NP3 Final Exam

Interventions for non-reassuring patterns

-Interventions for non-reassuring patterns: 1. ID cause: check mother's VS for hypo-hypertension, fever (fetal tachy). Maternal sedative meds. A vaginal examination may reveal a prolapsed cord (variable decelerations, brady, or both). 2. Increasing placental perfusion: position woman on her side to eliminate aortocaval compression. Give a bolus of isotonic intravenous fluid such as lactated Ringer's increases blood volume if hypotension is present. Discontinue oxytocin if excessive contractions. A tocolytic drug, such as TERBUTALINE (0.125 to 0.25 mg IV or 0.25mg subQ) may be given to reduce uterine activity. 3. Increasing maternal blood O2sat: Adm 100% oxygen at 8-10 L/min with snug facemask. Reducing cord compression--reposition mom, turned side to side, or hips may be elevated to shift the fetal presenting part toward her diaphragm. Changes may be done often. The fetal presenting part may be pushed upward slightly. Amnioinfusion or infusion of sterile isotonic solution into the uterus, can be used to increase the fluid around the fetus and cushion the cord. Lactated Ringer's solution or normal saline is infused into the uterus with an IUPC.

IM Injections: Safe vL, site, gauge for different age groups

IM Injections: Safe volume, site, size needle; depending on the size of the child; 22-25 gauge, ½ to 1 ½ inch, greater size for viscous medication (ex. Bicillin). 2 injections may be needed for larger doses. · Premature: Vastus lateralis; 0.5mL · Neonate: Vastus lateralis; 0.5-1mL · Infant (1-12mo): Vastus lateralis; 1mL (Babies <1yr, use vastus lateralis to avoid damaging the sciatic nerve w/ gluteal injection) · Toddler (13-36mo): Deltoid 0.5mL; Ventrogluteal 1mL; Vastus lateralis 1-1.5mL · Young Child (3-6yrs): Deltoid 0.5-1mL; Ventrogluteal 1.5mL; Vastus lateralis 1.5-2mL · Older Child (6-14yrs): Deltoid 0.5-1mL; Ventrogluteal 1.5-2mL; Vastus lateralis 1.5-2mL · Adolescent (15yrs-adult): Deltoid 1mL; Ventrogluteal 2-3mL; Vastus lateralis 2-3mL § Insert - bevel up with dart like motion; After removing needle, do not massage. Use dry gauze, not alcohol.

Recognize deviations from normal physiologic findings during examination of the newborn: Jaundice

Newborn's Hepatic system: o Hyperbilirubinemia: excessive bilirubin in the blood, can lead to accumulation in the brain (bilirubin encephalopathy). If LT can cause permanent injury (kernicterus); liver is one of the last things to mature. Physiologic & pathologic causes of bilirubinemia. o Physiologic jaundice: premature or immature liver is normal. Increase in bilirubin is gradual over first 24hrs of life—result of hemolysis of RBCs & immature liver. Gradual yellowing of skin usually starts on ABD & moves to face, once in face can move to the eyes. Eyes are an ominous s/s of it moving to the brain. Watch these gradual physiologic processes closely. o Breast milk jaundice: another physiological process; when breast feeding & there's not the fluid vL needed to push the bilirubin into the GI for removal. Not caused by breastfeeding, it's a lack of vL needed to clear out the bilirubin. Baby may have small amounts of jaundice; we still need to monitor & see if increasing—if increasing may need to admin fluids. Tx increased formula or breastfeeding, other fluid admin, Bili-lights (phototherapy breaks bilirubin down through the skin). o Pathologic jaundice: disease process; blood incompatibility for mom & baby. Rapid development of jaundice. Also mom & baby could have had hepatitis, or there may be another patho problem of the liver/body that causes excessive RBC loss o Factors that increase hyperbilirubinemia: hemolysis of erythrocytes (or underlying RBC problem), short RBC life in newborn, lack of albumin binding sites (sites help clear bilirubin from body through the liver), liver immaturity, preterm & late preterm infants, lack of GI flora, feeding was delayed, trauma that causes bruising (cephalohematoma), fatty acids from cold/stress/asphyxia. o Bili lights: for pathologic or physiologic jaundice. But physiologic is common, so all babies won't be put on photo Tx—watch/monitor, when level becomes higher, put on photo Tx.

Care & Communication in the ER, Based on Age

Care & Communication in the ER, Based on Age: - The infant- use pacifiers, use quiet/soothing voice; you or the parent should hold or rock the baby, can hold securely or swaddle. Keep warm, if they must be undressed, use a radiant warmer. Allay the parents' fears, so it will not be communicated to the baby. Infants feel pain, must manage this. - The toddler- perform most intrusive procedure last. Procedures done while they sit up on the stretcher, exam table, or parents lap. Tell parents the child will benefit from their confidence. Let the child have familiar (transitional) objects like a blanket, doll, or toy to help them feel safe. Keep frightening objects away from their line of vision, take loud machines away. Praise & distraction can decrease anxiety & increase cooperation. - The preschooler- explain procedure seconds before doing it, not minutes—keeps them from imagining scary fantasies. Talk throughout the procedure, explain what sensations they will/are feeling, tell them how they can help. Distract w/ noises or bright objects, some may like it if you count or sing ABCs w/ them to help keep them calm. Avoid criticizing them for crying, struggling, or fighting during Tx. Tell them they "did try their best to cooperate" can help build a positive self-image. Encourage them to talk about how the illness or injury occurred, if they are inappropriately taking responsibility for it, reassure them it is not their fault. They appear to understand more than they do, don't overestimate their comprehension, explain things w/ words they understand. Avoid scary words like "shot" & "cut"; use positive words like "make better" & "help". Use adhesive bandages over small wounds & injection sites bc they may think their blood will leak out. - The school-aged child- offer simple choices to help them feel more in control. Ex. what arm to get a shot in, what hand to hold nebulizer in—don't ask questions that allow for yes/no response. Talk directly to the child & explain Tx in simple terms; when explaining care/Tx to parents, include the child. Ask the child about their level of understanding & allow time for questions. Address their fears/concerns directly, don't treat their fears as foolish or inconsequential. Give physical rewards after a procedure, regardless of good/bad behavior—it's a reward for undergoing the Tx. - The adolescent- preserve modesty, offer choices about parents being present for the H&P, allow opportunity for questions, explain procedures thoroughly & allow choices—teens are capable of complex abstract thinking, can make intelligent & reasoned decisions about their own care. Consider legal issues regarding right to privacy in teen pregnancy & STIs. Listen to their concerns w/o judging or belittling. Don't tease them, potential for harm & embarrassment.

Approaches to the Physical Assessment

Approaches to the Physical Assessment: • Knowledge of physical G&D: Assessment of children requires creativity & flexibility, allow the child to hold medical equipment (if safe/clean) to reduce anxiety & increase cooperation. Allow the child to remain on mother's lap, enlisting the child's trust and increasing the likelihood of a successful physical exam. Involve parents in the exam as much as possible. • Provide a quiet, private environment for the H&P (not always possible in an ER situation). • Be sensitive to cultural needs of the family. • Systematic approach: from head to toe, same process as adults, but tailor it to the age & developmental level of the child. -Infant: birth to 6mo; if asleep or nursing in mom's arms auscultate heart, lungs, ABD w/o waking; if awake allow them to stay held by mom. Undress, leave diaper on male, assess body systems while checking reflexes. Leave all uncomfortable assessments last (Moro, hip abduction, tympanic membrane). If unhappy, speak softly, distract w/ rattle or pacifier. -Older Infant: 6-12mo; same as w/ infant, but have more stranger anxiety, increasing difficulty. Do as much of exam as possible w/ them on moms lap. Leave ear, oral, & uncomfortable exams for last; distract w/ toy or object. -Toddlers: most challenging to exam; uncooperative. Form supportive relationship by sitting next to the parent; help toddler relax w/ toys & books to encourage exploration; let them handle exam tools. Communicate w/ age-appropriate words about what will be done. Parts of exam can be done before they are totally undressed; order is flexible (least to most invasive). Reassure mom that resistance & crying is common & normal. Parent is best resource for cooperation; sooth & comfort child in familiar way. -Preschooler: more cooperative than toddler; still want mom near. Happy to show RN they can undress themselves; cooperation can be expected. Proceed head to toe, most invasive last--speculum exam of ear & exam of mouth. Reinforce interest by letting them participate in exam & praise their cooperation. -School-Age: establish trust by asking questions they can answer; elementary age will talk about school, friends, activities; older need encouragement to talk about school performance & activities. Encourage parent to support & reinforce child's participation in exam. Proceed head to toe. Simple drape over underwear or colorful gown; be sensitive to their modesty. Teach them about the body & care; answer questions openly & in simple terms. -Adolescent: comfortable w/ straightforward, non-condescending approach; openly discuss w/ teen who should be present during the exam--usually exam w/o parent present. Give parent time to talk about concerns to the RN. They will undress & wear gown, & be draped appropriately during exam. Proceed from head to toe. Genital exam should be in the middle, after ABD, to allow more time for questions & discussion. Assure the pubertal child about normal stages & answer concerns about their body.

Assisting the child w/ chronic illness & family members in Managing Feelings

Assisting Family Members in Managing Feelings: Stages of Grief—denial, anger, bargaining, sadness, or depression, & acceptance. • Shock and denial: 1st denial, "no, not me"; disbelief & shock; when they first hear the Dx or find out on their own. 2nd anger, range & resentment at themselves or others; "why me?"; can recur at any point during illness. 3rd bargaining, try to postpone the inevitable; usually directed towards God, but can also be with self or others. 4th depression, sadness for past loses or impending loss; physical or appearance loss, lifestyle changes, or changes in physical ability; imminent loss of loved one or preparing loved ones for the absence created by death. 5th (last) acceptance, no longer depressed or angry; not necessarily happy, but a time of comfort & peace. • Adjustment Phase: reintegration and acknowledgment that the illness is real & ongoing; as adjustment to the condition progresses, some parents may have "Chronic Sorrow" rt the unending nature of the illness & ongoing feelings of loss—deep sadness is common in bereavement, turns into solace. Chronic sorrow is normal; may never resolve, but adaptation to illness occurs & family forms a "new normal" & family life continues. "Chronic Grief" is an excessive duration of mourning, it interferes w/ the ability to return to normal life after the death. Poor grief outcomes ID by stress s/s like poor sleeping, anxiety, insecurity, fatigue, & depression. • Establishing a support system: RN must help the family establish a support system or refer to support groups to help them manage their feelings in this illness. • Dx of the child can create a situational crisis - an unexpected crisis for which the family's usual problem-solving abilities are not adequate. Some families become stronger; these families are considered resilient. Even when the child doesn't realize their illness has an effect on the family, RNs must assist family in managing feelings. The Child with Special Needs: RN must care for the concerns/needs rt their condition & successfully navigate their stages of G&D. Their response to the illness is affected by their age at the onset of the illness, & G&D concerns throughout the course of the illness—plan RN care accordingly. • Developmental aspects: needs will vary w/ each age group; RN must understand developmental aspects to successfully navigate these stages of G&D. Sometimes it's the emotional developmental aspect, & not the chronological age—ex. autistic child is 14yrs old but has the understanding of a 4yr old; don't speak to the child on the developmental level of a 14yr old. RN should understand issues w/ autonomy & self-esteem rt to each stage of G&D. • Coping mechanisms: are present, but they are more likely to experience behavioral and psychological issues w/ any of these special needs. • Hopefulness is present. • Health education and self-care: RN must assist w/ these • Goal is to maintain highest level of health & function possible—cognitively, emotionally, physically & psychosocially; achieve & maintain normalization. • Goal for the whole family is to remain intact; achieve & maintain normalization; maximize function throughout the course of the illness. • Not every child is in a hospital setting & not every RN is working in a hospital setting, so the RN process is on-going for the duration of the illness; achievement of these goals necessitates a family-centered approach to RN care.

AKI

Assessing AKI: -Assessment: Nausea, Headache, Lethargy, Edema, Hypertension due to volume retention. -Hydration status, vL depletion, decreased UO, decreased SBP, decreased PP, orthostatic hypotension, thirst, increased blood Osm. -Lab: Oliguria (<400 mL/day), Azotemia (Nitrogen retention: BUN >20 mg/dL), Acidosis (pH <7.35) -Analysis: Adequate urinary elimination. Status of fluid and electrolyte balance? Risk of cardiac arrhythmia due to hyperkalemia. -Interventions for AKI: -Implementation: Bed rest, Monitor I&O closely, daily wts. Monitor BUN and Cr. Watch for signs of hyperkalemia: diarrhea, paresthesia, ECG changes. Avoid IV contrast studies. Avoid sulfonylureas and tetracyclines. -Diet: AKI increases rate of protein catabolism, increasing uremia and azotemia. High CHO, Low protein, Low Na (60-90), Low K if hyperkalemia develops (60-70). May be on PN or EN. If dialysis not required: protein 40g/day. On Dialysis: protein 60g/day. -Fluids: diuretic phase, replace F&E. Retention phase, restrict fluid (UO+500mL/day). -Prevention is Key: ID and monitor high risk patients, teach pt. to avoid nephrotoxic agents, maintain fluid vL, prevent hypotension/hypovolemia, control HTN with ACEI. Before starting nephrotoxic agents, get baseline Cr/BUN, then measure bi-weekly. Chronic NSAID use increases risk of RF (interstitial nephritis). Radio contrast induced nephropathy (CIN), major cause of hospital acquired AKI, if baseline Cr >2 high risk! Admin acetelcystine and NaHCO3- before/after, flush with NS, closely monitor post-op. -Drugs: diuretics (lasix) don't stop AKI, they just prevent F&E imbalances by increasing UO. Ca-channel-blockers increase perfusion to kidneys, and improve GFR. Change dosing of drugs. -Dialysis: HD or PD, if in FVO, hyperkalemia, pericarditis, encephalopathy. RN considerations of AKI: -Monitor daily weights, strict I&O, Hct/Hgb-dont give whole blood if vL intolerant/HF, VS, nutritional status, pericarditis (pleuritic chest pain, tachycardia, pericardia friction rub), inadequate renal perfusion (hypotension), acidosis. -Major Goals: Reestablish renal function, Maintain internal environment, Live normally -Supportive measures: Diet high in calories (CHO are protein sparing). Low in protein, sodium and potassium. Restrict fluid, Monitor electrolytes, Avoid food high in K or P. --Don't give high CHO if pt has HF or DM.

Asthma

Asthma: is a reversible obstructive airway disease. -S/S during an episode: wheezing is the classic sign (difficulty exhaling), dry cough (nonproductive), SOB, dyspnea on exertion; retractions, nasal flaring, or stridor; nonproductive cough w/ or w/o wheezing that later becomes productive; tachypnea, orthopnea; restless, apprehensive, diaphoretic; ABD pain from straining muscles during labored breathing; tripod position; fatigue & difficulty w/ ADLs bc of SOB; chest tightness followed by dry cough, wheezing, & dyspnea; s/s are worse after going to bed at night bc increased narrowing of airways & pooling of secretions; also worse in cold weather. --Beginning of episode- wheezing heard only w/ stethoscope; increasing severity- wheezing audibly heard; severe respiratory distress- no wheezing heard bc of decreased air movement & child will not show s/s of clinical improvement, ominous s/s (silent chest)—increased wheezing can indicate improvement (increased air movement). Emergency Management of Asthma: • Worsening wheeze, cough, or shortness of breath. No improvement after bronchodilator use (short acting). Difficulty breathing, respiratory distress. Trouble with walking or talking. Feeling of chest tightening. Discontinuation of play. Listlessness or weak cry. Gray or blue lips or fingernails. Not hearing wheezing or previously heard wheezing has stopped—may be due to decreased movement of air - ominous sign. If you weren't hearing wheezing & after Tx wheezing starts—may indicate improvement bc the airway is starting to open. • Admin of meds & Tx: Acute - bronchodilator (SABA: short acting beta-adrenergic agonist, ex. Albuterol), O2 therapy, short course of corticosteroid. • Education for the child & family: ST & LT management, meds & how to admin correctly, emotions effect on asthma episodes, avoidance of triggers (type of exercise, animals, grass, pollen, smoke, perfumes, viral resp. infections, etc), exercise should not be discouraged- avoid sports that require sustained exertion, rapid breathing of large vL of cold/dry air can trigger episode. How to use a peak flow meter (measures the air flow during forced exhalation); can ID start of an episode before the child feels the s/s. • Recognize early s/s of an episode: itchy chest or chin, cough, irritable or tired, increased RR, dry mouth, dark circles under the eyes; then use the individualized Tx plan. • Prevent an asthma attack: Use SABA (Albuterol) 30min before exercise. Warm air by breathing through nose, or place scarf over mouth & nose when exercising in the cold. Decrease hyperventilation by keeping them calm & teach methods to help them stay anxiety-free (ex. progressive muscle relaxation, diaphragmatic breathing).

Bronchiolitis

Bronchiolitis- respiratory syncytial virus: - Inflammation of the bronchioles. RSV is the causative agent in 50% of cases; it is a significant cause of hospitalization in kids <1yr old; for adults & older kids it's the 'common cold'. Highly communicable; contact isolation & scrupulous hand hygiene needed. Peak times during winter & early spring. • URT infection from RSV; leads to edema, mucus, & cell debris that obstructs bronchioles; bronchiole constriction during expiration causing hyperinflation of lungs; atelectasis occurs when obstruction is complete & trapped air is absorbed; normal gas exchange impaired; hypoxemia occurs; metabolic acidosis & mild resp. alkalosis results. o Leads to hypoxemia then metabolic acidosis and mild respiratory alkalosis. Lots of mucus; child goes home w/ significant amounts still, even if O2sat is better. • S/S: tachypnea (RR 60-80), tachycardia (HR >140); wheezing, crackles, or rhonchi; intercostal or subcostal retractions w/ or w/o nasal flaring; cyanosis. Feeding difficulties bc of increased RR, interferes w/ sucking & swallowing. Temp. varies from hypothermia to as high as 105.8 (41 C). Lots of mucus. • Respiratory Distress: restlessness (early s/s), nasal flaring, retractions. • Feeding Difficulty: w/ thick nasal secretions, the baby will have difficulty feeding/sucking, spitting out the nipple, RR increasing. Due to the posterior soft palate covering the oropharynx and the tongue's proximity with the hard & soft palate, infants this age are obligate nose breathers. When the nose is congested, they cannot form a seal to suck. Their respiratory effort increases as they attempt to breathe through congested nasal passages & suck at the same time. • Tx: mild case Tx at home w/ fluids, humidification, & rest. Resp. distress Tx in hospital; cool humid O2 admin when O2sat <90% on room air—relieves dyspnea, hypoxemia, & insensible H2O loss from tachypnea. Suction kept at bedside; suction nasal passageways. INH NS 3% may improve resp. status & decrease hospital stay. IV fluids for dehydration. Position infant w/ head & chest at 30-40 degrees w/ neck slightly extended to maintain airway & decrease diaphragm pressure. Antibiotics given only for secondary bacterial infection. • IV dextrose 5% and sodium chloride 0.45%. Patient is NPO & likely to experience insensible losses due to increased RR or fever. Infants have a higher metabolic rate—dextrose is typically administered with IV fluids to meet metabolic demands. • Nebulized 3% hypertonic sodium chloride. Admin this solution prior to suctioning can help thin mucous secretions, aid their removal. • Salbutamol: Medical Tx for bronchiolitis is primarily supportive. Bronchodilators may prove of some ST benefit to those w/ underlying respiratory disorders that can result in exacerbation of bronchoconstriction due to viral infection; attempt 1 dose then assess for desired effect. • Contraindicated: PO Prednisone. Corticosteroids are not indicated for a client who has bronchiolitis. The appropriate use of corticosteroids remains controversial.

Care of an infant after cleft lip/palate surgery

Care of an infant after cleft lip/palate surgery: -Cleft lip/palate: results if the lip/palate fails to close. Cleft palate may involve the hard or soft palate, or both; may appear alone or w/ a cleft lip. Inspect the palate when the infant cries; insert gloved finger into mouth to palpate the soft & hard palate. A very small cleft of the soft palate may be missed, if only a visual exam is done. -3 anomalies: cleft lip, cleft palate, cleft lip & palate= abnormal opening in the lip or palate. Can be unilateral or bilateral; most common congenital craniofacial deformity. Risk of feeding difficulties, aspiration, resp. distress. Palate- risk of COM= hearing loss. -Etiology: multifactorial; genetics & environment. Genetic pattern (familial risk), maternal smoking. 10-15% of these infants have other associated defects. -Cleft Lip: notched vermillion border, variably sized clefts that involve the alveolar ridge, & dental anomalies (deformed, supernumerary, or absent teeth). -Cleft Palate: nasal distortion, midline or bilateral cleft w/ variable extension from the uvula & soft & hard palates, & exposed nasal cavities. -Dx: observation at birth or in utero w/ US; palate may be seen w/ milk coming out of the nose. Inspect w/ gloved finger & flashlight. -Tx: modification of feeding w/ techniques, obturators, unique nipples & feeders; Latham orthopedic device (pre-OP) expands & realigns parts of the palate or decrease size of wide lip cleft. Compressible plastic bottle w/ longer nipple; enlarge the nipple hole. -OP: lip repair done at 3-6mo; staggered suture line minimizes scaring; cosmetic mods may be needed at age 4-5yrs; early improves bonding & makes feeding easier. Palate repair done at 1yr old, completed by 2-6yrs; earlier facilitates speech development. -Post-OP: put on elbow restraints ('no-no') are lose but prevent bending; remove Q2h for 10-15min & play games w/ elbow movement, look for skin irritation; remove only 1 at a time; position for sleep on back; no brushing teeth for 1-2wks, give water after meals to clean. Keep suture line clean & intact; clean lip as ordered- ex. cotton swab w/ gentle rolling down the line, repeat w/ AB ointment. Avoid tension on sutures; gentle aspiration of the nasopharynx reduces chance of atelectasis.

CHF in children

CHF in Children: Reasons for the cause in kids are different than adults, congenital defect; could also be due to metabolic disorders, drugs or toxins during fetal G&D. Kids have respiratory related s/s. •S/S: Difficulty feeding (sweat on head), poor weight gain; Mild tachypnea, SOB, grunting, tachycardia; Cardiomegaly; Galloping rhythm; Poor perfusion, edema; Liver and spleen enlargement; Mottling, cyanosis, pallor. -RN: weight the infant every day, at the same time, w/ the same scale, w/ no clothing; ID wt gain/loss from fluids vs body mass. •Tx: correct underlying problem as soon as possible. o Medical Management: o Decrease workload/improve output o O2 (caution with left to right shunting); increases O2sat but is also a vasodilator & can increase pulmonary BF. o Inotropes (digoxin), diuretics, ACE inhibitors o Good nutritional intake to meet metabolic demands o Digoxin - cardiac glycoside; strengthens the force of myocardial contractions; increases CO & cardiac effectiveness. Slows the HR—so check HR before admin & know normal ranges for that age. Check serum levels as ordered by HCP. Can admin PO or IV. Watch for hypokalemia & hypomagnesemia—can indicate digoxin toxicity. o Diuretics - furosemide (loop diuretic); eliminates excess H2O & Na through urine; reduces pulmonary congestion. Preferred drug for initial diuretic Tx. o Additional meds: vasodilators- hydralazine, captopril, enalapril—relax vascular smooth muscle & reduce afterload. • Feeding the Infant w/ HF: o Feed the infant or child in a relaxed environment; frequent, small feedings may be less tiring. o Hold the infant in an upright position. This may provide less stomach compression and improve respiratory effort. o If the child is unable to consume appropriate amount during 30min feeding Q3hr, consider NG feeding. Feeding <30min & cluster care to conserve energy. o Monitor for increased tachypnea, diaphoresis, or feeding intolerance (vomiting). When tachypneic don't feed PO bc risk of aspiration. o Consider nutritional needs of the infant, normal formula is 20kcal/oz; concentrating formula to 30 kcal/oz may increase caloric intake w/o increasing vL & infant's work. • Educating Parents: some babies will be D/C home & have to wait until they are older/bigger in order to get an OP. Teach the s/s of HF; Increased cyanosis, Dehydration, Infection, Dysrhythmias - feeling pulses for change in rhythm (irregular, galloping), Decreased nutritional intake. Parents must learn CPR.

Caring for a child with Sickle cell anemia

Caring for a child with Sickle cell anemia: -HbSS: homozygous sickle cell dz, AKA sickle cell anemia. Inherited, life-long, autosomal recessive; more common in African, Mediterranean, Indian, & Middle Eastern decent. -Newborn screening, prophylactic penicillin, & pneumococcal & Hib vax have reduced death. -Patho: normal Hgb (HbA) is replaced by abnormal HbS; 1 parent HbAS + 1 parent HbAA= 50% chance of child inheriting the trait. Normal= HbAA, Trait= HbAS, Dz= HbSS. Pt w/ trait can have s/s of hematuria & bacteriuria in times of extreme stress (vigorous exercises, high altitude). Fetal Hgb (HbF) obscure the dz, at 4-6mo HgbS made & s/s present. -S/S: chronic hemolytic anemia, pallor, jaundice, fatigue, cholelithiasis, delayed growth & puberty, avascular necrosis of the hips & shoulders, renal dysfunction, retinopathy. Sickling event causes SC crisis; infection, dehydration, hypoxia, trauma, stress; crisis: vaso-occlusive, acute sequestration, or aplastic. -Vaso-occlusive: tissue ischemia & hypoxemia from obstruction of BVs by SCs. S/S Pain in affected body part; Acute chest synd.- chest pain, fever, cough, ABD pain; Dactylitis- swelling hands/feet, pain, warmth in affected area; Priapism; CVA- hemi/mono-paresis, aphasia/dysphasia, seizures, alt. LOC, vomit, vision changes, ataxia, headache. -Tx: PO analgesics, then IV (Morphine) by intermittent or continuous IV. PO or IV NSAIDs. PO & IV hydration. Aggressive IS (10x Q2h while awake). Consistent assessment of pain. Non-pharm pain management w/ pharm. Acute Chest Synd.- IV hydration 1-1.5x maintenance, ABs, O2, RBCs, analgesics. Dactylitis- PO analgesics, IV or PO hydration, rest. Priapism- hydration & analgesics, avoid hot/cold packs, transfusion if prolonged. CVA- LT RBC trans. Tx or erythrocytapheresis, possibly chelation. -Acute sequestration: BF out of organ blocked by SCs; organ is enlarged, causing acute anemia; in lungs= acute chest synd. w/ possible RF (common COD, peaks 2-4yrs old). S/S decreased Hgb, acutely ill-look, pallor, irritability, tachycardia, enlarged spleen, hypo-vL shock. -Tx: ER Tx to restore BvL w/ crystalloid & colloid blood infusion; recurrent- LT transfusion Tx; persistent reoccurrence- splenectomy. -Aplastic: increased destruction (fever, infection) or decreased production (viral; PV B19-5th's dz) of RBCs. S/S pallor, lethargy, headache, fainting. -Tx: RBC transfusion & Tx s/s.

Clinical S/S ESKD

Clinical S/S ESKD: -Neurologic System: Depression of CNS from encephalopathy bc of high BUN, Convulsion, Coma, Peripheral Neuropathy. All S/S improve with dialysis, except encephalopathy. -Cardiovascular System: Hypertension, Left ventricular hypertrophy (leads to CHF), Cardiac dysrhythmias* •Hematologic System: Anemia (iron deficiency, inadequate erythropoietin--give epigen or iron supplements), Bleeding Tendencies (impaired platelet aggregation) Especially GI (low Ca/impaired clotting, uric acid causes inflam/ulceration), Infection (Altered ImmSys). -Urinary System: Polyuria-initially UO>2.5L/day, Oliguria, Anuria - In late stages, no UO. •Metabolic System: Nitrogenous waste accumulation, Altered CHO metabolism--insulin resistance may improve with dialysis, Elevated Triglycerides--esp. if uremia present. Hiccups are a S/S of low HCO3, fix with dialysis or breathe into paper bag. -Electrolyte & Acid Base Imbalances: Potassium, Ca & Phosphate, Sodium, Metabolic acidosis -Immune System: Decreased immune response & inflammatory response--response to acidosis, Hyperglycemia--stress response that increases risk of infection. -Musculoskeletal System: Weakness, Renal Osteodystrophy(uremic bone dz)--lack calcitrol so less Ca absorbed and Ca removed from bones--High P causes calcifications. Pathologic Fractures. -Respiratory System: Kussmaul's Respirations, Dyspnea (HF-FVO), Respiratory Infection -Gastrointestinal System: Mucosal Ulcerations, Stomatitis (metalic taste/urinous breath), Diarrhea--high K, Constipation (aluminum hydroxide+ Ca containing P binders). -Integumentary System: Uremic frost (high BUN), Yellow discoloration (retention urine chromagens), Pallor(anemia), Dry skin, Pruritus (Ca-P deposits, scratch cause infection), Petechiae and ecchymosis (clotting problems). -Reproductive System: Infertility, Decreased Libido (low energy). May improve with dialysis. -Women: Decreased estrogen, progesterone and luteinizing hormone levels causes menstrual changes -Men: Decrease testosterone and low sperm count. Impotence may occur due to peripheral neuropathy. -Psychological Changes: Depression, Social Isolation, Impair body image, Lifestyle changes

Epidural Block analgesia/anesthesia

Epidural Block analgesia/anesthesia · Epidural Block analgesia/anesthesia: popular method; provides pain control for much of labor & the birth itself. Useful for vaginal and CS deliveries. · Epidural space is outside the dura mater, between the dura & spinal cavity—loosely filled w/ fat, connective tissue, & epidural veins that are dilated from pregnancy. · Practitioner injects a local anesthetic into the tiny epidural space, addition of opioids decreases the amount of anesthetic needed, thus limiting loss of movement & sensation. Provides substantial pain relief from contractions & birth canal distension—level of block can be extended upward for use in CS & tubal litigations. Started just after labor is established or just before a CS. Epidural space entered just below spinal cord (L3-L4) w/ needle, catheter passed through needle allowing for continuous or intermitted infusion, or via a PCA. · Test dose injected before full dose or intermittent dose to verify placement. Or inject total dose in small increments. If a large dose is admin in the subarachnoid space instead of the epidural, mom may experience rapid/intense sensory & motor block. Test dose also prevents accidental IV injection, IV injection causes numbness of face/lips, lightheadedness, dizziness, tinitus. Epinephrine may also be used as a test dose for IV, if in IV space produces tachycardia—helps distinguish labor tachycardia from IV admin tachycardia. · Local drugs: lidocaine drugs combined w/ small amounts of opioids, ex. fentanyl/sublimaze, morphine, sufenta. All drugs injected into the epidural or subarachnoid space are preservative free. Combining drugs allows for total lower doses to be used & less motor block. · Complications: dura puncture can occur, because it is close to the arachnoid membranes, these membranes will also be punctured. Punctured dura leads to leakage of CSF, causing spinal headache—can occur w/ or w/o obvious CSF leakage. · Precautions: supine position can cause aortocaval compression—if mom needs to be supine for procedure, then displace her uterus to one side w/ hands or a wedge, OR tables can tilt to one side during CS. · Contraindications: mom's refusal, coagulation defects, uncorrected hypovolemia, infection of insertion area or severe systemic infection, allergy, or fetal condition that required immediate birth. · Adverse Effects: -Maternal Hypotension: sympathetic nerves are blocked w/ pain nerves, may cause vasodilation & hypotension. Maternal hypotension may result in reduced placental perfusion, most likely to occur w/in 1st 15 min after initiation or dose admin. Some moms show s/s after 1hr or w/ repeat boluses. Maternal hypotension can cause non-reassuring FHR. · Tx: Rapid infusion of LR or NS 500-1000mL (non-dextrose solution) often warmed before block to counteract the vasodilation. If hypotension occurs, turn mom to her left lateral side, infusion IV crystalloid fluids, & IV ephedrine in 5-10mg increments to increase BP. Give mom O2 PRN. -Bladder Distension: bladder fills quickly bc of rapid IV infusion, but she has reduced sensation to urinate. Bladder catheterization is usually required, increasing risk of infection. -Prolonged 2nd Stage: urge to push is reduced, making vacuum or forceps assisted births more likely. -Migration of Catheter: may move after correct placement, leading to s/s of IV injection, intense block, too high of a block, absence of anesthesia, or unilateral block. -Fever: may occur w/o infection. Possible causes include: decreased sweating, hyperventilation, & activity after pain relief, leads to reduced heat dissipation. Vasodilation redistributes heat from core to periphery, w/ lower core temp, body increases its temp. Shivering accompanies block, w/ disassociation of hot/cold, body thinks it's cold so it increases the core temp. -Opiates: · N/V: adjunctive drugs, ex. promethazine (Phenergan) may be given to reduce n/v. · Pruritus: of face & neck; give Benadryl, small doses of Narcan Nubian, naltrexone to counteract. · Respiratory Depression: can occur for up to 24hrs after admin. · RN Considerations: Acquire informed consent, ensure maternal/fetal monitoring devices are in place, record baseline data of maternal VS & FHR for comparison of prenatal levels & post-block levels, ensure IV access is placed/patent, admin ordered pre-load infusion (500-1000mL). Support mom in the lateral decubitus or sitting position & tell anesthesiologist when she is having a contraction. Explain that she may feel an electric shock sensation as the catheter is passed, assist her in remaining still until block is complete. After admin of test dose, observe for s/s of IV injection, or subarachnoid puncture. -Assess FHR & BP every 5min during the first 15min after initiation of the epidural, or after any additional bolus doses. Repeat BP checks at 30min, & 1hr after epidural is started. Consider factors that indicate more or less frequent monitoring for each patient. -Assess her bladder frequently bc of fluid infusion & reduced sensation to urinate. Intermittent or indwelling catheterization is common. -Assess temp frequently for a rise, w/ possible rise in baseline FHR before the maternal fever. -Assess for s/s associated w/ catheter migration from epidural space. -Assess for adverse effects of opiates: n/v, pruritus. Reassure her that the pruritus is harmless & temporary. · After Epidural: -Patient may be numb, free from pain, happy. But it doesn't always work, it can be positional—keep mom off of her back, keep it even by redistributing the drug. -If on the right side, switch to the left side. -If it moves upward, it can cause resp. distress. -It can cause hypotension, so bolus given before admin of epidural. Even so hypotension can still occur—RN can lower the HOB (not a full Trendelenburg), raise her legs.

Increased ICP

Increased ICP: reflects pressure exerted by the blood, brain, CSF, fluid, or mass. Results from a disturbance in autoregulation; defined as a pressure sustained at >20mmHg for >5min. • Causes: brain Tumor, hematoma; brain swelling from trauma, infection, hypoxic episode; overproduction of fluid, malabsorption of fluid; communication problem w/in the system disrupting CSF dynamics; brain aneurysms, acute liver failure. • Patho: increased ICP results from alterations in the brain, CSF dynamics, & CBF. To maintain CPP & vl w/in normal range, changes in 1+ contents of cranium must be compensated by changes in the others—Monro-Kellie Doctrine. o Compensatory Mechanisms: reduction in CSF production, increase in CSF absorption, reduction in cerebral mass as result of fluid displacement; once these limits are reached any increase in pressure or vL will cause a sudden increase in ICP & decline in clinical status. Ultimately increased ICP will compromise cerebral perfusion & produce shifting of brain tissue, causing herniation. Consequences of herniation depend on severity & location. o Infants can compensate somewhat bc of open cranial sutures; craniosynostosis is premature closure of sutures, abnormal skull G&D results in abnormal shape of skull—craniectomy needed to manage the increased ICP. • Manifestations: dependent on developmental age; confusion & altered MS/LOC. • S/S Infant: poor feeding or vomiting; irritability, restlessness, or lethargy; bulging fontanel; high-pitched cry; increased head circumference; separation of cranial sutures; distended scalp veins; eyes deviated downward ("setting sun" sign: see whites of eyes above iris); increased or decreased response to pain. • S/S Child: headache; diplopia; mood swings; slurred speech; papilledema (edema of optic disk; after 48hrs); altered LOC; N/V (esp. in the morning). o LOC: assess w/ modified GCS; 15= no change, <8= aggressive management & monitor ICP, 3= deep coma. o Behavior: changes may be an early s/s of increased ICP; parents are 1st to notice change in normal behavior, take their observations seriously; further assess irritability, mild confusion, & agitation. S/S of deterioration- child doesn't recognize parents, can't follow commands, minimal response to pain. Decreased responsiveness to pain is a significant s/s of alteration in LOC. o Pupils: as ICP rises, 3rd CN is compressed, causing pupil dilation w/ sluggish or absent constriction in response to light. Transtentorial Herniation- herniation of center section of brain; s/s fixed dilated pupil ominous sign in an unconscious child. o Motor Function: purposeful movement decreases & abnormal posturing may be seen. § Flexion/decorticate posturing: flexion of the UE (elbows, wrists), extension of the LE, w/ possible plantar flexion of the feet. Implies injury to the cerebral hemispheres. § Extension/decerebrate posturing: extension of the UE w/ internal rotation of the upper arm & wrist, LE extend w/ some internal rotation at the knees & feet. Indicated damage to more areas f the brain, like the diencephalon, midbrain, or pons. § Progression from flexion to extension: indicates deteriorating neuro function, must report to HCP. § Flaccid Paralysis: further deterioration of the child's condition. o VS: temp. elevation may occur. § Cushing's response: increased systolic BP w/ widening PP, bradycardia, & change in RR & pattern (development of apnea); indicates alteration in brainstem perfusion, body is attempting to improve CBF by increasing BP; the response is a late s/s of increased ICP in kids; occurs at or just before brainstem herniation. § Cheyene-Stokes respirations: increasing RR & depth, then decreasing RR & depth w/ a pause of variable length; cycle keeps repeating. § Central Neurogenic Hyperventilation: rapid RR despite normal ABG values; usually indicates midbrain or pontine involvement. § Apneustic Breathing: prolonged inspiration & expiration. § Late S/S: tachycardia that leads to bradycardia, apnea, systolic HTN, widening PP, & flexion or extension posturing.

Examine RN interventions to facilitate & promote successful breastfeeding

Assisting w/ Breastfeeding: o Suckling causes the mother's posterior pituitary to release oxytocin, which triggers the let-down reflex (milk-ejection reflex). Suckling also causes the anterior pituitary to release prolactin, which increases milk production. o "Supply and demand" applies to breastfeeding: more suckling = more milk production. If baby is sick, in NICU, or there is a break in breastfeeding—mom needs to pump to stimulate the breasts, oxytocin, & prolactin to produce milk. o Position of the mother and infant: ensure mom is comfortable & admin analgesics if needed. Provide privacy & prevent interruptions. Cradle, football or clutch, cross-ladle holds & side-lying. Pillows behind back, supporting incision & arms—shoulders relaxed, not hunched. Use pillows/blankets to raise infant to breast level. o Position of the mother's hands: palmar or C hand position—hold breast w/ thumb on top & fingers under the breast for support w/ little finger against chest wall. Fingers behind areola, but don't press too hard—impedes sucking & causes nipple soreness. o Eliciting latch-on: rub breast on chin & baby's mouth will open, then slide nipple into baby's mouth. o Position of the mouth: baby's head & body is straight, not turned. You don't want the baby's head turned completely to L/R w/ body not in line. o Suckling pattern: assess for sucking & swallowing; are the cheeks moving in. Sucking should be smooth & continuous movements, w/ occasional pauses to rest—swallowing may be heard, swallow after every suck, or several sucks followed by a swallow. Soft "ka" or "ah" indicates swallowing. o Removal from the breast: don't just pull the baby off, there is a suction & pulling can cause mom pain. Stick your finger into the corner of the mouth, break the suction & release the baby, then move away from the breast. o Infant's Position While Suckling: mouth should be flanged open; nipple will be pulled to the back of their mouth—why they need as much nipple/areola in their mouth as possible. Compression & sucking of the nipple causes milk expulsion.

Newborn Cardiac Assessment

Newborn Cardiac Assessment: Cardiac: ABC assessment right after delivery; check heart for rate, rhythm, & murmurs or abnormal sounds. When baby is asleep, listen to heart/lung sounds before taking the apical pulse or temp—bc these assessments may upset them & make auscultation difficult. If crying, use a pacifier (some hospitals don't allow pacifiers) or gloved pinkie finger & let them suck on it, while you try to get a HR. Point of maximal impulse: 3rd or 4th intercostal space, midclavicular line—pneumothorax or dextrocardia (reversed heart position) change the position. Know the position of the infant heart structures/valves—ex. patent DA, remains open & causes a murmur—frequent in first 24hrs of life—Tx increased pressure from crying & breathing to close the shunt. o Apical pulse should be regular, strong, & HR [110] 120-160 (100 if sleeping, 180 if crying). HR 120+ BPM may be difficult to listen to, so take opportunities to practice & close your eyes to focus. Apical should be assessed for 1min, at least every 30min until baby is stable for 2hrs—more frequent if there are abnormalities. Once stable, check once every 8-12hrs. o Irregular beats between S1-S2 are abnormal. S1-S2 should be heard clearly. o Murmur: sound of irregular BF through the heart; may indicate opening in the septum or problem w/ BF through the valves. Murmurs are usually temporary, caused by incomplete transition from fetal to neonatal life; common until the DA is functionally closed in 72hrs (permanent in 1-2wks). Any abnormal sound needs to be investigated, could indicate a heart defect—assess, notify HCP, may order cardiac test w/ US or further Dx tests.

Compartment syndrome

Risk for Compartment syndrome: Swelling causes pressure to rise within the closed fascia compartments, compromising vascular perfusion to the muscles and nerves. Seen w/ halo traction; immobilizing devices. o Compartment syndrome is the compression of structures, such as arteries and nerves, w/in a closed compartment in an extremity. This complication typically occurs within 24hrs of a fracture. It should be reported to the HCP immediately bc permanent damage can occur w/in 12hrs of ID of the syndrome. Cast removal is often necessary to relieve the pressure, and surgical fasciotomy is sometimes needed as well. Don't elevate higher than the heart, apply ice, or encourage the patient to keep wiggling fingers or toes. o S/S: severe pain often unrelieved by analgesia (differentiates it from pain of a fracture) & signs of neurovascular impairment. Report to the HCP if extending the fingers or wiggling the toes produces pain, &/or the quality of the radial or pedal pulse is poor-absent. Also assess for pallor, paresthesia, pulselessness; paresis & paresthesia are late s/s, indicate permanent damage. Pain distal to the site may be the 1st s/s of a complication. o Tx: RN should immediately elevate the extremity only to the level of the heart, loosen restrictive bandages or dressings, split the cast, notify the HCP immediately, & admin pain meds as ordered; keep them NPO for possible emergency OP.

Stressors Associated w/ Hospitalization: Infants & toddlers

Stressors Associated w/ Hospitalization: Infants & toddlers ◦ Separation anxiety: RNs in acute care will see stage 1 & 2, stage 3 is usually in LT care settings. Parents may view it as behavioral issues; RN must reassure them this is normal & is usually not permanent. For this age group, the older child will have more elaborate protests & create a scene; tell parents this rx is a sign of a healthy parent-child relationship. Toddler may resist bedtime & eating, have temper tantrums more frequently, regression may occur in toileting & eating—explain this is normal, tell parents to reinforce appropriate behavior & allow regressive to occur. Avoiding separation can increase the child's resilience during hospitalization. ◦ Fear of injury and pain: past experience, separation from parents, & preparation affect their rx to pain & bodily injury; view pain/injury as concrete; most will rx to any intrusive procedure whether its painful or not. ◦ Loss of control: Erikson- task is autonomy, need to have control; experience environment through senses & love exploring; need same-ness, rituals, & routines to provide stability & security. Routines of the hospital may disrupt their lives bc everything is unfamiliar. Ask the parents about their routines around bedtime, feeding, & playing; offer simple choices to increase their autonomy. Weakened autonomy/control can result in regressive behaviors & temper tantrums. o Reduce Stressors: try not to separate the child from the parents; allow parents to be always there, as much as possible; encourage parents to stay or "room-in", most Peds units have a bed available for parents & bring parents meals, to help them through this time.

Tuberculosis

Tuberculosis: not often in US children but can come in contact w/ TB; contagious disease w/ high morbidity & mortality worldwide. Foreign born 2/3s higher incidence. Airborne precautions used. • TB: Acid-fast bacillus; Contamination through INH—children are infected by family members, babysitters, etc. Chronic illness, immunosuppression, HIV infection, malnutrition can contribute to the ease of getting TB. Ages most seen are infancy & adolescence; Nonwhite racial, ethnic groups; immigrants from areas with high TB incidence (2/3 are foreign born). -Dx: Mantoux test; initial method of testing & screening for TB; performed on kids w/ known risk factors. Skin test will be + 2-10wks after initial infection; once +, reactivity continues for life, even w/ Tx. 5 tuberculin units of purified protein derivative (PPD); admin intradermal into forearm. Read 48-72hrs later. Negative TB test does NOT rule out TB, esp. in infants. - Results: >15mm induration in child >4yrs= +TB, regardless of risk factors; >10mm induration if risk factors present= +TB; >5mm induration in child <4yrs or w/ risk factors= +TB. • S/S: age 3-15yrs are mostly asymptomatic in the beginning w/ normal chest x-ray & Dx only through +skin test; then malaise, fever, night sweats, a slight cough, weight loss, lymphadenopathy, or more specific s/s rt the site of extrapulmonary infection (ex. kidneys, brain, bone). • Therapeutic Management: meds/chemotherapy are priority. • Understand the difference between TB exposure, infection (+skin test), & disease (CXR changes w/ s/s & +skin test). Admin & evaluating TB skin tests. • Admin anti-TB meds as ordered: • Infection - admin INH for 9mo (or admin 4mo course of rifampin alternate for Tx-resistant: may affect efficacy of birth control pills, need an alternate method). • Disease - 6mo course of combined regime (first 2mo: INH, rifampin, ethambuterol, & pyrazinamide; next 4mo: INH & rifampin). • Instructing the child & family regarding: Importance of adequate rest; Nutritionally adequate diet; Adherence to med regime—this is LT admin & they might get tired of taking meds; Ways to prevent transmission of TB infection.

The Family of a Child with Chronic Illness: Effects of the child's chronic illness or disability

The Family of a Child with Chronic Illness: o Parental roles: may be changed bc of the illness; "vulnerable child syndrome" can make them doubt their ability to care for their child. o Mother-father differences: in how the illness should be handled; focusing too much on the child can make their relationship suffer. o Single-parent families: have additional difficulties that affect resilience and impede normalization. May not have adequate social support in family structure, so at an increased risk of social isolation. • Siblings: may have issues w/ the chronic illness of their brother/sister; ill child gets more attention, may feel left out or jealous—may act out w/ negative behavior. • Chronic illness or condition: is LT, persisting > 3mo. So, children with special HC needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional conditions. Need resources beyond those required for children generally.

Acute glomerulonephritis (GN): "Acute nephritic syndrome (ANS)"

Acute glomerulonephritis (GN): "Acute nephritic syndrome (ANS)" -Sudden onset, increased immune response in the kidney tissues, leading to improper filtering. -S/S: cola, smokey, or coffee colored urine, azotemia, RBC casts in urine, hematuria (3g/24hrs), GFR <50mL/min, anorexia, oliguria, fatigue (waste accumulation), N/V if uremia from severe kidney impairment. Mild to moderate edema, mild-severe HTN from Na/H2O retention causes crackles, FVO, edema, JVD, S3 gallop, dyspnea, SOB. Antigen/Antibody complexes lodged in glomerular capillaries. -Post-Streptococcal GN: begins 2-3wks after untreated pharyngitis, most common in males (esp. 3-10yrs), 95% children and 70% adults will recover, the rest will progress to CKD in a few months. -Dx: Antistreptolysin-O Tider. High serum BUN, Cr, K, Na, H2O. Low serum albumin causes fluid shift into interstitial, leading to edema. -Treat: manage S/S--treat proteinuria and edema. Restrict protein if BUN is high, restrict K+ if hyperkalemic give diuretic and monitor for hypok., restrict Na&H2O if HTN, edema, or CHF present. Meds--antibiotics if infection present, corticosteroids if inflammation is the cause, they will suppress the immune system (avoid exposure to new infections). Give anti-HTN meds. Preserve kidney function, teach patient to report S/S of RF: fatigue, N/V, low UO, record daily wts, set up follow-up visits.

Principles of G&D: Growth, Development, Learning & Maturation

Principles of G&D: · Newborn birth to 1mo (or 28 days), Infant 1mo-1yr, Toddler 1-3yrs, Preschool 3-6yrs, School 6-11yrs (or 12yrs). · Growth: an increase in the physical size of a whole or any of its parts or an increase in number and size of cells; can be measured easily and accurately (measure height, head circumference, BMI, etc.). o Growth spurts: brief period of rapid increase in growth rate; slow, steady weight gain in childhood is followed by a growth spurt in adolescents. Spurts occur frequently when the child preps to master a developmental task. Ex. Spurt around 1st birthday may promote neuromuscular maturation needed for taking 1st step. · Development: a continuous, orderly series of conditions that leads to activities, new motives for activities, and patterns of behavior. Also an increase in function & complexity that occurs through growth, maturation, & learning (an increase in capabilities). Ex. Normal activities or behaviors can be observed depending on their age. · Learning and maturation: development of the brain results in ability to read, write, etc. Ex. 10-12mo old will use single words to communicate simple desires or needs; 4-5yr old will use complete & complex sentences to relate tales. Language can be measured w/ vocabulary, articulation, & word use. o Maturation: physical change in the complexity of body structures that enable a child to function at increasingly higher levels. It is genetically programmed & occurs as result of changes to the body. o Learning: changes in behavior that occur as result of both maturation & experience w/ the environment. Occurs in a predictable pattern, that is orderly, sequential, & progressive. · RN: there are wide variations that can occur in G&D, each child is unique, reassure parents when variations are still w/in norm; parameters are used to ID abnormalities—detect delays early & start interventions ASAP to minimize the effect of the delay.

Communicating w/ the Child & family in the ER

Communicating w/ the Child & family in the ER: • Communicate an attitude of calm confidence, speak softly, maintain professionalism, & stay firmly in charge. Create a communication plan w/ designated adult's phone numbers & when to call them. Silence can be misinterpreted, keep them updated. Rapidly assess/Tx child while developing therapeutic relationship, communication must be effective & timely. • Establish a trusting relationship with the child and family—call them by name, make eye contact, provide frequent updates & info. Use simple, nonmedical language; provide comfort measures, protect their privacy. • Encourage caregivers (at least 1 of them) to stay with the child—promotes wellbeing; include the family in the Tx plan, let them stay for procedures, but some teens may not want their parents there—or some parents may not be able to tolerate watching certain procedures. Explain to them how they can help. Designate 1 staff member to care for the child & speak to the family, to make things less confusing; consistency is helpful in a crisis & new environment. • Tell the truth—to establish a trusting relationship. Tell them [right] before a procedure if it will be painful, that way they will believe you when you say a Tx will not be painful. When the painful Tx is done, tell them it's done & there will be no more pain. Keep child informed by describing sensations, rather than the actual procedure. • Provide incentives and rewards—to help create as positive an experience as possible; Positive feedback to both the parents and the child, when they are being helpful can reinforce that behavior. Children, esp. 3-12yr old, enjoy verbal praise & concrete rewards for good behavior (stickers, toys, badges). Adults appreciate being thanked for their patience & assistance in their child's care. Assess the child's unspoken thoughts and feelings—encourage the child to express thoughts; sometimes the child might be misinterpreting a situation or need to express emotions. Assess their nonverbals, acknowledge & ask questions to clarify. Acknowledge & address fears of the child & family. Families coping mechanisms may breakdown & cause inappropriate behavior. For violent or abusive behavior, may need to can law enforcement or hospital security guards. Negative family behavior can interfere w/ child's care & increase their anxiety, address it before it escalates. Speak calmly, step away for a moment if needed, ask about their feelings, address that their behavior is upsetting the child, ask what you can do or who you can call to help care for the child at the hospital.

PCA & Topical Anesthetics for Children

• PCA: Patient-controlled analgesia; one of the most effective ways to admin opiates; depending on policy, may need continuous monitoring w/ Pulse oximeter, Cardio-Respiratory monitoring, O2 must be available at bedside & Narcan (naloxone- admin slowly to prevent cardiac arrest) available for reversal. Children 5-7yrs if developmentally appropriate for them to be taught & use the PCA. Safety Benefit: a sedated or sleeping patient will not be able to activate a bolus dose. Children <5 or unable to operate a PCA: HCPs or family can admin "PCA by proxy"; AACA (authorized agent-controlled analgesia)—carefully select & educate RNs or caregivers, provide oral & written instructions on when the child should/not receive the bolus, select a single RN or caregiver who will be there consistently to assess for med effects & consequences, document teaching & supervision of the person giving the AACA. • Topical anesthetic agents: Lidocaine 5% EMLA cream, or patches; numbs the skin before invasive procedures or Tx pain on skin (ex. bee sting). Site must be intact & healthy, clean the site & dry, perform hand hygiene & wear gloves. Place a mound of EMLA cream (2.5g; ½ a 5g tube) on the site & cover w/ occlusive, transparent dressing—do not rub into skin. Leave for >1hr, max of 4hrs. Hand hygiene & gloves, remove dressing & all the cream. Begin the procedure, numbing will last 1-2hrs. Caution w/ infants <12mo old; do not apply to mucus membranes; prevent accidental ingestion in infants & young children; do NOT admin to child w/ methemoglobinemia.

Fetoscope, tocotransducer, scalp electrode, intrauterine pressure catheter, & Doppler transducer

-Fetoscope: detects actual fetal heart sounds. So it can detect fetal dysrhythmias/rhythm, FHR baseline, & changes from the baseline. -Tocotransducer: external; measures whether or not mom is having a contraction by sensing if her ABD gets hard. It's a pressure sensitive device that detects changes in ABD contour to measure uterine activity. It is also external, on moms ABD, so if she moves it will change the accuracy of the measurements. Determines contraction strength & uterine resting tone (uterine muscle tension) from 0-100mmHg. -Scalp electrode: detects electrical signals from the fetal heart, so it's more accurate bc it's not going through an US. The transducer is getting a beat-to-beat reading, as if we were to put the patches on the chest. But bc the fetal head is wet, we use a corkscrew device to go into the top of the baby's head—it's not very invasive bc it goes through the first layers of skin. -Intrauterine pressure catheter: measures contractions. Placed beside the baby's head, so when the uterus contracts down onto the baby, we can get an mmHg reading of the strength of the contraction. ID intensity & resting tone: changes as labor progresses; uterus should relax at least 30 seconds between contractions. Average resting tone is 5 -15, contractions should be 50-75mmHg during labor, may reach 110mmHg w/ pushing in 2nd stage. · Montevideo is calculated by noting the contraction intensity above the resting tone and multiplying the number of contractions in 10min. Excess would be 400 MVUs. Ex. 3 contractions in 10min, w/ intensity 110, resting tone of 15. (110-15)*3 = 285. If its 250 indicates they are strong enough to allow for dilatation—push the baby down & open cervix up. -Doppler transducer: external fetal monitor for IA; detects baseline, rhythm, & changes in the baseline.

RN interventions for the stages of labor: 1st, 2nd, 3rd

-First stage of labor: latent, active and transition: Let them know that 5 cm is more like 2/3 of the way to full dilation in time, rather than half the way because the rate of dilation increases during the active phase. Teach the woman to blow out in short breaths if she should not yet push -Second stage of labor: Delayed pushing; Results in significantly less time in active pushing and an insignificant increase in total second stage duration for nulliparous woman in epidural analgesia. Change positions to promote her natural pushing efforts with fetal rotation and descent. Teach the mother to curve her body around her uterus in a C shape with her chin on her chest--to reduce pressure on the sacral promontory & reduce back pain. Teach to pull on her knees, hand holds, or a squatting bar while pushing. Prolonged breath holding for more than 4s or pushing more than 4x/contraction is discouraged. Assess suprapubic area & bladder every 2hrs, remind her to urinate--full bladder increases discomfort & prolongs labor. Tell her to blow out at the peak of each contraction to avoid pushing, no pushing till 10cm. -Encouragement: Praise the woman and her labor partner when they use breathing or other coping techniques effectively -Giving of self -Offer pharmacologic measures: knowledge of the option offers a sense of control. -Caring for the birth partner: Imposing unrealistic expectations of leadership, care and comfort on the partner makes the birth experience unnecessarily stressful—accept the pattern of support the partner is able and willing to provide and whatever the couple finds comfortable. Encourage the partner to conserve physical health—tell them to have a snack or take a break -3rd Stage of Labor: encourage her to push w/ her contractions. Observe her perineum for crowning w/ each push--maintain safety should a rapid birth occur. Encourage her to exhale as she pushes strongly for 4-6s at a time--prolonged pushing against a closed glottis, esp. if done every time, reduced BF to the heart, placental BF, & O2Sat. Tell her to flex her head w/ each push & direct the push downward into the pelvic cavity, pull against flexed knees or bed handles & curve body around uterus. Encourage upright position-squatting to take advantage of gravity & slightly enlarge the pelvic outlet. Push toward the vaginal outlet. Help her relax her perineum to reduce resistance of decent. In semi-sitting, push sacrum against bed to straighten the pelvic curve. Do not talk to her unnecessarily, silence allows her to conserve energy for pushing.

Hypo/Hypercalcemia

-Hypocalcemia: Alcoholics are at high risk, low Magnesium affects PTH secretion. Malabsorption can result from increased intestinal motility seen with diarrhea or laxative abuse. Anticonvulsants esp Phenetorin or Phenobarbital affect Calcium levels. Calcitonin and drugs that lower Magnesium levels like Gentamycin, loop diuretics, and phosphates are a common cause of low Magnesium levels (Magnesium mirrors Calcium). Patients receiving massive blood transfusions are also at high risk. -S&S: Anxiety, confusion and irritability. Check using Trousseaus (spasm caused by inflating blood pressure cuff) and Chvostek's (twitching of facial muscles in response to tapping area of facial nerve). -Treatment: Focuses on correcting the imbalance, oral calcium supplements with Vit. D may be prescribed. IV calcium gluconate may be used. REMEMBER this is common after parathyroid surgery so this should be kept in the med cart or somewhere with easy access! Also, promote regular milk intake -Hypercalcemia: Hyperparathyroidism and cancer main causes. This happens when the body excretes more PTH then normal and calcium resorption from the bone and kidneys are increased. Medications that increase calcium levels are antacids, calcium supplements, lithium, thiazide diuretics, vit A and vit D. -S&S: Usually affect the GI system first! Abdominal pain, constipation, anorexia, confusion, bone pain, decreased deep tendon reflexes, ECG changes. -Treatments: Restricting dietary intake as well as hydration which increases diuresis. Loop diuretics and chelators may also be used to promote excretion. For life threatening -hemodialysis. --Phosphorous: Normal Value: 3.0-4.5; Parathyroid gland controls hormonal regulation of phosphorous levels through PTH changing calcium levels thereby changing phosphorous levels. (Phosphorous and Calcium have a reciprocal/inverse relationship if one goes up the other goes down)

Hypo/Hypernatremia

-Hyponatremia: Many medications can cause this by increasing the action of ADH or by causing SIADH secretion. Diuretics may also cause this by inhibiting sodium reabsorption. -S&S: Abdominal cramps, Altered LOC, lethargy, confusion, HA, muscle twitching, tremors and weakness. If hypovolemia accompanies this, you might also see dehydration. -Diagnostics: Serum Osmolality <280, Specific Gravity <1.010, elevated Hct, and plasma protein -Treatments: If mild can be treated with fluid restrictions and oral sodium supplements. Hypovolemia requires isotonic fluids. -Priority nursing care: Monitoring the patient's response to therapy and preventing hypernatremia and fluid overload. -Hypernatremia: Less common, occurs when there is excess sodium, severe cases can cause seizures and severe neurological damage. Thirst is the first line of defense, can be caused by water loss, inadequate water intake or sodium gain. It rarely is caused by a failure of the thirst mechanism. Results in increased osmolality, insensible water losses of several liters a day, pulmonary patients from hyperventilation, or with severe burns. High protein diets without adequate water. Infants and children are at high risk. Antacids, some antibiotics, Kayexalate, IV NaCl. Most important signs are neurologic. -Diagnostic tests: Sodium levels >145, specific gravity >1.080, and serum osmolality greater than 100. -Treatment: Treat slowly! Otherwise you can cause cerebral edema, oral salt free solutions should be encouraged, sodium intake restricted. Diuretics may be administered for renal involvement with oral or IV fluids to increase sodium loss. Patient teaching should focus on dietary restrictions, drug therapy and possible adverse effects.

Hypo/Hyperphosphatemia

-Hypophosphatemia: Caused by hyperventilation, sepsis, alcohol withdrawal, heat stroke, possible after treatment of hyperglycemia with Insulin where phosphorous shifts into the cell or with malabsorption. Diuretics can also cause this. -S&S: Muscle weakness, malaise, and anorexia. -Treatment: Nutritional-mild to moderate- should eat eggs, nuts, whole grains, meats and milk products. Severe-treat with potassium phosphate or sodium phosphate. -Monitor: Respiratory status, Cardiac output, and altered LOC -Hyperphosphatemia: Results from impaired renal excretion seen primarily in renal failure. When GFR <30 the kidneys can't excrete adequately. A shift of phosphorous from ICF to ECF is seen in resp acidosis. Can be caused by renal impairment, Resp. acidosis, chemotherapy, Increased dietary intake, Meds containing phosphorous (laxatives, enemas, Vit. B supplements), Infants that are fed cows milk are at high risk! -S&S: CHEMO (C: Cardiac irregularities, H: Hyperreflexia, E: Eating poorly, M: Muscle weakness, O: Oliguria) Organ dysfunction develops as calcium-phosphate precipitants are deposited in the heart, lungs, kidneys, cornea, and soft tissue. -Treatment: Low phosphorous diet, chelation, drug therapy-low phosphate binding antacids, Hemodialysis.

Metabolic & Respiratory Alkalosis

-Metabolic Alkalosis: INCREASED HCO3, LOSS OF POTASSIUM Loss of gastric juices (vomiting, GI suctioning), K+ Wasting Diuretics (increases loss of H+), Overuse of Antacids, NG suctioning, Cushing's Disease Factors that increase the risk: Diuretics like Thiazide b/c of loss of K+, H+, Chloride, Cushing's disease (retention of sodium and chloride and excretion of K+) S&S: Slow shallow resp which leads to hypoxia and eventually results in increased ventilations, muscle excitability, apathy, confusion Nursing Interventions: NG suction discontinued, discontinue diuretic therapy, prevent injuries, provide potassium supplements to body per MD order ABG: pH >7.45, HCO3 >26 -Respiratory Alkalosis: HYPERVENTILATION: decrease of CO2 in lungs. Pulmonary Embolism, Stress, Strenuous Exercise, Hypoxia, Fever, Pregnancy, High Altitude, Anxiety/ Panic Attacks Factors that increase the risk: Any clinical condition that increases the respiratory rate or depth. Anxiety, pain, fever, nicotine, higher progesterone levels in pregnancy. S&S: increased resp., Tachycardia, Anxious, Restless, Muscle weakness, difficulty breathing, confusion, syncope, ECG changes (prolonged PR interval, flat T wave, prominent U wave) Nursing Interventions: O2 Therapy, calm their hyperventilation (breathing in a paper bag) ABG: pH >7.45, CO2 <35

Metabolic & Respiratory Acidosis

-Respiratory Acidosis: HYPOVENTILATION : increase of CO2 in the lungs. OD, Pulmonary Edema, Chest Trauma, Neuromuscular Disease, Airway Obstruction, COPD -Factors that increase the risk: Lung Disease, Infants b/c of low residual lung volume -S&S: Rapid, shallow, resp., Decreased BP with vasodilation, Dyspnea, Muscle weakness, Drowsiness, Dysrhythmias, (^K+), headache, apprehension and confusion. -ABG Readings: pH <7.35, ^CO2 (>45) -Nursing Interventions: Maintain a patent airway, -Treatment: bronchodilators, supplemental oxygen, drug therapy to treat ^K+ if necessary -Metabolic Acidosis: -Causes: decreased HCO3 in body. DKA, Aspirin OD, Sepsis, Shock, Severe Diarrhea, Renal Failure -Factors that increase the risk: Alcoholism, uncontrolled blood glucose, diarrhea (extreme loss of HCO3) -s/s: Kussmaul Respirations, changes in LOC, decreases BP, HYPERkalemia, ECG changes, dull headache -Nursing Interventions: monitor neurological status closely, the cardiovascular / musculoskeletal systems are most important -ABG Readings: pH <7.35, HCO3 decreased (<22)

CKD

CKD: Clinical S/S, ALL body systems effected -Elevated serum Cr levels indicate underlying kidney disease and as the Cr level increases, S/S of CKD begin. Cr clearance test ID stage of CKD. •Anemia- from reduced erythropoietin production in kidney. •Metabolic acidosis- H+ buildup, Kussmaul respirations compensate--increased RR & depth to dump CO2. Give patient HCO3 or insulin. HCO3- used to measure extent of metabolic acidosis. •Calcium and Phosphorus abnormalities •Fluid retention causes edema and CHF •Hypertension- worsens with decreasing kidney function -Assessment: Anorexia, Lethargy, Breath smells like ammonia, Skin itching, Edema, HTN due to volume retention, Confusion→Apathy→Coma -Labs: Anemia (lack of erythropoietin production. Acidosis, Hyperkalemia, Uremia, Azotemia --Uremia: Metallic taste in the mouth, Anorexia, N/V, Muscle cramps. Leads to lethargy, seizures, coma from Nitrogen waste buildup. --Azotemia: increase Nitrogen waste buildup, is an early S/S of uremia. -Analysis: Adequate urinary elimination? Fluid and electrolyte balance? Altered thought process due to uremic toxins. -Uremia: Increased BUN, increased creatinine, Urine volume may be low or normal, Anemia, Bleeding tendency, Encephalopathy. -Hypertriglyceridemia: Increased production of triglycerides, Cholesterol levels normal, Premature atherosclerosis. -Metabolic Acidosis: Impaired NH³ synthesis by kidneys limits H+ excretion. -Implementation: Monitor I&O, Weigh daily. ---Watch for signs of pulmonary edema: dyspnea, rales ---Watch for signs of hyperkalemia: diarrhea, paresthesia, ECG changes -Initially: preserve kidney function by correcting S/S. High kCal diet to prevent wt loss and protein catabolism. Low protein diet. -Client education: Frequent nutritious meals, high in calories, low protein, low sodium, low potassium. Explain reason for meds or intervention to increase compliance.

Cast Care

Cast Care: -Check the Edges: if rough or irritating the skin, petal the cast by overlapping moleskin or tape 1-2inW, 3-4inL w/ 1 rounded edge, around cast edges. Use water proof tape in perineal area. -Drying the Cast: place child on firm mattress, support cast & adjacent joints w/ pillows; plaster- reposition Q2-4h to ensure drying. Lift cast w/ palms; direct fan toward the cast. If dry, it sounds hollow & is cool to the touch. -Prevent Problems: swelling peaks at 24-48hrs; apply bagged ice to cast area (w/o getting it wet); elevate extremity at heart level w/ pillows; check cap-refill Q2h for 24-48hrs (no >2s); casted extremity should be same color & temp. as other; check digits for sensation & movement several x/day for 2 days. Protect the Cast: cover w/ waterproof plastic & tape to keep dry in shower/bath; do not put anything in it, keep small toys away, supervise at meal times. -Contact the HCP: cast feels warm/hot, unusual smell; drainage or blood suddenly appears; child reports numbness, pain, tingling, burning; changes color or temp., or swelling persists; fever >101.5 (40C) oral; slipping of cast, inability to visualize digits. -Prep for Removal: explain process; remover works by vibration, creates a warm, tickling feeling, sounds like a vacuum. Allow time for child to adjust to the remover; ask HCP if child can exam remover. After, skin will be dry & flaky; wash w/ warm H20 & soap, discourage rom scratching. Extremity will be stiff & smaller; may need to support w/ sling; normal movement will correct stiffness.

Chronic glomerulonephritis (GN): Chronic Nephritic syndrome

Chronic glomerulonephritis (GN): Chronic Nephritic syndrome -Develops over years to decades. Mild proteinuria and hematuria, hypertension, fatigue, irritability, wt loss, nocturia, and occasional edema are often the only symptoms. Kidney reduces to 1/5 normal size and becomes scarred/distorted and tubules/RA thicken. Minimally symptomatic or generalized S/S. When S/S of CKD occur, it is usually irreversible resulting in RF. -Cause unknown, results from changes in kidney tissue due to infection, excessive immune response, HTN, reduced kidney BF. Kidney atrophies as a result, and nephrons are reduced. Repeat episodes of AGN, HTN nephrosclerosis, hyperlipidemia, chronic tubular interstitial injury, hemodynamically mediated glomerular sclerosis, lupus, hemolytic uremic syndrome---but the initial injury is rarely ID. -Biopsy in the late stages of atrophy may show glomerular changes, cell loss, protein and collagen deposits, and fibrosis of the kidney tissue. Deposits of immune complexes and inflammation. HTN and renal arteriole sclerosis are often present. The glomerular damage allows proteins to enter the urine. ALWAYS leads to ESKD. -Dx: decreased UO/fixed SG, proteinuria, blood & casts in urine, reduced GFR, increased Cr&BUN. -Treat: manage S/S--HTN, restrict Na/H2O, give anti-HTN meds, monitor daily wts, diuretics for FVO. Nutrition--increase protein intake to promote tissue growth/repair, restrict protein once RF develops. Dialysis will manage F&E imbalances and minimize risk of RF. FVO+hypernatremia can make Na look normal, oliguria can cause high K+ >5.4, P >4.7, Ca normal to slightly low, H+ retention, HCO3 excretion--watch out for resp. compensation (excrete CO2). Offer emotional support and encourage follow-ups. S/S AKI: oliguria, azotemia.

The Ill Child & their family

Effect of the Ill child on the Parents: o Situational crisis for the family—not sure what to do or how to care for child (hold, bathe), not in control, confused. o Guilt—for not bringing child to doctor earlier or missing s/s in child. o Denial—that the child was ill (esp. if serious like cancer, celiac dz). o Anger—result of denial; anger against RNs, family, God; may seem like it's aimed at you, but it's not. o Depression—result of anger; exhausted physically & psychologically from spending a long time in the hospital & concerns outside of hospital w/ work or other kids. • Siblings: Jealousy & resentment towards ill sibling, confusion as to whats going on, anxiety; may act out at home or in the hospital to get parents to pay attention to them (ex. pressing alaris buttons, or other actions that could cause problems w/ patients care). Could feel guilt; think something they said/did to their sibling made them ill. Children's Response to Illness: each child is unique, so its difficult to predict response; hospitalization results 1+ of in these threats or fears in children: Fear of the unknown; Separation anxiety; Fear of pain or mutilation; Loss of control; Anger; Guilt; Regression (ex. previously potty trained, now child doesn't use toilet; reassure parents this is a normal response). • RN: educate parents about what to expect; if child's behavior is different than normal, explain it may be a result of the illness (normal response); support their participation in the child's care to decrease parental stress & enable them to facilitate their child's adjustment. • Parents are encouraged to stay with their child whenever possible, if it is in the best interest of the child. If the child wants a family member w/ them, we allow & encourage it—promotes calming & feelings of security, helps w/ Tx when parent holds them. -Availability of Interpreters: the family of a hospitalized child may not speak the prevailing language. Interpreters are available (on-site or on-call) at many hospitals to help parents and children communicate with HC team members. This arrangement provides a familiar link to the parents' and child's culture and language. Having the child interpret is usually not appropriate; ensure there is a medical interpreter available to provide appropriate info when w/ Hx, teaching, consents, & D/C teaching.

Epiglottitis (Supraglottitis)

Epiglottitis (Supraglottitis): severe form of pharyngitis; emergency medical situation. Usually bacterial - H. influenzae. • Cardinal s/s: Drooling, Dysphagia (difficulty swallowing), Dysphonia (difficulty talking), Distressed respiratory efforts. Abrupt onset & rapid progression—complete obstruction w/in few hrs; child was well when put to bed & woke w/ sore throat & difficulty swallowing. Epiglottis looks cherry red & edematous; high fever of 39-40C (102.2-104F); appears toxic & very ill; anxious & frightened, irritable or lethargic; classic s/s insistent on sitting in tripod position, w/ chin thrust out & open mouth; nasal flaring, retractions, pale to cyanotic color, tachycardia. • DO NOT: Leave child unattended if epiglottitis is suspected. Examine or attempt to obtain culture; any stimulation by tongue depressor or culture swab could trigger complete airway obstruction. • Tx: • Have emergency equipment available at the bedside; intubation tray & suction tray. • Achieve a patent airway (usually intubation); all other tests can wait until airway is obtained & stabilized; don't do anything that will increase the child's stress. If in mild distress, you may be able to do an x-ray. • A sudden decreased respiratory effort (slowing RR) is a sign of exhaustion and impending cardiorespiratory arrest. • Never force the child to lie down; usually sitting in tripod position, let them sit however is most comfortable for them. • Humidified O2 in high concentrations. • Progresses rapidly; parents and child have high anxiety levels. Provide support, once stable reassure parents that it rarely reoccurs & won't happen every time the child gets sick.

How to Assess VS in Children

How to Assess VS in Children: Vital Signs: know normal ranges based on age • RR: done 1st bc they are calmest at beginning of assessment. For infants, RR changes w/ stimulation, crying, feeding; 1st observe pattern to ID irregular rhythm, then w/ infant or young child at rest & quiet, auscultate for 1min. Older child, observe chest movement or auscultate to get the RR. • Temperature: Oral- younger kids may not hold it in their mouth, Axillary- upsets babies, Rectal- true core temp., Temporal- most frequently used right now. Whatever method is chosen, always measure at the same site w/ the same method. If elevated/low temp. reading is obtained, consider measuring via a different route. Report if <98.6F (36C) or >100.4F (38C)--reporting is critical for an infant <3mo old. • Pulse: Apical pulse is preferred (esp. <2yrs old, irregular HR, or congenital Heart dz); Count for a full minute, when the child is quiet. Radial is appropriate for kids >2yrs. <7yrs Apical is lateral to the MCL at the 4th ICS. 7+yrs Apical is left of the MCL at the 5th ICS. • BP: Choose a cuff of the appropriate size—BP is off, may indicate incorrect size so recheck it before you tell the HCP the BP is abnormal; make sure you document the site—upper arm, lower arm, thigh, calf, or ankle (esp. w/ younger child). Take BP in same site consistently when possible; changing the site can result in inaccurate & inconsistent readings. Know what is normal for the age of the child!

Hypoglycemia in the Newborn

Hypoglycemia in the Newborn: -Risk Factors: pre or post-maturity, late preterm birth, IUGR, large or small for GA, asphyxia, problems at birth, cold stress, maternal diabetes, maternal intake of terbutaline. -RN: observe for s/s of hypoglycemia in all infants; screen BS (Cap, then lab to verify for low BS) for infants in risk categories or if any infant shows s/s of hypoglycemia. Warm the heel before puncturing on the lateral side to avoid nerve damage & osteomyelitis. -1-2hrs old: BGS can be as allow as 30mg/dL -12hrs old: BGS stabilizes above 45mg/dL -S/S Hypoglycemia: jitteriness, tremors, poor muscle tone, diaphoresis, poor suck, tachypnea, tachycardia, dyspnea, grunting, cyanosis, apnea, low temp., high-pitched cry, lethargy, irritability, seizures, coma; some may be asymptomatic. -Tx: infant is fed when BS is <45mg/dL to prvent further decreases; IV glucose may be needed for persistent low glucose. o Blood Glucose Maintenance: neonate uses glucose rapidly and is at risk for hypoglycemia. Temp. regulation, G&D, crying, etc—use up stores. Term infant glucose should be 40-60mg/dl at day 1 & 50-90mg/dl thereafter. o Infants at risk for hypoglycemia include: Glucose <40-45mg/dL—give extra breastmilk or formula. If <30, need to intervene bc of possible brain damage—admin IV D5 to keep glucose stores at a healthy level. -Preterm and late preterm (didn't quite make it to 37wks, normal size but lungs arent mature). -Small for gestational age or large for gestational age -Born to diabetic mothers—DM mom, hyperglycemia of fetus, fetus increases insulin production that continues after birth, leading to hypoglycemia. -Exposed to stressors—difficult delivery, shoulder dystocia, late decels at the end, very late delivery-meconium. Anything that increases stress will increase kcal & glucose need, leading to hypoglycemia as they use up stores.

Indications of Pregnancy: presumptive, probable, positive

Indications of Pregnancy: -Presumptive: subjective changes that most women experience during pregnancy. Least reliable indicators because other conditions can cause them. · Amenorrhea- ex. - low BMI, or + progesterone · Nausea and vomiting- ex + hormones, -infection · Fatigue- ex. + progesterone · Urinary frequency- ex - UTI, or + hormonal FvL · Breast and skin changes- ex + linea negra, melasma · Vaginal and cervical color changes- ex. + chadwick's · Fetal movement- ex - ascites, or + quickening (16-20wks) -Probable: objective findings that can be documented by an examiner. Stronger indications of pregnancy, but still can have other causes. · Abdominal enlargement- ex - ascites or - gaining weight · Cervical softening- ex. + Goodell's · Uterine changes- ex. + Hegar's sign: 6-8wks the lower uterine segment (isthmus) is so soft that can be compressed to the thinness of paper, can be flexed against the cervix. + Ballottement felt by examiner. Braxton Hicks contractions. Palpation of fetal outline. Uterine souffle: soft, blowing sounds may be auscultated over the uterus, the sound of the maternal pulse. Funic souffle is the sound listened over the umbilical cord, corresponds to the FHR. · Pregnancy tests: -Agglutination inhibition test: hCG in urine, + 3-7 days after conception; ex hCG in a 75yr old women doesn't indicate pregnancy. -Radioreceptor assay: 6-8 days after conception, used to detect small hCG in ectopic pregnancies -Radioimmunoassay: lab diagnostic, accurate before the first missed menstrual period. -Inaccurate pregnancy results: false-negative may happen if its too early, instructions were not followed properly, urine is too dilute, and if in diuretics. Hematuria and proteinuria as well. -Positive: definitive Dx of pregnancy, they can only be caused by pregnancy. · Auscultation of fetal heart sounds- can be heard w/ stethoscope by 16-20wks gestation. Doppler early as 9 wks. US early as 8 wks. --IMPORTANT: distinguish fetal heartbeat from maternal pulse, fetal HR 110-160 bpm · Fetal movements felt by examiner- not the mom. · Visualization of fetus- on US. Visualization of embryo or fetus: transvaginal US can be seeing as early as 3 wks.

Interventions for PP hemorrhage: Bimanual Compression & Balloon Tamponade

Interventions for PP hemorrhage: Bimanual Compression & Balloon Tamponade o When concerned about postpartum hemorrhage, immediately following delivery the HCP can do certain interventions. o Mom has trickling blood after deliver, or pad saturated w/in 1 hr after delivery—must consider possibility of hemorrhage. RN: assess for risk factors before it occurs. Hold uterus down at bottom, & massage w/ other hand, increase fluids. Notify HCP, may do bimanual compression. o Bimanual compression: done by HCP to stop hemorrhage; 1 hand in the vagina, other hand compresses the uterus through the ABD wall. o Balloon tamponade: done by HCP to stop hemorrhage; like a large foley catheter, balloon filled w/ fluid (NS) to provide pressure on inside of uterus to stop the hemorrhage from occurring.

Labor: s/s of true vs false

Labor: s/s of true vs false -RN has 2 Priorities: establish the therapeutic relationship, while assessing the condition of the mom/baby -Premonitory Signs of Labor: -Braxton Hicks contractions—uterus is getting prepared, its stretching & contracting in preparation. -Lightening—fetus moved down into the pelvis & out of maternal lungs, so mom feels lighter. -Increase in clear and nonirritating vaginal secretions—body is lubricating the vaginal canal for birth. -"Bloody show"—if mucus plug is removed & cervix starts to dilate where all the congested BVs are, blood may appear. Usually a brown-ish discharge. Bright red blood is a warning s/s—go see doctor immediately. -Energy spurt—"nesting" in preparation for L&D, mom is getting the house ready, cleaning, washing clothes, etc. Small weight loss—during time of the "energy spurt" from burning more kCals by keeping active. -Remember the warning s/s: high BP, bright red blood like a period, s/s infection—see doctor right away. o True Labor & False Labor: Can be difficult to differentiate for the 1st time mom. -Conclusive difference of true vs false is the progressive effacement & dilatation of the cervix. Ex. Mom can have Braxton Hicks contractions all day long, but if cervix doesn't change, she is NOT in labor. Some women don't have s/s that are typical of true labor. --Come to the hospital if you are unsure or have concerns—but generally w/ true labor the contractions are regular increase in intensity, duration will increase w/ walking. Felt in the lower back & radiate to the lower portion of the ABD, there is bloody show, & key conclusive difference is dilatation & effacement. The fetus is usually engaged. · False labor contractions are usually irregular & don't change w/ walking or sleeping. Contractions felt in the ABD above the umbilicus, like Braxton Hicks. No change in cervix & fetus is ballotable (up high, can't feel it during manual exam)

Magnesium Sulfate

Magnesium Sulfate: for preeclampsia & eclampsia. · Anticonvulsant Medications: reflexes +1 to +4, at +4 they will have a seizure. o Magnesium sulfate: drug of choice; its an anticonvulsant, not an anti-HTN, but it does end up lowering BP. 40g/500mL- 1L, lower fluid vL used when edematous. Give 6g/20min, then 2-3g/hr by IV piggyback—closest to port of entry bc if needs to be stopped, can prevent more from going into BVs. -SE: respiratory depression, reduced/absent reflexes—monitor closely. Always on a pump, if giving bolus watch mom/baby very closely. It's a CNS depression that prevents or Tx seizures, secondarily it increases peripheral BF, so decreases BP initially—but BP isn't the purpose of use. Can be used for preterm labor bc increase BF to the uterus, which inhibits contraction. Delivering on Mg can cause uterus to not contract after delivery, "boggy uterus", risk of hemorrhage at placental site—monitor more closely after delivery. Hold Mg if RR <12 & UO <25mL/hr. -Antidote: Calcium Gluconate, kept in a labeled syringe at pt bedside. o Continuous Fetal Monitoring: the entire time while on Mg-sulphate. Mg can cause decreased FHR variability, unlikely to cause late decelerations. o Induction of Labor: likely used in preeclampsia to delivery baby quicker. Mg inhibits contraction (risk of hemorrhage), so higher levels of Pitocin may be needed. Risk of high BP present for a few days PP, Mg is continued. -Baby: Reduced BF to the placenta in preeclampsia limits nutrients, fluids, and oxygen available to the fetus and often results in a low-birth-weight infant (SGA infant). SGA: hypoglycemia <40mg/dL, temp. instability, polycythemia, & bleeding tendency.

Identify nurse's role in providing family center support to child w/ chronic or terminal illness, siblings & parents

On-going care in chronic/terminal illness: continuous care involving the child & family; address physical & psychosocial needs. • Education: involvement of child life specialist; uses methods that are educational, supportive, & therapeutic—ex. play therapy or art. • Communication: involves honesty and compassion; based on child's age and development. • Care for Parents: grief education and support; cultural and religious beliefs; referrals (specialists, HCPs, etc.); schooling—child should receive appropriate education services and attend public school (laws protecting rights of special needs kids, allowing them to be in public school; school RN provides care). Promoting Normal Development: • Early childhood: basic trust, problems w/ separation from parents, beginning of independence. o Infant Task: achieve awareness that they are a separate being from their significant other; illness may distort this differentiation. o Toddler Task: initiation of autonomy; illness can interfere w/ or make them lose their sense of control & independence. o Preschooler Task: creation of their sense of initiative; illness can cause an interference w/ or loss of accomplishments like walking, talking, & control of basic bodily functions. • School age Task: sense of industry/activity; illness can cause feelings of inadequacy or inferiority if autonomy & independence are compromised. • Adolescence Task: achieving a sense of identity, developing independence/autonomy; peers are very important. Illness can cause an alteration in or relinquishment of newly acquired roles & responsibilities.

Pharmacologic Interventions: Admin of analgesics & pain management for children

Pharmacologic Interventions: Admin of analgesics • Ensure the correct med & dose are ordered & admin; combination of meds are more effective that single med; no 1 med or combination of meds will work for all patients & in all circumstances. Chosen Tx must have prompt onset of action, predictable duration of action, manageable SE, & a reversal agent. • Routes: PO, rectal, intranasal, topical, transdermal, IV, IM, SQ, & epidural—avoid rectal & IM w/ kids; choose least invasive route that provides optimal analgesia; once child tolerates PO nutrition, switch med to PO. Give meds by PO whenever possible. Pain Management for Children: • Preferred routes are IV or PO. • As soon as the child can tolerate oral intake, the route should be changed from IV to PO. • After starting w/ recommended initial dose for opioids, the dose is titrated to achieve best pain management w/ fewest SE. • Opiates do not have a dose limit, the max dose is the one that causes unacceptable SE. • Infants & children receiving epidural opioids should be monitored by cardiac & apnea monitor, & pulse oximetry. • Cardiac & apnea monitor, & pulse oximetry may be required for certain infants & children receiving IV opiates—neonates, opioid-naïve kids, Hx of apnea or respiratory difficulties; risk of respiratory depression is greatest in first 24hrs of admin. • Infants & children receiving IV & epidural opioids should be monitored by pulse oximetry. • If respiratory depression occurs with opioid use, naloxone hydrochloride should be used for reversal when oxygen & stimulation of the child are ineffective.

Risk factors for PP Hemorrhage, Infection; full bladder

Postpartum Hemorrhage: grand multiparity (5+), overdistension of uterus (large baby, twins, hydramnios), rapid or prolonged labor, retained placenta, placenta previa or previous placenta accrete or abruptio placentae, drugs (tocolytics, Mg sulphate, general anesthesia, prolonged oxytocin), OP procedures (CS, vacuum, forceps), uterine fibroids, Hx postpartum hemorrhage, preeclampsia, coagulation defects. · Infection: OP procedures (CS, vacuum, forceps), multiple cervical exams, prolonged labor, prolonged ROM, manual extraction of placenta or retained fragments, DM/GDM, catheterization, bacterial colonization of lower GU. -Be alert for possible complications associated with identified risk factors; Preeclampsia, diabetes, cardiac disease, c-section, problems with labor, distended uterus. Bladder: o Encourage her to void every 4-6hrs, & assess the bladder till there is complete emptying w/ each void. If there are issues, assess w/ bladder scanner to see if it's been emptied. Risk for overdistension of the bladder, incomplete emptying, & buildup of residual urine. HCP may order cath when bladder is distended & pt can't void, or if she hasn't been able to void in past 8hrs—esp. after epidural or spinal. o Full bladder may increase uterine relaxation by displacing uterus & interfering w/ contractility—can lead to hemorrhage. Full bladder won't allow uterus to contract, if there is loss of tone, she can bleed from where the placenta was. -S/S bladder distension: uterus high & displaced from midline--can cause PP hemorrhage & UTI. o Teach s/s of urinary retention, overflow voiding, & UTI w/ patient.

Preparing Children for Procedures, Consent, & Documentation

Preparing Children for Procedures: • A treatment room is the preferred location for painful procedures. • Ensure that a person the child trusts is there for support—ex. mom, dad, or RN if parents are unable or uncomfortable. • Use developmentally appropriate terminology. • Offer the child choices if appropriate—ex. "Do you want a red or green band aid?"—only offer choices that you can accept any answer to; if you offer then renege, you lose the child's trust. • Tell the child & parents how they can help with the procedure—ex. "You can help me by staying very still, or do you need someone to hold your arms to help you remember not to move?". • Do not threaten punishment for lack of cooperation—parents often do this; RN must encourage parents not to do this. Instead of "I'm going to take away X, if you don't to X", they should say "You can do X, when we are done doing X". RNs should have realistic expectations based on developmental level & capacity to cooperate. • Encourage parental participation, but do not force an unwilling parent to stay. Consent for Procedures: • Informed consent: Procedures that involve risk to the child, such as surgery or Dx & invasive procedures—Ex. Surgeries, Lumbar puncture, chest tube, bone marrow. Signed by the parent, even if child is 17yrs old, give explanation of the procedure to the parent & child. • General consent: done when child is admitted to the hospital; routine procedures such as medication administration, IV insertion, specimen collection. • Assent: It is customary to obtain agreement with the child if he or she is 7 years or older; indicates they agree w/ what Tx the HC team is going to provide. Don't ask "Is it okay if we put in an IV?", bc the answer will be "no". Phase in a way that their answer will be acceptable & in line w/ plan of care. Documentation of the Procedure: • Preparation process: done before the child enters the Tx room; Document the key elements of the procedure—who performed the procedure, child's tolerance of the procedure, & the outcome.

Med Admin: Psychological and Developmental Factors, Strategies for Med Admin w/ Children

Psychological and Developmental Factors: • G&D principles: Always approach a child according to their developmental level—get down to their eye level, provide explanations about meds; Give as many choices as possible—decreases powerlessness—ex. ask the preschooler, "Would you like to hold the cup or have X hold it while you take the med?". • Differences among age groups: Toddler may see as punishment (esp. needles), so allow them to examine/play w/ equipment (empty orange syringe). School age may feel loss of control, so offer choices. • Eliciting support from parents will alleviate a child's fears; ensure they are not threatening punishments—tell them "It's okay for the child to be upset or cry". Restraints are seldom necessary for med admin; an RN can assist child hold still for injection, parents can distract & comfort. Honesty, praise, & reward are important in all ages—name 1+ positive thing they did, tell them if something tastes bad or if it will hurt, & how long it will hurt. Strategies for Medicating Children: • Infants: cuddle & comfort before/after the admin; RN or caregiver. • Toddlers: use play, minimize restraint, & give praise and stickers as rewards. • Preschoolers: offer choices, give praise. Adhesive bandages are important because they feel it will make it better bc they believe it 'plugs up the hole', & it offers them a choice. • School-aged children: provide choices, explanations, distraction, and support; Still like praise & rewards. • Adolescents: explain, allow participation in decisions, & provide outlet for frustrations—ex. drawing & writing.

Reaction to Illness and Hospitalization: Adolescent

Reaction to Illness and Hospitalization: Adolescent § Separation: unsure of whether they want parents there; some enjoy freedom & independence, others become dependent on parents, & some cant decide (frustrates parents). Reassure parents this is normal teen behavior. Separation from peers is the major source of anxiety; some teens are uncomfortable visiting them in the hospital—causes the patient to be upset that their friends are "moving on" or "excluding" them. RN must provide activity areas & opportunities for them to socialize w/ other teens. § Fear of Injury & Pain: their appearance is crucial, an illness changes their self-perception can have a major impact; a once well-adjusted kid w/ chronic illness, can have difficulty in the teen yrs bc don't want to be different. Can be non-adherent to Tx plans, meds, diets to appear normal & not stand out. Think being "cool" means being in control; may be terrified even when they don't show it; may question everything or appear overly confident. Concern w/ their bodies; guarded during exams connected to sexual development. RN needs to be sensitive to their concerns, reassure them they are normal (if its true). Some believe they are invincible; nothing can hurt or kill them; may take risks or be non-adherent to plan bc they don't understand consequences of behavior. § Loss of control: RN must understand many of issues involved in teen care stem from control; give them some control to avoid power struggles. Loss of control can cause anger, withdrawal, & uncooperativeness. They desire autonomy, social acceptance, & increased self-esteem. Include them in the plan of care to increase control; ask about their perspective to increase feelings of involvement & responsibility. Give all explanations about care & condition; answer all their questions; must include them & realize that illnesses that change self-perception can have a major impact on their life. § Fear of the unknown: present for all children; sights & sounds of hospital can be confusing & cause anxiety. May have many questions about what they see & what we are doing to them; disruptions in their routine make them wonder what will happen next. RN must understand these fears to structure care & teaching in a way that avoids unnecessary anxiety. -Reduce Stress: Activities for the hospitalized child are important for G&D, stress relief, socialization, & a sense of control. Provide them w/ distractions that make them feel like a normal kid, even w/ their present illness/condition.

Reaction to Illness and Hospitalization: School-aged

Reaction to Illness and Hospitalization: School-aged § Separation: already accustomed to separation from parents, but it's more difficult w/ added stressors. Younger child may already have separation anxiety bc starting school; older may be worried about missing school & fear their friends will forget them. Unfamiliar environment w/ regression seen in ill kids, increase likelihood of separation anxiety occurring—become distressed over separation from family/peers. § Fear of body disability and death: more relaxed w/ physical exam & eye/ear exam; uncomfortable w/ genital exam. Understand cause-effect relationship & can relate actions to illness; they ask relevant questions about illness & want reasons for Tx & tests. Parents tell them that if they don't eat/sleep well, they will get a cold—so they associate their actions w/ the dz. RN should talk to them & not just the parents. § Loss of Control: "movers & shakers"; control their self-care & highly social. Like being involved & doing activities; illness changes these patterns. Physical limitations can cause helplessness & dependence; anxiety results from loss of control, hospitalization, & environmental changes—this changes the way they view the experience & resulting stress, may see hospital as a threat. Coping activities include sleeping, socializing, play, & distraction activities. Deal w/ stress of hospital better bc able to reason & communicate needs/thoughts; better understanding of HCP explanations; unsatisfied when lacking info about their care. Friends are important, may think their friends will forget about them. Normally make choices about meals & activities; RN should encourage them to be involved in care—select their menu, assist w/ some Tx, keep room neat, visit other kids when appropriate. Opportunities for independence help them retain sense of control, enhance self-esteem, & allow them to continue to achieve sense of industry.

Rubella (German Measles, 3-day rash)

Rubella - German Measles: RNA virus seen in late winter-early spring; incubation = 14-21 days; infectious = 7 days before onset of s/s to 14 days after rash seen; transmission = airborne particles, direct contact w/ droplets, transplacental can cause fetal death or abnormalities (congenital rubella- some infants shed virus for months after birth); Immunity = natural dz or live-attenuated vax. • AKA 3- day or German Measles Rash: usually a mild dz in children & adults, resolves in 5 days; virus enters host, rash occurs after 14-21 days. Young child usually asymptomatic until rash is seen; older may have profuse nasal drainage, diarrhea, malaise, sore throat, headache, low grade fever, polyarthritis, eye pain, aches, chills, anorexia, & nausea. All ages have impressive posterior cervical, posterior auricular, & occipital lymphadenopathy. • Rash: pinkish rose maculopapular exanthem; begins on face, scalp, & neck, then spreads downward to entire body in 1-3 days; usually pruritic. Fades on face as it spreads to trunk. Petechiae (red or purple pinpoint spots) may occur on soft palate—"Forchheimer's sign". • Complications: maternal infection during pregnancy (usually first 12wks/1st Tri), causes Congenital Rubella Syndrome, crosses the placenta & results in fetal death or abnormalities; results in intrauterine growth retardation—typically weight <2,500g, & failure to thrive in infancy. Mortality is highest in 1styr; common COD are pneumonia, heart defects, encephalitis, & immune deficiency. • Tx: Supportive & symptomatic treatment; dz is self-limiting, resolved in 5 days. Child can go back to school or daycare 7 days after rash begins.

Rubeola - Measles

Rubeola - Measles: RNA virus seen in winter & spring; incubation = 8-12 days from exposure to onset of s/s; infectious = 3-5 days before rash seen to 4-6 days after rash seen; transmitted by direct contact w/ droplets (less often airborne). Immunity through natural dz or live-attenuated vaccine. • Prodromal period: fever, rises gradually, & 3-C's; lasts 2-4 days, highly contagious & ill. Koplik spots occur 1-4 days before the rash; increase in number before disappearing at 3 days by sloughing off. o Rash preceded by Koplik's spots: small, blue-white spots w/ a red base that cluster near the molars on the buccal mucosa; lasts 3 days. o S/S "3 Cs": coryza (profuse runny nose), cough, conjunctivitis - most contagious. • Exanthem: present for 6-7 days; Deep red rash that begins behind the ears, at the hairline, & upper neck; then spreads to trunk, then LE & feet. Red maculopapular rash that blanches easily, gradually turn brown. • Tx: symptomatic; if hospitalized will be on airborne isolation precautions; if febrile period, restrict to quiet activities & bedrest. Encourage fluids, humidification & antitussives used to relieve cough. Supplementation w/ Vit-A.

Signs and symptoms of hypothermia in a newborn

Signs and symptoms of hypothermia in a newborn: o Thermogenesis: heat production, how the baby produces heat when cold. o Methods of heat production when cold: -Increase activity: when cold babies are restless & cry; crying & being awake increases heat. -Flexion: movement increases heat. -Metabolism: rises, increasing need for O2 & glucose. -Vasoconstriction: reduces heat loss, may cause acrocyanosis (bluish color of hands & feet). -Non-shivering thermogenesis (brown fat stored on front & between shoulder blades): shivering seen in cold adults, not often in babies unless exposure to cold is prolonged. Not an important method of heat production. Babies use NST as primary method to increase heat, metabolism of brown fat increases heat by 100%. Premature babies have little white & brown fat, extreme difficulties producing heat. o These factors increase oxygen and glucose consumption and may cause respiratory distress, hypoglycemia, and jaundice. -S/S hypothermia: Moving, crying, utilizing heat—uses up energy causing resp. distress, use up glucose causes hypoglycemia, & may cause jaundice. o Cold Stress: increases the need for O2, decreased production of surfactant—leads to resp. distress, metabolic acidosis, & hypoglycemia.

Stages of CKD

Stages of CKD: -Stage 1: At risk; normal kidney function, but urine findings indicate kidney disease. -eGFR >90 mL/min/1.73 m2 -Intervention- Screen for risk factors and manage care to reduce risk: Uncontrolled HTN, Diabetes with poor glycemic control, Congenital or acquired anatomic or UT abnormalities, Family Hx of genetic kidney diseases, Exposure to nephrotoxic substances. -Stage 2: Slightly reduced kidney function -eGFR 60-89 mL/min/1.73 m2 -Intervention-Focus on reduction of risk factors -Stage 3: Moderately reduced kidney function -eGFR 30-59 mL/min/1.73 m2 -Interventions- Implement strategies to slow disease progression -Stage 4: Severely reduced kidney function; a noticeable jaundice can occur, particularly around the eyes -eGFR 15-29 mL/min/1.73 m2 -Interventions- Manage complications. Discuss patient preferences and values. Educate about options and prepare for renal replacement therapy. -Stage 5: End-stage kidney disease (ESKD) -eGFR <15 mL/min/1.73 m2 -Implement RRT or kidney transplantation. Not all CKD patients end up here, some may have total failure, but then improve with no lingering problems.

Stressors Associated with Hospitalization: Preschooler

Stressors Associated with Hospitalization: Preschooler • Separation anxiety: is less obvious and less serious than in the toddler. May already be spending time away from home at daycare or preschool, but illness adds stress that makes separation more difficult. Have good recall of medical experiences, so make it positive for them by allowing them to express feelings & stress. Express similarly to toddler, but less direct—may quietly cry in a corner; may refuse to eat, take meds, & cooperate. May repeatedly ask when parents will visit & try to constantly call them on the phone—all these behaviors are s/s of difficulty coping w/ situation. • Fear of injury and pain: specifically, the fear of mutilation; OP on a limb or body part increases this fear bc don't understand body integrity. Fear of pain & procedures that may cause pain (shots, blood draws); perform potentially painful procedures in Tx room, their room & the playroom is a safe space. Literal interpretation of words, imagine things to be worse than in reality. Imagination is more active during illness; may believe they caused their illness w/ their behaviors/actions. • Loss of control: they have attained independence in self-care & been given independence in the home & school. May expect to keep this independence & become upset when told to stay in their room or bed. They like routines & rituals; may regress if not allowed to maintain some control. Give them a simple choice & some control, while maintaining boundaries. • Guilt and shame: thinking is egocentric & magical; may believe they caused their illness w/ a thought or deed, leading to guilt, shame, & increased stress when they are already trying to cope w/ other stressors. RN must be aware of these feelings of guilt bc they usually don't tell adults about it. RN must assess for this type of thinking, assist them ID unfounded fears & beliefs. Dolls or drawings can help them deal w/ feelings. Helping them ID perceived punishments & reassuring them their illness is not their fault, can greatly decrease anxiety. o Reduce Stress:Safe-Space; designated safe area can enhance a child's sense of security. Ex. their room. Intrusive procedures should take place in a treatment room, not the child's room. The playroom should not be used for treatments and/or administering medications.

Ectopic Pregnancy

· Ectopic Pregnancy: Implantation of the fertilized ovum in an area outside of the uterine cavity; 95% in fallopian tubes, usually the ampulla site. Sites: ampullar, fimbrial, isthmic, interstitial. o Increased Incidence: in the US; from pelvic inflammation—STIs that are untreated cause PID. Other causes: use of IUD, A&P defects in the tubes (failed tubal litigation), tobacco use, vaginal douching (fluid pushes ovum up). Anything that slows movement of fertilized ovum through the tube or causes it to implant early increases the risk. Also >35yrs, assisted reproductive techniques (GIFT), multiple induced abortions, Hx of ectopic pregnancy. o Dx: transvaginal US, hCG levels abnormal based on dates, severe lower right ABD pain 2-3wks passed missed period—why pregnancy test done for appendectomy pt. o Therapeutic management: prevent severe hemorrhaging in the mom, preserve fallopian tubes for future fertility. Less than 3.5cm, use metheltrexate, a folic acid antagonist that interferes w/ cell production & it's a chemo drug. Its stops growth of fertilized ovum. Greater than 3.5cm, try to save tube if it's not ruptured, do a linear salpingostomy, where they clear out the pregnancy. If it has been ruptured control bleeding & prevent hypovolemic shock, once CV status stable then do a salpingectomy, where they remove the ruptured tube—can still get pregnant w/ 1 tube.

Gestational Trophoblastic Disease

· Gestational Trophoblastic Disease: a spectrum of diseases that includes: o Benign hydatidiform mole: peripheral cells (trophoblasts) that attach the fertilized ovum uterine wall develop abnormally. Causes edema of the chorionic villi that forms fluid filled grape-like vesicles that may grow large enough to fill the uterus to the size of an advanced pregnancy. Complete: when there is no fetal tissue present. Partial: fetal tissue, membranes are present. o Gestational trophoblastic tumors: malignant change & proliferation of residual trophoblastic tissue. Life threatening complication. Goes beyond the outside of the uterus & becomes a cancer. o Acute respiratory distress: occurs if vesicles of the hydatidiform mole enter circulation & embolize to the lungs. o Dx: US exam shows no fetus & grape-like vesicles in a complete mole. Dx confirmed by patho study of the products of conception after evacuation. o Management: Evacuation of molar pregnancy w/ vacuum aspiration, after evacuation do a D&C. Test hCG levels every 1-2wks, until 3 normal prepregnancy levels—repeat every 1-2mo. Pt MUST avoid pregnancy for at least 1yr bc it will hide evidence of a choriocarcinoma—when chorion of uterus turns into cancer following Tx to rid the molar pregnancy. If pregnant we can't Tx the cancer, so she would have to have an abortion or risk her life/health. Proliferation of cells = cancer. Regular follow-up for 1 year to detect malignant changes w/ hCG levels. o Malignant transformation of any remaining tissue is suspected if hCG levels do not fall or if they rise after they initially fall. Chemo is the primary Tx for gestational trophoblastic neoplasm or choriocarcinoma.

Intrathecal Opioids & Combined Spinal-Epidural Analgesia

· Intrathecal Opioids: used for pain control during labor; addition measured are needed for pain control during late labor & birth. Mom feels contractions, but not pain. No sympathetic block, so no hypotension. · Combined Spinal-Epidural Analgesia: (CSE) allows subarachnoid injection (intrathecal space) of opioid via a spinal needle, followed by ongoing pain relief from anesthetics injected through the epidural catheter, w/o sedation. This technique combines the epidural w/ the intrathecal opioid. Drug binds to receptors in the intrathecal space, allowing much smaller doses than systemic opiates. · Advantages: rapid onset of pain relief w/o sedation, mom can ambulate during labor bs no motor block (unless she receives a concurrent epidural block), no sympathetic block w/ hypotension. · Disadvantages: dura puncture leads to possible post dural headache. · Technique: needle-through-needle technique in the midlumbar or spinous space. Epidural catheter is placed for on-going analgesia & anesthesia for delivery or CS. · Drugs: chosen by expected duration of labor at time of admin; preservative free drugs, ex. fentanyl, sufentainil, morphine. · Adverse Effects: same as w/ epidural opiates; n/v, pruritus, & delayed respiratory depression. · RN Care of CSE: · VS & FHR are taken at normal intervals for the woman's stage of labor. Report side effects (n/v, pruritus) & manage similarly to s/s occurring w/ epidural block. · Reduced effectiveness, indicated that the drug duration of action is ending or that mom is in late labor—other pain management methods may be needed for the rest of labor & birth.

Subarachnoid (Spinal) Block

· Subarachnoid (Spinal) Block: less commonly used · SAB may be done when quick CS birth is necessary & an epidural catheter is not in place. Typical SAB provides no pain relief during most of labor. · Practitioner injects local anesthetic, often w/ opioid (fentanyl) into the subarachnoid space in a single dose. Mom loses both sensory & motor function below the level of the SAB, w/ complete relief from painful contractions. Much lower dose of anesthetic is required bc less absorption into the surrounding tissues occurs compared w/ the epidural block. · Technique: spinal needle inserted into subarachnoid space, CSF in the needle hub indicated correct placement, then the local anesthetic combination is injected. The level of the anesthesia for both SAB & epidural blocks determined by the vL, concentration, & density of the drug injected. · Contraindications: mom's refusal, coagulation deficits, uncorrected hypovolemia, infection at insertion area, allergy, previous spinal injury (same as epidural). · Adverse effects & RN Care: -Bladder distension: from fluid preload & reduces sensation to urinate. Tx with catheterization. -Maternal hypotension: occurs from sympathetic blockade, but effects can be more severe than epidural. Tx is the same, but use a larger preload of IV solution. -Post-Spinal Headache: occurs w/ CSF leakage at side of dural puncture. It is postural, so it's worse when mom is upright & may disappear if she is lying flat. Incidence of spinal headache will be lower if a smaller gauge needle is used. Tx: bedrest w/ PO or IV fluids helps relieve the headache. A blood patch often gives dramatic, definitive relief—10-20mL of mom's blood is taken via sterile technique, then injected by anesthesia provider into the epidural space. The blood forms a gelatinous seal over the hole in the dura, stopping the CSF leak. This Tx can be repeated if needed.

Conductive Hearing Loss

-Conductive Hearing Loss: results from obstruction/disruption of sound wave transmission from outer to inner ear, obstructions can be a foreign body in the external canal, a retracted or bulging tympanic membrane, or fused bony ossicles. Also tumors, scar tissue, and overgrowth of soft bony tissue (otosclerosis) on the ossicles from previous middle ear surgery. -Disorders that cause conductive hearing loss are often corrected with minimal or no permanent damage. -Can benefit from amplification by hearing aid, or by removing the obstruction. -Causes: Cerumen, Foreign body, Perforation of the tympanic membrane, Edema, Infection of the external ear or middle ear (Otis Media), Tumor (neoplasm), Otosclerosis, stenosis -Assessment: Evidence of obstruction with otoscope, Abnormality in tympanic membrane, Speaking softly, Hearing best in a noisy environment. Equal loss of hearing at all sound frequencies. -Dx: Rinne test: air conduction greater than bone conduction. Weber test: lateralization to affected ear. -Hearing Aids: -In-canal: newest and smallest aid, patient needs good manual dexterity to insert. Can be used while exercising or talking on phone. -In-ear: placed in external ear, it is larger and easier to manipulate. It provides greater sound amplification. -Behind-ear: allows for finer adjustments of amplification, much easier to manipulate.

Hypo/Hypermagnesemia

-Hypomagnesemia: Any condition that impairs the GI and urinary systems can lead to a magnesium shortage. Usually 1 of 4 things: 1.poor dietary intake, 2.poor magnesium absorption by the GI tract, 3.excessive loss by the GI tract, or 4.loss from the urinary tract. Chronic alcoholics are at high risk because alcohol cause the urinary tract to excrete more magnesium and they usually have a poor diet. Malabsorption syndromes like ulcerative colitis, celiac, and Crohn's diminish magnesium absorption. Prolonged NG suctioning, prolonged diarrhea, or fistula drainage can also develop a deficiency. -S&S: irritation to the CNS (altered LOC, ataxia, confusion, delusions, emotional lability) Serious complications can be cardiac arrythmias, digoxin toxicity, laryngeal stridor, respiratory muscle weakness, and seizure. Magnesium and calcium mirror each other, so check for hypocalcemia using Chvostek's and Trousseau sign and watch for neuromuscular signs (tremors, twitching, tetany, hyperactive deep tendon reflexes. -Treatment: Nutrition/supplements or IV/IM injections for severe deficiencies. Before administration make sure they're able to urinate. -Hypermagnesemia: Addison's and adrenocortical deficiencies, as well as untreated DKA, can increase Magnesium. Hemodialysis with magnesium rich dialysate and TPN can increase levels. Meds that affect levels include antacids like Maalox, laxatives like milk of magnesia, and magnesium supplements taken to prevent constipation or to prepare for a colonoscopy. -S&S: Hypoactive deep tendon reflexes, weakness, leg extension or contractions of the quadricep muscle in front of thigh, patellar reflex absent=notify doc asap. · 3 mEq/L- feeling of warmth, flushed appearance, mild hypotension, N/V · 4 mEq/L- Diminished DTR, muscle weakness · 5 mEq/L- Somnolence, ECG changes, Bradycardia, worsening hypotension · 7 mEq/L- Loss of DTR · 8 mEq/L- Resp compromise · 12 mEq/L- Heart block, coma · 15 mEq/L- Resp arrest · 20 mEq/L- Cardiac arrest -Treatments: A loop diuretic will promote excretion, if emergent calcium gluconate might be ordered. Hemodialysis will be necessary, prepare for continuous cardiac monitoring and the need for mechanical ventilation to relieve resp depression.

Conservative therapy for CKD

Conservative therapy for CKD -Hypertension: BP < 130/80, Weight loss, Exercise, Avoid alcohol, Quit smoking, Diet changes, Medication -Hyperkalemia: restrict intake, kayexelate, temporary dialysis. -Renal Osteodystrophy: Limit daily phosphate, Administer phosphate binders, Supplement Vitamin D, Control hyperparathyroidism -Anemia: Meds to keep Hgb within normal range, ex. Epoetin Alfa (Epogen/ Procrit) (IV/SQ). Iron supplements--Do not take iron and calcium phosphate binders within 2hrs of each other, Folic acid, Blood transfusions prn

Daily Fluid Requirements by weight; Daily UO Requirements by Age

Daily Fluid Requirements by weight: · <10kg: 100ml/kg · 10-20kg: 1000mL + 50mL/kg for each additional kg between 10-20kg · >20kg: 1500ml + 20mL/kg for each additional kg over 20kg Minimum UO by age: · Infants & toddlers: >2-3mL/kg/hr · Preschoolers & school-age: 1-2mL/kg/hr · School-age & adolescence: 0.5-1mL/kg/hr

ESKD

ESKD, CRF: •Pathophysiology -Uremia: uremic frost, crystals/bumps on skin. Clean with warm H2O only! -Renal failure- only 25% nephrons remain •Diagnostic Criteria -GFR < 15 mL/min- reduced GRF damages remaining nephrons. Overworked nephrons become sclerotic/stiff, leads to their death. Severe renal insufficency Dx at GFR 15-29, ESKD <15. -Creatinine Clearance < 10ml/min, used to ID stage of CRF. -Urine specific gravity fixed at 1.010. UO contains protein, glucose, casts, RBCs, WBCs. -Serum: high BUN/Cr, high K, low pH/HCO3, low Hgb/Hct. Na/H20 imbalances, Ca/P imbalances (cant produce calcitrol to activate vitamin D) •Clinical Manifestations -Affects all body systems -Cardiovascular disease common causes death -RLS and neuropathy occur in early stages, restless leg syndrome.

Focused Assessment of ear/auditory

Focused Assessment of ear/auditory: -Assess the ability to hear high-frequency consonants (s, sh, f, th, and ch sounds) -Assess visible ear structures: --Position, size, and condition of the pinna; abnormalities include redness, excessive warmth, crusting, scaling, nodules, and pain. --Patency of the external canal; presence of cerumen or foreign bodies, edema, or inflammation --Condition of the tympanic membrane: intact, edema, fluid, inflammation --Mastoid process, which should be free from pain, redness and swelling -Assess functional ability, including: --Frequency of asking people to repeat statements, tilting head, leaning forward. --Withdrawal from social interactions or large groups --Shouting in conversation --Failing to respond when not looking in the direction of the sound --Answering questions incorrectly --Assess hearing aids (if present) for cracks, debris, proper fit

Functions of the eyes: provide clear images and vision

Functions of the eyes: provide clear images and vision -Refraction: bends light rays from the outside into the eye through curved surfaces and refractive media and finally to the retina. Each surface and media bend (refract) light differently to focus an image on the retina. Images fall on the retina inverted and reversed left to right. --Emmetropia is the perfect refraction of the eye in which light rays from a distant source are focused into a sharp image on the retina. --Hyperopia (farsightedness) occurs when the eye does not refract light enough. As a result, images actually converge behind the retina. Distant vision is normal, but near vision is poor. It is corrected with a convex lens in eyeglasses or contact lenses. --Myopia (nearsightedness) occurs when the eye over bends the light and images converge in front of the retina. Near vision is normal, but distance vision is poor. Myopia is corrected with a concave lens in eyeglasses or contact lenses. --Astigmatism is a refractive error caused by unevenly curved surfaces on or in the eye, especially the cornea. These uneven surfaces distort vision. -Pupilary Constriction: Miosis: pupil constriction. Mydriasis: pupil dilation. Controls the amount of light that enters the eye. If the level of light to one or both eyes is increased, both pupils constrict. The amount of constriction depends on lighting and retinas adaptability. Certain drugs can alter pupillary constriction. -Accommodation: process of maintaining a clear visual image when the gaze is shifted from a distant to a near object. The healthy eye can adjust its focus by changing the curve of the lens. -Convergence: ability to turn both eyes inward toward the nose at the same time. This action helps ensure that only a single image of close objects is seen.

Identify risk factors and develop and prioritize plan of care for patients with gastritis

Identify risk factors and develop and prioritize plan of care for patients with gastritis: Foods that can cause/exacerbate Gastritis, or cause gastric distress- alcohol, tobacco, caffeine, chocolate, mustard, pepper, and other strong or hot spices. -Acute- errosive gastritis Risk Factors: LT NSAID use- inhibit prostaglandin production in the mucosal barrier, thus inhibiting the protective factor of the stomach lining. Steroids, aldosterone antagonists, and SSRIs can contribute to gastroduodenal inflammation and ulceration. Alcohol, coffee, caffeine, stress and cigarette smoking. Local irritation from radiation therapy, ingestion of corrosive substances--including acids or alkalis (e.g., lye and drain cleaners). -Chronic gastritis risk factors: chronic local irritation and toxic effects caused by alcohol ingestion, radiation therapy, and smoking. Most common cause of Chronic gastritis type B is Heliobacter Pylori. Surgery of the pyloric sphincter (lower stomach sphincter), ex. pyloroplasty, can lead to gastritis by causing reflux of alkaline secretions into the stomach. Systemic disorders, ex. Crohn's disease, chronic kidney disease, graft-versus-host disease, and uremia. -Primary goal:prevent exacerbation/occurrence by limiting the causative factors. RN will educate on interventions to reduce the risk of gastritis before complications occur. -Treatment aimed at the following priorities: find the cause, then eliminate it. When you eliminate the cause the pain and discomfort will subside. If hemorrhage or GI bleed is present, a transfusion or IV fluids may be given. For severe bleeding/ulceration surgery may be indicated: partial gastrectomy, pyloroplasty, and/or vagotomy. For chronic treat the underlying disease process if it exists. Educate on proper diet, stress reduction, meds, avoid NSAIDS, avoid alcohol report S/S GI bleed or GERD.

Peritoneal Dialysis

PD in CKD: - 4x/day, 7 days per week. Takes 36-48hrs to accomplish what HD does in 6-8hrs. •Goal: to remove toxic substances and metabolic wastes and reestablish normal fluid and electrolyte balance. •The peritoneal membrane serves as the semi permeable membrane •Sterile dialysate (hypertonic solution) is placed into the peritoneal cavity through an abdominal catheter •Diffusion and osmosis occur (same as HD) -For young children (sm BVs), scheduling preference, Elderly/fragile (CVD, cant tolerate fluid shift), when no fistula/shunt is available (when NOT emergent, or fistula is maturing) -Advantages: Independence & mobility, Minimizes symptoms of rapid fluid shift, Fewer dietary restrictions--More protein, Peritoneal is simpler than HD, Heparin not required for long-term -Disadvantages: Time, Less effective in the catabolic patient --Inflow/Fill: solution, usually 2L, infused over 10min. Stay still, plan accordingly! Disconnecting/reconnecting increases risk of infection! --Dwell/Equilibration: diffusion and osmosis, dwells for 20min-8hrs --Drain: fluid removed from peritoneal cavity, takes 15-30min. Reposition to help drain, watch outflow for S/S infection. •Complications: Peritonitis (cloudy drainage, ABD pain/distension), Leakage, Bleeding, Blockage •Long-term complications: Hypertriglyceridemia, Hernia (increased ABD pressure)

Patterns of G&D

Patterns of G&D: o 1st direction of growth: cephalocaudal, from head to lower extremities (toe). Structures & functions in the head develop before the lower parts. Occurs in part bc of the myelinization of nerves in the brain, that later spreads downward. Ex. Baby raises its head before it can sit, & sits before it can walk. o 2nd aspect of directional growth: proximodistal, prom proximal to distal. Or from the center outward, midline to periphery. Ex. Trachea is center of respiratory tree, formed by 24 days gestation—bronchi, bronchioles, & alveoli G&D by branching out in fetal/infant life; alveoli are the most distal, continue to G&D till middle childhood. o General to specific: maturity causes the activities to be less general & more focused. Ex. Baby's pain response is general crying & flailing (whole body response), as child matures pain response is more specific to the local area that hurts (ABD pain = guarding ABD). o From simple to complex: easily observed in language development. Toddler uses simple sentences, noun + verb. By age 5yrs, construct detailed stories using complex modifiers. o Rate of G&D is not constant: spurts occur often before a developmental task needs to be mastered. o Wide variations w/in normal limits: mastery of a task is not static or permanent, developmental stages don't always correlate w/ chronological age. Child may master a task, then regress when ill or stressed. Struggle w/ the task can occur throughout life, even when more advanced levels are achieved. o Critical/Sensitive Periods: blocks of time when the child is ready to master a task; these periods exist after birth, for optimal G&D. Mastery can occur outside of the period, but some tasks may be learned easier during the period. Ex. Critical period for walking is the later part of the 1st yr & beginning of the 2nd yr, driven by an urge to walk & are prideful when they succeed. Kids who are immobilized for a condition at 10-18mo can learn to walk but may have more difficulty. Injury, illness, & malnutrition can also affect these periods. · Although heredity determines each individual growth rate, the normal pace of growth for all children falls into four distinct patterns: 1. A rapid pace from birth to 2 years 2. A slower pace from 2 years to puberty 3. A rapid pace from puberty to approximately 15 years 4. A sharp decline from 16 years to approximately 24 years, when full adult size is reached. · Directional Patterns of Growth and Development: o Growth spurts alternate with periods of slow or stagnant growth. Cephalocaudal (head to toe), head grows fastest in the fetus, then the trunk in the infant, then the legs in the child. Resulting in the baby being able to raise head, then sit, & finally walk. Proximodistal (center outward), 1st trachea develops in the embryo, then the tree branches outward in the fetus & infant. Motor control of the arms, then control of the hands, then control of the fingers.

PUD complications, treatment: drugs, diet, surgery

PUD complications, treatment: drugs, diet, surgery -Ulcers: most common complication from ulcer is bleeding—hemataemisis, melena, hemorrhage, perforation (life-threat-peritonitis), pyloric constriction, intractable dz (interfere with ADLs bc not responding to treatment). -Treatment, conservative: Drug Therapy: (1) pain relief (2) eliminate H. pylori (3) heal ulcerations (4) prevent recurrence -Opiates: temporary for pain, watch for CNS depression, addiction. -PPI-triple therapy: PPI, plus 2 antibiotics for 10-14 days (lansoprazole + metronidazole and tetracycline) -Ranitidine (zantac), Tagamet: to avoid recurrence of ulcers -Bismuth: for patients with penicillin allergy - prevents the bacteria to bind to the mucosal lining. Don't mix with aspirin, cause aspirin OD. May cause tongue/ stools to be black, is temporary and harmless. --PPI capsules can be opened and mixed in apple or orange juice, or given through feeding tube. Teach older adults to recognize PUD SS. Teach pt to tell HCP if they are taking clopidogrel, omeprazole will reduce its effect. PPI should be tapered. -Surgery: MIS via laparoscopy for chronic GU or bleed. Partial stomach removal (subtotal gastrectomy), pyloroplasty (to open the pylorus), and/or a vagotomy (vagus nerve cutting) to control acid secretion. Post-op assess Bowel sounds--paralytic ileus, meas. girth—perforation check, coughing/hiccups could pop the site. NGT placed so check patency, disconnect from suction—check tube every 4hrs or per hospital policy, GRV check >30ml, stop feeding because they have delayed gastric feeding, hold for 30min, reassess. Reglin will help. -Nutrition: -Food may decrease acid itself for 30-60min, but can be followed by rebound. Teach pt to avoid caffeine, both caffeinated and decaffeinated coffees. Acute phase: A bland, non irritant diet is recommended, eat six smaller meals may help, bed time snacks are avoided. -Teach the patient to exclude any foods that cause discomfort. Bedtime snacks are avoided. Avoid alcohol and tobacco.

Perform a focused assessment of the eye incorporating information about genetic risk & environmental risk

Perform a focused assessment of the eye incorporating information about genetic risk & environmental risk: -Age: increases risk of cataract and glaucoma. Presbyopia--beginning in early 40s. -Gender: men more likely to have retinal detachments. Women more likely to have dry-eye syndromes. -Occupation/leisure: Chronic exposure to UV light causes photophobia and cataract formation. Increased computer use leads to eyestrain. Machine operators have increase risk of injury (high speed particles). Trauma from sports can damage eye or brain structures for vision. -Fam Hx: screen for genetic diseases. -Social: Smoking/vaping can cause burning/watering of eyes from formaldehyde in air. -Systemic conditions and drugs effect eyes: -DM, HTN, Lupus, Sarcoidosis, Thyroid problems, HIV-III, Cardiac disease, Multiple sclerosis, Pregnancy -Antihistamine, Decongestants, Antibiotics, Opioids, Anticholinergics, Cholinergic agonist, Adrenergic agonists, Beta blockers, Oral contraceptives, Chemotherapy agents, Corticosteroids -Occular effects from drugs: itching, foreign body sensation, redness, tearing, photophobia, cataracts and glaucoma.

Gastritis

Perform focused physical assessment including laboratory values for patients with gastritis: -Gastritis: inflammation of gastric mucosa (stomach lining). Prostaglandins provide a protective barrier around the stomach, which prevents it from digesting itself. If there is a break in this barrier, the stomach begins to metabolize its lining (autodigestion). Can be erosive (causes ulcers) or nonerosive. -Hydrochloric acid destroys the stomach lining and the small BVs of the stomach, called "back-diffusion". Causing edema, bleeding and erosion of the stomach lining. S/S: nausea, anorexia, sour taste in mouth, belching, cramping, pain. -Acute: "erosive" can occur as a result of the mucosa inflammation—response after being exposed to local irritants. S/S Pain mild to severe, rapid onset of epigastric pain and dyspepsia (heartburn), stress ulcers. Gastric bleeding may occur (acute hemorage lesions), causing hematemesis or melena. Gastric hemorrhage is an emergency! Can quickly cause Hypovolemic shock. --Causes: LT NSAID use, Alcohol, coffee, and caffeine consumption. Stress and Cigarette smoking, Steroid, aldosterone antagonists and SSRI. Gastritis or food poisoning from endotoxins (ex. staphylococcal endotoxin), has an abrupt onset. Severe N/V often occurs within 5 hours of ingestion of contaminated food. S/S few are present unless there is an ulcer. Patient may complain of N/V, or upper ABD discomfort. Pain may be relieved with food. Periodic epigastric pain may occur after a meal. Some patients have anorexia. Intolerance of fatty and spicy foods. Pernicious anemia may result. -Chronic: is also inflammation of the mucosal lining but it appears patchy and spread out. As this disease progresses, the walls and the lining thins out and atrophy--parietal cells gone, no intrinsic factor produced, pernicious anemia results., inability to absorb vitamin b12 (Cyanocobalamin). High risk of gastric cancer. --Causes: Chronic gastritis type A: Autoimmune, Fundus/Body, w/ pernicious anemia.. Need lifelong B12 injections. Chronic gastrits type B: Infectious, body/antrum, Heliobacter Pylori (most common). E-coli is also a common cause. Chronic irritation from alcohol or smoking. Surgeries that involve pyloric sphincter--reflux alk., radiation therapy, injection of corrosive substances. Systemic disorders: Crohn's disease, Graft-versus-host disease, Uremia -Dx: EGD with a biopsy and cytology to rule out cancer. Blood tests-H-pylori or infecting agent are the cause. Tissue samples with rapid urease testing can also detect H-pylori. FOBT-shows blood in stool(avoid aspirin/NSAIDs, vitamin C, iron, and red meat for 48 hours before giving a stool specimen--3 samples/3 days). CBC-show anemia: men Hgb <13.5g/dL, women <12.0 g/dL. --Patient needs to stop taking antacids & PPIs for 1 week with the EGD/Biopsy, and the tissue sample for H-pylori. -Interventions: watchout for S/S GI bleed, monitor CBCs. -Meds: Sucralfate, Antacids, Aluminum Hydroxide combined with magnesium hydroxide, H2I, PPI, Antibiotics. -Diet: Avoid caffeine or anything that has high acid content, Tomato products, Citrus juices, Food that are heavily seasoned with strong or hot spices, Bell peppers, Onions, Avoid tobacco and alcohol.

Routes of Med Admin in Children

Routes of Med Admin in Children: o Oral medications - liquid is best for young kids; tablet, capsule, powder. o Per os = by mouth; used by older HCPs, means PO. o G-tube administration - 1st check placement; HCP order will specifically say GT route. o Most widely used but least reliable methods—bc gastric emptying time, GI motility, & stomach acidity. Before admin assess gag reflex & swallow. o Less predictable due to loss to spillage, leaking or spitting out—can't determine how much of the med the kid took. Do not crush time released capsule or enteric coated tablets. o Watch your dose - doctors order in mg but we give in mL—do med math; Only use mL with oral (orange) dosing syringe (babies dose <5mL)—to ensure an oral med isn't given as an IV; dose >5 mL should be put in a medicine cup, holds up to 30mL (1oz). o Avoid putting medicine in necessary food, like formula bc if it changes the taste, they won't drink it anymore; can mix in a small amount of applesauce or pudding in a med cup—if portion is too big & they don't eat it all, then they don't get the full dose. o Infant - put inside of cheek slowly as the baby sucks; can do while sucking on pacifier. o Toddlers & Preschoolers can use oral syringe • Injections: o Intramuscular - rapidly absorbed; use of EMLA- eutectic mixture of local anesthetic, put on 1hr before so it's not used in the ED. 2 methods of holding a child are supine (x2 assist) or sitting on parents lap; at the vastus lateralis is preferred. Insert - bevel up with dart like motion; After removing needle, do not massage. Use dry gauze, not alcohol. o Subcutaneous: Given in the connective tissue below the dermal layer. For meds that provide sustained effect—ex. Heparin, insulin. Give only in healthy tissue—avoid bruises, burns, scapes; Admin in outer aspects of upper arms, anterior aspect of thighs, abdomen (>2in around umbilicus). o Intradermal: Enters the dermis layer of the skin which is just below the epidermis. Admin in inner aspect of the forearm or on the upper back. Used for allergy testing or TB screening, PPD. Inject slowly and form a bleb or wheal.

Surgery for Hyperthyroidism

Surgery for Hyperthyroidism: Removal all/part of thyroid, when other Tx not working, & if goiter is compressing esophagus/trachea. -Pre-Op: Tx w/ thionamide first to have near-normal thyroid function (euthyroid) before thyroid surgery. Iodine prep also used to decrease thyroid size & vascularity, reducing the risk for hemorrhage & storm. HTN, dysrhythmias, and tachycardia must be controlled before surgery. May need to follow a high-protein, high-carbohydrate diet for days-weeks before surgery. -Teach: deep-breathing exercises. Importance of supporting the neck when coughing/moving by placing both hands behind the neck to reduce strain on the incision. Explain the surgery and the care after surgery to the patient. Remind him or her that a drain and a dressing may be in place after surgery. -Op: Thyroidectomies- usually MIS. The parathyroid glands & laryngeal nerves are avoided to reduce the risk for complications & injury. Subtotal thyroidectomy- remaining thyroid tissues are sutured to the trachea. Total thyroidectomy- entire thyroid gland is removed, but the parathyroid glands are left with an intact blood supply to prevent causing hypoparathyroidism. -Post-Op: RN Priorities-maintain airway & adequate ventilation because of proximity to parathyroid, frequently assess for hypocalcemia, assess for drainage (Quantity/Quality), stridor indicates obstruction. -Monitoring for complications is the most important nursing action after thyroid surgery (hemorrhage 1st 24hrs post). Monitor VS every 15 minutes until stable, then every 30 minutes. Assess for discomfort & give drugs for pain control PRN. Use pillows to support the head and neck. Place the patient, while he or she is awake, in a semi-Fowler position. Avoid positions that cause neck extension. Help the patient deep-breathe every 30 minutes to 1 hour. Suction oral and tracheal secretions when necessary. -Remain alert to the potential for complications and identify s/s early. Hemorrhage may be seen as bleeding at the incision site or as respiratory distress caused by tracheal compression. Mod amount of serosanguineous drainage is normal. Respiratory distress and reduced gas exchange can result from swelling, tetany, or damage to the laryngeal nerve, resulting in spasms. Laryngeal stridor is heard in acute respiratory obstruction. Keep emergency tracheostomy equipment in the patient's room. Check that oxygen and suctioning equipment are nearby and in working order. HypoCa & tetany may occur if the parathyroid glands compromised, causing low PTH- assess for S/S of hypocalcemia. Ca gluconate or Ca chloride for IV use should be available in an emergency situation. Laryngeal nerve damage- problem results in hoarseness and a weak voice. Assess the patient's voice at 2-hour intervals and document any changes. Reassure the patient that hoarseness is usually temporary.

Tx og Hyperglycemia: DKA & HHS

Tx of DKA and HHS are the same: --DKA in Type 1 DM; HHS more likely in Type 2: -Glucose: Monitor for DKA/document to evaluate Tx: first assess the airway, LOC, hydration status, electrolytes, and blood glucose level. Check the patient's BP, pulse, and RR every 15min until stable. Record UO, temp., and MS every hour. When a CVAD is present, assess central venous pressure every 30min or as prescribed. After treatment starts and these values are stable, monitor and record VS every 4 hours. Use blood glucose values to assess therapy and determine when to switch from saline to dextrose-containing solutions. Insulin therapy is used to lower serum glucose by about 50 to 75 mg/dL/hr. Unless the episode of DKA is mild, regular insulin by continuous IV is the usual management. An initial IV bolus dose is given, followed by an IV continuous infusion. Continuous insulin infusion is used because insulin half-life is short and subcutaneous insulin has a delayed onset of action. Subcu insulin is started when the patient can take PO fluids and ketosis has stopped. DKA is considered resolved when blood glucose is less than 200 mg/mL along with a serum HCO3 level >18 mEq/L, venous pH is >7.30, and anion gap is <12 mEq/L. Assess therapy effectiveness by monitoring BS levels and electrolyte levels. -F&E: Assess for acute wt loss, thirst, decreased skin turgor, dry mucous membranes, and oliguria with a high SG. Assess for weak and rapid pulse, flat neck veins, increased temp, decreased central venous pressure, muscle weakness, postural hypotension, and cool, clammy, and pale skin to determine if the patient is at risk for dehydration. Fluid Tx & return glucose to baseline level with IV insulin—done slowly over 36-72hrs. Return of baseline cognitive function is evidence that the tx is working. Priority for fluid Tx is to maintain perfusion to vital organs: Typically initial infusion rates are 15-20 mL/kg/hr during the 1st hour. 2nd priority is to replace total body fluids more slowly, hypotonic fluids are infused at 4-14 mL/kg/hr after the initial fluid bolus. When blood glucose levels reach 250 mg/dL, give 5% dextrose in 0.45% saline. This solution helps prevent hypoglycemia and cerebral edema, which can occur when serum osmolarity declines too rapidly. 1st 24hrs of Tx: patient needs enough fluids to replace the actual vL lost, as well as any ongoing losses, and the total may be as much as 6-10 L. Assess cardiac, kidney, and MS to avoid FVO. Watch for symptoms of HF &pulmonary edema. Assess the status of fluid replacement by monitoring BP, I&O, and changes in daily wt. -Electrolytes: Hyperglycemia causes hyperkalemia—when using insulin and other drugs to tx hyperkalemia, its possible to lower the K so much that it causes hypokalemia. Be aware of this, monitor K levels, and tx very slowly. Prevent hypokalemia: K replacement is initiated after serum levels fall below normal. Assess for signs of hypokalemia: fatigue, malaise, confusion, muscle weakness, shallow respirations, ABD distention or paralytic ileus, hypotension, and weak pulse. An ECG shows conduction changes related to alterations in potassium. Hypokalemia is a common cause of death in the treatment of DKA. Action Alert: Before giving IV K-containing solutions, ensure that UO >30 mL/hr.

Describe the ongoing assessment of maternal progress during the first, second, third, and fourth stages of labor.

o Stages of Labor: patterns/responses vary individually amongst women; each stage has qualities that differentiate it from the other ones. Regional anesthetics (epidural block) are used to modify maternal behaviors. Labor that is induced or augmented often differs from spontaneous labor. -First stage ("stage of dilation"): begins w/ onset of true labor contractions, mom goes from 0-10cm dilated, full effacement. Baby moves down. Longest phase. --Latent phase: 7.5-8.5hrs; 0-3 or 5cm, may take time & move slowly, esp. if 1st baby. Effacement & subtle fetal position changes occur, prep for the more active stages. Mom is usually sociable & excited. Contractions mild & infrequent, then moderate every 5min for 30-40s. --Active phase: 8-10hrs; at approx. 4-6cm dilation occurs more rapidly. Effacement & dilation are completed, internal rotation of the baby occurs as it descends into the pelvis during active labor. Discomfort increases & pace picks up. Contractions occur mod-strong, every 2-3min for 40-60s. At 5cm dilated, we offer pain meds, if admin too early it can slow the contractions & increase the length of the latent phase. --Transition phase: 3.5hrs; final 7 or 8-10cm, complete effacement & baby moves down. Intense faster contractions of fetal decent & final dilation. Phase is shorter, but contractions are longer & last 60-90s, and happen every 1 ½- 2min. Bloody show increases w/ final dilation, short/intense phase of very strong contractions. Mom may be irritable, anxious, have a serious inward focus, leg tremors, & n/v. -Second stage: 50min; expulsion at 10cm, mom pushes out baby when completely dilated. We don't want her to push until the cervix is moved completely out of the way, otherwise she could tear the cervix and hemorrhage. Contractions strong, every 2-3min for 40-60s. May be less intense than transition, w/ a pause right before 2nd stage begins. -Third stage: 5-10min, unassisted up to 30min; delivery of the placenta. Starts w/ birth of baby, ends with the delivery of the placenta. Uterus is firmly contracted. -Fourth stage: 1-4hrs after birth; physical recovery. Delivery to first hrs of birth but can last up to 6wks to return to normal pre-pregnancy state. Mom goes to get follow-up visits at the doctors. Uterus is firmly contracted. -Normal Labor Progress: characterized by consistent progression of uterine contractions, cervical dilation and effacement, fetal descent. Fetus is the more vulnerable of the maternal-fetal pair. Normal FHR at term average is 110-160 beats per minute.

Infections During Pregnancy

· Infections During Pregnancy o TORCH: Toxoplasmosis, Other infections (hepatitis), Rubella, Cytomegalovirus, & Herpes simplex. These infections negatively affect pregnant women. § STIs: affect fertility & pregnancy. Chlamydia, Gonorrhea, Syphilis can be Tx w/ antibiotics, but viral infections pose a great risk. o Viral: § Cytomegalovirus: herpes group; widespread fetal effects & can lead to mortality. If baby survives, 20-30% will have complications—leading cause of healing-loss in children. § Rubella: German measles; generally mild for mom, but can cross placenta & effect baby, in 1stT poses greatest risk. Congenital Rubella Syndrome: hearing-loss, intellectual disability, cataracts, cardiac defects, microcephaly, & IUGR. Infected child can infect other children. § Varicella-zoster (chickenpox): herpes group; transmitted by direct contact or via respiratory tract. Results are similar to Rubella + risk for limb hypoplasia, cutaneous scaring, & contact/airborne precautions must be maintained on mom & baby. § Herpes virus: vertical transmission of ROM during birth if an active lesion is present. CS recommended, ensure moms privacy bc partner may not know she has herpes. May be skin to mouth & cause encephalitis, has a high mortality rate, survivors are usually severely impaired. § Parvovirus: when during pregnancy, fetal death my result from failure of fetal RBC production, severe anemia, & high drops (general edema of fetus). § Hepatitis B: incidence decreased w/ screening; infection during pregnancy associated w/ increased incidence of premature birth, low birth weight, & neonatal death. Vaccine recommended for newborns, admin before D/C from hospital. o Nonviral infections: § Toxoplasmosis: protozoal infection from toxoplasmogondi; transmitted by organisms in raw or undercooked meat, infected cat feces—can cross placental barrier if acquired during pregnancy. Most severe effects in 1stT: hydrocephaly, microcephaly, & cranial calcifications. § Group B streptococcus: NORMAL flora that can cause sepsis, pneumonia, & meningitis in the newborn. Group-B testing of vaginal canal for all pregnancy women at 35-37wks, if positive antibiotics given intrapartum (in labor) a bolus & then every 4hrs. To ensure they have fought of the strep, they need that initial dose & at least 1 other dose before birth. Mom who is positive, get IV started & antibiotics right away. o CS: Group beta streptococcus (GBS+) status is unknown, therefore, she is immediately administered antibiotic prophylactically as part of the CDC Guidelines for GBS. The healthcare provider (HCP) prescribes the client 2 grams of ampicillin initially, then 1 gram every four hours until delivery. 1st assess for Hx of penicillin allergy. § Tuberculosis: in pregnancy is rare; perinatal infection can occur, causing fetal failure to thrive, lethargy, respiratory distress, fever, enlarged spleen, enlarged liver & lymph nodes. Mom may be given meds during pregnancy & PP, if TB is active need to be on respiratory isolation. o HIV During Pregnancy: § HIV: a retrovirus that gradually causes a fall in the effectiveness of the maternal immunity § Maternal Tx with zidovudine (ZDV) along with other antiviral medications can substantially reduce infection of the fetus. § The newborn should be started on the ZDV 6-12 hours after birth. § 98% of HIV moms w/ antiviral drug Tx give birth to HIV negative babies. Continue drug Tx to allow for breast feeding & prevent transmission during pregnancy.

Initial Antepartum Visit: Hx/OB Hx, Gravida/Para, GPTAL, EDD, Nagels Rule

· Initial Antepartum Visit: period before pregnancy, from conception up until pregnancy. All women should have a preconception visit to the HCP to ensure they are healthy before conceiving. -History/ Obstetric history: -Gravida: woman who is or has been pregnant, regardless of duration. ---Primigravida: pregnant for the first time ---Multigravida: pregnant more than once -Para: number of pregnancies that ended at 20 or more weeks--20 is considered a viable fetus, infant born alive or still born. ---Nullipara: never completed a pregnancy >20 weeks, because was never pregnant or had any type of abortion. ---Primipara: delivered 1 pregnancy at 20+ weeks ---Multipara: 2+ pregnancies at 20+ weeks ---*Same rules for multiple fetuses* -GTPAL: gravida, term pregnancies, preterm pregnancies, abortion-spontaneous or elected-before 20 weeks, living children. -Menstrual Hx and Estimated date of delivery (EDD): EDD is based on the first day of the last normal menstrual period (LNMP). -Average pregnancy duration is 40 weeks, or 280 days -Nägele's rule: subtract 3 months from the 1st day of LNMP, and add 7 days. -ex. June 5th - 3 months = March 5th + 7 days = March 12th!!! -Need a full medical & surgical Hx of the mom, then a Hx of the family & partner—because of chromosomal issues, and a psycho-social Hx to ensure the baby can be cared for once brought home. -Physical examination: · Potential risk factors: Once all the above is done you need to establish if they are a high risk pregnancy. --Demographic: <16yrs old or >35yrs. Low SES, of non-white race, multiparity (mult. Fetuses w/in pregnancy) --Social-personal: low weight or overweight, <5ft tall, smoke or use alcohol. --OB: previous baby of >4,000g or 8.8lbs, previous pre-term birth, previous fetal/neonatal death, Rh sensitivity (Rh-, give Rhogam) --Existing Medical Conditions: DM, Hyper or hypothyroidism, cardiac or renal disease, recurrent infections (inhibit pregnancy or cause defects). -Baseline data: Height & weight. VS & significant changes should be evaluated further. Measure BP in same arm, same position—each antepartum visit. -Plan of care: Education on self-care, nutrition, talk about the change's pregnancy brings to the body, don't take any meds w/o talking to HCP, and when to return for future appts.

Puerperal Infection

· Puerperal Infection: bacterial infection after birth; postpartum infection; temp. 38C+ (100.4F) after first 24hrs following birth, & occurs on 2+ of first 10 days PP. -S/S fever, chills, pain or redness of wounds, purulent drainage, edges not approximated, tachycardia, uterine subinvolution (not contracting the way it should), abnormal duration of lochia—rubra for too long, foul odor of lochia, elevated WBCs, frequency or urgency of urination, dysuria or hematuria (not associated w/ lochia), suprapubic pain, localized areas of warmth/redness or tenderness (includes breasts), body aches, or general malaise. o Endometritis: caused by normal flora of vagina & cervix. S/S Temp. 38C+, chills, malaise, anorexia, ABD pain & cramp, tender uterus, purulent/foul lochia; tachycardia & subinvolution; s/s usually occur w/in 36hrs of birth. WBCs 15,000-30,000 continuing beyond first few days PP. Risks: CS, extended labor or ROM w/o prophylactic ABs. Tx: IV ABs; broad-spectrum; continued till afebrile for 24hrs. o Wound infection: CS incision, episiotomy, laceration= portal of entry. S/S pain, edema, warmth, redness, edges pull apart. Un-Tx leads to general s/s: fever, malaise. Risks: obese, DM, hemorrhage, anemia, chorioamnionitis, steroid Tx, multiple vag-exams. Tx: incision & drainage; C&S on exudate; broad-spectrum ABs until results come back; analgesics, warm-compresses, & sitz baths; surgical debridement for necrotizing fasciitis. o Urinary tract infection: bladder & urethra trauma during L&D; CAUTI; PP bladder & urethra are hypotonic, w/ stasis & retention; residual & reflux of urine occur w/ voiding. S/S on 1-2 PP day; dysuria, urgency, frequency, suprapubic pain, hematuria; low fever may be only s/s. Pyelonephritis on 3-4 PP day; chills, spiking fever, CVA tenderness, flank pain, N/V; can cause permanent damage if Un-Tx. Tx: antibiotics, GU analgesics (Pyridium), hydration 2500-3000mL/day. o Mastitis: breast infection; usually just 1; occurs 2-4wks after birth, can occur at any time during breastfeeding. Break in skin allows bacteria to enter (mom's skin or baby's mouth). Soreness/pain of nipple, may cause insufficient emptying of breast; mastitis usually preceded by engorgement & milk stasis. S/S flu-like, fatigue, muscle aches, temp. 39C+ (102.2), chills, malaise, headache; local lump or wedge shape of pain, redness, heat, & enlarged axillary nodes; Un-Tx can lead to abscess. Tx: ABs & continued breast emptying (feed or pump) to prevent abscess; abscess drained w/ surgery + ABs; ABs resolve in 24-48hrs but continued for 7-10 days; moist heat or ice packs, breast support, bedrest, analgesics. o Tx postpartum infection: antibiotics, depends on location & type of organism—must do a C&S of the site we think is infected. May start w/ broad-spectrum AB & as culture comes back change to a specific AB.

Spontaneous Abortion

· Spontaneous Abortion: "miscarriage"; loss of fetus before it is viable (<20wks or <500g), most common in first 12wks. Leading cause of pregnancy loss; most commonly due to chromosomal abnormalities that are incompatible w/ life. Associated w/ bleeding, prevent complications—hypovolemic shock & infection, provide emotional support for grieving. o Types of Spontaneous Abortion: RN must teach the warning s/s of abortion or complications to mom, & when to call the HCP. Any type of bleeding is a warning, seek help right away. Fetal death occurs before s/s appear. § Threatened: bleeding in 1st half of pregnancy, spotting or light bleeding can be brief or last weeks. Followed by cramping, backache, pelvic pressure, cervix is closed. Beta-hCG will rise & uterus size will increase w/ embryonic growth if fetus is viable. § Inevitable (cant be stopped): membranes ruptures & cervix dilatates, active bleeding may be present & heavy. Products of conception usually naturally expelled, if not a D&C is performed. § Incomplete: some but not all the products of conception are expelled from uterus; placenta or parts of it may remain in place. Active bleeding w/ severe cramping, products may be trapped in the uterus or vaginal canal. Retained tissue prevents contraction, leading to profuse bleeding—ensure CV stability is #1 priority. Later pregnancy will need D&E w/ vacuum or curettage, then oxytocin IV or methergine IM. >14wks increases risk of bleeding, so oxytocin or prostaglandins may be used alone. § Complete: all the products of conception are expelled from uterus; cervix closes & bleeding/contractions abate at the end. No Tx is necessary unless she is bleeding or has an infection. Tell her to rest, watch for bleeding, pain, & fever. No vaginal sex till follow-up & may want to discuss contraceptives. § Missed: fetus dies in 1st half of pregnancy but is retained in the uterus, s/s of early pregnancy stop & uterus shrinks from absorption/maceration; infection or DIC may result, surgery may be indicated—dilatation & vacuum curettage(D&C)—where they dilate the cervix & scrape lining of uterus, to remove the retained products. § Recurrent: "habitual abortion" when 3+ consecutive spontaneous abortions occur. Cause may be chromosomal or genetic abnormalities, STIs, systemic dz, or anomalies of mom's reproductive tract. Also inadequate luteal phase w/ insufficient progesterone & immune factors—increased sharing of HLA by sperm/ovum, causes mom to not make blocking antibodies to protect the fetus. Assess reproductive system via US, then genetic counseling. Other: if infected Tx w/ antimicrobials, or give HRT for imbalances. · Incompetent Cervix: or cervical insufficiency. Possible cause of recurrent. Anatomic defect that causes painless dilation of the cervix in 2ndT as the fetus grows. o Cerclage: sutures/stitching placed, go around in circle (ex. Backpack w/ drawstring). Keeps the cervix closed. Removed near term (37-38 wks) if having vaginal delivery, to prevent ripping in labor. Left in for CS.

Care of Patient in sickle cell crisis

Care of Patient in sickle cell crisis: -Administer oxygen. -Administer prescribed pain medication. -Hydrate the patient with normal saline IV and with beverages of choice (without caffeine) orally. -Remove any constrictive clothing. -Encourage the patient to keep extremities extended to promote venous return. -Do not raise the knee position of the bed. -Elevate the HOB no more than 30 degrees. -Keep room temperature at or above 72°F (22.2°C). -Avoid taking BP with a standard or automatic external arm cuff. -Check circulation in extremities every hour: -Pulse oximetry of fingers and toes -Peripheral pulses -Capillary refill

Normal Vital signs by Age: Newborn, 2yrs, 4yrs, 10yrs, 16yrs

Normal Vital signs by Age: • Newborn: 97.7-99.1F axillary (36.5-37.3C), HR 100-150, RR 35-55, BP 65-95/30-60 • 2yrs: 97.5-98.6F axillary (36.4-37C), HR 70-110, RR 20-30, Girls BP 85-91/43-47; Boys BP 84-92/39-44 • 4yrs: 97.5-98.6F axillary (36.4-37C), HR 65-110, RR 20-25, Girls BP 88-94/50-54; Boys BP 88-97/47-52 • 10yrs: 97.5-98.6F oral (36.4-37C), HR 60-95, RR 14-22, Girls BP 98-105/59-62; Boys 97-106/58-63 • 16yrs: 97.5-98.6F axillary (36.4-37C), HR 55-85, RR 12-18, Girls BP 108-114/64-68; Boys BP 111-120/63-67

Nutrient restrictions for severe CKD

Nutrient restrictions for severe CKD: -Chronic Uremia- -Protein: 0.55-0.60 g/kg/day -Fluid: Depends on urine output but may be as high as 1500-3000 mL/day -K: 60-70 mEq or mmol daily -Na: 1-3 g/day -P: 700 mg/day -With HD- -Protein: 1.0-1.5 g/kg/day -Fluid: 500-700 mL/day plus amount of urine output -K: 70 mEq or mmol daily -Na: 2-4 g/day -P: 700 mg/day -With PD- -Protein: 1.2-1.5 g/kg/day -Fluid: Restriction based on fluid weight gain and blood pressure -K: Usually no restriction -Na: Restriction based on fluid weight gain and blood pressure -P: 800 mg/day

Risk Factors for Cholecystitis

Risk Factors for Cholecystitis: -Women of all ages (risk of calculi increases with aging) -American Indian, Mexican American, or Caucasian -Obesity- major risk factor, esp. in women -Rapid weight loss or prolonged fasting; low-fat diet -Increased serum cholesterol and lipids -Women on hormone replacement therapy (HRT) -Pregnancy and drugs such as HRT and birth control pills alter hormone levels and delay muscular contraction of the gallbladder, decreasing the rate of bile emptying. The incidence is higher in women who have had multiple pregnancies. -Patient most at risk for acute cholecystitis and gallstones by the four Fs: Female, Forty, Fat, and Fertile. Still, it often occurs in younger and older women and in those who are thin. -Cholesterol-lowering drugs -Family history of gallstones—genetics, or family lifestyle (eating habits, sedentary life) -Prolonged total parenteral nutrition -Crohn's disease, Gastric bypass surgery, Sickle cell disease -Glucose intolerance/diabetes mellitus type 2 -Pregnancy -Genetic factors—family genetics passed on and interacts with the environment, genes to make and secrete more cholesterol. -Highest frequency of cholelithiasis: American Indian and Mexican-American populations -Incidence/prevalence: Cholecystitis and cholelithiasis most often occur in affluent countries throughout the world. The incidence is 60% to 70% in American Indians and 15% in Caucasian adults.

S/S of Hyperglycemia vs Hypoglycemia

-Main S/S of hyperglycemia: All patients with diabetes have this. Polyuria- excessive urination, because the body needs to excrete the excess water intake. Polydipsia- excessive thirst, because the body needs more water to dilute the glucose. Polyphagia- excessive hunger, because glucose cant enter the cells, the body thinks its starving. Polyphagia is more common with hypoglycemia than hyper. -Causes: too much food, too little insulin, stress, or certain meds. -Other S/S: skin is warm, dry, vasodilated. Dehydration present. Respiratory- rapid, deep; Kussmaul type; acetone odor (rotten "fruity" odor) to breath. MS- varies from alert to stuporous, obtunded, or frank coma. Acidosis; hypercapnia; ABD cramps, N/V. Dehydration: decreased neck vein filling, orthostatic hypotension, tachycardia, poor skin turgor. BS >250mg/dL. Ketones in urine or blood. -Main S/S of hypoglycemia: skin is cool, clammy, "sweaty". Dehydration absent. Respiratory: No particular or consistent change. MS- Anxious, nervous, irritable, mental confusion, seizures, coma. Weakness, a double vision, blurred vision, hunger, tachycardia, palpitations. BS <70mg/dL. No ketones in urine or blood.

SCD: s/s & Tx

-SCD: RBC is a sickle shape, cells clump together, causing clots, poor perfusion of O2 and tissue perfusion, increased risk of infection, Death (due to poor blood perfusion). -S/S: Severe pain—dehydration increases pain. Clumping causes vaso-occlusive event. -Heart: HF as a result of anemia -Skin: pallor -ABD: spleen and liver damage. Spleen/liver full of blood, for clumping blood/sickled cells—have ischemia from blockages, hypoxia from low O2 blood to these organs. Further exacerbating issues. -Musculo-skeletal changes: edema occurs because of BV occlusion of arms and legs. Stasis and fluid pooling in lower extremities (legs and arms) -Respiratory: can cause pulmonary HTN, recurrent pneumonia, acute chest syndrome (heart attack feeling, most common cause of death). -Tx Priorities: Pain due to poor tissue perfusion and joint destruction with low oxygen levels. Potential for infection, sepsis, multiple organ dysfunction syndrome (MODS), and death. --Hydration: PO or IV route helps reduce the duration of pain episodes. Urge the patient to drink water or juices. Patient is often dehydrated and blood is hypertonic, hypotonic fluids are usually infused at 250 mL/hr for 4 hours. Once the patient's blood osmolarity is reduced to the normal range of 270 to 300 mOsm, the IV rate is reduced to 125 mL/hr if more hydration is needed. No caffeine is allowed, increased dehydration. --Pain: Tx starts with at least 48hrs of IV analgesics. Morphine and hydromorphone are given IV on a routine schedule or by infusion pump using PCA. When relief obtained IV dose can be tapered, and the drug given orally. Moderate pain may be managed with oral doses of opioids or NSAIDs. Non-opioids are better. --Barometric Pressure Tx: disease acts up when pressure changes, exacerbated in dehydrated states. --Penicillin: for risk of penumonia. --Oxygen Tx --Blood transfusions: PRBCs; admin HgbA to dilute the HgbS. In 120 days, HgbS will outnumber the HgbA. Watch for iron overload. --Hematopoietic stem cell transplantation (HSCT) may correct abnormal Hgb permanently during childhood.

Gallbladder Interventions

Gallbladder Interventions: -Patho- The liver, gallbladder, and pancreas make up the biliary system. Biliary system--secretes enzymes and other substances that promote food digestion in the stomach and small intestine. When these organs do not work properly, adults may experience impaired digestion, which can result in inadequate nutrition . -Inflammation and obstruction (blockage) in the biliary system from: gallstones, edema, stricture, or tumors. -Frequent S/S: moderate-to-severe acute or persistent ABD pain, fever, pain w/ DB, anorexia, fat intolerance, fullness/ABD distention. Rebound tenderness (Bloomgerg). Fetal position to reduce pain. Biliary colic (severe cramp, subsides 30-60min-obs/movement of gallstones). Cholangitis-Charcots triad: bilary pain, jaundice, fever. -Dx: bloomberg sign by HCP, increased WBCs, increased alk. phos., increased LDH, increased bilirubin, pancreas involved-increased amylase/lipase. Xray, US, HIDA scan (biliary system, used tracer to track BF), ERCP. -Meds: analgesics, antibiotics, Urisol (not for acute attack, dissolves stones) -Diet: reduce fat/cholesterol, fried food, and fast food. -Op: Laparoscopic (Lap-Chole) MIS and gold std, w/ few complications. Postop- O2sat monitored, food/H20 when FULLY awake, elevate HOB, early ambulation, oral pain control. -Open/traditional for severe biliary obs/adhesion of ducts. Post-op: t-tube or JPD monitor drainage. PCA pump for pain, or IV pain meds. Respiratory care and antiemetics may be needed. RN will monitor wound and encourage early ambulation. Clear liquid diet to start. -Post-Cholecysectomy Synd: pain continuing after OP, Dyspepsia, N/V, RUQ pain, flatulence/bloating, diarrhea. Teach pt to monitor, can be transient, persistent. or life long. May need OP to locate cause.

Identify risk factors for PUD, 3 types of PUD, S/S, Dx

Identify risk factors and develop and prioritize plan of care for patients with PUD: -Peptic Ulcer Disease: results when GI mucosal defenses become impaired and no long protect the epithelium from the effects of acids and pepsin. 3 types: duodenal, gastric, stress ulcers. Many are caused by H. pylori infection, transmitted oral-oral or fecal-oral. This bacterium breaks down urea into ammonia, neutralizing stomach acidity. LT use NSAIDS break down the mucosal barrier and disrupt mucosal protection -Duodenal Ulcer: MOST COMMON. High gastric acid secretion, ph levels are low in the duodenum. Protein-rich meals (delays gastric emptying), calcium, and vagus nerve excitation stimulate acid secretion. Pancreatic secretion may be insufficient to control the acid load. Food REDUCES pain -Gastric Ulcer: Normally near the acid-secreting mucosa. May be result from back diffusion of acid or dysfunction of the pyloric sphincter, allowing bile reflux into the stomach, which is acid and destroys the membrane. Food INCREASES the pain. Gastric emptying often delayed. -Stress Ulcers: Acute gastric mucosal lesions, after a medical crisis or trauma (sepsis, head injury), Post-OP NPO causes Gastritis, may lead to stress ulcers. Bleeding caused by gastric erosion is the main manifestation of acute stress ulcer. Lesions in stomach & proximal duodenum. B12 DEFICIENCY - anemia. -S/S: Epigastric pain. Peritonitis: rigid, boardlike abdomen, rebound tenderness and intense pain (need to irrigate). Dyspepsia: sharp, burning, gnawing pain. With bleeding, orthostatic BP, dizziness - Risk for Falls. -Dx: Blood: serologic testing for H. pylori / Hgb. Breath: urea breath test. Stool: tested for H. pylori. EGD: most accurate. ABCs, Gag reflex assessment after EGD. Nuclear medicine scan: GI bleeding

Other Dx tools for hearing loss: Labs & Imaging

Labs: -Used to assess whether an infection is present; microbial culture and antibiotic sensitivity can be performed for specific causative organism and the antibiotic that will best manage the infection. RN describe test and confirm that no special preparation is needed. Imagery: -CT (with or without contrast)—used to assess ear structures in great detail; very helpful in diagnosing acoustic tumors. -MRI—used to assess soft tissue changes. RN describes test. Teach to report claustrophobia prior to testing, as a mild sedative may be prescribed. Open MRI is an option for those who need this test.

RN interventions that prevent or minimize fear & the stress of separation & loss of control during hospitalization.

Play for the Ill Child: provide diversion & allow interaction with other children. Children learn through play; important to allow them to continue to play, but also allow them to learn through play. Play can allow you to assess how the child is coping w/ the stress of hospitalization. Ex. the play therapist wheels the child, while still in bed with traction in place, to the playroom. • Playrooms: children can play w/ toys, participate in age-appropriate arts & crafts, & socialize w/ other kids. This is a safe place, where medical Tx do not take place. When stable, kids can be taken to playroom in wheelchairs & beds. If possible, provide a separate area for teens to listen to music, play video games, use computer, & visit w/ peers. If playroom isn't available, provide age-appropriate toys, games, & books. • Therapeutic play: component of the plan of care; HC team guided activities that are planned to meet the physiological & psychological needs. Used to assess what a child is thinking or to help them through a dz process. Interpretation of play behavior & some types of therapeutic play require guidance w/ play therapist. Provides an emotional outlet, instruct, & improve physical abilities. Can do supervised play w/ medical equipment to reduce anxiety & separate fear from fantasy. If RN is using this method, you must put an evaluation of the play in the RN care plan. Goals: maintain normal living patterns, minimize psychological trauma, & promote optimal development. • Emotional play: AKA dramatic play; children act out real life stressors; can use dolls. Can tell you fears, experience w/ sexual abuse, emotional or physical stressors; can help w/ the healing process. Injection play (must be done safely) for the child who has undergone frequent Tx w/ needles; allows them to inject doll & release stress or anger. Assess cognitive level 1st. • Teaching through play: educate on pre-OP; before a new, painful, or extensive procedure. Assess cognitive level, teach per their level. Demonstrate things like taking a BP or doing a breathing Tx on the child's doll, before doing it on them. Drawings & diagrams may help; pre-OP visits where children can meet the staff, see the environment, ask questions, & meet other kids who underwent the OP can help the child cope. • Enhancing cooperation: stimulate & engage the child to participate in care; use age-appropriate developmental activities. School-age kids love competition & games—will increase ROM if points are made each time a foam ball is thrown through a hoop. Have the child blow bubbles, whistle, blow a pinwheel, or simulate blowing out the penlight can increase DB exercises. ROM can be done w/ throwing foam balls, beanbags, & paper balls. To increase intake, make a graph that shows the amount taken in & give them a reward for a selected goal. Include the child in the plan of care & ID rewards & goals to enhance motivation; use stickers, pencils, baseball cards, & small toys as rewards. • Unstructured play: allowing them an outlet to behave in whatever manner they need, helps them get sense of control back; control events, ideas, & relationships. Ex. music Tx w/ choices of instruments &/or singing, animal Tx to interact w/ animals & their trainers. • Evaluation of play: therapeutic play should be reflected in the care plan; when evaluating look at outcome criteria to ID if play has facilitated the achievement of the goals. Is the child coughing & DB every 2hrs? Are they expressing feelings about separation? Are they eating & sleeping? Have their goals been achieved?

Weber & Rhinne tests

Weber- should be equal bilaterally. -Fork at top of skull. Patient tells you if heard more in one ear. -Lateralization- heard more loudly in 1 ear. This is a bad finding. -It detects 1-sided coductive hearing loss (middle ear). -It detects 1-sided sensorineural hearing loss (inner ear) Rhinne- should hear 2x as long by air conduction than bone. Air= 2 x Bone Conduction. -Fork at base of mastoid, patient tells you when no longer heard. Move fork close to ear, patient tells you when no longer heard. -Bone>Air: conductive hearing loss -Bone and air impaired, Air>Bone but <2:1 ratio: sensorineural hearing loss

Placenta previa

Placenta previa: implantation of placenta in the lower uterus & near the fetal presenting part. 1:200-300 pregnancies. S/S: painless vaginal bleeding during last ½ of pregnancy, usually bright-red bc from lower segment of uterus. Dilation at location of placenta causes bleeding into vaginal canal. Not painful bc it's just the small dilatation of the cervix, most moms don't feel this right away. CS must be performed bc we don't want her to dilate (start labor), dilation causes bleeding so mom & baby will lose blood. CS planned right at 37wks or completion of 37wks. Types: marginal—low lying, right up to cervix but may not cover- can later be drawn upward, partial—at least 3cm from internal cervical os, total—completely covers the os, causes more bleeding.

Normal Lab Values for: -pH, PaCO2, HCO3HgB, Hct, WBC, RBC, Platelets -FBS "Fasting Blood Glucose" -glucose; protein; BUN; Serum Creatinine; Uric Acid; electrolytes (K,Na,Ca,Cl,P,Mg)

-pH (7.35 - 7.45) -PaCO2 (38-42)HCO3 (22-28) -Hgb: (M: 13-17, W: 12-15) -Hct: (M: 40-52%. W: 36-47%) -WBC: (4.5-11) -RBC: (w: 4.5-5.0, m: 4.5-6.2) -Platelets: (150,000-450,000) -FBS "Fasting Blood Sugar":<100mg is normal; 100-125mg= prediabetes; >126mg = diabetes -glucose (65-110) -protein (60-80) -BUN (8-21) -Creatinine (0.8-1.3) -Uric Acid (0.18-0.48) -K+ (3.5-5)Na (135-145) -Ca (9-10.5) -Cl (95-105) -P (3-4.5) -Mg (1.3-2.1)

Describe the physiologic changes that occur during pregnancy: Labs

Labs Pre-Pregnancy vs Pregnancy: · RBCs- 4.2-5.4mil; Pregnant: 3.8-4.4mil, slightly decreased because of hemodilution. · Hgb- 12-16g/dL; Pregnant: >11g/dL in 1st & 3rd trimester, >10.5g/dL in 2nd. · Hct- 37-47%; Pregnant: >33% in 1st & 3rd, >32% in 2nd. · WBCs- 5,000-10,000; Pregnant: 5,000-15,000, slight decrease but w/in normal range. · Platelets- 150,000-400,000; Pregnant: slight decrease but w/in normal range · PT- 11-12.5s; Pregnant: slight decrease · aPTT- 30-40s; Pregnant: slight decrease · D-dimer- negative; Pregnant: negative · FGB- 70-110mg/dL; Pregnant: 95mg/dl or less · Postprandial- <140mg/dL; Pregnant: <140mg/dL · Creatine- 0.65 +/- 0.14mg/dL; Pregnant: 0.46 +/- 0.13mg/dL · Cr Clearance Urine- 85-120mL/min; Pregnant: 110-150mL/min · Fibrinogen- 200-400mg/dL; Pregnant: 300-600g/dL.

Neurovascular Assessment

Neurovascular Assessment: • CSM (circulation, sensation, and motion): Assess every <2hrs during first 48hrs. Assess strength of the pulse distal to the site, compare to the pulse in the unaffected extremity. Sluggish capillary refill time suggests neurovascular impairment. Touch the skin proximal & distal to the device to check temp.; ask them to move fingers & toes. o S/S of circulatory impairment: coldness, pallor, blueness of extremity, swelling, loss of motion, & numbness & tingling of the extremity. § Paresthesia, or numbness, burning, & tingling; assess by touching the fingers or toes & noting any decrease or loss of feeling. Serious concern bc can result in paralysis if not corrected. Report child's complaints of pins-&-needles or the extremity 'falling asleep'. W/ young children, may not be able to describe sensation; avoid questions like, "Do you feel like this?"—instead ask to wiggle fingers or toes & ID motor impairment. • CSM (circulation, sensation, and motion): Assess every <2hrs during first 48hrs. Assess strength of the pulse distal to the site, compare to the pulse in the unaffected extremity. Sluggish capillary refill time suggests neurovascular impairment. Touch the skin proximal & distal to the device to check temp.; ask them to move fingers & toes. o S/S of circulatory impairment: coldness, pallor, blueness of extremity, swelling, loss of motion, & numbness & tingling of the extremity. § Paresthesia, or numbness, burning, & tingling; assess by touching the fingers or toes & noting any decrease or loss of feeling. Serious concern bc can result in paralysis if not corrected. Report child's complaints of pins-&-needles or the extremity 'falling asleep'. W/ young children, may not be able to describe sensation; avoid questions like, "Do you feel like this?"—instead ask to wiggle fingers or toes & ID motor impairment.

Zidovudine

Zidovudine: treats HIV & AIDS. -HIV Tx: 3 drugs, primary antiretroviral= Zidovudine (ZVD, AZT). Drug admin delayed till 10-12wks, if mom's viral load is low enough. -Pregnancy: ZDV 100mg PO 5x/day, started between 14-34wks. Alternative dose- ZDV PO 200mg 3x/day, or 300mg 2x/day. -Labor: IV ZDV w/ 1hr loading dose of 2mg/kg, then continuous IV 1mg/kg/hr until delivery. -Newborn: PO ZDV syrup, dose of 2mg/kg Q6h for 6wks, begining 6/8-12hrs after birth. -CS delivery at 38wks, before onset of labor & ROM is used to reduce transmission of HIV to the baby. HIV mom's told not to breastfeed bc HIV is in their milk. -Side effects = anemia; Monitor Hemoglobin .

Kidney replacement therapy (KRT)

-Kidney replacement therapy (KRT), AKA RRT, is used for patients with loss of kidney function and inadequate waste elimination. -Indications for KRT include symptomatic uremia (e.g., pericarditis, neuropathy, decline in cognition), persistent or rapidly rising high K levels (>6.0), severe metabolic acidosis (pH < 7.1), or FVO that inhibits tissue perfusion. When AKI occurs with drug/alcohol intoxication, KRT also can remove toxins. --FVO causing CHF, reducing perfusion --K+ >6 persistent or rapid increase, with ECG changes --Acidosis with HCO3<15 (pH 7.1) --BUN >120 -Significant changes in MS, pericarditis, pericardial effusion, cardiac tamponade --Placement of central catheter (for immediate vascular access) requires informed consent and "time-out". Long term catheter may be placed later. -RRT increased risk of CKD, treat them like a CKD/ESKD patient, schedule followups, labs, dietician consult, nephrologist appt.

Uterine Atony, Subinvolution, Early and Late Postpartum Hemorrhage

-Uterine Atony: decreased uterine muscle contraction (tone), primary cause of excessive bleeding bc uterus does not contract firmly around BVs when placenta separates. . · Subinvolution: uterus does NOT achieve involution (daily contraction & return to original size). At first seems like involution is occurring, then it does not continue the process. Causes retained placenta fragments & infection. o Early Postpartum Hemorrhage: usually occurs in 1st hr PP, often from uterine atony. Also trauma, hematoma, retained placental fragments, abnormal coagulation, placenta previa/acreta, uterine inversion. o Late Postpartum Hemorrhage: occurs between 24hrs & 6wks (up to 12wks). Usually due to subinvolution in some regard. o Delayed return of the uterus to its nonpregnant size and consistency caused by: Retention of placental fragments or Infection o Nurses should teach the family signs and symptoms that may need to be reported to the health care provider. Teach mom how to locate/palpate the fundus & how to determine the fundal height, assess lochia & its progressive changes, ID when pain increases to a level more than previous—s/s that indicate she needs to call the HCP. -Ex. D/C after 24hrs she had started involution, then notices her uterus is starting to get higher again even though she has voided & massaged—contact the HCP right away. -Risk Factors: multiple cervical exams, overdistension of uterus, multiparity, precipitate labor or birth, prolonged labor or ROM, forceps or vacuum, CS, manual removal of placenta, uterine inversion, placenta previa/acreta or low implantation, Drugs (oxytocin, prostaglandins, tocolytics, Mg), general anesthesia, chorioamnionitis, clotting ds, Hx PP hemorrhage or uterine surgery, DIC, uterine leiomyomas (fibroids).

ABGs

ABGs: ALL decreased in kidney disease -Blood pH: 7.35-7.45 -PO2: 80-100 -PCO2: 35-45 -HCO3: 21-28 -CBCs: -Hgb: females 12-16, males 14-18mg/dL, older adult slight decrease -Hct: females 37-47%, males 42-52%, older adult slight decrease § Ex. Patient has diarrhea, buffer leaves the body, causing metabolic acidosis; pH will be low (acidotic). § Ex. Patient is vomiting, acid leaves the body, causing metabolic alkalosis; pH will be high.

Case Study on Burns

Case Study on Burns: • Admission Priorities: Establish and maintain an open airway; the burns on client's trunk can cause constriction leading to a restricted airway. Additionally, smoke inhalation is always a concern following a fire. Remember Maslow's Hierarchy of Needs: ensuring an open airway is always the highest priority nursing intervention. • Percent of BSA: 45%; According to the Rule of Nines, lower extremities are 18% each. The front trunk is 18%, with the upper torso receiving 9% and the abdomen receiving 9%. Therefore, if the abdomen (9%) and both legs (36%) are burned, the total percentage is 45%. o 1st degree: usually minor, painful, but only involves the upper layer of the skin. o 2nd degree: partial thickness; affect the epidermis & dermis. Client grimaces in pain as the RN assesses the red & blistered wounds. Partial thickness wounds are painful, red, and moist and are known for their blistering appearance. o 3rd degree: full thickness, extend through every layer of the skin. The skin may appear leathery & stiff. o 4th degree: normally involves the muscle, tendon, & bone. • A client with a burn injury is at significant risk for hypovolemia from fluid loss and fluid movement from increased capillary permeability and vasodilation. -Tx: HCP inserts a CVAD via the subclavian vein and prescribes sodium lactate/Hartmann's solution (RL) at 1,000 mL/hr. Fluid vL requirements are calculated using an accepted formula such as the Parkland Formula to adequately hydrate client: o The first half is given over the first 8 hours from the time the burn occurred, and the second half over the following 16 hours. • UO during fluid replacement: o 0.5 mL to 1 mL/kg (1 mL/2.2 lbs) in children weighing less than 30 kg (66 lbs) is ideal. o A child who weighs more than 30 kg (66 lbs) should produce 30 mL/kg (30 mL/2.2 lbs) to 50 mL/kg (50 mL/2.2 lbs) per hour.

Communicating w/ a Person in Crisis

Communicating w/ a Person in Crisis: • Move the person to a quiet space to reduce external stimuli, let them talk about their feelings & facts of the situation—use reflective statements, avoid being defensive or justifying your (or another's) actions, use simple sentences that are no more than 5 words & each word is no more than 5 letters long, set limits & avoid asking them questions that would receive a yes/no response. • Listen rather than talk; being present & empathizing w/ them are useful interventions. Help them ID problems, their effective coping mechanisms, assist them explore solutions. • Emotional Decompensation: patient/families coping mechanisms breakdown entirely; consult w/ social services, spiritual counselor, crisis intervention staff to help you assist the family. Early ID, intervention & support for coping mechanisms are easier & less time consuming than intervening AFTER emotional decompensation.

Recognize deviations from normal physiologic findings during examination of the newborn: Umbilical Cord & Jaundice

Deviations from the Norm in the Newborn: · Cord: normal is 2 arteries/1 vein. Should be thick w/ Wharton's jelly (clear substance around the cord)—thicker = healthier cord, jelly protects the BVs in utero. Thin/depleted = malnourished; problem seen in IUGR, premature babies. o Abnormal if 1 artery/1 vein; indicates chromosomal problem (Trisomy 21 w/ associated cardiac anomalies). o Meconium Stained: cord looks yellow-brown or green, color also seen in amniotic fluid. Indicates meconium was released before birth & has been in place long enough to stain the cord. § Providing cord care: teach cord care; clamp is cut off before they go home, it will be dried & dark at this time. Let it dry naturally & don't do anything too it or get it wet—to prevent infection. If it looks red around the area, call the HCP. May need to do a C&S & give ABs. Generally, we let it dry naturally & it falls off w/in 2 wks. · Bilirubin: pathologic & physiologic jaundice; measure bilirubin & assess levels, ID babies at risk for jaundice. Explain condition to parents, so they can ID when the baby's skin starts to turn yellow & to report to HCP bc they will be spending the most time w/ the baby. May need to draw blood to evaluate the levels of bilirubin in the blood, provide Bili lights when indicated. o Sclera: should be white; hyperbilirubinemia will make it yellow (jaundice). Daily assessments will include monitoring of the eyes/sclera. · RN: ID jaundice, report to the HCP, & recommend getting labs drawn so assess/monitor the progression of the bilirubin levels. Some types of jaundice can be normal bc liver is immature & cant excrete the broken down RBCs efficiently; Tx w/ formula or breastmilk, to flush it out.

Factors Affecting the Child's Response to Hospitalization

Factors Affecting the Child's Response to Hospitalization: • Perception of events: "perception is everything"; effects how the child responds before, during, after the illness or hospitalization. • Cognitive development [age]: developmental differences are considered in planning RN care; how to prepare the child for hospitalization differs w/ each developmental level/age. The content, time frame, setting, & methods of prep are all based on the child's G&D. Speak to them in the language that they most understand. • Parental response: parental anxiety/fear will transfer to the child. If they talk outside the child's room or w/in hearing range but in a whisper, the child (esp. preschooler) may invent elaborate stories to explain what is happening. Parents who don't answer the child's questions or who aren't truthful bc they don't want to scare the child, end up confusing them & weakening their trust. Kids want to believe someone is in control & they can trust their parents. Some parents can't be honest bc they are afraid & insecure—RN must assess for all these issues. • Preparation: stress is a nonspecific response of the body to any demand made on it. Adaptation to stress is affected by the perceived stressors, conditioning factors brought to the situation, & coping mechanisms. Prep helps decrease stress by exploring the child's & parents' perception of the event, explore previous experiences w/ HC or illness that may affect impending hospitalization, & ID previous use of coping strategies. Prep as much as possible about what will happen; plan teaching sessions; teaching is more effective when RN & family develop trust & there is honesty. • Previous illness or hospitalization: Hx of illness or hospitalization & their experience/response to the event will greatly affect their future perceptions [vs a child w/ no experience]. • Coping skills of the child and family: coping is the process of contending w/ difficulties in an effort to overcome or work through them. How the child copes is rt their age, perception of event, Hx of hospitalization or encounters w/ HC staff, support from significant others, & the child's/parents' coping skills. • Psychological benefits: stress of illness & hospitalization can enhance G&D by promoting child's use of coping skills & bolster self-esteem. Kids can increase confidence as they overcome anxiety rt hospitalization & may master self-care skills.

Postpartum Hypovolemic shock

Hypovolemic Shock: During and after birth, women can tolerate a blood loss approaching that of blood added during pregnancy. 1500 to 2000 mL total. o Compensatory mechanisms maintain the blood pressure so that vital organs are perfused. o Hypovolemia occurs with excessive blood loss. -Pad saturated w/in 1 hr indicates excessive blood loss & postpartum hemorrhage. -Any loss >500mL is considered impactful to the patient. >500mL for vaginal, >1000mL for CS—get H&H values sooner following delivery. If delivery went well then the redraw can be after 12hrs to assess status. H&H tells us if they are truly in hypovolemic shock & need to receive blood or not. · Monitoring for Signs of Hypovolemic Shock: o When mom comes in bleeding: get her HR & FHR/tones right away. o Increased pulse rate, falling blood pressure, increased respiratory rate o Weak, diminished, or "thready" peripheral pulses o Cool, moist skin; pallor; or cyanosis (late sign) o Decreased urine output (<30mL/hr) o Decreased hemoglobin and hematocrit o Change in mental status (restless, agitated, reduced concentration)

MAP (mean arterial pressure)

MAP (mean arterial pressure): -The arterial blood pressure necessary (between 60 and 70 mm Hg) necessary to maintain perfusion of major body organs, such as the kidneys and the brain. -Product of CO and systemic vascular resistance, most reliable indicator of tissue perfusion. BP may be high/low, even when perfusion is low. ---- [SBP + (2 x DBP)] / 3 -Don't round up! Treat quickly! -Maintaining a mean arterial pressure of 80 to 85 mm Hg has been shown to lower rates of AKI in patients with pre-existing hypertension. -However, there is an increased risk of atrial fibrillation in patients with a MAP of 80 to 85 mm Hg as opposed to 65 to 70 mm Hg. Accordingly, BP goals are determined based on pre-existing conditions and risk versus benefit to the patient.

Differentiate among the RN interventions used for managing specific FHR patterns, including tachycardia and bradycardia, absent or minimal variability, and late and variable decelerations

VEAL CHOP MORE: -V: Variable decels; C: Cord Compression; M: Move Mom -E: Early Decels; H: Head Compression; O: Okay -A: Accels; O: Okay, Maybe O2; R: Right On -L: Late Decels; P: Placental Insufficiency; E: Emergency/"Labor Dance"= O2, turn, IV fluids -Early Decels: continue to monitor mom & see how the baby does, we need these contractions for labor to progress. -Late Decels: oxytocin off; mom induced for labor & given meds to cause contractions. Then improve the O2, turn mom onto her Lt side & admin O2 via mask at the same time. O2 admin to mom/baby is priority. IV fluids will also increase perfusion. Give her a bolus to increase the movement of plasma/blood to the placenta. -Variable Decelerations: look like a "V" formation, can occur w/ or w/o contractions. "V" indicates umbilical cord compression—leading to decrease in FHR. When the baby moved the FHR goes up. Can also look like a "U" sometimes. RN get baby off the cord by moving the baby—this is done by moving mom. If on back, move her to her side (preferably Lt). If on left side, turn mom to Rt side. May occur w/ cord prolapse- perform a vag exam & get head off the cord.

COMFORT Behavioral Scale & FACES Pain Rating Scale

• COMFORT Behavior Scale: Infants/Children in critical HC setting; 6 categories; Alertness; Calmness/Agitation; Respiratory Response (if on ventilator) or Crying (if spontaneously breathing); Physical Movement; Muscle Tone; Facial Tension. 1-5 points for each category, total of 6-30; Higher score = greater pain/distress. • FACES Pain Rating Scale: children 3yrs+; 6 cartoon faces w/ neutral to gradually increasing painful expressions, corresponding to an analog scale w/ words ranging from: -Happy face (0; No hurt) -Less happy face (1/5 or 2/10; Hurts little bit) -Neutral face (2/5 or 4/10; Hurts little more) -Slight frowny face (3/5 or 6/10; Hurts even more) -Very sad face (4/5 or 8/10; Hurts whole lot) -Crying face (5/5 or 10/10; Hurts worst) -Accommodates a 0-5 or 0-10 system. Explain what each face means, so they pick the correct one. o Explain to the child that each face is for a person who feels happy because he or she has no pain ("hurt") or sad because he or she has some or a lot of pain. Ask the child to choose the face that best describes his or her own pain. (Wong-Baker FACES Pain Rating Scale)

Newborn Assessment: APGAR

Newborn Assessment: APGAR § Maintain Cardio-Pulmonary Function: continue w/ ABCs used immediately post-delivery—clear their airway, dry them off. Maintain cardiopulmonary function & at 1min do the APGAR. § APGAR Scoring: At about 1min, scoring is done to let everyone know the baby's status. Created by Virginia Apgar, somewhat subjective, but helps us understand what is going on w/ the baby at 1min, 5min, & if score is <7 then do it again at 10min. Tool of assessment & communication. · Appearance: skin color; Pulse: HR; Grimace: reflexes; Activity: muscle tone; Respiration: RR & effort. · Appearance; 2: indicates everything is good. But most babies are acrocyanotic at delivery, so they only get a 1 for appearance—this is a normal finding. 0: indicates the baby is blue, pale, or cyanotic. · Pulse; taken at the apical. 2: normal, >100 BPM (normal FHR 120-160). 1: <100 BPM. 0: no pulse. · Grimace; reflexes. 2: sucking, turn away from procedure, sneeze, cough, cry w/ stimulation. 1: only grimace w/ stimulation. 0: no response to stimulation. · Activity; muscle tone. 2: active w/ spontaneous movement (flexion/extension). 1: arms/legs flexed w/ little movement. 0: no tone/movement, "floppy". · Respiration; RR (>30) & effort. 2: normal RR & effort, good cry. 1: slow or irregular breathing, grunting, weak cry. 0: absent, no breathing. · 2 points for each area = 10pts. If <7 we need to intervene. Ex lost a point for color, lost another for lack of activity, and another point for a weak cry or lack of reflexes (only grimace present)—could end up w/ a 7. Anything <7 means there is a problem, begin Tx the infant, reassess at 5min if still <7 reassess at 10min. This is an assessment & communication tool, parents may be anxious if its not a 10—1 point off for color is normal, & if at any point we had to offer O2 assistance but at 1min it was a 10/10 then that is a skewed score. So its really just an information-communication tool that will be provided at every change of shift to tell other staff what happened at delivery.

RN Care for Epidurals & Intrathecal Opiates

· Nursing care for epidural placement: -Nurse should record baseline maternal vital signs and FHR and patterns for comparisons with prenatal levels and those after the block -IV access: 500-1000mL fluid bolus is given -Nurse supports woman in lateral decubitus or SITTING position and tells the anesthesia provider when the woman is having a contraction -Observe for signs of subarachnoid puncture or intravascular injection -Assess BP every 5 minutes for the first 15 minutes after initiation of epidural—repeat at 30 minutes and 1 hour after epidural is started -Assess bladder and temperature · Nursing care for intrathecal opioids: -VS and FHR are taken -Report any side effects: nausea, vomiting, and pruritus

Describe modalities for induction and augmentation of labor

o Artificial Rupture of Membranes- Amniotomy: Many times it ruptures naturally, but sometimes if labor is slow or if we need to put in internal monitors—then we will artificially rupture the membranes, called an amniotomy. o "Crochet hook" pierces the membrane, but mom must be dilated for practitioner to get their hands in to the cervix. Like a manual exam, except dilation must be sufficient to get to the amniotic sac. --RN: make sure the head is engaged at 0-station. Monitor the fetal heart tones during the amniotomy bc the umbilical cord could come through—called prolapse of the umbilical cord, where it comes out ahead of the baby's head leading to compression of the cord. We never want a prolapsed cord, so if we rupture when the baby is up high, ballottable, & not engaged at 0-station (at ischial spines)—this could lead to a prolapse. Ensure that the head is engaged to prevent this. -Breaking the bag of waters can introduce infection, so if it is a prolonged rupture of membranes—we generally start prophylactic antibiotics after the membranes have been ruptured for 12hrs. May be started earlier if mom shows s/s of infection (fever, foul odor of amniotic fluid). Keep the perineum clean, change out the towels & chucks, clean perineum from front to back. -Increased risk of placental separation from uterus. If there is excessive amount of amniotic fluid, the fluid causes distension of the uterus. The placenta could compress & separate. Ensure there isn't excessive amniotic fluid before its ruptured. Post-dates would tell us we have too much fluid, do an US & evaluate. o Induction and Augmentation: Induction means we are starting the process bc mom hasn't; Augmentation means mom has started, but she's not moving along quickly enough based on indications (below). o Indications: Post-dates, BP problems; Fetal compromise—intrauterine growth restriction, Rh incompatibility; Spontaneous rupture of membranes near term & mom isn't contracting, don't wait 12hrs, augment her labor; Post-term pregnancy >40wks, at 41wks induce; Chorioamnionitis—infection of the chorion, causes problems w/ amniotic fluid, so induce; HTN associated with pregnancy (pregnancy induced HTN, or preclampsia); Maternal medical conditions—DM, large baby; Fetal death—induce or augment o Contraindications: Placenta previa—placenta is previous to the baby & covers the cervix, have to do a c-section; Abnormal presentation—ex. transverse, if we start an induction baby wont come down; Umbilical cord prolapse—during ROM or naturally, do not induce, it will cause more contractions; Previous uterine surgery—don't induce; Non-reassuring fetal heart rate patterns—ex. late decelerations, continuing labor will stress the baby out more & decrease placental perfusion. Need to do a c-section. o Techniques for Induction: Determine cervical readiness for labor before induction. -Bishop scoring: several factors considered to see if patient/cervix is ready--dilation, effacement, fetal station, cervical consistency, cervical position. Scores: 0-3; most successful if 7+. o Cervical ripening (softening): may be done morning of induction, sometimes the day before. Medical methods (prostaglandins)--Prostaglandins found in the prostate/semen. Recommend mom have deposits of prostaglandins near cervix to start labor. But some women who are 9mo pregnant will defer. Mechanical methods (transcervical catheter, laminaria)--Opens up the cervix; Pitocin/Oxytocin administration: Diluted in an isotonic solution (LR) and given as a secondary infusion. Put it as close as possible to the port as secondary infusion, not up high—so if we stop it, not extra med goes through. Usually 10u/1000mL LR, can be 20u/500mL if you don't want mom getting too much fluid (HTN). Start w/ small amounts, milliunits—2mL/2mu. Progress every hr, take a set of VS, watch baby & contractions.

Other Changes in the PP period: ABD, Blood vL & components, Weight loss, Chills/Diaphoresis, Urinary Tract

o Diastasis recti (separation of longitudinal muscles) may have occurred, minimal-severe. Improved w/ gentle exercise, diastasis resolves in 6wks. More often in fit moms. o VS and Blood Values: VS return back to normal, esp. if mom had any changes/issues during pregnancy. Blood vL—during pregnancy hemodilution to account for bleeding after delivery. Extra vL excreted in urine (3,000mL day, esp. day 2-5) & sweat, Hct 4-6wks to return to normal (unless hemorrhage). Take additional labs (12hrs postpartum) to check H&H. If mom has been bleeding, take sooner than 12hrs. Fibrinolysis decreased during pregnancy, increases after birth to several days—increased risk of thrombus. 4-6wks for hemostasis to return to normal. Thrombophlebitis increased w/ prior Hx, varicose veins, CS. Monitor, compression devices applied or ordered. o WBC is 25,000 2nd PP day, marked leukocytosis w/ WBCs as high as 30,000 normal during labor & immediate PP period. Returns to normal by 6th PP day. o Weight Loss: sudden from delivery of baby, amniotic fluid, placenta, blood loss. 5.5kg (12lbs) lost during birth. Additional 4kg (9lbs) over next 2wks, 2.5kg (5.5lbs) by 6mo. Loss of fat is slow, average wt gain of 1kg (2.2lbs) per pregnancy. RN: provide info on proper diet/exercise that wont deplete energy or impair health. o Chills & Diaphoresis: extra fluid of pregnancy, when not used to accommodate for blood loss, will need to be removed from circulatory system. Moms will find themselves saturated from head to toe (hormones & extra fluid)—and think something is wrong bc chills usually indicate fever/illness. Educate her that this is normal following delivery, assess lab values, provide showers & dry clothing. o Urinary Tract: sensation of need to void may not return immediately postpartum—could have incontinence bc she doesn't feel bladder filling up. This should return to normal after a few days-wks. Increased risk of UTIs, bleeding (distended bladder causes uterine atony), stress incontinence. Kidney & ureter dilation improves by 1st wk, normal by 2-8wks. Protein (catabolism) & acetone (dehydration) in UO for few days.

BUBBLE EE: U = Uterus

BUBBLE EE: U = Uterus -Involution: rapid reduction in size of uterus & return to pre-pregnancy state. After placenta separates, the uterus lining is irregular/jagged w/ varied thickness. Part of the lining is discarded by the body as lochia. The basal layer (not discarded) forms a new endometrium. Changes take 3 wks . The placental site takes 6-7wks for complete healing. -Lochia: bleeding after delivery, includes part of the lining of the uterus. -Exfoliation: process by which the placental site heals; important part of involution. The superficial placental site tissue becomes necrotic & sloughs off; lower decidua regenerates the site. If process doesn't occur properly, uterus heals w/ a scar—may cause future pregnancies to not implant in this area, may limit future pregnancies. -Exfoliation is enhanced by uncomplicated labor and birth—includes complete expulsion of placental fragments, breast feeding, & early ambulation of mother. -Involution is slowed by prolonged labor, anesthesia or excessive analgesia (increased time w/ med-Tx), difficult birth, grand multiparity, a full bladder, and retention of placental fragments · Specifics about the Uterus: -Fundus: top of the uterus; located midway between the symphysis pubis & umbilicus. -Assessment: while in L&D check every 5min for 1st 15min, to ensure bleeding is okay, then every 15min. Every 15min after 1st hr PP. Every 30min for next hr. Every hr for 2hrs, while in postpartum unit. Then every 8hrs (or every shift, based on clinical s/s). Typical recovery is 2hrs. -Location of the uterus: at level of umbilicus w/in 6-12hrs after birth. Descends by 1cm per day. Assess the fundus for location & consistency, we want it to be at or near the umbilicus & midline. -Slightly normal for fundus to be 1-2 finger breadths above the umbilicus right after delivery, but w/in 6-12hrs it should be at the level of the umbilicus or below. -1st day: fundus located 1cm (1 finger) below the umbilicus; 10th day: fundus descends into the pelvis; 14th day: deep in pelvis & can't be palpated on ABD. -Height of fundus: recorded in finger breadths. At umbilicus = 0; Above umbilicus = +1/+2; Below umbilicus = -1/-2. -If located above the umbilicus - the fundus is "boggy": soft/spongy fundus, not firm or well contracted. Associated w/ excessive uterine bleeding. We want the uterus to be firmly contracted. -Boggy uterus (atony): fundus above umbilicus & not firm; boggy means there is no tone. Occurs as blood collects & forms clots in uterus, causing the fundus to rise & it interrupts firm uterine contractions. Chart as, "uterus boggy", & if it becomes firm w/ light massage. -Monitor uterine status: · RN lightly massage the ABD until the fundus becomes firm. Support bottom of uterus during massage—hand at symphysis pubis while other hand massages & palpates, so it doesn't prolapse. Teach her to massage her uterus to check position & determine firmness. Monitor uterine status more than every 8hr if it is boggy, not midline, w/ heavy flow of lochia or clots are present. · When uterus is firmly contracted the uterine BVs are compressed by the myometrium & bleeding is controlled. Why we want mom to have contractions, manifest as after-pains. -Checking the uterus after C-section—palpate carefully bc incision is very tender. Inspect it for approximation, bleeding, s/s of infection (edema, foul odor, drainage, redness). Check suture line, staples, steri-strips for intactness. Teach the patient about normal healing, s/s infection, incision care while you're assessing. -If fundus is higher and not midline—usually deviated to the right; bladder distension is suspected. Tell her to void, then remeasure the uterus. If unable to void after delivery, an in & out cath may be indicated, esp. if she had an epidural & still can feel the need to void. ALWAYS have her void before an ABD or fundal exam. -If breastfeeding, oxytocin is released by the posterior pituitary in response to suckling, helps with uterine contraction & involution. Getting the baby to breastfeed right after delivery is vital in helping uterus contact & assist w/ involution.

Explain the baseline FHR and evaluate periodic changes

Baseline FHR: § Normal: 110-160BPM; 26-28wks on upper end of range § Bradycardia: <110BPM for 10min+; indicates maternal or fetal decrease in BF, or neurological issues. § Tachycardia: >160BPM for 10min+; most common issue, FHR >160BPM. Common cause is maternal fever. o Baseline FHR Variability: the movement between the beats. Fluctuations in the baseline FHR that cause the printed line to have a wave-like appearance, rather than a smooth/flat one. Shows the ability to adapt to stress; function of ANS, esp. PS branch. o Absent: undetectable/no variability noted, ex. FHR constantly 140BPM, but no movement from beat-to-beat. This is usually a problem—on meds or very stressed. o Minimal: <5BPM—baby could just be resting o Moderate: 6-25BPM, average around 20BPM o Marked: >25BPM—can indicate neurologic or other problems in baby o Accelerations: FHR goes up temporarily from the baseline >15BPM for >15s. Associated w/ fetal movement & is usually reassuring. Accelerations occur from contractions, means perfusion is good. Responsive CNS & absence of acidosis. Preterm fetus (<32wks)- 10x10 is healthy; fetus <28wks will appear flat. o Prolonged: >2min but <10min. o Accelerations >10min: change in the baseline or merging of several accels that later return to previous baseline. o Early Decelerations: fetal head compresses, increasing ICP, vagus slows the FHR. NOT associated w/ compromise; no intervention needed. FHR goes down w/ contraction (esp. 2nd stage). Look consistent, uniform, mirror the contraction, return to baseline by end of the contraction. Nadir (low pt; usually no lower than 30-40BPM from baseline) of FHR=contraction peak. Contractions decrease BF to the baby, so when the contraction occurs we expect to see FHR go down. § Maternal position changes usually have no effect on pattern—bc it is caused by uterine contractions pressing the baby. § Associated w/ fetal head compression—head is compressed as it moves down during contraction. § Not associated with fetal compromise—early decelerations are associated w/ labor. § Continue to monitor mom & baby, we need these contractions for labor to progress. o Late Decelerations: indicate a problem w/ baby; impaired O2/waste exchange in placenta (uteroplacental insufficiency)= late/delayed decels. Poor O2 in placenta causes shift to anaerobic metabolism= acidemia (depresses CV function). Cause can be acute or transient like maternal hypotension, or excessive uterine stimulation (tachysystole). Can be chronic, maternal HTN or DM. Can occur w/ reassuring s/s: normal baseline FHR w/ mod. variability & accels; means fetus is tolerating conditions--but w/o Tx fetal reserves will deplete & reassuring s/s will disappear. o Begin after contraction begins (shifted to the Rt; often near peak)—gradually fall from baseline & return to baseline after the contraction is over. Look consistent & subtle; similar to each other. o Nadir occurs after peak of contraction; its usually 5-30BPM lower than baseline FHR & rarely lower than 40BPM below baseline. o FHR may remain in normal range and not fall far from baseline; magnitude of fall does NOT indicate degree of uteroplacental insufficiency. o Reflect possible impaired placental exchange—no placental reserves, this baby is compromised. o Variable Decelerations: conditions that reduce BF through the umbilical cord; non-uniform in appearance. Shape, degree, & & duration of fall from baseline are variable. Fall/rise abruptly (w/in 30s) w/ onset & relief of cord compression--unlike the gradual rise/fall of early & late decels. May be non-periodic, occurring at times not rt contractions.

Newborn Assessment: Mouth & Head

Newborn Assessment: -Mouth: normal mouth palate is intact; Assess by taking gloved finger (pinkie) & feel the roof of the mouth to check for intactness—an open palate if in w/ trachea can lead to aspiration. -Abnormal is a cleft palate/lip—requires special feeding (ex. feeding tube for severe, longer bottle nipple for mild to reach past deformity to allow for swallowing w/o aspiration), facial deformities also impede bonding—reassure parents that the deformity can be fixed w/ OP. May take multiple OPs, w/ tubes inserted; ensure the baby does not touch or pull the tubes, may need restraints. Ensure parents know about all follow-ups. -Check gums, lift up the tongue (tongue tied-frenulum goes to the teeth reduces proper sucking), pearls (look like teeth), or may have an actual tooth coming through (rare). -Head: Round—only round if had a CS. Vaginal w/ vacuum extractor or forceps can cause bruising. -Fontanels: Anterior & Posterior; slightly elevate head w/ 1 hand & run fingers of other hand over the fontanel. Anterior is diamond shaped where the frontal & parietal bones meet, measures 4-5cm from bone to bone—should be soft & flat, even w/ surrounding bone. Posterior is toward the back, triangle shaped, where occipital & parietal bones meet—smaller & measures 0.5-1cm. Posterior closes by 2-4mo old, Anterior closes by 18mo old. Assesses dehydration, fluid status—babies have higher amount of fluid as total weight—dehydration can occur quickly, & anterior fontanels may appear sunken. Bulging of the fontanel may indicate increased ICP. -Cephalohematoma: bleeding between the periosteum & skull caused by pressure during birth; bruising/swelling on 1 side of the head (suture line), usually caused by vacuum extractor assisted delivery. Can occur on both sides of the head, usually over parietal bones. When the fluid crosses the suture line, deviation in the middle will be absent—this is caput. Risk for jaundice.

Serum values for Na, K, Ca, Mg, P; what can cause high & low

-Sodium (Na+): 136-145 mEq/L; Elevated: Hypernatremia; dehydration; kidney disease; hypercortisolism. Low: Hyponatremia; fluid overload; liver disease; adrenal insufficiency. -Potassium (K+): 3.5-5.0 mEq/L; Elevated: Hyperkalemia; dehydration; kidney disease; acidosis; adrenal insufficiency; crush injuries Low: Hypokalemia; fluid overload; diuretic therapy; alkalosis; insulin administration; hyperaldosteronism. -Calcium (Ca2+): 9.0-10.5 mg/dL; Elevated: Hypercalcemia; hyperthyroidism; hyperparathyroidism Low: Hypocalcemia; vitamin D deficiency; hypothyroidism; hypoparathyroidism; kidney disease; excessive intake of phosphorus-containing foods and drinks. -Magnesium (Mg2+): 1.8-2.6 mEq/L; Elevated: Hypermagnesemia; kidney disease; hypothyroidism; adrenal insufficiency Low: Hypomagnesemia; malnutrition; alcoholism; ketoacidosis. -Phosphorous (P): 3.4.5 mEq/L; Low: hyperventilation, sepsis, alcohol withdrawal, diuretics, heat stroke, Tx of hyperglycemia w/ Insulin, malabsorption. Elevated: renal failure (GFR <30), renal impairment, resp acidosis, chemotherapy, Increased dietary intake, Meds containing phosphorous (laxatives, enemas, Vit. B supplements), Infants that are fed cows milk.

Abruptio Placentae

Abruptio Placentae: placenta comes off the lining of the uterus. Blood may be visible or concealed, darker (w/ possible clots) bc its higher in the uterus, increases time to move into vaginal canal so it oxidizes. Almost always w/ severe pain, uterine tenderness & hyperactivity. Normal uterine resting tone is 20 or less, abruption will be higher than this. Can contribute to bleeding disorders like DIC—when the clotting factor thromboplastin is released into the maternal blood stream bc of placental bleeding & clot formation. Can be a complication of preeclampsia. -S/S: Abdominal pain with no palpable relaxation between contractions. Placental separation often begins at the top of the uterus, allowing some blood to seep into the uterine wall. This causes abdominal rigidity & pain; also manifested in a uterus that does not seem to relax between contractions. · S/S of Concealed Hemorrhage in Abruptio Placentae: placental margins still intact so it starts bleeding behind the placenta. o Fundus gets very hard & increase in height bc blood accumulates w/in uterus & doesn't come out. o Hard, board-like abdomen o High uterine baseline tone on monitor. o Persistent abdominal pain o Systemic signs of early hemorrhage—increased HR o Persistent late decelerations on monitor, why we don't wait, call for help ASAP. o Vaginal bleeding that may be slight or absent

Identify the principal techniques for performing a physical examination on a child

Techniques for Physical Examination: 1.) Inspection: visual observation- survey an area, then focus on size, color, shape, movement. Direct = w/ eyes, Indirect= w/ equipment 2.) Palpation: use touch to ID pulsations & vibrations, locate structures & masses 3.) Percussion: tapping of the fingers to produce sounds, ID position, size & density of structures 4.) Auscultation: listening to body sounds of the heart, lungs, BVs, ABD; usually w/ stethoscope. Diaphragm= high pitched sound; heart & lungs. Bell= low pitched sounds; BVs & BP. Assess pitch, intensity, duration, quality. 5.) Smell: general body orders are common in kids who are neglected or dirty. Odor can be infection—check mouth, urine, feces. Mouth odor can be from particular dz. • ABD exam: not normal order bc you don't want to change bowel sounds; first inspect, then auscultate, percuss, & palpate last. Percussion ID size of ABD organs before you palpate.

Developmental milestones & their relationship to communication approaches: Preschoolers, School-Age, Adolescents

Developmental milestones & their relationship to communication approaches: o Preschool (3-5yrs): use words they don't fully understand, don't fully understand words used by others. Language- further developed word combination (full sentences), growth in grammar usage, use pronouns, clearer articulation, vocab. expansion is rapid but may not understand words they use. Emotional- like to imitate activities & make choices, strive for independence but need adult support & encouragement, purposeful attention-seeking behaviors, learn cooperation & taking-turns in games, need clear limits & boundaries. Cognitive- begin to develop concepts of time, space, quantity; prominent magical thinking, only see from their perspective, short attention span 5-10min. RN Communication: offer choices, explain activities/Tx w/ play, use simple sentences & relative concepts, use pictures/storybooks & puppets, describe activities/Tx as they are about to be done, be concise & limit explanation to 5min, prep activities occur 1-3hrs before event. o School-Age (6-11yrs): can communicate thoughts & appreciate other viewpoints, words w/ multiple meanings & those describing things not yet experienced are not fully understood. Language- expanding vocab. allows to describe concepts, thoughts, feelings; conversational skills develop. Emotional- interact well w/ others, understands game rules, very interested in learning, build close friendships, begin to accept responsibility for actions, competition emerges, still depended on adults to meet needs. Cognitive- understand concepts of classification & conversation, emergence of concrete thinking, very "rule" oriented, process info in serial format, lengthened attention span 10-30min. RN Communication: to explain use photos, books, charts, diagrams, videos—make explanation sequential, engage in conversation that encourages critical thinking, set limits & consequences, used medical play techniques, prep materials used 1-5 days before the event. o Adolescents (12yrs+): can create theories & generate many explanations for situations, begin to communicate like an adult. Language- can verbalize & understand most adult concepts. Emotional- begin to accept responsibility for actions, perception of "imaginary audience", need independence, competitive drive, strong need for group ID, usually have small group of very close friends, question authority, strong need for privacy. Cognitive- think logically & abstractly, attention span up to 60min. RN Communication: engage in conversation about their interests; to explain use photos, books, charts, diagrams, videos; collaborate w/ them & foster/support independence, prep materials given 1wk before event, respect needs for privacy.

Dx AKI/CKD: labs

Dx AKI/CKD: labs -Monitor lab values for any changes that reflect poor kidney function. Monitor fluid status (strict I&Os, daily weights). -Monitor urine, report new sediment, hematuria (smoky or red color), foul odor, or other worrisome changes. Report UO of less than 30 mL/hr for 2 hours or dark amber urine. 6 hrs of oliguria to meet AKI criteria may allow progression of kidney damage. -Increase in Cr (may be subtle), esp. when it occurs over hrs-days, is a concern--report to HCP! Increase of 1-2mg/dL every 24-48hrs, OR increase 1-6mg/dL in a week or less. -Serum BUN: may be elevated, if very high will lyse RBCs and cause anemia. Usually elevated in CKD. -Potassium(3.5-5.0): increased (ECG shows peaked T, wide QRS, absent p wave. -Sodium(136-145): nml, increased, or decreased (not a good indicator) -Phosphorous(3.0-4.5): increased -Calcium(9.0-10.5): decreased -Magnesium(1.3-2.1): increased or decreased -Osm(285-295): elevated in FVD, increasing AKI risk -Urine SG(1.010-1.025): can be dilute or concentrated. -Sediment: RBCs, casts, tubular cells, Mgb, Hgb can damage nephrons. -Know the baseline (steady-state) GFR because a reduced GFR makes the patient more vulnerable to AKI. -Know all nephrotoxic drugs, question the prescription (esp. if 2+ meds), if it must be used, monitor labs--Cr, BUN, peaks/troughs. ---If contrast agent must be used, withhold nephrotoxic drugs (ex. Metformin) for 24hrs before/after, give IV fluids before/after as well.

Hypo/Hyperkalemia

Hypokalemia: (think alkalosis) -Causes: Prolong intestinal suction, recent ileostomy, some adenomas, Diarrhea, Vomiting, Diuretics like thiazide, furosemide, corticosteroids, insulin and some antibiotics. Potassium levels drop with adrenergic agonists (Benadryl, Albuterol) -S&S: Muscle weakness esp in the legs, paresthesia develops, deep tendon reflexes decreased, constipation (the chronic use of laxatives will often result in K+ loss, which then worsens the constipation) Treatment: High potassium diet and additional supplements may be needed, along with IV Potassium (Make sure patient is producing urine first!!) Nursing Safety Priority: Assess respiratory status of a patient with hypokalemia at least every 2 hours because respiratory insufficiency is a major cause of death. Implementation: Monitor ECG, especially if client is on digitalis, Carefully replace K+ -Hyperkalemia: (think acidosis); Less common, much more serious. Most dangerous, potassium is gained through intake and lost through excretion so it is rarely seen on patients with functioning kidneys. -Medication causes: ACE inhibitors, some antibiotics, beta blockers, hemo, INSAIDS, ASA, potassium supplements. Acute or chronic renal failure can be caused by multiple diseases or trauma, severe burns can release intracellular potassium. -S&S: Paresthesia's are an early symptom followed by weakness or flaccid paralysis. Irritability & Anxiety, Decrease BP, abdominal cramping, diarrhea - typically manifest in neurological and cardiovascular changes!! -Diagnostics: EKG Abnormalities (Tall peaked T waves, Long PR interval, Disappearing P wave), -Treatment: Mild increases may be treated with loop diuretics to increase loss. If severe renal failure then hemodialysis is the treatment. Kayexalate and Sorbitol are common treatments. -Implementation: Monitor ECG, Insulin plus IV glucose to redistribute K+, fluid to increase urinary output.

Aplastic Anemia

-Aplastic Anemia: impaired cellular regulation of the BM, fail to produce RBC cells; sometimes occurs alone, but often w/ leukopenia & thrombocytopenia (Pancytopenia: low RBCs, WBCs, & platelets). Caused by injury to pleuipotent ST cell--Long exposure to toxic agents, radiation, infection, Fanconi (hereditary), drugs that impair the hematologic system. -S/S: pallor, weakness, fatigue, tachycardia, bleeding, weak immunity (if low WBC). Severe anemia, CBC macrocytic anemia, leukopenia and thrombocytopenia. Biopsy shows replacement of the red BM that forms RBC with fat. -Interventions: risk of infection & hemorrhage -Isolation precautions if low WBCs -Blood transfusion - just when life threatening thrombocytopenia, due risk of immune reactions to platelets -ST Cells transplant: most successful Tx -Drug discontinuation -Immunosuppressive therapy: if autoimmune ds present; Steroids-Prednisone, antithymocyte globulin (ATG), and cyclosporine for remission. Moderate aplastic anemia: daclizumab to improve blood counts and transfusion requirements. Splenectomy may be needed. HSCT when pt is able to undergo and have a suitable donor -RN: patient on reverse isolation, monitor neutrophils: <1000 mod risk, <500 severe risk. Risk of bleeding: platelets <50,000 moderate; <20,000 severe risk.

Age-related changes affecting the eye and vision

Age-related changes affecting the eye and vision: -Appearance: Eyes look sunken because of loss of fat in the orbital, so this is no longer an indicator of hydration status. --Arcus Senilis forms- opaque, bluish-white ring within the outer edge of the cornea, caused by fat deposits. Tell the patient this doesn't affect vision. --Sclera yellows (fat deposits) or looks blue (thinning)- can no longer be used to assess for jaundice. -Cornea: flattens, blurring vision and can cause/worsen an astigmatism. Encourage patient to make regular eye appts. and wear prescribed lenses. -Ocular muscles: Muscle strength reduced, making it more difficult to maintain upward gaze or focus on a single image. Tell the patient this is normal, and to refocus gaze frequently to maintain a single image. -Ectropion- The lower eyelid may relax and fall away from the eye, leading to dry eye S/S, infection. -Entropion is when the lid turns in—both effect lubrication and cause dry eyes. -Pitosis- drooping of the eye lid. -Lens: Elasticity is lost, causing the near point of vision to increase (ex. Presbyopia- patient will have to hold a book farther away to see it). The far point of vision decreases, meaning the farthest point at which things can be seen clearly decreases. Together these all narrow their visual field. Encourage them to wear corrective lenses. The lens hardens, compacts, and forms cataracts—reducing accommodation. Emphasize importance of annual vision checks and monitoring. -Iris and Pupil: Decreased ability to dilate results in small pupil size & poor adaptation to darkness. More light is needed to stimulate the visual receptors. Tell patient good lighting is needed to prevent injuries. -Color vision: Discrimination among greens, blues, and purples decreases. Color indicator monitors of health may not be useful. -Tears: Production is reduced, leading to dry eyes, discomfort, and corneal damage or infections. Teach proper use of saline drops, and to increase humidity within the home.

Aggressive therapy: Hemodialysis

Aggressive therapy: Hemodialysis -Occurs 3x/week for 3-4 hours -Diffusion: toxins diffuse across the semi-permeable membrane from higher concentration in the blood to the lower concentration of the dialysate. Toxins and waste moved out of body. -Dialysate solution: ideal concentration of F&E, K+Na move out of body into dialysate, and Ca+HCO3 move into body from dialysate. Fresh dialysate is constantly introduced. •Osmosis: Excess Fluid is removed from high concentration in serum to low concentration in dialysate. •Ultrafiltration: the separation of particles from a suspension by passage through a filter with very fine pores. In ultrafiltration, the separation is performed by convective transport. Moves fluid more efficiently. Ultrafiltration+vL removal changes the pressure in the vessel. Dont give anti-HTN drugs before dialysis--cause hypotensive shock. Tell dialysis RN right away if you did give the drugs, so they can alter the dialysis/monitor the pt. -Heparin, citrate, or protamine sulfate used to prevent clotting. -In HD, restrict protein because of high BUN. -HD not for patients with bad vascular system, or pt who are caregivers bc of time. In cancer pt, place a medi-port bc bad vasculature.

Assessment of the Ear: for patient with suspected hearing loss -Whisper -Tuning fork -Otoscopic -Audiometry: tone/speech

Assessment of the Ear: for patient with suspected hearing loss -Use Contact Precautions- drainage may be present. -Whisper test- occlude 1 of patients ears or ask them to do it. Stand 1-2 ft away from unoccluded ear. Whisper numbers/letters and ask patient to repeat what you said. Patient should be able to correctly repeat 2 syllable words. -Tuning fork test- measures bone/air conduction. Rhinne and Weber- compare the time of air and bone conduction. -Otoscopic exams with an otoscope- assess ear canal (patency, lesions, cerumen), eardrum (color-inflammation, surface-intact, cone of light), middle ear structures seen through the ear drum. Pt must be relaxed/compliant or you could damage the eardrum. -Audiometry- performed by an audiologist, is the most reliable method of measuring the acuity of auditory sensory perception. Pure tone audiometry is used to assess hearing acuity (and demonstrates hearing loss). The test is done in a soundproof area and requires the patient to respond when a sound is heard. Speech audiometry is used to assess how intense (or loud) a simple speech stimulus must be before the patient can hear it well enough to repeat it correctly at least 50% of the time. Specific sounds are admin at different frequencies, then measure the intensity at which speech can be recognized and interpreted. -Tympanometry: Used to assess eardrum mobility by changing air pressure in the external air canal. Used to assess middle ear problems (and recovery after treatment and/or surgery), eustachian tube patency, eardrum perforation, and/or fluid and wax accumulation. It's an indirect measurement of compliance/impedance of the middle ear of sound transfer. RN teach that there may be some discomfort while a probe is in the ear, and that sounds heard during the procedure may be loud.

Burn Injuries

Burn Injuries: Ranges from a small painful area to most of the body; Infants and toddlers at greater risk; Unintentional or intentional; A leading cause of death and injury in children. Assessment priority= Airway. -Depth of Burn Injury: • Superficial: Destruction of epidermis; physiologic function intact • Superficial partial thickness: Destruction of epidermis and some dermis • Deep partial thickness: Destruction of epidermis and dermis • Full thickness: Destruction of epidermis, dermis, and underlying tissue • Extent: TBSA; To calculate TBSA the Lund and Browder chart is used; Corrects for age of the child. • Severity: Local or systemic reaction • Calculating total body surface area (TBSA) burned in children. The standard "rule of nines" and standard body surface charts must be adapted because of the difference in body proportions between adults and children. • Therapeutic Management: Tx priority= maintain F&E balance. • Wound cleaning: Burns should receive care at least daily until closure. Hydrotherapy - NO >20min, to prevent electrolyte loss through osmosis. • Debridement: Removal of dead material (eschar) • Protection: Application of antimicrobial agents and dressings. Burn dressings can be changed in the hydrotherapy room. The room is kept warm because children who have been burned have poor body temperature control. The child life therapist reads a book to the child to distract her from the discomfort associated with the procedure. -Pediatric Differences: Children who sustained burn injuries are at increased risk for the following • Higher mortality rate; More severe burns; Fluid & heat loss; Hypertrophic scarring; CV problems; Infection; Protein & calorie deficiency. Conditions with Sever Burns: Burn Shock • Hypovolemic (>15 - 20% of TBSA in children): All capillaries lose their capillary seal resulting in leakage into interstitial spaces; 24-48hrs. Tx: aimed at supporting until integrity is restored; fluid resuscitation. UO reflects end-organ tissue perfusion so insufficient urine indicates insufficient fluid replacement.

Care of the Patient With Reduced Vision

Care of the Patient With Reduced Vision: • Always knock or announce your entrance into the patient's room or area and introduce yourself. • Ensure that all members of the health care team also use this courtesy of announcement and introduction. • Ensure that the patient's reduced vision is noted in the electronic health record, communicated to all staff, marked on the call board, and identified on the door of the patient's room. • Determine to what degree the patient can see. • Orient the patient to the environment, counting steps with him or her to the bathroom. • Help the patient place objects on the bedside table and do not move them without the patient's permission. • Remove all obstacles and clutter between the patient's bed and the bathroom. • Ask the patient what type of assistance is preferred for grooming, toileting, eating, and ambulating; communicate these preferences with staff. • Describe food placement on a plate in terms of a clock face. • Open milk cartons; open salt, pepper, and condiment packages; and remove lids from cups and bowls. • Unless the patient also has a hearing problem, use a normal tone of voice when speaking. • When walking with the patient, offer him or her your arm and walk a step ahead.

Describe the physiologic changes that occur during pregnancy: VS

Changes during Pregnancy: -CV System: Expanded BvL- increases CO, but not BP. About 1.2-1.6L of extra fluid, helps get blood to placenta and baby as they grow (RAAS). Plasma vL expansion results in physiologic (pseudo) anemia. Because of the increase in vL of plasma, there are less RBCs per vL. Need iron supplementation. -Decreased Vascular resistance- caused by progesterone, helps BF, fetal/maternal heat go into or be taken out of body. So if mom has a high temp she can more easily remove the heat. -Vasodilatation- results from decreased vascular resistance. -Slight increase in HR- about 10-15 BPM starting around 32wks. -Supine hypotensive syndrome- if mom lays on back it will partially occlude the vena cava & aorta because of the wt of the baby. Correct this syndrome—during pregnancy we recommend mom lay on her left or right side. Left is best side for cardiac perfusion though—just no laying on her back. -Respiratory System: Impacted by progesterone & prostaglandins. Slight hyperventilation and decreased airway resistance allow oxygen needs to be met. · Done by relaxing smooth muscle in the respiratory tract. Raises sensitivity of the respiratory center in the medulla oblongata to CO2, which increases ventilation. Keeps perfusing blood O2 to the baby. -Increased GFR may result in spilling of glucose & other nutrients into the urine.

Chronic cholecystitis

Chronic cholecystitis--most often results when repeated episodes of cystic duct obstruction cause chronic inflammation. Calculi are almost always present. The gallbladder becomes fibrotic and atrophied, which results in decreased motility and deficient absorption. -Risk: Thin athletic women, low fat diet (vegetarian)-chronic cholecystitis without calculi. -S/S: jaundice (can occur in acute or chronic, but more in chronic). Icterus- yellow eyes (occur in both, but mostly chronic), obstructive jaundice-causes pruritis & burning. Clay colored stool, dark urine. ABD pain of chronic cholecystitis may be vague and nonspecific. ABD pain or discomfort that can radiate to the right shoulder/scapula. More pain w/ DB-"Bloomberg Sign", N/V, anorexia, fat intolerance, feel full/ABD distension, beltching, flatulence, indigestion, light-headed, chills/low fever. Severe S/S listed, occur during an "attack". --Pancreatitis and cholangitis (bile duct inflammation ) can occur as chronic complications of cholecystitis.

Complications and Treatment of HD

Complications and Treatment of HD: Full assessment before, during, after ---Blood loss •Clinical manifestations: Hypotension, Visualization of blood •Interventions: Rinse back blood, Monitor heparinization, Pressure on access site ---Disequilibrium syndrome •Clinical Manifestations: N/V, Confusion/Restlessness, Headache, Twitching/jerking, Seizures, Hypotension, cerebral edema--pulled too much FvL •Interventions: Stop or slow dialysis, Seizure Precautions, Hypertonic saline, albumin, mannitol. ---Hypotension •Clinical manifestations: Lightheadedness, N/V, Seizures, Vision changes, Chest pain •Interventions: Decrease volume removed, Infuse 100-300ml of normal saline, Elevate feet, Recurrent- hold BP meds prior to HD. ---Muscle cramps •Clinical manifestations: Very painful •Interventions: Reduce rate, Infuse hypertonic or normal saline ---Sepsis •Aseptic technique •Monitor: Fever, Hypotension, Increased WBCs

Drug Therapy for Glaucoma

Drug Therapy for Glaucoma: -Eyedrops: allows better circulation and decreases the IOP. Do not improve vision loss but only prevent further damage. Precise time administration is priority. -Drug Categories: -Prostaglandin Agonist: Bimatoprost, Travoprost, Latanoprost. Check cornea! If it's not intact, DO NOT USE. Darkening of eye color & elongation of eyelashes are NORMAL. DO NOT USE IN EYE WITH NORMAL IOP because it will LOWER it and reduces vision. Blocking receptors will increase if drug is overused. -Adrenergic Agonist: Apraclonidine, Brimonidine ,Titrate. Enzyme inhibitors like antidepressants from MAO class, will INCREASE BP. Pupils are dilated and remains dilated so tell pt to wear sunglasses. Do not use these when you have contacts on because it will discolor it or make it cloudy. -Beta-Adrenergic Blockers: Betaxolol Hydrochloride,, Carteolol, Levabunolol, Timolol. If pt has moderate to severe COPD or asthma, this drug type are absorbed systematically—constricting pulmonary smooth muscle and airways. Can induce hypoglycemia and can mask the hypoglycemic symptoms. If pt already taking oral beta blocker, do not administer if HR is below 60beats/min. Cholinergic Agonist: Carbachol, Echothiophate, Pilocarpine. Report if there is any increase salivation because it is readily absorbed by conjunctival mucous membranes. Report systemic symptoms of headaches, flushing, increased saliva and sweating. Use good light when reading and to turn lights on in the room because client will be risk for falls. Carbonic Anhydrase Inhibitors: Brinzolamide, Dorzolamide. Ask pt if they are allergic to sulfa drugs because this drug type is considered sulfonamide. Shake drug. Don't apply it when you have contact lens on; will discolor it

Interventions for Thrombocytopenic purpura

Interventions for Thrombocytopenic purpura: -Platelet transfusions: platelets are <10,000/mm3 or when the patient has an acute life-threatening bleeding episode. Platelets don't go on a pump, bc quicker is better (gravity)! -Maintaining a safe environment: protect the patient from bleeding. Closely monitor the amount of bleeding that is occurring. -Drug therapy: to control ATP & TTP, drugs that suppress immune function. Ex. corticosteroids, azathioprine, eltrombopag, rituximab, and romiplostim are used to inhibit production of antibodies directed against platelets or endothelial cells. --ATP: IV immunoglobulin & IV anti-Rho, help prevent the destruction of antibody-coated platelets. --Aggressive Tx: low doses of chemo. --TTP & HIT: also Tx w/ anticoagulants. --TTP: platelet inhibitors such as aspirin, alprostadil, & plicamycin. Plasma removal and the infusion of FFP (plasma exchange) reduce the clumping caused by elements in the pt blood. This Tx for autoimmune TTP has been responsible for dramatically increasing the survival rate. FFP doesn't go on a pump, but on gravity! --HIT: includes a direct thrombin inhibitor such as argatroban or lepirudin -Surgical management ATP: splenectomy for those patients who do not respond to drugs. (In ATP the spleen is the site of excessive platelet destruction.) --Splenectomy is usually not for TTP & HIT. --Depending on spleen size & risk for bleeding, may be open ABD Op or MIS by laparoscopy. RN post-op care is same as ABD Op. Post-op, increased risk for infection bc the spleen performs many protective immune functions, esp antibody generation. Vaccinations against pneumococcal and meningococcal disorders and Haemophilus influenzae are recommended- 2wks before planned Op or 2wks after. Teaching patients about their increased risk for infection, avoiding crowds and people who are ill, and when to consult with the primary HCP is RN priority.

Patient education with dialysis

Patient education with dialysis: •Hemodialysis-Client is attached to dialysis machine via a surgically created AV shunt -4 hours - 3 times a week -Complications: Infection, Thrombosis, Ischemia of the hand •Peritoneal dialysis-Dialyzing fluid is introduced via catheter into peritoneal cavity -4 exchanges 1 day, 7 days a week -Complications: Peritonitis, Bleeding -Teach: wt gain 2-3lbs is expected, if less not drinking enough, if more drinking too much. Must weight every day!

Presbycusis

Presbycusis is a type of sensorineural hearing loss that occurs with aging, it's the degeneration of cochlear nerve cells, loss of elasticity of the basilar membrane, or a decreased blood supply to the inner ear. Hair cells of cochlea degenerate, causing progressive hearing loss. S/S: high tones lost first, patients speech is louder than average, may appear angry or depressed. --Deficiencies of vitamin B12 and folic acid increase the risk for presbycusis. -Because it is so gradual the patient may not realize their hearing has degenerated—may appear withdrawn and they don't join in on conversations. -For this type of sensorineuro hearing loss, hearing aids and other amplification devices ARE useful. -RN: reduce background noise, get their attention when speaking, face patient when speaking, encourage them to use hearing aid—especially important in hospital where education is key! This will reduce their frustration when speaking to you or family, and they wont need to ask people to constantly repeat words.

Prioritize care and educational needs for patients with primary open-angle or closed-angle glaucoma

Prioritize care and educational needs for patients with primary open-angle or closed-angle glaucoma: -Glaucoma: group of eye disorders resulting in increased IOP. Untreated it can lead to complete loss of visual sensory perception. Glaucoma is usually painless, and the patient may be unaware of gradual vision reduction. -Primary open angle glaucoma/chronic (POAG); most common (90% cases), Higher in African Americans, gradual increase in IOP, affects both eyes, minimal S/S in early stages. Early: eye/headache, mild foggy vision. Later: headaches, halos around lights, loss of peripheral vision near vision "tunnel vision", and night vision. Usually painless. -Treat w/: miotics, adrenergic antagonists, B-blocker (timolol), Carbonic anhydrase inhibitors. Teach med compliance! --Need regular tonometry. -Op: pt lay on side of body of unoperated eye. Protect eye with patch/shield. -Acute Glaucoma/Narrow/Primary Angle Closure (PACG): EMERGENCY. 10% of cases. Higher in Asians, abrupt/sudden increase IOP, rapid progression, usually unilateral, obstructed outflow. Anything that causes pupil dilation can cause an episode. S/S severe eye/face pain, N/V, colored halos around lights, sudden decrease in vision, red eyes, dilated/non-reactive pupils, may first see pupil dilation. -Energency: pilocarpine or mannitol will rapidly decrease IOP, constrict pupils (miosis) & enhances outflow of AH, its a systemic osmotic drug. -Caused by: DM, HTN, Severe myopia, Retinal detachment

SCD

SCD: genetic disorder in which a mutation in the gene for the beta chains of Hgb causes chronic anemia, pain, disability, organ damage, increased risk for infection, and early death as a result of poor blood perfusion. Higher incidence in people of African decent. -SCD: >40% of the total Hgb is composed of 2 normal alpha chains and 2 abnormal beta chains (HbS) that fold poorly. HbS is sensitive to low oxygen content of RBCs, which causes them to fold even more, distorting the cells into sickle shapes. Average life span of an RBC w/ 40%+ of HbS is about 10-20 days—causes hemolytic (blood cell-destroying) anemia in patients with SCD. -The average life expectancy of adult men with SCD is 42 years and for women with SCD is 48 years. -Conditions that cause sickling: hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol consumption, high altitudes, low or high environmental or body temperatures, acidosis, strenuous exercise, emotional stress, nicotine use (esp. cigarettes), and anesthesia. -Dx: family Hx-Genetic counseling, Blood tests, xray. Dx based on the HbS% on electrophoresis. AS usually has less than 40% HbS, and the patient with SCD may have 80% to 100% HbS. This percentage does not change during crises. Another indicator of SCD is the # of RBCs w/ permanent sickling. This value is <1% among people with no Hgb disease, 5%-50% among people with AS, and up to 90% among patients with SCD. -Lab tests can indicate complications: -Hct low (between 20% and 30%) because of RBC shortened life span and destruction. Value decreases more during crises or stress (aplastic crisis). -Reticulocyte count is high, indicating anemia of long duration. -Total bilirubin level may be high because damaged RBCs release iron and bilirubin. -WBC count is usually high. This elevation is related to chronic inflammation caused by tissue hypoxia and ischemia. -X-Ray: skull may show changes as a result of bone surface cell destruction and new growth, giving the skull a "crew cut" appearance on x-ray. Joints may show necrosis and destruction. -US, CT, PET, and MRI may show soft-tissue and organ changes from poor perfusion and chronic inflammation. -ECG: changes indicate cardiac infarcts and tissue damage. Specific ECG changes are related to the area of the heart damaged. -Echocardiograms may show cardiomyopathy and decreased cardiac output (low ejection fraction).

Sensorineural hearing loss

Sensorineural hearing loss: occurs when the inner ear or auditory nerve (CN VIII) is damaged. Prolonged exposure to loud noise damages the hair cells of the cochlea. Many drugs are toxic to the inner ear structures, effects on hearing transient or permanent. -Sound waves are effectively transmitted to inner ear, but receptor cells damaged/lost. -Sensorineural hearing loss is often permanent. Hearing aids are NOT useful. Causes: Prolonged exposure to noise-factory workers or airline workers, Presbycusis, Ototoxic substance (aminoglycosides, Lasix, chemo, antimalarial), Meniere's disease, Acoustic neuroma, Diabetes mellitus, Labyrinthitis, Infection, Myxedema, aging process. -Assessment: Normal appearance of external canal and tympanic membrane, Tinnitus common, Occasional dizziness, speaking loudly, Hearing poorly in loud environment. -Dx: Rinne test: air conduction less than bone conduction. Weber test: lateralization to unaffected ear Perception of high frequency tones effected, resulting in loss off hearing for higher pitch tones/voices, ex. female voices. -Hearing Aids: -Cochlear Implant: for sensorineural hearing loss in a patient with remaining/intact neurons or no neurons. Provides perception of sound, but not normal hearing. Ex. recognize cars, sirens, telephones, doors. It doesn't go into the inner ear so its not a surgery. -Electrodes are placed near the internal ear, with the computer attached to the external ear. The electronic impulses then directly stimulate nerve fibers.

Thrombocytopenic purpura: ATP, TTP, HIT

Thrombocytopenic purpura is the destructive reduction of circulating platelets after normal platelet production. -Two common types: --Autoimmune thrombocytopenia purpura (ATP): formerly called idiopathic thrombocytopenic purpura. Immune system begins making antibodies against their own platelet membranes (antiplatelet antibody). When these antibodies attach to platelets, WBCs attack & destroy the circulating platelets & those stored in the spleen faster than new platelets are produced. As the number of circulating platelets decreases, clotting is impaired. This disorder is most common among women age 20-50yrs & w/ people who have other autoimmune disorders. --Thrombotic thrombocytopenia purpura (TTP): also thought to be an autoimmune disorder, w/ the reaction occurring in small BV cells (endothelial) & triggering abnormal platelet clumping in these BVs. Results in too few platelets remain in circulation. The patient's blood forms clots & platelet plugs where they are not needed, yet the blood fails to clot when trauma occurs. Tissues become ischemic (from blockages), leading to KF, MI, & stroke. W/o Tx, often fatal w/in 3mo. --Heparin-induced thrombocytopenia (HIT): serious immune-mediated clotting disorder with an unexplained drop in platelet count after heparin tx. The problem is increasing bc of increased use of heparin. HIT is an immune-mediated drug rx that is caused by heparin-dependent platelet-activating antibodies that allow heparin to bind with platelet factor 4 (PF4). (The antibodies are directed against the heparin rather than patient's own cells.) Heparin+PF4 creates an immune complex that activates the platelets, causing the formation of many microclots that use up circulating platelets, leading to thrombocytopenia. HIT can occur in patients receiving any type of heparin, more common w/ unfractionated heparin. The incidence is higher among females, Tx w/ unfractionated heparin for >1wk. -S/S: 1st seen in the skin & mucous membs & result from excessive bleeding in these tissues. Changes include large ecchymoses (bruises) or purpura (a reddish-purple fine petechial rash) on the arms, legs, upper chest, and neck. Mucous membranes bleed easily. If the patient has had significant blood loss, anemia may also be present. --ATP: distinguished from TTP by the presence of antiplatelet antibodies in the blood. --TTP & HIT: also have small microclots can block capillaries in major organs, causing tissue ischemia. This problem increases the risk for kidney damage, MI, & stroke. Other problems associated with --HIT: also have venous thromboembolism & pulmonary embolism. Dx made by the clinical s/s & Hx of heparin therapy w/in last 100 days. --Platelets are low in all 3 types of thrombocytopenia. If bleeding, Hct & Hgb levels may be low.

Tetralogy of Fallot

• Cyanotic lesions with decreased pulmonary BF: an error in fetal development; hypoplasia (incomplete development) on the right side of the heart; decreases BF to the lungs—may need PDA to stay open, admin PGE; hypoxemia w/ cyanosis—even w/ supplemental O2, does not always help saturations. Limited pulmonary BF & marked exercise intolerance; w/ babies when you move them or when they cry. Chronic hypoxia leads to polycythemia. Ex. Tetralogy of Fallot, Tricuspid valve anomalies, Pulmonary Atresia w/ intact ventricular septum. -Tetralogy of Fallot: Cyanotic lesions with decreased pulmonary BF. Most frequent cyanotic lesion; constellation of lesions results from misalignment of ventricular septum during fetal G&D: VSD, RV outflow tract obstruction (pulmonary stenosis), overriding of the aorta (RV), RV hypertrophy. -Equal R & L ventricle pressures rt the pulmonary artery obstruction & size of the VSD; desaturated blood enters systemic system by shunting R to L across the VSD, or into the overriding aorta. -Onset & severity of s/s rt extent of pulmonary BF obstruction. Mild= sat mildly low, pink tet. S/S worse in neonate when DA closes; cyanosis, extreme fatigue, hypercyanotic episodes, chronic hypoxemia. Harsh systolic murmur w/ palpable thrill; boot-shaped heart rt poor G&D of pulmonary artery. Difficulty feeding, poor wt gain, tachypnea. Chronic hypoxia leads to polycythemia -Tx: manage tet-spells w/ knee/chest position (C-position) helps dilate the RV which decreases the obstruction, morphine, O2. PG1 maintain patency of DA & BF to the lungs. OP at 3-4mo old w/ CP bypass machine. o Hyper-cyanotic Episode: Occur more often with children <2yrs. Last a few min-few hrs. Caused by feeding or crying. -"tet spells": unrepaired (OP) Tetralogy of Fallot; Acute spasm of the RV; Hypoxia & can lead to metabolic acidosis; Rapid respirations, irritability, crying, peripheral vasodilation, severe cyanosis. -Tx: 1st try calming the child, place in knee-chest position ("C", or squat down); Administer O2; Morphine to decrease respiratory center and hyperpnea—helps them settle down & allows O2 to occur.