NURSING TOOL BOX SERIES

  Liver Cirrhosis Nursing Care Plan & Management Description Is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Complications include hyponatremia, water retention, bleeding esophageal varices, coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.     Three major forms: Laennec’s (alcohol induced) Cirrhosis Fibrosis occurs mainly around central veins and portal areas. This is the most common form of cirrhosis and results from chronic alcoholism and malnutrition. Postnecrotic (micronodular) Cirrhosis Consist of broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis. Biliary Cirrhosis Consist of Scarring of bile ducts and lobes of the liver and results from chronic biliary obstruction and infection (

Fetal Skull Importance of the fetal skull Largest part of the fetal body. Most frequent [resenting part of the fetus. Least compressible of all fetal parts. Anatomy of the Fetal Skull Cranial Bones The fetal skull is made up of six cranial bones which are the following: Sphenoid Ethmoid Temporal Frontal Occipital Parietal The frontal, occipital and the parietal cranial bones could either be fetal presenting part if the presentation is vertex. Membrane Spaces During birth, bones move and overlap with each other to allow the fetal head to fit through the birth canal which is a process termed as molding. Molding is made possible because of the presence of the suture lines. Without these structures a fetus’ head cannot pass through the birth canal. There are different types of sutures: Sagittal suture line – joins the two parietal bones. Coronal suture line – joins the frontal and the parietal bones. Lambdoid suture line – joins the occiput and the parietal bones. Fontanelles Fontanelle is

  Birth Asphyxia Nursing Care Management Description Birth asphyxia is characterized by hypoxemia (decreased PaCO2), hypercarbia (increased PaCO2), and acidosis (lowered pH). Etiology Maternal causes include amnionitis, anemia, diabetes, pregnancy-induced hypertension, drugs, and infection. Uterine causes include prolonged labor and abnormal fetal presentations. Placental causes include placenta previa, abruption placental, and placental insufficiency. Umbilical causes include cord prolapsed and cord entanglement. Fetal causes include cephalopelvic disproportion, congenital anomalies, and difficult delivery. Pathophysiology Unless vigorous resuscitation begins promptly, irreversible multi-organ tissue changes will occur, possibly leading to permanent damage or death. During the 24 hours after successful resuscitation, the newborn is vulnerable to post-asphyxial syndrome. Assessment Findings Clinical manifestations include: Poor response to resuscitative efforts Hypoxia Hypercarbia Meta

APGAR Scoring System The APGAR Scoring System was developed by Dr. Virginia APGAR as a method of assessing the newborn’s adjustment to extrauterine life. It is taken at one minute and five minutes after birth. With depressed infants, repeat scoring every five minutes as needed. The one minute score indicates the necessity for resuscitation. The five minute score is more reliable in predicting mortality and neurologic deficits. The most important is the heart rate, then the respiratory rate, the muscle tone, reflex irritability and color follows in decreasing order. A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160 signifies distress.   Assess 0 1 2 A ppearance (Skin color) Blue all over Body pink, extremities blue Pink all over P ulse (Heart Rate) Absent Below 100 Above 100 G rimace (Reflex Irritability) No Response Grimace Vigorous cry A ctivity (Muscle Tone) Flaccid Some flexion Active motion R espiration (Breathing) Absent Slow Good crying SCORE: 7-10 G

  Anemia in Pregnancy Nursing Management Description Hemoglobin value of less than 11 mg/dL or hematocrit value less than 33% during the second and third trimesters Mild anemia (hemoglobin value of 11 mg/dL) poses no threat but is an indication of a less than optimal nutritional state. Iron deficiency anemia is the most common anemia of pregnancy, affecting 15% to 50% of pregnant women. It is identified as physiologic anemia of pregnancy. Etiology Causes of anemia include: Nutritional deficiency (e.g., iron deficiency or megaloblastic anemia, which includes folic acid deficiency and B12 deficiency). This can be a lot to get your head around, but if you do a quick search into something as simple as  lactoferrin anemia , you’ll be able to further your knowledge in this field. You never know, this information may come in handy one day. Acute and chronic blood loss Hemolysis (e.g., sickle cell anemia, thalassemia, or glucose-6-phosphate dehydrogenase [G-6-PD]) Pathophysiology The hemoglobi

  Abruptio Placenta Nursing Care Plan and Management Description Abruptio placenta is premature separation of a normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage. Etiology The cause of abruptio placenta is unknown. Risk factors include: Uterine anomalies Multiparity Preeclampsia Previous cesarean delivery Renal or vascular disease Trauma to the abdomen Previous third trimester bleeding Abnormally large placenta Short umbilical cord Pathophysiology The placenta detaches in whole or in par from the implantation site. This occurs in the area of the deciduas basalis. Assessment Findings Associated findings . Severe abruption placentae may produce such complications as: Renal failure Disseminated intravascular coagulation Maternal and fetal death Common  clinical manifestation  include: Intense, localized uterine pain, with or without vaginal bleeding. Concealed or external dark red bleeding Uterus firm to boardlike, with severe continuous pain U