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NCLEX REVIEW 2009. HEALTH PROMOTION AND MAINTENANCE.


NOTES FOR HEALTH PROMOTION AND MAINTENACE. GROWTH DEVELOPMENT.
  
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STAGES OF PLAY:
HOLDING TOYS
 
0-1 Y./0
STAGES OF PLAY:
IMITATION
 
1-7 Y/O
STAGES OF PLAY:
SOLITARY PLAY
 
INFANCY
STAGES OF PLAY:
PARALLEL PLAY
 
TODDLERS
STAGES OF PLAY:
ASSOCIATIVE PLAY
 
PRE-SCHOOL 3-6 Y/O
STAGES OF PLAY:
COOPERATIVE PLAY
 
SCHOOL AGE
TESF FOR: PERSONAL - SOCIAL, FINE MOTOR, LANGUAGE, GROSS MOTOR
 
DENVER DEVELOPMENT SCREENINT TEST(DDST)

ERICKSON'S
BIRTH - 18 MOS INFANCY
 
TRUST VS. MISTRUST
(+) TRUST SELF
(-) WITHDRAWN , ISOLATED
ERICKSON'S
18 MOS - 3 Y/O- TODDLER

 
AUTONOMY VS SHAME
(+) EXERCISE SELF CONTROL
(-) DEFIANT AND NEGATIVE
ERICKSON'S
3-6 Y/O PRESCHOOL

 
INITIATIVE VS GUILT
P- LEARNS LIMITS
N- FEARFUL, PESSIMISTIC
ERICKSON'S
6-12 Y/O
 
INDUSTRY VS INFERIORITY
P- SENSE OF CONFIDENCE
N- SELF DOUBT, INADEQUATE
ERICKSON'S
12-20 Y/O
 
IDENTITY VS DIFFUSION
P- COHERENT SENSE OF SELF
N- LACK OF IDENTITY
ERICKSON'S
20-45 Y/O

 
INTIMACY VS ISOLATION
P- INTIMATE RELATIONSHIP
N- AVOIDANCE OF INTIMACY
ERICKSON'S
45-65 Y/O
 
GENERATIVITY VS STAGNATION
P - CREATIVE AND PRODUCTIVE
N- SELF CENTERED
ERICKSON'S
65 ABOVE


 
INTEGRITY VS DESPAIR
P- SEES LIFE AS MEANINGFUL
N- LIFE LACKS MEANING
HEAD SAGS
 
1 MONTH----TOYS- MOBILE, WIND UP INFANT SWINGS

CLOSING OF POSTERIOR FONTANELLE,
TURNS FROM SIDE TO BACK,
SOCIAL SMILE
 
2 MONTHS--------TOYS---MOBILE, WIND UP INFANT SWINGS

BRINGS OBJECTS TO MOUTH,
HEAD ERECT
 
3 MONTHS-TOYS------RATTLES, CRADLE GYM, STUFFED ANIMALS

THUMB APPOSITION,
DROOLS
ABSENT TONIC NECK REFLEX, MORO REFLEX AND ROOTING REFLEX
 
4 MONTHS-----RATTLES, CRADLE GYMS, STUFFED ANIMALS
BIRTH WEIGHT DOUBLED, HOLD HEADS STEADY AND ERECT, NOTICING STRANGERS
 
5 MOS----BRIGHTLY COLORED, SMALL ENOUGH TO GRAS[, LARGE ENOUGH FOR SAFETY, TEETHING TOYS
BEGINS TEETHING, TURNS FROM BACK TO STOMACH,
 
6 MONTHS-----------BRIGHTLY COLORED, SMALL ENOUGH TO GRAS[, LARGE ENOUGH FOR SAFETY, TEETHING TOYS

SITS FOR SHORT PERIODS
FEAR OF STRANGERS, TRANSFER OBJECTS FROM 1 HAND TO OTHER, BANGING OBJECT, ATTENTION BY COUGHING
 
7 MOS-----LARGE WITH BRIGH COLORS, COLORED BLOCKS, JACK IN THE BOX, PLAYS PEEK ABOO
FEAR OF STRANGERS STRONGERS
 
8 MOS-----LARGE WITH BRIGH COLORS, COLORED BLOCKS, JACK IN THE BOX, PLAYS PEEK ABOO

ELEVATE SELF TO SITTING POSITION,
SAYS DADA
 
10 MOS--LARGE WITH MOVABLE PARTS, NOISE MAKERS

CRAWLS WELL
PULLS SELF TO STANDING POSITION
 
10 MONTHS-----LARGE WITH MOVABLE PARTS, NOISE MAKERS
ERECT STANDING POSTURE WITH SUPPORT
 
11 MONTHS---BOOKS WITH LARGE PICTURES, PUSH-PULL, TEDDY BEARS, LARGE BALL, SPONGE TOYS

BIRTH WEIGHT TRIPPLED
EATS WITH FINGERS
BABINKSI REFLEX DISAPPEARS
 
12 MONTHS---BOOKS WITH LARGE PICTURES, PUSH-PULL, TEDDY BEARS, LARGE BALL, SPONGE TOYS
POTENTIAL PROBLEMS OF TODDLERS
 

NEGATIVISM "NO" DON'T ASK YES OR NO QUESTION, TELL THEM WHAT TO EXPECT
SAFETY--INJURIES, POISONING, ABUSE

walkk alone
throws object
holds spoon
 
15 months-imitation plays

anterior fontanelle closed
climbs stairs
sucks thumb
 
18 months-imitation plays

300 word
obey easy commands
 
24 months--imitation plays

walks on tiptoe
stands on 1 foot
has sphinter control for toilet training
 
30 months---imitation plays
MENTAL RETARDATION
 

MILD--IQ-- 55-70
MODERATE 40-55
SEVERE--25-40
PROFOUND < 25
mental retard, growth retard, microcephaly,
  • Narrow, small eyes with large epicanthal folds
  • Small head
  • Small upper jaw
  • Smooth groove in upper lip
  • Smooth and thin upper lip
 
fetal alcohol syndrome---avoid alcohol 3 months before conception, monitor weight gain, promote nutrition
mental retard, hypotonia, altered development, hard to hold, compromise resp,
  • Decreased muscle tone at birth
  • Excess skin at the nape of the neck
  • Flattened nose
  • Separated joints between the bones of the skull (sutures)
  • Single crease in the palm of the hand
  • Small ears
  • Small mouth
  • Upward slanting eyes
  • Wide, short hands with short fingers
  • White spots on the colored part of the eye (Brushfield spots)
 
down's syndrome---provide stimulation, assess for physical problems, parenteral education---complication heart problems, hearing loss, respiratory infection
GPTA
 

GRAVIDA NUMBER OF PREG,
PARA NUMBER OF >20 WEEKS
TERM 38-442 WKS
ABORTION- BEFORE 20 WEEKS
BLUISH COLOR OF CERVIX
 
CHADWICK'S SIGN
PINK OR REDDISH STREAKS
 
STRIA GRAVIDARUM
DARK LINE FROM UMBILICUS TO SYMPHYBIS
 
LINEA NIGRA

MATERNAL PERCEPTION OF MOVEMENT AT
16-20 WEEKS GESTATION
 
QUICKENING
TORCH
 

TOXOPLASMOSIS
RUBELLA -TITER 1-16, DON'T GIVE IMMUNIZATION FROM 1-8
CYTOMEGALOVIRUS
HERPES SIMPLEX

gush of fluid or bleeding from vagina
regular uterine contractrions
severe h/a , visual disturbances, abd pain, persistent vomiting, fever or chills, swelling in face and finers
 

danger signs of pregnancy-pt to contact doctor

EFFACEMENT- PROGRESSIVE THINNING AND SHORTENING OF CERVIX
DILATION -OPENING OF CERVIX OS
 
CERVICAL CHANGES DURING LABOR

lightening- primipara (up 2 weeks before delivery) and multipara ( when labor begins)
softening of cervix
expulsion of mucus plug(show)
uterine contractions
 
onset of labor

ASSESS- PREMATURE RUPTURE OF MEMBRANES
PRESENTING PART NOT ENGAGED
FETAL DISTRESS
PROTRUDING CORD
IMPLEMENTATION- CALL FOR HELP>TAKE 2 FINGERS TO PRESENTING PARTS AND PUSH AGAINST >PLACE IN TRENDELENGBURG OR KNEE-CHEST COMPRESSION
SUCCESSFULL- IF FHT REMAIN UNCHANGED
 
PROLAPSE UMBILICAL CORD

> 160 BPM LASTING LONGER THAN 10 MINS
EARLY SIGNS OF HYPOXIA
MATERNAL FEVER
FETAL ANEMIA
FETAL OR MATERNAL INFECTION
NONREASSURING SIGN WHEN ASSOCIATED WITH LATE DECELATION, SEVERE VARIALBE DECELATIONS OR ABSENCE OF VARIABILITY
 
TACHYCARDIA

<110 BPM LASTING LONGER THAN 10 MINS
LATE SIGNS OF FETAL HYPOXIA
MATENAL DRUGS (ANESTHETICS)
PROLONGED CORD COMPRESSION
MATERNAL HYPOTENSIVE SYNDROME
NONREASSURING SIGN WHEN ASSOCITAED WITH LOSS OF VARIABILITY AND LATE DECELATIONS
 
BRADYCARDIA

NORMAL IRREGULARITY OF CARDIAC RHYTHYM
NORMAL 6-10 BPM
INDICATES FETAL WELL BEING
ABSENT (0-2) OR DECREASED 93-5) ASSOCIATED WITH FETAL SLEEP, PREMATURITY, DRUGS , HYPOXIA, ACIDOSIS
INCREASE (6-25) MAY BE SIGNIFICANT
 
VARIABILITY

15 BPM RISE ABOVE BASELINE FOLLOWED BY RETURN
INDICATES FETAL WELL BEING
CAUSED BY FETAL MOVEMENT OR CONTRACTIONS
SEEN WITH BREECH PRESENTATION
 
ACCELARATIONS- Accelerations
The presence of fetal heart rate accelerations is one of the most important signs of well-being during labor. Accelerations are defined as short-term rises in the heart rate of at least 15 beats per minute, which last at least 15 seconds. In many cases, they last longer. Viewing the accelerations assures the doctor that the baby is not lacking oxygen or accumulating acid, which results from lack of oxygen. Most fetuses have spontaneous accelerations at various points throughout the labor and delivery process. If a doctor is concerned about the well-being of a baby and does not see accelerations, she may attempt to induce accelerations either by gently rocking the mother's abdomen, pressing on the baby's head through the cervix with a finger, or administering a short burst of sound (vibro acoustic stimulation). If these techniques trigger accelerations, the doctor or nurse is reassured the baby is doing fine

OCCUR BEFORE THE PEAK OF CONTRACTION
INVERSELY MIRRORS THE CONTRACTIONS
ASSOCIATED WITH HEAD COMPRESSION
ASSOCIATED WITH PUSHING IN 2ND STAGE OF LABOR
REASSURING PATTERN
 
EARLY DECELERATIONS-Early decelerations are seen when the baby's head is compressed. This often happens during the later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position, causing its head to be squeezed by the uterus during contractions. Early decelerations have absolutely no clinical significance and are not harmful.

POSITION LEFT SIDE LYING OR THEN TRENDELENBERG OR KNEE CHEST
INCREASE IV
O2 AT 7-10 LPM
DISCONTINUE OXYTOCIN
 
; Late Decelerations
Unlike early decelerations, which begin to dip early during the uterine contraction or even before the contraction is visible, late decelerations do not begin until the peak of a contraction or thereafter. They are smooth, shallow dips in heart rate that mirror the shape of the contraction that is causing them.
Late decelerations are among the most worrisome form of heart rate patterns because they usually signify a reduced oxygen supply to the baby. When delivery is near and there are other reassuring features of the heart rate tracing (such as accelerations), it is often permissible to observe a fetus with late decelerations carefully and not intervene with a cesarean section. However, if worrisome features of heart rate tracing are present, such as a fast heart rate (tachycardia), reduced variability, and an absence of accelerations, a rapid delivery might be called for, since prolonged exposure to the type of contractions causing late decelerations may be harmful to the baby. This might be done by cesarean section or by assisting delivery with a vacuum or forceps.

INDICATES CORD COMPRESSION
RELIEVED BY CHANGE IN MATERNAL POSITION LEFT SIDE OR KNEE CHEST
02
DISCONTINUE OXYTOCIN
 
Variable Decelerations
Variable decelerations do not look like late or early decelerations. They are generally irregular, often jagged dips in the fetal heart rate that look more dramatic than late decelerations. Variable decelerations are caused when the umbilical cord of the baby is temporarily compressed. This happens in virtually all labors, and multiple variable decelerations can be found during the course of nearly all labors. As a rule, variable decelerations are not worrisome. However, the baby does depend upon steady blood flow through the umbilical cord to receive oxygen and other important nutrients. If variable decelerations are prolonged or repetitive, they can signify a reduction of blood flow, which is harmful to the baby. Doctors judge whether variable decelerations are worrisome or not primarily depending on the other features of the heart rate tracing, and how close to delivery they judge the woman to be. For example, severe variable decelerations with no variability in early labor would be an indication for cesarean section; the same decelerations seen with good variability and accelerations close to delivery would not require cesarean section.

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