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MEDICAL-SURGICAL NURSING
TABLE OF CONTENTS
DISEASE
NEURO
PANCREATITIS
ALZHEIMERS DISEASE
CHRONIC HEMORRHAGIC
INCREASED ICP
PANCREATITIS
Hypokalemia
DIABETES MELLITUS
Hypocalcemia
DIABETIC KETOACIDOSIS (DKA)
Ca gluconate toxicity
Insulin Therapy
Hyponatremia
Hyperglycemia
BLOOD DISORDER
Gouty Arthritis
SICKLE CELL ANEMIA
Morphine SO4 toxicity
ANEMIA
Magic 2s of drug monitoring
PERNICIOUS ANEMIA
(digitalis, lithium, aminophylline,
APLASTIC ANEMIA
dilantin, acetaminophen)
BLOOD TRANSFUSION
PARKINSONS DSE
Hemolytic Reaction
Extra Pyramidal Symptom
Allergic Reaction
MULTIPLE SCLEROSIS (MS)
Pyrogenic Reaction
Normal Resident Antibodies: IgA, etc.
Circulatory Overload
MYASTHENIA GRAVIS
DISSEMINATED INTRAVASCULAR
Guillain Barre Syndrome
COAGULATION
MENINGITIS
Oncologic Nsg (Cancer)
Lumbar puncture
Chemotherapy
Reverse/strict isolation
Radiation therapy
CEREBRO VASCULAR ACCIDENT
pulmo embolism
CARDIAC DISORDERS
cerebral embolism
ATHEROSCLEROSIS
CONVULSIVE Disorder
ANGINA PECTORIS
Cranial Nerves assessment
MYOCARDIAL INFARCTION
CONGESTIVE HEART FAILURE
ENDOCRINE
DIABETIS INSIPIDUS
PERIPHERAL MUSCULAR DSE
SIADH - Syndrome of Inappropriate
Thromboangiitis obliterates/
Anti-Diuretic Hormone
BUERGER DISEASE
SIMPLE GOITER
REYNAUDS PHENOMENON
HYPOTHROIDISM
VARICOSITIES / Varicose veins
HYPERTHYROIDISM
HYPOPARATHYROIDISM
RESPIRATORY DISORDERS
HYPERPARATHYROIDISM
THROMBOPHLEBITIS
Kidney Stone
PNEUMONIA
PHEOCHROMOCYTOMA
postural drainage
ADDISONS DISEASE
PULMONARY TUBERCULOSIS
Hypoglycemia
(KOCH DSE)
Steroids
HISTOPLASMOSIS
CUSHINGS SYNDROME
CHRONIC BRONCHITIS
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BRONCHIAL ASTHMA
BRONCHIECTASIS
Bronchoscopy
PULMONARY EMPHYSEMA
PNEUMOTHORAX

GENITO-URINARY
CYSTITIS
PYELONEPHRITIS
NEPHROLITHIASIS/
UROLITHIASIS
BENIGN PROSTATIC
HYPERTROPHY
ACUTE RENAL FAILURE
CHRONIC RF
Hemodialysis

GIT
PAROTITIS
APENDICITIS
LIVER CIRRHOSIS
Hepatic encephalopathy
Bleeding esophageal varices
PANCREATITIS
CHOLECYSTITIS/ CHOLELITHIASIS
PEPTIC ULCER DISEASE
GASTRIC ULCER / DUODENAL ULCER
Billroth I (Gastroduodenostomy)
Billroth II (Gastrojejunostomy
Dumping syndrome
BURNS

EYES, EARS
ERROR of refraction
GLAUCOMA
CATARACT
RETINAL DETACHMENT
MENIERES DISEASE

CRAM SHEET
Read the questions and all the answers carefully- dont jump to the
conclusion too quickly
2. Look for the keywords- avoid the answers that include the word always,
never,all, every, only, must, no , except, or none.
3. Watch for specific details- avoid vague answers. Look for adjectives
and adverbs
4. Elimate the answers that are clearly wrong or incorrect eliminating
any correct answer increases the probability of sellecting the correct
answer by 25%
5. Look for the information gives within the anwers- for examaple: the
phrase diabetic with acidosis makes you think of normal pH
6. Look for the same or similar wording in the question and the answers.
7. Watch for grammatical inconsistencies- subjects and verbs should
agree, meaning singular subjet, singular verb or plural subject, plural
verb. If the question is an incomplete sentences , the correct answer
should complete the question in grammatically correct manner.
8. Dont read into questions- reading into the question can create errors
in judgement. If the question asks for an immediate response or
prioritization of action, choose the answer that is critical to the life and
safety of the client.
9. Make an educated guess- if you are unsure after carefully reading the
question and all the answers choose the answer with the most
information.
10. Serum electrolytes a. Sodium (Na) 135-145 mEq/L
b. Potassium (K) 3.5-5.5 mEq/L
1.

c. Calcium (Ca) 9.3-10.9 mg/dl

d. Chloride (Cl) 95-105 mEq/ L
e. Magnesium (Mg) 1.5-2.5 mEq/L (Toxic level: 4.8-9.6mEq/L)
f. Phosphorous (P) 2.5-4.5 m Eq/L
11. Hematology values
a. RBC 4.5-5.0 million
b. WBC 5,000-10,000
c. Plt 200,000-400,000
d. Hgb F:40%-48% , M: 42%-50%
PHARMACOLOGY
Maria Joanna Navarro
Generally, the medication the nurse is expexted to administer depens on the
area of practice and the assigned client. However , the following medication
classifications are commonlu prescribed medications for adult clients within a
medical/ surgical setting:
Medications
Anti-infectives

Purpose
Treatment of infections

Antihypertensive

Lowers BP and inc blood flow to the

myocardium
Decrease gastric motility and reduce
water content in the bowel
Decrease water and Na from the Loop
of Henle (Loop Diuretics) or inhibit
ADH K sparing diuretics
Reduce HCl in the stomach. A
common side eddect of calcium- and
aluminumbased
antacids
is
constipation. Mg- based antacids
frequently cause diarrhea (MD)
Reduce fever
Block the release of histamine in
allergic rxn. Common side effects of
antihistamines
are
dry
mouth,
drowsiness and sedation.
Dilate large air passages and are
commonly prescribed for clients with
asthma and chronic obstructive lung
disease
Promote the passage of stool. Types
of laxatives includes stoolk softeners,
cathartics, fiber, lubricants and
stimulants.
Prevent clot formation of decreasing
vitamin K + levels and blocking the
clotting chain or by preventing
platelet aggregation

Antidiarrheals
Diuretics
Antacids

Antipyretics
Antihistamines

Bronchodilators

Laxatives

Anticoagulants

Antianemics

Narcotics/analgesics

Anticonvulsants

Anticholinergics

Mydriatics

Miotics

Medication
AngiotensinConverting
Agents
- pril

Action/use
Antihyperten
sive

Increase factors necessary for the

RBC production. Anti anemic include
vit
b12,
iron
and
Epogen(erythropoietin)
Relieve moderate to severe pain.
Medications
in
theis
category
includes opiods (morphine abnd
codeine),
synthetic
opiods
(meperidine) and NSAIDs (ketotolac)
Used for the management of seizure
disorder and the treatment of bipolar
disorder.
Medications
used
as
anticonsvulsants
include
benzodiazepines,Phenobarbital
and
phenytoin
Cause the mucous membranes to
become
dry;
therefore,
oral
secretions
are
decreased.
Anticholinergics such as atropine are
often administered preoperatively.
Dilate the pupils, mydriatics are used
in the tx of clients with cataracts.
MydriAtics=cAtaract=Atropine=dilAt
e
Contricts the pupils. Miotics such as
Pilocarpine HCl are used int eh tx of
clients
with
glaucoma.
MiOtics=glaucOma=pilOcarpine=cO
nstrict

Drug name
Benazepril
(Lotensin);
Lisinopril
(Zestril);
Captopril
(Capoten);
Enapril
(Vasotec);
Fosinopril
(Monopril);
Moexipril
(Univas);
Quinapril
5

SE/AD
Hypotension
Bradycardia
Tachycardia
Headache
N/V
Respiratory
symptoms

Nursing
Considerati
on
Monitor V/S
regularly
Monitor for
the WBC
Monitor for
the
electrolyte
levels

BetaAdrenergic
blockers

lol

Anti-infectice
(Aminoglycosi
des)
-cin/
-mycin

(Acupril);
Ramipril
(Altace)
Act
by Acebutolol
blocking
(Monitan,
sympathetic
Rhotal,
vasomotor
Sectral);
response
Atenolol
(tenormin, ApoAtenol, novaAtenol);
Esmolol
(Bevibloc)
Metaprolol
(Alupent,
Metaproterenol)
; Propanolol
(Inderal)

Interfere with
the
protein
synthesis of
bacteria,caus
ing
the
bacteria
to
die

Gentamicin
( Garamycin,
Alcomicin,
Genoptic);
Kanamycin
(Katrex);
Neomycin
(Mycifradin)
Streptomycin
(Streptomycin);
Tobramycin
(tobrex,
Nebcin)
Amikacin
(Amikin)

Orthostatic
hypotension
Bradycardia
N/V
Diarrhea
CHF
Blood dyscrasias

Ototoxicity
Nephrotoxicity
Seizures
Blood dyscrasias
Hypotension
rash

Monitor the
client for
changes in
lab values
(protein,
BUN,
creatinine )
that indicate
nephrotic
syndrome
Monitor the
clients BP,
HR and
rhythm
Monitor the
clients for
signs of
edema
Teach the
client to: rise
slowly,
report
bradycardia,
dizziness,
confusion,
depression
or fever,
taper off the
medication
Obtain a
history of
allergies
Monitor I and
O
Monitor V/S
during
infusion
Maintain a
patent IV
site
Monitor for
therapeutic
levels
Monitor for
the signs of
nephrotoxity
Monitor for

Benzodiazepin
es
(Anticonvulsa
nts/ Sedative/
Antianxiety)

Sedativehypnotic;
also used as
an
anticonvulsa
nt; has
antianxiety
effects

-pam

Phenothiazine
s
(Antipsychotic
/ Antiemetic)

Used as
antiemetics
or major
tranquilizer

-zine

Glucocorticoid
s
-sone /
-cort

These drugs
used to
decrease the
inflammatoru
diseases or
to decrease
the
possibility of
organ
rejection

the signs of
otoxicity
Teach the
client to
report any
changes in
urinary
elimination
Monitor peak
and trough
levels
Clonazepam
Drowsiness,
Monitor
(Klonopin)
Lethargy, Ataxia,
respirations
Diazepam
depression.\,
Monitor liver
(Valium)
restlessness, slurred function
Chlordiazepoxid speech, bradycardia, Monitor
e (Librium)
hypotension,
kiney
Lorazepam
diplopia, nystagmus, function
(Ativan)
N/V, constipation,
Monitor bone
Flurazepam
incontinence,
marrow
(Dalmane)
urinary retention,
function
respiratory
depression, rash,
uticaria
Chlopromazine Extrapyramidal
(Thorazine)
effects
Prochlorperazin Drowsiness
e (Compazine)
Sedation
Triflouoperazine Orthostatic
(Stelazine)
hypotension
Promethazine
Dry mouth
(Phenergan)
Hydroxyzine
(Vistaril)
Fluphenazine
(Prolixin)
Prednisolone
Acne, poor wound
Monitor
(delta-Cortet,
healing, ecchymosis, glucose
Prednisol,
bruising, petechia,
levels
prednisolone)
petechiae,
Weigh the
Prednisone
depression, flushing, client daily
(Aposweating, mood
Monitor BP
Prednisone,
changes,
Monitor for
deltasone,
hypertension,
signs of
Meticorten,
osteoporosis,
infection
orison, panasol- diarrhea,
S),
hemorrhage
Betamethasone
(Celestone,
Selestoject,
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Antivirals
-vir

These drug
are used for
their antiviral
effects

Betnesol),
Dexametasone
(Decadron,
Deronil, Dexon,
Mymethasone,
Dalalone),
Cortisone
(Cortone),
hydrocortisone
(Cortef,
hydrocortone
Phosphate,
cortifoam),
Methylprednisol
one (Solucortef, DepoMedrol,
depopred,
medrol, repPred),
triamcinolone
(Amcort,
Aristocort,
Atolone,
kenalog,
Triamolone)
Acyclovir
(Zovirax)
Ritonavir
(Norvir)
Saquinovir
(Invirase,
Fortovase),
Indinavir
(Crixivan),
Abacavir
(Ziagen),
Cidofovir
(Vistide),
Ganciclovir
(Cytovene,
Vitrasert)

n/V, vomiting,
diarrhea,
oliguria,proteinuria,
vaginitis, CNS less
commontremors,confusion,
seizures

Tell the client

to report a
rash
because this
can indicate
an allergic
reaction
Watch for
signs of
infection
Monitor
creatinine
levels
frequently
Monitor liver
profile
Monitor
bowel
pattern
before and
during
treatment

Cholesterol
lowering
agents

These drugs
are used to
lower
cholesterol

Atorvastatin
(Lipitor)
Fluvastatin
(lescol)
Lovastatin
(Mevacor)
Pravastatin
(Pravachol)
Simvastatin
(Zocar)
Rosuvastatin
(Crestor)

Rash, alopecia,
dyspepsia, liver
dysfunction, muscle
weakness(myalgia),
headache

These drugs
are used to
lower clood
pressure and
increase the
cardiac
output

Valsartan
(Diovan)
Candesartan
(Altacand)
Losartan
( Cozaar)
Telmisartan
(Micardis)

Dizziness, insomnia,
depression, angina
pectoris, 2nd dgree
AV block,
conjunctivitis,
diarrhea, N/V,
impotence, muscle
cramps,
neutropenia, cough

Antiinflammatory
drugs used to
treat arthritis
and pain
associated
with this
condition

Celecoxib
(Celebrex)
Valdecoxib
(Bextra)

Fatigue, anxiety,
depression,
dizziness,
tachycardia,
tinnitus, nausea,
gastroenteritis,
stomatitis

-statin

Angiotensin
receptor
Blockers
-sartan

Cox 2 Enzyme
Blockers
-cox

A diet low in
cholesterol
and fat
Monitor
cholesterol
level
Monitor renal
function
Monitor
visual
changes
because
opacities can
occur in
clients
taking
vastatins
Moinitor for
muscle pain
and
weakness
Monitor BP
and Pulse
Monitor BUN
Monitor
creatine
before
beginning tx
Monitor
electrolytes
Tell the client
to report
edema in
feet and legs
daily
Monitor
hydration
status
The client
should be
taught to
report any
changes in
bowel habits
because this
can indicate
GI bleeding
Monitor
platelet
count

Histamine 2
antagonists
-tidine

Proton pump
inhibitor

-prazole

Block
histamine 2
receptor sites
decreasing
acid
production;
used to treat
gastric ulcers
and GERD

Cimetidine
(Tagamet)
Famotidine
(Pepcid)
Nizatidine
(Axid)
Ranitidine
(Zantac)

Confusion,
bradycardia/tachyca
rdia, diarrhea,
psychosis, seizures,
agranulocytosis,
rash, alopecia,
gynecomastia,
galactorrhea

Used in the
treatment of
GERD, gastric
ulcers,
esophagitis

Esomeprazole
(nexium)
Lansoprazole
(Prevacid)
Pantoprazole
(Protonix)
Rabeprazole
(Aciphex)
Except
AripiprazoleAbilfy a
psychiatric
drug

Headahe, insomnia,
diarrhea, flatulence,
rash ,
hyperglycemia

10

Tell the client

to report
bruishing
Increase risk
of heart
attacks and
strokes
Gastric pH
should be
checked
periodically
Monitor BUN
Administer
with meals
If taking with
antacids,
take
antacids one
hour before
or after
taking these
drugs
Cimetidine
may be
prescribed in
one large
dose at
bedtime
Sucralfate
decreases
the effects of
histamine 2
receptor
blockers.
Do not crush
pantoprazole
May take
before meals
for best
absorption
Monitor liver
function

Anticoagulant
-parin

Used to treat
clotting
disorders and
to thin the
blood

Heparin sodium
(Hepalean)
Enoxaparin
sodium
(Lovenox)
Dalteparin
sodium
(Fragmin)

Fever, diarrhea,
stomatitis,bleeding,
heamturia,
dermatitis, alopecia,
pruritus

Blood
studies /(hct
and occult
clood in stool
)should be
checked
every 3
months
Monitor PTT
often
(Therapeutic
: 1.5-2.0 x
the control
Monitor the
Platelet
count
Monitor for
signs of
bleeding
Monitor for
signs of
infection

More drug Identification Helpers:

-caine
-mab
-ceph or cef
-cillin
-cycline
-stigmine
-phylline
-cal
-done

=anesthetics
=monoclonal antibodies
=cephalosporins
=penicillins
=tetracycline
=cholinergics
=bronchodilators
=calciums
=opiods

MEDICAL SURGICAL
Abby Tabuena
Overview of the Structures & Functions of Nervous System
Central NS
Brain & spinal cord

PNS

ANS
31 spinal & cranial
sympathetic NS
Parasypathatic NS
Somatic NS
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C- 8
T- 12
L- 5
S- 5
C- 1
ANS (or adrenergic of parasympatholitic response)
SNS involved in fight or aggression response
(anti-cholinergic/adrenergic)

Effects of SNS
1. Dilate pupil to aware of

surroundings
Release of norepinephrine (adrenaline cathecolamine)
medriasis
Adrenal medulla (potent vasoconstrictor)
2. Dry mouth
Increases body activities
VS = Increase
3. BP &
HR= increased
Except GIT decrease GITmotility
bronchioles
dilated to take more oxygen
4. RR increased
* Why GIT is not increased = GIT is not important!
5.
Constipation & urinary retention
Increase blood flow to skeletal muscles, brain & heart.
I. Adrenergic Agents Epinephrine (adrenaline)
SE: SNS effect
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic
agents) (all end in lol)
- Blocks release of norepinephrine.
- Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol
SE:
B broncho spasm (bronchoconstriction)
E elicits a decrease in myocardial contraction
T treats HPN
A AV conduction slows down
Given to angina & MI beta-blockers to rest heart
Anti HPN agents:
1. Beta blockers (-lol)
2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL
3. Calcium antagonist
ex CALCIBLOC or NEFEDIPINE
Peripheral nervous system: cholinergic/ vagal or sympatholitic response
Effect of PNS: (cholinergic)
- Involved in fly or withdrawal response
1. Meiosis
contraction of pupils
12

Release of acetylcholine (ACTH)

2. Increase
salivation
- Decrease all bodily activities except GIT (diarrhea)
3. BP
& HR decreased
4. RR decrease
broncho constriction
I Cholinergic agents
5. Diarrhea
increased GI motility
ex 1. Mestinon
6. Urinary
frequency
Antidote anti cholinergic agents Atropine Sulfate S/E SNS
-

S/E- of anti-hpn drugs:

1. orthostatic hpn
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.
CNS (brain & spinal cord)
I. Cells A. neurons
Properties and characteristics
a. Excitability ability of neuron to be affected in external
environment.
b. Conductivity ability of neuron to transmit a wave of excitation
from one cell to another
c. Permanent cells once destroyed, cant regenerate (ex. heart,
retina, brain, osteocytes)
Regenerative capacity
A. Labile once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
B. Stable capable of regeneration BUT limited time only ex salivary gland,
pancreas cells cell of liver, kidney cells
C. Permanent cells retina, brain, heart, osteocytes cant regenerate.
3.) Neuroglia attached to neurons. Supports neurons. Where brain tumors
are found.
Types:
1. Astrocyte
2. Oligodendria
Astrocytoma 90 95% brain tumor from astrocyte. Most brain tumors are
found at astrocyte.
Astrocyte maintains integrity of blood brain barrier (BBB).
BBB semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones DM.

13

OLIGODENDRIA Produces myelin sheath wraps around a neuron acts as

insulator facilitates rapid nerve impulse transmission.
No myelin sheath degenerates neurons
Damage to myelin sheath demyellenating disorders
DEMYELLENATING DSE
1.)ALZHEIMERS DISEASE atrophy of brain tissue due to a deficiency of
acetylcholine.
S&Sx:
A amnesia loss of memory
A apraxia unable to determine function & purpose of object
A agnosia unable to recognize familiar object
A aphasia
- Expressive broccas aphasia unable to speak
- Receptive wernickes aphasia unable to understand spoken
words
Common to Alzheimer receptive aphasia
Drug of choice ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.
Microglia stationary cells, engulfs bacteria, engulfs cellular debris.
II. Compositions of Cord & Spinal cord
80% - brain mass
10% - CSF
10% - blood
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one
component will increase ICP.
Normal ICP: 0-15mmHg
Brain mass
1. Cerebrum largest hemisphere

Connects R & L cerebral

- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Broccas area speech center
Damage - expressive aphasia
2.) Temporal
14

3.)
4.)
5.)
6.)

a. Hearing
b. Short term memory
c. Wernickes area gen interpretative or knowing Gnostic area
Damage receptive aphasia
Parietal lobe appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
Occipital - vision
Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ
Rhinencephalon/ Limbec
- Smell, libido, long-term memory

Basal Ganglia areas of gray matte located deep within a cerebral

hemisphere
- Extra pyramidal tract
- Releases dopamine- Controls gross voluntary unit
Decrease dopamine (Parkinsons) pin rolling of extremities &
Huntingtons Dse.
Decrease acetylcholine Myasthenia Gravis & Alzheimers
Increased neurotransmitter =
psychiatric disorder
Increase dopamine schizo
Increase acetylcholine bipolar
MID BRAIN relay station for sight & hearing
Controls size & reaction of pupil 2 3 mm
Controls hearing acuity
CN 3 4
Isocoria normal size (equal)
Anisocoria uneven size damage to mid brain
PERRLA normal reaction
DIENCEPHALON- between brain
Thalamus acts as a relay station for sensation
Hypothalamus (thermoregulating center of temp, sleep &
wakefulness, thirst, appetite/ satiety center, emotional responses,
controls pituitary function.
BRAIN STEM- a. Pons or pneumotaxic center controls respiration
Cranial 5 8 CNS
MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing,
vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12
CEREBELLUM lesser brain
- Controls posture, gait, balance, equilibrium
Cerebellar Tests:
a.) R Rombergs test- needs 2 RNs to assist
15

- Normal anatomical position 5 10 min

(+) Rombergs test (+) ataxia or unsteady gait or drunken like
movement with loss of balance.
b.) Finger to nose test
(+) To FTNT dymetria inability to stop a movement at a desired
point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to
cerebellum dymentrium
Composition of brain - based on Monroe Kellie Hypothesis
- Skull is a closed container. Any alteration in 1 of 3 intracranial
components = increase in ICP
Normal ICP 0 15 mmHg
Foramen Magnum
C1 atlas
C2 axis
(+) Projectile vomiting = increase ICP
Observe for 24 - 48 hrs
CSF cushions the brain, shock absorber
Obstruction of flow of CSF = increase ICP
Hydrocephalus posteriorly due to closure of posterior fontanel
CVA partial/ total obstruction of blood supply
INCREASED ICP increase ICP is due to increase in 1 of the Intra Cranial
components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis
B. S&Sx
change in VS = always late
symptoms
Earliest Sx:
a.) Change or decrease LOC Restlessness to confusion
Wide
pulse pressure: Increased ICP
- Disorientation to lethargy
Narrow pp:
Cardiac disorder, shock
- Stupor to coma
Late sign change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 80= 60 PP (wide)
16

3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea

with periods of apnea)
4. Temp increase
Increased ICP: Increase BP
Shock decrease BP
Decrease HR
Increase HR
CUSHINGS
EFFECT
Decrease RR
Increase RR
Increase Temp
Decrease temp
b.) Headache
Projectile vomiting
Papilledima (edema of optic disk outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stempons/
c.) Uncal herniation unilateral dilation of pupil. (Bilateral dilation of pupil
tentorial herniation.)
d.) Possible seizure.
Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia (decrease tissue oxygenation) &
hypercarbia (increase in CO2 retention).
Hypoxia cerebral edema - increase ICP
Hypoxia inadequate tissue oxygenation
Late symptoms of hypoxia B bradycardia
E extreme restlessness
D dyspnea
C cyanosis
Early symptoms R restlessness
A agitation
T tachycardia
Increase CO2 retention/ hypercarbia cerebral vasodilatation =
increase ICP
Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 excrete CO2
Respiratory Distress Syndrome (RDS) decrease Oxygen
Suctioning 10-15 seconds, max 15 seconds. Suction upon
removal of suction cap.
Ambu bag pump upon inspiration
c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
17

3. Elevate head of bed 30 45 degrees angle neck in neutral position

unless contra indicated to promote venous drainage
4. Limit fluid intake 1,200 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day
2,000 3,000 ml/day)- not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of
stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough antitussive
Dextrometorpham
-Excessive vomiting anti emetic (Plasil Phil only)/
Phenergan
- Lifting of heavy objects
- Bending & stooping
e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral
diuresis by decompressing brain tissue
Nursing considerations: Mannitol
1. Monitor BP SE of hypotension
2. Monitor I&O every hr. report if < 30cc out
put
3. Administer via side drip
4. Regulate fast drip to prevent formation
of crystals or precipitate
2.) Loop diuretic - Lasix (Furosemide)
Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine
after 10-15mins) should be in the morning.
If given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15
minutes. Max effect 6 hrs due (7am
1pm)

S/E of Lasix
Hypokalemia (normal K-3.5 5.5
meg/L)
S&Sx
1. Weakness & fatigue
18

2. Constipation
3. (+) U wave in ECG tracing
Nursing Mgt:
1.) Administer K supplements ex Kalium Durule, K
chloride
Potassium Rich food:
ABCs of K
Vegetables
Fruits
A - asparagus
A apple
B broccoli (highest) B banana green
C carrots
C cantalope/ melon
O orange (highest) for
digitalis toxicity also.
Vit A squash, carrots yellow vegetables & fruits,
spinach, chesa
Iron raisins,
Food appropriate for toddler spaghetti! Not milk
increase bronchial secretions
Dont give grapes may choke
S/E of Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca = 8.5
11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
(+) Trousseau sign pathognomonic or
carpopedal spasm. Put bp cuff on arm=hand
spasm.
(+) Chevosteks sign
Arrhythmia
Laryngospasm
Administer Ca gluconate IV slowly
Ca gluconate toxicity: Sx seizure
administer Mg SO4
Mg SO4 toxcicity administer Ca gluconate
B BP decrease
U urine output decrease
R RR decrease
P patellar reflexes absent
3.) Hyponatremia Normal Na level = 135 145
meg/L
S/Sx
Hypotension
Signs of Dehydration: dry skin, poor skin
turgor, gen body malaise.
19

Early signs Adult: thirst and agitation / Child:

tachycardia
Mgt: force fluid
Administer isotonic fluid sol
4.) Hyperglycemia increase blood sugar level
P polyuria
P polyphagia
P polydipsia
Nsg Mgt:
a. Monitor FBS (N=80 120 mg/dl)
5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in
joint.
renal

Gouty arthritis
kidney stonescolic (pain)
Cool moist skin
Sx joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritis

a.) Cheese (not sardines, anchovies, organ meat)
(Not good if pt taking MAO)
b.) Force fluid
c.) Administer meds Allopurinol/ Zyloprim inhibits
synthesis of uric acid drug of choice for gout
Colchicene excretes uric acid. Acute gout
drug of choice.
Kidney stones renal colic (pain). Cool moist skin
Mgt:
1.) Force fluid
2.) Meds narcotic analgesic
Morphine SO4
SE of Morphine SO4 toxicity
Respiratory depression (check RR 1st)
Antidote for morphine SO4 toxicity Narcan
(NALOXONE)
Naloxone toxicity tremors
Increase ICP meds:
3.) Corticosteroids - Dexamethsone decrease cerebral edema
(Decadrone)
4.) Mild analgesic codeine SO4. For headache.
5.) Anti consultants Dilantin (Phenytoin)
Question: Increase ICP what is the immediate nsg action?
a. Administer Mannitol as ordered
b. Elevate head 30 45 degrees
c. Restrict fluid
20

d. Avoid use of restraints

Nsg Priority ABC & safety
Pt suffering from epiglotitis. What is nsg priority?
a. Administer steroids least priority
b. Assist in ET temp, a/w
c. Assist in tracheotomy permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET cant pass.
Need tracheostomy onlyMagic 2s of drug monitoring
Drug
N range
Classification
Indication
D digoxin
.5 1.5 meq/L
CHF
L - lithium
.6 1.2 meq/L
bipolar
A aminophylline 10 19 mg/100ml
COPD
D Dilantin
10 -19 mg/100 ml
seizures
A acetaminophen
10 30 mg/100ml
analgesic
osteoarthritis

Toxicity
2

cardiac glycosides

antimanic
20

20

bronchodilator
anticonvulsant

200

narcotic

Digitalis increase cardiac contraction = increase CO

Nursing Mgt
1. Check PR, HR (if HR below 60bpm, dont giveDigoxin)
Digitalis toxicity antidote - Digivine
a. Anorexia
-initial sx.
b. n/v
GIT
c. Diarrhea
d. Confusion
e. Photophobia
f. Changes in color perception yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in
liver not in kidney.)
L lithium (lithane) decrease levels of norepinephrine, serotonine,
acetylcholine
Antimanic agent
Lithium toxicity
S/Sx a.) Anorexia
b.) n/s
c.) Diarrhea
d.) Dehydration force fluid, maintain Na intake 4 10g daily
21

e.) Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental
retardation)
A aminophyline (theophylline) dilates bronchioles.
Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity restlessness, agitation, tremors
a.
b.
c.
d.

Question: Avoid giving food with Aminophylline

Cheese/butter food rich in tyramine, avoided only
if pt is
given MAOI
Beer/ wine Hot chocolate & tea caffeine CNS stimulant
tachycardia
Organ meat/ box cereals anti parkinsonian

MAOI antidepressant
m AR plan
n AR dil
can lead to CVA or hypertensive crisis
p AR nate
3 4 weeks - before MAOI will take effect
Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa
D dilatin (Phenytoin) anti convulsant/seizure
Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or
precipitate
- Do sandwich method
- Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol bec alcohol + dilantin can lead to
severe CNS depression
Dilantin toxicity:
S/Sx:
G gingival hyperplasia swollen gums
i. Oral hygiene soft toothbrush
ii. Massage gums
H hairy tongue
A - ataxia
N nystagmus abnormal movement of eyeballs
A acetaminophen/ Tylenol non-opoid analgesic & antipyretic
febrile pts
Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) Serum Glutamic Piruvate Tyranase
22

SGOT- Serum Glutamic Acetate Tyranase

3. Monitor BUN (10 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
T tremors, Tachycardia
I irritability
R restlessness
E extreme fatigue
D depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity Acetylcesteine = causes outporing of
secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst hyperglycemia symptoms
c. Weakness
d. Diaphoresis
PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS
char by degeneration of dopamine
producing cells in substancia
nigra at mid brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis
High doses of the ff:
a. Reserpine (serpasil) anti HPN, SE 1.) depression - suicidal 2.)
breast cancer
b. Methyldopa (aldomet)
- promote safety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic
SE of anti psychotic drugs Extra Pyramidal Symptom
Over meds of anti psychotic drugs neuroleptic malignant syndrome
char by tremors (severe)
S/Sx: Parkinsonism
1. Pill rolling tremors of extremities early sign
2. Bradykinesia slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety always depressed suicide
23

Nsg priority: Promote safety

9. Increase salivation drooling type
10.
Autonomic signs:
- Increase sweating
- Increase lacrimation
- Seborrhea (increase sebaceous gland)
- Constipation
- Decrease sexual activity
Nsg Mgt
1.) Anti parkinsonian agents
- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl
(Symmetrel)
Mechanism of action
Increase levels of dopa relieving tremors & bradykinesia
S/E of anti parkinsonian
- Anorexia
- n/v
- Confusion
- Orthostatic hypotension
- Hallucination
- Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)
Nsg
1.
2.
3.

Mgt when giving anti-parkinsonian

Take with meals to decrease GIT irritation
Inform pt urine/ stool may be darkened
Instruct pt- dont take food Vit B6 (Pyridoxine) cereals,
organ meats, green leafy veg
- Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral
neuritis.
2.) Anti cholinergic agents relieves tremors
Artane
mech inhibits acetylcholine
Cogentin
action , S/E - SNS
3.) Antihistamine Diphenhydramine Hcl (Benadryl) take at bedtime
S/E: adult drowsiness, avoid driving & operating heavy equipt. Take
at bedtime.
Child hyperactivity CNS excitement for kids.
4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) respiratory depression. Monitor RR.
Nsg Mgt Parkinson
1.)
Maintain siderails
2.)
Prevent complications of immobility
- Turn pt every 2h
Turn pt every 1 h elderly
24

3.)
4.)
5.)
6.)

Assist in passive ROM exercises to prevent contractures

Maintain good nutrition
CHON in am
CHON in pm to induce sleep due Tryptopan Amino Acid
Increase fluid in take, high fiber diet to prevent constipation
Assist in surgery Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid
hemorrhage 2.) aneurism 3.) encephalitis

MULTIPLE SCLEROSIS (MS)

Chronic intermittent disorder of CNS white patches of demyelenation in
brain & spinal cord.
- Remission & exacerbation
- Common women, 15 35 yo
cause unknown
Predisposing factor:
1. Slow growing virus
2. Autoimmune (supportive & palliative treatment only)
Normal Resident Antibodies:
Ig G can pass placenta passive immunity. Short acting.
Ig A body secretions saliva, tears, colostrums, sweat
Ig M acute inflammation
Ig E allergic reactions
IgD chronic inflammation
S & Sx of MS: (everything down)
1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
b. Tingling
c. Paresthesia
3. Mood swings euphoria (sense of elation )
4. Impaired motor function:
a. Weakness
b. Spasiticity tigas
c. Paralysis major problem
5. Impaired cerebellar function
Triad Sx of MS
I intentional tremors
N nystagmus abnormal rotation of eyes
Charcots triad
A Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx MS
25

1. CSF analysis thru lumbar puncture

- Reveals increase CHON & IgG
2. MRI reveals site & extent of demyelination
3. Lhermittes response is (+). Introduce electricity at the back. Theres
spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH adenocorticotopic
Steroids to reduce edema at the site of demyelination to
prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. Interferone to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence give Prophantheline bromide (probanthene)
Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, biofeedback,
yoga techniques.
9. Provide acid-ash diet to acidify urine & prevent bacteria
multiplication
Grape, Cranberry, Orange juice, Vit C
MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from
nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release of cholenesterase enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease
acetylcholine
Descending muscle weakness
(Ascending muscle weakness Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
26

1.) Ptosis drooping of upper lid ( initial sign)

Check Palpebral fissure opening of upper & lower lids = to know if (+)
of MG.
2.) Diplopia double vision
3.) Mask like facial expression
4.) Dysphagia risk for aspiration!
5.) Weakening of laryngeal muscles hoarseness of voice
6.)
Resp muscle weakness lead respiratory arrest. Prepare
at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) temporarily strengthens muscles for
5 10 mins. Short term- cholinergic. PNS effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading
scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every
1 hr.
5. NGT feeding
Administer meds
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) Long term
- Increase acetylcholine
s/e PNS
b.) Corticosteroids to suppress immune resp
Decadron (dexamethasone)
Monitor for 2 types of
Myastinic crisis
A cause 1. Under medication
2. Stress
3. Infection
B S&Sx 1. Unable to see Ptosis &
diplopia
2. Dysphagia- unable to
swallow.
3. Unable to breath
C Mgt adm cholinergic agents

Crisis:
Cholinergic crisis
Cause: 1 over meds
S/Sx - PNS

Mgt. adm anticholinergic

- Atropine SO4
- SNS dry mouth
7. Assist in surgical proc thymectomy. Removal of thymus gland. Thymus
secretes auto immune antibody.
8. Assist in plasmaparesis filter blood
9. Prevent complication respiratory arrest
Prepare tracheostomy set at bedside.
27

GBS Guillain Barre Syndrome

- Disorder of CNS
- Bilateral symmetrical polyneuritis
- Ascending paralysis
Cause unknown, idiopathic
- Auto immune
- r/t antecedent viral infection
- Immunizations
S&Sx
1.
2.
3.
4.
5.
6.

Initial :
Clumsiness
Ascending muscle weakness lead to paralysis
Dysphagia
Decrease or diminished DTR (deep tendon reflexes)
Paralysis
Alternate HPN to hypotension lead to arrhythmia complication
Autonomic changes
increase sweating, increase salivation.
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals
increase in : IgG & CHON (same with MS)

Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding due dysphagia
7. Adm meds (GBS) as ordered: 1. Anti cholinergic atropine SO4
2. Corticosteroids to suppress immune
response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine SE confusion = VTach
b.) Bretyllium
c.) Quinines/Quinidine anti malarial agent.
Give with meals.
- Toxic effect cinchonism
Quinidine toxicity
S/E anorexia, n/v, headache, vertigo,
visual disturbances
8.
Assist in plasmaparesis (MG. GBS)
9.
Prevent comp arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.
28

INFL CONDITONS OF BRAIN

Meninges 3-fold membrane cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater
sub dural space
2. Arachmoid matter
3. Pia matter
sub arachnoid space
L3 & L4. Site for lumbar puncture.

where CSF flows

MENINGITIS inflammation of meningitis & spinal cord

Etiology Meningococcus
Pneumococcus
Hemophilous influenza child
Streptococcus adult meningitis
MOT direct transmission via droplet nuclei
S&Sx
- Stiff neck or nuchal rigidity (initial sign)
- Headache
- Projectile vomiting due to increase ICP
- Photophobia
- Fever chills, anorexia
- Gen body malaise
- Wt loss
- Decorticate/decerebration abnormal posturing
- Possible seizure
Sx of meningeal irritation nuchal rigidity or stiffness
Opisthotonus- rigid arching of back
Pathognomonic sign (+) Kernigs & Brudzinski sign
Leg pain

neck pain

Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub
arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
- RN dx procedure (lab)
- MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4
Nsg Ngt post lumbar
1. Flat on bed 12 24 h to prevent spinal headache & leak of CSF
29

2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
4. Assess for movement & sensation of extremeties
Result
1. CSF analysis:
a. increase CHON & WBC
Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis
c. increase CSF opening pressure
N 50 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection alteration in normal bacterial flora
- N flora throat streptococcus
- N flora intestine e coli
Sx of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A Cushings synd reverse isolation - due to increased corticosteroid
in body.
B Aplastic anemia reverse isolation - due to bone marrow
depression.
C Cancer anytype reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids lifetime.
E Prolonged use steroids reverse isolation
F Meningitis strict respiratory isolation safe after 24h of antibiotic
therapy
G Asthma not to be isolated
3.
4.
5.
6.
7.

Comfy & dark room due to photophobia & seizure

Prevent complications of immobility
Maintain F & E balance
Monitor vs, I&O , neuro check
Provide client health teaching & discharge plan
a. Nutrition increase cal & CHO, CHON-for tissue repair. Small freq
feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 yo post meningitis
- Audiologist due to damage to hearing- post repair myelomeningocele
- Urologist -Damage to sacral area spina bifida controls urination
30

9. Rehab for neurological deficit. Can lead to mental retardation or a delay in

psychomotor development.
CEREBRO VASCULAR ACCIDENT stroke, brain attack or cerebral
thrombosis, apoplexy
- Partial or complete disruption in the brains blood supply
- 2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
- Common to male 2 3x high risk
Predisposing factor:
1. Thrombosis clot (attached)
2. Embolism dislodged clot pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness
S/Sx: cerebral embolism
Headache, disorientation, confusion & decrease in LOC

2.)
3.)

Femur fracture complications: fat embolism most

feared complication w/in 24hrs
Yellow bone marrow produces fat cells at meduallary
cavity of long bone
Red bone marrow provides WBC, platelets, RBC found at
epiphisis
Hemorrhage
Compartment syndrome compression of nerves/ arteries

Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post
heart surgery mitral valve replacement
Lifestyle:

1. Smoking nicotine potent vasoconstrictor

2. Sedentary lifestyle
3. Hyperlipidemia genetic
4. Prolonged use of oral contraceptives
- Macro pill has large amt estrogen
- Mini pill has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats)
artherosclerosis HPN - stroke
5. Type A personality
a. Deadline driven person
b. 2 5 things at the same time
c. Guilty when not dong anything
6. Diet increase saturated fats
7. Emotional & physical stress
31

8. Obesity
S & Sx
1. TIA- warning signs of impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual &
speech disturbances, paresis or plegia (monoplegia 1 extreme)
Increase ICP
2. Stroke in evolution progression of S & Sx of stroke
3. Complete stroke resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia diff reading
6. Homoninous hemianopsia loss of half of field of vision
Left sided hemianopsia approach Right side of pt the
unaffected side
Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All graphy invasive due to iodine dye
Post
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding if pt cant swallow
7. Passive ROM exercise q4h
32

8. Alternative means of communication

- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia approach on unaffected side
9. Meds
Osmotic diuretics Mannitol
Loop diuretics Lasix/ Furosemide
Corticosteroids dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, prurituscaused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants Heparin & Coumadin sabay
Coumadin will take effect after 3 days
Heparin monitor PTT partial thromboplastin time if
prolonged bleeding give Protamine SO4- antidote.
Coumadin Long term. monitor PT prothrombin time if prolongedbleeding give Vit K Aquamephyton- antidote.
Antiplatelet PASA aspirin paraanemo aspirin, dont give to
dengue, ulcer, and unknown headache.
Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit physical therapy
1. Mental retardation
2. Delay in psychomotor development
CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by
paroxysmal seizures with or without loss of consciousness, abnormal motor
activity, alteration in sensation & perception & change in behavior.
Can you outgrow febrile seizure?
Seizure- 1st convulsive attack
Febrile seizure Normal if < 5 yo
2nd and with history of seizure
Pathologic if > 5 yo

Difference between:
Epilepsy

Predisposing Factor
Head injury due birth trauma
33

Toxicity of carbon monoxide

Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status
epilepticus
Status epilepticus drug of choice: Diazepam & glucose
S & Sx
I. Generalized Seizure
a.) Grand mal / tonic clonic seizures
With or without aura warning symptoms of impending
seizure attack- Epigastric pain- associated with olfactory,
tactile, visual, auditory sensory experience
- Epileptic cry fall
- Loss of consciousness 3 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC.
Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness unresponding sleep after tonic clonic
b.) Petimal seizure (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness 5 10 secs (quick & short)
II. Localized/partial seizure
a.) Jacksonian seizure or focal seizure tingling/jerky movement of index
finger/thumb & spreads to shoulder &
1 sideof the body with
janksonian march
b.) Psychomotor/ focal motor - seizure
-Automatism stereotype repetitive & non-purposive behavior
- Clouding of consciousness not in control with environment
- Mild hallucinatory sensory experience
HALLUCINATIONS
1. Auditory schitzo paranoid type
2. Visual korsakoffs psychosis chronic alcoholism
3. Tactile addict substance abuse
III. Status epilecticus continuous, uninterrupted seizure activity, if
untreated, lead to hyperprexia coma death
Seizure: inc electrical firing in brain=increased metabolic activity in
brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
Dx-Convulsion- get health history!
1. CT scan brain lesion
2. EEG electroencephalography
34

- Hyperactivity brain waves

Nsg Mgt
Priority Airway & safety
1. Maintain patent a/w & promote safety
Before seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
4. Maintain siderails
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE
SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) ( toxicity level 20 )
SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Dont give alcohol lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE:
arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations
2. Institute seizure & safety precaution. Post seizure: Administer O2.
Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal
sleep, the higher chance of having status epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis
Question: 1 yo grand mal immediate nursing action = a/w & safety
a. Mouthpiece 1 yr old little teeth only
b. Adm o2 inhalation post!
c. Give pillow safety (answer)
d. Prepare suction
Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale obj measurement of LOC or quick neuro
check
3 components of ECS
M motor 6
V verbal resp 5
35

E eye opening
15

15 14 conscious
13 11 lethargy
10 8 stupor
7 coma
3 deep coma lowest score
Survey of mental status & speech (Comprehensice Neuro Exam)
1.) LOC & test of memory
2.) Levels of orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test Romhberg, finger to nose
7.) DTR
8.) Autonomics
Levels of consciousness (LOC)
1. Conscious (conscious) awake levels of wakefulness
2. Lethargy (lethargic) drowsy, sleepy, obtunded
3. Stupor (stuporous) awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
4. Coma (Comatose) light (+) all forms of painful stimulations
Deep (-) to painful stimulation
Question: Describe a conscious pt ?
a. Alert not all pt are alert & oriented to time & place
b. Coherent
c. Awake- answer
d. Aware
Different types of pain stimulation
- Dont prick
1. Deep sternal stimulation/ pressure 3x fist knuckle
With response light coma
Without response deep coma
2. Pressure on great toe 3x
3. Orbital pressure pressure on orbits only below eye
4. Corneal reflex/ blinking reflex
Wisp of cotton used to illicit blinking reflex among conscious
patients
Instill 1-drop saline solution unconscious pt if (-) response pt is
in deep coma
5. Test of memory considered educational background
a.) Short term memory
- What did you eat for breakfast?
Damage to temporal lobe (+) antero grade amnesia
b.) Long term memory
(+) Retrograde amnesia damage to limbic system
36

6. Levels of orientation
Time
Place

Person

Graphesthesia- can identify numbers or letters written on palm with a

blunt object.
Agraphesthesia cant identify numbers or letters written on palm with a
blunt object.
CN assessment:
I
Olfactory
s
II
Optic
s
III
Oculomotor
m
IV
Trocheal
m
V
Trigeminal
b
VI
Abducens
m
VII
Facial
b
VIII
Acustic/auditory
IX
Glassopharyngeal
X
Vagus
XI
Spinal accessory
XII
Hypoglossal

smallest CN
largest CN
s
b
b
m
m

longest CN

I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa

use coffee, bar soap, vinegar, cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense of smell
- Anosmia absence of sense of smell
Either of 3 might indicate head injury damage to cribriform
plate of ethmoid bone where olfactory cells are located or
indicate inflammation condition sinusitis
II optic- test of visual acuity Snellens chart central or distance vision
Snellens E chart used for illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 ft
Numerator distance to snellens chart
Denominator distance the person can see the letters
OD Rt eye
20/20 20/200 blindness cant read E
biggest
OS left eye
20/20
OU both eye
20/20
2.
a.
b.
c.
d.

Test of peripheral vision/ visual field

Superiority
Bitemporally
Inferiorly
Nasally

Common Disorders see page 85-87 for more info on glaucoma, etc.
37

1. Glaucoma Normal 12 21 mmHg pressure

- Increase IOP - Loss of peripheral vision tunnel vision
2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision
3. Retinal detachment curtain veil like vision & floaters
4. Macular degeneration black spots
III, IV, VI tested simultaneously
- Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM
Rt eye
IO
SO
LR

MR
SR

left eye

O
S
E

3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil
Oculomotor
1. Raising of eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm
V Trigeminal Largest consists of - ophthalmic, maxillary, mandibular
Sensory controls sensation of the face, mucus membrane; teeth &
cornea reflex
Unconscious instill drop of saline solution
Motor controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia diff chewing & swallowing extreme food
temp is not recommended
a.
b.
c.
d.

Question: Trigeminal neuralgia, RN should give

Hot milk, butter, raisins
Cereals
Gelatin, toast, potato all correct but
Potato, salad, gelatin salad easier to chew

VI Facial: Sensory controls taste ant 2/3 of tongue test cotton applicator
put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group 40 yrs
old
Motor- controls muscles of facial expression, smile frown, raise
eyebrow
Damage Bells palsy facial paralysis
Cause bells palsy pedia R/T forcep delivery
38

Temporary only
Most evident clinical sign of facial symmetry: Nasolabial
folds
VIII Acoustic/ vestibule cochlear (controls hearing) controls balance
(kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti for hearing true sense organ of hearing

Outer tympanic membrane, pinna, oricle (impacted cerumen),

cerumen
Middle hammer, anvil, stirrup or melleus, incus, staples. Mid otitis
media
Eustachean ear
Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
Remove vestibule menieres dse disease inner ear

Archimedes law buoyancy (pregnancy fetus)

Daltons law partial pressure of gases
Inertia law of motion (dizziness, vertigo)
1.) Pt with multiple stab wound - chest
- Movement of air in & out of lungs is carried by what principle?
- Diffusion Daltons law
2.) Pregnant check up ultrasound reveals fetus is carried by amniotic fluid
- Archimedes
3.) Severe vertigo due- Inertia
Test for acoustic nerve:
- Repeat words uttered
IX Glossopharyngeal controls taste posterior 1/3 of tongue
X Vagus controls gag reflex
Test 9 10
Pt say ah check uvula should be midline
Damage cerebral hemisphere is L or R
Gag reflex place tongue depression post part of tongue
Dont touch uvula
XI Spinal Accessory - controls sternocleidomastoid (neck) & trapezius
(shoulders and back)
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or
phlegia
XII Hypoglossal controls movement of tongue say ah. Assess tongue
position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue
39

Tongue tied bulol

ENDOCRINE
Fx of endocrine ductless gland
Main gland Pituitary gland located at base of brain of Stella Turcica
Master gland of body
Master clock of body
Anterior pituitary gland adenohypophysis
Posterior pituitary gland neurohypophysis
Posterior pituitary:
1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/
hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH antidiuretic hormone (vasopressin) -Prevents urination conserve
H2O

A. DIABETIS INSIPIDUS (DI- dalas ihi) hyposecretion of ADH

Cause: idiopathic/ unknown
Predisposing factor:
1. Pituitary surgery
2. Trauma/ head injury
3. Tumor
4. Inflammation
* alcohol inhibits release of ADH

S & Sx:
1. Polyuria
2. Sx of dehydration
(1st sx of dehydration in childrentachycardia)
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & fatigue
4. Hypotension if left untreated 5. Hypovolemic shock
Anuria late sign hypovolemic shock
40

Dx Proc:
1. Decrease urine specific gravity- concentrated urine
N= 1.015 1.035
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia
Mgt:
1.
2.
3.
4.

Force fluid 2,000 3,000ml/day

Administer IV fluid replacement as ordered
Monitor VS, I&O
Administer meds as ordered
a.) Pitresin (vasopressin) IM
5. Prevent complications
Most feared complication Hypovolemic shock

B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone

- Increase ADH
- Idiopathic/ unknown
Predisposing factor
1. Head injury
2. Related to Bronchogenic cancer or lung canerEarly Sign of Lung Ca - Cough 1. non productive 2. productive
3. Hyperplasia of Pit gland
Increase size of organ
S&Sx
1.
2.
3.
4.
5.

Fluid retention
Increase BP HPN
Edema
Wt gain
Danger of H2O intoxication Complications: 1. cerebral edema
increase ICP 2. seizure

Dx Proc:
1. Urine specific gravity increase diluted urine
2. Hyponatremia Decreased Na

Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications increase ICP & seizures activity
Anterior Pituitary Gland adeno
1. Growth hormone (GH) (Somatotropic hormone)
41

Fx: Elongation of long bones

Decrease GH dwarfism children
Increase GH gigantism
Increase GH acromegaly adult
Puberty 9 yo 21 yo
Epiphyseal plate closes at 21 yo
Square face
Square jaw
Drug of choice in acromegaly: Ocreotide (Sandostatin) SE
dizziness
- Somatostatin Hormone antagonizes the release of of GH
2. Melanocytes stimulating hormone - MSH
- Skin pigmentation
3. Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes
development of mammary gland
(Oxytocin-Initiates milk letdown reflex)
4. Adrenocorticotropic hormone ACTH - Development & maturation of
adrenal cortex
5. Luteinizing hormone produces progesterone.
6. FSH- produces estrogen
PINEAL GLAND
1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion
THYROID GLAND (TG)
Question: Normal physical finding on TG:
a. With tenderness thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with
goiter
TG hormones:
T3
T4
Thyrocalcitonin
- Triodothyronine
-Tetraiodothyronine/ Tyroxine
FX
antagonizes effects of parathormone
- 3 molecules of iodine

- 4 molecules of iodine

Metabolic hormone
Increase metabolism brain inc cerebration, inc v/s
all v/s down, constipation
Hypo T3 T4 - lethargy & memory impairment
Hyper T3 T4 - agitation, restlessness, and hallucination
42

7. Increase VS, increase motility

HYPOTHYROIDISM all decreased except wt & menstruation, loss of
appetite but with wt gain
menorrhagia increase in mens
HYPERTHYROIDISM - Increase appetite wt loss, amenorrhea
SIMPLE GOITER enlarged thyroid gland - iodine deficiency
Predisposing factors
1. Goiter belt area - Place far from sea no iodine. Seafoods rich in
iodine
2. Mountainous area increase intake of goitrogenic foods (US: Midwest,
NE, Salt Lake)
Cabbage has progoitrin an anti thyroid agent with no iodine
Example: Turnips (singkamas), radish, peas, strawberries,
potato, beans, kamote, cassava (root crops), all nuts.
3.
Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter cause # 1
Sporadic goiter caused by #2 & 3
S & Sx enlarged TG
Mild restlessness
Mild dysphagia
Dx Proc.
1. Thyroid scan reveals enlarged TG
2. Serum TSH increase (confirmatory)
3. Serum T3, T4 N or below N
Nsg Mgt:
1. Administer meds
a.) Iodine solution Logols solution or saturated sol of K iodide
SSKI
Nsg Mgt Lugols sol violet color
1. use straw prevent staining teeth
2. Prophylaxis 2 -3 drops Treatment 5 to 6 drops
Use straw to prevernt staining of teeth
1. Lugols sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary
anticeptic-pyelonephritis. 4. Iron solution.
B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
43

3. Thyroid extract
Nsg Mgt: for TH/agents
1. Monitor vs. HR due tachycardia & palpitation
2. Take it early AM SE insomnia
3. Monitor s/e
Tachycardia, palpitations
Signs of insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN
3. Encourage increase intake iodine iodine is extracted from seaweeds
(!)
Seafood- highest iodine content oysters, clams, crabs, lobster
Lowest iodine shrimps
Iodized salt easily destroyed by heat take it raw not cooked
4. Assist surgery- Sub total thyroidectomyComplication: 1. Tetany 2. laryngeal nerve damage
3.Hemorrhage-feeling of fullness at incision site.Check nape for
wet blood. 4.Laryngeal spasm DOB, SOB trache set ready at
bedside.
2.) HYPOTHYROIDISM decrease secretion of T3, T4 can lead to MI /
Atherosclerosis
Adult myxedema
Child- cretinism only endocrine dis lead to mental retardation
Predisposing factor:
1. `Iatrogenic causes caused by surgery
2. Atrophy of TG due to:
a. Irradiation
b. Trauma
c. Tumor, inflammation
3. Iodine def
4. Autoimmune Hashimoto disease
S&Sx everything decreased except wt gain & mens increase)
Early signs weakness and fatigue
Loss of appetite increased lypolysis breakdown of fats causing
atherosclerosis = MI
Wt gain
Cold intolerance myxedema - coma
Constipation
Late Sx brittle hair/ nails
Non pitting edema due increase accumulation of
mucopolysacharide in SQ tissue -Myxedema
44

Horseness voice
Decrease libido
Decrease VS hypotension bradycardia, bradypnea, and
hypothermia
Lethargy
Memory impairment leading to psychosis-forgetfulness
Menorrhagia
Dx:
1. Serum T3 T4 decrease
2. Serum cholesterol increase can lead to MI
3. RA IU radio iodine uptake decrease
Nsg Mgt:
1. Monitor strictly V/S. I&O to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea,
hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement force fluid
Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories due to wt gain
3. Skin care due to dry skin
4. Comfortable & warm environment due to cold intolerance
5. Administer IVF replacements
6. Force fluid
7. Administer meds take AM SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
8. Health teaching & discharge plan
a. Avoidance precipitating factors leading to myxedema coma:
1. Exposure to cold environment
2. Stress 3. Infection
4. Use of sedative, narcotics, anesthetics not allowed CNS
depressants V/S already down
Complications:
9. Hypovolemic shock, myxedema coma
10.
Hormonal replacement therapy - lifetime
11.
Importance of follow up care

45

HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except

wt and mens)
-Increased T3 & T4
Predisposing factors:
1. Autoimmune disease release of long acting thyroid stimulator (LATS)
Exopthalmos
Enopthalmos severe dehydration depressed eye
2. Excessive iodine intake
3. Hyperplasia of TG
S&Sx:
1. Increase in appetite hyperphagia wt loss due to increase
metabolism
2. Skin is moist - perspiration
3. Heat intolerance
4. Diarrhea increase motility
5. All VS increase = HPN, tachycardia, tachypnea, hyperthermia
6. CNS changes
8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations
7. Goiter
8. Exopthalmos pathognomonic sx
9. Amenorrhea
Dx:
1. Serum T3 & T4 - increased
2. Radio iodine uptake increase
3. Thyroid scan reveals enlarged TG
Nsg Mgt:
1. Monitor VS & I & O determine presence of thyroid storm or most
feared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat,
leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis stroke CVS
3.
4.
5.
6.
7.

Diet increase calorie to correct wt loss

Skin care
Comfy & cool environment
Maintain siderails- due agitation/restlessness
Provide bilateral eye patch to prevent drying of eyesexopthalmos
8. Assist in surgery subtotal thyroidectomy
Nsg Mgt: pre-op
Adm Lugols solution (SSKI) K iodide
9. To decrease vascularity of TG
46

10.
To prevent bleeding & hemorrhage
Mgt post op:
Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis
Triad signs of thyroidstorm;
a. Tachycardia /palpitation
b. Hyperthermia
c. Agitation
Nsg Mgt Thyroid Storm:
1. Monitor VS & neuro check
Agitated might decrease LOC
2. Antipyretic fever
Tachycardia - blockers (-lol)
3. Siderails agitated
Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland
Secretes Para hormone
If removed, hypocalcemia - classic sign tetany 1. .(+) Trousseau sign/
2. Chvostecks sign
Nsg Mgt:
Adm calcium gluconate slowly to prevent arrhythmia
Ca gluconate toxicity antidote MgSO4
3.Laryngeal (voice box) nerve damage (accidental)
Sx: hoarseness of voice
***Encourage pt to talk or speak post operatively asap to determine
laryngeal nerve damage
Notify physician!
4. Signs of bleeding post subtotal thyroidectomy
- Feeling of fullness at incision site
Nsg mgt:
Check soiled dressing at nape area
5. Signs of laryngeal spasm
a. DOB
b. SOB
Prepare at bedside tracheostomy
6. Hormonal replacement therapy - lifetime
7. Importance of follow up care
(Liver cirrhosis bedside scissor if pt
complaints of DOB)
(Cut cystachean tube to deflate
balloon)
Parathyroid gland pair of small nodules located behind the TG
11.
Secrets parathyroid hormone promotes Ca reabsorption
47

Thyrocalcitonin antagonises secretion of parathyroid hormone

1. Hypoparthroidism decrease of parathyroid hormone
2. Hyperparathroidsm

HYPOPARATHYROIDISM decreased parathormone

Hypocalcemia
(Or tetany)

Hyperphosphatemia

[If Ca decreases, phosphate increases]

A. Predisposing, factors:
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to
a. Irradiation
b. Trauma
S&Sx:
1. Acute tetany
a. Tingling sensation
b. Paresthesia
c. Dysphagia
d. Laryngospasm
e. Bronchospasm
Pathognomonic Sign of tetany:
a. (+) Trousseaus or carpopedial spasm
b. (+) Chvostecks sign
f. Seizure
g. Arrhythmia

most feared complication

2. Chronic tetany
a. Loss of tooth enamel
b. Photophobia & cataract formation
c. GIT changes anorexia, n/v, general body malaise
d. CNS changes memory impairment, irritability
Dx:
1.
2.
3.
4.

Serum calcium decrease (N 8.5 11 mg/100ml)

Serum phosphate increase (N 2.5 4.5 mg/100ml)
X-ray of long bone decrease bone density
CT Scan reveals degeneration of basal ganglia
48

Nsg Mgt:
1. Administration of meds:
a.) Acute tetany
Ca gluconate IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
Ca carbonate
Ca lactate
Vit D (Cholecalceferol)
Drug
Cholecalceferol

diet

sunlight

calcidiol

calcitriol

7am 9am

2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC
MAD
Aluminum containing acids
Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel
Diarrhea
Constipation
Maalox magnesium & aluminum - Less s/e
2. Avoid precipitating stimulus such as bright lights & noise: photophobia
leading to seizure
3. Diet increase Ca & decrease phosphorus
- Dont give milk due to increase phosphorus
Good = anchovies increase Ca, decrease phosphorus + inc uric acid.
Tuna & green turnips- Inc Ca.
4. Bedside tracheostomy set due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild
respiratory acidosis to promote increase ionized Ca levels
6. Most feared complication : Seizure & arrhythmia
7. Hormonal replacement therapy - lifetime
8. Important fallow up care
HYPERPARATHYROIDISM - increase parathormone. Complication: Renal
failure
Hypercalcemia can lead to Hypophosphatemia
Bone dse Mineralization

kidney stones

49

Leading to bone fracture

Ca 99% bones
1% serum blood
Predisposing Factors:
1. Hyperplasia parathyroid gland (PTG)
2. Over compensation of PTG due to Vit D deficiency
Children Rickets
Vit D
Adults Osteomalacia
deficiency
Sippys diet Vit D diet not good for pt with ulcer
2 -4 cups of milk & butter
Karrels diet Vit D diet not good for pt with ulcer
6 cups of milk & whole cream
Food rich in CHON eggnog combination of egg & milk
S/Sx:
Bone fracture
1. Bone pain (especially at back), bone fracture
2. Kidney stone
a. Renal colic
b. Cool moist skin
3. GIT changes anorexia, n/v, ulcerations
4. CNS involvement irritability, memory impairment
Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones reveals bone demineralization
Nsg Mgt: Kidney Stone
1.
2.
3.
4.
5.

Force fluids 2,000 3,000/day or 2-3L/day

Isotonic solution
Warm sitz bath for comfort
Strain all urine with gauze pad
Acid ash diet cranberry, plum, grapefruit, vit C, calamansi to acidify
urine
6. Adm meds
a. Narcotic analgesic Morphine SO4, Demerol (Meperidine Hcl)
S/E resp depression. Monitor RR)
Narcan/ Naloxone antidote
Naloxone toxicity tremors
7. Siderails
8. Assist in ambulation
9. Diet low in Ca, increase phosphorus lean meat
10.
Prevent complication
50

Most
11.
12.
13.

feared renal failure

Assist surgical procedure parathyroidectomy
Impt ff up care
Hormonal replacement- lifetime

ADRENAL GLAND
12.
Atop of @ kidney
13.
2 parts
Adrenal cortex outermost layer
Adrenal medulla - innermost layer
14.
Secrets cathecolamines
a.) Epinephrine / Norephinephrine potent vasoconstrictor
adrenaline=Increase BP
Adrenal Medullas only disease:
PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla
-increase nor/epinephrine
-with HPN and resistant to drugs
-drug of choice: beta blockers
-complication: HPN crisis = lead to stroke
-no valsalva maneuver
Adrenal Cortex
1. Zona fasiculata secrets glucocorticoids
Ex. Cortisol - Controls glucose metabolism (SUGAR)
2. Zona reticularis secrets traces of glucocorticoids & androgenic
hormones
M testosterone
F estrogen & progesterone
Fx promotes development of secondary sexual
characteristics
3. Zona glomerulosa - secretes mineralcortisone
Ex. Aldosterone
Fx: promotes Na & H2O reabsorption & excretion of
potassium (SALT)

ADDISONS DISEASE Steroids-lifetime

Decreased adrenocortical hormones leading to:
a.) Metabolic disturbances (sugar)
b.) F&E imbalances- Na, H2O, K
c.) Deficiency of neuromuscular function (salt & sex)
Predisposing Factors:
1. Atrophy of adrenal gland
2. Fungal infections
51

3. Tubercular infections
S/Sx:
1. Decrease sugar Hypoglycemia Decreased glucocorticoids cortisol
T tremors, tachycardia
I - irritability
R - restlessness
E extreme fatigue
D diaphoresis, depression
2. Decrease plasma cortisol
Decrease tolerance to stress lead to Addisonians crisis
3. Decrease salt Hyponatermia Decreased mineralocorticoids Aldosterone
Hypovolemia
a.) Hypotension
b.) Signs of dehydration extreme thirst, agitation
c.) Wt loss
4. Hyperkalemia
a.) Irritability
b.) Diarrhea
c.) Arrhythmia
5. Decrease sexual urge or libido- Decreased Androgen
6. Loss of pubic and axillary hair
To Prevent STD Local practice monogamous relationship
CGFNS/NCLEX condom
7. Pathognomonic sign bronze like skin pigmentation due to
decrease cortisol will stimulate pituitary gland to release
melanocyte stimulating hormone.
Dx Proc:
1. FBS decrease FBS (N 80 120 mg/dL)
2. Plasma cortisol decreased
Serum Na decreased (N 135 145 meg/L)
3. Serum K increased (N 3.5 5.5 meg/L)
Nsg Mgt:
1. Monitor VS, I&O to determine presence of Addisonian crisis
15.
Complication of Addisons dse : Addisonian crisis
16.
Results the acute exacerbation of Addisons dse characterized by
:
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
17.
Lead to progressive stupor & coma
Nsg Mgt Addisonian Crisis (Coma)
1. Assist in mechanical ventilation
52

2. Adm steroids
3. Force fluids

2. Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone
Nsg Mgt with Steroids
1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the
normal diurnal rhythm.
2. Taper the dose (w/draw, gradually from drug) sudden
withdrawal can lead to addisonian crisis
3. Monitor S/E (Cushings syndrome S/Sx)
a.) HPN
b.) Hirsutism
c.) Edema
d.) Moon face & buffalo hump
e.) Increase susceptibility to infection sue to steroids- reverse
isolation
b.) Mineralocorticoids ex. Flourocortisone

3. Diet increase calorie or CHO

4.
5.
6.
7.
a)

8.
9.

Increase Na, Increase CHON, Decrease K

Force fluid
Administer isotonic fluid as ordered
Meticulous skin care due to bronze like
HT & discharge planning
Avoid precipitating factors leading to Addisonian crisis
1. Sudden withdrawal crisis
2. Stress
3. Infection
b) Prevent complications
Addisonian crisis & Hypovolemic shock
Hormonal replacement therapy lifetime
Important: follow up care

CUSHINGS SYNDROME increase secretion of adrenocortical hormone

Predisposing Factors:
1. Hyperplasia of adrenal gland
2. Tubercular infection milliary TB
S/Sx
1. Increase sugar Hyperglycemia
3 Ps
1. Polyuria
2. Polydipsia increase thirst
3. Polyphagia increase appetite
Classic Sx of DM 3 Ps & glycosuria + wt loss
2. Increase susceptibility to infection due to increased corticosteroid
53

3. Hypernatrermia
a. HPN
b. Edema
c. Wt gain
d. Moon face
Buffalo hump
Obese trunk
Pendulous abdomen
Thin extremities
4. Hypokalemia
a. Weakness & fatigue
b. Constipation
c. ECG (+) U wave
5. Hirsutism increase sex
6. Acne & striae
7. Increase muscularity of female
Dx:
1. FBS increase (N: 80-120mg/dL)
2. Plasma cortisol increase
3. Na increase (135-145 meq/L)
4. K- decrease (3.5-5.5 meq/L)

classic signs

Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium
Not lasix due to S/E hypoK & Hyperglycemia!
3. Restrict Na
4. Provide Dietary intake low in CHO, low in Na & fats
High in CHON & K
5. Weigh pt daily & assess presence of edema- measure abdominal girthnotify doc.
6. Reverse isolation
7. Skin care due acne & striae
8. Prevent complication
- Most feared arrhythmia & DM
(Endocrine disorder lead to MI Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10.
Hormonal replacement therapy lifetime due to adrenal gland
removal- no more corticosteroid!

PANCREAS behind the stomach, mixed gland both endocrine and exocrine
gland
54

Acinar cells (exocrine gland)

gland ductless)

Islets of Langerhans (endocrine

Secrete pancreatic juices at pancreatic ducts.

Aids in digestion (in stomach)

cells

secrets glucagon
Fxn: hyperglycemia (high glucose)
Cells
Secrets insulin
Fxn: hypoglycemia
Delta Cells
Secrets somatostatin
Fxn: antagonizes growth hormone

3 disorders of the Pancreas

1. DM
2. Pancreatic Cancer
3. Pancreatitis
Overview only:
PANCREATITIS (check page 72) acute inflammation of pancreas leading to
pancreatic edema, hemorrhage & necrosis due to
Autodigestion self-digestion
Cause: unknown/idiopathic
18.
Or alcoholism
Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish
color)- pasa
(+) Grey turners sign ecchymosis of flank area
Both sx means hemorrhage
CHRONIC HEMORRHAGIC PANCREATITIS- bangugot
Predisposing factors - unknown
Risk factor:
1. History of hepatobiliary disorder
2. Alcohol
3. Drugs thiazide diuretics, oral contraceptives, aspirin, penthan
4. Obesity
55

5. Hyperlipidemia
6. Hyperthyroidism
7. High intake of fatty food saturated fats

DIABETES MELLITUS - metabolic disorder characterized by non utilization

of CHO, CHON,& fat metabolism
Classification:
I.
Type I DM (IDDM) Juvenile onset, common in children, nonobese brittle dse
-Insulin dependent diabetes mellitus
Incidence rate
1.) 10% of population with DM have Type I
Predisposing Factor:
1. 90% hereditary total destruction of pancreatic dells
2. Virus
3. Toxicity to carbon tetrachloride
4. Drugs Steroids
both cause hyperglycemia
Lasix - loop
diuretics
S/Sx:
3 PS + G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing
Mgt:
1. Insulin Therapy
Diet
Exercise
Complications Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis (DKA) due to increase fat catabolism
or breakdown of fats
DKA (+) fruity or acetone breath odor
Kassmauls respiration rapid, shallow breathing
Diabetic coma (needs oxygen)
56

II. Type II DM (NIDDM)

Adult/ maturity onset type age 40 & above, obese
Incidence Rate
1. 90% of pop with DM have Type II
Mid 1980s marked increase in type II because of increase proliferation
of fast food chains!
Predisposing Factor:
1. Obesity obese people lack insulin receptors binding site
2. Hereditary
S/Sx:
1. Asymptomatic
2. 3 Ps and 1G
Tx:
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise
Complication: HONKC
H hyper
O osmolar
N non
K ketotic
C coma
III. GESTATIONAL DM occurs during pregnancy & terminates upon
delivery of child
Predisposing Factors:
1. Unknown/ idiopathic
2. Influence of maternal hormones
S/Sx :
Same as type II
1. Asymptomatic
2. 3 Ps & 1G
Type of delivery CS due to large baby
Sx of hypoglycemia on infant
1. High pitched shrill cry
2. Poor sucking reflex
IV. DM ASSOCIATED WITH OTHER DISORDER
a.) Pancreatic tumor
b.) Cancer
c.) Cushings syndrome

57

3 MAIN FOOD GROUPS

Anabolism Catabolism
1. CHON
glucose
glycogen
2. CHON
amino acids
nitrogen
3. Fats
fatty acids free fatty acids (FFA) Cholesterol & Ketones
Pancreas glucose ATP (Main fuel/energy of cell )
Reserve glucose glycogen
Liver will undergo glucogenesis synthesis of glucagons
& Glycogenolysis breakdown of glucagons
& Gluconeogenesis formation of glucose form CHO sources
CHON & fats
Hyperglycemia pancreas will not release insulin. Glucose cant go to cell,
stays at circulation causing hyperglycemia.
increase osmotic diuresis glycosuria
Lead to cellular starvation
Lead to wt loss
polyuria

stimulates the appetite/ satiety center

(Hypothalamus)
Cellular dehydration
Polyphagia
Stimulates thirst center

(hypothalamus)
Polydipsia
Increased CHON catabolism
Lead to (-) nitrogen balance
Tissue wasting (cachexia)

Increase fat catabolism

Free fatty acids
Cholesterol

ketones

Atherosclerosis
HPN
MI

DKA
coma
death

stroke
58

DIABETIC KETOACIDOSIS (DKA)

- Acute complication of Type I DM due to severe hyperglycemia leading
to CNS depression & Coma.
- Ketones- a CNS depressant
Predisposing factor:
1. Stress between stress and infection, stress causes DKA more.
2. Hyperglycemia
3. Infection
S/Sx:
3 Ps & 1G
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glycosuria
5. Wt loss
6. Anorexia, N/V
7. (+) Acetone breath odor- fruity
8. Kussmaul's resp-rapid shallow
9. CNS depression
10.
Coma

odor
pathognomonic DKA
respiration

Dx Proc:
1. FBS increase, Hct increase (compensate due to dehydration)
N =BUN 10 -20
mg/100ml --increased due to severe
dehydration
Crea - .8 1 mg/100ml
Hct 42% (should be 3x high)-nto hgb
Nsg Mgt:
1. Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy IV push
Regular Acting Insulin clear (2-4hrs, peak action)
b.) To counteract acidosis Na HCO3
c.)Antibiotic to prevent infection
Insulin Therapy
A. Sources:
1. Animal source beef/ pork-rarely used. Causes severe allergic reaction.
2. Human has less antigenecity property
Cause less allergic reaction. Humulin
59

If kid is allergic to chicken dont give measles vaccine due it

comes from chicken embryo.
3. Artificially compound
B. Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente
Types of Insulin
duration
1. Rapid
2. Intermediate
3. Long acting

color & consistency

clear
cloudy
cloudy

onset

peak

2-4h
- 6-12h
12-24h

Ex. 5am Hemoglucose test (HGT)

250 mg/dl
Adm 5 units of RA I
Peak 7-9am monitor hypoglycemic reaction at this time- TIRED
Nsg Mgt: upon injection of insulin:
1.Administer insulin at room temp! To prevent lipodystrophy
= atrophy/ hypertrophy of SQ tissues
2. Insulin is only refrigerated once opened!
3. Gently roll vial bet palms. Avoid shaking to prevent formation of
bubbles.
4. Use gauge 25 26needle tuberculin syringe
5. Administer insulin at either 45(for skinny pt) or 90 (taba
pt)depending on the client tissue deposit.
6. Dont aspirate after injection
7. Rotate injection site to prevent lipodystrophy
8. Most accessible site abdomen
9. When mixing 2 types of insulin, aspirate
1st regular/ clear before cloudy to prevent contaminating
clear insulin & to promote accurate calibration.
10. Monitor signs of complications:
a. Allergic reactions lipodystrophy
b. Somogyis phenomenon hypoglycemia followed by periods of
hyperglycemia or rebound effect of insulin.
11. 1ml or cc of tuberculin = 100 units of insulin

- - 1 cc = 100 units
- - .5cc = 50 units
- - .1 cc = 10 units
60

6 units RA
Most Feared Complication of Type II DM
Hyper
osmolarity = severe dehydration
Osmolar
Non
- absence of lipolysis
Ketotic
- no ketone formation
Coma S/Sx: headache, restlessness, seizure, decrease LOC = coma
Nsg Mgt; - same as DKA except dont give NaHCO3!
1.Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3.Monitor VS, I&O, blood sugar levels
4.Administer meds
a.) Insulin therapy IV
b.) Antibiotic to prevent infection
Tx:
O ral
H ypoglycemic
A gents
19.
Stimulates pancreas to secrete insulin
Classifications of OHA
1. First generation Sulfonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)
2. 2nd generation sulfonylurear
a. Diabeta (Micronase)
b. Glipside (Glucotrol)
Nsg Mgt or OHA
1. Administer with meals to lessen GIT irritation & prevent
hypoglycemia
2. Avoid alcohol (alcohol + OHA = severe hypoglycemic
reaction=CNS depression=coma) Antabuse-Disufram
Dx for DM
1. FBS N 80 120 mg/dl = Increased for 3
consecutive times
=confirms DM!!
+ 3 Ps & 1G
2. Oral glucose tolerance (OGTT) - Most sensitive test
61

3. Random blood sugar increased

4. Alpha Glucosylated Hgb elevated
Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.
Pt DM hinimatay
20.
You dont know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain cant tolerate low sugar!)
Cold, clammy skin hypo Orange Juice or simple sugar / warm
to touch hyper adm insulin
5. Provide nutritional intake of diabetic diet:
CHO 50%
CHON 30%
Fats 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis HPN, MI, CVA
b. Microangiopathy small blood vessels
Eyes diabetic retinopathy , premature cataract & blindness
Kidneys recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
c. Gangrene formation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking barefooted
b. Cut toe nails straight
c. Apply lanolin lotion prevent skin breakdown
d. Avoid wearing constrictive garments
9. Annual eye & kidney exam
10.
Monitor urinalysis for presence of ketones
Blood or serum more accurate
11.
Assist in surgical wound debridement
12.
Monitor signs or DKA & HONKC
13.
Assist surgical procedure
BKA or above knee amputation
Overview: HEMATOLOGICAL SYSTEMS
62

I Blood
II Blood vessels
III Blood forming organs
1. Thymus removed myasthenia gravis
2. Liver largest gland
3. Lymph nodes
4. Lymphoid organs payers patch
5. Bone marrow
6. Spleen destroys RBC
Blood vessels
1. Veins SVC, IVC, Jugular vein blood towards the heart
2. Artery carries blood away from the
21.
Aorta, carotid
3. Capillaries
Blood 45% formed elements 55% plasma fluid portion of vlood. Yellow
color.
Serum

Plasma CHONs (Produced in Liver)

1. Albumin- largest, most abundant plasma
Maintains osmotic pressure preventing

edema
FXN: promotes skin integrity
2. Globulins alpha transports steroids
Hormones & bilirubin
- Transports iron & copper
Gamma transport immunoglobulins or
antibodies
3. Prothrombin fibrinogen
clotting factor to prevent bleeding
Formed Elements:
1. RBC (erythrocytes)
Spleen life span = 120 days
(N) 3 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules of Hgb (red cell pigment)
Transports & carries O2
SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired
circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. a/w avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit promote hydration
3. Pain & comfort
Hgb ( hemoglobin)
63

F= 12 14 gms %
M = 14-16 gms %
Hct 3x hgb
12 x 3 = 36
(hamatocrit)
F 36 42% 14 x 3 = 42
M 42 48%
Average 42%
- Red cell percentage in whole red
Substances needed for maturation of RBC
a.) Folic acid
b.) Iron
c.) Vit C
d.) Vit B12 (cyanocobalamin)
e.) Vit B6 (Pyridoxine)
f.) Intrinsic factor
Pregnant:

1st trimester- Folic acid prevent neural tube deficit

3rd tri iron
Life span of rbc 80 120 days. Destroyed at spleen.

WBC leucocytes 5,000 10,000/mm3

GRANULOCYTES
NON-GRANULOCYTES
1.
1. Monocytes (macrophage) - largest
Polymorphonuclearneutrophi WBC
ls
- involved in long term phagocytes
Most abundant 60-70% WBC
- For chronic inflammation
- fx short term phagocytosis
- Other name macrophage
For acute inflammation
Macrophage in CNS- microglia
2. PM Basophils
Macrophage in skin Histiocytes
Macrophage in lungs alveolar
-Involved in Parasitic infection
macrophage
- Release of chem. Mediator for
Macrophage in Kidneys Kupffer
inflammation
cells
Serotonin, histamine,
prostaglandin, bradykinins
2. Lymphocytes
B Cell L bone marrow or bursa
3. PM eosinophils
dependent
- Allergic reactions
T cell devt of immunity- target site for
HIV
NK cell natural killer cell
Have both antiviral & anti-tumor
properties
3.Platelets (thrombocytes)
N- 150,000 450, 000/ mm3
it promotes hemostasis prevention of
64

blood loss by activating clotting

- Consists of immature or baby platelets
known as megakaryocytes target of
virus dengue
- Normal lifespan 9 12 days
Drug of choice for HIV Zidovudine (AZT or Retrovir)
Standard precaution for HIV gloves, gown, goggles & mask
Malaria night biting mosquito
Dengue day biting mosquito
Signs of platelet dis function:
a.) Petecchiae
b.) Ecchemosis/ bruises
c.) Oozing or blood from venipuncture site
ANEMIA
Iron deficiency Anemia chronic normocytic, hypocromic (pale),
microcytic anemia due to inadequate absorption of iron leading to hypoxemic
injury.
Incidence rate:
1. Common developed country due to high cereal intake
Due to accidents common on adults
2. Common tropical countries blood sucking parasites
3. Women 15 35yo reproductive yrs
4. Common among the poor poor nutritional intake
Suicide - common in teenager
Poisoning common in children (aspirin)
Aspiration common in infant
Accidents common in adults
Choking common in toddler
SIDS common in infant in US
22.
Common in tropical zone Phil due blood sucks
Predisposing factor:
1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesisii. Melena upper GIT duodenal cancer
iii. Hematochezia lower GIT large intestine fresh blood
from rectum
2.
Inadequate intake of food rich in iron
3.
Inadequate absorption of iron due to :
a. Chronic diarrhea
65

b. Malabsorption syndrome celiac disease-gluten free diet. Food

for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking of food
S/Sx:
1. Asymptomatic
2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body
malaise, pallor
3. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec
O2=hypoxia=atrophy of epidermal cells
4. Atropic glossitis, dysphagia, stomatitis
5. Pica abnormal craving for non edible food (caused by hypoxia=dec
tissue perfusion=psychotic behavior)
Brittle hair, spoon shaped nail atrophy of epidermal cells
N = capillary refill time < 2 secs
N = shape nails biconcave shape, 180
Atrophy of cells Plummer Vinsons Syndrome due to cerebral hypoxia
1. Atropic glossiti
inflammation of tongue due to
atrophy of pharyngeal and tongue
cells
2. Stomatitis mouth sores
3. Dysphagia
Dx Proc:
1. RBC
2. Hgb
3. Reticulocyte
4. Hct
5. Iron
6. Ferritin
Nsg Mgt
1. Monitor signs of bleeding of all hema test including urine & stool
2. Complete bed rest dont overtire pt =weakness and fatigue=activity
intolerance
3. Encourage iron rich food
23.
Raisins, legumes, egg yolk
4. Instruct the pt to avoid taking tea - impairs iron absorption
5. Administer meds
a.) Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
1. Administer with meals to lessen GIT irritation
2. If diluting in iron liquid prep adm with straw
66

Straw
1. Lugols
2. Tetracycline
3. Oral iron
4. Macrodantine
3.
4.
a.
b.
c.
d.
e.

Give Orange juice for iron absorption

Monitor & inform pts S/E
Anorexia
n/v
Abdominal pain
Diarrhea or constipation
Melena

If pt cant tolerate oral iron prep administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)
Nsg Mgt parenteral iron prep
1. Administer of use Z tract method to prevent discomfort, discoloration
leakage to tissues.
2. Dont massage injection site. Ambulate to facilitate absorption.
3. Monitor S/E:
a.) Pain at injury site
b.) Localized abscess (nana)
c.) Lymphadenopathy
d.) Fever/ chills
e.) Urticaria itchiness
f.) Hypotension anaphylactic shock
Anaphylactic shock give epinephrine
PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of
intrinsic factor leading to
Hypochlorhydria decrease Hcl acid secretion. Lifetime B12
injections. With CNS involvement.
Predisposing factor
1. Subtotal gastrectomy removal stomach
2. Hereditary
3. Infl dse of ileum
4. Autoimmune
5. Strict vegetable diet
STOMACH
Parietal or ergentaffen Oxyntic cells
Fxn produce intrinsic factor

Fxn secrets Hcl acid

For reabsorption of B12

Fx aids in digestion
67

For maturation of RBC

Diet high caloric or CHO to correct wt loss
S/Sx:
1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body
malaise, pallor
2. GIT changes
a. Red beefy tongue PATHOGNOMONIC mouth sores
b. Dyspepsia indigestion
c. Wt loss
d. Jaundice
3. CNS
Most dangerous anemia: pernicious due to neuroglogic
involvement.
a. Tingling sensation
b. Paresthesia
c. (+) Rombergs test
Ataxia
d. Psychosis
Dx:- Shillings test
Nsg Mgt Pernicious anemia
1. Enforce CBR
2. Administer B12 injections at monthly intervals for lifetime as
ordered. IM- dorsogluteal or ventrogluteal. Not given oral due
pt might have tolerance to drug
3. Diet high calorie or CHO. Increase CHON, iron & Vit C
4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is
encouraged.
5. Avoid applying electric heating pads can lead to burns
APLASTIC ANEMIA stem cell disorder due to bone marrow depression
leading to pancytopenia all RBC are decreased

WBC

Decrease RBC

decrease

Anemia

leukopenia

decrease platelets

thrombocytopenia
Increase WBC leukocytocys
Increase RBC polycythemia vera complication stroke, CVA, thrombosis
Predisposing factors leading to Aplastic Anemia
1. Chemicals Banzene & its derivatives
2. radiation
3. Immunologic injury
4. Drugs cause bone marrow depression
68

a. Broad spectrum antibiotic - Chlorampenicol

- Sulfonamides bactrim
b. Chemo therapeutic agents
Methotrexate alkylating agents
Nitrogen mustard anti metabolic
Vincristine plant alkaloid
S/Sx:
1. Anemia:
a. Weakness & fatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leucopenia increase susceptibility to infection
3. Thrombocytopenia
a.
Peticchiae
b.
Oozing ofblood from venipuncture site
c.
ecchymosis
Dx:
1. CBC pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest reveals
fatty streaks in bone marrow
Nsg Mgt:
1. Removal of underlying cause
2. Blood transfusion as ordered
3. Complete bed rest
4. O2 inhalation
5. Reverse isolation due leukopenia
6. Monitor signs of infection
7. Avoid SQ, IM or any venipuncture site = HEPLOCK
8. Use electric razor when shaving to prevent bleeding
9. Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6
days 3 weeks to achieve max therapeutic effect of drug.
BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if theres decrease WBC
4. To prevent bleeding if theres platelet deficiency
Nsg Mgt & principles in Blood Transfusion
1. Proper refrigeration
2. Proper typing & crossmatching
Type O universal donor
AB universal recipient
85% of people is RH (+)
3. Asceptically assemble all materials needed:
69

a.) Filter set

b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis
Hypotonic sol swell or burst
Hypertonic sol will shrink or crenate
c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis.
d.)
Instruct another RN to recheck the following .
Pts name, blood typing & cross typing expiration date,
serial number.
e.) Check blood unit for presence of bubbles, cloudiness, dark in
color & sediments indicates bacterial contamination. Dont
dispose. Return to blood bank.
f.) Never warm blood products may destroy vital factors in
blood.
- Warming is done if with warming device only in EMERGENCY!
For multiple BT.
- Within 30 mins room temp only!
g.) Blood transfusion should be completed < 4hrs because blood
that is exposed at room temp for > 2h causes blood deterioration.
h.) Avoid mixing or administering drug at BT line leads to
hemolysis
i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent
circulatory overload
j.) Monitor VS before, during & after BT especially q15 mins(local
board) for 1st hour. NCLEX-q5min for 1st 15min.
- Majority of BT reaction occurs within 1h.
BT reactions
S/Sx Hemolytic reaction:
H hemolytic Reaction
1. Headache, dizziness,
dyspnea, palpitation, lumbar/ sterna/ flank pain,
A allergic Reaction
hypotension, flushed skin ,
(red) port wine urine.
P pyrogenic Reaction
C circulatory overload
A air embolism
T - thrombocytopenia
C citrate intoxication expired blood =hyperkalemia
H hyperkalemia
Nsg Mgt: Hemolytic Reaction:
1. Stop BT
2. Notify Doc
3. Flush with plain NSS
4. Administer isotonic fluid sol to prevent acute tubular
necrosis & conteract shock
5. Send blood unit to blood bank for reexamination
6. Obtain urine & blood samples of pt & send to lab for
reexamination
7. Monitor VS & Allergic Rxn
70

Allergic Reaction:
S/Sx
1. Fever/ chills
2. Urticaria/ pruritus
3. Dyspnea
4. Laryngospasm/ bronchospasm
5. Bronchial wheezing
Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give
bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension anaphylactic shock administer epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension
indicates anaphylactic shock
24.
administer epinephrine
9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB
Pyrogenic Reaction:
S/Sx
a.) Fever/ chills
b.) Headache
c.) Dyspnea

d. tachycardia
e. palpitations
f. diaphoresis

Nsg Mgt:
1.
2.
3.
4.
5.
6.
7.
8.

Stop BT
Notify Doc
Flush with PNSS
Administer antipyretics, antibiotics
Send blood unit to blood bank
Obtain urine & blood samples send to lab
Monitor VS & IO
Tepid sponge bath offer hypothermic blanket

Circulatory Overload:
Sx
a. Dyspnea
b. Orthopnea
c. Rales or crackles
d. Exertional discomfort

2. Notify Doc. Dont flush due pt

has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn 1st due to
hypotension 1st priority attend

Nsg Mgt:
1. Stop BT
71

Circulatory 2nd

to destruction of Hgb O2 brain

damage
Allergic
3rd
Pyrogenic 4th

Hemolytic 2nd
Anaphylitic 1st priority

DIC DISSEMINATED INTRAVASCULAR COAGULATION

25.
Acute hemorrhagic syndrome char by wide spread bleeding &
thrombosis due to a def of clotting factors (Prothrombin &
Fibrinogen).
Predisposing factor:
1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia growth of new
tissue
8. Pregnancy

3. Oozing of blood from

venipunctured site
4. Hemoptysis cough blood
5. Hemorrhage
6. Oliguria late sx
Dx Proc
1. CBC reveals decrease
platelets
2. Stool for occult blood (+)
Specimen stool
3. Opthalmoscopic exam sub
retinal hemorrhage
4. ABG analysis metabolic
acidosis

S/Sx
1. Petechiae widespread &
systemic (lungs, lower &
upper trunk)
2. Ecchymosis widespread

pH
pH

HCO3
PCO2

respiratory alkalosis

ph

PCO2

respiratory acidosis

ph

HCO3

metabolic alkalosis

ph

HCO3

metabolic acidosis

Diarrhea met acidosis

Vomitting met alk
Pyloric stenosis met alkalosis vomiting
Ileostomy or intestinal tubing met acidosis
Cushings met alk
DM met acid
Chronic bronchitis resp acid with hypoxemia, cyanosis
Nsg Mgt DIC
1. Monitor signs of bleeding hema test + urine, stool, GIT
2. Administer isotonic fluid solution to prevent shock.
3. Administer O2 inhalation
72

4.
a.
b.
5.

Administer meds
Vit K aquamephyton
Pitressin or vasopressin to conserve water.
NGT lavage
- Use iced saline lavage
6. Monitor NGT output
7. Provide heplock
8. Prevent complication: hypovolemic shock
Late signs of hypovolemic shock : anuria
Oncologic Nsg:
Oncology study of neoplasia new growth
Benign (tumor)

Malignancy (cancer)

Diff - well differentiated

Encapulation (+)
Metastasis (-)
Prognosis good
Therapeutic modality surgery

poorly or undifferentiated
(-)
(+)
poor
1. Chemotherapy plenty S/E
2. Radiation
3. Surgery
most preferred treatment
4. Bone marrow transplant - Leukemia only
Predisposing factors:
- Hormones
(carcinogenesis)
- Smoking
G genetic factors
Male
I immunologic factors
3.) Prostate cancer - common
V viral factors
40 & above (middle age &
a. Human papiloma
above)
virus causing warts
BPH 50 & above
b. Epstein barr virus
1.) Lung cancer
E environmental Factors
2.) Liver cancer
90%
a. Physical irradiation,
Female
UV rays, nuclear explosion,
1. Breast cancer 40 yrs old
chronic irritation, direct
& up mammography 15
trauma
20 mins (SBE 7 days after
b. Chemical factors
mens)
- Food additives
2. Cervical cancer 90%
(nitrates
multi sexual partners
- Hydrocarbon
5% early
vesicants, alkalies
pregnancy
- Drugs (stillbestrol)
3. Ovarian cancer
- Uraehane
Classes of cancer
Tissue typing
1.
Carcinoma arises from surface epithelium &
glandular tissues
2.
Sarcoma- from connective tissue or bones
73

3.

Multiple myeloma from bone marrow

Pathological fracture of ribs & back pain
4. Lymphoma from lymph glands
5. Leukemia from blood
Warning / Danger Sx of CA
C change in bowel /bladder habits
A a sore that doesnt heal
U unusual bleeding/ Discharge
T thickening of lump breast or elsewhere
I indigestion? Dysphagia
O obvious change in wart/ mole
N nagging cough/ hoarseness
U unexplained anemia
A - anemia
S sudden wt loss
L loss of wt
Therapeutic Modality:
1. Chemotherapy use various chemotherapeutic agents that kills
cancer cells & kills normal rapidly producing cells GIT, bone marrow,
and hair follicle.
Classification:
a.) Alkylating agents
b.) Plant alkaloids vincristine
c.) Anti metabolites nitrogen mustard
d.) Hormones DES
Steroids
e.) Antineoplastic antibiotics
S/E & mgt
GIT - -Nausea & vomiting
Nsg Mgt:
1.
Administer anti emetic 4 6h before start of chemo
Plasil
2. Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
26. Non irritating / non spicy
- Diarrhea
1. Administer anti diarrheal 4 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care offer ice chips/ popsickles
2. Inform pt hair loss temporary alopecia
Hair will grow back after 4 6 months post
chemo.
-Bone marrow depression anemia
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
74

4. Monitor signs of bleeding

Repro organ sterility
1. Do sperm banking before start of chemo
Renal system increase uric acid
1. Administer allopurinol/ xyloprin (gout)
27.
Inhibits uric acid
28.
Acute gout colchicines
29.
Increase secretion of uric acid
Neurological changes peristalsis paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine plant alkaloid causes peripheral neuropathy
2. Radiation therapy involves use of ionizing radiation that kills cancer
cells & inhibit their growth & kill N rapidly producing cells.
Types of energy emitted
1. Alpha rays rarely used doesnt penetrate skin tissues
2. Beta rays internal radiation more penetration
3. Gamma ray external radiation penetrates deeper underlying tissues
Methods of delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation injection/ implantation of radioisotopes proximal to
CA site for a specific period of time.
2 types:
a.) Sealed implant radioisotope with a container & doesnt
contaminate body fluid.
b.) Unsealed implant radioisotope without a container &
contaminates body fluid.
Ex. Phosphorus 32
3 Factors affecting exposure:
A.) Half life time period required for half of radioisotopes to decay.
- At end of half life less exposure
B.) Distance the farther the distance lesser exposure
C. ) Time the shorter the time, the lesser exposure
D.) Shielding rays can be shielded or blocked by using rubber
gloves & gamma use thick lead on concrete.
S/E & Mgt:
a.) Skin errythema, redness, sloughing
1. Assist in battling pt
2. Force fluid 2,000 3,000 ml/day
3. Avoid lotion or talcum powder skin irritation
4. Apply cornstarch or olive oil
b.) GIT nausea / vomiting 1. Administer antiemetic 4 6h before start of chemo - Plasil
2
Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
75

Non irritating / non spicy

Dysglusia decrease taste sensitivity
-When atrophy papilla (taste buds) 40 yo
Stomatitis
c.) Bone marrow depression
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Overview of function & structure of the heart
HEART
- Muscular, pumping organ of the body
- Left mediastinum
- Weigh 300 400 grams
- Resembles a closed fist
- Covered by serous membrane pericardium
Pericardium
Parietal layer

Pericardial
Fluid prevent
Friction rub

Visceral layer

Layer
1. Epicardium outermost
2. Myocardium inner responsible for pumping action/ most dangerous
layer - cardiogenic shock
3. Endocardium innermost layer
Chambers
1. Upper collecting/ receiving chamber - Atria
2. Lower pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves gives rise to 1st heart sound or S1 or
lub
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve gives rise to 2nd heart sound or S2 or
dub
Extra heart Sound
S3 ventricular Gallop CHF
S4 atrial gallop MI, HPN

Heart conduction system

1. Sino atrial node (SA node) (or Keith-Flock node)
76

Loc junction of SVC & Rt atrium

Fx- primary pace maker of heart
-Initiates electric impulse of 60 100 bpm
2. Atrioventicular node (AV node or Tawara node)
Loc inter atrial septum
Delay of electric impulse to allow ventricular filling
3. Bundle of His location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
4. Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions
SA node
AV

Purkenjie Fibers
Bundle of His
Complete heart block insertion of pacemaker at Bundle Branch
Metal Pace Maker change q3 5 yo
Prolonged PR atrial fib
ST segment depression angina
ST elev MI

T wave inversion MI
widening QRS arrhythmia

CAD coronary artery dse or Ischemic Heart Dse (IHD)

Atherosclerosis Myocrdial injury
Angina Pectoris Myocardial ischemia
MI- myocardial necrosis
ATHEROSCLEROSIS
- Hardening or artery due to fat/
lipid deposits at tunica intima.

ARTEROSCLEROSIS
- Narrowing or artery due to calcium &
CHON deposits at tunica media.

Artery tunica adventitia outer

- Tunica intima innermost
- Tunica media middle
ATHEROSCLEROSIS
Predisposing Factor
1. Sex male
2. Black race
3. Hyperlipidemia
4. Smoking
77

5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10.
Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty
Obj:
1. To revascularize the myocardium
2. To prevent angina
3. Increase survival rate
PTCA done to pt with single occluded vessel .
Multiple occluded vessels
C coronary
A arterial
B bypass
A and
G graft surgery
Nsg Mgt Before CABAG
1. Deep breathing cough exercises
2. Use of incentive spirometer
3. Leg exercises
ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest
pain usually relieved by REST or NGT nitroglycerin, resulting fr temp
myocardial ischemia.
Predisposing Factor:
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
78

10.hypothyroidism
Precipitating factors
4 Es
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food saturated fats.
Signs & Symptoms
1. Initial symptoms Levines sign hand clutching of chest
2. Chest pain sharp, stabbing excruciating pain. Location substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3. Dyspnea
4. Tachycardia
5. Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG ST segment depression
3. Stress test treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG small doses venodilator
Large dose vasodilator
1st dose NTG give 3 5 min
2nd dose NTG 3 5 min
3rd & last dose 3 5 min
Still painful after 3rd dose notify doc. MI!
55 yrs old with chest pain:
1st question to ask pt: what did you do before you had chest pain.
2nd question: does pain radiate? If radiate heart in nature. If not
radiate pulmonary origin
Venodilator veins of lower ext increase venous pooling lead to
decrease venous return.
Meds:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the
drug.
2. Monitor S/E:
orthostatic hypotension dec bp
transient headache
dizziness
3. Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
79

i. avoid placing it near hairy areas-will dec drug absorption

ii. avoid rotating transdermal patches- will dec drug
absorption
iii. avoid placing near microwave oven or during defibrillationwill burn pt due aluminum foil in patch

3.)
4.)
5.)
6.)
7.)

B. Beta blockers propanolol

C. ACE inhibitors captopril
D. Ca antagonist - nefedipine
Administer O2 inhalation
Semi-fowler
Diet- Decrease Na and saturated fats
Monitor VS, I&O, ECG
HT: Discharge planning:
a. Avoid precipitating factors 4 Es
b. Prevent complications MI
c. Take meds before physical exertion-to achieve maximum
therapeutic effect of drug
d. Importance of follow-up care.

MI MYOCARDIAL INFARCTION hear attack terminal stage of CAD

- Characterized by necrosis & scarring due to permanent mal-occlusion
Types:
1. Trasmural MI most dangerous MI Mal-occlusion of both R&L
coronary artery
2. Sub-endocardial MI mal-occlusion of either R & L coronary artery
Most critical period upon dx of MI 48 to 72h
- Majority of pt suffers from PVC premature ventricular contraction.

Predisposing
factors
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral
contra
ceptive
prolon
ged

Signs & symptoms

Diagnostic Exam

1. chest pain excruciating,

vice like, visceral pain
located substernal or
precodial area (rare)
- radiates back, arm,
shoulders, axilla, jaw & abd
muscles.
- not usually relived by rest r
NTG
2. dyspnea
3. erthermia

1. cardiac enzymes
a.) CPK MB
Creatinine
Phosphokinase
b.) LDH lactic acid
dehydrogenase
c.) SGPT (ALT) Serum
Glutanic Pyruvate
Transaminase- increased
d.) SGOT (AST) Serum
Glutamic Oxalo-acetic -

80

8. sedentary
lifestyl
e
9. obesity
10. hypothyroidi
sm

4. initial increase in BP
5. mild restlessness &
apprehensions
6. occasional findings
a.) split S1 & S2
b.) pericardial friction
rub
c.) rales /crackles
d.) S4 (atrial gallop)

increased
2. Troponin test
increase
3. ECG tracing ST
segment increase,
widening or QRS
complexes means
arrhythmia in MI
indicating PVC
4. serum cholesterol &
uric acid - increase
5. CBC increase WBC

Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation &
decrease levels of anxiety.
2. Administer O2 inhalation low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs of cardiogenic
shock in MI oliguria
3. thrombophlebitis - deep vein
4. CHF left sided
5. Dresslers syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine
blocks release of norepenephrine
2. Brithylium
- Beta-blockers lol
1. Propanolol (inderal)
- ACE inhibitors - pril
1. Captopril (enalapril)
- Ca antagonist
1. Nifedipine
81

- Thrombolitics or fibrinolytics to dissolve clots/ thrombus

S/E allergic reactions/ uticaria
1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor
Monitor for bleeding:
- Anticoagulants
1. Heparin
3 days

2. Caumadin delayed reaction 2

PTT

PT

If prolonged bleeding

prolonged bleeding

Antidote
antidote Vit K
Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL sex/ activity 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert
Before meals not after, due after meals increase metabolism
heart is pumping hard after meals.
2.) Position non-weight bearing position.
When to resume sex/ act: When pt can already use staircase,
then he can resume sex.
e.) Diet decrease Na, Saturated fats, and caffeine
f.) Follow up care.
CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood
towards systemic circulation.
- Backflow
1.) Left sided heart failure:
Predisposing factors:
1.) 90% mitral valve stenosis due RHD, aging
RHD affects mitral valve streptococcal infection
Dx: - Aso titer anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis
S/Sx
82

Pulmonary congestion/ Edema

1. Dyspnea
2. Orthopnea (Diff of breathing sitting pos platypnea)
3. Paroxysmal nocturnal dysnea PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (from lungs)
6. Cyanosis
7. Rales/ crackles due to fluid
8. Bronchial wheezing
9. PMI displaced lateral due cardiomegaly
10.
Pulsus alternons weak-strong pulse
11.
Anorexia & general body malaise
12.
S3 ventricular gallop
Dx
1. CXR cardiomegaly
2. PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure
PAP measures pressure of R ventricle. Indicates cardiac
status.
PCWP measures end systolic/ diastolic pressure
PAP & PCWP:
Swan ganz catheterization cardiac catheterization is done at
bedside at ICU
(Trachesostomy bedside) - Done 5 20 mins scalpel &
trachesostomy set
CVP indicates fluid or hydration status
Increase CVP decrease flow rate of IV
Decrease CVP increase flow rate of IV
3.
Echocardiography reveals enlarged heart chamber or
cardiomayopathy
4.
acidosis

ABG PCO2 increase, PO2 decrease = = hypoxemia = resp

2.) Right sided HF

Predisposing factor
1. 90% - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. Left sided heart failure
S/Sx
Venous congestion
83

Neck or jugular vein distension

Pitting edema
Ascites
Wt gain
Hepatomegalo/ splenomegaly
Jaundice
Pruritus
Esophageal varies
Anorexia, gen body malaise

Diagnosis:
1. CXR cardiomegaly
2. CVP measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 hypervolemia
Decrease CVP < 4 hypovolemia
Flat on bed post of pt when giving CVP
Position during CVP insertion Trendelenburg to prevent
pulmonary embolism & promote ventricular filling.
3. Echocardiography enlarged heart chamber /
cardiomyopathy
4.Liver enzyme
SGPT ( ALT)
SGOT AST
Nsg mgt: Increase force of myocardial contraction = increase CO
3 6L of CO
1. Administer meds:
Tx for LSHF: M morphine SO4 to induce vasodilatation
A aminophylline & decrease anxiety
D digitalis (digoxin)
D - diuretics
O - oxygen
G - gases
a.) Cardiac glycosides
Increase myocardial
= increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney
failure.
b.) Loop diuretics: Lasix effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease
anxiety
e.) VasodilatoPERIPHERAL MUSCULAR DISEASE
Arterial ulcers

venous ulcer
84

1. Thromboangiitis Obliterans male/ feet

Varicose veins
2. Reynauds female/ hands
Thrombophlebitis

1.
2.

1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute

inflammatory disorder affecting small to medium sized arteries & veins of
lower extremities. Male/ feet
Predisposing factors:
- Male
- Smokers

S/Sx
1. Intermittent claudication leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes

3.
4.
5.
6.

White

bluish

Pallor

cyanosis

red
rubor

Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis

Tropic changes
Ulcerations
Gangrene formation

Dx:
1. Oscillometry decrease peripheral pulse volume.
2. Doppler UTZ decrease blood flow to affected extremities.
3. Angiography reveals site & extent of mal-occulsion.
5.
Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion prevent skin breakdown
85

d.) Avoid wearing constrictive garments

4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)
2.)REYNAUDS PHENOMENON acute episodes of arterial spasm affecting
digits of hands & fingers
Predisposing factors:
1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE pathognomonic sign butterfly
Chipmunk face bulimia
Cherry red skin carbon
Spider angioma liver
Caput medusae leg &
cirrhosis
Lion face leprosy

rash on face
nervosa
monoxide poisoning
cirrhosis
trunk umbilicus- Liver

b.) Rheumatoid arthritis

4. Direct hand trauma piano playing, excessive typing, operating
chainsaw
S/Sx:
1. Intermittent claudication - leg pain upon walking - Relieved by
rest
2. Cold sensitivity
Nsg Mgt:
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a
refrigerator.
d. Avoid smoking & exposure to cold environment

VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext
& trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return
Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
86

d.
e.
f.
g.
S/Sx:

Heart dse
Pregnancy
Obesity
Prolonged immobility - Prolonged standing
1.
2.
3.
4.

Pain especially after prolonged standing

Dilated tortuous skin veins
Warm to touch
Heaviness in legs

Dx:
1. Venography
2. Trendelenbergs test vein distend quickly < 35 secs
Nsg Mgt:
1. Elevate legs above heart level to promote venous return 1 to 2
pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy spider web varicosities
S/E thrombosis
THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with
thrombus formation
Predisposing factors:
1. Smoking
2. Obesity
2. Hyperlipedemia
4. Prolonged use of oral contraceptives
5. Chronic anemia
6. DM
7. MI
8. CHF
9. Postop complications
10.
Post cannulation insertion of various cardiac catheters
S/Sx:
1. Pain at affected extremities
2. Cyanosis
3. (+) Homans sign - Pain at leg muscles upon dorsiflexion of foot.
Dx:
1.
Angiography
2.
Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumference of leg muscles to detect if swollen.
87

4. Use anti embolic stockings.

5. Meds:
Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness
OVERVIEW OF RESPIRATORY SYSTEM:
I. Upper respiratory tract:
Fx:
1. Filtering of air
2. Warming & moistening
3. Humidification
a. Nose cartilage
- Parts:
Rt nostril
separated by septum
Lt nostril
b.

Consists of anastomosis of capillaries

Kessel Bach Plexus site of epistaxis
Pharynx (throat) muscular passageway for air& food
Branches:
1. Oropharynx
2. Nasopharynx
3. Layngopharynx

c. Larynx voice box

Fx:
1. For phonation
2. Cough reflex
Glottis opening
Opens to allow passage of air
Closes to allow passage of food
II. Lower Rt Fx for gas exchange
a. Trachea windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w tracheostomy
b. Bronchus R & L main bronchus
c. Lungs R 3 lobes = 10 segments
L 2 lobes 8 segments
Post pneumonectomy - position affected side to promote expansion of lungs
Post segmental lobectomy position unaffected side to promote drainage
88

Lungs covered by pleural cavity, parietal lobe & visceral lobe

Alveoli acinar cells
- site of gas exchange (O2 & CO2)
- diffusion: Daltons law of partial pressure of gases
Ventilation movement of air in & out of lungs
Respiration movement of air into cells
Type II cells of alveoli secrets surfactant
Surfactant - decrease surface tension of alveoli
Lecithin & spinogometer
L/S ratio 2:1 indicator of lung maturity
If 1:2 adm O2 - < 40% Concentration to prevent atelectasis & retinopathy
or blindness.

I. PNEUMONIA inflammation of lung parenchyma leading to pulmonary

consolidation as alveoli is filled with exudates.
Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.
High risk elderly & children below 5 yo
Predisposing factors:
1. Smoking
2. Air pollution
3. Immuno-compromised
a. AIDS PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue
S/Sx:
1. Productive cough pathognomonic: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
89

4.
5.
6.
7.
8.

Wt loss
Pleuritic friction rub
Rales/ crackles
Cyanosis
Abdominal distension leading to paralytic ileus

Sputum exam could confirm presence of TB & pneumonia

Dx:
1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+)
cultured microorganism.
2. CXR pulmo consolidation
3. CBC increase WBC
Erythrocyte sedimentation rate
4. ABG PO2 decrease
Nsg Mgt:
1. Enforce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids 2 to 3 L/day
5. Institute pulmonary toileta.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a.) Best done before meals or 2 4 hrs after meals to prevent
Gastroesophageal Reflux
b.) Monitor VS & breath sounds
Normal breath sound bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 30 min before procedure
e.) Stop if pt cant tolerate procedure
f.) Provide oral care it may alter taste sensation
g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP
(glaucoma)
Normal IOP 12 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
90

b.) Complication: Atelectacies & meningitis

c.) Compliance to meds
PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue
caused by invasion of mycobacterium TB or tubercle bacilli or acid fast bacilli
gram (+) aerobic, motile & easily destroyed by heat or sunlight.
Predisposing factors:
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
6. Over fatigue
S/Sx:
1.
2.
3.
4.
5.
6.
7.

Productive cough yellowish

Low fever
Night sweats
Dyspnea
Anorexia, general body malaise, wt loss
Chest/ back pain
Hemoptysis

Diagnosis:
1. Skin test mantoux test infection of Purified CHON Derivative PPD
DOH 8-10 mm induration
WHO 10-14 mm induration
Result within 48 72h
(+) Mantoux test previous exposure to tubercle bacilli
Mode of transmission droplet infection
2. Sputum AFB (+) to cultured microorganism
3. CXR pulmonary
infiltrate caseosis necrosis
4. CBC increase WBC
Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi fowler
5. Force fluid to liquefy secretions
6. DBCE
7. Nebulize & suction
8. Comfy & humid environment
9. Diet increase CHO & calories, CHON, Vit, minerals
10.
Short course chemotherapy

91

Intensive phase
INH isoniazide
- give before meals for absorption
Rifampicin
- given within 4 months, given
simultaneously to prevent resistance
-S/E: peripheral neuritis vit B6
Rifampicin -All body secretions turn to red
orange color urine, stool, saliva, sweat & tears.
PZA Pyrazinamide given 2 mos/ after meals. S/E: allergic rxn,
nephrotoxicity & hepatoxicity

Standard regimen
1. Injection of streptomycin aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity damage CN # 8 tinnitus hearing loss
b.) Nephrotoxicicity monitor BUN & Crea
HT:
a.) Avoid pred factors
b.) Complications:
1.) Atelectasis
2.) Miliary TB spread of Tb to other system
b.) Compliance to meds
- Religiously take meds
HISTOPLASMOSIS- acute fungal infection caused by inhalation of
contaminated dust with histoplasma capsulatum transmitted to birds
manure.
S/Sx: Same as pneumonia & PTB like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis
Dx:
1. Histoplasmin skin test = (+)
2. ABG pO2 decrease
Nsg Mgt:
1. CBR
2. Meds:
a.) Anti fungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
92

b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.

COPD Chronic Obstructive Pulmonary Disease

1. Chronic bronchitis
2. Bronchial asthma
3. Bronchiectasis
4. Pulmonary emphysema terminal stage
CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus
due to hypertrophy or hyperplasia of goblet mucus producing cells leading to
narrowing of smaller airways.
Predisposing factors:
1. Smoking all COPD types
2. Air pollution
S/Sx:
1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN a.)Leading to peripheral edema
b.) Cor pulmonary respiratory in origin
7. Anorexia, gen body malaise
Dx:
1. ABG
PO2

PCO2

Resp acidosis

Hypoxemia causing cyanosis

Nsg Mgt:
(Same as emphysema)
2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to
hyerpsensitivity leading to narrowing of smaller airway.
Predisposing factor:
1. Extrinsic Asthma called Atropic/ allergic asthma
a.) Pallor
93

b.) Dust
c.) Gases
d.) Smoke
e.) Dander
f.) Lints
2. Intrinsic AsthmaCause:
Herediatary
Drugs aspirin, penicillin, blockers
Food additives nitrites
Foods seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
3. mixed type: combi of both ext & intr. Asthma
90% cause of asthma
S/Sx:
1.
2.
3.
4.
5.
6.
7.
Dx:
1.
2.

C cough non productive to productive

D dyspnea
W wheezing on expiration
Cyanosis
Mild apprehension & restlessness
Tachycardia & palpitation
Diaphoresis
Pulmo function test decrease lung capacity
ABG PO2 decrease

Nsg Mgt:
1. CBR all COPD
2. Medsa.) Bronchodilator through inhalation or metered dose inhaled /
pump. Give 1st before corticosteroids
b.) Corticosteroids due inflammatory. Given 10 min after adm
bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist at bedside put suction machine.
e.) Antihistamine
2. Force fluid
3. O2 all COPD low inflow to prevent resp distress
4. Nebulize & suction
5. Semifowler all COPD except emphysema due late stage
6. HT
a.) Avoid pred factors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med
94

BRONCHIECTASIS abnormal permanent dilation of bronchus resulting to

destruction of muscular & elastic tissues of alveoli.
Predisposing factors:
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase
respiration.
4. Cyanosis
5. Hemoptisis
Dx:
1. ABG PO2 decrease
2. Bronchoscopy direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure MD/ lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding after return of gag reflex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs of frank or gross bleeding
4. Monitor of laryngeal spasm
- DOB
- Prepare at bedside tracheostomy set
Mgt: same as emphysema except Surgery
Pneumonectomy removal of affected lung
Segmental lobectomy position of pt unaffected side

PULMONARY EMPHYSEMA irreversible terminal stage of COPD

- Characterized by inelasticity of alveolar wall leading to air trapping,
leading to maldistribution of gases.
- Body will compensate over distension of thoracic cavity
- Barrel chest
Predisposing factor:
1. Smoking
2. Allergy
3. Air pollution
4. High risk elderly
95

5. Hereditary - 1 anti trypsin to release elastase for recoil of

alveoli.
S/Sx:
1.
2.
3.
4.
5.
6.

Productive cough
Dyspnea at rest due terminal
Anorexia & gen body malaise
Rales/ rhonchi
Bronchial wheezing
Decrease tactile fremitus (should have vibration) palpation 99.
Decreased - with air or fluid
7. Resonance to hyperresonance percussion
8. Decreased or diminished breath sounds
9. Pathognomonic: barrel chest increase post/ anterior diameter of
chest
10.
Purse lip breathing to eliminated PCO2
11.
Flaring of alai nares

Diagnosis:
1. Pulmonary function test decrease vital lung capacity
2. ABG
a.) Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease hypoxema
resp acidosis
bloaters
b.) Panacinar/ Centracinar
pCO2 decrease
pO2 increase hyperaxemia
resp alkalosis
puffers
Nursing Mgt:
1. CBR
2. Meds
a.) Bronchodilators
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 Low inflow
4. Force fluids
5. High fowlers
6. Neb & suction
7. Institute
P positive
E end
E expiratory
to prevent collapse of alveoli
P pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary R ventricular hypertrophy
2.) CO2 narcosis lead to coma
96

Blue

Pink

3.) Atelectasis
4.) Pneumothorax air in pleural space
9. Adherence to meds

RESTRICTIVE LUNG DISORDER

PNEUMOTHORAX partial / or complete collapse of lungs due to entry or
air in pleural space.
Types:
1. Spontaneous pneumothorax entry of air in pleural space without
obvious cause.
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung
conditions
Eg. open pneumothorax air enters pleural space through an opening
in chest wall
-Stab/ gun shot wound
2. Tension Pneumothorax air enters plural space with @ inspiration &
cant escape leading to over distension of thoracic cavity resulting to
shifting of mediastinum content to unaffected side.
Eg. flail chest paradoxical breathing
Predisposing factors:
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound of affected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance
Diagnosis:
1. ABG pO2 decrease
2. CXR confirms pneumothorax
Nursing Mgt:
1. Endotracheal intubation
2. Thoracenthesis
3. Meds Morphine SO4
- Anti microbial agents
4. Assist in chest tube thoracotomy
Nursing Mgt if pt is on CPT attached to H2O drainage
1. Maintain strict aseptic technique
2. DBE
3. At bedside
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage clamp
97

c.) Extra bottle

4. Meds Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs
When will MD remove chest tube:
1. If (-) fluctuations
2. (+) Breath sounds
3. CXR full expansion of lungs
Nursing Mgt of removal of chest tube
1. DBE
2. Instruct to perform Valsalva maneuver for easy removal, to prevent
entry of air in pleural space.
3. Apply vaselinated air occlusive dressing
- Maintain dressing dry & intact
GIT
I. Upper alimentary canal - function for digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach
e. 1st half of duodenum
II. Middle Alimentary canal Function: for absorption
- Complete absorption large intestine
a. 2nd half of duodenum
b. Jejunum
c. Ileum
d. 1st half of ascending colon
III. Lower Alimentary Canal Function: elimination
a. 2nd half of ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ
a. Salivary gland
b. Verniform appendix
c. Liver
98

d. Pancreas auto digestion

e. Gallbladder storage of bile
I. Salivary Glands
1. Parotid below & front of ear
2. Sublingual
3. Submaxillary
-

Produces saliva for mechanical digestion

1200 -1500 ml/day - saliva produced

PAROTITIS mumps inflammation of parotid gland

-Paramyxo virus
S/Sx:
1.
2.
3.
4.

Fever, chills anorexia, gen body malaise

Swelling of parotid gland
Dysphagia
Ear ache otalgia

Mode of transmission: Direct transmission & droplet nuclei

Incubation period: 14 21 days
Period of communicability 1 week before swelling & immediately when
swelling begins.
Nursing Mgt:
1. CBR
2. Strict isolation
3. Meds:
analgesic
Antipyretic
Antibiotics to prevent 2 complications
4. Alternate warm & cold compress at affected part
5. Gen liquid to soft diet
6. Complications
Women cervicitis, vaginitis, oophoritis
Both sexes meningitis & encephalitis/ reason why antibiotics is
needed
Men orchitis might lead to sterility if it occur during / after
puberty.
VERNIFORM APPENDIX Rt iliac or Rt inguinal area
- Function lymphatic organ produces WBC during fetal life - ceases to
function upon birth of baby
APENDICITIS inflamation of verniform appendix
Predisposing factor:
1. Microbial infection
2. Feacalith undigested food particles tomato seeds, guava seeds
3. Intestinal obstruction
99

S/Sx:
1.
2.
3.
4.
5.

Pathognomonic sign: (+) rebound tenderness

Low grade fever, anorexia, n/v
Diarrhea / & or constipation
Pain at Rt iliac region
Late sign due pain tachycardia

Diagnosis:
1. CBC mild leukocytosis increase WBC
2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area
rebound)
3. Urinalysis
Treatment: - appendectomy 24 45
Nursing Mgt:
1. Consent
2. Routinary nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema lead to rupture of appendix
3. Meds:
Antipyretic
Antibiotics
*Dont give analgesic will mask pain
- Presence of pain means appendix has not ruptured.
4. Avoid heat application will rupture appendix.
5. Monitor VS, I&O bowel sound
Nursing Mgt: post op
1. If (+) to Pendrose drain indicates rupture of appendix
Position- affected side to drain
2. Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
3. Monitor VS, I&O, bowel sound
4. Maintain patent IV line
5. Complications- peritonitis, septicemia
Liver
-

largest gland
Occupies most of right hypochondriac region
Color: scarlet red
Covered by a fibrous capsule Glissons capsule
Functional unit liver lobules

Function:
1. Produces bile
Bile emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine urobilin
Stool stircobilin
100

2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins
Hypevitaminosis vit D & K
Vit A retinol
Def Vit A night blindness
Vit D cholecalciferon
- Helps calcium
- Rickets, osteoarthritis
4. It destroys excess estrogen hormone
5. For metabolism
A. CHO
1. Glycogenesis synthesis of glycogens
2. Glycogenolysis breakdown of glycogen
3. Gluconeogenesis formation of glucose from CHO sources
B. CHON1. Promotes synthesis of albumin & globulin
Cirrhosis decrease albumin
Albumin maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath fetor hepaticus
C. FATS promotes synthesis of cholesterol to neutral fats called
triglycerides
LIVER CIRRHOSIS - lost of architectural design of liver leading to fat
necrosis & scarring
Early sign hepatic encephalopathy
1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic
coma.
Nursing priority assist in mechanical ventilation
Predisposing factor:
Decrease Laennacs cirrhosis caused by alcoholism
1. Chronic alcoholism
2. Malnutrition decreaseVit B, thiamin - main cause
3. Virus
4. Toxicity- eg. Carbon tetrachloride
5. Use of hepatotoxic agents
S/Sx:
Early signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.)
Urine tea color
Stool clay color
e.) Amenorrhea
101

f.) Decrease sexual urge

g.) Loss of pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria
2. Late signs
a.) Hematological changes all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- decrease
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusate, Palmar errythema
c.) GIT changes
Ascitis, bleeding esophageal varices due to portal HPN
d.) Neurological changes:
Hepatic encephalopathy - ammonia (cerebral toxin)
Late signs:
Early signs:
Headache
asterexis
Fetor hepaticus
(flapping hand tremors)
Confusion
Restlessness
Decrease LOC
Hepatic coma
Diagnosis:
1. Liver enzymes- increase

2.
3.
4.
5.
6.

SGPT
(ALT)
SGOT
(AST)
Serum cholesterol & ammonia increase
Indirect bilirubin increase
CBC - pancytopenia
PTT prolonged
Hepatic ultrasonogram fat necrosis of liver lobules

Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. With pt daily & assess pitting edema
5. Measure abdominal girth daily notify MD
6. Meticulous skin care
7. Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
102

8. Complications:
a.) Ascites fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics 10 15 min effect
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental
puncture of bladder as trochar is inserted
b.)
Bleeding esophageal varices
- Dilation of esophageal veins
1. Meds: Vit K
Pitrisin or Vasopresin (IM)
2. NGT decompression- lavage
- Give before lavage ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion of sengstaken-blackemore tube
- 3 lumen typed catheter
- Scissors at bedside to deflate balloon.
c.) Hepatic encephalopathy
1. Assist in mechanical ventilation due coma
2. Monitor VS, neuro check
3. Siderails due restless
4. Meds Laxatives to excrete ammonia

HEPATITIS- jaundice (icteric sclera)

Bilirubin
Kernicterus/ hyperbilirubinia
Irreversible brain damage

Pancreas mixed gland (exocrine & endocrine gland)

PANCREATITIS acute or chronic inflammation of pancreas leading to
pancreatic edema, hemorrhage & necrosis due to auto digestion.
Bleeding of pancreas - Cullens sign at umbilicus
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)
103

7. Diet increase saturated fats

S/Sx:
1. Severe Lt epigastric pain radiates from back &flank area
- Aggravated by eating, with DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain
5. Dyspepsia indigestion
6. Decrease bowel sounds
7. (+) Cullens sign - ecchymosis of umbilicus
hemorrhage
8. (+) Grey Turners spots ecchymosis of flank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase increase
2. Urine lipase increase
3. Serum Ca decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Dont give Morphine SO4 will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator NTG
d.) Antacid Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac)
to decrease
pancreatic stimulation
f.) Ca gluconate
2. Withold food & fluid aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications of TPN
1. Infection
2. Embolism
3. Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal like position
6. If pt can tolerate food, give increase CHO, decrease fats, and increase
CHON
7. Complications: Chronic hemorrhagic pancreatitis
GALLBLADDER storage of bile made up of cholesterol.
CHOLECYSTITIS/ CHOLELITHIASIS inflammation of gallbladder with
gallstone formation.
Predisposing factor:
1. High risk women 40 years old
2. Post menopausal women undergoing estrogen therapy
104

3.
4.
5.
6.
S/Sx:
1.
2.
3.
4.
5.
6.
7.
8.

Obesity
Sedentary lifestyle
Hyperlipidemia
Neoplasm
Severe Right abdominal pain (after eating fatty food). Occurring
especially at night
Fatty intolerance
Anorexia, n/v
Jaundice
Pruritus
Easy bruising
Tea colored urine
Steatorrhea

Diagnosis:
1. Oral cholecystogram (or gallbladder series)- confirms presence of
stones
Nursing Mgt:
1. Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan Phenothiazide with anti emetic properties
2. Diet increase CHO, moderate CHON, decrease fats
3. Meticulous skin care
4. Surgery:
Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection
Stomach widest section of alimentary canal
- J shaped structures
1. Anthrum
2. Pylorus
3. Fundus
Valves
1. 1.cardiac sphincter
2. Pyloric sphincter
Cells
1. Chief/ Zymogenic cells secrets
a.) Gastric amylase - digest CHO
b.) Gastric lipase digest fats
c.) Pepsin CHON
d.) Rennin digests milk products
2. Parietal / Argentaffin / oxyntic cells
Function:
a.) Produces intrinsic factor promotes reabsorption of vit B12
cyanocobalamin promotes maturation of RBC
b.) Secrets Hcl acid aids in digestion
105

3. Endocrine cells - Secrets gastrin increase Hcl acid secretion

Function of the stomach
1.Mechanical
2.Chem.
Digestion
3.Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats stored 2 3 hrs
PEPTIC ULCER DISEASE (PUD) excoriation / erosion of submucosa &
mucosal lining due to:
a.) Hypercecretion of acid pepsin
b.) Decrease resistance to mucosal barrier
Incidence Rate:
1. Men 40 55 yrs old
2. Aggressive persons
Predisposing factors:
1. Hereditary
2. Emotional
3. Smoking vasoconstriction GIT ischemia
4. Alcoholism stimulates release of histamine = Parietal cell release Hcl
acid = ulceration
5. Caffeine tea, soda, chocolate
6. Irregular diet
7. Rapid eating
8. Ulcerogenic drugs NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye
check up.
9. Gastrin producing tumor or gastrinoma Zollinger Ellisons sign
10.
Microbial invasion helicobacter pylori. Metromidazole
(Flagyl)
Types of ulcers
Ascending to severity
1. Acute affects submucosal lining
2. Chronic affects underlying tissue heals & forms a scar
According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer most common
Stress ulcers common among eritically ill clients
2 types
1.Curings ulcer cause: trauma & birth
hypovolemia
106

GIT schemia
Decrease resistance of mucosal barriers to Hcl acid
Ulcerations
2.Cushings ulcer cause stroke/CVA/ head injury
Increase vagal stimulation
Hyperacidity
Ulcerations

SITE
PAIN

GASTRIC ULCER
DUODENAL ULCER
Intrum or lesser curvature
Duodenal bulb
-30 min 1 hr after eating
-2-3 hrs after eating
- epigastrium
- mid epigastrium
- gaseous & burning
- cramping & burning
- not usually relieved by food
- usually relieved by food &
& antacid
antacid
- 12 MN 3am pain
Normal gastric acid secretion
Increased gastric acid
secretion
common
Not common
hematemeis
Melena
Wt loss
Wt gain
a. stomach cause
a. perforation
b. hemorrhage
60 years old
20 years old

HYPERSECRETI
ON
VOMITING
HEMORRHAGE
WT
COMPLICATION
S
HIGH RISK
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood
3. Gastric analysis N gastric
Increase duodenal
4. GI series confirms presence of ulceration
Nursing Mgt:
1. Diet bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products
Increase gastric acid secretion
107

3. Administer meds
a.) Antacids
AAC
Aluminum containing antacids
Magnesium containing antacids
Ex. aluminum OH gel
ex. milk of magnesia
(Ampho-gel)
S/E diarrhea
S/E constipation
Maalox (fever S/E)
b.) H2 receptor antagonist
Ex
1. Ranitidine (Zantac)
2. Cimetidine (Tagamet)
3. Tamotidine (Pepcid)
- Avoid smoking decrease effectiveness of drug
Nursing Mgt:
1. Administer antacid & H2 receptor antagonist 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats
mucosal lining of stomach
2. Cytotec
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics
1. Atropine SO4
2. Prophantheline Bromide (Profanthene)
(Pt has history of hpn crisis With peptic ulcer disease. Rn should not
administer alka seltzer- has large amount of Na.
4. Surgery: subtotal gastrectomy - Partial removal of stomach
Billroth I (Gastroduodenostomy)
Billroth II (Gastrojejunostomy)
-Removal of of stomach &
- removal of -3/4 of stomach &
anastomoses of gastric stump to
duodenal bulb & anastomostoses of
the duodenum.
gastric stump to jejunum.
Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) &
pyloroplasty (drainage) first.
Nursing Mgt:
1. Monitor NGT output
a.) Immediately post op should be bright red
b.) Within 36- 42h output is yellow green
c.) After 42h output is dark red
2. Administer meds:
108

a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage hypovolemic shock
Late signs anuria
b.) Peritonitis
c.) Paralytic ileus most feared
d.) Hypokalemia
e.) Thromobphlebitis
f.) Pernicious anemia
7.)Dumping syndrome common complication rapid gastric emptying of
hypertonic food solutions CHYME leading to hypovolemia.
Sx of Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations
Nursing mgt:
1. Avoid fluids in chilled solutions
2. Small frequent feeding s-6 equally divided feedings
3. Diet decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding
BURNS direct tissue injury caused by thermal, electric, chemical & smoke
inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd - pain
2nd priority for 3rd - F&E
Thermal- direct contact flames, hot grease, sunburn.
Electric, wires
Chem. direct contact corrosive materials acids
Smoke gas / fume inhalation
Stages:
1. Emergent phase Removal of pt from cause of burn. Determine source
or loc or burn
2. Shock phase 48 - 72. Characterized by shifting of fluids from
intravascular to interstitial space
=Hypovolemia
S/Sx:
- BP
decrease
- Urine output
109

HR
increase
Hct increase
Serum Na decrease
Serum K
increase
Met acidosis

3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from

interstitial to intravascular space
4. Recovery/ convalescent phase complete diuresis. Wound healing
starts immediately after tissue injury.
Class:
I. Partial Burn
1. 1st degree superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled
vesicles
nd
2. 2 degree deep burns
- Affects epidermis & dermis
- Cause chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th degrees burn
- Affects all layers of skin, muscles, bones
- Cause electrical
- Less painful
- Dry, thick, leathery wound surface known as ESCHAR devitalized
or necrotic tissue.
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest =
18%
Post chest =
18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total
100%
Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth
Claustridium tetany
Tetany
Tetanolysin

tetanospasmin
110

Hemolysis

muscle spasm

b.) Morphine SO4

c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic :
1. Silver Sulfadiazene (silvadene)
2. Sulfamylon
3. Silver nitrate
4. Povidone iodine (betadine)
2. Administer isotonic fluid sol & CHON replacements
3. Strict aseptic technique
4. Diet increase CHO, increase CHON, increase Vit C, and increase Korange
5. If (+) to burns on head, neck, face - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 30
minutes before debridement
8. Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curlings ulcer H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting
GUT genito-urinary tract
Function:
1. Promote excretion of nitrogenous waste products
2. Maintain F&E & acid base balance
1. Kidneys pair of bean shaped organ
- Retro peritonially (back of peritoneum) on either side of vertebral
column. Encased in Bowmanss capsule.
Parts:
1. Renal pelvis pyenophritis infl
2. Cortex
3. Medulla
Nephrones basic living unit
Glomerulus filters blood going to kidneys
Function of kidneys:
1. Urine formation
2. Regulation of BP
111

Urine
1.
2.
3.

formation 25% of total CO (Cardiac Output) is received by kidneys

Filtration
Tubular Reabsorption
Tubular Secretion

Filtration Normal GFR/ min is 125 ml of blood

Tubular reabsorption 124ml of ultra infiltrates (H2O & electrolytes is for
reabsorption)
Tubular secretion 1 ml is excreted in urine
Regulation of BP:
Predisposing factor:
Ex CS hypovolemia decrease BP going to kidneys
Activation of RAAS
Release of Renin (hydrolytic enzyme) at juxtaglomerular
apparatus
Angiotensin I mild vasoconstrictor
Angiotensin II vasoconstrictor
Adrenal cortex

increase CO

increase PR

Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Ureters 25 35 cm long, passageway of urine to bladder
Bladder loc behind symphisis pubis. Muscular & elastic tissue that is
distensible
- Function reservoir or urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reflex
Color
amber
Odor
aromatic
Consistency
clear or slightly turbid
pH
4.5 8
Specific gravity 1.015 1.030
WBC/ RBC
(-)
Albumin (-)
E coli
(-)
Mucus thread few
Amorphous urate (-)
112

Urethra extends to external surface of body. Passage of urine, seminal &

vaginal fluids.
- Women 3 5 cm or 1 to 1
- Male 20cm or 8
UTI
CYSTITIS inflammation of bladder
Predisposing factors:
1. Microbial invasion E. coli
2. High risk women
3. Obstruction
4. Urinary retention
5. Increase estrogen levels
6. Sexual intercourse
S/Sx:
1. Pain flank area
2. Urinary frequency & urgency
3. Burning upon urination
4. Dysuria & hematuria
5. Fever, chills, anorexia, gen body malaise
Diagnosis:
1. Urine culture & sensitivity - (+) to E. coli
Nursing Mgt:
1. Force fluid 2000 ml
2. Warm sitz bath to promote comfort
3. Monitor & assess for gross hematuria
4. Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial
multiplication
5. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides cotrimaxazole (Bactrim)
- Gantrism (ganthanol)
Urinary antiseptics Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex
c.) Female avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications:
Pyelonephritis

PYELONEPHRITIS acute/ chronic infl of 1 or 2 renal pelvis of kidneys

leading to tubular destruction, interstitial abscess formation.
- Lead to Renal Failure
113

Predisposing factor:
1. Microbial invasion
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dsyuria, hematuria
e.) Burning on urination
Chronic Pyelonephritis
a.) Fatigue, wt loss
b.) Polyuuria, polydypsia
c.)HPN
Diagnosis:
1. Urine culture & sensitivity (+) E. coli & streptococcus
2. Urinalysis
Increase WBC, CHON & pus cells
3. Cystoscopic exam urinary obstruction
Nursing Mgt:
1. Provide CBR acute phase
2. Force fluid
3. Acid ash diet
4. Meds:
a.) Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic Peridium
2. Complication- Renal Failure
NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract
- calcium ,
oxalate,
uric acid
milk

cabbage
anchovies
cranberries organ meat
nuts tea
nuts
chocolates sardines

Predisposing factors:
1. Diet increase Ca & oxalate
114

2.
3.
4.
5.

Hereditary gout
Obesity
Sedentary lifestyle
Hyperparathyroidism

S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP intravenous pyelography. Reveals location of stone
2. KUB reveals location of stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis composition & type of stone
5. Urinalysis increase EBC, increase CHON
Nursing Mgt:
1.Force fluid
2.Strain urine using gauze pad
3.Warm sitz bath for comfort
4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet if + Ca stones acid ash diet
If + oxalate stone alkaline ash diet - (Ex milk/ milk
products)
If + uric acid stones decrease organ meat / anchovies
sardines
6. Surgery
a.) Nephectomy removal of affected kidney
Litholapoxy removal of 1/3 of stones- Stones will recur. Not
advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure
BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to
a.) Hydro ureters dilation of ureters
b.) Hydronephrosis dilation of renal pelvis
c.) Kidney stones
d.) Renal failure
Predisposing factor:
1. High risk 50 years old & above
60 70 (3 to 4 x at risk)
2. Influence of male hormone
S/Sx:
115

1.Decrease force of urinary stream

2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
7.Sciatica
Diagnosis:
1. Digital rectal exam enlarged prostate gland
2. KUB urinary obstruction
3. Cystoscopic exam obstruction
4. Urinalysis increase WBC, CHON
Nursing Mgt:
1. Prostatic message promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No
incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms of infection
d. Monitor symptoms gross/ flank bleeding. Normal bleeding within
24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent
bladder spasm & distention

ACUTE RENAL FAILURE sudden immobility of kidneys to excrete

nitrogenous waste products & maintain F&E balance due to a decrease in
GFR. (N 125 ml/min)
Predisposing factor:
Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension
decrease flow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration
Intra-renal cause involves renal pathology= kidney problem
1. Acute tubular necrosis2. Pyelonephritis
3. HPN
116

4. Acute GN
Post renal cause involves mechanical obstruction
1. Stricture
2. Urolithiasis
3. BPH
CHRONIC RF irreversible loss of kidney function
Predisposing factors:
1. DM
2. HPN
3. Recurrent UTI/ nephritis
4. Exposure to renal toxins
Stages of CRF
1. Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
1.) Urinary System
2.) Metabolic disturbances
a.) polyuria
a.) azotemia (increase BUN &
b.) nocturia
Crea)
c.) hematuria
b.) hyperglycemia
d.) Dysuria
c.) hyperinulinemia
e.) oliguria
3.) CNS
4.) GIT
a.) headache
a.) n/v
b.) lethargy
b.) stomatitis
c.) disorientation
c.) uremic breath
d.) restlessness
d.) diarrhea/ constipation
e.) memory
impairment
5.) Respiratory
6.) hematological
a.) Kassmauls resp a.) Normocytic anemia
b.) decrease cough
bleeding tendencies
reflex
7.) Fluid &
8.) Integumentary
Electrolytes
a.) itchiness/ pruritus
a.) hyperkalemia
b.) uremic frost
b.) hypernatermia
c.)
hypermagnesemia
d.)
hyperposphatemia
e.) hypocalcemia
f.) met acidosis
Nursing Mgt:
1. Enforce CBR
117

2. Monitor VS, I&O

3. Meticulous skin care. Uremic frost assist in bathing pt
4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Obtain baseline data & monitor VS, I&O, wt, blood exam
3.) Strict aseptic technique
4.) Monitor for signs of complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion
Disequilibrium syndrome from rapid removal of urea & nitrogenous waste
prod leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia
2. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can
lead to compression of fistula.
3. Maintain patency of shunt by:
i. Palpate for thrills & auscultate for bruits if (+) patent
shunt!
ii. Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) common dialisate used
7. Complication
- Peritonitis
- Shock
8. Assist in surgery:
Renal transplantation : Complication rejection. Reverse isolation

EYES
118

External parts
1. Orbital cavity made up of connective tissue protects eye form
trauma.
2. EOM extrinsic ocular muscles involuntary muscles of eye needed for
gazing movement.
3. Eyelashes/ eyebrows esthetic purposes
4. Eyelids palpebral fissure opening upper & lower lid. Protects eye
from direct sunlight
Meibomean gland secrets a lubricating fluid inside eyelid
b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
5. Conjunctiva
6. Lacrimal apparatus tears
Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
2. Intrinsic coat
I. sclerotic coat outer most
a.) Sclera white. Occupies post of eye. Refracts light rays
b.) Canal of schlera site of aqueous humor drainage
c.) Cornea transparent structure of eye
II/ Uveal tract nutritive care
Uveitis infl of uveal tract
Consist of:
a.) Iris colored muscular ring of eye
2 muscles of iris:
1. Circular smooth muscle fiber - Constricts the pupil
2.radial smooth muscle fiber - Dilates the pupil
2 chambers of the eye
1. Anterior
a.) Vitereous Humor maintains spherical shape of the eye
b.) Aqueous Humor maintains intrinsic ocular pressure
Normal IOP= 12-21 mmHg
II. Retina (innermost layer)
i. Optic discs or blind spot nerve fibers only
No auto receptors
cones (daylight/ colored vision)

rods night twilight vision

phototopic vision
rods insufficient

scotopic vision = vit A deficiency

119

ii. Maculla lutea yellow spot center of retina

iii. Fovea centralis area with highest visual acuity oracute
vision
Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes
Unit of measurements of refraction diopters
Normal eye refraction emmetropia
ERROR of refraction
1. Myopia near sightedness Treatment: biconcave lens
2. Hyperopia/ or farsightedness Treatment: biconvex lens
3. Astigmatisim distorted vision Treatment: cylindrical
4. Prebyopia old slight inelasticity of lens due to aging Treatment:
bifocal lens or double vista
Accommodation of lenses based on thelmholtz theory of accommodation
Near vision =
Ciliary muscle contracts=

far vision=
ciliary muscle dilates /

relaxes=
Lens bulges

lens is flat

Convergence of the eye:

Error:
1. Exotropia 1 eye
normal
2. Esophoria
eye surgery
3. Strabismus- squint eye
4. Amblyopia prolong squinting

corrected by corrective

GLAUCOMA increase IOP if untreated, atrophy of optic nerve disc

blindness
Predisposing factors:
1. High risk group 40 & above
2. HPN
3. DM
4. Hereditary
5. Obesity
6. Recent eye trauma, infl, surgery
Type:
1. Chronic (open angle G.) most common type
120

Obstruct in flow of aqueous humor at trabecular meshwork of

canal of schlema
2. Acute (close angle G.) Most dangerous type
Forward displacement of iris to cornea leading to blindness.
3. Chronic (closed angle) - Precipitated by acute attack
S/Sx:
1.
2.
3.
4.
5.
6.
7.

Loss of peripheral vision tunnel vision

Halos around lights
Headache
n/v
Steamy cornea
Eye discomfort
If untreated gradual loss of central vision blindness

Diagnosis:
1. Tonometry increase IOP >12- 21 mmHg
2. Perimetry decrease peripheral vision
3. Gonioscopy abstruction in anterior chamber
Nursing mgt:
1. Enforce CBR
2. Maintain siderails
3. Administer meds
a.) Miotics lifetime - contracts ciliary muscles & constricts pupil.
Ex Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops decrease secretion of aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
2. Surgery:
Invasive:
a.) Trabeculectomy eyetrephining removal of trabelar meshwork
of canal or schlera to drain aqueous humor
b.) Peripheral Iridectomy portion of iris is excised to drain aqueous
humor
Non-invasive:
Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery

1. Apply eye patch on unaffected eye to force weaker eye to become
stronger.
Nursing Mgt post op all types of surgery
1. Position unaffected/ unoperated side - to prevent tension on suture
line.
2. Avoid valsalva maneuver
121

3. Monitor symptoms of IOP

a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
2. Eye patch both eyes - post op
CATARACT partial/ complete opacity of lens
Predisposing factor:
1. 90-95% - aging (degenerative/ senile cataract)
2. Congenital
3. Prolonged exposure to UV rays
4. DMS/Sx:
1.
2.
3.
4.

Loss of central vision - Hazy or blurring of vision

Painless
Milky white appearance at center of pupil
Decrease perception of colors

Diagnosis: Opthalmoscopic exam (+) opacity of lens

Nsg Mgt:
1. Reorient pt to environment due opacity
2. Siderails
3. Meds a.) Mydriatics dilate pupil not lifetime
Ex. Mydriacyl
c.) Cyslopegics paralyzes ciliary muscle. Ex. Cyclogye
4. Surgery
E extra
C - capsular
C cataract
L - lens
E extraction

partial removal of lens

I - intra
C - capsular
C cataract
L - lens
E extraction

total removal of lens & surrounding capsules

Nursing Mgt:
1.Position unaffected/ unoperated side - to prevent tension on suture line.
2.Avoid valsalva maneuver
3.Monitor symptoms of IOP
a.) Headache
b.) n/v
122

c.) Eye discomfort

d.) Tachycardia
4.Eye patch both eyes - post op
RETINAL DETACHMENT- separation of 2 layers of retina
Predisposing factors:
1. Severe myopia nearsightedness
2. Diabetic Retinopathy
3. Trauma
4. Following lens extraction
5. HPN
S/Sx:
1.
2.
3.
4.
5.

Curtain veil like vision

Flashes of lights
Floaters
Gradual decrease in central vision
Headache

Diagnosis- opthaloscopic exam

Nursing Mgt:
1. Siderails (all visual disease)
2. Surgery:
a.) Cryosurgery
b.)
Scleral buckling
EAR
1. Hearing
2. Balance (Kinesthesia or position sense)
Parts:
1. Outera.) Pinna/ auricle protects ear from direct trauma
b.) Ext. auditory meatus has ceruminous gland. Cerumen
c.) Tympanic membrane transmits sound waves to middle ear
Disorders of outer ear
Entry of insects put flashlight to give route of exit
Foreign objects beans (bring to MD)
H2O - drain
2. Middle ear
a.) Ear osssicle
1. Hammer
-malleus
2. Anvil -Incus
conductive hearing loss
3. Stirrups
-stapes
123

for bone conduction

disorder

b. Eustachian tube - Opens to allow equalization of pressure on both

ears
- Yawn, chew, and swallow
Children straight, wide, short
c.) Otitis media
Adult long, narrow & slanted
c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth for balance, vestibule
Utricle & succule
Otolithe or ear stone has Ca carbonate
Movement of head = Righting reflex = Kinesthesia
b. Membranous Labyrinth
1. Cochlea ( function for hearing) has organ of corti
2. Endolymph & perilymph for static equilibrium
3. Mastoid air cells air filled spaces in temporal bone in skull
Complications of Mastoditis meningitis
Types of hearing loss:
1. Conductive hearing loss transmission hearing loss
Causes:
a.) Impacted cerumen tinnitus & conduction hearing loss- assist in ear
irrigaton
b.) Immobility of stapes OTOSCLEROSIS
d.) Middle ear disease char by formation of spongy bone in the inner ear
causing fixation or immobility of stapes
e.) Stapes cant transmit sound waves
Surgery
Stapedectomy removal of stapes, spongy bone & implantation of graft/ ear
prosthesis
Predisposing factor:
1. Familiar tendency
2. Ear trauma & surgery
S/Sx:
1. Tinnitus
2. Conductive hearing loss
Diagnosis:
1. Audiometry various sound stimulates (+) conductive hearing loss
2. Webers test Normal AC> BC
124

result BC > AC
Stapedectomy
Nursing Mgt post op
1. Position pt unaffected side
2. DBE
No coughing & blowing of nose
- Night lead to removal of graft
3. Meds:
a.) Analgesic
b.) Antiemetic
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4. Assess motor function facial nerve - (Smile, frown, raise eyebrow)
5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS

Cause:
1. Tumor on cocheal
2. Loud noises (gun shot)
3. Presbycusis bilateral progressive hearing loss especially at high
frequencies elderly
Face elderly to promote lip reading
4. Menieres disease endolymphatic hydrops
f.) Inner ear disease char by dilation of endo lympathic system leading
to increase volume of endolin
Predisposing factor of MENIERES DISEASE
Smoking
Hyperlipidemia
30 years old
Obesity (+) chosesteatoma
Allergy
Ear trauma & infection
S/Sx:
1. TRIAD symptoms of Menieres disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
2. Nystagmus
3. n/v
4. Mild apprehension, anxiety
125

5. Tachycardia
6. Palpitations
7. Diaphoresis
Diagnosis:
1. Audiometry (+) sensory hearing loss
1.
2.
3.
4.

5.
6.
7.
8.

Nursing mgt:
Comfy & darkened environment
Siderails
Emetic basin
Meds:
a.) Diuretics to remove endolymph
b.)
Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
f.) Sedatives/ tranquilizers
Restrict Na
Limit fluid intake
Avoid smoking
Surgery endolymphatic sac decompression- Shunt

MATERNAL/OB NOTES
TABLE OF CONTENT
Human sexuality
Sexual anatomy and physiology
Stages of pubic hair development

Three parts of the uterus

126

Male and female homologues

Bartholomews rule
Haases rule
Physical examination

Basic knowledge in genetics and

obstetrics
Menstrual cycle

Pap smear
Stages of cervical cancer
Leopolds maneuver

Stages of sexual responses

Assessment of fetal well-being

Stages of fetal growth & development
3 processes of implantation
diagnostic test for amniotic fluid
placenta

Cardiff count to 10 method

Nonstress test
Recommended nutrient
requirement
that increases curing pregnancy

Trimester

Sexual activity

Torch
Physiological adaptation of the mother
to pregnancy
Pathogenic anemia

Exercise
Childbirth preparation
Bradley method
Grandly Dick Read Method
Different methods of delivery
Intrapartal notes

Edema
Varicosities
Vulbar varicosities
Thrombophlebitis
Morning sickness
Constipation
Flatulence
Heartburn

Theories of the onset of labor

The 4 Ps of labor
Passenger
Passageway

Hemorrhoids
Local changes
Problems related to the change of
vaginal environment
Vaginititis
Moniliasis or candidiasis

Important measurements

Breast self exam

Test to determine breast cancer
Signs and symptoms of pregnancy
Placental gradin
Psychological adaptation of pregnancy
Pre natal visit
Nageles rule
McDonalds rule
127

Power
Psyche/person
Pre-eminent signs of labor
Premature rupture of membrane
Cord prolapse
Difference between true labor &
false labor
Duration of labor
First stage: onset of true
contractions
Effacement
Dilation

Nsg interventions in each stage of

labor
Latent phase
Active phase
Transitional phase

Natural method
LAM
Symptothermal
Social method
Ovulation
Origoknause formula
Pills
Alerts on oral contraceptives
Signs of hypertension
Mechanism and chemical
barriers

Pelvic exam
Station
Presentation
Two types
Monitoring the contractions and fetal
heart tone
Parts of contractions

IUD
Condom
Diaphragm
Cervical cap
Foams, jellies, creams
Surgical method
High risk pregnancy
Hemorrhagic disorders

Health teachings
Second stage: fetal stage
Modified Ritgens maneuver
Mechanism of labor
Three parts of pelvis
Two major division of pelvis
Linea terminals
Third stage: birth to expulsion of
placenta
Signs of placental separation
Types of placental delivery
Brandt Andrews Maneuver
Fourth stage: after delivery of
placenta

First trimester bleeding

Abortions
Classifications of abortions
Ectopic pregnancy
Second trimester bleeding
Hydatidiform mole

Complications of labor
Precipitate labor
Uterine rupture
Amniotic fluid embolism
Trial labor

Third trimester bleeding

Placenta previa
Abruptio placenta
Hypersensitive disorders

Pre-term labor
Postpartal period
Principles underlying puerperium
Physiologic changes

Pregnancy induce hypertension

Transitional hypertension
Mild preeclampsia
Severe preeclampsia
Eclampsia

Lochia
Psychological response
Preventing complications
DIC

Diabetes Mellitus
Maternal effect
Fetal effect
Newborn defect
Heart disease

Late postpartum hemorrhage

Infection
General signs of inflammation
Motivate the use of family planning
128

Intrapartal complications
Cesarean delivery
Infertility
2 types of infertility
Anovulation
Tubal occlusion

129

MATERNAL/OB NOTES
Human Sexuality
A. Concepts
1. A persons sexuality encompasses the complex behaviors,
attitudes emotions and preferences that are related to sexual self
and eroticism.
2. Sex basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource
person on human sexuality.
B. Definitions related to sexuality:
Gender identity sense of femininity or masculinity
2-4 yrs/3 yrs gender identity develops.
Role identity attitudes, behaviors and attributes that differentiate
roles
Sex biologic male or female status. Sometimes referred to a specific
sexual behavior such as sexual intercourse.
Sexuality - behavior of being boy or girl, male or female man/ woman.
Entity life long dynamic change.
- developed at the moment of conception.
II. Sexual Anatomy and Physiology
A. Female Reproductive System
1. External value or pretender
a. Mons pubis/veneris - a pad of fatty tissues that lies over the
symphysis pubis covered by skin and at puberty covered by pubic hair
that serves as cushion or protection to the symphysis pubis.
Stages of Pubic Hair Development
Tannerscale tool - used to determine sexual maturity rating.
Stage 1 Pre-adolescence. No pubic hair. Fine body hair
only
Stage 2 Occurs between ages 11 and 12 sparse, long,
slightly pigmented & curly hair at pubis symphysis
Stage 3 occurs between ages 12 and 13 darker & curlier
at labia
Stage 4 occurs between ages 13 and 14, hair assumes
the normal appearance of an adult but is not so thick and
does no appear to the inner aspect of the upper thigh.
Stage 5 sexual maturity- normal adult- appear inner aspect
of upper thigh .
b. Labia Majora - large lips longitudinal fold, extends symphisis pubis
to perineum
c. Labia Minora 2 sensitive structures
clitoris- anterior, pea shaped erectile tissue with lots sensitive
nerve endings sight of sexual arousal (Greek-key)

fourchette- Posterior, tapers posteriorly of the labia minorasensitive to manipulation, torn during delivery.
Site episiotomy.
d. Vestibule an almond shaped area that contains the hymen,
vaginal orifice and bartholenes glands.
1. Urinary Meatus small opening of urethra, serves for urination
2. Skenes glands/or paraurethral gland mucus secreting subs for
lubrication
3. hymen covers vaginal orifice, membranous tissue
4. vaginal orifice external opening of vagina
5. bartholenes glands- paravaginal gland or vulvo vaginal gland -2
small mucus secreting subs secrets alkaline subs.
Alkaline neutralizes acidity of vagina
Ph of vagina - acidic
Doderleins bacillus responsible for acidity of vagina
Carumculae mystiformes-healing of torn hymen
e. Perineum muscular structure loc lower vagina & anus
Internal:
A. vagina female organ of copulation, passageway of mens & fetus,
3 4inches or 8 10 cm long, dilated canal
Rugae permits stretching without tearing
B. uterus- Organ of mens is a hollow, thick walled muscular organ. It
varies in size, shape and weights.
Size- 1x2x3
Shape: nonpregnant pear shaped / pregnant - ovoid
Weight - nonpregnant 50 -60 kg- pregnant 1,000g
Pregnant/ Involution of uterus:
4th stage of labor
- 1000g
2 weeks after delivery
- 500g
3 weeks after delivery
- 300 g
5-6 weeks after delivery
- returns to original, state 50 60
Three parts of the uterus
1. fundus
- upper cylindrical layer
2. corpus/body
- upper triangular layer
3. cervix
- lower cylindrical layer
* Isthmus lower uterine segment during pregnancy
Cornua-junction between fundus & interstitial
Muscular compositions: there are three main muscle layers which make
expansion possible in every direction.
1. Endometrium- inside uterus, lines the nonpregnant uterus. Muscle
layer for menstruation. Sloughs during menstruation.
Decidua- thick layer.
Endometriosis-proliferation of endometrial lining outside uterus.
Common site: ovary.
S/sx: dysmennorhea, low back pain.

Dx: biopsy, laparoscopy

Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit
ovulation
2. Lupreulide (Lupron) inhibit FSH/LH production
2. Myometrium largest part of the uterus, muscle layer for delivery
process
Its smooth muscles are considered to be the living ligature of the
body.
- Power of labor, resp- contraction of the uterus
3. Perimetrium protects entire uterus
C. ovaries 2 female sex glands, almond shaped. Ext- vestibule int
ovaries
Function: 1. ovulation
2. Production of hormones
d. Fallopian tubes 2-3 inches long that serves as a passageway of the
sperm from the uterus to the ampulla or the passageway of the mature ovum
or fertilized ovum from the ampulla to the uterus.
4 significant segments
1. Infundibulum distal part of FT, trumpet or funnel shaped,
swollen at ovulation
2. Ampulla outer 3rd or 2nd half, site of fertilization
3. Isthmus site of sterilization bilateral tubal ligation
4. Interstitial site of ectopic pregnancy most dangerous
B. Male Reproductive System
1. External
penis the male organ of copulation and urination. It contains of
a body of a shaft consisting of 3 cylindrical layers and erectile
tissues. At its tip is the most sensitive area comparable to that of
the clitoris in the female the glands penis.
3 Cylindrical Layers
2 corpora cavernosa
1 corpus spongiosum
Scrotum a pouch hanging below the pendulous penis, with a medial
septum dividing into two sacs, each of which contains a testes.
- cooling mechanism of testes
< 2 degrees C than body temp.
Leydig cell release testosterone
2. Internal
The Process of Spermatogenesis maturation of
sperm

Testes 900 coiled ( meter long

at age 13 onwards)
(Seminiferous tubules)

Blank! Cant erase!

Hypothalamus

Epididymis 6 meters coiled

tubules site for maturation of sperm

GnRH
Vas Deferens conduit for
spermatozoa or pathway of sperm

Ant Pit
Gland

FSH

Fx:
Sperm
Maturation

Seminal vesicle secretes:

1.) Fructose glucose has
nutritional value.
2.) Prostaglandin causes reverse
contraction of uterus

LF

Fx: Hormones
for
Testosterone
Production

Ejaculatory duct conduit of semen

Prostate gland- secrets alkaline substance

Cowpers gland secrets alkaline substance
Urethra

Male and Female homologues

Male
Female
Penile glans
Clitoral glans
Penile shaft
Clitorial shaft
Testes
ovaries
Prostate
Skenes gands
Cowpers Glands
Bartholin's glands
Scrotum
Labia Majora

III. Basic Knowledge on Genetics and Obstetrics

1. DNA carries genetic code

2. Chromosomes threadlike strands composed of hereditary material
DNA
3. Normal amount of ejaculated sperm 3 5 cc., 1 tsp
4. Ovum is capable of being fertilized with in 24 36 hrs after ovulation
5. Sperm is viable within 48 72 hrs, 2-3 days
6. Reproductive cells divides by the process of meiosis (haploid)
Spermatogenesis maturation of sperm
Oogenesis process - maturation of ovum
Gematogenesis formation of 2 haploid into diploid 23 + 23 = 46 or
diploid
7. Age of Reproductivity 15 44yo
8. MenstruationMenstrual Cycle beginning of mens to beginning of next mens
Average Menstrual Cycle 28 days
Average Menstrual Period - 3 5 days
Normal Blood loss 50cc or cup
Related terminologies:
Menarche 1st mens
Dysmenorrhea painful mens
Metrorrhagia bleeding between mens
Menorhagia excessive during mens
Amenorrhea absence of mens
Menopause cessation of mens/ average : 51 years old
9. Functions of Estrogen and Progestin
* Estrogen Hormone of the Woman
Primary function: development secondary sexual characteristic female.
Others:
1. inhibit production of FSH ( maturation of ovum)
2. hypertrophy of myometrium
3. Spinnbarkeit & Ferning ( billings method/ cervical)
4. development ductile structure of breast
5. increase osteoblast activities of long bones
6. increase in height in female
7. causes early closure of epiphysis of long bones
8. causes sodium retention
9. increase sexual desire
*Progestin Hormone of the Mother
Primary function: prepares endometrium for implantation of fertilized ovum
making it thick & tortous (twisted)
Secondary Function: uterine contractility (favors pregnancy)
Others:
1.inhibit prod of LH (hormone for ovulation)
2.inhibit motility of GIT
3. mammary gland development
4. increase permeability of kidney to lactose & dextrose causing
(+) sugar
5. causes mood swings in moms
6. increase BBT

10. Menstrual Cycle

4 phases of Menstrual Cycle
1. Phases of Menstrual Cycle:
1. Proliferative
2. Secretory
3. Ischemic
4. Menses
Parts of body responsible for mens:
1. hypothalamus
2. anterior pituitary gland master clock of body
3. ovaries
4. uterus
Initial phase 3rd day decreased estrogen
13th day peak estrogen, decrease progesterone
14th day Increase estrogen, increase progesterone
15th day Decrease estrogen, increase progesterone
I.
On the initial 3rd phase of menstruation , the estrogen level is
decreased, this level stimulates the hypothalamus to release GnRH or
FSHRF
II.
GnRH/FSHRF stimulates the anterior pituitary gland to release FSH
Functions of FSH:
1. Stimulate ovaries to release estrogen
2. Facilitate growth primary follicle to become graffian follicle
(secrets large amt estrogen & contains mature ovum.)
III.
Proliferative Phase proliferation of tissue or follicular phase, post
mens phase. Pre-ovularoty.
-phase of increase estrogen.
Follicular Phase causing irregularities of mens
Postmenstrual Phase
Preovulatory Phase phase increase estrogen
ESTROGENIC

IV.

V.

13th day of menstruation, estrogen level is peak while the

progesterone level is down, these stimulates the hypothalamus to
release GnRF on LHRF
1.) Mittelschmerz slight abdominal pain on L or RQ of
abdomen, marks ovulation day.
2.) Change in BBT, mood swing

GnRF/LHRF stimulates the ant pit gland to release LH.

Functions of LH:
1. (13th day-decreased progesterone) LH stimulates ovaries to
release progesterone
2. hormone for ovulation
VI. 14th day estrogen level is increased while the progesterone level is
increased causing rupture of graffian follicle on process of
ovulation.

VII. 15th day, after ovulation day, graafian follicle starts to degenerate
yellowish known as corpus luteum (secrets large amount of progesterone)
VIII.

Secretory
Lutheal Phase
Postovulatory
Premenstrual

PROGESTATIONAL

phasePhaseIncreased progesterone
Phase

th

IX. 24 day if no fertilization, corpus luteum degenerate ( whitish

corpus albicans)
X. 28th day if no sperm in ovum endometrium begins to slough
off to begin mens
Cornix- where sperm is deposited
Sperm- small head, long tail, pearly white
Phonones-vibration of head of sperm to determine location of ovum
Sperm should penetrate corona radiata and zona pellocida.
Capacitation- ability of sperm to release proteolytic enzyme to penetrate
corona radiata and zona pellocida.
11. Stages of Sexual Responses (EPOR)
Initial responses:
Vasocongestion congestion of blood vessels
Myotonia increase muscle tension
1. Excitement Phase (sign present in both sexes, moderate increase in
HR, RR,BP, sex flush, nipple erection) erotic stimuli cause increase
sexual tension, lasts minutes to hours.
2. Plateau Phase (accelerated V/S) increasing & sustained tension
nearing orgasm. Lasts 30 seconds 3 minutes.
3. Orgasm (involuntary spasm throughout body, peak v/s) involuntary
release of sexual tension with physiologic or psychologic release,
immeasurable peak of sexual experience. May last 2 10 sec- most
affected are is pelvic area.
4. Resolution (v/s return to normal, genitals return to pre-excitement
phase)
Refractory Period the only period present in males, wherein he cannot
be restimulated for about 10-15 minutes
A. Fertilization
B. Stages of Fetal Growth and Development
3-4 days travel of zygote mitotic cell division begins
*Pre-embryonic Stage
a. Zygote- fertilized ovum. Lifespan of zygote from fertilization to 2
months

b. Morula mulberry-like ball with 16 50 cells, 4 days free floating &

multiplication
c. Blastocyst enlarging cells that forms a cavity that later becomes
the embryo. Blastocyst covering of blastocys that later becomes
placenta & trophoblast
d. Implantation/ Nidation- occurs after fertilization 7 10 days.
Fetus- 2 months to birth.
placenta previa implantation at low side of uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization corpus luteum continues to function &
become source of estrogen & progesterone while placenta is not
developed.
3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion
C. Dicidua thickened endometrium ( Latin falling off)
* Basalis (base) part of endometrium located under fetus where
placenta is delivered
* Capsularies encapsulate the fetus
* Vera remaining portion of endometrium.
C. Chorionic Villi- 10 11th day, finger life projections
3 vessels=
A unoxygenated blood
V O2 blood
A unoxygenated blood
Whartons jelly protects cord
Chorionic villi sampling (CVS) removal of tissue sample from the fetal
portion of the developing placenta for genetic screening. Done early in
pregnancy. Common complication fetal limb defect. Ex missing
digits/toes.
E. Cytotrophoblast inner layer or langhans layer protects fetus against
syphilis 24 wks/6 months life span of langhans layer increase. Before 24
weeks critical, might get infected syphilis
F. Synsitiotrophoblast synsitial layer responsible production of hormone
1. Amnion inner most layer
a. Umbilical Cord- FUNIS, whitish grey, 15 55cm, 20 21. Short
cord: abruptio placenta or inverted uterus.
Long cord:cord coil or cord prolapse

b. Amniotic Fluid bag of H2O, clear, odor mousy/musty, with

crystallized forming pattern, slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo-skeletal development
3. maintains temp
4. prevent cord compression
5. help in delivery process
normal amt of amniotic fluid 500 to 1000cc
polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of
fluid
oligohydramnios- decrease amt of fluid kidney disease
Diagnostic Tests for Amniotic Fluid
A. Amniocentesis empty bladder before performing the procedure.
Purpose obtain a sample of amniotic fluid by inserting a needle
through the abdomen into the amniotic sac; fluid is tested for:
1. Genetic screening- maternal serum alpha feto-protein test
(MSAFP) 1st trimester
2. Determination of fetal maturity primarily by evaluating factors
indicative of lung maturity 3rd trimester
Testing time 36 weeks
decreased MSAFP= down syndrome
increase MSAFP = spina bifida or open neural tube defect
Common complication of amniocenthesis infection
Dangerous complications spontaneous abortion
3rd trimester- pre term labor
Important factor to consider for amniocentesis- needle insertion site
Aspiration of yellowish amniotic fluid jaundice baby
Greenish meconium
A. Amnioscopy direct visualization or exam to an intact fetal membrane.
B. Fern Test- determine if amniotic fluid has ruptured or not (blue paper
turns green/grey - + ruptured amniotic fluid)
C. Nitrazine Paper Test diff amniotic fluid & urine.
Paper turns yellow- urine. Paper turns blue green/gray-(+)
rupture of amn fluid.
1. Chorion where placenta is developed
Lecithin Sphingomyelin L/S
Ratio- 2:1 signifies fetal lung maturity not capable for RDS
Shake test amniotic + saline & shake
Foam test
Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity

a. Placenta (Secundines) Greek pancake, combination of chorionic villi +

deciduas basalis. Size: 500g or kg
-1 inch thick & 8 diameter
Functions of Placenta:
1. Respiratory System beginning of lung function after birth of baby.
Simple diffusion
2. GIT transport center, glucose transport is facilitated, diffusion
more rapid from higher to lower. If mom hypoglycemic, fetus
hypoglycemic
3. Excretory System- artery - carries waste products. Liver of mom
detoxifies fetus.
4. Circulating system achieved by selective osmosis
5. Endocrine System produces hormones

Human Chorionic Gonadrophin maintains corpus luteum

alive.
Human placental Lactogen or sommamommamotropin
Hormone for mammary gland development. Has a
diabetogenic effect serves as insulin antagonist
Relaxin Hormone- causes softening joints & bones
estrogen
progestin

6. It serves as a protective barrier against some microorganisms

HIV,HBV
Fetal Stage Fetal Growth and Development
Entire pregnancy days 266 280 days 37 42 weeks
Differentiation of Primary Germ layers
* Endoderm
1st week endoderm primary germ layer
Thyroid for basal metabolism
Parathyroid - for calcium
Thymus development of immunity
Liver lining of upper RT & GIT
* Mesoderm development of heart, musculoskeletal system,
kidneys and repro organ
* Ectoderm development of brain, skin and senses, hair, nails,
mucus membrane or anus & mouth
First trimester:
1st month -

Brain & heart development

GIT& resp Tract remains as single tube

1. Fetal heart tone begins heart is the oldest part of
the body
2. CNS develops dizziness of mom due to
hypoglycemic effect
Food of brain glucose complex CHO
pregnant womans food (potato)
Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum source of estrogen & progesterone of infant
life span end of 2nd month
3. Sex organ formed
4. Meconium is formed
Third
1.
2.
3.
4.

Month
Kidneys functional
Buds of milk teeth appear
Fetal heart tone heard Doppler 10 12 weeks
Sex is distinguishable

Second Trimester: FOCUS length of fetus

Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 20 weeks
3. buds of permanent teeth appear
1.
2.
3.
4.
5.

Fifth Month
lanugo covers body
actively swallows amniotic fluid
19 25 cm fetus,
Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks
multi
fetal heart tone heard with or without instrument

Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present
Third trimester: Period of most rapid growth. FOCUS: weight of fetus
Seventh Month development of surfactant lecithin
Eighth Month
1. lanugo begin to disappear
2. sub Q fats deposit
3. Nails extend to fingers
Ninth Month

1. lanugo & vernix caseosa completely disappear

2. Amniotic fluid decreases
Tenth Month bone ossification of fetal skull
Terratogens- any drug, virus or irradiation, the exposure to such
may cause damage to the fetus
A. Drugs:
Streptomycin anti TB & or Quinine (anti malaria) damage to
8th cranial nerve poor hearing & deafness
Tetracycline staining tooth enamel, inhibit growth of long bone
Vitamin K hemolysis (destr of RBC), hyperbilirubenia or
jaundice
Iodides enlargement of thyroid or goiter
Thalidomides Amelia or pocomelia, absence of extremities

B.
C.
D.
E.

Steroids cleft lip or palate

Lithium congenital malformation
Alcohol lowered weight (vasoconstriction on mom), fetal alcohol
withdrawal syndrome char by microcephaly
Smoking low birth rate
Caffeine low birth rate
Cocaine low birth rate, abruption placenta

TORCH (Terratogenic) Infections viruses

CHARACTERISTICS: group of infections caused by organisms that can cross
the placenta or ascend through birth canal and adversely affect fetal growth
and development. These infections are often characterized by vague,
influenza like findings, rashes and lesions, enlarged lymph nodes, and
jaundice (hepatic involvement). In some chases the infection may go
unnoticed in the pregnant woman yet have devastating effects on the fetus.
TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples
virus.
T toxoplasmosis mom takes care of cats. Feces of cat go to raw
vegetables or meat
O others. Hepa A or infectious heap oral/ fecal (hand washing)
Hepa B, HIV blood & body fluids
Syphilis
R rubella German measles congenital heart disease (1st month) normal
rubella titer 1:10
<1:10 less immunity to rubella, after delivery, mom will be given
rubella vaccine. Dont get pregnant for 3 months. Vaccine is terratogenic
C cytomegalo virus
H herpes simplex virus
VI.

Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes
1. Cardiovascular System increase blood volume of mom (plasma
blood) 30 50% = 1500 cc of blood
- easy fatigability, increase heart workload, slight
hypertrophy of ventricles, epistaxis due to
hyperemia of nasal membrane palpitation,
Physiologic Anemia pseudo anemia of pregnant women
Normal Values
Hct 32 42%
Hgb 10.5 14g/dL
Criteria
1st and 3rd trimester.- pathologic anemia if lower
HCT should not be 33%, Hgb should not be < 11g/dL
2nd trimester Hct should not <32%
Hgb Shdn't < 10.5% pathologic anemia if lower
Pathogenic Anemia
- iron deficiency anemia is the most common hematological disorder. It
affects toughly 20% of pregnant women.
- Assessment reveals:
Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia) due to
chronic physio hypoxia
Nursing Care:
Nutritional instruction kangkong, liver due to ferridin content, green
leafy vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya
Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if
improperly administered, hematoma.
Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty
stomach 1 hr before meals or 2 hrs after, black stool, constipation
Monitor for hemorrhage
Alert:
Iron from red meats is better absorbed iron form other sources
Iron is better absorbed when taken with foods high in Vit C such as
orange juice
Higher iron intake is recommended since circulating blood volume is
increased and heme is required from production of RBCs

Edema lower extremities due venous return is constricted due to large

belly, elevate legs above hip level.
Varicosities pressure of uterus
- use support stockings, avoid wearing knee high socks
- use elastic bandage lower to upper
Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position
side lying with pillow under hips or modified knee chest position
Thrombophlebitis presence of thrombus at inflamed blood vessel
- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate
outstanding sign (+) Homan's sign pain on cuff during dorsiflexion
milk leg skinny white legs due to stretching of skin caused by inflammation
or phlagmasia albadolens
Mgt:
1.) Bed rest
2.) Never massage
3.) Assess + Homan sign once only might dislodge thrombus
4.) Give anticoagulant to prevent additional clotting (thrombolytics will
dilute)
5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate
6.) Avoid aspirin! Might aggravate bleeding.
2. Respiratory system common problem SOB due to enlarged uterus &
increase O2 demand
Position- lateral expansion of lungs or side lying position.
3. Gastrointestinal 1st trimester change

Morning Sickness nausea & vomiting due to increase HCG. Eat dry
crackers or dry CHO diet 30 minutes before arising bed. Nausea
afternoon - small freq feeding. Vomiting in preg emesisgravida.
Metabolic alkalosis, F&E imbalance primary med mgt replace
fluids.
Monitor I&O

constipation progesterone resp for constipation. Increase fluid intake,

increase fiber diet
- fruits papaya, pineapple, mango, watermelon, cantaloupe,
apple with skin, suha.
Except guava has pectin thats constipating veg petchy,
malungay.
- exercise

-mineral oil excretion of fat soluble vitamins

* Flatulence avoid gas forming food cabbage
* Heartburn or pyrosis reflux of stomach content to esophagus
- small frequent feeding, avoid 3 full meals, avoid fatty & spicy
food, sips of milk, proper body mechanical
increase salivation ptyalsim mgt mouthwash
*Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort
4. Urinary System frequency during 1st & 3rd trimester lateral expansion
of lungs or side lying pos mgt for nocturia
Acetyace test albumin in urine
Benedicts test sugar in urine
5. Musculoskeletal
Lordosis pride of pregnancy
Waddling Gait awkward walking due to relaxation causes softening of
joints & bones
Prone to accidental falls wear low heeled shoes
Leg Cramps causes: prolonged standing, over fatigue, Ca & phosphorous
imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid
uterus (labor cramps) at lumbo sacral nerve plexus
Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or
3-4 servings/day. Cheese, yogurt, head of fish,
Dilis, sardines with bones, brocolli, seafood-tahong
(mussels), lobster, crab.
Vit D for increased Ca absorption
dorsiflexion
B. Local Changes
Local change: Vagina:
V Chadwicks sign blue violet discoloration of vagina
C Goodel's sign change of consistency of cervix
I Hegar's change of consistency of isthmus (lower uterine segment)
LEUKORRHEA whitish gray, mousy odor discharge
ESTROGEN hormone, resp for leucorrhea
OPERCULUM mucus plug to seal out bacteria.
PROGESTERONE hormone responsible for operculum
PREGNANT acidic to alkaline change to protect bacterial growth
(vaginitis)
Problems Related to the Change of Vaginal Environment:
a. Vaginitits trichomonas vaginalis due to alkaline environment of
vagina of pregnant mom

Flagellated protozoa wants alkaline

S&Sx:
Greenish cream colored frothy irritatingly itchy with foul
smelling odor with vaginal edema
Mgt:
FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so
dont give at 1st trimester
1. treat dad also to prevent reinfection
2. no alcohol has antibuse effect
VAGINAL DOUCHE IQ H2O : 1 tbsp white vinegar
b. Moniliasis or candidiasis due to candida albecans, fungal infection.
Color white cheese like patches adheres to walls of vagina.
Signs & Symptoms:
Management antifungal Nistatin, genshan violet, cotrimaxole,
canesten
Gonorrhea -Thick purulent discharge
Vaginal warts- condifoma acuminata due to papilloma virus
Mgt: cauterization
2. Abdominal Changes striae gravidarium (stretch marks) due enlarging
uterus-destruction of sub Q tissue avoid scratching, use coconut oil,
umbilicus is protruding
3. Skin Changes brown pigmentation nose chin, cheeks chloasma
melasma due to increased melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus
4. Breast Changes increase hormones, color of areola & nipple
pre colostrums present by 6 weeks, colostrums at 3rd
trimester
Breast self exam- 7 days after mens supine with pillow at back
quadrant B upper outer common site of cancer
Test to determine breast cancer:
1. mammography 35 to 49 yrs once every 1 to 2 yrs
50 yrs and above 1 x a yr
6. Ovaries rested during pregnancy
7. Signs & symptoms of Pregnancy
A. Presumptive s/s felt and observed by the mother but does not
confirm positive diagnosis of pregnancy . Subjective
B. Probable signs observed by the members of health team. Objective
C. Positive Signs undeniable signs confirmed by the use of instrument.

Ballotment sign of myoma

* + HCG sign of H mole
- trans vaginal ultrasound. Empty bladder
- ultrasound full bladder
placental grading rating/grade
o immature
1 slightly mature
2 moderately mature
3 placental maturity
What is deposited in placenta which signify maturity - there
Presumptive
Probable
Breast changes
Goodel's- change of consistency of
Urinary freq
cervix
Fatigue
Chadwicks- blue violet discoloration of
Amenorrhea
vagina
Morning sickness Hegar's- change of consistency of
Enlarged uterus
isthmus
Elevated BBT due to increased
Cloasma
progesterone
Linea negra
Positive HCG or (+)preg test
Increased skin
pigmentation
Ballottement bouncing of fetus when
Striae
lower uterine is tapped sharply
gravidarium
Enlarged abdomen
Quickening
Braxton Hicks contractions painless
irregular contractions

is calcium
Positive
Ultrasound
evidence
(sonogram) full
bladder
Fetal heart tone
Fetal movement
Fetal outline
Fetal parts
palpable

VII.

Psychological Adaptation to Pregnancy (Emotional response of

mom Reva Rubin theory)
First Trimester: No tanginal signs & sx, surprise, ambivalence, denial sign of
maladaptation to pregnancy. Developmental task is to accept biological facts
of pregnancy
Focus: bodily changes of preg, nutrition
Second Trimester tangible S&Sx. mom identifies fetus as a separate entity
due to presence of quickening, fantasy. Developmental task accept growing
fetus as baby to be nurtured.
Health teaching: growth & development of fetus.
Third Trimester: - mom has personal identification on appearance of baby
Development task: prepare of birth & parenting of child. HT:
responsible parenthood babys Layette best time to do shopping.
Most common fear let mom listen to FHT to allay fear
Lamaze classes
VII. Pre-Natal Visit:

1. Frequency of Visit:
1st 7 months 1x a month
8 9 months 2 x a month
10 once a week
post term 2 x a week
2. Personal data name, age (high risk < 18 & >35 yrs old) record to
determine high risk HBMR. Home base moms record. Sex
( pseudocyesis or false pregnancy on men & women)
Couvade syndrome dad experiences what mom goes through lihi)
Address, civil status, religion, culture & beliefs with respect, non
judgmental
Occupation financial condition or occupational hazards, education
background level knowledge
3. Diagnosis of Pregnancy
1.) urine exam to detect HCG at 40 100th day. 60 70 day peak
HCG. 6 weeks after LMP- best to get urine exam.
2.) Elisa test test for preg detects beta subunit of HCG as early as
7 10days
3.) Home preg kit do it yourself
4. Baseline Data: V/S esp. BP, monitor wt. (increase wt 1st sign
preeclampsia)
Weight Monitoring
First Trimester:
Normal Weight gain
Second trimester:normal weight gain
lb/wk)
Third trimester: normal weight gain
( 1lb/wk)
Minimum wt gain 20 25 lbs
Optimal wt gain 25 35 lbs

1.5 3 lbs (.5 1lb/month)

10 12 lbs (4 lbs/month) (1
10 12 lbs (4 lbs/ month)

5. Obstetrical Data:
nullipara no pregnancy
a. Gravida- # of pregnancy
b. Para - # of viable pregnancy
Viability the ability of the fetus to live outside the uterus at the earliest
possible gestational age.
age of viability - 20 24 wks
Term 37 42 wks,
Preterm -20 37 weeks
abortion <20 weeks
Sample Cases:
1 abortionGTPAL
1 2nd mo 2 0 01 0
G2
P0
1 40th AOG
1 36th AOG
2 misc

GT P A L
612 2 4

1 twins
35 AOG
th
1 4 month
G6 P3
39th week
miscarriage
GP GTPAL
stillbirth 33 AOG (considered as para)
4 2 4 11 1 1
preg 3rd wk

1
1
1
1

1
1
1
1
1
1

33 P
41st L
abort A
still 39
GP
triplet 32
64
th
4 mon
c. Important Estimates:

GTPAL
6 2 2 15

1. Nageles Rule use to determine expected date of delivery

Get LMP -3+ 7 +1 Apr-Dec
LMP Jan Feb Mar
M D Y
+9 +7 no year
LMP Jan 25, 04
+9 +7
10 / 32 / 04
- 1
add 1 month to month
11/31/04 EDD
2. McDonalds Rule to determine age of gestation IN WEEKS
FUNDIC HT X 7/8=AOG in WK
Fundic Ht X 7 = AOG in weeks
8
Fr sypmhisis pubis to fundus 24 X 7 =21 wks
8
3. Bartholomews Rule to determine age of gestation by proper
location of fundus at abdominal cavity.
3 months above sym pub
5 months level of umbilicus
9 months below zyphoid
10 months level of 8 months due to lightening
4. Haases rule to determine length of the fetus in cm.
Formula: 1st of preg , square @ month
2nd of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 10 x 5 =
50 cm
1st of preg
5 x 5 = 25 cm
6 x 5 = 30

cm

7 x 5 = 35 cm
8 x 5 = 40 cm
9 x 5 = 45 cm

2nd of preg

d. tetanus immunizations prevents tetanus neonatum

-mom with complete 3 doses DPT young age considered as TT1 &
2. Begin TT3
TT1
TT2
TT3
TT4
TT5

any time during pregnancy

4 wks after TT1 3 yrs protection
6 months after TT2 5 yrs protection
1 yr after TT3 10 yrs protection
yr after TT4 lifetime protection

5. Physical Examination:
A. Examine teeth: sign of infection
Danger signs of Pregnancy
C - chills/ fever - infection
Cerebral disturbances ( headache preeclampsia)
A abdominal pain ( epigastric pain aura of impending convulsions
B boardlike abdomen abruption placenta
Increase BP HPN
Blurred vision preeclampsia
Bleeding 1st trimester, abortion, ectopic pre/2nd H mole, incompetent
cervix
3rd placental anomalies
S sudden gush of fluid PROM (premature rupture of membrane) prone to
inf.
E edema to upper ext. (preeclampsia)
6. Pelvic Examination internal exam
1. empty bladder
2. universal precaution
EXT OS of cervix site for getting specimen
Site for cervical cancer
Pap Smear cervical cancer
- composed of squamous columnar tissue
Result:
Class I - normal
Class IIA acytology but no evidence of malignancy
B suggestive of infl.
Class III cytology suggestive of malignancy
Class IV cytology strongly suggestive of malignancy
Class V cytology conclusive of malignancy

Stages of Cervical Cancer

Stage
0 carcinoma insitu
1 cancer confined to cervix
2 - cancer extends to vagina
3 pelvis metastasis
4 affection to bladder & rectum
7. Leopolds Maneuver
Purpose: is done to determine the attitude, fetal presentation lie,
presenting part, degree of descent, an estimate of the size, and number of
fetuses, position, fetal back & fetal heart tone
- use palm! Warm palm.
Prep mom:
1. Empty bladder
2. Position of mom-supine with knee flex (dorsal recumbent to
relax abdominal muscles)
Procedure:
1st maneuver: place patient in supine position with knees slightly flexed; put
towel under head and right hip; with both hands palpate upper abdomen and
fundus. Assess size, shape, movement and firmness of the part to determine
presentation
2nd Maneuver: with both hands moving down, identify the back of the fetus
( to hear fetal heart sound) where the ball of the stethoscope is placed to
determine FHT. Get V/S(before 2nd maneuver) PR to diff fundic souffl (FHR) &
uterine souffl.
Uterine souffl maternal H rate
3rd Maneuver: using the right hand, grasp the symphis pubis part using
thumb and fingers.
To determine degree of engagement.
Assess whether the presenting part is engaged in the pelvis )Alert : if the
head is engaged it will not be movable).
4th Maneuver: the Examiner changes the position by facing the patients
feet. With two hands, assess the descent of the presenting part by locating
the cephalic prominence or brow. To determine attitude relationship of fetus
to 1 another.
When the brow is on the same side as the back, the head is extended. When
the brow is on the same side as the small parts, the head will be flexed and
vertex presenting.
Attitude relationship of fetus to a part or degree of flexion
Full flexion when the chin touches the chest

8.Assessment of Fetal Well-BeingA. Daily Fetal Movement Counting (DFMC) begin 27 weeks
Mom- begin after meal - breakfast
a. Cardiff count to 10 method one method currently available
(1) Begin at the same time each day (usually in the morning, after
breakfast) and count each fetal movement, noting how long it takes to count
10 fetal movements (FMs)
(2) Expected findings 10 movements in 1 hour or less
3) Warning signs
a.) more then 1 hour to reach 10 movements
b.) less then 10 movements in 12 hours(non-reactive- fetal distress)
c.) longer time to reach 10 FMs than on previous days
d.) movement are becoming weaker, less vigorous
Movement alarm signals - < 3 FMs in 12 hours
4.) warning signs should be reported to healthcare provider immediately;
often require further testing. Examples: nonstress test (NST), biographical
profile (BPP)
B. Nonstress test to determine the response of the fetal heart rate to
activity
Indication pregnancies at risk for placental insufficiency
Postmaturity
a.) pregnancy induced hypertension (PIH), diabetes
b.) warning signs noted during DFMC
c.) maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-fowlers position (w/
fetal monitor); external monitor is applied to document fetal activity; mother
activates the mark button on the electronic monitor when she feels fetal
movement.
Attach external noninvasive fetal monitors
1. tocotransducer over fundus to detect uterine contractions and fetal
movements (FMs)
2. ultrasound transducer over abdominal site where most distinct fetal
heart sounds are detected
3. monitor until at least 2 FMs are detected in 20 minutes
if no FM after 40 minutes provide woman with a light snack or
gently stimulate fetus through abdomen
if no FM after 1 hour further testing may be indicated, such as a
CST

Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good
i.

Interpretation of results
reactive result
1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per
minute, lasting at least 15 seconds in a 10 to 20 minute period
as a result of FM
3. Good variability normal irregularity of cardiac rhythm
representing a balanced interaction between the
parasympathetic (decreases FHR) and sympathetic (increase
FHR) nervous system; noted as an uneven line on the rhythm
strip.
4. result indicates a healthy fetus with an intact nervous system

ii. Nonreactive result

1. Stated criteria for a reactive result are not met
2. Could be indicative of a compromised fetus.
Requires further evaluation with another NST, biophysical profile,
(BPP) or contraction stress test (CST)
9. Health teachings
a. Nutrition do nutritional assessment daily food intake
High risk moms:
1. Pregnant teenagers low compliance to heath regimen.
2. Extremes in wt underweight, over wt candidate for HPN, DM
3. Low socio economic status
4. Vegetarian mom decrease CHON needs Vit B12 cyanocobalamin
formation of folic acid needed for cell DNA & RBC formation.
(Decrease folic acid spina bifida/open neural tube defect)
How many Kcal CHO x4,CHON x4, fats x 9
Recommended Nutrient Requirement that increases During
Pregnancy
Nutrients
Requirements
Food Source
Calories
300 calories/day
Caloric increase should
Essential to supply
above the
reflect
energy for
prepregnancy daily
- Foods of high nutrient
- increased metabolic
requirement to
value such as protein,
rate
maintain ideal body
complex
carbohydrates (whole
- utilization of nutrients weight and meet
energy requirement
grains, vegetables,
- protein sparing so it

can be used for

- Growth of fetus
- Development of
structures required for
pregnancy including
placenta, amniotic
fluid, and tissue
growth.

to activity level
- Begin increase in
second trimester
- Use weight gain
pattern as an
indication of
adequacy of
calorie intake.
- Failure to meet
caloric
requirements can
lead to ketosis as
fat and protein are
used for energy;
ketosis has been
associated with
fetal damage.

fruits)
- Variety of foods
representing foods
sources for the
nutrients requiring
during pregnancy
- No more than 30% fat

Protein
Essential for:
- Fetal tissue growth
- Maternal tissue
growth including
uterus and breasts
- Development of
essential pregnancy
structures
- Formation of red blood
cells and plasma
proteins
* Inadequate protein
intake has been
associated with onset of
pregnancy induces
hypertension (PIH)

60 mg/day or an
increase of 10%
above daily
requirements for age
group

Calcium-Phosphorous
Essential for
- Growth and
development of
fetal skeleton and
tooth buds
- Maintenance of
mineralization of
maternal bones
and teeth
- Current research
is :
Demonstrating an

Calcium increases of
Calcium increases should
reflect:
- 1200 mg/day
representing an
- dairy products : milk,
increase of 50%
yogurt, ice cream,
above
cheese, egg yolk
prepregnancy daily
- whole grains, tofu
requirement.
- green leafy vegetables
- 1600 mg/day is
- canned salmon &
recommended for
sardines w/ bones
the adolescent. 10
- Ca fortified foods such
mcg/day of
as orange juice
vitamin D is
- Vitamin D sources:
required since it
fortified milk,

Adolescents have a
higher protein
requirement than
mature women since
adolescents must
supply protein for
their own growth as
well as protein t meet
the pregnancy
requirement

Protein increase should

reflect
- Lean meat, poultry,
fish
- Eggs, cheese, milk
- Dried beans, lentils,
nuts
- Whole grains
* vegetarians must take
note of the amino acid
content of CHON foods
consumed to ensure
ingestion of sufficient
quantities of all amino
acids

association between
adequate calcium intake
and the prevention of
pregnancy induce
hypertension
Iron
Essential for
- Expansion of blood
volume and red blood
cells formation
- Establishment of fetal
iron stores for first few
months of life

enhances
absorption of both
calcium and
phosphorous
30 mg/day
representing a
doubling of the
pregnant daily
requirement
- Begin
supplementation
at 30- mg/day in
second trimester,
since diet alone is
unable to meet
pregnancy
requirement
- 60 120 mg/day
along with copper
and zinc
supplementation
for women who
have low
hemoglobin values
prior to pregnancy
or who have iron
deficiency anemia.
- 70 mg/day of
vitamin C which
enhances iron
absorption
- inadequate iron
intake results in
maternal effects
anemia depletion
of iron stores,
decreased energy
and appetite,
cardiac stress
especially labor
and birth
- fetal effects
decreased
availability of
oxygen thereby
affecting fetal
growth
* iron deficiency

margarine, egg yolk,

butter, liver, seafood

Iron increases should

reflect
- liver, red meat,
fish, poultry, eggs
- enriched, whole
grain cereals and
breads
- dark green leafy
vegetables,
legumes
- nuts, dried fruits
- vitamin C sources:
citrus fruits &
juices,
strawberries,
cantaloupe,
broccoli or
cabbage, potatoes
- iron from food
sources is more
readily absorbed
when served with
foods high in vit C

Zinc
Essential for
* the formation of
enzymes
* maybe important in the
prevention of congenital
malformation of the
fetus.
Folic Acid, Folacin,
Folate
Essential for
- formation of red
blood cells and
prevention of
anemia
- DNA synthesis and
cell formation;
may play a role in
the prevention of
neutral tube
defects (spina
bifida), abortion,
abruption placenta
Additional
Requirements
Minerals
- iodine
- Magnesium
- Selenium

Vitamins
E
Thiamine
Riborlavin
Pyridoxine ( B6)
B12
Niacin

anemia is the most

common nutritional
disorder of
pregnancy.
15mcg/day
representing an
increase of 3 mg/day
over prepreganant
daily requirements.

400 mcg/day
representing an
increase of more then
2 times the daily
prepregnant
requirement.
300mcg/day
supplement for
women with low
folate levels or
dietary deficiency
4 servings of
grains/day

175 mcg/day
320 mg/day
65 mcg/day

10 mg/day
1.5 mg/day
1.6 mg/day
2.2 mg/day
2.2 mg day
17 mg/day

Zinc increases should

reflect
- liver, meats
- shell fish
- eggs, milk, cheese
- whole grains,
legumes, nuts
Increases should reflect
- liver, kidney, lean
beef, veal
- dark green leafy
vegetables,
broccoli, legumes.
- Whole grains,
peanuts

Increased requirements
of pregnancy can easily
be met with a balanced
diet that meets the
requirement for calories
and includes food sources
high in the other
nutrients needed during
pregnancy.
Vit stored in body. Taking
it not needed fat
soluble vitamins. Hard to
excrete.

2.Sexual Activity
a.) should be done in moderation
b.) should be done in private place
c.)mom placed in comfy pos, sidelying or mom on top
d.) avoided 6 weeks prior to EDD
e.) avoid blowing or air during cunnilingus

f.) changes in sexual desire of mom during preg- air embolism

Changes in sexual desire:
a.) 1st tri decrease desire due to bodily changes
b.) 2nd trimester increased desire due to increase estrogen that enhances
lubrication
c.) 3rd trimester decreased desire
Contraindication in sex:
1. vaginal spotting
1st trimester threatened abortion
2nd trimester placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane
3. Exercise to strengthen muscles used during delivery process
- principles of exercise
1.) Done in moderation. 2.) Must be individualized
Walking best exercise
Squatting strengthen muscles of perineum. Increase circulation to
perineum. Squat feet flat on floor
Tailor Sitting 1 leg in front of other leg ( Indian seat)
Raise buttocks 1st before head to prevent postural hypotension dizziness
when changing position
-

shoulder circling exercise- strengthen chest muscles

pelvic rocking/pelvic tilt- exercise relieves low back pain & maintain
good posture
* arch back standing or kneeling. Four extremities on floor

Kegel Exercise strengthen pulococcygeal muscles

- as if hold urine, release 10x or muscle contraction
Abdominal Exercise strengthens muscles of abdominal done as if blowing
candle
4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while
promoting wellness behavior that can be used by parents and family thus,
helping them achieved a satisfying and enjoying childbirth experience.
a. Psychophysical
1. Bradley Method Dr. Robert Bradley advocated active participation of
husband at delivery process. Based on imitation of nature.
Features:

1.)
2.)
3.)
4.)

darkened rm
quiet environment
relaxation tech
closed eye & appearance of sleep

2. Grantly Dick Read Method fear leads to tension while tension leads to
pain
b. Psychosexual
1. Kitzinger method preg, labor & birth & care of newborn is an
impt turning pt in womans life cycle
- flow with contraction than struggle with contraction
c. Psychoprophylaxis prevention of pain
1. Lamaze: Dr. Ferdinand Lamaze
req. disciple, conditioning & concentration. Husband is coach
Features:
1. Conscious relaxation
2. Cleansing breathe inhale nose, exhale mouth
3. Effleurage gentle circular massage over abdominal to relieve
pain
4. imaging sensate focus
5.
Different Methods of delivery:
1.) birthing chair bed convertible to chair semifowlers
2.) birthing bed dorsal recumbent pos
3.) squatting relives low back pain during labor pain
4.) leboyers warm, quiet, dark, comfy room. After delivery, baby gets
warm bath.
5.) Birth under H20 bathtub labor & delivery warm water, soft music.
IX. Intrapartal Notes inside ER
A.
Admitting the laboring Mother:
Personal Data: name, age, address, etc
Baseline Data: v/s esppecially BP, weight
Obstetrical Data: gravida # preg, para- viable preg, 22 24
wks
Physical Exams,Pelvic Exams
B. Basic knowledge in Intrapartum.
b. 1 Theories of the Onset of Labor
1.) uterine stretch theory ( any hallow organ stretched, will always
contract & expel its content) contraction action
2.) oxytocin theory post pit gland releases oxytocin. Hypothalamus
produces oxytocin
3.) prostaglandin theory stimulation of arachidonic acid
prostaglandin- contraction

4.) progesterone theory before labor, decrease progesterone will

stimulate contractions & labor
5.) theory of aging placenta life span of placenta 42 wks. At 36 wks
degenerates (leading to contraction onset labor).
b.2. The 4 Ps of labor
1. Passenger
a. Fetal head is the largest presenting part common presenting part
of its length.
Bones 6 bones S sphenoid
F frontal - sinciput
E ethmoid O occuputal - occiput
T temporal
P parietal 2 x
Measurement fetal head:
1. transverse diameter 9.25cm
- biparietal largest transverse
- bitemporal 8 cm
2. bimastoid 7cm smallest transverse
Sutures intermembranous spaces that allow molding.
1.) sagittal suture connects 2 parietal bones ( sagitna)
2.) coronal suture connect parietal & frontal bone (crown)
3.) lambdoidal suture connects occipital & parietal bone
Moldings: the overlapping of the sutures of the skull to permit passage of
the head to the pelvis
Fontanels:
1.) Anterior fontanel bregma, diamond shape, 3 x 4 cm,( > 5 cm
hydrocephalus), 12 18 months after birth- close
2.) Posterior fontanel or lambda triangular shape, 1 x 1 cm. Closes 2
3 months.
4.) Anteroposterior diameter suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
occipitofrontal 12cm partial flexion
occipitomental 13.5 cm hyper extension submentobragmatic-face
presentation
2. Passageway
Mom 1.) < 49 tall
2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis
4 main pelvic types
1. Gynecoid round, wide, deeper most suitable (normal female pelvis)
for pregnancy
2. Android heart shape male pelvis- anterior part pointed, posterior
part shallow
3. Anthropoid oval, ape like pelvis, oval shape, AP diameter wider
transverse narrow

4. Platypelloid flat AP diameter narrow, transverse wider

b. Pelvis
2 hip bones 2 innominate bones
3 Parts of 2 Innominate Bones
Ileum lateral side of hips
- iliac crest flaring superior border forming prominence of
hips
Ischium inferior portion
- ischial tuberosity where we sit landmark to get external
measurement of pelvis
Pubes ant portion symphisis pubis junction between 2 pubis
1 sacrum post portion sacral prominence landmark to get
internal measurement of pelvis
1 coccyx 5 small bones compresses during vaginal delivery
Important Measurements
1. Diagonal Conjugate measure between sacral promontory and
inferior margin of the symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate.
(DC 11.5 cm=true conjugate)
2. True conjugate/conjugate vera measure between the anterior
surface of the sacral promontory and superior margin of the symphysis
pubis. Measurement: 11.0 cm
3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or
more.
Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial
tuberosity approximated with use of fist 8 cm & above.
3. Power the force acting to expel the fetus and placenta myometrium
powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person psychological stress when the mother is fighting the
labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
Pre-eminent Signs of Labor
S&Sx:
- shooting pain radiating to the legs

- urinary freq.
1. Lightening setting of presenting part into pelvic brim - 2 weeks
prior to EDD
* Engagement- setting of presenting part into pelvic inlet
2. Braxton Hicks Contractions painless irregular contractions
3. Increase Activity of the Mother- nesting instinct. Save energy, will be
used for delivery. Increase epinephrine
4. Ripening of the Cervix butter soft
5. decreased body wt 1.5 3 lbs
6. Bloody Show pinkish vaginal discharge blood & leukorrhea
7. Rupture of Membranes rupture of water. Check FHT
Premature Rupture of Membrane ( PROM) - do IE to check for cord
prolapse
Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
Abdominal palpations
Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP most common malposition
Bear down with contractions
Adequate hydration prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted
Cord Prolapse a complication when the umbilical cord falls or is washed
through the cervix into the vagina.
Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina

Nursing care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so
cord will remain slippery & prevent cord compression causing cerebral
palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS
Positioning trendelenberg or knee chest position
Emotional support
Prepare for Cesarean Section

Difference Between True Labor and False Labor

False Labor
True Labor
Irregular contractions
Contractions are regular
No increase in intensity Increased intensity
Pain confined to
Pain begins lower back radiates to
abdomen
abdomen
Pain relived by
Pain intensified by walking
walking
Cervical effacement & dilatation *
No cervical changes
major sx
of true labor.
Duration of Labor
Primipara 14 hrs & not more than 20 hrs
Multipara 8 hrs & not > 14 hrs
Effacement softening & thinning of cervix. Use % in unit of measurement
Dilation widening of cervix. Unit used is cm.
Nursing Interventions in Each Stage of Labor
2 segments of the uterus
1. upper uterine - fundus
2. lower uterine isthmus
1. First Stage: onset of true contractions to full dilation and
effacement of cervix.
Latent Phase:
Assessment:
Dilations: 0 3 cm mom excited, apprehensive,
can communicate
Frequency: every 5 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 3 hrs full bladder inhibit contractions
3. Breathing chest breathing
Active Phase:
Assessment:
Dilations 4 -8 cm
Intensity: moderate Mom- fears
losing control of self
Frequency q 3-5 min lasting for 30 60 seconds
Nursing Care:
M edications have meds ready
A ssessment include: vital signs, cervical dilation and effacement,
fetal monitor, etc.
D dry lips oral care (ointment)
dry linens
B abdominal breathing
Transitional Phase:
changes with hyperesthesia

intensity: strong

Mom mood

Assessment: Dilations 8 10 cm
Frequency q 2-3 min contractions
Durations
45 90 seconds
Hyperesthesia increase sensitivity to touch, pain all over
Health Teaching : teach: sacral pressure on lower back to inhibit
transmission of pain
keep informed of progress
controlled chest breathing
Nursing Care:
T ires
I nform of progress
R estless support her breathing technique
E ncourage and praise
D iscomfort
Pelvic Exams
Effacement
Dilation
a. Station landmark used: ischial spine
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
0 station = level at ischial spine engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning occurs at 2nd stage of labor
b. Presentation/lie the relationship of the long axis (spine) of the fetus to
the long axis of the mother
-spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
cephalic - Vertex complete flexion
Face
Brow Poor Flexion
Chin
Breech Complete Breech thigh breast on abdomen, breast lie on thigh
Incomplete Breech thigh rest on abdominal
Frank legs extend to head
Footling single, double
Kneeling
b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder
presentation.
c. Position relationship of the fatal presenting part to specific
quadrant of the mothers pelvis.
Variety:
Occipito LOA left occipito ant (most common and favorable position)
side of maternal pelvis

LOP left occipito posterior

LOP most common mal position, most painful
ROP squatting pos on mom
ROT
ROA
Breech- use sacrum
- put stet above umbilicus
Shoulder/acromniodorso
LADA, LADT, LADP, RADA

LSA left sacro anterior

LST, LSP, RSA, RST, RSP

Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP
Monitoring the Contractions and Fetal heart Tone
Spread fingers lightly over fundus to monitor contractions
Parts of contractions:
Increment or crescendo beginning of contractions until it increases
Acme or apex height of contraction
Decrement or decrescendo from height of contractions until it
decreases
Duration beginning of contractions to end of same contraction
Interval end of 1 contraction to beginning of next contraction
Frequency beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction
Contraction vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of
contractions
Placental reserve 60 sec o2 for fetus during contractions
Duration of contractions shouldnt >60 sec
Notify MD
Mom has headache check BP, if same BP, let mom rest. If BP increase ,
notify MD -preeclampsia
Health teachings
1.) Ok to shower
2.)NPO GIT stops function during labor if with food- will cause
aspiration
3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 18 inch ht enema tubing
Check FHT after adm enema
Normal FHT= 120-160

Signs of fetal distress1.) <120 & >160

2.) mecomium stain amnion fluid
3.) fetal thrushing hyperactive fetus due to lack O2
2. Second Stage: fetal stage, complete dilation and effacement to
birth.
7 8 multi bring to delivery room
10cm primi bring to delivery room
Lithotomy pos put legs same time up
Bulging of perineum sure to come out
Breathing panting ( teach mom)
Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal,
shorten 2nd stage of labor.
Episiotomy median less bleeding, less pain easy to repair, fast to heal,
possible to reach rectum ( urethroanal fistula)
Mediolateral more bleeding & pain, hard to repair, slow to heal
-use local or pudendal anesthesia.
Ironing the perineum to prevent laceration
Modified Ritgens maneuver place towel at perineum
1.)To prevent laceration
2.) Will facilitate complete flexion & extension. (Support head & remove
secretion, check cord if coiled. Pull shoulder down & up. Check time,
identification of baby.
Mechanisms of labor
1. Engagement 2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion
Three parts of Pelvis 1. Inlet AP diameter narrow, transverse diameter
wider
2. Cavity
Two Major Divisions of Pelvis
1. True pelvis below the pelvic inlet
2. False pelvis above the pelvic inlet; supports uterus during pregnancy
Linea Terminales diagonal imaginary line from the sacrum to the
symphysis pubis that divides the false and true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only vaginal pack

Bolus of Ptocin can lead to hypotension.

3. Third Stage: birth to expulsion of Placenta -placental stage

placenta has 15 28 cotyledons
Placenta delivered from 3-10 minutes
Signs of placental separation
1. Fundus rises becomes firm & globular Calkins sign
2. Lengthening of the cord
3. Sudden gush of blood
Types of placental delivery
Shultz
shiny begins to separate from center to edges presenting the
fetal side shiny
Dunkan dirty begin to separate form edges to center presenting natural
side beefy red or dirty
Slowly pull cord and wind to clamp BRANDT ANDREWS MANEUVER
Hurrying of placental delivery will lead to inversion of uterus.
Nsg care for placenta:
4.
5.
6.
7.

Check completeness of placenta.

Check fundus (if relaxed, massage uterus)
Check bp
Administer methergine IM (Methylergonovine Maleate) Ergotrate
derivatives
8. Monitor hpn (or give oxytocin IV)
9. Check perineum for lacerations
10.
Assist MD for episiorapy
11.
Flat on bed
12.
Chills-due dehydration. Blanket, give clear liquid-tea,
ginger ale, clear gelatin. Let mom sleep to regain energy.
4. Fourth Stage: the first 1-2 hours after delivery of placenta
recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.
If fundus above umbilicus, deviation of fundus
1.) Empty bladder to prevent uterine atony
2.) Check lochia
a. Maternal Observations body system stabilizes
b. Placement of the Fundus
c. Lochia
d. Perineum
R - edness
E- dema
E - cchemosis
D ischarges

A approximation of blood loss. Count pad &

saturation
Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc
e. Bonding interaction between mother and newborn
rooming in types
1.) Straight rooming in baby: 24hrs with mom.
2.) Partial rooming in: baby in morning , at night nursery

Complications of Labor
Dystocia difficult labor related to:
Mechanical factor due to uterine inertia sluggishness of contraction
1.) hypertonic or primary uterine inertia
- intense excessive contractions resulting to ineffective pushing
- MD administer sedative valium,/diazepam muscle relaxant
2.) hypotonic secondary uterine inertia- slow irregular contraction
resulting to ineffective pushing. Give oxytocin.
Prolonged labor normal length of labor in primi 14 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi & > 20 hrs in primi
- maternal effect exhaustion. Fetal effect fetal distress, caput
succedaneum or cephal hematoma
- nsg care: monitor contractions and FHR
Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse
bleeding, hypovolemic shock if with bleeding.
Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing dx: fluid volume deficit
Post of mom modified trendelenberg
IV fast drip due fluid volume def
Signs of Hypovolemic Shock:
Hypotension
Tachycardia
Tachypnea
Cold clammy skin
Inversion of the uterus situation uterus is inside out.
MD will push uterus back inside or not hysterectomy.
Factors leading to inversion of uterus
1.) short cord
2.) hurrying of placental delivery
3.) ineffective fundal pressure

Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
a.)
sudden pain
b.)
profuse bleeding
c.)hypovolemic shock
d.)
TAHBSO
Physiologic retraction ring
- Boundary bet upper/lower uterine segment
BANDLS pathologic ring suprapubic depression
a.) sign of impending uterine rupture
Amniotic Fluid Embolism or placental embolism amniotic fluid or
fragments of placenta enters natural circulation resulting to embolism
Sx:
dyspnea, chest pain & frothy sputum
prepare: suctioning
end stage: DIC disseminated intravascular coagopathy- bleeding to all
portions of the body eyes, nose, etc.
Trial Labor measurement of head & pelvis falls on borderline. Mom given
6 hrs of labor
Multi: 8 14, primi 14 20
Preterm Labor labor after 20 37 weeks) ( abortion <20 weeks)
Sx:
1. premature contractions q 10 min
2. effacement of 60 80%
3. dilation 2-3 cm
Home Mgt:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 -4 glasses of water full bladder inhibits contractions
5. consult MD if symptoms persist
Hosp:
1. If cervix is closed 2 3 cm, dilation saved by administer Tocolytic
agents- halts preterm contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles notify MD pulmo edema administer oral yutopar 30
minutes before d/c IV
Tocolytic (Phil)

Terbuthaline (Bricanyl or Brethine) sustained tachycardia

Antidote propranolol or inderal - beta-blocker
If cervix is open MD steroid dextamethzone (betamethazone) to
facilitate surfactant maturation preventing RDS
Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.
X. Postpartal Period 5th stage of labor
after 24hrs :Normal increase WBC up to 30,000 cumm
Puerperium covers 1st 6 wks post partum
Involution return of repro organ to its non pregnant state.
Hyperfibrinogenia
- prone to thrombus formation
- early ambulation
Principles underlying puerperium
1. To return to Normal and Facilitate healing
A. Physiologic Changes
a.1. Systemic Changes
1. Cardiovascular System
- the first few minutes after delivery is the most critical period in mothers
because the increased in plasma volume return to its normal state and thus
adding to the workload of the heart. This is critical especially to
gravidocardiac mothers.
2. Genital tract
a. Cervix cervical opening
b. Vaginal and Pelvic Floor
c. Uterus return to normal 6 8 wks. Fundus goes down 1 finger breath/day
until 10th day no longer palpable due behind symphisis pubis
3 days after post partum: sub involuted uterus delayed healing uterus with
big clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C
after, birth pain:
1. position prone
2. cold compress to prevent bleeding
3. mefenamic acid
d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.
1. Ruba red 1st 3 days present, musty/mousy, moderate amt
2. Serosa pink to brown 4 9th day, limited amt
3. Alba crme white 10 21 days very decreased amt
dysuria
- urine collection
- alternate warm & cold compress
- stimulate bladder

3. Urinary tract:
Bladder freq in urination after delivery- urinary
retention with overflow
4. Colon:
Constipation due NPO, fear of bearing down
5. Perineal area painful episiotomy site sims pos, cold compress for
immediate pain after 24 hrs, hot sitz bath, not compress
sex- when perineum has healed
II. Provide Emotional Support Reva Rubia
Psychological Responses:
a. Taking in phase dependent phase (1st three days) mom passive,
cant make decisions, activity is to tell child birth experiences.
Nursing Care: - proper hygiene
b. Taking hold phase dependent to independent phase (4 to 7 days).
Mom is active, can make decisions
HT:
1.) Care of newborn
2.) Insert family planting method
common post partum blues/ baby blues present 4 5 days 50-80% moms
overwhelming feeling of depression characterized by crying,
despondence- inability to sleep & lack of appetite. let mom cry
therapeutic.
c. Letting go interdependent phase 7 days & above. Mom - redefines
new roles may extend until child grows.
III. Prevent complications
1. Hemorrhage bleeding of > 500cc
CS 600 800 cc normal
NSD 500 cc
I.

Early postpartum hemorrhage bleeding within 1st 24 hrs. Baggy or

relaxed uterus & profuse bleeding uterine atony. Complications:
hypovolemic shock.

Mgt:
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip
1st degree laceration affects vaginal skin & mucus membrane.
2nd degree 1st degree + muscles of vagina
3rd degree 2nd degree + external sphincter of rectum
4th degree 3rd degree + mucus membrane of rectum

Breast feeding post pit gland will release oxytocin so uterus will
contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy
DIC Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to
coagulate.
- bleeding to any part of body
- hysterectomy if with abruption placenta
mgt: BT- cryoprecipitate or fresh frozen plasma
II.

Late Postpartum hemorrhage bleeding after 24 hrs retained

placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C
except placenta increta, percreta,
Acreta attached placenta to
myometrium.
Increta deeper attachment of
placenta to myometrium
hysterectomy
Percreta invasion of placenta to perimetrium
Hematoma bluish or purple discoloration of SQ tissue of vagina or
perineum.
- too much manipulation
- large baby
- pudendal anesthesia
Mgt:
1.) cold compress every 30 minutes with rest period of 30
minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing
Infection- sources of infection
1.)endogenous from within body
2.) exogenous from outside
1.) anaerobic streptococci most common - from members health team
2.) unhealthy sexual practices
General signs of inflammation:
1. Inflammation calor (heat), rubor (red), dolor (pain)
tumor(swelling)
2. purulent discharges
3. fever
Gen mgt:
1.) supportive care CBR, hydration, TSB, cold compress, paracetamol,
VITC, culture & sensitivity for antibiotic

prolonged use of antibiotic lead to fungal infection

inflammation of perineum see general signs of inflammation
2 to 3 stitches dislocated with purulent discharge
Mgt:
Removal of sutures & drainage, saline, between & resulting.
Endometriosis inflammation of endometrial lining
Sx:
Abdominal tenderness, pos.
Fowlers to facilitate drainage & localize infection oxytocin & antibiotic
IV. Motivate the use of Family Planning
1.)
determine ones own beliefs 1st
2.)
never advice a permanent method of planning
3.)
method of choice is an individuals choice.
Natural Method the only method accepted by the Catholic Church
Billings / Cervical mucus test spinnbarkeit & ferning (estrogen)
- clear, watery, stretchable, elastic long spinnbarkeit
Basal Body Temperature 13th day temp goes down before ovulation no
sex
- get before arising in bed
LAM lactation amenorrheal method hormone that inhibits ovulation is
prolactin.
breast feeding- menstruation will come out 4 6 months
bottle fed 2 3 months
disadvantage of lam might get pregnant
Symptothermal combination of BBT & cervical. Best method
Social Method 1.) coitus interuptus/ withdrawal - least effective method
2. coitus reservatus sex without ejaculation
3. coitus interfemora ipit
4. calendar method
OVULATION count minus 14 days before next mens (14 days before next
mens)
Origoknause formula
- monitor cycle for 1 year
- -get short test & longest cycle from Jan Dec
- shortest 18
- longest 11
June 26
- 18
8
-

Dec 33
-11
22 unsafe days

21 day pill- start 5th day of mens

28day pill- start 1st day of mens

missed 1 pill take 2 next day

Physiologic MethodPills combined oral contraceptives prevent ovulation by inhibiting the
anterior pituitary gland production of FSH and LH which are essential for the
maturation and rupture of a follicle. 99.9% effective. Waiting time to become
pregnant- 3 months. Consult OB-6mos.
Alerts on Oral Contraceptive:
-in case a mother who is taking an oral contraceptive for almost long time
plans to have a baby, she would wait for at least 3 months before attempting
to conceive to provide time for the estrogen and progesterone levels to
return to normal.
- if a new oral contraceptive is prescribed the mother should continue taking
the previously prescribed contraceptive and begin taking the new one on the
first day of the next menses.
- discontinue oral contraceptive if there is signs of severe headache as this is
an indication of hypertension associated with increase incidence of CVA and
subarachnoid hemorrhage.
Signs of hypertension
Immediate Discontinuation
A abdominal pain
C chest pain
H - headache
E eye problems
S severe leg cramps
If mom HPN stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
1.) chain smoker
2.) extreme obesity
3.) HPN
4.) DM
5.) Thrombophlebitis or problems in clotting factors
-

if forgotten for one day, immediately take the forgotten tablet plus the
tablet scheduled that day. If forgotten for two consecutive days, or
more days, use another method for the rest of the cycle and the start
again.

DMPA depoproveda has progesterone inhibits LH inhibits ovulation

Depomedroxy progesterone acetate IM q 3 months
- never massage injected site, it will shorten duration
Norplant has 6 match sticks like capsules implanted subdermally
containing progesterone.
- 5 yrs disadvantage if keloid skin

as soon as removed can become pregnant

Mechanism and Chemical Barriers

Intrauterine Device (IUD)
Action: prevents implantation affects motility of sperm & ovum
- right time to insert is after delivery or during menstruation
primary indication for use of IUD
- parity or # of children, if 1 kid only dont use IUD
HT:
1.) Check for string daily
2.) Monthly checkup
3.) Regular pap smear
Alerts;
- prevents implantation
- most common complications: excessive menstrual flow and expulsion
of the device (common problem)
- others:
P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic
pregnancy
Condom latex inserted to erected penis or lubricated vagina
Adv; gives highest protection against STD female condom
Alerts:
Disadvantage:
- it lessen sexual satisfaction
- it gives higher protection in the prevention of STDs
Diaphragm rubberized dome shaped material inserted to cervix
preventing sperm to get to the uterus. REVERSABLE
Ht:
1.) proper hygiene
2.) check for holes before use
3.) must stay in place 6 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome
Alerts: Should be kept in place for about 6 8 hours

Cervical Cap most durable than diaphragm no need to apply spermicide

C/I: abnormal pap smear
Foams, Jellies, Creams
Surgical Method BTL , Bilateral Tubal Ligation can be reversed 20%
chance. HT: avoid lifting heavy objects
Vasectomy cut vas deferense.
HT: >30 ejaculations before safe sex
O zero sperm count, safe
XI. High Risk Pregnancy
1. Hemorrhagic Disorders
General Management
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges for histopathology to determine if product of
conception has been expelled or not
First Trimester Bleeding abortion or eptopic
A. Abortions termination of pregnancy before age of viability (before 20
weeks)
Spontaneous Abortion- miscarriage
Cause:
1.) chromosomal alterations
2.) blighted ovum
3.) plasma germ defect
Classifications:
a. Threatened pregnancy is jeopardized by bleeding and cramping but
the cervix is closed
b. Inevitable moderate bleeding, cramping, tissue protrudes form the
cervix (Cervical dilation)
Types:
1.) Complete all products of conception are expelled. No mgt just
emotional support!
2.) Incomplete Placental and membranes retained. Mgt: D&C
Incompetent cervix abortion
McDonalds procedure temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan permanent surgery cervix. CS
c. Habitual 3 or more consecutive pregnancies result in abortion
usually related to incompetent cervix. Present 2nd trimester

d. Missed fetus dies; product of conception remain in uterus 4 weeks

or longer; signs of pregnancy cease. (-) preg test, scanty dark brown
bleeding
Mgt: induced labor with oxytocin or vacuum extraction
5.) Induced Abortion therapeutic abortion to save life of mom. Double
effect choose between lesser evil.
C. Ectopic Pregnancy occurs when gestation is located outside the
uterine cavity. common site: tubal or ampular
Dangerous site - interstitial
Unruptured
Tubal rupture
- missed period
- sudden , sharp, severe pain.
Unilateral radiating to
- abdominal pain within 3 -5
shoulder.
weeks of missed period (maybe
shoulder pain (indicative of
generalized or one sided)
intraperitoneal bleeding that extends
- scant, dark brown, vaginal
to diaphragm and phrenic nerve)
bleeding
Nursing care:
Vital signs
Administer IV fluids
Monitor for vaginal bleeding
Monitor I & O

+ Cullens Sign bluish tinged

umbilicus signifies intra peritoneal
bleeding
syncope (fainting)
Mgt:
Surgery depending on side
Ovary: oophrectomy
Uterus : hysterectomy

Second trimester bleeding

C. Hydatidiform Mole bunch or grapes or gestational trophoblastic
disease. with fertilization. Progressive degeneration of chorionic villi.
Recurs.
- gestational anomaly of the placenta consisting of a bunch of clear vesicles.
This neoplasm is formed form the selling of the chronic villi and lost nucleus
of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid
number 46 XX, it grows & enlarges the uterus vary rapidly.
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs vesicles passed thru the vagina
Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)
Early in pregnancy
High levels of HCG
Preeclampsia at about 12 weeks
Late signs hypertension before 20th week
Vesicles look like a snowstorm on sonogram
Anemia

Abdominal cramping
Serious complications
hyperthyroidism
Pulmonary embolus
Nursing care:
Prepare D&C
Do not give oxytoxic drugs
Teachings:
a. Return for pelvic exams as scheduled for one year to monitoring
HCG and assess for enlarged uterus and rising titer could
indicative of choriocarcinoma
b. Avoid pregnancy for at least one year
Third Trimester Bleeding Placenta Anomalies
D. Placenta Previa it occurs when the placenta is improperly
implanted in the lower uterine segment, sometimes covering the
cervical os. Abnormal lower implantation of placenta.
- candidate for CS
Sx: frank
Bright red
Painless bleeding
Dx:
Ultrasound
Avoid: sex, IE, enema may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR
Assessment:

Engagement (usually has not occurred)

Fetal distress
Presentation ( usually abnormal)
Surgeon in charge of sign consent, RN as witness
MD explain to patient
complication: sudden fetal blood loss
Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV

E. Abruptio Placenta it is the premature separation of the

placenta form the implantation site. It usually occurs after the
twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.
Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)inability of uterus to contract due to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)

F.
G.
H.
I.
J.
K.
L.

Complications:
Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
Strict I&O
Placenta succenturiata 1 or 2 more lobes connected to the placenta
by a blood vessel may lead to retained placental fragments if vessel is
cut.
Placenta Circumvalata fetal side of placenta covered by chorion
Placenta Marginata fold side of chorion reaches just to the edge of
placenta
Battledore Placenta cord inserted marginally rather then centrally
Placenta Bipartita placenta divides into 2 lobes
Vilamentous Insertion of cord- cord divides into small vessels before it
enters the placenta
Vasa Previa velamentous insertion of cord has implanted in cervical
OS

2. Hypertensive Disorders
I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of
pregnancy, solved 6 weeks post partum.
1.) Gestational hypertension - HPN without edema & protenuria H
without EP
2.) Pre-eclampsia HPN with edema & protenuria or albuminuria HE P/A
3.) HELLP syndrome hemolysis with elevated liver enzymes & low
platelet count
II. Transissional Hypertension HPN between 20 24 weeks
III. Chronic or pre-existing Hypertension HPN before 20 weeks not solved 6
weeks post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2
2.) Severe preeclampsia

Signs present: cerebral and visual disturbances, epigastric pain due to liver
edema and oliguria usually indicates an impending convulsion. BP 160/110 ,
protenuria +3 - +4
3.) Eclampsia with seizure! Increase BUN glomerular damage. Provide
safety.
Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to
chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake
of CHON
Nursing care:
P romote bed rest to decrease O2 demand, facilitate, sodium
excretion, water immersion will cause to urinate.
P- prevent convulsions by nursing measures or seizure precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling planning procedure
3.) avoid jarring bed
P- prepare the following at bedside
- tongue depressor
- turning to side done AFTER seizure! Observe only! for safely.
E ensure high protein intake ( 1g/kg/day)
- Na in moderation
A anti-hypertensive drug Hydralazine ( Apresoline)
C convulsion, prevent Mg So4 CNS depressant
E valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
1. BP decrease
2. Urine output decrease
3. Resp < 12
4. Patella reflex absent 1st sigh Mg SO4 toxicity. antidote Ca
gluconate
3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of
pancreas)
Function: of insulin facilitates transport of glucose to cell
Dx: 1 hr 50gr glucose tolerance test GTT
Normal glucose 80 120 mg/dl
< 80 hypoclycemic
( euglycemia)
> 120 - hyperglycemia
3 degrees GTT of > 130 mg/dL
maternal effect DM
1.) Hypo or hyperglycemia 1st trimester hypo, 2nd 3rd trim
hyperglycemic
2.) Frequent infection- moniliasis

3.) Polyhydramnios
4.) Dystocia-difficult birth due to abnormalities in fetus or mom.
5.) Insulin requirement, decrease in insulin by 33% in 1st tri; 50%
increase insulin at 2nd 3rd trimester.
Post partum decrease 25% due placenta out.
Fetal effect
1.) hyper & hypoglycemia
2.) macrosomia large gestational age baby delivered > 400g or 4kg
3.) preterm birth to prevent stillbirth
Newborn Effect : DM
1.) hyperinsulinism
2.) hypoglycemia
normal glucose in newborn 45 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose
3.) hypocalcemia - < 7mg%
Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium
Recommendation
Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant heparin doesnt cross placenta
Class I & II- good progress for vaginal delivery
Class III & IV- poor prognosis, for vaginal delivery, not CS!
NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver
Regional anesthesia!
Low forcep delivery due to inability to push. It will shorten 2nd stage of
labor.
Heart disease
Moms with RHD at childhood
Class I no limit to physical activity
Class II slight limitation of activity. Ordinary activity causes fatigue &
discomfort.
Recommendation of class I & II
1.) sleep 10 hrs a day
2.) rest 30 minutes & after meal
Class III - moderate limitation of physical activity. Ordinary activity causes
discomfort

Recommendation:
1.) early hospitalization by 7 months
Class IV. marked limitation of physical activity. Even at rest there is fatigue &
discomfort.
Recommendation: Therapeutic abortion
XII. Intrapartal complications
1. Cesarean Delivery Indications:
a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f.
Abruptio placenta
g. Prolapse of the cord
h. CPD primary indication
i.
Breech presentation
j.
Transverse lie
Procedure:
a. classical vertical insertion. Once classical always classical
b. Low segment bikini line type aesthetic use
VBAC vaginal birth after CS
INFERTILITY - inability to achieve pregnancy. Within a year of
attempting it
- Manageable
STERILITY - irreversible
Impotency inability to have an erection
2 types of infertility
1.) primary no pregnancy at all
2.) Secondary 1st pregnancy, no more next preg
test male 1st
- more practical & less complicated
- need: sperm only
- sterile bottle container ( not plastic has chem.)
- Sims Huhner test or post coital test. Procedure: sex 2 hours before
test
mom remains supine 15 min after ejaculation
Normal: cervical mucus must be stretchable 8 10 cm with 15 20 sperm. If
>15 low sperm count
Best criteria- sperm motility for impotency
Factors: low sperm count
1.) occupation- truck driver
2.) chain smoker
administer: clomid ( chomephine citrate) to induce spermatogenesis
Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count

Implant sperm in ampula

1.) Mom: anovulation no ovulation. Due to increase prolactin
hyperprolactinemia
Administer; parlodel ( Bromocryptice Mesylate)
Action; antihyper prolactineuria
Give mom clomid: action: to induce oogenesis or ovulation
S/E: multiple pregnancy
2.) Tubal Occlusion tubal blockage Hx of PID that has scarred tubes
- use of IUD
- appendicitis (burst) & scarring
= dx: hysterosalphingography used to determine tubal patency with use
of radiopaque material
Mgt: IVF invitrofertilization (test tube baby)
England 1st test tube baby
To shorten 2nd stage of labor!
1.) fundal pressure
2.) episiotomy
3.) forcep delivery

GROWTH
AND
DEVELOPMENT
TABLE OF CONTENTS
Rates of G & D
Growth and Development
2 primary factors affecting G &
Two parameters of growth
D
How to measure development
4 main rated categories
Cognitive development
Sequential
Basic division of life
Secular
Theories of G & D
Principles of G & D
Theorists
Patterns of G & D
Sigmund Freud

Erick Erickson
Stages of psychosocial
Jean Piaget
Stages of cognitive development
Preoperational thought 2 7 years
Concrete operational thought 7 12
years
Formal operational thought 12 and up
Kohlberg
Stages of moral development
Developmental milestones
Toddler parallel play
2 toddler playing separately
3 phases of separation anxiety

Process of heat loss

Effects of hypothermia
To prevent hypothermia
Establish adequate nutritional
intake
Physiology breast milk
production
Advantage of breastfeeding
Stages of breast milk
Health teachings
Criteria effective sucking
Problems experiencing in
breastfeeding
Involution of breast
Factors
Contra indication in breast
feeding

Characteristic traits of a toddler

Clues of toilet redness
Pre schoolers
Milestones
Character traits of pre schooler
Behavior problems preschool
School age
Significant development
Characteristic traits school age
Signs of sexual maturity
Significant development
Personality traits adolescents
Problems
Immediate care of newborn
Catheter suctioning
Nursing alert
Feto placental circulation
Shunts
Position of infant immediately after
birth
Signs of increased ICP
Temp regulation
Factors leading to development of
hypothermia

Establish of waste elimination

Assessment f well being
APGAR score
APGAR scoring chart
APGAR result
CPR
Silvermann Anderson Index
Respiration evaluation
Interpretation result
Assessment of gestational age
Ballards &
Dobowitz
Signs of pre term babies
Signs of post term babies
Neonates in nursery
Bathing
3 cleans in community
-

Credes prophylaxis
Vit K
Physical exam and deviations
from normal
Imperforate anus
Congenital heart disease

Acyanotic heart defects

ASD
Endocardial cushion defects
PDA
Pulmonary stenosis
Aortic stanosis
Duplication of aortic arch
Coartation of aorta
Cyanotic heart defects
Transporation of great arteries
Total anomalous pulmonary

Truncus arteriousus
Hypoplastic left heart syndrome
Trcuspid atresia
Tetralogy of Fallot
Acquired heart disease
RHD rheumatic heart disease
Jones criteria
Breath sounds heard during
auscultation
Fibrine hyaline
Laryngotracheo bronchitis
Broncholitis
Epligotitis
Skin
Birhmarks
3 types of hemangiomas
Burn trauma
Depth
Atopic dermatitis
Impetigo
Predicculosiscaptits
Acne
Anemia
Hemophilia
Leukemia
Most common cancer
Traid
4 levels of chemotherapy

ABO incompatibility
Hydrops fetalis
Physiologic jaundice
Craniostenosis or
craniosinustosis
Cephalhematoma
Seborrheic dermatitis
Hydrocephalus
Senses
Test for blindness
Retinobastoma
Nose
Epistaxis
Ears
Chromosomal aberrations
Trisomy 21
Klinefelters syndrome
Otitis media
Bells palsy
Epstein barr
Hypervitaminosis
Monilliasis
Kawasaki dse
Cleft lip
Cleft palate
Neck
Thyroid
Chest
Abdomen
Gastrochisis
Principles in supplementary
feeding
Total body fluids
Problems leading to F & E
imbalance
Diarrhea
Hirschprungs disease
Gastroesophagel reflux
Esophageal cancer

Obstructive disorders
Instussusception
Phenyleketonuria
Guthrie test
Galactosemia
Celiac disease
Poisoning
Lead poisoning
Amogenital
Hydroseal
Varicoseal
Nephrotic syndrome
Acute glomerulo nephritis
Open neural tube defect
Spina bifida occulta
Spina bifida cystica
Scoliosis
Extremities
Congenital hip dislocation
Talipes
Crutches
Principles of crutches
Different crutch gaits

GROWTH
AND
DEVELOPMENT
Growth- increase in physical size of a structure or whole.
-quantitative change.
Two parameters of Growth
1. weight- most sensitive measure of growth, especially low birth rate.
Wt doubles 6 months
3x
1yr
4x
2-2 yrs
2. Height- increase by 1/mo during 1st 6 months
- average increase in ht - 1st year = 50%
stoppage of ht coincide with eruption of wisdom tooth.
Development- increase skills or capability to function
- qualitative
How to measure development
1. Observe child doing specific task.
2. Role description of childs progress
3. DDST- Denver development screening test.
MMDST (Phil) Metro Manila Developmental Screening Test.
DDST measures mental
4 main rated categories of DDST
1. Language communication
2. personal social-interaction
3. fine motor adaptive- ability to use hand movement
4. gross motor skills- large body movement
maturation- same with development readiness
Cognitive development ability to learn and understand from experience
to acquire and retain knowledge. To respond to a new situation and to solve
problems.
IQ test- test to determine cognitive development
Mental age
x 100 = IQ
Chronological age
Average IQ 90-100
Gifted child- > 130 IQ

Basic Divisions of Life

I. Prenatal stage from conception- birth
II.
Period of infancy
1. Neonatal- 1st 28 days or 1st 4 weeks of life
2. Formal infancy- 29 day 1 year
III.
Early childhood
1. Toddler 1-3 yrs
2. Pre school 4-6 years
IV.
Middle childhood
1. School age- 7 12 yrs
V.
Late childhood
1. Pre adolescent 11 13 yrs
2. Adolescent 12 - 18 21
Principles of G & D
1. G&D is a continuous process
-begins form conception- ends in death
- womb to tomb principles
2. not all parts of the body grow at the same time or at same rate.
- asynchronism
Patterns of G&D
1. )renal
digestive
circulatory
musculoskeletal

grows rapidly during childhood

2. )Neuromuscular tissue (CNS, brain, S. cord)

- grow rapidly 1-2 years of life
- brain achieved its adult proportion by 5 years.
3. )Lymphatic system- lymph nodes, spleen grows rapidly- infancy and
childhood to provide protection -infection
- tonsil adult proportion by 5 years
4. )Repro organ- grows rapidly at puberty
Rates of G&D
1. fetal and infancy most rapid G&D
2. adolescent- rapid G&D
3. toddler- slow G period
4. Toddler and preschool- alternating rapid and slow
5. school age- slower growth
fetal and infancy- prone to develop anemia

3. Each child is unique

2 primary factors affecting G&D
A. Heredity R race
I intelligence
S sex
N - nationality
Females are born less in weight than males by 1 oz.
Females are born less in length than males by 1 inch
B. Environment
Q quality of nutrition
S socio eco. status
H health
O ordinal pos in family
P parent child relationship
Eldest- skillful in language and social skills
Younger- toilet trained self
4.G&D occurs in a regular direction reflecting a definitive and predictable
patterns or trends.
Directional trends- occur in a regular direction reflecting the development
of neuromuscular function. These apply to physical, mental, social and
emotional development and includes.
a. cephalo-caudal head to tail
- occurs along bodies long axis in which control over head, mouth and
eye movements and precedes control over upper body torso and
legs.
b. proximo- distal Centro distal
- progressing form center of body to extremities.
c. Symmetrical- at side of body develop on same direction at same time
at same rate.
d. Mass specific differentiation
- child learns form simple operations before complex function of move
from a broad general pattern of behavior. To a bore refined pattern.
B. Sequential- involves a predictable sequence of G&D to which the child
no9rmally passes.
a. locomotion- creep than crawls, sit then stand.
b. socio and language skills- solitary games, parallel games
C. Secular- worldwide trend of maturing earlier and growing larger as
compared to succeeding generations.
5.Behavioral in the most compressive indicator of developmental status.
6. universal language of child- play

7. great deal of skill and behavior is learned by practice. Practice makes

perfect.
9. neonatal reflexes us must be lost before one can proceed.
-plantar reflex should disappear before baby can walk
-moro reflex should disappear before baby can roll
persistent primitive infantile reflexes- case of cerebral palsy
Theories of G&D
Developmental tasks- different form chronological age
-skill or growth responsibility arising at a particular time in the individuals
life.
The successful achievement of which will ------- a foundation for the
accomplishments of future tasks.
Theorists
1. Sigmund Freud 1856-1939 Austrian neurologists. Founder of
psychoanalysis
- offered personality development
Psychosexual theory
a.) Oral Phase 0-18 months
- mouths site of gratification
-activity of infant- biting, sucking crying.
-why do babies suck?- enjoyment and release of tension.
-provide oral stimulation even if baby was placed on NPO.
-pacifier.
-never discourage thumb sucking.
b.) ANAL- 18 months-3 years
-site of gratification- anus
-activity- elimination, retention or defecation of feces make take place
- principle of holding on or letting go.
-mother wins or child wins
-child wins- stubborn, hardheaded anti social. (anak pupu na, child holds
pupu, child wins)
-mother wins- obedient, kind, perfectionist, meticulous
OC-anal phase
-help child achieve bowel and bladder control even if child is hospitalized.
c.) Phallic- 3-6 years
site of gratification
-genitals
activity- may show exhibitionism
-increase knowledge of a sexes
-accept child fondling his/her own genitalia as normal exploration
-answer Childs question directly.
Right age to introduce sexuality preschool
d.) Latent- 7-12 years
-period of suppression- no obvious development.
-Childs libido or energy is diverted to more concrete type of thinking

-helps child achieve (+) experience so ready to face conflict of adolescence

e.) Genital- 12-18 years
-site of gratification
-genitals
-achieve sexual maturity
-learns to establish relationships with opposite sex.
-give an opportunity to relate to opposite sex.
ERIC ERICKSON- psychoanalysis theory
- stresses important of culture and society to the development of ones
personality
- environment
- culture
stages of psychosocial
a.) trust vs mistrust 0-18 months.
-foundations of all psychosocial task
-to give and receive is the psychosocial theme
-know to develop trust baby
1. satisfy needs on time
- breastfeed
2. care must be consistent and adequate
-both parents- 1st 1 year of life
3.) give an experience that will add to security- touch, eye to eye contact,
soft music.
b.) Autonomy vs shame and doubt 18-3 years --- independence /self
govt
develop autonomy on toddler
1. give an opportunity of decision making like offer choices.
2. encourage to make decision rather then judge.
3. set limits
c. initiative vs guilt- 4-6 years
-learns how to do basic things
-let explore new places and events
-activity recommended- modeling clay, finger painting will
enhance imagination and creativity and facilitate fine motor devt
d. industry vs inferiority 7-12 yrs
-child learns how to do things well
-give short assignments and projects
e. Identity vs role confusion or diffusion 12-18 yrs
- learns who he/she is or what kind of person he/ she will become
by adjusting to new body image and seeking emancipation form
parents
-freedom form parents.

f. Intimacy vs isolation 20-40 yrs -looking for a lifetime partner and

career focus
g. generatively vs stagnation 40- 60
45-65 yrs
h. ego integrity vs, despair 60-65

JEAN PIAGET- Swiss psychologists

-develop reasoning power
STAGES OF COGNITIVE DEVELOPMENT
A-Sensory motor 0-2 yrs
-practical intelligence- words and symbols not yet available baby
communicates through senses and reflexes.
(sub div.)
Schema
1.) neonate reflex
2.) primary circular

Age
1 month
1-4
months

3.) secondary circular

reaction

4-8
months

Coordination of secondary
reaction

8-12
months

Tertiary circular reaction

12-18
months

Invention of new means there 18-24

mental combination
months

Behavior
All reflexes
-Activity related to body
-repetition of behavior
ex. thumb sucking
-activity not related to body
-discover obj and persons
permanence
-memory traces present
-anticipate familiar events.
-exhibit goal directed behavior
-increase of separateness (will
search of lost toy, knows mom)
-use trial and error to discover
places and events
- invention of new means
-capable of space and time
perception
(hits fork, spoon on table or drops
fork)
-transitional phase to the pre
operational thought period.

Preoperational thought 2-7 years

Schema
Preconcept
ual

age
2-4
yrs

Behavior
-thinking basically complete literal and static
-egocentric- unable to view others interrupt
-concept of dying is only now
-concept of distance is only as fat as they can see.
-concept of amenism inanimate object is alive
-not aware of concept of r3eversibility- in every action

Initiative

4-7
yrs

theories an opposite reaction or cause and effect

Beginning of causation

Concrete Operational thought 7-12 years

1. able to find solution to everyday problems which systematic reasoning.
2. have concept of reversibility- cause and effect
3. have concept of longer uation constancy despite of transformation.
4. 4. activity recommended- collecting and classifying
5. stamps stationeries, dolls, rubber band markers.
Formal Operational thought 12 and up.
1. Cognition achieved its final form
2. can deal with past present and future
3. have abstract and mature thoughts.
4. can find solutions to hypothetical problems with scientific reasoning.
5. activity ------- will sort out opinions and current events.
KOHLBERG- recognized the theory of moral devt as considered to closely
approximate cognitive stages of devt
-sabay with cognitive dev;t
Stages of Moral devt
Infancy premoral, prereligious, amoral stage
AGE
Preconventional
2-3 yrs

STAGE DESCRIPTION
Level 1

4-7

Conventional
7-10

Level
3

10-12

Postconventional

Level
III

-Punishment/ obedience oriented

(heteronymous morality) child does right
cause a parent tells him or her to and to avoid
punishment
-Individualism. Instrumental purpose and
exch. Carries out action to satisfy own needs
rather than society.
-Will do something for another if that person
does something for the child.
-Orientation to interpersonal relations of
mutuality. Child followers rules cause of a
need to be a good person in own eyes and
eyes of others.
-Maintenance of social order fixed rules and
authority. Child finds ff. rules satisfying.
Follows rules of authority figures.

Above 12 yrs

5
6

-Social contract, utilitarian level making

perspectives. Followers standards of society.
Universal ethical principle orientation. Follows
internalized standards of conduct.

E. DEVT MILESTONES-major markers of growth and devt

1. Period of infancy- universal language of child-play
a.) Play- Infancy- solitary plays
-solo, mom interactive
-facilitate motor and sensory devt
-safety- important age appropriate
solitary play- mobile, teeter, music box, rattle
b.) fear of infancy- stranger anxiety begin 6-7 months peak 8 months
diminishes 9 months
1 month- dance reflex disappears looks at mobile
2 months- holds head up when in prone,
social smile,
baby coos doing sound
cry with tears
-closure of frontal fontanel 2-3 months
head lag when pulled to sitting position.
3 months- holds head and chest up when prone
follows obj. past midline
grasp and tonic neck reflex fading
hand regard (looks at hand)
4 months turns form front to back
head control complete
needs space to turn
Laugh aloud, bubbling sounds
5 months- turn both ways roll over
-teething rings
-handles rattle well
-moro reflex disappears ( 4-5 months)
6 months- reaches out in anticipatory of being picked up
-sits with support
-uses palmar grasp
-eruption of 1st temp teeth 6-8 months 2 lower incisors
-say vowel sounds ah, oh
-handles bottle well
7 months- transfer obj. hand to hand
-likes obj that are good size
8 months- sits without support

-peak of stranger anxiety

-planters reflex disappears 8-9 months in prep for walking
9 months - creeps or crawls
-neat finger grasp reflex
- combine 2 syllables mama and papa
- needs space for creeping
10 months pull self to stand
-understands no
-responds to own name
-peak a boo, pat a cake
-can clap
11 months- cruisse
- stands with assistance
12 months- stand alone take 1st step
-walk with assistance
-drink from cup, cooperate in dressing
-says 2 words mama and dada
-pots and pans, pull tay, nursery rhymes
Toddler- parallel play- 2 toddlers playing separately
-provide with similar toys
-squeaky frog to squeeze
waddling duck to pull
trucks to push-push pull toy
building blocks, pounding peg
toys to ride on
fear- separation anxiety
begin 9 months
peak 18 months
3 phases of separation anxiety (in order)
1. P- protect
2. d despair
3. d- denial
-dont prolong goodbye
-say goodbye firmly to develop trust- say when ul be back

15 months plateau stage

walks alone
lateness in walking- mild mental retardation

-puts small pellets into small bowl

-holds spoon well
- seats self on chair
-creeps up stairs
- 4 - 6 words
18 months- height of possessiveness
favorite word- mine
bowel control achieved (bowel 1st before bladder)
-no longer rotates spoon
-can run and jump in place
walks up and down stairs holding railing or persons hand
-1-20 words
-name, body part
-puts both feet on 1 step before advancing.
24 months- terrible two
-can open doors by turning door knobs
-unscrew lids
-can walk upstairs alone using both feet on same step at same time
-50-200 words ( 2 words sentences)
-daytime bladder control achieved ( daytime 1st- next nighttime
bladder control)
30 months or 2 years makes simple lines or stroke for crosses with a
pencil
-can jump down from chairs
-knows full name
- copy a circle
- holds up finger to show age
- temp teeth complete
post molar- last temp teeth to appear
how many deciduous teeth -20
beginning of toothbrush 2-2 yrs
tooth brushing with little assistance 3 yrs
tooth brushing alone 6 yrs
right time to bring to dentist- when temp teeth complete
36 months or 3 yrs- trusting 3
- unbutton buttons (unbutton before learn to button)
-draw a +
- learns how to share
-knows full name and sex (gender identity)
- speaks fluently
-nighttime bladder control
-300-900 words
-ride a tricycle
Characteristic Traits of toddler

negativistic- NO! -way to search for independence

limit questions
modify questions to a statement
2.) rigid, ritualistic and stereotype
ritualism- for mastering
3.)Temper tantrums- head banging, screaming, stamping feet, holds
breath
ignore behavior
scaffoid abdominal-due to underdeveloped abdominal
muscles
physiologic anorexia- due to preoccupation with
environment- food jag that last for short period of time
loves rough and tumbling play
loves toilet trainingfailure of toilet training- unreadiness
Clues of toilet readiness:
1.) can stand, squat walk alone
2.) can communicate toilet needs
3.) can maintain dry for 2 hours
Pre schoolers- associative or cooperative play
1.) bahay-bahayan play house
2.) role playing
3.)
fear-body mutilation or castration
fear of dark places witches
fear of thunder and lightning
fear of ghosts
Milestones
4years old- furious 4 , noisy, aggressive, stormy
-can button buttons
-copy a square
-jumps and skips
-laces shoes
-vocabulary 1,500
-knows four basic colors
5 years old- frustrating 5
-copy a triangle
-draw a 6 part man
-imaginary playmates
-2,100 words
Character Traits of Pre-schooler:
1.) curious, creative imaginative, imitative
2.) 2. favorite words- why and how
3.) complexes- word identification to parent of same sex and
attachment to parent of opposite sex
ex. Oedipal complex- boy to mom

Electra complex- girl to dad

Cause of incest marital discord
Death-sleep only
Behavior problems Preschool
1.
2.
3.
4.

telling tall tales-over imagination

imaginary friend- to release tension and anxieties
sibling rivalry- jealousy to newly delivered baby.
regression- going back to early stage
-thumb sucking (should be oral stage only)
-baby talk
-bed wetting
-fetal position
5. masturbation- sign of boredom
-divert attention- offer a toy
School Age
Play- competitive play
Ex. Tug of war, track and field, basket ball
Fear. 1.) school phobia
-orient to new environment
2.) displacement from school
-teacher and peer of same sex
3. loss of privacy
-wants bra
4.) fear of death
-7-9yrs death is personified
-death- permanent loss of life
Significant Development
a. boys- prone to bone fracture
b. mature vision 20/20
6 years- temp teeth begin to fall
perm teeth appear- 1st molar
1st temp teeth- 5 months
1st perm teeth- 6 yrs
-yr of constant motion
clensy mout
recognize all shapes
-1st grade teacher becomes authority figure
-nail biting
-begin interest in God.
7 yrs- assimilation age
-copy a diamond

-enjoys teasing and playing alone

-quieting down period
8 yrs- expansive age
-smoother mouth
-loves to collect objects
-count backwards
9 yrs coordination improves
-tells time correctly
-hero worship
-stealing and lying are common
-takes care of body needs completely
-teacher finds this group difficult to handle
10 yrs- age of special talent
-writes legibly
-ready for competitive games
-more considerate and cooperative
-joins orgs.
-well mannered with adult
-critical of adults
11-12 yrs pre adolescents
-full of energy and constantly active
-secret language are common
-share with friends secrets
-sense of humor present
-social and cooperative
Character Traits School Age
1. industrious2. modest
3. cant bear to lose- will cheat
4. love collections- stamps
Signs of sexual maturity
GIRLS:
I-inc size breast and genitalia (pelarche- 1st sign sexual mat.
W- widening of hips
A- appearance axillary, pubic ( adrenarch)
M- menarche- last sign sexual mat. Girls
BOYS:
A-appearance axillary, pubic hair ( 1st sign sexual mat)
D-deepening voice
D- development of muscles
I--inc in testes and penis size
P- prod of viable sperm ( last sign sexual maturity)

Adolescent
Fear
1. obesity
2. acne
3. homosexuality
4. death
5. replacement from friends
6. significant person- opp sex.
Significant devt
1. experiences conflict bet his needs for sexual satisfaction and societies
expectation
2. change of body image and acceptance of opp/sex
3. nocturnal emission wet dreams
4. distinctive odor- due to stimulation apocrine glands
5. sperm is viable by 17 yrs
6. testes & scrotum increase until age 17
7. breast and female genitalia increase until age 18
Personality Traits Adolescents
1. idealistic
2. rebellious
3. reformers
4. conscious with body image
5. adventuresome
Problems:
1. vehicular accident
2. smoking
3. alcoholism
4. drug addiction
5. pre marital sex

IMMEDIATE CARE OF NEWBORN

1st days of life
1.
2.
3.
4.
5.
6.
7.
8.

initiation and maintenance of respiration

establishment of extra uterine circulation
control of body temp
intake of adequate nourishment
establishment of waste elimination
prevention of infection
establishment of an infant parent relationship
devt care that balances rest and stimulation or mental devt

1.) Initiation and maintenance of respiration

2nd stage of labor- initial airway
-initiation of a /w is a crucial adjustment
-most neonatal deaths with in 24 h caused by inability to initiate
a/w
-lung function begins after birth only
How to initiate a/w
a.) remove secretions bulb syringe
B. Catheter Suctioning
1.) place head to side to facilitate drainage
2,) suction mouth 1st before nose
-neonates are nasal breathers
3.) period of time
-5-10 sec suctioning, gentle and quick
prolonged and deep suctioning can lead to hypoxia, laryngo spasm,
brady cardia due to stimulation vagal nerve
4.) evaluate for patency
-cover nostril and baby struggles theres a need for additional suctioning
C. If not effective, requires effective laryngoscopy to open a/w. After deep
suctioning an endotracheal tube can be inserted and oxygen can be
administered by an (+) pressure bag and mask with 100% oxygen at
40-60b/m.
Nsg alert:
1. No smoking
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina leading to
blindness ( retro lentalfibrolasia or retinopathy of prematurity)
4. When mecomium stained (greenish) never administer oxygen with
pressure ( O2 pressure will push mecomium inside)
2.) Establishing extra uterine circulation
- circulation is initiated by lung expansion or pulmo ventilation and
completed by cutting of cord.
FETO PLACENTAL CIRCULATION
-Placenta(simple diffusion) oxygenated blood is carried by the umbilical
vein- passes liver-ductus venousus- IVC- RT atrium 70% blood is shunted to
foramen ovale- LT atrium mitral valve LT ventricle- aorta-lower extremities.
-Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for
nutrition) (vasoconstriction of lungs pushes blood to ductus arteriousus to
aorta to supply upper extremities.
SHUNTS-shortcuts

Ductus venosus- -shunts from liver to IVF

Foramen ovale- shunts bet 2 atrias
Ductus arteriosus- from pulmonary artery to aorta

Decrease PO2, increase PCO2 acidosis

Will cause 1st breath /cry of baby

Decrease pulmo artery pressure

Increase PO2

Closure of
ductus
arteriosus

Decrease blood
flow

Closure of
ductus venosus
& AVA

Increase pressure to Lt
side of heart

Closure of foramen
ovale

What will sustain 1st breath- decreased artery pressure

What will initiate lung circulation-lung expansion
What will complete circulation- cutting of cord
4.) 2 way to facilitate closure of foramen ovale
a.) Tangential Footstep- slap foot of baby
-never stimulate baby to cry if secretions not fully drained to
prevent aspiration
-check characteristic of cry
normal cry- strong, vigorous and lusty cry
cri-du-chat syndrome-chromosomal obliteration cat like cry
b.) proper position
-right side lying pos.
-will increase pressure on left and foramen ovale will close
Foramen Ovale and Ductus arteriosus will begin to close
within 24h

Obliteration-complete closure
Structure
F. Ovale

Appropriate time of
obliteration
1yr

Structure remaining

Failure to close

Fossa Ovalis

Atrial Septal
Defect
Patent ductus
arteriosus

Ductus
1 month
Ligamentum Arteriosum
Arteriosus
Ductus
2 months
Ligamentum venosum
Venosus
Umbilical
2-3 months
1.) lateral umb. Ligament
artery
2.) interior iliac artery
Umbilical
2-3 months
-ligamentum teres
vein
( round ligament of liver)
Position of infant immediately after birth:
NSD-trendelenberg/ T position for drainage
contraindication of trendelenberg position - increase ICP
CS- supine or crib level position

Signs of increased ICP

1.) abnormally large head
2.) bulging and tense fontanel
3.) increase BP and widening pulse pressure
#3 & #4 are Cushings
triad of
4.) Decreased RR, decreased PR
ICP
5.) projective vomiting- sure sign of cerebral irritation
6.) high deviation diplopia sign of ICP older child
4-6 months- normal eye deviation
>6 months- lazy eyes
7.)
High pitch shrill cry-late sign of ICP
Temp Regulation
- goal in temp regulation is to maintain it not less than 97.7% F
(36.5 C)
- maintenance of temp is crucial on preterm and SGA (small for
gestational age) - babies prone to hypothermia or cold stress
A. factors leading to devt of HYPOTHERMIA
1. preterms are born poi kilo thermic- cold blooded
- babies easily adapt to temp of environment due to immaturity of
thermo regulating system of body. Hypothalamus
2. inadequate SQ tissue
3. baby is not capable of shivering
4. babies are born wet
PROCESS OF HEAT LOSS
1.
evaporation2.
conduction3.
convection-

body to air (TSB)

body to cold solid object (cold compress)
body to cooler surrounding air (aircon)

4.
radiationbody to cold object not in contact with body
earliest sign of hypothermia- increase in RR
Effects of Hypothermia ( Cold stress)
1.) Hypoglycemia- 45-55 mg/dl normal
50- borderline
2.) met acidosis- catabolism of brown fats (best insulator of newborns
body)
will form ketones
3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy
4.) additional fatigue to allergy stressful heart
To Prevent Hypothermia
1. dry and wrap baby
2. mechanical pressure radiant warmer
i. pre-heated first isolette (or square acrylic sided incubator)
3. prevent an necessary exposure cover baby
4. cover baby with tin foil or plastic
5. embrace the baby- kangaroo care
A. Establish Adequate Nutritional Intake
CS- breastfeeding after 4 hours
NSD- breastfeeding asap
Physiology breast milk production
As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior
Posterior Gland (APG) releases prolactin acts on
acinar cells (or alveoli) produce foremilk
stored in lactiferous tubules ( or collecting
tubules)
where breast milk is produced alveoli post-pit.gland
Sucking- PPG oxytocin contraction of lactiferous tubules - milk ejection
reflex- let down reflex.
Advantages of Breastfeeding
1. Economical
2. Always available
3. Breastfed babies have higher IQ than bottle fed babies.
4. It facilitates rapid involution
5. Decrease incidence of breast cancer.
6. Has antibodies- IgA
7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria
in GIT
8. Has macrophages
Store milk- plastic storage container
Store milk good for 6 months from freezer- put rm temp. dont heat
Disadvantages:

1. Possibility of transfer HEP B, HIV, cytomegalo virus.

2. No iron
3. Father cant feed & bond as well
Stages of Breastmilk:
1. Colostrum- 2-4 days present
content: decrease fats, increase IgA, dec CHO, dec CHON, inc
minerals,
inc fat soluble minerals
2. Transitional milk- 4 14 days
content: inc lactose, inc water soluble vit., inc minerals
3. Mature milk- 14 & up
content: inc fats (linoleic acid) resp for devt of brain & integrity of
skin
inc CHO- lactose easily digested, baby not constipated.
- resp of sour milk smelling odor of stool.
Lactose intolerance- deficiency of enzyme LACTASE that digest
LACTOSE
Decrease CHON- lactalbumin
Cows milk inc fatsDec CHO
Inc CHON casing- has curd thats hard to digest.
Inc mineralstraumatic effect on kidneys of babies. Can trigger stone
formation.
Inc phosphorus
Health Teachings:
1. Proper hygiene- proper hand washing
Care of breast - cotton balls with lukewarm water
Caked colostrum- dry milk on breast
2. Best position in breastfeeding upright sitting -avoid tension!
3. Stimulate & evaluate feeding reflexes
a.) Rooting reflex- by touching the side of lips/cheeks then baby will
turn to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex
will be gone
- Purpose rooting- to look for food.
b.) Sucking when you touch middle of lips then baby will suck
- Disappears by 6 months
- When not stimulated sucking will stop.
c.) Swallowing- when food touches posterior of tongue then it will be
automatically swallowed
d.) Extrusion/ Protrusion reflex
-when food touches anterior portion of tongue then food will be
extruded.
Purpose: to prevent from poisoning
Disappear by 4 months & baby can already spit out by 4 months.
Criteria Effective Sucking

a.) Babys mouth is hiked up to areola

b.) Mom experiences after pain.
c.) Other nipple is also flowing with milk.
To prevent from crack nipples & initiate proper production of oxytocin.
- begin 2-3 min at @ breast ( 5 7 min other authors)
to initiate production of oxytocin
- increase 1 min/ day until reaching 10 mins @ breast or 20 mins/ feeding.
For proper emptying & continuous milk production / feeding
-feed baby on last breast that you feed her with, alternately ( if not emptied mastitis)
Problems experienced in Breastfeeding :
3RD day changes in breast post partum
a.)Engorged- feeling of fullness & tension in breast.
- sometimes accompanied by fever known as MILK FEVER.
Mgt: Warm compress- for breastfeeding mom
Cold compress for bottle feeding & wear supportive bra.
When is involution of breast- 4 weeks
b.) Sore nipple cracked with painful nipple
Mgt: 1.) exposure to air remove bra & wear dress, if not, expose to 20
Watt bulb
avoid wearing plastic liner bra
- will create moisture, cotton only
c.) Mastitis- inflammation of breast : staphylococcus aureus
Factors:
1. Improper breast emptying
2. Unhealthy sexual practices
-contraindicated for breast feeding
- manually express inflamed breast
feed on unaffected breast
- give antibiotics can still feed on unaffected breast
Contra Indications in Breast Feeding:
Maternal Conditions:
1. HIV
CMV
Hepa B Coumadin
Newborn Condition - Inborn errors of metabolism
Erythrobastosis Fetalis Rh incompatibility
Hydrops Fetalis
Phenylketonuria
Galactosemia
Tay Sachs disease
5. Establish of waste elimination
A. Diff stools

1. Meconium - physiologic stool

- black green, sticky, tar like, odorless (Sterile intestine)
will pass with in 24 36 hrs
failure to pass mecomium after 24h- GIT obstruction
ex. Hirschsprungs disease
imperforate anus
mecomium ileus due to Cystic Fibrosis
2. Transitional stool - green loose & shiny, like diarrhea to the untrained eye
3. Breastfed stool - golden yellow, soft, mushy with sour milk smell,
frequently passed
- recur every feeding
4. Bottlefed stool
- pale yellow, formed hard with typical offensive odor, seldom passed,
23 x/day
- with food added -brown & odorous
Jaundice baby
light stool
Under phototherapy
bright green
Mucus mixed with stool - milk allergy
Clay colored stool
obstruction to bile duct
Chalk clay stool
after barium enema
Black stool
GIT bleeding (melena)
Blood flecked stool anal fissure.
Currant jelly stool
instussusection
Ribbon like stool
hirschsprung disease
Steatorrhea stool
fatty, bulky foul smelling odor stool
- malabasorption syndrome ( celiac disease or
cystic fibrosis)
Cult blood
stool exam
III Assessment for Wellbeing
APGAR SCORE Dr. Virginia Apgar
Special Considerations: 1st 1 min determine general condition of baby
Next 5 min- determine babys capabilities to adjust
extra uterinely
Next 15 min dependent on the 5 min
A- appearance- color slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate apical pulse left lower nipple
G- grimace reflex irritability- tangential foot slap, catheter insertion
A activity degree of flexion or muscle tone
R respiration
Baby cry within 30 secs
Failure to cry after 30 secs asphyxia near the neatorum
Resp. depression due mom given Demerol. Administer Naloxone

APGAR Scoring Chart:

HR
Resp effort
Muscle tone

0
-absent
-absent
- flaccid
extremities

Reflex irritability
Catheter
- no response
Tangential
Footslap
Color

1
<100
- slow, irreg,
weak
- some flexion

2
>100
-good strong
cry
- well flexed

- grimace

- cough,
sneeze
- cry

- NR

- grimace

- blue/pale

- acrocyanosis
(body- pink
extremitiesblue)

- pinkish

APGAR result
0 3 = severely depressed, need CPR, admission NICU
4 6 = moderately depressed, needs addl suctioning & O2
7 - 10 =good/ healthy
CPR cardio pulmonary resuscitation or CPR
Cardio pulmonary cerebral resuscitation (CPCR)
5 min no O2 irreversible brain damage
1. shake, no resp, call for help
2. flat on head
3. head tilt chin lift maneuver except spinal cord injury over
extension may occlude airway
Breathing ( ventilating the lungs)
1. check for breathlessness
if breathless, give 2 breaths- ambu bag
> 1 yr old- mouth to mouth, pinch nose
< 1 yr mouth to nose
force different between baby & child
infant puff
Circulation
Check for pulslessness :carotid- adult
Brachial infants

CPR breathless/pulseless
Compression inf 1 finger breath below nipple line or 2 finger breaths or
thumb
CPR inf 1:5
Adults 2:15
Assessment tool determines respiration of baby
Silvermann Anderson Index
Respiration Evaluation lowest score best
Criteria
0
1
Chest
synchroniz Lag on
movement
ed
respiration
Intercostal
No
Just visible
retraction
retraction
Xiphoid
None
Just visible
retraction
Nares dilatation
None
Minimal
Expiratory grunt None
Heard on stet
only

2
See - saw
Marked
Marked
Marked
Heard on naked
ear

Interpretation result:
0 -3 normal, no RDS
4 6 moderate RDS
7 10 severe RDS
Assessment of Gestational Age
-Ballards & Dobowitz
Findings
Less 36 weeks
37 - 38
(Preterm)
Sole creases
Anterior transverse
Occasional
crease only
creases 2/3 in
Breast
2mm
4mm or 3.5 mm
nodules
Scalp hair
Fine & fuzzy
Fine & fuzzy
Ear lobe
Pliable
Some cartilage
Testes and
testes in lower
Some
Scrotum
canal
intermediate
Scrotum small few
rugae
Signs of Preterm Babies
Born after 20 weeks, after 37 weeks
-frog leg or laxed positon
-hypotonic muscle tone- prone resp problem
-scarf sign elbow passes midline pos.
- square window wrist 90 degree angle of wrist
- heal to ear sign-

39 and up
Covered with
creases
> 5 or 7mm
Coarse & silky
Thick cartilage
Testes pendulus
Scrotum full
extensive rugae

abundant lanugoSigns of Post term babies:

> 42 weeks
- classic sign old mans face
- desquamation peeling of skin
- long brittle finger nails
- wide & alert eyes
Neonates in Nursery
Nsg responsibility upon receiving baby- proper identification
- foot printing, affixing mother thumb print
- take anthropometic measurement
normal length- 19.5 21 inch or 47.5 53.75cm, average 50 cm
head circumference 33- 35 cm or 13 14
Hydrocephalus - >14
Chest 31 33 cm or 12 13
Abd 31 33 cm or 12 13
Bathing
- oil bath initial
- to cleanse baby & spread vernix caseosa
Fx of vernix caseosa
1. insulator
2. bacterio- static
Babies of HIV + mom immediately give full bath to lessen transmission of
HIV
- 13 39% possibly of transmission of HIV
Full bath safely given when cord fall
Dressing the Umbilical Cord strict asepsis to prevent tetanus
3 cleans in community
1. clean hand
2. clean cord
3. clean surface
betadine or povidone iodine to clean cord
check AVA, then draw 3 vessel cord
If 2 vessel cord- suspect kidney malformation
- leave about 1 of cord
- if BT or IV infusion leave 8 of cord best access - no nerve
- check cord every 15 min for 1st 6 hrs bleeding .> 30 cc of blood
bleeding of cord Omphalagia suspect hemophilia
Cord turns black on 3rd day & fall 7 10 days
Faiture to fall after 2 weeks- Umbilical granulation
Mgt: silver nitrate or catheterization

clean with normal saline solution not alcohol

dont use bigkis air
persistent moisture-urine, suspect patent uracus fistula bet bladder
and normal umbilicus
dx:
nitrazine paper test yellow urine
mgt: surgery
-

Credes Prophylaxis Dr. Crede

-prevent opthalmia neonatorum or gonorrheal conjunctivitis
- how transmitted mom with gonorrhea
drug: erythromycin ophthalmic ointment- inner to outer
silver nitrate (used before) 2 drops lower conjunctiva (not used now)
Vit-K to prevent hemorrhage R/T physiologic hypoprothrombinemia
- Aquamephyton, phytomenadione or konakion
- .5 1.5 ml IM, vastus lateral or lateral ant thigh
- 5 ml preterm baby
Vit K synthesized by normal flora of intestine
Vit K meds is synthetic due intestine is sterile
Weight:

Normal wt 3.000 3400 gms/ 3 3.4 kg / 6.5 -

7.5 lbs

Arbitrary lower limit 2500 gm

Low birth wt baby delivered < 2500g
Small for gestational age (SGA) < 10th % rank or born small
Large for gestational age > 90th % rank or macrosomia >4000 g
Appropriate for GA within 2 standard deviation of mean
Physiologic wt loss 5 10% wt loss few days after birth
Small GA < (less) 10
Large GA > (more) 90
Physical Exam and Deviations fr Normal
1. if client is new born, cover areas not being examined
2. if client is infant the 1st yr of life - get VS take RR 1st
- begin fr least intrusive to the most intrusive area
3. if client is a toddler and preschool, let them handle an instrument like:
- play syringe or stet, security blanket favorite article. Let baby hold it.
4. Explain procedure and respect their modesty - school age and
adolescent
V/S:
Temp: rectal- newborn to rule out imperforate anus
- take it once only, 1 inch insertion
Imperforate anus
1. atretic no anal opening
2. agenetic no anal opening

3. stenos has opening

4. membranous has opening
Earliest sign:
1. no mecomium
2. abd destention
3. foul odor breath
4. vomitous of fecal matter
5. can aspirate resp problem
Mgt:
Surgery with temporary colostomy
Cardiac rate: 120 160 bpm newborn
Apical pulse left lower nipple
Radial pulse normally absent. If present PDA
Femoral pulse normal present. If absent- COA - coartation of aorta
Congenital Heart Dse
Common in girls PDA, ASD atrial septal
Common in boys TOGA ( transportation of great arteries)
TA tronchus arteriosus
TOF tetralogy of fallot
Causes:
1. familial
2. exposure to rubella 1st month
3. failure of strucute to progress
acyanotic L to R
cyanotic R L
Acyanotic heart defects L to R
1. ventricular septal defect - opening between 2 ventricles
S&Sx 1. systolic murmurs at lower border of sternum and no other
significant sign
2. cardiac catheterization reveals increased o2 saturation @ R side of
heart
3. ECG reveals hypertrophy of R side of heart
Nsg Care:
Cardiac catheterization: site Rt femoral vein
1. NPO 6 hrs before procedure
2. protect site of catheterization. Avoid flexion of joints proximal to site.
3. assess for complication infection, thrombus formation check pedal
pulses
( dorsalis pedis)
Mgt.
1.) long term antibiotic to prevent subacute bacterial endocarditis

2.) open heart surgery2.) ASD failure of foramen ovale to close

S&SX
1. systolic murmur @ upper border of sternum
2. result of cardiac catheterization & ECG same with VSD
Mgt: open heart surgery
3.) endocardial cushion defects - atrium ventricular (AV) - affects both
tricuspid and mitral valve
Dx confirmed by cardiac catheterization
Mgt: - open heart surgery
Antibiotics to prevent subacute bacterial endocarditis
4.) PDA - failure of ductus arteriosus to close
- should close within 24 h -complete close 1 month
S&Sx
1. continuous machinery like murmurs
2. prominent radial pulse
3. ECG- hypertrophy Left ventricle
Drug:
1. endomethazine prostaglandin inhibitor - facilitate closing of PDA
2. ligation of PDA by 3-4 yo
3. thoracotomy procedure- nakadapa child
5.)Pulmunary Stenosis- narrowing of valve of pulmo artery
S &Sx:
1.) typical systolic ejection murmur
2. S2 sound widely split
3. ECG- Lt ventricular hypertrophy
6.)Aortic Stenosis narrowing of valve of aorta
S & Sx:
1. inactive, sx sme with angina
2. typical murmur
3. rough systolic sound and thrill
4. ECG- Left ventricular hypertrophy
cardiac catheterizationMgt Pulmo Stenosis & Aortic Stenosis
1.) balloon stenostomy
2.) surgery
Duplication of Aortic Arch- doubling of arch of aorta causing compression
to trachea and esophagus
S&Sx : 1. dysphagia 2. dyspnea
3. left ventricular hypertrophy
Mgt: - close heart surgery
8.) Coartation of Aorta narrowing of arch of aorta
outstanding Sx : absent femoral pulse
BP increased on upper extremities and decreased on lower extremities
ECG hypertrophy Lft ventricle

Mgt: close heart surgery

CYANOTIC HEART DEFECTS R to L
1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle
pulmo artery arising form Lt ventricle
Outstanding Sx:
1. cyanosis after 1st cry (due no exygenation)
2. polycythemia increased RBC =compensatory due to O2
supply=viscous blood
=thrombus = embolus = stroke
3. ECG cardiomegaly
Cardiac cath decreased O2 saturation
Palliative repair rashkind procedure
Complete repair mustard repair
2.) Total Anomalous Pulmonary
venous return pulmo vein instead of entering Lt atrium, enters Rt atrium or
SVC
Increased pressure on Rt so blood goes to Lft
Outstanding Sx: Open foramen ovale
Mild to moderate cyanosis
Polycythemia = thrombus = embolus = stroke
asplenia- absent spleen
Mgt: restructuring of heart
3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel
or common trunk with VSD
S & Sx
1. cyanosis
2. polycythemia thrombus = embolus = stroke
Mgt: Heart transplant
4.) Hypoplastic Left heart syndrome non fx Left ventricle
1. cynosis
2. polycythemia throm, emb, stroke
Mgt: heart transplant
5.) Tricuspid atresia failure of tricuspid valve to open
S&SX: open foramen ovale
(R to L shunting goes to Lt atrium)
cynosis, polycythemia
Mgt: fontan procedure open tricuspid valve
6.) Tetralogy of Fallot
P pulmonary stenosis
V ventricular SD
O overriding or dextroposition of aorta

R Rt ventricular hypertrophy
S &Sx:
1. Rt ventricular hypertrophy
2. high degree of cyanosis
3. polycythemia
4. severe dyspnea squatting position relief , inhibit venous return
facilitate lung expansion.
5. growth retardation due no O2
6. tet spell or blue spells- short episodes of hypoxia
7. syncope
8. clubbing of fingernails due to chronic tissue hypoxia
9. mental retardation due decreased O2 in brain
10.
boot shaped heart x-ray
Mgt:
1. O2
2. no valsalva maneuver , fiber diet laxative
3. morphine hypoxia
4. propranolol decrease heart spasms
5. palliative repair
BLT blalock taussig procedure
Brock procedure complete procedure
ACQUIRED HEART DSE
1. RHD Rheumatic Heart Disease
- inflammation disease ff an infection acquired by group A Beta hemolytic
strepto coccus
Affected body cardiac muscles and valves , musculoskeletal , CNS,
Integumentary
Sorethroat before RHD
Aschoff rounded nodules with nucleated cells and fibroblasts stays and
occludes mitral valve.

Jones Criteria
Major
1. polyarthritis multi joint pain
2. chorea sydenhamms chores or
st. vetaus dance-purposeless involuntary hand
and shoulder with grimace
3. carditis tachycardia
erythema marginatum - macular rashes
SQ nodules

Minor
1. arthralgia joint pain
2. low grade fever
3. all lab results
increase antibody

C reactive protein


erythrocyte
sedimentation rate

anti streptolysin
o titer (ASO)
Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat
will confirm the dx.
Nsg Care:
1. CBR
2. throat swab culture and sensitivity
3. antibiotic mgt to prevent recurrence
4. aspirin anti-inflammatory. Low grade fever dont give aspirin.
S/E of aspirin:
- Reyes syndrome encephalopathy- fatty infiltration of organs such as
liver and brain
Respiration
Newborn resp 30-60 cpm, irregular abd or diaphramatic with short period of
apnea without cyanosis.
< 15 secs normal apnea newborn
Resp Check
Newborn 40 90
1 yr - 20 40
2-3yr 20 30
5 yrs 20 25
10 yrs 17 22
15 & above 12- 20
BREATH SOUNDS HEARD DURING ASCULTATION:
1.) VESICULAR soft, low pitched, heard over periphery of lungs, inspiration
longer then expiration -Normal
2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi,
inspiration equals exp. Normal
3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration
longer than inspiration. Normal
4.) RHONCHI snoring sound made by air moving through mucus in bronchi.
Normal
5.) RALES-or crackles like cellophane made by air moving through fluid in
alveoli.
Abnormal- asthma, foreign body obstruction.
6.) WHEEZING- whistling on expiration made by air being pushed through
narrowed bronchi .Abnormal asthma, foreign body obstruction

7.) STRIDOR- crowing or ropster life sound air being pulled through a
constricted larynx. Abnormal resp obstruction
Asthma- pathognomonic sign expiratory wheezing
Pet fish. Sport swimming
Drugs amynophylline monitor bp, may lead to hypotension
Laryngo Tracheo Bronchitis LTB
- inspiratory stridor pathognomonic sign
RDS respiratory dist synd or hyaline membrane dis
Cause- lack of surfactant for lung expansion
Hypotonia, Post surgery, Common to preterm
Fibrine hyaline
Sx definite with in 1st of life
Increase RR with retraction
Inspiratory grunting pathognomonic
7 10 severe RDS (silvermenn Anderson index)
cyanosis due to atelectasis
Mgt:
1. surfactant replacement and rescue
2. pos- head elevated
3. proper suctioning
4. o2 with increase humidity- to prevent drying of mucosa
5. monitor V/S skin color , ABG
6. CPAP- continuous + a/w pressure
7. PEEP - + end expiratory pressure
Purpose of #6-7- to maintain alveoli partially open and alveoli collapse
LARYNGOTRACHEOBRONCHITIS
LTB most common Creup -viral infection of larynx, trachea & bronchi
outstanding sx croupy cough or barking
pathognomonic stridor
- labored resp
- resp acidosis
- end stage death
Lab:
1. ABG
2. neck and throat culture
3. dx- neck x-ray to rule out epiglotitis
Nsg Mgt:
1. bronchodilators
2.increase o2 with humidity
3. prepair tracheostomy set
BRONCHOLITIS- Inflammation of bronchioles tenatious mucus
Causative agaent RSV - Resp sincytial viruses

Sx:

flu like sx
Increased RR
Drug: Antiviral Ribavirin
End stage epiglotitis
EPIGLOTITIS - infl of epiglottis
- emer. Condition of URTI
Sx: sudden onset
Tripod position leaning forward with tongue protrusion
- never use tongue depressor
prepare tracheotomy set
< 5 yo unable to cough out, put on mist tent (humidifier o2) or croupe tie
Nsg Care: check edges tucked on mist tent
Provide washable plastic material
No toys with friction due O2 on
No hairy toys due moist environment medium for bacterial
growth
BP 80/46 mmHg newborn
BP after 10 days- 100/50
BP taking begins by 3 yo
COA take BP on 4 extremities
SKIN:
Acrocyanosis
BIRTHMARKS:
1. Mongolian spots stale gray or bluish discoloration patches commonly
seen across the sacrum or buttocks due to accumulation of
melanocytes. Disappear by 1 yr old
2. MIlla plugged or unopened sebaceous gland . white pin point patches
on nose, chin or cheek.
3. Lanugo fine, downy hair common preterm
4. Desquamation peeling of newborn, extreme dryness that begin sole
and palm.
5. Stork bites (Talengeictasi nevi) pink patches nape of neck
hair will grow as child grows old
6. Erythema Toxicum (flea bite rash)- 1st self limiting rash appear
sporadically & unpredictably as to time & place.
7. Harlequin sign dependent part is pink, independent part is blue
(side lying bottom part is dependent pink)
8. Cutis Marmorato transitory mottling of neonates skin when exposed
to cold.
9. Hemangiomas vascular tumors of the skin
3 types Hemangiomas
a.) Nevus Flammeus port wine stain macular purple or dark red lesions
seen on face or thigh. NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas nevus vasculosus dilated capillaries in the
entire dermal or subdermal area. Enlarges, disappears at 10 yo.

c.) Cavernous hemangiomas communication network of venules in SQ

tissue that never disappear with age. - MOST DANGERIOUS intestinal
hemorrhage
Skin color
blue cyanosis or hypoxia
White edema
Grey inf
Yellow jaundice , carotene
Vernix Caseosa white cheese like for lubrication, insulator
BURN TRAUMA injury to body tissue caused by excessive heat.

Head
Neck
Upper
arm
Lower
arm
Hand
Trunk
Back
Genital
@
buttocks
Thigh
Leg
foot

INFANT
ANTERIO POSTERIOR
R
9.5
9.5
1
1
2
2

5-9 yo
Ant
Post
6.5
1
2

6.5
1
2

1.5

1.5

1.5

1.5

13

1.25

1.25

1.2
5

2.75
2.5
1.75

13
13
1
2.5
@
4
3
1.75

13
13
1
2.5@
2.75
2.5
1.75

4
3
1.7
5

DEPTH
1st degree
partial thickness superficial epidermis - erythema,
dryness, PAIN
-sunburn, heals by regeneration from 1 10 days
nd
2 degree
epidermis & dermis- erythema, blisters, moist, extremely
painful
scalds
3rd degree
full thickness- epidermis, dermis, adipose tissue, fascia,
muscle & bone
lethargy, white or black, not painful nerve endings destroyed
ex. lava burns
Mgt:
1.) 1st aid

a.) put out flames by rolling child on blanket

b.) immerse burned part on cold H2o
c.) remove burned clothing of with sterile material

d.) cover burn with sterile dressing

2.) a/w
a.) suction PRN, o2 with increased humidity
b.) endotracheal intubation
c.) tracheostomy
3.) Preventiuon of shock & F&E imbalance
a. colloids to expand bld volume
b. isotonic saline to replace electrolytes
c. dextrose & H2o to provide calories
4.) Tetanus toxoid booster
5.) Relief of pain IV analgesic MORPHINE SO4 needed for 2nd degree very
painful
6.) 1st defense of body intact skin
prevention of wound infection
a.) cleaning & debriding of wound
b.) open or close method of wound care
c.) whirlpool therapy drum with solution
7.) skin grafting 3rd degree thigh or buttocks (autograft), pigs/ animals
xenograft
frozen cadaver hallow graft
8,) diet increase CHON, increase calories.
ATOPIC DERMATITIS- infantile eczema (galis)
Papulo vesicular erythematus lesions with weeping & crusting
Cause
food allergies: milk, citrus juice, eggs, tomatoes, wheat
Sx: extreme pruritus, linear excoriation, weeping crusting; scaly
shiny and white lechenification
Goal of care: decrease pruritus avoid food allergens
Diet: Prosobi or Isomil
Hydrate skin, borow solution 1% hydrocortisone cream
Prevent infection proper handwahsing, trim nails
IMPETIGO- skin disease.
Causative agent grp A beta Hemolytic streptococcus
- papulovesicular surrounded by localized erythema becomes purulent ,
oozes a honey colored crust
Pediculosiscapitis KUTO
- Mgt: proper hygiene wash soap and H2o, oral penicillin bactroban
ointment
Can lead to acute glomerulonephritis AGN
ACNE- adolescent problem
- self limiting infl dis sebaceous gland comedones sebum causing
white heads
- sebum- lipids causing acne bulgaris
Mgt: -proper hygiene- mild soap or sulfur soap- antibacterial retin A or
tretinoi

ANEMIA-pallor
Causes:
1.)early cutting of cord preterm cut umb cord ASAP
fullterm cut umb cord when pulsation stops
2.) Bleeding disorders blood dyscrasias
HEMOPHILIA deficiency of clotting factor. X linked recessive inherited
If mom carrier, son affected
If father carrier- transmitted to daughter
Hemophilia A deficiency of coagulation component factor 8
Hemophilia B or christmas disease, deficiency of clotting factor 9
Hemophilia C deficiency of clotting factor 11
Assessment:
- umphalagia earliest sign
- newborn receive maternal clotting factor
- newborn growing sudden bruising on bump area- marks earliest sign
- continuous bleeding hematrosis damage or bleeding synovial
membrane
Dx test :
PTT. Partial thromboplastin time reveals deficiency in clotting factor
Long Term Goal- prevention of injury
Nsg Dxincrease risk of injury
HT: avoid contact sport, swimming only, dont stop immunization just
change gauge of needle
Falls immobilized , elevate affected part, apply pressure-not more then 10
min
cold compress
-determine case before doing invasive procedure
LEUKEMIA- grp of malignant disease
- rapid proliferation of immature WBC
- WBC protection from infection, soldiers of body
Classification :
1. Lympho affects lymphatic system
2. Myelo affects bone marrow
3. acute / blastic- affects immature cells
4. chronic/ cystic- affects mature cells
MOST COMMON CANCER (ALL) Acute Lymphocytic Leukemia
S&Sx:
1. from invasion of bone marrow
signs of infection
a.) fever
b.) poor wound healing
c.) bone weakness & causes fracture

signs of bleeding
a.) petecchiae-small, round, flat, dark red spot
b.) epistaxis
c.) blood in urine/ emesis
signs of anemia
a.) pallor , body malaise , constipation
2. from invasion of body organ- hepato spenomegaly abd pain ,
CNS affectation, increase ICP
Dx Tests:
1. PBS- peripheral blood smear determine immature RBC
2. CBC determine anemia, leukocytosis, thrombocytopenia neutropenia
3. lumbar puncture (LP) determine CNS involvement. Before LP, fetal
pos.- avoid flexion of neck will cause a/w obstruction.C position or
shrimp position only.
4. bone marrow aspiration determine blast cells,
- common site- iliac crest
- post BMA s/effect bleeding
- apply pressure. Put pt on affected side to prevent hemorrhage
5. Bone scan determine bone involvement
6. CT scan determine organ involvement
Therapeutic Mgt:
TRIAD:
1. surgery
2. irradiation
3. chemotheraphy
Focus Nsg Care: prevent infection
4 LEVELS OF CHEMOTHERAPHY
1. induction goal of tx; to achieve remission
meds: IV vincristine
L- agpariginase
Oral predinisone
2. Sanctuary- treat leukemic cells that invaded testes & CNS
give: methotrixate- adm intrathecally via CNS or spine
cytocine, Arabinoside, steroids with irradiation
3. maintenance- to continue remission
give: oral methotrisate check WBC
-adm of methotrisate do weekly WBC check
4. Reinductin treat leukemic cells after relapse occurs. Meds same as
induction
- give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic
nephropathy.
Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement.
Based on Maslows heirarchy

S/Effect of Chemotherapy
1. N/V adm antiemetic drugs 30 mins before chemo until 1 day after
chemo
2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less
body req)
- oral care alcohol free mouthwash , betadine mouthwash
- dont brush use cotton pledgets
- topical xylocaine before meals
diet- soft, bland diet according to childs preference
Temporary S/E of chemo:
Alopecia altered body image
Hirsutism hair
-give emotional support to parents
ABO incompatibility
Most common incompatibility ( mom) O ( fetus) A
Most severe incompatibility
(Mom) O (Fetus) B
st
Can affect 1 pregnancy
Hydrops (h20) Fetalis edematous on lethal state with pathologic jaundice
Within 24 h
Mgt:
1. initiate breastfeeding to get colostrum
2. Temp suspension of breastfeeding
- content breast milk pregnanedioles that delays action of glucoronil
transferees
liver enzymes converts in direct bilirubin to become direct bilirubin
3. Needs phototherapy
4. needs exchange therapy
Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term
Normal 0-3 mg/dL
- bilirubin encephalopathy
- Kemicterus - > 20 mg/dL among full term &
>12 mg /dl of indirect preterm
=can lead to cerebral palsyPhysiologic jaundice jaundice within 48 -72 h (2-3 days) expose morning
sunlight
Pathologic Jaundice within 24h. Jaundice during delivery.
Breastfeeding jaundice caused by pregnanediole
Assessment of Jaudice :
1. Blanching neonates forehead, nose or sternum
- yellow skin & sclera
- color of stool light stool

- color of urine dark urine

Mgt: Phototheraphy photo oxygenation
Nsg Resp:
1. cover eyes prevent retinal damage
2. cover genitals prevent priapism painful continuous erection
3. change position regularly even exposed to light
4. increase fld intake due prone to dehydration
5. monitor I&O weigh baby
6. monitor V/S avoid use of oil or lotion due- heat at phototherapy
= bronze baby syndrome-transient S/E of phototherapy
weigh diaper 1gm = 1cc
Head largest part of baby
of its length
Craniostenosis or craniosinustosis premature closing of fontanel
Hydrocephalus ant fontanel open after 18 mos
Microcephaly small growing brain due- alcohol & HIV mom
Anencepahly absence of cerebral hemisphere
Craniotabes localized softening cranial bone. Common 1st born child
-due early lightening (2 weeks prior to EDD)
Rickets of Vit B deficiency soft cranial bone in older children
Caput Succedaneum edema of scalp due prolonged pressure at birth
Char:
1. present at birth
2. crosses suture lines
3. disappear after 2-3 days
Cephalhematoma- collection of blood due to rapture of pericostal
capillaries
Char :
1. present after 24 h
2. never cross suture line
3. disappear after 4-6 weeks
4. monitor for developing jaundice
Seborrheic Dermatitis craddle cap
Scaling, greasy appearing salmon colored patches seen on scalp
behind ears and umbilicus
Cause: - improper hygiene
Mgt:
1. proper hygiene
2. put oil night before shampoo
- baby oil
Hydrocephalus excessive accumulation of CSF
1. communicating extra ventricular hydrocephalus

2. non-communicating- intraventricular hydrocephalus or obstructive

hydrocephalus
due to tumor obstruction
Sx ICP abnormally large head, bulging fontanel
- cushings triad
- high pitched cry
older child diplopia eye deviation, projectile vomiting
- fontanel bossing prominent forehead
- - prominent skull vein
- sunset eyes
Mgt:
position to lessen ICP low semi-fowlers 30 degree angle
Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam
Decrease CSF production
Shunting AV shunt or Vp shunt (ventriculoperitoneal shunt)
Shave hair in OR to prevent growth of micro org.
Nsg Care:
1.) post VP shunt side lying on non operated site - to prevent increase
ICP
monitor for good drainage - sign sunken fontanel
bulging fontanel blocked shunt
change fontanel as child is growing
SENSES
EYES: Assessment
1. check for symmetry
2. sclera normal color light blue then become dirty white
pupil round- adult size
coloboma- part of iris is missing
sign: key hole pupil
whiteness & opacity of lens congenital cataract
cornea round & adult size
large congenital glaucoma
Test for blindness
common tests
1. newborn general appearance
- can only see 10 12
- visual acuity 20 /200 to 20/ 800
Dolls eyes test- test for blindness
- done 10th day
- pupil goes opposite to direction when head is moved
Globellars test test for blink reflex. Points near nose baby should blink
2. Infant & children
- appearance
- ability to follow object past midline
3. 3 yrs school age
- general appearance

Allen cards test for visual acuity. Show picture 20 ft away

Ishiharas plates test for color blindness
Prechool E chart - test for stereopsi of depth perception
Cover testing test cover 1 eye for 10 15 min. Then remove. Test for
strabismus
4. School age adult
- general appearance
- snellens test
Retinobastoma malignant tumor of retina
Outstanding sign : Cats eye reflex-whitish glow of pupil
- red painful eye
- blindness
surgery Enucliation removal of eyeball put artificial aye
NOSE:
1. flaring alenase case of RDS
2. cyanosis at rest choanal atresia - post nares obstructed with bone or
membrane
Sx:
1. resistance during catheter insertion
2. emer. Surgery within 24 h
normal color nasal membrane pinkish
rhinitis presence of creases & pale
check sense of smell blindfold smell
Hair in nose cilia
Adolescent no hair with ulceration of nasal mucosa suspect cocaine user
Epistasis nosebleed
- sit upright, head slightly forward to facilitate drainage
- cold compress , apply gentle pressure, epinephrine
most developed sense of newborn sense of touch
1st sense to develop & last to disappear hearing
EARS:
1. Properly aligned with outer cantus of eyes
low set ear kidney malformation
ex. Renal aginesis absence of kidney
sign in uterus : oligohydramnios
sign in newborn: 2 vessel cord
failure to void within 24 h
Mgt: kidney transplant
Chromosomal aberrations : -advance maternal age

1. non disjunction uneven division

Trisomy 21 - down syndrome - extra chromosome
47xx + 21 - related to advance paternal age
Sx:
Mongolian slant
Broad flat nose
Protruding neck
Puppys neck
Hypotonic prone to resp problem
Simean crease single transverse line on palm.
Trisomy 18
endvard syndrome
Trisomy 13patau syndrome
Turner
Monosomy of X synd.
- 45x0
- affected girls
- signs evident during puberty
- has poorly developed 2dary sexual char.
- Sterile
Klinefelters Syndrome- has male genitalia - 47 XXY
- poorly devt secpndary sexual characteristics
- no deepening of voice
-small testes, penis -sterile
Klinefelter Calvin Kline male
Turner Tina Turner female
Otitis Media inflammation of middle ear. Common children due to wider &
shorter Eustachian tube
Causes
1.) bottle propping
2.) Cleft lip/ cleft palate
Sx: Otitis
1. bulging tympanic membrane, color pearly gray
2. absence light reflex
3. observe for passage of milky, purulent foul smelling odor discharge
4. observe for URTI
Nsg Care:
1. position side lying on affected aside to facilitate drainage
2. supportive care- bedrest, increase fld intake
Med Mgt:
1. Massive dosage antibiotic
Complication bacterial meningitis
2. Apply ear ointment
School age up and down
< 3 yo down & back

> 3 yo up & back

Small child down & back ( no age)
surgery (to prevent permanent hearing loss) otitis media myringotmy with
tympanostomy tube
post surgery position affected side for drainage
both put ear plug
if tympanous tube falls healed na
Bells Palsy- facial nerve #7 paralysis R/T forcep delivery
Sx.
1. Continuous drooling saliva
2. inability to open , eye & close either eye
Mgt:
Refer to PT
TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and
stomach
Outstanding Sx Coughing
Choking
Continuous drooling
Cyanosis
Mgt:
Emergency surgery
Epstein pearl white glistering cyst at palate & gums related to
hypercalcemia
Hypervitaminosis
Natal tooth tooth at birth. Move with gauze
Neonatal tooth tooth within 28days of life
Moniliasis oral candidiasis
- white cheese like, curd like patches that coats tongue
- oral thrush
- Nsg Care dont remove, wash with cold boiled H2o
Meds nystatin / Mysnastatin antifungal
Kawasaki Dse--strawberry tongue - originated in Korea
- Dr. Kawasaki discovered it
- common in Japan
- mucocutaneous Lymphnode Syndrome
Sx:
-persistent fever 5 days
-strawberry tongue ,
-desquamation of palm & sole
- lymph adenopathy > 1.5 cm
Drug: aspirin
Can lead to MI

LIPS- symmetrical
Cleft lip failure of median maxillary nasal process to fuse by 5-8 wks of
pregnancy
- common to boys
- unilateral
Cleft Palate- Failed palate to fuse by 9 12 wks of pregnancy
- common to girls
- unilateral or bilateral
Sx:
1. evident at birth
2. milk escapes to nostril during feeding
3. frequent colic & otitis media or URTI
Mgt:
1. Surgery
cleft lip repair Cheiloplasty =done 1-3 months to save sucking reflex (lost in
6 months )
Cleft Palate- uranoplasty = done 4-6 months to save speech
Pre op care
1. emotional support especially to mom
2. proper nutrition
3. prevent colic
feed upright seating or prone pos
burp frequently 2x at middle and after feeding-lower to upper tap
4. orient parents to type of feeding
rubber tipped syringe cheiloplasty
paper cup/ soup spoon/ plastic cup urano plasty
5. apply restraints elbow restraints
so baby can adjust post op
Condition that warrants suspension of operation
- colds & pharyngitis = can lead to generalized infection septicemia
Post Op Nsg Care :
1. airway positon post cheilopasty side lying for drainage
post uranoplasty (tonsillectomy)- prone
2. assess for RDS sx bleeding
3. assess for bleeding freq swallowing. 6-7 days after surgery
bleeding
4. proper nutrition
- clear liquids- ( gelatin except red or brown color due may mask
bleeding)
- ( popsicle- not ice cream)
full liquid
soft diet
regular diet
5. Maintain integrity of suture line such as:

Logan bar wash strength Hydrogen Peroxide & saline solution- Bubbling
effect
traps microorganism
- prevent baby form crying
for pain- analgesic
NECK1.) check symmetry
Congenital torticolis- wryneck-burn injury of sternocleidomsstoid muscle
during
delivery due to excessive traction at cephalic delivery
Mgt: passive stretching exercise , Surgery
Complication scoliosis
THYROID gland for basal metabolism
Congenial cretinism absence or non functioning thyroid glands
reasons for delaying dx:
1. Thyroid glands covered by sternocleidomastoid muscles in newborn
2. baby received maternal thyroxine
3. baby sleeps 16 20 h a day
earliest sign:
1. change in crying
2. change in sucking
3. sleep excessively
4. constipation
5. edema moon face
late sign
1. mental retardation
prognosis : mental retardation preventable when Dx is early
Dx:
1. PPI-protein
2. radioimmunoassay test
3. radioactive iodine uptake
Mgt: synthroid sodium Levothyrosine -synthetic thyroid given lifetime
- check pulse rate before giving synthroid
- tachycardia Sx of hyperthyroidism
CHEST
1. symmetry
2. breast - transparent fluid coming out from newborn related to
hormonal changes3. chest has retroactive RDS
4. sternum sunken pectus excavation
ABDOMEN (in order)
1. inspection I

2. Auscultation A
3. percussion
P
4. Palpation
P = Will change bowel sounds, so do last
Normal contour of abd slightly protruding
Sunken abd- diaphramatic hernia protrusion of stomach content through
a defective diaphragm due to failure of puroperitoneal canal to close.
Sx:
1. sunken abd
2. Sx of RDS
3. R to L shunting
Mgt:
Emergency surgery within 24h
Omphalocele protrusion of stomach contents in between junction of abd
wall and
umbilicus.
Mgt- very small surgery
If large suspension surgery
Nsg Mgt: protect sac- sterile wet dressing
Gastrochisis absence of abd wall
Nsg Mgt: sterile wet dressing
Fx of GIT
1. assists in maintaining F&E & acid base balance
2. Processes & absorbs nutrients to maintain metabolism & support G & D
3. excrete waste products from digestive process
Recommended Daily Allowance
Calories : 120 cal / Kbw/day (kilo body wt)
360 380 cal/ day
CHON_ 2.2g /Kbw/day
Principles in Supplementary Feeding
Supplementary Feeding usually 6 mos
Supplementary feeding given 4 mos.
a.) solid food offered to ff sequence!
1. cereals rich in iron
2. fruits
3. veg
4. meat
b.) begin with small quantities
c,) finger foods offered 6 months
d.) soft table food modified family menu given 1 yr
e.) dilute fruit juices 6 mos
f.) never give half cooked eggs usually causes of salmoneliosis

g.) dont give honey infant botulism

h.) offered new food one at a time interval of 4 7days or 1 week
determines food allergens
Total Body Fluids- comprises 65 - 85% of body wt of infants &
children
Where fluids are greater in infants
Extracellular fld prone to develop dehydration
Acid Base Balance dependent on the ff:
a. chemical buffers
b. renal & resp system involvement
c. dilution of strong acids and bases in bld
Resp Acidosis carbonic acid excess
- hypoventilation
- RDS
- COPD
- Laryngotracheobronchitis (LTB)
Resp Alkalosis carbonic acid deficit
- hyperventilation
- fever
- encephalopathy
Met. Acidosis base HCO3 deficit
- diarrhea
- severe dehydration
- malnutrition
- ciliac crisis
Met Alkalosis base HCO3 excess
- uncontrolled vomiting
- NGT aspiration
- Gastric lavage
PROBLEMS LEADIING TO F&E IMBALANCE
1. vomiting forceful expulsion of stomach content
Sx:
1. nausea
2. dizziness
3. facial flushing
4. abd cramping
assess:

amt, freq, force

projectile vomiting= increase ICP or pyloric stenosis

Mgt:

BRAT diet - banana, rice cereal, apple sauce, toast

2. Diarrhea exaggerated excretion of intestinal contents

Types:
Acute diarrhea related to gastroenteritis, salmoneliosis
- dietary indiscretions

antibiotic use

Chronic non specific diarrhea

Cause:
1. food intolerance
2. excessive fld intake
3. CHO, CHON malabsorption
Assess: freq, consistency, appearance of given colored stool.
Best criteria to determine diarrhea : consistency
Complication = dehydration
Mild dehydration 5% wt loss
Moderate dehydration 10% wt loss
Severe dehydration 15 % wt loss
Earliest sx of dehydration
tachycardia
increase temp
tachypnea sunken fontanel & eyeballs
hypotension
absence of tears

weight loss
scanty urine

Severe dehydration:
Oliguria , Prolonged capillary refill time
Mgt:
Acute NPO ( rest the bowel )
- with fluid replacement IV
- prone to Hypokalemia give K chloride
before adm of K chloride check if baby can void, if cant void
hypokalemia
Drug: Na HCO3 adm slowly to prevent cardiac overload
Gastric Motility Disorder:
HIRSCHPRUNGS DISEASE congenital aganglionic megacolon
Aganglionic absence of ganglion cells needed for peristalis
Earliest sign
1. failure to pass mecomium after 24h
2. abd distension
3. vomitus of fecal material
early childhood ribbon like stool
foul smelling stool
constipations
diarrhea
Dx:
1. Barium enema reveals narrowed portion of bowel
2. Rectal Biopsy reveals absence of ganglionic cells
3. abd x-ray reveals dilated loops on intestine
4. rectal manometry revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care

1. NGT feeding measure tube fr nose to ear to midline of xyphoid &
umbilicus
2. surgery
a.) temp colostomy
b.) anastomosis & pull through procedure
Diet:
Increase CHON, increase calories , decrease residue pasta
GER- Gastroesophageal Reflux
Chalasia presence of stomach contents to esophagus
Will lead to esophagitis complication aspiration pneumonia
Esophageal cancer
Assessment :
1. chronic vomiting
2. faiture to thrive syndrome
3. organic organ affected
4. melena or hematemesis esophageal bleeding
Dx procedure
1. barium esophogram reveals reflux
2. esophageal manometry reveals lower esophageal sphincter pressure
3. intra esophageal pH content reveals pH of distal esophagus.
Meds of GERD
Anti-cholinergic
a.) Betanicol ( urecholine) increase esophageal tone & peristaltic activity
b.) Metachloporomide (Reglam) decrease esophageal pressure by
relaxing pyloric & duodenal segments
- increase peristalsis without stimulating secretions
c.) H2 Histamine Receptor Antagonist decrease gastric acidity & pepsin
secretion
- Zimetidine, Ranitidine (Zantac) take 30 min before meals
d.) antacid neutralizes gastric acid between feedings - Maalox
Surgery: Nissen funduplication :
Chronic vomiting
- thickened feeding with baby cereals - effective if without vomiting
- feed slowly, burp often every 1 ounce
- positioning
< 9 months infant sit with infant supine
> 9 months prone with head of mattress slightly elevated 30
degree angle
OBSTRUCTIVE DISORDERS
A.
PYLORIC STENOSIS hypertrophy of muscles of pylorus causing
narrowing &
obstruction.
1.) outstanding Sx- projectile vomiting
- vomiting is an initial sx of upper GI obstruction

- vomitus of upper GI can be blood tinged not bile streaked. (with blood)
- vomitus of lower GI is bilous ( with pupu)
- projectile vomiting increase ICP or GI obstruction
- abd distension major sx of lower GIT obst
2.) met alk
3.) failure to gain wt
4.) olive shaped mass on palpation
5.)serum electrolyte increase Na & K, decrease chloride
6.) ultrasound
7.) x ray of upper abd with barium swallow reveal string sign
Mgt:
1. Pyleromyotomy
2. Fredet Ramstedt procedure
INSTUSSUSCEPTION- invagination or telescoping of position of bowel to
another
Common site ilio-secal junction
Prone pt: person who eats fat
Complication peritonitis emergency
Sx:
1.) persistent paroxysmal abd pain
2.) vomiting
3.) currant jelly stool- dye bleeding & inflammation
- palpate sausage shaped mass
Mgt:
1.) Hydrostatic reduction with barium enema
2.) Anastomosis & pull thru procedura
Inborn Errors of Metabolism- deficient liver enzymes
PHENYLKETONURIA (PKU) deficiency of liver enzymes (PHT)
Phenylalaninehydroxylase Transferase liver enzyme that converts CHON to
amino acid
9 amino acids:
valine
isolensine tryptophase
lysine
phenylalanine
Thyronine decrease malanine production
1.) fair complexion
2.) blond hair
3.) blue eyes
Thyroxine decrease basal metabolism
- accumulation of Phenyl Pyruvic acid
4.) Atopic dermatitis
5.) musty / mousy odor urine
6.) seizure mental retardation

Test GUTHRIE TEST specimen blood

- preparation increase CHON intake
- test if CHON will convert to amino acid
specimen and urine
mixed with pheric chloride, presence of green spots at diaper a sign of PKU
DIET:
Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes,
cheese, peanuts
Give Lofenalac- milk with synthetic protein
Galactosemia deficiency of liver enzyme
- GUPT Galactose Urovil Phosphatetranferase
- Converts galactose to phosphate tranferace glucose
Galactose will destroy brain cells if untreated death within 3 days
Dx:
Beutler test get blood -done after 1st feeding
presence of glucose in blood sign of galactosemia
galactose free diet lifetime
neutramigen milk formula
CELIAC DISEASE gluten enteropathy
Common gluten food:
Intolerance to food with brow
B- barley
R- rye
O- oat
W- wheat

Early
Gluten glutamine ( normal absorption)
Gliadin ( toxic to epithelial cells of
villi of intestines, effects is
malabsorption syndrome)

Malabsorption

Fats

CHON & CHO

peripheral edema &
malnutrition

Vit D calcium

Vit K

Iron folic acid

Inadequate
blood

coagulation
Steatorrhea

Osteomalasia

Bleedin

anemia

gg

Sx:
1. diarrhea failure to gain wt ff diarrheal episodes
2. constipation
3. vomiting
Late Sx:
1. abd pain protruberant abd even if with muscle wasting
2. steatorrhea
Celiac Crisis- exaggerated vomiting with bowel inflammation
Dx:
1. lab studies stool analysis
2. serum antiglyadin confirmatory of disease
gluten free diet lifetime
all BROW not allowed
ok rice & corn
Mgt:
1. vitamin supplements
2. mineral supplements
3. steroids
POISONING- common in toddlers. (falls- common to infant)
1. determine substance taken, assess LOC
2. unless poison is corrosive, caustic (strong alkali such as lye) or a
hydrocarbon, vomiting is the most effective way to remove poison.
- Give syrup 1 pecac to induce vomiting

3.
4.
5.
6.
7.

1 pecac oral emetic

15 ml adolescent, school age & pre school
10 ml to infant
UNIVERSAL ANTIDOTE- charcoal, milk of magnesia & burned toast
Never adm charcoal before 1 pecac
antidote for acetaminophen poisoning acetylsysterine ( mucomyst)
caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar .
Dont vomit prepare tracheostomy set
8. Gas- mineral oil will coat intestine
Lead poisoning
Lead = Destroy RBC functioning = Hypochornic Microcytic Anemia = Destroy
kidney functioning
Accumulation of anemia = Encepalopathy
Sx:
1. beginning sx of lethargy
2. impulsiveness, learning difficulties
3. as lead increases, severe encepalopathy with seizure and permanent
mental retardation
Dx:
1.
2.
3.
Mgt:
1.
2.

Blood smear
abd x ray
long bones
remove child from source
if > 20 ug/dL need chelation therapy = binds with led & excreted by
kidney
=nephrotoxic

Amogenital
Female:
Pseudomenstration slight bleeding on vagina related to hormonal changes
Tearing of fourchette with blood rape/ child abuse
Rape- Report within 48 h
Shape pubic hair in inverted triangle ( female)
Male:
Undescended testes cyrptorchidism -common to preterm
surgery orchidopexy
assess scrotum- warm room & hands
baby pee within 24 h
-check for arch of urination
Epispadias- urinary meatus located dorsal or above glans penis
Hypospadias- urinary meauts loc ventral or below glans penis
Hypospadias with chordee- fibrous band causing penis to curb downward

Mgt:
Surgery
Phimosis- tight foreskin
Balanitis-infection of glands penis due smegma
Mgt:
Circusicion
Hydroseal fld filled scrotum
Tst of Dx:
Transillumination with use of flashlight - glowing sign
Varicoseal enlarged vein of epididimis ( girls- vulvular varicosities)
Renal
Disorder
NEPHROTIC
SYNDROME

AGN ( acute
Glomerulo
Nephritis)
3As;
AGN,
autoimmune
,
Grp A

Cause
infectious

Autoimmune
Grp A beta
hemolytic
streptococcu
s

Sx
1. Anasarcagen edema
2. massive
protenuria
3. microscopic
or no
hematuria
4. serum CHON
decreased
5. serum lipid
increased
6. fatigue
7. normal or
decreased BP
1. (PPP) primary
peripheral
periobital
edema
2. moderate
protenuria
3. gross
hematuria
( smokey
urine)
4. serum K
increased
5. fatigue
6. increase BP
Complication :

Tx

NSG CARE

Prednisone Focus of care:

Diuretic
monitor edema
- weigh
daily
Diet:
Increase CHON
Increase K- OJ,
beef broth,
banana
Decrease Na

1. anti
HPN drug
hydralazin
e or
apresoline
2. iron

1. weigh daily
2. monitor BP
& neurologiuc
status
3. Diet:
decrease K,
decrease Na

1. hypersensive
encephalopat
hy
2. anemia
BACK- check for flatness & symmetry
Open Neural Tube Defect- decreased Folic Acid intake
SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to fuse
Sx: dimpling of back , Abnormal tufts of hair
SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac
Types:
1. Meningocele protrusion of CSF & Meninges
2. Myelomeningocele protrusion of CSF & Meninges & spinal
cord ( most dangerous)
3. Encephalocele ( CNS complication hydrocephalus) cranial
meningocele or myelomeningocele
Most common problem
- rupture of sac
- prone pos
- sterile wet dressing
Most common complication - infection
Myelomeningocele genitourinary complication- urinary & fecal
incontinence
Nsg care: always check diaper
Orthopedic complication paralysis of lower extremities
Surgery to prevent infection
Post op prone position
SCOLIOSIS- lateral curvature of the spine
2 types:
1. structural rye neck
2. postural improper posture
Dx:
1. uneven hemline
2. bend forward- 1 hip higher
1 shoulder blade more prominent
Nsg care:
1. conservative avoid obesity, exercise
2. preventive Milwaukee brace - worn 23 h a day
3. corrective surgery insert Harrington rod
post op- how to move
log rolling- move client as 1 unit
EXTREMITIES:

check # of digits = 20
1. syndactyly webbing of digits
2. polydactyly extra digits
3. olidactyly lack of digits
4. Amelia total absence of digits
5. pocoamelia- absence of distal part of extremities
ErQ duchennes paralysis- brachial plexus injury or brachial palsy
- birth injury caused by lateral & excessive traction during a breech
injury
Sx:
1. unable to abduct arms from shoulders, rotate arm externally or
supinate forearm
2. absence or asymetrical moro reflex
Mgt:
1. abduct arm from shoulders with elbow flex.
CONGENITAL HIP DISLOCATION head of femur is outside acetabulum
Types;
1. subluxated most common type
2. dislocated
Sx:
1. shortening of affected leg
2. asymmetrical gluteal fold
3. limited movement earliest sx
4. (+) ortolanis sign abnormal clicking sound
5. when able to walk child limps late sx- trendelenburg sign
Goal of Mgt:
Facilitate abduction
Mgt.
1. triple diaper
2. carry baby astride
3. Frejka splint
4. Pavlik harness
5. Hip Spica Cast
TALIPES clubfoot
a.) Equinos plantar flexion horsefoot
b.) Calcaneous dorsiflexion heal lower that foot anterior posterior of
foot flexed towards anterior leg
c.) Varus- foot turns in
d.) Valgus- foot turns out
Equino varus- most common
Assessment:
1. Straighten legs & flexing them at midline pos
Mgt:
1. Corrective shoe- Dennis brown shoe, spica cast

Fx: of cast
to immobilize
- bone alignment
- prevent muscle spasm
lead pencil mark area to be amputated
cold H20 hasten setting process
hot H20- slow setting process
After cast application how to move pt:
- use open palm not fingers- fingers will cause indention
- dry cast natural air not blower
- priority check : neurovascular check
C- circulation
M- motion S- sensation
Cast with bleeding
- mask with ball pen edge of blood to know if bleeding is on going
sign cast is dry = resonant sound, cast cold to touch
do petaline making rough surface of cast smooth
CRUTCHES
Fx:
To maintain balance
- To support weakened leg
Principles in crutches
- wt of body on palm!
- Brachial pulsing if wt of body in axila
- Do palm exercise- squeeze ball
Different crutch Gaits:
1. Swing Through
2. Swing to
- no weight bearing are allowed into lower ext
3. Three point Gait
- wt bearing is allowed in 1 ext
4. Four point gait
5. Two point Gait
- wt bearing allowed in 2 lower ext

PSYCHIATRIC NURSING
Royal Pentagon Rvw Ctr
Mr. Mike Jimenez
BeliefsFeelingsBehavior
Sigmund Freud Father of Psychoanalysis
-structure of personality
Idimpulsive part, pleasure principle
-eat, urinate, have sex
-its all I
Superego small voice of God
-conscience
-should not eat yet, should not eat yet
Ego- arbiter, decision maker
-in touch with reality
Id___________________Superego
EGO

ID DOMINANT needs a superego-needs a conscience

M- manic
A- antisocial serial killer
N- narcissistic
SUPEREGO DOMINANT needs an Id
O- Obsessive Compulsive
A- Anorexia nervosa
EGO impaired reality perception (RN will present reality)
S- schizophrenia- cant distinguish fact from reality
Libido- sexual energy
FREUD - PSYCHOSEXUAL THEORY
ORAL 0-18 months
Cry, suck mouth- survival
Id dominant
Maternal deprivation if not feed, not given milk/water, not kept warm.
Narcissistic seeks the Id I love myself
Regression return to an earlier stage or earlier level
Fixation stopped in a stage
ANAL- 18 mos-3yrs
Toilet training
Mom is superego.
Superego is being formed
Child is caught in ambivalence pulled in 2 opposing factors
Too much toilet training with punishment will result to a child who is:

Obedient, organized, clean

= OC
=anal retentive

Rebel, dirty, disobedient

=Anti-social
=anal expulsive

PHALLIC 3-6 yrs old

-penis & vagina
-love of parent of opposite sex
Oedipal-boy loves mom
Electra-girl loves dad
Identification- boy imitates dad
Castration fears- fear that dad is angry at him and will cut off penis
Penis envy- girls envy little boys

Dr. Karen Horney- detractor of Freud, didnt believe in penis envy. Freud said that it is
maybe in her unconscious mind.
Or repressed.
Conscious- highest level of awareness
Pre-conscious- at tip of tongue
Unconscious forgotten
Repression-kept in unconscious. Unconscious forgotten.
Suppression conscious forgetting
LATENT- 6-12 years old
Latent- Logtu = sexual energy asleep
School age School phobia- 1st time to go to school Separation anxiety
Child is busy with Reading, writing, arithmetic.
Sublimation putting anger into something more productive
putting all energies into schooling
Ex. Angry at life, pour anger in singing.
GENITAL 12 years old
Genital-Gising sexual energy
Sexual intercourse most important in this stage!!
PHARMA MOMENTS
Anti-anxiety Drugs (used also for alcohol withdrawal)
Valium
Librium
Ativan
Serax
Miltown
Equanil
Vistaril
Atarax
Buspar

Tranxene
Inderal

ERIK ERIKSON
STAGE
(+)
(-)
0-18 months (Oral)Trust vs
Mistrust
18 mos- 3yrs old (Anal)
Autonomy vs
Shame/doubt
Au-(anal)
To-ilet training
No-No! Favorite word.
My
3-6 yrs old (Phallic)Initiative vs
Guilt anger
(Initiate 1st steps) turned inward
Phallic-oedipal,electra
6-12 yrs old (Latent)
Industry vs
Inferiority
12-20
20-25
25-45
45 up

(Genital) Identity vs
Intimacy vs
Generativity vs
Ego Integrity vs

Newly admitted pt- develop trust 1st

-pts are dependent=self care deficit
-develop/teach autonomy
-then pt will develop initiative

Role confusion
Isolation
Stagnation
Despair

FACTOR
Feeding
Toilet training

Independence
Industry
Induskul
Peers
Love
Parenting
Reflection

-etc
Frontal lobe- personality, learning, judgment, language
Occipital- vision
Temporal- hearing, smell
Parietal-taste, touch
Sensory Integration Motor
Somatic nervous system- voluntary movements
Acetylcholine- responsible for voluntary movements
- on switch of movement
Autonomic nervous system- involuntary movements
-Sympathetic(Anti cholinergic) and parasympathetic (cholinergic)
Heart
Respiratory
GI (opposite effect)
GU (opposite effect)
Neurotransmitter
Pupils
Blood vessels
BP

SYMPATHETIC (alert)
PARASYMPATHETIC (relax)
tachycardia
bradycardia
tachypnea
bradypnea
Slow, constipation
diarrhea
Slow, oliguria, retention
Polyuria, frequency
Dry mouth
Moist mouth
Epinephrine, Norepinephrine
Acetylcholine (AcH)
Dilated (dilat when alert) Constricted (Myotic)
(Midriasis)
vasoconstriction
vasodilated
increased
decreased

Anti-cholinergic / anti-parasympathetic =effect is sympathetic!

Sympathetic drug classifications:
Aanxiety
P- psychotic
Anti Ccholinergic
D- depressants
MONO AMINE OXIDASE INHIBITORS:
mARplan
nARdil
pARnate
DEFENSE MECHANISMS:

coping mechanism from stress:

DISPLACEMENT- -------------Your boss shouts at you, you shout at your subordinate.

SUBLIMATION - ---------------putting anger into something more productive or +
putting all energies into schooling
Ex. Angry at life, pour anger in singing.

DENIAL----------------------I am not an alcoholic!

DISSOCIATION --------------psychological flight from self. Amnesia. Ex. Rape, trauma
REGRESSION ----------------RETURN to an earlier developmental stage
FIXATION ---------------------stuck in a stage of development
REPRESSION -----------------unconscious forgetting
SUPPRESSION ---------------conscious forgetting. Avoidance. I dont want to talk about
it. I dont want to remember it.
RATIONALIZATION -------uses because. Has illogical reasoning. I drink because I
dont want to waste the beer in the ref.
REACTION FORMATION----plastic. Doing opposite of intention.
UNDOING- ----------------------show true feeling/color then feels guilty after.
IDENTIFICATION -----------models a certain behavior from a certain role model.
PROJECTION -----------------blame other people, pass load to others. Looks for a
scapegoat. Not me, but them.
INTROJECTION --------------assume another persons trait as your own. Not just you,
me too. Ako din, gusto ko yan.
CONVERSION
repression. Anger turned inward to herself. Converted to
physical symptoms.
Sensory-numbness. Motor-paralyzed, tremors.
COMPENSATION
-----------defects of the person, overachieve to cover a
defective part.
SUBSTITUTION -----------when you replace a difficult role with a more accessible one.
Ex.Wants to go to Disneyland but cant afford it. Went to Enchanted
Kingdom instead.
Defense mechanism:
Harm to self or others

Affects/interferes with ADL

Behavior Model Ivan Pavlov

Classical Conditioning -behavior learned-repeated (+)
BF Skinner operant conditioning-reinforcement
Confront (-) behavior to make it extinct.
MASLOWS HEIRARCHY OF NEEDS:
5.
4.
3.
2.
1.

Self-actualization
Self-esteem
Love and belonging
Safety and security
Air, food, water, shelter, clothing, sex Basic physiologic needs

LEVELS OF PREVENTION
PRIMARY
SECONDARY
TERTIARY
Healthy
ill
Relapse avoidance
Community teaching
Crisis intervention
Rehab centers
Community demographics
Treatment and diagnosisAl anon

STAGES OF INTERACTION
ORIENTATION
WORKING
Assessment
Problem solving
Establishment of trust Discussion
Tell patient about
Patient is most
termination
cooperative
Set contract
Patient is resistant

TERMINATION
Evaluation
Summarize
Say goodbye
Grief-ANGER-focus of
RN
Pt might become
violent/suicidal

ANTI-PARKINSON DRUGS (Capables) used with antipsychotics

Anti-cholinergic
ABC

Dopaminergic
PLSE

C- Cogentin
A- Artane
P- Parlodel
A- Akineton
B- Benadryl
L- Larodopa
E-Eldepryl
S- Symmetrel
THERAPEUTIC COMMUNICATION
1. Offer selfIll
stay/sit with you.
2. Explores use what, when,
where, how
3. Silence
4. Active listening-nodding, eye
contact, leaning
forward-show active
participation.
5. Make observations. You see/ I
have observed/
I have noticed
6. Broad opening- How are you?
You have combed your hair
today.
7. Clarification-What do you
mean by
ploopplank?

NON- THERAPEUTIC
Dont worry, be happy.
Why? Puts pt in defensive
position.
Change the subject.
Everythings going to be alright.
giving
False reassurance.
Ignore the patient.
Prejudicial. Nice weather today.
value based judgment.
Flattery dont use too much
adjectives. You have the most
beautiful hair in the ward.

8. Restating-I dont want to eat.

(Word per word repetition!)
You dont want to eat?
9. General leads- And then/What
else/Go on
10. Refocusing-We were talking
abt the exam
11. Focusing-Tell me more abt
this.

Arguing with the patient

Dont impose your opinion.

ABG ANALYSIS
Ph & PCO2-Respiratory-opposite signs
Ph & HC02-Metabolic same signs
Compensation: Ph is normal=Fully compensated.
C02 & HC03 same signs = Partially compensated
ANXIETY
-vague sense of impending doom. Sympathetic activation.
Assessment: Level of anxiety
MILD-------------------sit restlessly, widened perceptual field, enhanced
learning experience. You seem anxious.
MODERATE----------patient is pacing, selective inattention. Give PRN medsAnti-anxiety drugs-valium
SEVERE----------------patient cant make decisions. I dont know what to do or say. RN
directs patient. Sit down on the
PANIChighest level of anxiety. Suicidal. Priority: safety. Stay with patient.
Dont touch pt. Sympathetic activation.
I think Im having a heart attack!
Nrs Dx: -----------------Ineffective Individual Coping
P/I: Decrease anxiety, decrease stimuli
HT: relaxation technique
E: Effective Individual Coping
GENERALIZED ANXIETY DISORDER 6 months excessive worrying. Patient knows
what the problem is.
Cant sleep, concentrate, seat
Fatigue and palpitations
PANIC ATTACK ------------------------------15-30 minutes, happens without warning. SNS
activation.
-with or without agoraphobia -------------------- fear of open space
-social phobia ------------------------------------- fear of public
-provide safety
-alkalosis-brown bag

-stay with patient

-be directive
POST TRAUMATIC STRESS DISORDER
Victims rape, accident, war zone, disaster, trauma
1. Survivor
2. Flashback > 1 month
3. Memory nightmares
MALINGERING------------------------------------- no organic basis (no tissue change)
-pretending to be sick, conscious
-decrease anxiety for primary gain
-increase attention from RN secondary gain
SOMATOFORM DISORDER ------------------unconscious, not pretending, no organic
basis
- goes doctor hopping

Nervous system
DYSMORPHIC DISORDER
CONVERSION
structural defect
-loss of sensory/motor fx
real
-s/sx real (biglang nabulag)

Minor discomfort

BODY

-Feels like illness

-illusion of

-HYPOCHONDRIASIS

-S/sx not

PSYCHOSOMATIC DISORDER (Psychophysiologic) real illness, real s/sx, real pain,

with organic basis (with change in tissue)
- stress ulcers, migraine, HPN
PHOBIA---------------------------------------------------------- irrational fear
Etiology knowledge, experience
Immediate nsg intervention: Remove object of fear
(Increase stimuli=increase level of anxiety)
(Decrease stimuli=decrease anxiety)
Belief
Feeling
Object will hurt patient Scared

Behavior
Avoidant=interferes with ADL

Gradual exposure to feared object- SYSTEMATIC DESENSYTHEZATION

Individual Therapy
1. Hypnosis --------------relaxed state

2.
3.
4.
5.

Free association ------ ideas shared to psychoanalyst

Catharsis --------------free to express feeling
Transterence- -----------patient feels something for psychoanalyst
Countertransterence --RN feels something for patient

Green light-Go Epi & Norepinephrine

Red light Stop G-gamma
A-amino
B-butyric
A- acid
Anxiety
Increase

GABA

Anti-cholinergic S/E
GI-constipation
GU-retention

Anti-

Effect of GABA:
Drowsy, drink,
hypotension
anxiety drug

dont drive, orthostatic

Withdrawal from drug abrupt REBOUND PHENOMENA leads to seizures. 1 week

effect.
Gradual withdrawal tapered dose
Dependence- Cant live without valium
ANTI-PSYCHOTIC AGENTS Sympathetic effect.
Effect 2-4 weeks
STELAZINE
SERENTIL
THORAZINE
TRILAFON

CLOZARIL
MELLARIL
HALDOL
PROLIXIN

SCHIZOPHRENIA-------------------------------impaired reality perception. Ego

disintegration. Genetic vulnerability. Stress.
-Chose fantasy over reality. Increase dopamine
theory. Cause: unknown.
Increase dopamine, increase schizophrenia.
4 As:
1. Affect---------------------------------------------feelings & emotions (smiles, laughs).
External, readily observable.
Mood, internal, does not match affect. (sad
inside)
2. Ambivalence-------------------------------------pulled between 2 opposing forces

3. Autism --------------------------------------------self absorbed. Trapped in his own

world.Attached to odd objects.Poor eye contact.
4. Associative looseness---------------------------talk about so many things but
unrelated ideas.
Disturbed thought process-------------------------Nsg dx
Content of thought---------------Hallucinations/Illusions------------ADL---------------------------Harm
Disturbed thought process
Disturbed sensory
Perception

Self care deficit

Self
Directed Violence

Other

P/I: Reality/Orient/Safety
Eval: Improved thought process
S & Sx of Schizophrenia:
(-)neg sx
(+) positive sx
hypoactive
hyperactive
flight of ideas
withdrawn
restless
hallucinations
quiet, flat affect
talkative
delusions many ideas
poverty of words
queen of the
world
illusions
Types of schizophrenia:
1. Disorganized schizo---------------------------------sad inside, happy outside
inappropriate affect (+)
flat affect no affect (-)
disorganized manner/speech flight of ideas (+)
Hebephrenic- giggling (+)
Sx: both (+) and (-).
2. Catatonic ---------------------------------------------ambivalence anal stage (-)
No! Negativisim-rebel-anal (-)
Waxy flexibility--------------raise arm of patient. Patients arm
remains up for a long time. (-)
(-) > (+)
3. Paranoid ----------------------------------------------uses projection.
Mistrust
Scared/withdrawn/violent
Based on history

Develop trust: orientation

Leave door open
-1:1 interaction
length

-Distance from pt: 1 arms

-consistent approach
window
-short/frequent interaction
visibility:stand halfway in & out
-food: sealed container
reinforcement.
-meds: wrapped in tamper resistant foil
and firm

-stay near door not

-have
to be able to call for
-calm

4. Unclassified/ Undifferentiated-----------------------cant be classified anymore.

5. Residual-------------------------------------------------no more (+), (-). Social withdrawal
THOUGHT PROCESS DISTURBANCE
1. LOOSENESS OF ASSOCIATION----------------topics have connection but no thought.
I am going to the mall. The mall is in
town. The town flies. Flies are here.
2. FLIGHT OF IDEAS ---------------------------------New unrelated topics. I am going to
the mall. Where is the light? I treasure this
chalk. Hurray!
3. AMBIVALENCE-------------------------------------Pulled by 2 opposing forces.
4. MAGICAL THINKING----------------------------- believes he has magical powers. I can
turn you into a frog.
5. ECHOLALIA------------------------------------------repeat what is said. Parrots.
6. ECHOPRAXIA----------------------------------------repeats what you do. Repeats what is
seen.
7. WORD SALAD----------------------------------------mixes words that dont rhyme.
8. CLANG ASSOCIATION----------------------------uses words that rhyme. Flank, blank,
prank.
9. NEOLOGISM------------------------------------------invents new words not in the
dictionary. Ploopplank, pisnok.
10. DELUSIONS-----------------------------------------false belief
Grandeur--------------I am a queen/ king/millionaire!
Persecution------------NBI out to get me!
Ideas of reference-----They talk and write about me!
11. CONCRETE ASSOCIATION-----------------------pilosopo. What will you wear
tomorrow? Clothes!
12.
HALLUCINATIONS----------------------ILLUSIONS (with stimuli)
Stimuli
N
Y
Visual
N
Y
Auditory
N
Y
Tactile
N
Y
Present reality!!!

D-Directive. Lets go in the garden.

Acknowledge: I know the voices are real to you. Present reality. But I cant hear
them.

=Assess what voices are saying to know if patient will harm himself.
Increase Dopamine = increase schizo
Decrease dopamine = decrease schizo
Extra Pyramidal Side Effects (EPSE) (Happens when acetylcholine is up and
dopamine is down)
1. AKATHISIA-------------------------- restless, inability to sit still.
2. AKINISIA ---------------------------- rigidity
3. DYSTONIA--------------------------- affects neck
TORTICOLLIS -------------wry neck
OCULOGYRIC CRISIS fixed stare
OPISTHOTONUS ---------arched back, contracted
4. TARDIVE DYSKINESIA------------lip smacking, tongue is protruding,
puffy cheeks. Irreversible!
5. NEUROLEPTIC MALIGNANT SYNDROME- hyperthermia, unstable
BP, increase CPK, diaphoresis, pallor
-discontinue meds, medical emergency.
6. PHOTOSENSITIVITY------------------wear shades, sunscreen
7. WBC- Agranulocytosis---------------sore throat, fever, malaise,
leukopenia
AUTISM- boys > girls. 1:100 kids gift-autistic savants
-echolalis, poor eye contact, cant express verbally.
Assess:
A- appearance- neat, OC, wants constancy
B- behavior- ritualistic behavior, flat affect, repetitive
C- communication difficulty communicating
Nsg Dx:

P/I:
E:

Impaired social interaction cant form IPR (Interpersonal relationship)

Impaired verbal communication
Self mutilation cant express anger. Express it inward.
Risk for injury

constancy, promote safety

Expressive therapy uses art, music, poetry, decreasing risk for injury,
improved social interaction, be able to express feelings.
-Safety

ADHD- ATTENTION DEFICIT HYPERACTIVITY DISORDER (can progress to

conduct disorder to anti-social behavior)
Cant focus on anything.
Onset 7 yrs old and below
Duration >6 months
Setting: House & school
ID dominant: Mom or RN will act as superego
Assessment:

A- appearance: dirty
B- behavior: clumsy, impatient, easily distracted
C- talkative
Nsg Dx: High risk for injury
Safety
Structure- provide place to study, eat, play,bath,etc.
Schedule time for everything
Set limits
Residual ADHD grows up not anti-social
Meds: Ritalin, Dexedrine,Pemoline, Adderal
Best time to give meds: If once a day give AFTER MEALS- to prevent loss of
appetite.
Dont give at bedtime-its a stimulant-will cause insomia. Can be
given 6hours before bedtime (if q2d)

ANOREXIA NERVOSA diet, underweight < 85% of expected fat, 3 months

amenorrhea, failure to recognize problem.
BULIMIA NERVOSA induce vomiting, takes laxative, normal weight, irregular
menstruation, dental carries, diarrhea
- knows problem but ashamed and embarrassed,
Priority:

Fluid volume balance

Weight gain monitor weight, eating pattern, stay 1 hour after eating,
accompany in toilet
Problem:
NI:

Body image Disturbance

1. Establish nutrition pattern
2. Teach stress management, journal keeping
3. Monitor eating pattern and weight.
4. Anti-depressant
MANIA needs mood stabilizing agents- Lithium. Group therapy
L- 0.5-1.5 mEq/L
(If level is near 2.5-3 mEq/L will cause ataxia and mental
confusion)
I- increase urination
T- tremors
H- H20- 3L/d
I- increase
T- uu
M- mouth dry
N- Na- 135-145 mEq/L to hold water
Check kidney(blood level) before administration of Lithium BUN, CREA,
electrolyte

Lithium toxicity n/v, diarrhea = Diamox

BIPOLAR DISORDER 2 poles, happy (more dominant) & sad
-female, >20 yrs old, stress, obese
Self actualization
Task to decrease self esteem
Family therapy
Risk for injury, risk for other directed violence
Decrease eat, decreased sleep, hyperactive, increase sex masturbate in front of
others
Nsg Dx:

High risk for self or other directed violence

Risk for injury

Give task, no group games, any competition will increase anxiety, water the plants,
activities using gross motor skills, escorted walk, punching bag-displacement.
3 or more signs confirms disorder:
G grandiose, increase risk activities
F flt of ideas
S - sleeplessness
P pressured speech
E exaggerated SE
E extraneous stimuli (easily distracted)
D distractability
PERSONALITY DISORDER
1.
Schizoid --------doesnt care about people, believes that he can stand on his
own, never had a best friend
avoid groups & activities no enjoyment
cares more about computers, pets
2.
Avoidant ----------avoid group fear criticism, have talent but no
confidence.
3.
Anti-social ------as child steal, lie, always get reprimanded
Adult grand robbery, illegal activities against the law.
drug addiction, drives fast, unsafe sex, thrill seeker.
Good talker, charmer, witty, manipulator. Motto I will break the
law
4.
Borderline -------Favorite line life is an empty glass. Splitting, suicidal,
superficial relationship, labile-sudden change of
Mood, self mutilation.
(+)
(-)
fill glass with friends
suicide
have happy moments
LABILE AFFECT
sad
moment
labile- change from good to bad in a split moment

5.

Dependent ---------Decrease self esteem, dependent

Poor decision making skills
I cant live if living is without you

6.

Histrionics ----------excited, dramatic, manipulative

- CENTER OR ATTENTION
7.
Narcissistic----------I love myself insensitive, arrogant, self
absorbed
- exaggerated Self esteem, ambitious I am the best
8.
OC ------------------ perfectionist, organized, constancy in environment.
Provide time to do rituals.
9.

Paranoid ----------- always jealous, suspicious, violent

10.

Passive aggressive ------always say yes, but resistance is hidden.

Nsg Intervention: Improve IPR, build trust

A-LCOHOL ABUSE ----------------------happy socializing

oversode-give Narcan
-escape from problem
Methadone
-peer pressure
Antabuse

Narcotic
Narcotic detoxAversion therapy-

B-blackout ---------------- awake but unaware

C-confabulation ---------- invent stories to increase Self-Esteem
D-denial ------------------- I am at not an alcoholic.
D-dependence ------------ I cant live without alcohol.
a. physical tremors, tachycardia, restless
b. psychological craving
E-enabling/codependency (significant others tolerate abusers)
DISULFIRAM
voids alcohol
version therapy
ntabuse (DISULFIRAM)
lcoholics anonymous

beer
n/v
hypotension
interval of alcohol &

antabuse:
12h interval after alcohol intake
B1 Thiamine
Complications

wernickes

Encephalopathy
Korsakoff psychosis
Wernickes VROOM Motor sx effect
Korsakoff memory- confabulation
24 72h after alcohol intake
Delirium tremors happens due SNS activation
Tremors, hallucinations, illusions. Well lit room to avoid
hallucinations
ANTI DEPRESSANTS decrease serotonin problem
Anti depressants full stomach
All meds take on a full stomach, except anti anxiety.
ASENDIN TCA
NORPRAMIN
TOFRANIL
SINEQUAN
ANAPRANIL
AVENTYL TCA
VIVACTIL TCA
ELAVIL
PROZAC
PAXIL
ZOLOFF
LUVOX

TCA
TCA
TCA
TCA - OC
TCA
SSRI
SSRI
SSRI
SSRI

Serotonin ---------makes us happy

Decrease serotonin pt becomes sad depression
Increase serotonin antidepressant
SSRI:
Selective
Serotonin
Reuptake
Inhibitors

S
S (decrease S/E)
R
I (1 4 weeks)

If SSRI dont work, give TCA

Tri Cyclic Antidepressants ( TCA)
----------2 4 wks has increased
S/E
increased Serotonin & Norephinephrine
MAOI-------------------------- effect 2 6wks
Increase E, NE, serotonin
kills serotonin
- MAOI
increase MAO = decrease serotonin
*
decrease MAO = increase serotonin
give MAOI
Most dangerous, most S/E

Diet avoid tyramine food eat SARIWA, fresh foods

HPN crisis dangerous! Increase CR, diaphoresis
Tyramine rich food:
Avocado
Pickles
Alcohol
Fermented foods
Beer
Eggplant
Chocolate
preservatives tocino, bologna,canned meat etc.
Cheese mozerella, swiss cheese
W ine
S soysauce
Anticholinergic = antidepressants antiparasympathetic
Dry, constipation, retention, tachycardia
Male erectile dysfunction
MAOI
mARplan
NARdil
PARnate
DEPRESSION decrease serotonin. If unresponsive to drugs, ECTelectroconvulsive therapy
Assess:
1. Denial this cant be happening. This cant be real.
2. Anger Why me, why now, why God?!
3. Bargaining If returned, I will give reward.
4. Depression 2 wks or more of sx = clinical depression
5. Acceptance client acts according to situation. Pt prepares living will.
Increase risk for self directed violence.
Maslows:
5
4 decrease Self-esteem give TASK
3 Pt is withdrawn
2 Risk for self directed violence suicide
1 eat (wt gain) or not eat(wt loss), sleep or not sleep, hypoactive, decrease
sex
SUICIDE CUES:
I wont be a problem any longer
Remember me when Im gone
This is my last day
This is my wedding ring. Give it to my son
- Sudden change in mood.
Pt is suicidal, RN should:
suicide?

D d irect question Are you going to commit

I irregular interval of visit to pt room

E early am & endorsement period - time pts commit
suicide.
Who will commit suicide?
S sex male (more successful)/female (hesitant)
A age 15 24yo or above 45
D depression
P pt with previous attempts will try again
E ETOH (Ethanol) alcoholics
R irrational
S lacks social support
O organized plan greater risk
N no family
S sickness, terminal
Suicide Triad:
- Loss of spouse
- Loss of job
- Aloneness
Best approach for suicide: Direct approach
Nursing Mgt: close surveillance
Hospital area majority suicide happens at: weekends 1 3 am Sunday
Weekend less staff personnel
Early am every one is asleep
Give simple task. Dont give complex task no jigsaw puzzle
Water the plants
Wash the dishes except sharp objects
SUBSTANCE ABUSE
Type of Addict:
1. Nervous -----tremors
Give downers

Sx of overdose
1.
Identify if drug is upper or downer
2.
Check effect
3.
Sx of withdrawal
If patient takes a downer, all vital signs are down! If he stops
taking it (during withdrawal), patient will experience the opposite
effect of a downer. All his vital signs will shoot up! Same with
uppers.
Ex: Pt had cocaine intoxication. Pt will
manifest hyperactivity, tachypnea, seizure.

During withdrawal, pt will manifest

bradypnea or coma.
Substance Abuse Moments
(downer)
A alcohol
B barbiturates
O opiates
Antidote
N narcotics
- Narcan (narcotic antagonist)
M marijuana
Morph
CODE
HERO
(uppers)
C cocaine
H Hallucinogens
A amphetamines
Uppers
Seizure
Tachypnea

Downers
decrease RR, decrease HR
Para constricted pupil
Moist mouth
Dilated Blood Vessels
Coma
Asleep
Decreased GI constriction
Decrease GU retention
Decrease BP
State of euphoria

Sx of withdrawal reverse of effect

1. Know if upper or downer
2. Opposite of effect
Overdose
Withdrawal (opposite of withdrawal is overdose)
Alcohol coma
seizure
Morphine bradypnea
tachypnea
Detox withdrawal with MD supervision
Methadone
2. Depressed - Sits down on chair

Uppers
Codeine
increase, awake
Hallucinogen
Amphetamine

Stop uppers
Tremors
Fatigue

increased heart increase

sympathetic
HR increase
pupils- dilate
Mouth dry
Decrease appetite - thin
crash

syndrome

LEVELS OF MENTAL RETARDATION

Profound
severe
moderate
IQ

20
110

35

- BP
seizure
GI - diarrhea

Depressed Suicide

mild
50

borderline normal
70

90

Profound Mental retardation IQ <20 =thinks like an INFANT. Cant be trained.

Stay with patient.
Severe MR 20-35
Moderate 35-50 = Can be trained. Mental age is 2-7yo. Pre-operational
stage.
Mild 50-70 = (mild 7) Mental age is 7-12. Educable. Can go to school.
Borderline- 70-90
Normal- 90-110
JOHN PIAGET COGNITIVE THEORY
0-2 yrs old
S-ensory motor. Baby can sense, see, perceive and hear.
Object permanence
2-4 yoP-reconceptual- language.
4-7 yoI-ntuitive stage. Unidimentional classification or
unidimentional characteristic.
Child can fix toys according to size, color, height=one at a
time only.
7-12 yoC-conservation/concrete association. Multidemensional
12yoF-ormal operation good in abstract thinking. Can interpret
proverbs.

CHILD ABUSE
B=burns, bruises, bone fractures, bungi
Dont bathe child. Dont brush teeth. Body of evidence will be lost.
Bantay Bata 163

ALZHEIMER
Anomia- dont know name of object
Agnosia problem with senses (smell, taste, hear, touch)
Aphasia cant say it
Apraxia cant do it
Dissociative Fugue- takes a new personality from a tar away place. New
place new identity.
Dissociative Identity Disorder multiple personality
Dissociative Amnesia dont know who/where I am.

DEPERSONALIZATION- believe that they are not persons anymore

PERSEVERATION- kulit. I want to talk about something because this is
something that I want to do. It is something that I need to talk about. This is
something that I want to do.
ELECTROCONVULSIVE THERAPY- sign informed consent. For depressed pt. If meds
dont work, use ECT.
Pre-ECT
N-npo 6 hours
A-atropine sulfate dry mouth
B-barbiturate
S- succinylcholine chloride to relax muscles
Post-ECT
Side-lying- lateral
S/E headache, dizziness, temporary memory loss (distinct sx)=RN-orient pt.

EXAMS:
Nsg intervention:
Look for words like:
S=safety, support, stay, set limits, assist
Provide safety. Mobilize support system. I will stay with you. Assist in
activity.
Set limit- dont allow patient to misbehave.
Look for words like:
Orient=orient pt post delirium, ECT, pt with dementia
Accept
Seem, observed, noticed, comment, feelings
Group therapy- facilitator is RN.

Rape, battered pt
ALTRUISM Victim becomes a counselor, shares experience to new
victim.
Self-help group=facilitator is the pt themselves. AL ANON groups Alcoholics
Anonymous

RESEARCH
(Kerlinger) systematic, empirical, controlled & critical investigation of a
hypothetical proposition related to natural phenomenon.
PHENOMENON anything that affects human life
- disease, signs & symptoms, procedures, MD, RNs
HYPOTHESIS educated guess, scientific guess, tentative statement of a
supposed answer.
- not known yet if true of false, right or wrong
RESEARCH - must be conducted to affirm or deny a hypothesis.
4 major Characteristics of a Scientific Research
1. Systematic follow step by step process. Fr identification of problem to
conclusion.
2. Empirical proper objective. To collect data, facts & evidence to
support hypothesis.
3. Controlled proper planning/ direction. Research design.
4. Critical investigation fact finding investigation. (synonym)
PURPOSE OF ASIENTIFIC NURSING RESEARCH
D descriptive purpose. Gain richer familiarity regarding a
phenomena. Observation. 100% known to RN.
E exploratory purpose. 50% still unknown to RN.
E experimental purpose. Perform manipulation. Perform intervention.
What to find out cause & effect.

D developmental purposes. Fro improvement of system of care.

F Nightingale birthplace. Italy
Training ground: Germany
Greatest contribution: environmental theory & training of RNs in
Crimean War
School: St. Thomas School of Nursing
Patient nursing focus on research
10 MAJOR STEPS
1. Identification or formulation of research problem
2. Review of related literature
3. conceptualization of conceptual/ theoretical framework
4. Formulation/ Adapting hypothesis
5. Choosing the appropriate design
6. Choosing sample from pop
7. Conducting final study or pilot study
8. Collection of data base
9. Analysis & interpretation of data base
10.
Disseminating the conclusion & recommendation.
Problem: in res requires a solution
Sources (CLIENT) of good problem
C concepts
L literatures
I issues
E essays
N nursing problems
T theories
Char of good problem (GRIFINS)
G general applicability result should be helpful or applicable to all.
a.) basic/ Pre for personal knowledge
b.) Applied focus is solving problems of others
Re researchable collectable & abundant data
F feasible or measurable
a.) time
b.) money/ cost
c.) participants
d.) instruments
e.) experience
f.) proper ethics of good researcher
I important
N novelty original to avoid plagiarism.
S significant

ETHICS OF A PROPER RESEARCHER: (SCIENTIFIC)

S scientific objective always (good faith)
C consent
I integrity
E equitable (appropriate acknowledgments) liable for
N noble Respect 3 basic rights of research sample
T truthfulness
I importance of topic to nursing profession
C courage to look for data.
Legal owner of chart: Hospital
Legal owner of data in the chart: Patient
Plagiarism illegal replication: no consent & acknowledge
3 rights of sample/ pt
1.) Right not to be harmed
2.) Right to self determination get consent & right to withdraw consent
3.) Right to privacy
a.) anonymity privacy of identity of informant
b.) confidentiality name given but privacy of info/ data
Harm that can happen to sample/pt
1.) right from physical , mental & moral harm
2.) Right to self determination
Negligence
1.) Commission unacceptable in standard of practice
2.) Owrission didnt do anything. No intervention done.
Mental Harm:
1.) Assault threatened. Mental fear
2.) Assault & Battery with mental fear & physical harm
3.) Battery with physical harm.
Moral harm
Slander
Oral defamation
Libel
Restraint dependent with doctors order
- physical vest or jacket
- chemical valium
A study in the difference in the financial income of Filipinos working in NYC &
QC (comparative & basic)
Variables anything that is subject t change on manipulation.
1.) Independent variable target population IV stimulus intervention
2.) Dependent variable response
DV response measured

Independent
variable
(stimulus)
Place of work

Target
Population
(Organism)
Filipino RNs
Reviewers

Dependent Variable
(Response)
Financial income early
review Jan

Pavolovian Theory
(SOR) Stimulus Organism Response
Intervening variables comes between independent & dependent
ex. Organismic variable internal factors age, sex, gender, color.
Extraneous variable ext influences can be changed
Allure, citizenship, educational status
Dichotomus variable 2 choices/ results
Ex. Male or Female
Polychotmus multiple choices/ multi variables
Preferred food Japanese, Chinese, Filipino, American
Research
1.) Identity Problem
2.) Purpose objective (SMART)
3.) Define terms
4.) Revision of terms
S smart
M measurable
A attainable
R realistic
T time bound (limit)
Conceptual definition dictionary meaning
Operational definition based on use of research char of problem
Toxic conceptual waste products
Operational very busy day for RNs
Review of related literature
Purpose: for proper formulation of conceptual & theoretical framework.
Theory relationship bet concepts
Conceptual framework. Illustration showing relationship between variables
Paradigm- diagrammatic presentation / illustration of conceptual framework.

Source of review literature

1. Conceptual Sources authors & conceptualists ( DOH book,
Lippincott, Mosbys)
- for general use, can be sold.
2. Research sources researchers cant be sold.
Types of Hypothesis:
1. NULL hypothesis (-) no relationship, no difference bet 1 variable to
another
ex. Theres no diff regarding prof Opportunities in US & RP
2. Alterative, simple or operational hypothesis (+) show a relationship
bet 1 variable to another
ex. Filipino RNs has more prof opportunities un US
3. complex hypothesis shows a relationship bet 2 or more variables to
another.
Ex. Filipino RNs who worked for 5 yrs & passing all CG tests have
opportunities to acquire starting salaries, insurance.
4.

Directional Hypothesis specifies the direction of relationship bet

variables
Ex. Filipino RNs working in USA have more prof opportunities than
those in Phil
5. Non directional Hypothesis no specific direction
There is a big difference between all Filipino RNs working in the USA
5 Choosing appropriate design:
- skeletal framework of research
Research Design:
According to application or motive
According to approach
According to data
Method used applicable to quantitative research: survey
Case study focus 1 patient only or 1 family
Research Design
Application motive
Data
Basic / pure
Quantitative

Applied
Qualitative

Approach

(majority answer)
facts (single pt)
Survey
Case study
Non experimental
1.) Observe sample subject, Research has
2.) Massive participation
3.) Describe & record
4.) Natural setting where pop exists
Experimental:
1.) Active manipulation treatment or intervention done
2.) Active participation to sample pop
3.) Controlled setting lab research units
Types of non experimental res design.
1. Historical research design happened in the past
- collect written, published, circulated or archived
- pts chart
ex. Health practices during Crimean War
2. Expost Facto (after facts) (Retrospective)
- Antecedent facts happened
Study a group of people who have naturally experienced a
particular phenomena related to a problem & has something to
do with present study
- Interview only, no manipulation! Subject is related to present
problem.
3. Prospective focus; future time to look for a data existing subject
with future happening
Focus: weekend review in pentagon
Result: of board exam
this coming June
Present
future
4. Descriptive no intervention but merely observe & collect data.
Ex. Study on absentism in St Lukes
Study on environmental pollution in Quezon
Types:
a.) comparative study similarity & difference of variables
ex. Environmental pollution between variables
b.) Correlatonal relationship between variables
ex. Environmental pollution & increased TB cases
c.) Evaluative effects/ results

ex. Effects of environmental pollution

d.) Survey type data collection based on majority result
Types or survey research
1.) groups small group
2.) Face to face method
- can get response/ feed back right away
b.) Mailed survey method
Problem; data collection
3.) Time orientation
Cross sectional & longitudinal extend period of time.
2 or more # of groups 1 core group/ long term study
unidentical groups
- purpose: devt/ study
- purpose: comparison
- initial & fallow up survey
- short term study
# of time
Steps in experimental type of research design
1. controlled stage discipline/ direction
a controlled group will not be subjective
experimental group will be manipulated
2. Randominization choose your sample by chance
3. Manipulation - intervention
4. Measurements of effect determine the result
Quasi experimental- when you lack in steps in experimental
Pop group where you get your sample
Types of sampling
1.) Probability choose sample by chance
Types of probability
Incidental sampling these present in coffee
shop
a.) Simple random sampling equal chance/ opportunity to be
chosen
- done if identical or equal footing
b.) Stratified random sampling create subdivided population
(divide into 4 levels in school) or substrata before doing
randominization
c.) Cluster random sampling create sub areas MNL hospitals
UST 3rd floor
d.) Systematic random sampling sampling frame
3,000 HIV patients in Phil write list of names appearing in pop uses
multiple number in choosing.
2. Non probability sampling not by chance
- with pre-selected group, with braised group, favoritism
a.) Accidental or convenience sampling.
Criteria immediate availability/ accessibility of sample.
b.) Purposive/ judgmental sampling.

- based on personal knowledge/ info

ex. Research on prostitution
I know location of prostitution Ermita
Prostitution also in Pasay & Makati
I will not choose Pasay & Makati only
Ermita because I have personal info
c.) Snowball sampling based on last referral
d.) Quota sampling setting a certain criteria, with favoritism will
choose only who he likes.
Collection of Data Base:
- time & budget consuming 70 80% time
Methods of collection of data
1.) Questionnaire source of collection f data
- pen & paper type of data
3 Major type of Q
a.) Dichotomasis (2) answerable by T/F, Y/N, right or wrong
b.) Checklist style rating scale 1,2,3,4,5 poor, fair, average. . .
c.) Multiple choice a) man b) dog c) cat d) all of the above
2.) Records easiest get pre existing data journals, essays, documents,
newspapers
3.) Interviewer use oral communication
1.) Structured with checklist formal
2.) Non structured anything goes answer open ended questions.
The sample will expand on topic researcher will illicit answers
their ACTIVE LISTENING.
4.) observation ocular approach
a.) Participant journey
b.) Non-participant passive observer but uses tools to
determine results of data.
2 main problems in colleting data
1. Hawthornes effect problem in experimental design
inaccurate due to consciously being observed (PAASCU
accreditation management keeps school clean before
PAASCUA comes to school.
2. Halo Effect special relationship inaccurate due bias
- solution of researcher to avoid halo effect do double blind
res method
Double blind research no bias or prejudice on treatment blind folded
- gives accuracy due not conscious & biased
Analysis & Later pultation of data phase
- research is forming a body of knowledge for the purpose providing an
answer

2 Methods in presenting your analysis

1.) Qxuantitative using numerical or graphical presentation of answer
ex. 50% of q 500 Filipinos becomes 75% richer
- or use pie chart, bar graph, line graph
2.) Quantitive narrative approach using words (text) & facts
ex. Majority of all graduating students prefer to nursing course than
PT
LEADERSHIP
Dissemination of Finding/ Core/ Recommendations
Importance of core conc is final result of study
How can conc affect others recommendation
Methods of dissemination of Findings/ Result
a.) Book
b.) Symposia oral
c.) Publication
LEADER will influence
LEADERSHIP
S

T
1
L
E

R
Y

4
group
Called
Followers

O
C 2
E
S
S

5 goal/ objective patient recipient of care

RNs implementor, assistant to dentist, Not leader

Principles for effective leadership

1. Unity of command all will receive orders, command from nurse
manager/ supervisor
2. Unity of direction whole group leader &newborns will have goal
towards patient.
3. Subordination of personnel to the general interest
- save patient 1st before self (ex fire in pt room)
R remove/ rescue patients
A alert fire alarm

C confine fire in / area

E extinguish fire
R run
4. Esprit de corps team spirit
fault of one is fault of all
credit of 1 is credit of all
5. Chain of command - hierarchy
Patient reacted to meds given, allergy. Inform MD he will give anti-histamine.
Incident report for purpose of risk management
- Report of sudden occurrence
- Go to Head nurse
Pt has appendicitis. Pain in RLQ who is primarily responsible for patient
Head nurse.
HN can delegate to staff nurse pt died. Head Nurse is liable
Command responsibility Respondia Superior
Theories of effective leader.
1. Great man theory to be a good leader, leader must be born. Leaders
cant be developed. Some are born a follower.
2. Trait theory behavior/ characteristic
P personality
I intelligence
A ability
Personality
+ attitude/ trait/ knows to adjust to pt adaptability
a.) acceptability can cope, adjust to needs of pt
b.) independent
c.) creative/ assertive
d.) advocate
Char of nurse if you are defender of patient against harm/ negligence
advocate
Intelligence proper judgment
Proper decision
Fluency of speech
Ability influence others most effective way to influence pt HI optimum
level of is attain OLF
Command of others
Respect others
Participate
Cooperate
3. Charismatic theory charm, charisma, inspirational quality
4. situational theory a person can be a good leader in 1 situation & a
follower in another situation.

Case to case
Adv can get best person to the job
Disadvantage theres no continuity of leadership

Styles of leadership:
1. Autocratic authoritarian, dictatorial, bureaucratic traditional or
Hard leader
- Unilateral style of nursing
- Leader is only 1 performing without input from other staff.
- Not getting opinion, recommendations
Char unilateral from style of staff leadership leader does decision making
without.
A apathy not sensitive
B boisterous speech
C consistent
Demanding
E egoistic
F ferocious
Putting self in shoes of pet recognize & sensitive to pt. empathy
Not good style in leadership but good in emergency cases. Or during acute
crisis.
2. Laizzes Faire/ Frierein/ Loose
- excess freedom / or liberates to members
- authority
neglect
control
malpractice
discipline

patients will suffer

3. Democratic / Participative
- gets input from members (decision making)
- Mutual participation
- Members makes mistake member will get notice/ hearing before
discipline = due process
Quality/ Skills/ Abilities of good nursing leader:
A authority
B behavior
C Communication skills
D decision making
E ethics
F face conflict
A ability basis of a leader to unsure / demand task, obligation & resp to
his subordinates.

2 types
1. Centralized top to bottom for proper management of whole
hospital
- to problems of whole institution
2. Declaralized bottom (delegation)
- to manage directly pts or concerns
B. Behavior of good nurse leader:
S specific body of knowledge & skills to do safe care to patient. RN
should be competent with scientific rationale
P patient cettered/ client focus
A accountability liable for result of actions
C confidentiality
E ethics
General rule: RN: can be charged with :
Invasion of privacy, breach of confidentiality
Exemption to gen rule (RN cant be charged with breach of confidentiality )
P patients consent
I inform/ report to other members of HC team for precautionary
measure
C common dse (report) DOH/ WHO
C crimes within 48h report child abuse
RA 3573 Law on notifiable disease
Within 24h report disease like polio & measles
1 week HIV/ tetanus/ severs acute diarrhea
Priority for child rape sexual abuse, domestic abuse, all kinds of abuse
a.) report to barangay official
b.) report to police
c.) provide safe environment focus on pt 1st reporting can be done
within 48h
d.) call med legal
Rule!! (in order)
1. S safety
2. R report
3. R referral DSWD, NGO
C communication skills
- transfer of ideas / info with understanding
Without understanding barrier/ backlog
Sender message (idea/ info which sender would like to transmit
Encoding verbal or non verbal method
Receiver recipient of communication

Decoding manner of interpretation after receiving messages

Feedback response of receiving after interpreting messages
D decision making
E ethics
Principle:
1. Autonomy independent judgment & decision making who should decide
for care of patient.
a.) doc
b.) attending pt
c.) pt
d.) relatives
Pt refuses to remove lucky bracelet before surgery Bt due- Jehovahs witness
a.) respect decision of pt respect cultural diversity
b.) refer to doc let doc explain risks involve
c.) let pt sign a waver
Doctrine of assumption or risk
- pt given risks & signed waver
- pt will assume all the risks/ danger
Pills
IUD - string should be checked during & after mens
Diaphragm removed after 6h
Toxic shock syndrome
st
Vasectomy after 2 negative sperm count, 1 is probable 2nd is confirmatory
BTL can do coitus anytime. When pain & bleeding ceases.
Principles in leadership
Veracity truth dont give false reassurance
- all med prognosis, dx, sex of baby given by MD!
Beneficence doing good to pt
Non malefience do no harm
3 type of harm
1. Physical negligence by commission performed wrong action
negligence by omission neglect of care
2. Mental assault mental threat/ fear
battery physical harm
3. Moral slander verbal
libel written, published pictures
Tolality let pt feel like a whole being even if a part is removed.
- offer wigs, bandana CA pt prosthesis, casts, w/c
amputation
Double effect if made to choose between 2 evils, choose the one that will
have les bad effect. More good effect
Justice of care priority coz @ pt has unique needs.

Basic char or nursing process

A acceptance universable
B based on pts needs
C client focus
D dynamic update nursing process depending on clients needs
E equitable care
F familiarity
G goal oriented toward solving problem
Inviolability of life respect of life (promote H & prevent disease)
- no abortion!
Conflict clash of ideas resulting to crisis
Methods to solve conflict.
A avoidance putting in one corner dedma not good method
S smoothing appealing to conscience/ kindness
U unilateral force fear, threats correction
N negotiation best method both parties will mutually decide &
participate to solve problem.
Nsg management
Mgt MAN+ TASK = GOAL (pts)
Theories:
1. Human relations theory must focus on proper relationship
If needs provided to member (rest day, leave)
Achievement of organization
2. Frederick Taylors scientific mgt theory
4 ts
Tao get rt person/ tao
Training
Tool
Tx
3. Douglas McGregor mgt theory Theory Y
Positive worker
- efficient
diligent
trustworthy
reliable
love their job
= minimal supervision only
negligence affecting pts.

Theory X
Negative worker
- inefficient
negligent
non trustworthy
dont love job
for the money only
= increase cases of
= use cozf I d power to discipline

workers
4. Max Webers burocaratic (autocratic) theory
- whoever is on top would perform mgt functions
- centralized

- not good style of management

5. Elton Mayos behavioral theory
- overtime pay, rest day, day off
- provide physical needs of worker like rest & recreation
- HAWTHORNES EFFECT if worker knows that they are
being observed, workers will have better output.
6. Henry Fayols principles of mgt
a.) Unity of command one person given instructions to workers
b.) Unity of direction whole team should have one goal, objective,
direction towards pt.
c.) Subordination personal general interest pt 1st before self
d.) Esprit de corp team spirit all (-) & (+) output credited to the
group
e.) Chain of command heiarchy of command
Get appropriate orders from MD
f.) Channels of communication
MD orders
SN
SN
g.) Respondent supervisor command responsibility
- let master answer for negligence conduct of subordinate
- liable: both
HN
liable for damages due resp supervisor
SN negligence - jail
h.) Security of tenure
i.) Re-numeration of workers compensation
- probationary 6 months
- regular employee
Private RA 4901 40% work 8h a day 5 days a week
Govt RA 7375 magna carta for public HWorker 15k
Overtime = + 25%
Night shift differential = +10%
Special non working holiday + 30%
Legal Holiday= X2 +100%
Occupational Hazard work related disease
Private SSS employees compensation
Govt GSIS
National health Insurance Act PhilHealth
- Provide for unemployed/ employed
- Aesthetic, cosmetic, dental not included
Maternity leave 60 days NSD
78 days C/S
1st 4 pregnancies to legit spouse
4. Abortions 5th pregnant - & delivered not entitled to maternity leave
Paternity leave 7 days
Stage/ Steps in nursing management process
P planning

O organizing
S staffing
D directing/ delegating
Co coordinating
Co controlling/ eval
Planning stage conceptualizing/ product of mind/ looking at future/ looking
prospectively
Types:
Vision what org likes to achieve in future
Ex. Health for all by 2000
Heath in the hands of the people by 2020
Mission focus in present
- reason why org was established
ex. DOH to five quality health
Philosophy values. Besides org (members)
Goal gen statement of mission
Objective specific statement of mission
Goal- nursing form St. Lukes should provide quality care to pt
Objective nursing from St Lukes should have IV training (specific)
Policies set of rules/ regulation of org
3 types of plan
1.) Short term for every day ordinary activity
ex. NCP
2.) Contingency plan for emergency or acute crisis, stand by plan
3.) Long term plan duration of care is linger for chronic pts. Ex. CVA
pts
Budgeting performed in planning stage
- proper allocation of resources
- Money, manpower, machine
1.) Operati0nal budget cheapest everyday ordinary activities
(gloves, gown, goggles OR, LR, DR,ER)
2.) Personal/ labor budget used to compensate & re-numerate
labor most important
3.) Capital budget long term use equipment
- MRI equipment, beds
Budget asks How
Organizing stage answers the question WHO
Nurse Mgr

RN
Subordinate
Nsg personnel nurse aid
RN will do: (for stable & unstable pt)
A assessment
T health teaching
when best time start discharge
E explain proc to pt health teaching start during admission of pt
P preparation computation of dosage
A adm give meds or treatment
T treatment oral, IV, ID
E evaluation nursing care plan
J judgment PRN meds nursing will decide when to five
Subordinates can perform: (comfort measures only not VS)
R routine tasks standard procedure, monitor I & O ambulating,
bathing bed making
- stable pts predictable outcomes
S stable pts
S supervision of RN
Styles/ method delivery care
1. Primary nursing private duty nurse from admission to d/c!
D direct plan of care to pt
A active participation/ consent of pt.
M mgt of care from basic to complex PD will do
24h from admission t o discharge
tip = answer is primary nurse
2. Functional most useful type
D duty task 1 RN all patients
O one task
H highly recommended
RNS
budget
3. Case Method ICU critical case
resp for: T total care (from basic care to most complex)
O one RN: 1 patient
In extreme cases 1:2 pts
Staffing stage how many
- nurse manager will determine correct # of patients/ RN
Staffing pattern Phil 40h/ wk/ 5d
Traditional 8h/40h/5d
10h shift 10h/ 4d Monday Thursday
On call emergency schedule
Baylor plan M F (traditional)
Sat-Sun (skeletal force)

Directing/ Delegation stage job/ task is done by another pt for you.

Gen rule: RN can delegate any task to another RN
Except: disciplinary task (this is done by higher person)
: confidential task (charting)
: technical task (expertice should be done by same expert)
: official medical task
Coordinating/ collaboration stage
1. canned food highest purine content (uric)
2. Anchovies next highest purine content
1. Interpersonal/ intra departmental collaboration bet 1 nurse to another
nurse - under 1 ward
- ex. Endorsement
2. Interdepartmental collaboration between two or more hosp for benefit of
pt.
Why RN needs to collaborate to others in HC team?
- pt is entitled to continuous care.
Evaluation stage determine whether, plan goal, objective where met or
achieved
Types
1. Nurse rounds 2 x rounds/ day
- short term plan
Psyche ward contraindicated nurse rounds in psych ward
2. Checklist Nurse mgr evaluates/ rates member
3. Gam H chart used to evaluate nurses , multiple plan at same time
4. Peer evaluation co workers poorest type of eval cause might be
effected by halo effect due to special relationship.
Performance Appraisal pt or client evaluates most reliable coz --------- or
care evaluates.

PROFESSIONAL ADJUSTMENT / JURIS PRUDENCE

First Hospitals:
I Iloilo
P - PGH
L St Lukes
M Mary Johnson
S St Paul
Nsg is a profession.
Profession defined by PNA adapted from Americans NA
- a calling which its members profess to have acquired a unique body of
knowledge & skills for purpose of guiding & caring others.
Calling service oriented
Members RN
Unique special body of knowledge
Others pt recipient of care
Characteristics of nsg prof:
A ccountability liable for his/her actions
C ompetency having scientific knowledge
E thics
S ervice oriented
Prof nsg resp: RA 9173 Oct 21,02
Independent
Function:
1.
Promotive, Preventive, Curative, Rehabilitative in all health care
settings.
2.
Preventive immunization. Provide health education
3.
Utilization of nsg process
4.
Link of pts & families to diff community resources - community
health nurses libreng bakuna
5. Collaboration of pts care to other health care team - for continuity of
care.
6. Resp for training/ supervision of nsg students
7. Accurate reporting/ recording.
8. Observation of S&Sx provide proper intervention
Dependent fx
9. Execution of valid Drs order
General rule: RN cant give meds without Drs order otherwise RN will be
liable for malpractice.
Exception, under code of ethics, RN can give drugs during emergency,
calamity, national epidemics, no MD around.

Life of patient is in danger. Protected under Good Samaritan Act.

Good Samaritan Act universal law that protects any person who will
give an aid to another person whose life is in danger.
RA 8344 No deposit policy during emergency cases.
- emergency care 1st before asking for deposit.
Mom calls re: 2 yo girl ingested baby aspirin at home. Whats best action for
RN to advice mom on phone.
1. Advice mom to bring kid to hosp
2. Advice to call doc
3. Advice to take emetic meds
4. Advice to call h nrse
Health teaching child proofing the home! Aspirin should not be reached by
kid.
Principal direct author of crime. Dispensable
Accomplice dispensable, crime will still happen without accomplice.
Accessory entered scene after the crime

LEGAL RESPONSIBILITIES
1. CONTRACTS/ CONSENTS absence of coercion
char: V voluntary Free act. Independent act. Rational
O opportunity to ask questions, suggestions & make
recommendations
T treatment, surgery, procedure specifically explained to the
patient by MD
U understood by patient
M matured physically age 18 yo & above
Mentally with sound mind, same & not an imbecile.
Substitute or proxy consent if pt is mentally or physically incapable of
giving consent
1. Parent
2. Guardian
3. Adliter (not a relative!) DSWD, MD
2. ILLEGAL DETENTION limit freedom of patient to move or travel from
one place to another.
Hosp promissory note or guarantee
HIV dont detain patient
High risk HIV transmission felatio
Quarantine regulation SARS, Meningococcemia, anthrax
- public safety is priority.
3. LAST WILL & TESTAMENT - a person in permitted by the law to control/
dispose of his estate.

Effect is only upon his death.

Decedent person who died and left no will. The law will handle
estate.
Testator / Testatoux died and left a will
Testate succession heirs will inherit under a last will and
testament.
Illegitimate entitled to of what legit children will inherit
Kabit will get nothing
Intestate Succession without last will
2 types of last will & testament
1.) Properties
a) Ordinary will
directives
- RN should check LOC of pt
giving instructions
-determine location of signature
will DNR,
- end of last word last page
donation, order for cremation
- sign all pages
- RN is part of 3 witnesses
-

2.) Life/ Body

- Advance
- pt is still alive
a) Living
organ

b) Holographic will
handwritten by testator
dated and signed by testator
no need for witness

4. MEDICATONS/ PRESCRIPTIONS
Rules
1. MD, DVM, DMD can prescribe meds
2. Should have :
a.) Name MD, PTR, PRC#, location of clinic/ hospital
b.) Name of patient, age, sex
c.) Information about drug frequency duration
d.) Generic & brand name in prescription
-

RA 6675 Generics Act

Should have BOTH generic & brand name on prescription
Impossible Prescription generic & brand name does not
correspond with each other.

3. Know 10 rights in giving meds

What is the right way to ask identity of patient
a. call patent by his name
b. check chart

c. verify name at nurses station

d. check name at identification wrist band
4. Telephone orders General rule - no telephone order
Whatever is not written is not an order
Exception Emergency!
After MD says order repeat instruction on phone
Have resident MD sign! Administer meds.
When MD arrives have him counter sign his order
5. Documentation recording/ charting
Purposes:
C communication
A assurance of quality
R research purposes
L legal document
S statistics source
SUBPOENA - an order from court
Duces Tecum (papers) documents obj, materials, papers, chart
Ad Testificadum (person) witness
Dos & Donts of charting
Dos
F full, factual & accurate
unacceptable
L legible
I immediately after procedure
P personal notes, not delegated
much abbreviations

Donts
L language
I improper corrections
S- spaces, skips
A avoid using too

addendum late entry

Negligence failure to do something which a reasonable & prudent person
should have done.
2 types:
1. Commission
2. Omission total neglect of care didnt do anything
Elements to prove negligence
1. Duty
2. Failure to do his duty
3. Injury, harm, death= result
Malpractice doing acts or conducts that you are not authorized/ licensed/
competent/ skilled to perform, resulting to injuries/ non injurious
consequences
- RN exceeding the scope of nursing practice & does an MDs job.

Episioraphy after proper training, RN can perform this procedure.

In absence of fetal & maternal aberration, RN can perform internal
examination
RES IPSA LOQUITOR the thing speaks for itself
- obvious fault
FORCE MAJEURE - God nature storm, earthquake, flood, - not liable
Fortuitous event created by man traffic not liable due beyond his
control.
CRIMES AFFECTING RNs
Classification:
1.) Manner of its commission dolo (deceit) with criminal content
- culpa (fault) without criminal intention, negligence
2.)Stages of execution
Consumated all elements to commit crime were all present.
Frustrated offender performs everything to consummate but it did
not happen for reasons beyond his control
Attempted overt acts mere intensions to commit crime.
3.) Degree of participation
Principal indispensable. Without the principal = no crime- author of
crime
Accomplice with or without accomplice = crime will happen
- dispensable, look out.
- enters scene before or during crime
Accessory enters scene after crime is committed
- conceals/ destroys evidence.
RA 7877 anti sexual Harassment act
1. Any person who exercises authority (Prof & student, Dr & RN)
2. Asking sexual favors in exchange of another favor
Rape:
a.) Ordinary rape forcible penetration of sex organ to a sex organ
b.) Sexual assault anything forcibly inserted to any orifice.
Illegal abortion termination of product of conception before the age of
viability.
Infanticide crime committed of person killed is age < 72h or <3days old
Parricide killing of a person with relationship, ex. Bro in-law, sis, - relative
Homicide killed a person to whom you have no relationship- product of
negligence.
Murder killing of a person with intension.

Simulation of birth any person who shall substitute 1 child or identity of

a child for the purpose of losing his civil status.
PD651 Birth registration act
- requires any person (RN,OB, midwife, pilot) who shall assist in giving
birth to report within 30 days without penalty any live birth at Local
Civil Registrars Office.
RA 2808 (y1919) BON 1 chairman, 2 members = all RNs
1920 1st board exam
RA 9173 (Oct21,02)
BON qualifications
M masters in NSG
A- accredited nsg org (PNA)
S seven (1 chairman, 6 members)
I immediately resign upon appointment
N not convicted of any crime
P pecuniary interest, absence of
T ten yrs experience (last 5 years hr in RP)
C citizen & resident of RP
DEAN qualification- RN + MAN + 5 yrs experience in nsg
Nurse Licensure Exam
1. Cert of Good Moral Char (Optional)
2. Proof holder of Fil citizenship Birth cert.
3. Proof BSN degree Transcript with scanned picture done by reg.
NSG SERVICE ADMINISTRATOR
S
M

supervisor head nurse/ ward/ shift/ day

manager

C chief
D

nurse manage whole hosp

director
Supervisor B BSN holder RN
Manager
A accredited nsg org PNA
N Nine units nsg mgt
T two years practice

Chief
Director

nurse RN+ MAN

5 years supervisory experience

PD 223 - PRC regulatory body to all profession in Phil

RA 1080 Civil Svc Act
- Automatic civil service eligible once you pass PRC nsg exam

RA 6425 (9165) Dangerous Drugs Act

Prohibited totally absolutely, cant be used by human being.
Ex. Methaphetamine Hcl (Shabu) cocaine, cannabis
Regulated can use this drug
- with appropriate prescription
- MD with appropriated license (BFAD, PDEA licence)
- Valium, dormicum
Penalty for licensed health care provider
1. Fines
2. Imprisonment
3. Automatic revocation of license
RA 7600 Mother Baby Friendly Hosp Act
- early bonding of mom to child through breast feeding & rooming in
technique
- Sen. Flavier
December 1 World AIDS day
RA 8981 PRC modernization / Computerization Act
- after 5 days result of board exam will come out
- June 11 result
- www.prc.gov.ph
- results of board exam Nurse
- or txt 233 globe/ 136 smart
txt PRC (space) Rating (space) TABUENA,ABIGAILC
Registration. Sign in both of registry of BON
Special can get license by reciprocity
RN in a foreign country & that country where you are registering has
employment for Fil RN in their country
PROHIBITED / ILLEGAL PRACTICE OF NURSING
Imprisonment / jail 1-6 yrs / P50 100k fines
L license , without
O own (using as your own license of another)
I invalidated license + revoked , suspended
S sign name & attach title BSN, RN (not true)
F falsification of documents (diploma, experiences)
A assist another person in illegal practice of nsg
U underwaging
R review/ training centers for RN not accredited by government
A- any person violating this act