OB

High Risk Pregnancy

◦ Threatens the health or life of the mother or her fetus.

◦ Concurrent disorder, pregnancy-related complication, or external factor that jeopardizes the health of
the mother, the fetus, or both.

◦ Requires specialized care from specially trained providers.

Terminologies:

Maternal mortality or death

◦ Refers to deaths that occur during pregnancy or within 6 weeks after the pregnancy ends that are
related to pregnancy or its management.

Pregnancy-related deaths

◦ Refers to deaths during pregnancy and up to 1 year after the pregnancy ends that are related to
pregnancy or pregnancy care.

Maternal morbidity

◦ Describes unexpected short or long-term health problems that result from being pregnant or giving
birth.

SITUATION

40,000,000 childbirth per year w/ assistance of skilled personnel

99% of maternal deaths occurs in developing countries

PROBLEM

Lack of access to quality care by pregnant women before , during and after child birth

EFFECT

830 each day of women from preventable causes related to pregnancy and childbirth .

RISK FACTORS

◦Existing health conditions

◦Overweight and obesity

◦Multiple births

◦Maternal age
HIGH RISK PREGNANCY Screening

◦Initial screening – history taking

◦Non-invasive diagnostic test

◦ Fetal ultrasound or ultrasonic testing

◦ Cardiotocography

◦Non stress test (NST)

◦ Contraction stress test (CST)

HIGH RISK PREGNANCY Screening

◦Invasive diagnostic test

◦ Chorionic villus sampling

◦ Amniocentesis

◦ Embryoscopy

◦ Fetoscopy

◦ Percutaneous umbilical cord blood sampling

HIGH RISK NEWBORN

A Newborn, regardless of gestational age or birth, who has a greater than average chance of morbidity
or mortality, usually because of conditions beyond the normal events related to birth and the
adjustment to extrauterine life.

CLASSIFICATIO OF HIGH RISK NB

• According to size:

1. Low-birth-weight (LBW)

2. Very low-birth-weight (VLBW)

3. Extremely low-birth-weight (ELBW)

4. Appropriate-for-gestationalage (AGA)
5. Small-for-date (SFD) or small for gestational-age (SGA)

6. Intrauterine growth restriction (IUGR)

7. Large-for-gestational-age (LGA)

• According to gestational age:

1. Preterm (premature)

2. Full-term

3. Post-term (post mature)

4. Late-preterm

• According to mortality:

1. Live birth

2. Fetal death

3. Neonatal death

4. Perinatal mortality

5. Postnatal death

ASSESSMENT

• Initial: Apgar scoring

• Thorough, systematic physical assessment

– General assessment

– Respiratory

– Cardiovascular

– Gastrointestinal

– Genitourinary

– Neurologicmusculoskeletal

– Temperature

– Skin

PREMATURE/ PRETERM

• Born after 20 weeks and before 37 weeks gestation

• Low in birth weight

RISK FACTORS

• Maternal infection

• Multiple/ multifetal pregnancy

• Malnutrition

• Bleeding complications of pregnancy

• PIH, DM, cardiac disorder

• PROM

• Severe isoimmunization

• Trauma

• Incompetent cervix

• PHYSICAL APPEARANCE

• Old man’s facies

• Disproportionately large head, flat ears

• Fine, fuzzy hair and lanugo

• Small thorax, Breast buds (5mm or below)

• Relatively large, protruding abdomen

• Undescended testes, Scrotum (pink, fine rugae), underdeveloped Labia

• Skin: increased lanugo, thin, red and wrinkled, visible capillaries, decreased subcutaneous fats

• Poor muscle tone, soft nails

PREMATURE OR PRETERM INFANT

• ALTERED PHYSIOLOGY

• Respiratory system

• Thermoregulation

• Digestive system

• Liver function

• Renal system

• Nervous system

• Immune system

• Integumentary system
Nursing management

• Maintain respiration at less than 60/min

• Maintain thermoneutral body temperature & prevent cold stress

• Meet nutritional, fluids and electrolytes need

• Prevent bleeding

• Prevent infection

• Provide support to parents

• Initiate phototherapy as required

POST MATURE OR POST TERM INFANT

Delivered after the completion of 42 weeks of pregnancy or one that exceeds 294 days, from the first
day of the last menstrual period.

Assessment findings

• Behavior: wide awake and mentally alert

• Skin features are secondary to prolonged malnutrition and dehydration

• Dry, cracked, desquamating, parchment-like appearance of the skin

• Yellowish-greenish from meconium staining

• Absent lanugo and vernix

• Depleted stored fats/ subcutaneous tissues

• Old man’s look

• Long nails and scalp hair

• May have signs of distress due to aspiration of meconium (MAS)

NURSING MANAGEMENT

• Manage MAS

• Obtain serial blood glucose measurements

• Provide early feeding if not contraindicated

• Maintain skin integrity

PROBLEM RELATED TO GESTATIONAL WEIGHT

APPROPRIATE-FOR-GESTATIONAL AGE (AGA)

• Weight between the 10th to 90th percentile

• 2.5kg to 4kg

LARGE-FOR-GESTATIONAL AGE (LGA)

• Birthweight above the 90th percentile

• > 4kg

SMALL-FOR-GESTATIONAL AGE (SGA)

• Weight below the 10th percentile

• < 2.5kg

• Synonyms: dysmaturity, fetal growth restriction (FGR) or intrauterine growth restriction (IUGR)

MANAGEMENT OF HIGH RISK NEWBORN

• Respiratory support

• Maintaining thermoneutrality

• Protection from infection

• Hydration

• Nutrition

• Skin care

FIRST TRIMESTER BLEEDING DISORDER

Abortion , Ectopic pregnancy

1st TRIMESTER BLEEDING

ABORTION

• Termination of pregnancy before the age of viability usually before 20 – 24 weeks

• Miscarriage

Causes

• Defective ovum/ congenital defects

• Unknown causes
MATERNAL FACTORS

• Viral infection

• Malnutrition

• Trauma

• Congenital defects of the reproductive tract

• Incompetent cervix

• Hormonal

• Increased temperature

• Systemic diseases in the mother

• Environmental hazards

• Rh incompatibility

Types

Spontaneous abortion

• Without medical or mechanical intervention Induced abortion

• With medical or mechanical intervention

Induced abortion

• With medical or mechanical intervention

INDUCED ABORTION

Legal Aspects

• Only allowed for medical indications

• If continuation of pregnancy is risk to life of the woman

• At least two medical doctors should reach the decision and sign

• Elective abortions – are unlawful, considered a criminal act

COMPLICATIONS

• Perforation of uterus, intestines, urinary bladder

• Severe hemorrhage w/c may lead to hypovolemic shock

• Sepsis and its associated complications,

Types of Spontaneous abortion

Signs

• Vaginal bleeding or spotting, mild to severe

• Uterine/ abdominal cramps

• Passage of tissues or products of conception

• Signs related to blood loss/ shock:

• Pallor

• Tachycardia

• Tachypnea

• Cold clammy skin

• Restlessness

• Oliguria

• Hypotension

• Air hunger

Treatment

• Surgery

• Antibiotics

• Blood, plasma, fluid replacement

• Habitual abortion:

• Determine etiology
• Treatment of underlying causes

• Cerclage operation/ cervical closure for incompetent cervix (McDonald surgery, Shirodkar-Barter
surgery)

• Blood tests

Management of Abortion

ECTOPIC PREGNANCY

A condition where pregnancy develops outside the uterine cavity

Types:
• Tubal (Fallopian tube - interstitial, isthmic, ampulla, infundibulum & fimbrial portion)

• Cervical

• Abdominal

• Ovarian

PREDIS[OSING FACTORS

• Fallopian tube narrowing or constriction

• Pelvic Inflammatory Disease (PID)

• Puerperal and postpartal sepsis

• Surgery of the fallopian tubes

• Congenital anomalies of the fallopian tubes

• Adhesions, spasms, tumors

• IUD usage
ASSESSMENT FINDINGS

• Amenorrhea or abnormal menstrual period/ spotting

• Early signs of pregnancy

• Tubal rupture signs

• Sudden, acute low abdominal pain radiating to the shoulder (Kehr’s sign) or neck pain

• Nausea and vomiting

• Bluish navel (Cullen’s sign)

• Rectal pressure

• Positive pregnancy test (50%)

• Sharp localized pain when cervix is touched

• Signs of shock/ circulatory collapse

DIAGNOSIS

• Pelvic ultrasonography

• Culdocentesis

• Laparoscopy

• Serial testing of ECG beta-subunit

LABORATORY

• Low hemoglobin and hematocrit

• Low HCG (normal value at its peak: 400,000 IU/ 24 hours)

• Elevated WBC

TREATMENT

Surgical removal of ruptured tube (Salphingectomy)

• Management of profound shock if ruptured (Blood replacement)

• Antibiotics

COMLICATIONS

Hemorrhage

• Infection

• Rh sensitization
NURSING MANAGEMENT

➢ Carry out an ongoing assessment for shock

➢Implement promptly shock treatment

➢ Position on modified Trendelenburg

➢ Infuse D5LR for plasma administration, blood transfusion or drug administration as ordered

➢ Monitor VS, bleeding, I & O

➢ Provide physical and psychological support.

ACUTE CONDITIONS OF NEONATES

RESPIRATORY DISTRESS SYNDROME

Serious lung disorder caused by immaturity and inability to produce surfactant

INCIDENCE

• Common in preterm newborns ( weight between 1-1.5kg)

• High in babies of DM mothers, babies delivered via CS, and babies whose mothers had antepartum
bleeding

Complications/ Associated problems

• Hypoxia

• Retrolental fibroplasias

• Atelectasis

• Bronchopulmonary dysplasia (BPD)

ASSESSMENT FINDINGS

• Expiratory grunting

• Flaring of nares

• Retractions

• See-saw breathing

• Tachypnea

• Minor signs:

– Cyanosis, pale gray

– Tachycardia, ↓ body temperature

– Dyspnea, periods of apnea

– Decreased activity level

– Respiratory acidosis

– Fine rales and diminished breath sounds

– Decreased urine, edema of extremities

– Decreased muscle tone, absent bowel sounds

Laboratory/ Diagnostic studies

• Laboratory data are non-specific, and abnormalities observed are identical to those observed in
numerous biochemical abnormalities of the newborn

– Blood glucose

– ABG

– Pulse Oximetry

• Radiographic findings

– Diffuse granular pattern over both ling fields

– Dark streaks, or air bronchograms

NURSING MANAGEMENT

• Keep airway patent/ promote respiration

• Maintain and monitor oxygen concentration

• Administer prescribed oxygen under CPAP

• Frequent evaluation/ monitoring:

• Vital signs

• Color

• Breath sounds

• Blood gases

• Maintain hydration and nutrition

• Prevent infection

• Keep warm

• Give supportive care to parents

MECONIUM ASPIRATION SYNDROME (MAS)

• Fetal distress increases intestinal peristalsis, relaxing the anal sphincter and releasing meconium into
the amniotic fluid

• MAS occurs when meconium is present in infant lungs during or before delivery

Assessment findings Assessment:

• Respiratory distress

– Tachypnea

– Cyanosis

– Retractions

– Nasal flaring

– Grunting, crackles, and rhonchi

• Meconium stained nails, skin, and umbilical cord

Laboratory/ Diagnostic studies

• ABG

• Pulse Oximetry

• Radiographic findings

– Uneven distribution of patchy infiltrates, air trapping, hyperexpansion, and atelectasis

• ECG

• Laryngoscopy

MANAGEMENT OF MAS

• Suctioning

• Ventilatory support

• O2 support (Severe: Extracorporeal membrane oxygenation)

• Exogenous surfactant administration

• IV fluids

• Administer antibiotics as prescribed

• Ampicillin

• Gentamycin

• Amikacin
APNEA of PREMATURITY

• Lapse of spontaneous breathing for 20 seconds or longer, or shorter pauses accompanied by

bradycardia or oxygen desaturation.

CLASSIFICATION OF APNEA:

• CENTRAL APNEA

• Absence of diaphragmatic and other respiratory muscle function that causes lack of respiratory effort

• OBSTRUCTIVE PNEA

• Airflow stops because of upper airway obstruction, yet chest or abdominal wall movement is present

• MIXED APNEA

• Combination of central and obstructive apnea. Most common form of apnea in premature infants.

NURSING MANAGEMENT

• AROUSE!

– Flicking the soles and back

– Resuscitate

– Apnea monitor

• Maintain neutral environment

• Decrease fatigue

• Apnea monitor

• Suction gently – don’t stimulate vagus nerve – bradycardia

• No rectal temp

• DOC: Theophylline – bronchodilator, muscle relax, improve respiratory function

• High risk for SIDS

NEONATAL SEPSIS

CAUSES OF NEONATL SEPSIS

1. Congenital infection
- Present at birth
- Infect direct from mother
2. Early- onset sepsis
- onset birth 1 week
-Infection from birth canal

3. Late-onset sepsis
- onset beyond 1 week

-Maternal or external source of infection

• Generalized infection in the newborn

• A clinical syndrome of systemic illness accompanied by bacteremia

• Bacterial

RISK FACTORS

• Prematurity and prolonged period between rupture of membranes and delivery

• Dystocia

• Maternal infection

• Resuscitation

• Aspiration of mucus, meconium and vaginal secretions

• Iatrogenic-infected personnel/ equipments

ASSESSMENT FINDINGS

• Lethargy

• Poor respiratory effort, apnea, cyanosis, persistent hypoglycemia, signs of respiratory distress

• Jaundice or pallor

• Decreased or increased temperature

• Diarrhea, vomiting, dehydration, abdominal distention

• Weight loss, malnutrition

• Increased WBC

SEPSIS

Laboratory and Diagnostic studies

• Blood culture

• Urine culture and CSF analysis

• CBC

•ESR and C-reactive protein

Nursing Care:

• Isolate newborn

• Provide oxygen and respiratory support as indicated

• Administer ordered antibiotics

• Keep the newborn warm

• Maintain nutrition and hydration

• Meet the newborn’s emotional needs

• Provide psychological support to parents

HYPERBILIRUBINEMIA

• Excessive levels of serum bilirubin greater than 12-13mg/ 100mL (NV: 2- 6mg/ 100mL) Complications:

• Kernicterus

RISK FACTORS

• Prematurity

• Sepsis/ infection

• Exposure to drugs in utero

• Isoimmunization

• Polycythemia

• Hypothermia

• Birth trauma with bleeding

• Breastfeeding

• Poor meconium/ stool passage

ASSESSMENT FINDINGS

• Pathologic jaundice

• Pallor

• Irritability, lethargy

• Polycythemia

• High-pitched cry

• Increasing serum bilirubin

NURSING MANAGEMENT

• Monitor presence of jaundice (skin and sclera)

• Keep hydrated

• Early, frequent feeding

• Report any signs of jaundice in the 1st 24 hours of life and any abnormal signs and symptoms

• Prepare for phototherapy and monitor

PHOTOTHERAPY

• Use of intense fluorescent lights to reduce serum bilirubin levels in the newborn

• Transports bilirubin from the skin to the blood, then to the bile where it is excreted and passed out
through the stool

ADVERSE EFFECT

• Eye damage

• Dehydration

• Sensory deprivation

NURSING MANAGEMENT

• Expose much of the newborn’s skin

• Cover the:

– Genital area

– Eyes

• Monitor:

– Temperature

– Skin color

• Increase fluids

• Expect loose green stools and green urine

• Reposition every 2 hours

• Provide stimulation

• Turn off phototherapy during blood extraction

SUDDEN INFANT DEATH SYNDROME (SIDS)

Sudden Infant Death Syndrome

• Sudden unexpected death of any infant

• Death usually occurs during sleep

• Cause of death unexplained by post mortem examination

• Most common cause of death in children ages 1 months to 1 year

• Peak: 2-4 mos., 95% - 6 th mos.

Etiology

CAUSE: Unknown

• Hypoxemia

• Apnea

• Immature Nervous System

• Brain stem abnormality in neuroregulation of cardiorespiratory control

Risk factors

• Prematurity

• Maternal smoking during pregnancy

• Exposure to tobacco smoke from environment

• Co-sleeping, bed-sharing

• Prone-sleeping

• Soft beddings, inappropriate bed surface

Appearance when found

• Blue, apneic & lifeless

• Frothy blood tinged fluid in nose & mouth

• Blanket over head, huddled in a corner with dishevel bed

• Diaper is filled with stool & urine

• Mother: Horrified
Nursing management (Prevention)

• Monitor infants at risk for apnea

• Teach parents how to minimize the risk of SIDS

– Avoid smoking during and after pregnancy

– Encourage supine position or side-lying position

– Avoid:

• Co-sleeping

• Soft, moldable mattresses

• Use of pillows, blankets

• Overheating during sleep

Nursing management

• Evaluate family coping and grieving patterns

• Provide anticipatory guidance for typical feelings

• Allow the parents to verbalize; listen and validate feelings

• Refer family for counseling, if needed

SECOND TRIMISTER BLEEDING DISORDER

INCOMPETENT CERVIX

A condition characterized by a mechanical defect in the cervix causing cervical effacement and dilation
and expulsion of the POC.

RISK FACTORS

◦ CONGENITAL INCOMPETENCE

◦ Diethylstilbestrol (DES) exposure in-utero

◦ Women with a bicornuate uterus

◦ ACQUIRED INCOMPETENCE

◦ Inflammation

◦ Infection

◦ Subclinical uterine activity

◦ Cervical trauma

◦ Increased uterine volume

ASSESSMENT FINDINGS

• Painless contractions resulting in delivery of a dead or non-viable fetus

• History of abortions

• Relaxed cervical os on pelvic examination

TREATMENT

CONSERVATIVE MANAGEMENT:

• Bed rest; avoidance of heavy lifting; no coitus

FOR WOMEN WITH PREVIOUS LOSSES: elective cervical cerclage (late first trimester or early second
trimester)

• Shirodkar procedure

• McDonald procedure

NURSING MANAGEMENT

◦ Provide psychological support to client who may have negative feelings

◦ Provide post-cerclage procedure care

◦ Advise limitation of physical activities within 2 weeks after treatment

◦ Maternal and fetal growth monitoring

◦ Instruct to report promptly signs of labor

◦ Assessment for signs of labor, infection or premature rupture of membranes

◦ In labor, prepare STITCH REMOVAL SET in addition to delivery set (post McDonald surgery)

HYDATIDIFORM MOLE

• Abnormal proliferation and then degeneration of the trophoblastic villi.

• As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized
vesicles

• Cause: unknown

PATHOPHYSIOLOGY

◦ Fertilization occurs as the sperm enters the ovum. In instances of a partial mole, two sperms might
fertilize a single ovum.

◦ Reduction division or meiosis was not able to occur in a partial mole. In a complete mole, the
chromosome undergoes duplication.
◦ The embryo fails to develop completely. There are 69 chromosomes that develop for the partial mole,
and 46 chromosomes for the complete mole.

◦ The trophoblastic villi start to proliferate rapidly and become fluid-filled grapelike vesicles.

ASSESSMENT FINDINGS

◦ Brownish or reddish, intermittent or profuse vaginal bleeding by 12 weeks

◦ Expulsion, spontaneous, of molar cyst usually occurs between the 16th to 18th weeks of pregnancy

◦ Rapid uterine enlargement inconsistent with the age of gestation

◦ Symptoms of PIH before 20 weeks

◦ Excessive nausea and vomiting because of excessive HCG (1 to 2 million IU/L/24 hours)

◦ Positive pregnancy test

◦ No fetal signs – heart tones, parts, movements

◦ Abdominal pain

DIAGNOSIS

◦ Passage of vesicles – 1 st sign that aids to diagnosis

◦ TRIAD signs:

◦ Big uterus

◦ Vaginal bleeding

◦ HCG greater than 1 million

◦ Ultrasound

◦ Flat plate of the abdomen done after 15 weeks

PROGNOSIS

◦ 80% remission after D & C; may progress to cancer of the chorion: Choriocarcinoma

TREATMENT

◦ Evacuation by Suction D & C or hysterectomy if no spontaneous evacuation

◦ Hysterectomy if above 45 years old and no future pregnancy is desired or with increased chorionic
gonadotropin levels after D & C

◦ HCG titer monitoring for one year (no pregnancy for 1 year)

◦ Medical replacement: blood, fluid, plasma

◦ Chemotherapy for malignancy: Methotrexate is drug of choice

◦ Chest X-ray

COMPLICATIONS

◦ Choriocarcinoma

◦ Hemorrhage

◦ Uterine perforation

◦ Infection

NURSING MANAGEMENT

◦ Advise bed rest

◦ Monitor VS, blood loss, molar/ tissue passage, I & O

◦ Maintain fluid and electrolyte balance, plasma, and blood volume through replacements as ordered

◦ Prepare for suction D & C, hysterotomy or hysterectomy as indicated

◦ Provide psychological support

◦ Prepare for discharge

◦ Emphasize need for follow-up HCG titer determination for 1 year

◦ Reinforce instructions on NO PREGNANCY FOR ONE YEAR; give instructions related to contraception

DISEASES OF THE NEWBORN

NECROTIZING ENTEROCOLITIS

An acute inflammatory disease of the bowel with increased incidence in preterm and other high risks
infants;

Most common in preterm infants.

FACTORS IN THE DEVELOPMENT NEC

▪ Intestinal ischemia

▪ Colonization by pathogenic bacteria

▪ Substrate

ASSESSMENT FINDINGS

▪ Tense, distended abdomen

▪ Large residual greater than 2 ml

▪ Stool positive for occult blood

▪ Increased periods of apnea

▪ Decreased blood pressure

▪ Poor temperature stability

DIAGNOSTIC TESTING

▪CBC, CRP

▪Stool for occult blood

▪Abdominal X-ray

▪ Increase in abdominal girth measurement

TREATMENT

▪ NPO

▪ OGT (gastric decompression with intermittent suction)

▪ IV therapy

▪ Antibiotic therapy

▪ Oxygen therapy if indicated

▪ Keep away from other babies

▪ Regular X-rays for monitoring

▪ Surgery (perforation):

▪ Emergency Exploratory laparotomy

▪ Intestinal resection with enterostomy

▪ Primary anastomosis

▪ Colostomy or ileostomy

RETINOPATHY OF PREMATURITY

▪ A serious vaso-proliferative disorder that affects extremely premature infants

▪ Often regresses and heals

▪ May also lead to severe visual impairment or blindness

▪ Primary causes:

▪ Prematurity

▪ Supplementary use of Oxygen (>30days)

STAGES OF RETINOPATHY PREMATURITY

▪ Assesment:

▪ Leukorrhea

▪ Vitreous hemorrhage

▪ Myopia

▪ Strabismus

▪ Cataracts

▪ Management:

▪ Laser photocoagulation surgery

FAILUTR TO THRIVE

▪ Underfeeding is the single commonest cause of FTT

▪ Peak incidence of FTT the age 9-24 mos.

▪ No significance gender difference

▪ Majority of children less than or equal to 18 mos. old

▪ Uncommon after the age of 5 years

GENERAL CATEGORIES OF FFT

1. Organic FTT- secondary to underlying medical illnesses

2. Non-organic FTT (NFTT)- psychosocial FTT, no known medical condition that causes poor growth,
inadequate food or nutrition

3. Mixed FTT- organic and non-organic causes coexist

CATEGORIES OF FTT ACCORDING TO PATHOPHYSIOLOGY

Inadequate caloric intake

Inadequate absorption

Increased metabolism

Defective utilization

ASSESSMENT FINDING

Growth failure

▪ Developmental delays

▪ Undernutrition

▪ Withdrawn behavior

▪ Feeding or eating disorders

▪ No fear of strangers

▪ Avoidance of eye contact

▪ Stiff and unyielding, flaccid and unresponsive

▪ Minimal smiling

TRANSIENT TACHYPNEA OF THE NEWBORN (TTN)

• Respiratory condition that results from incomplete evacuation of fetal lung fluid in full term newborns

• Usually disappears within 24 to 48 hours

ASSESSMENT FINDINGS

Tachypnea

Expiratory grunting

Retractions

Nasal flaring

Difficulty in feeding

MANAGEMENT

Close monitoring of respiratory status

Fluid restriction until stable

Avoid tiring the newborn

Medication-inhaled Beta2-antagonist salbutamol

DOWN SYNDROME

▪ Trisomy 21

▪ A genetic disorder caused when abnormal cell division results in extra genetic material from
chromosome 21.

▪ Most common genetic chromosomal disorder

▪ Prognosis: >80% survive to age 60 years and beyond

▪ 1 in 691 to 1000 live births

▪ Cause: unknown

▪ High risk in older women (>35 y/o)

▪ Lifelong intellectual disability and developmental delays, and in some, causes health problems

▪ Associated health problems (congenital heart defects, respiratory tract infections, thyroid dysfunction,
and leukemia)

ASSESSMENT FINDINGS

▪ Small head (microcephaly)

▪ Flattened, broad head with flat posterior areas

▪ Underdeveloped, flattened middle face (midface hypoplasia)

▪ Almond-shaped, up-slanting eyes, with redundant tissue along inside

▪ Prominent epicanthal folds, with small downturned mouth

▪ Small oral opening with protruding tongue ▪ Small, low-set ears that may be cupped

▪ Chest may be broad, with heart murmurs related to defects

▪ Short hands with a single crease on the palm

▪ Tiny, white spots on the iris of the eye (Brush field spots)

▪ Low tone; can be floppy, with breathing and feeding problems at birth

SCREENING AND DIAGNOSIS

▪ Screening:

▪ Blood test – measures the levels of pregnancy-associated plasma protein-A and pregnancy hormone
HCG.

▪ Nuchal translucency test – ultrasound is used to measure a specific area on the back of the baby’s neck
(more fluid than usual tends to collect in the neck tissue)
▪ Quad screen – measures blood level of four pregnancy-associated substances: alpha fetoprotein,
estriol, HCG, and inhibin A)

▪ Diagnostic tests

▪ Chorionic villus sampling

▪ Amniocentesis

▪ Physical features

▪ Chromosomal Karyotype – analyzes chromosomes

NURSING MANAGEMENT

Support family at time of diagnosis

Assist family in preventing physical problems

Assist in prenatal diagnosis and genetic counseling

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

▪ A condition that makes it difficult for children to pay attention and/or control their behavior.

▪ Onset before age seven/preschool

▪ Main symptoms are:

- Inattention

- Hyperactivity

- Impulsivity

PREDISPOSING FACTORS

▪Exposure to toxins

▪Medications

▪Chronic otitis media

▪Head trauma

▪Perinatal complications

▪Neurologic infections

▪Mental disorders

CLASSIFICATION

1. Combined type

2. Predominantly inattentive type

3. Predominantly hyperactive and impulsive type

ASSESSMENT

▪ Predominantly inattentive type

▪ Fails to give close attention to details or makes careless mistakes

▪ Difficulty sustaining attention in tasks or play

▪ Does not listen when spoken to

▪ Does not follow through on instructions

▪ Fails to finish schoolwork, chores, or workplace activities

▪ Difficulty organizing

▪ Predominantly inattentive type

▪ Avoids or dislikes tasks that require sustained mental effort

▪ Loses things necessary for tasks

▪ Easily distracted and forgetful of daily activities

▪ Predominantly hyperactive and impulsive type

▪ Often fidgets and squirms

▪ Leaves seat in the classroom

▪ Runs or climbs excessively or during inappropriate times

▪ Difficulty playing or engaging in leisure activities quietly

▪Predominantly hyperactive and impulsive type

▪ Is “on the go” and talks excessively

▪ Often blurts out answers before questions are complete

▪ Difficulty waiting for his turn

▪ Interrupts or intrudes on others

GOAL OF CARE

▪ Promote full- capacity functioning

▪ Educate parents about:

▪ Importance and longevity of treatment

▪ Treatment plan

▪ Medications-stimulants (Methylphenidate or Ritalin)

▪ Environmental manipulation (using organizational charts, reducing distractions, and modeling positive
behaviors)

▪ Encourage appropriate placement in classrooms equipped for special training

▪ Encourage consistency both for home and at school

▪ Encourage counseling for children and families who demonstrate anxiety or depression

AUTISM

Autism is a developmental disorder that appears in the first 3 years of life, and affects the brains normal
development of social and communication skills Effects boys 3-4 times more than girls

PREDISPOSING FACTORS

▪ Genetic

▪ Prenatal environment advance age in either parent ,diabetes, bleeding, use of psychiatric drugs by
mother

▪ Prenatal viral infection-rubella

▪ Teratogens

▪ Thyroid problems-lead to thyroxine deficiency in mother

▪ Diabetes in mother

SIGNS AND SYMPTOMS

Appears disinterested or unaware of other people or what’s going on around them

Doesn’t know how to connect with others, play, make friends

Prefers not to be touched, held, cuddled Doesn’t play pretend games, engage in group games, imitate
others

Has trouble understanding or talking about feelings

Doesn’t seem to hear when others talk to him or her

Basic social interaction can be difficult, prefer to live in their own world, aloof and detached from others

COMMON SELF STIMULATORY BEHVAIOR

▪ Hand flapping

▪ Rocking back and fort

▪ Spinning in a circle

▪ Finger flicking

▪ Head banging
▪ Staring at lights

▪ Moving finger in front of the eye

▪ Flicking light switches on and off

▪ Repeating words or noises

THERAPEUTIC MANAGEMENT

▪ No Cure

▪ Educational interventions

-Applied Behavioral Analysis (ABA)

-Speech therapy

-Occupational therapy (OT)

-Physical therapy (PT)

▪ Medical Management

-Risperidone, Aripripazole

-Stem cell therapy

GOAL OF CARE

Promote full- capacity functioning

▪ Educate parents about:

-Stick to a schedule

-Reward good behavior

-Make time for fun

-Pay attention to child’s sensory sensitivities

-Create a home safety zone

THIRD TRIMESTER BLEEDING DISORDERS

PLACENTA PREVIA

Abnormal implantation of placenta in the lower uterine segment, partially or completely covering the
internal cervical opening (os)

RISK FACTORS

◦ Multiparity

◦ Decreased vascularity in the upper uterine segment (scarring and tumor)

◦ Increased age (>35 years old)

◦ Multiple pregnancy

Types/ Degree of Placenta Previa

◦Low-lying

◦Marginal ◦Partial

◦Complete or Total

Pathophysiology

Damage to endometrium

Predisposing Factors:

Age (35-40) Race (nonwhite ethnicity) Hereditary or familial

Precipitating Factors:

Previous abortion Previous placenta previa Multiple births Endometritis VBAC (vaginal birth after
cesarean delivery) Lifestyle (smoking, etc.)

FOLLOWS A VICIOUS CYCLE:

Bleeding – Contractions – Placental separation – Bleeding

Assessment findings

◦ Painless vaginal bleeding (fresh, bright red, external) – 7 th month

◦ Uterus soft/ flaccid

◦Bleeding may be slight or profuse

Diagnosis

◦Ultrasonography

◦ 95% accurate result

◦ Detects site of placenta

Complications

◦Hemorrhage

◦Prematurity

◦Obstruction of birth canal

MEDICAL MANAGEMENT
• IV access

• Laboratory examinations

• Blood typing and cross matching

• Administration of Betamethasone (if premature delivery)

SURGICAL MANAGEMENT

• Amniotomy

• CS delivery

Nursing management

◦ Maintain bed rest (left lateral recumbent with a head pillow)

◦ DO NOT PERFORM an IE or vaginal examination

◦ Careful assessment: VS, bleeding, onset/ progress of labor. FHT

◦ Prepare client for diagnostic ultrasonography

◦ Institute shock measures as necessary

◦ Provide psychological and physical comfort

◦ Prepare for conservative management, double set-up or classical CS

◦ Observe for bleeding after delivery

ABRUPTIO PLACENTA

Premature separation of the implanted placenta before the birth of the fetus

Predisposing factors

◦ Maternal hypertension: PIH, renal disease

◦ Sudden uterine decompression (multiple pregnancy, polyhydramnios)

◦Advance maternal age

◦ Multiparity

◦ Short umbilical cord

◦Trauma; fibrin defects

Types of Abruptio Placenta

Type I: Concealed, Covert or Central type

Type II: Marginal, Overt or External bleeding type

Types of separation.

1. Marginal/low separation

2. Moderate/high separation

3. Severe/complete separation

Assessment findings

◦ Painful, vaginal bleeding

◦ Rigid, board-like, and painful abdomen

◦ Enlarged uterus due to concealed bleeding

◦ If in labor: tetanic contractions with the absence of alternating contraction and relaxation of the uterus

Diagnosis

◦ Clinical diagnosis (signs and symptoms)

◦ Ultrasound – detects the retroplacental bleeding

◦ Clotting studies – reveal DIC, clotting defects

◦ The thromboplastin from retroplacental clot enters maternal circulation and consumes maternal free
fibrinogen resulting in:

◦ DIC: small fibrin clots in circulation

◦ Hypofibrinogenemia: decrease normal fibrinogen results in absence of normal blood coagulation

Complications

◦ Hemorrhagic shock

◦ Couvelaire uterus

◦ Disseminated intravascular coagulation (DIC)

◦ Cerebrovascular accident (CVA) from DIC

◦ Hypofibrinogenemia

◦ Renal failure

◦ Infection

◦ Prematurity, fetal distress/ demise (IUFD)

Nursing management

◦ Maintain bed rest, LLR

◦ Careful monitoring: Maternal VS, FHT, Labor onset/ progress, I & O, oliguria/ anuria, uterine pain,
bleeding

◦ Administer IV fluids, plasma, or blood as ordered

◦ Prepare for diagnostic examinations

◦ Provide psychological support

◦ Prepare for emergency birth

◦ Observe for associated problems after delivery:

◦ Poorly contracting uterus

◦ Disseminated Intravascular Coagulation

◦ Hypofibrinogenemia

◦ Prematurity, neonatal distress

PRETERM LABOR

Labor that occurs after the 20th week and before 37th week of gestation

Etiology

◦ In >30% cases exact cause of preterm labor is not known

◦ Occurs approximately 9-11% of all pregnancies

◦ Any woman having persistent uterine contractions (4 every 20 minutes)

Risk factors

◦ Maternal factors

◦ Maternal infection, illness or disease, DM

◦ Premature rupture of membranes (PROM)

◦ Bleeding

◦ Uterine abnormalities/ overdistention, incompetent cervix

◦ Previous preterm labor, spontaneous or induced abortion, preeclampsia, short interval (less than 1
year) between pregnancies

◦ Trauma, poor nutrition, no prenatal care, lack of childbirth experience

◦ Extremes of age, decreased weight (<100 lbs ) and less height (<5ft ) lack of rest/ excessive fatigue
◦ Smoking

◦ Extreme emotional stress

◦ Fetal factors

◦ Multiple pregnancy

◦ Infections

◦ Polyhydramnios

◦ Congenital Adrenal Hyperplasia

◦ Fetal malformations

◦ Placental factors

◦ Placental separation

◦ Placental disorders

◦ Unknown factors

Complications

◦ Prematurity

◦ Fetal death

◦ Small-for-gestational age (SGA)/ IUGR

◦Increase perinatal morbidity and mortality

Treatment (Hospitalization)

◦ Bed rest on LLR

◦ Adequate hydration

◦ Monitoring:

◦ Uterine contractions and irritability (every 1-2 hours)

◦ VS

◦I&O

◦ Signs of infection

◦ Cardiac and respiratory status and distress signs

◦ Cervical consistency, dilatation, and effacement

◦ Fetal well being

◦ Early signs of edema

◦ Promotion of physical and emotional comfort

◦ Administration of Tocolytics (magnesium sulfate, Terbutaline, Ritodrine)

◦ Contraindications:

◦ Advanced pregnancy

◦ Ruptured bag of waters

◦ Maternal distress (bleeding complications, PIH, cardiovascular disease)

◦ Fetal distress

◦ Presence of fetal problems (Rh isoimmunization)

◦Administration of corticosteroids

◦ Betamethasone (12mg IM every 24 hours x 2 doses)

◦ Dexamethasone (6mg IM every 12 hours x 4 doses)

◦ Assess effects of drugs on labor and fetus

◦ Monitor for side effects

Discharge (premature labor stopped)

◦ Maintain bed rest, LLR preferred

◦ Well-balanced diet (high in iron, vitamins, and important minerals)

◦ Continuation of oral medications

◦ Frequent prenatal visit every week

◦ Activity/ Lifestyle evaluated and restricted as necessary

◦ Illnesses: Chronic – monitored; Acute – treated stat

◦ Provide client teaching

◦ Symptoms of preterm labor

◦ Prompt reporting to physician

PREMATURE RUPTURE OF MEMBRANES (PROM)

Spontaneous rupture of fetal membrane any time after the period of viability but before the onset of
labor

◦Cause: UNKNOWN

◦Associated with infection of the membranes (Chorioamnionitis)

◦ Occurs in 5-10% of pregnancies

Assessment findings

◦ Maternal report of passage of fluid per vagina

◦ Determination of alkaline amniotic fluid and not acidic urine or vaginal discharge

Diagnosis

◦ Nitrazine test

◦ Change in color of Nitrazine paper from yellow (acidic vaginal pH = 4-6) to blue color because of
neutral to slightly alkaline amniotic fluid (pH = 7-7.5) ◦ Ferning test

◦ Amniotic fluid, high in sodium content, will assume a ferning pattern when dried on the slide

◦ Sterile speculum examination

◦ Direct visualization of fluid from cervical os is the most reliable diagnosis

Complications

◦Maternal infection/ chorioamniotnitis

◦Cord prolapse

◦Premature labor

Management of PROM

◦Initial Assessment - objectives of the initial assessment are:

- Confirm the diagnosis of PROM

- To determine the gestation of the fetus

- To identify the women who need to deliver

Management of PROM

◦ If Pregnancy is > 37 weeks and with presence of:

◦ Congenital anomalies

◦ Fetal distress , cord prolapse

◦ Signs of chorioamnionitis

Then deliver....

◦ Induction of labor- if no contraindication

Management of PPROM

◦ Balance between risk of infection in expectant management & Premature labor

◦ Shift the patient where the facility for neonatal care is available .
If pregnancy is > 34 and < 37 7 weeks

- CBC, cervical swab c/s

- Antibiotics

- Careful watch on signs of chorioamnionitis Maternal & fetal conditions

- If no spontaneous labor in 24-48hrs-induction of labor

◦ If pregnancy is < 34 weeks

Expectant Management

- The aim is to prolong the pregnancy for fetal maturity

- Bed rest

- CBC & Cervical swab c/s

- give corticosteroid & tocolytics

- Antibiotics

- Watch for signs of chorioamnionitis, Maternal & fetal condition.

NEWBORN SCREENING (NBS)

• Procedure to determine if the newborn infant has a heritable congenital metabolic disorder that may
lead to serious physical health complications, mental retardation, and even death if left undetected and
untreated

History of NBS in the Philippines

1996 - Initiated in the Philippines through PPS/ POGS “Philippine Newborn Screening Project” with 24
accredited hospitals

1998 - G6PD was added to the list of disorders and homocystinuria was deleted

1999 - DOH included NBSP in the CHILD 2025 Program

2001- DOH created the National Technical Working Group for the nationwide implementation of NBSP

2004 - NBS was integrated into the public health delivery system with the enactment of RA 9288 or
“Newborn Screening Act of 2004

• 6 Congenital Metabolic Disorders

2014 - Expanded newborn screening (ENBS)was implemented

• 22 more disorders were added (hemoglobinopathies and additional metabolic disorders Expanded
newborn screening (ENBS)was implemented

• 22 more disorders were added (hemoglobinopathies and additional metabolic disorders

2019 - PhilHealth coverage for the ENBS (28 Disorders)

OBJECTIVES O NBS

• Newborn has access to newborn screening

• Sustainable newborn screening system

• All health practitioners are aware of the advantages

• Parents recognize their responsibility

Newborn Screening Act of 2004 (RA 9288)

• Protect the rights of children to survival and full and healthy development as normal individuals

• Provide for a comprehensive, integrative and sustainable national newborn screening system to
ensure that every baby born in the Philippines is offered the opportunity to undergo newborn screening
and be spared from heritable conditions

COMPONENT AND COMPREHENSIVE OF NBS SYSTEM

Education of relevant stakeholders

Collection and biochemical screening of blood samples taken from newborns

Tracking and confirmatory testing to ensure the accuracy of screening results

Clinical evaluation and biochemical/medical confirmation of test results

Drugs and medical/ surgical management and dietary supplementation to address the heritable
conditions

Evaluation activities to assess long term outcome, patient compliance and quality assurance

PERFORMANCE OF NEWBORN SCREENING

Ideal time: 48 hours to 72 hours after birth

May also be done 24 hours after birth

High risk newborn in NICU may be exempted from the 3-day requirement but must be tested by 7 days

Note: (+) result, repeat test 14 days after

Blood Specimen Collection Procedure

Puncture heel

Lightly touch filter paper to LARGE blood drop

Dry the sample & send to the laboratory

NBS Screening Procedure

Blood sample collection (>24 hours of life in term newborns)

Analysis for the presence of the disorders screened (NIH laboratory)

Positive -Confirmatory

Positive -Appropriate treatment and referrals

Negative- No further testing

Obligation of healthcare provider

• Parents and practitioners have joint responsibility to ensure that NBS is performed

• Refusal of testing on grounds of religious belief shall be written for

HERITABLE CONDITIONS:

Congenital Hypothyroidism

• Endocrine disorder also referred to as cretinism or dwarfism

• Results from the absence or lack of development of thyroid gland causing absence or lack of thyroxine
needed for metabolism and growth of the body and the brain;

• Is not initiated within 4 weeks

• The baby’s physical growth will be stunted and he may suffer from irreversible mental retardation

UNTREATED CONGENITAL HYPOTHYROIDISM

- Jaundice
- Poor feeding
- Hypotonia
- Macroglossia (large tongue )
- Large fontanelles , delayed closure
- Course facial features
- Mental retardation
- Short stature

Congenital Hypothyroidism

TREATMENT:

• Lifelong thyroid hormone replacement therapy (as soon as possible after diagnosis) as a single
morning dose

• DOC: Synthetic Levothyroxine (Synthroid, Proloid and Levothroid)

• If treatment started early: normal physical growth and intelligence

Nursing Care Management

• Early identification

• Lifelong treatment – compliance with drug regimen (Levothroid and Synthroid)

– Tasteless, can be crushed and mixed

– If dose missed: double next dose

OVERDOSE

+ Rapid pulse

+ Dyspnea

+ Irritability

+ Insomnia

+ fever, sweating

Weight loss

INADEQUATE TREATMENT

+ fatigue

+ sleepiness

Decreased appetite

Constipation

CONGEITAL ADRENAL HYPERPLASIA

• An endocrine disorder caused by an inborn defect in the biosynthesis of adrenal cortisol that causes
severe salt or sodium losses, dehydration and abnormally high levels of male sex hormones in both boys
and girls

• Symptoms:

• Begin shortly after birth:

• Anorexia

• Progressive weight loss

• Vomiting

• Dehydration

• Disturbances in cardiac rate and rhythm

• Cyanosis

• Dyspnea

• If not treated early, babies may die within a few weeks

CONGENTAL ADRENAL HYPERPLASIA

• Treatment:

• Continued hormonal replacement of HYDROCORTISONE

• Glucocorticoid replacement therapy

• Mineralocorticoid therapy (Salt wasting form)

Phenylketonuria

• Inborn error of metabolism characterized by lack of enzyme phenylalanine hydroxylase (needed to

breakdown phenylalanine → elevated serum phenylalanine → brain damage and mental retardation

• Late physical signs reflect the absence of adequate melanin pigment: blond hair, fair skin and blue
eyes

Therapeutic Management

• Restriction of dietary protein

• Maintain safe range of phenylalanine (2-8mg/dl)

• Brain damage: 11-15mg/dl

• Meet child optimum level for growth

• Special milk substitute + tyroxine

• + Breastmilk low protein

• Low phenylalanine diet throughout life

• 93% Mental retardation, 72% Microcephaly

• No high protein and dairy products

• Pregnant mother should be placed in low phenylalanine diet

Nursing Care Management

• Diet restriction

• Peer pressure – temptation in food

• Involve in menu plan, reward – child

• Support family – express feelings

• Monitor physical, neurological, and intellectual development

Galactosemia

Type 1: defiant Galactokinase → inability to convert galactose to glucose → galactosemia→ galactosuria

Complications: mental deficiency, cataracts and death

Type 2: “Classic” galactosemia– Serious deficiency of Uridyl Transferase

Early symptoms: jaundice, vomiting, enlarged liver and spleen hypoglycemia, convulsions and feeding
difficulties

Complications: liver cirrhosis, and irreversible mental retardation

GLUCOSE 6 PHOSPHATE DEHYDROGENASE (G6PD) DEFICIENCY

• Deficiency in G6PD

• Red blood cells lack protection from the harmful effects of oxidative substances found in drugs, foods,
beverage

• Severe anemia and hyperbilirubinemia → kernicterus (jaundice of the brain) and mental retardation,
convulsion, coma and even death

Without G6PD, RBC’s undergo HEMOLYSIS when exposed to oxidative stress!

OXIDATIVE AGENTS LEADING TO HEMOLYSIS IN G6PD Deficiency

• Drugs

– Sulfonamides, quinolones, chloramphenicol,

Vitamin K

• Chemicals

– Mothballs

• Food

– Fava beans

• Infection

Maple syrup urine disease (MSUD)

• An inherited disorder in which the body is unable to process certain protein building blocks (amino
acids) properly.

• Inherited in an autosomal recessive pattern (inherit two mutated genes, one from each parent)

• Symptoms: Distinctive sweet odor of infant’s urine, poor feeding, vomiting, lack of energy (lethargy),
and developmental delay.

– If untreated, will lead to seizures, coma, and death.

Dietary treatment:

• Protein-free diet;

• Infants have a diet formula with low levels of the amino acids leucine, isoleucine, and valine;

• IV administration of amino acids that don’t contain branched-chain amino acids, combined with
glucose for extra calories;

Standard 6- test

Expanded nbs
CLINICAL MANIFESTATIONS AT BIRTH

When do typical signs and symptoms appear?

Summary: Treatment

Newborn hearing screening

• Designed to identify hearing loss in infants shortly after birth.

• Done prior to discharge from the hospital or birthing clinics

• Methods: – Auditory brainstem response (ABR) evaluation – Otoacoustic emission (OAE)

• Two different tests can be used to screen for hearing loss in newborns.

• Both tests are quick (5-10 minutes), safe and comfortable with no activity required from the newborn.

RA 9709 “Universal Newborn Hearing and Intervention Act of 2009

• An act establishing a universal newborn hearing screening program for the prevention, early diagnosis
and intervention of hearing loss
Universal Newborn Hearing Screening Program (UNHSP)

• Ensure all newborns have access to hearing loss screening

• Establish a network among pertinent government and private sector stakeholders for policy
development, implementation, monitoring, and evaluation to promote UNHSP.

• Provide continuing capacity building • Establish and maintain a newborn hearing screening database

• Ensures linkages to diagnosis and the community system of early intervention services

• Develop public policy in early hearing detection

• Develop models which ensure effective screening, referral and linkage with appropriate diagnostic,
medical, and qualified early intervention services, providers, and programs within the community

Newborn hearing screening Otoacoustic Emissions (OAE) Test

• Used to determine if certain parts of the newborn’s ear respond to sound.

• During the test, a miniature earphone and microphone are placed in the ear and sounds are played.
When a newborn has normal hearing, an echo is reflected back into the ear canal, which can be
measured by the microphone. If no echo is detected, it can indicate hearing loss.

Auditory Brain Stem Response (ABR) Test

• Used to evaluate the auditory brain stem and the brain’s response to sound.

• During the test, miniature earphones are placed in the ear and sounds are played. Band-Aid-like
electrodes are placed along the newborn’s head to detect the brain’s response to the sounds. If the
newborn’s brain does not respond consistently to the sounds, there may be a hearing problem.

PREGNANCY INDUCED HYPERTENSION

• A condition in which vasospasm occurs during pregnancy in both small and large arteries

• Characterized by:

– Hypertension

– Edema

– Proteinuria

• Appears after 20th – 24th week of pregnancy and disappears 6 weeks after delivery

Predisposing Factors

• Multiple pregnancy

• Primipara (40 years)

• Low socioeconomic backgrounds

• Multigravida women (>5 pregnancies)

• Polyhydramnios

• Co-existing medical conditions: heart disease, DM with renal involvement, and essential hypertension)

PHYSIOLOGIC CHANGES WITH PREGNANCY- INDUCED HYPERTENSION

Classifications of PIH

• Gestational hypertension

– an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema

– Mild- SBP 140-159 DBP 90-109

– Severe- SBP ≥ 160 DBP ≥ 110

• Management (Mild)

– Educate patient about s/s of preeclampsia and when to call the HCP

– Patient assess daily for signs of preeclampsia and decrease fetal movement

– B/P evaluated twice at week, one being done by provider along with assessing for proteinuria, liver
enzymes and platelets

Gestational Hypertension

• Management (Severe)

– Admit to hospital for stabilization

– Lower B/P to < 160/110: IV Hydralazine or labetalol

– Monitor B/P and s/s of preeclampsia

– Administer oral antihypertensive to control B/P

– Delivery based on fetal status and gestational age

• Mild Preeclampsia

– has proteinuria (1+ or 2+)

– elevated blood pressure (140/90 mm Hg), taken on two occasions at least 6 hours apart

– Edema (upper body)

• Severe Preeclampsia

– Elevated BP (>160/110 mm Hg) on at least two occasions 6 hours apart at bed rest

– Marked proteinuria, 3+ or 4+ or more than 5 g in a 24- hour sample,

– Extensive edema (tibia on anterior leg, ulnar surface of the forearm, and cheek bones)

Assessment findings

Management (Mild Preeclampsia)

• Conservative treatment- bed rest at home can be managed at home if:

• BP is 140/90 and below

• no proteinuria

• no fetal growth retardation

• Patient is not a young primipara

• Promote bed rest

• Advise to rest on lying left side to take the weight of the baby off the major blood vessels.

• Promote good nutrition

• Diet should be high in protein & carbohydrates with moderate sodium restrictions

• Drink at least 8 glasses of water a day

• Provide detailed instructions about warning signs such as:

➢Visual disturbances

➢Severe headache

➢Nausea & Vomiting

➢Epigastric pain

Management (Severe Preeclampsia)

✓ Needs hospital care, support bed rest

➢ Rest in left lateral position to promote fetoplacental perfusion

➢ Room should be dim, quiet, away from areas of activity

➢ Restrict visitors to allow the patient to rest

➢ Leave BP cuff in place so as not to disturb the patient

✓ Monitor Maternal well-being

➢ Monitor vital signs fetal heart tone continuously

➢ Inform on the warning signs

➢ Indwelling catheter to monitor urinary output accurately

➢ Weigh daily

➢ Laboratory tests (CBC with PC, liver function test, BUN, creatinine, hematocrit levels)

✓ Monitor fetal well-being

➢ Fetal movement counting

➢ Non Stress test/biophysical profile to assess uteroplacental perfusion

➢ Doppler flow studies

➢ O2 administration to the mother to maintain adequate fetal oxygenation & prevent bradycardia

✓ Support Nutritious diet

➢ moderate to high protein, ↓ sodium

➢ Start IV therapy

✓ Administer Medications to prevent Eclampsia

➢ Hydralazine - given IV when diastolic pressure reaches 110 mm/Hg but should not be lower than 80-
90 mm/Hg or inadequate placental perfusion may occur
➢ Magnesium Sulfate - drug of choice to prevent Eclampsia

➢act as CNS depressant - lessens the possibility of seizures by blocking the peripheral neuromuscular
transmission (Loading dose 4-6 g, given slow over 15- 30 minutes and maintenance dose 1-2 g/hr given
thru a piggyback method or deep IM using buttocks)

Administration of MgSO4:

✓ Check RR, should be at least 12 breaths/min

✓ UO, should be at least 100 ml/hr

✓ DTR should be present (Knee jerk or patellar reflex)

✓ Prepare the antidote, Calcium Gluconate if MgSo4 toxicity develops & notify physician at once

➢ ↓ UO, ↓ RR, ↓ DTR, ↓ LOC

✓ MgSo4 is given up to 24H after delivery or from the last convulsion

✓ If given during postpartum, monitor for uterine atony as it can cause uterine relaxation

Classifications of PIH

• Eclampsia

– Seizure or coma accompanied by signs and symptoms of preeclampsia

Management of Eclampsia

Goal of care is to ensure safety and prevention of injury

• Stabilize patient's condition

✓ Continuous monitoring of VS, FHR

• Seizure precautions

✓ Raise padded siderails at all times to prevent the woman from falling

✓ Put bed on its lowest position

✓ Have emergency equipment available for immediate use such as padded tongue blade, suction
apparatus, MgSo4, Calcium Gluconate, oxygen equipment

Stages of Convulsion

1. Stage of Invasion – facial twitching, rolling of the eyes to one side, staring fixedly in space

2. Tonic phase – Body becomes rigid as all muscles go into violent spasms or contractions, eyes
protrude, arms are flexed with legs inverted, hands are clenched, woman may stop from breathing
which last for 15-20 seconds
3. Clonic phase – Jaws & eyelids close and open violently, foaming of the mouth, face becomes
congested & purple, muscles of the body contract & relax alternately. The contractions are so violent
that the woman may throw herself out of bed. his phase lasts for about one minute

4. Postictal state – Woman is semi comatose, no more violent muscular contractions. The woman will
not remember the convulsion and the events immediately before & after that condition

Management (Convulsion)

• Monitor patient for impending signs of convulsions: epigastric pain, severe headache, N&V, blurring of
vision

• Priority goals are to maintain patent airway and to protect patient from injury

• Insert a padded mouth gag or tongue blade only before convulsion to prevent patient from biting her
tongue

• Turn patient on her side to allow drainage of saliva and prevent aspiration, may do suctioning if
needed

• Never leave an eclamptic patient alone

• Do not restrict movement during attack as this could result to fractures

• Watch for signs of abruptio placenta

• Take VS & FHR after a convulsion

• Do not give anything by mouth unless fully awake

Post seizure care

❖ The cure of PIH is termination of pregnancy or by delivery. S/s usually disappear once pregnancy is
terminated. Watchful waiting is performed, in severe cases, labor induction is performed irregardless of
gestational age

❖ Postpartum Care:

❖ Frequently assess maternal and fetal well-being

❖ The danger of convulsion exists until 24 hours after delivery. MgSo4

❖ Watch for uterine relaxation and increae lochial flow if the woman is receiving MgSo4

❖ Ergot products are contraindicated

❖ Advise woman to delay next pregnancy for at least 2 years

Anti-convulsants

• Have not been shown to be as effective as magnesium sulfate and may result in sedation that makes
evaluation of the patient more difficult
– Diazepam 5-10 mg IV

– Sodium Amytal 100 mg IV

– Pentobarbital 125 mg IV

– Dilantin 500-1000 mg IV infusion

HELLP Syndrome

❖ A serious complication of severe PIH w/c occurs in about 10% of women w/ ↑BP. It usually develops
before delivery but may also occur postpartum

❖ Hepatic Dysfunction characterized by:

– Hemolysis - RBC breakdown

– Elevated liver enzymes - damage to liver cells causing changes in liver function laboratory test

– Low platelets - cells found in the blood which act as clotting factor

Increase risk for:

• Placental abruption

• Acute renal failure

• Subcapsular hepatic hematoma

• Hepatic rupture

• Fetal and maternal death

• DIC

Management:

• Bed rest

• Transfusion of Fresh Frozen plasma or platelets to reverse thrombocytopenia (count below 100,000)

• MgSo4 and antihypertensive medications

• Laboratory testing of liver, urine and blood

• Betamethasone, a corticosteroid may be administer to help mature the fetal lungs

• Deliver immediately, if HELLP syndrome worsens and endangers the well being of the mother and
fetus

Pediatric clients with Special needs HOSPITALIZATION / PAIN/ DEATH AND DYING\

Child and Hospitalization Reactions to illness and hospitalization:

1. Infants and toddlers:

• Parent- child relationship is disturbed

• Unpredictable routine of hospital promotes feeling of distrust

• Regression

• Experience separation anxiety

Stages of separation anxiety:

1. Protest – child appears sad, agitated, angry, inconsolable, watches desperately for parents to return.

2. Despair – child appears sad, hopeless, withdrawn; acts ambivalent when parents return

3. Detachment – child appears happy, interested in environment, becomes attached to staff members;
may ignore parents

Nursing management:

1. Goal is to preserve child’s trust

2. Reassure child that parents will return

3. Provide rooming-in to encourage parent child attachment

4. Have parents leave a personal article, picture, or favorite toy with child

5. Maintain usual routine and rituals, whenever possible

6. Allow choices, whenever possible, to return control to parent and child

Reactions to illness and hospitalization:

2. Preschoolers: – Major fears: Mutilation / Intrusive procedures – Very egocentric and present-oriented
– Perceives illness as punishment; associates own actions with disease; may believe hospitalization is
punishment for bad behavior – Some degree of separation anxiety still exists; may become
uncooperative, develop nightmares, become withdrawn or aggressive – May show signs of regression,
like the toddler (loss of bowel and bladder control Reactions to illness and hospitalization:

2. Preschoolers:

– Major fears: Mutilation / Intrusive procedures

– Very egocentric and present-oriented

– Perceives illness as punishment; associates own actions with disease; may believe hospitalization

is punishment for bad behavior

– Some degree of separation anxiety still exists; may become uncooperative, develop nightmares,
become withdrawn or aggressive

– May show signs of regression, like the toddler (loss of bowel and bladder control)
Nursing management:

1. Encourage parents to participate in child care

2. Allow child to express feelings

3. Give simple explanations; avoid medical terminology

4. Provide therapeutic play (planned play techniques that provide an opportunity for children to deal
with their fears and concerns related to illness or hospitalization)

5. Allow child to manipulate and play with equipment

6. Maintain trusting relationship with parents and child; allow time for questions

7. Praise the child, focus n the desired behavior, given rewards (stickers)

3. School-age children:

– Major fears

• Pain and bodily injury

• Loss of control

• Fears often related to school, peers, and family

– Ask relevant questions, wants to know reasons for procedures, tests

– Have more realistic understanding of their disease

– Become distressed over separation from family and peers

Nursing management:

1. Communicate openly and honestly; explain rules

2. Clarify any misconceptions

3. Encourage child’s participation in care to maintain sense of control and independence

4. Provide visiting for siblings and peers

5. Use age-appropriate therapeutic play to provide an opportunity for children to deal with their fears
and concerns related to illness or hospitalization

6. Art therapy to assist child to express feelings

7. Provide explanations; use visual aids such as diagrams, models and body outlines

8. Praise the child; focus on desired behavior

4. Adolescents:
– Major fears

• Loss of independence

• Loss of identity

• Body image disturbance

• Rejection by others

– Separation from peers is a source of anxiety

– Physical appearance has major importance to how adolescents perceives themselves

– Behavior exhibited by loss of control; anger, withdrawal, uncooperativeness, power struggles

4. Adolescents:

– Reluctant to ask questions; questions competency of others, will verify answers from more than one
individual to determine if others are being truthful

– Often believe they are invincible, nothing can hurt them; resulting in risk-taking and noncompliant
behaviors

Nursing management:

• Involve adolescent in plan of care

• Support relationship with family and peers

• Provide consistent and truthful explanations; can use abstract terms

• Accept emotional outbursts

• Promote communication between adolescents and their parents

CARE OF PEDIATRIC CLIENT IN PAIN

• Pain in children occurs from reduced oxygen in tissues from impaired circulation; pressure on tissue;
external injury; or overstretching of body cavities with fluid or air

• Pain threshold

• Pain tolerance

TYPES:

1. Acute pain

2. Chronic pain

3. Cutaneous pain

4. Somatic pain

5. Visceral pain
6. Referred pain

Responses to Pain

Infants and toddlers

• Infants will have increases in blood pressure and heart rate and decrease in arterial oxygen saturation

• Harsh, tense, or loud crying

• Facial grimacing, flinching, thrashing of extremities

• Toddlers will verbally indicate discomfort (“no”, “ouch”, “hurts”)

• Generalized restlessness, uncooperative, clings to family member

Preschoolers

• All children have a major fear of needles; preschoolers will deny pain to avoid an injection

• Restlessness, irritability, cries, kicks with experiences of pain

• Able to describe the location and intensity of pain

School-age children

• Able to describe pain, concerned with disability and death

• Girls express pain more than boys

• Demonstrate overt behaviors; biting, kicking, crying, and bargaining

• Cues to pain: facial expression, silence, false sense of being “okay”

Adolescents

• Associates pain with being different from peers

• May exhibit projected confidence, conceited attitude, withdraws, rejects others

• Increase muscle tension and body control

• Understands cause and effect; able to describe pain

Pain assessment tools

1. CRIES (crying Requires O2 saturation, Increased Vital signs, Expression, Sleeplessness)

2. NIPS (Neonatal Infant Pain Scale)

3. FLACC (Face, Legs, Acuity, Cry, Consolability)

4. Faces Pain Rating scale

5. Visual Analogue Scale

Pain management

• Pharmacologic Pain relief:

– Oral analgesia

– Topical

– IV analgesia

• Non-pharmacologic pain

management:
– Distraction

– Substitution of meaning

– Guided imagery

– Thought stopping substitutes

PEDIATRIC PATIENTS FOR SURGERY

Preparing the Child and

Family for Surgery

• Parents should be allowed to stay with the child until surgery begins, and after surgery in post
anesthesia area

• Preparation and teaching must be geared to child’s age and developmental level

• Use of animal or dolls helps children to understand what is going to happen to them

CHRONICALLY ILL PEDIATRIC CLIENTS: CONCEPT OF DEATH AND DYING AND GRIEVING

DEATH AND DYING

Reaction to Death and Dying

Infants and toddlers

• Lack understanding of the concept of death

• Reacts to loss (crying, sleeping more, and eating less)

• Aware someone is missing, may experience separation anxiety

• Toddlers may develop fearfulness, become more attached to remaining parent, cease walking and
talking

Reaction to Death and Dying

Preschoolers

• View death as temporary and reversible

• Magical thinking and egocentricity lead to the belief that the dead person will come back

• View death as punishment; believe bad thoughts and actions cause death

• First exposure is frequently the death of a pet

• Common behaviors: nightmares, bowel and bladder problems, crying, anger, out of control behaviors

• Preschoolers will ask a lot of questions, may display fascination with death.
School-age children

• View death as irreversible, but not necessarily inevitable

• By age 10, understand death is universal and will happen to them

• May believe death serves as a punishment for wrongdoing

• May deny sadness, attempt to act like an adult

• Common behaviors: difficulty with concentration in school, psychosomatic complaints, acting-out

behaviors

Adolescents

• View death as irreversible, universal, and inevitable

• Seen as a personal but distant event

• Develop a better understanding between illness and death

• Sense of invincibility conflicts fear of death

• Common behaviors: feelings of loneliness, sadness, fear, depression; acting-out behaviors (risk-taking,
delinquency, suicide attempts, promiscuity

CARE OF PEDIATRIC CLIENTS WITH DISTURBANCE IN OXYGENATION

• Disorders of the Upper Respiratory Tract

a. Acute Viral Nasopharyngitis

b. Acute Streptococcal Pharyngitis

c. Tonsillitis

d. Otitis Media

e. Croup Syndrome

Respiratory System

• The respiratory system permits ventilation through the process of inspiration and expiration

Respiratory Infections

• Influencing factors

* Age

* Anatomical Size

* Resistance

* Seasonal Variations
• Etiology

* H. influenza, Group A -Hemolytic Streptococcus, Staphylococci, Chlamydia trachomatis, Mycoplasma,

Pneumococci

ACUTE VIRAL NASOPHARYNGITIS

• Common cold

• Caused by:

– Rhinovirus

– Respiratory Syncytial Virus (RSV)

– Adenoviruses

– enterovirus

– Influenza virus

– Parainfluenza virus

Signs and symptoms:

• Fever

• 3mos to 3 y/o:

– Irritability

– Restlessness

– Decreased appetite, activity, & fluid intake

• Initial symptoms: (older) dryness & irritation

• mouth breathing, sneezing, chills, muscle aches, cough

• Self-limiting 4-10 days

Therapeutic Management:

• At home and rest

• Decongestant ( >12mos) – shrink swollen nasal passages

• Cough suppressant – Dextromethorphan

• Antihistamines – dries secretion

• no antibiotics

• Protect from exposure

Nursing Care Management

• Position – elevate head, drainage of secretion

• Saline nose drop & gentle suctioning

• Increase fluid

• Avoid contact with secretions

• Hand washing

Family Support:

• Reassurance for recurrence <3 y/o URI

• 5 y/o develop immunity in virus

• Parent must know sign of respiratory complication

ACUTE STREPTOCOCCAL PHARYNGITIS

• Group A b-hemolytic streptococci infection (GABHS)

• Strep throat

• Risk for serious sequala:

– Acute Rheumatic fever

– Inflammatory disease of joints, heart, CNS

– Acute Glomerulonephritis (AGN)

Signs and Symptoms

ONSET

• Pharyngitis

• Headache

• Fever

• Abdominal pain

Group A Streptococcus

3 to 5 days

COMPLICATIONS

• Sinusitis or parapharyngeal • Peritonsillar • Retropharyngeal abscess

Diagnostics

Examinations:

• Throat culture

• + Rheumatic heart fever = 18 days

• + Glumerulonephritis = 10 days

Therapeutic Management:

• Strep sore throat = oral penicillin

– 24 hours non-infectious

• IM = penicillin G benzathines (avoid IV = FATAL embolism)

• Erythromycin (oral)

Nursing Care Management:

• Analgesics (acetaminophen, ibuprofen)

• Remain in bed

• Cold or warm compress

• Fluid intake

• Warm saline gargles

• Avoid sharing drinking or eating utensils

• Antibiotic full compliance

• Advise to discard toothbrush after 24 hours of taking antibiotics

TONSILLITIS

• An infection or inflammation (hypertrophy) of the palatine tonsils

• TONSILS: Waldeyer’s tonsillar ring

– Pharyngeal tonsil (adenoid)

– Tubal tonsil

– Palatine tonsil

– Lingual tonsil

Etiology

• May be bacterial or viral

• Often occur with pharyngitis

• Most common bacterial agent: Group A betahemolytic strep

Clinical Manifestation

• Inflammation

• Palatine --- Kissing tonsils = no passage of food & air

• Adenoid --- no air passage = mouth breather >>> dry oropharynx >>> impaired smell & taste, voice
nasal muffled quality - -- OM/ hearing impaired

Diagnostic Examination:

• CBC • PTT • Throat culture rapid strep test

Therapeutic

Management

• Self-limiting & Treatment is

symptomatic (Viral)

• Antibiotics (Bacterial infection)

• Drug of choice: amoxicillin

Surgical Treatment :

• TONSILLECTOMY

– Recurrent peritonsillar abcess, airway obstruction, with febrile convulsions, tissue pathology

• ADENOIDECTOMY

• Contraindications:

– Cleft palate

– Acute Infection at time of symptoms

– Uncontrolled systemic disease or blood dyscrasias

– Poor anesthetic risk

Nursing Care Management

• Provide comfort

• Minimize activities that precipitates bleeding

• Soft to liquid diet

• Cool mist vaporizer – moist, mouth breather

• Warm salt-water gargles, throat lozenges, analgesics

• History – bleeding tendencies, loose teeth

• Post surgery:

– Opioids – acetaminophen

– Avoid routine suctioning

– Position – on abdomen or side

– NPO until fully alert and no signs of hemorrhage

• Post surgery:

– Avoid using straw

– Avoid coughing, clearing of throat, blowing of nose (could aggravate operative site)

– Inspect for fresh blood or dark brown blood in emesis

– Cool water, crushed ice, Ice chips

– Antiemetics (Ondansetron)

– Avoid milk, ice cream and pudding

– Avoid red juices, citrus, milk, ice cream – coat the throat

– WOF: Continuous swallowing – notify MD

– Observe throat using light tongue depressor carefully

– Monitor for signs of shock, airway obstruction, respiratory distress

– Suction equipment & oxygen be available after surgery

Discharge Planning

• Avoid:

– Irritating and highly seasoned foods

– Gargle & vigorous tooth brushing

– Coughing/ clearing throat or putting objects in the mouth

• Analgesics or ice collar for pain

• Limit activity

– 1 to 2 weeks resume activities

• Hemorrhage may occur 10 days postop

• Common: low grade fever, slight ear pain, mouth odor

OTITIS MEDIA

• Inflammation of the middle ear

• Often caused by bacteria

• Streptococcus pneumonae, haemophilus influenzae

• Virus: RSV, Rhinoviruses, influenza virus, adenovirus

• 84% will have at least one episode before age 3

• Peak incidence – between 6 to 12 months

Incidence:

• Short, immature upper respiratory tract and the eustachian tubes being connected to the nasopharynx

– Bottle feeding with the infant supine can cause reflux of formula from the nasopharynx into the
eustachian tube

Assessment findings

• Earache, pulling at ears

• Bulging, red, or opaque eardrum

• Yellow or green or purulent, foul smelling drainage

• May be accompanied by other nonspecific signs of infection

• High-grade Fever

• Anorexia

• Crying

• Sleep disturbances

• Vomiting

• Diarrhea

• Lymph glands enlarged

Diagnostic Examination

• Otoscopy

• Tymphanometry

• Reflectometry

Surgical Management:

• Myringotomy
– Incision in the posterior inferior aspect of tympanic membrane

– For draining exudates and pressure

• Tympanoplasty

– Ventilating tubes or pressure equalizer to create an artificial canal that equalize pressure

Management

• Antibiotics (Amoxicillin, Azithromycin, cepahlosporins - cefuroxime)

• Analgesics

• Heat/ cool compress

• Lie on affected side

• Numbing eardrop:

Benzocaine(Auralgan)

• Avoid:

– Expose to smoking

– Swimming or bathtub

– Immunization

– Bottle feeding

CROUP SYNDROME

• Heterogeneous group of mainly acute and infectious processes

• Caused by HAEMOPHILUS INFLUENZA

• Incidence: Parainfluenza viruses (type 1,2,3) - 80% of cases

• Age group: 3 mos - 5 y/o; Peak: 6 mos – 3 y/o

• More in boys

• Epiglotitis – older children

• Laryngotracheo-bronchitis – young children

Signs and Symptoms

• Hoarseness

• Brassy or bark-like cough

• Varying inspiratory stridor

• Respiratory distress (resulting from swelling or obstruction in the larynx

Treatment:

• Careful monitoring of heart rate, respiratory rate, pulse oximetry

• Cool mist

• Nebulized racemic epinephrine - 0.25 to 0.75mL of 2.25% of epi in 3mL NSS q 20mins duration < 2 hrs

• Corticosteroids Dexamethasone IM - 0.6mg/kg single dose or 0.15mg/kg Budesonide nebulized - 2mg

• Heliox- Helium-oxygen mixture

Types of acute

• Discharge Criteria:

-Healthy color

-Good air entry

-Baseline consiousness

-No stridor at rest

-Have received a dose of corticosteroids

CARE OF PEDIATRIC CLIENTS WITH DISTURBANCE IN OXYGENTAION

• Infections of the Lower Respiratory Tract

a. Bronchiolitis

b. Bronchitis

c. Asthma

d. Pneumonia

e. Cystic Fibrosis
BRONCHIOLITIS

• An acute viral infection primarily occurring at the level of the bronchioles

• Respiratory Syncytial Virus (RSV) in approximately 75% cases.

• There is bronchiolar obstruction caused by edema and mucus leading to overinflation, atelectasis and
impaired gas exchange

Clinical manifestations:

• Mild (Initial phase)

* Pharyngitis

* Coughing and sneezing

* May present with ear or eye infection

* History of intermittent fever

• Moderate (Progressive)

* increase coughing and wheezing

* Air hunger and increase DOB

* Tachypnea and retraction

* Cyanosis

Clinical manifestations:

• Severe

* Tachypnea > 70 breaths/minute

* Restlessness

* Apnea spells

* Poor air exchange

* decrease breath sounds

Nursing care management:

• Provide increase humidity – cool, moist oxygen

• Adequate fluid intake

• Ongoing assessment and monitoring of O2 status, VS, activity level

• Possible administration of antiviral agents (RespiGam – used more for prophylactic value)

• Bronchodilators- adrenaline
Bronchitis vs Bronchiolitis

The diameter of an infant’s airway is approximately mm, in contrast to an adult’s airway diameter of 20
mm.

BRONCHITIS

• Inflammation of bronchi and production of mucus

• Viral infection (RSV)

• Peak : 6 mos

Signs and symptoms:

• Runny nose

• Pharyngitis

• Low grade fever

• Wheeze

• Poor feeding

• Tachypnea

Nursing care management:

• Supportive management

• Oxygen

• Hydration

• Bronchodilator

• Palivizumab (Synagis)

• Hand washing

ASTHMA

• Inflammatory process of the large airways, which results in heightened airway reactivity.

• Chronic inflammatory disorder of the airway

• Most common chronic disease of childhood

• Boys, before 4 y/o & 5 y/o

• Airflow limitation or air obstruction

• Caused by physical and chemical irritants, that lead to obstruction after initial exposure
Risk factors:

• Age

• Hereditary

• Gender

• Mother <20 y/o

• Smoking

• Ethnicity

• Previous life-threatening attacks

• Lack of access in medical care

• Psychological & physiologic problem

Pathophysiology

• Irritants

• Release of inflammatory mediator

• Migration & activation of inflammatory cell

• Alteration in epithelial integrity & autonomic neutral control of airway

• Smooth muscle responsiveness, wheezing, dyspnea

• Obstruction

Clinical manifestations

• Wheezing

• Breathlessness

• Dyspnea

• Chest tightness

• Cough (-)respiratory infection = night & early morning

• Activity induced cough/wheeze

Asthma Severity Classification

Diagnostic Examination:

• Laboratory assessment

– ABG

– CBC (elevated Eosinophil count)

– Elevated IgE levels

– Pulmonary function tests (most accurate test for asthma)

• Peak expiratory flow rate Highly suggestive of asthma when >15% increase in PEFR after inhaled short
acting B2 antagonist and When <15% decrease PEFR after exercise

Therapeutic Management:

• GOAL

– Maintain normal activity level

–Normal pulmonary function

– Prevent symptoms

–Drug therapy

Exacerbation

• Episode of progressively shortness of breath

• Cough

• Wheezing

• Chest tightness

• Mucus plugging

• AIRWAY TRAP >>> HYPOXEMIA

Asthmatic episode

• Begin with irritability, restlessness, headache, feeling tired, or chest tightness

• Accumulation of secretion – gelatinous sputum

• Lips deep red – cyanosis

• Tripod position

• (+) retraction

Interventions:

• Assess airway
• Meds

• Monitor respiratory status

• IV line to correct electrolytes

Therapeutic Management:

• Allergen control

• Drug therapy

– Bronchodilators

– Corticosteroid (Anti-inflammatory)

– Cromolyn & Nedocromil Na

– B-adrenergic agents

– Methylxanthines

–Anticholinergic (Heliox & MgSO4)

Therapeutic Management:

• Chest physiotherapy (not in episode)

• Hyposensitization

• Exercise – swimming

• Avoid cool environment

• Recognize early symptoms

Bronchodilators

Side effects:

• Chest pain or discomfort

• Irregular or fluttery heartbeat

• Unusual bruising

• Hives or rash

• Swelling

• Wheezing or other breathing problems

• Numbness in the hands or feet

• Blurred vision

Bronchodilators
• ᵝ2 agonist

– Albuterol (Ventolin)

– Bitolterol

– Pirbuterol

– Salmeterol

– Formterol

• Methylxanthines

– Theophylline, aminophylline, Oxtriphylline

˗ Monitor for SE: excessive cardiac & CNS stimulation (Check BP & pulse)

• Cholinergic antagonist

– Ipratropium (Atrovent)

Anti-inflammatory agents

• CORTICOSTEROIDS

– Oral (Prednisolone, Prednisone)

– Inhaler (Budesonide, Fluticasone, Beclomethasone, Triamcinolone, Flunisolide)

• MAST CELL STABILIZER

– Cromolyn sodium (Intal)

– Helps prevent atopic asthma attacks (prevent mast cell membranes from opening when an allergen
binds to IgE)

• Monoclonal Antibodies

– Omalizumab (Xolair)

– Binds to IgE receptor sites on mast cells & basophils preventing the release of chemical mediators for
inflammation

Nursing care management:

• Recognize sign & symptoms

• Position: sitting upright or leaning forward

• Ask questions that requires few words

• Reassure that they are safe & will be cared for during stressful situation

• Avoid allergen; encourage to cough

• Administer meds as ordered

• Clean devices used- oral candidiasis

• Increase fluid, inform condition, encourage self care

• Influenza vaccination annually

Client Education Guide:

• Avoid factors that triggers asthma attack

• Use bronchodilator 30 minutes before exercise to prevent or reduce exercise-induced asthma

• Proper technique & correct use of metered dose inhalers

• Adequate rest & sleep, reduce stress & anxiety; learn relaxation techniques

• Failure of medications to control worsening symptoms, seek immediate emergency care

PNEUMONIA

• An inflammatory process affecting the bronchioles and alveoli

• Most common cause of death from an infection

• Inflammation leading to consolidation of lung tissue as the alveoli fill with exudate that impairs
gaseous exchange

• Etiology:

– Pathogens (bacteria, viruses, myobacteria, chlamydiae, mycoplasma, fungi, parasites)

– Most common is S. Pneumonia, S. Aureus, E. coli, Pseudomonas, H. Influenza

Precipitating factors:

• Atelectasis/ aspiration

• Chronic illness & debilitation such as lung cancer

• Abdominal or thoracic surgery

• COPD, asthma bronchiectasis

• Smoking & alcoholism

• Malnutrition

• Sickle cell disease

• Tracheostomy

• Exposure to noxious stimuli

• Immunosuppresive therapy

• Radiation therapy

• Chemical ingestion or inhalation

• Aspiration of foreign bodies or gastric contents

Pathophysiology:

• Infection to the lung (bacteria,virus)

• Inflammatory response initiated

• Alveolar edema + exudate formation

• Alveoli and respiratory bronchioles fill with serious exudate,blood cells,fibrin,bacteria

• Consolidation of lung tissue

Signs and symptoms:

• Fever (quite high)

• Respiratory:

– Cough

– Tachypnea (reliable sign)

– Rhonchi/ crackles

– Chest pain, retraction

– Pallor to cyanosis

Diagnostic examination:

• Chest xray

• Sputum culture

• Blood cultures-should be performed to attempt to diagnose a bacterial cause

Therapeutic management:

• Antibiotic therapy

– Oral - Amoxicillin

– IV – Cefuroxime

– DOC: Erythromycin (older children)

• Oxygen, suction

• CPT / postural drainage q4 hours

• Bed rest

• Lie on affected side (unilateral)

• Isolation

• Antitussive & Antipyretic

Nursing care management:

• Oxygen & antibiotics

• Isolation

• Semi-fowlers position

• Lie on affected side in unilateral

• Cool environment

• Suction secretions

• CPT q4 hours

Nursing care management:

• Auscultate lung sounds & monitor for signs of respiratory difficulty

• Check oxygenation status (pulse oximetry) & monitor ABGs

• Encourage increase fluid intake, high calorie diet

• Monitor I & O, skin turgor, VS & serum electrolytes

• Administer antipyretics as ordered

• Encourage vaccinations

Prevention:

• VACCINATION

– PVC 14 (Heptavalent pneumococcal vaccine) <24 mos.

– PS23 (Pneumococcal vaccine) 24 mos. and older

CYSTIC FIBROSIS

• An inherited, autosomal recessive disorder, which affects the exocrine glands and results in
multisystem involvement.

Most significant factor - The increase viscosity of mucus gland secretions = obstruction

• It leads to chronic lung diseas, exocrine pancreatic insufficiency,hepatobiliary disease and abnormally
high sweat electrolytes
• Etilology: The responsible gene has been localized on the long arm of chromosome 7. It encodes a
membrane-associated protein called the cystic fibrosis. cAMP regulated CI channel

Areas of involvement:

• Respiratory system

• Integumentary system

• Gastrointestinal system

• Reproductive system

Major signs and symptoms due to:

* Lack of sufficient pancreatic enzymes

* Gradual obstructive lung disease

* decrease sweat gland function

Signs and symptoms:

Gastrointestinal tract

• Meconium ileus

• Abdominal distention

• Intestinal obstruction

• Increased frequency of stools

• Failure to thrive

• Flatulence, steatorrhea

• Recurrent abdominal pain

• Jaundice

• GI bleeding

Respiratory system

• Cough

• Recurrent wheezing

• Recurrent pneumonia

• Atypical asthma

• Dyspnea on exertion

• Chest pain
Genitourinary tract

• Hydrocele

• amenorrhea

Nursing care management:

• Administer and monitor effects of antibiotic,vbronchodilator, and nutritional management.

• Teach chest PT - MAINSTAY of therapy!

• Airway clearance- teach proper postural drainage technique.

• Promote exercise, deep breathing and directed coughing.

• Teach parents/child s/s of infection and complications i.e. pneumothorax

• Administer and/or monitor pancreatic enzyme replacement therapy.

*Always administer with meals and snacks - amount given relates to degree of insufficiency and the
child’s response to the enzyme therapy. Goal is to prevent FTT and to decrease number of stools.

• Teach parents/child about s/s of Na+ depletion and rectal prolapse