Nurse's Notes - The Black Book The Nurse's Notes - Black Book is a compilation of must-know concepts in nursing education. This will help aspiring nurses to be fully equipped in their future exams (e.g. Nursing Licensure Exam, NCLEX, CGFNS). Do you want to pass this exams? Of course! Then we will start our journey to uncover those topics as easy as 1,2,3. TUESDAY, FEBRUARY 17, 2009
Psychiatric Nursing PSYCHIATRIC NURSING Beliefs—Feelings—Behavior Sigmund Freud – Father of Psychoanalysis -structure of personality Id- impulsive part, pleasure principle -eat, urinate, have sex -it’s all “I” Superego – small voice of God -conscience -should not eat yet, should not eat yet Ego- arbiter, decision maker -in touch with reality Id___________________Superego EGO ID DOMINANT – needs a superego-needs a conscience M- manic A- antisocial – serial killer N- narcissistic SUPEREGO DOMINANT –needs an Id O- Obsessive Compulsive A- Anorexia nervosa EGO – impaired reality perception (RN will present reality) S- schizophrenia- cant distinguish fact from reality
Libido- sexual energy FREUD - PSYCHOSEXUAL THEORY ORAL – 0-18 months Cry, suck – mouth- survival Id dominant Maternal deprivation if not feed, not given milk/water, not kept warm. Narcissistic – seeks the Id – I love myself Regression – return to an earlier stage or earlier level Fixation – stopped in a stage ANAL- 18 mos-3yrs Toilet training Mom is superego. Superego is being formed Child is caught in ambivalence – pulled in 2 opposing factors Too much toilet training with punishment will result to a child who is:
Obedient, organized, clean Rebel, dirty, disobedient = OC =Anti-social =anal retentive =anal expulsive
PHALLIC – 3-6 yrs old -penis & vagina -love of parent of opposite sex Oedipal-boy loves mom Electra-girl loves dad Identification- boy imitates dad Castration fears- fear that dad is angry at him and will cut off penis Penis envy- girls envy little boys Dr. Karen Horney- detractor of Freud, didn’t believe in penis envy. Freud said that it is maybe in her unconscious mind. Or repressed. Conscious- highest level of awareness Pre-conscious- at tip of tongue Unconscious – forgotten
Repression-kept in unconscious. Unconscious forgotten. Suppression – conscious forgetting LATENT- 6-12 years old Latent- Logtu = sexual energy asleep School age – School phobia- 1st time to go to school – Separation anxiety Child is busy with Reading, writing, arithmetic. Sublimation –putting anger into something more productive putting all energies into schooling Ex. Angry at life, pour anger in singing. GENITAL –12 years old Genital-Gising sexual energy Sexual intercourse most important in this stage!! PHARMA MOMENTS Anti-anxiety Drugs (used also for alcohol withdrawal) Valium Librium Ativan Serax Tranxene Miltown Equanil Vistaril Atarax Inderal Buspar ERIK ERIKSON STAGE (+) (-) FACTOR 0-18 months (Oral) Trust vs Mistrust Feeding 18 mos- 3yrs old (Anal) Autonomy vs Au-(anal) To-ilet training No-No! Favorite word. My Shame/doubt Toilet training 3-6 yrs old (Phallic) Initiative vs (Initiate 1st steps) Phallic-oedipal,electra Guilt –anger turned inward Independence 6-12 yrs old (Latent) Industry vs Inferiority Industry Induskul 12-20 (Genital) Identity vs Role confusion Peers 20-25 Intimacy vs Isolation Love 25-45 Generativity vs Stagnation Parenting 45 up Ego Integrity vs Despair Reflection Newly admitted pt- develop trust 1st -pts are dependent=self care deficit -develop/teach autonomy -then pt will develop initiative
-etc
Frontal lobe- personality, learning, judgment, language Occipital- vision Temporal- hearing, smell Parietal-taste, touch Sensory Integration Motor Somatic nervous system- voluntary movements Acetylcholine- responsible for voluntary movements - on switch of movement Autonomic nervous system- involuntary movements -Sympathetic(Anti cholinergic) and parasympathetic (cholinergic) SYMPATHETIC (alert) PARASYMPATHETIC (relax) Heart tachycardia bradycardia Respiratory tachypnea bradypnea GI (opposite effect) Slow, constipation diarrhea GU (opposite effect) Slow, oliguria, retention Polyuria, frequency Dry mouth Moist mouth Neurotransmitter Epinephrine, Norepinephrine Acetylcholine (AcH) Pupils Dilated (dilat when alert) (Midriasis) Constricted (Myotic) Blood vessels vasoconstriction vasodilated BP increased decreased Anti-cholinergic / anti-parasympathetic =effect is sympathetic! Sympathetic drug classifications: A- anxiety P- psychotic Anti C- cholinergic D- depressants MONO AMINE OXIDASE INHIBITORS: mARplan nARdil pARnate
DEFENSE MECHANISMS: coping mechanism from stress: DISPLACEMENT- -------------Your boss shouts at you, you shout at your subordinate. SUBLIMATION - ---------------putting anger into something more productive or + putting all energies into schooling Ex. Angry at life, pour anger in singing. DENIAL- ----------------------“I am not” an alcoholic! DISSOCIATION – --------------psychological flight from self. Amnesia. Ex. Rape, trauma REGRESSION – ----------------RETURN to an earlier developmental stage FIXATION – ---------------------stuck in a stage of development REPRESSION – -----------------unconscious forgetting SUPPRESSION – ---------------conscious forgetting. Avoidance. “I don’t want to talk about it. I don’t want to remember it.” RATIONALIZATION – -------uses “because”. Has illogical reasoning. “I drink because I don’t want to waste the beer in the ref.” REACTION FORMATION----plastic. Doing opposite of intention. UNDOING- ----------------------show true feeling/color then feels guilty after. IDENTIFICATION – -----------models a certain behavior from a certain role model. PROJECTION – -----------------blame other people, pass load to others. Looks for a scapegoat. “Not me, but them.” INTROJECTION – --------------assume another persons trait as your own. “Not just you, me too.” “Ako din, gusto ko yan.” CONVERSION – repression. Anger turned inward to herself. Converted to physical symptoms. Sensory-numbness. Motor-paralyzed, tremors. COMPENSATION – -----------defects of the person, overachieve to cover a
defective part. SUBSTITUTION – -----------when you replace a difficult role with a more accessible one. Ex.Wants to go to Disneyland but can’t afford it. Went to Enchanted Kingdom instead.
Defense mechanism: Affects/interferes with ADL Harm to self or others Behavior Model – Ivan Pavlov Classical Conditioning -behavior learned-repeated (+) BF Skinner – operant conditioning-reinforcement Confront (-) behavior to make it extinct. MASLOW’S HEIRARCHY OF NEEDS: 5. Self-actualization 4. Self-esteem 3. Love and belonging 2. Safety and security 1. Air, food, water, shelter, clothing, sex –Basic physiologic needs LEVELS OF PREVENTION PRIMARY SECONDARY TERTIARY Healthy ill Relapse avoidance Community teaching Crisis intervention Rehab centers Community demographics Treatment and diagnosis Al anon STAGES OF INTERACTION ORIENTATION WORKING TERMINATION Assessment Problem solving Evaluation Establishment of trust Discussion Summarize Tell patient about termination Patient is most cooperative Say goodbye Set contract Grief-ANGER-focus of RN Patient is resistant Pt might become violent/suicidal
ANTI-PARKINSON DRUGS (Capables) –used with anti-psychotics
Anti-cholinergic Dopaminergic ABC PLSE C- Cogentin A- Artane P- Parlodel A- Akineton B- Benadryl L- Larodopa E- Eldepryl S- Symmetrel THERAPEUTIC COMMUNICATION NON- THERAPEUTIC 1. Offer self- “I’ll stay/sit with you.” “Don’t worry, be happy.” 2. Explores –use what, when, where, how Why? – Puts pt in defensive position. 3. Silence Change the subject. 4. Active listening-nodding, eye contact, leaning forward-show active participation. “Everything’s going to be alright.” – giving False reassurance. 5. Make observations. “You see/ I have observed/ I have noticed…” Ignore the patient. 6. Broad opening- “How are you?” “You have combed your hair today.” Prejudicial. “Nice weather today.” –value based judgment. 7. Clarification-“What do you mean by ploopplank?” Flattery – don’t use too much adjectives. “You have the most beautiful hair in the ward.” 8. Restating-“I don’t want to eat.” (Word per word repetition!) “You don’t want to eat?” Arguing with the patient Don’t impose your opinion. 9. General leads- “And then/What else/Go on…” 10. Refocusing-“We were talking abt the exam…” 11. Focusing-“Tell me more abt this.” ABG ANALYSIS Ph & PCO2-Respiratory-opposite signs Ph & HC02-Metabolic – same signs Compensation: Ph is normal=Fully compensated. C02 & HC03 –same signs = Partially compensated ANXIETY
-vague sense of impending doom. Sympathetic activation. Assessment: Level of anxiety MILD-------------------sit restlessly, widened perceptual field, enhanced learning experience. “You seem anxious.” MODERATE----------patient is pacing, selective inattention. Give PRN meds-Antianxiety drugs-valium… SEVERE----------------patient can’t make decisions. “I don’t know what to do or say.” RN directs patient. “Sit down on the chair.” – Directive. PANIC- highest level of anxiety. Suicidal. Priority: safety. Stay with patient. Don’t touch pt. Sympathetic activation. “I think I’m having a heart attack!” Nrs Dx: -----------------Ineffective Individual Coping P/I: Decrease anxiety, decrease stimuli HT: relaxation technique E: Effective Individual Coping GENERALIZED ANXIETY DISORDER – 6 months excessive worrying. Patient knows what the problem is. Cant sleep, concentrate, seat Fatigue and palpitations PANIC ATTACK – ------------------------------15-30 minutes, happens without warning. SNS activation. -with or without agoraphobia -------------------- fear of open space -social phobia –------------------------------------- fear of public -provide safety -Alkalosis-brown bag -stay with patient -be directive POST TRAUMATIC STRESS DISORDER Victims – rape, accident, war zone, disaster, trauma 1. Survivor 2. Flashback > 1 month 3. Memory – nightmares
MALINGERING------------------------------------- no organic basis (no tissue change) -pretending to be sick, conscious -decrease anxiety – for primary gain -increase attention from RN– secondary gain SOMATOFORM DISORDER –------------------unconscious, not pretending, no organic basis - goes doctor hopping
Nervous system Minor discomfort BODY DYSMORPHIC DISORDER CONVERSION -Feels like illness -illusion of structural defect -loss of sensory/motor fx -HYPOCHONDRIASIS -S/sx not real -s/sx real (biglang nabulag) PSYCHOSOMATIC DISORDER (Psychophysiologic)– real illness, real s/sx, real pain, with organic basis (with change in tissue) - stress ulcers, migraine, HPN PHOBIA---------------------------------------------------------- irrational fear Etiology – knowledge, experience Immediate nsg intervention: Remove object of fear (Increase stimuli=increase level of anxiety) (Decrease stimuli=decrease anxiety) Belief Feeling Behavior Object will hurt patient Scared Avoidant=interferes with ADL Gradual exposure to feared object- SYSTEMATIC DESENSYTHEZATION Individual Therapy 1. Hypnosis – --------------relaxed state 2. Free association –------ ideas shared to psychoanalyst 3. Catharsis – --------------free to express feeling 4. Transterence- -----------patient feels something for psychoanalyst 5. Countertransterence –--RN feels something for patient
Green light-Go – Epi & Norepinephrine Red light – Stop – G-gamma A-amino B-butyric A- acid Anxiety
Increase GABA Anti-cholinergic S/E GI-constipation GU-retention
Effect of GABA: Drowsy, drink, don’t drive, orthostatic hypotension Anti-anxiety drug
Withdrawal from drug – abrupt – REBOUND PHENOMENA – leads to seizures. 1 week effect. Gradual withdrawal – tapered dose Dependence- Can’t live without valium ANTI-PSYCHOTIC AGENTS – Sympathetic effect. Effect – 2-4 weeks STELAZINE CLOZARIL SERENTIL MELLARIL THORAZINE HALDOL TRILAFON PROLIXIN SCHIZOPHRENIA-------------------------------impaired reality perception. Ego disintegration. Genetic vulnerability. Stress. -Chose fantasy over reality. Increase dopamine theory. Cause: unknown. Increase dopamine, increase schizophrenia. 4 A’s: 1. Affect---------------------------------------------feelings & emotions (smiles, laughs). External, readily observable. Mood, internal, does not match affect. (sad inside) 2. Ambivalence-------------------------------------pulled between 2 opposing forces 3. Autism --------------------------------------------self absorbed. Trapped in his own
world.Attached to odd objects.Poor eye contact. 4. Associative looseness---------------------------talk about so many things but unrelated ideas. Disturbed thought process-------------------------Nsg dx Content of thought---------------Hallucinations/Illusions-----------ADL----------------------------Harm
Disturbed thought process Disturbed sensory Self care deficit Self Other Perception Directed Violence P/I: Reality/Orient/Safety Eval: Improved thought process S & Sx of Schizophrenia: (-)neg sx (+) positive sx hypoactive hyperactive flight of ideas withdrawn restless hallucinations quiet, flat affect talkative delusions many ideas poverty of words queen of the world illusions Types of schizophrenia: 1. Disorganized schizo---------------------------------sad inside, happy outside – inappropriate affect (+) flat affect – no affect (-) disorganized manner/speech –flight of ideas (+) Hebephrenic- giggling (+) Sx: both (+) and (-). 2. Catatonic ---------------------------------------------ambivalence –anal stage (-) No! Negativisim-rebel-anal (-) Waxy flexibility--------------raise arm of patient. Patients arm remains up for a long time. (-) (-) > (+) 3. Paranoid ----------------------------------------------uses projection. Mistrust Scared/withdrawn/violent Based on history
Develop trust: orientation -Leave door open -1:1 interaction -Distance from pt: 1 arms length -consistent approach -stay near door not window -short/frequent interaction -have visibility:stand halfway in & out -food: sealed container to be able to call for reinforcement. -meds: wrapped in tamper resistant foil -calm and firm 4. Unclassified/ Undifferentiated-----------------------can’t be classified anymore. 5. Residual-------------------------------------------------no more (+), (-). Social withdrawal
THOUGHT PROCESS DISTURBANCE 1. LOOSENESS OF ASSOCIATION----------------topics have connection but no thought. “I am going to the mall. The mall is in town. The town flies. Flies are here.” 2. FLIGHT OF IDEAS ---------------------------------New unrelated topics. “I am going to the mall. Where is the light? I treasure this chalk. Hurray!” 3. AMBIVALENCE-------------------------------------Pulled by 2 opposing forces. 4. MAGICAL THINKING----------------------------- believes he has magical powers. “I can turn you into a frog.” 5. ECHOLALIA------------------------------------------repeat what is said. Parrots. 6. ECHOPRAXIA----------------------------------------repeats what you do. Repeats what is seen. 7. WORD SALAD----------------------------------------mixes words that don’t rhyme. 8. CLANG ASSOCIATION----------------------------uses words that rhyme. “Flank, blank, prank.” 9. NEOLOGISM------------------------------------------invents new words not in the dictionary. “Ploopplank, pisnok.” 10. DELUSIONS-----------------------------------------false belief Grandeur--------------I am a queen/ king/millionaire! Persecution------------NBI out to get me! Ideas of reference-----They talk and write about me! 11. CONCRETE ASSOCIATION-----------------------pilosopo. “What will you wear tomorrow?” “Clothes!” 12. HALLUCINATIONS----------------------ILLUSIONS (with stimuli) Stimuli N Y Visual N Y Auditory N Y Tactile N Y
Present reality!!! H A R D-Directive. “Let’s go in the garden.”
Acknowledge: “I know the voices are real to you. Present reality. “But I can’t hear them.” =Assess what voices are saying to know if patient will harm himself.
Increase Dopamine = increase schizo Decrease dopamine = decrease schizo Extra Pyramidal Side Effects (EPSE) (Happens when acetylcholine is up and dopamine is down) 1. AKATHISIA-------------------------- restless, inability to sit still. 2. AKINISIA ---------------------------- rigidity 3. DYSTONIA--------------------------- affects neck TORTICOLLIS -------------wry neck OCULOGYRIC CRISIS – fixed stare OPISTHOTONUS ---------arched back, contracted 4. TARDIVE DYSKINESIA------------lip smacking, tongue is protruding, puffy cheeks. Irreversible! 5. NEUROLEPTIC MALIGNANT SYNDROME- hyperthermia, unstable BP, increase CPK, diaphoresis, pallor -discontinue meds, medical emergency. 6. PHOTOSENSITIVITY------------------wear shades, sunscreen 7. WBC- Agranulocytosis---------------sore throat, fever, malaise, leukopenia AUTISM- boys > girls. 1:100 kids gift-autistic savants -echolalis, poor eye contact, can’t express verbally. Assess: A- appearance- neat, OC, wants constancy B- behavior- ritualistic behavior, flat affect, repetitive C- communication – difficulty communicating Nsg Dx: Impaired social interaction – cant form IPR (Interpersonal relationship) Impaired verbal communication Self mutilation – cant express anger. Express it inward. Risk for injury P/I: constancy, promote safety Expressive therapy – uses art, music, poetry, decreasing risk for injury, improved social interaction, be able to express feelings.
E: -Safety
ADHD- ATTENTION DEFICIT HYPERACTIVITY DISORDER (can progress to conduct disorder to anti-social behavior) Cant focus on anything. Onset 7 yrs old and below Duration >6 months Setting: House & school ID dominant: Mom or RN will act as superego Assessment: A- appearance: dirty B- behavior: clumsy, impatient, easily distracted C- talkative Nsg Dx: High risk for injury Safety Structure- provide place to study, eat, play,bath,etc. Schedule – time for everything Set limits Residual ADHD grows up not anti-social Meds: Ritalin, Dexedrine,Pemoline, Adderal Best time to give meds: If once a day give AFTER MEALS- to prevent loss of appetite. Don’t give at bedtime-it’s a stimulant-will cause insomia. Can be given 6hours before bedtime (if q2d)
ANOREXIA NERVOSA – diet, underweight < 85% of expected fat, 3 months amenorrhea, failure to recognize problem. BULIMIA NERVOSA – induce vomiting, takes laxative, normal weight, irregular menstruation, dental carries, diarrhea - knows problem but ashamed and embarrassed, Priority: Fluid volume balance Weight gain – monitor weight, eating pattern, stay 1 hour after eating, accompany in toilet
Problem: Body image Disturbance NI: 1. Establish nutrition pattern 2. Teach stress management, journal keeping 3. Monitor eating pattern and weight. 4. Anti-depressant MANIA – needs mood stabilizing agents- Lithium. Group therapy L- 0.5-1.5 mEq/L (If level is near 2.5-3 mEq/L –will cause ataxia and mental confusion) I- increase urination T- tremors H- H20- 3L/d I- increase T- uu M- mouth dry N- Na- 135-145 mEq/L – to hold water Check kidney(blood level) before administration of Lithium – BUN, CREA, electrolyte Lithium toxicity – n/v, diarrhea = Diamox BIPOLAR DISORDER – 2 poles, happy (more dominant) & sad -female, >20 yrs old, stress, obese Self actualization Task to decrease self esteem Family therapy Risk for injury, risk for other directed violence Decrease eat, decreased sleep, hyperactive, increase sex – masturbate in front of others Nsg Dx: High risk for self or other directed violence Risk for injury Give task, no group games, any competition will increase anxiety, water the plants, activities using gross motor skills, escorted walk, punching bagdisplacement. 3 or more signs confirms disorder: G – grandiose, increase risk activities F – flt of ideas S - sleeplessness P – pressured speech E – exaggerated SE
E – extraneous stimuli (easily distracted) D – distractability PERSONALITY DISORDER 1. Schizoid – --------doesn’t care about people, believes that he can stand on his own, never had a best friend avoid groups & activities – no enjoyment cares more about computers, pets 2. Avoidant ----------avoid group – fear criticism, have talent but no confidence. 3. Anti-social– ------as child steal, lie, always get reprimanded Adult – grand robbery, illegal activities against the law. drug addiction, drives fast, unsafe sex, thrill seeker. Good talker, charmer, witty, manipulator. Motto – “I will break the law”
4. Borderline -------Favorite line – “ life is an empty glass.” Splitting, suicidal, superficial relationship, labile-sudden change of Mood, self mutilation. (+) (-) fill glass with friends suicide have happy moments LABILE AFFECT sad moment labile- change from good to bad in a split moment 5. Dependent ---------Decrease self esteem, dependent Poor decision making skills “I cant live if living is without you” 6. Histrionics ----------excited, dramatic, manipulative - CENTER OR ATTENTION 7. Narcissistic----------“I love myself” – insensitive, arrogant, self absorbed - exaggerated Self esteem, ambitious “I am the best” 8. OC ------------------ perfectionist, organized, constancy in environment. Provide time to do rituals. 9. Paranoid ----------- always jealous, suspicious, violent
10. Passive aggressive ------always say “yes”, but resistance is hidden.
Nsg Intervention: Improve IPR, build trust
A-LCOHOL ABUSE ----------------------happy – socializing Narcotic oversode-give Narcan -escape from problem Narcotic detox- Methadone -peer pressure Aversion therapy-Antabuse B-blackout ---------------- awake but unaware C-confabulation ---------- invent stories to increase Self-Esteem D-denial -------------------“ I am at not an alcoholic.” D-dependence ------------“ I cant live without alcohol.” a. physical – tremors, tachycardia, restless b. psychological – craving E-enabling/codependency (significant others tolerate abusers)
DISULFIRAM voids alcohol beer version therapy ntabuse (DISULFIRAM) lcoholics anonymous n/v hypotension interval of alcohol & antabuse: 12h interval after alcohol intake B1 – Thiamine Complications wernickes Encephalopathy Korsakoff psychosis Wernickes – VROOM – Motor sx effect Korsakoff – memory- confabulation 24 – 72h after alcohol intake Delirium tremors – happens due SNS activation Tremors, hallucinations, illusions. Well lit room – to avoid hallucinations ANTI DEPRESSANTS – decrease serotonin problem Anti depressants – full stomach All meds take on a full stomach, except anti anxiety. ASENDIN TCA NORPRAMIN TCA
TOFRANIL TCA SINEQUAN TCA ANAPRANIL TCA - OC AVENTYL TCA VIVACTIL TCA ELAVIL TCA PROZAC SSRI PAXIL SSRI ZOLOFF SSRI LUVOX SSRI Serotonin ---------makes us happy Decrease serotonin – pt becomes sad – depression Increase serotonin – antidepressant SSRI: Selective S Serotonin S – (decrease S/E) Reuptake R – Inhibitors I – (1 – 4 weeks) If SSRI don’t work, give TCA Tri Cyclic Antidepressants –( TCA) ----------2 – 4 wks has increased S/E increased Serotonin & Norephinephrine MAOI-------------------------- effect 2 – 6wks Increase E, NE, serotonin kills serotonin - MAOI increase MAO = decrease serotonin * decrease MAO = increase serotonin give MAOI Most dangerous, most S/E Diet – avoid tyramine food – eat SARIWA, fresh foods HPN crisis – dangerous! Increase CR, diaphoresis Tyramine rich food: Avocado Pickles Alcohol Fermented foods Beer Eggplant Chocolate preservatives – tocino, bologna,canned meat etc. Cheese – mozerella, swiss cheese W – ine S – soysauce
Anticholinergic = antidepressants – antiparasympathetic Dry, constipation, retention, tachycardia Male erectile dysfunction
MAOI mARplan NARdil PARnate DEPRESSION – decrease serotonin. If unresponsive to drugs, ECTelectroconvulsive therapy Assess: 1. Denial – this cant be happening. This cant be real. 2. Anger – Why me, why now, why God?! 3. Bargaining – If returned, I will give reward. 4. Depression – 2 wks or more of sx = clinical depression 5. Acceptance – client acts according to situation. Pt prepares living will. Increase risk for self directed violence. Maslows: 5 – 4 – decrease Self-esteem – give TASK 3 – Pt is withdrawn 2 – Risk for self directed violence suicide 1 – eat (wt gain) or not eat(wt loss), sleep or not sleep, hypoactive, decrease sex SUICIDE CUES: “I wont be a problem any longer” “Remember me when I’m gone” “This is my last day” “This is my wedding ring. Give it to my son” - Sudden change in mood. Pt is suicidal, RN should: D –d irect question – “Are you going to commit suicide? I – irregular interval of visit to pt room E – early am & endorsement period - time pt’s commit suicide. Who will commit suicide? S – sex – male (more successful)/female (hesitant) A – age – 15 – 24yo or above 45
D – depression P – pt with previous attempts will try again E – ETOH – (Ethanol) alcoholics R – irrational S – lacks social support O – organized plan – greater risk N – no family S – sickness, terminal Suicide Triad: - Loss of spouse - Loss of job - Aloneness Best approach for suicide: Direct approach Nursing Mgt: close surveillance Hospital area majority suicide happens at: weekends 1 – 3 am Sunday Weekend – less staff personnel Early am – every one is asleep Give simple task. Don’t give complex task – no jigsaw puzzle Water the plants Wash the dishes except sharp objects
SUBSTANCE ABUSE Type of Addict: 1. Nervous -----tremors Give downers Sx of overdose 1. Identify if drug is upper or downer 2. Check effect 3. Sx of withdrawal If patient takes a downer, all vital signs are down! If he stops taking it (during withdrawal), patient will experience the opposite effect of a downer. All his vital signs will shoot up! Same with uppers. Ex: Pt had cocaine intoxication. Pt will manifest hyperactivity, tachypnea, seizure. During withdrawal, pt will manifest bradypnea or coma.
Substance Abuse Moments (downer) A – alcohol B – barbiturates O – opiates Antidote N – narcotics - Narcan (narcotic antagonist) M – marijuana Morph CODE HERO (uppers) C – cocaine H – Hallucinogens A – amphetamines
Uppers Downers Seizure decrease RR, decrease HR Tachypnea Para constricted pupil Moist mouth Dilated Blood Vessels Coma Asleep Decreased GI constriction Decrease GU retention Decrease BP State of euphoria Sx of withdrawal – reverse of effect 1. Know if upper or downer 2. Opposite of effect
Overdose Withdrawal (opposite of withdrawal is overdose) Alcohol – coma seizure Morphine – bradypnea tachypnea Detox – withdrawal with MD supervision Methadone
2. Depressed - Sits down on chair
Uppers Codeine increased heart increase - BP increase, awake Hallucinogen sympathetic HR increase seizure Amphetamine pupils- dilate GI - diarrhea Mouth – dry Decrease appetite - thin Stop uppers Tremors crash syndrome Depressed Suicide Fatigue
LEVELS OF MENTAL RETARDATION Profound severe moderate mild borderline normal IQ 20 35 50 70 90 110 Profound Mental retardation IQ <20 =thinks like an INFANT. Cant be trained. Stay with patient. Severe MR 20-35 Moderate 35-50 = Can be trained. Mental age is 2-7yo. Pre-operational stage. Mild 50-70 = (mild 7) Mental age is 7-12. Educable. Can go to school. Borderline- 70-90 Normal- 90-110
JOHN PIAGET COGNITIVE THEORY 0-2 yrs old – S-ensory motor. Baby can sense, see, perceive and hear. Object permanence 2-4 yo- P-reconceptual- language. 4-7 yo- I-ntuitive stage. Unidimentional classification or unidimentional characteristic. Child can fix toys according to size, color, height=one at a time only. 7-12 yo- C-conservation/concrete association. Multidemensional 12yo- F-ormal operation – good in abstract thinking. Can interpret proverbs.
CHILD ABUSE B=burns, bruises, bone fractures, bungi Don’t bathe child. Don’t brush teeth. Body of evidence will be lost. Bantay Bata 163
ALZHEIMER Anomia- don’t know name of object Agnosia – problem with senses (smell, taste, hear, touch) Aphasia – can’t say it Apraxia – can’t do it Dissociative Fugue- takes a new personality from a tar away place. New place new identity. Dissociative Identity Disorder – multiple personality Dissociative Amnesia – don’t know who/where I am.
DEPERSONALIZATION- believe that they are not persons anymore PERSEVERATION- kulit. “I want to talk about something because this is something that I want to do. It is something that I need to talk about. This is something that I want to do.” ELECTROCONVULSIVE THERAPY- sign informed consent. For depressed pt. If meds don’t work, use ECT. Pre-ECT N-npo 6 hours A-atropine sulfate – dry mouth B-barbiturate S- succinylcholine chloride – to relax muscles Post-ECT Side-lying- lateral S/E headache, dizziness, temporary memory loss (distinct sx)=RN-orient pt.
EXAMS: Nsg intervention:
Look for words like: S=safety, support, stay, set limits, assist Provide safety. Mobilize support system. I will stay with you. Assist in activity. Set limit- don’t allow patient to misbehave. Look for words like: Orient=orient pt post delirium, ECT, pt with dementia Accept “Seem, observed, noticed, comment, feelings…” Group therapy- facilitator is RN. Rape, battered pt ALTRUISM – Victim becomes a counselor, shares experience to new victim. Self-help group=facilitator is the pt themselves. AL ANON groups –Alcoholics Anonymous Posted by Rey at 6:35:00 PM 1 comments Reactions:
Pediatric Nursing Growth and Development Growth- increase in physical size of a structure or whole. -quantitative change. Two parameters of Growth 1. weight- most sensitive measure of growth, especially low birth rate. Wt doubles 6 months 3x 1yr 4x 2-2 ½ yrs 2. Height- increase by 1”/mo during 1st 6 months - average increase in ht - 1st year = 50% stoppage of ht coincide with eruption of wisdom tooth. Development- increase skills or capability to function - qualitative
How to measure development 1. Observe child doing specific task. 2. Role description of child’s progress 3. DDST- Denver development screening test. MMDST (Phil) Metro Manila Developmental Screening Test. DDST measures mental 4 main rated categories of DDST 1. Language communication 2. personal social-interaction 3. fine motor adaptive- ability to use hand movement 4. gross motor skills- large body movement maturation- same with development “readiness” Cognitive development –ability to learn and understand from experience to acquire and retain knowledge. To respond to a new situation and to solve problems. IQ test- test to determine cognitive development Mental age x 100 = IQ Chronological age Average IQ – 90-100 Gifted child- > 130 IQ
Basic Divisions of Life I. Prenatal stage from conception- birth II. Period of infancy 1. Neonatal- 1st 28 days or 1st 4 weeks of life 2. Formal infancy- 29 day – 1 year
III. Early childhood 1. Toddler – 1-3 yrs 2. Pre school 4-6 years IV. Middle childhood 1. School age- 7 – 12 yrs
V. Late childhood 1. Pre adolescent 11 – 13 yrs 2. Adolescent 12 - 18 – 21 Principles of G & D 1. G&D is a continuous process -begins form conception- ends in death - womb to tomb principles 2. not all parts of the body grow at the same time or at same rate. - asynchronism Patterns of G&D 1. )renal digestive grows rapidly during childhood circulatory musculoskeletal 2. )Neuromuscular tissue (CNS, brain, S. cord) - grow rapidly 1-2 years of life - brain achieved its adult proportion by 5 years. 3. )Lymphatic system- lymph nodes, spleen grows rapidly- infancy and childhood to provide protection -infection - tonsil adult proportion by 5 years 4. )Repro organ- grows rapidly at puberty Rates of G&D 1. fetal and infancy – most rapid G&D 2. adolescent- rapid G&D 3. toddler- slow G period 4. Toddler and preschool- alternating rapid and slow 5. school age- slower growth fetal and infancy- prone to develop anemia 3. Each child is unique 2 primary factors affecting G&D A. Heredity - R – race I – intelligence S – sex N - nationality
Females are born less in weight than males by 1 oz. Females are born less in length than males by 1 inch
B. Environment Q – quality of nutrition S – socio eco. status H – health O – ordinal pos in family P – parent child relationship Eldest- skillful in language and social skills Younger- toilet trained self 4.G&D occurs in a regular direction reflecting a definitive and predictable patterns or trends. Directional trends- occur in a regular direction reflecting the development of neuromuscular function. These apply to physical, mental, social and emotional development and includes. a. cephalo-caudal “head to tail” - occurs along bodies long axis in which control over head, mouth and eye movements and precedes control over upper body torso and legs. b. proximo- distal “Centro distal” - progressing form center of body to extremities. c. Symmetrical- at side of body develop on same direction at same time at same rate. d. Mass specific “differentiation” - child learns form simple operations before complex function of move from a broad general pattern of behavior. To a bore refined pattern. B. Sequential- involves a predictable sequence of G&D to which the child no9rmally passes. a. locomotion- creep than crawls, sit then stand. b. socio and language skills- solitary games, parallel games C. Secular- worldwide trend of maturing earlier and growing larger as compared to succeeding generations. 5.Behavioral in the most compressive indicator of developmental status. 6. universal language of child- play
7. great deal of skill and behavior is learned by practice. Practice makes perfect. 9. neonatal reflexes us must be lost before one can proceed. -plantar reflex should disappear before baby can walk -moro reflex should disappear before baby can roll persistent primitive infantile reflexes- case of cerebral palsy Theories of G&D Developmental tasks- different form chronological age -skill or growth responsibility arising at a particular time in the individuals life. The successful achievement of which will ------- a foundation for the accomplishments of future tasks.
Theorists 1. Sigmund Freud 1856-1939 Austrian neurologists. Founder of psychoanalysis - offered personality development Psychosexual theory a.) Oral Phase 0-18 months - mouths site of gratification -activity of infant- biting, sucking crying. -why do babies suck?- enjoyment and release of tension. -provide oral stimulation even if baby was placed on NPO. -pacifier. -never discourage thumb sucking. b.) ANAL- 18 months-3 years -site of gratification- anus -activity- elimination, retention or defecation of feces make take place - principle of holding on or letting go. -mother wins or child wins -child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins) -mother wins- obedient, kind, perfectionist, meticulous OC-anal phase -help child achieve bowel and bladder control even if child is hospitalized. c.) Phallic- 3-6 years site of gratification -genitals activity- may show exhibitionism -increase knowledge of a sexes -accept child fondling his/her own genitalia as normal exploration -answer Childs question directly.
Right age to introduce sexuality – preschool d.) Latent- 7-12 years -period of suppression- no obvious development. -Childs libido or energy is diverted to more concrete type of thinking -helps child achieve (+) experience so ready to face conflict of adolescence e.) Genital- 12-18 years -site of gratification -genitals -achieve sexual maturity -learns to establish relationships with opposite sex. -give an opportunity to relate to opposite sex. ERIC ERICKSON- psychoanalysis theory - stresses important of culture and society to the development of ones personality - environment - culture stages of psychosocial a.) trust vs mistrust – 0-18 months. -foundations of all psychosocial task -to give and receive is the psychosocial theme -know to develop trust baby 1. satisfy needs on time - breastfeed 2. care must be consistent and adequate -both parents- 1st 1 year of life 3.) give an experience that will add to security- touch, eye to eye contact, soft music. b.) Autonomy vs shame and doubt 18-3 years --- independence /self gov’t develop autonomy on toddler 1. give an opportunity of decision making like offer choices. 2. encourage to make decision rather then judge. 3. set limits c. initiative vs guilt- 4-6 years -learns how to do basic things -let explore new places and events -activity recommended- modeling clay, finger painting will enhance imagination and creativity and facilitate fine motor dev’t d. industry vs inferiority 7-12 yrs
-child learns how to do things well -give short assignments and projects e. Identity vs role confusion or diffusion 12-18 yrs - learns who he/she is or what kind of person he/ she will become by adjusting to new body image and seeking emancipation form parents -freedom form parents. f. Intimacy vs isolation 20-40 yrs -looking for a lifetime partner and career focus g. generatively vs stagnation 40- 60 45-65 yrs h. ego integrity vs, despair 60-65
JEAN PIAGET- Swiss psychologists -develop reasoning power STAGES OF COGNITIVE DEVELOPMENT A-Sensory motor 0-2 yrs -“practical intelligence”- words and symbols not yet available baby communicates through senses and reflexes. (sub div.)
Schema Age Behavior 1.) neonate reflex 1 month All reflexes 2.) primary circular 1-4 months -Activity related to body -repetition of behavior ex. thumb sucking 3.) secondary circular reaction 4-8 months -activity not related to body -discover obj and person’s permanence -memory traces present -anticipate familiar events. Coordination of secondary reaction 8-12 months -exhibit goal directed behavior
-increase of separateness (will search of lost toy, knows mom) Tertiary circular reaction 12-18 months -use trial and error to discover places and events -“ invention of new means” -capable of space and time perception (hits fork, spoon on table or drops fork) Invention of new means there mental combination 18-24 months -transitional phase to the pre operational thought period. Preoperational thought 2-7 years Schema age Behavior Preconceptual 2-4 yrs -thinking basically complete literal and static -egocentric- unable to view others interrupt -concept of dying is only now -concept of distance is only as fat as they can see. -concept of amenism inanimate object is alive -not aware of concept of r3eversibility- in every action theories an opposite reaction or cause and effect Initiative 4-7 yrs Beginning of causation Concrete Operational thought 7-12 years 1. able to find solution to everyday problems which systematic reasoning. 2. have concept of reversibility- cause and effect 3. have concept of longer uation – constancy despite of transformation. 4. 4. activity recommended- collecting and classifying 5. –stamps stationeries, dolls, rubber band markers.
Formal Operational thought 12 and up. 1. Cognition achieved its final form 2. can deal with past present and future 3. have abstract and mature thoughts. 4. can find solutions to hypothetical problems with scientific reasoning. 5. activity ------- will sort out opinions and current events. KOHLBERG- recognized the theory of moral dev’t as considered to closely approximate cognitive stages of dev’t -sabay with cognitive dev;t Stages of Moral dev’t Infancy – premoral, prereligious, amoral stage
AGE STAGE DESCRIPTION Pre-conventional Level 1 2-3 yrs 1 -Punishment/ obedience oriented (heteronymous morality) child does right cause a parent tells him or her to and to avoid punishment 4-7 2 -Individualism. Instrumental purpose and exch. Carries out action to satisfy own needs rather than society. -Will do something for another if that person does something for the child. Conventional Level 7-10 3 -Orientation to interpersonal relations of mutuality. Child followers rules cause of a need to be a “good” person in own eyes and eyes of others. 10-12 4 -Maintenance of social order fixed rules and authority. Child finds ff. rules satisfying. Follows rules of authority figures. Post-conventional Level III Above 12 yrs 5 -Social contract, utilitarian level making perspectives. Followers standards of society. 6 Universal ethical principle orientation. Follows internalized standards of conduct. E. DEV’T MILESTONES-major markers of growth and dev’t 1. Period of infancy- universal language of child-play a.) Play- Infancy- solitary plays -solo, mom interactive -facilitate motor and sensory dev’t -safety- important age appropriate solitary play- mobile, teeter, music box, rattle b.) fear of infancy- stranger anxiety begin 6-7 months peak 8 months diminishes 9 months 1 month- dance reflex disappears looks at mobile 2 months- holds head up when in prone, social smile, baby coos “doing sound” cry with tears -closure of frontal fontanel 2-3 months head lag when pulled to sitting position. 3 months- holds head and chest up when prone follows obj. past midline grasp and tonic neck reflex fading hand regard (looks at hand) 4 months – turns form front to back head control complete
needs space to turn Laugh aloud, bubbling sounds 5 months- turn both ways “roll over” -teething rings -handles rattle well -moro reflex disappears ( 4-5 months) 6 months- reaches out in anticipatory of being picked up -sits with support -uses palmar grasp -eruption of 1st temp teeth 6-8 months 2 lower incisors -say vowel sounds “ah”, “oh” -handles bottle well 7 months- transfer obj. hand to hand -likes obj that are good size 8 months- sits without support -peak of stranger anxiety -planters reflex disappears 8-9 months in prep for walking 9 months - creeps or crawls -neat finger grasp reflex - combine 2 syllables “mama” and “papa” - needs space for creeping 10 months – pull self to stand -understands “no” -responds to own name -peak a boo, pat a cake -can clap 11 months- cruisse - stands with assistance 12 months- stand alone take 1st step -walk with assistance -drink from cup, cooperate in dressing -says 2 words mama and dada -pots and pans, pull tay, nursery rhymes Toddler- parallel play- 2 toddlers playing separately
-provide with similar toys -squeaky frog to squeeze waddling duck to pull trucks to push-push pull toy building blocks, pounding peg toys to ride on fear- separation anxiety begin 9 months peak 18 months 3 phases of separation anxiety (in order) 1. P- protect 2. d despair 3. d- denial -don’t prolong goodbye -say goodbye firmly to develop trust- say when ul be back 15 months – plateau stage walks alone lateness in walking- mild mental retardation -puts small pellets into small bowl -holds spoon well - seats self on chair -creeps up stairs - 4 - 6 words 18 months- height of possessiveness favorite word- “mine” bowel control achieved (bowel 1st before bladder) -no longer rotates spoon -can run and jump in place walks up and down stairs holding railing or persons hand -1-20 words -name, body part -puts both feet on 1 step before advancing. 24 months- terrible two -can open doors by turning door knobs -unscrew lids -can walk upstairs alone –using both feet on same step at same time -50-200 words ( 2 words sentences) -daytime bladder control achieved ( daytime 1st- next nighttime bladder control)
30 months or 2 ½ years – makes simple lines or stroke for crosses with a pencil -can jump down from chairs -knows full name - copy a circle - holds up finger to show age - temp teeth complete post molar- last temp teeth to appear how many deciduous teeth -20 beginning of toothbrush – 2-2 ½ yrs tooth brushing with little assistance 3 yrs tooth brushing alone – 6 yrs right time to bring to dentist- when temp teeth complete 36 months or 3 yrs- trusting 3 - unbutton buttons (unbutton before learn to button) -draw a + - learns how to share -knows full name and sex (gender identity) - speaks fluently -nighttime bladder control -300-900 words -ride a tricycle Characteristic Traits of toddler negativistic- “NO!” -way to search for independence –limit questions –modify questions to a statement 2.) rigid, ritualistic and stereotype ritualism- for mastering 3.)Temper tantrums- head banging, screaming, stamping feet, holds breath –ignore behavior scaffoid abdominal-due to underdeveloped abdominal muscles physiologic anorexia- due to preoccupation with environment- food jag that last for short period of time loves rough and tumbling play loves toilet trainingfailure of toilet training- unreadiness Clues of toilet readiness: 1.) can stand, squat walk alone 2.) can communicate toilet needs
3.) can maintain dry for 2 hours Pre schoolers- associative or cooperative play 1.) bahay-bahayan – play house 2.) role playing 3.) fear-body mutilation or castration fear of dark places witches fear of thunder and lightning fear of ghosts
Milestones 4years old- furious 4 , noisy, aggressive, stormy -can button buttons -copy a square -jumps and skips -laces shoes -vocabulary 1,500 -knows four basic colors 5 years old- frustrating 5 -copy a triangle -draw a 6 part man -imaginary playmates -2,100 words Character Traits of Pre-schooler: 1.) curious, creative imaginative, imitative 2.) 2. favorite words- why and how 3.) complexes- word identification to parent of same sex and attachment to parent of opposite sex ex. Oedipal complex- boy to mom Electra complex- girl to dad Cause of incest marital discord Death-sleep only Behavior problems Preschool 1. telling tall tales-over imagination 2. imaginary friend- to release tension and anxieties
3. sibling rivalry- jealousy to newly delivered baby. 4. regression- going back to early stage -thumb sucking (should be oral stage only) -baby talk -bed wetting -fetal position 5. masturbation- sign of boredom -divert attention- offer a toy School Age Play- competitive play Ex. Tug of war, track and field, basket ball Fear. 1.) school phobia -orient to new environment 2.) displacement from school -teacher and peer of same sex 3. loss of privacy -wants bra 4.) fear of death -7-9yrs death is personified -death- permanent loss of life Significant Development a. boys- prone to bone fracture b. mature vision 20/20 6 years- temp teeth begin to fall perm teeth appear- 1st molar 1st temp teeth- 5 months 1st perm teeth- 6 yrs -yr of constant motion clensy mou’t recognize all shapes -1st grade teacher becomes authority figure -nail biting -begin interest in God. 7 yrs- assimilation age -copy a diamond -enjoys teasing and playing alone -quieting down period
8 yrs- expansive age -smoother mouth -loves to collect objects -count backwards 9 yrs –coordination improves -tells time correctly -hero worship -stealing and lying are common -takes care of body needs completely -teacher finds this group difficult to handle 10 yrs- age of special talent -writes legibly -ready for competitive games -more considerate and cooperative -joins orgs. -well mannered with adult -critical of adults 11-12 yrs – pre adolescents -full of energy and constantly active -secret language are common -share with friends secrets -sense of humor present -social and cooperative Character Traits School Age 1. industrious2. modest 3. can’t bear to lose- will cheat 4. love collections- stamps Signs of sexual maturity GIRLS: I-inc size breast and genitalia (pelarche- 1st sign sexual mat. W- widening of hips A- appearance axillary, pubic ( adrenarch) M- menarche- last sign sexual mat. Girls
BOYS:
A-appearance axillary, pubic hair ( 1st sign sexual mat) D-deepening voice D- development of muscles I--inc in testes and penis size P- prod of viable sperm ( last sign sexual maturity) Adolescent Fear 1. obesity 2. acne 3. homosexuality 4. death 5. replacement from friends 6. significant person- opp sex. Significant dev’t 1. experiences conflict bet his needs for sexual satisfaction and societies expectation 2. change of body image and acceptance of opp/sex 3. nocturnal emission – wet dreams 4. distinctive odor- due to stimulation apocrine glands 5. sperm is viable by 17 yrs 6. testes & scrotum increase until age 17 7. breast and female genitalia increase until age 18 Personality Traits Adolescents 1. idealistic 2. rebellious 3. reformers 4. conscious with body image 5. adventuresome Problems: 1. vehicular accident 2. smoking 3. alcoholism 4. drug addiction 5. pre marital sex IMMEDIATE CARE OF NEWBORN 1st days of life 1. initiation and maintenance of respiration
2. establishment of extra uterine circulation 3. control of body temp 4. intake of adequate nourishment 5. establishment of waste elimination 6. prevention of infection 7. establishment of an infant parent relationship 8. dev’t care that balances rest and stimulation or mental dev’t
1.) Initiation and maintenance of respiration 2nd stage of labor- initial airway -initiation of a /w is a crucial adjustment -most neonatal deaths with in 24 h caused by inability to initiate a/w -lung function begins after birth only How to initiate a/w a.) remove secretions bulb syringe B. Catheter Suctioning 1.) place head to side to facilitate drainage 2,) suction mouth 1st before nose -neonates are nasal breathers 3.) period of time -5-10 sec suctioning, gentle and quick prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve 4.) evaluate for patency -cover nostril and baby struggles there’s a need for additional suctioning C. If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40-60b/m. Nsg alert: 1. No smoking 2. Always humidify to prevent drying of mucosa 3. Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or retinopathy of prematurity) 4. When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium inside) 2.) Establishing extra uterine circulation
- circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord. FETO PLACENTAL CIRCULATION -Placenta(simple diffusion) –oxygenated blood is carried by the umbilical veinpasses liver-ductus venousus- IVC- RT atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve – LT ventricle- aorta-lower extremities. -Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition) (vasoconstriction of lungs pushes blood to ductus arteriousus to aorta to supply upper extremities.
SHUNTS-shortcuts Ductus venosus- -shunts from liver to IVF Foramen ovale- shunts bet 2 atrias Ductus arteriosus- from pulmonary artery to aorta
What will sustain 1st breath- decreased artery pressure What will initiate lung circulation-lung expansion What will complete circulation- cutting of cord 4.) 2 way to facilitate closure of foramen ovale a.) Tangential Footstep- slap foot of baby -never stimulate baby to cry if secretions not fully drained to prevent aspiration -check characteristic of cry normal cry- strong, vigorous and lusty cry cri-du-chat syndrome-chromosomal obliteration cat like cry b.) proper position -right side lying pos. -will increase pressure on left and foramen ovale will close Foramen Ovale and Ductus arteriosus will begin to close within 24h
Obliteration-complete closure Structure Appropriate time of obliteration Structure remaining Failure to close F. Ovale 1yr Fossa Ovalis Atrial Septal Defect Ductus Arteriosus 1 month Ligamentum Arteriosum Patent ductus arteriosus Ductus Venosus 2 months Ligamentum venosum Umbilical artery 2-3 months 1.) lateral umb. Ligament 2.) interior iliac artery Umbilical vein 2-3 months -ligamentum teres ( round ligament of liver)
Position of infant immediately after birth: NSD-trendelenberg/ T position for drainage contraindication of trendelenberg position - increase ICP CS- supine or crib level position Signs of increased ICP 1.) abnormally large head 2.) bulging and tense fontanel 3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of 4.) Decreased RR, decreased PR ICP 5.) projective vomiting- sure sign of cerebral irritation 6.) high deviation – diplopia – sign of ICP older child 4-6 months- normal eye deviation >6 months- lazy eyes 7.) High pitch shrill cry-late sign of ICP Temp Regulation - goal in temp regulation is to maintain it not less than 97.7% F (36.5 C) - maintenance of temp is crucial on preterm and SGA (small for gestational age) babies prone to hypothermia or cold stress A. factors leading to dev’t of HYPOTHERMIA 1. preterms are born poi kilo thermic- cold blooded - babies easily adapt to temp of environment due to immaturity of thermo
regulating system of body. Hypothalamus 2. inadequate SQ tissue 3. baby is not capable of shivering 4. babies are born wet
PROCESS OF HEAT LOSS 1. evaporation-body to air (TSB) 2. conduction- body to cold solid object (cold compress) 3. convection-body to cooler surrounding air (aircon) 4. radiation- body to cold object not in contact with body earliest sign of hypothermia- increase in RR Effects of Hypothermia ( Cold stress) 1.) Hypoglycemia- 45-55 mg/dl normal 50- borderline 2.) met acidosis- catabolism of brown fats (best insulator of newborns body) will form ketones 3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy 4.) additional fatigue to allergy stressful heart
To Prevent Hypothermia 1. dry and wrap baby 2. mechanical pressure – radiant warmer pre-heated first isolette (or square acrylic sided incubator) 3. prevent an necessary exposure – cover baby 4. cover baby with tin foil or plastic 5. embrace the baby- kangaroo care A. Establish Adequate Nutritional Intake CS- breastfeeding after 4 hours NSD- breastfeeding asap Physiology breast milk production As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior Posterior Gland (APG) releases prolactin – acts on acinar cells (or alveoli) – produce foremilk – stored in lactiferous tubules ( or collecting tubules) where breast milk is produced – alveoli post-pit.gland
Sucking- PPG – oxytocin – contraction of lactiferous tubules - milk ejection reflexlet down reflex. Advantages of Breastfeeding 1. Economical 2. Always available 3. Breastfed babies have higher IQ than bottle fed babies. 4. It facilitates rapid involution 5. Decrease incidence of breast cancer. 6. Has antibodies- IgA 7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT 8. Has macrophages Store milk- plastic storage container Store milk – good for 6 months from freezer- put rm temp. don’t heat Disadvantages: 1. Possibility of transfer HEP B, HIV, cytomegalo virus. 2. No iron 3. Father can’t feed & bond as well Stages of Breastmilk: 1. Colostrum- 2-4 days present content: decrease fats, increase IgA, dec CHO, dec CHON, inc minerals, inc fat soluble minerals 2. Transitional milk- 4 – 14 days content: inc lactose, inc water soluble vit., inc minerals 3. Mature milk- 14 & up content: inc fats (linoleic acid) – resp for devt of brain & integrity of skin inc CHO- lactose – easily digested, baby not constipated. - resp of sour milk smelling odor of stool. Lactose intolerance- deficiency of enzyme LACTASE that digest LACTOSE Decrease CHON- lactalbumin Cows milk – inc fatsDec CHO Inc CHON – casing- has curd that’s hard to digest. Inc minerals–traumatic effect on kidneys of babies. Can trigger stone formation. Inc phosphorus Health Teachings: 1. Proper hygiene- proper hand washing Care of breast - cotton balls with lukewarm water Caked colostrum- dry milk on breast 2. Best position in breastfeeding – upright sitting -avoid tension!
3. Stimulate & evaluate feeding reflexes a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be gone - Purpose rooting- to look for food. b.) Sucking – when you touch middle of lips then baby will suck - Disappears by 6 months - When not stimulated sucking will stop. c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed d.) Extrusion/ Protrusion reflex -when food touches anterior portion of tongue then food will be extruded. Purpose: to prevent from poisoning Disappear by 4 months & baby can already spit out by 4 months. Criteria Effective Sucking a.) Baby’s mouth is hiked up to areola b.) Mom experiences after pain. c.) Other nipple is also flowing with milk. To prevent from crack nipples & initiate proper production of oxytocin. - begin 2-3 min at @ breast ( 5 – 7 min other authors) to initiate production of oxytocin - increase 1 min/ day – until reaching 10 mins @ breast or 20 mins/ feeding. For proper emptying & continuous milk production / feeding -feed baby on last breast that you feed her with, alternately ( if not emptied mastitis) Problems experienced in Breastfeeding : 3RD day changes in breast post partum a.)Engorged- feeling of fullness & tension in breast. - sometimes accompanied by fever known as MILK FEVER. Mgt: Warm compress- for breastfeeding mom Cold compress – for bottle feeding & wear supportive bra. When is involution of breast- 4 weeks b.) Sore nipple – cracked with painful nipple Mgt: 1.) exposure to air – remove bra & wear dress, if not, expose to 20 Watt bulb avoid wearing plastic liner bra - will create moisture, cotton only
c.) Mastitis- inflammation of breast : staphylococcus aureus Factors: 1. Improper breast emptying 2. Unhealthy sexual practices -contraindicated for breast feeding - manually express inflamed breast feed on unaffected breast - give antibiotics – can still feed on unaffected breast Contra Indications in Breast Feeding: Maternal Conditions: 1. HIV CMV Hepa B Coumadin Newborn Condition - Inborn errors of metabolism Erythrobastosis Fetalis – Rh incompatibility Hydrops Fetalis Phenylketonuria Galactosemia Tay Sachs disease 5. Establish of waste elimination A. Diff stools 1. Meconium - physiologic stool - black green, sticky, tar like, odorless (Sterile intestine) will pass with in 24 – 36 hrs failure to pass mecomium after 24h- GIT obstruction ex. Hirschsprungs disease imperforate anus mecomium ileus – due to Cystic Fibrosis 2. Transitional stool - green loose & shiny, like diarrhea to the untrained eye 3. Breastfed stool - golden yellow, soft, mushy with sour milk smell, frequently passed - recur every feeding 4. Bottlefed stool – - pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day - with food added -brown & odorous Jaundice baby – light stool Under phototherapy – bright green Mucus mixed with stool - milk allergy
Clay colored stool – obstruction to bile duct Chalk clay stool – after barium enema Black stool – GIT bleeding (melena) Blood flecked stool - anal fissure. Currant jelly stool – instussusection Ribbon like stool – hirschsprung disease Steatorrhea stool – fatty, bulky foul smelling odor stool - malabasorption syndrome ( celiac disease or cystic fibrosis) Cult blood – stool exam III Assessment for Well–being APGAR SCORE – Dr. Virginia Apgar Special Considerations: 1st 1 min – determine general condition of baby Next 5 min- determine baby’s capabilities to adjust extra uterinely Next 15 min – dependent on the 5 min A- appearance- color – slightly cyanotic after 1st cry baby becomes pink. P- pulse rate – apical pulse – left lower nipple G- grimace – reflex irritability- tangential foot slap, catheter insertion A – activity – degree of flexion or muscle tone R – respiration Baby cry – within 30 secs Failure to cry after 30 secs – asphyxia near the neatorum Resp. depression – due mom given Demerol. Administer Naloxone
APGAR Scoring Chart: 012 HR -absent <100 >100 Resp effort -absent - slow, irreg, weak -good strong cry Muscle tone - flaccid extremities - some flexion - well flexed Reflex irritability Catheter - no response - grimace - cough, sneeze Tangential Footslap - NR - grimace - cry Color - blue/pale - acrocyanosis (body- pink extremities-blue) - pinkish
APGAR result 0 – 3 = severely depressed, need CPR, admission NICU 4 – 6 = moderately depressed, needs add’l suctioning & O2 7 - 10 =good/ healthy CPR – cardio pulmonary resuscitation or CPR Cardio pulmonary cerebral resuscitation 5 min no O2 – irreversible brain damage 1. shake, no resp, call for help 2. flat on head 3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway Breathing ( ventilating the lungs) 1. check for breathlessness if breathless, give 2 breaths- ambu bag > 1 yr old- mouth to mouth, pinch nose < 1 yr – mouth to nose force – different between baby & child infant – puff Circulation Check for pulslessness :carotid- adult Brachial – infants CPR – breathless/pulseless Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb CPR inf 1:5 Adults 2:15 Assessment tool determines respiration of baby Silvermann Anderson Index Respiration Evaluation – lowest score – best Criteria 0 1 2 Chest movement synchronized Lag on respiration See - saw Intercostal retraction No retraction Just visible Marked Xiphoid retraction None Just visible Marked Nares dilatation None Minimal Marked Expiratory grunt None Heard on stet only Heard on naked ear
Interpretation result: 0 -3 – normal, no RDS 4 – 6 – moderate RDS 7 – 10 – severe RDS
Assessment of Gestational Age -Ballards & Dobowitz Findings Less 36 weeks (Preterm) 37 - 38 39 and up Sole creases Anterior transverse crease only Occasional creases 2/3 in Covered with creases Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky Ear lobe Pliable Some cartilage Thick cartilage Testes and Scrotum testes in lower canal Scrotum – small few rugae Some intermediate Testes pendulus Scrotum full extensive rugae Signs of Preterm Babies Born after 20 weeks, after 37 weeks -frog leg or laxed positon -hypotonic muscle tone- prone resp problem -scarf sign – elbow passes midline pos. - square window wrist – 90 degree angle of wrist - heal to ear signabundant lanugoSigns of Post term babies: > 42 weeks - classic sign – old man’s face - desquamation – peeling of skin - long brittle finger nails - wide & alert eyes Neonates in Nursery Nsg responsibility upon receiving baby- proper identification - foot printing, affixing mother thumb print - take anthropometic measurement normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm head circumference 33- 35 cm or 13 – 14 “
Hydrocephalus - >14” Chest 31 – 33 cm or 12 – 13” Abd 31 – 33 cm or 12 – 13” Bathing - oil bath – initial - to cleanse baby & spread vernix caseosa Fx of vernix caseosa 1. insulator 2. bacterio- static Babies of HIV + mom – immediately give full bath to lessen transmission of HIV - 13 – 39% possibly of transmission of HIV Full bath – safely given when cord fall Dressing the Umbilical Cord – strict asepsis to prevent tetanus 3 cleans in community 1. clean hand 2. clean cord 3. clean surface betadine or povidone iodine – to clean cord check AVA, then draw 3 vessel cord If 2 vessel cord- suspect kidney malformation - leave about 1” of cord - if BT or IV infusion – leave 8” of cord best access - no nerve - check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood bleeding of cord – Omphalagia – suspect hemophilia Cord turns black on 3rd day & fall 7 – 10 days Faiture to fall after 2 weeks- Umbilical granulation Mgt: silver nitrate or catheterization - clean with normal saline solution not alcohol - don’t use bigkis – air - persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal umbilicus dx: nitrazine paper test – yellow – urine mgt: surgery Credes Prophylaxis – Dr. Crede -prevent opthalmia neonatorum or gonorrheal conjunctivitis
- how transmitted – mom with gonorrhea drug: erythromycin ophthalmic ointment- inner to outer silver nitrate (used before) – 2 drops lower conjunctiva (not used now) Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia - Aquamephyton, phytomenadione or konakion - .5 – 1.5 ml IM, vastus lateral or lateral ant thigh - 5 ml preterm baby Vit K – synthesized by normal flora of intestine Vit K – meds is synthetic due intestine is sterile Weight: Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg / 6.5 - 7.5 lbs Arbitrary lower limit 2500 gm Low birth wt baby delivered < 2500g Small for gestational age (SGA) < 10th % rank or born small Large for gestational age > 90th % rank or macrosomia >4000 g Appropriate for GA – within 2 standard deviation of mean Physiologic wt loss – 5 – 10% wt loss few days after birth Small GA < (less) 10 Large GA > (more) 90 Physical Exam and Deviations fr Normal 1. if client is new born, cover areas not being examined 2. if client is infant – the 1st yr of life - get VS – take RR 1st - begin fr least intrusive to the most intrusive area 3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stet, security blanket – favorite article. Let baby hold it. 4. Explain procedure and respect their modesty - school age and adolescent V/S: Temp: rectal- newborn – to rule out imperforate anus - take it once only, 1 inch insertion Imperforate anus 1. atretic – no anal opening 2. agenetic – no anal opening 3. stenos – has opening 4. membranous – has opening
Earliest sign: 1. no mecomium 2. abd destention 3. foul odor breath 4. vomitous of fecal matter 5. can aspirate – resp problem Mgt: Surgery with temporary colostomy Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple Radial pulse – normally absent. If present PDA Femoral pulse – normal present. If absent- COA - coartation of aorta Congenital Heart Dse Common in girls – PDA, ASD atrial septal Common in boys – TOGA ( transportation of great arteries) TA – tronchus arteriosus TOF – tetralogy of fallot Causes: 1. familial 2. exposure to rubella – 1st month 3. failure of strucute to progress acyanotic L to R cyanotic R – L Acyanotic heart defects L to R 1. ventricular septal defect - opening between 2 ventricles S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign 2. cardiac catheterization reveals increased o2 saturation @ R side of heart 3. ECG reveals hypertrophy of R side of heart Nsg Care: Cardiac catheterization: site – Rt femoral vein 1. NPO 6 hrs before procedure 2. protect site of catheterization. Avoid flexion of joints proximal to site. 3. assess for complication – infection, thrombus formation – check pedal pulses ( dorsalis pedis) Mgt.
1.) long term antibiotic – to prevent subacute bacterial endocarditis 2.) open heart surgery2.) ASD – failure of foramen ovale to close S&SX 1. systolic murmur @ upper border of sternum 2. result of cardiac catheterization & ECG same with VSD Mgt: open heart surgery 3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve Dx – confirmed by cardiac catheterization Mgt: - open heart surgery Antibiotics to prevent subacute bacterial endocarditis 4.) PDA - failure of ductus arteriosus to close - should close within 24 h -complete close – 1 month S&Sx 1. continuous machinery like murmurs 2. prominent radial pulse 3. ECG- hypertrophy Left ventricle Drug: 1. endomethazine – prostaglandin inhibitor - facilitate closing of PDA 2. ligation of PDA by 3-4 yo 3. thoracotomy procedure- nakadapa child 5.)Pulmunary Stenosis- narrowing of valve of pulmo artery S &Sx: 1.) typical systolic ejection murmur 2. S2 sound widely split 3. ECG- Lt ventricular hypertrophy 6.)Aortic Stenosis – narrowing of valve of aorta S & Sx: 1. inactive, sx sme with angina 2. typical murmur 3. rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy Mgt Pulmo Stenosis & Aortic Stenosis 1.) balloon stenostomy 2.) surgery Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus S&Sx : 1. dysphagia 2. dyspnea
3. left ventricular hypertrophy Mgt: - close heart surgery 8.) Coartation of Aorta – narrowing of arch of aorta outstanding Sx : absent femoral pulse BP increased on upper extremities and decreased on lower extremities ECG – hypertrophy Lft ventricle Mgt: close heart surgery CYANOTIC HEART DEFECTS R to L 1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle pulmo artery arising form Lt ventricle Outstanding Sx: 1. cyanosis after 1st cry (due no exygenation) 2. polycythemia – increased RBC =compensatory due to O2 supply=viscous blood =thrombus = embolus = stroke 3. ECG – cardiomegaly Cardiac cath – decreased O2 saturation Palliative repair – rashkind procedure Complete repair – mustard repair 2.) Total Anomalous Pulmonary venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC Increased pressure on Rt so blood goes to Lft Outstanding Sx: Open foramen ovale Mild to moderate cyanosis Polycythemia = thrombus = embolus = stroke asplenia- absent spleen Mgt: restructuring of heart 3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD S & Sx 1. cyanosis 2. polycythemia – thrombus = embolus = stroke Mgt: Heart transplant 4.) Hypoplastic Left heart syndrome – non fx Left ventricle 1. cynosis 2. polycythemia – throm, emb, stroke Mgt: heart transplant
5.) Tricuspid atresia – failure of tricuspid valve to open S&SX: open foramen ovale (R to L shunting – goes to Lt atrium) cynosis, polycythemia Mgt: fontan procedure – open tricuspid valve 6.) Tetralogy of Fallot P – pulmonary stenosis V – ventricular SD O – overriding or dextroposition of aorta R – Rt ventricular hypertrophy S &Sx: 1. Rt ventricular hypertrophy 2. high degree of cyanosis 3. polycythemia 4. severe dyspnea – squatting position – relief , inhibit venous return facilitate lung expansion. 5. growth retardation – due no O2 6. tet spell or blue spells- short episodes of hypoxia 7. syncope 8. clubbing of fingernails – due to chronic tissue hypoxia 9. mental retardation – due decreased O2 in brain 10. boot shaped heart – x-ray Mgt: 1. O2 2. no valsalva maneuver , fiber diet laxative 3. morphine – hypoxia 4. propranolol – decrease heart spasms 5. palliative repair – BLT blalock taussig procedure Brock procedure – complete procedure ACQUIRED HEART DSE 1. RHD Rheumatic Heart Disease - inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary
Sorethroat before RHD Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and occludes mitral valve.
Jones Criteria Major Minor 1. polyarthritis – multi joint pain 1. arthralgia – joint pain 2. chorea – sydenhamms chores or st. vetaus dance-purposeless involuntary hand and shoulder with grimace 2. low grade fever 3. carditis – tachycardia erythema marginatum - macular rashes SQ nodules 3. all lab results increase antibody “ C reactive protein “ erythrocyte sedimentation rate “ anti streptolysin o titer (ASO) Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx. Nsg Care: 1. CBR 2. throat swab – culture and sensitivity 3. antibiotic mgt – to prevent recurrence 4. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin. S/E of aspirin: - Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and brain Respiration Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis. < 15 secs – normal apnea –newborn Resp Check Newborn – 40 – 90 1 yr - 20 – 40 2-3yr 20 – 30
5 yrs 20 – 25 10 yrs 17 – 22 15 & above 12- 20 BREATH SOUNDS HEARD DURING ASCULTATION: 1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal 2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal 3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration. Normal 4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal 5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli. Abnormal- asthma, foreign body obstruction. 6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction 7.) STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx. Abnormal – resp obstruction Asthma- pathognomonic sign – expiratory wheezing Pet – fish. Sport – swimming Drugs – amynophylline – monitor bp, may lead to hypotension Laryngo Tracheo Bronchitis LTB - inspiratory stridor – pathognomonic sign RDS respiratory dist synd or hyaline membrane dis Cause- lack of surfactant – for lung expansion Hypotonia, Post surgery, Common to preterm Fibrine hyaline Sx – definite with in 1st of life Increase RR with retraction Inspiratory grunting – pathognomonic 7 – 10 severe RDS (silvermenn Anderson index) cyanosis due to atelectasis Mgt: 1. surfactant replacement and rescue 2. pos- head elevated
3. proper suctioning 4. o2 with increase humidity- to prevent drying of mucosa 5. monitor V/S skin color , ABG 6. CPAP- continuous + a/w pressure 7. PEEP - + end expiratory pressure Purpose of #6-7- to maintain alveoli partially open and alveoli collapse LARYNGOTRACHEOBRONCHITIS LTB – most common Creup -viral infection of larynx, trachea & bronchi outstanding sx - croupy cough or barking pathognomonic - stridor - labored resp - resp acidosis - end stage – death Lab: 1. ABG 2. neck and throat culture 3. dx- neck x-ray to rule out epiglotitis Nsg Mgt: 1. bronchodilators 2.increase o2 with humidity 3. prepair tracheostomy set BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus Causative agaent – RSV - Resp sincytial viruses Sx: flu like sx Increased RR Drug: Antiviral – Ribavirin End stage – epiglotitis EPIGLOTITIS - infl of epiglottis - emer. Condition of URTI Sx: sudden onset Tripod position – leaning forward with tongue protrusion - never use tongue depressor prepare tracheotomy set < 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie Nsg Care: check edges tucked on mist tent Provide washable plastic material No toys with friction due O2 on No hairy toys – due moist environment medium for bacterial growth
BP – 80/46 mmHg newborn BP after 10 days- 100/50 BP taking begins by 3 yo COA – take BP on 4 extremities SKIN: Acrocyanosis BIRTHMARKS: 1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old 2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek. 3. Lanugo – fine, downy hair – common preterm 4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) – pink patches nape of neck hair will grow as child ♣ grows old 6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place. 7. Harlequin sign – dependent part is pink, independent part is blue (side lying – bottom part is dependent pink) 8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas – vascular tumors of the skin 3 types Hemangiomas a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo. c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage Skin color blue – cyanosis or hypoxia White – edema Grey – inf Yellow – jaundice , carotene Vernix Caseosa – white cheese like for lubrication, insulator BURN TRAUMA – injury to body tissue caused by excessive heat. INFANT 5-9 yo ANTERIOR POSTERIOR Ant Post Head 9.5 9.5 6.5 6.5
Neck 1 1 1 1 Upper arm 2 2 2 2 Lower arm 1.5 1.5 1.5 1.5 Hand 13 1.25 1.25 1.25 Trunk 13 13 Back 13 13 Genital 1 1 @ buttocks 2.5@ 2.5 @ Thigh 2.75 2.75 4 4 Leg 2.5 2.5 3 3 foot 1.75 1.75 1.75 1.75
DEPTH 1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN -sunburn, heals by regeneration from 1 – 10 days 2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful scalds ¬ 3rd degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone lethargy, ¬ white or black, not painful – nerve endings destroyed ex. lava¬ burns Mgt: 1.) 1st aid a.) put out flames by rolling child on blanket b.) immerse burned part on cold H2o c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing
2.) a/w a.) suction PRN, o2 with increased humidity b.) endotracheal intubation c.) tracheostomy 3.) Preventiuon of shock & F&E imbalance a. colloids to expand bld volume b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories 4.) Tetanus toxoid booster 5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree – very painful 6.) 1st defense of body – intact skin prevention of wound infection
a.) cleaning & debriding of wound b.) open or close method of wound care c.) whirlpool therapy – drum with solution 7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft frozen cadaver – hallow graft 8,) diet – increase CHON, increase calories. ATOPIC DERMATITIS- infantile eczema (galis) Papulo vesicular erythematus lesions with weeping & crusting Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white – lechenification Goal of care: decrease pruritus – avoid food allergens Diet: Prosobi or Isomil Hydrate skin, borow solution 1% hydrocortisone cream Prevent infection – proper handwahsing, trim nails IMPETIGO- skin disease. Causative agent – grp A beta Hemolytic streptococcus - papulovesicular surrounded by localized erythema –becomes purulent , oozes a honey colored crust Pediculosiscapitis –“KUTO” - Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment Can lead to acute glomerulonephritis AGN ACNE- adolescent problem - self limiting infl dis – sebaceous gland comedones – sebum causing white heads - sebum- lipids causing acne bulgaris Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi
ANEMIA-pallor Causes: 1.)early cutting of cord – preterm – cut umb cord ASAP fullterm – cut umb cord when pulsation stops 2.) Bleeding disorders – blood dyscrasias HEMOPHILIA – deficiency of clotting factor. X linked recessive – inherited If mom – carrier, son – affected If father carrier- transmitted to daughter
Hemophilia A – deficiency of coagulation component factor 8 Hemophilia B –or christmas disease, deficiency of clotting factor 9 Hemophilia C – deficiency of clotting factor 11 Assessment: - umphalagia – earliest sign - newborn receive maternal clotting factor - newborn growing – sudden bruising on bump area- marks earliest sign - continuous bleeding – hematrosis – damage or bleeding synovial membrane Dx test : PTT. Partial thromboplastin time – reveals deficiency in clotting factor Long Term Goal- prevention of injury Nsg Dx- increase risk of injury HT: avoid contact sport, swimming only, don’t stop immunization – just change gauge of needle Falls – immobilized , elevate affected part, apply pressure-not more then 10 min cold compress -determine case before doing invasive procedure LEUKEMIA- grp of malignant disease - rapid proliferation of immature WBC - WBC – protection from infection, soldiers of body Classification : 1. Lympho – affects lymphatic system 2. Myelo – affects bone marrow 3. acute / blastic- affects immature cells 4. chronic/ cystic- affects mature cells MOST COMMON CANCER – (ALL) – Acute Lymphocytic Leukemia S&Sx: 1. from invasion of bone marrow signs of infection a.) fever b.) poor wound healing c.) bone weakness & causes fracture signs of bleeding a.) petecchiae-small, round, flat, dark red spot b.) epistaxis c.) blood in urine/ emesis signs of anemia
a.) pallor , body malaise , constipation 2. from invasion of body organ- hepato spenomegaly – abd pain , CNS affectation, increase ICP Dx Tests: 1. PBS- peripheral blood smear – determine immature RBC 2. CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia 3. lumbar puncture (LP) – determine CNS involvement. Before LP, fetal pos.avoid flexion of neck – will cause a/w obstruction.“C” position or shrimp position only. 4. bone marrow aspiration – determine blast cells, - common site- iliac crest - post BMA s/effect – bleeding - apply pressure. Put pt on affected side to prevent hemorrhage 5. Bone scan – determine bone involvement 6. CT scan – determine organ involvement Therapeutic Mgt: TRIAD: 1. surgery 2. irradiation 3. chemotheraphy Focus Nsg Care: prevent infection 4 LEVELS OF CHEMOTHERAPHY 1. induction – goal of tx; to achieve remission meds: IV vincristine L- agpariginase Oral predinisone 2. Sanctuary- treat leukemic cells that invaded testes & CNS give: methotrixate- adm intrathecally via CNS or spine cytocine, Arabinoside, steroids with irradiation 3. maintenance- to continue remission give: oral methotrisate – check WBC -adm of methotrisate – do weekly WBC check 4. Reinductin – treat leukemic cells after relapse occurs. Meds – same as induction - give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy.
Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement. Based on Maslow’s heirarchy S/Effect of Chemotherapy 1. N/V – adm antiemetic drugs 30 mins before chemo until 1 day after chemo 2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req) - oral care – alcohol free mouthwash , betadine mouthwash - don’t brush – use cotton pledgets - topical xylocaine before meals diet- soft, bland diet according to child’s preference Temporary S/E of chemo: Alopecia – altered body image Hirsutism – hair -give emotional support to parents ABO incompatibility – Most common incompatibility – ( mom) O – ( fetus) A Most severe incompatibility (Mom) O– (Fetus) B Can affect 1st pregnancy Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice Within 24 h Mgt: 1. initiate breastfeeding to get colostrum 2. Temp suspension of breastfeeding - content breast milk pregnanedioles – that delays action of glucoronil transferees liver enzymes converts in direct bilirubin to become direct bilirubin 3. Needs phototherapy 4. needs exchange therapy Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term Normal – 0-3 mg/dL - bilirubin encephalopathy - Kemicterus - > 20 mg/dL among full term & >12 mg /dl of indirect – preterm =can lead to cerebral palsyPhysiologic jaundice – jaundice within 48 -72 h (2-3 days) expose morning sunlight Pathologic Jaundice – within 24h. Jaundice during delivery.
Breastfeeding jaundice – caused by pregnanediole Assessment of Jaudice : 1. Blanching neonates forehead, nose or sternum - yellow skin & sclera - color of stool – light stool - color of urine – dark urine Mgt: Phototheraphy – photo oxygenation Nsg Resp: 1. cover eyes – prevent retinal damage 2. cover genitals – prevent priapism – painful continuous erection 3. change position regularly – even exposed to light 4. increase fld intake – due prone to dehydration 5. monitor I&O – weigh baby 6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy = bronze baby syndrome-transient S/E of phototherapy weigh diaper 1gm = 1cc Head – largest part of baby ¼ of its length Craniostenosis or craniosinustosis – premature closing of fontanel Hydrocephalus – ant fontanel open after 18 mos Microcephaly – small growing brain due- alcohol & HIV mom Anencepahly – absence of cerebral hemisphere Craniotabes – localized softening cranial bone. Common – 1st born child -due early lightening (2 weeks prior to EDD) Rickets of Vit B deficiency – soft cranial bone in older children Caput Succedaneum – edema of scalp due prolonged pressure at birth Char: 1. present at birth 2. crosses suture lines 3. disappear after 2-3 days Cephalhematoma- collection of blood due to rapture of pericostal capillaries Char : 1. present after 24 h 2. never cross suture line 3. disappear after 4-6 weeks 4. monitor for developing jaundice
Seborrheic Dermatitis – ‘craddle cap” Scaling, greasy appearing salmon colored patches – seen on scalp behind ears and umbilicus Cause: - improper hygiene Mgt: 1. proper hygiene 2. put oil night before shampoo - baby oil Hydrocephalus – excessive accumulation of CSF 1. communicating – extra ventricular hydrocephalus 2. non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus due to tumor obstruction Sx – ICP – abnormally large head, bulging fontanel - cushings triad - high pitched cry older child – diplopia – eye deviation, projectile vomiting - fontanel bossing – prominent forehead - - prominent skull vein - sunset eyes Mgt: position to lessen ICP – low semi-fowlers 30 degree angle Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam Decrease CSF production Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt) Shave hair – in OR – to prevent growth of micro org. Nsg Care: 1.) post VP shunt – side lying on non operated site - to prevent increase ICP -monitor for good drainage - sign – sunken fontanel -bulging fontanel – blocked shunt -change fontanel as child is growing SENSES EYES: Assessment 1. check for symmetry 2. sclera – normal color – light blue then become dirty white pupil – round- adult size coloboma- part of iris is missing sign: key hole pupil -whiteness & opacity of lens congenital cataract cornea – round & adult size
large – congenital glaucoma Test for blindness common tests 1. newborn – general appearance - can only see 10 – 12 “ - visual acuity 20 /200 to 20/ 800 Doll’s eyes test- test for blindness - done 10th day - pupil goes opposite to direction when head is moved Globellars test – test for blink reflex. Points near nose – baby should blink 2. Infant & children - appearance - ability to follow object past midline 3. 3 yrs – school age - general appearance Allen cards – test for visual acuity. Show picture 20 ft away Ishiharas plates – test for color blindness Prechool E chart - test for stereopsi of depth perception Cover testing test – cover 1 eye for 10 – 15 min. Then remove. Test for strabismus 4. School age – adult - general appearance - snellens test Retinobastoma – malignant tumor of retina Outstanding sign : oat’s eye reflex-whitish glow of pupil - red painful eye - blindness surgery – Enucliation – removal of eyeball put artificial aye NOSE: 1. flaring alenase – case of RDS 2. cyanosis at rest – choanal atresia - post nares obstructed with bone or membrane Sx: 1. resistance during catheter insertion 2. emer. Surgery within 24 h normal color nasal membrane – pinkish rhinitis – presence of creases & pale
check sense of smell – blindfold – smell Hair in nose – cilia Adolescent no hair with ulceration of nasal mucosa suspect cocaine user Epistaxis – nosebleed - sit upright, head slightly forward to facilitate drainage - cold compress , apply gentle pressure, epinephrine most developed sense of newborn – sense of touch 1st sense to develop & last to disappear – hearing EARS: 1. Properly aligned with outer cantus of eyes low set ear – kidney malformation ex. Renal aginesis – absence of kidney sign in uterus : oligohydramnios sign in newborn: 2 vessel cord failure to void within 24 h Mgt: kidney transplant
Chromosomal aberrations : -advance maternal age 1. non disjunction – uneven division Trisomy 21 - down syndrome - extra chromosome 47xx + 21 - related to advance paternal age Sx: Mongolian slant Broad flat nose Protruding neck Puppy’s neck Hypotonic – prone to resp problem Simean crease – single transverse line on palm. Trisomy 18 – “edward syndrome” Trisomy 13- patau syndrome Turner – Monosomy of X synd. - 45x0 - affected girls - signs evident during puberty - has poorly developed 2dary sexual char.
- Sterile Klinefelters Syndrome- has male genitalia - 47 XXY - poorly devt secpndary sexual characteristics - no deepening of voice -small testes, penis -sterile Klinefelter – Calvin Kline – male Turner – Tina Turner – female Otitis Media – inflammation of middle ear. Common children due to wider & shorter Eustachian tube Causes 1.) bottle propping 2.) Cleft lip/ cleft palate – Sx: Otitis 1. bulging tympanic membrane, color – pearly gray 2. absence light reflex 3. observe for passage of milky, purulent foul smelling odor discharge 4. observe for URTI Nsg Care: 1. position side lying on affected aside – to facilitate drainage 2. supportive care- bedrest, increase fld intake Med Mgt: 1. Massive dosage antibiotic Complication – bacterial meningitis 2. Apply ear ointment School age – up and down < 3 yo – down & back > 3 yo – up & back Small child – down & back ( no age) surgery (to prevent permanent hearing loss)– otitis media – myringotmy with tympanostomy tube post surgery – position affected side for drainage both – put ear plug if tympanous tube falls – healed na Bells Palsy- facial nerve #7 paralysis R/T forcep delivery Sx. 1. Continuous drooling saliva 2. inability to open , eye & close either eye Mgt:
Refer to PT TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach Outstanding Sx – Coughing Choking Continuous drooling Cyanosis Mgt:: Emergency surgery Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia Hypervitaminosis Natal tooth – tooth at birth. Move with gauze Neonatal tooth – tooth within 28days of life Moniliasis – oral candidiasis - white cheese like, curd like patches that coats tongue - oral thrush - Nsg Care – don’t remove, wash with cold boiled H2o Meds – nystatin / Mysnastatin – antifungal Kawasaki Dse--strawberry tongue - originated in Korea - Dr. Kawasaki discovered it - common in Japan - “mucocutaneous Lymphnode Syndrome” Sx: -persistent fever – 5 days -strawberry tongue , -desquamation of palm & sole - lymph adenopathy > 1.5 cm Drug: aspirin Can lead to MI LIPS- symmetrical Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy - common to boys - unilateral Cleft Palate- Failed palate to fuse by 9 – 12 wks of pregnancy - common to girls
- unilateral or bilateral Sx: 1. evident at birth 2. milk escapes to nostril during feeding 3. frequent colic & otitis media or URTI Mgt: 1. Surgery cleft lip repair – Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months ) Cleft Palate- uranoplasty = done 4-6 months to save speech Pre op care 1. emotional support especially to mom 2. proper nutrition 3. prevent colic feed – upright seating or prone pos burp frequently 2x at middle and after feeding-lower to upper tap 4. orient parents to type of feeding rubber tipped syringe – cheiloplasty paper cup/ soup spoon/ plastic cup – urano plasty 5. apply restraints – elbow restraints so baby can adjust post op Condition that warrants suspension of operation - colds & pharyngitis = can lead to generalized infection – septicemia Post Op Nsg Care : 1. airway – positon post cheilopasty – side lying for drainage post uranoplasty (tonsillectomy)- prone 2. assess for RDS sx bleeding 3. assess for bleeding – freq swallowing. 6-7 days after surgery – bleeding 4. proper nutrition - clear liquids- ( gelatin except red or brown color due may mask bleeding) - ( popsicle- not ice cream) full liquid soft diet regular diet 5. Maintain integrity of suture line such as: Logan bar – wash ½ strength Hydrogen Peroxide & saline solution- Bubbling effect traps microorganism
- prevent baby form crying for pain- analgesic NECK1.) check symmetry Congenital torticolis- “ wryneck”-burn injury of sternocleidomsstoid muscle during delivery – due to excessive traction at cephalic delivery Mgt: passive stretching exercise , Surgery Complication – scoliosis THYROID gland – for basal metabolism Congenial cretinism – absence or non functioning thyroid glands reasons for delaying dx: 1. Thyroid glands covered by sternocleidomastoid muscles in newborn 2. baby received maternal thyroxine 3. baby sleeps 16 – 20 h a day earliest sign: 1. change in crying 2. change in sucking 3. sleep excessively 4. constipation 5. edema – moon face late sign 1. mental retardation prognosis : mental retardation preventable when Dx is early Dx: 1. PPI-protein 2. radioimmunoassay test 3. radioactive iodine uptake Mgt: synthroid – sodium Levothyrosine -synthetic thyroid given lifetime - check pulse rate before giving synthroid - tachycardia – Sx of hyperthyroidism CHEST 1. symmetry 2. breast - transparent fluid coming out from newborn related to hormonal changes3. chest has retroactive – RDS 4. sternum sunken – pectus excavation
ABDOMEN (in order) 1. inspection I 2. Auscultation A 3. percussion P 4. Palpation P = Will change bowel sounds, so do last Normal contour of abd – slightly protruding Sunken abd- diaphramatic hernia – protrusion of stomach content through a defective diaphragm due to failure of puroperitoneal canal to close. Sx: 1. sunken abd 2. Sx of RDS 3. R to L shunting Mgt: Emergency surgery within 24h Omphalocele – protrusion of stomach contents in between junction of abd wall and umbilicus. Mgt- very small surgery If large – suspension surgery Nsg Mgt: protect sac- sterile wet dressing Gastrochisis – absence of abd wall Nsg Mgt: sterile wet dressing Fx of GIT 1. assists in maintaining F&E & acid base balance 2. Processes & absorbs nutrients to maintain metabolism & support G & D 3. excrete waste products from digestive process Recommended Daily Allowance Calories : 120 cal / Kbw/day (kilo body wt) 360 – 380 cal/ day CHON_ 2.2g /Kbw/day Principles in Supplementary Feeding Supplementary Feeding usually – 6 mos Supplementary feeding given – 4 mos. a.) solid food offered to ff sequence! 1. cereals – rich in iron
2. fruits 3. veg 4. meat b.) begin with small quantities c,) finger foods – offered 6 months d.) soft table food – “modified family menu” given 1 yr e.) dilute fruit juices – 6 mos f.) never give half cooked eggs – usually causes of salmoneliosis g.) don’t give honey – infant botulism h.) offered new food one at a time – interval of 4 – 7days or 1 week – determines food allergens Total Body Fluids- comprises 65 - 85% of body wt of infants & children Where fluids are greater in infants Extracellular fld – prone to develop dehydration Acid Base Balance dependent on the ff: a. chemical buffers b. renal & resp system involvement c. dilution of strong acids and bases in bld Resp Acidosis – carbonic acid excess - hypoventilation - RDS - COPD - Laryngotracheobronchitis (LTB) Resp Alkalosis – carbonic acid deficit - hyperventilation - fever - encephalopathy Met. Acidosis – base HCO3 deficit - diarrhea - severe dehydration - malnutrition - ciliac crisis Met Alkalosis – base HCO3 excess - uncontrolled vomiting - NGT aspiration - Gastric lavage PROBLEMS LEADIING TO F&E IMBALANCE 1. vomiting – forceful expulsion of stomach content Sx:
1. nausea 2. dizziness 3. facial flushing 4. abd cramping assess: amt, freq, force projectile vomiting= increase ICP or pyloric stenosis Mgt: BRAT diet - banana, rice – cereal, apple sauce, toast 2. Diarrhea – exaggerated excretion of intestinal contents Types: Acute diarrhea – related to gastroenteritis, salmoneliosis - dietary indiscretions - antibiotic use Chronic non specific diarrhea Cause: 1. food intolerance 2. excessive fld intake 3. CHO, CHON malabsorption Assess: freq, consistency, appearance of given colored stool. Best criteria to determine diarrhea : consistency Complication = dehydration Mild dehydration 5% wt loss Moderate dehydration 10% wt loss Severe dehydration 15 % wt loss Earliest sx of dehydration tachycardia increase temp weight loss tachypnea sunken fontanel & eyeballs scanty urine hypotension absence of tears Severe dehydration: Oliguria , Prolonged capillary refill time Mgt: Acute – NPO ( rest the bowel ) - with fluid replacement – IV - prone to Hypokalemia – give K chloride before adm of K chloride – check if baby can void, if cant void – hypokalemia
Drug: Na HCO3 – adm slowly to prevent cardiac overload
Gastric Motility Disorder: HIRSCHPRUNGS DISEASE – congenital aganglionic megacolon Aganglionic – absence of ganglion cells needed for peristalis Earliest sign 1. failure to pass mecomium after 24h 2. abd distension 3. vomitus of fecal material early childhood – ribbon like stool foul smelling stool constipations diarrhea Dx: 1. Barium enema – reveals narrowed portion of bowel 2. Rectal Biopsy – reveals absence of ganglionic cells 3. abd x-ray – reveals dilated loops on intestine 4. rectal manometry – revels failure of intestine sphincter to relax Therapeutic Mgt/Nsg care 1. NGT feeding – measure tube fr nose to ear to midline of xyphoid & umbilicus 2. surgery a.) temp colostomy b.) anastomosis & pull through procedure Diet: Increase CHON, increase calories , decrease residue – pasta GER- Gastroesophageal Reflux Chalasia – presence of stomach contents to esophagus Will lead to esophagitis complication – aspiration pneumonia Esophageal cancer Assessment : 1. chronic vomiting 2. faiture to thrive syndrome 3. organic – organ affected 4. melena or hematemesis – esophageal bleeding Dx procedure
1. barium esophogram – reveals reflux 2. esophageal manometry – reveals lower esophageal sphincter pressure 3. intra esophageal pH content – reveals pH of distal esophagus. Meds of GERD Anti-cholinergic a.) Betanicol ( urecholine) – increase esophageal tone & peristaltic activity b.) Metachloporomide (Reglam) – decrease esophageal pressure by relaxing pyloric & duodenal segments - increase peristalsis without stimulating secretions c.) H2 Histamine Receptor Antagonist – decrease gastric acidity & pepsin secretion - Zimetidine, Ranitidine (Zantac) – take 30 min before meals d.) antacid – neutralizes gastric acid between feedings - Maalox Surgery: Nissen funduplication : Chronic vomiting – - thickened feeding with baby cereals - effective if without vomiting - feed slowly, burp often every 1 ounce - positioning < 9 months – infant sit with infant supine > 9 months – prone with head of mattress slightly elevated 30 degree angle OBSTRUCTIVE DISORDERS A. PYLORIC STENOSIS – hypertrophy of muscles of pylorus causing narrowing & obstruction. 1.) outstanding Sx- projectile vomiting - vomiting is an initial sx of upper GI obstruction - vomitus of upper GI can be blood tinged not bile streaked. (with blood) - vomitus of lower GI is bilous ( with pupu) - projectile vomiting – increase ICP or GI obstruction - abd distension – major sx of lower GIT obst 2.) met alk 3.) failure to gain wt 4.) olive shaped mass – on palpation 5.)serum electrolyte – increase Na & K, decrease chloride 6.) ultrasound 7.) x ray of upper abd with barium swallow reveal “string sign” Mgt: 1. Pyleromyotomy 2. Fredet Ramstedt procedure
INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another Common site – ilio-secal junction Prone pt: person who eats fat Complication – peritonitis – emergency Sx: 1.) persistent paroxysmal abd pain 2.) vomiting 3.) currant jelly stool- dye bleeding & inflammation - palpate sausage shaped mass Mgt: 1.) Hydrostatic reduction with barium enema 2.) Anastomosis & pull thru procedura Inborn Errors of Metabolism- deficient liver enzymes PHENYLKETONURIA (PKU) – deficiency of liver enzymes (PHT) Phenylalaninehydroxylase Transferase – liver enzyme that converts CHON to amino acid 9 amino acids: valine isolensine tryptophase lysine phenylalanine Thyronine – decrease malanine production 1.) fair complexion 2.) blond hair 3.) blue eyes Thyroxine – decrease basal metabolism - accumulation of Phenyl Pyruvic acid 4.) Atopic dermatitis 5.) musty / mousy odor urine 6.) seizure – mental retardation Test – GUTHRIE TEST – specimen – blood - preparation increase CHON intake - test if CHON will convert to amino acid specimen and urine mixed with pheric chloride, presence of green spots at diaper a sign of PKU DIET: Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts Give Lofenalac- milk with synthetic protein
Galactosemia – deficiency of liver enzyme - GUPT – Galactose Urovil Phosphatetranferase - Converts galactose to phosphate tranferace glucose Galactose – will destroy brain cells if untreated – death within 3 days Dx: Beutler test – get blood -done after 1st feeding presence of glucose in blood – sign of galactosemia galactose free diet lifetime neutramigen – milk formula CELIAC DISEASE – gluten enteropathy Common gluten food: Intolerance to food with brow B- barley R- rye O- oat W- wheat
Early Sx: 1. diarrhea – failure to gain wt ff diarrheal episodes 2. constipation 3. vomiting Late Sx: 1. abd pain – protruberant abd even if with muscle wasting 2. steatorrhea Celiac Crisis- exaggerated vomiting with bowel inflammation Dx: 1. lab studies – stool analysis 2. serum antiglyadin – confirmatory of disease gluten free diet – lifetime all BROW – not allowed ok – rice & corn Mgt: 1. vitamin supplements 2. mineral supplements
3. steroids
POISONING- common in toddlers. (falls- common to infant) 1. determine substance taken, assess LOC 2. unless poison is corrosive, caustic (strong alkali such as lye) or a hydrocarbon, vomiting is the most effective way to remove poison. - Give syrup 1 pecac to induce vomiting 3. 1 pecac – oral emetic - 15 ml – adolescent, school age & pre school - 10 ml to infant 4. UNIVERSAL ANTIDOTE- charcoal, milk of magnesia & burned toast 5. Never adm charcoal before 1 pecac 6. antidote for acetaminophen poisoning – acetylsysterine ( mucomyst) 7. caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t vomit prepare tracheostomy set 8. Gas- mineral oil will coat intestine Lead poisoning Lead = Destroy RBC functioning = Hypochornic Microcytic Anemia = Destroy kidney functioning Accumulation of anemia = Encepalopathy Sx: 1. beginning sx of lethargy 2. impulsiveness, learning difficulties 3. as lead increases, severe encepalopathy with seizure and permanent mental retardation
Dx: 1. Blood smear 2. abd x ray 3. long bones Mgt: 1. remove child from source 2. if > 20 ug/dL – need chelation therapy = binds with led & excreted by kidney =nephrotoxic Amogenital Female: Pseudomenstration slight bleeding on vagina related to hormonal changes
Tearing of fourchette with blood – rape/ child abuse Rape- Report within 48 h Shape pubic hair in inverted triangle ( female) Male: Undescended testes – cyrptorchidism -common to preterm surgery – orchidopexy assess scrotum- warm room & hands baby – pee within 24 h -check for arch of urination Epispadias- urinary meatus located dorsal or above glans penis Hypospadias- urinary meauts loc ventral or below glans penis Hypospadias with chordee- fibrous band causing penis to curb downward Mgt: Surgery Phimosis- tight foreskin Balanitis-infection of glands penis – due smegma Mgt: Circumsicion Hydrocele – fld filled scrotum Tst of Dx: Transillumination with use of flashlight - glowing sign Varicocele – enlarged vein of epididimis ( girls- vulvular varicosities)
BACK- check for flatness & symmetry Open Neural Tube Defect- decreased Folic Acid intake
SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to fuse Sx: dimpling of back , Abnormal tufts of hair SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac Types: 1. Meningocele – protrusion of CSF & Meninges 2. Myelomeningocele – protrusion of CSF & Meninges & spinal cord ( most dangerous) 3. Encephalocele ( CNS complication – hydrocephalus) – cranial meningocele or myelomeningocele Most common problem - rupture of sac - prone pos - sterile wet dressing Most common complication - infection Myelomeningocele – genitourinary complication- urinary & fecal incontinence Nsg care: always check diaper Orthopedic complication – paralysis of lower extremities Surgery to prevent infection Post op – prone position SCOLIOSIS- lateral curvature of the spine 2 types: 1. structural – rye neck 2. postural – improper posture Dx: 1. uneven hemline 2. bend forward- 1 hip higher 1 shoulder blade more prominent Nsg care: 1. conservative – avoid obesity, exercise 2. preventive – Milwaukee brace - worn 23 h a day 3. corrective surgery – insert Harrington rod post op- how to move log rolling- move client as 1 unit EXTREMITIES: check # of digits = 20 1. syndactyly – webbing of digits 2. polydactyly – extra digits 3. olidactyly – lack of digits
4. Amelia – total absence of digits 5. pocoamelia- absence of distal part of extremities
ErQ duchennes – paralysis- brachial plexus injury or brachial palsy - birth injury caused by lateral & excessive traction during a breech injury Sx: 1. unable to abduct arms from shoulders, rotate arm externally or supinate forearm 2. absence or asymetrical moro reflex Mgt: 1. abduct arm from shoulders with elbow flex. CONGENITAL HIP DISLOCATION – head of femur is outside acetabulum Types; 1. subluxated – most common type 2. dislocated Sx: 1. shortening of affected leg 2. asymmetrical gluteal fold 3. limited movement – earliest sx 4. (+) ortolanis sign – abnormal clicking sound 5. when able to walk – child limps – late sx- trendelenburg sign Goal of Mgt: Facilitate abduction Mgt. 1. triple diaper 2. carry baby astride 3. Frejka splint 4. Pavlik harness 5. Hip Spica Cast TALIPES – “clubfoot” a.) Equinos – plantar flexion – horsefoot b.) Calcaneous – dorsiflexion – heal lower that foot anterior posterior of foot flexed towards anterior leg c.) Varus- foot turns in d.) Valgus- foot turns out Equino varus- most common Assessment: 1. Straighten legs & flexing them at midline pos Mgt:
1. Corrective shoe- Dennis brown shoe, spica cast Fx: of cast – - to immobilize - bone alignment - prevent muscle spasm lead pencil – mark area to be amputated cold H20 – hasten setting process hot H20- slow setting process After cast application – how to move pt: - use open palm not fingers- fingers will cause indention - dry cast – natural air not blower - priority check : neurovascular check C- circulation M- motion S- sensation Cast – with bleeding - mask with ball pen edge of blood to know if bleeding is on going sign cast is dry = resonant sound, cast cold to touch do petaling– making rough surface of cast smooth CRUTCHES Fx: To maintain balance - To support weakened leg Principles in crutches - wt of body on palm! - Brachial pulsing – if wt of body in axila Renal Disorder Cause Sx Tx NSG CARE NEPHROTIC SYNDROME infectious 1. Anasarca- gen edema 2. massive protenuria 3. microscopic or no hematuria 4. serum CHON decreased 5. serum lipid increased 6. fatigue 7. normal or decreased BP Prednisone Diuretic Focus of care: monitor edema -weigh daily Diet: Increase CHON Increase K- OJ, beef broth, banana
Decrease Na AGN ( acute Glomerulo Nephritis) 3A’s; AGN, autoimmune, Grp A Autoimmune Grp A beta hemolytic streptococcus 1. (PPP) primary peripheral periobital edema 2. moderate protenuria 3. gross hematuria ( smokey urine) 4. serum K increased 5. fatigue 6. increase BP Complication : 1. hypersensive encephalopathy 2. anemia 1. anti HPN drug - hydralazine or apresoline 2. iron 1. weigh daily 2. monitor BP & neurologiuc status 3. Diet: decrease K, decrease Na - Do palm exercise- squeeze ball Different crutch Gaits: 1. Swing Through 2. Swing to - no weight bearing are allowed into lower ext 3. Three point Gait - wt bearing is allowed in 1 ext 4. Four point gait 5. Two point Gait - wt bearing allowed in 2 lower ext Posted by Rey at 6:34:00 PM 2 comments Reactions:
Obstetrical Nursing MATERNAL/OB NOTES Human Sexuality A. Concepts 1. A person’s sexuality encompasses the complex behaviors, attitudes emotions
and preferences that are related to sexual self and eroticism. 2. Sex – basic and dynamic aspect of life 3. During reproductive years, the nurse performs as resource person on human sexuality. B. Definitions related to sexuality: Gender identity – sense of femininity or masculinity 2-4 yrs/3 yrs gender identity develops. Role identity – attitudes, behaviors and attributes that differentiate roles Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse. Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change. - developed at the moment of conception. II. Sexual Anatomy and Physiology A. Female Reproductive System 1. External value or pretender a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis. Stages of Pubic Hair Development Tannerscale tool - used to determine sexual maturity rating. Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair at pubis symphysis Stage 3 occurs between ages 12 and 13 – darker & curlier at labia Stage 4 – occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh . b. Labia Majora - large lips longitudinal fold, extends symphisis pubis to perineum c. Labia Minora – 2 sensitive structures clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual arousal (Greek-key) fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery. Site – episiotomy.
d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice and bartholene’s glands. 1. Urinary Meatus – small opening of urethra, serves for urination 2. Skenes glands/or paraurethral gland – mucus secreting subs for lubrication 3. hymen – covers vaginal orifice, membranous tissue 4. vaginal orifice – external opening of vagina 5. bartholene’s glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs – secrets alkaline subs. Alkaline – neutralizes acidity of vagina Ph of vagina - acidic Doderleins bacillus – responsible for acidity of vagina Carumculae mystiformes-healing of torn hymen e. Perineum – muscular structure – loc – lower vagina & anus Internal: A. vagina – female organ of copulation, passageway of mens & fetus, 3 – 4inches or 8 – 10 cm long, dilated canal Rugae – permits stretching without tearing B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights. Size- 1x2x3 Shape: nonpregnant pear shaped / pregnant - ovoid Weight - nonpregnant – 50 -60 kg- pregnant – 1,000g Pregnant/ Involution of uterus: 4th stage of labor - 1000g 2 weeks after delivery - 500g 3 weeks after delivery - 300 g 5-6 weeks after delivery - returns to original, state 50 – 60 Three parts of the uterus 1. fundus - upper cylindrical layer 2. corpus/body - upper triangular layer 3. cervix - lower cylindrical layer * Isthmus lower uterine segment during pregnancy Cornua-junction between fundus & interstitial Muscular compositions: there are three main muscle layers whi
