HIGH-RISK PREGNANCY

CONDITIONS
POSTPARTUM PERIOD
POSTPARTUM HEMORRHAGE
UTERINE ATONY
LACERATIONS

Tagaro, James Kym

 Postpartum
Hemorrhage
 Definition:
• Postpartum hemorrhage is excessive bleeding
following the birth of a baby. About 4 percent of
women have postpartum hemorrhage and it is
more likely with a cesarean birth. Hemorrhage
may occur before or after the placenta is delivered.
The average amount of blood loss after the birth of
a single baby in vaginal delivery is about 500 ml
(or about a half of a quart). The average amount of
blood loss for a cesarean birth is approximately
1,000 ml (or one quart). Most postpartum
hemorrhage occurs right after delivery, but it can
occur later as well.
 Causatives/Risks:
• Some women are at greater risk for postpartum hemorrhage than others.
Conditions that may increase the risk for postpartum hemorrhage include the
following:
• placental abruption - the early detachment of the placenta from the uterus.
• placenta previa - the placenta covers or is near the cervical opening.
• overdistended uterus - excessive enlargement of the uterus due to too much
amniotic fluid or a large baby, especially with birthweight over 4,000 grams
(8.8 pounds).
• multiple pregnancy - more than one placenta and overdistention of the uterus.
• pregnancy-induced hypertension (PIH) - high blood pressure of pregnancy.
• having many previous births
• prolonged labor
• infection
• obesity
• medications to induce labor
• medications to stop contractions (for preterm labor)
 Pathophysiology:
• The physiology of postpartum hemostasis depends primarily
upon on mechanical events mediated by hormones, which
induce strong uterine muscular contraction. Virtually all recent
studies focus on the latter, but the phenomenon cannot be
understood without examining why uterine contraction stops
bleeding. Broadly speaking, myometrium and decidua are
arranged such that powerful muscular contraction after delivery
favor hemostasis.
• Spiral arteries “fan out” to create a lower-resistance vascular
bed in the intervillous space, which facilitates placental blood
flow. This flow has been shown to decrease with muscular
activity
• Third stage contractions are powerful and prolonged: they act
to stop placental blood flow and to separate the placenta and
membranes.
 Signs and Symptoms:
•uncontrolled bleeding
•decreased blood pressure
•increased heart rate
•decrease in the red blood cell count (hematocrit)
•swelling and pain in tissues in the vaginal and
perineal area
The symptoms of postpartum hemorrhage may
resemble other conditions or medical problems.
Always consult your physician for a diagnosis.
 Management Treatment:
Specific treatment for postpartum hemorrhage
will be determined by your physician based
on:
• your pregnancy, overall health, and medical
history
• extent of the condition
• your tolerance for specific medications,
procedures, or therapies
• expectations for the course of the condition
• your opinion or preference
The aim of treatment of postpartum hemorrhage is to find and stop
the cause of the bleeding as quickly as possible. Treatment for
postpartum hemorrhage may include:
• medication (to stimulate uterine contractions)
• manual massage of the uterus (to stimulate contractions)
• removal of placental pieces that remain in the uterus
• examination of the uterus and other pelvic tissues
• packing the uterus with sponges and sterile materials (to
compress the bleeding area in the uterus)
• tying-off of bleeding blood vessels
• laparotomy - surgery to open the abdomen to find the cause of
the bleeding.
• hysterectomy - surgical removal of the uterus; in most cases, this
is a last resort.
• Replacing lost blood and fluids is important in treating
postpartum hemorrhage. Intravenous (IV) fluids, blood, and
blood products may be given rapidly to prevent shock. The
mother may also receive oxygen by mask.
Postpartum hemorrhage can be quite serious. However, quickly
detecting and treating the cause of bleeding can often lead to a
full recovery.
 Nursing Care:
• Monitor amount of bleeding by weighing all
pads.
• Frequently monitor vital signs.
• Massage the uterus.
• Place the mother Trendelenberg position.
• Provide comfort measure like back rubs, deep
breathing. Instruct in relaxation or visualization
exercises.
• Administer oxygen as indicated.
• Administer medication as indicated. (e. g.
Pitocin, Methergin)
Uterine Atony
 Definition:
• The failure of the uterus to contract maximally
after the delivery of the baby and placenta,
resulting in heavy uterine bleeding.

*Uterine atony: failure of the myometrium to

contract after delivery of the placenta;
associated with excessive bleeding from the
placental implantation site.
• Uterine atony is the most common cause of postpartum
hemorrhage and the most common indication for
postpartum hysterectomy or blood transfusion.

• Normally, bleeding after delivery is stopped by uterine

contractions and compression of the vessels. If uterine
contractions are not adequate, bleeding can continue. At
times, the uterus is prevented from contracting
effectively by fragments of placenta that remain in the
uterus after delivery or by benign growths of uterine
muscle within the uterine wall (fibroids). In these cases,
the term 'atony' usually is not applied. In most cases, the
uterine muscle simply fails to contract adequately.
 Causatives/Risk:
• Multiple gestation, high parity
• Fetal macrosomia
• Polyhydramnios
• General anesthetics
• Prolonged labor, precipitous labor,
augmented labor
• Infection (chorioamnionitis)
 Patophysiology:
• The most frequent cause of postpartal
hemorrhage is UTERINE ATONY. The
myometrium fails to contract and the
uterus fills with blood because of the lack
of pressure on the open vessels of the
placental site.
• Once a baby is delivered, the uterus normally
continues to contract (tightening of uterine
muscles) and expels the placenta. After the
placenta is delivered, these contractions help
compress the bleeding vessels in the area
where the placenta was attached. If the uterus
does not contract strongly enough, called uterine
atony, these blood vessels bleed freely and
hemorrhage occurs. This is the most common
cause of postpartum hemorrhage. If small pieces
of the placenta remain attached, bleeding is also
likely. It is estimated that as much as 600 ml
(more than a quart) of blood flows through the
placenta each minute in a full-term pregnancy.
 Signs and Symptoms:
• Excessive bleeding at the time of delivery
• Excessive or bright red bleeding
• A boggy uterus that does not respond to
massage
• Abnormal clots
• Any unusual pelvic discomfort or
backache
 Management Treatment:
• Initial treatment consists of bimanual
compression, uterine massage.
• Uterine contraction medications: Oxytocin,
Methylergonovine, and Prostaglandins
• Surgery: uterine vessel ligation or
hysterectomy (the latter is rarely used)
• Blood and fluids must be replaced as
needed.
 Nursing Care:
• Medication ( to stimulate uterine contraction )
– IM Methergine
– IV Oxytocin
• Manual massage of the uterus
• Administer ice pack.
• Bimanual massage.
• Blood Transfusion.
• Hysterectomy
• If with respiratory distress from decreasing blood
volume
– Give O2
– Place in supine position to allow adequate blood flow to brain and
kidneys
Laceration
 Definition:
• A laceration is properly a tearing or
rupturing of soft tissue (e.g., skin, brain,
liver) by blunt trauma. Avoid extending this
term to all open wounds, including incised
wounds. A torn or jagged wound, or an
accidental cut wound. The process or act
of tearing the tissues.
 Causative/Risks:
• Spontaneous or Precipitous delivery
• Size, Presentation, and Position of baby
• Contracted Pelvis
• Vulvar, perineal, and vaginal varices
 Pathophysiology:
• Lacerations of the birth canal are second
only to uterine atony as a major cause of
postdelivery hemorrhage.
 Signs and Symptoms:
• Bright red bleeding where there is a
steady trickle of blood and the uterus
remains firm.
• Hypovolemia
• Continuous bleeding from so-called minor
sources may be just as dangerous as a
sudden loss of a large amount of blood.
 Management Treatment/Nursing
care:
• Meticulous inspection of the entire
lower birth canal
• Suture any bleeders
• Vaginal pack-- nurse may remove and
assess bleeding after removal.
• Blood replacement
SUBINVOLUTION OF THE
UTERUS
PUERPERAL INFECTIONS

Tomas, Fredderick
RETAINED PLACENTAL
FRAGMENTS
HEMATOMAS

Rivera Jim Lester

Retained Placental Fragments in the
Uterus. These fragments are the major
cause of late postpartum hemorrhage.
Uterine Atony-this is the inability of the myometrium to
contract and constrict the blood vessels within the
muscle fibers, resulting in open sinuses at the site of
placental separation. Decreased muscle tone causes
slow, insidious loss of blood.
• (1) Factors usually leading to uterine atony.
• (a) Conditions which result on overextension of uterine
musculature (multiple pregnancy - two or more fetuses
and hydramnios - excessive amniotic fluid).
• (b) Conditions resulting in exhaustion of the uterine
musculature are large fetuses, prolonged or difficult
labor, Pitocin® induced or augmented labor (this may
result in decreased response to postpartal administration
of pitocin) and precipitous or forceful delivery.
Signs and symptoms of uterine atony.
• (a) Signs of shock--decreased blood
pressure, increased pulse, and increased
and anxiety and irritability.
• (b) Bleeding-usually dark with clots
present.
• (c) Noncontracted, boggy uterine fundus.
Medical treatment
• (a) Intervenously fluids administered to increase
fluid and blood volume.
• (b) Oxytocin administration.
• (c) Methergine/prostin may be administered to
stimulate uterine contractions when oxytocin is
ineffective.
• (d) Blood transfusion if the patient's hematocrit
drops too low and/or if she is symptomatic.
Nursing interventions:
(a) Palpate the fundus frequently to determine
continued muscle tone.
(b) Massage the fundus, if boggy, until firm (do
not over massage, this fatigues the muscle).
(c) Monitor patient's vital signs every 15 minutes
until stable.
(d) Prevent bladder distention. Bladder
distention displaces the uterus and prevents
effective uterine contractions.
Signs and symptoms.
• (a) Large amount of bright red bleeding or
persistent trickle type bleeding.
• (b) Uterus may be boggy due to its
inability to contract properly.
• (c) Signs of shock.
• (d) Sudden rise in uterine fundal height
indicating the formation of clots inside the
uterine cavity.
 Medical treatment:
• (a) Manual removal of the remaining placenta
is done by the physician, if it is a result of
incomplete separations of the placenta with
increased vaginal bleeding.
• (b) A D&C is performed, if it is retained
fragments.
• (c) Intravenous fluids are administered.
• (d) Oxytocic drugs are given immediately after
either procedure.
 Nursing interventions
• (a) Check the uterine fundus tone frequently (every 15
minutes the first hour, then every 30 minutes for 2 hours,
and every hour until stable).
• (b) Check the nature and amount of lochia flow (every 15
minutes the first hour, then every 30 minutes for 2 hours,
and every hour until stable).
• (c) Keep accurate count of perineal pads used.
• (d) Monitor the patient's vital signs and blood pressure
every 15 minutes or more frequently as necessary.
• (e) Observe for signs of shock.
• (f) Turn the patient on her side to prevent pooling of blood
under her.
• (g) Provide emotional support to the patient and family.
HEMATOMAS
• Vulvar hematoma is a localized collection
of blood in the connective tissue beneath
the skin covering the external genitalia or
vaginal mucosa. It generally forms as a
result of injury to the perineal blood
vessels during the delivery process.
 Causes of Hematomas.
• (1) Rapid, spontaneous delivery.
• (2) Perineal varicosities.
• (3) Episiotomy repairs.
• (4) Laceration of perineal tissues.
 Signs and Symptoms.
• (1) Severe, sharp perineal pain.
• (2) Appearance of a tense, sensitive mass of
varying size covered by discolored skin.
• (3) Swelling in the perineal wall.
• (4) Often seen on the opposite side of the
episiotomy.
• (5) Inability to void due to pressure/edema on
or around the urethra.
• (6) Complaint of fullness or pressure in the
vagina.
Medical Treatment:
This is consists of analgesics given for
discomfort, opening the hematoma so
blood clots can be evacuated and the
bleeders can be ligated, and packing for
pressure.
 Nursing Interventions.
• (1) Apply ice to area of hematoma.
• (2) Observe for evidence of enlarged
hematoma.
• (3) Flag the patient's chart if packing was
inserted.
Pathophysiology:
When the third stage of labor is completed, the
placental attachment site is raw, elevated, and dark
red. The surface is nodular, owing to the numerous
veins, and offers an excellent portal of entry for
microorganisms. The uterine decidua is very thin and
has many small openings that offer a portal for
pathogens. In addition, small cervical, vaginal and
perineal lacerations, as well as the episiotomy site,
provide entry ports for pathogens. The resultant
inflammation and infection can remain localized or can
extend via blood or lymph vessels to other tissues.
Nursing Care of Puerperal Infection.
• (1) Isolation, if possible, the removal of the
patient from the maternity ward.
• (2) Meticulous hand washing.
• (3) Patient placed in Fowler's position to
facilitate drainage.
• (4) Reeducation of the patient on
handwashing and peri-care.
• (5) Emotional support since the patient may be
prevented from rooming in with her infant while
her temperature is elevated.
URINARY TRACT INFECTION
MASTITIS
TROMBOPHLEBITIS
Perez, Eileen
 Common
health problems
during School age
 DIABETES MELLITUS
HEMOPHILIA
RHEUMATIC ARTHRITIS

Ramores, Czarina P.
A group of metabolic diseases characterized by
elevated levels of glucose in the blood
(hyperglycemia) resulting from defects in insulin
secretion, insulin action, or both.
Insulin- a hormone produces by the pancreas
controls the level of glucose in the blood by
regulating the production and storage of
glucose. In the diabetic state, the cell may stop
responding to insulin or the pancreas may stop
producing insulin entirely.
-essential for CHO metabolism and is
important to the metabolism of fats and protein.
Type I DM- the principal childhood disorder
associated with pancreatic dysfunction
and cystic fibrosis.

Children with this type of diabetes must take

insulin to replace what their pancreas can
no longer produce.
 Etiology
Combine genetic, immunologic, and possibly environmental
factors (viral) contribute to beta cell destruction.
-genetic susceptibility is a common underlying factor in the
development of type1 diabetes.
-there is also evidence of an auto immune response in type 1
diabetes.
-environment factors such as viral infections destructions of
beta cells
-In addition, glucose derived from food cannot be stored in
the liver but instead remains in the bloodstream and
contribute to postprandial (after meals) hyperglycemia.
 Risk Factors
-family history of diabetes
-obesity
-hypertension
-HDL cholesterol level ≤35 mg/dL and/or
triglyceride level ≥250 mg/dL
 Symptoms
-Polydipsia
-Polyuria (often begins as bedwetting)
-Fatigue (marks fall in school)
-Blurred Vision
-Glycosuria
-Polyphagia
-Pruritus – itching (first indication of a
systemic internal disease such as D.M)
 Pathophysiology
Lack of
insulin
·Decreased utilization of
glucose by muscle, fat, liver Increased breakdown of fat
·Increased production of
glucose by liver Weight loss

Increased fatty acid

Hyperglycemia
Increased ketone bodies

Signs and symptoms

Blurred vision. Polyuria -Acetone breath
-Poor appetite
-nausea Acidosis

Dehydratio
n Increasingly rapid
Signs and respirations.
symptoms
Increased -Nausea
thirst -Vomiting
Weakness (Polydipsia -Abdominal Fatigue
Headache ) -pain
 Therapeutic Management

- Insulin administration
- Regulation of nutrition and exercise
- stress management
-Blood glucose and urine ketones
monitoring
 Nursing Care
-Teach about Disease and principles of care
- Establish mode of supervision and support
- Plan nutrition program
- Teach Hypoglycemic Management
- Teach signs of ketoacidosis
An inherited interference with blood coagulation.
There are numerous hemophilia types, each
involving deficiency of a different blood
coagulation factor.
– Hemophilia A – caused by a genetic defect that
result in deficient or defective factor VIII (the
antihemophilic factor). Transmitted as sub-linked
recessive trait
- More common than hemophilia b
– Hemophilia B (Christmas disease) – stems
from a genetic defect that causes deficient of
defective factor IX (Plasma thromboplastin
component)
 Risk factors:
• Hemophilia is an inherited genetic disease. The
risk of a child inheriting hemophilia depends on
the parents' genetic makeup.
• Sometimes, a child is born with hemophilia
because part of a normal chromosome changes
(mutates) in the eggs or sperm of one or both
parents. Medical researchers do not yet know
why this mutation occurs in some people.
 Signs and symptoms
Signs of hemophilia that may be noticed shortly
after birth:
• Bleeding into the muscle, resulting in a deep
bruise after receiving a routine vitamin K shot
• Prolonged bleeding after a male child is
circumcised
• In rare cases, prolonged bleeding after the
umbilical cord is cut at birth
Other symptoms of hemophilia include:
• Bleeding into a joint or muscle that causes
pain and swelling.
• Abnormal bleeding after an injury or surgery.
• Easy bruising.
• Frequent nosebleeds.
• Blood in the urine (hematuria)
• Bleeding after dental work
 Symptoms of bleeding into a joint
(hemarthrosis) include:
• Warmth and/or tingling in the joint during the early stages of
hemarthrosis. This is called an aura. If bleeding is not
treated, mild discomfort can progress to severe pain.
• Swelling and inflammation in the joint, caused by repeated
episodes of bleeding. If episodes continue, it may lead to
chronic pain and destruction of the joint.
• An infant's or child's reluctance to move an arm or leg
because of bleeding into an affected joint, often first noticed
when a child begins to walk.
 Symptoms of bleeding into
muscle:
• Bruising.
• Swelling.
• Muscle hardening.
• Tenderness.
• Pain, especially when large muscle
groups are affected.
 Pathophysiology
• Hemophilia A is caused by a recessive trait, with a
defective gene (the HEMA gene) located on the X-
chromosome
• HEMA gene codes for Factor VIII
• Human Factor VIII is a plasma glycoprotein 216
amino acids long that performs a substantial role in
blood-clotting
• However, Factor VIII circulates through the body as
a complex paired with the von Willebrand factor
• Once activated, factor VIII is released from
the vWF and binds to phospholipids
membrane surfaces such as those
provided by activated platelets
• There it interacts with the Christmas
Factor (IXa) to become the “intrinsic
system” factor X activator
• Intrinsic factor X activation is a critical step
in the early stages of coagulation
• Along with Factor V, calcium and platelet
factor 3 (PF3) convert prothrombin to
thrombin
• Thrombin then converts fibrinogen to
fibrin, which then forms a stabilized
meshwork, a fibrin clot, to occlude the
damaged blood vessel
Affected in Hemophilia type A
• The origin of Hemophilia A may be in the original
binding of factor VIII to von Willebrand factor.
• If factor VIII is not bound to vWf, the entire
cascade of events leading to the conversion of
prothrombin to thrombin is affected.
• This binding has been shown to be dependent
upon the C2 region of factor VIII.
• Structurally destabilizing mutations in this area
of the protein could cause factor VIII to become
unable to bind with von Willebrand factor, as
shown in the ribbon diagram.
 Medical Management
• Goal of Therapy: Normalize Factor VIII lab
values to normal plasma levels
• No “one-time cure” at present
• In the past, whole blood/fresh plasma
transfusions did not contain enough factor VIII
• Blood products were not screened for any
diseases until 80’s and 90’s
• Factor VIII REPLACEMENT THERAPY
• Decompressing Acetate (DDAVP):
– Treatment of mild hemophilia A
– NOT for severe hemophilia (why?)
– Increases plasma levels of factor VIII x 4
– Side effects: BP fluctuations, tachycardia and
facial flushing
• Antifibrinolytic Agents (e.g.: EACA
aka Amicar)
– Inhibits the activity of plasmin, which is
responsible for the degradation of
blood clots.
 Nursing care management
-Children require assistance in coping with the
condition.
-Patients are encouraged to be self-sufficient and
to maintain independence.
-Avoid agents such as aspirin, herbs, nutritional
supplement and alcohol.
-Dental hygiene.
-After surgery, a nurse frequently assesses the
surgical site for bleeding.
Is a chronic, systemic autoimmune disease
characterized by inflammation of connective
tissue in diarthrodial joints, typically with
periods of remission and exacerbation
-Occurs globally, affecting all ethnic
groups. It can occur at any times of life, but
the incidence increases with age, peaking
between the 30s and 50s. Women have an
incidence three times higher than men.
 The cause of rheumatoid is unknown.
Despite theories, no infectious agent has
been cultured from blood and synovial
tissue or fluid with enough reproducibility
to suggest an infectious cause for the
disease. An autoimmune etiology is
currently the most widely accepted.
 Signs and Symptoms
• morning stiffness that lasts ≥1 hour
• swelling in three or more joints
• swelling in hand joints
• erosions or decalcifications seen on hand
x-rays
• rheumatoid nodules
• presence of serum RF
Pathophysiology
Presentation of antigen
to T cells

Swelling in small joints,

T- and B-cell proliferatation. Angiogenesis in associated with pain,
synovial lining. stiffness, and fatigue

Warm, swollen,
Neutrophil accumulation in effusions, pain, and
synovial fluid. Cell proliferation. decreased motion with
No cartilage invasion. possible rheumatoid
nodules.

Synovitis. Early pannus

invasion. Chondrocyte Increase in severity of
activation. Degradation of physical signs and
cartilage by proteinase. symptoms.

Subchondral bone erosion. Pannus

Joint instability
invasion of cartilage. Chondrocyte contractures,
proliferation. Laxity of ligaments. decreased ROM,
systemic complications.
 Therapeutic Management
-nutritional and weight management counseling
-therapeutic exercise
-rest and joint protection
-heat and cold applications
-complementary and alternative therapies
-herbal products
-movement therapies
-drug therapy
-disease modifying antirheumatic drugs
-intraarticular or systemic corticosteroids
-nonsteroidal antiinlammatory drugs
-biologig/targeted therapy
-reconstructive therapy
-implants
-arthroplasty
 Nursing management
-health promotion
-acute intervention
-ambulatory and home care
-rest
-joint protection
-heat and cold therapy and exercise
-psychological support
RHEUMATIC FEVER
SCABIES

Rizo, Marilyn
PEDICULOSIS
IMPETIGO

Reyes, Gilbert John B.

 Pediculosis
Pediculosis is an infestation
of the hairy parts of the
body or clothing with the
eggs, larvae or adults of
lice. The crawling stages of
this insect feed on human
blood, which can result in
severe itching. Head lice
are usually located on the
scalp.
 Predisposing factors
• common in children
• people with long hair
• unhygienic
 Pathophysiology
• The female head louse lays her egg close to the scalp.
• The egg become firmly attached to the hair shafts with a
tenacious substance
• Head lice are found most commonly along the back of the
head and behind the ears.
• The eggs are visible to the naked eye as silvery, glistening
oval bodies that are difficult to remove from the hair.
• The bite of the insect causes intense itching, and the
resultant scratching often leads to secondary bacterial
infection. Impetigo or furunculosis.
 Signs and Symptoms
Usually, the first indication of an
infestation is the itching or scratching in
the area of the body where the lice feed.
Scratching at the back of the head or
around the ears should lead to an
examination for head louse eggs (nits) on
the hair.
 Management
• Treatment involves washing the hair with a
shampoo containing lindane (kwell) or
pyrethrin compounds with piperonyl
butoxide.
• Combed with a fine-toothed comb that is
dipped in vinegar to remove any remaining
nits or nit shells freed from the hair shafts.
 Nursing Care
• Physical contact with infested individuals and
their belongings, especially clothing, headgear
and bedding, should be avoided.
• Health education on the life history of lice, proper
treatment and the importance of laundering
clothing and bedding in hot water or dry cleaning
to destroy lice and eggs is extremely valuable.
 Impetigo
Contagious skin disease, which
commonly appears in young children and
infants, although adults may be affected.
Usually caused by group A streptococci or
by staphylococci, it appears on such
exposed parts of the skin as the face,
hands, arms, and legs and is spread to
adjacent areas by scratching.
 Etiology

• Nonbullous impetigo:
Group A-hemolytic streptococci, Staphylococcus
aureus, or both are the causative agents. Previously,
group A streptococcus was the most common bacterium
associated with nonbullous impetigo, but now S. aureus
is the most common.
• Bullous impetigo:
S. aureus is almost always the causative agent. The
formation of bullae is mediated by production of
exfoliative toxins. The exfoliative toxins excreted by
associated strains of S. aureus produce a cleavage
plane under the stratum corneum allowing the bacteria to
proliferate and spread.
 Predisposing factors
• Impetigo - epidemiology
• The most common bacterial skin infection in
children
• Transmitted by direct contact
• Highly contagious and rapidly disseminated
through day care centers and school
• Fomites can be a source of infection.
• Associated with crowded living
 Pathophysiology
• The lesions begin as small red macules.
• Which quickly become discrete.
• Thin-walled vesicles that soon rupture and
become covered with a loosely adherent
honey yellow crust.
• These crusts are easily removed and reveal
smooth red moist surfaces on which new
crusts soon to develop.
• If the scalp is involved.
• The hair is matted.
• Distinguishing the condition from the
ringworm.
 Signs and Symptoms
• Nonbullous impetigo starts as a small, tender,
erythematous papule. Often, there is evidence of minor
skin disruption by lesions such as an insect bite,
eczema, or a mild abrasion.
• Bullous impetigo appears on exposed and moist skin. It
starts as a transparent bulla that ruptures easily,
exposing a moist erosion surrounded by a thin rim of
scale.
• Impetigo may itch; but generally there is little or no pain,
and minimal surrounding erythema.
• Local lymphadenopathy is seen in 90% of cases.
• Constitutional symptoms, such as fever, are rare and
may suggest systemic bacterial infection.
 Management:
• Systematic antibiotic therapy is the usual
treatment. It reduces contagious spread.
Treats deep infections, prevents acute
glomerulonephritis.
• Non-bullous impetigo – benzathine
penicilin or oral penicilin
• Bullous impetigo – penicillinase
resistance (cloxacillin, Dicloxacillin)
• Topical antibacterial therapy may may be
prescribed when the disease is limited to a
small area.
• When topical therapy is prescribed,
lesions are soaked or washed with soap
solution to remove the central site of
bacterial growth.
 Nursing care
• Patient and family should be instructed to
bathe at least once a day with bactericidal
soap.
• Cleanliness and good hygienic practices
help prevent the spread of the lesions from
one skin area to another and from one
persons to another.
• Each person should have separate towel
and washcloth.
Common health
problems during
Adolescence
SCOLIOSIS
STD

Santos, Rainier
 Sexually transmitted disease
• STD’s are those conditions spread
through sexual contact with an infected
partner. Although all STD’s can be
serious, certain STD’s place the pregnant
woman at greater risk for problems
because if their potential effect on the
pregnancy, fetus, or neonate.
 Causes
• STD’s can be caused by infection with
various organisms, including:
– Fungi
– Bacteria
– Protozoa
– Parasites
– Viruses
 What to look for?
• The signs and symptoms exhibited by the
patient with STD typically involve some
type of vaginal discharge or lesion. Vulvar
or Vaginal irritation, such as itching and
pruritus, commonly accompany the
discharge or lesion.
 What to do?
• Explain the mode of transmission of the STD, and
instruct the patient in measures to reduce the risk of
transmission.
• Administer drug therapy, as ordered, and instruct the
patient in drug therapy regimen. Advise the patient to
comply with therapy, completing the entire course of
medication even if she feels better.
• Urge the patient to refrain from sexual intercourse
until the active infection is completely gone.
• Instruct the patient to have her partner arrange
to be examined so that treatment can be
initiated, thus preventing the risk of reinfection.
• Provide comfort measures for the client to
reduce vulvar and vaginal irritation; encourage
the client the woman to keep vulvar area clean
and dry and to avoid using strong soaps,
creams, or ointments unless prescribed.
• Suggest the use of cool or tepid sitz baths
to relieve itching.
• Encourage woman to wear cottoon
underwear and avoid tight fitting clothing
as much as possible.
• Instruct the patient in safer sex practices.
• Encourage follow-up to ensure complete
resolution of the infection.
 STD’s and their effects on pregnant
women
STD Causative Assessme Treatment Considerations
Agent nt
Findings
Candidiasis Candida Thick, cheese like Antifungal agent -Common during
(fungal infection) vaginal discharge, such as miconazole pregnancy because
pruritus, vaginal cream or oral increased estrogen
levels cause changes in
redness and fluconazole vaginal PPH
irritation
-Most commonly occurs
in women receiving
antibiotic therapy for
another infection and
women with gestational
diabetes or HIV
infection
-Possible neonatal
infection if infection is
present during delivery
STD CausativeAssessmen Treatmen Considerations
Agent t Findings t

Trichomoniasis Single- cell Yellow-gray, frothy, Topical -Possibly associated with

preterm labor, premature
protozoan odorous vaginal clotrimazole rupture of membranes, and
infection. discharge, vulvar postcesarean infection
itching, edema, and -treatment of partner
redness. required, even if
assymptomatic

Bacterial Gardnerella Thin, gray vaginal Tppical vaginal Untreated infections

vaginalis discharge with fish metronidazole associate with amniotic
Vaginosis
infection like odor, intense after the first fluid interactions and
pruritus. trimester, usually possibly, preterm labor and
premature rupture of
late in pregnancy membranes
STD CausativeAssessmen Treatmen Considerations
Agent t Findings t

Chlamydia Chlamydia Heavy, gray-white Amoxicillin Possible premature

trachomatis vaginal discharge, rupture of
painful urination membranes, preterm
labor and
endometrtis in the
post partum period
resulting from
infection.
Possible
development of
conjunctivitis or
pneumonia in
neonate born to
mother with an
infection.
STD CausativeAssessmen Treatmen Considerations
Agent t Findings t

Syphillis Treponema Painless ulcer in Penicillin G Possible transmission

pallidum vulva or vagina benzathine I.M. across placenta after
about 18weeks
(single dose) gestation, leading to
miscarriage, preterm
labor, stillbirth, or
congenital anomalies in
the neonate

Genital Herpes simplex -Painful, small Acyclovir orally Transmission to

herpes virus, type 2 vesicles with or in ointment neonate possible of
erythematous base form active lesions are
present in the vagina or
on vulva or vagina on the vulva at birth,
rupturing within 1-7 which can be fatal.
days to form ulcers. -cesarean delivery is
-Fever recommended if patient
-dyspareunia has active lesions
STD CausativeAssessmen Treatmen Considerations
Agent t Findings t

Gonorrhea Neisseria May not produce Cefixime as a Associated with

Gonorrheae symptoms one time I.M. miscarriage, preterm
-yellow-green injection. birth, and
vaginal discharge endometritis in the
postpartum period
-male partner
experiences severe -treatment of partner
pain on urination required to prevent
and purulent yellow reinfection.
penile discharge -severe eye infection
leading to blindness
in the neonateif
infection is present
at birth (opthalmia
neonatorum)
 Scoliosis
• A condition wherein the spine twists and
develops an exaggerated "S" or “C”
shaped
lateral curvature of the backbone. It is
also known as a lateral or sideways
curvature of
the spine, which is apparent when viewing
from behind
 RISK/PREDISPOSING FACTORS
• Genetic Inheritance- People with scoliosis are more likely to have children with
scoliosis like them; however, there is no correlation between the severities of the
curve from one generation to the next.
• Sex- Curves in girls are more likely to worsen than are curves in boys.
• Age- It can be seen at any age, but it is most common in those over 10 years
old. The younger the child when scoliosis appears, the greater the chance the
curve will worsen.
• Size of the curve- The greater the curve size, the higher the likelihood that it will
worsen.
• Location- Curves in the middle to lower spine are less likely to progress than are
those in the upper spine.
• Spinal problems at birth- Children who are born with scoliosis (congenital
scoliosis) have a greater risk of worsening of the curve. Congenital scoliosis is
thought of as a birth defect affecting the size and shape of the bones of the
spine.
 Signs and Symptoms
• Lordosis, axial rotation, and lateral curvature
• Asymmetry of hips and shoulders, scapulae,
flanks, and breasts
• Shortened trunk and unequal leg lengths
• Skin and soft-tissue changes
• Patches of hair in sacral area
• Malalignment of trunk and pelvis
• Clothes do not hang right
• A rib “hump”
 PATHOPHYSIOLOGY
• The vertebra turn toward the convex side and spinous processes rotate
toward the concave side in the area of the major curve.
• As the vertebra rotate, they push the ribs on the convex side posteriorly and
at the same time, crowd the ribs on the concave side together as well as push
them anteriorly. The posterior displaced ribs cause the characteristic hump in
the back with forward flexion. Young girls with scoliosis would often complain
of unequal breasts. This is due to recess of the chest wall on the convex side
of the curve.
• Disc space is narrower on the concave side and wider on the convex side.
• The vertebra may become wedged on the concave side in serve cases. The
lamina and pedicles are also shorter.
• Vertebral canal is narrower on the concave side. Spinal cord compression is
rare even in serve cases.
• Physiological changes include:
○ Decrease in lung vital capacity due to a compressed intrathoracic cavity
on the convex side.
○ With left scoliosis, the heart is displaced downward; and in conjunction
with intrapulmonary obstruction, this can result in right cardiac
hypertrophy.
 MANAGEMENT
• a. Medical
Spinal bracing
• b. Surgical
Spinal fusion
 Nursing Care
• Pre-Op Nursing Considerations for Scoliosis:
• Health Teachings and orientation to the patient and relatives concerning scoliosis
and its treatment procedures that they can chose from.
Post-Op Nursing Considerations for Scoliosis:
• Monitor for s/s to determine if there are any potential complications
• Promote proper body alignment
• Promote pulmonary ventilation by breathing and coughing exercises.
• Monitor fluid and electrolyte balance to assess dehydration.
• Provide pain relief measures as necessary.
Discharge Planning and Home Care - post-op for Scoliosis:
• Instruct the patient and family about the various aspects of care that can be done
for scoliosis patients at home.
• Encourage to patient ventilate fears and body image concerns to his/her relatives
and love one’s.
• Encourage adherence to follow-up regimen
 TUMORS
ACCIDENTS- Trauma/Injury

Suarez, Ma. Crissela Carisma

 AMENORRHEA
DYSMENORRHEA

Sunga, Sheena
 Amenorrhea
Amenorrhea is a menstrual condition
characterized by absent menstrual periods for
more than three monthly menstrual cycles.
Amenorrhea may be classified as:

• Primary Amenorrhea
• Secondary Amenorrhea
 Primary amenorrhea - from the beginning
and usually lifelong; menstruation never
begins at puberty.
Secondary amenorrhea - due to some
physical cause and usually of later onset; a
condition in which menstrual periods which
were at one time normal and regular
become increasing abnormal and irregular
or absent.
 Causes of amenorrhea
 Pregnancy
Females no longer ovulate when they are pregnant, thus,
menstruation ceases temporarily.
 Ovulation abnormality
Ovulation abnormalities are usually the cause of very irregular or
frequently missed menstrual periods.
 Birth defect, anatomical abnormality, or other medical condition
If a young woman has not started to menstruate by the age of 16, a
birth defect, anatomical abnormality, or other medical condition may
be suspected.
 Eating disorder
Females with anorexia nervosa (or simply anorexia) and/or bulimia
nervosa (or simply bulimia) often experience amenorrhea as a result
of maintaining a body weight that would be too low to sustain a
pregnancy. As a result, as a form of protection for the body, the
reproductive system "shuts down" because it is severely
malnourished.
 over-exercise or strenuous exercise
Many young female athletes in training experience absent
menstrual cycles due to low body fat content.
thyroid disorder
In many cases, an underactive thyroid gland,
(a condition called hypothyroidism in which the thyroid
gland is producing insufficient amounts of the thyroid
hormone) or an overactive thyroid gland,
(a condition called hyperthyroidism in which the thyroid
gland secretes too much thyroid hormone - resulting in too
much thyroid hormone in the bloodstream and over-activity
of the body's metabolism) is responsible for the absent
menstrual cycles.
obesity
Females who are obese often experience amenorrhea as a
result of excess fat cells interfering with the process of
ovulation.
 Pathophysiology:
 Physiological: Pregnancy, breastfeeding, menopause.
Pathogenesis of Compartment I: Disorders of the outflow tract or
uterine target organ.
Abnormalities in the systems of this compartment are uncommon.
Examples include: Ashermans Syndrome from inadvertent
endometrial ablation during D&C (causes 7% of amenorrhea),
agenesis or anomalies of the structure of the uterus, tubes or
vagina. (there may be appropriate Tanner stage).
Pathogenesis of Compartment II: Disorders of the ovary.
Examples: Abnormal chromosomes such as Turners Syndrome
(0.5%), Normal chromosomes(10%) such as in gonadal
dysgenesis or agenesis (there may be no or very delayed Tanner
stage), premature ovarian failure (premature menopause, before
age 40), effect of radiation or chemotherapy, polycystic ovarian
disease.
 Pathogenesis of Compartment III: Disorders of
the anterior pituitary.
Examples: Prolactin tumors (7.5%)
Pathogenesis of Compartment IV: Disorders of
the central nervous system (hypothalamic).
Hypothalamic amenorrhea is the most common
cause of amenorrhea (28%). There is a deficiency
in GnRH pulsatile secretion. Examples include a
stressful lifestyle (10%), weight loss as in anorexia
or bulimia (10%), extreme exercise, medications
such as hormones as in postpill amenorrhea,
hypothyroidism (1%), major medical disease such
as Crohns, systemic lupus erathematosis
Signs and Symptoms of Amenorrhea
• Lack of Menstruation by age 16, which may or may not be
devoid of signs of puberty.
• If caused by Chromosomal abnormalities, symptoms such
as short stature, webbed neck or mental retardation may
also be noted.
• Extreme Obesity in some, while in others there may be
Weight Loss.
• Ovarian Failure or Polycystic Ovarian Syndrome.
• Structural abnormalities of the uterus and vagina.
• Gonadotropin releasing factor (GnRH) deficiency.
• Hypothyroidism
 Management

Specific treatment for amenorrhea will be

determined by your physician based on:
 your age, overall health, and medical history
extent of the condition
cause of the condition (primary or secondary)
your tolerance for specific medications,
procedures, or therapies
expectations for the course of the condition
your opinion or preference
 Treatment for amenorrhea
includes:
 progesterone supplements (hormone treatment)
oral contraceptives (ovulation inhibitors)
dietary modifications (to include increased caloric and fat
intake)

In most cases, physicians will induce

menstruation in non-pregnant females who have missed
two or more consecutive menstrual periods, because of
the danger posed to the uterus if the non-fertilized egg
and endometrial lining are not expelled. Without this
monthly expulsion, the risk of uterine cancer increases.
 Dysmenorrhea
 Is a painful menstruation and is the most common of all
gynecologic complaints, and the leading cause of
absenteeism of women from work, school, and other
activities. In addition to identifiable pathological causes,
number of constitutional factors may lower pain threshold
thus appearing as worsening dysmenorrhea. Common
factors include anemia, an increase in obesity, chronic
illness, overwork, stress in general, diabetes, and poor
nutrition. Two forms of dysmenorrhea can be identified
as:

Primary Dysmenorrhea
Secondary Dysmenorrhea
 Primary dysmenorrhea
• Primary dysmenorrhea not related to any definable
pelvic lesion. This usually begins with the first ovulatory
cycles beginning in most cases before the age of 20.
Primary dysmenorrhea is associated with nausea in 50%
of patients, vomiting in 25% of patients and stool
frequency in 35% of patients. The pain is low and
crampy recurring in waves that probably correlate with
uterine contractions. The pain usually occurs a few hours
before bleeding, comes to a peak intensity within a few
hours, and dissipates within 1-2 days. It generally occurs
over the midline, and is relieved by the onset of good
menstrual flow.
 Secondary dysmenorrhea
Secondary dysmenorrhea related to the presence of
pelvic lesions secondary to organic pelvic disease such
as endometriosis, salpingitis and PID (pelvic
inflammatory disease), post surgical adhesions, etc.
Secondary dysmenorrhea begins up to a few days before
menstruation and lasts several days after the onset of
flow. Often it is lateralized to one side, and it does not
characteristically peak and diminish as clearly or quickly
as primary dysmenorrhea. It's onset is later in life in
women who have not had primary dysmenorrhea,
however it can be superimposed onto a pre-existing case
of primary dysmenorrhea. The I.U.D. may cause such
pain problems.
 Causes and Risk Factors of
Dysmenorrhea
Primary dysmenorrhea may affect up to 75
percent of women at some time, and 5-6 percent
may have incapacitating pain. The frequency of
cases increases up to age 20 and then
decreases with age.
Secondary dysmenorrhea usually begins well
after the age of onset of menstruation,
sometimes as late as the third or fourth decade
of life.
 Pathophysiology:
 Chemical Estrogens cause Dysmenorrhea. Chemical Estrogens
(Xenoestrogens) cause the part of the uterus that bleeds every
month to grow into the outer muscle of the uterus and bleed there
every month causing dysmenorrhea. Mainstream medicine typically
prescribes ibuprofen or Motrin that only treats the symptom NOT the
cause. There are two parts of the uterus. The first part is a layer
inside of the uterus that bleeds every month called the endometrium.
The second part of the uterus is the outside layer of the uterus. This
outside layer is a muscular wall called the myometrium. Chemicals
that mimic estrogen called xenoestrogens cause the endometrium
layer to grow deep and infiltrate into the second layer, the
myometrium. The two layers (endometrium and myometrium) should
normally be separate. However, the xenoestrogens cause the
endometrium to grow into the myometrium. This abnormal growth is
the cause of dysmenorrhea. Every month the endometrium bleeds
inside the myometrium and causes dysmenorrhea.
 Signs and Symptoms:
A medical history and pelvic exam alone may provide
enough information for the doctor to determine whether
the cramps are caused by primary dysmenorrhea. In
primary dysmenorrhea, the pelvic exam is normal
between menses. Examination during menses may
produce discomfort but no abnormal findings.
In secondary dysmenorrhea, there may be findings on
physical exam. Additional tests may include radiologic
studies (including ultrasound) and laparoscopy (involves
inserting a tiny, flexible lighted tube through a small
incision just below the navel to view the internal
abdominal and pelvic organs).
 Treatment of Dysmenorrhea
Actions indicated for the processes behind this
disease :
 Anti-spasmodic herbs will ease the muscle spasms that
are the immediate cause of pain.
Nervines will help associated psychological tension or
anxiety.
Diuretic remedies would be indicated if the dysmenorrhea
was of a congestive nature accompanied by water
retention.
Uterine Tonics provide the basis for any healing work in
this body system..
Hormonal Normalizers would be indicated if the
diagnosis suggests a pivotal contribution by hormonal
imbalance.
 Treatment of primary
Dysmenorrhea
• For treatment of primary dysmenorrhea, most doctors
prescribe antiprostaglandin drugs or NSAIDs (non-
steroidal anti-inflammatory drugs) such as aspirin,
ibuprofen, ketoprofen, or naproxen. These drugs inhibit
synthesis of prostaglandins, lessen the contractions of
the uterus and reduce the menstrual flow. These drugs
should be started at the onset of bleeding to avoid
inadvertent use during early pregnancy and taken for 2-3
days.
• Oral contraceptives are another alternative. By stopping
ovulation and decreasing prostaglandin levels, they may
eliminate cramps.
 Treatment of secondary
dysmenorrhea
 Treatment of secondary dysmenorrhea depends on the
cause. Endometriosis is the most common cause of
secondary dysmenorrhea. Depending on the stage of this
disease and the woman's age and desire to have children,
the treatment methods vary from conservative drug therapy
(androgens, progestin, oral contraceptives and
gonadotropin-releasing hormone agonists) to surgical
procedures.
If the problem is adenomyosis, a hysterectomy may be
necessary. Pelvic inflammatory disease may be treated with
antibiotics. Uterine fibroids, fibroid tumors and pelvic tumors
are often treated surgically. Cervical narrowing can be
corrected with surgery as well.
Occasionally, an IUD (intra-uterine device) may be the
cause, and if so, the doctor may prescribe antiprostaglandin
drugs, and suggest removing the device and using another
form of birth control.
 Nursing Care
• For relief of painful menstrual cramps and their
associated discomforts, start with a hot bath. The water
helps relax the uterus and other tensions that may be
contributing to the problem.
• Place a heating pad on your abdomen. The flow of heat
can provide soothing, temporary pain relief.
• Exercise regularly. Aerobic exercise such as walking,
swimming, running, bicycling, and aerobic dance may
diminish cramping symptoms. For some women,
exercise may inhibit prostaglandins or help release
endorphins, the brain's natural painkillers.
ANOREXIA NERVOSA
BULIMIA
SUBSTANCE ABUSE
Saloma, Donnalyn
ANOREXIA
NERVOSA
• Anorexia nervosa is an eating disorder that
involves limiting the amount of food a person
eats. It results in starvation and an inability to
stay at the minimum body weight considered
healthy for the person's age and height.

• Persons with this disorder may have an intense

fear of weight gain, even when they are
underweight. Not eating enough food or
exercising too much results in severe weight
loss.
• Anorexia is a disorder where the main characteristic is
the restriction of food and the refusal to maintain a
minimal normal body weight. Any actual gain or even
perceived gain of weight is met with intense fear by the
Anorexic. Not only is there a true feeling of fear, but also
once in the grasp of the disorder, Anorexics experience
body image distortions. Those areas of the body usually
representing maturity or sexuality including the buttocks,
hips, thighs and breast are visualized by the Anorexic as
being fat. For some Anorexics, weight loss is so severe
there is a loss of menses. In the obsessive pursuit of
thinness, Anorexics participate in restrictive dieting,
compulsive exercise, and laxative and diuretic abuse. If
Anorexia Nervosa is left untreated, it can be fatal.
• Two types of anorexia nervosa are recognized:
• Restricting type: Patients restrict food intake but do not
regularly engage in binge eating or purging behavior.
• Binge-eating/purging type: Patients regularly binge, then
induce vomiting, misuse laxatives, diuretics, or enemas,
or both.
• Binges are defined as consumption of a much larger
amount of food than most people would eat in a similar
time period under similar circumstances with loss of
control, ie, perceived inability to resist or stop eating.
 CAUSES
 Genetic.
Six to ten per cent of siblings of affected
women suffer from anorexia nervosa. There
is an increased concordance amongst
monozygotic twins, suggesting a genetic
predisposition.
Hormonal. The reductions in sex hormones
and the hypothalamic-pituitary-adrenal axis
are secondary to malnutrition and usually
reversed by refeeding.
• Psychological factor
• Individual
Anorexia nervosa has often been seen as an escape from
the emotional problems of adolescence and a regression
into childhood. Patients will often have had dietary
problems in early life. Perfectionism and low self-esteem
are common antecedents. Recent studies suggest that
survivors of childhood sexual abuse are at risk of
developing an eating disorder, usually anorexia nervosa,
in adolescence.
• Family.
Families of such patients are allegedly
characterized by overprotection, inflexibility and
lack of conflict resolution. Anorexia is alleged to
prevent dissension in families. However, a recent
case control study suggested that there is no
more evidence of these factors in families of
anorexia nervosa than in control families with a
child with an established physical disease
 Risk factors include:
• Accepting society's attitudes about thinness
• Being a perfectionist
• Being female
• Experiencing childhood anxiety
• Feeling increased concern or attention to weight and shape
• Having eating and gastrointestinal problems during early childhood
• Having a family history of addictions or eating disorders
• Having parents who are concerned about weight and weight loss
• Having a negative self-image

Anorexia nervosa usually occurs in adolescence or young

adulthood. It is more common in females. The eating disorder is
seen mainly in Caucasian women who are high academic achievers
and who have a goal-oriented family or personality.
 Symptoms
• People with anorexia may severely limit the amount of food they eat, or eat and
then make themselves throw up. They may also use water pills (diuretics) and
laxatives to lose weight.
• Most individuals with anorexia nervosa do not recognize that they have an eating
disorder.
• Behaviors that may be noticed in a person with anorexia include:
• Cutting food into small pieces
• Exercising compulsively
• Going to the bathroom right after meals
• Quickly eating large amounts of food
• Restricting the amount of food eaten
• Using laxatives, enemas, or diuretics inappropriately in an effort to lose weight
• Blotchy or yellow skin
• Confused or slow thinking
• Dental cavities due to self-induced vomiting
• Depression
• Dry mouth
• Extreme sensitivity to cold (wearing several layers of clothing to stay
warm)
• Fine hair
• Low blood pressure
• No menstruation
• Poor memory or poor judgement
• Significant weight loss (15% or greater below normal weight)
• Wasting away of muscle and loss of body fat
Pathophysiology
• Endocrine abnormalities are common; they include low levels of
luteinizing hormone (decreased secretion), low levels of thyroxine
(T4) and triiodothyronine (T3), and increased cortisol secretion.
Menses usually cease. Bone mass declines. In severely
malnourished patients, virtually every major organ system may
malfunction.
• Dehydration and metabolic alkalosis may occur, and serum K may
be low; all are aggravated by induced vomiting and laxative or
diuretic use.
• Cardiac muscle mass, chamber size, and output decrease; mitral
valve prolapse is commonly detected. Some patients have
prolonged QT intervals (even when corrected for heart rate), which,
with the risks imposed by electrolyte disturbances, may predispose
to tachyarrhythmias. Sudden death, most likely due to ventricular
tachyarrhythmias, may occur.
 Nursing Considerations
• The biggest challenge in treating anorexia nervosa is having the person
recognize that the eating behavior is itself a problem, not a solution to other
problems. However, most persons with anorexia nervosa deny that they
have an eating disorder. Individuals often enter treatment when their
condition is fairly advanced.
• The goals of treatment are to first restore normal body weight and eating
habits, and then to address the psychological issues.
• A hospital stay may be needed if:
• The person has lost a lot of weight (below 30% of their ideal body weight for
their age and height)
• Weight loss continues despite treatment
• Medical complications, such as heart rate problems, changes in mental
status, low potassium levels, or mental status problems, develop
• The person has severe depression or thinks about committing suicide
• Other treatment may include:
• Antidepressant drug therapy for depression
• Behavioral therapy
• Psychotherapy
• Supportive care
• Severe and life-threatening malnutrition may require feedings through a
vein.
BULIMIA
NERVOSA
• Bulimia, also called bulimia nervosa, is a psychological
eating disorder.
• Bulimia is characterized by episodes of binge-eating
followed by inappropriate methods of weight control
(purging).
• Inappropriate methods of weight control include
vomiting, fasting, enemas, excessive use of laxatives
and diuretics, or compulsive exercising. Excessive shape
and weight concerns are also characteristics of bulimia.
A binge is an episode where an individual eats a much
larger amount of food than most people would in a
similar situation.
• Binge eating is not a response to intense hunger. It is
usually a response to depression, stress, or self esteem
issues. During the binge episode, the individual
experiences a loss of control. However, the sense of a
loss of control is also followed by a short-lived calmness.
The calmness is often followed by self-loathing. The
cycle of overeating and purging usually becomes an
obsession and is repeated often.
• The Bulimic eats compulsively and then purges
through self-induced vomiting, use of laxatives,
diuretics, strict diets, fasts, vigorous exercise, or
other compensatory behaviors to prevent weight
gain. Binges usually consist of the consumption
of large amounts of food in a short period of
time. Binge eating usually occurs in secret.
Bulimics, like Anorexics, are also obsessively
involved with their body shape and weight. The
medical complications of the binge-purge cycle
can be severe and like Anorexia can be fatal.
• People with bulimia can look perfectly normal. Most of
them are of normal weight, and some may be
overweight. Women with bulimia tend to be high
achievers.
• It is often difficult to determine whether a person is
suffering from Bulimia. This occurs because bingeing
and purging is often done in secret. Also, individuals
suffering from Bulimia often deny their condition.
• Sufferers consume huge quantities of food. Sometimes
up to 20,000 calories at a time. The foods on which they
binge tend to be foods labeled as "comfort foods" --
sweet foods, high in calories, or smooth, soft foods like
ice cream, cake, and pastry. An individual may binge
anywhere from twice a day to several times daily.
 Causes
• Though the exact cause of bulimia is not known, a number
of factors appear to influence its development.
• Studies have shown eating disorders occur more frequently
in relatives of people with bulimia than in others. This
frequency appears to be related to genetics, but family
influences may also be important.
• Researchers have suggested that altered levels of the
chemical serotonin in the brain play a role. Serotonin levels
can be related to the development of clinical depression.
• Experts agree that cultural factors are very important in the
development of eating disorders. Modern society's emphasis
on health, in particular thinness, can greatly influence those
who seek the acceptance of others.
 Signs and Symptoms
• Anxiety
• Mood swings, depression
• Frequent trips to the bathroom after eating
• Hiding food in unusual places
• Highly self-critical
• Difficulties in breathing and swallowing
• Fainting spells
• Irregular menstrual periods
• Frequent weight fluctuations
• Pronounced jaw swelling from frequent vomiting
• Unlike anorexics, victims of bulimia may
have a normal body mass.
• The victims consume huge amounts of
food in a short period of time.
• The victims feel out of control and are
unable to stop eating during a binge. They
also feel guilty, ashamed, disgusted or
depressed following a binge.
 Pathophysiology
• Serious fluid and electrolyte disturbances,
especially hypokalemia, occur occasionally. Very
rarely, the stomach ruptures or the esophagus is
torn during a binge, leading to life-threatening
complications.
• Because substantial weight loss does not occur,
the serious nutritional deficiencies that occur
with anorexia nervosa are not present.
Cardiomyopathy may result from long-term
abuse of syrup of ipecac to induce vomiting.
 Nursing Considerations
• Patient with bulimia are aware of their problems and they want to be helped
because they feel helpless and unable to control themselves during episodes
of binging. But because of their intense desire to please and need to conform
they may resort to manipulative behavior and tell half-truths during interview to
gain trust and acceptance of nurses. Create an atmosphere of trust. Accept
person as worthwhile individual. If they know that no rejection or punishment is
forthcoming they disclose their problem, they will be more open and honest.
• Develop strength to cope with problems. Encourage patient to discuss positive
qualities about themselves to increase self-esteem.
• Help patient identify feelings and situations associated with or that triggers
binge eating.
• Assist to explore alternative and positive ways of coping.
• Encourage making a journal of incident and feelings before-during and after a
binge episode.
• Make a contract with the patient to approach the nurse when they feel the urge
to binge so that feelings and alternative ways of coping can be explored.
• Encourage adhering to meal and snack schedule of hospital. This decreases
the incidence of binging, which is often precipitated by starvation and fasting.
• Encourage participating in group activities with other persons having the same
eating disorder to gain additional support.
• For young adolescent living at home, encourage family therapy to correct
dysfunctional family patterns.
SUBSTANCE ABUSE
 SUBSTANCE ABUSE
- Misuse of substance with significance and
recurrent adverse consequences related to the
repeated use.
- refers to the continued use despite the
recurrence of the related problem
Substance or chemical dependence
- cluster of cognitive and behavioral and
physiologic symptoms indicating continued
use of the substance despite of the
significance
Characteristics of Substance Abuse

1. tolerance- increased amount of the

substance to obtained desired
effect
2. Withdrawal- behavioral, physiologic and
cognitive symptoms occuring when
blood or tissue concentration of
substance abruptly decline
3. Compulsive drug taking behavior
Intoxication- is use of substance that
results in maladaptive behavior
Detoxification- is the process of safe
withdrawal
Habituation- a psychological dependence
on the use of drug
Addiction- the physical dependence on a
substance
 Causes of Substance Abuse
1. Exact cause of substance abuse remains unclear
2. Biologic theories:
a. genetic factor
b. biochemical
3. Sociocultural Theory
a. hopelessness and defeat of living condition
b. peer pressure
c. easy availability of the substance
d. social ambivalence about the use of substance.
4. Family theory
- implicates dysfunctional family pattern
5. Behavioral Pattern
- substance abuse is a response to stressful stimuli because substance provide temporary
relief of anxiety
6. Psychoanalytic theory
- maladaptation in the early stage of development
• Use and abuse of substances such as cigarettes, alcohol, and
illegal drugs may begin in childhood or the teen years. Certain risk
factors may increase someone's likelihood to abuse substances.
• Factors within a family that influence a child's early development
have been shown to be related to increased risk of drug abuse.
– Chaotic home environment
– Ineffective parenting
– Lack of nurturing and parental attachment
• Factors related to a child's socialization outside the family may
also increase risk of drug abuse.
– Inappropriately aggressive or shy behavior in the classroom
– Poor social coping skills
– Poor school performance
– Association with a deviant peer group
– Perception of approval of drug use behavior
 Risk Factors
COMMUNITY INDIVIDUAL / PEER
Availability of Drugs Alienation and Rebelliousness
Community Laws and Norms Favorable Friends Who Engage in the Problem
Toward Drug Use Behavior
•
Transitions and Mobility Favorable Attitudes Toward the
Problem Behavior
Low Neighborhood Attachment and Early Initiation of the Problem Behavior
Community Disorganization
Extreme Economic Deprivation Constitutional Factors
FAMILY SCHOOL
Family History of the Problem Behavior Early and Persistent Antisocial
Behavior
Family Management Problems Academic Failure Beginning in Late
Elementary School
Family Conflict Lack of Commitment to School
Favorable Parental Attitudes and
Involvement in the Problem
Behavior
 Pathophysiology
• The primary factor in the development of addiction is
neurophysiologic reinforcement (reward). One specific
mesolimbic "reward pathway" has been identified in the
brain, and others may exist. This pathway involves
dopaminergic neurons that originate in the ventral
tegmental area (VTA) and project into the forebrain,
particularly the nucleus accumbens. The dopaminergic
neurons are probably under continuous inhibition in the
VTA, perhaps by gamma-aminobutyric acid (GABA).
Release of dopamine from these neurons onto the
dopamine receptors in the nucleus accumbens produces
positive reinforcement.
 Substance Abuse Symptoms
• Friends and family may be among the first to recognize the signs of
substance abuse. Early recognition increases chances for
successful treatment. Signs to watch for include the following:
• Giving up past activities such as sports, homework, or hanging out
with new friends
• Declining grades
• Aggressiveness and irritability
• Forgetfulness
• Disappearing money or valuables
• Feeling rundown, hopeless, depressed, or even suicidal
• Sounding selfish and not caring about others
• Use of room deodorizers and incense
• Paraphernalia such as baggies, small boxes, pipes, and rolling
paper
• Getting drunk or high on drugs on a regular basis
• Avoiding friends or family in order to get drunk or high
• Lying, particularly about how much alcohol or other drugs he or she is using
• Planning drinking in advance, hiding alcohol, drinking or using other drugs
alone
• Having to drink more to get the same high
• Believing that in order to have fun you need to drink or use other drugs
• Frequent hangovers
• Pressuring others to drink or use other drugs
• Taking risks, including sexual risks
• Having "blackouts"-forgetting what he or she did the night before
• Constantly talking about drinking or using other drugs
• Getting in trouble with the law
• Drinking and driving
• Suspension from school or work for an alcohol or drug-related incident
 COMMONLY ABUSE SUBSTANCES
Alcohol
- immediate effect due to action to the brain manifested by slurring of
speech, incoordination and unsteady gait, impaired attention and memory
- withdrawal symptoms
CNS Depressant
CLASSIFICATIONS
A. Barbiturates, other sedatives, hypnotics and anxiolytic
- it is a CNS depressant that have the same effect like alcohol
- chronic use can lead to depression and paranoia
- commonly abuses types:
a. Barbiturates- secobarbital, pentobarbital
b. Sedative/hypnotics- methoquolone, chloral hydrate
c. Anxiolytic- lorazipam, diazepam, alprazolam, valium
B. Narcotics
- a CNS depressant that are use medically to relieve
moderate and severe pain
- morphin, heroin and cocain-
derivatives of opium
- demerol and methadone- are synthetic substitutes
CNS Stimulant
A. Cocain- a CNS stimulant and causes dopamine depletion
- can cause euphoria, anxiety, anger, tachycardia and
DILATION OF PUPIL

Cannabinol/ marijuana
- the most common type of cannabis composed of
dried leaves, stems and flowers of a plant cannabis sativa
that can be smoked of added to food
- it alters sensory percepion due t active
ingredients TETRAHYCANNABINOL ( THC )
 Management:

1. Detoxification followed by residual or

outpatient program
2. Self-help 12 step program designed to help
members achieve and maintain sobriety one
day at a time
3. Psychotherapy on reality orientation focusing
on coping without the use of the drug
4. Family therapy
- improves communication by
encouraging the family members to
define and maintain family functioning
5. Alcoholic determinant therapy with disulfiram
6. Methodone treatment as a substitute for
opioid
7. Family support such as self helping
organizations
 Nursing Considerations
• Most substances abusers believe they can stop using drugs on their
own, but a majority who try do not succeed. Research shows that
long-term drug use alters brain function and strengthens
compulsions to use drugs. This craving continues even after your
drug use stops.
• Because of these ongoing cravings, the most important component
of treatment is preventing relapse. Treating substance abuse
depends on both the person and the substance being used.
Behavioral treatment provides you with strategies to cope with your
drug cravings and ways to avoid relapse. Your doctor may prescribe
medications, such as nicotine patches and methadone, to control
withdrawal symptoms and drug cravings.
• Often, a drug user has an underlying mental disorder, one that
increases risk for substance abuse. Such disorders must be treated
medically and through counseling along with the drug abuse.
OBESITY
SUICIDE

Rivero, Jenny Razie

 Suicide (to kill oneself) is the
intentional killing of one's self.
Suicide may occur for a number of
reasons, including depression, shame, guilt,
desperation, physical pain, emotional pressure,
anxiety, financial difficulties, or other undesirable
situations.
The World Health Organization noted that
over one million people commit suicide every
year, and that it is one of the leading causes of
death among teenagers and adults under 35.
 Causes of Suicide
• Alcohol Abuse and Alcoholism
• Drug Abuse
• Posttraumatic Stress
• Bipolar Disorder (Mania) Disorder
• Borderline Personality • Psychotic Disorders
Disorder • Schizoaffective Disorder
• Depression • Schizophrenia
• Depression in Children • Seasonal Affective
• Depression in the Elderly Disorder
 Other Causes of Suicide

• Conduct disorder • Physical or emotional

• Chronic or terminal illness abuse
• Dysthymic disorder • Sexual abuse
• Medications • "suicide contagion"
• Traumatic or tragic life
events
• Unresolved grief
 Risk factors
• depression
• Adverse or traumatic life events
• family history of mental disorder or
substance abuse .
• family history of suicide
• family violence
• physical or sexual abuse
• exposure to the suicidal behavior of
others.
• keeping firearms in the home
• physical or sexual abuse
 Pathophysiology of Suicide
Several biological systems might be involved in
suicidal behavior. Post-mortem studies have shown
changes in central neurotransmission functions in
association with suicide, particularly with regard to the
serotonin and noradrenalin systems, and in postsynaptic
signal transduction. Furthermore, dysfunction of the
hypothalamic-pituitary-adrenal axis might predict suicide
in patients with depression, whether or not they have
attempted suicide. Low cholesterol concentrations are
associated with an increased risk of suicide, but the
greater effect on the risk of suicide of cholesterol
lowering by diet than by treatment with statins is
unexplained. Family history of suicide increases the
 risk at least two-fold, particularly in girls and women,
independently of family psychiatric history. Concordance
rates of suicide are higher among monozygotic twins than
among dizygotic twins. Genetic factors account for 45% of
the variance in suicidal thoughts and behaviors, and
candidate genes include those encoding for tryptophan
hydroxylase and the serotonin transporter. The phenotypic
association with suicide is, however, unclear; disturbances in
the serotoninergic system are associated with suicide-related
characteristics including aggression, impulsivity,
dysfunctional attitudes about the future, hopelessness and
impaired decision making. Poor neuropsychological function
after exposure to particular stressors94 might explain the
association between disturbed serotoninergic prefrontal brain
function and an increased risk of suicidal behavior, and thus
constitute an endophenotype for suicidal behavior.
 Nursing Management
• Define the significant statistical issues
around the teen suicide.
• Describe the potential intervention
strategies for preventing suicide and the
national objectives of Gate keepers.
• Good health teaching.
• Let your client talks.
 Obesity
Is a medical condition in which excess body
fat has accumulated to the extent that it
may have an adverse effect on health,
leading to reduced life expectancy .(BMI),
which compares weight and height, is
used to define a person as overweight
(pre-obese) when their BMI is between 25
kg/m2 and 30 kg/m2 and obese when it is
greater than 30 kg/m2 .
• Obesity is associated with many diseases,
particularly heart disease, type 2 diabetes,
breathing difficulties during sleep, certain types
of cancer, and osteoarthritis. Obesity is most
commonly caused by a combination of
excessive dietary calories, lack of physical
activity, and genetic susceptibility, though a
limited number of cases are due solely to
genetics, medical reasons or psychiatric illness
 Being obese increases the
risk of:
• high blood pressure;
• heart disease;
• stroke;
• high cholesterol levels (fatty deposits
which block the arteries);
• breast cancer in women;
• gallbladder disease;
• gastro-esophageal reflux disease (when acid
from the stomach flows back up into the
gullet);
• arthritis of the back, hips, knees and ankles;
• diabetes and difficulty controlling existing
diabetes;
• polycystic ovarian syndrome;
• reduced life expectancy.
 The Signs and Symptoms of
Obesity
• breathlessness;
• sweating a lot;
• snoring;
• difficulty sleeping;
• inability to cope with sudden physical
activity;
• back and joint pains.
• Increased weight
• Increased BMI
• Increased abdominal girth
• Secondary medical complications
• feeling very tired every day;
 Obese may also experience
psychological problems

• having low self-esteem (self-worth) - or

poor self image;
• having low confidence levels;
• feeling isolated in society;
• having reduced mobility leading to a poor
quality of life.
• Weight loss medications may be
appropriate for use in selected patients
who meet the definition of obesity or who
are overweight with comorbid conditions.
• diet, exercise and lifestyle modification,
which remain the cornerstones of obesity
treatment.
 Medications
• Orlistat, exhibit novel mechanisms of action
and avoid some of the side effects that
occurred with earlier drugs.
• Sibutramine acts to block uptake of
serotonin.
• Norepinephrine and dopamine, while orlistat
decreases fat absorption in the intestines.
 Mastitis
Popular usage of the term mastitis varies by
geographic region. Outside the US it is commonly
used for puerperal and nonpuerperal cases, in the
US the term nonpuerperal mastitis is rarely used
and alternative names such as duct ectasia,
subareolar abscess and plasma cell mastitis are
more frequently used. It is also known as
inflammation of the breast.
 Causative/Predisposing Factors
• Poor drainage of breast causing milk
immobility due to poor sucking with
inadequate of one or more ducts
• Trauma due to pressure on one spot
caused by mother holding breasts too
tightly while expressing, tight or ill fitting
bra or other clothing, sleeping on a full
breast, kick on older baby or child
 Pathophysiology
• Generally occurs in Lactation several
weeks postpartum
• Bacteria enter through a cracked nipple.
 Sign and Symptoms
• Stress
• Fatigue
• Plugged duct
• Breast engorgement
• Cracked nipple
• Fatigue
• Malaise
• Myalgias
• Headache
 Management/Treatment
• Treatment
• Blocked duct
• Mastitis
• Should clear within 24 - 48 hoursIf symptoms persist for more than 24
hours, begin treatment with antibiotics include:
• Dicloxacillin 500mg orally 6 hourly OR
• Flucloxacillin 500 mg to 1 gm orally every 6 hours or
• Cephalexin 500 mg orally every 6 hours or
• Erythromycin 500 mg orally every 12 hours or
• Roxithyromycin 150 mg every 12 hours
• Treatment should be started early and continue for 10 days Note: If severe
cellulitis has developed, antibiotics should be given intravenously eg.
Flucloxacillin 1 to 2 gm intravenously every 6 hoursNB: The medications
mentioned in the above summary may or may not be available in your
country. If this is the case, please see your doctor for alternative
medications.
 Nursing Care
• The nurse may recommend that the patient wear
a supportive bra both day and night for a week.
• Decrease her salt and caffeine intake and take
ibuprofen as needed for it’s anti- inflammatory
actions.
• Encourage to take a Vitamin E supplements or
oil of evening primrose (an over the counter
herbal preparation) may also be helpful.
 Urinary Tract Infection
(UTI)
• A urinary tract infection (UTI) is a bacterial
infection that affects any part of the urinary tract.
Although urine contains a variety of fluids, salts,
and waste products, it usually does not have
bacteria in it. When bacteria get into the bladder or
kidney and multiply in the urine, they cause a UTI.
The most common type of UTI is a bladder
infection which is also often called cystitis. Another
kind of UTI is a kidney infection, known as
pyelonephritis, and is much more serious. Although
they cause discomfort, urinary tract infections can
usually be quickly and easily treated with a short
course of antibiotics
 Causative/Predisposing
Factors
• PREDISPOSING FACTORS: Female sex (no prostate, pregnancy,
short urethra), old age,
• Obstruction, P antigen on cells, no P antigen in secretions,
any anatomic lesions
• Of papilla or lower tract.
• The natural defense mechanisms against infection works
extremely well – 105 E. coli injected into the bladder are cleared,
and 105 injected IV do not cause pyelonephritis. Essentially the
only way to produce pyelonephritis experimentally is direct
medullary injection of bacteria (100 bacteria will do – WBC function
is paralyzed in the medulla due to osms, high H+ and NH4+
content), or in the presence of obstruction.
• UTI due to staph aureus, TB, & virus is thought to be via the
bloodstream – not ascending infection. Most infections, however,
are caused by gram negative rods which are thought to initiate
infection by the “ascending” route:
 Pathophysiology
• For infection to occur, bacteria must gain access
to the bladder, attach to colonize the epithelium
of the urinary tract to avoid being being washed
out with voiding, evade host defense mechanism
and initiate inflammation.
• Many UTI ‘S result from fecal organisms that
ascend from the perineum to the urethra and
the bladder and then adhere to the mucosal
surfaces.
 Sign and Symptoms
• Fever
• Irritability
• Inconsolable
• Vomiting and diarrhea
• Loss of appetite
• Failure to gain weight
• Since these are generalized symptoms in most infants, the diagnosis of
urinary tract infection may be overlooked.
• Older Children
• Burning or pain with urination
• Frequent or urgent urination
• Fever
• Lower abdominal pain
• New wetting episodes or more frequent occurrences
• Side or back pain
• Blood in urine
 Treatment/Management
• Treatment aims to eliminate the acute infection, prevent
urosepsis, and preserve renal parenchymal function.
Antibiotics are begun presumptively in all toxic-appearing
children and in nontoxic children with likely UTI (positive
leukocyte esterase or nitrite, or microscopy showing
pyuria or bacteriuria). Others can await culture results.
• VI. Nursing Care
• Encourage the patient to drink liberal amounts of fluid.
(water is best choice) to promote renal blood flow and to
flush the bacteria from the urinary tract.
• Encourage to empty the bladder completely because this
can significantly lower urine bacterial counts, reduce
urinary stasis, and prevent reinfection.
 Thrombophlebitis
• Is phlebitis (vein inflammation) related to a blood
clot or thrombus. When it occurs repeatedly in
different locations, it is known as
"Thrombophlebitis migrans" or "migrating
thrombophlebitis".
• Thrombophebitis is the inflammation of a vein
with blood clot formation inside the vein at the
site of the inflammation. Thrombophlebitis also is
known as phlebitis, phlebothrombosis, and
venous thrombosis
 Causative/Risk/Predisposing
Factor
• Thrombophlebitis (another medical term is
"White Leg") is related to a blood clot (thrombus)
in the vein. Risk factors include prolonged sitting
and disorders related to blood clotting. Specific
disorders associated with thrombophlebitis
include superficial thrombophlebitis (affects
veins near the skin surface) and deep venous
thrombosis (affects deeper, larger veins).
Thrombophlebitis migrans can be a non-
metastatic manifestation of pancreatic
carcinoma (Trousseau sign of malignancy).
 Pathophysiology
• Superficial veins, such as the greater saphaneous,
lesser saphaneous, cephalic, basilic and external jugular
veins are thick-walled muscular structures that lie just
under the skin.
• Deep vein are thin-walled and have less muscle in the
media.
• They run parallel to arteries and bear the same names
as the arteries.
• Deep and superficial veins have valves that permit
unidirectional flow back to the heart.
• The valves lie at the base of a segment of the vein that is
expanded into a sinus.
 Sign and Symptoms
• The following symptoms are often (but not always)
associated with thrombophlebitis:
• pain in the part of the body affected
• skin redness or inflammation (not always present)
• swelling (edema) of the extremities (ankle and foot)
• Doppler ultrasound
• Extremity arteriography
• Blood coagulation studies
 Management/Treatment
• For more specific recommendations, see the particular
condition. In general, treatment may include the following:
• Medications
– analgesics (pain medications)
– anticoagulants or blood thinners to prevent new clot formation
– thrombolytics to dissolve an existing clot
– nonsteroidal anti-inflammatory medications (NSAIDS) such as
ibuprofen to reduce pain and inflammation
– antibiotics (if infection is present)
– Support stockings and wraps to reduce discomfort
 Nursing Care
• Use large veins for irritating fluid.
• Stabilize venipuncture at area of flevion.
• Apply cold compress immediately to relieve
pain and inflammation, later follow with warm
compress to stimulate circulation, promote
absorption.
• Change IV site every 72 hours.

• Prepared by: Eileen Perez BSN

Scabies
• Scabies is a common skin infection that causes
small itchy bumps and blisters due to tiny mites
that burrow into the top layer of human skin to lay
their eggs .Scabies is an itchy skin condition
caused by an infestation by the itch mite Sarcoptes
scabiei. Mites are small eight-legged parasites (in
contrast to insects, which have six legs). They are
tiny, just 1/3 millimeter long, and burrow into the
skin to produce intense itching, which tends to be
worse at night. The mites that cause scabies are
not visible with the naked eye but can be seen with
a magnifying glass or microscope
SITES:
• The burrows sometimes appear as short, wavy, reddish, or
darkened lines on the skin's surface, especially around the
wrists and between the fingers. A child who has contracted
scabies can also develop a bumpy red rash.
• Scabies is contagious, and is usually transmitted by skin-to-
skin contact or through sexual contact with someone else who
is infected with it. The infection spreads more easily in
crowded conditions and in situations where there is a lot of
close contact — like childcare centers or nursing homes. So if
someone in your child's class or childcare group has scabies,
it's wise to have your child treated for the infection even
before he or she develops symptoms.
 Causes
• Scabies is caused by a microscopic (<1 mm) mite called
Sarcoptes scabiei var. hominis. The scabies mite causes
symptoms when it digs a little tunnel below the skin (referred to as
a burrow) and causes a type of allergic reaction. If the person has
never been exposed to scabies before, he or she may not show
symptoms until four to six weeks after the initial infestation.
Individuals who have been exposed in the past usually show
symptoms within a few days.
• Scabies is almost always spread by protracted skin-to-skin contact
with a person who carries the mite. Less commonly, scabies
infestation can happen through the sharing of clothes and
bedding. Theoretically, you can get scabies from touching
something that the mite is on, but that is not a major mode of
transmission
 Sign & Symptoms
• Symptoms include severe and continuous itching, especially at night.
An indication that you may have scabies is if other members of your
household are experiencing the same symptoms.
• The skin may show small insect-type bites on it, or the lesions may look
like pimples. The skin may also be red and or have sores due to
scratching of the area. Open scabs or sores are susceptible to infection
with bacteria. A burrow (a short S-shaped track that indicates the mite's
movement under the skin) may also be visible. The average affected
person has only five to 10 mites on their body at a time.
• Scabies frequently occurs in the crevasses of the body such as
between the fingers and toes, the buttocks, the elbows, the waist area,
the genital area, and under the breasts in women.
• In crusted scabies, the body is covered with a thick, dry, and scaly
rash. The rash of crusted scabies may or may not itch, but it contains
thousands to millions of mites. Crusted scabies is the most contagious
form of scabies and the hardest to treat
 Treatment
• Although you cannot cure a case of scabies without prescription medication from a
doctor, there are certain things you can do at home to keep from re-infecting yourself
or your family.
• Wash all clothing, towels, and bed linens that you have used in the last three days.
Use hot water. You should use the dryer at high heat rather than air drying. Since the
mites can survive nonliving objects for several days, place the objects that are not
machine washable (such as coats and stuffed toys) into a bag and store for a week.
• Use the medication as prescribed and instructed. Do not use it more than instructed
because you risk causing chemical irritation of your skin.
• You can also treat itching with antihistamine medications such as diphenhydramine
(Benadryl), hydroxyzine (Atarax), cetirizine (Zyrtec), and promethazine (Phenergan).
• Cut your nails, and clean under them thoroughly to remove any mites or eggs that
may be present.
• Thoroughly vacuum your rugs, furniture, bedding, and car interior and throw the
vacuum-cleaner bag away when finished.
• Try to avoid scratching. Keep any open sores clean.
 Public health and prevention
strategies
• There is no vaccine available for scabies, nor are there any
proven causative risk factors. Therefore, most strategies focus
on preventing re-infection. All family and close contacts should
be treated at the same time, even if asymptomatic. Cleaning of
environment should occur simultaneously, as there is a risk of
reinfection. Therefore it is recommended to wash and hot iron
all material (such as clothes, bedding, and towels) that has been
in contact with scabies infestation.
• Cleaning the environment should include:
• Treatment of furniture and bedding.
• Vacuuming floors, carpets, and rugs.
• Disinfecting floor and bathroom surfaces by mopping.
• Cleaning the shower/bath tub after each use.
 Pathophysiology:
• Mode of transmission
• Transmission of scabies is predominantly through direct skin-to-skin contact, and for this
reason, scabies has been considered a sexually transmitted disease. Those at high risk
include men who have sex with men and men with sexual contacts.4 A person infested with
mites can spread scabies even if he or she is asymptomatic.1 It is less frequently transmitted
by indirect contact through fomites such as infested bedding or clothing. However, the
greater the number of parasites on a person, as in crusted scabies, the more likely that
indirect contact will transmit the disease.
• The S scabiei var hominis mite that infects humans is female and can be seen with the naked
eye (0.3-0.4 mm long). The male is about half this size. The mite has 4 pairs of legs. It does
not penetrate deeper than the outer layer of the epidermis. Mites are unable to fly or jump.
They crawl at a rate of 2.5 cm/min.4 While the mite's life cycle occurs completely on its host,
they are able to live on bedding, clothes, or other surfaces at room temperature for 2-3 days,
while remaining capable of in burrowing.
• Life cycle
• The scabies mite is an obligate parasite and completes its entire life cycle on humans. Other
variants of the scabies mite can cause infestation in other mammals such as dogs, cats, pigs,
ferrets, and horses, and these variants can irritant human skin as well. However, they are
unable to reproduce in humans and only cause a transient dermatitis
Rheumatic Fever
What is rheumatic fever?

Rheumatic fever is a complicated,

involved disease that affects the joints,
skin, heart, blood vessels, and brain. It is
a systemic immune disease that may
develop after an infection with
streptococcus bacteria, such as strep
throat and scarlet fever.
 Causes
• Rheumatic fever is a delayed,
autoimmune reaction to the streptococcus
bacteria. It can be prevented with prompt
diagnosis of strep throat, and treatment of
strep throat with antibiotics. It is
uncommon in the US, except in children
who have had strep infections that were
untreated or inadequately treated.
 Sign & Symptoms
• The symptoms of rheumatic fever usually start about one to five weeks after
your child has been infected with streptococcus bacteria. The following are the
most common symptoms of rheumatic fever. However, each child may
experience symptoms differently. Symptoms may include:
• joint inflammation - including swelling, tenderness, and redness over multiple
joints. The joints affected are usually the larger joints in the knees or ankles.
The inflammation "moves" from one joint to another over several days.
• small nodules or hard, round bumps under the skin
• a change in your child's neuromuscular movements (this is usually noted by a
change in your child's handwriting and may also include jerky movements)
• rash - a pink rash with odd edges that is usually seen on the trunk of the body
or arms and legs.
• fever
• weight loss
• fatigue
• stomach pains
• Symptoms of rheumatic fever may resemble other medical conditions. Always
consult a physician for a diagnosis.
 Who is at risk for developing
rheumatic fever?
• Children ages 5 to 15, particularly if they
experience frequent strep throat infections, are
most at risk for developing rheumatic fever.
Rheumatic fever is also more common in
children who have a family history of the
disease. There is an increased prevalence of
rheumatic fever in the winter and spring, as
strep throats occur more frequently during these
seasons. Strep infections are contagious, but
rheumatic fever is not.
 Pathophysiology
• Acute rheumatic fever (ARF) is a delayed inflammatory
reaction in response to a streptococcal bacterial infection
(i.e., with group A beta-hemolytic streptococci). Members
of certain families appear to have an increased risk of
ARF and rheumatic heart disease. In addition to possible
hereditary factors, certain environmental factors, including
overcrowded living conditions and malnutrition, are also
thought to play some role in increasing susceptibility to
streptococcal infections as well as the risk of subsequent
ARF. Also, as mentioned previously, some investigators
suggest that sex hormones (e.g., the female hormone
estrogen) may be a contributing factor in some instances
of Sydenham's chorea. This is based upon various
findings, including the fact that females are more
commonly affected than males, particularly in the years
around puberty, and that recurrences have been
associated with estrogen therapy or pregnancy.
• The specific underlying mechanism responsible for development of
ARF remain unknown. However, evidence suggests that the disorder
may result from an abnormal immune reaction in which antibodies
produced in response to the invading bacterium act against certain of
the body's own cells. For example, according to such a theory
(sometimes known as "autoimmune mimicry"), a foreign protein
(antigen) from a particular bacterium may be similar to one of the
body's own proteins; as a result, the human immune system may be
unable to distinguish between its "self" protein and that of the invading
microorganism, potentially triggering an inappropriate autoimmune
response. The symptom-free period between recovery from sore
throat (pharyngitis) to the onset of symptoms associated with ARF
(i.e., latent period) may lend support to the theory of an abnormal
immune mechanism resulting in tissue damage.
 Treatment:
• If you are diagnosed with acute rheumatic fever you will be treated with antibiotics.
• Anti-inflammatory medications such as aspirin or corticosteroids reduce inflammation to help
manage acute rheumatic fever.
• You may have to take low doses of antibiotics (such as penicillin, sulfadiazine, or
erythromycin) over the long term to prevent strep throat from returning.

– Anti-inflammatory agents are used to control the arthritis, fever, and other acute symptoms.
Salicylates are the preferred agents, although other nonsteroidal agents are probably equally
efficacious. Steroids are also effective but should probably be reserved for patients in whom
salicylates fail. None of these anti-inflammatory agents has been shown to reduce the risk of
subsequent rheumatic heart disease.
– Bed rest is a traditional part of ARF therapy and is especially important in those with carditis.
Patients are typically advised to rest through the acute illness and gradually increase activity;
some clinicians monitor the patient’s ESR and restart activity only as it normalizes.
– Intravenous immunoglobulin has not been shown to reduce the risk of rheumatic heart disease
or to substantially improve the clinical course.
– Chorea is usually managed conservatively in a quiet nonstimulatory environment; valproic acid
is the preferred agent if sedation is needed. Intravenous immunoglobulin, steroids, and
plasmapheresis have all been used successfully in refractory chorea.
BONE TUMOR
• A bone tumor is an abnormal growth of cells
within the bone that may be noncancerous
(benign) or cancerous (malignant).

• A bone tumor refers to a neoplastic growth of

tissue in bone. It can be used for both benign
and malignant abnormal growths found in
bone, but is most commonly used for primary
tumors of bone, such as osteosarcoma. It is
may be applied to secondary bone tumors, i.e.
metastatic tumors found in bone.
 Primary tumors
• Primary tumors of bone can be divided into benign
tumors and cancers. Common benign bone tumors
may be neoplastic, developmental, traumatic,
infectious, or inflammatory in etiology. Examples of
benign bone tumors include osteoma,
osteochondroma, aneurysmal bone cyst, and fibrous
dysplasia of bone.
• Malignant primary bone tumors include
osteosarcoma, chondrosarcoma, Ewing's sarcoma,
malignant fibrous histiocytoma, fibrosarcoma, and
other sarcoma types. Multiple myeloma is a
hematologic cancer which also frequently presents as
one or more bone tumors.
• The tailbone is a common location for a teratoma,
known as a sacrococcygeal teratoma, and related
germ cell tumors.
 Secondary tumors
• Secondary bone tumors include
metastatic tumors which have spread
from other organs, such as the breast,
lung, and prostate. Metastatic tumors
more frequently involve the axial
skeleton than the appendicular
skeleton. Tumors which originate in the
soft tissues may also secondarily
involve bones through direct invasion
 Causes

• The cause of bone tumors is unknown.

They often arise in areas of rapid growth.
Possible causes include:
• Inherited genetic mutations
• Radiation
• Trauma
 Symptoms

• Bone fracture, especially fracture from

slight injury (trauma)
• Bone pain, may be worse at night
• Occasionally a mass and swelling can be
felt at the tumor site
Note: Some benign tumors have no
symptoms.
 Possible Complications

• Pain
• Reduced function, depending on the
extent of the tumor
• Side effects of chemotherapy (depending
on the type of chemotherapy)
• Spread of the cancer to other nearby
tissues (metastasis)
 Exams and Tests
• Alkaline phosphatase
• Bone biopsy
• Bone scan
• MRI
• X-ray of bone
This disease may also affect the results of the following tests:
• Alkaline phosphatase isoenzyme
• Calcium (ionized)
• Extremity x-ray
• Hands x-ray
• Joints x-ray
• PTH
• Serum calcium
• Serum phosphorus
 Treatment
• Benign bone tumors may not require treatment, but may be
looked at regularly to check if they grow or shrink. Surgical
removal of the tumor may be necessary.

• Treatment for malignant tumors that have spread to the bone

depends on the primary tissue or organ involved. Radiation
therapy with chemotherapy or hormone therapy is often used.

• Tumors that start in the bone (primary malignant tumors of the

bone) are rare and require treatment at centers with experience
treating these cancers. After biopsy, a combination of
chemotherapy and surgery is usually necessary. Radiation
therapy may be needed before or after surgery.
 Medication

• One of the major concerns is bone

density and bone loss. Non-hormonal
bisphosphonates increase bone strength
and are available as once-a-week
prescription pills.
 Surgical treatment
• Treatment for some bone cancers may involve surgery,
such as limb amputation, or limb-sparing surgery (often in
combination with chemotherapy and radiation therapy).
Limb sparing or limb salvage surgery, means the limb is
spared from amputation. Instead of amputation the
affected bone is removed and is done in two ways (a)
bone graft, in which a bone from elsewhere from the body
is taken or (b) artificial bone is put in. In upper leg
surgeries, limb salvage prostheses are available.
• The other surgery is called van-ness rotation or
rotationplasty which is a form of amputation, in which the
patient's foot is turned upwards in a 180 degree turn and
the upturned foot is used as a knee.
 Types of amputation:
LEG ARM
• Below knee  Below elbow
• Above knee  Above elbow
• Symes  Shoulder
• Hip disarticulation disarticulation
• Hemipelvectomy or  Forequarter
hindquarter, in which (amputation of the
the whole leg is whole arm, along
removed with one half with the shoulder
of the pelvis blade and the
clavicle)
• The most radical of amputations is
hemicorporectomy (translumbar or waist
amputation) which removes the legs, the pelvis,
urinary system, excretory system and the
genital area (penis/testes in males and
vagina/vulva in females). This operation is done
in two stages. First stage is doing the colostomy
and the urinary conduit, the second stage is the
amputation. This is a mutilating operation and is
only done as a last resort (e.g. when even
pelvic exenteration doesn't work or in cases of
advanced pelvic/reproductive cancers)
TRAUMA
 Trauma
The pregnant trauma patient presents a unique
challenge because care must be provided for two
patients—the mother and the fetus. Anatomic and
physiologic changes in pregnancy can mask or mimic
injury, making diagnosis of trauma-related problems
difficult. Care of pregnant trauma patients with
severe injuries often requires a multidisciplinary
approach involving an emergency clinician, trauma
surgeon, obstetrician, and neonatologist.
 Types of trauma
• Blunt (automobile accidents,
battering)
• Penetrating (knife or gunshot
wounds)
• Burns
• Electrical injuries
 Causes
• Causes of traumatic injuries in pregnancy are similar
to those in the general population; blunt injury
trauma is the most common cause.
• Motor vehicle accidents (MVAs) account for 49% of
injuries.
• Falls account for 25% of injuries (may be related to
physiologic changes that result in loss of balance).
• Assaults account for 18% of injuries.
• Guns account for 4% of injuries.
• Burns account for 1% of injuries.
• Intimate partner violence
 Risk factors

• simply pregnancy itself,

• younger age,
• drug use,
• alcohol use,
• and history of intimate partner violence.
 Complications
• Exsanguination: Dramatic increases in uterine blood flow (60 to 600
mL/min) may result in rapid exsanguination if there is avulsion of the
uterine vessels or rupture of the uterus.
• Retroperitoneal hemorrhage: A common complication of pelvic fracture
due to the tremendous increase in vascularity resulting from
pregnancy.Uterine rupture: Enlargement of the uterus makes it
susceptible to direct abdominal trauma. This rare complication is
estimated to complicate 0.6% of traumatic injury.
• Uterine rupture is associated with a fetal mortality rate approaching
100%. Maternal mortality of 10% is usually a result of associated
injuries.
• Rupture of amniotic membranes can lead to chorioamnionitis, preterm
labor, and cord prolapse.Amniotic fluid embolism (may lead to acute
respiratory distress syndrome)
• Placental abruption is the most feared complication in cases of trauma.
• Fetomaternal hemorrhage: Historically, fetomaternal hemorrhage has
been reported to occur in 9-30% of cases. However, one study of 151
women found an incidence of only 2.6%, which is similar to that of the
general population.
 Pathophysiology
 To evaluate the pregnant patient, the various physiologic changes that occur
during pregnancy must be understood. Because balance and coordination are most
adversely affected during the third trimester, the frequency of accidental injury is
greatest during this period. Although the pregnant patient's blood pressure
decreases during pregnancy, changes may not be as great as traditionally thought.
Systolic blood pressure changes by only 2-4 mm Hg, while diastolic pressure
decreases by 5-15 mm Hg in mid-trimester. In addition, the resting heart rate
usually increases by only 10-15 beats per minute. Thus, tachycardia or
hypotension in the pregnant trauma patient should not be attributed solely to the
gravid state.
 Physiologic anemia in pregnancy is due to a dilutional effect of plasma volume
increasing by 50% but red blood cell volume increasing by only 18-30%. Thus, the
average hematocrit level is 32-34% and is at its nadir around the 30th to 34th
week of gestation. Because the average estimated blood loss is approximately 500
mL for a vaginal delivery and 1000 mL for a cesarean delivery, no change in
hemodynamic parameters occurs because of these preemptive adaptations. The
uterus, which grows from 70 g to 1000 g, enlarges into the peritoneal cavity after
the 12th week of pregnancy. Although it now becomes more susceptible to injury,
it also provides protection for other maternal abdominal organs such as the small
bowel. The bladder is also moved into the abdomen by the uterus in the second
and third trimesters, and the ureters become dilated (right > left). Gastrointestinal
tract motility decreases.
Blood flow to the uterine arteries is normally maxillary vasodilated, so blood
delivery to the uterus is maximal in the normal physiologic state. Maternal
hypovolemia may result in vasoconstriction of the uterine vasculature. The third
trimester fetus can adapt to a decrease in uterine blood flow and oxygen delivery
by diverting blood distribution to the heart, brain, and adrenal glands. Because
fetal hemoglobin has a greater affinity for oxygen than does adult hemoglobin,
fetal oxygen consumption does not decrease until the delivery of oxygen is
Fetal/neonatal complications

• Direct injury due to skull fracture,

intracranial hemorrhage
• Indirect injury due to abruption placentae,
maternal hypovolemia, or uterine rupture
• Death of the mother (most common cause
of fatal death)
• Neurologic deficits sometimes found in
survivors
 Treatment
Prehospital Care
• As in any trauma patient, the ABCs of trauma resuscitation must be
followed in treating the pregnant patient. The mother should always
receive supplemental oxygen. Several additional issues must be
considered in treating the trauma patient who is pregnant.

• For patients beyond the 20th to 24th week of gestation, the patient should
be tilted 15° to the left by placing rolled towels beneath the spinal board.
This is completed to prevent supine hypotension syndrome, which occurs
when the gravid uterus compresses the inferior vena cava. Such
compression can decrease cardiac output by up to 28%, which then may
cause significant hypotension. Alternatively, one person may be
designated to manually displace the uterus to the left. If the patient does
not require spinal immobilization, then she can be asked to assume the
left lateral decubitus position.
• If warranted, fetal heart tones may be auscultated as part of the initial fetal
assessment and to reassure the mother.
• Military antishock trousers (MAST) are considered a class III intervention
(inappropriate, possibly harmful) for gravid patients. If they are used,
inflate only the leg compartments.
Emergency Department Care

• Patients who have minor trauma and who are at less than 20 weeks'
gestation do not require specific intervention or monitoring. All pregnant
women beyond 20-24 weeks' gestation who have direct or indirect
abdominal trauma should undergo at least 4 hours of cardiotocographic
monitoring. Resuscitation of the more serious trauma patient must focus
on the mother because the most common cause of fetal death is
maternal shock or death. It is important to remember that the mother will
maintain her vital signs at the expense of the fetus. Because plasma
volume is increased 50% and the mother is able to shunt blood away
from the uterus, maternal shock may not manifest itself until maternal
blood loss exceeds 30%. During the initial ABC assessment, the fetus is
addressed only during evaluation of circulation.
• If the patient is more than 20-24 weeks' pregnant, the patient should be
tilted 15° to the left. Alternatively, one person may be designated to
manually displace the uterus to the left. If the patient does not require
spinal immobilization, then she can be asked to assume the left lateral
decubitus position.
• Airway and breathing
– All pregnant trauma patients should receive supplemental oxygen because the fetus is
extremely sensitive to hypoxia and because the oxygen reserve is significantly
diminished in the pregnant patient.
– In general, pregnancy does not affect the decision to intubate, although the risk of
aspiration is increased (decreased gastric tone, delayed gastric emptying, and cephalad
displacement of intra-abdominal organs). The use of medications for rapid sequence
intubation in pregnancy is not well studied; however, no absolute contraindications exist.
– If a chest tube is placed, enter the chest 1 or 2 interspaces higher than usual, because
the diaphragm is elevated during pregnancy.
• Circulation
– It is extremely important to maintain adequate maternal blood volume as a first step in
fetal resuscitation. A decrease in maternal blood pressure may result in a decrease in
uterine blood flow, even without uterine artery vasoconstriction.
– Resuscitate the patient with warmed crystalloid administered through large-bore
catheters placed for intravenous lines because the relative hypervolemia of pregnancy
allows for a 30-35% loss of blood volume before hypotension develops.
– Rule out occult sources of bleeding because maternal blood flow is maintained at the
expense of fetal blood flow.
– If blood is needed on an emergency basis, use Rh-negative blood unless the patient's
Rh status is known.
– Blood pressure returns to prepregnancy levels as the gestational age approaches 40
weeks.
– Fetal assessment should be performed early as part of the maternal secondary survey.

Consultations
The pregnant patient with serious traumatic injury requires a multidisciplinary
team, which includes an obstetrician, trauma surgeon, and neonatologist.
 Medication

• The goal of therapy is to prevent immune response to Rh-negative

fetus after trauma.
Immune serum
• Suppresses immune response of nonsensitized Rho(D)–negative
mothers who are exposed to Rho(D)–positive blood from the fetus,
resulting from a fetomaternal hemorrhage, abdominal trauma,
amniocentesis, abortion, full-term delivery, or transfusion accident.
Rho(D) immune globulin (RhoGAM)
• Administered if the patient is Rh-negative, unless the father also is
Rh-negative. Suppresses the immune response of nonsensitized Rh-
negative mothers after delivery of Rh-positive infant. Prevents
sensitization to Rho(D) factor. Prevents erythroblastosis fetalis in
subsequent pregnancy. When administered near the time of delivery,
RhIgG may interfere with Rh typing of the newborn.
 Management

• Stabilization and care of maternal life

threatening injuries, then stabilization of
the fetus
• Delivery if the maternal condition warrants
and the fetus is likely to survive
• Delivery of the dead or extremely
immature fetus if that will improve the
maternal outcome
 Nursing consideration

• Place a wedge under one hip to

prevent supine hypotension and
improve placental blood flow
• Observe vital sign (frequent depends
on maternal condition) monitor FHR if
the fetus has reached a viable
gestational age
Patent Ductus
Arteriosus
 Is a congenital heart defect wherein a
neonate's ductus arteriosus fails to close
after birth. Symptoms are uncommon but in
the first year of life include increased work of
breathing and poor weight gain. With age, the
PDA may lead to congestive heart failure if
left uncorrected.
 Etiology

A patent ductus arteriosus can be

idiopathic (i.e. without an identifiable
cause), or secondary to another
condition. Some common contributing
factors in humans include: - Premature
infants - Congenital rubella syndrome -
Chromosomal abnormalities such as
Down Syndrome
 Risk factors

•The condition occurs more often in premature infants (on

average, occurring in about 8 of every 1,000 births).
However, PDA also occurs in full-term infants (on average,
occurring in about 2 of every 1,000 births).
•PDA also is more common in:
•Infants who have genetic conditions such as Down
syndrome
•Infants whose mothers had German measles (rubella)
during pregnancy
•PDA is twice as common in girls as it is in boys.
 Signs and symptoms
• While some cases of PDA are asymptomatic,
common symptoms include:
• tachycardia or other arrhythmia
• respiratory problems
• shortness of breath
• continuous machine-like murmur
• enlarged heart
• Left subclavicular thrill
• Bounding pulse
• Widened pulse pressure
 Pathophysiology:
Persistence or patency of the ductus with an otherwise normal systemic and
pulmonary circulatory system results in significant shunting of blood from left to
right, ie, systemic to pulmonary. Because the systemic vascular resistance is always
higher than that of the pulmonary circulation, shunting is continuous. The result is
volume overload of the pulmonary arteries and veins, left atrium, and left ventricle.
Left atrial and left ventricular dilatation may result in cardiac arrhythmias. Chronic
volume overload and dilatation of the left-sided cardiac chambers usually result in
signs of left-sided CHF. Therefore, most untreated cases develop refractory CHF.
Animals with a small ductus may reach adulthood without signs of heart failure but
are at an increased risk of infective endocarditis. In some animals with a large PDA,
increased pulmonary blood flow may induce pulmonary vasoconstriction and
development of pulmonary hypertension, which has several important implications:
shunting through the ductus slows and reverses, which causes disappearance of the
murmur and occurrence of caudal cyanosis (differential cyanosis); the right ventricle
becomes dilated and hypertrophied as a result of pulmonary hypertension; and
perfusion of the kidneys with deoxygenated blood causes excessive release of
erythropoietin and subsequent polycythemia. Thus, if the ductus shunts right to left,
clinical signs of polycythemia will predominate.
 Diagnosis
•PDA is usually diagnosed using non-invasive techniques.
Echocardiography, in which sound waves are used to
capture the motion of the heart, and associated Doppler
studies are the primary methods of detecting PDA.
Electrocardiography (ECG), in which electrodes are used to
record the electrical activity of the heart, is not particularly
helpful as there are no specific rhythms or ECG patterns
which can be used to detect PDA.
•A chest X-ray may be taken, which reveals the overall size
of neonate's heart (as a reflection of the combined mass of
the cardiac chambers) and the appearance of the blood flow
to the lungs. A small PDA most often shows a normal sized
heart and normal blood flow to the lungs. A large PDA
generally shows an enlarged cardiac silhouette and
increased blood flow to the lungs.
 Treatment
• Neonates without adverse symptoms may simply be monitored as
outpatients, while symptomatic PDA can be treated with both surgical
and non-surgical methods.
•Surgically, the DA may be closed by ligation, wherein the DA is
manually tied shut, or with intravascular coils or plugs that leads to
formation of a thrombus in the DA.
• Because Prostaglandin E-2 is responsible for keeping the ductus
patent, inhibitors of prostaglandin synthesis such as Indomethacin
have been used to help close a PDA. This is an especially viable
alternative for premature infants
•Recent days PDA can be closed by percutaneous interventional
method, through femoral vein or femoral artery, a coil can be placed
with the help of myocardial forceps to make an embolus, which closes
the PDA without open heart surgery.
 Medical management

digoxin - a medicine that helps strengthen the heart

muscle, enabling it to pump more efficiently.

diuretics - the body's water balance can be affected

when the heart is not working as well as it could. These
medications help the kidneys remove excess fluid from
the body.
 Adequate nutrition
high-calorie formula or breast milk
Special nutritional supplements may be added to formula or
pumped breast milk that increase the number of calories in
each ounce, thereby allowing your baby to drink less and still
consume enough calories to grow properly.

supplemental tube feedings

Feedings given through a small, flexible tube that passes
through the nose, down the esophagus, and into the stomach,
can either supplement or take the place of bottle-feedings.
Infants who can drink part of their bottle, but not all, may be fed
the remainder through the feeding tube. Infants who are too
tired to bottle-feed may receive their formula or breast milk
through the feeding tube alone.
 Surgical repair
Postoperative care for your child:
Some children who undergo PDA ligation may need to spend some time in
the intensive care unit after surgery. Others may return to a regular hospital
room. Your child will be kept as comfortable as possible with medications
which relieve pain or anxiety. The staff will also be asking for your input as
to how best to soothe and comfort your child.

You will also learn how to care for your child at home before your child is
discharged. The staff will give you instructions regarding medications,
activity limitations, and follow-up appointments before your child is
discharged. Most children will only need to stay in the hospital for a few
days after the operation.