because an authority figure tells him to do so.

- Obedience is compelled by the threat of punishment.

-At age 11 to 12 school and authority is questioned  or opposed. There is a need of being with their piers ( source of their standards and models)  behavior becomes  more rough and bold.
- It is important that their is parent role modeling, parental guidance, love and support for their development. 
- Child at this stage needs an opportunity to decisions within boundaries set by their parents.
-Spiritual lessons should be taught  because religious practices like praying and attending church will comfort them.
- Distinguish between what is right and wrong because they are rule oriented.

PEROXIDE
- COMMON PRESCRIPTION MEDICATION IS RETINOIN (RETIN-A CREAM)

SYSTEMIC MEDICATION
NOTE: STEROIDS MUST BE USED WITH CAUTION IN GROWING ADOLESCENTS, BECAUSE THEY CAN LEAD TO STUNTED GROWTH.

- ISOTRETINOIN (ACCUTANE) -REDUCING SEBUM PRODUCTION AND ABNORMAL KERATINIZATION OF GLAND DUCTS.

- CORTICOSTEROID  OR A NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) MAY BE PRESCRIBED

- CORTISONE MAY BE INJECTED DIRECTLY INTO CYSTIC LESIONS TO REDUCE INFLAMMATION

- ESTROGEN, ALONE OR IN COMBINATION WITH PROGESTERONE,USEFUL THERAPY IN SOME GIRLS.

OBESITY 
- Can be inheritance or from their environment.

MEASURES FOR THEM
- MAKING A DETAILED LOG OF THE AMOUNT THEY EAT, THE TIME, AND THE CIRCUMSTANCES

- ALWAYS EAT IN ONE PLACE
-  SUGGEST TO EAT SLOW, PUT THE FORK DOWN BETWEEN BITES AND EAT IN SMALLER PLATES. 

TOBACCO
- 23% of High-school student report current cigarette use and 14% uses Cigar.

MARIJUANA
- Derived from the leaves and stems of Indian hemp plant.
- Rolled into cigarettes and smoked but can be mixed with food or sniffed.
- Hashish - a stronger substance, scraping the resin from flowering leaves .
- Sinsemilla- seedless form that is more potent.

AMPHETAMINES

- Called UPPERS or SPEED ( Can cause false sense of well being alertness, or self esteem)

-  ICE - A NEWER, STRONGER FORM THAT PRODUCES INTENSE SYMPTOMS IS KNOWN.

- Used in treating hyperactivity and narcolepsy  and among CNS disorders.

-Easily manufactured in "Meth Labs"  in people's homes and readily available.

-  Side effects include aggressive or demanding behavior, paranoia and extreme restlessness.

- Abuse can cause blackened crumbling teeth, because it suppress appetite. Adolescents may lose weight or eat only sporadically while taking them.

- Using without prescription is illegal.
 
ALCOHOL
- 29%  OF STUDENTS REPORT HAVING RIDDEN IN A CAR OR OTHER VEHICLE DRIVEN BY SOMEONE WHO HAD BEEN DRINKING ALCOHOL.
- 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 🤬.

- PARENTS ARE MORE RELIVED THAT THEIR CHILDREN WILL RETURN HOME DRUNK AND BECAUSE OF DRUG USE.

COCAINE
- other names: SNOW, WHITE LADY because of its fine white powder
- Most popular drug of abuse begin in adolescents
- Maybe sniffed ,smoked or injected intravenously 
- Sometimes combined with heroin termed as ( SPEEDBALL) and then injected.
- CRACK- stronger form of eating cocaine powder with baking soda and water.
- Preparation is dangerous might ignite or explode.
- FREEBASE or ROCK- strong and can cause immediate cardiac and respiratory arrhythmias. 

HALLUCINOGENS
Common drugs:
- LYSERGIC ACID DIETHYLAMIDE (LSD)- increased popularity since 1960's because its a drug that can be manufactured by informed adolescents in "KITCHEN LAB"
- DIMETHYLTRYPTAMINE (DMT)
- 2,5-DIMETHOXY-4-METHAMPHETAMINE (STP)

- PHENCYCLIDINE HYDROCHLORIDE (PCP) • METHAQUALONE (QUAALUDE)

OPIATES

- DRUGS SUCH AS HEROIN, MEPERIDINE (DEMEROL), AND MORPHINE.

- CAN BE EXTREMELY DANGEROUS BECAUSE OF THEIR TENDENCY TO DECREASE RESPIRATORY RATE.

- CAN CAUSE PHYSIOLOGIC CRAVING THAT CAN  LEAD TO STEALING , DEFRAUD, TURN TO PROSTITUTION, OR RESORT TO WHATEVER METHOD IS AVAILABLE TO SECURE ENOUGH MONEY TO BUY A DAY’S SUPPLY.

- CAN CAUSE  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 they trust the health care personnel , they will admit they engaged in drug experimentation

COMMON FINDINGS:
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

- SELF INJURY WITH INTENTION TO END ONE'S LIFE
-  RANKS THIRD AS CAUSE OF DEATH ( 15-19 YEARS OLD) OCCURS MORE FREQUENTLY IN MALES THAN FEMALES (8:1)
- ATTEMPTED MOST OFTEN IN SPRING OR FALL
- REFLECTING SCHOOL STRESS , REFLECTING DEPRESSION INCREASES WITH THE DARK.
- BETWEEN 3PM AND MIDNIGHT

ASSESSMENT ( ALL BEHAVIORS  CAN BE DETECTED THROUGH ASSESSMENT & INTERACTION  )
- THOROUGH PHYSICAL EXAMINATION ASSURE THEM THEY ARE IN GOOD PHYSICAL HEALTH.

- ASSESS FOR SIGNS OF DEPRESSION SUCH AS ANOREXIA, INSOMNIA, EXCESSIVE FATIGUE, OR WEIGHT LOSS.

-  IN YOUNGER ADOLESCENT MANIFESTED BY BEHAVIOR PROBLEMS SUCH AS DISOBEDIENCE, TEMPER TANTRUMS, TRUANCY, RUNNING AWAY FROM HOME, SELF-DESTRUCTIVE BEHAVIOR.

- DIFFICULTIES IN SCHOOL

- ACTING OUT WITH CHEMICALS, ALCOHOL, OR SEXUAL    PROMISCUITY.

- TROUBLE WITH LEGAL AUTHORITIES  IS ANOTHER  CLUE.

- DEPRESSED ADOLESCENTS SEEK CONSTANT ACTIVITY AS A MEANS OF ESCAPE.

- SOME  WITHDRAW FROM HUMAN CONTACT  AND BECOME COMPLETELY ISOLATED.


CONCERNS REGARDING RUNAWAYS
- CHILDREN AGES OF 10 AND 17 YEARS WHO HAS BEEN ABSENT FROM HOME AT LEAST OVERNIGHT WITHOUT PERMISSION OF A PARENT OR GUARDIAN.

-  1 IN 20 ADOLESCENTS RUNAWAYS AS LONG AS 1 YEAR AND SOME NEVER COME HOME.

-MOST DO NOT GO FAR OR STAW AYAW FOR MORE THAN 1 WEEK.

-  MOST LIKEY COME FROM LOW OR HIGH INCOME FAMILIES.

- MAY ENCOUNTER TRAUMA AND DEVELOP A POSTTRAUMATIC SYNDROME.

- FREQUENT CHARACTERISTICS OF RUNAWAYS ARE:
UNEMPLOYMENT
ALCOHOLISM
SEXUAL ABUSE
ATTEMPTED SUICIDE
POVERTY ARE


ASSESSMENT 
REASONS: 

-PRECEDED BY AN ARGUMENT WITH PARENTS

-LAST STRAW AFTER A NUMBER OF LONG-TERM DISAGREEMENTS
-INCEST 
-PARENTAL ABUSE
-LONELINESS
-PREGNANCY 
-PROBLEMS WITH FRIENDS, SCHOOL, OR THE POLICE
-SCHOOL PROBLEMS( GRADES, POSSIBLE DRUG USE, RUNAWAY BEHAVIOR WITH PEERS)
-SOME REJECTED BY THEIR OWN FAMILIES " THROWAWAYS"

Young adults are defined as people 20 to 40 years old

Middle-aged adults as 40 to 65 years old

Late adulthood

ADULT AGE SPAN:
Baby Boomers (born in years 1945–1964)
- Highly educated and large percentage of women in the workforce.
 
Generation X (birth years 1965–1978)
-  Raised in two worker households( long hours)-
- less impressed in corporate values
- skeptical, resist authority
- enjoys challenges and opportunities
- creatively problem solve.

Generation Y or the Millennials (birth years 1979–2000)
- technologically sophisticated (and dependent) enjoys public affirmation of their efforts.

- Certain malignancies
- 🤬 cancer common  neoplasm in young men.
- Seminoma 🤬 cancer ffects men ages 30 to 45.
- Yolk sac tumor is most common in  ages 20- to 35.
- Men should have a 🤬 exam as part of a yearly physical exam.
-  Men at risk for 🤬 cancer should discuss monthly 🤬 self examination with health care provider.

HEALTH ASSESSMENT AND PROMOTION

- Young adults usually interested in meeting their health needs.
- Many stresses and changes that occur from ages 20 to 40. 
- Offer teaching and guidance in several health care areas.

COGNITIVE DEVELOPMENT

- Cognitive and intellectual abilities change very little.
- Processes include:
- Reaction time - may diminish during latter part in life
- Memory and Problem solving- maintained through their lives  and  task completion  will vary in the middle aged group.
- Perception
- Learning- still continuous and still be enhanced by increasing motivation .
- Creativity
-  Genetic, environmental, and personality factors plays a role in maintaining  mental abilities.
- Professional, social, and personal life experiences  will reflect cognitive performance.

MORAL DEVELOPMENT

-  Adults can move beyond the conventional level to the post conventional level.
- Extensive experience of personal moral choice and responsibility is needed to reach post conventional level.
-  To move from stage 4 ( law and order orientation) to stage 5 ( social contract orientation)  requires adults to move a stage to take precedence.



SPIRIT  DEVELOPMENT

- Accd. to Fowler's stages, not all adults(after 30) can progress to paradoxical-consolidative stage.
- Paradoxical-consolidative stage- can view truth from diff. view points.
- People tend to be less dogmatic about religious beliefs.
- Religion often offers more comfort to the middle-aged person than it did previously.
- Rely on spiritual belied to help them with circumstances in life.

HEALTH RISKS
-  Leading causes of death in this age group are motor vehicle and occupational injuries, chronic disease such as cancer and cardiovascular disease.

- Lifestyle patterns in combination with aging, family history, and developmental stressors  and situational stressors are often related to health problems that will arise.

-  Many diseases of older age may be decreased by health-conscious and lifestyle decisions made, and acted on, in midlife.

- The nurse  play an important role in teaching their  middle-aged clients about preventive health care  to minimize/ prevent health problems.

INJURIES
- Changing physiological factors and concern over personal and work-related responsibilities increases rate of injury to this age group.

- Health decisions made by midlife adults may affect their health in later life.

- Decreased reaction times and visual acuity may make the middle-aged adult prone to injury.
- Unintentional causes of death  for middle aged adults are:
falls, fires, burns, poisonings, drownings, and work related injuries.


CANCER
- leading cause of death in middle adulthood
- Men have a high incidence of cancer of the lung, prostate, and colon.
- Women, lung cancer is highest in incidence, followed by breast cancer and colon cancer.

CARDIOVASCULAR DISEASE

- Heart disease and cancer are the leading causes of death during middle adulthood.
- Risk factors:
Smoking
obesity
hypertension
hyperlipidemia
diabetes mellitus
Sedentary lifestyle
Family history of myocardial infarction 
Sudden death in a father less than 55 years old  
Sudden death in a  mother less than 65 years old, and the individual’s age

-Metabolic syndrome-increases the risk for heart disease.
- Risk factors:
Obesity with excessive abdominal fat
Hypertension
High lipid levels
Insulin resistance

- Teach clients about Diet modifications and increasing physical activity play an important role in preventing the development of metabolic syndrome .


OBESITY
- Middle-aged adults who gain weight may not be aware  about facts during this age period.

- Decrease caloric need- decrease metabolic activity and decreased physical activity.
- Nurse's role is to counsel clients to prevent obesity by reducing caloric intake and participating in regular exercise. Educate  the other risk for obesity such as diabetes and hypertension and for problems of mobility such as arthritis.

- Teach clients about seeking medical advice before changing anything in their diets.

ALCOHOLISM
- Excessive use of alcohol
- Can result in unemployment, disrupted homes, injuries, and diseases.
- May exacerbate other health problems.
- Teach   clients about the dangers of excessive alcohol use by clarifying values about health, and by referring the client who abuses alcohol to special groups such as Alcoholics Anonymous.


MENTAL HEALTH ALTERATIONS

- DEVELOPMENTAL AND SITUATIONAL STRESSORS :
Menopause, the climacteric, aging, and impending retirement, and divorce, unemployment, and death of a spouse, can precipitate increased anxiety and depression in middle- aged adults. 
- They may benefit from support grps. or individual therapy to cope with crises. 

HEALTH ASSESSMENT AND PROMOTION 
- Usually take care of their health needs and are interested in maintaining health and preventing the acceleration of the aging process.

- With the increase of population, nurses will be caring for older adults.
 - Be aware of their values and attitude toward aging . Examine if myths or stereotypes influence them.

AGEISM

- Negative attitudes toward aging or older adults.
- Discrimination based solely on age.
- Young adults distanced themselves from older adults from being aware of their own mortality.
- Being engaged in activities makes them strong , with higher energy  and diminished their vulnerability.
- Student frequently exposed  to older adults are positively influence and more like to get a career in caring for the elders.

MYTHS AND STEREOTYPES

- Wen younger people do not understand or identify with older adults as unique human beings.

- Older client only experiences loss of memory related to the onset of a neurological disease.

- Most causes of disability is from adverse effects of drugs such as pain meds.

-  Disease process also increases risk of disabling conditions.

- Important for Nurses to provide accurate information about aging helps improve interventions for reducing negative stereotypes and improving attitudes about aging. 

GERONTOLOGICAL NURSING

- Diverse individuals who require a variety of health care professionals to meet their health care needs.

GERONTOLOGY 
- Study of aging and older adults.
- Specialized area within various disciplines such as nursing, psychology, and social work.

GERIATICS
- Associated with the medical care (e.g., diseases and disabilities) of older adults. 

STAGES OF GROWTH AND DEVELOPMENT 

OLDER ADULTHOOD
- 65 – 74 years
- Adaptation to retirement and changing physical abilities.

- Chronic illness may develop.

- Assist to keep physically and socially active and maintain peer group interactions.

MIDDLE OLD
- 75–84years
- Decline in speed of movement, reaction time 
-  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
-  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.

HEALTH PROMOTION: 
- Needs to include positive health practices that can promote health and wellness

- Recommended physical, visual, hearing, and dental assessments
- Screenings for cardiovascular disease and tuberculosis
- Breast and 🤬 self-examinations
- Immunizations
- Papanicolaou smears for some older women
- Safety precautions to prevent injuries
- The importance of appropriate nutrition and exercise
- The importance of measures to prevent constipation

ROLES OF GERONTOLOGICAL NURSE
- Provider of care 
- Gives direct care to older adults in a variety of settings

- Teacher

- Focuses on modifiable risk factors

Manager
- Balance the concerns  older client , family, nurses and other interdisciplinary team members.

Advocate

– Empowers older adults to remain independent and strengthen their autonomy and decision-making ability.

Research consumer

– Read the latest professional literature for evidence- based practice to improve the quality of nursing care for older clients.

CARE SETTING FOR OLDER ADULTS

ACUTE CARE FACILITIES :

- Focuses  on protecting the health of the older adult with the goal of returning to his or her prior level of independence.
Peventing nosocomial infections
Preventing therapy-related problems
Treating the health problem
Assessing for potential undiagnosed health problems
Preventing complicationPreventing complicationss

LONG TERM CARE FACILITIES or NURSING FACILITIES

- Patients are referred as RESIDENT
- Provision of health care and personal care assistance to clients who have a chronic disease or disability.
- Includes providers of care who are certified.
- Difference between institutions is the care offered, and the level of care provided to the client.


DIFFERENT LEVELS OF CARE:

Assisted Living
- Residents who do not feel safe living alone or require additional help.

- Are part of a larger facility
- Provides meals, weekly activities, and a pleasant environment to socialize with other residents.

Intermediate Care
- Residents require additional assistance.
- No longer able to live independently.
- Provides 24- hour nursing oversight to protect the client from injury and increase the client’s quality of life.

Skilled Care Units or Skilled Nursing Facilities (SNFs)
- Provide for the needs of clients whose acuity levels require a higher level of nursing care.
- Care for clients who require tube feedings, intravenous therapy, chronic wound therapy, and mechanical ventilators.

Alzheimer’s units
- Gerontological nurses  in this units have specialized knowledge and be able to help family members understand and cope with the disease process affecting their loved one.

HOSPICE
- Majority of hospice clients are older adults.
-  Requires a great deal of patience, expertise, understanding, interdisciplinary communication, and compassion skills on the part of gerontological nurses.
- Goal is to provide and help clients with pain management with psychosocial and spiritual care through the dying process.

REHABILITATION
- Combines expertise in gerontological nursing with rehabilitation concepts and practice.
- Care for older adults with chronic illnesses and long-term functional limitations (e.g., orthopedic surgery, stroke, or amputation)
- Can be found in several settings such as  acute care hospitals, subacute or transitional care centers, and long-term care facilities.

- Nurses is an important member of the interdisciplinary rehabilitation team. They are often health care coordinator, manager and counselor for older adults and their families.

COMMUNITY

- Assess the older client’s needs and then try to match the need with a community resources

DIFFERENT COMMUNITY AREAS

- Home health care
clients  who are homebound due to the severity of illness or disability.

– Nurse-run clinics
 Focus on managing chronic illness.

– Adult day care 
focuses  on social activities and health care.

NEUROMUSCULAR
SARCOPENIA
muscle weakness leading to diminished independence affect the patient's ADLs ( undernourished)

- Exaggerated muscular weakness forming  stooping posture and kyphosis (humpback of the upper spine).

- Imbalance rate of absorption and bone formation tissues  comes with aging. Older adults have more porous and fragile bones making them prone to serious fractures.

OSTEOPOROSIS

Decrease in bone density, common in older than younger adults. May lead to spontaneous fractures called pathologic fractures.
 
frequent in people who have insufficient intake or dietary calciums, people who are  physically inactive.


SENSORY- PERCEPTUAL
- Loss of peripheral vision, atrophy of lacrimal glands resulting in dry eyes, and difficulty in discriminating similar colors, especially blues, greens, and purples.

PRESBYOPIA
- Inability to focus or accommodate due to a loss of flexibility of the lens, causes decreased near vision.
- Starts around age 40.
- Visual acuity lessens gradually.
- By the age of 80,  some have some lens opacity (cataracts) reduces visual acuity and causes glare to be a problem.

OTHER CONDITION THAT CAN RESULT TO VISUAL IMPAIRMENT AND BLINDNESS:

- Age-Related Macular Degeneration (ARMD)
- Glaucoma
- Diabetic retinopathy 

WHAT TO DO: 
- Teach  older clients that they should schedule routine eye examinations to maintain and protect their vision
- Advise to wear sunglasses  to  help avoid the damaging effect of ultraviolet light. 

PRESBYCUSIS
- Loss of hearing ability related to aging.
- Men are common to have gradual loss of hearing (men are more frequent to work in noisy environments)
- Hearing loss is greater in higher frequencies compared to lower ones
- Older adults with hearing loss usually hear speakers with low, distinct voices best.

DEVELOPMENTAL TASK OF THE OLDER ADULTS

60 TO 75 YEARS

- Adjusting to decreasing physical strength and health
- Adjusting to retirement and lower fixed income
- Adjusting to death of parents, spouses and friends
- Adjusting to new relationships with adult children
- Adjusting to leisure time
- Adjusting to slower physical and cognitive response
- keeping active and involved
- Masking satisfying living arrangements as aging progresses

75 YEARS OLDER

- Adapting to living alone
- Safeguarding physical and mental health
- Adjusting to possibility of moving into a nursing home
- Remaining in touch with other family members
- Finding meaning in life
- Adjusting to one's own death


PSYCHOSOCIAL AGING
- Theories focus on behavior and attitude changes during the aging process.

Disengagement theory ( 1960's)
-  Aging involves mutual (disengagement) between the older person and others in the older person’s environment

Havighurst’s activity theory (1972)

- Best way to age is to stay active physically and mentally.

Continuity theory
- Accounts for the great variety of behavior seen in older people.

- People maintain their values, habits, and behavior in old age.
People who are 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.

ERIKSON: EGO INTEGRITY V.S DESPAIR

- If ego integrity is achieved their view  of life with a sense of wholeness and derive satisfaction from past accomplishments.
- Death as an acceptable completion in life
- Accept “one’s one and only life cycle”
- In contrast  people who are in despair often believe they have made poor choices in their  life and wish they could live life again.

- Many people have difficulty in  rikson’s singular developmental task. Acknowledging that the “young-old” and “old-old” differ  in physical characteristics but also in psychosocial responses.

PECK (1968) PROPOSED THE FOLLOWING IN CONTRAST TO ERIKSON'S TASK 

1. Ego differentiation versus work-role preoccupation

2. Body transcendence versus body preoccupation
3. Ego transcendence versus ego preoccupation

RETIREMENT

-  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.

- 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.

-Intellectual capacity includes perception, cognitive agility, memory, and learning

PERCEPTION

- Interpret the environment, depends on the acuteness of the senses.
- If senses are impaired and the changes in the nervous system affects the ability to perceive the environment and react appropriately is diminished .

COGNITIVE AGILITY
- Changes are more often a difference in speed than in ability.

 - Overall the older adult maintains intelligence, problem solving, judgment, creativity, and other well-practiced.

- Intellectual loss generally reflects a disease process.

Atherosclerosis- causes the blood vessels to narrow and diminishes perfusion of nutrients to the brain.

-Memory impairment is more prevalent in persons over age 85.
- Cognitive impairment that interferes with normal life is not considered  normal aging.

- A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal.
 
- Teach family members  about so seeking prompt medical evaluation.

MEMORY
- Sensory memory- momentary perception of stimuli from the environment .
- Storage in short-term memory (information held in the brain for immediate use or what one has in mind at a given moment).
Deals with activities or the recent past of minutes to a few hours that is often referred to as recent memory.

- Encoding during which the information leaves short-term memory and enters long-term memory. Information stored longer than 72 hours and usually weeks and years.
- Memories are stored in long- term memory.

LEARNING
- Need additional time for learning  because  a problem of retrieving information.
- Motivation is also important.
- Nurses should be  careful to discover what is meaningful to the older adult before attempting client education.

MORAL REASONING
-  Kohlberg (1984) - moral development is completed in the early adult years.

- Older person at the preconventional level obeys rules to avoid pain and the displeasure of others.  They follow society’s rules of conduct in response to the expectations 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.
- Moral reasoning does not decline in old age.

SPIRITUALITY AND AGING
- contemplate new religious and philosophical views.Tries  to understand ideas missed previously .

- Derive a sense of worth by sharing experiences or views.
- Those who have not  matured spiritually  may feel despair as drive for economic and professional  success lessens.


HEALTH PROBLEM:

 INJURIES
- Prevention is a major concern for older people.
- Falls are a leading cause of morbidity and mortality among older adults .
- Since vision is limited, reflexes are slowed, and bones are brittle, caution is required in climbing stairs, driving a car, and even walking.

- Driving in fog or other hazardous conditions should be avoided.
-  Fires hazard for the older adult due to failing memory.
- Hypothermia- body temperature below normal.
Lowered metabolism and loss of normal insulation decrease the older client’s ability to retain heat.

CHRONIC DISABLING ILLNESS

- Afflicted with one or more chronic illnesses that may seriously impair their functioning.
- 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

- Older adults may self medicate using over the counter drugs (OTC)
- Accurate assessment  should include a listing of all medication
- Some agents had not gone through adequate testing for effectiveness, side effects, or interactions with other medications

STRATEGIES  FOR CLIENTS FOR A MORE SAFE MEDICATION
- Write a list of all the medications you are taking.
- Keep the list current and carry it in your purse or billfold.
- Know the reason you are taking each medicine.
- Use a “pill organizer” system to help you remember to take your medications.
- Ask pharmacist for easy to open containers

ALCOHOLISM
- TWO TYPES 
1. Began drinking alcohol in their youth.
2. Excessive alcohol use later in

life to help them cope.

DEMENTIA
- Progressive loss of cognitive function
- Different from Delirium  ( acute and reversible  syndrome)
- Changes in memory, judgment, language, mathematic calculation, abstract reasoning, and problem-solving ability.
- Common cause of Delirium  are infection, medications, and dehydration.
- Common type of dementia is Alzheimer’s disease (AD)- cause is unknown.


MISTREATMENT OF OLDER ADULTS
- Mistreatment of older adults may affect either gender.
- Often are women over 75 years of age who are physically or mentally impaired and dependent for care on the abuser.
- Can be physical, psychological , emotional in nature,
sexual abuse, financial abuse, violation of human or civil rights, and active or passive neglect .

GOALS OF NURSING CARE
- Promote independent function
- Support individual strengths
- Prevent complications of illness
- Secure a safe and comfortable environment
- Promote return to health

  

3. Prepare the body for childbirth
4. Prepare the body for lactation

Systematic change
- everything changes except the reproductive system
Local change
- Changes in the reproductive system

3 classification of “pregnancy signs”

PRESUMPTIVE 
- highly subjective, least indicative " I think Im pregnant"

PROBABLE
- Probable objective cues , sign and symptoms that can be indication of other diseases for e.g  pregnancy test can be false reading because it detects HGC hormones. But, other diseases like H. mole( HYDATIDIFORM MOLE) can also have positive sign of HGC( HUMAN CHORIONIC GONADOTROPIN - PRODUCED BY THE CELLS SURROUNDING THE GROWING FETUS(TROPHOBLAST) AT EARLY STAGE OF PREGNANCY BEFORE THE PLACENTA IS FORMED)( THEY ALSO PRODUCE LARGE AMOUNT OF PROGESTERONE NECESSARY FOR PREGNANCY TO CONTINUE.)
- THE BEST TIME TO TAKE THE PREGNANCY TEST IS ON THE DAY OF MISSED PERIOD, IF NEGATIVE RETAKE AGAIN AFTER 1 WEEK
- More reliable than presumptive,  but  still  considered as a  positive finding. 
- Can be documented by health care provider.

POSITIVE
- undeniable signs confirmed by the use of instrument
- 100% positive signs are
Fetal movement felt by examiner 
Fetal outline in UTZ
Fetal heart tone


CHANGES:
PHYSIOLOGC AND PSYCHOLOGIC AND SYSTEMIC OR LOCAL CHANGE

PSY- ambivalence, frequent mood changes, varying from anxiety, fatigue, exhaustion, sleepiness, depressive reactions to excitement.

PHY- BECAUSE OF HORMONES, ACTUAL PHYSICAL CHANGE,

SYS; CHANGES IN ALL SYTEM OF THE ENTIRE BODY

 EXCEPT REPRODUCTIVE SYSTEM

LOC: CHANGES IN THE REPRODUCTIVE ORGANS.

LOW IMMUNE SYSTEM 

BECAUSE IF IT IS HIGH THE MOTHER’S BODY MIGHT REJECT THE GROWING FETUS IN THE WOMB. THE BODY SEES THE FETUS A FOREIGN BODY.

NAUSEAU MOOD CHANGES AND ALL CHANGES APPEARS MEANS THAT YOUR HORMONES ARE GOOD AND HIGH ENOUGH TO SUPPORT THE MOTHER AND THE CHILD.

BEING AMBIVALENT- REGRET OR LIKE DOUBTING ABOUT BEING A PREGNANT AND BEING A MOTHER FOR THE CHILD. 

GOING TO YOUR DOCTOR FOR PRENATAL CHECK UP HELPS WITH BETTER DIAGNOSIS AND SUGGEST A HEALTHIER LIFESTYLE FOR THE MOTHER.

“AGES” IN PREGNANCY 

1ST TRIMESTER

1-3 MONTHS

2ND TRIMESTER

4-6 MOTHS

3RD TRIMESTER

7-9 MONTHS 

FULL TERM : BETTER TO GIVE BIRTH BECAUSE THE CHILD BECAUSE THERE IS LESS COMPLICATIONS AFTER BIRTH AND MORE THE BODY IS  MATURE WHEN BORN

39-40 WEEKS- FROM 1ST DAY OF LMP

EARLY TERM 

 37 WEEKS

AOG - AGE OF GESTATION - HOW LONG  HAVE YOU BEEN PREGNANT FOR (HOW MANY MONTHS)

BARTHOLOMEW’S RULE OF FOUR 

36 WEEKS 

20 WEEKS

16 WEEKS

12 WEEKS

ESTIMATE OF AOG

BASE ON LOCATION OF THE FUNDUS- TOP MOST PART OF THE UTERUS ON THE ABDOMEN 

LOCATE THE HIGHEST POINT 

BELOW XIPHOID PROCESS- 40 WEEKS

XIPHOID PROCESS -  36 WEEKS

BELOW XIPHOID PROCESS- 32 WEEKS

BETWEEN UMBILICUS AND XIPHOID PROCESS-28 WEEKS

2CM ABOVE UMBILICUS-24 WEEKS

UMBILICUS-  2O WEEKS

BETWEEN SYMPHYSIS AND UMBILICUS -16 WEEKS

ABOVE SYMPHYSIS PUBIS- 12 WEEKS 

AT 38TH WEEK IT WILL “LIGHTEN” - GOES DOWN, SETTLE AT THE PELVIC AREA (BELOW XIPHOID PROCESS) TO BE PREPARED FOR CHILD BIRTH

MCDONALD’S RULE:

AOG MEASURE OF HEIGH WILL BE  CONVERTED INTO WEEKS 

20 CM= 20 WEEKS

HOW TO MEASURE

SUPINE POSITION

RELAX ABDOMINAL POSITION

KNESS SLIGHTLY BENDED

SMALL PILLOW BEHIND THE RIGHT PELVIS

TAPE MEASURE 

0 CM ON THE PUBIC BONE TO THE FUNDUS

GI TRACT

CONTIPATION - PRESURE 

WHAT TO DO

INCREASE FIBER, FLUID MODERATE ACTIVITIES 

HEART BURN

ENCOURGE ELEVATED POSITION

DO NOT LIE DOWN

1ST 3 MONTHS 

SEATED POSITION ICE CHIPS

CHECK SIGN OF DEHYDRATION

PICA -ANEMIA- LACK OF OXYGEN IN THE BRAIN

INC. RR

INC HR

INC BP

WEIGHT GAIN

1LB PER MONTH FOR THE 1ST TRIMESTER

1LB PER WEEK 2ND-3RD TRIMESTER 

4TH TO 9TH MONTH - 4LB EACH

NAEGLLE RULE  EDD

JAN TO MARCH

+9 ,+7 

APRIL TO DECEMBER 

-3, + 7, +1

AOG

(LAST DAY OF THE MONTH OF LMP PERIOD - DATE OF LMP + 1)

REMAINDER AS DAYS

GPTPALM

(G )Gravida= # of total pregnancies (including the current)
(P) Para=  #of childbirths that reached the age of viability (24 weeks or 400g) regardless of OUTCOME (whether alive or not)
(T) Term=  # of childbirths that reached 37 weeks
(P) Preterm= # of childbirths between 24 and 36 weeks
(A) Abortion=  # of deliveries that did not reach the age of viability or that are less than 24 weeks
(L) Living children-= # of living children counted individually
(M) Multiple=  # of children with multiple pregnancies (twins, triplets, etc.) counted as ONE

OBSTETRIC HISTORY
- Determines presence of risk and pregnancy  outcomes.
- Must be deliberate, planned, and purposeful.
- Educate mothers about completing their prenatal check up for better results of delivery.
=
- WHO recommends 8 visits

- 1st to 2nd trimester
   Once a month

- 3rd trimester
   2x a month

- 9th month
    once a week

- Pass due date
   2x a week

- Medical conditions
assess all medical conditions, current and prexisting.

- FamilyHistory
Medical conditions

- Social History
 Risky lifestyle behavior ( smoking, alcohol use, recreational drug, occupation, domestic abuse.

- Exposure to teratogens
medication/ drugs and chemicals Can cause malformation of embryo

COMPONENTS :
Demography
Chief Concern
Family & Social
Past medical Hx
Gynecologic Hx
Obstetric Hx

LABORATORY ASSESSMENT (1st prenatal visit)
- Confirm general health rule out sexually transmitted infection that could affect the growing fetus.

BLOOD STUDIES
1. Complete Blood Count

Hemoglobin or hematocrit and red cell index

 to determine the presence of anemia

White blood cell count
 to determine infection

 Platelet count
estimate clotting ability

2. Genetic screen
- Common ethnically inherited diseases

- Sickle cell trait or disease and glucose- 6-phosphate dehydrogenase (G6PD) (African American women)

- Tay-Sachs disease (Jewish ancestry)

- Cystic fibrosis (Caucasian women)

3. A serologic test for syphilis (VDRL or rapid plasma
reagin test)

- Must be treated early in pregnancy if the  mother is positive for syphilis.

- Blood sample for a serologic test for gonorrhea

4. Blood typing (including Rh factor)
- Detect the possibility of Rh isoimmunization

- Blood type is documented if a woman is bleeding during pregnancy.


5. Maternal serum for alpha-fetoprotein (AFP) (MSAFP)
- Done during 16 to 18 weeks of pregnancy.
- Elevated if abdominal defect is present in the fetus.
- Decreased if chromosomal anomaly is present.
- Serum is expressed as “multiples of the mean” (MOM)

- normal value is 2.5 MOM
- ultrasound or amniocentesis will be ordered to assess for a fetal disorder.

6. An indirect Coombs’ test
- Determination if Rh antibodies are present in an Rh-negative woman
- Repeated at 28 weeks pregnant
- If the titers are not elevated, the mother will receive RhIG (RhoGAM) at 28 weeks of pregnancy and after.
- Procedure that might cause placental bleeding, such as amniocentesis or external version

7. Antibody titers for rubella and hepatitis B (HBsAg)
- Determine if the mother is protected against rubella. If exposed there is a chance of developing hepatitis B.
- HBsAg testing  may be repeated  at 36 weeks 

-  Antibodies for varicella is also be assessed
-  Vaccine against the diseases will be given postpartum period.

8. HIV screening

- Done by enzyme-linked immunosorbent assay (ELISA) on a blood sample.
- 2nd test called (Western blot ) is done if positive .

- Risk for contracting HIV infection should be asked.

- Can be difficult to ask depending  on the  culture of the patient.

- Who are at risk :
Who have used or are using intravenous drugs 
Have engaged in sex with multiple partners

Have had sexual partners who are infected Bisexual
Intravenousdrugabusers

Hemophiliacs

Women who received a blood transfusion between 1977 and 1985( according to research)

- Testing for HIV early in pregnancy allows to begin therapy with zidovudine (AZT) .

- Decrease the risk of Infant acquiring the virus.

-  Be accurate about test results  a high blood antibody titer means exposed to the virus not necessarily is infected.
 
- Findings should be kept confidential and given to the patient with 
tact and compassion, and with respect .

50-g oral 1-hour Glucose loading or tolerance test
- Done if a woman has a history of previously unexplained fetal loss and to rule out gestational diabetes toward the end of the first trimester.
- If not, this is done routinely at the 24th to 28th week evaluate insulin-antagonistic effects of placental hormones.

- Family history of diabetes.
- Babies who were large for gestational age ( 9 lb or more at term)
- Is obese, or has glycosuria

- The plasma glucose level should not exceed 140 mg/dL at 1

hour (during her pregnancy)

Urinalysis
- Test for proteinuria, glycosuria, and pyuria.
- Done by test strips or microscopic examination of the urine.


Tuberculosis Screening

- People with lowered immune system function are contracting tuberculosis and spreading it.

- Purified Protein Derivative (PPD), test for a woman to screen for tuberculosis.

-  To assess a woman’s current disease status, – (+) = chest radiograph  is done.

- Assure that she will be given a   lead apron to protect  the baby from radiation exposure.

- Woman with  history of tuberculosis or received bacillus Calmette-Guérin (bCG) vaccine should not be given a tuberculin skin test because of possibility of extreme reaction.


Ultrasonography
- If LMP is unknown, Ultrasonography  is  done to confirm the pregnancy length and document healthy fetal growth. 
- If done early in pregnancy  it will show the presence of a gestation sac, not a moving, kicking fetus.

- Move, eat, change position and with light abdominal massage and did not smoke for the last 2hrs.

- Fetus can sleep for up to 40 minutes.

REMEMBER ALONE
A - Ammniocentesis
L- L/S Ration (2:1)
O-Oxytocin test
N- Non-Stress test
E- Estriol Level

BIOPHYSICAL PROFILE
- More accurate in predicting fetal wellbeing than any single assessment
- Done as often as daily during a high-risk pregnancy

NORMAL= 2PTS
ABNORML = 0PTS

1. Fetal Breathing
 alteast 1 episode of breathing movement for 30 seconds in 30 min (FETAL CHEST EXPANSION)
- Fetal heart and breathing record measure short-term central nervous system function. 

Fetal  heart reactivity
-Nonstress test
- use of an ultrasonic Doppler technique

- 120 to 160 beats per minute throughout pregnancy
-Counted as early as the 10th to 11th week

- Two or more fetal heart rate accelerations of at least 15 beats/min  above baseline and 15 sec duration with fetal movement over 20 min time period.
- Indicator of oxygen perfusion to the fetal brain, heart, and adrenals

Rhythm Strip Testing
- Assessment of the fetal heart rate for whether a good baseline rate and a degree of variability are present. 
- Semi-Fowler’s position to prevent the uterus from compressing the vena cava and causing supine hypotension syndrome during the test.
- Attach monitor abdominally

- Record the fetal heart rate for 20 minutes
- Remain in a fairly fixed position for 20 minutes

Baseline Reading
- Average rate of the fetal heartbeat per minute.

Variability
- Small changes in rate occur parasympathetic and sympathetic nervous systems are receiving adequate oxygen and nutrients.

Categories
- Absent (none apparent)
- Minimal (extremely small fluctuations)
- Moderate (amplitude range of 6–25 beats per minute)
- Marked (amplitude range over 25 beats per minute)

BPP
- Obtained in third trimester (week 37)  of High Risk Pregnancies

2. FETAL TONE
Fetus must extend and then flex extremities  or spine atleast once in 30 min.

3. Fetal Body Movement
- atleast 3 separate episodes of fetal limb or trunk within  30 mins.

4. Amniotic Fluid Volume
- Range between 5- 25 cm 
- Helps measure long-term adequacy of placental function.

5. Non stress test
- Done for 10 to 20 minutes
- >2 Accelerations in 20 mins.
> 15 bpm (ABOVE BASE LINE)
> 15 seconds
- Measures the response of the fetal heart rate to fetal movement.
- Position and attach in both fetal heart rate and uterine contraction monitor.
- Instruct to push the bell if the fetus will move.
- POOR OXYGEN PERFUSION
no increase in beats per minute on fetal movement
Reactive:
- if two accelerations of fetal heart rate (by 15 beats or more) lasting for 15 seconds occur after movement
Nonreactive:
- if no accelerations occur with the fetal movements, or if there is low short-term fetal heart rate variability (less than 6 beats per minute).

Causes of lessened variability :
- Maternal smoking
- Drug use, or hypoglycemia. 
- If you give the woman an oral carbohydrate snack, such as orange juice, it can cause her blood glucose level to increase enough to cause fetal movement.

- May be stimulated by a loud sound to cause movement.

- Rhythm strip and nonstress testing cause no risk to either mother or fetus.

-  If a nonstress test is nonreactive, additional fetal assessment is done such as contraction stress test or a biophysical profile test. 

- The test can be done in all pregnancy and be done at home especially those experiencing complication of pregnancy.

NURSING ALERT Monitor tracings become part of the neonate’s and mother’s chart and are legal documents.

SCORING
8-10 = normal, low risk for chronic asphyxia

4-6 = Suspected chronic asphyxia
0-2 = strong suspicion of chronic asphyxia

Modified biophysical profile
- Amniotic fluid index
- nonstress test
- Predicts short term viability by the nonstress test an long term viability by the AFI.
- Healthy fetus shoes reactive nonstress and AFI range between 5 and 25 cm

Vibroacoustic Stimulation

- Acoustic stimulator is applied to the mother’s abdomen to produce a sharp sound of approximately 80 decibels at a frequency of 80 Hz, startling and waking the fetus.
-If  spontaneous acceleration has not occurred within 5 minutes, apply a single 1- to 2-second sound stimulation to the lower abdomen.


Oxytocin challenge test (OCT) or contraction stress test (CST)

- Response of the fetus in relation to uterine contractions produces by 🤬 stimulation
- Test of feto-placental well being

Contraction Stress Testing
- Fetal heart rate is analyzed with contractions.

-  Source of oxytocin for contraction stress testing currently is achieved by 🤬 stimulation.

- Gentle stimulation of the nipples releases oxytocin.

- External uterine contraction and fetal heart rate monitors in place, the baseline fetal heart rate is obtained.

- Three contractions with a duration of 40 seconds or longer must be present in a 10-minute window before the test can be interpreted.

- The test is normal (negative) if no fetal heart rate decelerations are present with contractions.

- It is positive (abnormal) if 50% or more of contractions cause a late deceleration.

- After a contraction stress test, encourage a woman to remain in the health care facility for about 30 minutes for contractions to be quiet and preterm labor is not a risk.

Amniocentesis
- Aspiration of amniotic fluid from the pregnant uterus for examination.

- Determination of genetic or metabolic diseases

- Scheduled between the 14th and 16th weeks of pregnancy for generous amount of amniotic fluid to be present.

- Done again for fetal maturity.

- Always ask for consent because it may cause infection of the amniotic fluid , hemorrhage from penetration of the placenta and  can initiate premature labor.

- Useful for women  who are:
35 or older
for those with a family history of metabolic disease
previous child with a chromosomal abnormality
family history of chromosomal abnormality
patient or husband with a chromosomal abnormality
or a possible female carrier of an X-linked disease.


Determination of lung maturity
- Lecithin/sphingomyelin (L/S) ratio of the amniotic fluid is analyzed.

- If the L/S ratio is 2:1 or greater, the fetal lung is considered mature and  chances respiratory distress syndrome in the neonate is low.

- Less reliable if there is  maternal diabetes  or  fluid is contaminated w/ blood or meconium.

- Presence of  phosphatidylglycerol (PG) is  most reliable indicator of fetal lung maturity.

- But not present until 36 weeks gestation.

-  PG is not affected by hypoglycemia, hypoxia, or hypothermia.


Nursing and Patient Care Considerations

1.Reduce anxiety related to the procedure
2.Determining their understanding
3.Reexplain the procedure before it begins, and answer any questions they have
4.Ensure informed consent is signed
5.Provide explanations during the procedure, correct misinformation they may have, and make sure they know when the results
6.Reduce pain and discomfort related to the procedure
7.Reduce potential for traumatic injury to fetus, placenta, or maternal structures


Amniotic fluid is analyzed for:
Alpha-Fetoprotein (AFP)
- If the fetus has an open body defect.
- Increased levels of AFP because of leakage of AFP into the fluid.
- Level will be decreased in the amniotic fluid with chromosomal defects such as Down syndrome.
- Can detect Acetylcholinesterase is another compound detected in high levels if a neural tube defect is present.

Bilirubin Determination
- Bilirubin may be analyzed if a blood incompatibility is suspected.
- False positive occur if the specimen is contaminated with blood.

Chromosome Analysis
- Fetal skin cells always present in amniotic fluid.
- These cells are cultured and stained for genetic analysis.

Color
-  Normal amniotic fluid is the color of water.
- Late in pregnancy , color changes to slightly yellow.
-  Strong yellow(presence of bilirubin released with the hemolysis of red blood cells)

 color suggests a blood incompatibility.
-  Green color suggests meconium staining( fetal distress)

Fibronectin
- Glycoprotein helps the placenta attach to the uterine decidua.
- As labor approaches, can be found again in cervical or vaginal fluid.
- Detection of fibronectin in her the amniotic fluid or in the mother’s 🤬 can serve as an announcement that preterm labor may be beginning.

Inborn Errors of Metabolism
- Inherited diseases, caused by inborn errors of metabolism can be detected by amniocentesis.
- To identify a condition, errant enzyme must be present in the amniotic fluid.
- Example: cystinosis and maple syrup urine disease (amino acid disorders)

Phosphatidyl Glycerol and Desaturated Phosphatidylcholine
- Addition to lecithin and sphingomyelin, found in surfactant.
- Pathways for these compounds mature at 35–36 weeks.

- if present in the sample of amniotic fluid obtained by amniocentesis. It can be predicted that respiratory distress syndrome is not likely to occur.

Percutaneous Umbilical Blood Sampling
- Ordocentesis or funicentesis
- Aspiration of blood from the umbilical vein for analysis.
- A thin needle is inserted by amniocentesis technique into the uterus and is guided by ultrasound until it pierces the umbilical vein.
- A sample of blood is then removed for blood studies ( CBC, direct Coombs’ test, blood gases, and karyotyping)
- To ensure blood  is obtained , submitted to a Kleihauer-Betke test (measures the difference between adult and fetal blood)
- If the fetus is anemic blood may be transfused using this same technique.
- Fetus is monitored by nonstress test before and after procedure to be sure that there will be no uterine contractions and also by using  the ultrasound to see that no bleeding is evident. 

- Protein components of the lung enzyme that the alveoli  forms  at the 22nd to 24th weeks of pregnancy.
- Determined quickly by a shake test (bubbles appear in the shaken amniotic fluid  means ration is mature)
- Mothers with severe diabetes may have false-mature readings of lecithin.(Due to stress the infant in utero tends to mature lecithin pathways early)
-  Interpreted a ratio of 2.5:1 or 3:1.
- Accepted L/S ratio is 2:1


Serial Estriol Determination
- Measures feto-placental well being
- Serum or 24H urine (most commonly used)

Normal:
Gradual increase which is 12 – 50 mg/day at term

Abnormal: 
Sudden drop of < 50% of the previous level=fetal distress

Persistent low level=fetal well being is compromised


Ultrasonography
- Noninvasive, safe technique uses reflected sound waves that travel in tissue to produce a picture.
- Images are produced onto a screen.
- During the early weeks of gestation, full bladder may be necessary to facilitate visualization.
- Diagnose pregnancy as early as 6 weeks’ gestation.
- Confirm presence, size, and location of the placenta and amniotic fluid.
- Establish that a fetus is growing and has no gross anomalies(defects)
- Establish sex if a 🤬 is revealed
- Presentation and position of the fetus
- Can predict maturity by measurement of the biparietal diameter of the head.
- Discover complications of pregnancy ( tumors, genetic disorders, multiple pregnancy.)
- Fetal anomalies( urethral stenosis) and Fetal death( lack heartbeat and respiratory movement)
- After birth detection of retained placenta or poor uterine involution in the new mother
 Uses in the 1st trimester:
- Early confirmation of pregnancy
- Diagnosis of an ectopic pregnancy
- Detection of an intrauterine device
- Evaluation of placental location
- Diagnosis of a multiple gestation
- Guidance for CVS

 Uses in the 2nd - 3rd trimester:
- Evaluation of fetal growth, weight, and gestational age.
- Evaluation of the placenta for placenta previa or separation associated with vaginal bleeding.
- Evaluation of fetal presentation and position.
- Evaluation of fetal abnormalities.
- Evaluation of fetal viability.
- Determination of the Biophysical Profile (BPP) Score.
- Evaluation of amniotic fluid volume.
- Guidance for amniocentesis or fetal blood sampling.
- Secondary survey for pregnant trauma patient

Endovaginal approach
- lubricated transducer probe is inserted by the mother or the examined into the 🤬.
- No full bladder is necessary, useful  during early weeks of pregnancy, when cervical evaluation  is important.

B-mode scanning
- Patterns merge and form a still picture, similar to a black-and-white snapshot (gray-scale imaging)

Real-time mode
- Uses multiple waves that allow the screen picture to move.(fetal heart can be seen to move and bringing a hand to the mouth to suck a thumb can also be seen)
- Parent can be greatly reassured by viewing a real-time ultrasound image.

Three- and four-dimensional (3-D and 4-D) ultrasonography
- Major and superficial vessels, cord; fetal physiologic development; and fetal behavior.

Advantages to 3-D and 4-D ultrasonography over Doppler velocimetry
- Decreases time of fetal exposure to ultrasound beam( 2 to 5 min than 30 min in Doppler velocimetry)
- Off-line image processing.
-  Identification of placental anastomoses.

Biparietal Diameter
- 80% of pregnancies , if the biparietal diameter of the fetal head  is 8.5 cm greater. Infant will weigh more than 2500 g (5.5 lb) or is at a fetal age of 40 weeks.

Other measurements to predict maturity are:
- Head circumference (34.5 cm indicates a 40-week fetus) and femoral length.

Doppler flow study or also known as Doppler velocimetry
- Noninvasive way to analyze uteroplacental blood flow within the umbilical, uterine and cerebral arteries.
- Focuses on placental analysis to identify risk for increased perinatal mortality.
- Systolic and diastolic ratios are measured within the arteries
- If ratios rise above normal ( blood flow to the placenta is decreased)


Doppler Umbilical Velocimetry
- Measures the velocity of red blood cells in the uterine and fetal vessels travel.
- helpful to determine the vascular resistance  in women with diabetes or hypertension of pregnancy.
- And if resultant placental insufficiency is occurring.
- Impt. to know because  it will limit the number of nutrients that can reach the fetus.
- Decreased velocity (predictor of poor neonatal outcome)

Nursing and Patient Care Considerations

1. Explain the purpose and procedure to patient, emphasizing the need to remain still.

2. Inform patient of the need for a full bladder, if indicated, before the procedure.

3. When indicated, instruct patient to drink three to four glasses of water if the bladder is not full.

4. Instruct patient not to void until the procedure is over.

5. Remove the lubricant from patient’s abdomen after the procedure or provide perineal cleaning products, as needed.

! Note !
Nurse can perform ultrasound if credentialed in limited ultrasound.

- The measurement of MSAFP, it requires only a simple venipuncture of the mother.



Chorionic Villi Sampling (CVS)

- Biopsy and chromosomal analysis of chorionic villi.
- Done at 10–12 weeks of pregnancy

Coelocentesis

- transvaginal aspiration of fluid from the extraembryonic cavity
- method to remove cells for fetal analysis.


Amnioscopy

- Uses an Amnioscope (small fetoscope)
- Visual inspection of the amniotic fluid through the cervix and membranes with an amnioscope.
- Detects meconium staining (carries some risk of membrane rupture)



Fetoscopy

- Fetoscope (narrow, hollow tube inserted by amniocentesis technique)

- Visualized by inspection through a fetoscope (assess fetal well being)
- Photograph through the fetoscope is taken for documention.

- Reassure parents that the infant is perfectly informed.
- Small risk of premature labor.
- Number of performing Fetoscopy is limited because of the manipulation  and the ethical quandary of the mother’s autonomy being compromised by fetal needs if further procedures are necessary.

- Can have Amnionitis (infection of the amniotic fluid)

What to do to prevent :
- Woman may be prescribed 10 days of antibiotic therapy after the procedure.

Uses are:
- Confirm the intactness of the spinal column. 
- Obtain biopsy samples of fetal tissue and fetal blood samples.
- Perform elemental surgery, ( inserting a polyethylene shunt into the fetal ventricles to relieve hydrocephalus)  or (anteriorly into the fetal bladder to relieve a stenosed urethra).
- Earliest time in pregnancy  to perform fetoscopy is about the 16th or 17th week.

-Newborn makes little use of the arms or hands
flailing motion
- 3 or 4 mo - enough arm control to support the upper body weight on the forearms.
infant can coordinate  to scoop up objects.
- 10 mo- coordinate the arm and thumb and index fingers.
pincerlike grasp

PATTERNS OF DEVELOPMENT
- (cephalocaudal) Head to toe direction
- (proximodistal) inward to outward


7. Development proceeds from gross to refined skills
- Once children gain control of their distal body parts that is when they  can do fine motor skills.
- 3-yr old colors best with a large crayon
-  12-yr-old can write with a fine pen

8. There is an optimum time for initiation of experiences or learning
- There are always conditions before a child will achieve a certain task, but its important to monitor and assist children in developing a certain skill.
 
- child cannot learn to sit until the nervous system has matured enough to allow back control
- Confined to a body cast at 12 mo, may take long time to learn this skill once free of the cast .The child has passed  the time for  optimal  learning that particular skills.

9. Neonatal reflexes must be lost before development can proceed
- replaced by purposeful movements
- e.g ( an infant cannot grasp until the grasp reflex has faded)

10. A great deal of skill and behavior is learned by practice
- If children fall behind in growth and development because of illness, they are capable of “catch-up”growth to bring them equal again with their age group.
- Takes practice before they can accomplish this securely


Factors Influencing Growth and Development:

Genetic Inheritance
- inherited from the parents through chromosomes.
• Race

• Intelligence
• Nationality
• Temperament
 • Sex

- Gender
related characteristics health intelligence, temperament

Environmental Influences
regular contact, the kind of care he/she receives affects formation of baby’s personality.

- Socioeconomic level:
- parent-child relationship

-  ordinal position in the family
- health
- nutrition

THEORIES OF DEVELOPMENT :

Theory
Systemic framework that explains some phenomenon .

Developmental Theories
-  Provides a map for explaining the different human development

Developmental Tasks
- Skill or growth responsibility arising at a particular time in individual's life.
-  Achievement that  will provide foundation for accomplishment of future tasks.
- Accomplishments will occur at a certain stage that will  have an effect on the subsequent developmental stages.
Physical Tasks – sit, crawl, walk, toileting

Psychological Tasks – learning trust, self-esteem
Cognitive Tasks- acquiring concepts of time and space, abstract thought.

Theories of Development:

Psychosexual Development – developing instincts or sensual pleasure
(Sigmund Freud)
- human sexuality is influenced by physical, emotional, and cultural aspects in the society in which we live.
- Sexuality is part of the total person, which develops over time.
- It’s expressed through  person’s attitudes, feelings, beliefs, and self-image

Psychosocial Development – personality development (Erik Erikson in 1959)
- framework for the entire life span

- function of ego (conscious part of the personality, immediately controls thought and behavior) as well as social and biologic processes.

TRUST vs. MISTRUST (INFANCY) (birth to age 1)
Foundations of all psychosocial tasks

Give and receive: give consistent and adequate care: hugs, kisses, touch at least 3X/day
SATISFY NEEDS ON TIME SECURITY
Develops trust as the primary caregiver meets his needs
+ Strong bonds, trust in mothering figure
- Inability to bond, insecure, distrustful

AUTONOMY vs. SHAME & DOUBT
(TODDLER) (ages 1 to 3)
- The child learns to control his body functions and becomes increasingly independent, preferring to do things himself
OFFER CHOICES → DECISION MAKING
 + Independence, some self-esteem
- Doubtful of own ability, dependent

 INITIATIVE vs GUILT (ages 3 to 6)
-  Child learns about the world through play • child develops a conscience
- EXPLORING →CREATIVITY &IMAGINATION→FINE MOTOR DEVELOPMENT
+ Sense of purpose and ability
 - Immobilized by guilt, dependent


INDUSTRY vs INFERIORITY (ages 6 to 12)
- Child enjoys working on projects and with others
and tends to follow rules
- Competition with others is keen and forming social relationships takes on greater importance
WORKLOAD INTO MANAGEABLE LEVEL→ DO THINGS WELL
 + Self-confidence by doing and achieving 
 - Sense of inferiority, inability to achieve

IDENTITY vs ROLE CONFUSION (ages 12 to 20)
- Changes in the child’s body are taking place rapidly
- Child is preoccupied with how he looks and how others view him/her
- While trying to meet the expectations of his peers,he’s also trying to establish his own identity
- SELF DISCOVERY→ACCEPTANCE OF SELF & NEW BODY IMAGE → SEEK FREEDOM
+ Secure sense of self, positive ideals
- Confusion, inability to make decisions

INTIMACY vs. ISOLATION (ages 20-30 yrs)
-SEARCH FOR LIFETIME PARTNER or CAREER FOCUS
+ Lasting relationship or commitment
- Isolation and a fear of commitment

GENERATIVITY vs. STAGNATION (ages 30-65 yrs)
 + Creates a family, considers future welfare of
others
- Stagnation, self-centered, unfulfilled life and
career

EGO INTEGRITY vs. DESPAIR (65-death )
+ Positive sense of self-worth, accepts and
prepares for death
- Feeling of hopelessness, fears and denies death  
31

Moral Development – know right from wrong and apply in real-life situations (Kohlberg)

Cognitive Development – learn or understand from experience, to acquire and retain knowledge to respond to new situation and solve problems (Piaget)

- According to Jean Piaget, cognitive or intellectual acts occur when an individual is  able to adapt, organize the perceived environment around him/her.

- Child moves through four stages of cognitive development.
- As he moves through each stage, he builds on structures gained from the previous stages, moving from relatively simple to very complex operations

SENSORIMOTOR (birth to age 2)
• The child progresses from reflex activity, through simple repetitive behaviors, to imitative behaviors.

Concepts to be mastered include:

object permanence
- Objects and events continue to exist, even when they can’t be seen, heard, or touched directly.

Causality - relationship between cause and effect.

spatial relationships- recognition of different shapes and the relationships between them.

PREOPERATIONAL (ages 2 to 7)

- Egocentricity- can’t comprehend a point of view  that is different from his own.

- Magical thinking and there is an increased ability to use symbols and language.

Concepts to be mastered include:

- Representational language and symbols

representing a reality into internal knowledge through language acquisition, using symbolic play.

- Transductive reasoning
generalization that items that share characteristics are labeled the same.


CONCRETE OPERATIONAL (ages 7 to 11)
- Thought processes become more logical and coherent.
- Uses inductive reasoning (facts gathered from one or more specific experiences to draw a general conclusion about a situation)
- Can solve problems but still can’t think abstractly.
- Child is less self-centered.

Concepts to be mastered:
Sorting
Ordering
Classifying facts to use in problem solving

FORMAL OPERATIONAL THOUGHT (ages 11 to 20)

- Adaptability and flexibility
- Adolescents can think more abstractly, make logical conclusions from his observation
- establish hypotheses

Concepts to be mastered:
- Abstract ideas and concepts

- Possibilities
- Inductive reasoning
- Complex deductive reasoning

Growth and Development
- Independent
- Interrelated

Growth – physical change;
- ↑physical size
- ↑weight
- Physiological growth (similar)
- Growth rates (vary on different stages)
- Height (in or cm)
- weight (lbs or kg)
- bone size; dentition
- Rapid (peak)–infancy, adolescence.
- Slows – childhood
- Minimal physical growth - adult

General growth
- Growth of the system (grows smoothly during childhood)
Respiratory
Digestive
Musculoskeletal
Ciculatory Tissue

- First 2 years of age the spinal cord and brain grows rapidly but reaches mature proportions at ages 2 to 5 years.

- Lymphoid tissues for the protection of the children (Spleen, Thymus, Lymph nodes, Tonsillar tissues) rapidly grows  during infancy and childhood.

- Spleen not usually palpable in adults
palpable 1 or 2 cm below the left ribs in preschool.

- Tonsillar tissue at the age of 5 years old (reached its peak size, twice the size of an adult)

- Upon assessment school age children they appear to have large tonsils ( back of the throat, seems to be ("all tonsils")

- Reproductive Organs (genital tissue) show little growth until Puberty


Development - ↑ in skill or ability to function.
- synonym MATURATION
- process of aging, begins to adapt and show competence in new situations
- Qualitative change
- Capacity and skill to adapt
- Behavioral aspect
- Perform specific task

Behavior
- most comprehensive indicator of developmental status

PRINCIPLE OF GROWTH AND DEVELOPMENT

1. Continuous processes  from conception until death
- children will regrow new cells and learn new skills

2. Proceed in an orderly sequence
- Sequence of each stage is predictable
- Some children will skip  or pass a certain stage quickly that the parents will not notice it.
- Sit before creep, creep before stand, stand before walking , walking before running.

3. Different children pass through the predictable stages at different rates
Principle of Asynchronism
- Not all body parts will go grow at the same time.
- Some children will begin to walk at 9 mo and some at 14 mo.


4. All body systems do not develop at the same rate
- Some body tissues mature more rapidly than others
- Neurologic tissue its peak growth is during the 1st year of life, genital tissues will grow until they reach puberty.


5. Development is cephalocaudal
Cephalo is a Greek word meaning “head”  and caudal means “tail”
- Motor Development from the head to the lower extremities
New borns can lift their heads
2 mo : can lift both head and chest off the bed
4 mo: the head, chest, and part of the abdomen
5 mo: infants have enough control to turn over
9 mo: they can control legs enough to crawl
1 yr: children can stand upright and perhaps walk

6. Development proceeds from proximal to distal body parts

-Newborn makes little use of the arms or hands
flailing motion
- 3 or 4 mo - enough arm control to support the upper body weight on the forearms.
infant can coordinate  to scoop up objects.
- 10 mo- coordinate the arm and thumb and index fingers.
pincerlike grasp

PATTERNS OF DEVELOPMENT
- (cephalocaudal) Head to toe direction
- (proximodistal) inward to outward


7. Development proceeds from gross to refined skills
- Once children gain control of their distal body parts that is when they  can do fine motor skills.
- 3-yr old colors best with a large crayon
-  12-yr-old can write with a fine pen

8. There is an optimum time for initiation of experiences or learning
- There are always conditions before a child will achieve a certain task, but its important to monitor and assist children in developing a certain skill.
 
- child cannot learn to sit until the nervous system has matured enough to allow back control
- Confined to a body cast at 12 mo, may take long time to learn this skill once free of the cast .The child has passed  the time for  optimal  learning that particular skills.

9. Neonatal reflexes must be lost before development can proceed
- replaced by purposeful movements
- e.g ( an infant cannot grasp until the grasp reflex has faded)

10. A great deal of skill and behavior is learned by practice
- If children fall behind in growth and development because of illness, they are capable of “catch-up”growth to bring them equal again with their age group.
- Takes practice before they can accomplish this securely


Factors Influencing Growth and Development:

Genetic Inheritance
- inherited from the parents through chromosomes.
• Race

• Intelligence
• Nationality
• Temperament
 • Sex

- Gender
related characteristics health intelligence, temperament

Environmental Influences
regular contact, the kind of care he/she receives affects formation of baby’s personality.

- Socioeconomic level:
- parent-child relationship

-  ordinal position in the family
- health
- nutrition

THEORIES OF DEVELOPMENT :

Theory
Systemic framework that explains some phenomenon .

Developmental Theories
-  Provides a map for explaining the different human development

Developmental Tasks
- Skill or growth responsibility arising at a particular time in individual's life.
-  Achievement that  will provide foundation for accomplishment of future tasks.
- Accomplishments will occur at a certain stage that will  have an effect on the subsequent developmental stages.
Physical Tasks – sit, crawl, walk, toileting

Psychological Tasks – learning trust, self-esteem
Cognitive Tasks- acquiring concepts of time and space, abstract thought.

Theories of Development:

Psychosexual Development – developing instincts or sensual pleasure
(Sigmund Freud)
- human sexuality is influenced by physical, emotional, and cultural aspects in the society in which we live.

- Sexuality is part of the total person, which develops over time.
- It’s expressed through  person’s attitudes, feelings, beliefs, and self-image

human nature has two sides: 

• rational intellect
• irrational desires

Personality is composed of three entities:

• Id 

(The ego acts as a censor to the id; if there’s conflict between the id and the ego, neuroses may develop)

-it’s in continuous battle with the Id

-Center around early years and the parent-child relationship. 

-instinctual libido

-focused on a different area of the body

-Each stage also centers on a conflict that must be resolved before the child progresses to the next stage. If no they will become fixated  and development is arrested

-ORAL STAGE (birth to age 1)

Erogenous zone : mouth

pleasure through sucking, biting, and other oral activities

reduces tension and provides sensual satisfaction

SUCK → ENJOYMENT & RELEASE of TENSION

🤬 stage 1 to 3 years old

Phallic stage  3 to 6 years old 

Erogenous zone:  Genitals

Interested in his genitalia and various sensations discovers the difference between girls and boys

May 🤬 or show exhibitionism 

ACCEPT BUT OFFER TOYS FOR DIVERSION

Answer questions directly about human sexuality

-Castration: boy fears daddy

-Penile envy: girl envies boy’s 🤬

-child may love the opposite-sex parent and consider the parent of the same sex a rival

- known as the Oedipal (boys) or Electra (girls) complex

Latent stage:(6 to puberty12) 

Libido Inactive

Genital stage: (12Puberty to Death)

Sexual maturity→learns to establish satisfying relationships with the opposite sex.

Sexual awakening →engage in sexual intercourse

Psychosocial Development – personality development (Erik Erikson in 1959)
- framework for the entire life span

- function of ego (conscious part of the personality, immediately controls thought and behavior) as well as social and biologic processes.

TRUST vs. MISTRUST (INFANCY) (birth to age 1)
Foundations of all psychosocial tasks

Give and receive: give consistent and adequate care: hugs, kisses, touch at least 3X/day
SATISFY NEEDS ON TIME SECURITY
Develops trust as the primary caregiver meets his needs
+ Strong bonds, trust in mothering figure
- Inability to bond, insecure, distrustful

AUTONOMY vs. SHAME & DOUBT (TODDLER) (ages 1 to 3)
- The child learns to control his body functions and becomes increasingly independent, preferring to do things himself
OFFER CHOICES → DECISION MAKING
 + Independence, some self-esteem
- Doubtful of own ability, dependent

 INITIATIVE vs GUILT (ages 3 to 6)
-  Child learns about the world through play • child develops a conscience
- EXPLORING →CREATIVITY &IMAGINATION→FINE MOTOR DEVELOPMENT
+ Sense of purpose and ability
 - Immobilized by guilt, dependent


INDUSTRY vs INFERIORITY (ages 6 to 12)
- Child enjoys working on projects and with others
and tends to follow rules
- Competition with others is keen and forming social relationships takes on greater importance
WORKLOAD INTO MANAGEABLE LEVEL→ DO THINGS WELL
 + Self-confidence by doing and achieving 
 - Sense of inferiority, inability to achieve

IDENTITY vs ROLE CONFUSION (ages 12 to 20)
- Changes in the child’s body are taking place rapidly
- Child is preoccupied with how he looks and how others view him/her
- While trying to meet the expectations of his peers,he’s also trying to establish his own identity
- SELF DISCOVERY→ACCEPTANCE OF SELF & NEW BODY IMAGE → SEEK FREEDOM
+ Secure sense of self, positive ideals
- Confusion, inability to make decisions

INTIMACY vs. ISOLATION (ages 20-30 yrs)
-SEARCH FOR LIFETIME PARTNER or CAREER FOCUS
+ Lasting relationship or commitment
- Isolation and a fear of commitment

GENERATIVITY vs. STAGNATION (ages 30-65 yrs)
 + Creates a family, considers future welfare of
others
- Stagnation, self-centered, unfulfilled life and
career

EGO INTEGRITY vs. DESPAIR (65-death )
+ Positive sense of self-worth, accepts and
prepares for death
- Feeling of hopelessness, fears and denies death  
31

Moral Development – know right from wrong and apply in real-life situations (Lawrence Kohlberg)))

-Children gain knowledge of right and wrong or moral reasoning

Ideas of moral reasoning (the basis for ethical behavior)

base on Piaget and the American philosopher John Dewey.

-At birth, all beings are devoid(lacking)of morals, ethics, and honesty.

through the  different stages, the family, and then the larger society, instills values, morality, and a sense of right and wrong

  -As the child’s intelligence and ability to interact with others mature, his patterns of moral behavior mature as well

That most moral development occurs through social interaction development could be promoted through formal education

Preconventional Level of Morality (ages 2 to 7)

Punishment & Obedient Orientation

Attempts to follow rules set by those in authority

Adjust his behavior according to good and bad and to right and wrong.

Nursing Implications: Child needs to determine what are right actions. Give clear instructions to avoid confusion

Instrumental Relativist Orientation

Carries actions to satisfy own needs rather than society’s

- “I’ll do something if I get something for it or because it pleases you.”

Nursing Implications: Child is unable to recognize that like situations require like actions

Conventional Level of Morality (ages 7 to 12)

Interpersonal Concordance Orientation

Decisions & behaviors are based on concerns about other’s reaction.

wants approval or reward; seeks conformity and loyalty 

attempts to justify, support, and maintain the social order, and he follows fixed rules

Nursing Implications: Child enjoys helping others because this is“nice” behavior. Allow child to help bed making. Praise behaviorsuch as sharing

Societal Focus (Adolescence and Adulthood)

Law and Order Orientation

Follows rules of authority figures in an effort to keep the “system” working  

I’ll do something because it’s the law and my duty

Nursing Implications: Child often asks what are the rules and is something “right”

(ages 12 and older)

Social Contract Legalistic Orientation

Follows standard for the good of all people

the adolescent strives to construct a personal and functional value system independent of authority figures and his peers

Nursing Implications: An adolescent can be responsible for self- care because he or she views this as a standard of adult behavior

Universal Focus (Middle-Age or Older Adult) 

-Universal Ethical Principle Orientation

-Follows internalized standards of conduct

 Nursing Implications: Many adults do not reach this moral development

Cognitive Development – learn or understand from experience, to acquire and retain knowledge to respond to new situation and solve problems (Piaget)

- According to Jean Piaget, cognitive or intellectual acts occur when an individual is  able to adapt, organize the perceived environment around him/her.

- Child moves through four stages of cognitive development.
- As he moves through each stage, he builds on structures gained from the previous stages, moving from relatively simple to very complex operations

SENSORIMOTOR (birth to age 2)
• The child progresses from reflex activity, through simple repetitive behaviors, to imitative behaviors.

Concepts to be mastered include:

object permanence
- Objects and events continue to exist, even when they can’t be seen, heard, or touched directly.

Causality - relationship between cause and effect.

spatial relationships- recognition of different shapes and the relationships between them.

PREOPERATIONAL (ages 2 to 7)

- Egocentricity- can’t comprehend a point of view  that is different from his own.

- Magical thinking and there is an increased ability to use symbols and language.

Concepts to be mastered include:

- Representational language and symbols

representing a reality into internal knowledge through language acquisition, using symbolic play.

- Transductive reasoning
generalization that items that share characteristics are labeled the same.


CONCRETE OPERATIONAL (ages 7 to 11)
- Thought processes become more logical and coherent.
- Uses inductive reasoning (facts gathered from one or more specific experiences to draw a general conclusion about a situation)
- Can solve problems but still can’t think abstractly.
- Child is less self-centered.

Concepts to be mastered:
Sorting
Ordering
Classifying facts to use in problem solving

FORMAL OPERATIONAL THOUGHT (ages 11 to 20)

- Adaptability and flexibility
- Adolescents can think more abstractly, make logical conclusions from his observation
- establish hypotheses

Concepts to be mastered:
- Abstract ideas and concepts

- Possibilities
- Inductive reasoning
- Complex deductive reasoning

1-12 months

PHYSICAL GROWTH 

Weight 

2X - 4-6 months

3x - 1 year

Weigh gain

 1st 6 months- 2lbs/month

2nd 6th month s- 1lb/month 

1 year- triple

Average 

1y/o male 10 kg

1y/o female 9.5 kg

 Height

50 % increase during 1st year

 Avg. birth length of 20 inches to 30 inches 

50.8 cm to 76. 2 cm

Head circumference 

Increases rapidly = brain growth

end of 1st year - 2/3 of adult size

Cardiovascular 

HR slows down to 110/120 bpm end of 1st year

 

Respiratory 

RR slows down to 20-30 breaths/min

Immune system 

Functional by 2 months of age

Can produce IgG and IgM by 1 year of age

Teeth 

Dentition at 6 month 

2 lower incisors

12 months - 6 to 8 teeth

Milk/Deciduous teeth (20)

Complete by 2-3 years old

Shed off by 6 to 7 yrs old

Permanent teeth by  32 years old

 

Formula age in month- 6

ex. 10 month -6 4 teeth 

Motor Development 

FINE

 Measured by observing prehensile ability ( to coordinate  hand movements)

Skill of an infant cannot accomplish  one day, may be accomplished the next 

IMPORTANT ONES ARE:

7: ability to pass an object from one hand to another

10: pincer grasp 

GROSS

Ability to accomplish large body movements

IMPORTANT ONES ARE :

2: lifting head to chest

6-8: sitting

9: creeping

10-11: cruising 

12: walking  

Ventral Suspension Position

 allows head of the newborn to hand down with little control

1 month 

can lift head momentarily

3 months

can maintain lifting the head

Landau Reflex

3 months

when in ventral suspensions

Infants head and legs and spine is extended

When head si depressed hips, knees and elbows are flexed

Parachute Reflex

 6-9 months

when lowered toward the table while in ventral suspension 

the arms extend to protect it self from falling.

Prone position

For breathing impaired when the baby is lying in their stomachs they turn their head to move it out .

Neck Righting Reflex:

4 months

when the head of the child is turned to the side, shoulder , trunk and pelvis turns in the same direction.

Sitting Position

1 month 

when placed on their back and pulled to a sitting position , the child has gross head lag in the 1st days of life

6 months

can sit momentarily with support

Standing position

Stepping reflex

In standing position

the knee’s and hips will flex 

Fades at 3 months

FiIne Motor Development 

 

1 month old 

have strong grasp reflex

2 months old

 hold an object for a few min before dropping it

4 months old

 begins to have thumb opposition 

(thumb and fingers together)

10 months old 

 Pincer grasp help children to pick up small objects

DEVELOPMENTAL MILESTONES

 LANGUAGE 

Cooing (dove-like) sounds

Squeals with pleasure

Talkative , cooing, babbling, gurgling, and Laugh out loud

Vowel sounds goo-goo and gah-gah oh-oh, ah-ah and oo-oo

Speak a first word da-da or ba-ba

Can say 2 word besides ma-ma  and use them with meaning

IMPORTANT ONES ARE:

2: differentiating a cry

5-6: simple vowel sounds

12: saying 2 words besides “mama” & “dada”

The more you speak to your infant the easier for them to acquire language

Play 

Spend time watching parent’s face 

watching mobile over crib

can handle small blocks rattles, plastic rings, keys and squeeze toys

Teething rubber rings and bathtub toys

Objects for transferring 

Enjoys toys with diff textures

space for creeping

Plays Peek- a-bo

Walks with support (Cruises)

Enjoys put in and take out toys

VISION

 Regards in middle vision

Focuses well and follows objects with eyes

Achieves binocular vision: fuse 2 img. in one

Hand regard

Recognizes familiar objects

Depth perception

Object permanence

IMPORTANT ONE:

3: Following moving objects past midline , focus securely without eyes crossing

Hearing

quiets momentarily at a distinct sound

Turns head to locate a sound

Recognize their names when spoken to

Locate sounds easily in any direction

 ERIKSON:

TRUST v.s MISTRUST

EMOTIONAL DEVELOPMENT SOCIALIZATION

COGNITIVE DEVELOPMENT

Explores by grasping

 Actions can initiate pleasurable sensations

 Object permanence 

Cephalocaudal Development 

Neonate : Head lag

2- head til chin

4- head until chest

6- head til buttocks sits with support

8- Sits w/o support

10- stands w/o support

12- Stands alone , walks with support

14-15 walks alone

PROXIMAL DEVELOPMENT 

0 Hands closed

3 can open hands

6 Palmar grasp (hold feeding bottles)

9 Pincer grasp

CNS develops faster

Reproductive system: slowest

MAJOR MILESTONES IN SUMMARY

Universal language of a child: Play 

Solitary play

mobile/teether/ music box/rattle

SAFETY 

Stranger anxiety

6-7 months peak at 8 months and diminishes at 9 months

1 - head lag

Dance reflex disappears

Regards an object but till midline only

2- Hold head up when in prone positions

Binocular vision

Social smile

Doing sound

Cries with tears

3 - head and chest up on prone

Follow object past midline

Grasp and tonic neck reflex fading

Hand regard 

Closure of posterior fontanel 2-3 months

4 -Neck-righting reflex

Complete head control

Can laugh out loud makes bubbling sound

5 Can roll over 

pick up objects with whole hand

Handle rattle well: Palmar grasp

Moro reflex disappears ( 4-5m/o)

6- Can sit with support

Learns to imitate

Peak of social smile

Eruption of 1st milk teeth (5-6 m/o)

Vowel sounds “ah’ and “oh”

7 - Transfer object from one hand to another

8 - sit w/o support 

peak of stranger anxiety

Plantar reflex disappears (8-9 m/o)

9 creeping or crawling 

stand w/ support 

1st word "da-da”

combine syllables : "mama" and “papa"

10- pull self to stand up

understand no

recognize own name

objt. permanence

Peak a boo/hide & seek/ can clap

pincer grasp ability to pick up smaller objects

11 cruising

12 can stand alone momentarily

drink from a cup

cooperate dressings

say 2 words mama and papa

PROMOTING SAFETY 

must be protected from falls and aspiration of small objects

Aspiration 

leading cause of death

parent’s underestimate or overestimate the child’s ability

CAUTION WITH

Round, cylindrical objects

Within reach of children

no removable parts

clothing decorative buttons

Popcorn and peanuts under 5 years old

Falls

2nd major cause of death

CAUTION:

Don't leave the child unattended on a high surface

Prepare parents for children at the age of 2 months old can roll over

Car safety

Always use car seats through toddlerhood

Infants weighing more than 20 lbs should be placed in rear facing seats 

Bathing & Swimming

Do not leave the child unattended  even if the water is gone

Childproofing 

Move furniture in front of electric sockets  or buy protective caps

Check out sources of lead paint on cribs and rails

Check stairways 

Check table tops for pins or sharp objects

Promoting Nutritional Health

Baby who is over weight in the 1st year of life will be most likely to be obese

Until 6 months normal term infants can thrive on breast milk or formula alone. They must lose their extrusion reflex first before introducing solid food.

Chewing begins at the age of 7 months to 9 months so need to give solid food before 7- 9 months.

Extrusion reflex

automatically thrusts with his/her tongue any object or food 2/3 anterior to the tongue

Life saving reflex to prevent swallowing of foreign objects

fades at 3-4 months

Complementary feeding

Offer new food one at a time to know possible food allergies

 Wait 5-7 days before introducing new items

Use small amounts when introducing new food (1-2 teaspoon at a time)

Newborn: 30 ml (2 tablespoons)

1 year ( 240 ml 1 cup)

Promoting Nutritional Health 

Quantities of types of food :

Cereal 

1st food given

Unnecessary to add sugar in the cereal

Rich in iron

Ideally fed at the age of 3 to 4 years

Vegetables & Fruit

Meat & Eggs

Weaning

Common Concerns related to infant development 

 Teething

Thumb-sucking

use of pacifiers

sleep problems

constipation 

colic

diaper dermatitis

baby bottle syndrome

obesity 

OUR JOB: Teaching parents about the problems and measures to deal with them 

Speaks in two words sentences

BPM of 90/110

Pouchy belly because of weak abdominal muscles 

Wider gait

Chest circumference is larger than the head at 2 yrs old

20 deciduous teeth at age 2.5 

Baby fat disappears in the legs 

visible lordosis - inward curvature of the back 

PARENTEAL DIFFICULTIES IN EVALUATING ILLNESSES
- Evaluation seriousness of illness

They ten to say “no”at everything , its best to observe indication of illnesses such as (holding arm stiffly, rubbing abdomen, crying when voiding, they do not eat when nausea or vomiting but difficult for parent when the child is a light eater)

Differentiating tiredness from illness
-Tend to whine or sleep when they are tired or ill

Review child’s day and its activity, if its not nap or bed time and no  break from the usual routine then crying and whinning or temper tantrums suggest illness.

Evaluation nutritional intake
- Toodlers are fussy eaters compared to infants

Evaluate children regarding their active and growing than assessing their food intake.

Check weekly intake history

- Toodler period is an important age to assess speech development

if they can use simple sentences composed of noun and verb 

(“me go”) by 2 yrs of age.

bone infection has high frequency of occurring to toddlers.( limping, swollen joints, arm or leg pain.

- Toodler contract 10-12 mild upper respiratory infections a year.

Otitis media( middle ear infection)
- occur as a complication of these
- High fever and pulling or manipulating of ear should be seen by their doctor.

Children who attend day care centers
- Have high change of getting hepatitis A, Giardia and Shigella infections
- Teach parents to report jaundice or diarrhea promply to detect the infection.

small pellets into small bottles
Scribbles voluntarily with a pencil or crayon 

Holds a spoon well but may still turn it upside down on the way to mouth

Walks alone well

 seat self in chair

Scribbles voluntarily can creep upstairs

4–6 words

Can stack 2 blocks

enjoys being read to

drops toys for adult to recover (exploring sense of permanence)

7-25 words, Jargoning (and can name 1 body part)

Fine motor
- No longer rotates the spoon to bring it to their mouth

Gross motor
- Jump and run in place
- Walks independently
- Climbs
-  Walk up and down the stairs holding the railing
-  Both feet on one step before making a new step

Play
- Imitates household chores
- Begins parallel play( playing but not beside another child)
- Appropriate toys: push/pull toys, blocks

24 MONTHS

Negativistic
Temper tantrums

Transitional object

- 50 words, 2-word sentences (noun- pronoun and Verb)

- 2-4 word sentences.

- Parallel play evident

- Builds tower of six blocks 

- Removes clothes

- Walks up and down the stairs alone still using both feet on same step same time

- Can open doors by turning doorknobs, unscrew lids.

- simple lines or strokes for crosses with a pencil

- Can jump down from chairs

- Verbal language increasing steadily. Knows full name; can name one

color and holds up fingers to show age.

- Imitating their parents, plays house, rough housing or active

Physiologic Development of Toddler
- Rapid  brain growth bone length and muscle strenght
- Finger to pick up objects
- 4x birth weight 
- Bladder control during the day but sometimes at night
- Turn pages of the book and draw stick figures at age of 3 
-  Sphincter control begins at age 2

- "little scientist"

- Trial and error method
- Experiments ( sense of permanence and imitations)

-Deferred Imitations
Remembers an action then imitates it later on 

- Try out various actions mentally than physically
- Beginning of problem solving and symbolic thought

- More constructively with symbols

-Assimilations

change the situation in a way they perceive it to fit their thoughts.

Sigmun Freud:

Potty training is major focus

Erik Erikson:

- Develops sense of independence and should be allowed to explore the environment with the encouragement of the primary caregiver

-Child should be taught to tolerate frustration through socialization and proper toilet training.

Control elimination

learn sex differences

forms concepts

learns the differences between sexes 

Distinguish right and wrong

Learn language

Negativisim 

Ritualistic behavior

Slowness in carrying out requests,ambivalence

Temper Tantrums

Health Promotion:
Accidental ingestion (poison) occurs frequently.

Potential Accidents:
Automative Accidents
Burns
Falls
Poison drowning
Suffocation and choking
Electric shock
Animal bites

Nursing Process:
Assessment:
Careful health history
ability to carry out ADL
Observation
Child parent relationship
BEST SOURCE OF INFORMATION ARE THEIR PARENTS


Nursing Diagnosis
- Focus on parent’s eagerness to learn about the parameters of normal growth and development and about safety or care .
- Health-seeking behaviors related to normal toddler development
- Deficient knowledge related to best method of toilet training
- Risk for injury related to impulsiveness of toddler
- Interrupted family process related to need for close supervision of 2-year-old
- Readiness for enhanced family coping related to parents’ ability to adjust to new needs of child.

- Readiness for enhanced parenting related to increased awareness for poison prevention.

- Disturbed sleep pattern related to lack of bedtime routine.


Outcome Identification and Planning:

- Focus on  family education and anticipatory guidance.

Establish realistic goals and outcomes so they can meet the rapidly changing needs of their toddler and learn to cope with typical toddler behavior.

- Good rule is to think of a toddler as a visitor from a foreign land who wants to participate in everything the family is doing but does not know the customs or the language.

- Teach parents how to learn adequate methods for resolving similar situations that are sure to arise 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.

- Children change so much and learn so many new skills. Abilities and associated parental concerns can change from day to day.

- Parents state child maintains a consistent bedtime routine within the next 2 weeks.

- Parents state they have childproofed their home by putting a lock on kitchen cupboard by next clinic visit

- Grandmother states she has modified usual activities to conservestrength to care for toddler granddaughter by 1 week’s time.

Appropriate Play:
parallel play, sand, riding toys, water play, finger paints

ManageTemper Tantrums: 

ignore behavior
monitor for safety

 Nutrition:

- Offer nutritious snacks

- May experience food jags

- Give 6 small meals esp. iron-rich food

- Avoid giving hotdog, peanuts, and grapes

Toilet-training
- consider readiness, never punish

Hospitalization:
- rooming-in, transitional object, offer choices

Preschool Stage
-Important period of growth for parents
- Setting limits
- Physical growth slows but personality and cognitive growth continue at rapid rate.

Watch adults and imitate behavior
- Imaginative= imaginary playmates
- Creative and curious = WHY, HOW
- Offensive language
- Oedipal/electra complex
- Sibling rivalry
- “sex” – be honest’
- Masturbation may be seen

GROWTH AND DEVELOPMENT OF A PRESCHOOLER

- Vocabulary increases
- Tonsils appears larger (levels of IgG and IgA increases)
- Pulse Rate decrease to 85bpm
- BP of 100/60 mmHg
- They all have  20 deciduous teeth at 3 yrs old( No new teeth development)
- Handedness begins to be obvious( knowing what is their dominant hand)
- Genu valgus
(knock knees) may be evident
but disappears w/ musculoskeletal growth at the end of the preschool period.
- Growth is only 2 to 3.5  inches a year
- Weight gain is slight. ( 4.5 lb or 2kg per year)
- Body contour changes to be more childlike(slimmer and taller) than babylike.

Classified into two:
- Ectomorphic (slim)
- Endomorphic( larger)

- Muscles are stronger
- Bladder palpable above symphysis pubis
- Voiding is frequent enough (9 or 10 times a day)
- Increased coordination ( riding bicycle, running, kicking, printing letters and numbers, skipping, jumping)

Physiologic Development or Preschooler
Head is close to adult size by six years old.

Preschool milestones


3 years old

LANGUAGE
- 300 to 400 questions
- 900 words
- how and why questions

- Runs; alternates feet on stairs; rides tricycle; stands on one foot

Fine Motor

Fine motor
- Undresses self; stacks tower of blocks, draws a cross


Play
- Able to take turns; very imaginative
- Associate play

Parallel play
- Along side with other but not together


4 years old
Language
1500 words


Play
-Pretend
- imaginative play, creative play, make‐believe play, fantasy play


Gross Motor
- Constantly in motion; jumps; skips


Fine Motor
- Can do simple buttons



5 years old

Fine Motor
- Draws a 6-part man; can lace shoes

Language
- Vocabulary of 2100 words

Gross Motor
- Throws overhand

Play
- Likes games with numbers or letters
- Cooperative Play




Psychosocial development

- Active ImaginationI
- Is not ready for competition because they might drop out from pressure.

Initiative v.s Guilt
- Children are criticized or punished for attempts at initiative, develops a sense of guilt for trying  new activities and new experiences.

Emotional Development
- Exposure to a wide variety of experiences and play materials so they can learn as much about the world as possible.
- Ready to reach outside their homes for new experiences.
- Urge parents to provide play encourage creative play, such as finger paints, soapy water to splash or blow into bubbles.

Imitation
- Imitate the roles of the people
around them.
-  Role playing should be fun and does not have to be accurate
imitate those activities they see their parents performing at home.


Fantasy
- Make this differentiation
- Become so engrossed in a fantasy however, become afraid they have lost their own identity or have become “stuck” in their fantasies.
- Supporting the fantasy and yet reassuring a child she is still herself.
- Let children know they are still recognizable.


Oedipus and Electra Complexes

- Child competes with the same-sex parent for the love and attention of the other parent.
- Parents may need help in handling feelings of jealousy and anger if their children voices out their feelings towards the parent.




Gender Roles

- Exposure to an adult of the opposite gender  so they can become familiar.
- Encourage single parents to plan opportunities for their children to spend some time with adults other than themselves.


Socialization

- Significant others now include grandparents, siblings, and preschool teachers (although parents remain central)
- Regular interaction with same-age children is necessary to further develop social skills. This is a sensitive and critical time for socialization.
- 3 yrs old- capable of sharing
- 4 yrs old- more involved in arguements, Involving some testing and identification of their group role.
- 5 yrs old- develop “best friend” of who they walk with or who is closest to them.

-Elementary Rule: an odd number of children will have difficulty playing well together pertains to children at this age: two or four will play, but three or five will quarrel.

- Running and jumping in an open space.
- Creative play with dress-up clothes, pretend kitchens, and dolls.
- Art activities with paints, paper, crayons, blunt scissors, and markers.
- Trips to the museum, park, fire station, zoo, library, and shopping mall.
- Swimming and other individual sports and activities to encourage gross motor development.
- Puzzles and toys to aid fine motor development and stimulate imagination.

COGNITIVE DEVELOPMENT

- Piaget, still  preoperational
- enter a second phase called intuitional thought (intuitive thought phase)

Centering
-put themselves in another’s place

- Important point to remember when explaining procedures to preschoolers
- Not yet aware of the property of conservation
- Not able to comprehend that a procedure done two separate ways is the  same procedure.
- Egocentrism increases
- Play more related to real-life events(associative or cooperative).
- Basic curiosity constant questions and improved reasoning ability.
- Language development more elaborate.


MORAL AND SPIRITUAL DEVELOPMENT

- Right from wrong based  on their parents’ rules.
- Little understanding of the rationale for these rules.
- Difficulty seeing that the rules they know may also apply to a new situation.
- Begin to have an elemental concept of God if provided some form of religious training.
- Belief in an outside force aids in the development of conscience.


Common Health Problems

-There is a low mortality for preschool children

- Major cause of death being automobile accidents, followed by poisoning and falls.

- Reassure parents that frequent minor illnesses(colds, ear infection, flu symptoms) are common in preschoolers.


COMMON FEARS

Fear of the Dark

-Heightened by a child’s vivid imagination
- Night waking from nightmares reaches its peak


WHAT TO DO:
- Use a night light
- Source of stress needs to be investigated

- Reassure that they are safe  and what ever was chasing them was a dream and not with him/her.

- Intense reaction of a preschooler to even a simple injury such as falling and scraping a knee.

provide a good explanation of the limits of the health procedures.

Fear of Castration

Fear of Separation or Abandonment

- Because of their imagination, they believe that they have been deserted when they are safe.

- Hospital admission or going to a new school will bring out the fear of separation.

What to do:
- Relate time and space with something the child knows like eating their meals and visiting their friends to play.
e.g:“Mommy will pick you up from preschool after you have had your snack”

Telling Tall Tales
- Do not encourage, help the child separate fact from fiction.

- Separate fact from fantasy about their imaginary friend.

- Preschoolers need to practice, to understand and learn the concept of sharing. Assure parents that children at this age finds it hard to understand the concept of sharing.

- Expose children to (mine, yours, ours)  and teach them to determine which objects belong to which category.

- Due to stress, they revert behaviors they outgrew like, sucking their thumbs, loss of bladder control, and separation anxiety.

- New baby in the family

- New school experience

- Seeing something tragic or graphic in television

- Stress in the home and seeing marital difficulties

- Separation because of hospitalization.

Remove the stressor to help discontinue the behaviors . Manifestations such as thumb sucking are best ignored. 

- Firstborn child is rarely allowed the privileges of a second child. The firstborn serves as the “trial run” for all children who come after. They  are unsure of what level of responsibility a child could accept.

- Make them feel secure,  and promote self -esteem  by giving them their own stuff that other children can’t touch 

Special Problems
- Thumb sucking
- Picky eater

- Enuresis

wetting of the bed

- Encopresis

Soiling , involuntary defecating

- Bruxism

grinding of teeth in the night(sleeping) its a way of “letting go”release tension to help them fall asleep. 

Identify the stressor and reliving the anxiety is essential to help them.

- Obtaining a health history and perform physical and developmental evaluation.

- History that details their usual activities for accurate evaluation

- Weight and Heigh  is according to standard growth charts

- Assess the general health appearance

- Be active w/o  become exhausted

- Assess for presence of cavities

- Evaluate symmetrical gait

- Frequency of upper respiratory infection

Outcome Identification and Planning

- Establishing a schedule for discussing normal preschool development with the parents.
- Accident prevention.
- Plan opportunities for adventurous activities or messy play.

- important nursing intervention

- Role playing a mood or attitude you would like a child to learn

- Health assessment is an enjoyable activity suggest preschoolers participate by listening to their heart or coloring the table paper.

– Accident prevention is also best taught by role modeling

 a parent always crosses streets at the corner and does not start the car until seatbelts are in place.

Nursing Diagnosis

- Health-seeking behaviors related to developmental expectations.
- Readiness for enhanced parenting related to parent’s pride in child.
- Delayed growth and development related to frequent illness.
- Risk for poisoning related to maturational age of child.
-Parental anxiety related to lack of understanding of childhood development.

Outcome Evaluation:

- Child states importance of holding parent’s hand while crossing streets.
- Parent states realistic expectations of 3-year old’s motor ability by next visit.
- Mother reports she has prepared 4-year-old for new baby by next visit.

- Age of 4  shows attitude of independence, ability to take care of their own needs.

 - Need supervision to be certain they do not injure themselves or other children.

- Gun safety or being sure that any gun in their home is locked away.

- Teach them not to walk in back of or in front of automobiles.

- Imitate taking medicine if they see family members do so.

(DO NOT DRINK MEDICATIONS IN FRONT OF CHILDREN)

- Food selection should be based on food pyramid groups

- Offer small servings

- NO SNACKING

- Offer healthy alternatives such as fruits and mild rather than milk and cookies

- Teach parents to make meal time a happy and enjoyable day for everyone
- The child’s Initiative, or learning can be used  by teaching them to prepare food like sandwiches or spreading their favorite jam on toast.

health nurses?
1. Provide Preconceptual health care
- Given to both men and women of reproductive age whether they have immediate plans of getting pregnant or not. Focuses on the health of both mother and father for the health of the baby.( Activities on nutrition, diet, supplementation, healthy lifestyle, etc.)

2. Care of women during three trimesters of pregnancy and the

puerperium.
3.Care of infants during the perinatal period (6 weeks before conception to 6 weeks after birth).
4.Care of children from birth through adolescence.
5. Care in settings as varied as the birthing room, the pediatric intensive care unit, and the home.

- Perinatal period is the period from 6 weeks before conception to 6 weeks after birth. 

- Knowledge of growth and development is imperative in caring for individuals from infancy to elderly.

- Includes health promotion activities about nutrition, exercise, etc., injury/illness prevention and management of common conditions associated with their development.

 
- Direct care in different settings where maternal and child, family-centered care is needed.

- keeping the family at the center of care or considering the family as the primary unit of care is an essential goal because family’s functioning affects the health status of its members.

- If a family’s level of functioning is low, the emotional, physical, and social health and potential of individuals in that family can be adversely affected.

- Healthy family establishes an environment conducive to growth and health-promoting behaviors that sustain family members during crises.

PRINCIPLES:

- The family is the basic unit of the society.

- Families come in many different forms and sizes and represent racial, ethnic, cultural, and socioeconomic diversity.

- Children grow both individually and as part of a family.


What are we expected to do as maternal and child health nurses?
Promotion
Maintenance
Restoration
Rehabilitation
CHILDBEARING

CONTEXTUALIZATION OF PRACTICE
PHILIPPINE SITUATION

1. Declining live births
- Decreasing trend, noticeably from 2012 to 2017.
- Factors may contribute to the declining births, such as social change or lifestyle choices associated by economic affluence.

2. Increased births attended by health professionals

- 93.3% birth deliveries were attended by health professionals.
- indicative of improving health services in terms of maternal and child  health care.

3. >50% born to unwed mothers
- Illegitimate babies in ten regions of the country, as usual residence of mother were more than half of its total births.

4. More babies born to adolescent mothers
- The median age of mothers giving birth was 26 and for fathers was 29 years old. 
- Modal age group of childbearing in 2017 was at 20-24 years old The highest frequency of live births (471,356 or 27.7%) belonged to mothers in this age group.

5. Infant Mortality remains unchanged
- Infant mortality rate is a measure of population health, infant deaths were registered in 2017 or 35 deaths per 1,000 births.

6. Relatively Low Maternal mortality ratio
-  Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Indicators of Sustainable Development goal 3:

Good Health & Well-being

2. Decidua capsularis – the portion of the endometrium that stretches or encapsulates the portion of the trophoblast.

3. Decidua vera- the remaining portion of the uterine lining.

* During birth the entire surface of the uterus is stripped away, leaving the organ highly susceptible to hemorrhage & infection.

CHORIONIC VILLI – as early as 11-12th day miniature villi or probing “ fingers” reach out into the endometrium.

✓ It is surrounded by a double layer of trophoblast cells.

a. The outer layer or the syncytial layer =instrumental in the production of hcg, somatomammotropin, human placental lactogen (hPL), estrogen and progesterone.

Inner layer – cytotrophoblast or theLanghan’s layer = present as early as 12days’ gestation, to protect the growingembryo and fetus from certain infectious organism such as spirochete of syphilis.

3. PLACENTA = Latin for pancake, which is descriptive of its size and appearance at term.

It serves as the fetal lungs, kidneys and gastrointestinal tract & as a separate endocrine organ throughout pregnancy.

4. UMBILICAL CORD=- is formed from the fetal membranes ( amnion and chorion) and provides a circulatory pathway connects the embryo to the chorionic villi of the placenta.

FUNCTIONS: 
- Transport oxygen and nutrients to the fetus from the placenta.
- Return waste products from the fetus to the placenta.

Two arteries and one vein. (AVA)

5. AMNIOTIC MEMBRANE
- Chorionic membrane- outermost fetal membrane, support to the sac that contains the amniotic fluid.

- Amniotic membrane or amnion 
forms beneath the chorion , produces amniotic fluid and prostaglandins causes uterine contractions and may trigger or initiate labor.

6. AMNIOTIC FLUID 
- Being newly formed by the amniotic membrane.
- Probably absorbed by direct contact with the fetal surface of the placenta.
- Major absorption happens because the fetus continually swallows the fluid.
- In the fetal intestine, it is absorbed into the fetal blood stream.
- Goes to the umbilical arteries to the placenta and it is exchanged across the placenta.

Development of organ system

- Primary Germ Layer each germ layer develops into specific body systems. 3 germ layers.
- All organ system are complete at 8 weeks gestation.
- Early time of organogenesis, the growing structures is most vulnerable.

GERM LAYER & BODY PORTIONS FORMED:

ECTODERM
Central nervous system (brain and SC)
 Peripheral nervous system
Skin, hair, nails
Sebaceous glandsSense organs
Mucous membrane of anus, nose and mouth
 Tooth enamel mammary glands

MESODERM
Supporting structures of the body
Dentin of the teeth
Upper portion of the urinary system (kidneys and ureters)
Reproductive system
Heart
Circulatory System
Blood cells
Lymph vessels

ENTODERM
Lining of pericardial, pleura and peritoneal cavities
Lining of the GI tract, RT, tonsils, parathyroid, thyroid and thymus gland
Lower urinary system (bladder, urethra)

! IMPORTANT !
- Heart beats 24 days; Doppler 12th week
- HR 120-160 bpm
- Surfactant formed & excreted by 24th week & reaches normal ratio by 35th week
- Nervous system develops during 3rd-4th week; brain waves 8th week
- Ear responsive to sound & sight is present
- Meconium forms 16th week, sterile GI tract
- Mature sucking & swallowing reflex (32 weeks)
- Fetal movement 11th wk; quickening 18th-20th week
- Gonads formed by 6th week; testosterone
- Formation of urine (12th week), excretion (16th week)
- Skin appears thin and almost translucent until sebaceous fat begins to be deposited (36th week)
- IgG gives fetus a temporary passive immunity during the 3rd trimester

Back is bent Rudimentary heart appears as prominent bulge Arms and legs are budlike structures Rudimentary eyes, ears and nose are discernable




TIME:
8TH WEEK

MEASUREMENTS:
L: 2.5cm W: 20 g

SIGNIFICANT DEVELOPMENTS:
Organogenesis is complete
The heart with septum and valves is beating rhythmically
Facial features are discernable
Arms and legs have developed
External genitalia are present
Primitive tail is regressing Abdomen appears large Sonogram shows a gestational sac





TIME:
12th WEEK

MEASUREMENTS:
L: 7-8cm W: 45 g

SIGNIFICANT DEVELOPMENTS:
Nail beds are forming on finger and toes Spontaneous movements are possible

Some reflexes present Bone ossification centers are forming
Tooth buds are present Sex is distinguishable Kidney secretion has begun
Heartbeat is audible through Doppler






TIME:
16th WEEK

MEASUREMENTS:
L: 10-17 cm W: 55-120 g

SIGNIFICANT DEVELOPMENTS:
Fetal heart sounds audible with an ordinary stethoscope
Lanugo is well formed Liver and pancreas are functioning

Fetus actively swallows Urine is present in amniotic fluid
Sex can be determined by UTZ.


TIME:
24th WEEK

MEASUREMENTS:
L: 28-36 cm W: 550 g

SIGNIFICANT DEVELOPMENTS:
Passive antibody transfer Meconium is present as far as the rectum
Eyebrows and eyelashes are well defined
Eyelids are now open
Pupils are capable of reacting to light
Achieved a practical low-end age of viability
Hearing can be demonstrated by response to sudden sound

TIME:
28th WEEK

MEASUREMENTS:
L: 35-38 cm W: 1,200 g

SIGNIFICANT DEVELOPMENTS:
Lung alveoli begin to mature, and surfactant can be demonstrated in amniotic fluid
🤬 begin to descend into the scrotal sac

The blood vessels of the retina are thin and extremely susceptible to damage from high oxygen concentration.

TIME:
32nd WEEK

MEASUREMENTS:
L:38-43 cm W: 1,600 g

SIGNIFICANT DEVELOPMENTS:
SQ fat begins to be deposited Fetus responds by movement to sounds outside the mother’s body Active moro reflex is present

Birth position may be assumed.

TIME:
36th WEEK

MEASUREMENTS:
L:42-48 cm
W: 1,800-2,700 g

SIGNIFICANT DEVELOPMENTS:
Body stores of glycogen, iron, carbohydrates, and calcium are deposited
Additional amounts of SQ fat are deposited

Sole of the foot has only one or two crisscross creases
Amount of lanugo begins to diminish

Most babies turn into a vertex or head-down presentation

TIME:
40th WEEK

MEASUREMENTS:
L:48-52cm W: 3,000 g

SIGNIFICANT DEVELOPMENTS:
Fetus kicks actively, hard enough to cause the mother considerable discomfort
Fetal hemoglobin begins its conversion to adult hemoglobin Vernix caseosa is fully formed Fingernails extend over the fingertips

Creases on the soles of the feet cover at least 2/3 of the surface

1. Fetal movement
- Movement should have consistency
- Ask the mother to observe and record the number of movements the fetus makes daily.
-  Should be at least 10x a day

Variations:
- Sandovsky method – 2x every 10 minutes/ 10-12/hour
- Cardiff method – usually 10 movements in 1 hour

2. Fetal Heart Rate

- Should be 120-160 bpm
-  Can be heard with Doppler at 12th week

Techniques:
- Rhythm Strip Testing – FHR (20 minutes)

- Non-stress Testing –FHR increase by 15 bpm for 15 seconds upon movement (reactive)

- Vibroacoustic Stimulation –Sound to startle and wake the fetus

- Contractions Stress Testing – 3 contractions with a duration of 40 seconds or more for 10 minutes; FHR does not decelerate (negative)

3. Ultrasound – sound waves displayed as visual image

- Confirm structures, position
- Placental grading
- Amniotic fluid volume (800-1200)
-  Biparietal diameter

Instructions:
- What to expect during the procedure
- Ensure a full bladder

- Present in amniotic fluid and maternal serum

- Increase – open spinal or abdominal defect;

-  Low –Down’s syndrome

 5. Chorionic Villi Sampling

-  Biopsy and analysis of CV for chromosomal analysis (10-12 weeks).

6. Amniocentesis

- Aspiration of amniotic fluid to test for genetic abnormalities and fetal maturity (12-13 weeks)

 Preparation/Instructions:
-   Explain the procedure
-  Ask the woman to void
-  Place in a supine position
- Drape properly
- Place a towel under her right thigh
- Attach monitors and take maternal BP and FHR (baseline)
- Do not ask the client to take a deep breath while the needle is being inserted.
- Administer Rhogam if the woman is Rh- negative.

-  It is used to determine the following:
- Color – water→slight yellow tinge
- Lecithin/Sphingomyelin ratio – to determine fetal lung maturity (2:1) by a shake test.
- PSG and Desaturated Phosphatidycholine 
presence in amniotic fluid is the BEST indicator for fetal lung maturity.

Others:
Billirubin, Chromosome Analysis, Fetal Fibronecting, Inborn Errors of metabolism , AFP

7.  Percutaneous Umbilical Blood Sampling

(cordocentesis/funicentesis)
-  Aspiration of blood from the umbilical vein for analysis.
- Can be subjected to CBC, direct Coomb’s test, blood gases and karyotyping.
- Can be a means for blood transfusion
- Rhogam is also given to Rh-negative women.
- Fetus is monitored by a non-stress test before and after the procedure.
- Yield results not available by any other means.

8. Biophysical Profile/fetal APGAR
- Combination of fetal breathing movement, fetal tone, amniotic fluid volume, placental grading, fetal heart reactivity.
- More accurate in predicting fetal well-being than any single assessment.
- Scores: 8-10 doing well, 4-6 fetus in jeopardy.

ASSESSMENT| INSTRUMENT| CRITERIA FOR A CORE OF 2

Fetal breathing
INSTRUMENT:
Sonogram
At least 1 episode of 30 sec of sustained fetal breathing movements within 3o min of observation

Fetal movement
INSTRUMENT:
Sonogram
At least 3 separate episodes of fetal limb or trunk movement within 30-min

Fetal tone
INSTRUMENT:
Sonogram
The fetus must extend and then flex the extremities or spine at least once in a 30-minute observation

Amniotic fluid volume
INSTRUMENT:
Sonogram
A pocket of amniotic fluid measuring more than 1 cm in vertical diameter must be present

Placental grade
INSTRUMENT:
Sonogram
Placenta is grade 3 grading based on structure and amount of calcium present

Fetal heart reactivity
INSTRUMENT:
Nonstress test
2 or more FHR acceleration of at least 15bpm above baseline and of 15 sec duration occur with fetal movement over a 20-minute period

TIME:
4TH WEEK

DESCRIPTION:
Rapidly growing Does not yet resemble human

MEASUREMENTS:
L: .75-1 cm W: 400 mg

SIGNIFICANT DEVELOPMENTS:
SC formed and fused
Lateral wings folded forward to fuse at midline Head fold forward and becomes prominent

Back is bent Rudimentary heart appears as prominent bulge Arms and legs are budlike structures Rudimentary eyes, ears and nose are discernable




TIME:
8TH WEEK

MEASUREMENTS:
L: 2.5cm W: 20 g

SIGNIFICANT DEVELOPMENTS:
Organogenesis is complete
The heart with septum and valves is beating rhythmically
Facial features are discernable
Arms and legs have developed
External genitalia are present
Primitive tail is regressing Abdomen appears large Sonogram shows a gestational sac





TIME:
12th WEEK

MEASUREMENTS:
L: 7-8cm W: 45 g

SIGNIFICANT DEVELOPMENTS:
Nail beds are forming on finger and toes Spontaneous movements are possible

Some reflexes present Bone ossification centers are forming
Tooth buds are present Sex is distinguishable Kidney secretion has begun
Heartbeat is audible through Doppler






TIME:
16th WEEK

MEASUREMENTS:
L: 10-17 cm W: 55-120 g

SIGNIFICANT DEVELOPMENTS:
Fetal heart sounds audible with an ordinary stethoscope
Lanugo is well formed Liver and pancreas are functioning

Fetus actively swallows Urine is present in amniotic fluid
Sex can be determined by UTZ.


TIME:
24th WEEK

MEASUREMENTS:
L: 28-36 cm W: 550 g

SIGNIFICANT DEVELOPMENTS:
Passive antibody transfer Meconium is present as far as the rectum
Eyebrows and eyelashes are well defined
Eyelids are now open
Pupils are capable of reacting to light
Achieved a practical low-end age of viability
Hearing can be demonstrated by response to sudden sound

TIME:
28th WEEK

MEASUREMENTS:
L: 35-38 cm W: 1,200 g

SIGNIFICANT DEVELOPMENTS:
Lung alveoli begin to mature, and surfactant can be demonstrated in amniotic fluid
🤬 begin to descend into the scrotal sac

The blood vessels of the retina are thin and extremely susceptible to damage from high oxygen concentration.

TIME:
32nd WEEK

MEASUREMENTS:
L:38-43 cm W: 1,600 g

SIGNIFICANT DEVELOPMENTS:
SQ fat begins to be deposited Fetus responds by movement to sounds outside the mother’s body Active moro reflex is present

Birth position may be assumed.

TIME:
36th WEEK

MEASUREMENTS:
L:42-48 cm
W: 1,800-2,700 g

SIGNIFICANT DEVELOPMENTS:
Body stores of glycogen, iron, carbohydrates, and calcium are deposited
Additional amounts of SQ fat are deposited

Sole of the foot has only one or two crisscross creases
Amount of lanugo begins to diminish

Most babies turn into a vertex or head-down presentation

TIME:
40th WEEK

MEASUREMENTS:
L:48-52cm W: 3,000 g

SIGNIFICANT DEVELOPMENTS:
Fetus kicks actively, hard enough to cause the mother considerable discomfort
Fetal hemoglobin begins its conversion to adult hemoglobin Vernix caseosa is fully formed Fingernails extend over the fingertips

Creases on the soles of the feet cover at least 2/3 of the surface

1. Fetal movement
- Movement should have consistency
- Ask the mother to observe and record the number of movements the fetus makes daily.
-  Should be at least 10x a day

Variations:
- Sandovsky method – 2x every 10 minutes/ 10-12/hour
- Cardiff method – usually 10 movements in 1 hour

2. Fetal Heart Rate

- Should be 120-160 bpm
-  Can be heard with Doppler at 12th week

Techniques:
- Rhythm Strip Testing – FHR (20 minutes)

- Non-stress Testing –FHR increase by 15 bpm for 15 seconds upon movement (reactive)

- Vibroacoustic Stimulation –Sound to startle and wake the fetus

- Contractions Stress Testing – 3 contractions with a duration of 40 seconds or more for 10 minutes; FHR does not decelerate (negative)

3. Ultrasound – sound waves displayed as visual image

- Confirm structures, position
- Placental grading
- Amniotic fluid volume (800-1200)
-  Biparietal diameter

Instructions:
- What to expect during the procedure
- Ensure a full bladder

- Present in amniotic fluid and maternal serum

- Increase – open spinal or abdominal defect;

-  Low –Down’s syndrome

 5. Chorionic Villi Sampling

-  Biopsy and analysis of CV for chromosomal analysis (10-12 weeks).

6. Amniocentesis

- Aspiration of amniotic fluid to test for genetic abnormalities and fetal maturity (12-13 weeks)

 Preparation/Instructions:
-   Explain the procedure
-  Ask the woman to void
-  Place in a supine position
- Drape properly
- Place a towel under her right thigh
- Attach monitors and take maternal BP and FHR (baseline)
- Do not ask the client to take a deep breath while the needle is being inserted.
- Administer Rhogam if the woman is Rh- negative.

-  It is used to determine the following:
- Color – water→slight yellow tinge
- Lecithin/Sphingomyelin ratio – to determine fetal lung maturity (2:1) by a shake test.
- PSG and Desaturated Phosphatidycholine 
presence in amniotic fluid is the BEST indicator for fetal lung maturity.

Others:
Billirubin, Chromosome Analysis, Fetal Fibronecting, Inborn Errors of metabolism , AFP

7.  Percutaneous Umbilical Blood Sampling

(cordocentesis/funicentesis)
-  Aspiration of blood from the umbilical vein for analysis.
- Can be subjected to CBC, direct Coomb’s test, blood gases and karyotyping.
- Can be a means for blood transfusion
- Rhogam is also given to Rh-negative women.
- Fetus is monitored by a non-stress test before and after the procedure.
- Yield results not available by any other means.

8. Biophysical Profile/fetal APGAR
- Combination of fetal breathing movement, fetal tone, amniotic fluid volume, placental grading, fetal heart reactivity.
- More accurate in predicting fetal well-being than any single assessment.
- Scores: 8-10 doing well, 4-6 fetus in jeopardy.

ASSESSMENT| INSTRUMENT| CRITERIA FOR A CORE OF 2

Fetal breathing 
INSTRUMENT:
Sonogram 
At least 1 episode of 30 sec of sustained fetal breathing movements within 3o min of observation

Fetal movement 
INSTRUMENT:
Sonogram 
At least 3 separate episodes of fetal limb or trunk movement within 30-min

Fetal tone 
INSTRUMENT:
Sonogram 
The fetus must extend and then flex the extremities or spine at least once in a 30-minute observation

Amniotic fluid volume 
INSTRUMENT:
Sonogram 
A pocket of amniotic fluid measuring more than 1 cm in vertical diameter must be present

Placental grade 
INSTRUMENT:
Sonogram 
Placenta is grade 3 grading based on structure and amount of calcium present

Fetal heart reactivity 
INSTRUMENT:
Nonstress test 
2 or more FHR acceleration of at least 15bpm above baseline and of 15 sec duration occur with fetal movement over a 20-minute period

Preliminary signs of Labor
- SUBTLE SIGNS

- INDICATES IMMINENT LABOR

- MUST EDUCATE PATIENTS FOR THEM TO DETECT THESE SIGNS

1. Lightening
- descent of the fetal presenting part into the pelvis
- occurs 10-14 days before labor
- changes woman’s abdominal contour
- gives woman relief from diaphragmatic pressure & SOB
-cause shooting leg pains, increased vaginal discharge & urinary frequency

2. Increase in Level of Activity
- morning of labor, woman may be full of energy related to an increase in epinephrine release, prepares a woman’s body for the work of labor ahead.

2. Braxton-Hicks Contractions
- Begin and remain irregular
- Felt first abdominally & remain confined to the abdomen & groin 
- Often disappear with ambulation & sleep
- Do not increase in duration, frequency, or intensity

- Do not achieve cervical dilatation

3. Nesting Instinct

4. Ripening of the cervix
- an internal sign seen only on pelvic examination

- Goodell’s sign – all throughout pregnancy, cervix has the same consistency as the earlobe • at term it becomes still softer
- described as “butter-soft” •internal announcement that labor is close at hand

4. Weight loss

SIGNS OF TRUE LABOR

Uterine Contractions
- Begin irregular but become regular & predictable
- Felt first in lower back & sweep around to the abdomen in a wave
- Continue no matter what the woman’s level of activity
- Increase in duration, frequency & intensity
achieve cervical dilatation

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

Rupture of membranes
- Sudden gush or as scanty, slow seeping of clear fluid from the 🤬
- There is no such thing as “dry labor”
- Early rupture is advantageous if it causes the fetal head to settle snugly into the pelvis, resulting to short labor

TRUE LABOR

Frequency of contractions | Irregular | Regular
Intensity of contractions
Irregular:
No increase
Regular:
Increases

Pain relief
Irregular:
Pain is relieved by walking 
Regular:
Pain is intensified by walking

Pain location
Irregular:
Confined on abdomen
Regular:
Begins on lower back and radiates to abdomen

Cervical changes
Irregular:
No cervical changes
Regular:
Effacement and dilation

Uterine changes
Irregular:
None
Regular:
Physiologic retraction ring

Duration of Labor:

1. Primipara: 14 hours-20 hours 
2. Multipara: 8-14 hours

Effacement
- Softening and thinning of cervical canal recorded in percentage.

Dilatation
- Widening of the external cervical os to 10 cm

*Primipara: 1st effacement then dilation

*Multipara: Both processes occur at the same time

- In true labor, contractions are accompanied by cervical dilatation and effacement

-  Should be adequate in size & contour.

2. The Passenger or the fetus

- Should be appropriate in size & in an advantageous position & presentation.

3. The Powers of labor or uterine factors

- Should be adequate.

4. A woman’s Psyche is preserved

- Should be preserved, so that afterward labor can be viewed as a positive experience.

Bony Pelvis

- Emphasize to parents Uterus that it is the pelvis that

is too small, not that the fetal head is too big.

Pelvic Shape:
Gynecoid

True Pelvis

The most important measurement of the inlet because it has the smallest diameter (N-11cm)


PASSAGE

- THE ROUTE A FETUS MUST TRAVEL

-  MOST IMPORTANT: BONY PELVIC RING

- REMEMBER YOUR PELVIMETRY

- DETERMINANTS OF ADEQUACY
-  DIAGONAL CONJUGATE (A-P INLET)
- TRANSVERSE DIAMETER (OUTLET)


PASSENGER →  Fetus
- Fetal skull is the largest part
- Fetal head – the body part that has the widest diameter least likely to be able to pass through the pelvic ring.

- AP> Transverse diameter of the skull
L: 9.5 cm
W: 9.25 cm 

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

- Suture Lines
Frontal

- Fontanelle
- Spaces compresses during birth to aid in molding of the fetal head.
Parietal
Occipital

- Can be assessed manually through the cervix.
- Helps to establish the position of the fetal head; to see if it is in favorable position for birth.


Fetal Presentation
- Refers to the foremost part of the fetus that enters the pelvic inlet.

Cephalic
- most frequent type, 95%
- Types: vertex, face, brow & mentum presentation

- Vertex is the ideal part because the skull is capable of molding effectively; aid in cervical dilatation & prevents complications such as prolapsed cord. 
- Fetal skull that contacts the cervix becomes edematous (capput succedaneum) due to continued pressure against it.

Breech
- Buttocks or feet are the first body parts that will contact the cervix, 3% of births.

-  Affected by fetal attitude: good attitude - fetal knees up against the umbilicus, poor attitude – knees are extended

- 3 types: complete, frank, footling.

Shoulder
-  Fetus lie horizontally (transverse) in the pelvis – longest fetal axis is perpendicular to that of the mother, 1% of births.

- Presenting part is usually the acromion process, iliac crest or elbow.

- Caused by: relaxed abdominal walls, pelvic contraction, placenta previa (placenta located low in the uterus).

- Must be born by caesarian birth.


FETAL LINE
- Relationship between the spine of the fetus to the spine of the mother; whether the fetus is lying in a
- Horizontal (transverse)
- Vertical(longitudinal)

position.
- 99% assume a longitudinal lie


Fetal attitude: Degree of Flexion

- Relationship of the fetal body parts to one another.
Good Attitude:
-  Advantageous for birth because it helps the fetus present the smallest AP diameter of the skull to the pelvis.

- Also puts the whole body into an ovoid shape, occupying the smallest space possible.

- Complete flexion: spinal column bowed forward, head is flexed forward, chin touches the sternum, arms are flexed & folded on the chest, thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs.

Complete flexion
- The most common attitude; most favorable for vaginal birth;

Skull smallest diameter to the bony pelvis:
- Sub-occipto bregmatic

PASSENGER
-MPORTANT STRUCTURES: FONTANELLES AND SUTURES

- NARROWEST: SUBOCCIPITOBREGMATIC (9.5 CM) 
-  WIDEST: OCCIPITOMENTAL (13.5)

Fetal Station
- How far the presenting part descended into the pelvis.
- Ischial spines→ 0 station “engaged”
- Above ischial spines→ negative

- Below ischial spines→ positive +3-+4 crowning

ENGAGEMENT

- SETTLING OF THE PRESENTING PART INTO THE PELVIS (LEVEL OF ISCHIAL SPINES)

- PELVIC INLET HAS BEEN TRAVERSED
- PELVIS IS PROVEN TO BE ADEQUATE
- NOT ENGAGED = FLOATING

Fetal Position
- Reference point on fetal presenting part to maternal specific pelvic quadrant.
- 1st: Maternal side
- 2nd: Fetal presentation
-  3rd: Maternal quadrant

- LOA – most common and favorable for birthing position

- The first letter denotes mother’s right (R) or left (L)

- The middle letter denotes the fetal landmark.
 (O = occiput,M = mentum, Sa = sacrum, A = acromion process)

- The last letter denotes whether the landmark points
   anteriorly (A), posteriorly (P), or transversely (T)

Mechanisms of Labor (D-F-IR-E-ER-E)

- Descent- A continuous process from engagement until birth

- Flexion- Nodding of the fetal head toward the chest.

- Internal Rotation- Occipito- transverse to the occipito anterior position while descending.

- Extension- Begins when the head crowns to head passing under the symphysis pubis

External Rotation (Restitution)
- Realignment of the fetal head with the body after the head emerges.

External Rotation (Shoulder Rotation)
- Shoulders externally rotate after the head emerges and restitution occurs

Expulsion
- Birth of the entire body

POWERS → FORCE
Nursing Responsibility: evaluate the rate, intensity & pattern of contractions.

(1) Increment or Crescendo 
(2) Acme or Apex 
(3) Decrement or Decrescendo

POWER

-  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.

Uterine Contraction (Contour Changes)
- As labor contraction progresses
 Uterus differentiates into two distinct functional areas:
a. Upper portion: becomes thicker & active, preparing to exert strength to expel the fetus when the expulsion phase is reached.
b. Lower portion: becomes thin-walled, supple & passive to easily push the fetus out of the uterus .

Boundary between the 2 portions becomes marked by a ridge – Physiologic retraction ring

- Each contraction squeezes the blood vessels that supply the placenta, thereby decreasing the amount of oxygen that flows to the fetus. The relaxation period allows the vessels to fill with oxygen-rich blood
to supply the placenta.


4. PSYCHE→ WOMAN

- Refers to the psychological state or feelings that a woman brings into labor.
- A feeling of apprehension or fright, or it includes a sense of excitement or awe.

- Woman who can manage best in labor are those who have strong sense of self-esteem & meaningful support with them.

- Woman without adequate support can have an experience so frightening & stressful; can develop to post traumatic stress syndrome.

- Nursing Responsibility: Encourage women to ask questions at prenatal visits & to attend classes to prepare them for labor.

Remember: Fear, tension, and pain can interfere progress of labor.

- 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
Onset of true contraction→Full effacement & dilatation

LATENT
- 0-3 cm
- Every 5-10 minutes 20-40 second duration
- Mild intensity
- Mother is excited, apprehensive, but can communicate

ACTIVE
- 4-8 cm
- 3-5 minutes
- 30-60 seconds Moderate
- Medications ready
-Assess VS/cervix/fetal status
- Dry lips..provide oral care, dry

- Linens
- Abdominal breathing

TRANSITION
- 8-10 cm
- 2-3 minutes 
- 40-90 seconds Strong
- Hyperesthesia
- Sacral pressure TIRED

- Small snacks and sips of water 
- Encourage to urinate
- Bathing is encouraged
-  Perineal preparation

- Left side-lying

- Monitor for fetal thrashing

- For pain:
- Demerol @6-8 cm WOF Respiratory Depression 
-  Epidural- WOF Hypotension

- X NPO, X Enema X Shaving

SECOND STAGE

- FULL CERVICAL DILATATION UP TO FETAL DELIVERY

SECOND STAGE (FETAL STAGE)
- 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
- Ssx: Inc RR, Lightheadedness, Tingling, Carpopedal spasm, Circumoral numbness

- Episiotomy- prevent laceration; not done routinely
- 2 types: median, mediolateral
- Complication: Urethroanal fistula

- Modified Ritgens Maneuever- Support the perineum to prevent laceration

MECHANISMS OF LABOR
- Engagement
- Descent
- Flexion
- Internal Rotation
- Extension

- External Rotation
-  Expulsion

Nursing management

- Modified Ritgen’s
- Support the head & (suction secretions?) 
-  Dry the baby
-  Initiate skin to skin interaction
- Wait for pulsation to stop

*When there is still birth, let the mother see the baby


THIRD STAGE

- PLACENTAL STAGE

TWO PHASES:
-  PLACENTAL SEPARATION 
-  PLACENTAL EXPULSION
- UTERUS STAYS AT THE LEVEL OF THE UMBILICUS

- UTERUS CONTRACTS AGAIN ASSUMING DISCOID SHAPE
- RETAINS DISCOID SHAPE UNTIL PLACENTA HAS SEPARATED

- APPROXIMATELY 5 MINUTES AFTER BIRTH

THIRD STAGE OF LABOR (PLACENTAL STAGE)

- 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


PLACENTAL SEPARATION
- LENGTHENING OF THE UMBILICAL CORD
- SUDDEN GUSH OF VAGINAL BLOOD
- CHANGE IN THE SHAPE OF THE UTERUS
- FIRM CONTRACTION OF THE UTERUS
- APPEARANCE OF THE PLACENTA AT THE VAGINAL OPENING

PLACENTAL EXPULSION

- NATURAL (BEARING-DOWN)

- GENTLE PRESSURE (CREDE’SMANEUVER)
- Check completeness
- Check fundus
- BP Check
- Methergine, methylergonovine mallate (IM) 
- Oxytocin IV if methergine is not present

- Check perineum for lacerations 
- Assist in episiorrhaphy


FOURTH STAGE OF LABOR (RECOVERY STAGE)

- 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)

- Flat on bed

- If with chills, give blanket

-  Give nourishment (progression of meals) 
- CL-juice, gelatins

- FL-milk, ice cream
-  SD
- RD

-  Check VS/Pain
- Psychological state 
- Bonding (MBFH)