Nursing Notes

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PUBERTY the appearance of male pubic, axillary, and


facial hair;
• laryngeal enlargement with its
accompanying voice change;
PUBERTY • maturation of spermatozoa; and
• closure of growth plates in long bones
• is the stage of life at which secondary sex (termed adrenarche).
changes begin.
• In most girls, these changes are stimulated THE ROLE OF ANDROGEN IN GIRLS
when the hypothalamus synthesizes and • In girls, testosterone influences the
releases gonadotropin-releasing hormone following:
(GnRH), which then triggers the anterior 1. enlargement of the labia majora and clitoris
pituitary to release follicle-stimulating 2. formation of axillary and pubic hair.
hormone (FSH) and luteinizing hormone
(LH). THE ROLE OF ESTROGEN

• FSH and LH are termed gonadotropin (gonad= • When triggered at puberty by FSH,
"ovary"; tropin = "growth") hormones not only ovarian follicles in females begin to
because they begin the production of androgen and excrete a high level of the hormone
estrogen, which in turn initiate secondary sex estrogen.
characteristics, but also because they continue to • This increase influences the following:
cause the production of eggs and influence • development of the uterus, fallopian
menstrual cycles throughout women's lives (Eggers, tubes, and vagina;
Ohnesorg, & Sinclair, 2014). • typical female fat distribution;
• hair patterns; and
THE ROLE OF ANDROGEN
• breast development.
• Androgenic hormones are the hormones • It also closes the epiphyses of long
responsible for: bones in girls the same way testosterone
1. muscular development closes the growth plate in boys.
2. physical growth • The beginning of breast development is
3. increase in sebaceous gland secretions that termed thelarche, which usually starts 1
cause typical acne in both boys and girls to 2 years before menstruation.
during adolescence.

• In males, androgenic hormones are produced by


the adrenal cortex and the testes and, in females, by MENSTRUATIONA
the adrenal cortex and the ovaries.

THE ROLE OF ANDROGEN IN MALES

• The level of the primary androgenic • menstrual cycle (the female reproductive
hormone, testosterone, is low in males until cycle) is episodic uterine bleeding in
puberty (between ages 12 and 14 years) response to cyclic hormonal changes.
when it rises to influence pubertal changes • The purpose of a menstrual cycle is to
in the testes, scrotum, penis, prostate, and bring an ovum to maturity and renew a
seminal vesicles; uterine tissue bed that will be necessary
for the ova's growth should it be • inactivity of any part results in an
fertilized. incomplete r ineffective cycle

MENARCHE
2. The Anterior lobe of the Pituitary Gland
• First menstruation
(the adenohypophysis)
• May occur as early as 9 years of age
• It is good to include health teaching • Under the influence of GRH, produces
information on menstruation to both two hormones:
school age children and their parents as 1. FSH, a hormone active early in the cycle
early as fourth grade as part of routine that is responsible for maturation of the
care. ovum
2. LH, a hormone that becomes most active at
THE LENGTH OF MENSTRUAL CYCLE
the midpoint of the cycle and is responsible
• differs from woman to woman. for ovulation, or release of the mature egg
• average length is 28 days (from the cell from the ovary.
beginning of one menstrual flow to the • It also stimulates growth of the uterine
beginning of the next). linin during the second half of the
• It is not unusual for cycles to be as short menstrual cycle.
as 23 days or as long as 35 days. 3. THE OVARIES
• Every month during the fertile period of
THE LENGTH OF MENSTRUAL FLOW
a woman’s life (from menarche to
(termed menses)
menopause), one of the ovary’s oocytes
• 4 to 6 days is activated by FSH to begin to grow and
• although women may have flows as mature.
short as 2 days or as long as 9 • As the oocyte grows, its cells produce a
• days (Ledger, 2012). clear fluid (follicular fluid) that contains
a high degree of estrogen and some
progesterone.
• As the follicle surrounding the oocyte
PHYSIOLOGY OF grows, it is propelled toward the surface
of the ovary.
MENSTRUATION • At full maturity, the follicle is visible on
the surface of the ovary as a clear water
blister approximately 0.25 to 0.5 in.
across.
1. Four body structures are involved: • At this stage of maturation, the small
1.hypothalamus ovum (barely visible to the naked eye,
2.Anterior pituitary gland about the size of a printed period) with
3.ovaries its surrounding follicular membrane and
4.uterus fluid is termed a graafian follicle.
• For a menstrual cycle to be complete, all • By day 14 or the midpoint of a typical
four organs must contribute their part; 28-day cycle, the ovum has divided by
mitotic division into two separate • With lutein production, the follicle is
bodies: renamed a corpus luteum (yellow body).
• a primary oocyte, which contains the • The basal body temperature of a woman
bulk of the cytoplasm, and drops slightly (by 0.5° to 1°F) just
• secondary oocyte, which contains so before the day of ovulation because of
little cytoplasm that it is not the extremely low level of progesterone
functional. that is present at that time.
• The structure also has accomplished its • It rises by 1°F on the day after ovulation
meiotic division, reducing its number of because of the concentration of
chromosomes to the haploid (having progesterone, which is thermogenic.
only one member of a pair) number of • The woman’s temperature remains at
23. this elevated level until approximately
• After an upsurge of LH from the day 24 of the menstrual cycle, when the
pituitary at about day 14, prostaglandins progesterone level again decreases
are released and the graafian follicle (Huether & McCance, 2012).
ruptures. • If conception (fertilization by a
• The ovum is set free from the surface of spermatozoon) occurs as the ovum
the ovary, a process termed ovulation. It proceeds down a fallopian tube and the
is swept into the open end of a fallopian fertilized ovum implants on the
tube. endometrium of the uterus, the corpus
• It is important to teach women that luteum remains throughout the major
ovulation does not necessarily occur on portion of the pregnancy (to about 16 to
the 14th day of their cycle; 20 weeks).
• it occurs 14 days before the end of their • If conception does not occur, the
cycle. unfertilized ovum atrophies after 4 or 5
• If their menstrual cycle is only 20 days days, and the corpus luteum (now called
long, for example, their day of ovulation a “false” corpus luteum) remains for
would be day 6 (14 days before the end only 8 to 10 days.
of the cycle). • As the corpus luteum regresses, it is
• If their cycle is 44 days long, ovulation gradually replaced by white fibrous
would occur on day 30, not at the tissue, and the resulting structure is
halfway point—day 22. termed a corpus albicans (white body).
• After the ovum and the follicular fluid
have been discharged from the ovary, the
cells of the follicle remain in the form of 4. THE UTERUS
a hollow, empty pit. • Uterine changes that occur monthly as a
• The FSH has done its work at this point result of stimulation from the estrogen
and now decreases in amount. and progesterone produced by the
• The second pituitary hormone, LH, ovaries.
continues to rise in amount and directs
the follicle cells left behind in the ovary
to produce lutein, a bright yellow fluid
high in progesterone.

PHASES OF If fertilization does not occur, the
corpus luteum in the ovary begins to
MENSTRUATION regress after 8 to 10 days, and therefore,
the production of progesterone
decreases.
• With the withdrawal of progesterone,
1. The First Phase of the Menstrual Cycle the endometrium of the uterus begins to
(Proliferative) degenerate (at about day 24 or day 25
• Immediately after a menstrual flow of the cycle).
(which occurs during the first 4 or 5 • The capillaries rupture, with minute
days of a cycle) hemorrhages, and the endometrium
• the endometrium, or lining of the sloughs off.
uterus, is very thin, approximately one
cell layer in depth.
• As the ovary begins to produce estrogen 4. The Fourth Phase of the Menstrual Cycle
(in the follicular fluid, under the (Menses)
direction of the pituitary FSH), the • Menses, or a menstrual flow, is
endometrium begins to proliferate so composed of:
rapidly the thickness of the 1) a mixture of blood from the ruptured
endometrium increases as much as capillaries;
eightfold from day 5 to day 14 2) mucin;
• ALSO CALLED the proliferative, 3) fragments of endometrial tissue; and
estrogenic, follicular, or postmenstrual 4) the microscopic, atrophied, and unfertilized
phase. 5. ovum.
• Because it is the only external marker
2. The Second Phase of the Menstrual Cycle of the cycle, however, the first day of
(Secretory) menstrual flow is used to mark the
• After ovulation, the formation of beginning day of a new menstrual
progesterone in the corpus luteum cycle.
(under the direction of LH) causes the • Contrary to common belief, a menstrual
glands of the uterine endometrium to flow contains only 30 to 80 ml of
become corkscrew or twisted in blood;
appearance and dilated with quantities • if it seems to be more, it is because of
of glycogen (an elementary sugar) and the accompanying mucus and
mucin (a protein). endometrial shreds. The iron loss in a
• It takes on the appearance of rich, typical menstrual flow is approximately
spongy velvet. 11 mg.
• Is termed the progestational, luteal, • This is enough loss that many
premenstrual, or secretory phase. adolescent women could benefit from a
daily iron supplement to prevent iron
depletion during their menstruating
3. The Third Phase of the Menstrual Cycle years (Bitzer, Sultan, Creatsas, et al.,
(Ischemic) 2014).
HEALTH ASSESSMENT DURING PRENATAL
PRENATAL VISITS VISITS

• Schedule of Prenatal Visits:


PRENATAL CARE 7. Up to 28th week of pregnancy
• Prenatal care is the health care you get while -Every 4 weeks
you are pregnant. It includes your checkups 8. 28th – 36th week of pregnancy
and prenatal testing. Prenatal care can help -Every 2 weeks
keep you and your baby healthy. It lets your 9. 36th week until Birth
health care provider spot health problems -Every week
early.
• Early treatment can cure many problems and
prevent others. Estimating the EDC and
Prenatal and perinatal care includes: AOG by Naegel’s Rule and
1. determining what tests are necessary and
when and how often they should be
MC Donald’s Rule
administered 1) If LMP was Feb. 20, 2023, compute the AOG
in weeks until Sept. 23, 2023
2. administering and interpreting abdominal
and vaginal ultrasound/sonography

3. early and ongoing assessment of a woman’s


risk status and risk reduction measures

4. health education, health promotion, and


psychosocial support

5. medical screening and related interventions

6. accessing and addressing risk factors and or


any other health problems that may emerge
PURPOSE OF PRENATAL CARE • The estimated due date (EDD or EDC) is
the date that spontaneous onset of labor is
expected to occur. The due date may be
1. Establish a baseline of present health. estimated by adding 280 days ( 9 months
2. Determine the gestational age of the fetus. and 7 days) to the first day of the last
menstrual period (LMP). This is the
3. Monitor the fetal development and maternal method used by "pregnancy wheels". The
well-being. accuracy of the EDD derived by this
4. Identify women at risk for complications. method depends on accurate recall by the
mother, assumes regular 28 day cycles,
5. Minimize the risk of possible complications and that ovulation and conception occurs
by anticipating and preventing problems on day 14 of the cycle. Use of the LMP to
establish the due date may overestimate
before they occur. the duration of the pregnancy, and can be
6. Provide time for education about pregnancy, subject to an error of more than 2 weeks
[5-7].
lactation, and NB care
1) Naegele’s Method
• LMP – 3 months + 7 days + 1 year

2) Another method is by Adding 9


months and 7 days (LMP from Jan – 3) Some women have cycles that are
Mar only) to the first day of the last consistently longer than the average
menstrual period (LMP) 28-day cycle. In these cases, a
pregnancy wheel can still be used, but
• This is the method used by "pregnancy some simple calculations are necessary
wheels".
• The accuracy of the EDD derived by this • The second half of a woman’s menstrual
method depends on cycle always lasts for 14 days. This is the
• accurate recall by the mother, assumes time from ovulation to the next menstrual
regular 2-day cycles, and that ovulation period.
and conception occurs on day 14 of the • If your cycle is 35 days long, for example,
then you probably
cycle. • ovulated on day 21 (35 – 14 = 21)
•Use of the LMP to establish the due date may
overestimate the duration of the pregnancy
and can be subject to an error of more than
2 weeks.
4) Once you have a general idea of when
you ovulated, you can use an adjusted
LMP to find your due date with a
pregnancy wheel

• For example, if your menstrual cycle is


usually 35 days long and the first day of
your LMP was November 1:
o Add 21 days (November 22).
o Subtract 14 days to find your
adjusted LMP date (November
8).
o After you calculate your adjusted LMP
date, simply mark it on the pregnancy
wheel and then look at the date where the
line crosses. That is your estimated due
date.

5) McDonald’s Rule (Fundal Height


Measurement)

• If LMP is not known.


• Palpate the fundus and relate height of
fundus with abdominal landmarks.
• After week 24 of pregnancy, the fundal
height for a normally growing baby will
match the number of weeks of pregnancy
— plus or minus 2 centimeters.
o For example: Fundal height 27 cm. = 27
weeks pregnant
• Height of fundus (cm) ÷ 3.5 = age
of pregnancy in lunar months.
• Typically, tape measurement from the
notch of the symphysis pubis to over the
top of the uterine fundus as a woman lies
supine is equal to the week of gestation
in centimeters
• between the 20th and 31st weeks of
pregnancy (e.g., in a pregnancy of 24
weeks, the fundal height should be 24 cm).
Common Teratogens

• Common teratogens include some


COMMON TERATOGENS medications, recreational drugs, tobacco
AND THEIR EFFECTS products, chemicals, alcohol, certain
infections, and in some cases, uncontrolled
Teratogens health problems in the birthing parent.
Alcohol is a well-known teratogen that can
• A teratogen is something that can cause cause harmful effects on the fetus after
birth defects or abnormalities in a exposure at any time during pregnancy.
developing embryo or fetus upon exposure. • Teratogenic agents include infectious agents
• Teratogens include some medications, (rubella, cytomegalovirus, varicella, herpes
recreational drugs, tobacco products, simplex, toxoplasma, syphilis, etc.); physical
chemicals, alcohol, certain infections, and in agents (ionizing agents, hyperthermia);
some cases, health problems such as maternal health factors (diabetes, maternal
uncontrolled diabetes in pregnant people. PKU); environmental chemicals (organic
• Teratogens can begin affecting the mercury compounds, polychlorinated
developing embryo as early as 10 to 14 days biphenyl or PCB, herbicides and industrial
after conception. solvents); and drugs (prescription, over- the-
• During embryonic development, there are counter, or recreational).
periods when the developing organ systems
show more sensitivity to teratogens. Effects of Teratogens
• Specifically, if exposure to a teratogen • During this time, teratogens can cause
occurs during the first 3.5 to 4.5 weeks of neural tube defects, such as spina bifida.
gestation, a neural tube defect, such as spina Some organs are sensitive to teratogens
bifida or anencephaly, may result. during the whole pregnancy. This includes
the baby's brain and spinal cord. Alcohol
affects the brain and spinal cord, so it can
cause harm at any time during pregnancy.
• Teratogens can also increase the risk for 5) Interpersonal interactions
miscarriage, preterm labor or stillbirth. • Ask about hobbies
• A teratogen is a substance that interferes o Smoking, drinking alcoholic beverages
with normal fetal development and causes • Medication history
congenital disabilities.
Biographical Data

Biographic data includes basic characteristics about


the patient, such as:
HEALTH HISTORY
• Patient name
Past, present, and potential • Contact information
HISTORY OF PAST ILLNESSES • Birthdate
• Age
1) Past medical history • Gender and preferred pronouns
• Kidney disease, varicosities • Allergies
• Heart disease, hypertension • Languages spoken
• STD, UTI • Preferred language
• Diabetes, Thyroid disease • Relationship status
• Recurrent seizures, Gallbladder disease • Occupation
• Phenylketonuria, TB • Resuscitation status.
• Asthma
2) Childhood diseases Menstrual History
• Chickenpox (varicella) • There real value in knowing the date of the last
• Mumps menstrual period. There are preliminary data to
• Measles (rubeola) suggest that a lack of agreement between
• German measles (rubella) menstrual and scan dates is an indicator of
• Poliomyelitis subsequent preterm delivery.
3) Ask about HPV (human papillomavirus
vaccine) Menstrual history includes the following:
• Has the potential to prevent cervical CA • Age at menarche or menopause
4) Ask about allergies • Number of days of menses
5) Ask about past surgical procedures • Length and regularity of the interval between
cycles
HISTORY OF FAMILY ILLNESSES • Start date of the last menstrual period (LMP)
• Dates of the preceding period (previous
• Can help identify potential problems in a menstrual period [PMP])
woman during pregnancy or in her infant at • Volume of menses
birth. • Passage of blood clots: Any history of passage
DAY HISTORY/SOCIAL PROFILE of clots warrants further evaluation and referral
to a gynecologist
• Elicit information about: • Any symptoms that occur with menses (eg,
1) Current nutrition (“24-hr. recall”) pain, cramping, migraine headaches)
2) Elimination
3) Sleep
4) Recreation
Current Pregnancy (EDD, AOG, gravid/gravida
and para)
GYNECOLOGIC
If LMP was Feb. 20, 2023, compute the AOG in HISTORY AND
weeks until Sept. 23, 2023
MEDICAL HISTORY

Gynecology Care

• For gynecologic care, a woman


should choose a health care
professional with whom she can
comfortably discuss sensitive topics,
such as sexual function concerns,
birth control, pregnancy, and
menopause. The clinician may be a
Comprehensive system of classifying pregnancy doctor, including a gynecologist,
status primary care physician, nurse-
• G (gravida) – total # of pregnancies midwife, nurse practitioner, or
• P (para) - number of deliveries that reached physician assistant.
viability, regardless of whether the infant was
born alive Ask about:
1) Age of menarche
• Para broken down into: 2) Menstrual cycle, including interval,
✓ T = # of full term infants born at 37 weeks duration, amount of
or after menstrual flow, and associated discomforts
✓ P = # of preterm infants born before 37 with her
weeks menstruation.
✓ A = # of spontaneous or induced abortions 3) Past surgery on the reproductive tract
✓ L = # of living children 4) Reproductive planning have been used
✓ M = # of multiple pregnancies 5) Sexual history

Previous pregnancies and outcome (GTPAL score) Medical History


• A 26-year-old female is
currently26weekspregnant. She had a • Familiarity with the maternal history
miscarriage at 10weeksgestation five years is crucial to identifying risk factors
ago. She has a threeyear-old who was born that can contribute to illness and/or
at 39 weeks. What is her GTPAL? later health risk of the infant.
Maternal health directly affects fetal
o Answer: and neonatal well-being. It is
✓ ▪G=3 important to learn about the family
✓ ▪T=1 constellation and the mother’s
✓ ▪P=0 physical and mental health, life
✓ ▪A=1 stressors, support systems, and
✓ ▪L=1
developmental adaptation to the lifelong consequences for
prospect of becoming a parent. development.

Example: Any special nutritional needs:

Medical History • Folic acid is a B vitamin that may help


prevent neural tube defects.
Medical history: Mild intermittent asthma
• Before pregnancy, you need 400
diagnosed in childhood requiring only occasional
mcg (micrograms) per day.
rescue inhaler use, no hospitalizations for asthma.
She is otherwise healthy. • During pregnancy and when
breastfeeding, you need 600 mcg
Surgical history: Wisdom teeth removed at age 18. per day from foods and/or
Medications: Albuterol inhaler as needed, about vitamins.
once a month. Daily prenatal vitamin. • Iron is important for your baby's growth
and brain development. During
Allergies: No known drug allergies. pregnancy, the amount of blood in your
Family history: Mother is healthy at age 50. Father body increases, so you need more iron
is 53 years old with high blood pressure. for yourself and your growing baby.
You should get 27 mg (milligrams) of
Social history: Patient is employed as an engineer. iron a day.
She exercises 3 days/week. She drinks 2 glasses of • Calcium during pregnancy can reduce
wine per week but stopped when she found out she your risk of preeclampsia. It's a serious
was pregnant. She does not smoke or use any illicit medical condition that causes a sudden
drugs. She has not had any recent travel. She is increase in your blood pressure.
monogamous with 1 male partner. Calcium also builds up your baby's
bones and teeth.
• Pregnant adults should get
NUTRITIONAL STATUS 1,000 mg (milligrams) of
calcium a day
• Pregnant teenagers (ages 14-
• Maternal nutritional and metabolic 18) need 1,300 mg of calcium a
factors affect the developmental day
process of the fetus which • Vitamin D helps the calcium to build
consequently influence the birth your baby's bones and teeth. All
weight of the newborn. However, the women, pregnant or not, should be
association between maternal getting 600 IU (international units) of
nutritional factors and birth weight is vitamin D per day.
complex and is not well
characterized in Ethiopia.
• Poor maternal nutritional status has FETAL GROWTH
been related to different adverse
birth outcomes including intrauterine ASSESSMENT
growth restriction and low birth
weight (LBW), which can have
• The assessment of fetal growth represents a fetal heart rate & uterine
fundamental step towards the identification contraction monitors for 20 min.
• Position: SEMI – FOWLERS
of the true growth restricted fetus that is • SHORT-TERM VARIABILITY –
associated to important perinatal morbidity small changes in FHB
• from second to second.
and mortality. The possible ways of
• LONG-TERM VARIABILITY –
detecting abnormal fetal growth are taken differences in FHR that occur
into consideration in this review and their over 20 min. period.
strong and weak points are discussed.
• Assessment of fetal growth is one of the
main aims of antenatal care, as fetal size and
growth trajectories are important indicators
of underlying fetal health. Both extremes of
fetal growth are associated with an increased
incidence of adverse perinatal outcomes.

METHODS IN ASSESSING THE FETAL


WELL-BEING

FETAL MOVEMENT (Kick counts)


• Quickening – begins at 18 – 20 wks. AOG;
peaks at 28 – 38 wks. AOG
• Average fetal movement = 10 – 12x/ day.
• Decreased fetal movement = placental
insufficiency.
2. NONSTRESS TESTING
SANDOVSKY METHOD ▪ Response of FHR to fetal movement
o Counting & recording the number of fetal in which the FHR
movements in o and Uterine Contraction Monitors
an hour after meal (mother in left are attached.
recumbent position). ▪ Position: SEMI-FOWLERS/ LEFT
LATERAL
o Normal: 2x/ 10 min. or 10 – 12x/ hr. ▪ Normal: REACTIVE NONSTRESS
o Needs Referral: 10 fetal movements in 2 TEST; 2 – 4 FHR
hours ▪ accelerations in 10min.
▪ Abnormal: NON-REACTIVE
CARDIFF METHOD (Count-to-Ten)
o Recording the time interval it takes 3. VIBROACOUSTIC STIMULATION
for the pregnant woman to feel the
fetal movement. • Test used to stimulate fetal
movement by the use of acoustic
o Normal: 10 fetal movements/ hr. stimulator especially if a
FETAL HEART RATE spontaneous acceleration has not
occurred within 20min. during
NONSTRESS TEST.
• As early as the 10th – 11th wk. AOG by 4. CONTRACTION STRESS TESTING
Doppler
• Normal: 120 – 160 beats/ min. • Assessing FHR response to uterine
contractions
1. RHYTHM STRIP TESTING • Purpose: to assess the fetal ability
to tolerate the
• Determine the presence of good • stress of labor.
baseline rate, long & short-term • Position: LEFT LATERAL/SEMI-
FOWLERS
variability by the use of external • Normal result: NEGATIVE; No late
FHR decelerations
• present by 3 contractions in 10 min.
period
• Abnormal: POSITIVE; Presence of
late FHR
• decelerations by 50% or more of
uterine
• contractions.
- Contraindication:
✓ Placenta previa
✓ Multifetal pregnancy
✓ Incompetent cervix
✓ Rupture of membranes

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