Case Study: Spontaneous Abortion

A. Description

1. Spontaneous abortion is the expulsion of the fetus and other products of conception from the uterus before the fetus is capable of living outside of the uterus.

2. Types of spontaneous abortions

a. Threatened abortion - is characterized by cramping and vaginal bleeding in early pregnancy with no cervical dilation. It may subside or an incomplete abortion may follow.

b. Imminent or inevitable abortion – is characterized by bleeding, cramping and cervical dilation. Termination cannot be prevented.

c. Incomplete abortion – is characterized by expulsion of only part of the products of conception (usually the fetus). Bleeding occurs with cervical dilation.

d. Complete abortion – is characterized by complete expulsion of all products of conception.

e. Missed abortion – is characterized by early fetal intrauterine death without expulsion of the products of conception. The cervix is closed, and the client may report dark brown vaginal discharge. Pregnancy test findings are negative.

f. Recurrent (habitual) abortion – is spontaneous abortion of three or more consecutive pregnancies.

B. Etiology – Spontaneous abortion may result from unidentified natural causes or from fetal, placental or maternal factors.

1. Fetal Factors

a. Defective embryologic development

b. Faulty ovum implantation

c. Rejection of the ovum by the endometrium

d. Chromosomal abnormalities

2. Placental Factors

a. Premature separation of the normally implanted placenta

b. Abnormal placental implantation

c. Abnormal placental function

3. Maternal Factors

a. Infection

b. Severe malnutrition

c. Reproductive system abnormalities (eg, incompetent cervix)

d. Endocrine problems (eg, thyroid dysfunction)

e. Trauma

f. Drug ingestion

C. Pathophysiology – The fetal or placental defect or the maternal condition results in the disruption of blood flow, containing oxygen and nutrients, to the developing fetus. The fetus is compromised and subsequently expelled from the uterus.

D. Assessment Findings

1. Associated findings – The client and family may exhibit a grief reaction at the loss of pregnancy, including:

a. Crying

b. Depression

c. Sustained or prolonged social isolation

d. Withdrawal

2. Clinical Manifestations – include common signs and symptoms of spontaneous abortion.

a. Vaginal bleeding in the first 20 weeks of pregnancy

b. Complaints of cramping in the lower abdomen

c. Fever, malaise or other symptoms of infection

3. Laboratory and diagnostic study findings

a. Serum beta hCG levels are quantitatively low

b. Ultrasound reveals the absence of a viable fetus.

E. Implementation

1. Provide appropriate management and prevent complications

a. Assess and record vital signs, bleeding and cramping of pain.

b. Measure and record intravenous fluids and laboratory test results. In instances of heavy vaginal bleeding; prepare for surgical intevention (D & C) if indicated.

c. Prepare for PhoGAM administration to an Rh-negative mother, as prescribed. Whenever the placenta is dislodged (birth, D & C, abruptio) some of the fetal blood may enter maternal circulation. If the woman is Rh negative, enough Rh-positive blood cells may enter her circulation to cause isoimminization, the production of antibodies against Rh-positive blood, thus endangering the well-being of future pregnancies. Because the blood type of the conceptus is not known, all women with Rh-negative blood should receive RhoGAM after an abortion.

d. Recommended iron supplements and increased dietary iron as indicated to help prevent anemia.

2. Provide client and family teaching

a. Offer anticipatory guidance relative to expected recovery, the need for rest and delay of another pregnancy until the client fully recovers.

b. Suggest avoiding intercourse until after the next menses or using condoms when engaging in intercourse.

c. Explain that in many cases, no cause for the spontaneous abortion is ever identified.

3. Address emotional and psychosocial needs.

Case Study: G6PD Deficiency

What is G6PD deficiency?
Glucose-6-phosphate dehydrogenase deficiency, or G6PD deficiency for short, is the most common “inborn metabolic disorder” in the world. This means that from the time a baby is born, there is already something wrong with how his body makes and breaks important substances. According to statistics, about 400 million people have G6PD deficiency, and it is most common in Africa, Southeast Asia and the Middle East.
Babies with G6PD deficiency have very little or no enzyme called Glucose-6-Phosphate Dehydrogenase (G6PD). An enzyme is a kind of protein that speeds up chemical reactions in the body. The enzyme G6PD is especially important to red blood cells. If this enzyme is lacking or missing, red blood cells are easily destroyed.

Another name for G6PD deficiency is favism because some people who have it, usually those living in the Meditteranean region, react very badly to fava beans

What causes G6PD deficiency?
In order to understand what causes G6PD deficiency, one must first learn a bit about genes and chromosomes.

Genes are like the body’s blueprints. They contain instructions on how specific parts of the body are made. For example, if the instructions in your hair genes say your hair is black, your hair will be black. Genes are packaged into threadlike structures called chromosomes. A chromosome is very much like a beaded bracelet. The beads are the different genes that give instructions for different part of the body; the entire bracelet is the chromosome. Genes usually come and act in pairs. One member of a specific pair comes from the father, and the other member comes from the mother. The members of a pair are located on paired chromosomes.

All normal human beings have 23 pairs of chromosomes. Each of the first 22 pairs contain the same number and kind of genes. The last and 23rd pair is the sex chromosomes. They are different from the first 22 pairs in that they do not have the same number and kind of genes. The sex chromosomes contain the genes that determine whether a baby will be a girl or a boy.

There are 2 kinds of sex chromosomes, X and Y. All baby girls have two X chromosomes. All baby boys have one X and one Y. The gene that gives instructions on how G6PD is made is found in the X chromosome only, thus G6PD deficiency is described as X-linked.
If a baby girl gets one defective G6PD gene from either of her parents, she will not have G6PD deficiency because she has another G6PD gene that can do the work (remember: a baby girl has two X chromosomes, thus two G6PD genes). But if she gets two defective G6PD genes from both her parents, she will have G6PD deficiency. On the other hand, a baby boy whose G6PD gene is defective will surely get G6PD deficiency because the Y chromosome has no G6PD gene.

A defective G6PD gene will give wrong instructions on how to make the enzyme G6PD. As a result, too little or none of it is made.

What are the harmful effects of G6PD deficiency?
G6PD has a very small but strategic role in protecting the body from substances that can cause damage to cells or oxidative substances. Because of this important role, G6PD is normally found in all parts of the body. To be sure, most parts of the body also keep a “spare” enzyme, one that can do the work of G6PD in case it is lacking or missing entirely. Unfortunately, this is not the case with red blood cells. They do not have spare enzymes that can do the work of G6PD. If a baby does not have enough G6PD, his red blood cells lack protection from the harmful effects of oxidative substances.

A baby with G6PD deficiency appears and remains healthy until he is exposed to a large amount of oxidative substances. When this happens, his red blood cells are destroyed, a process known as hemolysis.

Red blood cells carry oxygen to all parts of the body. When they undergo hemolysis, the baby will have hemolytic anemia. The signs and symptoms of hemolytic anemia are paleness, dizziness, headache, tea-colored urine, and abdominal or back pain or both. Hemolytic anemia, when very severe, can end in death. Destroyed red blood cells are brought to the liver to be broken down to smaller pieces for disposal. One of the end products of this process is bilirubin, a yellowish substance that accumulates in different parts of the body when too much of it is produced. Quite often, bilirubin accumulates in the skin and causes it to appear yellowish. In the worst cases, biliribin accumulates in the brain and causes mental retardation or death.

Where do oxidative substances come from?
Hemolysis of red blood cells will only occur IF and WHEN a G6PD deficient child is exposed to oxidative substances. Oxidative substances are found in certain drugs, foods, and beverages. The body also produces oxidative substances during severe infections or illnesses such as typhoid fever, pneumonia, or kidney failure.
Most drugs with strong oxidative effects are of kinds:
1. antibiotics of the sulfa group
2. medicines for malaria
3. some medicines for fever

How is G6PD deficiency treated?
When a child has taken oxidative substances and suddenly shows the signs and symptoms of hemolytic anemia, he is said to have a hemolytic crisis. During such crisis, the goal of doctors and nurses is to prevent the harmful effects from getting worse. Blood transfusion, oxygen, and folic acid may be given.
The ultimate treatment for G6PD deficiency is gene therapy (replacing a defective gene with a good one), but this is not yet available at the present time.

As parent, what should I do to prevent a hemolytic crisis?
1. Tell your child’s pediatrician that your child has G6PD deficiency. This is very important so that he will not prescribe oxidative drugs in case your child gets ill. He would also be able to watch out for hemolytic crisis and would immediately know what to do just in case it happens.
2. Keep your list of oxidative substances in a handy place. Better yet, post it in a convenient spot on the kitchen wall. Always double-check food, beverage, and medicine labels against the list.
3. Memorize the signs and symptoms of hemolytic anemia: paleness, dizziness, headache, difficulty in breathing, rapid and strong heartbeats, tea-colored urine, and abdominal or back pain. Bring your child to his pediatrician as soon as these signs and symptoms appear.
4. Do not ignore infections. Persistent fever signals an infection. Bring the child at once to his pediatrician.
5. As your child gets older, honestly and gently tell him about his condition and teach him to be careful about what he eats.

IMPORTANT REMINDERS for G6PD deficiency Individuals
1. If you have coughs, cold or other bacterial or viral infections, make sure to inform your doctor that your have G6PD.
2. If you have ingested or were exposed to any medication and your urine became tea-colred inform your doctor immediately.
3. If you have yellowish discoloration of your skin, sclera or any part of your body, consult your doctor immediately.
4. Avoid the following foods that are contraindicated among G6PD deficient individuals:

• fava beans
• red wine
• legumes (bitsuelas, garbansos, monggo beans)
• blueberries (also applies to food products containing these)
• soya foods (taho, tokwa, soy sauce)
• tonic water

Note: Except for fava beans, there is no adequate proof as yet of the hemolytic effects of these foods.

5. Avoid ingestion of or exposure to the following drugs and chemicals:

Generic Name	Brand Names
Acetanilid
Chloroquine	Aralen Maralex UL Chloroquine
Doxorubicin HCl	Adriblastina RD Adrim Biomedis Caelyx Doxorubicin HCI Doxorubicin Meiji Faulding/DBL K.U. Doxorubicin HCI Pfizer Doxorubicin Pharmachemie Pharmacia Doxorubicin HCI Rubidox
Furazolidone	Diafuran Diapectolin Drugmaker’s Biotech Furoxone Pseudoambin
Methylene blue Menthol	Alaxan Gel Begesic Ben-gay Broncho Rub White Efficascent Oil Listerine mouthwash Listerine Pocketpacks Mediplastin Megascent Oil Mentopas Medicated Plaster Metsal Omega Pain Killer Perskindol Rowachol Sarna
Nalidixic Acid	Hanadex Wintomylon
Naphthalene
Niridazole
Nitrofurantoin	Harfurin Macrodantin USA Lab Nitrofurantoin Transpulmin Balsam
Phenazopyridine	Azomir
Phenylhydrazine
Primaquine
Quinidine	Kinidin
Sulfacetamide	Acetopt Bleph 10 Cetapred Isopto Cetamide Isopto Cetapred Sensocet Spersacet C Sultrin
Sulfamethoxazole	Bacidal Bactille Forte Bactille-TS Bactrim Bacxal Baczole Colimox Cotrexel Cotribase Cotrimoxazole Cotrimoxazole-Vamsler DLI Cotrimoxazole Doctrimox Drugmaker’s Biotech Fedimed Globaxol Gutrisol Intrafort Kathrex Lagatrim Forte Lictora Macromed Microbid/Microbid DS Moxadden Neotrim Onetrim Pharex Cotrimoxazole Procor Ritemed Cotrimoxazole Septrin Synerzole Thoprim Trihexal Trimephar Trimoxol Trim S Trizole suspension Xanozole
Sulfanilamide
Sulfapyridine
Thiazolesulfone
Toluidine Blue
Trinitrotoluene
Vitamin K	Vitamin K with Adenogen Cycomin Hema-K Konakion MM/ Konakion MM Paed

Reference:
1. Philippine Pharmaceutical Directory Review 5th Edition. Jocelyn J. Yambao et al. Ed. Medicom Pacific Inc. 2005.
2. MIMS Philippines. Volume 31, Number 3, 2002. Medi Media. 2002.

Case Study: Fractures

A. Description

1. A fracture is a break in the continuity of the bone.
2. Common fracture sites:

• Clavicle
• Humerus – In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site.
• Radius and ulna
• Femur (often associated with child abuse)
• Epiphyseal plates (potential for growth deformity)

3. Types of Fracture

• Closed or simple fracture - The bone is broken, but the skin is not lacerated.
• Open or compound fracture - The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.
• Transverse fracture - The fracture is at right angles to the long axis of the bone.
• Greenstick fracture - Fracture on one side of the bone, causing a bend on the other side of the bone.
• Comminuted fracture - A fracture that results in three or more bone fragments.
• Oblique Fracture - The fracture is diagonal to a bone’s long axis.
• Spiral Fracture - At least one part of the bone has been twisted.

4. Complications of fractures include:

• problems associated with immobility (muscle atrophy, joint contracture, pressure sores)
• growth problems ( in children)
• infection
• shock
• venous stasis and thromboembolism
• pulmonary emboli and fat emboli
• and bone union problems

B. Etiology

1. Fractures in children usually are the result of trauma from motor vehicle accidents, falls or child abuse.
2. Because of the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries.

C. Pathopysiology

1. Fractures occur when the resistance of bone against the stress being exerted yields to the stress force.
2. Fractures most commonly seen in children:

• Bend Fracture – is characterized by the bone bending to the breaking point and not straightening without intervention.
• Buckle fracture – results from compression failure of the bone, with the bone telescoping on itself.
• Greenstick fracture – is an incomplete fracture.

D. Assessment Findings

1. Clinical Manifestations

• The five “Ps” – pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures.
• Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children).

2. Laboratory and diagnostic findings

• Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity.
• Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD).

E. Nursing Management

1. Provide emergency management when situation warrants, for a new fracture.

• Assess the five “Ps”.
• Determine the mechanism of injury.
• Immobilize the part. Move injured parts as little as possible.
• Cover any open wounds with a sterile, or clean dressing.
• Reassess the five “Ps”.
• Apply traction if circulatory compromise is present.
• Elevate the injured limb, if possible.
• Apply cold to the injured area.
• Call emergency medical services.

2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping).
3. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling).
4. Administer analgesic medications.
5. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast.
6. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care.
7. Prevent Complications

• Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately.
• Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider.
• Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage.
  
  • Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery.
  • Treatment entails pressure relief, which sometimes require performing a fasciotomy.
  
  

8. Prevent infection, including osteomyelitits, bys using infection control measures.
9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible.
10. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.
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Case Study: Carpal Tunnel Syndrome

• Is an entrapment syndrome resulting from compression of the median nerve in the tendon sheath within the ventral surface of the wrist.
• Similarly, tarsal tunnel syndrome is a group of symptoms caused by pressure on the posterior tibial nerve in the medial aspect of the ankle and cubital tunnel syndrome is caused by pressure on the ulnar nerve at the medial epicondyle of the elbow.
• Compression symptoms due to entrapment include paresthesias, numbness, pain, weakness, and muscle atrophy.
• Compression results from repetitive motion of the wrist, trauma, local tenosynovitis, and mass, such as ganglion or neuroma.
• Repetitive motion causing carpal tunnel include the use of computer, typing, and use of a jackhammer.
• Carpal tunnel syndrome is more common in those over age 50, in women, in pregnant women in the first trimester, and in those with rheumatoid arthritis.
• Complications include chronic pain and loss of function of the extremities.

Assessment:

1. Progressive sensory changes including paresthesias and numbness of the thumb, index finger, and ring finger of the involved hand; leads to pain waking the patient up at night.
2. Motor changes beginning with clumsiness and progressing to weakness; edema and thenar atrophy may be noted.
3. Positive Tinel’s sign: Increased paresthesias on tapping of tendon sheath (ventral surface of central wrist).
4. Positive Phalen test: Increased symptoms with acute palmar flexion for 1 minute.

Diagnostic Evaluation:

1. Electromyogram shows weakened response to median nerve stimulation.

Therapeutic and Pharmacologic Interventions:

1. Wrist splint in slight extension (cock-up splint) to relieve pressure aggravated by wrist flexion: worn at night, and during day if symptomatic.
2. Avoidance of flexion and twisting motion of the wrist.
3. Work or activity modification to relieve repetitive strain.
4. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 600 to 800 mg tid to relieve inflammation and pain.
5. Corticosteroid injection into tendon sheath to relieve inflammation.

Surgical Interventions:

1. Surgery is indicated when conservative measures fail to relieve symptoms.
2. Procedure is release of carpal ligament and tendon to relieve pressure on median nerve.

Nursing Interventions:

1. Monitor level of pain, numbness, paresthesias, and functioning.
2. Monitor for adverse effects of NSAID therapy, especially in elderly. GI distress or bleeding, dizziness, or increased serum creatinine.
3. After surgery, monitor neurovascular status of affected extremity: pulses, color, swelling, movement, sensation, or warmth.
4. Apply wrist splint so wrist is in neutral position, with slight extension of wrist and slight abduction of thumb; make sure that it fits correctly without constriction.
5. Administer NSAIDs and assist with tendon sheath injections as required.
6. Apply ice or cold compress to relieve inflammation and pain.
7. Teach patient the cause of condition and ways to alter activity to prevent flexion of wrists; refer to an occupational therapist as indicated.
8. Advise patient of NSAID therapy dosage schedule and potential adverse effects; instruct patient to report GI pain and bleeding.
9. Teach patient to gentle range-of-motion exercises; refer to a physical therapist as indicated.

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Procedure: Immediate Care of the Newborn

Goals:

• To establish, maintain and support respirations.
• To provide warmth and prevent hypothermia.
• To ensure safety, prevent injury and infection.
• To identify actual or potential problems that may require immediate attention.

Establish respiration and maintain clear airway

The most important need for the newborn immediately after birth is a clear airway to enable the newborn to breathe effectively since the placenta has ceased to function as an organ of gas exchange. It is in the maintenance of adequate oxygen supply through effective respiration that the survival of the newborn greatly depends.

Newborns are obligatory nose breathers. The reflex response to nasal obstruction, opening the mouth to maintain airway, is not present in most newborns until 3 weeks after birth.

To establish and maintain respirations:

1. Wipe mouth and nose of secretions after delivery of the head.

2. Suction secretions from mouth and nose.

• Compress bulb syringe before inserting
• Suction mouth first, then, the nose
• Insert bulb syringe in one side of the mouth

3. A crying infant is a breathing infant. Stimulate the baby to cry if baby does not cry spontaneously, or if the cry is weak.

• Do not slap the buttocks rather rub the soles of the feet.
• Stimulate to cry after secretions are removed.
• The normal infant cry is loud and husky. Observe for the following abnormal cry:
  
  • High, pitched cry – indicates hypoglycemia, increased intracranial pressure.
  • Weak cry – prematurity
  • Hoarse cry – laryngeal stridor
  
  

4. Oral mucous may cause the newborn, to choke, cough or gag during the first 12 to 18 hours of life. Place the infant in a position that would promote drainage of secretions.

• Trendelenburg position – head lower than the body
• Side lying position – If trendelenburg position is contraindicated, place infant in side lying position to permit drainage of mucus from the mouth. Place a small pillow or rolled towel at the back to prevent newborn from rolling back to supine position.

5. Keep the nares patent. Remove mucus and other particles that may be cause obstruction. Newborns are obligatory nose breathers until they are about 3 weeks old.

Care of the Eyes

It is part of the routine care of the newborn to give prophylactic eye treatment against gonorrhea conjunctivitis or opthalmia neonatorum. Neisseria gonorrhea, the causative agent, may be passed on the fetus from the vaginal canal during delivery. This practice was introduced by Crede, a German gynecologist in1884. Silver nitrate, erythromycin and tetracycline ophthalmic ointments are the drugs used for this purpose.

Erythromycin or tetracycline Opthalmic Ointment:

1. These ointments are the ones commonly used now a days for eye prophylaxis because they do not cause eye irritation and are more effective against Chlamydial conjunctivitis.
2. Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes.

Vitamin K or Aquamephyton

The newborn has a sterile intestine at birth, hence, the newborn does not possess the intestinal bacteria that manufactures vitamin K which is necessary for the formation of clotting factors. This makes the newborn prone to bleeding. As a preventive measure, .5 (preterm) and 1 mg (full term) Vitamin K or aquamephyton is injected IM in the newborn’s vastus lateralis (lateral anterior thigh) muscle.

Care of the cord

The cord is clamped and cut approximately within 30 seconds after birth. In the delivery room, the cord is clamped twice about 8 inches from the abdomen and cut in between. When the newborn is brought to the nursery, another clamp is applied ½ to 1 inch from the abdomen and the cord is cut at second time. The cord and the area around it are cleansed with antiseptic solution. The manner of cord care depends on hospital protocol. What is important is that the principles are followed. Cord clamp maybe removed after 48 hours when the cord has dried. The cord stump usually dries and fall within 7 to 10 days leaving a granulating area that heals on the next 7 to 10 days.

Instruction to the mother on cord care:

1. No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that cord does not get wet by water or urine.
2. Do not apply anything on the cord such as baby powder or antibiotic, except the prescribed antiseptic solution which is 70% alcohol.
3. Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when the diaper soaks with urine.
4. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and separates more rapidly if it is exposed to air.
5. If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose and fasten.
6. Report any unusual signs and symptoms which indicates infection.
   
   • Foul odor in the cord
   • Presence of discharge
   • Redness around the cord
   • The cord remains wet and does not fall off within 7 to 10 days
   • Newborn fever
   
   

THE APGAR SCORING SYSTEM

The APGAR Scoring System was developed by Dr. Virginia Apgar as a method of assessing the newborn’s adjustment to extrauterine life. It is taken at one minute and five minutes after birth. With depressed infants, repeat the scoring every five minutes as needed. The one minute score indicates the necessity for resuscitation. The five minute score is more reliable in predicting mortality and neurologic 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 above 160 signifies distress.

ASSESS	0	1	2
HEART RATE	Absent	Below 100	Above 100
RESPIRATION	Absent	Slow	Good crying
MUCLE TONE	Flaccid	Some flexion	Active motion
REFLEX IRRITABILITY	No response	Grimace	Vigorous cry
COLOR	Blue all over	Body pink, Extremities blue	Pink all over

Score:

• 7 – 10 Good adjustment, vigorous
• Moderately depressed infant, needs airway clearance
• Severely depressed infant, in need of resuscitation.

ASSESSING THE AVERAGE NEWBORN

Head Circumference	34 – 35 cm
Temperature	97.6 – 98.6 F axillary
Chest Circumference	32 – 33 cm
Heart Rate	120 – 140 bpm
Respirations	30 – 60 bpm
Weight	2.5 to 3.4 kg
Length	46 to 54 cm

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Case Study: Hemorrhoids and other Anorectal Conditions

• 
  
  Hemorrhoids are vascular masses that protrude into the lumen of the lower rectum or perianal area.
  
  
  
• They result when increased intra-abdominal pressure causes engorgement in the vascular tissue lining the anal canal.
• Loosening of vessels from surrounding connective tissue occurs with protrusion or prolapse into the anal canal.
• There are two main types of hemorrhoids: external hemorrhoids appear outside the external sphincter, and internal hemorrhoids appear above the internal sphincter.
• When blood within the hemorrhoids becomes clotted because of obstruction, the hemorrhoids are referred to as being thrombosed.
• Predisposing factors include pregnancy, prolonged sitting or standing, straining stool, chronic constipation or diarrhea, anal infection, rectal surgery or episiotomy, genetic predisposition, alcoholism, portal hypertension (cirrhosis), coughing, sneezing, or vomiting, loss of muscle tone attributable to old age, and anal intercourse.
• Complications include hemorrhage, anemia, incontinence of stool, and strangulation.
• Hemorrhoids are the most common of a variety of anorectal disorders.

Assessment:

1. Pain (more so with external hemorrhoids), sensation of incomplete fecal evacuation, constipation, and anal itching. Sudden rectal pain may occur if external hemorrhoids are thrombosed.
2. Bleeding may occur during defecation; bright red blood on stool caused by injury of mucosa covering hemorrhoid.
3. Visible and palpable masses at anal area.

Diagnostic Evaluation:

1. External examination with anoscope or proctoscope shows single or multiple hemorrhoids.
2. Barium edema or colonoscopy rules out more serious colonic lesions causing rectal bleeding such as polyps.

Therapeutic Interventions:

1. High-fiber diet to keep stools soft.
2. Warm sitz baths to ease pain and combat swelling.
3. Reduction of prolapsed external hemorrhoid manually.

Pharmacologic Interventions:

1. Stool softeners to keep stools soft and relieve symptoms.
2. Topical creams, suppositories or other preparation such as Anusol, Preparation H, and witch-hazel compresses to reduce itching and provide comfort.
3. Oral analgesics may be needed.

Surgical Interventions:

1. Injection of sclerosing solutions to produce scar tissue and decrease prolapse is an office procedure.
2. Cryodestruction (freezing) of hemorrhoids is an office procedure.
3. Surgery may be indicated in presence of prolonged bleeding, disabling pain, intolerable itching, and general unrelieved discomfort.

Nursing Interventions:

1. After thrombosis or surgery, assist with frequent repositioning using pillow support for comfort.
2. Provide analgesics, warm sitz baths, or warm compresses to reduce pain and inflammation.
3. Apply witch-hazel dressing to perianal area or anal creams or suppositories, if ordered, to relieve discomfort.
4. Observe anal area postoperatively for drainage and bleeding.
5. Administer stool softener or laxative to assist with bowel movements soon after surgery, to reduce risk of stricture.
6. Teach anal hygiene and measures to control moisture to prevent itching.
7. Encourage the patient to exercise regularly, follow a high fiber diet, and have an adequate fluid intake (8 to 10 glasses per day) to avoid straining and constipation, which predisposes to hemorrhoid formation.
8. Discourage regular use of laxatives; firm, soft stools dilate the anal canal and decrease stricture formation after surgery.
9. Tell patient to expect a foul-smelling discharge for 7 to 10 days after cryodestruction.
10. Determine the patient’s normal bowel habits and identify predisposing factors to educate patient about preventing recurrence of symptoms.

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FAQ about Meningococcemia

What is meningococcemia?

1. 
   
   • Meningococcemia or meningococcal meningitis is an acute communicable infection caused by gram-negative bacteria. Neisseria meningitidis. There are several groups and sub-types of this organism. The bacteria are sensitive to sunlight and changes in temperature. They do not survive for 30 minutes. The disease usually occurs sporadically in the Philippines. Epidemics rarely occur.
   
   
2. What are the signs and symptoms of meningococcemia?
   
   • Meningococcemia is usually characterized by a sudden onset of fever, nausea, vomiting and frequently, a petechial rash which becomes bigger with reddish or purplish color located mainly on the extremities. The patient usually becomes prrogressively sicker. Meningitis with symptoms such as stiff neck, intense headache, back pain and mental status changes is the most common localized manifestation. Meningococcal infection may also be asymptomatic, or may produce only acute nasopharyngitis.
   
   
3. Is meningococcemia fatal?
   
   • Yes. Up to 50% of cases are expected to die especially with the serious type of the disease, but this is drastically reduced to less than 10% with early dignosis and appropriate treatment.
   
   
4. How does meningococcemia spread?
   
   • Meningoceccemia is transmitted by direct contact with droplet secretions from the nose and throat of infected persons. This is called person to person transmission, which often occurs through sneezing, coughing, kissing or sharing of eating utensils. Contact with materials soiled by these discharges may also transmit the infection.
   
   
5. Can we get it from animals?
   
   • No. The bacteria only live in the nasopharynx of infected humans. Patients and carriers (infected individuals individuals whoa re apparently well) transmit the disease.
   
   
6. Who are commonly affected?
   
   • Meningococcemia commonly affects children, but it can occur among adults especially in crowded living conditions.
   
   
7. How long will the first sign or symptom appear after being exposed to the infectious secretions?
   
   • The incubation period varies from 2 to 10 days, commonly 3-4 days.
   
   
8. How long can patients or carriers transmit the disease?
   
   • Infected persons can transmit the disease even before the manifestations of signs and symptoms. Patients under treatment with antibiotics will usually not be infectious after 24 hours and carriers without symptoms continue to shed the bacteria indefinitely until they are detected and treated.
   
   
9. Can meningococcemia be treated?
   
   • Yes. Penicillin is the drug of choice. Ampicillin, chloramphenicol and sulfonamides are also effective.
   
   
10. How do we avoid getting sick of meningococcemia?
    
    • Preventive antibiotic medication
      
      • This is recommended only for the close contacts of meningococcal patients, because unnecessary and improper use of antibiotics can lead to emergence of drug resistant bacteria.
      • Close contacts are people directly exposed to the respiratory secretions of infected people. These include: a) household members b) visitors who stayed overnight within 7 days before the illness of the case c) stayed in the same room with a case for 4 hours or more d)anyone directly exposed to the patient’s orals secretions.This is given as soon as possible after exposure to a diagnosed case as prescribed by the physician.
      • Recommended medicines for prevention: rifampicin, ciprofloxacin, ceftriaxone, sulfadiazine.
      
      
    • Health workers and other close contacts should wear personal protective devices like masks and rubber gloves. Wash hands with soap and water after attending to each patient.
    • Properly dispose of articles soiled with discharges from the nose and throat of patients.
    • Avoid sharing of eating or drinking utensils.
    • Practice healthy lifestyle. Get enough rest and exercise, avoid smoking and eat well balanced diet which includes fruits and vegetables rich in vitamins to build up the immune system.
    • Avoid crowded places to minimize exposure to the disease.
    
    
11. Do we need to undergo vaccination?
    
    • Vaccination is 85% to 95% protective. It starts to be protective after 5 days from the injection. Protection lasts for 2.5 to 3 years. It is not protective to children below 2 years old. It is not a recommended public health measure but it may be taken as a personal protective measure.
    
    
12. What should be done in case a person manifests the above signs and symptoms?
    
    • Immediately consult a physician or visit your nearest health center or hospital.
    
    

Source:
DOH, Center for Health Development – CAR