Nursing Lecture AIDS nursing care plan

AIDS Nursing Care plan only here at nursinglectures.blogspot.com

Preparing an individualized Nursing Care plan can be quite confusing. Use this Nursing lecture to help with your preparation.



Nursing lecture about respiratory diseases

Today's nursing lectures are about diseases of the respiratory system namely:
Tuberculosis
Diptheria
Pertussis
Pneumonia 
and SARS (Severe Acute Respiratory Syndrome)

A detailed explanation,incubation,signs and symptoms of each disease is presented in this lecture.



Gastrointestinal Tract Visualization

This Nursing lecture provides a graphical review of the different operations and diagnostic tests used in the study of the Gastrointestinal tract. This nursing lecture includes nursing interventions and management for each particular GIT operation.

  1. GI tract Visualization http://nursinglectures.blogspot.com
  2. GIT Visualization
    • Barium Swallow- UGIS
    • Pretest: written consent, NPO the night
    • Intratest: administer barium orally, then followed by X-ray
    • Post-test: Laxative for constipation, increased fluids, assess for intestinal obstruction , warn that stool is light colored!


  3. GIT Visualization
    • Barium Enema- LGIS
    • Pretest: Informed consent, NPO the night, Enema the morning
    • Intratest: Position on LEFT side, administer enema, then X-ray follow
    • Post-test: Cleansing enema , Laxative for constipation, assess for intestinal obstruction

  4. Barium Enema
  5. GIT Visualization
    • Esophagogastroscopy
    • Pretest: Informed consent, NPO for 8 hours, warn that gag reflex is abolished
    • Intratest: Position on LEFT side during scope insertion
    • Post-test: NPO until gag returns. Monitor for complications

  6. GIT Visualization
    • Anoscopy, proctoscopy, proctosigmoidoscopy, colonoscopy
    • Pretest: Consent, NPO, and enema administration the morning
    • Intratest: Position on the LEFT side during scope insertion
    • Post-test: Monitor for complications

  7. Gallbladder
    • Oral cholescystogram
    • PTC
    • ERCP
    • Ultrasound
  8. IV Cholecystogram
    • X-ray visualization of the gallbladder after administration of contrast media intravenously
    • Pre-test: Allergy to iodine and sea-foods
    • Intra-test: ensure patent IV line
    • Post-test: increase fluid intake to flush out the dye, Assess for delayed hypersensitivity reaction to the dye like chills and N/V

  9. Oral Cholecystogram
    • X-ray visualization of the gallbladder after administration of contrast media
    • Done 10 hours after ingestion of contrast tablets
    • Done to determine the patency of biliary duct


  10. Endoscopic retrograde cholangiopancreatography
    • Examination where a flexible endoscope is inserted into the mouth and via the common bile duct and pancreatic duct to visualize the structures
    • Iodinated dye can also be injected after for the x-ray procedure
  11. Endoscopic retrograde cholangiopancreatography
    • Pre-test: consent, NPO for 12 hours, Allergy to sea-foods, Atropine sulfate
    • Intra-test: Gag reflex is abolished, Position on LEFT side
    • Post-test: NPO until gag reflex returns, Position side lying and monitor for perforation and hemorrhage



  12. Percutaneous Transhepatic Cholangiogram
    • Under fluoroscopy, the bile duct is entered percutaneously and injected with a dye to observe filling of hepatic and biliary ducts

  13. Ultrasound of the liver, gallbladder and pancreas
    • Consent MAY be needed
    • Place patient on NPO!!!
    • Laxative may be given to decrease the bowel gas
    • HIATAL HERNIA
      • Protrusion of the esophagus into the diaphragm thru an opening
      • Two types- Sliding hiatal hernia (most common) and Axial hiatal hernia
    • ASSESSMENT
      • Heartburn
      • Regurgitation
      • Dysphagia
      • 50%; without symptoms
    • DIAGNOSTIC TEST
      • Barium swallow and fluoroscopy.
    • NURSING INTERVENTIONS
      • Provide small frequent feedings
      • AVOID reclining for 1 hour after eating
      • Elevate the head of the head on 8 –inch block
      • Provide pre-op and post-op care
  14. Hiatal hernia – X-ray Hiatal hernia
    • Sliding Hiatal Hernia
      • Causes:
      • Muscle weakness in the esophageal hiatus:
        • Aging process
        • Congenital muscle weakness
        • Obesity
        • Trauma
        • Surgery
        • Prolonged increases in intra-abdominal pressure
  15. Sliding Hiatal Hernia
    • Paraesophageal / Rolling Hernias
        • Cause: anatomic defect.
    • Management
      • Medications
        • Antacids
        • Antiemetics
        • Histamine Receptor Antagonist
        • Gastric Acid Secretion Inhibitor
      • AVOID; These drugs lowers the LES (lower esophageal sphincter) pressure:
        • Anticholinergics
        • Xanthine derivatives
        • Ca-channel blockers
        • Diazepam
  16. GASTROESOPHAGEAL REFLUX DISEASE
    • Gastro-esophageal reflux (GERD)
      • Backlow
      • incompetent LES
      • May mimic ANGINA or MI
    • ASSESSMENT (for GERD)
      • Heartburn
      • Dyspepsia
      • Regurgitation
      • Epigastric pain
      • Dysphagia
      • Ptyalism
    • Diagnostic test
      • Endoscopy or barium swallow
      • Gastric ambulatory pH analysis

    • NURSING INTERVENTION
      • Provide small frequent feedings
      • AVOID reclining for 1 hour after eating
      • Elevate the head of the head on 8 –inch block
      • Provide pre-op and post-op care
  17. Gastritis
  18. Conditions of the Stomach
    • GASTRITIS
    • Inflammation of the gastric mucosa
    • May be Acute or Chronic
    • Etiology: Acute- bacteria, irritating foods, NSAIDS, alcohol
    • Etiology: Chronic- Ulceration, bacteria, Autoimmune disease, diet, alcohol, smoking
  19. Conditions of the Stomach
    • PATHOPHYSIOLOGY OF Gastritis
    • Insults  cause gastric mucosal damage  inflammation, hyperemia and edema  superficial erosions  decreased gastric secretions, ulcerations and bleeding
  20. Conditions of the Stomach
    • ASSESSMENT
    • (Acute)
    • Dyspepsia
    • Headache
    • Anorexia
    • Nausea/Vomiting
    • ASSESSMENT (Chronic)
    • Pyrosis
    • Singultus
    • Sour taste in the mouth
    • Dyspepsia
    • N/V/anorexia
    • Pernicious anemia
  21. Conditions of the Stomach
    • DIAGNOSTIC PROCEDURE
    • EGD- to visualize the gastric mucosa for inflammation
    • Low levels of HCl
    • Biopsy to establish correct diagnosis whether acute or chronic
  22. Conditions of the Stomach
    • NURSING INTERVENTIONS
    • 1. Give BLAND diet
    • 2. Monitor for signs of complications like bleeding, obstruction and pernicious anemia
    • 3. Instruct to avoid spicy foods, irritating foods, alcohol and caffeine
  23. Conditions of the Stomach
    • NURSING INTERVENTIONS
    • 4. Administer prescribed medications- H2 blockers, antibiotics, mucosal protectants
    • 5. Inform the need for Vitamin B12 injection if deficiency is present
  24. Gastritis
  25. Acute Gastritis Chronic Gastritis
  26. PEPTIC ULCER DISEASE
  27. Conditions of the Stomach
    • PEPTIC ULCER DISEASE
    • An ulceration of the gastric and duodenal lining
    • Gastric ulcer and Duodenal ulcer
    • Most common Peptic ulceration: anterior part of the upper duodenum
  28. Conditions of the Stomach
    • PATHOPHYSIOLOGY of PUD
    • Disturbance in acid secretion and mucosal protection
    • Increased acidity or decreased mucosal resistance  erosion and ulceration
  29. Duodenal Ulcer Gastric Ulcer Pain occurs 90 min to 3h after meals; wakes up patient midnight to 3 AM Commonly pain occurs within a short time of food intake Relieved by food, antacids and H2 blockers; is not associated with vomiting (if atypical features occur think of complications) High gastric acid levels Commonly accompanied by nausea, vomiting with food intake and a variable response to medications Low gastric acid levels H. pylori +++ H. pylori +++ Does not represent a malignancy Malignancy + Usually not accompanied by a high complication rate 25% will be accompanied by significant bleeding; higher mortality and morbidity
  30. DUODENAL / GASTRIC ULCER
    • Age: 30-60
    • M:F: 2-3:1
    • 80%- duodenal
    • Hypersecretion of HCL
    • (+) weight gain
    • Pain occurs 2-3 p.c .; often awakened between 1-2 am; ingestion of food relieves pain
    • 50 and over
    • 1:1
    • 15% GU
    • N-hyposecretion of HCl
    • Weight loss
    • Pain occurs ½ hrs pc ; rarely occurs at night; relieved by vomiting ; ingestion of food does not help, sometimes inc pain
  31. DUODENAL / GASTRIC ULCER
    • DU
    • Vomiting uncommon
    • Hge less common; melena more common
    • More likely to perforate
    • Malignancy rare
    • Risk factors:
    • a. H. pylori
    • b. Alcohol/Smoking
    • c. Cirrhosis
    • d. Stress
    • GU
    • Vomiting common
    • Hge more likely; hematemesis more common
    • Occasionally
    • Risk factors
    • a. H. pylori
    • b. Gastritis
    • c. Alcohol/Smoking
    • d. NSAIDs
    • e. Stress
  32. PUD
    • Laboratory:
    • CBC
    • Endoscopy
    • Gastric acid analysis
    • UGIS


    • Medical management
      • Supportive
      • Drug therapy
    • Nursing Interventions:
      • Administer medications as ordered
      • Provide nursing care for the client with ulcer surgery.
      • Prepare the client for diagnostic procedure for barium swallow and EGD.
      • Provide client teaching and discharge planning
      • Prepare the patient for surgery if warranted. Usually, the indication includes- unresponsive ulcer healing for 12-16 weeks, life-threatening hemorrhage and perforation.

  33. Ulcer Surgery

    • Ulcer Surgery
      • Surgery is performed when peptic ulcer disease does not respond to medical management.
      • Types
        • Vagotomy:
        • Antrectomy:
        • Pyloroplasty:
        • Gastroduodenostomy (Billroth I):
        • Gastrojejunostomy (Billroth II):
        • Gastrectomy: removal of 60%-80% of the stomach
        • Esophagojejunostomy (total gastrectomy): removal of the entire stomach with a loop of jejunum anastomosed to the esophagus
  34. Nursing Interventions
    • Relieving pain
    • Reducing anxiety
    • Maintaining optimal nutritional status
    • Monitoring and managing potential complications
          • Hemorrhage
          • Perforation and penetration
          • Pyloric obstruction
  35. Conditions of the Stomach
    • SURGICAL PROCEDURES FOR PUD
    • Post-operative Nursing management
    • 1. Monitor VS
    • 2. Post-op position: FOWLER’S
    • 3. NPO until peristalsis returns
    • 4. Monitor for bowel sounds
    • 5. Monitor for complications of surgery
  36. Conditions of the Stomach
    • Post-operative Nursing management
    • 6. Monitor I and O, IVF
    • 7. Maintain NGT
    • 8. Diet progress: clear liquid  full liquid  six bland meals
    • 9. Manage DUMPING SYNDROME
    • DUMPING SYNDROME
      • A group of unpleasant vasomotor and GI symptoms caused by rapid emptying of gastric content into the jejunum.
      • Associated with the presence of hyperosmolar chyme
        • Early signs and symptoms (5 to 30 minutes p.c.). Weakness, tachycardia, dizziness, diaphoresis, pallor, feeling of fullness or discomfort. Nausea and explosive diarrhea
    • Rapid emptying of hypertonic food from the stomach
    • Distention of the jejunum causing early symptoms
    • Fluid shift from the bloodstream into the jejunum
    • Decreased blood volume
    • Shock – like manifestations
  37. Late signs and symptoms (2 to 3 hrs. p.c.) Sudden hyperglycemia Increased insulin secretion Reactive HYPOGLYCEMIA

    • MANAGEMENT OF DUMPING SYNDROME
      • Eat in a low fowler’s position
      • Lie down after a meal (left side)
      • Moderate fat, high protein diet. Fats slows down gastric motility, proteins increase colloidal osmotic pressure and prevents shifting of plasma
  38. MANAGEMENT OF DUMPING SYNDROME
      • Small frequent feedings
      • Limit carbohydrates, no simple sugars
      • Give fluids 1 hr before and after meals
      • Avoid very hot and cold foods and beverages
      • Anticholinergic or antispasdomic medications are given
  39. Inflammatory Bowel Disease: Crohns and Ulcerative colitis


  40. CHRONIC INFLAMMATORY BOWEL DISORDERS A.Regional ENTERITIS (Crohn’s Disease) B. Ulcerative Colitis
    • Transmural
    • Mucous ulceration
    • Ileum/ascending colon
    • Rectum/ lower colon
    Cause
    • Unknown
    • Unknown
    • Jewish
    • Familial
    • Environmental
    • Jewish
    • Emotional stress
    Age
    • 20-30 years
    • 40-60 years
    • 15-40 years
    Bleeding
    •  ; stool with pus and mucus
    • Severe; stool with blood, pus and mucus
  41. Perianal involvement
    • Severe
    • Mild
    Fistulas
    • Common
    • Rare
    Rectal involvement
    • 20%
    • 100%
    Diarrhea
    • 5-6 soft stool/ day
    • 20-30 watery stool/ day
    Abdominal pain
    • +
    • +
  42. Weight loss
    • +
    • +
    Intervention
    • TPN
    • Steriods
    • Azulfidine (Sulfasalazine)
    • Ileostomy
    • Colectomy
    • Diet
    • TPN
    • Steriods
    • Azulfidine (Sulafasalazine)
    • Ileostomy/
    • Proctocolectomy
    • Nursing Interventions for Crohn’s and UC
      • Maintain NPO during the active phase
      • Monitor for complications like severe bleeding, dehydration, electrolyte imbalance
      • Monitor bowel sounds, stool and blood studies
      • Restrict activities
      • Administer IVF, electrolytes and TPN if prescribed
      • Instruct the patient to AVOID gas-forming foods, MILK products and foods such as whole grains, nuts, RAW fruits and vegetables especially SPINACH, pepper, alcohol and caffeine.
      • Diet progression- clear liquid  LOW residue, high protein diet
      • Administer drugs- anti-inflammatory, antibiotics, steroids, bulk-forming agents and vitamin/ iron-supplements
  43. Crohn’s Disease: Anatomic Distribution Small bowel alone (33%) Colon alone (20%) Ileocolic (45%) Least Most Freq of involvement
  44. Pathophysiology of IBD - pt. 1 fbg06
  45. Pathophysiology of IBD - pt. 2 fbg06
  46. APPENDICITIS
    • Appendicitis
      • Inflammation of the vermiform appendix that prevents mucus from passing into the cecum
  47. PATHOPHYSIOLOGY Obstruction of the appendix lumen Mucosal inflammation and bacterial proliferation Increased intra-luminal Pressure Lymphoid swelling Decreased venous drainage Thrombosis Bacterial invasion Abscess Gangrene Perforation (24 to 36 hours) Peritonitis
    • Assessment findings
      • Acute abdominal pain that usually starts in the epigastric or umbilical region
        • Mc Burney’s Point
        • initially intermittent then become steady and severe over a short period.
      • Appendicitis “signs”
        • Rebound tenderness
        • Psoas sign (lateral position with right hip is palpated)
        • Rovsing’s sign (right quadrant pain when the left is palpated)
        • Obturator sign (pain on external rotation of the right thigh)

    • Nursing Interventions
      • Administer antibiotics/ antipyretics as ordered
      • prevent perforation of the appendix; don’t give enemas or cathartics or use heating pad
    • Surgical procedure= APPENDECTOMY
          • If appendicitis ruptured (peritonitis): with penrose drains; Position: semi-fowler’s position to localize inflammation within the pelvic area
          • Resume all normal activities within 2 to 4 weeks
      • In addition to routine post-op care
        • Monitor NG tube (usually with low suction)
        • Monitor penrose drains
        • Position in semi-fowler’s or lying on right side to facilitate drainage
        • Administer antibiotics as ordered
  48. DIVERTICULITIS
    • DIVERTICULITIS
      • Diverticulum is outpouching of the mucosal lining of the GI tract, commonly in the colon.
      • Diverticula/ diverticulosis are multiple outpouching
      • Diverticulitis is acute inflammation and infection commonly caused by trapped fecal material and bacteria
      • Causes: Low fiber diet, chronic constipation and obesity

  49. Low fecal volume in the colon Increased intraluminal pressure Decreased muscle strength in the colon wall Herniation/Outpoutching of mucous membrane Entrapment of fecal material and bacteria Inflammation and infection Scarring Abscess Bleeding Perforation Peritonitis Decreased muscle strength in the colon wall
  50. CONDITIONS OF THE LARGE INTESTINE
    • ASSESSMENT findings for D/D
    • 1. Left lower Quadrant pain
    • 2. Flatulence
    • 3. Bleeding per rectum
    • 4. nausea and vomiting
    • 5. Fever
    • 6. Palpable, tender rectal mass
  51. CONDITIONS OF THE LARGE INTESTINE
    • NURSING INTERVENTIONS
    • 1. Maintain NPO during acute phase
    • 2. Provide bed rest
    • 3. Administer antibiotics, analgesics like meperidine (morphine is not used) and anti-spasmodics
    • 4. Monitor for potential complications like perforation, hemorrhage and fistula
    • 5. Increase fluid intake
  52. CONDITIONS OF THE LARGE INTESTINE
    • NURSING INTERVENTIONS
    • 6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping
    • 7. introduce soft, high fiber foods ONLY after the inflammation subsides
    • 8. Instruct to avoid activities that increase intra-abdominal pressure
  53. INTESTINAL OBSTRUCTION
  54. CONDITIONS OF THE LARGE INTESTINE
    • DIAGNOSTIC STUDIES
    • 1. If no active inflammation, COLONOSCOPY and Barium Enema
    • 2. CT scan is the procedure of choice!
    • 3. Abdominal X-ray
  55. Intestinal Obstruction
    • 2 Types:
    • Mechanical
    • Functional
  56. Small Bowel Obstruction
    • Intestinal contents, fluid, gas accumulate above the IO abdominal distention & retention of fluid absorption of fluids stimulates more gastric secretion pressure w/n intestinal lumen venous & arteriolar capillary pressure edema, congestion rupture
  57. Nursing Assessment
    • Crampy abdominal pain wavelike and colicky
    • (+) blood and mucus; (-) fecal (-) flatus
    • (+) vomiting
    • Obstruction complete reverse peristalsis
    • Ileal obstruction fecal vomiting
    • Distended abdomen
    • Signs of DHN
  58. Medical Management
    • NGT
    • IVF
    • Surgery
  59. LARGE BOWEL OBSTRUCTION
  60. PERITONITIS
    • Peritonitis
      • Local or generalized inflammation of part or all of the parietal and visceral surfaces of the abdominal cavity.
      • Initial response: edema, vascular congestion, hypermotility of the bowel and outpouring plasma-like fluid from the extracellular, vascular and interstitial compartments into the peritoneal space.
      • .
      • Later response: abdominal distention leading to respiratory compromise, hypovolemia results in decreased urinary output.
      • Intestinal motility gradually decrease and progresses to paralytic ileus
  61. Inflammation Adhesions Abscess Intestinal Obstruction Fluid shift into abdominal cavity (300-500 ml.)  Peristalsis Bowel distended with gas & fluid
      • Hypovolemia
      • Electrolyte imbalance
      • Dehydration
      • Shock
    Pathophysiology
    • Medical Management
      • Fluid, colloid and electrolyte
      • O2 therapy
      • Antibiotics
      • Surgery
  62. Nursing Management
    • Position on side with knees flexed
    • Monitor VS; I and O
    • Observe drainage
    • SIGNS THAT PERITONITIS IS IMPROVING:
    • 1. temperature
    • 2. pulse
    • 3. softening of the abdomen
    • 4. (+) bowel sounds (+) bowel movement
    • 5. (+) flatus


    • Nursing Interventions
      • Assess respiratory status for possible distress.
      • Assess characteristics of abdominal pain and changes overtime.
      • Administer medications as ordered.
      • Perform frequent abdominal assessment.
      • Monitor and maintain fluid and electrolyte balance; monitor for sings of septic shock.
      • Maintain patency of NG or intestinal tubes.
      • Place client in Fowler’s position to localize peritoneal contents.
      • Provide routine pre-and post-op care if surgery ordered.
  63. HEMORRHOIDS
    • HEMORRHOIDS
      • These are dilated blood vessels beneath the lining of the skin in the anal canal
      • Two types of Hemorrhoids exist
        • External Hemorrhoids: occur below the anal sphincter
        • Internal Hemorrhoids: occur above the anal sphincter
      • Causes
        • Chronic constipation
        • Pregnancy
        • Obesity
        • Prolonged sitting and standing
        • Wearing constricting clothes
        • Disease conditions like liver cirrhosis, RSCHF (right-sided CHF)
    • Assessment
      • Constipation in an effort to prevent pain or bleeding associated with defecation.
      • Anal pain.
      • Rectal bleeding (usually bright red-hematochezia)
      • Internal hemorrhoids may prolapse, usually painless. External hemorrhoids are usually painful.


    • Nursing Management
      • High fiber diet, liberal fluid intake
      • Bulk laxatives
      • Hot Sitz Bath; warm compress, witch hazel cream can be applied to decrease size.
      • Local anesthetic application- Nupercaine.
    • Surgery
      • Hemorrhoidectomy
      • Sclerotheraphy (5% phenol in oil)
      • Cryosurgery
      • Rubber-band ligation; done only if hemorrhoids are INTERNAL
      • Pre-op Care
        • Low residue diet to reduce the bulk of stool.
        • Stool softeners.
      • Post –op Care
        • Promotion of comfort
          • Analgesics as prescribed
          • Post-op position: Side-lying position or prone position
          • Hot sitz bath 12-24 hours post-op to promote comfort and hasten healing
        • Promotion of elimination
          • Stool softeners are given as prescribed.
          • Analgesic before initial defecation
          • Encourage the client to defecate as soon as the urge occurs
          • Enema as prescribed, using small-bore rectal tube
    • Anal Fissure
      • An elongated laceration between the anal canal and the perianal skin.
    • Anal Absess
      • Results from the obstruction of gland ducts in the anorectal region by feces, leading to infection.
    • Anal Fistula
      • Involves development of an abnormal communication between the anal canal and skin outside the anus.
      • Caused by rupture and drainage of an abscess.
  64. Conditions of the Accessory Organs
  65. The Gallbladder Conditions of the Accessory organs
  66. CONDITION OF THE GALLBLADDER
    • Cholecystitis
    • Inflammation of the gallbladder
    • Can be acute or chronic
  67. CONDITION OF THE GALLBLADDER
    • Cholecystitis
    • Acute cholecystitis usually is due to gallbladder stones
  68. CONDITION OF THE GALLBLADDER
    • Cholecystitis
    • Chronic cholecystitis is usually due to long standing gall bladder inflammation

  69. Cholelithiasis
    • Formation of GALLSTONES in the biliary apparatus

  70. Predisposing FACTORS
    • “ F”
    • Female
    • Fat
    • Forty
    • Fertile
    • Fair

  71. Pathophysiology
    • Supersaturated bile, Biliary stasis
    • Stone formation
    • Blockage of Gallbladder
    • Inflammation, Mucosal Damage and WBC infiltration
  72. CONDITION OF THE GALLBLADDER
    • ASSESSMENT findings for cholecystitis
    • 1. Indigestion, belching and flatulence
    • 2. Fatty food intolerance
  73. CONDITION OF THE GALLBLADDER
    • ASSESSMENT findings for cholecystitis
    • 3. Epigastric pain that radiates to the scapula or localized at the RUQ
    • 4. Mass at the RUQ
  74. CONDITION OF THE GALLBLADDER
    • ASSESSMENT findings for cholecystitis
    • 5. Murphy’s sign
    • 6. Jaundice
    • 7. dark orange and foamy urine
  75. CONDITION OF THE GALLBLADDER
    • DIAGNOSTIC PROCEDURES
    • 1. Ultrasonography- can detect the stones
    • 2. Abdominal X-ray
    • 3. Cholecystography
  76. CONDITION OF THE GALLBLADDER
    • DIAGNOSTIC PROCEDURES
    • 4. WBC count increased
    • 5. Oral cholecystography cannot visualize the gallbladder
    • 6. ERCP: reveals inflamed gallbladder with gallstone
  77. CONDITION OF THE GALLBLADDER
    • NURSING INTERVENTIONS
    • 1. Maintain NPO in the active phase
    • 2. Maintain NGT decompression
  78. CONDITION OF THE GALLBLADDER
    • NURSING INTERVENTIONS
    • 3. Administer prescribed medications to relieve pain. Usually Demerol (MEPERIDINE)
    • Codeine and Morphine may cause spasm of the Sphincter  increased pain. Morphine cause MOREPAIN
  79. CONDITION OF THE GALLBLADDER
    • 4. Instruct patient to AVOID HIGH- fat diet and GAS-forming foods
    • 5. Assist in surgical and non-surgical measures
    • 6. Surgical procedures- Cholecystectomy, Choledochotomy, laparoscopy
  80. CONDITION OF THE GALLBLADDER
    • PHARMACOLOGIC THERAPY
    • Analgesic- Meperidine
    • Chenodeoxycholic acid= to dissolve the gallstones
    • Antacids
    • Anti-emetics


  81. CONDITION OF THE GALLBLADDER
    • Post-operative nursing interventions
    • 1. Monitor for surgical complications
    • 2. Post-operative position after recovery from anesthesia- LOW FOWLER’s
  82. CONDITION OF THE GALLBLADDER
    • Post-operative nursing interventions
    • 3. Encourage early ambulation
    • 4. Administer medication before coughing and deep breathing exercises
    • 5. Advise client to splint the abdomen to prevent discomfort during coughing
  83. CONDITION OF THE GALLBLADDER
    • Post-operative nursing interventions
    • 6. Administer analgesics, antiemetics, antacids
    • 7. Care of the biliary drainageor T-tube drainage
    • 8. Fat restriction is only limited to 4-6 weeks. Normal diet is resumed
  84. T-tube

  85. Cholecystectomy/ Choledochostomy/ Choledochotomy
    • Cholecystectomy/Choledochostomy/Choledochotomy
      • Open Cholecystectomy:
      • Choledochostomy:
      • Laparoscopic Cholecystectomy
      • Choledochotomy:
  86. Pancreatitis
  87. Pancreatic secretions
    • 1. Bicarbonate- to neutralize the acidic chyme from the stomach
    • 2. Pancreatic amylase- for carbohydrate digestion
  88. Pancreatic secretions
    • 3. Pancreatic lipase- for fat digestion
    • 4. Trypsin and chymotrypsin- for protein digestion

  89. Fig. 16.22
  90. CONDITION OF THE PANCREAS
    • Pancreatitis
    • Inflammation of the pancreas
    • Can be acute or chronic
  91. CONDITION OF THE PANCREAS
    • Pancreatitis
    • Etiology and predisposing factors
      • Alcoholism
      • Hypercalcemia
      • Trauma
      • Hyperlipidemia
  92. CONDITION OF THE PANCREAS
    • Pancreatitis
    • Etiology and predisposing factors
      • Biliary tract disease - cholelithiasis
      • Bacterial disease
      • PUD
      • Mumps

  93. CONDITION OF THE PANCREAS
    • PATHOPHYSIOLOGY of acute pancreatitis
    • Self-digestion of the pancreas by its own digestive enzymes principally TRYPSIN
  94. CONDITION OF THE PANCREAS
    • PATHOPHYSIOLOGY of acute pancreatitis
    • Spasm, edema or block in the Ampulla of Vater  reflux of proteolytic enzymes  auto digestion of the pancreas  inflammation
  95. CONDITION OF THE PANCREAS
    • PATHOPHYSIOLOGY of acute pancreatitis
    • Autodigestion of pancreatic tissue
    • Hemorrhage, Necrosis and Inflammation
    • KININ ACTIVATION will result to increased permeability
    • Loss of Protein-rich fluid into the peritoneum
    • HYPOVOLEMIA
  96. CONDITION OF THE PANCREAS
    • ASSESSMENT findings
    • 1. Abdominal pain- acute onset, occurring after a heavy meal or alcohol intake
    • 2. Abdominal guarding
  97. CONDITION OF THE PANCREAS
    • ASSESSMENT findings
    • 3. Bruising on the flanks and umbilicus
    • 4. N/V, jaundice
    • 5. Hypotension and hypovolemia
    • 6. Signs of shock
  98. CONDITION OF THE PANCREAS
    • DIAGNOSTIC TESTS
    • 1. Serum amylase and serum lipase
    • 2. Ultrasound
    • 3. WBC
    • 4. Serum calcium
    • 5. CT scan
    • 6. Hemoglobin and hematocrit
  99. CONDITION OF THE PANCREAS
    • NURSING INTERVENTIONS
    • 1. Assist in pain management. Usually, Demerol is given . Morphine is AVOIDED
    • 2. Assist in correction of Fluid and Blood loss
  100. CONDITION OF THE PANCREAS
    • NURSING INTERVENTIONS
    • 3. Place patient on NPO to inhibit pancreatic stimulation
    • 4. NGT insertion to decompress distention and remove gastric secretions
    • 5. Maintain on bed rest
  101. CONDITION OF THE PANCREAS
    • NURSING INTERVENTIONS
    • 7. Position patient in SEMI-FOWLER’s to decrease pressure on the diaphragm
    • 8. Deep breathing and coughing exercises
    • 9. Provide parenteral nutrition
  102. CONDITION OF THE PANCREAS
    • NURSING INTERVENTIONS
    • 10. Introduce oral feedings gradually- HIGH carbo, LOW FAT
    • 11. Maintain skin integrity
    • 12. Manage shock and other complications
  103. Damage to pancreatic cells Inflammation Edema of the Pancreas and Pancreatic duct Obstruction to the Flow of Pancreatic Enzyme Activation of Pancreatic Enzymes inside Pancreas AUTODIGESTION of the Pancreas Fatty Necrosis, Ulceration, Hemorrhage, Infection Pathophysiology
  104. CHRONIC PANCREATITIS
    • NURSING ASSESSMENT:
    • Abdominal pain
    • LUQ mass
    • Steatorrhea and foul smelling stools
    • Weight loss
    • Muscle wasting
    • Jaundice
    • S/Sx DM
    • NIRSING INTERVENTION
    • Diet: fat/CHON limited
    • Avoid heavy meals/alcohol
    • Supplemental vitamins
    • Pancreatic enzyme
    • Insulin
    • Notify MD: increased steatorrhea, abdominal distention, cramping, and skin breakdown
  105. Hepatitis
    • Hepatitis
      • Infectious inflammation of the liver parenchyma caused by bacteria, viruses and other microorganisms.
      • Viral hepatitis is caused by systemic viral infections that predominantly affect the hepatocytes and cause an increase in transaminases. ALT is excreted mainly by the hepatocytes whereas AST may be excreted anywhere in the GI tract in addition to the liver. ALT is specific for hepatocyte damage; thus in viral hepatitis ALT>AST, unlike ethanol heapatitis which the opposite is true. Viral hepatitis is one of the three causes of transaminase elevation>1,000 (the other two being toxins- acetaminophen and shock liver). Cirrhosis can develop as a result of chronic hepatitis that occurs with hepatitis B and C. Fulminatic hepatic failure with massive hepatic necrosis is rare but can occur with all viral hepatitides. Viral hepatitides are caused by RNA viruses, except hepatitis B, which are caused by DNA virus.
      • There is wide spread inflammation of the liver tissue with liver cell damage due to hepatic cell degeneration and necrosis; proliferation and enlargement of the Kuppfer cells; inflammation of the perportal areas (may cause interruption of the bile flow).
    • Viral Hepatitis A
      • Single-stranded RNA virus transmitted via fecal-oral route predominantly. Poor hygiene or contaminated food and shellfish increase risk of transmission. There is no transplacental transmission. It carries the risk of fulminant hepatitis. There is incubation period: 15-45 days.
    • Viral Hepatitis B
      • Hepatitis B is caused by a DNA virus, identified in all body fluids, blood, saliva, synovial fluid, breast milk, ascites, cerebral spinal fluid, etc. Transmitted by blood and body fluids (saliva, semen, vaginal secretions): often from contaminated needles among IV drug abusers; intimate/ sexual contact. Hepatitis B accounts for 50% of cases of fulminant hepatitis. In an adult who develops acute hepatitis B, there is approximately 10% chance that it will progress into chronic hepatitis; in the neonate the chance is 90% for chronic hepatitis. Incubation period is very long: 1-6 months.
    • Viral Hepatitis C
      • This is caused by a single-stranded RNA virus that is generally transmitted predominantly by blood products. Currently it is the most common hepatitis among IV drug abusers and in prisons. Before 1990 it accounted for 90% of transfusion hepatitis. Risk for sexual transmission is present but much lower that with hepatitis B (<5%).>

    • Viral Hepatitis D
      • Caused by an RNA virus that affects either simultaneously with hepatitis B or as a super-infection in a person with chronic hepatitis B. Hepatitis D infection cannot occur unless there is current and ongoing replication of the hepatitis B virus. Overall this infection carries the highest risk among acute viral hepatitis for fulminant disease; the risk is even greater in super-infection. Predominantly seen in patients exposed to blood products (drug addicts and hemophiliacs). If anti-HBs antibodies are present, then that person is immune to hepatitis B and D.
    • Viral Hepatitis E
      • Similar to hepatitis A with fecal or oral transmission, there is no chronic form. The risk of fulminant disease has been described mainly in preganant patients.


    • Assessment findings
      • Preicteric stage
        • Anorexia, nausea and vomiting, fatigue, constipation or diarrhea, weight loss.
        • Right upper quadrant discomfort, hepatomegaly, splenomegaly, lymphadenopathy.
      • Icteric stage
        • Fatigue, weight loss, light-colored stools, dark urine.
        • Continued heapatomegaly with tenderness, lymphatomegaly, splenomegaly
        • Jaundice, pruritus.
      • Posticteric stage
        • Fatigue, but an increased sense of weel-being, hepatomegaly gradually decreasing
    • Pathophysiology of Viral Hepatitis
    • There is Diffuse Inflammatory Infiltration of Hepatic Tissue with Mononuclear Cells and local, spotty or single cell necrosis
        • Preicteric (prodromal phase)- lasts for 1 week. Assessment: Elevated temperature and chills, nausea and vomiting, dyspnea, anorexia (the major manifestation) headache, arthralgia, tenderness in RUQ, weakness, general malaise, weight loss, hepatomegaly and lymphadenopathy.
        • Icteric Phase: Starts with the onset of jaundice, it reaches its intensity in 2 weeks and lasts from 4 to 6 weeks= worsening of anorexia, anausea and vomiting, dyspnea, weakness and malaise and liver tenderness increases.
        • Posticteric Phase: Begins with the disappearance of jaundice, normally lasts for several weeks up to 4
      • Decrease Ammonia formation
        • Restrict protein in the diet
        • Duphalac (lactulose)
        • Neomycin sulfate
        • Tap water or NSS enema
      • Avoid sedatives and paracetamol.
      • Avoid ASA.
      • Avoid Hypokalemia
      • Diagnostic tests
        • All 5 types of hepatitis
          • SGPT, SGOT or AST, alkaline, phosphatase, bilirubin, ESR: all increased (preicteric)
          • Leukocytes, lymphocytes, neutrophils: all decreased (pericteric)
          • Prolonged PT
        • Hepatitis A
          • Hepatits A virus (HAV) in stool before onset of disease
          • Anti-HAV (IgM): positive in acute infection; indicating a recent exposure.
          • Anti-HAV (IgG) appears soon after onset of jaundice; indicates previous exposure and life-long immunity.
        • Hepatitis B
          • HBsAG (surface antigen): positive, develops 4-12 weeks after injection (in the acute phase.
          • Anti-HBsAG: negative in 80% of cases. If positive alone, indicates prior immunity via vaccination. If core antibody (anti-HBc) is also present his point toward a previous infection and immunity.
          • Anti-HBc: associated with infectivity, develops 2-16 weeks after infection
          • HBeAg: associated with infectivity and disappears before jaundice
          • Anti-HBe: present in carriers, represents low jaundice
        • Hepatitis C
          • Antibody to hepatitis C (anti-HCV) is usually posititve.
          • HCV RNA polymerase chain reaction is the most sensitive way to detect hepatitis C
    • Nursing Interventions
      • Promote adequate nutrition.
        • Administer anti-emetics as ordered, 30 minutes before meals to decrease occurrence of nausea and vomiting
        • Provide small, frequent meals of a high-carbohydrate, moderate- to high-protein, high vitamin, high- calorie intake
        • Avoid very hot or very cold foods
      • Ensure rest/ relaxation: plan schedule for rest and activity periods, organize nursing care to minimize interruption.
      • Monitor/ relieve pruritus
      • Administer corticosteroids are ordered.
      • Institute isolation procedures are required: pay special attention to good hand-washing technique and adequate sanitation.
      • In hepatitis A administer immune serum globulin (ISG) early to exposed individuals as ordered.
      • In hepatitis B
        • Screen donors for HBsAg.
        • Use disposable needles an syringes.
        • Instruct client/ others to avoid sexual intercourse while disease is active.
        • Administer ISG to exposed individuals as ordered.
        • Administer hepatitis B immunoglobulin (HBIG) as ordered to provide temporary and passive immunity to exposed individuals.
        • To produce active immunity, administer hepatitis B vaccine to those individuals at high risk.
      • In non-A, non-B: use disposable needles and syringes; ensure adequate sanitation.
      • Provide client teaching and discharge planning concerning
        • Importance of avoiding alcohol
        • Avoidance of persons with known infections
        • Balance of activity and rest periods
        • Importance of not donating blood
        • Dietary modifications
        • Recognition and reporting of signs of inadequate convalescence: anorexia, jaundice, increasing liver tenderness/ discomfort.
        • Techniques/ importance of good personal hygiene
    • General Preventive Measures
      • Hand washing by all persons
      • Feces, urine, blood and other fluids are considered potentially infectious and should be disposed properly.
      • Contaminated needles and other equipment that comes in contact with infected blood and body fluids, disposable and non-disposable needles, syringes and other equipment used in patient care must be handled with great care; discarded in appropriate containers.
    • Preventive Measures Used with Persons with Known Hepatitis
      • For clients with known hepatitis A, enteric precautions should be implemented
      • For clients with Hepatits B; non-A, non-B hepatitis; blood and body fluid precaution should be observed
      • Instruct clients with viral hepatitis not to donate blood.
      • Advise client with acute hepatitis B; non-A, non-B hepatitis or delta hepatitis not to have intimate sexual contact during the period of infection.
    • Summary of Collaborative Management in Viral Hepatitis
      • Promotion of rest to relieve fatigue
      • Maintenance of food and fluid intake
        • 3,000 ml/day of fluids for fever and vomiting; monitor I and O, weight
        • Well-balanced diet; encourage fruit juices and carbonated beverages
        • Fats may need to be restricted
        • Alcoholic beverages should be avoided
      • Prevention of injury
        • Prolonged prothrombin time leads leads to bleeding tendencies
        • Monitor urine and stools for fresh or old blood; the skin for petechiae
        • Monitor prpthrombin time, hematocrit and hemoglobin
        • Plan so that all blood samples are collected at one time to avoid several punctures
        • Avoid parenteral injections, if possible
      • Apply pressure to injection sites and venipuncture sites for minutes
        • Advise client to use soft toothbrush or swabs
        • Administer vitamin K as ordered
          • Provision of comfort measures
        • Relaxing baths, bakrubs, fresh linens and quiet dark environment
        • Relieve pruritus through the following measures:
          • Use of cool, light, non- restrictive clothing
          • Use of soft, dry, clean bedding, use of warm baths
          • Application of emollient creams and lotions to dry skin
          • Maintenance of cool environment
          • Administration of antihistamines as ordered
          • Use of diversional activities, e.g. reading, TV and radio
  106. Cirrhosis of the Liver
  107. LIVER Normal Function 1. Stores glycogen 2. Synthesizes proteins 3. Synthesizes globulins 4. Synthesizes Clotting factors 5. Secreting bile 6. Converts ammonia to urea 7. Stores Vitamims and minerals 8. Metabolizes estrogen
    • Liver function test:
    • AST aspartate aminotransferase formerly SGOT 4.8 - 19 U/L
    • ALT alanine aminotransferase formerly SGPT 2.4 - 7 U/L highly specific
  108. Liver Biopsy
  109. Jaundice
    • a symptom of a disease
    • yellow pigmentation of the skin
    • due to accumulation of bilirubin pigment
    • usually observed first in the sclera
    • kernicterus (brain) fatal

  110. Hemolytic Jaundice
    • due to:
    • rapid RBC destruction increased in indirect, unconjugated or B2
    • due to transfusion reaction or EBF
  111. Obstructive Jaundice
    • due to:
    • biliary atresia
    • inflammation of the biliary tract
    • tumors
    • cholestatic agent
    • total bilirubin is increased
    • bile is dammed into the liver and reabsorbed into the circulatory
    • s/sx:
    • deep orange, foamy urine
    • dark tea colored urine
    • clay colored stool
    • severe itchiness
    • steatorrhea
  112. Hepatic Jaundice
    • due to:
    • Diseased liver (hepatitis or cirrhosis)
    • Inability of the liver to clear normal amount of bilirubin from the blood
    • Increased bilirubin and albumin
  113. Jaundice Management:
    • Control pruritus
    • calamine
    • baking soda
    • NaHCO3
    • Antihistamine
    • Soothing baths
    • Drug
    • Cholestyramine = it binds bile salts in the intestine and eliminated via feces.
    • Look for the cause and manage it
    • Cirrhosis of the Liver
      • Chronic, progressive disease characterized by inflammation, fibrosis and degeneration of the liver parenchymal cells
      • Destroyed liver cells are replaced by scar tissue, resulting in architectural changes and malfunction of the liver
      • Types
        • Laennec’s cirrhosis: associated with alcohol abuse and malnutrition
        • Biliary cirrhosis: associated with biliary obstruction
        • Post necrotic cirrhosis
        • Cardiac cirrhosis
  114. Pathogenesis:
    • repeated destruction of hepatic cell  scar tissue formation (fibrotic)  regeneration of liver cell follows  another destruction will occur  cycle (scarring and regeneration) will be repeated until hepatocytes becomes fibrotic and liver function is compromised


  115. Pathophysiology Alcohol abuse Leonnec’s Cirrhosis Malnutrition Infection Postnecrotic Cirrhosis Drugs Biliary Obstruction- Biliary Cirrhosis RSCHF- Cardiac Cirrhosis Destruction of HEPATOCYTES FIBROSIS/SCARRING Obstruction of blood flow Increase Pressure in the venous and sinusoidal channels Fatty infiltration FIBROSIS/SCARRING PORTAL HYPERTENSION } }
    • Assessment of Liver Cirrhosis
      • Portal HPN and the consequences are:
        • Hepatomegaly = initially then the liver shrinks in size as fibrosis replaces the liver parenchyma
        • Splenomegaly = due to increased backpressure of the blood
        • Caput medusae (dilated veins over the abdomen)
        • Spider angioma (telangiectasia / dilated capillaries over the face and the anterior trunk) = due to increased estrogen.
        • Palmar erythema . This is also due to estrogen level in males.
    • PORTAL HYPERTENSION
    • Esophageal varices
    • Fluid extravasation
    • Ascites and edema
    •  collateral circulation
    • vein distention (angioma)
    • hemorrhoids
    • spiderangioma (red dot)
    • palmar erythema
    • telangiectasia (permanent)
    • esophageal varices
  116. Caput Medusae
  117. ASCITES
        • HYPOALBUMINEMIA
        • DECREASED METABOLISM OF ALDOSTERONE
        • Males (increased estrogen) will result to:
          • Gynecomastia
          • Decreased libido
          • Impotence
          • Fall of body hair
          • Atrophy of testicles
        • Females (Increased androgen)
          • Hirtuism
          • Acne
          • Deepening of voice
          • Virilism
  118. Esohageal Varices
    • Esophageal Varices
      • Definition:
      • ETIOLOGY:
      • Emergency condition
    • ASSESSMENT findings for EV
      • Hematemesis
      • Melena
      • Ascites
      • Jaundice
      • hepatomegaly/splenomegaly
      • Signs of Shock
    • DIAGNOSTIC PROCEDURE
      • Esophagoscopy to locate the bleeding site
  119. CONDITION OF THE ESOPHAGUS
    • NURSING INTERVENTIONS FOR EV
    • 1. Monitor VS strictly. Note for signs of shock
    • 2. Monitor for LOC
    • 3. Maintain NPO
  120. CONDITION OF THE ESOPHAGUS
    • NURSING INTERVENTIONS FOR EV
    • 4. Monitor blood studies
    • 5. Administer O2
    • 6. prepare for blood transfusion
  121. CONDITION OF THE ESOPHAGUS
    • INTERVENTIONS FOR EV
    • 7. prepare to administer Vasopressin and Nitroglycerin
    • 8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade
  122. CONDITION OF THE ESOPHAGUS
    • NURSING INTERVENTIONS FOR EV
    • 9. Prepare to assist in surgical management:
      • Endoscopic sclerotherapy
      • Variceal ligation
      • Shunt procedures
    • If bleeding esophageal varices occur:
      • Place in semi-Fowler’s position to prevent aspiration
      • Suction the mouth
      • Administer vasopressin as ordered
      • Gastric lavage with tap water (room temperature saline) as ordered.
      • Sclerotherapy
      • Balloon tamponade with the use of Sengstaken – Blakemore tube
      • Variceal band ligation
      • Portasystemic shunting
      • Portacaval
      • Splenorenal
      • Mesocaval
    • Nursing Interventions
      • Provide sufficient rest and comfort.
        • Bed rest with bathroom privileges.
        • Encourage gradual, progressive, increasing activity with planned rest periods.
        • Institute measures to relieve pruritus.
          • Bath with tepid water followed by application of an emollient lotion.
          • Provide cool, light, nonrestrictive clothing.
          • Keep nails short to
          • Apply cool, moist compresses to pruritic areas.
      • Promote nutritional intake.
        • Small frequent feedings.
        • Promote a high calorie, low to moderate protein, high carbohydrate, low fat diet, with supplemental vitamin therapy (vitamins A, B-complex, C, D, K and folic acid)
      • Prevent infection
        • Frequent turning and skin care.
        • Reverse isolation for clients with severe leucopenia
        • Monitor WBC.
      • Monitor/prevent bleeding.
      • Administer diuretics as ordered.
      • Provide client teaching and discharge planning concerning.
        • Avoidance of hepatotoxic agents ( sedatives, opiates, or OTC drugs detoxified by the liver).
        • Avoid infections, DHN, Fever
        • Avoidance of all alcohol.
        • Avoidance of straining at stool, vigorous blowing of nose and coughing to decrease the incidence of bleeding.

  123. Liver physiology and Pathophysiology Normal Function Abnormality in function 1. Stores glycogen = Hypoglycemia 2. Synthesizes proteins = Hypo-proteinemia 3. Synthesizes globulins =Decreased Antibody formation  risk for INFECTION 4. Synthesizes Clotting factors = Bleeding tendencies 5. Secreting bile = Jaundice and pruritus 6. Converts ammonia to urea =Hyper-ammonemia 7. Stores Vitamims and minerals =Deficiencies of Vit and min 8. Metabolizes estrogen = Gynecomastia, testes atrophy
    • HEPACTIC ENCEPHALOPATHY
    • Is due to increased AMMONIA levels. The liver cannot convert ammonia by products of protein metabolism into Urea Hepatic coma
    • The initial manifestations are BEHAVIORAL changes and MENTAL changes.
    • Advance Stage :
        • Asterixis –
        • Confusion / disorientation
        • Delirium / hallucination
        • Fetor hapaticus
    • Summary of Collaborative Management
      • Rest. To reduce metabolic demands of the liver.
      • Diet
        • Early stage
          • High calorie, HIGH carbohydrates, LOW protein that is restricted to complete protein only, moderate fats.
        • Late stage
          • HIGH calorie, HIGH carbohydrates, LOW protein.
      • Skin care
      • Avoid trauma/injury
      • Prevent infection
      • Decrease Ammonia formation
        • Restrict protein in the diet
        • Duphalac (lactulose)
        • Neomycin sulfate
        • Colchicine
        • Tap water or NSS enema
      • Avoid sedatives and paracetamol.
      • Avoid ASA.
      • Avoid Hypokalemia
      • Manage Ascites
        • Monitor weight, intake and output, abdominal girth
        • Restrict sodium and fluid intake
        • Administer diuretics as ordered
          • Initially, K – sparring diuretic
          • Later, K- wasting diuretic
        • Administer albumin / IV as ordered assist in paracentesis
  124. Abdominal Paracentesis
    • Withdrawal of fluid from the peritonealspace
    • Purpose: diagnostic and therapeutic
    • Pretest: consent, empty bladder
      • Position: sitting
      • Site: midway between the umbilicus and symphysis
  125. Abdominal Paracentesis
    • Intratest: 1,500 ml maximum amount collected at one time, Monitor VS
    • Post-test : monitor VS, bleeding complication
      • Measure abdominal girth and weight

  126. COLORECTAL CANCER
    • COLORECTAL CANCER
      • Cause: Unknown
      • Predisposing factors:
        • Age above 40 years
        • Diet
          • Low in fiber
          • High in fat, protein and refined carbohydrates
          • Obesity
          • History of IBD, familial polyposis or colon polyps
          • Family history of colon cancer
          • Most common site: Rectosigmoid area (70%)
    • Assessment
      • Ascending (right) Colon Cancer
        • Occult blood in stool
        • Anemia
        • Anorexia and weight loss
        • Abdominal pain above umbilicus
        • Palpable mass
      • Distal colon/ Rectal cancer
        • Bright rectal bleeding
        • Changed bowel habits
        • Constipation or Diarrhea
        • Pencil or ribbon- shaped stool
        • Tenesmus
        • Sensation of incomplete bowel emptying
    • Duke’s Classification of Colorectal Cancer
      • Stage A: confined to bowel mucosa, 80-90% 5 –year survival rate
      • Stage B: invading muscle wall
      • Stage C: lymph node involvement
      • Stage D: metastases or locally respectable tumor, less than 5%- 5- year survival rate.

    • Guidelines for Early Detection of Colorectal Cancer
      • Digital rectal examination yearly after age 40-45
      • Occult blood test yearly after age 50
      • Protosigmoidoscopy every 5 years after age 50, following 2 negative results of yearly examination
    • Collaborative Management
      • Surgery
        • Hemicolectomy
        • Abdomino-Perineal Resection (APR) for rectosigmoid cancer
      • Chemotherapy
        • Fluorouracil is the most effective drug for colorectal cancer
      • Radiotherapy
        • Adjuvant therapy for rectal cancer
    • Medical Management: chemotherapy, radiation therapy, bowel surgery
      • Colonic surgery
        • Pre-op care
          • Provide psychosocial support
          • Through bowel cleansing
            • Diet modification
            • Low residue diet 3 to days preop, to reduce the bulk of the stool in the colon
            • Clear liquid diet 24 hours preop
          • Mechanical cleansing
            • Laxatives as ordered
            • Cleansing enema as ordered
          • Pharmacologic suppression of colon bacteria
            • Neomycin sulfate tablets to reduce bacterial flora. (it is poorly absorbed in the colon, thereby enhance excretion of colonic bacteria).
            • Vitamin C and K supplement because these are lost during repeated enema administration.
    • Type of Colostomies
      • Ascending Colostomy
        • Stoma is on the right abdomen
        • Fecal drainage is watery
      • Transverse (Double-Barreled) Colostomy
        • The right stoma is also called proximal stoma; closest to the small intestine; drains semi-formed feces.
        • The left stoma is also called distal stoma; drains mucus
      • Transverse Loop Colostomy
        • Has 2 openings in the transverse colon, but one stoma
        • Indicated in IBD’s
      • Descending and Sigmoid Colostomy
        • Stoma on the left abdomen
        • Fecal drainage is well-formed
    • Post-op Care
      • Managing the perineal wound (APR)
        • May require up to 6 months to completely heal
        • Wound irrigations with normal saline and absorbent dressings until wound closes .
        • Drainage is initially copious and sero-sanguinous, to be drained at regular basis to prevent infection and abscess formation
        • T-binder is used to secure perineal dressing
        • Sitz baths once the patient is ambulatory
        • Foam pads or soft pillows to promote comfort when sitting
        • Side-lying position during sleep
      • Stoma Monitoring
        • The stoma is pinkish to cherry red and with slight edema for 5-7 days
        • Dark, dusky , or brown –black stoma indicates ischemia and necrosis
        • The stoma should protrude by ½ to ¾ inch over abdomen
        • Flatus and fecal drainage usually begin in 3 to 6 days, as peristalsis returns
        • Empty the pouch when it is 1/3 to ½ full of stool
        • Loop colostomy is opened 48-72 hours post-op, with cautery at bedside.
      • Teaching for Self-care
        • Stoma Care
          • Gently encourage the client to look at the stoma
          • Inform that the stoma has no touch of pain sensation
          • Instruct to report immediately any purple or black discoloration of stoma.
          • Cleanse the stoma initially with antiseptic
        • Skin Care
          • Wash the skin with warm water, pat dry.
          • Assess skin for signs of irritation or infection
          • When pouch seal leaks, change pouch immediately
          • Use skin barrier to protect the peristomal skin from liquid stool e.g. karaya preparation.
          • Skin infection caused by Candida Ablicans is treated with nystatin (Mycostatin) powder.
    • Colostomy Irrigation
      • Initially colostomy irrigation is done to stimulate peristalsis, subsequent irrigations are done to promote evacuation of feces at a regular and convenient time
      • Recommendation with sigmoid colostomy
      • Initiated 5 to 7 days Post-op
      • Done in semi-Fowler’s position; then sitting on a toilet bowl once ambulatory
      • Use warm normal saline solution
      • Initially, introduce 200 ml. of NSS then 500 to 1,000 ml. Subsequently
      • Dilate stoma with lubricated gloved finger before insertion of catheter
      • Lubricate catheter before insertion
      • Insert 2 to 4 inches of the catheter into the stoma
      • Height of solution is 18 inches above the stoma
      • If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution until peristalsis relaxes
      • Allow the catheter to remain in place for 5 to 10 minutes for better cleansing effect; then remove catheter to drain for 15 to 20 minutes
      • Clean the stoma, apply stoma, apply new pouch
    • Managing Odor
      • Avoid Gas – forming and foul odor foods, e.g. dairy products, highly seasoned foods, fish, cabbage, celery, cauliflower, eggs, carbonated beverages, nuts.
      • Rinse pouch with tepid water or weak vinegar solution
      • Place deodorant tablet or small amount of mouthwash or a piece of charcoal into the pouch
      • Do not use pulverized ASA- it causes irritation of the stoma and damages the colostomy appliance.
    • Supporting a Positive Self-Concept
      • Encourage to view the stoma
      • Encourage to verbalize feelings, fears and concern about stoma
      • Encourage to participate in colostomy care.
      • Encourage gradually resume all usual activities
      • Avoid tight belts or waistbands over the stoma
      • Advise to always carry colostomy supplies when traveling
      • Resolving grief
      • Encourage client to express feelings of loss
      • Explore client’s usual coping strategies for handling grief
      • Preventing Sexual Dysfunction
      • Explore positions that minimizes stress and pressure on the pouch
      • Empty and clean the pouch before sexual activity
      • Use smaller – sized pouch or pouch cover during sexual activity
      • Use of a binder of special underwear to hold the pouch secure
    • Home care instructions for colostomy.
      • Instruct the colostomy patient to change the stoma appliance as needed, to wash the stoma site with warm and mild soap every 2-3 days and to change the adhesive layer as needed. These measures will prevent irritation and excoriation .
      • Discuss dietary restrictions and suggestions to prevent blockage of the stoma, diarrhea, flatus, and odor. Tell patient to start on low fiber diet initially and then gradually introduce fiber foods.
      • Corn, dried beans, onions, cabbage, fish, spicy dishes and some antibiotics can cause odor. Apples, melons, avocados and cantaloupe are additional foods that can cause excessive gas.
      • Advise to drink liberal amount of fluids especially in hot weather and diarrhea.




Obstetric Nursing - Intrapartal Period

Nursing lectures is proud to share with you a comprehensive review about the Intrapartal period. Included in this lecture are the following
  1. A. Admitting the laboring Mother:
        • Personal Data: name, age, address, etc
        • Baseline Data: v/s especially BP, weight
        • Obstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wks
        • Physical Exams,Pelvic Exams
  2. B. Basic knowledge in Intrapartum .
  3. A. Theories of the Onset of Labor
    • 1.) uterine stretch theory
    • -( any hollow organ when stretched, will always contract & expel its content).
    • – contraction action.
    • 2.) Oxytocin Theory
    • – post pit gland releases oxytocin. Hypothalamus produces oxytocin
    • 3.) Prostaglandin Theory
    • – stimulation of arachidonic acid.
    • – prostaglandin- contraction
    • 4.) progesterone theory
    • – before labor, decrease progesterone will stimulate contractions & labor.
    • 5.) Theory of Aging placenta
    • – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).
  4. B. The 4 P’s of labor
    • Passenger
    • a. Fetal head
    • – is the largest presenting part
    • – common presenting part
    • ¼ of its length.
    • Bones – 6 bones
    • S–sphenoidF –frontal –sinciput
    • E–ethmoid O–occipital–occiput
    • T–temporal P– parietal 2 x
  5. Measurement fetal head:
    • transverse diameter – 9.25cm
    • biparietal – 9.5cm
    • largest transverse
    • bitemporal 8 cm
    • Sutures
    • – intermembranous spaces that allow molding.
        • 1.Sagittal Suture
        • – connects 2 parietal bones .
    • 2.Coronal suture
    • – connects parietal & frontal bone (crown).
      • 3.Lambdoidal suture
      • – connects occipital & parietal bone.
    • Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis
  6. Fontanels:
    • 1.Anterior fontanel
    • – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close.
    • 2.Posterior fontanel or lambda
    • – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.
    • 4. Anteroposterior diameter
    • - suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
    • occipitofrontal 12cm partial flexion
    • occipitomental – 13.5 cm hyper extension submentobregmatic-face presentation
  7. 2. Passageway
    • Mom
    • 1.) <>
    • 2.) <>
    • 3.) Underwent pelvic dislocation
  8. Pelvis
  9. 4 Main Pelvic Types
    • Gynecoid
    • – round, wide, deeper most suitable (normal female pelvis) for pregnancy.
    • 2. Android
    • – heart shape “male pelvis”- anterior part pointed, posterior part shallow.
    • 3. Anthropoid
    • – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
    • 4. Plattypelloid
    • – flat AP diameter – narrow, transverse – wider
    • 2 hip bones –2 innominate bones
  10. 3 Parts of 2 Innominate Bones
    • Ileum
    • – lateral side of hips
    • -iliac crest
    • – flaring superior border forming prominence of hips.
    • Ischium
    • – inferior portion
    • - ischial tuberosity where we sit
    • – landmark to get external measurement of pelvis
    • Pubes
    • – ant portion – symphysis pubis junction between 2 pubes
    • 1 sacrum
    • – post portion – sacral prominence – landmark to get internal measurement of pelvis
    • 1 coccyx
    • – 5 small bones compresses during vaginal delivery
  11. Important Measurements
    • Diagonal Conjugate
    • – measure between sacral promontory and inferior margin of the symphysis pubis.
    • Measurement: 11.5 cm - 12.5 cm
    • - basis in getting true conjugate. (DC – 11.5 cm=true conjugate)
    • 2. True conjugate/conjugate vera
    • – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm.
    • 3. Obstetrical conjugate
    • – smallest AP diameter. Pelvis at 10 cm or more.
    • Tuberoischi Diameter
    • – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.
  12. 3. Power
    • – the force acting to expel the fetus and placenta – myometrium – powers of labor.
  13. 4. Psyche/Person
    • – psychological stress when the mother is fighting the labor experience.
    • Cultural Interpretation
    • b. Preparation
    • c. Past Experience
    • d. Support System
  14. Pre-eminent Signs of Labor
  15. S&Sx
    • 1.Lightening
    • – setting of presenting part into pelvic brim - 2 weeks prior to EDD
    • -shooting pain radiating to the legs
    • -urinary freq.
    • 2.* Engagement- setting of presenting part into pelvic inlet
    • 3.Braxton Hicks Contractions
    • – painless irregular contractions.
    • 4. Increase Activity of the Mother
    • 5. Ripening of the Cervix
    • – butter soft.
    • 6. Decreased body wt
    • – 1.5 – 3 lbs
    • 7. Bloody Show
    • – pinkish vaginal discharge – blood & leukorrhea
    • 8. Rupture of Membranes
    • – rupture of water.
    • Premature Rupture of Membrane ( PROM)
    • check for cord prolapse.
    • Contraction drops in intensity even though very painful
    • Contraction drops in frequently
    • Uterus is tensed and/or contracting between contractions
  16. Nursing Care
    • Administer Analgesics
    • Attempt manual rotation for ROP or LOP
    • Bear down with contractions
    • Adequate hydration – prepare for CS
    • Sedation as ordered
    • Cesarean delivery may be required, especially if fetal distress is noted
    • Cord Prolapse
    • – a complication when the umbilical cord falls or is washed through the cervix into the vagina
  17. Danger signs
    • PROM
    • Presenting part has not yet engaged
    • Fetal distress
    • Protruding cord form vagina
  18. Nursing care
    • Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy
    • Slip cord away from presenting part
    • Count pulsation of cord for FHT
    • Prep mom for CS
    • Positioning – trendelenberg or knee chest position
    • Emotional support
    • Difference Between True Labor and False Labor
    • False Labor
    • Irregular contractions
    • No increase in intensity
    • confined to abdomen
    • relived by walking
    • No cervical changes
    • True Labor Contractions
        • are regular
        • Increased intensity
        • Pain – begins lower back radiates to abdomen
        • Pain – intensified by walking
        • Cervical effacement & dilatation * major sx of true labor.
  19. Duration of Labor
    • Primipara
    • – 14 hrs & not more than 20 hrs
    • Multipara
    • – 8 hrs & not > 14 hrs
    • Effacement – softening & thinning of cervix. Use % in unit of measurement
    • Dilation – widening of cervix. Unit used is cm
  20. Nursing Interventions in Each Stage of Labor
    • First Stage
    • onset of true contractions to full dilation and effacement of cervix.
  21. Latent Phase
    • Assessment:
    • a. Dilations
    • 0 – 3 cm
        • Frequency
    • every 5 – 10 min Intensity mild.
  22. Nursing Care
      • 1.Encourage walking
      • 2.Encourage to void q 2 – 3 hrs
    • 3.Breathing – chest breathing
  23. Active Phase
    • Assessment:
    • Dilations 4 -8 cm
    • Intensity: moderate
    • Mom- fears losing control of self
    • Frequency
    • q 3-5 min lasting for 30 – 60 seconds.
  24. Nursing Care
    • M –edications
    • – have meds ready
    • A –ssessment
    • include: vital signs, cervical dilation and effacement, fetal monitor, etc.
    • D – dry lips
    • – oral care (ointment)
    • dry linens.
    • B – abdominal breathing
  25. Transitional Phase
    • Assessment :
    • Dilations
    • - 8 – 10 cm
    • Frequency
    • -q 2-3 min contractions
    • Durations
    • -45 – 90 seconds
    • Intensity
    • -strong
    • Mom – mood changes
    • Hyperesthesia
    • – increase sensitivity to touch, pain all over.
  26. Health Teaching
    • teach: sacral pressure on lower back
    • keep informed of the progress
    • controlled chest breathing
  27. Nursing Care
        • T – ires
        • I – nform of progress
        • R – estless support her breathing technique
        • E – ncourage and praise
        • D – iscomfort
  28. Pelvic Exams
    • Effacement
    • Dilation
    • Station
    • – landmark used: ischial spine.
    • - 1 station = presenting part 1cm above ischial spine if (-) floating
    • -2 station = presenting part 2 cm above ischial spine if (-) floating
    • 0 station = level at ischial spine – engagement
    • + 1 station = below 1 cm ischial spine
    • +3 to +5 = crowning – occurs at 2nd stage of labor
    • Presentation/lie
    • – the relationship of the long axis (spine) of the fetus to the long axis of the mother.
    • -spine of mom and spine of fetus.
  29. Two types
    • Longitudinal Lie ( Parallel)
    • cephalic:
            • Vertex – complete flexion
    • Face
    • Brow
    • Chin
    • Breech :
        • a. Complete Breech
        • – thigh breast on abdomen, breast lie on thigh
        • Incomplete Breech
        • – thigh rest on abdominal
    • Frank – legs extend to head
    • Footling – single, double
    • 2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation
    • c. Position
    • – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.
  30. Variety
    • Occipito – LOA left occipito ant (most common and favorable position)– side of maternal pelvis
    • LOP – left occipito posterior
    • LOP – most common mal position, most painful
    • ROP – squatting pos on mom
    • ROT
    • ROA
    • *Breech
    • - use sacrum
    • - put stethoscope above umbilicus
    • LSA – left sacro anterior
    • LST, LSP, RSA, RST, RSP
    • *Shoulder/acromniodorso
    • LADA, LADT, LADP, RADA
    • Chin / Mento
    • LMA, LMT, LMP, RMP, RMA, RMT, RMP
  31. Monitoring the Contractions and Fetal heart Tone
    • Spread fingers lightly over fundus – to monitor contractions
  32. Parts of contractions
    • Increment or crescendo
    • – beginning of contractions until it increases.
    • Acme or apex
    • – height of contraction.
    • Decrement or decrescendo – from height of contractions until it decreases
    • Duration – beginning of contractions to end of same contraction
    • Interval – end of 1 contraction to beginning of next contraction
    • Frequency – beginning of 1 contraction to beginning of next contraction
    • Intensity - strength of contraction
    • Contraction – vasoconstriction
    • Increase BP, decrease FHT
    • Best time to get BP & FHT just after a contraction or midway of contractions
    • Duration of contractions shouldn’t >60 sec
    • Notify MD
    • 5. Fetal Heart Patterns
    • a. Early Decelerations – head compression
    • 1. begins early in contraction
    • 2. ominous
    • 3. continue monitoring
    • b. Late decelerations – uteroplacental insufficiency
    • 1. begins late in contraction
    • 2. ominous
    • 3. turn mother to the left lateral recumbent
    • 4. administer oxygen
    • 5. d/c oxytocin
    • c. Variable decelerations – umbilical cord compression
    • 1. not related to contractions
    • 2. not ominous, but requires interventions
    • 3. change maternal position
    • 4. administer oxygen
    • 5. assess for prolapsed cord
    • Mom has headache – check BP, if same BP, let mom rest. If BP increases , notify MD -preeclampsia
  33. Health teachings
    • 1.) Ok to shower
    • 2.)NPO – GIT stops function during labor if with food- will cause aspiration
    • 3.)Enema administer during labor
    • a.) To cleanse bowel
    • b.) Prevent infection
    • c.) Sims position/side lying
    • 12 – 18 inch – ht enema tubing.
    • Check FHT after adm enema
    • Normal FHT= 120-160
  34. Signs of fetal distress
    • 1.) <120>160
    • 2.) meconium stained- amniotic fluid
    • 3.) fetal thrashing – hyperactive fetus due to lack O2
    • 2. Second Stage
    • - fetal stage, complete dilation and effacement to birth
    • 7 – 8 multi – bring to delivery room.
    • 10cm primi – bring to delivery room
    • Lithotomy pos – put legs at the same time
    • Bulging of perineum
    • – sure to come out
    • Breathing
    • – panting ( teach mom)
    • Assist doc in doing episiotomy
    • Episiotomy
    • – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum (urethroanal fistula).
    • Mediolateral
    • – more bleeding & pain, hard to repair, slow to heal
    • -use local or pudendal anesthesia.
    • Modified Ritgens maneuver
    • – place towel at perineum
        • 1.)To prevent laceration
    • 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby.
  35. Mechanisms of labor
      • Engagement
      • Descent
      • Flexion
      • Internal Rotation
      • Extension
      • External rotation
      • Expulsion
  36. Parts of Pelvis
    • 1. Inlet
    • – AP diameter narrow, transverse diameter wider
    • 2. Cavity
  37. Two Major Divisions of Pelvis
    • True pelvis
    • – below the pelvic inlet
    • False pelvis
    • – above the pelvic inlet; supports uterus during pregnancy.
    • Linea Terminalis
    • -diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.
  38. Nursing Care:
    • To prevent puerperal sepsis
    • - <>
    • Bolus of Pitocin can lead to hypotension.
    • Third Stage
    • Birth to expulsion of Placenta
    • -placental stage placenta has 15 – 28 cotyledons. Placenta delivered from 3-10 minutes.
  39. Signs of placental separation
    • 1.Fundus rises – becomes firm & globular “ Calkins sign ”
    • 2.Lengthening of the cord
    • 3.Sudden gush of blood
  40. Types of placental delivery
    • a. Shultze “shiny”
    • – begins to separate from center to edges presenting the fetal side shiny
    • b. Duncan “dirty”
    • – begin to separate form edges to center presenting natural side – beefy red or dirty.
    • Slowly pull cord and wind to clamp.
    • – BRANDT ANDREWS MANEUVER.
  41. Nursing care for placenta
      • Check completeness of placenta.
      • Check fundus
      • Check bp
      • Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives
      • Monitor hpn (or give oxytocin IV)
      • Check perineum for lacerations
      • Assist MD for episiorrhapy
      • Flat on bed
      • Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.
    • Fourth Stage
    • -the first 1-2 hours after delivery of placenta.
    • – recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
    • Check placement of fundus at level of umbilicus.
  42. If fundus above umbilicus, deviation of fundus
    • Empty bladder to prevent uterine atony
    • Check lochia
    • a.Maternal Observations – body system stabilizes
    • b. Placement of the Fundus
    • c. Lochia
    • Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
    • d.Perineum
    • R - edness
    • E- dema
    • E – cchymosis
    • D – ischarges
    • A – approximation of blood loss. Count pad & saturation
    • Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
    • e. Bonding – interaction between mother and newborn – rooming in types
    • 1.Straight rooming in baby: 24hrs with mom.
    • 2.Partial rooming in: baby in morning , at night nursery.
  43. Complications of Labor
    • Dystocia
    • – difficult labor related to:
    • Mechanical factor
    • – due to uterine inertia
    • – sluggishness of contraction
    • 1.hypertonic or primary uterine inertia
      • Intense excessive contractions resulting to ineffective pushing
    • Interventions with Hypertonic Dysfunction
    • Short-acting barbiturates
    • IV fluids
    • If CPD – c/s.
    • Provide emotional support.
    • Provide comfort measures.
    • Prevent infection
    • Prepare patient for c/s if needed.
    • 2. hypotonic secondary uterine inertia
        • Slow irregular contraction resulting to ineffective pushing.
        • Give oxytocin.
    • Management:
      • Amniotomy (artificial ROM).
      • Oxytocin augmentation of labor.
      • If CPD, prepare for c/s.
      • Emotional support, comfort measures, prevent infection.
  44. Normal length of Labor
    • Primi 14 – 20 hrs
    • Multi 10 -14 hrs
  45. Prolonged Labor
    • > 14 hrs in multi &
    • > 20 hrs in primi
    • Maternal effect – exhaustion.
    • Fetal effect – fetal distress, caput succedaneum or cephalhematoma
  46. Precipitate Labor
    • Labor of <>
    • extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
    • Outstanding Nursing dx: fluid volume deficit
    • IV: fast drip due to fluid volume def
  47. Signs of Hypovolemic Shock:
    • Hypotension
    • Tachycardia
    • Tachypnea
    • Cold clammy skin
  48. Inversion of the uterus
    • Situation: uterus is inside out.
  49. Factors leading to inversion of uterus
        • short cord
        • hurrying of placental delivery
        • ineffective fundal pressure
  50. Uterine Rupture
    • Causes:
      • 1.)Previous classical CS
      • 2.)Large baby
      • 3.) Improper use of oxytocin (IV drip)
  51. Uterine Rupture
    • Sx:
      • Sudden pain
      • Profuse bleeding
      • Hypovolemic shock
      • TAHBSO
  52. Physiologic retraction ring
    • Boundary bet upper/lower uterine segment
    • BANDL’S pathologic ring – suprapubic depression
  53. Amniotic Fluid Embolism or Placental Embolism
    • Amniotic fluid or fragments of placenta enters natural circulation resulting to embolism
  54. Amniotic Fluid Embolism or Placental Embolism
    • Sx:
    • dyspnea, chest pain & frothy sputum
  55. Trial Labor
    • Measurement of head & pelvis falls on borderline.
    • Mom given 6 hrs of labor
    • Multi: 8 – 14, primi 14 – 20
  56. Preterm Labor
    • Labor Abortion: <20>
  57. Preterm Labor
    • Sx:
      • 1. premature contractions q 10 min
      • 2. effacement of 60 – 80%
      • 3. dilation of 2-3 cm
  58. Preterm Labor
    • Home Mgt:
      • 1. complete bed rest
      • 2. avoid sex
      • 3. empty bladder
      • 4. drink 3 -4 glasses of water
      • 5. consult MD if symptoms persist
  59. Preterm Labor
    • Hosp:
    • 1. If cervix is closed
      • dilation is saved by administering Tocolytic agents
      • halts preterm contractions. Ritodrine HCl (Yutopar)
      • 150mg incorporated 500cc Dextrose piggyback.
      • Terbutaline (Brethine)
  60. Preterm Labor
    • If cervix is open : MD  steroid dexamethazone (betamethazone)
    • Preterm: Cut cord ASAP
  61. Postpartal Period : 5th stage of labor
    • After 24hrs: Normal increase WBC up to 30,000 mm3
    • Puerperium  covers 1st 6 wks post partum
    • Hyperfibrinogenemia
    •  prone to thrombus formation
    •  early ambulation
  62. Principles underlying PUERPERIUM
    • To return to Normal and Facilitate healing
    • Systemic changes
  63. Cardiovascular System
    • The first few minutes after delivery is the most critical period in mothers
  64. Genital tract
    • a. Cervix – cervical opening
    • b. Vaginal and Pelvic Floor
    • c. Uterus – return to normal 6 – 8 wks.
  65. Genital tract
    • Birth pain:
    • 1. position prone
    • 2. cold compress – to prevent bleeding
    • 3. mefenamic acid
  66. Genital tract
    • Lochia  bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.
    • 1. Rubra  red 1st 3 days present, musty/mousy, moderate amt
    • 2. Serosa  pink to brown 4 – 9th day, limited amt
    • 3. Alba  créme white 10 – 21 days very decreased amt
  67. Genital tract
    • Dysuria
    • - urine collection
    • - alternate warm & cold compress
    • - stimulate bladder
  68. Urinary tract
    • Freq in urination after delivery
    • Urinary retention with overflow
  69. Colon
    • Constipation due to:
      • NPO
      • Fear of bearing down
  70. Perineal Area
    • Painful – episiotomy site
    • Sex  when perineum has healed
  71. Provide Emotional Support – Reva Rubin
    • Psychological Responses:
    • Taking in phase
    • Taking hold phase
    • Letting go
  72. Taking hold phase
    • Dependent to independent phase (4 to 7 days).
    • Mom  active, can make decisions
  73. Letting go phase
    • Interdependent phase – 7 days & above.
  74. Complication: HEMORRHAGE
    • Bleeding of > 500cc
    • CS – 600 – 800 cc normal
    • NSD 500 cc
  75. Early postpartum hemorrhage
    • Bleeding within 1st 24 hrs.
  76. Early postpartum hemorrhage
    • Complications :
    • Hypovolemic shock.
  77. Early postpartum hemorrhage
    • Breast feeding – post pit gland will release oxytocin so uterus will contract.
    • Well contracted uterus + bleeding = laceration
  78. LACERATION
    • 1st degree laceration – affects vaginal skin & mucus membrane.
    • 2nd degree – 1st degree + muscles of vagina
    • 3rd degree – 2nd degree + external sphincter of rectum
    • 4th degree – 3rd degree + mucus membrane of rectum
  79. DIC
    • Disseminated Intravascular Coagulopathy. Hypofibrinogen  failure to coagulate.
  80. Late Postpartum hemorrhage
    • Bleeding after 24 hrs  retained placental fragments
  81. Late Postpartum hemorrhage
    • Accreta
    • Increta
    • Percreta
    • Hematoma
  82. Late Postpartum hemorrhage
    • too much manipulation
    • large baby
    • pudendal anesthesia
  83. Infection
    • Sources of infection
    • 1.) endogenous
    • 2.) exogenous
    • Anaerobic streptococci
  84. Infection
    • General signs of inflammation:
      • Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)
      • Purulent discharges
      • Fever
  85. INFECTION
    • Gen mgt:
    • supportive care
    • inflammation of perineum
    • 2 to 3 stitches dislocated with purulent discharge
  86. INFECTION
    • Mgt:
      • Removal of sutures & drainage, saline, between & resulting.
      • Endometriosis – inflammation of endometrial lining
  87. INFECTION
    • Sx:
      • Abdominal tenderness,
  88. Family Planning
    • determine one’s own beliefs 1st
    • never advise a permanent method of planning
    • method of choice is an individual’s choice.
  89. Family Planning
    • Natural Method – the only method accepted by the Catholic Church
    • Billings / Cervical mucus – test spinnbarkeit & ferning (estrogen)
    • clear, watery, stretchable, elastic – long spinnbarkeit
    • Basal Body Temperature 13th day temp goes down before ovulation – no sex
    • get before arising in bed
  90. Family Planning
    • LAM – lactation amenorrhea method – hormone that inhibits ovulation is prolactin.
  91. Family Planning
    • Symptothermal – combination of BBT & cervical. Best method
    • Social Method – 1.) coitus interruptus/ withdrawal - least effective method
    • coitus reservatus – sex without ejaculation –
    • calendar method
  92. OVULATION
    • count minus 14 days before next mens (14 days before next mens)
    • Origoknause formula – monitor cycle for 1 year
    • get shortest & longest cycle from Jan – Dec
    • shortest – 18
    • longest – 11
  93. OVULATION
    • June 26 Dec 33
    • - 18 - 11
    • 8 - 22 unsafe days
    • 21 day pill- start 5th day of mens
    • 28day pill- start 1st day of mens
    • missed 1 pill – take 2 next day
  94. Pills
    • Combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle.
    • 99.9% effective.
  95. OCP Alert
    • If a new oral contraceptive is prescribed the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses.
  96. Pills
    • Signs of hypertension
    • Immediate Discontinuation
    • A – abdominal pain C – chest pain H - headache E – eye problems
    • S – severe leg cramps
    • If mom HPN – stop pills STAT!
    • Adverse effect: breakthrough bleeding
  97. Pills
    • If forgotten for one day , immediately take the forgotten tablet plus the tablet scheduled that day.
    • If forgotten for two consecutive days , or more days, use another method for the rest of the cycle and the start again.
  98. DMPA
    • Depoprovera – has progesterone inhibits LH – inhibits ovulation
    • Depomedroxy progesterone acetate – IM q 3 months
    • Never massage injected site, it will shorten duration
  99. DMPA
    • Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
  100. Mechanism and Chemical Barriers
    • IUD
    • Condom
    • Diaphragm
    • Cervical cap
    • Foams, Jellies, Creams
  101. Intrauterine Device (IUD)
    • Action: prevents implantation – affects motility of sperm & ovum
    • right time to insert is after delivery or during menstruation
    • primary indication for use of IUD
    • parity or # of children, if 1 kid only don’t use IUD
  102. Intrauterine Device (IUD)
    • ALERTS:
    • prevents implantation
    • most common complications: excessive menstrual flow and expulsion of the device (common problem)
  103. Intrauterine Device (IUD)
    • OTHERS:
    • P eriod late (pregnancy suspected)
    • Abnormal spotting or bleeding
    • A bdominal pain or pain with intercourse
    • I nfection (abnormal vaginal discharge)
    • N ot feeling well, fever, chills
    • S trings lost, shorter or longer
    • Uterine inflammation, uterine perforation,ectopic pregnancy
  104. CONDOM
    • – latex inserted to erected penis or lubricated vagina
    • Adv: gives highest protection against STD – female condom
    • Alerts:
  105. Diaphragm
    • – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSIBLE
    • S/effect: Toxic shock syndrome
    • Alerts: Should be kept in place for about 6 – 8 hours
  106. Cervical Cap
    • – more durable than diaphragm no need to apply spermicide
    • C/I: abnormal pap smear
    • Foams, Jellies, Creams
  107. Surgical Method
    • BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects
    • Vasectomy – cut vas deferens.
    • HT: >30 ejaculations before safe sex
    • O – zero sperm count , safe
    • High Risk Pregnancy
  108. Hemorrhagic Disorders
    • General Management
    • CBR
    • Avoid sex
    • Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
    • Ultrasound to determine integrity of sac
    • Signs of Hypovolemic shock
    • Save discharges – for histopathology
  109. First Trimester Bleeding
    • Abortion
    • Ectopic pregnancy
  110. Abortion
    • – termination of pregnancy before age of viability (before 20 weeks)
    • Spontaneous Abortion- miscarriage
    • Causes:
    • 1.) chromosomal alterations
    • 2.) blighted ovum
    • 3.) plasma germ defect
  111. Classifications:
    • Threatened
    • Inevitable
    • Complete
    • Incomplete
    • Habitual
    • Missed
    • Induced Abortion
  112. Threatened
    • – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
  113. Inevitable
    • Moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
  114. Complete – all products of conception are expelled. No mgt just emotional support! Incomplete – Placental and membranes retained. Mgt: D&C
  115. Habitual
    • 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
    • Present: 2nd trimester
  116. Missed
    • fetus dies ; product of conception remain in uterus 4 weeks or longer; signs of pregnancy ceases; (-) preg test; scanty dark brown bleeding
    • Mgt: induced labor with oxytocin or vacuum extraction
  117. Induced Abortion
    • – Therapeutic abortion to save life of mom.
  118. Ectopic Pregnancy
    • – occurs when gestation is located outside the uterine cavity.
    • Common site: tubal or ampular
    • Dangerous site - interstitial
  119. Unruptured
    • missed period
    • abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)
    • scant, dark brown, vaginal bleeding
    • Nursing care:
    • Vital signs
    • Administer IV fluids
    • Monitor for vaginal bleeding
    • Monitor I & O
  120. Tubal rupture
    • sudden , sharp, severe pain . Unilateral radiating to shoulder.
    • + Cullen’s Sign
    • syncope (fainting)
    • Mgt:
    • Surgery depending on side
    • Ovary: oophorectomy
    • Uterus : hysterectomy
  121. Second trimester bleeding
    • Hydatidiform Mole
    • Gestational anomaly of the placenta consisting of a bunch of clear vesicles.
  122. Second trimester bleeding
    • Hydatidiform Mole
    • This neoplasm is formed from the selling of the chronic villi and lost nucleus of the fertilized egg.
    • The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.
  123. Hydatidiform
    • Use: methotrexate to prevent choriocarcinoma
  124. Hydatidiform
    • Early in pregnancy
      • High levels of HCG
      • Preeclampsia at about 12 weeks
    • Late signs:
      • hypertension before 20th week
      • Vesicles look like a “ snowstorm” on sonogram
      • Anemia
      • Abdominal cramping
  125. Hydatidiform
    • Nursing care:
      • Prepare D&C
      • Do not give oxytoxic drugs
    • 2 . Incompetent Cervix – cervical dilation without uterine contractions
    • Assessment:
      • 1. Hx of previous abortions
      • 2. Cervical dilatation/effacement
      • 3. Membrane present in cervical os
    • Interventions
      • 1. bedrest
      • 2. cervical cerclage
    • McDonalds procedure – temporary cerclage on cervix
    • S/E: infection. During delivery, cerclage is removed. NSD
    • Sheridan – permanent surgery cervix. CS
    • Third Trimester Bleeding “Placenta Anomalies”
  126. Placenta Previa
    • Abnormal lower implantation of placenta .
    • Candidate for CS
    • Sx:
      • Bright red
      • Painless bleeding
  127. Placenta Previa
    • Dx:
    • Ultrasound
    • Avoid: sex, IE, enema – may lead to sudden fetal blood loss
    • Double set up: delivery room may be converted to OR
  128. Placenta Previa
    • Assessment:
    • Engagement (usually has not occurred)
    • Fetal distress
    • Presentation ( usually abnormal)
    • Surgeon – in charge of sign consent, RN as witness
    • MD explain to patient
  129. Placenta Previa
    • Nursing Care
    • NPO
    • Bed rest
    • Prepare to induce labor if cervix is ripe
    • Administer IV
  130. Abruptio Placenta
    • Outstanding Sx: dark red, painful bleeding , board like or rigid uterus.
  131. Abruptio Placenta
    • Assessment:
    • Concealed bleeding
    • Couvelaire uterus (caused by bleeding into the myometrium) Dropping coagulation factor (a potential for DIC)
  132. Abruptio Placenta
    • Complications:
    • Sudden fetal blood loss
    • Placenta previa & vasa previa
  133. Abruptio Placenta
    • Nursing Care:
    • Infuse IV, prepare to administer blood
    • Type and crossmatch
    • Monitor FHR
    • Insert Foley cath
    • Measure blood loss; count pads
    • Report s/sx of DIC
    • Monitor v/s for shock
    • Strict I&O
    • Placenta succenturiata
    • Placenta Circumvallata
    • Placenta Marginata
    • Battledore Placenta
    • Placenta Bipartita
    • Velamentous Insertion of cord
    • Vasa Previa
  134. Hypertensive Disorders
    • I. Pregnancy Induced Hypertension (PIH )
  135. Pregnancy Induced Hypertension (PIH )
    •  HPN after 20 wks of pregnancy, solved 6 weeks post partum.
    • Gestational hypertension - HPN without edema & proteinuria
    • Pre-eclampsia – HPN with edema & protenuria or albuminuria HE P/A
    • HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count
  136. Chronic or pre-existing Hypertension
    • – HPN before 20 weeks not solved 6 weeks post partum.
  137. Three types of pre-eclampsia
    • Mild preeclampsia – earliest sign of preeclampsia
    • a.) increase wt due to edema
    • b.) BP 140/90
    • c.) proteinuria +1 - +2
  138. Three types of pre-eclampsia
    • Severe preeclampsia
    • Signs present: cerebral and visual disturbances, epigastric pain and oliguria
    • BP 160/110
    • Proteinuria +3 - +4
  139. Three types of pre-eclampsia
    • Eclampsia – with seizure!
    • Increase BUN – glomerular damage.
    • Provide safety.
  140. Cause of preeclampsia
    • Idiopathic or unknown common in primi
    • Common in multiple pregnancy (twins)
    • Common to mom with low socioeconomic status
  141. Nursing care: PPPEACE
    • P – romote bed rest
    • P – prevent convulsions by nursing measures or seizure precaution
  142. Nursing care: PPPEACE
    • turning to side is done AFTER seizure! Observe only!
    • E – ensure high protein intake ( 1g/kg/day)
        • Na – in moderation
    • A – anti-hypertensive drug Hydralazine (Apresoline)
  143. Nursing care: PPPEACE
    • C – convulsion, prevent! – give Mg So4 – CNS depressant
    • E – evaluate physical parameters for Magnesium sulfate
    • DIABETES MELLITUS
  144. Diabetes Mellitus
    • Absence of insulin (Islet of Langerhans of pancreas)
    • is an endocrine disorder in which the PANCREAS cannot produce adequate insulin to regulate body glucose levels
    • Classifications of Diabetes Mellitus ( American Diabetes Association)
    • Type 1 Insulin-dependent DM
    • Type 2 Non-insulin- dependent DM
    • Gestational Diabetes
    • Impaired Glucose Homeostasis -A state between normal and diabetes
    • Dx: 1 hr 50gr glucose tolerance test GTT
    • Normal glucose  80 – 120 mg/dl;
    • <>
    • > 120  hyperglycemia
    • 3 degrees GTT of > 130 mg/dL
    • 3 hour oral glucose tolerance test
    • 100 g oral glucose solution
    • fasting 95mg/dL
    • 1 hour 180mg/dL
    • 2 hour 155mg/dL
    • 3 hour 140mg/dL
  145. Diabetes Mellitus
    • Maternal effect DM
    • Hypo or hyperglycemia
    • Frequent infection
    • Polyhydramnios
    • Dystocia
    • Hyperglycemia- fatigue , flushed hot skin, dry mouth, excessive thirst, frequent urination, rapid deep respirations, fruity odor, depressed reflexes, drowsiness, headache
    • Hypoglycemia-
    • shakiness, dizziness, sweating, pallor, cold clammy skin, disorientation, irritability, headache, hunger, blurred vision, nervousness, weakness, fatigue, shallow respirations, normal PR
  146. Diabetes Mellitus
    • Insulin requirement: decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd – 3rd trimester.
    • Post partum decrease 25%
  147. Fetal effect: DM
    • hyper & hypoglycemia
    • macrosomia – large gestational age – baby delivered > 4000g or 4kg
    • preterm birth to prevent stillbirth
  148. Newborn Effect : DM
    • hyperinsulinism
    • hypoglycemia
    • hypoglycemic <>
    • Heel stick test – get blood at heel
  149. Newborn Effect : DM
    • Hypoglycemia: high pitch shrill cry tremors, administer dextrose
    • Hypocalcemia - <>
      • Calcemia tetany
      • Trousseau sign
      • Give calcium gluconate if decrease calcium
    • HEART DISEASE
  150. Heart disease
    • Class I – no limit to physical activity
    • Class II – slight limitation of activity.
  151. Heart disease
    • Class III - moderate limitation of physical activity.
    • Class IV - marked limitation of physical activity.
  152. Recommendation
    • Therapeutic abortion
    • If push through with pregnancy
      • Antibiotic therapy
      • Anticoagulant
  153. Recommendation
    • Class I & II- good progress for vaginal delivery
    • Class III & IV- poor prognosis, for vaginal delivery, not CS!
    • RH INCOMPATIBILITY (ISOIMMUNIZATION)
    • Occurs when an Rh-negative mother (one negative for a D antigen or one with a dd genotype) is CARRYING A FETUS WITH AN Rh-positive blood type (DD or Dd genotype).
    • Subsequent exposure to Rh-positive blood can cause a serious reaction that results in agglutination and hemolysis of red blood cells
    • * A fetus can become so deficient in red blood cells that sufficient O2 transport to the body cannot be maintained=HEMOLYTIC DISEASE OF THE NEWBORN or ERYHTROBLASTOSIS FETALIS
    • CAUSES:
    • 1. SEPARATION OF PLACENTA
    • 2. AMNIOCENTESIS
    • 3. PERCUTANEOUS UMBILICAL BLOOD SAMPLING
    • ANTIBODY SCREENING TEST (indirect Coomb’s test)
      • -done on the mother’s blood to measure the number of Rh-positive antibodies
    • DIRECT COOMBS’ TEST
      • -done on the infant’s blood to detect antibody-coated Rh-positive RBC’s
  154. ASSISTED BIRTH
    • Cesarean Delivery
    • Indications:
    • Multiple gestation
    • Diabetes
    • Active genital herpes II
    • Severe toxemia
    • Complete Placenta previa
    • Abruptio placenta
    • Prolapse of the cord
    • UTERINE INCISIONS
    • a. kerr
    • b. sellheim- vertical incision in the lower uterine segment
    • c. classic
    • FORCEPS DELIVERY
    • 3 Categories
    • Outlet forceps
    • Low forceps
    • midforceps

    • INDICATIONS:
    • Heart dse
    • Pulmonary edema
    • Infection
    • Exhaustion
    • Premature placental separation
    • Fetal nonreassuring status
    • Conditions before forceps delivery:
      • Cervical dilatation is complete
      • Membranes must be ruptured
      • Type of pelvis should be known
      • Maternal bladder should be empty and adequate anesthesia given
      • No degree of CPD can be present
    • VACUUM- ASSISTED BIRTH
    • used to facilitate the birth of a fetus by applying suction to the fetal head
    • Composed of soft suction cup attached to a suction bottle (pump) by tubing
    • Suction cup is placed against the fetal occiput.
  155. INFERTILITY
    • Inability to achieve pregnancy. Within a year of attempting it
    • Manageable
    • In order to get pregnant:
    • 1. A woman must release an egg from one of her ovaries (ovulation).
    • 2. The egg must go through a fallopian tube toward the uterus (womb).
    • 3. A man's sperm must join with (fertilize) the egg along the way.
    • 4. The fertilized egg must attach to the inside of the uterus (implantation).
    • Is infertility a common problem?
    • Is infertility just a woman's problem?
          • NO
    • What causes infertility in men?
    • Infertility in men is most often caused by:
    • problems making sperm -
    • problems with the sperm's ability to reach the egg and fertilize it
    • Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury.
    • What increases a man's risk of infertility?
    • The number and quality of a man's sperm can be affected by his overall health and lifestyle.
    • What causes infertility in women?
    • Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized.
    • Less common causes of fertility problems in women include:
    • blocked fallopian tubes physical problems with the uterus
    • uterine fibroids
    • What things increase a woman's risk of infertility?
    • Many things can affect a woman's ability to have a baby. These include:
      • 1.age
      • 2.stress
      • 3.poor diet
      • 4.athletic training
    • How long should women try to get pregnant before calling their doctors?
    • Some health issues also increase the risk of fertility problems. So women with the following issues should speak to their doctors as soon as possible :
    • irregular periods or no menstrual periods
    • very painful periods
    • endometriosis
    • pelvic inflammatory disease
    • more than one miscarriage
    • How will doctors find out if a woman and her partner have fertility problems?
    • For a woman, the first step in testing is to find out if she is ovulating each month.
    • Some common tests of fertility in women include :
    • Hysterosalpingography : In this test, doctors use x-rays to check for physical problems of the uterus and fallopian tubes.
    • Laparoscopy:
    • During this surgery doctors use a tool called a laparoscope to see inside the abdomen.
    • How do doctors treat infertility?
    • Infertility can be treated with medicine, surgery, artificial insemination or assisted reproductive technology.
    • Doctors often treat infertility in men in the following ways:
    • Sexual problems: Behavioral therapy and/or medicines can be used in these cases.
    • Too few sperm:, doctors can surgically remove sperm from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count.
    • Intrauterine insemination (IUI) - is known by most people as artificial insemination.
      • IUI is often used to treat:
    • mild male factor infertility
    • women who have problems with their cervical mucus
    • couples with unexplained infertility
    • What medicines are used to treat infertility in women?
    • Some common medicines used to treat infertility in women include:
    • 1.Clomiphene citrate ( Clomid ): This medicine causes ovulation by acting on the pituitary gland.
    • 2.Human menopausal gonadotropin or hMG ( Repronex, Pergonal ): This medicine is often used for women who don't ovulate due to problems with their pituitary gland.
    • 3.Follicle-stimulating hormone or FSH ( Gonal-F, Follistim ): FSH works much like hMG..
    • 4.Gonadotropin-releasing hormone (Gn-RH) analog : These medicines are often used for women who don't ovulate regularly each month.
    • 5. Metformin ( Glucophage ): Doctors use this medicine for women who have insulin resistance and/or Polycystic Ovarian Syndrome (PCOS) . This drug helps lower the high levels of male hormones in women with these conditions.
    • 6. Bromocriptine ( Parlodel ): This medicine is used for women with ovulation problems due to high levels of prolactin.
    • Many fertility drugs increase a woman's chance of having twins, triplets or other multiples.
    • What is assisted reproductive technology (ART)?
    • Assisted reproductive technology (ART) is a term that describes several different methods used to help infertile couples.
    • How often is assisted reproductive technology (ART) successful?
    • age of the partners
    • reason for infertility
    • clinic
    • type of ART
    • if the egg is fresh or frozen
    • if the embryo is fresh or frozen
    • What are the different types of assisted reproductive technology (ART)?
    • Common methods of ART include:
    • 1. In vitro fertilization (IVF) . Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.
    • 2. Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer - Fertilization occurs in the laboratory. Then the very young embryo is transferred to the fallopian tube instead of the uterus.
    • 3.Gamete intrafallopian transfer (GIFT) involves transferring eggs and sperm into the woman's fallopian tube.
    • 4. Intracytoplasmic sperm injection (ICSI)
    • In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.
  156. 2 types of infertility
    • 1.) primary
    • 2.) Secondary
    • Sims Huhner test
  157. Infertility
    • Normal: cervical mucus must be stretchable 8 – 10 cm
    • Best criteria- sperm motility for impotency
  158. Infertility
    • Mgt:
    • GIFT= Gamete Intra Fallopian Transfer for low sperm count
    • Mom: anovulation – no ovulation
    • hyperprolactinemia
    • Tubal Occlusion – tubal blockage
    • = dx: hysterosalphingography
    • Mgt: IVF – invitrofertilization
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