ABRUPTIO PLACENTA

Definition:- Premature separation of the placenta from the uterine wall.- Common cause of bleeding during the second half of pregnancy - Usually occurs after 20 to 24 weeks of pregnancy but may occur as late as during first or

second stage of labor.

Placental abruption (also known as abruptio placentae) is an obstetric catastrophe (complication of pregnancy), wherein the placental lining has separated from the uterus of the mother. It is the most common cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies worldwide with a fetal mortality rate of 20-40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality.

The heart rate of the fetus can be associated with the severity.

Risk factors:- women with parity of 5 or more- women over 30 years of age- women with pre-eclampsia - eclampsia and renal or vascular disease.

Factors contributing to ABRUPTIO PLACENTA- multiple gestations- hydramnios- cocaine use- dec. blood flow to the placenta- trauma to the abdomen- dec. serum folic acid levels- PIH

Cause: UnknownTheories proposed relating it’s occurrence to dec. blood flow to the placenta through the

sinuses during the last trimester; Excessive intrauterine pressure caused by hydramnios or multiple pregnancy may also be contributing factors.

Clinical manifestations:

ℜ Covert (severe)/ Mild separation/ Mild Abruptio Placenta

The placenta separates centrally and the blood is trapped between the placenta and the uterine wall.Signs and Symptoms:

1. no overt bleeding from vagina2. rigid abdomen3. acute abdominal pain4. dec. BP5. inc. pulse6. uteroplacental insufficiency

ℜ Overt (partial)/ Moderate separation/ Moderate Abruptio Placenta

The blood passes between the fetal membranes and the uterine wall and escapes vaginally. May develop abruptly or progress from mild to extensive separation with external hemorrhage.Signs and Symptoms:

1. vaginal bleeding2. rigid abdomen3. acute abdominal pain4. dec. BP5. inc. pulse6. uteroplacental insufficiency

ℜ Placental Prolapse/ Severe separation/ Severe Abruptio Placenta

Massive vaginal bleeding is seen in the presence of almost total separation with possible fetal cardiac distress.Signs and Symptoms:

1. massive vaginal bleeding2. rigid abdomen3. acute abdominal pain4. shock5. marked uteroplacental insufficiency

Management:- monitoring of maternal vital signs, fetal heart rate (FHR), uterine contractions and vaginal

bleeding- likelihood of vaginal delivery depends on the degree and timing of separation in labor- cesarean delivery indicated for moderate to severe placental separation- evaluation of maternal laboratory values- F & E replacement therapy; blood transfusion- Emotional support

Nursing Interventions:- Assess the patient’s extent of bleeding and monitor fundal height q 30 mins.- Draw line at the level of the fundus and check it every 30 mins (if the level of the fundus

increases, suspect abruptio placentae)- Count the number of pads that the patient uses, weighing them as necessary to determine

the amount of blood loss- Monitor maternal blood pressure, pulse rate, respirations, central venous pressure, intake

and output and amount of vaginal bleeding q 10 – 15 mins- Begin electronic fetal monitoring to continuously assess FHR- Have equipment for emergency cesarean delivery readily available:

-prepare the patient and family members for the possibility of an emergency CS delivery, the delivery of a premature neonate and the changes to expect in the postpartum period-offer emotional support and an honest assessment of the situation

- if vaginal delivery is elected, provide emotional support during labor-because of the neonate’s prematurity , the mother may not receive an analgesic during labor and may experience intense pain-reassure the patient of her progress through labor and keep her informed of the fetus’ condition

- tactfully discuss the possibility of neonatal death-tell the mother that the neonate’s survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive disorders-assure her that frequent monitoring and prompt management greatly reduce the risk of death.

- encourage the patient and her family to verbalize their feelings- help them to develop effective coping strategies, referring them for counseling if necessary.

Goals of Care:1. blood loss is minimized, and lost blood is replaced to prevent ischemic necrosis of distal

organs, including kidneys2. DIC is prevented or successfully treated.3. normal reproductive functioning is retained4. the fetus is safely delivered5. the woman retains a positive sense of self-esteem and self-worth.

Additional lab results:

Hgb- ↓Platelet - ↓Fibrinogen - ↓

Fibrin degradation products - ↑

Other possible nursing diagnosis:

• Impaired gas exchange: fetal related to insufficient oxygen supply secondary to premature

separation of the placenta.

• Pain related to bleeding between the uterine wall and the placenta secondary to premature

separation of the placenta.

• Fear related to perceived or actual grave threat to body integrity secondary to excessive

bleeding and threat to fetal survival.

• Grieving related to actual or threatened loss of infant.

• Powerlessness related to maternal condition and hospitalization.

• Risk for deficient fluid volume related to excessive losses secondary to premature placental

separation.

Pathophysiology

Trauma, hypertension, or coagulopathy, contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption.

Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death.

Abruptions are classified according to severity in the following manner:

• Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta.

• Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus.

• Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring.

• Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

Intervention

Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative.

Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first.

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.

ANATOMY & PHYSIOLOGY OF FEMALE REPRODUCTIVE ORGAN

FEMALE EXTERNAL STUCTURES

a. Mons Veneris

• A pad of adipose tissue located over the symphisis pubis, the pubic bone joint.

• It protects the junction of pelvic bone from trauma.

b. Labia Minora

• Just posterior to the mons veneris spread two hairless folds of connective tissue.

c. Labia Majora

• Two halves of adipose tissue covered by loose connective tissue and epithelium.

d. Vestibule

• Flattened smooth surface inside the labia.

• The space wherein we can see the vaginal and uretral opening.

e. Clitoris

• Small rounded erectile tissue at the forward junction of the labia minora.

• Sensitive to touch and temperature center of sexual arousal and orgasm.

f. Skene’s Gland

PARAURETRAL GLANDS• Located just lateral to urinary meatus.

• It produces lubricating fluid that helps to maintain the moistness of the vestibule.

Bartholin’s Gland (vulvovaginal)• Located just lateral to vaginal opening.

• It secretes mucus to provide vaginal lubrications.

g. Fourchette

• Ridge of tissues formed by the posterior joining the two labias.

INTERNAL STRUCTURES

1. Ovaries • Almond shaped• Produce, mature and discharge ova• Initiate and regulate menstrual cycle• 4 cm long, 2 cm in diameter, 1.5 cm thick• Produce estrogen and progesterone

- Estrogen: promotes breast development & pubic hair distribution prevents osteoporosis and keeps cholesterol levels reduced & so limits effects of atherosclerosis Fallopian tubes.

2. Fallopian tubes • Approximately 10 cm in length• Arises from each corner of the uterine body• Conveys ova from ovaries to the uterus• Site of fertilization• Parts: interstitial

isthmus – cut/sealed in BTLampulla – site of fertilizationinfundibulum – most distal segment; covered with fimbria

3. Uterus • Hollow muscular pear shaped organ

- uterine wall layers: endometrium(inner); myometrium(middle); perimetrium(outer)

• Organ of menstruation• Receives the ova• Provide place for implantation & nourishment during fetal growth• Protects growing fetus• Expels fetus at maturity• Has 3 divisions: corpus – fundus , isthmus (most commonly cut during CS

delivery) and cervix.

4. Uterine Wall • Endometrial layer: formed by 2 layers of cells which are as follows:• basal layer- closest to the uterine wall.• glandular layer – inner layer influenced by estrogen and progesterone; thickens

and shed off as menstrual flow.

• Myometrium – composed of 3 interwoven layers of smooth muscle; fibers are arranged in longitudinal; transverse and oblique directions giving it extreme strength.

5. Vagina • Acts as organ of copulation• Conveys sperm to the cervix• Expands to serve as birth canal• Wall contains many folds or rugae making it very elastic

Fornices – uterine end of the vagina; serve as a place for pooling of semen followingcoitus.

• Bulbocavernosus – circular muscle act as a voluntary sphincter at the external opening to the vagina (target of Kegel’s exercise).

PLACENTA

• It serve s as the fetal lungs, kidneys and gastrointestinal tract and as a separate endocrine organ throughout pregnancy.

CIRCULATION

• The fetus is connected by the umbilical cord to the placenta, the organ that develops and implants in the mother's uterus during pregnancy.

• As early as the 12th day of pregnancy, maternal blood circulation begins to collect in the intervillus spaces of the uterine endometrium surrounding the chronic villi.

• By the 3rd week of pregnancy, through the blood vessels in the umbilical cord, the fetus receives all the necessary nutrition, oxygen, and life support from the mother through the placenta..

• From there, the nutrients are being transported back to the growing embryo.• Waste products and carbon dioxide from the fetus are sent back through the

umbilical cord and placenta to the mother's circulation to be eliminated.• The blood from the mother enters the fetus through the vein in the umbilical cord. It

goes to the liver and splits into three branches. The blood then reaches the inferior vena cava, a major vein connected to the heart.

Inside the fetal heart- Blood enters the right atrium, the chamber on the upper right side of the

heart. Most of the blood flows to the left side through a special fetal opening between the left and right atria, called the foramen ovale.

- Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta, (the large artery coming from the heart).

- From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava.

- About one-third of the blood entering the right atrium does not flow through the foramen ovale, but, instead, stays in the right side of the heart, eventually flowing into the pulmonary artery.

• Because the placenta does the work of exchanging oxygen (O2) and carbon dioxide (CO2) through the mother's circulation, the fetal lungs are not used for breathing. Instead of blood flowing to the lungs to pick up oxygen and then flowing to the rest of the body, the fetal circulation shunts (bypasses) most of the blood away from the lungs. In the fetus, blood is shunted from the pulmonary artery to the aorta through a connecting blood vessel called the ductus arteriosus.

Pathophysiology of Abruptio Placentae

PreeclampsiaPreeclampsia, also referred to as toxemia, is a condition that pregnant women can get. It is

marked by high blood pressure accompanied with a high level of protein in the urine. Women with

preeclampsia will often also have swelling in the feet, legs, and hands. Preeclampsia, when present,

usually appears during the second half of pregnancy, generally in the latter part of the second or in

the third trimesters, although it can occur earlier.

In addition symptoms of preeclampsia can include:

• Rapid weight gain caused by a significant increase in bodily fluid

• Abdominal pain

• Severe headaches

• A change in reflexes

• Reduced output of urine or no urine

• Dizziness

• Excessive vomiting and nausea

The exact causes of preeclampsia are not known, although some researchers suspect poor

nutrition, high body fat, or insufficient blood flow to the uterus as possible causes.

The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild

preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation in a

woman who did not have hypertension before; and/or having a small amount of protein in the urine

can be managed with careful hospital or in-home observation along with activity restriction.

Pathophysiology:

Efforts to unravel the pathogenesis of pre-eclampsia have been hampered by the lack of clear

diagnostic criteria for the disease and its subtypes. Consequently, several studies have included a

variety of other conditions that do not necessarily reflect an adverse pregnancy outcome.

Abnormal placentation (stage 1), particularly lack of dilatation of the uterine spiral

arterioles, is the common starting point in the genesis of pre-eclampsia, which compromises blood

flow to the maternal–fetal interface. Reduced placental perfusion activates placental factors and

induces systemic hemodynamic changes. The maternal syndrome (stage 2) is a function of the

circulatory disturbance caused by systemic maternal endothelial cell dysfunction resulting in

vascular reactivity, activation of coagulation cascade and loss of vascular integrity. Pre-eclampsia

has effects on most maternal organ systems, but predominantly on the vasculature of the kidneys,

liver and brain.

Summary

What Is Preeclampsia?

Also referred to as toxemia, preeclampsia is a condition that pregnant women can get. It is marked by high blood pressure accompanied with a high level of protein in the urine. Women with preeclampsia will often also have swelling in the feet, legs, and hands. Preeclampsia, when present, usually appears during the second half of pregnancy, generally in the latter part of the second or in the third trimesters, although it can occur earlier.

What Is Eclampsia?

Eclampsia is the final and most severe phase of preeclampsia and occurs when preeclampsia is left untreated. In addition to the previously mentioned signs of preeclampsia, women with eclampsia often have seizures. Eclampsia can cause coma and even death of the mother and baby and can occur before, during, or after childbirth.

What Causes Preeclampsia and Eclampsia?

The exact causes of preeclampsia and eclampsia are not known, although some researchers suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible causes.

Who Is at Risk for Preeclampsia?

Preeclampsia is most often seen in first-time pregnancies and in pregnant teens and women over 40. Other risk factors include:

• A history of high blood pressure prior to pregnancy.

• Previous history of preeclampsia.• A history of preeclampsia in mother or sisters.• Obesity prior to pregnancy.• Carrying more than one baby.• History of diabetes, kidney disease, lupus, or rheumatoid arthritis.

What are the Signs of Preeclampsia?

In addition to swelling, protein in the urine, and high blood pressure, symptoms of preeclampsia can include:

• Rapid weight gain caused by a significant increase in bodily fluid• Abdominal pain• Severe headaches• A change in reflexes• Reduced output of urine or no urine• Dizziness• Excessive vomiting and nausea

Does Swelling Mean I Have Preeclampsia During Pregnancy?

Some swelling is normal during pregnancy. However, if the swelling doesn't go away with rest and is accompanied by some of the above symptoms, be sure to see your doctor right away.

How Can Preeclampsia Affect My Baby?

Preeclampsia can prevent the placenta from receiving enough blood, which can cause your baby to be born very small. It is also one of the leading causes of premature births and the difficulties that can accompany them, including learning disabilities, epilepsy, cerebral palsy, and hearing and vision problems.

What Is the Treatment for Preeclampsia and Eclampsia?

The only real cure for preeclampsia and eclampsia is the birth of the baby.

Mild preeclampsia (blood pressure greater than 140/90 that occurs after 20 weeks of gestation in a woman who did not have hypertension before; and/or having a small amount of protein in the urine can be managed with careful hospital or in-home observation along with activity restriction.

If the baby is pre-term, the condition can be managed until your baby can be safely delivered. Your health care provider may prescribe bed rest, hospitalization, or medication to prolong the pregnancy and increase your unborn baby's chances of survival. If your baby is close to term, labor may be induced.

The treatment for more severe preeclampsia (having vision problems, lung problems, abdominal pain, fetal distress, or other signs and symptoms) may require more emergent treatment -- delivery of the baby -- irrespective of the baby's age.

Other treatments include:

• Magnesium can be injected into the veins to prevent eclampsia-related seizures.• Hydralazine or another antihypertensive drug to manage severe elevations of blood

pressure.• Monitoring fluid intake.

CARDIOVASCULAR SYSTEM

INTRODUCTION

The cardiovascular/circulatory

system transports food, hormones, metabolic

wastes, and gases (oxygen, carbon dioxide) to

and from cells. Components of the circulatory

system include:

• blood : consisting of liquid plasma

and cells

• Blood vessels (vascular system): the

"channels" (arteries, veins,

capillaries) which carry blood to/from

all tissues. (Arteries carry blood

away from the heart. Veins return

blood to the heart. Capillaries are

thin-walled blood vessels in which

gas/ nutrient/ waste exchange occurs.)

• heart : a muscular pump to move the blood

There are two circulatory "circuits": Pulmonary circulation, involving the "right heart," delivers

blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the "right heart" to

the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich

blood from tbe lungs back to the "left heart." Systemic circulation, driven by the "left heart," carries blood

to the rest of the body. Food products enter the sytem from the digestive organs into the portal vein.

Waste products are removed by the liver and kidneys. All systems ultimately return to the "right heart"

via the inferior and superior vena cavae.

A specialized component of the circulatory system is the lymphatic system, consisting of a

moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone marrow,

liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the veins, and through

the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and

bacterial invasion.

BLOOD COMPONENTS

Adults have up to ten pints of blood.

• Forty-five percent (45%) consists of cells - platelets, red

blood cells, and white blood cells (neutrophils, basophils,

eosinophils, lymphocytes, monocytes). Of the white blood

cells, neutrophils and lymphocytes are the most important.

1. Fifty-five percent (55%) consists of plasma, the liquid

component of blood.

MAJOR BLOOD COMPONENTS

Component Type Source Function

Platelets, cell fragments Bone marrow life-span: 10 days

Blood clotting

Lymphocytes (leukocytes) Bone marrow, spleen, lymph nodes

Immunity T-cells attack cells containing viruses. B-cells produce antibodies.

Red blood cells (erythrocytes), Filled with hemoglobin, a compound of iron and protein

Bone marrow life-span: 120 days

Oxygen transport

Neutrophil (leukocyte) Bone marrow Phagocytosis

Plasma, consisting of 90% water and 10% dissolved materials -- nutrients (proteins, salts, glucose), wastes (urea, creatinine), hormones, enzymes

1. Maintenance of pH level near 7.4

2. Transport of large molecules (e.g. cholesterol)

3. Immunity (globulin)

4. Blood clotting (fibrinogen)

VASCULAR SYSTEM - THE BLOOD VESSELS

Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout

the body with a web-like network of capillaries connecting them. Arteries use vessel size, controlled by the

sympathetic nervous system, to move blood by pressure; veins use one-way valves controlled by muscle

contractions.

Arteries

Arteries are

strong, elastic vessels adapted

for carrying blood away from the heart at relatively high pumping pressure. Arteries divide into progressively

thinner tubes and eventually become fine branches called arterioles. Blood in arteries is oxygen-rich, with the

exception of the pulmonary artery, which carries blood to the lungs to be oxygenated.

The aorta is the largest artery in the body, the main artery for systemic circulation. The major branches of

the aorta (aortic arch, ascending aorta, descending aorta) supply blood to the head, abdomen, and extremities. Of

special importance are the right and left coronary arteries that supply blood to the heart itself.

MAJOR BRANCHES OF SYSTEMIC CIRCULATION

Name Serves

Head Carotid Brain & skull

Abdomen Mesenteric Celiac (Abdominal) Renal Iliac

Intestines Stomach, liver, spleen Kidney Pelvis

Upper Extremity Brachial (axillary) Radial & Ulnar Dorsal Carpal

Upper arm Forearm & hand Fingers

Lower Extremity Femoral Popliteal Dorsal pedis Posterior tibial

Thigh Leg Foot Foot

Capillaries

The arterioles branch into the microscopic capillaries, or capillary beds, which lie bathed in

interstitial fluid, or lymph, produced by the lymphatic system. Capillaries are the points of exchange

between the blood and surrounding tissues. Materials cross in and out of

the capillaries by passing through or between the cells that line the

capillary. The extensive network of capillaries is estimated at between

50,000 and 60,000 miles long.

Three types of capillaries can be distinguished based on features of

ethe endothelium.

1. Continuous capillaries -- are formed by "continuous" endothelial cells and basal lamina. The

endothelial cell and the basal lamina do not form openings, which would allow substances to

pass the capillary wall without passing through both the endothelial cell and the basal lamina.

Both endothelial cells and the basal lamina can act as selective filters in continuous

capillaries.

2. Fenestrated capillaries -- The endothelial cell body forms small openings called

fenestrations, which allow components of the blood and interstitial fluid to bypass the

endothelial cells on their way to or from the tissue surrounding the capillary. The

fenestrations may represent or arise from pinocytotic vesicles which open onto both the

luminal and basal surfaces of the cell. The extent of the fenestration may depend on the

physiological state of the surrounding tissue, i.e. fenestration may increase or decrease as a

function of the need to absorb or secrete. The endothelial cells are surrounded by a

continuous basal lamina, which can act as a selective filter.

3. Discontinuous capillaries -- are formed by fenestrated endothelial cells, which may not even

form a complete layer of cells. The basal lamina is also incomplete. Discontinuous capillaries

form large irregularly shaped vessels, sinusoids or sinusoid capillaries. They are found where

a very free exchange of substances or even cells between bloodstream and organ is

advantageous (e.g. in the liver, spleen, and red bone marrow).

Veins

Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules,

which in turn unite to form veins. Veins are responsible for returning blood to the heart after the blood

and the body cells exchange gases, nutrients, and wastes. Pressure in veins is low, so veins depend on

nearby muscular contractions to move blood along. Veins have valves that prevent back-flow of blood.

Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry

oxygenated blood from the lungs back to the heart. The major veins, like their companion arteries, often

take the name of the organ served. The exceptions are the superior vena cava and the inferior vena cava,

which collect body from all parts of the body (except from the lungs) and channel it back to the heart.

Artery/Vein Tissues

Arteries and veins have the same three tissue layers, but the proportions of

these layers differ. The innermost is the intima; next comes the media; and the

outermost is the adventitia. Arteries have thick media to absorb the pressure waves

created by the heart's pumping. The smooth-muscle media walls expand when pressure surges, then snap

back to push the blood forward when the heart rests. Valves in the arteries prevent back-flow. As blood

enters the capillaries, the pressure falls off. By the time blood reaches the veins, there is little pressure.

Thus, a thick media is no longer needed. Surrounding muscles act to squeeze the blood along veins. As

with arteries, valves are again used to ensure flow in the right direction.

ANATOMY OF THE HEART

The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of

the chest midline the heart, along with the pulmonary (to and from the lungs) and systemic (to and from

the body) circuits, completely separates oxygenated from deoxygenated blood.

Internally, the heart is divided into four hollow chambers, two on the left and two on the right.

The upper chambers of the heart, the atria (singular: atrium), receive blood via veins. Passing through

valves (atrioventricular (AV) valves), Blood then enters the lower chambers, the ventricles. Ventricular

contraction forces blood into the arteries.

Oxygen-poor blood empties into the right atrium via the superior and inferior vena cavae. Blood

then passes through the tricuspid valve into the right ventricle which contracts, propelling the blood into

the pulmonary artery. The pulmonary artery is the only artery that carries oxygen-poor blood. It branches

to the right and left lungs. There, gas exchange occurs -- carbon dioxide diffuses out, oxygen diffuses in.

Pulmonary veins, the only veins that carry oxygen-rich blood, now carry the oxygenated blood

from lungs to the left atrium of the heart. Blood passes through the bicuspid (mitral) valve into the left

ventricle. The ventricle contracts, sending blood under high pressure through the aorta, the main artery for

systemic circulation. The ascending aorta carries blood to the upper body; the descending aorta, to the

lower body.

℘ Basic Parts and their functions

o Coronary Arteries

Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and

relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of

blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue.

The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two coronary

arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near

the top of the heart.

The initial segment of the left coronary artery is called the left main coronary. This blood vessel is

approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller

arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left

anterior descending coronary artery is embedded in the surface of the front side of the heart. The left

circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the

back of the heart.

Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The

larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart

muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single

file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and

bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal

through the lungs, kidneys and liver.

When cholesterol plaque accumulates to the point of blocking the flow of blood through a

coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is

deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The

condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is

called a myocardial infarction or heart attack.

o Superior Vena Cava

The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body

to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the

right atrium of the heart.

o Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body

to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the

right atrium of the heart.

o Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter of your

thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.

o Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to

the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to

classify arteries as vessels carrying blood away from the heart.

o Pulmonary Vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium.

A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify

veins as vessels carrying blood to the heart.

o Right Atrium

The right atrium receives de-oxygenated blood from the body through the superior vena cava

(head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse

that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The

tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated

blood collected in the right atrium to flow into the right ventricle.

o Right Ventricle

The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary

valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the

ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and the

pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right

atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward

the lungs.

o Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the

contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral

valve into the left ventricle.

o Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through

the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the

ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the

mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing

into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow

throughout the body.

o Papillary Muscles

The papillary muscles attach to the lower portion of the interior wall of the ventricles. They

connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral

valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary

muscles relax, the valves close.

o Chordae Tendineae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right

ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae

tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to

open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart

strings."

o Tricuspid Valve

The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-

oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle

contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the

pulmonary valve into the pulmonary artery.

o Mitral Value

The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated

blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts,

preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into

the aorta.

o Pulmonary Valve

o The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles

contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the

lungs. It closes as the ventricles relax, preventing blood from returning to the heart.

o Aortic Valve

The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to

allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the

ventricles relax, preventing blood from returning to the heart.

BLOOD PRESSURE AND HEART RATE

The heart beats or contracts around 70 times per minute. The human

heart will undergo over 3 billion contraction/cardiac cycles during a normal

lifetime.

One heartbeat, or cardiac cycle, includes atrial contraction and

relaxation, ventricular contraction and relaxation, and a short pause. Atria

contract while ventricles relax, and vice versa. Heart valves open and close to limit flow to a single

direction. The sound of the heart contracting and the valves opening and closing produces a characteristic

"lub-dub" sound.

The cardiac cycle consists of two parts: systole (contraction of the heart muscle in the ventricles)

and diastole (relaxation of the ventricular heart muscles). When the ventricles contract, they force the

blood from their chambers into the arteries leaving the heart. The left ventricle empties into the aorta

(systemic circuit) and the right ventricle into the pulmonary artery (pulmonary circuit). The increased

pressure on the arteries due to the contraction of the ventricles (heart pumping) is called systolic

pressure.

When the ventricles relax, blood flows in from the atria. The decreased pressure due to the

relaxation of the ventricles (heart resting) is called diastolic pressure.

Blood pressure is measured in mm of mercury, with the systole in ratio to the diastole. Healthy

young adults should have a ventricular systole of 120mm, and 80mm at ventricular diastole, or 120/80.

Receptors in the arteries and atria sense systemic pressure. Nerve messages from these sensors

communicate conditions to the medulla in the brain. Signals from the medulla regulate blood pressure.

THE LYMPHATIC SYSTEM

The lymphatic system functions 1) to absorb excess fluid, thus preventing tissues from swelling;

2) to defend the body against microorganisms and harmful foreign particles; and 3) to facilitate the

absorption of fat (in the villi of the small intestine).

Capillaries release excess water and plasma into intracellular spaces, where they mix with lymph,

or interstitial fluid. "Lymph" is a milky body fluid that also contains proteins, fats, and a type of white

blood cells, called "lymphocytes," which are the body's first-line defense in the immune system.

Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in having

valves that prevent backflow. Contraction of skeletal muscle causes movement of the lymph fluid through

valves. Lymph vessels connect to lymph nodes, lymph organs (bone marrow, liver, spleen, thymus), or to

the cardiovascular system.

• Lymph nodes are small irregularly shaped masses through which lymph vessels flow. Clusters of

nodes occur in the armpits, groin, and neck. All lymph nodes have the primary function (along

with bone marrow) of producing lymphocytes.

• The spleen filters, or purifies, the blood and lymph flowing through it.

• The thymus secretes a hormone, thymosin that produces T-cells, a form of lymphocyte.

PATHOPHYSIOLOGY OF HYPERTENSION

Hypertension (high blood pressure) is a disease of vascular regulation resulting from malfunction

of arterial pressure control mechanisms (central nervous system, rennin-angiotensinaldosterone system,

extracellular fluid volume.) the cause is unknown, and there is no cure. The basic explanation is that

blood pressure is elevated when there is increased cardiac output plus increased peripheral vascular

resistance.

The two major types of hypertension are primary (essential) hypertension, in which diastrolic

pressure is 90 mm Hg or higher and systolic pressure is 140 mm Hg or higher in absence of other causes

of hypertension (approximately 95 % of patients); and Secondary hypertension, which results primarily

from renal disease, endocrine disorders, and coarctation of the aorta. Either of these conditions may give

rise to accelerated hypertension – a medical emergency – in which blood pressure elevates very rapidly to

threaten one or more of the target organs: the brain, kidney, or the heart.

Hypertension is one of the most prevalent chronic diseases for which treatment is available;

however, most patients with hypertension are unaware, untreated, or inadequately treated. Risk factors for

hypertension are age between 30 and 70; black; overweight; sleep apnea; family history; cigarette

smoking; sedentary lifestyle; and diabetes mellitus. Because hypertension presents no over symptoms, it

is termed the “silent killer.” The untreated disease may progress to retinopathy, renal failure, coronary

artery disease, heart failure, and stroke.

Hypertension in children is defined as the average systolic or diastolic blood pressure greater than

or equal to the 95th percentile for age and sex with measurement on at lease three occasions. The

incidence of hypertension in children is low, but it is increasingly being recognized in adolescents; and it

may occur in neonates, infants, and young children with secondary causes.

Anatomy and Physiology

• Vagina: A muscular passageway that leads from the vulva (external genitalia) to the

cervix.

• Cervix: A small hole at the end of the vagina through which sperm passes into the

uterus. Also serves as a protective barrier for the uterus. During childbirth, the cervix

dilates (widens) to permit the baby to descend from the uterus into the vagina for

birth.

• Uterus: A hollow organ that houses the baby during pregnancy. During childbirth, the

uterine muscles contract to push out the baby. Each month, unless a fetus has been

conceived, the uterine wall sheds its lining (see The Menstrual Cycle and Ovulation

below).

• Ovaries: Two organs that produce hormones and store eggs. Each ovary releases one

egg per month.

• Fallopian tubes: Muscular tubes that eggs released from the ovaries must traverse to

reach the uterus.

The Menstrual Cycle and Ovulation

Each month a woman’s body goes through a menstrual cycle. A woman can become

pregnant only during ovulation, a several-day phase in the middle of the menstrual cycle when one

of the ovaries releases an egg.

If the ovulated egg is fertilized by a man’s sperm following sexual intercourse, it will

implant in the endometrium, the lining of the uterus that becomes the placenta during

pregnancy. The placenta nurtures the fertilized egg as it develops and grows into a baby.

Female Anatomy

Events Weeks of Pregnancy

1st Trimester

The woman's last period before fertilization occurs.

0

Fertilization occurs.

The fertilized egg (zygote) begins to develop into a hollow ball of cells called the blastocyst.

2

The blastocyst implants in the wall of uterus.The amniotic sac begins to form.

3

The area that will become the brain and spinal cord (neural tube) begins to develop.

5

The heart and major blood vessels are developing. The beating heart can be seen during ultrasonography.

6

The beginnings of arms and legs appear.

7

Bones and muscles form. The face and neck develop.

Brain waves can be detected.

The skeleton is formed. Fingers and toes are fully defined.

9

The kidneys begin to function.

Almost all organs are completely formed.

The fetus can move and respond to touch (when prodded through the woman's abdomen).

The woman has gained some weight, and her abdomen may be slightly enlarged.

10

2nd Trimester

The fetus's sex can be identified.

The fetus can hear.

14

The fetus's fingers can grasp. The fetus moves more vigorously, so that the mother can feel it.

The fetus's body begins to fill out as fat is deposited beneath the skin. Hair appears on the head and skin. Eyebrows and eyelashes are present.

16

The placenta is fully formed. 20

The fetus has a chance of survival outside the uterus.

The woman begins to gain weight more rapidly.

24

3rd Trimester

The fetus is active, changing positions often.

The lungs continue to mature.

The fetus's head moves into position for delivery.

On average, the fetus is about 20 inches long and weighs about 7 pounds. The woman's enlarged abdomen causes the navel to bulge.

25

Delivery 37-42

MEDICAL MANAGEMENT AND NURSING INTERVENTION

℘ Medical management

1. The pharmacological therapy includes the following:

• Amoxicillin (antibiotic) 500 mg cap BID x 7 days

• Mefenamic Acid 500 mg cap BID as needed

• Ferrous Sulfate 1 cap OD x 30 days

• Methyllergometrine 1 tab BID

• Magnesium Sulfate (anticonvulsant) 4g slow IV

2. The pharmacological therapy for inducing diuresis is:

• 5% Dextrose in Lactated Ringer's

3. Recommended for low fat low salt diet because of high blood pressure.

4. Advise to massage her uterus.

5. Advise to remain on drug therapy to control blood pressure.

℘ Nursing consideration

1. Monitor vital signs q4h

2. Administer medications as prescribed

3. Record urine output

4. Provide health education:

• Advised patient to massage uterus

• Advised patient to massage and apply warm compress on the breast

• Decrease fluid intake

• Advised patient to elevate lower extremities and apply warm compress on edema

• Encouraged to decrease sodium intake

• Advised patient to complete immunization on time

Predisposing Factors Etiologic Factor Precipitating Factors• Age (<20, >35 years old) • Unknown • Sedentary Lifestyle• Race • Poor Diet• Family History of Hypertension

↑ BP – vasospasm

Decreased placental perfusion

Endothelial cell activation

Intravascular fluid redistribution

Vasoconstriction Activation of coagulation of cascade

Decreased organ perfusion

A

Increased thromboxane to prostacyclinIncreased sensitivity to angiotensin IIDecreased nitric oxide

Fluid shifts from Intravascular to intracellular space(Decreased plasma volume)(Increased hematocrit)

Increased endothelin

Intravascular coagulation

Visual edema of face, hands, andabdomenFixing edema alter 12 hours of bed rest

HypertensionGeneralized vasoconstriction

Hemolysis of RBC

Cortical brain spasms

A Decreased placental perfusion

Placental production of endothelin

Endothelial cell damage

Vasospasms

Uteroplacental arteriole lesions

IUGRAbruptio placentaIncreased uterine contractility

Glomerular damaged

ProteinuriaIncreased plasma uric acid and creatinineOliguriaIncreased sodium retention

Generalized Edema

Platelet aggregation and fibrin deposition

Low platelet count(Thrombocytopenia)-DIC

Hepatic microemboli;Liver damage

Pulmonary edema

Retinal arteriolar spasms

HeadacheHyperreflexiaSeizure activity

Elevated liver enzymes (AST and LDH)Nausea and vomitingEpigastric painRight upper quadrant painDecreased blood glucoseLiver rupture

Decreased HemoglobinMaternal hyperbilirubinemia

Dyspnea

Blurred visionScotoma

DRUG USES DOSAGE SIDE-EFFECTS PRECAUTIONS

Amoxicillin

It is a penicillin-type antibiotic used to treat a wide variety of bacterial infections. It works by stopping the growth of bacteria.

This antibiotic treats only bacterial infections. It will not work for viral infections (e.g., common cold, flu).

Take this medication by mouth with or without food, usually every 8 or 12 hours, or as directed by your doctor. The dosage is based on your medical condition and response to therapy.

Nausea, vomiting or diarrhea may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly

It can commonly cause a mild rash that is usually not serious. However, you may not be able to tell it apart from a rare rash that could be a sign of a severe allergic reaction. Therefore, seek immediate medical attention if you develop any rash.

Tell your doctor immediately if any of these highly unlikely but very serious side effects occur: dark urine, persistent nausea or vomiting, stomach/abdominal pain, yellowing eyes or skin, easy bruising or bleeding, persistent sore throat or fever.

Before taking amoxicillin, tell your doctor or pharmacist if you are allergic to it; or to penicillin or cephalosporin antibiotics; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney disease, a certain type of viral infection (infectious mononucleosis).

This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor.

Ferrous Sulfate It is an iron supplement used to treat or prevent low blood levels of iron (e.g., for anemia or during pregnancy). Iron is an important mineral that the body needs to produce red blood cells and keep you in good health.

Follow all directions on the product package, or take as directed by your doctor. Do not take more than the recommended dosage. If you are uncertain about any of the information, consult your doctor or pharmacist.

This medication is best taken on an empty stomach 1 hour before or 2 hours after meals. Take with a full glass of water (8 ounces or 240 milliliters) unless your doctor directs you otherwise. If stomach upset occurs, you may take this medication with food. Avoid taking antacids, dairy products, tea, or coffee within 2 hours before or after this medication because they will decrease its effectiveness. Do not lie down for 30 minutes after taking this medication.

If you are taking a time-release tablet or capsule, it must be swallowed whole. Do

Constipation, diarrhea, stomach cramps, or upset stomach may occur. These effects are usually temporary and may disappear as your body adjusts to this medication. If any of these effects persist or worsen, contact your doctor or pharmacist promptly.

Before taking this medication, tell your doctor or pharmacist if you are allergic to it; or to tartrazine; or if you have any other allergies.

This medication should not be used if you have certain medical conditions. Before taking this medication, consult your doctor or pharmacist if you have: iron overload disorder (e.g., hemochromatosis, hemosiderosis).

During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.

not crush, chew, or break the tablet or capsule. Doing so can destroy the long action of the drug and may increase side effects.

Mefenamic Acid Mefenamic acid is

used for the short-term treatment of mild to moderate pain from various conditions. It is also used to decrease pain and blood loss from menstrual periods.

Mefenamic acid is known as a nonsteroidal anti-inflammatory drug (NSAID).

Dosage is based on your medical condition and response to therapy. To reduce your risk of stomach bleeding and other side effects, take this medication at the lowest effective dose for the shortest possible time. Do not increase your dose, take it more frequently, or take it for a longer time than prescribed. This medication usually should not be taken for more than 7 days at a time.

If you are taking this drug on an "as needed" basis (not on a regular schedule), remember that pain medications work best if they are used as the first signs of pain occur. If you wait until the symptoms have worsened, the medicine may not

Upset stomach, nausea, heartburn, dizziness, drowsiness, diarrhea, and headache may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

Tell your doctor immediately if any of these unlikely but serious side effects occur: fainting, persistent/severe headache, hearing changes (e.g., ringing in the ears), fast/pounding heartbeat, mental/mood changes, stomach pain, difficult/painful swallowing, swelling of the ankles/feet/hands, sudden/unexplained weight gain, vision changes.

Stop taking mefenamic acid and tell your doctor immediately if

Before taking mefenamic acid, tell your doctor or pharmacist if you are allergic to it; or to aspirin or other NSAIDs (e.g., ibuprofen, naproxen, celecoxib); or if you have any other allergies.

Before using this medicine, consult your doctor or pharmacist if you have: aspirin-sensitive asthma (a history of worsening breathing with runny/stuffy nose after taking aspirin or other NSAIDs, severe kidney disease, recent heart bypass surgery (CABG), active bleeding/sores in stomach/intestines (ulcer, gastrointestinal bleeding).

This drug may make you dizzy or drowsy

This medicine may

work as well. If you are using this

medication for painful periods, take your first dose as soon as your period starts or pain begins. Usually, you will only need to take it for the first 2 to 3 days of your period.

any of these rare but very serious side effects occur: easy bruising/bleeding, signs of infection (e.g., fever, persistent sore throat), unexplained stiff neck, change in the amount/color of urine.

This drug may rarely cause serious, possibly fatal liver disease. If you notice any of the following rare but very serious side effects, stop taking mefenamic acid and consult your doctor or pharmacist immediately: persistent nausea/vomiting, severe stomach/abdominal pain, extreme/unusual tiredness, weakness, dark urine, yellowing eyes/skin.

A very serious allergic reaction to this drug is rare. However, stop taking mefenamic acid and immediately seek medical attention if you notice any of the following symptoms of a serious allergic reaction: rash/blisters, itching/swelling

cause stomach bleeding. Daily use of alcohol and tobacco, especially when combined with this medicine, may increase your risk for stomach bleeding. Limit alcohol and stop smoking.

During the first 6 months of pregnancy, this medication should be used only when clearly needed. It is not recommended for use during the last 3 months of pregnancy due to possible harm to the unborn baby and interference with normal labor/delivery. Discuss the risks and benefits with your doctor.

This drug may pass into breast milk and could have undesirable effects on a nursing infant. Therefore, breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.

(especially of the face/tongue/throat), severe dizziness, trouble breathing.

Methylergometrine

This medication is used to help stop bleeding after delivery of the placenta in childbirth. Methylergonovine maleate belongs to a class of drugs known as ergot alkaloids. It works by increasing the stiffness of the uterus muscles after the last stage of labor. This effect decreases bleeding.

Take this medication by mouth without food, usually 3-4 times daily for a maximum of 1 week or as directed by your doctor.

Dosage is based on your medical condition and response to therapy.

Headache, nausea, dizziness, or vomiting may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

Tell your doctor immediately if any of these unlikely but serious side effects occur: leg cramps, ringing in the ears, stuffy nose, diarrhea, bad taste in the mouth.

Tell your doctor immediately if any of these rare but very serious side effects occur: sweating, fast/irregular heartbeat, breathing problems, hallucinations.

Seek immediate medical attention if this rare but very serious side effect occurs: chest pain.

Before taking methylergometrine, tell your doctor or pharmacist if you are allergic to it; or to similar ergot alkaloids (e.g., ergonovine); or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: heart disease (e.g., venoatrial shunt, mitral valve stenosis), other complications during pregnancy (e.g., pre-eclampsia, eclampsia), a serious blood infection (sepsis), blood vessel problems (e.g., Raynaud's phenomenon, obliterative vascular disease), kidney problems, liver problems.

This medication must not be used during pregnancy. It may harm an unborn baby.

This drug passes into breast milk

Disseminated intravascular coagulopathy

Disseminated intravascular coagulation (DIC) is a complex systemic thrombohemorrhagic disorder involving the generation of intravascular fibrin and the consumption of procoagulants and platelets.

Definition:

The subcommittee on DIC of the International Society on Thrombosis and Hemostasis has suggested the following definition for DIC: "An acquired syndrome characterized by the intravascular activation of coagulation with loss of localization arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction"

Acute and chronic forms

DIC is a pathophysiologic term describing a continuum of events that occur in the coagulation pathway in association with a variety of disease states. DIC occurs in acute and chronic forms.

Pathophysiology:

The pathophysiology of DIC involves the initiation of coagulation via endothelial injury or tissue injury and the subsequent release of procoagulant material in the form of cytokines and tissue factors. Interleukin-6 and tumor necrosis factor may be the most influential cytokines involved in coagulation activation (via tissue factor) and may be responsible for the end-organ damage that occurs. Further, in the setting of sepsis, neutrophils and their secretory products may promote platelet-mediated fibrin formation.

Signs and symptoms

The affected person is often acutely ill and shocked with widespread haemorrhage (common bleeding sites are mouth, nose and venipuncture sites), extensive bruising, renal failure and gangrene. The onset of DIC can be fulminant, as in endotoxic shock or amnioitic fluid embolism, or it may be insidious and chronic, as in cases of carcinomatosis or retention of dead fetus.

The mechanism of disseminated intravascular coagulation:

Causes

DIC can occur in the following conditions:

• Cancers of lung, pancreas, prostate and stomach• Obstetric: abruptio placentae, retained dead fetus, pre-eclampsia, amniotic fluid embolism• Massive tissue injury: Trauma, burns, extensive surgery• Infections: Gram-negative sepsis, Neisseria meningitidis, Streptococcus pneumoniae,

malaria, histoplasmosis, aspergillosis, Rocky mountain spotted fever• Miscellaneous: Liver disease, snake bite, acute intravascular hemolysis, giant hemangioma,

shock, heat stroke, vasculitis, aortic aneurysm, Serotonin syndrome

Treatment

The only effective treatment is the reversal of the underlying cause. Anticoagulants are given exceedingly rarely when thrombus formation is likely to lead to imminent death (such as in coronary artery thrombosis or cerebrovascular thrombosis). Platelets may be transfused if counts are less than 5,000-10,000/mm3 and massive hemorrhage is occurring, and fresh frozen plasma may be administered in an attempt to replenish coagulation factors and anti-thrombotic factors,

Systemic activationOf coagulation

Depletion of plateletsAnd coagulation factors

Intravascular depositionOf fibrin

Thrombosis of smallMidsize vessels

And organ failureBleeding

although these are only temporizing measures and may result in the increased development of thrombosis.

DIC results in lower fibrinogen levels (as it has all been converted to fibrin), and this can be tested for in the hospital lab. A more specific test is for "fibrin split products" (FSPs) or "fibrin degradation products" (FDPs) which are produced when fibrin undergoes degradation when blood clots are dissolved by fibrinolysis.

In some situations, infusion with antithrombin may be necessary.

DIC

Consumption of coagulation factors Microvascular coagulation and fibrin deposition

Secondary fibrinolysis with FDP production Microvascular obtructionDeficiency of coagulation factors

Haemorrhagic diathesis Organ ischaemia

Hydatidiform MoleWHAT IS GESTATIONAL TROPHOBLASTIC DISEASE?

Gestational Trophoblastic Disease, existing in many terms like Hydatidiform Mole, is a

condition associated with second-trimester bleeding. It is an abnormal proliferation and

degeneration of the trophoblastic villi. As the cells degenerate, they become filled with fluid and

appear as clear fluid-filled, grape-sized vesicles. With this condition, the embryo fails to develop

beyond a primitive start. Such structures must be identified because they are associated with

choriocarcinoma, a rapidly metastasizing malignancy. The incidence of gestational trophoblastic

disease is approximately 1 in every 1,500 pregnancies.

Two types of molar growth can be identified by chromosomal analysis:

Complete Mole: All trophoblastic villi swell and become cystic. If an embryo forms, it dies early at

only 1 to 2 mm in size, with no fetal blood present in the villi. On chromosomal analysis, although

the karyotype is a normal 46XX or 46XY, this chromosome component was contributed only by a

father or an “empty ovum” was fertilized and the chromosome material was duplicated (Fig. 1).

Fig. 1.Complete mole.

Partial Mole: With a partial mole, some of the villi form normally. The syncytiotrophoblastic

layer of the villi, however, is swollen and misshapen. A macerated embryo of approximately 9

weeks; gestation may be present in the villi. A partial mole has 69 chromosomes (a triploid

formation in which there is three chromosomes instead of two for every pair, one set supplied by

an ovum that apparently was fertilized by two sperm or an ovum fertilized by one sperm in which

meiosis or reduction division did not occur). This could also occur if one set of 23 chromosomes

was supplied by one sperm and an ovum did not undergo reduction division supplied 46 (see Fig.

2). In contrast to complete moles, partial moles rarely lead to choriocarcinoma.

Sperm Ovum

+ + Duplication =2 4

Sperm Ovum

+ =

or

+ + =

4

2

2

2

2

6

6

Fig. 2. Partial mole.

III. PREDISPOSING FACTORS

A. Diet: Low CHON and low Vitamin A (carotene) intake.

B. Age: Women older than 35 years. GTD is higher toward the beginning and toward the end of

child bearing period. It is ten times more in women who are 45 years old and beyond.

C. Race: Asian heritage. Molar pregnancy has no racial or ethnic predilection, although Asian

countries show a rate 15 times higher than the US rate.

IV . SIGNS AND SYMPTOMS

A. Symptoms:

1. amenorrhea

2. exaggerated symptoms of pregnancy especially vomiting

3. symptoms of preeclampsia that may be present as headache and edema

4. vaginal bleeding as the main complaint; due to the separation of vesicles from the uterine

wall and there may be blood-stained, watery discharge (the watery part is from the ruptured

vesicles)

• Prune juice-like discharge may occur brownish because it is retained for sometime

inside the uterine cavity.

• Blood may be concealed in the uterus, thereby causing enlargement.

5. abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by

concealed hemorrhage; colicky due to start of expulsion

6. ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as

torsion

B. Signs:

1. preeclampsia develops in 20 – 30 % cases, usually before 20 weeks’ AOG

2. pallor indicating anemia may be present

3. hyperthyroidism develops in 3-10% of cases manifested by enlarged thyroid gland and

tachycardia (due to chorionic thyrotropin secreted by the trophoblast and hCG also has a

thyroid-stimulating effect)

Nursing Management:

Nursing Considerations:

• A gynecologic oncologist should be consulted if the patient is believed to be at risk for or

has developed malignant disease.

• No special diet is required.

• Patients may resume activity as tolerated.

• Pelvic rest is recommended for 4-6 weeks after evacuation of the uterus, and the patient is

instructed not to become pregnant for 12 months. Adequate contraception is recommended

during this period.

• Monitor serial beta-HCG values to identify the rare patient who develops malignant

disease. If a pregnancy does occur, the elevation in beta-HCG would be confused with

development of malignant disease.

V. PATHOPHYSIOLOGY

Low intake of proteins and vitamin A, Asian heritage, Women older than 35 years

Partial mole

or

Complete mole

Chronic villi degenerates and become filled with fluid

No vasculature in chorionic villi

Early death & absorption of embryo

Trophoblastic proliferation

High secretion of hCG High progesterone low estrogen High chorionic

thyrotropin

Decreased contractionHyperthyroidism

Separation of vesicles fromuterine wall

Multiple theca lutein cystsin the ovaries

Uterus expands faster

than normalAbdominal pain

Absence of FHT

Marked nausea & vomiting

Ovarian pain

Vaginal bleeding & discharge of vesicles

Pallor Preeclampsia

Enlarged thyroid gland; tachycardia

Amenorrhea

Note: Those inside the boxes end up as the signs & symptoms of H mole.

SCHIZOPHRENIA

Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women.

TYPES OF SCHIZOPHRENIA:

The diagnosis is made according to the client’s predominant symptoms:

• Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile and aggressive behavior.

• Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior.

• Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor.

• Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior.

• Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social withdrawal, flat affect and looseness of associations.

ANATOMY AND PHYSIOLOGY:

Structure and function of the nervous system

I. Structures

A. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of both central and peripheral elements.

1. The CNS is composed of the brain and spinal cord.

2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves.

3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia.

B. The brain is covered by three membranes.

1. The dura matter is a fibrous, connective tissue structure containing several blood vessels.

2. The arachnoid membrane is a delicate serous membrane.

3. The pia matter is a vascular membrane.

C. The spinal cord extends from the medulla oblongata to the lower border of the first lumbar vertebrae. It contains millions of nerve fibers, and it consists of 31 nerves – 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral.

D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia matter. It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of Sylvius to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and the two foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the arachnoid membrane.

II. Function

A. CNS

1. Brain

a The cerebrum is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and right) and four lobes, each with specific functions.

i The frontal lobe controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses.

ii The temporal lobe is the center for taste, hearing and smell, and in the brain’s dominant hemisphere, the center for interpreting spoken language.

iii The parietal lobe coordinates and interprets sensory information from the opposite side of the body.

iv The occipital lobe interprets visual stimuli.

b The thalamus further organizes cerebral function by transmitting impulses to and from the cerebrum. It also is responsible for primitive emotional responses, such as fear, and for distinguishing between pleasant and unpleasant stimuli.

c Lying beneath the thalamus, the hypothalamus is an automatic center that regulates blood pressure, temperature, libido, appetite, breathing, sleeping patterns, and peripheral nerve discharges associated with certain behavior and emotional expression. It also helps control pituitary secretion and stress reactions.

d The cerebellum or hindbrain, controls smooth muscle movements, coordinates sensory impulses with muscle activity, and maintains muscle tone and equilibrium.

e The brain stem, which includes the mesencephalon, pons, and medulla oblongata, relays nerve impulses between the brain and spinal cord.

2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do not involve brain control.

B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord.

C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS contains two divisions.

1. The sympathetic nervous system serves as an emergency preparedness system, the “flight-for-fight” response. Sympathetic impulses increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood vessels, stronger and faster heart contractions, peripheral blood

vessel constriction, decreased peristalsis, and increased perspiration. Sympathetic stimuli are mediated by norepinephrine.

2. The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic impulses are mediated by acetylcholine.

TREATMENTS AND MEDICATIONS:

Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of disease depends mainly on early diagnosis and, appropriate pharmacological and psycho-social treatments. Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will minimize symptoms and maximize quality of life.

A comprehensive treatment program can include:

• Antipsychotic medication • Education & support, for both ill individuals and families • Social skills training • Rehabilitation to improve activities of daily living • Vocational and recreational support • Cognitive therapy

Medication is one of the cornerstones of treatment.

Once the acute stage of a psychotic episode has passed, most people with schizophrenia will need to take medicine indefinitely. This is because vulnerability to psychosis doesn’t go away, even though some or all of the symptoms do. In North America, atypical or second generation antipsychotic medications are the most widely used. However, there are many first-generation antipsychotic medications available that may still be prescribed. A doctor will prescribe the medication that is the most effective for the ill individual

Another important part of treatment is psychosocial programs and initiatives. Combined with medication, they can help ill individuals effectively manage their disorder. Talking with your treatment team will ensure you are aware of all available programs and medications.

In addition, persons living with schizophrenia may have access to or qualify for income support programs/initiatives, supportive housing, and/or skills development programs, designed to promote integration and recovery.

NURSING INTERVENTIONS:

Strengthening differentiation

• Provide patient with honest and consistent feedback in a non threatening manner. • Avoid challenging the content of patient’s behavior • Focus interactions on patient’s behavior. • Administer drugs as prescribed while monitoring and documenting patient’s

response to drug regimen. • Use simple and clear language when speaking with the patient. • Explain all procedures, test and activities to patient before starting them

Promoting socialization

• Encourage patient to talk about feelings in the context of a trusting, supportive relationship.

• Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions.

• Use supportive, emphatic approach to focus on patient’s feelings about troubling events or conflicts.

• Provide opportunities for socialization and encourage participation in group activities.

• Be aware of personal space and use touch judiciously. • Help patient to identify behaviors that alienate significant others and family

members.

Ensuring safety:

• Monitor patient for behaviors that indicate increased anxiety and agitation. • Collaborate patient to identify anxious behaviors as well as causes. • Establish consistent limits on patients behavior and clearly communicate these

limits to patients, family member, and health care providers. • Secure all potential weapons and articles from patients room and the unit

environment that could be used to inflict injury. • Determine the need for external control, including seclusion or restraints.

Communicate the decision to patient and put plan into action. • Frequently monitor the patient within guidelines of facility’s policy on restrictive

devices and assess the patients level of agitation. • When patient’s level of agitation begins to decrease and self control regained,

establish a behavioral agreement that identifies specific behaviors that indicate self control against are escalation agitation.

Phases of COPARDefinitions of COPAR:

D A social development approach that aims to transform the apathetic, individualistic

and voiceless poor into dynamic, participatory and politically responsive community.

a A collective, participatory, transformative, liberative, sustained and systematic

process of building people’s organizations by mobilizing and enhancing the capabilities

and resources of the people for the resolution of their issues and concerns towards

effecting change in their existing oppressive and exploitative conditions (1994 National

Rural Conference)

R A process by which a community identifies its needs and objectives, develops

confidence to take action in respect to them and in doing so, extends and develops

cooperative and collaborative attitudes and practices in the community (Ross 1967)

� A continuous and sustained process of educating the people to understand and develop their critical awareness of their existing condition, working with the people collectively and efficiently on their immediate and long-term problems, and mobilizing the people to develop their capability and readiness to respond and take action on their immediate needs towards solving their long-term problems

Importance of COPAR:

1. COPAR is an important tool for community development and people empowerment

as this helps the community workers to generate community participation in

development activities.

2. COPAR prepares people/clients to eventually take over the management of a

development programs in the future.

3. COPAR maximizes community participation and involvement; community resources

are mobilized for community services.

Principles of COPAR:

1. People, especially the most oppressed, exploited and deprived sectors are open to

change, have the capacity to change and are able to bring about change.

2. COPAR should be based on the interest of the poorest sectors of society

3. COPAR should lead to a self-reliant community and society.

COPAR Process:

C A progressive cycle of action-reflection action which begins with small, local and

concrete issues identified by the people and the evaluation and the reflection of and on

the action taken by them.

t Consciousness through experimental learning central to the COPAR process because

it places emphasis on learning that emerges from concrete action and which enriches

succeeding action.

Ê COPAR is participatory and mass-based because it is primarily directed towards and

biased in favor of the poor, the powerless and oppressed.

b COPAR is group-centered and not leader-oriented. Leaders are identified, emerge

and are tested through action rather than appointed or selected by some external force

or entity.

Phases of the COPAR Process

I. Pre-entry Phase

A. Is the initial phase of the organizing process where the community/organizer looks for

communities to serve/help.

B. It is considered the simplest phase in terms of actual outputs, activities and strategies and

time spent for it.

Activities include:

1. Designing a plan for community development including all its activities and

strategies for care development.

2. Designing criteria for the selection of site

3. Actually selecting the site for community care

Preparation of the Institution

o Train faculty and students in COPAR.o Formulate plans for institutionalizing COPAR.o Revise/enrich curriculum and immersion program.o Coordinate participants of other departments.

Site Selection

o Initial networking with local government.o Conduct preliminary special investigation.o Make long/short list of potential communities.o Do ocular survey of listed communities.

Criteria for Initial Site Selection

o Must have a population of 100-200 families.o Economically depressed.o No strong resistance from the community.o No serious peace and order problem.o No similar group or organization holding the same program.

Identifying Potential Municipalities

o Make long/short list.

Identifying Potential Barangay

o Do the same process as in selecting municipality.o Consult key informants and residents.o Coordinate with local government and NGOs for future activities.

Choosing Final Barangay

o Conduct informal interviews with community residents and key informants.o Determine the need of the program in the community.o Take note of political development.o Develop community profiles for secondary data.o Develop survey tools.o Pay courtesy call to community leaders.o Choose foster families based on guidelines.

Identifying Host Family

o House is strategically located in the community.o Should not belong to the rich segment.o Respected by both formal and informal leaders.o Neighbors are not hesitant to enter the house.o No member of the host family should be moving out in the community.

II. Entry Phase

A. Sometimes called the social preparation phase as to the activities done here includes the

sensitization of the people on the critical events in their life, innovating them to share their

dreams and ideas on how to manage their concerns and eventually mobilizing them to take

collective action on these.

B. This phase signals the actual entry of the community worker/organizer into the

community. She must be guided by the following guidelines however.

1. Recognizes the role of local authorities by paying them visits to inform them of their

presence and activities.

2. The appearance, speech, behavior and lifestyle should be in keeping with those of the

community residents without disregard of their being role models.

3. Avoid raising the consciousness of the community residents; adopt a low-key profile.

Guidelines for Entry

o Recognize the role of local authorities by paying them visits to inform their presence and activities.

o Her appearance, speech, behavior and lifestyle should be in keeping with those of the community residents without disregard of their being role model.

o Avoid raising the consciousness of the community residents; adopt a low-key profile.

Activities in the Entry Phase

o Integration - establishing rapport with the people in continuing effort to imbibe community life.

living with the community seek out to converse with people where they usually congregate lend a hand in household chores avoid gambling and drinking

o Deepening social investigation/community study verification and enrichment of data collected from initial survey conduct baseline survey by students, results relayed through community

assembly

Leader Spotting Through Sociogram.

Key persons - approached by most people

Opinion leader - approach by key persons

Isolates - never or hardly consulted

III. Organization Building Phase

A. Entails the formation of more formal structures and the inclusion of more formal

procedures of planning, implementation, and evaluating community-wide activities. It is at

this phase where the organized leaders or groups are being given trainings (formal,

informal, OJT) to develop their skills and in managing their own concerns/programs.

Key Activities

o Community Health Organization (CHO) preparation of legal requirements guidelines in the organization of the CHO by the core group election of officers

o Research Team Committeeo Planning Committeeo Health Committee Organizationo Otherso Formation of by-laws by the CHO

IV. Sustenance and Strengthening Phase

A. Occurs when the community organization has already been established and the

community members are already actively participating in community-wide undertakings.

At this point, the different communities setup in the organization building phase are already

expected to be functioning by way of planning, implementing and evaluating their own

programs with the overall guidance from the community-wide organization.

1. Strategies used may include:

a. Education and training

b. Networking and linkaging

c. Conduct of mobilization on health and development concerns

d. Implementing of livelihood projects

e. Developing secondary leaders

Key Activities

o Training of CHO for monitoring and implementing of community health program.o Identification of secondary leaders.o Linkaging and networking.o Conduct of mobilization on health and development concerns.o Implementation of livelihood projects.

Ten (10) Herbal Medicines in the PhilippinesApproved by the Department of Health (DOH)

These are the list of the ten (10) medicinal plants that the Philippine Department of Health (DOH) through its "Traditional Health Program" has endorsed. All ten (10) herbs have been thoroughly tested and have been clinically proven to have medicinal value in the relief and treatment of various aliments:

LAGUNDI (Vitex Negundo)

A shrub known in English as the “5-leaved chase tree” which grows wild in vacant lots and waste land. The flowers are blue and bell-shaped and small fruits turn black when ripe. It is better to collect the leaves where are in bloom. Matured branches are planted.

Parts utilized: leaves, flower.

Uses and Preparation:

Asthma, cough and fever- boil the chopped raw fruits or leaves in 2 glasses of water left for 15 minutes until the water left in only one glass. Strain. The following dosages of the decoction are given to age group.

Dysentery, colds and pain in any part of the body as influenza – boil a handful of leaves and flowers in water to produce a glass full of decoction 3 times a day.

Skin Diseases (dermatitis, scabies, ulcer, eczema) and wounds – prepare a decoction of the leaves. Wash and clean the skin/ wound with the decoction.

Headache- crushed leaves may be applied on the forehead.

Rheumatism, sprain, contusion insect bites- pound the leaves and apply on affected part.

Aromatic bath for sick patients - prepare leaf decoction for use in sick and newly delivered patients.

Yerba Buena (Clinopodium douglasii)

A small multi- branching aromatic herb commonly known as Peppermint. The leaves are small, elliptical ands with soothed margin. The stem creeps to ground, and develops roots. May also be propagated through cuttings.

Parts utilized: leaves, sap of plant

Uses:

For pain in different parts of the body as headache, stomach ache – boil chopped leaves in two glasses of water for 15 minutes. Cool and strain.

Preparation: Divide decoction into two parts and drink one part every three hours.

Rheumatism, arthritis and headache – crush the fresh leaves squeeze sap. Massage sap on painful parts with eucalyptus.

Cough and colds – get about 10 fresh leaves and soak in a glass of hot water. Drink as tea. Acts as an expectorant.

Swollen Gums – steep 6 grams of fresh plant in a glass of boiling water for 30 minutes. Use solution as gargle.

Toothache – cut fresh plant and squeeze sap. Soak a piece of cotton in the sap and insert this in aching tooth cavity. Mouth should be rinsed by gargling salt solution before inserting the cotton. To prepare salt solution add 5 grams of table salt to one glass of water.

Menstrual and gas pain – soak a handful of leaves in a glass of boiling water. Drink infusion. It induces menstrual flow and sweating.

Nausea and fainting – crush leaves and apply at nostrils of patients.

Insect bites – crush leaves and apply juice on affected part or pound leaves until paste-like. Then rub this on affected part.

Pruritis- boil plant alone or with eucalyptus in water. Use decoction as wash on affected area.

Sambong ( Blumea Balsamifera)

English name: Blumea camphoraA plant that reaches 1.5 to 3 meters high with rough hairy leaves. Young plants around mother plant may be separated when they have three or more leaves.

Parts utilized: leaves

Uses: Anti- edema, diuretic, anti- urolithiasis -boil chopped leaves in water for 15 minutes until one glassful remains. Cool and strain.

Preparation: Divide decoction into 3 parts. Drink one part 3 times a day.

Remember that sambong is not a medicine for kidney infection.

Tsaang Gubat (Carmona retusa)

A shrub with small, shiny nice- looking leaves that grows in wild uncultivated areas and forests. Mature stems are used for planting.

Parts utilized: leaves

Uses:

Diarrhea – boil the following amount of chopped leaves in 2 glasses of water for 15 minutes or until amount of water goes down to 1 glass. Cool and strain.

Preparation: Divide decoction into 4 parts. Let patient drink 1 part every 3 hours.

Stomachache- wash leaves and chop. Boil chopped leaves in 1 glass of water for 15 minutes. Cool and filter, strain and drink.

Niyug- Niyugan (Quisqualis Indica L.)

A vine known as “Chinese honey suckle” which bears tiny fruits and grows wild in backyards. It is effective for the elimination of intestinal worms. The seeds must come from mature. Dried but newly opened fruits. Propagated through stem cuttings about 20cm in height.

Parts utilized: seeds

Uses: An anti- helmintic- used to expel round worms ascariasis. Preparation: The seeds are taken 2 hours after supper. If no worms are expelled, the dose may be repeated after one week.

This is not to be given to children below four years old.

Special precautions: Follow recommended dosage. Overdose causes hiccups.

Bayabas / Guava (Psidium Guajava L.)

A tree about 4- 5 meters high with tiny flowers with round or oval fruits that are eaten raw. Propagated through seeds.

Parts utilized: leaves

Uses: For washing wounds- may be used twice a day. For diarrhea- may be taken 3-4 twice a day.

Preparation: As gargle and to relieve toothache. Warm decoction is used for gargle. Freshly pounded leaves are used for toothache. Guava leaves are to be washed well and chopped. Boil for 15 minutes at low fire. Do not cover pot. Cool and strain before use.

Akapulko (Cassie, alata L.)

It is also known as "bayabas-bayabasan" and "ringworm bush" in English, this herbal medicine is used to treat ringworms and skin fungal infections.

Parts utilized: leaves

Use: anti-fungal: Tinea Flava, ringworm, athlete’s foot and scabies.

Preparation: Fresh, matured leaves pounded. Apply as soap to the affected part 1-2 times a day.

Ulasimang- bato (Peperonia Pellucida)

A weed, with heart-shaped leaves also known as "pansit-pansitan", grows in shady parts of the garden and yard. It is effective in fighting arthritis and gout. The leaves can be eaten fresh (about a cupful) as salad or like tea.

Parts utilized: leaves

Use: Lowers uric acid. (rheumatism and gout)

Preparation: Wash leaves well. One and a half cup leaves are boiled in two glassfuls of water over lower fire. Do not cover pot. Cool and strain. Divide into three parts and drink each part three times a day after meals.

May also be eaten as salad. Wash the leaves well. Prepare one and a half cups of leaves. Divide into 3 parts and take as salad three times s day.

Bawang (Allium sativum) popularly known as "garlic", it mainly reduces cholesterol in the blood and hence, helps control blood pressure. Also a remedy for toothache

Parts utilized: Garlic Bulb

Uses: For hypertension: Toothache; to lower cholesterol levels in blood.

Preparation:

May be fried, roasted, soaked in vinegar for 30 minutes or blanched in boiled water for 5 minutes. Take 2 pieces three times a day after meals.

For toothache: Pound a small piece and apply to affected part.

Ampalaya (Mamordica Charantia)

known as "bitter gourd" or "bitter melon" in English, it most known as a treatment of diabetes (diabetes mellitus), for the non-insulin dependent patients.

Parts utilized: leaves

Use: Lower blood sugar levels

Preparation: Gather and wash young leaves very well. Chop. Boil 6 tablespoons in two glassfuls of water for 15 minutes under low fire. Do not cover pot. Cool and strain. Take one third cup 3 times a day after meals.

Remember that young leaves may be blanched/ steamed and eaten ½ glassful 2 times a day.

Reminders on the Use of Herbal Medicine.

1. Avoid the use of insecticide as these may leave poison on plants.2. In the preparation of herbal medicine, use a clay pot and remove cover while boiling at low

heat.3. Use only part of the plant being advocated.4. Follow accurate dose of suggested preparation.5. Use only one kind of herbal plant for each type of symptoms or sickness.6. Stop giving the herbal medication in case untoward reaction such as allergy occurs.7. If signs and symptoms are not relieved after 2 to 3 doses of herbal medication, consult a

doctor.