NUPC 108 Care of Mother, Child, and Adolescent (Well Clients) Module PDF

Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union BACHELOR OF SCIENCE IN NURSING CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)...

Don Mariano Marcos Memorial State University South La Union Campus COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES Agoo, La Union BACHELOR OF SCIENCE IN NURSING CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NUPC 108 SHERILLE A. OREJUDOS JEWELL F. LLAVORE MODULE WRITERS  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) COURSE DESCRIPTION The course consists of four (4) modules. This course deals with concepts, theories and techniques in the nursing care of individuals and families during childbearing and childrearing years toward health promotion, disease prevention, restoration and maintenance , and rehabilitation. The learners are expected to provide safe, appropriate and holistic nursing care to clients utilizing the nursing process. At the end of the course, the students should have been able to: 1. Demonstrate safe, appropriate and holistic care to individuals ,families and population groups utilizing the nursing process during childbearing and childrearing years 2. Identify their own learning needs based from the outcome/results of the activities and assessment materials they will undertake. 3. Apply concepts, theories and principles of sciences and humanities in the formulation and application of appropriate nursing care during childbearing and child rearing years. 4. Communicate effectively in speaking, writing, and presenting using culturally appropriate language with children and families. 5. practice maternal and child nursing in accordance with existing laws, legal, ethical and moral principles, CLASS INTRODUCTION It is an honor and a privilege to be your Instructor for this course, I am Sherille A. Orejudos you subject instructor for Care of Mother, Child, and Adolescent (well clients) for this 1st semester, S.Y. 2021-2022. Unfortunately, we cannot introduce ourselves in person because of this pandemic. Please accept my invitation for you to join our group chat in your messenger account. This group chat account will be our venue of correspondence for the whole semester. Feel free to introduce yourselves in a way or manner that suits you. Be comfortable also in expressing your thoughts and/or questions within the context of our lessons. It is the best interest of this course to help you expand your understanding, interest, and capabilities in your study and practice of Nursing. For other inquiries, you may also contact us thru messenger, SMS, or Email. ☑ COURSE REQUIREMENTS 1  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) 1. Read and comprehend the entirety of the modules and attend the face-to-face meeting when required. 2. Answer all the discussion activities and the given assignments 3. Take the graded written quizzes 4. Accomplish the Midterm and Final Evaluation/Exams. COURSE STUDY GUIDE This module was prepared for you to work on independently and diligently. It aims for you to be confident in honing and performing your nursing skills. Do it with enthusiasm 1. Give your best – you have the knowledge and skills to make it through. You can do it! 2. Be patient – do not miss any important part in the module. 3. Focus your attention and motivate yourself – read other materials or references for a better understanding of the subject matter. Ask any member of your family or friends to assist you if you encounter difficulties. Do not give up. 4. Answer confidently – make sure to answer completely and concisely. Cite your references. Answers to essays should be direct to the point. 5. Submit on time – before the end of midterms and finals, you will need to submit your output or accomplished activities thru correspondence or during our face-to-face meeting. Rest assured of my prompt reply once you correspond to submit. If you need assistance during the course of your study, you may contact me thru messenger, SMS or email. Read on and ponder. Study well!!! GRADING SYSTEM Module Activities and Assignments - 60% Midterm/Final Examination - 40% Total 100% COURSE CONTENT Module I Foundations for Maternal and Child Health Nursing Lesson 1 Goals and Philosophies of Maternal and Child Health Nursing Lesson 2 Theories Related to Maternal and Child Nursing Lesson 3 Legal Considerations of Maternal and Child practice Module II Reproductive and Sexual Health 2  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) Lesson 1 Female/male Reproductive System Lesson 2 Menstruation Lesson 3 Human Sexuality/ Sexual Response Cycle Lesson 4 Reproductive Life Planning Lesson 5 Contraception Lesson 6 Alternative Methods of Birth Lesson 7 Common Reproductive Issues Lesson 8 Reproductive Health Bill Module III Care of the Mother and the Fetus during The Perinatal Lesson 1 Prenatal Care Lesson 2 Intrapartal Care Lesson 3 Postpartal Care Module IV Growth and Development Lesson 1 Theoretical Approaches to the Growth and Development Of Children Lesson 2 Nursing process for promotion of Normal growth and Development Lesson 3 Health Promotion and Disease Prevention in Different Stages of Growth Development Lesson 4 Communication and Teaching with Children and Families Module V Filipino Cultures, Values and Practices in Relation to Maternal and Child Care Lesson 1 Cultural Diversity Lesson 2 Myths and Beliefs related to Pregnancy Lesson 3 Maternal and Child Care Entrepreneurial Opportunities REFERENCES Evans, S. (2019). Maternal-Neonatal Nursing Made Incredibly Easy (Incredibly Easy!Series) (4th Ed.). LWW. Saunders S. (2018) Study Guide for Foundations of Maternal-Newborn and Women’s Health Nursing - Elsevier eBook on vital source. Faan, S. P. (2017). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family (8th Ed.). LWW. Lippincott, Pillitteri, A. (2019). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. LWW. Flagg, J. (2017). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. LWW. Murray, S. et al (2019) Maternal-Newborn and Women’s Health Nursing 7th Edition. Singapore: Elsevier Goh, (2017) Pediatric Differences Diagnosis. Singapore: Elsevier LEARNING CONTRACT To ensure that you will benefit from studying and accomplishing the NCM 108 -course modules you will need to identify your responsibilities as a learner by taking part in constructing a Learner’s Contract with your parent’s/guardian’s assistance. Be guided with the following: 3  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) Name: ______________________________________________________________ Address: _____________________________________________________________ CP/Tel no: ___________________________________________________________ Name of Parent/Guardian: _____________________________________________ CP/Tel no: ___________________________________________________________ Academic success is the product of cooperative effort. In order that each party will benefit from this unified effort, each will have the following responsibilities: As a student: Obey rules/policies of the University : Be guided by my parent’s rules at home : Spend at least _________________ study for each subject : As a parent: Maintain a discipline policy with my child : Spend at least ___________________ to supervise my child’s work : : As a teacher: Enforce rules/policies of the University : Provide ample time to guide and assist you in your study of this Course : Work to make learning enjoyable : Review and revise learning activities when necessary : Be available when you need additional assistance in your study : Update you of school activities and : Be open to suggestions and/or recommendations. Agreeing Party: Student Signature: _________________________ Date: ________________ Parent Signature: __________________________ Date: ________________ Teacher Signature: _________________________ Date: ________________ MODULE I Foundations for Maternal and Child Health Nursing This chapter discusses competencies, philosophies, challenges, Goals and new roles for nurses in maternal–child health care and how these challenges and changes mold and affect care. 4  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) After studying the module, you should be able to: 1. Describe the goals, standards philosophies and professional roles of maternal-child health nursing. 2. Have a deep understanding about theories related to maternal and child nursing 3. Understand the legal issues, ethical considerations and standards of maternal and child practice HOW ARE YOU GOING TO LEARN 1. Examine carefully the module objectives 2. Read through the module test( self-test) and try to answer them to the best of your ability 3. Your answers to this self-test are to be submitted to the faculty concerned 4. Take note of the following icons presented with in this module There are three lessons in the module. Read each lesson carefully then answer the exercises/activities to find out how much you have benefited from it. Work on these exercises carefully and submit your output to your respective instructor or adviser. In case you encounter difficulty, discuss this with your instructor during the face-to-face meeting. If not contact your instructor at CCHAMS office. Good luck and happy reading!!! Lesson 1 The area of childbearing and childrearing families is a major focus of nursing practice in promoting health for the next generation. Comprehensive preconception and prenatal care is essential in ensuring a healthy outcome for mother and child. Although childbearing and childrearing are often viewed as two separate entities, they are interrelated, and a deeper understanding is achieved when they are viewed as a continuum. Maternal and child health nursing includes care of the pregnant woman, child, and family. The primary goal of both maternal and child health nursing is the promotion and maintenance of optimal family health. Major philosophical assumptions about combined maternal and child health nursing are listed in the table 1-1 below. Maternal and 5  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) child health nursing extends from preconception to Menopause with an expansive array of health issues and healthcare providers. Examples of scope of practice include: 1. Preconception health care 2. Care of women during three trimesters of pregnancy and the puerperium (the 6 weeks after childbirth, sometimes termed the fourth trimester of pregnancy) 3. Care of infants during the perinatal period (the time span beginning at 20 weeks of pregnancy to 4 weeks [28 days] after birth) 4. Care of children from birth through late adolescent 5. Care in a variety of hospital and home care settings Regardless of the setting, a family-centered approach is the preferred focus of nursing care. The health of an individual and his or her ability to function as a member of a family can strongly influence and improve overall family functioning. Family-centered care enables nurses to better understand individuals and their effect on others and, in turn, to provide more holistic care. It includes encouraging rooming-in with the mother by the mother’s partner or support person and with the child by their caregiver. Family members are encouraged to provide physical and emotional care based on the individual situation and their comfort level. Nurses provide guidance and monitor the interaction between family members to promote the health and well-being of the family unit. Listed below are tips on how to assist a family choose a healthcare setting that is Family Centered ✔ If the setting is for child care, are personnel interested in you as well as your child? ✔ If the setting is a maternal care site, do they ask about family concerns as well as individual ones? ✔ Will the staff provide continuity of care so you’ll always see the same primary care provider if possible? ✔ Does the physical setup of the facility provide for a sense of privacy, yet a sense that healthcare providers share pertinent information so you do not have to repeat your history at each visit? ✔ Is health education done at your learning level? ✔ Do healthcare providers respect your opinion and ask for your input on healthcare decisions? ✔ Will the facility still be accessible if a family member becomes disabled? Maternal and child health nursing can be visualized within a framework in which nurses use nursing process, nursing theory, and Quality & Safety Education for Nurses (QSEN) competencies to care for families during childbearing and childrearing years and through the four phases of health care: 1. Health promotion 3. Health restoration 2. Health maintenance 4. Health rehabilitation 6  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) TABLE1-1 DEFINITIONS AND EXAMPLES OF PHASES OF HEALTH CARE TERMS DEFINITIONS EXAMPLES Health promotion Educating parents and Teaching women the importance children to follow sound of rubella immunization before health practices through pregnancy; providing preteens teaching and role modeling with information about safer sex practices well before they are likely to become sexually active Health maintenance Intervening to maintain health Encouraging women to be when risk of illness is present partners in prenatal care; teaching parents the importance of safeguarding their home by childproofing against poisoning Health restoration Using conscientious Caring for a woman during a assessment to be certain that complication of pregnancy such symptoms of illness are as gestational diabetes or a child identified and interventions during an acute illness such as are begun to return patient to pneumonia wellness most rapidly Health Helping prevent complications Encouraging a woman with rehabilitation from illness; helping a patient gestational trophoblastic disease with residual effects achieve (abnormal placenta growth) to an optimal state of wellness continue therapy or a child with and independence; helping a a renal transplant to continue to patient to accept inevitable take necessary medications death INSTRUCTIONS: Answer this question in a separate sheet of Paper, this is a graded activity. 7  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) Maternal and Child Health Goals and Standards Healthcare technology has contributed to a number of important advances in maternal and child health care. Through immunization, childhood diseases such as measles and poliomyelitis almost have been eradicated. New fertility drugs and fertility techniques allow more couples to conceive. The ability to prevent preterm birth and improve the quality of life for both preterm and late preterm infants has increased dramatically. As specific genes responsible for children’s health disorders are identified, stem cell therapy may make it possible to replace diseased cells with new growth cells and cure these illnesses. In addition, a growing trend toward healthcare consumerism, or self-care, has made childbearing and childrearing families active participants in their own health monitoring. Access to health care and social determinants of health, impact the role of the nurse and the health of the patient. These factors have expanded the roles of nurses in maternal and child health and, at the same time have made the delivery of quality maternal and child health nursing care a challenge. 2020 NATIONAL HEALTH GOALS The importance a society assigns to human life can best be measured by the concern a nation places on its most vulnerable members—its elderly, its disadvantaged, and its youngest citizens. In light of this, in 1979, the U.S. Public Health Service first formulated healthcare objectives for the nation. Healthcare goals are reviewed every 10 years. In 2010, new goals to be achieved by 2020 were set (U.S. Department of Health and Human Services [DHHS], 2010) The two main overarching national health goals are: To increase quality and years of healthy life. To eliminate health disparities. The 2020 National Health Goals are intended to help citizens more easily understand the importance of health promotion and disease prevention and to encourage wide participation in improving health in the next decade. It’s important for maternal and child health nurses to be familiar with these goals because nurses play such a vital role in helping the nation achieve these objectives through both practice and research (see www.healthypeople.gov). The goals also serve as the basis for grant funding and financing of evidence-based practice. Each of the following sections highlights goals as they relate to that specific area of care. GLOBAL HEALTH GOALS 8  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) The United Nations (UN) and the World Health Organization established millennium health goals in 2000 in an effort to improve health worldwide. As with 2020 National Health Goals, these concentrate on improving the health of women and children because increasing the health in these two populations can have such long-ranging effects on general health. These Global Health Goals are: To end poverty and hunger. To achieve universal primary education. To promote gender equality and empower women. To reduce child mortality. To improve maternal health. To combat HIV/AIDS, malaria, and other diseases. To ensure environmental sustainability. To develop a global partnership for development. WHO ’s 17 Sustainable Development goals The seventeen Sustainable Development Goals (SDGs) are our shared vision of humanity and a social contract between the world’s leaders and the people” 9  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) INSTRUCTIONS: answer the question in a separate sheet of Paper, this is a graded activity. Lesson 2 NURSING THEORY One of the requirements of a profession (together with other critical determinants, such as members who set their own standards, self-monitor their practice quality, and participate in research) is that a discipline’s knowledge flows from a base of established theory. Nursing theories are designed to offer helpful ways to view patients so nursing activities can be created to best meet patient needs—for example, Calistra Roy’s theory stresses that an important role of the nurse is to help patients adapt to change caused by illness or other stressors (Roy, 2011); Dorothea Orem’s theory concentrates on examining patients’ ability to perform self-care (Orem & Taylor, 2011); Using a theoretical basis such as these can help you appreciate the significant effect of a child’s illness or the introduction of a new member on the total family. Family plays a vital role in health care, representing the primary target of health care delivery for maternal and newborn nurses. It is crucial that nurses assist families as they incorporate new additions into their family (see Nursing Care Plan). When treating the woman and family with respect and dignity, health care providers listen to and honor perspectives and choices of the woman and family. They share information with families in ways that the family is supported in participating in the care and decision 10  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) making at the level of their choice. Because so many variables affect ways of relating, the nurse must be aware that family members may interact and communicate with each other in ways that are distinct from those of the nurse’s own family of origin. Most families will hold some beliefs about health that are different from those of the nurse. Their beliefs can conflict with principles of health care management predominant in the Western health care system. Family Theories A family theory can be used to describe families and how the family unit responds to events both within and outside the family. Each family theory makes certain assumptions about the family and has inherent strengths and limitations. Most nurses use a combination of theories in their work with families. A brief synopsis of several theories useful in working with families is included in Table 2-1. Application of these concepts can guide assessment and interventions for the family. TABLE 1-2 THEORIES AND MODELS RELEVANT TO FAMILY NURSING PRACTICE THEORY SYNOPSIS OF THEORY Family Systems Theory (Wright The family is viewed as a unit, and interactions among and Leahy, 2009) family members are studied rather than studying individuals. A family system is part of a larger suprasystem and is composed of many subsystems. The family as a whole is greater than the sum of its individual members. A change in one family member affects all family members. The family is able to create a balance between change and stability. Family members’ behaviors are best understood from a view of circular rather than linear causality. Family Life Cycle Families move through stages. The family life cycle is (Developmental) Theory (Carter the context in which to examine the identity and and McGoldrick, development of the individual. Relationships among family members go through transitions. Although families have roles and functions, a family’s main value is in relationships that are irreplaceable. The family involves different structures and cultures organized in various ways. Developmental stresses may disrupt the life-cycle process. Family Stress Theory (Boss, How families react to stressful events is the focus. 1996) Family stress can be studied within the internal and 11  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) external contexts in which the family is living. The internal context involves elements that a family can change or control, such as family structure, psychologic defenses, and philosophic values and beliefs. The external context consists of the time and place in which a particular family finds itself and over which the family has no control, such as the culture of the larger society, the time in history, the economic state of society, maturity of the individuals involved, success of the family in coping with stressors, and genetic inheritance McGill Model of Nursing (Allen, Strength-based approach in clinical practice with 1997) families, as opposed to a deficit approach, is the focus. Identification of family strengths and resources; provision of feedback about strengths; assistance given to family to develop and elicit strengths and use resources are key interventions. Health Belief Model (Becker, The goal of the model is to reduce cultural and 1974; Janz and Becker, 1984) environmental barriers that interfere with access to health care. Key elements of the Health Belief Model include the following: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and confidence. Human Developmental Ecology Behavior is a function of interaction of traits and (Bronfenbrenner, 1979; 1989 abilities with the environment. Major concepts include ecosystem, niches (social roles), adaptive range, and ontogenetic development. Individuals are “embedded in a microsystem [role and relations], a mesosystem [interrelations between two or more settings], an ecosystem [external settings that do not include the person], and a macro system [culture]” (Klein and White, 1996). Change over time is incorporated in the chronosystem. Other issues most nursing theorists address include how nurses should be viewed or what the goals of nursing care should be. Extensive changes in the scope of maternal and child health nursing have occurred as health promotion (teaching, counseling, supporting, and advocacy, or keeping parents and children well) has become a greater priority in care (Salsman, Grunberg, Beaumont, et al., 2012). As promoting healthy pregnancies and keeping children well protects not only patients at present but also the health of the next generation, maternal–child health nurses fill these expanded roles to a unique and special degree. 12  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) QSEN: QUALITY & SAFETY EDUCATION FOR NURSES In 2007, the Robert Wood Johnson Foundation challenged nursing leaders to improve the quality of nursing care and to build the knowledge, skills, and attitudes necessary to 68 help achieve that level of care into pre licensure and graduate programs (Disch, 2012). Because of this challenge, the QSEN Learning Collaborative created six competencies deemed necessary for quality care (Cronenwett, Sherwood, & Gelmon, 2009). These competencies included five competencies that originated from a study by the Institute of Medicine The QSEN Learning Collaborative added safety as the sixth competency The overall goal is to address the challenge of preparing future nurses with the abilities necessary to continuously improve the quality and safety of the healthcare systems in which they work. Definitions for each of the six competencies along with examples of the knowledge, skills, and attitudes necessary to achieve quality maternal and child health care are shown in the table2-2 Competency Knowledge Skills Attitudes A.Patient-Centered Care The patient or designee is Take an Encourage family Don’t think of thought of as the source of admission to spend as much admitting Anna to the control and full partner in history time as possible neonatal care nursery the provision of detailing with her while as a single patient but compassionate and Document the she is rather as admitting her coordinated care based on roles of family hospitalized; family to the setting. respect for the patient’s members and assess that she preferences, values, and who will be the will have family needs support on 13  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) chief childcare transition to provider. home B.Teamwork and Collaboration Nurses function effectively Familiarize Discuss with Consider and respect within nursing and yourself with patient’s parents patient parents as interprofessional teams, how many what problems, if integrative members fostering open other any, they will of her healthcare communication, mutual healthcare have visiting so team. respect, and shared providers will other team decision making as they be interacting members can achieve quality with patient help reassure and (e.g., support them neonatologist, when they visit. nurse practitioner, nutritionist) to help appreciate how frightening having to meet so many people could be to a family. Evidence-Based Practice Nurses integrate the best Read journal Implement Value the need for current evidence with articles related evidence-based change based on new clinical expertise and to new practice so evidence so you can patient/family preferences evidence about patient’s family explain to patient’s and values for delivery of healthy families are confident family with confidence optimal health care. or neonatal that care is based any need for change in care to be on credible care better prepared research to help patient seamlessly transition from one setting to the next. Quality Improvement (QI) 14  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) Nurses use data to monitor View QI as an Use whatever Appreciate that the outcomes of care and important role aids, such as continuous QI is an use improvement methods for all checklists, flow essential part of to design and test changes healthcare sheets, or patient successful working to continuously improve the professionals information with and respecting quality and safety of beginning with forms, necessary families. healthcare systems. prelicensure in order to students provide seamless nursing care from nursery admission to home. Safety Nurses minimize the risk of Learn the Be certain Anna Recognize families harm to patients and requirements receives under stress do not providers through both for a safe developmental “hear” instructions system effectiveness and healthcare stimuli as well as well and so may need individual performance. setting for a is cared for in an these repeated or vulnerable environment that provided in a written preterm infant. promotes a sense form as well as orally. of security and is as free from pain as possible. Informatics Nurses use information and Keep records Document care in Recognize that technology to and an electronic documentation must documentation health record so be current so it various healthcare Communicate, manage Providers can Can be available Complete to be knowledge, mitigate error, keep informed to various valuable (in audit and support decision in order to healthcare reviews, what wasn’t making. provide providers. documented as being seamless care done is considered as shifts and not done). setting shifts in care. 15  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) 3. QUALITY IMPROVEMENT Nurses must always be aware of quality improvement because as society changes with new situations, nursing care must make responding adjustments. Which of the following is a trend that will influence the care that the Chung family’s new baby is likely to receive? a. More and more children are treated in ambulatory, not hospital, settings so nurses will be less significant in the future. b. Immunizations are available for all childhood infectious diseases so the baby will never need treatment for these. c. The use of multiple technologies can make parents feel overwhelmed unless they receive nursing support. d. Prematurely born infants, assuming their mother received prenatal care, rarely need long-term or follow-up care. SAFETY Mrs. A waited until she was 42 years old to have her second baby. She asks the nurse if that is the reason her baby was born prematurely. Which statement would be the most reassuring for her? a. “It’s hard to say because so few women over 40 years are having babies today.” b. “No one can say for certain. You did all you could to ensure a healthy pregnancy.” c. “It’s good to see you taking responsibility for your child’s prematurity.” 16  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) d. “You should ideally have had your children as a teenager as that’s the safest time.” Lesson 3 Legal concerns arise in all areas of health care. Maternal and child health nursing carries some legal concerns above and beyond other areas of nursing because care is often given to patients who are not of legal age for giving consent. Additionally, reproductive healthcare rights and laws are complex and vary from state to state. These issues require specific attention when caring for expectant families. New technologies (e.g., assisted reproduction, surrogate motherhood, umbilical cord sampling, safety of new medicines with children, and end-of-life decisions) can lead to potential legal action, especially if patients are uninformed about the reason or medical necessity for these procedures. Nurses are legally responsible for protecting the rights of their patients, including confidentiality, and are accountable for the quality of their individual nursing care and that of other healthcare team members. New regulations on patient confidentiality guarantee patients can see their medical record if they choose, but health information must be kept confidential from others (Duffy, 2011). Unfortunately, although nurses recognize the need for patient privacy, it is not practiced at the same rates. Patients are also not aware of the importance for their own medical record privacy (Kim, Han, & Kim, 2016) ☑ Understanding the scope of practice (the range of services and care that may be provided by a nurse based on state requirements) and standards of care can help nurses practice within appropriate legal parameters. ☑ Documentation is essential for justifying actions. it is long lasting because children who feel they were wronged by healthcare personnel can bring a lawsuit at the time they reach legal age. ☑ Personal liability insurance is strongly recommended for all nurses, so they do not incur great financial losses during a malpractice or professional negligence lawsuit. ☑ Nurses need to be conscientious about obtaining informed consent for invasive procedures in children and determining if pregnant women are aware of any risk to the fetus associated with a procedure or test. A parent can be contacted by phone or e-mail if not present with the child at the time the consent is needed. ☑ In divorced or blended families (those in which two adults with children from 96 previous relationships now live together), it is important to establish who has the right to give consent for health care. Adolescents who support themselves or who are pregnant are frequently termed “emancipated minors” or “mature minors” and have the right to sign for their own health care. 17  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) ☑ The term “wrongful birth” is the birth of a disabled child whose pregnancy the parents would have chosen to end if they had been informed about the disability during pregnancy. “Wrongful life” is a claim that negligent prenatal testing on the part of a healthcare provider resulted in the birth of a disabled child. “Wrongful conception” denotes that a contraceptive measure failed, allowing an unwanted child to be conceived and born. As many genetic disorders can be identified prenatally, the scope of both “wrongful birth” and “wrongful life” grows yearly (Whitney & Rosenbaum, 2011). If a nurse knows the care provided by another practitioner was inappropriate or insufficient, he or she is legally responsible for reporting the incident. Failure to do so can lead to a charge of negligence or breach of duty ETHICAL AND SOCIAL ISSUES IN PERINATAL NURSING THINK INSTRUCTIONS: write your answers in a separate sheet of Paper, this is a graded activity 18  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) Most difficult ethical quandaries in health care today: Those that involve children and their families Examples include: 1) Conception issues, especially those related to in vitro fertilization, embryo transfer, ownership of frozen oocytes or sperm, and surrogate motherhood 2) Pregnancy termination 3) Fetal rights versus rights of the mother 4) Stem cell research 5) Resuscitation (and length of its continuation) 6) Number of procedures or degree of pain a child should be asked to endure to achieve a degree of better health 7) Balance between modern technology and quality of life 8) Difficulty maintaining confidentiality of records when there are multiple caregivers Legal and ethical aspects of issues are often knotted, which makes the decision-making process in this area is difficult. Because maternal and child health nursing is so strongly family centered, it is common to encounter some situations in which the interests of one family member are in conflict with those of another or the goals of a healthcare provider are different from the family’s. Maintaining privacy yet sustaining problem solving in these instances can be difficult but is a central nursing role. Nurses can help patients by providing factual information and supportive listening, and helping the family and healthcare providers clarify their values. If you want to know more about the bill of rights, you may read this file for more information The Pregnant Woman’s Bill of Rights and the UN Declaration of Rights of the Child (available at http://thePoint.lww.com/Flagg8e) provide guidelines for determining the rights of women and children with regard to maternal and child health care. 19  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) THINK INSTRUCTIONS: Write your answer in a separate sheet of Paper, this is a graded activity. STANDARDS OF PRACTICE AND LEGAL ISSUES IN DELIVERY OF CARE Nursing standards of practice in perinatal and women’s health nursing have been described by several organizations, including the ANA, which publishes standards for maternal-child health nursing; AWHONN, which publishes standards of practice and education for perinatal nurses (American College of Nurse-Midwives (ACNM), which publishes standards of practice for midwives; and the National Association of Neonatal Nurses (NANN), which publishes standards of practice for neonatal nurses. In legal terms the standard of care is that level of practice that a reasonably prudent nurse would provide in the same or similar circumstances. In determining legal negligence, the care given is compared with the standard of care. If the standard was not met and harm resulted, negligence occurred. The number of legal suits in the perinatal area typically has been high. As a consequence, malpractice insurance costs are high for physicians, nurse-midwives, and nurses who work in labor and birth settings. STANDARDS OF CARE FOR WOMEN AND NEWBORNS 20  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) A. Standards That Define the Nurse’s Responsibility to the Patient 1. Assessment Collection of health data of the woman or newborn 2. Diagnosis Analysis of data to determine nursing diagnosis 3. Outcome Identification Identification of expected outcomes that are individualized 4.Planning Development of a plan of care 4. Implementation Performance of interventions for the plan of care 5. Evaluation Evaluation of the effectiveness of interventions in relation to expected outcomes B. Standards of Professional Performance That Delineate Roles and Behaviors for Which the Professional Nurse is Accountable 1. Quality of Care Systemic evaluation of nursing practice 2. Performance Appraisal Self-evaluation in relation to professional practice standards and other regulations 3. Education Participation in ongoing educational activities to maintain knowledge for practice 4. Collegiality Contribution to the development of peers, students, and others 5.Ethics Use of American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) to guide practice 6.Collaboration Involvement of patient, significant others, and other health care providers in the provision of patient care 7. Research Use of research findings in practice 8. Resource Utilization Consideration of factors related to safety, effectiveness, and costs in planning and delivering patient care 9. Practice Environment Contribution to the environment of care delivery 10. Accountability Legal and professional responsibility for practice LEGAL TIP: Standard of Care When you are uncertain about how to perform a procedure, consult the agency procedure book and follow the guidelines printed therein. These guidelines are the standard of care for that agency Ethical concerns have multiplied with increasing use of technology and scientific advances. 21  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) THINK! INSTRUCTIONS: write your answers in a separate sheet Of paper. This is a graded activity. Congratulations! You have just studied Module I. now you are ready to evaluate how much you have benefited from your reading by answering the summative test. Good Luck!!! SUMMATIVE TEST 1. Explain how a nurse could use social media to improve the health care provided to pregnant women and their families. Identify the precautions the nurse must take to ensure that patient confidentiality and privacy are respected 2. Discuss measures that can be taken to ensure that the health literacy needs of patients are met. 3. What is the importance of mother infant bonding after birth? MODULE II REPRODUCTIVE AND SEXUAL HEALTH This chapter reviews the anatomy and physiology of the reproductive system.it addresses sexuality as it relates to each stage of growth and development in the lives of human being. Also discusses the use of contraceptives in reproductive life planning methods of contraception are presented with their physiological actions and impact on future pregnancies. After studying the module, you should be able to: 1. Determine the female and male reproductive system 2. Described the concept of menstruation 22  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) 3. Distinguished the different methods of contraception 4. Recognized the alternative methods of birth 5. Identify the common reproductive issues DIRECTIONS/ MODULE ORGANIZER There are eight lessons in the module. Read each lesson carefully then answer the exercises/activities to find out how much you have benefited from it. Work on these exercises carefully and submit your output to your respective instructor or adviser. In case you encounter difficulty, discuss this with your instructor during the face-to-face meeting. If not contact your instructor thru SMS, Messenger, email. Good luck and happy reading!!! Whether or not someone is planning on childbearing, everyone is cleverer for being familiar with reproductive anatomy and physiology and his or her own body’s reproductive and sexual health. Patients and their partners who are planning on childbearing may become curious about reproductive physiology and the changes they will undergo during pregnancy. Patients who are pregnant are also often interested about physiologic changes, so nurses are frequently asked by both patients and their partners about reproductive and gynecologic health (Callegari, Ma, & Schwarz, 2015). Although the general public is becoming increasingly erudite about their bodies because of courses in school on sexual health, misunderstandings about sexual health, conception (preventing or promoting), and childbearing still abound. When caring for children of school age or adolescence, they may ask you a variety of detailed questions about sexual or reproductive health they heard about in class but didn’t really understand. For instance, many adolescents want to know more about what is a normal” menstrual period; Late adolescents may want to know what the “normal” expected frequency is for sexual relations. A general rule in answering a question about sexual relations is normal sexual behavior includes any act mutually satisfying to both sexual partners. Actual frequency and type of sexual activity vary widely. According to a definition by the Centers for Disease Control and Prevention (CDC, 2014), Sexual health is not just an absence of disease, dysfunction, or infirmity but a condition of physical, emotional, and psychosocial well-being. Encouraging patients to ask questions about sexual health is one of the most important influences nurses can make. With this attitude, sexual and reproductive health problems can be openly discussed and made as answerable as other health concern. If this is an area that you were raised to not discuss freely, learning to be comfortable with the topic and your own sexuality can be the first step needed (Johnson & Williams, 2015). A sample of 2020 23  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) National Health Goals that speak directly to improving reproductive or sexual health are shown below. Nurses help the nation achieve these goals by: Educating adolescents about abstinence as well as refusal skills, safer sex practices, And the advantage of obtaining a vaccine against human papillomavirus (HPV), the virus associated with cervical cancer. The need to participate in screening activities such as vulvar and: testicular self-examination are also important to teach. INSTRUCTIONS: answer the question in a separate sheet of Paper, this is a graded activity. ACTIVITY #1 Andrea and Jason Sanchez, a young adult couple, planned to have a baby as soon as they married; however, it took Andrea 1 year before she conceived. Now, 14 weeks pregnant, she comes to your clinic for a prenatal visit. In tears, she states, “My husband isn’t interested in me anymore. We haven’t had sex since I became pregnant.” Jason states, “I’m afraid I’ll hurt the baby.” Previous episodes presented the range of maternal and child health nursing and how the configuration, function, and culture of families can have a significant impact on health. This chapter adds information about how to educate patients and their families about anatomy, physiology, and sexual health to better prepare them for childbearing and childrearing. How would you counsel Andrea and Jason Sanchez? THE MALE REPRODUCTIVE SYSTEM Although the structures of the female and male reproductive systems differ greatly in both appearance and function, they are homologues; that is, they arise from the same or matched embryonic origin. Andrology is the study of the male reproductive organs. The male reproductive system consists of both external and internal divisions 24  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) MALE EXTERNAL STRUCTURES External genital organs of the male include the testes (which are encased in the scrotal. The Scrotum The scrotum is a rugated, skin-covered, muscular pouch suspended from the perineum. Functions: Are to support the testes and help regulate the temperature of sperm. In very cold weather, the scrotal muscle contracts to bring the testes closer to the body. In very hot weather, or in the presence of fever, the muscle relaxes, allowing the testes to fall away from the body. In this way, the temperature of the testes can remain as even as possible to promote the production and viability of sperm. The Testes The testes are two ovoid glands, 2 to 3 cm wide, that rest in the scrotum. Each testis is encased by a protective white fibrous capsule and is composed of a number of lobules. Each lobule contains interstitial cells (Leydig cells) that produce testosterone and a seminiferous tubule that produces spermatozoa. Testes in a fetus first form in the pelvic cavity and then descend late in intrauterine life (about the 34th to 38th week of pregnancy) into the scrotal sac. Because this descent occurs so late in pregnancy, many male infants born preterm still have undescended testes. These infants need to be monitored closely to be certain their testes do 25  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) descend at what would have been the 34th to 38th week of gestational age because testicular descent does not occur as readily in extra uterine life as it does in utero. Testes that remain in the pelvic cavity (cryptorchidism) may not produce viable sperm and have a four to seven times increased rate of testicular cancer (Fantasia, Aidlen, Lathrop, et al., 2015). In most males, one testis is slightly larger than the other and is suspended slightly lower in the scrotum than the other (usually the left one). Because of this, testes tend to slide past each other more readily on sitting or muscular activity, and there is less possibility of trauma to them. Most body structures of importance are more protected than the testes (e.g., the heart is surrounded by ribs of hard bone). However, spermatozoa do not survive at a temperature as high as that of the internal body, so the location of the testes outside the body, where the temperature is about 1°F lower than body temperature, provides protection for sperm survival (Huether & McCance, 2012). ☑ Normal testes feel firm and smooth and are egg shaped. Beginning in early adolescence, boys need to learn testicular self-examination so they can detect tenderness or any abnormal growth in testes. The Penis The penis is composed of three cylindrical masses of erectile tissue in the penis shaft. The urethra passes through these layers of tissue, allowing the penis to serve as both the outlet for the urinary and reproductive tracts in men. With sexual excitement, nitric oxide is released from the endothelium of blood vessels. This causes dilation and an increase in blood flow to the arteries of the penis (engorgement). The ischiocavernosus 225 muscle at the base of the penis, under stimulation of the parasympathetic nervous system, then contracts, trapping both venous and arterial blood in the three sections of erectile tissue. This leads to distention (and erection) of the penis. At the distal end of the organ is a bulging, sensitive ridge of tissue called the glans. A retractable casing of skin, the prepuce, protects the nerve-sensitive glans at birth. Based on religious or cultural beliefs, many male infants have the prepuce tissue removed surgically (circumcision) shortly after birth. Although controversial to some, the American Academy of Pediatrics (AAP) advises that the health benefits of male circumcision outweigh its medical risks; however, the benefits are not strong enough to recommend every male newborn be circumcised. The AAP advises that circumcision decisions should be made in consultation with parents with consideration of their cultural or religious beliefs. Its advantages allow for lower rates of urinary tract infections, HIV, STIs, and penile cancer. Its disadvantages include surgical complications, such as bleeding and pain, and reduction of sensation with sexual stimulation (AAP, 2012; Bossio, Pukall, & Steele, 2014) 26  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) MALE INTERNAL STRUCTURES The male internal reproductive organs are the epididymis, the vas deferens, the seminal vesicles, the ejaculatory ducts, the prostate gland, the urethra, and the bulbourethral glands 1. The Epididymis a. The seminiferous tubule of each testis leads to a tightly coiled tube, the epididymis, which is responsible for conducting sperm from the tubule to the vas deferens, b. the next step in the passage to the outside. Because each epididymis is so tightly coiled, its length is extremely deceptive: It is actually over 20 ft long. Some sperm are stored in the epididymis, and a part of the alkaline fluid (semen, or seminal fluid that contains a basic sugar and protein) that will surround sperm at maturity is produced by the cells lining the epididymis. c. Sperm are immobile and incapable of fertilization as they pass through or are stored at the epididymis level. It takes at least 12 to 20 days for them to travel the length of the tube and a total of 65 to 75 days for them to reach full maturity. d. This is one reason that aspermia (absence of sperm) and oligospermia (fewer than 20 million sperm per milliliter) do not appear to respond immediately to therapy but do respond after 2 months of treatment (Tortora & Derrickson, 2014). 2. The Vas Deferens (Ductus Deferens) a. The vas deferens is an additional hollow tube surrounded by arteries and veins and protected by a thick fibrous coating. Altogether, these structures are referred to as the spermatic cord. b. It carries sperm from the epididymis through the inguinal canal into the abdominal cavity, where it ends at the seminal vesicles and the ejaculatory ducts below the bladder. c. Sperm complete maturation as they pass through the vas deferens. They are still not mobile at this point, however, probably because of the fairly acidic medium of semen. 3. The Seminal Vesicles a. The seminal vesicles are two convoluted pouches that lie along the lower portion of the bladder and empty into the urethra by ejaculatory ducts. 27  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) b. These glands secrete a viscous alkaline liquid with a high sugar, protein, and prostaglandin content. Sperm become increasingly motile because this added fluid surrounds them with a more favorable pH environment. 4. The Prostate Gland a. The prostate is a chestnut-sized gland that lies just below the bladder and allows the urethra to pass through the center of it, like the hole in a doughnut. b. The gland’s purpose is to secrete a thin, alkaline fluid, which, when added to the secretion from the seminal vesicles, further protects sperm by increasing the naturally low pH level of the urethra. 5. The Bulbourethral Glands a. Two bulbourethral, or Cowper’s, glands lie beside the prostate gland and empty by short ducts into the urethra. They supply one more source of alkaline fluid to help ensure the safe passage of spermatozoa. b. Semen, therefore, is derived from the prostate gland (60%), the seminal vesicles (30%), the epididymis (5%), and the bulbourethral glands (5%). 6. The Urethra The urethra is a hollow tube leading from the base of the bladder, which, after passing through the prostate gland, continues to the outside through the shaft and glans of the penis. It is about 8 in. (18 to 20 cm) long. Like other urinary tract structures, it is lined with mucous membrane. LEARNING ACTIVITY #2 THE FEMALE REPRODUCTIVE SYSTEM The female reproductive system, like the male, has both external and internal components. The study of the female reproductive organs is gynecology. FEMALE EXTERNAL STRUCTURES The structures that form the female external genitalia are termed the vulva (from the Latin word for “covering”) 28  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) 1. The Mons Veneris The mons veneris is a pad of adipose tissue located over the symphysis pubis, the pubic bone joint. Covered by a triangle of coarse, curly hairs, The purpose of the mons veneris is to protect the junction of the pubic bone from trauma. 2. The Labia Minora a. Immediately posterior to the mons veneris spread two hairless folds of connective tissue, the labia minora. b. Before menarche, these folds are fairly thin; by childbearing age, they have become firm and full; and after menopause, they atrophy and again become much smaller. c. Normally, the folds of the labia minora are pink in color; the internal surface is covered with mucous membrane, and the external surface is covered with skin. d. The area is abundant with sebaceous glands, so localized sebaceous cysts may occur here. Women who perform monthly vulvar examinations are able to detect infection or other abnormalities of the vulva such as sebaceous cysts or herpes lesions. 3. The Labia Majora a. The labia majora are two folds of tissue, fused anteriorly but separated posteriorly, which are positioned lateral to the labia minora and composed of loose connective tissue covered by epithelium and pubic hair. b. The labia majora serve as protection for the external genitalia; they shield the outlets to the urethra and vagina. c. Trauma to the area, such as occurs from childbirth or rape, can lead to extensive edema formation because of the looseness of the connective tissue base. 4. Other External Organs The vestibule is the flattened, smooth surface inside the labia. 29  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) a. The openings to the bladder (the urethra) and the uterus (the vagina) both arise from this space. b. The clitoris is a small (approximately 1 to 2 cm), rounded organ of erectile tissue at the forward junction of the labia minora. It’s covered by a fold of skin, the prepuce; is sensitive to touch and temperature; and is the center of sexual arousal and orgasm in a woman. c. Arterial blood supply for the clitoris is plentiful. When the ischiocavernosus muscle surrounding it contracts with sexual arousal, the venous outflow for the clitoris is blocked and this leads to clitoral erection. In nations which allow it, young girls approaching puberty may be circumcised or have their clitoris removed with the labia minora excised as well. Aside from being a very painful procedure, female circumcision can lead to contractions and scarring of the vulva that make vaginal childbirth difficult because the vagina is unable to expand with birth (Nour, 2015). Two Skene glands (paraurethral glands) are located on each side of the urinary meatus; their ducts open into the urethra. Bartholin glands (vulvovaginal glands) are located on each side of the vaginal opening with ducts that open into the proximal vagina near the labia minora and hymen. Secretions from both of these glands help to lubricate the external genitalia during coitus. The alkaline pH of their secretions also helps to improve sperm survival in the vagina. If the Skene glands or the Bartholin glands (the most common site) become infected, they swell, feel tender, and produce a serous discharge d. The fourchette is the ridge of tissue formed by the posterior joining of the labia minora and the labia majora. This is the structure that sometimes tears (laceration) or is cut (episiotomy) during childbirth to enlarge the vaginal opening. Posterior to the fourchette is the perineal muscle (often called the perineal body). Because this is a muscular area, it stretches during childbirth to allow enlargement of the vagina and passage of the fetal head. Many exercises suggested for pregnancy (such as Kegel exercises, squatting, and tailor sitting) are aimed at making the perineal muscle as flexible as it can be to allow for optimal expansion during birth and to prevent tearing of this tissue e. The hymen is a tough but elastic semicircle of tissue that covers the opening to the vagina during childhood. It is often torn during the time of first sexual intercourse. However, because of the use of tampons and active sports participation, many girls who have not had sexual relations can also have torn hymens at the time of their first pelvic examination. Occasionally, a girl has an imperforate hymen, or a hymen so complete that it does not allow for the passage of menstrual blood from the vagina (hematocolpometra) or for sexual relations until it is surgically incised (Fischer & Kwan, 2014). 5. The Vulvar Blood Supply The blood supply of female external genitalia is mainly from the pudendal artery and a portion is from the inferior rectus artery. a. Venous return is through the pudendal vein. Pressure on this vein by the fetal head during pregnancy can cause extensive back pressure and development of varicosities (distended veins) in the labia majora and in the legs. 30  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) b. A disadvantage of this rich blood supply is that trauma to the area, such as occurs from pressure during childbirth or a bicycle seat injury, can cause large hematomas. c. An advantage is that it contributes to the rapid healing of any tears in the area after childbirth or other injury (Huether & McCance, 2012). 6. The Vulvar Nerve Supply a. The anterior portion of the vulva derives its nerve supply from the ilioinguinal and genitofemoral nerves (L1 level). b. The posterior portions of the vulva and vagina are supplied by the pudendal nerve (S3 level). Such a rich nerve supply makes the area extremely sensitive to touch, pressure, pain, and temperature. c. Luckily, at the time of birth, normal stretching of the perineum causes a temporary loss of sensation to the area, limiting the amount of local pain felt during childbirth FEMALE INTERNAL STRUCTURES Female internal reproductive organs include the ovaries, the fallopian tubes the uterus, and the vagina. 1. The Ovaries The ovaries are approximately 3 cm long by 2 cm in diameter and 1.5 cm thick, or the size and shape of almonds. a. They are grayish-white and appear pitted, with minute indentations on the surface. The ovaries are located close to and on both sides of the uterus in the lower abdomen. Normally, they lie so low they cannot be located by abdominal palpation. Only if an abnormality exists, such as an enlarging ovarian cyst, can the resulting tenderness and enlargement be evident on lower left or lower right abdominal palpation. b. The function of the two ovaries is to produce, mature, and discharge ova (the egg cells). In the process of producing ova, the ovaries also produce estrogen and progesterone and initiate and regulate menstrual cycles. c. If the ovaries are removed before puberty (or are nonfunctional), the resulting absence of estrogen normally produced by the ovaries prevents maturation and 31  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) maintenance of secondary sex characteristics; in addition, pubic hair distribution will assume a more male than female pattern. d. The ovaries are held suspended and in close contact with the ends of the fallopian tubes by three strong ligaments that attach both to the uterus and the pelvic wall. e. Ovaries are unique among pelvic structures in that they are not covered by a layer of peritoneum. Because they are not covered this way, ova can readily escape from them and enter the uterus by way of the fallopian tubes. Because they are suspended in position rather than being firmly fixed, an abnormal tumor or cyst growing on them can enlarge to a size easily twice that of the organ before pressure on surrounding organs. 2. The Fallopian Tubes The fallopian tubes arise from each upper corner of the uterine body and extend outward and backward until each opens at its distal end, next to an ovary. a. Fallopian tubes are approximately 10 cm long in a mature woman. b. Their function is to convey the ovum from the ovaries to the uterus and to provide a place for fertilization of the ovum by sperm. c. Although a fallopian tube is a smooth, hollow tunnel, it is anatomically divided into four separate parts The most proximal division, the interstitial portion, is the part of the tube that lies within the uterine wall. This portion is only about 1 cm in length; its lumen is only 1 mm in diameter. The next distal portion is the isthmus. This is about 2 cm in length and, like the interstitial tube, remains extremely narrow. This is the portion of the tube that is cut or sealed in a tubal ligation, or tubal sterilization procedure. The ampulla is the third and also the longest portion of the tube. It is about 5 cm in length and is the portion of the tube where fertilization of an ovum usually occurs. The infundibular portion is the most distal segment of the tube. It is about 2 cm long, funnel shaped, and covered by fimbria (small hairs) that help to guide tube the ovum into the fallopian The lining of the fallopian tubes is composed of a mucous membrane, which contains both mucus-secreting and ciliated (hair-covered) cells. Beneath this mucous lining are connective tissue and a circular muscle layer. The muscle layer is important because it is able to produce peristaltic motions that help conduct the ovum the length of 233 the tube (probably also aided by the action of the ciliated lining and the mucus, which acts as a lubricant). The mucus produced may also serve as a source of nourishment for the fertilized egg because it contains protein, water, and salts. 32  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) Because the fallopian tubes are open at their distal ends, a direct pathway exists from the external genital organs, through the vagina to the uterus and tubes, to the peritoneum. This open pathway is what makes conception possible. It also, however, can lead to infection of the peritoneum (peritonitis) if germs spread from the perineum through the uterus and tubes to the pelvic cavity. For this reason, clean technique must be used during pelvic examinations. During labor and birth, vaginal examinations are done with sterile technique to ensure no organisms can enter by this route 3. The Uterus The uterus is a hollow, muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder and anterior to the rectum. During childhood, it is about the size of an olive; the cervix is the largest portion and the uterine body is the smallest part. When a girl reaches about 8 years of age, an increase in the size of the organ begins. This growth is so slow, however, the young woman is closer to 17 years old before the uterus reaches its adult size and changes its proportions so that the body cavity, not the cervix, is its largest portion. Small uterine size may be a contributing factor to the number of low–birth-weight babies typically born to adolescents younger than this age (March of Dimes Foundation, 2012). With maturity, a uterus is about 5 to 7 cm long, 5 cm wide, and, in its widest upper part, 2.5 cm deep. In a no pregnant state, it weighs approximately 60 g. The function of the uterus is to A. receive the ovum from the fallopian tube; B. provide a place for implantation and nourishment; C. furnish protection to a growing fetus; and, at maturity of the fetus, expel it from a woman’s body. After a pregnancy, the uterus never returns to exactly its no pregnant size but remains approximately 9 cm long, 6 cm wide, 3 cm thick, and 80 g in weight. Anatomically, the uterus consists of three divisions: the body or corpus, the isthmus, and the cervix. A. The body of the uterus is the uppermost part and forms the bulk of the organ. The lining of the cavity is continuous with the fallopian tubes, which enter at its upper aspects (the cornua). The portion of the uterus between the points of attachment of the fallopian tubes is termed the fundus. During pregnancy, the body of the uterus is the portion of the structure that expands to contain the growing fetus. The fundus is the portion that can be palpated abdominally to determine the amount of uterine growth during pregnancy, to measure the force of uterine contractions during labor, and to assess that the uterus is returning to its nonpregnant state after childbirth. B. The isthmus is a short segment between the body and the cervix. In the nonpregnant uterus, it is only 1 to 2 mm in length. During pregnancy, this portion also enlarges greatly to aid in accommodating the growing fetus. It is the portion where the incision most commonly is made when a fetus is born by a cesarean birth. C. The cervix is the lowest portion of the uterus. It represents about one third of the total uterine size and is approximately 2 to 5 cm long. About half of it lies above the vagina and half extends into the vagina. Its central cavity is termed the 33  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) cervical canal. The opening of the canal at the junction of the cervix and isthmus is the internal cervical os; the distal opening to the vagina is the external cervical os. The level of the external os is at the level of the ischial spines (an important relationship in estimating the level of the fetus in the birth canal at the time of birth) Uterine and Cervical Coats The uterine wall consists of three separate coats or layers of tissue Uterine Blood Supply The large descending abdominal aorta divides to form two iliac arteries; these then form the hypogastric arteries and the uterine arteries, which supply the uterus. Because the uterine blood supply is not far removed from the aorta this way, it is guaranteed to be copious and adequate to supply the growing needs of a fetus. As an additional guarantee that enough blood will be available, after supplying the ovaries with blood, the ovarian artery (a direct subdivision of the aorta) joins the uterine artery and adds more blood to the uterus. The blood vessels that supply the cells and lining of the uterus look tortuous against the sides of the uterine body in nonpregnant women. As a uterus enlarges with pregnancy, the vessels “unwind” and stretch as another guarantee that the uterus will maintain an adequate blood supply as the organ grows larger. The uterine veins follow the same twisting course as the arteries; they empty into the internal iliac veins. An important organ relationship to be aware of is the close proximity of uterine blood vessels and ureters. Ureters pass from the kidneys on their way to the bladder directly behind the ovarian vessels, near the fallopian tubes. This close anatomic relationship has implications in procedures such as tubal ligation, cesarean birth, and hysterectomy (removal of the uterus) because a ureter this close to the fallopian tubes can be injured if bleeding during surgery is controlled by clamping of the uterine or ovarian vessels. This is a reason a first voiding after uterine or tubal surgery is measured and assessed carefully for color or the presence of blood. Uterine Nerve Supply 34  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) The uterus is supplied by both efferent (motor) and afferent (sensory) nerves. a. The efferent nerves arise from the T5 through T10 spinal ganglia. b. The afferent nerves join the hypogastric plexus and enter the spinal column at T11 and T12. ☑ The fact that sensory innervation from the uterus registers lower in the spinal column than does motor control has implications for controlling pain in labor. An anesthetic solution can be injected to stop the pain of uterine contractions at the T11 and T12 levels without stopping motor control or contractions (which are registered higher, at the T5 to T10 level). This is the principle of both epidural and spinal anesthesia. Uterine Supports The uterus is suspended in the pelvic cavity by a number of ligaments that also help support the bladder; it is further supported by a combination of fascia and muscle. Because the uterus is suspended this way, it is free to enlarge without discomfort during pregnancy..If its ligaments become overstretched during pregnancy, however, they may not support the bladder well afterward, and the bladder can then herniate into the anterior vagina (a cystocele), possibly causing frequent urinary infections from status of urine If the rectum pouches into the vaginal wall, a rectocele develops, possibly leading to constipation (Podzemny, Pescatori, & Pescatori, 2015). A. A cystocele. The bladder has herniated into the anterior wall of the vagina. B. A rectocele. The posterior of the vagina is herniated. A fold of peritoneum behind the uterus is the posterior ligament. This forms a pouch (Douglas cul-de-sac) between the rectum and uterus. Because this is the lowest point of the pelvis, any fluid (such as blood) released from a condition, such as a ruptured tubal (ectopic) pregnancy, tends to collect in this space. The space can be examined for the presence of fluid or blood to help in diagnosis by inserting a culdoscope through the posterior vaginal wall (culdoscopy) or a laparoscope through the abdominal wall (laparoscopy) (Sholapurkar, 2015). 35  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) The broad ligaments are two folds of peritoneum that cover the uterus in the front and back and extend to the pelvic sides to help steady the uterus. The round ligaments are two fibrous, muscular cords that pass from the body of the uterus through the broad ligaments and down into the inguinal canal, inserting into the fascia of the vulva. The round ligaments act as additional “stays” to further steady the uterus. If a pregnant woman moves quickly, she may pull one of these ligaments, causing a quick, sharp pain of frightening intensity in one of her lower abdominal quadrants. Pain of this type calls for conscientious assessment or it can be mistaken for labor or appendicitis pain. THINK! INSTRUCTIONS: answer the question in a separate sheet of paper , this is a graded activity 4. The Vagina The vagina is a hollow, musculomembranous canal located posterior to the bladder and anterior to the rectum. It extends from the cervix of the uterus to the external vulva. Its function is to act as the organ of intercourse and to convey sperm to the cervix. With childbirth, it expands to serve as the birth canal. Even though the vagina opens to the outside, it is considered an internal reproductive organ. When a woman lies on her back, as she does for a pelvic examination 1. The course of the vagina is inward and downward. Because of this downward slant and the angle of the uterine cervix, the length of the anterior wall of the vagina is about 6 to 7 cm and the length of the posterior wall is 8 to 9 cm. 2. At the cervical end of the structure, there are recesses on all sides, termed the posterior, anterior, and lateral fornices. 36  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) 3. The posterior fornix serves as a place for the pooling of semen after coitus; this allows for a large number of sperm to remain close to the cervix and encourages sperm migration into the cervix. 4. The vaginal wall is so thin at the fornices that an examiner can palpate the bladder through the anterior fornix, the ovaries through the lateral fornices, and the rectum through the posterior fornix. 5. The vagina is lined with stratified squamous epithelium similar to that covering the cervix. Under this, it has a middle connective tissue layer and a strong muscular wall 6. Normally, the walls contain many folds or rugae that lie in close approximation to each other. These folds make the vagina very elastic and able to expand so much that at the end of pregnancy, a full-term baby can pass through without tearing. 7. A circular muscle at the external opening of the vagina, called the bulbocavernosus muscle, acts as a voluntary sphincter. Relaxing and tensing this external vaginal sphincter muscle a set number of times each day (Kegel exercises) makes it suppler for birth and helps maintain tone after birth. 8. The blood supply to the vagina is furnished by the vaginal artery, a branch of the internal iliac artery. Vaginal tears at childbirth tend to bleed profusely because of this rich blood supply. The same rich blood supply, however, is also the reason any vaginal trauma at birth heals rapidly. 9. The vagina has both sympathetic and parasympathetic nerve innervations originating at the S1–S3 levels. Despite this dual nerve supply, the vagina is not an extremely sensitive organ. Sexual excitement, often attributed to a vaginal origin, is actually mainly a clitoral function. ☑ Mucus produced by the vaginal lining has a rich glycogen content. When this glycogen is broken down by the lactose-fermenting bacteria that frequent the vagina (Döderlein bacillus), lactic acid is formed. You can advise women not to use vaginal douches or sprays as a daily hygiene measure so they do not clear away this natural acidic medium because this would invite infection (Sheth & Keller, 2015). The Breasts The mammary glands or breasts, form early in intrauterine life. They then remain in a halted stage of development until a rise in estrogen at puberty causes them to increase in size. 1. This increase occurs mainly because of growth of connective tissue plus deposition of fat. 2. The glandular tissue of the breasts, necessary for successful breastfeeding, remains undeveloped until a first pregnancy begins. Boys, especially those who are obese, may notice a temporary increase in breast size at puberty, termed gynecomastia (Narula & Carlson, 2014). 3. If boys are not prepared that this is a normal change of puberty, they may be concerned that they are developing abnormally. Breasts are located anterior to the pectoral muscle , and, 37  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) 4. Many women, breast tissue extends well into the axilla. When palpating for breast health, always include the axillary region in the examination, or this breast tissue can be missed. 5. It is not uncommon for women or men to have supernumerary breast tissue along mammary lines on the front of their body. 6. The nipple on these auxiliary sites may look like a mole, so adolescents may report this as a “mole changing in color” or be concerned they have skin cancer. You can assure them supernumerary breast tissue or nipples are not uncommon and are innocent findings Women should be aware of the usual appearance of their breasts (breast awareness) so they can report any change in contour or density to their healthcare provider. Milk glands of the breasts are divided by connective tissue partitions into approximately 20 lobes. All of the glands in each lobe produce milk by acinar cells and deliver it to the nipple via a lactiferous duct. The nipple has approximately 20 small openings through which milk is secreted. An ampulla portion of the duct, located just posterior to the nipple, serves as a reservoir for milk before breastfeeding The nipple is composed of smooth muscle capable of erection on manual or sucking stimulation. On stimulation, it transmits sensations to the posterior pituitary gland to release oxytocin, which then acts to constrict milk glands and push milk forward into the ducts that lead to the nipple (a let-down reflex). The skin surrounding the nipples is darkly pigmented out to about 4 cm and termed the areola. The area appears rough on the surface because it contains many sebaceous glands, called Montgomery tubercles. Because the milk glands are the structures important for breastfeeding and the size of breasts is associated with fat deposits, the size of breasts has no effect on whether a woman can successfully breastfeed. MENSTRUATION MENSTRUATION CYCLE 38  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) Characteristic Description Beginning (menarche) – Average age at onset, 12.4 years; average range, 9–17 years Interval between cycles – Average, 28 days; cycles of 23–35 days not unusual Duration of menstrual flow- Average flow, 4–6 days; ranges of 2–9 days not abnormal Amount of menstrual flow Difficult to estimate; average 30–80 ml per menstrual period; saturating a pad or tampon in less than 1 hr is heavy bleeding Color of menstrual flow- Dark red; a combination of blood, mucus, and endometrial cells Odor – Similar to marigolds THINK! INSTRUCTIONS: write your answer in a separate sheet paper, this is a graded activity ACTIVITY #4 SEXUALITY is a multidimensional phenomenon that includes feelings, attitudes, and actions. It has both biologic and cultural diversity components. It encompasses and gives direction to a person’s physical, emotional, social, and intellectual responses throughout life. Sexuality has always been a part of human life, but only in the past few decades has it been studied scientifically. One common finding of researchers has been that feelings and attitudes about sex vary widely across cultures and individuals. Although 39  NUPC 108 CARE OF MOTHER CHILD AND ADOLESCENT (WELL CLIENTS) the sexual experience is unique to each individual, sexual physiology (how the body responds to sexual arousal) has common features (Resetkova & Rogers, 2015). SEXUAL RESPONSE The hypothalamus and anterior pituitary glands in females regulate the production of FSH and LH. The target tissue for these hormones is the ovary, which produces ova and secretes estrogen and progesterone. A feedback mechanism between hormone secretion from the ovarie