Lecture 2

-communication and language development for a growing child

-emotional and social development of a growing child

-need of growth and development of different stages in childhood

communication and language development

Infants

Crying = messages of urgency, signals displeasure

1 year = cry for attention due to fear and frustration

Parent-infant relationship

+/- Hearing loss

1-3m baby coos

4-5m simple vowel sound

6m yelling

7-10 m progresses strings (mama, papa)

12m 2-3 recognizable words with meaning

Toddler

Increasing level of comprehension

Linguistic milestones

2yr multiword sentences

3yr simple sentences with grammatical rules

Preschooler

Express feelings

Nonverbal communication

3-4yr Ask many question

4-5yr Longer sentences

Emotional and social development

Infant

Attachment, separation anxiety

Stanger fear 6-8m

(clinging to parents, crying, turning away from the stranger)

Toddler

Transitional objects (blanket or toys from home for hospitalization)

Reproachment

Development in personal-social behavior

Positive reinforcement, redirection, timeouts

Temper tantrums (inability to control emotion)

Negativism

-offer options, set boundaries, praise when the children for positive behavior)

Preschooler

Personal- social behavior

(sociable, verbalizing request, increasingly aware of their position)

School Age child

Peer group identification

Appropriate sex role

Gender differences

Sensitive to peer group

Appreciate point of view

Formation of friendship

Value system
Nutrition

Assessment

-history taking (dietary history)

-anthropometry (body measurement e.g., skinfold thickness, arm circumference)

-biochemical result (blood test result e.g. plasma, hemoglobin, albumin)

Infant

Breastfeeding (recommend 12 months)

Formula milk

After 6 months

Pureed (meat, fish, egg yolk)

Avoid honey, excessive amount of fruit juice, choking, allergic reaction food

Toddler

Weaning from bottle feeding to avoid dental caries

Weaning from breast feeding

Food jags

Use utensil to feed

Bite-sized pieces

Always under supervision

Avoid food hard to chew

Nutrients

Iron, calcium, protein, fiber, calories

Child maltreatment (child neglect, physical abuse, sexual abuse)

Child neglect (physical neglect, emotional neglect, psychological maltreatment)

Assessment on physical abuse

Inspect the skin

• bruises, burn, cuts, abrasion, contusions, scars, and

any other unusual or suspicious marks

• Current or healed scratches or cuts

the body ordinarily covered by clothing in the child who self-mutilates

• Burns
in a stocking or glove pattern, or only to the soles or palms
•Bruises on the chest, head, neck, or abdomen

Abusive head trauma

Munchausen syndrome by proxy

Sexual abuse

Bruises, bleeding, lacerations, or irritation of external genitalia, anus, mouths, or throat

Torn, stained, or bloody underclothing

Pain on urination or pain, swelling, and itching of genital area

Sexually transmitted disease, nonspecific vaginitis

Difficulty in walking or sitting

Unusual odor in the genital area

Recurrent urinary tract infections

Presence of sperm

Pregnancy in young adolescent

Laboratory and Diagnostic Tests

• Radiographic skeletal survey or bone scan • reveal current or past fractures

• CT scan of the head
• intracranial hemorrhage

• Rectal, oral, vaginal or urethral specimens

• reveal sexually transmitted infections such as gonorrhea or chlamydia

Lecture 3 Home Safety

Fall

Causes and Prevention

(inadequate supervision, lack of window guards, level of activity, unsafe product, lack of restraints)

Consequence of fall

(Maxillofacial injuries, cervical spine injuries, traumatic spinal cord injuries, infant head injuries)

First aid

(comfort the child, stop bleeding, cover with clean cloth, monitor 1-2 days, admission if vomiting)

Cast Care

Before cast application (check any abrasion, cuts, skin integrity, items that cause constriction)

After cast application (neurovascular integrity, expose the plaster cast until dry)

Poisoning

Causes (medicine, household chemicals or pesticides, alcohol, cosmetic products, plant)

Signs (drowsiness, sick feeling, diarrhea, stomach pain, chills, cyanosis, LOC, blurred vision)

Prevention (out of reach, store in locked cabinet)

Emergency Management (cardiorespiratory support, mental status, vital signs, ocular or dermal exposure,
identify the poison)

terminate exposure: remove contaminated clothes, fresh air, flush body, empty mouth)

Gastric decontamination (activated charcoal administration within 1 hour (nasogastric tube))

gastric lavage (gastrointestinal perforation, hypoxia, aspiration) (+sedation, protected airway)

e.g. Naloxone <-> opioid

Burn and scald (Thermal agents, Electrical injury, Chemical burns, Radiation)
Extent of injury (Total surface area, More than 10% admissions)
Depth of injury (4degrees)
Superficial (epidermal)
Partial-thickness (epidermis and varying degrees of the dermal layers) (blister)
Full-thickness (third degree) (entire epidermis and dermis, extent to subcutaneous tissue, nerves ending,
sweat glands, hair follicles)
Fourth degree (underlying structure) muscle fascia
Emergency treatment
-stop burning process
-cool running water
-adequate airway and breathing
-cover with a clean cloth
-keep patient warm
-transport to medical aid

Therapeutic management
-high flow oxygen or 100% oxygen
-apply endotracheal tube before severe edema
-fluid replacement (compensate water and sodium, prevent acidosis)
-parkland formula (crystalloid solution
50% in the first 8hours, 50% 16 hours)
-monitor urine output (0.5 to 1ml/kg/hr)
-protein, calories for metabolic requirements and catabolism)
-medication like sedation and analgesia
-wound management
-hypothermia
-pain and anxiety
-scar management

Prevention of burn and scald

-electrical outlet, water, hot liquid out of reach, cigarettes

-smoke detectors, instruct kids

Drowning

Causes and Prevention (bathtub, bucket, swimming pool) (supervised, empty, lid, fence)
Choking

Causes (fish bone, improper sleep position, large chunks of food, swallow hard)

Signs (cyanosis, cough forcefully, unable to speak or cry, universal choking sign)

Prevention (sit up when eating, mealtime calm, prepare food in right shape, size, texture)

Lecture 4 Health assessment of a hospitalized child

General inpatient unit/ Emergency and urgent care department/ Paediatric intensive care unit/ Rehabilitation

Building trusting and caring relationship (called preferred name, eye contact, smile, age-appropriate level,
orientation, explain procedure)

Children’s reaction to hospitalization (fear, separation anxiety, loss of control)

Fear of disability, death, altered body image (age-appropriate communication techniques, soft tone,
empathetic approach, explain procedure, quick, comfort after)

Separation anxiety (Protest> Despair> Detachment or denial) (recognize stage, family-centered approach,
familiar objects)

Loss of control (minimized physical restriction, allow the children participate in care and decision, explain)

Nursing intervention to parents (provide information, educate on additional resources, idemtify support
system, parental involvement in care)

Nursing intervention to siblings (promote healthy siblings relationship, assist sibling to cope, appreciate)

Restraint

(device to limit or prevent movement of the whole or a portion of the patient’s body, last resort only)

Types

Soft limb restraint (wrist or ankle restraint) (check any signs of circulatory, integumentary or neurologic
compromise)

Elbow restraint (flexing, reaching face, head, IV, tubing) (no rub against axilla, capillary refill of the
extremity)
Mummy restraint (short-term restraint for examination or treatment) (protect airway, secured extremities)

Vest restraint (keep children flat in bed) (place ties back, non-moveable part of bed frame)

Component of paediatric health assessment

(child interaction, health history, physical exam, physiological psychological, cognitive, emotional
development, state of nutrition, pain level)

History Taking

1. Chief complaint, present illness (information, description, COLDSPA) (Character, Onset, Location,
Duration, Severity, Patterns, and Associated Factors), current medication
2. Past health history (birth history: mother’s health during pregnancy, labor and delivery, child’s condition)
(Dietary history: mealtimes, appetites, feeding habits, cultural practice) (previous illness, injuries,
surgeries) (Allergy history) (immunization history)
3. Growth and Development (weight, length, head circumference at birth, Development milestones)
4. Habit (behavior pattern, security blanket, thumb sucking, daily routine)
5. Family health history and psychosocial history (genetic disease, parent-child relationship, school
adjustment)

Physical Examination (general appearance, growth and development, vital signs, head to toe assessment)

Preparation (observe behaviors, allow sitting on parents’ lap, examine painful areas last, age-appropriate
method, involve parent)

1. General appearance (facial expression, behavior, posture, position, body movement, speech)
2. Growth (body length, height, weight, BMI, growth chart, head circumference (brain growth, greatest
occipital-frontal circumference) *Documentation for medication
3. Vital signs taking (RR>sPO2> pulse> temp> bp) (recheck+ record child behavior)
(RR: Abdominal movements) (Pulse: Apical pluse, >2 years old radial pulse)
Temperature
Tympanic: <3 years old down and backward
Temporal artery (infrared sensor to scan the forehead)
Oral: >5 years old, place under tongue in right or left posterior or sublingual pocket,
CONTRADICTATED if oral surgery, unconscious
Axillary: place at the center of the axilla
 Rectal: well-lubricated tip, risk of rectal perforation CONTRADICTATED anal surgery, diarrhea,
neutropenia

Blood pressure: upper arm, lower arm, thigh, calf-ankle

4. Head to toe assessment (IAPP)

Skin (inspection)

Cyanosis (bluish), Pallor (paleness, anemia), Erythema (redness, inflammation, hyperthermia), Jaundice
(yellow, bile pigment), Strawberry nervus (reddish papule made of blood vessel, no complication), Petechiae
(reddish purple macules, coughing, bleeding disorders), Purpura (large purple macules, bleeding disorders)

Skin (palpation)

Temperature, moisture, texture, turgor, edema

Moist (perspiration, fever resolution, shock) Skin turgor (dehydration, pinched-up skin remained tented)

Hair and nails

(colour, texture, amounts, quality) (nutritional deficiency, dry, brittle nails) (clubbing, hypoxemia)

Airway, breathing, circulation (patency, respiratory distress, refill, temp)

Head (inspection)

Look down on it from above, (molding, vaginal deliveries) (Caput Succedaneum, birth trauma, resolved few
days) (head control, hold head erect in midline)

Head (palpation)
Gently palpate the fontanel lymph nodes with fingertips and (closed by 9-18 months) (soft and flat)
(dehydration, sunken)

Neck (inspection)

Symmetry, (Turner syndrome, excessive neck skin fold) (Meningeal irritation, pain or resistance to range of
motion)

Eyes (inspection)

Symmetry, spacing, free of discharge, PERRLA(pupils, equal, round, reactive, light, accommodation),
extraocular muscle motility, ophthalmoscope

Ears

Inspection (Symmetry, ear alignment (top of the pinna meet or across this line), (low set ears, renal
abnormities or cognitive impairment), secretion, Otoscopic examination (the end of the physical
assessment))

Mouth and throat

Inspection ((tonsil, uvula, oropharynx) (colour, symmetry, absence of inflammation))

Nose (symmetry, nasal flaring, secretion)

Thorax and lungs

Inspection (Size, shape, ratio, symmetry nasal flaring, subcostal/ intercostal retraction

Palpation and percussion (symmetric respiratory excursion, tactile fremitus with fingertips)

Auscultation (clear breath sound)

Heart and peripheral perfusion

Inspection (Pallor, cyanosis, mottling, edema, clubbing fingers

Palpation (apical pulse, radical pulse, capillary refill time)

Auscultation (S1, S2, extra sound, heart murmur)

Abdomen

Inspection (rounded but not be distended) (newborn ‘umbilicus: colour, bleeding, odor, drainage, hernia,
normally dry, black and hard)

Auscultation (normal active, hypoactive, hyperactive or absent)

Percussion (Dullness, tympany)

Palpation (Soft and non-tender)

Anus

Inspection (rash, haemorrhoid, prolapse or skin tags, diaper dermatitis, imperforate anus)

Musculoskeletal

Inspection (posture, symmetry of limbs, movement, presence of scoliosis, club foot)

Palpation (clavicles)

PAIN ASSESSMENT

Responses to pain

1. Newborn and young infant

Crying, facial appearance of pain, generalized body responses of rigidity or thrashing, physical struggle
2. Young child
Crying, screaming, thrashing of arms and limbs, push away, beg
3. School-age child
Time-waiting behavior, muscular rigidity
4. Adolescent
More verbal expression, increased muscle tension

Methods

1. FLACC Behavioral pain scale (infancy to 4 yr)

Face, legs, activity, cry, consolability (0,1,2) (0-10@)
2. Wong-Baker FACES Pain Rating scale (>4 yr)
Self-rating, smiling face for no pain, tearful face for worst pain
3. Visual Analog Scale (VAS) (>7 yr)
Line with 5 marks
SPECIEMEN COLLECTION

Urine (UTI, renal disorders)

1. Urine collection bags (wash and dry genitalia, attach to the perineum, firmly apply, diaper)
2. Clean-catch specimen (soap to clean from front to back/ tip, midstream urine)
3. Suprapubic aspiration (sterile, when bladder cannot be accessed through urethra)
4. Urine catheterization (sterile, urgently needed only)

Stool (parasite and other organism, occult blood)

Blood Specimen (venipuncture, aspiration) (capillary blood sample, heel stick)

Nasopharyngeal Aspiration (respiratory infection, suction catheter, sputum trap)

Lecture 5.2 Benefits of play and play therapy

Classification

Associative play (play together but no organization)

Cooperative play (group play, plan activities)

Dramatic or pretend play (acting out events of daily life)

Social-affective play (pleasure in relationships with people)

Sense-pleasure play (non-social stimulating)

Skill play (ability to grasp and manipulate)

Solitary play (play alone with toys different than others in the same area)

Unoccupied behavior (focusing their attention momentarily e.g. Daydreaming)

Unoccupied play (not playimg but watching anything to happen)

Games (peek-a-boo, cards, London bridge)

Onlooker play (watch other play, no attempt to enter)

Parallel play (play independently, similar toys, no group association)

Functions of play
1. Intellectual development (problem-solving skills by puzzles, understanding of abstract concepts, spatial
relationship, color, sizes, shapes, textures, objects, numbers
2. Socialization (establish social relationship, solve social problem, responsibility)
3. Creativity
4. Self-awareness (self-identify, ability, effects of behavior)
5. Therapeutic value (express emotion, undergo fearful situations)
6. Morality (accepted codes, core value)

Therapeutic play

Emotional outlet play (talking to puppet, throwing bean bags)

Physiologically enhancing play (enhance physical health, blowing bubbles)

 Therapeutic power of play to prevent or resolve physiological difficulties and achieve optimal growth
and development

Play therapy (directive/ non-directive)

(Sand tray, telling stories, making art, imaginative play, dancing, making music, using toys)

Lecture 6 Nursing Care for Common Neonates Disorders (Down’s syndrome, cerebral palsy, hydrocephalus)

Down’s syndrome
1. Causes (extra chromosome 21, advanced maternal age >35)
2. Clinical features: small nose, depressed nasal bridge, short statue, transverse palmar crease, intellectual
disability, learning difficulties, excess and lax skin, short and broad neck
3. Investigation & diagnosis: Prenatal screening test (ultrasound at 1st trimester for nuchal translucency
fluid behind the baby’s neck) Chorionic villus sampling (material from placenta) Amniocentesis
(amniotic fluid)
4. Physical problems: Congenital heart malformations, Respiratory tract infection (hypotonicity of chest
and abdominal muscles, dysfunction of immune system, Hearing and vision impairment, constipation,
gag on food, developmental delay, thyroid dysfunction (congenital hypothyroidism), Leukaemia
5. Therapeutic management: Lifelong, symptomatic and support care (surgery for heart defects),
Echocardiogram (cardiac defects), Vision and hearing screening(impairment), Thyroid hormone level
6. Nursing intervention
Regular exercise, prevent complication, prevent respiratory infections (clean the nose with a bulb-type
syringe, rinse the mouth after feeding, increase fluid intake, hand hygiene, small and frequent me,
increase fiber and fluid intake)

Cerebral Palsy (nonprogressive neurological disorders that affect movement and muscle tone or posture)

 abnormal brain development or damage=> abnormal body movement and muscle coordination
1. Causes: before, during or shortly after birth, gene mutation, damage to the white matter (transmission of
signal), intracranial haemorrphage (blood supply), Asphyxia (lack of oxygen supply, destroy tissues),
brain infection, head trauma, choking or drowning
2. Risk factors: premature birth, multiple births, infection during pregnancy (cytomegalovirus, rubella),
jaundice and kernicterus, Rh incompatibility, mother with thyroid abnormalities, birth complication
(detachment of placenta)
3. Diagnostic tests: Computed tomography (CT), Magnetic resonance imaging (MRI), Cranial ultrasound,
Electroencephalogram (EEG), Neuromotor tests, genetic and metabolic tests, developmental monitoring
and screening, GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM

Types of cerebral palsy

1. Spastic cerebral palsy (affect the motor cortex, poor control of posture, balance, and coordinated motion,
impairment of fine and gross motor skills)
- Spastic hemiplegia (affects one side of the body, walks on tip toe, normal intelligence)
- Spastic diplegia (affects symmetrical parts of the body, legs or arm)
- Spastic quadriplegia (widespread damage to the brain, affects all extremities, frequent hard to control
seizures, intellectual disability)
2. Dyskinetic cerebral palsy (affect basal ganglia, hearing impairment and dysarthria)
3. Ataxic cerebral palsy (affects the cerebellum, balance and depth perception, poor coordination and walk
unsteadily
4. Mixed cerebral palsy (affects multiple areas of the brain, no dominant motor pattern)

Therapeutic management

 Establish locomotion, communication and self-help skills

 Optimal appearance and integration of motor function
 Correct associated defects as early and effective
 Provide educational opportunities adapted to the child’s capabilities
 Promote socialization experiences
1. Surgical management
Orthopedic surgery (severe spasticity and stiffness)
1. Achilles tendon lengthening (increase the ankle range of motion
2. Hamstring release (correct knee flexion contractures)
3. Selective dorsal rhizotomy SDR (cutting the afferent nerves contributed to spasticity)
4. Spinal fusion for scoliosis (correct hip or spine deformities)
2. Orthotic devices (compensate for muscle imbalance and increased independent mobility)
1. Ankle (foot orthoses) -reduce deformity, inc. the energy deficiency of gait, control alignment
2. Adaptive seating device (more comfortable and to perform daily functions
3. Standing aids (promote body symmetry, circulation to the lower extremities, muscle endurance)
4. Walkers, wheelchairs
3. Pharmacological management
Benzodiazepines, Baclofen, Botulinum toxin injection (control spasticity), Dantrolene (muscle relaxant),
Antiepileptic drugs (Tegretol, Epilim)
4. Physiotherapy, occupational therapy, speech therapy, Dietitian, Clinical psychologist
5. Nursing care management
1. Provide adequate nutrition
-high calories diet (feeding difficulties due to hypotonia, spasticity)
-small amounts of soft foods (prevent aspirations)
-large and padded utensils
-ensure adequate fluid (cant express themselves)
-+/- gastrostomy or NG tube
-adequate fiber
2. Maintain skin integrity
-protect bony prominences from skin breakdown (pressure injury)
-monitor splints and braces for proper fits, any redness
 -remove braces until the skin is healed
3. Promote growth and development
-positive self-image
-audio or visual activities for quadriplegic
-adaptive and assistive technology

Nursing diagnosis

Nutrition, Imbalanced: Less than Body Requirements

Monitor height and weight and plot on a growth grid

Rationale: Assess and monitor the growth

Perform hydration status assessment

Rationale: Insufficient intake can lead to impaired growth and dehydration

Teach the family techniques to promote caloric and nutrient intake

 Position the child upright for feedings

 Place foods far back in the mouth to overcome tongue thrust
 Use soft and blended foods. Allow extra time for chewing and swallowing
 Obtain adaptive handles for utensils and encourage self-feeding skills

Rationale: Special techniques can facilitate food intake. Adaptive handles may help the child better manage
self feeding

Perform frequent respiratory assessments. Teach the family the preceding techniques to prevent aspiration.
Teach care of the gastrostomy and tube-feeding technique as appropriate

Rationale: Aspiration pneumonia is a risk for the child with poor swallowing coordination. Special feeding
techniques or tube feeding may be needed

Mobility: Physical, Impaired

Perform development assessment and record age at which milestones are achieved.

Rationale: Delayed development milestones are common with CP. As one milestone is achieved,

interventions are revised to focus on the next skill.

Plan activities to use gross and fine motor skills. Allow time for the child to complete activities.
Rationale: Many activities of daily living and play activities promote physical development. The child may
perform tasks more slowly than most children.

Perform range-of-motion exercises every 4 hours for the child unable to move body parts. Position the child
to promote tendon stretching.

Rationale: Exercises and positioning promote mobility and increased circulation and decrease the risk of
contractures.

Arrange for and encourage parents to keep appointments with a rehabilitation therapist.

Rationale: A regular and frequently reevaluated rehabilitation program assisting and promoting

development.

Teach the family to use braces and other positioning devices.

Rationale: Adaptive devices are often necessary to maximize physical mobility.

Hydrocephalus

Cerebral ventricular system (4 ventricles) 2 lateral within the cerebral hemispheres, third ventricles lays in
the midline within in thalamus, fourth ventricles lays midline of the brainstem and cerebellum

1. Causes: imbalance production and absorption of cerebral spinal fluid (CSF), congenital/acquired

 ventriculomegaly (accumulation of CSF)

 compress the brain subtances
 enlargement of the skull, Inc. intracranial pressure (ICP)
 permanent damage

2. Types (nonobstructive, block after existing the ventricles VS obstructive, block along the passages)
3. Signs and symptoms (before the closure of cranial sutures) (Sunsetting eyes, apnea spells, high-pitched
cry, difficulty swallowing or feeding, vomiting, seizures, sluggish pupils, unequal response to light,
cardiopulmonary depression)
4. Signs and symptoms (after closure) (no head enlargement, headache, vomiting, sleepiness, apathy,
lethargy, blurred vision, photophobia, spasticity, poor judgement
5. Diagnostic investigations (CT, MRI, Ultrasonography, Lumbar puncture)

Therapeutic management
 Relieve ventricular pressure
 Ventriculomegaly
 Associated complications
 Treat psychomotor development

1. Shunt (passes the CSF to peritoneal cavity, right atrium, pleural spaces of the lungs) eg,
ventriculoperitoneal shunt (ventricular catheter, pumping chamber reservoir, one-way pressure valve,
distal catheter)

Complication: shunt blockage of blood cells, tissure, bacteria, shunt infection (+external ventricular
drain EVD), not the best positioning, haemorrphage, leakage, overshunt or undershunt)

2. Endoscopic third ventriculostomy (ETV)

- Hole on the bottom third ventricles, for obstructive hydrocephalus

- + choroid plexus catheterization

3. Pre-op, Post-op care

*position on the unoperated side (prevent pressure on the shunt valve)

*flat position (prevent rapid CSF drainage)

*vital signs (Inc ICP: shallow breathing, rapid changes in BP)

*monitor neurological signs (inc ICP, extraocular movements, changes in muscle tone, pupil size to
light)

*head circumference (bulging fontanelles, accumulation of fluid)

*shunt malfunction (obstruction, leakage?)

*infection (poor appetite, responsiveness, sleep pattern low-grade fever)

Newborn disorders (congenital heart defects, Phimosis)

Congenital heart defect

Fetal circulation (three shunts)

1. Ductus arteriosus (pulmonary artery to aorta) (oxygenated blood, prevent circulation overload in
lungs, strengthen right ventricle)
2. Ductus venosus (umbilical vein to the inferior vena cava, oxygenated blood)
3. Foramen ovale (right atrium to left atrium) (blood flow to coronary arteries and cerebral), closes at
birth

Steps

1. Blood from placenta travels through umbilical vein to the fetus

2. Blood enters portal and hepatic circulation of the liver, then inferior vena cava. OR. Directly to IVC
by ductus venosus.
3. Blood enters the right atrium and then left atrium via patent foramen ovale then left ventricles and
out of the aorta.
4. Deoxygenated blood from head and extremities travels to the right atrium and ventricle.
5. Blood leaves the right ventricles through ductus arteriosus bypassing the lungs, or pumps through the
pulmonary artery to lung.
6. Blood travels to the lower extremities, leave the fetus through the umbilical arteries and enter the
placenta,

After first breath, lung expands, Pressure in left atrium > right atrium, Foramen ovale closes,
Increases oxygen concentration in blood, ductus arteriosus closes
Classification of Congenital Heart Defects (haemodynamic)

Acyanotic defect

-increase pulmonary blood flow e.g. Atrial septal defects, Ventricular septal defects, Patent ductus arteriosus

-obstructive blood flow e.g. Aortic stenosis (blockage), Coarctation of the aorta (narrowing)

Cyanotic defects

-decreased pulmonary blood flow e.g. Tetralogy of Fallot

-mixed blood flow e.g. transposition of the great vessels

Atrial septal defects (ASD)

-abnormal opening in the septum between left and right atria (just a hole not foramen ovale)

-blood flow from left atrium into right atrium (L>R), increase pulmonary blood flow

The failure of the foramen ovale to close is a separate issue that can predispose someone to developing an
ASD, but the ASD itself is a distinct anatomical abnormality.
Ventricular septal defects (VSD)

- abnormal opening in the septum between left and right ventricles

- increase pulmonary blood flow, right ventricle hypertrophy, pulmonary venous congestion, ineffective
ventilation

Complication of ASD, VSD

Right atrial ad ventricular hypertrophy (cardiomegaly), pulmonary hypertension, heart failure

Clinical manifestation (signs and symptoms)

Systolic murmur, tachypnoea, fatigue, failure to thrive (no weight gain or grow), recurrent respiratory
infections

Management of ASD, VSD

1. Monitor weight gain (systemic venous congestion) (blood build

2.
3. up in vein, vein distended, engorged)
4. Monitor signs of respiratory infections
5. Cardiac catheterization (percutaneous occlude devices) (closing the defects)
6. Open heart surgery (stitch, patch closure, closing defects)

Complications (atrial arrythmias, ventricular arrythmias, heart block, residual shunt, leaking patch)

Medication of ASD, VSD

 For pulmonary hypertension, congestive heart failure

1. Digoxin

- Inotropic (more intracellular calcium, improve heart contractility and filling)

- Improve myocardial relaxation
- Monitor 1-minute apical pulse before administration
- Withhold if <70bpm in child, <90bpm in infant
- (fibrillation= inc heart rate) (heart failure= dec heart rate)
- Leading to bradycardia, cardiac arrhythmias
2. ACE inhibitor (treat CHF, systemic afterload) e.g. Captopril, Enalapril (pril)
3. Diuretics (relive edema) e.g. Furosemide (lasix)

Patent Ductus Arteriosus (PDA) (cyanotic)

 Failure of the fetal ductus arteriosus to close (vessels connect aorta, pulmonary artery) (carry blood away
from lung to body)
 Systemic pressure >pulmonary pressure
 Blood from aorta to pulmonary artery
 Abnormal* lungs to left atrium and left ventricle
 Burden pulmonary circulation
 Increase right ventricular pressure and hypertrophy
 Congestive heart failure

Management

1. Indomethacin, ibuprofen to facilitate closure of the ductus arteriosus

2. Percutaneous occlude devices (closing the defects)
3. Ligation of the ductus by left thoracotomy

Complications (endocarditis, pulmonary hypertension, congestive heart failure)

Tetralogy of Fallot (TOF) (cyanotic)

Stenosis of the pulmonary artery + right ventricle hypertrophy + ventricular septal defects + dextroposition
of the aorta (normal aorta connect left ventricles and left pulmonary artery, abnormal to the right PA)

 The VSD allows deoxygenated blood to flow from the right ventricle to the left ventricle and the
aorta, resulting in a right-to-left shunt and cyanosis (bluish discoloration of the skin and mucous
membranes).
 The pulmonary outflow tract obstruction impedes the flow of blood from the right ventricle to the
lungs, causing the right ventricle to work harder to pump blood.
 The overriding aorta (midline) (absorb blood from both left and right ventricle) allows deoxygenated
blood to be pumped directly into the systemic circulation, further contributing to the cyanosis.

Clinical manifestation (cyanosis, clubbing finger, murmur, feeding problem, tet spell, failure to thrive)

Hyper cyanotic episodes (decrease pulmonary blood flow, more right to left shunt, more cyanosis, increase
return of unoxygenated blood, low arterial saturation) = Acute demand for air
Management of TOF

 Increase pulmonary blood flow, venous return to the right heart

Places in a knee-chest position

• ↑venous return to the right heart and ↑ systemic vascular resistance

Administer high flow oxygen via mask

• Act as pulmonary vasodilator and a systemic vasoconstrictor

Use comforting and calm approach (Avoid exacerbating distress)

Correct any underlying cause/secondary problems

Administer Morphine (subcutaneously, or through an existing IV line)

Calm the child down, ↓ tachypnea and ↓ pulmonary vascular resistance

Continuous ECG, BP, oxygen saturation monitoring (Closely monitor patient condition to provide
immediate treatment if condition deteriorate)

Administer intravenous fluids, e.g., 0.9% NaCl 10ml/kg

• Correct potential hypovolaemia, ↑ circulating volume and pulmonary blood flow

Administer Beta blocker

• ↓ right ventricular infundibular spasm, ↑ pulmonary blood flow

Administer sodium bicarbonate

• Correct metabolic acidosis

Administer phenylephrine

• Stimulate of peripheral alpha-adrenergic receptors → ↑ the systemic vascular resistance

Diagnostic (Murmur, Chest Xray heart size and shape, echocardiogram

Surgery (palliative shunt, tube graft between aorta and PA) (complete repair, closure of VSD, resection of
infundibular stenosis, placement of pericardial patch) 後者一歲做

Nursing intervention (weight gain, preserve energy)

1. Monitor growth pattern

Infants with congenital heart disease and CHF gain weight slowly
2. Encourage small and frequent milk
Infant with congenital heart defects often develop SOB during feeding, consume small meals spend less
 energy.
3. Use soft nipples
Difficult on normal nipples, softer one takes up less energy
4. High-calories formula
They require more calories, provide calories efficiently and maintain constant weight gain
5. NG tube feeding if infant have intolerance of oral feeding
Reduce energy expenditure more weight gain

Prepuce (the fold of skin cover the glans, protect from abrasion)

Phimosis 包莖 the foreskin over the glans cannot be retracted

1. Physiological phimosis (prepuce cannot be retracted) (sperate gradually)

2. Pathological phimosis
Caused by BXO, chronic progressive inflammatory
Balanitis (chronic inflammation of the glans penis)
Xerotica (abnormally dry appearance of the lesion)
Obliterans (occasional endarteritis)
= stenosis scarring and pallor of the preputial opening
(long prepuce, ballooning during urination, weakened urinary stream, pain, redness, itching, swelling)
3. Paraphimosis (emergencies) (the prepuce have been left retracted)
- Painful, swollen glans, inability to pull the foreskin back, decreased urinary system
+reinforcement of proper preputial hygiene, avoid strong soap, always bring the foreskin back
+soften inflammatory thickening to prevent retraction
+gentle manual retraction
+circumcisions (removal of the foreskin) (not for hypospadias, penile curvature, buried penis, webbed
penis)
Post-operation care
Access penile wound
 Record first void
Wound dressing with NS after diaper changes
Apply diaper loosely, avoid tight clothing to prevent friction and pressure
Pain management
Educate patients to report any bleeding, unusual swelling, absence of voiding

Lecture 7

Prematurity

Moderate to late preterm = 32-37 weeks

Very preterm = 28-32 weeks

Extremely preterm = <28 weeks

Low birth weight = <2500g

Very low birth weight =<1500g

Extremely low birth weight =<1000g

Major health problems

1. Respiratory problems
- respiratory distress syndrome, immature lung development, low lug compliance
=> atelectasis, alveolar collapse, hypoxia and acidosis

2. Cardiovascular problem

- PDA, low BP

3. Thermoregulation problems

- heat loss, little fat, thinner skin

4. Gastrointestinal problems

- risk of aspiration, necrotizing enterocolitis, growth delay

5. Neurological problem

- intraventricular haemorrphage, hydrocephalus

6. Retinopathy of prematurity (ROP)

7. Infection (bacterial sepsis, fungal infection, viral infection)

8. Feeding difficulties (high nutritional needs, poor coordination of sucking and swallowing)

Jaundice

Causes: Accumulation of bile pigments and excessive amount of bilirubin in the blood

Classification of jaundice

1. Physiological jaundice
First 24 hours
Causes: increase RBC destruction, immature liver function, reduced intestinal motility
2. Pathological jaundice (infection, excessive hemolysis of RBC, metabolic disorder, blood
incompatibilities)
3. Breastfeeding jaundice (reduced intake of breastmilk, reduced passage of meconium)
4. Breastmilk jaundice (decrease excretion of bilirubin)
 Kernicterus

Investigation and diagnosis

Blood test through heel stick, Coombs test for testing hemolytic disease, Transcutaneous bilirubin
measurement at forehead and sternum

Therapeutic management

Phototherapy to oxidized bilirubin, increase feeding for intestinal motility and bacterial flora,

Blood exchange transfusion for severe hyperbilirubinemia

Nursing care

Provide eye shield, ensure closed eyes, only with nappy during phototherapy
Monitor temperature, monitor intake and outout

Blood glucose level, skin condition vital signs for blood transfusion

Cleft lips and cleft palate

Unilateral/ bilateral, Complete/incomplete

 Feeding difficulties, altered dentition, delay speech development, otitis media

Nursing care management

1. Imbalanced nutrition (CLEFT LIP NIPPLE, parent involvement in care

2. Risk aspiration (upright for feedings, burping, suction)
3. Impaired verbal communication

Hypertrophic pyloric stenosis

Hypertrophied circular muscle of the pylorus and obstruct the pyloric canal (stomach and small intestine)

-olive-shaped mass, gastric peristalsis, projectile vomiting

Intussusception

Intestine slip into an adjacent part oof it => intestinal obstruction

Abdominal pain, red mucoid jelly-liked stool, fever

+NG tube for decompression, NPO, IO

Hypospadias (below) / epispadias (dorsal surface)

Post-op

Urine drainage, pain scale, care for indwelling catheter, double diaper, abnormalities like bleeding, redness,
vomiting

Hydrocele

Painless collection of peritoneal fluid between parietal and visceral layers

Non-communicating/ communicating

=transillumination

Varicocele

Dilation of the pampiniform venous plexus

Laparoscopic varicocelectomy, percutaneous embolization

Lecture 8

Croup (laryngotracheobronchitis)

Clinical manifestations:

inspiratory stridor, cough, hoarseness, barking cough, inflammation in the larynx and subglottic, airway
narrowing progress (mild tachypnea, prolonged inspiratory, severe respiratory distress)

Croup score

Cyanosis, stridor, air entry, retractions, level of consciousness

Nursing care airway

Maintain patent airway

1. Position with airway open or elevate head of bed (allow for adequate ventilation)
2. Administer humidified oxygen and ensure adequate fluid intake (liquefy secretions to facilitate the
clearance)
3. Perform prn suctioning, especially before feeding (promote airway clearance)
4. Avoid oral feeding if tachypneic (prevent aspiration)
Nursing education on home care
1. Educate parents about signs and symptoms of respiratory distress (monitor and allow early recognition
of worsening symptoms)
2. Educate parents to expose the child to humidified air to relieve coughing (liquefy secretion to facilitate
the clearance)
3. Keep the child calm and discourage crying (minimize distress)
4. Enough rest and fluid intake (help body to fight with the infection)
5. Close monitor the child, seek for medical advice if the child (e.g., presents with breathing difficulty,
becomes cyanotic, increase irritability or becomes confused) educate the red flag of deterioration

Kawasaki disease e
Inflammation of medium-sized blood vessels
High fever+ Last 5 days + rashes
Gastroenteritis
Inflammation of the stomach and intestines

Gastroesophageal reflux (GER) disease

Febrile seizures

Risk factors (high fever, viral infections, family history)

Therapeutic management

Stabilization of ABCs (airway, breathing, circulation)

Treat underlying cause (source of infection)

Medication (IV, rectal diazepam) (Panadol, ibuprofen)

Fever management

-encourage fluid intake to prevent dehydration

-relieve discomfort

-antipyretic drugs

-remove excessive dress

-place ice bag

-tepid tub bath and sponging

Lecture 9

Club foot

Causes: abnormal positioning, embryonic development, neurological disorders, genetic factor

Common types rus inner, gus outer

1. Talipes varus (inversion)

2. Talipes valgus (reversion)
3. Talipes equinus (plantar flexion)
4. Talipes calcaneus (Dorsiflexion)

Classification

1. Congenital

Idiopathic

Wide range of rigidity and prognosis

Can be detected in utero by USG

Requires surgical intervention(bone abnormality)

2. Positional (transitional, mild or postural)

Occurs from a deformed position in utero

May correct spontaneously or require passive exercise

No bony abnormality

3. Syndromic(teratologic)

Associates with other congenital anomalies

Mores evere form

Requires surgical correction

Ponseti method

1. Manipulation and stretching of tissues

2. Series casting

3 weeks + bracing program

Nursing care management

Neurovascular chart (color, temperature, capillary refill, edema, skin integrity, sensation, movement)

Keep the cast clean and dry

Expose the top of the toes

Check circulation every 30 mins for the first 2 hours, every 2 hours in the first day

Developmental dysplasia of the hip (DDH)

Neurotically intact/ neuromuscular defect

Classification

1. Acetabular dysplasia
2. Hip subluxation (incomplete dislocation)
3. Dislocation (no contact)

Causes: genetic, hormonal, intrauterine malposition, postnatal

Test: Barlow test, ortolani test

Surgery: Open or close reduction,

L9
SCOLIOSIS (progression of the curvature)

Idiopathic scoliosis

Clinical manifestation

-Asymmetry of shoulder and hip height, scapular or flank shape:

-Adams test (Asking patient to bend forward, look the asymmetry of the back )

-Vertebral rotation and posterior displacement of the ribs

-scoliometer to measure truncal rotation

-Neurologic (pain, hairy patches, abnormal reflexes, bowel or bladder incontienece)

Complications

-breathing, back problems, appearance

History taking

1. When start
2. Rate of progression
3. Associated pain
4. SOB
5. Symptoms of neuromuscular etiology
6. Girl, menarche occur
7. History of leg fracture

Braces adverse effects

Adverse effects

psychosocial effects

skin irritation

disturbed sleep

restriction of physical and recreational activities

difficulty finding clothes that fit properly

Spinal Bifida
CS 2 forms
I Spina bifida occulta (hidden)
6. In the lumbosacral area
7. Normal nerves development
® Spina bifida cystica (sac or cyst)
• Meningocele (membrane + tumor, spinal fluid)
• Myelomeningocele: membrane & spinal nerves form a sac → expose
03 DiagnosisI Fetal ultrasound
10 Blood test
I Amniocentesis
I Hairy patch of skin
∞ Radiological imaging (MRI, ultrasound, CT, X-ray)
cs Nursing management
∞ Prone position
® Monitor size, area of the sac, leakage of cerebrospinal fluid I Assess the extremities for deformity &
movement
® Cover the sac with moist sterile dressings of NS & antimicrobial solution
® Head circumference & fontanels, signs of tension or bulging
10 Assess vital signs & signs of infection
10 Assess bladder distension
10 General post-op care & signs of leakage of CSF, ROM exercises
∞ Keep the diaper away from the incision site

Obstetrics

5P affecting labour process

1. Passage
2. Passenger (fetal size)
3. Power (uterine contractions, maternal pushing)
4. Psyche
5. Position

Stages of labour

1. Effacement and dilation stage

Latent phase(0-3cm), Active phase(4-7cm), Transition phase(8-10)
2. Expulsion stage (full dilated, expulsive contraction, +-episiotomy, cord clamping 2 arteries 1 vein, cord
blood for screening)
3. Placental stage (placental separation, placental expulsion, Haemostasis) (controlled cord traction, fundal
massage, examination of placenta,2 layers of membrane + cotyledons, blood loss for PPH)
4. 4th stage first hour after the delivery of placenta, observe perineal tear (level 3 external anal and sphincter
complex, level 4 internal anal and mucosa)

Puerperium (begins after the delivery of the placenta>6 months>pre-pregnant state)

1. endocrine system

--oestrogen, progesterone

++oxytoxin (contractions of uterus, ejection of milk)

-/+prolactin (elevated in lactating women, decline if don’t)

throid gland recesses, basal metabolic rate

2. Reproductive system

a. Involution of the uterus (uterus return to their pre-gravid size and condition)

1. Contraction ->afterpains (acute in multiparous and breastfeeding) (oral analgesics)

2. Catabolism->autolysis (enzyme to breakdown protein in uterine muscle cells)

3. Regeneration->uterine epithelium shed=lochia discharge

Measurement

1. Fundal height
return to umbilical level after delivery, descends 1cm/day, day3 (2-3 fingerbreadths below umbilicus), 2
weeks fundus cannot be palpate
2. Size of the placental site
Gradually cover by endometrium
3. Cervical changes (os size)
Permanently change, slit os of the multipara (end of 6 weeks)
4. Lochia
RBC, WBC, Fibrin, degenerate decidua
Change pad every 3 hours
10 days to 3 weeks, should stop at 6 weeks, Lighter amount and color by days, stop=cervix closed
Locia Rubra D1-4, Lochia Serosa D5-9, Lochia Alba D10 紅橙黃
Abnormal: increase amount that need to change pads every hour, blood clots, bright red after 4 weeks,
foul smelling
5. Vaginal changes
6-8 weeks to recover, decrease in size gradually
6. Perineum and pelvic floor =>pelvic relaxation
Pelvic floor restoring the tone up to 6 months, Kegel exercise
3. Breasts (size, contour, asymmetry, engorgement)

day1-2: soft day3: warm and firm, milk comes in day4-5:engorgement, hard, tense
2. Cardiovascular system
Cardiac output: remains high at the first few days, 6-12 weeks gradually declines
Blood volume: decline rapidly in 2 weeks = edema
BP and Pulse: slight increase in BP, *pre-eclampsia, puerperal bradycardia, *hypovolemia
Blood cellular component; increase haemoglobin
3. Urinary system
12 hours, excrete excess fluid, diuresis during day2-3
4. Musculo-skeletal system
Decrease relaxin, ostrogen, progesterone = return to prepregnant position
Loss in muscle tone and separation of the longitudinal muscles of the andomen
+early ambulation and postnatal exercises
5. Integumentary system
Increase perspiration (eliminate excess fluid and waste)
Decrease melanocyte-stimulating hormone (fading linea nigra and chloasma, silvery or whitening of
striae gravidarum)
Loose skin over abdomen
Excessive hair loss, recover after 6 months
6. Gastro-intestinal system (Quickly return, no more heart burn)
7. Respiratory system (Decrease pressure, easier respirations)
8. Body weight (decrease 4-6 kg immediately, 2 kg loss in early postpartum)
Immediate post-partum care

BUBBLE-EE (breasts, uterus, bladder, bowel, lochia, episiotomy, extremities, emotional status)
*infection, Deep vein thrombosis, Post partum haemorrphage, hematoma, wound gapping, dysuria, SOB,
UTI, pulmonary embolism, mood swings

1. Promote rest and sleep

2. Promotion. Of uterine involution (prone position, uterine massage)
3. Bladder care (positioning, fluid intake, stimulation, urinary retention, cath)
4. Wound care (vulvar swabbing and rinsing, change pad, abnormal: potassium permanganate, lamp
treatment, avoid tub bath, sexual activity, remove suture if needed)
5. Care of the breasts
Cold compress, analgesics
6. Pain management fur afterpains, breast engorgement
7. Nutritional and hydration extra 500 kcal, folate, iodine, zinc, vitamin A, DHA) (avoid Chinese herb,
promote blood circulation, cold or irritating food)
8. Bowel care *constipation (fear of defecation, wound pain, hemorrhoid, narcotic analgesic, iron
replacement, reduce mobility) (fluid intake, laxatives, analgesic)
9. Early ambulation and postnatal exercise (better drainage of lochia, dec. retention, dec. venous
thrombosis, involution of uterus, low back pain, restoration of body shape)
10. Psychological care
Maternal-child relationships, signs of postnatal depression \
Edinburgh postnatal depression scale (EPDS) 9-13 abnormal

Puerperal Infections (UTI/ Puerperal sepsis)

o Obstetric interventions
o Poor hygiene
o Underlying conditions
o Cesarean section delivery, laceration of lower genital tract
 Management:
o Antibiotics
o Supportive care
o Prevention of complications
 Prevention:
o Aseptic technique
o Active management
o Patient education
Lecture 7 Newborn care

Transition and physiology adaptations of newborn

For respiration, newborn adapt extra uterine life by mechanical, chemical, thermal and sensory stimuli.
Mechanically, fluid are squeezed out by chest compression from lungs through nose and mouth. Chest wall
recoils, creating a negative intra-thoracic pressure and lung expansion.

Chemically, the decline of pHlevel, and partial O2 and CO2 triggers the chemoreceptors and hence
respiratory center.

Thermally, decrease environmental temperature stimulate skin sensors and triggers respiratory center.

For sensory stimuli, tactile, auditory and visual trigger respiratory center.

Immediate care at birth

1. Airway care
-clear the airway by suction, if start breathing, don’t apply, apply on *meconium-stained amniotic fluid
-lateral head down position to facilitate drainage
-stimulate by rubbing the back
-pre-warmed radiant warmer (37)
*Meconium aspiration syndrome (MAS) (dec. respiration, <100 pulse, poor muscle tone)
(suction+NICU)

2. Eye care

-gently wipe the eyelids from inner canthus to outer canthus to remove mucus from vagina

3. Prevention of Hypothermia

-dried immediately from top to bottom and head, wrapped in dry towel, SSC

-delay first bath

-radiant heater, pre warmed incubator, placed away from outlets of air-conditioner

-Conduction, evaporation, convection, radiation

4. Initial assessment

-Apgar scoring (appearance, pulse, grimace, activity, respiration) (0,1,2)

-gestational age assessment

5. Skin-to skin contact SSC

 -uninterrupted, unhurried SSC, immediately following birth

-promote breastfeeding, temperature regulation, bonding

6. Newborn identification

- protect safety, prevent mismatch and abduction

-two for left ankle and wrist

-double check for procedure, mother, handover, avoid too tight or loose

7. Body weight, length, frontal-occipital measurement

8. Vital signs

-apical rate 120-160 bpm, Respiration 30-60 breaths/minute, Rectal temperature 36.5-37.4

-Every 30-60 minutes

9. Physical assessment

-Head (size and shape, excessive moulding, laceration, cephalohaematoma)

-Face (forceps marks, traumatic cyanosis)

-Eyes (slanting eyes, discharge)

-Ears (accessory auricles)

-Mouth (cleft palate or cleft lip)

-Shoulder (fracture clavicle)

-Chest (in-sucking chest, accessory nipples, tachypnoea)

-Abdomen (abdominal distention, mass)

-Cord (bleeding, 2 arteries 1 vein)

-External genitalia (short penis, undescended testis, hydrocele, ambiguous sex)

-Hands and feet (symmetrical, extra digits, webbing, talipes)

-Back (spina-bifida)

-Birthmark, rash, petechia

10. Newborn injection

-1mg of vitamin K prevent haemorrohagic disease

-hepatitis B immunoglobin for carrier mother

 -VASTUS LATERALIS

11. Blood glucose monitoring

-prevent hypoglycemia

-heel stick

->2.6 mmol/l

12. Record and report

Subsequent care of newborn

1. Hygiene (first bath, >36.5, at least 24 hours)

2. Skin care (vernix caseosa, biofilm, antimicrobial; milia, neonatal acne, 2-3 weeks)
3. Elimination (meconium, meconium+ product of digested milk, metabolic waste) 1, 2-5, 5
*diaper rash (vulva, perineum, buttock)
Lukewarm water, avoid diaper wipes, air dry, moisturizing cream, zinc oxide, don’t use baby powder
4. Observation (jaundice, cyanosis, input and output)
5. Mother-baby bonding (promote rooming-in)
6. Prevention of infection

Newborn Screening

1. Glucose-6-phosphate Dehydrogenase Deficiency (G6PD) (absence of enzyme, unstable RBC)

-early jaundice?, +green card listed avoidance food, avoid self-medication

2. Congenital hypothyroidism

3. Automated auditory brainstem response (AABR) hearing disability

4. Inborn errors of metabolism (IEM)

Breastfeeding

1. Nutrition need (first 6 months recommend breastfeeding)

2. Physiology of lactation
Prolactin is secreted from anterior pituitary gland for milk production. The suckling of the baby and
emptying of the breasts provide stimuli to the hypothalamus, which then stimulates the anterior pituitary
gland to produce more prolactin, thereby continuing milk secretion.
Oxytocin is secreted from posterior pituitary gland.
3. Composition of milk
Protein, lactose, Fat (DHA,AHA, LA, ALA), epidermal growth factors, iron, zinc
+iron, vitamin k, vitamin d
*colostrum (small amount, yellowish, creamy, vitamin A, Growth factor)
4. Benefits: newborn, mother, environment, society

5. Techniques

Latch (infant mouth cover nipple, areola, breast) (seal, create adequate suction)

Open wide mouth, lower lip flanges out, cover all areola, upper part of areola exposed more than lower,
visible baby swallowing, rhythmic, long and slow sucks, no pain, rounded nipples

7. Common problems
1. Sore nipples (incorrect latching, cracked nipples)

Change side, express breastmilk on nipple for healing, stop direct BF, correct latch on

2. Block duct (lump, reddened and warm,*mastitis)

Warm compresses, gentle but firm massage, therapeutic ultrasound

3. Mastitis (blocked milk duct)

Effective milk removal, rest, continue breastfeed, psychological support, antibiotics, incision and drainage

4. Inadequate milk supply

BF more often, breast pump, music, relax, SSC, warm compress, reduce stress, limit alcohol

+cup feeding, breast pump

Obstetric emergencies

Placental abruption, placenta previa, eclampsia, umbilical cord prolapses, shoulder dystopia, rupture of
uterus, inversion of uterus, amniotic fluid embolism, placenta accreta, Postpartum hemorrhage

H--> Help (Call for Help)

E--> Evaluate for episiotomy
L--> Legs (the McRoberts maneuver)

P--> Pressure (Suprapubic Pressure)

E--> Enter maneuvers

R--> Remove the posterior arm
R--> Roll the patient

Pre-eclampsia (hypertension, proteinuria, headaches, blurring vision,

epigastric pain and edema)
 100% O2 for hypoxia
Magnesium sulphate for seizures ; Antidote: Calcium gluconate
Control hypertension with calcium channel blocker like nicardipine
Evaluation of prompt delivery

Postpartum haemorrphage PPH

Causes: Tone, Trauma, Tissue, Thrombin

Risk factors: Multiple pregnancy, fetal macrosomia, grand multipara, PET pre-eclampsia

Severity and management: minor 500-1000ml, major >100ml, severe >2000ml

Management

1. Primary PPH: delivery of placenta, promote uterus contractions, check completeness of placenta
2. Emergency measure protocol
Infuse isotonic crystalloid solution, 1:1:1 packed RBC, Plasma, Platelets, cryoprecipitate
O2 , 14-gauge IV assess X2, blood bank
Monitor temperature every 15 minutes, foley, central line, arterial line
Laboratory test: type and screen, complete blood count, arterial blood gas, clotting profile, renal and
liver function
1. Mechanical measure: gentle fundal massage, bimanual uterine compression
2. Pharmacological measures: uterotonic medications, oxytocic (Oxytocin, Carbetocin), prostaglandin
(Carboprost, Misoprostol), anti-fibrinolytic agent (Tranexamic acid)
3. Surgical measures
Uterine balloon tamponade (maximum insertion for 24 hours)
B-Lynch or uterine compression suture
Bilateral ligation of utero-ovarian arteries
Hysterectomy
4. Complication: anemia, hypovolemic shock, coagulopathy, puerperal sepsis, renal failure, death

Maternal resuscitation

100% oxygen

Chest compression higher on the sternum

>20weeks, no return of spontaneous circulation (ROSC) after 4 minutes of resuscitation, Perimortem

caesarean delivery
Mental L1,2,4

9 Roles and responsibilities of psychiatric nurses

 Assessing client needs and evaluating care
 Collect information of clients through observation, interview and discussion
with informants, caregivers and other nurses.
 Conduct assessment and evaluation of clients with other members of the
health care team
 Planning care
 Share information and discuss about care options of clients within the nursing
team.
 Plan care with other professionals including doctors, occupational therapists,
medical social workers etc.
 Nurse/client caring interactions
 Physical dimension – perform, assist to perform or supervise clients to
performing activities of daily living (ADL) and take care of the physical
wellbeing of the patient such as nutritional needs and health risks.
 Safety dimension – ensure safety of clients through checking on locations of
clients, maintaining vigilance on clients with risk of suicide, and managing
client violence.17
 Social dimension – considers the needs of clients’ families through clarifying
questions and answers, giving support to the relatives.
 Provision of information – explain symptoms to clients’ families, giving
information about medications, encouraging discussion with clients on
activities relating to life skills, occupation and finances.
 Spiritual dimension – pay respect to patient as individual and demonstrates
care about the connectedness with others, the search for a meaning of life and
specific religious needs.
 Providing treatment - provide support to clients through psychotherapy and
counselling, encouraging clients to express themselves through different types
of therapies such as art therapy.
 Promotion of recovery despite the mental illness
 Pharmaceutical interventions
 Co-ordinate pharmaceutical services to their clients, including administering
the medications, ensuring compliance with the prescriptions, being vigilant
about the effects and adverse effects of medication.
 Give education about medications to clients and caregivers.
 Education
 Engage in health education to public about mental health, early signs and
symptoms of mental illness, alcohol/drug misuse and addiction.
 Documenting information
 Document observation and recording the physical, psychological and social
status of clients.
 Coordinating services of nurses and other professionals for clients
 Match client needs with the services available by referring them to other
specialist services such as counselling, medical social worker etc.
 Communicating with other professionals and other staff
 Share with other health care disciplines on information about clients.
 Administration/organization of the clinical area18
 Have a wide range of managerial duties which involves managing staff of the
ward, clinical environment and clinical activities.
 Provide a therapeutic environment for clients and implementing infection
control measures.

Mental Status Assessment

appearance, behavior, mood and affect, perception, thoughts, speech, memory, consciousness, orientation,
and insight
Appearance - what a person looks like
 Poor grooming and hygiene provide information on physical ability,
selfconcept and the mood state and indicative of the physical and mental
capacity of taking of self.
 Facial expression, the affect, may convey information about mood.
Decreased facial expression - common in person with schizophrenia and it
can be due to the side effects of psychotropic drugs such as antipsychotic
and benzodiazepine. An expressionless or mask-like face - a typical feature
of Parkinson’s disease and cerebral vascular accident (CVA).
 Posture conveys a patient’s emotional state and attitude. Arms tightly
crossed across the body may be a sign of anxiety or resistance to the
interview. A “kicked back” posture may reflect general comfort with or
indifference to the circumstances. Abrupt changes in posture often indicate
a patient is having an emotional reaction to or at least is uncomfortable with
the topic at hand.
 Scars and wound with healing stages on the wrists may represent previous
self-harm. Different level bruise marks at usual site of body may indicate
the possibility of physical abuse.
 Eye contact may reflect various features of emotional functioning. Limited
eye contact and down turned gaze may reflect depression, anxiety,
awkwardness, or low self-esteem. A glaring may signal hostility.
 Behaviour - how a person acts.
 Mannerisms – appeared odd and repetitive behaviours that are part of a
goaldirected activity that appear to have social purpose, such as repeatedly
using hand to touch one side of head or pushing up three figures while
speaking.
 Compulsions - an extreme form of mannerisms that are stereotyped, often
ritualistic.
 Movements – a change of position, not only indicate a need for
selfregulation of position but also a change in perception.
 Psychomotor retardation - decreased level of motor activity.
 Catatonia - an extreme form of psychomotor retardation. The catatonic
patient will remain immobile for prolonged periods of time despite prompts
or circumstances that will elicit responses in person with other psychiatric
disorders.
 Waxy flexibility - posture can be changed by someone else, but is
maintained in whatever position the patient is left, even if it is odd.
 Tremors - oscillating involuntary movements that occur in a relatively
consistent rhythm, often occurring in distal body parts such as the hands.
That could be indicative a neurological problem.4
 Tics- involuntary movements or vocalisations that range from simple to
complex including blinking, facial grimacing, neck jerks, shoulder
shrugging, and throat clearing.
 Echopraxia – repeating the movement or behaviour of another person.
 Negativism – doing the opposite of what is asked to do and resist to comply.
e.g. sit when told to stand up.
 Mood and affect
 Mood – a person’s subjective report on his/her pervasive feeling that lasts
for some length of time affecting the overall experience of the person.
 Affect – observed physical manifestations of an emotional state of a person,
and usually assessed by observing the patient’s facial expression in
conjunction with nonverbal cues. Congruous affect refers to emotional
expression that matches the person’s description of mood or other verbal
contents. Incongruous affect refers to those expressions not matching with
the reported mood or other verbal contents.
 Labile mood - rapid change in emotional expression.
 Elated or euphoric mood – high and exceptionally positive mood.
 Angry or irritable mood –manifested in antagonism, hostile, confrontation,
and opposition.
 Apprehensive mood - distinguished by worry, dread, and fear.
 Panic - an extreme form of apprehension, usually is accompanied by
pronounced autonomic nervous system symptoms such as palpitations,
hyperventilation, sweating, sometimes chest pains and a sense of going to
die.
 Blunting or flattening of affect – reduced variation of mood.
 Apathy – severe flattening of mood.
 Perception - the process of making sense of what is presented through the sense organs.
 Illusion – a misinterpretation of external stimuli, for example a curtain is
perceived as trees in forest.
 Hallucinations - a perception experienced in the absence of an external
stimulus in the corresponding sensory organ. A localized seizure can cause
a person to have visual, gustatory and tactile hallucination. Tactile
hallucination can occur in those people abusing certain drug,
methamphetamine. Hence, person with visual hallucination should have
excluded the organic cause before coming to the diagnosis of psychosis.
According to the senses, there are five common types of hallucination
i. Auditory hallucination
 In the form of audible noises, music, or voices.
 Voices may be heard clearly or indistinct; the contents can unstructured and structured with specific
contents in forms of words, phrases, or sentences.
 Specific form of auditory hallucination, such as voices arguing, and discussing the person in third person
are suggestive of schizophrenia.
ii. Visual hallucination
For example, a person might see insects crawling on your hand or on the face of someone. Sometimes it
presents as flashes of light.
iii. Olfactory hallucination
 Infrequent and smells are often reported unpleasant iv. Gustatory hallucination
 Infrequent but tastes are often reported unpleasant
v. Tactile hallucination
Sensations of being touched, pricked, or strangled are often reported.
Sometimes felt as movements as below the skin, which a patient may attribute to insects, worms, or other
small creatures burrowing through the skin
 Speech (only speech can reflect thoughts)
 Aphasia - impairment of language because of brain damage.
 Dysarthria - distorted pronunciation because of impaired neuromuscular control of oral–facial muscles.
 Mutism - complete absence of speech.
 Neologism - words or phrases invented by the client, often to describe morbid experience
 Echolalia- Repetition of words of another.
 Pressure of speech- A person who speaks in an incessant manner, so that there is no room for
interruptions
 Incoherent speech- Lack of systematic connection or of organization in the thoughts and may lead to
unintelligible speech.
 Irrelevant speech- inability to respond to the question.
 Thoughts
 Circumstantial – it must be involuntary and it was presented with thought and speech giving excessive
and unnecessary details that may be relevant to a question although an answer is eventually provided.
 Tangentiality - speech that deviates from an answer to a question. The feature is that the first part of
response is relevant but soon deviates from the related subjects. Actually the person is not answering of the
question.
 Flight of ideas – over-productive speech characterised by rapid shifting from one topic to another and
fragmented ideas, giving no space and time for other to response.
 Loose association – lack of logical connections between thoughts and ideas
that renders speech and thought indefinite, vague, diffuse, and unfocused.
 Perseveration – repetition of a single response, idea, or activity; may apply to speech or movement, but
most often verbal.
 Thought blocking – sudden halt in the train of thought or in the middle of a sentence.
 Word salad – series of words that seem totally unrelated.
 Delusions - a belief that is firmly held on inadequate ground, is not affected by rational argument or
evidence to the contrary and is not a conventional belief that the person might be expected to hold given her
educational, cultural and religious background.
o Persecutory delusions - most concerned with persons or organisations that are thought to be trying to
inflict harm on the person, damage his reputation, or plot against him or her.
o Delusions of reference (idea of reference)- these are concerned with the idea that objects, events, or
people, independent of the person, have a personal significance for him or her.
o Grandiose delusions - beliefs of exaggerated self-importance. The person may think oneself is wealthy,
extreme powerful endowed with unusual abilities, or a special person.
o Delusions of guilt - typical themes are that a minor infringement of the law in the past will be discovered
and bring shame upon the person, or that the sinfulness will lead to a payback. o Nihilistic delusions - beliefs
that oneself, a part of one's body, or the real world does not exist, or has been destroyed
o Hypochondriacal delusions - a patient believes, wrongly and in the face
of all medical evidence to the contrary, that he is suffering from a disease.
 Disturbance of memory
 A failure of memory is called amnesia. With reference to time dimension,
immediate memory concerns the retention of information over a short period
measured in minutes. Recent memory Concerns events in the last few days.
Long term (remote) memory concerns events over longer periods of time.
 Confabulation is typically noted on part of the person substitutes the gaps of
memory with self-created information despite no intent to deceive and
patient’s unawareness of the falsehood.
 Déjà vu refers to a false memory or known as paramnesia that the person
has an erroneous feeling of familiarity with a person or a room. Jamais vu,
the opposite of déjà vu, the person feel things totally unfamiliar, instead of
feeling extra familiarized. Impairment of consciousness
 Coma - the most extreme form of impaired consciousness. A person shows
no external evidence of mental activity and little motor activity other than
breathing.
 Clouding of consciousness refers to a state ranging from barely perceptible
impairment to definite drowsiness in which a person reacts incompletely to
stimuli. Attention, concentration, and memory are also impaired to varying
degree and orientation is disturbed. Thinking seems mixed up, and events
may be interpreted inaccurately. It is a defining feature of delirium.
 Stupor is a condition in which a person is totally immobile, mute, and
unresponsive but appears to be fully conscious in that the eyes are usually
open and follow external objects. If the eyes are closed, a person resists
attempts to open them. All the reflexes are normal and resting posture is
maintained, reflecting neurologically intact.
 Confusion is a condition of inability to think clearly, often occurs in the state
of impaired consciousness. However, confusion can also occur when a
person’s consciousness is normal.
 Impairment of orientation – When the person is fully aware of the information
regarding self, others, time and place being in that moment, he or she is fully oriented.
Any impairment in specific aspects such as person, time or space will be referred as
disorientation to specific domain.
 Insight - refers to the awareness of morbid change in oneself and a correct attitude to
this change including, in appropriate cases, a realization that it signifies a mental
disorder.

Clinical Features (schizophrenia)

Positive symptoms
 Delusions – paranoid, grandiose, nihilistic, somatic
 Hallucinations – auditory, visual, olfactory, gustatory, tactile
 Thought disorder – thought broadcasting, thought insertion, thought control
 Disintegrated speech – as a result of thought disorders, speech symptoms like
incoherence, neologism and circumstantiality are often noted.
 Bizarre behaviour – catatonia, deterioration in social behaviour
 Inappropriate affect
Negative symptoms
 Affective flattening – limited range and intensity of emotional expression
 Alogia – poverty of speech
 Avolition – lack of initiation of goal-directed behaviour
 Anhedonia – inability to experience pleasure or maintain social contacts
Attention deficit – inability to focus and sustain attention
Cognitive functioning
 Deteriorated executive functioning - the ability to processing the received information to come up with a
decision
 Attention deficit - Troubled focusing or paying attention to specific issue.
 Limited working memory - difficulty using use information immediately after learning it.

Nursing management
 Assessment
 Personal and family history: mental illness, childhood development
 Presenting signs and symptoms – positive symptoms, negative symptoms,
cognitive symptoms, social/occupational dysfunction
 Support system – family members’ knowledge about the illness, their
understanding the need for medication adherence
 Nursing diagnoses
 Disturbed sensory perception
 Disturbed thought process
 Risk and potential risk for violence: self-directed and other-directed
 Impaired verbal communication
 Impaired social interactions
 Social isolation
 Implementation
Build up relationship
➢ Use a non-judgemental, respectful, and neutral approach
➢ Be patient, show acceptance and use of active listening skills
➢ Be honest and consistent with client regarding expectations and
enforcing rules
 Provide a safe environment
 Provide a calm and tranquil environment
 Keep all potentially dangerous articles in locked cupboards
 Close monitor clients’ behaviour, with special attention to clients who have risks
of violence towards self and others.
 Use physical and chemical restraint if client attacks others or attempts to harm
oneself9
 Manage delusions
 Identify false beliefs about real situations
 Convey acceptance of client’s need for the false belief while letting client know
that you do not share the belief.
 Do not argue with client’s belief or try to correct false beliefs using facts but
understand how patient react to the delusional contents and assess the potential
risks, such as potential violence to self and others.
 Do not touch client; use gestures carefully
 Try to distract client from his/her delusions by engaging in reality-based activities
(e.g. simple arts, playing cards etc.)
 Protect the client and others from delusional behaviours that might prove harmful
 Teach coping skills that minimise “worrying” thoughts such as singing, talking to
a trusted friend, thought-stopping technique
 Manage hallucinations
 Observe and understand the characteristics of hallucinations
 Identify the related anxiety level
 Decrease environmental stimuli when possible to minimise triggering
hallucinations
 Accept the fact that the voices are real to client, but explain that you do not hear
the voices
 Understand how patient react to the contents of hallucination and assess the
potential risks, such as potential violence to self and others.
 Encourage self-monitoring of what makes the voices better or worse
 Work with client to find out which activities help reduce anxiety and distract client
from hallucination such as listening to music, keeping busy, using relaxation
techniques
 Meet nutritional and elimination needs
 Assess if client refuses food and fluid intake due to delusions (e.g. nihilistic
delusions)
 Prepare client‘s favourite food
 Allow relatives to bring food or order pre-packed food for client
 Provide nutrition through naso-gastric tube / IV infusion if refusal of food
continues
 Provide high fibres and ensure fluid intake to prevent constipation
 Bring client to toilet regularly to prevent constipation, and urinary retention
 Regular body weight, and keep an I & O chart
 Maintain personal hygiene and appearance
 Use simple instructions to remind client carrying out personal hygiene during
withdrawn state
 Give adequate time to complete the personal cleansing
 Remind client to observe personal appearance
 Give praise and encouragement if client initiates self-care activities
 Increase social contacts
 Provide social skill training to enhance client’s communication ability and reduce
stress arising from interaction with others
 Start with one-to-one contact, gradually to extend to small groups after client
builds up confidence to contact with other people.10
 Provide support to family
 Identify family’s ability to cope and provide opportunities for family to discuss
feelings related to ill family members
 Provide information on illness and treatment strategies
 Teach family on how to manage client’s positive and negative symptoms
 Educate family on early signs and symptoms of relapse
 Inform family about the drug treatment and the importance of supervising client
to take drugs
 Provide information on community resources after discharge
 Evaluation
 Interact with others appropriately
 Refrain from acting on delusional thinking
 Learn ways to refrain from responding to hallucinations
 Engage in social interactions in goal directed manner

I. Before restraint
a. Assess the client, restraint as the last resort
b. Approach the client in a team
c. Ensure to have sufficient staff available to assist
d. Ensure safety or others around
e. Plan to apply the least restrict
f. Apply reasonable devices (limb holder, safety vest, safety
belt) properly, correctly and safely
II. During restraint
a. Comply with the hospital policy
b. Protect patient’s privacy and dignity
c. Transport client to restraint room
d. Reassure client that restraint will terminate after the client
is calm down and able to control his behaviour
e. Apply padding to prevent skin breakdown. Pay attention to
fragile body parts
f. Client in supine position during restraint6
g. Precaution client’s head and prevent biting
h. Support and reassurance
i. Explain to client on the reasons of restraint
j. Facilitate the position is comfort and prevent aspiration
k. Closely observe client’s mental state
l. Ensure the circulation of extremities (check temperature,
colour, pulse) and check regularly
m. Vital signs should be checked and monitored
n. Ensure client’s basic needs including nutrition, hydration,
and elimination
III. Terminating restraint
a. Remove client from seclusion or restraints as soon as they
meet the criteria for release
b. Explain the reason of restraint and reassure the client.
c. Conduct debriefing: provides staff and clients with an
opportunity to clarify the rationale for the seclusion/
restraint, offer mutual feedback, and identify alternative
methods of coping that might help the client avoid
seclusion/restraint in future
d. Record the restraint properly (legal considerations)
(1) Complete restraint forms
(2) Nursing documentation
e. Encourage client to continue with ward routine activities,
for outside ward activities
f. Ensure client safety and protect patient’s rights
g. Inform and explain to clients’ relatives
H. Adverse effects of restraint use
I. Psychological/ emotion
 Feeling loss of dignity
 Fear
 Increase stress
 Depression, withdrawal, isolation
 Anger, frustration7
 Increased agitation and aggression
II. Physical effects
 Pressure ulcers and skin irritation
 Muscle atrophy from lack of use
 Increase risk of respiratory infection
 Decreased ambulation / mobility -> risk of fall
 Risk of death from struggling / strangulation / asphyxiation
 Increase constipation
 Increase urinary tack infection
 Restrained circulation
 Decreased appetite
 Sleep disturbances