ampicillin, gentamicin, 3rd ✓ Tubal scarring = tries to affect the other parts
generation cephalosporins (cefixime (fallopian tube)
✓ No antibiotics during breastfeeding = observe ✓ Interference with future fertility = prevents
infant for the presence of white plaque or fertilization of egg cell because of tubal
thrush (oral candida) = because the portion of scarring = ECTOPIC PREGNANCY
the maternal antibiotic passes into the MANAGEMENT
breastmilk and cause overgrowth of fungal
organisms = a decreased in microorganisms in ✓ Antibiotic = Clindamycin (Cleocin) =
the bowel caused by an antibiotic passed in determined by a culture of the lochia.
breast milk may lead to insufficient Vitamin K ✓ Vaginal culture using a sterile swab rather
formation and decreased blood clotting than from a perineal pad
ability. ✓ Oxytocic agent = methylergonovine (via IM) =
✓ Hot sitz bath 2x a day = to heal episiotomy/ to encourage uterine contraction
lacerations ✓ Increase fluid intake
o use lukewarm water with ✓ Analgesic = for afterpains
medications added (guava leaf); ✓ Sitting in a fowler’s position or walking =
client will sit on the encourage lochia drainage by gravity = helps
paddle/commode prevent pooling of infected secretion
✓ Wear gloves when changing perineal pad =
MANAGEMENT assess the COLOR, ODOR, QUANTITY
✓ antibiotic after culture and sensitivity testing Early recognition of signs:
of the isolated organisms
✓ Group B streptococci ✓ Normal color
✓ Escherichia coli ✓ Quantity and odor of discharge
✓ Staphylococcus == cause of toxic syndrome ✓ Size, consistency, tenderness of a normal
similar to puerperal infection postpartal uterus

ENDOMETRITIS PERINEAL HEMATOMA

▪ An infection of the endometrium, the lining of ▪ Collection of blood in the subcutaneous layer
the uterus. tissue of the perineum.
▪ Bacteria gain access through the vagina and ▪ Caused by the injury to the blood vessels in the
enter the uterus at the time of birth or during perineum during birth.
the postpartal period. ▪ Occur during rapid spontaneous birth an
perineal varicosities.
ASSESSMENT ▪ May occur at the site of episiotomy or
▪ Temperature elevation on the third and 4th laceration repair if a vein was punctured
postpartal day = occurs at the same time during repair.
during breast filling ▪ Present minor bleeding and discomfort.
▪ Increase WBC 20,000-30, 000cells.mm3 ASSESSMENT
(NORMAL)
▪ Chills ▪ Severe pain in the perineal area
▪ Loss of appetite ▪ Feeling of pressure between legs = difficulty in
▪ General malaise walking
▪ Uterus not well contracted and painful to ▪ With hematoma = purplish discoloration with
touch swelling 2cm or 8cm in diameter
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▪ Tenderness during palpation CAUSES


▪ Palpates as firm globe
▪ Injury to blood vessels usually occurs during
NURSING CARE MANAGEMENT delivery, indwelling catheterization and
infection
✓ Report the presence of hematoma = size, ▪ Increased clotting that normally occurs during
degree of woman’s discomfort pregnancy and after delivery and with the use
✓ Assess the size by measuring it in centimeters of oral contraceptives
with each inspection. ▪ Blood stasis that occurs as a result of varicose
✓ Describe a hematoma = small, large veins, bed rest after CS and prolonged
✓ Describe the lesion inactivity
✓ Administer mild analgesic = pain relief
✓ Apply an ice pack = covered with towel to DIAGNOSIS
prevent thermal injury to the skin
✓ If the hematoma is large or continues to 1. Doppler ultrasound
increase = returned the woman in the delivery 2. X-ray dye injection called venogram.
room to have the site incised and vessel be TYPES ACCORDING TO LOCATION
ligated under local anesthesia.
✓ If an episiotomy incision line is opened to drain Superficial Inflammation affecting
a hematoma, it may be left open and packed thrombophlebitis/ the superficial veins of the
with gauze rather than resutured. Phlebothrombosis/ extremities, the veins that
✓ Packing is usually removed within 24-48 hours Venous thrombosis are near the skin and
✓ Instruct the client before discharge that she visible to the eye. Main
has to keep the area dry symptom is tenderness
and pain in the affected
THROMBOEMBOLIC DISORDERS vein followed by edema

▪ Thrombi or blood clots are formed when there Location of the clot can be
is stasis of circulation or repair of damaged seen by the eye on
tissue. inspection of the painful
▪ The postpartum woman is especially and reddened area in the
susceptible for the formation of thrombi affected leg. These blood
because of increased fibrinogen and clots are large and hard
enough to be felt by
prothrombin levels which increases blood
palpation
coagulability.
Deep Vein This is inflammation of a
▪ Thrombi have a tendency to occlude
Thrombophlebitis/DVT vein located deep within a
circulation and are a good medium of bacterial muscle tissue. Since the
growth. vein affected is
▪ Problem pertaining circulation surrounded by muscles,
blood clot may break free
RISK FACTORS
during muscular
▪ Varicosities of the legs = injury of blood vessels movement and travel in
the circulation.
▪ Obesity = weight to the lower extremities
▪ Over 30 years old
The main danger is of the
▪ Multiparity emboli (moving blood clot
▪ Use of estrogen supplement is called embolus,
▪ History of thromboembolic disease stationary blood clot is
▪ Anesthesia, surgery thrombus) reaching the
▪ Smoking lungs and obstruct
▪ Trauma to extremities = related to the pulmonary blood flow
position; NORMAL POSITION = Semi Upright resulting in pulmonary
o Raise foot less than an hour embolism. There is more
o Cover stirrup swelling in deep vein
o Legs should be raised at the same thrombosis than in
superficial vein
time
thrombosis.
▪ DM
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TYPES ACCORDING TO VEINS AFFECTED Avoid pressure on the l


vessels
Femoral Infection of the veins of the If post CS encourage leg
Thrombophlebitis legs femoral, popliteal veins exercises to promote
venous return while patient
MANIFESTATIONS is not yet able to get out of
bed
Homan’s sign = calf pain
when the foot is dorsiflexed Avoid activities that
contribute to venous stasis
Milk leg or phlegmasia such as prolonged bed rest,
alba dolens = the leg is standing and sitting.
shiny white in appearance Superficial Venous Involving small clots in the
because of extreme Thrombosis absence of infection usually
swelling and lack of resolves without
circulation anticoagulant treatment.

Swelling of affected leg, There is a presence of pain


pain stiffness
The management is
Fever directed towards relief of
pain and resolution of clot
Infection of the ovarian, which include
uterine and pelvic veins
manifestations are Application of heat = to
relieve pain
✓ Fever and chills
✓ Pain in the lower Aspirin and ibuprofen =
abdomen or flank anti-inflammatory drugs to
✓ Palpable relieve pain and prevent
parametrail mass inflammation
in some cases.
If the woman is receiving
MANAGEMENT heparin (does not cross the
breast milk) = aspirin
Early ambulation after should never be given to
delivery = best her.
management to PREVENT
thrombophlebitis Instruct to avoid massaging
the area = can elevate
Use of support stocking in
woman with varicosities to
promote circulation and DVT/ DEEP VEIN THROMBOSIS
prevent stasis. Instruct the
patient to put stocking ▪ Requires intensive management to prevent
before rising from bed in serious complications like pulmonary
the morning. = if may embolism
thrombophlebitis na
MANAGEMENT
Provide adequate
hydration ✓ Hospitalization during acute phase
✓ Bedrest until signs and symptoms disappear.
Avoid trauma to Gradual ambulation after disappearance of
extremities = do not signs and symptoms but the patient must
massage the legs wear elastic stockings to improve circulation in
the leg and prevent venous stasis
Pad stirrups well ✓ Leg elevation

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✓ Anticoagulant therapy to prevent venous happens it is life


stasis = Warfarin Coumadin ; Antidote = threatening
VITAMIN K
✓ Heparin- Mother may breastfeed as it is not
MASTITIS
passed to breastmilk. ; Antidote =
PROTAMINE SULFATE ▪ Breast tissue inflammation due to milk stasis
✓ Keep antagonist, protamine sulfate available. or infection of the lactiferous ducts
✓ Dicumarol- passed on breastmilk, so mother ▪ Infectious agents are introduced through
must stop breastfeeding. maternal hands or infants mouth, cracked
✓ Keep antagonist, Vitamin K available. nipples
✓ Monitor PTT level or APTT Apply warm wet ▪ Symptoms appear by 3rd or 4th week
compress dressing to promote circulation and postpartum
for comfort Administer prescribed antibiotic
to combat infection and analgesic to relieve Due to:
pain
✓ Surgery may be used if the affected vein is ▪ Breast injury (overdistention, stasis, cracking
likely to present a long term threat of of nipples) = poor attachment and positioning
producing blood clots. ▪ Missed feeding = can cause obstructed
lacterous duct; BF should be every 2-3 hours
2 major complications associated with the ▪ Tight feeding bra
hypercoagulable state brought by pregnancy: ▪ Impaired infant sucking

Thrombophlebitis Infection of the lining of the ASSESSMENT


vein with formation of
thrombi (thrombo for the ▪ Fever
presence of clots and ▪ Chills
phlebitis meaning ▪ General discomfort
inflammation of the lining ▪ Pain
of blood vessels. ▪ Malaise
▪ Localized pain
Venous Thrombosis/ ▪ Increased heart rate
phlebothrombosis = if the ▪ Breast engorgement, firmness and reddening
inflammation is minor and ▪ Sore and fissured nipples
involves only superficial
▪ Axillary lymph node swelling and tenderness
veins of the extremities.
MANAGEMENT
Location of the clot can be
seen by the eye on ✓ BEST MANAGEMENT = breast feeding
inspection of the painful nd ✓ Evaluate for s/s of infection
reddened area in the ✓ Administer antibiotics as prescribed
affected leg. These blood ✓ Provide comfort measures (pillow, ice packs,
clots are large and hard warm compress)
enough to be felt by
✓ Educate the patient and her family
palpation
✓ Discuss infection through proper handwashing
Thrombophlebitis = if the and immediate attention to clogged milk ducts
inflammation involves deep ✓ Encourage frequent breastfeeding, proper
veins breast care and nipple care
Pulmonary embolism Most common
complication

may occur when these


thrombi formed in the deep
leg veins are carried by
circulation to the
pulmonary artery and
obstruct blood flow to the
lungs. It is rare but when it
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NURSING CARE OF A FAMILY WITH A HIGH-RISK RESUSCITATION


NEWBORN
If breathing is ineffective = Circulatory shunts ( ductus
Newborn priorities in first days of life arteriosus) fails to close because:

1. Initiation and maintenance of respirations ✓ There is increase pressure in the left side than
2. Establishment of extrauterine circulation at the right side of the heart
3. Control of body temperature ✓ Blood circulates through a patent ductus
4. Intake of adequate nourishment arteriosus left to right or from aorta to
5. Establishment of waste elimination pulmonary artery
6. Prevention of infection
7. Establishment of an infant-parent relationship RESULT: newborn struggles to breathe and circulate
8. Developmental care or care that balances blood uses available serum glucose hypoglycemic
physiologic needs and stimulation for best ▪ Resuscitation is done for those newborns who
development fails to take first breath
INITITATION AND MAINTENANCE OF RESPIRATIONS RESUSCITATION PROCESS
Establish respiration immediately to prevent:
✓ Respiratory acidosis Establish and Bulb syringe suction (mouth then
✓ Falling of blood pH and bicarbonate maintain an nose)
✓ Cerebral hypoxia airway
Rub the back (be sure that the baby
Causes of asphyxia/acidosis while inside the utero is dry)
✓ Cord compression ▪ If a newborn has to
✓ Maternal anesthesia attempt to raise body
✓ Placenta previa temperature because of
✓ Abruptio placenta chilling, this will increase
the need for oxygen
Factors predisposing infants to respiratory difficulty which the baby cannot
in the 1st few days of life supply because breathing
✓ Low birth weight has not yet initiated.
✓ Maternal history of diabetes
✓ Premature rupture of membranes Warmed, blow-by oxygen by face
✓ Maternal use of barbiturates or narcotics mask or positive pressure mask
close to birth may be administered
✓ Meconium staining
✓ Irregularities detected by fetal heart If meconium stained:
monitor during labor ▪ DO NOT stimulate an
✓ Low birth weight infant to breathe by
✓ Maternal history of diabetes rubbing the back or
✓ Premature rupture of membranes administering air or
✓ Maternal use of barbiturates or narcotics oxygen under pressure
close to birth ▪ EFFECT: could push
✓ Meconium staining meconium down into an
✓ Irregularities detected by fetal heart infant’s airway
monitor during labor compromising
✓ Low birth weight respiration
✓ Maternal history of diabetes ▪ GIVE oxygen by mask
✓ Premature rupture of membranes without pressure
✓ Maternal use of barbiturates or narcotics ▪ Wait for a laryngoscope
close to birth to be passed and the
✓ Meconium staining trachea to be deep
✓ Irregularities detected by fetal heart suctioned before giving
monitor during labor oxygen under pressure

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If for deep suctioning: Lung Once an airway has been


▪ Place an infant on the Expansion established, newborn’s lungs need
back and slide a folded to be expanded
towel or pad under the
shoulders to raise them Lungs are inflated by the first
slightly to the head is in a breath
neutral position.
▪ Slide a catheter (French Cry – proof of lung expansion
8- French 12) over the
infant’s tongue to the 40 cm H20 = pressure to open the
back of the throat lung
▪ Do not suction for longer alveoli for the first time
than 10 seconds – to
avoid removing excessive 15- 20 cm H2o – pressure to
air from an infant’s lungs continue inflating alveoli
▪ Use a gentle touch =
bradycardia or cardiac The levels of oxygen should not
arrhythmias can occur fluctuate
because of vagus ▪ Effect: can cause
stimulation from bleeding from immature
vigorous suctioning cranial vessels

An infant who still makes no effort No pressure above what is


at spontaneous respiration requires necessary
immediate laryngoscopy to open ▪ Effect: excessive force
the airway. can rupture lung alveoli
▪ Laryngoscope = deep
tracheal suctioning – To be certain that oxygen is
endotracheal tube reaching the lungs with
insertion – oxygen resuscitation- monitor the
administration by a newborn’s oxygen level with pulse
positive pressure bag and oximetry and auscultating the
mask with 100% oxygen chest.
at 40 to 60
breaths/minute If air can be heard on only one side
or sounds are not symmetric
PRIMARY APNEA = period of halted ▪ Reason: the endotracheal
respiration, a pause in respiration tube is probably at the
longer than 20 seconds with an bifurcation of the trachea
accompanying bradycardia after 1 and blocking one of the
or 2 minute. main stem bronchi.
▪ Resuscitation attempts
are generally successful When oxygen is given under
pressure, the stomach quickly fills
SECONDARY APNEA = respiratory with oxygen (causes vomiting and
effort will become weaker, heart aspiration of stomach contents)
rate will fall, stopes breathing
▪ Resuscitation attempts If resuscitation continues for over 2
become difficult and Minutes
ineffective ▪ insert an orogastric tube
and leaving the distal end
SIZE OF LARYNGSCOPE open
▪ Newborn = 0-1 cm ▪ reasons:
SIZE OF ENDOTRACHEAL TUBE ▪ will help deflate the
▪ Infants under 100 g = 2.5 stomach
mm ▪ decreases the possibility
▪ Over 3000g = 4.0 mm of vomiting and
aspiration of stomach

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contents from ▪ Places under a warmer


overdistention and remove the clothing
from the chest= this
Administration of narcotic prevents acidosis
(morphine or meperidine ▪ Place the infant in supine
(Demerol) during labor causes and elevate the bed at 15
respiratory depression. degrees= this allows the
abdominal contents to
Narcan (narcotic antagonist)- fall away from the
Naloxone diaphragm, offering
▪ injected into the additional breathing
umbilical vessel space.
▪ or injected ▪ Suction secretions
intramuscularly into a ▪ Monitor oxygen level
thigh
▪ Relieves depression
▪ Dose: 0.01 to 0.1 mg/kg ESTABLISHMENT OF EXTRAUTERINE CIRCULATION
body weight If an infant has NO audible heartbeat or if the cardiac
rate is below 80 beats/minute

OTHER DRUGS USED IN RESUSCITATION Action: closed chest massage should be started
▪ hold an infant with fingers supporting the
DRUG USE back and depress the sternum with two
Atrophine Reduces bronchial secretions fingers
▪ Depress the sternum approximately 1/3 of
Reduces vagus nerve effects its depth (1 or 2 cm) at a rate of 100
times/min.
Relives bradycardia ▪ Lung ventilation at a rate of 30x/min
Calcium chloride Increases heart contractility ▪ Ratio: 1:3
Dopamine Increases systemic blood
perfusion by increasing blood If heart sounds are not resumed above 80 bpm after
pressure through beta agonist 30 seconds of combined positive pressure ventilation
action and cardiac compression
Epinephrine Strengthens or initiates cardiac ▪ Action: spray epinephrine 0.1 to 0.3 ml/kg
contractions (1:10,000) into endotracheal tube to
stimulate cardiac function.
Increases heart rate and blood
pressure
Lidocaine Counteracts ventricular MAINTAINING FLUID AND ELECTROLYTE BALANCE
arrhythmias Lactated Ringers solution or 5% dextrose are
Sodium Corrects metabolic acidosis commonly used to maintain fluid and electrolytes
bicarbonate/ levels.
tromethamine Do not give this unless
ventilation is adequate or Sodium, potassium and glucose are needed.
acidosis can be increased by
retained CO2 Rate of fluid administration must be carefully
Monitored
▪ WHY? Can lead to patent ductus arteriosus
Ventilation An increase respiratory rate in a or heart failure
Maintenance newborn is the first sign of
obstruction or respiratory Use of radiant warmer may increase in water loss
compromise. from convection and radiation.
▪ Therefore: the newborn requires fluid than
If RR is increased = undress the he or she is placed in a double walled
baby’s chest and look for incubator.
retractions
Monitor urine output and specific gravity to
Interventions: determine dehydration.
▪ A Urine Output of <2ml/kg/hr or a
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specific gravity >1.luid intake.015 to 1.020 suggests If RR is rapid and with NEC
inadequate ▪ Action: gavage feeding preterm infants
should be breastfed/ manually express
If an infant has hypotension without hypovolemia, a breastmilk
vasopressor such as dopamine may be given to
increase BP and improve cell perfusion. Expressed breastmilk should be stored in a nonshiny
plastic bags or bottles to avoid the infant being
If hypovolemia is present, the cause is fetal blood loss exposed to polycarbonate
from placenta previa or twin-twin transfusion.

If hypovolemia is present observe the ff: ESTABLISHING WASTE ELIMINATION


✓ Tachypnea Immature infants void within 24 hours of birth
✓ Pallor ▪ Reason: BP may not be adequate to
✓ Tachycardia optimally supply their kidneys
✓ Decreased arterial blood pressure
✓ Decreased central venous pressure Immature infants pass stool late than term
✓ Decreased tissue perfusion of peripheral ▪ Reason: meconium has not yet reached the
tissue end of the intestine at birth
✓ Metabolic acidosis

PREVENTING INFECTION
REGULATING TEMPERATURE Infection from prenatal, perinatal and postnatal
▪ All high-risk infants have difficulty causes
maintaining a normal temperature. ✓ PROM
▪ Maintain a neutral temperature ✓ Pneumonia
environment ✓ Skin lesions
▪ If the environment is TOO HOT,
metabolism decreases Viruses that causes infection
▪ If the environment is TOO COLD, increases Early onset sepsis Late onset sepsis
metabolism Grp b Streptococcus Staphylococcus aureus
▪ The increased metabolism requires E. Coli Enterbacter
increased oxygen Kelbsiella Candida
Without oxygen Listeria
✓ Hypoxic monocytogenes
✓ Vasoconstriction of blood vessels occurs Common viruses that
✓ Decreased pulmonary perfusion (if affects the utero
prlonged) Cytomegalovirus
Toxoplasmosis
▪ PO2 lever falls and PCO2 increases
▪ Decreases PO2
Effect = may open fetal right to left shunts, ESTABLISHING PARENT-INFANT BONDING
surfactant production may stop Be certain that the parents of a high risk newborns
are kept informed
To prevent newborn from becoming chilled after
birth: If an infant dies despite newborns resuscitation
✓ Wipe an infant dry attempts, parents need to see the infant without
✓ Cover the head with a cap being covered by a myriad of equipment
✓ Place the baby immediately under a
prewarmed radiant warmer or in a warmed
incubator ( 97.8 F/36.5C) ANTICIPATING DEVELOPMENTAL NEEDS
✓ Skin-skin High risk newborns need special care to ensure that
the amount of pain they experience during the
procedures is limited to the least amount possible’
ESTABLISHING ADEQUATE NUTRITIONAL INTAKE
Infants with severe asphyxia at birth receive IVF Follow up of high-risk infants at home
▪ Reason: for them not to be exhausted from
sucking or until necrotizing enterocolitis
has been ruled out.

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PROBLEMS RELATED TO MATURITY ✓ IVF within hours after birth via infusion pump
✓ Check infusion site frequently
▪ live –born infant born before the end of week ✓ Monitor weight
37 gestation. ✓ Monitor urine output and specific gravity –
▪ weight of less than 2,500g (5lb 8oz) at birth weigh diaper
▪ Preterm infant deaths account for80-90% of ✓ Test urine for glucose and ketones (blood
the infant mortality in the first year of life. glucose should range between 40-60mg/dl)
▪ Low birth weight infants (LBW) = infants born ✓ Check for blood in the stools to evaluate
weighing 1,500 -2,500 g possible bleeding from the intestinal tract
▪ Very low birth weight (VLBW) = 1,000-1,500g ✓ Fed by total parenteral nutrition
▪ Extremely (EVLBW) = very-low-birth –weight- ✓ Chest radiograph before a first feeding
500-1,000g ✓ Feed every 2-3 hours ( 1 or 2 ml)
▪ Lack of surfactant makes them vulnerable to ✓ Offer pacifier during gavage feeding- to
RDS. strengthen the sucking reflex
▪ Hypoglycemia ✓ Administer vit K
▪ Intracranial hemorrhage ✓ Kept under radiant warmer /skin-skin contact
RISK FACTORS ✓ Linen and equipment used with preterm
infants must not be shared with other infants
✓ low socio-economic level ✓ Handwashing
✓ Inadequate nutrition before and during ✓ Monitor closely for respiratory or cardiac
pregnancy complications
✓ Lack of prenatal care
✓ Multiple pregnancy POSTMATURITY
✓ Prior previous early birth ▪ Born after the 42nd week of pregnancy
✓ Cigarette smoking ▪ Fetus remains in the utero with a failing
✓ Age of the mother placenta may die or develop Post term
✓ Closely spaced pregnancies Syndrome
✓ Abnormalities of the mother’s reproductive ▪ Dry cracked, almost leather like skin from lack
system of fluid
✓ Obstetric complications- Premature Rupture ▪ Absence of vernix caseosa
of Membranes, Premature separation of ▪ Lightweight from a recent weight loss that
placenta occurred because of placental function.
CHARACTERISTICS OF PREMATURE INFANT ▪ The amount of amniotic fluid may be less at
birth than normal, may be meconium stained.
1. Immature respiratory system ▪ Fingernails have grown well beyond the end of
2. Temperature regulation the fingertips.
3. Low resistance to infection ▪ May demonstrate alertness much more like a
4. Immature liver 2-week-old baby than a newborn.
5. Gastrointestinal- increased NEC
6. Renal- unable to concentrate urine ASSESSMENT
7. Neuromuscular ▪ Dry, cracked, leather-like skin =from lack of
8. Physiologically immature fluid(desquamation)
COMPLICATIONS ▪ Absence of vernix
▪ Light weight- because of poor placental
1. Anemia of prematurity function
2. Kernicterus ▪ Less amniotic fluid
3. Persistent patent ductus arteriosus ▪ Meconium stained
4. RDS ▪ Fingernails have grown at the end of fingertips
5. Retinopathy of prematurity ▪ Reduced subcutaneous tissue-loose skin,
6. NEC especially of buttocks and thighs
▪ Abundant scalp hair
NURSING INTERVENTIONS ▪ Having the alert appearance of a 2-to 3-week
✓ Keep the baby warm old neonate after delivery
✓ Give 100% oxygen ▪ Difficulty establishing respiration
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▪ Hypoglycemia
▪ Polycythemia
▪ Elevated hematocrit – because of
polycythemia and dehydration

INTERVENTION

1. Determine gestational age by physical


examination. Measure weight, length, and
head circumference and plot on Colorado
intrauterine growth chart
2. Determine blood sugar; below 40 mg/100 m
indicates hypoglycemia
3. Assess for asphyxia neonatorum by APGAR
score and blood gas analysis
▪ Be alert for meconium aspiration
▪ Thick meconium in amniotic fluid at delivery
▪ Tachypnea, increasing signs of cyanosis;
difficulty breathing with need for ventilation
▪ Tachycardia
▪ Inspiratory nasal flaring and retraction of
chest
▪ Expiratory grunting
▪ Increased anteroposterior diameter of the
chest
▪ Palpable liver
▪ Crackles and rhonchi on chest auscultation
▪ Concomitant cerebral irritation-jitteriness,
hypotonia, seizures
▪ X-ray- classic coarse, patchy, irregular
pulmonary infiltrates ranging in severity
▪ Additional signs: metabolic acidosis,
hypotension, hypoglycemia, hypocalcemia
▪ Provide supportive treatment for meconium
aspiration
▪ Warmth
▪ Adequate oxygenation and humidification to
maintain partial pressure of arterial oxygen at
50-70 mm Hg
▪ Respiratory support with ventilator
▪ Adequate administration of calories and fluid
▪ Accurate monitoring of intake and output
▪ Administration of antibiotics prophylactically
▪ Provide oral feedings or IV glucose after birth
to treat or prevent hypoglycemia

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PROBLEMS RELATED TO GESTATIONAL AGE –yellow

SMALL FOR GESTATIONAL AGE (SGA) Skull may be firmer


▪ SGA = weight below then 10th percentile on an
Unusually alert and active for
intrauterine growth curve for the age that weight.
▪ Preterm = infant is born before week 37 of
gestation Lack subcutaneous fat = less
▪ Term = between 37 and 42 able to control body
▪ Postterm = infant is one who remained in the temperature
utero past 42 weeks of pregnancy
▪ SGA infants are small for their age Underdeveloped chest muscles
▪ Infants have difficulty maintaining warmth = unable to sustain the rapid RR
▪ The infant may be preterm, termor, post term of a normal newborn

CAUSES Impaired cognitive


development = due to lack of
✓ Mother’s nutrition oxygen and nourishment in the
✓ Pregnant adolescents have a high incidence of utero
SGA infants
✓ Placental damage
✓ Women with systemic diseases - DM, PIH LABORATORY FINDINGS
✓ Mothers who smoke heavily or use narcotics ▪ High hematocrit level
✓ Infants with intrauterine infections – rubella, ▪ Increase in the total number of Rbc
toxoplasmosis (polycythemia) = due to state anoxia during
✓ Babies with chromosomal abnormalities intrauterine life.
ASSESSMENT ▪ Polycythemia causes increase blood viscosity
▪ Acrocyanosis = blueness of hands and feet
Prenatal Fundal Height during ▪ Hypoglycemia
Assessment pregnancy becomes ▪ Birth Asphyxia
progressively less than ▪ Decreased glycogen stores
expected
MANAGEMENT
A sonogram can demonstrate
decrease in size. ▪ Assess for the presence of meconium during
labor and delivery
A biophysical profile, non-stress ▪ Thoroughly suction airway immediately after
test, placental grading and UTZ delivery if present
can provide additional ▪ Assess temperature and provide neutral
information. thermal environment
Appearance The infant has over all wasted ▪ Assess for signs of hypoglycemia
appearance ▪ Weigh daily and assess changes in weight
▪ Observe RR in the first few hours of life
Small liver ▪ Encourage parents to provide toys suitable for
the child’s chronologic age, not physical size
poor skin turgor
▪ Intravenous glucose to sustain blood sugar
Appears to have large head until they are able to suck vigorously

PRIORITY NURSING DIAGNOSES


Skull sutures maybe widely
separated from lack of normal ▪ Hypothermia
bone growth ▪ Risk for Injury
▪ Imbalanced nutrition: less than body
Hair is dull and lustress
requirements
Abdomen may be sunken

Cord- appear dry and stained


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LARGE FOR GESTATIONAL AGE ▪ Encourage parents to treat the newborn as


fragile newborn who needs warm nurturing
▪ Birthweight above 90th percentile ▪ Remind parents that an infant’s weight is not
ETIOLOGOGY in correlation of the child’s projected adult
size.
▪ Overproduction of growth hormone in utero -
Primary cause: infant of diabetic mother (IDM) PRIORITY NURSING DIAGNOSES
▪ Multiparous women ▪ Risk for injury
▪ Transposition of great vessels, BECKWITH ▪ Risk for imbalanced nutrition less than body
SYNDROME (a rare condition characterized by requirements
overgrowth) ▪ Risk for impaired parenting related to high-risk
▪ Congenital anomalies such as omphalocele status of large gestational age infant
INCREASED RISK OF

▪ Hyperbilirubinemia
▪ Birth injury:
✓ fractured clavicle
✓ Erb-Duchenne paralysis secondary
to shoulder dystocia

ASSESSMENT

1. Immature reflexes
2. Low scores on gestational age examinations in
relation to their size
3. Extensive bruising
4. Birth injury such as broken clavicle/Erb-
Duchenne
5. Head is large
6. Caput succedaneum, cephalhematoma,
molding
7. Signs of hyperbilirubinemia
8. Polycythemia
9. If with cyanosis – sign of transposition of the
great vessel
10. Macrosomia (large body size and high
birthweight)
11. Signs of birth trauma related to cephalopelvic
disproportion (CPD)
12. Hypoglycemia, especially with an IDM – early
hours of life
13. Have difficulty establishing respirations at
birth because of birth trauma
14. Increased intracranial pressure
15. Diaphragmatic paralysis – because of cervical
trauma as the head is bent sideways to allow
for birth of large shoulders
16. Have the size of a 2-month-old
17. Sucking is not effective

NURSING INTERVENTION

▪ Assess for signs of birth injury


▪ Assess for signs of hypoglycemia
▪ Needs to be breastfeed immediately
to prevent hypoglycemia
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ALTERATIONS IN OXYGEN ✓ Crackles


✓ Sweating
✓ Low growth rate
✓ Loud, harsh pansytolic
CLASSIFCATION OF HEART DISEASE
murmur (left sterna
border, 3rd or 4th
ACYANOTIC HD CYANOTIC HD
interspace)
INCREASED DECREASED
✓ Thrill (variation) =
PULMONARY PULMONARY
vibratory sensation felt
BLOOD FLOW BLOOD FLOW
on the skin overlying an
area of turbulence and
1.
Ventral septal 1. Tricuspid
indicates a loud heart
defect atresia
murmur usually caused
2. Atrial septal 2. Tetralogy of
by an incompetent
defect fallot
heart valve.
3. Patent ductus
arteriosus
DIAGNOSIS Echocardiography with color flow
OBSTRUCTION OF MIXED BLOOD FLOW
BLOOD FLOW LEAVING Doppler
THE HEART 1. Transposition MRI = reveals right ventricular
of the Great
hypertrophy and possibly
1. Pulmonary arteries
pulmonary artery dilatation from
stenosis 2. Total
the increased blood flow
2. Aortic stenosis anomalous
3. Coarctation of Pulmonary ECG = reveal ventricular
aorta venous return
hypertrophy
3. Hypoplastic
left heart THERAPEUTIC Cardiac catheterization (to close
syndrome MANAGEMENT in moderate size)

Open heart surgery (large/


ACYANOTIC HEART DISEASE/INCREASED PULMONARY
>3mm)
BLOOD FLOW
Digoxin
▪ Moves blood from the arterial to the venous
system
Diuretics
▪ oxygenated to unoxygenated blood or LEFT-
RIGHT shunts).
▪ Indicates the presence of a defect that permits ATRIAL SEPTAL DEFECT
the passage of blood from the higher pressure,
left sided cardiac chamber to a lower pressure, ▪ Abnormal communication between the two
right sided cardiac chamber. atria, allowing blood to shift from left to the
▪ Causes the heart to function as an ineffective right atrium.
pump and make the child prone to heart ▪ More common in girls than boys
failure.
TYPES Ostium Premium (ASD1) =
VENTRAL SEPTAL DEFECT opening is at the lower end of the
septum
▪ Most common type of congenital heart
disease Ostium secundum (ASD2) =
▪ Opening is present in the septum between the opening is near the center of the
two ventricles septum
▪ Pressure in the left ventricle is greater than in ASSESSMENT Harsh systolic murmur over the
2nd or 3rd interspaces (pulmonic
the right ventricles
area)
▪ This impairs the effort of the HEART

ASSESSMENT ✓ Easy fatigue WHY? Because of the extra


✓ Dyspnea amount of shunted blood that
✓ Swelling of extremities crosses the pulmonic valve,

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leading to the fixed splitting of ▪ Risk for:


second heart sound ✓ Decreased o2
✓ Risk for lung infection
Enlarged right side of the heart via ✓ Heart failure
echocardiography ▪ Increase pressure = damage lining of the heart
= increase risk of bacteria = endocarditis
Increased pulmonary circulation
▪ Remains open due to the stimulation of
prostaglandin (PGE1) from the placenta and
Separation in the atrial septum
low oxygen level of fetal blood.
Increased oxygen saturation in the ▪ After birth, when the PGE1 level falls and the
right atrium oxygen level increases = the ductus arteriosus
DIAGNOSIS Echocardiography is stimulated to close.
Cardiac catheterization

Doppler
ASSESSMENT Common in girls than boys
THERAPEUTIC Surgery = to close the defect ( the
MANAGEMENT edges of the septum are Wide pulse pressure = difference
approximated and sutured with between systolic and diastolic
cardiac catheterization technique blood pressure
if the defect is small)
Low diastolic pressure = because
Large defects may require open of the shunt run off of blood
heart surgery and which reduces resistance
cardiopulmonary bypass = a
Silastic or Dacron patch may be Machinery murmur = heard at
sutured into place to occlude the the upper left sterna border or
space under the clavicle in older
children
Done between 1 and 3 years of
age ECG is normal – but may show
ventricle enlargement if the
shunt is large
PATENT DUCTUS ARTERIOSUS

▪ Ductus arteriosus is an accessory fetal C = cardiac (continuous


structure that connects the pulmonary artery machinery murmur; endocarditis,
Increase HR, low O2 level, wide
to the aorta.
pulse pressure (low diastolic
▪ Closes begins with the first breath and usually
pressure); heart failure, crackles
complete between 7- 14 days of age
▪ Full closure occur until 3 months A = activity intolerance
▪ If it fails to close at birth, blood will shunt from
the aorta (oxygenated blood) to the L = lungs risk for infections,
pulmonary artery (deoxygenated blood) feeding prob
because of the increased pressure in the aorta
▪ The shunted blood returns to the left atrium L = loss of weight ( burning calorie
of the heart, passes to the left ventricle out to in order to breath)
the aorta and shunts back to the pulmonary DIAGNOSIS Echocardiography – provides
artery good visualization of patent
▪ EFFECT: increased pressure in the pulmonary ductus arteriosus.
circulation from the extra shunted blood THERAPEUTIC Indomethacin or Ibuprofen via IV
MANAGEMENT ( if does not close spontaneously)
LEADING to right ventricular hypertrophy and
ineffective heart action
Assess the following Effects:
▪ Extra blood to the lungs = stresses the lungs ✓ Reduced glomerular
overtime = creating increase pressure = filtration
Damaging the integrity of arteries of the lungs ✓ Impaired platelet
= narrowed = pulmonary hypertension aggregation

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✓ Diminished MANAGEMENT IV infusion of PGE1 to ensure that


gastrointestinal and ductus remains open
cerebral blood flow
Surgery – construction of a vena
Ibuprofen = drug of choice cava to pulmonary artery shunt
which deflects more blood to the
Prophylaxis = in preterm infants lungs (Fontan procedure/ Glenn
Shunt baffle)
Insertion of Dacron = coated
stainless steel coils by
interventional cardiac TETRALOGY OF FALLOT
catheterization = when child is 6
months to 1 year of age (done if ▪ Because of pulmonary stenosis = pressure
medical management fails) builds up in the right side of the heart = blood
shunts from this area of increased pressure
Ductal ligation = this involves into the left ventricle and the overriding aorta.
major surgery = because ▪ The extra effort involved to force blood
opening the chest (Thoracotomy) through the stenosed pulmonary artery
and manipulating the great causes the fourth deformity = hypertrophy of
vessels is necessary. the right ventricle.

Prostaglandin inhibitors 4 anomalies are present:

✓ VSD
CYANOTIC HEART DISEASE DECREASED BLOOD FLOW ✓ Dextroposition (overriding) of the aorta
✓ Hypertrophy of the right ventricle
▪ Occurs when blood is shunted from the ✓ Pulmonary stenosis
venous to the arterial system as a result of
abnormal communication between the two ASSESSMENT Skin is cyanotic/bluish
system (deoxygenated blood to oxygenated
blood) or RIGHT-LEFT shunts. Polycythemia = an increase in
▪ Indicates an abnormality that permits some of RBC as the body attempts to
the systemic venous return (unoxygenated provide enough RBC to supply
blood) to bypass the lungs and enter general oxygen to all body parts)
circulation directly.
EFFECT: causes the blood to
▪ Decreased pulmonary blood flow that involves
become thick (increased
obstruction in the pulmonary artery = because
viscosity) and clots in blood
of the obstruction: vessels may occur.
▪ Increases pressure in the right side of the
heart Complication
▪ Deoxygenated blood shunts from right to left ✓ Thrombophlebitis
RESULTING in deoxygenated blood invading ✓ Embolism
the systemic circulation ✓ cerebrovascular
accident
TRICUSPID ATRESIA ✓ Severe dyspnea
✓ Growth restriction
▪ Extremely serious disorder because the
tricuspic valve is completely closed allowing Clubbing of the fingers
no blood to flow from the right atrium to the
right ventricle. The child assumes a
▪ EFFECT: blood crosses through the patent SQUATTING/KNEE CHEST
foramen ovale into the left atrium, bypassing position when resting.
the lungs. ✓ Squatting gives
▪ If the shunts are close = the infant will develop physiologic relief to an
extreme cyanosis, tachycardia and dyspnea overstressed heart by
trapping blood in the
lower extremities.

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Syncope (fainting) return to the left side of the


heart, the aorta and the body.
Hyper cyanotic episodes (spells) =
caused by decreased blood and NO palpable pulse in the right
oxygen supply to the brain arm because the subclavian
artery is used.
Cognitive challenge
No taking of BP and
Loud, harsh, widely transmitted venipuncture in the affected arm
murmur or a soft, scratchy
localized systolic murmur in the Brock procedure = repair that
left second, third or fourth relieves pulmonary stenosis, VSD
parasternal interspace may be and verriding aorta
present.
DIAGNOSIS Echocardiography = shows the POSTOPERATIVELY = observe
enlarged chamber of the right arrhythmias = which may result
from any ventricular septal
ECG side of the heart; repair, edema and conduction
echocardiography shows interference.
✓ The decrease in the size
of the pulmonary
✓ Artery and the reduced MIXED BLOOD FLOW
blood flow through the
lungs ▪ Cardiac anomalies that involve mixing of blood
Cardiac catheterization = permit from the pulmonary and systemic circulation
a definitive evaluation of the in the heart chambers
extent of the defect particularly ▪ The mixing results in a relative deoxygenation
the pulmonary stenosis and the of systemic blood flow, although a cyanosis is
VSD. most always visible.

Laboratory findings TRANSPOSITION OF GREAT ARTERIES


✓ Polycythemis
✓ Increased hemoglobin ▪ The aorta arises from the right ventricle
✓ Hematocrit instead of the left and the pulmonary artery
✓ Total RBC count arises from the left ventricle instead of the
✓ Oxygen saturation right.
THERAPEUTIC Surgery = to connect the heart ▪ Blood enters the heart from the vena cava to
MANAGEMENT defects done at 1 to 2 years of age the right atrium -- right ventricle -- out to the
aorta -- to the body completely deoxygenated
Administer oxygen -- returns to the vena cava.
▪ A secondary source of blood enters the heart
Place the baby in a knee chest from the pulmonary veins -- left atrium -- left
position = to trap blood in the ventricle -- pulmonary artery -- lungs to be
lower extremities and keep the
oxygenated -- returns to left atrium
heart from being overwhelmed
▪ Atrial and ventricular septal defects occur in
Administer morphine sulfate connection with transposition
▪ Occur in large newborns ( 9-10lbs)
Oral Propanolol (Inderal – a beta ▪ Occur most often in boys
blocker) = to aid pulmonary
artery dilation ASSESSMENT Cyanotic from birth

Blalock-Taussig procedure = Enlarged heart


create a shunt between the aorta
and the pulmonary artery Heart changes
(creating a ductus arteriosus) =
this will allow blood to leave the Low oxygen saturation
aorta and enter the pulmonary DIAGNOSIS Echocardiography – reveals
artery , oxygenate the lungs and enlarge heart

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ECG – reveals heart changes HYPOPLASTIC LEFT HEART SYNDROME

Cardiac catheterization – reveals ▪ The left ventricle is nonfunctional.


low oxygen saturation ▪ Lacks adequate strength to pump blood into
THERAPEURIC PGE1/prostaglandin – IF NO the systemic circulation
MANAGEMENT septal defect ▪ Causes the right ventricle to hypertrophy as it
tries to maintain the entire heart action.
To keep the ductus arteriosus ▪ There may be accompanying mitral or aortic
patent valve atresia.

Balloon atrial septal pull- ASSESSMENT Mild to moderate cyanosis


through operation
Deoxygenated blood is shunted
A deflated balloon catheter is across the foramen ovale
passed from the right atrium because of the greater pressure
through the foramen ovale into on the right
the left atrium THERAPEUTIC Ultrasound –prenatally
MANAGEMENT
The balloon is then inflated and Echocardiography
the catheter is drawn back into
the right atrium = enlarging the Prostaglandin therapy- to
opening of the foramen ovale and maintain a PDA = to increase
creates an artificial ASD. blood supply to the aorta

Done at week to 3 months of age Heart transplantation = to


prolonged the child’s life
Involves an arterial switch
procedure in which the major
vessels are switched in position. OBSTRUCTION OF BLOOF FLOW

Survival rate is 95% ▪ A vessel or valve is narrower than usual.


▪ Pressure from blood flow increases prior to
the narrowing and decreases after the
TOTAL ANOMALOUS PULMONARY VENOUS RETURN narrowing.
▪ They prohibit enough blood from reaching its
▪ The pulmonary veins return to the right atrium
intended size, the lungs or the rest of the body
or the superior vena cava instead to the left
▪ They threated or overwhelm the heart
atrium
because of back pressure
▪ For blood to reach the systemic circulation, it
must shunt across a patent foramen ovale or a PULMONARY STENOSIS
PDA.
▪ Narrowing of the pulmonary valve or the
ASSESSMENT Absent spleen pulmonary artery just distal to the valve
▪ 10% of congenital anomalies
Mildly cyanotic ▪ Inability of the right ventricle to evacuate
blood by way of the pulmonary artery because
Easily gets tired
of the obstruction leads to right ventricular
THERAPEUTIC Surgery – reimplanting the hypertrophy.
MANAGEMENT pulmonary veins into the left
ASSESSMENT Cyanosis – if narrowing is severe
atrium.
Due to inability of the blood to
Balloon atrial septal pull-
reach the lungs for oxygenation
through- to enlarge a foramen
or there is right-left shunting
ovale
across the foramen ovale = this
happens because of the increase
Maintain on a continuous IV
pressure at the right side of the
infusion of PGE1 to help keep the
heart
ductus arteriosuS

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Systolic ejection murmur (grade Rough systolic sound heard


IV or V crescendo-decresendo in loudest in the 2nd right
quality) loudest at the upper left interspace ( aortic space)
sterna border radiating to the
suprasternal border. Thrill = at suprs sterna notch

Thrill- from the upper left sterna Decreased cardiac output = if


border or at suprasternal notch. severe

Widely split of the 2nd heart Faint pulses


sound = because of late closure f
the pulmonary valve. Hypotension
DIAGNOSIS ECG/ echocardiography = reveal
ventricular hypertrophy Tachycardia

Cardiac catheterization = used Inability to suck for long periods


for interventional enlargement of
the stenosed valve Chest pain similar to angina
THERAPEUTIC Balloon angioplasty – procedure
MANAGEMENT of choice Because the coronary arteries
✓ A catheter with an receive inadequate amount of
uninflated balloon at its oxygen needed by the heart
tip is inserted and muscle on exertion far exceeds
passed through the what is available
heart into the stenosed DIAGNOSIS ECG/echocardiography = reveal
valve left ventricular hypertrophy
✓ As the balloon is THRERAPEUTIC Beta-blocker/calcium channel
inflated, it breaks the MANAGEMENT blocker = to reduce cardiac
valve adhesions and hypertrophy before the defect is
relieves the stenosis. corrected
✓ Children may have
residual heart murmur Balloon valvuloplasty =
✓ Can expect a normal life treatment of choice
span
Dividing the stenotic valve r
dilating an accompanying
AORTIC STENOSIS constrictive aortic ring

▪ Stenosis or stricture of the aortic valve May lead to aortic valve


prevents blood from passing freely from the insufficiency later in life = further
left ventricle of the heart into the aorta. surgery may be needed
▪ Because the heart cannot force blood through
the stricture valve Some children will need artificial
▪ Increased pressure and hypertrophy of the left valve replacement for correction
ventricle occur
▪ If the left ventricular pressure become acute = If prosthetic valve is used =
increase continue to receive
▪ pressure in the left atrium back pressure in anticoagulation or antiplatelet
therapy and antibiotic
pulmonary veins pulmonary edema
prophylaxis against endocarditis
ASSESSMENT Asymptomatic
Children need exercise testing
Murmur = can be transmitted to before participating in
the right shoulder, clavicle and up competitive sports if an artificial
the vessels of the neck, heart valve is in place.
apex

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COARCTATION OF AORTA BP is higher in upper extremities


= because of the pull of gravity
▪ Narrowing of the lumen of the aorta due to
constricting band Headache
▪ Occurs most frequently in boys than in girls
▪ Leading cause of congestive heart failure in Epistaxis
the first few months of life.
▪ 2 locations: Pulse in the upper extremities will
✓ Preductal – the constriction occurs be rapid and bounding
between the subclavian artery and DIAGNOSIS BP in the arms will be at least
the ductus arteriosus 20mmHg higher than in the legs
✓ Postductal – constriction is distal to
Echocardiography
the ductu arteriosus
▪ Difficult for blood to pass through the
ECG = reveal left-sided heart
narrowed lumen of the aorta enlargement from
▪ Blood pressure increases proximal to the
coarctation decreases distal MRI = back pressure and also
▪ Increased BP in the heart and upper portions notching of the
of the body as pressure in the subclavian
artery X-ray = ribs from the enlarge
▪ Increases headache, vertigo epistaxis (nose collateral vessels.
bleed) cerebrovascular accident THERAPEUTIC Interventional angiography
MANAGEMENT (balloon catheter)/surgery
ASSESSMENT Absence of palpable femoral
pulses- slight coarctation The narrowed portion of the
aorta is removed and the new
Always include evaluation of ends of aorta are anastomosed
femoral pulses in all initial
newborn assessment and A graft of transplanted subclavian
admission inspections artery may be necessary if the
narrowed section is so extensive
Absent brachial pulses = those than an anastomosis cannt be
with an obstruction proximal to accomplished readily
the left subclavian artery
Digoxin given before the time of
Lower BP in the lower extremities surgery

Leg pain on exertion Diuretics aims to reduce the


severity of congestive heart
Because of diminished blood failure
supply to the lower extremities
From hypertension
Cold feet
PLANNING IS IMPORTANT:
Muscle spasms
IT would be ideal if children could
Pulse is weak, delayed or even achieve the greater part of their
absent adult height before surgical
correction, preventing strain on
Collateral arteries enlargement the incision site as they grow

Seen on the ribs as obvious In terms of self-image =


nodules as the child grows older correction is best done before
children begin to think of
Soft, moderately loud systolic themselves as chronically ill or
murmur = from the base of the before they develop
heart and transmitted to the left complications such as chronic
interscapular area hypertension.
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Girls must have the defect ✓ Hematological


repaired before childbearing age ✓ Neurological
= or the extra blood volume ✓ Cardiovascular
during pregnancy can cause heart ✓ Respiratory
failure ✓ Abdominal
✓ Pharmacological
Surgical repair is scheduled by 2
years of age Symptoms

After operation = abdominal ▪ Airways


vessels receives more blood ✓ Choanal atresia
resulting to abdominal pain or ✓ Pierre – Robin sequence
generalized abdominal ✓ Vocal Cord paralysis
discomfort
▪ Lungs
Some may have elevated upper
✓ Transient tachypnea of the newborn
body hypertension after the
✓ Meconium aspiration syndrome
repair
✓ Persistent pulmonary HNT of the
Need continual treatment with newborn
antihypertensive agents

Some may require repeat balloon


angioplasty at adolescence to re-
enlarge the aortic lumens and
help reduce this upper body
hypertension.

MECONIUM ASPIRATION SYNDROME

▪ Meconium aspiration syndrome (MAS) is a


respiratory disorder caused by inhalation of MANAGEMENT When the infant is not vigorous
amniotic fluid contaminated with meconium 1. Clear airways as quickly
into the tracheobronchial tree. as possible
▪ Aspiration of meconium into the lungs 2. Free flow 02
▪ MECONIUM = first stools 3. Radiant warmer but
▪ Contents of meconium drying and stimulation
✓ Water should not be delayed
✓ Amniotic fluid 4. Direct laryngoscopy
✓ Mucopolysaccharides with suction of the
✓ Bile salts mouth and
hypopharynx under
✓ Desquamated epithelium
direct visualization,
✓ Desquamated epidermis
followed by intubation
✓ Vernix and then suction
▪ What makes meconium pass? directly to the ET tube.
✓ FETAL STRESS = the older the fetus, 5. The process is repeated
the more the meconium until either “little
additional meconium is
Where is the problem? recovered, or until the
baby’s heart rate
✓ Airways
indicated that
✓ Lungs
resuscitation must
Respiratory Distress in Neonates proceed without delay”
TREATMENT Ventilation strategies
✓ Infectious ✓ Avoid air leak, check
✓ Metabolic CXR with acute
deterioration
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✓ Prevent pulmonary
hypertension =
generous 02
✓ HFOV if unable to
maintain on
conventional

Steroids (no human data,


controversial)

ROS, Antibiotics = ampicillin,


gentamicin

Surfactant

Inhaled nitric oxide

ECMO

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ALTERATIONS IN FLUID AND ELECTROLYTES, ACID-BASE ▪ Water accounts for about 60% of a man’s body
BALANCE weight. It represents about 50% of a woman’s
weight
INTRODUCTION ▪ Young and middle-aged adults who drink
▪ The GI sytem plays a major role in maintaining when they’re thirsty do not generally have to
fluid, electrolyte, and acid-base balance do anything more to maintain their body’s
▪ It is the main route by which substances are fluid balance
taken into the body and can be a major source ▪ Children need more water = because they
of loss if vomiting or diarrhea occurs expend more energy, but most children who
▪ Greater importance in the body chemistry of drink when they are thirsty get as much water
infants than that of adults = because fluid as their systems need.
constitutes a greater fraction of the infant’s 3 MAIN TYPES OF DEHYDRATION
total weight.
✓ In adults, body water accounts for Hypertonic Primary loss of water, cell shrinks
approximately 60% of total weight Isotonic Equal loss of water and electrolytes
✓ In infant, it accounts for as much Hypotonic Primarily a loss of electrolytes, cell
75% to 80% of total weight swell
✓ In children, it averages
approximately 65% to 70%
HYPERTONIC DEHYDRATION
▪ Fluid is distributes in 3 body compartments
a. Intracellular (within cells), 35% to 40% od ▪ Also known as HYPERNATREMIA = refers to an
body weight imbalance of water and sodium in the body
b. Interstitial (surrounding cells and characterized by relatively increased levels of
bloodstream), 20% of body weight sodium. Generally, when water is excreted
c. Intravascular (blood plasma), 5% of body from the body, electrolyte concentration in
weight the blood increase
▪ Fluid is normally obtained by the body through ▪ Losing more solution than solute. Decreased
oral ingestion of fluid and by the water formed urine output, Cells SHRINK
in the metabolic breakdown of food
▪ Food is lost from OCCUR IN A Nausea = preventing fluid
✓ Urine and feces CHILD WITH intake
✓ Insensible losses due to evaporation
occurs from: skin, saliva, lungs Fever = increased fluid loss
▪ INFANTS do not concentrate urine as well as through perspiration, fever will
increase the respiratory rate
ADULTS because their kidneys are immature
and therefore, water loss.
✓ RESULTS: They have proportionally
Water intake is commonly
greater loss of fluid in their urine decreased during a fever which
▪ Fluid intake is altered when a child is will aggravate dehydration.
nauseated and unable to ingest fluid or is
vomiting and losing fluid that was ingested. Overexposure to heat
▪ When diarrhea occurs, or when a child
become diaphoretic because of fever, the fluid Profuse diarrhea = where there
output can be markedly increased is a greater loss of fluid than salt
▪ Dehydration occurs when there is an
excessive loss of body water Renal disease = associated with
polyuria such as nephrosis with
FLUID IMBALANCES diuresis

▪ DEHYDRATION occurs when the body loses Diabetes insipidus = which


more fluid than it takes in. this condition can occurs when the kidneys
result from illness. cannot regulate bodily fluid,
▪ A hot, dry climate, prolonged exposure to sun typically leads to frequent
or high temperature, not drinking enough urination and can cause
water, and overuse of diuretics or other hypertonic dehydration.
medications that inc urination.
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The use of diuretics, A person with gastroenteritis


medication used to increase may lose notable amounts of
urine excretion, may also lead fluids and electrolytes within a
to dehydration short time and their oral
SYMPTOMS Common are replacement is limited due to
• Fatigue recurrent vomiting, which can
• Dark urine result in severe dehydration
• Less frequent MANAGEMENT Wash your hands with soap and
urination water frequently. Wash mouth
• Dry skin and lips area and practice good oral
hygine.
Severe dehydration symptoms
are Drink lots of clear fluid = like
• Low blood pressure = water and get plently of rest
HYPOTENSION
• Lightheadedness Follow the BRAT diet, which
• Muscle cramps consists of bland floods. BRAT =
• Headaches or bananas, rice, applesauce,
dizziness toast
MANAGEMENT Treatment of hypertonic
dehydration is largely focused Avoid foods that are greasy,
in fluid replacement to return spicy, or high in fat and sugar
the individual to euvolemia, or
a healthy fluid-electrolyte Avoid caffeine
balance.
Antiemetic drugs such as =
MILD DEHYDRATION = can Dramamine and Gravol, which
often be treated with oral often contain the ingredient
rehydration therapy, if the dimenhydrinate
individual can tolerate oral
intake.
CAUSES BURNS = in severe or
widespread burns, fluid is lost
Individuals with dehydration
through the skin, and the
requiring intravenous fluid =
person can become
Intravenous Ringer’s Lactate,
dehydrated. Dehydration can
or if not available = Normal
lead to life-threatening shock.
saline.
Fluid loss starts immediately
after the burn occurs, because
Who have been dehydrated for
heat damage increases the
fewer than 24 hours, can
permeability of the capillaries,
usually experience rapid
which means that plasma is
correction of their electrolyte
able to leak out of the blood
levels.
circulation. This increase
disrupts the normal exchange
ISOTONIC DEHYDRATION of blood plasma into the
extracellular space at the site of
▪ It Is a condition in which both water and injury, which results in rapid
sodium are lost proportionally and the serum fluid loss.
sodium concentration maintains normal MANAGEMENT FIRST-DEGREE BURNS
serum osmolality. • Run cool water over
the burn. DO NOT
CAUSES Vomiting and Diarrhea = APPLY ICE
severe water diarrhea and • For sunburns = apply
vomiting can be aloe vera gel
life=threatening conditions, • For thermal burns =
especially in children. apply antibiotic
cream and cover
lightly with gauze
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SECOND-DEGREE BURNS In severe dehydration =


• Similar treatment for restoration of the blood volume
first degree burns. is the main goal and is achieved
• Your hcp may with a fluid saline or Ringer;s
prescribe stronger lactate. Adults can use oral
antibiotic cream that fluids if they are conscious and
contains silver, such able to drink, otherwise,
as silver sulfadiazine, intravenous fluids should be
to kill bacteria. use. Correction of electrolyte
Elevating the burned abnormalities should follow.
are can reduce pain
and swelling Treatment options include fluid
replacement orally if the child is
THRID-DEGREE BURNS conscious and able to drink.
• Can be life- Water, fluids, and an oral
threatening and rehydration solution can be
often require skin used. In severe cases,
grafts. intravenous fluids should be
• Skin grafts replace used.
damaged tissue with
healthy skin from Breastfeeding and normal diet
another of the should be continued, as long as
uninjured part of the the treatment with fluid
person’s body. The replacement prevents weight
area where the skin loss or developmental delays in
graft is taken from infants
generally heals on its
own.
OVERHYDRATION

HYPOTONIC DEHYDRATION ▪ Occur when people drink much more water


than their body needs
▪ Refers to a DECREASE in electrolyte ▪ People, particularly athletes, who drink
concentration in the extracellular fluid. In excessive water to avoid dehydration can
hypotonic dehydration, the cells grow as develop overhydration. People may also drink
water in the extracellular fluid moves toward excessive water because of a psychiatric
the higher sodium concentration inside the disorder called PSYCHOGENIC POLYDIPSIA
cells. ▪ Much more common among people whose
▪ Losing more solute than solution. Increase kidneys do not excrete urine normally
urine output = cells swells. This could result ▪ May also result from the syndrome of
from inappropriate antidiuretic hormone secretion
✓ Excessive loss of electrolytes by
vomiting SYMPTOMS When overhydration occurs
slowly and is mild or moderate,
✓ Low intake of salt associated with
brain cells have time to adapt,
extreme losses through diuresis
so only mild symptoms like
✓ In diseases = adrenocortical
distractibility and lethargy may
insufficiency or diabetic acidosis. ensue.
✓ Renal failure
When overhydration occurs
MANAGEMENT Treatment of the cause should
quickly, vomiting and trouble
always be considered, along
develop. If overhydration
with the treatment of
worsens, confusion, seizures,
symptoms and dluif
or coma may develop
replacement. Urine output
TREATMENT Regardless of the cause of
should be monitored in
overhydration, fluid intake
hospitalized patients as an
usually must be restricted.
indicator of treatment efficacy
Restricting drinking to less than
and renal function recovery.
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a quart fluids (abt 0.9 liters) a water and sodium in


day usually results in approximately the same
improvement over several proportions in which they
days. normally exist in the ECF.

If overhydration occurs with S&S:


excess blood volume because ✓ Edema
of heart, liver, or kidney ✓ Distended neck
disease, restricting the intake veins
of sodium is also helpful = ✓ Crackles
sodium causes the body to HYPONATREMIA Refers to a serum sodium
retain water. level that is less than 135
mEq/L
Doctors prescribe diuretics =
drugs that increases the S&S:
excretion of sodium and water ✓ Anorexia
in the urine. ✓ Nausea and
Vomiting
✓ Lethargy
ALTERATIONS ON FLUID AND ELECTROLYRES AND ✓ Dizziness
ACID-BASEBALNCE ✓ Confusion
✓ Muscle cramps
FLUID VOLUME HYPOVOLEMIA and weakness
DEFICIT ✓ Muscular
Occurs when loss of ECF twitching
volume exceeds the intake ✓ Seizures
of fluid ✓ Dry skin
✓ Edema
S&S: HYPERNATREMIA Is a serum sodium level

Acute weight higher than 145 mEq/L
loss
✓ Decreased skin S&S:
turgor ✓ Thirst
✓ Oliguria ✓ Elevated body
✓ Concentrated temperature
urine ✓ Hallucinations
✓ Orthostatic ✓ Lethargy
hypotension ✓ Restlessness
✓ Weak, rapid ✓ Pulmonary
heart rate edema
✓ Flattened neck ✓ Twitching
veins ✓ Increased BP
✓ Increased and Pulse
temperature HYPOKALEMIA Usually indicates a deficit
✓ Thirst in total potassium stores
✓ Decreased or
delayed S&S
capillary refill ✓ Fatigue
✓ Cool and ✓ Anorexia
Clammy skin ✓ Muscle
✓ Muscle weakness
weakness ✓ Polyuria
✓ Cramps ✓ Decreased
FLUID VOLUME EXCESS HYPERVOLEMIA bowel
movement
Refers to an isotonic ✓ Paresthesia
volume expansion of the ✓ Ileus
ECF caused by the ✓ Abdominal
abnormal retention of distention
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✓ Hypoactive HYPOMAGNESEMIA Refers to a below-normal


reflexes serum magnesium
HYPERKALEMIA Refers to a potassium concentration
level greater than 5.0
mEq/L S&S
✓ Neuromuscular
S&S irritability
✓ Muscle ✓ Positive
weakness Trousseau’s and
✓ Tachycardia Chvostek’s sign
✓ Paresthesia ✓ Insomnia
✓ Dysrhythmias ✓ Mood changes
✓ Intestinal colic ✓ Anorexia
✓ Cramps ✓ Vomiting
✓ Abdominal ✓ Increased deep
distention tendon reflexes
✓ Anxiety HYPERMAGNESEMIA Are serum levels over 2.3
HYPOCALCEMIA Are serum levels below mg/dl
8.6 mg/dl
S&S
✓ Flushing
S&S: ✓ Hypotension
✓ Numbness ✓ Muscle
✓ Tingling of weakness
finges, toes and ✓ Drowsiness
circumoral ✓ Hypoactive
region reflexes
✓ Positive ✓ Depressed
trousseau’s sign respirations
and Chvostek’s ✓ Diaphoresis
sign HYPOPHOSPHATEMIA Indicated by a value below
✓ Seizures 2.5 mg/dl
✓ Hyperactive
deep tendon S&S:
reflexes ✓ Paresthesias
✓ Irritability ✓ Muscle
✓ Bronchospasms weakness
HYPERCALCEMIA Is calcium level greater ✓ Bone pain and
than 10.2 mg/dl tenderness
✓ Chest pain
S&S: ✓ Seizures
✓ Muscle ✓ Tissue hypoxia
weakness ✓ Nystagmus
✓ Constipation HYPERPHOSPHATEMIA Is a serum phosphorus
✓ Anorexia level that exceeds 4.5
✓ Nausea and mg/dl in adults
Vomiting
✓ Dehydration S&S:
✓ Hypoactive ✓ Tetany
deep tendon ✓ Tachycardia
reflexes ✓ Anorexia
lethargy ✓ Nausea and
✓ Calcium stones Vomiting
✓ Flank pain ✓ Muscle
✓ Pathological weakness
fractures ✓ Hyperactive
✓ Deep bone pain reflexes

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ARTERIAL BLOOD GAS (ABG) ANALYSIS S – sac elasticity of alveoli is damages = COPD,
emphysema
▪ Are simply the measurements of the acidity or
alkalinity of the arterial circulation. It also S&S:
measures gases such as oxygen and carbon ✓ neuro (drowsy, confused, headache)
dioxide. ✓ RR <12
▪ This test I used to check how well your lungs ✓ < BP
are able to move oxygen into the blood and
remove carbon dioxide from the blood. INTERVENTION:
✓ administer O2
PURPOSES OF ABG ANALYSIS ✓ watch potassium levels
✓ administer antibiotics
✓ Acid base statis ✓ endotracheal intubation
✓ Degree of oxygenation of blood and adequacy
of alveolar ventilation
✓ Continuous arterial blood pressure monitoring
in an emergency

COMPONENTS OF ABG

▪ pH = measurement of how acidic or alkalotic


you blood is.
✓ NORMAL VALUE = 7.35 – 7.45 RESPIRATORY ALKALOSIS
✓ “pH” = refers to 2 french words that expelling too much CO2 due to TACHYPNEA
means the “power od hydrogen” ✓ pH in blood is &gt;7.45
▪ PaCO2 = measurement of carbon dioxide. ✓ PaCo2 <35
✓ Kidneys compensate by increasing
✓ NORMAL VALUE = 35 – 45
urination, decreasing HCO3
✓ PaCO2 or carbon dioxide = is being
controlled by our lungs. It is CAUSES:
connected with the word “Acid” T – temperature is elevated = feve
▪ HCO3 = measurement of bicarbonate A – aspirin toxicity
✓ NORMAL VALUE = 22 – 26 C – controlled mechanical ventilation
✓ The bicarbonate is being controlled H – hyperventilation
by your kidneys. It is connected with Y – hYsteria = anxiety attacks, rapid breathing
the word “base’ P – Pain
▪ PaO2 = or oxygen, it is regulated by lungs. N – Neurological injury
✓ NORMAL VALUE = 80 – 100 E – embolism and edema in lungs
✓ Not really needed in reading ABG A – Asthma
but it helps to identify when the
S&S
patient is having hypoxemia or not
✓ RR>20 – >HR
RESPIRATORY ACIDOSIS ✓ Tetany
build up CO2( Co2 retention)in the blood due to ✓ Muscle cramps < Calcium and potassium
BRADYPNEA
✓ decrease Ph, increase PaCO2 INTERVENTION:
✓ body compensates by releasing HCO3 to ✓ teach breathing techniques
increase pH ✓ WOF for K and Ca levels
✓ depress breathing

CAUSES:
D – drugs = opioids, morphine’s, sedatives, fentanyl
(causes respiratory depression)
E – edema = extreme fluid in the lungs
P – pneumonia = excessive mucus production
R – respiratory center of brain is damaged
E – emboli
S – spasms of bronchioles

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METABLIC ALKALOSIS S&S:


Body has experienced an excessive loss of acid ✓ Kussmaull’s breathing- blowing Co2. Deep
(Hydrogen ion) and rapid
✓ Increase HCO3 in the body ✓ Confused
✓ Body compensates by HYPOVENTILATION ✓ Decrease BP
to increase CO2 levels ✓ Weak
✓ RR <12 ✓ RR >20

LAB VALUES: INTERVENTION


✓ pH = >7.45 ✓ Watch for respiratory distress- intubation
✓ HCO3 = >26 ✓ WOF electrolytes (potassium)
✓ PaC2 = >45 ✓ Neuro status
✓ I and O
CAUSES ✓ WOF diet
A – Aldosterone production is excessive ✓ Insulin, monitor blood sugar (DKA)
= hyperaldosteronism
L – Loop Diuretics = Lasix, Thiozides
K – alkaline ingestion = baking soda, antacid, milk
A – anticonvulsant
L – loss of fluids = Vomiting, Nasogastric suctioning
I – Increase Sodium bicarbonate administration

S&S:
✓ Bradypnea
✓ Kussmaul’s breathing
✓ Hypokalemia (tremor, muscle weakness)
✓ RR <12
INTERVENTION
Treat the cause
✓ Antiemetic – vomiting
✓ Stop suctioning
✓ Stop diuretics
✓ WOF potassium and chloride
✓ Watch arterial blood gas

METABOLIC ACIDOSIS
✓ Increase acid in the body (DKA)
✓ DECREASE HCO3
✓ Decrease acid excretion
✓ Losing CO3 due to diarrhea
✓ Respiratory system compensates-
✓ HYPERVENTILATION to expel CO2 to
Increase HCO3

LAB VALUES:
✓ pH = <7.35
✓ HCO3 = <22
✓ PaCO2 = <35

CAUSES:
C – Carbohydrates not metabolize
I – insufficiency of kidneys
D – diarrhea/ DKA
O – ostomy drainage
T – fistula
I – intake of high fat diet
C – carbonic anhydrase inhibitor = Diamox

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ALTERATIONS WITH INFECTIOUS AND INFALMMATORY Pain below the ear = particularly
RESPONSES on moving the jaws

Parotid gland (70% cases) are


swollen, painful, enlarged and
MUMPS tender in varying degrees
(involvement often bilateral)
▪ Is an acute viral infection of the salivary glands
particularly the parotids with constitutional
Submaxillary and sublingual
manifestation of varying degrees glands may also be affected
▪ An acute contagious disease, the which may lead to anorexa and
characteristic figure of swelling of one or both dysphagia
of the parotid glans
▪ OTHER NAMES: In large swelling, the ear lobe
✓ Epidemic parotitis may be pushed upwards and
✓ Viral parotitis outwards
✓ Infectious parotitis DIAGNOSIS Blood examination = leukocytes
count which shows leukopenia
ETIOLOGY Caused by an RNA containing with relative lymphocytosis
mumps virus of the
paramyxovirus group Viral culture = isolation of virus
from saliva, mouth swabs or urine
Sources = Discharges coming and if associated with
from nose and mouth of infected meningoencephalitis. CSF
persons ( saliva)
MODE OF Direct by person-to-person Viral serology
TRANSMISSION contact COMPLICATION Meningoencephalitis
✓ Droplet ✓ primary infection of the
✓ Airborne neurons with the
parotitis occurring at
Portal of entry = OROPHARYNX the same time or after
INCIDENCE A childhood disease with the the onset
peak of age 5 and 15 years old
PERIOD OF From 7 days before until 9 days Epididymo-orchitis
COMMUNICABI after the parotid glands swell ✓ May occur even
LITY without evident
Recovery = 2 weeks swelling of the parotids
PATHOGENESIS Following entry of the virus ✓ May last about 5 days
through droplet infection, there ✓ Incidence: 15%-30% of
is virema with primary males before puberty
multiplication in the upper and of those who
respiratory tract. At the same develop orchitis 30%
time, localization occurs in the may have atrophy
salivary glands and other organs Clinical Manifestations:
✓ Hyperpyrexia
The glands are edematous and ✓ Chills
hyperemic with occasional small ✓ Headache
hemorrhages in the capsule. The ✓ Nausea and vomiting
ducts are obstructed by swelling ✓ Lower abdominal pain
of the lining. The acinar cells may = testes may be
be necrosed but subsequently swollen, painful and
regenerate without fibrosis tender which is
CLINICAL Slight malaise with low grade generally unilateral
MANIFESTATIO fever but it may be absent at ✓ Inflammation of ovary =
NS times female

Headache and lassitude = lack of Oophoritis


energy ✓ pelvic pain and
tendrness without any
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evidence of impairment of Control Measures


fertility a. Active immunization =
live attenuated mumps
Pancreatitis virus vaccine ( given
✓ epigastric pain, chills, between 12 and 15
vomiting months 2nd dose bet 4
Nephritis and 6 years)
b. Disinfection of articles
Thyroiditis contaminated with
✓ diffuse, tender swelling saliva or
of the thyroid about a nasopharyngeal
week after the onset of secretions
parotitis followed by NURSING Isolation
the production of INTERVENTION
antithyroid antibodies Comfort of the patient
✓ Remains in bed for at
Myocarditis least 4 days after the
✓ precordial pain, disappearance of all
bradycardia and fatigue swelling
with depression of the ✓ For comfort of the
ST segment in the ECG patient- either hot or
cold application may be
Mastitis used on the swollen
jaws to alleviate the
Deafness discomfort
✓ usually unilateral with ✓ Diet: soft bland
complete and
permanent hearing loss Encourage rest
TREATMENT Isolation precaution = contagious
from the 2nd day of swelling to its Encourage increased fluid intake
disappearance
Avoid acidic foods
Analgesics = headache

Lumbar tap = to relieve headache PNEUMONIA


meningoencephalitis
▪ Occurs at a rate of 2 to 4 children in 100.
Corticosteroids = to relieve pain = ▪ Common cause of death among infants
orchitis younger than 48 hours of life
▪ Newborns who are born more than 24 hours
Support for comfort = orchitis after rupture of membranes and birth are
particularly prone in developing pneumonia in
Care of exposed persons their first few days of life
a. Before puberty: no ▪ BACTERIAL ORIGIN
prophylaxis indicated ✓ Pneumococcal
b. After puberty: live ✓ Streptococcal
attenuated mumps
✓ Staphylococcal
virus vaccine or
✓ Chlamydial
attenuated vaccine
▪ VIRAL ORIGIN = RSV
Contraindications = with allergy ▪ Aspiration of lipid or hydrocarbon
to eggs, administration of
HOSPITAL ACQUIRED Pneumococcal or
immunosuppressive drugs or the
streptococcal
presence of immune deficiencies
COMMUNITY Chlamydia, Viral
**Not recommended below 1 ACQUIRED Pneumonias
year of age

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PNEUMOCOCCAL PNEUMONIA Assess oxygen saturation levels


via pulse oximetry
▪ Infants = remain to be bronchopneumonia
with poor consolidation of exudate into the Chest physiotherapy- =
alveoli encourages the movement of
▪ Older children = localize in a single lobe, mucus and prevents obstruction
consolidation occur
✓ blood-tinged sputum as an exudate For older children – encourage to
anf RBC invade the alveoli cough
✓ After 24-48 hours – the alveoli are
no longer filled with RBC and serum
CHLAMYDIAL PNEUMONIA
but Fibrin, leukocytes and
pneumococci ▪ Most often seen in newborns up to 12 weeks
of age – because the chlamydial organism is
ASSESSMENT ✓ High fever
contracted from the mother’s vagina during
✓ Nasal flaring
birth.
✓ Retractions
✓ Chest pain ASSESSMENT ✓ Nasal congestion
✓ Dyspnea ✓ Sharp cough
✓ Appear acutely ill ✓ Infants fail to gain back
✓ Tachypnea their birth weight
✓ Tachycardia ✓ Tachypnea
✓ Pain - abdominal ✓ Wheezing
✓ Breath sounds become ✓ Rales
bronchial (sound is ✓ Elevated level of
transmitted from the Immunoglobulin (IgG
trachea), air no longer and IgM
or poorly enters fluid- MANAGEMENT Macrolide antibiotics -
filled alveoli erythromycin
✓ Crackles- due to fluid
✓ Dullness on percussion-
due to total VIRAL PNEUMONIA
consolidation
✓ Chest x-ray –patchy ▪ Caused by viruses of upper respiratory tract
diffusion infection
✓ Lab result - leukocytosis ✓ RSV’s
THERAPEUTIC Antibiotics – ampicillin or 3rd gen ✓ Myxovirus ar adenovirus
MANAGEMENT ✓ Cephalosphorin
✓ amoxicillin clavulanate ASSESSMENT ✓ Low grade fever
✓ augmentin = for ✓ Non-productive cough
penicillin resistant ✓ Tachypnea
organisms ✓ Diminished breath
sounds
Rest = to prevent exhaustion ✓ Fine rales
✓ Apnea
Turn and reposition the child ✓ Chest-x-ray shows
frequently = to avoid pooling of diffuse infiltrated areas
secretions MANAGEMENT ✓ Rest
✓ Antypyretic for fever
IV therapy ✓ IVF
✓ Explain the difference
Antipyretic = acethaminophen of bacterial and viral
infections to parents
Humidified oxygen = to alleviate
labored breathing and prevent
hypoxemia

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CELLULAR ABERRATIONS usual, bone pain and


muscle weakness,
failure to thrive, low
muscle tone
ACUTE LYMPHOCYTIC LEUKEMIA (ALL)

▪ “Acute” means that the leukemia can progress ASSESSMENT ✓ Pallor


✓ Low grade fever
quickly, and if not treated, would probably be
✓ Lethargy
fatal within a few months.
✓ Petechiae
▪ "Lymphocytic" means it develops from early
✓ Bleeding from oral
(immature) forms of lymphocytes, a type of mucous membrane
white blood cell. ✓ Bruise easily (due to
▪ B lymphocytes (B cells): B cells help protect low thrombocyte ct)
the body by making proteins called antibodies. ✓ Abdominal pain due to
The antibodies attach to germs (bacteria, enlargement of
viruses, and fungi) in the body, which helps the ✓ Vomiting spleen and
immune system destroy them. liver
▪ T lymphocytes (T cells): There are several ✓ Anorexia
types of T cells, each with a special job. Some ✓ Bone and joint pain =
T cells can destroy germs directly, while others due to abnormal
lymphocytes in the
play a role in either boosting or slowing the
bone periosteum
activity of other immune system cells.
✓ Headache = invaded
▪ Bone marrow = makes stem cells which CNS
produce platelets, WBC and RB ✓ Unsteady gait
▪ Are neoplasms composed of immature T cells ✓ Painless, generalized
which are referred as lymphocytes swelling of lymph
▪ Is a type of cancer of the blood and bone nodes especially in
marrow submaxillary or
▪ Involves the lymphoblasts or immature cervical nodes
lymphocytes = with the rapid proliferation of ✓ Variable leukocyte ct
immature lymphocytes, the production of RBC ✓ Low Hct and platelet
and platelets fall, the invasion of body organs ✓ normocytic and
by the rapidly increasing WBC begins. normochromic RBC
DIAGNOSIS Bone marrow aspiration – to
▪ Most common cancer in children
identify the type of wbc
✓ between 2 and 6 years of age
involved/type of leukemia
✓ Prognosis = younger than 1 year old
✓ if there are more than
or older than 10 year old at the first 25% blast
time of occurrence is not as good cells=leukemia is
those between 2 and 10 years of established
age. ✓ bone marrow is
aspirated at iliac crest
CONTRIBUTORY 1. Radiation rather than the
FACTORS 2. Exposure to chemicals sternum
3. Genetics
4. Down syndrome Radiograph = may reveal lesions
5. Fanconi syndrome = of the long bones
defect of proximal
tubule leading to Lumbar puncture = evidence of
malabsorption of blast cells in CSF
various electrolytes THERAPEUTIC Chemotherapy
and substances that MANAGEMENT ✓ Administered by
are usually absorbed central venous
by the proximal catheter= bec
tubule; due to faulty administration of
genes, kidney damage drugs into a major
s/s: peeing a lot, vessel helps prevent
drinking more than

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irritation to the vessel systemically and could lead to


wall toxic reaction.
✓ The access device can
be clamped or trapped Insertion silicon tubing into a
so the child can be cerebral ventricle and threading
ambulatory under the scalp (Ommaya
reservor) provides easy access to
Drugs to initiate remission: the CSF for sampling or injection
✓ Vincristine = given at without the need for repeated
about 1 month lumbar puncture
✓ Prednisone
✓ Asparaginase RENAL INVOLVEMENT
✓ Doxorubicin ✓ Kidneys may enlarge
✓ Methotrexate and function may be
✓ ALLUPURINOL = to impaired
reduce the formation ✓ Increase uric acid ( due
of uric acid to breakdown of
leukemic cells during
Increase uric acid due to rapid chemotherapy)
death of cancer cells in a short ✓ Plugging of renal
time = as it dies it releases uric tubules with uric acid,
acid in the blood stream kidney failure may
result
**well hydrated helps maintain *renal involvement may limit
safe uric aid excretion the use of chemotherapeutic
INCIDENCE cell ALL peaks – abt 3 years of agents because they cannot be
age excreted effectively because of
kidney damage.
Peak incidence of T cell is in
adolescence TESTICULAR INVOLVEMENT
COMPLICATIONS Central nervous system ✓ Leukemic cells tend to
involvement invade the testes and
✓ Blindness cannot be destroyed
✓ Hydrocephalus with chemotherapy
✓ Recurrent seizures ✓ Once chemotherapy is
✓ The meninges and the halted, leukemic cells
6th and 7th cranial may grow and
nerves are usually proliferate
affected ✓ Testes will be
✓ Nuchal rigidity irradiated—leads to
✓ Headache sterilization
✓ Irritability *boy is past puberty- sperm
✓ Vomiting banking before chemo and
✓ Papilledema radiation to preserve sperm
NURSING DX & Risk for infection related to
Lumbar puncture result: INTERVENTION nonfunctioning WBCs and
presence of blast cells in the CSF immunosuppressive effects to
= will be treated with intrathecal therapy
injections of methotrexate ✓ Temp= lower than
98,6F ( 37 C)
Intrathecal = injection around ✓ Septicemia
the spinal cord ✓ Pneumonia
✓ Meningitis
*Check if the child is not taking • When at home:
oral or IV methotrexate at the parents must report
same time = bec some of the signs of infection such
dose of intrathecal as low grade fever or
methotrexate is absorbed behavior that does not

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seem typical for the • Ask the child’s school


child. to notify them if any
• Prophylactic other child in the
antibiotics school develops
• Limit visitors chichenpox = immune
• Leukocytes protection can be
transfusion – to given
increase functioning • Evaluation/follow-up
leukocytes ct. ( fever TREATMENT CHEMOTHERAPY AND
and chills are not true RADIOTHERAPY
signs of transfusion
reaction) Induction (remission induction)
✓ To kill the most of the
Risk for deficient fluid volume tumor cells rapidly
related to increased chance of ✓ Drugs commonly used:
hemorrhage from poor platelet vincristine,
production asparginase,
✓ Prone to massive dexamethasone
hemorrhage
✓ Epistaxis (most
common type of Consolidation
bleeding) ✓ high doses of
✓ Digital pressure is multidrug
effective to stop chemotherapy are
epistaxis used to eliminate the
• BT – platelet disease or reduce
transfusion tumor burden to very
• Heparin low level
lock/millilumen ✓ Drugs commonly used:
central nervous Vincristine,
catheters- minimizing cyclophosphamide,
the need for repeated cytosine arabinoside,
venipunctures daunorubicin,
etoposide or
Pain related to invasion of mercaptopurine
leukocytes
✓ Due to vast number of Maintenance Therapy
RBC that invades the ✓ Aims to eliminate
periosteum of the completely any
bone remaining leukemic
• Handle arms and legs cells
gently ✓ Given with daily oral
• Use of an alternating mercaptopurine and
mattress or sheepskin once weekly oral
underneath bony methotrexate. (
joints helps to reduce continued for 2-3
skin irritation caused years)
by always resting in ✓ Leukovorin is given
the same position after systemic
• Give analgesia as methotrexate to
needed neutralize its action
abd protect normal
Ineffective health maintenance cells from the effects
related to long term therapy for of drugs
leukemia ✓ Blood values are
• Report signs of monitored at least
infection monthly
✓ if still with leukemic
cells- new induction
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phase will be initiated


followed by a
sanctuary,
intensification, and
maintenance phase
✓ Bone marrow
transplantation or
immunotherapy can
be used for children
who do not respond
well to standard
therapy

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ALTERATIONS IN NUTRITION. GASTROINTESTINAL, b. Repair at 12 to 18


METABOLISM AND ENDOCRINE months of age
If the anus is deprived of nerve
endings = a permanent
colostomy will be established
HIRSCHSPRUNG DISEASE
POST-OP
▪ Otherwise known as aganglionic megacolon or
▪ NGT in place attached
intestinal aganglionosis
to low suction, an IV
▪ is the absence of ganglionic innervation to the infusion and IFC
muscle section of the bowel. ▪ Observe for abdominal
▪ Normally, nerves tell the colon, rectum, and distention
anus to work together to push waste out of ▪ Assess bowel sounds
the body. ▪ Observe for the
▪ With HD= a section of colon is missing nerves. passage of flatus and
Waste backs up behind this section stools
▪ As soon as peristalsis
CAUSE associated with a genetic has returned approx
mutation. 24Hours
➢ remove NGT
occurs when nerve cells in the ▪ Full fluids = soft diet =
colon don't form completely. minimal residue diet =
ASSESSMENT ✓ Failure to pass normal diet for age.
meconium within the
first 24 hours of life
✓ Chronic constipation
✓ Abdominal distention INTUSSUCEPTION
✓ Ribbon like stool
✓ Thin, undernourished ▪ common cause of intestinal obstruction in
✓ Rectum is empty children between ages 3 months and 6 years
✓ Vomiting
▪ telescoping of one portion of the bowel into
DIAGNOSIS ✓ Abdominal X-ray.
✓ Contrast enema. another portion which results in an
✓ Rectal biopsy. obstruction to the passage of intestinal
✓ Anorectal manometry contents
COMPLICATIONS ✓ constipation, SIGNS AND ✓ Nausea, vomiting
✓ fecal incontinence. SYMPTOMS ✓ Abdominal pain
✓ Enterocolitis and (intermittent)
colonic rupture ✓ Currant jelly stool
MANAGEMENT PRE OP (bloody red) =
1. Minimal residue diet engorgement and
= low in undigestible ischemia of intestinal
fiber, connective mucosa that causes
tissue and residue. bleeding and out oaring
2. omit foods like: highly of mucous
seasoned foods ✓ Lethargic
3. Stool softeners ✓ Sausage shaped mass
4. Daily enema (Dance’s sign)
5. IVF Normal saline ✓ Cry, draw legs towards
chest (15-20 min)
SURGERY ✓ Fever
Dissection and removal of the ✓ Hypoactive/hyperactive
affected section with bowel sounds
anastomosis of the intestine ( a MANAGEMENT ✓ Monitor fever,
pull through operation increased heart rate.
LOC, BP and respiratory
two staged surgeries: distress
a. Temporary ✓ Antibiotics
colostomy ✓ IVF
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✓ Monitor for normal
brown stool
CARE OF THE MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)

▪ Hydrostatic reduction COMPLET Opening on the both sides of


▪ Barium enema BILATERAL CLEFT the lip that extend up into the
(detailed part of lower LIP nose and typically involve the
intestine) gum ridge and palate.
▪ Ultrasound of the
abdomen
▪ Rectal exam PREOPERATIVE ✓ Feed in upright
*surgery = general MANAGEMNT position
anesthesia, part of the ✓ Feed with soft large
intestine will be holed nipple or
removed rubber tipped syringe
or cleft lip or palate
nurser
CLEFT LIP AND PALATE ✓ Burp frequently
because of
▪ Are congenital malformations resulting from swallowed air
the failure of fusion of maxillary process ✓ Teach parents to give
during intrauterine development. This defect water after each
may occur alone or together feeding to cleanse
▪ A cleft lip is a physical split or separation of the the mouth
2 sides of the upper lip and appears as narrow ✓ Prevent infection
opening or gap in the skin of the upper lip. This from irritation of the
separation often externs beyond the base of lip
the nose and includes the bones of the upper ✓ Restrain infant’s arm
if needed
jaw and/or upper gum.
✓ Provide a pacifier to
▪ Deviation may be unilateral or bilateral
increase sucking
▪ Nose is usually flattened = because the pleasure
incomplete fusion of the upper lip has allowed POST OPERATIVE ✓ Maintain patent
it to expand in a horizontal dimension. MANAGEMNT airway
▪ Prevalent among boys than girls ✓ Cleanse the suture
▪ Have associated birth defects line to prevent crust
formation and
CAUSES eventual scarring
✓ Prevent crying –
▪ Occurs as a familial tendency or occurs from
because of the
the transmission of multiple genes pressure on the
➢ teratogenic factors present during suture line
weeks 5 to 8 o intrauterine life (encourage the
▪ Viral infection parent to stay with
▪ Deficiency of folic acid the infant)
✓ Place the infant in
TYPES OF CLEFT LIP SUPINE position with
arm or elbow
FORME FRUSTE A small indentation on one or
restraints (change
OR MICROFORM both sides of the lip
the position to the
CLEFT LIP
side or sitting up to
INCOMPLETE An opening on one side of the prevent hypostatic
UNILATERAL lip that does not extend into the pneumonia; remove
CLEFT LIP nose restraints at least 3X
COMPLETE An opening on one side of the a day only when
UNILATERAL lip that extends up into the supervised)
CLEFT LIP nose and typically involves the ✓ Support the parents
gum ridge and palate by accepting and
INCOMPLETE Opening on the both sides of treating the infant as
BILATERAL CLEFT the lip that do not extend into normal
LIP the nose ✓ Suture line is held by
a LOGAN BAR (A wire

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bow taped to both ✓ If parents has


cheeks disorders = 1:30
THERAPEUTIC ▪ Cleft lip- fetal surgery ✓ Monozygotic twin =
MANAGEMENT while still in the utero more prone to get
or repaired surgically than the non-zygotic
shortly after = during twins
hospital stay or ✓ Cleft lip and palate is
between 2-10 weeks higher in ASIAN and
of age lowest in AFRICANS,
▪ Nasal mold AMERICANS
apparatus applied COMPLICATIONS Children with cleft lip with or
before surgery to without cleft palate face has
shape a better nostril variety of challenges
▪ Early repair helps
infants enjoy the Difficulty feeding = one of the
pleasure of sucking most immediate concerns after
▪ Gives a problem on birth is feeding. While most
facial contours = babies with cleft lip can breast-
another surgery will feed, a cleft palate may make
be done when the sucking difficult.
child reaches 4-6
years = Nasal Ear infection and hearing loss =
rhinoplasty = to babies with cleft palate are
straighten a deviated especially at risk of developing
nasal septum middle ear fluid and hearing loss

Dental problems = if cleft


CLEFT PALATE extends through the upper gum,
tooth development may be
▪ A cleft palate is split or opening in the roof of affected.
the mouth. A cleft palate can involve the hard
palate (the bony front portion of the roof of Speech difficulties = because
the mouth), and or the soft palate (the soft the palate is used in forming
back portion of the roof of the mouth) sounds, the development of
normal speech can be affected
TYPES OF CLEFT PALATE by a cleft palate. Speech may
sound too nasal.
INCOMPLETE Opening in the back of the
CLEFT PALATE mouth, called the soft palate Challenges of coping with
COMPLETE CLEFT Opening in the front anf back of medical condition = children
PALATE the mouth, or the soft and hard with clefts may face social,
palates emotional, and behavioral
SUBMUCOUS Muscles within the soft palate problems due to differences in
CLEFT PALATE are separated of cleft but the appearance and the stress of
skin or mucous membrane is intensive MC.
close. At times the uvula may
be bifid CLINICAL ✓ A notched vermillion
MANIFESTATION border
S ✓ Dental anomalies =
INCIDENCE ✓ Cleft Lip = 1:750
supernumerary teeth,
births, predominantly
extra teeth, teeth may
seen in MALES
be absent, variably
✓ Cleft Palate = 1:2500
sized clefts that
births, most seen in
involve the alveolar
FEMALES
ridge
✓ If the sibling has
INCLUDES ✓ Opening in roof of the
disorders = 1 in 20 to
outh felt examiners
1 in 10
finger on palate
✓ Nasal distortion
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✓ Breathing difficulty NURSING ✓ Detected immediately


✓ Exposed nasal cavities MANAGEMENT after birth
✓ Recurrent ear and ✓ Avoid complications
throat infection ✓ The defect evokes
✓ Speech defects and negative eavtion and
psychological shock in parents. The
problems nurse must explain to
✓ Feeding problems the parents about the
✓ Inability to coordinate possibility of defect
breathing and feeding correction.
leads to inadequate ✓ Feeding = reduces
nutrition infants’ ability to suck
✓ Difficulty in feeding • Breast
leads to anemia, feeding is
malnutrition and possible
failure to thrive with the use
✓ Mouth breathing of PLATAL
DIAGNOSTIC History collection = collect the PROSTHESIS
EVALUATION history of a parent with cleft and (PALATAL
cleft palate, and antenatal OBTURATO
check-up R)
• If baby is
Prenatal ultrasonography = unable to
enables many cleft lips and suck,
some cleft palates to be expressed
identified in utero breast milk
may be
Physical examination = cleft lip given using
and palate is diagnosed by syringe with
inspection. Physical rubber tube
examination reveals the • Long
anemia, breathing difficulty handled
speech defects and dental spoon or
anomalies dropper or
soft nipple
X-ray = shows the deformity of with large
palatine bone hole
✓ Cleft palate needs a 2
MRI = to evaluate extent of stage palate repair
abnormality before treatment • Soft palate
repair at 3-6
Dental imprecision’s for months of
expansion prosthesis age
• Hard palate
Genetic evaluation to repair at 15
determine recurrence risk -18 months
of age
SURGICAL Management is based on the ✓ Mother and family
MANAGEMENT severity of the defect should be
demonstrated, the
Management of the cleft lip and various techniques of
cleft palate requires a team feeding the baby
effort involving ✓ Explain to parents
✓ Pediatrician about the risk of
✓ A plastic surgeon aspiration
✓ Orthodontist ✓ Small bolus should be
✓ ENT specialist given from the corner
✓ Speech therapist of the mouth
✓ Psychologist and CHN
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✓ Give baby sufficient hydrogen peroxide or


time to swallow saline solution and
✓ Burp the baby in dried carefully several
between the feeds times a day to ensure
and after feeding proper healing
✓ The baby must give all ✓ The parents are
essential care taught the ways by
including which injury to the
immunization, palate can be
warmth, hygiene, prevented after
prevention of discharge and
infection prevention of upper
✓ Explain about follow respiratory tract
up to the parents infection
✓ Speech therapy
PRE-OPERATIVE ✓ Keep the infant NPO should be give
MANAGEMENT for 6 hours before ✓ Encourage the child to
surgery socialize with family
✓ Administer members and others
premedication as per ✓ When maintaining a
doctors order patent airway, try to
✓ Physical, avoid use of suction
Physiological, that traumatizes the
Psychological, and operative site
legal preparation ✓ Place the child in
should be done. PRONE
POST-OPERATIVE ✓ Keep the airway clear Trendelenburg
MANAGEMENT from accumulation of position to prevent
in the nose and mouth aspiration and
✓ Mild sedation may be promote postural
prescribe to prevent drainage
infant from crying ✓ Avoid trauma to
✓ Careful positioning suture line by
(never on the ✓ Telling the child not to
abdomen) rub tongue on roof of
✓ Restraining the arms if mouth
necessary ✓ avoid the use of
✓ The mother and straw, spoon,
father should be toothbrush =
encouraged to remain PROVIDE LIQUID DIET
with their child as ✓ NO MILK – because of
much as possible curd formation on
✓ The infant is fed with suture line
medicine dropper. ✓ Recognize the need
✓ Clear fluids offers for emotional support
initially breast milk or of the parents since
formula can be given recovery is longer and
when tolerated. the progress is
✓ The mouth should be uncertain
rinsed with water
before and after
feeding.
✓ Do not brush the
teeth 1-2 weeks after
the surgery
✓ The suture line must
be cleaned gently
with cotton or gauze =
tipped swab dipped in
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DIABETES MELLITUS may start wetting his


or her pants)
▪ Diabetes mellitus involves absence of insulin ✓ Extreme hunger but
secretion (type 1) or peripheral insulin weight loss
resistance (type 2), causing hyperglycemia. ✓ Loss of appetite in
younger children
RISK FACTORS ✓ Weight = Being ✓ Blurred vision
overweight is a strong ✓ Nausea and vomiting
risk factor for type 2 ✓ Belly (abdominal) pain
diabetes in children. ✓ Weakness and fatigue
✓ Inactivity =The less ✓ Irritability and mood
active children are, the changes
greater their risk of ✓ Serious diaper rash
type 2 diabetes. that does get better
✓ Diet with treatment
✓ Family history ✓ Fruity breath and fast
✓ Race or ethnicity breathing
✓ Age and sex ✓ Yeast infection in girls
✓ Maternal gestational DIAGNOSIS Fasting plasma glucose = The
diabetes blood is tested after at least 8
✓ Low birth weight or hours of not eating.
preterm birth.
DIAGNOSIS A blood sample is taken at a Random plasma glucose = The
random time. blood is tested when there are
✓ A blood sugar level of symptoms of increased thirst,
200 milligrams per urination, and hunger.
deciliter (mg/dL), or TREATMENT ✓ Daily injections of
11.1 millimoles per liter insulin
(mmol/L), or higher, ✓ Eating the right foods
along with symptoms, to manage blood
suggests diabetes. glucose levels. This
includes timing meals
Glycosylated hemoglobin (A1C) and counting
test. carbohydrates.
✓ This test indicates your ✓ Exercise, to lower
child's average blood blood sugar
sugar level for the past ✓ Regular blood testing
3 months. to check blood-
glucose levels
✓ Regular urine testing
TYPE 1 DIABETES MELLITUS
to check ketone levels
▪ is a long-term (chronic) condition. COMPLICATIONS Ketoacidosis
✓ blood sugar levels are
▪ a condition in which the child's body no longer
very high and the body
produces an important hormone (insulin)
starts making ketones.
▪ can develop at any time during childhood,
✓ Risk for diabetic coma.
even during infancy, but it usually begins A child with a diabetic
between ages 4 years and 6 years or between coma loses
ages 10 years and 14 years. consciousness
because of brain
SYMPTOMS ✓ High levels of glucose swelling. The brain
in the blood and urine swells because of the
when tested very high blood sugar
✓ Unusual thirst levels.
✓ Dehydration
✓ Frequent urination = a Low blood sugar
baby may need more (hypoglycemia).
diaper changes, or a ✓ This is also sometimes
toilet-trained child called an insulin
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reaction. This occurs SYMPTOMS ✓ Increased thirst


when blood glucose ✓ Frequent urination
drops too low. ✓ Increased hunger
✓ Fatigue
✓ Eye problems ✓ Blurry vision
✓ Kidney disease ✓ Darkened areas of
✓ Nerve damage skin, most often
✓ Tooth and gum around the neck or in
problems the armpits and groin
✓ Skin and foot ✓ Unintended weight
problems loss, although this is
✓ Heart and blood vessel less common in
disease children with type 2
OTHER Symptoms develop quickly in diabetes than in
COMPLICATIONS type 1 diabetes, usually over children with type 1
several days to weeks, and tend diabetes
to appear in a typical pattern. ✓ Frequent infection
✓ Diabetes screening is
High blood glucose levels cause recommended for
the child to urinate excessively. children who have
Children may wet the bed or started puberty or are
become unable to control their at least 10 years old,
bladder during the day. Children who are overweight or
who are not toilet-trained may obese, and who have
have an increase in wet or heavy at least one other risk
diapers. This fluid loss causes an factor for type 2
increase in thirst and the diabetes.
consumption of fluids. About CAUSES ▪ Family history
half of children lose weight and ▪ Genetics
have impaired growth. ▪ Children with type 2
diabetes can't process
Some children become sugar (glucose)
dehydrated, resulting in properly.
weakness, fatigue, and a rapid
pulse. Most of the sugar in the body
comes from food.
Children may also have nausea
and vomiting due to ketones = When food is digested, sugar
(by-products of the breakdown enters the bloodstream. Insulin
of fat) in their blood. allows sugar to enter the cells
and lowers the amount of sugar
Vision may become blurred. If in the blood.
the symptoms are not RISK FACTORS Weight = Being overweight is a
recognized as being caused by strong risk factor for type 2
diabetes and treated, children diabetes in children. The fattier
may develop tissue children have — especially
inside and between the
muscle and skin around the
TYPES 2 DIABETES abdomen — the more resistant
their bodies' cells become to
▪ is a chronic disease that affects the child's insulin.
body processes sugar (glucose) for fuel.
▪ Without treatment, the disorder causes sugar Inactivity. The less active
to build up in the bloodstream, which can lead children are, the greater their
to serious long-term consequences. risk of type 2 diabetes.
▪ occurs more commonly in adolescents/ adults.
▪ called adult-onset diabetes. Diet. Eating red meat and
processed meat and drinking
sugar-sweetened beverages is
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associated with a higher risk of conditions is often called


type 2 diabetes. metabolic syndrome:
✓ High blood pressure
Family history. Children's risk of ✓ Low levels of high-
type 2 diabetes increases if they density lipoproteins
have a parent or sibling with the (HDL), the "good"
disease. cholesterol
✓ High triglycerides
Race or ethnicity. Although it's ✓ High blood sugar levels
unclear why, certain people — ✓ Large waist size
including Black, Hispanic, POLYCYSTIC Polycystic ovary syndrome
American Indian and Asian OVARY (PCOS) affects young females
American people — are more SYNDROME after puberty. PCOS is caused by
likely to develop type 2 diabetes. an imbalance of hormones,
resulting in signs such as weight
Age and sex. Many children gain, irregular menstrual
develop type 2 diabetes in their periods, and excess face and
early teens, but it may occur at body hair. People with PCOS
any age. Adolescent girls are often have problems with
more likely to develop type 2 metabolism that can result in
diabetes than are adolescent insulin resistance and type 2
boys. diabetes.
COMPLICATION ✓ High cholesterol
Maternal gestational diabetes. ✓ Heart and blood vessel
Children born to women who disease
had gestational diabetes during ✓ Stroke
pregnancy have a higher risk of ✓ Nerve damage
developing type 2 diabetes. ✓ Kidney disease
✓ Eye disease, including
Low birth weight or preterm blindness
birth. Having a low birth weight PREVENTION Healthy-lifestyle choices can
is associated with a higher risk of help prevent type 2 diabetes in
developing type 2 diabetes. children. Encourage your child
Babies born prematurely — to:
before 39 to 42 weeks' gestation
—have a greater risk of type 2 Eat healthy foods. Offer your
diabetes. child foods low in fat and
calories. Focus on fruits,
Maternal gestational diabetes. vegetables and whole grains.
Children born to women who Strive for variety to prevent
had gestational diabetes during boredom.
pregnancy have a higher risk of
developing type 2 diabetes. Get more physical activity.
Encourage your child to become
Low birth weight or preterm active. Sign up your child for a
birth. Having a low birth weight sports team or dance lessons.
is associated with a higher risk of Many children do not have any
developing type 2 diabetes. symptoms, and doctors
Babies born prematurely — diagnose type 2 diabetes only
before 39 to 42 weeks' gestation when blood or urine tests are
—have a greater risk of type 2 done for other reasons (such as
diabetes during a physical
METABOLIC When certain conditions occur before playing sports or going to
SYNDROME with obesity, they are associated camp).
with insulin resistance and can
increase the risk of diabetes = Symptoms in children with type
and heart disease and stroke. A 2 diabetes are milder than those
combination of the following in

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type 1 diabetes and develop solution containing a large


more slowly. amount of glucose.

Parents may notice an increase Doctors then measure blood


in the child’s thirst and urination glucose levels 2 hours
or only vague symptoms, such as later. If the level is 200 mg/dL
fatigue. Children with type 2 (11.1 mmol/L) or higher,
diabetes are less likely to children are considered to have
develop ketoacidosis or severe diabetes. This test is similar to
dehydration than those with the test that pregnant women
type 1 diabetes. have to look
COMPLICATIONS Diabetes can cause immediate for gestational diabetes.
OF DIABETES IN complications and long-term MANAGEMENT Metformin = is the main drug
CHILDREN AND complications. The most serious given by mouth (orally) for
ADOLESCENTS immediate complication is children and adolescents. It is
diabetic ketoacidosis. started at a low dose and often
increased over several weeks to
Long-term complications are higher doses. It can be taken
usually due to social and with food to prevent nausea and
psychologic issues or to blood abdominal pain.
vessel problems. Although blood
vessel problems take years to Liraglutide is an injectable drug
develop, the better the control that can be given to children
of diabetes, the less likely that over
complications will ever occur. 10 years of age who have type 2
diabetes. Liraglutide may lower
If the fasting glucose level is 126 hemoglobin A1C levels and may
milligrams per deciliter (mg/dL— also reduce appetite and
7.0 mmol/L) or higher on 2 promote weight loss. It may be
different occasions, children given to children who are taking
have diabetes. metformin but whose
hemoglobin A1C level is not in
If the random glucose level is the target range or it can be
200 mg/dL (11.1mmol/L) or given instead of metformin to
higher, children probably have children who cannot tolerate
diabetes and should have their that drug.
fasting glucose level tested to
confirm. Other drugs used for adults with
type 2 diabetes may help some
People whose hemoglobin A1C adolescents, but they are more
level is 6.5% or higher are expensive, and there is limited
considered to have diabetes. evidence for their use in
Hemoglobin A1C levels are more children.
helpful in the diagnosis of type 2
diabetes in children who do not Insulin
have typical symptoms.

Oral glucose tolerance test

may be done in children who


have no symptoms or whose
symptoms are mild or not
typical.

In this test, children fast, have a


blood sample taken to
determine the fasting glucose
level, and then drink a special

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ALTERATIONS IN PERCEPTION AND COORDINATION 3. Interference with the absorption of CSF from
the subarachnoid space if a portion of the
subarachnoid membrane is removed
HYDROCEPHALUS ASSESSMENT If obstruction is present
✓ Excessive fluid
▪ The term hydrocephalus is derived from the
accumulates and
Greek words "hydro" meaning water and
dilates the system
"cephalus" meaning the head.
above the point of
▪ A condition in which excess cerebrospinal fluid obstruction
(CSF) builds up within the fluid-containing
cavities or ventricles of the brain. If atresia is in the aqueduct od
▪ CSF is formed in the 1st and 2nd ventricles of sylvius
the brain then passes through the aqueduct of ✓ The 1st, 2nd and 3rd
sylvus and the 4th ventricle to empty into the ventricles will dilate
subarachnoid space of spinal cord where it is
absorbed. If it is at the exit from the 4th
▪ Infant: cranial nerves are not yet firmly knitted ventricle
= the excess fluid causes enlargement of the ✓ All ventricles will dilate
skull
If hydrocephalus is present
CLASSIFICATION prenatally
✓ Can be detected on a
1. communicating hydrocephalus or extra prenatal sonogram
ventricular hydrocephalus = If fluid reaches ✓ Infants fontanelles
the spinal cord widen, appear tense
2. Obstructive hydrocephalus or ✓ Suture lines separate
intraventricular hydrocephalus = if there is a ✓ Head diameter enlarge
✓ As fluid accumulates:
block to passage of fluids
scalp becomes shiny
OTHER CLASSIFICATION and scalp veins
becomes prominent
1. Congenital = due to maternal infection ✓ Brow bulges forward
(toxoplasmosis) infant meningitis (bossing)
2. Acquired = from an incident later in life ✓ Sunset eyes (sclera
shows above the iris
EXCESSIVE CSF due to: because the upper lid
retract
1. Overproduction of fluid by the choroid plexus ✓ Increased intracranial
in the 1st and 2nd ventricle pressure (decreased
2. Obstruction of the passage of fluid pulse and RR,
✓ in the narrow aqueduct of sylvius increased temperature
(common cause) and BP)
✓ Foramina of magendei and Luschka ✓ Hyperactive reflexes
(opening that allow the fluid to leave ✓ Strabismus
the 4thventricle) ✓ Optic atrophy
✓ Failure to thrive,
OBSTRUCTION occurs because of: lethargic, irritable
✓ High pitched cry
a. Infection = meningitis, encephalitis = that
leave adhesions behind the block fluid flow all children under 2 years old
b. Hemorrhage = from trauma, tumor should have their head
c. Arnold chiari disorder = elongation of the circumference be recorded and
lower brain stem and displacement of the 4th plotted
ventricle into the cervical canal
measure the head circumference
of all infants within an hour after
birth and before discharge

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note for any asymmetry- could another point of


suggest obstruction absorption
✓ Shunting procedure-
a skull that is enlarging anteriorly threading a thin
with a shallow posterior fossa polyethylene catheter
suggest an obstruction in the under the skin from the
aqueduct or 3rd ventricle ventricles to the
peritoneum
Infant’s motor function becomes *after insertion: bed is flat or
impaired as the head enlarges- raised only about 30 degrees
because of both neurologic
impairment and atrophy caused *if raised excessively- CSF may
by the inability to move such as flow too rapidly and
heavy head decompression can occur too
rapidly leading to the possible
Children’s intelligence remain tearing of cerebral arteries
normal even those with
extremely large head but fine A one way valve is inserted in the
motor are affected shunt that opens when CSF has
DIAGNOSIS ✓ UTZ accumulated to the extent that
✓ Computed pressure has increased.
tomography
✓ MRI It closes when enough fluid has
✓ Skull x-ray = reveal drained to reduce the pressure.
separating of sutures
and thinning of the Infants lie on the unaffected side
skull to prevent pressure on the valve
✓ Transillumination/chu POSTOPERATIV Assess signs of increased
n gun = reveal that the E intracranial pressure = Tense
skull is filled with fluid MANAGEMENT fontanelle, increasing head
rather than solid brain circumference, irritability,
lethargy, decreased loc, poor
if non communicating sucking ability, vomiting and
hydrocephalus – dye inserted increase BP, increasing temp,
into a ventricle through the decreasing pulse and respiration
anterior fontanelle will not
appear in CSF obtained from a Assess for symptoms of infection
lumbar puncture = increased temp, increased
THERAPEUTIC If caused by overproduction of pulse rate, general malaise
MANAGEMENT fluid:
✓ Acetazolamide Assess for symptoms of
(diamox) = diuretic, to meningitis = stiff neck and
promote the excretion marked irritability
of the excess fluid
Assess if the child receives
Destruction of a portion of the adequate pain mgt = crying
choroid plexus elevated CSF pressure
✓ Ventricular endoscopy
✓ NPO until bowel
If tumor is the cause of sounds returned
overproduction of fluid ✓ Introduce fluid
✓ Remove tumor gradually in small
quantities after
If caused by obstruction: removal of the tube
✓ Laser surgery to (NGT)
reopen the route of ✓ Held when being fed
flow or bypassing the ✓ Support head when
point of obstruction by moving them to avoid
shunting the fluid to
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strain on the neck from reaching with only one


their heavy head hand or dragging a leg
✓ Hold their head with while crawling
whole palm not just ✓ Difficulty walking, such
the fingertips as walking on toes, a
✓ Urge parents to use crouched gait, a
rocking chair with an scissors-like gait with
✓ arm rest to provide knees crossing, a wide
support for their arm gait or an asymmetrical
while feeding the child. gait
✓ Note how the child ✓ Crouched gait = knees
sucks are bent and upper
✓ Observe for body are brought
constipation- could forward and down,
cause increased scissor gait- thighs are
intracranial pressure together
✓ Urge parents to ✓ Excessive drooling or
increase fluids and high problems with
roughage diet swallowing
✓ Difficulty with sucking
or eating
CEREBRAL PALSY ✓ Delays in speech
development or
▪ Cerebral palsy is a disorder of movement, difficulty speaking
muscle tone or posture that is caused by ✓ Difficulty with precise
damage that occurs to the immature, motions, such as
developing brain, most often before birth. picking up a crayon or
▪ Signs and symptoms appear during infancy or spoon
preschool years. ✓ Seizures
✓ The disability
SIGNS & Signs and symptoms can vary associated with
SYMPTOMS greatly. Movement and cerebral palsy may be
coordination problems limited primarily one
associated with cerebral palsy side of the body, or it
may include: may affect the whole
body. However, muscle
✓ Variations in muscle shortening and muscle
tone, such as being rigidity may worsen if
either too stiff or too not treated
floppy aggressively.
✓ Spasticity = Stiff
muscles and Brain abnormalities associated
exaggerated reflexes with cerebral palsy also may
✓ Rigidity = Stiff muscles contribute to other neurological
with normal reflexes problems. People with cerebral
✓ Ataxia = Lack of muscle palsy may have:
coordination ✓ Difficulty with vision
✓ Tremors or involuntary and hearing
movements ✓ Intellectual disabilities
✓ Athetosis = Slow, ✓ Seizures
writhing movements ✓ Abnormal touch or pain
✓ Delays in reaching perceptions
motor skills ✓ Oral diseases
milestones, such as ✓ Mental health
pushing up on arms, (psychiatric) conditions
sitting up alone or ✓ Urinary incontinence
crawling AGE-SPECIFIC Infants younger than 6 months
✓ Favoring one side of SIGNS
the body, such as
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✓ Cannot hold their head ✓ Traumatic head injury


when picked up from to an infant from a
lying on their back motor vehicle accident
✓ Stiff or floppy or fall
✓ When picked up, their ✓ Lack of oxygen to the
legs gets stiff or cross brain (asphyxia) related
✓ When held, they may to difficult labor or
overextend their back delivery, although
and neck, constantly birth-related asphyxia
acting although they is much less commonly
are pushing away from a cause than historically
you thought
RISK FACTORS Maternal health

Certain infections or health


Infants older than 6 months problems during pregnancy can
✓ Cannot roll over significantly increase cerebral
✓ Cannot bring their palsy risk to the baby. Infections
hands to their mouth of particular concern include:
✓ Have a hard time ✓ German measles
bringing their hands (rubella). Rubella is a
together viral infection that can
✓ Reach out with only cause serious birth
one hand while holding defects. It can be
the other in a fist prevented with a
vaccine.
Infants older than 10 months ✓ Cytomegalovirus.
✓ Crawl in a lopsided way, Cytomegalovirus is a
pushing with one hand common virus that
and leg while dragging causes flu-like
the opposite hand and symptoms and may
leg lead to birth defects if a
✓ Scoot around on their mother experiences
buttocks or hop on her first active infection
their knees but do not during pregnancy.
crawl on all fours ✓ Herpes. Herpes
✓ Cannot stand even infection can be passed
when holding onto from mother to child
support during pregnancy,
CAUSES Cerebral palsy is caused by an affecting the womb and
abnormality or disruption in brain placenta. Inflammation
development, usually before a triggered by infection
child is born. In many cases, the may then damage the
exact trigger isn't known. Factors unborn baby's
that may lead to problems with developing nervous
brain development include: system.
✓ Mutations in genes ✓ Toxoplasmosis. Is an
that lead to abnormal infection caused by a
brain development parasite found in
✓ Maternal infections contaminated food, soil
that affect the and the feces of
developing fetus infected cats.
✓ Fetal stroke, a ✓ Syphilis. Syphilis is a
disruption of blood sexually transmitted
supply to the bacterial infection.
developing brain ✓ Exposure to toxins.
✓ Infant infections that such as methyl
cause inflammation in mercury, can increase
or around the brain the risk of birth defects.
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✓ Zika virus infection. exhibit vascular or


Infants for whom respiratory problems
maternal Zika infection during labor and
causes microcephaly delivery may have
can develop cerebral existing brain damage
palsy. or abnormalities.
✓ Other conditions. ✓ Low birth weight.
Other conditions may Babies who weigh less
increase the risk of than 5.5 pounds (2.5
cerebral palsy, such as kilograms) are at higher
thyroid problems, risk of developing
intellectual disabilities cerebral palsy. This risk
or seizures. increases as birth
weight drops.
Infant illness ✓ Multiple babies.
Cerebral palsy risk
Illnesses in a newborn baby that increases with the
can greatly increase the risk of number of babies
cerebral palsy include: sharing the uterus. If
✓ Bacterial meningitis. one or more of the
This bacterial infection babies die, the chance
causes inflammation in that the survivors may
the membranes have cerebral palsy
surrounding the brain increases.
and spinal cord. ✓ Premature birth. A
✓ Viral encephalitis. This normal pregnancy lasts
viral infection similarly 40 weeks. Babies born
causes inflammation in fewer than 37 weeks
the membranes into the pregnancy are
surrounding the brain at higher risk of
and spinal cord. cerebral palsy. The
✓ Severe or untreated earlier a baby is born,
jaundice. Jaundice the greater the cerebral
appears as a yellowing palsy risk.
of the skin. The ✓ Rh blood type
condition occurs when incompatibility
certain byproducts of between mother and
"used" blood cells child. If a mother's Rh
aren't filtered from the blood type doesn't
bloodstream. match her baby's, her
immune system may
Other factors of pregnancy and not tolerate the
birth developing baby's
blood type and her
While the potential contribution body may begin to
from each is limited, additional produce antibodies to
pregnancy or birth factors attack and kill her
associated with increased baby's blood cells,
cerebral palsy risk include: which can cause brain
✓ Breech births. Babies damage.
with cerebral palsy are
more likely to be in a
feet-first position TYPES OF CEREBRAL PALSY
(breech presentation)
at the beginning of ATAXIC C.P. Characterized by voluntary
labor rather than muscle movements that often
headfirst. appear disorganized, clumsy, or
✓ Complicated labor and jerky. They may have difficulty
delivery. Babies who walking and performing fine

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motor function, such as grasping ✓ Orthopedic surgery


objects and writing. may be used to relieve
HYPOTONIC Cause diminished muscle tone pain and improve
C.P. and overly relaxed muscles. The mobility. It may also be
arms and legs move very easily needed to release
and appear floppy, like those of a tight muscles or
rag doll. As they grow older, they correct bone
may struggle to sit up straight as irregularities caused
a result of their weakened by spasticity.
muscle. COMPLICATIONS Muscle weakness, muscle
SPASTIC C.P. It causes weak or stiff muscle and spasticity and coordination
exaggerated reflexes, making it problems can contribute to a
difficult to walk. Abnormalities number of complications either
include unintentionally crossing during childhood or later during
their knees or making scissor-like adulthood, including:
movements with their legs ✓ Contracture. s muscle
DYSKINETIC Have trouble controlling their tissue shortening due
C.P. body movements. The condition to severe muscle
causes involuntary, unusual tightening (spasticity).
movements in the arms, legs, and Contracture can
hands. It also affects the face and inhibit bone growth,
tongue. It is difficult for the cause bones to bend,
affected person to sit, walk, and result in joint
swallow, or talk. deformities,
dislocation or partial
dislocation.
MANAGEMENT Assistive aids includes: ✓ Malnutrition.
✓ Eyeglasses Swallowing or feeding
✓ Hearing aids problems can make it
✓ Walking aids difficult for someone
✓ Body braces who has cerebral
✓ Wheelchairs palsy, particularly an
infant, to get enough
Medications: nutrition. This may
✓ Muscle relaxants are cause impaired growth
commonly used to and weaker bones.
treat the symptoms of Some children may
spasticity. Relaxing the need a feeding tube
muscles helps reduce for adequate nutrition.
pain from muscle ✓ Mental health
spasms. conditions. People
with cerebral palsy
HCP might prescribe: may have mental
✓ Baclofen health (psychiatric)
✓ Dantrolene (Dantrium) conditions, such as
✓ Diazepam (Valium) depression. Social
✓ Tizanidine (Zanaflex) isolation and the
challenges of coping
Other treatment: with disabilities can
✓ Speech therapy contribute to
✓ Occupational therapy depression.
✓ Physical therapy ✓ Lung disease. People
✓ Recreational therapy with cerebral palsy
✓ Counseling or may develop lung
Psychotherapy disease and breathing
✓ Social services disorders.
consultations ✓ Neurological
conditions. People
Surgery with cerebral palsy
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may be more likely to health risks to you and


develop movement your unborn baby.
disorders or worsened Seeing your doctor
neurological regularly can help
symptoms over time. prevent premature
✓ Osteoarthritis. birth, low birth weight
Pressure on joints or and infections.
abnormal alignment of ✓ Practice good child
joints from muscle safety. Prevent head
spasticity may lead to injuries by providing
the early onset of your child with a car
painful degenerative seat, bicycle helmet,
bone disease safety rails on beds
(osteoarthritis). and appropriate
✓ Osteopenia. Fractures supervision.
due to low bone
density (osteopenia)
can stem from several ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
common factors such
as lack of mobility, ▪ A chronic condition that affects millions of
nutritional children and often continues into adulthood.
shortcomings and Marked by an ongoing pattern of inattention
antiepileptic drug use. and/or hyperactivity-impulsivity that
✓ Eye muscle interferes with functioning or development.
imbalance. This can
affect visual fixation PREVELENCE
and tracking; an eye
specialist should ▪ 3 to 5% of the population aged 0-14 years in
evaluate suspected the Philippines
imbalances. ▪ 388,000 children aged 2-5 years
PREVENTION Most cases of cerebral palsy ▪ 2.4 million children aged 6-11 years/ 3.3
can't be prevented, but you can million children aged 12-17 years
lessen risks. If you're pregnant or ▪ 5.4 million children (8.4%) have a current
planning to become pregnant, diagnosis of ADHD.
you can take these steps to keep
healthy and minimize pregnancy TYPES OF ADHD
complications:
✓ Make sure you're INATTENTIVE ✓ Fails to give close
vaccinated. attention to details or
Vaccination against makes careless
diseases such as mistakes
rubella may prevent ✓ Has difficulty sustaining
an infection that could attention
cause fetal brain ✓ Does not appear to
damage. listen
✓ Take care of yourself. ✓ Struggles to follow
The healthier you are instructions
heading into a ✓ Has difficulty with
pregnancy, the less organization
likely you'll be to ✓ Avoids or dislikes tasks
develop an infection requiring sustained
that may result in mental effort
cerebral palsy. ✓ Loses things
✓ Seek early and ✓ Is easily distracted
continuous prenatal ✓ Is forgetful in daily
care. Regular visits to activities
your doctor during HYPERACTIVE- ✓ Fidgets with hands or
your pregnancy are a IMPULSIVE feet or squirms in chair
good way to reduce
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✓ Has difficulty remaining ✓ Trouble coping with


seated stress
✓ Runs about or climbs COMPLICATIONS ✓ Often struggle in the
excessively; extern classroom, which can
restlessness in adults lead to academic
✓ Difficulty engaging in failure and judgement
activities quietly by other children and
✓ Acts as if driven by a adults
motor; adults will often ✓ Tend to have more
feel inside as if they are accidents and injuries
driven by a motor of all kinds than do
✓ Talk excessively children who don’t
✓ Blurts out answers have ADHD
COMBINED ✓ Meets criteria for both ✓ Tend to have poor self-
inattention and esteem
hyperactive-impulse ✓ Are more likely to have
presentations. trouble interacting
with and being
accepted by peers and
CAUSE ✓ Genetics adults
✓ Environment ✓ Are at increased risk of
✓ Significant head alcohol and drug
injuries abuse and other
✓ Problems with the delinquent behavior
central nervous
system at key COEXISTING Oppositional Defiant Disorder
moments in CONDITIONS (ODD)
development. ✓ Generally defined as a
RISK FACTORS ✓ Gender pattern of negative,
✓ Hereditary defiant and hostile
✓ Age behavior toward
Maternal factors, such as: authority figures
✓ Smoking during
pregnancy Disruptive Mood Dysregulation
✓ Preterm labor Disorder
✓ Mental health ✓ Characterized by
conditions irritability and
✓ Exposure to certain problems tolerating
environmental toxins frustration
✓ High blood pressure
✓ Prematurity Conduct Disorder
SIGNS & ✓ Impulsiveness ✓ Marked by antisocial
SYMPTOMS ✓ Disorganization and behavior such as
problems prirotizing stealing, fighting,
✓ Poor time destroying property,
management skills and harming people or
✓ Problems focusing on animals
a task
✓ Trouble multitasking Learning Disabilities
✓ Excessive activity or ✓ Including problems
restlessness with reading, writing,
✓ Poor planning understanding and
✓ Low frustration communicating
tolerance
✓ Frequent mood swings Substance use disorder
✓ Problems following ✓ Including drugs,
through and alcohol and smoking
completing tasks
✓ Hot temper Axiety Disorder
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✓ Which may cause language


overwhelming worry developments
and nervousness, and
include obsessive Interviewing parents about
compulsive (OCD) speech and language develop
✓ Does a child stutter?
Mood Disorders ✓ Good pronunciation?
✓ Including depression ✓ Evaluating the ability
and bipolar disorder, to explain or re-tell a
which includes story
depression as well as ✓ Assessing social
manic behavior communication skills
DIAGNOSIS ✓ Initial history
Substance use disorder ✓ Physical assessment
✓ Autism spectrum ✓ Completion of
disorder, a condition evidence = based
related to brain rating scales
development that ✓ IQ Testing = used to
impacts how a person document intelligence
perceives and ✓ The Wechsler
socializes with others Intelligence Scale for
Children (WISC) = the
Tic disorder or Tourette test most often
Syndrome chosen, consists of 2
✓ Disorders that involve portions: a verbal scale
repetitive movements and a performance
or unwanted sounds scale.
(tics) that can’t be ✓ A child is given 3 final
easily controlled scores = verbal IQ,
performance IQ, and a
ASSESSMENT ✓ Soft neurologic signs combination or full-
✓ Mirroring scale IQ
✓ Evidence of cerebellar ✓ Children with ADHD
difficulty show a “scatter”
✓ Abnormal response to pattern on both
graphesthesia = ability performance and
to recognize a shape verbal portions doing
that has been traced well on some portions
on the skin and poorly on others
✓ Abnormal THERAPEUTIC ENVIRONMENTAL
stereognosis = ability MANAGEMENT MODIFICATION
to recognize an object ✓ Construction od a
by touch stable learning
✓ Choreiform environment is crucial
movements = aimless for children with
movements ADHD so instruction
✓ Unilateral Babinski can be free from the
Reflex distractions of entire
class
Assessment to tell is child has
ADHD is by: Educational Modification
✓ Observing interactions ✓ Preferential seating
with peers in ✓ Extended time for test
classroom taking
✓ Work setting ✓ A written list of due
✓ During formal testing dates and assignments
interviewing parents ✓ Note-taking support
about speech and
It is important to:
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✓ Ecoruage parents to adulthood. They may


be fair but firm and to need counseling to
set consistent limits to find a career that fits
reduce arguments with these behaviors
✓ Teach parents to give
instructions slowly and MEDICATIONS
to make certain they ✓ Medication
have their child’s management is a
attention before giving proven tretanment for
instructions many individuals with
✓ Consequences needed ADHD, but not all
to be established and children and teens
discussed ahead of with ADHD need to
time and delivered take medication.
immediately. If a child Those with milder
has difficulty making forms may be
decisions because of successful with a
easy distractibility, a structured
question such a “Do environment and firm,
you want to wear your but fair types of
red or your blue shirt discipline and reward.
today.” ✓ Stimulants work by
✓ Urge parents to make stimulating dopamine
sure their child receptors so there is
recognizes their anger more regular nerve
is at the behavior, not transmission, which
the child. results in increased
attention span.
FAMILY SUPPORT ✓ Short, intermediate,
✓ Ask parents if they are and long-acting
having difficulty formula
managing the ✓ Methylphenidate
challenge of raising a transdermal
child with ADHD (daytrana) in a patch
✓ Help them understand form.
the behavior is the ✓ Stimulant medications
best their child can ✓ Amphetamines
achieve
✓ Organizations such as Other medications that may be
Children and Adults used for ADHD include:
with Attention- ✓ Nonstimulant
Deficit/Hyperactivity medication
Disorder (CHADD), ✓ Atomoxetine
Attention Deficit (Strattera)
Disorder Association ✓ SNRIs, and centrally
(ADDA), and the acting adrenergic
Attention Deficit agents
Information Network ✓ Guafacine (Intuniv,
(AD-IN) may have Tenex) and clonidine
local, community ✓ Atomoxetine
chapters and may also HOW TEACHERS Teachers can provide
be available online. AND PARENTS accommodations in the
✓ Inform them that, CAN HELP? classroom
some children and ✓ Preferential seating
teens with ADHD ✓ Shorter assignments
continue to ✓ Closer supervision and
experience problems Clearer instructions
with impulsivity and ✓ Help in getting started
inattention into on assignments
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✓ Closer supervision of ✓ Use simple direct


homework instructions.
✓ Frequent ✓ Implement scheduled
communication with routine every day.
parents/doctors Make his routine
✓ Allow time for predictable and
movement something like
✓ Environment with ritualistic so that it will
fewer distractions only be easy for him to
during tests. grasp for his
independent
functioning
✓ Avoid stimulating or
Parents can provide distracting setting
accommodations in the ✓ Give positive
classroom reinforcements
✓ Take a disability ✓ Encourage physical
perspective activity
✓ Use rewards and
incentives more than
punishments AUTISM
✓ Work closely with the
school ▪ Complicated condition that includes problems
✓ Know what your with communication and behavior
child’s responsibilities ▪ An involve a wide range of symptoms and skills
are in school ▪ Diagnosed when the child is 2-3 years old
✓ Provide close
supervision for ASSESSMENT ✓ Lack of eye contact
homework ✓ Narrow range of
✓ Help your child stay interest
organized ✓ Hand flapping
✓ Monitor the child’s ✓ Frequent walking on
performance and let tiptoe
doctors know ✓ Consistent fussiness or
✓ Find the things your screaming in public
child does well and places
encourage them ✓ Repetitive head
✓ Learn as much about banging
ADHD as you can ✓ Excessive biting or
✓ Maintain a good sense aggressiveness
of humor ✓ Lack of response
✓ Not wanting to be
NURSING ✓ Accept the child or cuddled
MANAGEMENT individual as what he ✓ Like repeating
is. Considered his words/phrases
condition and ✓ Trouble adjusting to
communicate with change in routine
him as equal ✓ Not looking or listening
✓ Approach the child at to other people
his current level of ✓ Highly sensitive to
functioning. Do not sounds, touch, smell
use baby talk nor and sight
direct him as his ✓ Decrease sensitivity to
chronological age; pain
encourage him to SIGNS ✓ Issues with
express his thoughts communication. Child
or emotions and doesn’t respond to
respond to him his/her name
therapeutically. ✓ Prefers to be alone

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✓ Trouble interpreting ✓ Use structure and


what others feel consistency.
✓ Repetitive movements ✓ Use reduced language.
or speech patterns ✓ Provide light praise for
✓ Avoiding eye contact good transitions.
✓ Sensitive loud noises ✓ Consistency.
✓ Eccentric way of ✓ Have Clear
moving Expectations. Set clear,
EARLY SIGNS ✓ Unusual visual attainable
fixations. Usually expectations for your
strong and persistent child and your family.
examination of objects ✓ Anticipate the Next
✓ Abnormal Repetitive Move.
behaviors. Spending ✓ Never Miss a Chance to
unusually long periods Catch Your Child Being
of time repeating an Good.
action, such as looking ✓ Get Measuring.
at their hands or rolling ✓ Engage
an object POSITIVE ✓ always be person-
✓ Lack of age- BEHVAIOR centered and promote
appropriate sound SUPPORT autistic people's
development. Delayed dignity.
development of vowel ✓ keep people safe,
sound, such as “mama, healthy and happy.
dada, tata” ✓ enable autistic people
✓ Delayed intentional to do the things they
communication. love.
Neutral facial tones ✓ never try and make
and decreased efforts someone 'less autistic',
to restore and gain which is impossible
parent attention anyway.
✓ Decreased interest in ✓ never use punishment.
interaction. Greater
interest in object than
people and difficult to
sustain face-to-face
interactions
DIAGNOSIS Developmental screening
✓ 9months, 18 mnths, 24
months, 30 months of
age
✓ Common = 18 and 24
months

Hearing and vision test/genetic


test
TREATMENT Behavioral and comunication
a. Applied behavioral
analysis
b. Occupational therapy
c. Sensory integrtaeion
therapy

Medication
INTERVENTIONS ✓ Give advance notice
before a transition is
going to occur.
✓ Use visual supports.

117 | N C M 1 0 9 RDA
● The Healthcare Information and
PRELIM Management Systems Society (HIMSS)
defines nursing informatics as "a specialty
NURSING INFORMATICS that integrates nursing science, computer
Introduction to Informatics science, and information science to manage
● We are in the digital age. What does this and communicate data, information,
mean to us as nurses? knowledge, and wisdom in nursing practice.”
● The convergence of the telecommunications ● Informatics is becoming increasingly present
and computer industry has seen a pervasive in our profession due to rapidly changing
increase in how we communicate and technological advances.
process information. ● Healthcare systems are assimilating
● Integrated systems support evidence-based technology into daily practice at a quick pace.
nursing practice ● Security and patient privacy must be upheld
○ Facilitate nurses participation in the while achieving the goal of transforming data
health care team and document nurses into useful knowledge.
contribution to patient care outcomes. ● Integrating informatics with evidenced-based
practice (EBP) can only help improve the
AN OVERVIEW care we provide to our patients.
The evolution of the terms informatics and ● Applying technology to knowledge may help
nursing informatics as follows: potential problems earlier.
● In 1957 – first coined by Karl Steinbuch as ● For example, with the use of electronic
“informatics” documentation, identifying changes in patient
● In 1962, Philippe Dreyfus used the term status can occur quickly because the
“informatique” ; Walter Bauer translated it information is readily available.
into “informatics” ● Trending of patient vital signs is always
● In 1980, Scholes and Barber coined the term accessible, and data are interpreted,
“nursing informatics”. systematized, and arranged.
● The term nursing informatics was initially ● The nurse is able to use this knowledge to
seen in literature in the 1960’s, including a formalize an appropriate plan of action.
definition of “combining nursing, information ● Standardizing nursing language will facilitate
and computer sciences for managing and acceptance of new methods of
processing data into knowledge for use in documentation in the electronic health
nursing practice”. record.
● In 1994, The American Nurses Association ● A template for nursing notes is one method
(ANA) began developing a statement to of assisting with our daily workload.
describe and define the scope of NURSING ● The use of a template can remind nurses of
INFORMATICS as “a specialty that integrates important information required in the
nursing science, computer science and documentation of patient care.
information science to manage and ● Research studies, patient care data, and
communicate data, information, knowledge national and local standards are used to
and wisdom in nursing practice”. develop informatics programs at healthcare
● Another definition of nursing informatics organizations.
comes from the American Medical ● Other measures include return on investment
Informatics Association (AMIA), which states analysis, patient preferences and/or needs,
— “Nursing Informatics science and practice and infection control data.
integrates nursing. Its information and
knowledge and their management, with How's the need for technology addressed?
information and communication technologies ● For example, a high rate of medication errors
to promote the health of people, families and is identified.
communities worldwide.”

1
● Analysis of how and why the errors are ● The term patient refers to consumers in both
occurring must be conducted. a wellness and illness model.
● The research can include collecting data ● NI is one example of a discipline-specific
from other facilities in the area to determine if informatics practice within the broader
the same problem exists elsewhere. category of health informatics.
● Following data collection, the findings are ● NI has become well established within
presented to a review board. nursing since its recognition as a specialty for
● A plan to improve the problem is registered nurses by the American Nurses
implemented, such as the use of bar code Association (ANA) in 1992.
scanners. ● It focuses on the representation of nursing
data, information, knowledge and wisdom as
● Data collection continues to determine if well as the management and communication
implementation is successful. of nursing information within the broader
● The most important piece of implementation context of health informatics
is presentation of the evidence to staff to ● DIKW - Data, Information, Knowledge, and
identify how the change will improve the Wisdom
actions of nurses.
● Staggers and Thompson (2002) believed BENEFITS OF NURSING INFORMATICS IN
that there were too many definitions for HEALTHCARE
Nursing informatics (NI), which was causing 1. Nursing Informatics informs and
the specialty to grow without a solid influences IT systems
foundation. ● Nursing informatics specialists spend much
of their time helping to develop, implement
● They believed that without this foundation it
and optimize computerized patient
was difficult to build a solid informatics
information systems.
practice or the needed educational base for
● It’s their blend of clinical and technical
this specialty practice. Staggers and
knowledge and experience that makes them
Thompson performed a critical.
perfect liaisons between the clinical and
technical communities.
The new definition is as follows:
● One of the early contributions of nursing
The goal of NI is to improve the health of
informatics was to help move healthcare
populations, communities, families, and
away from paper forms and into electronic
individuals by optimizing information management
documentation.
and communication (Staggers and Thompson)
● Today, a nurse’s standardized notes are
immediately available to physicians and other
These activities include the design and use of
caregivers through EHR systems.
informatics solutions and/or technology to support
● Workflows and decisions are more
all areas of nursing, including, but not limited to:
informed and efficient.
1. The direct provision of care,
● Many EHR vendors recognized the value of
2. Establishing effective administrative systems,
hiring nurse informaticists to help design and
3. Designing useful decision support systems
build their system.
4. Managing and delivering educational
● EHR vendors acquired a double-barreled
experiences,
secret weapon because nurse informaticists.
5. Enhancing supporting life- long learning, and
6. Supporting nursing research.
A. Recommend the most practical layout of forms
and reports, and the best processes for electronic
● The term individual refers to patients,
medication administration.
healthcare consumers and any other
B. Prevent EHR mutiny because they can predict
recipient of nursing care or informatics
clinician reactions to technically efficient-but
solutions.
clinically clumsy - workflows, and shape EHRs
that avoid these poor workflows.
2
● But nursing informatics specialists are
well-suited to teach other nurses how to get
the full benefits of these systems.
Nursing informatics specialists are trilingual: ● Because in some cases, nurse informaticists
1. They understand the clinical language of helped design and create those very
efficient patient care. systems. But at the very least , they
2. They translate knowledge and clinician understand the reasons, from a nursing care
feedback into the technical language of perspective, for the structure of each digital
business analysts and programmers. form and the sequence of clicks.
3. They communicate clinical and technical ● They can explain built-in interoperability and
matters with administrative leadership. behind-the-scenes interfaces to other clinical
systems in language that’s easily understood
● It's not simple to speak effectively with by nurses.
clinical, technical, and administrative people.
● Still, nursing informatics specialists are 4. Nursing Informatics leverages IT
qualified and have proven to be investments
indispensable to the development of superior ● Every health facility - from the
healthcare IT systems. single-physician practice to the large
● Informatics professionals with a nursing academic medical center invests a significant
background combine the best of both worlds: amount of their budget on essential health
deep expertise in clinical care helps nurse information technology and services.
informaticists understand the needs and ● These include patient care systems like the
stresses of the clinical workflow, while their PACS and electronic medical records
education and background with information system, communication technologies like
technology systems and data analytics helps pagers and secure messaging systems, and
them sculpt health IT infrastructure into a analytics tools.
meaningful and helpful tool.
Nurse informaticists help get maximum value
2. Nursing Informatics leverages from these investments in at least three ways:
evidence-based clinical best practices 1. They ensure that systems are designed to
● Most clinicians want to apply their knowledge support effective patient care workflow.
and experience to improve patient care. 2. They help train other nurses to use IT
The nurse informaticist takes it a few steps efficiently.
further by: 3. They apply advanced analytics strategies
1. Researching clinical nursing practices to develop predictive models.
outside of their own experiences. 4. As an example of predictive models,
2. Finding evidence to prove which clinical consider Texas Health Resources in
practices are best. Dallas-Fort Worth. Their informatics
3. Influencing the design of clinical systems nurses use analytics tools to identify the
to support and promote the best evidence risk of sepsis, risk of readmission, and
­based practices and workflows. potential benefit from palliative care.
4. Training other nurses to use clinical IT
systems. 5. Nursing informatics contributes unique
wisdom to clinical care that is acquired
3. Nursing Informatics generates stronger through a deep understanding of both
nurse training in clinical IT systems clinical practice and data analysis
● Clinical IT systems are complicated, and their ● “Informatics nurse specialists work with
interfaces and workflows are not always leadership regarding regulatory and quality
intuitive. initiatives and governance for technology
implementation and change. For example,
they work with the delivery-of-care team.”
3
● The chief nursing officer, chief medical seeing their providers - from the other side of
officer, and quality leadership who might give town, or the other side of the world.
us a directive based on improving patient ● And nurse informatics specialists are helping
safety by decreasing readmissions. design and implement telehealth systems, as
● Informatics nurse specialists identify the key well as training their fellow nurses in how
areas where studies identify where problems best to use the systems.
arise: inadequate discharge education, a
patient doesn't have support at home, poor 7. Nursing Informatics Improves Patient
hearing or sight- or being on multiple Care, Patient Safety, and Outcomes
medications. ● The more generalized field of healthcare
● They’ll take those variables and identify how informatics focuses mainly on administrative
and where in the system they should alert a issues, whereas nursing informatics focuses
nurse that this is a possible red flag and give on patient care.
her the elements of a plan to decrease the ● In fact, the substance of the first six benefits
risk for a readmit. of nursing informatics is all about improving
● They explain to the technical and application care, safety, and outcomes for patients.
team what nurses need the system to do.
● They build it, and the nurses validate the The nurse informaticists resume is like an
build. Then nurses go back to clinical endowment to patients and their families:
leadership and demonstrate what was ● More efficient electronic health records
designed and built. ● Better IT systems
● Because nurse informaticists understand ● Research and application of clinical best
data analysis and nursing practice, they practices
immediately know which trends are worth ● Training of other nurses
analyzing ,and which anomalies are ● Analytics-based predictive models
significant enough to escalate. ● New avenues for patient education
● Support for telehealth technology
6. Nursing informatics enriches the evolving
healthcare delivery system HOW DO PATIENTS BENEFIT FROM NI?
● Advances in healthcare technology launch ● Fewer medical errors
new options for healthcare delivery, and ● More informed clinical decision-making
nurse informatics specialists are helping ● Shorter hospital length of stay
ensure these new options are beneficial to ● Lower admission and readmission rates
both patients and clinicians. ● Better self-management
● Two examples are developments in
communication technology and remote Application of informatics as an enabling
healthcare, known as telehealth. mechanism that improves operational tasks
● Regarding communication technology, towards enriched jobs, increased job satisfaction,
vendors are using Smartphones to transform and enhanced quality centric customer service
the way communication in nursing happens. both in the hospital and in the academe is
● Advanced applications - from secure strongly supported by Filipino theorist, Locsin’s
messaging to EHR integrations that push “Technological Competency as Caring in
critical results to a physician’s phone just Nursing: A Model.”
seconds after the results hit the EHR - are
dramatically improving the efficiency of Articulates that:
healthcare delivery. 1. “Technological Competency as Caring in
● Regarding the growing field of telehealth, Nursing” is illustrated in the practice of
patients are receiving education and nursing grounded in the harmonious
self-management training, automatically coexistence between technology and caring
storing and forwarding medical data, and in nursing.

4
Assumptions of the theory include the and devices that are a part of patient care as
following among others: these will provide opportunities for the nurse to
a. Technology is used to know wholeness of know the patient fully as a person.
persons moment to moment
b. “Nurses value technological competency as Nurses use and encounter technology in nearly
an expression of caring in nursing” every aspect of their profession. What does it
mean to be technologically competent? What
2. Dimensions of Technological Value in the does it mean to be a caring nurse? How does
Theory technology support nursing work? How does it
a. Technology as completing human beings hinder nursing work? How can nurses care for
to re-formulate the ideal human being such their patients as technological advancements are
as replacement parts, both mechanical introduced nearly every day?
(prostheses) or organic (transplantation of
Organs). Technological Competency as Caring in
b. Technology as machine technologies, Nursing: A Model for Practice provides insight
e.g., computers and gadgets enhance and answers into how nurses can express their
nursing activities to provide quality patient nursing by being technologically competent. As
care such as Penelope or Da Vinci in the such, Locsin sustains the understanding that
Operating theaters. being technological competent is being caring.
c. Technologies that mimic human beings
and human activities to meet the demands Dr. Locsin’s work is obviously guided by the
of nursing care practices, e.g., Cyborgs question asked by thoughtful nurses
(cybernetic organisms) or anthropomorphic everywhere: How can I satisfactorily reconcile
machines and robots such as nursebots. the idea of competent use of technology with the
idea of caring in nursing? His theory significantly
3. Technological Competency as Caring in describes a practical understanding of the
Nursing solution, enriching the practice value of all of
● Technological competency as Caring in the general theories of nursing which are
nursing is the harmonious coexistence grounded in caring. Technological competency as
between technologies and caring in nursing. caring in nursing informs nursing as a critical
● The harmonization of these concept can process of knowing a person's wholeness.
co-exist
● Technology brings the patient closer to the Dr. Locsin’s theory book explores, clarifies, and
nurse. Conversely, technology can also advances the conception of technological
increase the gap between the nurse and competency as caring in nursing. His theory is
nurse. essential to modeling a practice of nursing from
the perspective of caring. It is a practical
IN CAPSULE: Locsin’s “Technological illumination of excellent nursing in a technological
Competency as Caring in Nursing Nursing: A aspect.
Model for Practice”
Dr. Locsin, middle - range nursing theory is an INFORMATION SCIENCE
interesting discussion of the correlation between ● Information science is the science and
hands-on patient care and the use of technology. practice dealing with effective collection,
storage, retrieval, and use of information.
Technology is defined as anything that makes ● It is concerned with recordable information
things efficient - from diagnostic technologies to and knowledge, and the technologies related
therapeutic practices familiar to all nurses. services that facilitate their management and
use.
Specifically, he discusses the importance of
understanding the need of knowing
“high-tech” instruments e.g monitors, implants,
5
Multidisciplinary science
● Involves aspects from computer science,
cognitive science, social science,
communication science, and library science
to deal with obtaining, gathering, organizing,
manipulating, managing, storing, retrieving,
recapturing, disposing of, distributing, or
broadcasting information.
● Studies everything that deals with information
and can be defined as the study of
information systems.
● Originated as a sub-discipline of computer
science, in an attempt to understand and
rationalize management of technology within
organizations.
CLINICAL INFORMATION SYSTEM
● Has matured into a major field management
All members of the interprofessional healthcare
that is increasingly being emphasized as an
team, including nurses, physicians, pharmacists,
important area of research in management
social workers, and therapists, use programs
studies,
available on Clinical Information System (CIS).
● Has expanded to examine the
human-computer interaction, interfacing, and
These programs include:
interaction of people , information systems,
1. Monitoring systems – includes devices that
and corporations.
automatically monitor and record biometric
● It is taught at all major universities and
measurements (e g vital signs, oxygen
business schools around the world.
saturation, cardiac index, and stroke volume)
● Organizations have become intensely aware
in acute care, critical care and specialty
of the fact that information and knowledge
areas. The devices electronically send
are potent resources that must be cultivated
measurements directly to the nursing
and honed to meet their needs.
documentation.
2. Order entry systems
In the mid-1980‘s, Blum (1986) introduced the
3. Laboratory Radiology
concepts of data, information knowledge as a
4. Pharmacy systems
framework for understanding clinical information
systems and their impact on health care.
A well-designed nursing clinical information
system (NCIS) incorporates the principles of
He did this by classifying the then current clinical
nursing informatics to support the work that
information systems by the three types of objects
nurses do by facilitating documentation of nursing
that these systems processed.
process activities and offering resources for
These were: DATA, INFORMATION, & managing nursing care delivery.
KNOWLEDGE
As a nurse you need to access a computer
program easily, review a patient's medical history
and health care provider orders, and then go to
the patient’s bedside to conduct a comprehensive
assessment.

Once you complete an assessment, enter data


into the computer terminal at the patient's bedside

6
and develop a plan of care from the information ● The amount of RAM (Random Access
gathered. Memory)
○ Storage
This allows you to quickly share the plan of care ● The speed of Data location or transfer rate of
with your patient. Periodically return to the the disk drives.
computer to check on laboratory test results and ○ How fast the CPU interpret the
document the care you deliver. instructions

The computer screens and optional popup Open Source and Free Software
windows make it easy to locate information, enter ● Software are the instructions being given to
and compare data, and make changes. the hardware to perform certain task
● Classified based on availability and
NCISs have two designs: shareability as to free and open source and
1. The nursing process design is the most proprietary or closed software.
traditional.
More advanced systems incorporate standardized Free and Open-source Software (FOSS)
nursing languages into the software such as: ● Allows users and programmers to edit,
a. North American Nursing Diagnosis modify or reuse the software’s source code.
Association-International (NANDA) nursing ● The term “free” indicates that the software
diagnoses does not have constraints on Copyrights.
b. The Nursing Interactions Classification (NIC), ● The term “open source” indicates the
and software is in its project form, enabling easy
c. The Nursing Outcomes Classification (NOC) software development from the expert
2. Protocol or Critical Pathway design developers collaborating worldwide without
Facilities interdisciplinary management of any need for reverse engineering.
information because all healthcare providers use ● Free and open-source software may also be
evidenced-based protocols or critical pathways to referred to as free/libre open-source software
document the care they provide. (FLOSS) or free/open-source software.
● The basic and old classifications of
software includes:
UNIT 2 - COMPUTER SYSTEM
Computer Hardware a. System Software
● Hardware refers to the physical parts of the ● Helps the user, hardware and the application
computer. It allows the user to enter the data software to interact and function together
into computer ● Type of computer software allow an
● Essential Parts: CPU (Central Processing environment or platform for other software
Unit) and other different input and output and applications work
devices (Ex. USB or Universal Serial Bus) ● When you power up a computer, it is the
system software that is initially loaded into
Computer Hardware System memory.
● The power supply, disk drives, chips and ● Example: like macOS, Linux, Android and
connections for all other computer hardware Microsoft Windows, computational science
are also located in the CPU. software, game engines, search engines,
● The performance of the CPU or determinant industrial automation, and software as a
of how fast the CPU’s performance is known service applications.
by three components.
● CPU processor cores and clock speed, which b. Application Software
is typically measured in GHz (Gigahertz) ● Most popularly known as “apps”
○ How fast the processor core received ● Productive end-user programs that help you
the task perform the tasks

7
● Can range from word processing and image ● Is an emerging sub-discipline of education
editing, voice communication or conferences, and informatics that “incorporate(s) new
internet browsers and many more technologies and learning strategies to
enhance the capture, organization and
Data Assessment utilization of information within the field of
● Data Quality Assessment (DQA) is the education
process of scientifically and statically ● Covers K-12 and higher education
evaluating data in order to determine whether
they meet the quality required for projects or
business processes and are of the right type Unit 2 - Concepts, Principles and Theories in
and quantity to be able to actually support Nursing Informatics
their intended use.
● It can be considered as a set of guidelines Informatics Theory
and techniques that are used to describe Theories
data, given an application context, and to In nursing informatics, there are different theories,
apply processes to assess and improve the which help to frame and inform this discipline.
quality of data This include the:
● Maintain the integrity of the systems, quality ● General systems theory,
assurance standards and compliance ● Change theory,
concerns. ● Cybernetics theory and the
● DQA is usually performed to fix subjective ● Cognitive learning theory
issues related to business processes, such
Novice to Expert Theory and the DIKW Theory
as the generation of accurate reports, and to
also support the framework of Nursing
ensure that data-driven and data-dependent Informatics. All the theories support nursing
processes are working as expected. informatics in different ways.
● DQA processes are aligned with best
practices and a set of prerequisites as well Nursing practitioners can combine the knowledge
as with the five dimensions of data quality they acquire from the theories, with that they
○ Accessibility obtain from their nursing practice to enhance their
performance.
○ Accuracy and reliability
○ Serviceability General Systems Theory
○ Methodological Soundness ● Developed by biologist Ludwig von
○ Assurances of Integrity Bertalanffy in 1936
● Includes purpose, content and process,
Personal, Professional, and Educational breaking down the “whole” and analyzing the
Informatics parts
Personal Informatics ● The relationships between the parts of the
● Information services, often accessible via a whole are examined to learn how they work
mobile, that search, sort, mine, correlate or together
otherwise filter information for a person ● A system is made up of separate
based on their preferences , transaction logs, components. The parts rely on one another,
location, social networks and other personal are interrelated, share a common purpose
Data. and together form a whole.
● Health informatics professionals use their
knowledge of healthcare, information Assumptions of General System Theory
systems, databases and information ● All systems must be goal directed
technology security to gather, store, interpret ● A system is more than the sum of its parts
and manage the massive amount of data ● A system is ever changing and any change in
generated when care is provided to patients. one part affects the whole.

Educational Informatics
8
● Boundaries are implicit and systems are opportunities to make corrections in the
open and dynamic processes used.
2. The portion of the world studies (system)
Concepts and Definition must exhibit predictability.
● Input – Energy & raw Material (Ex. 3. Though each sub-system is a self-contained
Information, Money, Energy, time) unit, it is part of wider and higher order
● Throughput – processed used by the 4. The central objective of a system can be
system to convert raw materials to products identified by the fact that other objectives will
(Ex. Thinking , planning, Decision making, be sacrificed in order to attain the central
constructing, meeting
objective.
● Output – The product or service from
5. Every system, living or mechanical, is an
throughput
information system. Must analyze how
● Feedback – Information about some aspect
of data or energy processing that can be suitable the symbols used are for information
used to evaluate and monitor the system. transmission.
● Subsystem – A system which is a part of a 6. An open system and its environment are
larger system. They can work parallel to each highly interrelated
other or in a series with each other 7. A highly complex system may have to be
● Static System – Neither system elements broken into subsystems so each can be
nor the system itself changed much over time analyzed and understood before being
in relation to the environment reassembled into a whole.
● Dynamic system – The system constantly 8. A system consists of a set of objectives and
changes the environment & is changed by their relationships
the environment 9. A system is a dynamic network of
● Closed systems – Fixed , automatic interconnecting elements A change in only
relationships among system components no
one of the elements must produce change in
give or take with the environment.
● Open Systems – Interacts with the all the others.
environment trading energy & raw material 10. When subsystems are arranged in a series,
the output of one is the input for another;
for goods & services produced by the system
therefore, process alterations in one requires
● Boundary – The line or point where a alterations in other subsystems.
system or subsystem can be differentiated 11. All systems tend toward equilibrium, which is
from its environment or from other
a balance of various forces within and
subsystems
● Goal – The overall purpose for existence or outside of a system.
the desired outcomes. (mission statement) 12. The boundary of a system can be redrawn at
will by a system analyst.
● Entropy – The tendency for a system to
13. 13.To be viable, a system must be strongly
develop order & energy over time.
● Negentropy – the tendency of system to goal-directed, governed by feedback, and
lose energy & dissolve chaos have the ability to adapt to changing
● Control or cybernation – The activities and circumstances.
processes used to evaluate input, throughput
& output in order to make corrections. Change Theory
● Equifinality – Objectives can be achieved ● Developed by Kurt Lewin who is considered
with varying inputs & in different ways. the father of Social Psychology
● Lewin’s definition of behavior in this model is
Basic Principles of a System Approach “a dynamic balance of forces working in
1. A system is greater than the sum of its parts. opposite direction”
● Requires investigation of the whole
situation rather than one or two aspects 3 Major Concepts
of a problem. 1. Driving Forces – are those that push in a
● Mistakes can’t be blamed on one direction that causes change to occur.
person, rather a system analyst would They cause a shift in the equilibrium
investigate how the mistakes occurred towards change
within a subsystem and look for
9
2. Restraining Forces – are those forces
that counter the driving forces
3. Equilibrium – is a state of being where
driving forces equal restraining forces and
no change occurs.

3 Stages
1. Unfreezing – process which involves
finding a method of making it possible for
people to let go of an old pattern that was
somehow counterproductive.
2. Change Stage – “moving to a new level”
or “movement”. Involves a process of
change in thoughts, feeling, behavior, or
all three, that is In some way more
liberating or more productive.
3. Refreezing Stage – establishing the
change as the new habit.

Major Assumptions
● People grow and change throughout their
lives
● Change happens daily
● Reactions to change are grounded in the
basic human needs for self-esteem, safety
and security
● Change involves modification or alteration

10
6 Components sensing comparison with the desired goal,
1. Recognition of the area where change is and again to action.
needed ● Its focus is how anything (digital, mechanical
2. Analysis of a situation or biological) processes information, reacts to
3. Identification of methods by which change information and changes or can be changed
can occur to better accomplish the first two tasks.
4. Recognition of the influence of group ● Comes from the Greek word “Kubernetes”
mores or customs on change. which means “steering” and “governor” in
5. Identification of the methods that the Latin.
reference group uses to bring about
change Major Concepts
6. The actual process of change ● Cybernetics introduces the concept of
circularity and circular causal systems
Kurt Lewing’s Model of Change ● Systems are defined by boundaries
● Every system has a goal
● Environment affects aim
● Information returns to system- “feedback”
● System measures difference between state
and goal
● Detects “error”
● System corrects action to aim toward goal
● Cycle Repeat

Scope and Application of Cybernetics


● Basis of modern communication systems
Cybernetics Theory ● Application in cognitive science for modeling
and learning
● Application in management science

Conclusion
Cybernetics is applicable in any discipline relying
on feedback processes including health sciences,
sociology and psychology, which are based on
communication process
● A transdisciplinary approach for exploring
regulatory systems, their structures,
Cognitive Learning Theory
constraints and possibilities
● Explains why the brain is the most incredible
● “the scientific study of control and
network of information processing and
communication in the animal, machine and
interpretation in the body as we learn things
society” as defined by Norbert Wiener.
● Applicable when a system being analyzed
2 specific Theories
incorporates a closed signaling
A. Social Cognitive Theory
loop-originally referred to as “circular
We consider 3 variables
causal” relationship, that is where action by
1. Behavioral factors
the system in some manner (feedback)
2. Environmental factors (extrinsic)
triggers a system change.
3. Personal Factors (intrinsic)
● The essential goal of the broad field of
cybernetics is to understand and define the
functions and processes of systems that
have goals and that participate in circular,
causal chains that move from action to

11
● Novice – Competent – Proficient –
Expertise – Mastery was initially proposed
by Hubert and Dreyfus

Distinguishing Features
● Deliberate Practice – is a trait shown by
people who use a personal, goal-oriented
approach to skill and knowledge
development. This requires years of
Basic Concepts sustained effort to continually improve quality
● Observational Learning of practice and performance within the skill.
● Reproduction ● Taking Risks – Continuous climb to expert
● Self Efficacy level – requires people to move beyond the
● Emotional Coping status quo of mere competence through the
● Self regulatory Capability levels of Proficiency then Expertise.
B. Cognitive Behavioral Theory
Novice
● Describes the role of cognition
● A novice doesn’t know anything about the
(knowing) to determine and predict the
subject he/she is approaching and has to
behavioral pattern of an individual.
memorize its context-free features.
● Developed by Aaron Beck
● The novice is then given rules for
determining an action on the basis of these
The Novice to Expert Theory
features.
A construct theory first proposed by Hubert and
● To improve the novice needs monitoring
Stuart Dreyfus (1980) as the Dreyfus Model of
either by self observation or instructional
Skill Acquisition and later applied and modified to
feedback.
nursing by Patricia Benner (1984).
This theory can be applied to:
Advance Beginner
● The development of nursing informatics
● Still dependent on rules, but as he/she gains
skills, competencies, knowledge and
more experience with the real-life situations,
expertise in NI
he/she begins to notice additional aspects
● The development of technological system
that can be applied to related conditions.
competencies in practicing nurses working in
an institution
Competent
● The education of nursing students, from first
● The competent person grasps all relevant
year to graduation and
rules and facts of the field and is, for the first
● Transition of graduate nurse to expert nurse
time, able to bring his/her own judgment to
each case.
Novice to Expert
● This is the stage of learning that is often
characterized by term problem-solving.
● A competent level nurse would be able to
use a hospital information system with ease
and know-how to solve technical difficulties.

Proficient
● Is called “fluency” and is characterized by
the progress of the learner from the
step-by-step analysis and solving of the
situation to the holistic perception of the
● The currently accepted five levels of entirety of the situation.
development as presented by Benner
12
● The proficient hospital information system
learner would know how to interpret data
from all departmental information and provide
guidance to other disciplinary members as
needed.

Expert
● An expert’s repertoire of experienced
situations immediately dictates an intuitively
appropriate action.
● After a great deal of experience actually
using a system in everyday situations, the
expert nurse discovers that without his
consciously using any rules, situations simply
elicit from him/her appropriate responses.
A. The “Data” of DIKW
The DIKW Theory The first step
● When raw data is collected, it gets mixed up ● Collection of Raw data is the main
and the view seems jumbled requirement
● Model by Fricke (2018) and Russell Ackoff ● Any measurements, logging, tracking,
(1989) records and many others are all considered
● “D” = Data as data.
● “I” = Information ● Since the raw data is collected in bulk, it
● “K” = Knowledge includes both useful and not useful contents.
● “W” = Wisdom ● Example: 300 Users visits a website daily to
● The DIKW model of transforming data into take online lessons
wisdom can be viewed from two different B. The “Information” of DIKW
concepts ● Data that has been given meaning by
○ Contextual Concept – one moves from defining relational connections
a phase of gathering data parts (data), ● “meaning” represents processed and
the connection of raw data parts understandable data.
(information), formation of whole ● Example: 150 Users Visit Nursing
meaningful contents (knowledge), and Pharmacology section, 145 for Nursing
conceptualizing and joining those whole Research , Out of them, 60% is in the age
meaningful contents(wisdom) group of 18-22 years old , 70% of our visitors
● Understanding Concept – the DIKW between 9am – 11pm
Pyramid can be viewed as a processing ● The information hierarchy stage of DIKW
starting with researching & absorbing, doing, Pyramid reveals the relationships in the data,
interacting, and reflecting and then the analysis is carried out to find the
answer to Who, What, When and Where
questions.

13
tutorials to get help with their certifications
and technology needs.

Analyzing Organizational Issues Using the


DIKW Hierarchy
● Data: A way to identify the raw external
inputs such as the facts and figures that are
yet to be interpreted.
● Information: Analyze the raw data to
determine the organizational needs. An
important aspect of information management
is that apart from answering questions it can
C. The “Knowledge” of DIKW also help to find other solutions in
● The third level of the DIKW Model. organizational contexts.
Knowledge means the appropriate collection ● Knowledge: Determines how something is
of information that can make it useful. remembered by an individual or how
● Knowledge stage of DIKW hierarchy is a information is applied by them.
deterministic process. When someone ● Wisdom: Uncover why the derived
"memorizes" information due to its knowledge is applied by individuals in a
usefulness, then it can be said that they have specific way. i.e. - finding the reason behind
accumulated knowledge. any decision-making
● The knowledge step tries to find the answer
to the "How" question. Specific measures are
pointed out, and the information derived in
the previous step is used to answer this
question.
● With respect to our scenario, we must find
the answer to “ How do student nurses
between the age group of 18-22 years old
use our modular approach.
D. The “Wisdom” of DIKW
● The Wisdom is the fourth and the last step of The Usage and Limitations of DIKW Model
the DIKW Hierarchy. It is a process to get the ● Same as all other models, DIKW Model also
final result by calculating through has its own limits. You may have noticed that
extrapolation of knowledge. It considers the the DIKW Hierarchy is quite linear and
output from all the previous levels of DIKW follows a logical sequence of steps to add
Model and processes them through special more meaning to data in every step forward.
types of human programming (such as the But the reality is often quite different than
moral, ethical codes, etc.). that. The Knowledge stage, for example, is
● Therefore, Wisdom can be thought of as the practically more than just a next stage of
process by which you can take a decision information.
between the right and wrong, good and bad, ● One of the principal critiques of this DIKW
or any improvement decisions. Pyramid is that it’s a hierarchical process and
● Wisdom is the topmost level in the DIKW misses several important aspects of
pyramid and answers the questions related knowledge. In today's world, where we use
to "Why". various ways to capture and process more
● In the case of our example scenario, one and more unstructured data, sometimes it
example of wisdom gained might be that 70 forces us to bypass a few steps of DIKW.
% of the working professionals visit our ● Though the previous statement is quite true,
however, the result still stays the same, such

14
as what we do with the data warehouse and 1. Measure hemodynamic parameters –
transforming data through big data analytics closely examine cardiovascular function.
into decisions and actions (Wisdom). 2. Evaluate cardiac pump output and volume
status.
UNIT 3 - Information Technology System 3. Recognize patterns (arrhythmia analysis)
Application in Nursing Practice and extract features.
4. Assess vascular system integrity –
Hospital and Critical Care Applications evaluate the patient’s physiologic
Physiologic Monitoring Systems response to stimuli.
Physiological monitors were developed to 5. Continuously assess respiratory gasses
oversee the vital signs of the astronauts. By the (capnography).
1970’s these monitors found their way into the 6. Continuously evaluate glucose levels.
hospital setting. Physiologic systems consist of 5 7. Store waveforms.
basic parts. 8. Automatically transmit selected data to a
1. Sensors computerized patient database.
2. Signal conditioners
3. File - rank and order information. Pulse Oximetry
4. Computer processor - analyze data and ● A critical piece of hemodynamic information
direct reports. involves the availability of oxygen to bodily
5. Evaluation or controlling component - tissues. The standard for measurement of
regulate the equipment or alert the nurse. blood’s oxygen saturation is co-oximetry.
● Pulse oximetry is a noninvasive method of
Microprocessors measuring oxygen saturation that also uses
● Physiologic signals are typically of very small spectrophotometry. Light is emitted through a
amplitude and must be amplified, pulsatile arteriolar bed and then detected by
conditioned, and digitized by the device in photosensor.
preparation for processing by its embedded
microprocessors. Anticipated Problems
● It analyzes information, stores pertinent Largest contributor to alarms in the ICU caused
information in specific places and controls by:
the direction in reporting. 1. Blood pressure cuff
● It also alerts nursing personnel through a 2. Tourniquet
report, an alarm, or a visual notice. 3. Air splint that may cause venous pulsations.
● Monitoring systems also store various data Limits the sensors' ability to distinguish
elements with a timestamp derived from the between arterial or venous blood pressure
monitoring system’s internal clock. while pulse oximetry provides a measure of
● Typically have modern platforms allowing the oxygen delivered to the tissue, mixed venous
selection of various monitoring capabilities to oxygen saturation provides a measure of the
match the needs of a variety of clinical amount of oxygen used by the patient.
settings. 4. Limits the sensors' ability to distinguish
● More specialized monitoring capabilities such between arterial or venous blood pressure
as intracranial pressure or bispectral index while pulse oximetry provides a measure of
monitoring are also in modular format. oxygen delivered to the tissue, mixed venous
● Physiologic monitors are usually built to oxygen saturation provides a measure of the
incorporate both arrhythmia and amount of oxygen used by the patient.
hemodynamic monitoring capabilities.
These problems usually cause nurses to spend
Hemodynamic Monitors more time in troubleshooting and can lead to
Machines under the human machine interface less hours doing the necessary bedside care.
used specifically for the following:

15
To prevent these from happening, it is important ● The organization of a patient’s current and
for nurses to become familiar with the user historical data
guide of the respective machines specifically on ● Allows the free flow of data between the
the trouble shooting part. critical care unit and other departments.
● Provides a rich repository of patient
Some pulse oximeters are more sensitive as information that can be integrated for use in
compared to the others, some need specific outcomes management.
charging times, and some are more durable than ● Each patient’s data can be accessed from
the others. any terminal or workstation. This capability
can extend across units and departments or
Telemetry be restricted to a single unit. CCIS include:
● Hemodynamic monitoring can take place at Patient management service, length of stay,
the bedside or can be conducted from a mortality, readmission rates.
remote location via telemetry. Telemetry
allows for the continuous monitoring of Provider Order Entry
patients usually outside of the ICU. ● Electronic entry and communication of
● Telemetry monitoring is susceptible to patient orders can help clinicians improve
signal loss. Remember that computer-based communication, streamline processes,
hemodynamic monitoring offers the critical facilitate care, and can help clinicians, all
care nurse a wealth of information that does providers in managing quality.
not replace clinical judgment.
Community Health Applications
Arrhythmia Monitor ● Focuses on the health information system of
● Computerized monitoring and analysis of the community, it is centered on the majority
cardiac rhythm have proved reliable and part of the public.
effective in detecting potentially lethal heart ● Emphasizes the prevention of the disease,
rhythms. medical intervention, and public awareness.
● A key functional element is the system’s ● Fulfills a unique role in the community,
ability to detect ventricular fibrillation and promoting and protecting the health of the
respond with an alarm. SYSTEM TYPES: community at the same time maintaining
Detection Surveillance Diagnostic or sustainability and integrity of health data and
Interpretive. information.

What is the Difference? Goal of Community Health Informatics


● In the detection system, the criteria for a ● Effective and timely assessment that involves
normal ECG are programmed into the monitoring and tracking the health status of
computer. populations including identifying and
Interpretive systems search the ECG complex for controlling disease outbreaks and epidemics.
five parameters:
● Location for QRS complex; time from the Primary Focus of Community Health System
beginning to the end of the QRS; comparison ● Preventing, identifying, investigating, and
of amplitude, duration, and rate of QRS eliminating communicable health problems.
complex with all limb leads P and T waves; ● Accessibility of data and information, through
comparison of P and T waves with all limb communication.
leads. ● Educating and empowering individuals to
adopt a healthy lifestyle.
Critical Care Information System (CCIS) ● Facilitate the retrieval of data.
● A system designed to collect, store, organize, ● Effective transformation of data into
retrieve, and manipulate all data related to information.
care of the critically ill patient.

16
Primary Focus of Community Health
Information System
● Effective integration of information to others
disciplined to concretized knowledge and
creates better understanding.
● Creation of computerized patient records,
medical information system
● Central repositions of all data such as data
warehouse.
● Simple Graphical User Interface (GUI) for
nurses and other healthcare providers,
patients, and consumers.
● Preventing, identifying, investigating, and
eliminating communicable health problems.
● Accessibility of data and information, through
communication.
● Educating and empowering individuals to
adopt a healthy lifestyle.
● Facilitate the retrieval of data.
● Effective transformation of data into
information.
● Effective integration of information to others
disciplined to concretized knowledge and
creates better understanding.

17
Computer Based Survey System
Health Statistical Surveys
● Are used to collect quantitative information
about items in a population to establish
certain information from the obtained data.
● Focused on opinions or factual information
depending on its purpose and many surveys
involve administering questions to
individuals.
Advantages:
● Consistent exchange of response
● Disease tracking
● Data and information sharing. Building
strategies
● Early detection and monitoring of disease
and sickness – control of spread of disease.
● National alertness and preparedness –
building strong communication.
● Maintaining strong relation between nurse
and other healthcare provider.
● Continuous coordination of the healthcare
professionals - synchronization of the
decisions.
● Streamlining of the process.
● Effective management of data and
information - optimal operation of hospitals
and clinics.

18
PHILIPPINE INTEGRATED DISEASE by applying appropriate nursing
SURVEILLANCE AND RESPONSE (PIDSR) interventions, such as :
A multi-faceted public health disease surveillance ● Coordinating nursing and other health
system that provides public health officials the services,
capabilities to monitor the occurrence and spread ● Assisting the patient to navigate the
of diseases. healthcare system, and
Goal ● Evaluating patient outcomes.
● Strengthen the surveillance and response The ambulatory care / outpatient
capabilities at each level of the health system ● Covers a wide range of services that can be
by building local capacities and leveraging offered to patients that need medical
strengths and areas of expertise through attention.by integrating the ambulatory care
partnership and coordination. information system in the nursing practice will
Vision really help in making the work easy like the
● To improve the availability and use of processing of data and information and the
surveillance and laboratory data so that billing and charges etc.
public health managers and decision makers
can plan for and carry out more timely There are advantages of the ambulatory care
detection and response to the leading causes information like first, the access of medical
of illness, death, and disability. records of patients to health care providers,
FUNCTIONS: second, the nurses will be able to give quality
Information from PIDSR is expected to be used care and improve workflow, reduce medical
for the following purposes: errors, and lastly the management and monitoring
1. Facilitate collecting, managing, analyzing, of the billing, doctor’s fees, prescriptions and
interpreting, and disseminating health-related many more.
data for diseases designated as nationally
notifiable. One of the most important responsibilities of a
2. Develop and maintain national standards, nurse is to make sure that the patient receives
such as consistent case definitions for the care that he/she needs and with the use of
nationally notifiable diseases applicable this system I believe the quality of care can be
across all the provinces and cities. given.
3. Maintain the official national notifiable
diseases statistics. EMERGENCY PREPAREDNESS AND
4. Provide detailed data to control programs to RESPONSE
facilitate the identification of specific disease ● Same with the objective in the application of
trends. informatics in community health the overall
5. Work with cities and provinces and partners objective is public health. The only difference
to implement and assess prevention and is the focus and level of prevention.
control programs. ● In Community Health, the focus of the use of
informatics is on the promotive and
AMBULATORY CARE SYSTEMS preventive side, while in emergency
● The ambulatory care nurse focuses on preparedness and response focus in the
patient safety and the quality of nursing care mitigation and control of emergencies.
by applying appropriate nursing ● The use of informatics here is much wider
interventions, such as : and critical. The need for information in
● identifying and clarifying patient needs, real-time is very crucial in saving the lives of
● performing procedures, many.
● conducting health education,
● promoting patient advocacy TELEHEALTH
● The ambulatory care nurse focuses on ● According to Mayo Clinic (2020), telehealth is
patient safety and the quality of nursing care the use of digital information and
communication technologies, such as
19
computers and mobile devices, to access To promote safety among the public, telehealth
health care services remotely and manage has been adopted by private and government
your health care. hospitals.
● These may be technologies you use from
home or that your doctor uses to improve or The University of the Philippines – Manila
support health care services. (UPM) is one of the earliest in the Philippines to
Consider for example the ways telehealth could adopt telehealth in 1998.
help you if you have diabetes. You could do some
or all the following: They established the UP National Telehealth
● Use a mobile phone or other device to Center with the commitment to engage people to
upload food logs, medications, dosing, and use available technologies to improve health care
blood sugar levels for review for a nurse who albeit distance barriers.
responds electronically.
● Watch a video on carbohydrate counting and Since its conception, it continues to develop
download an app for it to your phone. telehealth applications derived from people’s own
● Use an app to estimate, based on your diet problem-solving contributions.
and exercise level, how much insulin you
need. Through research-cum-service activities, the
● Use an online patient portal to see your test center helps both patients and health care
results, schedule appointments, request providers maximize widely available and
prescription refills or email your doctor. cost-effective ICT tools to improve delivery of
● Order testing supplies and medications health.
online.
● Get a mobile retinal photo screening at your
doctor’s office rather than scheduling an
appointment with a specialist.
● Get email, text, or phone reminders when
you need a flu shot, foot exam, or other
preventive care.
GOALS
Also called e-health or m-health (mobile health),
include the following:
● Make health care accessible to people who
live in rural or isolated communities.
● Make services more readily available or
convenient for people with limited mobility,
time, or transportation options.
● Provide access to medical specialists.
● Improve communication and coordination of
care among members of a health care team
and a patient.
● Provide support for self-management of
health care.

In the Philippines, we have also adopted


telehealth and have become an increasing
necessity with the emergence of the pandemic
and implementing the community quarantine
measures.

20
4. Work of the Philippine government, unless
MIDTERM there was a prior approval by the appropriate
government agency.
UNIT 5: COPYRIGHT LAW 5. Statutes, rules and regulations, speeches,
Under the Intellectual Property Code of the lectures, sermons, addresses and
Philippines dissertations, pronounced, read or rendered
in courts of justice before administrative
A COPYRIGHT is a collection of all rights enjoyed agencies in deliberative assemblies and in
by the owner of an artistic or literary work. meetings of public character.

What are considered copyrightable works in Is a copyright registration necessary to


the Philippines? protect artistic or literary works?
● Books, No, copyrightable works are protected
● Pamphlets from the moment of their creation.
● Articles and other writings, periodicals and
newspapers Who can apply for a copyright registration?
● Lectures, Sermons The owner of the work his/her assignees
● Addresses, Dissertations, Letters or successors-in-interest has the right to apply.
● Musical compositions
● Choreographic works What are considered owners of copyrightable
● Drawings, Painting works?
● Architecture, Sculpture 1. Author of books/ Co Authors/ Author of each
● Models or design for work of art, part
● Original ornamental designs, 2. If the work is created in the course of
● Illustration maps employment
● Plans, Sketches, Charts ● Employee is the owner – not part of
● Works relative to geography, topography, employees regular duties even if he
architecture or science, drawings or plastic uses time, facilities and materials of the
works of a scientific or technical character, employer.
photographic works ● Employer is the owner – if the work
● Lantern slides created is the result of the performance
● Audio visual works cinematography of employees regularly assigned duties ,
● Visual recordings unless otherwise agreed upon.
● Pictorial illustrations 3. If the work was commissioned – one who
● Advertisements and computer programs commissioned jointly owns – but the
copyright of the work remains with the
What works are not protected by copyright author/creator.
under Philippine Law?
1. Idea, procedure, system method or 4. Audio visual work
operation, concept, principle, discovery or ● copyright belongs to the producer,
mere data as such, even if they are author of scenario, music composer, film
expressed, explained, illustrated and director, author of work adopted.
embodied in a work. ● However, unless otherwise agreed upon
2. News of the day and other miscellaneous among the creators , the producer has
facts having the character of mere items of the right to exercise copyright to the
press information. extent required for the exhibition of the
3. Official text of a legislative, administrative or work in any manner, except for the right
legal nature, as well as any official to collect licensing fees for the
translation. performance of musical compositions,
with or without words, which are
incorporated into the work.
21
5. Letters
● copyright belongs to the writer subject to The use of intellectual property bears a social
the ff: function
a. Letters and private – The State shall promote the diffusion of
communications in writing are knowledge and information for the promotion
owned by the person to whom they of national development and progress and the
are addressed and delivered common good.
without the consent of the writer or – It is also the policy of the state to streamline
his heirs. administrative procedures of registering
b. However, the court may authorize patents, trademarks and copyright, to
the publication or dissemination if liberalize the registration on the transfer of
the public goods or the interest of technology, and to enhance the enforcement
justice so requires. of intellectual property rights in the
Philippines.
UNIT 5: INTELLECTUAL PROPERTY LAW
– Refers to creations of the mind, such as Effect on international conventions and on
inventions, literary and artistic works, designs principle of reciprocity
and symbols, names and images used in – Any person who is national or who is
commerce. domiciled or has a real effective industrial
– Protected in law by for example: patents, establishment in a country which is a party
copyright and trademarks, which enable to any convention, treaty or agreement
people to earn recognition or financial benefit relating to intellectual property rights or the
from that they invent or create. repression of unfair competition, to which the
– By striking the right balance between the Philippines is also a party, or extends
interest of innovators and the wider public reciprocal rights to nationals of the Philippines
interest, the IP system aims to foster an by law, shall be entitled to benefits to the
environment in which creativity and extent necessary to give effect to any
innovation can flourish. provision of such convention, treaty or
reciprocal law, in addition to the rights to
Republic Act 8293 which any owner of an intellectual property
An Act Prescribing the Intellectual Property Coder right is otherwise entitled by this act.
and Establishing the Intellectual Property Office,
Providing for Its Powers and Functions, and for Parts of the law
other purposes) otherwise known as the PARTI – The Intellectual Property office
Intellectual Property Code of The Philippines. PART II – The law on Patents
PART III – The law on trademarks, Service Marks
State Policy declaration: and Trade Names
– The state recognizes that an effective PART IV – The law on Copyright
intellectual and industrial property system is: PART V – Final Provisions
⮚ Vital to the development of domestic and
creative activity, The intellectual property rights under the
⮚ Facilitates transfer of technology, intellectual property code are as follows:
⮚ Attracts foreign investments, and 1. Copyright and related rights
ensures market access for our products. 2. Trademarks and service marks
⮚ It shall protect and secure the exclusive 3. Geographic indications
rights of scientists, inventors, artists and 4. Industrial Designs
other gifted citizens to their intellectual 5. Patents
property and creations, particularly when 6. Layout designs of integrated circuits and
beneficial to the people, for such periods 7. Protection of undisclosed information
as provided in this act.
Government agencies
22
The agency of the government in charge of the
implementations is the Intellectual Property office
which replaced the Bureau of patents, trademarks
and technology transfer.
Divided in 6 Bureaus:
1. Bureau of patents
2. Bureau of trademarks
3. Bureau of Legal affairs
4. Documentation , information and
technology transfer bureau
5. Management information system and EDP
Bureau
6. Administrative, financial and personnel
services bureau

UNIT 5: DATA PRIVACY ACT


“Do not COLLECT if you cannot PROTECT.”

Who stores data about you?


“In the future, job interviews will be done by
● Social Media Company: Facebook, Youtube
machines. And they won’t even have to ask you a
● Search Engine: Google
single question. They’ll just search your social
● Medical Records
media history.” By Dondi Mapa – Former NPC
● National Government Agencies
Deputy Commissioner
● Online Shopping Applications/ Websites
● Banks
PRIVACY vs CONFIDENTIALITY

Privacy is the state when an individual is free


from public interruption and intrusion.
● Derived from the word “private” which
means the role of the public is limited
● Refers to a condition where a person is apart
from public attention and observation
● It is the right of every individual to be left
alone in his personal matters because
everybody has a personal life.
● Can draw boundaries on the access of
information from the use of others (Surbhi,
S.,2018)
● It is a human tendency to hide certain facts
about yourself or else people will use them
against you.
● Is a matter of choice of an individual
Example: Internet Privacy (limit access of
your personal stuff such as your pictures
The amount of data collected in the internet in 60
photos , videos etc)
SECONDS

Confidentiality
● State when it is intended or expected from
someone to keep the information secret

23
● Extracted from the word “confidence”

which means “trust”. ● Everyone is disallowed from
● When information is entrusted to someone interfering in the personal
, it will be kept secret from the reach of matters of a person
unauthorized people until the parties ● Is at the voluntary; the
agree to uncover the information. choice of a person
● In medical, legal and other professions, it ● Is a right
is common that the information shared CONFIDEN ● Situation when an
between client and the solicitor or doctor TIALITY information is kept secret
and patient will not be told to the third from the reach of other
party. person
● In the military only authorized officers are ● Talks about information
● Protects the information
allowed to access confidential information.
from the reach of
Example: Confidentiality in bank details unauthorized persons
like ATM pin or user ID or password of ● Some specified and
any social networking site. trustworthy people are
allowed to have access to
information
MAJOR DIFFERENCES ● Compulsory if the
relationship between parties
PRIVACY ● Person is free from public
is fiduciary
interference
● Is an agreement

● Talk about a person.

● Restricts the public from
accessing the personal
details of a person.

Conclusion: Confidentiality is an advanced version of privacy.

COMPARISON CHART
Basis for Comparison PRIVACY CONFIDENTIALITY

Meaning The state of being Refers to the situation when it is expected from
secluded is known as someone that he will not divulge the information
privacy to any other person

What is it? It is the right to be let It is an agreement between the persons standing
alone in fiduciary to maintain the secrecy of sensitive
information and documents

Concept Limits the access of the Prevents information and documents from
public unauthorized access

Applies to Individual Information

Obligatory No, it is the personal Yes, when the information is professional and
choice of an individual legal.

Disallowed Everyone is disallowed Only unauthorized persons are disallowed from


from involving the using the information
personal affairs of an
individual

24
The Importance of Preserving Anonymity, able to trust data for patient care and
Confidentiality and Privacy of Health decision making
Information 5. To prevent unintended consequences
1. To ensure safe and compassionate nursing detrimental to health research and public
practice that includes an understanding of health practice
the ethico-moral and legal boundaries within 6. To ensure availability of accurate health
which nurses must function vis-à-vis information when needed by the patient
protectioning the patient’s rights to: respect 7. To help maintain a professional attitude in
of human dignity, anonymity, privacy, and health care settings.
confidentiality of the health information. 8. To prevent legal suits – thus avoid negative
repercussions on the health care institutions
Nurses must understand the ethico-moral and reputation
legal implications of nursing to be able to
determine what is good or valuable for all people What is the Data Privacy Act of 2012?
and to judge what is right and wrong. The nurse SECTION 1. Short Title. – This Act shall be
must understand the law to protect themselves known as the “Data Privacy Act of 2012”.
from liability and to protect clients rights.
Republic Act 10173, the Data Privacy Act of
As technology has expanded the role of the 2012
nurse, the ethical dilemmas associated with the AN ACT PROTECTING INDIVIDUAL PERSONAL
client care and health information have increased INFORMATION IN INFORMATION AND
and often become legal issues as well. Nurses COMMUNICATIONS SYSTEMS IN THE
familiarity with ethico-moral and legal implications GOVERNMENT AND THE PRIVATE SECTOR,
of nursing, enhances their ability to be client CREATING FOR THIS PURPOSE A NATIONAL
advocates. PRIVACY COMMISSION, AND FOR OTHER
PURPOSES
2. To ensure protection of patients from identity
theft, and other improper use of patient The National Privacy Commission (NPC) is a
information, specifically for financial gain. body that is mandated to administer and
implement this law. The functions of the NPC
3. To maintain the patient's trust. They will include:
prevent hiding certain facts about ● rule-making,
themselves. “During the present times of ● advisory,
crisis caused by COVID 19, the very ● public education,
devastating effects of patients not being ● compliance and monitoring,
forthright with their history of travels, ● investigations and complaints,
being exposed to PUI’s, PUM’s. Having ● and enforcement.
signs and symptoms of ULAN (Ubong
walang plema, lagnat, Nahihirapan sa SCOPE OF THE DPA
paghinga) had caused the untimely, The DPA applies to the processing of all types of
heartbreaking deaths of doctors, nurses, personal information and to any natural and
other healthcare workers and frontliners.” juridical person, in the country and even abroad,
subject to certain qualifications.
REMEMBER: Open and honest communication Sec. 4, DPA
between the patient and healthcare workers is of
utmost importance for therapeutic relationship Structure of RA 10173 - The Data Privacy Act
● Sections 1–6. Definitions and General
4. The integrity and availability of the electronic Provisions
health information will be essential for ● Sections 7–10. National Privacy
physicians and the entire clinical team to be Commission
25
● Sections 11–21. Rights of Data Subjects,
and Obligations of Personal Information Registration Requirements: All personal data
Controllers and Processors processing systems (DPS) operating in the
● Section 22–24. Provisions Specific to Philippines that involve Personal Data concerning
Government at least 1,000 individuals/ personal records must
● Section 25–37. Penalties be registered with NPC.

PERSONAS DEFINED IN THE LAW KEY ROLES IN THE DATA PRIVACY ACT
Data Subject Data Subjects
● Individual whose personal information is ● Refers to an individual whose, sensitive
being processed. personal, or privileged information is
Personal Information Controller processed personal
● Person or organization who controls Personal Information Controller (PIC)
collection, holding, processing, or use of ● Controls the processing of personal data, or
personal information. instructs another to process personal data on
● Including those who instruct others to do its behalf.
so. Personal Information Processor (PIP)
Personal Information Processor ● Organization or individual whom a personal
● Natural or judicial person to whom a information controller may outsource or
personal information controller may instruct the processing of personal data
outsource the processing of personal data pertaining to a data subject
pertaining to a data subject. Data Protection Officer (DPO)
● Responsible for the overall management of
The National Privacy Commission is an compliance to DPA
independent body mandated to administer and National Privacy Commission
implement the Data Privacy Act, and to monitor ● Independent body mandated to administer
and ensure compliance of the country with and implement the DPA of 2012, and to
international standards set for personal data monitor and ensure compliance of the
protection. country with international standards set for
personal data protection
Timeline of DPA Law and other issuances
passed to Organization’s Compliance

2012 Data Privacy Act (DPA) Passed into


law

March National Privacy Commission (NPC)


2016 was formed

August Implementing rules and Regulations


2016 (IRRs) was published

Sept. 9, IRR came into effect


2016

Sept. 9, 12 mos after, Deadline: DPO


2017 Registration Rights of the Data Subject
● Right to be informed -- IRR, Section 34.a
March Deadline: (ANNUAL) Registration of ● Right to object - IRR, Section 34.b
8, 2018 DPS
● Right to access - IRR, Section 34.c
June 30, Deadline: (ANNUAL) Security ● Right to data portability - IRR, Section 36
2018 Incident Reports
26
● Right to correct (rectification) - IRR, Section ● Right to erasure or blocking - IRR, Section
34.d 34.e
● Right to file a complaint - IRR, Section 34.a.2 ● Transmissibility of Rights - IRR, Section 35
● Right to damages - IRR, Section 34.f
CLASSIFICATION OF PERSONALLY IDENTIFIABLE INFORMATION
PERSONAL SENSITIVE PERSONAL PRIVILEGED INFORMATION
INFORMATION INFORMATION (List based on IRR) (List based on Rules of Court

Name Race, Color and Ethnic origin Data received within the context
of a protected relationship –
Address Marital status husband and wife
Place of work Age

Telephone Number Health Data received within the context


of a protected relationship –
Gender Philosophical affiliation attorney and client

Location of an Religious and Philosophical affiliation Data received within the context
individual at a of a protected relationship –
particular time priest and penitent
IP Address Education

Birthdate and Genetics and sexual life


Birthplace
Country of citizenship Proceeding for any offense committed or Data received within the context
alleged to have been committed, the of a protected relationship –
Payroll and benefits disposal of such proceedings, the doctor and patient
information sentence of any court in such
Contact information proceedings

Social Security Number

License or its denials, suspension or


revocation
Tax returns

Other personal information issued by


government agencies
Bank and credit/debit card numbers

Websites visited

Materials downloaded

Any other information reflecting


preferences and behaviors of an
individual
Grievance information

Discipline information

27
Leave of absence reason

28
PERSONAL DATA LIFECYCLE
● Acquisition 6. Cedula in Malls – Disposal Policy/Improper
● Storage Disposal
● USE 7. Security issues in buildings – logbook
● Transfer 8. Use of recycled papers – Disposal Policy /
● Destruction Access due to negligence
9. Hard drives sold online – Disposal Policy
Key considerations when listing your personal 10. Use of CCTV – Privacy Issues
data: 11. Use of USB/CD/Personal laptop –
● What personal data do you collect? Encryption issue
● In what form and through which channels?
● For what purpose you collect personal data Access Control and Security Policy
● How is it used? 1. Personal Records stolen from home of an
● Who is this data shared with internally and employee – Security
externally? 2. Viewing of Student Records in Public –
● Who is authorized to access this data? Physical Security
● Where do you keep your data? 3. Raffle stubs – Privacy Notice/ Storage and
● How long do you keep your data? Disposal Policy
● How do you dispose of this data? 4. Universities and Colleges websites with weak
authentication
Retention/Disposal should be based on: 5. Photocopiers re-sold without wiping the hard
1. Law drives
2. Industry Best Practice 6. Password hacked/revealed –
3. Business Needs 7. Accidentally sent an email attachment –
Unauthorized Disclosure
EXAMPLES OF POTENTIAL BREACHES AND
SECURITY INCIDENTS INVOLVING Other Violations/ Data Privacy Act Principles
PERSONAL INFORMATION 1. No Data Sharing Agreement (DSA)
2. No Privacy Notice
Potential Breaches 3. No Subcontracting Agreement
1. Bank – Consent form 4. No Breach Drill
2. Hospital and School Records – Storage 5. Profiling of customers of malls – Targeted
and Disposal Policy Marketing
3. Student transferred – Without Consent 6. Unjustifiable collection of personal data of a
4. Clinical record of a student to disclose school – Principle of Proportionality
with her parents – Consent
5. List of top students/passers – Consent

29
Potential Penalties listed in the Data Privacy Act

DPA Punishable Act For Personal For Sensitive Fine (Pesos)


Section Information Personal Information

JAIL TERM
25 Unauthorized 1-3 years 3-6 years 500 k – 4 million
processing
26 Access due to 1-3 years 3-6 years 500 k – 4 million
negligence
27 Improper 6 months – 2 3-6 years 100 k – 1 million
disposal years
28 Unauthorized 18 months – 5 2-7 years 500 k – 2 million
purposes years
29 Intentional 1-3 years 500 k – 2 million
breach
30 Concealment of 18 months – 5 years 500 k – 1 million
breach
31 Malicious 18 month – 5 years 500 k – 1 million
disclosure
32 Unauthorized 1-3 years 3-5 years 500 k – 2 million
disclosure
33 Combination of 1-3 years 1 million – 5 million
acts

“In the event of a data breach, we will not ask you how many millions you’ve spent on your hardware and
IT experts. We will, instead, ask whether you’ve implemented NPC’s five data privacy guidelines.” – Privacy
Commissioner and Chairman, Raymund E. Liboro

Adherence to Data Privacy Principles


● Transparency Legitimate Purpose
● Legitimate Purpose ● The processing of information shall be
● Proportionality compatible with a declared and specified
purpose, which must not be contrary to law,
Data Privacy Principles in the Philippines morals, or public policy
Transparency – “the CONSENT regime”
● A data subject must be aware of the nature, Proportionality
purpose, and extent of the processing of his ● The processing of information shall be
or her personal data, including the risks and adequate, relevant, suitable, necessary, and
safeguards involved, the identity of the not excessive in relation to a declared and
personal information controller, his or her specified purpose. Personal data shall be
rights as a data subject, and how these can processed only if the purpose of the
be exercised. Any information and processing could not reasonably be fulfilled
communication relating to the processing of by other means.
personal data should be easy to access and
understand, using clear and plain language. Avoid this mentality:
“just in case we need it”
30
“this is what we always do” ● signature
● opt-in box/clicking an icon
RECOMMENDATION: Holding Data and ● sending a confirmation email
Keeping it Up-to-Date ● oral confirmation(recorded)
Carry out an information audit at least annually.
● Write a letter at the start of each school Opt-in silence, pre-ticked boxes or inactivity does
year asking parents and students to check not constitute consent
that their details are correct. This also
helps prevent emergency risks, e.g. if an “Be prepared to accept that notifying a personal
old address or phone number is on record. data breach might open the door for further
regulatory investigations”. By Dondi Mapa –
● Check that ‘live’ files are accurate and up
Former NPC Deputy Commissioner
to date.
● Any time you become aware that Recommended Security Measures
information needs amending, do so 1. Shredding all confidential waste.
immediately 2. Using strong passwords.
● Any personal data that is out of date or no 3. Installing a firewall and virus checker on your
longer needed should be ‘destroyed’. This computers.
may involve shredding documents or 4. Encrypting any personal information held
deleting computer files securely so that electronically.
they cannot be retrieved. 5. Disabling any ‘auto-complete’ settings.
● Organizations must follow the disposal of 6. Holding telephone calls in private areas.
records schedule. This schedule states 7. Checking the security of storage systems.
how long certain types of personal data 8. Keeping devices under lock and key when
can be held for until it must be destroyed. not in use.
Some stipulations are legal obligations 9. Not leaving papers and devices lying around.
while others are best practice. 10. Lock rooms containing confidential
You are violating the Data Privacy Act if you information when not in use.
keep any data for longer than it is needed. 11. Make sure employees don’t write their
passwords down.
CONSENT of the data subject means: "any freely 12. Use swipe cards or keypads to access the
given, specific, informed and unambiguous office.
indication of the data subject's wishes by which 13. Use CCTV cameras to monitor your office
he or she, by a statement or by a clear affirmative space.
action, signifies agreement to the processing of 14. Shield keyboards when inputting passwords.
personal data relating to him or her". 15. Install an alarm system.
16. Hide valuable equipment from view when not
Consent of Data Subject in the office.
● Express and Specific 17. Assign a limited number of trustworthy
● Time-bound employees as key
● Documented
● Specifies the purpose TOP FIVE KEY AREAS OF DATA PRIVACY
● Confirms data sharing ACT
1. Client Consent
The data subject agrees to the collection and 2. Rights of the Data Subjects
processing of personal information 3. Breach Management
● Freely given 4. Profiling
● Specific 5. Compliance
● Informed indication of will
Recommendation in Preparation for
Evidenced by written, electronic or recorded Compliance to the Data Privacy Act of 2012
means: ● Awareness
31
● Information you hold time that it takes nurses to research medication
● Communicating privacy information information.
● Individuals’ rights
● Subject access requests The integration of PDAs into nursing practice
● Lawful basis for processing personal data poses individual, technical and financial
● Consent challenges, as well as patient confidentiality and
● Data breaches infection control concerns.
● Data Protection by Design and Data
Protection Impact Assessments However, as nurses and organizations begin to
● Data Protection Officer recognize the potential for PDAs, and as more
● International nursing-focused software and resources continue
to be developed, PDAs truly have the potential to
Nurse’s Guidelines to avoid Data Breach revolutionize the way that nurses provide and
● Never breach a patient’s information (SPI) record care (Predhomme, 2009).
● If you are unsure about disclosing a
patient’s information, seek guidance from
the Hospital’s Data Protection Officer PERSONAL DIGITAL ASSISTANT
(DPO) The era of PDAs went for a while between 1992
● Know by heart your hospital’s Privacy to 2007 (Edwards, 2018), PDA applications have
Manual without fail. been slowly being incorporated to today’s
● Never seek information about a patient for smartphones and other mobile devices such as
whom you are not providing care. tablets. Being more compact and losing the stylus
● Always maintain your patient’s information for it to be a practical touch screen device,
confidential. smartphones and tablets have definitely replaced
the PDA.
“Compliance to Data Privacy Act is not a one-shot
initiative. It is a discipline and culture that must EMAILS
be embedded on a continuous basis within the Emails or electronic mails are ways to send
organization.” CULTURE OF PRIVACY in the messages between one user to another or to
PHILIPPINES multiple users. Most of the companies today
including hospitals provide work-related email
NURSING INFORMATION SYSTEM accounts to their employees for efficient
communication within and outside the institution.
Internet Applications Requests and follow-ups are made faster and
PERSONAL DIGITAL ASSISTANT (PDA) & documented as it is time-stamped, clutter-free,
WIRELESS DEVICES and traceable in terms of message history.
Pocket-sized computers that can access the
internet, sending and receiving data, and BOOKMARKS
storing textbooks worth of information. These Just as it is used in books for easy retrieval of the
tools have the potential to help nurses increase page you are reading or for common reference, it
the quality of care that they provide in the also has the same function in the context of the
hospital setting. internet browsers and other reading applications
such as Kindle and iBook to name a few. In the
PDAs have been shown to increase practice of nursing, nurses utilize bookmarks with
evidence-based practice and decrease its intended purpose to quickly retrieve
medication errors by making relevant information on drugs, medical diagnosis,
information available right at the point-of-care. procedures, and other necessary information
in planning and implementing care to patients.
PDAs have also been shown to save nurses’ time
by increasing the efficiency and accuracy of WIRELESS PHONES (MOBILE DEVICES)
electronic patient charting, and by decreasing the
32
Mobile devices as discussed previously have TWO-WAY or MULTI-PERSON VIDEO
replaced the function of PDAs. With its TELECONFERENCING
multi-function capabilities as a smart phone, Video conferencing is a visual communication
health care professionals can access information session between two or more users regardless of
quickly and communicate. their location, featuring audio and video content
transmission in real time. This platform became
Nurses communicate with multiple members of very popular in the rise of COVID-19 pandemic
the health member team, often while maintaining because social and physical distancing was
heavy patient loads. Optimal communication instituted as part of the health and safety
procedures can help nurses use their time more protocols.
efficiently to improve patient safety and outcomes.
(VanDusen, 2017). For effective video conferencing, business
companies or organizations need to set up
Healthcare personnel are often in different profiling conferencing software and hardware
locations when collaboration is needed. solutions for rooms, PCs, mobile devices, and
Maintaining safe patient care may require fast, browsers.
accurate communication among mobile staff.
Delays in communication have been identified by Video conferencing consists of an endpoint
The Joint Commission as significant contributors (ranging from a simple PC to a telepresence
to adverse events. The Joint Commission has system), video conferencing server (to run group
made communication between healthcare video conferencing), peripherals (webcam,
workers a patient safety goal in an effort to reduce microphone, speakerphone, headset, etc.) and
medical errors (VanDusen, 2017). software infrastructure (video processing, content
transmission, integrations).
Nurses use many different methods of electronic
communication in the clinical setting to coordinate Video conferencing is modern high-tech
patient care. This includes e-mail, smartphone communication tools for increasing efficiency for
application, and two-way or group texting options. businesses, optimizing and accelerating
The Joint Commission standards have been decision-making processes, and cutting customer
redefined, and they now allow texting of orders and company staff travel costs.
and patient information, if the clinician is
compliant with a secure texting platform and There are a lot of video teleconferencing
maintains safety measures to ensure order applications that people in various sectors utilize
accuracy. Texting lets members of the healthcare to continue their operations such as Zoom,
team communicate and collaborate effectively Microsoft Teams (between office 365 Users)
and among several disciplines. These methods Google Meet, and Facebook Messenger Rooms
reduce response time in emergencies and to name a few.
increase the frequency of provider responses to
nurses (VanDusen, 2017). Each platform presents various features and
prices from free to premium subscriptions. As we
Confidentiality is also a concern. Improved draw near the new normal, this video
efficiency could be offset by communication conferencing platform will remain to be used in
difficulties and loss of reliability and confidentiality. various industries.
Several studies have raised doubts about
information security, inadequate technical skills,
and poor staff interrelations. Nurses may perceive
a worsening of interprofessional relationships FACETIME
due to an overreliance on text messaging and a For more personal communication especially
subsequent lack of verbal communication during this time of pandemic, which resulted in
(VanDusen, 2017). feelings of anxieties between patients and their
families, they found the significance of video
33
calling mobile applications such as Apple’s 3. Organization Promotion
Facetime, and Facebook Messenger to 4. Patient Care
communicate safely yet efficiently. Based on the 5. Patient Education
study by Padala et al (2020) interaction with 6. Public Health
family members using FaceTime improved
behavioral problems in a patient with Alzheimer’s PATIENT CARE
dementia during the COVID-19 pandemic. Although there has been a reluctance among
HCPs to use social media for direct patient care,
Use of such applications need to be studied both this practice is slowly being accepted by clinicians
and healthcare facilities. For example, Georgia
for clinical and research care to be prepared for
Health Sciences University has provided patients
future pandemics. with access to a platform called Web View, which
allows the patient to reach their doctors to ask
As nurses caring for these patients, it is very questions or request prescription refills (Ventola,
important that we support and value the use of 2014).
such applications to aid in the need for
communication of our patients. VENTOLA (2014)
Recent studies have found that physicians have
TEXT MESSAGING/ SHORT MESSAGING begun to develop an interest in interacting with
SYSTEM patients online. Some physicians are using social
Text messaging has already been normal to us for media, including Twitter and Facebook, to
communicating faster and clearer. Text enhance communication with patients.
messaging is the act of sending short, Approximately 60% of physicians were found to
alphanumeric communications between favor interacting with patients through social
cellphones, pagers or other hand-held devices, as media for the purpose of providing patient
implemented by a wireless carrier. education and health monitoring, and for
encouraging behavioral changes and drug
Mobile Phones, nurses and other healthcare adherence, with the hope that these efforts will
professionals are already using text messaging lead to “better education, increased
as a form of communication and providing orders compliance, and better outcomes.” However,
for treatment and care for the patient. other studies have shown that considerable
resistance still exists to using social media to
SOCIAL MEDIA interact with patients. In a survey of
Social Media like Facebook, Twitter, and approximately 480 practicing and student
Instagram have been a norm to all of us. Mostly physicians, 68% felt it was ethically problematic to
this is our personal space in the online world, interact with patients on social networks for either
where we can express our thoughts, appreciation, personal or professional reasons.
achievements, sorrow, and many more. The way
we share our information depends on how we PUBLIC HEALTH
choose to share it. Either by the public or anyone According to Ventola (2014) social media have
who is registered user or visitor of Facebook can created vast global networks that can quickly
access the content; or by selected audiences spread information and mobilize large numbers of
such as users who are on the friends list or more people to facilitate greater progress toward public
precise list such as those that the user chose to health goals. Social media can therefore be a
share it with. In the healthcare setting, we take a powerful tool for public education and
look at how social media can be used to benefit advocacy regarding public health issues.
the practice. Some states ‘public health departments are using
Twitter and other social media for these purposes.
Uses of Social Media according to Ventola
(2014): Other public health organizations use keyword
1. Professional Networking content from Twitter and other social networks, in
2. Professional Education combination with location-tracking technologies,
34
to respond rapidly to disasters and to monitor the ● These communication techniques can be
health and welfare of populations. The CDC found on TeamSTEPPS by the Agency for
maintains an active presence on Twitter and Healthcare Research and Quality (AHRQ).
Facebook to track tweets that might indicate a flu ● According to AHRQ (2013) individuals can
outbreak and to share updates about such learn four primary trainable teamwork
incidents. The CDC has also used social media to skills. These are:
locate and monitor sources and suspected cases 1. Leadership
of Legionnaires disease. 2. Communication
3. Situation monitoring
Dangers of Social Media in the Health Care 4. Mutual support
Practice according to Ventola (2014): ● If a team has tools and strategies it can
1. Poor Quality of Information leverage to build a fundamental level of
2. Damage to Professional Image competency in each of those skills, research
3. Breaches of Patient Privacy has shown that the team can enhance three
4. Violation of Professional-Patient Boundary types of teamwork outcomes:
5. Licensing Issues and other Legal Issues 1. Performance
2. Knowledge
WEB 2.0 3. Attitudes
● Term devised to differentiate the ● Effective teamwork is important not only
post-dotcom bubble Word Wide Web with its for an organization to succeed but also for
emphasis on social networking, content its people’s wellbeing.
generated by users, and cloud computing ● For example, if every member of the team
from that which came before. has basic competency in situation
● The 2.0 appellation is used in analogy with monitoring and communication, it is
common computer software naming compulsory upon them to build shared
conventions to indicate a new, improved mental models more effectively.
version. ● Improved outcomes bring greater
● In simple terms, Web 1.0 involves websites proficiency (improved teamwork skills) and
that are not interactive or is not based on a desire to be a part of the team
contents being posted or delivered by user (attitudes).
● Web 2.0 are websites that are interactive ● Informatics systems have a key role in
such as social media websites. Blogs and ensuring that communication between the
wikis are also samples of Web 2.0. healthcare team will be made possible
● The use of Web 2.0 for the benefit of the whether from simple mobile device
healthcare practice has wide variations from functions to mobile applications.
patient care schedules e-consultation such
as in private hospitals where you can Essential Communication Techniques Under
consult with a physician virtually, patient TeamSTEPPS according to AHRQ (2013)
information on diagnostic tests, its
preparation, what to expect, and other SBAR (Situation, Background, Assessment,
pertinent details can be the variation of Recommendation)
use. A technique for communicating critical information
that requires immediate attention and action
RELEVANCE OF INFORMATICS SYSTEM TO concerning a patient’s condition.
COMMUNICATION IN NURSING
● Patient safety is of utmost priority among the Situation - What is going on with the patient?
healthcare team. “I am calling about Mrs. Joseph in room 251.
● We should practice effective communication Chief complaint is shortness of breath of new
techniques to reach this goal. onset.”

35
Background - What is the clinical background or
context?
“Patient is a 62-year-old female post-op day one HANDOFF
from abdominal surgery. No prior history of ● Examples of transitions in care include shift
cardiac or lung changes; transfer of responsibility between
Disease.” and among nursing assistants, nurses nurse
practitioners, physician assistants, and
Assessment - What do I think the problem is? physician; and patient transfers.
“Breath sounds are decreased on the right side ● Strategy designed to enhance information
with acknowledgement of pain. Would like to exchange during transitions in care.
rule-out pneumothorax.”

Recommendation and Request - What would I


do to correct it? “I PASS THE BATON”
“I strongly feel that the patient should be ● I – Introduction: Introduce yourself and your
assessed now. Can you come to room 251 now?” role/job (including patient).
● P – Patient Name, identifiers, age, sex,
CALL-OUT location.
Strategy used to communicate important or ● A – Assessment Present chief complaint,
critical information. vital signs, symptoms,and diagnosis.
● Informs all team members simultaneously ● S – Situation
during emergent situations. Current status/circumstances including code
● Helps team members anticipate next steps. status, level of (un) certainty, recent changes, and
● Important to direct responsibility to a specific response to treatment.
individual responsible for carrying out the ● S – Safety Critical lab values/reports,
task. socioeconomic factors, allergies, and alerts,
(falls, isolation, etc.)
Example during an incoming trauma:
Leader: “Airway status?” THE
Resident: “Airway clear” ● B – Background Comorbidities, previous
Leader: “Breath sounds?” episodes, current medications, and family
Resident: “Breath sounds decreased on right” history.
Leader: “Blood pressure?” ● A – Actions Explain what actions were taken
Nurse: “BP is 96/62” or are required. Provide rationale.
● T – Timing Level of urgency and explicit
CHECK-BACK timing and prioritization of actions.
Using closed-loop communication to ensure that ● O – Ownership Identify who is responsible
information conveyed by the sender is understood (person/team)including patient/family
by the receiver as intended. members.
● N – Next
The steps include the following: ○ What will happen next?
1. Sender initiates the message. ○ Anticipated changes?
2. Receiver accepts the message and provides ○ What is the plan?
feedback. ○ Are there contingency plans?
3. Sender double-checks to ensure that
message was received.

Example:
Doctor: “give 25 mg Benadryl IV push”
Nurse: “25 mg Benadryl IV push”
Doctor: “That’s correct”
36
Unit 7: NURSE INFORMATICIST ROLE during technology-related discussions and
● Technologies optimized for the nursing debates.
process organize and prioritize patient care
data against a complex backdrop of quality Two Key Areas Of Expertise
and patient safety. Nurse executives and NIs involved in technology
● Nurse executives' responsibility to evaluate, decision-making need to leverage two specific
select, and deploy these advanced type of IT expertise when they evaluate, select,
technologies requires one of two things: and implement clinical information systems:
1) Either a deep personal and 1. Process mapping – delineates the actual
nursing-centric knowledge of steps of clinical practice as they occur during
technology or patient care,
2) Access to that knowledge, which is 2. Workflow design – spans the mechanical
resident in a technology expert. arrangement of information, forms, and
triggers to document nursing practice.
● Considering the organizational and
interdisciplinary demands on nurse The success of every HIT implementation hinges
executives, a direct reporting structure to the on having a clear understanding of process
technology expert offers the most efficient mapping and workflow design, as well as the
and effective pathway to this highly ability to chart these activities in a format
specialized knowledge. understandable by computers.
● Often, this direct reporting relationship with ● Vendor-resident engineers lack the
the technology-infused individual leads to a site-specific and nursing practice-specific
Nurse Informaticist (NI). knowledge required to add the context of the
● While some confusion over the preferred lived experience to the workflow creation
background of the graduate-prepared NI process.
exists, nursing experts agree that effective ● While evidence in the standardization of
Nis command highly specialized processes and practices is a universal
knowledge from three distinct disciplines: application goal, site-specific modifications
1) clinical nursing are needed to have the software accepted
2) information technology, and and used by nurses delivering patient care.
3) Research. ● From a nursing perspective, leaving this
critical foundational work to engineers and
● NIs use a rich, interdisciplinary technologists who lack the hands-on
perspective to analyze patient care and experience of delivering patient care at the
outcome data, creating new knowledge that bed-side is pure folly.
advances the clinical practice of nursing. ● Delegating these two key foundational
● As a trusted advisor to the nurse activities to non-nurses resembles the
executive, the NI serves a "translator" of potential disaster created by allowing
technology capabilities, options, and individual motorists to build their own
alternatives to the nurse executive, who roads—with no regard for the needs of their
looks to the NI to align technologies and fellow motorists and no knowledge of
systems under consideration with construction, traffic flow, volume, or local
organizational objectives. weather conditions.
● The nurse executive must be able to
converse, debate, and champion specific Informatics Competencies and Roles
technologies and clinical information systems ● Very few of today's nurses have worked in
personally. only one role or even one specialty of nursing
● They are the only ones at the executive throughout their careers, and this will likely
decision-making table with the expertise, hold true for coming generations of nurses.
knowledge, or perspective to advance the ● The need for informatics competencies exists
requirements and needs of patient care in all nursing roles and specialties.
37
● The National Council of State Boards of curricula focus on gaining specific knowledge
Nursing (NCSBN) has developed and is and skills in nursing and healthcare
studying a Transition to Practice (TTP) informatics, thereby supporting
nursing preceptor model that includes "five evidence-based practice and the
transition units consisting of “: improvement of healthcare outcomes.
1. communication and teamwork, ● AACN's Essentials of Doctoral Education for
2. patient-centered care Advanced Nursing Practice lists
3. evidence-based practice informatics-based competencies in
4. quality improvement and "Essentials III: Clinical Scholarship and
5. Informatics Analytical Methods for Evidence-Based
● The model incorporates many key aspects Practice."
from the Institute of Medicine's report on ● Although only the Doctor of Nursing Practice
The Future of Nursing: Leading Change, (DNP) is specifically addressed by the
Advancing Health related to competencies AACN, this does not imply that informatics
for all nurses, and is an inclusive model, education is not important in PhD programs.
which would take place in all health care ● In many PhD programs, computer science
settings that hire newly graduated nurses and biomedical informatics are required
and for all educational levels of nurses, courses. However, because the DNP is
including practical nurse, associate degree, considered a "practice doctorate and the
diploma, baccalaureate and other entry-level PhD a "nursing
graduates” research doctorate," the emphasis on
● Because informatics and technology are now informatics and clinical practice impact is
integral tools used in all aspects of nursing reduced, though these areas are not
practice, from entry-level to advanced considered unimportant .
practice, it is strongly recommended that the ● Thus, it is strongly recommended that PhD
state boards of nursing require that basic curriculum writers incorporate courses that
informatics competencies be incorporated examine the tenets of nursing informatics
into all nursing program curricula, ranging and focus on the methods of data entry,
from licensed practical nurse (LPN) to data storage, data retrieval, and data
doctoral levels. analysis from EHRs, report writing
● As noted previously, the American programs, and database management
Association of Colleges of Nursing (2008) systems.
provided guidance on the educational
requirements for the baccalaureate education Informatics Competencies for Informatics
for professional nursing practice. Nurses and Informatics Nurse Specialists
● "Essential IV: Information Management ● are found in the "Standards of Nursing
and Application of Patient Care Informatics Practice"
Technology identified informatics ● As part of its preparation for the new nursing
competencies that all BSN graduates informatics certification exam test form, the
should possess. American Nurses Credentialing Center
● For nurses prepared at the graduate level, (ANCC) completed its Role Delineation
the AACN provided foundational informatics Study: Nursing Informatics--National Survey
competencies in The Essentials of Master's Results which reported the collected
Education in Nursing, "Essential V: information on the work activities that
Informatics and Healthcare informatics nurses perform in practice. The
Technologies." final report listed 8 domains and 71 separate
● Nurses who hold a master's degree in tasks, as well as calling out the 20 task
something other than nursing can gain a post statements with the highest and lowest
master's certificate in nursing informatics. values of initial risk.
● Many of the numerous programs available ● The McGonigle, Hunter, Hebda, and
have similar competencies, but in general the Hill online assessment of nursing informatics
38
competencies can assist faculty and Nursing Informatics Deep Dive
management to develop curricula or Workshop" was co-sponsored by the
continuing education that best meets the American Association of Colleges of Nursing
needs of their students or employees. and the Schools of Nursing at the
● While there are obvious concrete informatics Universities of Minnesota and Maryland.
competencies that every nurse must have, ● The presentations and resources are
there are many other, more progressive, available to anyone, without charge, on the
processes that will likely never be part of an AACN website
educational curriculum or added to a formal (http://www.aacn.nche.edu/qsen-informatics/
list of competencies. 2012-workshop ).
● An example is the ever-changing landscape
of meaningful use criteria. Another example Additional challenges include:
is the 1) Continuing to enhance and disseminate
numerous ways in which technologies are resources and teaching strategies for all
enhancing practitioners' ability to monitor faculties across the country;
patients and coordinate care remotely via 2) The lack of requirements for PhD programs
telehealth methodologies. in nursing to include informatics (researchers
● All of these areas require informatics nurses are going to need advanced informatics
and informatics nurse specialists to be skills); and
involved in defining benefit versus impact, 3) The need for methods required for "big data”
although it may be difficult to predict how the research to be integrated into curricula for
evolving technologies will be used in the future faculty and nurse researchers.
future.
● In addition to numerous researchers, Informatics Nurse (IN) and Informatics Nurse
academics, and employers, many Specialist (INS) in the Philippines
professional organizations are actively Hebda, Hunter and Czar (2019) describe the role
working toward validating, creating of the Informatics Nurse (IN) and the Informatics
resources, and providing education in Nurse Specialist (INS) in relation to their distinct
nursing informatics. These include the: roles as stated in the Scope of Nursing
○ American Nurses Association (ANA) Informatics Practice statement revised by the
○ American Medical Informatics American Nurses Association (ANA) in 2008.
Association (AMIA)
○ American Nursing Informatics ● "The IN refers to the RN who works in the
Association (ANIA) area of informatics. She has experience or
○ Health Information and Management an interest in the area but no formal
Systems Society (HIMSS) Nursing informatics preparation.
Informatics Working Group ● the INS has advanced, graduate education in
nursing informatics or a related field and may
Informatics Competencies for Nurse hold ANCC certification."
Educators
● Today's nursing educators are challenged to Issues and Challenges of Nursing Informatics
include information on informatics in a basic in the Philippines:
nursing education curriculum that is already ● Nursing informatics face many challenges
full. while in its infancy stage.
● A second challenge is that many nurse ● The inclusion of informatics as an integral
educators themselves lack informatics part of the undergraduate curriculum has
competencies (AACN, 2013; Flood, been one of the most influential factors for
Gasiewicz, & Delpier, 2010). the increased awareness and interest in this
● The Gordon and Betty Moore Foundation field of nursing.
funded a pilot conference to teach faculty
how to teach 110 informatics. The "QSEN
39
● However, the contents of the curriculum were
adapted from international materials which For INS in the Philippines, the following would
do not match the local needs." be some of the roles:
● A community-centered approach to the use 1. Research and theory development
of information, communication and 2. Design information systems that work well in
technology in nursing practice must be the Philippines
adapted to ensure the impact of the program 3. Test human-computer interfaces
in the local healthcare system. 4. Contribute to Health Informatics Policy
● Lack of certification and credentialing 5. Champion or advocate for nursing
programs in post-graduate levels are also informatics in the country
absent with the scarcity of local nursing 6. Help develop standardized nursing
informatics experts. This new field has yet to terminology in the Philippines
gain acceptance and recognition in the
nursing community as a sub-specialty. UNIT 7: NURSING INFORMATICS
LEADERSHIP
Future Direction of Nursing Informatics in the
Philippines: The role of the nurse
● Development of training, certification and The role of the NURSE EXECUTIVE in
credentialing programs are in the pipeline for information technology decision making
the Philippine Nursing Informatics ● To productively contribute and, ultimately,
Association (PNIA). drive technology discussions, nurse
● Future partnerships with local and executives need to be constantly updating
international nursing and health informatics and advancing their hospital information
organizations have started as well. technology (HIT) knowledge.
● Other programs are expected to be slowly ● This knowledge needs to go beyond
delivered with PNIA's CORE X strategic baseline functionality – level of information
platform which stands for Competency, of nursing and clinical information systems,
Organization, Recognition, Experience and which describes what systems can
Expertise. accomplish to a more complex
● It is also a major thrust to support the use of understanding of enterprise – wide
health information standards in the integration, data and process mapping, and
Philippines and to have nursing informatics business analytics.
specialists in every hospital in the country. ● Commanding a deep well of HIT expertise
helps nurse executives understand the
IN in the Philippines will include the following delicate interplay of nursing and outcome
roles: data inside the health care organization
1. Ensure proper record or documentation with and beyond- to regulator and payers
the use of technology whether in clinical worlds.
practice, administration, or the academe ● Few industries collect , analyze, and
2. Utilize information and technology disseminate information with the velocity
responsibly in health education seen in healthcare and in no industry does
3. Collaborate with other health professionals the data- driven decision have more
with the use of hospital information system importance. In health care every patient care
(clinical) or educational information system decision can have a life- and-death
(academe implication.
4. Use of simulation learning in education or ● That is why the timely communication of
continuing education accurate data plays such a critical role in
5. Educate students about nursing informatics healthcare delivery.
and facilitate learning through the use of According to parker (2014)
Information Communication Technology (ICT)
Tools
40
● Health Information Management Systems use these data in standardized performance
Society Nursing Informatics Workflow survey measures.
in 2014 shows;
● 60% have master’s or doctoral level of NI leaders in business are working across a
education spectrum of roles:
● 41% have more than 16 years of clinical ● CEO to Chief Nursing Informatics Officer
experience before becoming informatics (CNIO)
nurse ● Helping to design and implement products to
● 46 % have more than 7 years of informatics improve the workflow of clinicians
experience. ● Use data and information to inform nursing
practice
Today’s nursing informatics leaders can be found ● Brings years of clinical experience to provide
in multiple environments beyond the four walls of quality care to patients.
the hospital they can be found on: ● Holds executive positions at most of the
● Corporate headquarters of healthcare major HER vendors
organizations ● Sit on advisory board s
● Government ● And act as consultants to industries and
● Academia and healthcare organizations
● Business world
Technology’s Lifecycle
In the US government sector The six stages or six phases:
● Informatics nurses help keep the patient the 1. Planning
primary focus of policy and law as well as in 2. Procurement
the development of standards for the design 3. Deployment
and implementation of EHRs, patient 4. Management
engagement, clinical quality, system 5. Support
interoperability , and quality measures. 6. Disposition
● Informatics nurse leaders in academe are not
only helping educate the next generation of The cycle goes back to planning.
informatics leaders, but also helping to 1. Various stops and start are internally caused
transform nursing education as a whole. and others are triggered externally
Basic informatics skills are now required 2. Issue that are not present in planning and
competency for every RN. procurement will be noticed during
● Technologies to support nursing education, deployment, management, and disposition
such as simulation laboratories, use of the
Learning Management System (LMS), are Overlying the lifecycle with the present
becoming commonplace. technology obsolescence complicates
technology- related decision making.
Research in the usage of informatics to
improve care is ongoing: Three key types of obsolescence
Example; 1. Technology providers’ architecture, product
● A recent study explored the use of and integration plans
nurse-sensitive indicators and healthcare 2. Third parties’ priority shifts
information technology. 3. Regulators
● The goal was to establish linkages between
nursing care and improved nursing Types of obsolescence
outcomes in order to better use technology to 1. Technology providers’ architecture,
improve care. product and integration plans
● This study demonstrated the complexities of ● The impact of planned obsolescence
establishing these linkages and the need to can not be overlooked when nurse
executives make HIT-related decisions.
41
● Technology providers worldwide require
engineers to design obsolescence into 3. Regulators’ unexpected recalls
their system to ensure ongoing market ● Unexpected nature
demands, protect market share, and ● Can derail technology decision–making
preserve revenue streams. and implementation
● Technology with nurse executives on ● Pertains to regulators changing the
staff tend to exercise considerable status of medical devices or technology
influence over architecture, product and either by narrowing the approved scope
integration efforts. of use or even recalling the product after
● Those without internal nursing it was introduced to the market and is
advocates may find nursing issues generally available.
significantly overshadowed by the
financial and business pressure public
and private held technology companies Example:
faced. ● The hospital selected an FDA -
● System face should be updated or approved monitoring device and
even phase out when the external conducted extensive staff training only to
market landscape changes. have the product recalled 3 months
● Consider the massive overhaul before the product is deployed.
needed to move financial information ● This will not be used and to be replaced
systems from a cost-plus orientation to a with a new monitoring technology.
system of reimbursement. ● Time and money were expended for a
2. Third parties’ priority shift second time and created a previously
● Healthcare organizations had to replace unpredict-able drain on cost and staff.
large, charge – capture legacy systems
with technology that could accurately All 3 types carries an import of its own
predict total cost by procedure. ● The nurse executive should be more critical
● Shift in regulatory – or payer related to recognize that the healthcare organization
priorities can trigger a range of system does not control them.
changes from code revisions all the way ● Third party decisions have an enormous
up to system replacement. impact on when and how nursing uses
● A third-party payer is an entity that technology- based product, devices and
pays medical claims on behalf of the system.
insured. ● Third party decisions occur in a time - table
Examples of third party payers: government over which health organizations have a little
agencies, insurance companies, health or no influence
maintenance organizations (HMOs), and
employers. MULTI LAYERED DECISION MAKING
● Nursing-centric technology decisions emerge
When Healthcare organizations face significant from a context that includes:
penalties, non-compliance is not an option. ● Cultural
Example of penalties ● Economic
● Funding loses or reductions ● Social
● Fines or legal consequences ● And physical requirements
● Fiscal threats to their very existence Note: adding an outcome orientation impacts the
cost, quality and satisfaction
Complying with environmental mandates can ● Nursing centric analysis of the process
throw technology lifecycle into free fall as legacy reveals further complexity coming from the
systems struggle to accommodate regulatory or dynamics of the physician- dominated HIT
payer mandates that were nowhere in the horizon discussion.
when this system were built
42
● The nursing- centered discussion of the HIT Position titles are:
decision –making highlights several reasons ● Chief Nursing Informatics Officer (CHIO)
why medical staff demands often relegate ● Director or similar leadership titles
nursing’s HIT requirements to a subservient ○ Leaders are expected to be visionaries
position during technology evaluation and and establish the direction of large –
selection. scale informatics solutions.
○ Serves as a catalyst for developing
FUNCTIONAL AREAS OF NURSING strategic plans and creating national or
INFORMATICS system policies and procedures while
● Informatics Nurse(IN) and Informatics Nurse serving as the champion for integrated
Specialist(INS) projects and systems.
○ Commonly practiced in interpersonal ● Mid – level management
healthcare environments, interacting INS may supervise resources and activities for
with information technology (IT) all phases of the system cycle.
professionals during all phases of Activities includes:
system life cycle. ○ Needs analysis
○ Use scientific and informatic principles ○ Requirements gathering
and employ creative strategies in ○ Design
informatics solutions. ○ Development
○ Bring the perspective of nursing and the ○ Selection and purchase
patient to interprofessional work through ○ Testing
a solid understanding of operational ○ Implementation
processes and the value of consumer ○ Evaluation of systems to support all
advocacy to informatics function. facets of nursing and health care
○ May need additional education or other delivery.
types of advance preparation to manage
the informatics projects at hand At all levels , leadership is by the combination
of the following:
Dynamic and evolving functional areas: ● Superb communication skills,
1. Administration, leadership and management ● Collaboration
2. system analysis and design ● Change management
3. Compliance and integrity management ● Risk assessment
4. Consultation ● Coalition building with political finesse,
5. Coordination, facilitation, and integration business acumen and strategic application
6. Development of systems, product and knowledge.
resources
7. Educational and professional development Other positions:
8. Genetics and genomics 1. INS in large hospitals;
9. Information management/ operational ● Supervise an implementation and
architecture education team
10. Policy development and advocacy ● Representing nursing interest on various
11. Quality and performance improvement IT committees
12. Research and evaluation ● Performing project management for
13. Safety, security and environmental health multiple documentation project
● Having oversight of the nursing
Administration, Leadership and Management standards and vocabularies used in the
● Nursing informatics incorporates both higher application.
- level and mid-level administrative functions. 2. Project director for a clinical software
● INSs are attaining senior leadership company
positions.

43
● Managing implementing teams for
various client projects(hospital and
ambulatory facilities)
● Consulting with clients on all aspects of
system selection customization adoption
and use of software.
3. Grants administrator for an information
science research agency, seeking and
writing grants that would fund NI - related
projects, designing budgets, and ensuring
optimal allocation of resources.

44
UNIT 7: STANDARDS OF NURSING ● Conducts a needs analysis to refine the issue
INFORMATICS PRACTICE or problem when necessary.
● Involves the healthcare consumer, family,
Standards of Nursing Informatics Practice interprofessional team, and key stakeholders,
According to American Nurses Association as appropriate, in relevant data collection.
● Prioritizes data collection activities.
Significance of the Standards ● Uses analytical models, algorithms, and tools
The Standards are based on the Standard of that facilitate assessment.
Professional Nursing Practice
● They are authoritative statements of the One example of an assessment algorithm is
duties that all registered nurses, regardless PIECES:
of role, population, or specialty, are expected ✔ Performance – throughput or response time;
to perform competently. ✔ Information – outputs, inputs, and/or stored
● The standards published are utilized as data;
evidence of the care, with the ✔ Economics – costs versus profits;
understanding that application of the ✔ Control – too little security or control or too
standards is context dependent. much control or security;
● The standards are subject to change with ✔ Efficiency – people, machines, or computers
the dynamics of the nursing profession, as waste time, and;
new patterns of professional practice are ✔ Service – inaccurate, inconsistent,
developed and accepted by the nursing unreliable, hard to learn, difficult to use,
profession and the public. inflexible, incompatible, not coordinated with
● In addition, specific conditions and clinical other systems (Wetherbe, 1994).
circumstances may affect the application
of the standards at a given time (e.g., during Standard 1. Assessment
a natural disaster). Competencies
● The standards are subject to formal, The informatics nurse (CON’T):
periodic review and revision. ● Synthesizes available data, information,
● The competencies that accompany each evidence, and knowledge relevant to the
standard may be evidence of compliance situation to identify patterns and variances.
with the corresponding standard. ● Applies ethical, legal, and privacy regulations
● The list of competencies is not exhaustive. and policies for the collection, maintenance,
● Whether a particular standard or competency use, and dissemination of data and
applies depends on the circumstances. information.
● Documents relevant data in a retrievable
Standards of Nursing Informatics Practice format.
Standard 1. Assessment
● The informatics nurse collects Standard 2. Diagnosis, Problems, and Issues
comprehensive data, information, and Identification
emerging evidence ● The informatics nurse analyzes assessment
pertinent to the situation. data to identify diagnoses, problems, issues,
and opportunities for improvement.
Competencies ● Competencies
The informatics nurse: ● The informatics nurse:
● Uses evidence-based assessment ● Derives diagnoses, problems, needs, issues,
techniques, instruments, tools, and effective and opportunities for improvement based on
communication strategies in collecting assessment data.
pertinent data to define the issue or problem.
● Uses workflow analyses to examine current Competencies
practice, workflow, and the potential impact The informatics nurse:
of an informatics solution on that workflow.
45
● Validates the diagnoses, problems, needs, ● Documents expected outcomes as
issues, and opportunities for improvement measurable goals.
with the healthcare consumer, family,
interprofessional team, and key stakeholders Standard 4. Planning
when possible and appropriate. The informatics nurse develops a plan that
● Identifies actual or potential risks to the describes strategies, alternatives and
healthcare consumer’s health and safety, or recommendations to attain expected outcomes.
barriers to health, which may include, but are
not limited to, interpersonal, systematic or Competencies
environmental circumstances. The informatics nurse:
● Uses standardized clinical terminologies, ● Develops a customized plan considering
taxonomies, and decision support tools, clinical and business characteristics of the
when available, to identify problems, needs, environment and situation.
issues, and opportunities for improvement. ● Develops the plan in collaboration with the
● Documents problems, needs, issues, and healthcare consumer, family, healthcare
opportunities for improvement in a manner team, key, stakeholders, and others as
that facilitates the discovery of expected appropriate.
outcomes and development of a plan. ● Establishes the plan priorities with key
stakeholders and others as appropriate.
Standard 3. Outcome Identification ● Incorporates strategies in the plan address
The informatics nurse identifies expected each of the identified diagnoses, problems,
outcomes for a plan individualized to the needs, and issues.
healthcare consumer of the situation. ● Incorporates planes strategies addressing
health and wholeness across life span.
Competencies ● Incorporates an implementation pathway or
The informatics nurse: timeline within the plan
● Involves the healthcare consumer, family, ● Considers the clinical, financial, social and
healthcare provider and key stakeholder in economic impact of the plan on the
formulating expected outcome when possible stakeholders.
and appropriate. ● Integrate current scientific evidence,
● Involves the healthcare consumer, family, trends, and research into the planning
healthcare provider and key stakeholder in process
formulating expected outcome when possible ● Utilizes the plan to provide direction for the
and appropriate. healthcare team and other stakeholders.
● Defines expected outcome in terms of the ● Integrates current status, rules and
healthcare consumer, health-care worker, regulations, and standards within the
and other stakeholder; their values; ethical; planning process and plan.
and environmental, organizational, or ● Modifies the plan according to the ongoing
situational considerations assessment of the healthcare consumer’s
● Formulates expected outcomes after response and other outcome indicators.
considering associated risks, benefits, costs, ● Integrates informatics principles in the design
available expertise, evidence-based of interprofessional processes to address
knowledge, and environmental factors. identified situations or issues.
● Develops expected outcomes that provide ● Documents the plan in a manner that uses
direction for project team members, the standardized terminologies and taxonomies.
healthcare team, and key stakeholders.
● Includes a time estimate for the Standard 5. Implementation
attainment of expected outcomes. The informatics nurse implements the identified
● Modifies expected outcome based on plan
changes in the status or evaluation of the
situation. Competencies
46
The informatics nurse: ● Incorporates new information and strategies
● Partners with healthcare consumers, to initiate change if desired outcomes are not
healthcare teams, and others, as achieved
appropriate, to implement the plan on time, ● Documents implementation and any
within the budget, and within plan modifications, including changes or
requirements. omissions, of the identified plan
● Utilizes health information technology to
measure, record, and retrieve healthcare Standard 5.a. Coordination of Activities
consumer data, implement and support the The informatics nurse coordinates planned
nursing process, and improve overall activities
healthcare outcomes.
● Partners with healthcare consumers, Standard 5.b. Health Teaching and Health
healthcare teams, and others, as Promotion
appropriate, to implement the plan on time, The informatics nurse employs informatics
within the budget, and within plan solutions and strategies for education and
requirements. teaching to promote health and a safe
● Utilizes health information technology to environment
measure, record, and retrieve healthcare
consumer data, implement and support the Standard 5.c.Consultation
nursing process, and improve overall The informatics nurse provides consultation to
healthcare outcomes. influence the identified plan, enhance the abilities
● Uses specific evidence-based actions and of others, and effect change.
processes to resolve diagnoses, problems, or
issues to achieve the defined outcomes. Standard 6. Evaluation
● Advocates for health care that is sensitive to The informatics nurse evaluates progress toward
the needs of healthcare consumers, with attainment of outcomes
emphasis on the need of diverse populations
and use of self-theory Competencies
● Applies available healthcare technologies to The informatics nurse:
maximize access and optimize outcomes for ● Conducts a systematic, ongoing and
healthcare consumers. criterion-based evaluation of the outcomes in
● Uses community and organizational relation to the structure and processes
resources systematically to implement the prescribed by the project plan and indicated
plan. timeline.
● Collaborate with the healthcare team and ● Collaborates with the healthcare consumer,
other stakeholder from diverse backgrounds health care team members and other key
to implement and integrate the plan stakeholders involved in the plan or situation
● Accommodates different styles of in the evaluation process.
communication used by healthcare ● Evaluates in partnership with the key
consumers, families, healthcare providers, stakeholders, the effectiveness of the
and others planned strategies in relation to attainment of
● Implements the plan using principle and the expected outcomes.
concepts of enterprise management, project ● Evaluates the link between outcomes and
management and system change theory evidence-based methods, tools, and
● Promotes the healthcare consumer’s guidelines
capacity for the optimal level of participation ● Documents the results of the evaluation.
and problem-solving. ● Disseminates the results to key
● Fosters an organizational culture that support stakeholders and others involved,
implementation of the plan accordance with organizational
requirements and federal and state
regulations
47
● Standards of Professional Performance for
Nursing Informatics Standard 12. Leadership
● The standards of professional performance Promotes that the informatics nurse leads in the
express the role performance requirements professional practice setting, as well as the
for the informatics nurse and informatics profession. Accompanying competencies address
nurse specialist such skills as mentoring, problem-solving, and
promoting the organization’s vision, goals, and
Standard 7. Ethics strategic plan.
Identifies the informatics nurse practices ethically,
with further detailing of associated competencies, Standard 13. Collaboration
such as the use of the Code of Ethics for Nurses Encompasses the informatics nurse’s
with Interpretive Statements to guide practice collaborative efforts with the healthcare
consumer, family, and others in the conduct of
Standard 8. Education nursing and informatics practice
Addresses the need for the informatics nurse to
attain knowledge and competence, including the Standard 14. Professional Practice Evaluation
competency associated with demonstration of a Identifies that the informatics nurse conducts
commitment to lifelong learning evaluation of their own nursing practice
considering professional practice standard and
Standard 9. Evidence-based Practice and guidelines, relevant statutes, rules and
Research regulations
Confirms that the informatics nurse integrative
evidence and research findings into practice Standard 15. Resource Utilization
Addresses that the informatics nurse uses
Standard 10. Quality of Practice appropriate resources to plan and implement
Describes the expectation for the informatics safe, effective, and fiscally responsible informatics
nurse’s contribution related to the quality and and associated services
effectiveness of both nursing and informatics
practice. Standard 16. Environment Health
Close out the list of professional performance
Standard 11. Communication standards by describing that the informatics nurse
Explains that the information nurse supports practice in a safe and healthy
communicates effectively through a variety of environment.
formats, with several accompanying
competencies delineating specific requisite
knowledge, skills, and abilities for demonstrated
success in this area.

48
● Cochrane Groups, aka About the
FINALS COchrane Collaboration

UNIT 8 - LECTURE 1: COMPUTER


APPLICATIONS THAT SUPPORT NURSING
RESEARCH
How do I access CINAHL?
Open the link for tutorial:
LITERATURE SEARCHES
https://indwes.libguides.com/cinahl
Reliable Search Engine and Databases
EMBASE: Excerpta Medica Database
Based on commonly visited and utilized
An abstract and indexing database in biomedicine
databases by nurse researchers, the following
which also excels in its coverage of
were considered as major research databases:
pharmaceutical research. It currently contains
more than 15 million records from Excerpta
CINAHL Plus with Full Text
Medica Database (1974 to present) and selected
The Cumulative Index to Nursing and allied
medicine records (1966 - present). Currently the
Health (CINAHL) database provides authoritative
Library does not own the archives of Embase
coverage of the literature related to nursing and
from 1972 - 1973.
allied health.
EBSCOhost
+ Background. The Cumulative Index to
An intuitive online research platform used by
Nursing and Allied Health Literature
thousands of institutions and millions of users
(CINAHL) is generally thought to be a good
worldwide. With quality databases and search
source to search when conducting a review of
features, EBSCOhost helps researchers of all
qualitative evidence. In addition, CINAHL
kinds find the information they need fast.
Database provides access to health care books,
EBSCOhost offers high-quality articles
nursing dissertations, selected conference
licensed from reputable publishers recognized
proceedings, standards of practice, audiovisuals
by library professionals, chosen to meet the
and book chapters. It includes full-text journals,
specific needs of researchers. Users can view,
legal cases, clinical innovations, critical paths,
save, print, email, or export citations in many
research instruments and clinical trials.
formats directly from the database.

Cochrane Library
HAPI: Health and Psychosocial Instruments
A collection of databases that contain
This is a database that provides information on
independent evidence on which base clinical
measurement instruments such as:
treatment decisions.
● Questionnaires
● Interview
● Cochrane Reviews, aka Cochrane
● Schedules
Database of Systematic Reviews (CDSR)
● Checklists
● Other Reviews, aka Database of
● Index
Abstracts of Reviews of Effects (DARE)
● Measures
● Clinical Trials, aka Cochrane Central
● Coding schemes/ manuals
Register of Controlled Trials (CENTRAL)
● Rating scales
● Methods Studies, aka Cochrane
● Projective techniques
Methodology
● Vignettes/ scenarios, tests
● Technology Assessments, aka Health
in the health fields, psychosocial sciences,
Technology Assessment Database (HTA)
organizational behavior, and library and
● Economic Evaluations, aka National
information science. Limited 10 simultaneous
Health Service (NHS) Economic
users.
Evaluation Database (NHSEED)

49
MEDLINE through Ovid (1947 - present) conference papers and provides 100% Medline
The National Library of Medicine’s premier coverage with interoperability with ScienceDirect,
bibliographic database covering the fields of Engineering Village and Reaxys.
medicine, nursing, dentistry, veterinary medicine,
the healthcare system, and preclinical sciences. Web of Science
MEDLINE contains bibliographic citations and Access to the web of science core collection
author abstracts from more than 4,600 biomedical which is the largest citation database inscience,
journals published in the United States and 70 engineering, medicine, and technology. Also, the
other countries. The database contains over 12 social sciences, arts and humanities are
million citations dating back to the mid-1950’s. represented. This resource was acquired with
Coverage is worldwide, but most records are from funding from the Library/ IT Assessment. The web
English language sources or have English of Science, provided by the Institute of Scientific
abstracts. Information (ISI) a division of Thomson Reuters,
is an index of current and retrospective
MEDLINE via PubMed multidisciplinary information from 1975 on. The
PubMed, a service of the National Library of bibliographic records from approximately 8,700
Medicine, provides access to ver 12 million high impact research journals are mostly linked to
MEDLINE citations back to the mid-1960’s and full-text articles.
additional life science journals. PubMed includes
links to many sites providing full text articles and Additional Databases:
other related resources. Google Scholar
This is a research engine that focuses on
Nursing Reference Center Plus academic output. This link is proxied for users off
Master nursing best practices with the source for campus so you can download full text.
evidence-based information designed specifically
for nurses. Includes PERC (go to more and select Health Source: Nursing/ Academic Edition
patient Ed.) This resource was partially acquired This is a database that focuses on nursing and
with funding from the library/ IT assessment. This allied health, and which provides nearly 600
database complements CINAHL, providing the scholarly full text journals including nearly 450
most recent clinical evidence to nurses and other peer-reviewed journals.
health care professionals, directly at the
point-of-care. Sociological Abstracts
Sociological Abstracts and indexes the
PsychINFO international literature in sociology and related
Now called APA PsychINFO. PsychINFO contains disciplines in the social and behavioral sciences.
bibliographic citations and abstract from materials
in the field of psychology and the psychological Virginia Henderson International Nursing
aspects related disciplines such as medicine, Library
psychiatry, nursing, sociology, education, This free resource has the following features:
pharmacology, physiology, linguistics ● Free registration
anthropology, business, and law. Updated weekly. ● Abstracts from dozens of nursing
conferences
SAGE: Research Methods ● Investigator entered information on cutting
Contains information on research methods edge search
including over 120,000 pages of SAGE book, ● Contact information for investigations and
journal, and reference content. authors
● Access to 6 free full-text articles a month
Scopus on nursing topics.
Scopus contains over 20,500 titles from 5,000 ● Access to free full-text articles from the
publishers worldwide with 49 million records, 78% current volume, first issues of Journal of
with abstracts. It includes over 5.3 million
50
Nursing Scholarship and worldwides on
Evidence-Based Nursing.

51
UNIT 8 - LECTURE 2: DATA COLLECTION AND measurement can be described as the set of
STATISTICAL TOOL rules used to assign scores and is an indicator of
the kind of information that the scores provide
Two types of Variables or data: (Dayrit, 2011). The scale to which measurement
1. QUALITATIVE VARIABLES belongs will be important in determining
Represents differences in quality, character, or appropriate methods for data description and
kind but not in amount. In short, they do not yield analysis.
numeric variables. The following are examples of
qualitative variables but not limited to birthplace, Four Levels of Scales of Measurement:
geographic locations, religion, civil status, sex, 1. Nominal Data
skin color, eye color, etc. These are categorical in nature. It has the
purpose of identifying name or membership to a
2. QUANTITATIVE VARIABLES specific group. All qualitative variables are
Represent the quantity, thereby is numerical in measured on this scale. Observations can be
nature. It can be ordered and ranked. The classified and counted without particular order or
following are examples of quantitative variables ranking imposed on the data. Specific example
but not limited to age, height, weight, test scores, would be the flexible learning options. We might
vital signs, etc. There are instances that variables use "1" for the identification of those under the
can express both quantitatively and qualitatively blended online learning, "2" for complete
as in the grading system in schools, colleges, and asynchronous online learning, and "3" for the
universities. Quantitative as to the percent complete offline analog mode of learning.
scores (60%, 80%, 100%) and qualitative as to Religion, types of diagnosis, medical
the letter grades (A+, A, A-, B) Quantitative specializations, species of flowers can also be
variables can be further classified to the another example of nominal data.
following:
● Discrete variables are counted using 2. Ordinal Data
integral (non-decimal) values like number Means the imposition of ranks or inequalities.
of students, number of admissions, This implies that one category is higher than the
number of testing centers, etc. other. This type of data presents numbers to be
● Continuous variables are counted using either greater than or less than measurements.
decimals or fractions that represent a This can be typically seen on surveys such as
numerical difference over an interval such when you answer in scales of excellent down to
as height, weight, temperature, blood unsatisfactory. In this example, it is clearly noted
pressure. that excellent is higher than very satisfactory, and
so on. Other examples of data include the
Classification of variables depending on how following but not limited to social class or income
it is used or applied in a study: bracket, letter grades, body frames, birth order,
Independent variable is the stand-alone variable contest winners, etc.
that cannot be affected by other controlled
variables. It is the predictor while the Dependent 3. Interval Data
variable is the one being predicted. For example, Indicate an actual amount and there is an equal
to predict the increase in comfort level of geriatric unit of measurement separating each value at
patients using music therapy. The dependent equal intervals. For example, the difference
variable is the comfort level, while the between 60 and 70 is the same as the difference
independent variable is the music therapy. After between 80 and 90. The distance between two
determining the type of variable, we now consider numbers or scores reflects the distance between
its scale of measurement of data. the values of the characteristic being measured
(Dayrit, 2011). Furthermore, interval data do not
Scales of Measurement of Data include the greater than or less than relationship,
The process of assigning numerical value to a but also have a limit of measurement that permits
variable is called measurement. A scale or level us to describe how much more or less one object
52
possesses than another (Dayrit, 2011). Other answers, it offers a lot. These diverse elements
examples of interval data are temperatures, score make it convenient to craft a variety of quizzes
on formative assessments and many more. and forms. Just click on those elements to add
them. Also, you can easily separate a single form
4. Ratio into multiple sections or add conditional logic. In
Data are similar to interval data, but the difference short, there is a bevy of options to meet every
is that ratio data has an absolute zero and need.
multiples have meanings. For example, if you
have 0 balance in your mobile number or Sad to say that the answer types in Microsoft
E-wallet, then this means you have no e-money Forms are quite limited. You get only six options
to use for your mobile services. Ratio data include which include multiple choices, text, ratings, and
all usual measurements of length, height, weight, others. Though Microsoft forms do not have the
area, volume, density, velocity, money, and support for separate sections, it does let you add
duration (Dayrit, 2011). This is the highest level of conditional logic, commonly referred to as
measurement. Other examples include the branching. Branching is not visible easily and you
following but not limited to horsepower or an air will have to add it from the three-dot menu.
conditioner, compensation of faculty members,
ages of students enrolled in a Muay Thai class, ● SHARING AND COLLABORATION
etc. When it comes to creating quizzes and surveys
on Microsoft form, you will need an active
METHODS OF DATA COLLECTION Microsoft ID. Thankfully, anyone with a link can
Now that we have been refreshed with the basic respond to them and as far as sharing is
information about the types of data and the scales concerned, you can either share the link directly
of measurement of data, we now take into with the users or email it to them. You can also
consideration the methods of data collection. The embed the form on any web page. Moreover, the
following discussions focus on survey as a standard version limits some of the features. For
popular method of quantitative data collection one, you cannot restrict the audience to the
among researchers. people of your organization unless you have an
Office 365 Education or Office 365 commercial
Online Questionnaires (Google Forms, subscription. Likewise, you cannot add
Microsoft Forms) collaborators if you are on the standard version.
Survey is one way of gathering data from a
specific population. It is one of the most Google Forms also supports similar sharing
commonly used tools by researchers to facilitate features: you can email or share links directly, but
their study. It is usually done on a face-to-face the free feature which steals the spotlight is
basis and would take up around 15-20 minutes to adding collaborators. You can add anybody with a
finish the questionnaire. Along with the Covid-19 working email address as a collaborator. You can
pandemic, the performance of surveys has shifted also edit their access or prevent them from
from face-to-face to online forms. Here we adding more people or collaborators.
introduce to you two of the most popular online
survey form creators, which are Google Forms ● TEMPLATES
and Microsoft Forms. One primary reason for using Google Forms is its
distinctive range of templates. From creating a
Google Forms & Microsoft Forms: PRIMARY plain text-based survey to making an elegant
FUNCTIONS (Gogoi, 2019) invitation card, almost everything is manageable
● QUESTION AND ANSWER TYPES with this simple tool. All it takes is a click on the
Diverse options and features are what separates template gallery and the available template will be
good service from a great one. Google form takes displayed neatly. Staying through the concept of
the lead since it provides a range of question templates, they have preset questions. You will
types. From multiple choice answers and have to add or modify the answer type or add a
checkboxes to linear scale and text-based few more questions and that is it.
53
Google Forms & Microsoft Forms:
As opposed to it, Microsoft struggles to stand UNCOMMON FEATURES
when it comes to templates, at the time of writing ● QR CODE
there are only three types-Form, Quiz, and Party Whether it is the clutter-free interface or the cool
invitation. Users can modify these templates to graphic-based theme, Microsoft Forms has a
tailor them according to their needs. So, if you slightly modern feel to it. A part of this chic look is
have visualized your form to look a certain way, the inclusion of a QR-based sharing option. With
you will have to invest your time and energy. it, you can share a QR code with your
There are no presets to help you with them. respondents thus making it incredibly easy for
tablet users and mobile users to respond. On top
● THEMES of that, surveyors can download the QR code or
What Microsoft forms loses out in the form of add it on emails to make it easily accessible.
templates and tries to make it up with themes.
Long story short, it carries enough graphic ● FILE UPLOAD
themes in a variety of attractive shades and the If you are a regular user of Google Forms, you
best part is that Microsoft Forms applies the might recollect that the file upload feature was not
theme to the whole form to uplift the overall look common until 2016. This essential feature makes
and feel of the form. it simple to keep track of college/school
assignments as it is with most google services the
As opposed to it, Google's approach to themes steps are easy to figure out. As you might have
seems a bit dated. You get the same old figured it out, Microsoft Forms lack that ability
pastel-colored themes and only the primary color making it sort of unusable for submitting
gets applied to the upper portion. assignments or any survey that needs document
verification. At the time of writing, a lot of users
Thankfully, both services let you upload custom shared feedback regarding the same in
images. While Microsoft paints the whole UserVoice. As per the team, Microsoft is working
background, Google only applies them to on the update.
headers.
● BUILT-IN SPREADSHEET SUPPORT
● EMBEDDING VIDEO AND OTHER Both the services have support for spreadsheets.
MEDIA Google Forms supports sheets and MS Forms
Do you often include videos and photos in your supports MS Excel. The difference is how they
surveys and polls? If yes, you might want to side accomplish the task of linking spreadsheets. The
with Google Forms. Though Microsoft Forms good news is that Google Forms stores
allow adding videos and images, they can be everything in the cloud. Just tap on the view
done only as a part of questions. You cannot responses on the sheets button and the
include them in between questions or as a respective sheet will open right away. Though you
separate section. can easily import the form data to Microsoft Excel,
you would need to download the spreadsheet to
While it may serve the purpose for many, when it your system. Again. your system must have an
comes to crafting birthday or party invitations, it active Office Suite to open it. In a worst-case
proves to be a serious limitation. Interestingly, scenario, if your system does not have one, you
Google Forms will let you insert images as part of will have to settle with the data on the responses
questions. Also, you can add videos in a separate tab.
section. So, if you want your form to begin with a
beautiful video before you get down to the actual ● RESPONSE VALIDATION
business it is possible. Both the services allow In 2018, Google released an update for response
adding YouTube URLS and pictures from your validation which will check the answers before
computer. submission, So, if makers only want an email
address or a URL, they can specify the same
when they craft the quiz, and it will be taken care
54
of. In addition to it, there is also the option to measurement of data to answer the research
validate text-based answers and numbers. For question, therefore, the intent should be to
now, Microsoft Forms only lets you validate achieve accuracy. In addition, the validity should
numbers. It will provide you the general option of also be checked. This means that the instrument
greater than, less than, etc. must be tested if the possible answers in the
instrument reflect the individual's moral values.
● COLLECTING EMAIL ADDRESSES (Brink and Wood, 2011).
Google Forms has a nifty little feature which lets
you collect email addresses from respondents. After determining how you are going to collect
That is not a mandatory option and makers can data, the next thing to think of is how you are
opt to use it when the need arises. going to process this data. Processing data
means that you must think of a statistical formula
METHODS OF DATA COLLECTION appropriate for the type of data to be processed.
● DIGITAL POLLS The flowchart on the next pages can help you.
Digital Polls or online polls allow people to see decide on which statistical formula to use.
responses or votes of other people toward a topic
or an issue in real-time. Polls are distributed DISCLAIMER: You may still opt to consult with a
and/or embedded in social media pages such as qualified statistician if in case your type of
the Facebook messenger, wherein anyone from research data does not fit in any of the
the group can start a poll and can instantly reach algorithms.
an agreement within the group in an organized
manner. Google Forms and Microsoft Forms can
also perform a poll function with the option to
allow the participants to view responses as a
whole or not. Data from these polls can be easily
utilized and save time in the tallying and collation
of data.

● SURVEY MONKEY
A leading global survey platform trusted by
millions of organizations and individuals to help
them uncover insights about their customers,
employees, and prospects. Their platform is
powerful enough for professional researchers, yet
easy enough that a survey novice can also get
started with it right away. With 20 years of survey
expertise and insights from billions of questions
answered, we fuel the curiosity of over 17.5
million active users worldwide. The company
provides free basic features of online service with
ready-made templates and easy to use interface.
Advanced features and collaborations are made
available through an upgrade of plan from basic
to standard plan and up to the different plans they
offer.

After you have chosen and designed your


instrument, may it be a survey questionnaire or a
more structured instrument for data collection, the
words RELIABILITY and VALIDITY must come
to mind. They refer specifically to the
55
● PSPP
A program for statistical analysis of sampled data
developed by the GNU Operating System. It is a
free replacement for the proprietary program,
SPSS. PSPP provides many transformations and
utilities. Procedures provide the ability to perform
t-tests, anova, linear regression, logistic
regression, cluster analysis, reliability analysis,
factor analysis, non-parametric tests, and other
analyses.
METHODS OF DATA COLLECTION: DATA
PROCESSING AND DATA APPLICATIONS
● SAS
● SPREADSHEETS
Stands for Statistical Analysis Software. One of
Microsoft Excel and other spreadsheets like
the modern statistical software's in the market.
Google Sheets and Open office spreadsheets
Organizations of all types and sizes depend on
have a function of data processing. Certain
statistical analysis to guide critical decisions.
statistical functions are available for use by the
Modern statistical methods provide trustworthy
researchers particularly on quantitative studies.
evidence for creating effective treatments for
Features vary from version and software utilized.
disease, improving manufacturing processes,
Raw data is usually recorded using the
predicting customer behavior, and making policy
above-mentioned applications for easy computing
decisions. SAS/STAT provides a comprehensive
and maintaining accuracy in summing up
set up-to-date tools that can meet the data
responses.
analysis needs of your entire organization. From
analysis of variance and linear regression to
● SPSS
Bayesian inference and high-performance
The IBM SPSS or the Statistical Package for
modeling tools for massive data, SAS/STAT
Social Sciences software platform is the leading
software provides tools for both specialized and
statistical software for advanced statistical
enterprise-wide statistical needs. It is designed for
analysis, a vast library machine learning
use by business analysts, statisticians, data
algorithm, text analysis, open-source extensibility,
scientists, researchers, and engineers (SAS,
integration with big data, and seamless
2020).
deployment into applications.
● N Vivo
It is easy to use. Flexibility and scalability make
This is a qualitative data analysis software that
SPSS accessible to users of all skill levels. What
allows you to organize and manage qualitative
is more is that it is suitable for projects of all sizes
data. This software allows the researcher to save
and levels of complexity and can help you and
time in doing manual organizations of qualitative
your organization find new opportunities, improve
data. Researchers can import text, audio, video,
efficiency, and minimize risk.
emails, images, spreadsheets, online surveys,
web content, and social media from various
Within the SPSS software family of products,
sources into a simple intuitive interface.
SPSS Statistics supports a top-down, hypothesis
Centralize data from multiple sources to conduct
testing approach to your data while SPSS
the most in-depth analysis possible. This also
Modeler exposes patterns and models hidden in
allows the researcher to have an efficient coding
data through a bottom-up hypothesis generation
of data to quickly identify themes and trends.
approach. The SPSS might be a go to application
Organize the people, places, and core metrics of
by researchers but with budget matrons. Some
your analysis as cases. Link cases to attribute
researchers find innovative ways on how to
values such as age and gender to compare
analyze their data with a freeware alternative for
different groups in your data. Researchers can
SPSS which is the PSPP.
quickly visualize your data with word frequency
56
charts, word clouds, comparison diagrams and
many more. Look for emerging topics and
sentiment using specific queries to identify
themes and draw conclusions (QSR, 2020).

57
UNIT 8 - LECTURE 3: DATA PRESENTATION The methods section tells readers how you
conducted your study. It includes information
Presentation of data needs planning and about your population, sample, methods, and
appropriate means of presentation. Readers need equipment. The "gold standard" of the methods
to be interested and understand the presented section is that it should enable readers to
data. The mere gathering of data is not a simple duplicate your study. Methods sections typically
task, more so the task of making these data use subheadings; they are written in past tense,
comprehensible and meaningful. The gathered and they use a lot of passive voice. This is
data are summarized and presented in different typically the least read section of an IMRAD
forms as to textual form, tabular form, and report.
graphical form.
● RESULTS
Textual form a paragraph explanation of the data. WHAT DID YOU FIND?
Tabular form presents data in rows and columns In this section, you present your findings.
for summary and comparison purposes. Typically, the results section contains only the
Graphical form is used for a more visual findings, not any explanation of or commentary of
presentation which makes it easier for the readers the findings. Results sections are usually written
to understand. This is useful for larger sets of in the past tense. Make sure all tables and figüres
data which can be presented in graphs or are labeled and numbered separately. Captions
diagrams. Each form has its own purpose and go above tables and beneath figures.
rules to follow when choosing the appropriate
graph or diagram. ● DISCUSSION
WHAT DOES IT MEAN?
The IMRAD Report In this section, you summarize your main findings,
The following was taken from The Writing Center comment on those findings, and connect them to
of George Mason University (2020): other research. You also discuss limitations of
your study and use these limitations as reasons
"IMRAD" format refers to a paper that is to suggest additional future research.
structured by four main sections:
Introduction, Methods, Results, and ABSTRACT
Discussion. This format is often used for lab SUMMARIZE THE ENTIRE STUDY
reports as well as for reporting any planned, The abstract of the report comes at the beginning
systematic research in the social sciences, of the paper, but you should write it after you have
natural sciences, or engineering and computer drafted the full report. The abstract provides a
sciences. very short overview of the entire paper including a
sentence or two about the report's purpose and
The IMRAD Report importance, a sentence or two about your
● INTRODUCTION methods, a few sentences that present the main
MAKE A CASE FOR YOUR RESEARCH findings, and a sentence or two about the
The introduction explains why this research is implications of your findings.
important or necessary. Begin by establishing the
problem or situation that motivates the research. Reporting vs Commenting on your Findings
Move to discussing the current state of research In the results section, you simply report your
in the field then reveal a "gap" or problem in the findings. In the discussion section, you comment
field. Finally, explain how the present research is on them.
a solution to that problem or gap. If the study has
1. Refer to your table or figure
hypotheses, they are presented at the end of the and state the main trend.
introduction. Report Table 3 shows that Spam
(Result Filter A correctly filtered more
● METHODS Section) junk emails than Filter B.
WHAT DID YOU DO?
58
is transforming care delivery and
2. Support the trend with data.
Filter A correctly filtered... communication between health professionals
The average difference is… and between nurses and patients.
3. (If needed) Note any ● Information of different forms may be
additional, secondary trends communicated to multiple providers and
and support them with data. patients across settings, in real-time over
In addition, Figure 1 also short and long distances.
shows.
4. (If needed) Note any ● Innovations in ICTs are creating more
exceptions to your main opportunities to deliver care virtually.
trends or unexpected ● Virtual health care delivery establishes
outcomes. However.. opportunities for communicating health
information between patients/clients and
1. (If needed) Provide an
health care providers.
explanation. A feasible
explanation is. This trend can
be explained by… II. APPLICATION OF NURSING
2. (If needed) Compared to INFORMATICS IN CLINICAL SETTINGS
Comment other research. X is
(Discussio consistent with X's finding. In Application of Nursing Informatics in Clinical
n Section) contrast, Y found. Settings
3. (If needed) Evaluate whether
A. ASSESSMENT
the findings support or
contradict a hypothesis. ● Digitalization helps in gathering and
4. State the bottom line: what storing data about each patient.
does the data mean? These ● Assessment data can be physiological
findings overall measures automatically documented
suggest…These data through a patient monitoring system.
indicate… ● Other assessment data can be added
to the electronic patient record by
Common Problems in IMRAD Drafts departments in the healthcare facility
● The Abstract does not provide a clear such as the laboratory and radiology.
statement of the main findings. ● The largest source of assessment data
● The Introduction does not communicate is the ongoing nursing assessment.
clearly why the research is important.
● The Methods section is not detailed enough The following sections briefly describe these
or is disorganized. The Results section sources of assessment data.
provides comments and explanations instead 1. Patient Monitoring
of simply reporting results. ● Patient monitors measure, record,
The material for this handout was drawn from distribute and display combinations of
Carnegie Mellon's "Cheatsheet" on IMRAD vital signs such as heart rate, SPO2,
reports. blood pressure, temperature and more.
● Originally built for coronary care.
BOOK REFERENCE: ● In coronary care units, intensive care
Cu, N.R.S. & Udan, J.Q. (2021). Nursing units, and other cardiovascular clinics
Informatics: Textbook, workbook, and study guide handling pacemakers, computers were
(1st Edition). Manila City: APD Educational initially used to monitor
Publishing House electrocardiograms, analyze the
information, and reduce former
UNIT 9 - APPLICATION OF NURSING volumes of data to manageable
INFORMATICS (CLINICAL) proportions, generally some type of
I. UNIT INTRODUCTION graph.
● The evolution of information and ● High-capability, multi-function monitors
communication technology use in health care are typically used in hospitals and
59
clinics to ensure a high-level of quality decision support systems (Hannah,
patient care. K.J. 2015 on Staggers, 2003).
● Portable patient monitors are designed
to be compact and power efficient. It is 2. Nursing-Generated Assessment Data
also programmed to recognize ● Source data capture is essential in the
deviations from accepted norms and to generation of patient data.
alert attending personnel to the ● means gathering data and information
deviation by some indication either an about patients where it originates, that
alarm, a light alert, or any like. is, with the patient.
● Portable patient monitors ● By entering data wherever the patient
● This allows them to be used in remote is, the reliability of the data is
areas or by paramedics to aid increased. (Hannah, KJ, 2015).
diagnosis in the field, enabling ● Accessing research data directly from
monitoring and transmitting data to Electronic Health Records (EHRS),
health care providers in other locations. known as electronic source data
● In addition to arrhythmia monitoring, capture (eSource), can create
digital devices in acute care areas, efficiencies in the clinical research
such as emergency departments and process while improving data quality,
intensive care unit (ICU), coronary care reducing cost, maintaining integrity and
unit (CCU), and neonatal intensive care preserving audit trails.
units (NICU), are now widely used for ● A significant portion of the growing
hemodynamic and vital sign monitoring, costs of clinical trials, and hence drug
calculation of physiological indices such development, relates to source data
as peripheral vascular resistance, verification (SDV), a process by which
respiratory patterns and cardiac output data from clinical trial collection
among others, and environmental systems are compared to the source
regulation of isolates. information.
● Modern and sophisticated ● The use of Electronic Health Records
computerized ICU monitoring systems (EHRs) in clinical research has the
for management of patient data, potential to eliminate the need for this
including patients' temperature, heart comparison, and for this reason
rates, respiratory rate, arterial blood electronic source data capture
pressure, central venous pressure, (eSource) from EHRs has been a
intracranial pressure, and pulmonary priority for the US Food and Drug
artery pressures, are used around the Administration (FDA) and the subject of
world (Hannah, K.J. 2015 on Varon and a guidance published in 2018.
Marik, 2002; Wong et al., 2003). ● According to Hannah (2015), for source
● Automated approaches to patient data capture to be feasible, nurses
monitoring made the nurses free from must be able to encode patient data
the technician role of watching remotely or outside of the nursing
machinery and allowed them to focus station.
on patient care, the family, and the ● This need has required a revolution in
nursing process. digital hardware and software.
● It is now widely accepted that ● This need has required a revolution in
computerized cardiac monitoring of digital hardware and software.
patients dramatically increases the ● The local-area network nursing station
early detection of arrhythmias and terminal of the hospital mainframe
contributes to decreased mortality of computer is no longer adequate as it
CCU patients. increases time needed for nurses to
● Additionally, many of these monitoring document care rather than focusing
systems are already integrated into
60
those time needed to the patient care According to Hannah (2015), when
whichever nursing setting it might be. considering the adoption of point of care
● Computer data entry must occur systems, the following points should be
wherever patients are found. This is evaluated:
called a "point of care" information 1. Point of care systems must allow the
system. nurse to interact with the main
information system. Systems that do not
Goals for moving to point of care systems are allow information to be extracted, as well
identified as follows. as entered, are not useful to nurses.
2. Point of care systems must interface
● To minimize the time spent
documenting patient information. with the existing hospital information
● To eliminate redundancies and system. The nurse at the patient's
inaccuracies of charted information. bedside must be able to access data that
● To improve the timeliness of data has been generated by the laboratory, or
communication. radiology, or pharmacy.
● To optimize access to information. 3. The open systems concept is valuable
● To provide information required by the to nurses considering point of care
clinician to make the best possible systems. This concept allows machines
patient care decisions from all vendors to communicate. Open
systems allow the most appropriate type
● Source data capture is the first step in of machine to be selected for each nursing
reducing the time nurses spend on environment.
documentation of care and eliminating 4. Point of care systems must have a
redundancies and inaccuracies small footprint (take up a small amount
● Time is saved and data have been of floor space). Not all hospitals have the
accurately transformed into usable opportunity to configure a new building
information when information can be from the ground up. Most hospitals are
entered directly into the patient's trying to fit new technology into “old skin."
electronic health record at the point of Early examples of bedside terminals took
care by the healthcare professional or a up a large amount of space in patient
medical device such as hemodynamic rooms. With limited electrical outlets and
monitors, infusion pumps, or ventilators no piped in oxygen or suction, a patient
and it is made immediately available to room that had all the equipment
others involved in the patient's care. necessary to care for seriously ill patients
● Point of care systems use a left no room for the nurse.
wide-array of digital hardware and 5. Point of care systems must be easy to use
software. Something that is mobile, and must adapt to a variety of nursing
portable, real-time, and environments. Patient contact occurs 24
remotely-accessible communication hours a day. For example, bedside
device with many input options (e.g., terminals must allow the nurse to access
touch, pen, voice) that has the ability to and input data without turning on the lights
display patient information as needed, or disturbing the patient. The annoying
including graphics, an easy little "beeps" a computer makes when
documentation method, and long you have made a mistake in data entry
battery life, is ideally preferred. have no place in bedside terminals.
● Technology is fast moving toward this 6. Point of care systems must be easily
ideal and is continually developing new disinfected and cleaned between
standards for the improvement of the patients. Bedside keyboards should have
delivery of care leaning towards a membrane keyboard or a protective
digitalization. "skin" over the keyboard to protect it from
liquids.
61
7. For source data capture to be easily ● With the first approach, a digital library
accomplished, nurses require a variety of of frequently used phrases is arranged
ways by nurses. Traditional nursing notes in subject categories.
are voluminous. Trying to find key data for ● The nurse chooses the phrase or
entering data. Keyboards require some combination of phrases that best
typing skills. Other devices include bar describes the patient's condition. For
code readers for scanning identification example, by selecting a primary subject
bands and medications, physiological such as "sleeping habits", a screen
probes, microphones for voice input, light menu of standard descriptions appear,
pens and touch screens, digital cameras, allowing for additionally selected
and natural speech input devices. The comments such as "slept through
touch screen uses icons (pictures) rather breakfast-voluntarily” or “awoke
than words. Icon menus are easier to use, early at a.m."
especially if the exact keyword is not ● When completed, the nursing station
known. printer immediately prints a standard,
8. For effective source data capture, the easy-to-read, complete narrative that
nurse must go wherever the patient is. If could then be attached to the patient's
that is the visiting lounge or the coffee chart. An example of an assessment
shop or the outside deck, a fixed bedside screen is shown below.
terminal is not appropriate. Notebook
technology and pen-based portable
systems offer the best choice for mobility.
9. Information to be retrieved using the point
of care system must be represented in
ways that can be quickly used and easily
understood in a narrative is too
time-consuming when the information is
urgently needed. Figure below illustrates a
cardiac risk assessment tool. At a glance,
the nurse can tell which factors must be
addressed.

3. Documentation
● An ideal nurses' notes are generally ● The second approach has been to
lengthy, problem-focused narrative, develop a "branching questionnaire.”
handwritten, and unbiased ● The terminal displays a list of choices,
observations. At their worst, they are and the nurse selects her choice and
inaccurate, inconsistent, incomplete, or indicates it by pressing the
trivial as some statements are routinely corresponding number on the keyboard
placed such as "endorsed, for or touching the terminal with a
continuity of care, kept warm” that light-sensitive input device(called a light
are at times already irrelevant to the pen). The terminal then displays a
actual patient scenario. further list of choices appropriate to the
● Hannah (2015) stated that automated original selection.
methods for recording nursing ● Thus, the nurse is led through a series
observations are some of the most of questions that can be "customized"
readily available nursing informatics for each patient (Hannah, 2015).
applications. Two approaches ● Many advantages that have been
predominate. claimed for automated documentation
of nursing observations include the

62
following (Hannah 2015 on Husting and e. Better diagnostic and treatment capabilities
Cintron, 2003; Moody et al.,2004). due to quick access and sharing of health
● Content standardization: increased information, and Improved health care
charting completeness including in- access for rural and remote groups via
creased numbers of observations telehealth (Canada Health Infoway, 2012b).
because of prompting or forced recall
and increased standardization, ● EHRs are fundamental to the success
accuracy, and reliability of observations. of the retail clinics model of care. Like
Improved standards compliance all practice EHRs, those developed for
● Increased efficiency: legible notes, retail clinics support the assessment,
which decrease reading time and diagnosis, and treatment workflows of
increase accuracy of interpretation and the provider.
elimination of repetitive data recording
and resulting transcription errors. The goal of the retail EMR is to:
● Enhanced timeliness: less time spent A. Help providers practice autonomously
writing notes, specifically end-of-shift of B. streamlining administrative functions,
charting while suggesting clinically appropriate
● Expanded accessibility: data actions generated from evidence-based
available on-line immediately and practice guidelines and clinical
access not limited to one person at a documentation.
time as with paper record
● Augmented data archive: ready 5. Data Issues
statistical analysis and easier nursing ● Nurses spend a great deal of time and
audit because of the use of standard energy gathering data.
terminology. ● Considering the data privacy
confounding issues many of data might
4. Clinical Documentation Management be used for multiple purposes such as
● The introduction of EHR systems administrative or government statistics
presents both opportunities and in order to determine the eligibility to
challenges for healthcare professionals. avail certain services or healthcare
● Nurses need to utilize EHR systems to premiums.
improve interdisciplinary ● Often the same data are duplicated by
communication and ultimately patient/ the data-gathering activities of other
client safety. healthcare professionals (e.g., how
● EHRs are considered to be patient/ many times are patients who are being
client-centered. admitted to your institution asked by
Potential benefits for patients/clients include: different categories of staff why these
a. Quick access to health information during patients have presented themselves)
medical emergencies; for quality improvement, training
b. Improved management of chronic disease purposes and the like for healthcare
through trending of information and improved institutions (Hannah, 2015).
communication between multiple health care ● Nurses should only be gathering data
professionals; that are essential for nursing
c. Shorter waiting times through improved decisions about patient care.
communication about wait-lists for diagnostic ● The principle involved is to gather
testing and interventions. essential information while avoiding
d. Reduction of unnecessary repetition of replication and duplication of data that
diagnostic tests by improved flow of waste resources such as manpower,
information between healthcare professionals storage space, and memory
and health sites; (Hannah, 2015).

63
The Shift to Electronic Documentation ● Each of these providers is able to access
● Traditionally health care professionals patient data from the EHR at the same time.
documented on paper medical records.
Paper records are episode oriented, with a The key advantages of an EHR for nursing
separate record for each patient visit to a include:
health care agency. 1. A means for nurses to compare current
● Key information such as patient allergies, clinical data about a patient with data from
current medications, and complications from previous health care encounters and
treatment are sometimes lost from one 2. To maintain an ongoing record of health
episode of care (e.g., hospitalization or clinic education provided to a patient and the
visit) to the next, jeopardizing a patient's patient's response to that information.
safety (Hebda and Czar, 2013). RISKS AND BENEFITS OF ELECTRONIC
● Although the terms EHR (Electronic Health HEALTH RECORDS
Record) and EMR (Electronic Medical
Record) frequently are used interchangeably ELECTRONIC HEALTH RECORD systems are
in practice, there are differences between used in various hospitals, community health
them. settings, and doctor's offices to enter and view
● An EHR is a digital version of patient data client information.
that is found in traditional paper records. ● Unique client identifiers are used to ensure
● The term EHR is used increasingly to refer to that information about the client is linked with
a longitudinal (lifetime) record for all the correct health care provider, the client's
healthcare encounters for an individual most recent results of laboratory and
patient (Hebda and Czar, 2013). diagnostic tests, and an updated list of
● An EMR is the legal record that describes a currently prescribed medications.
single encounter or visit created in hospitals ● Information about the client's vaccination
and out-patient health care settings that is history, allergies, consults, operative reports,
the source of data for the HER. and discharge information is also provided.
● A benefit of using electronic health records is
The promise of the EHR is two fold: that health care providers have quick access
1) Making a positive impact on the quality of to medical information.
patient care through interprofessional ● Clients benefit as they receive improved
collaboration with improved data management of chronic diseases, such as
availability and information synthesis, and when health care professionals can receive
2) Improving patient safety through the use reminders of follow-up tests.
of clinical decision support (Saleem et ● Electronic health records also reduce
al., 2013). unnecessary repetition of laboratory and
diagnostic testing, which ultimately saves
● The EHR provides access to a patient's money.
health record information at the time and ● Electronic health records may also include
place that clinicians need it. the use of standardized evidenced-based
● The EHR provides access to a patient's protocols for nursing care.
health record information at the time and ● Nurses can access the most current
place that clinicians need it. evidenced-based protocol to see potential
● A unique feature of an EHR is its ability to nursing interventions, which can serve to
integrate all patient information into one improve documentation of assessments and
record, regardless of the number of times a interventions by providing reminders to chart
patient enters a health care system. specific symptoms or to chart the
● Example of how an EHR works: A patient administration of PRN medications.
with a complex medical history sees multiple ● A risk of electronic health records is that
specialists (endocrinologist, cardiologist, people not within the circle of care may
nephrologist) to manage his or her health. access confidential information.
64
● Regional health authorities have taken password is a collection of alphanumeric
measures to monitor for such risks. characters that a user types into a computer
● These measures include providing limited before accessing a program after the entry
access and monitoring who is viewing any and acceptance of an access code or user
confidential health information. name.
● When using a health care agency computer
PRIVACY, CONFIDENTIALITY, AND SECURITY system, it is essential that nurses do not
MECHANISM share computer passwords with anyone
● Electronic documentation has legal risks. It is under any circumstances.
possible for anyone to access a computer ● To protect patient privacy, health care
station within a health care agency and gain agencies track who accesses patient records
information about any patient. and when they access them.
● Therefore, protection of information and ● Disciplinary action, including loss of
computer systems is a top priority. employment, occurs when nurses or other
● Ensuring appropriate access to and health care personnel inappropriately access
confidentiality of PHI (Personal Health patient information.
Information) is the responsibility of all people
working in health care. HANDLING AND DISPOSING OF
● Most security mechanisms for computerized INFORMATION
information systems use a combination of ● Maintaining the confidentiality of medical
logical and physical restrictions to protect records is an essential responsibility of all
information. members of the care team.
● For example, an automatic sign-off is a ● It is equally important to safeguard any
safety mechanism that logs a user off a information that is printed from the record or
computer system after a specified period of extracted for report purposes.
inactivity. ● Destroy (e.g., shred) anything that is printed
● Other security measures include firewall and when the information is no longer needed.
the installation of antivirus and Nursing students must write patient data
spyware-detection software. A firewall is a needed for clinical paperwork directly from a
combination of hardware and software that patient's medical record on the computer
protects private network resources (e.g., the screen or the physical chart.
information system of the hospital) from ● De-identify all PHI, keep the documents
outside hackers, network damage, and the secure, and destroy documents by shredding
theft or misuse of information. or disposing of them in a locked receptacle
● Physical security measures include placing as soon as possible.
computers or file servers in restricted areas ● Destroy all papers containing PHI (e.g.,
or using privacy filters for computer screens Social Security number, date of birth or age,
visible to visitors or others without access. patient's name or address) immediately after
● This form of security has limited benefit, you use or fax them. Most agencies have
especially if an organization uses mobile shredders or locked receptacles for
wireless devices such as notebooks, tables, shredding and incineration.
personal computers (PCs), and personal
digital assistants (PDAs). B. PLANNING
● These devices are easily misplaced or lost, 1. Automated Care Planning
falling into the wrong hands. ● Majority of the healthcare settings use
● Some organizations use motion detectors or the kardex or some similar tool to
alarms with these devices to help prevent serve repositories of nursing care
theft. plans.
● Access or log-in codes along with passwords ● This tool is being used to handoff or
are frequently used for authenticating endorse patient care between one
authorized access to electronic records. A nurse to another, but has had
65
drawbacks similar to those encountered ● The evolving and redesigning approach
with nursing notes as well as other to care planning is the development of
drawbacks that are unique to the decision support systems for nursing
kardex. practice (Hannah, 2015).
● Nursing care plans, if they are ever
entered in the kardex at all, usually are The advantages of automated care plans or
outdated, illegible, irrelevant, pathways over traditional nursing care plans:
inconsistent, and incomplete. a. Time is saved by eliminating the need for
● Sadly, it is only during quality care daily handwriting of patient assignments
audits that these documents get and by decreasing the amount of verbal
precise and updated. explanation required.
● Notations are made by all levels of Implication: Time saved during the preparation
nursing personnel from nursing aides to and communication of care plans means more
head nurses. time available for the nursing process.
● Written patient care assignments are b. Accountability is increased because
usually accompanied by verbal personnel have printouts of care plans for
explanations that are often forgotten. each of their patients.
● This approach is often one source of Implication: improves nursing practice because
faulty communication between documentation is available to evaluate the quality
nurses caring for the patient. of care and thus the quality of practice
c. Errors and omissions are decreased.
d. Consistency of care from shift to shift
and day to day is increased; quality of
patient care improves
Implications: Benefits to patient care of
decreased errors and omissions and increased
consistency of care include more rapid
diagnosis, more valid assessment, and more
rapid recovery.
e. Judgments for nursing care are no
longer delegated to whoever walks into a
room to care for the patient; they are the
responsibility of the professional nurse
who now has tools available to help make
● Alternative approaches to the nursing judgments.
automation of nursing care plans is Implication: The responsibility for nursing
to design care maps or pathways for judgments is clearly placed on the professional
meeting patient needs, store them in nurse, which helps in defining nursing practice.
the computer memory banks, and then
adapt them to individual patients 2. Decision Support Systems
(Hannah, 2015 on Catt et al., 1997; ● Help nurses maintain and maximize
Renholm et al., 2002). their decision-making responsibilities
● The resulting output is unique for each and focus on the highest priority
patient's assessed needs for daily aspects of patient care.
care. ● The care planning systems are not
● In all cases, it is the nurse who decision support systems.
assesses, plans, and evaluates the Standardized care plans, whether
plan for care, and auxiliary personnel manual or computer-based, provide
might also be involved in the care only for standardized patients.
implementation of the plan. ● Standardized care plans do not
enhance nursing decision-making; on
66
the contrary, their template approach ● Decision support systems are usually
discourages active decision-making by designed to address nursing diagnoses
nurses. one at a time, not in combination.
● a computerized clinical pathway with ● Decision support systems can never
the room for variance may be an replace the need for nurses with expert
alternative to having only standardized clinical and decision-making skills.
care plans. ● Therefore, the nurse is still required to
● A true decision support system exercise clinical judgment, regardless
allows nurses to encode their of whether a decision-modeling or
assessments at the bedside using expert system has been used.
source data capture technology and ● The fundamental idea that must be
then use the computer to analyze those stressed is that decision support tools
assessments and recommend nursing should add to the nurse's
diagnoses. decision-making capacity, not attempt
● The nurse then accepts or rejects the to replace it.
recommendations.
● After accepting a particular diagnosis,
the range of interventions acceptable in
that institution can be retrieved and
presented by the digital device.
● The nurse can then choose the nursing
interventions appropriate for the
patient.
● Are being developed for different care
settings and situations.
● Are useful because each nurse's
collection of interventions is based
solely on professional experience.
● The nurse's collection of interventions
is also influenced by a "forgetting”
curve .
C. IMPLEMENTATION
● If the nurse has not encountered a
Digital devices rarely help the nurse in the giving
specific nursing diagnosis for a long
of care or nursing service. Generally, computers
time, the remembered interventions
are used more in other phases of the nursing
may not reflect the whole collection.
process. One example of how computers are
● The advisory or expert system not only
used in intervention is the programmed
accumulates the experience of all
administration of preloaded drugs in the ICU
nurses in the organization but also
(Hannah, 2015).
serves as a "reminding" function.
● Have been developed for a variety of
D. EVALUATION
settings, including critical care, cancer
Digital devices can be used to evaluate nursing
pain management and pediatric fever
care through real-time auditing and quality
● Decision support systems may not be
improvement and management activities.
appropriate for all patient care
settings or at all times.
HOW NURSING INFORMATICS IMPROVES
● Highly complex patient problems
PATIENT CARE
may also prove a great challenge for
● The healthcare information revolution is upon
the current types of decision support
us.
systems.

67
● Clinicians have more access than ever to procedures used in a healthcare
electronic health records, diagnostics, and organization.
treatment plans. ➢ A nurse informaticist will measure and
● Clinical communication and collaboration analyze how specific parts of the
platforms are making it easier to manage organization are performing, with a
healthcare workflows, improve coordination, focus on the resulting patient
and enhance patient outcomes. outcomes.
● Systems integration and data access mean ➢ They can then make changes to
that information and analysis are more vital specific parts of the process to
than ever. streamline activities, avoid bottlenecks,
● The secret to using this data to provide better and improve care.
care comes down to nursing informatics ➢ Informaticists will see what the results
integrating nursing science with other areas are and continue making changes to
to identify, define, manage, and communicate enhance every part of the clinical care
data, information, knowledge, and wisdom to process.
provide better care. 3. Providing Training and Learning Based on
● The informatics nurse is part of the delivery Objective Data
of care, the building of knowledge, skills, and ➢ One of the most valuable ways a
experience in the use of information nursing informaticist can enhance
technology. patient outcomes is through providing
● They often lead clinical informatics training to clinical staff.
committee meetings that have a major ➢ They can use data to identify endemic
influence for nurses in assisting them to issues in a healthcare organization and
coordinate all the multifaceted technology consult on the best way to resolve
activities in regards to patient care, these problems.
documentation, and safety. ➢ These learnings can be integrated with
onboarding new staff, ongoing in-house
1. Aligning Nursing Best Practice with training, or external education and
Clinical Workflows and Care certification.
➢ Nursing informatics is focused on the ➢ Nursing informaticists can help to
best ways to achieve good patient create highly-targeted educational
outcomes - it is about applying the programs to deal with specific gaps
overall process and best practice to between ability and provider
maximize patient care wherever expectations.
possible. 4. Selecting and Testing New Medical
➢ As a result, nurse informaticists are Devices
often involved in process design, ➢ Connected medical devices can
clinical workflow reviews, and new provide vast amounts of health data on
diagnostics and treatment plans. patients.
➢ They take into account the various ➢ Nursing informaticists are ideally
options for providing care and use positioned to understand the true value
objective facts and analysis to of that data and provide
determine the actions that will lead to recommendations on how it can be
the most patient-centered, value-based recorded, accessed, and used.
care. ➢ Involving informaticists in the selection
2. Improving Clinical Policies, Protocols, of medical devices will ensure you have
Processes, and Procedures additional criteria for understanding
➢ Data is the lifeblood of nursing how device data can inform
informatics. That data and information diagnostics, treatment plans, and
can be used to measure the success of ultimately patient outcomes.
the various protocols, processes, and 5. Reducing Medical Errors and Costs
68
➢ Nursing informaticists can reduce the
chance of medical errors in a ASYNCHRONOUS ACTIVITY ON CLINICAL
healthcare organization, together with APPLICATIONS:
associated costs. I. PHYSICAL ASSESSMENT
➢ A combination of staff training, process 1. For appreciation of Physical Assessment in
improvement, and best practice will the EHR, ask your students to fill in the
enhance the quality of care and limit physical assessment template with the given
patient risks. link below:

There are four main areas that drive medical Healthy Simulation Physical Assessment EHR
errors: Template:
a. Communication doesn't take place when it https://www.healthysimulation.com/wp-content/upl
should. oads/2018/03/EHR-Physical-Assessment-From-H
b. Incorrect or incomplete information is ealthySimulation.xlsx
communicated.
c. Information is shared with the wrong recipient 2. The student may use a classmate or a
or third part. relative as a patient, provided that a consent
d. The message lacks critical facts or is unclear, will be obtained prior to assessment. This
meaning it isn't understood correctly consent should also be submitted.
Informaticists can look at how your
organization communicates and collaborates
around patient information. They can audit II. ELECTRONIC HEALTH RECORD
individual cases, identify gaps, and provide 1. For appreciation of what an electronic health
recommendations for avoiding errors in the record is like. Allow your students to access
future. the link below:

6. Enhancing End-to-End Treatment and Marymount University Electronic Health


Continuity of Care Record Template: https://bit.ly/2PKWTM0
➢ A patient's care may involve several
areas, many teams, and dozens of 2. Use the sample scenario below:
individuals. Client is 72 Yr. an old male lives alone. Hx:
➢ Nursing informaticists can create Bilateral lower extremity edema cellulitis of lower
protocols and processes to ensure extremities, HTN, venous stasis, renal
proper communications and insufficiency, hypercholesterolemia and obesity.
interactions between departments, Alert and oriented X3 (Time, Place, Person),
teams, individuals, and patients. self-directing. Ambulates and transfers
➢ They can help healthcare employees to independently with walkers. Skin is intact.
seek out “one view of the truth" Incontinent of bladder & bowel at times. No
through electronic health records, so issues are noted with regards to chewing or
everyone has the context and insight swallowing. Appetite is fair, stating his appetite is
they need to ensure excellent continuity not what it used to be. He is very intent on healthy
of care. eating and is eager to stop eating high sodium
foods. He is 5'8" and is 352#. Senses WNL with
Further readings and video resource/s: glasses for reading. Sleeps on a hospital bed
● Introduction to clinical decision which is easier for him to transfer into. PERS
support: https://youtu.be/e8a6hE1PrcQ checked this visit. Response time.
● Clinical Decision
Support: https://youtu.be/BBRDPXEBIxs Alternative scenario:
● Clinical Decision Support Client is 27 y.o. female dx: spinal cord injury
Demonstration: https://youtu.be/leynspb with quadriplegia (MVA when client was 16),
mGp0 spasticity, neurogenic bowel and bladder. Client is
69
alert oriented x3, self directing client is A. MOVING AROUND
non-ambulatory is transferred via stand pivot; has 1. Open up a new spreadsheet and click
power which client is able to maneuver PWC your cursor in cell B2.
independently; needs assistance with manual 2. Note that the cell B2 is seen in the left
which client purchased van with lift access. Client hand corner.
graduated from law school and is now employed 3. Type 1 into the cell and press the enter
full and part time evenings. CDPAP gets client key.
ready for work, makes breakfast feeds, does all ● Or: You can move around the spreadsheet
personal care and grooming, cleans up client's by either clicking on the cell with your mouse
area, accompany client to work and assist with cursor or by using the arrow keys on the
toileting (st cath every 2-4hrs) feeding and taking keyboard.
notes for client at work, bowel regimen, ● Note: text is on the left hand side of the cell
(suppository), and assist with PM care and putting and numbers are on the right side of the
client to bed, ROM, incidental groceries, laundry, cell.
HHC's client area. Weight stable approx. 100-105
lbs. Client has Baclofen pump monitored by BGH B. THE DRAG HANDLE
3mos. Skin intact, sleeps well, appetite good, no ● A feature that allows the user to extend (and
problem chewing or swallowing. Client has fill) a series of numbers, dates or even text to
received PT and OT in the past and follows a a desired number of cells.
home program based on previous instruction of ● In an active cell of the spreadsheet, the drag
the therapist. Client feels no further need for handle is a small black box at the bottom
formal PT and OT at this time. Parents assist with right corner.
medication pick up and setup, parents provide a. Dragging to copy cells
care at night for turning and positioning and all ➢ In the bottom right corner of the
care during non-covered hours. Coworker gives a highlighted cell is a small square.
client a ride to work. CDPAP care plan of 85 hrs. ➢ By clicking and holding down
a week as safe and adequate at this time. the left mouse button you can
drag the contents of the cell
MICROSOFT EXCEL across other cells and copy into
● Electronic Spreadsheet Computer program the new cells.
created by Microsoft inc. b. Filling numbers in the cells
● Used for storing, organizing and ➢ not only can you copy cells across
manipulating data cells, you can also have
● Composed of grid rows and columns numbers added consecutively
● The horizontal rows are identified by across cells.
numbers (1,2.3) the vertical column with ➢ To do this the computer needs to
letters of the alphabet(A,B,C). know how much you want the
● For columns beyond 26, columns are numbers to increase.
identified by two or more letters such as AA, ➢ For example: 1,2,3, or 1,3,5 or
AB,AC. more

C. CHANGING CELL WIDTHS BY DRAGGING


Cell 1. Changing cell widths by Dragging
● The intersection point between a column is a a. Moving your cursor between A
small rectangular box and B on the Column row as
● The basic unit for sorting in the spreadsheet shown left.
● An excel spreadsheet contains thousand of b. Click and hold down your left
cell mouse button and drag the cell A
● Each is given a cell reference or address to out to make more room in the cell.
identify it. Note: What happens if you move the cell
boundary too far and the words can not fit into the

70
cell? What happens when you move the cells with ● Use the following buttons to create
the numbers too close? mathematical symbols In the
2. Changing cells with automatically spreadsheet.
a. by double clicking on the lines a. (+) to add
between the columns A and B. b. (-) to subtract
The columns then will increase or c. (/) to divide
decrease to fit the biggest entry d. (*) to multiply
e. (=) to make equals
D. MOVING DATA ON THE SPREADSHEET ● It is important to note the order of the
1. Cut and copy symbols when creating formula:
2. Click and drag PEMDAS
a. mark a whole column from the a. () brackets are the 1st priority
heading to what’s written below. b. / division is next
b. Move your cursor to the edge, or c. * Multiplication
boundary of the highlighted area. d. + addition
c. Click and hold down the left e. - Subtraction
mouse button and drag the cells ● Example:
back into their original place. a. 3+10/2 = 8
E. INSERTING ROWS AND COLUMNS b. 4+6*6 = 40
1. Inserting a new column c. (3+7)/5 = 2
a. Click the column marker to d. (5-3)+(9-6)/3 = 4
highlight the entire column. e. ((5-3)+(3+1))/2 = 3
b. Right click your mouse button and f. ((4+6)/2)/(8-3) = 1
choose insert. g. (6-1)(2+3) = 25
c. A new column will be inserted, ● Formulas with numbers
moving the total column over one. a. Type in the formulas into the
2. Inserting a new row/s formula bar.
a. Click the row marker to highlight b. Always include an = before the
the entire column. formula.
b. Right click your mouse button and c. Formulas with cell reference
choose insert. d. Inserting cell references
c. A new row will be inserted, automatically
moving the total row over one. e. Auto sum/average
f. If- then
F. DELETE ROWS AND COLUMNS g. ranking
1. Deleting a column/s
a. Click the column/s marker to
highlight the entire column.
b. Right click your mouse button and
choose delete.
2. Deleting a row/s
a. Click the row/s marker to highlight
the entire column.
b. Right click your mouse button and
choose delete.

G. FORMULAS
● Are calculations created on the
spreadsheets?
● Formulas range in complexity from
extremely complicated to easy ones.
71
H. RANKING d. Degree program: Bachelor Of
a. =RANK(F3,$F$3:$F$7) Science In Nursing
e. Name/s of the research
proponent/s
f. Month and year of graduation
2. Approval sheet. It is placed
immediately after the title page.
a. Generally it contains statements of
recommendation and
acceptance.
b. The approval of the adviser that
BMI the thesis proposal is complete
● Formula: weight (kg) / [height (m)]2 and the recommendation of the
● With the metric system, the formula for BMI same for oral examination.
is weight in kilograms divided by height in c. The approval of the panel of the
meters squared. Since height is commonly examiners that the thesis proposal
measured in centimeters, divide height in has been examined
centimeters by 100 to obtain height in d. The acceptance of the department
meters. of nursing and of the academic
● Example: Weight = 68 kg, Height = 165 cm office.
(1.65 m) 3. Acknowledgement sheet. This reflects
● Calculation: 68 ÷ (1.65)2 = 24.98 the researcher/s expression of
appreciation for the assistance and
PREPARING THE FINAL COPY OF THE encouragement extended to him/them
THESIS PROPOSAL in making the research paper.
Pronouns used must be in third
I. GENERAL FORMAT person.
1. Margins 4. Abstract
a. Left – 1.5 a. It is a brief yet comprehensive
b. Top. Bottom. Right – 1 inch summary of the paper.
2. Font type and size – times new roman b. It describes the:
or arial, size 12 ➢ Problem research on
3. Spacing – double spacing except for ➢ The number and kind of
figures., tables and abstract (single participants or respondents,
spacing) ➢ The hypothesis,
4. Paragraph indention five letter spaces ➢ summary of procedures and
5. Pagination – one inch from the right methods
edge of the paper on the 1st line of ➢ Instrumentation, Results ,
every page. Conclusion, Implication,
II. PRELIMINARY PARTS recommendation
1. Title Page – it is center-justified and 5. Table of contents
ALL CAPS, follows the inverted ● This is an ordered and paginated listing of
pyramid style and is single- spaced. the different parts of the thesis.
Contents: ● It must show the chapter and section titles in
a. Title full and must have entries for the references
b. Classification of paper: Thesis and appendices sections.
proposal a. The heading TABLE OF
c. Department to which the paper is CONTENTS should be typed
presented and the college to which centered and in all capital letters.
it belongs b. Spacing should be 1.5 in.
throughout
72
c. Preliminaries should be listed figure from the corresponding page
first. number.
d. The heading Chapter should be III. THE BODY OF THE PROPOSAL
flushed left on the same line with 1. Each chapter should have a heading
Page flushed right. Only the first that is center justified. The chapter
letters of the words are capitalized. numbers should be in Arabic numerals,
e. Below the heading Chapter are e.g., “Chapter I.”
the titles of the different chapters in 2. The chapter number is followed by the
uppercase. title in all capital letters and encoded at
f. Opposite each chapter title is the the center.
corresponding page number led 3. All element/s titles should be flushed
by dots. left.
g. Chapter and section titles should
not extend beyond the right margin IV.END MATTERS
of the leaders (dots). If a chapter/ 1. References
section titles occupies more than a. All should appear on the new
one line, the second line onwards page, separate from the body of
must align- left with the first. the thesis.
6. List of tables. It appears on the page b. All references cited on the body of
immediately following the table of the research paper must appear in
contents. the References section.
a. LIST OF TABLES should be typed c. The heading References is
centered and in all capital letters. centered–justified on the first line
b. The heading Table should be below the page header.
typed three lines spaces below the d. The entries with changing
title and flushed to the left margin; indentions, begin on the line
opposite the word Page which is following the heading References
flushed to the right margin. e. Entries begin with the surnames of
c. Arabic numerals are used for the the authors and are arranged
table numbers which are placed alphabetically.
right under the heading Table. A Components of a reference entry
tab is inserted after each table i. Author’s Name – type the surname first
number, Then the little table followed by a comma, then the first name
appears. and the middle initial. If there are six authors,
7. List of Figures all their names are written. If they are more
It is placed on the separate page right after the than six, the remaining authors can be
list of the tables represented by the words “et al”
a. LIST OF FIGURES is typed ii. Year of Publication. It should follow the
centered and in upper case. period after the author’s name and should be
b. The heading Figure should be enclosed in parenthesis
typed three line spaces below the iii. Book Title. The complete title and book
title and flushed to the left margin: edition should be written. The entire book title
opposite is the heading Page must be italicized. Only the first letter of the
which is flushed to the right first word and of proper names must be
margin. capitalized.
c. Arabic numerals are used for the iv. Journal title. The title of the article, in roman
table numbers, which are placed face and sentence case (only the first letter
right under the heading Figure. A of the first word and of proper names are
tab is inserted after each table capitalized), appears first. The title of the
number, followed by the title of the journal itself appears in italics and in the title

73
case (the first letter of each substantial word
is capitalized.
v. Place of publication. The city where the
book is published should be written followed
by a colon.
vi. Publishing house. The name of the
publishing house follows the place of
publication
2. Examples of reference entries:
a. Book revised edition
Example:
Smeltzer, S. C., Bare, B. G.,
Hinkler, J. L., & Cheeves, K. H.
(2008). Brunner and Suddart’s
textbook of medical- surgical
nursing (11th ed). Philadelphia:
Lippincott Williams and Wilkins.
b. Journal Supplement
Example:
Chouinard, M. C.,&
Robichaud-Ekstrand, S (2005)The
effectiveness of a nursing inpatient
smoking cessation program in
individuals with cardiovascular
disease. Journal of Nursing
Research, 54(4), 243-254

74

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