NUR 317 Final Exam for Ob/Peds

Fetal risk from Maternal Hemorrhage

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

Bone Healing and Remodeling

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

Genitalia and Anus

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

KD: Resolution and prognosis

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

Mixed Defects

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

Physical growth

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

Development of School Aged Child or Middle Childhood

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

Preeclampsia

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

Ovulatory factors: Problems R/T ovulation and hormonal activity

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

Lithium Batteries

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

Edema

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

Definition

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

Non-Hodgkin Lymphoma

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

Weight loss

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

Viral (Aseptic) Meningitis

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

Kawasaki Disease

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

Defects with increased Pulmonary Blood Flow

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

Diagnostic Studies

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

Non-opioid Drugs

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

Acetaminophen Poisoning

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

Salicylate Poisoning

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

Retinopathy of Prematurity

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

Appendectomy

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

Bacterial Meningitis

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

JIA ( Juvenile idiopathic arthritis)

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

Early Adolescence

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

Middle Adolescence

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

Late Adolescence

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

Pregnancy induced hypertension

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

Focal Seizures

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

Psychogenic Seizures

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

Nursing Diagnosis

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

Hepatic adaptations

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

Obstructive defects

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

Head

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

Other focal seizures

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

Preterm labor (PTL)

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

Nursing Care Prevent infection

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

Nursing Care - Assessment of Patient on Magnesium Sulfate

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

Nursing Care

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

Psychological Support

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

Nursing Assessment: Post Seizure

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

Patellar reflex and clonus

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

Neck

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

Abdomen

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

Psychological care

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

Nursing Care Management of Pre-eclampsia

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

Care Management

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

Bottle Feeding Tips

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

Basics of Breastfeeding

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

Septic Arthritis

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

Traction

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

Admission to Hospital

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

Diabetes Mellitus

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

Seizures: Clonic

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

Pubertal Growth for Boys

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

Overview of Tocolytic Drugs

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

Predicting Preterm Labor and Birth

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

Breast feeding Complications

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

Chest, lungs and Breath sounds

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

Complications of Oxygen Therapy

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

Diagnosing Viral Meningitis

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

Cardiac Dysrhythmias

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

Inhaled poisons: Carbon monoxide (CO)

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

Overview of Maternal risk factors

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

Heart

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

Other- Syphilis

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

Toxoplasmosis

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

Other- Varicella

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

Generalized Seizures: Tonic-Clonic Seizures

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

Generalized Seizures: Myoclonic Seizures

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

Early Childhood

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

Chronic Hypertension

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

Signs and Symptoms

Classic Triad Hypertension Edema Proteinuria

Etiology and Pathophysiology of Seizure

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

Face

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

Piaget's Cognitive Development

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

Epilepsy

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

Types of Cardiac Defects

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

Is Baby Getting Enough?

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

IBD

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

Mortality Data

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

Moderate-Severe Preeclampsia-Hospitalized

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

Gestational Age

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

Indications for Problems

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

Magnesium Toxicity

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

Cerebral Palsy (CP)

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

Poisoning

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

Post Partum Hemorrhage

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

Spontaneous Abortions (Miscarriage)

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

Post-Partum Infections

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

Anemia

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

Missed Abortions

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

Ectopic Pregnancy (First Trimester)

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

Placenta Previa

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

Placental Abruption (2nd & 3rd Trimester)

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

Risk factors

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

Pre-gestational diabetes mellitus

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

Diagnosing Meningitis and Therapeutic Management

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

Diagnosis, Management and Goals of fractures

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

Diagnosis & Management

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

Seizure response Dogs

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

Complex Focal Seizures

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

Clinical Presentation

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

Color

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

Neoplasmic Disorders

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

Prevention of PTL

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

Hypertension

Elevated Blood Pressure Compare with baseline B/P

Coping with Concerns: School Experience

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

Obstruction of Pulmonary blood flow and an anatomic defect

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

Fetal assessments

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

Coping with Concern: Stress and Fear

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

RHD Presentation

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

Meningitis 3 Classic Signs

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

Clinical diagnosis

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

Magnesium Sulfate for Fetal Neuro-protection

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

Preexisting Conditions

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

Advantages to Formula Feeding

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

Confidentiality

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

Necrotizing Enterocolitis (NEC)

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

Gastrointestinal adaptations

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

Snake Bites

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

Urinary Tract Infections

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

Enhancing Let-Down Reflex

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

Other Signs

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

The Infertility Study

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

Nursing Implementation

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

Biologic Development of Middle childhood

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

HELLP syndrome

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

Hemophilia

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

Cardiovascular Dysfunction

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

Treatment/Management

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

Discharge planning and Teaching

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

Diseases of Prematurity

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

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

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

Drug Therapy

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

KD Treatment: Meds

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

Nursing Care Management of healthy Preterm baby

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

Etiology and Pathophysiology of epilepsy

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

Developing a Body Image

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

Cerclage

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

Congenital Heart Disease (CHD)

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

Recurring Spontaneous Losses / Incompetent Cervix

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

Chronic Hypertension

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

Delivery of Preterm Infant

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

Nose

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

Mastitis

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

Rheumatic Fever and Rheumatic Heart Disease (RHD)

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

Ingested & Inhaled Poisonings

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

Types of Poisoning

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

Corrosive Poisoning

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

Mouth and Throat

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

Pathogenesis of DM

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

Birth

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

Seizures: Tonic

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

Heart Transplantation

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

Epistaxis (Nose Bleeding)

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

Leukemia

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

Alternative interventions

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

Antihypertensive Drugs

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

Morbidity and Mortality

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

Activity for PTL

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

Ears

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

Medications for PIH

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

Magnet Ingestion

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

Management of IRDS

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

Clinical Manifestations of seizures

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

Gavage Feeding

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

pPROM (Preterm ruptured of membranes)

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

Plan of care and implementation

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

Early Pregnancy Bleeding

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

Well Baby Nursery

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

Coping with Concern: Injury Prevention

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

Concussion

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

Meningitis

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

Osteogenesis Imperfecta

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

Duchenne Muscular Dystrophy

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

Lead Poisoning (Plumbism)

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

Getting report when born

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

Safety Promotion and Injury Prevention

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

Clinical Manifestations

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

Hodgkin Lymphoma (HL)

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

Immunologic Adaptations

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

Treatments for infertility

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

Eyes

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

Skin

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

Neurologic Examination

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

Nutritional and Eating Disorders

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

Medication

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

Complications and Residual effects

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

Febrile Seizures

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

Female hormones

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

Milk Production

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

Seizures

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

Sickle Cell Anemia

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

Intraventicular Hemorrhage (IVH)

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

Neurologic Adaptations

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

Lymphomas

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

Problems related to the female partner:

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

Pharmacologic Management and Complications

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

Ballard Gestational Assessment Scoring Scale

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

Other- HIV Human Immunodeficiency Virus

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

Implementation of Care

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

Sickle Cell Disease

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

Cast, Cast Care and Removing the cast

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

Nursing Interventions

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

Positive signs

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

Differentiate between Preterm infant and low birth weight infant

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

Parental Bonding

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

Prepubescence (Tween)

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

Treatment of PIH

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

Definitions of types of Hypertension in Pregnancies

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

Proteinuria

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

Nursing care of Hypertensive disorders

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

KD: Diagnostics

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

Biologic Develoment

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

Risks to Preterm Infant:

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

Prognosis and Prevention

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

Severe Pre-eclampsia

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

Pubertal growth for girls

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

KD: Management

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

Tetralogy of Fallot

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

Purposes of Traction

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

Aplastic Anemia

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

Fractures

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

Nursing Care Management

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

Play in Middle Childhood

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

Premature Rupture of Membranes (PROM)

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

Newborn Care Tips for Parents

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

Caregiver Education

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

Eclampsia

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

Collaborative Care

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

Seizures: Metabolic Cause

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

Psychological issues associated with infertility:

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

Diagnostic tests

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

Psychosocial development

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

Sexual Orientation

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

Combined problems: Attributed to both partners

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

Other- Gonorrhea

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

Cytomegalovirus (CMV)

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

HSV I and II (Herpes Simplex Virus)

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

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

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

Simple Focal Seizures

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

Types of Fractures

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

Relating to Teenagers

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

Characteristics of Preterm Infant

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

Problems related to the male partner:

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

Spiritual and Social Development of Middle Childhood

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

Kohlberg's Moral Development

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

Erikson's Industry vs Inferiority

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

Sexual Maturation Tanner stages of sexual maturity

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

Physical Examination

Start with warm hands and a gentle approach Start with observation Then Auscultation of the chest Palpation of the abdomen Eyes, ears, throat and hips should be last as these are the most disturbing to the infant Normal Newborn Vitals: Apical rate: 120 to 160 bpm Respiratory rate: 30 to 60 breaths Temperature 97.5 to 99.0 F Systolic BP: 50 to 70 mm Hg Head circumference: 33-35 cm Chest circumference: 30-33 cm Length Average is 19.5 inches Weight Average is 7 lbs. 8 oz.

Brazelton Behavioral Assessment Sleep Scale

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

Complications

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

Infant Reflexes

Sucking- disappears at 6 months of age Rooting- disappears at 3 to 4 months of age Traction response: Checks head lag Palmar grasp: disappears at 3 to 4 months Deep tendon reflex: Babinski is normal Moro- Startle: disappears by 3 months Tonic neck reflex- fencing position- disappears by 8 months Stepping: variable disappearance rate (around 3 to 4 months)

Fetal and Neonatal risks

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

Management of Meningitis

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

Surface Toxins

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

Treatment

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

T.O.R.C.H. Complex

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

Home Nursing Care *

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

Homosexual Identity in Adolescence

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

Assessment of Fractures

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

Complications: Congestive Heart Failure (CHF)

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

Definitions of Infertility:

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

Renal adaptations

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

Respiration

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

Cardiac adaptation

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

Etiology of PIH

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

Nursing Care of the Healthy Preterm Infant

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

Another ballard scoring

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

Diagnosis of PTL

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

KD: Disease Process

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

Developmental Passage of Adolenscence

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

Latching On

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

Other- Hepatitis B Virus (HBV)

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

Antibiotics for PTL

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

Classification of DM

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

Types of Traction (general)

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

Etiology for Preterm labors

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

Generalized Seizures: Absence seizures

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

Overview of S&S Preterm Labor

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

Criteria for Treatment

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

Care Management for a Neonate of a Diabetic Mom

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

Group B Strep (Streptococcus Infection)

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

Rubella

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

Managing ingested poisons

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

Iron Deficiency Anemia (IDA)

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

Growth Plate (Physeal) Injuries

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

Wilm's Tumor

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

Breastfeeding

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

Osteomyelitis

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