Professional Documents
Culture Documents
step process, then a 4-step process (APIE), then a 5-step (ADPIE), now
NURSING PROCESS
directs the nurse and the client to determine the need for
the result.
nursing care.
Goal-oriented – nurse make her objective based on client’s health
needs.
as the nurse.
sequence.
Humanistic care
money/cost)
Cyclic and Dynamic in nature – data from each phase provides the
status.
Uses Critical Thinking skills – the nurse may encounter new ideas
nursing care.
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
standard/norm.
client):
• physical assessment
4 Types of Assessment:
on admission
problems.
a cardiac arrest.
obtained.
Activities:
1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data
I. Collection of data
Types of Data:
a. Subjective data
b. Objective data
skin
a. Interview
instruments.
c. Examination
affected
Source of data:
occupation, religion.
systems
neighborhood conditions.
state.
the client says, or what the nurse can see, hear, feel, smell or
measure.
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
model, pattern:
V. Communicate/Record/Document Data
• nurse records all data collected about the client’s health status
nurse
problems
Diagnosis.
Nursing Diagnosis
problems that a nurse can identify and for which she can order
interventions.
3 activities in Diagnosing:
of Nursing Diagnosis
2. Etiology/related factors/causes = E
and symptoms.
Examples:
appetite nausea.
Diagnosis
Examples:
• Possible nutritional deficit
does not exist, therefore no S/S are present, but the presence of RISK
Examples:
• Risk for Impaired skin integrity (left ankle) r/t decrease peripheral
circulation in diabetes.
insufficient, incomplete
deteriorated
VS: T=39.2C RR = 35 P = 96; With flush skin and warm to touch, teary
skin, warm to touch, teary eyed and dry lip and mucous membrane.
Nauseated x 2 days
Nsg. Dx: Imbalanced Nutrition: Less than body Requirements r/t
Nsg Dx: Disturbed Sleep Pattern r/t a disease process, orthopnea and
pain.
Anxious
Nsg. Dx: Anxiety r/t difficulty of breathing and concerns over parenting
roles.
PLANNING
Purpose:
1. Establish/Set priorities
in the afternoon.
afternoon.
Nursing interventions
skills.
specific routines.
care team.
NCP
identified goal.
intervention.
IMPLEMENTATION
Activities:
Requirements of Implementation:
EVALUATION
outcome criteria.
Activities:
A. External Structures:
1. Mons Veneris/Pubis - Pad of fat which lies over the symphysis
pubis where dark and curly hair grow in triangular shape that
from mons veneris to the perineum that protect the labia minora,
support the pelvic organs, the arteries that supply blood and the
anesthesia.
B. Internal Structures:
1. Fallopian tube/Oviduct - 4 inches long from each side of the
the uterus and provide a place for fertilization of the ova by the
usually occurs.
conception.
Layers:
structure.
of pathologic bacteria.
b. Site of Fertilization.
4. Ovaries a. Endocrine glands that secrete estrogen and
progesterone.
Ovum
ovulation.
resorbed.
The sperm cell has three parts: a head that contain the chromatin
the genital tract 4-6 hours before they are able to fertilize an ovum to
give time for the enzyme hyaluronidase to be activated. There are two
Fertilization
• Per ejaculation the average 2.5ml of seminal fluid contains 50 to
fallopian tube.
spermatozoon.
Segmentation:
Within a few hours after fertilization, after the nucleus of the sperm
has united with the nucleus of the egg, the result of their union, the
cells, then four, eight, sixteen, and so on, doubling the number with
this time, it has developed into a hollow ball of cells called blastocyst.
Implantation
mitotic cell division happens. Floating freely in the uterus for the
fertilization to implantation.
• Implantation occurs at high and posterior portion of the uterus.
on conception.
menstrual period until the last day before the next menstrual period.
Purpose:
growth
TERM DESCRIPTION
Beginning (Menarche) average age of onset: 12 or 13
years;
Discomforts of Menstruation
Abnormalities of Menstruation
menstrual cycle:
1. Hypothalamus
2. Pituitary gland
3. Ovaries
4. Uterus
Reproductive Hormones:
1. Gonodotropin-
Releasing Hormone
(GnRH)
o Stimulates release of
menstrual cycle
o stimulate growth and maturation of graafian follicle before
ovulation
causes ovulation
luteum
4. Estrogen
characteristics
secretion of Prolactin
5. Progesterone
pregnancy
o inhibits secretion of LH
uterus
Pregnancy
6. Prolactin
7. Oxytocin
breastfeeding
8. Prostaglandins
o fatty acids’ categorized as hormones
o produced by many organs of the body, including the
endometrium
Spontaneous Abortion
A. Description
1. Spontaneous abortion is the expulsion of the fetus and
dilation.
1. Fetal Factors
d. Chromosomal abnormalities
2. Placental Factors
placenta
3. Maternal Factors
a. Infection
b. Severe malnutrition
cervix)
e. Trauma
f. Drug ingestion
D. Assessment Findings
a. Crying
b. Depression
E. Implementation
complications
cramping of pain.
(D & C) if indicated.
c. Prepare for PhoGAM administration to an Rh-
abortion.
intercourse.
c. Explain that in many cases, no cause for the
Preparation:
uterine contractions).
Fundal lying in the part lying in Breech is less well defined that
the body.
To
determine
presentatio
n.
Second To identify One hand is Fetal back is smooth, hard, and
position. the
abdomen
while the
other hand
moves
slightly on a
circular
motion from
top to the
lower
segment of
the uterus
to feel for
the fetal
back and
small fetal
parts.
Use gentle
but deep
pressure.
Third To Using The presenting part is not
: engagemen finger,
It is not yet engaged if it is still
Pawlik’s t of grasp the
movable.
Grip presenting lower
part. portion of
the
abdomen
above
symphisis
pubis, press
in slightly
and make
gentle
movements
from side to
side.
Fourth To Facing foot Good attitude - if brow
development.
RESPONSE
Rooting and Newborns turns head Weak or no
secondary to
maternal drug
ingestion (eg.
narcotics).
Extrusion Newborn pushes Continuous
and seizures.
Swallowing Newborn swallows in coordination Gagging, coughing,
possibly associated
with cyanosis
secondary to
prematurity,
neurologic deficit,
or injury; typically
seen after
laryngoscopy.
Moro Bilateral symmetrical extension and Asymmetrical
injury or fracture of
injury or fracture of
long bone of leg.
and neurologic
disorders.
Complete and
consistent absence
of response to loud
deafness. Response
may be absent or
diminished during
sleep.
Crossed Newborn’s opposite leg will flex and Weak or absent
neurologic deficit.
Palmar Newborn’s finger Response is
nerve damage
(brachial plexus) or
fracture of
humerus. No
response occurs
with severe
neurologic deficit.
Plantar Newborn’s toes will Diminished
with severe
neurologic deficit.
Babinski Newborn’s toes will No response occurs
apart from
extrauterine life. It is taken at one minute and five minutes after birth.
The one minute score indicates the necessity for resuscitation. The five
deficits. The most important is the heart rate, then the respiratory rate,
the muscle tone, reflex irritability and color follows in decreasing order.
A heart rate below 100 signifies an asphyxiated baby and a heart rate
Assess 0 1 2
HEART RATE Absent Below 100 Above 100
RESPIRATION Absent Slow Good crying
MUSCLE TONE Flaccid Some flexion Active motion
REFLEX No Response Grimace Vigorous cry
IRRITABILITY
COLOR Blue all over Body pink, Pink all over
extremities
blue
SCORE:
12. Enters pulmonary artery with some blood going to the lungs to
extremeties)
placenta
to the fetus
Foramen Ovale - Connects the left and right atrium. It pushes blood
from the right atrium to the left atrium so that blood can be supplied to
from the obvious changes in your body shape and the size of your
they are not experienced by all pregnant women and may not be a
• You may need to try more than one remedy before you find one that
works for you.
• Good nutrition is especially important for a comfortable and healthy
pregnancy. Eating well can minimize discomforts and help your body
cope with the stress of daily life.
• If you have a physical discomfort that is severe or does not go away,
contact your health care provider.
• If you have a chronic health condition, such as diabetes or asthma, it
is very important that you see your health care provider throughout
your pregnancy.
DISCOMFORT SOLUTION
Ankle Edema Rest with your feet elevated. Avoid
heeled shoes.
Breast Tenderness Wear a supportive bra. Decrease the
beverages ingested.
Constipation Increase fiber in your diet. Drink additional
movements.
Difficulty Sleeping Drink a warm, caffeine-free drink before
for comfort.
Faintness Move slowly. Avoid crowds. Remain in a
when at rest.
Headache Avoid eye strain. Visit your eye doctor.
Rest with a cool cloth on your forehead.
fried foods.
Hemorrhoids Avoid constipation and straining with a
relieve discomfort.
Shortness of Use proper posture. Use pillows behind
tight pantyhose.
Varicose veins Walk regularly. Rest with feet elevated.
support hosiery.
childbirth.
contraceptive method:
1. Religious orientation
3. Medical contraindications
4. Psychological contraindications
6. Cost
9. Personal lifestyle
This has 0% failure rate. Also, this is the most effective way to prevent
STDs.
ovulation).
falls about half a degree. At the time of ovulation, her BBT rises a
month, the cervical mucus is thick and does not stretch when
anterior tilt to the cervix occur. All the days the mucus is copious
and the 3 days after the peak day are considered to be fertile
days, or days the woman should abstain from sex to avoid
conception.
days after the rise in temperature or the fourth day after the
even if she has not had a period since childbirth. After 6 months
conception.
II. Barrier Methods – are forms of birth control that works by the
required.
internal ring forming the cervical barrier and a wide outer ring
spontaneity.
C. Male condom - This is a rubber sheath that fits over the erect
penis and prevents sperm from entering the vagina. The condom
but they are expensive and do not protect against most STDs.
rubber cap that inserts into the vagina and covers the cervix.
The posterior rim rests on the posterior fornix and the anterior
rims fits snugly behind the pubic bone. It is used with spermicide
in the dome and around the rim, is applied no more than 2 hours
are that there are possibly serious side effects. The device is
ovum. The tablets are taken daily and are available in numerous
97% effective. Advantages are that they are among the most
calf or thigh.
and it must be taken at the same time each day. There is no data
to suggest that minipills increase the risk of cardiovascular
disease or malignancy.
years). Advantages are that they are long acting (effective for up
the life of the drug, and require little attention other than health
year.
STDs.
necessary inserted
No costs; acceptableRequires high
Periodic
20 to Roman Catholicmotivation and
Abstinence
Church periods of abstinence
Withdrawal 18 No cost Requires Motivation
Can use for severalMay be difficult to
cervix
No major health risks;Insertion may be
Diaphragm 18
easy to use difficult
Female Protection againstInsertion may be
15
Condom STDs difficult
Protects againstRequires interruption
necessary
No memory orCramping, bleeding;
e 12 weeks
Implanted Coitus independent;Initial cost;
e years
Female Permanent and highlyInitial cost;
0.4
sterilization reliable irreversible
Male Permanent and highlyInitial cost;
0.1
sterilization reliable irreversible
CLINICAL MANIFESTATIONS
2. Suprapubic pressure
3. Vaginal presure
8. Bloody show
NURSING MANAGEMENT
contractions
prescribed.
hydration
Before performing Leopold’s Maneuver, ask the mother to empty the bladder, warm
hands, and apply them to the mother’s abdomen with firm and gently pressure.
2. Place pals on each side of the upper abdomen and palpate around the fundus
3. You would feel a hard, round, movable object if the head is in the fundus
4. You would feel soft and have an irregular shape and are more difficult to move
1. Move hand downward over each side of the abdomen, applying firm, even
pressure.
2. The fetus’s back which is a smooth, hard surface should be felt on one side of
the abdomen.
3. The hands, feet, elbows, and knees which are as irregular knobs and lumps
3. Bring thumb and fingers together and grasp the part of fetus between them
1. It is used in the late stage of pregnancy to determine how far the fetus has
descended into the pelvic inlet.
2. Place hand on the sides of the lower abdomen close to the midline
4. If you have determined that the buttocks are in the fundus, then feel for the
head
• Home
• Classes
• En español
•
Search
• Finding a Doctor/Midwife
• Pregnancy
• Breastfeeding
• Your Newborn
Pregnancy
• Month-by-Month Guide
• Fetal Development
• Common Discomforts
development.
diabetes.
provider.
delivering at.
lactation consultant.
Breastfeeding
breast milk directly from human breasts rather than from a baby bottle
suck and swallow milk. Most mothers can breastfeed for six months or
Human breast milk is the most healthful form of milk for human babies.
[1]
There are a few exceptions, such as when the mother is taking
promotes health, helps to prevent disease and reduces health care and
Both the World Health Organization (WHO) and the American Academy
more common in babies fed formula.[7] The WHO[8] and AAP[9] both
include:
[hide]
• 1 Lactation
• 2 Breast milk
o 4.2 Bonding
• 5 Organisational endorsements
• 6 Breastfeeding difficulties
[edit] Lactation
Not all the properties of breast milk are understood, but its nutrient
an average of 500 calories a day it helps the mother lose weight after
how long the baby nurses at each session, as well as on the age of the
child.
requirements:[12]
Energy: 29%
Folate: 76%
Protein: 43%
Vitamin
94%
B12:
Calcium: 36%
Vitamin C: 60%
Vitamin A: 75%
bad food habits, chronic illnesses, smoking, and drinking. [13][unreliable source?]
[14]
Breast milk has just the right amount of fat, sugar, water, and protein
also reduce viral shedding of the HIV virus in Breast milk.[22] Due to
Two initial studies suggest babies with a specific version of the FADS2
compared with babies with a less common version of the gene who
metabolism of fatty acids, such as DHA and AA, which are known to be
have been adding DHA and AA fatty acids to their products since this
the idea that the nutritional content of breast milk accounts for the
infant."[25]
were breastfed for more than eight months had significantly higher
evidence to suggest that breast milk feeding may have small long term
an earlier exposure to cow milk and solid foods. [27] Breastfeeding also
allergies.[dubious – discuss][32]
However, another study showed breastfeeding
(CD) concluded that breast feeding while introducing gluten to the diet
were breast fed in infancy may have a lower risk of developing breast
infections
effusion, OME) in the first two years of life. The researches concluded,
"For a decrease in the amount of time with OME during the first 2 years
Limiting early child care in large groups might also be advisable.". [38]
Another study found that breastfed babies had half the incidence of
diarrheal illness, 19% fewer cases of any otitis media infection and
80% fewer prolonged cases of otitis media than formula fed babies in
(atopy)
though these benefits may not be present after four months of age.[40]
infants
times more common in infants fed formula exclusively, and three times
exclusively on formula.[43]
Breastfed babies have better arousal from sleep at 2–3 months. This
the best nourishment for a child at a small nutrient cost to the mother.
released into the mother's body.[15] and the maternal bond can be
Women who breast feed for longer have less chance of getting
Women Who Breast Feed for More than a Year Halve Their Risk of
because they contain hormones that are raised in pregnancy, did not
have the same effect. Simply having children but not breast feeding
[edit] Bonding
baby with expressed breast milk. The various breast pumps available
for sale and rent help working mothers to feed their babies breast milk
and store enough milk to feed the child for the time she is away, and
mother and make her feel more nurturing toward her baby.[55]
levels, making her uterus contract more quickly and reducing bleeding.
uterus contract.[51]
women, and diet and exercise are more reliable ways of losing weight.
[57]
absent differs for each woman. This Lactational amenorrhea has been
98% effectiveness during the first six months after birth if specific
“
[the] vast majority of mothers can and should breastfeed, just
“
Extensive research, especially in recent years, documents
and child.
the birth helps to avoid many problems. The AAP breastfeeding policy
mothers do not breast feed their children due to work pressures. For
breaks, and find a clean, private and quiet place at work for pumping.
guidelines:
week. This average is taken from the lowest weight, not the birth weight.
The average breastfed baby doubles its birth weight in 5–6 months. By
one year, a typical breastfed baby will weigh about 2½ times its birth
weight. At one year, breastfed babies tend to be leaner than bottle fed
In the half hour after birth, the baby's suckling reflex is strongest, and
the baby is more alert, so it is the ideal time to start breastfeeding. [63]
problems [64]
means feeding when the baby shows signs of hunger; feeding this way
rather than by the clock helps to maintain milk production and ensure
the baby's needs for milk and comfort are being met.[8] However, it
exhausting feeling.[67]
and needs of babies vary. While some infants' sucking needs are met
the breast soon after a feeding even though they are not really hungry.
Babies may also nurse when they are lonely, frightened or in pain.[2]"
breastfeeding success.[3]"
Rooming-in bassinet
Most US states now have laws that allow a mother to breastfeed her
permits the baby to stay with the mother and improves the ease of
soreness and allow the baby to obtain enough milk.[68] The "rooting
reflex" is the baby's natural tendency to turn towards the breast with
the mouth open wide; mothers sometimes make use of this by gently
stroking the baby's cheek or lips with their nipple in order to induce the
moving baby onto the breast while baby's mouth is wide open.[69] In
order to prevent nipple soreness and allow the baby to get enough
milk, a large part of the breast and areola need to enter the baby's
mouth.[68][70] To help the baby latch on well, tickle the baby's top lip
with the nipple, wait until the baby's mouth opens wide, then bring the
baby up towards the nipple quickly, so that the baby has a mouthful of
nipple and areola. The nipple should be at the back of the baby's
throat, with the baby's tongue lying flat in its mouth. Inverted or flat
nipples can be massaged so that the baby will have more to latch onto.
Resist the temptation to move towards the baby, as this can lead to
poor attachment.
much longer period of time. Normal feeds at the breast can last a few
Sometimes, after the finishing of a breast, the mother may offer the
other breast.
While most women breastfeed their child in the cradling position, there
are many ways to hold the feeding baby. It depends on the mother and
child's comfort and the feeding preference of the baby. Some babies
prefer one breast to the other, but the mother should offer both
supporting pillows.
Two 25ml samples of human breast milk. The left hand sample is
foremilk, the watery milk coming from a full breast. The right hand
sample is hindmilk, the creamy milk coming from a nearly empty
breast.[72]
recommend that all infants be breastfed exclusively for the first six
diarrhea and infectious diseases. It has also been shown to reduce HIV
per feed. Each baby is different, but as it grows the amount will
assumed that the baby knows how much milk it needs and it is
therefore advised that the baby should dictate the number, frequency,
and length of each feed. The supply of milk from the breast is
milk expressed. The birth weight of the baby may affect its feeding
requirements to be. For example, a baby born small for gestational age
may lead a mother to believe that her child needs to feed more than if
soiled nappies (diapers): 8 wet cloth or 5–6 wet disposable, and 2–5
newborns older than 5–6 days old. After 2–3 months, stool frequency is
(artificially remove and store) her milk. With manual massage or using
a breast pump, a woman can express her milk and keep it in freezer
use. Breast milk may be kept at room temperature for up to ten hours,
milk decreases over time but it still remains at higher levels than in
infant formula.[74]
Expressing breast milk can maintain a mother's milk supply when she
and her child are apart. If a sick baby is unable to feed, expressed milk
an older baby bites the nipple, the mother's reaction - a jump and a cry
for a mother who feeds her baby exclusively on her breastmilk while
habits, particularly in the first 12 weeks when the milk supply is being
to exclusive pumping.
milk until the baby is 4–6 weeks old and is good at sucking directly
from the breast.[75] As sucking from a bottle takes less effort, babies
can lose their desire to suck from the breast. This is called nursing
mother (or wet nurse), so that the baby can learn to associate direct
feeding with the mother (or wet nurse) and associate bottle feeding
wet nurses was common, some women dislike the idea of feeding their
own child with another woman's milk; others appreciate being able to
give their baby the benefits of breast milk. Feeding expressed breast
by bottle
with infant formula, baby food and even water, depending on the age
of the child. Babies feed differently with artificial teats than from a
breast. With the breast, the infant's tongue massages the milk out
rather than sucking, and the nipple does not go as far into the mouth;
with an artificial teat, an infant will suck harder and the milk may come
using a pacifier) before the baby is used to feeding from its mother can
teats, which are generally slightly longer, are closer to the nipple.
continue to nurse the older as well as the younger. As the appetite and
feeding habits of each baby may not be the same, this could mean
feeding each according to their own individual needs, and can also
feeding around the appetites of all the babies. While breasts can
Tandem breastfeeding may also occur when a woman has a baby while
milk will change to colostrum, and some older nurslings will continue to
feed even with this change, while others may wean due to the change
and emotional, continue for as long as a child nurses. Often the older
nurse. Islam has codified the relationship between this woman and the
infants she nurses, and also between the infants when they grow up,
[edit] Weaning
Weaning is the process of introducing the infant to other food and
reducing the supply of breast milk. The infant is fully weaned when it
no longer receives any breast milk. Most mammals stop producing the
throughout life and so can drink milk - usually cow or goat milk - well
beyond infancy.[86]
it was discovered that when used for this purpose, this medication
posed serious health risks to women, such as stroke, and the U.S. Food
and Drug Administration withdrew this indication for the drug in 1994.
[87]
or goat milk were not very positive. In the 18th century, flour or cereal
this did not have a favorable outcome, either. True commercial infant
formulas appeared on the market in the mid 19th Century but their use
did not become widespread until after WWII. As the superior qualities
article for a summary of the key points of the subject. (May 2009)
whether or not to breastfeed and how long she breastfeeds her child.
• Race and culture Singh et al. also found that African American
were ever breast fed. They found that 71.5% of Caucasians had
work following the birth of their child are less likely to continue