MATERNAL NEWBORN NURSING

• REVIEW OF REPRODUCTIVE A&P, FETAL CONCEPTION AND DEVELOPMENT

• ANTEPARTUM TERMINOLOGY• ANTEPARTUM ASSESSMENT• PHYSIOLOGICAL CHANGES IN PREGNANCY• PSYCHO-SOCIAL CHANGES IN PREGNANCY• MATERNAL NUTRITION• ASSESSMENT OF FETAL WELL BEING

MODULE 1 PART 1 REVIEW OF REPRODUCTIVE ANATOMY AND

PHYSIOLOGY

• REVIEW• REPRODUCTIVE A&P, FETAL

CONCEPTION & DEVELOPMENTTHIS WILL NOT BE COVERED IN THIS THIS WILL NOT BE COVERED IN THIS LECTURE—BE PREPARED TO ANSWER LECTURE—BE PREPARED TO ANSWER REVIEW QUESTIONS IN CLASSREVIEW QUESTIONS IN CLASS

THE QUIZ IN CLASS 1 WILL FOCUS THE QUIZ IN CLASS 1 WILL FOCUS ON CHANGES IN PREGNANCY AND ON CHANGES IN PREGNANCY AND TERMINOLOGYTERMINOLOGY

Review of Reproductive A&PExternal GenitalsInternal Reproductive Organs

VaginaUterusUterine corpusCervixUterine ligamentsFallopian TubesOvaries

Figure 2–2 Female internal reproductive organs.

Figure 2–4 Structures of the uterus.

REVIEW OF REPRODUCTIVE A&P

• UTERINE LIGAMENTS–ROUND LIGAMENTS–OVARIAN LIGAMENTS–CARDINAL LIGAMENTS– INFUNDIBULOPELVIC LIGAMENT–UTEROSACRAL LIGAMENT

Figure 2–6 Uterine ligaments.

Figure 2–3b Blood supply to vagina, ovaries, uterus, and fallopian tube.

Figure 2–3a Blood supply to internal reproductive organs. Pelvic blood supply.

Figure 2–5a Uterine muscle layers. Muscle fiber placement.

MODULE 1 PART 2 REVIEW OF REPRODUCTIVE

A & P

• PELVIC STRUCTURE–Innominate bones• ILIUM– ILIAC CREST

• ISCHIUM– ISCHIAL TUBEROSITY– ISCHIAL SPINES

• PUBIS–SYMPHYSIS PUBIS

– Sacrum• SACRAL PROMOTORY, SACROILIAC JOINTS

– Coccyx

REVIEW OF REPRODUCTIVE A&P

• PELVIC DIVISION– TRUE PELVIS

• INLET

• PELVIC CAVITY

• OUTLET

Figure 2–8 Pelvic bones with supporting ligaments.

Figure 2–10a Female pelvis. False pelvis is shallow cavity above the inlet; true pelvis is deeper portion of cavity below the inlet.

Figure 2–11 Pelvic planes: coronal section and diameters of the bony pelvis.

REVIEW OF REPRODUCTIVE A&P• PELVIC DIAPHRAGM– LEVATOR ANI– COCCYGEAL MUSCLES– DEEP FASCIA

• PELVIC FLOOR MUSCLES– LEVATOR ANI– ILLIOCOCCYGEUS– PUBOCOCCYGEUS, COCCYGEUS– PUBORECTALIS, PUBORECTALIS– PUBOVAGINALIS

Figure 2–9 Muscles of the pelvic floor. (The puborectalis, pubovaginalis, and coccygeal muscles cannot be seen from this view.)

REVIEW OF REPRODUCTIVE A&P–BREASTS• NIPPLE• AREOLA• TUBERCLES OF MONTGOMERY• LACTIFEROUS DUCTS• ADIPOSE, GLANDULAR, FIBROUS TISSUE• COOPER’S LIGAMENTS

Figure 2–12 Anatomy of the breast: sagittal view of left breast.

MODULE 1 PART 3 CONCEPTION

• MATURATION OF OVARIAN FOLLICLE• OVULATION• CORPUS LUTEUM• NEUROHUMORAL RESPONSE–HYPOTHALMUS RELEASES

GONADATROPIN-RELEASING HORMONE TO PITUITARY FROM RESPONES FROM CNS–ANTERIOR PITUITARY THEN SECRETES

FSH AND LH

• FEMALE REPRODUCTIVE CYCLE–OVARIAN CYCLE• FOLLICULAR PHASE• LUTEAL PHASE

• FEMALE HORMONES–ESTROGEN–PROGESTERONE–PROSTAGLANDINS

• UTERINE CYCLE (MENSTRUAL)

Figure 2–13 Female reproductive cycle: interrelationships of hormones with the four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle.

Figure 2–14 Various stages of development of the ovarian follicles.

REVIEW OF CONCEPTION AND FETAL DEVELOPMENT

• CELLULAR DIVISION– MITOSIS– MEIOSIS

• OOGENESIS• SPERMATOGENESIS• PRE-FERTILIZATION– CAPACIATION– ACROSOMAL REACTION– FERTILIZATION

PREEMBRYONIC STAGE

CELLULAR MULTIPLICATIONCLEAVAGEMORULABLASTOCYSTTROPHOBLAST

IMPLANTATIONCHANGES IN ENDOMETRIUM

DECIDUA CAPSULARISDECIDUA BASALISDICIDUA VERA

Figure 3–2a Sperm penetration of an ovum. The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. Source: Scanning electron micrograph from Nilsson, L. (1990). A child is born. New York: Dell Publishing.

Figure 3–1b Each spermatogonium produces four haploid spermatozoa.

Figure 3–5 Formation of primary germ layers. A, Implantation of a 71⁄2-day blastocyst in which the cells of the embryonic disc are separated from the amnion by a fluid-filled space. The erosion of the endometrium by the syncytiotrophoblast is ongoing. B, Implantation is completed by day 9, and extraembryonic mesoderm is beginning to form a discrete layer beneath the cytotrophoblast. C, By day 16 the embryo shows all three germ layers, a yolk sac, and an allantois (an outpouching of the yolk sac that forms the structural basis of the body stalk, or umbilical cord). The cytotrophoblast and associated mesoderm have become the chorion, and chorionic villi are developing. Source: Adapted from Marieb, E. N. (1998).

Figure 3–4 During ovulation, the ovum leaves the ovary and enters the fallopian tube. Fertilization generally occurs in the outer third of the fallopian tube. Subsequent changes in the fertilized ovum from conception to implantation are depicted.

MODULE 1 PART 4 REVIEW OF CONCEPTION AND

FETAL DEVELOPMENT

• CELLULAR DIFFERENTIATION–THREE PRIMARY GERM LAYERS• ECTODERM•MESODERM• ENDODERM

• EMBRYONIC MEMBRANES–AMNION–CHORION–AMNIOTIC SAC

REVIEW FETAL DEVELOPMENT

• AMNIOTIC FLUID

• UMBILICAL CORD

• PLACENTA

REVIEW OF FETAL DEVELOPMENT

• EMBRYONIC AND FETAL DEVELOPMENT

–EMBRYONIC STAGE—DAY 15 T0 8TH WEEK

–FETAL STAGE—8TH WEEK TO BIRTH

Figure 3–10 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returns through the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.

Figure 3–7 Early development of primary embryonic membranes. At 41⁄2 weeks, the decidua capsularis (placental portion enclosing the embryo on the uterine surface) and decidua basalis (placental portion encompassing the elaborate chorionic villi and maternal endometrium) are well formed. The chorionic villi lie in blood-filled intervillous spaces within the endometrium. The amnion and yolk sac are well developed. Source: Adapted from Marieb, E. N. (1998).

Figure 3–10 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returns through the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.

Figure 3–7 Early development of primary embryonic membranes. At 41⁄2 weeks, the decidua capsularis (placental portion enclosing the embryo on the uterine surface) and decidua basalis (placental portion encompassing the elaborate chorionic villi and maternal endometrium) are well formed. The chorionic villi lie in blood-filled intervillous spaces within the endometrium. The amnion and yolk sac are well developed. Source: Adapted from Marieb, E. N. (1998).

Figure 3–6 Endoderm differentiates to form the epithelial lining of the digestive and respiratory tracts and associated glands. Source: Adapted from Marieb, E. N. (1998).

Figure 3–12 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage begins in the third week after fertilization; the fetal stage begins in the ninth week. Source: Adapted from Marieb, E. N. (1998).

MODULE 1 PART 5 REVIEW QUESTIONS

REVIEW QUESTIONS• WHAT IS THE SIGNIFICANCE OF THE

ENDOMETRIAL (MUCOSAL) LAYER OF THE UTERUS?

• THE UTERUS IS MADE UP OF WHAT TYPE OF MUSCLE?

• ESTROGEN IS SECRETED BY THE_______? • PROGESTERONE IS SECRETED BY THE_______?• WHAT IS THE FUNCTION OF FSH AND LH?• DESCRIBE MEIOSIS.

REVIEW QUESTIONS

• WHERE DOES FERTILIZATION OCCUR?• THE BLASTOCYST DEVELOPS INTO THE ______.• THE TROPHOBLAST DEVELOPS INTO THE ____. • THE PLACENTA DEVELOPS FROM THE ______. • WHICH SYSTEMS/STRUCTURES DEVELOP

FROM THE MESODERM LAYER?

• NAME THREE FACTORS THAT AFFECT FETAL DEVELOPMENT.

• WHAT IS THE ROLE OF THE BROAD AND ROUND LIGAMENTS?

• WHAT IS THE UPPER PORTION OF THE UTERUS CALLED?

• WHATS CHANGES OCCUR IN THE FUNCTION OF THE OVARIES AT ABOUT THE 12- 14TH WEEK OF PREGNANCY?

MODULE 1 PART 6A PHYSIOLOGICAL CHANGES IN

PREGNANCY

PHYSIOLOGICAL CHANGES IN PREGNANCY

ENDOCRINE

MUSCULOSKELETEL

RENAL

INTEGUMENTARYRESPIRATORY

GIGU REPRODUCTIVE

GROWTH OF

PLACENTA

CARDIOVASCULAR

• REPRODUCTIVE SYSTEM

–PLACENTA–AMNION–CHORION–UMBILICAL CORD–AMNIOTIC FLUID

REPRODUCTIVE SYSTEM

• PLACENTAL FUNCTION–METABOLIC

–TRANSPORT

–ENDOCRINE

REPRODUCTIVE SYSTEM• OVARIES – STOP PRODUCING OVA. CORPUS LUTEUM IS

ACTIVE 10-12 WEEKS INTO PREGNANCY TO PRODUCE ESTROGEN AND PROGESTERONE. THEN WHAT HAPPENS?

• BREASTS• INCREASED VASCULARITY AND SIZE• HYPERTROPHY OF MAMMARY AVEOLI• BECOME MORE NODULAR; NIPPLES ENLARGE• PIGMENTATION OF AREOLA; COLUSTRUM

• REPRODUCTIVE SYSTEM–UTERUS• INCREASE IN SIZE, WEIGHT, AND

VOLUME CAPACITY• FIBROUS TISSUE INCREASES• INCREASE IN BLOOD FLOW

–CERVIX•GOODALL’S SIGN, CHADWICK’S SIGN• DEVELOPMENT OF MUCOS PLUG

REPRODUCTIVE SYSTEM

• VAGINA–MUCOSA THICKENS– INCREASE IN SECRETIONS– LOOSENING OF CONNECTIVE TISSUE—

WHY?

• RESPIRATORY SYSTEM–O2 CONSUMPTION INCREASES–BREATHING CHANGES FROM

ABDOMINAL TO THORACIC–INCREASED VACULARITY–DIAPHRAGM ELEVATES

• CARDIOVASCULAR SYSTEM–BLOOD VOLUME INCREASES–DECREASE IN SYSTEMIC AND

PULMONARY RESISTANCE IN THIRD TRIMESTER–INCREASE IN CARDIAC OUTPUT, PULSE

INCREASE (10-15 BPM) Why?–SVR DECREASE IN THIRD TRIMESTER

• MUSCULOSKELETAL SYSTEM–PELVIC JOINTS RELAX–CENTER OF GRAVITY CHANGES

• METABOLISM– EXTRA WATER, FAT, AND PROTEIN STORED– FATS ARE MORE COMPLETELY ABSORBED–BMR INCREASE (CAN BE UP TO 25%)

MODULE 1 PART 6B PHYSIOLOGICAL CHANGES IN

PREGNANCY

• GASTRONTESTINAL

–SMOOTH MUSCLE RELAXATION—RELATED TO PROGESTERONE INFLUENCE

• RENAL– FREQUENCY–DILATATION OF KIDNEYS, URETERS

ELONGATE– INCREASED GFR, CREATININE CLEARANCE

AND RENAL PLASMA—FLOW-WHY?–GLYCOSURIA MAY OCCUR

• INTEGUMENTARY–HYPERPIGMENTATION–STRIAE–CHLOASMA (MELASMA)–VASCULAR SPIDER NEVI–DECREASED HAIR GROWTH–HYPERACTIVE SWEAT AND SEBACEOUS

GLANDS

• ENDOCRINE SYSTEM– THYROID—T4 AND BMR INCREASE (25% BY

TERM), TSH DECREASES THYROID—GLAND ENLARGES, INCREASED IODINE METABOLISM, INCREASED VASCULARITY–PITUITARY—FSH AND LH SUPPRESSED,

SECRETION OF PROLACTIN, OXYTOCIN, AND VASOPRESSION–PANCREAS—INSULIN PRODUCTION

INCREASE– TO COMPENSATE FOR PLACENTAL

HORMONE INSULIN ANTAGONISTS

• ENDOCRINE SYSTEM

• CONCENTRATION OF PARATHYROID HORMONE INCREASES—WHY IS THIS SIGNIFICANT?

• INCREASED ALDOSTERONE

• ADRENALS—LITTLE CHANGE

ENDOCRINE SYSTEMESTROGEN

LIST THREE ACTION OF ESTROGEN DURING PREGNANCY

ESTROGEN IS PRIMARILY EXCRETED BY THE ______ DURING PREGNANCY

• ENDOCRINE SYSTEM• PROGESTERONE–LIST THREE ACTIONS OF

PROGESTERONE DURING PREGNANCY

ENDOCRINE SYSTEM

hCG--(HUMAN CHORIOGONADATROPIC HORMONE)--STIMULATES PROGERTERONE AND ESTROGEN TO MAINTAIN PREGNANCY

hPL—(HUMAN PLACENTAL LACTOGEN)—DECREASES MATERNAL METABOLISM FOR GLUCOSE (INSULIN ANTAGONIST)

PROSTGLANDINS

• ENDOCRINE SYSTEM

–RELAXIN•DECREASES UTERINE CONTRACTILITY• SOFTENS CERVIX• SOFTENS JOINTS•REMODELS COLLAGEN

MODULE 1 PART 7 PSYCHOLOGICAL CHANGES IN

PREGNANCY

MOTHER’S RESPONSE TO PREGNANCY

• AMBIVALENCE• ACCEPTANCE• INTROVERSION• MOOD SWINGS• FEAR• CHANGES IN BODY IMAGE• ANTEPARTUM DEPRESSION?

FATHER’S RESPONSE TO PREGNANCY• CONFUSED BY PARTNER’S MOOD SWINGS• FEELS LEFT OUT• RESENTS ATTENTION GIVEN YO THE WOMAN• RESENTS CHANGES IN THEIR RELATIONSHIP• NEEDS TO RESOLVE CONFLICTS ABOUT

FATHERING

MODULE 1 PART 8 ANTEPARTUM TERMINOLOGY

GESTATION

ANTEPARTUM

INTRAPARTUM

POSTPARTUM

PRETERM LABOR

POSTTERM LABOR

• GRAVIDA

–NULLIGRAVIDA

–PRIMIGRAVIDA

–MULTIGRAVIDA

• PARA

–NULLIPARA

–PRIMIPARA

–MULTIPARA

• ABORTION: 4-20 WEEKS

• PRE-TERM: 21-39 WEEKS

• TERM: 39 WEEKS, 1 DAY- 42 WEEKS

• TPAL• T--NUMBER OF TERM PREGNANCIES

• P--NUMBER OF BIRTHS AFTER 20 WEEKS

• A—NUMBER OF ABORTIONS

• L—NUMBER OF LIVING CHILDREN

G/TPAL EXERCISES• G T P A L

• G3 1 2 0 1

• G2 0 3 1 3

• G5 2 1 3 3

• G2 0 5 0 3

MODULE 1 PART 9AANTEPARTUM PHYSICAL AND PSYCHO-SOCIAL ASSESSMENT

ANTEPARTUM PHYSICAL AND PSYCHO-SOCIAL ASSESSMENT

FINDINGSRELATED

TOPREGNANCYPHYSICAL

ASSESSMENT

ECONOMICSENVIRONMENT

SUPPORT SYSTEM

FAMILYFUNCTION

CLIENT PROFILE

EDUCATIONALNEEDS

CULTURE

RISKFACTORS

CULTURAL BELIEFS AND PRACTICE ASSESSMENT IN ANTEPARTUM PERIOD

• HOME REMEDIES• NUTRITION• ALTERNATIVE HEALTH CARE PROVIDERS • FAMILY SUPPORT• EXERCISE• SPIRITUALITY

CULTURAL CONSIDERATIONS/ASSESSMENT IN ANTEPARTUM PERIOD

• VIEW OF PREGNANCY• SELF CARE PRACTICES• PAIN• CHILDBIRTH PRACTICES• CARE OF THE NEWBORN• POST PARTUM

SIGNS OF PREGNANCY

• SUBJECTIVE (PRESUMPTIVE)

• OBJECTIVE (PROBABLE)

• DIAGNOSTIC (POSITIVE)

DUE DATE

• EDD, EDC, EDB

• NAEGLE’S RULE—SUBTRACT 3 MONTHS FROM FIRST DAY OF LAST MENSTRUAL PERIOD AND ADD 7 DAYS

• EXAMPLE: LMP OCT. 12—EDB---JULY 19

CLIENT PROFILE

CURRENT PREGNANCYPAST PREGNANCYCURRENT MEDICAL/SUGICAL HISTORYGYN HISTORYFAMILY MEDICAL HISTORYRELIGIOUS, SPIRITUAL, CULTURAL HISTORYOCCUPATIONAL HISTORYPERSONAL INFORMATION—(PSYCHOSOCIAL)

ANTEPARTUM RISK FACTORS

• FACTORS RELATED TO:• ECONOMICS• ENVIRONMENT• CURRENT HEALTH STATUS/PRACTICES• AGE• NUTRITION• CHILDBIRTH HISTORY• SOCIAL ISSUES• PYSCHOLOGICAL STATUS

MODULE 1 PART 9B ANTEPARTUM PHYSICAL AND PSYCHOSOCIAL ASSESSMENT

ANTEPARTUM PHYSICAL ASSESSMENT

VS UTERUSSKIN EXTERNAL GENITALSMOUTH, EARS, NECK CERVIX, VAGINACHEST AND LUNGS ANUS AND RECTUMBREASTS LAB EVALUATIONHEARTABDOMENEXTREMITIESREFLEXESSPINE

LAB EVALUATIONS INITIAL ANTEPARTUM VISIT

• SCREENING TESTS– CBC– ABO AND Rh TYPING– WBC WITH DIFFERENTIAL– FIRST TRIMESTER ANEUPLOIDY – STD SCREENING, HIV– GLUCOSE– RUBELLA TITER– HEPATITS B– SICKLE CELL– PAP SMEAR

PSYCHO-SOCIAL ANTEPARTUM ASSESSMENT

• CULTURE• PSYCHOLOGIC STATUS• EDUCATIONAL NEEDS• SUPPORT SYSTEMS• FUNCTIONING OF FAMILY• ECONOMIC STATUS• ENVIRONMENT

MATERNAL NUTRITION

• AVERAGE WEIGHT GAIN

• PATTERN OF WEIGHT GAIN

• NUTRITIONAL REQUIREMENTS–CALORIES

–PROTEIN

MATERNAL NUTRITION

– FAT–CARBS–VITAMINS–MINERALS

CULTURAL CONSIDERATIONS

MATERNAL NUTRITION–VEGETARIANISM– LACTOSE DEFICIENCY– EATING DISORDERS–PICA–ADOLESCENT

WHAT TEACHING WOULD YOU DO FOR THESE ALTERATIONS/ CHANGES IN NUTRITION?

ANTEPARTUM ASSESSMENTFETAL DEVELOPMENT

• FUNDAL HEIGHT

• QUICKENING

• FETAL HEART RATE

• ULTRASOUND

Figure 7–5 Approximate height of the fundus at various weeks of pregnancy.

Figure 8–3 A cross-sectional view of fetal position when McDonald’s method is used to assess fundal height.

MODULE 1 PART 10 ASSESSMENT OF FETAL WELL

BEING

• FETAL ACTIVITY• ULTRASOUND–TRANSABDOMINAL–TRANSVAGINAL

• NUCAL TRANSLUCENCY TESTING (NTT)• DOPPLER BLOOD FLOW STUDIES

• AMNIOCENTESIS (AMNIOTIC FLUID ANALYSIS)–EVALUATION OF FETAL HEALTH–EVALUATION OF LUNG MATURITY

• CHORIONIC VILLI SAMPLING (CVS)• WHAT IS THE ADVANTAGE OF THE

CVS?

TERATOGENESIS

• MEDICATIONS MATERNAL: NUTRITION VIRUS

• ALCOHOL RADIATION• COCAINE TOBACCO• HYPERTHERMIA• CAFFEINE• MARIJUANA

MODULE 1 PART 11 DANGERS/DISCOMFORTS IN

PREGNANCY

DANGER SIGNS OF PREGNANCY

• VAGINAL BLEEDING• LEAKAGE OF FLUID FROM VAGINA• ABDOMINAL PAIN• TEMP > 101• DIZZINESS, BLURRING OF VISION• SEVERE HEADACHE• EDEMA OF HANDS, FACE, FEET

DANGER SIGNS OF PREGNANCY

• PERSISTENT VOMITING• MUSCULAR IRRITABILITY• EPIGASTRIC PAIN• OLIGURIA• DYSURIA• ABSENCE OF FETAL MOVEMENT

DISCOMFORTS OF PREGNANCY

• FIRST TRIMESTER–NAUSEA AND VOMITING

–URINARY FREQUENCY

–FATIGUE

–BREAST TENDERNESS

DISCOMFORTS OF PREGNANCY

–INCREASED VAGINAL DISCHARGE

–NASAL STUFFINESS & EPITAXIS

–PTYALISM

DISCOMFORTS OF PREGNANCY

• SECOND & THIRD TRIMESTER–HEARTBURN

–ANKLE EDEMA

–VARICOSE VEINS

–HEMORRHOIDS

DISCOMFORTS OF PREGNANCY

– CONSTIPATION

– BACKACHE

– LEG CRAMPS

– FAINTNESS

DISCOMFORTS OF PREGNANCY

–DYSPNEA

– FLATULENCE

–CARPAL TUNNEL SYNDROME

–DIFFICULTY SLEEPING–ROUND LIGAMENT PAIN

DISCOMFORTS OF PREGNANCY• DETERMINE WHICH SYSTEM IS RESPONSIBLE

FOR EACH OF THE DISCOMFORTS OF PREGNANCY.

• EXPLAIN HOW THE PHYSIOLOGICAL CHANGES THAT OCCUR IN EACH SYSTEM DURING PREGNANCY CAN BE RESPONSIBLE FOR THE DISCOMFORTS.

• WHAT INTERVENTIONS WOULD YOU USE TO TREAT THE DISCOMFORTS? (EBP)

SUBSEQUENT LAB EVALUATION

• HEMOGLOBIN• QUAD MARKER (15-20 WEEKS)• INDIRECT COOMBS • 50 G 1 HOUR GLUCOSE SCREEN• URINALYSIS—GYCOSURIA, PROTEINURIA• GROUP B STREP SCREENING (35-37

WEEKS)

SELF CARE PROMOTION

• BATHING• EMPLOYMENT• TRAVEL• ACTIVITY, REST• FETAL ACTIVITY MONITORING• BREAST CARE• CLOTHING• BATHING

SELF CARE PROMOTION

• DENTAL CARE• IMMUNIZATIONS• SEXUAL ACTIVITY• COMPLEMENTARY & ALTERNATIVE THERAPIES• ABSTINENCE FROM ALCOHOL, TOBACCO,

DRUGS• PSYCHO-SOCIALSUPPORT