Sunday, May 10, 2009
Monday, April 27, 2009
LIVER AND PORTAL HYPERTENSION
Liver and Portal Hypertension
Afroz Lakhani, RN,BScN
Pathophysiology 2009
Liver
The liver is the largest organ in the body, normally weighing about 1 to 2.3kg (although this can increase to over 10kg in chronic cirrhosis). The liver is the main organ of metabolism and energy production; its other main functions include:
Bile production
Storage of iron, vitamins and trace elements
Detoxification
Conversion of waste products for excretion by the kidneys
Functions of Liver
Carbohydrate metabolism: Maintains plasma glucose levels. Post-meal when glucose levels rise, glucose with the influence of insulin is converted to glycogen for storage.
When glucose levels falls, the hormone glucagon stimulates glycogen into glucose again. That’s how our glucose levels stays in normal range.
Fat metabolism: Excess dietary carbs or protein will store as fat. (under the skin, around kidneys)
Digested fat convert triglycerides for energy and storage.
Protein metabolism:
Deamination of amino acids: a)Nitrogenous portion is removed to form into urea, excreted into urine.
b) nucleic acids breaks down to uric acidsurine.
Transamination: removal of nitrogenous portion of amino acids and attaches to carb moleculenon-essential amino acids.
Synthesis of plasma proteins and most blood clotting factors from amino acids.
Portal Circulation
The liver is unusual has a double blood supply; the right and left hepatic arteries carry oxygenated blood to the liver, and the portal vein carries venous blood from the GI tract to the liver.
Portal vein enters the liver, the blood drains into the hepatic sinusoids, where it is screened by specialized macrophages (Kupffer cells) to remove any pathogens that manage to get past the GI defenses. The plasma is filtered through the endothelial lining of the sinusoids and bathes the hepatocytes; these cells contain vast numbers of enzymes capable of breaking down and metabolizing most of what has been absorbed.
The portal venous blood contains allof the products of digestion absorbed from the GI tract, so all useful and non-useful products are processed in the liver before being either released back into the hepatic veins which join the inferior vena cava just inferior to the diaphragm, or stored in the liver for later use.
Liver Cirrhosis
Scarring of the Liver
Cx: alcoholism, viral hepatitis, toxic reaction to drugs, biliary obstruction
S/S: wt loss, anorexia, weakness, hepatomegaly, jaundice, abdominal pain (stretching of Glisson’s cap)
Pathophysiology Liver Cirrhosis
Portal Hypertension
Obstructed blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system.
Pressure normally 3mm Hg;
portal HTN at least 10 mmHg
Cx: thrombosis, inflammation, fibrosis of sinusoids, viral hepatitis, cardiac disorders, most common is cirrhosis of liver.
Long term PHTN can lead to Ascites, Varices, Splenomegaly, Hepatic encephalopathy.
Ascites
Pathophysiology
PHTN and decreased serum albumin capillary hydrostatic pressure to exceed capillary osmotic pressure and causes fluid into peritoneal cavity.
The failure of the liver to metabolize aldosterone increases sodium and water retention by the kidney.
Loss of fluid into the peritoneal space causes further sodium and water retention by the kidney in an effort to maintain the vascular fluid volume.
Treatment
No salt diet
Diuretics: Spironolactone (Aldactone), an aldosterone blocking agent.
Ammonium chloride and acetazolamide are contraindicated because of the possibility of precipitating hepatic coma.
Bed rest
Paracentesis
Insertion of a peritoneovenous shunt to redirect ascitic fluid from the peritoneal cavity into the systemic circulation.
Caput medusae is the appearance of distended and engorged paraumbilical veins which are seen radiating from the umbilicus across the abdomen to join systemic veins
Esophageal Varices
Are extremely dilated sub-mucosal veins in the esophagus.
Bleeding or hemorrhage from esophageal varices occurs in approximately one third of patients with cirrhosis and varices.
The mortality rate resulting from the first bleeding episode is 45% to 50%;
It is one of the major causes of death in patients with cirrhosis
Pathophysiology EV
Increased obstruction of the portal vein causes venous blood from the intestinal tract and spleen seeks an outlet through collateral circulation (new pathways of return to the right atrium).
The effect is increased pressure, particularly in the vessels in the of the lower esophagus and upper part of the stomach.
These collateral vessels are not very elastic but rather are tortuous and fragile and bleed easily.
Treatment:
Prevent hemorrhage
Straight to ICU
potential hypovolemia
Oxygen
Intravenous fluids with electrolyte
Blood transfusion
Strict I/O
vasopressin, vasopressin with nitroglycerin, somatostatin, balloon tamponade, TPSS (transhepatic portosystemic shunt), transhepatic catheter embolization, shunt surgery, gastric stapling and sclerotherapy
Splenomegaly
an enlargement of the spleen.
Caused by increased pressure in the splenic vein, which branches from the portal vein.
Hepatic Encephalopathy
CNS totality
Lack of mental alertness, confusion, coma, convulsions.
Flapping tremor called asterixis (liver flap)
Memory loss
Pathophysiology HEn
Ammonium ion produced in the intestinal tract, abundance in colon by bacterial degradation of luminal proteins and amino acids.
Normally: Ammonium ion diffuse into portal blood, transported to the liver, where they converted to urea.
When the blood from intestines bypass the liver, ammonia is not converted to urea, and ammonia moves directly into general circulation then to cerebral circulation thus hepatic encephalopathy occurs.
Treatment
No big protein diet
Prevent GI bleeding
No narcotics or tranquilizers
Nonabsorbable antibiotic like neomycin (to eradicate bacteria from the colon)
Lactulose (acts in Large intestine, low ph)
References:
Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Huether & McCane. (2000). Understanding Pathophysiology (2nd edition) Mosby
Illustrated manual of Nursing Practice (2002). 3rd edition. Springhouse
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Porth.(2005). Pathophysiology (7th edition) Lippincott
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone
Afroz Lakhani, RN,BScN
Pathophysiology 2009
Liver
The liver is the largest organ in the body, normally weighing about 1 to 2.3kg (although this can increase to over 10kg in chronic cirrhosis). The liver is the main organ of metabolism and energy production; its other main functions include:
Bile production
Storage of iron, vitamins and trace elements
Detoxification
Conversion of waste products for excretion by the kidneys
Functions of Liver
Carbohydrate metabolism: Maintains plasma glucose levels. Post-meal when glucose levels rise, glucose with the influence of insulin is converted to glycogen for storage.
When glucose levels falls, the hormone glucagon stimulates glycogen into glucose again. That’s how our glucose levels stays in normal range.
Fat metabolism: Excess dietary carbs or protein will store as fat. (under the skin, around kidneys)
Digested fat convert triglycerides for energy and storage.
Protein metabolism:
Deamination of amino acids: a)Nitrogenous portion is removed to form into urea, excreted into urine.
b) nucleic acids breaks down to uric acidsurine.
Transamination: removal of nitrogenous portion of amino acids and attaches to carb moleculenon-essential amino acids.
Synthesis of plasma proteins and most blood clotting factors from amino acids.
Portal Circulation
The liver is unusual has a double blood supply; the right and left hepatic arteries carry oxygenated blood to the liver, and the portal vein carries venous blood from the GI tract to the liver.
Portal vein enters the liver, the blood drains into the hepatic sinusoids, where it is screened by specialized macrophages (Kupffer cells) to remove any pathogens that manage to get past the GI defenses. The plasma is filtered through the endothelial lining of the sinusoids and bathes the hepatocytes; these cells contain vast numbers of enzymes capable of breaking down and metabolizing most of what has been absorbed.
The portal venous blood contains allof the products of digestion absorbed from the GI tract, so all useful and non-useful products are processed in the liver before being either released back into the hepatic veins which join the inferior vena cava just inferior to the diaphragm, or stored in the liver for later use.
Liver Cirrhosis
Scarring of the Liver
Cx: alcoholism, viral hepatitis, toxic reaction to drugs, biliary obstruction
S/S: wt loss, anorexia, weakness, hepatomegaly, jaundice, abdominal pain (stretching of Glisson’s cap)
Pathophysiology Liver Cirrhosis
Portal Hypertension
Obstructed blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system.
Pressure normally 3mm Hg;
portal HTN at least 10 mmHg
Cx: thrombosis, inflammation, fibrosis of sinusoids, viral hepatitis, cardiac disorders, most common is cirrhosis of liver.
Long term PHTN can lead to Ascites, Varices, Splenomegaly, Hepatic encephalopathy.
Ascites
Pathophysiology
PHTN and decreased serum albumin capillary hydrostatic pressure to exceed capillary osmotic pressure and causes fluid into peritoneal cavity.
The failure of the liver to metabolize aldosterone increases sodium and water retention by the kidney.
Loss of fluid into the peritoneal space causes further sodium and water retention by the kidney in an effort to maintain the vascular fluid volume.
Treatment
No salt diet
Diuretics: Spironolactone (Aldactone), an aldosterone blocking agent.
Ammonium chloride and acetazolamide are contraindicated because of the possibility of precipitating hepatic coma.
Bed rest
Paracentesis
Insertion of a peritoneovenous shunt to redirect ascitic fluid from the peritoneal cavity into the systemic circulation.
Caput medusae is the appearance of distended and engorged paraumbilical veins which are seen radiating from the umbilicus across the abdomen to join systemic veins
Esophageal Varices
Are extremely dilated sub-mucosal veins in the esophagus.
Bleeding or hemorrhage from esophageal varices occurs in approximately one third of patients with cirrhosis and varices.
The mortality rate resulting from the first bleeding episode is 45% to 50%;
It is one of the major causes of death in patients with cirrhosis
Pathophysiology EV
Increased obstruction of the portal vein causes venous blood from the intestinal tract and spleen seeks an outlet through collateral circulation (new pathways of return to the right atrium).
The effect is increased pressure, particularly in the vessels in the of the lower esophagus and upper part of the stomach.
These collateral vessels are not very elastic but rather are tortuous and fragile and bleed easily.
Treatment:
Prevent hemorrhage
Straight to ICU
potential hypovolemia
Oxygen
Intravenous fluids with electrolyte
Blood transfusion
Strict I/O
vasopressin, vasopressin with nitroglycerin, somatostatin, balloon tamponade, TPSS (transhepatic portosystemic shunt), transhepatic catheter embolization, shunt surgery, gastric stapling and sclerotherapy
Splenomegaly
an enlargement of the spleen.
Caused by increased pressure in the splenic vein, which branches from the portal vein.
Hepatic Encephalopathy
CNS totality
Lack of mental alertness, confusion, coma, convulsions.
Flapping tremor called asterixis (liver flap)
Memory loss
Pathophysiology HEn
Ammonium ion produced in the intestinal tract, abundance in colon by bacterial degradation of luminal proteins and amino acids.
Normally: Ammonium ion diffuse into portal blood, transported to the liver, where they converted to urea.
When the blood from intestines bypass the liver, ammonia is not converted to urea, and ammonia moves directly into general circulation then to cerebral circulation thus hepatic encephalopathy occurs.
Treatment
No big protein diet
Prevent GI bleeding
No narcotics or tranquilizers
Nonabsorbable antibiotic like neomycin (to eradicate bacteria from the colon)
Lactulose (acts in Large intestine, low ph)
References:
Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Huether & McCane. (2000). Understanding Pathophysiology (2nd edition) Mosby
Illustrated manual of Nursing Practice (2002). 3rd edition. Springhouse
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Porth.(2005). Pathophysiology (7th edition) Lippincott
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone
Tuesday, February 10, 2009
Management of conditions affecting GI and accessory organs of digestion
Afroz Lakhani, RN,BScN
Quick Review of GI A&P
"alimentary canal"
all organs through which food passes (mouth to anus)
Accessory Structures
1. assist in digestion
2. includes teeth, salivary glands, liver, gall bladder, pancreas
Layers of GI Tract
Esophagus
Passage about 10 inches long, lined with a mucous membrane.
Function is to complete the act of swallowing.
The involuntary movement of material down the esophagus is carried out by the process known as peristalsis, which is the wavelike action produced by contraction of the muscular wall. This is the method by which food is moved throughout the alimentary canal.
Stomach
• four major secretory cells:
• chief cells: pepsinogen activation by low pH to form pepsin , is a protease for protein digestion
• parietal cells : HCl secretion enhanced by histamine via H2 receptors
Tagamet blocks H2 histamine receptors to inhibit HCl secretion
intrinsic factor binds to and allows B12 absorption in intestines
• G-cell : secretes gastrin hormone
activates gastric juice secretion & gastric smooth muscle “churning” , activates gastroileal reflex which moves chyme from ileum to colon
• mucus cell :protective role of mucus against acids and digestive enzymes
• pyloric sphincter regulates entry into the duodenum
• chyme is liquified digested material
Small Intestine
• 22 ft long
• divided into three continuous parts: duodenum, jejunum, and ileum.
• Most of the absorption of food takes place in the small intestine, villi
• receives digestive juices from three accessory organs of digestion: the pancreas, liver, and gallbladder
Large intestine
• 5 ft long
• Cecum, appendix , ascending, transverse, descending colon , sigmoid colon, rectum
• The main function is the recovery of water and electrolytes from the mass of undigested food it receives from the small intestine. As this mass passes through the colon, water is absorbed and returned to the tissues. Waste materials, or feces, become more solid as they are pushed along by peristaltic movements.
• Constipation is caused by delay in movement of intestinal contents and removal of too much water from them.
• Diarrhea results when movement of the intestinal contents is so rapid that not enough water is removed
Diagnostic Procedures
• Upper GI studies (barium swallow)
Examination of the upper GI tract under fluoroscopy after patient drinks barium sulfate.
Pre : NPO midnight
Post: Instruct for increased oral fluids to help pass the barium.
Monitor stools for passage of barium. Stools should appear chalky white in color.
Lower GI tract study (barium enema)
Fluoroscopic and radiographic examination of large intestine after rectal instillation of barium sulfate
Pre: low residue diet 1 or 2 days prior,
clear liquid and laxative evening before,
NPO midnight, cleansing enema morning of test.
Post: Increase oral fluids to pass barium, mild laxative, monitor stools, report absence of bowel movement more than 2 days.
Gastric analysis:
Aspirate gastric contents thru NG tube for the analysis of acidity, appearance, volume.
4 Upper GI fiberoscopy: ( EGD)
5 Anoscopy, proctoscopy, and sigmoidoscopy:
6 Fiberoptic colonoscopy:
7 Cholecystography: to detect gall stones, and assess ability to fill, concentrate , contract and empty.
Pre: no allergies to iodine or seafood, NPO, anaphylactic shock symptoms.
Post: dysuria is common cause contrast agent excreted in urine, fatty meal to pass contrast agent.
8 Paracentesis: Transabdominal removal of fluid from the peritoneal cavity.
Pre: Consent, void prior procedure, measure ab girth, wt, upright or fowler’s position.
Post: v/s, dry sterile dressing and monitor bleeding, ab girth, look for hematuria, hypovolemia.
9 Liver biopsy:
Pre:consent, must ck prothombin time, partial thromboplastin time, platelet.
Post: site bleeding, peritonitis, bedrest, place patient on the rt side with a pillow under the coastal margin to decrease the risk of hemorrhage, avoid coughing, straining, no heavy weights for one week.
Assessment
Dietary History:
The number of meals ate per day.
Meal times.
Food restrictions or special diets followed.
Changes in appetite. Increased? Decreased? No appetite?
What foods, if any, have been eliminated from the diet? Why? What foods are not well tolerated?
Alterations in taste.
Medications used. Dosage and frequency.
Assessment contd…
Bowel pattern history: Frequency of bowel movements. Use of laxatives and/or enemas. Changes in bowel habits. Stool Description (color, consistency, any blood)
any complaints??
Nausea. Frequency? Duration? Associated with meals? Relieved by?
Vomiting. Frequency? Character of emesis? Relieved by?
Heartburn/indigestion. Frequency? Duration? Associated with specific foods? Relieved by?
Gas (belching and flatus). Frequency? Associated with specific foods? Relieved by?
Pain. Location? Frequency? Duration? Character of the pain?
Weight loss. How much? In what time period?
Assessment
Inspect skin for color, abnormalities, contour, abdomen for distention.
Auscultate bowel sounds, normal 5-30/min or every 5-15 secs in all quadrants.
Listen at least 5 minutes in each quadrant to be certain for any absence.
Stool test
Stool samples can be examined on the ward and in the laboratory to determine the presence of substances that aid in diagnosis. For example:
color, consistency, and amount of stool. The presence of unseen blood (occult)
In the laboratory, tests can be performed to determine the presence of fat, urobilinogen, ova, parasites, bacteria, and other substances.
Small, dry, hard stools may indicate constipation or fecal impaction.
Diarrhea may indicate fecal impaction or fecal mass, or it may be the result of a disease process (such as colitis or diverticulitis) or a bacterial infection (such as dysentery)..
Black, tarry stools may be the result of upper GI bleeding, iron supplements, or diet selection (eating black licorice, for example).
Reddish colored stools may be the result of bleeding in the lower GI tract or diet selection (eating carrots or beets).
Gastroesophageal Reflux (GER)
Back flow of gastric and duodenal contents into the esophagus.
Cx: incompetent lower esophageal sphincter, pyloric stenosis or motility disorder. May mimic heart attack.
Pathophysiology Gastritis
In gastritis, the gastric mucous membrane becomes edematous
and hyperemic (congested with fluid and blood) and undergoes
superficial erosion . It secretes a scanty amount of gastric juice, containing very little acid but much mucus. Superficial ulceration may occur and can lead to hemorrhage.
Gastritis
Stomach or gastric mucosa inflammation.
Acute: Contaminated food, irritating (spicy), over use of aspirin, excess alcohol
Abdominal discomfort, headache, anorexia, n/v, hicupping
Chronic: benign or malignant ulcers or H pylori, medications, caused by autoimmune diseases, smoking or reflux.
Anorexia, heartburn, belching, vit B12 def, sour taste
PUD
An ulceration in the mucosal wall of the stomach, pylorus, duodenum or esophagus.
Gastric and duodenal are common
Predisposing factors: Stress, smoking, use of steroids, NSAIDs, alcohol, gastritis, family hx, infection with H-pylori.
Complication: hemorrhage, perforation, pyloric obstruction.
Assessment: Gnawing, sharp pain LT of midepigastric 1 0r 2 hrs after eating.
Implementation: v/s, signs of bleeding, Meds
Pathophysiology Irritable Bowel Syndrome IBS results from a functional disorder of intestinal motility.
The change in motility may be related to the neurologic regulatory system, infection or irritation, or a vascular or metabolic disturbance.
The peristaltic waves are affected at specific segments of the intestine and in the intensity with which they propel the fecal matter forward. There is no evidence of inflammation or tissue changes in the intestinal mucosa.
IBS contd…
S/S:
constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany
The abdominal pain is sometimes precipitated by eating and is frequently relieved by defecation.
Mngt: aimed at relieving abdominal pain, controlling the diarrhea or constipation, and reducing stress.
Restriction and then gradual reintroduction of foods that are possibly
irritating may help determine what types of food are acting as irritants
(eg, beans, caffeinated products, fried foods, alcohol, spicy
foods).
A healthy, high-fiber diet to help control the diarrhea and constipation.
Exercise to reducing anxiety and increasing intestinal motility.
APPENDICITIS Pathophysiology
The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body.
The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours.
Eventually, the inflamed appendix fills with pus.
Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation.
Nursing Management:
Goals : relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection , disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition.
The nurse prepares the patient for surgery, which includes an
intravenous infusion to replace fluid loss and antibiotic therapy to prevent infection.
An enema is not administered because it can lead to perforation.
After surgery, the nurse places the patient in a semi-Fowler
position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.
An opioid, morphine sulfate, is prescribed to relieve pain.
When tolerated oral fluids are administered.
Any patient who was dehydrated before surgery receives intravenous fluids.
Food is provided as desired and tolerated on the day of surgery.
COLOSTOMY:
A colostomy is a surgically created, artificial opening (stoma) into the colon through the abdomen. It may be temporary or permanent.
A temporary colostomy is normally made for diversion of fecal material. Fecal diversion is utilized in order to rest a portion of the colon following intestinal surgery, in preparation for further surgery, or in cases of severe inflammatory disease (such as diverticulitis).
A permanent colostomy serves as an artificial anus for the remainder of the patient's life. This procedure is done in conjunction with the removal of the lower bowel and rectum. Although there is no sphincter muscle control at the stoma, bowel movements may be controlled by a daily routine that encompasses diet, physical activity, and colostomy irrigation. Consistency of the bowel movements generally depends upon the location of the colostomy, but can be manipulated by the patient's choice of diet.
Colostomy Irrigation
Irrigation should be done at the same time each day in order to establish regularity of bowel evacuation. Unless contraindicated or otherwise ordered by the physician, it is best to establish a routine of daily irrigation in accordance with the patient's former bowel habits. For example, if the patient has always moved his bowels after breakfast, establish the irrigation routine for that time, rather than some other arbitrary schedule.
Ileostomy:
An ileostomy is a surgically created, artificial opening (stoma) into the small bowel (ileus) through the abdomen. The stoma is located low on the abdomen (lower quadrants.) Most ileostomies are performed because of inflammatory bowel disease.
An ileostomy may be temporary or permanent. If temporary, the bowel is left intact. In a permanent ileostomy, the colon is removed.
Unlike a colostomy, an ileostomy cannot be regulated. The fecal contents of the ileum are fluid, and drain continuously. For this reason, an ileostomy patient must always wear an appliance.
Dietary considerations (ileostomy)
Most physicians do not recommend dietary restrictions once the patient has recovered from surgery and is released from the hospital. However, foods that cause discomfort, gas, or diarrhea should be omitted.
Hard to digest foods should be avoided if they cause discomfort. Examples are celery, popcorn, berries, and high-fiber foods.
Odor-causing foods include cabbage, onions, fish, and eggs. These foods should be tested individually to determine if they can be tolerated.
Spinach, parsley, yogurt, and buttermilk act as deodorizers on the intestinal tract.
All foods ingested will normally pass through the ileostomy within 4-6 hours.
Afroz Lakhani, RN,BScN
Quick Review of GI A&P
"alimentary canal"
all organs through which food passes (mouth to anus)
Accessory Structures
1. assist in digestion
2. includes teeth, salivary glands, liver, gall bladder, pancreas
Layers of GI Tract
Esophagus
Passage about 10 inches long, lined with a mucous membrane.
Function is to complete the act of swallowing.
The involuntary movement of material down the esophagus is carried out by the process known as peristalsis, which is the wavelike action produced by contraction of the muscular wall. This is the method by which food is moved throughout the alimentary canal.
Stomach
• four major secretory cells:
• chief cells: pepsinogen activation by low pH to form pepsin , is a protease for protein digestion
• parietal cells : HCl secretion enhanced by histamine via H2 receptors
Tagamet blocks H2 histamine receptors to inhibit HCl secretion
intrinsic factor binds to and allows B12 absorption in intestines
• G-cell : secretes gastrin hormone
activates gastric juice secretion & gastric smooth muscle “churning” , activates gastroileal reflex which moves chyme from ileum to colon
• mucus cell :protective role of mucus against acids and digestive enzymes
• pyloric sphincter regulates entry into the duodenum
• chyme is liquified digested material
Small Intestine
• 22 ft long
• divided into three continuous parts: duodenum, jejunum, and ileum.
• Most of the absorption of food takes place in the small intestine, villi
• receives digestive juices from three accessory organs of digestion: the pancreas, liver, and gallbladder
Large intestine
• 5 ft long
• Cecum, appendix , ascending, transverse, descending colon , sigmoid colon, rectum
• The main function is the recovery of water and electrolytes from the mass of undigested food it receives from the small intestine. As this mass passes through the colon, water is absorbed and returned to the tissues. Waste materials, or feces, become more solid as they are pushed along by peristaltic movements.
• Constipation is caused by delay in movement of intestinal contents and removal of too much water from them.
• Diarrhea results when movement of the intestinal contents is so rapid that not enough water is removed
Diagnostic Procedures
• Upper GI studies (barium swallow)
Examination of the upper GI tract under fluoroscopy after patient drinks barium sulfate.
Pre : NPO midnight
Post: Instruct for increased oral fluids to help pass the barium.
Monitor stools for passage of barium. Stools should appear chalky white in color.
Lower GI tract study (barium enema)
Fluoroscopic and radiographic examination of large intestine after rectal instillation of barium sulfate
Pre: low residue diet 1 or 2 days prior,
clear liquid and laxative evening before,
NPO midnight, cleansing enema morning of test.
Post: Increase oral fluids to pass barium, mild laxative, monitor stools, report absence of bowel movement more than 2 days.
Gastric analysis:
Aspirate gastric contents thru NG tube for the analysis of acidity, appearance, volume.
4 Upper GI fiberoscopy: ( EGD)
5 Anoscopy, proctoscopy, and sigmoidoscopy:
6 Fiberoptic colonoscopy:
7 Cholecystography: to detect gall stones, and assess ability to fill, concentrate , contract and empty.
Pre: no allergies to iodine or seafood, NPO, anaphylactic shock symptoms.
Post: dysuria is common cause contrast agent excreted in urine, fatty meal to pass contrast agent.
8 Paracentesis: Transabdominal removal of fluid from the peritoneal cavity.
Pre: Consent, void prior procedure, measure ab girth, wt, upright or fowler’s position.
Post: v/s, dry sterile dressing and monitor bleeding, ab girth, look for hematuria, hypovolemia.
9 Liver biopsy:
Pre:consent, must ck prothombin time, partial thromboplastin time, platelet.
Post: site bleeding, peritonitis, bedrest, place patient on the rt side with a pillow under the coastal margin to decrease the risk of hemorrhage, avoid coughing, straining, no heavy weights for one week.
Assessment
Dietary History:
The number of meals ate per day.
Meal times.
Food restrictions or special diets followed.
Changes in appetite. Increased? Decreased? No appetite?
What foods, if any, have been eliminated from the diet? Why? What foods are not well tolerated?
Alterations in taste.
Medications used. Dosage and frequency.
Assessment contd…
Bowel pattern history: Frequency of bowel movements. Use of laxatives and/or enemas. Changes in bowel habits. Stool Description (color, consistency, any blood)
any complaints??
Nausea. Frequency? Duration? Associated with meals? Relieved by?
Vomiting. Frequency? Character of emesis? Relieved by?
Heartburn/indigestion. Frequency? Duration? Associated with specific foods? Relieved by?
Gas (belching and flatus). Frequency? Associated with specific foods? Relieved by?
Pain. Location? Frequency? Duration? Character of the pain?
Weight loss. How much? In what time period?
Assessment
Inspect skin for color, abnormalities, contour, abdomen for distention.
Auscultate bowel sounds, normal 5-30/min or every 5-15 secs in all quadrants.
Listen at least 5 minutes in each quadrant to be certain for any absence.
Stool test
Stool samples can be examined on the ward and in the laboratory to determine the presence of substances that aid in diagnosis. For example:
color, consistency, and amount of stool. The presence of unseen blood (occult)
In the laboratory, tests can be performed to determine the presence of fat, urobilinogen, ova, parasites, bacteria, and other substances.
Small, dry, hard stools may indicate constipation or fecal impaction.
Diarrhea may indicate fecal impaction or fecal mass, or it may be the result of a disease process (such as colitis or diverticulitis) or a bacterial infection (such as dysentery)..
Black, tarry stools may be the result of upper GI bleeding, iron supplements, or diet selection (eating black licorice, for example).
Reddish colored stools may be the result of bleeding in the lower GI tract or diet selection (eating carrots or beets).
Gastroesophageal Reflux (GER)
Back flow of gastric and duodenal contents into the esophagus.
Cx: incompetent lower esophageal sphincter, pyloric stenosis or motility disorder. May mimic heart attack.
Pathophysiology Gastritis
In gastritis, the gastric mucous membrane becomes edematous
and hyperemic (congested with fluid and blood) and undergoes
superficial erosion . It secretes a scanty amount of gastric juice, containing very little acid but much mucus. Superficial ulceration may occur and can lead to hemorrhage.
Gastritis
Stomach or gastric mucosa inflammation.
Acute: Contaminated food, irritating (spicy), over use of aspirin, excess alcohol
Abdominal discomfort, headache, anorexia, n/v, hicupping
Chronic: benign or malignant ulcers or H pylori, medications, caused by autoimmune diseases, smoking or reflux.
Anorexia, heartburn, belching, vit B12 def, sour taste
PUD
An ulceration in the mucosal wall of the stomach, pylorus, duodenum or esophagus.
Gastric and duodenal are common
Predisposing factors: Stress, smoking, use of steroids, NSAIDs, alcohol, gastritis, family hx, infection with H-pylori.
Complication: hemorrhage, perforation, pyloric obstruction.
Assessment: Gnawing, sharp pain LT of midepigastric 1 0r 2 hrs after eating.
Implementation: v/s, signs of bleeding, Meds
Pathophysiology Irritable Bowel Syndrome IBS results from a functional disorder of intestinal motility.
The change in motility may be related to the neurologic regulatory system, infection or irritation, or a vascular or metabolic disturbance.
The peristaltic waves are affected at specific segments of the intestine and in the intensity with which they propel the fecal matter forward. There is no evidence of inflammation or tissue changes in the intestinal mucosa.
IBS contd…
S/S:
constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany
The abdominal pain is sometimes precipitated by eating and is frequently relieved by defecation.
Mngt: aimed at relieving abdominal pain, controlling the diarrhea or constipation, and reducing stress.
Restriction and then gradual reintroduction of foods that are possibly
irritating may help determine what types of food are acting as irritants
(eg, beans, caffeinated products, fried foods, alcohol, spicy
foods).
A healthy, high-fiber diet to help control the diarrhea and constipation.
Exercise to reducing anxiety and increasing intestinal motility.
APPENDICITIS Pathophysiology
The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body.
The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours.
Eventually, the inflamed appendix fills with pus.
Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation.
Nursing Management:
Goals : relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection , disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition.
The nurse prepares the patient for surgery, which includes an
intravenous infusion to replace fluid loss and antibiotic therapy to prevent infection.
An enema is not administered because it can lead to perforation.
After surgery, the nurse places the patient in a semi-Fowler
position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.
An opioid, morphine sulfate, is prescribed to relieve pain.
When tolerated oral fluids are administered.
Any patient who was dehydrated before surgery receives intravenous fluids.
Food is provided as desired and tolerated on the day of surgery.
COLOSTOMY:
A colostomy is a surgically created, artificial opening (stoma) into the colon through the abdomen. It may be temporary or permanent.
A temporary colostomy is normally made for diversion of fecal material. Fecal diversion is utilized in order to rest a portion of the colon following intestinal surgery, in preparation for further surgery, or in cases of severe inflammatory disease (such as diverticulitis).
A permanent colostomy serves as an artificial anus for the remainder of the patient's life. This procedure is done in conjunction with the removal of the lower bowel and rectum. Although there is no sphincter muscle control at the stoma, bowel movements may be controlled by a daily routine that encompasses diet, physical activity, and colostomy irrigation. Consistency of the bowel movements generally depends upon the location of the colostomy, but can be manipulated by the patient's choice of diet.
Colostomy Irrigation
Irrigation should be done at the same time each day in order to establish regularity of bowel evacuation. Unless contraindicated or otherwise ordered by the physician, it is best to establish a routine of daily irrigation in accordance with the patient's former bowel habits. For example, if the patient has always moved his bowels after breakfast, establish the irrigation routine for that time, rather than some other arbitrary schedule.
Ileostomy:
An ileostomy is a surgically created, artificial opening (stoma) into the small bowel (ileus) through the abdomen. The stoma is located low on the abdomen (lower quadrants.) Most ileostomies are performed because of inflammatory bowel disease.
An ileostomy may be temporary or permanent. If temporary, the bowel is left intact. In a permanent ileostomy, the colon is removed.
Unlike a colostomy, an ileostomy cannot be regulated. The fecal contents of the ileum are fluid, and drain continuously. For this reason, an ileostomy patient must always wear an appliance.
Dietary considerations (ileostomy)
Most physicians do not recommend dietary restrictions once the patient has recovered from surgery and is released from the hospital. However, foods that cause discomfort, gas, or diarrhea should be omitted.
Hard to digest foods should be avoided if they cause discomfort. Examples are celery, popcorn, berries, and high-fiber foods.
Odor-causing foods include cabbage, onions, fish, and eggs. These foods should be tested individually to determine if they can be tolerated.
Spinach, parsley, yogurt, and buttermilk act as deodorizers on the intestinal tract.
All foods ingested will normally pass through the ileostomy within 4-6 hours.
Wednesday, September 24, 2008
SLEEP REST PATTERN
SLEEP REST PATTERN
Afroz Lakhani, R.N., BScN
What is sleep?
SOMNOLOGY: Study of sleep
Basic human need
We spend about 8 hours/day, 56 hours/week, 224 hours/month and 2,688 hours/year sleeping (1/3 of our lives)
We need sleep
To cope with daily stress
To prevent fatigue
To conserve energy
To restore mind and body
Healing of damaged tissue is greatest during sleep
Physiology of sleep
Altered state of consciousness. (perception and reaction to the environment is decreased)
Minimal physical activity
Changes in physiologic processes
Decreased responsiveness to (some) external stimuli
The cyclic nature of sleep is controlled by neurons located within the reticular formation.
Reticular Formation
A diffuse network of nerve fibers and cells in parts of the brainstem, important in regulating consciousness or wakefulness.
Stimulation induces arousal
Destruction induces sleep
Neurotransmitters located within neurons affect sleep-wake cycles.
Acetylcholine (Ach antagonist and Ach agonist)
Serotonin (lessen to sensory response)
Histamine (keeps us awake)
Sleep is sensitive to darkness
Decreases stimulation of RF
Pineal gland secretes melatonin, and the person feels less alert,
GH released, cortisol inhibited
Beginning of daylight, melatonin is at its lowest level and stimulating cortisol at its highest, also Ach , dopamine and nonadrenaline.
Types of Sleep
Two types
NREM
REM
NREM: 75% to 80% of sleep during a night
Divided into 4 stages
Stage 1: very light sleep, few mins, drowsy, relaxed, can easily awakened
Stage 2: light sleep, 44% to 55%, 10 to 15 mins, requires stimuli to be awake
Stage 3 & 4: deepest, difficult to arouse, not disturbed by sensory stimuli, reflex diminished, snoring.
REM: (paradoxical sleep)
occurs every 90 mins, lasts 5 to 30 mins, dreams, Brain highly active, Ach, dopamine at highest, eye movements, voluntary muscle tone decreased, sleeper difficult to arouse or wakes up spontaneously.
Initially lasts 5-10 minutes, gradually lengthens until final REM period lasts 50minutes.
Very important stage of sleep.
Sleep Cycles
NREM and REM
Lasting about 90 to 110 mins in adults
In first sleep cycle: passes thru all 3 NREM stages in 20 to 30 mins,
then stage 4 NREM for about 30 mins
Sleep passes back through stage 3 and 2 for 20 mins
Thereafter, the first REM occurs, lasting 10 mins
This completes first sleep cycle.
Healthy adult experiences 4 to 6 cycles in 7 to 8 hrs
Functions of sleep
Restores normal levels of activity and balance among parts of nervous system
Important of protein synthesis (repair )
important psychological well-being ( emotionally irritable, poor concentration, difficulty making decisions)
Normal Sleep Patterns
NEWBORNS: 16 to 18 hrs/day, enters REM immediately, sleep cycle about 50 mins, tuck in when sleepy.
INFANTS: 14 to 15 hrs, awakens 3 to 4 hrs, eat and back to sleep. By 6 months sleeps entire night, nap patterns. Put them to bed when drowsy.
TODDLERS: 12 to 14 hrs, afternoon nap, resistance going to bed and awakens during night. Nightmares common.
SCHOOL-AGE CHILDREN: (5-12 yrs) needs 10 to 11 hrs, but they sleep less, avoid caffeinated drinks and late TV, have bedtime routine.
ADOLESCENTS: (12-18 yrs), needs 9 to 10 hrs, few sleeps that long and sleepy at school results in lower grades, negative moods.
ADULTS: needs 7 to 9 hrs but some can function well with 6 hrs as well.
ELDERS: earlier bedtime and wake times, disturbed sleep impacts quality of life, mood and alertness.
Factors Affecting Sleep
Sleep quality: subjective, person wakes up energetic or not.
Sleep quantity: total time of sleep
ILLNESS: pain, physical distress (arthritis, SOB, ulcers, low estrogen__hot flashes, elevated body temperature, urge to urinate)
ENVIRONMENT: noise, unfamiliar, hospital, temperature, lack of ventilation, lights, snoring partner.
LIFESTYLE: irregular am and pm schedule, late exercise, inability to relax before bedtime.
EMOTIONAL STRESS: #1 cx of sleep disturbance, Anxiety increases norepinephrine.
STIMULANTS AND ALCOHOL: coffee, caffeine stimulates CNS, excessive alcohol disrupts REM but hasten the onset.
DIET: weight gain cx broken sleep and early awakening, weight loss in total sleep time and less broken sleep. Warm milk can help.
SMOKING: Nicotine
MOTIVATION: can increase alertness.
MEDICATIONS: Hypnotics interfere deep sleep and suppress REM sleep. Beta blockers cx insomia, Narcotics suppress REM cx drowsiness, awakenings.
Common Sleep Disorders
INSOMNIA: inability to fall asleep or remain sleep,
stimulus control, Cognitive therapy (positive sleep thoughts and beliefs), Sleep restriction, antihistamine.
HYPERSOMNIA: sufficient sleep at night but still sleepy, cx CNS damage, metabolic disorder.
NARCOLEPSY: sleep attacks or EDS, Ritalin
SLEEP APNEA: frequent short breathing pauses during sleep. More than 5 episodes or longer than 10 seconds/hr is abnormal, loud snoring, frequent awakenings, morning headaches, EDS.
Nursing Management
History:
Generally rested and ready for daily activities after sleep?
Sleep onset problems
Aids
Dreams, nightmares
Early awakening
Rest_ relaxation period
Nursing Diagnosis:
Sleep Deprivation (prolong time without sleep)
Sleep Pattern, Disturbance
Insomnia (delayed onset of sleep)
Related to:
Over stimulation prior to bedtime
Pain
Discomfort
Anxiety
Alcohol
Fatigue r/t insufficient sleep
Risk for impaired gas exchange r/t sleep apnea
Activity intolerance r/t sleep deprivation or EDS
Goal:
To maintain or develop sleep pattern that provides sufficient energy for daily activities.
Improving quality and quantity of sleep.
Keep the etiology in mind
Implementing: Largely non pharmacologic measures like health teachings about sleep habits, bedtime rituals, provision of restful environment, avoid heavy meals before bedtime.
For hospitalized clients activities should be scheduled, less stimulus environment, support for anxious patients, safe use of sleep medications.
Evaluating:
Goals and outcomes achieved?
Observation about client’s sleep pattern
How the client feels on awakening?
Client’s level of alertness during the day
If desired outcomes not met then identify following:
Etiologic factors were correct?
Any change in medication therapy?
Client’s compliance
Were the measures effective?
References:
Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone
Afroz Lakhani, R.N., BScN
What is sleep?
SOMNOLOGY: Study of sleep
Basic human need
We spend about 8 hours/day, 56 hours/week, 224 hours/month and 2,688 hours/year sleeping (1/3 of our lives)
We need sleep
To cope with daily stress
To prevent fatigue
To conserve energy
To restore mind and body
Healing of damaged tissue is greatest during sleep
Physiology of sleep
Altered state of consciousness. (perception and reaction to the environment is decreased)
Minimal physical activity
Changes in physiologic processes
Decreased responsiveness to (some) external stimuli
The cyclic nature of sleep is controlled by neurons located within the reticular formation.
Reticular Formation
A diffuse network of nerve fibers and cells in parts of the brainstem, important in regulating consciousness or wakefulness.
Stimulation induces arousal
Destruction induces sleep
Neurotransmitters located within neurons affect sleep-wake cycles.
Acetylcholine (Ach antagonist and Ach agonist)
Serotonin (lessen to sensory response)
Histamine (keeps us awake)
Sleep is sensitive to darkness
Decreases stimulation of RF
Pineal gland secretes melatonin, and the person feels less alert,
GH released, cortisol inhibited
Beginning of daylight, melatonin is at its lowest level and stimulating cortisol at its highest, also Ach , dopamine and nonadrenaline.
Types of Sleep
Two types
NREM
REM
NREM: 75% to 80% of sleep during a night
Divided into 4 stages
Stage 1: very light sleep, few mins, drowsy, relaxed, can easily awakened
Stage 2: light sleep, 44% to 55%, 10 to 15 mins, requires stimuli to be awake
Stage 3 & 4: deepest, difficult to arouse, not disturbed by sensory stimuli, reflex diminished, snoring.
REM: (paradoxical sleep)
occurs every 90 mins, lasts 5 to 30 mins, dreams, Brain highly active, Ach, dopamine at highest, eye movements, voluntary muscle tone decreased, sleeper difficult to arouse or wakes up spontaneously.
Initially lasts 5-10 minutes, gradually lengthens until final REM period lasts 50minutes.
Very important stage of sleep.
Sleep Cycles
NREM and REM
Lasting about 90 to 110 mins in adults
In first sleep cycle: passes thru all 3 NREM stages in 20 to 30 mins,
then stage 4 NREM for about 30 mins
Sleep passes back through stage 3 and 2 for 20 mins
Thereafter, the first REM occurs, lasting 10 mins
This completes first sleep cycle.
Healthy adult experiences 4 to 6 cycles in 7 to 8 hrs
Functions of sleep
Restores normal levels of activity and balance among parts of nervous system
Important of protein synthesis (repair )
important psychological well-being ( emotionally irritable, poor concentration, difficulty making decisions)
Normal Sleep Patterns
NEWBORNS: 16 to 18 hrs/day, enters REM immediately, sleep cycle about 50 mins, tuck in when sleepy.
INFANTS: 14 to 15 hrs, awakens 3 to 4 hrs, eat and back to sleep. By 6 months sleeps entire night, nap patterns. Put them to bed when drowsy.
TODDLERS: 12 to 14 hrs, afternoon nap, resistance going to bed and awakens during night. Nightmares common.
SCHOOL-AGE CHILDREN: (5-12 yrs) needs 10 to 11 hrs, but they sleep less, avoid caffeinated drinks and late TV, have bedtime routine.
ADOLESCENTS: (12-18 yrs), needs 9 to 10 hrs, few sleeps that long and sleepy at school results in lower grades, negative moods.
ADULTS: needs 7 to 9 hrs but some can function well with 6 hrs as well.
ELDERS: earlier bedtime and wake times, disturbed sleep impacts quality of life, mood and alertness.
Factors Affecting Sleep
Sleep quality: subjective, person wakes up energetic or not.
Sleep quantity: total time of sleep
ILLNESS: pain, physical distress (arthritis, SOB, ulcers, low estrogen__hot flashes, elevated body temperature, urge to urinate)
ENVIRONMENT: noise, unfamiliar, hospital, temperature, lack of ventilation, lights, snoring partner.
LIFESTYLE: irregular am and pm schedule, late exercise, inability to relax before bedtime.
EMOTIONAL STRESS: #1 cx of sleep disturbance, Anxiety increases norepinephrine.
STIMULANTS AND ALCOHOL: coffee, caffeine stimulates CNS, excessive alcohol disrupts REM but hasten the onset.
DIET: weight gain cx broken sleep and early awakening, weight loss in total sleep time and less broken sleep. Warm milk can help.
SMOKING: Nicotine
MOTIVATION: can increase alertness.
MEDICATIONS: Hypnotics interfere deep sleep and suppress REM sleep. Beta blockers cx insomia, Narcotics suppress REM cx drowsiness, awakenings.
Common Sleep Disorders
INSOMNIA: inability to fall asleep or remain sleep,
stimulus control, Cognitive therapy (positive sleep thoughts and beliefs), Sleep restriction, antihistamine.
HYPERSOMNIA: sufficient sleep at night but still sleepy, cx CNS damage, metabolic disorder.
NARCOLEPSY: sleep attacks or EDS, Ritalin
SLEEP APNEA: frequent short breathing pauses during sleep. More than 5 episodes or longer than 10 seconds/hr is abnormal, loud snoring, frequent awakenings, morning headaches, EDS.
Nursing Management
History:
Generally rested and ready for daily activities after sleep?
Sleep onset problems
Aids
Dreams, nightmares
Early awakening
Rest_ relaxation period
Nursing Diagnosis:
Sleep Deprivation (prolong time without sleep)
Sleep Pattern, Disturbance
Insomnia (delayed onset of sleep)
Related to:
Over stimulation prior to bedtime
Pain
Discomfort
Anxiety
Alcohol
Fatigue r/t insufficient sleep
Risk for impaired gas exchange r/t sleep apnea
Activity intolerance r/t sleep deprivation or EDS
Goal:
To maintain or develop sleep pattern that provides sufficient energy for daily activities.
Improving quality and quantity of sleep.
Keep the etiology in mind
Implementing: Largely non pharmacologic measures like health teachings about sleep habits, bedtime rituals, provision of restful environment, avoid heavy meals before bedtime.
For hospitalized clients activities should be scheduled, less stimulus environment, support for anxious patients, safe use of sleep medications.
Evaluating:
Goals and outcomes achieved?
Observation about client’s sleep pattern
How the client feels on awakening?
Client’s level of alertness during the day
If desired outcomes not met then identify following:
Etiologic factors were correct?
Any change in medication therapy?
Client’s compliance
Were the measures effective?
References:
Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone
Friday, September 19, 2008
ASSESSMENT OF A NEWBORN
Assessment of a Newborn
Nuruddin Lakhani, M.D., M.P.H.
Pediatrician
HISTORY
Important to review Mother’s chart
- Mother’s age
- Mother’ s gravida / para status
- Pregnancy complications
- Labor events
- Rupture of membranes (SROM, AROM, PROM, PPROM)
- Mother’s labs (blood group, HBsAg, HIV, VDRL, GC / Chlam)
- ? Fever, medications (antibiotics, narcotics etc)
- Mode of delivery
Important to review the events immediately after birth
- Resuscitation
- Any medications given
- APGARS
SCORE 0 1 2
Heart Rate Absent < 100 >100
Resp Effort Absent/irr Slow, Crying Good
Muscle Tone Limp Some flexion Active motion
Reflex irritability No response Grimace Cough or sneeze
Color Blue. Pale Acrocyanosis Pink
NEONATAL EXAMINATION
General
- Appearance, size, color, vitals, gestational age assessment and growth parameters
Systemic
- Head and Neck - CNS
- Respiratory - Skin
- Cardiovascular - Musculoskeletal
- Abdominal - Primitive Reflexes
- Genitourinary
Size
- PAGA, PSGA, PLGA
- TAGA, TSGA, TLGA
- PTAGA, PTSGA, PTLGA
Gestational Age Assessment
- Ballard Score based on neuromuscular and physical maturity
- Ballard chart for the gestational assessment is used
HEAD
- Birth trauma (caput succedaneum, cephalhematoma)
- Size (microcephaly, macrocephaly)
- Fontanelles
EYES
- Red reflex
- Neonatal conjunctivitis
MOUTH / OROPHARYNX
- Cleft lip / palate
NOSE
- Obstructions
EARS
- Position
NECK
- Masses
RESP
- Rate, distress
- Apnea, cyanosis (? Causes)
- Auscultation
CVS
- Distress, apnea, cyanosis (? Causes)
- Palpation (apical impulse, thrills)
- Auscultation (murmurs)
ABDOMEN
- Abdominal wall defects, umbilical cord, shape
- Palpation
- Auscultation
- Check anal area for patency
GU
- Males – check for testes in scrotum or in the canal
- Females – check for ambiguous genitalia
MUSCULOSKELETAL
- Brachial plexus injury
- Range of motion
- Barlow’s and Ortolani test for hip dysplasia
- Check spine
CNS
- Movements and tone
- Primitive reflexes
SKIN
- Color (jaundice)
- Skin hair
- Texture
- Neonatal rashes
- Lower back hair or sacral dimple
Nuruddin Lakhani, M.D., M.P.H.
Pediatrician
HISTORY
Important to review Mother’s chart
- Mother’s age
- Mother’ s gravida / para status
- Pregnancy complications
- Labor events
- Rupture of membranes (SROM, AROM, PROM, PPROM)
- Mother’s labs (blood group, HBsAg, HIV, VDRL, GC / Chlam)
- ? Fever, medications (antibiotics, narcotics etc)
- Mode of delivery
Important to review the events immediately after birth
- Resuscitation
- Any medications given
- APGARS
SCORE 0 1 2
Heart Rate Absent < 100 >100
Resp Effort Absent/irr Slow, Crying Good
Muscle Tone Limp Some flexion Active motion
Reflex irritability No response Grimace Cough or sneeze
Color Blue. Pale Acrocyanosis Pink
NEONATAL EXAMINATION
General
- Appearance, size, color, vitals, gestational age assessment and growth parameters
Systemic
- Head and Neck - CNS
- Respiratory - Skin
- Cardiovascular - Musculoskeletal
- Abdominal - Primitive Reflexes
- Genitourinary
Size
- PAGA, PSGA, PLGA
- TAGA, TSGA, TLGA
- PTAGA, PTSGA, PTLGA
Gestational Age Assessment
- Ballard Score based on neuromuscular and physical maturity
- Ballard chart for the gestational assessment is used
HEAD
- Birth trauma (caput succedaneum, cephalhematoma)
- Size (microcephaly, macrocephaly)
- Fontanelles
EYES
- Red reflex
- Neonatal conjunctivitis
MOUTH / OROPHARYNX
- Cleft lip / palate
NOSE
- Obstructions
EARS
- Position
NECK
- Masses
RESP
- Rate, distress
- Apnea, cyanosis (? Causes)
- Auscultation
CVS
- Distress, apnea, cyanosis (? Causes)
- Palpation (apical impulse, thrills)
- Auscultation (murmurs)
ABDOMEN
- Abdominal wall defects, umbilical cord, shape
- Palpation
- Auscultation
- Check anal area for patency
GU
- Males – check for testes in scrotum or in the canal
- Females – check for ambiguous genitalia
MUSCULOSKELETAL
- Brachial plexus injury
- Range of motion
- Barlow’s and Ortolani test for hip dysplasia
- Check spine
CNS
- Movements and tone
- Primitive reflexes
SKIN
- Color (jaundice)
- Skin hair
- Texture
- Neonatal rashes
- Lower back hair or sacral dimple
NUTRITION AND METABOLIC PATTERN
What is Nutrition?
The study of foods and nutrients and their effect on health, growth and development of the individual.
Nutrition is the good we get from all the food we eat and it helps our bodies work.
Nutrients are the substances found in the food that is essential requirement for body functioning.
Body needs adequate food intake with balanced essential nutrients.
Essential Nutrients
water
carbohydrates
proteins
lipids
vitamins and
minerals.
Carbohydrates
Preferred source of energy
Include simple and complex carbohydrates
Promote fat metabolism, spare protein and enhance lower GI function
Major good sources milk, grains, fruits and vegetables
Inadequate carbohydrates intake affects metabolism
Carbs metabolism
Carbohydrates breaks into glucose
Some glucose circulate in the blood to maintain blood level and source of energy.
Reminder stored
Insulin enhances transport of glucose into cells
Proteins
Made of carbon, hydrogen, oxygen and nitrogen
Each protein molecule is made of amino acids
Essential: must supplied from diet and are necessary for tissue growth and maintenance.
Nonessential: body makes it and mix it with dietary protein to make new protein molecules
Classification of proteins
Complete proteins
Contains all essential and some non essential amino acids.
Found in animal, dairy, eggs
Incomplete proteins
Missing one or more essential amino acids.
Derived from vegetables
Balanced combination of food can provide essential amino acids e.g. maize and beans.
Protein metabolism
Three activities
Anabolism ( building)
Catabolism (breaking down)
Nitrogen balance (balance N intake = N output)
Lipids
Contains carbon, hydrogen and oxygen but more hydrogen than carbohydrates
Greasy, insoluble in water but soluble in alcohol
Fats are lipids that are solid at rtp
Oils are lipids that are liquid at rtp
Structured with fatty acids described as saturated and unsaturated fatty acids. (saturated, unsaturated fat)
Meat, butter, milk, coconut are saturated fat
Fish, oil, cereal, legumes (maize oil), breast milk are unsaturated fat.
Enzyme lipase converts fat into usable energy
Micronutrients
Vitamin are not manufactured by the bodies and needed to catalyze metabolic processes.
Fat soluble vitamins ( A, D, E and K)
Water soluble vitamins ( C, B-complex)
Minerals ( calcium, phosphorus, sodium, potassium, iron, iodine)
Energy Balance
Is the relationship between the energy derived from food and the energy used by the body.
Body obtains energy in the form of calories form carbohydrates, fat, protein and uses energy for daily voluntary and involuntary activities like walking, breathing.
Energy intake thru calorie value.
BMR by which body metabolizes food to maintain the energy requirements at awake and at rest.
Balanced Diet
Provides appropriate amounts of all nutrients in the correct proportions to meet body requirements which is achieved by eating variety of foods.
Any nutrient eaten in excess or deficient can affect health. (obesity, anemia)
Is important in maintaining a healthy body weight and can be assessed by body mass index (BMI)
Check out: wt kg divided ht squared (18.5---24.9)
Example: weight 60 kg ÷ height (1.52)² meters = 26 is the BMI.
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/index.htm
Young children
(one serving )
Grain group 1 slice of bread, 1/2 cup of cooked rice or pasta, 1/2 cup of cooked cereal,
Vegetable group 1/2 cup of chopped or raw vegetables, or 1 cup of raw leafy vegetables.
Fruit group 1 piece of fruit or melon wedge, 3/4 cup of 100% fruit juice, 1/2 cup of canned fruit, or 1/4 cup of dried fruit.
Milk group 1 cup of milk or yogurt or 2 ounces of cheese.
Meat group 2 to 3 ounces of cooked lean meat, poultry or fish, 1/2 cup of cooked dry beans, substitute 2 tablespoons of peanut butter or 1 egg for 1 ounce of meat.
Elder’s:
NUTRITION AND METABOLIC PATTERN
Tuft's University adjusted the food pyramid for those over age 70 to include:
8 glasses of water a day and plenty of fiber to help manage constipation.
Calcium, vitamin D, and B12 supplements.
Fancy pyramid food possible in Africa?
Factors affecting nutrition
Accessibility
Affordability
Food safety
Traditions
Lifestyle
Medications and therapy
Health
Alcohol consumption
Psychologic factors
Assessment
ABCD
Anthropometric Data: Ht, wt, waist circumference, BMI
Biochemical Data: Hemoglobin, serum albumin
Clinical: Skin, Hair and nails, mucus membrane
Dietary Data: 24-hour food recall, food diary
Nursing Diagnosis
Imbalanced nutrition: Less than body requirements/intake of nutrients insufficient to meet metabolic needs
Imbalanced nutrition: More than body requirements related to excess intake and decreased activity expenditure
Low self-esteem related to obesity
Risk for infection related to immunosuppresion secondary to insufficient protein intake.
Therapeutic Diets
Clear liquid diet
Full liquid diet
Soft diet
Bland diet
Low residue/low fiber diet
High fiber diet
Fat controlled diet
High calorie diet
Sodium restriction diet
Protein restriction diet
High protein diet
Low calcium diet
High calcium diet
Low purine diet
High iron diet
Carbohydrate controlled diet
References
Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone.
Savage King and Burgess. (1993). Nutrition for developing countries (2nd edition) Oxford.
Images: google images
The study of foods and nutrients and their effect on health, growth and development of the individual.
Nutrition is the good we get from all the food we eat and it helps our bodies work.
Nutrients are the substances found in the food that is essential requirement for body functioning.
Body needs adequate food intake with balanced essential nutrients.
Essential Nutrients
water
carbohydrates
proteins
lipids
vitamins and
minerals.
Carbohydrates
Preferred source of energy
Include simple and complex carbohydrates
Promote fat metabolism, spare protein and enhance lower GI function
Major good sources milk, grains, fruits and vegetables
Inadequate carbohydrates intake affects metabolism
Carbs metabolism
Carbohydrates breaks into glucose
Some glucose circulate in the blood to maintain blood level and source of energy.
Reminder stored
Insulin enhances transport of glucose into cells
Proteins
Made of carbon, hydrogen, oxygen and nitrogen
Each protein molecule is made of amino acids
Essential: must supplied from diet and are necessary for tissue growth and maintenance.
Nonessential: body makes it and mix it with dietary protein to make new protein molecules
Classification of proteins
Complete proteins
Contains all essential and some non essential amino acids.
Found in animal, dairy, eggs
Incomplete proteins
Missing one or more essential amino acids.
Derived from vegetables
Balanced combination of food can provide essential amino acids e.g. maize and beans.
Protein metabolism
Three activities
Anabolism ( building)
Catabolism (breaking down)
Nitrogen balance (balance N intake = N output)
Lipids
Contains carbon, hydrogen and oxygen but more hydrogen than carbohydrates
Greasy, insoluble in water but soluble in alcohol
Fats are lipids that are solid at rtp
Oils are lipids that are liquid at rtp
Structured with fatty acids described as saturated and unsaturated fatty acids. (saturated, unsaturated fat)
Meat, butter, milk, coconut are saturated fat
Fish, oil, cereal, legumes (maize oil), breast milk are unsaturated fat.
Enzyme lipase converts fat into usable energy
Micronutrients
Vitamin are not manufactured by the bodies and needed to catalyze metabolic processes.
Fat soluble vitamins ( A, D, E and K)
Water soluble vitamins ( C, B-complex)
Minerals ( calcium, phosphorus, sodium, potassium, iron, iodine)
Energy Balance
Is the relationship between the energy derived from food and the energy used by the body.
Body obtains energy in the form of calories form carbohydrates, fat, protein and uses energy for daily voluntary and involuntary activities like walking, breathing.
Energy intake thru calorie value.
BMR by which body metabolizes food to maintain the energy requirements at awake and at rest.
Balanced Diet
Provides appropriate amounts of all nutrients in the correct proportions to meet body requirements which is achieved by eating variety of foods.
Any nutrient eaten in excess or deficient can affect health. (obesity, anemia)
Is important in maintaining a healthy body weight and can be assessed by body mass index (BMI)
Check out: wt kg divided ht squared (18.5---24.9)
Example: weight 60 kg ÷ height (1.52)² meters = 26 is the BMI.
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/index.htm
Young children
(one serving )
Grain group 1 slice of bread, 1/2 cup of cooked rice or pasta, 1/2 cup of cooked cereal,
Vegetable group 1/2 cup of chopped or raw vegetables, or 1 cup of raw leafy vegetables.
Fruit group 1 piece of fruit or melon wedge, 3/4 cup of 100% fruit juice, 1/2 cup of canned fruit, or 1/4 cup of dried fruit.
Milk group 1 cup of milk or yogurt or 2 ounces of cheese.
Meat group 2 to 3 ounces of cooked lean meat, poultry or fish, 1/2 cup of cooked dry beans, substitute 2 tablespoons of peanut butter or 1 egg for 1 ounce of meat.
Elder’s:
NUTRITION AND METABOLIC PATTERN
Tuft's University adjusted the food pyramid for those over age 70 to include:
8 glasses of water a day and plenty of fiber to help manage constipation.
Calcium, vitamin D, and B12 supplements.
Fancy pyramid food possible in Africa?
Factors affecting nutrition
Accessibility
Affordability
Food safety
Traditions
Lifestyle
Medications and therapy
Health
Alcohol consumption
Psychologic factors
Assessment
ABCD
Anthropometric Data: Ht, wt, waist circumference, BMI
Biochemical Data: Hemoglobin, serum albumin
Clinical: Skin, Hair and nails, mucus membrane
Dietary Data: 24-hour food recall, food diary
Nursing Diagnosis
Imbalanced nutrition: Less than body requirements/intake of nutrients insufficient to meet metabolic needs
Imbalanced nutrition: More than body requirements related to excess intake and decreased activity expenditure
Low self-esteem related to obesity
Risk for infection related to immunosuppresion secondary to insufficient protein intake.
Therapeutic Diets
Clear liquid diet
Full liquid diet
Soft diet
Bland diet
Low residue/low fiber diet
High fiber diet
Fat controlled diet
High calorie diet
Sodium restriction diet
Protein restriction diet
High protein diet
Low calcium diet
High calcium diet
Low purine diet
High iron diet
Carbohydrate controlled diet
References
Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone.
Savage King and Burgess. (1993). Nutrition for developing countries (2nd edition) Oxford.
Images: google images
CLASSIFICATION OF NANDA NURSING DIAGNOSES BY GORDON’S
HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
Energy Field, Disturbed
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Infection, Risk for
Injury, Risk for
Risk for injury, Suffocation
Risk for injury, Poisoning
Risk for injury, Trauma
Latex Allergy Response, Risk for and Actual
Management of Therapeutic Regimen, Effective
Management of Therapeutic Regimen (Individual, Family,
Community), Ineffective
Management of Therapeutic Regimen, Readiness for
Enhanced
Noncompliance (Specify)
Perioperative-Positioning Injury, Risk for
Protection, Ineffective
Surgical Recovery, Delayed
NUTRITIONAL-METABOLIC PATTERN
Adult Failure to Thrive
Aspiration, Risk for
Body Temperature, Imbalanced, Risk for
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Dentition, Impaired
Fluid Balance, Readiness for Enhanced
Fluid Volume, Deficient, Risk for and Actual
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for
Hyperthermia
Hypothermia
Infant Feeding Pattern, Ineffective
Nausea
Nutrition, Imbalanced, Less Than Body Requirements
Nutrition, Imbalanced, More Than Body Requirements,
Risk for and Actual
Nutrition, Readiness for Enhanced
Swallowing, Impaired
Thermoregulation, Ineffective
Tissue Integrity, Impaired
Skin Integrity, Impaired, Risk for and Actual
Oral Mucous Membrane, Impaired
ELIMINATION PATTERN
Bowel Incontinence
Constipation, Risk for, Actual, and Perceived
Diarrhea
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence
Functional Urinary Incontinence
Reflex Urinary Incontinence
Stress Urinary Incontinence
Total Urinary Incontinence
Urge Urinary Incontinence, Risk for and Actual
Urinary Retention
ACTIVITY-EXERCISE PATTERN
Activity Intolerance, Risk for and Actual
Airway Clearance, Ineffective
Autonomic Dysreflexia, Risk for and Actual
Bed Mobility, Impaired
Breathing Pattern, Ineffective
Cardiac Output, Decreased
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Dysfunctional Ventilatory Weaning Response
Falls, Risk for
Fatigue
Gas Exchange, Impaired
Growth and Development, Delayed
Development, Risk for Delayed
Growth, Risk for Disproportionate
Home Maintenance, Impaired
Infant Behavior, Disorganized, Risk for and Actual, and Readiness
for Enhanced Organized
Peripheral Neurovascular Dysfunction, Risk for
Physical Mobility, Impaired
Sedentary Lifestyle
Self-Care Deficit
Feeding
Bathing-Hygiene
Dressing-Grooming
Toileting
Spontaneous Ventilation, Impaired
Tissue Perfusion, Ineffective (Specify Type:
Renal, Cerebral, Cardiopulmonary,
Gastrointestinal, Peripheral)
Transfer Ability, Impaired
Walking, Impaired
Wandering
Wheelchair Mobility, Impaired
SLEEP-REST PATTERN
Sleep, Readiness for Enhanced
Sleep Deprivation
Sleep Pattern, Disturbed
COGNITIVE-PERCEPTUAL PATTERN
Adaptive Capacity, Intracranial, Decreased
Confusion, Acute and Chronic
Decisional Conflict (Specify)
Environmental Interpretation Syndrome, Impaired
Knowledge, Deficient (Specify)
Knowledge, Readiness for Enhanced (Specify)
Memory, Impaired
Pain, Acute and Chronic
Sensory Perception, Disturbed (Specify:
Visual, Auditory, Kinesthetic, Gustatory,
Tactile, Olfactory)
Thought Processes, Disturbed
Unilateral Neglect
SELF-PERCEPTION AND SELF-CONCEPT
PATTERN
Anxiety
Body Image, Disturbed
Death Anxiety
Fear
Helplessness
Loneliness, Risk for
Personal Identity, Disturbed
Powerlessness, Risk for and Actual
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low, Situational Low,
and Risk for Situational Low
Self-Mutilation, Risk for and Actual
ROLE RELATIONSHIP PATTERN
Caregiver Role Strain, Risk for and Actual
Communication, Readiness for Enhanced
Family Process, Interrupted, and Family Process,
Dysfunctional: Alcoholism
Family Process, Readiness for Enhanced
Grieving, Anticipatory
Grieving, Dysfunctional, Risk for and Actual
Parent, Infant, and Child Attachment, Impaired,
Risk for
Parenting, Impaired, Risk for and Actual, and
Parental Role Conflict
Parenting, Readiness for Enhanced
Relocation Stress Syndrome, Risk for and Actual
Role Performance, Ineffective
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Verbal Communication, Impaired
Violence, Self-Directed and Other-Directed,
Risk for
SEXUALITY-REPRODUCTIVE PATTERN
Rape-Trauma Syndrome: Compound Reaction
And Silent Reaction
Sexual Dysfunction
Sexuality Patterns, Ineffective
COPING-STRESS TOLERANCE PATTERN
Adjustment, Impaired
Community Coping, Ineffective and Readiness
for Enhanced
Coping, Readiness for Enhanced
Family Coping, Compromised and Disabled
Family Coping, Readiness for Enhanced
Individual Coping, Ineffective
Coping, Defensive
Denial, Ineffective
Post-Trauma Syndrome, Risk for and Actual
Suicide, Risk for
VALUE-BELIEF PATTERN
Impaired Religiosity, Risk for and Actual
Spiritual Distress, Risk for and Actual
Spiritual Well-Being, Readiness for Enhanced
Energy Field, Disturbed
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Infection, Risk for
Injury, Risk for
Risk for injury, Suffocation
Risk for injury, Poisoning
Risk for injury, Trauma
Latex Allergy Response, Risk for and Actual
Management of Therapeutic Regimen, Effective
Management of Therapeutic Regimen (Individual, Family,
Community), Ineffective
Management of Therapeutic Regimen, Readiness for
Enhanced
Noncompliance (Specify)
Perioperative-Positioning Injury, Risk for
Protection, Ineffective
Surgical Recovery, Delayed
NUTRITIONAL-METABOLIC PATTERN
Adult Failure to Thrive
Aspiration, Risk for
Body Temperature, Imbalanced, Risk for
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Dentition, Impaired
Fluid Balance, Readiness for Enhanced
Fluid Volume, Deficient, Risk for and Actual
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for
Hyperthermia
Hypothermia
Infant Feeding Pattern, Ineffective
Nausea
Nutrition, Imbalanced, Less Than Body Requirements
Nutrition, Imbalanced, More Than Body Requirements,
Risk for and Actual
Nutrition, Readiness for Enhanced
Swallowing, Impaired
Thermoregulation, Ineffective
Tissue Integrity, Impaired
Skin Integrity, Impaired, Risk for and Actual
Oral Mucous Membrane, Impaired
ELIMINATION PATTERN
Bowel Incontinence
Constipation, Risk for, Actual, and Perceived
Diarrhea
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence
Functional Urinary Incontinence
Reflex Urinary Incontinence
Stress Urinary Incontinence
Total Urinary Incontinence
Urge Urinary Incontinence, Risk for and Actual
Urinary Retention
ACTIVITY-EXERCISE PATTERN
Activity Intolerance, Risk for and Actual
Airway Clearance, Ineffective
Autonomic Dysreflexia, Risk for and Actual
Bed Mobility, Impaired
Breathing Pattern, Ineffective
Cardiac Output, Decreased
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Dysfunctional Ventilatory Weaning Response
Falls, Risk for
Fatigue
Gas Exchange, Impaired
Growth and Development, Delayed
Development, Risk for Delayed
Growth, Risk for Disproportionate
Home Maintenance, Impaired
Infant Behavior, Disorganized, Risk for and Actual, and Readiness
for Enhanced Organized
Peripheral Neurovascular Dysfunction, Risk for
Physical Mobility, Impaired
Sedentary Lifestyle
Self-Care Deficit
Feeding
Bathing-Hygiene
Dressing-Grooming
Toileting
Spontaneous Ventilation, Impaired
Tissue Perfusion, Ineffective (Specify Type:
Renal, Cerebral, Cardiopulmonary,
Gastrointestinal, Peripheral)
Transfer Ability, Impaired
Walking, Impaired
Wandering
Wheelchair Mobility, Impaired
SLEEP-REST PATTERN
Sleep, Readiness for Enhanced
Sleep Deprivation
Sleep Pattern, Disturbed
COGNITIVE-PERCEPTUAL PATTERN
Adaptive Capacity, Intracranial, Decreased
Confusion, Acute and Chronic
Decisional Conflict (Specify)
Environmental Interpretation Syndrome, Impaired
Knowledge, Deficient (Specify)
Knowledge, Readiness for Enhanced (Specify)
Memory, Impaired
Pain, Acute and Chronic
Sensory Perception, Disturbed (Specify:
Visual, Auditory, Kinesthetic, Gustatory,
Tactile, Olfactory)
Thought Processes, Disturbed
Unilateral Neglect
SELF-PERCEPTION AND SELF-CONCEPT
PATTERN
Anxiety
Body Image, Disturbed
Death Anxiety
Fear
Helplessness
Loneliness, Risk for
Personal Identity, Disturbed
Powerlessness, Risk for and Actual
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low, Situational Low,
and Risk for Situational Low
Self-Mutilation, Risk for and Actual
ROLE RELATIONSHIP PATTERN
Caregiver Role Strain, Risk for and Actual
Communication, Readiness for Enhanced
Family Process, Interrupted, and Family Process,
Dysfunctional: Alcoholism
Family Process, Readiness for Enhanced
Grieving, Anticipatory
Grieving, Dysfunctional, Risk for and Actual
Parent, Infant, and Child Attachment, Impaired,
Risk for
Parenting, Impaired, Risk for and Actual, and
Parental Role Conflict
Parenting, Readiness for Enhanced
Relocation Stress Syndrome, Risk for and Actual
Role Performance, Ineffective
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Verbal Communication, Impaired
Violence, Self-Directed and Other-Directed,
Risk for
SEXUALITY-REPRODUCTIVE PATTERN
Rape-Trauma Syndrome: Compound Reaction
And Silent Reaction
Sexual Dysfunction
Sexuality Patterns, Ineffective
COPING-STRESS TOLERANCE PATTERN
Adjustment, Impaired
Community Coping, Ineffective and Readiness
for Enhanced
Coping, Readiness for Enhanced
Family Coping, Compromised and Disabled
Family Coping, Readiness for Enhanced
Individual Coping, Ineffective
Coping, Defensive
Denial, Ineffective
Post-Trauma Syndrome, Risk for and Actual
Suicide, Risk for
VALUE-BELIEF PATTERN
Impaired Religiosity, Risk for and Actual
Spiritual Distress, Risk for and Actual
Spiritual Well-Being, Readiness for Enhanced
Subscribe to:
Comments (Atom)