.1.

Hyperemesis Gravidarum DISEASE

2. Ectopic Pregnancy
3. Hydatidiform Mole (H. Mole)
4. Spontaneous/ Threatened/ Incomplete/ Subjective Data
Complete/ Imminent/ Missed Abortion
5. Septic Abortion
Objective Data
6. HIV
7. Sexually Transmitted Infections
8. Incompetent Cervix Labs and Diagnostic Procedures
9. Placenta Previa
10. Abruptio Placenta Laboratory Tests:
11. Oligohydramnios
12. Polyhydramnios Diagnostic Procedures:
13. Premature Rupture of Membranes
14. Preterm Labor Pathophysiology
15. Pregnancy Induced Hypertension
16. Pre-Eclampsia
17. Eclampsia Risk factors:
18. Gestational Diabetes Mellitus
19. Cephalopelvic Disproportion NCP
20. Postpartum Hemorrhage
21. Disseminated Intravascular Coagulation
22. Puerperal Infection
23. Mastitis Planning:
24. Tonsillitis
25. Otitis Media Interventions:
26. Bronchitis Independent:
27. Pneumonia
28. Asthma Dependent:
29. Acute Respiratory Distress Syndrome
30. Hyperbilirubinemia Collaborative:
31. Atrial Septal Defect
32. Patent Ductus Arteriosus
33. Tetralogy of Fallot
34. Rheumatic Fever Planning:
35. Endocarditis
36. Kawasaki Disease Interventions:
37. Cardiomyopathy Independent:
38. Hydrocephalus
39. Microcephaly Dependent:
40. Spina Bifida
41. Sickle Cell Anemia Collaborative:
42. Hemophilia
43. Thalassemia Drugs:
44. Acute Lymphocytic Leukemia
45. Cerebral Palsy
46. Hirschsprung's Disease
47. Irritable Bowel Syndrome
48. Meckel Diverticulitis
49. Crohn's Disease
50. Intussusception
51. Galactosemia
52. Phenylketonuria
53. G6PD Deficiency
54. Maple Syrup Urine Disease
55. Biliary Atresia
56. Acute Gastroenteritis
57. Congenital Hypothyroidism
58. Congenital Adrenal Hyperplasia
59. Burns
60. Urinary Tract Infection
61. Acute Glomerulonephritis

1
 1. HYPEREMESIS GRAVIDARUM due to excessive vomiting as evidenced by __

Planning:
-​ Persistent N/V leading to significant weight loss (more than 5% of -​ After 1 hour of nursing intervention, the patient will:
pre-pregnancy weight), dehydration, and electrolyte imbalance. - Mucous membrane will appear moist
Goes beyond typical morning sickness. - Maintain stable vital signs
-​ 4th–12th week
-​ After 8 hours of nursing intervention, the patient will:​
Subjective Data - Demonstrate adequate hydration status
-​ - Tolerate fluids and small meals without vomiting
-​ Persistent N/V - Intake and output are balanced
-​ Lightheadedness, weakness, fatigue, headache
-​ Epigastric and abdominal pain/ discomfort due to prolonged Interventions:
vomiting Independent:
-​ Inability to keep food or fluids down -​ Monitor I & O
-​ Check vital signs regularly, particularly BP, HR, and Temp, for signs
of dehydration
Objective Data
-​ Monitor lab results of Hct, Na, K, and Cl levels
-​ Assess for signs of dehydration of the skin, mucous membrane,
-​ Tachycardia - Due to dehydration, the heart compensates by and skin turgor
beating faster to provide blood flow throughout the organs -​ Educate patient on triggers to strong food, movement, and smells
-​ Hypotension - dehydration leads to less pressure in the -​ Encourage small, frequent feedings and slow sips of fluids.
bloodstream -> decreased blood volume -> decreased blood
pressure Dependent:
-​ Elevated temperature - dehydration impairs the ability of the body -​ Administer antiemetics such as metoclopramide as prescribed
to stabilize temperature, leading to an increase in temperature -​ Administer IV fluids such as Normal Saline (0.9% Sodium Chloride)
-​ Signs of dehydration - dry skin & mucous membrane, poor skin for rehydration
turgor, and decreased urine output
-​ Ketonuria - Because of decreased food intake, insufficient Collaborative:
glycogen for metabolic needs leads to the use of stored fat. It is -​ Collaborate with dietitian for plain, bland, and easy-to-digest meal
then broken down and the byproduct is ketones, which are plans.
accumulated in the blood and then excreted in the urine. -​ Work with MT
-​ Hyponatremia, hypokalemia, hypokalemic alkalosis
2) Risk for Imbalanced nutrition: less than body requirement r/t inability to
Labs and Diagnostic Procedures ingest or absorb nutrients due to excessive vomiting as evidenced by ____

-​ CBC - elevated hematocrit. Due to dehydration, the liquid portion Planning:

(plasma) of the RBC is depleted, leading to an increased -​ After 1 hour of nursing intervention, the patient will:
concentration of the blood. -​ Tolerate fluids and small meals without vomiting
-​ Serum panel - Hyponatremia- Dehydration stimulation ADH causes
water retention and then dilution of sodium. [135-145 mEq/L] -​ After 1 day of nursing intervention, the patient will:
Hypokalemia- vomiting leads to a significant decrease of -​ Meet at least 75 % of daily caloric intake
potassium in the gastric content. -​ Maintain a stable weight
-​ Serum hCG levels - abnormally high hCG may indicate HG -​ No signs of nutritional deficiency
-​ Urinalysis - Increased specific gravity. (+) ketones
-​ UTZ - to rule out molar pregnancy and multiple gestation (risk Interventions:
factors for HG) Independent:
-​ Assess nutritional status (I&O, bowel movement)
Hematocrit 37-47% -​ Weigh the patient daily
Sodium 135-145 mEq/L -​ Monitor blood glucose levels
-​ Suggest herbal teas such as ginger, mint, or chamomile for GI
Potassium 3.5- 5 mEq/L
soothing
Specific Gravity 1.005-1.030
-​ Provide a calm and odor-free environment to reduce stimuli
hCG 10,000- 20,000 -​ Educate the patient about avoiding irritating foods, strong smells,
or movements that worsen nausea
Pathophysiology -​ Encourage small, frequent feedings and slow sips of water

Risk Factors Dependent:

-​ Younger pregnant individuals -​ Administer antiemetics such as metoclopramide as prescribed
-​ Primigravida -​ Administer IV fluids such as Normal Saline (0.9% Sodium Chloride)
-​ Multiple pregnancies for rehydration.
-​ Having HG in a prior pregnancy.
-​ A biological family history of HG Collaborative:
-​ Having gestational trophoblastic disease (GTD) -​ Collaborate with nutritionists for plain, bland, easy-to-digest, and
energy-sufficient meal plans.

Drugs:
1. Metoclopramide (Reglan)
-​ Antiemetic
-​ MOA: blocks dopamine in the chemoreceptor trigger zone in the
brain, reducing N/V
-​ S/E: Drowsiness, fatigue, dizziness, constipation, diarrhea, dry
mouth
-​ N/R: Administer 30 mins before meals, dilute and infuse slowly for
IV, PE on S/E

2. Normal Saline (0.9% Sodium Chloride) [Baxter Normal Saline]

-​ IV fluids
-​ MOA: a sterile isotonic solution containing 0.9% sodium chloride in
water to treat or prevent dehydration
-​ S/E: Hypernatremia, Fluid overload, edema, F/E imbalances
-​ NR: Monitor I&O, Daily weights, check vitals, monitoring of serum
sodium levels, ensure iv site is intact, ensure infusion rate is
appropriate
NCP

1)​ Deficient fluid volume

2)​ Risk for / Imbalanced nutrition: less than body requirements

1) Deficit fluid volume r/t excessive fluid loss

2
 -​ Understand at least 2 pain management strategies
2. ECTOPIC PREGNANCY
-​ After 8 hours of nursing intervention, the patient will:
-​ Remain pain-free
-​ Implantation of the fertilized egg outside the uterus, commonly in -​ Vital signs are stable and within normal range
the fallopian tube.
Interventions:
Subjective Data Independent:
-​ Assess pain level using a pain scale
-​ Lower quadrant abdominal or pelvic pain (sharp, stabbing, -​ Monitor vital signs
cramping) -​ Encourage the patient to verbalize their pain experience.
-​ Vaginal spotting/ bleeding -​ Position the patient in a semi-Fowler’s or lateral position to reduce
-​ Delayed or missed menstrual period pelvic pressure.
-​ Dizziness, weakness, fatigue -​ Provide a calm, quiet environment and limit visitors.
-​ Encourage slow, deep breathing or guided imagery.
-​ Educate the patient about the cause of pain and what treatments
Objective Data
to expect.
-​ Prepare the patient for possible surgical intervention
-​ Positive pregnancy test but no intrauterine pregnancy in UTZ
-​ Decreased hCG levels - the trophoblast (which eventually forms Dependent:
the placenta) doesn’t develop properly due to abnormal -​ Administer morphine sulfate for pain relief as prescribed
implantation, causing lowered hCG production)
-​ Lower abdominal tenderness or adnexal mass upon palpation - Collaborative:
abnormal implantation leads to stretching and inflammation of -​ Collaborate with the surgical team for surgical removal of ectopic
tissues pregnancy.
-​ Hypovolemic shock due to bleeding (hypotension, tachycardia, pale
skin) 2) Risk for shock r/t internal bleeding
secondary to rupture of fallopian tube
Labs and Diagnostic Procedures
Planning
-​ CBC: low HCT and Hgb due to blood loss -​ After 4 hours of nursing intervention the patient will:
-​ Serum hcg test: low hcg [10,000- 20,000] -​ Maintain stable vital signs (BP, HR, RR, SpO₂) within acceptable
-​ Urinalysis: rule out UTI that may mimic symptoms limits and show no signs of progressing into shock.
-​ Transvaginal UTZ- to identify the location of pregnancy
-​ After 24 hours of nursing intervention the patient will:
Hematocrit 37-47% -​ Remain hemodynamically stable and demonstrate adequate tissue
Hemoglobin 12-16 g/dL perfusion (normal urine output, warm extremities, normal mental
status).
Human chorionic 4-5 weeks after conception: 1,000–50,000 mIU/mL
gonadotropin 5-6 weeks after conception: 10,000–100,000
Interventions:
mIU/mL
Independent:
6-8 weeks after conception: 15,000–200,000
-​ Assess vital signs to monitor signs of bleeding or shock
mIU/mL
-​ Observe signs of hypovolemic shock: pallor, cold/clammy skin,
8-12 weeks after conception: 20,000–200,000
delayed capillary refill, restlessness, dizziness.
mIU/mL
-​ Assess level of consciousness frequently for signs of decreased
perfusion to the brain.
Pathophysiology -​ Educate patient (if stable) and family about the signs and urgency
of the condition.
Risk Factors -​ Prepare the patient for possible surgical intervention
-​ History of previous ectopic pregnancy
-​ Congenital abnormalities of the fallopian tubes Dependent:
-​ Increased maternal age (≥35 years) -​ Administer IV fluids as ordered for volume resuscitation
-​ Endometriosis (can cause scarring of reproductive organs) -​ Administer oxygen therapy via nasal cannula or mask as
-​ History of infertility prescribed.
-​ Previous pelvic or abdominal surgery -​ Administer Packed Red Blood Cells (PRBCs) to replenish
oxygen-carrying capacity.

Collaborative:
-​ Work with the blood bank to ensure availability of blood products.
-​ Coordinate with the surgical team if rupture is suspected or
confirmed.

DRUGS
1. Acetaminophen (Tylenol) [unruptured]]
-​ MOA: Inhibits prostaglandin synthesis in CNS
-​ S/E: Liver toxicity (in high doses)
-​ N/R: Monitor liver enzymes, limit to <4g/day

2. Morphine sulfate (Duramorph) [ruptured]

-​ IV, Opioid analgesic
-​ MOA: binds to opioid receptors in the central nervous system
(CNS). This blocks pain signals and alters the perception and
emotional response to pain, resulting in analgesia and sedation.
-​ S/E: Drowsiness, dizziness, sedation, confusion, N/V
-​ N/R: Monitor respiratory rate (can cause respiratory depression),
Assess level of consciousness and pain relief, Check BP and HR,
Watch for N/V & constipation, Ensure availability of naloxone
(opioid antidote)
NCP
3. Normal Saline (0.9% Sodium Chloride) [Baxter Normal Saline]
1)​ Acute pain r/t tissue damage -​ IV fluids
2)​ Risk for shock r/t internal bleeding secondary to rupture of -​ MOA: a sterile isotonic solution containing 0.9% sodium chloride in
fallopian tube water to treat or prevent dehydration
-​ S/E: Hypernatremia, Fluid overload, edema, F/E imbalances
1) Acute pain r/t tubal distension and tissue damage -​ NR: Monitor I&O, Daily weights, check vitals, monitoring of serum
sodium levels, ensure iv site is intact, ensure infusion rate is
Planning: appropriate
-​ After 2 hours of nursing intervention, the patient will:
-​ Report a reduced pain level of ≤ 3/10
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 2)​ Risk for bleeding r/t abnormal growth of trophoblastic tissue

3. HYDATIDIFORM MOLE Risk for bleeding related to abnormal growth of trophoblastic tissue as
evidenced by tissue passage

Definition: A hydatidiform mole is a gestational trophoblastic disease (GTD) Planning:

caused by abnormal fertilization, leading to a non-viable pregnancy -​ After 4 hours of nursing intervention:
characterized by the growth of cystic trophoblastic tissue within the uterus. -​ Patient takes measures to prevent bleeding and
recognizes signs of bleeding that needs to be reported
Common Complications: Hemorrhage, anemia, persistent GTD, immediately
choriocarcinoma. -​ Patient will be able to have a stable vital signs​

Subjective Data -​ Upon discharge:

-​ Patient will be able to maintain a stable hematocrit and
-​ Complaints of heavy vaginal bleeding hemoglobin levels
-​ Severe nausea and vomiting
-​ Pelvic pressure or pain: due to rapidly enlarging uterus Interventions:
-​ Symptoms of hyperthyroidism (palpitations, heat intolerance) Independent:
-​ Anxiety due to pregnancy complications -​ Monitor for and document the amount, color, and consistency of
vaginal bleeding.
-​ Assess for signs of hypovolemic shock (e.g., tachycardia,
Objective Data
hypotension, pallor).
-​ Provide emotional support and education on the potential risks of
-​ Tachycardia: internal bleeding due to the rupture of molar tissue or tissue passage and what to expect during treatment.
hyperthyroidism
-​ Uterus larger than expected for gestational age: due to proliferation Dependent:
of trophoblastic tissue and accumulation of fluid-filled vesicles -​ Administer oxytocin (Pitocin) and/or misoprostol (Cytotec) as
-​ Absence of fetal heartbeat: no viable fetus ordered.
-​ Passage of grape-like vesicles from the vagina: vesicles are
swollen chorionic villi filled with fluid Collaborative:
-​ Elevated serum hCG disproportionate to gestational age: -​ Collaborate with surgical team
trophoblastic tissue in H. mole secretes excessive amounts of hCG
Acute pain r/t uterine cramping
Labs and Diagnostic Procedures as evidenced by verbal complaints of pain and discomfort.

Laboratory Tests: Planning:

-​ Serum hCG: Markedly elevated (often >100,000 mIU/mL) -​ Within 1 hour of nursing intervention, the patient will report a
-​ CBC: Possible anemia decrease in pain intensity from 7/10 to 4/10 after administration of
-​ Thyroid panel: May show suppressed TSH, elevated T3/T4 analgesics and non-pharmacologic interventions.
-​ Blood type and Rh: Important for managing Rh-negative mothers -​ By discharge, the patient will verbalize understanding of effective
pain management strategies and demonstrate techniques for
Diagnostic Procedures: comfort.
-​ Transvaginal ultrasound: “Snowstorm” or “cluster of grapes”
pattern, absence of fetus in complete mole Interventions:
-​ Abdominal UTZ: No FHR Independent:
-​ Chest X-ray (if metastasis suspected) -​ Assess pain level using a standardized pain scale, monitor for
-​ Histopathologic exam: Examining tissue to confirm diagnosis changes in pain intensity or quality.
post-evacuation -​ Provide comfort measures such as positioning, applying heat pads,
and encouraging relaxation techniques.
Pathophysiology -​ Offer emotional support and reassurance regarding the normalcy
of post-surgical discomfort.

Risk Factors: Dependent:

Non-Modifiable: -​ Administer prescribed analgesics (acetaminophen (Tylenol),
-​ Age <20 or >35 ibuprofen (Advil))
-​ Previous molar pregnancy
Collaborative:
Modifiable: -​ Collaborate with a physical therapist to address long-term pain
-​ Nutritional deficiencies (low beta-carotene, folic acid) management.
-​ Low socioeconomic status (limited access to prenatal care)
Drugs:
Disease Progression: Rapid growth of trophoblastic tissue → elevated hCG 1. Oxytocin (Pitocin)
→ possible invasion into the uterine wall or metastasis (in invasive moles or -​ Uterine stimulant
choriocarcinoma). -​ MOA: Stimulates uterine contractions to control bleeding.
-​ S/E: Tachycardia, hypertension, hyperstimulation, water
In detail: intoxication.
-​ NR: Monitor bleeding, uterine tone, and IV rate.

2. Misoprostol (Cytotec)
-​ Prostaglandin analog
-​ MOA: Promotes uterine contractions to expel tissue and reduce
bleeding.
-​ S/E: Nausea, diarrhea, cramping, hyperstimulation.
-​ NR: Monitor contractions, give with food, watch for rupture signs.

3. Ibuprofen (Advil)
-​ MOA: Inhibits COX enzymes → reduced prostaglandin synthesis →
less pain and inflammation
-​ S/E: GI upset, kidney effects, bleeding risk
-​ N/R: Give with food, monitor renal function

4. Acetaminophen (Tylenol)
-​ MOA: Inhibits prostaglandin synthesis in CNS
-​ S/E: Liver toxicity (in high doses)
-​ N/R: Monitor liver enzymes, limit to <4g/day

NCP

1)​ Acute pain r/t uterine cramping

4
 Acute pain r/t abdominal cramping secondary to infection
5. SEPTIC ABORTION
Planning:
-​ Within 30 minutes of pain medication administration, the patient
Definition: Septic abortion is a serious uterine infection occurring during or will report decreased pain level from 7/10 to ≤3/10.
after miscarriage or abortion. It's a gynecologic emergency, often caused by -​ By discharge, the patient will report sustained pain control and
non-sterile techniques used for uterine evacuation. increased mobility.

Common Complications: Sepsis, septic shock, disseminated intravascular Interventions:

coagulation (DIC), infertility, uterine perforation, multi-organ failure, death. Independent:
-​ Assess pain level using numeric pain scale every 4 hours.
Subjective Data -​ Provide comfort measures (positioning, warm compress).

-​ Lower abdominal pain: due to irritation of the uterine walls and Dependent:
surrounding tissues. -​ Administer prescribed analgesics (e.g., acetaminophen, ibuprofen).
-​ Foul-smelling vaginal discharge: bacterial growth and necrotic
(dead) tissue inside the uterus, releasing malodorous byproducts. Collaborative:
-​ Fever and chills: occur due to rapid temperature elevation and -​
activation of inflammatory cytokines.
-​ Weakness, malaise: body redirects energy to fight the pathogen
-​ Nausea or vomiting: toxin circulation or systemic inflammation Hyperthermia r/t uterine infection
Planning:
-​ After 1 hr of NI
Objective Data
-​ Return to 36.5-37.5 C

-​ Fever >38°C: Pyrogens from bacteria trigger the hypothalamus to Interventions:

raise body temperature. Independent:
-​ Tachycardia >100 bpm: body attempts to compensate for infection -​ Monitor temperature
and possible hypovolemia -​ Provide tepid sponging
-​ Hypotension <90/60 mmHg: As sepsis progresses, vasodilation -​ Encourage fluid intake
and capillary leakage reduce effective circulating blood volume, -​ Encourage rest
causing low blood pressure. -​ Remove excess clothing and blanket to promote heat loss
-​ Uterine tenderness -​
-​ Open cervical os with discharge Dependent:
-​ Decreased urine output -​ Administer Ibuprofen (advil) as indicated.
-​ Confusion or altered mental status (in advanced sepsis)
Collaborative:
Labs and Diagnostic Procedures -​ MT labs blood culture
Drugs:
Laboratory Tests:
-​ CBC: ↑WBC >12,000/mm³, ↓Hgb <12 g/dL, ↓Hct <36% 1. Ibuprofen (Advil)
-​ Blood Cultures: Positive for organisms (e.g., E. coli, anaerobes) -​ MOA: Inhibits COX enzymes → reduced prostaglandin synthesis →
-​ Urinalysis: Cloudy, +nitrites/+leukocyte esterase (possible UTI) less pain and inflammation
-​ Coagulation Profile: Prolonged PT/INR, ↓platelets (DIC risk) -​ S/E: GI upset, kidney effects, bleeding risk
-​ Serum Lactate: >2 mmol/L (suggests sepsis) -​ N/R: Give with food, monitor renal function

Diagnostic Procedures: 2. Acetaminophen (Tylenol)

-​ Pelvic Ultrasound: Shows retained products of conception -​ MOA: Inhibits prostaglandin synthesis in CNS
(echogenic material), intrauterine fluid -​ S/E: Liver toxicity (in high doses)
-​ Pelvic Exam: Open cervix, uterine tenderness, purulent discharge -​ N/R: Monitor liver enzymes, limit to <4g/day

Pathophysiology

Risk Factors:
Non-Modifiable:
-​ Adolescents or women >35 years
-​ Female

Modifiable:
-​ Lifestyle: Unprotected sex, poor hygiene
-​ Limited access to sterile abortion services
-​ Self-induced or illegal abortion methods
-​ Delay in seeking care, poor prenatal follow-up

Disease Progression:

NCP

5
 6. HIV Planning:
-​ Short-term: After 12 hours of nursing interventions, the patient will
report reduced/minimal fatigue and improved energy levels.
Definition: HIV (Human Immunodeficiency Virus) is a virus that attacks the -​ Long-term: After 24 hours of nursing interventions, the patient will
immune system, specifically the CD4 cells (T cells), which help the immune demonstrate sustained ability to daily activities with minimal
system fight off infections. Over time, HIV can destroy so many of these cells fatigue
that the body becomes vulnerable to infections and certain cancers, a
condition known as AIDS (Acquired Immunodeficiency Syndrome). Interventions:
Independent:
Common Complications: -​ Assess fatigue level (intensity, pattern, duration, and impact on
-​ Maternal: Opportunistic infections, anemia, poor pregnancy ADLs)
outcomes -​ Promote rest
-​ Fetal: Preterm birth, low birth weight, vertical transmission of HIV -​ Encourage balanced diet and oral fluid intake
-​ Encourage light exercise like walking, stretching to promote
Subjective Data endurance

-​ Fatigue, weight loss, fever Dependent:

-​ History of unprotected sex or previous STIs -​ Administer ART as prescribed such as Zidovudine (AZT)
-​ Anxiety or fear about diagnosis and baby’s health -​ Administer iron or vitamin supplements.

Collaborative:
Objective Data
-​ Collaborate with a dietitian for planning nutrient dense dient

-​ Low-grade fever, lymphadenopathy Risk for imbalanced nutrition: less than body requirements r/t decreased
-​ Possible oral thrush, skin rashes appetite secondary to HIV
-​ Weight loss, anemia, low WBC on labs
Planning:
Labs and Diagnostic Procedures -​ Short-term: After 24 hours of nursing interventions:
-​ Patient will consume 75%–100% of meals provided.
Laboratory Tests: -​ Patient will verbalize understanding of dietary needs and
-​ HIV Antibody/Antigen Test (ELISA): (+) HIV antibodies high-protein/high-calorie options.
-​ HIV-1 RNA PCR test: Confirms HIV and measures viral load. High -​ Long-term: After 72 hours of nursing interventions:
viral load= high risk of vertical transmission -​ Patient will gain appropriate weight for gestational age
-​ Western blot test: positive= confirmed HIV infection and trimester (as guided by OB team).
-​ CD4 count test- low [N: 500 to 1,200 cells/mm3) -​ Patient will show stable or improved lab values (e.g.,
-​ CBC: Anemia, leukopenia hemoglobin, albumin, CD4 count).

Diagnostic Procedures: Interventions:

-​ Ultrasound: Fetal growth and development Independent:
-​ Amniocentesis: Only if needed, done cautiously to avoid -​ Monitor daily food intake and document percentage consumed.
transmission -​ Weigh patient daily
-​ Non-Stress Test (NST): Monitor fetal well-being -​ Encourage high-protein and high carb diet
-​ Educate patient about the importance of proper nutrition in
Pathophysiology boosting immunity.
-​ Involve the patient in meal planning to include preferred foods
when possible.
Risk Factors:
Non-Modifiable: Dependent:
-​ Female gender -​ Administer Zidovudine (AZT) to the newborn as prescribed,
-​ Age (especially 15–45 years) typically within 6–12 hours after birth, to reduce the risk of HIV
-​ History of blood transfusion before 1985 transmission and support long-term health and development.
-​ Partner HIV status
Collaborative:
Modifiable: -​ Coordinate with a nutritionist/dietitian to develop a feeding plan
-​ Unprotected sex suitable for a low birth weight infant (e.g., caloric intake, frequency
-​ Multiple partners of feeds).
-​ IV drug use
-​ Lack of prenatal care Drugs:
-​ Poor ART adherence 1. Zidovudine (AZT)
-​ MOA: Inhibits viral reverse transcriptase, stopping HIV replication.
Disease Progression: -​ S/E: Anemia, headache, GI upset.
-​ N/R: Monitor CBC, liver function. Administer IV during labor.
-​

NCP

Fatigue r/t chronic disease progression of HIV

6
 8. INCOMPETENT CERVIX Independent:
-​ Assess for signs of cervical insufficiency
-​ Educate the patient on avoiding heavy lifting, prolonged standing,
Definition: Incompetent cervix (or cervical insufficiency) is the painless sexual activity, and high-impact exercise.
dilation of the cervix without contraction, usually in the second trimester, -​ Encourage regular prenatal visits – to monitor cervical length and
leading to preterm birth or pregnancy loss. fetal status.
-​ Instruct on signs of preterm labor – cramping, backache, pelvic
Common Complications: Preterm labor, miscarriage, infection (e.g., pressure, or change in vaginal discharge.
chorioamnionitis), premature rupture of membranes (PROM). -​ Monitor FHR nad uterine activity
-​ Monitor vital signs
Subjective Data
Dependent:
-​ Pelvic pressure or fullness: premature dilation -> weight of fetus -​ Administer progesterone therapy as prescribed
and AF press down on the cervix -> sensation of heaviness or -​ Administer tocolytics
pressure
-​ Vaginal discharge (watery, pink, or brown): watery- possible Collaborative:
leakage of AF. Pink/brown- minor bleeding as cervix changes. -​
-​ Mild backache or cramping: cervix shares nerve pathways with the -​
lower back and pelvic area. As it opens it creates pressure and
tension on the surrounding tissues. Anxiety r/t risk of pregnancy loss

Planning:
Objective Data
-​ After 5 hours of nursing interventions:
-​ Patient will verbalize at least one effective coping
-​ Painless cervical dilation on pelvic exam strategy to manage anxiety by the end of the shift/day.
-​ Shortened cervix on ultrasound (<25 mm before 24 weeks): -​ Patient will identify specific fears or concerns related to
suggests reduced strength and support, making it easier for the her pregnancy during a therapeutic conversation.
cervix to open prematurely. -​ After 24 hours of nursing interventions:
-​ Bulging fetal membranes at the cervix: dilation of cervix -> -​ Patient will maintain healthy coping mechanisms (e.g.,
protruding of amniotic sac journaling, relaxation techniques, support groups)
-​ Preterm rupture of membranes (PROM): due to pressure and throughout pregnancy.
weakened support -​ Patient will report a reduction in anxiety levels (e.g., on a
scale of 0–10) and improved emotional well-being.
Labs and Diagnostic Procedures
Interventions:
Laboratory Tests: Independent:
-​ CBC: WBC count (normal: 4,500–11,000/mm³; ↑ may indicate -​ Allow client to verbalize fears.
infection) -​ Provide clear explanations.
-​ CRP: Inflammatory marker (normal <10 mg/L; ↑ if infection) -​ Encourage support system involvement.
-​ Vaginal/cervical cultures to rule out infection
Dependent:
Diagnostic Procedures: -​ Administer prescribed sedatives.
-​ Transvaginal ultrasound: Cervical length <25 mm before 24 weeks
(normal >30 mm) Collaborative:
-​ Pelvic exam: To examine the cervix to see if the amniotic sac has -​ Refer to support groups.
begun to protrude through the opening. -​ Arrange counseling services.
-​ Speculum exam: Visible dilation of the cervix or fetal membranes -​ Coordinate mental health support if needed.
-​ Fetal monitoring: To assess viability and fetal well-being
Drugs:
Pathophysiology 1. Acetaminophen (Tylenol)
-​ MOA: Inhibits prostaglandin synthesis in CNS
-​ S/E: Liver toxicity (in high doses)
Risk Factors -​ N/R: Monitor liver enzymes, limit to <4g/day
Non-Modifiable:
-​ History of 2nd trimester loss
-​ Congenital uterine or cervical anomalies
-​ Trauma from prior surgical procedures (e.g., D&C, cervical biopsy)
-​ Ethnicity (African-American women at higher risk)

Modifiable:
-​ Smoking
-​ Multiple gestation (increased uterine pressure)
-​ Infections (e.g., bacterial vaginosis)
-​ Poor prenatal care

NCP

Risk for disturbed maternal and fetal dyad r/t premature dilation of cervix

Planning:
-​
Interventions:
7
 9. PLACENTA PREVIA -​ Administer oxygen via nasal cannula or mask as ordered
-​ Start or maintain IV access for fluid replacement to support fetal
perfusion
Definition: Placenta previa is a condition where the placenta partially or -​ Administer corticosteroids (e.g., betamethasone) if preterm labor
completely covers the cervical os (opening), preventing normal vaginal is suspected
delivery. It is a low implantation of the placenta. -​ Prepare for possible cesarean section if significant bleeding or
fetal distress occurs
Common Complications: Painless vaginal bleeding, hemorrhage, preterm
labor, fetal distress, abnormal placental attachment (e.g., placenta accreta). Collaborative:
-​ Coordinate with neonatal team (NICU) for immediate neonatal
Subjective Data resuscitation or care if preterm birth occurs.

-​ Sudden, painless, bright red vaginal bleeding (often in the 2nd or Deficient fluid volume r/t active blood loss secondary to disrupted placental
3rd trimester). Painless= no contractions, bleeding due to tearing implantation
of placental blood vessels.
-​ Anxiety or fear due to bleeding Planning:
-​ Client will exhibit improved fluid balance
-​ Client will experience no further vaginal bleeding; pulse <100; BP >
Objective Data
(specify for individual client);
-​ capillary refill <3 seconds
-​ Hypotension, tachycardia (if bleeding is severe)
-​ Uterus soft and nontender Interventions:
-​ Fetal malpresentation (e.g., breech or transverse) Independent:
-​ Normal fetal heart rate unless compromised -​ Assess color, odor, consistency, amount of vaginal bleeding: weigh
pads
Labs and Diagnostic Procedures -​ Assess hourly intake and output.
-​ Assess BP and HR
Laboratory Tests: -​ Monitor for signs of fluid volume deficit: dizziness, pallor, delayed
-​ CBC: ↓ Hemoglobin (<11 g/dL), ↓ Hematocrit (<33%) if bleeding capillary refill, decreased urine output.
-​ Blood type & Rh: For transfusion prep -​ Position the patient in left lateral or semi-Fowler's to improve
-​ Coagulation profile: PT, aPTT, INR – check clotting ability uteroplacental blood flow and reduce vena cava compression.
-​ Kleihauer-Betke test: Detect fetal blood in maternal circulation -​ Ensure bed rest to reduce uterine stimulation and risk of increased
bleeding.
Diagnostic Procedures:
-​ Transabdominal/Transvaginal Ultrasound: Placenta location (gold Dependent:
standard) -​ Administer IV fluids PNSS as ordered to maintain circulation and
-​ Fetal non-stress test (NST): Assess fetal well-being BP.
-​ Biophysical profile (BPP): Evaluate fetal status in high-risk cases -​ Administer Packed Red Blood Cells (PRBCs) as indicated.

Pathophysiology Collaborative:
-​ Collaborate with blood bank to prepare for possible blood
transfusion (PRBCs, platelets).
Risk Factors: -​ Involve a dietitian post-crisis to assist with recovery nutrition,
Non-modifiable: especially iron-rich foods if anemia is present.
-​ Advanced maternal age (>35)
-​ History of placenta previa or C-section
-​ Multiparity Drugs:
-​ Multiple gestation 1. Betamethasone (Celestone)
-​ To accelerate fetal lung maturity if preterm delivery is likely
Modifiable: -​ MOA: Stimulates fetal lung maturity by increasing surfactant
-​ Smoking production.
-​ Cocaine use -​ S/E: Fluid retention, hyperglycemia, headache.
-​ Uterine scarring (from surgery or D&C) -​ N/R: Monitor blood glucose, educate mother on purpose (lung
-​ Poor prenatal care development if early delivery is needed).

2. Nifedipine (if contractions present)

-​ Tocolytics - to temporarily stop uterine contracts and delay preterm
labor
-​ MOA: Calcium channel blocker that relaxes uterine muscles.
-​ S/E: Hypotension, dizziness, flushing.
-​ N/R: Monitor BP, educate on lying on left side to enhance placental
perfusion.

NCP

Risk for impaired gas exchange (fetal) r/t disruption of placental

implantation

Planning:

Interventions:
Independent:
-​ Monitor fetal heart rate (FHR) and pattern regularly
-​ Assess for any changes in fetal movements for signs of respiratory
distress
-​ Position mother in left lateral recumbent position: improves
uteroplacental perfusion by improving venous return
-​ Prepare for possible emergency cesarean delivery

Dependent:

8
 10. ABRUPTIO PLACENTA -​ Monitor vital signs
-​ Encourage the patient to verbalize their pain experience.
-​ Position the patient in a semi-Fowler’s or lateral position.
Definition: Placental abruption is the separation of a normally implanted -​ Provide a calm, quiet environment and limit visitors.
placenta before birth of the baby. The separation may be partial or complete. -​ Encourage slow, deep breathing or guided imagery.
A marginal abruption describes detachment of the edges of the placenta. -​ Educate the patient about the cause of pain and what treatments
Partial separation may also occur in the cen- ter of the placenta. With a total to expect.
placental abruption the entire placenta detaches. -​ Prepare the patient for possible surgical intervention

Subjective Data Dependent:

-​ Administer acetaminophen (tylenol) for pain as ordered
-​ Sudden, severe abdominal pain
-​ Uterine tenderness: detachment of the placenta from the uterine Collaborative:
wall results in inflammation and irritation of the uterine muscles -​ MT cbc
-​ Decreased fetal movements: fetal distress
Risk for shock r/t rupture of placental blood vessels
Objective Data
Planning:
-​ After 4 hours of nursing intervention the patient will:
-​ Vaginal bleeding- dark red/brown (may be concealed or visible): -​ Maintain stable vital signs (BP, HR, RR, SpO₂) within acceptable
blood vessels within the placenta tear as it separates from the limits and show no signs of progressing into shock.
uterine wall -​ After 24 hours of nursing intervention the patient will:
-​ Rigid, board-like abdomen: Uterus contracts and hardens due to -​ Remain hemodynamically stable and demonstrate adequate tissue
internal bleeding perfusion (normal urine output, warm extremities, normal mental
-​ Abnormal fetal heart rate: Decreased oxygen and blood flow to the status).
fetus due to placental separation
-​ Signs of shock (e.g., tachycardia, hypotension): due to excessive Interventions:
blood loss Independent:
-​ Assess vital signs to monitor signs of bleeding or shock
Labs and Diagnostic Procedures -​ Observe signs of hypovolemic shock: pallor, cold/clammy skin,
delayed capillary refill, restlessness, dizziness.
Laboratory Tests: -​ Assess level of consciousness frequently for signs of decreased
-​ CBC: ↓ Hemoglobin/Hematocrit perfusion to the brain.
-​ Coagulation profile: ↑ PT, aPTT; ↓ Fibrinogen -​ Educate patient (if stable) and family about the signs and urgency
-​ Kleihauer-Betke test: Detects fetal blood in maternal circulation of the condition.
-​ Prepare the patient for possible surgical intervention
Diagnostic Procedures:
-​ Ultrasound: May show retroplacental clot (not always diagnostic) Dependent:
-​ Non-Stress Test (NST): Shows late decelerations or absent -​ Administer IV fluids as ordered for volume resuscitation
variability -​ Administer oxygen therapy via nasal cannula or mask as
-​ Fetal Biophysical Profile: Low score indicates distress prescribed.
-​ Administer Packed Red Blood Cells (PRBCs) to replenish
Pathophysiology oxygen-carrying capacity.
-​
Collaborative:
Risk factors: -​ Work with the blood bank to ensure availability of blood products.
Non-Modifiable: -​ Coordinate with the surgical team if rupture is suspected or
-​ Age >35 confirmed.
-​ Previous abruptio placenta
-​ Multiparity Drugs:
Oxytocin (pitocin) – Used after delivery or during induction (if fetus is viable)
Modifiable: Drug class: Uterotonic agent; Hormone
-​ Smoking MOA: Stimulates uterine smooth muscle contractions. Induce labor or
-​ Cocaine use control postpartum hemorrhage
-​ Hypertension/pre-eclampsia SE: Uterine tachysystole, fetal distress, water intoxication (with prolonged
-​ Abdominal trauma use)
NR: Continuous fetal and uterine monitoring is required. Monitor for uterine
hyperstimulation or rupture.

Betamethasone (Celestone) – Given if the pregnancy is preterm and delivery

is likely
Drug class: corticosteroids
MOA: Stimulates fetal surfactant production to improve lung function.
Enhance fetal lung maturity in preterm labor
SE: Fluid retention, increased blood glucose, potential immunosuppression
NR: Administer deep IM (usually 12 mg every 24 hrs × 2 doses). Monitor
maternal glucose (may elevate blood sugar)

NCP

Acute pain r/t sudden abdominal cramping secondary to placental

detachment

Planning:

Interventions:
Independent:

-​ Assess pain level and characteristic

9
 11. OLIGOHYDRAMNIOS
Deficient fluid volume r/t decreased production of amniotic fluid secondary
to oligohydramnios
Definition: Oligohydramnios is a medical condition in pregnancy
characterized by a deficiency of amniotic fluid—the protective liquid that Planning:
surrounds the fetus in the amniotic sac. This fluid is essential for fetal -​ Within 8 hours, the fetus will demonstrate an improved
development, especially for lung development and movement. It is typically
diagnosed when the amniotic fluid index (AFI) is ≤5 cm or the single deepest Interventions:
pocket (SDP) is <2 cm. Independent:
-​ Monitor amniotic fluid index (AFI) and SDP
Common complications: Umbilical cord compression, IUGR, pulmonary -​ Measure fundal height
hypoplasia, preterm birth, infection -​ Assess and document fetal movement daily using kick counts
-​ Encourage maternal hydration
Subjective Data -​ Position the mother in left lateral position to enhance
uteroplacental circulation and reduce pressure on the vena cava.
-​ Reports of decreased fetal movement. -​ Prepare patient and equipment for amnioinfusion (labor)
-​ Abdominal discomfort or tightness. -​ Assess FHR
-​ Leaking of amniotic fluid, which may indicate premature rupture of
membranes. Dependent:
-​ Administer IV fluids for maternal hydration
Objective Data
Collaborative:
-​ Work with a dietitian to optimize maternal nutrition for better
-​ Fundal height smaller than expected for gestational age. placental function.
-​ Easy palpating fetal parts during abdominal examination.
-​ Abnormal fetal heart rate patterns. Risk for fetal injury related to decreased amniotic fluid volume and potential
-​ Ultrasound findings: cord compression
-​ AFI ≤5 cm or SDP <2 cm.
-​ Fetal malpresentation (e.g., breech position). Planning:
-​ Evidence of cord compression or meconium-stained -​ After 1 hour of nursing interventions, the mother will verbalize at
amniotic fluid. least 3 techniques to reduce umbilical cord compression risks.
-​ After 3 hours of nursing interventions, the fetus will demonstrate
Labs and Diagnostic Procedures stable heart rate patterns suggesting absence of cord
compression.
Laboratory Tests:
-​ CBC: Assess for signs of infection or anemia. Interventions:
-​ Urinalysis: To rule out UTI Independent:
-​ Renal Function Tests: Evaluate maternal kidney function, -​ Encourage side-lying, semi-Fowler's, or knee-chest positions to
especially in hypertension alleviate cord compression.
-​ Blood Glucose Test: Screens of GDM, which can impact amniotic -​ Educate the mother on maintaining adequate hydration.
fluid levels -​ Perform frequent fetal heart rate assessments using Doppler or
continuous electronic monitoring to detect abnormalities.
Diagnostic Procedures: -​ Teach the mother how to monitor fetal movements and recognize
-​ Ultrasound: Confirms reduced amniotic fluid levels (AFI or SDP signs of distress.
measurements).
-​ Non-stress test (NST): May show fetal heart rate abnormalities. Dependent:
-​ Amniocentesis: May be performed to evaluate for infections or -​ Administer saline or lactated Ringer’s solution as prescribed.
genetic abnormalities. -​ Administer maternal oxygen as ordered to improve fetal
oxygenation and relieve hypoxia risks.
Pathophysiology
Collaborative:
-​ Collaborate with the respiratory therapist to ensure effective
Risk factors: maternal oxygen therapy, optimize fetal oxygenation, and monitor
Non-modifiable: maternal respiratory function for better outcomes.
-​ Placental insufficiency.
-​ Premature rupture of membranes (PROM). Drugs:
-​ Fetal anomalies (e.g., renal agenesis). 1. Saline or lactated Ringer’s solution
-​ Post-term pregnancy. 2. Oxygen
-​ Maternal conditions like preeclampsia or diabetes.

Modifiable: MATERNAL FOCUSED:​

-​ Maternal dehydration.
-​ Use of certain medications (e.g., ACE inhibitors, NSAIDs).
-​ Smoking or substance use.

NCP
10
 12. POLYHYDRAMNIOS NCP

Definition: Polyhydramnios is a condition during pregnancy characterized by Impaired gas exchange r/t diaphragmatic pressure secondary to
an excessive amount of amniotic fluid. It is typically diagnosed when the polyhydramnios
amniotic fluid index (AFI) is ≥24 cm or the single deepest pocket (SDP) is ≥8
cm. Planning:

Common complications: Interventions:

-​ Preterm labor due to uterine overstretching. Independent:
-​ Premature rupture of membranes (PROM).
-​ Umbilical cord prolapse, risking oxygen deprivation. -​ Monitor RR and O2
-​ Placental abruption causing fetal distress. -​ Position patient in semi fowler’s position to reduce diaphragmatic
-​ Fetal malpresentation (e.g., breech or transverse lie). pressure and improve lung function
-​ Increased likelihood of cesarean delivery. -​ Deep breathing technique, pursed-lip breathing to slow RR and
-​ Postpartum hemorrhage from uterine overdistension. enhance gas exchange
-​ Ensure well ventilated room
-​ Encourage rest periods to avoid dyspnea on exertion
Subjective Data
-​ Educate signs on worsening respiratory status

-​ Excessive weight gain. Dependent:

-​ Dyspnea (difficulty breathing). -​ Oxygen therapy
-​ Reports of abdominal discomfort or tightness. -​ Diuretics
-​ Complaints of shortness of breath due to uterine enlargement.
-​ Decreased fetal movements in severe cases. Collaborative:
-​ Respiratory therapists
Objective Data
Excessive fluid volume r/t increased amount of amniotic fluid secondary to
-​ Fundal height larger than expected for gestational age. polyhydramnios
-​ Difficulty auscultating fetal heart tones due to excessive fluid.
-​ Ultrasound findings: Planning:
-​ AFI ≥24 cm or SDP ≥8 cm.
-​ Evidence of fetal malpresentation (e.g., breech or Interventions:
transverse lie). Independent:
-​ -​ Monitor I&O
-​ Monitor and measure abdominal girth
Labs and Diagnostic Procedures
-​ Monitor weight
-​ Monitor AFI and SDP
Laboratory Tests: -​ Monitor FHR
-​ Oral Glucose Tolerance Test (OGTT): To screen for maternal -​ Prepare patient for possible amnioreduction
diabetes mellitus
Dependent:
Diagnostic Procedures: -​ Administer indomethacin
-​ Ultrasound: Confirms excessive amniotic fluid levels (AFI or SDP Collaborative:
measurements). -​ Collaborate with rad team
-​ Amniocentesis: May be performed to evaluate for fetal anomalies
or infections. Drugs:
-​ Non-Stress Test (NST): Evaluates fetal heart rate patterns and Indomethacin
detects signs of fetal distress. Drug class: Nonsteroidal Anti-inflammatory Drug (NSAID); Tocolytic​
-​ CBC: Checks for infections (e.g., TORCH screening) or Rh MOA: Inhibits prostaglandin synthesis → causes fetal renal vasoconstriction
incompatibility. → reduces fetal urine output → decreases amniotic fluid volume. Reduce
amniotic fluid volume by decreasing fetal urine production; Prevent or slow
Pathophysiology preterm labor​
SE: Premature closure of ductus arteriosus (fetal), oligohydramnios, maternal
Risk factors: nausea, GERD, headache​
Non-modifiable: NR: Used before 32 weeks' gestation (risk of premature ductus arteriosus
-​ Fetal anomalies (e.g., anencephaly, esophageal atresia). closure after 32 weeks). Monitor fetal echocardiography if prolonged use.
-​ Multiple gestations (e.g., twin-to-twin transfusion syndrome). Monitor for oligohydramnios (too little amniotic fluid). Monitor maternal GI
-​ Maternal conditions like Rh incompatibility. side effects (nausea, heartburn).
​
Modifiable: Nifedipine (Procardia), Terbutaline (Brethine)
-​ Poorly controlled gestational diabetes. Drug class: Tocolytics
-​ Maternal obesity.
-​ Use of certain medications (e.g., beta-agonists). Nifedipine (Procardia) – Calcium channel blocker​
Terbutaline (Brethine) – Beta-adrenergic agonist​

Drug Use Key Nursing Notes

Nifedipi Relax uterine Monitor BP; can cause hypotension,

ne muscles dizziness

Terbuta Inhibit uterine Monitor HR (can cause maternal

line contractions tachycardia, tremors)

MATERNAL FOCUSED:​
Impaired gas exchange r/t diaphragmatic pressure
Pain r/t abdominal distension

11
 ●​ Short-term: After 24 hours of nursing interventions, the child’s Fetal
heart tones will remain within normal baseline ranges (110–160
13. PREMATURE RUPTURE OF MEMBRANES bpm) without evidence of distress during monitoring.
●​ Long-term: Maternal patient will remain afebrile with no signs of
infection throughout hospitalization.
Definition: Preterm rupture of the fetal membranes describes ruptured
membranes before 38 weeks of gestation. The term refers to the gestational Interventions:
age of the fetus at the time of rupture. Premature rupture of membranes Independent:
(PROM) describes membrane rupture before the onset of labor. PROM may -​ Monitor temp
occur with either term of preterm gestations. The terminology for ruptured -​ Monitor labs
membranes with no labor before 38 weeks gestation would be preterm -​ Assess and document color, odor, and amount of amniotic fluid
premature rupture of membranes or PPROM. Like preterm labor, the exact -​ Limit vaginal exam
cause of preterm rupture of membranes is unknown. Infection, which may -​ Educate patient on proper perineal hygiene
not be clinically apparent, is often implicated and is also one of the most -​ Instruct patient to report any signs of infection
serious complications. -​ Prepare patient for labor
​
Common complications: Dependent:
-​ Infection -​ Administer ceftriaxone
-​ Preterm labor
-​ Umbilical cord prolapse Collaborative:
-​ Abruptio placenta -​ MT
-​ Fetal distress -​ Surgical team

Subjective Data Risk for fetal injury related to possible cord prolapse

-​ Reports of a gush of fluid or constant leakage from the vagina. Planning:

-​ Mild abdominal discomfort or cramping.
-​ Bad smelling vaginal discharge. Interventions:
Independent:
-​ Monitor FHR
Objective Data
-​ Position the patient side lying/ Trendelenburg to relieve pressure
from the cord
-​ Pooling of amniotic fluid observed during speculum examination. -​ Strict bed rest or limited ambulation
-​ Positive Nitrazine test (blue-green color indicating alkaline fluid). -​ Encourage reporting of any sudden changes in fetal activity
-​ Positive Fern test (microscopic pattern confirming amniotic fluid). -​ Prepare patient for surgery/ labor
-​ Maternal fever or fetal tachycardia (if infection is present). -​ Prepare neonata resuscitation support

Labs and Diagnostic Procedures Dependent:

-​ Administer oxygen
Laboratory Tests:
-​ CBC: Elevated white blood cell count may indicate infection. Collaborative:
-​ Vaginal Swabs: Tests for infections like Group B Streptococcus. -​ Surgical team

Diagnostic Procedures: Drugs:

-​ Nitrazine Test: Confirms alkaline amniotic fluid.
-​ Fern Test: Identifies amniotic fluid under a microscope. Antibiotics: Ampicillin + Erythromycin
-​ Ultrasound: Assesses amniotic fluid levels and fetal condition. Drug class: Antibiotics (Penicillin class + Macrolide class)
Mechanism of Action: Ampicillin: Bactericidal, inhibits bacterial cell wall
Pathophysiology synthesis; Erythromycin: Bacteriostatic or bactericidal (depending on dose),
inhibits protein synthesis. Prophylaxis to prevent ascending infections (e.g.,
chorioamnionitis, neonatal sepsis)
Risk factors: SE: Rash, nausea, diarrhea, allergic reactions (especially with ampicillin)
Non-modifiable: NR: Monitor for signs of allergic reaction (especially to penicillins). Assess
-​ History of PROM in previous pregnancies. for diarrhea or superinfections (e.g., yeast infections). Administer IV initially,
-​ Multiple gestations. then may switch to oral.
-​ Cervical insufficiency or uterine abnormalities.
-​ Maternal age <20 years and >35 years Betamethasone or Dexamethasone
Drug class: Corticosteroid
Modifiable: MOA: Stimulates surfactant production in fetal lungs. Enhance fetal lung
-​ Smoking or substance use during pregnancy. maturity if <34 weeks gestation (reduce risk of respiratory distress syndrome,
-​ Poor prenatal care or hygiene. intraventricular hemorrhage, and neonatal death).
-​ Untreated infections (e.g., UTIs or STIs). SE: Fluid retention, hyperglycemia, potential immunosuppression
NR: Administer IM (deep into gluteal muscle). Typically 2 doses of
betamethasone 24 hours apart (12 mg IM × 2 doses). Monitor maternal
blood glucose; can cause hyperglycemia. Monitor for signs of infection
because steroids can suppress the immune system slightly.

NCP

Risk for infection related to loss of protective barrier as evidenced by

rupture of membranes

Planning:

12
 14. PRETERM LABOR

Preterm labor is the onset of regular uterine contractions causing cervical

changes (dilation and/or effacement) before 37 completed weeks of
gestation.

Common complications:
-​ Preterm birth
-​ Neonatal respiratory distress syndrome (RDS)
-​ Intraventricular hemorrhage
-​ Necrotizing enterocolitis
-​ Sepsis or infection
-​ Long-term developmental delays
-​ Low birth weight

Subjective Data

-​ Reports of pelvic pressure or a feeling of heaviness.

-​ Lower back pain that is persistent or intermittent.
-​ Menstrual-like cramps.
-​ Increased vaginal discharge or spotting.
-​ Contractions occurring more frequently than every 10 minutes.
NCP
Objective Data
Labor pain r/t uterine contractions
-​ Uterine contractions (≥4 every 20 minutes or ≥8/hour)
-​ Cervical dilation ≥2 cm or effacement ≥80% Planning:
-​ Positive fetal fibronectin (fFN) test -​ After 1 hour of nursing interventions, the patient will report reduced
-​ Shortened cervix on transvaginal ultrasound (<25 mm) pain level.
-​ After 1 hour of nursing interventions, the patient will demonstrate
Labs and Diagnostic Procedures at least 3 relaxation techniques to reduce pain.

Laboratory Tests: Interventions:

-​ Fetal Fibronectin Test: A positive result suggests a higher risk of Independent:
preterm delivery. Fibrocentin is a protein produced by the fetal -​ Assess pain score using pain scale.
membranes that can leak into vaginal secretions if uterine activity, -​ Encourage deep breathing exercises, relaxation, guided imagery
infection, or cervical effacement occurs. -​ Teach proper positioning such as side-lying or semi-Fowler’s
-​ Urinalysis and Vaginal Swabs: Detect infections that may trigger reduce pressure on the pelvis
preterm labor. -​ Maintain a calm, and quite environment
-​ CBC: Elevated white blood cell count may indicate infection. -​ Encourage voiding
-​ Amniotic Fluid Analysis: Assesses for infection or inflammation. -​ Prepare for emergency surgery for possible progression of labor

Diagnostic Procedures: Dependent:

-​ Transvaginal Ultrasound: Measures cervical length; a shortened -​ Administer analgesics acetaminophen
cervix (<25 mm) is a risk factor. -​ Administer tocolytics
-​ NST (Non-stress Test) or Biophysical Profile -​ Administer corticosteroid
-​ Administer IV fluids
Pathophysiology
Collaborative:
-​
Risk factors: Activity intolerance r/t physical activity restrictions
Non-modifiable:
-​ History of preterm labor or preterm birth. Planning:
-​ Multiple gestations (e.g., twins, triplets). -​ After 1 hour of nursing intervention, the patient will verbalize
-​ Uterine or cervical abnormalities (e.g., incompetent cervix).
-​ Maternal age (<17 or >35 years). Interventions:
Independent:
Modifiable: -​ Assess the patient’s tolerance for activity (e.g., fatigue, shortness
-​ Smoking, alcohol, or substance use of breath, increased uterine contractions).
-​ Urinary tract or vaginal infections -​ Monitor uterine activity during and after movement
-​ Short interpregnancy interval -​ Encourage rest and energy conservation
-​ Poor nutrition -​ Educate patient on the importance of limiting activity
-​ High stress Dependent:
-​ Physically demanding work -​ Tocolytics

Collaborative:
-​ PT

Drugs:
+ Morphine
1. Terbutaline (Brethine)
-​ MOA: Relaxes uterine smooth muscle → delays preterm
contractions
-​ S/E: Maternal - tachycardia, palpitations, tremors, nervousness,
headache, hypokalemia, hyperglycemia; Fetal - tachycardia,
hypoglycemia
-​ N/R: Nurses should monitor vital signs, uterine activity, and fetal
heart rate, and watch for side effects. Instruct the patient to report
chest pain or palpitations.

2. Ampicillin (Omnipen)
-​ MOA: It works by inhibiting bacterial cell wall synthesis, leading to
bacterial cell lysis and death.
-​ S/E: Diarrhea, nausea, rash, and allergic reactions
-​ N/R: Checking for allergies, monitoring for side effects like allergic
reactions and diarrhea, and ensuring the full course of treatment is
completed. Vital signs and lab results should be observed to
assess effectiveness.
13
 15. PREGNANCY INDUCED HYPERTENSION

Definition: Pregnancy Induced Hypertension (PIH), also known as gestational

hypertension, is a condition characterized by new-onset high blood pressure
(≥140/90 mmHg) after 20 weeks of gestation in a previously normotensive
woman, without proteinuria or signs of end-organ dysfunction. It can
progress to preeclampsia if not properly managed.

Common complications:
-​ Preeclampsia / Eclampsia
-​ Placental abruption
-​ Intrauterine Growth Restriction (IUGR)
-​ Preterm labor
-​ Fetal distress or stillbirth
-​ HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low
Platelets)
-​ Maternal stroke or seizure

Subjective Data

-​ Headache (persistent, often frontal) : pressure in the brain’s blood

vessels
-​ Visual disturbances (blurred vision, floaters, flashing lights):
damage to retinal blood vessels -> retinal vasospasm
NCP
-​ Dizziness: decreased blood flow to the brain

Objective Data Risk for decreased cardiac output related to increased systemic vascular
resistance secondary to hypertension

Planning:
-​ After 1 hour of nursing interventions, the patient will be able to
maintain adequate blood pressure within normal limits.

Interventions:
Independent:
-​ Assess vital signs every hour.
-​ Position the patient comfortably on the left side-lying position.
-​ Encourage reduced activity.

Dependent:
-​ Administer oxygen as prescribed.
-​ Administer antihypertensives as prescribed.

-​ Elevated blood pressure readings (≥140/90 mmHg on two Collaborative:

occasions 4 hours apart): heart works harder because of narrowed -​ Collaborate with obstetrician and maternal-fetal specialist for
blood vessels management plan
-​ Edema (face, hands, or generalized): poor kidney function
-​ Decreased fetal movement: placental insufficiency Risk for impaired fetal gas exchange related to uteroplacental insufficiency

Labs and Diagnostic Procedures Planning:

●​ Short-term: Fetal heart rate will remain within normal limits
(110–160 bpm) with no signs of distress during hospitalization.
Laboratory Tests: ●​ Long-term: Fetus will be delivered safely without complications of
-​ CBC: Hemoconcentration, low platelet count (thrombocytopenia) hypoxia or acidosis.
-​ Liver function tests (AST, ALT): Elevated in preeclampsia
-​ Serum creatinine: May be elevated Interventions:
-​ 24-hour urine protein: To confirm proteinuria Independent:
●​ Position mother in left lateral to optimize uteroplacental blood flow
Diagnostic Procedures: ●​ Limit unnecessary activity to reduce oxygen demand.
-​ Ultrasound: Assess fetal growth, amniotic fluid volume ●​ Teach mother to report decreased fetal movements immediately.
-​ Non-stress test (NST) or biophysical profile (BPP): Evaluate fetal Dependent:
well-being ●​ Administer oxygen via nasal cannula if fetal distress is detected.
●​ Administer corticosteroids (Betamethasone) to promote fetal lung
Pathophysiology maturity if <34 weeks.
●​ Prepare for delivery (induction or C-section) if persistent fetal
Risk factors: distress occurs.
Non-modifiable: Collaborative:
-​ First pregnancy ●​ Work with the obstetrician to determine timing of delivery.
-​ Age <20 or >35 years ●​ Notify neonatology team for potential NICU support at birth.
-​ Family history of PIH or preeclampsia
-​ History of PIH in previous pregnancy Drugs:
-​ Multiple gestation (twins, triplets)
Labetalol
Modifiable: Drug class: Antihypertensive; Beta-blocker (Nonselective Beta-1 and Beta-2
-​ Obesity Blocker + Selective Alpha-1 Blocker)
-​ Poor nutrition MOA: Blocks beta-1 receptors → decreases heart rate and contractility
-​ Smoking (reduces cardiac output). Blocks alpha-1 receptors → causes vasodilation
-​ Sedentary lifestyle (lowers vascular resistance and BP). To lower maternal blood pressure in
-​ Poorly controlled diabetes or chronic hypertension pregnancy-induced hypertension or preeclampsia. Used especially for severe
hypertension (≥160/110 mmHg).
SE: Dizziness, fatigue, hypotension, bradycardia, nausea
NR: Monitor maternal BP and HR closely before and after administration.
Watch for bradycardia and hypotension. Use cautiously in patients with
asthma (due to possible bronchospasm from beta-2 blockade). Can be given
IV push for acute control or PO for maintenance therapy. Assess fetal heart
rate for any signs of distress.

14
Hydralazine
Drug class: Antihypertensive; Direct Arteriolar Vasodilator
MOA: Directly relaxes arteriolar smooth muscle, leading to vasodilation.
Reduces afterload (resistance the heart pumps against), lowering BP. To
rapidly reduce dangerously high blood pressure in severe PIH or
preeclampsia. Used often for acute hypertensive crises during pregnancy.
NR: Monitor BP and HR closely after administration (risk of reflex
tachycardia). Administer slow IV push to avoid sudden hypotension. Monitor
for signs of headache, palpitations, flushing (common after hydralazine).
Assess fetal monitoring continuously during administration. May be
combined with other antihypertensives if needed.
SE: Headache, tachycardia, flushing, nausea

15
 16. PRE-ECLAMPSIA

Pre-eclampsia is a progressive disorder characterized by high blood pressure

and proteinuria that occurs after 20 weeks of pregnancy.

Subjective Data

-​ Persistent headache
-​ Visual disturbances (e.g., blurry vision, photophobia)
-​ Epigastric or right upper quadrant pain
-​ Nausea or vomiting
-​ Reduced fetal movements
-​ Sudden and significant weight gain (due to edema)

Objective Data

-​ Hypertension: Blood pressure ≥140/90 mmHg on two readings, 4

hours apart
-​ Proteinuria: ≥0.3 g in a 24-hour urine collection or a urine dipstick
reading of ≥1+
-​ Edema: Particularly in the face, hands, and lower extremities
-​ Hyperreflexia or clonus
-​ Oliguria (urine output <30 mL/hour in severe cases)

Labs and Diagnostic Procedures

Decreased cardiac output r/t increased systemic vascular resistance as

Laboratory Tests: evidenced by alterations in blood pressure
-​ Complete Blood Count (CBC): Decreased platelets (<100,000/μL),
hemoconcentration Planning:
-​ Liver Function Tests (LFTs): Elevated AST/ALT -​ After 1 hour of nursing interventions, the patient will be able to
-​ Serum Creatinine: Elevated >1.1 mg/dL or doubling of baseline maintain adequate blood pressure within normal limits.
-​ Uric Acid: Elevated
-​ LDH (Lactate Dehydrogenase): Elevated (marker for hemolysis in Interventions:
HELLP syndrome) Independent:
-​ Urinalysis: Confirms proteinuria (≥0.3 g in 24-hour urine collection) -​ Assess vital signs every hour.
-​ Position the patient comfortably on the left side-lying position.
Diagnostic Procedures: -​ Encourage reduced activity.
-​ Non-Stress Test (NST): To assess fetal well-being
-​ Ultrasound: Evaluates fetal growth, amniotic fluid volume, and Dependent:
placental function -​ Administer oxygen as prescribed.
-​ Administer antihypertensives as prescribed.
Pathophysiology
Collaborative:
Risk factors:
Non-modifiable: Impaired skin integrity r/t edema/hypertension/decreased platelets as
-​ Nulliparity evidenced by petechiae/pitting edema
-​ Advanced maternal age (>35) or young maternal age (<20)
-​ Family or personal history of pre-eclampsia Planning:
-​ Multiple gestation (e.g., twins) -​ After 1 hour of nursing interventions, the patient will maintain
-​ Pre-existing conditions (e.g., hypertension, diabetes, renal disease) intact skin integrity.
-​ Development of abnormal placenta -​ After 1 hour of nursing interventions, the patient will verbalize
understanding of the condition and demonstrate interventions that
Modifiable: promote skin health.
-​ Obesity
-​ Smoking Interventions:
-​ Sedentary lifestyle Independent:
-​ Poor nutrition -​ Assess vital signs every hour.
-​ Inadequate prenatal care -​ Encourage the patient to keep the legs elevated.
-​ Encourage the patient to wear comfortable clothing and shoes.
NCP
Dependent:
-​ Administer antihypertensives as ordered.

Collaborative:

Drugs:
1. Labetalol
-​ MOA: Blocks both alpha and beta receptors, causing vasodilation
and lowering blood pressure without significant risk of fetal
bradycardia.

16
 17. ECLAMPSIA NCP

Definition: Eclampsia is a severe complication of pre-eclampsia Decreased cardiac output r/t increased systemic vascular resistance as
characterized by the onset of generalized tonic-clonic seizures in a pregnant evidenced by alterations in blood pressure
person, usually occurring after 20 weeks of gestation or postpartum. It is not
attributable to other neurological causes and represents a critical, Planning:
life-threatening condition requiring immediate medical intervention. -​ After 1 hour of nursing interventions, the patient will be able to
maintain adequate blood pressure within normal limits.
Common complications: -​ Cardiac and respiratory status will remain stable during
-​ Cerebral hemorrhage hospitalization.
-​ Pulmonary edema
-​ Acute renal failure Interventions:
-​ Disseminated intravascular coagulation (DIC) Independent:
-​ Liver rupture or failure -​ Assess vital signs every hour.
-​ Placental abruption -​ Position the patient comfortably on the left side-lying position.
-​ Cardiac arrest -​ Encourage reduced activity.
-​ Intrauterine growth restriction (IUGR)
-​ Hypoxia and acidosis Dependent:
-​ Preterm birth -​ Administer oxygen as prescribed.
-​ Stillbirth -​ Administer antihypertensives as prescribed.

Collaborative:
Subjective Data
-​ Collaborate with obstetrician and critical care team for ongoing
management.
-​ Severe headache (unrelieved by medications) -​ Consult cardiology if signs of cardiac failure appear.
-​ Blurred or double vision, photophobia -​ Work with pharmacy for accurate medication dosing (especially
-​ Epigastric or right upper quadrant pain Magnesium Sulfate levels).
-​ Dizziness
-​ Nausea or vomiting Risk for seizures

Objective Data Planning:

●​ Short-term: Within 24 hours of nursing interventions, the patient’s
-​ Tonic-clonic seizures or convulsions magnesium Sulfate levels will remain within therapeutic range.
-​ Blood pressure ≥160/110 mmHg ●​ Long-Term Goal: Patient will remain seizure-free through delivery
-​ Hyperreflexia or clonus and postpartum stabilization.
-​ Oliguria (<30 mL/hr) or anuria
-​ Cyanosis or respiratory distress Interventions:
-​ Generalized edema Independent:
●​ Maintain a quiet, darkened environment to decrease CNS
stimulation.
Labs and Diagnostic Procedures
●​ Pad bed side rails to prevent injury during possible seizures.
●​ Stay at bedside during periods of instability; never leave patient
Laboratory Tests: alone.
-​ Blood pressure measurement ●​ Educate patient to report early signs (visual changes, headache).
-​ Urinalysis: Healthy kidneys don’t allow significant amount of Dependent:
protein to pass into the urine ●​ Administer Magnesium Sulfate infusion as prescribed.
-​ Complete blood count: Assessment of creatinine, liver enzyme ●​ Administer antiseizure medications (e.g., additional Lorazepam if
levels, and sometimes uric acid seizures occur).
●​ Monitor serum magnesium levels and adjust infusion rate as
Diagnostic Procedures: needed.
-​ Non-Stress Test (NST): Assesses fetal well-being ●​ Administer oxygen therapy during or after seizure activity if
-​ Biophysical Profile (BPP): Comprehensive fetal assessment indicated.
-​ CT/MRI: To evaluate potential cerebral edema or hemorrhage Collaborative:
-​ Ultrasound: Monitors fetal growth and placental function ●​ Collaborate with neurologist if seizures are refractory or atypical.
●​ Prepare for urgent delivery if maternal or fetal status worsens.
Pathophysiology
Drugs:
Risk factors: 1. Labetalol (Trandate)
Non-modifiable: -​ MOA: Blocks both alpha and beta receptors, causing vasodilation
-​ Nulliparity and lowering blood pressure without significant risk of fetal
-​ Extremes of maternal age (<20 or >35) bradycardia.
-​ Family or personal history of pre-eclampsia/eclampsia
-​ Multiple gestation 2. Magnesium Sulfate
-​ Pre-existing conditions (e.g., hypertension, diabetes, renal disease) -​ Prevention and treatment of seizures in eclampsia and severe
pre-eclampsia.
Modifiable: -​ MOA: Magnesium sulfate has a neuroprotective effect, reducing
-​ Obesity the risk of seizures. It also causes vasodilation, which can help
-​ Smoking or substance abuse control blood pressure.
-​ Poor prenatal care
-​ Sedentary lifestyle

17
 18. GESTATIONAL DIABETES MELLITUS

Definition: Diabetes mellitus metabolic disorder caused by inadequate insulin

production or inability to adequately utilize insulin. Insulin is a hormone that
moves glucose from the blood into the cells for energy use or storage.
Gestational diabetes mellitus (GDM) results from the inability to meet the
need for increased insulin production during pregnancy. The mother’s body
stores more glucose during the first half of pregnancy and later, the placental
hormone hPL (hCS) works to resist maternal insulin, allowing more glucose
to be available for the fetus. GDM may be controlled by diet alone or may
require insulin injections.

Subjective Data

-​ Excessive thirst (polydipsia)

-​ Excessive urination (polyuria)
-​ Fatigue
-​ Hypoglycemic symptoms (dizziness/shakiness)
-​ Extreme hunger (polyphagia)
-​ Blurry vision

Objective Data

Risk for deficient fluid volume r/t osmotic dehydration secondary to

-​ Elevated blood glucose readings (e.g., random blood sugar >140
hyperglycemia
mg/dL)
-​ High fundal height (macrosomia suspicion in fetus)
Hyperglycemia → Glycosuria → Osmotic Diuresis → Water Loss →
-​ Weight gain greater than expected during pregnancy
Dehydration
-​ Presence of glucose in urine (glucosuria) (although not always
reliable)
Planning:
-​ Elevated blood pressure (if coexisting with preeclampsia)
-​ After nursing interventions, the patient will:
-​ Maintain adequate hydration
Labs and Diagnostic Procedures -​ Achieve stable vital signs
-​ Verbalize understanding of the importance of hydration
Laboratory Tests:
-​ Glucose challenge test (GCT) Interventions:
-​ Normal: <140 mg/dL Independent:
-​ Abnormal: ≥140 mg/dL → proceed to OGTT -​ Monitor intake and output closely.
-​ Oral glucose tolerance test (OGGT) -​ Assess for signs of dehydration (dry mucous membranes,
-​ Measure fasting blood sugar, then drink 100g glucose decreased skin turgor, low urine output).
solution. -​ Educate patient on the importance of fluid intake and symptoms of
hyperglycemia.
-​ Blood glucose measured at 1, 2, and 3 hours.
-​ Diagnosis if 2 or more values are elevated: Dependent:
-​ Administer insulin therapy as prescribed to reduce hyperglycemia.

Time Normal Range Collaborative:

-​ Coordinate with a dietitian for a fluid- and glucose-appropriate
Fasting <95 mg/dL meal plan.

Risk for impaired gas exchange (fetal) r/t placental vascular changes
1 hour <180 mg/dL secondary to poor glycemic control

The risk for impaired fetal gas exchange stems from the placental changes
2 hour <155 mg/dL
caused by maternal hyperglycemia, which reduce oxygen delivery to the fetus
and increase the risk for fetal distress, IUGR, or stillbirth.
3 hour <140 mg/dL
Planning:
-​ Urinalysis -​ After nursing interventions, the patient will:
-​ May show glucosuria -​ Maintain stable maternal blood glucose levels
-​ Fetal monitoring tests -​ Verbalize understanding of glucose control measures to
-​ Ultrasound → estimate fetal weight, amniotic fluid reduce fetal risk
-​ Non-stress test (NST) - monitor FHT, and movements -​ Maintain normal FHR and movement pattern
-​ Biophysical profile (BPP) - needed for fetal well-being -​
Diagnostic Procedures: Interventions:
Independent:
Pathophysiology -​ Assess VS
-​ Educate the mother about blood glucose monitoring and
maintaining target glucose levels.
Risk factors:
-​ Encourage adherence to meal plans and exercise to improve
Non-modifiable:
glycemic control.
-​ Native American, Hispanic, or African-American heritage
-​ Family history of diabetes Previous GDM
Dependent:
-​ Previous unexplained stillbirth
-​ Administer insulin as prescribed.
-​ Previous infant >9.5 pounds
-​ Maternal age >30
Collaborative:
-​ Coordinate with a dietitian for a fluid- and glucose-appropriate
Modifiable:
meal plan.
-​ Maternal obesity
Drugs:
NCP 1. Insulin
-​ Does not cross the placenta
-​ MOA: Insulin lowers blood glucose by enhancing its uptake into
cells and suppressing hepatic glucose production.
-​ S/E: Insulin may cause hypoglycemia, weight gain, lipodystrophy at
injection sites, allergic reactions, and hypokalemia.
-​ N/R: Monitor blood glucose and signs of hypoglycemia, rotate
injection sites, educate the patient, double-check doses, and
monitor potassium levels.
18
 19. CEPHALOPELVIC DISPROPORTION

Definition: Cephalopelvic Disproportion is a condition in which the fetal head

is too large to pass through the maternal pelvis due to either a large baby
(macrosomia), a small maternal pelvis, or both. This often leads to
obstructed labor.

Common complications:
-​ Prolonged or obstructed labor
-​ Uterine rupture
-​ Fetal distress
-​ Birth trauma (e.g., shoulder dystocia)
-​ Increased likelihood of cesarean delivery
-​ Postpartum hemorrhage
-​ Maternal exhaustion and infection
-​ Neonatal asphyxia or stillbirth (in severe cases)

Subjective Data

-​ Maternal report of severe, continuous labor pain without

progression
Acute pain related to ineffective labor progression and uterine muscle
-​ Feeling of pressure without descent of the baby
fatigue
-​ Anxiety and fatigue from prolonged labor
-​ History of difficult or long previous labors
Planning:
-​ Within 1-2 hours of nursing interventions, the patient will report a
Objective Data
decrease in perceived pain to an acceptable level (≤ 4/10).
-​ Throughout labor until delivery, the patient will maintain effective
-​ Lack of cervical dilation and effacement despite strong coping strategies for pain management.
contractions Interventions:
-​ Fetal head remains high in the pelvis even in active labor Independent:
-​ Abnormal fetal heart rate patterns (e.g., late decelerations) -​ Assess pain
-​ Caput succedaneum or molding of the fetal head -​ Guided imagery, breathing exercise
-​ Uterine contractions may become ineffective or hypertonic -​ Side lying alleviate pelvic pressure
-​ Fever, tachycardia -​ Provide a calm and quiet environment
-​ Encourage rest periods
Labs and Diagnostic Procedures -​ Prepare patient for c-section
Dependent:
Laboratory Tests: -​ Administer prescribed analgesics (e.g., IV opioids like butorphanol)
-​ Complete Blood Count (CBC): to check for signs of infection or or epidural anesthesia as ordered.
anemia Collaborative:
-​ Urinalysis: to rule out urinary tract infection -​ Work with anesthesia for pain management options (e.g., epidural
-​ Blood type and crossmatch: in case cesarean delivery is needed placement).
-​ CRP or ESR: if infection is suspected -​ Collaborate with the obstetrician for decisions regarding labor
augmentation or proceeding to C-section if ineffective progression
Diagnostic Procedures: persists.
-​ Ultrasound: to estimate fetal size and position
-​ Pelvimetry (clinical or radiologic): to assess pelvic dimensions Risk for fetal injury related to obstructed labor
-​ Non-stress test (NST) or CTG: to monitor fetal well-being
-​ Biophysical Profile (BPP): if fetal compromise is suspected Planning:
-​ X-ray or MRI pelvimetry: rarely done, used for borderline cases -​ Fetus will maintain reassuring fetal heart rate patterns throughout
labor.
-​ Fetus will be delivered safely without signs of birth trauma,
Pathophysiology
hypoxia, or acidosis.
Interventions:
Risk factors: Independent:
Non-modifiable: -​ FHR
-​ Maternal age (adolescence or advanced age) -​ Contraction patterns
-​ Genetic predisposition to small pelvis or large fetus -​ Monitor labor progression
-​ History of pelvic trauma or malformations -​ Prepare patient for C-section
-​ Position mother in lateral recumbent or hands-and-knees position
Modifiable: to optimize uteroplacental perfusion.
-​ Excessive maternal weight gain during pregnancy -​ Instruct mother to report any changes in fetal movements.
-​ Poor prenatal care -​ Maintain a calm environment to reduce maternal stress, which can
-​ Gestational diabetes management affect uteroplacental blood flow.
Dependent:
NCP -​ Administer supplemental oxygen at 8–10 L/min via face mask if
fetal distress is detected.
-​ Increase IV fluid rate as ordered to improve placental perfusion if
needed.
-​ Prepare for possible emergency cesarean delivery if fetal distress
or labor arrest occurs.
Collaborative:
-​ Immediate consultation with obstetrician for evaluation and
possible operative delivery (forceps, vacuum, or C-section).
-​ Collaborate with neonatal team to prepare for newborn
resuscitation at delivery if needed.
-​ Involve anesthesia team early if surgical intervention is likely.

Drugs:
Butorphanol (Stadol)
Drug class: Opioid analgesic
MOA: Binds to opioid receptors in the CNS, altering perception and response
to pain. Moderate to severe pain relief during labor
SE: Drowsiness, dizziness, nausea, vomiting, respiratory depression,
hypotension
NR: Monitor maternal respiratory rate and sedation level; monitor FHR; have
naloxone (Narcan) available in case of respiratory depression.

19
 20. POSTPARTUM HEMORRHAGE

Definition: Puerperal hemorrhage is classified as early (within the first 24

hours) or late (after the first 24 hours and up to 6 weeks postpartum). The
causes of early hemorrhage are uterine relaxation (atony), lacerations, uterine
rupture, hematomas, retained placental fragments, and coagulation
deficiencies (DIC). Late puerperal hemorrhage may be related to abnormal
healing of the placental site or retained placental fragments. The amount of
blood lost during a hemorrhage greatly exceeds the usual definition of more
than 500 cc.

Common complications:
-​ Hypovolemic shock
-​ Anemia
-​ Disseminated Intravascular Coagulation (DIC)
-​ Acute renal failure
-​ Sheehan’s syndrome (pituitary infarction)
-​ Need for blood transfusion or hysterectomy
-​ Death (if uncontrolled or untreated)

Subjective Data

-​ Reports of dizziness, lightheadedness, or fainting

-​ Sensation of heaviness or fullness in the vaginal area
-​ Anxiety or panic
-​ Fatigue or weakness NCP
-​ Feeling of persistent uterine cramping or pain

Ineffective tissue perfusion r/t excessive blood loss secondary to ___

Objective Data
Planning:
-​ Excessive vaginal bleeding (saturating a pad within 15–30 -​ After nursing interventions, the patient will:
minutes) -​ Maintain adequate tissue perfusion as evidenced by
-​ Boggy uterus (indicating uterine atony) stable vital signs, normal urine output (≥30 mL/hr), and
-​ Decreased blood pressure, increased heart rate (tachycardia) alert mental status.
-​ Pale, cool, clammy skin -​ Exhibit no signs of hypovolemic shock during the
-​ Decreased urine output postpartum period.
-​ Signs of shock (restlessness, confusion, shallow breathing) -​ Verbalize understanding of signs of excessive bleeding
and when to seek help.
Labs and Diagnostic Procedures
Interventions:
Laboratory Tests: Independent:
-​ CBC: To assess hemoglobin and hematocrit levels. -​ Monitor vital signs
-​ Coagulation profile: To evaluate clotting factors (e.g., PT, aPTT, -​ Observe and record vaginal bleeding
fibrinogen). -​ Massage the uterine fundus if boggy to encourage contraction
-​ Type and crossmatch: For potential blood transfusion. -​ Provide emotional support and reassurance to reduce anxiety.

Diagnostic Procedures: Dependent:

-​ Ultrasound: To detect retained placental fragments or uterine -​ Administer blood products as ordered (PRBCs, platelets, plasma).
abnormalities. -​ Administer prescribed uterotonics (e.g., oxytocin, misoprostol,
-​ Pelvic examination: To assess uterine tone and identify trauma. methylergonovine, carboprost).
-​ Blood gas analysis: To monitor oxygenation and acid-base
balance. Collaborative:
-​
Pathophysiology
Risk for deficient fluid volume r/t excessive blood loss

Risk factors: Planning:

Non-modifiable: -​ After nursing interventions, the patient will:
-​ Grand multiparity (≥5 pregnancies reaching viable gestational age) -​ Maintain normal VS
-​ Placental defects (hx of placenta previa, placental abruption, -​ Achieve normal skin turgor
incomplete placental separation, placenta accreta) -​ Achieve normal capillary refill
-​ Verbalize understanding of the need for prompt bleeding
Modifiable: control and fluid replacement
-​ Poor general health status (Malnutrition, infection, anemia
pregnancy-induced hypertension (PIH), clotting deficiencies (if Interventions:
acquired)) Independent:
-​ Over-distended uterus during pregnancy (macrosomic infant, -​ Monitor VS
hydramnios, multiple gestation) -​ Assess bleeding (amount, color, clots)
-​ Rapid or prolonged labor, oxytocin induction or augmentation -​ Encourage rest
-​ Difficult birth (Forceps rotation, Intrauterine manipulation) -​ Educate on proper positioning

Dependent:
-​ Administer IV fluids (e.g., lactated Ringer's or normal saline).

Collaborative:
-​ Work with a dietician for iron-rich dietary recommendations if
recovering from blood loss.

Drugs:
1. Lactated Ringer's or normal saline
2. Oxytocin (Pitocin)
3. Blood transfusion

20
 21. DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Definition: DIC is a serious condition where widespread activation of the

clotting cascade leads to formation of tiny blood clots throughout the
bloodstream, consuming clotting factors and platelets — ultimately resulting
in severe bleeding.

Common complications:
-​ Severe hemorrhage – uncontrolled bleeding from multiple sites
-​ Organ ischemia or infarction – due to microthrombi
-​ Shock – especially hypovolemic shock from blood loss
-​ Respiratory distress or ARDS – caused by pulmonary microthrombi
or bleeding
-​ Neurological damage – seizures, stroke, altered level of
consciousness
-​ Acute renal failure – from decreased perfusion or microvascular
clotting
-​ Multi-organ dysfunction syndrome (MODS)
-​ Death – if left untreated or poorly managed
-​
Subjective Data

-​ Reports of unusual bleeding (e.g., gums, nose, injection sites)

-​ Complaints of abdominal or chest pain
-​ Reports of shortness of breath
-​ Anxiety or restlessness NCP
-​ Fatigue or weakness

Risk for bleeding r/t depletion of clotting factors and platelets

Objective Data
Planning:
-​ Petechiae, purpura, or ecchymosis ●​ Within 12 hours of nursing interventions, the patient will exhibit no
-​ Oozing from venipuncture or surgical sites active signs of bleeding.
-​ Hypotension and tachycardia ●​ Within 3 days of nursing interventions, the patient will be able to
-​ Hematuria or gastrointestinal bleeding maintain stable coagulation parameters and demonstrate no
-​ Decreased urine output Signs of organ dysfunction (e.g., further bleeding episodes.
confusion, oliguria)
Interventions:
Labs and Diagnostic Procedures Independent:
●​ Assess for bleeding from IV sites, gums, urine, stool, and vaginal
Laboratory Tests: discharge every 2–4 hours.
-​ Complete Blood Count (CBC): Low platelet count ●​ Educate the patient/family about minimizing trauma (e.g., no hard
(thrombocytopenia). tooth brushing, avoid injections unless necessary).
-​ Coagulation profile: Prolonged PT, aPTT, and decreased fibrinogen ●​ Implement bleeding precautions: avoid rectal temperatures, soft
levels. toothbrush, gentle suctioning if needed.
-​ D-dimer test: Elevated levels indicating fibrin degradation. Dependent:
-​ Fibrinogen levels: Reduced due to consumption in clotting. ●​ Administer prescribed medications (e.g., anticoagulants like
heparin if ordered early in DIC to halt clotting cascade).
Diagnostic Procedures: Collaborative:
-​ Blood cultures (if sepsis is suspected) ●​ Collaborate with hematology for coagulation management.
-​ Imaging (CT, MRI) may be ordered to identify sources of organ
damage or hemorrhage Risk for shock severe blood loss and hypovolemia
-​ Ultrasound or Doppler for evidence of thrombosis
Planning:
Pathophysiology -​ Within 2 hours of nursing interventions, the patient will maintain
systolic BP >90 mmHg and urine output ≥30 mL/hr
-​ Patient will be hemodynamically stable without signs of
Risk factors: hypovolemic shock until full recovery.
Non-modifiable: Interventions:
-​ History of malignancy (especially hematologic cancers) Independent:
-​ Previous history of DIC -​ Position patient flat with legs elevated (Trendelenburg if not
-​ Genetic predisposition to clotting disorders (rare but relevant) contraindicated) during hypotensive episodes.
-​ Maintain a calm, reassuring environment to reduce stress and
Modifiable: oxygen demand.
-​ Sepsis – early detection and treatment -​ Continuously monitor and document vital signs every 15 minutes if
-​ Abruptio placenta – some risk factors like smoking or trauma can unstable.
be managed Dependent:
-​ Amniotic fluid embolism – risk reduced with proper labor -​ Administer IV fluids rapidly as prescribed (e.g., isotonic crystalloids
management like Lactated Ringer’s or NS)
-​ Severe preeclampsia or eclampsia – managed through prenatal -​ Administer vasopressors (e.g., norepinephrine) if ordered to
care maintain blood pressure.
-​ HELLP syndrome – closely monitored during pregnancy -​ Administer oxygen at 8–10 L/min via non-rebreather mask if
-​ Trauma or burns – risk reduction with safety and timely care oxygen saturation <94%.
-​ Major surgery – risk minimized with perioperative care Collaborative:
-​ Transfusion reactions – preventable with proper cross-matching -​ Collaborate with critical care and obstetric teams for rapid
and protocols stabilization.

Drugs:

21
 22. PUERPERAL INFECTION

-​ Reproductive tract infection occurring after delivery and within 6

weeks following childbirth.

Subjective Data

-​ Pelvic pain
-​ Foul-smelling vaginal discharge
-​ Fatigue or malaise
-​ Chills
-​ Pain during urination

Objective Data

-​ Fever
-​ Tachycardia
-​ Uterine tenderness

Labs and Diagnostic Procedures

Laboratory Tests:
-​ CBC: ↑ WBC
-​ Blood culture: (+) bacterial growth
-​ Urinalysis: (+) leukocytes, rule out UTI

Diagnostic Procedures:
-​ UTZ: assess for retained placental fragments

Pathophysiology

Risk factors:

NCP

1.​ Hyperthermia r/t inflammatory response to infection

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

2.​ Pain r/t inflammation and edema or reproductive tract secondary

to invading microorganism

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Drugs:

22
 23. MASTITIS

-​ infection of the breast tissue, typically results from bacteria

entering the breast through a cracked or sore nipple, causing
inflammation and infection.

Subjective Data

-​ Breast pain or tenderness in one area of the breast

-​ Swelling or a feeling of fullness in the breast
-​ Redness or warmth in the affected breast
-​ Painful/ difficulty breastfeeding
-​ Flu-like symptoms (infection)

Objective Data

-​ Fever
-​ Tenderness
-​ Abscess formation or puss drainage

Labs and Diagnostic Procedures

Laboratory Tests:
-​ Breast milk culture: (+) Staphylococcus aureus, Streptococcus
species.
-​ CBC: ↑ WBC

Diagnostic Procedures:
-​ Breast UTZ: abscess formation

Pathophysiology

Risk factors:

NCP

1.​ Acute pain r/t inflammation and infection of the breast tissue

Planning:

Interventions:
Independent:
-​ Assess pain COLDSPA
-​ Apply warm compress
-​ Educate the mother on proper breastfeeding techniques
Dependent:

Collaborative:

2.​ Impaired skin integrity r/t niplle trauma

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Drugs:

23
 Collaborative:

24. TONSILLITIS 1.​ Acute pain r/t inflammation of tonsils

Planning:
-​ inflammation of the tonsils, typically caused by viral or bacterial
infections. Interventions:
-​ The tonsils are two lymphoid structures located at the back of the Independent:
throat that help in defending against infections.
-​ Viruses: Adenovirus, influenza virus, Epstein-Barr virus (EBV) Dependent:
-​ Bacteria: Most commonly Group A β-hemolytic Streptococcus
(GABHS) Collaborative:

Drugs:

Subjective Data

-​ Sore throat: Painful swallowing or a scratchy throat.

-​ Difficulty swallowing (odynophagia): Due to inflammation of the
tonsils.
-​ Chills: Accompanying fever, often in bacterial tonsillitis
-​ Headache: Often reported due to systemic symptoms of infection.
-​ Ear pain: Referred pain due to the proximity of the tonsils to the ear.
-​ Fatigue: General feeling of weakness or malaise.
-​ Bad breath (halitosis): Caused by bacteria in the throat.

Objective Data

-​ Red and swollen tonsils: Visible upon inspection of the throat.

-​ White or yellow spots or coating on the tonsils: Especially in
bacterial tonsillitis (e.g., Streptococcus).
-​ Enlarged, tender lymph nodes: Notable in the neck or jaw area.
-​ Fever: Measured body temperature greater than 38°C (100.4°F).

Labs and Diagnostic Procedures

Laboratory Tests:
-​ Throat culture: (+) Streptococcus in bacterial tonsillitis
-​ Rapis Antigen Test: quickly determine if the infection is caused by
Group A Streptococcus
-​ CBC: ↑ WBC

Pathophysiology

Risk factors:

NCP

1.​ Ineffective airway clearance r/t inflammation of tonsils

Planning:

Interventions:
Independent:

Dependent:
24
 25. OTITIS MEDIA

-​ infection or inflammation of the middle ear, often caused by

bacteria or viruses.
-​ Due to dysfunction of eustachian tube
-​ Acute Otitis Media (AOM) – sudden onset, infection +
inflammation
-​ Otitis Media with Effusion (OME) – fluid in the middle ear without
infection
-​ Chronic Otitis Media – persistent or recurrent infection or effusion

NCP

1.​ Acute Pain related to inflammation and pressure in the middle ear
Subjective Data
Planning:

-​ Ear pain (otalgia): A common symptom, especially if the infection Interventions:

is causing pressure in the middle ear. Independent:
-​ Feeling of fullness or pressure in the ear: A sensation that the ear
is “blocked” or “stuffed.” Dependent:
-​ Hearing loss: Due to fluid buildup behind the eardrum, which can
cause temporary hearing impairment. Collaborative:
-​ Irritability or fussiness: Especially in young children, they may be
unusually irritable. 2.​ Risk for Impaired Hearing related to fluid accumulation in the
middle ear
Objective Data
IMPAIRED VERBAL COMMUNICATION DUE TO HEARING LOSS
-​ Red, swollen eardrum: Visible during otoscopic examination,
indicating infection or inflammation. Planning:
-​ Bulging eardrum: The eardrum may appear to be pushed outward
due to fluid buildup in the middle ear. Interventions:
-​ Fever: A temperature greater than 38°C (100.4°F). Independent:
-​ Purulent drainage: If the eardrum ruptures, pus or fluid may drain
from the ear. Dependent:

Collaborative:
Labs and Diagnostic Procedures
Drugs:
Laboratory Tests: 1.
-​ Ear Culture or Tympanocentesis (Rarely): identify bacterial
pathogen
Diagnostic Procedures:
-​ Otoscopy: red, bulging, fluid filled tympanic membrane
-​ Tympanometry: measures movement of fluid

Pathophysiology

Risk factors:
-​ Children: Short and horizontal Eustachian tubes leads to poor
drainage and ventilation
-​ Recent Upper respiratory tract infection: spread of inflamation
-​ Bottle feeding in supine position: Allows fluid to enter the
Eustachian tube.

25
 26. BRONCHITIS

-​ inflammation of the bronchial tubes (airways in the lungs),

typically caused by a viral infection. It results in coughing, mucus
production, and difficulty breathing
-​ Acute bronchitis – most common in children;
self-limiting and viral.
-​ Chronic bronchitis – rare in children unless underlying
disease (e.g., cystic fibrosis, asthma).

Subjective Data

-​ Cough: Body tries to clear mucus from inflamed airways

-​ Chest tightness: ​ Swelling and mucus create a “heavy” chest
feeling

Objective Data

-​ Mucus/ phlegm (white/yellow): Inflammation-> stimulation of

goblet cells & mucus glands -> mucus production
-​ Shortness of breath: swollen airway -> difficulty breathing
-​ WHEEZING on auscultation: High-pitched whistling sound
indicating narrowed airways.
-​ Low grade fever

Labs and Diagnostic Procedures

Laboratory Tests:
-​ Sputum culture: (+) growth of pathogens- Streptococcus
pneumoniae or Haemophilus influenzae
-​ ABG: hypoxia/ hypercapnia
-​ Chest X-ray: Elevated WBC (bacterial)

Diagnostic Procedures:
-​ Chest X-ray: rule out pneumonia NCP

Pathophysiology 1.​ Ineffective Airway Clearance related to excess mucus and

bronchial inflammation
Risk factors:
Planning:

Interventions:
Independent:

Dependent:

Collaborative:

2.​ Impaired gas exchange

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Drugs:

26
 27. PNEUMONIA

-​ infection alveoli/ air sacs and surrounding tissues that causes

inflammation and fluid or pus accumulation.
-​ Can be caused by:
-​ Bacteria (e.g., Streptococcus pneumoniae)
-​ Viruses (e.g., influenza, COVID-19)
-​ Fungi (less common, but possible in
immunocompromised people)
-​ Aspiration (inhalation of food/liquids into the lungs)

Subjective Data
-​ Chest pain: Sharp or stabbing pain that worsens when breathing
deeply or coughing.
-​ Cough: attempts to expel mucus, pus, or pathogens from the
lungs.
Objective Data

-​ Fever, chills: Infection triggers the hypothalamus to increase body

temperature to fight off microbes.
-​ Tachypnea: body compensates for low oxygen by breathing faster
to improve oxygen intake.
-​ Shortness of breath NCP
-​ Crackles or rales on auscultation: Air passes through fluid-filled
alveoli, producing abnormal breath sounds.
-​ Decreased oxygen saturation 1.​ Ineffective Airway Clearance related to increased mucus
-​ Cyanosis: Bluish discoloration of the lips, face, or extremities, production and bronchial inflammation
indicating inadequate oxygenation.
Planning:
Labs and Diagnostic Procedures
Interventions:
Independent:
Laboratory Tests:
-​ Sputum cultural: identify the specific pathogen causing the Dependent:
pneumonia (bacterial, viral, or fungal). Streptococcus pneumoniae,
Haemophilus influenzae, or Legionella Collaborative:
-​ CBC: ↑ WBC (bacterial)
-​ ABG: hypoxia/ hypercapnia 2.​ Impaired gas exchange

Diagnostic Procedures: Planning:

-​ Chest X-ray: infiltrates (patchy areas of infection), consolidation
(solidified tissue), or pleural effusion (fluid buildup around the Interventions:
lungs). Independent:
-​
Pathophysiology Dependent:

Risk factors: Collaborative:

Drugs:

27
 28. ASTHMA

-​ chronic inflammatory condition of the airways that causes

recurrent episodes of wheezing, shortness of breath, chest
tightness, and coughing.
-​ caused by hyperresponsiveness to various triggers (like allergens,
exercise, cold air, or smoke).

Subjective Data

-​ Chest tightness: A feeling of pressure or constriction in the chest.

-​ Difficulty sleeping: Often reports disturbed sleep due to nighttime
coughing or shortness of breath.

Objective Data

-​ Wheezing upon expiration: due to narrowed/ inflamed bronchi

-​ Dyspnea: narrowed airway -> trapped air
-​ Increased respiratory rate (tachypnea): compensation to low
oxygen
-​ Signs of respiratory effort: use additional muscles in the neck or
chest to help with breathing + nasal flaring

Labs and Diagnostic Procedures

Laboratory Tests:
-​ Spirometry: amount of inhalation and exhalation and how fast
-​ FEV, FVC, FEV1/FVC
Diagnostic Procedures:
-​ Chest X-ray: hyperinflation
NCP
Pathophysiology

Risk factors:
Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Drugs:

ASTHMA VS BRONCHITIS
ASTHMA
-​ Airway hyperresponsiveness DUE TO ALLERGENS
-​ CHRONIC
-​ Signs of respiratory effort
-​ EOSINOPHILS

BRONCHITIS
-​ Viral/ bacterial infection
-​ ACUTE
-​ FEVER
-​ NEUTROPHILS

PNEUMONIA VS ARDS
ARDS
-​ Cause is sepsis, trauma, pneumonia
-​ Dyspnea, hypoxia cyanosis
-​ BILATERAL diffuse infiltrates, "white-out" lungs, ground-glass
opacity

PNEUMONIA
-​ Caused BY BACTERIAL OR VIRAL INFECTION
-​ FEVER
-​ UNILATERAL

28
 ACUTE RESPIRATORY DISTRESS SYNDROME
Collaborative:

-​ A life-threatening condition characterized by acute inflammation Drugs:

and fluid accumulation in the alveoli, leading to severe hypoxemia
and impaired gas exchange.
DISEASE
Subjective Data

-​ Shortness of breath Subjective Data

Objective Data
Objective Data
-​ Tachypnea
-​ Cyanosis Labs and Diagnostic Procedures
-​ Hypoxemia
-​ Crackles
Laboratory Tests:
-​ Tachycardia
Diagnostic Procedures:
Labs and Diagnostic Procedures
Pathophysiology
Laboratory Tests:
-​ PaO₂/FiO₂ Ratio (P/F Ratio):
Risk factors:
-​ Mild ARDS: 200–300 mmHg
-​ Moderate ARDS: 100–200 mmHg
-​ Severe ARDS: <100 mmHg NCP
-​ ABG: hypoxia
Diagnostic Procedures:

Pathophysiology Planning:

Interventions:
Risk factors:
Independent:

Dependent:

Collaborative:

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Drugs:

NCP

1.​ Impaired gas exchange

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

2.​ Ineffective breathing pattern

Planning:

Interventions:
Independent:

Dependent:
29
 31) ATRIAL SEPTAL DEFECT secondary to congenital heart defect (ASD), as evidenced by fatigue,
dyspnea during feeding or play, and tachycardia.

-​ An atrial septal defect (ASD) is a congenital heart defect. It’s a hole Planning:
in the atrial septum, the muscular wall between the two upper ●​ Short-term: Within 3-5 days, the child will demonstrate improved
chambers (atria) of your heart. activity intolerance
●​ Long-term: Within 6 months, the child will participate in
Subjective Data age-appropriate activities with minimal fatigue.

●​ Shortness of breath Interventions:

●​ Fatigue Independent:
●​ Activity intolerance ●​ Assess baseline and post-activity heart rate, respiratory rate, and
●​ Palpitations oxygen saturation.
●​ Swelling ●​ Schedule activities and care during periods when the child is well
●​ stroke rested.
●​ Encourage frequent rest periods between feedings or play.
Dependent:
Objective Data
●​ Administer oxygen as prescribed during activity if desaturation
occurs.
●​ An infant that tires with feeding Collaborative:
●​ Frequent respiratory symptoms ●​ Collaborate with physical/occupational therapists to tailor safe
●​ Heart murmur play or feeding activities.
●​ Tachypnea
Drugs:
Labs and Diagnostic Procedures Digoxin
Oral/IV
●​ Chest x-ray Drug class: Cardiac glycoside
○​ To determine if the pt has an enlarged heart or increased Moa: Increases myocardial contractility (positive inotrope) Decreases heart
pulmonary blood flow rate by increasing vagal tone (negative chronotrope). Used when ASD causes
●​ Echocardiogram right ventricular volume overload and heart failure symptoms (e.g.,
○​ To show the blood flow through the heart; to see if an tachypnea, poor feeding, failure to thrive in infants)
opening is present in the heart where it shouldn’t be S/E: NV, dizziness, headache, visual disturbances, changes in heart rhythm,
fatigue, diarrhea, loss of appetite
Pathophysiology NR: Check apical pulse before administration (hold if HR < 90 bpm in infants,
< 60 bpm in older children/adults) Monitor for toxicity: nausea, vomiting,
bradycardia, visual disturbances (yellow vision) Monitor serum digoxin
levels: therapeutic range is 0.5–2.0 ng/mL

Furosemide (Lasix)
Oral/IV
Drug class: Loop diuretic
Moa: Inhibits sodium and chloride reabsorption in the loop of Henle, causing
diuresis; Reduces preload and pulmonary congestion from increased blood
volume due to left-to-right shunt. Used to relieve pulmonary overcirculation
and congestion in patients with large ASDs and signs of heart failure
S/E: Low blood pressure, electrolyte changes, increased blood sugar,
increased urination
NR: Monitor intake/output and daily weight. Watch for signs of dehydration.
Monitor electrolytes, especially potassium, calcium, and magnesium

NCP

Decreased Cardiac Output related to structural cardiac anomaly (ASD) as

evidenced by fatigue, tachycardia, and poor feeding.

Planning:
●​ Short-term: Within 3 days, the patient will demonstrate improved
feeling tolerance and energy levels
●​ Long-term: After 6 months, the patient will maintain optimal
cardiac output and growth parameters.

Interventions:
Independent:
●​ Monitor apical pulse, respiratory rate, and oxygen saturation every
4 hours.
●​ Observe for signs of fatigue or respiratory distress during feeding
or activity.
●​ Position child in semi-fowler's position to easter breathing and
reduce cardiac workload

Dependent:
●​ Give Digoxin and/or Furosemide as prescribed to improve cardiac
output and reduce fluid overload.

Collaborative:
●​ Collaborate with a pediatric cardiologist to monitor cardiac
function and plan long-term management (e.g., ASD closure).

Activity Intolerance r/t imbalance between oxygen supply and demand

30
 32) PATENT DUCTUS ARTERIOSUS
Activity Intolerance r/t imbalance between oxygen supply and demand
secondary to congenital heart defect (ASD), as evidenced by fatigue,
-​ A congenital heart defect where there is an incomplete closing of dyspnea during feeding or play, and tachycardia.
the ductus arteriosus. The constant opening causes too much
blood to flow to the baby's lungs and heart. Untreated, the blood Planning:
pressure in the baby's lungs might increase. The baby's heart might ●​ Short-term: Within 3-5 days, the child will demonstrate improved
grow larger and get weak. feeding or activity tolerance (e.g.. Feeding longer and with less
-​ ductus arteriosus is a fetal blood vessel that connects the fatigue)
pulmonary artery to the aorta, allowing blood to bypass the lungs ●​ Long-term: After 1 month of nursing interventions, the child will
in the womb participate in age-appropriate activities and show no signs of
oxygen deprivation or fatigue.
Subjective Data
Interventions:
●​ Poor weight gain Independent:
●​ Fatigue ●​ Monitor and document heart rate, respiratory rate, and oxygen
●​ Shortness of breath saturation before and after feeding or activity.
●​ Feeding difficulties ●​ Observe for early signs of activity intolerance: irritability, fatigue,
tachypnea, retractions.
Dependent:
Objective Data
●​ Administer digoxin to improve cardiac output if prescribed.
●​ Administer diuretics (e.g., furosemide) to reduce pulmonary
●​ Machinery-like murmur: high pressure aorta-> low pressure congestion as indicated.
pulmonary artery-> machinery-like Collaborative:
●​ Bounding pulses ●​ Work with a dietitian to plan high-calorie meals that require less
●​ Widened pulse pressure: difference between systolic and diastolic. effort for intake.
Increase systolic to compensate for blood loss. Blood that should
stay in the aorta during diastole escapes through the PDA into the Drugs:
pulmonary artery. Digoxin
●​ Tachycardia: compensatory mechanism Oral/IV
●​ Tachypnea: increased blood to the lungs causes congestion and Drug class: Cardiac glycoside
fluid buildup Moa: Increases myocardial contractility (positive inotrope) Decreases heart
●​ Active precordium rate by increasing vagal tone (negative chronotrope). Used when ASD causes
right ventricular volume overload and heart failure symptoms (e.g.,
Labs and Diagnostic Procedures tachypnea, poor feeding, failure to thrive in infants)
S/E: NV, dizziness, headache, visual disturbances, changes in heart rhythm,
●​ Chest x-ray fatigue, diarrhea, loss of appetite
○​ Enlarged heart (left ventricle) NR: Check apical pulse before administration (hold if HR < 90 bpm in infants,
●​ Echocardiography < 60 bpm in older children/adults) Monitor for toxicity: nausea, vomiting,
○​ To diagnose PDA & estimate magnitude of shunt volume bradycardia, visual disturbances (yellow vision) Monitor serum digoxin
●​ Cardiac catheterization levels: therapeutic range is 0.5–2.0 ng/mL
○​ To reveal PDA

Pathophysiology Furosemide (Lasix)

Oral/IV
Drug class: Loop diuretic
Moa: Inhibits sodium and chloride reabsorption in the loop of Henle, causing
diuresis; Reduces preload and pulmonary congestion from increased blood
volume due to left-to-right shunt. Used to relieve pulmonary overcirculation
and congestion in patients with large ASDs and signs of heart failure
S/E: Low blood pressure, electrolyte changes, increased blood sugar,
increased urination
NR: Monitor intake/output and daily weight. Watch for signs of dehydration.
Monitor electrolytes, especially potassium, calcium, and magnesium

Indomethacin
Oral/IV
Drug class: Non-steroidal anti-inflammatory drug (NSAID)
Moa: Inhibits cyclooxygenase (COX-1 and COX-2), reducing prostaglandin
synthesis. Prostaglandins keep the ductus arteriosus open, so their inhibition
promotes closure.
S/E: Decreased urine output (oliguria), Increased serum creatinine (renal
impairment), Gastrointestinal bleeding
NR: Monitor urine output closely; report if <1 mL/kg/hr. Assess renal
NCP function: monitor BUN, creatinine, and electrolytes. Check abdominal girth
and assess for signs of NEC (e.g., vomiting, bloody stools, abdominal
distension).
Impaired Gas Exchange r/t pulmonary congestion secondary to left-to-right
shunting via PDA as evidenced by tachypnea, decreased oxygen saturation, Ibuprofen
and use of accessory muscles. Oral/IV
Drug class: Non-steroidal anti-inflammatory drug (NSAID)
Planning: Moa: IInhibits COX enzymes, reducing prostaglandin levels. Promotes
●​ Short-term: Within 24-48 hours, the infant will maintain SpO2 > 95% closure of the ductus arteriosus in neonates. Pharmacologic treatment of
●​ Long-term: After 1 month of nursing interventions, the child will PDA in preterm infants.
show no signs of respiratory distress. S/E: Mild to moderate renal impairment. Elevated liver enzymes (rare).
Gastrointestinal disturbances (feeding intolerance)
Interventions: NR: Monitor urine output and renal function labs (BUN, creatinine). Assess
Independent: for feeding intolerance, vomiting, or abdominal distention. Monitor liver
●​ Monitor respiratory rate, depth, and pattern every 2–4 hours. function tests if prolonged use or oral route is used.
●​ Assess for signs of increased work of breathing (nasal flaring,
retractions).
●​ Position infant in semi-Fowler’s to facilitate lung expansion.

Dependent:
●​ Administer indomethacin or ibuprofen (if PDA closure is planned
pharmacologically).

Collaborative:
●​ Collaborate with pediatric cardiology for echocardiogram follow-up
and surgical decision-making.

31
 33) TETRALOGY OF FALLOT

Tetralogy of Fallot (ToF) is a condition in which a baby has four abnormalities

in their heart at birth. These issues make it hard for your baby’s heart to send
enough oxygen to their entire body

-​ Ventricular septal defect: Opening in the ventricular septum in

between th L and R ventricles
-​ Overriding aorta: Aorta is connected to both L & R ventricles
-​ Pulmonary stenosis: Narrowing of the pulmonary artery
-​ Right ventricular hypertrophy: R ventricle thickens due to chronic
pressure overload NCP

Subjective Data
Decreased cardiac output r/t lack of oxygenated blood and poor perfusion
to tissues and organs evidenced by cyanosis, tet spells, murmur upon
●​ Poor weight gain auscultation
●​ Getting tired easily during play or exercise
●​ Shortness of breath Planning:
●​ Short-term: Within 24-48 hours, the infant will maintain oxygen
Objective Data saturation level within expected limits
●​ Long-term: After 2 weeks of nursing interventions, the child will be
●​ Blue or gray skin color able to tolerate playing or exercise without dyspnea, fatigue, or
●​ Irritability fainting
●​ Crying for long periods of time
●​ Fainting Interventions:
●​ Clubbing of fingers Independent:
●​ Tet spells ●​ Place the patient on their left side, knees to chest to improve blood
circulation to the lungs.
Labs and Diagnostic Procedures
Dependent:
●​ Administer morphine and propranolol to lessen tet spells’
●​ Chest x-ray incidence and severity.
○​ Use: Initial imaging study to evaluate heart size and
pulmonary vascular markings. Collaborative:
○​ Findings: ●​ Collaborate with pediatric cardiology for echocardiogram follow-up
■​ “Boot-shaped” heart (due to right ventricular and surgical decision-making.
hypertrophy).
■​ Decreased pulmonary vascular markings Impaired gas exchange r/t inadequate gas exchange and poor production of
(oligemia) due to pulmonary stenosis. oxygenated blood as evidenced by difficulty breathing, coughing, and rapid
■​ Possible right aortic arch. breathing
●​ Echocardiogram
○​ Evaluates electrical activity of the heart, identifies Planning:
arrhythmias or chamber enlargement. ●​ Short-term: Within 24-48 hours, the infant will maintain oxygen
○​ Findings: saturation level within expected limits
■​ Right ventricular hypertrophy (tall R waves in ●​ Long-term: After 2 weeks of nursing interventions, the child will be
right precordial leads). able to tolerate playing or exercise with no complaints of difficulty
■​ Right axis deviation. breathing.
■​ Possible signs of right atrial enlargement.
●​ Cardiac catheterization Interventions:
○​ Reserved for detailed hemodynamic assessment or Independent:
when echo findings are inconclusive. ●​ Assist patient in knee-chest position
○​ Findings: ●​ Promote aerobic exercise to increase aerobic capacity and gas
■​ Measures pressures in heart chambers. exchange
■​ Assesses degree of pulmonary stenosis. Dependent:
■​ Visualizes coronary artery anatomy (important ●​ Administer oxygen therapy as ordered.
for surgical planning). Collaborative:
■​ Confirms presence and size of VSD, and ●​ Collaborate with respiratory therapists to carry out prescribed
position of the overriding aorta. breathing exercises and drug treatments.
●​ Pulse oximetry
○​ Non-invasive measurement of oxygen saturation. Drugs:
○​ Findings: Morphine (Duramorph, MS Contin)
■​ Low oxygen saturation, especially during "tet IV/Subcutaneous
spells" (cyanotic episodes). Drug class: Opioid analgesic
■​ Helps determine need for oxygen therapy or Moa: Management of hypercyanotic spells (“Tet spells”) by decreasing
surgical intervention. catecholamine release, reducing respiratory drive (less crying), and calming
the patient.
Pathophysiology (not sure lol) S/E: Respiratory depression, Hypotension, Sedation, Nausea and vomiting,
Constipation
NR: Monitor respiratory rate and oxygen saturation. Have naloxone available
in case of overdose. Monitor level of consciousness and sedation. Use
cautiously with other CNS depressants. Check for signs of bradycardia or
hypotension.

Propranolol (Inderal)
Oral/IV
Drug class: Non-selective Beta-Blocker
Moa: Blocks β1 and β2 adrenergic receptors → decreases heart rate and
contractility. Prevent and manage hypercyanotic spells by reducing heart
rate and myocardial oxygen demand. Increases systemic vascular resistance,
improving left-to-right shunting.
S/E: Bradycardia, Hypotension, Bronchospasm, Fatigue, Hypoglycemia (in
infants)
NR: Monitor heart rate and blood pressure before and after administration.
Watch for signs of hypoglycemia, especially in neonates/infants. Caution in
patients with reactive airway diseases. Educate caregivers about missed
doses and withdrawal symptoms.

Oxygen
32
Drug class: Medical gas / inhaled therapeutic agent
Moa: Increases the fraction of inspired oxygen (FiO₂) → improves oxygen
delivery to [Link] reduce pulmonary vascular resistance. Supportive
treatment during cyanotic episodes or hypoxia
S/E: Oxygen toxicity (with prolonged high-concentration use) Dry nasal
passages Retinopathy of prematurity (in neonates with prolonged use)
NR: Monitor oxygen saturation with pulse oximeter. Warm and humidify
oxygen to avoid mucosal drying. Reassure and comfort the child to reduce
agitation. Always assess for clinical improvement (not just SpO₂).

33
 34) RHEUMATIC FEVER ●​ Long-term: The child will demonstrate improved mobility and
comfort with minimal or no pain during movement by discharge.

Interventions:
Independent:
●​ Assess and monitor pain level using an age-appropriate pain scale
(e.g., FLACC scale, Wong-Baker Faces)
●​ Encourage rest and limit joint movement during acute
inflammation phase.
●​ Provide comfort measures (e.g., positioning, distraction techniques
like games or storytelling).

Dependent:
●​ Administer prescribed analgesics (e.g., acetaminophen or NSAIDs
like ibuprofen) as ordered.

Collaborative:
●​ Coordinate with physical therapy if recommended once acute
inflammation subsides.
-​ Acute rheumatic fever is an inflammatory autoimmune disease
that occurs 2 to 6 weeks following an untreated or undertreated Hyperthermia related to infectious/inflammatory process secondary to
group A beta-hemolytic streptococcal infection. It affects the rheumatic fever as evidenced by elevated body temperature, flushed skin,
heart, joints, central nervous system (CNS), and skin. and tachycardia.

Subjective Data Planning:

●​ Short-term: The child will have a reduced temperature to within
normal limits (36.5°C–37.5°C or 97.7°F–99.5°F) within 24–48
●​ Fever: Inflammatory response hours of nursing intervention.
●​ Joint pain: migratory polyarthritis due to inflammation of synovial ●​ Long-term: The child will maintain normal body temperature and
membranes show no signs of recurrent fever throughout hospitalization.
●​ Subcutaneous nodules
●​ Erythema marginatum- pink-ring shaped rash Interventions:
Independent:
Objective Data ●​ Monitor and record temperature every 2–4 hours using an
appropriate method for age
●​ Subcutaneous nodules ●​ Assess for associated symptoms (e.g., chills, sweating, headache).
●​ Erythema marginatum- pink-ring shaped rash ●​ Encourage fluid intake to prevent dehydration (offer oral
rehydration solutions, water, juice as tolerated).
Labs and Diagnostic Procedures Dependent:
●​ Administer antipyretics (e.g., acetaminophen or ibuprofen) as
prescribed.
●​ Elevated inflammation markers Collaborative:
○​ Elevated levels of C-reaction protein (CRP), or ●​
erythrocyte sedimentation rate (ESR) indicating
inflammation Drugs:
●​ Blood tests / throat swabs Acetaminophen (Paracetamol)
○​ Evidence of strep infection PO
●​ Echocardiography Drug class: Analgesic/antipyretic
○​ Reveals heart valve damage or inflammation Moa: Inhibits prostaglandin synthesis (central action), To reduce fever
●​ Electrocardiogram (EKG) (antipyretic effect). To relieve mild to moderate pain associated with joint
○​ Shows heart rhythm abnormalities or heart block inflammation (arthralgia). Especially useful if NSAIDs are contraindicated or
●​ Chest x-ray not well tolerated.
○​ Reveals cardiomegaly (enlarged heart) or pulmonary S/E: Hepatotoxicity, rash, mild GI upset
congestion NR: Assess pain level (before and 30–60 min after administration), Confirm
accurate weight-based dosing, Instruct caregivers to avoid double-dosing
Pathophysiology with other acetaminophen-containing products (like cold meds)

Ibuprofen
Oral/IV
Drug class: Non-steroidal anti-inflammatory drug (NSAID)
Moa: IInhibits COX enzymes, reducing prostaglandin levels. To reduce fever
(antipyretic). To relieve pain from arthritis/arthralgia. To reduce
inflammation in joints affected by the rheumatic process.
S/E: Mild to moderate renal impairment. Elevated liver enzymes (rare).
Gastrointestinal disturbances (feeding intolerance)
NR: Monitor urine output and renal function labs (BUN, creatinine). Assess
for feeding intolerance, vomiting, or abdominal distention. Monitor liver
function tests if prolonged use or oral route is used.

NCP

Acute Pain related to inflammatory process of joints secondary to

rheumatic fever as evidenced by verbal reports of pain, limited mobility, and
guarding behavior

Planning:
●​ Short-term: The child will verbalize decreased pain level (from 8/10
to ≤3/10) within 24–48 hours after interventions.

34
 35) ENDOCARDITIS
Planning:
●​ Short-term: Within 1 hour of nursing intervention, the child will
-​ Endocarditis is an infection of the inner lining of the heart verbalize decreased pain level (from 8/10 to ≤3/10).
(endocardium), typically involving the heart valves. It occurs when ●​ Long-term: Within 24 hours of nursing intervention, the child will
bacteria (or fungi) enter the bloodstream and attach to damaged demonstrate improved comfort as evidenced by relaxed behavior,
areas of the heart. improved sleep, and reduced irritability.

Interventions:
Independent:
●​ Assess and monitor pain level using an age-appropriate pain scale
(e.g., FLACC scale, Wong-Baker Faces)
●​ Assess vital signs for increased heart rate and blood pressure
●​ Provide comfort measures (e.g., positioning, distraction techniques
like games or storytelling).

Dependent:
●​ Administer prescribed analgesics (e.g., acetaminophen or NSAIDs
like ibuprofen) as ordered.

Collaborative:
●​

Hyperthermia related to infectious/inflammatory process

as evidenced by elevated temperature, flushed skin, irritability, diaphoresis,
increased heart rate and respiratory rate

Planning:
●​ Short-term: The child will have a reduced temperature to within
normal limits (36.5°C–37.5°C or 97.7°F–99.5°F) within 24–48
hours of nursing intervention.
●​ Long-term: The child will maintain normal body temperature and
Subjective Data show no signs of recurrent fever throughout hospitalization.

●​ Fever, Chills: immune response Interventions:

●​ Fatigue: Ongoing infection increases energy demands Independent:
●​ Monitor and record temperature every 2–4 hours using an
Objective Data appropriate method for age
●​ Assess for associated symptoms (e.g., chills, sweating, headache).
●​ Encourage fluid intake to prevent dehydration (offer oral
●​ Heart murmur: Turbulent blood flow due to vegetations on valves rehydration solutions, water, juice as tolerated).
●​ Splinter hemorrhages (black streaks on nail beds): Tiny blood clots Dependent:
under fingernails due to emboli ●​ Administer antipyretics (e.g., acetaminophen or ibuprofen) as
●​ Petechiae: Microemboli or capillary rupture from infection prescribed.
●​ Janeway lesions (red, nontender lesions on palms and soles) Collaborative:
●​ Osler’s nodes (painful red nodules on fingers/toes) ●​ Uhh wala akong mahanap yall :c

Labs and Diagnostic Procedures Drugs:

Acetaminophen (Paracetamol)
●​ CBC: elevated WBC PO
●​ Elevated inflammation markers Drug class: Analgesic/antipyretic
○​ Elevated levels of C-reactive protein (CRP), or erythrocyte Moa: Inhibits prostaglandin synthesis (central action), To reduce fever
sedimentation rate indicating inflammation (antipyretic effect). To relieve mild to moderate pain associated with joint
●​ Blood culture inflammation (arthralgia). Especially useful if NSAIDs are contraindicated or
○​ Confirmatory test not well tolerated.
●​ Echocardiogram S/E: Hepatotoxicity, rash, mild GI upset
○​ Show vegetations, valve disruption and ineffective NR: Assess pain level (before and 30–60 min after administration), Confirm
ventricular action accurate weight-based dosing, Instruct caregivers to avoid double-dosing
with other acetaminophen-containing products (like cold meds)
Pathophysiology
Ibuprofen
Oral/IV
Drug class: Non-steroidal anti-inflammatory drug (NSAID)
Moa: IInhibits COX enzymes, reducing prostaglandin levels. To reduce fever
(antipyretic). To relieve pain from arthritis/arthralgia. To reduce
inflammation in joints affected by the rheumatic process.
S/E: Mild to moderate renal impairment. Elevated liver enzymes (rare).
Gastrointestinal disturbances (feeding intolerance)
NR: Monitor urine output and renal function labs (BUN, creatinine). Assess
for feeding intolerance, vomiting, or abdominal distention. Monitor liver
function tests if prolonged use or oral route is used.

NCP

Acute pain r/t inflammatory process as evidenced by verbal reports of pain

(if verbal), irritability, restlessness, crying, increased heart rate, guarding
behavior

35
 36) KAWASAKI DISEASE ●​ Long-term: Within 3 days of nursing interventions, the patient will
demonstrate improved cardiac function as evidenced by normal
heart rate and absence of tachycardia.
-​ Kawasaki disease (KD), also known as Kawasaki syndrome, is a
disease that can cause damage to the heart and blood vessels, Interventions:
mostly in children younger than 5 years old. It affects boys more Independent:
often than girls. The cause of KD is not known. ●​ Measure the child’s temperature every 2–4 hours and document
fluctuations to assess fever patterns.
Data ●​ Ensure the child drinks fluids frequently to prevent dehydration.
Offer cool fluids such as water, electrolyte solutions, and
CRASH & BURN popsicles.
-​ Conjunctivitis: Inflammation of conjunctival blood vessels ●​ Instruct on recognizing signs such as dry mouth, sunken eyes, and
(vasculitis) reduced urine output.
-​ Rash: Immune-mediated skin inflammation Dependent:
-​ Adenopathy: Lymph node inflammation due to immune activation ●​ Administer acetaminophen or ibuprofen for fever management as
-​ Strawberry tongue/ red, dry cracked lips: Mucosal inflammation prescribed. Be mindful of dosages appropriate for the child’s
-​ Hands and feet edema weight and age.
-​ Burn: Fever >5 DAYS ●​ Administer intravenous (IV) fluids if necessary: If the child shows
signs of dehydration or cannot maintain adequate oral intake,
initiate IV fluids as prescribed to maintain hydration.
Collaborative:
Labs and Diagnostic Procedures
●​ Work with the pediatric cardiologist: Monitor the child’s
cardiovascular status, as Kawasaki disease can lead to coronary
●​ CBC artery involvement and aneurysms.
○​ mild-to-moderate normochromic anemia is observed in
the acute stage; Drugs:
○​ the white blood cell count (WBC) is moderate to high Acetaminophen (Tylenol)
(50% of patients have a WBC greater than 15,000/µL) PO/IV
●​ Urinalysis​ Drug class: Analgesic/antipyretic
○​ 2 urine proteins hold promise as biomarkers of Kawasaki Moa: Inhibits prostaglandin synthesis in the CNS (minimal anti-inflammatory
disease: meprin A or filamin C; these 2 biomarkers were action). Used to manage fever and mild to moderate pain. Especially useful if
diagnostically superior to ESR or CRP NSAIDs are contraindicated or not well tolerated.
●​ Echocardiography S/E: Hepatotoxicity, rash, mild GI upset
○​ To evaluate for coronary artery aneurysms NR: Assess pain level (before and 30–60 min after administration), Confirm
accurate weight-based dosing, Instruct caregivers to avoid double-dosing
Pathophysiology - not sure with other acetaminophen-containing products (like cold meds)

NCP

Chronic pain r/t inflammation of the myocardium or pericardium as

evidenced by restlessness, irritability, verbal and nonverbal cues of pain
(e.g., crying, guarding, facial grimacing)

Planning:
●​ Short-term: Within 3 days, the child will demonstrate a decrease in
pain score or behavioral indicators of pain.
●​ Long-term: Within 2-4 weeks, the patient will demonstrate
improved activity tolerance with minimal or no pain.

Interventions:
Independent:
●​ Encourage comfort measures such as cuddling, rocking, soft
music, or use of a favorite toy/stuffed animal.
●​ Teach and encourage relaxation techniques suitable for the child’s
developmental stage (e.g., breathing games, blowing bubbles).
Dependent:
●​ Administer prescribed pain relievers (e.g., acetaminophen or
ibuprofen if no contraindications).
Collaborative:
●​ Consult pediatric cardiology for evaluation of cardiac pain and
inflammation.

Hyperthermia r/t inflammation and immune response associated with

Kawasaki disease as evidenced by elevated body temperature, irritability,
and tachycardia.

Planning:
●​ Short-term: The patient will demonstrate a reduction in body
temperature to within normal limits (36.5°C to 37.5°C or 97.7°F to
99.5°F) within 24 hours of intervention.
36
 37) CARDIOMYOPATHY
RESTRICTIVE CARDIOMYOPATHY - not sure

-​ Cardiomyopathy refers to a group of diseases that affect the heart Infiltrative Storage Radiation or Idiopathic
muscle, leading to its dysfunction. The heart muscle becomes diseases (e.g., disorders (e.g., chemotherapy-i
weakened, stiff, or enlarged, and as a result, the heart's ability to amyloidosis, hemochromato nduced fibrosis
pump blood effectively is compromised. sarcoidosis) sis)

-​ Dilated Cardiomyopathy (DCM): The heart muscle weakens and

stretches, causing the heart chambers, especially the left ventricle, Stiff, noncompliant ventricles due to infiltration or fibrosis
to enlarge.
-​ Hypertrophic Cardiomyopathy (HCM): The heart muscle thickens, Diastolic dysfunction: Normal contractility (EF preserved), but impaired
especially in the left ventricle, which can obstruct blood flow and filling
affect the heart's ability to pump.
-​ Restrictive Cardiomyopathy (RCM): The heart muscle becomes Elevated atrial pressures leads to atrial enlargement
stiff and less able to expand, which limits the heart's ability to fill
with blood.
Pulmonary and systemic venous congestion
-​ Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC):The
muscle of the right ventricle is replaced by fatty or fibrous tissue,
disrupting the heart's electrical signals. Signs of right-sided heart failure arrhythmias reduced
exercise
tolerance
Subjective Data

●​ Shortness Of breath NCP

●​ Chest pain
●​ Fatigue Activity intolerance r/t imbalance supply/demand of oxygen and generalized
weakness as evidenced by abnormal BP and HR response to activity, and
Objective Data exertional discomfort, dyspnea, and fatigue

●​ Heart murmur Planning:

●​ Rapid heart rate ●​ Short-term: Patient will demonstrate reduced physiological signs
●​ Edema in the feet, ankles, or legs of intolerance (e.g., stable HR/BP) during mild activity within 3
●​ Pale or bluish skin days.
●​ Long-term: Patient will engage in activity at an individualized,
Labs and Diagnostic Procedures tolerable level without abnormal cardiovascular responses or
excessive fatigue within 1 week.
●​ CBC Interventions:
○​ mild-to-moderate normochromic anemia is observed in Independent:
the acute stage; ●​ Monitor vital signs (HR, BP, SpO₂) before, during, and after activity.
○​ the white blood cell count (WBC) is moderate to high ●​ Assess level of dyspnea and fatigue using standardized scales
(50% of patients have a WBC greater than 15,000/µL) (e.g., Borg or Modified Borg Dyspnea Scale).
●​ Urinalysis​ ●​ Instruct patient in energy conservation techniques (e.g., sit while
○​ 2 urine proteins hold promise as biomarkers of Kawasaki bathing, break tasks into steps).
disease: meprin A or filamin C; these 2 biomarkers were
diagnostically superior to ESR or CRP Dependent:
●​ Echocardiography ●​ Administer prescribed pain relievers (e.g., acetaminophen or
○​ To evaluate for coronary artery aneurysms ibuprofen if no contraindications).
Collaborative:
Pathophysiology ●​ Refer to Physical Therapy (PT) for activity progression plans.

DILATED CARDIOMYOPATHY Risk for decreased cardiac output r/t accumulation of fluid in the pericardial
sac.

Planning:
●​ Short-term: After 24-72 hours of nursing intervention, the patient
will show no signs of decreased perfusion (e.g., cap refill <2
seconds, adequate urine output).
●​ Long-term: After 2-4 weeks or before discharge, the patient will
remain free from cardiac complications related to pericardial
effusion.

Interventions:
Independent:
●​ Monitor vital signs frequently, especially heart rate, BP, and oxygen
saturation.
●​ Assess for signs of tamponade: narrowed pulse pressure, jugular
vein distension, muffled heart sounds (Beck's triad).
●​ Monitor intake and output closely to detect early signs of
decreased perfusion.
Dependent:
HYPERTROPHIC CARDIOMYOPATHY ●​ Administer medications as prescribed (e.g., beta blockers, ACE
inhibitors, diuretics) and monitor their effects on activity tolerance.
Collaborative:
●​ Coordinate with pediatric cardiology for management and
monitoring of cardiac complications.

Drugs:
Captopril / Enapril
PO
Drug class: ACE Inhibitors
Moa: Inhibits the conversion of angiotensin I to angiotensin II, leading to
vasodilation, reduced afterload, and decreased preload → improves cardiac
output and reduces heart workload.
S/E: Hypotension, Hyperkalemia, Renal dysfunction
NR: Monitor BP before and after dose, Monitor renal function (BUN,
creatinine), Monitor serum potassium, Watch for dry persistent cough or
angioedema

37
Furosemide (Lasix)
PO/IV
Drug class: Loop diuretic
Moa: Inhibits reabsorption of sodium and chloride in the ascending loop of
Henle, promoting diuresis and decreasing fluid volume → reduces preload
and improves breathing and oxygenation.
S/E: Hypokalemia, hyponatremia, Dehydration, Hypotension, Ototoxicity (with
rapid IV push or high doses), Metabolic alkalosis
NR: Monitor I&O, daily weight, Monitor electrolytes (esp. K+, Na+), Watch for
signs of dehydration (dry mucous membranes, low UO), Administer early in
the day to avoid nocturia, Slow IV push (1–2 mg/min) to avoid ototoxicity

38
 38) HYDROCEPHALUS respirations), CT/MRI findings showing ventricular dilation

Planning:
-​ Hydrocephalus is the excessive accumulation of cerebrospinal ●​ Short-term: Within 1-3 days of nursing intervention, the patient will
fluid (CSF) within cavities of your brain called ventricles. This maintain stable neurological status with normal LOC and vital
excess fluid causes your ventricles to widen, which puts harmful signs.
press on the tissues of your brain. ●​ Long-term: Within 2 weeks, the patient will maintain adequate
cerebral perfusion as evidenced by normal neurological function
Subjective Data and development.

●​ Headaches Interventions:
●​ Changes in appetite Independent:
●​ Confusion ●​ Keep the head of bed elevated 30°, head midline to promote
●​ Memory loss venous drainage
●​ Conduct neuro checks and vital signs every 2–4 hours, or per
facility protocol.
Objective Data
Dependent:
●​ Administer Osmotic diuretics (e.g., mannitol) or hypertonic saline
●​ Head enlargement to reduce ICP.
●​ Disjunction of sutures Collaborative:
●​ Dilated scalp veins ●​ Consult with pediatric neurology for seizure management and
●​ Tense fontanelle developmental concerns.
●​ Increased spasticity
●​ Setting sun sign (retracted upper eyelids, downward deviation of Drugs:
ocular globes, visible white sclera above iris) Levetiracetam (Keppra)
PO/ IV (common, fewer interactions)
Labs and Diagnostic Procedures Drug class: Anticonvulsants
●​ CT scan Moa: Suppress abnormal neuronal firing in the brain. Stabilize nerve
○​ Assess the size of the ventricles membranes and increase seizure threshold. Control or prevent seizures
●​ MRI caused by increased intracranial pressure (ICP) or cerebral irritation.
○​ To assess for the presence of periaqueductal / S/E: Drowsiness, dizziness, GI upset (nausea/vomiting), Rash (monitor for
cerebellar tumors and chiari malformation (a condition signs of allergy/SJS)
in which brain tissue extends into the spinal canal) NR: Monitor for sedation, ataxia, and behavioral changes. Ensure seizure
●​ Ultrasound (in infants) precautions are in place.
○​ To determine sub ependymal & intraventricular
hemorrhages Mannitol (Osmitrol)
Pathophysiology PO
Drug class: Bulk-forming laxative / dietary fiber
Moa: Create an osmotic gradient between brain tissue and blood. Promotes
water movement out of cerebral cells and reduces brain volume/swelling.
Reduce increased intracranial pressure (ICP) by drawing fluid from brain
tissue into the vascular space for renal excretion.
S/E: Electrolyte imbalances (hyponatremia, hypokalemia).Dehydration,
Hypotension or rebound increased ICP (if overused), Pulmonary edema (in
patients with cardiac issues)​
NR:Administer IV with filter, monitor for crystallization in solution. Monitor
electrolytes, especially sodium and potassium. Strict I&O monitoring and
daily weights. Monitor for signs of fluid overload or dehydration.

NCP

Risk for injury r/t increased ICP

Planning:
●​ Short-term: Within 24-48 hours, the patient will remain free from
injury or seizure during hospitalization
●​ Long-term: Within 2-4 weeks, the patient will maintain stable
neurological status with no signs of increased ICP or shunt
malfunction.

Interventions:
Independent:
●​ Elevate head of bed 30° and maintain midline head alignment to
reduce ICP.
●​ Minimize environmental stimuli (dim lights, quiet room) to reduce
ICP spikes.
●​ Implement seizure precautions: padded side rails, O₂/suction at
bedside.
Dependent:
●​ Administer prescribed anticonvulsants for seizure management
Collaborative:
●​ Physical and occupational therapy for developmental support and
neuro rehab

Ineffective cerebral tissue perfusion r/t decreased arterial or venous blood

flow as evidenced by: changes in LOC, irritability, lethargy, bulging fontanel
(infants), vomiting, altered vital signs (e.g., bradycardia, irregular

39
 39) MICROCEPHALUS ●​ Administer prescribed medications to manage spasticity or
seizures (e.g., baclofen, diazepam).
●​ Implement a prescribed physical therapy regimen or assist with
-​ Microcephaly is a condition that causes your baby’s head to be exercises per doctor's instructions.
smaller than expected for their size and age. Microcephaly
happens when your baby’s brain needs more time to grow or Collaborative:
doesn’t develop completely. ●​ Refer to and coordinate with physical and occupational therapists
for a customized developmental plan.
Subjective Data
Delayed Growth and Development r/t neurological impairment as evidenced
●​ Headaches by failure to meet developmental milestones, abnormal motor tone, and
●​ Changes in appetite cognitive delays.
●​ Confusion
●​ Memory loss Planning:
●​ Short-term: Within 2 weeks, the child will demonstrate progress
toward age-appropriate developmental tasks.
Objective Data
●​ Long-term: Within 3 months, the child will show measurable
improvement in at least one area of development (e.g., motor,
●​ Seizures speech, cognitive).
●​ Issues with cognitive development
●​ Balance, movement and coordination challenges Interventions:
●​ Difficulty feeding or swallowing Independent:
●​ Hearing or vision loss ●​ Monitor and document developmental progress using
age-appropriate screening tools (e.g., Denver Developmental
Labs and Diagnostic Procedures Screening Test).
●​ Encourage the use of age-appropriate stimulation (toys, music,
●​ Prenatal ultrasound games, talking to the child).
○​ Conducted in the second or early third trimester to ●​ Promote bonding and interaction through touch, eye contact, and
detect microcephaly verbal cues.
●​ Blood tests Dependent:
○​ To detect changes to their genetic code or any ●​ Administer prescribed supplements or medications as ordered
underlying conditions (e.g., for seizures, nutrition support).
●​ Head ultrasound or brain MRI Collaborative:
●​ Consult with pediatric neurology for seizure management and
Pathophysiology developmental concerns.

Drugs:
Baclofen
PO, Intrathecal (via pump for severe spasticity)
Drug class: Skeletal muscle relaxant
Moa: Inhibits transmission of reflexes at the spinal cord level by
hyperpolarizing afferent terminals, reducing muscle spasticity. Used to
manage spasticity related to neurological impairments.
S/E: Drowsiness, dizziness, hypotonia (muscle weakness), nausea,
hypotension, seizures (if abruptly withdrawn)
NR: Monitor muscle tone and spasticity. Assess for CNS depression or
changes in mental status. Do not stop abruptly – may cause withdrawal
symptoms including seizures.

Multivitamins (e.g., Poly-Vi-Sol)

PO (drops or syrup)
Moa: Given for overall nutritional supplementation, especially in patients with
feeding difficulties.
S/E: Mild GI upset, Nausea if taken on empty stomach, Staining of teeth
(liquid form)
NR: Monitor growth parameters, nutritional labs (albumin, prealbumin).
Educate caregivers on safe administration of feeds/supplements. Watch for
aspiration risk in oral-fed children.

NCP

Impaired Physical Mobility r/t neuromuscular impairment secondary to

microcephaly as evidenced by limited range of motion, delayed gross motor
development, and dependence on caregivers for movement.

Planning:
●​ Short-term: Within 1 week of nursing interventions, the child will
demonstrate improved range of motion.
●​ Long-term: Within 1-3 months of nursing interventions, the child
will show progress in motor development appropriate to their
condition

Interventions:
Independent:
●​ Assess and monitor motor function and developmental milestones
regularly.
●​ Encourage frequent repositioning to prevent pressure sores and
improve circulation.
●​ Promote age-appropriate play and movement activities (e.g.,
tummy time, reaching for toys).
Dependent:

40
 40) SPINA BIFIDA
Interventions:
Independent:
-​ Spina bifida is when a baby's spine and spinal cord does not ●​ Reposition child every 2 hours to prevent pressure injuries.
develop properly in the womb, causing a gap in the spine. ●​ Encourage age-appropriate mobility activities (e.g., tummy time,
-​ Spina bifida is a type of neural tube defect. The neural tube is the supported sitting)
structure that eventually develops into the baby's brain and spinal Dependent:
cord. ●​ Administer prescribed medications (e.g., antispasmodics,
-​ The neural tube starts to form in early pregnancy and closes about analgesics).
4 weeks after conception. Collaborative:
-​ In spina bifida, part of the neural tube does not develop or close ●​ Coordinate with occupational therapy for fine motor skill
properly, leading to defects in the spinal cord and bones of the development and adaptive equipment.
spine (vertebrae).
Risk for Infection r/t impaired skin integrity, urinary stasis (neurogenic
Subjective Data bladder), and surgical interventions (e.g., spinal lesion repair).

●​ Pain Planning:
●​ Weakness ●​ Short-term: Within 72 hours, the child’s surgical site or open lesion
●​ Bowel/bladder dysfunction area will remain clean, dry, and show no signs of redness, swelling,
or drainage.
●​ Long-term: Within 2 weeks of discharge, the child will return for a
Objective Data
follow-up visit with no evidence of infection (e.g., afebrile, intact
skin, no urinary symptoms).
●​ Visible defects
●​ Muscle weakness Interventions:
●​ Sensory deficits Independent:
●​ Orthopedic deformities ●​ Inspect surgical site or back lesion area for signs of infection daily.
●​ Educate caregivers on clean intermittent catheterization (if used)
Labs and Diagnostic Procedures and proper hygiene.
Dependent:
●​ Blood test. ●​ Administer prophylactic or prescribed antibiotics as ordered.
○​ A test called a quad screen measures 4 substances in Collaborative:
the mother's blood to see if there is an increased risk for ●​ Collaborate with a wound care nurse for specialized dressing
neural tube defects and other problems. This test is recommendations.
done between 16 and 18 weeks of pregnancy. It
measures levels of alpha-fetoprotein (AFP) and other Drugs:
things in the blood. Baclofen
○​ The test isn’t conclusive, but it can show if your baby is PO, Intrathecal (via pump for severe spasticity)
at risk for an open neural tube defect. Drug class: Skeletal muscle relaxant
●​ Chorionic villus sampling Moa: Inhibits transmission of reflexes at the spinal cord level by
○​ A method for prenatal diagnosis of NTDs; however it hyperpolarizing afferent terminals, reducing muscle spasticity and improves
carries certain risks (skeletal limb depletion) and is not mobility.
recommended before 10 weeks of gestation S/E: Drowsiness, dizziness, hypotonia (muscle weakness), nausea,
●​ Prenatal ultrasound. hypotension, seizures (if abruptly withdrawn)
○​ Ultrasounds let healthcare providers see the internal NR: Monitor muscle tone and spasticity. Assess for CNS depression or
organs as they function. They also show blood flow changes in mental status. Do not stop abruptly – may cause withdrawal
through blood vessels. Prenatal ultrasound may be able symptoms including seizures.
to find an open neural tube defect. Your provider may
also use ultrasound to look at other organs and body Ceftriaxone
systems of the baby IV/IM
●​ Amniocentesis. Moa: Inhibits bacterial cell wall synthesis, leading to cell death and lysis.
○​ To sample the amniotic fluid and check for AFP. The test Treatment or prevention of surgical site or urinary infections.
may not be able to find small or closed defects S/E: Diarrhea, Rash, Possible yeast infections
NR: Monitor for allergic reaction, especially if penicillin allergy, Assess for
Pathophysiology signs of superinfection (e.g., thrush, diarrhea)

NCP

Impaired physical mobility r/t neuromuscular deficit as evidenced by limited

lower limb function and inability to ambulate independently.

Planning:
●​ Short-term: Within 1 week of nursing interventions, the child will
demonstrate improved participation in mobility-related activities
(e.g., rolling, sitting, use of wheelchair)
●​ Long-term: Within 6 months, the child will achieve optimal mobility
using assistive devices.
41
 41) SICKLE CELL ANEMIA As evidenced by verbal reports of pain, crying, guarding behavior,
decreased activity, increased heart rate, grimacing

-​ Sickle Cell Anemia is a genetic blood disorder where red blood Planning:
cells become sickle-shaped (like a crescent moon) instead of ●​ Short-term: Within 1 hour of nursing interventions, the child will
being round and flexible. This abnormal shape can block blood report decreased pain (≤ 3/10) or demonstrate reduced pain
flow in small blood vessels, causing pain and potentially damaging behaviors.
organs. It mainly affects people of African, Mediterranean, and ●​ Long-Term: Within 6 months, the child will experience fewer sickle
Middle Eastern descent. cell crises through adherence to pain management and
preventative strategies.
Subjective Data
Interventions:
●​ Pain Independent:
●​ Weakness ●​ Use non-pharmacologic pain relief (distraction, heat application,
●​ Bowel/bladder dysfunction guided imagery).
●​ Provide a calm environment to reduce stress-induced pain crises.
●​ Encourage hydration if tolerated (to reduce sickling).
Objective Data
Dependent:
●​ Administer prescribed analgesics (e.g., opioids like morphine,
●​ Visible defects NSAIDs).
●​ Muscle weakness ●​ Administer IV fluids as prescribed to promote blood flow.
●​ Sensory deficits Collaborative:
●​ Orthopedic deformities ●​ Consult with pain management team for persistent or complex
pain.
Labs and Diagnostic Procedures
Ineffective tissue perfusion r/t obstruction of blood flow by sickled red
●​ Routine hematologic tests blood cells as evidenced by delayed capillary refill, cool extremities, weak
○​ To evaluate the anemia. peripheral pulses, pallor or cyanosis
●​ Sickle-turbidity test (Sickledex)
○​ frequently used because it can be performed on blood Planning:
from fingerstick and yields accurate results in 3 minutes. ●​ Short-term: Within 12 hours of nursing interventions, the child will
However, if the test is positive, Hgb electrophoresis is maintain adequate peripheral tissue perfusion as evidenced by
necessary to distinguish between those children with the warm skin, capillary refill < 2 seconds, and strong peripheral
trait and those with the disease. pulses.
●​ Hemoglobin electrophoresis (fingerprinting of the protein) ●​ Long-term: Within 24 hours of nursing interventions, the child will
○​ An accurate, rapid and specific test for detecting the exhibit warm, pink extremities with brisk capillary refill and
homozygous and heterozygous forms of the disease, as maintains normal range of oxygen saturation.
well as the percentages of the various types of Hgb
●​ CBC Interventions:
○​ Reticulocytosis (count may vary from 30%–50%); Independent:
leukocytosis (especially in vaso-occlusive crisis), with ●​ Encourage adequate oral fluid intake to decrease blood viscosity.
counts over 20,000 indicate infection, decreased Hb ●​ Position child to promote circulation (avoid restrictive clothing,
(5–10 g/dL) and total RBCs, elevated platelets, and a avoid pressure on extremities).
normal to elevated MCV. ●​ Educate family about recognizing early signs of impaired
●​ ESR perfusion.
○​ Elevated. Dependent:
●​ ABGs ●​ Administer prescribed IV fluids to promote hydration.
○​ May reflect decreased Po2 (defects in gas exchange at ●​ Administer blood transfusions if ordered to correct severe anemia
the alveolar capillary level); acidosis (hypoxemia and and improve perfusion.
acidic states in vaso-occlusive crisis). Collaborative:
●​ Collaborate with hematology specialists for long-term
Pathophysiology management (e.g., hydroxyurea therapy).

Drugs:

Morphine sulfate
Drug class: Opioid Analgesic (Narcotic)​
Mechanism of Action: Binds to opioid receptors in the CNS, altering the
perception of and response to painful stimuli. Moderate to severe pain
SE: Constipation, sedation, respiratory depression, nausea, hypotension​
NR: Monitor respiratory rate and depth (risk of respiratory depression).
Assess pain intensity regularly. Use a sedation scale if available. Have
naloxone (antidote) available for overdose.

Hydroxyurea
Drug class: Antineoplastic Agent; Sickle Cell Disease Modifier
Moa: Increases production of fetal hemoglobin (HbF), which reduces the
sickling of red blood cells and decreases vaso-occlusive events. Reduction of
frequency of sickle cell crises; Severe sickle cell anemia​
SE: Myelosuppression (low WBCs, platelets), nausea, rash, gastrointestinal
discomfort
NR: Monitor complete blood count (CBC) regularly (risk of bone marrow
suppression). Educate patient/family about teratogenic effects; use
contraception if of childbearing age. Watch for signs of infection or unusual
bleeding.

NCP

Acute pain r/t tissue ischemia secondary to sickled red blood cells
obstructing blood flow
42
 42) HEMOPHILIA ●​ Teach signs of internal bleeding (joint swelling, limited movement,
pain).
Dependent:
-​ Hemophilia is a rare, genetic blood disorder that happens when ●​ Administer prophylactic clotting factor replacement as ordered.
your blood doesn’t clot enough to make your bleeding slow down Collaborative:
or stop. Hemophilia happens when you don’t have the normal ●​ Work with physical therapy to develop a safe exercise plan.
amount of clotting factors. Clotting factors help blood clot.
Healthcare providers treat hemophilia by replacing missing clotting Acute pain r/t bleeding into joints or soft tissues as evidenced by verbal
factors. reports of pain, guarding behavior, swelling, limited range of motion

Subjective Data Planning:

●​ Short-term: Within 24 hours of nursing interventions, the child will
●​ Pain report reduced pain level.
●​ Swelling ●​ Long-term: Within 1 month, the child will remain free from chronic
●​ Bleeding episodes joint damage related to repeated hemarthrosis.

Interventions:
Objective Data
Independent:
●​ Apply ice packs (as tolerated) to affected area for
●​ Bruising vasoconstriction.
●​ Hematomas ●​ Elevate painful extremities to reduce swelling.
●​ Joint inflammation ●​ Provide distraction techniques (toys, music, breathing exercises).
Dependent:
Labs and Diagnostic Procedures ●​ Give analgesics (e.g., acetaminophen); avoid NSAIDs like ibuprofen
(increased bleeding risk).
●​ Complete blood count (CBC) Collaborative:
○​ Providers use this test to measure and study blood cells. ●​ Refer to pain management team if recurrent severe pain.
○​ Usually normal in hemophilia, since the disorder is ●​ Work with physical therapy for safe joint exercises after acute
related to clotting factors, not platelets—but this helps bleeding resolves.
rule out other bleeding disorders like thrombocytopenia.
○​ WBCs: Elevated WBCs may suggest infection, especially Drugs:
with joint bleeds (hemarthrosis) or if fever is present. Factor VIII (for hemophilia A) / Factor IX (for hemophilia B)
●​ Prothrombin time test (PT) IV infusion
○​ Providers use this test to see how quickly your blood Drug class: Coagulation factor replacement
clots. Moa: Directly supplies the deficient factor, promoting normal clot formation.
○​ PT is usually normal in Hemophilia A (Factor VIII To replace missing clotting factor and prevent or treat bleeding episodes
deficiency) and Hemophilia B (Factor IX deficiency), S/E: Fever, injection site reaction, development of inhibitors (antibodies)
because these clotting factors are part of the intrinsic NR: Confirm type and severity of hemophilia (A vs B). Administer ASAP
pathway. during bleeding episode. Monitor for signs of allergic reaction
○​ Helps rule out other clotting disorders involving the
extrinsic pathway (e.g., liver disease, vitamin K Acetaminophen (paracetamol, tylenol)
deficiency). Oral, rectal, IV
●​ Partial thromboplastin time test (PTT) Drug class: non-opioid analgesic, antipyretic
○​ This is another blood test to time blood clot formation. Moa: Inhibits prostaglandin synthesis (central action). Pain relief from
○​ Prolonged PTT is a hallmark of Hemophilia A or B, since hemarthrosis or soft tissue bleeding
these disorders involve Factor VIII or IX deficiency. S/E: Hepatotoxicity, rash, mild GI upset
○​ If PTT is high, suspect hemophilia—but further testing NR: Use weight-based dosing. Avoid exceeding max daily dose (generally 75
(see next) is needed to confirm which factor is deficient. mg/kg/day or 4g max). Monitor liver function if used long-term

Pathophysiology

NCP

Risk for Injury r/t deficiency of clotting factors

Planning:
●​ Short-term: Child will remain free from new bleeding episodes
during hospitalization.
●​ Long-term: Within 3 months, the child will have no emergency
hospital visits for bleeding episodes

Interventions:
Independent:
●​ Educate child and caregivers about avoiding contact sports and
high-risk activities.
●​ Encourage use of helmets, knee pads, and soft play surfaces.
43
 43) THALASSEMIA ●​ Refer to nutritionist for diet supportive of iron balance (avoid
excess iron intake if iron overload is present).

-​ Thalassemia is a genetic blood disorder where the body doesn’t Activity intolerance r/t imbalance of oxygen supply and consumption needs.
make enough hemoglobin, the protein in red blood cells that
carries oxygen. This leads to anemia—a condition where the body Planning:
doesn't get enough oxygen. There are two main types: ●​ Within 24 hours, the child demonstrated improved activity
tolerance.
Subjective Data ●​ Within 1-3 days, the child will maintain adequate energy levels to
participate in age-appropriate activities and achieve normal growth
●​ Fatigue and development milestones.
●​ Weakness
●​ Dizziness Interventions:
●​ Headache Independent:
●​ Leg cramps ●​ Encourage energy conservation techniques (e.g., rest periods
between activities, prioritize important tasks).
●​ Teach the child and family about signs of overexertion and the
Objective Data
importance of pacing activities.
●​ Promote a balanced diet rich in iron (if not contraindicated) and
●​ Pale or yellowish skin essential nutrients.
●​ Facial bone deformities Dependent:
●​ Slow growth ●​ Administer blood transfusions as prescribed to improve
●​ Dark urine hemoglobin levels and reduce symptoms of anemia.
●​ Abdominal swelling ●​ Administer folic acid supplements if ordered (to support red blood
●​ tachycardia cell production).
●​ Administer iron chelation therapy (e.g., deferoxamine) if the child is
Labs and Diagnostic Procedures receiving regular transfusions to prevent iron overload.
Collaborative:
●​ Chorionic villus sampling. ●​ Collaborate with a hematologist for individualized treatment plans
○​ Usually done around the 11th week of pregnancy, this (e.g., transfusion schedules, chelation therapy).
test involves removing a tiny piece of the placenta for ●​ Refer to a dietitian for nutritional counseling tailored to the child’s
evaluation needs (high protein, high folate foods).
●​ Amniocentesis. ●​ Work with a physical therapist or occupational therapist to develop
○​ Usually done around the 16th week of pregnancy, this an appropriate activity/exercise plan.
test involves examining a sample of the fluid that
surrounds the fetus Drugs:
●​ Blood test Packed Red Blood Cell Transfusion (PRBC)
○​ To test for anemia, abnormal hemoglobin, and the shape IV infusion
of the blood cells. Oddly shaped RBCs are a sign of Drug class: Blood product
thalassemia. Moa: Increases oxygen-carrying capacity by replacing lost red blood cells.
●​ Hemoglobin electrophoresis test Used for severe anemia, low hemoglobin levels, symptomatic hypoxia.
○​ Separates out the different molecules in the red blood S/E: Febrile non-hemolytic transfusion reaction, allergic reactions, iron
cells, allowing them to identify abnormal type. overload, hemolytic reaction (rare)

Pathophysiology NR: Confirm patient identity, blood type, and crossmatch before infusion.
Monitor vital signs before, during, and after transfusion. Watch for signs of
transfusion reaction (fever, chills, rash, hypotension)

Deferasirox (Exjade, Jadenu)

OP
Drug class: Oral iron-chelating agent
Moa: Binds to iron and enhances excretion via feces. Used for iron overload
in chronic transfusion-dependent thalassemia.
S/E: GI upset (nausea, diarrhea). Increased liver enzymes. Proteinuria
NR: Administer on an empty stomach, preferably at the same time daily.
Monitor kidney and liver function regularly. Educate caregivers about correct
dosing and preparation

NCP

Ineffective Tissue Perfusion r/r reduced cellular components (hemoglobin)

essential for oxygen delivery as evidenced by pallor, fatigue, tachycardia,
delayed capillary refill, low hemoglobin/hematocrit, weakness

Planning:
●​ Short-term: Within 3 days, the patient will demonstrate improved
perfusion as evidenced by warm skin and capillary refill <2
seconds OR Hemoglobin levels will increase or stabilize (per MD
goal) within 72 hours post-transfusion (if given).
●​ Long-term: Within 1 month, the patient will show consistent
improvement in energy levels and oxygenation parameters.

Interventions:
Independent:
●​ Monitor skin color, temperature, and perfusion every 4 hours.
●​ Elevate lower extremities if extremities are cool or cyanotic.
●​ Educate family on signs of poor perfusion and when to seek help.
Dependent:
●​ Administer blood transfusions as prescribed.
●​ Administer prescribed iron chelation therapy (e.g., deferoxamine) if
iron overload occurs.
Collaborative:
●​ Collaborate with hematologist for transfusion schedule.

44
 44) ACUTE LYMPHOCYTIC LEUKEMIA ●​ Encourage adequate hydration and rest to support immune
function.
Dependent:
-​ Acute lymphocytic leukemia (ALL) is a type of cancer of the blood ●​ Administer prescribed antibiotics, antifungals, or antivirals as a
and bone marrow — the spongy tissue inside bones where blood prophylactic or treatment.
cells are made. Collaborative:
-​ The word "acute" in acute lymphocytic leukemia comes from the ●​ Collaborate with the oncologist/hematologist regarding the
fact that the disease progresses rapidly and creates immature treatment plan.
blood cells, rather than mature ones. The word "lymphocytic" in
acute lymphocytic leukemia refers to the white blood cells called Ineffective tissue perfusion r/t reduced red blood cell production and
lymphocytes, which ALL affects. Acute lymphocytic leukemia is anemia secondary to leukemia and chemotherapy.
also known as acute lymphoblastic leukemia.
Planning:
Subjective Data ●​ Short-term: Within 3 days, the child will demonstrate improved
perfusion as evidenced by capillary refill <3 seconds, warm
●​ Shortness of breath extremities, and stable vital signs. goal).
●​ Weakness, fatigue, or a general decrease in energy ●​ Long-term: Within 1 week, the child and caregivers will verbalize
●​ Fever understanding of the need for regular monitoring and management
●​ Bone pain of anemia to maintain adequate perfusion.

Interventions:
Objective Data
Independent:
●​ Monitor vital signs (HR, BP, O2 saturation) and assess for signs of
●​ Bleeding gums poor perfusion every shift.
●​ Lumps caused by swollen lymph nodes in and around the neck, ●​ Assess for pallor, cold extremities, delayed capillary refill, and
armpits, abdomen, or groin changes in mental status.
●​ Pale skin ●​ Encourage quiet activities and frequent rest periods to reduce
oxygen demand.
Labs and Diagnostic Procedures ●​ Elevate legs slightly when lying down to promote venous return (if
not contraindicated).
●​ Blood tests ●​ Educate family on signs of worsening perfusion and importance of
○​ May also show the presence of blast cells — immature follow-up.
cells normally found in the bone marrow.
●​ Bone marrow tests Dependent:
○​ During bone marrow aspiration and biopsy, a needle is ●​ Administer packed red blood cell (PRBC) transfusions as
used to remove a sample of bone marrow from the hip prescribed for anemia.
bone or breastbone. The sample is sent to a lab for Collaborative:
testing to look for leukemia cells. ●​ Coordinate with the oncologist for chemotherapy schedules and
●​ Imaging tests dose adjustments based on perfusion status and labs.
○​ Imaging tests such as an X-ray, a computerized ●​ Work with a nutritionist to promote a diet rich in iron, folic acid, and
tomography (CT) scan or an ultrasound scan may help B12 to support RBC production (if applicable).
determine whether cancer has spread to the brain and
spinal cord or other parts of the body.
●​ Spinal fluid tests Drugs:
○​ The sample is tested to see whether cancer cells have
spread to the spinal fluid.

Pathophysiology - inc

NCP

Risk for infection r/t overproduction of immature WBCs

Planning:
●​ Short-term: Within 24 hours, the child will remain afebrile and show
no clinical signs of infection.
●​ Long-term: Within 1 week, the child will remain infection-free
throughout the treatment phase.
Interventions:
Independent:
●​ Educate child (age-appropriate) and caregivers about infection
prevention, including proper hand hygiene and avoiding sick
contacts.
●​ Assess and monitor for early signs of infection (e.g., fever, rash,
behavioral changes).
●​ Promote a clean, safe environment: disinfect high-touch surfaces,
toys, etc.​

45
 ●​ Short-term: After 1 hour of nursing intervention, the caregivers will
45) CEREBRAL PALSY demonstrate and verbalize at least 2 seizure precautionary
methods
●​ Long-term: After 24 hours, the patient will remain free from injury
-​ Cerebral palsy (CP) is a neurological condition that can present as during seizure activities
issues with muscle tone, posture and/or a movement disorder. It’s
the result of damage to your brain during fetal development or Interventions:
another developmental disability that affects the way your brain Independent:
develops. The signs and symptoms of CP appear early in ●​ .Pad side rails and keep bed in low position.
childhood and can vary widely from person to person. ●​ Supervise child during mobility or transfers.
●​ Maintain a calm environment to reduce spasticity and seizure
Subjective Data triggers.
●​ Educate caregivers on seizure first aid (e.g., positioning, timing,
●​ Patient's and family's perspectives on the child's development, when to call for help)
motor skills, and any reported symptoms or concerns Dependent:
●​ Administer antiepileptic drugs (e.g., valproic acid, levetiracetam)
as prescribed.
Objective Data
Collaborative:
●​ Collaborate with physical and occupational therapists to develop a
●​ Irritability safe mobility plan.
●​ Hypotonia
●​ Delayed development Impaired physical mobility r/t spasms and muscle weakness.
●​ Stiffness in your arms and legs that makes them hard to bend or
use (spasticity). Planning:
●​ Uncoordinated movements. ●​ Short-term: Within 1 week of nursing interventions, the child will
●​ Movements that look like they’re slow and writhing or twisting. maintain or increase muscle strength and function of the affected
●​ Movements that look like you’re flinging or throwing or fidgeting or extremity.
dancing. ●​ Long-term: Within 1 month of nursing interventions, the child will
●​ Spasms or contractions might cause you to hold an uncomfortable achieve or progress toward individualized mobility milestones (e.g.,
or painful pose (dystonia). sit with support, transfer independently)

Labs and Diagnostic Procedures Interventions:

Independent:
●​ MRI. ●​ Perform passive or active ROM exercises.
○​ An MRI can often identify changes in your child's brain. ●​ Position in alignment to prevent complications.
This test is painless, but it is noisy and can take up to an ●​ Teach how to ambulate with adaptive equipment.
hour to complete. Your child will likely receive a sedative Dependent:
or light general anesthesia beforehand. ●​ Administer a baclofen pump as ordered.
●​ Cranial ultrasound. Collaborative:
○​ An ultrasound doesn't produce a detailed image, but it ●​ Collaborate with PT/OT.
may be used because it's quick and it can provide a ○​ PT programs can improve muscle strength and balance,
valuable preliminary assessment of the brain. and OT can recommend ways to complete everyday
●​ Electroencephalogram (EEG) activities.
○​ If your child is suspected of having seizures, an EEG can
evaluate the condition further. Seizures can develop in a Drugs:
child with epilepsy. In an EEG test, a series of electrodes Valproic Acid (Depakene, Depakote)
are attached to your child's scalp. The EEG records the PO/IV
electrical activity of your child's brain. Changes in brain Drug class: Anticonvulsant, mood stabilizer
wave patterns are common in epilepsy. Moa: Increases brain concentrations of GABA (an inhibitory
●​ Tests of the blood, urine or skin neurotransmitter). Suppresses abnormal electrical activity in the brain.
○​ Used to screen for genetic or metabolic conditions. Management of generalized or focal seizures associated with cerebral palsy.
●​ If your child is diagnosed with cerebral palsy, your child likely will S/E: Common: Drowsiness, GI upset, weight gain, tremor; Serious:
be referred to specialists to have tests for other conditions. These Hepatotoxicity, pancreatitis, thrombocytopenia, hyperammonemia
tests can look at: NR: Monitor liver function tests (AST, ALT), especially during first 6 months.
○​ Vision. Watch for signs of liver toxicity (jaundice, vomiting, lethargy). Educate family
○​ Hearing. about importance of medication adherence and seizure tracking
○​ Speech.
○​ Intellect. Baclofen (Lioresal)
○​ Development. PO/Intrathecal
○​ Movement. Drug class: Skeletal muscle relaxant, central-acting
○​ Other medical conditions. Moa: Acts as a GABA-B agonist in the spinal cord. Reduces transmission of
nerve signals that cause muscle spasms. Treatment of muscle spasticity and
Pathophysiology involuntary spasms.
S/E: Common: Drowsiness, hypotonia, nausea, dizziness; Serious:
Respiratory depression (at high doses), withdrawal seizures (if stopped
abruptly)
NR: Start low and titrate slowly to minimize sedation and hypotonia. Monitor
for improvement in mobility and reduced spasticity. Teach caregivers not to
suddenly stop the drug – taper under supervision. Intrathecal pump therapy
may be considered for severe spasticity – requires surgical placement and
maintenance.

NCP

Risk for injury r/t spasms, uncontrolled movements, and seizures.

Planning:
46
 46) HIRSCHSPRUNG'S DISEASE
Imbalanced Nutrition: Less than body requirements r/t poor feeding and
malabsorption
-​ Congenital condition where ganglion cells (nerve cells) are
missing in a portion of the colon leading to stool buildup and Planning:
obstruction. ●​ Within 24 hours of nursing interventions, the child will demonstrate
-​ Ganglion cells- coordinate rhythmic contractions and relaxations of improved feeding tolerance and gain at least 100–200 grams per
the colon wall. (peristalsis) week (depending on age) within 1 week.
●​ Within 1 week of nursing interventions, the child will achieve and
Subjective Data maintain weight and growth parameters appropriate for age and
N/A show no signs of malnutrition
Objective Data
Interventions:
Independent:
●​ No meconium passage within the first 24–48 hours of life: no ●​ Encourage small, frequent feedings to enhance tolerance.
nerve stimulation = no stool passage ●​ Position child upright during and after feedings to reduce
●​ Abdominal distention: stool and gas accumulation abdominal pressure and promote digestion.
●​ Bilious vomiting: backflow of contents due to obstruction ●​ Provide a calm feeding environment to prevent fatigue.
●​ Constipation ●​ Educate parents about recognizing signs of feeding intolerance
●​ Ribbon-like, foul-smelling stools (if present) (e.g., vomiting, distention).
Dependent:
Labs and Diagnostic Procedures ●​ .Administer prescribed nutritional supplements (e.g., high-calorie
formulas or oral supplements).
●​ CBC ●​ Administer parenteral nutrition (TPN) if ordered in cases of severe
○​ To test if enterocolitis is suspected; elevation of WBC malabsorption or pre/post-surgical support.
count or a bandemia should raise concern for Collaborative:
enterocolitis ●​ Collaborate with a pediatric dietitian to develop an individualized
●​ Abdominal X-ray feeding and nutrition plan based on caloric needs.
○​ Diagnosing intestinal obstruction and hirschsprung’s
associated enterocolitis. Drugs:
○​ Shows narrowed segment of colon Fleet enema (sodium phosphate)
●​ Rectal biopsy ! ! ! - to confirm diagnosis Drug class: saline laxative (osmotic)
○​ Shows absence of ganglion cells Moa:Draws water into the bowel by osmotic activity, increasing pressure in
the colon and stimulating peristalsis, leading to bowel evacuation.
Pathophysiology S/E: Abdominal cramping, diarrhea, dehydration, electrolyte imbalance
NR:Monitor for signs of dehydration (sunken fontanelles, dry mucous
membranes, decreased urine output), Assess electrolyte levels, especially in
repeated or frequent use, Ensure proper administration technique (insert
lubricated tip rectally, retain as long as possible).

During fetal development, neural crest cells fail to migrate completely to the
distal colon → aganglionic segment → this portion can't relax or coordinate
peristalsis → leads to functional obstruction and stool buildup behind the
affected area.

NCP

Constipation related to absence of peristalsis in a portion of the colon

(aganglionic segment)

Planning:
●​ Short-term: The child will pass stool or have a successful bowel
evacuation within 24–48 hours.
●​ Long-term: The child will maintain regular bowel movements
post-surgery without need for enemas.

Interventions:
Independent:
●​ Assess and record bowel patterns, abdominal girth, and feeding
tolerance daily.
●​ Educate caregivers on signs of bowel obstruction and home bowel
care routines.
●​ Encourage proper positioning during and after feeding.

Dependent:
●​ Administer ordered enemas for bowel evacuation.
●​ Keep patient NPO if preparing for surgical correction.

Collaborative:
●​ Coordinate with pediatric surgeon for pull-through procedure or
colostomy.
●​ Involve a nutritionist for feeding plans post-intervention.
47
 47) IRRITABLE BOWEL SYNDROME Drug class: Analgesic/antipyretic
Moa: Inhibits prostaglandin synthesis (central action), relief of mild
abdominal pain
-​ Irritable bowel syndrome (IBS) is a group of symptoms that affect S/E: Hepatotoxicity, rash, mild GI upset
your digestive system. It’s a common but uncomfortable chronic NR: Assess pain level (before and 30–60 min after administration), Confirm
gastrointestinal disease, or condition that affects your intestines. accurate weight-based dosing, Instruct caregivers to avoid double-dosing
-​ People with IBS experience symptoms that include abdominal pain with other acetaminophen-containing products (like cold meds)
and cramps. With IBS, you may also have frequent diarrhea,
constipation or both. Psyllium Husk (Metamucil, Konsyl, Fiberall)
-​ Abdominal pain and altered bowel habits (diarrhea, constipation, PO
or both) without any structural or biochemical abnormalities. Drug class: Bulk-forming laxative / dietary fiber
Moa: Psyllium is a soluble fiber that absorbs water in the intestine, forming a
Subjective Data gel-like bulk. This promotes natural peristalsis and helps regulate stool
consistency—either softening hard stools (IBS-C) or adding bulk to loose
●​ Bloating stools (IBS-D).
●​ Pain during eating S/E: Gas, bloating, cramping
●​ Constipation NR:Introduce gradually to prevent bloating, Ensure adequate hydration to
support fiber action (minimum 6–8 cups/day)
Objective Data
Polyethylene Glycol (3350)
PO
●​ Abdominal distention and tenderness on palpation Drug class: Osmotic laxative
●​ Altered bowel patterns (alternating constipation and diarrhea) MOA: PEG 3350 causes water retention in the stool, which helps to soften the
●​ Increased bowel sounds (hyperactive or hypoactive depending on stool and increase bowel movement frequency. This makes it effective for
IBS subtype) treating constipation.
S/E: Bloating, gas, nausea, diarrhea
Labs and Diagnostic Procedures NR: Monitor Bowel Function: Assess the patient's usual pattern of bowel
function, including frequency and consistency of stools. Ensure the correct
●​ Blood test dosage is administered. PEG 3350 is typically given as 17 grams of powder
○​ To determine if pt has anemia, infection, or illness mixed with 240 mL of water. Encourage the patient to drink plenty of fluids to
caused by inflammation or irritation help the medication work effectively.
●​ Stool sample
○​ To check for bacteria and parasites that may cause
diarrhea
●​ Urinalysis and culture
○​ To check for UTI

Pathophysiology
Risk factors: stress, history of GI infections → Heightened sensitivity of the
nerves in the intestine → causes are UNSURE but are likely due to short-chain
carbohydrates → draws water across the GI & into the lumen → causes pain,
smooth muscle spasm, diarrhea

NCP

Chronic pain r/t altered gastrointestinal motility as evidenced by __

Planning:
●​ Short-term: The child will report reduced abdominal pain within
24-48 hours of dietary or pharmacologic interventions.
●​ Long-term: The child will maintain regular bowel patterns within 2-4
weeks with lifestyle modifications.

Interventions:
Independent:
●​ Assess and document pain location, intensity, duration, and
aggravating/relieving factors every shift.
●​ Monitor and record bowel patterns (frequency, color, consistency
of stools).
Dependent:
●​ Administer mild analgesics as prescribed (e.g., acetaminophen) for
abdominal discomfort.
Collaborative:
●​ Refer to dietitian for personalized meal planning (especially if
initiating low-FODMAP diet).

Constipation r/t inadequate fluid/fiber intake as evidenced by __

Planning:
●​ Short-term: The child will have a soft, formed bowel movement
within 24–48 hours of intervention.
●​ Long-term: The child will establish a regular bowel pattern (every
1–2 days) within 2–3 weeks.

Interventions:
Independent:
●​ Encourage increased fluid intake (at least 6–8 cups/day unless
contraindicated).​
Promote high-fiber food choices (fruits, vegetables, whole grains).
Dependent:
●​ Administer prescribed osmotic laxatives (e.g., Polyethylene
Glycol/PEG 3350) or stool softeners
●​ Give fiber supplements as ordered (e.g., psyllium husk).
Collaborative:
●​ Consult a dietitian for a child-friendly high-fiber diet plan.

Drugs:
Acetaminophen (Tylenol)
PO
48
 48. MECKEL DIVERTICULITIS ●​ Notify physician if patient develops:

Drugs:
-​ Meckel diverticulum is a congenital anomaly resulting from the Acetaminophen (Tylenol)
incomplete obliteration of the vitelline duct, leading to a true PO
diverticulum in the ileum. It often contains ectopic tissue, such as Drug class: Analgesic/antipyretic
gastric or pancreatic tissue, which can cause complications like Moa: Inhibits prostaglandin synthesis in the CNS, lowering the pain threshold
bleeding or inflammation. and reducing fever; No anti-inflammatory effect, making it gentler on the GI
-​ Outpouching in the small intestine tract compared to NSAIDs.
S/E: Generally well-tolerated; Rare: rash, GI upset; Overdose risk:
Subjective Data hepatotoxicity (may present as nausea, RUQ pain, confusion)
NR: Ensure accurate weight-based dosing; Educate parents to avoid duplicate
●​ RLQ pain dosing from multiple meds (e.g., cold meds with acetaminophen); Monitor
●​ NV liver function in prolonged use or high-dose therapy

Objective Data

●​ Elevated white blood cell (WBC) count indicating infection

●​ Abdominal distention and tenderness on palpation
●​ Fever and chills

Labs and Diagnostic Procedures

●​ Blood test
○​ To determine if pt has anemia, infection.
●​ Meckel’s scan
○​ Indicates areas where acid-secreting stomach tissue
exists
●​ Colonoscopy
○​ The inside of the rectum and large intestine are
evaluated for bleeding, blockage and other problems

Pathophysiology

During fetal development, vitelline duct connects the yolk sac to the
midgut of embryo

(If) Failure of vitelline duct to involute / doesn’t disappear between 5-7

weeks gestation

Presence of ectopic gastric tissue

Secrete acid Inflammation

Ulceratio Bleeding Pain Obstructi Perforati Peritoniti

n on on s

Bloody
stool,
black
tarry
stool

NCP

Acute Pain r/t inflammation of the intestinal wall as evidenced by

Planning:
●​ Short-term: The child will report decreased abdominal pain within 1
hour of pain management interventions.
●​ Long-term: The child will be pain-free and resume normal bowel
function within 3–5 days of treatment.

Interventions:
Independent:
●​ Assess pain level using age-appropriate scale (e.g., FLACC,
Wong-Baker Faces).
●​ Encourage position of comfort (fetal position, side-lying with knees
bent).
Dependent:
●​ Administer prescribed analgesics (e.g., acetaminophen or IV
opioids for moderate to severe pain).
Collaborative:
●​ Collaborate with nutritionists for post-op diet advancement (clear
→ soft → regular).

Risk for deficient fluid volume r/t vomiting, bleeding

Planning:

Interventions:
Independent:

Dependent:
Collaborative:
49
 49. CROHN’S DISEASE ●​ Short-term: The patient will consume at least 75% of meals within
3 days
●​ Long-term: The patient will demonstrate weight gain of 0.5–1 kg
-​ An inflammatory bowel disease (IBD) that causes chronic, within 2 weeks
relapsing inflammation of the gastrointestinal (GI) tract. It can
affect any part of the GI tract from the mouth to the anus, but most Interventions:
commonly involves the terminal ileum and colon. Independent:
●​ Monitor daily weight and calorie intake.
Subjective Data ●​ Encourage small, frequent, nutrient-dense meals to reduce satiety
fatigue.
●​ Abdominal pain/tenderness (RLQ): Inflammation of the terminal ●​ Encourage intake of well-tolerated, low-fiber, high-protein foods
ileum during flare-ups.
●​ Loss of appetite: Chronic inflammation, abdominal pain, and Dependent:
nausea lead to reduced desire to eat ●​ Administer anti-inflammatory therapy (e.g., corticosteroids or
biologics) to reduce bowel inflammation and improve nutrient
absorption.
Objective Data
Collaborative:
●​ Collaborate with a dietitian to develop a tailored nutrition plan
●​ Diarrhea: Inflammation disrupts normal absorption and motility in based on caloric and protein needs.
the intestines, leading to frequent, loose stools.
●​ Weight loss: Due to malabsorption of nutrients, poor appetite, and Drugs:
increased metabolic demands from chronic inflammation.
●​ Fever: Inflamm response Corticosteroids (Prednisone, Methylprednisolone)
●​ Bloody stools: Crohn’s can also cause bloody stools if the colon is IM/IV
involved or if ulcers in the intestinal wall erode into blood vessels. Drug class: Anti-inflammatory / Immunosuppressant
Moa: Suppresses inflammatory cytokine production. Improves symptoms by
Labs and Diagnostic Procedures decreasing mucosal inflammation and edema. Used for short-term control
of moderate to severe disease flares. Not used for long-term maintenance
●​ Stool test due to side effects.
○​ To assess for infections, culture and sensitivities, ovum S/E: Insomnia, mood changes, hyperglycemia, increased appetite, fluid
and parasites, Clostridium difficile toxins, and leukocyte retention​
count. NR: Monitor blood glucose, BP, electrolytes, and signs of infection.
○​ Positive fecal leukocytes indicate [Link] Administer with food to reduce GI upset. Educate patient on tapering
in the gut schedule—never stop abruptly.
○​ Elevated fecal calprotectin or lactoferrin confirms
intestinal inflammation
●​ Elevated C-reactive protein (CRP) or elevated erythrocyte Nutritional supplements (vitamin D, iron, folate)
sedimentary rate (ESR)
○​ To monitor the severity of the inflammation.
●​ Complete blood count with a metabolic panel
○​ To check for anemia (B12 or iron deficiency) or liver
disease
●​ Colonoscopy w/ biopsy
○​ To reveal Skip lesions (patchy inflammation)

Pathophysiology

NCP

Chronic Pain r/t inflammation, ulcers, and strictures in the gastrointestinal

tract
OR DIARRHEA
Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Imbalanced Nutrition: Less Than Body Requirements

r/t malabsorption, and increased metabolic demand as evidenced by
weight loss, fatigue, low albumin levels, and poor appetite

Planning:

50
 50. INTUSSUSCEPTION
Planning:

-​ Intussusception is a process in which a segment of intestine Interventions:

invaginates or telescopes into the adjoining intestinal lumen, Independent:
causing bowel obstruction. ●​ Assess for frequency, consistency, and pattern of bowel
movements.
Subjective Data ●​ Monitor for signs of increasing abdominal pain or distention.
●​ Educate parents/patient about symptoms that require immediate
●​ NV attention (e.g., blood in stool, severe pain).
●​ Fever ●​ Prepare the patient for diagnostic imaging (e.g., abdominal
ultrasound or contrast enema).
Objective Data
Dependent:
●​ Administer IV fluids as ordered to maintain hydration.
●​ Pale, lethargic and unwell Collaborative:
●​ Severe, colicky abdominal pain ●​ Collaborate with dietitian for appropriate fluid and feeding
●​ Redcurrant jelly stools ! ! ! reintroduction plans.
●​ RUQ mass that is sausage shaped ! ! ! ●​ Coordinate with the surgical team if operative intervention is
●​ Abdominal distention needed.

Labs and Diagnostic Procedures Drugs:

Acetaminophen (Tylenol)
●​ Ultrasonography Oral/IV/Rectal
○​ Assessment of possible pediatric intussusception Drug class: Analgesic, antipyretic
●​ Rectal examination Moa: Inhibits prostaglandin synthesis in the CNS, raising pain threshold and
●​ Contrast enema reducing fever.
○​ To confirm diagnosis in intussusception (either barium S/E: Generally well-tolerated; Rare: rash, GI upset; Overdose risk:
or air) hepatotoxicity (may present as nausea, RUQ pain, confusion)
●​ UTZ - “target sign” or “doughnut sign” NR: Ensure accurate weight-based dosing; Educate parents to avoid duplicate
dosing from multiple meds (e.g., cold meds with acetaminophen); Monitor
Pathophysiology liver function in prolonged use or high-dose therapy

IV Fluids (NS, D5 0.45%, NaCl with KCl)

IM/IV
Drug class: Crystalloid fluid, electrolyte replenisher
Moa: Expands extracellular volume and provides hydration and electrolyte
support. Used for Fluid volume restoration due to vomiting, fever, and poor
intake, and electrolyte rebalancing
S/E: Fluid overload (edema, crackles, increased BP), Electrolyte imbalances,
Phlebitis at IV site
NR: Monitor I&O, daily weight, electrolytes, and urine output.​
Assess for signs of fluid overload, especially in infants (fontanels, lung
sounds). Confirm urine output before administering KCl.

NCP

Acute Pain r/t intestinal obstruction and distension

Planning:
●​ Short-term: Child will demonstrate reduced signs of pain (e.g.,
relaxed posture, less crying) within 1 hour of intervention.
●​ Long-term: The child will remain pain-free or report minimal
discomfort after successful treatment of intussusception.

Interventions:
Independent:
●​ Assess pain using Flacc scale (face, legs, activity, cry,
consolability)
●​ Position the child in a comfortable position. Side lying with knees
flexed to relieve pressure
●​ Use comfort measures like swaddling, rocking, and distraction
techniques
●​ Allow adequate rest
●​ Minimize stimuli (clam and dim)

Dependent:
●​ Administer Acetaminophen (tylenol) for pain as indicated

Collaborative:
●​ Coordinate with radiology and pediatric surgery for timely
reduction.

Constipation r/t mechanical obstruction secondary to intussusception

51
 51) GALACTOSEMIA -​ Administer prescribed soy-based or lactose-free formula
-​ Administer IV fluid as prescribed

-​ Deficiency or absence of the enzyme GALT Collaborative:

(galactose-1-phosphate uridyltransferase), needed to metabolize -​ Coordinate with a dietitian to plan a lifelong galactose-free
galactose. nutrition plan

Subjective Data Risk for impaired liver function r/t Accumulation of galactose-1-phosphate
leading to hepatotoxicity
Reports of:
-​ Poor feeding: Accumulation of galactose and its metabolites in the Planning:
blood causes GI discomfort -​ After 12 hours of nursing intervention, the patient will:
-​ Lethargy, weakness: impaired energy production -​ Show early signs of liver function stabilization, with reduced
-​ Vomiting: GI irritability nausea and improved appetite

-​ After 72 hours of nursing intervention, the patient will:

Objective Data
-​ Maintain stable liver function tests

-​ Jaundice: liver damage caused by accumulation of GALT Interventions:

-​ Cataract: galactose -> galactitol -> draws water into the lens -> Independent:
clouding (cataracts) -​ Monitor for early signs of liver dysfunction such as jaundice,
-​ Hypotonia: Floppy, poor head control, limbs hanging loosely hepatomegaly, dark urine, pale stools, and irritability
-​ Signs of hypoglycemia: irritability, jitteriness, lethargy, seizures, -​ Monitor liver function tests
apnea. -​ Assess for bleeding tendencies
-​ Document daily weight and abdominal girth
Labs and Diagnostic Procedures -​ Educate parents about lifelong galactose restriction to prevent liver
injury
Laboratory Tests:
-​ Newborn Screening test: ↓ or absent GALT enzyme activity Dependent:
-​ Galactose-1-Phosphate in RBCs: measures toxic metabolites. ↑ -​ Administer prescribed soy-based or lactose-free formula
Galactose-1-phosphat -​ Administer IV fluid as prescribed
-​ Serum galactose: measures free galactose in the blood. ↑ serum
galactose levels Collaborative:
-​ -​ Coordinate hepatologists for ongoing monitoring of liver function
Diagnostic Procedures: -​ Collaborate with dietitians for galactose-free dietary planning
-​ Enzyme Assay: confirmatory test, measures GALT enzyme activity
in RBC. ↓ , or absence of GALT enzyme activity Drugs:
-​ Genetic Testing: confirms the presence of mutations in the GALT
gene Isomil (Similac)
Soy-based infant formula
Pathophysiology Moa: Provides essential nutrients using soy protein instead of milk protein
S/E: gas and bloating, constipation
NR: Monitor for soy allergy, track intake and growth parameters to assess
effectiveness

D10W 10% Dextrose in water

Moa: provides a concentrated glucose solution that increases blood sugar
levels.
S/E: hyperglycemia, phlebitis, fluid overload, F/E imbalances
NR: Monitor blood glucose levels, monitor for signs of hyperglycemia,
monitor IV site, Assess fluid balance

DEFICIENT FLUID VOLUME r/t vomiting and poor feeding secondary to

metabolic intolerance

NCP

Imbalanced nutrition: less than body requirements r/t inability to metabolize

galactose

Planning:
-​ After 2 hours of nursing intervention, the patient will:
-​ Be able to tolerate feedings with galactose-free formula

-​ After 1 day of nursing intervention, the patient will

-​ Exhibit increased energy levels
-​ Balanced intake & output
-​ Steady weight gain

Interventions:
Independent:
-​ Assess feeding patterns and tolerance
-​ Monitor weight daily
-​ Observe for signs of dehydration and malnutrition
-​ Educate parents about lifelong galactose restriction
-​ Educate parents on the early signs of feeding intolerance

Dependent:
52
 52) PHENYLKETONURIA Dependent:
-​ Administer prescribed emollients to reduce inflammation and
itching.
-​ Absence of the enzyme phenylalanine hydroxylase (PAH) is
needed to metabolize the essential amino acid phenylalanine. Collaborative:
-​ Phenylalanine: precursor to tyrosine needed to make dopamine, -​ Coordinate with a dermatologist for specialized skin care or allergy
norepinephrine, epinephrine. testing if needed.
-​ Refer to a dietitian to ensure nutrition supports skin healing and
Subjective Data low phenylalanine meal plans.
Reports of
-​ Behavioral and Intellectual problems: Elevated phenylalanine levels 2)​ Risk for injury r/t seizure activity
in the brain can impair cognitive development
Planning:
Objective Data
-​ After 1 hour of nursing intervention, the caregivers will:
-​ Demonstrate and verbalize at least 2 seizure precautionary
-​ Eczema: toxic effects of high phenylalanine leading to an methods
inflammatory skin condition
-​ “Musty” or “mousy” body odor: accumulation of phenylacetate and -​ After 24 hours, the patient will:
phenylpyruvate (byproducts of phenylalanine) -​ Remain free from injury during seizure activities
-​ Fair hair and skin: enzyme deficiency disrupts phenylalanine
metabolism, leading to low melanin production. Interventions:
-​ Seizures: impair neurotransmitter synthesis, like dopamine and Independent:
serotonin. Neurotoxicity increases the risk of seizures. -​ Assess neurological status regularly
-​ Restlessness/ irritability: early indicators of neurocognitive -​ Monitor phenylalanine levels
dysfunction -​ Keep the side rails up and padded
-​ Remove sharp objects or hard toys
Labs and Diagnostic Procedures -​ Keep the bed in the lowest position
-​ Educate caregivers on recognizing early signs of seizure activity
Laboratory Tests: and what to do if one occurs.
-​ Guthrie Test (Newborn Screening): elevated phenylalanine levels -​ Minimize stimulation (e.g., reduce bright lights, loud noises) that
may trigger seizures.
Phenylalanine >120 µmol/L -​ Promote adherence to a low-phenylalanine diet to help prevent
≥ 360 µmol/L is usually diagnostic for PKU seizures.

Dependent:
Pathophysiology
-​ Administer anti-seizure medications if prescribed
-​ Administer Oxygen therapy or suctioning during/after seizures as
Risk factors: ordered.

Collaborative:
-​ Refer to a pediatric neurologist for seizure management and
monitoring.
-​ Work with a dietitian to develop and adjust a low-phenylalanine
meal plan.

Drugs:
Emollient (Aquaphor Healing Ointment)
Moa: Forms a protective barrier on the skin that locks in moisture, reduces
dryness, soothes irritation, and helps repair the damaged skin barrier.
S/E: mild stinging or rash with certain ingredients
NR: Apply 2-3x per day or every time after bath, use liberally on affected
areas, monitor for signs of allergy or worsening of rash

Phenobarbital (Luminal)
Anti-seizure
Moa: Slows down brain activity by enhancing the action of GABA, a calming
NCP chemical in the brain.
S/E: Drowsiness, sedation, irritability, breathing problems, feeding difficulty
1)​ Impaired Skin Integrity r/t inflammatory response secondary to NR: Monitor respiratory rate and effort, check for excessive sedation or
eczema drowsiness, monitor drug levels if ordered (narrow therapeutic range),
Educate parents about drowsiness and feeding challenges
Planning:

-​ After 2 hours of nursing intervention, the patient (Caregivers/ 1.​ IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS r/t
parents) will: restricted diet
-​ Demonstrate proper application of topical creams 2.​ Impaired skin integrity r/t eczema
-​ Verbalize at least three foods that are low in phenylalanine

-​ After 1 day of nursing intervention, the patient (Caregivers/

parents) will:
-​ Demonstrate reduced redness and itching of the skin, with no new
lesions

Interventions:
Independent:
-​ Assess skin condition regularly (color, temperature, lesions,
moisture, excoriation)
-​ Maintain skin hygiene by cleansing skin gently with lukewarm
water and patting dry.
-​ Keep fingernails short to prevent skin trauma from scratching.
-​ Encourage the use of soft, breathable fabrics like cotton to reduce
irritation.
-​ Monitor and document skin changes using a skin assessment tool.
-​ Apply cool compresses to relieve itching if no open wounds are
present.
-​ Educate patient/caregiver on the importance of avoiding known
skin irritants (e.g., scented soaps, wool clothing, harsh detergents).
-​ Educate a patient/ caregiver) on low-phenylalanine foods

53
 53) GLUCOSE 6-PHOSPHATE DEHYDROGENASE DEFICIENCY Planning:

-​ After 12 hours of nursing intervention, the patient will:

-​ Deficiency in the Glucose-6-Phosphate Dehydrogenase enzyme -​ Demonstrate reduced bilirubin levels
responsible for the protection of RBC from oxidative substances
-​ X-linked -​ After 24 hours of nursing intervention, the patient will:
-​ Maintain stable bilirubin levels
Subjective Data
Interventions:
-​ Irritability Independent:
-​ Fatigue, weakness- hemolysis-> RBC is destroyed -> oxygen level -​ Monitor skin and sclera color for signs of jaundice
drops -​ Monitor biliribun levels
-​ Monitor CBC and reticulocyte count to assess the degree of
hemolysis.
Objective Data
-​ Encourage frequent feeding to promote hydration and stooling,
which helps eliminate bilirubin.
-​ Pallor- due to fewer RBC -​ Maintain a neutral thermal environment to prevent cold stress,
-​ Jaundice- hemolysis-> bilirubin accumulation which may increase bilirubin levels.
-​ Tea-colored urine- hemolysis -> RBC releases hgb -> filtered by the -​ Educate parents on the early signs of jaundice and when to seek
kidneys -> urine appears dark medical attention.
-​ Enlarged spleen- spleen works overtime to clear out damaged RBC -​ Educate caregivers about avoiding triggers (e.g., fava beans,
-​ Tachycardia- to compensate for low oxygen certain drugs) to prevent further hemolytic episodes.

Labs and Diagnostic Procedures Dependent:

-​ Administer prescribed phototherapy (1st line treatment)
Laboratory Tests:
-​ G6PD Enzyme Assay- low G6PD enzyme activity Collaborative:
-​ CBC: low Hgb and hct due to hemolysis -​ Collaborate with a dietitian to plan meals that avoid G6PD triggers,
-​ Serum bilirubin- elevated bilirubin levels (byproduct of RBC preventing RBC hemolysis and bilirubin buildup.
breakdown)
Drugs:
Hematocrit 37-47%
Hemoglobin 12-16 g/dL
Bilirubin 0.2- 1.3 mg/dL
G6PD mutation (x-linked recessive inheritance)​
Lack of G6PD enzyme activity​
Pathophysiology Cannot produce NADPH for protection against oxidative stress​
Glutathiaone (antioxidant) relies on NADPH to neutralize oxidative stress
Easily destroyed RBC
Excessive hemolysis → byproduct bilirubin in the liver → jaundice
Hemolytic anemia → pallor

NCP

1)​ Impaired tissue perfusion r/t decreased oxygen-carrying capacity

due to hemolysis of RBC

Planning:

-​ After 1 hour of nursing intervention, the patient will:

-​ Report relief of dyspnea
-​ Have an oxygen saturation of greater than 95%
-​ Manifest RR within normal limits.

-​ After 8 hours of nursing intervention, the patient will:

-​ Maintain stable RR and O2 Sat.
-​ No signs of respiratory distress like grunting and nasal flaring.
-​ Demonstrate stable ABG levels

Interventions:
Independent:
-​ Monitor respiratory status
-​ Assess oxygen saturation regularly
-​ Monitor skin color and mucous membranes
-​ Position the patient in semi-Fowler’s or high-Fowler’s position
-​ Encourage deep breathing exercises
-​ Educate caregivers about avoiding triggers (e.g., fava beans,
certain drugs) to prevent further hemolytic episodes.

Dependent:
-​ Administer supplemental oxygen

Collaborative:
-​ Work with a respiratory therapist for oxygen therapy support or
advanced respiratory management if needed.

2)​ Risk for | Neonatal Hyperbilirubinemia r/t accumulation of

bilirubin due to hemolysis of RBC
54
 -​ Exhibit improved tolerance to dietary modifications
54) Maple Syrup Urine Disease -​ Stable weight maintenance

Interventions:
-​ Deficiency of enzyme complex branched-chain alpha-keto acid Independent:
dehydrogenase (BCKAD) needed to metabolize amino acids -​ Assess daily nutritional intake
leucine, isoleucine, and valine. -​ Assess nutritional status (I&O, bowel movement)
-​ BCAA: Branched chain amino acids -​ Weigh the patient daily
-​ Leucine → neurotoxicity -​ Monitor for signs of malnutrition
-​ Isoleucine → sweet smelling urine -​ Educate parents/caregivers about reading food labels and avoiding
-​ Valine → vomiting, poor muscle coordination high- protein foods

Subjective Data Dependent:

-​ Administer prescribed specialized formula (e.g., MSUD-specific
-​ Poor feeding: Accumulation of branched-chain amino acids formula low in leucine, isoleucine, valine).
(especially leucine) leads to neurologic depression -​ Administer supplement essential amino acids and nutrients as
-​ Lethargy/ excessive sleepiness: neurologic depression of cns prescribed.
-​ Irritability: due to cerebral irritation
-​ Vomiting: Metabolic acidosis and elevated amino acid levels can Collaborative:
trigger the vomiting center in the brainstem -​ Work with a dietitian for low protein, low in branched-chain amino
acids meal planning and long-term dietary education.
Objective Data
2) Risk for injury r/t seizure activity

-​ Maple syrup or burnt sugar odor in urine or body: Due to buildup of Planning:
isoleucine and its byproducts
-​ Poor weight gain or failure to thrive: Metabolic imbalance and -​ After 1 hour of nursing intervention, the caregivers will:
dietary restrictions prevent proper nutrition and energy use. -​ Demonstrate and verbalize at least 2 seizure precautionary
-​ Muscle tone abnormalities (hypotonia or hypertonia): Imbalance of methods
amino acids affects motor neurons and muscle control — causing
either floppiness (hypotonia) or stiffness (hypertonia). -​ After 24 hours, the patient will:
-​ Seizures -​ Remain free from injury during seizure activities
-​ Lose sucking reflex: neurologic deterioration impairs cranial nerve
-​ Coma in severe cases Interventions:
Independent:
Labs and Diagnostic Procedures -​ Assess neurological status regularly
-​ Monitor BCAAs levels
Laboratory Tests: -​ Keep the side rails up and padded
-​ Plasma Amino Acid Analysis: ↑ leucine, isoleucine, and valine -​ Remove sharp objects or hard toys
-​ Urine Organic Acid Test: ↑ Branched-chain ketoacids. Sweet/ -​ Keep the bed in the lowest position
maple syrup odor -​ Educate caregivers on recognizing early signs of seizure activity
-​ Serum bicarbonate: Metabolic acidosis (↓ bicarbonate, ↓ pH) and what to do if one occurs.
-​ Urinalysis: (+) ketones -​ Minimize stimulation (e.g., reduce bright lights, loud noises) that
may trigger seizures.
Diagnostic Procedures: -​ Promote adherence to a low branched-chain amino acids diet to
-​ Genetic testing: Mutation in BCKDHA, BCKDHB, or DBT gene help prevent seizures.

Leucine 40–160 µmol/L Dependent:

Isoleucine 40–130 µmol/L -​ Administer anti-seizure medications if prescribed
-​ Administer Oxygen therapy or suctioning during/after seizures as
Valine 150–300 µmol/L
ordered.
Bicarbonate HCO3 22–28 mEq/L
Blood pH 7.35–7.45 Collaborative:
-​ Refer to a pediatric neurologist for seizure management and
Pathophysiology monitoring.
-​ Work with a dietitian to develop and adjust a low branched-chain
Risk factors: amino acids meal plan.
-​ Family history of MSUD

Drugs:
1. Specialized Infant Formula (Ketonex-1)
Moa: Provides essential nutrients without leucine, isoleucine, and valine
(BCAAs)
S/E: Possible nutritional deficiency if not taken with complete diet, Taste
intolerance
NR: Monitor growth parameters (weight, length). Educate caregivers on
proper preparation and administration. Ensure formula is taken with
appropriate caloric supplementation if needed. Watch for feeding difficulties
or GI upset

2. Protein restricted diet

3. Diazepam

NCP

1.​ Imbalanced Nutrition: Less than body requirements r/t inability to

metabolize branched-chain amino acids leading to dietary
restriction

Planning:
-​ After 2 hours of nursing intervention the patient (caregiver) will
-​ Verbalize at least 3 low protein food

-​ After 8 hours of nursing intervention the patient will:

55
 55) Biliary Atresia
Interventions:
Independent:
-​ Absence or blockage of bile ducts inside or outside the liver
leading to accumulation of bile in the liver. Dependent:

Subjective Data Collaborative:

-​ Abdominal discomfort: enlargement and inflammation of liver

causing distention or pain in the abdomen.
-​ Irritability: due to discomfort Planning:
-​ Feeding difficulties: may feel full quickly or become to weak to
suck Interventions:
Independent:
Objective Data
Dependent:

-​ Jaundice (beyond 2 weeks of age): accumulation of bilirubin Collaborative:

-​ Dark urine: Excess bilirubin leaks into the urine
-​ Pale, clay-colored stools: Since bile can’t reach the intestines, the Drugs:
stool lacks pigment
-​ Hepatomegaly: bile retention causes liver inflammation and
swelling
-​ Splenomegaly
-​ Ascites: fluid accumulation in the abdomen due to liver
dysfunction and low albumin (a protein that keeps fluid in blood
vessels), along with increased pressure in abdominal veins.
-​ Failure to thrive: body can’t properly digest and absorb fats and
nutrients without bile

Labs and Diagnostic Procedures

Laboratory Tests:
-​ Total and direct bilirubin: ↑ direct bilirubin
-​ LFTs: ↑ ALT, AST, GGT, ALP
-​ Serum Albumin: ↓ albumin in advanced liver dysfunction

Diagnostic Procedures:
-​ Abdominal UTZ: Hepatomegaly, splenomegaly, Absent or small
gallbladder
-​ Hepatobiliary Iminodiacetic Acid (HIDA) Scan: No bile excretion
into intestines confirms obstruction.

Direct (Conjugated) < 0.3 mg/dL

Bilirubin
AST 20 – 60 U/L
ALT 5 – 45 U/L
GGT 10 – 60 U/L
ALP 150 – 420 U/L
Serum Albumin 3.4 – 5.4 g/dL

"AST & ALT = Liver cells; ALP & GGT = Bile flow."
If ALT is high, think liver cells are damaged.
If ALP & GGT are high, think bile can't flow out properly

Pathophysiology

Risk factors:
-​ Viral infections during fetal development (rotavirus)
-​ Genetic predispositions
-​ Exposure to toxins or harmful chemicals during pregnancy.
-​ Immune system dysfunction leading to bile duct inflammation or
damage.

NCP

Planning:
56
 56) ACUTE GASTROENTERITIS
Interventions:
Independent:
-​ inflammation of the stomach and intestines that typically results in
sudden onset of diarrhea, with or without nausea, vomiting, Dependent:
abdominal cramping, and fever.
Collaborative:
Data
Drugs:
-​ Watery diarrhea (sometimes with blood or mucus, depending on
the pathogen)
-​ Nausea and vomiting
-​ Abdominal cramps or pain
-​ Fever and chills
-​ Headache and muscle aches
-​ Signs of dehydration

Labs and Diagnostic Procedures

-​ Stool examination (for bacteria, ova/parasites, or toxins like C.

difficile)
-​ Stool culture (to identify specific pathogen)
-​ Electrolytes panel (to assess dehydration and electrolyte
imbalance)
-​ CBC (to detect infection or inflammation)
-​ Blood culture (if sepsis is suspected)

Pathophysiology

NCP

Diarrhea r/t intestinal inflammation

Planning:

Interventions:
Independent:

Dependent:

Collaborative:

Fluid

Planning:
57
 57) Congenital Hypothyroidism -​ Assess growth and development regularly using standardized
charts and milestone checklists.
-​ Educate caregivers on the importance of strict medication
-​ Complete or partial absence of the thyroid gland or defect in the adherence for levothyroxine.
pituitary gland responsible for stimulating thyroid hormone -​ Reinforce routine lab follow-ups for TSH and free T4 monitoring.
production. -​ Promote developmental stimulation through age-appropriate play,
-​ A condition present at birth where the thyroid gland fails to reading, and interaction.
produce sufficient thyroid hormones, essential for brain Dependent:
development and growth. -​ Administer levothyroxine as prescribed and monitor for signs of
-​ Primary: absence of thyroid gland under/overdose.
-​ Secondary: pituitary or hypothalamic dysfunction -​ Ensure routine thyroid function tests are ordered and reviewed
(e.g., every 1–2 months in infancy).
Subjective Data Collaborative:
-​ Coordinate with a pediatric endocrinologist for ongoing
-​ Inactive defecation: hypothyroidism slows down metabolism management and dosing adjustments.
-​ Sleepy -​ Refer to a developmental specialist or early intervention program if
-​ Poor feeding delays are identified.

Fatigue r/t metabolic imbalance secondary to CH

Objective Data
Planning:
-​ Prolonged jaundice: impaired liver enzyme activity -> delayed
breakdown of bilirubin -> jaundice Interventions:
-​ Edema: Accumulation of mucopolysaccharides in tissues causes Independent:
myxedema -​ Assess fatigue levels
-​ Enlarged tongue: Mucopolysaccharide buildup -​ Monitor thyroid levels
-​ Umbilical hernia: poor abdominal muscle tone (hypotonia) allows -​ Encourage rest
abdominal contents to push through the umbilical area -​ Encourage increased oral fluid
-​ Pallor, coldness, hypothermia: due to reduced metabolism -​ High protein, high carb
-​ Open posterior fontannels: delayed bone growth and ossification -​ Assist prioritization of task for energy conservation
-​ Hypotonia: Thyroid hormones are needed for neuromuscular -​ Encourage light exercise
development.
-​ Rough, dry skin: due to low metabolism Dependent:
-​ Administer levothyroxine
Labs and Diagnostic Procedures -​ Administer iron, vitamin B12, or other necessary medications if
fatigue is related to deficiencies.
Laboratory Tests:
-​ Newborn Screening test: ↑TSH, ↓T4/ Free T4 Collaborative:
-​ Total T4 test: ↓T4 -​ Dietitian
-​ T3 Resin uptake test: ↓T3 -​ PT
-​ Thyroid Hormone Globulin test: ↑TBG -​ MT

Diagnostic Procedures: Drugs:

-​ Thyroid scan: assess the size, shape, and function of the thyroid
gland.

TSH 24- 28 hrs: < 10 mIU/L; 2-4 days: 1.0 – 10 mIU/L

Total T4 7–16 µg/dL
T3 Resing Uptake 25-35%
Free t4 0.8–2.0 ng/dL
TBG 12–30 µg/mL

Pathophysiology

Risk factors:

NCP

Risk for delayed growth and development r/t decreased thyroid hormone
production

Planning:
-​ Within 1-2 weeks, the infant will begin thyroid hormone
replacement and show signs of improved energy, feeding, and
alertness. Notes:
-​ Within 6 months, the child will meet age-appropriate -​ T3 and T4 are crucial for normal growth and development of the
developmental milestones and maintain growth within normal body and brain among newborns
percentiles for age and sex.

Interventions:
Independent:

58
 58) Congenital Adrenal Hyperplasia -​ Monitor labs Sodium serum levels
-​ Monitor vital signs, BP & HR
-​ Assess signs of dehydration, skin, mucous membrane, skin turgor
-​ a deficiency in the enzyme 21-hydroxylase leading to deficiency in -​ Encourage oral fluid intake
cortisol and aldosterone and excess testosterone.
-​ Cortisol - Maintenance of normal blood sugar Dependent:
-​ Aldosterone - Maintenance of serum sodium levels in the -​ Administer PNSS for rehydration as indicated
bloodstream -​ Administer (Fludrocorisone/ hydrocortisone/ prednisone)
-​ Androgen (testosterone)- male sex differentiation mineralocorticoid for sodium and water retention as indicated
-​ DEFICIENCY IN CORTISOL AND ALDOSTERONE LEADS TO
IMPAIRED SODIUM AND FLUID RETENTION!!!!! Collaborative:
-​ Work with dietitian for high sodium diet plan
Subjective Data
Risk for electrolyte imbalance r/t
-​ Vomiting
-​ Diarrhea Planning:
-​ Weight loss: due to dehydration and poor feeding (salt-wasting
form) Interventions:
Independent:
Objective Data
Dependent:

-​ Low BP: sodium loss & water loss -> reduced blood volume Collaborative:
-​ Low sodium, high potassium: Loss of sodium, retains potassium
-​ Dehydration: loss of sodium, loss of water Drugs:

EXCESS ANDROGEN
-​ Early sexual maturity and bone maturation
-​ Accelerated growth during childhood
-​ Short adult stature
-​ Pubic hair growth, oily skin, and body odor
-​ Dark skin color: ACTH is elevated in CAH due to low cortisol. ACTH
Autosomal recessive mutation in CYP21A2 gene → 21-hydroxylase enzyme
is derived from the same precursor as melanocyte-stimulating
deficiency.
hormone (MSH), which darkens the skin.
-​ Ciltoromegaly
-​ Ambigous clitoris ↓ Synthesis of cortisol → triggers ↑ ACTH release (via negative feedback).

Labs and Diagnostic Procedures Adrenal hyperplasia due to chronic ACTH stimulation.

Laboratory Tests: Accumulation of 17-OHP and shunting into androgen pathway → ↑

-​ Serum 17- hydroxyprogesterone: elevated-definitive diagnosis androgens → masculinization of females
-​ Serum cortisol: low
-​ Serum aldosterone: low If aldosterone is also low → salt-wasting crisis (hyponatremia, hyperkalemia,
-​ Serum ACTH: Elevated- Compensatory response due to low dehydration).​
cortisol
-​ Serum electrolyte: Hyponatremia, hyperkalemia
-​ Blood glucose: low

Diagnostic Procedures:
-​ Newborn screening
-​ Genetic testing: mutations in the CYP21A2 gene responsible for
21-hydroxylase deficiency.
-​ Pelvic UTZ: to check for internal female organs if genetalia are
ambigous

Serum 17-OHP <200 ng/dl Newborn

Serum cortisol 5–25 mcg/dL (morning, lower in the evening)
Serum aldosterone 3.5–30 ng/dL
Serum ACTH 10–60 pg/mL
Blood glucose 70–110 mg/dL (fasting)
Sodium 135-145 mEq/L
Potassium 3.5-5 mEq/L

Pathophysiology

Risk factors:

NCP

Deficient Fluid Volume r/t aldosterone deficiency leading to salt-wasting

Planning:

Interventions:
Independent:
-​ Monitor I&O
59
 59. BURNS Dependent:
-​ Apply prescribed dressing
Collaborative:
-​ tissue damage caused by heat, chemicals, electricity, sunlight, or
radiation. The severity of burns is classified by depth (degree) and Drugs:
extent (TBSA – Total Body Surface Area).

Degrees of Burns:
-​ Superficial (1st degree) – only epidermis (e.g., sunburn) 3RD: RISK FOR INFECTION
-​ Partial-thickness (2nd degree) – epidermis + part of dermis -​ Hand hygiene
-​ Full-thickness (3rd degree) – entire dermis destroyed -​ Clean environment
-​ 4th degree – extends to muscle, bone -​ Sterile dressing and wound care
-​ Monitor for signs of infection: redness, swelling, discharge
Data -​ Monitor vitals
-​ Monitor labs
Local Symptoms (based on severity): -​ Adequate nutrition and hydration
-​ Redness, pain, swelling (1st/2nd) -​ Patient educ on wound care and dressing
-​ Blistering (2nd) -​ Antibiotics
-​ White/charred, leathery skin (3rd) -​ Collab with infection control team
-​ No pain in full-thickness areas due to nerve damage -​ Nutritionist
-​ Edema around wound
-​ Delayed capillary refill
-​ Burn eschar (hard crust)

Labs and Diagnostic Procedures

Laboratory Tests:
-​ CBC: Decreased rbc, hgb, hct because of blood loss
-​ PT (Prothrombin Time): May be prolonged in severe burns,
indicating clotting issues (normal: 11–13.5 sec).

Diagnostic Procedures:

Pathophysiology

Risk factors:

NCP

1st and 2nd degree

Acute pain r/t tissue injury and inflammation

Planning:

Interventions:
Independent:
-​ Assess pain levels
-​ Position the client in a comfortable position, elevate the affected
site for reduced swelling.
-​ Apply cooling measures, cold compress and ice pack
-​ Encourage deep breathing or guided imagery for relaxation
technique

Dependent:
-​ Administer neosporin (topical antibiotic ointment)
-​ Administer morphine sulfate

Collaborative:
-​ Pain management specialists

Impaired skin integrity r/t tissue injury secondary to burns

Planning:

Interventions:
Independent:
-​ Assess degree of burn
-​ Apply proper dressing (hydrocolloid)
-​ Educate patient proper dressing and proper wound care
60
 60. URINARY TRACT INFECTION -​ Within 3 days, the patient will report decreased pain and improved
ability to void comfortably with reduced urgency and frequency.
-​ Within 1 week, the patient will return to normal voiding patterns
-​ infection that affects part of the urinary system—most commonly and demonstrate understanding of UTI prevention strategies.
the bladder (cystitis) and urethra (urethritis), but it may also involve
the kidneys (pyelonephritis). It’s usually caused by bacteria, Interventions:
particularly Escherichia coli (E. coli), which normally lives in the Independent:
bowel but can enter the urinary tract. -​ Monitor urinary pattern (frequency, urgency, color, odor) and
intake/output.
Data -​ Encourage increased fluid intake (unless contraindicated) to flush
out bacteria.
-​ Dysuria -​ Educate the patient on proper perineal hygiene (e.g., wiping front to
-​ Frequent urination: common in cytitis back).
-​ Suprapubic pain or pressure: bladder infection -​ Advise avoidance of irritants such as caffeine, alcohol, and spicy
-​ Cloudy or strong-smelling urine: indicates infection foods.
-​ Hematuria (blood in urine)
-​ Low-grade fever (sometimes) Dependent:
-​ Administer antibiotic (ceftriaxone)
Labs and Diagnostic Procedures
Collaborative:
-​ Collab with MT
Laboratory Tests:
-​ Urinalysis: (+) leukocytes, cloudy Drugs:
-​ CBC: ↑ WBC count
Diagnostic Procedures:
-​ Renal UTZ: for checking of obstructions, stones, abscess

Pathophysiology

Risk factors:

NCP

Acute pain r/t inflammation of the urinary tract secondary to infection

Planning:

Interventions:
Independent:
-​ Monitor pain using COLDSPA (adult) FLACC/Wong baker pain
scale (pedia)
-​ Assess and monitor urinalysis and urine culture
-​ Apply heating pad to lower back (increases blood flow -> relaxing
muscles)
-​ Educate about avoiding food UTI irritants (spicy foods, alcohol,
coffee)
-​ Encourage sitz bath

Independent:
-​ Administer Ibuprofen (advil) for pain as indicated

Collaborative:
-​ Collaborate with MT for lab results

Impaired urinary elimination r/t irritation and inflammation of the urinary

tract lining secondary to UTI.

Planning:

61
 61) ACUTE GLOMERULONEPHRITIS -​ Monitor I&O
-​ Monitor vital signs, particularly blood pressure
-​ Assess for edema in the extremities, abdomen, and face
-​ Inflammation of the glomeruli, often triggered by an immune -​ Weigh the patient daily at the same time each morning
response, most commonly after a Streptococcal throat or skin -​ Encourage a low-sodium diet
infection. -​ Encourage mobility and physical activity
-​ Elevate the patient's legs when sitting or lying down
Subjective Data
Dependent:
-​ Abdominal or flank pain: Swelling and stretching of the kidney -​ Administer diuretics such as furosemide as prescribed
capsule, which is rich in pain-sensitive nerves
-​ Fatigue, nausea, and vomiting: Consequences of accumulated Collaborative:
toxins in the bloodstream, known as uremia. -​ Work with a dietitian to ensure adherence to fluid and sodium
restrictions
-​ Consult with a nephrologist for ongoing assessment and
Objective Data
management of renal function

-​ Blood in urine (hematuria): Indicates damage to the glomeruli, 2)​ Risk for Electrolyte imbalance r/t impaired kidney filtration and
allowing red blood cells to pass into the urine. fluid retention as evidenced by__
-​ Foamy urine (proteinuria): Suggests a breakdown in the filtering
barrier, permitting large molecules like proteins to leak out. Planning:
-​ Swelling (edema): Results from fluid retention due to reduced
kidney function. -​ After 12 hours of nursing intervention, the patient will:
-​ High blood pressure: The kidneys regulate blood pressure, and -​ Show improved serum potassium or sodium levels
their dysfunction leads to fluid accumulation and elevated -​ HR and BP within normal range
pressures.
-​ Reduced urine output (oliguria): Signals a decline in filtration -​ After 72 hours of nursing intervention, the patient will:
capacity. -​ Maintain stable electrolyte levels
-​ Report reduced or no symptoms related to imbalances, such as
Labs and Diagnostic Procedures muscle weakness, cramps, or fatigue.

-​ Urinalysis: (+) hematuria and proteinuria Interventions:

-​ BUN: elevated. When kidneys are inflamed and filtering poorly, urea Independent:
(a waste product of protein metabolism) accumulates in the blood.
-​ Creatinine: elevated. A byproduct of muscle metabolism is -​ Monitor vital signs particularly BP and HR regularly, changes may
normally filtered out by the kidneys. indicate fluid or electrolyte shifts.
-​ ASO Titer (Antistreptolysin O): elevated. Indicates a recent -​ Assess daily weight
streptococcal infection -​ Assess for edema and skin turgor
-​ Renal UTZ: rule out obstruction or structural anomalies. -​ Observe level of consciousness and neurological status
-​ Kidney biopsy: definitive test to directly assess glomerular -​ Promote mobility as tolerated
inflammation and damage, and identify the exact cause. -​ Encourage fluid intake within limits

Blood Urea Nitrogen 6-20 mg/dL Dependent:

Creatinine 0.6-1.3 mg/dL -​ Administer electrolyte replacements
-​ Administer IV fluids as ordered
ASO Adults <200 IU/mL ; Children under 5 <100 IU/ml
Collaborative:
Pathophysiology -​ Consult nephrologist for ongoing management and monitoring of
renal function and fluid-electrolyte regulation.
-​ Collaborate with dietitian for individualized meal planning to help
manage electrolyte levels, fluid restrictions, and promote kidney
health.

Drugs:

Furosemide (Lasix) Diuretics

Moa: Inhibits reabsorption of sodium, chloride, and water
S/E: Hypokalemia, Hypotension, Electrolyte imbalance, Dehydration,
Ototoxicity
NR: Monitor electrolytes (esp K and mg), Assess renal function (BUN,
creatinine), Monitor vital signs, Administer IV slowly, monitor signs of
dehydration, monitor weight.

NCP

1)​ Excess fluid volume r/t fluid retention due to impaired renal
function as evidenced by___

Planning:

-​ After 1 hour of nursing intervention, the patient will:

-​ Urine output within 30-60 ml/ hr
-​ Stable blood pressure levels

-​ After 8 hours of nursing intervention, the patient will:

-​ Report reduced discomfort and swelling of the edema
-​ Balanced I & O

Interventions:
Independent:
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