Combined NUR 317 Final Exam for Ob/Peds

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What does the placenta function?

Acts as lung, kidneys, endocrine and digestive systems, liver and immune system Prevents most harmful substances from crossing but not all Some viruses do cross like Hep. B and HIV

How to do a fetal assessment?

Fetal Heart Tones EFM - electronic fetal monitor Doppler Fundal Height Fetal Kick Count 10 movements in 2 hours If it does not kick or move at all in 30 minutes, go to the hospital do not wait 2 hours Leopolds Maneuvers (picture below) Lie the patient down Feel around the outside of the abdomen When you put the heart rate monitor on the stomach and hear a heart beat on top of the abdomen, the baby is breech and is getting a c-section

Fetal risk from Maternal Hemorrhage

Fetal Risks from Maternal Hemorrhage Blood loss Anemia Hypoxemia (Poor tissue perfusion) that is due from hypoxia Hypoxia (low arterial O2 Sat) Anoxia (NO Oxygen) Preterm birth

What are the other methods of assessments and interventions?

Fetal scalp and Vibroacoustic stimulation Scratch the baby head to see if you have the response Or place a little vibrator to see if the baby is awake Umbilical cord blood sampling Fetal scalp blood sampling Amnioinfusion Tocolytic therapy Fetal Scalp and Vibroacoustic Stimulation Used to elicit accelerations in fetal heart rate pattern MAY indicate absence of metabolic acidemia Neither should be instituted if FHR decelerations or bradycardia is present

What are the changes to the abdominal wall post partum?

Flabby when standing Pouches over like a 3 month pregnancy Picture - directly following birth to 6 months after birth with routine exercise

Bone Healing and Remodeling

Fractures heal in less time than adults. The approximate healing times for a femoral shaft are: Neonatal period: 2-3 weeks Early childhood: 4 weeks Later childhood: 6-8 weeks Adolescence: 8-12 weeks

Genitalia and Anus

Male and female genitals should be characteristic of gestational age White vaginal discharge with or without blood is a normal finding in newborns for the first few days Check the location and patency of the anus

KD: Resolution and prognosis

Managing Complications Managing cardiac complications Anticoagulant drugs Furosemide Coronary angioplasty ± stent Return to "Normal" If cardiac complications, continue to monitor and manage as needed Usually complete resolution Rarely recurs

How to determine EDB (estimated date of birth) or EDD (estimated date of delivery)?

Nagel's rule: 1st day of last period minus 3 months add seven days Ex: 12/10 - 3 months = 9/10 + seven days = 9/17 EDD - estimated date of delivery EDB - estimated date of birth EDC - estimated date of confinement - old term When women were pregnant, they were confined to the house Very subjective Do an ultrasound at 18 to 20 weeks to verified the due date and measure the baby Nagel's Rule: The due date or expected date of confinement (EDC) can be calculated using Naegele's Rule. Begin on the first day of the last menstrual period (LMP), subtract 3 months, add 7 days, and then add 1 year. Example LMP: February 14, 2015 Subtract 3 months (Great Scott x 3): November 14, 2014 Add 7 days (N-A-E-G-E-L-E): November 21, 2014 Add 1 bear (year): November 21, 2015

Physical growth

Weight almost doubles during adolescence Height increases by 15%-20% Major organs double in size except for lymphoid tissue which decreases in mass Muscle mass and muscle strength increase for both sexes

What is post partum depression?

"Baby Blues" Cry easily Restlessness Fatigue Insomnia Headache Anxiety Sadness Anger 5-10 days after delivery Right after delivery until 2 to 3 weeks after delivery PPD Similar to baby blues, but more severe Last for several weeks after delivery Despondency - not paying attention completely zone out to their environment Excessive irritability - cant sit down Rejection of infant Thoughts of harming baby Have you ever thoughts of harming yourself or your baby? Usually after 2 to 3 weeks of delivery They can't stop crying

Development of School Aged Child or Middle Childhood

"School age" generally defined as ages 6 to 12 years Physiologically begins with shedding of first deciduous teeth; ends at puberty with acquisition of final permanent teeth Gradual growth and development Progress with physical and emotional maturity Child is directed away from the family group and is centered around the wider world of peer relationships Social cooperation and early moral development take on more importance This is a critical period in the development of self-concept Start to building an idea of themselves and their self-worth Not the age to start telling girls that they are getting fat

What is the intra-operatvie nursing care of c section?

"Time Out" & Patient ID Maintain a sterile field Who's who in operative delivery room As a circulating nurse assist scrub nurse, surgeon/obstetrician, anesthesia, NICU nurses, Neonatology, Pediatrician Assist with counts, patient care, patient positioning, patient safety Assist father or significant other Assist with baby care Patient positioning - Very important Use of BOvie Suction Available Keep field sterile and delivery supplies maintain sterility Know what the circulator and what the scrub nurse does to insure safety of the patient and the baby

What are the nursing interventions of fetal dysrhythmias? What should I do?

#1 Discontinue IV Pitocin - Stop Most common cause of late decelerations is uterine tachysystole (hyperstimulation) It stimulate contraction of the uterus #2 Change maternal position (lateral) Left lateral side - ideal You can change to her right side if already on the left #3 Increase IV fluid rate Increase blood volume BP=CO x SVR Increase the CO which is caused by increasing the IVF #4 Administer O2 @ 8-10L/min via mask (face mask) Still you are still going to give her O2 because of the baby Mom's bp and O2 sat could be great but it's the baby we're worry about #5 Assess for bleeding/vaginal exam Can be done in any order #6 Notify Physician Do all of these interventions before call the doctor whether you resolve them or not Have a standing order to do all of these things #7 Prepare for emergency C-Section

What is replication of cells?

(Cleavage - Rapid mitotic) This continues or is repeated until 64 cells are produced This cell mass or zygote travels the length of tube and enters uterus at the 16 cell stage At 16 cells stage is referred to as a morula 16 cells solid ball surrounded by a zona pellucida The fertilized ovum continues to divide further into a blastocyst before embedding takes place

What is the pre-embryonic period?

(First 2 weeks) 3 main events Replication of cells When the cells cleavage Implantation Development of fetal membranes

Preeclampsia

- A progressive form of PIH - Pregnancy-specific syndrome Hypertension develops after 20 weeks of gestation in previously normotensive woman Disease of reduced organ perfusion with presence of hypertension and proteinuria Mild to severe Etiology Signs and symptoms develop only during pregnancy and disappear after birth Associated high risk factors Primigravidity - first time mom New FOB (father of baby) - first time father of the baby can affect it Multifetal pregnancy Obesity Before age 20 and after age 40 Age distribution remains U shaped Pathophysiology Differs from chronic hypertension Main pathogenic factor is not an increase in BP, but poor perfusion resulting from vasospasm Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP Not allowing for the easy flowing of blood and causing a decrease of flow to the uterus Function in placenta, kidneys, liver, and brain depressed as much as 40% to 60% Assess BUN and Creatinine Assess Liver Enzymes ALT (Alanine Transaminase) Normal 7-53 Units per liter AST (Aspartate Transaminase) Normal 5 - 35 Units per liter GGT (Gamma Glutanyl Transaminase) Normal 0 - 40 Units per liter

NCLEX Questions

1. A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib padB. Turning on the overhead radiant warmerC. Closing the doors to the roomD. Drying the infant in a warm blanket Answer D. Drying the infant in a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation. A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "You infant needs vitamin K to develop immunity."B. "The vitamin K will protect your infant from being jaundiced."C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." Answer Answer: C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion. While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency systemB. Do nothing because acrocyanosis is normal in the neonateC. Immediately take the newborn's temperature according to hospital policyD. Notify the physician of the need for a cardiac consult Answer Answer: B. Do nothing because acrocyanosis is normal in the neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth. A mother with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A. Negative Coombs testB. Bleeding from the nose and earC. Jaundice after the first 24 hours of lifeD. Jaundice within the first 24 hours of life Answer Answer: D. Jaundice within the first 24 hours of life. The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result. A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. LanugoB. MiliaC. Nevus flammeusD. Vernix Answer Answer: D. Vernix. A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? A. Wrap the neonate warmly and place her in an open cribB. Administer an oral glucose feeding of 10% dextrose in waterC. Increase the temperature setting on the radiant warmerD. Obtain an order for IV fluid administration Answer Answer: D. Obtain an order for IV fluid administration. Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn't be fed but should receive IV fluids until the respiratory rate returns to normal ( 30 to 60 bpm). To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer. Within 3 minutes after birth the normal heart rate of the infant may range between: A. 100 and 180B. 130 and 170C. 120 and 160D. 100 and 130 Answer Answer: C. 120 and 160. The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected. The nurse is aware that a healthy newborn's respirations are: A. Regular, abdominal, 40-50 per minute, deepB. Irregular, abdominal, 30-60 per minute, shallowC. Irregular, initiated by chest wall, 30-60 per minute, deepD. Regular, initiated by the chest wall, 40-60 per minute, shallow answer Answer: B. Irregular, abdominal, 30-60 per minute, shallow. Normally the newborn's breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute. The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. AnemiaB. HypoglycemiaC. Nitrogen lossD. Thrombosis answer Answer: B. Hypoglycemia. Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia. A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeksB. It doesn't cross the cranial suture lineC. It's a collection of blood between the skull and the periosteumD. It involves swelling of tissue over the presenting part of the head Answer Answer: D. It involves swelling of tissue over the presenting part of the presenting head. Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days. A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeksB. Stop the breast feedings and switch to bottle-feeding permanentlyC. Feed the newborn infant less frequentlyD. Continue to breast-feed every 2-4 hours Answer Answer: D. Continue to breastfeed every 2-4 hours. Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary. A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outletB. Turn on the apnea and cardiorespiratory monitorsC. Set up the intravenous line with 5% dextrose in waterD. Set the radiant warmer control temperature at 36.5* C (97.6*F) Answer Answer: A. Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.

Late decelerations @38 weeks

1. reposition client on her side, elevate legs 2. increase maintenance IV 3. Palpate uterus to assess for tachysystole 4. administer O2 8L/min

Ovulatory factors: Problems R/T ovulation and hormonal activity

15-20% of infertility problems Anovulation: the failure to produce, mature, or release the ovum Cervical factors: Problems that affect the survival and motility of the sperm. Cervical mucus hostile to sperm Can be caused by vaginal infections or hormonal deficiencies

What occurred to the gastrointestinal system during antepartum?

1st Trimester Gums become extra sensitive to irritants Motility and tone of gastrointestinal tract decrease- causes constipation. - can use a stool softener Pepsin and hydrochloric acid levels decrease Time for absorption of nutrients increases Iron absorption from small intestine increases Water absorption from large intestine increases- causes constipation Nausea and vomiting are experienced - Morning Sickness Taste and smell are altered Nutritional requirements change You are not eating for two. 2nd Trimester Gum sensitivity to irritants continue Stomach capacity perceived to be decreased Cardiac valve works less efficiently with resulting gastric reflux Secretion of hydrochloric acid and pepsin in stomach decreases Absorption of nutrients and water increases Predisposition to gallstones Stomach does not really expand so that is why pregnant women are always eating 3rd Trimester Gums continue to be sensitive to irritants Gastric reflux continues or increases Stomach capacity decreases because of enlarging uterus Predisposition to gallstones continues Decreased motility and tone continue and foster increased absorption of nutrients and water Intestines have a predisposition to constipation

What occurred to the integumentary system during antepartum?

1st Trimester Hair Seems to be thicker Skin Pigmentation changes start. Linea nigra start to appear. Increased blood flow gives a feeling of warmth Nails Soften Grow Quickly 2nd Trimester Hair Same as 1st trimester Skin Pigment deepens- skin darkens around the: Areola, nipples, and vulva Melasma( Mask of Pregnancy) is possible- skin darkens on the face. Linea nigra is apparent Nails Continues to be soft Growth increases 3rd Trimester Hair Same Skin Striae increases and becomes more apparent Sweat gland activity increases Spider veins may develop Nails Grow fast Still soft Break easily

What occurred to the kidney/renal system during antepartum?

1st Trimester Kidneys increase in size and weight Glomerular Filtration Rate and Renal Plasma Flow Increase. Ureters and, renal pelves' of kidney dilate. Woman prone to UTI, because of the dilation of these structures - increase the risk of having bacteria to coming in and causing an infection BUN and creatinine levels remain unchanged. Increase in urinary frequency due to enlargement of uterus pressing against bladder. May have excretion of glucose and H20 soluble vitamins. 2nd Trimester Urinary frequency decrease Glomerular filtration rate (GFR) rises about 50% Possible increase in excretion of glucose, electrolytes, and H20 soluble vitamins Kidneys increase in size Renal plasma flow remains elevated 3rd Trimester Urinary frequency returns due to presenting part of fetus putting pressure on urinary bladder. Increase in GFR is still present. Increase in renal plasma flow.

What occurred to the musculoskeletal system during antepartum?

1st Trimester Minimal changes 2nd Trimester Sacroiliac, sacrococcygeal and pubic joints relax Center of gravity shifts resulting in gait changes Pressure on round ligaments causes lower abdominal and inguinal pain Ask questions to find out if it is abdominal pain or ligament pain 3rd Trimester Joints of pelvic girdle continue to relax Walking becomes more difficult Woman starts to "waddle" Diastasis of rectus muscle may develop( separation of the rectus abdominal muscle.)

What occurred to the respiratory system during antepartum?

1st Trimester Tidal volume increases Total O2 carrying capacity of red blood cells increases Woman breathes more deeply. Respiratory rate shows little or no change. Respiratory Passages: Hormonally induced vasocongestion. congestion and edema of mucus membranes Causes nasal stiffness (stuffiness), nose bleeds, clear runny discharge and general feelings of congestion. They don't have a cold so no need for cold medication It is because their blood vessels are large and more blood is coming into the blood so they feel congested all of the time Recommended using humifier - usually treat the symptoms 2nd Trimester Expanding uterus displaces diaphragm and causes rib cage to expand and flare Shortness of breath starts to develop with walking and activity. 3rd Trimester Diaphragm rises higher in the chest cavity. A-P and transverse chest diameters increase. O2 consumption increases (sec to increased demand, BMR) Shortness of breath common with minimal activity

What occurred to the cardiovascular system during antepartum?

1st trimester Blood Pressure remains the same Blood Volume begins in increase Cardiac output increases (reflected in stroke volumne and heart rate) Resting pulse elevates( 8 beats over non-pregnant rate) 2nd Trimester Cardiac output reaches peak of 30-50% above non pregnant output. Heart rate is 10 BPM above non pregnant state. Blood Pressure declines slightly Associated with decrease in peripheral vascular resistance. Blood volume continues to expand very rapidly First there is an increase in plasma followed by an increase in red blood cells This may be reflected by a slight decrease in patients hemoglobin We may see a HgB at 10 and it is no concern because it depends on how much of a drop between before pregnancy and afterward and delivery Called the " physiological anemia of pregnancy" (NORMAL) This will be noted during pre-natal visits. Care management allows for a slight drop, but 11-12/Hmg is minimal. Anemia before pregnancy will lead to greater anemia during pregnancy. Rationale for increased volume Hypertrophy of uterus with increase vascular system to supply placenta and fetus with blood. Increase in blood volume also allows for loss of blood during delivery. 3rd Trimester Cardiac output remains elevated up to 40% over pre pregnancy levels. Blood volume remains elevated 30-50% over non pregnant levels. The body may hold on to 500 mL of blood due to expected loss of 500 mL during delivery. Heart is pushed upward and to the left. (Anatomic accommodation) Heart rate is 15 BPM above non pregnant levels. Blood pressure remains the same.

What are the paternal tasks during pregnancy?

1st trimester To accept the biologic fact of pregnancy 2nd trimester To accept the mother's changing body and the reality of the fetus 3rd trimester To negotiate with his partner the role he is to play in labor and to prepare for the reality of parenthood Psychological changes and concerns of women during pregnancy (see attached handout)

What are the maternal task during pregnancy?

1st trimester To accept the biological fact of pregnancy Needs to be able to state "I am pregnant" Should accept by 12 weeks ( ambivalence is common) Will feel unbalanced at first 2nd trimester To accept the growing fetus as distinct from themselves Women can state "I am going to have a baby" 3rd trimester To prepare realistically for the birth of the child and to prepare to relinquish it physically from herself Prepare for active parenting Get mom and dad in parenting classes

What is the pregnancy duration?

280 days 42 weeks 9 ½ calendar months 10 lunar months Trimesters First - weeks 1-12 (conception) Second - weeks 13-24 Third - weeks 25-40

What is the embryonic period?

3-8 Weeks Product of conception referred to as "embryo" Very fragile time for embryo due to organ system development or organogenesis Embryo very susceptible to environmental influences Drugs, alcohol, chemicals, x-rays, toxins Can cause disruption to cell development and cell differentiation thereby causing congenital defects

Lithium Batteries

35,000 Lithium batteries are swallowed in USA per year Sources - "button" batteries Used to power hearing aids, watches, toys, games, flashing jewelry, singing greeting cards, etc. May pass through GI Many pass and are eliminated in stool BUT, if lodged in GI track Permanent damage / multiple surgeries An electrical current can form around the outside of the battery, generating hydroxide (an alkaline chemical) and causing a tissue burn Could cause a loop of intestine in between two magnets and the magnets are going to cause chemical burn and will eat thorugh the lining of area

What is the care management of post partum patient?

4th stage of labor - First 2 hours post partum Assessments and Implementations Vital Signs- every 15 mins for 1 hour . Mild temp elevation expected due to dehydration of labor . Any temp>100.4 after the first 24hrs is considered a true elevation. Fundus- firm at umbilicus, should be midline. Bladder fullness will alter this location. Fundus should not be BOGGY. Boggy like a bag of sand you should not be able to squish it. It means that the uterus is not contracting and blood vessels are not constricted Lochia- rubra Turn on left side to check blood loss under bottom of perineal area. Moderate amt is Normal. Check episiotomy for intactness. General wellbeing- tired, hungry, happy, talkative, excited Vaginal bleeding can continue for 4 to 6 weeks. The first 24 hours is heavy and become lighter each days Effects of anesthesia Epidural effects resolved Continue drip and keep her numb from ribs down to the toes. She can move but can't walk or feel sensation. It stays in place until she delivers After we sit her up and take the tape off and pull catheter out. Then the epidural start to wear off and takes about an hour or two. Big safety issues: tell her she is not to get out of bed by herself and ask for assistance. Use the call bell. If she starts to walk by herself, she is going to drop to the floor and big issues with falls!!! Fall risk!! Can feel and move legs completely before OOB

How is communication involved in labor and delivery? And what is the essential principles of Effective communication?

80% of prenatal death and injuries is caused by lack of communication Next greatest cause is poor patient assessment Open Clear Honest Concise Respectful DIRECT

Edema

85% of all women develop edema Dependent edema Associated with elevated B/P Weight gain > than 2 lbs./week The general rule: 3-4 lbs during first trimester. 1 lb a week for the 2nd and 3rd trimesters . Edema above waist-fingers, face, extremities are more significant Not related to body position

What is the fetal period?

9 weeks - Birth Referred to as a fetus Time of rapid growth and continued maturation of organs and systems

Definition

A diastolic Blood Pressure of at least 90 mm /Hg or a rise of 15 mm /Hg. A systolic Blood Pressure of at least 140 mm/Hg or a rise of 30 mm/Hg >140/90 About 35 weeks, the hospital gets a copy of the prenatal records of the patients that includes blood pressure Classifications Chronic Hypertension: Hypertension that predates the pregnancy Past 42 days postpartum Diagnosed before week 20 of gestation Chronic hypertension with superimposed preeclampsia Women with chronic hypertension may acquire preeclampsia or eclampsia Gestational hypertension does not start until after 20 weeks Pregnancy Induced HTN Two basic class during pregnancy; Chronic PIH-Refers to a variety of conditions- yrs ago called "Toxemia"of Pregnancy- no toxins have been found Chronic and PIH can occur simultaneously or independently

Non-Hodgkin Lymphoma

A diverse group of cancers accounting for 5-10% of malignancies in children younger than age 15 years About 500 new cases are diagnosed each year in the US The incidence of NHL increases with age and the disease is uncommon before 5 years of age Male predominance 3:1 Occurs more frequently in children than Hodgkin Lymphoma (HL) Childhood NHL is rapidly proliferating, high-grade, diffuse malignancies The tumors exhibit aggressive behavior but usually respond very well to treatment Different from HL by: The disease is usually diffuse rather than nodular The cell type is either undifferentiated or poorly differentiated Dissemination occurs early, more often and rapidly Mediastinal involvement and invasion of meninges are common Signs and Symptoms Cough, dyspnea, orthopnea, swelling of the face, lymphadenopathy, mediastinal mass, pleural effusion Abdominal pain, abdominal distention, vomiting, constipation, abdominal mass, ascites, hepatosplenomegaly Adenopathy, fevers, neurologic deficit, skin lesions Presentation of symptoms are determined by location of lesions and the degree of dissemination Treatment Aggressive use of irradiation and chemotherapy Similar to Leukemia therapy: induction, consolidation, and maintenance phases Chemotherapy is the main component of treatment for NHL children

What is the definition of dystocia?

A long, difficult, or abnormal labor Eutocia - normal childbirth Incidence 8% to 11% of all deliveries Dysfuctional labor responsible for about 60% of all primary C-sections in the U.S.

Weight loss

A weight loss of between 5% and 15% of birth weight may occur in the newborn during the first 4 to 5 days of life. Weight loss is the result of continued voidings and stool passage, limited intake, insensible water loss and a high metabolic rate Weigh loss should stabilize by about the fifth day and a weight gain of approximately 1 ounce per day should occur with adequate fluid and caloric intake By 6 months of age, baby should have doubled their birthweight.

Weight loss in newborn

Viral (Aseptic) Meningitis

AKA: "aseptic meningitis" Caused by enteroviruses Various viral agents - Associated with measles, mumps, herpes, and leukemia Transmitted by enteric-oral pathways Less severe than bacterial Symptoms subside spontaneously without residual effects Onset abrupt or gradual Incidence peaks in late summer and early fall More common in children Rarely occurs in persons over 40 years old Age Incidence

Kawasaki Disease

AKA: Mucocutaneous lymph node syndrome Acute systemic vasculitis of unknown cause 3 phases 75-80% of cases: children younger than 5 years Peak age 18m - toddler range Uncommon in adolescents Winter/spring Self-limiting Multiple body systems -- life-threatening cardiovascular consequences, CA thrombosis, coronary stenosis Increased risk of formation of coronary artery aneurysm

Defects with increased Pulmonary Blood Flow

Abnormal connection between two sides of heart Increased blood volume on right side of heart Increased pulmonary blood flow Decreased systemic blood flow Path of least resistance Examples Septal defect Atrial Abnormal opening of the right and left atrium Ventricular Abnormal opening of the right and left ventricles Patent ductus arteriosus

What is acceleration?

Abrupt increase of FHR above the baseline Peak is > 15 bpm above baseline Duration is at least 15 seconds, and less than 2 minutes Prolonged Acceleration is > 2 minutes and < 10 minutes Acceleration is less than 2 minutes Want to see two accelerations in 20 minutes period which is a reactive tracing Prolonged acceleration is more than 2 minutes Tachycardia is longer than 10 minutes

Diagnostic Studies

Accurate, comprehensive description of seizures with patient's health history EEG May help determine the type of seizure and help pinpoint the seizure focus Many patients did not have abnormal findings. See Table 59-7 for more information. Ideally, an EEG should be done within 24 hours of a suspected seizure. Abnormal findings help determine the type of seizure and help pinpoint the seizure focus. Only a small percentage of patients with seizure disorders have abnormal findings on the EEG the first time the test is done. Either repeated EEGs or continuous EEG monitoring may be needed to detect abnormalities. An EEG is not a definitive test because some patients who do not have seizure disorders have abnormal patterns on their EEGs, whereas many patients with seizure disorders have normal EEGs between seizures. If abnormal discharges do not occur during the 30 to 40 minutes of sampling during EEG, the test may not indicate an abnormality. Magnetoencephalography in conjunction with EEG Greater sensitivity for detecting small magnetic fields generated by neuronal activity CBC, serum chemistries, liver and kidney function, UA to rule out metabolic disorders CT or MRI in new-onset seizure to rule out structural lesion Cerebral angiography, SPECT, MRS, MRA, and PET in selected situations Collaborative Care Most seizures do not require emergency medical care because they are self-limiting and rarely cause bodily injury. Immediate medical care if Status epilepticus occurs Significant bodily harm occurs The event is a first-time seizure Table 59-8 summarizes emergency care of the patient with a generalized tonic-clonic seizure, the seizure most likely to warrant professional emergency medical care. Diagnostic studies and collaborative care of seizure disorders are outlined in Table 59-7.

Non-opioid Drugs

Acetaminophen Tylenol Non-opioid analgesic Fever reduction Dosage varies by age Adult: 325-650 Q4-6H; max 4G/d Child: 10-15 mg/kg Q4-6H; max 5 doses/d Ibuprofen Advil; Motrin NSAID Relieve pain Decrease inflammation Reduce fever 200 - 800 mg TID/QID Max dose 3200 mg/d Acetylsalicylic acid (Aspirin) "ASA" 4 actions Analgesic Anti-platelet Antiinflammatory Antipyretic Can have rebound fever as a result of an overdose Two dosing strengths 81 mg; 325 mg Now primarily recommended for its antiplatelet effects in adults with CAD

Acetaminophen Poisoning

Acetaminophen is one of several ingredients in many OTC meds Second most common cause of liver failure requiring transplantation 4 phases Phase 3 is renal and hepatic failure If patient survives phase 3, organ failure essentially fully resolves N-acetylcysteine (NAC) for Acetaminophen Poisoning PO Loading dose: 140 mg/kg, Then, followed by 17 doses -- each at 70 mg/kg -- every 4 hours. The total duration of the treatment course is 72 hours Early enough for gastric decontamination IV Loading dose, followed by two more doses continuous over the next 16 hours Loading dose: 150 mg/kg IV in 200 mL of D5W; infuse over 1 h It smells and taste like rotten eggs - you can try to putting it in cherry cola or a cola with chocolate syrup and put a lid on it and try to get the kid to drink it Worse case scenario - use a NGT If done in IV, it is caustic and worsen in kids

Salicylate Poisoning

Acid-base, fluid, and electrolyte abnormalities Early signs: Tinnitus Ringing in the ear Tachycardia Tachypnea w/hyperventilation Greater risk for seizures Fever Affects most systems CNS Tinnitus! Fever Also disorientation, seizures, cerebral edema, hyperthermia, coma, cardiorespiratory depression, and, eventually, death The fever is reflective of the toxicity CV- tachycardia, dysrhythmias Respiratory - tachypnea & hyperpnea; risk for pulmonary edema GI - N/V; increased risk of bleeding GU - renal failure MS - risk for rhabdomyolysis Electrolyte Findings Dehydration Hypocalcemia Acidemia Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Hypokalemia Altered glucose metabolism - risk for hypoglycemia Assessment findings Pulmonary Hyperventilation Hyperpnea Severe dyspnea (noncardiogenic) pulmonary edema SOB Respiratory arrest Apnea Auditory Tinnitus Deafness Decreased hearing Managing Salicylate Poisoning In ED Gastric decontamination With polyethylene glycol Glucose boluses Begin serial UA Start interventions to alkalize urine Ongoing Serial UA Keep pH 7.5 - 8 Monitor: K BUN & creatinine Monitor serum ASA level Correct metabolic abnormalities Hemodialysis if: Serum salicylate level >120 mg/dL acutely or > than 100 mg/dL 6 h post-ingestion Refractory acidosis Coma or seizures Noncardiogenic pulmonary edema Volume overload Renal failure

Retinopathy of Prematurity

Acquired disease resulting in an eye injury with possible blindness The tiny blood vessels in the retina are so immature they can get damaged with high levels of oxygen or exposure to light. In NICU they may be wearing foam sunglasses Etiology: changes in retinal vasculature due to abnormal blood vessel growth in response to high levels of oxygen, retinal immaturity, and exposure of light Vasoconstriction -> revascularization -> capillary hemorrhages -> possible retinal detachment, scar tissue formation Diagnosis: Eye exam only Tx: series of eye exams / possible laser surgery to prevent retinal detachment Wean from Oxygen Vitamin E - modifies tissue response to oxygen

Appendectomy

Acute Appendicitis Most common indication for emergency abdominal surgery in children Peak age is between 15 and 30 years Incidence of perforation is high in childhood (40%), especially in children younger than 2years of age Pain is usually poorly localized and symptoms nonspecific Signs and Symptoms Fever Periumbilical abdominal pain which then localizes to the RLQ. Anorexia, vomiting, constipation and diarrhea also occur. Helpful Hint: Vomiting before pain= gastroenteritis Vomiting after pain= appendicitis Diagnosing Appendicitis Clinical Presentation Pain Clinical signs Psoas Obturator Dunphy's Rebound tenderness Labs CBC (WBC) >10,000 <15000 mm3 and C-reactive protein (CRP) >8 mg/L= 92% predictive value for acute appendicitis Appendicitis: Signs Soas Sign Pain secondary to psoas muscle stretch or contraction; the muscle borders the peritoneal cavity and friction with inflamed tissues causes pain; positive when pain occurs while patient is lying on left side and right thigh is hyperextended by clinician or when hip is flexed against resistance. Obturator sign Pain secondary to obturator muscle irritation; positive if pain occurs when patient lies supine with hip flexed at 90 degrees; clinician stabilizes ankle with one hand and then with the other hand on the knee moves hip through internal and external rotation. Dunphy's Sign Sharp pain in RLQ with cough; pain caused by peritoneal irritation. Rebound Tenderness Pain is greater when deep palpation is quickly released than during palpation; indicates peritoneal irritation. Managing Appendicitis Surgery! Appendectomy Post-op antibiotics Be alert for perforated appendix

Bacterial Meningitis

Acute inflammation of meninges and the CNS Causative agents: Streptococcus pneumoniae (pneumococcal) and Neisseria meningitidis 95% of children older than 2 years old Group B streptococci, Escherichia coli, and Listeria monocytogenes seen most commonly in infants < 2 months old (neonatal meningitis) Meningococcal meningitis readily transmittable by droplet. School age-college students: Re-vaccinate! Meningitis Seasonal variations: H. influenza-autumn and early winter Pneumococcal and meningococcal common in late winter and early spring- can occur at any time The infection usually starts as URI that moves to the meningeal space then rapidly through the cerebral spinal fluid Spreads into the meningeal folds and into the brain tissue. Overview of Bacterial Meningitis Incidence Dramatic decrease since 1990 with the advent of Haemophilus Influenza vaccine HIB) Pneumococcal conjugate vaccines in 2000 Most frequently affects children between ages 1-5 years but does occur in adults More frequent in males in neonate population Pathophysiology Through a bacterial infection - inflammation, exudation, white blood cell accumulation, and tissue damage occurs the brain becomes hyperemic and edematous Accumulation of purulent exudate extends to the ventricles Thick pus, fibrin, and /or adhesions obstructs the flow of CSF through the aqueduct of Sylvius Progression causes Increase ICP Pathophysiology (cont.) Aqueduct of sylvius connects the third and fourth ventricles. 4 ventricles in all-2 lateral, third, and fourth (3&4 are midline) Pressure from a build up of fluid leads to ischemia SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone secretion causing hyponatremia

What is decidua?

Additionally the endometrium changes over to decidua once fertilization occurs and implantation is taking place Decidua Basalis - part directly under the embedded ovum that forms that maternal part of the placenta Decidua Capsularis - portion that over lies the ovum and separates it from the rest of the uterine cavity Decidua Vera - remaining portion that is not in immediate contact with the fertilized ovum Decidua is the altered endometrium of pregnancy Decidua formation is limited to body of uterus and doesn't extend below internal cervical os Implantation starts about one week after conception and the whole process takes about 1 week to 10 days to complete

Position of mother

Affects anatomic and physiologic adaptations to labor Sitting up in bed- works well for early labor and again for pushing in the second stage of labor Side lying- works well for the active and transition phase of the first stage of labor (Mother very uncomfortable) Walking-best works for the early phase of the first stage of labor Ideal position when a patient is in labor when she has an epidural, is left tilt. Not completely left lateral but left tilt

JIA ( Juvenile idiopathic arthritis)

Affects twice as many girls as boys Often undiagnosed Cause is unknown however two theories exist: Immunogenic susceptibility Environmental or external trigger such as a virus Classification JIA is not a single disease but a heterogeneous group of diseases Several disease categories: Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy) Oligoarthritic (involves ≤4 joints) Polyarthritic (involves ≥5 joints) Psoriatic Enthesitis and Undifferentiated) Diagnostic Evaluation of Juvenile Idiopathic Arthritis No definitive diagnostic tests Elevated sedimentation rate in some cases Antinuclear antibodies common, but not specific for juvenile idiopathic arthritis Leukocytosis during exacerbations Diagnosis based on criteria of American College of Rheumatology Therapeutic Management of Juvenile Idiopathic Arthritis No specific cure Goals of therapy: Preserve function Prevent deformities Relieve symptoms Primarily outpatient care Juvenile Idiopathic Arthritis: Pharmacology Nonsteroidal anti-inflammatory drugs Slow-acting anti-rheumatic drugs Corticosteroids Cytotoxic agents (methotrexate) Biologic agents Care Management of Juvenile Idiopathic Arthritis Physical therapy, occupational therapy Pain relief Promote general health Facilitate compliance Encourage the use of heat and exercise Support child and family

Early Adolescence

Ages 10 to 13 years Period of rapid growth and development of secondary sex characteristics Body image, self concept and self esteem fluctuate dramatically Concerns to teens as they compare themselves to peers: boys with short stature or girls with delayed breast development Curiosity about sexuality but feel more comfortable with members of their own sex "Best Friends" Peer relationships become increasingly important. Friendships are an important link in the progress toward forming an intimate relationship. Teens think concretely and cannot easily conceptualize about the future. Usually have vague and unrealistic professional goals (rock star, NFL, movie star)

Middle Adolescence

Ages 14 to 16 years Less pubertal development and are now more comfortable with their new bodies Intense emotions and mood swings are typical Need for independence and autonomy can be a period of struggle for teens and parents Move from concrete thinking to formal operations and abstract thinking Develop the belief that the world can be changed by merely thinking about it: "I don't need contraception because I won't get pregnant, it won't happen to me" World is biased against them: 16 year old who believes he is the best driver in the world and the insurance companies are conspiring against them by charging high rates With the onset of abstract thinking, teenagers begin to see themselves as others see them and may become extremely self-centered Because they are establishing their own identities, relationships with peers and others are narcissistic Experimenting with different self-images is common Sexuality becomes more important: dating and experimenting with sex Relationships tend to be more one-sided and narcissistic Peers determine the standards for identification, behavior, activities and clothing and provide emotional support, intimacy, empathy and the sharing of guilt and anxiety

Late Adolescence

Ages 17 years and later Teen becomes less self-centered and more caring of others Social relationships shift from peer group to individual Dating becomes more intimate Abstract thinking allows older adolescents to think more realistically about their plans for the future This is a period of idealism: rigid concepts of what is right or wrong

Pregnancy induced hypertension

Aka Gestational Hypertension Onset of hypertension after 20 weeks gestation or in the first 24 hours after birth Cure for preeclampsia is the delivery of the baby and the patient is still at risk 24 hours after the delivery of the baby. Risk Factors for PIH History of hypertension Diabetes Multiple pregnancy Hydraminos Nutrition Family history Poverty Under age 16 Over age 35 Large disparity between rates of maternal death by race African-American women more likely to die of preeclampsia than women of all other races Nutrition-protein deficiency Poverty-poor medical care Age- especially primiparity

What are the landmarks of embryonic period?

All organs formed - "Organogenesis" Heartbeat present by the end of 4th week (28 days) Cardiovascular system - 1st to function in embryo May not be able to hear the heart beat but see it on the monitor This is when mom needs to stop drinking and smoking and other drugs Mom needs to be in good control of diabetes or hypertension

Focal Seizures

Also called partial or partial focal seizures Caused by focal irritations Begin in specific region of cortex Produce signs and symptoms related to the function of the area of the brain involved Focal seizures have unilateral manifestations that arise from localized brain involvement. Focal seizures begin in one hemisphere of the brain in a specific region of the cortex as indicated by the EEG. For example, if the discharging focus is located in the medial aspect of the postcentral gyrus, the patient may experience paresthesias and tingling or numbness in the leg on the side opposite the focus. If the discharging focus is located in the part of the brain that governs a particular function, sensory, motor, cognitive, or emotional manifestations may occur. Divided according to their clinical expression into Simple focal seizures Person remains conscious Complex focal seizures Person has a change or loss of consciousness. Produces a dreamlike experience

Psychogenic Seizures

Also called pseudoseizures Psychiatric in origin Resemble epileptic seizures Accurate diagnosis usually requires use of video-EEG monitoring to capture a typical episode. Patients with psychogenic seizures frequently have a history of emotional abuse, physical neglect, or a specific traumatic episode.

What is post partum period?

Also known as puperial time 4th Trimester of pregnancy- 6 weeks post partum 6 weeks after delivery- the return of reproductive organs to pre pregnant condition. 6 months is when you can start having sex

How is Passage one of the 5 Ps of causative factors?

Alteration in Pelvic Structure Pelvic Dystocia Contractures of the pelvic diameters reducing the capacity of the outlet Causes Congenital abnormalities Maternal Malnutrition Neoplasms Lower spinal disorders Soft Tissue Dystocia Obstruction in birth passage by anatomic abnormality Fibroids, full bladder or rectum, cervical edema, STIs Pelvic dystocia inlet is < 11.5 cm Inc in face and shoulder presentation Presentation interferes with engagement and fetal descent Inc risk of prolapse umbilical cord Maternal Malnutrition rickets / flat pelvis Midplane contracture is most common The interischial spinous and post sagittal diameters of the midpelvis is 13.5 cm or less Arrest of progession due to large head - can not rotate c/s is indicated (vaccum if cervix fully dilated) Soft Tissue Dystocia Causes Placenta previa, uterine fibroid (leiomyomas), ovarian tumors, full bladder Also, swollen cervix and STDs (human papilomavirus) Bandl's ring pathologic retraction that forms between the upper and lower uterine segment is associated with prolonged rupture of membranes , protracted labor, and inc risk of uterine rupture

Nursing Diagnosis

Alteration in safety of Mother and Fetus related to abnormal cardiovascular adaptation evidenced by increased B/P, proteinuria and edema Alteration in activity status related to bed rest High risk for injury to Mother and Fetus related to CNS irritability Fear related to threat to Mom and baby

Hepatic adaptations

Although the neonatal liver is immature, it is capable of performing vital functions such as: Bilirubin conjugation Production of coagulation factors Iron storage Carbohydrate metabolism Hepatic: Bilirubin Conjugation Indirect (fat soluble) bilirubin is a breakdown product of red blood cell lysis. It is converted by a liver enzyme, glucuronyl transferase, into direct (water-soluble) bilirubin. Direct bilirubin can be excreted in urine or stool. The newborn's liver is immature liver and has a limited ability to conjugate or convert the bilirubin. This limitation, plus the high red blood cell count and increased hemolysis of fetal blood cells leads to jaundice 48 to 72 hours after birth. Indirect bilirubin is fat -soluble. Accumulation in subcutaneous tissue causes the typical jaundice appearance. Two Types of Jaundice Physiologic jaundice is seen in approximately 50% of full-term newborns. Serum levels range from 4mg/dl to 12mg/dl at 3 days; the average peak serum level is 6mg/dl. Phototherapy is usually initiated at levels 10mg/dl to 12mg/dl. Levels less than 10mg/dl usually resolve with hydration and frequent feedings which promotes elimination of direct bilirubin Pathologic jaundice occurs within the first 24 hours of life and can be caused by blood incompatibilities, inherited metabolic disorders and severe birth asphyxia. Red Flag: High levels of indirect (fat) bilirubin can accumulate in brain tissue and cause kernicterus. This condition can cause permanent brain damage and retardation. Monitor these levels closely! Production of Blood Coagulation Factors Newborns suffer from a temporary deficit in coagulation factors that are synthesized in the liver. Therefore newborns have prolonged blood coagulation time Four of the factors (II,VII,IX, and X) are all activated by the Vitamin K that is produced by bacteria in the gut. Since the GI tract is sterile(No bacteria) until birth, the newborn is at risk for bleeding disorders For this reason, we give Vitamin K prophylactically to protect the newborn(approx. 4 hours after birth) Iron Storage The newborn is born with iron stores accumulated during fetal life If the mother's iron intake was adequate, the infant should have sufficient iron to produce red blood cells until about 5 months of age As fetal red blood cells are lysed after birth, iron is recycled and stored in the liver until needed for new red blood cell production AAP recommends iron supplementation starting at 4 months of age Infants are screened routinely at 9 months of age for anemia by obtaining a Hemoglobin level at their 9 month well visit and recheck for anemia at age 2. Carbohydrate Metabolism The newborn stores glucose in the liver as glycogen. Glucose is the major energy source in the first hours after birth before feeding begin. As blood glucose levels drop, glycogenolysis occurs and glucose is released into the newborn's bloodstream in order to maintain a blood glucose level of approximately 60 mg/dl. Red Flag: Glycogen stores can be rapidly depleted in the presence of stressors. Beware of hypoglycemia in difficult births where birth asphyxia may have occurred. Hypothermia will also deplete glycogen stores. Accuchecks should be ordered for : Newborns with blood glucose levels below 40mg/dl after the first feeding Babies less than 2500g (SGA) and those greater than 4000g (LGA) Preterm infants Infants of Diabetic Mothers Newborns will may be asymptomatic or can present with these signs of hypoglycemia: Lethargy, Poor feeding, Irritability, jitteriness, apnea, tremors and seizures

What are the hepatic adaptations?

Obstructive defects

Anatomic narrowing of blood vessel exiting the heart Examples Coarctation of the aorta Valvular stenosis Aortic Pulmonic

How is Passenger is one of the 5 Ps of causative factors?

Anomalies of fetus Hydrocephalus Tumors Neural Tube Defects Cephalopelvic Disproportion (CPD) Over 4000 grams Malposition 20% in right occipitoposterior or left occipitoposterior position Malpresentation Breech presentation most common Frank Breech Complete Breech 2 types of incomplete Breech Multi-fetal Pregnancy (twins, triplets, etc.) Still a risk to delivery vaginally Only works if one baby is in position first and the second baby is in position behind the first baby In ROP or LOP second stage is prolonged and pt has severe back pain due to pressure from the fetal head Page 500 Measures to reduce back pain Low forcept delivery or manual rotation Counter pressure - fist or heel of hand to sacral area / cold or hot applications to sacral area Double hip squeeze Knee Press Overview of measures to facilitate rotation of fetal head Lateral abdominal stroking Hands and knee position (on all fours) Squatting Pelvic rocking Stair climbing Lateral position Lunges Occipitoposterior Passenger Malposition Overview Occipitoposterior 20% in all labors Prolonged 2nd stage Severe back pain Rotate fetus to facilitate birth Operative delivery - Cesarean Section Face / Brow Uncommon Occipito-Posterior Presentation Occipito-Anterior most favorable position for delivery ROA LOA Most favorable position for the baby Breech Presentations External version of fetus from breech to vertex presentation. Manual Rotation

Head

Anterior fontanel closes around 18 months of age. Posterior fontanel closes by 2 months of age. Fontanels should be flat, soft and firm Third fontanelle -along the sagittal suture- seen often with trisomy 21(Downs Syndrome) Head Control Degree of Head Control is assessed. Although Head Lag is normal in the newborn, the degree of ability to control the head in certain positions is assessed. Hypertonia - see that in some congenital issues. Those are the babies that we have trouble feeding Head: Minor abnormalities Usually after 48 hours the head is in much better shaped. There is a cap on the head and the baby is being bathe so it helps with shaping the head Bulging Fontanel- Increased intracranial pressure - could be indicative of meningitis Sunken Fontanel- Dehydration

Heads of newborn

Anterior fontanel closes around 18 months of age. Posterior fontanel closes by 2 months of age. Fontanels should be flat, soft and firm Third fontanelle -along the sagittal suture- seen often with trisomy 21(Downs Syndrome) Head Control Degree of Head Control is assessed. Although Head Lag is normal in the newborn, the degree of ability to control the head in certain positions is assessed. Hypertonia - see that in some congenital issues. Those are the babies that we have trouble feeding Head: Minor abnormalities Usually after 48 hours the head is in much better shaped. There is a cap on the head and the baby is being bathe so it helps with shaping the head Caput Succedaneum Bulging Fontanel- Increased intracranial pressure - could be indicative of meningitis Sunken Fontanel- Dehydration

How is psychological responses is one of the 5 Ps of causative factors?

Anxiety Apprehension Hormones and Neurotransmitters Catecholamines released in response to stress PAIN FEAR TENSION

Other focal seizures

Any tonic-clonic seizure preceded by aura or warning is a partial seizure that generalizes secondarily Second generalized seizure may result in transient residual neurologic deficit postictally Focal seizures may be confined to one side of the brain and remain partial or focal in nature, or they may spread to involve the entire brain, culminating in a generalized tonic-clonic seizure. Many tonic-clonic seizures that appear to be generalized from the outset may actually be secondary generalized seizures, but the preceding partial component may be so brief that it is undetected by the patient, by the observer, or even on the EEG. Unlike the primary generalized tonic-clonic seizure, the secondary generalized seizure may result in a transient residual neurologic deficit postictally. This is called Todd's paralysis (focal weakness), which resolves after varying lengths of time.

Preterm labor (PTL)

Any true labor experienced after 20 weeks gestation to the end of 37 weeks gestation True labor includes: Uterine contractions Cervical change

What is the immediate nursing care of newborn?

Apgar- assessment and 1min and 5 mins of life 1953- Dr. Virginia Apgar developed standard methodology to evaluate newborn at birth. Identification 4 bands 2 baby 2 parents Number on bands must be the same !!!(Very Important for Security) Footprints of newborn Mom- right thumb/finger print is taken Eye care Eye ointment of Erythromycin administered after bonding It is now to give the baby to mom and let the mom hold the baby as long as she can. You can do the identification bands and the Apar score with the mom holding the baby Everyone is 0 at 1 minute of age but at 5 minutes, they are pink except for their hands and feet and it is called acrocyanosis. It is important for the blood to get to the important parts of the baby such as the heart and the brain but not the hands and feet Cord Care 3 vessels (AVA) 1 vein 2 arteries Clamped for ~ 24 hours, then unclamped. So the baby does not breathe through the cord We leave it on until the day of discharged Alcohol/Triple Dye to cord?? - to help dry the cord and prevent infection Let it dry naturally Vitamin K 0.5 mg of Aquamephyton administered I.M. To assist in clotting formation. Necessary because neonatal intestinal flora is not present yet (produced in the GI tract). This should be done after the admission bath in the newborn nursery. Prevents Hemorrhagic disease of the newborn (intracranial bleeding) Birth Video https://www.tribecapediatrics.com/parenting-videos/deborahs-birth/

What happened to ovulation and menstruation post partum?

Are influenced by whether or not a woman breast feeds - Related to prolactin levels Many women will not get their period until they stop breast feeding and sometimes it is several weeks after that stop breast feeding Not a form of birth control!!!!! The first ovulation after delivery in non-lactating women occurs on an average of 10-14 weeks Among lactating women, first ovulation occurs after 3-6 months The average time is 17 weeks With the increase in lactation duration, the average time of ovulation rises By 12 weeks post-partum 70% of non-lactating women have their first menses For lactating women menses return more gradually 55-75% begin menstruating by 36 weeks(8 months after birth) Still able to get pregnant without menstruation!

Nursing Care Prevent infection

Aseptic technique at all times Good peri care C&S if necessary Assess for Hx of prolonged ROM Increase fluids Administer antibiotic as ordered Administer pain medication prn Ongoing assessment of all v/s

Nursing Care - Assessment of Patient on Magnesium Sulfate

Assess Deep Tendon Reflexes Strict Intake and Output (foley) Vital signs- q 30 minutes LOC Assess for Clonus Next step is a seizure FHR Assess Magnesium levels 1.3 to 2.1 mEq/l (theraputic 4-7) Mag Toxicity: Calcium Gluconate- 1Gm 10% -given IV over 3 minutes If they are sleepy, then the mg is normal. If they are somnolence and needs to be awaken by a sternal rub, their mg levels is toxic Demonstrate Knee jerk -patellar reflex Done q1hr-continuous, q4 r if single dose I&O - will have a Foley catheter , check color, protein and amount hourly Old MGSo4 if respirations are < 12/minute, pulse < 60 or fetal distress FHR_continuous- q15 min Mg levels -q6 hrs KEEP CA GLUCONATE AT BEDSIDE

Nursing Care

Assess degree of respiratory distress Administer warm humidified oxygen per order Evaluate infant's response to therapy Wean from mechanical ventilation Nutritional Care Types of nourishment (Breast milk, preterm formulas) Have the mother to start pumping right away even though we are not going to get much Hydration (parenteral fluids) We try to do peripheral lines such as doing an iv in the foot. We can use the umbilical vein so we snip off the clamp of the umbilical cord and feed it into the umbilical is vein and give fluids through this Elimination Patterns (time, amount - weigh diapers) Oral feeding (breast, bottle, gavage) Nonnutritive sucking Feeding the baby during distress is going to make them more distress

Psychological Support

Assess family support system Explain all procedures Keep couple informed of status-both mom and fetus Diversional activity Provide anticipatory guidance with respect to NICU These patients should be cared for by a Perinatologist and a Neonatologist at the delivery

Nursing Assessment: Post Seizure

Assess for Bitten tongue, soft tissue damage, cyanosis Abnormal respiratory rate Apnea (ictal) Absent or abnormal breath sounds Airway occlusion Nursing Assessment (cont.) Hypertension, tachy/bradycardia Bowel/urinary incontinence, excessive salivation Weakness, paralysis, ataxia (postictal) Planning Overall goals are that patient will Be free from injury during seizure. Have optimal mental and physical functioning while taking antiseizure medications. Have satisfactory psychosocial functioning.

Patellar reflex and clonus

Assess for Clonus Ankle Clonus Dorsiflex the foot three times in rapid succession As you take your hand away there should be no movement If the foot continues to move involuntary, clonus is present

Neck

Assess for evidence of webbing which is associated with congenital abnormalities Assess range of motion- nuchal rigidity can be a sign of damage to the sternocleidomastoid muscle (congenital torticollis) or meningitis The clavicle is the most frequently fractured bone during delivery. Assess for crepitus (snapping or crackling feeling). Hint: Assess for the Moro(startle) reflex- if the clavicle is fractured the Moro will be diminished on the affected side

Neck of newborn

Abdomen

Assess for tenderness, distention and bowel sounds Examine the umbilical cord for two arteries and one vein Palpate for femoral pulses Palpate for both kidneys Assess for bladder distention- newborn should void at least once in the 24 hour period

Abdomen of newborn

Psychological care

Assess how parents perceive events Does mom blame herself? Post coping patterns (Denial, anger, fear) Support from extended family Give accurate information Parental Support Provide accurate and consistent information (Plan of treatment) Clarify NICU policies Help parents connect with other NICU parents (Support groups)

Nursing Care Management of Pre-eclampsia

Assessment Interview Physical examination Dependent edema Pitting edema Deep tendon reflexes (?) Laboratory tests (CBC, UA, Uric acid, AST/ALT, T&S) Nursing diagnoses

Care Management

Assessment Interview Physical examination Laboratory tests - A1c, 24 hr. Urine for protein. creat. Clearance, tight glycemic control. (fasting 60-90 mg/dl) Plan of care and interventions Antepartum Diet, exercise, insulin therapy, monitoring blood glucose levels, fetal surveillance (NST), complications requiring hospitalization, determining birth date and mode of birth, Intrapartum Q1hr blood glucose; Continuous EFM Maintain BG levels at 80-120 Postpartum BG assessment 4-6 times a day Insulin based on doctors orders; Insulin requirements decrease immediately Breast feeding is encouraged Helps regulate sugar Lessens need for insulin Normal post-partum care: Higher risk for preeclampsia, hemorrhage, and infection Discharge instructions See primary care doctor as directed Family planning and contraception

How to treat dystocia?

Assist with interventions to treat dystocia Positioning Version Augmentation of labor Whenever a mom is on pitcoin. She has to be on the monitor continuously No monitor, no pitcoin! Cervical ripening Monitor FHR during all procedures Monitor Maternal VS Assess maternal level of comfort and treat appropriately Maintain communication with patient and family Provide support to patient and family

Bottle Feeding Tips

Assume the (Best) Position Unless your baby is a speed-eater, you're going to be holding her up to 20 minutes per feeding. Support head with the crook of your arm, prop her up at a 45-degree angle so that she doesn't swallow a lot of air, and align her head and neck. The baby's head is higher than the feet. If not, they are at risk for ear infections Filled Up A bottle-fed baby knows when she's had enough and will turn her head away from the nipple when she's full . Trying to force feed the baby, you will have a baby that have reflex issues and vomiting Baby turn the head away meaning they are done even they did not finish the bottle Burping When air gets trapped in the baby's stomach, it can make her feel full before she's had enough to eat. Burp the baby when she's halfway through the bottle. (This is a great time to shift her position, too.) Minimize her air intake by using an angled bottle or one with disposable liners. Discourage Dozing If your baby routinely falls asleep mid-meal, you may have to change her feeding schedule. Make sure bottle-feeding doesn't spill over into nap time. Never Bottle Prop Denies baby the closeness of feeding Can cause more middle ear infections by milk pooling in the pharynx It could lead to suffocation Be Alert to Allergies Babies who are allergic to the protein in cow's milk, the basic ingredient in most infant formulas, can have allergic reactions right after a feeding or a week or so later. What should you watch for? Fussiness, vomiting, wheezing, swelling, colic, loose stools, and hives or other skin rashes. Dealing with a milk allergy is simply a matter of switching formulas Once you find a formula that your baby can tolerate, her symptoms should clear up within two to four weeks. Spitting-up Give her smaller feedings more often. Hold her head higher than her feet when you feed her Hold her upright after a feeding and try not to bounce or jiggle her. Keep her diaper and clothing loose around her belly. If your baby has projectile vomiting or is a vomiting after every feeding, check in with the pediatrician.

Bottle feeding tips

Upon birth quiz

Baby takes first breath and the Foramen______ __ovale_____ snaps shut due to increased pressure in the _left artrium______ _________. Foramen ovale Left atrium Circulation through the placenta_______ ceases. Placenta _ductus _______ _venosus________ and _ductus_______ __arteriosus_____ atrophy and become ligaments. Ductus venosus and Ductus arteriosus Failure of the foramen ovale to shut leads to artial______ septal_______ defect________. Atrial Septal Defect (ASD) Failure of the ductus arteriosus to shut leads to _patent_______ __ductus_______ arteriosus________. Patent Ductus Arteriosus (PDA) Ovulation and Fertilization Videos <iframe width="560" height="315" src="//www.youtube.com/embed/nLmg4wSHdxQ" frameborder="0" allowfullscreen></iframe> <iframe width="560" height="315" src="//www.youtube.com/embed/BFrVmDgh4v4" frameborder="0" allowfullscreen></iframe>

What is ovulation?

BEFORE CONCEPTION COMES OVULATION Ovaries -> Estrogen -> Hypothalamus -> GnRH -> Pituitary -> FSH + LH -> Ovulation -> Progesterone The ovary secrete the hormones, estrogen and stimulate the hypothalamus and that secrete the gondatrope releasing hormones and once that is release, it stimulates the pituitary gland to release the follicle stimulating hormone and the LH. Once FSH and LH is release, it goes back down and stimulates the release of the egg which is ovulation - the release of the egg from ovary. Once Ovulation occurs, it release progesterone, a very important hormones for pregnancy

Basics of Breastfeeding

Baby's first feeding can occur in the delivery room after birth when baby is in the "quiet alert" state. Vaginal deliveries can either hold the baby in the cradle position or lie on their side with the baby facing them Cesarean-section deliveries can use either of the above positions or use the "football" hold Burp your baby at least twice during feeding Bring the baby in to the breast and ensure that the nipple and the areola in the baby's mouth. Do not lean in and try to look, it will not help Put a finger in the baby's mouth to break the suction and then burp twice Never pull the baby from the breast

Basics of breastfeeding

Septic Arthritis

Bacterial infection of the joint Direct inoculation from trauma accounts for 15 to 20% of all cases Most common organism is Staph aureus MRSA can also cause septic arthritis Knees, hips, ankles and elbows are most common joints affected Signs and Symptoms of Septic Arthritis Characteristic appearance Affected joint: warm, tender, painful, swollen Frequently follows traumatic injury Fever, leukocytosis, increased sedimentation rate Neisseria gonorrhoeae: frequent cause of septic arthritis in sexually active teenagers Therapeutic Management of Septic Arthritis Diagnosis based on results of blood culture, joint fluid aspirate, and radiography Treatment: Intravenous antibiotic therapy Pain management Surgical intervention for wounds Physical therapy Juvenile Idiopathic Arthritis Replaces JRA- Juvenile Rheumatoid Arthritis Change was due to the fact that only a small percentage of diagnosed children tested positive for the RA factor A chronic autoimmune inflammatory disease causing inflammation of joints and other tissues Peak onset between 1 and 3 years of age

Traction

Balanced skeletal traction is used for children Aligns bone fragments Permits closer evaluation of the injured site Newer orthopedic fixation devices allow for partial or full mobility Often surgical intervention is carried out in a matter of days eliminating the need for traction

Fetal Heart Rate Patterns

Baseline Fetal Heart Rate - average rate for a 10 minute period (110-160 beats/minute) Tachycardia - greater than 160 bpm for a 10 minute period or longer Bradycardia - less than 110 bpm for a 10 minute period or longer Tachycardia Fetal hypoxemia Fetal cardiac arrhythmias Maternal fever/infection Fetal infection Medications (atropine, terbutaline) Drugs (caffeine, cocaine, meth) Fetal anemia Need to find out because we are very cautious Bradycardia Fetal arrhythmias (heart block) Structural defects Viral infections (cytomegalovirus) Fetal heart failure Maternal hypoglycemia Maternal hypothermia Maternal hypotension or some kind of bleeding

Admission to Hospital

Bedrest Hydration Medications - Tocolytic Therapy Terbutaline (Brethine) Off label uses - use for asthmatics patient that relaxes the smooth muscles such as bronchospasm and it also relaxes uterine smooth muscles Magnesium Sulfate Lot of side effect so it is used cautiously Nifedipine (Procardia) Calcium channel blocker It prevent calcium from entering the cardiac muscle which relaxes the heart - same idea for the uterus Indomethacin Another muscle relaxant Fetal Monitoring Non Stress Test Intermittent monitor for baby which is put it on for 20 to 40 minutes at the heart rate and contraction pattern and we sent mom down for ultrasound Ultrasound - Polyhydramnios Too much amniotic fluid (more than 2 L in the womb) Causes distension of the uterus Polyhydramnios could be a result of gestational diabetes in which it cause the child to pee a lot too

Diabetes Mellitus

Before the discovery of insulin in 1922, it was uncommon for a woman with diabetes to give birth to a healthy baby Pregnancy complicated by diabetes is considered high risk Care requires nurse to fully understand normal physiologic responses to pregnancy and altered metabolism of diabetes

Seizures: Clonic

Begin with loss of consciousness and sudden loss of muscle tone Followed by limb jerking

Pubertal Growth for Boys

Begins 2 years later than girls Boys reach peak height velocity between 13.5 and 14 years of age Pubertal growth lasts longer than 4 years for boys At age 12, boys will have attained 83% to 89% of their height An additional 25-30cm of height is achieved during late puberty Lean body mass increases from 80% to 90% at maturity Muscle mass doubles between 10 and 17 years

What are the food sources for folic acid, calcium and iron?

Best answer: green, leafy vegetables and total cereal! Folic Acid Green leafy vegetables Breads Cereal Orange juice Beans Iron Red meats Fish Poultry Dried beans Fortified cereals Calcium Milk Fortified orange juice Nuts Green leafy vegetables

Overview of Tocolytic Drugs

Beta Adrenergic Agents/Agonist Relaxes smooth muscles inhibiting uterine activity Terbutaline 0.25mg sq (Brethine) - Not to be used with vaginal bleeding Magnesium Sulfate "Off Label" CNS depressant relaxing the smooth muscle in the uterus Overview of Adverse Rx and Nursing Considerations Pulm edema; Resp paralysis; Hypotension; Depressed reflexes; Drowsiness; Flushing; Visual changes; Low Ca Calcium Channel Blockers Calcium movement relaxes the uterine smooth muscle Nifedipine (Procardia) (30mg initial dose; 10-20mg q4-6 hrs) Avoid with MgSO4 Increase Hypotension Prostaglandins Inhibitors Prostaglandin inhibitor - relaxes smooth muscles including Uterus Indomethacin (Indocin) Administration PO or PR Use for 48 hours or less; < 30 -32 weeks gestation (increases risk for PP hemorrhage and premature closure of DA in fetus) We do not use NSAID or motrin because it can close the ductus arterioles then where would fetus get the oxygenated blood? Side effects of Smooth Muscle Relaxants Tacchycardia / Palpitations SOB Coughing Heachache N & V Facial Flushing Tremors Side Effects of MgSO4 Hot flashes / flushing N&V Hypocalcemia Hypotension Hypotonia / dec deep tendon reflexes Resp Depression Glucocorticosteroid Betamethasone, Dexamethasone (12mg IM x2 q24hrs) (6m IM x4 q12 hrs) Recommended by NIH for all women at risk for preterm delivery (<34 weeks) Stimulates fetal lung maturation Promote release of enzymes to produce or release surfactant (L/S Ratio) - must be at exactly at 34 weeks Not recommended if: Cord Prolapse, Chorioamnionitis/Other Infection, Abruptio Placenta (when the placenta is not attached to the uterine wall so there is no oxygen tank for the baby) Delay of Delivery is Detrimental We do not want to prolong the labor - get the baby out of there Nursing Considerations Given IM Assess for Pulmonary Edema Assess Blood Glucose Levels Contraindicated if patient has an infection

Breast care

Between feeding, gently pat the nipples dry. This will prevent irritation It is helpful to apply a small amount of expressed colostrum, breast milk or medical grade lanolin on the nipples to prevent dryness Do not use soap on the nipple it will lead to cracked nipples. Another way is to allow the expressed milk on the nipple and pat it dry on the nipple If the baby is pulling their knees up, it is a sign of gas Diet does play a role of breast feeding - your baby will receive what you ate - you are what you eat

Predicting Preterm Labor and Birth

Biochemical Markers Two Most Common Fetal Fibronectin Glycoproteins found in plasma and produced in fetal life Produced in cervical canal between 16-24 weeks; tested during vaginal exam, + at 24-34 weeks predicts labor False positives can occur after cervical exam, sex, vaginal bleeding; Negative result is predictive Salivary Estriol: form of estrogen produced by the placenta; Enters the mother's bloodstream and other body fluids, including saliva up to 3 weeks before delivery; Unreliable Endocervical Length Shortened endo-cervical length precedes preterm labor (<25mm = increased risk of infection) Assessment via ultrasound (transvaginal) Combined with Fetal Fibronectin increase risk of spontaneous preterm birth Many reason we can have a false positive readings - sexual intercourse and vaginal bleeding If we have a positive endocervical length and a negative FF that tells us that she is more likely to be in labor Cost for Biochemical Markers is expensive

What are the ongoing assessments during prenatal care?

Blood pressure Pulse rate Fetal growth Fundal height Urine assessed for protein and glucose Review of normal changes in pregnancy Review of signs and symptoms of problems during pregnancy

How to do assessment and implementations post partum?

Bonding- 1st step in attachment Eye contact, talking, touching, kissing In delivery room, hold off eye erythromycin ointment till parents make eye contact with newborn.

What are the changes of the uterus during antepartum period?

Braxton Hicks are present but not felt yet because it is not big yet in first trimester. Education is a huge part of the care in maternity Difference between Braxton Hicks and Labor contraction is that Labor is painful and crampy. Braxton Hicks is not painful.

Breast feeding Complications

Breast Care Between feeding, gently pat the nipples dry. This will prevent irritation It is helpful to apply a small amount of expressed colostrum, breast milk or medical grade lanolin on the nipples to prevent dryness Do not use soap on the nipple it will lead to cracked nipples. Another way is to allow the expressed milk on the nipple and pat it dry on the nipple If the baby is pulling their knees up, it is a sign of gas Diet does play a role of breast feeding - your baby will receive what you ate - you are what you eat Engorgement Feed the baby on demand. Engorgement occurs when the breasts become too full with milk. If the breast become engorged: Express some milk before breastfeeding, either manually or by pump Soak a cloth in warm water and put on the breasts or take a warm shower before feeding baby. Stimulation circulation and allow the milk to flow more easily For severe engorgement, warmth will not help and cold compresses must be used as you express milk. Ice packs between feedings will help reduce pain and swelling Tylenol is one of the safe medication that can be use for discomfort Gently massage the breasts from under the arm and down toward the nipple- this will reduce soreness and ease milk flow Medications should not be taken unless cleared by the doctor. Tylenol can relieve discomfort and is safe to take occasionally during breastfeeding Remember: Engorgement is a temporary condition. The more the mother nurses the less engorged the breasts will become Mastitis An infection of the breast Symptoms are swelling, burning, redness and pain Usually occurs in just one breast Mother may develop fever and feel ill Treatment: rest, warm compresses and antibiotics. Breastfeeding does not have to stop. The infection will not spread to the milk You can keep breastfeeding the breast that is inflamed The antibiotics are not to worry about crossing over into the milk. Mom does not have to stop breastfeeding Cracked Nipples Caused by poor positioning of infant or inadequate "latch on" Treatment: Use modified lanolin. Wash breasts with water, not soap

Chest, lungs and Breath sounds

Breast Discharge (Witch's milk) is normal as well as breast engorgement. Both are due to the effects of withdrawal of maternal estrogen. Accessory nipples may be noted below and medial to the nipples. These are benign and fairly common. Assess for symmetrical chest expansion with respirations (30 to 60/min) Assess breath sounds: Rales heard immediately after birth can indicate retained fetal lung fluid and areas of atelectasis which are normal findings. Rales should be absent within several hours after birth as lung fluid is absorbed Rhonchi indicates fluid, mucus or meconium in the larger bronchi as can indicate more serious conditions like meconium aspiration syndrome

Daily nursing care post partum

Breasts Ask about issues with bread feeding Uterus More children she has, the more severe the uterine cramping it will be during breast feeding Bladder How are you emptying bladder, any pain or burning or any difficulty starting your stream or controlling your bladder? Any odor to your urine Bowel Do a bowel assessment They don't have to have a bowel movement before disharge C section patients can get distention with gas Are they passing gas? If they are not having gas, feeling nauseous and vomiting they might have an ileus related to the anesthesia and surgery Lochia When you go to the bathroom, is it heavy, moderate or light period? Find out what her definition of bleeding Episiotomy To see if there is no draining. Does she need ice pack Emotional Big part of treatment Are they bonding appropriately? Observing them with their babies True post-partum don't show up until 2 to 3 weeks of delivery Ask them if they have a history of depression and then educate the signs and symptoms of depression Remember BUBBLE - Breast, Uterus, Bladder, Bowel, Lochia, Episiotomy and Emotional

Complications of Oxygen Therapy

Broncho-Pulmonary Dysplasia (BPD) Newborn chronic lung disease, alveolar damage sec to prolonged mechanical ventilation Difficult to wean from ventilator Recovery takes several months with frequent reoccurrences of respiratory complications Long term oxygen Medication (diuretics, corticosteroids, bronchodilators) Chest Physiotherapy (CPT) Mortality is 30 to 50%

Breastfeeding:Why is it good for the mother?

Burns more calories and gets mother back to her pre-pregnancy weight more quickly Reduces the risk of ovarian cancer and in premenopausal women, breast cancer Build bone strength to protect against bone fractures in older age Delays the return of menses which will extend time between pregnancies ( not a form of birth control alone) Remind the mothers that it is not a method of birth control!!! Helps the uterus return to it regular size more quickly

Diagnosing Viral Meningitis

CSF WBC: Increased, but less than with bacterial meningitis Glucose: WNL Protein: slightly elevated Bacterial culture: Negative

What are the substances to avoid during pregnancy?

Caffeine - limited to 300 mg daily Too much can increase risk of spontaneous abortions or fetal intrauterine growth restriction 1 cup of coffee (240 mL) Same for soda, tea and sport drinks Alcohol None during pregnancy No known safe amount Drugs Over the counter or otherwise unless Rx by doctor Smoking Associated with low fetal weight and placental problems Smoking can constrict the blood vessels and deprive the baby of the oxygen and nutrient needed to survive.

Homan's Sign

Calf pain Redness, swelling Tenderness Report to Dr. No ambulation until evaluated It will travel to the lungs or the hearts or the brain Supposedly a test for DVT - do not use

What are the signs of oncoming labor?

Cervical changes- soft, effaced, dilated Dilation- opening of external os to 10cm Effacement- thinning out of internal os to 100% Bloody show- blood-tinged cervical mucus Release of mucus plug Rupture of membranes- Spontaneous rupture of amniotic sac with release of fluid (SROM)

What are the changes of the vagina during antepartum?

Can lose elasticity due to the size of children and number of children

Cardiac Dysrhythmias

Can occur in children with normal hearts Bradydysrhythmias Tachydysrhythmias Conduction disturbances Less common Issue with the SA node Follow Up RF lasts about 12 weeks, 15 at the outset Continued monitoring for cardiac complications

Inhaled poisons: Carbon monoxide (CO)

Carbon Monoxide Poisoning Intentional or accidental CO is colorless, tasteless, odorless gas Highly poisonous Children as highest risk groups Smokers with higher risk Common causes House fires Charcoal grills inside Inhaling "methylene chloride, a volatile liquid found in degreasers, solvents, and paint removers" CO Poisoning: Pathophysiology Accidental or Intentional ~64% of deaths from unintentional household causes CO binds to circulating Hg causing reduction of oxygen carrying capacity of RBC's Tissues can't release oxygen Impairs aerobic metabolism CO readily crosses capillary membranes in the lungs Hg absorbs CO 200 times more readily than O2 CO bound Hg = carboxyhemoglobin "An experimental study in Norway showed that a kerosene camping stove used inside a closed tent for 2 hours raised ambient CO levels enough to cause a mean carboxyhemoglobin (COHb) level of 21.5% and clinically significant hypoxia in healthy volunteers." Carboxyhemoglobin: S&S Early symptoms vague: Headache Dizziness Nausea Loss of consciousness Dyspnea Loss of muscle control Symptoms often passed off as a viral syndrome, migraine or tension headache, anxiety attack, hyperventilation syndrome, or a nonspecific illness. Other S&S Dysrhythmias Tachycardia Tachypnea Hypoxia Hypo- or hypertension Mild hyperthermia. Neuro changes "Pulse oximetry may remain in the normal range despite cyanosis and tissue hypoxia because the wavelengths produced by carboxyhemoglobin (COHb) and oxyhemoglobin are read similarly by these machines." It becomes invalid because it may not read the CO Skin Discoloration Skin pale, cyanotic, or mottled The classic "cherry red" appearance to skin is not an early sign unless severe CO poisoning; typically found post mortem Diagnosing: Labs Best indicator is assessing the blood carboxyhemoglobin (COHb) concentration by means of CO-oximetry ABGs also helpful to assess for metabolic lactic acidosis UA and serum creatine kinase (CK) to assess for rhabdomyolysis Coagulation studies CBC Initial Management CO Poisoning Biggest problem is failure to correctly diagnose Prehospital High flow oxygen via non-rebreather mask Begin cardiac monitoring In ED Intubate if obtunded or severely hypoxic 100% oxygen quickly drops CO levels ECG and continuous monitoring CO oximetry & ABG Ongoing Transfer for hyperbaric oxygen delivery for continued symptoms Also used for divers that have the bends Ongoing Potential Complications Potential Complications Rhabdomyolysis Acute respiratory distress syndrome (ARDS) Disseminated intravascular coagulation (DIC) SIRS or multiple organ dysfunction syndrome (MODS) Acute tubular necrosis (ATN) Discharge Criteria Asymptomatic patients with COHb concentrations lower than 10% may be discharged home after observation. Patients with only mild symptoms may be safely discharged home after 4 hours of treatment with 100% oxygen if their symptoms completely resolve in that time. Patient should be reevaluated within 24-48 hours after discharge because symptoms may recur or be delayed.

Overview of Maternal risk factors

Cardiac Disease Diabetes Renal Disease Severe Anemia Infection UTI's Abdominal Surgery Cervical Surgery Fibroids Placental Previa Smoking / Drugs Preeclampsia Maternal age < 18 or > 40 years old Previous preterm delivery Multiple Pregnancies /Multiple fetuses Psychosocial Factors Over distension of Uterus Pregnancy Complications (HTN, Hydramnios, Bleeding, PROM) Infection thought to be the major etiologic factor UTI, Cervical infection, bacterial infections

Heart

Cardiac murmurs are common in the first hours are a benign finding Red Flag: The two most common presentations of heart disease in the newborn are: Cyanosis Congestive Heart Failure with abnormalities in pulses and perfusion (Example critical aortic stenosis will have diminished pulses at all sites)

Heart of newborn

What are the fetal heart rate categories?

Category I: * Baseline rate: 110-160 * Moderate variability (6-25) * No late or variable decelerations Category II: * Tachycardia or bradycardia * Minimal, absent, or marked variability * Absence of accelerations * Prolonged, recurrent late, or recurrent variable decelerations Category III: * Either Sinusoidal pattern OR absent variability with recurrent late or variable decelerations, or bradycardia Reportable Conditions Nonreassuring fetal heart patterns: Persistent/Recurrent decelerations - Late or Variable - > 50% in a 20 minute period Absent or minimal variability lasting longer than 40 minutes - call the doctor Fetal bradycardia/tachycardia Fetal dysrhythmia Call the doctor if it look weird. You don't need to make the diagnosis

Poisoning

Definition Any substance taken into the body by ingestion, inhalation, injection or absorption that interferes with the body's normal physiological function. Categories of Poisoning Accidental Intentional / purposeful

What is back labor?

Cause: Baby's position is occiput posterior (OP) - "sunny side up" 25-30% of women experience back labor "All of the pain is in my back and does not go away between contractions" Common characteristic - often slow to progress Coping strategies for Back Labor Change of position (every 30 min unless contraindicated) Side lying Taylor fashion Squatting All fours Counter pressure Push against the wrist of your hands against the patient's lower back providing the counter pressure of the baby pushing against the tailbone Breathing techniques - "distraction" Use of Heat or Cold - Shower/Jacuzzi, rice sock Music Patients can fracture their tailbone due to the baby's being OP. Best way to do it is try to reposition the baby. Change position from side to side

Other- Syphilis

Caused by spirochete treponema pallidum Sexual transmission usual route If high risk sexual behavior then tested during early pregnancy by V.D.R.L. or R.P.R. Prompt treatment will decrease/ eliminate most fetal infections and associated complications Transmission of spirochete to fetus is blocked till about 18 weeks of pregnancy by protective layer of the chorion (this special layer starts to atrophy after 18 weeks gestation) Any infant born to a woman treated in the last 20 weeks before birth should be investigated for congenital syphilis Example: microcephaly, poor feeding, "snuffles" (clear mucus from nose), copper colored maculopapular dermal rash on soles or palms Treatment Penicillin (aqueous) ASAP Erythromycin- if patient is penicillin allergic Treat the baby prophylactically

Toxoplasmosis

Caused by toxoplasmagondi (parasite, protozoan) Cat liter- major source of infection thru exposure to cat feces in liter box (cats eat dead birds and mice) Organism passes thru placenta- causes many congenital malformations Examples: hydrocephalus, mental retardation, chorioretinitis, seizures, psychomotor delays 80-90% that are infected at birth are asymptomatic Onset of problems (developmental) start after birth (weeks to years) May be cause of pre-term labor Prevention No exposure to cat litter Good hand washing If high risk- have toxo titer done Treatment Pyrimethamine (Daraprim) Oral Sulfadiazine Blocks enzyme needed for synthesis

Other- Varicella

Caused by varicella- zoster (chicken pox) and shingles Member of herpes family Risk of infection- low Most child bearing women are immune Transmission or infection of varicella most significant in first trimester (0.4-2%) Causes neurological abnormalities and limb atrophy Delivery within 4 days of maternal exposure increases neonatal mortality Women who are immunized to varicella, but are exposed can be given VZIG (varicella zoster immune globulin) This VZIG does not decrease incidence of infection, but decreases the effects of the virus on the fetus. VZIG must be given within 72 hours of exposure to varicella Infant born to mothers who get varicella between five days before birth and 48 hours after birth should get VZIG to lessen risk of severe case of virus to neonate/ infant

What are the probably signs of pregnancy?

Chadwick's sign Goodell's sign McDonald's sign Hegar's sign Uterine enlargement Braxton Hicks contractions Uterine contraction that are painful Ballottement of uterus You can't move the uterus but when you push on the cervix and you feel like the cervix is moving, there is a little pass Positive pregnancy test Positive Signs(3) Fetal heartbeat heard - heard or seen on ultrasound Fetal movements felt by examiner Fetal outline seen - on ultrasound

What are the changes of the cervix during antepartum period?

Chadwicks sign is seen upon visual inspection. First baby they don't dilate until labor. If the second baby or more, the mom may dilate one or the cm before she is even in labor. Losing your mucus plug does not mean you are going into labor. Sometimes you can lose it a week or two weeks prior to labor. Sometimes it is not noticeable.

Generalized Seizures: Tonic-Clonic Seizures

Characterized by loss of consciousness and falling Body stiffens (tonic) with subsequent jerking of extremities (clonic) Cyanosis, excessive salivation, and tongue or cheek biting may occur The most common generalized seizure is the generalized tonic-clonic (formerly known as grand mal) seizure. The tonic phase lasts for 10-20 seconds. The clonic phase lasts for another 30-40 seconds. Postictal phase for tonic-clonic characterized by muscle soreness & fatigue Patient may sleep for hours May not feel normal for hours to days No memory of seizure

Generalized Seizures: Myoclonic Seizures

Characterized by sudden, excessive jerk of body and extremities Can be forceful enough to cause fall Brief and may occur in clusters Atonic seizure involves tonic episode or paroxysmal loss of muscle tone. Begins suddenly and person falls Consciousness usually returns by time person hits ground. Can resume normal activity immediately Great risk for head injury Atonic seizures are also known as "drop attack" seizures. Patients with this type of seizure often have to wear protective helmets.

What is lochia?

Check every shift and note color and amount If you saturated the pad within one hour of putting it on, it is too heavy and could be an emergency The size of the clots is important - if the clot is about 35 cm, it may not mean anything so if the clot is bigger than your first or size of small apple, that is too big for it to be normal. Bigger than your fist is not normal. Smaller is normal!

What is cervical ripening and stimulation?

Chemical Prostaglandin E soften and thin the cervix Misoprostol (Cytotec) Decreases need to Augment Labor with IV Oxytocin Mechanical Mechanical Dilators / Foley Catheter to stimulate and dilate the cervix Amniotomy Artificial rupture of membranes Assess FHR pre and post procedure

What is oxytocin?

Chemical Induction for labor Hormone produced by posterior pituitary (also known as Pitocin) Stimulates uterine contractions Complication with Oxytocin Water Intoxication (cause them to retain fluids) Tetanic Contractions Premature separation of placenta Rupture of uterus Post partum hemorrhage Given IV in NSS/ RL through a secondary line - must be regulated and monitored closely Patient signs an informed consent

Chest, Lungs and breath sounds of newborn

Chest and Lungs Breast Discharge (Witch's milk) is normal as well as breast engorgement. Both are due to the effects of withdrawal of maternal estrogen. Accessory nipples may be noted below and medial to the nipples. These are benign and fairly common. Assess for symmetrical chest expansion with respirations (30 to 60/min) Breath Sounds Assess breath sounds: Rales heard immediately after birth can indicate retained fetal lung fluid and areas of atelectasis which are normal findings. Rales should be absent within several hours after birth as lung fluid is absorbed Rhonchi indicates fluid, mucus or meconium in the larger bronchi as can indicate more serious conditions like meconium aspiration syndrome

Early Childhood

Child explores Still experiencing oral gratification Increased risk for ingestion of toxic agents Caregiver education needs Lock cabinets Keep products out of reach Never treat medication like candy

Chronic Hypertension

Chronic hypertension associated with increased incidence Abruptio placentae Separation of placenta from the uterine wall Superimposed preeclampsia Increased perinatal mortality Postpartum complications include: Pulmonary edema Renal failure Hypertensive encephalopathy Important for the mothers to maintain a very good control of blood pressure - also risky because they are a lot of medications they are not allow to take to manage it

What occur upon birth?

Circulation changes completely Changes involve baby's heart and lungs Pressure in left side of heart rises due to onset of respiration Foramen ovale snaps shut ensuring the pressure remains high in left side of heart so normal circulation can proceed The circulation of blood through the placenta ceases When the umbilical cord is cut, the babies is to cry. Crying mean they have taken the first breath and cause the lungs to expand flooding with oxygen (increase pressure) Stimulate the baby by drying the baby vigorously. In an emergency, the baby is limp and you may need to smack the bottom of the feet to get them to cry Ductus arteriosus and ductus venosus atrophy and become ligaments If foramen ovale does not snap shut, ASD (atrial-septal defect) results This is a congenital deformity Defect in the wall between the atriums If ductus arteriosus doesn't close then a patent ductus arteriosus results (PDA) These may or may not cause symptoms at first. They are not considered to be cyanotic deformities because they do not cause the baby to turn blue but will eventually turn into an issue Infants first breath Inflated the lungs, markedly reducing pulmonary vascular resistance and increasing pulmonary blood flow The ductus arterosus closes because of increased O₂ pressure changes The increased pulmonary blood flow elevates the pressure in the left atrium, greater than the right atrium, thus closing the foramen ovale

What is the childbirth preparation?

Classes discussing labor, birth options, and pain relief 4-6 weeks long Given at hospitals No preparation and hope for the best!

Signs and Symptoms

Classic Triad Hypertension Edema Proteinuria

How to educate about breast care and breast feeding?

Colostrum is secreted from breasts till 3-4 days post-partum - pre milk - small amount and is high in calories and proteins. It is exactly what the baby needs. As long as the baby is latched properly, the baby is getting what they need True breast milk follows Breast feeding must be kept up to maintain milk supply Soft first 1-2 days then firm If breast feeding Warm compresses or shower as needed for engorgement. Encourage Nursing every 2-3 hours Will see a lot of encouragement to get mom's pumping to stimulate breast to produce milk Relieve their anxiety of their milk production - the more they breast feed or pump, they are going to make milk depend on their schedule If not breast feeding No stimulation, tight bra, ice, pain med as needed prn. No stimulation of the nipple which can caused milk production Tight sport bra will prevent them to produce milk Cabbage leaves help with engorgement

Etiology and Pathophysiology of Seizure

Common causes during the first 6 months of life Severe birth injury Congenital birth defects involving CNS Infections Inborn errors of metabolism Common causes from ages 2y to 20y Birth injury Infection Trauma Genetic factors Common causes between ages 20 and 30 Structural lesions Trauma Brain tumor Vascular disease Gliosis (scar tissue) often found in area of brain from which epileptic activity arises Thought to interfere with normal chemical and structural environment of neurons This makes them more likely to fire abnormally. Genetic Link Genetic abnormalities may be the most important factor contributing to IGE. Some types of epilepsy run in families. Other types of IGE are related to abnormalities in specific genes. More than 500 genes could play a role. • Other types of IGE are related to abnormalities in specific genes that control the flow of ions in and out of cells and regulate neuron signaling or are involved with protein and carbohydrate metabolism. Genetic Link Difficult to determine the role of genetics due to the problem of separating genetic from environmental or acquired influences Clinical Manifestations Determined by site of electrical disturbance Divided into two major classes: generalized and focal The preferred method of classifying seizures is presented in Table 59-6. This system is based on the clinical and electroencephalographic manifestations of seizures. In some forms of epilepsy, families carry a predisposition to seizure disorders in the form of an inherently low threshold to seizure-producing stimuli. So the person may have such a reponse in the presence of trauma, disease, and high fever. Abnormal genes may influence the disorder in subtle ways. For example, a person with epilepsy may have an abnormally active version of a gene that increases resistance to drugs. This may help explain why antiseizure drugs do not work for some people. • If a patient is diagnosed with a seizure disorder, it is very important to classify the seizure type correctly. The choice of treatment depends on the type of seizure.

Face

Concern about facial nerve damage Forceps Bruising Vacuum Bruising Red Flag: Face Normal Crying Infant - needs to be symmetrical Always assess your baby is crying

Piaget's Cognitive Development

Concrete Operations thought becomes increasingly logical and coherent Children are able to classify, sort, order and organize facts to use in problem solving They do not have the capacity to deal in the abstract: they solve problems in a concrete and systematic way based on what they can perceive Children can consider points of view other than their own

Epilepsy

Condition in which a person has spontaneously recurring seizures caused by underlying chronic condition In United States 3 million people have epilepsy. Incidence is increasing in older adults. There are more than 200,000 new cases of epilepsy diagnosed in the United States each year. New cases of epilepsy are more common in African Americans and in socially disadvantaged populations. Males are slightly more likely to develop epilepsy than females. People at high risk to develop epilepsy include those with Alzheimer's disease or those who have had a stroke. The risk is also increased in a person who has a parent who has epilepsy.

What is capacitation?

Conditioning responses of sperm when exposed to reproductive tract enabling a physiologic change that removes the protective coating from head of sperm (acrosome) that allows sperm to fertilize ovum Additionally small perforations form in acrosome allowing enzymes to escape These enzymes are necessary for sperm to penetrate protective layer of ovum before fertilization

Types of Cardiac Defects

Congenital Anatomic: abnormal function present at birth Acquired Disease process Infection Autoimmune response Environmental factors Familial tendencies Can get a systemic infections as a result of the heart problems We can have problems with the kidneys

What is the umbilical cord?

Connects fetus to placenta and ultimately the mother Unique structure Has 2 arteries and 1 vein (AVA) The arteries carry deoxygenated blood (blood with lower O₂ content) - away from the baby The vein carries oxygenated blood - toward the baby Get oxygen from the placenta which came from the mother Nurse is responsible for looking for the three vessels cord - AVA Substance that separates the vessels in the cord is called Wharton's Jelly Is a "jelly-like" substance that is about 90% H₂O Cord is about 18-22 inches long we don't measure unless it is suspected too short or too long

Is Baby Getting Enough?

Count the diapers: 1 diaper to Day of life. By end of the week, baby should be having 6 to 8 wet diapers per day Feeding patterns: Wake baby every 4 hours to feed in the first 2 weeks of life Weight Gain Pediatrician may prescribe Vitamin D drops and iron supplements at 5 months To ensure adequate hydration, you need two wet diaper on day two - if not that is a big problem

Is baby getting enough?

IBD

Crohn's Disease Crohn's disease is swelling and inflammation in the wall of the digestive tract. Both the inner lining (mucosa) and the deeper layers of the wall become inflamed. 30% of children with Crohn's disease have a close family member who also has the disease. We know that it affects boys and girls equally. Crohn's disease most often affects the end of the small intestine but can happen anywhere along the digestive tract from mouth to anus. Crohn's disease can move along the digestive tract and can cause inflammation in one area of the digestive tract, leave the next area disease free and affect another area further down. Symptoms of Crohn's Disease Common symptoms can include: frequent diarrhea stomach pain or cramping blood in stool fevers weight loss joint, skin or eye irritations Nutritional complications: malabsorption, anorexia, short stature, secondary lactose intolerance, decreased bone mineralization and specific nutrient deficiencies. Corticosteroid therapy may impact growth and bone mineral density Most patients achieve a reasonable final adult height Intestinal obstruction, fistulae, abdominal abscess, perianal disease, arthritic can occur Crohn colitis carries a risk for adenocarcinoma of the colon Ulcerative Colitis Ulcerative colitis is a condition in which the inner lining of the large intestine gets swollen and inflamed. Over time, this can damage the intestine and cause sores, or ulcers Research indicates that ulcerative colitis happens because something goes wrong between a child's genetic makeup, their immune system and their microbiome. This causes the intestine to become inflamed. The immune system isn't able to stop the process and restore the balance. Instead, the area stays inflamed. Up to 20% of people with ulcerative colitis or Crohn's disease are younger than age 18. Ulcerative colitis tends to run in families. About one in five people with ulcerative colitis has a close relative with some form of IBD. Symptoms Of Ulcerative Colitis Cramping pain in the belly Ongoing diarrhea, sometimes bloody The symptoms range from mild pain, loose stools or gassy belly to severe, where a child doubles over with pain, loses weight, passes stools more than eight times a day and passes blood. They can vary over time. It's normal for a child to go without symptoms for months or even years and then have symptoms reappear. Medications for IBD Reduce inflammation in the inner lining of the intestine (amino salicylates) Suppress the overactive immune system (corticosteroids). Block the immune reaction that worsens inflammation (immunomodulators, such as azathioprine) Block certain substances that fuel the process of inflammation (TNF-alpha blocking agents, such as infliximab or adalimumab) Control bacteria growth (antibiotics) Surgical Options for UC There are two main types of surgery for ulcerative colitis. Both are surgeries to remove the colon. J-pouch surgery (temporary ileostomy) Ileoanal anastomosis Pull-through operation Restorative proctocolectomy (permanent ileostomy) Surgery is not curative for Crohn's. Surgery is curative for UC and recommended for the steroid dependent or resistant patient Managing IBD Collaborative Bowel rest Improve nutrition TPN/PPN Surgical resection? Can lead to short bowel syndrome with repeated surgeries Prevent infection Symptom relief Enhance quality of life Medications Azulfidine (sulfasalazine) Antibacterials Flagyl (metronidazole) Cipro (ciprofloxin) Immunosupressants (Imuran) Biologics Remicade, Humira, Cimzia, Tysabri) Steroids Oral vs. IV

Mortality Data

Cultural and environmental rather than organic factors pose the greatest threats to life. Three leading causes of death include: Unintentional Injury (48.8%) Homicide (16.7%) Suicide (11.1%) Motor vehicle crashes are the leading cause of death among teens in the US Graduated Driver Licensing Programs More Vigorously enforced laws on minimum legal drinking age, blood alcohol concentration (BAC) and safety belt use Demographic and economic changes that impact adolescents: Decrease in two parent households from 79% in 1980 to 66%in 2015 Number of children living below the official poverty threshold increased by 14.7% Consequences for adolescents: Unintended pregnancy Sexually transmitted diseases Substance abuse and tobacco use Dropping out of school Depression Runaways Physical violence Juvenile Delinquency Most of the teaching is focus on the environmental risk factors

Moderate-Severe Preeclampsia-Hospitalized

Daily weights Urine dipstick for Protein; 24 hour urine Strict Intake and Output Fetal activity Increase Fluids Nutrition Lot of the patients are on clear liquids Same time, same clothes each day ,post voiding, before breakfast Report ^ in Protein and Decrease in output Activity- kick count , fetal monitor- takes > than 3 hours for 10 kicks call M.D. Fluids should be at least 2500-3000/day. Hospital- receive IV fluids- prevent dehydration. *Plasma volume is now decreasing because fluid has moved out of the cells and into the tissues- need to increase fluids to prevent dehydration of those cells Nutrition-^protein- What is a good protein meal? Snack?^ calcium(1200mg) Don't limit salt intake-PIH have decreased blood volume- salt will help to retain volume and placental perfusion- Avoid potato chips No ETOH, No Smoking Foods high in roughage-bed rest -need to ^ peristalsis Water Therapy is a treatment of ideep immersing the pregnant women into water to remobilize extravascular fluid. This will ^diuresis, ^ renin and decreases progression of preeclamsia Homan's Sign Environment Seizure Precautions Padded side rails Suction equipment at bedside Oxygen available Emergency equipment and medications available Greater risk of Thromboembolism due to prolonged bed rest- TEDS needed Environment- quiet, non stimulating- particularly as condition worsens, subdued lighting

Gestational Age

Date of Last Menstrual Period Fetal ultrasound Ballard Score AGA: Appropriate for gestational age SGA: Small for gestational age (also known as IUGR) LGA : Large for gestational age SGA: Is the growth disorder symmetrical or asymmetrical? Symmetrical: Weight, length and head circumference all <10% Asymmetrical: only one of the above would be less than 10% (example weight) Asymmetrical growth restrictions imply a problem late in the pregnancy such as placental insufficiency or PIH. Symmetrical growth restrictions imply an event in early pregnancy such as chromosomal abnormalities, drug or alcohol use

How to obtain the gestational age?

Indications for Problems

Decline in school performance Excessive school absences or cutting class Frequent or persistent psychosomatic complaints Changes in sleeping or eating habits Difficulty concentrating or persistent boredom Signs or symptoms of depression, extreme stress or anxiety Withdrawal from friends or family or change to a new group of friends Severe violent or rebellious behavior or radical personality change 9. Conflict with parents 10. Sexual acting out 11. Conflicts with the law 12. Suicidal thoughts or preoccupation with themes of death They may make comments such as things would be much better if I was not here. Talk to them because study have shown that talking to them will help them talk them out of suicide. They want someone to talk to. 13. Drug or alcohol use 14. Running away from home

Magnesium Toxicity

Decrease DTRs -> Loss of DTRs EKG changes - prolonged P-R and S-T, Heart block Somnolence (inability to arouse verbally or light touch) Respiratory arrest Cardiac arrest Assessment of DTR +1 is therapeutic but 0 is toxic

What is conception?

Defined as the union of egg and sperm and marks the beginning of pregnancy Occurs in the ampulla of the tube Or the curvature of the fallopian tubes is where the fertilization occurs

Cerebral Palsy (CP)

Definition "A group of permanent disorders of the development of movement and postures, causing activity limitations that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain" Characterized by abnormal muscle tone and coordination Incidence: 2.4-3.6 per 1000 live births Most common permanent physical disability in childhood It is going to stay with them for the rest of their life Affected children: 15%-60% also have epilepsy Causes of Cerebral Palsy Prenatal brain abnormalities Gross abnormalities of the brain Vascular occlusion Laminar degeneration Effects of low birth weight Anoxia Hypoxic infarction or hemorrhage Movement Disorders in Cerebral Palsy Defined CP based on their movements Diagnostic Evaluation of Cerebral Palsy Infants at risk: Require careful assessment during early infancy Neurologic examination and history are the primary means of diagnosing Neuroimaging Metabolic and genetic testing Clinical Manifestations of Cerebral Palsy Delayed gross motor development Abnormal motor performance Alterations in muscle tone Abnormal postures Reflex abnormalities Associated disabilities Goals of Therapy for Cerebral Palsy Foster locomotion, communication, and self-help skills Correct associated defects as effectively as possible Provide educational opportunities adapted to the child's capabilities Promote socialization experiences Therapeutic Management of Cerebral Palsy Ankle-foot braces: may be worn Orthopedic surgery to correct spastic deformities Pharmacologics to treat pain r/t spasms and seizures Botulinum toxin A injections Stop the muscle spasms Paralyzing Facilitate dental hygiene Physical/occupational therapy Get them up and moving Working on fine and gross motor skills May have a different length in their legs Ongoing Issues Moderate impairment: 85% of patients can achieve ambulation Cognitive impairments: in 30%-50% variable Growth can be affected Survival dependent on comorbid conditions Care Management of Cerebral Palsy Assisting the family in devising and modifying equipment and activities Optimizing nutrition Medication administration Safety precautions Recreational activities Physical, speech, and occupational therapy To prevent complications Improve their ADL Support for family Assisting with Feeding Could be at risk for aspiration if not swallowing properly

What is the definition of prenatal care?

Definition- care delivered by a combination of professionals throughout pregnancy and the post- partum period. Including: MD, RN, CRNP, midwife, NP, nutritionist, social worker, CB educator Make referral to the hospital they are going to deliver such as nutrition

Post Partum Hemorrhage

Definition- Loss of 500 cc's of blood or more after delivery More than 1000 mL after c sections Post-partum hemorrhage- most serious and most common type of excessive obstetric blood loss Two types of the post-partum hemorrhage Early- from delivery up to 24 hours post-partum Late- from the 2nd day to the 28th day post-partum If the patient is d/c- late post-partum hemorrhage can be severe and life threatening because of home status Etiology Uterine Atony- most common cause of post-partum hemorrhage Lacerations of birth canal Retained placental fragments- causes sub involution of uterus. This is most common cause of late post-partum hemorrhage Assessment Obvious large loss of blood at delivery- report of large loss of blood Consistent trickle of blood or spurting (laceration) Boggy Fundus with large clots Signs of physiologic shock (decrease BP, increase pulse, shortness of breath- skin pale and diaphoretic) Saturation of large pad in 60 minutes or less Nursing Interventions Priority- reverse physiologic shock Start IV fluids with pitocin Stop bleeding- uterine massage IM prostaglandins Oxygen - 10-12 L/ min. face mask Foley Surgical interventions- ligation of uterine and hypogastric arteries or possible hysterectomy

Spontaneous Abortions (Miscarriage)

Definition- Spontaneous termination of pregnancy before viability of fetus is reached (before 20 weeks) as a result of either maternal or fetal stressors. Most spontaneous losses occur between 8-12 weeks of pregnancy. Etiology Fetal stressors- 70-80% of all miscarriages are due to defects in the ovum or placenta. Maternal stressors- 15-20% of all miscarriages are due to maternal stressors Ex: Hormone interruptions- specifically progesterone. *Either as a carry over from an inadequate luteal phase or from a failing corpus luteum of pregnancy. Malnutrition Maternal illness (Immunologic factors, Infections, Systemic disorders) Types of Spontaneous Abortions Threatened- Presentation of any vaginal bleeding that occurs during early pregnancy. Woman may experience MILD uterine cramping or backache NO dilation or effacement of cervix Products of conception are not passed Bleeding usually stops spontaneously Inevitable Abortion Presentation of vaginal bleeding with uterine cramping accompanied with dilatation and effacement of cervix. Suggesting impeding loss of the products of conception. Inevitable loss is either complete or incomplete Usually in the early pregnancy like first term Spontaneous abortions (SAB) may be due to the genetic defect in the ovum that causes the loss of the fetus EAB (elective abortions) Management of Spontaneous Abortions Bed rest Avoidance of physical stress Avoidance of intercourse for 2-3 weeks following the stoppage of bleeding Hospitalization not required Progesterone may be given if deficient endogenous progesterone is cause HCG assessment and ultrasound HCG levels is still elevated which means that there is a baby in utero or at least some form of conception If the HCG levels went down, there is no product of conception Complete and Incomplete Complete- All P.O.C. are passed completely- usually occurs up to 10 wks. of pregnancy Incomplete- occurs after 10 wks. of pregnancy. P.O.C. are passed but not passed completely. Pain and bleeding persist. POC = product of conception DE - Dilation and evacuation - a doctor that scrapes and evacuates the uterus and contents in there DC - same procedure which is a dilation and curettage which means just cleaning of uterine lining May get motrin for pain Management for Complete No D&C necessary because all fetal tissue is passed Bleeding will stop and cramping will subside Pain meds can be given for cramping Recovery is one of normal involution Rhogam given if patient is RH- Management for Incomplete D&C usually necessary to remove residual contents of uterus (decidua) Patient may require blood replacement if blood loss is great May be on antibiotic after D&C May be on ergotrate product (vasoconstriction and uterine contraction) Methergine .2 mg (po) q 4 hrs. x 3-4 doses; im x1-2 Rhogam if RH-

Post-Partum Infections

Definition- puerperal infection is any clinical infection of the genital tract that occurs within 28 days of delivery Infections result from bacteria found within the vagina or from the introduction of bacteria from outside Types (2) Local lesion Placental site- becomes infected and endometrium becomes infected- endometritis Lacerations of vagina and cervix Episiotomy Peri urethral Vulva Extensions Infections that occur secondary to original cause Extends into tubes and veins of pelvic area and soft tissue Clinical Assessment of Endometritis or Other Genital Tract Infections Fever over 100.4 or more after the first 24 hours on 2 or more occasions Malaise, fatigue, anorexia, chills Foul smelling lochia Tachycardia Uterine and pelvic tenderness Subinvolution of uterus Hx of ROM > 18-24 hours Sources of Infection Exogenous Resp-transfer Poor hand washing + colonization of GBS Prolonged ROM Endogenous Occurs from within body Traumatic delivery can traumatize tissue and make it devitalized. Makes it more vulnerable to pathogenic organisms.

Anemia

Definition: A condition in which the number of red blood cells (RBCs) or the hemoglobin (Hgb or Hb) concentration is reduced below normal values for age Concern: This condition diminishes the oxygen-capacity of the blood, causing a reduction in the oxygen available to the tissues Signs and Symptoms tiredness and weakness pale skin, especially around the hands, nails, and eyelids rapid heartbeat or a heart murmur irritability low appetite dizziness or feeling lightheaded Anemia is not a disease but an indication or manifestation of an underlying pathologic process- Diagnostic Evaluation Relatively Inexpensive: History and physical examination CBC- Complete Blood Count Decreased RBCs Decreased Hemoglobin and Hematocrit Anemia is defined as a Hemoglobin of under 10g/dL

Missed Abortions

Definition: After spontaneous death in utero, the P.O.C. are retained for longer than one month. Signs of threatened abortion subside Loss of symptoms of pregnancy Uterus does not continue to enlarge but shrinks and becomes irregularly firm Brown vaginal discharge may develop Placental function stops and decreases levels of HCG in blood - absence of healthy gestational sac on ultrasound Rx - D&C is usually done When you stop feeling nausea in the first trimester, that means the pregnancy could be loss. It is a good sign that nausea occurs during first trimester Very normal for mother to be nauseous and vomiting nt eh first 12 weeks and then stops. But stops before 12 weeks, it is an issue. Nausea occurs because the fetus is making the extra hormones that's making the mother sick.

Ectopic Pregnancy (First Trimester)

Definition: Any gestation located outside of uterine cavity. 90% of ectopic pregnancies are tubal. Physiology: Wall of tube is not sufficiently elastic to allow beyond 8-12 weeks of gestation. Rupture of tubal wall is inevitable Endometriosis - when the inner lining of the uterus (endometrial lining) is located outside of the uterus and can float away to other parts of the organs. Very severe pain and uncomfortableness! Causes of Ectopic Pregnancy Caused by any condition, which narrows the tube or brings about some constriction within it. Examples P.I.D. from STD's (pelvic inflammatory disease) Congenital narrowing Tuboplasty or surgical reconstruction Like tubes tied (tubal ligation) Will cause scar tissue Anything that can cause the narrowing of the tubes Tubal scarring from endometriosis Clinical S&S Patient usually exhibits the common signs and symptoms of pregnancy Patient experiences sharp knife-like pain either (R) or (L) lower quad May have vaginal bleeding May show signs of shock if large amount of blood has escaped into peritoneal cavity Hypovolemic shock Women who have had one ectopic pregnancy have a higher chance of another due to underlying cause. Pregnancy Test + Hormones are being produced No evidence of gestation sac in uterus Nothing in the uterus in the ultrasound then they go looking elsewhere to see where did it attached Management of Ectopic Pregnancy with Rupture Hospitalization IV Fluids Surgical removal of tube if ruptured Tuboplasty may be attempted in order to preserve fertility Post-Op Care IV Fluids Pain Control ABD Incision care & assessment v/s Diet as written for Activity Rhogam in RH - Management Before Rupture Administration of Methotrexate (chemotherapeutic drug that kills dividing cells) drug will stop cellular division. Integrity of tube is preserved. In patient is RH negative - must receive Rhogam Breast cancer patients take this drug. It is associated with cancer patient

Placenta Previa

Definition: Implantation of the placenta in the lower uterine segment Types of Previa (4) Complete - placenta covers internal cervical os completely -100% Have to have a c section Partial- placenta covers internal cervical os partially or 30% Marginal- placenta is @ margin of internal cervical os Low-lying- placenta is a low implantation and only a small area is encroaching on the internal os Etiology of Previa Exact cause is unknown Perhaps uterine scarring from previous surgery (Example D&C) Anatomical abnormality in upper uterus or presence of small fibroids Multiple gest with large placental site Incidence: 1 out of 200 pregnancies Clinical Manifestations Main symptom is painless vaginal bleeding For complete and partial, there is intermittent, painless bleeding starting around 28 weeks For marginal and low-lying- bleeding usually starts with labor Bleeding with previa is not associated with activity level Uterus is relaxed and non-tender Interventions The DX of previa is confirmed with ultra sound If complete or partial, should be hospitalized for stabilization or may be the duration of the pregnancy Patient on CBR if at home to prevent pre-term labor Regular monitoring of FHR and NST (for fetal activity) Never perform vaginal exam on the patient with a suspected previa Put her on fetal monitoring to see if the uterus is contracting and send the mother off to c section We don't want her to be dilated and we don't want to irritated her cervix Goals for complete and for partial previa is to get fetal age to 35-37 weeks without compromise to mother, then deliver via C-section C-section incision on the uterus is vertical so that placenta won't be cut Marginal and low-lying BR with BRP's at home Frequent assessment of FHR and fetal activity (NST) SVD will be planned or possible C-section

Placental Abruption (2nd & 3rd Trimester)

Definition: Premature separation of a normally implanted placenta Usually occurs after 20-24 weeks Can occur with labor Placental abruption is classified according to degree of separation Types of Abruption (4) & Clinical Signs Classifications based on degree of separation After the baby is delivered, look at the placenta to see what are the clots are and that it has 22 lobes Mild (10-20%) No external bleeding Less than 1/6 of placenta + FHT Some pain Moderate (20-50%) Bleeding is either retro-placental or vaginal Separation is ½ or less + FHT Moderate pain Severe (75%) 2/3 of placenta separated Uterus is board-like and rigid Bleeding is retro-placental and sometimes vaginal FHR shows severe distress or is absent Severe pain Complete (100%) Placenta completely separated Maternal shock will develop quickly (low BP, high pulse, change in L.O.C. FHT- absent- fetal death will occur within 6-8 mins. Neonatal resuscitation mandatory Mother will have severe, agonizing pain in fundal area Uterus is HARD Bleeding is retro placental Etiology of Placental Abruption Any condition that contributes to vascular changes Examples: P.I.H. (Pregnancy - induced hypertension) Diabetes (type I or I.D.D.M.) Renal disease Drug abuse - especially cocaine and crack Short cord Occasionally severe, blunt trauma to abdomen Medical Interventions Determined by the amount of separation and blood loss - compared with fetal age and status Mild Conservative RX-BR with close observation until 37 weeks Moderate C-section after stabilization of mother Severe Very serious- emergency c-section -fetal distress + Reverse maternal shock ASAP (IV's, blood, vasopressers) Complete OB emergency- Crash c/s (emergency c/s) Very quick general anesthesia Fetal Distress + -- neonatal resuscitation necessary! Mother in hemorrhagic shock due to blood loss ICU post c-section Cardiac monitoring and hemodynamic monitoring IV's Blood Replacement Oxytoxic drugs To ensure that the area where the placenta separated that those vessels are constricting Nursing Care with Placental Abruption Be alert for any development of sudden unrelenting uterine pain, with board-like rigidity, with or without vaginal bleeding. Especially in those that are in a high risk category Ongoing assessment of FHT's with uterine status Oxygen at 10-20 L/min. via face mask with decreased FHR Initiate pad count if vaginal bleeding present Insert foley Monitor hourly outputs T&C 2 units whole blood Ultrasound to assess status placenta If severe abruption or complete- then emergency c/s No hemostasis till placenta is removed Post: OP Care for Severe or Complete IV's Blood Pain control- PCA Oxygen Cardiac Monitoring Foley with hourly assessment v/s Rhogam if candidate Complications of Placental Abruption Couvelaire uterus- condition where by blood is absorbed into muscle of uterus. Muscle fibers become drenched or soaked with blood and uterus can't contract on its own. May lead to uterine rupture Rx- heavy doses of oxytoxic drugs are used to force uterus to contract and press blood out DIC- Disseminated Intravascular Coagulation Pathologic form of clotting Condition whereby the coagulation sequence is activated in a clinically inappropriate manner and leads to a series of events that results in hemorrhage or thrombosis or both Placenta Accreta Placenta invades or is inseparable from the uterine wall Risk: Previous C/S Placenta Previa Treatment is hysterectomy (removal of the uterus) Placenta Increta Chorionic villi invade myometrium Placenta Precreta Chorionic villi through the myometrium into adjacent organs (bladder)

Risk factors

Demographic Risks: Race, age, socioeconomic background, number of pregnancies/births Biophysical Risks: Maternal medical conditions; obesity; stress Behavioral-Psychosocial Risks: Poor prenatal care, domestic violence, smoking, homelessness, drug use Demographic Risks SEE PAGE 487 Low socio-economical Unmarried Less than high school education Age < 15 OR > 35 yrs old Non-white Population Behavioral-Psychosocial Risks Poor nutrition Smoking (> 10 cigarettes per day) Substance abuse Inadequate prenatal care Excessive physical activity Excessive stress in life (incl. long commutes)

Pre-gestational diabetes mellitus

Diabetes mellitus before pregnancy Preconception counseling is very important: Stop oral hypoglycemic (?? Effectiveness and safety) Start insulin Strict glycemic control before pregnancy. Strict glycemic control in the early weeks of pregnancy (organogenesis) is instrumental in decreasing the risk of congenital anomalies. Understand effects of pregnancy on diabetic condition Insulin needs during pregnancy First Trimester Insulin need is reduced because of increased utilization of glucose by embryo and fetus Increased levels of estrogen and progesterone stimulate pancreas to increase insulin production Because of "morning sickness" and decreased food intake patients tend toward hypoglycemia. IDDM Moms are prone to hypoglycemia Insulin needs during pregnancy Second trimester Insulin needs increase as placental hormones (cortisol, insulinase) increase The hormones act as insulin antagonist These hormones cause the body to resist the uptake of insulin and cause insulin resistance Maternal insulin requirements gradually increase from 18-24 weeks Insulin needs during pregnancy Third trimester Similar to 2nd trimester, but insulin requirements start to level off at about 36 weeks Pre-gestational diabetes mellitus Maternal risks and complication Hydramnios - 2000 ml's or more of amniotic fluid Polyhydramnios Very common in diabetic pregnancy (fetal polyuria) Overdistension of uterus -> compression of maternal vena cava and aorta -> supine hypotension Increase risk of PROM, PTL, PP Hemorrhage Ketoacidosis (accumulation of ketones in the blood sec to hyperglycemia) - occurs most often in 2nd and 3rd trimester when insulin resistance is greatest Can occur with a sugar of 200 mg/dl. IU death can happen with a "DKA" episode Hypoglycemia - most common in 1st trimester Hyperglycemia - most common in 2nd and 3rd trimesters

Diagnosing Meningitis and Therapeutic Management

Diagnosing Meningitis Lumbar Puncture (LP) analyze CSF To √ gram stain, blood cell count, & culture Findings supporting dx of meningitis ↑ pressure ↓ protein ↓ glucose ↑ WBC (Leukocytes) Blood & Nasal / Throat Cultures May be helpful in DDx Lumbar Puncture Therapeutic Management Isolation - Respiratory Antimicrobial therapy Maintain hydration - IV / PO Support ventilation Reduce ICP Management of bacterial shock Control seizures Control temperature / febrile state Correct anemia Treat and prevent complications

Diagnosis, Management and Goals of fractures

Diagnostic evaluation Radiographs History taking Suspicion of fracture in a young child who refuses to walk or bear weight Reduction and immobilization Restoring function Preventing deformity

Diagnosis & Management

Diagnostics Throat culture BUT (-) by time RF presents Group A streptococci (GAS) antigen Antistreptococcal antibody levels peak when RF symptoms present Assess for Joint inflammation Skin nodules or rash CXR Echocardiogram ECG Management Rest Maintain hydration Manage dysrhythmias Medications Antibiotics X 10 days PCN Cephalosporins Antiinflammatory drugs ASA Can give aspirin and NSAID Not sure of the correlation with ASA and Reye's Disease Prednisone ACE inhibitors for afterload reduction Digoxin and furosemide if heart failure

Seizure response Dogs

Did you know... Seizure response dogs receive special training to assist those in distress. They can find help if owner is in trouble. They can pull away objects that pose danger. Can carry information about their handler for emergency response teams. Provide emotional support. Do you know what to tell someone if they are interested in buying a seizure response dog? Contact Canine Assistants - one of the largest nonprofits that provide seizure response dogs; they actually specialize in seizure dogs. Understand the process. Although the cost to train a seizure response dog is up to $20,000+, they provide the dogs free of charge to recipients. The cost is covered by private donations to Canine Assistants. However, your patient will need to fill out an application and get on the waiting list. Complete the application. The application and medical form needed is located on the Canine Assistants website. Mail to the address provided on the form. Consider getting on a wait list with a few organizations. If your patient is anxious about getting a dog, you can suggest they fill out applications for a few organizations. This will give you a better chance of finding a dog sooner. Paws With a Cause offers a program, and you can check the American Dog Trainers Network's listing for programs in your state. Be patient while waiting for a dog. The wait list for seizure dogs can be a couple of years.

Complex Focal Seizures

Display strange behavior Lip smacking Automatisms - repetitive movements that may not be appropriate Does not remember an activity started before and continued during seizure Usually last just a few seconds Some automatisms are organized, such as counting out change or picking items from a grocery shelf. Other automatisms are less organized, such as picking at clothing, fumbling with objects (real or imaginary), or simply walking away.

Clinical Presentation

Drowsiness Myalgias Malaise Chills Sore throat Abdominal pain Nausea and vomiting Headache Fever Stiff neck Photophobia Meningeal signs It could be seen as an URI (upper respiratory infections)

What are the colors of newborn?

Color

Due to the large number of red cells present at birth, Caucasian and Asian newborns will have a pale pink skin tone. When the infant cries or passes stool, the color changes to bright pink or beefy red. African American infants have a warm brown skin color that also becomes ruddy with crying Acrocyanosis is localized cyanosis of the hands and feet and is a normal finding Cutis marmorata (Mottling) - baby is cold. Wrap the baby to keep warm Transient Pattern seen when infant is cold Harlequin's Sign - The harlequin color change is most common in low birthweight infants, but can occur in any child. - like a pooling of blood and caused by immaturity of the vessels to contract and dilate. As soon as they put the baby upright it will go away. Only see this in the first few days of life. Temporary condition. The condition is benign, and the change of color fades away in 30 seconds to 20 minutes. It may recur when the infant is placed on her or his side. Jaundice

Neoplasmic Disorders

Each year approximately 150 out of every 1 million children younger than 20 years are diagnosed with cancer. Cancer is the 4th leading cause of death in children behind: unintentional injuries, homicides and suicides Almost half of all childhood cancers involve the blood or blood-forming organs

How is human milk produced?

During pregnancy the body increases its production of the hormone prolactin. Prolactin stimulates the cells in the breast to make milk The amount of prolactin increases when the mother nurses. The size of the breasts is not a factor in the amount of milk that a woman can produce. The baby's nursing needs will control milk production THE MORE A WOMAN NURSES, THE MORE MILK WILL BE PRODUCED

How does the body prepare?

During the 4th or 5th month of pregnancy the body is capable of producing milk. This first milk is called colostrum. Colostrum has all the nutrients that a newborn will need and also contains antibodies to protect babies against infection Colostrum is thick and yellowish in color. It is produced several days after delivery until mature milk "comes in". Mature milk is thinner in consistency and the content will change to match the newborn's needs

What is deceleration?

Early: Pressure on fetal head -> Increase ICP -> Alteration in cerebral blood flow -> Central vagal stimulation -> FHR deceleration It is contraction It means that the baby head is getting lower and lower in the mom's pelvis and the baby's head get squeezed with each reaction and it cause his heart rate to drop When the contraction stop, the nerve is no longer stimulate and the heart rate comes back up It means the baby is coming down closer to the light Variable: Umbilical Cord Compression 15 by 15 counts There is no necessary correlation to the variable deceleration with the contraction Very shaped 15 seconds long and 5 seconds wide and occur as a result of cord compression - has a cord around of the baby's neck Late: Decreased utero-placental oxygen transfer to the fetus PPP - poor placental perfusion and that means something is decreasing the profusion of oxygen through the placenta to the baby Early Deceleration: Gradual; Onset to Nadir >30 seconds Nadir of Deceleration

What are the development of germ layers?

Ectoderm - outer layer forms skin, hair, nails, nasal passages, CNS Mesoderm - middle layer Forms reproductive organs, circulatory system, urinary system Endoderm - inner layer Forms epithelial linings of GI and respiratory tract, liver, thyroid, lungs, pancreas, bladder

Prevention of PTL

Education - Prenatal care, S/S PTL, risks, consequences Assess for risk factors Promote nutrition Improve access *Preterm birth is responsible for almost 2/3 of infant deaths - 75% of infant death

Hypertension

Elevated Blood Pressure Compare with baseline B/P

What are the indications of the C section birth (cesarean birth)?

Emergency: fetal distress Medical: Hypertension, diabetes, heart disease, placenta previa, prolapsed cord, abruption, active herpes infection Placenta previa - when the placenta supposed to be attached to the uterine wall, is really covering the cervix. When the cervix dilates, you have decreased blood flow to the baby and increased risk of bleeding for the mom Active herpes infections - if active, c - section but not can deliver vaginally. WE can premeditate them in the third trimester with Zevorax and not active lesions Cephalo Pelvic Disproportion Head is too big Arrest of dilation/descent Breech/Transverse Previous uterine surgery Vbac - a vaginal birth after c section She can only have it if her c section was a result of fetal distress, breech or like a previa or an abruption Because all of those things have nothing to do with her body's shape, her body's size and her pelvis ability to pass a baby through. If she had a c section because the baby was too big (CPD) will not be eligible for a Vbac What happened, the incision was made in the uterine wall, it weakness that area. If it becomes too thin, it can rupture and if the uterus ruptures, someone dies. The more c section someone has, the weaker and weaker that uterine wall area gets Emergency Birth: C-Section Due to maternal bleeding or fetal bradycardia/ fetal distress Any sudden maternal or fetal life threatening developments

Breast feeding complications

Engorgement Feed the baby on demand. Engorgement occurs when the breasts become too full with milk. If the breast become engorged: Express some milk before breastfeeding, either manually or by pump Soak a cloth in warm water and put on the breasts or take a warm shower before feeding baby. Stimulation circulation and allow the milk to flow more easily For severe engorgement, warmth will not help and cold compresses must be used as you express milk. Ice packs between feedings will help reduce pain and swelling Tylenol is one of the safe medication that can be use for discomfort Gently massage the breasts from under the arm and down toward the nipple- this will reduce soreness and ease milk flow Medications should not be taken unless cleared by the doctor. Tylenol can relieve discomfort and is safe to take occasionally during breastfeeding Remember: Engorgement is a temporary condition. The more the mother nurses the less engorged the breasts will become Mastitis An infection of the breast Symptoms are swelling, burning, redness and pain Usually occurs in just one breast Mother may develop fever and feel ill Treatment: rest, warm compresses and antibiotics. Breastfeeding does not have to stop. The infection will not spread to the milk You can keep breastfeeding the breast that is inflamed The antibiotics are not to worry about crossing over into the milk. Mom does not have to stop breastfeeding Cracked Nipples Caused by poor positioning of infant or inadequate "latch on" Treatment: Use modified lanolin. Wash breasts with water, not soap

Coping with Concerns: School Experience

Entrance to school is a sharp break in the structure of the child's world School is second only to the family as socializing agent Values of the society are transmitted in school Peer relationships become increasingly important Seek Approval Teachers Parents "Latchkey children" Kids come home to an empty home and left to care for themselves until the parents come home Limit setting and discipline Guide desired behaviors and eliminate unwanted ones Beyond time out. Best way to get rid of bad behaviors is to eliminate privileges Reasoning, withholding privileges, compensation Dishonest behavior Tend to embellish stories not telling lies like toddlers Reinforce that it is important to be honest

What is spinal anesthesia?

Epidural Block (Anesthesia from T10 to feet) Walking Epidural - Opioid only Injected Intermittent or Continuous (Via pump) Spinal Block Medications Injected Local and Opioid (Lidocaine & Fentanyl) Injection into the Subarchnoid Space at 4th -5th Lumbar area) Also known as Intrathecal Injection

What is the nursing responsibilities for epidural?

Epidural For C-Section or Vaginal Delivery Set up for Epidural Pre-procedural Assess IV - patient needs to be well hydrated During Procedure Set up Epidural - maintain sterility Support patient S/P Procedure & during Assess for: Hypotension Decrease Respirations Fetal HR Loss of sensation / paralysis lower extremities Hydration give bolus of 500 to 1000 ml IV fluid pre procedure (Crystalloid) Supporting patient Lying - assume knee chest position Sitting - chin to chest and arch back like a cat Nurse stays with patient and holds them steady and still during produre Patient can not move during procedure even with a contraction Takes about 1-2 minutes to take effect and lasts 1-3 hours Done at 5 cm of cervix dilation (not before) Dec. BP is due to Sympathetic blockade with vasodilation of vessels with pooling of blood in the lower extremities Complications associated with Epidural Anesthesia Hypotension Bradycardia / Asystole Dura Tear "Wet Tap" Spinal Headache Catheter Migration Abscess Epidural Hematoma Bradycardia / Asystole Dura Tear - Severe headache Assoc with Dura Tear Tx Headache conservatively - Bedrest, inc fluids (IV), analgesics, Caffeine Headache due to displacement of brain tissue due to dec CSF from leak Treat surgically - blood patch Inject 10-15 ml of pt own blood at or near Epidural puncture site Keep patient supine for 1 hour after blood patch Catheter Migration Danger spinal medication toxicity Systemic Vascular Absorption - inc mortality Sx Circumoral numbness, facial tingling, vertigo/tinnitus, seizures, metabolic acidosis New - Lipid rescue Abscess Check for increase temp and gen malaise May have swollen, redden, warm area at catheter site Epidural Hematoma Sx Numbness, Sharp leg pain, bowel & bladder dysfunction Post Delivery Assess for hypotension and respiratory depression Bladder and bowel atoney - narcan available Stress Incontinence / decrease urinary output (oliguria) Spinal Headache Tx maintain Supine position, hydration, Tylenol, and /or blood patch Pruritis N&V

Defintions and type

Episiotomy A surgical incision of the perineum to enlarge the vaginal outlet to allow for a safe delivery preventing a vaginal wall tear Txbk Surgical incision of the perineal body to enlarge the outlet Second most common procedure in maternal- child care Cesarean Delivery A surgical procedure with an incision through the trans-abdominal site to remove a fetus Oldest surgical procedure ( next to trephening) Types Elective /Planned Emergency / Unplanned

Obstruction of Pulmonary blood flow and an anatomic defect

Examples Tetralogy of Fallot Narrowing of the pulmonary valve Thickening of the right ventricle Displacement of aorta - overriding aorta Ventricular Septal defect Tricuspid atresia

Fetal assessments

FHR- q 8 hours-continuous monitoring Fetal activity Non Stress Tests Stress Test "practice labor" - give pitocin and make the mother contrat to see if the baby tolerate it so they could deliver. If not, then it is stat c sections Estriol Testing- urine/ blood Oxygen to Mom NST will be done at least weekly- -x2-3/wk Estriol - take 24 hour urine and then blood level to see functioning of the placental O2 - especially if fetal bradycardia

Face of newborn

Face Concern about facial nerve damage Red Flag: Face Normal Crying Infant - needs to be symmetrical Always assess your baby is crying

Coping with Concern: Stress and Fear

Family, interpersonal relationships, poverty, gun violence, academic expectations, pressure to have a boyfriend/girlfriend, sports Signs of Stress Stomach pains or headaches Changes in sleep patterns/ nightmares Bed wetting Changes in eating habits Aggressive or stubborn behavior Withdrawal or reluctance to participate Regression to earlier behaviors- thumb-sucking Trouble concentrating or changes in academic performance

What is amniotic fluid?

Fetus floats in it Helps to maintain even temperature Provides cushion against injury Permits symmetric and external growth At term there is almost 1000 cc's of amniotic fluid (1000 mL) Fluid is clear yellow to straw colored Contains fetal hair (lanugo), albumin, urea, epithelial cells, vernix (look like a cream cheese that protect the baby) Fetus drinks and voids into it Amniotic fluid is produced by the fetus's kidneys. It tells the healthcare provider if the fetus's kidneys are working or not by measuring the amount of fluid. Fluid volume controlled by a complex system of fluid exchange Amniotic fluid is referred to as "Bag of Water" in lay terms When the amniotic fluid is wrap around the fetus's limb, it will prevent the limb development as the fetus develops. That is one of the reasons why babies can be born without a certain limb. Having less than 300 mL of amniotic fluid (oligohydramnios) is associated with fetal renal abnormalities and having more than 2 L of amniotic fluid (hydramnios) is associated with gastrointestinal and other malformation An appropriate amount of amniotic fluid is 700 to 1000 mL

RHD Presentation

Fever Painful and tender joints Most often the ankles, knees, elbows or wrists; less often the shoulders, hips, hands and feet Pain in one joint that migrates to another joint Red, hot or swollen joints Small, painless nodules beneath the skin Chest pain Heart murmur Involved with the valves Fatigue Flat or slightly raised, painless rash with a ragged edge (erythema marginatum) Irregular border Jerky, uncontrollable body movements (Sydenham chorea or St. Vitus' dance) — most often in the hands, feet and face Outbursts of unusual behavior, such as crying or inappropriate laughing, that accompanies Sydenham chorea

Meningitis 3 Classic Signs

Fever Headache Meningeal signs Note: "The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs." (Medscape)

Clinical diagnosis

Fever more than 5 days PLUS 4 more S&S Redness of palms and soles Desquamation Beau's lines Rash Oropharyngeal changes Conjunctivitis (no drainage) Cervical lymphadenopathy

Bowel care

Fiber and increase liquids. (Water is best!!) Walking and OOB -ASAP Stool softeners daily, prn

What is release of cord compression

Fig. 19-16. Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord. Pressure exerted by examiner's fingers in A, vertex presentation, and B, breech presentation.

Uterus care

Firm, decreases 1 cm (fingerbreath) per day Fundal Assessment If there is abdominal stitches, make sure it supported

Magnesium Sulfate for Fetal Neuro-protection

For Pre-term deliveries From Viability to 31.6 weeks Magnesium Sulfate given 2 hours prior to delivery and discontinued at time of delivery Evidence shows Magnesium Sulfate treatment prior to delivery decreases the risk of cerebral palsy in these newborns CP is related to fetal hypoxia

Preexisting Conditions

For some women, pregnancy represents significant risk because it is superimposed on preexisting illness Unique maternal and fetal needs due to these preexisting conditions must be met in addition to usual pregnancy-related feelings, needs, and concerns Metabolic Disorders Endocrine and metabolic disorders require careful management to promote maternal and fetal well-being and positive pregnancy outcomes Diabetes mellitus is the most common endocrine disorder associated with pregnancy

Assisted Birth

Forceps Tong like instrument that assists in birth of fetal head History of poor outcome due to doctors who are not trained with them. Helps with the reposition with the baby not pulling the baby Mom still have to push Vacuum Vacuum cup attached to head to assist in birth of head, using negative pressure. Mother pushes and vacuum helps to pull out at the same time. Increase risk of hematoma - lead to increase of jaundice

Advantages to Formula Feeding

Formula feeding is also a healthy choice for babies. If you use a formula, your baby will get the best possible alternative to breast milk. (You should not attempt to make your own formula or feed an infant cow's milk.) It's convenient. Formula-fed babies can be fed by anyone at any time. It's flexible. You don't have to fit pumping into your work schedule. Instead, you can simply leave formula for your babysitter or day care center. Your partner can help out with nighttime feedings and share that bonding experience with your baby. Scheduling feedings may be easier. Formula isn't digested as quickly as breast milk, so formula-fed babies don't need to eat as often, especially in the first few months. You don't have to worry about what you eat. Moms who breastfeed may have to avoid certain foods that her baby can't tolerate. You can have a glass of wine or a cocktail once in a while. Alcohol is not recommended for women who breastfeed because they pass on small amounts of it to their babies.

Confidentiality

Foster a sense of trust and comfort Sometimes the stated chief complaint conceals the teen's real concern By age 11 or 12, patients should be seen alone Sometimes it is necessary to meet with parents first to obtain a history of the concern, but then it is important to meet with the adolescent alone. This conveys that your primary interest is in them but gives you an opportunity to address parental concerns You have to advise patient that you will maintain their confidence and will obtain permission first from them before speaking to parents unless you feel it is life-threatening Speak with the parent to get their side of the story and then speak with the teen second because it make them feel they are the most important person. After the age of 14 years, we don't have to discuss any mental health issues or sexual behavior unless we have permission of the child. However if the 12 years old is sexually active, it put us in an awkward position because we have to tell them that although we are glad they told us but we have to tell their parents and find out who they been sexually active with because it becomes a legal issue. They cannot consent legally to sex

Necrotizing Enterocolitis (NEC)

GI disease - comes as a result of bowel injury to the intestines as a result of bacteria or inflammation Perforated bowel Etiology - Ischemic injury to the intestinal mucosa, presence of bacteria; Inflammatory disease of the GI mucosa; Complicated by perforation Risk factors: Preterm birth, asphyxia, hypoxia, VLBW Symptoms: Feeding intolerance, abdominal distention, blood stool, bile stained emesis Tx: NPO, NGT w/suction, TPN, Antibiotic therapy, Surgery (Colostomy/ Bowel resection) Nursing Care: IV therapy , Pain Management, assess for abdominal distension

Gastrointestinal adaptations

Gastric capacity is limited in the first day of life to approximately 40 to 60 ml (Shooter Marble) Capacity increases as feedings are introduced and reaches about 90mls by 3 to 4 days of age(ping-pong ball). Pepsinogen is present and begins digestion of the milk when it enters the stomach. Stomach emptying time is approximately 2 to 4 hours. The cardiac sphincter is immature and slight regurgitation of milk after feedings is common. Content of the fetal bowel is called meconium. Most newborns (94%) pass the first meconium stool within 24 hours of birth. Meconium is odorless, thick, dark-green substance composed of bile, fetal epithelial cells and hair, and amniotic fluid. Feedings change the consistency, color and odor of the stools. Transitional stools, seen after 2 to 3 days of milk ingestion, are greenish brown in color and less viscous than meconium By Day 4, breast fed infants pass sweet-smelling, golden yellow, loose "seedy" stools. Formula- fed infants produce pungent, pale yellow "pasty" stools. Breastfed infants usually have more frequent stools After establishing a regular feeding schedule, bowel movements may range from one stool every 2 to 3 days to as many as 10 stools per day.

What are the Gastrointestinal adaptations?

What is amnion?

Generated from fluid filled space around embryo called the amniotic cavity This space is lined with a glistening smooth membrane Amnion encases the amniotic cavity with its fluid, and encases the fetus Amnion is closest to the fetus

Snake Bites

Get to ED! Initial assessment of snake bite determines plan for treatment / antidote ABC's Labs CBC, Coagulation Studies, BUN, Creatinine Serum Antidote Danger of Anaphylactic Rx Immediate treatment Elevate limb No ice, No tourniquet, No cutting or sucking bite Loosen clothing, no restricting clothes or jewelry (take rings off) Due to risk of swellings Manage hypovolemic shock

Urinary Tract Infections

Girls older than 6 months have more UTIs than boys but uncircumcised boys younger than 3 months have more UTIs than girls Common: 8% of girls and 2% of boys will have a UTI in childhood Circumcision reduces the risk of UTIs in boys Most UTIs are ascending infections-which means they are caused by disease agents traveling upward through the urethra to the bladder Most common organisms responsible are E.Coli (85%), Klebsiella, Proteus, Pseudomonas, and other gram-negative bacteria Enterococcus and Coagulase-negative staphylococci less common More the issue is not wiping well - Front to back! Pathogenesis Dysfunctional voiding leading to incomplete emptying of the bladder and stasis are the primary cause Any condition that interferes with the complete emptying of the bladder: Constipation Neurogenic bladder Poor perineal hygiene, structural abnormalities, catheterization and sexual activity Structure of the lower urinary tract is believed to account for the increased incidence of infection in females Vesicoureteral reflux, anatomic abnormalities or bladder compression are conducive to infection Types of UTIs Recurrent: repeated episodes Persistent: bacteriuria despite antibiotics Febrile: typically indicates pyelonephritis Cystitis: inflammation of the bladder Pyelonephritis: upper urinary tract and kidneys Urosepsis: bacterial illness; urinary pathogens in blood Signs and Symptoms Newborns and infants have non-specific signs: fever, hypothermia, poor feeding, irritability, vomiting and sepsis Strong, foul smelling urine may be noted Preschool children may have abdominal pain or flank pain, vomiting, fever, urinary frequency, dysuria , urgency and enuresis School age: Cystitis (frequency, dysuria, urgency or Pyelonephritis (fever, vomiting and flank pain) Diagnostic Evaluation of Urinary Tract Infections Urine culture and sensitivity (Primary tool) Suprapubic aspiration (for culture) Percutaneous kidney taps Bladder washout procedure Ultrasonography Voiding cystourethrography (VCUG) VUR: congenital abnormality present in 1% of the population Intravenous pyelography Treatment Children younger than 3 months should be admitted and treated with IV antibiotics(increased risk for dehydration, toxicity, sepsis) Uncomplicated cystitis: amoxicillin, Bactrim, or first generation cephalosporin Course (po): 7 to 10 days Pyelonephritis: cefixime (Suprax) Therapeutic Management of Urinary Tract Infections Eliminate current infection Identify contributing factors to reduce the risk of recurrence Prevent systemic spread of infection Ensure adequate or increased fluid intake Preserve renal function Prevention of Urinary Tract Infections Instruct parents to observe child regularly for signs of infection Teach patients that simple hygiene habits should be routine Teach patients & caregivers proper cleansing of genital area Encourage sexually active adolescent girls to urinate as soon as possible after intercourse

What is episiotomy?

Goal to minimize laceration of perineum and over stretching of perineum tissue Make room for the baby's head and to prevent any further damage to the mother Types Midline Mediolateral Controversy Indications Complications Methods to reduce episiotomies Midline Straight down towards the rectum Mediolateral can be left or right and it is to the side of the midline inscision (lateral) Txbook see page 550 Although an episiotomy is still performed it is done less than previously Txbk discusses controversy to performing episiotomies past purpose to minimize the risk of lacerations to the perineum to ovoid a 3 or 4th degree laceration Episiotomy increase risk of deep perineal tears Perineal lacerations heal more quickly than episiotomy Can increase risk of 4 degree trauma (laceration through anal sphincter) Studies show inc risk of laceration Indications prevent tearing Complications: Inc tear Blood loss Infection Pain Perineal discomfort Methods to reduce Incidence in performing episiotomy Kegel exercises during pregnancy to increase vaginal tone Perineal massage during pregnancy Avoid lithotomy position during procedure Avoid pulling up legs during delivery (pushing stage) thightens the perineum inc risk of tearing Sidelying when pushing during delivery promote slow birth and less tearing Warm compresses to perineum Proper breathing technique during delivery Indications for an Episotomy Prevent damage to the peri-urethra, perineum, sphincter & rectum from a laceration Prevent jagged tears Reduce mechanical and metabolic risk to fetus Protect maternal bladder Prevent future perineal relaxation Extensive vaginal tearing appears likely baby is in an abnormal position baby is large (fetal macrosomia) baby needs to be delivered quickly Through research Today episotomies are done due to time, avoid malpractice, conventional medical education practices, birth setting, lack of experience with perineal stretching techniques and interventionist practice patterns Dec amount of epistomies performed about 1/3 of all vaginal births (MayoClinic.org) Complications associated with Episiotomies: Blood loss Infection Pain Perineal discomfort including painful intercourse Management: Methods to reduce need for episiotomies: Kegel Exercises during pregnancy Better control over the speed of the delivery of the head and not lead ot severe tears or the need for episiotomy Perineal Massage Massaging the tissue during pregnancy for at least 10 minutes at least once a day Avoid Lithotomy Position during pushing stage Safest position for the baby to be in Side lying to promote slow delivery and less tearing Warm Compresses Teach proper breathing techniques Lithotomy position causes excessive perineal stretching Encouraging or requiring sustained breath hold during second stage of labe causes excessive perineal stretching , can adversely affect blood flow in the mother and fetus and encourages the woman to be responsive to the caregiver directions rather to her own urges to push. Time on the physician during the second stage

Definition of terms

Gravidity - state of pregnancy Gravida - woman who is pregnant Multigravida - woman who has had two or more pregnancies Parity - number of past pregnancies in which the fetus or fetuses have reached 20 weeks gestation. Parity is not affected by whether the fetus is born alive or is stillborn. G3, P1 = 3 Pregnancies, 1 birth over 20 weeks. G1, P2 = 1 Pregnancy, 2 births (twins) Viability - the ability to live outside the uterus. Usually considered to be 22-24 weeks of gestation of fetal weight of 500 grams or more. Consider the nature of the care by the viability of the fetus a woman that is pregnant at 16 weeks vs a woman that is pregnant at 25 weeks Multipara - women who have had 2 or more pregnancies to stage of viability Stillborn - fetus that shows no sign of life at birth Anything that dies over 22 weeks while in utero is considered to be stillborn Anything that dies under 22 weeks while in utero is considered to be a miscarriage Preterm - pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks Post term - pregnancy that goes beyond 42 weeks This is when you are considered to be overdue Term - pregnancy from beginning of 38 weeks to the end of week 42

Enhancing Let-Down Reflex

Have mother sit in a comfortable chair with support for arms and back. Rocking chairs are also good choices. Make sure the baby is positioned correctly on the breast Have her listen to soothing music to help her and baby relax Smoking, alcohol or illegal drugs will interfere with let-down and affect the content of the breast milk

Enhancing let down reflex

What is shoulder dystocia?

Head is delivered but anterior shoulder cannot pass under the pubic arch 0.6-1.4% of all vagina births Fetopelvic disproportion; Maternal pelvic abnormalities; Fetal macrosomia (maternal diabetes) S/S Turtle sign

Other Signs

Headaches- frontal or occipital Visual Disturbances-blurred vision, visual spots Most of the time tylenol does not take away the headaches. Usually a early sign Right upper quadrant pain-Epigastric Pain (?) Nausea/ vomiting Oliguria < 30 ml/hr, <400 ml/24 hr Also measure the creatitine clearance that measure kidney function and the volume and the volume of urine headache is not relieved by analgesics Epigastric Pain- very late sign Hyper-reflexia Patients deep tendon reflexes ar ehyper Irritability Cyanosis - late sign Pulmonary edema uric acid, creatine, liver function tests (all elevated) Reflexes- tap patellar- +3,+4 too brisk Cyanosis- very late sign Pulmonary edema- fluids fill the lungs due to stress on the cardiac system- late sign Labs: due to poor renal and livel functioning

The Infertility Study

Health History: a complete history for each partner Sexual history (multiple partners, STDs) Reproductive history (pregnancies, SAB, IAB, ectopics, endometriosis, fibroid tumors, abnormal paps) Occupational risks (radiation, toxic chemicals) Medications (antihypertensives, SSRIs, illicit drugs) Past surgery Lifestyle: diet, smoking, ETOH, drugs, stress, caffeine Physical Examination: Body type has nothing to do with infertility Female Pelvic exam - bimanual exam Cervical culture Pap smear - Cervical cancer Male Prostate exam Varicocele

Nursing Implementation

Health Promotion Promote safety measures. Wear helmet if risk for head injury. General health habits (diet, exercise) Assist to identify events or situations precipitating seizures and avoid if possible. Instruct to avoid, fatigue, loss of sleep, and excessive alcohol. Improved approaches to perinatal, labor, and delivery care have reduced fetal trauma and hypoxia and thereby have reduced brain damage leading to seizure disorders. Help the patient to handle stress constructively. Nursing ImplementationAcute Intervention Observe, treat, and document seizure. Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor. Do not restrain patient or place any objects in their mouth. May require positioning, suctioning, or oxygen after seizure. When a seizure occurs, the nurse should carefully observe and record details of the event because the diagnosis and subsequent treatment often rest solely on the seizure description. Note all aspects of the seizure. What events preceded the seizure? When did the seizure occur? How long did each phase (aural [if any], ictal, postictal) last? What occurred during each phase? Both subjective data (usually the only type of data in the aural phase) and objective data are important. Note the exact onset of the seizure (which body part was affected first and how); the course and nature of the seizure activity (loss of consciousness, tongue biting, automatisms, stiffening, jerking, total lack of muscle tone); the body parts involved and their sequence of involvement; and the presence of autonomic signs, such as dilated pupils, excessive salivation, altered breathing, cyanosis, flushing, diaphoresis, or incontinence. Assessment of the postictal period should include a detailed description of the level of consciousness, vital signs, pupil size and position of the eyes, memory loss, muscle soreness, speech disorders (aphasia, dysarthria), weakness or paralysis, sleep period, and the duration of each sign or symptom. A seizure can be a frightening experience for the patient and for others who may witness it. Assess the level of their understanding and provide information about how and why the event occurred. This is an excellent opportunity for you to dispel many common misconceptions about seizures. Ambulatory and Home Care Prevention of recurring seizures is the major goal in treatment. Instruct on importance of adherence to medication, not to adjust dose without physician. Medi-alert bracelets Keep regular appointments. Teach family members emergency management. If a dose is missed, usually the dose should be made up if the omission is remembered within 24 hours. Guidelines for teaching are shown in Table 59-12. Remind family, caregivers, and significant others that it is not necessary to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred.

What are the changes to the cardiovascular system post partum?

Heart rate Transient bradycardia for 24-48 hours. As low as 50 bpm. Never treat the number. Treat the patient - ask how is she doing Caused by hemodynamic changes and vagal hyper reactivity in response to the increased stimulation of the sympathetic nervous system during labor. Blood volume The increase of 50% blood volume gradually decreases till normal at about 2 weeks post partum Allows for loss of blood at delivery up to 500 cc's(500 mL) anything more than that is considered to be a hemorrhage and is an emergency There is still a 15-30% increase in circulating blood volume in the first 2-3 days post partum This causes or accounts for diuresis that occur in the post partum period Also accounts for decrease in hematocrit in the early post partum period Usually rises 5-7 days post partum Increased coagulopathy Increase in clot formation possible, DVT in legs and PE possible. Increase in plasma fibrinogen Related to blood volume is a more accurate reason why increase risk of DVT Bed rest for four hours and then get them to get up and move around - teach them exercises to move Blood Pressure Remains essentially unchanged Similar to pre-pregnancy levels Hemoglobin - Hemotocrit Will see a change in hemoglobin Slightly decrease in the early post partum period Usually rises by 5-7 days post partum Eat total cereal Contiune pre natal vitamins until after 6 weeks or as long as they are breast feeding A large decrease in hemoglobin will be seen in large blood loss. - Some patients get iron supplements to counter the effects of the blood loss. Take it before they deliver and then take it afterward. Will see about 2% loss

Biologic Development of Middle childhood

Height increases by 2 inches/year (birth length triples by the end of this period) Total height gain is 1-2 feet Weight increases by 2-3 kg/year (4 ½- 6 ½ lb.) Weight almost doubles Boys and girls differ little in size Proportional changes Movements more graceful than those of preschoolers Skeletal lengthening and fat diminution (thin, long legs) Increased muscle tissue Decrease in head circumference related to standing height Change in facial proportions (large teeth) The age of "loose teeth" Maturation of Systems Bladder capacity increases (greater in girls than boys) Bed wetting starts to become a concern at this age because it is not more physical but psychological (emotional) Heart is smaller in relation to rest of body (grows slower than the rest of the body) Immune system is increasingly effective Bones continue to ossify Physical maturity is not necessarily correlated with emotional and social maturity ( A 7 year old who looks like 10 still behaves like a 7 year old)

HELLP syndrome

Hemolysis Elevated Liver enzymes Low Platelets <100,000/mL. B/P > 160/110 >+3 Proteinuria Decreased urine output Visual disturbances This is a variant of preeclampsia which has been labeled in the past few years Hemolysis is red blood cell destruction giving low o2 and see decreased hemoglobin Low platelets lgive bleeding tendencies- norm platelets are 150,000-300,000 B/p elevated, oliguria- low output < 30 cc/hr HELLP Syndrome Associated with increased risk for: Placental abruption Renal failure Pulmonary edema Ruptured liver hematoma Disseminated intravascular coagulation (DIC) Run out of blood clotting factors and bleeding a lot Fetal and maternal death

Hemophilia

Hemostasis The process that stops bleeding when a blood vessel is injured Clotting depends on: Vascular influence Platelet role Clotting factors Dysfunction in these systems leads to bleeding or abnormal clotting Hemophilia Refers to a group of bleeding disorders in which there is a deficiency of one of the factors necessary for coagulation of blood You need to identify which specific factor is deficient to determine treatment with replacement agents In about 80% of all cases of hemophilia, the inheritance pattern is demonstrated as a X-linked recessive Incidence of Hemophilia A deficiency is 1:5000 male births Mothers with the hemophilia gene can pass it on to either their sons or daughters. Their sons may have hemophilia, and their daughters may be carriers. There is 50% chance of having a boy with hemophilia if the mother is a carrier, and 50% chance of having a girl who is a carrier. Fathers with hemophilia will not have sons with hemophilia. However, their daughters will always be carriers. Hemophilia Two most common forms of Hemophilia are: Factor VIII deficiency: Hemophilia A or Classic Hemophilia (80%) Factor IX deficiency: Hemophilia B or Christmas Disease (20%) Has nothing to do with the holiday! It was named after a medical doctor whose name is Christmas Von Willebrand is another bleeding disorder that affects both males and females. It is caused by the absence of a protein. (von Willebrand factor) and factor VIII Pathophysiology Hemophilia A is a deficiency in Factor VIII (AHF: anti-hemophiliac factor) AHF is produced by the liver and necessary for the formation of thromboplastin in blood coagulation. Patients with Hemophilia have two of the three factors required for coagulation: vascular influence and platelets. Therefore: They bleed longer not faster than other people Signs and Symptoms Frequent spontaneous or prolonged bleeding episodes: epistaxis, injections, circumcision, excessive bruising from a slight injury, hematomas Hemarthrosis: Bleeding into the joint space is the most frequent type of internal bleeding: Swelling, warmth, redness, pain, loss of movement Bony changes and crippling deformities occur after repeated bleeding episodes over several years Depending on the severity of the hemophilia, participation in sports should be considered as a risk factor to complications Therapeutic Management Focus: To replace the missing clotting Factor On demand treatment If the child has mild hemophilia, or bleeds infrequently, they may choose to give a dose of clotting factor only when an injury occurs. Prophylaxis (or preventative treatment) If the child has severe hemophilia, or has severe bleeds often, they may need clotting factor on a regular basis to prevent bleeds from happening. Regularity of dose may be anywhere from once a day to weekly. Hemophilia A: Factor VIII (FVIII) concentrate injected directly into a vein through an intravenous infusion. People with milder forms of hemophilia can take a synthetic (man-made) hormone, DDAVP, which triggers the body to release factor VIII. Hemophilia B: Factor IX (FIX) concentrate injected directly into a vein through an intravenous infusion. Desmopressin (DDAVP) People with mild or moderate hemophilia A might be treated with a medication called Desmopressin (DDAVP). DDAVP is a chemical that helps to release factor VIII that is already stored in the body. Before using this method, they will perform a "DDAVP Challenge". This is a test that will allow them to see if the use of DDAVP releases enough factor VIII in the child's body to prevent and treat bleeds. Treatment of hemophilia with DDAVP is not recommended until the child is at least three years of age. Care Management Teach the signs of internal bleeding especially cerebral bleeding : headache, slurred speech, loss of consciousness and Internal bleeding: black tarry stools Teach controlling of bleeding: RICE: Rest, Ice, Compression and Elevation Use of protective equipment: helmets, padding Non-contact sports: swimming, tennis, golf, bowling Soft toothbrushes or irrigation to prevent oral bleeding Substitute subcutaneous route for IM injections whenever possible Children are taught to take responsibility for their disease at an early age. They learn their limitations, other preventive measures And self-administration of AHF. Management is met with a comprehensive team approach: pediatrician, hematologist, orthopedist, social work, physical therapist

Cardiovascular Dysfunction

History and physical examination findings Poor feeding Tachypnea/tachycardia Failure to thrive/poor weight gain Activity intolerance Developmental delays Positive prenatal history Positive family history of cardiac disease Inspection Nutritional status FTT? Color Is it dusty? Bluish color? Chest deformities R/T enlarged heart Unusual pulsations Neck veins - CHF Respiratory excursion difficulties Clubbing of fingers Change in the shape and the profile of the fingers Palpation & Percussion Abdomen Enlarged spleen or liver? Peripheral pulses Abnormal pattern/quality Heart rate and rhythm ∆ Children do well with respiratory distress than cardiac distress Character of heart sounds Muffled Diagnostic evaluation Electrocardiography Echocardiography Cardiac catheterization Diagnostic If we need to use a dye for diagnostic procedure, we have to sedate the child The ability of cooperation and the developmental age with children Interventional Electrophysiology studies Nursing care: cardiac catheterization Pre-procedural care Post-procedural care Vital signs Dressings Fluid intake Adequately hydrated Blood glucose levels Looking for hypoglycemia

Treatment/Management

Home Management Home Uterine Activity Monitoring (HUAM) Tocodynamometer Monitor uterine activity twice daily Home Nurse Visits Issues with HAUM Done if patient is obese with inc adipose tissue < 26 weeks gestation Tocodynamometer The second component of a fetal monitor is the tocodynamometer. This device measures the relative strength, rate, and duration of uterine contractions. It is basically a ring-style pressure transducer attached to the maternal abdomen via a belt that maintains tight continuous contact with the abdomen. The transducer contains a plunger that is depressed when the uterus changes its rigidity and shape with each contraction. This depression changes the voltage of the current associated with the plunger and is proportional to the strength of the contraction. While the transducer can monitor the activity of the uterus (frequency and relative strength of contraction), it cannot determine the absolute intrauterine pressure

Discharge planning and Teaching

Home care needs of parents for infant is assessed Assessment of parental knowledge deficits Referrals for appropriate resources Referrals for Home Health Assistance Resources for equipment Transportation to & from regional center Discharge Teaching - Taking the High Risk Infant Home Parents need special instruction and teaching CPR Apnea monitor Oxygen Therapy Suctioning NG tube / GT care Colostomy Care Development assessment and understanding

Diseases of Prematurity

Hyaline Membrane Disease (H.M.D.)/Infant Respiratory Distress Syndrome (IRDS) Incidence and severity increase with a decrease in gestational age Immature lungs and lack of surfactant Respiratory distress evident within 6-24 hours of birth (s/s disappear after 72 hours) S&S Cyanosis Tachypnea / See Saw Respirations (unequal side of respiration could mean that one side might be developing a pneumothorax) Grunting / Nasal Flaring / Retractions If more than 10 seconds without breathing, that is an issue Apnea Atelectasis

"To Stop, or Not to Stop???"

Hypertension/preeclampsia It is better to deliver the baby preterm than keep the baby in utero If the mother is compromised, it is better for the baby to come out. Maternal compromise - Hypovolemia, hypoxemia, acid/base imbalances Infection - Chorioamnionitis We can't test for the presence of infection until the baby is born Non-Reassuring Fetal Heart Rate

What is the fetal heart rate variability?

IRREGULAR FLUCTUATIONS IN BASELINE Fetal heart rate should fluctuate. It means that the PNS and the SNS are working properly Absent - Undetectable amplitude Minimal - Visually detectable but < 5 bpm amplitude Moderate - 6-25 bpm amplitude Marked - > 25 bpm amplitude Chart #1 - someone is in trouble That is bad! Poor oxygenation Chart #2 - minimum variability and it means that the variation in the heart beat don't go any more than five beats above or below the baseline. Frequently occurs when the baby is sleeping. If it is going on for longer period of time, it Is not good. It could be mom got an epidural or narcotics Chart #3 - good fluctuation. Everyone is happy Chart #4 - marked variability it is hard to find the baseline. Constant up and down. It could be bleeding or mom had coffee. Short period of that is ok but longer than 10 minutes is bad. Chart#5 - sinocidal - look like a sawtooth but the baby is not having arrhythmia due to severe fetal anemia very bad!

Drug Therapy

IV Antibiotics - usually 10 days ceftriaxone (Rocephin) q 12 hours 50 - 75 mg/kg/day IV every 12—24 hours cefotaxime (Claforan) q 8 hours < 50 kg and Infants: 50 -180 mg/kg/day IV or IM divided every 6-8 hours vancomycin q 8 hours 10 mg/kg IV every 6 hours Nephrotoxicity Steroids Dexamethosone Headache Acetaminophen with Codeine Antipyretics Acetaminophen IV hydration

KD Treatment: Meds

IVIG ASA Acute phase: 80 to 100mg/kg/day in four divided doses Continue until child afebrile, then 3-5 mg/kg/day in a single daily dose for 6 to 8 weeks. Can D/C when ECG WNL Be alert for adverse effects (flu-like symptoms) An adult is given 81 mg a day to prevent heart problems

What are the changes with the uterus in post partum period?

Immediately following delivery, the fundus can be palpated at or about 1- 2 cm below umbilicus Size of a large grapefruit 12 hours after delivery, may rise to 1 cm above the umbilicus and then begins its decent of about 1-2 cm every 24 hours By 10 days post-partum, fundus should be below symphysis pubis bone Get your patient to empty their bladder every two to three hours Uterus - Involution Process Accounts for the decrease in size of uterus Requires 6 weeks for return to pre-pregnancy state Accounts for the regeneration of endometrium Assisted by breast feeding due to increase 0xytocin release Contractions (after pains) help process along Breast feed right away Stimulation of the oxytocin is caused by the breast feeding which will make her fundus firm No motrin (NSAID) during pregnancy but it is ok after delivery because it can prematurely close the ductus arterioles which is the opening in the heart that allows oxygenated blood to bypass the lungs it can prematurely close in utero and what will happen if no bypass from the lung to body then no oxygenated blood get to the baby and that could be dangerous to the baby. 3 weeks for necrotic tissue to slough off Takes 3 additional weeks for placenta site to have new regenerated endometrium Not having your period! Do not count your cycle and you will get pregnant Contractions of uterus - decrease size of myometrial cells Autolysis- process in which the protein material of uterine wall is broken down into simpler components which are absorbed by body Uterus - Exfoliation Process Prevents scar tissue formation . Is the undermining of the placental site by growth of new endometrium from behind placental site forward toward uterine cavity. Uterus- Lochia 3 types Rubra (red) Day 1-3 Dark heavy red that look like period bleeding Serosa (pink or brown) Day 4-9 (may last longer) Alba (yellow or white) Day 10 - 2-6 weeks Color and volume get lighter and lighter

What is the post operative nursing care of c section?

Immediately post op assess Fundus / Lochia and Vital signs per protocol Assess: Abdominal dressings, Pain, foley drainage, IV infusion (Pitocin indicated) Assess for post op bleeding / hemorrhage Assess Fundus Pad Count / Lochia on Pad post delivery Assess under patient C&DB, Incentive Spirometer Anti-Thrombolic Stockings Breast Feeding and mother/Infant bonding (if no complications in delivery) Dependent on Faculty Assess Infant - Most hospital will have neonatal team in the room to asses the newborn Turn patient over during assessment to assess bleed / pooling of blood sx of hemorrhaging VS q 15 mins then q 30 mins - q 1 hour to q 4 hours when stable follow care map If patient has had narcotic epidural (fentanyl) Epidural precautions Check respirations Check LOC Check pain level ½ dose of pain narcotic for pain management during epidural precautions Precautions for 12 hours to 24 hours post delivery Check q 1 hours to q 2 hours until precautions up Photos of Hemorrhage s/p C-Section EBL following a Vaginal Delivery > 500 ml EBL following a C-Section > 1000 ml Daily C/S Care and Assessment Similar to Vaginal delivery assessment and care BUBBL(I)E B - baby on breast U - uterus B - bleeding B - bowel I - incision E - episiotomy Perineum Care Homan Sign Assess Incision and Sutures/Staples Routine VS OOB Mother & Infant Bonding Pain medications - criteria for assessment B Breast U Uterus (Fundus) B Bladder B bowel Very important s/p a c/s due to inactive bowel increase risk of paralytic ileus that can lead to ischemic or dead bowel with risk of bowel resection or death Maintain NPO status until bowel sounds return Promote ambulation to enhance the return of peristalilis and bowel sounds L Lochia E Incision (episiotomy or c/s incision) When dressing removed OTA Types of Pain medication Demerol Fentanyl (Epidural) Morphine Sulfate (epidural) Tylenol with codeine Percocet - Oxycodone and tylenol Motrin -Ibuprofen C-Section Care Path without complications Expected length of stay in the hospital is 3-4 nights

Nursing Care Management of healthy Preterm baby

Implementation Environmental concerns (reduce noise/stimulation) Developmental outcomes Inappropriate stimulation (increases stress) Containment or facilitated tucking Blanket swaddling or nesting Skin to Skin "Kangaroo care"

What are the vitamin and minerals?

Important for life and growth Water soluble C B1 B6 B12 B2 Niacin Folic acid Pantothenic acid Fat soluble A D K E Prenatal vitamins will meet these requirements when added to a good diet Vitamin D is critical for absorption of calcium and phosphorus Good source of vitamin D Milk, egg yolk, butter, sunlight

Etiology and Pathophysiology of epilepsy

In epilepsy, abnormal neurons undergo spontaneous firing. Firing spreads to adjacent or distant areas of the brain. If activity involves whole brain, generalized seizure occurs. Cause of abnormal firing is unclear. Any stimulus that causes the cell membrane of the neuron to depolarize induces a tendency toward spontaneous firing. Etiology and Pathophysiology Seizure disorders have many possible causes. The most common causes vary by age.

Developing a Body Image

In general, children like their physical selves less as they grow older The head is the most important part of the body (hair and eye color) Body image is influenced by significant others Highly influenced by cultural norms and fads of the time Increased awareness of "differences" may influence feelings of inferiority (e.g., hearing or visual defects) Children whose bodies deviate from the norm are often subject to criticism

Cerclage

In most cases patient is 16-20 weeks gestation, cervix dilates with SROM, then delivers a immature fetus. Two procedures available for incompetent cervix- both reinforce the cervix with an encircling purse string suture (Cerclage) Shirodkar Procedure Purse string tie thru the cervix—keeps cervix closed. This tie remains in place so future manipulation is not necessary. Do not play with it too much! This procedure is usually done around 10-14 weeks of gestation Patient must be hospitalized for procedure and observed for 48 hours. Post-Procedure- Patient is placed in Trendelenburg position to relieve pressure of fetus from cervix. The mother has to lay upside down for a couple of days FHS and uterine assessment - patient on C.B.R. C-section method of delivery When a pregnant woman is in labor and says I have to go to the bathroom, they are not allowed!! McDonald's Procedure Similar to Sherodkar but tie can be removed for vaginal delivery Both procedures are most successful when cervix is not more than 3 cm's dilated or 50% effaced and membranes are intact.

Congenital Heart Disease (CHD)

Incidence: 5-8 per 1000 live births About 2 or 3 of these cases are symptomatic in first year of life Excluding children that are premature Major cause of death in first year of life (after prematurity) Most common anomaly is ventricular septal defect Often associated with other anomalies (trisomies 21, 13, 18) Altered hemodynamics Acyanotic Cyanotic Classification of defects Blood flows from an area of high pressure to one of lower pressure Blood takes the path of least resistance Left-to-right shunt Right-to-left shunt Left side - systemic circulation - high pressure Right side - lung - low pressure

Recurring Spontaneous Losses / Incompetent Cervix

Incompetent cervix which is an opened cervix. Typically the cervix is closed during the pregnancy. When the cervix can't stay closed during the pregnancy it opens and the baby comes out. May feel vaginal pressure and the doctor may see the amniotic fluid coming out Definition: 3 of more spontaneous, consecutive abortions, usually after 16 weeks Major causes Incompetent external cervical OS where there is painless dilation of cervix without uterine contractions Cervical incompetence due to Congenitally short cervix Previous traumatic dilation of cervix Exposure to DES (estrogen) in utero Late 1930s to early 1970s to prevent miscarriage

What is VBAC (Vaginal birth after cesarean sections)?

Increase trend in late 1990's Guidelines for VBAC (ACOG-2004) A woman with one previous cesarean birth with a low transverse uterine incision Clinically adequate pelvis Woman with two previous cesareans who has also had a previous vaginal delivery Be able to have a C/S within 30 minutes in case of complications or inability to deliver vaginally Surgeon, anesthesia and staff must be available Classic (T) Uterine incision is contraindicated for a VBAC Danger increase risk of uterus rupture in attempting a vaginal delivery s/p a cesarean section Never a classic incision Uterine rupture 6% Patient who has had Prostoglandin agent has a 24.5 per 100,000 birth risk of uterine rupture Risk of Uterine Rupture with VBAC is 0.1 to 0.7% Other risks Uterine Dehiscence Hysterectomy s/p rupture or dehiscence Uterine infection Success of a VBAC is 60-80% with no complications and no C-Section

Chronic Hypertension

Increased risk of perinatal deaths, rates of preterm birth, and small-for-gestational-age infants Lifestyle changes may be necessary In postpartum, high risk women monitored for complications: renal failure, pulmonary edema, heart failure, and encephalopathy

Induction/Augmenting of Labor

Induction- mechanical or chemical initiation of uterine contractions before spontaneous onset Getting away from elective induction Augmentation- mechanical or chemical stimulation of existing uterine contractions Stimulate the labor that is already started. Start the dilation and then it stops why? Maybe the baby is to baby or the head is too big or the contraction are not strong enough Cervical ripening methods Before labor, the cervix is very firm like inside of a melon When she is in labor, it is soft like a firm banana It cannot dilate if its not soft it has to be soft If the cervix is firm, we insert cervidial and it will make it soft - it dilates the blood vessel in the cervix and helps it soften up Amniotomy- artificial rupture of membranes AROM- artificial rupture of membranes SROM- spontaneous rupture of membranes Document: time, color, amount, FHR, prolapsed cord If the baby is in a amniotic fluid, the head is not going to be firm on the cervix. Once that burst, his head will be firm on the cervix causing it to be soft Oxytocin/ Pitocin- drug used for induction/augmentation Induction of Labor Ripening of the cervix with medication (Cervidil/Cytotec) if there is an unfavorable cervical exam (2hrs bedrest) Mechanical methods: Balloon catheters, Amniotomy (AROM) (Increases pressure on cervix, increases strength and frequency of contractions) Followed by I.V. Pitocin Continuous electronic fetal monitoring **Goal: Uterine contractions with cervical change** Why? Post-dates Two weeks past her due date Gestational Diabetes Or any diabetes out of control Moms with diabetes have babies who are bigger. IT is because babies get all of mom's blood sugar but don't get mom's insulin. They make their own insulin and because they are not making enough insulin,, that baby stores all of that sugar as fat and get bigger. Induce at 39 or 38 weeks Hypertension If the baby is not growing right or not looking great on the fetal monitor May need to induce her Poor biophysical profile (8/10) (breathing, movement, tone, fhr, amniotic fluid) It is an ultrasound They inhale and exhale the amniotic fluid We assess the fetal heart rate and it is indicative of the renal status - one of the first organs being compromised Perform two bad test to induce labor Why? If it is high risk in any ways such as hypertension, gestational diabetes or post dates Multiparity

Delivery of Preterm Infant

Infant - Small fragile blood vessels Scalp and skin Very thin skin where you can see the blood vessels Mother administered small amounts of analgesics Liberal Episiotomy (reduce resistance) Usually done Preterm baby is even more soft and fragile than a full term baby so a decrease of pressure of the delivery that is put on the baby's head and decrease the risk of injury to the baby's health Cesarean Birth usually recommended Not recommend because they don't engage until the third trimester so a lot of the babies are breach and they ar enot breathing Mother at risk for Post-Partum Hemorrhage Baby at risk of brain hemorrhage, asphyxia, and birth trauma Present at Delivery Obstetrician Labor and Delivery Nurse Neonatologist NICU Nurses

Nose

Infants under 1 month of age are nose breathers so any obstruction could cause respiratory distress Really important that parents know how to use the bulb syringe and when to use it Patency can be assessed by occluding each naris Bruising and thin white discharge from nares is a normal finding Tell parents that sneezing is common in newborns Red Flags: Nose Snuffles "Snuffles"-thick, bloody nasal discharge without sneezing can be a sign of congenital syphilis Nasal Flaring Serious sign of air hunger and respiratory distress

Mastitis

Infection of breast Occurs mostly in 1st time mothers Usually occurs 4th-6th day post-partum Often engorgement has occurred Usually unilateral Organism and Course of Infection Staph aureus Gains access through cracked nipple or fissure on nipple Organism on skin Ductal system becomes involved Inflammation and engorgement obstructs flow of milk in lobe and then the infection follows Symptoms and Nursing Care Symptoms Chills Fever Malaise Hard, red breasts Headache Nursing Care Rest Antibiotics Fluids Continue BF infant or use electric pump BF increased blood flow to breast and promotes better antibiotic effect Warm compresses Frequent feeding or pump Vary positions Analgesics Baby may get diarrhea due to antibiotic

Rheumatic Fever and Rheumatic Heart Disease (RHD)

Inflammatory disease that occurs after group A β-hemolytic streptococcal (GABHS) pharyngitis Now less common in United States Still a devastating problem in developing countries Complex disease that involves/affects the joints, skin, heart, blood vessels, and brain Comes from strep throat Once it cause rheumatic fever, it is considered to be a systemic infection Typically occurs in ages 5-15 years AKA "Rheumatic Heart Disease" Permanent valve damage

Ingested & Inhaled Poisonings

Ingested Food poisoning Staphylococcus, Salmonella, Botulism, Listeria Drugs - OTC or Rx Corrosive poisoning Lead poisoning (Plumbism) Mercury poisoning Cleaning agents Plants Philodendron, Poinsettia, Holly, Poison Ivy/Oak/Sumac, Hemlock, Hyacinth, Daffodil, Mistletoe Inhaled Accidental vs Intentional Carbon monoxide Huffing Drug Poisonings OTC: ASA, acetaminophen, ibuprofen Rx What is drug action Heart?? HTN? DM Fe supplements Drugs of abuse Oxy, cocaine, heroin

Types of Poisoning

Ingested Swallowed via GI tract Inhaled Breathed in via respiratory system Surface toxin Absorbed via skin Injected toxin Piercing the skin and entering the circulatory system

Corrosive Poisoning

Ingestion of toxic / corrosive poisons Hydrocarbons (gasoline, kerosene, paint thinner, motor oil, Pine oil cleaners) Symptoms Gagging, choking, coughing, lethargy, weakness, tachypnea, cyanosis, N&V DO NOT INDUCE VOMITING Reburning the GI tract again - worsen the symptoms Milk and water to dilute poison If the child is vomiting or can cause irriate the stomach, it will cause another burn again

Mouth and Throat

Inspect the palates: hard and soft for any clefts Epstein pearls (milia in the mouth)cysts along the gum margins at the junction of the hard and soft palates is not a significant finding Assess for reflexes: Sucking Reflex: should be strong when nipple placed in mouth. Reflex disappears at 6 months Rooting Reflex: Newborn turns his face in the direction of the cheek being stroked. Reflex disappears at 3 to 4 months Gag reflex

Mouth and Throat of newborns

Pathogenesis of DM

Insulin enables glucose to enter fat and muscle cells -> energy Insulin -> Hyperglycemia -> Hyperosmolality -> intracellular fluid into vascular system -> cellular dehydration, Polyuria and Glycosuria to regulate excess vascular volume -> Polydypsia

Fetal monitoring

Intermittent- listening to the FHR and feeling contractions at periodic intervals. Electronic- use of electronic equipment to asses FHR and uterine contractions External- use of external transducers placed on maternal abdomen Internal- use of spiral electrode to asses FHR and IUPC to asses uterine activity Fetal heart changes Bradycardia <110 Tachycardia >160 Variability- fluctuations with movement and stimulation Types of fetal heart patterns (Page 431-Text- for photos) Type I- early deceleration Head compression (HC) Baby's head is coming down further and being compressed in small area Type II- late deceleration Uteroplacental Insufficiency (UPI) Most problematic for fetal well being Type III- variable deceleration Umbilical Cord Compression (CC) V shaped deceleration

Birth

Intrauterine Environment Thermoconstant Dark Aquatic Completely Life-sustaining environment Successful transition to extrauterine represents an extreme change to a variable pressurized environment that requires physiologic alterations for survival About three quarters of all deaths during the first year of life will occur within the first 4 weeks.

Birth: the Miraculous Transition

Seizures: Tonic

Involve sudden onset of maintained increased tone in the extensor muscles Patients often fall

Epistaxis (Nose Bleeding)

Isolated and transient episodes of epistaxis are common in childhood The nose, especially the septum is a highly vascular structure Bleeding occurs through direct trauma, foreign bodies, nose picking or mucosal inflammation Recurrent epistaxis may indicate vascular abnormalities like leukemia or clotting factor deficiency diseases Care Management Have child sit up and lean forward. DO NOT HAVE CHILD LAY DOWN. Apply continuous pressure to nose with thumb and forefinger for at least 10 minutes Insert cotton or wadded tissue into each nostril and apply ice or cold cloth to bridge of nose if bleeding persists Keep child calm and quiet

Leukemia

It is a cancer of the blood-forming tissues and is the most common form of childhood cancer It is most common in boys and Caucasians with the peak of onset between 2 and 5 years of age Survival Rates Acute Lymphoid Leukemia(ALL): 80% Acute Non-Lymphoid Leukemia(ANLL or AML): 50-65% Is a broad term given to a group of malignant diseases of the bone marrow and lymphatic system Disease of varying heterogeneity (diversity) Classification has become more complexed, sophisticated and essential for therapeutic and prognostic implications Pathophysiology Leukemia is an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body Although not a "tumor", leukemia demonstrates the same neoplastic properties as solid tumors. Meaning that nonfunctional leukemic cells infiltrate and replace healthy cells. In the acute form of leukemia, the leukocyte count is low: although the definition of leukemia is an overproduction of immature WBCs These immature cells do not attack and destroy normal cells. The destruction takes place by infiltration and through competition for metabolic elements Signs In all types of leukemia, the proliferating cells depress the production of formed elements of the blood in the bone marrow As a result, the presenting signs will be: Anemia from decreased RBCs Infection from neutropenia Bleeding from decreased platelet production The leukemic cells will weaken the bone marrow as they infiltrate so fractures may be common. As leukemic cells invade the periosteum, increased pressure causes severe pain (bone pain) Marked infiltration, enlargement, and fibrosis of spleen, liver, and lymph glands Signs, Symptoms and Complications Diagnostic Evaluation History and Physical Examination Symptoms of fever, low blood counts, lymph node enlargement and enlarged liver and spleen Peripheral blood smear reveals immature forms of leukocytes combined with low blood counts Definitive diagnosis is based on bone marrow aspiration or biopsy A lumbar puncture is performed to determine CNS involvement Therapeutic Management Chemotherapeutic agents: 1.Induction therapy which achieves a complete remission or less than 50% leukemic cells in the bone marrow (4-6 weeks) 2. CNS prophylactic therapy which prevents leukemic cells from invading the CNS 3. Intensification therapy (consolidation) which eradicates residual leukemia cells followed by delayed intensification which prevents emergence of resistant leukemic clones (Outpatient care, over several months) 4. Maintenance therapy which serves to maintain the remission phase Can last up to 3 years Hematopoietic Stem Cell Transplantation Has been successful for treating children who have ALL or AML It is not recommended for children with ALL during first remission because of the excellent results usually from 4 phase chemotherapy plan. It is a procedure that is accompanied by significant morbidity and mortality including graft Vs. Host disease, overwhelming infection or severe organ damage Intermediate risk and high risk AML with a suitable donor available are recommended for transplant during the first clinical remission Prognosis Most important prognostic factors for determining long-term survival for children with ALL are: The initial WBC count The child's age at the time of diagnosis The type of cell involved The sex of the child Karyotype analysis Children with normal or low WBC count who are CALLA positive have a better prognosis than those with a high count or other cell types Children diagnosed between 2 and 9 years of age have a better prognosis than those diagnosed before 2 or after 10 years of age Girls have a better prognosis than boys Care Management Prepare the child and family for diagnostic and therapeutic procedures Pain Management- sometimes around the clock narcotics Prevent Complications of Myelosuppression: 1. Results in secondary infections Granulocyte colony -stimulating factor (GCSF) Strict hand washing, isolated from sick children at school etc. Nutrition: adequate protein to better fight infection 2. Bleeding tendencies and anemia Transfuse platelets as needed to avoid hemorrhage Mouth Care for gingival bleeding No rectal temperatures to avoid trauma Children have activities limited to avoid injuries and bleeding Managing the Effects of Chemotherapy Be aware of side effects: Nausea and vomiting Anorexia Mucosal Ulceration Stomatitis Neuropathy Hemorrhagic Cystitis Alopecia Moon Face Mood Changes

What are the advantages of Formula Feedings?

It's convenient. Formula-fed babies can be fed by anyone at any time. It's flexible. You don't have to fit pumping into your work schedule. Instead, you can simply leave formula for your babysitter or day care center. Your partner can help out with nighttime feedings and share that bonding experience with your baby. Scheduling feedings may be easier. Formula isn't digested as quickly as breast milk, so formula-fed babies don't need to eat as often, especially in the first few months. You don't have to worry about what you eat. Moms who breastfeed may have to avoid certain foods that her baby can't tolerate. You can have a glass of wine or a cocktail once in a while. Alcohol is not recommended for women who breastfeed because they pass on small amounts of it to their babies.

Alternative interventions

Ketogenic diet has been effective in controlling seizures in some. High-fat, low carbohydrate diet Ketones pass into the brain and replace glucose as an energy source. Biofeedback to control seizures teaches patient to maintain a certain brain wave frequency. The diet may be effective for some patients with drug-resistant epilepsy, but the long-term effects of the diet are not clear. Patients on this diet who use anticoagulants need close monitoring for bleeding. Biofeedback is aimed at teaching the patient to maintain a certain brain-wave frequency that is refractory to seizure activity. Further trials are needed to assess the effectiveness of biofeedback for seizure control.

Antihypertensive Drugs

Labetalol Beta blocker- decreasing the nerve response in the heart decreases pulse and blood pressure Side effects: blurred vision, chills, nausea, dizziness Apresoline -vasodilator, increases cardiac output Side Effects: Mom: tachycardia , headache and flushing Fetus: tachycardia, late decelerations Aldomet- given PO used if maintenance dose of antihypertensive is needed Mild preeclampsia and gestational hypertension Procardia-calcium channel blocker- decreases systemic vascular resistance Procardia and labetalol are Given PO with minimal side effects- for long term use Antihypertensive drugs found in breast milk Methyldopa or hydralizine are the choices for woman needing medication for hypertension and wishing to breastfeed Short-term studies have not found adverse effects on infants of these mothers

What is prolonged labor?

Lasting longer than 24 hours Risk include: Fatigue Pain Over distended uterus-hemorrhage Tired uterus Mom begins to hemorrhages Hypoxia to fetus

Morbidity and Mortality

Leading cause of morbidity and mortality for both Mom and baby 13% of Eclamptic women will die 35% of babies will die African-American women more likely to die of preeclampsia than women of all other races Fall 2010 Preeclampsia complicates approximately 6% to 8% of all pregnancies Morbidity and mortality Ranks second only to embolic events as a cause for maternal mortality Accounts for 15% of these deaths

Fetopelvic relationship

Lie- relationship as long axis of mother to long axis of fetus Version Longitudinal 99% vertex 1% breech If the baby is breeched, it is very uncomfortable for mom. We could try to push the baby by grabbing on the mother's stomach and sort of push the baby. We don't her to go into labor when doing that Head is toward the heart not toward the pelvic Transverse Fetus is perpendicular to long line(backbone) of mother Can't be delivered vaginally Usually becomes C-section if external rotation is unsuccessful (Version). Passenger Fetopelvic Relationship: Attitude- relationship of fetal body parts to each other Flexion- Head is bent down and chin is on the chest. Arms and legs are folded (eg: vertex presentation). Flexion is the classic "fetal position". Extension- Opposite of Flexion. Body parts are extended in relation to each other. Eg: Complete flexion; Moderate flexion; Poor flexion; Hyperextension Presentation- part of the fetus that enters the pelvic inlet first Cephalic (vertex) Head first- most common 95% Shoulder "Transverse lie" Long axis of fetus is perpendicular to long axis of mother Shoulder presentation occurs < 1% of deliveries Usually C-section is done if safe external version can not be accomplished Breech- classified according to attitude of fetal legs and knees Complete- buttocks first with flexing at both legs and knees Frank- thighs are flexed and legs extended over the anterior surface of the fetal body with the buttocks still presenting Incomplete or floating- presenting part is one or both feet with extension at both hips and knees

Activity for PTL

Limit activity No sports / exercising No heavy lifting No hard physical work Including no heavy housework Bedrest - May have adverse effects Should be relaxing and resting Can get up and get food or go to the bathroom Fluids at least 2 liters / day Urinate every 2 hours Full bladder irritates the uterus and so is dehydration No sexual activity - "pelvic rest" Nothing in the vagina!

Ears

Look for position, structure and auditory function Malformed or posteriorly rotated ears are associated with congenital anomalies Ears too low is a sign of congenital defects Newborns receive an initial hearing screening by the Pennsylvania Department of Health High Risk infants for hearing loss are: family history, congenital perinatal infection (herpes, syphilis, rubella), Birthweight less than 1500 grams(3lbs, 5oz), hyperbilirubinemia, bacterial meningitis, severe asphyxia (Apgar scores 0-3)

Ears of newborn

Expect weight of the newborn

Lose 5-15% of birth weight Weight should stabilize by Day 5 and then newborn should gain 1 oz. per day if adequate intake Newborns should be at birth weight by end of second week Baby should Double birth weight by 6 months Triples birth weight in one year Breast milk provides 20 kcal/oz. Formulas provide 20 kcal/oz. Newborns at Risk for Feeding Failure

Medications for PIH

Magnesium Sulfate Anticonvulsant-decreases neuromuscular irritability Administered IV infusion Pump or IM Given a loading dose 4-6 gms over 30 minutes Maintenance dose-2-4 gms/hr Goal is to prevent Eclampsia-prevent Seizures MgSo4 is not an antihypertensive Loading dose- higher amount of drug to bring mom's blood level to a high dose quickly the maintenance Diuresis with in a 24 hr period is an excellent prognosis sign Critical Values of MG < 0.5 mEq OR > 3 mEq/l Side Effects Flushing - vasodilation, makes them red Sweating Depressed CNS -Reflexes Flaccid muscles Respiratory depression Respiratory arrest is not normal Continuous pulse ox Assess their respirations and lung sound Any respiratory issues under 10 or 8 is considered to be respiratory depression Fetal bradycardia Respiratory arrest

Magnet Ingestion

Magnets erode the intestines / stomach mucosa Damage worsens over time S&S: Vomiting Abdominal pain Fever "Viral illness"

Management of IRDS

Maintain patient Airway Prevent ventilation-perfusion mismatch and atelectasis (increased PVR sec to alveolar instability -> R to L shunting) From babies being on ventilators Suction PRN Oxygen Therapy Continuous Positive Airway Pressure (CPAP) Mechanical Ventilation Surfactant Therapy We can inject surfactant through the ET tube down into their lungs not as effective as steroids but we like the alveoli to open Surfactant replacement was established as an effective and safe therapy for immaturity-related surfactant deficiency by the early 1990s.1-21 Systematic reviews of randomized, controlled trials have confirmed that surfactant replacement reduces initial inspired oxygen and ventilation requirements as well as the incidence of respiratory distress syndrome, death, pneumothorax, and pulmonary interstitial emphysema

Mixed Defects

Many complex cardiac anomalies Transposition of great arteries or vessels Total anomalous pulmonary venous connection Truncus arteriosis Hypoplastic left heart syndrome Very little space for the left ventricle All fibrous tissue Children often die quickly of this before they can get a cardiac transplant

Complications in forceps assisted birth

Maternal indications Shorten second stage in event of dystocia Compensate for deficient expulsive efforts Reverse a dangerous condition Fetal indications Distress or certain abnormal presentations Arrest of rotation Delivery of head in a breech presentation Forceps Delivery Risks and complications Maternal Laceration to birth canal, perineum Increase swelling, bleeding and bruising Hematoma Pelvic floor injuries Increase urinary and rectal incontinence Infant Caput succedaneum or cephalhematoma Inc. incidence of hyperbilirubinemia Bruising on face Facial paralysis / Erb's paralysis Retinal hemorrhage, Corneal abrasion &/or other ocular damage Erb's Palsy:Damage to upper plexus; Paralysis of affected extremity; Shoulder and arm adducted and rotated internally

What are the characteristics of placenta?

Maternal side is rough and bloody with 22 irregular shaped lobes Placenta is round in shape and 8-10 inches in diameter and 1 inch thick at center 500 grams in weight at 40 weeks gestation Fetal side is smooth and shiny Nurses check to see if everything is included in the placenta because if not all removed with birth, it can cause the mom to continually hemorrhage while being attached to the uterine wall. The doctor may have to digitally (using fingers) to remove it or worst case scenario, surgical remove it. It is deposed by sending it home with the family or the hospital send it to the morgue because it is consider a body part Woman like to get it dried like freeze dried and then chop it and put it in a capsule and take it like a vitamin because it is chock full of iron and can help with low HgB and decrease symptoms of post-partum

Clinical Manifestations of seizures

May progress through several phases Prodromal phase Aural phase Ictal phase Postictal phase Prodromal phase precedes seizure with signs or activity. Aural phase with sensory warning. Ictal phase with full seizure. Postictal phase with rest and recovery.

How to management labor complications?

McRoberts maneuver Suprapubic pressure Knee-chest position Episiotomy Complications Brachial plexus and phrenic nerve injuries Fractured clavical, humerus Post partum hemorrhage https://youtu.be/K5kLHkl5RsI

Gavage Feeding

Measure Gavage feeding tube Feed by gravity Insertion of gavage tube via orogastric nasogastric route Indwelling gavage tube, nasogastric route Assessment of proper placement Check via chest xray

Measurement of fetal skull

Measurements of fetal skull- Assessment of the diameters of the fetal skull is useful in judging the ability of fetus to fit through the maternal pelvis. Biparietal This is a transverse diameter Extends from one parietal prominence to the other Usually measures 9.5cm Suboccipitobregmatic Extends from the under surface of the occipital bone to the center of the anterior fontanelle or Bregma (another name for anterior fontanelle) It's the shortest A-P diameter of the head and presents to the maternal pelvis most effectively, when the fetal head is well flexed Usually measures 9.5cm Measurements of fetal skull Occipitofrontal Extends from a point just above the top of the nose(fetal) to the most prominent portion of the occipital bone. Usually measures 11.7cm Occipitomental Extends from the chin(of fetus)(mentum is another name for chin) to the most prominent portion of the occipital bone. This is found when the head is in an extended position Usually measures 13.5cm Molding- overlapping of bones of fetal head that occurs during labor caused by accommodation of fetal head to maternal pelvis Syclitism Position of fetal head in the pelvic inlet, in which the smallest A-P diameter of head enters the widest part of pelvic inlet Best position for fetal decent: suboccipitobregmatic (smallest) to diagonal conjugate(widest part) Baby is in line with the pelvic opening Asynclitism: Absence of syclitism The head is not line up with the pelvic inlet IT can prevent the mother to deliver vaginally It is why it is important for the mother to change position every 30 minutes. To ensure properly placement of the baby's head with the pelvic inlet

More labor complications

Meconium Stained Amniotic Fluid Green amniotic fluid First stool Can be thin, thick, particulate Causes Post dates Breech presentation Hypoxia induced peristalsis and sphincter relaxation Vagal stimulation; cord compression Management Neonatology present at birth No stimulation after birth Immediate assessment and possible deep suctioning Obstetrical Emergencies Prolapsed Umbilical Cord When the cord lies below the presenting part of the fetus Contributing factors Long cord (longer than 100 cm) Fetal Malpresentation (Breech) Transverse lie Unengaged presenting part Prolapsed Cord

Breast or bottle?

Method of feeding should be decided prior to delivery How to feed the baby is a personal decision- do not think that bottle feeding mothers need less teaching or care than breastfeeding mothers Provide information on breastfeeding but do not be judgmental but respectful if they choose to bottle feed. Physical, Psychological , Social and Culture influences can affect the decision

pPROM (Preterm ruptured of membranes)

Membranes rupture before 37 weeks gestation Occurs in up to 25% of preterm labor cases Often is preceded by an infection We would send the placenta off to the lab for microbiology testing to see if there is an infection and it is more likely the cause Etiology maybe unknown Diagnosed after woman complains of sudden gush or slow leak of vaginal fluid Amnioswab/Nitrizine; Speculum exam; Ferning Care Management Home Management vs Hospitalization

Plan of care and implementation

Mild preeclampsia and home care Activity restrictions (Lateral recumbent) Diet BP Assessment NSTs 1-3x per week (non stress test) Severe preeclampsia and HELLP syndrome Hospital care Magnesium sulfate Prevent seizure activity It does lower blood pressure which is a bonus Control of BP Strict bed rest Delivery (the only cure) Not going home - we stabilize them and then deliver the baby Under 34 weeks - give steroids (betamethasone) Strict I&O because being on Mg and being preeclamptic - holding on to sodium and water and not an increase risk of pulmonary edema by holding on too much urine. We foley cath them Reposition them - concern about the skin integrity Eclampsia Immediate care (airway, fhr, safety, Ativan, Valium) Postpartum nursing care (Mag sulfate, assess for PP hemorrhage) - uterine atony Prevention Prenatal care for assessment and early interventions

Early Pregnancy Bleeding

Miscarriage Ectopic pregnancy Premature cervical dilation Molar pregnancy AMA (advanced maternal age) Smoking Prior preterm birth

Well Baby Nursery

Monitor infants for temperature instability, change in activity, refusal to feed, pallor, cyanosis, early or excessive jaundice, tachypnea, respiratory distress, delayed (beyond 24 hours) stool or void and bilious vomiting Prophylactic erythromycin ointment (gonococcal infection) Vitamin K(1 mg) either IM or SQ within 4 hours of birth to prevent hemorrhagic disease Give Hepatitis B vaccine Give HBIG if mother is positive for Hepatitis B surface antigen Glucose testing Monitor Hematocrit at 3 to 6 hours State Mandated Metabolic Screening (36-48 hours of age) CF, Sickle cell, Maple Syrup disease, PKU and others - check the baby for all of kinds of congenital abnormalities

Well Baby nursery

What is IUPC?

Montevideo Units Measure the exact number of the pressure of the uterus Peak amplitude of contraction - amplitude at rest +'d over 10 minutes MVU 180-240 MVU's for adequate labor Follow Hospital policy - could be like 320 Baseline is 5 so it goes up to 100 so its 95 Highest peak - the baseline = the number needed Add it all up and then get the average You don't want the uterus to contract too much because it can ruptured WE can give them medications to stop or slow down the contractions

Coping with Concern: Injury Prevention

Most common cause of severe injury and death in school-age children is motor vehicle crashes: either pedestrian and passenger Bicycle injuries: benefits of bike helmets Appropriate safety equipment for all sports Lot of head injuries

Concussion

Most common form of TBI Concussion is considered a mild TBI "Concussion can happen when the head or body is moved back and forth quickly" (nih.gov) Dangerous when individual has multiple concussions Main concern is post-concussion syndrome Diagnostics Management Patient history and initial presentation Thereafter CT scan MRI for prolonged S&S Rest Pain management with acetaminophen Acetaminophen Dosing Weight-based dosing <12 years: 10-15 mg/kg/dose PO q4-6hr; not to exceed 5 doses/24hr Fixed dosing <6 years: Use weight-based dosing guidelines 6-12 years: 325 mg PO q4-6hr; not to exceed 1.625 g/day for not more than 5 days unless directed by healthcare provider >12 years Regular strength: 650 mg q4-6hr; not to exceed 3.25 g/24hr; under supervision of healthcare professional, doses of up to 4 g/day may be used Extra strength: 1000 mg q6hr; not to exceed 3 g/24hr; under supervision of healthcare professional, doses of up to 4 g/day may be used Extended release: 1.3 g q8hr; not to exceed 3.9 g/24hr Post-concussion Syndrome Occurs in about 40% of concussion patients Symptoms: Headache Vertigo Memory problems Anxiety Depression Concussion Complications: CTE Concussion Traumatic Encephalopathy Degenerative changes found in persons with repetitive TBI Begins months to years after last TBI event Memory loss Confusion Impaired judgment Reduced impulse control Aggression, including explosive anger Depression Progressive dementia CTE "According to a report from the US Department of Veterans Affairs and Boston University, 87 of 91 deceased former players for the National Football League (NFL) (96%) who donated their brains for study were found to have changes consistent with CTE." (http://emedicine.medscape.com/article/92095-clinical#b3) Return-to-Play "The main criteria for an athlete's return to play include complete clearing of all symptoms, complete return of all memory and concentration, and no symptoms after provocative testing." (http://emedicine.medscape.com/article/92095-followup)

Meningitis

Most common infection of the CNS Inflammation of the meninges and brain Three main types: Bacterial Viral or Aseptic Tuberculous

Osteogenesis Imperfecta

Most common osteoporosis syndrome in childhood It is often caused by a defect in the gene that produces type 1 collagen, an important building block of bone. Symptoms: Type 1 Autosomal Dominant The classic symptoms include: Blue tint to the whites of their eyes (blue sclera) Multiple bone fractures Early hearing loss (deafness) Because type I collagen is also found in ligaments, people with OI often have loose joints (hypermobility) and flat feet. Some types of OI also lead to the development of poor teeth. Symptoms of more severe forms of OI may include: Bowed legs and arms Kyphosis Scoliosis (S-curve spine) Symptoms: Type 2 Autosomal Recessive Lethal, stillborn or die in infancySevere bone fragility Multiple fractures at birth 10% of all cases Symptoms: Type 3 Autosomal Recessive or Dominant Severe bone fragility leading to progressive deformities Normal sclera Marked growth failure OI Blue Sclera Bowed Legs Therapeutic Management of Osteogenesis Imperfecta Primarily supportive care (Support Groups) Intravenous bisphosphonate therapy (increase bone density) Rehabilitative approach for prevention of further complications Positional contractures and deformities Muscle weakness and osteoporosis Malalignment of lower extremity joints

Duchenne Muscular Dystrophy

Most severe and most common of muscular dystrophies in childhood Not apparent at birth X-linked inheritance pattern; one third of cases result from fresh mutations Incidence: 1 per 3600 male births Duchenne MD: Characteristics Onset between ages 3 and 7 years Met their developmental milestones Complains of falling, muscle weakness, fatigue All of muscles - including cardiac, smooth and skeletal Progressive muscle weakness, wasting, and contractures Hypertrophic calf muscles in most patients Progressive generalized weakness in adolescence Death from respiratory or cardiac failure Assessing for Duchenne MD Look for motor development delays which typically include delays/difficulty with: Sitting Standing Walking Running Going up stairs Duchenne MD: Diagnostic Evaluation Prenatal diagnosis as early as 12 weeks of gestation Established primarily by blood polymerase chain reaction (PCR) for dystrophic chain mutation Confirmation by electromyelography, muscle biopsy, and serum enzyme measurement Positive family history and display of the usual characteristics of the disease Clinical Manifestations Waddling gait Frequent falls Gower sign Lordosis Abnormal curvative of the lower spine Enlarged muscles, especially in thighs and upper arms Profound muscular atrophy in later stages Mild to moderate mental impairment Obesity Clinical Signs Duchenne MD: Therapeutic Management No effective "curative" treatment Primary goal: maintain function in unaffected muscles as long as possible Keep child as active as possible Range-of-motion exercises, bracing, performance of activities of daily living, surgical release of contractures as needed Genetic counseling for family General Care Management Multidisciplinary team helps child and family cope with chronic, progressive, debilitating disease Design program to foster independence and activity as long as possible Teach child self-help skills Provide appropriate health care assistance as child's needs intensify (e.g., home health, skilled nursing facility, respite care for family) Often in pediatric long term facility for care They do not make it past adolescence Ongoing Therapeutic Interventions Pulmonary support CPAP/BiPAP ? GI support Nutritional support Manage constipation Emotional support MDA

Lead Poisoning (Plumbism)

Mostly affects children < 6 y Significant decline in lead poisonings since changes to household paints Ingested or Inhaled Pica "the habitual, purposeful, compulsive ingestion of nonfood substance" Sources of Lead Poisoning Sources Paint in old home Fishing weights Lead pipes Sniffing gasoline Toys/games Pottery Cosmetics (kohl) - lead poison based Lead Poisoning: S&S* Developmental delay Learning difficulties Irritability Loss of appetite Weight loss Sluggishness and fatigue Abdominal pain Vomiting Constipation Hearing loss (*http://www.mayoclinic.org/diseases-conditions/lead-poisoning/basics/symptoms/con-20035487) Risk for irreversible brain and/or kidney damage Affecting the cranial nerves "Lead lines" on x-ray A line in where the epiphyseal line in which it contain lead will show up in the x ray. It affect growth Lead Poisoning Diagnosis Obtain blood lead level BLL > 5 mcg/dL or higher = indicates child may have unsafe levels of lead in their blood BLL > 45 mcg/dL = begin treatment Outpatient treatment OK BLL > 70 hospitalize Treatment Chelation therapy Begin when BLL > 45 mcg/dL Typically use two drugs: dimercaprol and calcium disodium edetate (EDTA) Stop source Drugs to bind to the lead so it can be excreted in the urine through the kidneys and sometimes the stool

What are the contraindications to Breast Feedings?

Mother has tuberculosis Infant has galactosemia (unable to process lactose) Mother has HIV infection Maternal use of illicit or recreational drugs Cystic Fibrosis babies can be breast fed successfully if pancreatic enzymes are provided. These babies are at higher risks for need of macronutrient supplements especially Vitamins A,D, E,K and sodium chloride

Getting report when born

Mother's Medical History: chronic medical conditions, medications during pregnancy, unusual dietary habits, smoking history, occupational exposure to chemicals or infections of potential risk to the fetus and any social history that might increase risk for parenting problems and child abuse Important to know the social history because the child may be at risk for child abuse. May need counseling from social work Past Obstetric History: maternal age, gravidity, parity, blood type, and pregnancy outcomes Current Obstetric History: Results of procedures during the current pregnancy such as ultrasound, amniocentesis, screening tests( rubella, Hepatitis B), HIV and antepartum tests of fetal well-being Pregnancy-related complications: UTIs, pregnancy induced hypertension, eclampsia, gestational diabetes, vaginal bleeding, and preterm labor Peripartum Events: duration of ruptured membranes, maternal fever, fetal distress, length of the second stage, meconium stained amniotic fluid, type of delivery, anesthesia and analgesia used, reason for operative or forceps delivery, infant status at birth, resuscitative measures and Apgar scores

What to expect in getting report?

What happened to the GI system post partum?

Motility and tone return to normal within 2 weeks of delivery Constipation is common Encourage to take stool softener a day when they go home because it will increase to fluid in the bowel and to help to increase bowel motility and to make things easier until regular bowel movements. If you are having diarrhea maybe you can stop the stool softener! Pain from episiotomy and hemorrhoids makes bowel movements painful Stool softeners are given

Safety Promotion and Injury Prevention

Motor vehicle-related injuries Other vehicle-related injuries Firearms- availability in the home Sports injuries Injury prevention Anticipatory guidance

Fetal presenting position

Mri of live birth: https://youtu.be/5MSS2b9CVlA

What is labor onset?

Multifactorial - many reasons for labor onset Hormonal stimulation Prostaglandin- hormone produced by fetal membranes during pregnancy that can stimulate the uterus to contract at any stage during pregnancy Relaxin- hormone produced by the placenta. As placenta starts to age and the decreased supply of this hormone make uterus irritable. Oxytocin- primary hormone/factor that initates labor Produced by posterior pituitary gland Very potent uterotonin Estrogen/Progesterone Hormone balance Shift in the balance can cause labor Progesterone levels (as the placenta ages) starts to decrease and the uterus becomes irritable. Increased levels of estrogen cause increased uterine receptor sites for oxytocin.

Clinical Manifestations

Neonate: Poor feeding Lethargy Irritability Apnea Normal is 30 to 40 and then all of the sudden, they stop breathing Listlessness Apathy Fever Hypothermia Seizures Jaundice Bulging fontanelle Pallor Shock Hypotonia Shrill cry Hypoglycemia Intractable metabolic acidosis Infants and Children: Nuchal rigidity Opisthotonos Severe rigidity Bulging fontanelle Convulsions Photophobia Headache Fever Generally present, although some severely ill children present with hypothermia Alterations of the sensorium Irritability Lethargy Anorexia Nausea Vomiting Coma Older Child and Adolescents Fever / Chills Severe Headache Vomiting Nuchal Rigidity + Kernig's Sign + Brudzinski's Sign Purpuric / petechial rash Photophobia Seizures Increase ICP Petechial / Purpuric Rash Meningitis Purpuric Rash Opisthotonus

Hodgkin Lymphoma (HL)

Neoplastic disease originating in lymph system Primarily involves lymph nodes Often metastasizes to spleen, liver, bone marrow, lungs, and other tissues Main areas of lymphadenopathy Hodgkin Disease Children have a better response to treatment rate than adults with 75% overall survival rate at more than 20 years following diagnosis Lymph nodes feel firmer than inflammatory nodes and have a rubbery texture They may be discrete or matted together and are not fixed to surrounding tissue Diagnostic Evaluation of Hodgkin Lymphoma Lymph node biopsy for diagnosis and staging Presence of Reed-Sternberg cells: characteristic of Hodgkin's disease ( "owl's eyes" appearance) Staged according to Ann Arbor staging system Bone marrow aspiration with advanced disease Therapeutic Management Radiation and chemotherapy Used alone or in combination based on clinical staging Treatment : MOPP Mechlorethamine Vincristine (Oncovin) Procarbazine Prednisone Or Treatment : COPP Cyclophosphamide Vincristine Prednisone Procarbazine

Heart Transplantation

Orthotopic transplantation Heterotopic transplantation (piggyback) Organ donation evaluation Ventricular assist devices Rejection Potential long-term problems

Immunologic Adaptations

Newborn's response to infection is limited at birth Infants have low levels of antibody, IgM which make them more susceptible to gram-positive infections (60% of hospital acquired infections are gram positive) - Wash your hand - Strict hand washing protocol Infants have passive immunity to which the mother has developed antibodies, including diphtheria, poliomyelitis, tetanus, measles and mumps. Reason: IgG crosses the placenta in the third trimester IgA is secreted in colostrum and confers passive immunity to certain GI and respiratory infections in the breastfed infant Passive immunity is depleted after 3 months of age At two months we start to vaccinating the newborn against diseases

What are the immunologic adaptations?

Treatments for infertility

Non-medical: Fertility promotion Successful pinpointing of ovulation (corrects approx. 50% of infertility problems) Intercourse 3-4 X week No hot tubs/saunas for males Only water soluble lubricants No douching before or after intercourse Herbal remedies by Rx only Medical treatments - Stimulate ovulation Clomiphene (Clomid, Serophene) ( increases the risk of twins, etc.) due to multiple ovulation. Human Menopausal Gonadotropin (Pergonal) (multiple ovulation) Human Chorionic Gonadotropin (Profasil) Purified FSH (metrodin) Danozol (Danocrine) GnRH agonists (Synarel, Lupron, Zoladex) Surgical treatments Tubal microsurgery Repair of varicocele Laparoscopy Direct visualization of the pelvic area Assesses tubal patency, endometriosis, cysts, PID, congenital anomalies, adhesions Minor surgical repairs may be done Hysteroscopy may be done Assisted Reproductive Technology - See p. 137 (IVF, IUI)

Eyes of newborn

Normal Findings: Edematous lids Absence of tears (3 to 12 weeks) Eyes are usually closed Strabismus is a normal finding (cross eyed) the muscles are immature Presence of a red reflex (absence suggest retinal hemorrhages or congenital cataracts) Corneal reflex in response to touch Pupillary reflex in response to light (absence suggest blindness) Blink reflex in response to light or touch Rudimentary fixation on objects and ability to follow midline Red Flag: Eyes No red reflex- Congenital Cataract

Eyes

What is the skin of the newborn?

Normal Findings: Bright red, puffy smooth at birth. Second to third day, pink, flaky, dry Vernix Caseosa - thick cheese covering - try to get it get it off when born Lanugo Edema around eyes, face, legs, dorsa of hands, feet, scrotum or labia Sebaceous Gland Hyperplasia Difference between that and milia is that this has a more yellow tint to them but they are totally normal - hormonal related Neonatal Acne can be present at birth but is usually seen at between 2 and 4 weeks of life Milia, white papules, will spontaneously rupture and exfoliate their contents Erythema Toxicum seen at 24-48 hours of age. Usually seen on the chest but can also be found on face, back and extremities. Usually disappear within 48 to 72 hours. Sucking Blisters result from vigorous sucking in utero - on the lips and on the fingers Mongolian Spots are seen in Native American, African American and Asian newborns. Spots fade over time - can be mistaken as child abuse Stork bite, Salmon Patch, or Telangiectatic Nevi Found on lower occiput, eyelids and forehead Red Flags: Skin Progressive Jaundice especially in the first 24 hours Cracked or peeling skin Generalized cyanosis Pallor Greyness Hemorrhage, ecchymoses or petechiae that persist Poor skin turgor

Skin

Normal Findings: Bright red, puffy smooth at birth. Second to third day, pink, flaky, dry Vernix Caseosa - thick cheese covering - try to get it get it off when born Lanugo Edema around eyes, face, legs, dorsa of hands, feet, scrotum or labia Skin: Transient Common Abnormalities Sebaceous Gland Hyperplasia Difference between that and milia is that this has a more yellow tint to them but they are totally normal - hormonal related Neonatal Acne can be present at birth but is usually seen at between 2 and 4 weeks of life Milia, white papules, will spontaneously rupture and exfoliate their contents Erythema Toxicum seen at 24-48 hours of age. Usually seen on the chest but can also be found on face, back and extremities. Usually disappear within 48 to 72 hours. Sucking Blisters result from vigorous sucking in utero - on the lips and on the fingers Mongolian Spots are seen in Native American, African American and Asian newborns. Spots fade over time - can be mistaken as child abuse Stork bite, Salmon Patch, or Telangiectatic Nevi Found on lower occiput, eyelids and forehead Red Flags: Skin Progressive Jaundice especially in the first 24 hours Cracked or peeling skin Generalized cyanosis Pallor Greyness Hemorrhage, ecchymoses or petechiae that persist Poor skin turgor

Neurologic Examination

Normal newborns have reflexes that facilitate survival and sensory abilities (hearing and smell) to identify their mothers Babies are very sensitive to smell so if the baby refuse to be fed by their mother, ask the mother if she has started to wear perfume. It is hiding their smell. Recommend that fathers if they are having trouble feeding, to wear the mother's shirt to feed the baby Babies can hear the mother's voice Assess tone and symmetrical movements Assess cry - Red flag: high pitched cries can indicate CNS disorders

What is general anesthesia during labor?

Not usually done unless an emergency due to severe fetal depression Balance anesthesia O2, Nitrous, Volatile Inhalation Agent, Barbituate, Opioid, Benzodiazepines, Anti-emetic, muscle relaxer Nursing Responsibility Assess anesthesia Cricoid Pressure Roll under patient hip to relieve aorta and vena cava Routine Intra-op responsibilities

Nutritional and Eating Disorders

Obesity Defined as increase in body weight caused by accumulation of excessive body fat in relation to lean body mass Obese: generally considered when body mass index (BMI) is in >95th percentile for age, gender, and height Overweight: generally considered when BMI is between the 85th and 95th percentile

Medication

Nursing care similar to bacterial meningitis Maintain patient comfort Pharmacologic Intervention Antibiotics Antivirals Steroids Helpful if cause is H influenzae, tuberculous, or pneumococcal meningitis and increased ICP Administer before antibiotics Dexamethasone Antiseizure Phenytoin Phenobarbital Comparison of CSF in Meningitis

Complications and Residual effects

Obstructive hydrocephalus Subdural effusion Thrombosis in meningeal veins of venous sinuses Brain abscess Deafness Blindness Weakness / paralysis of facial and other muscles of head and neck SIADH - Hyponatremia and excessive release of the antidiuretic hormone S&S of water retention in extracellular space, lethargy, coma, seizures, nausea, and vomiting, electrolyte imbalance Waterhouse-Friderichsen Syndrome Meningococcal Sepsis Sudden, rapid, severe onset of overwhelming septic shock DIC Massive bilateral adrenal hemorrhage and purpura Seizure disorders Hearing loss Visual alterations Neurological sequelae - cognitive delays, cerebral palsy (CP), hydrocephalus Meningococcemia - septic infection that can lead to circulatory collapse and tissue necrosis

Febrile Seizures

Occur with fever > 101 0F Associated with OM, URI + Family history Typically occur in children 6m - 5y Loss of consciousness "Shaking" of extremities Long-term health problems unlikely

What is fertilization?

Occurs in the outer 1/3 of tube (ampulla) Once sperm has entered ovum, all others are kept out by a reaction known as Zona Reaction Soon after penetration the nucleus of spermatoza and nucleus of ovum become pronuculei (distinct bodies of chromatin) Each nucleus contains 22 autosomes and a sex chromosome Sperm carries 22 autosomes and 1 sex chromosome 22+1 (X or Y) = 23 Ovum carries 22 autosomes and 1 sex chromosome 22+1 (X) = 23 XX = female fetus XY = male fetus Nuclei fuse giving 22 pairs of autosomes and 1 pair of sex chromosomes New name for structure with 46 chromosomes is zygote The process of fertilization takes up to 24 hours to complete Pregnancy last about 10 lunar months, 9 calendar months, 40 weeks or 280 days - Length of pregnancy is computed from the first day of the last menstrual period (LMP) until the day of birth https://youtu.be/_5OvgQW6FG4

What is the nursing care for episiotomy?

Offer mother support and comfort Be available for surgical needs Local Anesthesia, Suture, Sponges Maintain sterile area Document Episiotomy We have to ask the physician what was the degree of the tear 1 - slight tear 2 - deeper tear 3 - up to but not through the rectal sphincter 4 - through the rectal sphincter S/P Episiotomy Ice to area Assess pain level Assess perineum (redness, swelling, tenderness, bruising, hematoma) Teach post partum perineal care Sitz bath Topical Anesthetic Creams to perineum Ice to area 20 minutes on and 20 minutes off RE: Area will be very uncomfortable and tender Inc discomfort sitting Diff and pain during 1st BM Discomfort voiding Promote proper, aseptic perineal cleaning No soap Warm water poured over area Apply topical local creams as prescribed by the physician

Weight loss post partum

On average 20-22 lbs Fetus- 7-8 lbs Placenta- 1 ½ - 2 lbs Amniotic fluid- 1 lb Blood at delivery -1 lb Diuresis- 4 lbs Involution of uterus and lochial discharge- 4 lbs All weight of pregnancy usually gone by 6-9 months post partum Exercise can be started 6 weeks post partum Wait for 6 weeks because they need to allow for their body to heal due to bleeding heavily No heavy exercising but can do pregnancy yoga and can put the baby in the stroller and go for a walk

What is the fourth stage of labor?

Otherwise known as recovery stage. Assessment/ Interventions Vital signs, lochia, and fundal height. Warm blanket to help manage involuntary shaking that occurs (actually due to sudden loss of intra-abdominal pressure). Apply ice to perineum for 24 hrs. - every 15 minutes like a post op patient - we determined the location of the uterus is right at the umbilicus. Later it goes to one above the umbilicus and then you are documenting. If it is more than one finger breath above the umbilicus, you start to worry about the bladder being full When the placenta separates, all of the blood vessels where the placenta was attached are open. What closes it? The contraction of the uterus - if the bladder is in the way, it won't let the uterus to contract then the mother is hemorrhaging Ice to decrease the swelling and help with comfort However if she had an epi, balance the application of ice like 20 to 30 minute on and then 20 to 30 minutes off and repeat for 24 hours Viewed as a time of recovery and stabilization. KEPT IN THE LABOR AND DELIVERY AREA FOR APPROX. ONE HOUR. Skin to skin bonding time Pt is washed ( partial bath) , peri care given. Pt usually breastfeeds(if she chooses) very soon after birth in the recovery time. This helps the uterus to contract, due to the release of the hormone oxytocin when breastfeeding.

What is Chorion?

Outermost embryonic membrane, closest to the mother Developed from the trophoblast and is closest to the uterine lining Chorion membrane is continuous with and covering the fetal side of the placenta forms the outer surface of the umbilical cord

Female hormones

Ovaries -> Estrogen -> Hypothalamus -> GnRH -> Pituitary -> FSH + LH -> Ovulation -> Progesterone

Milk Production

Oxytocin is another hormone that increases during pregnancy This hormone causes muscle cells within the breast to contract and squeeze milk down the milk ducts towards the nipples. This process, called the "let-down reflex" occurs each time the mother nurses the baby Initially, let-down reflex may take a few minutes but after several feedings, will occur within a few seconds. Let-down reflex feels different for each mother: brief prickle, tingle or even slight pain are all normal sensations Strong cramping in the uterus may also be felt. Oxytocin, which stimulates milk flow also causes the uterus to contract

What is the post partum care?

Pain Meds: Vaginal: Motrin, Tylenol (#3); C/S: Toradol (anti-inflammatory and it is an iV, given around the schedule) , Morphine, Percocet Rhogam: given within 72 hours of birth (Mom Rh -, Baby Rh+) Rubella vaccine: For Rubella nonimmune pts. Can NOT be given with Rhogam; Should NOT get pregnant for 3 months after vaccine Nothing that the doctor ordered is not harmful for the baby! Even naroctics in short term use Pain from C/S is all of that tugging and pulling of tissues so the antiiflammatory takes away the pain that is caused in the tissue - Toradol Spinal - takes 24 hours for the effect to wear off and start to gradually feel the pain General anesthesia - you wake up and pain is a 10! May receive a PCA

What are the nursing diagnosis?

Pain r/t to dystocia Potential for fetal injury & fetal compromise Potential for maternal injury / infection Powerlessness r/t loss of control Ineffective coping r/t disappointment, fear, pain, exhaustion Knowledge deficit r/t procedures, positioning, relaxation techniques

Seizures

Paroxysmal, uncontrolled electrical discharge of neurons in brain, interrupting normal function May accompany other disorders or occur spontaneously without apparent cause

Sickle Cell Anemia

Part of the State Metabolic Screening Testing for Newborns (Hemoglobins FS) Predominantly African, Mediterranean, Middle Eastern, Indian or Caribbean ancestry Elevated Reticulocyte count-Usually jaundice Recurrent episodes of musculoskeletal or abdominal pain Often hepatomegaly and splenomegaly that resolves Increased risk of bacterial sepsis Sickle Cell Anemia One of a group of diseases called 'hemoglobinopathies" Normal Adult Hemoglobin (Hgb A) is partly or completely replaced by abnormal sickle Hemoglobin (HbS) Causes of Sickle Cell Anemia Autosomal recessive disorder 9% of African Americans are carriers (have sickle cell trait) 40% of native Africans are carriers If both parents have trait, each of their children has a 25% chance of having disease In areas of world where malaria is common, individuals with sickle cell trait tend to have survival advantage over those without trait. It is believed that this is an adapted selective protection afforded trait carriers against one type of malaria. Pathophysiology Sickle Cell Anemia results from: Obstruction caused by the sickled RBCs Vascular inflammation Increased RBC destruction The abnormal adhesion, entanglement and enmeshing of the rigid sickle-shaped cells accompanied by the inflammatory process intermittently blocks circulation causing vasoocclusion. The absence of blood flow to the tissues causes local hypoxia leading to tissue ischemia and infarction (cell death).

Intraventicular Hemorrhage (IVH)

Pathology Bleeding around and/or into the ventricular system of brain Fragile blood vessel rupture easily in response to sudden changes. Vessels are responsible for supplying the developing brain Symptoms Apnea, Flaccidity, and full fontanel Usually appear within the first 72 hrs of birth Treatment Minimize trauma and discomfort, stress, and heat loss Assess seizure activity Measure head circumference

Neurologic Adaptations

Patterns of Development Cephalocaudal: progression is from HEAD to TOE Example: Head control precedes ability to walk Proximodistal: Progression from the trunk to the tips of the extremities Example: Infant can move his arms and legs but can't pick up objects with his fingers General to Specific: From simple tasks to more complex tasks Example: Child progresses from crawling to walking to skipping thermoregulation The ability of the neonate to produce heat and maintain a normal body temperature is a vital metabolic function Non-shivering thermogenesis is the primary heat production in newborns Brown fat is a very dense, highly vascular adipose tissue metabolized to produce heat. Found only in infants. REMEMBER: Producing heat causes increased demands for oxygen and glucose Environmental Factors Contributing to neonatal heat lossEvaporation: Loss of heat when water is converted to vapor Examples: Wet blankets or diapers, water or urine on the skin Convection: Transfer of heat when a flow of cool air passes over the infant's skin Examples: Drafts from open windows, air conditioning, Conduction: Transfer of heat when the infant comes in direct contact with cooler surfaces Examples: cold weight scale, cold stethoscope, cold hands Radiation: Transfer of heat from infant to cooler objects not in direct contact Examples: Cold sidewalls of crib or isolette, cold equipment, cold outside building walls and windows

What are neurologic adaptations?

Lymphomas

Pediatric lymphomas are the third most common group of malignancies in children and adolescents It is a group of neoplastic diseases that arise from the lymphoid and hematopoietic systems It is divided into : Hodgkin Lymphoma (HL) Hodgkin Lymphoma is more prevalent in adolescence and in young adults with an increase seen in ages 15 to 19. Non- Hodgkin Lymphoma (NHL) Non-Hodgkin Lymphoma is more prevalent with children younger than 14 years. Manifestations of Lymphoma Fatigue Unexplained fever Drenching Night sweats Loss of appetite or weight loss (10% in 6 months) Coughing or difficulty breathing Painless cervical (70-80%)or supraclavicular (25%) adenopathy Abdominal swelling (lymphomas in the chest or abdomen can grow to a very large size before symptoms appear)

Problems related to the female partner:

Pelvic Factors: problems with fertilization or implantation of the fertilized ovum. Infections Endometriosis Structural disorders Bicornuate or septate uterus Fibroid tumors Endometriosis

How to fertilize?

People can have intercourse on Sunday and still get pregnancy because as long as the sperm is viable for three days. It can sit in the fallopian tube, waiting for the egg. In patients issue with fertilization, we tell them to have sex every other days to make sure that the 24 periods is there.

Pharmacologic Management and Complications

Pharmacologic Management Tonic-clonic and focal seizures Phenytoin Carbamazepine Phenobarbital Phenytoin: Pediatric Dosing Therapeutic level: 10 - 20 mcg/mL Initially: 5 mg/kg/day (BID or TID); max 300 mg/day Children > 6y: Maintenance: 4 to 8 mg/kg with minimum dose 300 mg/d Complications Suicidal ideation Stevens Johnson Syndrome (SJS) Toxic epidermal necrolysis Decreased bone density Hepatotoxicity Pancytopenia ±BMD Seizure Drugs Carbamazepine OK for pediatric patients Obtain baseline labs before beginning Rx Monitor for renal problems Monitor LFTs Other uses Diabetic neuropathy Trigeminal neuralgia Bipolar disorder Contact prescriber if rash, fever, bleeding, or weakness Phenobarbital 60 - 120 hours half-life Can take up to 2-3 weeks to be fully effective Withdrawal gradually 15-50 mg 2 or 3 times daily for general seizure management 3-4 mg/kg daily for febrile seizures Pharmacologic Management Absence seizures Ethosuzimide Valproic acid Lamotrigine Some of these drugs are broad spectrum and appear to be effective for multiple seizure types. Pharmacologic Management Status epilepticus Initially, rapid-acting IV lorazepam or diazepam Followed by long-acting drugs Because Ativan and Valium are short-acting drugs, you need to follow their administration with a long-acting drug such as phenytoin or phenobarbital Pharmacologic Management Neurologic assessment for drug toxicity. Nystagmus Hand and gait coordination Cognitive functioning General alertness Noncompliance is a concern. You need to be knowledgeable about these side effects so that patients can be informed and institute proper treatment. A common side effect of phenytoin is gingival hyperplasia (excessive growth of gingival tissue) and hirsutism, especially in young adults. Medication nonadherence can be a problem in persons with a seizure disorder. Take measures to increase patient adherence to the prescribed drug regimens. If made aware of the issue, health care providers can work with the patient to find an acceptable drug regimen.

Ballard Gestational Assessment Scoring Scale

Performed within 48 hours of birth Looks at the neuromuscular development of the newborn Preterm infant has an extended body posture with low muscle tone Assessment Scores Neuromuscular Maturity Physical Maturity ▶ Gestational Age Assessment (PART 1) - FPB School of Nursing - YouTube.webarchive http://youtu.be/7Ca3a6MR5Zc

Other- HIV Human Immunodeficiency Virus

Perinatal transmission - via placenta (usual route) Accounts for majority of pediatric HIV positive cases Since 1994- prenatal administration of AZT starting @ 14-16 weeks of pregnancy to decrease transmission of HIV to fetus (AZT is an anti-retroviral medication) HIV positive mother should not breast feed (HIV is transmitted thru breast milk) Infants of HIV positive mothers should get neonatal AZT for 6 weeks after birth (minimally)

Implementation of Care

Physical Care Maintain Body Temperature Care of the hypothermic infant Transition to the incubator Or an islet Oxygen Therapy Oxygen Hood Nasal Cannula Continuous Distending pressure (CPAP) Keeps the alveoli open a little bit so it does not collapse Mechanical Ventilation

Sickle Cell Disease

Physical findings are normal at birth through 3-4 months because high levels of fetal hemoglobin inhibit sickling Symptoms are: pallor, fatigue, jaundice and a predisposition to gallstones during childhood and adolescence Intense congestion of the spleen with sickled cells results in splenomegaly could result in a non-functional spleen as early as 3 months of age in sickle cell anemia. This places the child at risk for an overwhelming infection with encapsulated bacteria such as pneumococci Pathophysiology of Sickle Cell Types of Sickle Cell Crisis 1. Vasoocclusive crisis: (VOC): "painful episode" is characterized by ischemia causing mild to severe pain that may last from minutes to days. 2. Sequestration Crisis: a pooling of a large amount of blood- usually in the spleen and sometimes in the liver that causes decreased blood volume and ultimately shock. 3.Aplastic crisis: diminished RBC production usually caused by a viral infection that results in profound anemia. 4. Hyperhemolytic Crisis: an accelerated rate of RBC destruction characterized by anemia, jaundice and reticulocytosis Diagnosis Newborn Screening Can be first diagnosed during a crisis during the toddler or preschool years Sickle-Turbidity Test (Sickledex) finger prick that can give results in 3 minutes If Positive, Hemoglobin electrophoresis to detect children with the trait and those with the disease Hematologic studies of the parents Therapeutic Management Aim of Therapy: To prevent the sickling phenomena and Treat the medical emergencies of sickle cell crisis Medical Management Rest to minimize energy expenditure and to improve oxygen utilization Hydration through oral and IV therapy Electrolyte replacement because hypoxia results in metabolic acidosis which also promotes sickling Analgesia for the severe pain caused from vasoconstriction Blood replacement to treat anemia and decrease the viscosity of the sickled blood Antibiotics to treat any existing infection Therapeutic Management Make sure vaccines are up to date especially pneumococcal and meningococcal vaccines ( Prevnar and Menactra) SCD children should always get a yearly influenza vaccination Oral penicillin prophylaxis is recommended by 2 months of age to reduce the chance of pneumococcal sepsis Erythrocytapheresis: transfusions to replace sickled cells with normal RBCs Research: Successful stem cell transplantation cures sickle cell disease but has been limited due to risks associated with the procedure, the inability to predict the severity of future complications and the scarcity of HLA-identical sibling donors Therapeutic Management Teach the family to : seek medical treatment if a fever of 101.3F (38.5C) or greater Give penicillin as ordered Recognize signs and symptoms of splenic sequestration Splenic sequestration causes sudden and severe anemia, with symptoms of sudden weakness, pale lips, rapid breathing, excessive thirst, belly pain, and rapid heartbeat. As well as respiratory problems that can lead to hypoxia Adequate hydration to prevent sickling Treat the child normally Prognosis Most patients with SCD will live into their fifth decade The greatest risk to children under 5 year of age is an overwhelming infection Physical and sexual maturation is usually delayed in patients with SCD Hydroxyurea is an approved medication that increases production of HbF, reduced adhesion of sickle cells, improves sickle cell hydration, increases nitric oxide production (vasodilator) and lowers leukocyte and reticulocyte counts

Endocrine system

Pituitary Gland Increase production of prolactin from anterior pituitary gland-which prepares breasts for lactation. Anterior pituitary enlarges slightly. Hypothalamus inhibits LH and FSH, also circulating estrogen and progesterone inhibit the secretion of LH and FSH by the anterior pituitary gland Suppression of a new follicle or follicles along with the secretion of HCG by the trophoblastic cells sustains the Corpus Luteum of pregnancy until the placenta matures. Thyroid Gland Mild Enlargement due to maternal basal metabolic rate increasing. Pancreas Maternal insulin requirements and production changes in response to fetal demand for glucose throughout the pregnancy. Gestational Diabetes Placenta Develops and becomes fully functional by the end of 1st trimester (12 weeks) Takes over production of progesterone ,estrogen and relaxin. As the pregnancy progress, the baby is pressing on the other organs such as the bladder, rectum and the stomach. Their stomach can only fit so much which is why they are always having "craving" and they have a need to go to the bathroom more and they may become constipated. It is ok for them to take a stool softener and it is recommended but check with the doctor.

What is placenta?

Placenta is a special organ of pregnancy Connects fetus to the uterine wall (via the umbilical cord) and is the organ by means of which nutritive, respiratory, and excretory functions of the fetus are carried out The fetus's liver is not really functional until after it is born like the lungs Formed at the site of attachment of chorion to uterine wall Formed through union of chorionic villi (fetal portion) and deciduas basalis (maternal portion) Placenta forms during the first 3 months (12 weeks) of pregnancy. By the end of 12 weeks it is completely formed and functional. https://youtu.be/MzkIE8zn3b4

What is the third stage of labor?

Placental separation Placenta usually delivers 5-15 mins after baby Repair of the episiotomy or tears(lacerations) Can do it before the placenta is delivered A piece of the placenta can lodged into the uterine wall and cause a hemorrhage. May need a visit to the OR to do a scraping of the lining of the uterus to get the placenta off.

Cast, Cast Care and Removing the cast

Plaster- mold more closely to the body part- take 10 to 72 hours to dry, inexpensive and heavy Fiberglass-Synthetic: lightweight, dry in 5 to 20 minutes, more expensive but does not mold as close as plaster. Keep casted extremity elevated Observe extremities for swelling or discoloration Check movement and sensation frequently Restrict strenuous activities for the first few days Keep things from being placed inside the cast Use crutches as directed Can be frightening- Oscillating blade cutter Feels like a "tickle" After removal, skin will be caked with desquamated skin and sebaceous secretions Do not scrub off. It is very fragile skin so it can break and bleed. Be gentle and after a couple of washing, it will come off. It has not been exposed to air and sunlight for a couple of weeks Apply mineral oil or lotion after soaking the extremity to help remove material Instruct not to pick or vigorously scrub the skin since it may cause excoriation and bleeding

Nursing Interventions

Positive Attitude of nurse is correlated with successful outcomes Provide clear information and written instructions for each procedure. Options Adoption Surrogate Legal and Ethical Concerns Assisted Conception: Religious considerations Confidentiality Embryo Disposition: Cryopreservation Reduction of fetuses Business of Infertility: Insurance coverage; Cost = $15,000-$20,000 each cycle; Only about 25% of all cycles are successful

Positive signs

Positive Kernig's Sign Severe stiffness of Hamstrings Unable to straighten the leg when the hip is flexed to 90 degrees Positive Brudzinski's Sign Severe neck stiffness Causes the patient to flex their knees and hips when the neck is flexed

What are the changes to the urinary system post partum?

Post-partum bladder has increased capacity and is relatively insensitive to increased pressure Results in over distension , incomplete emptying, and residual urine This is an optimal time for bladder infections due to urine stasis GFR remains increased for few weeks combined with increased blood volume Causes diuresis up to 2000 ml's a day for 4-5 days Ureters and renal pelvis of kidneys remain dilated after delivery and return to normal in 3-6 weeks The baby is so big doesn't allow the bladder to fill up s omuch so it will set off mo's ability to control bladder sometimes and allow the bladder to distend. It could be more of an effect of anesthesia She may find difficulty voiding in the first 24 hours Usually expected 30 mL/hr but in 24 hours she should be putting out at least 30 mL/hr or may be about 500 mL/hr If she is giving 150 mL then she is adequate and not distended bladder is not displacing her uterus Also at an increase risk of UTI and bladder infection because her anatomy has not returned to pre-pregnancy state. Tell her to drink cranberry juice to help deter UTI

Differentiate between Preterm infant and low birth weight infant

Pre-term Infant An infant born before 37 weeks gestation Low Birth Weight Infant An infant weighing < 2500 grams Extremely Low Birth Weight Infant An infant weighing < 1000 grams How many kg's will these weights be equivalent to? How many lb's will these infants weigh? 2500g = 5.5 lbs; 1000g = 2.2 lbs

Parental Bonding

Pre-term infant has less energy Behaviors Irritability Poor sleep patterns Poor feeding patterns Parents feel guilt/ fear of loss / anxiety Be support / emphasize positives Encourage short frequent visits when infant in NICU

Prepubescence (Tween)

Preadolescence is the period of 2 years before age 13 (10 to12) Prepubescence It is the beginning of the development of secondary sex characteristics Looking at the tanner scale and look at their pubic hair and development of the size of the scrotum and the penis typically occurs during preadolescence Age at prepubescence varies from 9 to 12 (girls about 2 years earlier than boys) Puberty begins at approximately age 10 in girls and age 12 in boys

Treatment of PIH

Preeclampsia Home care Nurse needs to assess home environment, support system Modified bed rest Vital signs Home Care for Mild Preeclampsia- if body is not responding and see increase in symptoms or poor compliance then HOSPITALIZED Bed rest is Left lateral position- maximizes utero placental blood flow . Takes large Gravida uterus of of Superior Vena Cava and improven venous return Promotes renal perfusion-excess fluid-particularly extravascular is remobilized VS will be weekly in Dr's office or VNA. May be taught to take own B/P at home Once Hospitalized VS will be at least q 4 hours. Nursing care plan pg 344 in book

Definitions of types of Hypertension in Pregnancies

Preeclampsia is a progression of gestational hypertension. It is pregnancy specific. - Hypertension with proteinuria. Eclampsia leads to seizure activity. Seizures related to pregnancy and hypertension Preeclampsia superimposed is the new onset or development of proteinuria with chronic hypertension. Difference between GH (gestational hypertension) and preeclampsia is the proteinuria that occurred during preeclampsia stage. Proteinuria dx > 30 mg/dl after 2 urine specimens 6 hours apart Diagnosis should be based on a 24 hour urine collect Gestational hypertension (high BP)- preeclampsia (proteinuria)- severe preeclampsia (uncontrolled HTN and proteinuria) - eclampsia (seizure)

What is the family response to pregnancy?

Pregnancy involves the whole family Mother, father, and siblings Many factors offer one's response to pregnancy One's culture and own childhood can affect a mother's response Most people are excited and happy for the birth of their child. If not, may need to an assessment to see what is wrong such as lack of support, financial issues Prenatal period is preparation for assuming a new role Prenatal period is a time of transition from non-parent to parent or from parent of one to two etc. The trimesters of pregnancy should represent a progression on steps in the emotional development of a new parent

What are the red flags of newborn?

Premature or early term infants(< 38 weeks gestation) Birth weight under 2700g (6 lbs.) Infants difficult to arouse for feeding; not demanding regularly in newborn nursery Medical or neurologic problems that interfere with feeding (Down syndrome, hypotonia, cardiac problems) Twins or higher multiples ABO blood group incompatibility or previous child experienced severe jaundice Mother whose previous breast-fed infant gained weight poorly Mother with breast surgery involving periareolar areas (if attempting to nurse)

What is the preoperative nursing care for c-section?

Prenatal education should include the possibility of a Cesarean Section Scheduled / Planned C/S Preop Labs Baseline VS Preop Shave / Bath Preop H&P Meet Anesthesia and decide on type of anesthesia NPO 8 to 12 hours preop (if possible) Antacids preop Consent for surgery - by physician/CNM Making sure that the doctor do their job of getting consent! Immediately Preop (next slide) Aspiration of gastric contents is the most dangerous to the pregnant women undergoing surgical procedure Give antacids 30 minutes prior to going to surgery Immediately Pre-op IV started Insertion of indwelling catheter Removal of dentures, partials, contacts, glasses, prosthesis, nail polish We do not ask the patient to take off their contact lenses or glasses because they want to see their baby However if you know the doctor is using an electric quarterly to aid in stopping the bleeding, take all metals off the patient including glasses Prepare patient for surgical delivery Verify Permit Allergies NPO Status IV Antibiotics Prepare patient for what is happening and what to expect Offer emotional support Assessment and verify operative permit Assure anesthesia and surgeon has answered all patient concerns Review post op expectations What is going to happen Why a c/s What sensations they may feel Pre op make sure surgical and anesthesia permit is signed by patient (consent form for surgical procedure) Must verify signature of patient and that surgeon and anesthesia spoke to patient and explained procedure Need to include husband and significant other in planning and explanations Need to wear OR coverup, mask, OR cap, Shoe covers Where to stand or sit (usually at mothers side at head of OR bed) What he can see or touch Where can he see the baby

What are the presumptive symptoms and signs of pregnancy?

Presumptive Symptoms(6) Amenorrhea Nausea/ vomiting Breast tenderness Urinary frequency Fatigue Quickening (fetal movements felt by mother) Presumptive Signs(6) Increase basal body temperature Linea nigra - a dark line from the umbilicus to the pubic bone due to thickening of the skin Melasma-chloasma (pregnancy mask) - blotchy skin or darkening of the skin Striae Enlargement of secondary breast tissue Colostrum secretion A woman that may have presumptive symptoms and signs does not make her pregnant but she could be.

Proteinuria

Presence of protein in urine Dipstick +1, +2 > 300 mg /L / 24 hr. collection Typically a late sign Increased rate of mortality Trace protein with no elevated B/P - is no concern-normal physiologic renal changes

Nursing care of Hypertensive disorders

Prevention Early prenatal care Identify those at risk Teach patients signs and symptoms to report High protein, low sodium diet, Calcium, Magnesium ,Zinc ,fish and evening Primrose oil, vitamin C and E Low dose Aspirin Most effective treatment is prevention Most effective tx. Is PREVENTION

KD: Diagnostics

Primarily confirmed by history and clinical findings ECG Echo CBC Leukocytosis Mild anemia CSF Aseptic meningitis Protein and glucose WNL

How is power as one of the five Ps of causative factors?

Primary Power Abnormal uterine contractions preventing normal cervical dilation and effacement Hypertonic or Hypotonic Uterine Dysfunction Secondary Power Fetal abnormal descent through the pelvis Precipitous Power Labor that lasts less than 3 hours Hypertonic Contractions Tetanic Like Primary Power Hypertonic Uterine Dysfunction Painful, frequent contractions Occur in latent phase Cervical dilation is < 4 cm Usually uncoordinated contractions Uterus does not completely relax Treatment Rest Analgesics Force of the contraction is in the midsection of the uterus and not the fundus The uterus is unable to apply downward pressure to push the presenting part against the uterus Analgesics Stadol Nubain Morphine After a few hours sleep following the analgesic (4 to 6 hrs) pt will mostly likely have a normal contraction pattern Primary Power Hypotonic Uterine Dysfunction Second and more common dysfunction After active, progression of labor contractions become weak or stop Common causes CPD / Malposition Treatment Ultrasound to determine fetal position and FHR / pattern Assess characteristics of amniotic fluid and if membranes have ruptured Decrease in uterine pressure < 25 mg Hg prevents progression of labor Mother becomes exhausted Inc risk of infection Nursing Process r/t Uterine Dysfunction Risk of Injury Prolonged labor Oxytocin augmentation associated with labor Acute pain r/t dysfunction Hypertonic increase pain with increasing, irregular, prolonged labor Anxiety r/t to prolong labor, pain, and fatigue Hypertonic prolonged and painful Hypotonic cessation of labor Precipitous Labor (< 3 hours) Causes Multipara Large Pelvis Small fetus Previous precipitous births Cocaine abuse Complications Maternal uterine rupture Laceration of the birth canal Amniotic fluid embolism Fetal hypoxia Intracranial Hemorrhage

What is power as a factor affecting labor?

Primary Powers of labor are the contractions 0-3cm- early phase of the first stage of labor- mild.-moderate 4-7cm - active phase first stage of labor-moderate- strong. 8-10cm- transition phase of the first stage of labor-very strong( See attached handout on Stages and Phases of Labor) Contractions have 3 phases to them 1. increment, 2.acme or peak ( most intense) and 3. decrement.(See p. 454 for pics) Contraction frequency , duration and intensity change with the stage of labor. Frequency- how often are the contractions occurring? Duration- how long do they last? Intensity- how strong are they? Mild, Moderate, Strong Only way to objectively measure intensity is IUPC Effacement- shortening and thinning of internal cervical os so that it becomes part of the lower uterine segment (Measured or assessed in %: 0-100%) Dilatation- opening or widening of external cervical os 0-10cms.( Measured or assessed in cms. 2.5cm's. = 1 inches 10cm = 4 inches (10 divided by 2.5=4) Effacement Dilation When at 10 cm, there is no cervical tissue left. We do not measure it.

Biologic Develoment

Primary sex characteristics External and internal organs necessary for reproduction Secondary sex characteristics Result of hormonal changes: voice change, hair growth, breast enlargement, fat deposits Play no direct role in reproduction Puberty: development of secondary sex characteristics Prepubescence: period of approximately 2 years before onset of puberty; preliminary physical changes occur Postpubescence: period of 1-2 years after puberty; skeletal growth is complete; reproductive functions become well established

What are carbohydrates?

Primary source of energy and fiber Increased need in 2nd and 3rd trimester Sources Dairy Fruits Vegetables Cereal Breads Carbohydrates promote weight gain and growth of fetus, placenta, and maternal tissues A balance of carbs is needed. Too little or too much can send them into a carbs coma!

Risks to Preterm Infant:

Problems related to: Feeding Neurodevelopment Thermoregulation Full term babies cant regulate their temp anyway but preterm don't have the brown fat layer and cannot regulate their temp even worse Hypoglycemia Hyperbilirubinemia Sepsis Respiratory function

What is the Ovum (human egg)?

Produced by female ovary each month Comes from the graafian follicle at ovulation and is brought into tube by fimbrated ends of the tube Has two protective layers Zona Pellucida - thick shapeless membrane (inside of the egg) - takes the shape of whatever it is surrounding Corona Radiata - outer ring composed of elongated cells held together by hyaluronic acid Is fertile for about 24 hours after ovulation (grows for 12 to 24 hours) If unfertilized then it degenerates

What is the hormone production of placenta?

Produces progesterone (hormone of pregnancy), estrogen, relaxin (keeps the uterus relax and relaxes the joints in the feet and the fingers and causing swelling) and HPL (human placental lactogen) Assumes full hormone production by 12 weeks gestation

Prognosis and Prevention

Prognosis Neonatal meningitis - highest mortality Latest studies: < 10% mortality rate in meningitis caused by H. influenza type B, S. pneumoniae, and Meningococcal meningitis Hearing impairment most common - CN VIII Prevention Treat immediately - URI, OM, sinusitis, and mastoiditis Immunizations - H. influenza type B for all children 2 months of age Meningococcal vaccine for all college students Pneumococcal vaccine - under the age of 2 years give at 2 months, 6 months, and 12-15 months old Rifampin - give to those who been exposed to child with a + diagnosis

What are the indication for vacuum assistance?

Prolonged second stage labor Non reassuring heart rate pattern on the fetal strip Relieves the woman's pushing effect especially when analgesia or fatigue interferes with her pushing attempts Vacuum Extraction Assist the birth of fetus by applying suction to the head 4% of all vaginal births (http://www.uptodate.com/contents/operative-vaginal-delivery) Soft suction cup is attached to a suction bottle (pump) by tubing and is placed against the occiput of the fetal head Creates a negative pressure of 50-60 mmHg of pressure Vacuum Extraction Attachment of a vacuum cap to fetal head and using negative pressure Prerequisites Vertex presentation Ruptured membranes Absence of CPD

Breastfeeding: Why is it good for the baby?

Protective substances: Less ear infections, allergies, vomiting, diarrhea, respiratory infections and meningitis Economical: easier for baby to digest, does not need to be prepared, costs nothing to make, always in supply, environmentally friendly Bonding: Provides physical contact, warmth and closeness

Severe Pre-eclampsia

Proteinuria (>5g/day) Kidneys are not functioning so decreased kidney function BP >160 systolic mm hg BP >110 diastolic mm hg Cerebral disturbances (HA, visual changes) Brain is not being perfused Systemic and pulmonary edema Poor perfusion Hepatic tenderness Tender to palpate and mom is start to complain of epigastric pain and right sided pain even not being palpated HELLP

What is psyche of the mother as a factor affecting labor?

Psychological response Being prepared and aware for child birth experience fosters a favorable outcome. (Prenatal childbirth classes discuss this) When you tense your muscles, any kind of pain you're having is exacerbated or felt more When you have fear and when you exhibit tension in your muscles, your body release chemicals called catecholamines, and they actually tell your brain to feel pain more or stronger Distract with breathing techniques, movies, music and other ways to help produce the endorphins to with deal with the pain Labor is affected by a level of tension and fear. Prenatal preparation helps with patient's knowledge and will cause less stress and anxiety during the birth process As a nurse you need to be aware that patients preparation or lack of preparation may affect their progress. The More prep the BETTER!!

Pubertal growth for girls

Puberty starts earlier Reach peak height velocity between 11.5 and 12 years Pubertal growth lasts 2-4 years By age 11 years in girls: 83%-89% of ultimate height is attained Additional 18-23cm growth occurs during late puberty Following menarche, height rarely increases more than 5-7.5cm Lean body mass decreases from approximately 80% of body weight in early puberty to 75% at maturity

What is Cesarean Delivery?

Purpose Preserve the life or health of the mother and fetus Prevent further complications to mother and / or fetus Txbook: reviews cultures with inc and dec c/s Brazil and Chili 40% Boliva lowest c-section 5% USA 29.1% C/S in 2003 Other purposes: Inc scheduled c/s for meeting the needs of parents and surgeon and staff Prevent damage to the pelvic floor during vaginal delivery Avoid pain during labor Safety of patient Dec. legal problems With inc. epidurals inc c/s Indications for C-Section Transverse, breech or other malpresentation of the fetus Prolapsed umbilical cord Abruptio Placenta / Placenta Previa Placenta Accreta Active Genital Herpes or Positive HIV Previous C/S CPD (Cephalopelvic Disproportion) Failure to Progress Maternal Diabetes Maternal Hypertension Preclampsia / Eclampsia Major congenital anomalies Pelvic types on Page 388 Placenta Accreta - Placenta attaches too deeply to the uterine wall about 1 in 2.500 pregnancies Placenta Accreta - attaches deeply into the uterine wall but does not penetrate the uterine muscle(75% of cases) Placenta Increta - does penetrate the uterine muscle too (15% of cases) Placenta Percreta - penetrate through the entire uterine muscle and can attach to another organ such as the bladd (5% of cases) Inc in multiple c-sections (60%) Types of Incisions Vertical Incision through skin and uterus Horizontal incision through skin and vertical through uterus Horizontal through skin and through uterus Advantages and disadvantages of each type reviewed on page 555 Txbook illus Pg 573 Low transverse takes longer Never done in an emergency situation More pleaseable incision Classic Incision Done in emergency situation Vertical up and down incision Will always need a c/s in following deliveries Uterine incisions on page 555 Abdominal Incisions C-Section Care Map for a C-Section Pelvic Types Adequate for Vaginal Birth Gynecoid Round, very adequate for vaginal delivery Anthropoid Oval but adequate for vaginal delivery Inadequate for Vaginal Birth - requires C-Section Android Oval too short for adequate vaginal delivery Platypelloid Flat, long and transverse Mortality and Morbidity Mortality Increase over vaginal birth Increase in emergency sections Mortality associated with Anesthesia Blood Clots/ PE Hemorrhaging Morbidity Increase Infection Increase complications Pneumonia Women who have had a c/s has increase risk of bleeding in future pregnancies Txbook goes into statistics 2.1 per 100,000 women die in vag births 5.9 per 100,000 women die in elective c/s 18.2 per 100,000 die in emergency c/s Major Complications S/P C-Section Aspiration PE Wound Infections Wound Dehiscence Thombophlebitis Hemorrhage UTI Injuries to Bowel and Bladder Anesthesia / Spinal Complications

What is electronic fetal monitoring?

Purpose: Instituted to assess for fetal hypoxia Reduce infant mortality Reduce incidence of Cerebral Palsy Outcome: Increased likelihood of C-Section Increased incidence of assisted delivery NO effect on rate of infant mortality or cerebral palsy American Congress of Obstetricians and Gynecologists Guidelines "Given that the available data do not show a clear benefit for the use of EFM over intermittent auscultation, either option is acceptable in a patient without complications." "the labor of women with high risk conditions...should be monitored with continuous FHR monitoring" Follow Your Hospital Policy!!!!!

KD: Management

Quiet environment Rest! Comfort Meds Prevent/minimize complications Aneurysm Myocarditis Heart valve problems

Tetralogy of Fallot

Rare condition 4 defects in one VSD Over-riding aorta RVH Pulmonary valve stenosis Symptoms A bluish coloration of the skin caused by blood low in oxygen (cyanosis) Shortness of breath and rapid breathing, especially during feeding or exercise Loss of consciousness (fainting) Clubbing of fingers and toes Poor weight gain Tiring easily during play or exercise Irritability Prolonged crying Heart murmur Tet Spells Most common between ages 2 - 4 months Sudden onset of cyanosis (deep blue skin, nails and lips) after crying or feeding, or when agitated Toddlers will quickly squat Trying to conserve oxygen in their body Managing Tetralogy of Fallot Multi-stage surgical intervention Limit physical activity/exertion Antibiotics Could lead to bacteria endocarditis Manage Tet spells Knee - chest position

What is the recommended nutrition?

Recommended daily intake (RDI) for pregnancy 300 calories more than non-pregnant state 1300mg of calcium 27mg of iron 60 grams of protein 400 mcg of folic acid All women should take this during child bearing years to prevent the possibility of NTD (neural tube defects)

What is the expected weight gain during pregnancy?

Recommended weight gain during pregnancy is usually 25-35 lbs The general rule: 3-4 lbs during first trimester. 1 lb a week for the 2nd and 3rd trimesters . Pregnancy is not a good time to engage in a weight loss program. Poor weight gain may result in a newborn with low birth weight. Or not enough weight gain can have infants with low birth weight

Purposes of Traction

Relieve fatigue in involved muscles Position distal and proximal bone ends Immobilize fracture site until realignment Prevent deformity Immobilize healing bone and prevent further injury Reduce muscle spasms (rare in children)

Aplastic Anemia

Refers to a bone marrow failure condition in which the formed elements of the blood are simultaneously depressed. Peripheral blood smear will demonstrate pancytopenia or the triad of profound anemia (deficiency of all three cellular components of the blood red cells, white cells, and platelets). Can be primary: congenital or present at birth. Best known congenital disorder is "Fanconi syndrome" Or Can be secondary (acquired) Acquired Aplastic Anemia Most Cases are considered idiopathic (unknown origin) about 50% Common Causes of Acquired Aplastic Anemia: Human parvovirus, hepatitis or an overwhelming infection Irradiation Immune disorders Certain chemotherapeutic agents, anticonvulsants and antibiotics Industrial and household chemicals (dyes, paint removers, shellac) Infiltration and replacement of myeloid elements such as in leukemia or the lymphomas Clinical Findings Weakness Fatigue Pallor Petechiae Purpura Fevers Rare: hepatosplenomegaly and significant lymphadenopathy Laboratory Findings Normocytic Red cells Low reticulocyte count WBC count is low Marked neutropenia Platelet count between 20,000 and 50,000 Bone Marrow biopsy shows decreased cellularity less than 20% of normal ( conversion of red bone marrow to yellow fatty bone marrow) Therapeutic Management Purpose: To restore function of the bone marrow 1) Immunosuppressive therapy (65-80%) SR Antilymphocyte globulin (ALG) or antithymocyte globulin (ATG) 2) Bone marrow transplantation (>80%) SR Treat all fevers with parenteral antibiotics Red blood cell transfusions for anemia symptoms Platelet transfusions sparingly

Fractures

Resistance of bone against the stress exerted yields to the stress force- "it breaks" Most common in children and older adults Fractures heal faster in children than adults Most often occur with everyday activities that predispose them to injury- MVA -heights Fractures in children under 12 months may indicate abuse Should also consider "osteogenesis imperfecta"- inherited disorder "brittle bone disease" Distal forearm is most common fracture in children. Clavicle fractures are also common in children under 10 years of age Neonatal clavicle fractures can occur with difficult birth- unilateral Moro Reflex

What is the discharge teaching?

Return to care provider in 6 weeks (2 weeks for C/S) Empty bladder, change pads every 2-3 hours and prn Peri care: clean w/water, Tucks, Dermoplast spray No scrubbing on the stitches!! Increase calorie intake 300 cal if breastfeeding you will still loose the baby weight High protein diet because it help with wound healing and muscle regeneration Increase fluids!! If they are dehydrated their milk production is going to drop! Drink plenty of water like 3 L a day When to call Care Provider Temperature >100.5o Temperature of 99.8 or a low grade fever it could be from the milk production Change in vaginal discharge Pain in lower extremities DVT usually don't occur in both side Warm, swollen, tender to touch on one side then it could be DVT Mom could be swollen in both legs and it could be excess fluid it is normal Pain in breast/ "Flu-like" symptoms Mastitis Incision leakage/redness/increased pain Prolonged post-partum blues (>2 weeks) They can use their OBGYN as a resource If they had a history of depression, then tell them to go back to whomever been treating you for depression before pregnancy Neonatal care Establish feeding and diapering Get into a pattern of changing the baby diaper before feeding Back to sleep Supervised tummy time! You can put the baby on their belly but only they are being supervised Why? Increased strength of upper extremity and increase neck muscles and also to prevent their head to be flatten The baby can spend as much time on their belly but only if you are watching the baby! No getting up to let the dogs out or answering the phone! No fluffy bed covers, pillows, or comforters Nothing the crib but a blanket Check temp axillary And rectally - at least the first year Cord and circumcision care For circumcision - take vasline and put the whole thing on the head of the penis and make the dressing soft. You don't want to dry it and gone to stick to the diaper and pull of the baby and cause more bleeding Watch for signs of infection Giving child a pacifier decreases the risk of SIDS Listen to what the American Academy of Pediatrics says No bath until cord drops off (10 days- 2 weeks) Sponge bath their baby and Q tip around the base of the cord No alcohol! Danger signs Decrease in wet diapers( less then 6-8 wet diapers a day) - at a week old Correlates to the baby's age Day 1 : Pee 1 and Poop 1 Day 2: Pee 2 and Poop 2 Day 3: Pee 3 and Poop 3 Day 4: Pee 4 to 5 and Poop: 2 to 4 Strict I&O Lethargic Fever Poor eating like vomiting not splitting

Rh Isoimmunization

Rhogarn - if mom is RH negative and the baby is RH positive, she can developed antibodies that could attack the baby in utero. Mom and babies blood does not mix in utero. Her body is going to reject the baby and cause severe anemia called hydrops. If at 25 to 30 weeks, we give her rhogarn that not to attack the baby. WE give it to everyone that is RH negative. Then her baby is born. Right after the delivery of every RH negative delivery, we tes the baby with the cord. If the baby is negative, we don't have to give rhogarn. If the baby is positive, we give the Rhogarn. If she didn't get it, if the baby is RH positive, her body is going ot attack that baby

What is labor?

Rhythmic contraction and relaxation of the uterine muscles with the progressive effacement and dilatation of cervix leading to the birth of the child. Definition of Labor: Contractions + Cervical Change = Labor

Nursing Care Management

Risk Factors Respiratory Function Look for signs of respiratory distress Like flaring of the nostrils, grunting sounds and sometimes babies make a mewing sound like a cat which is not good, not cute! Flaring, grunting retractions Cardiovascular Function Irregular heart sounds Look at lips, gums and tongue for cyanosis Cyanosis Body Temperature Kangaroo care - skin to skin contact Temp <97.4; Skin to skin Central Nervous System Function Jittery Seizure activity; Resp distress Renal Function I&O Nutritional Status Suck/swallow/breathe; hypoglycemia Give a pacifier need to learn how to suck Hematology Status Observe for jaundice Infection Prevention Maternal history - GBS, prom

Play in Middle Childhood

Rules and rituals Team play Quiet games and activities "Collections" Creative- "The Arts" Ego mastery

Premature Rupture of Membranes (PROM)

Rupture of amniotic sac and leakage of amniotic fluid beginning more than 1 hour before onset of labor at any gestational age Preterm rupture of membranes vs premature rupture of membranes Premature - it can occur at any gestational age like preterm or full term and she does not go into labor within one hour. We keep an eye on the mother but not really upset by it

More labor complications

Ruptured Uterus: 1/2000 births Primary risk factor: Previous uterine surgery; Classical incision S/S: Fetal distress, bradycardia; Severe abdominal pain; s/s shock Management: Conservative use of Pitocin; C/S; Hysterectomy Amniotic Fluid Embolus (AFE) S/S: Sudden acute maternal hypoxia, hypotension, cardiovascular collapse, coagulopathy 1/8000 - 1/30,000 Foreign substance is introduced into the maternal circulation, resulting in DIC, hypotension, and hypoxia >61% maternal mortality rate Poor neonatal outcome Risks: AMA (advanced maternal age - any woman over the age of 35 years), minority race, placenta previa, preeclampsia, precipitous labor Management: O2, intubation, CPR, IVF, Blood products, C/S

Newborn Care Tips for Parents

Safe Sleeping- Always on back in an empty crib! No baby bumpers or toys or anything in the crib - increase the risk of SIDS Demonstrate how to use a bulb syringe to clear baby's mouth and nose Support baby's head Do not carrying or transferring the baby - ask the parent but help the parent to support the baby's head! See the pediatrician within 48 hours of discharge Be sure to keep on schedule for infant vaccinations Bathing- every 2-3 days. Sponge baths till the cord falls off (1 to 4 weeks). Discuss water temp, choice of soap, cradle cap, ear care, gum care Use the lateral side of the forearm or elbow to assess the temperature - room temperature for anything Do not microwave the formula! Soft toothbrush is good for cleaning the baby's scalp Do not stick anything in the baby's ear! Circumcision care Sleep- Newborns can sleep 16 or more hours per day. Do not let baby sleep more than 4 hours without feeding Cord Care: know signs and symptoms of infection. Alcohol to dry the cord is no longer practiced The alcohol is absorbed into the baby's blood stream so it is not good. Just clean the area with water. It will dry on its own. Elimination: During first 5 days, your newborn should have 4-6 wet diapers in a 24 hour period. Have parents keep a daily log of stool/ wet diapers Car seat, shaken baby, environmental safety issues Choking, fall prevention, smoking around newborn, Babies that are inhaling second hand smoke are more prone to ear infections

Newborn care tips for parent

Caregiver Education

Safety! Cabinet locks Meds in secure place Cleaning products in secure place Poison Control # in house Teach Ipecac should not be automatically given

What are the fetal complications?

Scalp lacerations Bruising Cephalohematoma Neonatal jaundice Fractured clavicle Shoulder Dystocia Erb's paralysis Damage to VI and VII Cranial Nerve Retinal hemorrhages Fetal death Cephalohematoma

Eclampsia

Seizure activity or coma in woman diagnosed with preeclampsia Similar to Preecalmpsia-severe form Grand Mal Seizure occurs Antepartum, Intrapartum, or early Postpartum If Pre-ecalmpsia is diagnosed and treated aggressively incidence of eclampsia is rare Cerebral hemorrhage occurs with uncontrolled B/P Fetus becomes hypoxic Seen with placental abruption Cerebral hemorrhage - can lead to death Pathophysiology Vasoconstriction Systemic Vasospasms Vascular Damage Generalized arterial vasoconstriction leads to: Poor renal perfusion-malfunction of glomerular capillaries and decreased utero placental perfusion Vascular walls become damaged and may see an increase platelets (initially) Damaged Red Blood Cell's (Hemolysis) Vascular changes lead to tissue hypoxia, necrosis, and infarctions Eclampsia is caused by occlusion of blood vessels Occlusion causes seizures which causes a stroke Impaired renal functioning cause protein to spill into urine Dehydration of cells causes decreased plasma volume Sodium and Water retention (Edema) When they have swellings above the waist like in the face and in the fingers, it could be a sign of severe preeclampsia

Collaborative Care

Seizure disorders are primarily treated with antiseizure drugs. The goal of therapy is preventing seizures with minimum toxic side effects from drugs. Medications control seizures in about 70% of patients. Drugs act by stabilizing nerve cell membranes and preventing spread of the epileptic discharge. About 1/3 of patients require a combination regimen for adequate control. Therapeutic drug ranges are guides. Serum drugs levels can be helpful. The principle of drug therapy is to begin with a single drug based on patient age, weight, type, frequency, and cause of seizure and increase the dosage until seizures are controlled or toxic side effects occur. If seizure control is not achieved with a single drug, the drug dosage or timing of administration may be changed, or a second drug may be added. The therapeutic range for each drug indicates the serum level above which most patients experience toxic side effects and below which most continue to have seizures. If the patient's seizures are well-controlled with a subtherapeutic level, the drug dose need not be increased. Likewise, if a drug level is above the therapeutic range and the patient has good seizure control without toxic side effects, the drug dosage does not need to be decreased. Serum drug levels are monitored if seizures continue to occur, if seizure frequency increases, or if drug compliance is questioned. Many of the newer drugs do not require drug-level monitoring because the therapeutic range is very large. Surgical intervention to remove the epileptic focus or prevent spread of epileptic activity in brain Benefits of surgery Cessation of seizures Reduction in frequency of seizures Collaborative Care Anterior temporal lobe resection is the most common surgical intervention. About 70% of patients are essentially seizure free after this procedure. Not all types of epilepsy benefit from surgery. An extensive preoperative evaluation is important, including continuous EEG monitoring and other specific tests to ensure precise localization of the focal point.

Seizures: Metabolic Cause

Seizures resulting from metabolic disturbances are not considered epilepsy if seizures cease when underlying condition is treated. Acidosis, hypoxemia, hypoglycemia, electrolyte alterations, ETOH/barbiturate withdrawal, dehydration, water intoxication Hypertension Systemic lupus erythematosus Diabetes mellitus Septicemia

Psychological issues associated with infertility:

Self esteem Loss of control Grief Isolation Guilt Depression Physical strain of tests and treatments Financial strains

Diagnostic tests

Semen analysis Abstain from ejaculation 48-72 hr prior Performed within 1 hour of ejaculation Measures volume & viscosity of semen Measures the number & quality of the sperm (>20 million/ml). Evaluates the sperm shape & motility Motility should be >60% Pelvic ultrasound: Tumors, blockages, inflammation, anatomical anomalies Assessment of the menstrual cycle to determine if ovulation is occurring Calendar Basal Body Temperature (BBT) Monitoring cervical mucous OTC ovulation predictor urine test Hormonal Assays- Can be done on one or both partners to measure hormonal levels. Estrogen, progesterone, thyroid hormones, prolactin, FSH and LH levels. Hysterosalpingogram Day 7-10 of menstrual cycle Assesses tubal patency Postcoital exam 1-2 days before ovulation (0vulatory phase of cycle) Cervical mucous examined for: clarity elasticity, spinnbarkheit (stretchability), ferning Sperm in mucus analyzed for number, mobility, & normally shaped Endometrial biopsy Day 26-27 of cycle Cervix is dilated and tissue is obtained from endometrium If adequate progesterone production during the luteal phase of menstrual cycle the endometrium will mature

Psychosocial development

Sense of identity (Erikson) Early adolescence: group identity vs. alienation Development of personal identity vs. role diffusion Sex role identity Emotionality Spiritual Development Some adolescents may question values and beliefs of family Adolescents are capable of understanding abstract concepts and of interpreting analogies and symbols Adolescents may fear that others will not understand their feelings Greater levels of spirituality are associated with fewer high-risk behaviors

What are the sequence of visits?

Sequence of visits 1st trimester - one visit every month 2nd trimester - one visit every two weeks 3rd trimester - one visit every week 1st Visit = longest visit Full health history including medical, family surgical, social, ob Nutritional Assessment Prescription for prenatal vitamins is given May need Iron and Folic acid supplements Full physical assessment done including having all the lab work done. Pregnancy test Blood type and RH factor Rubella titer (if mother NON-IMMUNE give MMR after delivery) GC culture of the Cx Hep B, Hiv status if indicated Serology for Syphilis HCG level Glucose, protein, ketones ( check urine) Woman who get rogaine? Which means they are RH negative and they get to prevent the antibodies from attacking the fetus who may be RH positive. Get in first trimester and get one after they deliver. Subsequent visits Blood pressure, pulse, fundal height measurement, weight, urine check for sugar (glucose and protein) are all done at every subsequent visit Many have ultra sound to check fetal growth during the 2nd and 3rd trimester At 16 to 20 weeks and that will confirm our due date and the placement of the placenta and if there is anything abnormal about the baby itself Determine fetal activity and fetal movement Alpha Fetoprotein Studies Done at 14-20 weeks Detects neural tube .defects

Sexual Orientation

Sexual orientation develops during early childhood and gender identity is established by age 2 years. Sense of masculinity or femininity usually solidifies by age 5 or 6 years of age Most homosexual adults describe homosexual feelings during late childhood and early adolescence Homosexual experimentation is common during early and middle adolescence

Combined problems: Attributed to both partners

Sexual technique Position Frequency & timing of intercourse Immunologic factors Antibodies formed by the couple 10-15% of infertility is "unexplained"

Other- Gonorrhea

Sexual transmission is the usual route Gonorrhea culture done in early pregnancy (cervix) If tested positive, then treated in first trimester Fetal/ Neonatal infection occurs as infant passes thru cervix and vagina Rational for routine eye prophylaxis with erythromycin sulfate (ophthalmic)

Cytomegalovirus (CMV)

Sexually transmitted (usual route) and.respiratory transmission Maternal symptoms are "mono-like" (fever, fatigue) Can cause many congenital anomalies Example: microcephaly Can cause IUGR- leading to low birth weight, jaundice from hemolytic syndrome Babies/ Infants born with CMV infection have a classic "blue berry muffin rash" Virus can be found in neonatal urine and saliva (hand washing and gloves are necessary) Long term effects from CMV are pediatric hearing loss, mental retardation, and choriorentinitis (1-2 years)

HSV I and II (Herpes Simplex Virus)

Sexually transmitted - type II - affects genitalia Cold Sores- type I Transplacental transmission Direct contact from birth canal and genitalia C-section usual mode of delivery if active infection, due to 40-60% chance of transmission with vaginal delivery C-section decreases chance of direct contact to lesions Neonatal HSV can be serious Examples: fulminating infections may involve organ systems Liver Lungs Adrenal glands 80-90% mortality rate with infection Key Points of Care Management of HSV I and II Standard precautions Hand washing Gloves Lesion cultures Treatment with acyclovir Prophylactic topical eye ointment for 5 days

Hypertension in Pregnancy (used to toxemia or PIH - pregnancy induced hypertension)

Significance and incidence Preeclampsia complicates approximately 6% to 8% of all pregnancies Hypertensive disorders of pregnancy are the most common medical complication reported during pregnancy Significant contributor to maternal and perinatal morbidity and mortality

Simple Focal Seizures

Simple focal seizures Person experiences unusual feelings or sensations that can take many forms. Sudden and unexplainable feelings of joy, anger, sadness, or nausea May hear, smell, taste, see, or feel things that are not real

Types of Fractures

Simple or closed: does not produce a break in the skin Open or compound: fractured bone protrudes through the skin Complicated: bone fragments have damaged other organs or tissues Comminuted: small fragments of bone are broken from fractured shaft and lie in surrounding tissue (rare in children) Plastic deformation fractures: This occurs when the bones bend but do not break. Many times you cannot see a break on the x-ray but the bones may look bowed. Again, this occurs in children only because their bones are still very soft. X-ray example of plastic deformation. The bones in the forearm are bowed but not broken.Torus or buckle fracture: This occurs when only one side of the bone is compressed and buckles but does not break all the way through. The other side of the same bone is not affected. Greenstick Fracture This occurs when one side of the bone breaks but the other side of the bone is simply bent (red arrows). This is occurs because children's bones are still very soft compared to adult bones. Complete This is when the bones are completely separated and not touching on the x-ray.

Relating to Teenagers

Simple- Honest Approach without an authoritarian or excessively professional manner Recognize that outward appearance and chronologic age may not be an accurate reflection of cognitive development Teenagers are consumed with their own emotional needs Counter-transference Over-identification with the parents will be sensed by the teenager as another authority figure who cannot understand the problems of a teen Over-identification with the teen may cause parents to become defensive about their parenting role and to discount the health care provider's experience and ability

What is fetal circulation?

Since the fetal lungs and liver are not called to function independently while in utero, oxygenation of the fetus depends on a specialized circulatory flow The 2 blood circulations do not directly meet Fetal blood bypasses fetal lung Oxygenation occurs via the placenta As blood returns from the placenta through the single umbilical vein, a majority of the blood supply bypasses the liver through ductus venosus and goes directly to the inferior vena cava Oxygen to placenta to the umbilical vein to the inferior vena cava and bypass the liver to the ductus venosus and then travels to the right atrium. Oxygenated blood is going to the RA and the deoxygenated blood and the oxygenated blood from the RA are moxing. It finds it way from the superior vena cava. The oxygenated blood from the inferior VC and find it way across to the left atrium. Opening called the foramen ovale. Oxygenated blood is carried to the right side of the heart to the left side of the heart. It bypasses the lung called the ductus arterioles Think of bypass is Duct like Ductus Venosus. As blood enters the right atrium from the inferior vena cava, most of it is directed across the right atrium into the left through an opening called the foramen ovale This enables oxygen-rich blood from the placenta to by-pass the lung and is circulated to the body The blood that enters the right atrium from the superior vena cava is mostly deoxygenated and passes through the tricuspid valve into the right ventricle and pulmonary artery The blood in the pulmonary artery mostly passes through the ductus arteriosus into the descending aorta From there it flows into the two fetal arties back to the placenta where it becomes oxygenated The umbilical cord has three vessels, two arteries that return fetal blood to the placenta and one vein that takes blood from the placenta and returns it to the fetus Infants born with only two vessels often have other fetal anomalies

What is passenger as a factor affecting labor?

Size of fetal head Fetal Presentation Fetal Lie Fetal Attitude Fetal Position Fetal head bones/ Fontanelles Fetal head most important parameter of fetal body because it's the largest and least yielding of the fetal body. Openings of the cranial bone. Baby's soft spot. The baby's head needs to accommodate the narrow passageway and the bones of the skull cross over each other - overriding sutures will feel it if touch the anterior fontanelle (2) Frontal bones- anteriorly (2) Parietal bones- on each side of head. (1) Occipital bone located posteriorly Fontanelles(2)- Membrane covered spaces where the sutures meet. Anterior- diamond Shaped-closes at about 18months of age (located at junction of the sagital and coronal suture) Posterior- Triangular shaped. Smaller than the anterior. Closes at about 10 weeks(located at post. junction of the lambdoid and the sagital suture. Fetal head bones Bones are not fused together but separated by suture lines. Sutures: membranous interspaces- the sutures in the cranial vault allow for molding of fetal head. Sagital Suture- located between parietal bones and follows the A-P line of the skull. Frontal Suture- anterior continuation of sagital suture and between the two frontal bones. Coronal- located between parietal and frontal bones extending transversely on both sides. Lambdoid- between occipital bone and two parietal bones extending transversely on either side of posterior fontanelle.

Characteristics of Preterm Infant

Skin transparent / fragile Lanugo absent to sparse Younger the baby, less hair Increase Vernix Casesoa Younger the baby is in gestational, the more cheesy covering his eyes Lids fused or open Ears - Pinna flat and poor recoil Male genitals - smooth scrotum Female genitals - Prominant labia minor and clitoris Eyelids completely or partially fused The younger the baby, their genitals are more ambiguous. Females may have an enlarged labia and the clotoris is small in full term baby but it is the opposite in pre term baby. The preterm males do not have descended testicles.

What are the changes to the cervix and vagina in post partum period?

Soft and open to about 2 cm. Immediately following delivery the cervix takes a fish mouth appearance. Usually admits two fingers and is about 1cm thick. External Cervical os gradually closes after a few days- 1 week post-partum. Vagina regains elasticity in 3-6 weeks Episiotomy with repair (if done) heals in 4-6 weeks. If she receive stitches, those will dissolve. Does not need to come back to get them to take off. However it would be a good idea to look at it by using a mirror to see if there is redness or unusual discharge

Problems related to the male partner:

Sperm production problems Infections of the reproductive organs that affect sperm production(eg., orchitis-inflammation of the testicles). Mechanical problems: varicocele (varicose vein of the scrotum) or undescended testicles(cryptorchidism) Sperm motility problems R/T decreased testosterone levels, infections, prostate disease Sperm transport problems Male reproductive tract obstruction Scar tissue (Infections, STDs) Problems with ejaculation Premature or retrograde ejaculation Hypospadias Impotence

What is anesthesia for c-section?

Spinal or Epidural anesthesia Local anesthesia agent is injected into the Subarchnoid Space It is the space between dura mater and spinal cord General Anesthesia Induced unconsciousness using balanced anesthesia Usually not anesthetic of choice for deliveries due to adverse fetal affects and maternal risks Problem subarchnoid space decreases during pregnancy due to distention of epidural veins Complications of spinal anesthesia Spinal Headache Hypotension Drug reaction Total spinal neurological sequelae Side effects shivering, nausea and urinary retention Usually injected into L3 or L4

Spiritual and Social Development of Middle Childhood

Spiritual Development Children think in very concrete terms Children are avid learners with a desire to know their God Children expect punishment for misbehavior Children may view illness or injury as punishment for a real or imagined misdeed Social Development The peer group is extremely important Identification with peers is a strong influence in achieving independence from parents Sex roles are strongly influenced by peer relationships Peer group establishes standards for acceptance and rejection Children will often modify their behavior to be accepted by the group Clubs and peer groups Formation of formalized groups Bullying- Long term affects "Best friends" Relationships with families Parents are primary influence in shaping child's personality, behavior, and value system Increasing independence from parents is primary goal of middle childhood Parents need to be adults, not friends

Kohlberg's Moral Development

Stage 3: The interpersonal concordance or "good boy- nice girl" orientation Behavior that meets with approval and pleases or helps others is viewed as good Conformity to the norm is the "natural" behavior and one earns approval by being "nice" Want to be rewarded for good behavior They like to start asking questions to generate discussions Stage 4: The "law and order" orientation Obeying the rules, doing one's duty and showing respect for authority is the correct behavior. The rules or authority can be social or religious depending on which is most valued Want to know the rules Showing respect

Erikson's Industry vs Inferiority

Stage of accomplishment Eagerness to develop skills and participate in meaningful and socially useful work Acquisition of sense of personal and interpersonal competence Growing sense of independence Peer approval: a strong motivator Very important at this age to reward Feelings may derive from self or social environment Feelings may occur if child is unable or unprepared to assume the responsibilities associated with developing a sense of accomplishment All children feel some degree of inferiority regarding skill(s) they cannot master Significant Points: Children should be allowed to engage in tasks and activities and carry them through to completion They need and want real achievement Children have to learn to compete with others and to cooperate and learn the rules Feelings of inadequacy, stress can develop if too much is expected or if they feel they don't measure up or if goals that are set are unrealistic Teachers and peers are important socializing agents You can allow them to fail because that is how they learn When they don't complete the task, take the time to talk to them. You don't want them to feel like a failure and teach them a lesson and you know we will do it better next time This is the age when parents get a little over zealous and start signing their kids up Kids love to take on little tasks

Sexual Maturation Tanner stages of sexual maturity

Stages of development of secondary sex characteristics and genital development Defined as guide for estimating sexual maturity Occur in an orderly sequence A pictorial chart of sexual development is useful for discussion with counseling teens who lag behind their peers in physical development Girls Thelarche: appearance of breast buds; ages 9-13 years Adrenarche: growth of pubic hair on mons pubis; 2-6 months after thelarche Menarche: initial appearance of menstruation, approximately 2 years after first pubescent changes; average age, 12 years 4 months in North America Boys First pubescent changes: testicular enlargement, thinning, reddening, and increased looseness of scrotum; ages 9½-14 years Penile enlargement, pubic hair growth, voice changes, facial hair growth Temporary gynecomastia in one third of boys; disappears within 2 years

Physical Examination

How to do a physical examination?

Start with warm hands and a gentle approach Start with observation Then Auscultation of the chest Palpation of the abdomen Eyes, ears, throat and hips should be last as these are the most disturbing to the infant Normal Newborn Vitals: Apical rate: 120 to 160 bpm Respiratory rate: 30 to 60 breaths Temperature 97.5 to 99.0 F Systolic BP: 50 to 70 mm Hg Head circumference: 33-35 cm Chest circumference: 30-33 cm Length Average is 19.5 inches Weight Average is 7 lbs. 8 oz. Harlequin's sign - The harlequin color change is most common in low birthweight infants, but can occur in any child. - like a pooling of blood and caused by immaturity of the vessels to contract and dilate. As soon as they put the baby upright it will go away. Only see this in the first few days of life. Temporary condition. The condition is benign, and the change of color fades away in 30 seconds to 20 minutes. It may recur when the infant is placed on her or his side.

Brazelton Behavioral Assessment Sleep Scale

State 1: Deep Sleep Eyes closed, no eye movement, breathing regular, occasional startles. VERY loud noises may not disturb baby State 2: Light Sleep Eyes closed, rapid eye movement, respirations irregular. Random movements, occasional sucking and startles noted. State 3: Drowsy State Eyes can be open or closed, eyelids flutter, intermittent motor activity and startles noted. Infant reacts to sensory stimuli but response is delayed. Movements are smooth State 4: Quiet Alert State Infant has a bright look and focuses attention on the source of stimulation. Ideal time for parent-infant interaction. Other stimuli may eventually interrupt concentration but response is delayed. Motor activity is minimal State 5: Eyes Open State Infant demonstrates considerable motor activity with thrusting movements of the extremities and occasional startles. Infants react to external stimulation with increased startles and motor activity Crying State Cries loudly and does not respond to outside stimuli readily. Sleep States For the first hour infants born of unmedicated mothers spend 60% of the time in the quiet alert state and only 10% of the time in the irritable crying state. They are intensely alert, eyes wide open and demonstrate vigorous sucking behavior. Breastfeeding should be initiated after birth if possible. Days 2 and 3 are days which the baby will have more periods of sleep as they recover from the exhaustive process of birth Infants sleep an average of 16 ½ hours per day The baby needs to be fed every two to three hours. Baby cannot sleep past four hours because if the baby is not wakened up for feedings, we would be concerned and that the baby need to be evaluated for some abnormal findings. The baby may need to be woken up to be fed.

Passenger continued

Station- Measurement of descent(in cm's) that reflects the relationship of the presenting part to the maternal ischial spines. How far up or down is the presenting head Evaluated as the following: Floating- presenting part is above true pelvis Dipping- presenting part is starting to descend into true pelvis but is still unengaged Engagement/zero station- presenting part reaches level of maternal ischial spines. Crowning of fetal head-+3, +4( ready for birth)

Complications

Status epilepticus "A state of constant seizure or condition when seizures recur in rapid succession without return to consciousness between seizures" Most serious complication of epilepsy Neurologic emergency Can involve any type of seizure Subclinical seizures are a form of status epilepticus in which the sedated patient seizes, but without external signs because of the sedating medication. For example a patient under sedation for ventilatory support in the ICU could experience a seizure without physical movements. The health care providers caring for the patient may miss the seizure occurrence. Status epilepticus causes the brain to use more energy than is supplied Neurons become exhausted and cease to function Permanent brain damage can result Tonic-clonic status epilepticus Most dangerous Can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis Can be fatal Severe injury and death from trauma during a seizure Patients who lose consciousness are at greatest risk. Persons with epilepsy have a mortality rate 2-3 times the rate of the general population. Forty percent of these deaths are epilepsy-related and are caused by accidents occurring during seizures, suicide, treatment-related death, death due to underlying disease, and sudden unexplained death in epilepsy (SUDEP). SUDEP is higher in males, those on multiple antiseizure medications, and patients with long-standing epilepsy. The direct cause of SUDEP is unknown, but it is thought to be related to respiratory dysfunction, cardiac dysrhythmias, or cerebral depression. Effect on lifestyle is the most common complication of seizure disorder. Social stigma still exists. Discrimination/limitations in employment and education Driving sanctions The patient may develop ineffective coping methods because of the psychosocial problems associated with having a seizure disorder.

Infant reflexes

Sucking- disappears at 6 months of age Rooting- disappears at 3 to 4 months of age Traction response: Checks head lag Palmar grasp: disappears at 3 to 4 months Deep tendon reflex: Babinski is normal Moro- Startle: disappears by 3 months Tonic neck reflex- fencing position- disappears by 8 months Stepping: variable disappearance rate Brazelton Behavioral Assessment Sleep Scale State 1: Deep Sleep Eyes closed, no eye movement, breathing regular, occasional startles. VERY loud noises may not disturb baby State 2: Light Sleep Eyes closed, rapid eye movement, respirations irregular. Random movements, occasional sucking and startles noted. State 3: Drowsy State Eyes can be open or closed, eyelids flutter, intermittent motor activity and startles noted. Infant reacts to sensory stimuli but response is delayed. Movements are smooth State 4: Quiet Alert State Infant has a bright look and focuses attention on the source of stimulation. Ideal time for parent-infant interaction. Other stimuli may eventually interrupt concentration but response is delayed. Motor activity is minimal State 5: Eyes Open State Infant demonstrates considerable motor activity with thrusting movements of the extremities and occasional startles. Infants react to external stimulation with increased startles and motor activity Crying State Cries loudly and does not respond to outside stimuli readily. Sleep States For the first hour infants born of unmedicated mothers spend 60% of the time in the quiet alert state and only 10% of the time in the irritable crying state. They are intensely alert, eyes wide open and demonstrate vigorous sucking behavior. Breastfeeding should be initiated after birth if possible. Days 2 and 3 are days which the baby will have more periods of sleep as they recover from the exhaustive process of birth Infants sleep an average of 16 ½ hours per day The baby needs to be fed every two to three hours. Baby cannot sleep past four hours because if the baby is not wakened up for feedings, we would be concerned and that the baby need to be evaluated for some abnormal findings. The baby may need to be woken up to be fed.

Infant Reflexes

Fetal and Neonatal risks

Sudden and unexplained stillbirth Congenital anomalies Cardiac defects (VSD, Transposition of Great Vessels) Central nervous system (Anencephaly, open spina bifida) Skeletal defects (Caudal regression/sacral agenesis) Other problems that cause significant neonatal morbidity Macrosomia (big babies) Birth weight > 4000-4500 grams Neonate has large torso, shoulders Shoulder dystocia is common in macrosomic fetuses Macrosomia is due to fetal hyperinsulinemia

Management of Meningitis

Support ventilation Monitor respiratory status and administer oxygen as needed Control environmental stimuli to decrease ICP Quiet Room Low lights Monitor and treat ↑ temperature Control seizures Administer pain medications - avoid narcotics Most narcotics act as a CNS depressant so it is important to monitor of the neuro status Correct anemia Treat complications The child may lose the limb due to bleeding issues Vital signs with neurological assessment LOC, PERRLA, GCS Position to support therapeutic interventions No pillow slightly elevated HOB to ↓ ICP Strict I&O Measure head circumference daily < 2 years old NPO; advance to clear liquids Family support GCS for Children ICP monitoring

Surface Toxins

Surface Toxin Poisoning Plants Poison Ivy, Poison Oak Chemical Agents Household cleaners and agents can cause harm to skin Snake bites Poison ivy, poison sumac, poison oak Initial treatment Wash affected area Wash clothes & shoes Wash pets Calamine lotion QID or 1% hydrocortisone to affected area Oatmeal baths, cool/tepid water Cool compresses Oral antihistamines Diphenhydramine Benadryl Rx steroids for severe cases

Treatment

Symptomatic Disease is self limiting Decrease external and environmental stimuli Rest Control fever - acetaminophen Hydration Isolation until viral meningitis confirmed

What is pain management during labor?

Systemic Analgesia Crosses the Blood Brain Barrier to provide central analgesia including crossing placental barrier Effects - Dec. Respiration / Dec. LOC / Delayed Reflexes of Infant / Dec. APGAR Types Stadol IV Nerve Block Anesthesia (Review with Anesthesia) Demerol will dec. pain and relaxes the cervix Onset is 30-60 seconds and lasts 2-4 hours Given during labor - usually later stages of first stage as contraction become more intense Take the edge of and lets the mother handle the labor better and provides relaxation during contractions Danger Mothers with cardiac disease - Demerol causes tachycardia Remember Fentanyl is more potent than other Opioids therefore can only be used with 1:1 care / observation Works quicker than Demerol but has shorter duration Used for Anesthesia not usually for labor pain Other Medications for Pain Other Medications to enhance Analgesia Benzodiazepines (Valium, Versed, Ativan) Decreases pain with other med and decreases N&V Phenergan and Vistaril Decrease anxiety and apprehension Increases sedation Potentiates the Opioid Decrease N&V Other meds to decrease N&V and delay gastric emptying is Reglan and H2 Inhibitors (Pepcid / Tagament) Do not use for during labor. It was used for people who are undergoing induction of labor and they come in the night before and was given that night Nerve Block Analgesia Local injection of Xylocaine or Marcaine Local is injected into perineal tissue or Pudendal Nerve Block Pudendal is used to relieve discomfort of prolonged 2nd stage of labor, episiotomy, and birth Perineal injection for episiotomy Pudendal Nerve Block Anesthesizes nerves peripherally to Pudendal Nerve Less maternal complication and no fetal complications Problem decreases bearing down reflex for delivery

T.O.R.C.H. Complex

T: Toxoplasmosis O: Other (Syphilis, Gonorrhea, Varicella, HBV, HIV) R: Rubella C: Cytomegalovirus H: Herpes simplex virus

Home Nursing Care *

Take temperature and pulse every 4 hrs while awake If they're sleeping, they do not have to wake up to take their temperature Report any temperature > 100 degrees F Maintain BR/Modified Modified bed rest - they can't go out. They have to stay at home Insert nothing into vagina / no intercourse Assess for uterine contractions Fetal Movements counts NO tub baths Assess for discharge / Assess for foul smell discharge Maintain proper perineal hygiene - Wipe front to back And hand hygiene! Antibiotics if prescribed Maintain Health provider visits Once a week for a stress test and to do an ultrasound

Homosexual Identity in Adolescence

Teen feels different and develops feelings for a person of the same sex without clear self-awareness of a gay identity. The coming-out stage in which homosexual identity is defined for the individual and revealed to others The coming out stage may be difficult for the individual and family. Behaviors during this struggle may include both homosexual and heterosexual promiscuity, STD infections, depression, substance abuse, attempted suicide, school avoidance and failure and running away from home

Assessment of Fractures

The 6 "P"s: Pain and point of tenderness Pulses- distal to fracture site Pallor Paresthesia-sensation distal to fracture site Paralysis- Movement distal to fracture site Pressure

What are the fetal heart rate characteristics?

The MOST important characteristics in a fetal heart rate pattern are VARIABILITY and ACCELERATIONS

What is chorionic villi?

The chorionic villi are very important because They contain blood vessels that obtain O₂ and nutrients from maternal blood and dispose of CO₂ and waste products back to the maternal blood The placenta is taking the place of the embryos' lungs. They can't breathe yet. The lung are not expanded so they obtain oxygen and release CO2 though these villi Chorionic villi secrete HCG (human choronic gonadatropin) a hormone that maintains progesterone production by the corpus luteum and in turn progesterone supports and maintains the endometrium to support the products of conception Patients with the experience multiple miscarriages, many time it is having inadequate progesterone hormone and the body is unable to hold on to the embryo. Sometimes the patient is schedule for progesterone injections either when she just found out or before she is pregnant.

What is the maternal nutrition during pregnancy?

The first trimester is crucial for embryonic and fetal organ development A balance diet is the highest priority and an extra 500 kcal a day will be fine. You are not eating for two! A healthy diet before conception is the best way to ensure adequate nutrition is present for the developing fetus 2nd and 3rd trimesters account for more fetal growth so good nutrition is critical for a healthy pregnancy and a healthy baby If the patient has been doing things such as running or participating in a high intensity exercise class prior to pregnant, they can continue. If it hurt, stop!

Complications: Congestive Heart Failure (CHF)

The inability of the heart to pump an adequate amount of blood into the systemic circulation In children, can occur as result of structural abnormalities Heart muscle may become damaged if left untreated Right- or left-sided failure can occur Clinical manifestations Impaired myocardial function Abnormality of the rate and rhythms It may appeared to be slow and not fast Pulmonary congestion Systemic venous congestion Diagnostic evaluation Made on the basis of clinical symptoms Therapeutic Management of Congestive Heart Failure Goals: Improve cardiac function Digoxin Remove accumulated fluid and sodium Diuretics Furosemide Lose potassium Spironolactone Save potassium Decrease cardiac demands ACE inhibitors Improve tissue oxygenation Nursing Care Decrease cardiac demands Reduce respiratory distress Maintain nutritional status Monitor I & O If heart affected, then the kidneys is going to be affected Support child and family They are going to be very protective of this child so less interaction and less play time Hypoxemia Condition in which arterial oxygen tension is less than normal Acute or chronic Identified by a decreased arterial O2 saturation Hypoxia Cyanosis Polycythemia Increased hemoglobin in the blood Clubbing

Definitions of Infertility:

The inability to conceive after one year of regular sexual intercourse . Primary Infertility- inability to conceive, with no history of a successful pregnancy. Secondary Infertility- inability to conceive, after one or more successful pregnancies.

Renal adaptations

The kidney is still immature at birth. Tubules are short and narrow and this limits the effectiveness of tubular reabsorption and urine concentration mechanisms. Amino acids and bicarbonate may be lost in the urine This means that the newborn is EXTREMELY susceptible to dehydration, acidosis and electrolyte imbalance if normal fluid intake is restricted or vomiting or diarrhea occur. Most newborns (92%) void within 24 hours after birth. First void may be dark amber and cloudy due to mucus and urate content. Uric acid crystals excreted in the urine leave "brick dust" stains in the diaper- this is not considered significant. Urine becomes clear, straw-colored and less concentrated with increased fluid intake Frequency increases from 2 to 6 voids the first day to up to 20 voids per day once the infant's intake improves Output equivalent to age 1 day = 1 wet; 2 days = 2 wet, etc. 6-8 wet diapers/day (by one week of age)

What are the renal adaptations?

Respiratory

The most critical physiologic change required by the newborn- the ability to breath in extrauterine life Four categories of stimuli assist in the initiation of respiration: Chemical Stimuli Fetus experiences a transient asphyxia as a result of : interruptions in placental blood flow during uterine contractions Compressions of the umbilical cord The severing of the umbilical cord at birth Aortic and carotid chemoreceptors are stimulated by: Decreased PaO2 Increased Pa CO2 Decreased pH These Chemoreceptors send impulses to stimulate the respiratory center in the medulla These nerve impulses cause the diaphragm to contract initiating respiration Sensory Stimuli New stimuli during birth: sound, light, smell, touch and pain stimulate chemoreceptors Thermal Stimuli Research shows that "cold" appears to be a powerful stimulus in the initiation of breathing in the newborn When the infant's wet body is delivered, evaporation causes an immediate drop in skin temperature Thermal receptors, particularly on the face and chest, relay impulses to the medulla, triggering the first breath. However, Profound cooling can cause a drop in the core temperature and lead to respiratory depression Mechanical Stimuli During passage through the birth canal, approximately 30% of the fetal lung fluid filling the airways and alveoli is squeezed out When the chest is delivered, recoil of the chest wall occurs, drawing air into the partially cleared passages Red Flag: Infants born by cesarean delivery do not experience the compression of the thorax and are at an increased risk of transient respiratory distress due to retained fetal lung fluid

Respiration

Cardiac adaptation

The most important factor controlling ductal closure is the increased oxygen concentration of the blood Ductus Venosus closes with the clamping of the umbilical cord The clamping of the cord increases the blood volume and causes a rise in pressure in the left atrium. This causes the closure of the Foramen Ovale The Ductus Arteriosus closes by the 4th day of life with the onset of respirations and the fall in endogenous prostaglandins

What are the cardiac adaptation?

What is McDonald's sign?

The neck of the uterus - not pregnant it is very short but it get longer when she is pregnant and enables the examiner to sort of flip the uterus over the neck and it is a probable sign

How to feed the well newborn?

The newborn is ready to feed if : They are alert and vigorous Has no abdominal distention Has good bowel sounds Has a normal hunger cry Rooting, sucking , swallowing and gag reflexes are intact These signs usually occur within 6 hours after birth but fetal distress or traumatic delivery may prolong the period The healthy full-term infant should be allowed to feed every 2-5 hours on demand First breast feeding may occur in the delivery room Formula- fed infants will have their first feeding by 3 hours of life Feeding volume generally increases from 0.5 to 1 oz. per feeding initially to 1.5 to 2.0 oz. per feeding by Day 3 By Day 3, the average full term newborn takes 100 ml/kg/d of milk Breast milk and infant formulas both provide adequate water DO NOT GIVE SUPPLEMENTAL WATER!!! Both breast milk and formulas have enough water no need to give more

NCLEX questions

The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is A. as soon as possible after the infant's birth.B. after the mother has rested for 4-6 hours.C. during the infant's second period of reactivity.D. after the infant has taken sterile water without complications. Answer Answer: A. as soon as possible after the infant's birth The nurse is preparing to discharge a multipara 24 hours after a vaginal delivery. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should A. wear a tight fitting bra or breast binder.B. apply warm, moist heat to the breasts.C. contact the nurse midwife for a lactation suppressant.D. restrict fluid intake to 1000 ml. daily . Answer Answer: B. apply warm, moist heat to the breasts. Standard commercial infant formulas contain 20 calories per ounce. An infant was fed 45 mL at each of eight feedings in a 24-hour period. How many calories did this infant receive? A. 160B. 240C. 360D. 900Answer Answer B: An ounce contains 30 mL, therefore this infant consumed 1.5 ounces, or 30 calories' worth, at each feeding. 30 calories multiplied by 8 feedings equals a total of 240 calories consumed by the infant in the 24-hour period A cup is 240 mL which is 8 oz total

What are mechanism of labor?

The terms mechanism of labor or cardinal movements of labor are used to describe the simultaneous accommodation of the fetal anatomy to the maternal pelvis and birth canal and passage of the fetus from the uterus to the outside world Although they are described in a list fashion; several of the mechanisms occur either at the same time or in overlapping time frames. Engagement/ Decent Presenting part enters the true pelvis Specifically in a vertex presentation, engagement occurs when the bi partial diameters of the fetal head has passed thru the maternal pelvis inlet and has reached the level of the ischial spines. Decent Relationship of presenting part to ischial spines A variable of normal labor that is continuous and measurable Progress of fetal movements thru maternal pelvis to monitored by station. Flexion Flexion of the head is necessary to bring the smaller sub occipital diameter into and out of the mid pelvis of the mother. Occurs when the fetal head meets resistance from the bony pelvis and soft tissue. 2 additional factors make flexion of fetal head possible Fetus has the typical receding chin and the mandible recedes even more in response to pressure to permit hyper flexion of the head . Hormone relaxin may contribute to the process permitting a degree of hyper flexion that will never again be possible. Internal Rotation Caused by 3 factors Powerful pressure exerted by contractions on fetus Curved shape of the pelvic floor Relationship of the vertex to the projection of the ischial spines in the mid pelvic cavity Ischial spines act as a guide- helping the fetal skull to assume the position that will facilitate birth. Extension The birth of the head occurs by extension in the occiput anterior position and by flexion then extension in the occiput posterior position. Additional pressure from the contracting uterus and from maternal pushing helps to extend the head further till it emerges thru the vaginal opening. Restitution After birth of infant's head, head rotates 45 degrees returning to the position it assumed when it first entered the pelvis. This maneuver restores the normal anatomic alignment of infant's neck and shoulders. External Rotation Occurs as the shoulders (which are still in the pelvis) rotate 45 degrees to bring them in line with the A-P diameter of the pelvis Expulsion Birth of shoulders is by lateral flexion Anterior shoulder is usually born first with continual forces of maternal pushing. The posterior shoulder distends the perineum and is born. Remainder of body follows readily because it is smaller and more flexible. Video www.youtube.com/watch?v=B84MewU8h7Y

Etiology of PIH

Theories of Heredity Physiological and psychological stress Nutritional excess or deficiencies Endocrine disturbance PLACENTA??? Starts to produce the hormones and could be making too much or too little to cause hypertension Cause remains unknown

Breastfeeding: Can I breast feed if I have had plastic surgery on my breast?

There is no evidence to support that Silicone breast implants can harm infants. The surgery for breast implants usually does not interfere with milk ducts or the nipples unless the incision was made around the edge of the areola Plastic surgery to reduce the size of breasts may interfere with breastfeeding especially if the nipples were transplanted Usually that woman that have breast implanted can breast feed - only problem is breast reduction surgeries and that involved the transplantation of the nipple which is transplanted to the center of the breast and they can't breast feed

Nursing Care of the Healthy Preterm Infant

Thermoregulation Maintain Neutral Thermal Environment Warming bed Warm Hands Skin to Skin "Kangaroo Care" Nutrition Assess Glucose Levels Assess swallowing Assess and document I&O Daily Weights Level of Activity Increase Calories Cal/oz formulas If breastfeed and then supplement afterward Burp Frequent Prevent abdominal distension

Another ballard scoring

Think of preterm baby having less resistance to or poorer muscle tone so it is easier for them to be flexible in comparison to a full term baby.

Diagnosis of PTL

Three major diagnostic criteria Gestational Age between 20 to 37 weeks Onset of Contractions Wait until five minutes apart and they have been five minutes apart for an hour Call the doctor when there are any signs of labor Progressive cervical changes Cervical effacement of 80% Cervical dilation 2 cm or more If there are any issues under 20 weeks, we are not working hard to save this pregnancy because it tells us that the body is rejecting this pregnancy and it was not meant to be viable

KD: Disease Process

Three phases 1st phase: Acute Febrile Phase High fever Red eyes Lymphadenopathy Palpable lymph nodes in neck Dry cracked lips Strawberry tongue Swollen red skin on palms and soles Phase 2 12-25 days Arthralgia Fever starts to decrease Desquamation Start with the swollen red skin and then slough off New skin underneath At risk for a greater infection Risk for aneurysms increases V/D; abdominal pain Phase 3 6-8 weeks Patient demonstrates improvement Low energy may persist for additional eight weeks

Developmental Passage of Adolenscence

To complete the development from childhood to adulthood includes the following steps: Completing puberty and somatic growth Developing socially, emotionally and cognitively and moving from concrete to abstract thinking Establishing an independent identity and separating from the family Preparing for a career or vocation Generally adolescence begins at 11-12 years and ends between 18 and 21.

What are the goals for the patient?

To educate patient regarding dysfunctional labor Prevention of complications (measures to improve fetal oxygenation, reduce risk of infection from prolonged labor) Provide physical and psychological support Comfort measures Relaxation techniques Provide feedback / information Present care options / patient control Once that water breaks, she is at risk for infections. WE only check when we absolutely need to

What is tocolytic therapy?

Tocolysis = relaxation of the uterus Administration of medications to inhibit uterine activity Improved placental blood flow Management of fetal stress Terbutaline (Brethine), IV Fluid bolus, discontinue Oxytocin Contraction too much or preterm Dehydration can irritate the bladder which can irritate the uterus which can cause unwanted uterine activity

Latching On

Touch the breast to the center of the baby' lip to stimulate the rooting reflex When baby opens his mouth, pull the infant straight forward onto the nipple and areola. Correct position or "latched on" will have the nipple and much of the areola in the baby's mouth Baby's lips and gums should be around the areola not on the nipple Remember to break suction by slipping your finger into the corner of the baby's mouth Breastfed babies do NOT need supplemental water, sugar etc. unless instructed by the pediatrician Breast fed babies tend to feed more often that formula fed babies, usually 8 to 12 times per day - breast milk is more easily digested and they will feel hunger faster and they will have more stool Baby should nurse when: He nuzzles against the breast Shows the rooting reflex Makes suckling noises or puts hand to mouth Cries

Latching on

What is the post partum psychological adaptations?

Transition to parenthood Pregnancy is a anticipatory stage to becoming a parent Characteristically: intense feelings, challenges in responsibilities, preparing to accept and integrate the new family member Certain tasks should be accomplished during pregnancy Division of labor Role assignment Honeymoon phase Refers to the post child birth period during which time attachment is achieved between parents and child "Psychic" honeymoon When parents are exploring the new family member Bonding and attachment Bonding is the first step in the attachments process Period after birth appears to be the best time for bonding to be initiated Talking to infant, eye contact, touching, kissing Reva Ruben's - Assumption of maternal role Reva Ruben had identified numerous phases of maternal behavior particularly related to maternal touch and the infant. Tasks are Identify the new child Determining one's relationship with the new child Guiding and reconstructing the family unit to include the new family member Certain behaviors have been found to accompany the numerous tasks and the assumption of the role of mothering Taking in phase Mothers are concerned with own needs Needs to be "mothered" Passive and dependent Lasts 1-2 days Nurse needs to meet dependency needs No initiation of care taking activities but "takes in" information which will help to identify and get to know the infant. (Eg. Holding technique, feeding,) Taking hold phase Mother strives for independence In more control of self and body Actively beginning mothering Can become easily frustrated at not achieving tasks. ( eg. Breastfeeding, bottlefeeding, managing a crying newborn, changing and diapering) Lasts about 10 days (research based), but may be shorter in actuality. Health teaching- optimal time Letting go phase Happens when mother goes home Must accept physical separation from baby relinquish role of a "childless person" Must adapt to loss of freedom, autonomy, and social stimulation (for awhile) Be aware of post partum "blues" and the normalcy of this Nurses must reinforce the normalcy of these events and feelings and relate that they are part of the role transition to parenthood. Work on the positive aspects

Other- Hepatitis B Virus (HBV)

Transmission thru infected blood and sexual activity Most common cause of acute and chronic hepatitis Prenataly, women are tested for Hep B surface antigen Desired result should be HBSA - negative Transmission via placenta or vaginally Fetal and neonatal effects: Acute or chronic Hepatitis Infants born to Hep B positive mothers should get Hep B immoglobulin within 12 hours of birth Normal Hep B vaccine administered per protocol 1st dose- at birth- after admission bath 2nd dose- 1 month after 1st dose 3rd dose- 6 months after 1st dose Protection thought to be 10 years duration Note: Hep B vaccine protocol for all infants regardless of mothers Hep B status (positive or negative)

Antibiotics for PTL

Treat Maternal Infections Chorioamnionitis Broad spectrum antibiotics to fight multiple organisms - PCN, Ampicillin, Gentamycin We don't know what is the bacteria is causing the infection

Classification of DM

Type 1 diabetes Type 2 diabetes Pregestational diabetes mellitus is either type 1 or type 2 existing before pregnancy Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy All women are screened between 24-28 weeks of pregnancy Prediabetes impaired fasting glucose (IFG) Normal metabolic changes associated with pregnancy Key changes in maternal glucose and insulin production Normal pregnancy allows for adjustments in maternal metabolism to allow for adequate nutrition for mother and fetus Glucose, the primary fuel for metabolism, utilized by the fetus, crosses placenta Maternal glucose = fetal glucose Maternal insulin does not cross the placenta, so that by 10 weeks of gestation fetus starts to produce its own insulin. So increased maternal glucose leads to increased insulin production by fetus.

What is pelvis/passageway as a factor affecting labor?

Types Gynecoid (round)- normal- most common Android (heart) Anthropoid (oval) Difficult because the pelvis cannot stretch from left to right. It can stretch anteriorly and posteriorly as the baby moves through Platypelloid (flat) Least likely to pass the baby through We don't measure it because it is challenging and inaccurate Areas of important diameters Pelvic inlet- upper entrance to true pelvis Obstetrical conjugate Smallest front to back distance thru which the fetal head must pass. Should be 11cm. Diagonal conjugate Measure from the lower margin of symphysis pubis to sacral promontory. Should be 12.5cm Pelvic Cavity- mid- section of pelvis Anterior-posterior Lower boundary of symphisis pubis to junction of 4th - 5th sacral vertebrae. Should be 10cm. Transverse Distance between ischial spines. Should be 10.5cm. This is one of the more critical sections of the pelvis for the fetus to navigate. Areas of important diameters Pelvic Outlet Anterior-posterior Front to back distance. Should be 11.5cm Transverse Distance between the inner parts of the lower aspect of the ischial tuberosities. Should be 11cm.

What are umbilical cord blood sampling and fetal scalp blood sampling?

Umbilical Cord Blood Sampling Performed after delivery Withdrawal of blood from both the umbilical artery and vein Tested for pH, Pco2, Po2, and base excess Umbilical artery = fetal condition Umbilical vein =placental function Fetal Scalp Blood Sampling We don't do! Very invasive and you have to keep doing it like 24 hour urine output Through dilated cervix after the ROM Need for repetitive testing of pH Uncertainty of interpretation and application of results Seldom used in U.S.

Etiology for Preterm labors

Unknown to Multifactorial (Maternal behaviors and characteristics) Infections Cervical Infections UTI's Bacterial Infections Periodontal Infection Socioeconomic/ Sociodemographic Factors Other (Stress, uterine irritability, multiple gestation; no prenatal care) Periodontal Infection assoc with preterm labor due to inc levels of prostoglandins released by the causative pathogen Recommendation Preg Women maintain dental hygiene and dental care including dental appts Socio economic / Socio demographic factors Poverty Low educ level Lack of socio support systems Smoking Min to no prenatal care Domestic violence Other Not all preterm labor should be prevented 25% due to pregnancy complications with danger to fetus and/or mother 25% preceded by premature ROM Thus, only 50% can be prevented

Types of Traction (general)

Upper extremity (uncommon in children) Lower extremity Bryant traction Buck extension Russell traction Balance suspension Cervical (halo brace or vest) Gardner-Wells tongs Distraction Process of separating opposing bone to encourage regeneration of new bone in created space Can be used when limbs are unequal in length and new bone is needed to elongate shorter limb

How is position of the mother is one of the 5 Ps of causative factors?

Upright and squatting position most favorable for delivery Recumbent or Lithotomy Position Increase Dystocia with increase need to augment delivery with forceps or vacuum - for second stage of labor

What are the normal discomforts during pregnancy?

Urinary frequency Nausea and vomiting Heartburn Constipation Backache Dyspnea Varicose veins Hemorrhoids Leg cramps Edema Ptyalism Bleeding gums Breast tenderness Nasal stuffiness Leukorrhea Fatigue

What is amnioinfusion?

Use of room temperature or warmed isotonic fluid into the uterine cavity Used to relieve cord compression Document amount of fluid returned (approximately) Occur when the water is broken Creates a buoyancy again

Generalized Seizures: Absence seizures

Usually occurs only in children and rarely beyond adolescence May cease as the child matures or develop into another type Can be precipitated by flashing lights and hyperventilation Generalized Seizures Typical absence seizures Typical symptom is staring spell "daydreaming." Lasts only a few seconds Often goes unnoticed May occur up to 100 times/day if untreated EEG demonstrates pattern unique to this type of seizure The electroencephalogram (EEG) demonstrates a 3-Hz (cycles per second) spike-and-wave pattern that is unique to this type of seizure.

Overview of S&S Preterm Labor

Uterine Contraction (>6/hr) More than 6 in an hour - need to call the doctor Pain or no pain Low back pain Pelvic Pressure (rectal/vaginal) Menstrual Cycle Cramps Intestinal Cramps Change in Vaginal Discharge (watery or bloody) Gush or trickle of fluid from vagina Does not have to be a big gush of water but can be continuous discharge

What is post partum hemorrhage?

Uterine atony - "Boggy" uterus; bladder distension Continue to massage the uterus to be firm If she was still under the effects of epidural then yes just straight cath her Make sure that her bladder is empty Retained placenta Vaginal or cervical lacerations Vaginal or vulvar hematoma Blood blister - in 24 hours could become a big tissue filled blood Important to do an assessment of perineum

Criteria for Treatment

Uterine contractions with progressive change in cervix Cervical dilatation of 2 to 4 cm Cervical effacement of 80% or more Fetus is viable with no fetal distress Woman gives informed consent for treatment

What are the anatomical changes in the post partum period?

Uterus Cervix and Vagina Abdominal Wall Cardiovascular System Urinary System Ovulation and Menstruation G.I. System Weight Loss Breasts

What is uterine distention?

Uterus becomes very large and muscle becomes over distented and irritable and starts to contract. BEFORE TRUE Labor Lightening- decent of fetal head into pelvis Occurs most commonly in vertex presentation without cephalopelvic disproportion (C.P.D). Occurs 2-3 weeks before the onset of labor in primagravidas. Occurs with the onset of labor in multigravidas Braxton-Hicks contractions- strong, irregular uterine contractions Felt in abdomen

Care Management for a Neonate of a Diabetic Mom

Vaginal delivery or C-Section Vital signs and APGAR score Neonates tend toward hypoglycemia due to high circulating sugar level in mother during pregnancy - then sudden withdraw of sugar level from mother once born Use chemstrip ("Accu check") for BG assessment per protocol Normal is 40-70 mg/dl Feed early if hypoglycemic Blood sugar will regulate with in 4-6 hours Signs of hypoglycemia Jittery then lethargic, poor thermoregulation, pallor

Group B Strep (Streptococcus Infection)

Very serious infection of perinatal period Causes serious effects in mother and infant 33% of pregnant women are colonized 70% of newborns of colonized mothers will also be colonized The greater the colonization, the more likely the newborn will be infected Sites of Colonization in Pregnant Women Cervix, vagina, rectum During Pregnancy GBS can cause UTI's, intra amniotic infections and chorioamnionitis Chorioamnionitis can lead to premature ROM and premature labor Post Partum GBS can cause endometritis with high fevers and fundal pain and tenderness presenting in just 24 hours Diagnosis of GBS Prenataly Cervical culture done at 35-37 weeks on all women Treatment for GBS Prenatal - Ampicillin 500mg p.o. qid x 7-10 days (3rd trimester) Intrapartum- Ampicillin 2 gms IV q 6 hours till delivery; PCN 5mu x1, then 2.5mu q4hrs until delivery Also any patient with ROM greater than 18 hrs or fever should have antibiotic protocol Neonatal Effects 50% mortality rate in neonates with early onset (before 7 days) Many neonates are treated with Ampicillin and Gentamycin even though mother had intrapartum protocol All neonates of GBS positive mothers must be assessed for lethargy, poor color, fever, poor thermoregulation, and poor appetite Neonatal mortality due to Pneumonia Bactremia - general sepsis Meningitis It is essential for all GBS positive mothers should be treated aggressively according to ACOGN standard to prevent maternal and neonatal morbidity and mortality

Rubella

Viral infection that causes "german measles" Serious viral infection with serious fetal anomalies if contracted during first three months of pregnancy Rubella immunity determined pre-nataly If rubella non-immune, then mother immunized in post-partum period before discharge Always remind patient- no pregnancy for a minimum of three months (nurse must chart this) Congenital Rubella Syndrome Cataracts Hearing Loss Glaucoma Cardiac defects (pulmonary artery stenosis) Patent ductus arteriosis

What are the supplements?

Vitamins First week Fluoride After 5 Months of age Formula Feeding Formula feeding is also a healthy choice for babies. If you use a formula, your baby will get the best possible alternative to breast milk. (You should not attempt to make your own formula or feed an infant cow's milk.)

Bladder care

Void 150 first 3 voids

Managing ingested poisons

Vomiting Is Often Contra-Indicated DO NOT INDUCE VOMITING: IF patient ingested corrosives and hydrocarbons IF seizure present IF patient is comatose IF patient does not have a gag reflex Expect to have patient undergo gastric decontamination in ED Ipecac The American Academy of Pediatrics recommends that ipecac syrup NOT be stocked at home. The American Association of Poison Control Centers no longer recommends that parents keep ipecac syrup at home. The U.S. Food and Drug Administration is considering a recommendation from one of its expert panels to make ipecac syrup a prescription-only drug Poison control doesn't tell you to use it. "You can't even buy ipecac in the drugstore." Call Poison Control: 1-800-222-1222 www.aapcc.org Have the following information ready: Child's condition Severity of symptoms Name of product / agent if known How much was taken Time of event / exposure Route of exposure Your name and phone number Age& weight of child Child's PMH Gastric Lavage "Stomach pumping" Insert large-diameter NGT Lavage with NSS Put the saline in the stomach and then pull the substances out Rinsing the stomach Place the patient in a head-down, left side-lying position to reduce the risk of aspiration if the patient vomits Activated Charcoal Emergency treatment in poisoning by drugs and chemicals Odorless, tasteless, fine black powder absorbing agent that produces a stable compound to be eliminated from the body Mix with sorbitol, use straw Will stain the teeth - not permanent Give ASAP -- preferably within 1 hour of ingestion Continue therapy may in the presence of good bowel function -- until drug levels are declining and clinical improvement is expected Educate patient and caregiver about dark stools Black because of the characol

Iron Deficiency Anemia (IDA)

Was once considered the most common cause of anemia in pediatrics Improved nutrition and iron-fortified formulas and cereals has decreased the incidence significantly Normal infants are born with sufficient iron stores for the first 4 to 5 months Nutritional iron deficiency is most common between 6 and 24 months Iron Deficiency Anemia A deficiency prior to 6 months of age may occur if the iron stores are reduced as in: Prematurity SGA- small birth weight Neonatal anemia Perinatal blood loss or loss due to hemorrhage A deficiency over 24 months should evaluate for blood loss. Signs and Symptoms Mild Iron Deficiency: Asymptomatic Severe Iron Deficiency: Pallor, fatigue, irritability and delayed motor development. "Milk Babies"- Iron deficiency due to ingestion of unfortified cow's milk may be fat and have poor muscle tone. They often have an increased fecal loss of blood History of pica is common. Laboratory Findings Severe anemia: Hemoglobin can be as low as 3-4 g/dL Red cells are microcytic and hypochromatic Low MCV and MCH Reticulocyte count is normal or slightly elevated Iron Studies: Decreased Serum Ferritin, Iron and transferrin saturation. The Total iron binding capacity will be elevated. Treatment Focus: Increase the amount of supplemental iron the child receives Oral Elemental Iron Supplements: 6mg/kg/d given in three divided doses Adequate treatment usually results in the resolution of the anemia within 4-6 weeks. Treatment is continued for a few additional months to replenish the iron stores Liquid Iron supplements will stain teeth and should be taken with a straw or with a syringe to the back of the mouth. Brushing teeth after dose will also decrease staining. Treatment Diet: Encourage Iron fortified formula and foods. Infants should not be given cow's milk before 12 months of age. If a child fails to respond to oral therapy, parenteral iron preparations may be prescribed. Iron Dextran is given IM. Site is not to be massaged or rubbed after injection to minimize skin staining and irritation IV Iron Preparations had to be monitored closely for toxicity and anaphylaxis. New medication: Ferumoxtol is less toxic than previous drugs.

Growth Plate (Physeal) Injuries

Weakest part of the long bones is the cartilage growth plate or physis Classified using the Salter- Harris Classification system May affect future bone growth Treatment: may include open reduction and internal fixation to prevent growth disturbances

NCLEX Questions

While evaluating the fetal heart monitor tracing on a client in labor with an internal fetal scalp lead, you note that there are decelerations on the monitor. Which of the following assessments must you make first? The relationship between the decelerations and the labor contractions - answer Is it late? Is it variable? Is it deceleration? The maternal blood pressure The gestational age of the fetus The placement of the fetal heart electrode in relation to the fetal position You are caring for a patient in active labor. While assessing the fetal heart patterns you notice late decelerations on the monitor strip. The most appropriate nursing actions would be to: Place the mother in the supine position (lateral position) Document the findings and continue to monitor the fetal patterns (never happens) Administer oxygen via face mask - answer Increase the rate of Pitocin IV infusion (supposed to stop) You are caring for a client in labor and note the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? Take the mother's vital signs and tell the mother that bedrest is required to conserve energy Notify the physician or midwife of the findings asap Reposition the mother and check the monitor for changes in the fetal tracing Document the findings and tell the mother that the monitor indicates fetal well-being - answer You are caring for a patient in labor who is experiencing variable decelerations. One intervention the doctor or midwife may order to resolve this problem is: Umbilical cord blood sampling Vibroacoustic stimulation Amnioinfusion - for cord compression - answer Fetal scalp stimulation You are caring for a patient, 41 weeks gestation, whose labor is being induced. After several hours of monitoring, you notice recurrent late decelerations on the monitor. You understand that these decelerations are caused by: Fetal movement Uteroplacental insufficiency - PPP - late deceleration - answer Head compression - early deceleration Cord compression - variable deceleration

Stimulation of labor

Why?: The labor mechanism may slow down and fail to progress Quality and quantity of uterine contractions (HYPOTONIC UTERINE DYSFUNCTION) it means that a normal active labor slows down. Cervical dilation stops Cervical dilation Station Treatment: Pitocin (synthetic form of Oxytocin) through I.V. Similar to labor induction

Wilm's Tumor

Wilms' tumor is a rare kidney cancer that primarily affects children. Also known as nephroblastoma Wilms' tumor is the most common cancer of the kidneys in children. Wilms' tumor most often affects children ages 3 to 4 and becomes much less common after age 5. Wilms' tumor most often occurs in just one kidney, though it can sometimes be found in both kidneys at the same time. Improvements in the diagnosis and treatment of Wilms' tumor have improved the prognosis for children with this disease. The outlook for most children with Wilms' tumor is very good Wilms' tumor doesn't always cause signs and symptoms. Children with Wilms' tumor may appear healthy, or they may experience: Abdominal swelling An abdominal mass you can feel Abdominal pain Fever Blood in the urine Treatment Treatment for Wilms' tumor usually involves surgery and chemotherapy. Wilms' tumor is a rare kidney cancer that primarily affects children. Also known as nephroblastoma, Wilms' tumor is the most common cancer of the kidneys in children. Wilms' tumor most often affects children ages 3 to 4 and becomes much less common after age 5. Wilms' tumor most often occurs in just one kidney, though it can sometimes be found in both kidneys at the same time. Improvements in the diagnosis and treatment of Wilms' tumor have improved the prognosis for children with this disease. The outlook for most children with Wilms' tumor is very good Symptoms Wilms' tumor doesn't always cause signs and symptoms. Children with Wilms' tumor may be asymptomatic, appear healthy, or they may experience: Abdominal swelling An abdominal mass you can feel Abdominal pain Fever Blood in the urine Risk Factors African American children have a slightly higher risk of developing Wilms' tumor than do children of other races. Children of Asian descent appear to have a lower risk than do children of other races. Having a family history of Wilms' tumor. If someone in the child's family has had Wilms' tumor, then the child has an increased risk of developing the disease. Other Links Wilms' tumor occurs more frequently in children with certain abnormalities present at birth, including: Aniridia. In this condition the iris — the colored portion of the eye — forms only partially or not at all. Hemihypertrophy. A condition that occurs when one side of the body is noticeably larger than the other side. Undescended testicles. One or both testicles fail to descend into the scrotum (cryptorchidism). Hypospadias. The urinary (urethral) opening is not at the tip of the penis, but is on the underside. Diagnosis Imaging tests. Imaging tests that create images of the child's kidneys can help determine whether the child has a kidney tumor. Imaging tests may include ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI). Surgery. If the child has a kidney tumor, they may recommend removing the tumor or the entire kidney to determine if the tumor is cancerous. The removed tissue is analyzed in a laboratory to determine whether cancer is present and what types of cells are involved. This surgery may also serve as treatment for Wilms' tumor. Staging The stages of Wilms' tumor are: Stage I. The cancer is found only in one kidney and generally can be completely removed with surgery. Stage II. The cancer has spread to the tissues and structures near the affected kidney, such as fat or blood vessels, but it can still be completely removed by surgery. Stage III. The cancer has spread beyond the kidney area to nearby lymph nodes or other structures within the abdomen, and it may not be completely removed by surgery. Stage IV. The cancer has spread to distant structures, such as the lungs, liver, bones or brain. Stage V. Cancer cells are found in both kidneys. Wilms Tumor: Management Surgical removal Quickly, after diagnosis Remove kidney & adrenal gland Chemotherapy, radiation, or both Post op radiation for large tumors Nursing alert Do not palpate abdomen pre op! Good prognosis

What is the sperm?

With sexual intercourse and ejaculation there are about 200-500 million sperm present Will swim with flagella movement up through uterus toward ovum Transit time to reach ovum is approximately 4-6 hours on average Sperm are viable for 72 hours

Breast feeding

Breastfeeding

World Health Organization recommends exclusive breast feeding for the first 6 months of life, with continued breast feeding along with appropriate complimentary foods through the first 2 years of life Breastfeeding has been reestablished as the predominant initial mode of feeding young infants in the United States Breast feeding rates still remain low in subpopulations of low-income, minority and young mothers Contraindications to Breast feeding Mother has tuberculosis Infant has galactosemia (unable to process lactose) Mother has HIV infection Maternal use of illicit or recreational drugs Cystic Fibrosis babies can be breast fed successfully if pancreatic enzymes are provided. These babies are at higher risks for need of macronutrient supplements especially Vitamins A,D, E,K and sodium chloride Why is it good for baby? Protective substances: Less ear infections, allergies, vomiting, diarrhea, respiratory infections and meningitis Economical: easier for baby to digest, does not need to be prepared, costs nothing to make, always in supply, environmentally friendly Bonding: Provides physical contact, warmth and closeness Why is it good for Mother? Burns more calories and gets mother back to her pre-pregnancy weight more quickly Reduces the risk of ovarian cancer and in premenopausal women, breast cancer Build bone strength to protect against bone fractures in older age Delays the return of menses which will extend time between pregnancies ( not a form of birth control alone) Remind the mothers that it is not a method of birth control!!! Helps the uterus return to it regular size more quickly How does the body prepare? During the 4th or 5th month of pregnancy the body is capable of producing milk. This first milk is called colostrum. Colostrum has all the nutrients that a newborn will need and also contains antibodies to protect babies against infection Colostrum is thick and yellowish in color. It is produced several days after delivery until mature milk "comes in". Mature milk is thinner in consistency and the content will change to match the newborn's needs How is human milk produced? During pregnancy the body increases its production of the hormone prolactin. Prolactin stimulates the cells in the breast to make milk The amount of prolactin increases when the mother nurses. The size of the breasts is not a factor in the amount of milk that a woman can produce. The baby's nursing needs will control milk production THE MORE A WOMAN NURSES, THE MORE MILK WILL BE PRODUCED Can I breast feed if I have had plastic surgery on my breast? There is no evidence to support that Silicone breast implants can harm infants. The surgery for breast implants usually does not interfere with milk ducts or the nipples unless the incision was made around the edge of the areola Plastic surgery to reduce the size of breasts may interfere with breastfeeding especially if the nipples were transplanted Usually that woman that have breast implanted can breast feed - only problem is breast reduction surgeries and that involved the transplantation of the nipple which is transplanted to the center of the breast and they can't breast feed

NCLEX Questions

You are caring for a client in labor. You determine that the client is beginning the 2nd stage of labor when which of the following assessments is noted? The client begins to expel clear vaginal fluid The contractions are regular and strong The placenta is detaching The cervix is dilated completely Your client arrives to the birthing center in active labor. Her membranes are still intact, and the nurse midwife prepares to perform an amniotomy. You explain to the client that after this procedure, she will most likely have Less pressure on her cervix Stronger more efficient contractions Fewer, more mild contractions The need for more frequent blood pressure monitoring You are assisting a client who is experiencing hypotonic uterine dysfunction and signs of slowing labor. Which of the following prescribed treatments would you expect the physician/midwife to order? A sedative IV fluids for hydration Oxytocin IV infusion A tocolytic medication You have been caring for your patient in active labor for several hours. She is now becoming extremely irritable, having difficulty concentrating on breathing and relaxation, and begins shaking and vomiting. You tell her and her labor partner... Her cervix is fully dilated and she is ready to push She probably has an infection from being in labor for so long These are normal responses in the Transitional phase of labor You will call the doctor immediately and prepare for a Cesarean delivery Your active labor patient is complaining of back pain. During a vaginal exam, you determine that the baby's anterior fontanel is facing the right side of mom's pubic bone. You assess that the baby is in what position? ROA LOA ROP LOP You are caring for a patient in the second stage of labor. Measures to help with fetal descent can include: (Select all that apply) Changing mother's positions frequently Increasing the epidural infusion rate Bearing down in between contractions Pushing with contractions - we utilize with the power of the contraction and ush with it to increase the power of descent

NCLEX questions for labor and delivery complications

Your labor patient puts on her call bell and tells you that she thinks her water just broke. Which assessment is your highest priority? Color Time - answer Odor Fetal heart rate pattern After your patient's SROM, you note fetal bradycardia on the monitor. You perform a vaginal exam and note the presence of a prolapsed umbilical cord. Which nursing action is your highest priority? Place the client in Trendelenburg position - answer Call the C-section staff Gently push the cord back into the vagina - Never push the cord back. Just the head Call the doctor You are assisting with your labor patient's delivery. She delivers the baby's head and you immediately note a "turtle sign". Interventions to resolve this complication include all EXCEPT: McRobert's maneuver Suprapubic pressure Episiotomy Vacuum assistance - answer You are caring for a patient undergoing and induction of labor with IV Pitocin. You notice she is experiencing hypertonic uterine contractions. Your highest priority nursing intervention is: Performa vaginal exam Increase IV infusion of Lactated Ringers - 2 Stop Pitocin infusion - highest priority - answer Administer Terbutaline - 3

NCLEX questions

Your patient must have a C-section delivery, but hopes to have a vaginal delivery for her nest child. Which of the following incision s poses the LEAST risk to a client who desires VBAC? Vertical uterine incision Vertical incision through the skin and uterus Classic "T" incision Low transverse uterine incision - answer A client presents with her second child tells the nurse that she wishes to have a VBAC. Which of the following assessment data would prevent the client from having a VBAC? Maternal weight gain during pregnancy of 40 lbs Anticipated infant weight greater than 4400 gm - answer Pre-delivery anxiety First C-section for fetal distress The laboring client who has elected to give birth vaginally after a cesarean is at increased risk for which of the following complications? Prolonged labor Uterine rupture - answer Precipitous labor Large for gestational age infant Which statement reflects an appropriate discharge instruction for the cesarean birth mother? A. Change positions frequently B. Start exercising as soon as you get home C. Have someone else assume total care for the baby for the first week D. Limit your activity to caring for yourself and do not lift anything heavier than your baby - answer

What is implantation?

Zona pellucida degenerates Structural changes continue to occur to cell mass Fluid appears in the center of the mass that pushes cells to the periphery of the sphere Also the external envelope of cells is made up of 2 different layers - inner and outer layer Inner cell mass is called blastocyst and develops into the embryo and the embryonic membranes (amnion) The outer cell mass is a foraging unit called the trophoblast Principle functions of these cells are to secure food for the embryo - develops into a placenta Eventually develop into one of the embryonic membranes known as the chorion The trophoblast is responsible for embedding the ovum, usually in the upper part of the posterior uterine wall The egg usually implants in the posterior part and upper part or the outer wall of the uterus. If it implants in the lower part of the uterus, it is still consider to be a viable pregnancy, just more dangerous These trophoblast cells burrow into the endometrium and carve out a nest for the ovum. Trophoblast cells also digest the walls of many small blood vessels beneath the surface of endometrium. Finger-like projections develop out of the trophoblasts called "choronic villi" and extend into blood filled spaces of the endometrium. The placenta is not connected to the mom. It acts as a filter to receive the nutrients from the mother. It is through the acts of diffusion

Fetal circulation quiz

__1__ Vein(s) _2___ Arterie(s) Fetal oxygenation occurs via the _Placenta________ Placenta Fetal blood bypasses the _Fetal______ _Lungs______ Fetal lungs As oxygenated blood returns from the placenta through the _umbilical________ _cord_______, it bypasses the liver through the ductus_venosus________ directly to the __inferior______ _vena_____ cava______. Umbilical Vein; Ductus venosus; Inferior vena cava The blood then enters the right_____ _atrium_____ from the _inferior _______ vena _______ _cava_____ to the left atrium through the __foramen_____ _ovale________. Right atrium Inferior vena cava Foramen Ovale This oxygen-rich blood then travels to the _body____. Body Deoxygenated blood from the _superior________ vena____ cava____ passes through the tricuspid______ valve______ into the __right____ _ventricle______ and the _pulmonary _____ _artery_____, then through the ductus_______ arteriosis________ into the descending aorta. Superior vena cava Tricuspid valve Right ventricle Pulmonary artery Ductus arteriosus From there it flows into the two fetal _arteries_____, and back to the ___placenta____ where it becomes oxygenated. Arteries Placenta

What is second stage of labor?

from full cervical dilation of 10cm to birth of baby.( Mother pushes during this phase) Full dilation (10cm) to delivery The mother is pushing with contractions; Have mother change positions frequently Should not be 90 degree or flat on her back when pushing If she is lying flat, gravity is not helping If she is 90 degree, the baby is going to hit her tail bone. She need to curl over her belly and that get her pubic bone in position and can push out easily She can squat Crowning (fetal head appearing at vaginal opening) See the baby head and not pushing - time to call the doctor Episiotomy (Surgical incision into perineal sling muscles) Two types: Median or Mediolateral If to be done, done at this time with head crowning Make room for the baby's head if the baby is not progressing and tissue is tearing especially occur with first baby Patient can tear straight down into and through the rectal sphincter.

electronic fetal monitoring

https://ncc-efm.org/game/efmgame.cfm

Episiotomy care

ice For 24 hours Check every shift Turn on left at and check for intactness. Sutures will absorb. Emotional-Crying is normal. Mothers under- go a cascade of emotions and quick hormone shifts that tend to cause sudden crying and put them into an emotional rollercoaster state. Remind pts this is normal!!

Osteomyelitis

infection of the bone Infectious process in the bone Most frequent in children younger than 10 years May be caused by exogenous or hematogenous sources Staphylococcus aureus: the most common causative organism Types Acute Hematogenous :results when a blood borne bacterium causes the infection Exogenous: acquired from direct inoculation of the bone from a puncture wound, open fracture, surgical contamination Subacute: caused by less virulent microbes Chronic: progression of acute osteomyelitis and is characterized by dead bone, bone loss and drainage Symptoms 2 to 7 day history of pain, warmth, tenderness and decreased range of motion in affected extremity Fever , irritability and lethargy Leukocytosis and elevated sedimentation rate (ESR) and C-reactive protein (CRP) Bone cultures obtained from biopsy or aspirate Radiographs: may appear normal at first Bone scans for diagnosis Therapeutic Management of Osteomyelitis Prompt, vigorous intravenous antibiotics for extended period (3-4 weeks or up to several months) Monitor hematologic, renal, hepatic responses to treatment Care Management of Osteomyelitis Complete bed rest and immobility of limb Pain management concerns Long-term intravenous access (for antibiotic administration) Nutritional considerations Long-term hospitalization/therapy Psychosocial needs

Noses of newborn

nfants under 1 month of age are nose breathers so any obstruction could cause respiratory distress Really important that parents know how to use the bulb syringe and when to use it Patency can be assessed by occluding each naris Bruising and thin white discharge from nares is a normal finding Tell parents that sneezing is common in newborns Red Flags: Nose Snuffles "Snuffles"-thick, bloody nasal discharge without sneezing can be a sign of congenital syphilis Nasal Flaring - Serious sign of air hunger and respiratory distress

What is the first stage of labor?

onset of labor to cervical dilation of 10cm. Latent phase/Early Labor (0-3cm) Admission to unit Baseline information is taken(Admission process) Prenatal record reviewed FHR, IV, GBS status noted, RH factor, (RH- will need cord blood obtained) vital signs, bottle or breast feeding ,orientation to room provided. Pt usually talkative, happy, calm We ask questions such as planning to breast fed, do they want an epidural. Labor is a time of education Active phase (4-7cm) Continuing assessments Continue to monitor FHR( Usually continuous fetal monitoring is done), more painful contractions, SROM or AROM will occur. SROM Check FHR, time, color, observe for cord prolapse When the mom's water breaks, always check the fetal monitor! Then document the time and date of when the water breaks. Baby should be born 24 hours after the water breaks Doctor will do a visual exam in which they do a visual speculum in the vagina and the cervix to see if there is any opening and ask the patient to cough. If there is a pooling of the fluid, the plug had ruptured and may be going into labor soon. If it is light blood with pink, it might be mixed with cervical bleeding. It there is bleeding going on, not good. If it is brown, it mean brown, it mean bowel movement. It is meconium The woman in labor will be contiunally leaking aminotic fluid thorughout the labor Normal if they have meconium and not cry. They may need to be deep suctioning by the NICU doctor. If not, they need to cry. If the water broke, and the baby's monitor is not good like tanking, do an internal exam because you need to feel that cord Transitional phase (8-10cm) Patient want to be left alone Loss of control of maternal emotions Very irritable Very difficult time, hardest part of the first stage. May experience vomiting, shaking Stay with patient, cx's coming every 2 mins or so Will start to feel rectal pressure and want to push No pushing till full dilation Can tear cervix and cause cervical edema (impede progress to full dilation) May see increased amt of bloody show How to keep from pushing when she feels the urge to push? Teach breathing techniques and teach them to blow out the candle.. Little bit of a pattern so they don't hyperventilate First stage is 12 to 14 hours long, active labor is 6 hours and the late phase is 2 hours Do clear liquid during labor - No food! They may vomit during labor Give her the warm blanket to help with the shaking. Help relax the patient and it will reduce the shaking.

uterus

ovulation video: https://youtu.be/nLmg4wSHdxQ

What is position as a factor of affecting labor?

relationship of the presenting part to the mother's pelvis. When describing fetal position, three( 3)sets of terms are used Denominators of fetal body- occiput, mentum, sacrum, scapula Anterior- facing forward( towards front of mother). Posterior(facing backwards) or Transverse(side to side). Right or Left- Depending on which side the denominator is in. Examples: LOA, LOP, ROA, ROP ( all of these positions are the most common) ROA - mom's right LOA - mom's left - Left occipital anterior Baby's occipital bone (back of the baby's head) is facing mom's left anterior which means he is looking toward her so the right of her back His nose is facing the posterior side of mom Most common position - most ideal position to be in Remember MBM - Mom baby Mom OP Is not ideal. Sunny side up - mean that he is facing her pubc bone which is not goo. IF he is facing her tailbone, it is fine Mom can deliver vaginally if the baby is OP. It will take longer to dilate and she really have to push. Lot of hard work to do that

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