COMMUNITY HEALTH NURSING Nurse-Centered

LECTURE PRELIMS COVERAGE 1. To increase the competency of individuals,

families, groups and community to deal with
their own health and nursing needs
REVIEW OF THE BASIC CONCEPTS OF 2. To strengthen community resources
COMMUNITY HEALTH NURSING 3. To control environment and develop resistance
to environmental conditions
Overview 4. To prevent and control communicable and non-
• “The utilization of the nursing process in the communicable diseases
different levels of clientele: individuals, 5. To provide specific services to mothers, children,
families, population groups and workers, elderly, eligible couples and handicaps
communities, concerned with the promotion of etc.
health, prevention of disease and disability and 6. To conduct research and training programs
rehabilitation.” 7. To supervise, guide and help health personnel in
• Community Health refers to the health status carrying out their functions
of the members of the community, to the
problems affecting their health and to the totality Characteristics of a Community
of health care provided to the community. Characteristics
(WHO, 1971)
1. The community has a defined geographical
• Public health is the science and art of
boundaries which has the beginning and the end
preventing diseases, prolonging life and
2. The community is composed of people who live
promoting health and efficiency through
together in the defined boundaries of the
organized community efforts for the sanitation of community
environment, the control of diseases, the 3. The community people have common
education of individuals in personal hygiene, the
psychological characteristics, for example, there
organization of medical and nursing services for
is similarity in language, lifestyle, customs and
early diagnosis and preventive treatment of traditions
disease and development of social machinery to
4. The people in the community interact with each
ensure for every individual a standard of living
other and have free communication
adequate for maintenance of health, so 5. The community has organized social structure
organizing these benefits as to enable every
and system and common organization which
citizen to realize the birth right of health and carry various functions
longevity.
• According to the American Nursing
Functions
Association (ANA), community health
nursing is a synthesis of nursing practice and 1. It provides space for housing, shelter,
public health practice applied in promoting and socialization and recreation
preserving the health of populations. The nature 2. It provides means and facilities for livelihood
of this practice is general and comprehensive. It 3. Community provides opportunity for
is not limited to a particular age or diagnostic employment
group. It is continuous and not episodic. The 4. It takes care of socialization and education of its
dominant responsibility is to the population as a members
whole. 5. It provides safety and security for its members
• Community Health Nursing is a unique blend by enforcement of norms and legislation
or mix of nursing and community health, woven formulated by the society
into a service which when properly developed 6. It provides opportunities for people participation
and implemented can have a tremendous impact and communication
on human health.
• Public health nursing practice focuses on Objectives of Community Health
population health through continuous • The objective of community health is to provide
surveillance and assessment of the multiple need based comprehensive services which
determinants of health with the intent to include the following:
promote health and wellness; prevent disease, 1. Promotion and protection of health
disability, and premature death; and improve Example: Primary level prevention
neighborhood quality of life. (ANA, 2013) 2. Early diagnosis and treatment and control of
further spread of disease
Goals and Objectives of Community Health Example: Secondary level prevention
Nursing 3. Control of disability and rehabilitation
Example: Tertiary level prevention
Client-Centered • The major emphasis is on primary level
1. To promote and preserve health prevention with the active involvement of people
2. To restore health when it is impaired (as majority of the health problems are
3. To minimize suffering and distress preventable by simple measures)
4. To promote quality of living
5. To develop self-care abilities

February 9, 2021 │ Compilation by April Tom O. Cuenca and Rogen Kate Azarcon 1
Community as a Client The following principles involve the new
• In community health, the whole community is a philosophical base of community health in the
client and the services are focused and hence it Alma Alta Declaration (1978):
is important to: 1. Availability of health care for all
1. Know the community 2. Promotive and preventive aspects of health care
(community identification) 3. Integration of curative and preventive care
2. Identify the health needs of the community 4. Active involvement of individuals and
(community diagnosis) communities in planning and providing care
3. Understand the underlying factors affecting 5. Development of maximum potential for self-care
health problems 6. Utilization of all levels and types of health man
4. Plan and implement comprehensive power
services 7. Inter-sectoral approach (multisectoral approach)

Principles of Community Health Principles of Community Health Nursing

• Principles or precepts are rules for practice or
action.
• These are the guidelines or directives derived
from concepts, theory and philosophy of
community health nursing.
Need for Principles
• Ensuring relevant, safe, and correct practices to
meet the health needs of the individuals,
families, groups and communities.
• More important in changing socio-economic
conditions of the people. More knowledgeable of
what is wrong or right, and are more demanding.
• Knowledge on working principles and apply them
in their daily activities regardless of their position
and training.
Principles of Community Health
1. Health care should be shaped around the life
patterns of the population. It should serve and
should meet the needs of the community.
2. Primary health care should be an integral part of
the national health system and other services
should be designed in support of the needs of the
peripheral level.
3. Health care activities should be fully integrated
with the activities of other sectors involved in
community development
4. The local population should be actively involved
in the formulation and implementation of health
care activities, so that health care can be brought
into line with local needs and priorities
5. The health care offered should place a maximum
reliance on available community resources,
especially those which have remained untapped
and should remain within the cost limitations
relevant to each country.
6. Health care should be an integrated approach of
preventive, promotive, curative, and
rehabilitative services for the individual, family
and community
7. The majority of interventions should be
undertaken at the most peripheral practice level
of the health services by the workers most
suitably trained for performing these activities
1. Recognize need of individuals, families, and
communities
2. Knowledge and understanding of the objectives
and policies of the agency facilities goal
achievements
3. Community health nursing considers the family
as the unit of service
4. Respect for values, customs and beliefs
5. Community health nursing integrates health
education and counseling as vital parts of
functions
6. Collaborative work relationships with the co-
workers and members of the health team
facilitates accomplishment of goals
7. Periodic and continuing evaluation provides the
means for assessing the degree to which
community health nursing goals and objectives
are being attained
8. Continuing staff education program quality
services to clients are essential to upgrade and
maintain sound nursing practices in their setting
9. Utilization of indigenous and existing community
resources maximizing the success of the efforts
of the community health nurses
10. Active participation of the individual, family and
community in planning and making decisions for
their health care needs, determine to a large
extent, the success of community health nursing
programs
11. Supervision of nursing services qualified by
community health nursing personnel provides
guidance and direction to the work to be done
12. Accurate recording and reporting serve as the
basis for evaluation of the progress of planned
programs and activities and as a guide for the
future actions
13. Develop the community to become self-reliant
Key Characteristics of Public Health Nursing
(PHN)
1. A focus on the health needs of an entire
population, including inequities and the unique
needs of subpopulations;
2. Assessment of population health using
comprehensive, systematic approach;
3. Attention to multiple determinants of health;
4. An emphasis on primary prevention
5. Application of interventions at all level –
individuals, families, communities, and systems
that impact their health

February 9, 2021 │ Compilation by April Tom O. Cuenca and Rogen Kate Azarcon 2
Philosophy and Theoretical Framework
• Philosophy is a set or system of beliefs that
provides a basis and guide for action. It Includes
general beliefs, concepts, attitudes, ethical
considerations and guidelines, as well as values
that explain the way a life is lived, or the manner
in which an organization is run or how a
profession is practiced.
• Theoretical framework refers to the basic
structure of ideas, concepts, beliefs and
principles proposed or followed as the basic
conduct of the particular profession.
• Being aware of the philosophy and theoretical
framework for practice of a profession makes the
action of practitioners well-directed, purposive
and systematic, and consequently productive
and effective.
Philosophy of Community Health Nursing
1. Nursing is a unique and distinct component of
health care
2. Community health nursing subscribes to the
philosophy of interdependence among the health
professions
3. As a special field of nursing practice, community
health nursing shares the humanistic beliefs and
values of the nursing profession
4. Community health nursing believe in the primacy
of health as a goal and as essential element that
affects the quality of life of individuals, families,
groups and communities
5. The goal of nursing is interdependence and self-
reliance in health care for the client or patient,
be it an individual, a family, a group or the whole
community
6. Nursing, in general, and community health
nursing in particular, recognizes the relationship
of non-health interventions in the solution of
health problems
7. To achieve the goal of community health, the
nurse works with, not for, individual clients or
patients, families, specific population groups and
the community at large
8. Nursing goals and standards of care should
consider constraints imposed by client, health
agency and community resources
9. Community health nursing practice is not a body
of set of the same repeating tasks
10. Nurses have the responsibility to keep their
knowledge and skills current and up-to-date
according to developments in nursing, public
health and other related sciences
a) Philosophy of individual’s right of being
healthy
• Health is believed to be one of the rights of all
human beings nationally and internationally
according to the WHO charter
• Goal of health for all is based on the philosophy
of individual’s right of being healthy
• This philosophy encompasses all the aspects of
the society, for example. Sociocultural, economic
aspects, so that there is no hindrance of anu kind
to attain these rights
February 9, 2021 │ Compilation by April Tom O. Cuenca and Rogen Kate Azarcon
b) Philosophy of working together under a
competent leader for the common good
• It is from the primitive ages of human ages; man
has learnt to live together to meet their needs
• The basis of modern community health nursing
is to share responsibility of helping each other
• When it comes to considering organization, equal
participation of the people working through the
community groups or people with the people, for
the people, f their mutual benefit, change in
behavior and health practices
• A democratic team functioning is essential for
effective delivery of health care services
c) Philosophy that people in the community
have the potential for continual
development and are capable of dealing
with their own problems if educated and
helped
• An individual with average intelligence can learn
and deal with his or her own needs, modify his
or her lifestyles, adjust to his or her changing
environment, for example, he can learn to solve
his or her problems.
• On the basis of this philosophy, emphasis is
placed on health education projected towards the
individuals in home, health center, place of work,
school, community places or hospital
• This helps to modify their behaviors respective to
health
d) Philosophy of Socialism
• Socialism as one of the social system in the
community has control over production and
distribution, for example food, housing, material
production of all kinds, education,
transportation, etc which should be shared with
all people.
Parable of the Trees: Population-Focused
Practice
• There were once two sisters who inherited a
large tract of heavily fostered land from their
grandmother. In her will, the grandmother
stipulated that they must preserve the health of
the trees. One sister studied tree surgery and
became an expert in recognizing and treating
diseased trees. She was able to spot conditions
that might lead to problems and prevent them.
Her work was invaluable in keeping single or
small clusters of trees healthy. The other sister
became a forest ranger. In addition to learning
how to care for individual trees, she studied the
environmental conditions that affected the
wellbeing of the forest. She learned the
importance of proper ecological balance between
flora and fauna and the impact of climate,
geography, soil conditions, and weather. Her
work was to oversee the health and growth of the
whole forest. Although, she spent her time
walking through the forest assessing conditions,
her aerial view through from their small plane
was equally important for spotting fires, signs of
disease, or other potential problems. Together,
the sisters preserved a health forest.
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Theoretical Models or Approaches b) Milio’s Framework for Prevention
• Nancy Milio, a nurse and leader in public health
1. Health Belief Model (HBM)
policy and public health education developed a
2. Milio’s Framework for Prevention
framework for prevention that includes concepts
3. Nola Pender’s Health Promotion
of community-oriented, population focused care
4. Lawrence Green’s PRECEDE-PROCEED Model
(1976, 1981)
(PRECEDE – Predisposing, Enabling Constructs in
• These three (3) general categories of nursing
Educational Diagnosis and Evaluation)
intervention have also been put forward, they
5. (PROCEED – Policy, Regulatory and
are:
Organizational Constructs in Educational and
1. Education direct toward voluntary change in
Environmental Development)
the attitude and behavior of subjects
2. Engineering directed at managing risk-related
a) Health Belief Model: Major Components and
variables
Concepts
3. Enforcement directed at mandatory regulation
• There are six (6) major concepts in the Health
to achieve better health
Belief Model:
1. Perceived susceptibility to the condition in
question
2. Perceived severity or seriousness of the
condition in question
3. Perceived benefits to taking action
4. Barriers to taking action
5. Cues to action
6. Self-efficacy

c) Nola Pender’s Health Promotion

• First published in the 1980s
• Envisioned as a framework for exploring health-
related behaviors within a nursing and behavioral
science context
• Includes three (3) general areas of concern to
health-promoting behavior:
1. Individual characteristics and experiences
2. Behavior specific cognitions and affect
3. Behavioral outcomes

February 9, 2021 │ Compilation by April Tom O. Cuenca and Rogen Kate Azarcon 4
d) The PRECEDE and PROCEED Models
• First published by Lawrence Green in 1974
• The PROCEED model works in tandem with the
PRECEDE model as the community health nurse
proceeds to plan, implement, and evaluate
health education programs
• The entire PROCEDE-PROCEED model includes
eight (8) phases in the formulation and
evaluation of health education programs
• A hallmark of the model is the emphasis on the
desired outcome
• The PRECEDE PHASES includes:
1. Social
2. Epidemiologic
3. Educational or ecological assessments
4. Administrative and policy assessment and
intervention alignment
5. Implementation
• The PRECEED PHASES includes:
1. Process evaluation
2. Impact evaluation
3. Outcome evaluation
• The framework provides direction and guidelines
to the community health nurse in terms of who
or to whom she or he is giving care, who should
receive care in the face of limited time and
resources, the objectives of his or her actions
and intervention measures, and the how of
providing care and delivering nursing services.
• The use and application of the philosophy and
theoretical framework for community health
nursing practice would bolster nursing as a
profession, making a distinction between
professional nursing care and the care provided
by people and auxiliary health workers.
February 9, 2021 │ Compilation by April Tom O. Cuenca and Rogen Kate Azarcon
Different Fields of Community Health Nursing
• School Health Nursing
• Occupational Health Nursing
• Community Mental Health Nursing
a) School Health Nursing
• A specialized practice of professional nursing that
advances the well-being, academic success and
lifelong achievement of students.
• A school nurse works primarily with the student
who attend the nurse’s assigned schools, as well
as with the families of those school children
members of the school staff and administration,
health care providers and other helping
professionals within the school and community.
Standards and Practice for School Nurse
1. Develop school health policies and procedures
2. Evaluate their own nursing practice
3. Keep up with nursing knowledge
4. Interact with the interprofessional health care
team
5. Ensure confidentiality in providing health care
6. Consult with others to give complete care
7. Use research findings in practice
8. Ensure the safety of children, including when
delegating care to other school personnel
9. Have a good communication skills
10. Manage a school health program effectively
11. Teach others about wellness
Roles and Functions of School Nurses
1. Direct Caregiver
2. Health Educator
3. Case Manager
4. Consultant
5. Counselor Community Outreach
6. Researcher
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b) Occupational Health Nursing Roles of Community Mental Health Nursing
• Utilizes an interdisciplinary approach to 1. Provide basic care to patients
advocate for the employee's right to have cost- 2. Conducting therapies and health education to
effective, prevention-oriented health and safety patients and family
programs. 3. Training of professionals and non-professionals
and PHC’s about mental health
Objectives of Occupational Health 4. Supervise MPWs in mental health care delivery
1. To maintain and promote the physical, mental 5. Assist psychiatrist in research activities
and social well-being of the workers 6. Social skill training
2. To prevent occupational diseases and injuries. 7. Anxiety management and relaxation
3. To adopt the work place and work environment 8. Assertive training
to the needs of the works i.e application of 9. Bereavement counselling
ergonomics principle. 10. Group meetings
4. It should be preventive rather than curative. 11. Community outreach work services
12. Child care services
Functions of Occupational Health Service 13. Adult care and elderly care services.
1. Pre-employment medical examination
2. First Aid and emergency service. SPECIAL MENTION TO AUBREY MILES MONTA
3. Supervision of the work environment for the FOR THE PICTURES AND ROGEN KATE AZARCON
control of dangerous substances in the work FOR HELPING WITH THE COMPILATION
environment.
4. Special periodic medical examination particularly
for the workers in dangerous operations
5. Health education for disseminating information
on specific hazards and risk in the work
environment.
6. Special examination and surveillance of health of
women and children.
7. Advising the employer or management for
improving working conditions and placement of
hazards
8. Monitoring of working environment for
assessment and control of hazards
9. Supervision over sanitation, hygiene and
canteen facilities.
10. Liaison and cooperation with the safety
committees
11. Maintenance of medical records for medical
check-up and follow-up for maintaining health
standards and als0o for evaluation.
12. To carry out other parallel activities such as
nutrition program, family planning, social
services recreation etc., Concerning the health
and welfare of the workers.

c) Community Mental Health Nursing

• Application of specialized knowledge to
population communities
• To promote and maintain mental health
• To rehabilitate population at risk
• Psychiatric nurse must possess knowledge about
community resources

Goals of Community Mental Health Nursing

1. Provide prevention activities to population for the
purpose of promoting mental health
2. Provide prompt interventions
3. Provide corrective learning experiences
4. Help individuals develop a sense of self-worth
and independence
5. Anticipate emotional problems
6. Identify and change social and psychological
factors that influence human interactions
7. Develop innovative approach to primary
preventive activities
8. Provide mental health education and how to
assess the mental health. e.g.. SIGECAPS

February 9, 2021 │ Compilation by April Tom O. Cuenca and Rogen Kate Azarcon 6
COMMUNITY HEALTH NURSING 2
LECTURE MIDTERMS COVERAGE
THE CONCEPT OF COMMUNITY
Who are our clientele? (Recipients of Care)
1. The Individual
• The individual is a specific person or client
in various stages of health or illness who is
given the appropriate nursing intervention
by the community health nurse and other
members of the health team as the
condition warrants.
2. The Family
• The family is a group of people affiliated by
consanguinity, affinity, or co-residence.
• In many societies, including the Philippines,
the family is the principal institution for the
socialization of children and is often called
the “basic unit of society”.
3. Population Groups
• Are vulnerable groups or those at risk of
developing certain health or health-related
problems.
• Groups of people who share common
characteristics, developmental stage or
common exposure to particular
environmental factors, thus resulting in
common health problems.
• Women, children, young people, older
people, people with disabilities
4. The Community
• Community comes from the Old French
word “communite” which is derived from the
Latin “communitas” (cum, “with/together”
+ munus, “gift”)
• A broad term for fellowship or organized
society.
Community
• Refers to a collection of people who interact with
one another and whose common interests or
characteristics form the basis for a sense of unity
or belonging.
• It can be a society of people:
a. Holding common rights and privileges
ex. Citizens of a town
b. Sharing common interests
ex. A community of farmers
c. Living under the same laws and regulations
ex. A prison community
d. Functions within a particular socio-cultural
context (no two communities are alike)
• A community can be defined according to:
a. Geographic
b. Common interest
c. Health problem or solution
1. Geographic Community
• A community often defined by its geographic
boundaries. Like a city, town, or neighborhood.
• Can be classified as rural, urban, suburban
• On a larger scale, the world can be considered as
a global community.
2. Common-interest Community
• A collection of people, even if they are widely
scattered geographically, can have an interest or
goal that binds the members together.
• The members of a church in a large metropolitan
area, the members of an international nursing
professional organizations.
3. Community of Solution
• Is a group of people who come together to solve
a problem that affects all of them.
• The shape of this community varies with the
nature of the problem, the size of the geographic
area affected and the number of resources
needed to address the problem.
Ex: water pollution that involve several
communities, HIV/AIDS society of community
• There are three types of community:
a. Rural
b. Urban
c. Suburban, rurban, or the capitals
1. Rural Communities
• Also known as open lands, often agricultural in
nature which is more spacious and less densely
populated.
• Have low population (fewer people)
• Are found in the country near ranches and farms
• Have lots of open spaces and very few buildings,
roads or parks
2. Urban Communities
• Often known as city or cities which are non-
agricultural by nature, are densely populated,
and marked by industrial products and
technology.
• Many people living close together
• Small amount of space
• Not very much open space or natural areas
• Tall buildings, skyscrapers, bus, walk, taxi, and
train
3. Suburban, rurban or the capitals
• Usually the administrative capital of a province
characterized by a unique mix of agriculture and
industry.
• A medium-sized community near a large city,
houses are close together, you may see parks
and malls.
March 12, 2021 │ Compilation by April Tom O. Cuenca 1
Characteristics of a Healthy Community
1. A clean and safe physical environment
2. An environment that meets everyone’s basic
needs
3. An environment that promotes social harmony
and actively involves everyone
4. An understanding of local health and
environmental issues
5. A community that participates in identifying local
solutions to local problems
6. A community whose members have access to
varied experiences, means of interaction and
communication
7. Accessible and appropriate health services and
facilities
8. The promotion and celebration of historical and
cultural heritage
9. A diverse and innovative economy
10. A sustainable use of available resources for all
WHEN THE CLIENT IS A COMMUNITY
• Nursing exists to address people’s health care
needs and nurses fulfill this purpose through
their work in various specialty area.
• Public Health Nursing is a specialty in which
the unit of care is a specific community or
aggregate, and the nurse has responsibility to
promote group health. The goal of this specialty
is health improvement of the community.
• Characteristics of Community or Public
Health Nursing are:
a. Community-oriented
b. Population-focused care
• Community Orientation is a process that is
actively shaped by the unique experiences,
knowledge, concerns, values, beliefs and culture
of a given community.
• The public health nurse does more than just
simply treat infection in individuals. The nurse
also:
a. uses disease investigation skills to locate
possible sources of infection
b. determines how the community’s
knowledge, values, beliefs, and prior experiences
with infectious disease may influence its
interpretation of the disease, response to the
outbreak and treatment preferences
c. uses knowledge and suggestions gathered
from the community to develop, in collaboration
with other health professionals, a community-
specific program to prevent future outbreak.
• Population is any group of people who share at
least one characteristic, such as age, gender,
race, a particular risk factor, or disease.
e.x. smokers and breast cancer survivors
• The concept of population may also include
delineation by time. (e.g. all infants born in same
year)
• A population focus implies that a nurse uses
population-based skills such as epidemiology,
research in community assessment, and
community organizing as the basis for
interventions.
• Community-oriented and population-
focused care employs population-based skills
and is shaped by the characteristics and needs of
a given community.
SOCIETAL INFLUENCES AND COMMUNITY-
ORIENTED, POPULATION-FOCUSED NURSING
• Society is constantly changing, and these
changes influence a community’s health, either
positively or negatively.
• For this reason, public health nurses need to
continually alter their strategies to respond to
these changing conditions.
• Societal Issues include:
1. Technology
a. Communication
b. Genetics, genomics and genetic
engineering
2. Global Economy
3. Migration
4. Terrorism and Bioterrorism
5. Climate change
Technology
• Refers to the application of science to change
processes of production or industry.
• The 20th century was filled with technologic
innovations that simultaneously disrupted old
patterns of production and created new
opportunities to increase production but new
technology also presents new challenges.
Communication Technology
• Because of advances in satellite and
telecommunications technology, communication
is possible anywhere in the world where
resources are available.
• Beneficial both for the public health nurse and
the health care consumers.
• Public Health Nurse must bear in mind that
disparities exist among those who have access to
new technology and those who do not.
• This could present a barrier to accessing critical
information to protect and promote health.
Genetics, Genomics, and Genetic Engineering
• Genetics – the science of heredity
• Genomics - the study of the entire genome
• Genetic engineering - the group of applied
techniques of genetics and biotechnology used to
cut up and join together genetic material
especially DNA from one or more species of
organism and to introduce the result into an
organism in order to change one or more of its
characteristics.
• The Public health Nurse has the responsibility to
be aware of the latest scientific information when
educating communities, so that decisions made
best fit the community’s value system.
• Advocating for the highest scientific rigor in
genetic engineering research is another
important role of public health nurse.
March 12, 2021 │ Compilation by April Tom O. Cuenca 2
• Healthy People 2020 objectives currently
include two recommendations related to
genomics:
1. For women at increased risk for breast,
ovarian, tubal, or peritoneal cancer to receive
genetic counseling
2. For people who are newly diagnosed with
colorectal cancer
Genomics
• Another rapidly changing field
• Issues of future exploration:
- Assuring privacy and confidentiality of
information acquired through genomics which
includes information in electronic health record,
implementation of testing and exploration of how
practitioners can use this information for patient
education and recommendations.
• The Human Genome Project has opened
dramatic possibilities for health and well- being,
as well as created ethical challenges in the near
future.
• Another source of concern is that science is
“playing God.”
• Genetic screening could be used to deny rights
and opportunities to people.
Global Economy
• The United Nations adopted the SDGs in an effort
to counter the impact of global poverty and
hunger.
• Interventions would focus on universal primary
education, improved maternal and child health,
address gender inequalities, promote
environmental stability and reduced rates of
HIV/AIDS and other communicable diseases.
• Financing for global health and shifts in
governance have potential to impact these goals.
• Universal health coverage (UHC) is another
economic issues that impacts the global
economy.
• The WHO is moving toward promoting UHC
globally.
Migration
• Is the act of moving from one region or country
to another, temporarily, seasonally, or
permanently.
• The health care needs of migrants and migrant
refugees are enormous.
• Environmental factors are a primary reason for
compromised health and include inadequate
waste disposal, crowded and unsanitary living
conditions, lack of access to healthful foods, and
air pollution.
• The Public Health Nurse ensure that surveillance
systems able to detect emerging health problems
are in place; programs to prevent health
problems and treat existing conditions also need
to be developed.
Terrorism and Bioterrorism
• Bioterrorism is the use of living organisms, such
as bacteria, viruses, or other organic materials to
harm or intimidate others, in order to achieve
political ends.
• Some of the possible biologic agents used include
Bacillus anthracis, smallpox virus, Brucella,
botulinum toxin
• The Public health nurse increasingly recognize
the need for skills in dealing with a bioterrorist
attack.
• They need to engage in emergency preparedness
activities and be prepared to initiate response
activities in the event of an actual bioterrorism
attack.
Climate Change
• Can be considered societal changes because they
may be influenced by economics.
• Carbon dioxide, methane, nitrous oxide created
by manufacturing industries,, automobile
emissions, consumer products, have been
introduced into the earth’s atmosphere.
• The Public health Nurse need to educate the
public about the potential dangers of continuing
to contaminate the environment and to advocate
for changes in public policy that reduce air and
water contaminants.
FACTORS AFFECTING HEALTH OF THE
COMMUNITY
PHYSICAL FACTORS
1. Industrial development
• Communities that are industrially developed are
more likely to be affected by numerous diseases
due to the toxic waste products from the
industries that are released into water bodies and
the atmosphere and due to the congestion of
settlement leading to slum development hence
contagious disease compared to areas that are
not industrially developed
2. Industrial development
• A densely populated or over populated
community can easily be attacked by
communicable diseases
3. Industrial development
• Some communities are more prone to diseases
due to the geographical location
• For example, some communities are located in
swampy areas are more prone to diseases
especially during heavy rains they are affected
by floods which can lead to the:
a. Manipulation of disease causing organisms if
the water is stagnant
b. Spread of disease causing organisms, like
malaria and diarrhea disease
March 12, 2021 │ Compilation by April Tom O. Cuenca 3
4. Environment
• A clean environment is very vital to the proper
health of a community which minimizes the
occurrence and transmission of diseases, unlike
a dirty environment which easily leads to
outbreak of diseases
SOCIO-CULTURAL FACTORS
1. Tradition Beliefs
• Beliefs or traditions possessed by communities
greatly affect the health of its people. For
example, the female genital mutilation (FGM)
2. Economy
• A community that is economically well-off has
low chances of suffering from disease breakouts
because they have proper health care and water
drainage systems unlike a poor community
3. Government
• Since the government involves planning,
implementing and provision of community
services such as water supply, medical supplies
and other needs which can directly affect the
community
4. Community Organization
• Ways in which communities organize their
resources such as taxes which can be very
helpful in control of diseases and supply of
sufficient and efficient medical care even in times
of crisis unlike communities without proper
accountability of their taxes which can partly be
allocated to the health sector
5. Individual Behavior
• Community health is greatly influenced by
individuals, their personal health, habits etc. And
in order to achieve a healthy community, it takes
a team work. For instance, proper disposal of
waste products from and individuals compound,
clearing all stagnant water in the compound to
prevent harboring of mosquitoes, active smokers
to quit smoking to avoid passive smokers thus
preventing lung cancer, abstainance from sexual
activities and for sexually active individuals to
use protection to prevent the spread of HIV/AiDs
and STDs etc. Thus proper individual healthy
living can greatly promote a healthy community.
6. Educational factors
• Poor education or illiteracy affects the health of
a community when people doesn’t have
education on how they can prevent themselves
from disease.
Ex. Health education on the use of mosquito
treated nets to prevent malaria, health education
on the environmental hygiene so as to prevent
diseases such as cholera and trachoma
ROLES AND ACTIVITIES OF A COMMUNITY
HEALTH NURSE
• Role refers to a set of behavior patterns that are
deemed appropriate for and expected of a person
by virtue of his/her status in society and/or a
position he/she occupies in an organization.
• Activities and tasks are units of a function
• An activity is a combination of specific tasks
whose fulfillment leads directly to the
performance of a function.
• A task, on the other hand, is a set of action or
piece of work that needs to be done to fulfill a
given activity.
1. Care Provider
• She provides a continuous and comprehensive
care to the family, group of people and
community at large
2. Health Educator
• The community health nurse educations the
individual, family, groups of people and
community at large
3. Counsellor
• The community health nurse helps individual,
families and the community at large to recognize
and understand their problems to be solved, find
solutions within resources and implement
feasible and acceptable solutions
• Advice, help, support, tips, guidance, and
assistance
4. Resource Person (Human Resources)
• The community health nurse explores
community resources in terms of money,
manpower, material and agencies
• She makes use of these resources in helping
individual, family groups and community to meet
their health and nursing needs
5. Sensitive Observer
• The community health nurse makes observations
of any untoward change in health behavior and
health status of the community, people, their
surroundings, unusual occurrence of disease and
take action accordingly
Ex. Proving information, health education to
people to improve their behavior and health
status, working with the family and provide
direct care during illness, notification to health
authority about communicable disease
6. Advisor
• The community health nurse gives some
suggestions on practical situation which requires
immediate actions and where there is little scope
of health education.
7. Planner
• The community health nurse while giving
comprehensive care to family and community
makes a plan on the basis of identified health
problems and health nursing needs
8. Care Manager
• The community health nurse implements the
care which is planned for the family and
community
• She directly provides the care with the active
participation of family and community members
• She makes use of family and community
resources
• She guides the family and the community and
refers when required. She maintains a record of
the care given to families and the community.
9. Medical Assistant
• The community health nurse assists the
physician and coordinates with the other team
members in the community health care team in
rendering community health services
March 12, 2021 │ Compilation by April Tom O. Cuenca 4
10. Health Monitor • In cities, births & deaths are registered at the
• Detecting deviations from health in individuals, City Health Department.
families, specific population groups and the
community as a whole through contacts and Use of Vital Statistics
visits with them and with the use of scientific, • Indices of the health & illness status of the
systematic, valid and reliable assessment community.
methods and tools • Serves as bases for planning, implementing,
11. Health Monitor monitoring & evaluating community health
• Corollary to the roles of a health teacher and nursing programs and services.
counselor is that of a change agent
Ex. Changing individual, family, group or Sources of Demographic Data
community behavior, including lifestyle and the • Census of population
environment, in order to promote and maintain - population, demographic structure and
health characteristics
• Registration of vital statistics
TOOLS OF STATISTICS - population processes of births and death
Statistics • Administrative data
- local population changes, geographic mobility
• Refers to a systematic approach of obtaining,
and migration
organizing, and analyzing numerical facts so that
conclusion may be drawn from them.
Health Indicators
Demography • Rate – shows the relationship between a vital
event & those persons exposed to the occurrence
• Is the statistical study of human populations.
of said event, within a given area & during a
• Examines the size, structure, and movements of
specified unit of time.
populations over space and time.
• Ratio - used to describe the relationship
• Is useful for governments and private businesses
between two (2) numerical quantities or
as a means of analyzing and predicting
measures of events.
social, cultural, and economic trends related
• Crude or General Rates - referred to the total
to population.
living population. It is presumed that the total
• Researchers use demographic analysis to
population was exposed to the risk of the
analyze whole societies or just groups of people.
occurrence of the event.
• Some examples of demographics are age, sex,
• Specific rate - the relationship is for a specific
education, nationality, ethnicity, or religion, to
population class or group
name a few
Measures of Fertility or Natality
Composition
• In statistics, compositional data are quantitative
Crude Birth Rate (CBR) – the number of live births
descriptions of the parts of some whole,
per 1000 population in a given calendar year
conveying relative information.
• Mathematically, compositional data is
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑎 𝑐𝑎𝑙𝑒𝑛𝑑𝑎𝑟 𝑦𝑟 𝑥 1000
represented by points on a simplex.
𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑦𝑟
• Measurements involving probabilities,
proportions, percentages, and ppm can all be
Crude Death Rate (CDR)
thought of as compositional data.
• A measure of one mortality from all causes which
may result in a decrease of population
Distribution
• The number of death from all causes per 1000
• Is the arrangement of the population at a given
population in a given calendar year.
time, geographically or among various types of
residential areas. 𝑇𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑖𝑛 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑐𝑎𝑙𝑒𝑛𝑑𝑎𝑟 𝑦𝑟 𝑥 1000
𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑠 𝑜𝑓 𝐽𝑢𝑙𝑦 1 𝑜𝑓 𝑠𝑎𝑚𝑒 𝑦𝑟
Vital Statistics
• Refers to the systematic study of vital events Infant Mortality Rate (IMR)
such as births, illnesses, marriages, divorce, • Measures the risk of dying during the 1st year of
separation and deaths. life.
• Statistics of disease (morbidity) & death • A good index of the general health condition of a
(mortality) indicate the state of health of a community since it reflects the changes in the
community & the success or failure of health environment.
work
• Statistics on population & the characteristics 𝑇𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑢𝑛𝑑𝑒𝑟 1 𝑦𝑟 𝑜𝑓 𝑎𝑔𝑒 𝑖𝑛 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑐𝑎𝑙𝑒𝑛𝑑𝑎𝑟 𝑦𝑟 𝑥 1000
such as age, & sex, distribution are obtained
𝑇𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑜𝑓 𝑠𝑎𝑚𝑒 𝑐𝑎𝑙𝑒𝑛𝑑𝑎𝑟 𝑦𝑟
from the National Statistics Office (NSO) now
Philippine Statistics Authority (PSA)
• Births and deaths are registered in the Office of
the Local Civil Registrar of the municipality or
city.

March 12, 2021 │ Compilation by April Tom O. Cuenca 5

Neonatal Death Rate (NDR) Functions of the Nurse
• Measures the risk of dying the 1st month of life. 1. Collects data
• It serves as an index of the effects of prenatal care 2. Tabulates data
and obstetrical management of the newborn. 3. Analyzes and interprets data
4. Evaluates data
# 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑢𝑛𝑑𝑒𝑟 28 𝑑𝑎𝑦𝑠 𝑜𝑓 𝑎𝑔𝑒 𝑖𝑛 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑐𝑎𝑙𝑒𝑛𝑑𝑎𝑟 𝑦𝑒𝑎𝑟 𝑥 1000 5. Recommends redirection or strengthening of
# 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑜𝑓 𝑠𝑎𝑚𝑒 𝑐𝑎𝑙𝑒𝑛𝑑𝑎𝑟 𝑦𝑒𝑎𝑟 specific areas of health programs as needed.

Maternal Mortality Rate (MMR) HEALTH SITUATION IN THE PHILIPPINES

• Measures the risk of dying from causes related to
pregnancy, childbirth & puerperium Philippine Demographics
• An index of the obstetrical care needed & received • The current population of the Philippines is
by women in a community 110,551, 676 (as of Wednesday, March 3, 2021
based on Worldometer elaboration of the latest
𝑇𝑜𝑡𝑎𝑙 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑓𝑟𝑜𝑚 𝑚𝑎𝑡𝑒𝑟𝑛𝑎𝑙 𝑐𝑎𝑢𝑠𝑒𝑠 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑥 1000 United Nations data)
𝑓𝑜𝑟 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑦𝑒𝑎𝑟 • The Philippines population is equivalent to 1.41%
𝑇𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑜𝑓 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟 of the total world population.
• The Philippines ranks number 13 in the list of
Incidence Rate (IR) countries (and dependencies) by population
• The number of new cases of a disease per 100,000 • Population: Sex ratio (2016)
population in a given time interval, usually a calendar a. Male – 1.01
year. b. Female – 1.0
• Total fertility rate (2016) is 3.06 child per
# 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎 𝑝𝑎𝑟𝑡𝑖𝑐𝑢𝑙𝑎𝑟 𝑑𝑠𝑒 𝑟𝑒𝑠𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑑𝑢𝑟𝑖𝑛𝑔 𝑥 1000 woman
𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒 • Life expectancy is 71.7 years (life expectancy
𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑠 𝑜𝑓 𝐽𝑢𝑙𝑦 𝑜𝑓 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟 at birth, both sexes)
• Life expectancy at birth by sexes:
Prevalence Rate (PR) a. Male – 67.7 years
• Measures the proportion of the population which b. Female – 75.9 years
exhibits a particular disease at a particular time. • Crude death rate (2016) is 6.1 deaths per
• Determined following a survey of the population 1000 persons
concerned, deals with total(new and old) number of • Infant mortality rate is 17.5 infant deaths per
cases 1000 live births
• Deaths under age 5 is 24.8 per 1000 live births
# 𝑜𝑓 𝑛𝑒𝑤 𝑎𝑛𝑑 𝑜𝑙𝑑 𝑜𝑓 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑥 1000
𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑎𝑡 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒 Dependency Ratio
𝑇𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑒𝑥𝑎𝑚𝑖𝑛𝑒𝑑 𝑎𝑡 𝑎 𝑠𝑎𝑚𝑒 𝑔𝑖𝑣𝑒𝑛 𝑡𝑖𝑚𝑒 • Three types of age dependency ratio:
1. Youth dependency ratio
Case Fatality Ratio (CFR) o Definition: population ages 0-15 divided
• Index of a killing power of a disease and is by the population ages 16-64.
influenced by incomplete reporting and poor o Formula: ([Population ages 0-15] ÷
morbidity data [Population ages 16-64]) × 100
2. Elderly dependency ratio
# 𝑜𝑓 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑑𝑒𝑎𝑡ℎ𝑠 𝑓𝑟𝑜𝑚 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 1000 o Definition: population ages 65-plus
𝑓𝑜𝑟 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑦𝑒𝑎𝑟 divided by the population ages 16-64.
𝑁𝑜. 𝑜𝑓 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑐𝑎𝑠𝑒𝑠 𝑓𝑟𝑜𝑚 𝑠𝑎𝑚𝑒 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 o Formula: ([Population ages 65-plus] ÷
𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟 [Population ages 16-64]) × 100
3. Total dependency ratio
Presentation of Data o Definition: sum of the youth and old-age
• The following are most commonly used graphs in ratios
presenting data: o Formula: (([Population ages 0-15] +
[Population ages 65-plus]) ÷ [Population
Line or curved graphs ages 16-64]) × 100
• Shows peaks, valleys & seasonal trends. Used to
show the trends of birth & death rates over a Ten Leading Causes of Mortality (2019)
period of time. 1. Ischaemic heart diseases 97,475 (15.7%)
Bar graphs 2. Neoplasms (“cancer”) 68,657 (11.1%)
• Each bar represents a quantity in terms of rates 3. Cerebrovascular diseases 63,548 (10.2%)
or percentage of a particular observation. 4. Pneumonia
Area diagram (pie charts) 5. Diabetes Mellitus
• Shows the relative importance of parts to the 6. Hypertensive disease
whole 7. Chronic Lower respiratory infections
8. Respiratory tuberculosis
9. Other heart diseases
10. Remainder of diseases of the genitourinary

March 12, 2021 │ Compilation by April Tom O. Cuenca 6

 CONCEPTS BASIC TO EPIDEMIOLOGY
Epidemiology
• The term is derived from the Greek words “epi”
(upon), “demos” (the people) and “logos”
(knowledge).
• The knowledge or study of what happens to
people.
• Is the scientific discipline that studies the
distribution and determinants of health-related
states or events in specified populations, and the
application of this study to the control of health
problems.
• The study of occurrence & distribution of
diseases as well as the distribution &
determinants of health states or events in
specified population
• It is the backbone of the prevention of the
disease.
Two Main Areas of Investigation
1. The study of distribution of disease
- Describes the health status in terms of age,
gender, race, geography and time
2. The search for the determinants (causes) of
the disease & its observed distributions
- Disease distribution in terms of causal factors
Uses of Epidemiology (Morris)
• Study the history of the health population & the
rise & fall of disease & changes in their character.
• Diagnose the health of the community & the
condition of the people
• Study the work of health services with a view of
improving them.
• Estimate the risk of disease, accident, defects &
the chances of avoiding them.
• Identify syndromes by describing the distribution
& association of clinical phenomena in the
population.
• Complete the clinical picture of chronic disease &
describe their natural history.
• Search for causes of health & disease by
comparing the experience of groups that are
clearly defined by their composition, inheritance,
experience, behavior & environments.
Epidemiological Triangle or Triad
• Host, Agent and Environmental Model
• Epidemiologist began to consider disease states
generally
• Interactions among these three elements
explained infectious and other disease patterns.
The Ecological Triangle
Host
Disease Agent Environment
The Man Disease-Environment Ecological Triangle
1. Host
• It is a susceptible human or animal who harbors
and nourishes a disease-causing agent.
• Many physical, psychological, and lifestyle
factors influence the host’s susceptibility and
response to an agent.
• Inherent resistance-ability to resist pathogen
2. Agent
• It is a factor that causes or contributes to a
health problem or condition.
• Causative agents can be factors that are present
(bacteria) or factors that are lacking (low serum
iron level)
• May also be classified as infectious or
noninfectious
• Infectious agents cause communicable diseases
such as AIDS or tuberculosis.
• Noninfectious agents have similar characteristics
in that their relative abilities to harm the host
vary with type of agent
3. Environment
• Refers to all the external factors surrounding the
host that might influence vulnerability or
resistance.
• Physical environment such as geography,
climate, weather, water, food supply.
• Psychosocial environment refers to social,
cultural, economic and psychological influences.
In the Man-Disease Agent-Environment triad,
we can do three preventive strategies namely:
1. First strategy: Change the people’s behavior
to manipulate environment and reduce their
exposure to biological and non-biological disease
agents.
2. Second strategy: Manipulate the environment to
prevent production or presence of disease
agents
3. Third strategy: Increase man’s resistance or
immunity to infectious disease agents.
Causality
• Refers to the relationship between a cause and
its effect.
• The purpose of epidemiologic study has been to
discover causal relationships, in order to
understand why conditions develop, and to offer
effective prevention and protection.
March 12, 2021 │ Compilation by April Tom O. Cuenca 7
Immunity NATURAL HISTORY OF A DISEASE
• Refers to a host’s ability to resist a particular
• Any disease or health condition follows a
infectious disease-causing agent.
progression known as its natural history, this
• This occurs when the body forms antibodies and
refers to events that occur before its
lymphocytes that react with the foreign antigenic
development, during its course, and during its
molecules and render them harmless.
conclusion.
Four Types of Immunity
The Four Stages
1. Passive Immunity Phase 1:
1. Susceptibility stage
• Refers to short-term resistance that is acquired Pre-pathogenesis
2. Subclinical disease stage
either naturally or artificially.
3. Clinical disease stage
• Newborns, through maternal antibody transfer, Phase 2: Pathogenesis
4. Resolution stage
have natural passive immunity that lasts up to 1
year for certain disease.
Exposure
• Artificial passive immunity through inoculation
Stage 1 Stage 2 Stage 3 Stage 4
with antibody .
Ex. Hep. A, Hep. B, Measles
Susceptibility Subclinical Clinical Recovery,
2. Active Immunity
Disease Disease disability or
• It is long-term and sometimes offers life-long
death
resistance that is acquired either naturally or
artificially.
• Naturally acquired active immunity comes Natural History Stages of a Disease
through host infection . A disease often develops • Stage 1 - host and environment factors
long-lasting antibodies. influence population’s vulnerability
• Artificially acquired active immunity through • Stage 2 – invasion by causative agent; people
vaccination from killed (inactivated) or live are asymptomatic
attenuated (weakened) • Stage 3 - disease or condition evident in
3. Cross-Immunity population
• Refers to a situation in which a person’s • Stage 4 - disease or condition concludes in
immunity to one agent provides immunity to a renewed health, disability or death
related agent as well.
• The immunity can be either passive or active. Levels of Prevention Pyramid
• The vaccine against Mycobacterium tuberculosis
appeared to provide these individuals with a
degree of cross-immunity to the related
infectious agent, Mycobaterium leprae.
4. Herd Immunity
• Describes the immunity level that is present in a
population group.
• A population with low herd immunity is one with
few immune members, consequently, it is more
susceptible to a particular disease.
• Nonimmune people are more likely to contract
the disease and spread it throughout the group, Primary Prevention
placing the entire population at greater risk.
Health Promotion Health Protection
Risk and Education
• It is the probability that a disease or other May include: May include:
unfavorable health condition will develop. Nutrition counseling - Improved housing and
• Risk of developing a health problem is either - Diabetes sanitation-waterborne
influenced by their: Sex education disease
- biology – Pregnancy - Immunizations
- environment Smoking cessation - Removal of
- lifestyle - Lung cancer environmental hazards
- system of health care
Secondary Prevention
Risk Factors
• Are negative influences. Early Diagnosis Prompt Treatment
• The degree of risk is directly linked to
susceptibility or vulnerability to a given health The third stage of - Initiate prompt
problem. disease, the early treatment
pathogenesis or - Arrest progression
onset - Prevent associated
disability
Screening program

March 12, 2021 │ Compilation by April Tom O. Cuenca 8

 - Breast & testicular
cancer
Tertiary Prevention
Rehabilitation
- Reduce the extent and severity of a health
problem to minimize disability
- Restore or preserve function
Causality
• Refers to the relationship between a cause and
its effect.
• The purpose of epidemiologic study has been to
discover causal relationships, in order to
understand why conditions develop, and to offer
effective prevention and protection.
Disease Distribution
• The methods and technique of epidemiology are
desired to detect the cause of a disease.
• Three (3) epidemiology variables:
a. Time
- Refers both to the period during which the
cases of the disease being studied were
exposed to the source of infection and the
period during which the illness occurred.
b. Person
- Refers to the characteristics of the individual
who were exposed and who
contacted the infection or the disease in
question.
- Age, sex and occupation
c. Place
- Refers to the features, factor or conditions
which existed in or described the environment
in which the disease occurred.
- Urban or rural differences
- Socio-economic areas
Patterns of Occurrence and Distribution
1. Sporadic
• It is the intermittent occurrence of a few
isolated & unrelated cases in a given locality.
• The cases are few & scattered
• Ex: tetanus, rabies, and plague.
2. Endemic
• Continuous occurrence throughout a period of
time, of the usual number of cases in a given
locality
• The disease is more or less inherent in that
locality
• Ex. Schistosomiasis, malaria
3. Epidemic
• It is of unusually large number of cases in a
relatively short period of time.
• A problem that grew out of control.
• Ex. Measles outbreak, Dengue
4. Pandemic
• simultaneous occurrence of epidemic of the
same disease in several countries.
• More global affecting the whole country or even
the whole world.
• Ex. COVID-19
EPIDEMICS
Epidemics
• Of the pattern of occurrence of disease, epidemic
is the most interesting and meaningful as it
demands immediate effective action which
includes epidemiological investigation.
Factors Contributory to Epidemic Occurrence
1. Agent – the result of the introduction of new
disease agents into the population
2. Host – related to lower resistance as a result of
exposure or change of immunity and
susceptibility.
3. Environmental – change in physical
environment, temperature, humidity
Goals of Epidemiologic Investigation
• To identify the causal mechanisms of health and
illness.
Methods in the Epidemiologic Investigative
Process
1. Descriptive Epidemiology
• Includes investigations that seek to observe and
describe patterns of health related conditions
concerned with disease distribution & frequency.
• Seeks to establish occurrence of a problem
• Data suggest hypothesis for further testing
• Ex: The nurse might seek to learn
- How many children in a school district have
been immunized for measles
- How man home births occur each year - how
many cases of STDs
• Measures:
- Counts
- Incidence
- Rates
- Prevalence
2. Analytic Epidemiology
• Seek to identify associations between a
particular human disease or health problem and
its possible causes
• Analyze the causes or determinants of disease
thru hypothesis testing
• Three (3) types of analytic studies:
a. Prevalence studies – describes patterns of
occurrence
b. Case-Control studies – compares people
who have a health or illness condition (number
of cases with the condition) with those who lack
this condition (control)
c. Cohort studies – a group of people who share
a common experience in a specific time period.
3. Experimental Epidemiology
March 12, 2021 │ Compilation by April Tom O. Cuenca 9
• Answers questions about the effectiveness of
new methods for controlling diseases or for
improving underlying conditions
• Builds on information gathered from descriptive
and analytic approaches.
Outline of Plan for Epidemiological
Investigation
1. Establish fact of presence of epidemic
- Verify diagnosis (clinical & laboratory studies)
- Reporting
- Unusual prevalence of the disease (past
experience of a given community)
2. Establish time and space relationship of the
disease
- Are the cases limited or concentrated in any
particular geographical subdivision of the
affected community
- Relation of cases by days of onset to onset of
the first known cases
3. Relations to characteristic of the group of
community
- Relation of cases to age, group, sex, color
- Relation of sanitary facilities
- Relation of cases and known carriers if any
4. Correlation of all data obtained
- Summarize the data clearly with the aid of such
tables and charts which are necessary to give a
clear picture of the situation
- Make suggestion as to the control, if disease is
still present in community and some prevention
of future outbreaks.
National Epidemic Sentinel Surveillance System
(NESS)
• Is a hospital based information system that
monitors the occurrence of infectious disease
with outbreak potential.
• It also serves as a supplemental information of
the Department of Health
Objectives of NESS
1. To provide early warning on occurrence of
outbreaks.
2. To provide program managers, policy makers and
public administrators, rapid, accurate and timely
information so that inventive and control measures
can be instituted.
Importance of Outbreak Investigation
1. Control and prevention measure
2. Severity and risk to others
3. Research opportunities
4. Public, political or legal concerns
5. Program consideration
6. Training
Dsda

Public Health Surveillance

• Is a continuous (on-going) systematic collection,
analysis, interpretation and dissemination of
health data.
• Surveillance system is often considered
information loops or cycles involving health
providers, public health agencies and the public.

Field Health Services Information System

(FHSIS)
• It is a network information source developed by
the Department of Health (DOH)
• It is intended to address the short-term data
needs of the DOH staff with managerial or
supervising functions in the DOH facilities and in
each of the program areas.
• The process of storing and retrieving information
is a crucial part of the documentation
responsibilities of the nurse.

List of FHSIS Report and Forms

1. Upon Occurrence of Events
- FHSIS/E-1 notification of death form
- FHSIS/E-2 Maternal death report
- FHSIS/E-3 Perinatal death report
2. Weekly
3. Monthly
- FHSIS/M-1
4. Quarterly
- FHSIS/Q-1
5. Annual
- FHSIS/A-1

March 12, 2021 │ Compilation by April Tom O. Cuenca 10

MATERNAL AND CHILD HEALTH NURSING
LECTURE PRELIMS COVERAGE
NURSING CARE OF A FAMILY EXPERIENCING A
PREGNANCY COMPLICATION FROM A
PREEXISTING OR NEWLY ACQUIRED ILLNESS
3.
Overview
• Although pregnancy can be a stressful time,
generally women experience overall good health
during pregnancy, perhaps, in part because of
their extra care and concern in healthy for two.
This extra motivation also encourages a woman
with a high risk pregnancy to carefully follow a
therapeutic regimen established for her to help
or to keep herself and her fetus safe.
4.
High Risk Pregnancy
• All types of women desire pregnancy, including
those with an underlying disease process such as
diabetes or heart disease which can worsen with
pregnancy.
• Some complications lead to early pregnancy loss
or preterm delivery. Other complications arise
due to specific characteristics of the mother such
as her age or her use of substances.
• High risk pregnancy may include those with
concurrent disorders, pregnancy-related
complications and those with external factors
that jeopardizes the health of the woman, fetus,
or both.
• It is important that women with such
pregnancies be identified because illness during
pregnancy can complicate not only the
pregnancy but also a woman’s entire lifestyle and
that of her family.
A Woman with Cardiac Disease
• All types of women desire pregnancy, including
those with an underlying disease process such as
diabetes or heart disease which can worsen with
pregnancy.
ASSESSMENT
• Assessment may include that nurses play a
major role in the care of pregnant women with
cardiovascular disease because continuous
assessment of women without health status,
health education and health promotion activities
are essential.
• Assessment begins with a thorough health
history to document the pre-pregnancy cardiac
status.
1. FATIGUE
• Try to document a woman’s level of
exercise performance.
Example: What level she can do before
growing short of breath and what
physical symptoms she can experience.
It could be cyanosis of the lips or nail
bed.
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
2. COUGH
• It is important that women with cardiac
disease always report coughing during
pregnancy because pulmonary edema
from heart failure may manifest first as
cough.
EDEMA
• Documenting edema is also important
because the usual innocent edema of
pregnancy must be distinguished from
the beginning of edema from a heart
failure which is serious. The important
difference is that the usual edema of
pregnancy involves only the feet and
ankles but becomes systemic with heart
failure.
IRREGULAR PULSE, RAPID OR
DIFFICULT RESPIRATIONS, AND CHEST
PAIN ON EXERTION
INTERVENTIONS:
• Be certain that goals and outcomes
established with a woman with heart
disease are realistic.
• There are positive actions a woman with
heart disease can take to reduce or
eliminate complications during
pregnancy.
a. Promote rest. As a rule, women with
cardiac disease need two rest periods a
day and a full night’s sleep. Rest should
be in the left lateral recumbent position
to prevent hypotension syndrome and
increase heart effort.
b. Promote health nutrition. Be certain
that the pregnant woman takes prenatal
vitamins that contains iron to prevent
anemia because it places an extra
burden on the heart. It is important to
prevent anemia because it causes our
circulatory system to circulate more
vigorously. We also have to limit sodium
intake, so it is important to obtain
enough sodium to maintain fluid volume
and balance, as well as to furnish an
adequate supply of blood to the fetus.
c. Educate regarding medications.
Digoxin - A woman taking cardiac
medications such as digoxin before
pregnancy may need to increase their
maintenance dose because of their
expanded blood volume during
pregnancy. A woman not taking before
pregnancy may need such therapy
prescribed as pregnancy advances and
her cardiac output has to be increased
and should be strengthened.
Penicillin - A woman taking penicillin
prophylactically because she had
arrhythmic fever as a child should
continue to take this drug during
pregnancy because penicillin is not
known to be a teratogen.
1
 Ampicillin, amoxicillin, and 2. Eat a diet high in iron and vitamins -
clindamycin – This is to prevent Examples are green leafy vegetables, meat, and
streptococci bacteria from invading the legumes.
denuded placental site on the uterus and 3. Prescribe therapeutic levels of medication –
creating a subacute bacterial 100 to 200 mg of elemental iron per day in the
endocarditis. form of ferrous sulfate or ferrous gluconate.
d. Educate regarding the avoidance of Some women report constipation or gastric
infection – Systemic infection almost irritation, so they have to increase roughage in
automatically increases the body the diet and always taking the pills with food can
temperature, forcing a woman to spend help reduce the symptoms. We also have to
more energy and increase the cardiac caution the woman about ferrous sulfate which
output as her metabolism increases turns stool to color black.
which is an effect that could be too
extreme for a woman with heart disease A Woman with Urinary Tract Infection
to withstand. We also have to tell the
• In pregnant women, stasis of urine occurs due to
pregnant woman to avoid visiting or
the dilated ureters from the effect of
being visited by people with infections.
progesterone. So, asymptomatic infections are
e. Inform the pregnant woman to be
potentially dangerous because they can progress
prepared for any emergency actions
to pyelonephritis and are associated with
– If woman with heart disease overexert
preterm labor and premature rupture of
during a prenatal visit, they may need
membrane.
supplemental oxygen or cardiac
• The organism most commonly responsible for
resuscitation.
UTI is the E.coli or the Escherichia coli.

A Woman with Iron-Deficiency Anemia

ASSESSMENT
• Because blood volume expands during
1. Frequency and pain on urination
pregnancy slightly ahead of the red cell count,
2. If it progresses to pyelonephritis the woman may
most women have a pseudo-anemia especially
experience:
during early pregnancy.
a. Pain in the lumbar region, specifically at the
• True anemia is typically considered to be
right side that radiates downward area and feels
present when a woman’s hemoglobin
tender during palpation
concentration is around 11 grams per dL
b. Nausea and vomiting
(deciliter) or hematocrit of less than 33.
c. Malaise
• Iron-deficiency anemia is the most common
d. Pain
anemia of pregnancy. This type of anemia is
e. Frequency on/and urination
characteristically a micro-acetic and
f. Elevated temperature
hypochromic anemia.

THERAPEUTIC MANAGEMENT
COMMON CAUSES
1. Obtain a clean catch urine sample for
1. Diet low in iron
culture and sensitivity – This is to assess for
2. Heavy menstrual periods
asymptomatic bacteria or symptoms of UTI.
3. Unwise weight-reducing programs
Sensitivity test will determine which antibiotic
4. Women with less than 2 years before the
will best combat the infection.
concurrent pregnancy
2. Administer either amoxicillin, ampicillin, or
5. Low socioeconomic levels who have not had iron-
cephalosporins – These are effective against
rich diet
most organisms causing UTI and are safe
antibiotics during pregnancy.
ASSESSMENT
1. A woman experiences extreme fatigue and poor
exercise tolerance because she cannot transport
oxygen effectively
2. The condition is mildly associated with low birth
weight and preterm birth
3. Pica or cravings and eating of substances such as
ice or starch
4. The women experiences restless leg syndrome

PREVENTION
1. Women should take prenatal vitamins
containing 27mg of iron - Iron is absorbed
best in acid medium. Advise women therefore to
take supplements with orange juice or vitamin C
supplement.

Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio 2
A Woman with Asthma
• Asthma is a disorder marked by reversible air
flow obstruction airway hyperactivity and airway
inflammation.
• Symptoms are often triggered by an inhaled
allergen such as pollen or cigarette smoke.
• Asthma has the potential of reducing the oxygen
supply to a fetus leading to a preterm birth or
fetal growth restriction if a major attack should
occur during pregnancy, however, this is less of
a threat especially with well-managed asthma.
SIGNS AND SYMPTOMS
1. Chronic constriction of the bronchial smooth
muscle
2. Marked mucosal inflammation and swelling
3. Production of thick bronchial secretions
• These three processes causes a woman to have
difficulty pulling in air on exhalation, difficulty
releasing air, and makes high-pitched whistling
sound from air being pushed past the bronchial
narrowing
INTERVENTIONS
1. Administering corticosteroid
2. IV Administration of hydrocortisone because of
the added stress during pregnancy
3. Administering terbutaline and albuterol which
may be taken safely during pregnancy. Potential
to reduce labor contractions calls for the need to
taper dosage to term if possible. Tapered means
from smaller amounts to bigger amounts.
A Woman with Hepatitis
• Hepatitis is a liver disease that occurs from
invasion of the hepatitis A,B, C, D, and E viruses.
• Hepatitis during pregnancy may lead to
spontaneous miscarriage or pre-term labor.
CLASSIFICATION
1. Hepatitis A – Spread mainly by fecal oral
contact, so children in daycare settings have a
high incidence of hepatitis A. It can be also
spread by ingestion of fecally contaminated
water or shellfish. It has an incubation period of
around 2-6 weeks. Pregnant women exposed to
hepatitis A may be given prophylactic globulin to
try to prevent the disease after exposure. This
form of hepatitis follows a rather benign course
and is not thought to be transmitted to the fetus.
2. Hepatitis B and C – Spread by exposure to
contaminated blood or blood products or by
contact with contaminated semen or vaginal
secretions which are also considered as sexually
transmitted infections. This can be transmitted to
the fetus across the placenta.
a. Hepatitis B - Occurs about 1 in every 2,000
pregnancies and it has an incubation period of 6
weeks – 6 months. It occurs in both an acute and
chronic form leading to liver cell necrosis with
scarring and inability to convert indirect to direct
bilirubin or to excrete and direct bilirubin.
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
b. Hepatitis C – Demonstrates few symptoms
and may not be present for 12 months after
exposure. It is however the most common cause
of chronic liver disease and liver transplantation
in the United States.
3. Hepatitis D and E – Are spread by the same
methods as hepatitis B and C but are rarely seen
among women.
ASSESSMENT
1. Nausea and vomiting
2. Liver area may feel tender to palpation
3. Dark yellow urine due to the excretion of bilirubin
4. Light colored stool due to the lack of bilirubin
5. Jaundice which is a late symptom of hepatitis
6. Hepatomegaly
7. Increased serum bilirubin levels
8. Increased liver enzymes
THERAPEUTIC MANAGEMENT
1. Prescribe bed rest
2. Encourage to eat high calorie diet because her
liver has difficulty converting stored glycogen
into glucose in its disease state and so
hypoglycemia can occur
3. A cesarean birth may be planned a term to
reduce the possibility of blood exchange between
the mother and the fetus
4. Follow a standard infection precaution when you
give care to avoid contact with body fluids
A Woman with Diabetes Mellitus
• Diabetes mellitus is an endocrine disorder in
which the pancreas cannot produce adequate
insulin.
• To regulate body glucose level, the primary
concern for any woman with this disorder is
controlling the balance between insulin and blood
glucose levels to prevent hyperglycemia or
hypoglycemia. Both of these conditions are
dangerous during pregnancy, not only because
of long-term effects on the woman’s health but
also because of the threat to normal fetal growth.
CLASSIFICATION
1. Type 1 – State characterized by the destruction
of the beta cells in the pancreas that usually
leads to absolute insulin deficiency.
a. Immune-mediated type 1 diabetes
mellitus results from autoimmune destruction of
the beta cells
b. Idiopathic type 1 diabetes mellitus refers
to forms that have no known cause
2. Type 2 – State that usually arises because of
insulin resistance combined with a relative
deficiency in the production of the insulin.
3. Gestational diabetes – A condition of abnormal
glucose metabolism that arises during
pregnancy. Possible signal of an increased risk
for type 2 diabetes later in life.
3
4. Impaired glucose homeostasis – State NURSING CARE OF A FAMILY EXPERIENCING A
between normal and diabetes in which the body SUDDEN PREGNANCY COMPLICATION
is no longer using and or secreting insulin
properly. Impaired fasting glucose is a state
when fasting plasma glucose is at least 110 but Overview
under 126 mg/dL, while impaired glucose • Most women who enter pregnancy is in good
tolerance is a state when results of the oral health, so we should expect women to complete
glucose tolerance tests are at least 140 but under a pregnancy and birth without complications.
200 mg/dL in a 1-hour sample. • In few women, however, unexpected deviations
or complications from the course of normal
RISK FACTORS FOR DEVELOPING pregnancy occurs which place a severe burden
GESTATIONAL DIABETES on a woman and her family, and of course to her
1. Obesity health care providers.
2. Age over 25 years old
Bleeding During Pregnancy
3. History of large babies
4. History of unexplained fetal or perinatal loss a) Vaginal bleeding during pregnancy is always a
5. History of congenital anomalies in previous deviation from the normal
pregnancies b) It is always potentially serious
6. History of polycystic ovary syndrome c) It may occur at any point during pregnancy
7. Family history of diabetes d) It is s always frightening
8. Member of a population with a high risk for e) It must be carefully investigated because it can
diabetes impair both the outcome of the pregnancy and
the woman’s health or life.
ASSESSMENT CAUSES OF BLEEDING DURING PREGNANCY
1. A fasting plasma glucose greater than or equal to FIRST TRIMESTER: Miscarriage (either threatened
126 mg/dL spontaneous, imminent, missed, incomplete,
2. A non-fasting plasma glucose greater than or spontaneous, complete spontaneous, or ectopic
equal to 200 mg/dL pregnancy)
3. 50g glucose challenge test results around
140mg/dL during 24-28 weeks of gestation SECOND TRIMESTER: Gestational trophoblastic
• This is to determine if they are at risk for disease (hydatidiform mole) or premature cervical
gestational diabetes dilatation

THIRD TRIMESTER: Placenta previa, abruptio

HOW IS GLUCOSE TOLERANCE TEST DONE?
placenta, and preterm labor
• After a fasting glucose sample is obtained, the
woman drinks around 100g of oral glucose SIGNS AND SYMPTOMS OF HYPOVOLEMIC
solution then after that a venous blood sample is SHOCK
taken for glucose determination. It is taken after 1. Increased pulse rate since the heart attempts
an hour, after two hours and three hours later. If to circulate and decrease blood volume
two of the four blood samples collected for this 2. Decreased blood pressure because there is
test are abnormal or the fasting value is above less peripheral resistance which is present
95 mg/dl, a diagnosis of diabetes is made. because of decreased blood volume
• The normal values are most likely: 3. Increased respiratory rate as the respiratory
Fasting – 96 mg/dL system attempts to increase gas exchange to
After an hour – 180 mg/dL better oxygenate and decrease red blood cell
After two hours – 155 mg/dL volume
After three hours – 140 mg/dL 4. Cold clammy skin due to vasoconstriction that
occurs to maintain blood volume in the central
body core
5. Decreased urine output since there is
inadequate blood that is entering the kidneys
because of decreased blood volume
6. Dizziness or decreased level of
consciousness since there is an inadequate
blood that is reaching the cerebrum because of
the decreased blood volume
7. Decreased central venous pressure since
decreased blood is returning to the heart
because of the main reason which is decreased
blood volume

Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio 4
Spontaneous Miscarriage
What is the difference between abortion and
miscarriage?
• Abortion is a medical term for any interruption
of pregnancy before a fetus is viable, so it is
better to speak of these early pregnancy losses
as spontaneous miscarriages to avoid confusion
with the intentional termination of pregnancy.
• A viable fetus is usually defined as a fetus of
more than 20-24 weeks of gestation or one that
weighs at least 500 grams. A fetus born at this
point is considered a miscarriage or is termed
as a premature or immature birth.
• A miscarriage is an early miscarriage if it
occurs before 16 weeks of pregnancy and a late
miscarriage if it occurs between week 16-20.
COMMON CAUSES
1. Abnormal fetal development either due to a
teratogenic factor or to a chromosomal
aberration
2. Immunologic factor that can be present which
leads to the rejection of the embryo through an
immune response
3. Implantation abnormalities
4. Corpus luteum on the ovary fails to produce
enough progesterone which is needed to
maintain the decidua basalis. A progesterone
therapy may be attempted to prevent this if the
cause is documented.
5. Ingestion of alcohol at the time of conception
or during early pregnancy can contribute to a
pregnancy loss because of abnormal fetal growth
6. Urinary tract infection may be a cause but are
more strongly associated with a preterm birth
7. Systemic infections such as rubella, syphilis,
poliomyelitis cytomegalovirus and toxoplasmosis
readily cross the placenta and may be
responsible for miscarriages. With an infection, if
the fetus fails to grow estrogen and progesterone
production by the placenta fails, it can lead to
endometrial sloughing which cause the release of
prostaglandins that causes uterine contractions
and cervical dilatation along with the expulsion
of the products of pregnancy to begin
ASSESSMENT
• Vaginal spotting: It is almost always the
presenting symptom of spontaneous
miscarriage. Upon the first indication of this, the
woman should contact her healthcare provider
and she needs to describe how much spotting
she is having and its appearance. For example,
is it dark of fresh blood?
Threatened Miscarriage
SYMPTOMS
1. It usually begins with a vaginal bleeding,
initially only scant and usually bright red
2. Slight cramping
3. No cervical dilatation is present on or
during vaginal examination
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
• A threatened miscarriage becomes imminent
miscarriage if uterine contractions and cervical
dilatation occur as with cervical dilatation, so the
loss of products of conception cannot be halted
or cannot be stopped.
Complete Miscarriage
• Most women who enter pregnancy is in good
health, so we should expect women to complete
a pregnancy and birth without complications.
SYMPTOMS
1. The entire products of conception, which includes
the fetus, membranes, and placenta are being
expelled without any assistance. Bleeding usually
slows within two hours and then ceases within a
few days after passage of the products of
conception.
Incomplete Miscarriage
SYMPTOMS
1. Part of the conceptus (usually the fetus) is
expelled
2. The membranes or placenta are retained in the
uterus
• With an incomplete miscarriage, there is a
danger of maternal hemorrhage as long as part
of the conceptus is being retained in the area
because the uterus cannot contract effectively
under this condition.
Missed Miscarriage
• Commonly referred as early pregnancy failure.
This is when the fetus dies in the uterus but it is
not expelled.
• Therapeutic management depends on the
symptoms and the description of the bleeding so
a woman’s health care provider will decide
whether she needs to be seen ambulatory in an
ambulatory setting or will be brought to the
hospital.
Ectopic Pregnancy
• It is when implantation has occurred outside the
uterine cavity. Common site is the fallopian tube,
specifically in the ampullar portion.
ASSESSMENT
• There are no usual symptoms at the time of
implantation so the corpus luteum of the ovary
continues to function as if the implantation were
in the uterus. Often no menstrual flow occurs.
• A woman may begin to experience the usual
nausea and vomiting of early pregnancy and a
pregnancy test for HCG (human chorionic
gonadotropin) will be positive
1. Sharp, stabbing pain in one of the lower
abdominal quadrants at the time of rupture
2. Followed by a scant vaginal spotting
3. Hypotension from blood loss
4. Light-headedness
5. Rapid pulse
6. Signs of hypovolemic shock
5
THERAPEUTIC MANAGEMENT
1. Administration of methotrexate – The
advantage of this therapy is that the tube is left
intact with no surgical scarring that could cause
a second ectopic implantation
2. Perform hysterosalpingogram – Ultrasound is
usually performed after this test to asses that the
pregnancy is no longer present and also if
whether the tube appears fully patent
3. Perform laparoscopy – This is to ligate the
bleeding vessels and to remove or repair the
damaged fallopian tube
Gestational Trophoblastic Disease
• Commonly known as the hydatidiform mole,
which is an abnormal proliferation and
degeneration of the trophoblastic villi and it
becomes filled with fluid and appear as clear
fluid-filled grape-sized vesicles
ASSESSMENT
• Because of the proliferation of the abnormal
trophoblast cells that grow so rapidly, the uterus
tends to expand faster than usual or the uterus
reaches its landmark. For example, at 12 weeks
we expect that the uterus is already over the
symphysis pubis, so at 20-24 weeks we expect
that the level would be at the umbilicus,
however, the size goes beyond 20 cm, and this
rapid development is also diagnostic of multiple
pregnancy or a miscalculated due date. However,
this finding must be evaluated carefully.
1. Nausea and vomiting probably because of the
high HCG levels
2. Symptoms of gestational hypertension such
as increased blood pressure, edema, and
proteinuria which are ordinarily not present
before week 20 of pregnancy. But with this
complication, they may appear before this time.
3. An ultrasound will show dense growth typically a
snowflake pattern but there is no fetal growth
seen in ultrasound.
4. Since there is no growing fetus, therefore, there
is no fetal heart sounds heard during the
taking of fetal heartbeat using a Doppler.
5. Spotting of dark-brown blood usually begins
resembling a prune juice or a profuse fresh flow
6. Discharges of clear fluid-filled vesicles as
the bleeding progresses
THERAPEUTIC MANAGEMENT
1. Suction curettage – To evacuate the abnormal
trophoblast cells following extraction
2. Baseline Pelvic Examination
3. Serum test for the beta subunit of HCG which
is analyzed every two weeks until the levels
becomes normal again
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
Placenta Previa
• A condition of pregnancy in which the placenta is
implanted abnormally in the lower part of the
uterus.
• It is the most common cause of painless bleeding
in the third trimester of pregnancy
FOUR DEGREES OF PLACENTA PREVIA
1. Low-lying placenta – In which implantation is
in the lower rather than in the upper portion of
the uterus
2. Marginal implantation – The placenta edge
approaches that of the cervical os
3. Partial placenta previa – Implantation that
occludes a portion of the cervical os
4. Total placenta previa – Implantation that
totally obstructs the cervical os
ASSESSMENT
Bleeding is usually:
1. Abrupt
2. Painless
3. Bright red
4. Sudden (enough to frighten a women) and is not
associated with increased activity or participation
in sports
• Bleeding may stop as abruptly as it began so by
the time the woman is seen at the healthcare
setting, she is no longer bleeding.
THERAPEUTIC MANAGEMENT
1. Inspect perineum for bleeding
2. Estimate the present blood loss – Either you
weigh perennial pads before us and after use and
calculate the difference by subtraction which is a
good method to determine vaginal blood loss.
3. Obtain baseline vital signs – To determine
whether symptoms of hypovolemic shock are
present
4. Continue to assess blood pressure – This
should be done every 5-15 minutes or
continuously with an electronic cuff.
5. Never attempt a pelvic or rectal
examination with painless bleeding –
Especially during late pregnancy because any
agitation of the cervix when there is placenta
previa might tear the placenta further and
initiate massive hemorrhage and possibly this is
fatal for both the mother and child
Abruptio Placenta
• This is premature separation of the placenta.
• The placenta appears to have been implanted
correctly but suddenly begins to separate and
bleedings results.
• Separation generally occurs late in pregnancy or
even as late as the first or second stage of labor
because premature separation of the placenta
may occur during a normal labor. It is important
to be always alert to both the amount and kind
of pain, and of course the vaginal bleeding a
woman is having during labor.
6
PREDISPOSING FACTORS THERAPEUTIC MANAGEMENT
• The primary cause of premature separation is 1. Bed rest – To relieve the pressure of the fetus
unknown but certain predisposing factors are the on the cervix
following: 2. Monitor external fetal and uterine
1. High parity contraction – Monitors are attached to monitor
2. Advanced maternal age the fetal heart rate as well as the intensity of
3. Short umbilical cord contractions
4. Chorionic hypertensive disease 3. Intravenous fluid therapy – To keep the
5. Hypertension of pregnancy woman well hydrated and it is also begun
6. Direct trauma, as from example automobile because although not well-documented,
accident or intimate partner violence hydration may help stop contractions. This is
7. Vasoconstriction from cocaine or even cigarette thought to be effective because if a woman is
use dehydrated, the pituitary gland will be activated
8. Thrombophilic conditions which lead to to secrete antidiuretic hormone which might
thrombosis formation cause the pituitary gland to release oxytocin as
well as strengthening uterine contractions.
ASSESSMENT 4. Vaginal and cervical cultures and a clean-
catch urine sample – It is prescribed to rule out
1. Sharp, stabbing pain high in the uterine
any infection so if there is a urinary tract
fundus as the initial separation occurs. If labor
infection, the woman will be prescribed an
begins with a separation, each contraction will be
antibiotic that is especially effective for Group B
accompanied by pain over and above the pain of
streptococcus as this type of infection is fatal
the contraction
especially in newborn.
2. Tenderness can be felt on uterine palpation
3. Heavy bleeding which is usually accompanied
by premature separation of the placenta Premature Rupture of Membranes
although it may not be readily apparent so if you • This is the rupture of the fetal membranes with
notice external bleeding, it will only be evident if loss of amniotic fluid before 37 weeks of
the placenta separates first at the edges so blood pregnancy.
escapes freely into the uterus and then the
cervix. ASSESSMENT
1. Sudden gosh of clear fluid from the vagina
THERAPEUTIC MANAGEMENT with continued minimal leakage – Amniotic
1. Monitor fetal heart sounds externally fluid cannot be differentiated from urine by
2. Record maternal vital signs every 5-15 appearance so a sterile vaginal speculum
minutes – To establish baseline and observe examination is done to observe for vaginal
progress pulling of fluid. If fluid is tested using nitrogen
3. Keep the woman in lateral recumbent paper, amniotic fluid causes an alkaline reaction
position – This position will prevent pressure on so therefore the paper appears blue but if it’s
the vena cava and additional interference with urine it causes an acidic reaction so the paper
the fetal circulation remains color yellow.
4. Do not perform any abdominal, vaginal, or
pelvic examination – Especially on the woman THERAPEUTIC MANAGEMENT
with a diagnosed or suspected placenta
1. Intravenous administration of oxytocin – If
separation
the fetus is estimated to be mature enough by
amniocentesis to survive in an extrauterine
Preterm Labor environment, so labor contractions may be
• This is labor that occurs before the end of week induced by your oxytocin.
37 of gestation. 2. Administer corticosteroid – To hasten fetal
lung maturity
ASSESSMENT 3. Prophylactic administration of broad-
spectrum antibiotic – Effective against Group
1. Persistent, dull and low backache
B streptococcus
2. Vaginal spotting
• During this period, it may both delay the onset
3. Feeling of pelvic pressure or abdominal
of labor and reduce the risk of infection in the
tightening
newborn.
4. Menstrual-like cramping
5. Increased vaginal discharge
6. Uterine contraction
7. Intestinal cramping
• Remember to listen carefully to any woman who
has the symptoms or believes she is in preterm
labor because beginning symptoms of labor are
subtle and is best recognized by the woman
herself.

Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio 7
Hypertensive Disorders in Pregnancy NURSING INTERVENTIONS OF PREECLAMPSIA
• This includes: WITH SEVERE FEATURES
1. Gestational hypertension 1. Support bed rest – Visitors are usually
2. Preeclampsia without severe features restricted to support people such as partner,
3. Preeclampsia with severe features father of child, mother, or older children because
4. Eclampsia a loud noise such as a crying baby or a drop of a
tray or any equipment can be sufficient to trigger
a seizure that initiates eclampsia. We can also
SYMPTOMS OF GESTATIONAL HYPERTENSION darken the room if possible because a bright light
1. Blood pressure of 140/90 mmHg can also trigger seizures, however, the room
2. No proteinuria or edema should not be so dark that caregivers needs to
3. Blood pressure returns to normal after birth use a flashlight to make her assessment. Shing
a flashlight beam into the woman’s eyes is the
kind of sudden stimulation that needs to be
SYMPTOMS OF PREECLAMPSIA WITHOUT avoided.
SEVERE FEATURES 2. Monitor maternal well-being – Take blood
1. Blood pressure of 140/90 mmHg pressure frequently so at least every four hours
2. Proteinuria of 1+ to 2+ or with a continuous monitoring device to detect
3. Weight gain of over 2 pounds per week in the any decrease which is a warning that a woman’s
second trimester, and 1 pound per week in the condition is worsening. We also have to obtain
third trimester daily weights at the same time each day as
4. Mild edema in the upper extremities or face another evaluation of fluid retention. We also
have to ensure that a woman is wearing the
same amount of clothing at each weighing so any
NURSING INTERVENTIONS OF PREECLAMPSIA change in weight is not influenced by a change in
WITHOUT SEVERE FEATURES the weight of her clothing. We can also have an
1. Monitor anti-platelet therapy – Low dose indwelling urinary catheter to be inserted to
aspirin may prevent or delay the development of allow accurate recording of the output and
preeclampsia. Aspirin is such a common over- comparison with intake urinary output should be
the-counter drug but be certain that women more than 30 ml per hour so an output lower
appreciate that this is not something to be taken than this suggest oliguria.
lightly but a serious drug prescription from them, 3. Monitor fetal well-being – Generally, a single
so be certain that they purchase low-dose aspirin doppler auscultation at approximately four hour
as excessive salicylic levels can cause maternal intervals is sufficient at this stage of
bleeding at the time of birth. management
2. Promote bed rest – This is the best method of 4. Support nutritious intake – A woman needs a
aiding increased evacuation of sodium and diet moderate to high in protein and moderate in
encouraging diuresis of edema sodium to compensate for the protein that is lost
3. Promote good nutrition – Stringent restriction in the urine
of salt is advised in order to reduce edema but 5. Administer medication to prevent
this is no longer true because stringent sodium eclampsia – Hypotensive drugs such as
restriction may activate the renin-angiotensin hydralazine and nifedipine may be prescribed to
aldosterone system and actually result in reduce hypertension
increased blood pressure, thus compounding the
problem. It is better to perform assessment
when the woman has someone to help her SYMPTOMS OF ECLAMPSIA
prepare food or either bed rest or nutrition may 1. Seizure or coma accompanied by signs and
be compromised. symptoms of preeclampsia – Tonic-clonic
4. Provide emotional support type of seizure occurs in stages so after the
preliminary signal of aura that something is
happening, all the muscles in the woman’s
SYMPTOMS OF PREECLAMPSIA WITH SEVERE contract so her back arches, her arms and legs
FEATURES stiffen, and her jaw closes so abruptly she may
1. Blood pressure of 160/110 mmHg even bite her tongue. Respirations halt because
2. Proteinuria of 3+ to 4+ her thoracic muscles are held in contraction, so
3. Oliguria in this phase of the seizure, is called the tonic
4. Cerebral or visual disturbances phase which usually lasts for about 20 seconds.
5. Pulmonary or cardiac involvement During the second stage which is the clonic, the
6. Extensive peripheral edema woman’s bladder and bowel muscles contract
7. Hepatic dysfunction and relax so you will notice incontinence of urine
8. Thrombocytopenia and feces will occur.
9. Epigastric pain

Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio 8
NURSING INTERVENTIONS OF ECLAMPSIA
1. Maintain patent airway
2. Prevent aspiration – By turning the woman to
her side to allow secretions to drain from her
mouth
3. Administer magnesium sulfate or diazepam
– This may be administered intravenously as
emergency measure
4. Assess oxygen saturation – Via pulse
oximeter
5. Administer oxygen by face mask – As needed
to protect fetal oxygenation
6. Apply an external fetal heart monitor – If
one is not already in place to assess the fetal
heart rate
7. Check for vaginal bleeding – To detect
placental separation
NURSING CARE OF A FAMILY EXPERIENCING A
COMPLICATION OF LABOR OR BIRTH
Complications with the Power
(The Force of Labor)
• Inertia is a time-honored term to denote
sluggishness of contractions or that the force of
labor is less than usual.
• A more current term is dysfunctional labor.
Dysfunction can occur at any point in labor but it
is generally classified as:
Primary - which is occurring at the onset of
labor
Secondary which is occurring in labor or later in
labor
Prolonged labor – which appears to result from
several factors but is most likely to occur if a
fetus is large or if the contractions are hypotonic,
hypertonic or uncoordinated
Precipitate Labor
• Precipitate dilatation – It is a cervical
dilatation that occurs at a state of 5 centimeters
or more per hour in a primipara or 10
centimeters per hour in a multipara
• Precipitate birth – Occurs when uterine
contractions are so strong a woman gives birth
with only a few, rapidly occurring contractions,
often defined as a labor that is completed in
fewer than 3 hours. Contractions can be so
forceful that they lead to premature separation
of the placenta or lacerations of the perineum
placing the woman at risk for hemorrhage.
Rapid labor (other term for precipitate labor)
also poses a risk to the fetus because subdural
hemorrhage may result from the rapid release of
pressure on the head. The woman and her
support person can feel overwhelmed by the
speed of labor
• A precipitate labor can be predicted from a labor
graph. If during the active phase of dilatation,
the rate is greater than 5 centimeters per hour
or 1 centimeter every 12 minutes in a nullipara
or 10 centimeters per hour or 1 centimeter every
6 minutes in a multipara.
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
• We have to caution a multiparous woman by
week 28 of gestation because a past labor was
so brief, her labor this time may also be brief so
that she has time to plan for adequate
transportation especially going to the hospital or
alternative birthing center.
• Both grand multiparous and woman with
histories of precipitate labor should have the
birthing room converted to birth readiness before
full dilatation is being obtained.
Uterine Rupture
• Rupture of the uterus during labor although rare
is always a possibility. It occurs most often in
women who have previous cesarean scar.
CONTRIBUTING FACTORS
1. Prolonged labor
2. Abnormal presentation
3. Multiple gestation
4. Unwise use of oxytocin
5. Obstructed labor
6. Traumatic maneuvers of forceps or traction
• When uterine rupture occurs, fetal death will
follow unless immediate cesarean birth can be
accomplished.
• If a uterus should rupture, the woman
experiences a sudden severe pain during a
strong labor contraction which she may report as
a tearing sensation. You also have to take note
of signs of hypertensive shock.
• During a complete rupture, you have to take
note of rapid weak pulse, falling blood pressure,
cold and clammy skin and dilation of the nostrils
from air starvation. You could also take that fetal
hearts sounds fade and are absent. With
complete rupture, uterine contractions will also
immediately stop.
• If the rupture is incomplete, the signs of rupture
are less evident or a woman may experience only
a localized tenderness and persistent aching pain
over the area of the lower uterine segment,
however, fetal hears sounds, a lack of
contraction and the changes in the woman’s vital
signs will gradually reveal fetal and maternal
distress.
NURSING INTERVENTIONS
1. Administer emergency fluid replacement
therapy as prescribed
2. Anticipate the use of IV oxytocin – To
attempt to contract the uterus and minimize
bleeding
3. Prepare the woman for a possible
laparotomy – As an emergency measure to
control bleeding and birth of the fetus
• We have to consider the viability of the fetus
which depends on the extent of the rupture and
the time elapsed between rupture and abdominal
extraction.
• A woman’s prognosis depends on the extent of
the rupture and the blood loss.
9
• A woman in uterine rupture or a woman who
experiences uterine rupture is advised not
conceive again after a rupture of the uterus
unless the rupture occurred in the inactive lower
segment.
Inversion of the Uterus
• Refers to the uterus turning inside out with either
a birth of the fetus or delivery of the placenta
• It may occur if traction is applied to the umbilical
cord in the attempt to remove the placenta or if
pressure is applied to the uterine fundus when
the uterus is not contracted.
• It may also occur if the placenta is attached at
the fundus so that during birth the passage of
the fetus pulls the fundus downward because the
inversion of the uterus occurs in various degrees,
the inverted fundus may lie within the uterine
cavity or the vagina or in total inversion it may
protrude from the vagina.
ASSESSMENT
1. When an inversion occurs, a large amount of
blood suddenly gushes from the vagina
2. The fundus is no longer palpable in the abdomen
3. The woman begins to show signs of blood loss
which includes hypotension, dizziness, paleness
or diaphoresis
• Because the uterus is not able to contract in this
position, bleeding cannot be halted or will
continue to such an extent that exsanguination
could occur within 10 minutes
NURSING INTERVENTIONS
1. Never attempt to replace an inversion –
Because handling of the uterus could increase
the bleeding
2. Never attempt to remove the placenta – If it
is still attached, we should never remove it as
this will create a larger surface area for bleeding
3. Discontinue oxytocin – Using oxytocin would
create a large surface area for bleeding and
makes the uterus more tense and difficult to
replace.
4. IV fluid line should be inserted – If one is not
already present, use a large gauge needle
because blood will need to be replaced. If a line
is already in place, open it to achieve optimal
flow or fluid to restore fluid volume.
5. Administer oxygen by mask
6. Assess vital signs
7. Be prepared to perform a cardiopulmonary
resuscitation (CPR) – If the woman’s heart
should fail from the sudden blood loss
• The woman will immediately be given general
anesthesia or possibly nitroglycerine or a
tocolytic drug by IV to relax the uterus.
• Primary care provides replaces the fundus
manually. The administration of oxytocin after
manual replacement helps the uterus to contract
and remain in its natural place.
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
Complications with the Passenger (The Fetus)
• Although the fetus is basically passive during
birth, complications may still arise if an infant is
immature or pre-term or if the maternal pelvis is
so undersized that its diameters are smaller than
the fetal skull which occurs in women in early
adolescence or women with altered bone growth.
Prolapse of the Umbilical Cord
• A loop of umbilical cord sleeps down in front of
the fetal presenting part, especially it occurs at
any time after the membranes has ruptured.
Prolapse of the umbilical cord tends to occur
most often with:
1. Premature rupture of membranes
2. Fetal presentation other than cephalic
3. Placental previa
4. Intrauterine tumors preventing the presenting
part from engaging
5. A small fetus
6. Cephalopelvic disproportion (CPD) preventing
firm engagement
7. Polyhydramnios
8. Multiple gestation
• The incidence is about 0.5% of the cephalic birth
but can rise as high as 10% or even higher with
breach or transverse lies
ASSESSMENT
• The cord may be felt as the presenting part on
an initial vaginal examination during labor or can
be visualized on ultrasound if one of this is taken
during labor.
• More often, however, cord prolapse is first
discovered only after membranes have ruptured
especially when the fetal heart rate is discovered
to be unusually slow or there’s a variable
deceleration.
• Fetal heart rate pattern suddenly becomes
apparent on a fetal monitor but on inspection the
cord may be visible at the vulva.
• To rule out chord prolapse, always assess the
fetal heart sounds immediately after rupture of
the membranes, whether this occurs
spontaneously or by amniotomy.
THERAPEUTIC MANAGEMENT
• A prolapsed cord is always an emergency
situation because the pressure of the fetal head
against the cord at the pelvic brin leads to cord
compression and it decreases the oxygenation to
the fetus.
• Management is aimed therefore at relieving
pressure on the cord thereby relieving the
compression and the resulting fetal anoxia.
1. Place gloved hand in the vagina and
manually elevating the head of the cord
2. Place the woman in a knee-chest position or
Trendelenburg position – To cause the fetal
head to fall back from the cord
3. Administer oxygen at 10L/min by facemask
- To improve oxygenation to the fetus
10
4. Give a tocolytic agent as prescribed – To
reduce uterine activity and pressure on the fetus
if the cord has prolapsed to the extent that it is
exposed to room air as it will start drying which
will lead to constriction and atrophy of umbilical
vessels.
5. Do not attempt to push any exposed cord
back into the vagina - Because this could add
to the compression by causing knotting or
kinking.
6. Cover an exposed portion with a sterile
saline compress - To prevent drying because
cervical dilatation is unusually incomplete at the
point where the cord prolapse has occurred.
7. The birth method of choice: cesarean birth
– The birth method choice is upward pressure on
the presenting part applied by a practitioner’s
hand in the woman’s vagina to keep pressure of
the cord until the baby can be born by cesarean
birth
Complications with the Passage (The Pelvis
and other Maternal Soft Parts)
• Dystocia is a contraction or narrowing of the
passageway or birth canal. This can happen at
the inlet at the mid-pelvis or at the outlet.
• The narrowing causes a cephalopelvic
disproportion or a disproportion between the size
of the fetal head and the pelvic diameters which
then results in failure to progress in labor.
Anomalies of the Placenta and Cord
• The placenta and cord are always examined for
the presence of anomalies after birth.
• The normal placenta weighs approximately
around 500 grams and is 15-20 centimeters in
diameter and 1.5-3.5 centimeters thick. Its
weight is approximately one-sixth (1/6) of that
of the fetus.
• A placenta may be unusually enlarged in a
woman with diabetes, so in certain diseases such
as syphilis or erythroblastosis, the placenta may
be so large that it weighs half as much as the
fetus.
• If the uterus has scars or a septum, the placenta
may be wide in diameter because it was forced
to spread out to find implantation space.
Placenta Succenteriata
• It is a placenta that has one or more accessory
lobes connected to the main placenta by blood
vessels.
• There is no fetal abnormality associated with this
type, however, it is important for it to be
recognized because the small lobes may be
retained in the uterus after birth thus it will lead
to severe maternal hemorrhage

Forceps Birth
• Obstetrical forceps are steel instruments
constructed of two blades that slide together at
their shafts to form a handle.
• In years, past babies were routinely born with
forceps but today the technique is rarely used
because it can lead to rectal sphincter tears in
the woman that lead to dyspareunia, anal
incontinence or increased urinary stress
incontinence.

Vacuum Extraction
• With the fetal head at the perineum, a soft, disk-
shaped cup is pressed against the fetal scalp and
over the posterior fontanelle
• Vacuum extraction has advantages over forceps
birth as little anesthesia is necessary thus
leaving the fetus with less respiratory depression
at birth. One disadvantage over natural birth is
that more perennial lacerations may occur. Its
major disadvantage is that it causes a marked
caput on the newborn head that may be
noticeable as long as seven days after birth.
• A woman may need reassurance that the caput’s
swelling is harmless for her infant which will
rapidly decrease.
• Vacuum extraction should not be used as a
method of birth if a fetal scalps sampling was
used because the suction pressure can cause
severe bleeding at the sampling site.
• Moreover, vacuum extraction is not
advantageous for preterm infants because of the
softness of the preterm skull.

Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio 11
Placenta Circumvallata
• The fetal side of the placenta is covered to some
extent with chorion, the umbilical cord enters the
placenta at the usual midpoint and large vessels
spread out from there.
• Although no abnormalities are associated with
this type of placenta, its presence should also be
noted
Battledore Placenta
• The chord is inserted marginally rather than
centrally
• This anomaly is rare and has no known clinical
significance
Velamentous Insertion of the Cord
• It is a situation in which the cord, instead of
entering the placenta directly, separate into
small vessels that reach the placenta by
spreading across a fold of amnion
• This form of cord insertion is most frequently
found with multiple gestations because the fetal
blood supply may not be generous, as usual, as
this type of placenta is associated with fetal
anomalies
• An infant born with this type of placenta needs
to be examined carefully at birth
Placenta Accreta
• It is the unusually deep attachment of the
placenta to the uterine myometrium, so deep
that the placenta will not loosen and deliver
• Attempts to remove it manually may lead to
extreme hemorrhage because of the deep
attachment
• Hysterectomy is done to remove the uterus or
treatment with methotrexate to destroy the still
attached tissue may be necessary
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
ANOMALIES OF THE CORD
Two-Vessel Cord
• The normal cord contains one vein and two
arteries (AVA), so the absence of the umbilical
arteries is associated with congenital heart and
kidney anomalies.
• Inspection of the cord as to how many vessels
must be made immediately after birth before the
cord begins to dry as drying distorts the
appearance of the vessels, then you have to
document the number of vessels conscientiously
because an infant with two vessels needs to be
observed carefully for other anomalies during the
newborn period
Unusual Cord Length
• Although the length of the umbilical cord really
varies, some abnormal lengths may occur.
• Unusually short umbilical cord can result in
premature separation of the placenta or an
abnormal fetal lie
• An unusually long card may be easily
compromised because of its tendency to twist or
not occasionally a cord actually forms a knot but
the natural pulsations of the blood through the
muscular vessel walls usually keep the blood flow
adequate
• It is not unusual for a cord to wrap once around
the fetal neck but again with no interference to
fetal circulation
12
 Complications with Fetal Position,
Presentation or Size
Occipitoposterior Position
Mechanism of Occipitoposterior Labor
(Long Rotation)
• This video will demonstrate the mechanism the
baby makes of a long rotation in an our Opie
labor the baby in an ROP position will have a
longitudinal lie the presentation will be Co phallic
the position in this case is our Opie that's right
occipital posterior the attitude of the head is one
of flexion the denominator therefore is the oxy
port and the engaging diameter of this oxy port
is the sub occipital frontal of 10 centimeters
towards the end of the pregnancy or in early
labor the fetal head is going to enter the
maternal pelvis with a sagittal suture in the
transverse diameter similar position for a baby
that's in the occipital anterior position this
demonstration is going to be talking about the
long rotation which requires a flexed head as the
baby descends in the maternal powers through
labor we get some increasing flexion through the
labor the occiput will meet the resistance of the
pelvic floor but instead of rotating one-eighth as
it would do if it was in the OE position it's now
going to rotate forwards 3/8 of a turn and the
shoulders will only rotate to eighths of a turn and
Tara Lee so it's the same misalignment that we
have for a fetus that's lying in the air a position
and there is a slight twist in the neck so the head
and the shoulders are not aligned once the fetus
head has made his 3/8 rotation then it follows
the same mechanism for fetus that's now lying in
the occipital anterior position so we have
increasing flexion increasing defense and the
occiput slips underneath the sub pubic arch and
crowning can occur we get extension as the fetal
head pivots on the sub occipital region and
extends this releases the sinks that put the face
and the chin which sweep the perineum we get
the correcting and untwisting of a fetal alignment
called restitution and the occiput rotates one
eighth of the rotation we then get further descent
of the fetus and the anterior shoulder meets the
resistance of the power of ik floor and rotates
anteriorly by 1/8 to lay directly underneath the
symphysis and we get simultaneous external
rotation of the head by 1/8 and the occipital is
laterally the anterior shoulder then sleeps
beneath the pubic arches would get increasing
descent and the posterior shoulder sweeps the
perineum and we get lateral flexion to deliver the
baby.
Mechanism of Occipitoposterior Labor
(Short Rotation)
• This short video is going to be demonstrated the
mechanism by which a baby which is laying in
the occipital posterior position in this case the
ROP position makes its mechanism through the
second stage of labor so the purpose of this one
we're going to be talking about a fetus which
head is in a D flexed position so we have the
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
longitudinal lie a co phallic presentation the
position for this fetus is the ROP the attitude of
the head is one of D flexed the denominator then
becomes the sink seaport and the presenting
diameter is the occipital frontal diameter of
eleven point five centimeters the fetus has had
has descended into the maternal pelvis and is in
the cavity there is no flexion within a short
rotation and the fetus head remains D flexed
throughout because the denominator is thus in
support the since it will meet resistance of the
pelvic floor and will rotate anteriorly by 1/8
causing the fetus to maintain an Opie position
that is persistent there is now the same
misalignment between the fetuses head and the
shoulders by 1/8 thus in support will escape
under the pubic arch you can see how difficult
this is in a baby that is in a persistent Opie
position and the head is born by flexion as the
occiput is delivered over the perineum the head
crowns and the face is born by extension the
mechanism then follows the normal mechanism
but in a no piso restitution will occur the fetuses
head will realign by 1/8 to realign back with the
anterior shoulder internal rotation of the
shoulder will occur when the anterior shoulder
meets resistance of the pelvic floor with
simultaneous rotation externally of the fetal head
the fetus is now lying in a lateral position the
anterior shoulder will pivot the pubic arch and
the posterior shoulder will sweep the perineum
and the baby is born by lateral flexion.
Breach Presentation
• Breech presentation occur in 3-4% of
pregnancies at term. There are three types of
breech presentation: footling breech, flexed
breech, and extended breech.
• If the buttocks are presenting, deliver them as
you would ahead. Once the pelvis is delivered,
hold the pelvis and rotate so that the back is
anterior. Deliver the baby until you see the
shoulder blades. Then you can perform your
normal breech maneuvers:
a. Løvset's maneuver - Rotate the baby 90
degrees and deliver the anterior arm. Then
rotate the baby 180 degrees in the opposite
direction to deliver the other arm. Once you
identify the nape of the neck, you can apply
the Mauriceau-Smellie-Veit maneuver
technique.
b. Mauriceau-Smellie-Veit maneuver -
Place two fingers on the baby's cheek bones
and two fingers on the back of the baby's
neck. Use both hands to flex the baby's head
for delivery. If the feet are present, you
should hold both feet and deliver them first.
• If the above measures are not successful you can
use Wrigley's forceps. Ask your assistant to hold
the baby's legs vertically. Apply the forceps
below the body as you would in a vaginal
delivery.
13
Top Tips for Breech Delivery:
1. Ensure that you have adequate access on the
skin and uterus.
2. The lower segment may be less developed.
3. Only handle the baby by its bony parts.
4. Breech presentation is associated with abnormal
presentation maternal and fetal abnormalities,
so always be prepared.
Face Presentation
• Fetal descent is impacted by the maternal pelvis
the maternal pelvis is a bony structure and it
forces the baby to make several movements in
order for it to fit through and to deliver vaginally
safely with the face presentation the baby's face
is the presenting part that's coming first through
the birth canal this baby in this scenario is not
going to deliver vaginally where the problems
occur is when there is a failure or a delayed
recognition of this presentation a baby that's in
this presentation could be exposed to a
prolonged labor and excessive contractions and
puts that baby at risk for hypoxia.
Brow Presentation
• So this is occipital presentation and he was like
this he trained it because this and so it was his
dream yeah so this presentation is the widest
widest diameter that could try to come through
now sometimes when babies are coming down
brow they'll actually convert to a face yeah and
they can be born face but he didn't convert so he
was presenting with the largest part of us and
there's no way for him to shift I was he kind of
stuck in there to where you could once your
water broke but there wasn't really anywhere for
him to go so he was actually eating your pelvis
coming down like this instead of like this and in
fact dr. Romberg said when they went in there to
do the c-section and the assistant reached in she
said you're going to have to flex the head would
just get give him to tuck his chin in order to get
him out because he was wedged in there so tight
so just to honor you know cry explanation you
know.
Transverse Presentation
• Welcome to our educational video this video has
been developed by met nav met nav is an
organization that helps to promote women's and
children's health worldwide through education
and innovation if you'd like to know more about
our work or indeed support us please visit this
website link transverse lie a vagina delivery is
not indicated in this presentation if an external
catholique version which involves 10 in the baby
to the calf alec position is not successful contain
dictated or declined then a cesarean section is
indicated transverse lie could be tossie inferior
with a back as facing downwards or Dorsey
superior where the back is facing upwards in
order to deliver a dorsi inferior baby you must
identify the posterior leg this is farthest away
from the incision apply gentle traction towards
the incision if possible you may deliver both feet
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
together if you deliver the closer foot first the
legs may split and it may become difficult to
deliver the baby or Dorsey superior where the
back is facing upwards you.
Macrosomia
• Fetal macrosomia is a complication that occurs
during pregnancy when the baby becomes
abnormally large any baby with a birth weight
over nine pounds is classified as macro stomach
fetal macrosomia is a fairly common condition
condition affecting about 10% of all pregnancies
but what is fetal macrosomia fetal macrosomia is
the result of genetics some babies are genetically
bigger than others fetal macrosomia can also be
caused by gestational diabetes gestational
diabetes increases the occurrence rate of fetal
macrosomia from 10 to 50 percent and what are
the risks of fetal macrosomia well the fetus gets
bigger over time so prolonging or pregnancy
increases the risk of fetal macrosomia and fetal
birth weight fetal macrosomia is a potentially
dangerous condition that automatically creates a
high-risk pregnancy the reason for this is very
simple when a baby is overly large it makes it
much more difficult to pass through the small
birth canal making a normal vaginal delivery very
problematic macro stomach babies can become
stuck in the birth canal during a vaginal delivery
and suffer birth injuries from loss of oxygen or
from excessive pulling for this reason it is very
important that doctors accurately measure and
estimate fetal weight during pregnancy if a fetal
macrosomia is diagnosed in advance doctors can
avoid any risks by scheduling a c-section delivery
how is fetal macrosomia diagnosed while
measuring fetal weight and diagnosing fetal
macrosomia may seem easy but it is actually
very complicated and notoriously difficult this is
because there is no practical method for
weighing a fetus inside the womb you can
obviously not take the fetus out and put it on a
scale sonograms and ultrasounds only provide
visual images and they are not able to accurately
measure the weight of a fetus accurate diagnosis
of a fetal macrosomia is usually made of two
indicators the first is amniotic fluid levels and
fundal height measurements is the second if the
volume of amniotic fluid is too high it is a sign
the fetus is growing abnormally fast fundal
height is basically the different distance
measured in centimeters between the uterus in
the very top of the mother's pelvic bone if fundal
height is considered shorter than normal that's
going to be a sign that the baby is overly large
for more information about fetal macrosomia.
14
Shoulder Dystocia
• Definition – Vaginal cephalic delivery that
requires additional obstetric maneuvers to
deliver the fetus after the head has delivered and
gentle traction has failed (either positive or
negative turtle-neck sign)
• Call for additional help when there is no fundal
pressure and maternal pushing. Ask for help
from either an experienced midwife, experienced
obstetrician, neonatal resuscitation team and
anesthetist.
• Perform McRobert’s maneuver (Flexion and
abduction of the maternal hips, positioning the
maternal thighs on her abdomen) with
suprapubic pressure and routine axial
traction of the fetal head
• Internal maneuvers – The choice of the
maneuver applied should be based on the
healthcare professional’s training, clinical
experience and the prevailing circumstances
• Jacquemier’s maneuver – In this maneuver
the anterior shoulder is pushed towards the
baby's chest, and the posterior shoulder is
pushed towards the baby's back, making the
baby's head somewhat face the mother's rectum.
• In case of failure of internal maneuvers, consider
“all four” technique or repeat all maneuvers
again.
• In case of failure of all previous maneuvers,
consider Zavanelli maneuver (vaginal
replacement of the head and then the delivery by
cesarean section) or symphysiotomy
THANK YOU SA TABANG KRISTA AND JERWEN!
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
NURSING CARE OF A FAMILY EXPERIENCING A
POSTPARTUM COMPLICATION
Overview
• Although the puerperium is usually a period of
health, complications can occur.
• It is important to be knowledgeable about
predisposing factors and clinical manifestation of
postpartum complications. This is to ensure the
prompt initiation of corrective measures in order
to prevent long-term consequences to a woman
and her family.
• Postpartum complications are always potentially
serious because they can impact so many
people. A complication may be so serious, it
could cause a personal injury, leave a woman
with her future fertility impaired, or even result
in death.
• Any complication that affects the health of the
mother can also affect her interactions with her
newborn such as causing her to discontinue
breastfeeding.
Postpartum Hemorrhages
• Hemorrhage is one of the primary causes of
maternal mortality associated with childbearing.
It is a major threat during pregnancy throughout
labor and continuing into the postpartum period.
• Traditionally, postpartum hemorrhage is defined
as blood loss of 500ml or more following a
vaginal birth. This occurs as many as 5%-15% of
postpartum women.
• With cesarean birth, hemorrhage is present when
there is a 1000ml blood loss or a decrease in the
hematocrit level, although hemorrhage may
occur either early, that is within the first 24 hours
following birth or late from 24 hours to 6 weeks
after birth.
• The greatest danger is in the first 24 hours
because of the grossly denuded and unprotected
uterine area left after detachment of the
placenta.
FOUR MAIN REASONS FOR POSTPARTUM
HEMORRHAGE
1. Uterine atony
2. Trauma (laceration, hematomas, uterine
inversion, and uterine rupture)
3. Retained placental fragments
4. Development of disseminated intravascular
coagulation
• These causes are generally referred to as the
“four T’s” of postpartum hemorrhage, so that
would include tone, trauma, tissue, and
thrombin. This is a common mnemonic for the
etiology of hemorrhage which is experienced
during the puerperium.
15
Uterine Atony
• Uterine atony or the relaxation of the uterus is
the most frequent cause of postpartum
hemorrhage.
• Factors that predispose a woman to poor uterine
tone or the inability of her uterus to maintain a
contracted state includes the following:
SOME CAUSES OF UTERINE ATONY
1. Multiple gestation
2. Polyhydramnios
3. Having a large baby
4. Presence of uterine myomas
5. Operative birth
6. Rapid birth
7. Placenta previa and accreta
8. Premature separation of the placenta
9. Retained placental fragments
THERAPEUTIC MANAGEMENT OF UTERINE
ATONY
1. Attempt fundal massage – This is to
encourage contraction so unless the uterus is
extremely lacking in tone, this procedure is
usually effective in causing a contraction after a
few seconds. The uterus assumes its healthy
grape fruit-like feel with the uterine atony even
if the uterus responds well to the massage. The
problem may not be completely resolved
because as soon as you remove your hands from
the fundus the uterus may relax and the lethal
seepage will begin again. To prevent this, you
have to remain with the woman after massaging
her fundus and assess to be certain that her
uterus is not relaxing again. As a nurse, you have
to continue to assess carefully for the next four
hours after birth.
2. Oxytocin (Pitocin) - If a woman’s uterus does
not remain contracted, you need to contact her
primary care provider so that interventions to
increase contraction such as administering a
bolus or a dilute intravenous infusion or oxytocin
or pitocin. Pitocin can be prescribed as this help
the uterus maintain its tone. When oxytocin is
given intravenously, its action on the uterus is
immediate but we need to be aware, however,
that oxytocin only has a short duration of action,
approximately an hour, so symptoms of uterine
atony can reoccur quickly if it is administered in
a single dose.
3. Carboprost tromethamine (Hemabate) - If
oxytocin is not effective in maintaining the tone,
you can give the carboprost tromethamine or
Hemabit. This is given intramuscularly. This is a
second possibility. This may be repeated every
15-90 minutes up to eight doses.
4. Methylergonovine maleate (Methergine) –
This can be given if oxytocin is not effective and
is administered intramuscularly. This is a second
possibility. This may be repeated every 2-4 hours
up to 5 doses.
5. Misoprostol (Cytotec) – This is administered
rectally to decrease any postpartum
hemorrhage. A second dose of cytotec should not
be administered unless a minimum of 2 hours
has lapsed.
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
• It is important to check that all of these drugs
are readily available for use on a hospital unit in
the event of a postpartum hemorrhage.
Therefore, this emergency drugs.
MEASURES TO COMBAT UTERINE ATONY
1. Elevating the woman’s lower extremities –
This is to improve circulation to the essential
organs
2. Offering a bed pan or assisting the woman
to the bathroom at least every 4 hours – This
is to be certain that her bladder is emptying
because a full bladder predisposes a woman to
uterine atony. This is also to reduce the
possibility of bladder pressure especially during
the insertion of a urinary catheter, most
importantly if it is prescribed.
3. Administer oxygen by face mask at a rate of
about 10-12L/min – This is done especially if
the woman is experiencing respiratory distress
from decreasing blood volume.
4. Position woman in a supine or flat position
– This is to allow adequate blood flow to her brain
and kidneys
5. Obtain vital signs frequently and assess
them for tends - Assess for trends such as
continually decreasing blood pressure with a
continuously rising pulse rate.
Lacerations
• Small lacerations or tears of the birth canal are
common and may be considered a normal
consequence of childbearing.
• If you have large lacerations, this can be sources
of infection or hemorrhage which commonly
occurs when there is a difficult or precipitate
birth. It occurs in primigravidas, births of a large
infant, with the use of a lithotomy position and
instruments such as the forceps or vacuum
extraction.
• Lacerations may also occur in the cervix, vagina,
or perineum after birth or anytime a uterus feels
firm but bleeding persists. You have to suspect a
laceration at one of these three sites in causing
the bleeding.
TYPES OF LACERATIONS
1. Cervical – These are lacerations of the cervix
which is usually found on the sides of the cervix
near the branches of the uterine artery. If the
artery is torn, blood loss may be so great that
blood gushes from the vaginal opening.
2. Vaginal – These are easier to locate and assess
than cervical laceration because they are so
much easier to view.
3. Perineal – These are lacerations of the perineum
which are more apt to occur when a woman is
placed especially in a lithotomy position for birth
rather than in a supine position because a
lithotomy position increases tension on the
perineum. Perineal lacerations are classified by
four categories depending on the extent and
depth of the tissue involved.
16
 a. First degree – It is a first degree perineal
laceration when the involved area is the
vaginal mucous membrane and skin of the
perineum to the forshare (foreshay?) [dili
nako maklaro ang voice ni Ma’am]
b. Second degree – It includes the bagina,
perennial skin, fascia, levator ani muscle
and perennial body.
c. Third degree – The entire perineum
extending to reach the external sphincter
of the rectum
d. Fourth degree – Entire perineum, rectal
sphincter, and some of the mucous
membrane of the rectum
Retained Placental Fragments
• Occasionally, a placenta does not detach in its a
placenta does not detach in its entirety,
fragments of it separate and are left still attached
to the uterus because the portion retained keeps
the uterus from contracting fully thus uterine
bleeding occurs.
• So if you're going to remove a deep embedded
placenta, this will lead to severe postpartum
hemorrhage to identify the complication of a
retained placenta.
• Every placenta should be inspected carefully
after birth as this is to be certain that the
placenta is complete.
• You can determine that there are retained
placenta or it can be detected through ultrasound
or you may have a blood serum sample that
contains your Hcg (human chronic
gonadotropin). This hormone will reveal that part
of the placenta is still present.
ASSESSMENT
• If an undetected retained fragment is large,
bleeding will be apparent in the immediate
postpartal period because the uterus cannot
contract with the fragment in place
• If the fragment is small, bleeding may not be
detected until postpartum day 6 to 10. This is
when the woman notices an abrupt discharge
and a large amount of vaginal bleeding. During
examination usually the uterus is found to be
fully contracted.
THERAPEUTIC MANAGEMENT
1. Removal of retained placental fragment
2. Administer methotrexate – This is to destroy
the retained fragments
Perineal Hematoma
• It is a collection of blood in the subcutaneous
layer of tissue of the perineum. The overlying
skin as a rule is of course intact with no
noticeable trauma. Blood accumulates
underneath, however, this is due to an injury to
blood vessels in the perineum during birth.
• Hematomas are most likely to occur after a rapid
spontaneous birth and in women who have
perennial varicosities. This may also occur at the
site of the episiotomy or laceration repair if a vein
was punctured during suturing. This can cause a
woman acute discomfort and concern.
Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio
ASSESSMENT
• Perennial sutures almost always give a
postpartum woman some discomfort. If a woman
reports severe pain in the perennial area or
feeling of pressure between her legs, you
have to inspect the perennial area to see if a
hematoma could be causing this.
• If a hematoma is present, it appears as an area
of purplish discoloration with obvious swelling in
the perennial area. It could be as small as two
(2) centimeters or as large as eight (8)
centimeters in diameter. At first it may feel
fluctuant but as seepage in the area continues
and tissue is drawn taut, it palpates as firm glove
(glowve) and feels tender.
THERAPEUTIC MANAGEMENT
1. Report presence of hematoma
2. Include estimated size of the degree of the
woman’s discomfort – You have to report this
to the primary care provider and describe the
definite size such as 5 centimeters or the size of
a quarter or a half coin rather than documenting
it something that is large or small as this
establishes a baseline and will enable you to
assess if the hematoma is growing larger.
3. Apply ice pack (for relief) – When applying ice
pack, be sure to cover with a towel to prevent
thermal injury to the skin and applying ice back
will also prevent further bleeding.
4. Give mild analgesic as prescribed (for
relief)
Puerperial Infections
• Infections of the reproductive tract in the
postpartal period is another major cause of
maternal mortality.
• Some factors that predispose women to
infections during this time are:
- Rupture of membranes more than 24 hours
before birth
- Retained placental fragments within the uterus
- Postpartum hemorrhage
- Preexisting anemia
- Prolonged and difficulty labor particularly with
instrument birth
- Internal fetal heart monitoring electrode
PUERPERIAL INFECTION
• Theoretically, the uterus is uterus is sterile
during pregnancy and up until the membranes
rupture
• After rupture, pathogens can begin to invade so
the risk of infection grows even greater if tissue
edema and trauma are present. If infection
should occur, the prognosis for complete
recovery depends on such factors as the
woman's general health, virulence of the
invading organism and the portal of entry. You
also have the degree of uterine involution at the
time of invasion and the presence of lacerations
in the reproductive tract.
17
1. It is always potentially serious
2. Although it usually begins as only a local
infection, it has the potential to spread to the
peritoneum to cause peritonitis or circulatory
system to cause septicemia that can be fetal in a
woman whose body is already stressed from
child birth.
3. The organisms that commonly cause puerperial
infections are the Group B streptococci,
staphylococci and aerobic gram-negative bacilli
4. Therapeutic management focuses on the use of
appropriate antibiotic after culture and
sensitivity is being done

Infection of the Perineum

• If a woman has a suture lying on her perineum
from an episiotomy or a laceration repair, a
ready portal of entry exists for bacterial invasion.

ASSESSMENT
• Infection of the perineum usually remain
localized. They are revealed by symptoms similar
to those of any suture line infection such as:
- Pain, heat, and feeling of pressure
- The woman may or may not have an elevated
temperature depending on the systemic effects
and spread of the condition
- Inspection of the suture line will reveal that
there is an inflammation
- You can also notice that one or two stitches may
have sloughed away on the area of the should
line
- You can see purulent drainage is present
• If you observe the signs and symptoms, you
have to notify the woman’s primary care provider
with the localized symptoms the woman is
experiencing.

THERAPEUTIC MANAGEMENT
1. Systemic or topical antibiotic – It is ordered
even before the culture report is returned
2. Give analgesic – To alleviate discomfort
3. Sitz bath or moist warm compresses –
Prescribed to hasten drainage and cleanse the
area
4. Remind woman to change perennial pads
frequently – Because they are contaminated by
drainage or left in place for too long that they
might cause vaginal contamination or reinfection
5. Remind woman to wipe from front to back –
After urinating or during or after bowel
movement to prevent bringing contamination
forward from the rectum onto the healing area

Updated February 13, 2020 │ Compilation by Tom Cuenca, Krista Balla, and Jerwen Julio 18
COMMUNITY HEALTH NURSING 2
LECTURE MIDTERMS COVERAGE
CARE OF THE HOSPITALIZED CHILD
Overview
• Hospitalization of a child brings about a range of
emotions in the child and his or her family. In
order to care for the hospitalized child, one must
take into consideration the child’s development
and family coping skills. Being hospitalized
versus receiving care at home affects the child’s
response to his or her illness. In addition, family
presence is often an integral part of pediatric
patient care. Facilitating family-centered care
allows the family to fully support the child during
his or her hospitalization. Knowledge of these
aspects will assist the registered nurse in
providing appropriate pediatric patient care.
Role of Nurses
• In the most instances, the nurse is the primary
person involved in the care of a hospitalized child
• The nurse is the first one to see the child and
family and spend more time with them than
other health care personnel
• The nurse must try to minimize the child’s
distress so that the hospital stay will be as
pleasant an experience as possible
Hospitalization
• In spite of best preventive and promotive health
care, some children become sick and need
hospitalization. Preparation for hospitalization is
important to prevent psychological or emotional
trauma of hospitalization.
Beneficial Effects of Hospitalization
• Although hospitalization can be and usually is
stressful for children, it can also be beneficial.
• The most obvious benefit is the recovery from
illness, but hospitalization also can present an
opportunity for children to master stress and feel
competent in their coping abilities
• The hospital environment can provide children
with new socialization experiences
• The psychological benefits need to be considered
and are maximized during hospitalization
Children’s Reaction to Hospitalization
• Major stressor of hospitalization include
separation, loss of control, anxiety, fear, bodily
injury and pain. Children’s reaction to these crisis
are influenced by their developmental age, their
previous experiences with illness, their coping
skill and support system available
Impact of Hospitalization
For Children:
• Separation anxiety
• Fear
• Loss of control (restraint of movement, sleep,
and feed)
• Pain
• Body image
For Parents (Psychological Impact)
• Separation from the child
• Other people taking care of their children
• Feeling of inadequacy
• Anxiety anger
• Disappointment
• Guilt
Nursing Management
1. Preparing child and families for hospitalization
2. Admitting the child to the facility
3. Addressing the effect of hospitalization
developmentally
4. Preparing the child and family for surgery
5. Maintaining safety during hospitalization
6. Providing basic care for the hospitalized child
7. Providing play, activities, and recreation for the
hospitalized child
8. Promoting schoolwork and education during
hospitalization
9. Addressing the needs of family members
10. Preparing the child and family for discharge
Stress
• It is when individuals perceive that they cannot
cope with demands being made on them or with
threats to their well-being
• Things are only stressful if the person believes
they are a stressor
• What is stressful to one person may not be
stressful to another
Effects on Health
1. If stress is excessively prolonged it can be
maladaptive and lead to harm or disease
2. Stress can effect cognitive function
3. Chronic and intense stress can effect brain
structure and function. It can lead to
hippocampus atrophy memory impairments
4. Long term exposure to catecholamines can
increase cardiovascular disease
5. Aggravate migraine headaches, IBS, peptic
ulcers and control of diabetes can be affected by
stress
Coping
• Cognitive and behavioral efforts to manage
stress that seems to exceed available resources
• It can either be emotional-focused or
problem-focused
Hospitalization of the Child
• The act of putting a child in the hospital adds
stress to a child already coping with illness
• With hospitalization comes a change from the
usual state of health and change in routine
Stressors of Hospitalization
• Separation from family
• Change of environment
• Loss of control
• Bodily injury and pain
March 14, 2021 │ Compilation by April Tom O. Cuenca 1
Risk Factors that Increase Vulnerability to Loss of Control
Stressors of Hospitalization • Infants’ Needs
• “Difficult” temperament - Trust
• Lack of fit between child and parent - Consistent loving caregivers
• Age (especially from 6 months to 5 years) - Daily routines
• Male gender • Toddlers’ Needs
• Below-average intelligence - Autonomy
• Multiple and continuing stresses (e.g. frequent - Daily routines and rituals
hospitalizations) - Loss of control may contribute to (1) regression
of behavior; (2) negativity and (3) temper
Changes in the Pediatric Population tantrums
• More frequent and lengthy stays in the hospital
• More serious and complex problems Response to Pain
• Fragile newborns • Young Infant
• Children with severe injuries - Generalized responses of rigidity, thrashing
• Children with disabilities who have survived - Loud crying
because of increased technological advances - Facial expressions of pain (grimace)
- No understanding of relationship between
Infants and Toddlers stimuli and subsequent pain
• Parent child relationship is disturbed
• Change in routine promotes distrust Facial Expression of Physical Distress
• Separation anxiety (6-30 months)
• Protest phase
- Cry and scream, cling to parent
• Despair phase
- Crying stops; evidence of depression
• Detachment phase
- Denial: resignation, not contentment
- May seriously affect attachment to parent after
separation

Separation Anxiety
• Nursing Interventions include:
- Preserve trust
- Reassure child parent will return
- Provide place for parent to stay in hospital to
promote attachment • Older Infant
- Have parents leave personal articles with child - Withdrawal from painful stimulus
(pictures, toys, clothes etc.) - Loud crying
- Maintain pre-hospital routines and rituals when - Facial grimace
possible - Physical resistance
- Return control to parent and child by providing
choices FLACC Pain Scale

Protest Phase of Separation Anxiety

Despair Phase of Separation Anxiety

Regression
• Common in toddlers and young children (infants
and toddlers)

March 14, 2021 │ Compilation by April Tom O. Cuenca 2

Preschooler (3-5 years old)
• Fear mutilation
• Egocentric, present-oriented
• Sees illness as punishment
• Separation anxiety still exists
• May show signs of regression
Loss of Control
• Egocentric and magical thinking typical of age
• May view illness or hospitalization as punishment
for misdeeds
• Preoperational thought
Nursing Interventions
1. Encourage parents to participate in care
2. Give simple explanations
3. Provide therapeutic play
4. Allow child to play with equipment
5. Praise the child, give rewards (stickers)
Response to Pain (Young Child)
• Loud crying, screaming
• Verbalizations: “ow, ouch, and it hurts”
• Thrashing of limbs
• Attempts to push away stimulus
• May deny pain for fear of an injection
• Often can described location and intensity of pain
Wong-Baker FACES Pain Rating Scale
Preventing or Minimizing Separation Anxiety
• It is the primary nursing goal, especially for
children younger than 5 years old
• Family-centered care
• Parents are not “visitors”
• Familiar items from home
• Provide comfort to hospitalized child, most
especially with significant others such as the
mother or father
School-Age
1. Fear: Pain, bodily injury and loss of control
2. Fears are often related to school peers and family
3. Will ask relevant questions and want to know
reasons for tests etc.
4. Have a more realistic understanding of their
disease
5. Become stressed over separation from family
and peers
6. Vulnerable to event that lessens their feelings of
control and power
7. Hospital activities that limit control may be a
direct threat to children’s anxiety
8. Allow children to exert control whenever possible
9. Boredom is a big problem with hospitalized
children
Nursing Interventions
1. Communicate openly, explain rules
2. Clarify misconceptions
3. Encourage self-care
4. Allow peers and siblings to visit
5. Age appropriate therapeutic play
6. Provide explanations; use visual aids
7. Praise child, focus on behavior
Response to Pain (School Child)
• Able to describe pain
• Become concerned with disability and death
• May bite, kick, cry when in pain
• Stalling behavior (“wait a minute”)
• Muscle rigidity
• May use all behaviors of young child
Adolescents
1. Fear: Loss of independence, loss of identity,
body image disturbance, rejection by others
2. Separation from peers is a main source of
anxiety
3. Physical appearance is of great importance
4. May be reluctant to ask questions, may fear
being lied to, may verify information from
multiple sources to be sure others are being
truthful
5. Often feel they are “invincible” which puts them
at risk for noncompliance and risk taking
behaviors
Loss of Control
• Struggle for independence and liberation
• Separation from peer group
• May respond with anger, frustration
• Need for information about their condition
Response to Pain (Adolescents)
• Less vocal protest, less motor activity
• Increased muscle tension and body control
• More verbalizations (“it hurts, you’re hurting me)
Nursing Interventions
1. Involve adolescent in plan of care
2. Support relationship with family and peers
3. Provide consistent and truthful explanations
4. Accept emotional outbursts
5. Promote communication between adolescent and
family
March 14, 2021 │ Compilation by April Tom O. Cuenca 3
 CARE OF FAMILY WITH A HOSPITALIZED Family
CHILD • Hospitalizing a child adds stress and anxiety to
the entire nuclear family including (1) parents
and (2) siblings
Overview
• A child being hospitalized may also change family
• Hospitalization is a stressful event for both the roles
child and the family. Children and families may
experience feelings ranging from fear of the Parental Responses to Stressors of
unknown to complete loss of control. These Hospitalization
feelings complicate the clinical situation and
• Disbelief, anger, and guilt especially if sudden
detract from the development of a healing
illness
environment.
• Fear and anxiety related to child’s pain and
seriousness of illness
Family
• Frustration especially related to need for
• Family is defined as a group of persons who are
information
connected by blood or by affinity or through law
• Depression
within two or three generations. It consists of
Parents and their children. living together and
Sibling Reactions
having a shared commitment to a domestic
relationship. It is the basic unit of the society. 1. Fear and worry
• When a child becomes ill, a change usually takes 2. Loneliness
place in the parent-child relationship. The 3. Resentment and Guilt
parents become more protective and indulgent; 4. Jealousy
the child, at the same time, becomes more 5. Anger
dependent on his parents and more demanding
of their presence and attention. If the illness Altered Family Roles
necessitates hospitalization, this entails • Anger and jealousy between siblings and ill child
separation of parent and child and • Ill child obligated to play sick role
relinquishment of the child's care, usually to • Parents continue pattern of overprotection and
strange physicians and other health care team indulgent attention
such as the nurses.
• Family is very important in the care of the What can we do for the child?
hospitalized child, that is why family-centered 1. Prevent or minimize separation. Parent
care is considered as the best care a nurse could participation can minimize effects of separation.
give while taking care of the child. 2. Minimize loss of control. This can be done by
promoting free movement, maintaining routine and
The Family’s Role During Patient’s encouraging independence
Hospitalization 3. Prevent or minimize bodily injury
• Family has been already described as an integral 4. Provide developmental activities
system. So, illness of a member can threaten the 5. Use play to decrease stress
system. The result of threat of this system can 6. Maximize benefits of hospitalization
include fear, distress, feeling of weakness, and
lack of hope, which can lead to physical and Family Presence During Hospitalization
emotional exhaustion. For this reason, each
intervention that decreases the effect of these Providing Developmentally Appropriate
pressures, benefits family. Activities
• Using play or expressive activities to minimize
Nursing Care of Hospitalized Child and Family stress
(Principles and Practice) - Divisional or diversional activities
1. Primary goal is to prevent separation anxiety - Toys
particularly in children younger than 5 years of age - Expressive activities
2. Welcome the presence of parents at all time - Play therapy
throughout the child's hospitalization a. Energy release – pounding, hitting, running
3. Many hospitals developed a system of family- b. Dramatic play – acting out an anxiety-
centered care. producing situation
4. During the time of separation anxiety, nurse c. Creative play – draw a picture that express
provide support through physical presence their emotion
5. Ensure that parental visits is frequent • Using play to ease children’s fears
6. If the parents can't room-in, ask them to leave a
favorite article from home the child gain comfort and Normalizing the Hospital Environment
provide reassurance from them.
• Promote freedom of achievement
• Maintain child’s routine, if possible
• Time structuring
• Self-care (age appropriate)
• Schoolwork
• Friends and visitors

March 14, 2021 │ Compilation by April Tom O. Cuenca 4

Maximizing Potential Benefit of Hospitalization School-age History and Physical Examination
• Fostering parent-child relationships • Children become aware of the difference in
• Providing educational opportunities sexes, privacy becomes important
• Promoting self-mastery • Vital signs of 6-9 years old
• Providing socialization - HR: 70-110 beats/min
• Supporting family members - RR: 16-20 breaths/min
- BP (6y/o): 96/57 mmHg
What can we do for the family? - BP (9y/o): 100/61 mmHg
1. Provide family-centered care • Vital signs of 10-12 years old
2. Provide information - HR: 60-100 beats/min
- RR: 16-20 breaths/min
Assessment Techniques, History Taking and - BP (12y/o): 104/64 mmHg
Physical Examination
Adolescent Teens History and Physical
Newborn History and Physical Examination
Examination
• Maternal history is important
• History comes from teen, not from parent
• For physical examination:
• Want to be treated like an adult
- Do all you can with infant asleep, ex.
• Do not talk down to patient, no “honey” or
Respiratory rate, heart rate, listen to abdomen
“sweetie” remarks
- Umbilical cord needs to be checked
• Ask if they want parent in the room for exam
- Continue to check fontanels
• Ask about drug use, sexual activity without
- HR: 120-160 beats/min
parent in room
- RR: 30-80 breaths/min
• Observe confidentiality
- BP: 73/55 mmHg
• Vital signs of 13-14 years old
- HR: 60-100 beats/min
Infant History and Physical Examination
- RR: 16-20 breaths/min
• Maternal history and birth process should still be
- BP: 107/64 mmHg
addressed
• Vital signs of 15-18 years old
• All history from mother
- HR: 60-100 beats/min
• Continue to assess all possible while infant is
- RR: 12-20 breaths/min
asleep
- BP: 114/65 mmHg
• Play with older infants
- BP (18y/o): 121/70 mmHg
• May be more comfortable being assessed in
mother’s arms
General Hygiene and Care
Toddler History and Physical Examination • Skin care
• Maternal and birth history continue to be • Bathing
important • Oral hygiene
• Establish relationship with mom before trying to • Hair care
talk to the child • Feeding
• Allow child to play with equipment prior to use if • Temperature management
possible
• Do not separate child from parent Supporting Infant During Tub Bath
• May play with toddlers
• Allow parent to help when possible with
assessment (may need mom to move
stethoscope around chest)
• Stranger or separation anxiety

Average Vital Signs

• 12 months
- HR: 80-130 beats/min
- RR: 20-40 breaths/min
- BP: 90/56 mmHg
• 24 months
- HR: 70-120 beats/min
- RR: 20-40 breaths/min
- BP: 90/56 mmHg

Preschool History and Physical Examination

• Child tend to be more outgoing, cooperative
• Explain procedures prior to starting, allow child
to play with equipment
• Use distraction
• Vital signs of 3-5 years old
- HR: 70-120 beats/min
- RR: 20-30
- BP: 92/55 mmHg

March 14, 2021 │ Compilation by April Tom O. Cuenca 5

Providing Safety Papoose Board
• Name bands
• Patient identity
• Environment
• Activity supervision
• Hugs tags
• Nurse maintain hands contact
• Carrying infants

Cradle Hold Football Hold

Specimen Collection
• Urine
• Stool
• Blood
• Sputum

Shoulder Hold Application of a Urine Collection Bag

Transporting Pediatric Patient

• Infants must be in bassinet
• Older kids in wheelchairs, stretchers and
“buggies”

Restraining Methods
• Therapeutic hugging
• Mummy or swaddle restraint
• Limb restraints
• Papoose board

Therapeutic Hugging for Extremity Vein

Puncture

Mummy Restraint Elbow Restraint

March 14, 2021 │ Compilation by April Tom O. Cuenca 6

 CARE OF THE PATIENT WITH REPRODUCTIVE The Reproductive Cycle
DISORDER Menarche
• The beginning of menses
• Follows breast development by 2-2½ years
Human Sexuality
• Average age range is between 9 and 17 years
Sexual Identity • Cycle length ranges from 24-32 days
• The sense of being feminine or masculine • The average flow lasts 3-5 days
Influences on Sexual Health • The average flow is 35mL/cycle
• Overall wellness includes sexual health, and Amenorrhea
sexuality should be part of the health care • Etiology and pathophysiology
program - Absent or suppressed menstrual flow
Illness and sexuality - Clinical manifestations or assessment
• Illness may cause changes in a patient’s self- - No menstrual flow for at least 3 months
concept and result in an inability to function - Medical management or nursing interventions
sexually - Based on underlying cause
- Hormone replacement may be necessary
Assessment Dysmenorrhea
History Taking • Etiology and pathophysiology
• Menarche, menopause, premenopausal - Uterine pain with menstruation
syndrome - The causes of dysmenorrhea can relate to an
• Number of pregnancies, parity, term, abortion endocrine imbalance, an increase in
and live birth prostaglandin secretions, or chronic illness,
• Planning method fatigue and anemia
• Are you sexually active? Is your sexual partner • Clinical manifestations or assessment
of the same sex or different gender? - Breast tenderness; headache
• How many sexual partners have you had in the - Abdominal distention; nausea and vomiting
past six months? - Vertigo
• Do you practice safer sex? STIs? - Palpitations
• Have you had a vaccine against HPV? - Excessive perspiration
- Colicky, cyclic pain; dull pain in the lower pelvis
Assessment • Medical management or nursing
• Excessive weight loss or gain interventions
• Disfiguring scar from surgery or accident - Exercise
• Hair loss such as occurs with chemotherapy - Nutritious foods, high in fiber
• Surgery or inflammation or infection of the - Warm compress to pelvic area
reproductive organs - Mild analgesics
• Chronic fatigue or pain - Prostaglandin inhibitors
• Spinal chord injury
• Presence of retention catheter Abnormal Uterine Bleeding
• Menorrhagia
Physical Examination - Excessive bleeding during the regular
• Distribution of body hair (triangle-shaped pubic menstrual flow
hair in women, diamond-shaped pubic hair in - Causes: Endocrine disorders; inflammatory
men) disturbances and uterine tumors
• Signs of bleeding (metrorrhagia, post-coital • Menorrhagia
bleeding, spotting) - Uterine bleeding between regular menstrual
• Erectile dysfunction, failure to achieve orgasm or periods or after menopause
pain during intercourse - May indicate cancer or benign tumors of the
uterus
Laboratory and Diagnostic Examinations
Diagnostic Tests for Females Postmenstrual syndrome (PMS)
• Colposcopy; laparoscopy • Etiology and pathophysiology
• Papanicolaou (Pap) smear - Believed to be related to the neuroendocrine
• Biopsies: breast, cervical, endometrial events occurring within the anterior pituitary
• Dilation and curettage gland
• Cultures and smears • Clinical manifestations or assessment
• Schiller’s iodine test - Irritability, lethargy and fatigue
• Hysterograms
- Sleep disturbances and depression
• Mammography; pelvic ultrasonography
- Headache; backache and breast tenderness
• Tubal insufflation (Rubin’s test)
• Human chorionic gonadotropin; serum CA-125 - Vertigo
Diagnostic Tests for Males - Abdominal distention
• Testicular biopsy - Acne
• Semen analysis
• Prostatic smears
• Cytoscopy
• Rectal digital exam
• Prostrate specific antigen (PSA)

March 14, 2021 │ Compilation by April Tom O. Cuenca 7

• Medical management or nursing Infertility
interventions • Etiology and pathophysiology
- Pharmacological management: (1) Analgesics, - Inability to conceive after 1 year of sexual
(2) diuretics and (3) progesterone intercourse without birth control
- Dietary recommendations: (1) high in complex • Medical management or nursing
carbohydrates, (2) moderate in protein, (3) low interventions
in refined sugar and sodium, and (4) limit - Depends on the cause
caffeine, chocolate, and alcohol - Hormone therapy
- Reduce or eliminate smoking - Repair occlusion
- Exercise, adequate rest, sleep and relaxation - Intrauterine insemination
- In vitro fertilization
Menopause
• Etiology and pathophysiology Infections of the Female Reproductive Tract
- The normal decline of ovarian function resulting Simple Vaginitis
from the aging process • Etiology and pathophysiology
- May be induced by irradiation of the ovaries or - Common vaginal infection
surgical removal of both ovaries - Causative organisms: E. coli; staphylococcal;
- Not considered complete until 1 year after the streptococcal; T. vaginalis; C. albicans;
last menstrual period Gardnerella
• Clinical manifestations or assessment • Clinical manifestations or assessment
- Decrease in frequency, amount and duration of - Inflammation of the vagina
the normal menstrual flow - Yellow, white or grayish white, curd-like
- Shrinkage of vulval structures; shortening of discharge
the vagina - Pruritus and vaginal burning
- Dryness of the vaginal wall; pelvic relaxation • Medical management or nursing
- Loss of skin turgor and elasticity interventions
- Increased subcutaneous fat; decreased breast - Douching
tissue; thinning of hair - Vaginal suppositories, ointments, and creams
- Osteoporosis (organism-specific)
• Medical management or nursing - Sitz baths
interventions - Abstain from sexual intercourse during
- Estrogen therapy: (1) Premarin and (2) provera treatment
- Calcium supplements - Treat partner if necessary

Male Climacteric Cervicitis

• Etiology and pathophysiology • Etiology and pathophysiology
- Gradual decrease of testosterone levels and - Infection of the cervix
seminal fluid production; 5-70 years of age • Clinical manifestations or assessment
• Clinical manifestations or assessment - Backache
- Decreased erections; decreased seminal fluid - Whitish exudate
- Enlarge prostate gland; decreased muscle tone - Menstrual irregularities
- Loss or thinning of hair • Medical management or nursing
• Medical management or nursing interventions
interventions - Vaginal suppositories, ointments, and creams
- Emotional support; treatment for impotence (organism-specific)

Erectile Dysfunction Pelvic Inflammatory Disease (PID)

• Etiology and pathophysiology • Etiology and pathophysiology
- Inability of an adult man to achieve penile - Any acute, subacute, recurrent or chronic
erection infection of the cervix, uterus, fallopian tubes,
- Types: (1) Functional, (2) Anatomical and (3) and ovaries that has extended to the connective
Atonic tissues
• Medical management or nursing - Most common causative organisms:
interventions Gonorrhea: streptococcus; staphylococcus;
- Remove cause, if possible Chlamydia: Tubercle bacilli
- Treat diseases - High risk: Surgical and examination
- Viagra procedures; sexual intercourse (especially with
- Mechanical devices: penile prosthesis multiple partners) and pregnancy
• Clinical manifestations or assessment
- Fever and chills
- Severe abdominal pain
- Malaise
- Nausea and vomiting
- Malodorous purulent vaginal exudate

March 14, 2021 │ Compilation by April Tom O. Cuenca 8

• Medical management or nursing Displaced Uterus
interventions • Etiology and pathophysiology
- Antibiotics; analgesics - Congenital
- Bed rest - Childbirth
- Backward displacement:
Toxic shock syndrome a. Retroversion – the entire uterus is
• Etiology and pathophysiology tipped backward
- Acute bacterial infection caused by b. Anteversion – the entire uterus is tipped
staphylococcus aureus forward
- Usually occurs in women who are menstruating c. Retroflexion – the uterine body is bent
and using tampons sharply back just above the cervix
• Clinical manifestations or assessment d. Anteflexion – the uterine body is bent
- Usually occurs between days 2 and 4 of the sharply forward at the junction with cervix
menstrual period • Clinical manifestations or assessment
- Flu-like symptoms; sore throat and headache - Backache
- Red macular palmar or diffuse rash - Muscle strain
- Pulmonary edema - Leukorrheal discharge
• Medical management or nursing - Heaviness in the pelvic area
interventions • Medical management or nursing
- Antibiotics; IV fluid therapy; oxygen interventions
- Pessary: a device worn in the vagina to
Endometriosis support the uterus
• Etiology and pathophysiology - Uterine suspension
- Endometrial tissue appears outside the uterus
- The tissue responds to the normal stimulation
of the ovaries; bleeds each month
• Clinical manifestations or assessment
- Lower abdominal and pelvic pain
- May radiate to lower back, legs and ground
• Medical management or nursing
interventions
- Anti-ovulatory medications; pregnancy
- Laparoscopy; total hysterectomy
• Common site of endometriosis

Uterine Prolapse
• Etiology and pathophysiology
- Prolapse of the uterus through the pelvic floor
and vagina opening
• Clinical manifestations or assessment
- Fullness in vaginal area
Disorders of the Female Reproductive System - Backache
- Bowel or bladder problems
Vaginal Fistula
- Protrusion of cervix and vaginal walls in
• Etiology and pathophysiology
perineal area
- Abnormal opening between the vagina and
• Medical management or nursing
another organ
interventions
• Clinical manifestations or assessment
- Pessary
- Urine and or feces being expelled from vagina
- Surgery: (1) Vaginal hysterectomy and (2)
• Medical management or nursing
anteroposterior colporrhaphy
interventions
- Oral or parenteral antibiotics
- Diet: high protein, increase vitamin C
- Surgery: Repair fistula; urinary or fecal
diversion
• Types of fistulas that may develop in the vagina
and uterus

March 14, 2021 │ Compilation by April Tom O. Cuenca 9

Cystocele and rectocele Ovarian Cysts
• Etiology and pathophysiology • Etiology and pathophysiology
- Cystocele: Displacement of the bladder into - Benign tumors that arise from dermoid cells of
the vagina the ovary
- Rectocele: Rectum moves toward posterior • Clinical manifestations or assessment
vaginal wall - May be no symptoms
• Clinical manifestations or assessment - Palpable on examination
- Cystocele: Urinary urgency, frequency, and - Disturbance of menstruation
incontinence; pelvic pressure - Pelvic heaviness and pain
- Rectocele: Constipation, rectal pressure and • Medical management or nursing
hemorrhoids interventions
• Medical management or nursing - Ovarian cystectomy
interventions
- Surgical repair: (1) Anteroposterior
colporrhaphy and (2) bladder suspension

Cancer of the Female Reproductive Tract

Cancer of the Cervix
• Etiology and pathophysiology
- Squamous cell carcinoma
- Carcinoma in situ
- If untreated, invades the vagina, pelvic wall,
bladder, rectum, and regional lymph nodes
- High risk: (1) Sexually active during teens, (2)
Leiomyomas of the Uterus (fibroids, myomas) multiple sexual partners, (3) multiple births and
• Etiology and pathophysiology (4) chronic cervical infections
- Arise from the muscle tissue of the uterus • Clinical manifestations or assessment
- Stimulated by ovarian hormones - Few symptoms in early stages
• Clinical manifestations or assessment - Leukorrhea
- Pelvic pressure; pain and backache - Irregular vaginal bleeding; spotting
- Dysmenorrhea; menorrhagia - Advanced: Pain in the back, upper thighs and
- Constipation; urinary symptoms legs
• Medical management or nursing • Medical management or nursing
interventions interventions
- Surgery: (1) Myomectomy and (2) - Carcinoma in situ: (1) Removal of the
Hysterectomy affected area
- Early carcinoma: (1) Hysterectomy, (2)
Intracavitary radiation and (3) Brachytherapy
- Advanced carcinoma: (1) Radical
hysterectomy with pelvic lymph node dissection

Cancer of the Endometrium

• Etiology and pathophysiology
- Adenocarcinoma of the uterus
• Clinical manifestations or assessment
- Postmenopausal bleeding (50% will have
cancer)
- Abdominal pressure; pelvic fullness
• Medical management or nursing
interventions
- Surgery: Total abdominal hysterectomy with
bilateral salpingo-oophorectomy (TAH-BSO)
- Radiation, chemotherapy

March 14, 2021 │ Compilation by April Tom O. Cuenca 10

Cancer of the Endometrium Acute Mastitis
• Etiology and pathophysiology • Etiology and pathophysiology
- Adenocarcinoma of the uterus - Acute bacterial infection of the breast
• Clinical manifestations or assessment • Clinical manifestations or assessment
- Postmenopausal bleeding (50% will have - Breasts are tender, inflamed and engorged
cancer) • Medical management or nursing
- Abdominal pressure; pelvic fullness interventions
• Medical management or nursing - Keep breasts clean
interventions - Application of warm packs
- Surgery: Total abdominal hysterectomy with - Support: Well-fitting bra
bilateral salpingo-oophorectomy (TAH-BSO) - Systemic antibiotics
- Radiation, chemotherapy
Chronic Mastitis
Cancer of the Ovary • Etiology and pathophysiology
• Etiology and pathophysiology - Fibrosis and cysts in the breast
- Fourth most common cause of cancer death in • Clinical manifestations or assessment
women - Tender, painful, and palpable cysts
- High risk: Infertile, anovulatory, nulliparous, - Usually unilateral
habitual aborters, high-fat diet, exposure to • Medical management or nursing
industrial chemicals interventions
• Clinical manifestations or assessment - Same as for acute mastitis
- Early: (1) Vague abdominal discomfort and (2)
flatulence, mild gastric disturbance Breast Cancer
- Advanced: (1) Enlarged abdominal girth, (2) • Etiology and pathophysiology
flatulence, constipation, (3) urinary frequency, - Unknown cause; usually adenocarcinoma
(4) nausea and vomiting and (5) weight loss • Clinical manifestations or assessment
• Medical management or nursing - Small, solitary, irregular-shaped, firm, non-
interventions tender and non-mobile tumor
- Surgery: TAH-BSO and omentectomy - Change in skin color
- Radiation and or chemotherapy - Puckering or dimpling of tissue
- Nipple discharge; retraction of nipple
Hysterectomy - Axillary tenderness
• Total hysterectomy: Removal of the uterus • Medical management or nursing
including the cervix interventions
• TAH-BSO: Removal of the uterus, fallopian - Depends on the stage
tubes and ovaries - Radiation
• Radical hysterectomy: TAH-BSO with removal - Chemotherapy
of the pelvic lymph nodes - Surgery: (1) Lumpectomy and (2)
• Vaginal hysterectomy: The uterus is removed Mastectomy, either simple or radical
through the vagina
• Abdominal hysterectomy: Abdominal incision Inflammatory Disorders of the Male
is made to perform procedure Reproductive System
Prostatitis
Disorders of the Female Breast • Etiology and pathophysiology
Fibrocystic breast condition - Acute or chronic infection of the prostate gland
• Etiology and pathophysiology • Clinical manifestations or assessment
- Hyperplasia and cystic formation in mammary - Chills and fever
ducts - Dysuria, urgency and frequency of urination
• Clinical manifestations or assessment - Cloudy urine
- Cysts are soft, well-differentiated, tender, and - Perineal fullness and lower back pain
freely moveable; often bilateral and multiple - Arthralgia and myalgia
• Medical management or nursing - Tenderness, edema, and firmness of the
interventions prostate
- Eliminate methylxanthines (caffeine, • Medical management or nursing
theophylline) interventions
- Danazol (danocrine): Synthetic androgen - Antibiotics
that inhibits the release of gonadotropins - Digital massage of the prostate
- Vitamin E (alpha-tocopherol): A potent anti- - Sitz baths
oxidant - Monitor input and output

March 14, 2021 │ Compilation by April Tom O. Cuenca 11

Epididymitis Hydrocele
• Etiology and pathophysiology • Etiology and pathophysiology
- Infection of the epididymis - Accumulation of fluid between the membranes
• Clinical manifestations or assessment of the testes
- Scrotal pain and edema • Clinical manifestations or assessment
- Pyuria; chills and fever - Enlargement of the scrotum; pain
• Medical management or nursing • Medical management or nursing
interventions interventions
- Bed rest - Aspiration of fluid
- Elevate scrotum; cold compresses - Surgical removal of testicular sac
- Antibiotics - Bed rest; elevate scrotum; cold compresses

Varicocele
• Etiology and pathophysiology
- Dilation of scrotal veins causing obstruction and
Disorders of the Male Genital Organs malfunction of circulation
• Clinical manifestations or assessment
Phimosis
- Engorgement and elongation of the scrotum
• Etiology and pathophysiology
- Pulling sensation in scrotum; dull, aching pain
- Prepuce is too small to allow retraction of the
• Medical management or nursing
foreskin over the glans
interventions
- Usually congenital; may be due to inflammation
- Surgery: Removal of obstruction
or disease
- Bed rest
• Clinical manifestations or assessment
- Elevate scrotum; cold compresses
- Infection of foreskin and glans penis
- Occasionally causes obstruction of urine flow
• Medical management or nursing
interventions
- Circumcision

Cancer of the Male Reproductive Tract

Cancer of the Testis
• Etiology and pathophysiology
- Cause unknown
- Most common malignancy in men ages 15-35
years
• Clinical manifestations or assessment
- Enlarged scrotum; feeling of heaviness
- Firm, painless, smooth mass
Paraphimosis
• Medical management or nursing interventions
• Etiology and pathophysiology - Radical inguinal orchiectomy
- An edematous condition of the retracted - Radiation and or chemotherapy
uncircumcised foreskin preventing a normal - Teach testicular self-examination
return over the glans
• Medical management or nursing Cancer of the Penis
interventions • Etiology and pathophysiology
- Warm compress - Very rare
- Circumcision • Clinical manifestations or assessment
- Painless, wart-like growth or ulceration, usually on
the glans penis
• Medical management or nursing interventions
- Surgery: (1) Removal of tissue, (2) partial or total
amputation of the penis and (3) metastasis: radical
surgical procedures

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Sexually Transmitted Disease
Genital Herpes
• Etiology and pathophysiology
- Infectious viral disease; usually acquired
sexually
- Common sexually transmitted disease
• Clinical manifestations or assessment
- Fluid filled vesicles
- Eventually rupture and devlop shallow, painful
ulcers
- Fever; malaise
- Dysuria
- Leukorrhea (female)
• Medical management or nursing
interventions
- Circumcision
Syphilis
• Etiology and pathophysiology
- Troponema pallidum organism
- Transmission occurs primarily with sexual
contact
• Clinical manifestations or assessment
- Incubation period: No symptoms
- Primary stage: Chancre, headaches, enlarged
lymph nodes
- Secondary stage: (1) Rash on palms of hands
and soles of feet and (2) generalized
enlargement of lymph nodes
- Latent stage: No symptoms
- Tertiary or late stage: Lesions may affect
many different systems; may be fatal
• Medical management or nursing
interventions
- Pharmacological management: (1) Penicillin
and (2) tetracycline or erythromycin, if allergic
to penicillin
- May be treated in any stage; damage from
previous stage will not be reverse
- Treat all sexual contacts
Gonorrhea
• Etiology and pathophysiology
- N. gonorrhoeae
- Transmitted by sexual contact
- Most common STD
• Clinical manifestations or assessment
- Vaginal (female): (1) Urinary frequency and
pain; (2) yellowish discharge and (3) nausea and
vomiting
- Urethra (male): (1) Urethral discomfort;
dysuria, (2) yellowish discharge containing pus
and (3) red and swollen meatus
- Rectal (male and female): Perineal
discomfort; purulent rectal discharge
- Pharyngitis (male and female): Sore throat,
swallowing discomfort, and edema of the throat
• Medical management or nursing
interventions
- Pharmacological management: (1) Penicillin,
(2) rocephin and (3) doxycycline or tetracycline
- Patient education
- Treat all sexual contacts
Trichomoniasis (“Trich”)
• Etiology and pathophysiology
- T. vaginalis protozoan
- Usually sexually transmitted but could be
transmitted with contaminated douche nozzle,
douche container or washcloth
• Clinical manifestations or assessment
- Most are asymptomatic
- Male: Urethritis, dysuria, urinary frequency,
pruritus and purulent exudate
- Female: (1) Frothy, gray, green or yellow
malodorous discharge, (2) Pruritus, (3) Edema,
(4) Tenderness of vagina, (5) Dysuria and
urinary frequency, (5) Spotting; menorrhagia;
dysmenorrhea
• Medical management or nursing
interventions
- Pharmacological management: Metronidazole
(Flagyl)
- Patient education
- Treat all sexual contacts
March 14, 2021 │ Compilation by April Tom O. Cuenca 13
Candidiasis (“Yeast or thrush”)
• Etiology and pathophysiology
- Fungal infection caused by C. albicans and C.
tropicalis
• Clinical manifestations or assessment
- Mouth: Edema, white patches
- Nails: Edematous, darkened, erythematous
nail base; purulent exudate
- Vaginal: Cheesy, tenacious white discharge,
pruritus, inflammation of the vagina
- Penis: Purulent exudate
- Systemic: Chills, fever, general malaise
• Medical management or nursing
interventions
- Pharmacological management: (1) Nystatin
(Mycostatin) and (2) Topical amphotericin B
- Treat underlying condition

Chlamydia
• Etiology and pathophysiology
- Chlamydia trachomatis
• Clinical manifestations or assessment
- Usually asymptomatic
- Male: (1) Scanty white or clear exudate, (2)
burning or pruritus, and (3) urinary frequency;
mild dysuria
- Female: (1) Vaginal pruritus or burning, (2)
dull pelvic pain, (3) Low-grade fever and (4)
vaginal discharge; irregular bleeding
• Medical management or nursing
interventions
- Pharmacological management: (1)
Tetracycline, (2) doxycycline and (3) zithromax
- Treat all sexual contact

Nursing Diagnosis
• Anxiety
• Body image, disturbed
• Coping, ineffective
• Fear
• Fluid volume, deficient
• Health maintenance, ineffective
• Infection, risk for
• Knowledge, deficient
• Pain, acute or chronic
• Self-esteem, situational low
• Sexual dysfunction
• Skin integrity, impaired
• Tissue perfusion, ineffective
• Urinary elimination, impaired

March 14, 2021 │ Compilation by April Tom O. Cuenca 14

MATERNAL AND CHILD HEALTH NURSING 2 3. Third space
RLE SEMIFINALS COVERAGE • The third space is space in the body where fluid
does not normally collect in larger amounts.
• For examples the peritoneal cavity and pleural
INTRAVENOUS FLUID THERAPY cavity are major examples of the third space.
• Small amount of fluid does exist normally in such
spaces, and function for example as lubricant in
Introduction
the case of pleural fluid.
Can You Imagine Life Without Water?
• Total body fluid (TBW), accounts for Water
approximately 60% of total body weight (this
• Water is the body's primary fluid and is essential
can be 70% or higher in a newborn down to 50–
for proper organ system functioning and
55% in a mature woman).
survival.
• Total Body Fluid can be divided into (1)
• People can live several days or even weeks
intracellular and (2) extracellular
without food, but they cannot survive only a few
days without water
Intracellular Fluid
• Water has many functions in the body
• 2/3 of the total body water a. Essential for Cell life
• Found inside the plasma membrane of the b. Interfere in the Chemical and metabolic
body's cells. In humans (average 70 kg), the reactions
intracellular compartment contains on average c. Nutrients absorption and transport
about 28 liters of fluid d. Regulate the Body temperature
e. Elimination of waste products through urine

How Much of You Is Water?

• Body muscle mass is rich in water, while Adipose
Tissue has a lower percentage of water content.
That’s why:
• Overweight or obese people have a lower
percentage of water compared to someone
who's lean and muscular.
• Women typically have a lower percentage of
total body water than men due to a higher
percentage of body fat.
Extracellular Fluid • Older adults tend to have a lower concentration
• Accounts for 1/3 of the TBW, either: of water overall, due to an age-related decrease
a. Interstitial in muscle mass.
b. Intravascular • Children tend to have a higher percentage of
c. 3rd space water weight-as much as 70-80% in a full-term
1. Interstitial compartment neonate.
• Is the small, narrow spaces between tissues or • Input and Output of the “Normal” Adult
parts of an organ. It is filled with what is called Minimal Obligatory Daily input:
interstitial fluid 500mL: Ingested water
• When excessive fluid accumulates in the 800mL: Water content in food
interstitial space, edema develops. In the 300mL : Water from oxidation
average male (70 kg) human body, the TOTAL: 1600mL
interstitial space has approximately 10.5 liters Minimal Obligatory Daily Water Output
of fluid (15% of the TBW) 500mL: Urine
Importance: 500mL: urine
- It acts as the microenvironment that allows 400mL: Respiratory tract
movement of ions, proteins and nutrients across 200mL: Stool
the cell barrier TOTAL: 1600mL
2. Intravascular compartment • On average, an adult input and output is 30-35
• The main intravascular fluid in humans is blood; ml/kg/day (about 2.4L/day)
the average volume of blood in humans is
approximately 70-75 ml/kg Water Requirements Increase With:
- Fever
- Sweating
- Burns
- Tachypnea
- Surgical drains
- Polyuria
- Gastrointestinal losses through vomiting or diarrhea
• Water requirements increase by 100 to 150
mL/day for each C degree of body temperature
elevation.

March 14, 2021 │ Compilation by April Tom O. Cuenca 1

Solutes
• A substance dissolved in another substance
• There are many SOLUTES, for example:
a. Plasma proteins (eg. albumin, globulins,
fibrinogen)
b. Ions (sodium chloride, magnesium, calcium,
bicarbonates)
c. Food molecules (eg. glucose, amino-acids),
waste products as urea
Osmolality
• Term refers to the solute concentration in the
body fluid by weight. The number of milliosmols
(mOsm) in a kilogram (kg) of solution.
• In humans normally the osmolality in plasma is
about 275-295 mOsm/Kg
Fluid Therapy
Importance
• Can be life-saving in certain conditions
• Loss of body water, whether acute or chronic,
can cause a range of problems from mild
headache to convulsions, coma, and in some
cases, death.
• Though fluid therapy can be a lifesaver, it's never
always safe, and can be very harmful.
Types of Fluid
• The fluids used in clinical practice are usefully
classified into colloids, crystalloids and blood
products
1. Colloid
• Solutions that contain large molecules that don't
pass the cell membranes.
• When infused, they remain in the intravascular
compartment and expand the intravascular
volume and they draw fluid from extravascular
spaces via their higher oncotic pressure
2. Crystalloid
• Solutions that contain small molecules that flow
easily across the cell membranes, allowing for
transfer from the bloodstream into the cells and
body tissues.
• This will increase fluid volume in both the
interstitial and intravascular spaces
(Extracellular)
• It is subdivided into:
a. Isotonic
b. Hypotonic
c. Hypertonic
Isotonic Fluids
When to consider an isotonic solution?
• When the concentration of the particles (solutes)
is similar to that of plasma, So it doesn't move
into cells and remains within the extracellular
compartment thus increasing intravascular
volume.
Types of Isotonic Solutions
1. 0.9% sodium chloride (0.9% NaCl or Normal
Saline)
• Simply salt water that contains only water,
sodium (154 mEq/L), and chloride (154 mEq/L).
• It's called "normal saline solution" because the
percentage of sodium chloride in the solution is
similar to the concentration of sodium and
chloride in the intravascular space.
• When to be given?
a. To treat low extracellular fluid, as in fluid
volume deficit from hemorrhage, severe
vomiting or diarrhea, heavy drainage from GI
suction, fistulas, or wounds
b. Shock
c. Mild hyponatremia
d. Metabolic acidosis (such as diabetic
ketoacidosis)
e. It’s the fluid of choice for resuscitation efforts.
f. It's the only fluid used with administration of
blood products
• Take care because 0.9% sodium chloride
replaces extracellular fluid, it should be used
cautiously in certain patients (those with cardiac
or renal disease) for fear of fluid volume
overload.
2. Lactated Ringer's solution (Ringer’s lactate
or Hartmann solution)
• It is the most physiologically adaptable fluid
because its electrolyte content is most closely
related to the composition of the body's blood
serum and plasma.
• Another choice for first-line fluid resuscitation for
certain patients, such as those with burn
injuries.
• When to be used?
a. To replace GI tract fluid losses ( Diarrhea or
vomiting )
b. Fistula drainage
c. Fluid losses due to burns and trauma
d. Patients experiencing acute blood loss or
hypovolemia due to third-space fluid shifts.
• Notice:
a. Both 0.9% sodium chloride and LR may be
used in many clinical situations, but patients
requiring electrolyte replacement (such as
surgical or burn patients) will benefit more from
an infusion of LR.
b. LR is metabolized in the liver, which converts
the lactate to bicarbonate. LR is often
administered to patients who have metabolic
acidosis not patients with lactic acidosis
c. Don't give LR to patients with liver disease as
they can't metabolize lactate
d. Used cautiously in patients with severe renal
impairment because it contains some potassium
e. LR shouldn't be given to a patient whose pH is
greater than 7.5
3. Ringer’s solution
• Like LR, contains sodium, potassium, calcium,
and chloride in similar. But it doesn't contain
lactate.
• Ringer's solution is used in a similar fashion as
LR, but doesn't have the contraindications
related to lactate.
March 14, 2021 │ Compilation by April Tom O. Cuenca 2
4. Dextrose 5%
• It is considered an isotonic solution, but when the
dextrose is metabolized, the solution actually
becomes hypotonic and causes fluid to shift into
cells.
• How does it work?
a. D5W provides free water that pass through
membrane pores to both intracellular and
extracellular spaces. Its smaller size allows the
molecules to pass more freely between
compartments, thus expanding both
compartments simultaneously
b. It provides 170 calories per liter, but it doesn't
replace electrolytes.
c. The supplied calories doesn't provide enough
nutrition for prolonged use. But still can be
added to provide some calories while the patient
is NPO.
• Take care
a. D5W is not good for patients with renal
failure or cardiac problems since it could cause
fluid overload.
b. Patients at risk for intracranial pressure should
not receive D5W since it could increase cerebral
edema
c. D5W shouldn't be used in isolation to treat
fluid volume deficit because it dilutes plasma
electrolyte concentrations
d. Never mix dextrose with blood as it causes
blood to hemolyze.
e. Not used for resuscitation, because the
solution won't remain in the intravascular space.
f. Not used in the early postoperative period,
because the body's reaction to the surgical
stress may cause an increase in antidiuretic
hormone secretion
Difference Between NS and D5W In Distribution
Precautions in Usage of Isotonic Solutions
• Be aware that patients being treated for
hypovolemia can quickly develop hypervolemia
(fluid volume overload) following rapid or over-
infusion of isotonic fluids.
• Document baseline vital signs, edema status,
lung sounds, and heart sounds before beginning
the infusion, and continue monitoring during and
after the infusion.
• Frequently assess the patient's response to I.V.
therapy, monitoring for signs and symptoms of
hypervolemia such as hypertension, bounding
pulse, pulmonary crackles, peripheral edema,
dyspnea, shortness of breath, jugular venous
distention (JVD)
• Monitor intake and output
• Elevate the head of bed at 35 to 45 degrees,
unless contraindicated
• If edema is present, elevate the patient's legs
• Monitor for signs and symptoms of continued
hypovolemia, including urine output of less than
0.5 ml/kg/hour, poor skin turgor, tachycardia,
weak and thready pulse and hypotension
• Educate patients and their families about signs
and symptoms of volume overload and
dehydration
• instruct patients to notify if they have trouble
breathing or notice any swelling
• Instruct patients and families to keep the head
of the bed elevated (unless contraindicated)
Colloid Solutions
Examples:
1.) 1-5% Albumin (Human albumin solution)
• The most commonly utilized colloid solutions.
• It contains plasma protein fractions obtained
from human plasma and works to rapidly
expand the plasma volume used for:
a. volume expansion
b. moderate protein replacement
c. achievement of hemodynamic stability in
shock states.
• Considered a blood transfusion product and
requires all the same nursing precautions used
when administering other blood products.
• It can be expensive and its availability is limited
to the supply of human donors
Albumin Contraindications
1. Severe anemia
2. Heart failure
3. Known sensitivity to albumin
4. Angiotensin-converting enzyme inhibitors ( ACEI)
should be withheld for at least 24 hours before
administering albumin because of the risk of atypical
reactions, such as flushing and hypotension
What To Do If You Suspect Transfusion
Reaction
• Sings of transfusion reaction may include:
a. fever
b. flank pain
c. vital sign changes
d. nausea and headache
e. urticaria
f. dyspnea
g. bronchospasm.
• If you suspect a transfusion reaction, take
these immediate actions:
a. Stop the transfusion.
b. Keep the I.V. line open with normal saline
solution.
c. Notify the physician and blood bank.
d. Intervene for signs and symptoms as
appropriate.
e. Monitor the patients vital signs.
March 14, 2021 │ Compilation by April Tom O. Cuenca 3
2. Hydroxyethalstarches g. Vasopressors (Dopamine, epinephrine)
• Another form of hypertonic synthetic colloids h. Dextrose > 10%
used for volume expansion i. Lorazepam
• Contain sodium and chloride and used for j. Dilantin
hemodynamic volume replacement following Infection
major surgery and to treat major burns • Cellulitis: An acute, spreading, bacterial
• Less expensive than albumin and their effects infection below the surface of the skin
can last 24 to 36 hours characterized by redness (erythema), warmth,
swelling, and pain. Usually localized.
Precautions When Using Colloid Solutions • Sepsis: Clinical symptoms of systemic illness,
1. The patient is at risk for developing fluid volume such as fever, chills, malaise, hypotension, and
overload mental status changes. Sepsis can be life
2. As for blood products, use an 18-gauge or larger threatening.
needle to infuse colloids. • > 200,000 infections per year
3. Monitor the patient for signs and symptoms of • More than 60,000 patients die annually from
hypervolemia, including: bloodstream infections caused by intravenous
a. Increased BP therapy
b. Dyspnea or crackles in the lungs • Cost for one patient is $56,000
c. Edema • Annual US total = $2.3 billion
4. Closely monitor intake and output • Causes
5. Colloid solutions can interfere with platelet a. Poor insertion site
function and increase bleeding times, so monitor the b. Squad starts
patient’s coagulation indexes c. Unsterile start
6. Elevate the head of bed unless contraindicated. d. IV Left too long – change every 96 hours
7. Anaphylactoid reactions are a rare but potentially e. Hub contamination
lethal adverse reaction to colloids. Take a careful • Prevention
allergy history from patients receiving colloids (or a. Handwashing
any other drug or fluid), asking specifically if they've b. Sterile technique
ever had a reaction to an I.V. infusion c. Catheter size
d. Insertion site
IV Statistics e. Site inspection every two hours
• 85% of all hospitalized patients have some type f. Encourage patient to report any discomfort
of IV therapy
• 118 million IV catheters inserted yearly

Complications of IV Therapy
Phlebitis
• Inflammation of the vein wall—precursor to
sepsis
• What causes phlebitis?
a. IV left in too long
b. Cannula too large
c. Vein in poor condition
d. Acidic solution or high osmolality
e. Infusion rate too fast
• Prevention
- Choose vein appropriately
a. Location
b. Size
c. Soft, spongy resilient a.) The large upper cephalic vein lies above the
d. No pain or tenderness or redness with antecubital space and is often difficult to visualize
injection and stabilize. It can accommodate 22-16 gauge
Infiltration catheters, but it should be reserved for a midline
• Leaking of nonvesicant fluid into tissues catheter or peripherally inserted central catheter.
surrounding the vein b.) The accessory cephalic vein branching off the
• Check IV site every two hours cephalic vein is located on the top of the forearm.
• Complications Medium to large-sized, it’s easy to stabilize and can
a. Nerve compression requiring fasciotomy accommodate 22 to 18 gauge catheters. However,
Extravasation the catheter tip shouldn’t be placed in the bend of the
• Inadvertent administration of vesicant drug into arm.
surrounding tissues c.) The median vein of the forearm originates in the
a. Calcium palm of the hand, extends along the underside of the
b. Magnesium arm, and empties into the basilic vein or median
c. Phenergan cubital vein. This vessel is medium-sized and easy to
d. Potassium chloride stabilize and can accommodate 24 to 20 gauge
e. Antibiotics catheters.
f. Chemotherapy drugs

March 14, 2021 │ Compilation by April Tom O. Cuenca 4

d.) The median cubital vein lies in the antecubital
fossa. This site is generally used to draw blood and
to place a midline or peripherally inserted central
catheter. A short peripheral catheter in this site limits
mobility, and I.V complications, especially infiltration,
are difficult to detect in this area. An IV-related
complication here means that the veins below this
site can’t be used.
e.) The basilic vein lies along the medial (little
finger) side of the arm. Large and easy to see, it rolls
and is difficult to stabilize. Often ignored because its
location makes it difficult to work with, it can
accommodate 22 to 16 gauge catheters. Increase
your success with this vein by placing the patient’s
arm across his chest and standing on the opposite
side of the bed to perform the venipuncture.
f.) The cephalic vein lying along the lateral (thumb)
side of the arm, is large and easy to access.
Accommodating 22 to 16 gauge catheters, it’s an
excellent choice for infusing chemically irritating
solutions and blood products. Because the radial
nerve is close to this vein, venipuncture can be done
several centimeters proximal to the wrist, but not in
the wrist.
• The metacarpal and dorsal veins on top of the
hand are good sites to begin IV therapy in some
patients. Easily visualized, they can
accommodate 24 to 20 gauge catheters. Do not
use this site for vesicant medications.
• Other sites to avoid include:
a. Veins below a previous IV infiltration
b. Veins below a phlebitic area
c. Sclerosed or thrombosed veins
d. Areas of skin inflammation, disease, bruising,
or breakdown
f. An arm affected by a radical mastectomy,
edema, blood clot, or infection an arm with an
arteriovenous shunt or fistula
BLOOD TRANSFUSION
Introduction
• Blood transfusion is the process of transferring
blood or blood components from one person
into the bloodstream of another person.
• Transfusion may be done as a life-saving
procedure to replace blood cells or blood
products lost through bleeding.
• Blood transfusion is essential in conditions like
surgery, anemia, hemorrhage, trauma.
Precautions To Be Taken Before Transfusion of
Blood
• Donor must be healthy without any diseases like
syphilis, AIDS, etc.
• Only compatible blood must be transfused and
RH compatibility must be confirmed.
• Both matching and cross-matching must be
done.
Blood Storage
• Blood is stored in blood bank in refrigerator at 4
degree Celsius
• RBC lose their ability to release Oxygen to the
tissues of recepient within 7 days
• WBC are rapidly destroyed in the stored blood
• Platelets are also destroyed at 4 degree Celsius
• Shelf life of stored blood in CPD solution is about
3 weeks when blood is stored in CPDA-I solution,
storage life increased by 5 weeks
March 14, 2021 │ Compilation by April Tom O. Cuenca 5
Blood Groups and Compatibility
• BLOOD GROUPS: the red cells contains
agglutinogens named A & B & the serum
contains agglutinins named Anti A and Anti B
• According to the presence or absence of the
2 agglutinogen A & B there are 4 blood
groups:
GROUP A – RBC contain A agglutinogen and
serum contain Anti B agglutinin
GROUP B – RBC contain B agglutinogen and the
serum contain neither Anti A nor Anti B agglutinin
GROUP AB – RBC contain both A&B
agglutinogens and the serum contains neither
Anti A nor Anti B agglutinin
GROUP O – RBC contain neither A nor B
agglutinogen and the serum contains both Anti A
and Anti B agglutinins
RH Factor
• This is an ANTIGEN found in the red cells
• Human being can be divided into Rh + & Rh –
group
• Person with Rh + blood does not possess Rh
antibody in the serum
• Whether Rh + cell are infected into Rh – person
antibody Rh develops
• First transfusion fails to produce any symptoms
but further transfusion will definitely produce
serious reaction
• Approx. 85% of population are Rh + 15% are
Rh –
Precautions To Be Taken While Transfusing
Blood
• Apparatus for transfusion must be sterile
• The temperature of blood to be transfused must
be same as body temperature
• The transfusion of blood must be slow. The
sudden rapid infusion of blood into the body
increases the load on the heart result in many
complications.
Indications of Transfusion
• Loss of blood in an accident
• Bleeding disorder (hemophilia, Christmas
disease, thrombocytopenic purpura)
• Supportive therapy in infection
• Septicemia
• Carbon monoxide poisoning
• Pack cells are given in anemias and leukemias
• Whole blood transfusion is indicated in
erythroblastosis foetalis
• In case of burns blood is given as an adjunct to
saline therapy
• Major operations, where good amount of blood
loss (eg: radical mastectomy)
Complications of Transfusion
Immune Complications
Hemolytic reactions:
a. Major (ABO) incompatibility reaction
• This is result of mismatched blood transfusion
• Majority of cases are due to technique errors like
sampling , labelling , dispatching, etc
• This causes intravascular hemolysis
Clinical features:
• Hematuria
• Pain in the loins
• Fever with chills and rigors
• Oliguria is due to the products of mismatched
blood transfusion blocking the renal tubules. it
results in acute renal tubular necrosis
b. Minor incompatibility reaction
• Occurs due to extravascular hemolysis
• Usually mild, occurs at 2-21 days
• Occurs due to antibodies to minor antigens
• Malaise, jaundice and fever
Non-hemolytic reactions
a. Febrile reaction
• Occurs due to sensitization to WBCs or platelets
• Increased temperature-no hemolysis
b. Allergic reaction
• Occurs due to plasma products; manifest as
chills, rigors and rashes all over
c. Transfusion- related acute lung injury
(TRALI)
• Anti-leucocyte antibodies cause patient’s white
cells to aggregate in pulmonary circulation
d. Congestive cardiac failure (CCF)
• CCF can occur if whole blood is transfused rapidly
in patients with chronic anemia
Infectious Complications
• Serum hepatitis
• AIDS
• Malaria
• Syphilis
March 14, 2021 │ Compilation by April Tom O. Cuenca 6
Autologous Transfusion
• Safest form of blood transfusion and involves
pre-operative collection of patient’s own blood
for reinfusion during an
• elective surgery (only in cases where hemoglobin
is more than 11 gm% and hematocrit value of
34%).
• One or two units of blood are safely drawn and
stored one or two weeks prior to surgery.
• The patient is put on good nourishing diet for
haemopoietic regeneration and build-up of
hemoglobin level prior to surgery.

ADVANTAGES
1. Autotransfusion eliminates the risk of viral
hepatitis and HIV infection
2. It avoids blood incompatibility and other
transfusion reactions
3. It ensures the availability of blood especially when
no donor is available

• Cross matching is mandatory prior to

transfusion to avoid incompatibility on account
of misidentification.

March 14, 2021 │ Compilation by April Tom O. Cuenca 7

MICHAEL JOEL B. APAS, RN, MAN
 According to existing studies, an increasing data reveals
that a growing number of nurses are needed to be trained
as Information specialists (Saba & McCormick, 2006).

The refinement of the Nursing Knowledge

Data needs Evolution of Nursing Care (Patient Assessment
and and Data
requirements Continuous need for Quality Improvement
High Information Demands
Saba, V. & McCormick, K. (2006) Essentials of Nursing Informatics- International Edition 4th Edition. McGraw Hill Publishing Incorporated Education Asia pp (4-7)

Ball, MJ ; Edwards, M. (2006) Introduction to Nursing Informatics. Springer Publishing Incorporated. New York.

Graves, JR.; Corcoran, S. (2019) The Study of Nursing Informatics. Image. The Journal of Nursing . Wiley Online Library.
With the existing factors that continuously
requires high volume of data. Data of the patient
includes not only the demographic data such as
name ,age ,sex , etc. , but also assessment
findings.
To illustrate, nursing practice today is focused on
scientific practice and at the same time the
caring side of it.
This progressive trend in the global scale requires the
integration of technology in the profession. Supported by
Saba et. Al (2006) Nursing Informatics is moving
towards the forefront of nursing profession.
Clinical Practice
Community Health
Utilization of
Technology = Nursing
Efficiency
Administration
Research
Education

Saba, V. & McCormick, K. (2006) Essentials of Nursing Informatics- International Edition 4th Edition. McGraw Hill Publishing Incorporated Education Asia pp (4-7)

Ball, MJ ; Edwards, M. (2006) Introduction to Nursing Informatics. Springer Publishing Incorporated. New York.

Graves, JR.; Corcoran, S. (2019) The Study of Nursing Informatics. Image. The Journal of Nursing . Wiley Online Library.
 In the study conducted in 2002, Hobbs discussed that as early as
19th Century the use of gizmos and other devices relevant to
nursing care was already FORESEEN. However, they focused on
something that nurses would take for granted.

In addition to the st d of B rkes (1991) N rse s

individual characteristics and computer-use
satisfaction, beliefs, and motivation.

Hobbs, Steven (2002). Measuring Nurses’ Computer Competency: An Analysis of Published Instruments. CIN: Computers, Informatics, Nursing 20(2). 63-73.

Burkes, M. (1991). Identifying and relating nurses’ attitudes towards computer use. Computers in Nursing 9 (5) 190-201, 1991
One of the factors that involves in the adoption of
Nursing Informatics is the acceptance of nurses.
Because there will be no success in the
implementation if nurses are hesitant to
acceptance to change and development.
Data analysis showed that the
overall computer knowledge
and skills were at moderate
levels and computer attitudes
were neutral.
S a egie e ha ce e
knowledge, attitude, and
skills were proposed.

Liu, JE, Pothiban L., Lu, Z. Khamponsiri T. (2000). Computer knowledge, attitudes, and skills of nurses in People’s
Hospital of Beijing Medical University. Computers in Nursing 18 (4); 197-206,
 MEANING
Informatics comes from the French word
Informatique hich means Comp ter
Science .

Informatics is defined as computer +health

science+information science.
Computer science- Is focused on how nurses uses the
existing information system, devices, softwares, and other
machineries that help them in their daily practice.
Health Science- The body of nursing knowledge. Example of
this is knowledge on anatomy, basic procedures, etc.
Information Science- is centered on how the data of the
patient is actually protected, used, and stored.
WHAT IS INFORMATICS?
Informatics is the science
of information and
computer information
systems.

1957- First coined by Karl

Steinbuch as
Informatiks
WHAT IS INFORMATICS?
1962
Philippe Louis Dreyfus
used the term as
Informatique
WHAT IS INFORMATICS?

Walter Bauer translated

the word to
Informatics
 1 50
urge of the computer industry.
everal identified experts on the field.
ervices were now improving: Both in Image
and complexity.
tore.Sort.Print : Teletypewriters
 1 60
Eneral questions were raised.
Enerated studies were existent on the
effectiveness of Informatics.
Ood source of information: Hospital
Reat number of vendors supplies HIS billing
and accountancy.
aps: Technology limitation, lack of
standards, diversity of records was slow.
 1 70
The nurses recognize the value of computers
The crafting of innovation making HIS a
meaningful tool in documentation.
Technological cost saving measure.
There were upsurge of grants and contracts
from federal agencies.
Third party payers.
 1 80
Igger scope and range in healthcare and
nursing industry.
ecame apparent of the need to update
practice standards, systems, and vocabulary.
Roader range in nursing documentation.
Eginning to use microcomputers in
workstations and point-of-care systems.
 1 0
N I was approved by ANA
I nternet was widely used in data transfers.
N eed for computer-based databases,
minimum data set, and the like.
E xpert systems were created to suit the
growing information needs.
 2000
verall growth in the computer industry.

Pen source solution, wireless POC Systems.

Opening to ne er Gi mos s ch as PDA s.
Overall approaches to minimize cost in healthcare:
HIPAA (1996)
According to the American N rse s Association (ANA) in
2001, Nursing Informatics is a specialty that integrates
nursing science and information science to manage and
communicate data, information and knowledge in the
nursing practice. Nursing informatics facilitates the Data,
information and knowledge to support patients, nurses
and other providers in their decision making in all roles
and settings. This support is accomplished through the use
of information structures, information processes and
information technology.
TRANSFORMATION OF DATA TO WISDOM
DATA
Discrete entities that are described objectively without
interpretation.
These are just the plain figure,number or value.
Example:
Blood Pressure: 120/80mmHg
CBG: 345g/dL
Nursing intervention to a patient such as CBB
TRANSFORMATION OF DATA TO WISDOM
INFORMATION
Reflects Interpretation, organization or structuring of data.
-Processed data
-Data with meaning

BP: 120/80mmHg = Normal BP

This becomes an INFORMATION as you
interpreted 120/80mmHg as within the NORMAL
RANGE.
TRANSFORMATION OF DATA TO WISDOM
KNOWLEDGE
Transformation of information.
Information that is synthesized so that relationships are
identified and formalized. In this example, you
DIET try to link as to what
caused the increase
High Blood of patient’s blood
LIFESTYLE
Sugar
sugar. Therefore,
STRESS
you are establish
Connections.
TRANSFORMATION OF DATA TO WISDOM
WISDOM
-Highest form of data transformation.
-Application of Ethics in using knowledge.
Insulin Porcine is a type
of medication for Diabetes
mellitus that is derived
ARE YOU GOING TO from the pancreas of the
GIVE INSULINE MUSLIM PATIENT pigs. Given this
PORCINE knowledge, are you going
to give it to a muslim
patient? It requires
wisdom for you to know
the answer.
In the current Information Age, the
doubling knowledge every five years and
the increased specialization of knowledge
make it imperative that nurses have access
to the latest scientific information to assist
in the quality of healthcare (Hudgens, 1992;
Saba, 2008)
Nursing Informatics facilitates
INFORMATION
Nursing Informatics allows articulation of
ORGANIZED INFORMATION.
NI leads to CREDIBILITY.
MICHAEL JOEL B. APAS, RN, MAN
Welcome to our 2nd session in the subject Nursing
Informatics. Last time, we talked about the
different eras of Informatics development in the
Nursing Profession. In this session, we will focus
more on GATE: General Application,
Theory, Educational and
Professional Informatics.

Shall we now start?

This section generally focuses of Nursing Informatics the following domain:

Clinical Practice C ommunity Health Administration Research Education

 Computer generated documentation lessens mistakes and enhances efficiency.
This becomes beneficial as nurses could easily read notes, doc or s order, or
even makes their charting reliable and readable.

L ists to remind staff on planned intervention.

Nursing Interventions that are new and rare may be beneficial for nurses as the use of
informatics, it can guide them how to properly manage a certain illness condition.

I mportant client information is not missed with the use of Electronic

Health Record.
Patients admitted have their important information in the computer. It would
reappear as a record in the hospital even if they are re-admitted. Thus important
information regarding previous hospitalization is easily retrieved.

Clinical Practice
Which of the two enhances patient SAFETY?
***Sample Electronic Health Record used for educational purposes.
***Sample Clinical Pathway wherein nurses enhances effectivity by choosing appropriate nursing intervention for their patients.
 Increases nurse s vigilance for the high-risk patients.
With the use of monitoring machines, it enhances nurses monitoring to their
patient. Thus, high-risk patients are monitored.

C omputer generated NCPs and Clinical-Pathway.

A utomatic billing for supplies and procedures given.
Processing discharge flow of the patient can be hastened with the use of
c e a a ca c e a e a ab e e b e e f
their existing health insurances.

L ess chances of errors in patient care and documentation.

Clinical Practice
 Doc men a ion is done immedia el on pa ien s bedside af er
giving the intervention to prevent mistakes and errors.

The use of Nursing Informatics, particularly, the

Bar Code Medication Administration
wherein medications are scanned prior to
administration.
 Hotlines and emergency response systems.
Nursing Informatics becomes beneficial to the general public as hotlines are easily
accessible by local hotlines and emergency response systems.

O nline consultations becomes evident nowadays.

M edical specialists can easily be reached thru online conferences.
Experts needs not to travel in case their expertise are sought by general
practitioners as conferences are easily done online.

E xisting technology such as Telehealth that makes health accessible

in remote areas with the use of wireless internet connection.

C
ommunity Health
C
ommunity Health
 RX Box
RxBox is a multi-component program (biomedical
device, electronic medical record system and
telemedicine training) designed to provide better
access to life-saving health care services in
isolated and disadvantaged communities
nationwide. It is one among the Department of
Science and Technolog efforts for a Smar er
Philippine . It is also an ICT (Information and
Communications Technology) innovation
designed to support the Department of Heal h
call for Kalusugang Pangakalahatan or Universal
Health Care.
Lifted from: https://rxbox.chits.ph/what_is_rxbox/

C
ommunity Health
 Lesser time in retrieval important information in the unit such as material
inventory, statistics, and other information.

Electronic mail usage to hasten communication such as release of

memorandums, report, communication, staff schedule and the like.

Automated staff scheduling.

Decrease errors in reports such as quality assurance and outcome analysis
among patients.

A dministration
 Systematic record-keeping and grade computation.
Technology: Computerized and Interactive Learning.
Use of Software for Slides, hand-out, and powerpoint.
Distance learning makes accessible education for all worldwide.
Yielding wide-range of literature of global publication and references.

R
esearch and E ducation
 NURSING INFORMATICS
Information Systems used in healthcare
include the people, structures and processes
and manuals as well as tools that collect, store
and interpret, transform, and report practice
management and information (Rao, 2015)

Hobbs, Steven (2002). Mea gN e C e C ee c :A A a fP b ed I e . CIN: Computers, Informatics, Nursing 20(2). 63-73.

Burkes, M. (1991). Ide f ga d ea g e a de a d c e e. Computers in Nursing 9 (5) 190-201, 1991

Communicates and coordinates care with all
other disciplines.
Coordinate discharge planning, education
and teaching and transition of care.
Manages ALL information related to nursing
process and patients.
1. Informatics Nurse (IN)
Nurse with specialized skills, knowledge &
competencies in informatics
RN with an interest or experience working in an
informatics field
Generalist in the field of informatics in nursing

2. Informatics Nurse Specialist (INS)

RN with formal, graduate education in the field
of informatics or a related field
Specialist in the field of nursing informatics
THE AMERICAN NURSES ASSOCIATION (ANA,1994)
LISTS SEVERAL FUNCTIONS OF THE NIS
Theory development –the NIS contributes to the specific knowledge base of the
nursing informatics.

Analysis of information needs – the identification of information that nurses need

in order to accomplish their work; client care, education, administration, &
research.

Selection of computer system – the INS, guides the user in making informed
decisions related to the purchased of computer systems.

Design of computer system & customizations – the NIS collaborates with users &
computer programmers to make decisions about how data will be displayed &
accessed.

Testing of computer systems – systems must be checked for proper functioning

before they are made available for use in patient care.
Training users of computer systems users need to be trained in
how the system works, the importance of accurate data entry, & how
the system will benefit them, & more importantly how it will improve
patients outcomes.

Evaluation of the effectiveness of computer systems- the unique

role of the NIS makes them the ideal person to evaluate the
effectiveness of computer systems.

Ongoing maintenance & enhancements - the NIS makes sure the

computerized system functions properly & explores possible
enhancements to the system that will better serve the users & the
patients.

Identification of computer technologies that can benefits nursing

the NIS must keep abreast of the changes in the fields of computers
& information technology, including new hardware & software that will
benefit the nurse & patient.
4 LEVELS OF INFORMATICS COMPETENCIES
1. The Beginning Nurse
- Have fundamental information & management skills

2. The Experienced Nurse

- Highly skilled in use of informatics to support her practice

3. Informatics Nurse Specialist

- Has advanced preparation in information management, she focuses on
applications to support nursing practice & use skills in critical thinking, decision
making & system development.

4. Innovator Nurse
-conducts informatics research & general informatics theory & creative in
developing solutions & has a sophisticated level of understanding & skills in
computer technology.
LEVEL OF EXPERTISE COMPETENCIES

Users Technical

Modifiers Utility

Innovators Leadership
 USER MODIFIER INNOVATOR
A "User" level of competency A "Modifier" level of competency An "Innovator" level of
indicates nurses who indicates nurses who competency indicates nurses who
demonstrate core nursing demonstrate intermediate demonstrate advanced and
informatics competencies. This nursing informatics specialized nursing informatics
level includes practicing nurses, competencies. This level competencies. This level
nursing administration, nurse includes practicing nurses, includes practicing nurses,
researchers and educators. In nursing administration, nurse nursing administration, nurse
most taxonomy, this is the basic researchers and educators who researchers and educators who
level that ALL nurses should have mastered basic skills and have mastered expert skills and
minimally demonstrate, no matter use technology in inventive use technology in design, plan
what area of practice he or she ways in their practice. and coordinate the use of
works in. Even user level technologies and informatics
competencies include technical, theory in nursing.
utility and leadership related
skills and knowledge.
 TECHNICAL UTILITY LEADERSHIP
Technical competencies are Utility competencies are related to Leadership competencies are
related to the actual the process of using computers related to the ethical and
psychomotor use of computers and other technological management issues related to
and other technological equipment within nursing using computers and other
equipment. Specific nursing practice, education, research technological equipment within
informatics competencies include and administration. Specific nursing practice, education,
the ability to use selected nursing informatics competencies research and administration.
applications in a comfortable include the process of applying Specific nursing informatics
and knowledgeable way. It is evidenced based practice, competencies include the process
important that nurses feel critical thinking, and of applying accountability,
confident in their use of accountability in the use of client privacy and
computers and software in the selected applications in a confidentiality and quality
practice setting, especially at comfortable and knowledgeable assurance in documentation in
the bedside, in order to be able way. the use of selected applications
to attend to the client at the in a comfortable and
same time. knowledgeable way.
NURSING INFORMATICS
LECTURE MIDTERMS COVERAGE
NETIQUETTE: ONLINE RULES AND GUIDELINES
TO SAFE LEGAL NURSING PRACTICE
Netiquette or Network Etiquette
• Concerned with the “proper” way to
communicate in an online environment.
• Etiquette
- “forms required by good breading or prescribed
by authority to be required in social or official
life”
General Guidelines for Cyberspace Behavior
Rule 1: Remember the Human
• When communicating online, remember the
other person is a human with feelings.
• Do not do unto other what you don’t want others
to do unto you.
• Stand up for yourself but try not to hurt other
people’s feelings
• Example: When you’re communicating
electronically, it is easy for your correspondent
or other people to misinterpret your message.
• The prime directive of netiquette is that real
people are out there, so treat them with outmost
respect even when online
• Our messages and posts are written online and
there is a great chance that it can come back to
haunt us, so be think before you post anything
on social media
• Remember that although you are in the
cyberspace, do not forget that at the back of the
computers are real people who have feelings.
Rule 2: Adhere to the Same Standards of
Behavior Online That You Follow in Real Life
• Be ethical
• Breaking the law is bad netiquette
• In real-life, most people are law-abiding because
they are afraid of getting caught while in
cyberspace, people think that the chances of
getting caught is slim that’s why they act
inappropriately sometimes
• Some people believe that a lower standard of
ethics is acceptable in cyberspace
• Some people are mistaken that there are
different standards in real life and cyberspace,
but the truth is that the standards of behavior in
cyberspace are not lower than in real life
• Example: If you share where you have to pay for
it, always remember to pay shareware as it can
benefit the cyberspace and keep the website
running. (If you share a Netflix account with your
friends, always remember that you and your
friends should all pay for it.)
• Netiquette mandates that you do your best to act
within the laws of society for you not to fall into
bad netiquette
• “Think before you click”
Rule 3: Know Where You Are in Cyberspace
• Netiquette varies from domain to domain
• Lurk before you leap
• Remember that what’s perfectly acceptable in
one area may be dreadfully rude in another
• Example: Spreading adult rumors in an online
discussion is fine, but sharing rumors to a group
of journalist online is very bad and will make you
unpopular.
• When entering a certain domain of cyberspace,
you have to first take a look around, spend a
while listening to the chat or read archives to get
a sense of how the people act in that domain of
cyberspace before you participate.
Rule 4: Respect Other People’s Time and
Bandwidth
• Avoid wasting time
• Be as concise as possible
• It’s a cliché that people today seem to have less
time than ever before, even though we sleep less
and have more labor-saving devices
• It is your responsibility to ensure that the time
others spend on reading your post should be
worthwhile and is not wasted
• Bandwidth is synonymous with time but it is the
information carrying capacity of wires and
channels that connect everyone in cyberspace.
There is a limit to the amount of data that any
piece of wiring can carry at any given moment.
• The word bandwidth is also sometimes used to
refer to the storage capacity of a whole system.
• Example: You accidentally post the same note
five times on a discussion group, with that you
are wasting both time of the people who check
all five copies of the posting and also the
bandwidth by sending repetitive information over
the wires and requiring it to be stored
somewhere.
• Remember that you are not the center of
cyberspace
• Other people have concerns other than yours, so
don’t expect instant responses to all your
questions and don’t assume that all readers will
agree with or care about your passionate
arguments.
• When reading news article, sometime you find
out that after reading the entire article, you still
did not read the meat of the news and is not
worth the trouble. With this, we should be
concise and direct with our messages online.
Rule 5: Make Yourself Look Good Online
• Always check for spelling and grammar
errors
• Know what you’re talking about and state it
clearly
• Be pleasant and polite
• Take advantage of your anonymity
• You will be judge by the quality of your writing
• Spelling and grammar do count if you’re
spending a lot of time in the internet
• You have to make sense so pay attention to the
content of your writing
• Check your facts before posting online because
bad information propagates like wildfire in the
internet
March 14, 2021 │ Compilation by April Tom O. Cuenca 1
• People tend to put words into our mouth so we
have to be responsible of what we post
• Make sure that your paragraph contains no
errors in grammar or spelling and make it simple
• Don’t post flame bait, always remember to be
pleasant and polite
• Do not use offensive language and do not be
confrontational
Rule 6: Share Expert Knowledge
• Share your expert knowledge
• Do not be afraid to share what you know
• Share results of your questions with others
• Requests replies by email instead
• If you get a response, write up a summary and
post it to the discussion group. In this way,
everyone benefits from the experts who took
time to write to you.
Rule 7: Help Keep Flames Wars Under Control
• “Flaming” is when people express their
opinions strongly and with emotion, despite
other feelings on a topic
• Be careful how involved you get into a flame
war. They may be fun at first, but they get
old fast.
• Netiquette does forbid the perpetration of flame
wards as these are serious of angry messages
directed toward each other that can dominate
the tone and destroy the camaraderie
• Flame wars are an unfair monopolization of the
bandwidth
Rule 8: Respect Other People’s Privacy
• Respect the privacy of others. Do not share
their personal information online or snoop
on their devices.
• Do not be afraid to share what you know
• Share results of your questions with others
• Requests replies by email instead
• If you get a response, write up a summary and
post it to the discussion group. In this way,
everyone benefits from the experts who took
time to write to you.
• Failing to respect other people’s privacy is not
just but netiquette, it could also cost you your
job.
Rule 10: Be forgiving of Other People’s Mistakes
• Do not paint out mistakes to people online
• Remember that you were once the new kid
on the block
• You still need to have good manners even
though you are online and cannot see the
person face to face
• Knowing more than others or having more power
than they do doesn’t give you the right to take
advantage of them
• Example: System admins should never read
other people’s private emails
• Whether it’s a spelling error or an unnecessary
long answer, be kind about it
• Think twice before reacting. Having good
manners yourself doesn’t give you license to
correct everyone else.
• If you decide to inform someone of a mistake,
point it out politely and preferably by private
email rather than in public
How Can It Be Applied To Health Care?
• Communication may be via e-mail or website
forums
• The nurse and patient should both use proper
etiquette to decrease misunderstandings and
protect patient information
• Both nurses and doctors can use the Internet to
further enhance care and suggest optional
sources of information. (Interdisciplinary)
• The patient must still employ netiquette when
interacting with these sites and forums (Penson
et.al., 2002)

Rule 9: Don’t Abuse Your Power

• Do not take advantage of other people just
because you have more knowledge or
power than them
• Treat others as you would want them to
treat you if the roles were reversed
• Knowing more than others or having more power
than they do doesn’t give you the right to take
advantage of them
• Example: System admins should never read
other people’s private emails

March 14, 2021 │ Compilation by April Tom O. Cuenca 2

 INTEGRATING INFORMATION SYSTEMS TO
THE PRACTICE OF NURSING:
CLINICAL DECISION SUPPORT SYSTEM (CDSS)
Clinical Decision Support System (CDSS)
• Automated tools designed to support decision
making activities and improve the decision
making process and the decision outcomes
• Such systems are intended to use the enormous
amount of data that exists in information
systems to facilitate decision processes
• It is designed to support healthcare providers in
making decisions about the delivery and
management of patient care
Definition
• Johnston et al (1994) defined CDDS as
“computer software employing a knowledge base
designed for use by a clinician involved in patient
care, as a direct aid to clinical decision-
making
• Sims et al (2001) broadened the definition as
“CDDS are software designed to be a direct aid
to clinical decision-making, in which the
characteristics of an individual patient are
matched to a computerized clinical knowledge
base and patient-specific assessments or
recommendations are then presented to the
clinician or the patient for a decision.”
• The role of CDDS is augmenting human
performance and providing assistance for
healthcare provides, especially for tasks subject
to human error.
• Healthcare is being transformed through
information and knowledge management and
technology which is being used to obtain data
and transform information.
• The application of CDSS helps clinicians access
and use what science has learned
• With the rapid exponential increase in the use of
the internet and the ability to store electronic
data, it has proved to a bond to the development
of CDSS.
• Computers have unlimited capacity for
processing and storage of data however humans
have limited time storage or memory and
processing power. But computers do not have
the judgement that we have and the experience
and intuition that are not present in technology.
• CDSS integrate and capitalize on the strengths of
both the computer and the human
Three Main Purposes of a CDSS
1. Assist in problem solving with semi-structures
problems
2. Support, not replace the judgement of a manager
or clinician
3. Improve the effectiveness of the decision-making
process
Types of CDSS
1. Administrative and Organizational Systems
• These systems encompass decision processes
other than direct patient care delivery, and even
if clinical in nature, such as quality improvement
systems, are mainly used for strategic planning,
budgeting, financial analysis, quality
management, continuous process improvement
and clinical benchmarking
• Systems that support organizational executive or
managerial financial and clinical decisions
• Administrative systems include those designed
for finance or quality monetary, generally
support the business decision making process.
• Decisions occur at the strategic tactical
population or aggregate and operational levels
and not at an individual level
• Tend to be batch-oriented in nature, meaning not
real time, mostly concerned with aggregations of
many data elements largely for the purpose of
intelligence gathering
• Tend to be unstructured, goal-seeking or
searching and long-range in nature whereas
CDSS tend to focus on real-time decision
support, goal orientation and intelligence
gathering and are designed to be used at the
point of care by clinicians
2. Integrated Systems
• Such systems are able to support outcomes
performance management by integrating
operational data with clinical data
• Just recently, healthcare agencies began to
understand that combination systems offer
optimal value to the organizations.
• Integrated systems are able to support outcome
performance management by integrating
operational data (business side)
Examples of operational data: Budgeting,
executive-decision making, financial analysis,
quality management and strategic planning
data with clinical data (clinical side)
• Examples of clinical data: Clinical event
tracking, results reporting, pharmaceutical
ordering and dispensing, differential diagnosis,
real-time clinical pathways literature, research,
and clinical alerts
• The intent, content and methods may differ but
this two approaches to CDSS (business and
clinical) have common elements and the
integration of the two can increase effective
decisions.
Characteristics of DSS
1. These systems can be studied based on their
structure, organization, content or purpose
2. Teich and Wrinn (2000) examines DSS from the
aspects of functional and logical classes and
structural elements
• Examples of functional classes: Feedback
provided by the clinician to other clinician,
organization of data, extent of proactive
information provided, intelligent actions of the
system and the communication method
• Examples of logical classes: Substitute
therapy alerts, drug family checking, structured
entry consequent actions, parameter checking,
redundant utilization checking, relative
information display, time-based checks,
template and order sets, profile display and
analysis, rule-based event detection and
aggregate data trending
March 14, 2021 │ Compilation by April Tom O. Cuenca 3
• Examples of structural elements: Triggering
dispatching process control notification or
acknowledgement action choices, action
execution and rule editor
Key CDSS Functions
• Perreault (1999) organized key CDSS
functions as:
1. Administrative
– Support for clinical coding and documentation
2. Management at clinical complexity and
details
- Keeping patients on research and chemotherapy
protocols, tracking orders, referrals, follow-up, and
preventive care
3. Cast control
- Monitoring medication orders and avoiding
duplicate or unnecessary texts
4. Decision support
- Supporting clinical diagnostic and treatment plan
processes, promotion of best practices, use of
condition-specific guidelines, and population-based
management
Key CDSS Functions
• If we are going to classify CDDS on an
ontological perspective, we could divide it
into four (4):
1. Data-based systems (population based)
- Capitalize on the fundamental input into any
intelligent system or data
- Provide decision support with a population
perspective and use routinely collected longitudinal,
cohort and cross-sectional database
- Population based information is used to enhance
clinical decision-making which funnels patients to
medical care and enhanced medical practice
- The development of technologies and techniques for
OLAP (Online Analytical Processing) and building and
using data warehouses are combined with the
increased ability to store and process vast amounts
of data effectively allowing users to access data for
decision support at the speed of thought.
2. Model-based systems (case based)
- Driven by access to and manipulation of a
statistical, financial, optimization and or simulation
model
- The data in this instance are compared to various
decision-making and analytical models
- A model is a generalization that can be used to
describe the relationships among a number of
observations to represent a perception of how things
fit together
- The models may be pathophysiologic, statistical or
analytic
- Some model based examples are linear
programming such as scheduling nurses or
physicians or resource allocation simulation such as
emergency department or operating room scheduling
or provider profiling
3. Knowledge-based systems (rule based)
- Rely on expert knowledge that is either embedded
in the system or accessible from another source and
uses some type of knowledge acquisition process to
understand and capture the cognitive processes of
healthcare providers
- Evidenced based practice refers to the knowledge
based decision support, however there are still
hanging issues in maintaining current evidence in the
CDSS
- Sim et all identified the policy and research
challenges in developing and maintaining practice
evidence in machine readable repositories
- The CDSS must have a knowledge base that is
constantly updated with the most current evidence
available and should be viewed as both a goal and a
necessity
4. Graphic-based systems
- Take advantage of the user interface to support
decisions by providing decision “cues” to the user in
the form of color, graphical representation options,
and data visualization
- Examples: Low O2 representation in the IC gives
you a decision to act on the hypoxia
Examples of CDSS Applications
1. Reminders and alerts which are computer tools for
focusing attention such as “flags” for abnormal
values
2. Therapy critiquing and planning as well as care
maps, guidelines, protocols, and so on
3. Diagnostic assistance providing patient-specific
consultations using diagnostic or management tools
such as problem knowledge couplers (PKC)
4. Lab systems with interpretation of measured
values and automated preparation of reports as well
as physician guidance as to which tests to order
5. Prescribing decision support such as drug advisory
systems used for advising on drug-drug interactions,
side effects, selecting most-cost-effective drug
6. Clinical workstations with online literature, e-tools
for calculation and patient guidelines
7. Image recognition and interpretation with
capabilities of mass screening
8. Signal interpretation such as interpretative alarms
for real-time clinical signals in intensive care unit
(ICU), automated electrocardiogram (ECG)
interpretation, retinal scans and voice recognition
9. Natural language or speech recognition which
offers interpretation of freely entered clinical notes
and archiving to make electronically accessible in the
future
10. Evidence-based quality improvement using up-
to-date and consistent tools
11. Multitask tools for assessment, diagnosis and
management
Evaluation of CDSS
• Sim et al (2001) have identified as essential
“ongoing iterative reevaluations and redesigns of
CDSS to identify and amplify system benefits
while identifying and mitigating unanticipated
system errors or dangers.”
Five Elements for a Real-Time Clinical Decision
Support System
1. Integrated real-time patient database
- Combines patient data from multiple sources, ex:
laboratory, radiology, pharmacy, admission, nursing
notes and etc.
- This is needed to provide context for result
interpretation and good clinical decision
March 14, 2021 │ Compilation by April Tom O. Cuenca 4
2. Data-driven mechanisms
- Allows event triggers to go into effect and activate
alerts and reminders automatically
3. Knowledge engineer
- Translate the knowledge representation scheme
used in the system so that the clinical knowledge in
the system can be extracted and translated into
machine executable logic
4. Time-driven mechanism
- Permit automatic execution of programs at a
specific time, for example 4 hours after surgery to
alert provider to carry out a specific action or ensure
that the action had been completed
5. Long-term clinical data repository
- Data collected over time from a variety of sources
allowing unlimited outpatient record
- Very important as dilemma at one point of life,
history of admission and history itself is vital in
understanding the course of the illness or the disease
that the person has
A Sample List of Clinical Decision Support
Systems
1. Clin-eguide
• A point-of-care CDDS designed for integration
with electronic health records that makes
recommendations on diagnosis, management
and treatment of specific diseases
2. Clinical Pathway Constructor
• Zynx Health’s Web-based tool with a terms and synonyms
compendium of evidence-based guidelines.
Available by subscription
3. CURE (Carotid U.S. Report Enhancement,
Washington University, St. Louis)
• Augments carotid ultrasound reports with
treatment-specific prognostic information
4. Diagnosis Pro
• Contains a database of 9,000 diseases and drug
terms and 16,000 symptoms, signs, lab and x-
ray findings linked with 120,000 relationships to
suggest diagnosis and treatment
5. DXplain (Harvard/MIT/Mass General)
• A system using a set of clinical findings including
signs, symptoms, and lab data to produce a
ranked list of diagnosis that might explain the
clinical signs and symptoms
6. Healthaction (Health Development Agency or
HAD/HAD)
• A web site that is a knowledge management
service for primary care; shares approaches to
reduce health inequalities and facilitated
interactive learning exchange
7. HDP-The Heart Disease Program (MIT) Iliad
• A system to assist in the diagnosis of
cardiovascular
8. IMKI-Institute for Medical Knowledge
Implementation
• Has developed and maintains a library of medical
knowledge applications and is developing a
process for development, evaluation and
dissemination of CDDS rules
9. InfoRetriever (InfoPOEMS)
• Contains seven evidence databases, clinical
decision rules, practice guidelines, risk
calculators, and basic information on drugs; can
be loaded on a PDA
•
10. ISABEL
• A diagnostic reminder system from the United
Kingdom that covers the spectrum of pediatric
medicine and is designed to integrate with
electronic medical record (EMR) systems
11. LISA
• A DSS for treatment of childhood acute
lymphoblastic leukemia
12. Logiciana
• MedicaLogic’s electronic record system that
checks medications and formulary compliance
and includes clinical reminders and patient
education material
13. MICROMEDEX
• A system designed to provide clinicians with
alerts, recommendations and evidence-based
references
14. Misys Insight
• A open CDDS designed to work with a broad
spectrum of clinical information systems
15. ORAD (oral radiographic differential
diagnosis)
• A system designed to evaluate radiographic and
clinical features of patients with intrabony dental
problems
16. Oxford Clinical Mentor (Oxford)
• A UK electronic medical knowledge support
system with details on more than 2,000 diseases
cross-referenced with 26,000 commonly used
17. PIER – Physician’s Information and
Education Resource
• American College of Physicians-American Society
of Internal medicine web-based DSS tool which
combs medical literature and provides bullet lists
under six different topics. Available to members
only
18. PKC-Problem Knowledge Couplers (Weed,
1991)
• A system of data capture and clinical guidance
that provides decision and management support
to clinicians
19. PRODIGY-Prescribing rationally with
decision support in genera-practice study
• A UK initiative for evaluation of a prescribing
practices in general practice
20. QMR-quick medical reference (University of
Pittsburgh/first databank)
• A system with a knowledge base of close to 700
diseases, signs, symptoms, and lab information
to suggest relevant diagnosis
21. TheraSim CS-HIV (International Society of
Infectious Diseases)
• A system of clinical simulation, DES, and medical
education technology for the management of HIV
22. TraumAID
• A system of decision support for emergency
center management of multiple trauma that
produces diagnostic and therapeutic plans for
patient management
15. VisualDx
• An image-based system that serves as a
reference to support diagnosis and treatment
March 14, 2021 │ Compilation by April Tom O. Cuenca 5