ABRUPTIO PLACENTA Definition: - Prematu Premature re separ separati ation on of the placenta placenta from from the uterine uterine wall wall.. - Common Common cause cause of bleeding bleeding during during the second second half half of preg pregnancy nancy - Usuall Usually y occurs occurs after after 20 to 24 weeks weeks of preg pregnanc nancy y but may may occur occur as late late as during during first first or second stage of labor. Placental abruption abruption (also known as abruptio placentae placentae ) is an obstetr obstetric ic catastr catastrophe ophe (complication of pregnancy), pregnancy), wherein the placental the placental lining has separated from the uterus of the mother . It is the most common cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies worldwide with a fetal mortality rate of 20-40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality.
The heart rate of the fetus can be associated with the severity.
Risk factors: - wome women n wit with h par parit ity y of of 5 or or more more - wome women n ove overr 30 30 yea years rs of age age - women women with with pre-ec pre-eclam lampsi psiaa - eclamp eclampsia sia and and renal renal or vascula vascularr diseas disease. e. Factors contributing to ABRUPTIO PLACENTA - multiple ple ge gestat tations - hydramnios - cocaine use - dec. dec. bloo blood d flo flow w to to the the plac placen enta ta - trauma uma to the abdo abdom men - dec. dec. ser serum um foli folicc aci acid d lev level elss - PIH Cause: Unknown Theories proposed relating it’s occurrence to dec. blood flow to the placenta through the sinuses during the last trimester; Excessive intrauterine pressure caused by hydramnios or multiple pregnancy may also be contributing factors. Clinical manifestations:
ℜ Covert (severe)/ Mild separation/ Mild Abruptio Placenta The placenta separates centrally and the blood is trapped between the placenta and the uterine wall. Signs and Symptoms: 1. no over overtt bleed bleeding ing fro from m vagi vagina na 2. rigi rigid d abd abdome omen 3. acut acutee abd abdom omin inal al pain pain 4. dec. BP 5. inc. pulse 6. utero uteropla place centa ntall insu insuffi ffici cienc ency y
ℜ Overt (partial)/ Moderate separation/ Moderate Abruptio Placenta The blood passes between the fetal membranes and the uterine wall and escapes vaginally. May develop abruptly or progress from mild to extensive separation with external hemorrhage. Signs and Symptoms: 1. vagi vagina nall blee bleedi ding ng 2. rigi rigid d abd abdome omen 3. acut acutee abd abdom omin inal al pain pain 4. dec. BP 5. inc. pulse 6. utero uteropla place centa ntall insu insuffi ffici cienc ency y
ℜ Placental Prolapse/ Severe separation/ Severe Abruptio Placenta Massive vaginal bleeding is seen in the presence of almost total separation with possible fetal cardiac distress. Signs and Symptoms: 1. mass massiv ivee vag vagina inall ble bleedi eding ng 2. rigi rigid d abd abdome omen 3. acut acutee abd abdom omin inal al pain pain 4. shock 5. marked marked uteropl uteroplacen acental tal insuffi insufficie ciency ncy Management: - monitori monitoring ng of maternal maternal vital vital signs signs,, fetal heart heart rate rate (FHR), (FHR), uterine uterine contra contracti ctions ons and vaginal vaginal bleeding - likeli likelihood hood of vagina vaginall deliver delivery y depends depends on the the degree degree and timing timing of of separat separation ion in labor labor - cesarea cesarean n deliver delivery y indicate indicated d for modera moderate te to severe severe plac placenta entall separat separation ion - evalu evaluati ation on of of mat mater ernal nal labor laborat atory ory values values - F & E rep repla lacem cement ent thera therapy py;; blood blood trans transfu fusi sion on - Emotional su support
Nursing Interventions: - Assess Assess the the patien patient’s t’s exten extentt of bleedi bleeding ng and moni monitor tor fundal fundal heig height ht q 30 mins. mins. - Draw Draw line line at the level level of of the fundu funduss and check check it it every every 30 mins mins (if (if the level level of of the fundus fundus increases, suspect abruptio placentae) - Count Count the number number of pads pads that that the patie patient nt uses, uses, weighin weighing g them as as necessa necessary ry to deter determin minee the amount of blood loss - Monitor Monitor mater maternal nal blood blood pressure, pressure, pulse pulse rate, rate, respirati respirations, ons, centra centrall venous press pressure ure,, intake and output and amount of vaginal bleeding q 10 – 15 mins - Begin Begin electr electroni onicc fetal fetal monit monitori oring ng to to continu continuousl ously y asses assesss FHR FHR - Have equipme equipment nt for for emerg emergency ency cesare cesarean an delive delivery ry readil readily y availabl available: e: -prepare the patient and family members for the possibility of an emergency CS delivery, the delivery of a premature neonate and the changes to expect in the postpartum period -offer emotional support and an honest assessment of the situation - if vagina vaginall delive delivery ry is elected elected,, provide provide emotio emotional nal suppo support rt duri during ng labor labor -because of the neonate’s prematurity , the mother may not receive an analgesic during labor and may experience intense pain -reassure the patient of her progress through labor and keep her informed of the fetus’ condition - tactful tactfully ly discuss discuss the possib possibili ility ty of neonata neonatall death death -tell the mother that the neonate’s survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive disorders -assure her that frequent monitoring and prompt management greatly reduce the risk of death. - encoura encourage ge the the patie patient nt and and her family family to verbal verbalize ize thei theirr feelin feelings gs - help them them to to develop develop effective effective coping strategies, strategies, referri referring ng them them for counseling counseling if if necessary. necessary. Goals of Care: 1. blood loss loss is minimize minimized, d, and lost blood is replaced replaced to prevent prevent ischemic ischemic necrosis necrosis of distal organs, including kidneys 2. DIC is preven prevented ted or or succes successfu sfully lly trea treated. ted. 3. normal normal repro reproduct ductive ive funct functioni ioning ng is retai retained ned 4. the fetu fetuss is safel safely y deli deliver vered ed 5. the woman woman retains retains a positive positive sense sense of self-es self-esteem teem and and self-wort self-worth. h. Additional lab results:
Hgb- ↓ Platelet - ↓ Fibrinogen - ↓
Fibrin degradation products - ↑ Other possible nursing diagnosis:
• Impaired gas exchange: fetal related to insufficient oxygen supply secondary to premature separation of the placenta.
• Pain related to bleeding between the uterine wall and the placenta secondary to premature separation of the placenta.
• Fear related to perceived or actual grave threat to body integrity secondary to excessive bleeding and threat to fetal survival.
• Grieving related to actual or threatened loss of infant. • Powerlessness related to maternal condition and hospitalization. • Risk for deficient fluid volume related to excessive losses secondary to premature placental separation.
Pathophysiology Trauma, Trauma, hypertension, or coagulopathy, or coagulopathy, contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death. Abruptions are classified according to severity in the following manner:
•
Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. • Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus.
• •
Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring. Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus. uterus.
Intervention Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta out placenta praevia but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative. negative. Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.
ANATOMY & PHYSIOLOGY OF FEMALE REPRODUCTIVE ORGAN
FEMALE EXTERNAL STUCTURES a. Mons Ven Vener eris is
• A pad of adipose tissue located over the symphisis pubis, the pubic bone joint.
• It protects the junction of pelvic bone from trauma. b. Labi bia a Min Mino ora
• Just Just post poster erio iorr to the the mons mons vene veneri riss spre spread ad two two hair hairle less ss fold foldss of connective tissue. c. Labi bia a Majo jorra
•
Two halves of adipose tissue covered by loose connective tissue and epithelium.
d. Vestibule
• Flattened smooth surface inside the labia. • The space wherein we can see the vaginal and uretral opening. e. Clitoris
• Small rounded erectile tissue at the forward junction of the labia minora. • Sensitive to touch and temperature center of sexual arousal and orgasm. f.
Skene’ e’ss Gl Gland PARAURETRAL GLANDS • Located just lateral to urinary meatus.
• It produces lubricating fluid that helps to maintain the moistness of the vestibule. Bartholin’s Gland (vulvovaginal) • Located just lateral to vaginal opening.
• It secretes mucus to provide vaginal lubrications. g. Fourchette
• Ridge of tissues formed by the posterior joining the two labias.
INTERNAL STRUCTURES 1. Ovaries • Almond shaped • Produce, mature and discharge ova • Initiate and regulate menstrual cycle • 4 cm long, 2 cm in diameter, 1.5 cm thick • Produce estrogen and progesterone
-
promotess breast breast develop development ment & pubic pubic hair distri distributi bution on prevent preventss Estrogen: promote osteo osteopor poros osis is and and keeps keeps chol cholest ester erol ol level levelss reduc reduced ed & so limi limits ts effec effects ts of atherosclerosis Fallopian tubes.
2. Fa Fall llop opia ian n tub tubes es • Approximately 10 cm in length • Arises from each corner of the uterine body • Conveys ova from ovaries to the uterus • Site of fertilization • Parts: interstitial isthmus – cut/sealed in BTL ampulla – site of fertilization infundibulum – most distal segment; covered with fimbria
3.
Uterus • Hollow muscular pear shaped organ uterin inee wall wall laye layers rs:: endo endome metr triu ium( m(in inne ner) r);; myom myomet etri rium um(m (mid iddl dle) e);; - uter perimetrium(outer) • Organ of menstruation • Receives the ova • Provide place for implantation & nourishment during fetal growth • Protects growing fetus • Expels fetus at maturity • Has 3 divisions: corpus – fundus , isthmus (most commonly cut during CS delivery) and cervix.
4.
Uter eriine Wa Wall • Endometrial layer: formed by 2 layers of cells which are as follows: • basal layer- closest to the uterine wall. • glandular layer – inner layer influenced by estrogen and progesterone; thickens and shed off as menstrual flow.
• Myometrium – composed of 3 interwoven layers of smooth muscle; fibers are arranged in longitudinal; transverse and oblique directions giving it extreme strength. 5.
Vagina • Acts as organ of copulation • Conveys sperm to the cervix • Expands to serve as birth canal • Wall contains many folds or rugae making it very elastic Fornices – – uterine uterine end of the vagina; serve as a place for pooling of semen following coitus. • Bulbocavernosus – circular muscle act as a voluntary sphincter at the external opening to the vagina (target of Kegel’s exercise).
PLACENTA
• It serve s as the fetal lungs, kidneys and gastrointestinal tract and as a separate endocrine organ throughout pregnancy.
CIRCULATION
• The fetus is connected by the umbilical cord to the placenta, the organ that develops • • • • •
and implants in the mother's uterus during pregnancy. As early as the 12th day of pregnancy, maternal blood circulation begins to collect in the intervillus spaces of the uterine endometrium surrounding the chronic villi. By the 3rd week of pregnancy, through the blood vessels in the umbilical cord, the fetus receives all the necessary necessary nutrition, oxygen, and life support from the mother through the placenta.. From there, the nutrients are being transported back to the growing embryo. Waste products and carbon dioxide from the fetus are sent back through the umbilical cord and placenta to the mother's circulation to be eliminated. The blood from the mother enters the fetus through the vein in the umbilical cord. It goes to the liver and splits into three branches. The blood then reaches the inferior vena cava, a major vein connected to the heart.
Inside the fetal heart - Blood enters the right atrium, the chamber on the upper right side of the heart. Most of the blood flows to the left side through a special fetal opening between the left and right atria, called the foramen ovale. - Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta, (the large artery coming from the heart). - From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. - About one-third of the blood entering the right atrium does not flow through the foramen ovale, but, instead, stays in the right side of the heart, eventually flowing into the pulmonary artery.
• Because the placenta does the work of exchanging oxygen (O2) and carbon dioxide (CO2) through the mother's circulation, the fetal lungs are not used for breathing. Instead of blood flowing to the lungs to pick up oxygen and then flowing to the rest of the body, the fetal circulation shunts (bypasses) most of the blood away from the lungs. In the fetus, blood is shunted from the pulmonary artery to the aorta through a connecting blood vessel called the ductus arteriosus.
Pathophysiology of Abruptio Placentae
Preeclampsia Preeclampsia, also referred to as toxemia, is a condition that pregnant women can get. It is marked by high blood pressure accompanied with a high level of protein in the urine. Women with preeclampsia will often also have swelling in the feet, legs, and hands. Preeclampsia, when present, usually appears during the second half of pregnancy, generally in the latter part of the second or in the third trimesters, although it can occur earlier. In addition symptoms of preeclampsia can include:
•
Rapid weight gain caused by a significant increase in bodily fluid
•
Abdominal pain
•
Severe headaches
•
A change in reflexes
•
Reduced output of urine or no urine
•
Dizziness
•
Excessive vomiting and nausea
The exact causes of preeclampsia are not known, although some researchers suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible causes.
The only only real real cure cure for for pree preecl clam ampsi psiaa and eclam eclampsi psiaa is the birth birth of the baby baby.. Mild Mild preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation in a woman who did not have hypertension before; and/or having a small amount of protein in the urine can be managed with careful hospital or in-home observation along with activity restriction.
Pathophysiology: Efforts to unravel the pathogenesis of pre-eclampsia have been hampered by the lack of clear diagnostic criteria for the disease and its subtypes. Consequently, several studies have included a variety of other conditions that do not necessarily reflect an adverse pregnancy outcome.
Abnorma Abnormall placent placentati ation on (stage (stage 1), partic particular ularly ly lack lack of dilatat dilatation ion of the uterine uterine spiral spiral arterioles, is the common starting point in the genesis of pre-eclampsia, which compromises blood flow to the maternal–fetal interface. Reduced placental perfusion activates placental factors and induces systemic hemodynamic changes. The maternal syndrome (stage 2) is a function of the circula circulator tory y distur disturbanc bancee caused caused by system systemic ic matern maternal al endothel endothelial ial cell cell dysfunc dysfunction tion result resulting ing in vascular vascular reactivity, reactivity, activation of coagulation coagulation cascade and loss of vascular integrity. Pre-eclampsia Pre-eclampsia has effects on most maternal organ systems, but predominantly predominantly on the vasculature of the kidneys, kidneys, liver and brain.
Summary What Is Preeclampsia?
Also referred to as toxemia, preeclampsia is a condition that pregnant women can get. It is marked by high blood pressure accompanied with a high level of protein in the urine. Women with preeclampsia will often also have swelling in the feet, legs, and hands. Preeclampsia, when present, usually appears during the second half of pregnancy, generally in the latter part of the second or in the third trimesters, although it can occur earlier. What Is Eclampsia?
Eclampsia is the final and most severe phase of preeclampsia and occurs when preeclampsia is left untreated. In addition to the previously mentioned signs of preeclampsia, women with eclampsia often have seizures. Eclampsia can cause coma and even death of the mother and baby and can occur before, during, or after childbirth. What Causes Preeclampsia and Eclampsia?
The exact causes of preeclampsia and eclampsia are not known, although some researchers suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible causes. Who Is at Risk for Preeclampsia?
Preeclampsia is most often seen in first-time pregnancies and in pregnant teens and women over 40. Other risk factors include:
•
A history of high blood pressure prior to pregnancy.
• • • • •
Previous history of preeclampsia. A history of preeclampsia in mother or sisters. Obesity prior to pregnancy. Carrying more than one baby. History of diabetes, kidney disease, lupus, or rheumatoid arthritis.
What are the Signs of Preeclampsia?
In addition to swelling, protein in the urine, and high blood pressure, symptoms of preeclampsia can include:
• • • • • • •
Rapid weight gain caused by a significant increase in bodily fluid Abdominal pain Severe headaches A change in reflexes Reduced output of urine or no urine Dizziness Excessive vomiting and nausea
Does Swelling Mean I Have Preeclampsia During Pregnancy?
Some swelling is normal during pregnancy. However, if the swelling doesn't go away with rest and is accompanied by some of the above symptoms, be sure to see your doctor right away. How Can Preeclampsia Affect My Baby?
Preeclampsia can prevent the placenta from receiving enough blood, which can cause your baby to be born very small. It is also one of the leading causes of premature premature births and the difficulties that can accompany them, including learning disabilities, epilepsy, cerebral palsy, and hearing and vision problems. What Is the Treatment for Preeclampsia and Eclampsia?
The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild preeclampsia (blood pressure greater than 140/90 that occurs after 20 weeks of gestation in a woman who did not have hypertension before; and/or having a small amount of protein in the urine can be managed with careful hospital or in-home observation along with activity restriction. If the baby is pre-term, the condition can be managed until your baby can be safely delivered. Your health care provider may prescribe bed rest, hospitalization, or medication to prolong the pregnancy and increase your unborn baby's chances of survival. If your baby is close to term, labor may be induced.
The treatment for more severe preeclampsia (having vision problems, lung problems, abdominal pain, fetal distress, or other signs and symptoms) may require more emergent treatment -- delivery of the baby -- irrespective of the baby's age. Other treatments include:
• •
Magnesium can be injected into the veins to prevent eclampsia-related seizures. Hydralazine or another antihypertensive drug to manage severe elevations of blood pressure. • Monitoring fluid intake.
CARDIOVASCULAR CARDIOV ASCULAR SYSTEM INTRODUCTION
The The
card cardio iova vasc scul ular ar/c /cir ircu cula lato tory ry
system transports food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include: blood:: consis consistin ting g of liquid liquid plasma plasma • blood and cells
•
Blood vessels (vascular system): the "channels"
(arteries,
veins,
capillaries) which carry blood to/from all all tiss tissue ues. s. (Arteries carry carry blood blood away away from from the heart heart.. Veins return blood blood to the heart heart.. Capillaries are thin-wall thin-walled ed blood blood vessels vessels in which which gas/ nutrient/ waste exchange occurs.)
•
heart:: a muscular pump to move the blood heart There are two circulatory "circuits": Pulmonary circulation, circulation , involving the "right heart," delivers
blood to and from the lungs. The pulmonary artery carries oxygen- poor blood from the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen- rich blood from tbe lungs back to the "left heart." Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter the sytem from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena c avae. A specialized component of the circulatory system is the lymphatic system, system, consisting of a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, nodes , and organs ( bone marrow, marrow,
liver , spleen spleen,, thymus thymus). ). Through the flow of blood in and out of arteries, and into the veins, and through through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion.
BLOOD COMPONENTS
Adults have up to ten pints of blood.
•
Forty-fiv Forty-fivee percent percent (45%) (45%) consists consists of cells cells - platelets, red blood cells, cells, and white blood cells (neutrophils neutrophils,, basophils basophils,, eosinophils,, lymphocytes eosinophils lymphocytes,, monocytes monocytes). ). Of the white blood cells, neutrophils and lymphocytes are the most important.
Fifty-fiv fivee percen percentt (55%) (55%) consis consists ts of plasma plasma,, the the liqu liquid id 1. Fiftycomponent of blood.
MAJOR BLOOD COMPONENTS Component Type
Source
Function
Platelets, cell fragments
Bone marrow life-span: 10 days
Blood clotting
Lymphocytes (leukocytes)
Bone marrow, spleen,, lymph spleen nodes
Immunity T-cells attack cells containing viruses. B-cells B-cells produce produce antibodies antibodies..
erythrocytes), ), Filled with Red blood cells (erythrocytes hemoglobin,, a compound of iron and protein hemoglobin
Bone marrow life-span: 120 days
Oxygen transport
Neutrophil (leukocyte)
Bone marrow
Phagocytosis
Plasma , consisting consisting of 90% water and 10% dissolved materials -- nutrients (proteins, salts, glucose), wastes (urea, creatinine), hormones, enzymes
1. Main Mainte tena nanc ncee of of pH pH lev level el near 7.4 2. Tran Transp spor ortt of of lar large ge molecules (e.g. cholesterol) 3. Immu Immuni nity ty (glo (globu buli lin) n) 4. Blood Blood clott clotting ing (fibri (fibrino nogen gen))
VASCULAR SYSTEM - THE BLOOD VESSELS Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout
the body with with a web-like web-like network network of capillaries capillaries connectin connecting g them. them. Arterie Arteriess use vessel size, control controlled led by the sympathe sym pathetic tic nerv nervous ous syst system em,, to move move blood blood by press pressure ure;; veins veins use use one-w one-way ay valve valvess contr controll olled ed by muscle muscle contractions.
Arteries
Arteries strong, strong,
elastic elastic
are
vessels vessels adapted adapted
for carrying blood away from the heart at relatively high pumping pumping pressure. Arteries divide into progressively progressively arterioles.. Blood in arteries is oxygen-rich, with the thinner tubes and eventually become fine branches called arterioles exception of the pulmonary the pulmonary artery, artery, which carries blood to the lungs to be oxygenated.
The aorta is the largest artery in the body, the main artery for systemic circulation. circulation . The major branches of the aorta (aortic (aortic arch, ascending aorta, aorta , descending aorta) aorta) supply blood to the head, abdomen, and extremities. Of special importance importance are the right and left coronary arteries that supply blood to the heart itself.
MAJOR BRANCHES OF SYSTEMIC CIRCULATION Name
Serves
Head
Carotid
Brain & skull
Abdomen
Mesenteric Celiac (Abdominal (Abdominal)) Renal Iliac
Intestines Stomach, liver , spleen Kidney Pelvis
Upper Extremity
Brachial (axillary) Radial & Ulnar Dorsal Carpal
Upper arm Forearm & hand Fingers
Lower Extremity
Femoral Popliteal Dorsal pedis Posterior tibial
Thigh Leg Foot Foot
Capillaries
The arterioles branch into the microscopic capillaries capillaries,, or capillary beds, which lie bathed in system . Capillaries are the points of exchange interstitial fluid, or lymph, produced by the lymphatic system.
between the blood and surrounding tissues. Materials cross in and out
the capillaries by passing through or between the cells that line the capillary. The extensive network of capillaries is estimated at between 50,000 and 60,000 miles long.
Three types of capillaries can be distinguished based on features of
ethe endothelium.
1. Continuous capillaries -- are formed by "continuous" endothelial cells and basal lamina. The endothelial cell and the basal lamina do not form openings, which would allow substances to pass the capillary wall without passing through both the endothelial cell and the basal lamina. Both Both endoth endotheli elial al cells cells and the the basal basal lamina lamina can act as select selective ive filter filterss in contin continuou uouss capillaries. Fenestrated trated capi capillari llaries es -- The The endo endoth thel elia iall cell cell body body form formss small openings openings called called 2. Fenes
which allow allow compon component entss of the blood blood and inters interstit titial ial fluid fluid to bypass bypass the fenestrations, which endo endoth thel elia iall cells cells on thei theirr way way to or from from the the tiss tissue ue surr surrou ound ndin ing g the the capi capill llar ary. y. The The fenestrations may represent or arise from pinocytotic vesicles which open onto both the luminal and basal surfaces of the cell. The extent of the fenestration may depend on the physiological state of the surrounding tissue, i.e. fenestration may increase or decrease as a functi function on of the need to absorb absorb or secret secrete. e. The endothe endothelia liall cells cells are surround surrounded ed by a continuous basal lamina, which can act as a selective filter.
3. Discontinuous capillaries -- are formed by fenestrated endothelial cells, which may not even form a complete layer of cells. The basal lamina is also incomplete. Discontinuous capillaries form large irregularly shaped vessels, sinusoids or sinusoid sinusoid capillaries. They are found where a very very free free exchan exchange ge of substa substance ncess or even even cells cells betwee between n bloods bloodstre tream am and organ organ is advantageous (e.g. in the liver, spleen, and red bone marrow). Veins
Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules, which in turn unite to form veins veins.. Veins are responsible for returning blood to the heart after the blood
of
and the body cells exchange gases, nutrients, and wastes. Pressure in veins is low, so veins depend on nearby muscular contractions to move blood along. Veins have valves that prevent back-flow of blood. Blood Blood in veins veins is oxygen oxygen-po -poor, or, with the the except exception ion of the the pulmonar pulmonary y vein veinss, whic which h carr carry y oxygenated blood from the the lungs back to the heart. The major veins, like their companion companion arteries, often take the name of the organ served. The exceptions are the superior vena cava and the inferior vena cava, cava , which collect body from all parts of the body (except from the lungs) and channel it back to the heart. Artery/Vein Tissues
Arteries and veins have the same three tissue layers, but the proportions of these layers differ. The innermost is the intima; next comes the media; and the outermost is the adventitia. Arteries have thick media to absorb the pressure waves created by the heart's pumping. The smooth-muscle media walls expand when pressure surges, then snap back to push the blood forward when the the heart rests. Valves in the arteries prevent prevent back-flow. As blood enters the capillaries, the pressure falls off. By the time blood reaches the veins, there is little pressure. Thus, a thick media is no longer needed. Surrounding muscles act to squeeze the blood along veins. As with arteries, valves are again used to ensure flow in the right direction.
ANATOMY OF THE HEART
The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of the chest midline the heart, along with the pulmonary (to and from the lungs) and systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated blood. Internally, the heart is divided into four hollow chambers, two on the left and two on the right. The upper chambers of the heart, the atria (singular: atrium), receive blood via veins. Passing through valves (atrioventricular (atrioventricular (AV) valves), valves) , Blood then enters the lower chambers, the ventricles. Ventricular contraction forces blood into the arteries . Oxygen-poor blood empties into the right atrium via the superior and inferior vena cavae. Blood then passes through the tricuspid valve into the right ventricle which contracts, propelling the blood into the pulmonary artery. The pulmonary The pulmonary artery is the only only artery that carries oxygen-poor oxygen-poor blood. blood. It branches to the right and left lungs. There, gas exchange occurs -- carbon dioxide diffuses out, oxygen diffuses in.
Pulmonary veins, the only veins that carry oxygen-rich blood, now carry the oxygenated blood from lungs to the left atrium of the heart. Blood passes through through the bicuspid (mitral) valve into the left ventricle. The ventricle contracts, sending blood under high pressure through the aorta, the main artery for systemic circulation. The ascending aorta carries blood to the upper body; the descending aorta, to the lower body.
℘
Basic Parts and their functions o
Coronary Arteries
Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue. The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries arteries:: the left anterior anterior descendin descending g coronary coronary artery and the left circumflex circumflex coronary coronary artery. artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger larger vessels vessels travel along along the surface of the heart; however, however, the smaller branches branches penetrat penetratee the heart muscle. The smallest branches, called capillaries, capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver. When When cholester cholesterol ol plaque accumulates accumulates to the point of blocking blocking the flow of blood blood through through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack.
o
Superior Vena Cava
The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart.
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Inferior Vena Cava
The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart.
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Aorta
The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.
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Pulmonary Artery
The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.
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Pulmonary Vein
The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart.
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Right Atrium
The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated de-oxygenated blood collected in the right atrium to flow into the right ventricle.
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Right Ventricle
The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve valve leading leading into the pulmonary pulmonary artery is closed, closed, allowing allowing the ventricle ventricle to fill with blood. Once the ventricl ventricles es are full, they contract. contract. As the right right ventricl ventriclee contrac contracts, ts, the tricuspid tricuspid valve valve closes closes and the pulmonar pulmonary y valve valve opens. opens. The closure closure of the tricuspid tricuspid valve prevents prevents blood blood from backing backing into the right right
atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs.
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Left Atrium
The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle.
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Left Ventricle
The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.
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Papillary Muscles
The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary muscles relax, the valves close.
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Chordae Tendineae
The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings."
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Tricuspid Valve
The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the deoxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contract contracts, s, preventin preventing g blood blood from from returnin returning g to the right right atrium; atrium; thereby, thereby, forcing forcing it to exit through through the pulmonary valve into the pulmonary artery. artery.
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Mitral Value
The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta.
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Pulmonary Valve
o
The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart.
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Aortic Valve
The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.
BLOOD PRESSURE AND HEART RATE
The heart beats or contracts around 70 times per minute. The human heart will undergo over 3 billion contraction/cardiac cycles during a normal lifetime. One One heart heartbea beat, t, or cardiac cardiac cycle, cycle, inclu includes des atrial atrial contra contracti ction on and relaxation, ventricular contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice versa. Heart valves open and close to limit flow to a single direction. The sound of the heart contracting and the valves opening and closing produces a characteristic "lub-dub" sound. The cardiac cycle consists of two parts: systole (contraction of the heart muscle in the ventricles) and diastole (relaxation of the ventricular heart muscles). When the ventricles contract, they force the blood from their chambers into the arteries leaving the heart. The left ventricle empties into the aorta (systemic circuit) and the right ventricle into the pulmonary artery (pulmonary circuit). The increased
pressure on the arteries due to the contraction of the ventricle ventricless (heart (heart pumping) pumping) is called called systolic
pressure. When the ventricles relax, blood flows in from the atria. The decreased pressure due to the relaxation of the ventricles (heart resting) is called diastolic pressure.
Blood pressure is measured in mm of mercury, with the systole in ratio to the diastole. Healthy young adults should have a ventricular systole of 120mm, and 80mm at ventricular diastole, or 120/80. Receptors in the arteries and atria sense systemic pressure. Nerve messages from these sensors communicate conditions to the medulla in the brain. Signals from the medulla regulate blood pressure.
THE LYMPHATIC SYSTEM
The lymphatic system functions 1) to absorb excess fluid, thus preventing tissues from swelling; 2) to defend the body against microorganisms and harmful foreign particles; and 3) to facilitate the absorption of fat (in the villi of the small intestine). intestine ). Capillaries release excess water and plasma into intracellular spaces, where they mix with lymph, or interstitial fluid. "Lymph" is a milky body fluid that also contains proteins, fats, and a type of white blood cells, called "lymphocytes," which are the body's first-line defense in the immune system. system. Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in having valves that prevent backflow. Contraction of skeletal muscle causes movement of the lymph fluid through valves. Lymph vessels connect to lymph nodes, nodes , lymph organs ( bone marrow, marrow , liver , spleen spleen,, thymus thymus), ), or to the cardiovascular system.
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Lymph nodes are small irregularly shaped masses through which lymph vessels flow. Clusters of nodes occur in the armpits, groin, and neck . All lymph nodes have the primary function (along with bone marrow) of producing lymphocytes.
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The spleen filters, or purifies, the blood and lymph flowing through it.
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The thymus secretes a hormone, thymosin that produces T-cells, a form of lymphocyte.
PATHOPHYSIOLOGY OF HYPERTENSION
pressure ) is a disease of vascular regulation resulting from malfunction Hypertension (high blood pressure) of arterial pressure control mechanisms ( central nervous system, rennin-angiotensinaldosterone rennin-angiotensinaldosterone system, extracellular fluid volume.) the cause is unknown, and there is no cure. The basic explanation is that blood pressure is elevated when there is increased cardiac output plus increased peripheral vascular resistance. The two major types of hypertension are primary (essential) hypertension, in which diastrolic pressure is 90 mm Hg or higher and systolic pressure is 140 mm Hg or higher in absence of other causes of hypertension (approximately 95 % of patients); and Secondary hypertension, which results primarily from renal disease, endocrine disorders, and coarctation of the aorta. Either of these conditions may give rise to accelerated hypertension – a medical emergency – in which blood pressure elevates very rapidly to threaten one or more of the target organs: the brain, kidney, or the heart. Hypertension is one of the most prevalent chronic diseases for which treatment is available; however, most patients with hypertension are unaware, untreated, or inadequately treated. Risk factors for hypertens hypertension ion are age between 30 and 70; black; black; overweigh overweight; t; sleep apnea; family history; history; cigarette cigarette smoking; sedentary lifestyle; and diabetes mellitus. Because hypertension presents no over symptoms, it is termed the “silent killer.” The untreated disease may progress to retinopathy, renal failure, coronary artery disease, heart failure, and stroke. Hypertension in children is defined as the average systolic or diastolic blood pressure greater than or equal to the 95 th percen percentil tilee for age and sex with with measur measureme ement nt on at lease lease three three occasi occasion ons. s. The The incidence of hypertension in children is low, but it is increasingly being recognized in adolescents; and it may occur in neonates, infants, and young children with secondary causes.
Anatomy and Physiology
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Vagina: A muscular passageway that leads from the vulva (external genitalia) to the
cervix.
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Cervix: A small hole at the end of the vagina through which sperm passes into the
uterus. Also serves as a protective barrier for the uterus. During childbirth, the cervix
dilates (widens) to permit the baby to descend from the uterus into the vagina for birth.
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Uterus: A hollow organ that houses the baby during pregnancy. During childbirth, the
uterine muscles contract to push out the baby. Each month, unless a fetus has been conceived, the uterine wall sheds its lining ( see The Menstrual Cycle and Ovulation below). below).
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Ovaries: Two organs that produce hormones and store eggs. Each ovary releases one
egg per month.
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Fallopian tubes: Muscular tubes that eggs released from the ovaries must traverse to
reach the uterus.
The Menstrual Cycle and Ovulation
Each month a woman’s body goes through a menstrual cycle. A woman can become pregnant only during ovulation, a several-day phase in the middle of the menstrual cycle when one of the ovaries releases an egg.
If the ovulated egg is fertilized by a man’s sperm following sexual intercourse, it will impl implant ant in the endometrium, the the lini lining ng of the the uter uterus us that that beco become mess the the placenta during pregnancy. The placenta nurtures the fertilized egg as it develops and grows into a baby.
Female Anatomy
Events 1st Trimester
Weeks of Pregnancy
The woman's last period before fertilization occurs.
0
Fertilization occurs.
2
The fertilized egg (zygote) begins to develop into a hollow ball of cells called the blastocyst. The blastocyst implants in the wall of uterus.The amniotic sac begins to form.
3
The area that will become the brain and spinal cord (neural tube) begins to develop.
5
The heart and major blood vessels are developing. The beating heart can be seen during ultrasonography.
6
The beginnings of arms and legs appear.
7
Bones and muscles form. The face and neck develop.
9
Brain waves can be detected. The skeleton is formed. Fingers and toes are fully defined. The kidneys begin to function. Almost all organs are completely formed. The fetus can move and respond to touch (when prodded through the woman's abdomen). The woman has gained some weight, and her abdomen may be slightly enlarged. 2nd Trimester
10
The fetus's sex can be identified.
14
The fetus can hear. The fetus's fingers can grasp. The fetus moves more vigorously, so that the mother can feel it.
16
The fetus's body begins to fill out as fat is deposited beneath the skin. Hair appears on the head and skin. Eyebrows and eyelashes are present. The placenta is fully formed.
20
The fetus has a chance of survival outside the uterus.
24
The woman begins to gain weight more rapidly. 3rd Trimester
The fetus is active, changing positions often.
25
The lungs continue to mature. The fetus's head moves into position for delivery. On average, the fetus is about 20 inches long and weighs about 7 pounds. The woman's enlarged abdomen causes the navel to bulge.
Delivery
37-42
MEDICAL MANAGEMENT AND NURSING INTERVENTION
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Medical management
1. The pharma pharmacolo cological gical therapy therapy inclu includes des the the follow following: ing:
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Amoxicillin (antibiotic) (antibiotic) 500 mg cap BID x 7 days
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Mefenamic Acid 500 mg cap BID as needed
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Ferrous Sulfate 1 cap OD x 30 days
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Methyllergometrine Methyllergometrine 1 tab BID
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Magnesium Sulfate (anticonvulsant) 4g slow IV
2. The pharma pharmacolo cological gical therapy therapy for for inducing inducing diuresis diuresis is: is:
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5% Dextrose in Lactated Ringer's
3. Recommende Recommended d for low fat fat low salt salt diet diet because because of high high blood blood pressure. pressure. 4. Advise Advise to massag massagee her her uteru uterus. s. 5. Advise Advise to remain remain on drug drug therapy therapy to cont control rol blood blood pressur pressure. e.
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Nursing consideration
1. Moni Monito torr vit vital al sign signss q4h q4h 2. Admini Administe sterr medica medicatio tions ns as pres prescri cribed bed 3. Reco Record rd urin urinee out outpu putt 4. Prov Provid idee healt health h educ educat atio ion: n:
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Advised patient to massage uterus
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Advised patient to massage and apply warm compress on the breast
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Decrease fluid intake
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Advised patient to elevate lower extremities and apply warm compress on edema
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Encouraged to decrease sodium intake
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Advised patient to complete immunization on time
Predisposing Factors • Age (<20, >35 years old) • Race • Family History of Hypertension
Etiologic Factor • Unknown
Precipitating Factors • Sedentary Lifestyle • Poor Diet
↑ BP – vasospasm
Decreased placental perfusion
Endothelial cell activation
Vasoconstriction
Activation of coagulation of cascade
Intravascular fluid redistribution
Decreased organ perfusion
Generalized vasoconstriction Decreased placental perfusion
Placental production of endothelin
Utero lacental lacental arteriol arteriolee lesions lesions
Glomer Glomerula ularr dama dama ed
Endothelial cell damage Vasospasms
H
ertension
IUGR Abruptio placenta Increased uterine contractility Proteinuria Increased plasma uric acid and creatinine Oliguria Increased sodium retention
Generalized Edema
Visual edema of face, hands, and abdomen Fixing edema alter 12 hours of bed rest
Cortica Corticall brain brain s asms asms
Headache Hyperreflexia Seizure activity
Increased thromboxane to prostacyclin Increased sensitivity to angiotensin II Decreased nitric oxide
Pulmo Pulmonar nar edema edema
Fluid shifts from Intravascular to intracellular space
Retina Retinall arteriol arteriolar ar s asms asms
Dyspnea Blurred vision Scotoma
Generalized vasoconstriction Decreased placental perfusion
Placental production of endothelin
Utero lacental lacental arteriol arteriolee lesions lesions
Glomer Glomerula ularr dama dama ed
Endothelial cell damage Vasospasms
Increased thromboxane to prostacyclin Increased sensitivity to angiotensin II Decreased nitric oxide Fluid shifts from Intravascular to intracellular space (Decreased plasma volume) (Increased hematocrit) Increased endothelin
H
ertension
IUGR Abruptio placenta Increased uterine contractility Proteinuria Increased plasma uric acid and creatinine Oliguria Increased sodium retention
Generalized Edema
Visual edema of face, hands, and abdomen Fixing edema alter 12 hours of bed rest
Cortica Corticall brain brain s asms asms
Headache Hyperreflexia Seizure activity
Pulmo Pulmonar nar edema edema
Dyspnea
Retina Retinall arteriol arteriolar ar s asms asms
Blurred vision Scotoma
Hemolysis of RBC
Decreased Hemoglobin Maternal hyperbilirubinemia
Intravascular coagulation Hepatic microemboli; Liver damage
Elevated liver enzymes (AST and LDH) Nausea and vomiting Epigastric pain Right upper quadrant pain Decreased blood glucose Liver rupture
Platelet Platelet aggregatio aggregation n and fibrin deposition
Low platelet count (Thrombocytopenia)-DIC
DRUG
USES
It is a penicillin-type antibiotic used to treat a wide variety of bacterial infections. It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. It will not work for viral infections (e.g., common cold, flu).
DOSAGE
Take this medication by mouth with or without food, usually every 8 or 12 hours, or as directed by your doctor. The dosage is based on your medical condition and response to therapy.
SIDE-EFFECTS
Amoxicillin
Nausea, vomiting or diarrhea may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly It can commonly cause a mild rash that is usually not serious. However, you may not be able to tell it apart from a rare rash that could be a sign of a severe allergic reaction. Therefore, seek immediate medical attention if you develop any rash. Tell your doctor immediately if any of these highly unlikely but very serious side
PRECAUTIONS
Before taking amoxicillin, tell your doctor or pharmacist if you are allergic to it; or to penicillin or cephalosporin antibiotics; or if you have any other allergies. Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney disease, a certain type of viral infection (infectious mononucleosis). This medication should be used only when clearly needed during pregnancy. Discuss the
DRUG
USES
It is a penicillin-type antibiotic used to treat a wide variety of bacterial infections. It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. It will not work for viral infections (e.g., common cold, flu).
DOSAGE
Take this medication by mouth with or without food, usually every 8 or 12 hours, or as directed by your doctor. The dosage is based on your medical condition and response to therapy.
SIDE-EFFECTS
Amoxicillin
Ferrous Sulfate
It is an iron supplement used to treat or prevent low blood levels of iron (e.g., for anemia or during pregnancy). Iron is an important mineral that the body needs to produce red blood cells and keep you in good health.
Follow all directions on the product package, or take as directed by your doctor. Do not take more than the recommended dosage. If you are uncertain about any of the information, consult your doctor or pharmacist. This medication is best taken on an empty stomach 1 hour before or 2 hours after meals. Take with a full glass of water (8 ounces or 240 milliliters) unless your doctor directs you otherwise. If stomach upset occurs, you may take this medication with food. Avoid taking antacids, dairy products, tea, or coffee within 2 hours before or
Nausea, vomiting or diarrhea may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly It can commonly cause a mild rash that is usually not serious. However, you may not be able to tell it apart from a rare rash that could be a sign of a severe allergic reaction. Therefore, seek immediate medical attention if you develop any rash. Tell your doctor immediately if any of these highly unlikely but very serious side effects occur: dark urine, persistent nausea or vomiting, stomach/abdominal pain, yellowing eyes or skin, easy bruising or bleeding, persistent sore throat or fever.
Constipation, diarrhea, stomach cramps, or upset stomach may occur. These effects are usually temporary and may disappear as your body adjusts to this medication. If any of these effects persist or worsen, contact your doctor or pharmacist promptly.
PRECAUTIONS
Before taking amoxicillin, tell your doctor or pharmacist if you are allergic to it; or to penicillin or cephalosporin antibiotics; or if you have any other allergies. Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney disease, a certain type of viral infection (infectious mononucleosis). This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor.
Before taking this medication, tell your doctor or pharmacist if you are allergic to it; or to tartrazine; or if you have any other allergies. This medication should not be used if you have certain medical conditions. Before taking this medication, consult your doctor or pharmacist if you have: iron overload disorder (e.g., hemochromatosis, hemosiderosis). During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.
Ferrous Sulfate
It is an iron supplement used to treat or prevent low blood levels of iron (e.g., for anemia or during pregnancy). Iron is an important mineral that the body needs to produce red blood cells and keep you in good health.
Follow all directions on the product package, or take as directed by your doctor. Do not take more than the recommended dosage. If you are uncertain about any of the information, consult your doctor or pharmacist. This medication is best taken on an empty stomach 1 hour before or 2 hours after meals. Take with a full glass of water (8 ounces or 240 milliliters) unless your doctor directs you otherwise. If stomach upset occurs, you may take this medication with food. Avoid taking antacids, dairy products, tea, or coffee within 2 hours before or after this medication because they will decrease its effectiveness. Do not lie down for 30 minutes after taking this medication. If you are taking a timerelease tablet or capsule, it must be swallowed whole. Do
Constipation, diarrhea, stomach cramps, or upset stomach may occur. These effects are usually temporary and may disappear as your body adjusts to this medication. If any of these effects persist or worsen, contact your doctor or pharmacist promptly.
Before taking this medication, tell your doctor or pharmacist if you are allergic to it; or to tartrazine; or if you have any other allergies. This medication should not be used if you have certain medical conditions. Before taking this medication, consult your doctor or pharmacist if you have: iron overload disorder (e.g., hemochromatosis, hemosiderosis). During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.
not crush, chew, or break the tablet or capsule. Doing so can destroy the long action of the drug and may increase side effects.
Mefenamic Acid
Mefenamic acid is used for the shortterm treatment of mild to moderate pain from various conditions. It is also used to decrease pain and blood loss from menstrual periods. Mefenamic acid is known as a nonsteroidal antiinflammatory drug (NSAID).
Dosage is based on your medical condition and response to therapy. To reduce your risk of stomach bleeding and other side effects, take this medication at the lowest effective dose for the shortest possible time. Do not increase your dose, take it more frequently, or take it for a longer time than prescribed. This medication usually should not be taken for more than 7 days at a time. If you are taking this
Upset stomach, nausea, heartburn, dizziness, drowsiness, diarrhea, and headache may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Tell your doctor immediately if any of these unlikely but serious side effects occur: fainting, persistent/severe headache, hearing changes (e.g., ringing in the ears), fast/pounding heartbeat,
Before taking mefenamic acid, tell your doctor or pharmacist if you are allergic to it; or to aspirin or other NSAIDs (e.g., ibuprofen, naproxen, celecoxib); or if you have any other allergies. Before using this medicine, consult your doctor or pharmacist if you have: aspirinsensitive asthma (a history of worsening breathing with runny/stuffy nose after taking aspirin or other
not crush, chew, or break the tablet or capsule. Doing so can destroy the long action of the drug and may increase side effects.
Mefenamic Acid
Mefenamic acid is used for the shortterm treatment of mild to moderate pain from various conditions. It is also used to decrease pain and blood loss from menstrual periods. Mefenamic acid is known as a nonsteroidal antiinflammatory drug (NSAID).
Dosage is based on your medical condition and response to therapy. To reduce your risk of stomach bleeding and other side effects, take this medication at the lowest effective dose for the shortest possible time. Do not increase your dose, take it more frequently, or take it for a longer time than prescribed. This medication usually should not be taken for more than 7 days at a time. If you are taking this drug on an "as needed" basis (not on a regular schedule), remember that pain medications work best if they are used as the first signs of pain occur. If you wait until the symptoms have worsened, the medicine may not
work as well. If you are using this medication for painful periods, take your first dose as soon as your period starts or pain begins. Usually, you will only need to take it for the first 2 to 3 days of your period.
Upset stomach, nausea, heartburn, dizziness, drowsiness, diarrhea, and headache may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Tell your doctor immediately if any of these unlikely but serious side effects occur: fainting, persistent/severe headache, hearing changes (e.g., ringing in the ears), fast/pounding heartbeat, mental/mood changes, stomach pain, difficult/ painful swallowing, swelling of the ankles/feet/hands, sudden/unexplained weight gain, vision changes. Stop taking mefenamic acid and tell your doctor immediately if
any of these rare but very serious side effects occur: easy bruising/bleeding, signs of infection (e.g., fever, persistent sore throat), unexplained stiff neck, change in the amount/color of urine. This drug may rarely cause serious, possibly fatal liver disease. If you notice any of the following rare but very serious side effects, stop taking mefenamic acid and consult your doctor or pharmacist immediately: persistent nausea/vomiting, severe stomach/abdominal pain, extreme/unusual tiredness, weakness, dark urine, yellowing eyes/skin.
Before taking mefenamic acid, tell your doctor or pharmacist if you are allergic to it; or to aspirin or other NSAIDs (e.g., ibuprofen, naproxen, celecoxib); or if you have any other allergies. Before using this medicine, consult your doctor or pharmacist if you have: aspirinsensitive asthma (a history of worsening breathing with runny/stuffy nose after taking aspirin or other NSAIDs, severe kidney disease, recent heart bypass surgery (CABG), active bleeding/sores in stomach/intestines (ulcer, gastrointestinal bleeding). This drug may make you dizzy or drowsy This medicine may
cause stomach bleeding. Daily use of alcohol and tobacco, especially when combined with this medicine, may increase your risk for stomach bleeding. Limit alcohol and stop smoking. During the first 6 months of pregnancy, this medication should be used only when clearly needed. It is not recommended for use during the last 3 months of pregnancy due to possible harm to the unborn baby and interference with normal labor/delivery. Discuss the risks and benefits with your doctor. This drug may pass into breast milk and could have undesirable
work as well. If you are using this medication for painful periods, take your first dose as soon as your period starts or pain begins. Usually, you will only need to take it for the first 2 to 3 days of your period.
any of these rare but very serious side effects occur: easy bruising/bleeding, signs of infection (e.g., fever, persistent sore throat), unexplained stiff neck, change in the amount/color of urine. This drug may rarely cause serious, possibly fatal liver disease. If you notice any of the following rare but very serious side effects, stop taking mefenamic acid and consult your doctor or pharmacist immediately: persistent nausea/vomiting, severe stomach/abdominal pain, extreme/unusual tiredness, weakness, dark urine, yellowing eyes/skin. A very serious allergic reaction to this drug is rare. However, stop taking mefenamic acid and immediately seek medical attention if you notice any of the following symptoms of a serious allergic reaction: rash/blisters, itching/swelling
cause stomach bleeding. Daily use of alcohol and tobacco, especially when combined with this medicine, may increase your risk for stomach bleeding. Limit alcohol and stop smoking. During the first 6 months of pregnancy, this medication should be used only when clearly needed. It is not recommended for use during the last 3 months of pregnancy due to possible harm to the unborn baby and interference with normal labor/delivery. Discuss the risks and benefits with your doctor. This drug may pass into breast milk and could have undesirable effects on a nursing infant. Therefore, breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.
(especially of the face/tongue/throat), severe dizziness, trouble breathing.
Methylergometrine
This medication is used to help stop bleeding after delivery of the placenta in childbirth. Methylergonovine maleate belongs to a class of drugs known as ergot alkaloids. It works by increasing the stiffness of the uterus muscles after the last stage of labor. This effect decreases bleeding.
Take this medication by mouth without food, usually 3-4 times daily for a maximum of 1 week or as directed by your doctor. Dosage is based on your medical condition and response to therapy.
Headache, nausea, dizziness, or vomiting may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly. Tell your doctor immediately if any of these unlikely but serious side effects occur: leg cramps, ringing in the ears, stuffy nose, diarrhea, bad taste in the mouth. Tell your doctor immediately if any of these rare but very serious side effects occur: sweating, fast/irregular heartbeat, breathing problems,
Before taking methylergometrine, tell your doctor or pharmacist if you are allergic to it; or to similar ergot alkaloids (e.g., ergonovine); or if you have any other allergies. Before using this medication, tell your doctor or pharmacist your medical history, especially of: heart disease (e.g., venoatrial shunt, mitral valve stenosis), other complications during pregnancy (e.g., preeclampsia, eclampsia), a serious blood infection (sepsis),
(especially of the face/tongue/throat), severe dizziness, trouble breathing.
Methylergometrine
This medication is used to help stop bleeding after delivery of the placenta in childbirth. Methylergonovine maleate belongs to a class of drugs known as ergot alkaloids. It works by increasing the stiffness of the uterus muscles after the last stage of labor. This effect decreases bleeding.
Take this medication by mouth without food, usually 3-4 times daily for a maximum of 1 week or as directed by your doctor. Dosage is based on your medical condition and response to therapy.
Headache, nausea, dizziness, or vomiting may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly. Tell your doctor immediately if any of these unlikely but serious side effects occur: leg cramps, ringing in the ears, stuffy nose, diarrhea, bad taste in the mouth. Tell your doctor immediately if any of these rare but very serious side effects occur: sweating, fast/irregular heartbeat, breathing problems, hallucinations. Seek immediate medical attention if this rare but very serious side effect occurs: chest pain.
Before taking methylergometrine, tell your doctor or pharmacist if you are allergic to it; or to similar ergot alkaloids (e.g., ergonovine); or if you have any other allergies. Before using this medication, tell your doctor or pharmacist your medical history, especially of: heart disease (e.g., venoatrial shunt, mitral valve stenosis), other complications during pregnancy (e.g., preeclampsia, eclampsia), a serious blood infection (sepsis), blood vessel problems (e.g., Raynaud's phenomenon, obliterative vascular disease), kidney problems, liver problems. This medication must not be used during pregnancy. It may harm an unborn baby.
This drug passes into breast milk
This drug passes into breast milk
Disseminated Dissemina ted intravascular coagulopathy Disseminated intravascular coagulation (DIC) is a complex systemic thrombohemorrhagic disorder involvi involving ng the generati generation on of intravas intravascula cularr fibrin fibrin and the consump consumptio tion n of procoag procoagula ulants nts and platelets.
Definition: The subcom subcommit mittee tee on DIC of the Interna Internatio tional nal Societ Society y on Thromb Thrombosi osiss and Hemost Hemostasi asiss has sugg sugges este ted d the foll follow owing ing defi definit nitio ion n for for DIC: DIC: "An "An acquir acquired ed syndr syndrom omee chara characte cteri rized zed by the intravascular activation of coagulation with loss of localization arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction"
Disseminated Dissemina ted intravascular coagulopathy Disseminated intravascular coagulation (DIC) is a complex systemic thrombohemorrhagic disorder involvi involving ng the generati generation on of intravas intravascula cularr fibrin fibrin and the consump consumptio tion n of procoag procoagula ulants nts and platelets.
Definition: The subcom subcommit mittee tee on DIC of the Interna Internatio tional nal Societ Society y on Thromb Thrombosi osiss and Hemost Hemostasi asiss has sugg sugges este ted d the foll follow owing ing defi definit nitio ion n for for DIC: DIC: "An "An acquir acquired ed syndr syndrom omee chara characte cteri rized zed by the intravascular activation of coagulation with loss of localization arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction"
Acute and chronic forms DIC is a pathophysiologic term describing a continuum of events that occur in the coagulation pathway in association with a variety of disease states. DIC occurs in acute and chronic forms.
Pathophysiology: The pathophysiology of DIC involves the initiation of coagulation via endothelial injury or tissue injury and the subsequent release of procoagulant material in the form of cytokines and tissue factors. factors. Interleukin-6 Interleukin-6 and tumor necrosis factor may be the most influential cytokines involved in coagulation activation (via tissue factor) and may be responsible for the end-organ damage that occurs. Further, in the setting of sepsis, neutrophils and their secretory products may promote platelet-mediated fibrin formation.
Signs and symptoms The affected person is often acutely ill and shocked with widespread haemorrhage (common bleedin bleeding g sites sites are mouth, mouth, nose nose and venipunc venipuncture ture sites) sites),, extensiv extensivee bruisin bruising, g, renal renal failur failuree and gangrene. The onset of DIC can be fulminant, fulminant, as in endotoxic shock or amnioitic fluid embolism, or it may be insidious and chronic, as in cases of carcinomatosis or retention or retention of dead fetus fetus..
The mechanism of disseminated intravascular coagulation: Systemic activation Of coagulation
Intravascular deposition Of fibrin
Depletion of platelets And coagulation factors
Thrombosis of small Midsize vessels And organ failure
Bleeding
Causes DIC can occur in the following conditions:
• • • • •
Cancers of lung of lung,, pancreas, pancreas, prostate and stomach Obstetric: Obstetric: abruptio placentae, placentae, retained dead fetus, fetus, pre-eclampsia, pre-eclampsia, amniotic fluid embolism Massive tissue injury: Trauma, burns, extensive surgery Infections: Gram-negative sepsis, Neisseria sepsis, Neisseria meningitidis, Streptococcus pneumoniae, pneumoniae, malaria, histoplasmosis, histoplasmosis, aspergillosis, Rocky mountain spotted fever Miscellaneous: Liver disease, Liver disease, snake bite, bite, acute intravascular hemolysis, hemolysis, giant hemangioma, hemangioma, shock , heat stroke, stroke, vasculitis, vasculitis, aortic aneurysm, aneurysm, Serotonin syndrome
Treatment The only effective treatment is the reversal of the underlying cause. Anticoagulants are given exceedingly rarely when thrombus formation is likely to lead to imminent death (such as in coronary artery thrombosis or cerebrovascular thrombosis). Platelets may be transfused if counts are less than 5,000-10,000/mm3 and massive hemorrhage is occurring, and fresh frozen plasma may be administered in an attempt to replenish coagulation factors and anti-thrombotic factors,
although these are only temporizing measures and may result in the increased development of thrombosis. DIC results in lower fibrinogen lower fibrinogen levels (as it has all been converted to fibrin), and this can be tested for in the hospital lab. lab. A more specific test is for "fibrin split products" (FSPs) or " fibrin degradation products" products" (FDPs) which are produced when fibrin undergoes degradation when blood clots are dissolved by fibrinolysis. In some situations, infusion with antithrombin may be necessary.
DIC Consumption of coagulation factors
Deficiency of coagulation factors
Microvascular coagulation and fibrin deposition
Secondary fibrinolysis with FDP production
Haemorrhagic diathesis
Organ ischaemia
Microvascular obtruction
Hydatidiform Mole WHAT IS GESTATIONAL TROPHOBLASTIC DISEASE?
Gestational Trophoblastic Disease, existing in many terms like Hydatidiform Mole, is a condi conditi tion on associ associat ated ed with with secon second-t d-tri rime meste sterr bleed bleeding ing..
It is an abnor abnorma mall prol prolif ifer erati ation on and
degeneration of the trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles. With this condition, the embryo fails to develop beyond a primitive start. Such structures must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy. The incidence of gestational trophoblastic disease is approximately 1 in every 1,500 pregnancies.
Hydatidiform Mole WHAT IS GESTATIONAL TROPHOBLASTIC DISEASE?
Gestational Trophoblastic Disease, existing in many terms like Hydatidiform Mole, is a condi conditi tion on associ associat ated ed with with secon second-t d-tri rime meste sterr bleed bleeding ing..
It is an abnor abnorma mall prol prolif ifer erati ation on and
degeneration of the trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles. With this condition, the embryo fails to develop beyond a primitive start. Such structures must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy. The incidence of gestational trophoblastic disease is approximately 1 in every 1,500 pregnancies.
Two types of molar growth can be identified by chromosomal analysis: Complete Mole: Mole: All trophoblastic villi swell and become cystic. If an embryo forms, it dies early at only 1 to 2 mm in size, with no fetal blood present in the villi. On chromosomal analysis, although the karyotype is a normal 46XX or 46XY, this chromosome component was contributed only by a father or an “empty ovum” was fertilized and the chromosome material was duplicated (Fig. 1).
Sperm
Ovum 2
4 +
+ Duplication =
Fig. 1.Complete mole.
Partial Mole: Mole: With a partial mole, some some of the villi form normally. normally. The syncytiotrop syncytiotrophoblast hoblastic ic layer of the villi, however, is swollen and misshapen. A macerated embryo of approximately 9 weeks; gestation may be present in the villi. A partial mole has 69 chromosomes (a triploid formation in which there is three chromosomes instead of two for every pair, one set supplied by Sperm Ovum an ovum that apparently apparently was fertilized fertilized by two sperm or an ovum fertilized fertilized by one sperm in which meiosis or reduction division of 23 chromosomes 4 did not occur). 2This could also occur if one set 6 + = was supplied by one sperm and an ovum did not undergo reduction division supplied 46 (see Fig. or 2). In contrast to complete moles, partial moles rarely lead to choriocarcinoma. 2 +
+ 2
2
=
6
Fig. 2. Partial mole.
III. PREDISPOSING III. PREDISPOSING FACTORS
A. Diet: Diet: Low CHON and low Vitamin A (carotene) intake. B. Age: Women older than 35 years. GTD is higher toward the beginning and toward the end of child bearing period. It is ten times more in women who are 45 years old and beyond. C. Race: Asian heritage. Molar pregnancy has no racial or ethnic predilection, although Asian countries show a rate 15 times higher than the US rate.
IV . SIGNS AND SYMPTOMS
A. Symptoms: 1. amenorrhea 2. exaggerated symptoms of pregnancy especially vomiting 3. symptoms of preeclampsia that may be present as headache and edema 4. vaginal bleeding as the main complaint; due to the separation of vesicles from the uterine wall and there may be blood-stained, watery discharge (the watery part is from the ruptured vesicles)
• Prune juice-like juice-like discharge may occur brownish because it is retained for sometime sometime inside the uterine cavity.
• Blood may be concealed in the uterus, thereby causing enlargement.
5. abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by concealed hemorrhage; colicky due to start of expulsion 6. ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as torsion
B. Signs: 1. preeclampsia develops in 20 – 30 % cases, usually before 20 weeks’ AOG 2. pallor indicating anemia may be present 3. hyperthyroidism develops in 3-10% of cases manifested by enlarged thyroid gland and tachycardia (due to chorionic thyrotropin secreted by the trophoblast and hCG also has a thyroid-stimulating effect)
Nursing Management: Nursing Considerations:
•
A gynecologic oncologist should be consulted if the patient is believed to be at risk for or has developed malignant disease.
• No special diet is required. •
Patients may resume activity as tolerated.
•
Pelvic rest is recommended recommended for 4-6 weeks after evacuation of the uterus, uterus, and the patient is instructed not to become pregnant for 12 months. Adequate contraception is recommended during this period.
•
Monitor Monitor serial beta-HC beta-HCG G values values to identif identify y the rare rare patient patient who develop developss malign malignant ant disease. If a pregnancy does occur, the elevation in beta-HCG would be confused with development of malignant disease.
V. PATHOPHYSIOLOGY V. PATHOPHYSIOLOGY
Low intake of proteins and vitamin A, Asian heritage, Women Women older than 35 years
Partial mole or Complete mole
Chronic villi degenerates and become filled with fluid
No vasculature in chorionic villi
Absence of FHT
Early death & absorption of embryo
Trophoblastic Trophoblastic proliferation proliferation
High secretion of hCG
High progesterone
Uterus expands faster than normal
low estrogen
Abdominal pain
High chorionic thyrotropin
Marked nausea & vomiting
Amenorrhea
Decreased contraction
Hyperthyroidism Separation Separation of vesicles from uterine wall
Multiple theca lutein cysts in the ovaries
Enlarged thyroid gland; tachycardia Vaginal bleeding & discharge of vesicles
Ovarian pain Pallor
Preeclampsia
Note: Those inside the boxes end up as the signs & symptoms of H mole.
SCHIZOPHRENIA Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood.
Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. TYPES OF SCHIZOPHRENIA:
The diagnosis is made according to the client’s predominant symptoms:
•
• •
• •
Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations hallucinations,, and occasionally, excessively religiosity (delusional focus) or hostile and aggressive behavior. Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) flexibility) or stupor. undifferentiated tiated type is characterized by mixed schizophrenic symptoms Schizophrenia, undifferen (of other types) along with disturbances of thought, affect, and behavior. Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social withdrawal, flat affect and looseness of associations.
ANATOMY AND PHYSIOLOGY: Structure and function of the nervous system I. Structures
A. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of both central and peripheral elements. 1. The CNS is composed of the brain and spinal cord.
2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves. 3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. cord. Its peripheral division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia. B. The brain is covered by three membranes. 1. The dura matter is a fibrous, connective tissue structure containing several blood vessels. 2. The arachnoid membrane is a delicate serous membrane. 3. The pia matter is a vascular membrane. C. The spinal cord extends from the medulla oblongata to the lower border of the first lumbar vertebrae. vertebrae. It contains millions of nerve fibers, and it consists of 31 nerves – 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral. D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia matter. It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of Sylvius to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and the two foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the arachnoid membrane.
II. Function
A. CNS 1. Brain a The cerebrum is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and right) and four lobes, each with specific functions. i The frontal lobe controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses. ii The temporal lobe is the center for taste, hearing and smell, and in the brain’s dominant hemisphere, the center for interpreting spoken language.
iii The parietal lobe coordinates and interprets sensory information from the opposite side of the body. iv The occipital lobe interprets visual stimuli. b The thalamus further organizes cerebral function by transmitting impulses to and from the cerebrum. It also is responsible for primitive emotional responses, such as fear, and for distinguishing between pleasant and unpleasant stimuli. c Lying beneath the thalamus, the hypothalamus is an automatic center that regulates blood pressure, temperature, libido, appetite, breathing, sleeping patterns, and peripheral nerve discharges associated with certain behavior and emotional expression. It also helps control pituitary secretion and stress reactions. d The cerebellum or hindbrain, controls smooth muscle movements, coordinates sensory impulses with muscle activity, and maintains muscle tone and equilibrium.
e The brain stem, which includes the mesencephalon, pons, and medulla oblongata, relays nerve impulses between the brain and spinal cord.
2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do not involve brain control. B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord. C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS contains two divisions. 1. The sympathetic nervous system serves as an emergency preparedness system, the “flight-for-fight” response. Sympathetic impulses increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood vessels, stronger and faster heart contractions, peripheral blood
vessel constriction, decreased peristalsis, and increased perspiration increased perspiration.. Sympathetic stimuli are mediated by norepinephrine. 2. The parasympathetic The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic impulses are mediated by acetylcholine. TREATMENTS AND MEDICATIONS:
Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of disease depends mainly on early diagnosis and, appropriate pharmacological and psychosocial treatments. Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will minimize symptoms and maximize quality of life.
A comprehensive treatment program can include:
• • • • • •
Antipsychotic medication Education & support, for both ill individuals and families Social skills training Rehabilitation to improve activities of daily living Vocational and recreational support Cognitive therapy
Medication is one of the cornerstones of treatment.
Once the acute stage of a psychotic a psychotic episode has passed, most people with schizophrenia will need to take medicine indefinitely. This is because vulnerability to psychosis doesn’t go away, even though some or all of the symptoms do. In North America, atypical or second generation antipsychotic medications are the most widely used. However, there are many first-generation antipsychotic medications available that may still be prescribed. A doctor will prescribe the medication that is the most effective for the ill individual Another important part of treatment is psychosocial programs and initiatives. Combined with medication, they can help ill individuals effectively manage their disorder. Talking with your treatment team will ensure you are aware of all available programs and medications. In addition, persons living with schizophrenia may have access to or qualify for income support programs/initiatives, supportive housing, and/or skills development programs, designed to promote integration and recovery. NURSING INTERVENTIONS:
Strengthening differentiation
• • • • • •
Provide patient with honest and consistent feedback in a non threatening manner. Avoid challenging the content of patient’s behavior Focus interactions on patient’s behavior. Administer drugs as prescribed while monitoring and documenting patient’s response to drug regimen. Use simple and clear language when speaking with the patient. Explain all procedures, test and activities to patient before starting them
Promoting socialization
• • • • • •
Encourage patient to talk about feelings in the context of a trusting, supportive relationship. Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions. Use supportive, emphatic approach to focus on patient’s feelings about troubling events or conflicts. Provide opportunities for socialization and encourage participation in group activities. Be aware of personal space and use touch judiciously. Help patient to identify behaviors that alienate significant others and family members.
Ensuring safety:
• • • • • • •
Monitor patient for behaviors that indicate increased anxiety and agitation. Collaborate patient to identify anxious behaviors as well as causes. Establish consistent limits on patients behavior and clearly communicate these limits to patients, family member, and health care providers. Secure all potential weapons and articles from patients room and the unit environment that could be used to inflict injury. Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action. Frequently monitor the patient within guidelines of facility’s policy on restrictive devices and assess the patients level of agitation. When patient’s level of agitation begins to decrease and self control regained, establish a behavioral agreement that identifies specific behaviors that indicate self control against are escalation agitation.
Phases of COPAR Definitions of COPAR: D A social development approach that aims to transform the apathetic, individualistic
and voiceless poor into dynamic, participatory and politically responsive community. a A collective, participatory, transformative, liberative, sustained and systematic process of building people’s organizations by mobilizing and enhancing the capabilities and resources of the people for the resolution of their issues and concerns towards effecting change in their existing oppressive and exploitative conditions (1994 National Rural Conference) R A R A process by which a community identifies its needs and objectives, develops confidence to take action in respect to them and in doing so, extends and develops cooperative and collaborative attitudes and practices in the community (Ross 1967)
A continuous and sustained process of educating the people to understand and develop their critical awareness of their existing condition, working with the people collectively and efficiently on their immediate and long-term problems, and mobilizing the people to develop their capability and readiness to respond and take action on their immediate needs towards solving their long-term problems
Importance of COPAR:
1. COPAR is an important tool for community development and people empowerment as this helps the community workers to generate community participation in development activities. 2. COPAR prepares people/clients to eventually take over the management of a development programs in the future. 3. COPAR maximizes community participation and involvement; community resources are mobilized for community services.
Principles of COPAR:
1. People, especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to change and are able to bring about change. 2. COPAR should be based on the interest of the poorest sectors of society 3. COPAR should lead to a self-reliant community and society. COPAR Process: C A progressive cycle of action-reflection action-reflection action which begins with small, local and
concrete issues identified by the people and the evaluation and the reflection of and on the action taken by them. t Consciousness through experimental learning central to the COPAR process because it places emphasis on learning that emerges from concrete action and which enriches succeeding action.
COPAR is participatory and mass-based because it is primarily directed towards and
biased in favor of the poor, the powerless and oppressed. b COPAR is group-centered and not leader-oriented. Leaders are identified, emerge and are tested through action rather than appointed or selected by some external force or entity.
Phases of the COPAR Process I. Pre-entry Phase A. Is the initial phase of the organizing process where the community/organizer looks for communities to serve/help. B. It is considered the simplest phase in terms of actual outputs, activities and strategies and time spent for it. Activities include: 1. Designing a plan for community development including all its activities and strategies for care development. 2. Designing criteria for the selection of site 3. Actually selecting the site for community care Preparation of the Institution o o o o
Train faculty and students in COPAR. Formulate plans for institutionalizing institutionalizing COPAR. Revise/enrich curriculum and immersion program. Coordinate participants of other departments.
Site Selection o o o o
Initial networking with local government. Conduct preliminary special investigation. investigation. Make long/short list of potential communities. Do ocular survey of listed communities.
Criteria for Initial Site Selection o o o o o
Must have a population of 100-200 families. Economically depressed. No strong resistance from the community. No serious peace and order problem. No similar group or organization holding the same program.
Identifying Potential Municipalities o
Make long/short list.
Identifying Potential Barangay o o o
Do the same process as in selecting municipality. Consult key informants and residents. Coordinate with local government and NGOs for future a ctivities.
Choosing Final Barangay o o o o o o o
Conduct informal interviews with community residents and key informants. Determine the need of the program in the community. Take note of political development. Develop community profiles for secondary data. Develop survey tools. Pay courtesy call to community leaders. Choose foster families based on guidelines.
Identifying Host Family o o o o o
House is strategically located in the community. Should not belong to the rich segment. Respected by both formal and informal leaders. Neighbors are not hesitant to enter the house. No member of the host family should be moving out in the community.
II. Entry Phase A. Sometimes called the social preparation phase as to the activities done here includes the sensitization of the people on the critical events in their life, innovating them to share their dreams and ideas on how to manage their concerns and eventually mobilizing them to take collective action on these. B. This phase signals the actual entry of the community worker/organizer into the community. She must be guided by the following guidelines however.
1. Recognizes the role of local authorities by paying them visits to inform them of their presence and activities. 2. The appearance, speech, behavior and lifestyle should be in keeping with those of the community residents without disregard of their being role models. 3. Avoid raising the consciousness of the community residents; adopt a low-key profile. Guidelines for Entry o
o
o
Recognize the role of local authorities by paying them visits to inform their presence and activities. Her appearance, speech, behavior and lifestyle should be in keeping with those of the community residents without disregard of their being role model. Avoid raising the consciousness of the community residents; adopt a low-key profile.
Activities in the Entry Phase o
o
Integration - establishing rapport with the people in continuing effort to imbibe community life. living with the community seek out to converse with people where they usually congregate lend a hand in household chores avoid gambling and drinking Deepening social investigation/community investigation/community study verification and enrichment of data collected from initial survey conduct baseline survey by students, results relayed through community assembly
Leader Spotting Through Sociogram. Key persons - approached by most people Opinion leader - approach by key persons Isolates - never or hardly consulted
III. Organization Building Phase
A. Entails the formation of more formal structures and the inclusion of more formal procedures of planning, implementation, and evaluating community-wide activities. It is at this phase where the organized leaders or groups are being given trainings (formal, informal, OJT) to develop their skills and in managing their own concerns/programs. Key Activities o
o o o o o
Community Health Organization (CHO) preparation of legal requirements guidelines in the organization of the CHO by the core group election of officers Research Team Committee Planning Committee Health Committee Organization Others Formation of by-laws by the CHO
IV. Sustenance and Strengthening Phase A. Occurs when the community organization has already been established and the community members are already actively participating in community-wide undertakings. At this point, the different communities setup in the organization building phase are already expected to be functioning by way of planning, implementing and evaluating their own programs with the overall guidance from the community-wide organization. 1. Strategies used may include: a. Education and training b. Networking b. Networking and linkaging c. Conduct of mobilization on health and development concerns d. Implementing of livelihood projects
e. Developing secondary leaders Key Activities o o o o o
Training of CHO for monitoring and implementing of c ommunity health program. Identification of secondary leaders. Linkaging and networking. Conduct of mobilization on health and development concerns. Implementation of livelihood projects.
Ten (10) Herbal Medicines in the Philippines Approved by the Department of Health (DOH) These are the list of the ten (10) medicinal plants that the Philippine Department of Health (DOH) through its "Traditional Health Program" has endorsed. All ten (10) herbs have been thoroughly tested and have been clinically proven to have medicinal value in the relief and treatment of various aliments:
Negundo) LAGUNDI (Vitex Negundo) A shrub known in English English as the “5-leaved chase tree” which grows wild in vacant lots and waste land. The flowers are blue and bell-shaped and small fruits turn black when ripe. It is better to collect the leaves where are in bloom. Matured branches are planted. Parts utilized: leaves, flower. Uses and Preparation: Asthma, cough and fever - boil the chopped raw fruits or leaves in 2 glasses of water left for 15 minutes until the water left in only one glass. Strain. The following dosages of the decoction are given to age group. Dysentery, colds and pain in any part of the body as influenza – – boil boil a handful of leaves and flowers in water to produce a glass full of decoction 3 times a day. Skin Diseases (dermatitis, scabies, ulcer, eczema) and wounds – prepare a decoction of the leaves. Wash and clean the skin/ wound with the decoction. Headache- crushed leaves may be applied on the forehead. Rheumatism, Rheum atism, sprain, contusion insect bites - pound the leaves and apply on affected part. Aromatic bath for sick patients - prepare leaf decoction for use in sick and newly delivered patients.
douglasii) Yerba Buena (Clinopodium douglasii) A small multi- branching aromatic herb commonly known as Peppermint. The leaves are small, elliptical ands with soothed margin. The stem creeps to ground, and develops roots. May also be propagated through cuttings.
Parts utilized: leaves, sap of plant Uses:
For pain in different parts of the body as headache, stomach ache – boil chopped leaves in two glasses of water for 15 minutes. Cool and strain. Preparation: Divide decoction into two parts and drink one part every three hours. Rheumatism, arthritis and headache – crush the fresh leaves squeeze sap. Massage sap on painful parts with eucalyptus.
– get get about 10 fresh leaves and soak in a glass of hot water. Drink as tea. Acts as Cough and colds – an expectorant. Swollen Gums – steep 6 grams of fresh plant in a glass of boiling water for 30 minutes. Use solution as gargle.
– cut cut fresh plant and squeeze sap. Soak a piece of cotton in the sap and insert this in Toothache – aching tooth cavity. Mouth should be rinsed by gargling salt solution before inserting the cotton. To prepare salt solution add 5 grams of table salt to one glass of water. – soak soak a handful of leaves in a glass of boiling water. Drink infusion. It Menstrual and gas pain – induces menstrual flow and sweating. – crush crush leaves and apply at nostrils of patients. Nausea and fainting – Insect bites – – crush crush leaves and apply juice on affected part or pound leaves until paste-like. Then rub this on affected part.
Pruritis - boil plant alone or with eucalyptus in water. Use decoction as wash on affected area.
Sambong ( Blumea Balsamifera) English name: Blumea camphora A plant that reaches 1.5 to 3 meters high with rough hairy leaves. Young plants around mother plant may be separated when they have three or more leaves. Parts utilized: leaves Uses: Anti- edema, diuretic, anti- urolithiasis -boil chopped leaves in water for 15 minutes until one glassful remains. Cool and strain. Preparation: Divide decoction into 3 parts. Drink one part 3 times a day.
Remember that sambong is not a medicine for kidney infection.
Tsaang Gubat (Carmona retusa) A shrub with small, shiny nice- looking leaves that grows in wild uncultivated areas and forests. Mature stems are used for planting. Parts utilized: leaves Uses:
– boil boil the following amount of chopped leaves in 2 glasses of water for 15 minutes or Diarrhea – until amount of water goes down to 1 glass. Cool and strain. Preparation: Divide decoction into 4 parts. Let patient drink 1 part every 3 hours. Stomachache - wash leaves and chop. Boil chopped leaves in 1 glass of water for 15 minutes. Cool and filter, strain and drink.
Niyug- Niyugan (Quisqualis Indica L.) A vine known as “Chinese honey suckle” which bears tiny fruits and grows wild in backyards. It is effective for the elimination of intestinal worms. The seeds must come from mature. Dried but newly opened fruits. Propagated through stem cuttings about 20cm in height. Parts utilized: seeds Uses: An anti- helmintic- used to expel round worms ascariasis. supper. If no worms are expelled, expelled, the dose may be Preparation: The seeds are taken 2 hours after supper. repeated after one week.
This is not to be given to children below four years old. Special precautions: Follow recommended dosage. Overdose causes hiccups.
Bayabas / Guava (Psidium Guajava L.) A tree about 4- 5 meters high with tiny flowers with round or oval fruits that are eaten raw. Propagated through seeds. Parts utilized : leaves Uses: For washing wounds- may be used twice a day. For diarrhea- may be taken 3-4 twice a day.
Preparation: As gargle and to relieve toothache. Warm decoction is used for gargle. Freshly pounded leaves are used for toothache. Guava leaves are to be washed well and chopped. Boil for 15 minutes at low fire. Do not cover pot. Cool and strain before use.
Akapulko (Cassie, alata L.) It is also known as "bayabas-bayabasan" and "ringworm bush" in English, this herbal medicine is used to treat ringworms and skin fungal infections. Parts utilized: leaves Use: anti-fungal: Tinea Flava, ringworm, athlete’s foot and scabies. Preparation: Fresh, matured leaves pounded. Apply as soap to the affected part 1-2 times a day.
Ulasimang- bato (Peperonia Pellucida) A weed, with heart-shaped leaves also known as "pansit-pansitan", grows in shady parts of the garden and yard. It is effective in fighting arthritis and gout. The leaves can be eaten fresh (about a cupful) as salad or like tea. Parts utilized: leaves Use: Lowers uric acid. (rheumatism and gout) Preparation: Wash leaves well. One and a half cup leaves are boiled in two glassfuls of water over lower fire. Do not cover pot. Cool and strain. Divide into three parts and drink each part three times a day after meals.
May also be eaten as salad. Wash the leaves well. Prepare one and a half cups of leaves. Divide into 3 parts and take as salad three times s day.
Bawang (Allium sativum) popularly known as "garlic", it mainly reduces cholesterol in the blood and hence, helps control blood pressure. Also a remedy for toothache Parts utilized: Garlic Bulb Uses: For hypertension: Toothache; to lower cholesterol levels in blood.
Preparation:
May be fried, roasted, soaked in vinegar for 30 minutes or blanched in boiled water for 5 minutes. Take 2 pieces three times a day after meals. For toothache: Pound a small piece and apply to affected part.
Ampalaya (Mamordica Charantia) known as "bitter gourd" or "bitter melon" in English, it most known as a treatment of diabetes (diabetes mellitus), for the non-insulin dependent patients. Parts utilized: leaves Use: Lower blood sugar levels Preparation: Gather and wash young leaves very well. Chop. Boil 6 tablespoons in two glassfuls of water for 15 minutes under low fire. Do not cover pot. Cool and strain. Take one third cup 3 times a day after meals.
Remember that young leaves may be blanched/ steamed and eaten ½ glassful 2 times a day.
Reminders on the Use of Herbal Medicine.
1. Avoid the use use of insecticide insecticide as these may leave poison on plants. plants. 2. In the preparati preparation on of herbal herbal medicine, medicine, use a clay pot and remove remove cover while boiling boiling at low low heat. 3. Use only part of the the plant plant being being advocat advocated. ed. 4. Follow Follow accura accurate te dose dose of sugge suggested sted prep preparat aration. ion. 5. Use only one kind of herbal plant plant for each type of symptoms symptoms or sickness. sickness. 6. Stop giving giving the herbal herbal medicati medication on in case untowar untoward d reaction reaction such as allergy allergy occurs. occurs. 7. If signs signs and sympto symptoms ms are not relieve relieved d after 2 to 3 doses doses of herbal herbal medicati medication, on, consult consult a doctor.
