fetus (unborn baby) develops and grows.

PLACENTA PREVIA Also called the womb.

DEFINITION
• Is a condition of pregnancy in which the • Cervix - is the opening in the lower part of
placenta is implanted abnormally in the the uterus (womb) that opens to the top of
uterus. the vagina (birth canal). During pregnancy,
• It is the most common cause of painless the cervix stays firm and closed until late in
bleeding in the third trimester of pregnancy. the third trimester.
• Prevalence rate: approximately 5 per 1000
pregnancies • Vagina - the pathway (the birth canal)
through which a baby leaves a woman's
IT OCCURS IN FOUR DEGREES: body during childbirth.

1.Low-lying placenta- implantation in the Lower In Placenta Previa, the placenta forms partially
portion rather than in the upper portion of the or totally toward the lower end of the uterus,
uterus. including the cervix, rather than closer to its
Normally the placenta is implanted on the upper upper part
portion of the uterus. Low-lying is lower than
normal. In cases of complete Previa, the internal os—that
is, the opening from the uterus to the vagina—is
2.Marginal implantation- the placenta edge completely covered by the placenta. During labor,
approaches that of the cervical os. Does not the cervix begins to thin out (efface) and open up
cover/reach the cervical os. (dilate), the dilation of the cervix further tears the
placenta and causes bleeding.
3.Partial placenta previa- implantation that The placenta can move up until 32 weeks of
occludes a portion of the cervical os. Halfway pregnancy. It is common to have a placenta that
covering the cervical os. moves upwards and away from the cervix as the
baby gets bigger.
4.Total placenta previa-implantation that totally
obstructs the cervical os. Covers the cervical os. ETIOLOGY
Needs a surgical intervention (CS).
The exact etiology of placenta previa is unknown.
The condition may be multifactorial and is
postulated to be related to the following risk
factors:

• Increased parity
• Advanced maternal age
• Past cesarean births
• Past uterine curettage
ANATOMY & PHYSIOLOGY • Multiple Gestation
• Placenta - provides oxygen and nutrients SYMPTOMATOLOGY
to a growing baby and removes waste
products from the baby's blood. Produces Bleeding:
human chorionic gonadotropin (hCG),
human placental lactogen (hPL), estrogen,
• Begins when the lower uterine segment
and progesterone.
starts to differentiate from the upper
segment starts to differentiate from upper
• Uterus - the hollow, pear-shaped organ in segment
a woman's pelvis. The uterus is where a
• Abrupt
 • Painless LABORATORY & DIAGNOSTIC TEST
• Bright red- sudden so fresh pa ang color
• Sudden enough to frighten a woman (To detect a possible clotting disorder, and
• Not associated with increased activity or prepare blood replacement)
participation in sports ● Hemoglobin
• Stop as abruptly as it began ● Hematocrit
● Prothrombin time
P- painless bright red bleeding ● Partial thromboplastin time
R-relaxed soft uterus non-tender ● Fibrinogen
E- episodes of bleeding (mild profuse) 3rd- ● Platelet count type and crossmatch
trimester body for baby; thinning of the cervix ● Antibody screen
V-visible bleeding ● Placenta previa can be detected through
I-intercourse post bleeding (spontaneous labor) sonogram/ultrasound
A-Abnormal fetal position (breech, transverse lie) Most cases of placenta previa are
diagnosed during a second-trimester
GENERAL PATHOPHYSIOLOGY ultrasound exam.
● A healthcare provider may attempt a
Placental implantation careful speculum examination of the
vagina and cervix to establish the degree
- initiated by the embryo (embryonic plate) of fetal engagement and to rule out
adhering in the lower (caudad) uterus. another cause of bleeding
- With placental attachment and growth, the
developing placenta may cover the cervical MEDICAL MANAGEMENT
os.
- However, it is thought that a defective Betamethasone (Celestone)
decidual vascularization occurs over Action: Betamethasone is a corticosteroid
the cervix, possibly secondary to that acts as an anti-inflammatory and
inflammatory or atrophic changes. immunosuppressive agent. It is given to
- As such sections of the placenta having pregnant women 12 to 24 hours before birth
undergone atrophic changes could to hasten fetal lung maturity if a fetus is less
persist as a vasa previa. than 34 weeks’ gestation and help prevent
- A leading cause of third-trimester respiratory distress syndrome in the
hemorrhage, placenta previa, presents newborn (Karch, 2009).
classically as painless bleeding.
- Bleeding is thought to occur in
Pregnancy Risk Category: C
association with the development of
the lower uterine segment in the third Possible Adverse Effects: Burning, itching, and
trimester. irritation at the injection site; swelling, tachycardia,
headache, dizziness, weight gain, sodium, and
Placental attachment is disrupted fluid retention; increased risk of infection if used
long term.
- as this area gradually thins in
preparation for the onset of labor. Nursing Implications
- this leads to bleeding at the implantation -Explain the purpose of the drug to the client.
site because the uterus is unable to
contract adequately and stop the flow -Administer the initial dose IM. Anticipate the
of blood from the open vessels. need for repeat dosing within 24 hours and
- Thrombin release from the again in 1 to 2 weeks.
bleeding sites promotes uterine
contractions and leads to a vicious cycle -Assist with measures to halt preterm labor if
of bleeding contractions placental indicated.
separation—bleeding.
-Continue to monitor the client’s vital signs environment is ideal for the growth of
and fetal heart rate for changes. microorganisms.
5. Assess abdomen for tenderness or
-If the client is also receiving a tocolytic agent, be rigidity- if present, measure abdomen at
alert for possible cardiac decompensation the umbilicus (specify time interval)
because of a drug-drug interaction. R: Detecting increase in measurement
of abdominal girth suggests active
-Observe for signs such as increased pulse, abruption
decreased blood pressure, and presence of
edema. Decreased cardiac output related to altered
cardiac contractility secondary to placenta
-Assess for signs and symptoms of possible previa
infection with long-term use. Nursing interventions:
1. Establish Rapport
-Instruct the client about the possibility that a R: to gain patient’s trust
repeat dose may be necessary.
2. Assess vital signs, conduct a physical
SURGICAL MANANGEMENT examination, and commence daily
weight monitoring. Monitor the patient
Surgical interventions are carried out once the
condition of both the mother and the fetus has for any changes in heart rate and
reached a critical stage and their lives are signs of dysrhythmia.
exposed to undeniable danger. R: fluid retention may be evident if the
mother has a weight gain of more than
Cesarean delivery. Although the best way to 1.5kg/month during the 2nd trimester,
deliver a baby is through normal delivery, if the or more than 0.5 kg/week during the
placenta has obstructed more than 30% of the 3rd trimester
cervical os it would be hard for the fetus to get past
the placenta through normal delivery. Cesarean 3. Instruct the patient to have bed rest and
birth is then recommended by the physician. avoid environmental stressors
R: to avoid further bleeding, maintain blood
pressure levels, improve cardiac rate, and
NURSING MANAGEMENT enhance uteroplacental perfusion.
Nursing Diagnosis (5):
4. For high blood pressure levels, administer
Deficient Fluid Volume related to active blood antihypertensives as prescribed
loss secondary to disrupted placental R: To lower blood pressure levels as
implantation needed
Nursing Interventions
1. Establish Rapport 5. Prepare to deliver the baby by cesarean
R: to gain patient’s trust section
2. Monitor Vital Signs R: The baby may be delivered earlier than
R: to obtain baseline data expected if the risks for the mother and the
3. Assess color, odor, consistency, and baby become higher
amount of vaginal bleeding; weigh pads
R: Provides information about active Impaired gas exchange related to altered
bleeding versus old blood, tissue loss, and blood flow and decreased surface area of gas
degree of blood loss exchange at the site of placental detachment
4. Assess baseline data and note changes. Nursing Intervention:
Monitor FHR 1. Maintain bed rest or chair rest as indicated.
R: Assessment provides information about Provide frequent rest periods.
possible infection, placenta previa, or R: Systemic rest is mandatory and
abruption. A warm, moist, bloody important throughout all phases of disease
 to reduce fatigue and improve strength. Risk for Activity Intolerance r/t Enforced Bed
Rest During Pregnancy Secondary to
2. Monitor amount and amount of bleeding. Potential for Hemorrhage
R: Provide objective evidence of bleeding. Nursing Interventions:
1. Establish rapport with the patient-S/O
3. Position mother on her left side. R: To alleviate anxiety and distress
R: To promote placental perfusion. and enhance patients' involvement in
decisions about their care.
4. Monitor urine contractions and fetal heart
rate by an external monitor. 2. Plan care to carefully balance rest periods
R: Assess whether labor is present and with activities.
fetal status and external system avoids R: To reduce fatigue if present.
cervical trauma.
3. Provide a positive atmosphere while
5. Administer oxygen as indicated. acknowledging the difficulty of the situation
for the client.
R: Provide adequate fetal oxygenation
R: This helps to minimize frustration
despite of lowered maternal circulating
and rechannel energy.
volume.
4. Assist client in learning and demonstrating
Fear related to the outcome of pregnancy after appropriate safety measures.
an episode of placenta previa bleeding R: To prevent injuries.
Nursing Interventions:
1. Establish rapport with the patient-S/O 5. Encourage the client to maintain a positive
R: To alleviate anxiety and distress attitude; suggest the use of relaxation
and enhance patients' involvement in techniques, such as visualization or guided
decisions about their care imagery, as appropriate.
R: To enhance the sense of well-being.
2. Measure vital signs and physiological
responses to the situation. PROGNOSIS
R: Fear and acute anxiety can both involve
sympathetic arousal (e.g., increased heart There's no cure for placenta previa. The goal of
rate, respiration, and blood pressure) treatment is to limit the bleeding so the mother
can get a s close as possible to her due
3. Compare verbal and nonverbal date. The d o c t o r could give the mother
responses to note congruencies or medicine to prevent premature labor. They may
misperceptions of the situation. also give corticosteroid shots to help the baby’s
R: The client may be able to verbalize what lungs develop faster. Once they feel that the
he or she is afraid of if asked, providing an baby can be safely delivered (by about 36 weeks
opportunity to address actual fears. of pregnancy), they’ll schedule a C-section.
4. Assess family dynamics. The biggest risk is severe bleeding that can be
R: Actions and responses of family life-threatening to the mother and baby. If the
members may exacerbate or soothe fears mother has severe bleeding, the baby may need
of the client; conversely, if the client is to be delivered early, before major organs, such
immersed in illness, whether from crisis or as the lungs have developed.
fear, it can take a toll on the family/involved
others

5. Provide an opportunity for questions and

answer honestly.
R: This enhances a sense of trust and the
nurse-client relationship.
 Heart
GESTATIONAL DIABETES - The heart is responsible for pumping enough
blood to deliver a continuous supply of
DEFINITION oxygen and other nutrients to the brain and
• Gestational diabetes (GDM) is defined as the other vital organs.
any degree of impaired glucose tolerance
of onset or first cognition during pregnancy. - It is located between lungs in the middle of
- a type of diabetes that occurs in pregnant the chest, behind and slightly to the left of the
women who have never had it. breastbone (sternum). A double-layered
• It is one of the most common health membrane called the pericardium surrounds
problems for pregnant women. the heart like a sac.

Diabetes mellitus is an endocrine disorder in - Gestational diabetes may increase the risk of
which the pancreas cannot produce adequate blood vessel dysfunction and heart disease in
insulin to regulate body glucose levels. offspring by altering a smooth muscle protein
responsible for blood vessel network
ANATOMY & PHYSIOLOGY formation.

Pancreas Kidneys
- The pancreas is a gland, about six inches - The kidneys remove wastes and extra fluid
long, located in the abdomen. It is shaped like from the body. It also
a flat pear and is surrounded by the stomach,
small intestine, liver, spleen, and gallbladder. - removes acid that is produced by the cells of
the body and maintain a healthy balance of
- Exocrine function: Produces substances water, salts, and minerals - such as sodium,
(enzymes) that help with digestion. calcium, phosphorus, and potassium in the
blood.
- Endocrine function: Sends out hormones
(insulin) that control the amount of sugar in - Located just below the rib cage, with one on
the bloodstream. each side of the spine. The right kidney is
generally slightly lower than the left kidney to
Liver make space for the liver.
- The liver is located in the upper right-hand
portion of the abdominal cavity, beneath the - Poorly controlled diabetes can cause
diaphragm, and on top of the stomach, right damage to blood vessel clusters in kidneys
kidney, and intestines. that filter waste from blood. This can lead to
kidney damage and cause high blood
- All the blood leaving the stomach and pressure.
intestines passes through the liver. The liver
processes this blood and breaks down, Placenta
balances, and creates the nutrients and - The placenta supplies a growing fetus with
metabolizes drugs into forms that are easier nutrients and water, and produces a variety
to use for the rest of the body or that are of hormones to maintain the pregnancy.
nontoxic. Some of these hormones (estrogen, cortisol,
and human placental lactogen) can have a
- GDM is associated with upregulated hepatic blocking effect on insulin. This is called
glucose production (gluconeogenesis). contra-insulin effect, which usually begins
Gluconeogenesis is increased in the fasted about 20 to 24 weeks into the pregnancy.
state, and not adequately suppressed in the
fed state. - As the placenta grows, more of these
hormones are produced, and the risk of
insulin resistance becomes greater.
Normally, the pancreas can make additional
 insulin to overcome insulin resistance, but Nausea and Vomiting
when the production of insulin is not enough - Feeling extreme nausea (maybe even
to overcome the effect of the placental vomiting) after eating. Unusually strong
hormones, gestational diabetes results. cravings for sweet foods and drinks.

ETIOLOGY Blurred Vision

- The blurring of vision could be the initial
Predisposing Factors warning sign of gestational diabetes affecting
- Advanced maternal age (25 or older) eyesight. As the pregnancy progresses, the
- Race/ ethnicity- women who are Black, risk of vision changes caused due to the rise
Hispanic, American, Indian, and Asian in blood sugar levels and associated
American have a higher risk of developing hormonal and metabolic disruptions can
gestational diabetes increase.
- Family history of diabetes
- History of large babies (10 lbs. or more) Yeast Infections
- History of unexplained fetal or perinatal loss - Pregnant women with diabetes have a high
- History of congenital anomalies in previous risk of Candida infection because the
pregnancies elevated sugar level in the blood provides
- History of polycystic ovary syndrome food for yeast and encourages Candida
overgrowth.
Precipitating Factors
- Pregnancy PATHOPHYSIOLOGY
- Obesity/ overweight
- Sedentary lifestyle (lack of physical activity) The primary problem of any woman with this
disorder is controlling the balance between insulin
SYMPTOMATOLOGY and blood glucose levels to prevent
hyperglycemia or hypoglycemia.
Increased, frequent urination (POLYURIA) - If a woman’s insulin level is insufficient,
- Gestational diabetes tends to cause fluid glucose cannot be used by body cells
imbalances. Your kidneys are more likely to - Liver quickly converts stored glycogen to
let excess amounts of liquid pass into your glucose to increase the serum glucose level
urine. As a result, you may find yourself going - Because of the insulin insufficiency, however,
to the restroom more often. You will notice the body cells still cannot use the glucose, so
yourself needing to visit the bathroom a lot the serum glucose levels continue to rise
more frequently than normal. (hyperglycemia) > 150 mg/100 mL (nor- mal
is 80 to 120 mg/dL)
Increased thirst (POLYDIPSIA) - Kidneys begin to excrete quantities of
- Thirst and having to urinate too often are both glucose in the urine (glycosuria) to lower the
caused by too much sugar (glucose) in your level.
blood. When you have diabetes, your body - Increased amount of glucose in the urine
cannot use sugars from food properly. This reduces fluid absorption in the kidney, and
causes sugar to collect in your blood. High large quantities of fluid are lost in urine
blood sugar levels force your kidneys to go (polyuria).
into overdrive to get rid of the extra sugar. - Dehydration begins to occur
- The blood serum becomes concentrated, and
Increased hunger (POLYPHAGIA) the blood volume may fall
- Cells need insulin to absorb glucose from the - With the reduced blood flow, cells do not
blood. If the cells do not take in enough receive adequate oxygen, and anaerobic
glucose, it can build up in the blood. The cells metabolic reactions cause large stores of
need glucose to provide energy. Fatigue and lactic acid to pour out of muscles into the
weakness might result when the cells do not bloodstream.
get enough glucose. - Fat is mobilized from fat stores and
metabolized for energy, pouring large
 amounts of ketone bodies into the
bloodstream Blood glucose monitoring
- Ketone bodies are acidic (the best example is - Completed four times a day by the patient.
acetone). These two acid sources lower the The patient pricks her finger and uses a
pH of the blood, and a metabolic acidosis glucometer to determine her blood glucose.
develops. She should track these numbers with a chart
- Next, protein stores are tapped by the body and bring it to her OB visits. Her provider will
as it attempts to find a source of energy determine if any adjustments in her insulin or
- Protein breakdown reduces the supply of oral diabetic regimen are needed.
protein to body cells. - The patient should obtain fasting and 1-hour
- As cells die, they release potassium and postprandial values. Her goals include fasting
sodium, and this is lost from the body in the numbers that are 90 and below and
extensive polyuria. postprandial values that are less than 140.
- Long-term effects of diabetes mellitus are - If the patient is hypoglycemic, she should
vascular narrowing that leads to kidney, have some carbohydrate rich food, like
heart, and retinal dysfunction. crackers, and a protein, like milk. Simple
sugars can create hyperglycemia and
LABORATORY & DIAGNOSTICS rebound hypoglycemia.

50-g glucose challenge test Insulin pump therapy

- it is recommended that all pregnant women - An insulin pump is an automatic pump with
receive a 50-g glucose challenge test between 24- thin tubing, which is placed subcutaneously,
and 28-weeks gestation to determine if they are at most often on the woman’s abdomen. Insulin
risk for gestational diabetes. is given through this tube and injection of
insulin is therefore eliminated.
Three-hour glucose tolerance test - A continuous rate (basal) of insulin is given to
– it is done if the result of the 50-g glucose the patient through the pump, and the patient
challenge test is 140 mg/dl (some providers use can program the pump to give extra doses as
130 mg/dl as the cutoff). boluses prior to meals or correctional doses
related to her blood glucose values after
meals.
MEDICAL MANAGEMENT - The patient should clean the site daily and
cover it with a dressing to keep it clean. The
Insulin Therapy site also needs to be changed every 24– 48
- Needed by pregestational and gestational hrs. to ensure optimal absorption and
diabetics who are uncontrolled with diet or decrease infection medical management.
oral therapy. Necessary for the cells to take
glucose from the bloodstream.
- Short-acting insulin may be used alone or PHARMACOLOGIC MANAGEMENT
with an intermediate type. Two thirds of daily
insulin needs are given before breakfast and - Insulin
one third before dinner. Insulin should be - Oral Hypoglycemic Agents
given subcutaneously and at a 90-degree o Metformin - Controls blood sugar,
angle to the skin. The injection site should by improving body to handle insulin
generally be the same each injection (arms o Acetohexamide - lowers blood
OR legs OR abdomen). sugar by stimulating the pancreatic
- Early in pregnancy, insulin needs may be beta cells to secrete insulin and by
less. Later in pregnancy, increased insulin helping the body use insulin
may be needed. Women should eat efficiently
immediately after injecting insulin to avoid o Glipizide - lowers blood glucose
hypoglycemia. Different body areas take up levels by stimulating the release of
insulin at different rates. Rotate within the insulin from the pancreas
same type of injection site.
 o Repaglinide - lowers blood glucose • Assess patients for cognitive or sensory
levels by stimulating the release of impairments, which may interfere with
insulin from the pancreas the ability to accurately administer
o Pioglitazone - helps body use insulin.
insulin better by altering the
transcription of genes influencing • Assess feet and legs for skin
carbohydrate and lipid metabolism, temperature, sensation, soft tissues
resulting in metabolic changes injuries, corns, calluses, dryness, hair
o Miglitol - reversible inhibition distribution, pulses, and deep tendon
reflexes.

NURSING DIAGNOSIS • Perform examination of foot, skin,

nervous system, and mouth.
- Unstable Blood Glucose Level, related to
Insulin Resistance AEB Hyperglycemia • Maintain skin integrity by protecting feet
with a blood sugar level of 260 mg/dl from breakdown.
- Ineffective Breathing Pattern, related to
Metabolic Acidosis secondary to • Laboratory examinations. HgbA1C,
Hyperglycemia fasting blood glucose, lipid profile,
- Deficient fluid volume r/t compromised microalbuminuria test, serum creatinine
regulatory mechanism AEB polyuria and level, urinalysis, and ECG must be
polydipsia requested and performed
- Impaired Skin Integrity related to Pruritus
as evidenced by demonstration of • Review dosage and time of injections in
discomfort, itching the presence of rashes relation to meals, activity, and bedtime
from the patient’s skin. based on patients' individualized insulin
- Fatigue related to decreased metabolic regimen.
energy production.
• Demonstrate and explain thoroughly
NURSING MANAGEMENT the procedure for insulin self-injection.
Help the patient to achieve mastery of
• Assess the patient’s history. To technique by taking a step-by-step
determine if there is presence of approach
diabetes, assessment of history of
symptoms related to the diagnosis of • Advise the patient about the importance
diabetes, results of blood glucose of an individualized meal plan in
monitoring, adherence to prescribed meeting weekly weight loss goals and
dietary, pharmacologic, and exercise assist with compliance.
regimen, the patient’s lifestyle, cultural,
psychosocial, and economic factors, • Instruct patients on the importance of
and effects of diabetes on functional accuracy of insulin preparation and
status should be performed. meal timing to avoid hypoglycemia.
• Assess physical condition. Assess the • Explain the importance of exercise in
patient’s blood pressure while sitting maintaining or reducing weight.
and standing to detect orthostatic
changes. • Advise the patient to assess blood
glucose level before strenuous activity
and to eat carbohydrate snacks before
• Assess the body mass index and visual exercising to avoid hypoglycemia.
acuity of the patient.
 • Advise patients who smoke to stop
smoking or reduce, if possible, to
reduce vasoconstriction and enhance
peripheral flow.

PROGNOSIS

- Gestational diabetes mellitus brings an

increased risk for fetal and neonatal
morbidity and mortality, as well as
obstetric complications. There is an
associated increased risk for obesity in
offspring, as well as for glucose
intolerance and type 2 diabetes.

- For gestational diabetes mellitus,

reclassification is performed at 6-12
weeks postpartum. In most patients
with gestational DM, glucose tolerance
becomes normal after delivery. The
lifetime risk for IGT and diabetes is
increased substantially in these
women, however.
 ● The main function of the placenta is for
ABRUPTIO PLACENTA nutritional support for the fetus (nutrition in
the womb).
DEFINITION ● It provides the fetus with oxygen and
nutrients while simultaneously removing
- Also called as a premature separation carbon dioxide and waste from the fetus
of the placenta. into the mother’s body for elimination.
- The placenta appears to have been ● When the placenta partly or completely
implanted correctly, Suddenly, it begins separates from the inner wall of the uterus
to separate and bleeding results before delivery, placental abruption
happens.
● This then decreases/blocks the baby's
supply of oxygen and nutrients and causes
heavy bleeding in the mother.

Uterus
● Also known as the womb is a female
reproductive organ that is responsible for
many functions in the processes of
implantation, gestation, menstruation, and
- Degrees of placental separation can be labor.
graded ● This is composed of both maternal tissue
and tissue derived from the embryo.
● This is the site where the fertilized egg is
DEGREES OF SEPARATION; Grade Criteria implanted for gestation.
● This is lined with mucus membrane rich in
0 No symptoms of separation are apparent
the blood capillaries to form the placenta
from maternal or fetal signs; the
which is responsible for the nourishment of
diagnosis is made after birth when the
the fetus during the pregnancy through the
placenta is examined and a segment of umbilical cord.
the placenta shows an adherent clot on ● The partial or complete separation of the
the maternal surface
placenta from the uterine wall is the
1 Minimal separation, but enough to cause structural change in abruptio placenta.
vaginal bleeding and changes in the
maternal vital signs; no fetal distress or Uterine Arteries
hemorrhage shock occurs. ● These are the main blood vessels that
supply blood to the uterus.
2 Moderate separations, there is evidence ● They serve the purpose of nourishing the
of fetal distress; the uterus is tense and placenta.
painful on palpation ● For a number or variety of reasons, these
uterine arteries can tear, rupture, and the
3 Extreme separation; without immediate blood inside them will flow out and start to
interventions, maternal hypovolemic build up between the uterus and the
shock and fetal death will result. placenta.
● At such a point, the placenta is not
attached to the uterus anymore, the
ANATOMY & PHYSIOLOGY placenta isn’t receiving the oxygenated and
nutrient-rich blood anymore.
Placenta
● It develops in the uterus during pregnancy.
ETIOLOGY carboxyhemoglobin concentrations that interfere
with oxygenation. We believe that such hypoxic
Predisposing Factors change can cause microinfarctions occurring at
- High parity the periphery of the placenta leading to necrotic
- Advanced maternal age] foci, separation at the necrotic foci, and
- Short umbilical cord (fetus) eventually, an abruption. (Kaminsky et al., 2007).
- Chronic Hypertensive disease
- Thrombophilic conditions that lead to SYMPTOMATOLOGY
thrombosis formation
- Chorioamnionitis (or infection of the D.E.T.A.C.H.E.
fetal membranes and fluid
- Rapid decrease in uterine volume Dark red bleeding The bleeding that is
occurring in abruptio
placenta has been
Precipitating Factors
concealed somewhat; if
- Direct trauma (accident, violence) ever the blood comes out
- Vasoconstriction from cocaine or through the vaginal area,
cigarette use it's been there for a while
so it’s going to be dark
High parity. A woman who has given birth red. Dark red blood
multiple times predisposes herself to abruptio implies deoxygenated or
placentae. low oxygen-carrying
blood.
Short umbilical cord. A short umbilical cord
Extended Fundal In cases of concealed
could cause the separation of the placenta
Height bleeding, it enlarges the
especially if trauma occurs. uterus increasing the
fundal height.
Advanced maternal age.
Women over the age of 35 years old have a higher Tender Uterus Due to detachment of the
risk of acquiring abruptio placentae. The placenta from uterine wall;
association between increased maternal age and wound
abruption is suggested to be due to decreased
Abdominal Pain May due to contractions
vascularisation of the uterus which occurs with
age and predisposes to placental insufficiency. Concealed Bleeding Stays or backflows

Chorioamnionitis. Hard Abdomen Due to contractions

This is an infection of the fetal membranes and
fluid that could predispose the woman to Experience DIC A serious disorder in
premature placental separation. (Disseminated which the proteins that
Intravascular control blood clotting
Coagulation) become overactive; after
Rapid decrease in uterine volume. the detachment of the
when the uterine tissue stretches suddenly, the placenta, there is the
placenta remains stable and the vascular release of lots of
structure connecting the uterine wall to the thromboplastins into
placenta tear away mother’s circulation
causing clots.
Direct trauma.
Any trauma to the abdomen could cause a Distressed Baby Occurs if the situation
separation of the placenta. goes on for too long, the
baby will not get enough
oxygen.
Vasoconstriction from cocaine or cigarette use.
The direct effect of smoking may be mediated
through vasoconstrictive effects of nicotine on
uterine and umbilical arteries as well as increased
GENERAL PATHOPHYSIOLOGY clotting throughout the body's blood
vessels
- Abruptio placenta is that there is the - Uteroplacental apoplexy is a rare but
separation of the uterine wall and nonfatal complication of severe forms of
decidua basalis placental abruption. It occurs when
vascular damage within the placenta
causes hemorrhaging that progresses to
and infiltrates the wall of the uterus.
- Hypovolemic shock is an emergency
condition in which severe blood or other
fluid loss makes the heart unable to pump
enough blood to the body.

LABORATORY & DIAGNOSTIC TEST

- caused by degeneration of uterine - Placental abruption is diagnosed through

arteries that supply blood to the placenta an exam and monitoring.
- vessels rupture, causing bleeding and - Placental abruption is primarily
separation of the placenta diagnosed on the clinical findings of
- if the separation is near the margin; there is vaginal bleeding, abdominal pain, uterine
vaginal bleeding tenderness, loss of uterine contractions,
- if the separation is more central; there might and fetal distress.
be a pocket of blood that stays concealed - The diagnosis of placental abruption can
within the deciduous only truly be confirmed after birth, when
the placenta can be examined and the
presence of a clot or tissue damage.

Diagnostic tests to finally diagnose the presence

of abruption placenta:

- Hemoglobin level and fibrinogen level:

To rule out disseminated intravascular
coagulation.

Other lab tests:

- whether blood is evident or not, signs of
- Physical examination: To check uterine
hypovolemic shock usually follow quickly
tenderness or rigidity.
- the uterus becomes tense and feels rigid
- Ultrasound: To observe the placenta
to touch
and its displacement; locate the bleeding
- If blood infiltrates the uterine
and check fetus.
musculature, Couvelaire uterus or
- Kleihauer-Betke (K-B) test: This test
uteroplacental apoplexy, forming a hard,
evaluates fetal blood in the maternal
boardlike uterus occurs
circulation, and is often used as part of
- As bleeding progress, a woman’s reserve
the diagnostic investigation when
of blood fibrinogen becomes diminished
placental abruption is suspected. This
- as her body attempts to accomplish
assesses the severity of a fetomaternal
effective clot formation, and DIC
hemorrhage (FMH), a condition in which
syndrome can occur.
a disruption in the placental barrier allows
fetal blood to enter the maternal
- Disseminated intravascular
circulation.
coagulation (DIC) is a rare but serious
- Urine test: To check creatinine levels,
condition that causes abnormal blood
assessing kidney function.
 - Fetal monitoring: Monitor fetus’s heart - Encourage turning, coughing, deep
rate and for any lack of oxygen; to check breathing, and early ambulation
if distressed. - Encourage fluid intake.

MEDICAL MANAGAMENT NURSING DIAGNOSIS

To avoid a worsening condition, these medical 1.Ineffective Tissue Perfusion related to

procedures are implemented for both the excessive blood loss
mother and the fetus. - Assess the patient's vital signs, O2
● Intravenous therapy. Once the woman saturation, and skin color.
starts to bleed, the physician would order R: For baseline data
a large-gauge catheter to replace the
fluid losses. - Monitor I&O
● Oxygen inhalation. Delivered via face R: To obtain data about renal perfusion
mask, this would prevent fetal anoxia. and function and the extent of blood loss.
● Fibrinogen determination. This test would
be taken several times before the birth to - Monitor FHT continuously
detect DIC. R: To obtain data about renal perfusion
● If the client is in active labor and bleeding and function and the extent of blood loss.
cannot be stopped with bed rest,
emergency cesarean delivery may be - Elevate extremity above the level of the
indicated. heart
R: Helps promote circulation
SURGICAL MANAGEMENT
- Instruct patient and/or SO to report
Separation of the placenta is immediately an immediately signs and symptoms of
emergency situation. thrombosis: (1) pain in leg, groin (2)
unilateral leg swelling (3) pale skin
- Cesarean birth - If DIC developed; if R: To immediately provide additional
birth is imminent, it is safest to deliver the interventions
baby via cesarean delivery
o the possibility of hemorrhage 2.Risk for shock related to
- Hysterectomy - to prevent a. Separation of the placenta
exsanguination (severe blood loss) b. External or internal bleeding
o for the worst outcome - Monitor for persistent or heavy fluid or
o a procedure to remove the uterus blood loss.
R: The amount of fluid or blood loss must
Postoperative Care be noted to determine the extent of
- Assess for signs of hemorrhage shock.
- Monitor vital signs every 4 hours,
auscultate lungs every shift, and measure - Assess vital signs and tissue and organ
intake and output. These data are perfusion.
important indications of hemodynamic R: For changes associated with shock
status and complications. states
- Assess for complications, including
infection, ileus, shock or hemorrhage, - Administer oxygen by an appropriate
thrombophlebitis, and pulmonary embolus route.
- Assess vaginal discharge, instruct the R: To maximize oxygenation of tissues.
woman in perineal care - Monitor uterine contractions and fetal
- Assess incision and bowel sound every heart rate by an external monitor.
shift
 R: Assesses whether labor is present
and fetal status; external system avoids - Avoid performing any vaginal or
cervical trauma. abdominal examinations
R: To prevent further injury to the
- Collaborate in prompt treatment of placenta.
underlying conditions and prepare for or
assist with medical and surgical - Measure maternal blood loss by
interventions. weighing perineal pads and save any
R: To maximize systemic circulation and tissue that has passed.
tissue and organ perfusion. R: Provides objective evidence of
amount bleeding.
3. Acute pain related to
a.Sudden separation of the placenta 5. Fear related to the outcome of pregnancy
from the uterine wall - Be with the patient to promote safety,
b.Pain accompanying labor especially during frightening procedures
contractions during initial separation or treatment.
- Assess for referred pain as appropriate. R: The physical connection with a trusted
R: To help determine the possibility of an person helps the patient feel secure and
underlying condition or organ dysfunction safe during a period of fear.
requiring treatment.
- Maintain a relaxed and accepting
- Monitor skin color and temperature and demeanor while communicating with the
vital signs. patient.
R: These are usually altered in acute R: The patient’s feeling of stability
pain. A normal response to pain is an increases in a peaceful and non-
increase in heart rate, breathing rate, and threatening environment.
blood pressure.
- Provide accurate information if irrational
- Provide comfort measures, a quiet fears based on incorrect information are
environment, and calm activities. present.
R:To promote non-pharmacological pain R: Replacing inaccurate beliefs into
management. accurate information reduces anxiety.

- Administer analgesics as indicated. - If a patient's fear is a reasonable

R:To maintain an acceptable level of response, empathize with him or her.
pain. Avoid false reassurances and be truthful.
R: Reassure patients that asking for help
- Encourage adequate rest periods. is both a sign of strength and a step
R:To prevent fatigue. toward resolution of the problem.

4. Deficient fluid volume related to bleeding - Allow the patient to have rest periods.
during premature placental separation. R: Relaxation improves the ability to
- Place the woman in a lateral, not supine cope.
position.
R: To prevent pressure on the vena cava PROGNOSIS
and additional interference with fetal
circulation. The prognosis of Placenta Abruptio varies and
they depend on the severity of the abruption -
- Monitor fetal heart sounds. partial versus complete, as well as the amount
R: To monitor fetal status. of blood loss incurred, and timely medical
- Monitor maternal vital signs. attention.
R: For baseline data
GOOD PROGNOSIS:
- The prognosis of Placenta Abruptio is
usually good with prompt treatment.
- May be treated with close monitoring or
immediate delivery by vaginal birth or C-
section.
- The severity of the abruption and
gestational age of your baby are the two
most important factors:

Baby is not close to full term

• mild abruption: close monitoring until
34weeks of pregnancy, medication for
fetal’s lung development; may go home if
not bleeding and FHR is normal

• severe abruption: immediate delivery if

both fetus and mother’s health are at risk
○ Baby is near full-term

● mild abruption: possible close-

monitored vaginal delivery
abruption got worse: emergency C-
section if both fetus and mother’s health
are in danger

Blood transfusion, will be performed in

cases of severe blood loss.

BAD PROGNOSIS:
Maternal
○ depends on how promptly treatment can be
instituted
○ death can occur from massive hemorrhage,
leading to shock and circulatory collapse of
renal failure from circulatory collapse.
Fetal
○ depends primarily on the gestational age at
which the abruption occurs, and on the
degree of the abruption.
○ result in blood clots, anoxia, organ failure,
and even death.
 EYE
PREECLAMPSIA

DEFINITION

- Preeclampsia and eclampsia is a

pregnancy-induced hypertension, a
condition in which vasospasm occurs
during pregnancy in both small and large
arteries causing increased blood
pressure

- The difference between preeclampsia

and eclampsia is that preeclampsia is a - A peripheral organ of vision which can receive
sudden spike in blood pressure whereas visual images that are transmitted to the brain.
eclampsia is more severe that would lead
to seizures or coma. - In preeclampsia/eclampsia, the most common
visual complaint is blurry vision. Specifically, the
- occurs after 20 weeks gestation up to 6 retina is the part of the eye that is affected in
weeks after delivery preeclampsia/eclampsia.

ANATOMY & PHYSIOLOGY - Since the retina is responsible for receiving

light that the lens has focused, converted, and
BRAIN sent into the brain for visual recognition.

HEART

- This is the primary organ that controls all the A muscular organ found in all vertebrates
functions of the body. The blood supply to the responsible for pumping oxygenated blood
brain can be disturbed as a result of high blood throughout the blood vessels by repeated,
pressure caused by pre-eclampsia (a stroke). rhythmic contractions. It also receives
deoxygenated blood and carries metabolic
- If the brain doesn't get enough oxygen and waste products from the body and pumps it to
nutrients from the blood, brain cells will start to the lungs for oxygenation, and it is responsible
die, causing brain damage and possibly death. for maintaining blood pressure.

- Preeclampsia mainly damages the

hearts ability to relax between
contractions, making the organ
overworked and poor at pumping blood.
BLOOD VESSELS stretching of the capsule usually leads to
epigastric pain, which is one of the symptoms
of severe preeclampsia.

PANCREAS

- A channel or conduit in which blood is

distributed to body tissues. The function - A gland that is about six inches long, located in
of blood vessels is to deliver blood to the the abdomen. It plays an essential role in
organs and tissues in the body since converting food intake into fuel for the body's
blood supplies oxygen and nutrients that cells. The pancreas has two main functions: an
the body needs to function. It also carries exocrine function that helps in digestion and an
waste products and carbon dioxide away endocrine function that regulates blood sugar.
from the organs and tissues. - Due to reduction of blood supply in the
pancreas, ischemia may occur which possibly
- In the case of preeclampsia/eclampsia results in epigastric pain and elevated amylase-
blood vessels don't seem to develop or creatine ratio.
function properly becomes narrow and
reacts differently to hormonal signaling
which limits the amount of blood that can
flow through them. KIDNEYS
LIVER

- The largest solid organ in the body. The main

function of the liver is filtering blood coming
from the digestive tract before passing it to
the other pat of the body. This is also, of fats,
proteins, and carbohydrates, excretion of
bilirubin, cholesterol, hormones and drugs,
enzyme activation, storage of glycogen,
vitamins, and minerals, and the synthesis of
plasma proteins, such as albumin and clotting
factors.
- Reduced blood flow to the liver, which leads -A two bean-shaped organs, each about the
to injury and swelling that causes elevation of size of a fist. It filters the blood of solutes and
liver enzymes, and stretches out the capsule then secretes, concentrates, and excretes urine
of the into the lower urinary tract via the uterus.
said
organ. -Preeclampsia may lead to kidney disease by
The causing acute kidney injury, endothelial
damage, and podocyte loss. Also, women with
pre-eclampsia can develop impaired glomerular
filtration and in severe cases, renal failure
PLACENTA outcomes and could partially explain
racial disparities in a wide array of health
conditions.
• Age - The risk of preeclampsia is higher
for 20 years younger and as well as
pregnant women older than 40. There is
no actual pathology but when being
older, the blood vessels become less
elastic and have an increased
calcification. These results in restricted
blood flow and decrease of oxygen and
nutrients delivered to tissues.

PRECIPITATING FACTORS:
- An organ that develops in the uterus during
pregnancy. This is composed of both maternal
• Obesity – Insulin resistance that results
tissue and tissue derived from the embryo.
from an excessive weight gain during
Generally, the placenta serves as the fetal
gestation is associated with reduced
lungs, kidneys, gastrointestinal tract, and as a
cytotrophoblast migration and uterine
separate endocrine organ throughout the
spiral artery remodeling, which turn
pregnancy. It is composed of fetal blood vessels
conduce to placental hypoxia and
and trophoblasts such as spiral arteries that
ischemia.
would dilate into 5-10 times than their normal
• High blood pressure - There is
sizes. This will develop into large uteroplacental
accumulating evidence suggesting that
arteries that are capable of delivering large
endothelial dysfunction, caused by
quantities of blood to the developing fetus.
placental factors that enter the maternal
circulation, may play a central role in the
- In the case of preeclampsia/eclampsia, there
pathogenesis of preeclampsia.
is a development of abnormal placenta in which
• Diet and nutrition - Foods that are rich
the uteroplacental arteries are fibrous causing
in sodium stiffens and narrows the blood
them to be narrow meaning the blood going into
vessels making the heart pump faster
the placenta is lesser than usual.
with more pressure to get oxygen to
where the body needs it. Too much
ETIOLOGY
saturated fat can cause cholesterol to
build up in the arteries. When the arteries
PREDISPOSING FACTORS:
become hardened and narrowed with
cholesterol plaque this causes the heart
• Genetic Factor - preeclampsia can be
to strain much harder to pump blood
affected by genetic variations carried by
through them. As a result, blood pressure
either parent, and genetic variations
becomes abnormally high.
carried by the unborn child may also play
• Multigravida - Some women experience
a role
post-traumatic stress after pregnancy.
• Multiple Gestation - increased placental
This may be caused by having a
mass that leads to increased circulating
traumatic birthing experience,
levels of sFlt1
miscarriage or neonatal death. Stress
• Race - Studies shows that black women
can result in high blood pressures.
have a higher risk of developing
• History of preeclampsia/eclampsia -
preeclampsia than women of other races
The patient's history may show certain
because of the weathering hypothesis,
conditions before becoming pregnant
which is that chronic exposure to social
that may have caused high blood
and economic disadvantage leads to
pressure.
accelerated decline in physical health
SYMPTOMATOLOGY (that lead to ischemia and may result to
epigastric pain).
• Visual disturbance - changes occur • Seizures - Decreased blood flow in the
because of the retinal vasospasm brain. This abnormality interferes with the
caused by the damage in the endothelial normal brain function and leads to
cells. There is a resistance to blood flow seizure activity.
therefore, visual disturbances occur. • Hyperreflexia - the woman's reflexes are
unusually active. This is due to
• Hypertension - This is because of hypertension that leads to increasing
vasospasm that resulted in endothelial hyperreflexia and can result in seizure.
cell damage. This reduces blood flow in
the kidney which regulates the blood PATHOPHYSIOLOGY
pressure of an individual and thus,
hypertension occurs. PREDISPOSING FACTORS:
primarity, genetic factor, multiple gestation,
• Proteinuria - It results to impaired race, age
integrity of the glomerular filtration barrier
and altered tubular handling of filtered PRECIPITATING FACTORS:
proteins (hyperfiltration) leading to obesity, diet and nutrition, high blood pressure,
increased nonselective protein multigravida, history of preeclampsia/PIH

• Weight Gain - Much of the weight gained 1. Vasospasm in arteries due to increased
is extra fluid (water) in the body. This is cardiac output, imbalance of thromboxane and
needed for things like the baby's prostacyclin, endothelial cell damage.
circulation, the placenta and the amniotic
fluid. 2. Inadequate blood supply to organs due to
vasoconstriction
• Oliguria - The increased blood flow • placenta - growth developmental
resistance in the kidney also decreases problems (premature birth, LBW, birth
glomerular filtration that lowered the defects)
urine output. • pancreas - pancreatic ischemia
(epigastric pain, elevated amylase-
• Edema - Develops in eclamptic patients creatinine ratio)
because of protein loss, sodium • Brain - cerebral and visual disturbances
retention, and lowered glomerular (blurry vision, headache, blindness)
filtration due to the decreased kidney • liver - epigastric pain
perfusion. • kidney
o increased permeability of
• Thrombocytopenia - Because of glomerular membrane =
damage to endothelial cells in the blood proteinuria
vessels, the platelets gather at the site of o decreased glomerular filtration =
the injured area and are used to fix the fluid retention
damage, causing a decreased amount of o increased kidney tubular
platelets (thrombocytopenia). reabsorption of sodium = sodium
retention, edema, extreme edema
• Epigastric pain - When the blood (on bony surfaces, breathing
pressure rises, there is a low amount of difficulties, headache, marked
blood supply circulating to the different hyperreflexia, ankle clonus,
organs such as liver (that cause liver grand-mal seizure, coma)
abnormalities like liver hypertrophy which • blood - thrombocytopenia
causes epigastric pain) and pancreas
3. Lab/diagnostic tests: SURGICAL MANAGEMENT
blood test, urinalysis, ultrasound, NST, alpha-
fetoprotein test if diagnosed then if : C-Section
1. TREATED = CS delivery, medications There is no surgical treatment for preeclampsia.
(Hydralazine, Nifedipine, MgSO4, A cesarean section delivery is used when: A
Labetalol), nursing managements (bed rapid delivery is medically needed for the
rest, monitor vital signs, monitor s/s of mother's or baby's well-being or survival.
MgSO4 toxicity & proper lighting of Induction of labor has not been successful,
patient’s room) usually after 24 hours.
2. NOT TREATED = poor prognosis
(hypoxia, fetal acidosis) graver prognosis NURSING DIAGNOSIS
(abruptio placenta) multiple organ
dysfunction for mother Ineffective tissue perfusion r/t
vasoconstriction of blood vessels
LABORATORY AND DIAGNOSTICS TESTS
• CheckforoptimalfluidbalanceAdministerI
1. Blood Test Vfluidsasordered
-assess kidney function, liver function, blood • Note urine output.
cells • Maintain oxygen therapy as ordered.
● Total leukocyte count • Administer anticonvulsants as needed.
● Differential leukocyte count: Neutrophils • Assist with position changes.
● Lymphocytes
● Eosinophils HB Fluid volume excess r/t compromised
● Platelet regulatory mechanism as evidenced by
● Blood grouping & cross matching peripheral edema
● Coagulation profile: BT, CT, INR
● Biochemistry: urea, creatinine, sodium, • Instruct patient, caregiver, and family
potassium, bilirubin total, bilirubin direct, members regarding fluid restrictions, as
SGOT (AST), SGPT (ALT), total protein appropriate.
albumin, LDH, RBS, uric acid. • Limit sodium intake as prescribed.
• Explain the need to use antiembolic
2. Urinalysis stockings or bandages, as ordered.
- Assess kidney function test • Educate patients and family members
- Protenuria the importance of proper nutrition,
- Glycosuria hydration, and diet modification.
3. Ultrasound/non stress test • Monitor Intake and output.
- monitor baby’s fetal well being
(blood flow through umbilical cord Impaired urinary elimination pattern related
and placenta) to low urine output as evidenced by
4. Alpha-fetoprotein test decreased blood supply to kidneys
- high AFP suggest placental injury
and risk for IUGR • Encourage adequate fluid intake (2–4
L per day), avoiding caffeine and use
MEDICAL MANAGEMENT of aspartame, and limiting intake
during late evening and at bedtime.
• Pharmacologic Management Recommend use of cranberry
○ Corticosteroids juice/vitamin C.
○ Magnesium sulfate • Observe cloudy or bloody urine, foul
○ Labetalol odor. Dipstick urine as indicated.
○ Slow-release nifedipine • Promote continued mobility.
○ Hydralazine • Cleanse perineal area and keep dry.
Provide catheter care as appropriate.
 • Recommend good hand washing and affects filtration of proteins including albumin
proper perineal care. that is responsible for keeping the fluid in the
bloodstream. Immediate intervention would aid
Risk for injury r/t seizures to prevent complications.

• Explore and expound seizure warning Monitor presence of protein through urine
signs (if appropriate) and usual seizure dipstick
patterns. Teach SO to determine and R: Substantial loss of protein can indicate
familiarize warning signs and how to care preeclampsia or severe preeclampsia which
for the patient during and after seizure needs immediate medical intervention.
attack.
• Use and pad side rails with the bed in Monitor Fetal Heart Rate
lowest position, or place bed up against R: Hypertension raises the risk for decreased
wall and pad floor if rails are not available blood flow to the placenta thus, there is less
or appropriate. oxygen and fewer nutrients for the baby that can
• Educate the patient not to smoke except lead to slow growth, low birth weight or
while supervised. premature birth.
• Evaluate the need for or provide
protective headgear. Measure and record urine output, protein
• Do not leave the patient during and after level, and specific gravity.
a seizure. R: Monitoring these measurement aids in
indicating the current condition of the patient.
Deficient knowledge r/t insufficient Also, urine output is an indicator of circulatory
information of pre-eclampsia/eclampsia blood volume.

• Provide information about Monitor weight

signs/symptoms indicating worsening of R: Sudden weight gain indicates accumulation
the condition, and instruct the client when of fluid in the body that is associated with
to notify the healthcare provider. proteinuria and hypertension.
• Inform the client of health status, results
of tests, and fetal well-being. Encourage intake of (unless
• Educate the client on monitoring her contraindicated): Prune juice, skim milk, and
weight at home and notify the healthcare berry juice.
provider if the gain is more than 2 lbs (0.9 R: These drinks are a good source of potassium
kg)/wk, or 0.5 lb (0.23 kg)/day. and magnesium that helps in managing blood
• Educate and assist family members in pressure. Berries are rich in natural compounds
learning the procedure for home called flavonoids and are found to help prevent
monitoring of blood pressure. hypertension and help lower blood pressure.
• Review techniques for stress
management and diet restriction. Encourage them to avoid smoking cigarettes
and drinking alcohol
NURSING INTERVENTION R: Smoking and chewing tobacco can
immediately raise your blood pressure
Assess vital signs, especially blood temporarily. It damages the lining of the artery
pressure. walls causing arteries to narrow. Alcohol may
R: Elevation of the blood pressure 140/90 stimulate the release of adrenaline, resulting in
mmHg and above indicates hypertension. increased heart rate, cardiac output and systolic
blood pressure.
Assess for edema of face, arms, hands, legs,
ankles, and feet Promote good nutrition
R: Edema can occur due to hypertension that R: Eating foods rich in whole grains, fruits,
damages the small arteries in the kidneys thus, vegetables and low-fat dairy products can lower
blood pressure. In addition, intake of too much
salt and fatty foods can contribute to
hypertension.

Promote adequate rest in a lateral position.

R: It decreases pressure on the vena cava and
also relieves pressure on blood vessels that
return blood to the heart. It is also known to help
ease high blood pressure.

PROGNOSIS

IF TREATED
• Medical procedure is cesarean delivery
• Medications are Hydralazine, Nifedipine,
MgSO4, Labetalol
• Nursing management:

o Keep patient room dark

o Monitor signs and symptoms of
MgSO4 toxicity
o Monitor patient’s blood pressure
o Monitor patient’s INO fluid
o Support patient to bedrest

IF NOT TREATED
Mother
Multiple organs are in dysfunction which will
cause:

o Edema
o Fluid accumulation in the lungs
o Lesser oxygen transported to
organs
o System failure

Fetus

• Arteries carrying blood to placenta

continues to narrow
• Poor placental nutrition is being given to
growing fetus
• Fetal growth restriction which will cause:
• Lack of oxygen which will stress the
infant
• Anoxia (when your body or brain
completely loses its oxygen supply)
• Preterm birth
• Low birth weight
 - Blood group A woman who marry
HYADATIDIFORM MOLE blood group O men

DEFINITION SYMPTOMATOLOGY

- A Hydatidiform mole is a rare mass or growth - Abnormal growth of the uterus

that forms inside the uterus at the beginning - Nausea and vomiting maybe severe enough
of a pregnancy . to require hospitalization
- It is a type of gestational trophoblastic - Vaginal bleeding during the first 3 months
disease(GTD) AOG
- It is an abnormal form of pregnancy, wherein - Symptoms of hyperthyroidism and heat
a non-viable, fertilized egg implants in the intolerance
uterus. - Loose stools
- Thereby converts normal pregnancy - Rapid heart rate(tachycardia)
processes into pathological ones. - Restlessness and nervousness
- High Blood pressure
TYPES OF H-MOLE: - Swelling in feet ankles and legs.
- Complete mole- all trophoblastic villi swell
and become cystic. Chromosomal analysis: PATHOPHYSIOLOGY
46xx or 46 xy, empty ovum fertilized by
sperm. o Penetration of sperm to the egg but the egg cell
- Abnormal placenta but no fetus. fails to change composition.
- Partial mole- some villi form normally. o There will be entrance of multiple sperms to an
Chromosomal analysis: 69 chromosomes empty egg and fertilization takes place.
- Abnormal placenta and some fetal o Implantation leads to trophoblast maturation.
development. o All and some vesicular chorionic villi will formed
o Which will result to infant development failure
ANATOMY & PHYSIOLOGY o The mother will have pelvic discomfort and
increase BP/profuse bleeding
- The uterus is a hollow muscular organ o There will be incomplete implantation that will
located in the female pelvis ,between bladder cause spontaneous abortion
and rectum o And abnormally high HCG
- The ovaries produce egg that travels through o Some trophoblast become malignant which may
the fallopian tube. lead to Choriocarcinoma.
- Once egg has left the ovary, it can fertilized
and implant in the lining of uterus
- The main function of uterus is to nourish the LABORATORY AND DIAGNOSTIC TEST
developing fetus prior to birth.
- Pelvic examination may reveal continued
ETIOLOGY uterine swelling
- Blood Test:
- A hydatidiform mole, results from over o CBC,
production of the tissue that supposed to o Liver function test
develop into the placenta. o kidney function test
- In this condition the tissues develop into an - Imaging/ultrasound test or MRI and CT
abnormal growth called mass scan

- Risk Factors: MEDICAL MANAGEMENT

- Low protein intake
- Maternal age of 35 yrs old above • Methotrexate IM: medicine used to stop rapid
- Asian growth of Hydatidiform
SURGICAL MANAGEMENT weakness, decreased urinary output, and
pale, clammy skin
• Uterine suction: use in evacuating the uterus ● Assess vital signs, conduct physical
• Surgical curettage: ASAP after diagnosis to examination, and commence daily weight
avoid choriocarcinoma. monitoring.
● Start input and output monitoring.
Nursing management: ● Speak to the patient and family about the
- Assess vital signs, vaginal bleeding, need for hospitalization for the treatment
uterine fundus of serious hemorrhage and the need for
- Assess emotional distress of the surgery.
mother ● Prepare the patient for the surgical
- Assess nausea and vomiting intervention for hydatidiform mole. Place
- Report to health care provider of the patient on a nothing by mouth (NBM
abnormal VS, acute abdominal pain or NPO) status.
- Administer IV fluids as ordered ● Encourage the patient to have a low salt
- Provide emotional support intake.
- Allow one support person at bedside
if desired by the patient 3. Risk for injury
- Provide and review information about ● Assess the patient’s mental status.
prescribed medications. ● Monitor the patient’s level of
consciousness using AVPU. Heavy
NURSING DIAGNOSIS vaginal bleeding may result to
hypotension and lower level of
1. Acute pain related to hydatidiform mole as consciousness. Using AVPU scale (i.e.
evidenced by pain score verbalization of Alert, Voice, Pain stimuli, or
pain. Unresponsive/unconscious) can help
● Administer prescribed pain medications. determine the urgency of surgical
● Assess the patient’s vital signs and treatment and increased risk for injury.
characteristics of pain at least 30 minutes ● Prepare the patient for surgical
after administration of medication. intervention for the removal of the
● Elevate the head of the bed and position hydatidiform mole.
the patient in semi Fowler’s. ● Place the patient in complete bed rest if
● Place the patient in complete bed rest there is evidence of severe bleeding.
during severe episodes of pain. Perform ● Instruct watcher to maintain environmen
non-pharmacological pain relief methods free from noise.
such as relaxation techniques such as
deep breathing exercises, guided 4. Grieving r/t loss of pregnancy as
imagery, and provision of distractions evidenced by anger and social detachment.
such as TV or radio. ● Measure abdominal girth and fundal
● Post-surgery, advise the patient to: Have height to establish baseline data
no strenuous activity for a few regarding the growth of the uterus.
weeks.Apply support on the abdomen ● Assist patient in obtaining a urine
when coughing, laughing, or moving by specimen for urine test of hCg.
placing a pillow over the pelvic ● Save all pads used by the woman during
areaInform the healthcare team if the bleeding to check for clots and tissues
pain medications are not working she may have discharged.
● Provide your patient with an open
2. Deficient Fluid Volume related to heavy environment and a trusting relationship
vaginal bleeding secondary to hydatidiform so she would be encouraged to express
mole / molar pregnancy, as evidenced by an her feelings.
average blood pressure level of 85/50, body ● Honestly answer the patient’s questions
to foster a trusting relationship between
 nurse and client. Provide an assurance
that it is not her own fault that this
happened to her to lessen her sense of
guilt and self-blame.

5. Anxiety related to threat to or change in

health status [progressive/debilitating
disease, terminal illness], interaction
patterns, role function/ status, environment
[safety], economic status
● Assess the level of anxiety, the factors
that influence the onset of anxiety.
● Provide preoperative education,
including visit with OR personnel before
surgery when possible. Discuss
anticipated things that may concern the
patient: masks, lights, Is, BP cuff,
electrodes, bovie pad, feel of oxygen
cannula or mask on nose or face,
autoclave and suction noises, child
crying.
● Identify fear levels that may necessitate
postponement of surgical procedure.
● Validate source of fear. Provide accurate
factual information.
● Give simple, concise directions and
explanations to sedated patient. Review
environmental concerns as needed.

PROGNOSIS

- More than 80% of hydatidiform moles are

benign. The outcome after treatment is
usually excellent.

- Some cases hydatidiform develop into

invasive moles. These grows so far into
the uterine wall and cause bleeding and
other complications.

- Most woman whose cancer has not

spread can be cured and will maintain
reproductive function.
 - Consists of the caecum; the ascending,
HIRSCSPRUNG’S DISEASE transverse, descending and sigmoid
colons; and the rectum and anus
DEFINITION - Functions of the large intestine include:
o Absorption of water, electrolytes
• A congenital condition characterized by and vitamins
the absence of ganglion cells in the o Secretion of mucus for the
submucosal (Meissner’s) and myenteric lubrication of faeces
(Auerbach’s) plexus of the distal bowel o Storage of indigestible foodstuff
which results in decreased motility in the such as cellulose and vegetable
affected segment. fibre
o The absence of nerve cells means o Production of vitamin k and some
there are no peristaltic waves in b complexes (b1, b2, and folic
this section to move fecal material acid)
through the segment of the o Defecation
intestine. - In the lower part of the descending colon,
o This results in chronic constipation long, relatively sluggish contractions
or ribbonlike stools (stools passing cause propulsive waves known as mass
through such a small, narrow movements. These movements propel
segment that looks like ribbons). the intestinal contents into the rectum
and produce the urge to defecate.
• Also known as congenital megacolon or
congenital colonic aganglionosis

• The portion of the bowel proximal to the

obstruction dilates, thus distending the
abdomen.

CLASSIFICATION
Length of bowel involved Proportion

Rectosigmoid 70 - 80%

Long segment (above 10 - 25%

sigmoid)
ETIOLOGY
Total colonic 3 - 15%
Gender
Total intestinal 0.4 - 4% - this disease is more frequently seen in boys
than girls
Ultrashort segment < 1% Embryology
- Precursor neuroblasts do not migrate to the
affected segment
ANATOMY & PHYSIOLOGY - Neuroblasts are present but do not
mature
1. Large intestine - Cells develop, but then degrade
- Also called the large bowel secondary to microenvironmental effects
- Also known as the colon Genetics
- Approximately 2m in length and 6cm in - Family member (more specifically sibling)
diameter who has a history of the disease
 - Causative gene linked to chromosome 10 PATHOPHYSIOLOGY
- Associated with RET proto-oncogene
(codes for a tyrosine kinase receptor In patients with Hirschsprung’s Disease, ganglion
molecule) cells are absent

SYMPTOMATOLOGY Marked increase in extrinsic intestinal innervation

(2-3 times that of normal innervation)
CLINICAL FEATURES
The adrenergic (excitatory) system is thought to
- Newborns with Hirschsprung disease predominate over the cholinergic (inhibitory) system
may manifest:
• Failure to pass meconium (stool) in
Increase in smooth muscle tone
first 24-48 hours of life
• Constipation
• Abdominal Distention With the loss of the intrinsic enteric inhibitory nerves,
• Bilious vomiting (which may look the increased tone is unopposed
green or brown)
Imbalance of smooth muscle contractility,
LATE FEATURES uncoordinated peristalsis, and a functional
obstruction
- Symptoms of aganglionic megacolon
generally do not become apparent until 6-12
months of age. - 3 neuronal plexus innervate the intestine:
the submucosal plexus (ie, Meissner),
- By age 6-12 months, children appear thin the intermuscular plexus (ie, Auerbach),
and undernourished (sometimes and the smaller mucosal plexus.
unnoticeable because their abdomen is
large and distended) - Finely integrated and involved in all
aspects of bowel function, including
- Gross abdominal distention absorption, secretion, motility, and blood
flow.
- Chronic constipation
- Normal motility is primarily under the
- Failure to thrive control of intrinsic neurons.
- Bowel function is adequate, despite a
- Contracted rectal wall felt by examining loss of extrinsic innervation.
finger
- These ganglia control both contraction
ENTEROCOLOTIS and relaxation of smooth muscle, with
- Most feared complication of relaxation predominating.
Hirschsprung’s Disease
- Extrinsic control is mainly through the
- Presented with fever, explosive diarrhea, cholinergic and adrenergic fibers.
and prostration (extreme exhaustion or o cholinergic fibers cause
lack of energy) contraction
o adrenergic fibers mainly cause
- May lead to acute inflammatory and inhibition
ischemic changes in the colon, with
perforation and sepsis. LABORATORY & DIAGNOSTICS

1. Abdominal Plain X-ray - An X-ray of the

abdomen may reveal a bowel obstruction
 or colon distension. This is only the first MEDICAL MANAGEMENT
step. It is unable to provide a precise
diagnosis of Hirschsprung disease. 1. Rehydration and correction of electrolyte
a. Distended bowel loops imbalances
b. Fluid level 2. Intravenous broad spectrum antibiotic
therapy to prevent progression of
2. Barium enema or ultrasound with septicemia
contrast medium - Generally prescribed 3. Prompt rectal decompression with large-
to substantiate the diagnosis. The bore rectal tube with side holes
contrast mediums will outline the narrow, 4. Serial washouts (rectal irrigation) several
nerveless portion and the large proximal times a day
distended portion of the bowel.
a. A transition zone exist between SURGICAL MANAGEMENT
the dilated, proximal, normal
bowel and the narrow distal Surgical Procedure: Hirschsprung's Disease
segment needs to be treated with surgery. The earlier it
3. Anorectal manometry - a technique that is done, the better the results may be. The goal
tests the strength or innervation of the of surgery is to remove the part of the colon that
internal rectal sphincter by inserting a does not work the right way.
balloon catheter into the rectum and
measuring the pressure exerted against 1. Dissection and removal of the affected
it. section, with anastomosis of the
a. Sphincter does not relax with intestine (termed a pull-through
increased rectal ampullary operation). Three most common
pressure procedures:
4. Rectal biopsy - This test confirms the a. Swenson pull-through
diagnosis. It entails extracting a sample (rectosigmoidectomy)
of the cells in the rectum to be examined b. Duhamel pull-through (retrorectal
under a microscope by a pathologist. The transanal pullthrough)
absence of ganglion cells and other c. Soave pull-through (endorectal
aberrant nerve-related findings lead the pull-through)
pathologist to conclude that a kid has
Hirschsprung disease. 2. Because it is a technically difficult
a. Full thickness biopsy - gold operation to perform in a small abdomen,
standard the condition is generally treated in
b. Suction biopsy - popular infants by two-stage surgery:
c. Should be 1.5cm proximal to a. temporary colostomy
dentate line b. bowel repair at 12 to 18 months
5. Rectal Exam - A rectal exam only of age
suggests the diagnosis. If a gloved finger *After the final surgery, children should
is inserted into the rectum of a child with have a functioning, normal bowel.
true constipation, the examining finger
will touch hard, caked stool. With 3. Permanent colostomy will need to be
aganglionic colon disease (Hirschsprung established if the anus is deprived of
Disease), the rectum is empty because nerve endings.
fecal material cannot pass into the
rectum through the obstructed portion. Recently, the surgery is being performed in the
6. Suction aspiration - determines the lack newborn period using a laparoscopic approach:
of ganglion cells using a tiny tube - was first described in 1999 by Georgeson
introduced into the rectum. - The transition zone is first identified
laparoscopically, followed by mobilization
 of the rectum below the peritoneal 3. Administer enema as ordered.
reflection. R: Enemas generally act by causing rectal
- A transanal mucosal dissection is distention allowing easy evacuation.
performed, followed by prolapsing of the
rectum through the anus and 4. In children prescribed with daily enemas to
anastomosis. achieve bowel movements, remind
parents that the fluid used for enemas
NURSING DIAGNOSIS must be normal saline (0.9% NaCl) and not
tap water.
Imbalanced nutrition, less than body R: Because tap water is hypotonic, if it is
requirements r/t reduced bowel function instilled into the bowel, it moves rapidly
1. Obtain a nutritional history with the across the intestinal wall into interstitial
participation of the patient's family or and intravascular fluid compartments to
guardian. equalize osmotic pressure, and can lead to
R: To note the patient’s dietary practice the death of infants from cardiac
with his/her condition. congestion or cerebral edema (water
2. Review laboratory values that indicate intoxication).
well-being or deterioration.
R: An abnormal value in a single 5. Explain the use of pharmacological agents
diagnostic study may have many possible to the parents/caregiver as ordered.
causes. R: Some medications can be prescribed
3. For postoperative infants with nasogastric by the physician to treat the patient’s
tube, position the patient in a appropriate constipation due to reduced bowel
position that will not disrupt the inserted function.
lines.
R: To keep the patient in a comfortable Risk for compromised family coping r/t
position. chronic illness in child
4. Instruct the parents/caregiver of older 1. Set a working relationship with the patient
children to strictly follow the dietary and the patient’s family through
guidelines prescribed to the child such as establishing rapport.
a minimal-residue diet, intake of vitamin R: To establish trust and may
supplements and stool softeners. facilitate coping
R: To prevent further complications to the
child’s condition and to help supplement 2. Determine the family's understanding of
the child’s imbalanced nutrition. the stressful situation.
5. Instruct the patient’s caregiver about when R: To provide a foundation for planning
and what to feed the child post-operation. care and choosing relevant
R: To make sure that the childis given interventions
appropriate food after operation.
3. Provide chances to express concerns,
Constipation r/t reduced bowel function fears, feelings, and expectations.
1. Assess and review the patient’s bowel R: Verbalization of actual or perceived
habits and patterns of elimination. threats can help reduce anxiety and open
R: To have an idea of the patient’s bowel doors for ongoing communication.
habits and to manage accordingly.
4. Use empathetic communication.
2. Encourage the patient/caregiver to R: Acknowledging and empathizing
increase the patient’s fluid intake. creates a supportive environment that
R: Adequate fluid intake makes the stool enhances coping.
softer and easier to pass through the large
intestine.
 5. Convey feelings of acceptance and 2. Provide clear, thorough, and
understanding. Avoid false understandable explanations and
reassurances. demonstrations.
R: An honest relationship facilitates R: It allows the caregivers to ask more
problem-solving and successful coping. questions when they have basic
information about what to expect.
Acute Pain r/t postoperative abdominal
incisional wound 3. Give information with the use of media
1. Observe and assess the patient’s such as visual aids like diagrams, or
behavioral and physiologic pictures.
manifestations of pain (ie. crying) R: Different people take in information in
R: To keep check of the patient’s different ways.
response to the ongoing pain and the
interventions. 4. Demonstrate to the family caregiver how to
care for the colostomy at home.
2. Assess the patient’s operative site for R: To provide family teaching and promote
any signs of infection or possible family centered care
complications. Surgical wound dressing
should also be assessed. 5. Instruct the caregivers to demonstrate their
R: For early intervention in possible understanding by caring for the colostomy
complications. under the supervision of nursing personnel
several days before discharge.
R: To ensure understanding and continuity
3. Position the patient in a position of care
appropriate for him/her based on the
location of incision site. PROGNOSIS
R: To prevent touching the operative
site (abdomen). IF TREATED:
● When it is diagnosed at an early stage
4. Regularly monitor the patient’s vital where there is no infection, the prognosis
signs. is favorable.
R: To monitor the patient’s condition ● Most children who have treatment and
and to refer to the physician any surgery do very well and go on to have
abnormalities. normal, healthy bowel function.

5. Administer medications for pain as IF NOT TREATED:

ordered by the physician and document ● A serious infection called enterocolitis
its efficacy. can occur, which causes fever, pain, and
R: If the infant does not stop manifesting diarrhea.
behavior of pain, the physician may
prescribe pain medications.

Deficient knowledge of caregivers r/t

postoperative care of the colostomy

1. Assess ability to learn or perform

desired health-related care.
R: Cognitive impairments must be
recognized so an appropriate teaching
plan can be outlined.
 • Normally, the heart is structured in
TETRALOGY OF FALLOT such a way that oxygenated blood
does NOT mix with deoxygenated
DEFINITION blood.
• If we review back to our normal
• One of the first types of congenital heart anatomy and physiology, the flow of
disease described, occurs in about 10% blood in the heart starts after the vena
of children with congenital cardiac cavae collects deoxygenated blood
disease (Dambro, 2008). It is called a from the body and delivers it to the
tetralogy because “four anomalies are right atrium.
present” that serves as the defining • From the right atrium, blood passes
characteristics of tetralogy of Fallot: through the tricuspid valve then to the
o Pulmonary stenosis right ventricle.
o Ventricular septal defect • It then gets delivered to the lungs
o Dextroposition (Overriding) of the through the pulmonary valve and the
aorta, and pulmonary artery.
o Hypertrophy of the right ventricle. • The now oxygenated blood returns to
• Because of the pulmonary stenosis, the heart from the lungs through the
pressure builds up in the right side of the pulmonary veins into the left atrium
heart. and gets pumped into the left
• Blood then shunts from this area of ventricle, passing through the mitral
increased pressure into the left ventricle valve.
and the overriding aorta. • From the left ventricle, it passes
• The extra effort involved to force blood through the last valve in the heart, the
through the stenosed pulmonary artery aortic valve, and it gets delivered to
causes the fourth deformity, hypertrophy the aorta.
of the right ventricle. • The aorta then pumps oxygenated
• It becomes a problem because blood throughout the body. (See
deoxygenated blood could get mixed up illustration below for better
with oxygenated blood. visualization of the blood flow in the
heart)
ANATOMY & PHYSIOLOGY

• The main system involved in Tetralogy of

Fallot is the cardiovascular system,
specifically the cardiopulmonary
circulation of blood.

However, in Tetralogy of Fallot, there are four

(4) defects that prevent a smooth-sailing and
efficient cardiopulmonary circulation. The four
defects are discussed below along with how
they affect the blood flow in the heart.
 heart to get pumped to the lungs for
1. Ventricular Septal Defect (VSD) oxygenation.
d. However, because of this specific
a. The main defect in Tetralogy of defect, less blood travels to the
Fallot. This one happens first before lungs because of the narrow path.
anything else. The other three (3) e. The heart also has to pump harder
defects happen secondary to this because of the resistance caused by
defect. the narrow pathway.
b. VSD happens when there is a - The result of this is 1) less blood gets
malalignment in the conal septum delivered to the lungs and 2) blood is built
from the rest of the ventricular up in the right ventricle because it cannot
septum, resulting in a septal defect. pass through the pulmonary valve.
In layman’s terms, there is a hole in
the septum (the wall separating the 3. Right Ventricular Hypertrophy
ventricles of the heart). (See
illustration below for comparison to a. Defined as the thickening of the
the normal heart) muscular wall of the right ventricle.
This happens because of the huge
systemic pressure caused by the
VSD and the right ventricle is
pumping at high pressure.
b. The thickened wall can contribute
to blocking the flow of blood
through the pulmonary valve,
further decreasing the amount of
blood pumped into the lungs.

4. Overriding Aorta

- Basically means that the artery that

c. Since the purpose of the septum is carries oxygenated blood to the body
to act as a barrier that prevents becomes inclusive and arises both
blood from both sides of the heart, ventricles when it normally should just
septal defect causes oxygenated receive blood from the left ventricle.
blood and deoxygenated blood to - This allows some deoxygenated blood to
get mixed up. get pumped out into the systemic
d. This can lead to little or too much circulation, lessening the delivery of
blood being pumped to the rest of oxygen to the rest of the body.
the body

2. Pulmonary Stenosis

a. Defined as narrowing of the

pulmonary valve. This is caused by
the malalignment of the conal
septum to the ventricular septum.
b. Since the two are malaligned, the
pulmonary valve gets pushed to the
side, causing the narrowing.
c. The pulmonary valve acts as a
passageway for the blood in the
 afterwards. This is called “tet
spells”.
● Shortness of breath and rapid
breathing
o Some infant with TOF may
experience Shortness of breath
and rapid breathing, due to
narrowing of the valve that
separates the lower right chamber
of the heart (right ventricle) from
the main blood vessel leading to
the lungs (pulmonary artery)
reduces blood flow to the lungs.
- These four (4) defects contribute to the The narrowing might also affect
decreasing amount of oxygen reaching the muscle beneath the
the tissues in the body. In the anatomy pulmonary valve.
and physiology of TOF, it is important to ● Loss of consciousness (fainting)
review the normal flow of blood in the o because of the low oxygen levels
heart, what the four defects are, and how in their blood
they affect the body. ● Clubbing of fingers and toes (an
- To summarize, basically the oxygenated abnormal, rounded shape of the nail bed)
and deoxygenated blood gets mixed up o Due to lack of oxygen
because of the defects, causing a ● Loud heart murmur
decrease in oxygen delivery to the rest of o systolic ejection murmur at the left
the body. upper sternal border due to
pulmonic stenosis and/or
ETIOLOGY holosystolic murmur at the left mid
sternal border due to a ventricular
Tetralogy of fallot is a rare condition caused by septal defect
a combination of four heart defects that are o
present at birth (congenital). These defects, Any of these can be symptoms of tetralogy of
which affect the structure of the heart, cause Fallot. The symptoms of tetralogy of Fallot may
oxygen-poor blood to flow out of the heart and resemble other medical conditions or heart
to the rest of the body. problems. Always consult your child's doctor for
a diagnosis.
SYMPTOMATOLOGY
PATHOPHYSIOLOGY
Signs of TOF are dependent on the extent of
obstruction of blood flow. The typical signs • The definitive etiology and cause of
include the following: tetralogy of Fallot are unknown.
However, there have been attempts to
● Cyanosis explain the condition, which will be
o Infant with TOF can have a bluish- discussed in this part.
looking skin color, due to their • Since tetralogy of Fallot is a congenital
blood doesn’t carry enough of condition, which means it is present at
oxygen or because of low levels of birth, the prenatal development of the
circulating oxygen in the blood. infant could be explored.
Infants’ skin may not appear bluer • The etiological factors (both predisposing
at birth, but they may develop and precipitating) contribute to the
unexpected periods of bullish skin heightened risk of the infant developing
during crying or feeding later TOF.
• Both genetic and environmental factors only in the cardiovascular system but can
contribute to the alteration in the also reach the nervous system.
development of the cardiovascular • Continuous decreased oxygen supply
system in utero. could lead to necrosis of cells that may
• It starts with the malalignment in the result in organ failure and in the worst
conal and ventricular septum causing the case may cause death.
ventricular septal defect. Because of this
defect, the conal septum (upper portion) DIAGNOSTIC AND LABORATORY TESTS
pushes the pulmonary valve on the right,
causing a narrowing which results in ● ECG
pulmonary stenosis. ● CBC
• Other defects follow such as overriding ● 4D ECHd
aorta and right ventricular hypertrophy ● ABG
and these four defining characteristics ● O2 MEASUREMENT
are what make up the Tetralogy of Fallot. ● X-RAY
• Because of these defects, deoxygenated ● CARDIAC CATHETERIZATION
and oxygenated blood can get mixed up
and pumped into the circulation, having Complete Blood Count (CBC)
less than normal oxygen supply delivered • A complete blood count (CBC) is a series
to the rest of the body. of tests used to evaluate the composition
• Because of the oxygen insufficiency, and concentration of the cellular
symptoms such as cyanosis and in components of blood. CBC provides
extreme cases “tet” spells occur. These valuable information about the patient's
symptoms indicate that there is not blood and can serve as a preoperative
enough oxygen received by the other test to ensure both adequate oxygen
parts of the body. carrying capacity and hemostasis of the
• The definitive treatment of TOF is patient.
through a surgical procedure that repairs • Expected Results for Patients w TOF:
the defects in the heart. The surgery may ○ The red blood cell count and
be done immediately or postponed hemoglobin may be elevated as
according to the severity of the the body attempts to compensate
symptoms and condition of the patient. for the lack of oxygen to the
• Another management option while tissues.
awaiting surgery is ensuring that the
patient is getting enough oxygen since Oxygen Level Measurement
the consequence of TOF is oxygen • Pulse oximetry is a non-invasive test
insufficiency. used to measure the oxygen level
○ Knee-chest position that (oxygen saturation) of the blood. It can
improves circulation and rapidly detect even small changes in
supplementing oxygen through oxygen levels. These levels show how
mechanical means are key efficiently blood is carrying oxygen to the
interventions. extremities furthest from the heart, which
○ Medications, on the other hand, include upper and lower extremities.
are those that overall improve the Using this small, clip-like device, it
heart’s ability to pump blood to the attaches to a body part, most commonly
rest of the body such as in the finger. Tetralogy of fallot is a
metoprolol, phenylephrine, and congenital heart disease that affects
morphine. blood oxygen levels or hypoxemia.
• If not treated, there will be a continued Hypoxemia which results in cyanosis if
lack of oxygen in the body that could the measurement of arterial oxygen
result in many other complications, not saturation is <80%.
 • Expected Results for Patients w TOF: common sign of tetralogy of Fallot on an
○ Patients with tetralogy of Fallot x- ray is a “boot-shaped heart” because
(TOF) typically develop increasing the right ventricle is enlarged.
hypoxia as their ductus arteriosus • Expected Results for Patients w TOF:
closes and they have progressive ○ The abnormal “coeur-en-sabot”
right ventricular outlet obstruction (boot-liked) appearance of a heart
which may lower blood oxygen with tetralogy of Fallot is easily
levels(cyanosis) and as a result, visible via chest x-ray.
pulse oximetry reading is <80%
arterial oxygen saturation. Cardiac Catheterization
○ Note: lower ABG or arterial • Cardiac catheterization is performed with
oxygen saturation reading related a radiopaque catheter that’s passed
to TOF needs further test through the femoral artery directly into
assessment to validate the the heart and lungs. It may also be
diagnosis such as(EKG, performed in conjunction with
Echocardiogram, cardiac angiography, in which a radiopaque
catheterization). contrast medium is injected through the
catheter into the circulation, allowing
Echocardiogram visualization of blood circu- lation through
• Echocardiography is used to evaluate the heart chambers.
cardiac structures and functions using • Expected Results for Patients w TOF:
echoes from pulsed, high-frequency ○ Cardiac catheterization will show
sound waves. An ultrasound transducer narrowing of pulmonary arteries
is placed on the chest, and the sound and severe subpulmonary
waves produce an image of the heart. obstruction.
The test is noninvasive and painless and ○ Severe Right Ventricular Outflow
is one of the most commonly used tests Tract Obstruction (RVOTO)
to detect cardiac problems in children. It ○ Visibility of the overriding and
will demonstrate the ventricular septal displacement of Aorta.
defect or large hole between the left and
right ventricles, the degree of pulmonary MEDICAL MANAGEMENT
stenosis, and it will reveal other
unanticipated defects. • Children with Tetralogy of Fallot are
generally medically managed by a
Electrocardiogram (ECG) pediatric cardiologist. So, when there are
• ECG provides a graphic representation sudden episodes of profound cyanosis
of the heart’s electrical activity. It’s used and hypoxia, also known as
to detect the presence of ischemia, hypercyanotic or "tet" spells, this requires
injury, necrosis, bundle-branch block, immediate intervention.
fascicular blocks, conduction delay,
chamber enlargement, and arrhythmias. • Tetralogy of Fallot requires corrective
surgery performed by a heart
Chest X-ray Imaging (cardiovascular) surgeon on all infants.
• Chest x-ray is commonly performed for Without therapy, the baby's growth and
diagnostic x-ray examination. A chest x- development may be affected. The
ray produces images of the heart, lungs, doctor will determine which surgery is
airways, blood vessels, and the bones of most appropriate and when it should be
the spine and chest (thoracic cavity) performed based on the child's condition.
which helps diagnose and treat medical Also, there are other medical intervention
conditions. A chest x-ray can show the for TOF
structure of the heart and lungs. A
 • Knee-chest position Metoprolol
Place the child in the knees to the chest Administration of beta-blockers helps in
position; this increases systemic reducing heart rate, improves cardiac filling, and
resistance, reducing the right to left may increase systemic vascular resistance.
shunting. Furthermore, the increased
aortic and left ventricular pressure SURGICAL MANAGEMENT
reduces the rush of blood through the
septal hole from the right ventricle and Tetralogy of Fallot is treated by repairing the
improves the lungs' blood circulation. defects surgically. Cardiac surgeons usually
Goal - To promote significant changes in perform the surgery before an infant reaches the
venous return and cardiac output. age of one year.

• Supplemental Oxygen In most cases, the repair is usually done

Administering oxygen through a nasal tube or around six months or even earlier. By
nasal cannula as much as 2-3 liters per correcting the heart defects, oxygen-depleted
minute may be effective in treating cyanotic blood will travel through the pulmonary artery
spells. This allows more blood flow to the and receive oxygen.
lungs by decreasing shunting of
deoxygenated blood from the right to left
ventricle through the VSD (ventricular septal
defect). It also increases systemic resistance
and may help improve oxygen delivery. Goal
- To improve oxygenation.

• Fluid Administration
Fluid bolus can be administered to increase
intravascular volume. Dextrose normal
saline can be given as 10ml/kg bolus. Goal -
To restore circulating volume and increase
cardiac output, thereby restoring tissue
perfusion and oxygen delivery.
Blalock‐Taussig shunt
MEDICATIONS:

Morphine
Sedation is an essential part of the treatment
plan to alleviate and prevent the recurrence of
cyanosis in patients with hypercyanotic spells.
By administering morphine 0.1-0.2 mg/kg IM,IV
helps calm the child down, reduces tachypnea
and decreases pulmonary vascular resistance.

Phenylephrine
Systemic vasoconstriction helps reduce the
right to left shunt and improves pulmonary blood
circulation. This is generally used as last-line The Blalock-Taussig shunt is used when the
medication. patient has Tetralogy of fallot. Also, it is
indicated to those who have pulmonary atresia,
pulmonary stenosis, and hypoplastic left heart
syndrome and tricuspid atresia. Creates a shunt
between the aorta and the pulmonary artery
using the subclavian artery.
 -Monitor for alteration in HR.
This is used as a palliative procedure in infants R: HR, and respiratory rate all increase with
who are not suitable candidates for intracardiac initial hypoxia and hypercapnia
repair due to prematurity, hypoplastic
pulmonary arteries, or coronary artery anatomy. -Monitor for signs of hypercapnia
Since this is not a curative procedure, patients R: Hypercapnia is the buildup of carbon dioxide
will require additional surgery. in the bloodstream. Signs of hypercapnia
include headaches, dizziness, lethargy, reduced
Intracardiac Repair ability to follow instructions, disorientation, and
coma.

-Monitor oxygen saturation continuously, using

a pulse oximeter.
R: Pulse oximetry is a useful tool to detect
changes in oxygenation

Decreased cardiac output related to

The definitive repair for patients with TOF is the structural factors of congenital heart defect
preferable procedure. This consists of patch
closure of the ventricular septal defect, and -Assess heart rate
enlargement of the right ventricular outflow tract R: Most patients have compensatory
with relief of all sources of obstruction. tachycardia in response to reduced cardiac
output.
In some cases, the pulmonary valve may need
to be removed to eliminate the obstruction. The - Note skin color, temperature, and moisture.
ventricular septal defect is closed with a patch. R: Cold, clammy, and pale skin is secondary to
a compensatory increase in sympathetic
The right ventricular outflow tract is enlarged by nervous system stimulation and low cardiac
opening the right ventricular outflow tract and output and oxygen desaturation.
pulmonary valve, resecting the sub-infundibular
muscle bundles, and patching the area open. -Check for peripheral pulses, including capillary
refill.
In some cases, a conduit may be inserted to R: Weak pulses are present in reduced stroke
further open the right ventricular outflow tract. volume and cardiac output.

NURSING DIAGNOSIS -Monitor electrocardiogram (ECG) for rate,

rhythm, and ectopy.
Impaired gas exchange related to ineffective R: Cardiac dysrhythmias may occur from low
circulation secondary to cardiac perfusion, acidosis, or hypoxia.
malformations
-Administer oxygen therapy as prescribed.
-Assess respiratory rate R: The failing heart may not be able to respond
R: Rapid and shallow breathing patterns and to increased oxygen demands
hypoventilation affect gas exchange
Activity Intolerance related to imbalance
-Assess the lungs for areas of decreased between oxygen supply and demand
ventilation and auscultate presence of -Assess the patient’s nutritional status.
adventitious sounds. R: Adequate energy reserves are needed
R: Any irregularity of breath sounds may during activity.
disclose the cause of impaired gas exchange.
- Observe and monitor the patient’s sleep
pattern and the amount of sleep achieved over - Monitor and report any signs and symptoms of
the past few days. infection.
R: Sleep deprivation and difficulties during sleep R: Signs and symptoms of infection vary
can affect the activity level of the patient according to the body area involved.
-
- Assess the need for ambulation aids - Assess and monitor nutritional status
R: Assistive devices enhance the mobility of the R: Patients with inadequate nutrition may be
patient by helping him overcome limitations. anergic or unable to muster a cellular immune
response to pathogens, making them
- Use portable pulse oximetry to assess oxygen susceptible to infection.
desaturation during activity.
R: May determine the use of supplemental -Assess immunization status and history.
oxygen to help compensate for the increased R: People with incomplete immunizations may
oxygen demands during physical activity. not have sufficient acquired active immunity.

- Observe and document response to activity. - Maintain strict asepsis for dressing changes,
R: Close monitoring will serve as a guide for wound care, intravenous therapy, and catheter
optimal progression of activity handling.
R: Aseptic technique decreases the chances of
Interrupted family processes related to crisis transmitting or spreading pathogens to or
associated with congenital heart disease between patients.

- Observe erratic behaviors, perception of crisis -Ensure that any articles used are properly
situations. disinfected or sterilized before use.
R: Information affecting the ability of the family R: This reduces or eliminates germs.
to cope with an infant/child’s cardiac condition.
NURSING MANAGEMENT
- Encourage expression of feelings and provide
factual information about infants/children. 1. Provide bed rest to the child
R: Reduces anxiety and enhances family’s R: bed rest can help to avoid stress to the
understanding of the condition. child and give comfort
2. Ensure uninterrupted period of rest and
-Assess usual family coping methods and sleep
effectiveness. R: Helps to give comfort and avoid
R: Identifies the need to develop new coping getting sick
skills if existing methods are ineffective in 3. Provide feeding, tactile stimulation, and
changing behaviors exhibited. change wet diapers
R: To prevent child from crying
- Assess need for information and support. 4. Administer oxygen as required
R: Provides information about the need for R: To maintain adequate oxygenation of
interventions to relieve anxiety and concern. tissue and vital organs
5. Monitor oxygen saturation through pulse
- Encouragement to maintain the health of oximeter
family members and social contacts. R: To evaluate effectiveness of oxygen
R: Chronic anxiety, fatigue, and isolation as a therapy
result of infant care will affect health and care 6. Do not allowed the child to do heavy
capabilities of the family. activities
R: To reduce risk of injury
Risk for infection related to need for invasive 7. Monitor BP
procedure secondary to need to correct R: To provide data about patients
cardiac malformations cardiovascular status
8. Administer medications- digoxin and
diuretics.
R: To treat heart failure
9. Provide visual, tactile, and auditory
stimulation approp to child’s age
R: Help the patient develop sense of
control over the environment
10. Encourage parents to provide tender
loving care
R: To improves their well-being
 sends and receives chemical and
SPINA BIFIDA electrical signals throughout the body.
● Cerebrospinal Fluid - CSF Assists the
DEFINITION brain by providing protection,
nourishment, and waste removal.
-Spina Bifida is a birth defect where there is ● Meninges - Layered unit of membranous
incomplete closing of the backbone and connective tissue that covers the brain
membranes around the spinal cord. and the spinal cord, it primarily protects
and supports the central nervous system.
IT HAS 3 FORMS: It connects the brain and spinal cord to
the skull and spinal canal.
Spina Bifida occulta – mildest form of spina ● Spine - Central support structure of the
bifida; splits in the vertebrae are small and the body. Connects different parts of the
spinal cord does not protrude. musculoskeletal system.
s/s: hairy patch, dimple, dark spot, ● Vertebrae - has 33 stacked vertebrae
swelling at the site of gap in the spine that form the spinal canal. The spinal
canal protects the spinal cord and nerves
Meningocele – the meninges are forced into the from injury.
gaps between the vertebrae; may be classified ● Spinal cord - A long bundle of nerves
through their location. and cells that extends from the lower
-ex: endonasal meningoceles (lie at the portion of the brain to the lower back. It
roof of the nasal cavity) carries signals between the brain and the
-causes: teratoma, other tumores of rest of the body.
sacrococcyx ane presacral space,
currarino syndrome.

Myelomeningocele – most severe type of

spina bifida; meningeal membranes that cover
the spinal cord protrude through the opening,
forming a sac enclosing the spinal elements
(meninges, cerebrospinal fluid, spinal cord).
Comparison between the normal spine and
- Myeloschisis – most severe form of spine with spina bifida
myelomeningocele; meningeal membranes
protrude through the opening with no sac ETIOLOGY
making the baby more prone to infections such
as meningitis. Spina bifida is believed to be caused by a
combination of genetic and environmental
-There is usually some degree of paralysis and factors.
loss of sensation below the level of the spinal
cord defect. Genetic factors:
• After having one child with the condition,
or if a parent has the condition, there is a
4% chance the next child will also be
affected
• White or Hispanic races have a higher
risk
ANATOMY AND PHYSIOLOGY • Girls are more prone than boys

● Brain - The brain is one of the most

complex organs in the human body. It
Environmental factors: Precipitating factors - increased body
• folic acid deficiency temperature, folate deficiency
• anti seizure medications
• obesity 1. Neural groove develops to form the
• poorly managed diabetes neural tube around day 20 after
• drinking alcohol – triggers macrocytosis conception.
which discard folate after stopping the
drinking of alcohol; it takes months to 2. In normal development, the upper end is
rejuvenate bone marrow and recover supposed to close at day 25 and the
from macrocytosis lower end is supposed to close at day 27.

SYMPTOMATOLOGY 3. Three opportunities could cause

abnormal closure of the neural tube.
● Physical signs of Spina Bifida may a. If the hyaluronic acid matrix or
include: actin microfilaments have
○ leg weakness and paralysis abnormalities early on, the neural
○ orthopedic abnormalities (club tube will not close.
foot, hip dislocation, scoliosis) b. If an overgrowth occurs over the
○ bladder and bowel control caudal end the neural tube will not
problems (incontinence, UTI, poor close, but this occurs later in
kidney function) development.
○ pressure sores and skin irritations c. The last chance for the tube not to
○ abnormal eye movement close properly occurs when the
○ 68% of children with SB may have glycoproteins that typically hold
allergy to latex the cells together during closure
● Neurological problems include: fail to adhere to the tube together.
○ Arnold Chiari II malformation –
abnormality of the cerebellum 4. Incomplete closing of the backbone and
○ back portion of brain is displaced membranes around the spinal cord is
into the upper neck now called as Spina Bifida.
○ hydrocephalus – displaced ★ Disease progression
cerebellum interferes with the flow ★ Lack of fusion of the posterior
of cerebrospinal fluid causing an surface of the embryo
accumulation of excess fluid
○ corpus callosum – common to 5. Vertebral Dysgenesis
individuals with ● Spina Bifida
myelomeningocele; this affects ● SB Occulta
the communication processes ● Meningocele
between the left and right brain ● Myelomeningocele
hemispheres
○ less organized or impaired white 6. Posterior Fossa Hypoplasia
matter ● Chiari 2 malformation
○ cortex abnormalities; neurons ● CSF Obstruction in the posterior
may be displaced fossa and foramen magnum
A. Increased Spinal Pressure
PATHOPHYSIOLOGY ● Spina Bifida
● SB Occulta
Predisposing factors - Family history of neural ● Meningocele
tube defects, obesity, diabetes, some ● Myelomeningocele
medications, race. B. Increased Cranial Pressure
● Hydrocephalus
 ● Anencephaly
7. Cranial Dysgenesis MEDICAL MANAGEMENT
● Anencephaly
● Physical therapy (prevents muscles from
LABORATORY AND DIAGNOSTIC TESTS weakining)
● Assistive technologies (wheelchair)
Antenatal Period Testing: ● Occupational therapy (help perform
● Maternal Serum Alpha-Fetoprotein everyday activities)
Test ● Medications
○ Alpha-fetoprotein (AFP) screening ○ Anticonvulsants (Valproic acid)
to measure AFP levels in the ○ Antibiotics (Amoxicillin,
blood at 16 to 18 weeks’ gestation. Cephalexin)
AFP is a fetal-specific gamma-1 ○ Anticholinergic (Oxybutynin)
globulin in the amniotic fluid that
indicates the presence of myelo-
meningocele. If the AFP screen is SURGICAL MANAGEMENT
abnormal, amniocentesis and fetal
ultrasound are performed. “SPINA BIFIDA MUST BE CLOSED BY A
● Ultrasound SPINAL SURGERY”
○ used to detect open NTDs or
ventral wall defects. ● Postnatal Surgery:
● Amniocentesis Treating meningocele requires surgical
○ high level of alpha-fetoprotein intervention to put the protective
(AFP) = higher risk of spina bifida membranes around the spinal cord
(meninges) back in place and close the
Diagnostic Testing: opening in the vertebrae.
● X-ray Myelomeningocele also requires surgery.
● Computed Tomography (CT) Performing the surgery early (24 to 48
○ Computed tomography (CT) scan hours after birth) can help minimize risk
is indicated when CNS disease is of infection that's associated with the
suspected. The scan produces exposed nerves and may also help
three-dimensional images that protect the spinal cord from more trauma.
can identify congenital ● Fetal Surgery:
abnormalities, fractures, brain A very high risk closure surgery
tumors, in- farction, bleeding, and performed between 21-25 week of
hematomas as well as provide pregnancy. Surgeons expose the
information about the ventricular pregnant mother's uterus surgically,
system of the brain. CT scan may open the uterus and repair the baby's
be done with or without contrast. spinal cord.
● Magnetic Resonance Imaging (MRI)
○ Magnetic resonance imaging Treatment options depend on the severity of the
(MRI) is a noninvasive diagnostic condition, for instance, spina bifida occulta often
procedure that provides valuable doesn't require treatment at all, but other types
information about the body’s of spina bifida do.
anatomy in greater detail than a
CT scan does. It doesn’t require NURSING DIAGNOSIS
exposure to ionizing radiation.
MRI is indicated for the evaluation Impaired physical mobility related to sensory-
of headache or neurologic signs of perceptual impairment secondary to
CNS lesions; it’s also used to meningomyelocele as evidenced by lack of
assess neck and back pain as well sensation of the extremities.
as lesions of the bones and joints. Nursing Responsibilities:
 R: These measures reduce skin
1. Assess for impediments to mobility. breakdown, and the compression
R: Identifying barriers to mobility guides devices promote increased venous
the design of optimal treatment. return.

2. Assess the ability to perform ROM or 10. Provide recommendations for nutritional
reflexes to all joints. intake for adequate energy resources
R: This assessment provides data on the and metabolic requirements.
extent of any physical problems and R: The patient will need an adequate,
guides therapy. properly balanced intake of
carbohydrates, fats, protein, vitamins,
3. Assess the parent/guardian’s emotional and minerals to provide energy
response to the disability or limitation. resources.
R: Acceptance of complete or partial
paralysis can vary among individuals. Impaired Urinary Elimination related to
Each person has their own definition of neuromuscular defect as evidenced by
acceptable quality of life. urinary incontinence
Nursing Responsibilities:
4. Assess for developing thrombophlebitis 1. Assess urine for color, amount, odor, and
(localized swelling, rise in temperature, turbidity.
vital signs monitoring). R: Cloudy, dark, bloody, or strange-
R: Immobility affects peripheral circulation smelling urine indicates urinary bladder
and can progress to clot formation. infection.

5. Evaluate the need for assistive devices. 2. Assess the presence of neurogenic
R: Proper use of assistive devices can bladder, the degree of incontinence,
promote safety. potential for rehabilitation, age of the child.
R: Provides information about the
6. Evaluate the need for home assistance. condition for use in the plan of establishing
R: Obtaining proper assistance for the urinary elimination routine.
patient can ensure safe and proper
progressions. 3. Keep the genital and anal area clean after
7. Provide a safe environment: bed rails up, each elimination episode or as needed if
bed in a down position, necessary items incontinent.
close by. R: Prevents the introduction of
R: These measures promote a safe, microorganisms into the urethra and
secure environment and may reduce the urinary bladder.
risk for falls.
4. Encourage adequate fluid intake of 30
8. Perform passive or active assistive ROM ml/1lb/day including acid-containing
exercises to all extremities. beverages and addition of foods high in
R: Exercise promotes increased venous acid content in the diet.
return, prevents stiffness, and maintains R: Promotes renal blood flow and acidifies
muscle strength and endurance. urine to prevent infection.

9. Teach parent/s to institute measures to 5. Encourage parents to use pad and water-
prevent skin breakdown and proof undergarment instead of the use of
thrombophlebitis from prolonged diapers for a child over 3 years of age.
immobility: clean, dry, and moisturize the R: Prevents an embarrassment for the
skin as needed, use compression devices child.
like stockings as indicated, use pressure-
relieving devices as indicated.
 6. Perform a scheduled rehabilitation R: Relieves anxiety and concern and
program of placing the child on toilet or allows a show of acceptance for their
potty chair at same times each day. responses.
R: Establishes a routine for urinary
elimination if this is a possibility. 3. Encourage expression of feelings and
provide accurate, honest information
7. Perform intermittent catheterization every 3 about care with or without surgical repair,
to 4 hours if indicated to resolve abilities, and disabilities.
incontinence. R: Allow reduction in anxiety and
R: Ensures emptying of the bladder to enhances family understanding of
prevent incontinence and infection. condition and child’s needs.

8. Advise parents on alternative procedures 4. Provide anticipatory guidance for crisis

to control incontinence such as resolution.
implantation of an artificial sphincter, R: Assists family to adapt to the situation
creation of an artificial reservoir, or creation and develop a new coping mechanism.
of a urinary diversion.
R: Provides information about other 5. Reinforce positive coping behaviors.
methods that can be performed if R: Promotes behavior change and
intermittent catheterization is not attained. adaptation to care for the child.

9. Educate parents and child about changes 6. Teach that overprotective behavior may
in urine characteristics indicating bladder hinder growth and development, and that
infection and measures to take to prevent children should have limits and rules to
this complication. live by.
R: Allows for early interventions to control R: Enhances family understanding of the
infection and eventual renal complications. condition and need for integration of the
child into family activities.
10. Advice to keep a record on fluid intake/day,
weights and changes to report foods and 7. Explain causes, treatment, and prognosis
fluids. of condition; inform parents that they are
R: Maintains a monitoring system to ensure not at fault for development of the
control of possible complications. congenital defect.
R: Reduces guilt and provides
Interrupted family process related to altered information about the condition.
health status as evidenced by irritability and
impatience as a response by family 8. If hospitalization is frequent, assign the
members to child same personnel to care for the child if
Nursing Management: appropriate.
1. Assess anxiety level of family and child, R: Promotes trust and communication
perception of crisis situation, coping and with family members.
problem-solving methods used and 9. Assist to identify helpful techniques to
effectiveness. use to problem solve and cope with the
R: Identifies the need to develop new problem and gain control over the
coping skills and realistic behaviors in situation.
goal setting and interventions necessary R: Provides support for problem solving
for family and child to adapt to crises. and management of the situation.

2. Encourage family members to vent 10. Inform the need for follow-up
feelings and reactions to the appearance appointments with physicians and
and condition of a child. therapists.
 R: Ensures compliance with the 8. Teach the parent/s or caregiver the signs
medical regimen. and symptoms of infection.
R: Early recognition of infection signs and
symptoms can lead to early treatment.
Risk for infection related impaired skin
integrity secondary to spina bifida. 9. If an infection occurs, let the patient take
Nursing Management: antibiotics as prescribed.
1. Assess for the presence and history of R: Proper instruction during prescription
risk factors such as open wounds, must be followed accordingly to avoid
abrasions, and the like. antibiotic resistance.
R: These data represent a break in the
body's normal first line of defense. 10. Inform parent/s or caregivers to let the
patient take the full course of antibiotics
2. Assess nutritional status. if prescribed whether symptoms
R: Patients with poor nutritional status improve or disappear.
may be unable to muster a cellular R: Not completing the entire course of the
immune response to pathogens and are prescribed antibiotic regimen can lead
therefore more susceptible to infection. to drug resistance and reactivation of
symptoms.
3. Monitor the following signs: redness or
swelling, purulent discharge, elevated Readiness for enhanced knowledge related
temperature. to spina bifida as evidenced by the mother
R: These classic signs of infection must expressing desire to learn about the
be detected early to identify appropriate condition.
antibiotics for therapy. Nursing Management:
1. Verify client’s level of understanding of
4. Wash hands and teach caregiver/s to therapeutic regimen. Note specific
wash hands before contact with the health goals.
patient. R: Provides opportunity to assure
R: Hand hygiene reduces the risk for accuracy and completeness of
transmitting pathogens. knowledge base for future learning.

5. Maintain or teach asepsis technique to 2. Identify steps necessary to reach

the caregiver when changing wound desired health goals.
dressings or during wound care. R: Understanding the process
R: Any prevention-related intervention is enhances commitment and the
to interrupt the transmission of infection. likelihood of achieving the goals.

6. Limit visitors. 3. Accept client’s evaluation of their own

R: Restricting visitation reduces the strengths/limitations while working
transmission of pathogens to patients at together to improve abilities.
risk for infection. R: Promotes sense of self-esteem and
confidence to continue efforts.
7. Demonstrate and allow return
demonstration of all high-risk procedures 4. Acknowledge individual
that the caregiver will do after discharge efforts/capabilities to reinforce
like dressing changes. movement toward attainment of desired
R: Parent/s or caregivers need outcomes.
opportunities to know skills to reduce the R: Provides positive reinforcement
risk for infection. encouraging continued progress toward
desired goals.
5. Promote client/care giver choices and
involvement in planning for
implementing added
tasks/responsibilities.
R: Promotes proactive problem solving.

6. Determine the motivation/expectations

for learning.
R: To develop a plan for learning.

7. Provide information about additional

learning resources. Such as: books,
internet.
R: Promotes ongoing learning at your
own pace.

8. Assist the patient to identify learning

goals.
R: To help focus on content to be
learned.

9. Encourage the patient to verbalize

concerns regarding knowledge and
skills needed by the patient.
R: To promote ease in handling difficult
situations.

10. Repeat instructions and demonstrations

of skills needed by the patient.
R: Repetition reinforces learning.

PROGNOSIS

Children with spina bifida can lead relatively

active lives. Prognosis, activity, and
participation depends on the number and
severity of the disease and associated factors
(environmental and genetic). They can have
normal intelligence and can walk, usually with
an assistive device.
 diaphragm, and other parts of your body. The
RHEUMATIC HEART heart weighs between 7 and 15 ounces (200 to
DISEASE 425 grams) and is a little larger than the size of
your fist. By the end of a long life, a person’s
heart may have beat (expanded and contracted)
DEFINITION more than 3.5 billion times. In fact, each day, the
average heart beats 100,000 times, pumping
● Rheumatic heart disease is a condition in about 2,000 gallons (7,571 liters) of blood.
which the heart valves have been Heart valves Are flaps found in the heart and is
permanently damaged by rheumatic fever. made of fibrous connective tissues that prevent
(rheumatic fever is the body's response to a blood from flowing back in the chamber. In
strep infection of the throat or tonsils, known patients with rheumatic heart disease, scar
as "strep throat.") tissues from repeated inflammation results in
● The heart valve damage may start shortly stenosis of valves (bicuspid), wherein there is a
after untreated or under-treated narrowing and cannot open fully
streptococcal infection such as strep throat ○ Tricuspid valve – 3 flaps in between the right
or scarlet fever. atrium and right ventricle
● An immune response causes an ○ Bicuspid valve – 2 flaps in between the left
inflammatory condition in the body which can atrium and left ventricle
result in ongoing valve damage
● Rheumatic heart disease refers to the ETIOLOGY
cardiac manifestations of rheumatic fever. It
includes pancarditis (myocarditis, Acute rheumatic fever is a systemic disease of
pericarditis, and endocarditis) during the childhood, often recurrent that follows group A
early acute phase and, later in the course of beta hemolytic streptococcal infection
the disease, chronic valvular disease.
Cardiac involvement develops in up to 50% • It is delayed non-suppurative sequelae to
of patients with rheumatic fever. Upper respiratory tract infection (URTI)
with Group A beta-hemolytic
ANATOMY & PHYSIOLOGY Streptococcus pyogenes GABH
streptococci.
• It is a diffuse inflammatory disease of
connective tissue, primarily involving
heart, blood vessels, joints, subcut.tissue
and CNS
• Causative agent – Streptococcus
Pyogenes (beta-hemolytic streptococci,
group A)

Predisposing factors:

o Low socioeconomic status

o Age - 5 to 15 years old
o Family history
Heart Your heart is located between your lungs
in the middle of your chest, behind, and slightly
Precipitating factors:
to the left of your breastbone (sternum). A
double-layered membrane called the
o Bad hygiene (oral)
pericardium surrounds your heart like a sac. The
o Untreated rheumatic fever
outer layer of the pericardium surrounds the
roots of your heart's major blood vessels and is
attached by ligaments to your spinal column,
SYMPTOMATOLOGY LABORATORY & DIAGNOSTIC TESTS

• Fever – fever is always a symptom or • Echocardiogram (echo)

manifestation of inflammation R: To help diagnose and monitor certain
• Heart murmur (mitral) – due to mitral heart conditions by checking the
insufficiency structure of the heart and surrounding
• Polyarthritis – inflamed multiple joins blood vessels, analyzing how blood flows
due to fluid accumulation through them and assessing the pumping
• Jerky movements – there is a loss of chambers of the heart.
control of voluntary muscles
• Skin sores – the causative agent, Strep • Electrocardiogram (ECG
A can cause skin sores as lesions R: To evaluate the extent of heart
• Recurrent sore throat - the causative involvement
agent, Strep A can cause “strep throat” ●
Fatigue due to decreased cardiac output • Chest X-ray
R: To check the lungs and see if the heart
PATHOPHYSIOLOGY is enlarged.

• Streptococcus Pyogenes (beta- • Cardiac MRI

hemolytic streptococci, group A) R: To get a more accurate look at the
• Invasion of bacteria in nasopharynx heart valves and heart muscle.
• Immune response
• Inflammation (pharyngitis) • Antistreptolysin-O (ASO)
• Rheumatic fever R: To show whether a recent
○ Signs and symptoms: streptococcal infection occurred
■ Fever
■ Heart murmur PHARMACOLOGIC MANAGEMENT
■ Polyarthritis
■ Jerky movement • Antibiotic
■ Skin sores ○ Benzathine benzyl penicillin
■ Recurrent sore throat ○ Phenoxymethyl penicillin (Pen
■ Fatigue VK)
• Pathogens dwell in the endocardium ○ Erythromycin ethylsuccinate
• Scar from repeated inflammation • Pain relievers – to alleviate the pain in
• Fusion of tissues joints
○ Ibuprofen
• Stenosis
• Rheumatic heart disease
SURGICAL PROCEDURE WITH NURSING
○ Confirmed thru:
INTERVENTION/POST-OP CARE
■ ASO
■ Cardiac MRI
If there is an extreme myocardial involvement,
■ ECG
valve repair or valve replacement is
○ Good prognosis:
recommended.
■ Repaired or replaced
damaged valve
• Assess area for hematoma (swelling,
■ Improved heart function
○ Bad prognosis pain, discoloration)
■ Progression of stenosis • Monitor vital signs: heart rate, heart
■ Decreased cardiac output sound, heart rhythm
■ Heart failure • Encourage bed rest
■ Death • Give medication as ordered (antiplatelet)
 10 NURSING MANAGEMENT 4. Assist in gentle handling and supporting
of body parts.
1. Assess for the recurrence of sore throat. R: Prevents extra pain to affected parts.
2. Assess for presence of joint pains.
3. Assess for body temperature or presence 5. Provide toys, games for quiet, sedentary
of fever. play.
4. Assess the child's mobility (ask for R:Provides diversionary activity to
presence of jerky movements). distract from the pain.
5. Advise patients to perform proper hand
washing technique. Hyperthermia related to inflammation as
6. Encourage patients to practice good oral evidenced by temperature > 38.5C
hygiene.
7. Encourage the patient to rest (prevent 1. Assess for signs of hyperthermia.
fatigue). R: Assess for hyperthermia signs and
8. Inform guardian/s and patients to follow symptoms, including flushed face,
the full course of 10-day antibiotic weakness, rash, respiratory distress,
therapy. tachycardia, malaise, headache, and
9. Inform guardians that there is a irritability. Monitor for reports of sweating,
possibility for surgery if the condition hot and dry skin, or being too warm.
worsens.
10. Encourage both the patient and 2. Assess for signs of dehydration as a
guardian/s to reiterate/demonstrate result of hyperthermia.
important things to remember. R: Look for signs of dehydration,
including thirst, furrowed tongue, dry lips,
NURSING DIAGNOSIS dry oral membranes, poor skin turgor,
decreased urine output, increased
Pain related to inflammation as evidenced by concentration of urine, and weak, fast
joint swelling. pulse.

1. Assess the child’s pain perception using 3. Monitor the patient’s heart rate and blood
an appropriate scale every 2 to 3 hours. pressure.
R: Provides information about the pain R: HR and BP increase as hyperthermia
level of the child progresses.

2. Assess changes in behavior, such as 4. Identify the triggering factors for

high-pitched cry, irritability, restlessness, hyperthermia and review the client’s
refusal to move, facial grimace, history, diagnosis, or procedures.
aggressive or dependent behavior. R: Understanding the changes in
R:Nonverbal pain descriptions that are temperature or the cause of
age-related as child or infant may be hyperthermia will help guide the
unable to describe pain; fear and anxiety treatment and nursing interventions.
associated with pain cause changes in
behavioral responses 5. Determine age and weight.
R: Extremes of age or weight increase
3. Examine affected joints, degree of joint the risk of the inability to control body
pain, level of joint movement. temperature. The elderly are prone to
R:Provides data about pathologic hyperthermia because of the physiologic
changes in joints; reversible joint changes related to aging, the presence of
involvement usually affecting large joints, chronic diseases, and the use of
such as knees, hips, wrists, and elbows; polypharmacy.
an increase in numbers of affected joints
occurs over a period of time.
Fatigue related to decreased cardiac output. or permanent as well as physical or
psychological. Determining the cause
1. Assess heart rate and blood pressure. can help guide the nurse during the
R: Compensatory tachycardia is a nursing intervention.
common response for patients with
significantly low blood pressure to reduce 3. Assess the patient’s nutritional status
cardiac output. Initially, this R: Adequate energy reserves are
compensatory response has a favorable needed during activity.
effect on cardiac output but can be
harmful when it becomes persistent. 4. Observe and monitor the patient’s sleep
pattern and the amount of sleep
2. Check for peripheral pulses. Perform achieved over the past few days.
capillary refill test (CRT). R: Sleep deprivation and difficulties
R: Weak pulses are present in reduced during sleep can affect the activity level
stroke volume and cardiac output. of the patient – these needs to be
Capillary refill is sometimes slow or addressed before successful activity
absent. progression can be achieved.

3. Note skin color, temperature, and 5. Use portable pulse oximetry to assess for
moisture. oxygen desaturation during activity.
R: Cold, clammy, and pale skin is R: May determine the use of
secondary to a compensatory increase in supplemental oxygen to help
sympathetic nervous system stimulation compensate for the increased oxygen
and low cardiac output and oxygen demands during physical activity.
desaturation.
Risk for infection related to chronic
4. Check for any alterations in level of recurrence of disease secondary to RHD
consciousness.
R: Decreased cerebral perfusion and 1. Assess parents’ knowledge and skills in
hypoxia are reflected in irritability, the administration of prescribed
restlessness, and difficulty concentrating. antimicrobials; daily oral administration
or monthly intramuscular injections.
5. Assess oxygen saturation with pulse R: Providing long-term antibiotic therapy
oximetry both at rest and during and after (as long as 5 years) as a preventive
ambulation. measure may be challenging.
R: An alteration in oxygen saturation is
one of the earliest signs of reduced 2. Monitor for chest pain, shortness of
cardiac output. Hypoxemia is common, breath, fatigue, cough, night sweats,
especially with activity. Administer friction rub, gallop during the acute stage
supplemental oxygen as needed. of the disease.
R: Signs and symptoms of carditis, which
Activity intolerance related to muscle may result in endocarditis causing
weakness. vegetation that becomes fibrous at the
valve areas that is at increased risk of
1. Assess the physical activity level and recurrent infections.
mobility of the patient.
R: Provides baseline information for 3. Administer antibiotic therapy during the
formulating nursing goals during goal acute phase of disease as prescribed.
setting. R: Inhibits cell wall synthesis of
2. Investigate the patient’s perception of microorganisms, destroying the
causes of activity intolerance causative pathogen.
R: Causative factors may be temporary
 4. Instruct in the long-term antibiotic
regimen, the need for protection prior
dental work or any invasive procedure,
and inform of importance to prevent
recurrence
R: Therapy begins after the acute phase
and medical supervision is needed for life
as rheumatic fever may recur; a high
percentage of children who incur the
disease have cardiac complications later
in life.

5. Notify the physician immediately for any

upper respiratory infections, elevated
temperature, joint pain, or non-
compliance to antibiotic therapy.
R: May indicate recurrence of the
disease or need to change or adjust
medication.

PROGNOSIS

● Good prognosis for older age group & if no

carditis during the initial attack
○ damaged valve is repaired or replaced,
improved heart function

● Bad prognosis for younger children & those

with carditis with valvular lesions
○ progression of stenosis, decreased
cardiac output due to the heart not being able to
pump enough blood, heart failure, death
 • The liver processes this blood, breaking
HYPERBILIRUBINEMIA down, balancing, and creating nutrients,
as well as metabolizing drugs into forms
DEFINITION that are easier for the rest of the body to
use or that are nontoxic. More specific
• Higher expected levels of bilirubin in the functions of the liver are :
blood. • Bile production, which aids in the
• a disorder in which the blood contains too removal of waste and the breakdown of
much bilirubin, resulting in jaundice fats in the small intestine during
(yellow coloring of the eyes and skin). digestion.
• “hyper”-higher than expected, elevated • The manufacture of specific proteins for
“Bilirubin” blood plasma
“nemia”-blood • Production of cholesterol and special
• A condition in which there is a build proteins to aid in the transport of fats
up of bilirubin in the blood, causing throughout the body
yellow discoloration of the eyes and • Excess glucose is converted into
skin, called jaundice. Low levels of glycogen for storage (glycogen can later
bilirubin in the newborn is common and be converted back to glucose for energy),
does not cause any trouble and will and glucose is balanced and produced
resolve on its own in the first week of life. as needed.
• Blood amino acid levels, which are the
ANATOMY AND PHYSIOLOGY building blocks of proteins, are regulated.
• Hemoglobin is processed in order to
• The liver is situated in the upper right make use of its iron content (the liver
quadrant of the abdominal cavity, stores iron)
beneath the diaphragm and on top of the • Conversion of toxic ammonia to urea
stomach, right kidney, and intestines. (urea is an end product of protein
The liver is a dark reddish-brown organ metabolism and is excreted in the urine)
that is shaped like a cone and weighs • removing drugs and other noxious
about 3 pounds. substances from the bloodregulating
• The liver receives blood from two distinct blood clotting
sources: oxygenated blood from the • Infection resistance is done by producing
hepatic artery and nutrient-rich blood immune factors and removing bacteria
from the hepatic portal vein. The liver from the bloodstream.
stores around one pint (13%) of the • Clearance of bilirubin from red blood cells
body's blood supply. as well. When bilirubin levels rise, the
• Two primary lobes make up the liver. skin and eyes turn yellow.
Both have eight segments with 1,000
lobules each (small lobes). The common ETIOLOGY
hepatic duct is formed by connecting
small ducts (tubes) with bigger ducts. • Premature birth- A baby born before 38
• The bile produced by liver cells is weeks of gestation may not be able to
transported to the gallbladder and process bilirubin as quickly as full-term
duodenum (the first part of the small babies do. Premature babies also may
intestine) via the common hepatic duct. feed less and have fewer bowel
• The liver regulates the majority of movements, resulting in less bilirubin
chemical levels in the blood and excretes eliminated through stool.
bile. This aids in the removal of waste • Significant bruising during birth -
products from the liver. The liver filters all Newborns who become bruised during
blood that leaves the stomach and delivery gets bruises from the delivery
intestines.
 may have higher levels of bilirubin from • Genetics and familial risk - Incidence is
the breakdown of more red blood cells. higher in infants with siblings who had
• Breast-feeding - Breast-fed babies, significant neonatal jaundice and
particularly those who have difficulty particularly in infants whose older
nursing or getting enough nutrition from siblings were treated for neonatal
breast-feeding, are at higher risk of jaundice. Incidence is also higher in
jaundice. Dehydration or a low caloric infants with mutations/polymorphisms in
intake may contribute to the onset of the genes that code for enzymes and
jaundice. However, because of the proteins involved in bilirubin metabolism,
benefits of breast-feeding, experts still and in infants with homozygous or
recommend it. It's important to make sure heterozygous glucose-6-phosphatase
your baby gets enough to eat and is dehydrogenase (G-6-PD) deficiency and
adequately hydrated. other hereditary hemolytic anemias.
• Race - Studies show that babies of East • Nutrition - Incidence is higher in infants
Asian ancestry have an increased risk of who are breastfed or who receive
developing jaundice. inadequate nutrition. The mechanism for
• ABO Incompatibility if the mother's this phenomenon may not be fully
blood type is different from her baby's, understood. However, when inadequate
the baby may have received antibodies feeding volume is involved, increased
through the placenta that cause enterohepatic circulation of bilirubin
abnormally rapid breakdown of red blood probably contributes to prolonged
cells. jaundice.
• Rh incompatibility occurs when an Rh-
negative woman carries an Rh-positive PATHOPHYSIOLOGY
fetus, causing the mother to develop
antibodies to the Rh antigen on fetal red - Premature birth
blood cells that enter maternal circulation - Significant bruising during birth
during pregnancy on occasion or during - Breast-feeding
labor. These maternal anti-Rh antibodies - Race
cross the placenta and induce lysis of - ABO Incompatibility
fetal red blood cells in utero and/or - Rh incompatibility
postnatally - Sepsis
• Sepsis is an infection coupled with a - Birth Trauma
systemic inflammatory response and can - Maternal factors
be dangerous both in the way the - Genetics and familial risk
infection affects our body and in the way - Nutrition
our body responds to the infection.
• Birth Trauma (e.g. cephalohematoma, → Increased hemolysis
cutaneous bruising, instrumented → Increased number of RBC to be broken
delivery) A bruise happens when blood down
leaks out of a blood vessel. Sometimes → Increased amount of heme to be
babies get bruises during labor and birth. metabolized
• Liver disease → Unconhugated bilirubin cannot be
• Maternal factors - Infants of mothers removed from the body as it is fat soluble
with diabetes have higher incidence. Use → Unconjugated bilirubin remains in the
of some drugs may increase the blood
incidence, whereas others decrease the → Since it is lipid soluble unconjugated
incidence. Some herbal remedies taken bilirubin crosses blood-brain barrier
by the lactating mother may apparently → It collect in the basal ganglia of the
exacerbate jaundice in the infant. brain(kernecterus)
→ Death/brain damage
 → Dystonia - Constipation
→ intractable seizure and acute respiratory - Bloating
failure - Vomiting
→ Death (POOR PROGNOSIS)
MEDICAL MANAGEMENT

LABORATORY & DIAGNOSTIC TESTS ● Tin-mesoporphyrin

○ tin-mesoporphyrin, a drug that
- Urinalysis: May be ordered to evaluate inhibits the production of heme
the amount of bilirubin excreted in the oxygenase.
urine. ○ Tin-mesoporphyrin is not
- Imaging tests: Ultrasound and approved by the US Food and
computed tomography (CT) can help Drug. If approved, tin-
distinguish between biliary obstruction mesoporphyrin could find
and liver disease, including cancer. immediate application in
- Ultrasound doesn't use ionizing preventing the need for exchange
radiation. transfusion in infants who are not
- CT scans are more sensitive in detecting responding to phototherapy
abnormalities of the liver or pancreas.1
- Liver biopsy: This would be considered ● Phenobarbital - an inducer of hepatic
if there is a concern about possible liver bilirubin metabolism; used to enhance
cancer. bilirubin metabolism
- A bilirubin concentration > 10 mg/dL (> ○ Solfoton
171 micromol/L) in preterm infants or > ● Antibiotic
18 mg/dL (> 308 micromol/L) in term ○ Ceftriaxone
infants warrants additional testing, ● Acyclovir
including hematocrit, blood smear, ○ Zovirax
reticulocyte count, direct Coombs test,
total serum bilirubin and direct serum SURGICAL MANAGEMENT WITH NURSING
bilirubin concentrations, and blood type INTERVENTION/POST-OP CARE
and Rh group of the infant and mother.
- Other tests, such as blood, urine, and ● Transjugular intrahepatic
cerebrospinal fluid cultures to detect portosystemic shunting (TIPS)
sepsis and measurement of red blood ○ bypassing the high flow rate of the
cell enzyme levels to detect unusual portal vein into the systemic veins.
causes of hemolysis, may be indicated ● Laparoscopic Cholecystectomy -
by the history and physical examination. surgical removal of the gallbladder via
Such tests also may be indicated for any the abdomen
neonates with an initial bilirubin level > 25 ○ Child will need to get out of bed
mg/dL (> 428 micromol/L). and begin to walk and move
around.
SYMPTOMATOLOGY
○ When you are allowed to give your
- Yellowing of the skin and whites of the child a bath or shower, carefully
eyes wash the incisions with soap and
- Darkening of urine, sometimes to a water. Afterwards, put on clean,
brownish tone new bandages. Change your
- If the liver is the source of the issue, pale, child's bandages any time they get
clay-colored stools can be present wet or dirty.
- Fever ● Liver transplant
- Extreme fatigue ○ To replace a child's diseased or
- Loss of appetite malfunctioning liver with a healthy
- Abdominal pain one from another person.
 ○ The liver may come from a ○ Monitor blood pressure, pulse,
deceased organ donor or from a and respiration.
family member who is willing to ○ Adjust the room temperature
donate a part of their liver and is a
suitable candidate. ● Risk for Injury (CNS Involvement)
○ Assess infant/maternal blood
10 NURSING MANAGEMENT group and blood type.
○ Assess the infant in daylight.
● Clinically assess the initial level of ○ Review infant’s condition at birth,
jaundice noting need for resuscitation or
● Draw blood for bilirubin determinations evidence of excessive
● Weigh the infant in the home ecchymosis or petechiae, cold
● Encourage frequent feedings stress, asphyxia, or acidosis.
● Oversee the set-up of the phototherapy ○ Note use of vacuum extractor for
system delivery. Assess infant for
● Explain all aspects of the phototherapy presence of cephalhematoma and
system to the parents excessive ecchymosis or
● Available for follow-up clinical petechiae.
assessments ○ Note use of vacuum extractor for
● Assess for neurologic changes delivery. Assess infant for
● Note color and frequency of stools and presence of cephalhematoma and
urine excessive ecchymosis or
● Keep the body warm and dry; monitor petechiae.
skin and core temperature frequently
● Fatigue related to elevated serum
NURSING DIAGNOSIS bilirubin levels as evidenced by
overwhelming lack of energy,
● Knowledge Deficit related to the generalized weakness, and shortness
limitations of exposure. of breath upon exertion
○ Describe the pathophysiology of ○ Assess the patient’s degree of
the disease. fatigability by asking to rate the
○ Describe the signs and symptoms child's fatigue level (mild,
of the disease that usually moderate, or severe). Explore
appears in the right way. activities of daily living, as well as
○ Describe the disease process in a actual and perceived limitations to
proper way. physical activity. Ask for any
○ Provide information on the exercise that he/she used to do or
patient's family about the wants to try.
conditions in an appropriate ○ Encourage progressive activity
manner. through self-care and exercise as
○ Provide appropriate referral for tolerated.
home phototherapy program, if ○ Teach deep breathing exercises
necessary. and relaxation techniques.
○ Provide adequate ventilation in
● Hyperthermia related to exposure to a the room.
hot environment ○ Refer the patient to the
○ Assess the patient’s vital signs at physiotherapy/occupational
least every 4 hours therapy team as required.
○ Remove excessive clothing,
blankets and linens. ● Impaired Skin Integrity related to
○ Monitor skin color. jaundice or radiation
○ Avoid wrinkles in the bed.
 ○ Keep your skin clean and dry.
○ Mobilization of the patient every 2
hours.
○ Monitor the existence of skin
redness.
○ Wash with soap and warm water.

PROGNOSIS

The prognosis in this condition is excellent. The

jaundice may continue for 4 weeks but promptly
resolves when breastfeeding is discontinued.
Even so, the bilirubin level needs to be closely
monitored, with adjustments in care made
accordingly to prevent persistent
hyperbilirubinemia and its potential
complications (ie, kernicterus in the fragile
neonatal period).

Kernicterus in infancy or later in life is the main

cause of death in Crigler-Najjar syndrome type
1. This disease can also result in permanent
neurologic sequelae, due to bilirubin
encephalopathy. Even with treatment, most, if
not all, patients with Crigler-Najjar (CN)
syndrome type 1 eventually develop some
neurologic deficit.

streptococci, group