NCM 107 Lesson Summaries by Danica C. Ardiente

INTRODUCTION

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Goal

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"promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and childrearing."

What is expected from maternal and child health nurses?

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1. give preconceptual health care
2. care of women during the three trimesters and the puerperium
3. care of infants during the perinatal period
4. care of children from brith through adolescence
5. care in settings as varied like birthing room or home

Principles

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- Family is the basic part of society.
- Families can come in various forms and sizes and racial, ethnic, cultural ,and socioeconomic diversity.
- Children and grow both individually and as part of a family.

Levels of Care

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"from womb to tomb"

- health promotion: preparing clients to become aware of good health through teaching and role modeling
- health maintenance: intervening to maintain health when there are risks of illnesses
- health restoration: diagnosing and treating illnesses using interventions that will help client return to wellness quickly
- health rehabilitation: stopping further complications from an illness; bringing an ill client back to their most optimal state of wellness or helping a client accept the inevitable death

MODULE 1 LESSON 1: GROWTH AND DEVELOPMENT

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Terms

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- Growth and development can be independent and interrelated.
- Growth = physical change
- increase in physical size or quantitative change, increase in weight
- growth rates vary on different stages
- rapid (peak) - infancy, adolescence
- slows - childhood
- minimal physical growth - adult

- General Growth
- Respiratory, Digestive, Renal, Musculoskeletal, and Circulatory Tissue peak time is during childhood
- Neurologic tissue peak time is first 2 years
- Lymphoid Tissue peak time is during infancy and childhood
- Reproductive Organs peak time is puberty

- Development increases ability to function
- synonym: maturation (aging and adapting to new situations)
- Behavior is the most thorough indicator of one's developmental status

Principles of Growth and Development

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1. constant process that starts from conception and ends at death
2. proceeds in an orderly manner (sequences are predictable)
3. different children passes through the stages, but at different rates (principle of asynchronism)
4. every body system does not grow at the same rate
5. development is head to toe (cephalocaudal)
6. development starts from proximal to distal parts of the body
7. development starts from gross to refined skills
8. there are best times for initiating experiences or learning
9. neonatal reflexes have to be gone before development can continue
10. a big amount of skill and behavior is learned through practicing

Factors Influencing Growth and Development

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- Genetic Inheritance
- examples: race, intelligence, nationality, temperament, sex
- Environmental Influences
- example: parent-child relationship, ordinal position in the family, health, nutrition

Theories of Development

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- Developmental Theories give maps that explain human development.
- Accomplishments happen at one stage and affect the following stages afterwards.
- Psychosocial Development (Erickson)

- Psychosexual Development (Freud)
- Trust vs. Mistrust (Infancy): satisfying needs on time leads to security
- Autonomy vs. Shame and Doubt (Toddler age 1 to 3): offering choices leads to decision making
- Initiative vs. Guilt (age 3 to 6): exploring and imagination leads to fine motor development
- Industry vs. Inferiority (age 6 to 12): giving workload in manageable levels leads to doing things well
- Identity vs. Role Confusion (age 12 to 20): self discovery leads to acceptance of self and new body image and that leads to seeking freedom
- Intimacy vs. Isolation (age 20-30): searching for lifetime partner or career focus
- Generativity vs. Stagnation (age 30-65)
- Ego Integrity vs. Despair (65-death)

- Psychosexual Development (Freud)
- Oral Stage (birth to age 1): suck leads to enjoyment and release of tension
- Anal Stage (age 1 to 3): ready for toilet training
- Phallic Stage (age 3 to 6): interested in their genitalia and various sensations; learns difference between genders
- Latency Period (age 6 to 12): school phobia
- Genitalia Stage (age 12 and older): sexual maturity leads to learning to establish satisfying relationships with opposite sex; sexual awakening leads to engaging in sexual intercourse

- Moral Development (Kohlberg)
- Preconventional Level of Morality (age 2 to 7): punishment and obedient orientation and instrumental relativist Orientation
- Conventional Level of Morality (age 7 to 12): Interpersonal Concordance Orientation, Societal Focus, and Law and Order Orientation
- Postconventional Autonomous Level of Morality (age 12 and older): social contract legalistic orientation, universal focus, universal ethical principle orientation

- Cognitive Development (Piaget)
- Sensorimotor (brith to age 2):from reflex activity, through simple repetitive behaviors to imitative behaviors
- Preoperational (age 2 to 7): magical thinking time and increased capability to use language and symbols
- Concrete Operational (age 7 to 11): thought process becomes more logical and reasonable
- Formal Operational Thought (age 11 to 20): adaptability and flexibility, can make logical conclusions from observations

MODULE 1 LESSON 2: THE FAMILY WITH AN INFANT

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Physical Growth

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Weight
2x 4-6 months
3x 1 year

Weight Gain
1st 6 months 2 lbs/month
2nd 6 months 1 lb/month

Average
1 y/o male 10 kg
1 y/o female 9.5 kg

Height
- increases by 50% during the first year
- grows from the average birth length of 20 in. to about 30 in (50.8 cm to 76.2 cm)

Head Circumference
- increases very quickly and reflects brain growth
- Brain reaches 2/3 of adult size at the end of the first year

Body Systems

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Cardiovascular: heart rate decreases to 110-120 bpm by the end of the first year
Respiratory: respiration rate decreases to 20-30 breaths per minute
Immune System: function by 2 months of age and able to create immunoglobulin G and M by 1 year of age

Teeth

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dentition starts at 6 months
2 lower incisors

milk/deciduous teeth (20)
- complete by 2-3 yrs old
- sheds off by 6 to 7 yrs old
- replaced by 32 permanent teeth

formula
- age in month - 6 = answer

Motor Development

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Gross Motor

ability to accomplish big body movements
ventral suspension position
- newborn allows the head to hang down with little effort or control
- 1 month old child can lift the head momentarily
- 3 month child can maintain lifting the head
Landau Reflex
- 3 month olds' head, legs, and spine extend when held at ventral suspension
- hips, knees, and elbows flex when head is depressed
Parachute Reflex
- 6-9 month olds' arms extend like they are to protect themselves from falling when the infants are suddenly lowered toward a table from ventral suspensions

Gross Motor Development

Prone Position
- Newborns can turn their heads to move it out of position where breathing is impaired when they are lying on their stomach
Neck Righting Reflex
- when 4 month olds turn their head to the side, shoulder, trunk, and pelvis turn in that same direction
Sitting Position
- When a 1 month old is placed on his/her back and is pulled to a sitting position, they have gross head lag in the first days of life
- 6 month olds can sit momentarily with support
Standing Position
- The infant's knees and hips flex rather than support more than momentary weight in a standing position
- fades away at 3 months

Fine Motor

measured by watching or testing prehensile ability (ability to coordinate hand movements)

Fine Motor Development

1 month olds continue to have a strong grasp reflex
2 month olds will hold an object for a few minutes before dropping it as the grasp reflex starts to fade
4 month olds begin to have thumb opposition which is the ability to bring the thumb and fingers together
10 month olds have pincer grasp which enable the child to pick up small objects

Developmental Milestones

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Language Development

1. Cooing sounds

3. Squeals with pleasure

4. Talkative, cooing, babbling, gurgling and able to lol

5. Simple vowel sounds like goo-goo gah-gah

7. Can imitate simple vowel sounds like oh-oh ah-ah

9. Speaks a first word like da-da

12. Can say 2 words beside ma-ma and da-da
- Use those 2 words with meaning

Play

1. Interested in watching the mobile over the crib
- Spends time watching parent's face

3. Can handle small blocks or rattles

5. Handles plastic rings, keys, and squeeze toys

6. Enjoy teething rubber rings and bathtub toys

7. Likes objects for transferring

8. Enjoys toys with different textures

9. Needs space for creeping

10. Plays games like peek-a-boo

11. Cruises like walks with support

12. Enjoys put-in, take-out toys

Development of Senses
Vision

1. Regards object in middle of vision

2. Focuses well and follows objects with eyes
- Achieves binocular vision which is the ability to fuse 2 images in one

3. Hand regard

4. Recognizes familiar objects

6. Capable of depth perception

7. Object permanence

Hearing

1. Quiets momentarily at a distinct sound (example bell)

3. Turns head to attempt to locate sound
10. Can recognize his/her name and listen when spoken to
12. Can easily locate sound in any direction

Emotional Development: Socialization
1. Can differentiate between face of caregiver and other objects
6 wks Social smile
5. May show displeasure when object is taken away
- Laughs when seeing a funny face
8. Stranger anxiety
9. Aware of changes in tone of voice (cries when scolded)
12. Overcomes fear of strangers
- Likes to play interactive games and joins family activities

Cognitive Development
3. Primary Circular Reaction

Explores objects by grasping or mouthing them
Infant appears to be unaware of what actions he/she can cause

6. Secondary Circular Reaction

Realizes that his/her actions can initiate pleasurable sensations

10. Coordination of Secondary Schema

The infant discovers object permanence or realizes that an object out of sight still exists

Cephalocaudal Development
Neonate. No head control: Head Lag
2. Lifts head until chin
4. Lifts head until chest
6. Lifts head until buttocks (sits with support)
8. Sits without support
10. Stands with support
12. Stands alone, walks with support
14-15. Walks alone

Proximo-distal Development
0. Hands closed
3. Can open hands
6. Palmar Grasp
- Can hold feeding bottle
9. Pincer Grasp
Note:
CNS develops fastest
Reproductive System: slowest

Major Milestones: Summary

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Universal language of child: play
Solitary play
- Enjoys mobile/ teether/ music box/ rattle
Important: safety
Stranger anxiety begins at 6-7 months, peak at 8 months, and diminishes 9 months

Promoting Safety

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Aspiration

Leading cause of death in infants
Parents either underestimate or overestimate the child's ability
Round, cylindrical objects are more dangerous
Things within the child's reach must be safe to put into the mouth
Toys should not have removable parts
examples: clothings with decorative buttons or popcorn or peanuts for children under 5 yrs old

Falls

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

Car Safety

Always use car seats through toddlerhood
Infants up to 20 lbs should be placed in rear facing seats

Bathing and Swimming

Don't leave an infant unattended in a tub, even when propped up out of the water

Childproofing

Move furniture in front of electrical sockets or buy protective caps for the outlets
Check 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

Promoting Nutritional Health

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A baby who is overweight during the first year of life is more likely to become an obese child

Introducing Solid Food

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 to 9 months thus food that require chewing are not given before this age.

Extrusion Reflex

The infant automatically thrusts with his/her tongue any object/food placed on the its anterior 2/3 of the tongue.
Life saving reflex that prevents an infant from swallowing or aspirating foreign objects.
This reflex fades at 3-4 months

Complementary Feeding

Offer new food one at a time to make out possible food allergies
Wait 5-7 days before introducing new things
Introduce small amounts of new food: 1 or 2 teaspoonfuls at a time
Newborn: 30 ml (2 tablespoons)
1 year: 240 ml (1 cup)

Quantities of Types of Food
Cereal

First food given to infants
Not needed to ass sugar in the cereal
Rich in iron
Children should preferably be fed cereal until age 3 or 4 years

Vegetable and Fruit

Vegetable have HIGH iron content, they are usually the second food added to the diet
Fruit is usually offered 1 month after beginning vegetable (approx 8 months)

Meat and Eggs

Meat is presented at 9 months and egg yolks is introduced at 10 months
Egg yolk alone should be given first
Protein of egg while could cause allergies or may be difficult to digest
Cook eggs well due to danger of salmonella

Weaning

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

Key Points

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Infant period is from 1-12 months
Children double their weight at 4-6 months and triple it at 1 year
Infants get their first tooth at about 6 months
By 12 months, they have 6-8 teeth.
Important gross motor milestones during the infant year are:
- 2: lifting the chest off at bed
- 6-8: sitting
- 9: creeping
- 10-11: cruising
- 12: walking
Important fine motor accomplishments during the first year are:
- 7: ability to pass an object from one hand to the other
- 10: pincer grasp
Important milestones of language development during the first year are:
- 2: differentiating a cry
- 5-6: simple vowel sounds
- 12: saying 2 words besides mama and dada
The more the infants are spoken to, the easier it is for them to learn a language
Giving infants the right toys to play with helps with development
Important milestones of vision development during the first year are:
- 3: follows moving object past midline
  - focus securely without eyes crossing
According to Erikson, the development task of an ifnat is Trust vs Mistrust
Nurses play a key role in teaching parents about these problems and measures to deal with them

MODULE 2 LESSON 3: FAMILY WITH A TODDLER

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Developmental Milestones

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15 Months
Fine Motor

Places small pellets into small bottles
Scribbles on their own with a pencil or crayon
Holds spoon well but could still turn it upside down on the way to mouth

Gross Motor

Walks alone well
Seat themselves in chair
Can creep upstairs

Play

Can stack 2 blocks
Enjoys being read to
Drops toys for adult to get for them (sense of permanence)

Language

4-6 words

18 Months
Fine Motor

Doesn't rotate the spoon anymore to bring it to mouth

Gross Motor

Can run and jump in place
Can walk up and down the stairs while holding onto a railing
Usually places both feet on one step before advancing

Language

7-20 words
Uses jargon
Can name 1 body part

Play

Copies household chores
Starts parallel play

24 Months
Fine Motor

Can open doors by turning doorknobs
Can unscrew lids

Gross Motor

Can walk upstairs alone
Still using both feet on same step at once

Language

50 words
2-words sentences with noun-pronoun and verb

Play

Parallel play

30 Months
Fine Motor

Can make simple lines or strokes for crosses with pencil

Gross Motor

Can jump down from chairs

Language

Verbal language increases steadily
Knows full name
Can name a color and hold up fingers to show age

Play

Spend times playing house
Copying parents' actions
Active or "rough-housing"

Physiologic Development of Toddler

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Quick brain growth, bone length and muscle growth increase
Uses fingers to pick up smaller objects
Walks, runs, kicks, climbs, rides tricycles, and drinks from up
4x birth weight
Bladder control during the day, occasionally at night
Turns pages in book, and by 3 years old draws stick people

Freud - anal stage, toilet training is a big focus
Erikson - autonomy versus shame and doubt
Havinghurst - tasks of learning to control elimination process, learn sex differences, form concepts, learn language, and distinguish right from wrong

Cognitive Development of Toddler

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Stage 5 (btw 12 and 18 months)

Tertiary Circular Reaction Stage
- "little scientist"
- experiments through trial and error methods

Stage 6 (btw 18 and 24 months)

Toddlers are capable to try out different actions mentally instead of having to actually perform them - this is the beginning of problem solving or symbolic thought
Deferred Imitation
- remembers an action and imitates it later

Preoperational Thought

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

Personality Traits

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Negativism
Ritualistic behavior
Slowness in carrying out requests/ambivalence
Temper tantrums

Health Promotion

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Accidental ingestions (poisoning) are the type of accident that happens most frequently

Potential Accidents

Automative accident
Burns
Falls
Poisoning drowning
Suffocation and choking
Electric shock
Animal bites

Nursing Process

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Assessment

Taking a careful health history
- Ability to carry out ADL
- Careful observation
- child-parent relationship
- Parents = BEST source of info

Nursing Diagnosis

Focus on the parent's eagerness to learn more about the parameters of normal growth and development or issues of safety or care

Outcome Identification and Planning

Focus mainly on family education and anticipatory guidance
Create realistic goals and outcomes so they can meet the quickly changing needs of their toddler and learn to cope with usual toddler behavior

Implementation

Teach parents a good rule is to think of a toddler as a visitor from a foreign land who wants to be part of everything the family is doing but doesn't know the customs or language
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 come up in the future
Health visits provide opportunities to help parents learn healthy coping techniques
Demonstrating good communication skills with toddlers can serve as a model for healthy communication behavior with them

Outcome Evaluation

Children change so much and learn so many new skills during this time that their abilities and associated parental concerns can change from day to day

MODULE 1 LESSON 4: FAMILY WITH A PRESCHOOLER

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Preschool Stage

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An important period of growth for parents
- setting limits
physical growth slows considerably during this period, personality, and cognitive growth continue at a very fast rate

Physiological Development of Preschooler

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Head is near to adult size by 6 years old
Pulse rate lessens to about 85 bpm; blood pressure holds at about 100/60 mm Hg
Bladder is easily palpable above the symphysis pubis
- Voiding is frequent enough (9-10x a day) that play must be interrupted
Motor abilities include jumping, skipping, throwing a ball, printing letters and numbers
Full set of 20 deciduous teeth
Weight gain is slight
- Average child gains only about 4.5 (2 kg) a year

Preschool Milestones

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3 Years Old
Fine Motor

Undresses themselves
Stacks tower of blocks
Draws a cross

Gross Motor

Runs
Alternates feet on stairs
Rides tricycle
Stands on one foot

Language

Vocabulary of 900 words
"How" and "why" questions

Play

Ables to take turns; very imaginative

4 Years Old
Fine Motor

Can do simple buttons

Gross Motor

Constantly moving
Jumps, skips

Language

Vocabulary of 1500 words

Play

Pretend
Imaginative, creative play
Make-believe, fantasy play

5 Years Old
Fine Motor

Draws a 6-part man
Can tie shoe laces

Gross Motor

Throws overhand

Language

Vocabulary of 2100 words

Play

Likes games with numbers or letters

Psychosocial Development

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Developmental Task: Initiative Versus Guilt
- If children are criticized or punished for attempts at initiative, they develop a sense of guilt for wanting to try new activities or have new experiences
- Need exposure to a wide variety of experienced and play materials so they can learn as much about the world as possible
  - Ready to reach outside their homes for new experiences, such as a trip to the zoo or an amusement park

Socialization

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Significant others now include grandparents, siblings, and preschool teachers (parents stay central)
Regular interaction with same-age children is needed to further develop social skills

Play of Pre-School Age

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Running and jumping in open space
Creative play
Art activities
Trips to museum or shopping mall
Swimming and other individual sports to encourage gross motor development
Puzzles and toys to aid fine motor development

Emotional Development

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Urge parents to provide play materials that encourage creative play
- Finger paints
- Mud to make into pies
- Clay to make into pretend cookies
Imitation
- Need free rein to imitate roles of people around them
- Role playing should be fun and doesn't have to be accurate
- Imitate those activities best that they see their parents performing at home
Fantasy
- Begin to make this differentiation
- Become so engrossed in a fantasy role, however, they become scared they have lost their own identity or have become "stuck" in their fantasies
- Both supporting the fantasy and yet reassuring a child they are still themselves
- Let children know they are still recognizable
Oedipus and Electra Complexes
- Each child competes with the same-sex parent for the love and attention of the other parent
- Parents may need assistance in handling feelings of jealousy and anger if a child is vocal in expressing feelings toward a parent
Gender Roles
- Need exposure to an adult of the opposite gender so they can become familiar with opposite gender roles
- Encourage single parents to plan opportunities for their children to spend some time with adults other than themselves
Socialization
- Play with other children their age much more
  - sensitive and critical time for socialization
- Elementary Rule: an odd number of children will have difficulty playing well together pertains to children at age 5: 2 or 4 will play, but 3 or 5 will quarrel

Cognitive Development

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3 years, cognitive development according to Piaget is still preoperational
Enter a 2nd phase known as intuitional thought (intuitive thought phrase)
- Centering
  - Lack the insight to view themselves as others see them or put themselves in another's place
  - An important point to remember when explaining procedures to preschoolers
Not aware of the property of conservation yet
- Implications: not able to comprehend that a procedure done two separate way is the same procedure

Moral and Spiritual Development

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Determine right from wrong based
On their parents' rules
- Have little understanding of the rationale for these rules or even whether the rules are consistent
- Depend on parents to supply rules them, thus, with difficulty seeing that the rules they know may also apply to a new situation
Begin to have en elemental concept of God if they have been provided some form of religious training
- Belief in an outside force aids int he development of conscience

Common Health Problems

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Mortality of children during the preschool years is low
- Major cause of death being automobile accidents, followed by poisoning and falls
- Minor illnesses, such as colds, ear infections, and flu symptoms, is also high

Common Fears

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Fear of the dark
- heightened by a chid's vivid imagination
  - Night waking from nightmares or night terrors reaches its peak
    • Night light
    - reassurance they are safe, that whatever was chasing them was a dream and is not in their room
- source of the stress needs to be investigated

Fear of Mutilation
- revealed by the intense reaction of a preschooler to even a simple injury such as falling and scraping a knee or having a needle inserted for an immunization
- need good explanations of the limits of health care procedures
- fear of castration

Fear of Separation or Abandonment
- intensifies because their keen imagination allows them to believe they have been deserted when they are safe
- Relating time and space to something a child knows, such as meals, television shows, or a friend’s house, is
- most effective
  - “Mommy will pick you up from preschool after you have had your snack”
A hospital admission or going to a new school often brings a child’s fear of separation

Behavior Variations

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Telling Tall Tales
- Caution parents not to encourage the kind of storytelling, but instead help the child separate fact from fiction
Imaginary Friends
- separate fact from fantasy about their imaginary friend

Difficulty Sharing
- Assure parents that sharing is a difficult concept to grasp and that, as with most skills, preschoolers need practice to understand and learn it
- Defining limits and exposing children to these three categories (mine, yours, ours) helps them determine which objects belong to which category

Regression
- in relation to stress, revert to behavior they previously outgrew, such as thumbsucking, negativism, loss of bladder control, and inability to separate from their parents
  - new baby in the family
  - a new school experience
  - seeing frightening and graphic television news
  - stress in the home from financial or other problems, marital difficulties
  - separation caused by hospitalization
- removing the stress is the best way to help
- a child discontinue this behavior
- Thumb-sucking or other manifestations of stress are best ignored

Sibling Rivalry
- A firstborn child is rarely allowed the privileges of a second child. The parents were untried, unsure of how far they should let a child venture or what level of responsibility a child could accept when the child was younger, or the firstborn serves as the “trial run” for all children who come after
  - feel secure and promote self-esteem, by supplying them with a private drawer or box for their things that parents or other children do not touch can be helpful

Special Problems

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Thumbsucking
Food likes and dislikes
Enuresis
- Bed-wetting
Encopresis
- fecal incontinence or soiling
Bruxism or grinding the teeth at night
- (usually during sleep), is a habit of many young children
- way of “letting go” , to release tension and allow themselves to fall asleep
identifying and relieving the source of anxiety is essential for treatment

MODULE 1 LESSON 5: CARE OF A FAMILY WITH A SCHOOL-AGE CHILD

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School Age...

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School age
- or middle childhood
- refers to the stage of a child’s life from ages
- 6 to 12 years
- The school-age years can be a spectacular
- journey filled with joys and successes as the child
- continues to grow and mature
- time of slow physical growth, cognitive growth
- and development continue to proceed at rapid rates
- always assess children as individuals to understand the
  particular developmental
  needs of each child based on what
  developmental status has been achieved,
  not on what stage you think the child
  should have reached
Children of school age may be
more influenced by the attitudes of
their friends
the first time children begin to make truly
independent judgments

Physical Growth

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annual average weight gain is approximately 3 to 5 lb (1.3 to 2.2 kg); the increase in height is 1 to 2 in (2.5 to 5 cm)
posture becomes more erect
slims down and becomes more agile and graceful
10 years of age
- brain growth is complete, so fine motor coordination becomes refined
adult vision level is achieved
If the eruption of permanent teeth and growth of the jaw do not correlate with
final head growth
- malocclusion (a deviation from the normal) with teeth malalignment
immunoglobulins IgG and IgA reach adult levels and lymphatic tissue continues to
grow up until about age 9
- Appendicitis
- Frontal sinuses develop at about 6 years
  - sinus headache
pulse rate decreases to 70 to 80 beats per minute; blood pressure rises to about 112/60 mm Hg
Maturation of the respiratory system leads to increased oxygen–carbon dioxide
exchange
- increases exertion ability and stamina
Scoliosis may become apparent for the first time in late childhood
- over age 8 should be screened
Girls tend to develop slightly faster than boys; although boys are, on average, taller and heavier than girls until the adolescent growth spurt
- The pubertal growth spurt begins in girls at about age 10 and in boys at about
  age 12
Feet are the first part of the body to experience a growth spurt
- Increased foot size is followed by a
  rapid increase in leg length and then
  trunk growth
- leg growth increases more dramatically
  than trunk growth in boys although girls
  have a greater growth spurt in hip width,
  boys exceed girls in other areas of bone
  growth

Sexual Maturation

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in girls usually occurs between 12 and 18 years; in boys, between 14 and 20 years
gonadal hormone levels increase and cause the sexual organs to mature
onset of puberty varies widely, between 10 and 14 years of age

Sexual and Physical Concerns

time for parents to discuss with children the physical changes that will occur and the sexual responsibility these changes dictate
time to reinforce previous teaching with children that their body is their own, to be used only in the way they choose

Concerns of Girls

Prepubertal girls are usually taller, by about 2 in (5 cm) or more than preadolescent boys
girl notices the change in her pelvic contour when she tries on a skirt or dress from the year before and realizes her hips are becoming broader
- Crash diet
Girls are usually conscious of breast development and whether they are overdeveloped or underdeveloped
- Breast self-examination and sexual responsibility
Supernumerary (additional) nipples may darken or increase in size at puberty
Early preparation for menstruation is important for future childbearing and for
the girl’s concept of herself as a woman
- good hygiene and reassurance they can bathe, shower, and swim during their periods
- use either sanitary napkins or tampons take precautions to avoid toxic shock syndrome
first menstruation, called menarche, usually starts around age 12 but can occur as early as age 9 and still be considered normal
- The menstrual cycle may be irregular at first
- consistent irregularities in her period should be assessed for
  malnourishment and obesity
  - Emotions
  - if irregularity continues beyond the first year, a careful history of the
    girl’s school, social, nutrition, level of exercise, and home
    adjustment should be taken
- vaginal secretions will begin to be present
  - Explain that any secretions that cause vulvar irritation should be
    evaluated

Concern of Boys

aware of increasing genital size
testicular development precedes penis growth
be informed that hypertrophy of breast tissue
(gynecomastia) can occur in prepuberty (most often in stocky or obese boys)
although they have pubic hair, they cannot yet grow a beard or do not have chest hair
seminal fluid is produced, boys begin to notice ejaculation during sleep, termed nocturnal emissions

Physiological Development of School-Age Child (6 to 12 years)

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Brain reaches 90% to 95% of adult size, nervous system almost mature by age 12
Motor abilities progress to writing in script and in sentences by age 12
Sexual organs grow but are dormant until late in this period
All permanent teeth present except for 2nd and 3rd molars by age 12
The average child gains 28 teeth between 6 and 12 years of age: the central and lateral incisors; first, second, and third cuspids; and first and second molars

Physiological Development

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Attending school marks an acceleration in the separation of the child from his parents
introduces the child to a new set of authority figures (teachers, school administrators) and strengthens the concept of peer relationships
Erikson’s stage of industry versus inferiority
- child wants to work and produce, accomplishing and achieving tasks
- focus on learning useful skills, self-identity emerges
- if too much is expected of him, or if he feels unable to measure up to set standards, the negative attributes of inadequacy and inferiority may prevail
Language development and socialization
- child has an efficient vocabulary and begins to correct previous mistakes in usage
- begins to understand the double meanings of words and becomes proficient at giving others directions without using physical signals
Six-year-olds talk in full sentences, using language easily and with meaning
- define objects by their use: a key is to unlock a door; a fork is to eat with
7-year-olds can tell the time in hours, but they may have trouble with concepts such as “half past” and “quarter to,” especially with the prevalence of digital clocks and watches
- know the months of the year and can name the months in which holidays fall
- can add and subtract and make simple change
age 9
- discover “dirty” jokes
  - Like to tell them to friends or try to understand those told by
    adults
  - use swear words to express anger or just to show other
    children they are growing up
  - have a short period of intense fascination with “bathroom
    language”
- 12 years of age
  - a sense of humor is apparent
  - can carry on an adult conversation, although stories are
    limited because of their lack of experience

First and Second Grades

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peers are increasingly significant to the child
Same-sex cliques are established
competition becomes more common
bragging over accomplishments
child may be overly concerned with peer rules
more sensitive to criticism and ridicule

Play

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continues to be rough at age 6
when children discover reading as an enjoyable activity that opens doors to other worlds, they can begin to spend quiet time with books
Many children spend hours playing increasingly challenging video games, an activity that can either foster a healthy sense of competition or create isolation from others
7 years of age
- decline in imaginative play
- interest in collecting items such as baseball cards, dolls, rocks, or marbles
8 years of age
- collections may become increasingly structured as
  children develop skills for sorting and cataloging
10 years of age
- children become very interested in rules and fairness in competitive play situations
Children also begin discovering the Internet and how other children out there are waiting to talk to them in chat rooms
Music and artistic expression

Cognitive Development

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School and learning are viewed as an exciting experience
- require concentration, attendance, and complex auditory and visual processing
major developmental tasks at this time are achievement in school and acceptance by peers

Cognitive Development of School-Age Child

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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 about people, places, and things
Develops classification systems, understands reversal of events
Has an awareness of other’s feelings

New Concepts Learned

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Decentering
- the ability to project oneself into other people’s situations and see the world from their viewpoint rather than focusing only on their own view
Accommodation
- the ability to adapt thought processes to fit what is perceived such as understanding that there can be more than one reason for other people’s actions
Conservation
- the ability to appreciate that a change in shape does not necessarily mean a change in size
Class Inclusion
- the ability to understand that objects can belong to more than one classification

Emotional Development

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ability to trust others and with a sense of respect for their own worth
can accomplish small tasks independently because they have gained a sense of autonomy
have practiced or mimicked adult roles and had the opportunity to explore at preschool or other social environments
should have learned to share, to have discovered that learning is fun and an adventure

Moral and Spiritual Development

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Kohlberg’s Conventional Level
- child behaves according to socially acceptable norms because an authority figure tells him to do so
- This obedience is compelled by the threat of punishment (external factors)
Ages 11 to 12
- as the child begins to approach adolescence, 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 and models
Parental guidance, love, and support are absolutely essential for the development of values during this time
- child at this age needs the opportunity to make decisions within defined boundaries
- those boundaries are set by responsible adults in the child’s life
- Spiritual lessons should be taught in concrete terms during this stage
- Repeated religious rituals, such as praying and attending church services, may comfort them
- begin to learn about the rituals and meaning behind their religious practices, so the distinction between right and wrong becomes more important
- Parent role modeling is also important
- school-age children are rule-oriented; when they pray, they may expect their God to follow rules also (if you are good and pray for something, you should receive it)

Coping with Concerns

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School Phobias
- called school refusal or school avoidance
- may be a sign of a separation anxiety
  - occur after a particular trauma, such as the death of a pet, illness within the family, or a move to a new school
fear of the school itself and what the child experiences there
Possible reasons for school phobias include:
- being the target of a bully
- anxiety about academic achievement
- having problems adapting to the school structure

Stealing
- simply wants items for himself
- Stealing at the end of middle childhood is commonly a sign that something is lacking in that child’s life
- Possible causes include a lack of:
  - financial means
  - attention from a parent or caregiver
  - sense of property rights
- Parents should recognize the child’s property rights and 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

MODULE 1 LESSON 6: CARE OF FAMILY WITH ADOLESCENTS

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Adolescence

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THE PERIOD BETWEEN 13 AND 18 OR 20 YEARS
TIME THAT SERVES AS A TRANSITION BETWEEN CHILDHOOD AND YOUNG ADULTHOOD
DEFINED NOT SO MUCH BY CHRONOLOGIC AGE BUT BY PHYSIOLOGIC, PSYCHOLOGICAL, AND SOCIOLOGIC CHANGES
DIVIDED INTO:
- EARLY PERIOD (13 TO 14 YEARS)
- MIDDLE PERIOD (15 TO 16 YEARS)
- LATE PERIOD (17 TO 20 YEARS)

Nursing Process

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ASSESSMENT
- OBTAIN A HEALTH HISTORY SEPARATELY FROM PARENTS TO PROMOTE INDEPENDENCE AND RESPONSIBILITY FOR SELFCARE
- BE AWARE THEY MAY BE VERY SELF-CONSCIOUS WITH PHYSICAL EXAM
NURSING DIAGNOSIS
- 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
OUTCOME IDENTIFICATION AND PLANNING
- RESPECT THE FACT THEY HAVE A STRONG DESIRE TO EXERT INDEPENDENCE OR DO THINGS THEIR OWN WAY
- INCLUDING THEM IN PLANNING IS ESSENTIAL SO THE PLAN WILL BE AGREEABLE AND ACCEPTED
- ESTABLISHING A CONTRACT
- ARE VERY PRESENT ORIENTED
- TEACHING BY PEERS
IMPLEMENTATION
- EVALUATE HOW AN INTERVENTION APPEARS FROM AN ADOLESCENT’S STANDPOINT BEFORE BEGINNING TEACHING
OUTCOME EVALUATION
- 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

Growth and Development of an Adolescent

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GROW BOTH RAPIDLY AND MATURE DRAMATICALLY
RECOGNIZING THAT ADOLESCENTS MAY HAVE DIFFERING RESPONSIBILITIES AND LIFE EXPERIENCES BASED ON CULTURAL EXPECTATIONS CAN BE USEFUL WHEN MAKING AN ASSESSMENT
INCLUDE FACTORS SUCH AS OCCUPATIONAL HAZARDS OR THE EFFECTS OF JOB, FAMILY, AND FINANCIAL STRESS ON AN ADOLESCENT
READINESS FOR EARLY CHILDBEARING MAY ALSO BE IMPORTANT

Physical Growth

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Apocrine sweat glands
Heart and lungs increase in size more slowly than the rest of the body
PR: 70 bpm
RR: 20 breaths per minute
BP: 120/70 mm Hg
Major milestone: onset of puberty at 9 to 12 years of age and cessation of body growth at 16-20 years of age

What's Happening?

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Ages 11 and 14 years
- Begins to menstruate
- Begins to produce spermatozoa
- Puberty is the time at which an individual first becomes capable of sexual reproduction

Physical Development

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Primary Sexual Characteristics
- Body structures that make reproduction possible
  - Penis
  - Testes
  - Vagina
  - Ovaries

Primary and Secondary Sex Characteristics

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Males
- Primary sex characteristics
  - Growth of scrotum and testes
  - Secretion of hormones related to sperm production
  - Growth of penis
- Secondary sex characteristics
  - Body and facial hair
  - More muscle mass
  - Greater height than females
  - Broadening shoulder
Females
- Primary sex characteristics
  - Increase in size of vagina and uterus
  - Ovaries produce hormones to start the menstrual cycle
- Secondary sex characteristics
  - Hips widen
  - Development of breasts
  - Distribution of fats to hips
  - Body gets curvier
Similarities
- Pubic hair
- Oily skin
- Voice deepens
- Acne
- Increase in height
- Increase in body odor

Adolescent Developmental Milestone

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Opportunity
Potential
Danger
Who am I?
Play or Recreation
- Urge parents to encourage youngsters to play sports for their own health and well-being and the companionship involved
15-old children may spend a great deal of time in their room
work with others, accept responsibility, and spend money wisely

Emotional Development

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Developmental Tasks: Identity versus Role Confusion
Establishing a value system or what kind of person they want to be
Accepting their changed body image
Becoming emancipated from their parents
Give adolescents more freedom, help parents continue to place some restrictions on adolescents behavior thus, helping adolescents accept the responsibility that must come with independence

Health Promotion for an Adolescent and Family

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PROMOTING ADOLESCENT SAFETY
- ACCIDENTS, MOST COMMONLY THOSE INVOLVING MOTOR VEHICLES, ARE THE LEADING CAUSE OF DEATH
  - MOTORCYCLES, MOTORBIKES, AND MOTOR SCOOTERS
  - EVERY SAFETY PRECAUTION AVAILABLE WHEN IN A MOTOR VEHICLE
  - DRIVERS AND RIDERS SHOULD WEAR SAFETY HELMETS TO PREVENT HEAD INJURY
  - LONG PANTS TO PREVENT LEG BURNS FROM EXHAUST PIPES
  - FULL BODY COVERING TO PREVENT ABRASIONS IN CASE OF AN ACCIDENT.
    - ADVISE ADOLESCENTS WHO CHOOSE THESE FORMS OF TRANSPORTATION TO BE AS FAMILIAR WITH SAFETY RULES AS AUTOMOBILE DRIVERS
    - THEY NEED TO WAIT TO DRIVE MOTORCYCLES OR SCOOTERS UNTIL THEY ARE EMOTIONALLY MATURE ENOUGH TO USE SOUND DRIVING JUDGMENT
  - DROWNING IS ANOTHER CHIEF ACCIDENT
    - TEACHING ALL CHILDREN TO SWIM IS NOT THE ONLY PREVENTIVE MEASURE, BECAUSE SOME DROWNINGS OCCUR WHEN GOOD SWIMMERS GO BEYOND THEIR CAPABILITIES
      ON DARES OR IN HOPES OF IMPRESSING FRIENDS
    - TEACHING WATER SAFETY, SUCH AS NOT SWIMMING ALONE OR WHEN TIRED
  - HOMICIDE AND SUICIDE, RELATED TO THE EASY ACCESSIBILITY OF GUNS TO TEENAGERS
    - GANG VIOLENCE AND THE DESIRE TO PROTECT THEMSELVES
    - ACCIDENTAL GUNSHOT INJURIES
  - ATHLETIC INJURIES BECAUSE OF THE VIGOROUS LEVEL OF COMPETITION

Recommended Dietary Reference Intakes

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INCREASED NUMBER OF CALORIES
NECESSARY CARBOHYDRATES, VITAMINS, PROTEIN, AND MINERALS ARE ESSENTIAL
LARGE AMOUNTS OF IRON ARE NECESSARY
- FEMALES REQUIRE A HIGH IRON INTAKE
INCREASED CALCIUM PLUS PHYSICAL EXERCISE IS NECESSARY FOR RAPID SKELETAL GROWTH AS WELL AS TO “STOCKPILE” CALCIUM TO PREVENT OSTEOPOROSIS LATER IN LIFE
ZINC IS NECESSARY FOR SEXUAL MATURATION AND FINAL BODY GROWTH
GOOD SOURCES OF IRON ARE MEAT AND GREEN VEGETABLES; CALCIUM IS ABUNDANT IN MILK AND MILK PRODUCTS; MEAT AND MILK ARE ALSO HIGH IN ZINC

Promoting Nutritional Health with a Varied Diet

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VEGETARIAN DIETS
- VEGETABLES SHOULD BE CONSUME LARGE AMOUNTS
  - BE CERTAIN ALL ADOLESCENT VEGETARIANS ARE FOLLOWING A DIET AND NOT EATING ONLY FRUITS AND VEGETABLES AS A METHOD TO LOSE WEIGHT
GLYCOGEN LOADING
- ATHLETES NEED MORE CARBOHYDRATE OR ENERGY THAN DO PEOPLE WHO DO NOT ENGAGE IN STRENUOUS ACTIVITY
- GLYCOGEN LOADING IS A PROCEDURE USED TO ENSURE THERE IS ADEQUATE GLYCOGEN TO SUSTAIN ENERGY THROUGH AN ATHLETIC EVENT
- THEY THEN SWITCH TO A DIET HIGH IN CARBOHYDRATE. WITH THE RENEWED CARBOHYDRATE INTAKE, MUSCLE GLYCOGEN IS STORED AT APPROXIMATELY TWICE THE USUAL LEVEL, READY TO SUPPLY TWICE THE GLUCOSE FOR SUSTAINED ENERGY
  - EATING A WELL-BALANCED DIET, ARE ALSO THE BEST RULES FOR ATHLETES, RATHER THAN DIETS THAT INTERFERE WITH CARBOHYDRATE, FLUID, OR FAT INTAKE

Promoting Development of an Adolescent in Daily Activities

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ADEQUATE SLEEP
- FREQUENT LACK OF SLEEP CAN LEAD TO CHRONIC FATIGUE OR DEPRESSION
DRESS AND HYGIENE
EXERCISE
- LITTLE REAL EXERCISE
- ADVICE ON INCREASING EXERCISE GRADUALLY SO THEY DO NOT OVERDO AND CONSEQUENTLY DEVELOP MUSCLE SPRAINS OR OTHER OVERUSE INJURIES
CARE OF TEETH

Promoting Healthy Family Functioning

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COUNSEL PARENTS TO APPRECIATE THAT ALTHOUGH IT IS NOT EASY TO LIVE WITH A TEENAGER, IT IS EQUALLY DIFFICULT TO BE THE TEENAGER
“FALLEN ANGEL” SYNDROME
- HAVE TROUBLE RESPECTING PARENTS WHO ARE SO OBVIOUSLY IMPERFECT
MAY FOLLOW HEALTH ADVICE POORLY BECAUSE THEY VIEW HEALTH CARE PERSONNEL IN THE SAME LIGHT

Common Health Patterns

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HYPERTENSION
- BLOOD PRESSURE IS ABOVE THE 95TH PERCENTILE, OR 127/81 MM HG FOR 16-YEAR-OLD GIRLS AND 131/81 FOR 16-YEAR-OLD BOYS FOR TWO CONSECUTIVE READINGS IN DIFFERENT SETTINGS
- OBESE
- WHO ARE AFRICAN AMERICAN
- WHO EAT A DIET HIGH IN SALT
- WHO HAVE A FAMILY HISTORY
- NEW MEDICATION PLUS EDUCATION IN RISK FACTORS MAKES TREATMENT AT THIS AGE SUCCESSFUL
POOR POSTURE
- 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
    MUSCLES
- ADOLESCENTS WHO REACH ADULT HEIGHT BEFORE THEIR PEERS
- URGE CHILDREN OF BOTH SEXES TO USE GOOD POSTURE DURING
  THESE RAPID-GROWTH YEARS
  - TALL ADOLESCENTS OF BOTH SEXES ARE GENERALLY PICKED
    OUT BY BASKETBALL OR TRACK COACHES AND SO MAY HAVE
    THE INCENTIVE, IF PROPERLY GUIDED, TO MAINTAIN GOOD
    POSTURE
- ASSESS POSTURE AT ALL ADOLESCENT HEALTH APPRAISALS TO
  DETECT THE DIFFERENCE BETWEEN SIMPLE POOR POSTURE AND
  THE BEGINNING OF SCOLIOSIS (LATERAL CURVATURE OF THE SPINE)
BODY PIERCING AND TATTOOS
- STRONG MARK OF ADOLESCENCE
- BOTH SEXES HAVE EARS, LIPS, CHINS, NAVELS, AND BREASTS PIERCED
  AND FILLED WITH STUDS, OR TATTOOS APPLIED TO ARMS, LEGS, OR
  THEIR CENTRAL BODY
- TO MAKE A STATEMENT THAT THEY ARE DIFFERENT FROM THEIR
  PARENTS
- KNOW THE SYMPTOMS OF INFECTION AT A PIERCING OR TATTOO SITE
  (REDNESS, WARMNESS, DRAINAGE, SWELLING, MILD PAIN) AND TO
  REPORT THESE TO A HEALTH CARE PROVIDER IF THEY OCCUR AS
  SERIOUS STAPHYLOCOCCAL OR STREPTOCOCCAL INFECTIONS CAN
  OCCUR AT PIERCING SITES
- CAUTION ADOLESCENTS THAT SHARING NEEDLES FOR PIERCING OR
  TATTOOING CARRIES THE SAME RISK AS SHARING NEEDLES FOR INTRAVENOUS DRUG USE
FATIGUE
- INVESTIGATE AS A LEGITIMATE CONCERN AND NOT UNDERESTIMATED
- ASSESS AN ADOLESCENT’S DIET, SLEEP PATTERNS, AND ACTIVITY
  SCHEDULES, BECAUSE ALL CAN CONTRIBUTE GREATLY TO FATIGUE
- NOTE WHEN THE FATIGUE BEGAN
- SHORT PERIOD OF EXTREME TIREDNESS IS MORE LIKELY TO SUGGEST
  DISEASE THAN A LONG, ILL-DEFINED REPORT OF ALWAYS FEELING TIRED
ACNE
- SELF-LIMITING INFLAMMATORY DISEASE THAT INVOLVES THE SEBACEOUS GLANDS THAT EMPTY INTO HAIR SHAFTS (THE PILOSEBACEOUS UNIT)
- MOST COMMON SKIN DISORDER OF ADOLESCENCE, OCCURRING IN AS MANY AS 80% TO 95% OF ADOLESCENTS
- SLIGHTLY MORE FREQUENTLY IN BOYS THAN IN GIRLS
- PEAK AGE FOR THE LESIONS TO OCCUR IN GIRLS IS 14 TO 17 YEARS;
  FOR BOYS, 16 TO 19 YEAR
- ACNE IS CATEGORIZED AS:
  - MILD (COMEDONES ARE PRESENT),
  - MODERATE (PAPULES AND PUSTULES ARE ALSO PRESENT)
  - SEVERE (CYSTS ARE PRESENT)
- MOST COMMON LOCATIONS OF ACNE LESIONS ARE THE FACE, NECK, BACK, UPPER ARMS, AND CHEST
OBESITY
- BOTH INHERITANCE AND ENVIRONMENT PLAY A PART

Concerns Regarding Sexuality and Sexual Activity

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BECAUSE OF INCREASING EXPOSURE TO AND ACCEPTANCE OF PREMARITAL SEXUAL RELATIONS IN SOCIETY, MORE ADOLESCENTS THAN EVER BEFORE ENGAGE IN HIGH-RISK SEXUAL BEHAVIORS EXPOSING THEM TO SEXUALLY TRANSMITTED INFECTIONS OR CONCEPTION
- ASK IF THEY ARE SEXUALLY ACTIVE OR ARE CONCERNED ABOUT SEXUAL RISK BEHAVIORS
OFFER SUPPORT TO ADOLESCENTS WHO ARE HAVING DIFFICULTY TELLING
THEIR PARENTS ABOUT THEIR PERCEIVED SEXUAL ORIENTATION. TO THEIR
SURPRISE, THEY OFTEN DISCOVER THEIR PARENTS ALREADY KNOW WHAT THEY ARE GOING TO SAY BEFORE IT IS VOICED
CAUTION ADOLESCENTS ABOUT THE DANGERS OF FLUNITRAZEPAM
(ROHYPNOL), THE “DATE-RAPE DRUG,” A COLORLESS, ODORLESS, AND
FLAVORLESS BENZODIAZEPINE DRUG THAT, IF DROPPED INTO A DRINK,
CAN REMAIN UNDETECTED BUT CAUSE DROWSINESS, IMPAIRED
MOTOR SKILLS, AND AMNESIA
STALKING
- REFERS TO REPETITIVE, INTRUSIVE, AND UNWANTED ACTIONS
  DIRECTED AT AN INDIVIDUAL TO GAIN THE INDIVIDUAL’S ATTENTION OR EVOKE FEAR
- THE USUAL STALKER IS A MALE WHO STALKS A FEMALE WHO HAS
  REJECTED HIM
- STALKERS INSTILL FEAR INTO THEIR VICTIMS BY CONSTANT AND
  THREATENING PURSUIT
- IN SOME INSTANCES, THE STALKER CAN RESORT TO ATTACKING A VICTIM AND EVEN MURDER IF FURTHER REJECTED

Concerns Regarding Hazing

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HAZING
- REFERS TO DEMEANING OR HUMILIATING RITUALS THAT PROSPECTIVE MEMBERS HAVE TO UNDERGO TO JOIN SORORITIES, FRATERNITIES, ADOLESCENT GANGS, OR SPORTS TEAMS
- MOST RITUALS ARE SECRET AND IN THE PAST WERE ACCEPTED AS “RITES OF PASSAGE”
- HAZING HAS BECOME SO EXTREME THAT THE PRACTICE HAS MOVED OUT OF THE "JUST FUN” CATEGORY INTO ACTIVITIES THAT CAN CAUSE PHYSICAL AND CERTAINLY PSYCHOLOGICAL HARM
- RITUALS MAY BE AS SUBTLE AS BEING CALLED NAMES, FORCED TO WEAR RIDICULOUS CLOTHING, OR ENGAGE IN CRUDE OR LEWD SKITS

Concerns Regarding Substance Abuse

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REFERS TO THE USE OF CHEMICALS TO IMPROVE A MENTAL STATE OR INDUCE EUPHORIA
- COMMON AMONG ADOLESCENTS THAT AS MANY AS 50% OF HIGH SCHOOL SENIORS REPORT HAVING EXPERIMENTED WITH SOME FORM OF DRUG
- DRUG USE OCCURS FROM A DESIRE TO EXPAND CONSCIOUSNESS OR TO FEEL MORE CONFIDENT AND MATURE
- CAN BE A RESPONSE TO PEER PRESSURE OR A FORM OF ADOLESCENT REBELLION
  - THIS TYPE OF REBELLION IS MORE EMOTIONALLY CHARGED THAN ACTS SUCH AS STAYING OUT LATE OR WEARING CLOTHING OTHER THAN THOSE APPROVED BY PARENTS, BECAUSE IT IS NOT ONLY HARMFUL BUT ALSO ILLEGAL
TYPES OF ABUSED SUBSTANCES
- PRESCRIPTION AND OVER-THE-COUNTER DRUGS
  - ADOLESCENTS MAY BEGIN DRUG EXPERIMENTATION BY TAKING SEDATIVES, PAIN MEDICATION, OR COUGH SYRUP CONTAINING DEXTROMETHORPHAN, ABBREVIATED DXM, PRESCRIBED FOR ANOTHER FAMILY MEMBER OR A PET
  - A SMALL AMOUNT OF DXM CAUSES LIGHTHEADEDNESS
- TOBACCO
  - ALTHOUGH IT IS WELL DOCUMENTED THAT CIGARETTE SMOKING LEADS TO INCREASED CARDIOVASCULAR AND RESPIRATORY ILLNESSES BY MIDDLE AGE, EVERY DAY APPROXIMATELY 4000 AMERICAN YOUTH AGED 12 TO 17 YEARS TRY THEIR FIRST CIGARETTE
  - ABOUT 23% OF HIGH SCHOOL STUDENTS REPORT CURRENT CIGARETTE USE AND 14% REPORT CURRENT CIGAR USE. EIGHT PERCENT OF HIGH SCHOOL STUDENTS AND 18% OF WHITE MALE HIGH SCHOOL STUDENTS REPORT CURRENT SMOKELESS TOBACCO USE
- ALCOHOL
  - AS MANY AS 90% OF HIGH SCHOOL SENIORS REPORT HAVING USED ALCOHOL
  - AS MANY AS 25% OF HIGH SCHOOL STUDENTS REPORT HAVING ENGAGED IN EPISODIC HEAVY OR BINGE DRINKING
  - AT LEAST 10% OF HIGH SCHOOL STUDENTS REPORT DRIVING A CAR OR OTHER VEHICLE WHEN THEY HAD BEEN DRINKING ALCOHOL
  - TWENTYNINE PERCENT OF STUDENTS REPORT HAVING RIDDEN IN A CAR OR OTHER VEHICLE DRIVEN BY SOMEONE WHO HAD BEEN DRINKING ALCOHOL
  - ALTHOUGH ITS USE IS CORRELATED WITH MOTOR VEHICLE ACCIDENTS, HOMICIDE, AND SUICIDE IN ADOLESCENTS, ALCOHOL HAS NEVER CARRIED THE STIGMA OF OTHER DRUGS
  - SOME PARENTS ARE ACTUALLY RELIEVED WHEN THEY REALIZE THEIR CHILD’S STRANGE BEHAVIOR ON RETURNING HOME FROM A PARTY IS CAUSED BY DRUNKENNESS AND NOT ILLEGAL DRUGS
  - ALCOHOL USE CANNOT BE TAKEN LIGHTLY
    - LINKED TO DISEASES SUCH AS CIRRHOSIS, COGNITIVE CHALLENGE, AND DESTRUCTIVE BEHAVIORS SUCH AS ADDICTION, DEPRESSION, AND VULNERABILITY TO DATE RAPE
- PERFORMANCE-ENHANCING DRUG ABUSE
  - ANABOLIC STEROIDS ARE DERIVATIVES OF THE NATURAL HORMONE
    TESTOSTERONE
    - COMMON
      NAMES ARE STANOZOLOL, AN ORAL COMPOUND, AND TESTOSTERONE
      PROPIONATE, AN INJECTABLE FORM. ADOLESCENTS TAKE STEROIDS (OBTAINED
      ILLEGALLY) TO ENHANCE LEAN BODY MASS AND MUSCULAR
      DEVELOPMENT AND SO IMPROVE THEIR ATHLETIC ABILITY OR APPEARANCE (VAN DEN
      BERG ET AL., 2007). ANABOLIC STEROIDS ALSO HAVE
      THE SIDE EFFECTS OF EUPHORIA AND LESSENED FATIGUE, WHICH MAKE
      THEM DOUBLY APPEALING
- MARIJUANA
  - MARIJUANA (WIDELY KNOWN AS POT OR GRASS) IS DERIVED FROM THE LEAVES AND STEMS OF THE INDIAN HEMP PLANT, CANNABIS SATIVA
  - IT IS GENERALLY ROLLED INTO CIGARETTES (“JOINTS” OR “REEFERS”) AND SMOKED, ALTHOUGH IT CAN BE MIXED WITH FOOD OR SNIFFED
  - SCRAPING THE RESIN FROM THE FLOWERING LEAVES PRODUCES A MUCH STRONGER SUBSTANCE CALLED HASHISH
  - SINSEMILLA IS A SEEDLESS FORM THAT IS EVEN MORE POTENT
- AMPHETAMINES
  - GROUP OF DRUGS SOMETIMES USED IN THE TREATMENT OF HYPERACTIVITY AND NARCOLEPSY, AMONG OTHER CENTRAL NERVOUS SYSTEM DISORDERS
  - EASILY MANUFACTURED IN “METH LABS” IN PEOPLE’S HOMES AND SO ARE READILY AVAILABLE TO ADOLESCENTS
  - AMPHETAMINES ARE CALLED UPPERS OR SPEED BECAUSE THEY GIVE THE USER A FALSE SENSE OF WELL-BEING, ALERTNESS, OR SELF-ESTEEM A NEWER, STRONGER FORM THAT PRODUCES INTENSE SYMPTOMS IS KNOWN AS ICE
  - SOME OF THE SIDE EFFECTS THAT CAN OCCUR ARE AGGRESSIVE OR DEMANDING BEHAVIOR, PARANOIA, AND EXTREME RESTLESSNESS
  - CHRONIC METHAMPHETAMINE ABUSE RESULTS IN SEVERE BLACKENED, CRUMBLING TEETH. BECAUSE AMPHETAMINES SUPPRESS THE APPETITE, ADOLESCENTS MAY LOSE
    WEIGHT OR EAT ONLY SPORADICALLY WHILE TAKING THEM
  - THEIR USE WITHOUT A PRESCRIPTION IS ILLEGAL
- COCAINE
  - ONE OF THE MOST POPULAR DRUGS OF ABUSE FOR YOUNG ADULTS AND ITS USE MAY BEGIN IN ADOLESCENTS
  - MAY BE SNIFFED INTO THE NOSE (SNORTED), SMOKED, OR INJECTED INTRAVENOUSLY
  - OCCASIONALLY IT IS COMBINED WITH HEROIN AND INJECTED (TERMED A SPEEDBALL). COMMON STREET NAMES FOR COCAINE ARE SNOW AND WHITE LADY, BECAUSE OF ITS FINE, WHITE POWDER
  - A STRONGER FORM, CALLED CRACK, IS MANUFACTURED BY EATING COCAINE POWDER WITH BAKING SODA AND WATER
  - THIS PREPARATION PROCESS IS DANGEROUS IN ITSELF BECAUSE IT INVOLVES USING VOLATILE SOLVENTS THAT CAN IGNITE OR EXPLODE
  - THE RESULTING DRUG, OFTEN CALLED FREEBASE OR ROCK, IS SO STRONG IT CAN CAUSE IMMEDIATE CARDIAC AND RESPIRATORY ARRHYTHMIAS
- HALLUCINOGENS
  - EXAMPLES OF HALLUCINOGENIC DRUGS USED BY ADOLESCENTS ARE:
    - LYSERGIC ACID DIETHYLAMIDE (LSD)
    - DIMETHYLTRYPTAMINE (DMT)
    - 2,5-DIMETHOXY-4-METHAMPHETAMINE (STP)
    - PHENCYCLIDINE HYDROCHLORIDE (PCP)
    - METHAQUALONE (QUAALUDE)
  - THE USE OF LSD HAS INCREASED IN POPULARITY SUBSTANTIALLY SINCE THE 1960S WHEN IT FIRST BECAME AVAILABLE, BECAUSE IT IS A DRUG THAT CAN BE MANUFACTURED BY AN INFORMED ADOLESCENT IN A “KITCHEN LAB
- OPIATES
  - DRUGS SUCH AS HEROIN, MEPERIDINE (DEMEROL), AND MORPHINE. AT ONE TIME, THESE WERE NOT TYPICALLY USED BY ADOLESCENTS BECAUSE THEY ARE EXPENSIVE, BUT THEY NOW ARE GAINING POPULARITY AMONG TEENS
  - CAN BE EXTREMELY DANGEROUS BECAUSE OF THEIR TENDENCY TO DECREASE RESPIRATORY RATE
  - ADDICTION TO OPIATES AN CAUSE SUCH A PHYSIOLOGIC CRAVING THAT ADOLESCENTS, LIKE ADULTS, WILL STEAL, DEFRAUD, TURN TO PROSTITUTION, OR RESORT TO WHATEVER METHOD IS AVAILABLE TO SECURE ENOUGH MONEY TO BUY A DAY’S SUPPLY
  - IN ADDITION TO THE DIRECT DANGER OF OPIATES, ADOLESCENTS WHO USE THEM 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
ASSESSMENT OF SUBSTANCE ABUSE
- IF ADOLESCENTS TRUST HEALTH CARE PERSONNEL, THEY WILL GENERALLY ADMIT THEY HAVE ENGAGED IN DRUG EXPERIMENTATION
- SOME COMMON FINDINGS ON THE HEALTH HISTORY THAT SUGGEST AN
  ADOLESCENT IS ABUSING SOME SUBSTANCE ARE:
  - FAILURE TO COMPLETE ASSIGNMENTS IN SCHOOL
  - DEMONSTRATION OF POOR REASONING ABILITY
  - DECREASED SCHOOL ATTENDANCE
  - FREQUENT MOOD SWINGS
  - DETERIORATING PHYSICAL APPEARANCE
  - RECENT CHANGE IN PEER GROUP
  - EXPRESSED NEGATIVE PERCEPTIONS OF PARENTS

Concerns Regarding Depression and Attempted Suicide

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SUICIDE
- IS DELIBERATE SELF-INJURY WITH THE INTENT TO END ONE’S LIFE
- SUCCESSFUL SUICIDE OCCURS MORE FREQUENTLY IN MALES THAN IN FEMALES, ALTHOUGH MORE FEMALES APPARENTLY ATTEMPT SUICIDE THAN MALES (ABOUT 8:1)
- ADOLESCENT SUICIDES ARE ATTEMPTED MOST OFTEN IN THE SPRING OR THE FALL, REFLECTING SCHOOL STRESS AT THESE TIMES OF YEAR, AND BETWEEN 3 PM AND MIDNIGHT, REFLECTING DEPRESSION THAT INCREASES WITH THE DARK
- SUICIDE IS SO COMMON IN ADOLESCENTS THAT IT RANKS THIRD AS A CAUSE OF DEATH IN THE 15-TO 19-YEAR-OLD GROUP
- THIS STATISTIC MAY ACTUALLY BE UNDERESTIMATED, BECAUSE SOME WELL-MEANING CORONERS OR PHYSICIANS MAY REPORT THESE DEATHS AS ACCIDENTS TO SPARE THE FAMILY ADDITIONAL PAIN
ASSESSMENT
ADOLESCENTS NEED TO HAVE THOROUGH PHYSICAL EXAMINATIONS
AT HEALTH MAINTENANCE VISITS TO ASSURE THEM THEY ARE IN GOOD
PHYSICAL HEALTH
ASSESS FOR SIGNS OF DEPRESSION SUCH AS ANOREXIA, INSOMNIA, EXCESSIVE FATIGUE, OR WEIGHT LOSS
IN YOUNGER ADOLESCENTS, DEPRESSION MAY BE MANIFESTED BY BEHAVIOR PROBLEMS SUCH AS DISOBEDIENCE, TEMPER TANTRUMS, TRUANCY, AND RUNNING AWAY FROM HOME
SELF-DESTRUCTIVE BEHAVIOR OR ACCIDENT PRONENESS MAY BE NOTED
DIFFICULTIES IN SCHOOL;
- ACTING OUT WITH CHEMICALS, ALCOHOL, OR SEXUAL PROMISCUITY
- TROUBLE WITH LEGAL AUTHORITIES MAY BE FURTHER CLUES
- OCCASIONALLY, DEPRESSED ADOLESCENTS FIND IT SO HARD TO BE ALONE THEY SEEK CONSTANT ACTIVITY AS A MEANS OF ESCAPE
- IN CONTRAST, OTHERS MAY WITHDRAW FROM CONTACT WITH OTHER PERSONS AND BECOME COMPLETELY ISOLATED
- EITHER BEHAVIOR CAN BE DETECTED THROUGH ASSESSMENT OF ACTIVITY AND INTERACTION LEVELS

Concerns Regarding Runaways

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RUNAWAY
- IS COMMONLY DEFINED AS 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
- THE FREQUENCY OF RUNNING AWAY FOR ADOLESCENTS MAY BE AS HIGH AS ONE IN EIGHT
- FORTUNATELY, MOST DO NOT GO FAR OR STAY AWAY LONG (LESS THAN 1 WEEK)
- ABOUT 1 IN 20 ADOLESCENT RUNAWAYS STAYS AWAY AS LONG AS 1 YEAR; SOME NEVER RETURN HOME
- RUNAWAY ADOLESCENTS ARE MOST LIKELY TO BE FROM LOW- OR HIGH-INCOME FAMILIES
- UNEMPLOYMENT, ALCOHOLISM, SEXUAL ABUSE, ATTEMPTED SUICIDE, AND POVERTY ARE FREQUENT CHARACTERISTICS
- THEY ARE SLIGHTLY MORE LIKELY TO BE MALE THAN FEMALE
- EVENTS THEY ENCOUNTER MAY BE SO TRAUMATIC THEY DEVELOP A POSTTRAUMATIC SYNDROME
ASSESSMENT
- RUNNING AWAY IS USUALLY PRECEDED BY AN ARGUMENT WITH PARENTS
  THAT IS OFTEN THE LAST STRAW AFTER A NUMBER OF LONG-TERM
  DISAGREEMENTS
- OTHER REASONS MAY BE PERSONAL CONCERNS SUCH AS LONELINESS,
  PREGNANCY, AND PROBLEMS WITH FRIENDS, SCHOOL, OR THE POLICE
- INCEST CAN ALSO BE A PRECIPITATING CAUSE, AS CAN OTHER PARENTAL
  ABUSE
- A SCHOOL HISTORY OFTEN REVEALS FREQUENT TRUANCY, FAILING
  GRADES, POSSIBLE DRUG USE, AND RUNAWAY BEHAVIOR BY FRIENDS
- IT IS A SAD FACT THAT SOME ADOLESCENTS ARE “THROWAWAYS” OR
  CANNOT REMAIN AT HOME BECAUSE THEY HAVE BEEN REJECTED BY THEIR FAMILIES

MODULE 1 LESSON 7: REPRODUCTIVE AND SEXUAL HEALTH

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Cycle of Reproduction

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Sexual Differentiation

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Sex: determined at time of conception
Gonad: a body organ that produces the cells necessary for reproduction
- Ovary in females
- Testis in males
At approximately week 5 of intrauterine life, primitive gonadal tissue is already formed
The gender of the child is all about dad’s genes. Aside from the fact that it is the father that carries the Y chromosome that combines with the X chromosome to make a BOY, according to studies, the balance in the amount of X and Y chromosome in the male can contribute to the gender of the child, (UTS Southern Medical Center, 2019). As soon as the Y carrying sperm fertilizes the mature ovum, the gender of the child has been sealed.
Week 5: primitive gonadal tissue is formed
Two undifferentiated ducts
- Mesonephric (Wolffian)
- Paramesonephric (Mullerian)
Week 7-8 (Chromosomal Males - srY gene)" differentiation into primitive testes
Week 10: In the absence of testosterone, differentiation into ovaries, containing oocytes
Week 12: external genitals develop

Puberty

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Secondary sexual characteristics
Stimulated when the hypothalamus synthesizes and releases gonadotropin-releasing hormone (GnRH)
GnRH triggers the anterior pituitary to begin the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
FSH and LH stimulate production of estrogen and androgen
Poorly understood, especially in boys
The hypothalamus, under the direction of the central nervous system, may serve as a gonadostat
The theory is that a girl must reach a critical weight of approximately 95 lbs or develop a critical mass of body fat before the hypothalamus is triggered
The onset of puberty in girls usually start at the age of 10, peaks at 10 and 14 years of age, a year before the boys. Although girls might experience growth spurt earlier, it does not last long.
Before girls start menstruating, they have already reached close to their maximum height. The growth in height is accompanied by widening of the pelvis taking on a pelvis (hip)shape ideal for childbearing and childbirth (gynecoid shape).
Girls experience menarche at varied age (start of menstrual period). In the Philippines, the average menarche is 13 years old. Menarche signals the beginning of the capacity to reproduce (because of the maturation of the ovum that has been present even before birth)and the development of the secondary sex characteristics.
Up until puberty, there isn’t much difference between boys and girls who grows at about the same rate per year. Growth rates change during puberty when hormones start the process of physical change. The average boy starts growth spurt at 12 years old. At the end of puberty, boys are usually much taller than the girls. In boys, the muscles also develop at this time. Also, note that unlike in female oogenesis, spermatogenesis in male starts at the onset of puberty.
Remember: Genetics and epigenetics play a big part in growth patterns

MODULE 1 LESSON 8: YOUNG AND MIDDLE-AGED ADULT

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Introduction

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Adulthood is often divided into three phases:
- 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
Adult Age Span includes three very different generations:
- Baby Boomers(born in years 1945–1964)
  - more highly educated and have a large percentage of
    women in the workforce occupying management roles
- Generation X(birth years 1965–1978)
  - were frequently raised in two worker households where 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
- Generation Y or the Millennials (birth years 1979–2000)
  - technologically sophisticated (and dependent), and enjoy
    public affirmation of their efforts

Young Adults (20-40 Years)

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adult depends on how adulthood is described in the social context of the individual, and this defining age is changing
Another criterion of adulthood is financial independence, which is also highly variable
boomerang kids have evolved, as young adults have moved back into their parents’ homes after an initial period of independent living
factors contributing to this trend include high housing costs, high divorce rates, high unemployment rates, and the problems resulting from substance abuse and maladaptive behaviors
Physical Development
- Human body is at its most efficient functioning at about age
  25 years
- musculoskeletal system is well developed and coordinated
- period when athletic endeavors reach their peak. All other systems of the body (e.g., cardiovascular, visual, auditory, and reproductive) are also functioning at peak efficiency
- physical changes are minimal during this stage, 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
- psychosocial development of the young adult is great
- basic developmental task is establishing intimacy or very close friendship
- Occupational choice and education are largely inseparable
- sense of intimacy versus isolation
Cognitive Development
- Young adults are able to use formal operations, characterized by the ability to think abstractly and employ logic
- For example, 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
Moral Development
- Young adults who have mastered the previous stages of Kohlberg’s theory of moral development enter 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
Spiritual Development
- 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 that the young adult had as a child may now be accepted or redefined
Health Risks
- Young adulthood is generally a healthy time of life
- Health risks that do occur and are common in this age group include:
  - injury and violence
  - Suicide
  - hypertension
  - substance abuse
  - sexually transmitted infections (STIs)
  - eating disorders
  - certain malignancies
INJURY AND VIOLENCE
- The leading causes of death differ among the various
  population groups.
  - For example, unintentional injuries (primarily motor vehicle crashes) are the fifth leading cause of death for the total population but the leading cause of death for people 1 to 44 years of age
- Education about safety precautions and injury prevention is a major role of the nurse in promoting the health of young adults
- nurse needs to become familiar with community resources, such as adult protective services, shelters
- Partners Anonymous, advocacy programs, victim assistance programs, and hotlines
SUICIDE
- leading cause of death in the young adult age group (Edelman & Mandle, 2010, p. 585)
- Many suicides may actually be mistaken for accidental death (motor vehicle crashes, combining alcohol and barbiturates, or discharging a gun while cleaning it)
- Suicide may result from problems with close relationships such as those with marriage partners or parents, or from depression related to perceived occupational, academic, or financial failure
- In general, suicide results from the young adult’s inability to cope with the pressures, responsibilities, and expectations of adulthood
HYPERTENSION
- major problem for young African American adults, particularly men
- Many of the causes for this higher incidence of hypertension are unknown
- In addition to biologic inheritance, contributing factors may include smoking, obesity, a high-sodium diet, and high stress levels
- Hypertension is a major risk factor in the development of chronic heart disease or stroke (cerebrovascular accidents)
- Blood pressure measurements are usually advised at least every 2 years for young adults to screen for hypertension
SUBSTANCE ABUSE
- major threat to the health of young adults
- Alcohol, marijuana, amphetamines, and cocaine, for example, can bring about feelings of well-being that may be highly valued by people with adjustment problems
- Prolonged use can lead to physical and psychological dependency and subsequent health problems
- Addiction or physical and psychological dependence on a substance, is related to properties of the substance, the individual user, and the social network of the individual
- For example, drug abuse during pregnancy can lead to fetal damage
- Prolonged use of alcohol can lead to such diseases as cirrhosis of the liver and cancer of the esophagus
SEXUALLY TRANSMITTED INFECTIONS
- STIs such as genital herpes, AIDS, syphilis, and gonorrhea are common infections in young adults
- Chlamydia is the most prevalent STI, and in fact is the most prevalent infectious disease in the United States (Centers for Disease Control and Prevention, 2010).
- Other STIs, such as gonorrhea, are becoming resistant to multiple antibiotics and therefore cause an increased risk for future health
- Nursing functions are largely educational
  - The use of condoms greatly reduces the transfer of infectious microorganisms from one partner to another
  - Knowledge about the symptoms of these diseases can help the client
    obtain early treatment. In dealing with clients with an STI, the nurse
    must be nonjudgmental and accepting of the client’s lifestyle and treat
    any information obtained as confidential
EATING DISORDERS
- Many young adults battle with obesity
- According to Healthy People 2020 goals and objectives for nutrition and weight status all Americans will avoid unhealthy weight gain (USDHHS, 2010a)
- 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
- Other areas of nutritional needs for young women include meeting calcium requirements and proper nutrition during the childbearing years
MALIGNANCIES
- Testicular cancer is the most common neoplasm in young men
- Seminoma testicular cancer most commonly affects men ages 30 to 45
- The yolk sac tumor is most common in 20- to 35-year olds (Holdstock, 2010).
- More recent recommendations from the American Cancer Society (ACS) (2013b) are that men should have a testicular exam as part of a yearly physical exam
- Men who have risk factors for testicular cancer should discuss monthly testicular self-examination with their primary care provider
Health Assessment and Promotion
- Assessment guidelines for the growth and development of the young adult are shown in the accompanying Developmental Assessment Guidelines
- Young adults are usually interested in meeting their health needs
- because of the many stresses and changes that occur throughout the 20-year period from ages 20 to 40, the nurse needs to offer teaching and guidance in several health care areas

Middle-Aged Adults (40-65 Years)

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The middle years, from 40 to 65, have been called the years of stability and consolidation
For most people, it is a time when children have grown and moved away or are moving away from home
Thus, partners generally have more time for and with each other and time to pursue interests they may have deferred for years
Maturity is the state of maximal function and integration or the state of being fully developed
Mature individuals are guided by an underlying philosophy of life
They take many perspectives into account and are tolerant of the views of others
A comprehensive philosophy allows a person to make sense out of life and thus helps that person maintain a sense of purpose and hope in the face of human tragedies.
Physical Development
- A number of changes that start when young adults are 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
- However, during ages 40 to 65 many physical changes take place
- Both men and women experience decreasing hormonal production during the middle years
- The term menopause refers to the so-called change of life in women, when menstruation ceases
  - occurred when a woman has not had a menstrual period
    for 12 months
  - menopause usually occurs sometime between ages 40
    and 55
  - average is about 47 years
  - At this time, ovarian activity declines until ovulation ceases
  - Common symptoms, related o 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. Insomnia and headaches may also occur
Psychosocial Development
- Erikson viewed the developmental choice of the middle-aged adult as Generativity versus Stagnation
- Generativity is defined as 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
- People in their 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 in the middle years of life
- Partners have time to work together in volunteer activities, and time for one partner to go out for lunch and for the other to go fishing
- Generative middle-aged persons are able to feel a sense of comfort in their lifestyle and receive gratification from charitable endeavors
Cognitive Development
- The middle-aged adult’s cognitive and intellectual abilities change very little
- Cognitive processes include reaction time, memory, perception, learning, problem solving, and creativity.
  - Reaction time during the middle years stays much the same or diminishes
    during the latter part of the middle years
  - Memory and problem solving are maintained through middle adulthood
  - Learning continues and can be enhanced by increased motivation at this time in life.
- Genetic, environmental, and personality factors in early and middle
  adulthood account for the large difference in the ways in which individuals maintain mental abilities
- The professional, social, and personal life experiences of middle-aged
  individuals will be reflected in their cognitive performance
  - approaches to problem solving and task completion will vary considerably in a middle-aged group.
Moral Development
- 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
- Kohlberg found that 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
Spiritual Development
- 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 to the middle-aged person than it did previously
- People in this age group often rely on spiritual beliefs to help them deal with illness, death, and tragedy
Health Risks
- Leading causes of death in this age group include motor vehicle and occupational injuries, chronic disease such as cancer and cardiovascular disease
- Lifestyle patterns in combination with aging, family history, and developmental stressors (e.g., menopause, climacteric) and situational stressors (e.g., divorce) are often related to health problems that do arise
  - Example: smoking and excessive alcohol consumption place an individual at greater risk of developing chronic respiratory problems, lung cancer, and liver disease
  - Overeating can result in obesity, diabetes mellitus, atherosclerosis, and its associated risk for hypertension and coronary artery disease
  - 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 middle-aged clients
  about preventive health care to avoid or minimize the risk of such health
  problems.
INJURIES
- Changing physiological factors, as well as concern over personal and work-related responsibilities, may contribute to the injury rate of middle-aged people
- Motor vehicle crashes are the most common cause of unintentional death in this age group
- Decreased reaction times and visual acuity may make the middle-aged adult prone to injury
- Other unintentional causes of death for middle-aged adults include falls, fires, burns, poisonings, and drownings. Work-related injuries continue to be a significant safety hazard during the middle years
CANCER
- Cancer is the leading cause of death in middle adulthood
- The patterns of cancer types and incidences for men and women have changed during the past several decades
- 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 as new data are analyzed
CARDIOVASCULAR DISEASE
- Heart disease and cancer are the leading causes of death during middle adulthood
- Risk factors for heart disease 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
- A newly recognized cluster of risk factors that often occur together, termed
  metabolic syndrome, increases the risk for heart disease
- This syndrome includes the following risk factors: obesity with excessive
  abdominal fat, hypertension, high lipid levels, and insulin resistance (McClendon, Dunbar, Clark, & Coverson, 2010)
- Lifestyle activities and behaviors, such as diet modifications and increasing
  physical activity play an important role in preventing the development of
  metabolic syndrome risk factors
OBESITY
- Middle-aged adults who gain weight may not be aware of some common
  facts about this age period
- Decreased metabolic activity and decreased physical activity mean a
  decrease in caloric need
- The nurse’s role in nutritional health promotion is to counsel clients to
  prevent obesity by reducing caloric intake and participating in regular
  exercise
- 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
- Recent changes in the Food Guide Pyramid propagated by the U.S.
  Department of Agriculture now encourage nutrient intake based on physical activity, age, and gender
- 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
- It is estimated that 4 million people in the United States are dependent on alcohol and can be considered alcoholics
- Alcohol use may exacerbate other health problems
- Nurses can help clients by providing information about the dangers of excessive alcohol use, by helping the individual clarify values about health, and by referring the client who abuses alcohol to special groups such as Alcoholics Anonymous
MENTAL HEALTH ALTERATIONS
- Developmental stressors, such as menopause, the climacteric, aging, and impending retirement, and situational stressors, such as divorce, unemployment, and death of a spouse, can precipitate increased anxiety and depression in middle aged adults
- Clients may benefit from support groups or individual therapy to help them cope with specific crises
Health Assessment and Promotion
- Assessment guidelines for the growth and development of the middle-aged adult are shown in the accompanying 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

MODULE 1 LESSON 9: PROMOTING IN OLDER ADULTS

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Attitudes Toward Aging

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Because of the increase in numbers, nurses will be caring for older adults at some point
It is important for nurses to be aware of their own values and attitudes toward aging, and examine whether myths or stereotypes influence those attitudes
Ageism
- is used to describe negative attitudes toward aging or older adults (Mauk, 2014, p. 10)
- Ageism is discrimination based solely on age
- young adults distanced themselves from older adults to shield themselves from being aware of their own mortality
- These individuals engaged in activities that made them feel strong, increased their energy, and diminished their vulnerability
- students who were exposed to the older population through frequency and quality of interactions were positively influenced and were more likely to make
  careers of elder care
Myths and Stereotypes
- 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
- Most causes of disability are related to the adverse effects of many drugs such as pain medications
- Disease processes also increase the client’s risk of developing disabling conditions
  - Example: diabetes mellitus can result in loss of feeling in the extremities, diminished kidney function, and loss of vision
- important for nurses to provide accurate information about aging
  - an effective intervention for reducing negative stereotypes and improving attitudes about aging

Gerontological Nursing

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The older adult population is characterized by unique and diverse individuals who may require a variety of health care professionals to meet their health care needs
Gerontology
- is the study of aging and older adults
- is multidisciplinary and is a specialized area within various disciplines such as nursing, psychology, and social work
Geriatrics
- is associated with the medical care (e.g., diseases and disabilities) of older adults

Stages of Growth and Development

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Older Adulthood
- 65 – 74 years
- Adaptation to retirement and changing physical abilities often necessary
- Chronic illness may develop.
  - Assist to keep physically and socially active and maintain peer group interactions
Middle Old
- 75 – 84 years
- Adaptation to decline in speed of movement, reaction time and increasing dependence on others may be necessary
  - Assist to cope with loss. Provide necessary
    safety measures
Old-old
- 85 and over
- Increasing physical probs
  - Assist with self-care and maintaining independence
Development
Gerontological nursing involves advocating for the health of older adults at all levels of prevention (Mauk, 2014)
- 1960s, gerontological nursing became a subspecialty of nursing
- 1980s, gerontological nursing leaders stated that most practicing nurses did not have sufficient knowledge about gerontology
  - This prompted discussion of how to prepare nurses for gerontological nursing
- late 1990s, the nursing profession has recognized the importance of preparing all practicing nurses with basic gerontological knowledge
  - As a result, schools of nursing provide classes or courses about nursing care of older clients
  - Practicing gerontological nurses can obtain gerontological nursing certification through the American Nurses Association
  - Advanced practice in gerontological nursing requires a master’s degree in nursing, of which there are two options: the gerontological clinical nurse specialist and the gerontological nurse practitioner

Roles of Gerontological Nurse

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provider of care
- The nurse gives direct care to older adults in a variety of settings
Teacher
- often focuses on modifiable risk factors (e.g., healthy diet, physical activity, stress management)
Manager
- balance the concerns of the older client and family, as well as the concerns of nurses and other interdisciplinary team members
Advocate
- empowers older adults by helping them remain independent and strengthen their autonomy and decision-making ability
- research consumer
  - requires nurses to read the latest professional literature for evidence based practice to improve the quality of nursing care for older clients

Care Setting for Older Adults

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Acute Care Facilities
- 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
- Examples include the following:
  - Preventing nosocomial infections (e.g., urinary tract infections, pneumonia).
  - Preventing therapy-related problems (e.g., confusion, sleeplessness, dehydration, decreased nutrition)
  - Treating the health problem that resulted in the older adult’s admission plus assessing for potential undiagnosed health problems (e.g., depression, drug and/or alcohol abuse).
  - Preventing complications (e.g., decubitus ulcer)
Long-Term Care Facilities
- Long-term care is the provision of health care and personal care assistance to clients who have a chronic disease or disability (Li & Jensen, 2011)
- Long-term care facilities are also known as nursing facilities
- Nursing facility is a new term that includes providers of care who are
  certified by Medicare and institutions previously referred to as intermediate care
- The primary difference between institutions is the care offered, and the level of care provided to the client

Different Levels of Care

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Assisted Living
- Older adults who do not feel safe living alone or require additional help with ADLs
- usually have their own apartment
- provides meals, weekly activities, and a pleasant environment to socialize with other residents
- Some assisted living units are part of a larger facility
Intermediate Care
- residents require additional assistance
- 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 (Pratt, 2010, pp. 18–19).
Skilled Care Units or Skilled Nursing Facilities (SNFs)
- 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
Alzheimer’s units.
- 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
Hospice
- 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 on the part of gerontological nurses
- The goal of hospice care is to provide the client with pain management and with psychosocial and spiritual care through the dying process (End-ofLife Nursing Education Consortium Core Curriculum, 2013)
Rehabilitation
- Gerontological rehabilitation nursing combines expertise in gerontological nursing with rehabilitation concepts and practice
- Nurses working in gerontological rehabilitation often care for older adults with chronic illnesses and long-term functional limitations (e.g., orthopedic surgery, stroke, or amputation)
- This rehabilitative care may be found in several settings: acute care hospitals, subacute or transitional care centers, and long-term care facilities
- The nurse is an important member of the interdisciplinary
  rehabilitation team
- The role of the nurse is often as a health care coordinator, manager,
- and counselor for older adults and their families
- For example, nurses monitor the client’s health care, assist with ADLs, and assist older adults to regain and maintain the highest level of function and independence possible while preventing complications and enhancing quality of life
Community
- Nurses often assess the older client’s needs and then try to match the need with a community resource
- Examples of the different community areas in which gerontological nurses practice include the following:
  - 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 health care
    - bathing, medication administration, wound dressing

Neuromuscular

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Sarcopenia
- is a syndrome that results in muscle weakness leading to diminished independence and contributes to the client’ s decreased ability to perform ADLs
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 than do younger adults, making older adults prone to serious fractures
Osteoporosis, a pathologic decrease in bone density that is more common in older than younger adults, may lead to spontaneous (i.e., without a fall or other trauma to the bone) fractures that are called pathologic fractures
- Osteoporosis 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

Sensory-Perceptual

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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 and more rapidly after age 70 (Miller, 2012)
- 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
Three other conditions result in visual impairment and blindness
- 1. age-related macular degeneration (ARMD)
- 2. glaucoma
- 3. diabetic retinopathy (Miller, 2012)
promote health by informing older clients that they should schedule routine eye examinations to maintain and protect their vision
wearing sunglasses will help avoid the damaging effect of ultraviolet light
The loss of hearing ability related to aging, called presbycusis, affects people over age 65
Gradual loss of hearing is more common among men than women, perhaps because men are more frequently in noisy work environments
Hearing loss is greater in the higher frequencies than the lower
- older adults with hearing loss usually hear speakers with low, distinct voices best

Psychosocial Aging

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These theories focus on behavior and attitude changes during the aging process
One of the earliest, disengagement theory, developed in the early 1960s proposed that aging involves mutual withdrawal (disengagement) between the older person and others in the older person’s 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
- A person who is accustomed to having people around will continue to do so, and the person who prefers not to be involved with others is more likely to disengage (Tabloski, 2014)
- 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” (Erikson, 1963, p. 263)
- By contrast, people who despair often believe they have made poor choices during life and wish they could live life over
Acknowledging that the “young-old” and “old-old” differ not only in physical characteristics but also in psychosocial responses, many people have difficulty with Erikson’s singular developmental task
Peck (1968) proposed the following three developmental tasks of the older adult in contrast to Erikson’s task of ego integrity versus despair:
1. Ego differentiation versus work-role preoccupation
2. Body transcendence versus body preoccupation
3. Ego transcendence versus ego preoccupation.

Retirement

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The ability to retire at the age of 65 is becoming increasingly more challenging for older adults based on the changes within the U.S. labor force
Economic risk has risen in the past several years
Today’s seniors may lack the assets needed to retire
Complicating this situation are rising health care costs and inadequate monthly income to meet the needs of seniors (Polivka, 2013)
Older adults may find that their retirement income has not kept up with inflation
They may need to continue working to meet medical, insurance, and housing costs.

Cognitive Abilities and Aging

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Piaget’s phases of cognitive development end with the formal operations phase
However, considerable research on cognitive abilities and aging is currently being conducted
Intellectual capacity includes perception, cognitive agility, memory, and learning
Perception
- the ability to interpret the environment, depends on the acuteness of the senses
- If the aging person’s senses are impaired, the ability to perceive the environment and react appropriately is diminished
- Changes in the nervous system may also affect perceptual capacity
Cognitive Agility
- In older adults, changes in cognitive abilities are more often a difference in
  speed than in ability. Overall the older adult maintains intelligence, problem
  solving, judgment, creativity, and other well-practiced cognitive skills. Intellectual loss generally reflects a disease process such as atherosclerosis, which causes the blood vessels to narrow and diminishes perfusion of nutrients to the brain. Most older adults do not experience cognitive impairments. Dementia affects 2.4 to 5.5 million Americans. Mild cognitive impairment is different from dementia since the client is able to perform ADLs independently (Lin, O’Connor, Rossom, Perdue, & Eckstrom, 2013).
- It is important to note, that memory impairment is more prevalent in persons over age 85 than persons between the ages of 65 and 69. Cognitive impairment that interferes with normal life is not considered part of normal aging. A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal. Family
  members should be advised to seek prompt medical evaluation
Memory
- is also a component of intellectual capacity that involves the following steps:
  1. Momentary perception of stimuli from the environment referred to as
  sensory memory
  2. Storage in short-term memory (information held in the brain for immediate
  use or what one has in mind at a given moment).
  – An example of this type of memory is when you call information for a
  telephone number and remember the number only for the brief time
  needed to dial the number
  – Short-term memory also deals with activities or the recent past of
  minutes to a few hours that is often referred to as recent memory
  3. Encoding during which the information leaves short-term memory and enters
  long-term memory, the repository for information stored for periods longer
  than 72 hours and usually weeks and years
  – Memories of childhood friends, teachers, and events are stored in longterm memory
  – Older people who remember the flowers in their wedding bouquet or the
  names of the boys on their dance card are drawing from long-term memory
Leaning
- Older people need additional time for learning, largely because
- of the problem of retrieving information. Motivation is also important. Older adults have more difficulty than younger ones
- in learning information they do not consider meaningful; therefore, the nurse should be particularly careful to discover what is meaningful to the older adult before attempting client education

Moral Reasoning

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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
- stage 1: a person defines good and bad in relation to self
- stage 2: may act to meet another’s needs as well as their own
Older adults at the conventional level follow society’s rules of conduct in response to the expectations of others found that moral reasoning does not decline in old age

Spirituality and Aging

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Older adults can contemplate new religious and philosophical views and try to understand ideas missed previously or interpreted differently
The older person may derive a sense of worth by sharing experiences or views
In contrast, the older adult who has not matured spiritually may feel impoverishment or despair as the drive for economic and professional success lessens

Health Problems

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Injuries
Chronic disabling disease such as hypertension
and arthritis
Drug abuse and misuse, alcoholism, dementia, and mistreatment
Leading causes of death in people ages 65 and over are heart disease, cancer, cerebrovascular disease (stroke), lower respiratory disease, pneumonia/influenza, and diabetes mellitus

Injuries

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Injury prevention is a major concern for older people
Falls are a leading cause of morbidity and mortality among older adults (Edelman & Mandle, 2010, p. 635)
Because vision is limited, reflexes are slowed, and bones are brittle, caution is required in climbing stairs, driving a car, and even walking
Driving, particularly night driving, requires caution because accommodation of the eye to light is impaired and peripheral vision is diminished
Older people need to learn to turn the head before changing lanes and should not rely on side vision, for example, when crossing a street
Driving in fog or other hazardous conditions should be

Chronic Disabling Illness

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Many older adults function well within the community without impairments; others are afflicted with one or more chronic illnesses that may seriously impair their functioning
- Examples of these are arthritis, osteoporosis, heart disease, stroke, obstructive lung disease, hearing and visual alterations, and cognitive dysfunctions
- acute illnesses such as pneumonia and fractures and trauma from falls, motor vehicle crashes, or other incidents may create chronic health problems
Chronic illness brings many changes to the client and the family members
- may need increasing help with the ADLs of ambulation
- Feeding
- Hygiene
- health care expenses often escalate and may become an economic concern
- family roles may need to be altered
- family members may need to change their lifestyle to meet caregiving needs

Drug Abuse and Misuse

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Added to this, older adults may purchase over-the counter (OTC) drugs to remedy common discomforts related to aging, such as constipation, sleep disturbance, and joint pain
During the past few years, the use of vitamins, food supplements, and herbal remedies has increased
- These agents fall under the category of OTC drugs and are often not reported by clients as part of their medicine regimen
- An accurate assessment should include a listing of all these agents
- Many of these agents have not had adequate testing for effectiveness, side effects, or interactions with other medications

Alcoholism

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There are two types of older alcoholics:
- 1. those who began drinking alcohol in their youth
- 2. those who began excessive alcohol use later in life to help them cope with the changes and problems of their older years
Approximately one third of older alcoholics are late-onset drinkers (after age 60) and that number includes a higher number of women

Dementia

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is a progressive loss of cognitive function
It is critical that dementia be differentiated from delirium, which is an acute and reversible syndrome
Both may be characterized by changes in memory, judgment, language, mathematic calculation, abstract reasoning, and problem-solving ability
The most common causes of delirium are infection, medications, and dehydration
The most common type of dementia is Alzheimer’s disease (AD), of which the cause is unknown

MODULE 2 LESSON 1: CARE OF PREGNANT WOMAN AND HER FAMILY

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Laboratory Assessment

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Blood Studies

Complete Blood Count
A genetic screen
A serologic test for syphilis
Blood typing
Maternal serum for alpha-fetoprotein
An indirect Coombs' test
Antibody titers for rubella nad hepatitis B
HIV
glucose loading or tolerance test

Urinalysis

performed to test for proteinuria, glycosuria, and pyuria

Tuberculosis Screening

incidence of tuberculosis is on the rise, related to the HIV epidemic

Ultrasonography

If the date of the last menstrual period is unknown, a woman will be scheduled for an ultrasound to confirm the pregnancy length and document healthy fetal growth

Assessment of Fetal Maturity and Well-Being

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Fetal Movement

fetal movements or “kick counts” may be evaluated daily by the pregnant woman to provide reassurance of fetal well-being.
Sandovsky Method
- lie in a left recumbent position after a meal and record how many fetal movements over the next hour
“Count-to-Ten” (the Cardiff method)
- the woman records the time interval it takes for her to feel 10 fetal movements

Biophysical Profile

combines five parameters (fetal reactivity, fetal breathing, fetal body movement, fetal tone, and amniotic fluid volume) into one assessment

Fetal Heart Rate

fetal hearts beat at 120 to 160 beats per minute throughout pregnancy
Rhythm Strip Testing
- assessment of the fetal heart rate for whether a good baseline rate and a degree of variability are present

Nonstress Testing

measures the response of the fetal heart rate to fetal movement

MODULE 2 LESSON 2: CHANGES DURING PREGNANCY

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Diagnosis of Pregnancy

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Changes are considered necessary for the following purposes:
- Support fetal growth
- Support and maintain maternal health
- Prepare the body for childbirth
- Prepare the body for lactation

Psychological changes could be a result of bodily changes like the presence of hormones or by the actual physical changes that could lead to changes in a woman's ability to function or in their self-perception.
Early diagnosis enables women to change their lifestyle.

Presumptive signs are subjective while probable signs are observed by a health care professional.
Probable signs are not considered as positive signs because they could be present in conditions other than pregnancy.

The most common way to diagnose pregnancy is the presence of HCG or human chorionic gonadotropin.
HCG maintains the corpus luteum which secretes large amounts of progesterone necessary for pregnancy to continue.
The best time to take a pregnancy test is on the day of the missed menstrual period.
- If it is negative, it could be taken again one week after.
- Accuracy of pregnancy test could be altered by certain medications, and medical conditions resulting to a false positive result.

Presumptive Signs
- Breast changes is one of the earliest signs of pregnancy.
- By the 12th week, the uterus rises above the symphysis pubis.
- By the 18th week, quickening is present.
- Remember that all signs under presumptive could be signs of other conditions besides pregnancy and are highly subjective.

Probable Signs
- Ballotement is done by tapping the lower uterine segment.
- Braxton-Hicks contraction or practice contractions are still considered as probably due ti the conditions that may cause uterine spasms or tightening.

Positive Signs
- On the 8th week, a fetal outline is seen in a UTZ.
- The fetal heart can be heard by the 10-12th week using a doppler.
  - It can be heard by the 18-20th week using an ordinary stethoscope.
- The normal FHT is 120-160 bpm and is best heard at the location of the fetal back.

Physiologic Changes in Pregnancy

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New hormones are being produced by an organ that is present only during the pregnancy - the placenta.

Can be categorized as local or systemic
- Local - confined to the reproductive organs
- Systemic - affecting the entire body

Uterine blood flow increases from 50 ml/minute to 1L/minute or more at term.
The uterus is expected to follow a predictable rate of growth.
- It rises above the symphysis pubic at 12 weeks at 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 by making it thick and tortuous to maintain the pregnancy.
- It is now called decidua.

Braxton-Hicks may start as early as the 16th week and are called practice contractions.
- They are irregular and do not increase in intensity and are non-rhythmic.
- They do not cause opening of the cervix.

The regular ovulatory and menstrual cycle will not occur.
Chadwick's sign is the change in color.
The increase in estrogen will cause the cervix to soften (Goodel's sign).
- The consistency of the cervix becomes softer as time of birth is approaching.

An operculum or mucus plug is present int he cervix that serves as a protective mechanism against ascending infection.
Estrogen causes an increase vaginal discharge.
The environment of the vagina becomes more acidic to prevent the proliferation of microorganisms.

Colostrum is the earliest breastmilk produced by the 12-18th week of pregnancy.
- Colostrum is a clear yellowish fluid that is continuously produced for the first few weeks after birth.

Systemic Changes

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Integumentary System
- Skin changes are brought about by the stretching of the skin causing the breakdown of the elastin and collagen that supports it.
- There is also hyperpigmentation of the skin resulting from an increase production of MSH melanocyte stimulating hormones.
Respiratory System
- The biggest factor that leads to a mild alteration in breathing is the pressure exerted by the growing uterus on the lungs.
- Vital capacity does not change.
- The residual volume on the other hand decreases because of the extra "push" the uterus is exerting on the lungs that results to a fewer amount of air left in the lungs during exhalation.
- Other changes include marked congestion or stuffiness.
Cardiovascular System
- A factor that could lead to pseudoanemia or physiologic anemia is the delayed increase in RBC in proportion to the increase in blood volume.
- If anemia persists beyond 2nd trimester, this may be attributed to iron deficiency and is considered pathologic or true anemia.
- Heart murmurs are innocent unless accompanied by other symptoms.
- The weight of the gravid uterus impedes the venous return from the lower extremity.
Gastrointestinal
- Common in pregnancy are constipation and vomiting
Endocrine System
- There is an increased demand on the thyroid gland during pregnancy because of the increased metabolic requirements to support a growing fetus.
- Corticosteroid has anti-inflammatory actions that is beneficial in preventing the woman's body to initiate an inflammatory response against the fetus.
- Insulin that is produced is less effective because of the effect of HPL
- Mechanisms in the body ensures that the glucose is always readily available.

MODULE 2 LESSON 2: PSYCHOLOGICAL CHANGES DURING PREGNANCY

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Psychological Changes of Pregnancy

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Social Influences
Cultural Influences
Individual Influences
Family Influences

Tasks that Occur with Pregnancy

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1st Trimester: accepting the pregnancy
2nd Trimester: accepting the baby
3rd Trimester: preparing for the baby and end of pregnancy

Emotional Responses to Pregnancy

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Ambivalence
Grief
Narcissism
Introversion vs. Extroversion
Body Image and Boundary
Stress
Couvade Syndrome
Emotional Liability (mood changes and mood swings)

Changes in Sexual Desire

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1st Trimester
- Decrease in libido due to nausea, fatigue, and breast tenderness
2nd Trimester
- Libido and sexual enjoyment rise markedly
3rd Trimester
- Sexual desire remain high or may decrease because of difficulty finding comfortable position and increasing abdominal size

MODULE 2 LESSON 3: THE GROWING FETUS

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Stage of Fetal Development

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Period of fetal growth and development
Pre-embryonic period
Embryonic period
Fetal period

Terms

Ovum: from ovulation to fertilization
Zygote: from fertilization and implantation
Embryo: from implantation to 5-8 weeks
Fetus: from 5-8 weeks until term
Conceptus: developing embryo or fetus and placental structures throughout pregnancy
Age of viability: earliest age at which fetuses could survive if they were born at that time

Fertilization: The Beginning of Pregnancy

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Fertilization is never a certain occurrence
- It depends on at least three separate factors:
  1. Equal maturation of both sperm and ovum
  2. The ability of the sperm to reach the ovum
  3. The ability of the sperm to penetrate the zona pellucida and cell membrane and achieve fertilization

Embryonic and Fetal Structures

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Layer of Trophoblast Cells

Syncytiotrophoblast, or the syncytial later
- outer later of the two
Cytotrophoblast, or Langhans' layer
- middle layer

The Placenta

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15 to 20 cm in diameter and 2 to 3 cm in depth, covering about half the surface area of the internal uterus at term

Placental Circulation

Metabolic gas exchange starts at 4 weeks
Funic souffle is a soft blowing heard over the umbilical cord
Uterine souffle is heard above the mother's pelvis

Mechanisms by Which Nutrients Cross the Placenta

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Diffusion: When there is a greater concentration of a substance on one side of a semipermeable membrane than on the other, substances of correct molecular weight cross the membrane from the area of higher concentration to the area of lower concentration
Facilitated Diffusion: To ensure that a fetus receives sufficient concentrations of necessary nutrients, some substances cross the placenta guided by a carrier so move more rapidly or easily than would occur if only simple diffusion were operating
Active Transport: The process ensures that a fetus will have adequate amino acid concentrations for fetal growth
Pinocytosis: absorption by the cellular membrane of microdroplets of plasma and dissolved substances

Functions of the Placenta

Makes a barrier between mother and embryo
Removes waste from embryonic blood
Delivers nutrients and oxygen

The Placenta: Endocrine Function

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Human Chorionic Gonadotropin

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
Purpose of hCG
- 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
- 8th week of pregnancy, the outer layer of cells of the developing placenta begins to produce progesterone, making the corpus luteum, which was producing progesterone, no longer necessary

Estrogen

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

Progesterone

the “hormone of mothers”
necessary to maintain the endometrial lining of the uterus during pregnancy
appears to reduce the contractility of the uterus during pregnancy, preventing premature labor

Human Placental Lactogen (Human Chorionic Somatomammotropin)

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

The Amniotic Membranes

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Embryonic Membranes

Chorion: outer most membrane
- fingerlike projections, "villi"
Amnion: think protective membrane
- contains amniotic fluid

The Amniotic Fluid

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constantly being newly formed and reabsorbed by the amniotic membrane, so it never becomes stagnant
HYDRAMNIOS
- Excessive amniotic fluid
- more than 2000 mL in total, or pockets of fluid larger than 8 cm on ultrasound
OLIGOHYDRAMNIOS
- Reduction in the amount of amniotic fluid
- Less than 300 cc, no pocket on ultrasound larger than 1 cm
Functions/Purpose
- Protection
- Temperature regulation
- Protects the umbilical cord from pressure
  - protecting the fetal oxygen supply
- Aids in muscular development
  - gives freedom of movement

The Umbilical Cord

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Function: to transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta
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

MODULE 2 LESSON 4: LABOR AND BIRTH

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Onset of Labor

Unclear in humans
Attributed to progesterone withdrawal in animals
Multiple theories

Theories of Labor Onset
A result of changes in the following hormones/chemicals:

Decrease in progesterone
Release of oxytocin
Production of prostaglandins

.... all lead to contraction

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Preliminary Signs of Labor

Subtle signs
Indicates imminent labor
Must educate pts for them to detect these signs

Lightening
Braxton-Hicks Contractions
Nesting Instinct
Ripening of the cervix
Weight Loss
Bloody show
Rupture of membranes

Signs of True Labor

Uterine contractions
Show
Rupture of the membranes

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Effacement: softening and thinning of cervical canal recorded in percentage

Dilation: widening of the external cervical as to 10 cm
- Primipara: first effacement then dilation
- Multipara: both processes occur at the same time

Components of Labor

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The passage or the woman's pelvis
- The route a fetus must travel
- Most important: bony pelvic ring
- Remember your pelvimetry
The passenger or the fetus
- Fetal skull is the largest part
- Molding
  - Change in contour of fetal head due to uterine force with undilated cervix
  - overlapping of sutures
  - may be palpable at birth, lasts 1-2 days
- Passenger
  - Important structures: fontanelles and sutures
  - Narrowest: suboccipitobregmatic (9.5 cm)
  - Widest: occipitomental (13.5)
- Setting of the presenting part into the pelvis (level of ischial spines)
- Pelvic inlet has been transversed
- Pelvis is proven to be adequate
- Not engaged = floating
The powers of labor or uterine factors
- Effective powers are essential
- Supplied by the fundus of the uterus through contractions
- Remind women not to bear down until the cervix is fully dilated
A woman's psyche is preserved
- Remember that feat, tension, and pain can interfere progress of labor

Labor

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Duration of Labor

Primi- 14 hours-20 hours
Multi- 8-14 hours
4 stages

First Stage of Labor

Onset of true contraction -> full effacement and dilation
Latent
Active
Transition

Second Stage of Labor

Full cervical dilation up to fetal delivery
s/sx: increased RR, lightheadedness, tingling, carpopedal spasm, circumoral numbness
Modified Ritgen Maneuever - support the perineum to prevent laceration

Third Stage of Labor (Placental Stage)

Two Phases
- Placental separation
  - Appearance of the placenta at the vaginal opening
- Placental Expulsion
  - Gentle pressure
  - Natural
Uterus stays at the level of the umbilicus
Uterus contracts again assuming discoid shape

Fourth Stage of Labor (Recovering Stage)

First 1-2 hours after placenta delivery
Assess placement of fundus

Mechanisms of Labor

Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion

MODULE 3 LESSON 1: CARE OF NEWBORN

200002c — 2021-11-06 21:21:14 UTC

200002c — 2021-11-06 21:42:05 UTC

Profile of a Newborn (Vital Statistics)

A newborn loses 5% to 10% of birth weight (6-10 oz) during first few days after birth because
- They are no longer under the salt and fluid retaining maternal hormones
- They void and pass stools

Profile of a Newborn (Vital Signs)

Temperature – 97.60F - 98.60F axillary
Newborns lose heat by 4 mechanisms
- Convection – flow of heat from newborn’s body surface to cooler surrounding air
- Conduction – transfer of body heat to cooler solid object in contact with the baby
- Radiation – transfer of body heat to cooler solid object not in contact with the baby
- Evaporation – loss of heat through conversion of a liquid to vapor

Physiologic Function

Blood coagulation
- Newborns have lower level of Vitamin K, have prolonged coagulation or prothrombin time (PT)
- Since newborn’ s intestine is sterile at birth, it has no flora needed to synthesize Vitamin K
- Synthesized vitamin K is necessary for the formation of clotting factors
- Vitamin K is administered intramuscularly
The Senses
- Hearing – able to hear even before birth.
  - Calm in response to soothing voice, startle at loud noise
- Vision – see as soon as they are born
  - Cannot follow past the midline vision
  - Pupillary reflex present at birth
- Touch – well developed at birth
  - React to painful stimuli
- Taste – taste buds developed and functioning at birth
  - Swallowing decreases if bitter, readily accepts sweet taste
- Smell – present as soon as nose is clear of
  mucus
  - Turns towards mother’s breast

Physiologic Adjustment to Extrauterine Life

Periods of reactivity occurs in the first 6 hours of life before newborn’s body systems stabilize
- First Periods of Reactivity – lasts for half an hour
  - Baby is alert, exhibits exploring, searching activity.
- Resting Period – 90 minutes
  - Baby sleeps
- Second Period of Reactivity – 2-6 hours of life
  - Baby wakes again, alert and responsive to surroundings

Appearance of a Newborn

Skin
- Color
- Term baby has ruddy complexion due to increased concentration of RBC and decreased subcutaneous fats
Fontannels
- Anterior – diamond shaped, closes at 12-18 mos.
- Posterior – triangular, closes by end of 2nd month
- Indented fontannel – a sign of dehydration
- Bulging fontannel – a sign of increased ICP

Assessment for Well-Being

Physical Assessment
- Height and weight
  - Weighed nude once a day, same time everyday
Laboratory Studies
- Heel stick tests
  - Anemia, ploycythemia, hypoglycemia (<40mg / 100 ml)

Immediate Newborn Care

Necessary equipment includes
- Radiant heat table, warmer bassinet, warm soft blanket, equipment for O2 administration, resuscitation, suction, eye care, identification and weighing of newborn
Newborn Identification and registration
- ID band with permanent locks and built in sensor
Birth record documentation

Nursing Care of a Newborn and Family in Post Partal Period

Sleeping Position
- Sudden Infant death syndrome (SIDS) – cause is unknown. But placing infants in supine position has decreased the incidence of the syndrome.
Diaper Area Care
- To prevent diaper dermatitis, wash area with clean water and dry well
Metabolic Screening Tests
- Tests PKU, hypothyroidsm, cystic fibrosis, galactosemia

Assessment of Family's Readiness to Care for a Newborn at Home

Parental concerns related to breathing
- Stuffy nose, snoring noises, sneeze frequently, periods of apnea are all normal for newborns
Continued health maintenance for a newborn
- Make appointments with primary care provider (2-6 wks)
- Judge infant’s health status by overall appearance
Car safety
- Child placed in car seat, at the back seat facing the back of the car

MODULE 2 LESSON 4: LABOR AND BIRTH

200002c — 2021-11-29 05:52:16 UTC

Labor

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Duration of Labor
Primi-14 hours-20 hours
Multi-8-14 hours
4 stages
- FIRST
  - ACTIVE LABOR TO FULL CERVICAL DILATATION
- SECOND
  - FULL CERVICAL DILATATION TO DELIVERY OF INFANT
- THIRD
  - DELIVERY OF INFANT TO DELIVERY OF PLACENTA
- FOURTH
  - DELIVERY OF PLACENTA UP TO 1-4 HOURS

First Stage of Labor

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onset of true contraction -> full effacement and dilation
Small snacks and sips of water
Encourage to urinate
Bathing is encouraged
Perineal preparation
Left side-lying
Monitor for fetal thrashing

Second Stage

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Complete effacement and dilatation to birth
Crowning
Lithotomy- put legs at the same time
Bulging of the perineum is the surest sign that delivery is starting
Pant & blow breathing
Respiratory Alkalosis

Mechanisms of Labor

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• Engagement
• Descent
• Flexion
• Internal Rotation
• Extension
• External Rotation
• Expulsion

Third Stage

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• Up to 30 minutes after delivery
• Signs of Placental Separation: Calkin’s sign- the fundus rises, Cord lengthens, Sudden gush of blood
• Brandt-Andrews Maneuver
• Schultz vs. Duncan

Fourth Stage

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• First 1-2 hours after placental delivery
• Observation/monitoring
• 1st hour-q 15 minutes
• 2nd hour- q 30 minutes
• Assess placement of fundus (empty bladder)
• Lochia- 30-40 cc fully saturated
• Perineum (REEDA)

MODULE 4 LESSON 4: NURSING CARE OF A POSTPARTAL WOMAN AND FAMILY

200002c — 2021-12-06 03:52:54 UTC

Definition

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6 week period after birth
Considered as the fourth trimester
Time for maternal changes (retrogressive and progressive)
Post-partal care can influence her health for the rest of her life
Also considered as the transition phase

BUBBLESHE(V)

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B—breast
U—uterus
B—bowel
B—bladder
L—lochia
E—episiorrhapy/ episiotony
S—skin
H—oman’s sign/hemorrhage
E—emotions
(V) - ( vital signs)

What are the changes that happen?

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Breast Changes

Formation of breast milk (lactation)→increase breast tissue
Primary engorgement: On the 3rd day, breast feels tender, fuller , enlarged & tensed as milk forms within breast ducts (the ducts becomes dilated); feeling of heat/throbbing pain

Uterus

Undergoes involution
- Area where placenta was implanted is sealed off
- Organ is reduced to pre-pregnant size (approximately)
Uterine contraction begins immediately after birth

Bladder

Extensive diuresis & urine output increases to 3,000mL (2nd-5th PPD)
Transient loss of bladder tone+ edema surrounding the urethra (4 weeks) + effect of anesthesia= decrease ability to sense fullness of bladder

Bowel

Bowel sounds are active
The woman feels hungry & thirsty immediately after giving birth

Lochia

Layer adjacent to the uterine cavity becomes necrotic & is cast off as uterine discharge similar to a menstrual flow
Composed of blood, fragments of decidua, white blood cells, mucus & some bacteria

Episiotomy

Ask the woman to turn on her side (Sim’s position)
Perineum develops edema & generalized tenderness, ecchymosis from rupture capillaries/hematoma, intactness of suture & presence of drainage/bleeding
Labia majora & minora remain atophic & softened

MODULE 3 LESSON 1: CARE OF PREGNANT WOMAN AND HER FAMILY

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Profile of a Newborn (Vital Statistics)

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Weight – 2.5 to 3.4 kg (5.5 to 7.5 lbs)
- Plotted in conjunction with height and head circumference to highlight disproportionate measurements
- A newborn loses 5% to 10% of birth weight (6-10 oz) during first few days after birth because
  - They are no longer under the salt and fluid retaining maternal hormones
  - They void and pass stools

Length – 46 to 54 cm
Head Circumference – 34 to 35 cm
- Measured using a tape measure drawn across the center of the forehead around the occiput
Chest circumference – 32 to 33 cm
- usually about 2 cm less than head circumference and is measured at the level of the nipples

Temperature – 97.60F - 98.60F axillary
Newborns lose heat by 4 mechanisms

Convection – flow of heat from newborn’s body surface to cooler surrounding air
Conduction – transfer of body heat to cooler solid object in contact with the baby
Radiation – transfer of body heat to cooler solid object not in contact with the baby
Evaporation – loss of heat through conversion of a liquid to vapor

Pulse - 120-160 bpm
- Heart rate remains slightly irregular
- Transient murmurs may be heard due to incomplete closure of fetal shunts
- Femoral pulses must be palpable, its absence suggests possible coarctation of aorta

Respiration – 30 – 60 breaths per minute
- Rate may be irregular, with short periods of apnea
- They are obligate nose breathers and involves the use of diaphragm and abdominal muscles
- Short periods of crying aids in aerating deep portions of lungs

Physiologic Function

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Blood values
- Blood volume is 80-110 ml per kg of BW (300 ml)
- Baby is born with increased erythrocyte count, increased hemoglobin and hematocrit
- Increased indirect bilirubin occurs as excessive RBC begins their breakdown
- Newborn has increased WBC in response to the trauma of birth and is nonpathogenic

Respiratory System
- Newborns have some fluids in their lungs that eases the surface tension, allowing alveoli to inflate more easily.
- Within 10 minutes after birth, newborns have established good residual volume
- By 10-12 hours, vital capacity is established

Urinary System
- Newborn voids within 24 hours after birth
- Voids only about 15 ml per single voiding. Daily urine output in first 1 -2 days is about 30-60 ml. By week 1, total volume rises to about 300 ml
- Kidneys of newborn do not concentrate urine well making urine light colored and odorless

The Senses
- Hearing – able to hear even before birth.
  - Calm in response to soothing voice, startle at loud noise
- Vision – see as soon as they are born
  - Cannot follow past the midline vision
  - Pupillary reflex present at birth
- Touch – well developed at birth
  - React to painful stimuli
- Taste – taste buds developed and functioning at birth
  - Swallowing decreases if bitter, readily accepts sweet taste
- Smell – present as soon as nose is clear of mucus
  - Turns towards mother’s breast

Physiologic Adjustment to Extrauterine Life

200002c — 2021-12-13 05:51:40 UTC

Skin
- Color
- Term baby has ruddy complexion due to increased concentration of RBC and decreased subcutaneous fats
  - Cyanosis, mottling of skin is common
  - Acrocyanosis – blueness of hands and feet (24-48 hrs)
  - Central cyanosis – indicates decreased oxygenation

Appearance of a Newborn

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Cephalhematoma
- collection of blood under the periosteum of the bone. Appears 24 hours after birth.
• Kernicterus
- permanent neurologic damage caused by build up of indirect bilirubin that interferes with chemical synthesis of brain cells
- Mgt: phototherapy to initiate maturation of liver enzymes

Mongolian spots
- Collection of melanocytes that appear slate gray patches in sacrum or buttocks
- Disappears at school age
Vernix caseosa
- White cream cheese like substance that serves as lubricant
Lanugo
- fine downy hair, disappears by 2 weeks of age

MODULE 4 LESSON 1: POST PARTAL CARE

200002c — 2022-01-14 06:41:47 UTC

Introduction

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6 week period after birth
Considered as the fourth trimester
Time for maternal changes (retrogressive and progressive)
Post-partal care can influence her health for the rest of her life
Also considered as the transition phase

The Changes

200002c — 2022-01-14 06:47:29 UTC

Breast

Formation of breast milk (lactation)→increase breast tissue
Primary engorgement: On the 3rd day, breast feels tender, fuller , enlarged & tensed as milk forms within breast ducts (the ducts becomes dilated); feeling of heat/throbbing pain
Breast may appear reddened

Uterus

Undergoes involution
Area where placenta was implanted is sealed off
Organ is reduced to pre-pregnant size (approximately)
Uterine contraction begins immediately after birth
Fundus of the uterus may be palpated at certain areas/levels at a specified time to determine contraction
Uterine involution maybe delayed in several conditions

Bladder

Extensive diuresis & urine output increases to 3,000mL (2nd-5th PPD)
Transient loss of bladder tone+ edema surrounding the urethra (4 weeks) + effect of anesthesia= decrease ability to sense fullness of bladder
Increases the possibility of permanent bladder damage & urinary tract infection

Bowel

Bowel sounds are active
The woman feels hungry & thirsty immediately after giving birth
If without GA, patient can eat without difficulty from nausea or vomiting
Hemorrhoids are often present
May develop constipation because of presence of relaxin & pain d/t episiotomy or hemorrhoids

Lochia

Layer adjacent to the uterine cavity becomes necrotic & is cast off as uterine discharge similar to a menstrual flow
Composed of blood, fragments of decidua, white blood cells, mucus & some bacteria
It takes 6 weeks for the placental implantation site to be cleansed & healed

Skin

Striae lightens or becomes slightly darker (reddened) over 3-6 months
Chloasma and linea nigra will be barely detectable in 6 weeks
Diastasis recti will appear as slight indentation or a bluish area

MODULE 4 LESSON 1: PROMOTING MATERNAL AND FETAL HEALTH

200002c — 2022-01-14 06:49:10 UTC

Teratogenic Maternal Infection

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• Can either be sexually transmitted or systemic infections
• Organisms cause the placental barrier (viral, bacterial, protozoan)
• Maybe subclinical but still injure a fetus

Teratogenic Vaccines

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Live virus vaccines cannot be administered during pregnancy
They may transmit viral infection to a fetus
Make sure that clients are not pregnant during routine immunizations

Teratogenic Drugs

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Women should be cautious in taking any type of drug, whether it be over-the-counter, herbal or prescription drugs
Although most herbal medicines are safe, some may not be
Recommendations:
- Women (pregnant or child-bearing age) should not take any drugs or supplements not specifically prescribed or approved by their physician

Environmental Teratogens

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Women are exposed to this at home or at work. Environmental teratogens are equally damaging to the fetus as those that are ingested
Can be classified into:
- Metal and chemical hazards: includes pesticides, carbon monoxide, lead, paints, etc
- Radiation: destroys rapidly growing cells; all women should only be exposed to x-ray during the first 10 days of menstruation; pregnancy test should be done before x-ray
- Hyperthermia & hypothermia: It interferes with cell metabolism; results from the use of sauna, hot tub, etc. Maternal fever may also cause abnormal fetal brain development, possible seizure disorder, hypotonia and skeletal deformities