PCH Final 2018- HNMCSON

Peds: digoxin

(Lanoxin) Classification: Inotropic Use: Heart Failure Nursing implications: Hold in infants if apical pulse less than 90 Held in older children for a pulse rate less than 70 *MD should order parameters Monitor serum levels (0.8-2 mg/ml) Monitor signs toxicity: Nausea, vomiting, diarrhea Lethargy Bradycardia Irregular rate and rhythm

intervention for an atonic uterus

**The myometrium fails to contract and the uterus fills with blood because of the lack of pressure on the open vessels of the placental site- the placenta site should eventually look like scar tissue/ scab. but with Atonic it does not happen- it bleeds. *Most common cause of Hemorrhage Key to successful management is: PREVENTION! Nurse many times can predict which women are at risk for hemorrhaging- knowing ahead of time prolionged labor, overdistention of uterus -Document Vaginal Bleeding -Fundal massage / Bimanual Compression- massage fundus- do not leave her- keep massaging until firm. void and reassess*** straight cath if not voiding -Assess Vital Signs (look for shock) -Give medications--Pitocin, Methergine, Hemabate -D & C, Hysterectomy- can end up if d/c doesn't work, Replace blood / fluids- if not firming up. blood has to be used within 15min of its arrival so need to be sure that it will be used.

Peds: sensory- Infections of eye conjunctivitis nasolacrimal duct obstruction eyelid lesions/ stye periorbital cellulitis

-Conjunctivitis: viral or bacterial, very contagious -Nasolacrimal duct obstruction: very common -Eyelid lesions: stye, a localized infection. -Periorbital cellulitis: bacterial infection of eyelids and surrounding tissue.

Peds: disorders of the eye refractive errors strabismus amblyopia nystagmus glaucoma cataracts

-Strabismus: misalignment of eye -Amblyopia: "lazy eye" -Nystagmus: rapid irregular movement -Glaucoma: increase intraocular pressure in eye, genetic -Cataracts: opaque lenses at birth

Peds: pancreas- Diabetes mellitus/ juvenile diabetes/ type 1

1 (Type 1 DM or Insulin-Dependent DM) • A metabolic disorder with relative or absolute deficiency of the hormone insulin which is produced by the Beta cells of the Islets of Langerhans in the Pancreas • Etiology: o Autoimmune o Virus o Diet o Heredity • Signs and Symptoms: o Polyuria o Polydipsia o Polyphagia o Enuresis o Weight loss o Ketones (urine) o Ketoacidosis o Nausea, vomiting, abdominal pain • Diagnosis: o History: infants, preschool, school age, adolescents o Laboratory Tests: Urine dip stick-glucose and ketones Blood- 8hr fasting, random with S/S, oral GTT, HgbA1c o Results of Tests: FBS>100 Random glucose over 200 Oral GTT>200 in 2hr sample HgbA1c >7.0 • Management: o Exercise o Diet/nutrition o Insulin Therapy o Blood glucose monitoring Management of Hypoglycemia • Causes o Too little food o Too much exercise o Too much insulin in food being eaten • Signs o Rapid onset o Irritable, shaky, hungry o Confused, dizzy o Tachycardia o Unconscious o Slurred speech • Treatment o 15 grams carbohydrates (PO, rapid absorption) Wait 15 minutes --> check blood sugar • If <70, repeat carbs and recheck • If >70, have snack with complex carb and protein o IM Glucagon - EMERGENCY Management of Hyperglycemia Causes o Too little insulin for food eaten o Too much food (carbohydrates) o Stress/illness o Too little activity/exercise o Improper injection technique/pump failure Signs o Gradual onset o Lethargic, confused o Thirsty, dry mucous membranes o Abdominal pain, nausea, vomiting o Rapid breathing o Ketone urine Treatment Give additional insulin Hydrate

Inversion

: top of uterus collapses into cavity • Causes: 1. Pulling on cord 2. Fundal pressure during birth 1. You will not feel fundus upon palpation 3. Very adherent placenta 4. Fundal placenta implant 5. Weak uterine wall ** wait for placenta to deliver on it's own

Peds: atraumatic care

Atraumatic Care: care that minimizes or eliminates the psychological and physical distress experienced by children and their families in the health care system. - Minimizing Stress Techniques for Providing Atraumatic Care: 1. Therapeutic communication - child and caretakers (explain in age appropriate manner) 2. Therapeutic play - purposeful to help child express themselves 3. Distraction 4. Child and family education - being knowledgeable decreases stress 5. Minimize physical stress, pain - if a parent tells you their child is in pain, listen to them 6. Minimize family separation - encourage family members to stay 7. Promote a sense of control - routine

Postpartum assessment: normal findings

BUBBLE

preterm delivery

Born before completion of 37 weeks Infections/inflammation- GBS Maternal or fetal distress Bleeding Stretching- if mother stretches the wrong way can cause an abruption Effects of NB:Body system immaturity affecting transition to extrauterine life; increasing risk for complications Respiratory system Cardiovascular system- ductus are not completely closed. PDA needs surgical intervention GI system- may not be able to tolerate feeding Renal system- cant concentrate urine to begin with so this will be effected Immune system- breastfeeding is important for premies Central nervous system nursing management: Oxygenation- OWL= try to give minimal amount of oxygen to protect retina from pressure that leads to blindness. Thermal regulation Nutrition and fluid balance until 33-34w cant suck on bottle so watch for aspiration- IV fluid or gavache fed. Infection prevention- make sure hands are washed Stimulation- skin to skin and Kangaroo care- mom focusing on baby and not having serious conversations with people if central line or umbilical line only mom and dad can visit! Pain management- succrose Growth and development monitor especially head circumference increased weekly Parental support: high-risk status; possible perinatal loss Discharge preparation- first 72hr are the hardest there will be good days and bad days

fundal height palpation during postpartum period

By approximately one hour post delivery, the fundus is firm and at the level of the umbilicus. The fundus continues to descend into the pelvis at the rate of approximately 1 cm or finger-breadth per day and should be nonpalpable by 14 days postpartum

Educating on birthcontrol

CHOICE OF METHOD •Offering the right to the client to choose the method means giving confidence to the individual. •He/she feels more comfortable in using the method for which he/she has been provided with clear, accurate and specific information and which is the best for his/her needs. GOOD INTERPERSONAL COMMUNICATION (VERBAL & NON VERBAL) •It helps in conveying the right message and to build a rapport with the client. •The language should be simple enough, without any technical terms so to put him/her at ease. •Get acquainted to the client's knowledge, attitude, perceptions and feelings about the subject INFORMATION •Providing all the necessary information to the client helps him/her in using the selected method correctly, without any fear. •Right information will certainly clear the myths and rumors about the subject and will improve the adopting rate among the potential clients. APPROACH TO COUNSELING •Greet the client in a friendly and respectful manner •Ask the client about FP/RH needs •Tell the client about different methods/services •Help the client to make her own decision about which method/service to use •Explain to the client how to use the method/service she has chosen •Return visit and follow-ups of client scheduled INSTRUCTION AFTER METHOD OF CONTRACEPTION IS CHOSEN •Emphasize a second method to use as backup •Provide written and oral instructions on method chosen •Discuss the need for STI protection if not using a condom •Inform the client about ECs EDUCATION ON CONTRACEPTION TO CONSIDER •OCs: s/e, different forms, medical history •Condoms: spermicide decreases risk, male condom you leave some space for ejaculation. Natural higher risk for HIVAIDS •Diaphragm/Cervical Cap: need spermicide. Know time periods •IUD: feel for the strings •Sponge: TSS. Activate with water FOLLOW- UP •Correct and continuous follow up of the users is indispensable to monitor the possible complications with the use of contraceptives. • It ensures eventually an improved continuation rate among the users.

Peds: dehydration

Dehydration: expel more than taking in • Increased risk for infants and young children - WHY???? o Kidneys are not fully developed, so more is excreted in urine o Also more insensible loss (faster breathing) o Vomiting more than others • Rule of 5's vs. mild, moderate and severe - how do we get this?? • Astute assessment skills (changes quickly) o Size, shape, behavior/mental status, paleness/yellowness • Intervene rapidly • Deterioration is quick (reserves) • Dehydration levels - Mild, Moderate and Severe o % of body weight loss changes for each stage o Mild = lose about 5% weight o Moderate = lose about 5-10% o Severe = 10-15% • Types o Isotonic = taking the exact same consistency in the cell o Hypotonic = less solution outside cell, more solution inside cell (swollen cell) o Hypertonic = more solution outside cell, less solution inside cell (shriveled up cell) • ORS-Oral Rehydration Solution o Pedialyte, infalyte, ricelyte o 75 mmol/L NaCl and 13.5g/L glucose are given Mild-moderate dehydration require 50-100ml/kg of ORS over 4hrs Then re-evaluate, when rehydrated child can resume regular diet o Not appropriate - tap water, milk, soups, broths, undiluted fruit juice o Homemade - quart of water, add 8 tsp. sugar and 1 tsp. of salt • Urinalysis, CBC • Severe Dehydration: o Intravenous fluids (Normal Saline or Lactated Ringers) o 20 ml/kg bolus*** initially o IV maintenance First 10 kg of weight: 100 ml/kg Second 10 kg of weight: 50 ml/kg Rest of weight: 20 ml/kg Add together for total ml in 24 hrs.

Post term assessment Pre term

Dry, cracked, wrinkled skin; possibly meconium-stained- due to passing meconium in utero, look at nails, eyes Long, thin extremities; long nails; creases cover entire soles of feet Wide-eyed, alert expression Abundant hair on scalp- lots Thin umbilical cord Limited vernix and lanugo nails longer than normal baby wide eyed, very alert Inability of placenta to provide adequate oxygen and nutrients to fetus after 42 weeks

emergency contraception

EMERGENCY CONTRACEPTION PILLS CAN REDUCE THE CHANCE OF A PREGNANCY BY 75% IF TAKEN WITHIN 72 HOURS OF UNPROTECTED SEX! Prevents pregnancy from occurring EMERGENCY CONTRACEPTION (ECP) AKA THE MORNING AFTER PILL •Progestin-only pills, Plan B, Next Choice, combined estrogen and progestin pills, copper- releasing IUD up to 7 days, Ulipristal acetate •Must be taken within 72 hours of unprotected coitus or failure of contraception method •Almost 80% effective in reducing pregnancy Very heavy dose of estrogen and progesterone Nausea vomiting Sperm can live 5 days inside of vagina- so need to take within 24hr to be most effective ECP- PLAN B •Floods the ovaries with high amount of hormone and prevents ovulation •Alters the environment of the uterus, making it disruptive to the egg and sperm

Molar pregnancy

Hydatidiform Mole- a form of gestational trophoblastic disease, abnormal growth of cells inside uterus. tumors start in cells that would normally become placenta but instead turn into a mass. Embryo dies early in utero development Complete mole= at risk for choriocarcinoma- have to make sure hCg is low for a year- NO PREGNANCY FOR 1yr! nursing assessment: Vaginal bleeding, anemia larger than expected uterus hyperemesis- excessive n/v high level of hCG early development of preeclampsia inability to detect FHR after 10-12w Dx: ultrasound and very high hCG levels can tell if nursing interventions: prep client for d/c provide emotional suppot and edu about risk of developing carcinoma advise for need for extensive follow up for 12mo 1year follow up; weekly for 3weeks monthly for 6mo and every 2mo for 6mo. No pregnancy for year- use contraceptives

magnesium sulfate

IV magnesium sulfate, antihypertensive medication (if needed), calcium gluconate at bedside, neuro checks, urinary catheter IV magnesium sulfate - prevents seizures Calcium gluconate - antidote for magnesium overdose

neonatal deviations: hyperbilirubinemia

Imbalance in rate of bilirubin production and elimination; total serum bilirubin level >5 mg/dL Physiologic jaundice after 24hr d/t breakdown of RBC(3rd to 4th day of life) Early-onset breast=feeding jaundice Late-onset breast-feeding jaundice Pathologic jaundice (within first 24 hours of life) can lead to Kernicterus- high amounts of bilirubin lining of brain is full of jaundice causing brain damage: irritated, poor feed, lethargy. Rh isoimmunization- when mom is rh- and baby rh+ but is not treated properly= must get rhogam ; ABO incompatibility- can cause hyperbilirubinemia Nursing Assessment: Risk factors Jaundice Signs of Rh incompatibility ABO incompatibility look at blood type, look at coumbs - if positive then baby could be jaundice and end up with kernicterus. Negative= normal Bilirubin levels Nursing Management: Reduction of bilirubin levels: early feeding- to get meconium out of baby to get RBC, phototherapy- warm isolate with diaper and mask on and eating every 3hr , exchange transfusions- umbilical cath pulling out blood and wasting it while new blood at same time and is going in slowly d/t chance of hemolysis and bilirubin increase Education and support; home phototherapy- biliblanket= wallaby that has a light wrapped around baby. keep eyes covered

Depo-Provera

Include progestin-only and combination estrogen and progestin •Birth control shot given once every 12 wks. to prevent pregnancy •99.7% effective preventing pregnancy •Requires four injections per year •Can be given IM and SubQ •No daily pills to remember Pt should be taking vitamin D & calcium

peds: mononucleosis

Infectious Mononucleosis: Kissing Disease • Self limiting • Causative agent-Epstein-Barr Virus • Characterized by o Fever, sore throat, fever and lymphadenopathy • Most often diagnosed in adolescence and young adults • Complications include splenic rupture, Guillain-Barre Syndrome and Aseptic (viral) Meningitis • Assessment: o History: Note exposure to infected persons Fever - how long Onset and progression of sore throat/body aches Malaise Periorbital edema Pharynx, tonsils for inflammation Lymphadenopathy Splenomegaly Hepatomegaly Erythematous rash Diagnostic tests - Monospot or Epstein Barr virus titers • Treatment: o Symptomatic - usually advised to rest o For severe pharyngeal edema - corticosteroids o Hydration o Analgesics - for fever and pain o Rest-frequent rest periods o Salt water gargles (sore throat) o If splenomegaly or enlarged liver present, no strenuous activity, avoid all contact sports o Oct 2015 - 17 year old football player Collapsed and died on field because of ruptured spleen o 4-6 weeks to be cured fully

prenatal diagnostic testing

Medical Condition Diabetes- can be preexisting or gestational. If gestational the fetus will be large for gestational age. HTN- hypertension. Chronic or gestational. This can effect growth of fetus. Small for gestational age. Chronic Infections- kidney disease and needs to be treated. Any infection can affect the health of the fetus Genetics- family history of cystic fibrosis, sickle cell STD's - effect growth of fetus Too much or too little weight gain Use of drugs/ alcohol Demographics Maternal age of mother- if less than 16yo or older than 35yo there is a concern. Poverty- restricts resources for proper care. Must look into. Inadequate prenatal care- lack of compliance with prenatal care Obstetric factors Is there a Hx of low birth weight- average weight for newborn is 5.5-8.5lbs Is there a Hx or LGA (large for gestational age)- diabetic mother Postmaturity- over 42 weeks Malpresentation- breech birth Grand multiparity- 5 or more pregnancies Multifetal pregnancy- two or more fetus ; how many times pregnant total Hydramnios- too much amniotic fluid Look at Gestational age- ask mother about last date of period Suspected IUGR- (intrauterine growth restriction) can be caused by genetic defect or too little fluid Preterm labor- occurs between 20th-37th week Discordant twins- difference in size; they are not growing equally Previous fetal loss- miscarriage Ultrasonography • High frequency sound waves • Real time picture on monitor screen • Safe, noninvasive, accurate, and painless • Usually fully covered by insurance • Use to assess fetal hr and problems 1st Trimester • Determine gestational age- Measure crown to buttock • Assess fetal heartbeat • Assess maternal pelvis & uterus • Procedure: • Can be done Transvaginally- to confirm pregnancy • Lithotomy position • 10-15 min • Get pictures 2nd & 3rd Trimester • Assess Fetal viability, anatomy & growth, and look for malformations • Locate placenta/cord- use ultrasound during amniocentesis to guide • Fetal presentation- if it is in beech position • Amniotic fluid volume- CVS chorionic sampling • Guides placement for procedures • Procedure • Transabdominal • Supine position • Full bladder- usually in first & second trimester but not in third Advantages- noninvasive, safe, relatively comfortable, immediate results with pictures(: Disadvantages- can't see every defect, costly if not insured, abnormal findings can cause anxiety due to uncertainty. Ultrasound- Doppler Flows checks for blood flow from placenta to fetus Visualizes movement of blood through vessels Used with HTN & IUGR- hypertension & restricted growth Checks umbilical vessels & placental vessels Checks heart structure- is it normal are are structures in place Checks relationship of vessels to heart When mother has hypertension or restricted growth to fetus there may be vascular issue- Doppler helps determine cause Alpha-Fetoprotein (AFP) The main protein in fetal plasma- produced by fetal liver and enters blood of fetus. Diffuses from blood to urine -> amniotic fluid If someone is getting this test, it is because the dr felt it was needed due to US report Some AFT crosses placental membrane in maternal circulation so it can be measured in maternal serum MSAFP and Amniotic fluid AFAFP. Abnormal concentrations of AFP are associated with fetal anomalies • Conditions with elevated MSAFP • Open neural tube defect- most common: anencephaly & spina bifida • Abdominal wall defects- organs left exposed • Hydronephrosis- infection of kidneys • Multi gestation • Maternal diabetes • Low maternal weight • Conditions associated with decreased MSAFP levels • Chromosomal trisomies- Down's syndrome- 21 trisomy, Edward syndrome 18 trisomy • Gestational trophoblastic diseases-group of diseases where abnormal trophoblastic cells form in uterus after conception. Usually end in termination • Overestimation of gestational age- occur from incorrect date of last period • Higher maternal weight Procedure: • Gather data, date, race, last period, get gestational date • Simple blood test done between 16-18 weeks- if not done by 18th week then can have false result • Screening test • Need further testing if abnormal- usually another ultrasound Advantages: Simple, economic, least invasive, allows preparation Disadvantages: only a screening- first step in a series of tests, false positives, time limits due to false result by not having before 18th week Chorionic Villus Sampling (CVS) Invasive procedure-needle pulling chorionic fluid sample for prenatal evaluation looking for chromosomal disorders Purpose: cells can be used for diagnosis or fetal chromosomal, metabolic or DNA abnormalities between 10-13 weeks gestation Only recommended for women at high risk, genetic carriers, age over 35yo. Procedure: • Need counseling prior • Informed/ signed consent • Transcervical or transabdominal approach Advantages: earlier results, has choice to terminate Disadvantages: pregnancy loss rate higher than amniocentesis, possible uterine infection, RH factors, $$ Post Procedure: Show fetal HR, maternal vital signs, rest at home for several hrs, report heavy bleeding, passage of amniotic fluid, monitor for adverse effects. If heavy bleeding or passage of amniotic fluid- call dr immediately If infection of vagina or cervix- procedure can not be done If incompatibility is found with Rh then must be given Rhogam- mother negative, infant positive RH Transcervial Chorionic Sampling Transabdominal is with needle through abdomen Amniocentesis From greek word- amnion (Sac) and Kentesis (puncture) Aspiration of amniotic fluid from amniotic sac Done during 2nd and 3rd trimester- rare but can be done between 11-14 weeks- but rate of fetal loss is higher. Second trimester Amniocentesis- examine cells and any fetal abnormalities Done depending on: Maternal age, Chromosomal abnormality in family, Previous infant with chromosomal defect, Elevated MSAFP, and Pregnancy after 3 or more abortions Third Trimester Amniocentesis Determines lung maturity • L/S Ratio- used for fetal lung maturity Can also diagnose fetal hemolytic disease As lungs mature and become better able to produce surfactant- the LS ratio increases in amniotic fluid- higher ratio the better Procedure for Amniocentesis Informed/signed consent Supine position BP and FHR US to locate fetus and placenta Skin prep Local anesthetic • 3-4 inch 20-21g needle • Discard first 2 ml • Remove 20 ml Show mom FHR Fetal monitoring done for 30-60 minutes Report any vaginal bleeding, contractions and leakage of amniotic fluid, fever, BP, headache- most important one is contractions because there should not be contractions at this point. Rh IG if needed post procedure Advantages: Relatively safe, painless, fetal loss rate is low Disadvantages: timing- results wait 2weeks Percutaneous Umbilical Blood Sampling PUBS- aka cordocentesis Procedure- aspiration of fetal blood from umbilical cord or fetal hepatic vein- can get same for amniocentesis . Taken near placenta for stability Purpose- diagnose • Rh disease • Genetic studies • Infections • Fetal acid/base balance Risks • Infection • Fetal bradycardia find out from fetal monitor • Cord laceration • Cord hematoma • Thrombosis • Can send mother into Preterm labor- contractions • PROM- premature rupture of membranes- can cause to go into labor which you do not want because too early Non-Stress Test Overview Purpose-assess fetal well being. Evaluate fetal heart rate Procedure-external monitor attached to abdomen- only consists of monitoring. Manipulation of abdomen or breast is done to stimulate fetus. Mother given sweet drink to cause fetus to move Mother not in supine position because of hypotension Interpretation: • reassuring/reactive = 2 accelerations of FHR remain elevated -GOOD • Non-reassuring/ Non-reactive-FHR may vary a bit but if there are no movements within 14min period- NOT GOOD 15/15 rule- 2 accelerations in 15 min Advantages: Can be done in office, noninvasive, painless, 20-40min to complete, quick results if good, no limited # Disadvantages: high rate of false positive results • Vibroacoustic Stimulation VAS- applied to abdomen over fetal head- vibration and sound is given every 3 seconds and is repeated at 1min intervals • Done 26-28 weeks gestation because this is when fetal brain responds to sound- no damage done to fetal hearing Used to verify questionable findings Contraction Stress Test CST or Oxytocin Challenge Test OCT Purpose- assess fetal response to labor; maybe done if Non-stress is nonreactive • Stimulate labor to determine is fetus can tolerate labor process Indications- mother has history of diabetes, HNT, IUGR< Rh, previous stillborn and post maturity- puts at risk for low tolerance for labor Procedures- IV oxytocin until 3 contractions in a 10 min period; must be done in hospital Contraindications are patients with previous csection or placentaprivia Interpretation: • Negative= stable FHR • Positive = late deceleration after 50% of contractions • Suspicious= intermittent decelerations • Hyperstim=deceleration with excessive contractions • Unsatisfactory = fewer than 3 contractions in 10 min Deceleration- decrease in fetal hr BioPhysical Profile BPP Rationale-assess fetal well being Add up all points Five parameters: • Reassuring Nonstress test-2 pts • Fetal breathing movements -rhythmic- 2 pts • Gross fetal movements large trunk movements -2 pts • Fetal tone small movements- sucking or hand movement -2 pts • Amniotic fluid volume -pockets or fluid 2 pts Criteria for scoring-desired score of 8-10- adequate neuro function and oxygenation

Peds: infections of ear Otitis media

Middle Ear Infection • Clinical signs: fever, pain, bulging eardrum, red tympanic membrane, ear pulling. • Treatments: antibiotics. If chronic/severe myringotomy with grummets. Between 6mos-3yrs. Allows fluid to drain. Fall out by 4-6mos. • Education: cause: horizontal Eustachian tubes. o Prevention: eardrops, earplugs, avoid bedtime bottles • tx: Myringotomy with Grummets

peds: infectious diseases care

Mumps: bed rest and fluids- main concern is orchitis Rubella- avoid exposure to pregnant, nsaids, keep isolated, bed rest, fluids , nails short Varicella- i. Prevent spread of disease, wear mask, hand washing, short fingernails, Tylenol only 1. (NO IBUPROFEN; will cause necrotizing fasciitis) Antiviral therapy and VZ IGG may be used in high risk patients Parovirus- pregnant women at risk Roseola- 6th disease- bed rest fluids, prevention of spread Lyme: 8 or older= doxycycline younger= amoxicillin Impetigo- o Penicillin PO X 10 days o Wash lesions with soap and water (may be very painful) o Topical antibiotic ointment not as effective as oral. o Complications are rare (similar to those of strep infections) o No immunity to impetigo!! Scabies- o Shower and dry thoroughly, then apply scabicidal lotion from the neck to feet. o Kept on for 12 hours and then washed off. GBH or Permethrin Cream o May need retreatment after several days but usually one is sufficient if applied properly. o Mites are killed with treatment but pruritus and rash to persist. o It is recommended to treat all family members regardless of symptoms • Nurses always wear isolation gown and gloves (contact precaution) • Nursing Interventions: o Educate, isolate, prevent spread, use soap as prescribed o Inspect groin, umbilicus, armpits Pinworm- o Antihelminthics - treatment of choice o Mebendazole 100 mg x 1 dose, repeat in 2 weeks x 1 (recommended for children above 2) o Pyrantel pamaote - children under 2 5 mg/kg x 1 dose, repeat in 2 weeks, colors stool bright red, include in teaching o Albendazole o Reinfection occurs easily o Personal hygiene, bedding/clothes, hand hygiene o Clean all doorknobs (esp. bathroom) o All family members are treated Gastroenteritis- o Restoring fluid and electrolyte balance Diarrhea - losing potassium Vomiting - losing sodium o Providing family education Probiotics o Skin care, clean toilets/nails/linens daily o Foods should be cooked and/or refrigerated and should avoid fruit juices • Most effected rom 3-15 months and symptoms appear 1-3 days after exposure check Stool culture, CBC, bun and creatinine Vomitting- o ORS, timing of ORS and gradual increase, IVF's o ORS = Oral Rehydration Solution (homemade solution = 1 quart water + 8 tsp sugar + 1 tsp salt) given ½ oz. to 2 oz. (15 mL to 60 mL) every 15 minutes NEVER give fruit juices Gradually increase fluids (pedialyte can also be used) If it is severe, IV therapy will be given o Assess abdomen (distention, tenderness Although toddlers have beer bellies, when they lay flat it will flatten out. So distention while lying flat is abnormal o Elevate baby to prevent aspiration o Check dehydration by assessing skin turgor on the belly instead of the hand • May require use of antimetics o Never use antimetics in infants • Use of ginger?

assessment findings of GI during pregnancy

N/V may occur due to hormonal changes and or an increase of pressure within the abdominal cavity as the stomach and intestines are displaced within the abdomen. Flatulence. Constipation may occur due to increased transit time of food through the GI tract and increased water absorption. Decreased gastric motility due to relaxin- hormone produced by ovaries. Progesterone effects smooth muscles of intestines making it less active. The acidity of stomach decrease during pregnancy and patient may experience reflux/heartburn. The gums become more vascular and become prone to bleeding- DENTAL CARE! Increased saliva due to estrogen. Decreased emptying of bile from gallbladder- reabsorption of bilirubin in fetal bloodstream- result in itching. Decreased acidity may relieve peptic ulcers. Concerned about absorption of iron*.... Hemorrhoids

Peds: Seizuress- clinical manifestations tx and teaching

Nursing Care of a Child with Seizures: • Observe child during entire shift for an seizure activity and document, • Prevent seizures by creating SAFE quiet, non-threatening environment, make sure child gets adequate rest • Pad side rails or crib rails • At bedside: airway, Oxygen, ambu bag, suction setup • Observe child, time the event, observe motor activity, LOC, position of eyes, color, respirations • Keep as safe as possible (Safety first) • Do not try to restrain child • Don't force anything into the child's mouth • When completed assess for LOC, V.S., suction, turn head to side, incontinence • Allow child to rest • Stat Valium (diazepam) or Ativan (lorazepam) usually PRN • May be incontinent Teaching Parents Care of Seizure At Home: • Valium (Diastat) or Phenobarbital suppositories if seizure lasts more than 5 minutes. • Teach parent the same care of child for a seizure at home. • Encourage self-care in child and encourage parent to allow child to live a normal life with some precautions (MD may limit contact sports). • Overall goal is for child to have seizure-free life with development of a positive self-image. • Teaching Points: • Never leave alone - Buddy system • Activities to AVOID • Horseback riding, swimming • Activities to encourage • Reading, academics • Medical alert bracelet • Medication compliance • Aura's • Driver's license • Management of seizures at home • Oral contraceptives/sexual practices Causes of Seizures: • Metabolic changes - electrolye changes (decreased sodium, calcium, magnesium, hypoglycemia, etc.) • High Fevers • Perinatal asphyxia - decreased oxygen to tissues (commonly seen in Cerebral Palsy patients because of this) • Head trauma • Infections esp. sepsis and meningitis • Children exposed to free-based cocaine (crack) • Excessive lead • Idiopathic - Most common cause in childhood • especially febrile seizures • Familial/Genetic Types of Seizures: (General, whole brain, vs. Partial, part of the brain) 1. Generalized Seizures - involves both brain hemispheres (most dramatic) a. Generalized Tonic-Clonic Seizures (GTC) i. Classic convulsive seizure ii. Aura may precede seizure - may be a recognizable sensation that precedes seizure iii. Loss of consciousness with sometimes epileptic cry 1. Abdominal muscles contract b. Tonic phase: (20 seconds) - stiff phase i. Extreme muscle rigidity, eyes deviate upward, apnea, cyanosis, loss of bowel and bladder control c. Clonic Phase: (2-5 minutes) - jerking i. Rhythmic contraction of muscles, may bite tongue, may have jerking movements ii. Most active part of seizure when they are at risk for injury a. Postictal Phase: a. Always after the seizure, child usually falls into a deep sleep or may be confused for several hours, b. May cause sore muscles, headache, or vomiting once awake c. May become incontinent, typically do not want to eat, may not recall seizure at all 2. Status Epilepticus a. Status Epilepticus: MEDICAL EMERGENCY i. Continuation of a seizure beyond 10 minutes or recurrence of a seizure without regaining consciousness within 30 minutes or more b. Considered to be a medical emergency. Usually need IV Valium, Ativan, and Phenobarbital to break this. c. May need to be intubated and on respirator i. Many medications administered VERY quickly - increase cerebral blood flow and decreased metabolic requirements cause the need for medications in order to prevent further damage d. May cause profound damage 3. Absence Seizures a. Absence (Petit mal) Seizures: Usually last less than one minute. b. Can involve staring, and a brief loss of consciousness, may have rhythmic blinking of the eye or contractions of the hand. i. Looks like they are daydreaming c. May be diagnosed from toddler to preschool (onset between 4-12 years) d. 20 or more can occur in one day e. Difficult to diagnose especially in preschoolers 4. Epileptic Spasms (West Syndrome) a. Epileptic (formally Infantile) Spasms: b. Occur 3-9 months old, up to 100 times/day i. Disappear after infancy. 90% are mentally challenged ii. Presents as sudden jerk followed by stiffening c. Infant may stop developing d. Steroid therapy and anticonvulsants common forms of treatment e. If not picked up early, they can cause severe brain damage (cerebral palsy can develop) f. If treated early, there is a good prognosis 5. Generalized a. Myoclonic i. Sudden, brief, massive muscle jerks b. Atonic i. Sudden loss of muscle tone (drop attacks) - may have to wear helmet ii. Child will regain consciousness within a few seconds to a minute iii. Can result in injury r/t violent fall 6. Focal Seizures a. Focal (formally called Partial) Seizures: b. Occurs in one part of the brain, child will remain conscious, may verbalize during the seizure c. Motor activity-tonic, clonic movements d. Sensory signs such as numbness, tingling paresthesia, changes in vision and hearing, possible hallucinations or pain e. May have changes in b/p, HR and bowel f. May include psychic symptoms such as fear, anxiety g. No post dictal state h. Focal with impaired consciousness i. May or may not have preceding aura j. Consciousness will be impaired k. Automatisms and complex purposeful movements l. Infants will present with lip smacking, chewing, swallowing m. Older children-picking, pulling at bed sheets, repetitive walking or running /walking in nondirective fashion n. Can be difficult to control 7. Febrile Seizures - always due to a fever (benign) a. Febrile Seizures: Generalized seizures which occur with a fever above 102.2 or 39 C degrees i. Caused by increasing temperature ii. Usually becomes more susceptible to recurring febrile seizures b. Occur (3% of children) 6 months-5 years, peak 12-18 months c. Most common type of seizure seen in children less than 5 d. Benign but need to investigate cause e. Familial f. Usually seizure occurs as the temperature rises rather than prolonged elevation i. When temperature starts to rise, nurse and parents should start anti-fever control 1. Cool compresses, Tylenol, etc. g. Febrile seizures are not associated with a chronic seizure disorder h. May give rectal diazepam, buccal or intranasal midazolam, intranasal lorazepam i. Will always give rectal diazepam before anything else 2. EPILEPSY • Condition where seizures are triggered recurrently through the brain • 2 or more unprovoked (or reflex) seizures which occur more than 24 hours apart • One unprovoked (or reflex) and a chance of further seizures the same as the general recurrence risk (at least 60%) after 2 unprovoked seizures, happening over the next 10 years • Prognosis • Living with a seizure disorder

menstrual Cycle hormones

On Day 1 of the menstrual cycle, estrogen and progesterone levels are low. Low levels of estrogen and progesterone signal the pituitary gland to produce Follicle Stimulating Hormone (FSH). FSH begins the process of maturing a follicle (fluid-filled sac in the ovary containing an egg).

neonatal deviations: metabolic screening

PKU: drawing blood on filter paper PKU, maple syrup urine disease taysacks, Sickle Cell, thyroid. fetal ketone urea special diets needed otherwise can result in severe mental retardation

Peds: pediculosis

Pediculosis Capitus - aka Head Lice • 10 million cases reported each year in U.S. o Females affected 2x more than males o Whites 20x more affected than Blacks due to makeup of the hair shaft • The louse (adult form - black speck) lives off the scalp's blood supply (1 month) o Away from its host it lives about 48 hours. • Eggs (NITS) o Not communicable are produced and are readily visible 1/4 inch away from the scalp. o Look like dandruff but don't detach easily from hair shaft. • Lice do not jump but spread by direct contact (combs, headgear, clothing etc.) • Symptoms: o Pruritus at nape of the neck/occipital area and behind the ears o Low-grade temp and cervical lymphadenopathy may occur o Secondary infection can occur due to scratching • Treatment: o Kwell - GBH Gamma Benzene Hexachloride - Pediculicidal shampoo prescription, destroys head lice not nits (CNS toxicity) **Many strains of lice are now resistant to GBH o Use of an electric comb to detect and kill lice. o Permethrin - (Prioderm, Nix, Triple X, Rid) destroys lice and nits PREFERRED TREATMENT Do not need prescription o After shampoo hair needs to be combed out thoroughly with fine-toothed comb to remove nits. o Combs and brushes should be soaked in pediculicidal shampoo. o Sheets and towels must be changed. o Launder in hot water

nursing assessments for preeclampsia

Preeclampsia • Multisystem disorder that targets the cardiovascular, hepatic, renal, and CNS. o Classified as mild or severe with potential to progress to eclampsia. • Characterized by HTN, proteinuria, and organ damage Generalized vasospasm = ∧ in BP, ∨ blood flow to brain, liver, kidneys, placenta, lungs ∨liver perfusion = epigastric pain and ∧ liver enzymes (less perfusion to pancreas and liver) ∨ brain perfusion = small cerebral hemorrhages, headaches, visual disturbances, blurred vision, DTRs ∨ kidney perfusion = ∨Glomerular filtration rate = ∨ urine output = ∧ levels of Na+, BUN, uric acid, and creatinine ∧capillary permeability in kidneys = ∨ albumin = ∨ colloid osmotic pressure = pulmonary and generalized edema Albumin keeps everything together in the blood If albumin is decreased, you have more free-floating agents in membranes and increase edema because protein in albumin is not holding it all in o Thromboxane/prostacyclin imbalance= thrombocytopenia Low clotting factor • Poor placental perfusion r/t prolonged vasoconstriction = uterine growth restriction, placental abruption, persistent fetal hypoxia, and acidosis Mild Preeclampsia • Mild preeclampsia - BP >140/90 after 20 wks. (2X, 4-6 hours apart) o Proteinuria = 300 mg or more of urinary protein per 24 hour or 1+ protein on dipstick with 2 random samples collected 4-6 hours apart with no UTI Protein is being peed out instead of to the baby, where it should be going o Seizures/coma = no o Hyperreflexia = no o Other s/s = mild facial or hand edema, weight gain o Risk for postpartum HTN (diet, ethnicity, etc.) • ASSESSMENT: o Identify risk for preeclampsia o Nutritional assessment o Blood pressure and weight o Amount and location of edema o Fetal heart rate o Clean catch urine specimen o Labs: CBC, serum electrolytes, BUN, creatinine, hepatic (liver) enzyme levels • Interventions o Mild at Home - bed rest, lateral position, increase antepartal visits with labs: CBC, clotting studies, liver enzymes, platelets, BP and WT monitoring, protein measure with dipstick, daily fetal kick counts, balanced diet, six-eight 8oz glasses water daily o Hospital - BP not reduced at home. Monitored for s/s of severe preeclampsia/eclampsia. BP and WT, fetal monitoring, Management continues until pregnancy reaches term, fetal lung maturity (inject surfactant), or complications warranting immediate birth o Labor - focus on preventing progression to eclampsia. BP monitored, quiet environment, IV magnesium sulfate, antihypertensive medication (if needed), calcium gluconate at bedside, neuro checks, urinary catheter IV magnesium sulfate - prevents seizures Calcium gluconate - antidote for magnesium overdose Neuro checks - DTRs, visual disturbances, speech Severe Preeclampsia • Classification: o May develop suddenly. Immediate hospitalization is required o BP > 160/110, weight gain o Proteinuria is >500 mg in 24hrs and greater than 3+ on random dipstick urine sample o Oliguria of less than 400 mL in 24 hours (typically 30ccs per hour) o Seizures/coma - No o Hyperreflexia (irritated) - YES +4 deep tendon reflexes o Other signs and symptoms - headache, blurred vision, blind spots, rapid weight gain, pulmonary edema, thrombocytopenia, cerebral disturbances, epigastric or RUQ pain, HELLP, +4 DTR o Birth of infant is the only cure • ASSESSMENT: o Blood pressure of more than 160/110 o Protein of more than 500 in 24 hours o Oliguria of less than 400 mL in 24 hours o Cerebral and visual symptoms o Weight gain and edema- pitting degree o Pulmonary edema o Thrombocytopenia < than 100 mm3 o Epigastric or RUQ pain, HELLP o Labs: CBC, serum electrolytes, BUN, creatinine, hepatic enzyme levels • Interventions: o Bed rest left lateral lying position o Room dark and quiet to reduce stimulation - helps with irritation o Administer sedatives as ordered to encourage quiet bed rest o Seizure precautions (padding, side rails, O2, suction equipment, call light) o Closely monitor BP, administer antihypertensives o Assess vision and LOC (headache and visual disturbance) o Assess s/s pulmonary edema o Offer high protein diet with 8-10 glasses water (because they're peeing a lot of protein) o Monitor intake/output every hour o Administer fluid and electrolyte replacement o Fetal monitoring

Peds:immunizations for preschool and school age

Preschool: Boosters needed for DTaP, IPV, MMR, Varicella Annual flu vaccine School age: Boosters as needed Annual flu vaccine 11-12 year olds - TdaP, HPV, MCV4 o Meningitis

assessment of postpartum urinary complication

Prevention: Monitor the patients urination diligently! Don't allow to go longer than 3 - 4 hours before intervening. Treatment: Antibiotics -- Ampicillin Urinary Tract Antispasmodics- for discomfort and pain. Causes: Stretching or Trauma to the base of the bladder results in edema of the trigone that is great enough to obstruct the urethra and to cause acute retention. Anesthesia treat before becomes nephritis. 100.4 or greater for 2 days excluding the 1st 24 hours. foul smelling lochia/ discharge, with sutures or staples- look for oozing- there may be redness from irritation but if it is draining then it could be infected. if UTI- urine specimen, ask about burning itching, how frequently- after cath tell increase fluids because burning is normal for the first time. have her run water in sink, go in shower, or use peribottle to help her to urinate If going home on AB- teach to finish, probiotic, properly cleaning, look for s/s of infection- call Dr. hand washing is very important! vaginal is aseptic section is sterile technique

nursing intervention for late pregnancy bleeding

Previa: focus on monitoring maternal fetal status such as pain and vitals assess for s/s vag bleeding and fetal distress provide info on section, support and edu on dx and treatment teach client to monitor fetal movements to eval well being if long bedrest edu on nutrition skin care fluid intake- s/s of thrombosis s/s of preterm labor and notify provider immediately Abruptio: Labs: CBC, fibrinogen, PT, type and cross, nonstress test, biophysical profile lie pt on left side oxygen, vitals q15min Foley, IV Assess fundal height MOnitor amount and character of bleeding q15-30min, monitor for hypovolemic shock and DIC fetal monitoring assess fetal contractions FHR administer corticosteroids to promote fetal lung maturity when in utero. Communicate empathy and understanding assist family with the loss or with NICU

PPD & baby blues/ psych

Risk factors: Primiparity History of postpartum depression Lack of social and relational support Clinical therapies: Counseling and support groups Medication (usually SSRI's) Childcare assistance -Baby Blues- transient ;10d to 2weeks -Postpartum Depression -Bipolar Disorder Baby blues 50-80% of moms are affected Self-limiting (up to 10 days) Cause:Seems to be related to changes in progesterone, estrogen, and prolactin levels Symptoms: Tearful yet happy overwhelmed Postpartum Psychosis Predisposing factors: Similar to those of postpartum depression Assessments: Grandiosity Decreased need for sleep (insomnia) Flight of ideas Psychomotor agitation/hyperactivity Rejection of infant pregnancy does NOT cause psychosis, must have prenatal hx of psych issues

normal characteristics of newborn (ALL)

SGA Newborns: Assessment: Typical Characteristics -Head disproportionately large compared to rest of body -Wasted appearance of extremities; loose dry skin -Reduced subcutaneous fat stores -Decreased amount of breast tissue -Scaphoid abdomen (sunken appearance) -Wide skull sutures -Poor muscle tone over buttocks and cheeks- looks shriveled up -Thin umbilical cord due to lack of nutrition -linugo -small genitals LGA Newborns: Assessment: Common Characteristics Large body, plump, full-faced Proportional increase in body size Poor motor skills Difficulty regulating behavioral states Preterm: Weight <5.5 lbs Scrawny appearance Poor muscle tone Minimal subcutaneous fat Undescended testicles Plentiful lanugo- very hairy Poorly formed ear pinna- push ear dowl and it stays there. make sure ears are in place when putting hat on Fused eyelids- depending on how early they are born. Soft spongy skull bones Matted scalp hair Absent to few creases in soles and palms Minimal scrotal rugae; prominent labia minora than majora and clitoris large Thin transparent skin- can see veins Abundant vernix

Dysfunctional Labor complications

Shoulder dystocia Mc Roberts maneuver, suprapubic pressure Explain to woman & family the dysfunctional pattern If baby does not release shoulder, it is an emergency Erb's Palsy of Brachial Plexus injury (can be from fractured clavicle, nerve damage) • Good prognosis if PT is started immediately

Peds: Meningitis- clinical manifestations tx and teaching

Signs and Symptoms • Newborns: o Vague, diff to diagnose o Poor muscle tone o Weak cry o Poor suck o Refuses feeding o Vomiting o Diarrhea o Poss fever o Hypothermia • 3 months - 2 years o Seizures with high pitched cry o Fever, irritability o Bulging fontanels o Poss nuchal rigidity poor feeding, vomiting Nuchal ridigity - stiff neck o Brud/Kernig not reliable • 2 years - adolescence o Nuchal rigidity o Headache o Vomiting o Fever, chills o Photophobia - lights are bothersome o Generalized malaise can progress quickly to lethargy and coma if untreated o Opisthotonus - extreme overextension of the spine o + Brud/Kernig sign o Irritability o Petechiae or purpura type rash o SEIZURES!!! • Kernig's sign (inability to fully extend the legs when supine) • Brudzinski's sign (flexion of the hips when neck is flexed) • Infant may have a high-pitched cry, bulging tense fontanels irritability, anorexia, blank stare • Cannot lay flat • Opisthotonus • Vital Signs: • (Cushings Triad) - o 1. Increased temperature o 2. Decreased blood pressure, especially pulse pressure o 3. Decrease pulse and respirations o Vital sign changes are a late sign of increase intracranial pressure • Indicate pressure on the brainstem • Meningococcal meningitis causes a purpural rash over body. • Seizures - 60% experience seizures due to increased ICP. Management: • Droplet isolation until the organism is identified • I.V. antibiotics x 7-14 days. Given in high doses to cross blood-brain barrier • I.V. fluids (1 ½ maintenance IV given to keep child slightly overhydrated) o Not only does it have to get to the brain, but it also has to be excreted out of the brain • Assessment and treatment of seizures • Antipyretics/Analgesics - decrease fever and inflammation • Corticosteroids • GCS - coma scale • 15% of children have sequela from bacterial meningitis (hearing loss, arthritis, mental retardation) o Obstructive hydrocephalus - thick pus and fibrin clog the ventricles • Mortality Rate is less than 15% (including neonatal period) • ASEPTIC MENINGITIS: also called Viral Meningitis, caused by a virus, Child is not as ill o Treatment is supportive o No sequela • Tuberculous Meningitis: TB separated from bacterial, treated similarly but medications are taken for one year usually (usually with HIV +)

cleft lip repair

Therapeutic Management: cleft lip, surgical repair between 6 and 12 weeks. cleft palate, surgical repair between 6 and 18 months. Nursing Management: Provide adequate nutrition and parental- make sure baby is eating well; breast feeding is the best for cleft. longer nipple bottle, dont want to tube feed. after surgery- do not want baby to put hands by mouth.. use elbow boards to restrain and check q2hr. education and promote parental bonding

Fetal deceleration: veal chop

Variable Decel- cord compression Early Decel- Head Compression Acceleration- may need O2 but normal Late decel- placental insufficiency

suppression of lactation

Wear a firm bra both day and night to support your breasts and keep you comfortable. Use breast pads to soak up any leaking milk. Relieve pain and swelling by putting cold/gel packs in your bra, or use cold compresses after a shower or bath. Cold cabbage leaves worn inside the bra can also be soothing. Pain medications- Advil, motrin

iron enriched foods during pregnancy

Your body uses iron to make extra blood (hemoglobin) for you and your baby during pregnancy. Iron also helps move oxygen from your lungs to the rest of your body -- and to your baby's.

nausea in pregnancy

Zofran is NOT allowed increased smell can cause nausea should have small freq meals- eat crackers before getting up in morning N/V may occur due to hormonal changes and or an increase of pressure within the abdominal cavity as the stomach and intestines are displaced within the abdomen avoid empty stomach. Eat dry crackers/toast in bed before getting up. Eat several small meals t/o the day. Avoid brushing teeth immediately after eating to avoid gag reflex. Acupressure wrist bands worn daily. Drink fluids between meals rather than with meals. Avoid greasy foods or foods with strong odors.

Peds: Rubeola

a. 4 phases: i. Incubation - asymptomatic (8-10 days) ii. Prodromal - symptoms begin 1. Onset of Symptoms: Cough, Conjunctivitis, Coryza (runny/inflamed nose) + fever iii. Full Stage Illness 1. Respiratory symptoms appear after 10 days 2. Koplick spots will then appear 2 days before the appearance of a rash a. Koplick spots = small blue-white spots with a red base (looks like salt with red membrane contrast) i. Usually start in mouth b. The spots appear for 2 days, then disappear, and then rash appears from head and works its way down c. 48 hours after rash - fever begins again and will eventually taper off iv. Convalescent (Recovery) 1. Body begins to heal b. WHO recommend administration of Vitamin A i. Should be taken 24 hours apart ii. Prevents blindness c. Nursing Interventions: i. Isolation, patient teaching (vaccine)

peds: Transposition of the great Vessels

a. Cyanotic heart defect because the condition results in insufficiently oxygenated blood pumped to the body, which leads to cyanosis and shortness of breath. b. Symptoms included: i. Murmur ii. Cyanosis iii. Cardiomegaly iv. Heart failure c. Surgical repair in infancy d. ** There is usually an associated defect, septal defect and PDA necessary for oxygenated blood that permits the mixing of the systemic and pulmonary circulation to provide some oxygenated blood to the body. Without such a defect, the condition is rapidly fatal.

peds: Coarctation of aorta

a. Elevated blood pressure in the arms, lowered blood pressure in the legs b. Weak or absent femoral pulse c. Harsh murmur heard in the back d. Signs of heart failure i. Dizziness, headaches, fainting e. Medical Management: i. Balloon angioplasty ii. Surgical Repair: Stent placement/adolescent

Peds: PDA

a. Symptoms depend on defect size b. Bounding pulses c. Machine sounding murmur d. Wide pulse pressure i. Low diastolic BP e. Feeding difficulties, poor weight gain f. Pale, feeble appearance g. Possible heart enlargement and heart failure h. Medications: i. Indomethacin i. Medical management: i. Coils inserted to occlude PDA via cardiac cath ii. Surgical closure via PDA ligation both acyanotic and cyanotic

Precipitous Labor care

abrupt onset of labor a. Completed in less than 3 hours from start of contractions to birth b. Too rapid of a labor can result in maternal injury and place fetus at risk for traumatic deprivation of oxygen c. Mom can experience in cervical laceration or a possible uterine rupture d. Infant may experience intracranial hemorrhage, nerve damage, or hypoxia Monitor closely if previous history Anticipate scheduled induction - in order to control labor rate Administer tocolytics, such as terbutaline, magnesium sulfate, indomethacin, nifedipine or atosiban --> all reduce muscle contractions • Tocolytic = anti-contraction medications which reduce muscles ability to contract o Slows down labor o Terbutaline - discontinued in some hospitals • Magnesium sulfate - not for long term use (calcium gluconate on hand) • Indomethacin - NSAID that relaxes smooth muscle • Nifedipine = calcium channel blocker • Atosiban = oxytocin antagonist receptionist Remain in attendance to monitor labor if any of these meds are given!!

measurement of bloodloss

check pad-

Neonatal deviations: NAS

drug dependency acquired in utero manifested by neurologic and physical behaviors WITHDRAWL

Postpartum deviations vitals

during the postpartum period, women may exhibit a slight temperature elevation due to dehydration following delivery or as a result of breast milk coming in around day 3 or 4. Immediately after delivery, the blood pressure should remain the same as during delivery.

Relief of constipation postpartum

fiber, water, activity. possible use of stool softeners.

Effects of prenatal care

helped eliminate deaths.

peds: tonsillectomy- plan of care- hemorrhage

hemorrhage not common. Usually occurs postop period until 10 days postop. o Encourage fluids: ice chips, ice pops, no citrus, red or brown juices/drinks o Avoid clearing throat, coughing, blowing nose and use of straws. May end up taking off scab forming in back of throat o Pain management: Ice collar, analgesics with or without narcotics o Airway: side lying until awake then sitting comfortably. Small amount of bleeding may occur; Suction gently PRN o Fluid volume: hemorrhage not common. Tonsillitis • Occurs after pharyngitis • Caused by streptococcus A bacteria or virus o Symptoms: sore throat, muffled sound, hoarseness, fever, malaise o Treatment: Viral - symptomatic (fluids, rest, pain meds: Tylenol/Advil Bacterial: treat same as pharyngitis • Nursing Assessment: o History: include fever, appetite, fluids, o Assess throat for redness, swelling, exudate o Note sound of voice o Kissing tonsils 4+ o Enlarged adenoids (behind soft palate) o Palpate cervical nodes o Surgery necessary with recurrent strep infections of 4+ in one year

Peds: injury prevention - infants and toddlers

infants: o Car seats o Falls o Burns o Crib safety o Choking o Poisoning Sudden Infant Death Syndrome (SIDD) toddler: o Motor vehicle o Choking o Drowning o Burns o Falls o Poisoning

Fetal heart Tones

intermittent fetal monitoring doppler is more effective. allows woman to freely more does not provide continuous FHR record or stress of labor Variable Decel- cord compression Early Decel- Head Compression Acceleration- may need O2 but normal Late decel- placental insufficiency

Peds: pain assessment and management for all age groups

kids use smiley faces scale. infants use cry scale

Elimination and thermoregulation of NB

making sure infant has 6-8 wet diapers/ day keeping temperature above 97.7 warmer, swaddle, skin to skin, mother holding infant

Peds: Duchenne's MD- assessment tx & teaching

most common childhood form, almost exclusively boys (universally fatal) o X-linked disorder in 50% of cases (see genetics) o 1:3500 live male births (incidence) o Early onset, 3-5 years Signs and Symptoms: • Calf muscle hypertrophies - muscle fibers are replaced by fibrous tissue and fat deposits o AKA pseudohypertrophy • Developmental lag • Waddling gait and extreme lordosis (lower back curvature) • Gower's sign - difficulty arising from squatting or sitting position o Use there hands to arise instead of their legs • 25% of children are severely mentally challenged • There is "mild mentally challenged" (20 pts below normal) in majority • Development of disuse and flexion contractures • XP 21 Chromosome Defect • Tripping, toe walking, enlarged calf muscle Diagnostics: • EMG - very painful but cannot be put out o Electrodes inserted into muscle • Enzymes - CPK o CPK is enlarged from hypertrophy • Muscle Biopsy - definitive factor • Typically will be missing dystrophin Therapeutic Management: • No cure • Use of corticosteroids may slow progression • Focuses on symptomatic, preventative and supportive treatment o Physical therapy o May have surgery for contractures o Respiratory therapy and physical therapy PT several times a day Respiratory muscles and heart will be negatively effected from disease o Nutritional management o ACE inhibitors, beta blockers (why) Because of the decreased heart and lung muscle functioning Cardiac and respiratory systems need help HEART IS A MUSCLE • Heart will decompensate at some point Oral pharyngeal muscles are also effected causing aspiration pneumonia o Depression, Obesity Inactivity, not able to play, etc. o Eventual resp./cardiac failure Lungs are techinically fine, but muscles surround lungs are negatively effected

Peds: epiglotitis plan of care

must be acted upon quickly • Inflammation and swelling of the epiglottitis, difficulty swallowing • Often related to Haemophilus influenza • Most often occurs in children 2-7 years old • Complications: o Can be life-threatening o Respiratory arrest o Death o Pneumothorax o Pulmonary edema • Assessment: o Sudden onset and high fever o Overall toxic appearance o May refuse to speak or speak in a whisper o Common position of comfort: sitting forward with neck extended o Drooling o Anxiety, fearfullness o Absent cough • Management: o DO NOT LEAVE CHILD ALONE o Remain calm and keep parents calm o Allow child to position for comfort NOT supine o Provide O2 o If airway occlusion occurs-> Emergency Tracheostomy o Have emergency equipment available

Cervical effacement and dilation

needs to be 100%effaced and 10cm dilated inorder to deliver

Peds: infant gross motor development

o 0-1 months: neonatal o 2 months: keeps head erect, but "bobs", head lag when pulled to sitting o 4 months: minimal head lag, sits erect if propped up, rolls abdomen to back o 6 months: sits in high chair with back straight, bear some weight when held in standing position, rolls back to abdomen o 8 months: sits unsupported, bears weight while holding on (bounces)/ may crawl o 10 months: pulls self to stand o 12 months: walks "holding on" sits from a standing position o 15 months: walks independently

Peds: failure to thrive

o Organic vs. Non-organic Organic - not developing as they should for genetic, physical reason Non-organic - probably due to psychosocial reason • Ex. Mother is an alcoholic and is non-engaging of her child, so child lacks development

Peds: communicating with toddler

o Receptive language skills occur before expressive skills Understand adult language/expression before they can express it themselves o 15-18months: "jargon" or baby talk o 2 year olds speak in 2-3 word sentences, egocentric language (I, me, mine ), 200-300 word vocabulary o 3 year olds: 3 word sentences, should be understood by strangers, 900 word vocabulary • Nutrition so talk to toddlers- make them feel like they are helping. Make sure you do not use medical jargon or say things a certain way.

Peds: minimizing lead exposure

o Sources of Lead Poisoning: Soil Water Cigarettes Matches in some paint Children under the age of 6 years old are at risk because they are growing so rapidly and because they tend to put their hands or other objects, which may be contaminated with lead dust, into their mouths. prevent child from playing in soil, make sure child does not drink water with lead. Keep child away from matches and cigarettes keep child from paint on walls in older houses that contain lead. household dust also contains lead wash hands get house checked for lead- if built before 1978 there is a possibility for lead paint

placental abruption

premature separtation fo placenta from uterus, bleeding may be visible or concealed, accompanied by pain, uterine tenderness, and uterine hyperactivity Risk factors: Maternal HTN over 35yr poor nutrition alcohol drug use male fetal gender smoking cocaine use multifetal preg abortions abd trauma hx of abruptio placenta premature rupture membranes Assessment; diagnose with CT onset is sudden bleeding: -visible: sudden onset uterine pain with dark red vaginal bleed.... Concealed: enlarging uterus w/o bleeding Area of localized or diffuse uterine pain. Uterine tone: stiff/ board like (firm/ ridgid) FHR: fetal distress or absent Interventions: Labs: CBC, fibrinogen, PT, type and cross, nonstress test, biophysical profile lie pt on left side oxygen, vitals q15min Foley, IV Assess fundal height MOnitor amount and character of bleeding q15-30min, monitor for hypovolemic shock and DIC fetal monitoring assess fetal contractions FHR administer corticosteroids to promote fetal lung maturity when in utero. Communicate empathy and understanding assist family with the loss or with NICU Complications: vitals can be WNL even with bloodloss r/t pregnant woman can lose up to 40% of total blood volume without showing sighs of shock due to pregnancy increases blood volumes! increased pulse, falling BP, increased RR, weak/diminished or thready peripheral pulses cool, moist skin: pallor, cyanosis( late sign) decrease urine outpur decreased hgb hct change in mental status DIC

causes of urinary frequency during pregnancy

pressure on bladder r/t pregnancy teaching: pelvic floor exercises to increase control over leakage. Empty bladder when first feel full sensation. Avoid caffeinated drinks- stimulate voiding. Reduce fluid intake after dinner to reduce nocturia.

Fetal Station

relationship of presenting part to maternal ischeal spine. Cm. Can be positive or negative depending on location above ischeal spine is negative below is positive

Peds: abdominal assessment

respirations in young children are abdominal assess for color, distention, pain, tenderness

Stages & phases of Labor

stage one: dilation of cervix and ends when reaches 10cm membranes can rupture during or remain intact mother must empty bladder- full bladder dislodge uterus. Longest stage 3parts: Latent- early phase. first s/s of labor. regular contactions and ends when rapid cervical dilation begins 20% effacement and 0-3cm dilated , active- begins at end of latent and lasts until cervial dilation 4-7cm and 40-80% effaced contractions become more frequent and increases in duration. discomfort intensifies becomes more focused. what is taught at CB class is used now. pace breathing , transitional- last phase of 1st stage 8-10cm 100% effaced. shortest and most difficult phase contractions stronger more frequent and painful. pressure on rectum. great desire to push, n/v, trembiling, backache, increased irritability, restless, increased bloody sho, diaphoretic, feeling of loss of control, overwhelmed. 2nd stage of labor: compelete dilation 10cm to birth of baby mother feels more incontrol and less irritable/ focus is pushing. 3rd stage of labor: birth of infant and ends with placental birth 2 phases: separation and expulsion. Signs of separation: uterus rises up umbilicord drops/ lengthens sudden trickle of blood from vagina uterus changes to globular shape Expulsion: birthing of placenta. baby stays attached until cord drops- cord is cut and then massage abd for contractions to birth placenta. need firm uterus so massage 4th stage of labor 1-4hr after delivery begins with expulsion of placenta and ends with stabilization and psych adjustment of MOM. initiates postpartus period fundus should be firm and well contracted- located midline bt umbilicus and pubic symphasis then slowly rises above umbilicus during 1st hr after birth if boggy massage dicharge from vagina= lochia should be red with small clots. flow should be moderate. if woman had episiotomy - make sure site is intact and no redness or edema look for homan signs thirst and hunger during this time bladder is hypotonic so does not feel when need to urinate note vitals, lochia, fundus q15min for 1st hr then 30 q1hr next. there will be cramps

Assessment of subinvolution

subinvolution of placental sight due to retained placental fragments. should NOT feel fundus at 6weeks- teach to feel fundus. look at color of blood.

first trimester physical symptoms/ educating client

uncertainty, ambivalence, focus on self- feeling of disbelief , mood swings. : N/V, urinary frequency and urgency, breast tenderness, increased vaginal discharge • If N/V- have small frequent meals • Void frequently • Wear good supportive bra without wire • Wear pad or panty liner and change it every 2hr 3.5lbs during the first trimester

Amniotomy interventions

• Artificial rupture of membrane or breaking of sac • Management: o Limit exams (increased risk of infection) o Assess & document the characteristics of the amniotic fluid including color, odor & consistency o Monitor FHR o Maternal temperature Q2 hrs o Provide comfort measures, frequently change pads & perineal cleansing • Typically done in conjuction with Pitocin

Peds: appendicitis- clinical manifestations nursing care and tx

• Assessment: o Abdominal pain (right lower quadrant), may be vague-early 40% children experience referred pain If pain subsides, it can cause perforation (it is important to keep track of the pain and not give pain medications until removal) o Nausea, vomiting (after pain) o Fever (low grade vs. high grade) o Small volume, frequent soft stools (not diarrhea) or constipation o Maximum tenderness occurs over McBurney's point in right lower quadrant o Tachycardia, rapid, shallow breathing o Abdominal CAT scan o Elevated WBC count and C-reactive protein o Rebound pain and referred pain can occur • Treatment: o Laparoscopic or abdominal (depends on what is found???) o Nonruptured, nongangrenous, no AB o Suppurative or nonperforate - 48 to 72 hours AB o Perforated appendix 7-14 days of IV AB o Pre and Post Op care VS, IVF, pain, surgical site, s/s peritonitis, diet, ambulation You don't want to overmedicate children - you want them up and going Ambulate, incentive spirometer o May have NGT, Penrose drain o Family teaching

Peds: ITP- Clinical manifestations, tx, and teachign

• Assessment: o Petechiae (pinpoint hemorrhaging) Can be seen in skin, mucosa, conjunctiva o Purpura - blood collects under the skin o Ecchymosis - bruises o GI bleeding o Hemarthralgia - painful bleeding into joints o Intracranial bleeding from low platelet counts (less than 50k) o Bleeding from mucous membranes • Management: o Self limiting disease that is usually treated conservatively; Acetaminophen Corticosteroids- 1-2 mg/kg/day (low platelet counts) Gamma globulin-IV 1-3 days (low platelet counts) Platelets (only if life threatening condition) Splenectomy (persists over a year) o Immunoglobulin - concentrated immunoglobin with antibodies and antigens Increases platelet production • Nursing Care: o Potential for injury - kids like to run, jump, and explore, which can cause crazy risk for bleeding HOUSE PROOF TO THE MAX o Prevent trauma o Assess for s/s bleeding o Invasive procedures No rectal meds, no subQ or IM o Quiet activities o Management at home Avoid rough play House proof for any injuries that may cause bleeding DO NOT USE: ASA, NSAIDS, or antihistamines Assess for s/s bleeding Follow ups

peds: asthma plan of care- meds and tx

• Chronic inflammatory airway disorder characterized by airway hyper-responsiveness, airway edema and mucus production • Airway obstruction resulting for asthma might be partially or completely reversed o Even though they have asthma as a child, they can outgrow it • Asthma accounts for almost 13 million lost school days/year and 14.5 million lost work days for parents • Asthma diagnosis are increasing • Causes: o Air pollution, allergens, family history and viral infection o Children more susceptible to more serious bacterial and viral respiratory infections • PATHOPHYSIOLOGY: o Control or prevention is the best management o Results from a variety of responses to triggers (finding more allergens) o Mast cells, T lymphocytes, macrophages and epithelial cells are involved with the release of inflammatory mediators o Eosinophils and neutrophils attack the airway causing injury o Leukotrienes, bradykinin, histamine and platelet activating factor are released o Prolonged airway constriction, increased mucus production o Bronchoconstriction, airway edema and mucus plugging occurs • Airway Restructuring: o Occurs with chronic inflammation o Thickening of sub-basement membrane, sub-epithelial fibrosis, airway smooth muscle hypertrophy and hyperplasia, and hypersecretions o Changes may be permanent and treatment may not work --> may not be able to reverse itself • Nursing Considerations: o Health history o Cough - barking/productive/secretions o Difficulty breathing o Wheezing - can be heard without a stethoscope sometimes o Recurrent allergic rhinitis, atopic dermatitis Atopic dermatitis - can indicate allergy (allergy is causing asthma) o Family history o Known allergies - You don't become allergic to something on first exposure (it can take several different exposures) o Seasonal response to pollen o Tobacco smoke exposure o Poverty o Assessment, Observation, Auscultation, Percussion A quiet chest may be an ominous sign • Can indicate airway obstruction • Percussion would be hyper-resonance • Diagnostic Tests o Pulse Ox o Chest X-ray: hyperinflation o Blood gases: Hypoxemia and High CO2 o Pulmonary function tests: shows degree of disease. Can be done with 5 y/o and older o Peak expiratory flow rate: decreased during exacerbation Peak inspiratory flow meter o Allergy testing • Management o Education of family and child o May have symptom free periods disbursed with exacerbations o Importance of compliance of treatment plan o Educate on use of nebulizers, metered-dose inhalers, spacers, powdered inhalers, and Diskus Oxygen should be humidified o Educate on purpose, functions and side effects of medications o Require return demonstrations - nurse can verify that patient understands • How Nurses Can Help o Promote Childs Self-Esteem - encourage activities that don't require activities, introduce to kids with asthma as well (maybe someone older) o Community Asthma Education Schools Churches Day Care Peer educators • Asthma Severity Classification in Children Not Taking Long-Term Control Medications •

Peds: AGN clinical manifestations nursing care and tx

• Clinical Manifestations - can range from mild to severe o A. Facial edema: Peri-orbital, most severe in morning, as day progresses may extend to abdomen and extremities o B. Generalized edema (anasarca) seen in severe cases only o C. Hematuria: Cola or tea-colored urine, occurs in 30-50 % of children Microscopic hematuria occurs in 90% of children Not your classic hematuria with blood in urine o D. Decreased urinary output: Oliguria, less than 1cc/kg/hr. o E. Proteinuria (+1, +2) o E. Flank or Abdominal Pain o F. Weight gain, anorexia o G. Low grade fever o H. Hypertension*** - big issue because body cannot handle this at such a young age Most important indicator!! • Management o If symptoms are mild, managed as outpatient. Parents are often taught to monitor I/O, weight, and blood pressure daily Measure weight daily, with same clothes, on the same scale Use appropriate size blood pressure cuff Save urine for I/O o If hypertension, edema, oliguria occur, child is hospitalized o Major danger during the acute phase of renal failure, hypertension, circulatory overload, and encephalopathy (caused by HTN) leads to seizures • Treatments: o Diuretics (for severe edema) - kids respond well to this o Antihypertensive (for severe HTN) o Fluid Restriction (usually restricted to the amount of urinary output plus est. insensible H2O loss) o Anticonvulsants may be needed o Diet: High in CHO, moderate protein, low in Na and K - common sense (no added salt) o Limited activity - Increases waste products (creatinine) and ↑ kidney workload o Monitor skin for breakdown o Decreased activity o Monitor and prevent infection o Age appropriate diversional activities

Peds: SCD- clinical manifestations tx and teaching

• Clinical Manifestations: usually shown around 6-9 months because of fetal hemoglobin o Pallor, weakness (result of anemia) o Jaundice (hemolysis of RBCs) Seen in sclera, buccal mucosa (bilirubin) o Growth retardation seen by 6-7 years old o Puberty delayed o Chronic leg ulcers (due to chronic stasis of blood flow) o Decreased fertility, priapism (constant painful penile erections last 2-6 hours) o Retinopathy • Sickle Cell CRISIS: o Most common type is Vaso-occlusive crisis (thrombic or painful crisis) *Sickled cell obstruct blood flow leading to painful ischemia and necrosis o Fever o Acute abdominal (from visceral hypoxia) o Arthralgia o Hand-Foot Syndrome (sickle cell dactylitis) Seen in infants and toddlers - swelling of the hands and feet and infarction in the joints o Acute Chest Syndrome: not as common, ischemia in the lungs causes pain, most common cause of death o Sequestrian Crisis: Large amount of blood is sequestered or pooled in the liver and spleen. This causes circulatory collapse. Affects children less than 5 year old. Treated with blood transfusions and fluids. Very high mortality rate (hypovolemic shock) o Aplastic Crisis: dramatic ↓ in RBC production, treated with blood transfusions. o CNS complications: Stroke (CVA) Seizures o Acute vs. Chronic manifestations • Management o No cure for SCD. Lifelong disorder! o Treatment is palliative Important to teach parents and child to avoid known "triggers" of sickle cell crisis. • BMT only cure but risky! o During Crisis care: A. Adequate oxygenation: Keep on bedrest with minimal activity. • Use of oxygen on a short term basis (prevents further sickling) o Used only when O2 sat is low (less than 95) Prevents further sickling, but does not help previous sickling B. Blood Transfusions: Keep Hgb greater than 10 Gm/dl. • Exchange transfusions can also be given (withdrawing patients blood and transfusing with normal RBCs) • Neocyte Transfusions given. • Blood must be warmed through blood warming coil o Otherwise, it would increase sickling C. Hydration: Most important aspect of treatment, IV therapy and encourage intake of fluids • Fluids increased to 1.5-2 times maintenance (100x50x20) • 25 kg = 10x100 + 10x50 +5x20 = 1600 mL D. Comfort Measures: • Relieve pain through use of narcotic analgesics • MS or Hydromorphone for severe pain (usually IV) o Dilaudid = Hydromorphone • PCA above 4 years old • Assess need for pain med • Analgesia may be given around the clock basis to lessen anxiety caused by pain • Handle gently, move slowly, support joints, good positioning and alignment • Do not attempt to do ROM until pain subsides • The use cold or heat to joints is controversial - both may be ineffective (but can be tried) o PAIN: A - assess B - believe C - complications D - drugs/distraction E - environment F - fluids - hypotonic typically • Prevent Infection o SCA are prone to serious bacterial infections because of splenic dysfunction On prophylactic antibiotics at a young age o Less than 3yo --> Susceptible to H. Influenza and pneumococcus organisms Immunizations are a must!!!! INFECTION MAKES CHILD MORE SUSCEPTIBLE TO CRISISES o Use of daily penicillin prophylaxis in young SCD (less than 5-6 years) o Older children have a high incidence of Salmonella. Fifth Disease - Parvovirus - very common viral illness o If children at home develop a fever, parents need to be taught to immediately bring them for medical attention o Hydroxurea - Chemotx agent which stimulates HbF production in the bone marrow and slows normal HbA production Stimulates fetal hemoglobin in bone marrow to slow down the hemoglobin A production • Family Education o Seek medical attention immediately if... Fever Pale, listless Abdominal pain Limp or swollen joints - dactylitis Cough, SOB, CP Increasing fatigue Unusual HA, loss of feeling, sudden weakness Sudden vision change Painful erection that won't go down

Peds: thyroid- congenital hypothyroidism

• Clinical Signs: o Poor sucking reflex, hypotonic, enlarged tongue, pale mottled skin, prolonged jaundice, prolonged open fontanel, lethargy, dull expression, bradycardia, mottled skin • Cause: Defective thyroid gland produces low amounts of T3 and T4 • If left untreated: o Causes intellectual disabilities, growth and development failure o Detected in newborn screening o Few symptoms at birth • One of the most common and preventable causes of intellectual disability • Nursing Care: o Monitor: Assess infant for signs of hypothyroidism. If newborn screening done within first 2-4 days may need to repeat if S/S present. Measure and record growth at regular intervals. Observe child for normal development patterns. Monitor thyroid levels until target met. o Medication: Levothyroxine will increase metabolic rate and assist cardiac and nervous systems. Life long treatment Administer PO daily with nipple or dropper. Crush pill and mix with formula/breast milk. Titrated dose. o Side effects: HA, insomnia, irritable, abdominal pain o Education: Administration of medication and life long treatment. Watch for signs and symptoms of hyper and hypothyroidism.

Peds: nephrotic syndrome clinical manifestations nursing care and tx

• Common Signs and Symptoms o Edema Periorbital (upon wakening) Anasarca (generalized edema) o Recent weight gain o Weakness or fatigue o Irritability or fussiness o B/P usually normotensive • Respiratory rate may be increased • Nursing management o Promoting diuresis Diuretics-Furosemide (Lasix) Monitor urine output, K+ levels, daily weights, abd girth IV albumin 25% o Preventing infection Corticosteroids (#1 treatment) Respond well to prednisone • Typically through IV because they push through large amounts over several days • 60 mg/kg/day o Encouraging adequate nutrition and growth o Educating the family (steroids) Steroids can cause immunosuppression (at risk for infection) • Strict hand washing, avoid large crowds, home school, increase appetite, slows linear growth • Cannot get any vaccines o Providing emotional support o Cytoxan for children who cannot tolerate steroids

Peds: endocrine- diabetes insipidus

• Disorder of posterior pituitary which releases Anti-Diuretic Hormone (ADH) • Due to decrease amount ADH-genetic or due to sudden onset (head trauma) • Leads to increase water loss • Results in hypernatremia, polydipsia, polyuria o Urine specific gravity <1.005 o Serum osmolality>300mOSM/kg • Cannot satisfy thirst, can lead to severe dehydration • Nursing Care: o Assess: UOP > 1 to 2 mL/kg/hr Urine SG Blood Na Level Signs of dehydration, weight loss, irritability o Medication: DDVAP (Vasopressin) - allows kidneys to reabsorb water back into blood Administer to infants intranasally Subcutaneous or PO for children Dosage is titrated for best results Side Effects: Overhydration, confusion, drowsiness, HA, sudden weight gain o Education: How to administer medications Rotate sites for subcutaneous injections Monitor I/O and keep a log • Infants may need extra nocturnal fluid intake and/or NG feedings Liberal BRP at school • MD f/u every 6 months (Med Alert Badge)

Peds: endocrine- GH deficiency- hypopituitarism

• Failure of anterior pituitary to produce sufficient Growth Hormone (GH/somatropin) o Growth hormone metabolizes protein, fat, CHO. • Insufficient GH results in: o Poor growth and short stature o Delay in puberty o Delayed epiphyseal closure o Increase insulin sensitivity • Signs and Symptoms: o Short stature with proportional height and weigh OR weight is > height o Decrease muscle mass o Large prominent forehead o Teeth and jaw underdeveloped o Prominent abdominal fat deposits o High pitched voice o Underdeveloped sexual organs o Delayed skeletal maturity o • Nursing Care: o Monitor: Growth - especially height and weight every 3-6 months X-ray for epiphyseal closure Blood work for GH o Educate: Normal growth and development Bone age and growth potential Lack of treatment leads to premature aging, short stature, and delayed sexual development o Enhance Self esteem: Sports, activities, dress, support groups. Positive focus! • Treatment: o SOMATROPIN Therapeutic use: • Stimulates bone and muscle growth • Administered SQ injection daily Adverse Effects: • Hyperglycemia, musculoskeletal pain, edema of hands/feet, rapid wt. gain, limping Nursing Interventions: • Check blood glucose and GH • Growth rate = 3-5" 1st year, then less than 1 inch a year until about 14 years for girls and 16 years for boys Client Education: • How to administer medication: o Rotate injection sites o Follow up with endocrinologist every 3-6 months

gestational diabetes

• Gestational Diabetes - glucose intolerance develops with pregnancy results in progressive resistance to insulin • Resistance to insulin = inability of body to obtain nutrients for fuel and storage, resulting in postprandial hyperglycemia • Complications - macrosomia (LGA), hyperglycemia, birth trauma, and maternal complications • Risk Factors: o Obesity o Maternal age > 25 years o Family history of diabetes mellitus o Previous delivery of an infant that was large or stillborn o African American, Hispanic, Native American, and Asian women • Effects on Mother: o Hydramnios (too much amniotic fluid) o Gestational HTN o Ketoacidosis - body is breaking down too much fat o Preterm labor because of premature membrane rupture o Stillbirth o Hypoglycemia o UTIs o Difficult labor, C/S, postpartum hemorrhage s/t overdistended uterus to accommodate macrosomic infant • Effects on Fetus: o Cord prolapse o Congenital anomaly o Macrosomia o Birth trauma o Preterm birth o Fetal asphyxia o Intrauterine growth restriction o Respiratory distress o Polycythemia, hyperbilirubinemia, hypoglycemia, childhood obesity Polycythemia - abnomorally increased RBC production in bone marrow (high Hct) Hyperbilirubinemia - jaundice • Lab Tests and Diagnostics: o Urinalysis with glycosuria (sugar in urine) o Glucose screening test 24 to 28 weeks gestation 1-hr oral glucose followed by glucose analysis 1 hr later (fasting not necessary) Blood glucose above 140 mg/dL requires an additional testing with 3-hr oral glucose tolerance test. Glucose levels are then determined at 1,2, and 3 hr following glucose ingestion o Presence of ketones in urine = assess ketoacidosis o Diagnostic procedures -biophysical profile, amniocentesis, non-stress test • Assessment: o Hypoglycemia: Shakiness Sweating Pallor Disorientation Headache Hunger Blurred vision Tingling of mouth or extremities o Hyperglycemia: Thirst Nausea Abdominal pain Frequent urination Flushed dry skin Fruity breath Shallow respirations • Management: o Diet - 3 meals and 3 snacks per day 40% calories from carbs, 35% protein, and 25% from unsaturated fats. o Exercise - improves glucose metabolism o Glucose level monitoring - instruct on self-administration of insulin and self glucose monitoring o Fetal surveillance - perform daily kick counts around 28 weeks, usually 10 within 2 hours Frequent ultrasounds, amniocentesis for lung maturity, stress test for fetal well-being o Educate on need for postpartum laboratory testing on OGTT and blood glucose levels o Medications - glyburide and metformin does not cross placenta = no fetal hypoglycemia - Pancreas is not producing enough insulin, which breaks down sugar. If there is no insulin, the sugar is not breaking down and it stays as sugar in the blood, causing blood to have less viscosity. This makes the blood more difficult to be delivered to the baby. Fetus responds by fetal pancreas producing more insulin, which can cause diabetes in child

Induction of Labor

• Lactated ringers with piggyback Pitocin • Pitocin is monitoring and increased very slowly!!! • Deliberate induction in labor, initiation of uterine contractions o Bringing labor about via chemical and physical needs • Indications: Failure to progress, IUGR, spontaneous ROM, gestation hypertension, fetal demise • Contraindicated - placenta previa, breech position, or umbilical cord prolapse • At risk for hypertonic uterine dysfunction • Place mom side lying to increase profusion to infant

Peds: Scoliosis - Assessment tx, teaching

• Lateral curvature of the spine that exceeds 10 degrees • Idiopathic or congenital, neuromuscular • Can be seen in infancy and up to adolescence • Girls outnumber boys by 7:1 • Right thoracic and left thoracolumbar curves most common • Can cause many problems in the rib cage if not detected Clinical Manifestations: • Asymmetry in hips and shoulders • Scoliosis screening in school (scolimeter) • Forward bending test • Uneven curve at waist • Hemline is uneven; nipples are uneven • Spinal x-rays Management: • Bracing (if curve is 20-40 Degrees) o Must be worn 23 hours a day But at least 18 hours o Avoid contact sports o Skin care (cotton t-shirt underneath) o Compliance - difficult for teenage girls o Combined with exercises to strengthen back o Body image o Environment o • Post Operative Care (most in PICU) --> SPINAL FUSION SURGERY o Neurovascular checks to LE q 1-4 hours (5 P's) 5 Ps --> Pain, Pallor, Pulses, Paresthesia, Paralysis • Paresthesia - numbness of tingling Donate their own blood, or have family member donate blood Prepare for ICU o **Logrolling** - spine and neck must be kept linear!! Teach patient that when they want to move, they MUST call nurse - cannot move on own o IVF, possible blood transfusions (autologous), AB therapy o Foley (bedpan also if needed) - always ask if they have passed gas! o Pain control (PCA pump) o Hemovac or drains coming out of back o Incentive spirometer, cough, deep breathe Up and out of bed within 24 hours o Nutrition - advance as tolerated o Physical therapy o School work

effect of enlarged uterus on the vena cava

• Position of pregnant woman may have affect of BP - supine position BP might appear lower due to the weight and pressure of the gravid uterus on the vena cava. Maternal hypotension and fetal hypoxia might occur, which is referred to as supine hypotensive syndrome include dizziness, lightheadedness, and pale, clammy skin. Encourage to position on left-lateral side, semi-fowlers position or if supine- with a wedge place under one hip to alleviate pressure to the vena cava.

peds: cystic fibrosis- diet tx and meds

• Therapeutic Management o Goal is to minimize pulmonary complications, maximize lung function, prevent infection, and facilitate growth. o Daily CPT with postural drainage o Physical exercise o Daily nebulizer with Recombinant human D-nase (Pulmozyme): Decrease sputum viscosity and clear secretions. o Inhaled bronchodilators, anti-inflammatory agents, aerosol antibiotics o Pancreatic enzymes and fat soluble vitamins to help with digestion and must be administered with all meals and snacks. A well-balanced, high calorie, high protein diet is necessary for adequate growth and development. Need supplements to help their body grow normally • Nursing Considerations o Health history o Meconium plug at birth (meconium is the first stool the baby passes) Kids with CF, will pass meconium plug, where it looks like dry mucus o Stools - Once they start to eat, it will be fatty, bulky, smelly o Salty taste to skin o Difficulty passing stools: indicative of obstruction/intussusception o Poor weight gain o Chronic/recurrent cough o Activity tolerance - if they are having trouble breathing, these are signs of activity intolerance • Physical Exam o Note respiratory rate, any accessory muscles in use, retractions? o WOB? - Work of breathing o Position of comfort? - Do they need to sit up to breath o Frequency/severity of cough? o Quality and quantity of sputum? - Thick and hard? Thin and loose? o Shape of chest: CF= barrel chest? o Nail beds: clubbing present? o Rectal prolapse? o Abdomen distended? - Sign of obstruction o Palpable liver? o Thin? o Edema? o Breath sounds? - audible, diminished, wheezing, rales o Heart sounds: gallop = cor pulmonale • Pathophysiology of Cystic Fibrosis and Resultant Respiratory and Gastrointestinal Clinical Manifestations