Prenatal period

Gestation

A. Time from fertilization of the ovum until the date of delivery

B. About 280 days
C. Näegele’s rule for estimating the date of delivery, also known as date of birth

Based on Näegele’s Rule, the estimated date of delivery (EDD) is calculated as follows:

● First day of last menstrual period (LMP): September 12, 2023

● Subtract 3 months: June 12, 2023

● Add 7 days: June 19, 2023

● Add 1 year (if necessary): June 19, 2024

Estimated Date of Delivery (EDD): June 19, 2024

1. Use of Näegele’s rule requires that the person have a regular 28-day menstrual cycle.

2. Subtract 3 months and add 7 days to the first day of the last menstrual period; then add
1 year if appropriate. Alternatively, add 7 days to the first day of the last menstrual period
and count forward 9 months.

Gravidity and Parity

A. Gravidity

1. Gravida refers to a pregnant person.

2. Gravidity refers to the number of pregnancies.

3. A nulligravida is a person who has never been pregnant.

4. A primigravida is a person who is pregnant for the first time.

5. A multigravida is a person in at least the second pregnancy.

B. Parity

1. Parity is the number of births (not the number of fetuses, e.g., twins) carried past 20
weeks of gestation, whether or not the fetus was born alive.

2. A nullipara is a person who has not had a birth at more than 20 weeks of gestation.

3. A primipara is a person who has had one birth that occurred after the 20th week of
gestation.

4. A multipara is a person who has had two or more pregnancies to the stage of fetal
viability.

C. Use of GTPAL: Pregnancy outcomes can be described with the acronym GTPAL

GTPAL Example Calculation

A client is pregnant for the fourth time. Their pregnancy history includes:

● One elective abortion in the first trimester (before 20 weeks).

● One child born at 40 weeks (term birth).

● One child born at 36 weeks (preterm birth).

Using the GTPAL system:

● G (Gravidity) = 4 (total pregnancies, including current one).

● T (Term births) = 1 (one child born at 40 weeks).

● P (Preterm births) = 1 (one child born at 36 weeks).

● A (Abortions or miscarriages) = 1 (one elective abortion before 20 weeks).

● L (Living children) = 2 (both term and preterm children are alive).

Final GTPAL: 4, 1, 1, 1, 2

Parity = 2 (since they carried two pregnancies past 20 weeks, regardless of the outcome).
G is gravidity, the number of pregnancies, including the present one.

1. T is term births, the number born at term (longer than 37 weeks of gestation).

2. P is preterm births, the number born before 37 weeks of gestation.

3. A is abortions or miscarriages, the number of abortions or miscarriages (included in

gravida if before 20 weeks of gestation).

4. L is the number of current living children. This number can be greater than the P if
multiples were delivered, or less than the P if a loss occurred. Note: Multiples count as a
1 for gravidity, as well as a 1 for term, preterm, or abortions, but are recorded as the
actual number for living.

Pregnancy Signs

A. Presumptive signs

1. Amenorrhea

2. Nausea and vomiting

3. Breast tenderness, tingling, feelings of fullness, increased size and pigmentation of the
areola

4. Urinary frequency

5. Quickening: The first perception of fetal movement by the pregnant individual may occur
at the 16th to 20th week of gestation; every pregnancy is unique, and quickening could
happen earlier or later.

6. Fatigue

7. Changes to skin pigmentation such as linea nigra, melasma

B. Probable signs

1. Uterine enlargement
 2. Hegar’s sign: Compressibility and softening of the lower uterine segment that occurs at
about week 6

3. Goodell’s sign: Softening of the cervix that occurs at the beginning of the second month

4. Chadwick’s sign: Violet coloration of the mucous membranes of the cervix, vagina, and
vulva that occurs at about week 6

Fundal Height

A. Fundal height is measured to evaluate the gestational age of the fetus.

B. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters
approximately equals fetal age in weeks ± 2 cm.

C. At 16 weeks, the fundus can be found approximately halfway between the symphysis pubis
and the umbilicus.

D. At 20 to 22 weeks, the fundus is approximately at the level of the umbilicus.

E. At 36 weeks, the fundus is at the xiphoid process.

F. Ask the client to void before measurement because a full bladder can displace the uterus,
affecting accuracy.

Steps for Measuring Fundal Height

1. Place the client in the supine position.

2. Place the end of the tape measure at the level of the symphysis pubis.

3. Stretch the tape to the top of the uterine fundus.

4. Note and record the measurement.

Physiological Pregnancy Changes

Pregnancy causes various physiological changes in different body systems to support fetal
development and prepare the body for childbirth.

A. Reproductive System

1. Uterine enlargement to accommodate fetal growth.

 2. Increased vascularity of the cervix, vagina, and vulva.

3. Chadwick’s sign (bluish discoloration of cervix/vagina).

4. Goodell’s sign (softening of the cervix).

5. Increased vaginal discharge (leukorrhea).

B. Cardiovascular System

1. Increased blood volume by 30-50%.

2. Increased cardiac output and heart rate.

3. Possible physiological anemia due to hemodilution.

4. Increased clotting factors, raising the risk of thrombosis.

C. Respiratory System

1. Increased oxygen demand and tidal volume.

2. Diaphragmatic elevation due to an enlarged uterus.

3. Shortness of breath in later pregnancy.

D. Gastrointestinal System

1. Slower gastric emptying, leading to constipation.

2. Nausea and vomiting (morning sickness).

3. Heartburn due to relaxation of the lower esophageal sphincter.

E. Urinary System

1. Increased renal blood flow and glomerular filtration rate (GFR).

2. Urinary frequency, especially in the first and third trimesters.

3. Possible urinary stasis, increasing UTI risk.

F. Musculoskeletal System

1. Relaxation of pelvic joints and ligaments due to relaxing hormone.

2. Lumbar lordosis, leading to back pain.

3. Increased weight-bearing on joints, causing discomfort.

G. Endocrine System

1. Increased hormone production (estrogen, progesterone, hCG).

2. Enlargement of the thyroid gland, increasing metabolism.

3. Increased insulin resistance, affecting glucose metabolism.

H. Skin and Hair Changes

1. Linea nigra (dark line on the abdomen).

2. Melasma (chloasma) or "pregnancy mask."

3. Striae gravidarum (stretch marks).

4. Increased hair and nail growth.

Psychological Pregnancy Changes

Pregnancy brings significant emotional and psychological changes as the individual prepares for
parenthood. These changes vary by trimester and can be influenced by personal, social, and
cultural factors.

A. Emotional Reactions by Trimester

1. First Trimester

○ Mixed emotions: Excitement, joy, anxiety, or fear.

○ Mood swings due to hormonal changes.

○ Possible ambivalence, even in planned pregnancies.

 ○ Increased fatigue and nausea may contribute to emotional distress.

2. Second Trimester

○ Increased emotional stability as discomforts of early pregnancy subside.

○ Growing attachment to the fetus as quickening (first fetal movements) occurs.

○ Increased confidence and acceptance of pregnancy.

○ Concerns about body image and physical changes.

3. Third Trimester

○ Heightened anticipation and impatience for delivery.

○ Increased anxiety about labor, delivery, and parenting.

○ Possible nesting behavior (strong desire to prepare for the baby).

○ Concerns about relationships, financial stability, and support system.

Psychological Adaptation

1. Maternal Role Acceptance

○ Transition from self-focused to baby-focused mindset.

○ Adjustments in lifestyle and priorities.

2. Partner and Family Involvement

○ Support from a partner and family enhances emotional well-being.

○ Possible stress if relationships are strained or unsupportive.

3. Body Image and Self-Esteem

○ Some embrace the physical changes; others struggle with body image.

○ Cultural and societal expectations may influence feelings.

 4. Fears and Anxiety

○ Worries about childbirth pain, baby’s health, and parenting abilities.

○ Emotional reassurance and prenatal education help ease concerns.

5. Attachment to the Fetus

○ Talking, singing, and bonding activities may begin before birth.

○ Ultrasounds and fetal movements strengthen the emotional connection.

Discomforts of Pregnancy: Nausea & Vomiting

● Occurs in the first trimester, usually subsiding by the third month.

● Caused by elevated hCG levels and changes in carbohydrate metabolism.

Interventions:

✔ Eat dry crackers before getting up.

✔ Avoid brushing teeth immediately after waking.
✔ Eat small, frequent, low-fat meals.
✔ Drink liquids between meals, not with meals.
✔ Avoid fried and spicy foods.
✔ Have a protein snack at bedtime.
✔ Suck on hard candy for relief.
✔ Consult PHCP about acupressure or CAM therapies.
✔ Ask PHCP about herbal remedies and antiemetics if needed.

Syncope

1. Usually occurs in the first trimester; supine hypotension occurs particularly in the second
and third trimesters.

2. May be triggered hormonally or caused by increased blood volume, anemia, fatigue,

sudden position changes, or lying supine.

3. Interventions:
a. Sitting with the feet elevated
 b. Risk for falls; teach to change positions slowly

The nurse needs to instruct the pregnant individual to avoid lying in the supine position,
particularly in the second and third trimesters. The supine position places the individual at risk
for supine hypotension, which occurs as a result of pressure of the uterus on the inferior vena
cava.

C. Urinary Urgency and Frequency

1. Usually occurs in the first and third trimesters.

2. Caused by pressure of the uterus on the bladder.

3. Interventions:
a. Drinking no less than 2000 mL of fluid during the day
b. Limiting fluid intake in the evening
c. Limiting intake of natural diuretics such as coffee, tea, watermelon, lemons
d. Voiding at regular intervals
e. Sleeping side-lying at night
f. Wearing perineal pads, if necessary
g. Performing Kegel exercises

D. Breast Tenderness

1. Can occur in the first through the third trimesters.

2. Caused by increased levels of estrogen and progesterone.

3. Interventions:
a. Wearing a supportive bra
b. Avoiding the use of soap on the nipples and areolar area to prevent drying of skin

E. Increased Vaginal Discharge

1. Can occur in the first through the third trimesters.

2. Caused by hypertrophy and thickening of the vaginal mucosa and increased mucus
production.
 3. Interventions:
a. Using proper cleansing and hygiene techniques

F. Nasal Stuffiness

1. Occurs throughout pregnancy (first to third trimesters).

2. Caused by increased estrogen, leading to nasal edema and dryness.

3. Interventions:
a. Use a humidifier.
b. Avoid nasal sprays or antihistamines (consult PHCP; normal saline may be
acceptable).

G. Fatigue

1. Common in the first and third trimesters.

2. Caused by hormonal changes.

3. Interventions:
a. Arrange frequent rest periods.
b. Use proper posture and body mechanics.
c. Engage in regular exercise.
d. Perform muscle relaxation and strengthening exercises.
e. Avoid caffeine and stimulants.
f. Maintain a well-balanced diet to prevent anemia.

H. Heartburn

1. Occurs in the second and third trimesters.

2. Caused by progesterone, decreased GI motility, reflux, and stomach displacement.

3. Interventions:
a. Eat small, frequent meals.
b. Sit upright for 30 minutes after eating.
c. Drink milk between meals.
d. Avoid fatty and spicy foods.
e. Avoid bending over or lying flat.
f. Wear loose-fitting clothes.
g. Take deep breaths and sip water.
 h. Avoid carbonated drinks, citrus, chocolate, and peppermint if triggering.
i. Consult PHCP before using antacids.

I. Ankle Edema

1. Common in the second and third trimesters.

2. Caused by vasodilation, venous stasis, and increased pressure below the uterus.

3. Interventions:
a. Elevate legs at least twice a day and when resting.
b. Sleep side-lying.
c. Wear support stockings.
d. Avoid prolonged sitting or standing.
e. Drink plenty of fluids.

J. Varicose Veins

1. Common in the second and third trimesters.

2. Caused by weakened vein walls/valves and venous congestion.

3. Thrombophlebitis is rare but possible.

4. Interventions:
a. Wear support stockings.
b. Elevate feet when sitting.
c. Lie down with feet and hips elevated.
d. Avoid long periods of standing/sitting.
e. Move around while standing.
f. Avoid crossing legs.
g. Avoid tight clothing (e.g., knee-high stockings).
h. Perform leg exercises.
i. Avoid flying (prolonged sitting).

K. Headaches

1. Common and benign in the first trimester; requires evaluation if persistent in the second
or third trimester.

2. Caused by blood volume changes and vascular tone shifts.

 3. Interventions:
a. Change positions slowly.
b. Apply a cool cloth to the forehead/neck.
c. Eat a small salty snack.
d. Take acetaminophen only if prescribed by PHCP.

L. Hemorrhoids

1. Common in the second and third trimesters.

2. Caused by increased venous pressure and constipation.

3. Interventions:
a. Take warm sitz baths.
b. Sit on a soft pillow or lie on the side with hips elevated.
c. Eat high-fiber foods and drink enough fluids.
d. Engage in regular exercise (e.g., walking).
e. Apply ointment, suppositories, or compresses as prescribed.

M. Constipation

1. Common in the second and third trimesters.

2. Caused by progesterone, decreased intestinal motility, uterine pressure, and iron

supplements.

3. Interventions:
a. Eat high-fiber foods (whole grains, fruits, vegetables).
b. Avoid constipating foods (e.g., cheese).

Antepartum Diagnostic Testing

A. Ultrasound
B. Doppler Flow Studies
C. Alpha-Fetoprotein (AFP) Screening
D. Chorionic Villus Sampling (CVS)
E. Amniocentesis
F. Percutaneous Umbilical Blood Sampling (PUBS)
G. Nonstress Test (NST)
H. Contraction Stress Test (CST)
I. Biophysical Profile (BPP)
J. Kick Counts
Risk Conditions Related to
Pregnancy
Bleeding During Pregnancy

A. Implantation Bleeding – Occurs 10 to 14 days after conception, lasts 1–2 days, lighter than a
period, no treatment needed.
B. Other Causes – Includes abortion, malignancy, polyps, trauma, ectopic pregnancy, infection,
molar pregnancy, subchorionic hemorrhage, cervicitis, placenta previa, abruptio placentae, etc.
C. Low Progesterone – Can cause bleeding; treatable but may lead to miscarriage if untreated.

abortion

A. Description

● Pregnancy loss before 20 weeks’ gestation, either spontaneous or elective.

B. Types

● Miscarriage (Spontaneous Abortion) – Pregnancy ends due to natural causes.

● Induced Abortion – Termination for therapeutic or elective reasons.

● Threatened Abortion – Spotting & cramping occur without cervical changes.

● Inevitable Abortion – Spotting, cramping, cervical dilation, and effacement.

● Incomplete Abortion – Partial loss of products of conception (placenta retained).

● Complete Abortion – All products of conception expelled.

● Missed Abortion – Fetal death occurs, but products remain in utero.

● Habitual Abortion – Three or more consecutive miscarriages.

●

C. Risk Factors
 1. Advanced maternal age

2. History of miscarriage or elective abortion

3. Uterine abnormalities (fibroids, adhesions)

4. Low progesterone levels

5. Endocrine disorders (thyroid dysfunction, PCOS, Cushing’s)

6. Autoimmune conditions (lupus)

7. Infections, trauma, or fever

8. Low BMI (<18.5), smoking, alcohol, drug use, high caffeine intake

D. Assessment

1. Vaginal bleeding (spontaneous)

2. Cramping or contractions

3. Passing of blood clots or tissue

4. Hemorrhage or shock if bleeding is excessive

E. Interventions

1. Bed rest as prescribed

2. Monitor vitals, bleeding, and cramping

3. Weigh perineal pads (1g = 1mL blood loss), save expelled tissue

4. Administer IV fluids, monitor for hemorrhage/shock

5. Prepare for dilation & curettage (D&C) if incomplete abortion

6. Administer Rho(D) immune globulin if Rh-negative

7. Provide psychological support

 Cardiac Disease in Pregnancy

A. Description

● Increased plasma volume and cardiac output may overload the heart.

● Blood volume peaks at 32–34 weeks, then slightly declines by week 40.

C. Assessment

1. Signs of Cardiac Decompensation:

○ Cough & respiratory congestion

○ Dyspnea & fatigue

○ Palpitations & tachycardia

○ Peripheral edema

○ Chest pain

2. Signs of Respiratory Infection

3. Signs of Heart Failure & Pulmonary Edema

Interventions for Cardiac Disease in Pregnancy

1. Monitor vital signs, fetal heart rate, and fetal condition.

2. Limit physical activity and emphasize adequate rest.

3. Watch for signs of cardiac stress & decompensation (e.g., cough, fatigue, dyspnea,
chest pain, tachycardia).

Chorioamnionitis

A. Description

● Bacterial infection of the amniotic cavity.

● Causes: Prolonged rupture of membranes, vaginitis, amniocentesis, intrauterine
procedures.

● Can lead to postpartum endometritis & neonatal sepsis.

B. Assessment

1. Uterine tenderness & contractions

2. Elevated temperature

3. Maternal or fetal tachycardia

4. Foul-smelling amniotic fluid

5. Leukocytosis

C. Interventions

1. Monitor maternal vital signs & fetal heart rate.

2. Assess uterine tenderness, contractions, & fetal activity.

3. Check blood culture results.

4. Administer antibiotics after cultures are taken.

5. Prepare for neonatal cultures post-birth.

Diabetes Mellitus in Pregnancy

A. Description

1. Pregnancy alters carbohydrate metabolism, affecting insulin needs.

2. Insulin resistance & hyperinsulinemia increase the risk of diabetes.

Gestational Diabetes Mellitus (GDM) – Key Points

Definition:
● Develops in the 2nd or 3rd trimester when the pancreas cannot meet increased insulin
demands.

● May indicate undiagnosed diabetes if discovered early in pregnancy.

Risk Factors:

● Age >35 years, obesity (BMI >30), nonwhite race

● PCOS, family history of diabetes, previous GDM

● Previous macrosomic baby (>9 lb), hypertension, glucocorticoid use

Assessment

● Excessive thirst & hunger

● Weight loss despite increased appetite

● Frequent urination

● Blurred vision

● Recurrent UTIs & yeast infections

● Glycosuria & ketonuria

● Signs of gestational hypertension & preeclampsia

● Polyhydramnios (excess amniotic fluid)

● Large for gestational age (LGA) fetus

●

Effects & Complications:

● Maternal risks: Preeclampsia, polyhydramnios, increased C-section risk

● Neonatal risks: Macrosomia, hypoglycemia, congenital anomalies

Management:
 ● Blood glucose targets:

○ Fasting: <95 mg/dL

○ 1-hour postprandial: <130–140 mg/dL

○ 2-hour postprandial: <120 mg/dL

● Diet & exercise as first-line treatment

● Insulin or safe oral medications if needed

● Monitor for hypo-/hyperglycemia, ketonuria, weight changes

Disseminated Intravascular Coagulation (DIC)

Description:

A serious condition where widespread clotting depletes platelets and clotting factors, leading to
excessive bleeding. It is often triggered by obstetric complications such as placental abruption,
preeclampsia, amniotic fluid embolism, or sepsis.

Assessment:

1. Uncontrolled bleeding (gums, IV sites, incision sites)

2. Petechiae, ecchymosis, purpura

3. Hematuria, GI bleeding

4. Hypotension & tachycardia (shock signs)

5. Decreased platelet count & fibrinogen levels

6. Prolonged PT, aPTT, INR

7. Elevated D-dimer (indicative of fibrinolysis)

Interventions:

1. Identify & treat underlying cause (e.g., infection, hemorrhage).

2. Monitor vital signs, urine output, and clotting studies.

 3. Administer IV fluids, blood products (platelets, fresh frozen plasma, cryoprecipitate) as
prescribed.

4. Provide oxygen support.

5. Prevent further injury by avoiding unnecessary invasive procedures.

Ectopic Pregnancy

Description:

A pregnancy that implants outside the uterus, most commonly in the fallopian tube. It is a
medical emergency if rupture occurs.

Risk Factors:

● Previous ectopic pregnancy

● Pelvic inflammatory disease (PID)

● Tubal surgery or scarring

● Intrauterine device (IUD) use

● Assisted reproductive techniques (IVF)

● Smoking

Assessment:

● Unilateral abdominal pain

● Missed period with positive pregnancy test

● Vaginal spotting or bleeding

● Shoulder pain (if rupture causes diaphragmatic irritation)

● Signs of shock (hypotension, tachycardia, dizziness, pallor) if ruptured

Interventions:
1. Monitor vital signs & bleeding

2. Confirm diagnosis with ultrasound & β-hCG levels

3. Administer methotrexate for non-ruptured cases (stops fetal growth)

4. Prepare for surgery (salpingectomy/salpingostomy) if ruptured

5. Provide emotional support & Rh immunoglobulin if Rh-negative

Hepatitis B in Pregnancy

Risks:

● Increased risk of prematurity, low birth weight, and neonatal death

● Transmitted via blood, saliva, vaginal secretions, semen, breast milk, and placental
barrier

Interventions:

1. Limit vaginal exams to reduce infection risk

2. Remove maternal blood & suction fluids immediately after birth

3. Bathe newborn before invasive procedures

4. Administer Hepatitis B immune globulin (HBIG) & vaccine post-bath

5. Avoid kissing the newborn until vaccinated

6. Ensure newborn receives Hep B vaccine at birth, 1 month, and 6 months

7. Breastfeeding is safe after neonatal vaccination

Vulvar Hematoma

Causes:
● Blood collection in maternal tissue post-delivery

● Risk factors: forceps delivery, vessel injury

Interventions:

1. Monitor vitals & pain levels

2. Inspect perineal area

3. Apply ice & administer analgesics

4. Encourage fluids & voiding; catheterization if needed

5. Monitor for signs of infection & administer antibiotics

6. Prepare for hematoma incision & drainage if necessary

Hydatidiform Mole (Molar Pregnancy)

Description:

● Abnormal trophoblastic growth leading to a nonviable pregnancy

● Characterized by grape-like vesicles in the uterus

● Can develop into gestational trophoblastic neoplasia (GTN)

Assessment:

1. Abnormal uterine bleeding (dark brown or bright red)

2. Excessive nausea and vomiting (hyperemesis gravidarum)

3. Rapid uterine enlargement (larger than expected for gestational age)

4. Absence of fetal heart tones

5. Elevated hCG levels

6. Preeclampsia before 20 weeks

7. Passage of vesicular tissue

Interventions:

1. Prepare for evacuation via dilation & curettage (D&C)

2. Monitor for hemorrhage & infection

3. Assess serial hCG levels to detect persistent trophoblastic tissue

4. Advise against pregnancy for 6–12 months (until hCG normalizes)

5. Monitor for signs of gestational trophoblastic disease (choriocarcinoma)

Hyperemesis Gravidarum

Description:

● Severe, persistent nausea and vomiting during pregnancy

● Leads to dehydration, electrolyte imbalances, and weight loss

Assessment:

1. Excessive vomiting leading to dehydration

2. Weight loss >5% of pre-pregnancy weight

3. Electrolyte imbalances (hypokalemia, hyponatremia)

4. Ketonuria (due to starvation)

5. Hypotension and tachycardia

6. Signs of malnutrition (muscle wasting, vitamin deficiencies)

Interventions:

1. Monitor hydration & electrolyte levels

2. Administer IV fluids & electrolyte replacements

3. Provide antiemetics as prescribed (e.g., ondansetron, metoclopramide)

4. Encourage small, frequent meals (high-protein, dry foods)

5. Vitamin supplementation (B6, thiamine to prevent Wernicke’s encephalopathy)

6. Monitor weight, urine output, and vital signs

7. Assess for complications (metabolic imbalances, esophageal rupture, liver dysfunction)

1. Types of Hypertensive Disorders in Pregnancy

A. Gestational Hypertension

● Defined as BP ≥140/90 mmHg after 20 weeks of gestation without proteinuria or end-organ

dysfunction.

● Resolves by 12 weeks postpartum.

● May progress to preeclampsia.

B. Preeclampsia

● BP ≥140/90 mmHg after 20 weeks + proteinuria (≥300 mg in 24-hour urine) OR evidence of end-
organ dysfunction (even without proteinuria).

● Severe Preeclampsia: BP ≥160/110 mmHg + one or more of the following:

○ Persistent headache, visual disturbances (blurry vision, flashing lights)

○ Severe right upper quadrant (RUQ) or epigastric pain (liver involvement)

○ Pulmonary edema or cyanosis

○ Platelet count <100,000/mm³

○ Elevated liver enzymes (AST, ALT)

○ Serum creatinine >1.1 mg/dL or renal insufficiency

C. Eclampsia
● Preeclampsia + seizures (generalized tonic-clonic).

● Life-threatening for both mother and fetus.

● Preceded by warning signs:

○ Persistent severe headache

○ Hyperreflexia with clonus

○ Visual disturbances

○ RUQ pain

○ Severe hypertension

D. Chronic Hypertension

● Pre-existing hypertension before pregnancy or before 20 weeks gestation.

● BP remains high beyond 12 weeks postpartum.

E. Chronic Hypertension with Superimposed Preeclampsia

● Chronic hypertension + new onset of proteinuria or end-organ dysfunction.

● May rapidly progress to severe preeclampsia or eclampsia.

2. Risk Factors
● First pregnancy (nulliparity)

● Advanced maternal age (>35 years)

● Multiple gestation (twins, triplets, etc.)

● Obesity
● Chronic hypertension or renal disease

● Diabetes mellitus

● Autoimmune disorders (SLE, antiphospholipid syndrome)

● Previous history of preeclampsia or family history

3. Assessment Findings
Mild Preeclampsia

BP ≥140/90 mmHg (measured twice, 4 hours apart)

Proteinuria (≥300 mg in 24-hour urine or protein/creatinine ratio ≥0.3 mg/dL)
Mild edema (hands, face, feet)

Severe Preeclampsia

BP ≥160/110 mmHg
Severe proteinuria (>5 g/24 hours)
Persistent headache, blurred vision, photophobia
Severe RUQ pain (hepatic involvement)
Pulmonary edema, dyspnea
Oliguria (<500 mL urine in 24 hours)
Platelet count <100,000/mm³ (risk of DIC)
HELLP Syndrome:

● Hemolysis (low hemoglobin, schistocytes on smear)

● Elevated Liver enzymes (AST, ALT)

● Low Platelets (<100,000/mm³)

Eclampsia (Severe Complication of Preeclampsia)

Seizures (generalized tonic-clonic)

Severe hypertension
Sudden fetal distress
Severe hypoxia, cerebral hemorrhage

4. Complications
Maternal Complications

Stroke
HELLP syndrome
Placental abruption
Disseminated intravascular coagulation (DIC)
Acute kidney injury
Pulmonary edema
Eclampsia (seizures)

Fetal Complications

Intrauterine growth restriction (IUGR)

Prematurity
Oligohydramnios
Hypoxia and acidosis
Intrauterine fetal demise (IUFD)

5. Management & Interventions

Mild Preeclampsia (BP <160/110 mmHg, no severe symptoms)

Monitor BP, urine protein, fetal well-being

Encourage left lateral positioning (improves placental perfusion)
Restrict sodium intake and encourage adequate hydration
Monitor weight and assess for edema
Frequent prenatal visits for BP and urine checks

Severe Preeclampsia or Eclampsia

Hospitalization Required
Administer Magnesium Sulfate (to prevent seizures)

● Loading dose: 4-6 g IV over 15-30 min

● Maintenance dose: 1-2 g/hr IV infusion

● Monitor for magnesium toxicity (loss of reflexes, respiratory depression, lethargy)

● Antidote: Calcium gluconate IV push

Antihypertensive Medications (for BP ≥160/110 mmHg)

● Labetalol (first-line IV)

● Nifedipine (oral, second-line)

● Hydralazine IV (alternative)
Avoid ACE inhibitors & ARBs (teratogenic)

Monitor for Signs of HELLP Syndrome

● Frequent liver function tests, platelet count

● Check for RUQ pain, nausea, jaundice

Delivery Planning

● At ≥37 weeks: Induction of labor or cesarean section

● If <37 weeks with severe preeclampsia: Corticosteroids for fetal lung maturity + delivery
if worsening

Eclampsia Management

● Maintain airway, administer oxygen

● IV Magnesium sulfate to prevent recurrent seizures

● Prepare for emergency delivery if fetal distress occurs

 6. Postpartum Care
● Monitor BP for up to 12 weeks postpartum (risk of persistent hypertension)

● Assess for postpartum eclampsia (can occur up to 6 weeks postpartum)

● Monitor for signs of DIC, stroke, or hemorrhage

● Encourage lifestyle changes if chronic hypertension is present

7. Key Points
Gestational hypertension: BP ≥140/90 mmHg after 20 weeks, no proteinuria.
Preeclampsia: Hypertension + proteinuria or organ dysfunction.
Severe preeclampsia: BP ≥160/110 mmHg, headache, visual changes, liver dysfunction.
Eclampsia: Preeclampsia + seizures.
HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets.
Magnesium sulfate prevents seizures; calcium gluconate is the antidote.
Delivery is the only cure for preeclampsia/eclampsia

Multiple Gestation

1. Description

● Results from the fertilization of two ova (fraternal/dizygotic) or splitting of one fertilized
ovum (identical/monozygotic).

● Complications include:

○ Miscarriage, anemia, congenital anomalies

○ Hyperemesis gravidarum (severe nausea/vomiting)

○ Intrauterine growth restriction (IUGR)

○ Gestational hypertension, polyhydramnios

 ○ Postpartum hemorrhage (from uterine overdistention)

○ Premature rupture of membranes (PROM), preterm labor & delivery

2. Assessment Findings

Excessive fetal activity

Uterus larger than expected for gestational age
Palpation of three or more large fetal parts
Auscultation of multiple fetal heart rates
Excessive weight gain

3. Management & Interventions

Monitor maternal vital signs, fetal heart rates, and growth

Monitor for cervical changes & signs of preterm labor
Perform ultrasound assessments as prescribed
Assess for anemia; administer iron & vitamins as needed
Prepare for possible cesarean section if abnormal presentation
Administer oxytocic medications postpartum to prevent hemorrhage

Placental abnormalities

Placenta Previa

A. Description

1. Improper implantation of the placenta in the lower uterine segment near or over the
internal cervical os.

2. Types:

○ Total (Complete): Placenta fully covers the internal cervical os when cervix is
dilated.

○ Partial: Placenta is within 3 cm of the internal cervical os but does not fully cover
it.
 ○ Marginal (Low-Lying): Placenta implanted in lower uterus, but its lower border is
more than 3 cm from the os.

3. Management depends on the type and gestational age of the fetus.

B. Assessment Findings

Sudden onset of painless, bright red vaginal bleeding (second half of pregnancy)
Soft, relaxed, non-tender uterus
Fundal height larger than expected for gestational age

C. Management & Interventions

Monitor maternal vital signs, fetal heart rate, and fetal activity
Confirm diagnosis via ultrasound (NO vaginal exams!)
Avoid any procedures that may stimulate uterine activity
Maintain bed rest in a side-lying position
Monitor bleeding & treat signs of shock
Administer IV fluids, blood products, or tocolytics as prescribed
Administer Rho(D) immune globulin if indicated

Abruptio Placentae

A. Description

Premature separation of the placenta from the uterine wall after 20 weeks but before
delivery

B. Assessment Findings

Dark red vaginal bleeding (may be absent if bleeding is concealed)

Severe abdominal pain & uterine tenderness
Uterine rigidity
Signs of fetal distress
Signs of shock (if bleeding is excessive)
 C. Management & Interventions

Monitor maternal vital signs & fetal heart rate

Assess for excessive vaginal bleeding & abdominal pain
Monitor for increase in fundal height (suggests concealed bleeding)
Maintain bed rest & administer oxygen, IV fluids, and blood products as prescribed

Place the client in trendelenburg's position

Complications, Risk Factors, Prevention, and Management

Complications

Dental abscess
Broken or missing teeth
Pregnancy gingivitis
Periodontal disease
Pyogenic granuloma
Oral cancer

Risk Factors

Tobacco use
High sugar consumption
Poor oral hygiene
High stress level
Substance use (especially methamphetamine)
Diabetes
HIV infection
Immunosuppression
Low income
Poor nutrition
Medications reducing saliva
Hormonal changes
Genetic predisposition
Poor access to oral health provider

Prevention & Management

Adequate fluid intake
Brushing teeth twice daily with fluoridated toothpaste

Analgesics

Soft diet

antibiotics

iron-Deficiency Anemia
■ Low dietary intake of iron
■ Adolescence
■ Pregnancy and breast-feeding/chest-feeding
■ Low socioeconomic status
■ African American, Hispanic, Native American, recent immigrant
■ History of anemia before pregnancy
■ Underweight before pregnancy
■ Eating problems
■ Multiparity

treatment

■ Screening during pregnancy: complete blood cell count (CBC) at initial visit, at 24-28 weeks,
and at 36 weeks
■ Iron supplementation in addition to prenatal vitamins as prescribed
■ Teach to take iron supplementation between meals so that absorption of zinc is not affected
■ Advise on foods high in iron
■ Advice on medications inhibiting absorption of iron, such as antacids, proton pump inhibitors
(PPIs), certain antibiotics
■ Referral to dietitian
■ May need blood transfusion or IV iron if severely anemic
■ Short interval between pregnancies
■ Pica
■ Blood loss
■ Menorrhagia before pregnancy
■ Frequent blood donation
■ Chronic infectious process
■ Malabsorptive disorder
■ Strict vegetarian diet
■ Alcohol and substance abuse
■ Tobacco use

Asthma
■ Exposure to allergens, dust mites, animal dander, cockroaches, mold, pollen, grass, flowers,
smoke, tobacco, air fresheners, chemical cleaners, sprays
■ Upper respiratory infections
■ Sinusitis
■ Cold temperatures
■ Physical activity
■ Sulfites in food and drinks
■ Gastroesophageal reflux disease (GERD)
■ Weather changes

Treatment

■ Education on prevention or exacerbation

■ Avoid triggers and exposures
■ Asthma action plan education
■ Asthma medications generally safe during pregnancy
■ Short-acting beta-agonist (SABA), long-acting beta-agonist (LABA), and inhaled
corticosteroid (ICS) use
■ Instructions on use of inhalers and nebulizers
■ Oral medications may be needed, depending on severity
■ Serial growth scans by ultrasound should be done starting at 32 weeks
■ Frequent nonstress tests are advised

Zika virus
■ Recent travel or history of residing in an area with local transmission within the past 6 months

■ Treatment revolves around symptom relief

■ Rest
■ Fluids to prevent dehydration
■ Acetaminophen for fever and pain
■ Avoiding aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)
■ May need serial ultrasounds to monitor fetal well-being

Labor and Birth

Engagement
■ Engagement is the mechanism whereby the fetus nestles into the pelvis.
■ Engagement occurs when the presenting part reaches the level of the ischial spines.

Descent
■ Descent is the process that the fetal head undergoes as it begins its journey through the
pelvis.
■ Descent is a continuous process, from before engagement until birth, and is assessed by the
measurement called station.

Flexion
■ Flexion is a process of nodding of the fetal head forward toward the fetal chest.

Internal Rotation
■ Internal rotation of the fetus occurs most commonly from the occipitotransverse position,
assumed at engagement into the pelvis, to the occipitoanterior position while continuously
descending.

Extension
■ Extension enables the head to emerge when the fetus is in a cephalic position.
■ Extension begins after the head crowns.
■ Extension is complete when the head passes under the symphysis pubis and occiput, and
the anterior fontanel, brow, face, and chin pass over the sacrum and coccyx and are over the
perineum.

Restitution
■ Restitution is realignment of the fetal head with the body after the head emerges.

External Rotation
■ The shoulders externally rotate after the head emerges and restitution occurs so that the
shoulders are in the anteroposterior diameter of the pelvis.

Expulsion
■ Expulsion is the birth of the entire body.

Fetal Positions
vertex Presentations

● ROA: Right occiput anterior

● LOA: Left occiput anterior

● ROP: Right occiput posterior

● LOP: Left occiput posterior

● ROT: Right occiput transverse

● LOT: Left occiput transverse

Face Presentations
 ● RMA: Right mentoanterior

● LMA: Left mentoanterior

● RMP: Right mentoposterior

Breech Presentations

● LSA: Left sacroanterior

● LSP: Left sacroposterior

Other Presentations

● Brow presentation

● Shoulder presentation

Leopold’s Maneuvers
A. Description: Methods of palpation to determine presentation and position of the fetus and
aid in location of fetal heart sounds

If the head is in the fundus a hard ,round, movable object is felt

The fetus is back which is smooth ,hard surface,should be felt on one side of the abdomen

Breathing Techniques

First-Stage Breathing

Cleansing Breath
Each contraction begins and ends with a deep inspiration and expiration.

Slow-Paced Breathing
Slow-paced breathing promotes relaxation.
Slow-paced breathing is used for as long as possible during labor.

Modified Paced Breathing

Modified paced breathing is used when slow-paced breathing is no longer effective.
Breathing is shallow and fast.

Pattern-Paced Breathing
Pattern-paced breathing sometimes is referred to as pant-blow.
 After a certain number of breaths (modified-paced breathing), the client exhales with a slight
blow and then begins modified-paced breathing again.

Breathing to Prevent Pushing

The client blows repeatedly, using short puffs, when the urge to push is strong.

Second-Stage Breathing
Several variations of breathing can be used in the pushing stage of labor, and the client may
grunt, groan, sigh, or moan as the client pushes. Prolonged breath holding while pushing with a
closed glottis may result in a decrease in cardiac output. If breath holding while pushing is used,
the open glottis method or limiting breath holding to less than 6 to 8 seconds should be done.

Four Stages of Labor

First Stage: Dilation and Effacement

● Begins with the onset of true labor contractions and ends with full cervical dilation (10
cm).

● Divided into three phases:

1. Latent Phase (0–3 cm dilation): Mild contractions, lasting 30–45 seconds, every
5–30 minutes.

2. Active Phase (4–7 cm dilation): Stronger contractions, lasting 45–60 seconds,

every 3–5 minutes.

3. Transition Phase (8–10 cm dilation): Very strong contractions, lasting 60–90

seconds, every 2–3 minutes.

Second Stage: Expulsion of the Fetus

● Begins with full cervical dilation (10 cm) and ends with the birth of the baby.

● Strong, frequent contractions (every 2–3 minutes, lasting 60–90 seconds).

● The mother experiences an intense urge to push.

● The baby progresses through the birth canal, completing cardinal movements
(engagement, descent, flexion, internal rotation, extension, restitution, external rotation,
expulsion).

Third Stage: Delivery of the Placenta

● Begins after the birth of the baby and ends with the expulsion of the placenta.

● Usually occurs within 5–30 minutes.

● Signs of placental separation:

○ Uterus rises and becomes globular.

○ Sudden gush of blood.

○ Lengthening of the umbilical cord.

Fourth Stage: Immediate Postpartum Recovery

● First 1–2 hours after placenta delivery.

● Close monitoring of vital signs, uterine tone, bleeding, and overall maternal condition.

● The uterus should remain firm and contracted to prevent hemorrhage.

● Mother and baby bonding and initial breastfeeding occur.

Problems with Labor and Birth

Premature Rupture of Membranes (PROM)

Description

● Spontaneous rupture of amniotic membranes before labor onset.

● Management depends on gestational age.

● If preterm, delaying birth increases the risk of infection.

Assessment

● Fluid pooling in the vaginal vault; positive Nitrazine test.

● Assess fluid’s amount, color, consistency, and odor.

● Monitor vital signs; maternal fever suggests infection.

● Fetal tachycardia may indicate maternal infection.

Interventions

● Determine gestational age.

● Avoid vaginal exams to reduce infection risk.

● Monitor maternal and fetal well-being.

● Administer antibiotics as prescribed.

Prolapsed Umbilical Cord

Description

● The umbilical cord slips between the presenting part and the amnion or protrudes
through the cervix, leading to cord compression and impaired fetal circulation.

Assessment

● Sensation of something coming through the vagina.

● Visible or palpable umbilical cord.

● Irregular, slow fetal heart rate.

● Fetal monitor shows variable decelerations or bradycardia after membrane rupture.

● Severe fetal hypoxia may cause rapid fetal activity followed by cessation.

Interventions

1. Emergency Response

○ Call for immediate assistance and notify the healthcare provider.

2. Relieve Cord Compression

○ Place the client in Trendelenburg or knee-chest position to reduce pressure on

the cord.
 ○ Use a sterile-gloved hand to gently push the presenting part off the cord without
repositioning it.

3. Oxygen & IV Fluids

○ Administer oxygen (8–10 L/min) via face mask to improve fetal oxygenation.

○ Initiate or increase IV fluids as prescribed to maintain perfusion.

4. Monitor Fetal Status

○ Monitor fetal heart rate continuously.

○ Prepare for emergency cesarean delivery if indicated.

5. Maintain Moisture

○ If the cord is protruding, cover it with a sterile saline-soaked gauze to prevent

drying.

6. Emotional Support

○ Keep the client informed and provide reassurance throughout the process.

Supine Hypotension (Vena Cava Syndrome)

Description

● A condition where the weight of the uterus compresses the inferior vena cava when the
client lies in a supine position, reducing venous return, cardiac output, and blood
pressure, leading to hypotension.

Assessment

● Dizziness, lightheadedness, or fainting.

● Pallor and clammy skin.

● Nausea.

● Hypotension.

● Tachycardia.
● Fetal distress (detected through fetal heart rate monitoring).

Interventions

1. Reposition the Client

○ Place in a left lateral position to relieve pressure on the vena cava.

○ If the client must remain supine, place a wedge or pillow under one hip to tilt the
uterus.

2. Monitor Vital Signs & Fetal Heart Rate

○ Assess blood pressure and heart rate frequently.

○ Monitor for signs of fetal distress.

3. Encourage Position Changes

○ Advise side-lying or semi-Fowler’s position to prevent recurrence.

4. Provide Oxygen if Needed

○ If symptoms persist or fetal distress occurs, administer oxygen (8–10 L/min) via
face mask.

5. Increase IV Fluids if Prescribed

○ Helps maintain blood pressure and circulation.

Preterm Labor

Description

● Preterm labor is the onset of regular uterine contractions with cervical changes before 37
weeks of gestation.

● It is a leading cause of neonatal morbidity and mortality.

Risk Factors

● History of preterm labor or birth

● Multiple gestation (twins, triplets, etc.)

● Infection (e.g., urinary tract infection, bacterial vaginosis)

● Premature rupture of membranes (PROM)

● Uterine or cervical abnormalities (e.g., short cervix, cervical insufficiency)

● Placental abnormalities (e.g., placenta previa, abruption)

● Chronic conditions (e.g., hypertension, diabetes)

● Substance use (e.g., smoking, alcohol, drugs)

● High stress levels or physical exertion

Assessment

● Regular contractions every 10 minutes or less

● Lower abdominal cramping or back pain

● Pelvic pressure or increased vaginal discharge

● Rupture of membranes

● Cervical dilation and effacement

Interventions

1. Monitor Maternal & Fetal Status

○ Assess contraction pattern, cervical changes, and fetal heart rate.

2. Administer Tocolytics (if prescribed)

○ Magnesium sulfate – Relaxes uterine muscles.

○ Nifedipine (calcium channel blocker) – Reduces contractions.

○ Terbutaline (beta-adrenergic agonist) – Delays labor.

 3. Corticosteroids (if indicated)

○ Betamethasone or dexamethasone to enhance fetal lung maturity if delivery is

imminent.

4. Hydration & Rest

○ Encourage oral or IV fluids to reduce uterine irritability.

○ Bed rest in a lateral position may be recommended.

5. Monitor for Infection

○ Check for fever, uterine tenderness, and foul-smelling discharge (signs of

infection).

○ Administer antibiotics if infection is present or for group B strep prophylaxis.

6. Prepare for Delivery (if Necessary)

Dystocia (Difficult Labor)

Description

Dystocia refers to difficult or prolonged labor due to abnormalities in any of the following:

1. Power (Uterine Contractions) – Weak, uncoordinated, or ineffective contractions.

2. Passenger (Fetus) – Large fetus, malpresentation (e.g., breech, face presentation).

3. Passageway (Pelvis & Soft Tissues) – Cephalopelvic disproportion (CPD) or

small/abnormal pelvis.

4. Psyche (Emotional State) – Anxiety or fear leading to increased catecholamines, which

inhibit labor.

Assessment

● Prolonged labor (active phase > 6 hours without cervical change)

 ● Inadequate contractions (hypotonic or hypertonic)

● Failure of fetal descent

● Signs of fetal distress (e.g., abnormal fetal heart rate, meconium-stained amniotic fluid)

Interventions

1. Monitor Labor Progress

○ Assess contractions, cervical changes, and fetal position via ultrasound if

needed.

2. Manage Uterine Dysfunction

○ For hypotonic labor: Administer oxytocin (Pitocin) to enhance contractions.

○ For hypertonic labor: Provide hydration, pain relief, or tocolytics if needed.

3. Facilitate Fetal Positioning

○ Encourage maternal repositioning (hands-and-knees, squatting, side-lying).

○ Manual rotation or external cephalic version (for malpositioned fetus).

4. Prepare for Assisted Delivery or C-Section

○ Forceps or vacuum extraction if needed.

○ Cesarean delivery if CPD or fetal distress is present.

5. Emotional Support & Pain Management

○ Epidural anesthesia, breathing techniques, reassurance.

Fetal Distress
A. Assessment

1. Fetal heart rate <110 or >160 bpm

 2. Meconium-stained amniotic fluid

3. Fetal hypoactivity or hyperactivity

4. Progressive decrease in baseline variability

5. Severe variable decelerations

6. Late decelerations

B. Interventions

1. Emergency situation

2. Discontinue oxytocin if infusing

3. Tocolytic may be prescribed if distress persists

4. Place client in lateral position

5. Administer oxygen (8–10 L/min via face mask)

6. Administer IV fluids (usually as a bolus)

7. Monitor maternal and fetal status

Postpartum Period
physiological Maternal Changes
A. Involution

1. Rapid uterine size reduction post-birth.

2. Faster in breast/chest-feeding clients due to oxytocin.

3. Uterus shrinks from 2 lb (900 g) to 2 oz (57 g) in 6 weeks.

4. Fundal height decreases ~1 cm/day, non-palpable by day 10.

5. Flaccid fundus = uterine atony (massage needed); tender fundus = infection.

 6. Afterpains subside within days.

B. Lochia (Uterine Discharge)

1. Rubra (bright red, days 1–3).

2. Serosa (brownish-pink, days 4–10).

3. Alba (white, days 11–14).

4. Normal menstrual-like odor, decreases daily, may increase with movement.

5. Monitor flow by weighing pads; assess color, odor, clots.

C. Cervix – Begins regenerating within a week.

D. Vagina – Gradual return to pre-pregnancy state.

Postpartum Emotional Changes

Postpartum Blues: Mood swings, crying, sadness, anxiety, anger, fatigue, insomnia,
restlessness, headaches, and feeling of let-down.

Postpartum Depression: Persistent sadness, loss of interest, appetite changes, fatigue, guilt,
difficulty concentrating, irritability, lack of energy, withdrawal from infant, and suicidal thoughts.

Postpartum Psychosis: Severe confusion, hallucinations, delusions, panic, and a break from
reality.

Postpartum Complications

1. Hemorrhage

● Blood loss >500 mL (vaginal) or >1000 mL (C-section).

● Causes: Uterine atony, retained placenta, lacerations, hematomas.

● Signs: Excessive bleeding, boggy uterus, tachycardia, hypotension.

● Management: Fundal massage, oxytocin, IV fluids, blood transfusion if needed.

2. Infection (Puerperal Sepsis)

● Causes: Endometritis, wound infections, UTIs, mastitis.

● Signs: Fever >100.4°F (38°C), foul-smelling lochia, uterine tenderness, malaise.

● Management: Antibiotics, fluids, proper hygiene.

3. Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE)

● Risk Factors: Immobility, C-section, obesity, smoking.

● DVT Signs: Leg pain, redness, swelling.

● PE Signs: Chest pain, dyspnea, tachycardia.

● Management: Anticoagulants, compression devices, early ambulation.

4. Postpartum Depression & Psychosis

● Depression: Persistent sadness, guilt, loss of interest, suicidal thoughts.

● Psychosis: Hallucinations, delusions, confusion, paranoia.

● Management: Therapy, medications, support groups, hospitalization (if severe).

5. Retained Placenta

● Placental fragments left in the uterus, preventing involution.

● Signs: Heavy bleeding, prolonged lochia, boggy uterus.

● Management: Manual removal, dilation & curettage (D&C).

PAEDIATRIC NURSING
Pediatric Integumentary Disorders
1. Atopic Dermatitis (Eczema)

● Cause: Allergic response, genetic predisposition.

● Signs: Pruritic, dry, scaly, erythematous patches on flexor surfaces.

● Management:

○ Hydration with emollients.

○ Avoid irritants (soaps, fragrances).

○ Topical corticosteroids for inflammation.

○ Antihistamines for itching.

2. Impetigo (Highly Contagious Bacterial Infection)

● Cause: Staphylococcus aureus or Streptococcus pyogenes.

● Signs: Honey-colored crusted lesions, most common on face.

● Management:

○ Topical mupirocin or oral antibiotics (severe cases).

○ Hand hygiene to prevent spread.

3. Diaper Dermatitis (Diaper Rash)

● Cause: Prolonged moisture exposure, irritants, Candida infection.

● Signs: Red, inflamed skin in diaper area, satellite lesions (if fungal).

● Management:

○ Frequent diaper changes.

○ Barrier creams (zinc oxide, petroleum jelly).

○ Antifungal cream if Candida suspected.

4. Tinea Infections (Fungal Infections)

● Types:
 ○ Tinea capitis (scalp) → Scaly patches, hair loss.

○ Tinea corporis (ringworm) → Annular red lesions with central clearing.

○ Tinea pedis (athlete’s foot) → Itchy, cracked, peeling skin between toes.

● Management:

○ Topical antifungals (clotrimazole, terbinafine).

○ Oral antifungals for scalp involvement (griseofulvin).

5. Scabies (Parasitic Infestation by Mites)

● Signs: Intense itching (worse at night), burrow lines on skin (wrists, fingers, axillae).

● Management:

○ Topical permethrin 5% cream (apply overnight, repeat in 1 week).

○ Treat household contacts.

○ Wash bedding/clothes in hot water.

6. Pediculosis Capitis (Head Lice)

● Signs: Itchy scalp, visible lice/nits behind ears and nape of the neck.

● Management:

○ Topical pediculicides (permethrin, malathion).

○ Fine-tooth comb to remove nits.

○ Wash clothes/bedding in hot water.

7. Burns in Pediatrics

● Assessment:

○ Superficial (1st-degree): Red, painful (e.g., sunburn).

 ○ Partial-thickness (2nd-degree): Blisters, moist, painful.

○ Full-thickness (3rd-degree): White, leathery, painless.

● Management:

○ Minor burns: Cool water, pain control, topical antibiotics.

○ Severe burns: IV fluids (Parkland formula), wound care, infection prevention.

Hematological Problems
● Definition: Sickle cell anemia (SCA) is an inherited blood disorder characterized by the
production of abnormal hemoglobin (HbS), leading to rigid, sickle-shaped red blood cells
(RBCs).

● Cause: Autosomal recessive inheritance (both parents must carry the sickle cell gene).

● Risk Groups: More common in African, Mediterranean, Middle Eastern, and Indian
populations.

2. Pathophysiology

● Sickled RBCs have a shorter lifespan (10–20 days vs. 120 days in normal RBCs),
leading to chronic hemolytic anemia.

● Abnormal RBCs clump together, blocking small blood vessels (vaso-occlusion), causing
pain crises and organ damage.

● Triggers: Dehydration, infections, extreme temperatures, stress, hypoxia.

3. Signs & Symptoms in Children

Vaso-Occlusive Crisis (Pain Crisis)

● Severe pain in bones, joints, chest, or abdomen.

● Swelling of hands and feet (dactylitis), often the first sign in infants.

Hemolytic Anemia
 ● Fatigue, pallor, tachycardia.

● Jaundice (due to RBC breakdown).

● Splenomegaly (enlarged spleen, leading to sequestration crisis).

Acute Chest Syndrome (Emergency!)

● Fever, cough, shortness of breath, chest pain.

● Can cause respiratory failure if untreated.

Splenic Sequestration Crisis

● Sudden spleen enlargement due to trapped sickled RBCs.

● Severe anemia, hypovolemic shock.

● Common in infants & young children.

Stroke Risk

● Weakness, speech difficulties, vision changes.

● Common in children aged 2–10 years.

5. Management in Children

Hydration: IV/oral fluids to prevent sickling.

Pain Control: NSAIDs, opioids (morphine for severe pain).
Oxygen Therapy: Used in hypoxia or acute chest syndrome.
Blood Transfusions: Used for severe anemia, stroke prevention.
Hydroxyurea: Increases fetal hemoglobin (HbF), reducing sickling crises.
Infection Prevention:

● Prophylactic penicillin (daily until age 5).

● Vaccinations: Pneumococcal, meningococcal, Hib, and annual flu shot.

Bone Marrow Transplant: The only potential cure, but rare due to donor availability.
 6. Nursing Interventions

Monitor for fever, infections, and signs of crisis.

Encourage hydration and a balanced diet rich in folic acid.
Teach parents to recognize early signs of complications (pain, jaundice, swelling).
Avoid triggers (cold exposure, dehydration, stress).
Ensure regular follow-up for stroke screening (TCD scans).

Oncological Problems

Leukemia (Most Common Pediatric Cancer)

Types:
Acute Lymphoblastic Leukemia (ALL) – Most common (80% of childhood leukemia cases).
Acute Myeloid Leukemia (AML) – Less common but more aggressive.

Signs & Symptoms:

Frequent infections (due to low WBCs).

Pallor, fatigue (due to anemia).
Easy bruising, petechiae (low platelets).
Bone pain, limping.
Hepatosplenomegaly (enlarged liver/spleen).

Diagnosis:

● CBC (low RBCs, low platelets, high or low WBCs).

● Bone marrow biopsy (blast cells >20%).

● Lumbar puncture (to check CNS involvement).

Treatment:

● Chemotherapy (phases: induction, consolidation, maintenance).

● Bone marrow transplant (for high-risk cases).

● CNS prophylaxis (intrathecal chemotherapy).

 2. Brain Tumors (Second Most Common Pediatric Cancer)
Types:
Medulloblastoma (most common malignant brain tumor).
Astrocytoma (better prognosis if low grade).
Ependymoma, Brainstem Gliomas.

Signs & Symptoms:

Headache (worse in morning).

Vomiting (without nausea).
Ataxia (loss of coordination).
Vision changes, papilledema.
Seizures, personality changes.

Diagnosis:

● MRI or CT scan of the brain.

● Lumbar puncture (if no increased ICP).

● Biopsy for definitive diagnosis.

Treatment:

● Surgery (for accessible tumors).

● Chemotherapy, radiation (avoid radiation in children <3 years to prevent cognitive

impairment).

3. Neuroblastoma
● Affects sympathetic nervous system (arises from adrenal glands or nerve tissue).

● Common in children <5 years.

Signs & Symptoms:

Abdominal mass, firm & irregular.
Periorbital bruising ("raccoon eyes").
Hypertension (if adrenal involvement).
Opsoclonus-myoclonus syndrome (dancing eye movements).

Diagnosis:

● Urine catecholamines (↑ VMA & HVA).

● MRI, CT scan.

● Biopsy for histological confirmation.

Treatment:

● Surgery (if localized).

● Chemotherapy, radiation for advanced cases.

4. Wilms’ Tumor (Nephroblastoma)

● Kidney tumor, common in children 2-4 years.

● Associated with WT1 gene mutation.

Signs & Symptoms:

Painless, unilateral abdominal mass.

Hematuria, hypertension.
Aniridia (absence of iris in the eye) in some cases.

Diagnosis:

● Abdominal ultrasound, CT scan.

● DO NOT palpate mass (risk of rupture).

Treatment:
 ● Nephrectomy (surgical removal).

● Chemotherapy, radiation (for advanced stages).

5. Retinoblastoma (Eye Cancer)

● Genetic mutation of RB1 gene.

● Can be inherited (bilateral) or sporadic (unilateral).

Signs & Symptoms:

Leukocoria (white reflex instead of red reflex in the eye).

Strabismus (crossed eyes).
Vision loss

Treatment:

● Enucleation (removal of the affected eye if severe).

● Chemotherapy, laser therapy for smaller tumors.

6. Osteosarcoma & Ewing Sarcoma (Bone Cancers)

Osteosarcoma

● Affects long bones (femur, tibia, humerus).

● Common in adolescents.

Ewing Sarcoma

● Affects pelvis, ribs, vertebrae.

 ● More aggressive than osteosarcoma.

Signs & Symptoms:

Bone pain (worse at night).

Swelling, mass over the bone.
Pathological fractures.

Treatment:

● Chemotherapy, surgery (limb-sparing or amputation).

● Radiation for Ewing sarcoma.

7. Rhabdomyosarcoma (Soft Tissue Tumor)

● Most common soft tissue sarcoma in children.

● Can arise anywhere but often affects head, neck, GU tract, extremities.

Signs & Symptoms:

Painless mass.
Tumor-specific symptoms (e.g., proptosis if orbital, hematuria if bladder).

General Pediatric Cancer Treatment & Nursing Care

Chemotherapy Side Effects:

● Bone marrow suppression (neutropenia, anemia, thrombocytopenia).

● Nausea/vomiting (give antiemetics like ondansetron).

● Mucositis, stomatitis (oral care with saline rinses).

 ● Alopecia (temporary hair loss).

Nursing Considerations:
Prevent infections (hand hygiene, avoid crowds).
Monitor for bleeding & anemia.
Provide pain relief (opioids if needed).
Offer emotional support to family & child.

. Growth Hormone Deficiency (Hypopituitarism)

● Caused by inadequate secretion of growth hormone (GH).

● Can be congenital or acquired (tumors, infections, trauma).

Signs & Symptoms:

Short stature, delayed skeletal growth.

Increased fat around the abdomen.
Delayed puberty.
Hypoglycemia in newborns.

Diagnosis:

● GH stimulation test.

● Bone age X-ray (delayed bone growth).

● MRI (check for pituitary abnormalities).

Treatment:

● Recombinant GH injections (Somatropin).

● Monitor growth & bone age regularly.

2. Hyperpituitarism (Excess GH) - Gigantism &

Acromegaly
 ● Gigantism (before growth plate closure → excessive height).

● Acromegaly (after growth plate closure → enlarged hands, feet, facial features).

● Usually caused by a pituitary tumor.

Signs & Symptoms:

Rapid height increase (gigantism).

Large hands, feet, facial features (acromegaly).
Joint pain, thickened skin.

Diagnosis:

● GH suppression test.

● MRI of the pituitary gland.

Treatment:

● Surgery (remove tumor).

● Radiation or octreotide (GH-inhibiting medication).

3. Precocious Puberty
● Early activation of hypothalamic-pituitary-gonadal axis.

● Girls: Puberty before 8 years.

● Boys: Puberty before 9 years.

Signs & Symptoms:

Early breast/testicle development.

Rapid growth, advanced bone age.
Acne, adult body odor.
 Diagnosis:

● Increased LH & FSH levels.

● Bone age X-ray (shows early growth plate closure).

Treatment:

● GnRH agonists (Leuprolide) to delay puberty.

4. Diabetes Insipidus (DI) - Low ADH

● Caused by deficiency of antidiuretic hormone (ADH/vasopressin).

● Leads to excessive urine output & dehydration.

Signs & Symptoms:

Polyuria (excess urine output).

Polydipsia (excessive thirst).
Dehydration, hypernatremia.

Diagnosis:

● Water deprivation test (urine remains dilute).

● Low urine osmolality, high serum osmolality.

Treatment:

● Desmopressin (DDAVP) for central DI.

● Thiazide diuretics for nephrogenic DI.

● Monitor hydration & electrolytes.

 5. Syndrome of Inappropriate ADH (SIADH) - High
ADH
● Excess ADH leads to water retention & hyponatremia.

● Can be caused by CNS infections, head injury, tumors.

Signs & Symptoms:

Decreased urine output, concentrated urine.

Hyponatremia (confusion, seizures).
Weight gain (without edema).

Diagnosis:

● High urine osmolality, low serum osmolality.

● Low sodium (<135 mEq/L).

Treatment:

● Fluid restriction.

● Hypertonic saline (3%) if severe hyponatremia.

● Diuretics (furosemide) to remove excess fluid.

6. Congenital Hypothyroidism
● Thyroid hormone (T3 & T4) deficiency at birth.

● Can lead to intellectual disability if untreated.

Signs & Symptoms:

 Large fontanelles, protruding tongue.
Hoarse cry, poor feeding.
Hypotonia, dry skin, constipation.

Treatment:

● Levothyroxine (lifelong therapy).

● Monitor growth & development.

7. Hyperthyroidism (Graves' Disease)

● Autoimmune disorder causing overactive thyroid.

● More common in adolescents.

Signs & Symptoms:

Weight loss, increased appetite.

Heat intolerance, sweating.
Tachycardia, tremors.
Exophthalmos (bulging eyes).

Treatment:

● Antithyroid medications (Methimazole).

● Beta-blockers (Propranolol) for symptom control.

● Radioactive iodine or surgery (if severe).

8. Congenital Adrenal Hyperplasia (CAH)

● Enzyme deficiency (21-hydroxylase) → cortisol deficiency & androgen excess.
 Signs & Symptoms:

Ambiguous genitalia in females (virilization).

Salt-wasting crisis (vomiting, dehydration, low sodium).
Early puberty, rapid growth.

Treatment:

● Hydrocortisone (replace cortisol).

● Fludrocortisone (replace aldosterone in salt-wasting type).

● Monitor growth & puberty progression.

9. Addison’s Disease (Adrenal Insufficiency)

● Deficiency of cortisol & aldosterone.

● Can be autoimmune or caused by infections (TB, fungal infections).

Signs & Symptoms:

Fatigue, weakness.
Weight loss, hypotension.
Hyperpigmentation (bronze skin).
Salt cravings, hyponatremia, hyperkalemia.

Treatment:

● Hydrocortisone (cortisol replacement).

● Fludrocortisone (if aldosterone deficiency).

● Stress dose steroids during illness.

 10. Cushing’s Syndrome (Excess Cortisol)
● Overproduction of cortisol due to adrenal tumors, pituitary tumors, or long-term steroid
use.

Signs & Symptoms:

Moon face, buffalo hump.

Truncal obesity, thin limbs.
Hypertension, osteoporosis.
Purple striae, fragile skin.

Treatment:

● Gradual tapering of steroids (if iatrogenic).

● Surgery for adrenal/pituitary tumors.

GASTROINTESTINAL PROBLEMS

Gastroesophageal Reflux (GER) & GERD

● GER: Common in infants, resolves by 12-18 months.

● GERD: Persistent reflux with complications (esophagitis, aspiration).

Signs & Symptoms:

Spitting up, regurgitation.

Crying, irritability after feeding.
Arching of the back (Sandifer syndrome).
Poor weight gain, chronic cough (GERD).

Diagnosis:

● pH probe study, esophageal endoscopy.

Treatment:
 ● Small, frequent feeds; keep upright after feeding.

● Thickened formula (with rice cereal).

● GERD: H2 blockers (Ranitidine), PPIs (Omeprazole).

● Surgery (Nissen fundoplication) in severe cases.

2. Hypertrophic Pyloric Stenosis

● Thickening of the pyloric sphincter → gastric outlet obstruction.

● Usually presents at 2-6 weeks of life.

Signs & Symptoms:

Projectile, non-bilious vomiting after feeding.

Olive-shaped mass in RUQ.
Visible peristaltic waves.
Dehydration, weight loss.

Diagnosis:

● Ultrasound (thickened pylorus).

● Electrolytes (hypokalemia, metabolic alkalosis).

Treatment:

● IV fluids, electrolyte correction.

● Pyloromyotomy (definitive treatment).

3. Intussusception
 ● Telescoping of one bowel segment into another (commonly at ileocecal junction).

● Most common in infants 3 months - 3 years.

Signs & Symptoms:

Severe intermittent abdominal pain (child draws knees to chest).

Sausage-shaped mass in RUQ.
Red, "currant jelly" stools (blood + mucus).
Vomiting, lethargy.

Diagnosis:

● Ultrasound ("target sign").

● Air or contrast enema (diagnostic & therapeutic).

Treatment:

● Air enema (first-line treatment).

● Surgery if enema fails or bowel perforation occurs.

4. Hirschsprung Disease
● Congenital absence of ganglion cells in the colon → no peristalsis.

● Leads to functional obstruction.

Signs & Symptoms:

Failure to pass meconium in 48 hours.

Chronic constipation, abdominal distension.
Bilious vomiting.
Ribbon-like, foul-smelling stools (if partial obstruction).

Diagnosis:
 ● Rectal biopsy (gold standard - absent ganglion cells).

● Barium enema (narrowed aganglionic segment with dilation above).

Treatment:

● Surgical resection (pull-through procedure).

● Temporary colostomy in severe cases.

5. Necrotizing Enterocolitis (NEC)

● Intestinal ischemia & necrosis in preterm infants.

● Linked to formula feeding, infection, & gut immaturity.

Signs & Symptoms:

Feeding intolerance, bloating.

Bloody stools.
Abdominal distension, tenderness.
Lethargy, temperature instability.

Diagnosis:

● Abdominal X-ray (pneumatosis intestinalis – air in bowel wall).

Treatment:

● NPO (bowel rest), IV fluids, TPN.

● Broad-spectrum IV antibiotics.

● Surgery for perforation.

 6. Celiac Disease
● Autoimmune disorder triggered by gluten (wheat, barley, rye).

● Leads to villous atrophy & malabsorption.

Signs & Symptoms:

Chronic diarrhea, steatorrhea (fatty stools).

Abdominal bloating, pain.
Failure to thrive, weight loss.
Iron-deficiency anemia.

Diagnosis:

● Tissue transglutaminase (tTG) IgA antibodies.

● Small bowel biopsy (villous atrophy - gold standard).

Treatment:

● Lifelong gluten-free diet.

● Vitamin & iron supplements as needed.

7. Lactose Intolerance
● Deficiency of lactase enzyme → inability to digest lactose.

Signs & Symptoms:

Abdominal pain, bloating.

Diarrhea after dairy intake.
Gas, cramping.

Diagnosis:
 ● Lactose hydrogen breath test.

Treatment:

● Lactose-free diet.

● Lactase enzyme supplements.

8. Appendicitis
● Inflammation of the appendix → risk of rupture.

Signs & Symptoms:

Periumbilical pain → RLQ pain (McBurney’s point).

Rebound tenderness, guarding.
Fever, nausea, vomiting.
Pain increases with movement (coughing, jumping - "hop test").

Diagnosis:

● Ultrasound or CT scan (enlarged appendix, inflammation).

● Elevated WBC count.

Treatment:

● Appendectomy (surgery).

● IV antibiotics if perforation.

9. Meckel’s Diverticulum
 ● Remnant of the fetal vitelline duct → painless rectal bleeding.

Signs & Symptoms:

Painless, bright red rectal bleeding.

Iron-deficiency anemia.
Possible intestinal obstruction.

Diagnosis:

● Meckel’s scan (technetium-99 scan).

Treatment:

● Surgical resection.

10. Biliary Atresia

● Blocked bile ducts → liver damage & jaundice in neonates.

Signs & Symptoms:

Persistent jaundice (>2 weeks).

Pale, clay-colored stools.
Dark urine, hepatomegaly.

Diagnosis:

● Abdominal ultrasound, liver biopsy.

Treatment:

● Kasai procedure (surgical bile drainage).

● Liver transplant if severe.

 CLEFT LIP AND CLEFT PALATE
. Description

● Cleft Lip: Incomplete fusion of the upper lip.

● Cleft Palate: Failure of the hard and/or soft palate to close.

● Can occur separately or together.

● Increases risk of feeding difficulties, speech problems, recurrent ear infections, and
aspiration.

2. Causes & Risk Factors

Genetic factors (family history).
Maternal exposure to:

● Smoking, alcohol, or drug use.

● Folic acid deficiency.

● Certain medications (anticonvulsants, steroids).

3. Signs & Symptoms

Visible separation in lip or palate.
Difficulty latching and feeding.
Nasal regurgitation of milk.
Recurrent ear infections → risk of hearing loss.
Speech and dental problems later in life.

4. Diagnosis
● Prenatal ultrasound (detected by 13-14 weeks of gestation).

● Physical examination at birth.

5. Treatment & Management

A. Feeding Techniques (Before Surgery)

Use special feeding devices:

● Haberman feeder or special cleft lip bottle.

● Syringe feeding if severe.

● Upright positioning to prevent aspiration.

B. Surgical Correction

Surgery Timing

Cleft Lip Repair 2-3

(Cheiloplasty) months
old

Cleft Palate Repair 6-12

(Palatoplasty) months
old

●
Multiple surgeries may be needed as the child grows.

● Lip repair before palate to aid feeding & speech development.

 C. Post-Operative Care

Protect surgical site (use elbow restraints).

No pacifiers, straws, or sharp objects in the mouth.
Feed with syringe/dropper (avoid sucking motion).
Position on side or back (avoid pressure on suture).
Clean incision with saline after feeding.
Pain management (acetaminophen).

D. Long-Term Care

Monitor for ear infections → may need ear tubes.

Early dental care (may need orthodontics).
🗣 Speech therapy for articulation difficulties.
Multidisciplinary team (pediatrician, surgeon, speech therapist, dentist, audiologist).

6. Complications

Feeding difficulties → Poor weight gain.

Aspiration & choking risk.
Hearing loss (frequent otitis media).
Speech & dental problems.
Psychosocial concerns (self-esteem issues).

7. Nursing Interventions

✔ Support parents emotionally.

✔ Teach feeding techniques.
✔ Monitor weight gain & growth.
✔ Post-op care & suture protection.

Upper Respiratory Tract Infections (URTIs)

Common Cold (Viral Rhinitis)
Pharyngitis (Strep Throat) – Group A Streptococcus
Tonsillitis – Enlarged tonsils can cause airway obstruction
Croup (Laryngotracheobronchitis)

● Barking cough, stridor, hoarseness

● "Steeple sign" on X-ray

● Treatment: Cool mist, corticosteroids, racemic epinephrine

2. Lower Respiratory Tract Infections (LRTIs)

Bronchiolitis (RSV - Respiratory Syncytial Virus)

● Common in infants (<2 years)

● Wheezing, nasal flaring, retractions, low-grade fever

● Treatment: Supportive (oxygen, fluids, suctioning)

● Prevention: Palivizumab for high-risk infants

Pneumonia

● Viral (more common in children) vs. Bacterial

● Signs: Fever, cough, tachypnea, crackles

● Diagnosis: Chest X-ray, sputum culture

● Treatment: Antibiotics if bacterial, supportive care for viral

Tuberculosis (TB)

● Chronic cough, weight loss, night sweats

● Diagnosis: Mantoux test, chest X-ray

● Treatment: Anti-TB drugs (RIPE therapy)

3. Airway Obstruction Conditions

Foreign Body Aspiration

● Sudden choking, coughing, stridor

● Diagnosis: X-ray, bronchoscopy

● Management: Back blows (infants), Heimlich maneuver (older children)

Epiglottitis (Haemophilus influenzae type B) – Emergency

● Drooling, tripod position, muffled voice, stridor

● Do NOT examine throat → Risk of sudden airway obstruction

● Treatment: Immediate intubation, IV antibiotics

4. Chronic Respiratory Disorders

Asthma

● Reversible airway obstruction → Wheezing, dyspnea, coughing

● Triggers: Allergens, exercise, cold air

● Treatment:

○ Rescue: Short-acting beta-agonists (SABA - Albuterol)

○ Maintenance: Inhaled corticosteroids (ICS), leukotriene receptor antagonists

○ Peak flow monitoring to assess severity

Cystic Fibrosis (CF)

● Genetic disorder (autosomal recessive) → Thick mucus production

● Symptoms: Chronic cough, recurrent lung infections, pancreatic insufficiency

● Diagnosis: Sweat chloride test

● Treatment: Airway clearance therapy, pancreatic enzymes, high-calorie diet

5. Neonatal Respiratory Conditions

Respiratory Distress Syndrome (RDS)

● Premature infants (surfactant deficiency)

● Signs: Grunting, nasal flaring, retractions

● Treatment: Surfactant therapy, CPAP, oxygen

Meconium Aspiration Syndrome (MAS)

● Fetal distress → Meconium-stained amniotic fluid

● Signs: Respiratory distress, cyanosis, coarse crackles

● Treatment: Suctioning, oxygen, ventilation support

Apnea of Prematurity

● Intermittent cessation of breathing (>20 sec) in preterm infants

● Treatment: Caffeine therapy, CPAP

6. Nursing Interventions for Pediatric Respiratory Disorders

 Assess respiratory rate, effort, breath sounds, and oxygen saturation
Provide oxygen therapy as needed
Position child in high Fowler’s or prone (CF patients)
Encourage fluids to thin secretions
Teach proper inhaler/spacer use for asthma
Educate caregivers on infection prevention (handwashing, vaccines, avoiding smoke
exposure)

CARDIAC DISORDERS.

Congenital Heart Defects (CHDs)

Classified as:

● Acyanotic (Increased Pulmonary Blood Flow or Obstructive Defects)

● Cyanotic (Decreased Pulmonary Blood Flow or Mixed Defects)

Acyanotic Defects (Increased Pulmonary Blood Flow)

Atrial Septal Defect (ASD)

● Hole in the atrial septum → Left-to-right shunt

● Signs: Asymptomatic or mild heart murmur, fatigue

● Treatment: May close spontaneously; surgery if large

Ventricular Septal Defect (VSD)

● Most common CHD → Left-to-right shunt

● Signs: Loud murmur, heart failure signs, poor feeding

● Treatment: May close spontaneously; surgery if needed

Patent Ductus Arteriosus (PDA)

● Ductus arteriosus fails to close after birth

● Signs: "Machine-like" murmur, bounding pulses

● Treatment: Indomethacin (NSAID) to close PDA, or surgical closure

Coarctation of the Aorta (CoA)

● Narrowing of the aortic arch → High BP in upper extremities, low BP in lower extremities

● Signs: Weak femoral pulses, headache, nosebleeds

● Treatment: Balloon angioplasty, surgery

Cyanotic Defects (Decreased Pulmonary Blood Flow or Mixed Blood

Flow)

Cyanosis (blue skin, lips, nail beds) is a key feature

Tetralogy of Fallot (TOF) → 4 Defects ("PROV")

● Pulmonary stenosis

● Right ventricular hypertrophy

● Overriding aorta

● Ventricular septal defect (VSD)

● Signs: Cyanosis, "Tet spells" (cyanotic episodes, relieved by squatting/knee-to-chest

position)

● Treatment: Surgery

Transposition of the Great Arteries (TGA)

● Aorta and pulmonary artery are switched → No oxygenated blood to the body

● Signs: Severe cyanosis at birth, no improvement with oxygen

● Treatment: Prostaglandin E to keep PDA open, surgical correction

Hypoplastic Left Heart Syndrome (HLHS)

● Underdeveloped left side of the heart

● Signs: Weak pulses, cyanosis, heart failure signs

● Treatment: Prostaglandin E to maintain PDA, surgery

2. Acquired Heart Diseases

Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)

Inflammation of blood vessels (vasculitis) → Risk of coronary aneurysms

Signs (5+ days of fever + 4 of the following):

● Strawberry tongue

● Red/swollen hands & feet

● Rash (no blisters)

● Conjunctivitis (no discharge)

● Cervical lymphadenopathy

Treatment:

● IV immunoglobulin (IVIG)

● Aspirin (rare exception to avoid Reye’s Syndrome)

● Monitor for coronary aneurysms

Rheumatic Fever

Autoimmune inflammatory disease following untreated Group A Strep infection

Major symptoms ("J NES"):
● Joint pain (polyarthritis)

● (Carditis - heart inflammation)

● Nodules (subcutaneous)

● Erythema marginatum (rash)

● Sydenham's chorea (involuntary jerky movements)

Treatment:

● Penicillin (long-term prophylaxis to prevent recurrence)

● Anti-inflammatories (NSAIDs, steroids if severe carditis)

3. Pediatric Heart Failure (HF)

Causes: CHD, cardiomyopathy, rheumatic fever, Kawasaki disease
Signs & Symptoms:

● Tachycardia, poor feeding, failure to thrive

● Edema, hepatomegaly, crackles in lungs

● Diaphoresis with feeding (infants)

Treatment:

● Diuretics (Furosemide - Lasix)

● Digoxin (improves contractility - monitor toxicity: bradycardia, vomiting)

● ACE inhibitors (reduce afterload, BP control)

 4. Hypertension in Children
Causes: Coarctation of the aorta, obesity, kidney disease
Treatment:

● Lifestyle changes (diet, exercise, weight loss)

● Antihypertensive medications (if severe)

Nursing Interventions for Pediatric Cardiovascular

Disorders
Monitor vital signs (BP, HR, oxygen saturation)
Assess for cyanosis, clubbing, failure to thrive
Encourage frequent small feedings for infants with CHD
Educate parents on signs of worsening heart failure (tachypnea, sweating, poor feeding)
Monitor for complications (thromboembolism, endocarditis)

RENAL PROBLEMS

1. Urinary Tract Infection (UTI)

Caused by bacterial infection (most common: E. coli)
Risk factors:

● Female (shorter urethra)

● Poor hygiene, wiping back to front

● Urinary stasis (e.g., vesicoureteral reflux, constipation)

● Uncircumcised males (<1 year)

Signs & Symptoms:

● Infants: Fever, poor feeding, irritability, vomiting

● Children: Dysuria (painful urination), frequency, urgency, abdominal pain, bedwetting

Diagnosis: Urinalysis (positive leukocytes, nitrites)

Treatment:

● Oral antibiotics (Amoxicillin, TMP-SMX, Cephalosporins)

● Encourage hydration & frequent voiding

● Educate on proper hygiene

2. Vesicoureteral Reflux (VUR)

Urine flows backward from bladder to kidneys, increasing UTI risk
Graded from I-V (mild to severe reflux)
Signs & Symptoms: Recurrent UTIs, bedwetting, hydronephrosis (kidney swelling)
Diagnosis: Voiding Cystourethrogram (VCUG)
Treatment:

● Mild cases: Antibiotic prophylaxis, monitoring

● Severe cases: Surgery (ureteral reimplantation)

3. Nephrotic Syndrome
Autoimmune kidney disorder → massive protein loss
Patho: Damaged glomeruli allow protein (albumin) loss, causing fluid retention (edema)

Signs & Symptoms ("PALE"):

● Proteinuria (Foamy urine)

● Albumin low (Hypoalbuminemia)

● Lipid high (Hyperlipidemia)

● Edema (Periorbital → Generalized)

Treatment:

● Corticosteroids (Prednisone) to reduce inflammation

● Diuretics (Furosemide) + Albumin replacement

● Low-sodium, high-protein diet

● Monitor for infections (risk due to steroid use)

4. Acute Post-Streptococcal Glomerulonephritis

(APSGN)
Inflammation of glomeruli after a Strep infection (1-2 weeks post-strep throat)
Immune complexes deposit in kidneys → decreased filtration → fluid retention

Signs & Symptoms ("HAD STREP"):

● Hypertension

● Azotemia (↑BUN, Creatinine)

● Decreased urine output

● Swelling (Edema)

● Tea-colored (Hematuria)

● Recent Strep infection

● Elevated BP

● Proteinuria (mild)
Diagnosis: ASO (antistreptolysin O) titer, Urinalysis
Treatment:

● Supportive (fluids, BP control)

● Antibiotics if active Strep infection

● Diuretics for edema

● Limit sodium & fluids

5. Hemolytic Uremic Syndrome (HUS)

Caused by E. coli (from undercooked meat, contaminated food/water)
Leads to: Hemolysis + Kidney failure + Low platelets

Signs & Symptoms:

● Triad: Anemia (pallor, fatigue) + Thrombocytopenia (bruising) + Acute kidney injury

(oliguria, hematuria)

● GI symptoms: Bloody diarrhea, vomiting

● Neurological: Seizures, confusion in severe cases

Treatment:

● Supportive care (IV fluids, dialysis if needed)

● NO antibiotics (worsens toxin release)

● Blood transfusions if severe anemia

6. Acute Kidney Injury (AKI)

Sudden loss of kidney function → Decreased urine output, fluid overload
Causes:

● Prerenal: Dehydration, shock

● Renal: Glomerulonephritis, nephrotoxins

● Postrenal: Obstruction (stones, VUR)

Signs & Symptoms:

● Oliguria (<0.5 mL/kg/hr urine output)

● Fluid overload (edema, HTN, crackles in lungs)

● High BUN & Creatinine

Treatment:

● Correct underlying cause (fluids, BP control, remove obstruction)

● Dialysis if severe

7. Chronic Kidney Disease (CKD)

Progressive kidney function loss
Causes: Congenital anomalies, recurrent infections, untreated AKI
Signs: Growth failure, anemia, electrolyte imbalances, bone disease
Management:

● Dietary restrictions (low protein, low phosphorus, controlled fluids & sodium)

● Erythropoietin for anemia

● Dialysis or transplant if end-stage

 8. Cryptorchidism (Undescended Testicle)
Testes fail to descend into the scrotum
Risk factors: Prematurity, low birth weight
Complications: Infertility, testicular cancer risk
Treatment: Surgery (Orchiopexy) if not descended by 6 months

9. Hypospadias & Epispadias

Hypospadias → Urethral opening on underside of penis
Epispadias → Urethral opening on top of penis
Treatment: Surgical correction before toilet training (no circumcision before surgery)

10. Testicular Torsion

Twisting of spermatic cord → cuts off blood supply (EMERGENCY!)
Signs:

● Severe scrotal pain, swelling, redness

● Absent cremasteric reflex (testicle does not retract when inner thigh is stroked)
Treatment: Surgery within 6 hours to save testicle

Nursing Interventions for Renal/Genitourinary

Disorders
Monitor urine output (I&O, daily weight, fluid restrictions if needed)
Assess for edema, BP changes, electrolyte imbalances
Encourage proper hygiene (prevent UTIs)
Educate parents on medication compliance & dietary modifications
 Neurological and Cognitive Problems in
Pediatrics

Hydrocephalus
Excess cerebrospinal fluid (CSF) accumulation in the brain → Increased intracranial pressure (ICP)

Causes:

● Congenital: Aqueductal stenosis, neural tube defects (e.g., spina bifida)

● Acquired: Infections (meningitis), hemorrhage, tumors

Signs & Symptoms:

● Infants:

○ Bulging fontanelle, increased head circumference

○ Setting-sun eyes (downward deviation)

○ Irritability, high-pitched cry

○ Poor feeding

● Older children:

○ Headache, vomiting (especially in the morning)

○ Vision problems, balance issues

○ Cognitive delays

Diagnosis: CT scan, MRI

Treatment:

● Surgical placement of ventriculoperitoneal (VP) shunt

● Monitor for shunt malfunction/infection (fever, headache, vomiting, lethargy)

2. Spina Bifida (Neural Tube Defect)

Incomplete closure of the spinal cord during fetal development

Types:

● Spina Bifida Occulta → No visible sac, dimple or tuft of hair at the base of the spine

● Meningocele → CSF-filled sac, no nerve involvement

● Myelomeningocele (most severe) → CSF + spinal nerves in sac → paralysis, bowel/bladder

dysfunction

Diagnosis: Prenatal ultrasound, elevated AFP in maternal serum

Treatment:

● Surgical closure after birth

● Prevent infection (cover with sterile saline dressing)

● Monitor for hydrocephalus (common in myelomeningocele)

● Lifelong management: PT, bowel/bladder training, braces

Prevention: Folic acid supplementation during pregnancy

3. Cerebral Palsy (CP)

Non-progressive brain disorder affecting movement & muscle tone
Causes: Prenatal hypoxia, prematurity, infections, birth trauma

Types:
● Spastic CP (most common) → Stiff muscles, scissor gait

● Dyskinetic CP → Involuntary movements

● Ataxic CP → Poor balance, coordination issues

Signs & Symptoms:

● Delayed milestones (not sitting by 8 months, not walking by 18 months)

● Abnormal muscle tone (stiff or floppy)

● Persistent primitive reflexes (Moro, tonic neck)

● Seizures, intellectual disabilities possible

Treatment:

● Physical & occupational therapy (improve mobility)

● Braces, walkers, wheelchairs if needed

● Baclofen or botulinum toxin (reduce spasticity)

4. Seizure Disorders (Epilepsy)

Abnormal electrical activity in the brain

Types:

● Generalized (Tonic-Clonic/Grand Mal) → Loss of consciousness, convulsions

● Absence (Petit Mal) → Staring spells, brief loss of awareness

● Febrile Seizures → Triggered by rapid fever rise in children < 5 years

Management:
● During seizure: Protect airway, place on side, remove dangerous objects

● After seizure: Assess LOC, reorient child

● Meds: Phenytoin, Valproic acid, Levetiracetam

● Education: Avoid triggers, maintain med compliance

5. Meningitis
Inflammation of the meninges (brain & spinal cord covering)
Caused by: Bacterial (more severe) or viral infection

Signs & Symptoms:

● Infants: Poor feeding, bulging fontanelle, high-pitched cry

● Older children: Nuchal rigidity (stiff neck), photophobia, fever, headache, vomiting

● Kernig’s sign (pain with knee extension)

● Brudzinski’s sign (involuntary knee/hip flexion when neck is flexed)

Diagnosis: Lumbar puncture (bacterial = cloudy, high WBC/protein, low glucose)

Treatment:

● IV antibiotics ASAP (for bacterial meningitis)

● Droplet precautions for 24 hrs after antibiotics start

● Seizure precautions, monitor for increased ICP

Prevention: HIB & meningococcal vaccines

6. Guillain-Barré Syndrome (GBS)

Autoimmune attack on peripheral nerves → Weakness & paralysis
Triggered by viral infection, vaccination, Campylobacter infection

Signs & Symptoms:

● Ascending paralysis (starts in legs & moves up)

● Loss of reflexes

● Respiratory distress if severe (monitor breathing closely!)

Treatment:

● IV immunoglobulin (IVIG), plasmapheresis

● Monitor respiratory function (risk of respiratory failure!)

7. Reye’s Syndrome
Rare, life-threatening disorder causing encephalopathy & liver damage
Triggered by: Aspirin use in children recovering from viral infections (flu, chickenpox)

Signs & Symptoms:

● Severe vomiting

● Altered mental status (confusion, seizures, coma)

● Liver dysfunction (↑AST/ALT, ammonia levels)

Treatment:

● Supportive care (manage ICP, hydration, monitor liver function)

● Prevention: Avoid aspirin in children!

 8. Muscular Dystrophy (Duchenne's)
Genetic disorder (X-linked recessive) causing progressive muscle weakness
Caused by: Absence of dystrophin protein

Signs & Symptoms:

● Gower’s sign (child uses hands to push up from the floor)

● Waddling gait, frequent falls

● Pseudohypertrophy (large calves due to fat buildup)

● Late complications: Respiratory & cardiac failure

Treatment:

● Physical therapy, steroids (slow progression)

● Monitor cardiac & respiratory function

Nursing Care for Neurological & Cognitive Disorders

Monitor for signs of increased ICP (bulging fontanelle, vomiting, bradycardia, high BP)
Ensure proper positioning & safety for mobility-impaired children
Seizure precautions (padded rails, O2 available, avoid triggers)
Encourage developmental support & therapy for delays
Educate families about lifelong management & early intervention

. Pediatric Immunodeficiency Disorders

A. Severe Combined Immunodeficiency (SCID)

"Bubble boy disease" – congenital absence of immune function (T & B cells)

Causes: Genetic mutation affecting lymphocyte development

Signs & Symptoms:

● Frequent, severe infections (pneumonia, chronic diarrhea, otitis media)

● Failure to thrive

● Absent lymphoid tissue (small tonsils, no palpable lymph nodes)

Treatment:

● Bone marrow or stem cell transplant (curative)

● IV immunoglobulin (IVIG)

● Avoid live vaccines (MMR, varicella, rotavirus, oral polio)

B. HIV/AIDS in Children

Transmission:

● Perinatal (from mother during pregnancy, delivery, breastfeeding)

● Blood transfusions (rare in modern settings)

Signs & Symptoms (Early Childhood):

● Failure to thrive, chronic diarrhea, oral candidiasis (thrush)

● Recurrent infections (pneumonia, otitis media, TB)

● Lymphadenopathy, hepatosplenomegaly

Diagnosis:

● <18 months: PCR test for viral load

● >18 months: ELISA & Western blot

Treatment:
● Antiretroviral therapy (ART) ASAP

● Trimethoprim-sulfamethoxazole (Bactrim) for Pneumocystis jirovecii pneumonia

prophylaxis

● No live vaccines if immunocompromised

2. Common Pediatric Infectious Diseases

A. Measles (Rubeola)

Cause: Measles virus (highly contagious)

Transmission: Airborne (droplet, contact with contaminated surfaces)

Signs & Symptoms:

● 3 C’s: Cough, Coryza (runny nose), Conjunctivitis

● Koplik spots (small white lesions inside the mouth)

● Maculopapular rash (spreads from face downward)

● High fever (up to 104°F/40°C)

Complications:

● Pneumonia, encephalitis, otitis media

Prevention: MMR vaccine (12-15 months, booster at 4-6 years)

Treatment:

● Supportive care (hydration, fever control with acetaminophen)

● Vitamin A supplementation (reduces severity)

 B. Mumps

Cause: Mumps virus (paramyxovirus)

Transmission: Droplet spread

Signs & Symptoms:

● Swollen parotid glands ("chipmunk cheeks")

● Fever, malaise, headache, ear pain

● Orchitis (testicular swelling in postpubertal boys, can cause infertility)

Prevention: MMR vaccine

Treatment: Supportive care, pain relief, fluids

C. Rubella (German Measles)

Cause: Rubella virus

Transmission: Droplet, vertical (mother to baby)

Signs & Symptoms:

● Pink maculopapular rash (starts on face, spreads downward)

● Mild fever, swollen lymph nodes (postauricular, occipital)

● For pregnant women: Causes congenital rubella syndrome (deafness, heart defects,
cataracts, intellectual disability in newborns)

Prevention: MMR vaccine (avoid pregnancy for 1 month after vaccination)

Treatment: Supportive care

D. Chickenpox (Varicella)

Cause: Varicella-zoster virus

Transmission: Airborne, direct contact with lesions
Signs & Symptoms:

● Itchy vesicular rash ("dew drop on a rose petal")

● Lesions in different stages (papules, vesicles, crusts)

● Fever, malaise, sore throat

Complications: Secondary bacterial infections, pneumonia, encephalitis

Prevention: Varicella vaccine (12-15 months, booster at 4-6 years)

Treatment:

● Acyclovir (for immunocompromised patients)

● Antihistamines, calamine lotion for itching

E. Whooping Cough (Pertussis)

Cause: Bordetella pertussis (bacterial)

Transmission: Droplet

Signs & Symptoms:

● Paroxysmal "whooping" cough (gasping for air after fits of coughing)

● Apnea, cyanosis (especially in infants)

● Post-tussive vomiting (vomiting after coughing spell)

Prevention: DTaP vaccine (5 doses before age 6, booster in adolescence & pregnancy)

Treatment:

● Azithromycin or erythromycin (early stage only)

● Supportive care (humidified oxygen, hydration, suctioning)

 F. Hand, Foot, and Mouth Disease

Cause: Coxsackievirus A
Transmission: Fecal-oral, droplet

Signs & Symptoms:

● Painful oral ulcers, vesicular rash on hands & feet

● Low-grade fever, sore throat

Treatment: Supportive care (hydration, pain relief)

3. Pediatric Meningitis
Cause:

● Bacterial (more severe): Neisseria meningitidis, Streptococcus pneumoniae, HIB

● Viral (milder): Enteroviruses, mumps, herpes

Signs & Symptoms:

● High fever, severe headache

● Nuchal rigidity (stiff neck), photophobia

● Kernig’s & Brudzinski’s signs

● Infants: Poor feeding, bulging fontanelle, high-pitched cry

Diagnosis: Lumbar puncture (bacterial = cloudy CSF, high WBC/protein, low glucose)

Treatment:

● IV antibiotics (bacterial)
 ● Droplet precautions for first 24 hours

● Monitor for increased ICP, seizures

Prevention: HIB, pneumococcal, and meningococcal vaccines

4. Nursing Care for Immune/Infectious Diseases

Monitor fever, hydration, and signs of worsening infection
Isolate contagious infections (airborne, droplet, contact precautions as needed)
Administer vaccines & educate parents on vaccine-preventable diseases
Teach parents about symptom management (hydration, fever control, hygiene)
Monitor immunocompromised children closely (HIV, SCID, chemo patients)