• Neurological tissue (spinal cord and brain) grows the first 2 years that the brain reaches mature proportions by 2 to 5 years.
• Lymphoid Tissue (Spleen, Thymus, Lymph Nodes and Tonsillar Tissue) grows rapidly during infancy and childhood.
• Spleen is not usually palpable in adults, the spleen is palpable 1 or 2 cm below the left ribs in preschool children because of this rapid growth.
• In 5-year-olds, tonsillar tissue has already reached its peak size (about twice that of an adult). 
• Upon a/s: young school-age children appear to have large tonsils (the back of their throat seems to be “all tonsils”).
• In contrast, Reproductive Organs (genital tissue) show little growth until Puberty.
• Musculoskeletal System - childhood.

The child’s pattern of growth is in a head-to-toe direction, or cephalocaudal, and in an inward to outward pattern called proximodistal.

• Characteristics that babies inherit from the parents through the chromosomes 
• Race 
• Intelligence 
• Nationality 
• Temperament 
• Sex 
• Gender 

• parent-child relationship 
• ordinal position in the family 
• health 
• nutrition

• 0-18 months
• Foundations of all psychosocial tasks
• Give and receive: give consistent and adequate care: hugs, kisses, touch at least 3X/day
• SATISFY NEEDS ON TIME → SECURITY
  
  

• 18 months- 3 years old
• Seeking for independence / self-governance
• OFFER CHOICES → DECISION MAKING

• 4-6 years old
• Allowed to basic things
• EXPLORING → CREATIVITY & IMAGINATION → FINE MOTOR DEVELOPMENT

• 7-12 years old
• WORKLOAD INTO MANAGEABLE UNITS → DO THINGS WELL

• 12-18 years old
• SELF DISCOVERY (who he/she is and what kind of person) → ACCEPTANCE OF SELF & NEW BODY IMAGE → SEEK FREEDOM

• 18-20 years old / 40/45 years old
• SEARCH FOR LIFETIME PARTNER or CAREER FOCUS

• 40/ 45- 60/65 years old

• 60-65 years old and above

• Object Permanence - knowing that an object still exists, even if it is hidden. It requires the ability to form a mental representation (i.e. a schema) of the object.
• Causality - cause-and-effect thinking ; allows us to make inferences and reason about things that happen around us.
• Spatial relationships - in infancy, children use their senses to observe and receive information about objects and people in their environment. 

• Marked by egocentricity (the child can’t comprehend a point of view different from his own) 
• Time of magical thinking and increased ability to use symbols and language 

• Representational language and symbols
• Transductive reasoning - refers to when a child reasons from specific to specific, drawing a relationship between two separate events that are otherwise unrelated. 

• The child’s thought processes become more logical and coherent 
• Can use inductive reasoning 
• Child is less self-centered 

• Sorting 
• Ordering 
• Classifying facts to use in problem solving 

• Can think abstractly 
• Form logical conclusions from his observations 
• Establish and test hypotheses 

• Abstract ideas and concepts 
• Possibilities, 
• Inductive reasoning 
• Complex deductive reasoning

• Rational intellect 
• Irrational desires 

• The largest portion of the mind 
• The center of our primitive instincts and requires immediate gratification. 

• Develops in infancy and is the conscious, rational part of the personality; 
• Recognizes the larger picture 

• Represents the person’s conscience and ideals 
• It’s in continuous battle with the Id

• Decisions & behaviors are based on concerns about other’s reaction 
• The person wants approval or reward; seeks conformity and loyalty 

• First food given to infants
• Unnecessary to add sugar in the cereal
• Rich in iron
• Feed cereal until 3 or 4 years

• Vegetables have HIGH iron content
• Usually the second food given
• Fruit is usually offered 1 month after beginning vegetables (approximately 8 months)

• Meat is introduced at 9 months & egg yolks at 10 months
• Protein of egg white may cause allergies or may be difficult to digest
• Cook eggs thoroughly: danger of salmonella

• Infants are capable of approximating their lips to a cup effectively and controlling the flow at 9 months
• The sucking reflex begins to diminish in intensity between ages 6 months and 9 months making this the time to consider weaning

• A normal term infant can thrive on breast milk or formula milk without the addition of any solid food until 6 months.
• Chewing movements do not begin until 7-9 months.

• Offer new food one at a time.
• Wait 5-7 days before introducing new items.
• Introduce small amounts of new food: 1 or 2 teaspoons at a time.

• Leading cause of death
• Parents either underestimate or overestimate the child’s ability
• Things within the child’s reach must be safe to put into the mouth
• Toys should not have removable parts

• Second major cause of infant accidents
• Don’t leave child unattended on a raised surface
• Teach parents to be prepared for their infant to roll over by 2 months of age

• Always use car seats 
• Infants up to 20 lbs. should be placed in rear facing seats

• Move furniture in front of electrical sockets or buy protective caps for the outlets
• Check for sources of lead paint on painted cribs and rails
• Check stairways for safety
• Check table tops for pins or sharp objects that could be swallowed

• Immunoglobulin G (IgG): Protects against bacterial and viral infections. IgG can take time to form after an infection or immunization.
• Immunoglobulin M (IgM): Found mainly in blood and lymph fluid, this is the first antibody the body makes when it fights a new infection.

• ignore behavior
• monitor for safety

• Offer nutritious snacks
• May experience food jags
• Give 6 small meals esp. iron-rich food
• Avoid giving hotdog, peanuts, and grapes

• Rooming-in, transitional object, offer choices
• Consider water safety and injury prevention

• Sphincter control begins at age 2
• All deciduous teeth erupt by 2½ years
• Pot-bellied appearance

• Vocabulary of 25 words
• Walks independently
• Can use spoon
• Climbs
• Appropriate toys: push/pull toys, blocks

• Negativistic
• Temper tantrums
• Transitional object
• 2-4 word sentences
• Builds tower of six blocks

• Taking a careful health history
• Ability to carry out activities of daily living (ADL)
• Careful observation
• Child-parent relationship
• Parents: BEST source of information

• Health-seeking behaviors related to normal toddler development
• Deficient knowledge related to best method of toilet training
• Risk for injury related to impulsiveness of toddler
• Interrupted family process related to need for close supervision of 2-year-old
• Readiness for enhanced family coping related to parents’ ability to adjust to new needs of child
• Readiness for enhanced parenting related to increased awareness for poison prevention
• Disturbed sleep pattern related to lack of bedtime routine

• Establish realistic goals and outcomes so they can meet the rapidly changing needs of their toddler.

• Teach parents not only how to approach a current problem but also how to learn adequate methods for resolving similar situations that are sure to arise in the future
• Health visits 
• Demonstrating good communication skills with toddlers 

• Their abilities and associated parental concerns can change from day to day
• Parents state the child maintains a consistent bedtime routine within the next 2 weeks.
• Parents state they have childproofed their home by next clinic visit
• Grandmother states she has modified usual activities to conserve strength to care for toddler granddaughter by 1 week’s time.

1. They must have control of rectal and urethral sphincters, 
2. They must have a cognitive understanding of what it means to hold urine and stools until they can release them at a certain place and time
3. They must have a desire to delay immediate gratification 

• Important that toddlers do this if they are to grow up to be persons who are independent and able to take care of their own needs and desires
• Limit the number of questions asked of the child
• Parent could give a secondary choice

• Kick, scream, stomp feet, shout “no, no, no”, lie on the floor, flail arms and legs, and bang the head against the floor
• Response to an unrealistic request by a parent
• Best approach is for parents to tell a child simply that they disapprove of the tantrum and then ignore it

• Teach parents to place a small amount of food on a plate and allow their child to eat it and ask for more 
• Allowing self-feeding 
• Offering finger foods and allowing a choice between two types of food 

• Encourage parents to offer fruit or protein foods rather than high carbohydrate items for snacks.
• Schedule a first visit to a dentist skilled in pediatric dental care at about 12 months of age for assessment of dentition

• Learning self-reliance is the primary goal 
• Child still needs firm limits to feel secure
• A child must be given some room to make independent decisions in areas that the parents feel they do not need to control

• Tertiary Circular Reaction Stage
• Child experiments by trial and error methods

• Toddlers are able to try out various actions mentally 
• The beginning of problem solving or symbolic thought
• Deferred Imitation - remember an action and imitate it later

• Children deal much more constructively with symbols
• Assimilation - change the situation (or how they perceive it) to fit their thoughts

• Parallel play - child imitating what a playmate is doing while not seeming to interact with him directly.
• Stacking blocks ; toys children can control, giving them a sense of power in manipulation, an expression of autonomy

• Role playing a mood or attitude you would like a child to learn
• Health assessment is an enjoyable activity
• Accident prevention is also best taught by role modeling
• A parent always crosses streets at the corner and does not start the car until seatbelts are in place

Initiative, or learning how to do things, can be strengthened by allowing a child to prepare simple foods.

• vivid imagination = nightmares
• Reluctant to go back to bed or sleep again by themselves without light on
• Dim night light

• If parents take precautions but there are still nightmares: may be due to STRESS
• Find out the source of stress
• X sleep medications
• Hospital setting: more intensified

• Intense reaction of child to simple injury: PAIN & sight of injury
• Boys: fear of castration
• Good explanations: feeling of safety

• Distorted sense of time
• Limited sense of distance

Give reassurance that frequent minor illnesses are common in preschoolers.

• Play with other children their age much more
• Sensitive and critical time for socialization
• Four year old, involving some testing and identification of their group role
• Five-year-olds begin to develop “best” friendships
• Elementary Rule: an odd number of children will have
  difficulty playing well together pertains to children at
  this age: two or four will play, but three or five will
  quarrel

Need exposure to a wide variety of experiences and play materials.

• Undresses self
• Stacks tower of blocks
• Draws a cross

• Runs
• Alternate feet on stairs
• Rides tricycle
• Stands on one foot

• Constantly in motion
• Jumps 
• Skips 

• Draws a 6-part man
• Can lace shoes

• called school refusal or school avoidance
• may be a sign of a separation anxiety

• offer some privacy in this regard, when possible
• A child who knows that his own property is respected is more likely to understand the importance of respecting the property of others

• Encourage to help the child begin healthy habits for a lifetime
• Sports

• Brush at least twice a day and, if possible, after meals
• Flossing should be taught, and parents should monitor for method and compliance until the child is 8 years old
• Regular dental cleanings should be scheduled every 6 months
  
  

• Generally don’t require an afternoon nap
• Children should develop healthy sleep habits by not having a television in their bedrooms

• school and parental authority is questioned and, occasionally, even challenged or opposed
• importance of the peer group intensifies, and rough, bold, or even brazen behavior becomes increasingly common 
• peer group becomes the source of behavior standards 

• In Piaget’s concrete operational stage, organizing facts and problem-solving
• Uses inductive reasoning to solve new problems
• Thinks logically and develops concepts of measurement
• Generalizes
• Understands reversal of events
• Has an awareness of other’s feelings

• decline in imaginative play
• interest in collecting items

• Early period (13 to 14 years) 
• Middle period (15 to 16 years) 
• Late period (17 to 20 years)

• High-risk sexual behaviors exposing them to sexually transmitted infections or conception
• Caution adolescents about the dangers of flunitrazepam (rohypnol), the “date-rape drug,” a colorless, odorless, and flavorless benzodiazepine drug

• Refers to repetitive, intrusive, and unwanted actions directed at an individual to gain the individual’s attention or evoke fear
• Instils fear into their victims by constant and threatening pursuit

• Refers to demeaning or humiliating rituals that prospective members have to undergo to join sororities, fraternities..
• Most are secret ; "rites of passage"
• Moved out of the “just fun” category into activities that can cause physical and certainly psychological harm

• The use of chemicals to improve a mental state or induce euphoria
• Can be a response to peer pressure or a form of adolescent rebellion 
• Prescription and over-the-counter drugs -  experimentation containing dextromethorphan, abbreviated dxm
• Tobbaco 
• Alcohol -  correlated with motor vehicle accidents, homicide, and suicide 
• Performance-enhancing Drug Abuse - adolescents take steroids (obtained illegally) to enhance lean body mass and muscular development
• Marijuana - (widely known as pot or grass) is derived from the leaves and stems of the indian hemp plant, cannabis sativa

• Amphetmines - group of drugs sometimes used in the treatment of hyperactivity and narcolepsy, among other CNS disorders

• Cocaine - may be sniffed into the nose (snorted), smoked, or injected intravenously    

• Hallucinogens 
• Opiates - decreases repiratory rate ; risk the danger of contracting hiv/aids and hepatitis b infection if they share contaminated needles ; “snorting” heroin can lead to acute cerebral vascular accident and death

• Suicide 

• a child between the ages of 10 and 17 years who has been absent from home at least overnight without permission of a parent or guardian
•  most likely to be from low or high-income families

• BP is above the 95th percentile, or 127/81 mm Hg for 16-year-old girls and 131/81 for 16-year-old boys
• Obese 
• Who are african american 
• Who eat a diet high in salt 
• Who have a family history

• Tendency to round shoulders, and a shambling, slouchy walk 
• Imbalance of growth that arises from the skeletal system growing a little more rapidly than the muscle

• Strong mark of adolescence
• Know the symptoms of infection at a piercing or tattoo site (redness, warmness, drainage, swelling, mild pain) and to report if they occur as serious staphylococcal or streptococcal infections 

• Assess an adolescent’s diet, sleep patterns, and activity schedules
• Note onset
• Short period of extreme tiredness is more likely to suggest disease than a long, ill-defined report of always feeling tired

• Self-limiting inflammatory disease that involves the sebaceous glands that empty into hair shafts (the pilosebaceous unit) 
• Peak age for the lesions to occur in girls is 14 to 17 years; for boys, 16 to 19 year 

• Most common locations of acne are the: face, neck, back, upper arms, and chest
• As androgen levels rise in both sexes, sebaceous glands become active = abnormal keratinization (cell growth) of the lining of the ducts occurs; this overgrowth obstructs the ducts = the output of sebum increases
• whiteheads, or closed comedones
• blackheads, or open comedones
• Bacteria (generally, propionibacterium acnes) lodge and thrive in the retained secretions, forming papules
• Ask if they are troubled with acne and to what extent it interferes with their self-image 
• Most frequently used over-the-counter medications contain benzoyl peroxide
• Common prescription medication is retinoin (retin-a cream)
• Systemic Medication for cystic acne: Isotretinoin (Accutane), a form of vitamin A, is an extremely effective oral drug for reducing sebum production and abnormal keratinization of gland ducts
• Cortisone may be injected directly into cystic lesions to reduce inflammation
• Estrogen, alone or in combination with progesterone, suppresses sebaceous gland activity and is therefore useful therapy in some girls

1. high estrogen levels tend to close epiphyseal centers of long bones, causing bone growth to stop; and 
2. long-term therapy does have potential side effects, including embolism and thrombophlebitis and possibly breast and uterine cancer

• Both inheritance and environment
• Make a detailed log of the amount they eat, the time, and the circumstances (including how they felt)

• Athletes need more carbohydrate or energy than do people who do not engage in strenuous activity 
• a procedure used to ensure there is adequate glycogen to sustain energy through an athletic event 

• Motor vehicles are the leading cause of death
• Safety Helmets
• Long pants to prevent leg burns from exhaust pipes
• Full body covering to prevent abrasions
• Drive until they are emotionally mature enough to use sound driving judgment
• Drowning - teach all children to swim
• Homicide and Suicide - related to easy access of guns
• Athletic injuries because of vigorous level of competition

• Establishing a value system or what kind of person they want to be
• Accepting their changed body image
• Making a career decision
• Give Adolescents more freedom, help parents continue to place some restrictions on adolescent behavior 
• Thus, helping adolescents accept the responsibility that must come with independence
• Socialization: Be a positive role model
• Formal Operations: being able to manipulate the world in your mind
• Moral and Spiritual Development

• begins to menstruate 
• begins to produce spermatozoa
• puberty is the time at which an individual first becomes capable of sexual reproduction

• Penis
• Testes
• Vagina
• Ovaries

• Grow both rapidly and mature dramatically
• Recognizing that adolescents may have differing responsibilities and life experiences based on cultural expectations

• Obtain a health history separately from parents to promote independence and responsibility for self-care 
• Very self-conscious with physical exam

• Health-seeking behaviors related to normal growth and development 
• Low self-esteem related to facial acne 
• Anxiety related to concerns about normal growth and development 
• Risk for injury related to peer pressure to use alcohol and drugs 
• Readiness for enhanced parenting related to increased knowledge of teenage years

• Respect they want to exert independence or do things their own way 
• Including them in planning  
• Establishing a contract
• Teaching by peers 

• Client states she is able to feel good about herself even though she is the shortest girl in her class 
• Client states he has not consumed alcohol in 2 weeks 
• Parents state they feel more confident about their ability to parent an adolescent. 
• Client states she feels high self-esteem despite persistent facial acne

• Young Adulthood - young adults are defined as people 20 to 40 years old
• Middle Adulthood - middle-aged adults as 40 to 65 years old
• Late Adulthood 

1. Baby Boomers (1945–1964) - more highly educated ; women in the workforce occupying management roles.
2. Generation X (1965–1978) - long hours at work were common ; less impressed with corporate values, more skeptical, and resist authority, but enjoy challenges and opportunities to creatively problem solve.
3. Generation Y or the Millennials (1979–2000) - technologically sophisticated (and dependent); enjoys public affirmation.

• Most efficient functioning at about age 25 years 
• Musculoskeletal system - well developed and coordinated
• Functioning at peak efficiency: athletic endeavors (cardiovascular, visual, auditory, & reproductive).
• Physical changes are minimal
• Weight and muscle mass may change as a result of diet and exercise.
• Extensive physical and psychosocial changes occur in pregnant and lactating women.

• Psychosocial development is great.
• Basic developmental task is establishing intimacy
  or very close friendship.
• Occupational choice and education are largely
  inseparable.
• Sense of intimacy versus isolation.

• Formal operations, characterized by the ability to think abstractly and employ logic.
• Young adults are able to generate hypotheses about what will happen, given a set of circumstances and do not have to engage in trial-and-error behavior.

• Enters the postconventional level
• At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles. 
• When individuals perceive a conflict with society’s rules or laws, they judge according to their own principles.

• According to Fowler (1981), the individual enters the individuating reflective period sometime after 18 years of age.
• The individual focuses on reality.
• The religious teaching had as a child may now be accepted or redefined.

• Injury and violence - unintentional injuries (motor vehicle
  crashes) are the 5th leading cause of death for the total
  population ; Education about safety precautions and injury prevention ; Nurse needs to become familiar with community resources.
• Suicide - leading cause of death ; may be mistaken for accidental death ; in general, results from inability to
  cope with the pressures, responsibilities, and expectations of adulthood.
• Hypertension - major problem for young African American adults ; contributing factors may include smoking, obesity, a high-sodium diet, and high stress levels ; BP measurements are usually advised at least
  every 2 years.
• Substance abuse - can bring about feelings of well-being that may be highly valued by those with adjustment problems ; prolonged use can lead to such diseases as cirrhosis of the liver and cancer of the esophagus.
• Sexually transmitted infections (STIs) - STIs such as genital herpes, AIDS, syphilis, and gonorrhea
  are common ; Chlamydia is the most prevalent ; other STIs, such as gonorrhea, are becoming resistant to
  multiple antibiotics ; Nursing functions are largely educational (use of condom, knowledge about the symptoms can help the client obtain early treatment).
• Eating disorders - many battle with obesity ; the nurse needs to assess nutritional concerns, discuss diet and exercise patterns with the client and assist in the development of an individualized wellness plan.
• Certain malignancies - testicular cancer is the most common neoplasm ; Seminoma testicular cancer (ages 30-45) ; The yolk sac tumor (20-35 year olds) ; Men should have a testicular exam as part of a yearly physical exam ; Men who have risk factors should discuss monthly testicular self-examination.

• Developmental Assessment Guidelines.
• Interested in meeting their health needs.
• Because of the many stresses and changes that occur
  throughout the 20-year period (20 to 40), the nurse needs to offer teaching and guidance in several health care areas.

• A number of changes in their mid-20s become noticeable as the fifth decade approaches.
• At 40, most adults can function as effectively as they did in their 20s.
• Many physical changes take place.
• Both men and women experience decreasing hormonal
  production.
• Menopause, when menstruation ceases / when a woman has not had a menstrual period for 12 months ; between ages 40 and 55 ; average is about 47 years.
• At this time, ovarian activity declines until ovulation ceases.
• Common symptoms, related to a decline in estrogen are:
  hot flashes, chilliness, a tendency of the breasts to
  become smaller and less dense, and a decrease in
  metabolic rate that may lead to weight gain. 

• Generativity versus Stagnation.
• Generativity - the concern for establishing and guiding the next generation ; The concern about providing for the welfare of humankind is equal to the concern of providing for self 
• 20s and 30s tend to be self and family-centered.
• In middle age, the individual collaborates with others
• Marriage partners have more time for companionship and recreation; thus marriage may be more satisfying.
• Partners have time to work together in volunteer activities.
• Generative middle-aged persons are able to feel a sense of comfort in their lifestyle and receive gratification from charitable endeavors.

• Cognitive and intellectual abilities change very little.
• Cognitive processes include reaction time, memory, perception, learning, problem solving, and creativity.
• Reaction time stays much the same or diminishes.
• Memory and problem solving are maintained.
• Learning continues and can be enhanced by increased motivation.
• Genetic, environmental, and personality factors account for the large difference in the ways in which individuals maintain mental abilities.
• Individuals will be reflected in their cognitive performance.

• According to Kohlberg, the adult can move beyond the conventional level to the postconventional level.
• Kohlberg believed that extensive experience of personal moral choice and responsibility is required before people can reach the postconventional level.
• Few of his subjects achieved the highest level of moral reasoning.
• To move from stage 4, a law and order orientation, to stage 5, a social contract orientation, requires that the individual move to a stage in which rights of others take precedence.

• Not all adults progress through Fowler’s stages to the fifth, called the paradoxical-consolidative stage.
• At this stage, the individual can view “truth” from a number of viewpoints.
• Fowler believes that only some individuals after the age of 30 years reach this stage.
• In middle age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort.

• Leading causes of death include motor vehicle and occupational injuries, chronic disease such as cancer and cardiovascular disease.
• Lifestyle patterns in combination with developmental stressors and situational stressors are often related to health problems that do arise.
• Many diseases of older age may be decreased by health-conscious and lifestyle decisions made, and acted on, in midlife.
• The nurse can play an important role in teaching about preventive health care.
• INJURIES - Motor vehicle crashes are the most common cause of unintentional death ; Decreased reaction times and visual acuity may make them prone to injury.
• Falls, fires, burns, poisonings, and drownings. Work-related injuries continue to be a significant safety hazard.
• Heart disease and cancer are the leading causes of death.
• CANCER - The ACS (2014) states that men have a high incidence of cancer of the lung, prostate, and colon ; In women, lung cancer is highest in incidence, followed
  by breast cancer and colon cancer ; Screening guidelines for early detection of cancer are constantly evolving.
• CARDIOVASCULAR DISEASE - Risk factors include smoking, obesity, hypertension, hyperlipidemia, diabetes mellitus, sedentary lifestyle, a family history of myocardial infarction or sudden death in a father less than 55 years old or in a mother less than 65 years old, and the individual’s age.

• Lifestyle activities and behaviors, such as diet modifications and increasing physical activity play an important role.
• OBESITY - Decreased metabolic activity and decreased physical activity mean a decrease in caloric need ; Clients should also be educated that being overweight is a risk
  factor for many chronic diseases such as diabetes and hypertension and for problems of mobility such as arthritis ; Clients may be directed to the new MyPlate website to design a customized, healthy diet plan for themselves ; Clients should seek medical advice before considering any major changes in their diets.
• ALCOHOLISM - excessive use of alcohol can result in unemployment, disrupted homes, injuries, and diseases ;
  Alcohol use may exacerbate other health problems ; Nurses can help clients by providing information about the dangers of excessive alcohol use and by referring the client who abuses alcohol to special groups.
• MENTAL HEALTH ALTERATIONS - Developmental stressors can precipitate increased anxiety and depression ; Clients may benefit from support
  groups or individual therapy to help them
  cope with specific crises.

• Developmental Assessment Guidelines
• Middle-aged adults usually take care of their health needs and are interested in maintaining health and preventing the acceleration of the aging process.

• describes negative attitudes toward aging or older adults.
• Discrimination based solely on age.
• Young adults distanced themselves from older adults to shield themselves from being aware of their own mortality.

• Ageism contributes to the development of negative stereotypes about older adults. 
• Stereotypes occur when younger people do not understand or identify with older adults as unique human beings.
• An older client only experiences loss of memory related to the onset of a neurological disease.
• Disease processes also increase the client’s risk of developing disabling conditions.
• Important for nurses to provide accurate information about aging.

• The study of aging and older adults.
• Is multidisciplinary and is a specialized area within various disciplines such as nursing, psychology, and social work.

• Nurses in an acute care setting focus on protecting the health of the older adult, with the goal of the older adult returning to his or her prior level of independence.
• Treating the health problem that resulted in the older adult’s admission plus, assessing for potential undiagnosed health problems.

• Long-term care is the provision of health care and personal care assistance to clients who have a chronic disease or disability.
• Long-term care facilities are also known as nursing facilities.
• In the long-term care setting or nursing facilities, the individual is referred to as a resident.

• Older adults who do not feel safe living alone or require additional help with ADLs.

• Residents of intermediate care are no longer able to live independently. This level of care provides 24-hour nursing oversight to protect the client from injury and increase the client’s quality of life.

• designed to provide for the needs of clients whose acuity levels require a higher level of nursing care.
• Gerontological nurses working in SNFs often care for clients who require tube feedings, intravenous therapy, chronic wound therapy, and mechanical ventilators.

• AD is characterized by progressive dementia, memory loss, and inability to care for oneself.
• Gerontological nurses working in AD units have specialized knowledge and help family members understand and cope with the disease process affecting their loved one.

• Gerontological nurses may also work in hospice and care for dying clients and their families.
• The majority of hospice clients are older adults.
• Hospice requires a great deal of patience, expertise, understanding, interdisciplinary, communication, and compassion skills.
• The goal of hospice care is to provide the client with pain management and with psychosocial and spiritual care through the dying process.

• Gerontological rehabilitation nursing combines expertise in gerontological nursing with rehabilitation concepts and practice.
• Often cares for older adults with chronic illnesses and long-term functional limitations.
• This rehabilitative care may be found in several settings: acute care hospitals, subacute or transitional care centers, and long-term care facilities.
• The role of the nurse is often as a health care coordinator, manager, and counselor for older adults and their families.

• Nurses often assess the older client’s needs and then try to match the need with a community resource.
• Home health care is designed for those who are homebound due to the severity of illness or disability.
• Nurse-run clinics focus on managing chronic illness
• Adult day care focus on social activities and healthcare.

• had a higher prevalence of being undernourished
• can be exaggerated by muscular weakness resulting in a stooping posture and kyphosis (humpback of the upper spine).
• Imbalance in the rates of absorption and formation of bone tissue occurs with aging, so that older adults have more porous and fragile bones making older adults prone to serious fractures.

• Occurs more frequently in people with insufficient intake of dietary calcium, in women after menopause, in Caucasians and Asians, and in people who are immobilized or physically inactive.

• Loss of peripheral vision, atrophy of lacrimal glands resulting in dry eyes, and difficulty in discriminating similar colors, especially blues, greens, and purples, also occur.
• Presbyopia, the inability to focus or accommodate due to a loss of flexibility of the lens, causes decreased near vision.
• This process generally starts around age 40. Visual acuity lessens gradually after age 50.
• By the age of 80, nearly all older adults have some lens opacity (cataracts) that reduces visual acuity and causes glare to be a problem.

1. Age-related macular degeneration (ARMD)
2. Glaucoma
3. Diabetic retinopathy

• Should schedule routine eye examinations to maintain and protect their vision
• Wearing sunglasses will help avoid the damaging effect of ultraviolet light.

• Hearing loss is greater in the higher frequencies than the lower ; older adults with hearing loss usually hear speakers with low, distinct voices best.

• These theories focus on behavior and attitude changes during the aging process.
• Disengagement theory, developed in the early 1960s proposed that aging involves mutual withdrawal (disengagement) between the older person and others in their environment (Tabloski, 2014).
• According to Havighurst’s activity theory (1972), the best way to age is to stay active physically and mentally.
• The continuity theory proposes that people maintain their values, habits, and behavior in old age. 
• This theory accounts for the great variety of behavior seen in older people.
• According to Erikson, the developmental task at
  this time is Ego Integrity versus Despair
• People who attain ego integrity view life with a sense
  of wholeness and derive satisfaction from past
  accomplishments; They view death as an acceptable completion of life.
• People who develop integrity accept “one’s one
  and only life cycle”; By contrast, people who despair often believe they have made poor choices during life and
  wish they could live life over.

• Piaget’s phases of cognitive development end with the formal operations phase
• Intellectual capacity includes perception, cognitive agility, memory, and learning.

• According to Kohlberg (1984), moral development is completed in the early adult years.
• Kohlberg hypothesized that an older person at the preconventional level obeys rules to avoid pain and the displeasure of others.

• Older adults at the conventional level follow society’s rules of conduct in response to the expectations of others; does not decline in old age.

If a photograph is taken through the fetoscope, it can document a problem or reassure parents that their infant is perfectly formed.

• The main use of the technique is to detect meconium staining.
• It carries some risk of membrane rupture.

• After the umbilical cord is located by ultrasound, a thin needle is inserted by amniocentesis technique into the uterus and is guided by ultrasound until it pierces the umbilical vein.
• A sample of blood is then removed for blood studies, such as a complete blood count, direct Coombs’ test, blood gases, and karyotyping.
• To ensure that the blood obtained is fetal blood, it is submitted to a Kleihauer-Betke test which measures the difference between adult and fetal blood.
• If the test reveals that a fetus is anemic, blood may be transfused using this same technique.
• Fetus is monitored by a nonstress test before and after the procedure to be certain that uterine contractions are not present and by ultrasound to see that no bleeding is evident.

• As labor approaches and cervical dilatation begins, it can be found again in cervical or vaginal fluid. 
• Damage to fetal membranes from cervical dilatation releases a great deal of the substance, so detection of fibronectin in the amniotic fluid or in the mother’s vagina can serve as an announcement that preterm labor may be beginning.

• If the fetus has an open body defect, such as anencephaly, myelomeningocele, or omphalocele.
• Increased levels of AFP will be present in the amniotic fluid because of leakage of AFP into the fluid.
• Level will be decreased in the amniotic fluid of fetuses with chromosomal defects such as Down syndrome.
• Acetylcholinesterase is another compound that can be obtained from amniotic fluid in high levels if a neural tube defect is present.

• Presence of bilirubin may be analyzed if a blood incompatibility is suspected.
• If bilirubin is going to be analyzed, the specimen must be free of blood or a false-positive reading will occur. 

• A few fetal skin cells are always present in amniotic fluid.
• These cells may be cultured and stained for karyotyping for genetic analysis.

• Normal amniotic fluid is the color of water.
• Late in pregnancy, it may have a slightly yellow tinge.
• A strong yellow color suggests a blood incompatibility (the yellow results from the presence of bilirubin released with the hemolysis of red blood cells).
• A green color suggests meconium staining, a phenomenon associated with fetal distress.

• Procedure can be done in a physician’s office or in an ambulatory clinic.
• Typically scheduled between the 14th and 16th weeks of pregnancy to allow for a generous amount of amniotic fluid to be present.
• The technique can be used again near term to test for fetal maturity.

• When the L/S ratio is 2:1 or greater, the fetal lung is considered mature and the incidence of respiratory distress syndrome in the neonate is low.
• Results may be less reliable with maternal diabetes or if the fluid is contaminated with blood or meconium.

• PG is not present until 36 weeks’ gestation and is measured as being present or absent.
• Unlike the L/S ratio, PG is not affected by hypoglycemia, hypoxia, or hypothermia.

• The level is abnormally high in maternal serum (MSAFP) if the fetus has an open spinal or abdominal defect such as spina bifida or omphalocele, because the open defect allows more AFP to enter the mother’s circulation. 
• Although the reason is unclear, the level is low if the fetus has a chromosomal defect such as Down syndrome.
• MSAFP levels begin to rise at 11 weeks’ gestation and then steadily increase until term.
• Traditionally assessed at the 15th week of pregnancy, between 85% and 90% of neural tube defects and 80% of Down syndrome babies can be detected by this method.

• Inaccurate before the 20th week, because until this time fetal electrical conduction is so weak that it is easily masked by the mother’s ECG tracing.
• Rarely used unless a specific heart anomaly is suspected.

Because fetal lungs are apt to be mature at 38 weeks, a grade 3 placenta suggests that the fetus is mature.

• Allows heavy uterus to compress inferior vena cava.
• Reduces blood returned to her heart.
• Can lead to fetal hypoxia.

1. Fainteness
2. Light-headedness
3. Dizziness
4. Agitation

Turning to one side relives pressure on inferior vena cava, preferable the left side.

Note: Nurse can perform ultrasound if credentialed.

• Images are produced onto a screen.
• During the early weeks of gestation, when the uterus remains a pelvic organ, a full bladder may be necessary to facilitate visualization.

• No full bladder is necessary.
• Especially useful during the early weeks of pregnancy or when cervical evaluation is important (ie, for assessment of preterm labor). 

• Diagnose pregnancy as early as 6 weeks’ gestation.
• Confirm the presence, size, and location of the placenta and amniotic fluid.
• Establish that a fetus is growing and has no gross anomalies, such as hydrocephalus, anencephaly, or spinal cord, heart, kidney, and bladder defects.
• Establish sex if a penis is revealed.
• Establish the presentation and position of the fetus.
• Predict maturity by measurement of the biparietal diameter of the head.

• Early confirmation of pregnancy and determination of the estimated date of confinement
• Diagnosis of an ectopic pregnancy
• Detection of an intrauterine device
• Evaluation of placental location
• Diagnosis of a multiple gestation
• Guidance for CVS

• Evaluation of fetal growth, weight, and gestational age
• Evaluation of the placenta for placenta previa or separation associated with vaginal bleeding
• Evaluation of fetal presentation and position
• Evaluation of fetal abnormalities
• Evaluation of fetal viability
• Determination of the Biophysical Profile (BPP) Score
• Evaluation of amniotic fluid volume.
• Guidance for amniocentesis or fetal blood sampling.
• Secondary survey for pregnant trauma patient

• B-mode scanning allows patterns to merge and form a still picture, similar to a black-and-white snapshot (called gray-scale imaging).
• Real-time mode involves the use of multiple waves that allow the screen picture to move.
• Fetal heart can be seen to move, and even movement of the extremities, such as bringing a hand to the mouth to suck a thumb.
• A parent who is in doubt that her fetus is well or whole can be greatly reassured by viewing a real-time ultrasound image.

• Evaluates major and superficial vessels of the placenta, including the cord; fetal physiologic development; and fetal behavior.
• Advantages to 3-D and 4-D ultrasonography over Doppler velocimetry.
• Decreased time of fetal exposure to ultrasound beam (2 to 5 minutes for 3-D versus 15 to 30 minutes for velocimetry).
• * off-line image processing
• Identification of placental anastomoses

• Discover complications of pregnancy, such as the presence of an intrauterine device, hydramnios or oligohydramnios, ectopic pregnancy, missed miscarriage, abdominal pregnancy, placenta previa, premature separation of the placenta, coexisting uterine tumors, multiple pregnancy, or genetic disorders such as Down syndrome.
• Fetal anomalies such as neural tube disorders, diaphragmatic hernia, or urethral stenosis.
• Fetal death can be revealed by a lack of heartbeat and respiratory movement.
• After birth, an ultrasound may be used to detect a retained placenta or poor uterine involution in the new mother.

• Normal: gradual increase which is 12 – 50 mg/day at term.
• Abnormal: sudden drop of < 50% of the previous level = fetal distress.
• Persistent low level = fetal well being is compromised.

• After amniocentesis, the L/S ratio may be determined quickly by a shake test (if bubbles appear in the amniotic fluid after shaking, the ratio is mature) or sent for laboratory analysis.
• An L/S ratio of 2:1 is traditionally accepted as lung maturity.
• Infants of mothers with severe diabetes may have false-mature readings of lecithin because the stress to the infant in utero tends to mature lecithin pathways early.
• Some laboratories interpret a ratio of 2.5:1 or 3:1 as a mature indicator in infants of women with diabetes.

• During a standard non-stress test, if a spontaneous acceleration has not occurred within 5 minutes, apply a single 1-to-2-second sound stimulation to the lower abdomen.
• Can be repeated again at the end of 10 minutes if no further spontaneous movement occurs, so that two movements within the 20- minute window can be evaluated.

• Position and attach to both a fetal heart rate and a uterine contraction monitor.
• Instruct to push a button attached to the monitor (similar to a call bell) whenever the fetus moves.
• This will create a dark mark on the paper tracing at these times.

• Non-stress test usually is done for 10 to 20 minutes.
• Reactive if two accelerations of fetal heart rate (by 15 beats or more) lasting for 15 seconds occur after movement within the chosen time period.
• Non-reactive if no accelerations occur with the fetal movements.
• The results can be interpreted as non-reactive if no fetal movement occurs or if there is low short-term fetal heart rate variability (less than 6 beats per minute) throughout the testing period.
• If a 20-minute period passes without any fetal movement, it may mean only that the fetus is sleeping. 
• Other reasons for lessened variability are maternal smoking, drug use, or hypoglycemia. If you give the woman an oral carbohydrate snack, such as orange juice, it can cause her blood glucose level to increase enough to cause fetal movement.
• Fetus also may be stimulated by a loud sound to cause movement.
• Both rhythm strip and non-stress testing are non-invasive procedures and cause no risk.
• Can be used as screening procedures in all pregnancies.
• Can be done at home daily as part of a home monitoring program for the woman who is having a complication.
• If a nonstress test is non-reactive, additional fetal assessment, such as a contraction stress test or a biophysical profile test, will be scheduled.

NURSING ALERT ⚠️ Monitor tracings become part of the neonate’s and mother’s chart and are legal documents. They may be used in litigation if certain health problems develop in years to come.

• Semi-Fowler’s position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent the uterus from compressing the vena cava and causing supine hypotension syndrome during the test.
• Attach an external fetal heart rate monitor abdominally.
• Record the fetal heart rate for 20 minutes.
• Baseline Reading refers to the average rate of the fetal heartbeat per minute.
• Variability refers to small changes in rate that occur if the fetal parasympathetic and sympathetic nervous systems are receiving adequate oxygen and nutrients.

• Rhythm strip testing requires a woman to remain in a fairly fixed position for 20 minutes.
• Keep her well informed of the purpose of the test, how it is interpreted, and the meaning of results after the test.
• The more she understands about the process, the better she can cooperate to make it successful.

• Fetal heart and breathing record measure short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function.
• More accurate in predicting fetal well-being.

• For simplicity, some centers use only two assessments (amniotic fluid index and a non-stress test) for assessment
• Referred to as a modified biophysical profile this predicts short-term viability by the non-stress test and long-term viability by the AFI.
• A healthy fetus should show a reactive non-stress test and an AFI range between 5 and 25 cm.

• Lie in a left recumbent position after a meal and record how many fetal movements over the next hour.
• Fetus normally moves a minimum of twice every 10 minutes or an average of 10–12 times an hour.
• If less than 10 movements occur within an hour, repeat the test for the next hour.
• CALL her health care provider if she feels fewer than 10 movements (half the normal number) during the chosen 2 hours.

• The woman records the time interval it takes for her to feel 10 fetal movements.
• Usually, this occurs within 60 minutes.
• Assure a woman that fetal movements do vary, especially in relation to sleep cycles of the fetus, her activity and the time since she last ate.
• Fetal movements are best assessed after meals, after or with light abdominal massage, or after short walks, and if she has not smoked for the last 2 hours.
• Instruct patient that the fetus can sleep for up to 40 minutes.

• Can be felt by the mother (quickening), occurs at approximately 18 to 20 weeks of pregnancy and peaks in intensity at 28 to 38 weeks.
• Healthy fetus moves with a degree of consistency or at least 10 times a day.
• Fetus not receiving enough nutrients because of placental insufficiency has greatly decreased movements.
• Asking a woman to observe and record the number of movements the fetus is making offers a gross assessment of fetal well-being.

• Using the biophysical profile score, a 60-70% reduction in stillbirth rates has been shown in tested populations.
• Perinatal fetal hypoxemia leads to irreversible tissue damage and is related to a myriad of problems for the neonate, child, and adult.
• Fetal asphyxia → cerebral palsy, learning disability, adult-onset hypertension and cardiovascular disease.

• More people with lowered immune system function (i.e., those with HIV infection) are contracting tuberculosis and then spreading it to others.
• Physician or nurse-midwife may order a purified protein derivative (PPD) tuberculin test for a woman to screen for tuberculosis.

• If a woman has a history of tuberculosis or has received a bacillus Calmette-Guérin (bCG) vaccine for
• tuberculosis, a tuberculin skin test should not be given because the reaction would be extreme.
• To assess a woman’s current disease status, a chest radiograph will be ordered instead.

A woman is often reluctant to have this done because she knows radiation is harmful to a growing fetus.

• African American women for sickle cell trait or disease and glucose6-phosphate dehydrogenase (G6PD) 
• Asian and Mediterranean women for beta-thalassemia
• Jewish ancestry for Tay-Sachs disease
• Caucasian women for cystic fibrosis

• Blood type is documented because blood may have to be made available if a woman has bleeding during pregnancy.
• To detect the possibility of Rh isoimmunization.

• Elevated if a neural tube or abdominal defect is present in the fetus.
• Decreased if a chromosomal anomaly is present
• Done at 16 to 18 weeks of pregnancy
• Level in serum is expressed as “multiples of the mean” (MOM).
• Normal value is 2.5 MOM
• If elevated or decreased, an ultrasound or amniocentesis will be ordered to assess for a fetal disorder.

• Generally repeated at 28 weeks of pregnancy.
• If the titers are not elevated, an Rh negative woman will receive RhIG (RhoGAM) at 28 weeks of pregnancy and after.
• Any procedure that might cause placental bleeding, such as amniocentesis or external version.

• HBsAg testing may be repeated at about 36 weeks
• Antibodies for varicella (chickenpox) may also be assessed.
• Vaccine against these diseases can then be offered in the postpartum period.

• who have used or are using intravenous drug
• have engaged in sex with multiple partners
• have had sexual partners who are infected
• Bisexual
• intravenous drug abusers
• Hemophiliacs
• women who received a blood transfusion between 1977 and 1985

• If this is positive, the finding is confirmed by a second test (a Western blot)
• Testing for HIV early in pregnancy allows a woman who is found to be HIV antibody positive the opportunity to begin therapy with zidovudine (AZT) - can decrease the risk of her infant acquiring the virus

• If not, she will have this done routinely at the 24th to 28th week to evaluate insulin-antagonistic effects of placental hormones, which can register a noticeable effect at this time.
• Unless a problem is developing, the plasma glucose level should not exceed 140 mg/dL at 1 hour.

• Internal and external reproductive organs
• Prepare needed equipment
• Help the patient to relax
• Position the woman correctly: lithotomy position with pillow under her head and ask to void
• DRAPE and ask to remain in the same position for a short time after the procedure
• Allow support people
• If desired, allow to watch the pelvic examination

• Endocervical
• Cervical os
• Vaginal pool

• Done during the first pregnancy

• Educate
• Emphasize the importance 
• Ensure privacy and comfort
• Engage and involve

• Health history
• Physical exam
• Diagnostic test
• Health education

• IgG production is decreased to avoid the initiation of an immune response that would cause the mother’s body to attack the fetus. 
• WBC is increased as protection. 
• For the skeletal system, the pelvic joints and ligaments relax and become more pliable in order to prepare the body for childbirth. 
• This increased pliability leads to the separation of the symphysis pubis, causing pain on walking, backache and change in posture of lordosis (an excessive inward curve of the spine).

• Relaxin is a hormone that relaxes smooth muscles which leads to symptoms such as reflux, constipation and waddling gait. 
• The sustained increased levels of estrogen and progesterone in pregnancy halts the release of FSH and LH thus stopping the ovarian cycle. 
• Melanocyte is increased that results in darkening of some areas of the skin.
• Melasma or mask in pregnancy 
• Oxytocin is important late in pregnancy for effective uterine contraction and prolactin to promote lactation.

• Some women will consider limiting their fluid intake but this practice is wrong. 
• Fluids are necessary to increase the blood volume for better placental perfusion. 
• Also, it is important to maintain the normal amount of amniotic fluid. 
• A woman is more prone to infection during pregnancy because of the obstruction of the urine flow due to bladder and ureter compression. 
• There is a risk for retention of urine. The urine is also less acidic and contains more proteins, sugar and hormones. These factors increase the risk of UTI.

• It is normal for a pregnant woman to experience vomiting during the first 3 months (first trimester) of pregnancy, an effect of the hormone HCG. 
• However after that, the condition is called hyperemesis gravidarum and can be dangerous due to fluid and electrolyte loss. 
• Vomiting in the first trimester may be attributed to reflux resulting from the relaxation of the gastroesophageal sphincter as an effect of the hormone, Relaxin. Aside from this, reflux may also be brought about by the pressure of the growing uterus on the stomach.

Assuming the left side-lying position will relieve the pressure off the vena cava. 

The consistency of the cervix becomes softer as time of birth is approaching. 

• It rises above the symphysis pubis at 12 weeks and the umbilicus at 20 weeks. 
• Estrogen promotes growth of muscle fibers to accommodate the growing fetus
• Progesterone prevents uterine contraction and at the same time maintains the uterine wall (endometrium) making it thick and tortuous (highly vascularized) to maintain the pregnancy, and is now called decidua.

• Breast changes are one of the earliest signs of pregnancy apart from amenorrhea. 
• Frequent urination as an early sign is caused by an increase in the levels of HCG and not by the weight of the uterus. 
• On the 18th week, quickening, a term used to describe fetal movement felt by the mother is present at this time.  Quickening is only a presumptive sign because fluttering may be caused by other conditions such as presence of gas or flatus. 
• Highly subjective.

1. Laboratory test: detects the presence of hCG (human chorionic gonadotropin) in blood or urine - present as early as 24-48 H after implantation; measurable at 7-9 days after conception; 
2. Home Pregnancy Test: 97% accuracy if followed properly 

• Can detect as little as 35mIU/mL 
• Advise to wait until the day of the missed menstrual period to test 
• There maybe a FALSE POSITIVE result

1. Support fetal growth
2. Support and maintain maternal health
3. Prepare the body for childbirth
4. Prepare the body for lactation

• Officially diagnosed on the basis of the SYMPTOMS reported by the woman and the SIGNS elicited by the healthcare team.
• Serves to date the diagnosis of birth and helps predict the existence of a high-risk status.

TRIVIA: The phenomenon whereby women do not become consciously aware of their pregnancy until the last week of pregnancy or birth is called CRYPTIC PREGNANCY.

• the environment in which she was raised 
• the messages about pregnancy her family communicated to her as a child
• the society and culture in which she lives as an adult 
• whether the pregnancy has come at a good time or less than a good time in her life

• alone to a physician’s office for care 
• Time of birth: separated from her family and admitted to a hospital 
• hospitalized in seclusion from visitors and even from the new baby for a week afterward …

• bring their families during prenatal care 
• participate actively in the experience 

• related to their cultural background 
• their personal experiences, and the experiences of friends and relatives 
• as taught by childbirth educators 
• the current public philosophy of childbirth
• Teenage pregnancy affects about 6% of Filipino girls.

• Ask at prenatal visits if there is anything they believe should or should not be done to make the pregnancy successful and keep the baby healthy 
• Supporting these beliefs shows respect for the individuality of a woman and her knowledge of good health

• Ability to cope with or adapt to stress 
• Relationship with people around 

• Narcissism and introversion as they concentrate on what it will feel like to be a parent 
• Role playing and increased dreaming

• Ambivalence - interwoven feelings of wanting and not wanting that can exist at high levels 
• Provide outlet to discuss concerns and other parenting information at prenatal visit 
• Grief - not just a daughter anymore, a wife, a friend but a mother
• Narcissism - self-centeredness (early reaction) 
• dressing is time-consuming, mirror studying procedure 
• change activity level 
• criticize husband’s driving
• Introversion vs Extroversion 
• turning inward to concentrate on oneself and one’s body (common) 

• more active, appear healthier than ever before and more outgoing
• Body Image and Boundary 

• basis for narcissism and introversion 

• Protect self from harm
• Stress - difficult for a woman to make decisions, be as aware of her surroundings as usual or maintain time management with her usual degree of skill 

• men are experiencing physical symptoms like N & V, backache to some degree or more intensely than partner 
• due to stress, anxiety and empathy

• as a manifestation of narcissism 
• partly because of hormonal changes 

• beginning with early pregnancy

• It’s a good idea for you and your partner to spend a bit of time thinking about the positive and negative emotions that may arise
• Work out some strategies that will help you if feelings become overwhelming

• To transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta
• About 53 cm (21 in) in length at term and about 2 cm
  (3⁄4 in) thick
• Bulk of the cord is a gelatinous mucopolysaccharide
  called Wharton’s jelly ; gives the cord body and prevents pressure on the vein and arteries that pass through it
  - outer surface is covered with amniotic membrane

• Rate of blood flow through an umbilical cord is rapid (350 mL/min at term) ; it is unlikely that a cord will twist or knot
  enough to interfere with the fetal oxygen supply.
• 20% of all births, a loose loop of cord is found around the fetal neck (nuchal cord) at birth ; If this is removed before the newborn’s shoulders are born, there is no traction in it, the oxygen supply to the fetus remains unimpaired.
• Adequacy of blood flow (blood velocity) can be determined by ultrasound examination during pregnancy
• Blood can be withdrawn from the umbilical vein or transfused into the vein during intrauterine life for fetal assessment or treatment (termed percutaneous umbilical blood sampling [PUBS]).
• Walls of the umbilical cord arteries are lined with smooth muscle
• Constriction of these muscles after birth contributes to hemostasis and helps prevent hemorrhage of the newborn 
• Because the umbilical cord contains no
  nerve supply, it can be cut at birth
  without discomfort to either the child or
  woman

• Protection
• Temperature regulation
• Protects the umbilical cord from pressure
• Protecting the fetal oxygen supply
• Aids in muscular development
• Gives freedom of movement

• Major method of absorption
• The fetus continually swallows the fluid
• In the fetal intestine, it is absorbed into the fetal bloodstream --> it goes to the umbilical arteries and to the placenta, and it is exchanged across the placenta
• At term, the amount of amniotic fluid has increased so
  much it ranges from 800 to 1200 cc

• Excessive amniotic fluid
• More than 2000 mL in total, or pockets of fluid larger
• Than 8 cm on ultrasound

• Reduction in the amount of amniotic fluid
• Less than 300 cc, no pocket on ultrasound larger than 1 cm
• Disturbance of kidney function

• Outer most membrane
• Fingerlike projections, “villi”

• Thin protective membrane
• Contains amniotic fluid

As embryo grows, amnion comes in contact with chorion and forms fluid filled sac.

• Produces a phospholipid that initiates the formation of prostaglandins
• Can cause uterine contractions and may be the trigger that initiates labor
• Occasionally, fibrous amniotic bands that can constrict an arm or leg of the fetus form in utero
• Can close off the blood supply to the distal extremity and cause growth of the extremity to halt at that point 

• First placental hormone produced
• Can be found in maternal blood and urine as early as the first missed menstrual period (shortly after implantation has occurred) through about the 100th day of pregnancy
• A false-negative result from a pregnancy test may be obtained before or after this period
• Blood serum will be completely negative for hCG within 1 to 2 weeks after birth
• Testing for hCG after birth can be used as proof that placental tissue is no longer present

• Act as a fail-safe measure to ensure that the corpus luteum of the ovary continues to produce progesterone and estrogen
• Play a role in suppressing the maternal immunologic response so that placental tissue is not detected and rejected as a foreign substance
• The structure of hCG is similar to that of luteinizing hormone of the pituitary gland, if the fetus is male, it exerts an effect on the fetal testes to begin testosterone production
• Presence of testosterone causes maturation of the male reproductive tract
• 8th week of pregnancy, the outer layer of cells of the developing placenta begins to produce progesterone, making the corpus luteum
• The production of hCG, which sustained the corpus luteum, begins to decrease

• Primarily estriol
• Produced as a second product of the syncytial cells of the placenta
• Contributes to the woman’s mammary gland development in preparation for lactation and stimulates uterine growth to accommodate the developing fetus
• Referred to as the “hormone of women”

• The “hormone of mothers”
• Necessary to maintain the endometrial lining of the uterus during pregnancy
• Present in serum as early as the fourth week of pregnancy, as a result of the continuation of the corpus luteum
• After placental synthesis begins (at about the 12th week), the level of progesterone rises progressively during the remainder of the pregnancy
• Appears to reduce the contractility of the uterus during pregnancy, preventing premature labor
• Reduced contractility is probably produced by a change in electrolytes (notably potassium and calcium), which decreases the contraction potential of the uterus

• hPL is a hormone with both growth-promoting and lactogenic (milk-producing) properties
• Produced by the placenta beginning as early as the sixth week of pregnancy, increasing to a peak level at term
• Can be assayed in both maternal serum and urine
• Promotes mammary gland (breast) growth in preparation for lactation  
• Serves the important role of regulating maternal glucose, protein, and fat levels so that adequate amounts of these nutrients are always available to the fetus

• Forms a barrier between mother and embryo (blood is not exchanged)
• Delivers nutrients and oxygen
• Removes waste from embryonic blood
• Becomes an endocrine organ (produces hormones) and takes over for the corpus luteum
• Estrogen
• Progesterone
• Other hormones that maintain pregnancy

• If a placenta is smaller, circulation to the fetus may have been inadequate.
• If placenta is larger, circulation to the fetus was threatened, because it suggests that the placenta was forced to spread out in an unusual manner to maintain a sufficient blood supply
• The fetus of a woman with diabetes may also develop a larger-than-usual placenta from excess fluid collected between cells

• Metabolic gas exchange begins at 4 weeks
• Funic souffle soft blowing heard over umbilical cord – synchronous with fetal heartbeat, hearing bloodflow through vessel
• Uterine souffle heard just above mother’s pelvis – synchronous with maternal pulse

• This position lifts the uterus away from the inferior vena cava, preventing blood from being trapped in the woman’s lower extremities
• If the woman lies on her back and the weight of the uterus compresses the vena cava, placental circulation can be so sharply reduced that supine hypotension (very low maternal blood pressure and poor uterine circulation) occurs

• Outer of the two covering layers
• Layer of cells produces various placental hormones, such as hCG, somatomammotropin (human placental lactogen [hPL]), estrogen, and progesterone

• Middle layer
• Present as early as 12 days’ gestation
• Function early in pregnancy to protect the growing embryo and fetus from certain infectious organisms such as the spirochete of syphilis
• Disappears, however, between the 20th and 24th weeks

• First 2 weeks, beginning with fertilization
• Ends at implantation, which occurs on day 7 post-conception
• Period of pre-differentiation of organs
• Includes fertilization, cleavage of oocyte, and formation of blastocyst
• The conceptus is transported from the ovary, through the oviduct, into the uterine cavity
• When exposed to a teratogen, “all” or “none” law applies
• Ovum is damaged and is out in spontaneous abortion or
• Not affected at all and continues to grow normally

• Weeks 3 through 8
• Begins with blastogenesis (i.e., formation of germ layers)
• Period of organ differentiation (organogenesis)
• Most dangerous period
• A teratogen introduced may result in severe organ malformation and dysfunction

• From 8 weeks to birth 
• Period of post-differentiation of organs
• When exposed to teratogen: malformation is least likely to occur
• If ever the fetus is affected, the effects will be most likely be alteration in size or function

as a fetus grows, body organ systems develop from specific tissue layers called germ layers

1. The ectoderm gives rise to the nervous system and the epidermis, among other tissues. 
2. The mesoderm gives rise to the muscle cells and connective tissue in the body. 
3. The endoderm gives rise to the gut and many internal organs.

• to provide a source of red blood cells until the embryo’s hematopoietic system is mature enough to perform this function 
• yolk sac then atrophies and remains only as a thin white streak discernible in the cord at birth

• (the end of the embryonic period) 
• all organ systems are complete, at least in a rudimentary form 

• the growing structure is most vulnerable to invasion by teratogens 
• factor that adversely affects the fertilized ovum, embryo, or fetus 

• Fetus depends on placenta to meet Oxygen needs while organs continue formation 
• Oxygenated blood flows from the placenta to the fetus via the umbilical vein

• 2 umbilical arteries: carry or return deoxygenated blood, fecal waste, CO2 from the fetus to the placenta 
• 1 umbilical vein: brings oxygenated blood and nutrients from the placenta to the fetus

• respiratory center for the fetus 
• water, glucose, amino acids, vitamins, and inorganic salts freely diffuse across the placenta along with oxygen 

1. Ductus arteriosus - protects lungs against circulatory overload; allows the right ventricle to strengthen 
2. Ductus venosus - fetal blood vessel connecting the umbilical vein to the IVC 
3. Foramen ovale - shunts highly oxygenated blood from right atrium to left atrium

• Length: 2.5 cm, weight: 20 g 
• Organogenesis is complete 

• Length: 7-8 cm, weight: 45 g 
• Nail beds are forming 

• Length: 10-17 cm, weight: 55-120g 
• FHT by stethoscope 
• Lanugo is well formed 
• Liver and pancreas are functioning 
• Sex can be determined by ultrasound 

• Length: 25cm, weight: 223 g 
• Hair forms including eyebrows and on the head 
• Meconium is present in the upper intestine 
• Vernix caseosa begins to form and cover the skin 

• Length: 28-36cm, weight: 550g 
• Meconium is present as far as the rectum 
• Active production of lung surfactant begins 

• Length: 35–38 cm; Weight: 1200 g 
• Lung alveoli begin to mature and surfactant can be demonstrated in amniotic fluid 

• Length: 38–43 cm; Weight: 1600 g 
• Subcutaneous fat begins to be deposited 
• Little old man appearance is lost 
• Fetus responds by movement to sounds outside the mother's body 

• Length: 42-48 cm, weight: 1800-2700g 
• Body stores of glycogen, iron, carbohydrate, and calcium are deposited 
• Additional amounts of subcutaneous fat are deposited 

• Length: 48–52 cm (crown to rump, 35–37 cm); Weight: 3000 g (7–7.5 lb) 
• Kicks hard enough that causes discomfort to the mother 
• Fetal hgb to adult hgb so rapid that about 20% of hgb is adult in character 

• Uterine Muscle Stretching Releasing Prostaglandins 
• Cervical Pressure Causing Release of Oxytocin 
• Oxytocin and Progesterone Balance 
• Placental Aging 
• Fetal Cortisol and Prostaglandin

• Occurs 10-14 days before labor begins (primiparous women, 2 weeks before)
• Relief of shortness of breath from the lungs but now presses more on the bladder

• Felt first abdominally & remain confined to the abdomen & groin 
• Often disappear with ambulation & sleep 

• It is related to an increase in epinephrine release – prepares a woman’s body for the work of labor ahead
• Do not encourage, they must not expend their energy, rest instead (conserve)

• Goodell’s sign - all throughout pregnancy, cervix has the same consistency as the earlobe 
• At term, it becomes still softer & described as “butter-soft” 

• Begin irregular but become regular & predictable
• Sweeps around to the abdomen 
• Continue no matter what 
• Increase in duration, frequency & intensity
• Achieve cervical dilatation

• Mucus plug that filled the cervical canal is expelled
• “Bloody show” exposed capillaries seep blood and mixed with mucus resulting to pink-tinged color

• Sudden gush or a scanty, slow seeping of clear fluid from the vagina
• Early rupture is advantageous if it causes the fetal head to settle snugly into the pelvis, resulting to short labor

• Pelvic Shape: Gynecoid 
• True Pelvis: The bony passageway through which the fetus must pass during delivery 
• Obstetric/True Conjugate: The most important measurement of the inlet because it has the smallest diameter (at least N-11 cm)
• For the pelvic outlet (below the ischial spine), AP > T, transverse is measured
• Measurement is the ischial tuberosity = at least 10 cm 

• Most Important: Bony Pelvic Ring 
• AP: 9.5 cm ; Transverse: 9.25 
• Fontanelle spaces compress during birth to aid in molding of the fetal head

• Primi -14 hours-20 hours 
• Multi - 8-14 hours 
• 4 stages. First stage is the longest.

• 1cm dilation per hour is not expected especially if the cervix has not reach 5cm
• It’s okay if the dilatation is slow. You can expect it to speed up when it reaches 5cm (active phase)
• The rate of cervical dilatation does not automatically indicate whether augmentation is required
• Augmentation of labor - you want the labor to speed up IF there is fetal & maternal distress

• Cleansing / organizing breath - deep breath through nose; do this at the beginning and end of each contraction
• Slow Breathing - for mild to moderate contractions; done during contractions

• Cleansing / organizing breath - deep breath through nose; do this at the beginning and end of each contraction
• Light Accelerated Breathing - woman breathes 1 breath per second during contractions. 

• Cleansing / organizing breath - deep breath through nose; do this at the beginning and end of each contraction
• Pant and Blow (hee-ha!) / Variable Breathing - fast type of breathing wherein you breathe 5 times for every 10 seconds (3 fast breaths and the 4th-5th will be a blow); done when the woman is exhausted
• Expulsive Breathing - a type of breathing when there is already a strong urge to push; breathe in and when there is a strong urge to push, the woman will hold her breath and bear down)

• Modified Ritgen's Maneuver - Support the perineum to prevent laceration; also controls the speed of delivery (dominant hand on the perineum, non-dominant hand on the occiput, chin if head is out)

• Modified Ritgen’s 
• Support the head & (suction secretions? No longer recommended unless there is a sign of fetal distress) 
• Dry the baby 
• Initiate skin to skin interaction 
• Wait for pulsation to stop 

• Natural (bearing-down) 
• Gentle pressure (Crede’s maneuver) - must be trained or else, uterine prolapse
• Check completeness (check which side came out first because it will tell you how the placenta separated ; shiny or dirty), completeness of the cotyledon (divided into lobes/divisions) should be 15-20 cotyledons (not important to count) 
• As long as there are no spaces in-between or depressions on the cotyledons for it to be complete. Check because if there are fragments left in the uterus, there will be bleeding/hemorrhage (anything that will impair or prevent the uterus from contracting could lead to bleeding) and must be manually removed by the midwife
• Check fundus (has to be firm = contracted like a grapefruit really hard at the level of umbilicus; soft/boggy = non-contracted, perform fundal massage)
• BP Check 
• Methergine, methylergonovine maleate (IM) - used to prevent or treat bleeding from the uterus that can happen after childbirth or an abortion like oxytocin.
• Oxytocin IV if methergine is not present 
• Check perineum for lacerations 
• Assist in episiorrhaphy - repair of episiotomy

• Flat on bed (epidural-given), if went through normal vaginal delivery = ambulate to prevent other complications like thrombosis or clog formation
• If with chills, give blanket (epidural-given) side effect of anesthesia, blood loss, dehydration
• Give nourishment (progression of meals) 

• Check VS/Pain 
• Psychological state (taking-in passive in caring for the child, taking hold partially participating in the care of the NB, letting go mother fully care for the NB)
• Bonding (MBFH) 

• Assess woman’s breasts: Inspect & palpate for breast size, shape & color  
• What to expect?  
• Soft - 1st-2nd PPD  
• Firm & warm, reddened, with taut, shiny skin (engorgement)– 3rd/4th PPD; hard, tensed & painful on palpation.
• ***If only one area of the breast is reddened or warmed, suspect for mastitis/inflammation/infection. 
• Note for a firm nodule. Take note of location & report.
• Assess breast nipples—erect/inverted, cracks/fissures/presence of caked milk. Do not squeeze or manipulate nipples unnecessarily.

• Position the patient supine: Assess for contour, striae & diastasis; measure width & length in fingerbreadths  
• What to expect?  
• Uterus is firm/ contracted (if relaxed—uterine atony)  
• At a specific location  
• Uterus is in midline  
• Presence of after pains maybe normal 

The 1st hour after birth is potentially the most dangerous. 
Ask the patient to empty bladder.

• If the uterus is boggy / not contracted, what will be the nursing action?  
• Massage gently using gentle rotating motion  
• Administer oxytocin as ordered / place the infant on the woman’s breast to suck  
• Assess the uterine fundus every 10 to 15 minutes  
• Assess for height less frequently after 1 hour

• Assess the bladder for fullness frequently & encourage regular voiding habits  
• What to expect?  
• If bladder is full: Hard or firm above the symphysis pubis, resonant on percussion, displaces the uterus. Ask the patient to void  
• Increase nitrogen and lactose levels 

Stool softeners, suppositories or an enema given as ordered.

• Check perineal pad and evaluate lochia for character, amount, color, odor, and presence of any clots once every 15 minutes for the 1 st hour 
• A constant trickle of vaginal flow or soaked perineal pad every 60 minutes is not the normal amount of blood loss. 
• Instruct on hygiene: perineal hygiene, handwashing and use of personal equipment ✓ Encourage frequent changes of perineal pads to prevent infection and to hasten wound healing. 
• Educate not to use tampons until she returns for postpartal check-up and to distinguish the normal type and amount of lochia

• A time for reflection where the woman is largely PASSIVE  
• Encourage to talk about the birth and help integrate it into life experiences  

• Begins to initiate action  
• Learning to make decisions and to do things well  
• Give brief demonstration of baby care  
• Praise efforts  

• Redefines new role and gives up old role  
• Extended and continues during the child’s growing years

• Feeling less important/jealous  
• Allow verbalization of feelings and make infant care a shared responsibility  

• Difficult for parents to feel positive immediately about the child who does not meet their expectations.  
• Nurses should handle the child warmly and comment on the child’s good points  

• They burst into tears easily or feel let down or irritable  
• May be caused by hormonal changes or a response to dependence and low self-esteem 
• Can lead to postpartal depression  
• Reassure the woman and family and allow to verbalize feelings & low to make decisions

• Weight loss: 5lbs for diuresis + 2-3 lb for lochial flow + 12 lb at birth = 19 lbs  
• Dependent on pregnancy weight gain  
• The weight a woman achieves in 6 week s becomes her baseline postpartum weight

All clients should be assessed for depression during pregnancy and in the postpartum period.

• Profuse sweating (Diaphoresis) may occur 
• Clients are usually hungry after delivery 
• Hyperpigmented areas begin to fade but not completely return to pre-pregnant state 
• Weight loss of 10 lbs. occurs immediately after delivery

• 6 weeks after birth in non-nursing moms 24 weeks in nursing moms 
• Breasts – lactation begins 
• PROLACTIN - stimulates milk Production
  OXYTOCIN - initiates the let-down reflex with milk ejection as the baby suckles

Women may ovulate without menstruating, so breastfeeding should not be considered a form of birth control.