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Copyright © 2006 by F. A. Davis.
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Copyright © 2006 by F. A. Davis.
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OB Peds Women’s Health Notes Nurse’s Clinical Pocket Guide Brenda Holloway, CRNP, FNP, MSN Cheryl Moredich RNC, MS, WHNP Kathie Aduddell, Ed.D, MSN, RN-BC Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book
F. A. Davis Company • Philadelphia
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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2006 by F. A. Davis Company All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Robert G. Martone Project Editor: Ilysa H. Richman Developmental Editor: Marla Sussman Consultant: Kim Cooper, RN, MSN As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1466/06 0 + $.10.
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Waterproof and Reusable Wipe-Free Pages Write directly onto any page of OB Peds Women’s Health Notes with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse. GYN ANTE- INTRA- POSTPEDS PEDS BASICS PARTUM PARTUM PARTUM BASICS ASSESS
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1 Nurses Impact the Health of Women Through ■ ■ ■ ■ ■
Educating women about healthy lifestyle choices Role modeling healthy behavior and promoting wellness Describing the role of prevention and early detection Informing women about disease treatment and progression Being an advocate and resource for community referrals
Cervical/Gynecological Health ■ According to the guidelines of the American College of Obstetrician and Gynecologists (ACOG) and the American Cancer Society (ACS), initial cervical screen for cancer should begin 3 years after first sexual intercourse or by age 21, whichever comes first ■ However, ACOG recommends that a visit to an obstetrician/gynecologist occur before that time for health guidance, screening, and prevention ■ Follow-up cervical screen for low-risk women less than 30 years of age ACOG Guidelines ACS Guidelines
Annually Annually with conventional Pap smear Every 2 years with liquid-based cytology
■ Women 30 years of age and older, with three consecutive negative cervical screens, are recommended to have repeat exams every 2–3 years
GYN BASICS
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Sexually Transmitted Infections (STIs) ■ Abstinence from sexual activity (both oral and genital) is the only 100% effective method of STI prevention ■ Consistent and proper use of condoms during sexual intercourse will decrease the incidence of STIs ■ STIs transmitted via skin contact (human papillomavirus [HPV], herpes simplex virus [HSV]) may still be transmitted with use of latex condoms ■ Sexual partners should be tested and treated when an STI is identified; sexual activity should be avoided until treatment regimen completed ■ Patients diagnosed with a viral STIs should consult their health-care provider for long-term management ■ Reportable STIs must be forwarded to the local health department along with treatment rendered ■ Encourage immunization against hepatitis B ■ Visit CDC Web site www.cdc.gov for latest treatment guidelines for STIs
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Infection Gonorrhea
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Chlamydia
Trichomoniasis
Hepatitis
Human Papilloma Virus (HPV)
Symptoms (May be asymptomatic) Yellow-green vaginal discharge Dyspareunia Abdominal pain Dysuria Mucopurulent discharge Postcoital bleeding Dyspareunia Abdominal pain Dysuria Frothy malodorous vaginal discharge Dyspareunia Vaginal itching/irritation Dysuria Fatigue Dark urine Clay-colored stool Jaundice/abdominal pain Many subtypes exist, some associated with cervical dysplasia Visible wartlike growths in genital area associated with subtypes 6, 11
Detection Endocervical culture Urine test
Endocervical culture Urine test
Saline wet mount of vaginal discharge viewed under microscopy Serological testing
Pap smear report Colposcopy/biopsy
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Sexually Transmitted Infections (STIs) (Continued)
Primary Chancre (painless raised ulcer) Secondary Skin rash, lymphadenopathy Latent Lacking clinical manifestations Tertiary Cardiac, ophthalmic, auditory involvement
HIV
Fever Malaise Lymphadenopathy Skin rash
Herpes Simplex Virus (HSV)
Painful, recurrent vesicular lesions Fever, malaise Enlarged lymph nodes
GYN BASICS
Detection Serological testing Nontreponemal (RPR, VDLR) ■ Reported quantitatively (titers) ■ Four-fold change in titers clinically significant ■ Effective treatment will result in falling titers ■ False-positive possible; verify with treponemal test Treponemal (FTA-ABS) Reported as positive or negative Serological testing (Pretest and posttest counseling with informed consent required) Positive screen must be confirmed by more specific test (Western blot) Viral culture with DNA probe
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Symptoms (May be asymptomatic)
Syphilis
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Sexually Transmitted Infections (STIs) (Continued) Infection
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5 Breast Health ■ Monthly breast self-exam, starting at age 20, instructed to woman as an optional tool for identifying and reporting breast changes ■ Clinical breast exam at least every 3 years (age 20–40) during a physical exam by a health professional; yearly after age 40 ■ Annual mammogram starting at age 40
Instructions for Breast Self Exam (BSE) Step 1: Inspection 1. Visually inspect the breasts, looking for dimpling, lumps, skin irregularities, symmetry 2. Visually inspect in several positions; may accentuate an abnormality ◆ Hands at the side ◆ Hands above the head ◆ Hands pressed onto hips ◆ Leaning over
BSE positions. (From Dillon PM. (2003) Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p. 459.)
GYN BASICS
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Step 2: Palpation 1. Feel the breast tissue and lymph node chain for lumps or thickening by using three finger pads while exerting light, medium, and deep pressure in a systematic fashion
BSE palpation patterns. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p 461.)
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7 2. Begin by lying down on a flat surface with arm raised and a folded towel under the back of the breast being examined 3. After examining breast tissue, bring arm toward body and feel the axilla and the skin above as well as below the collar bone 4. Repeat technique on the other side 5. Report lumps, thickening, nipple discharge or any suspicious findings to health-care provider
Preconception Counseling Preconception counseling should be included in health screenings for all women of childbearing age and focus on factors that impact organogenesis. ■ Discuss chromosomal abnormalities associated with advanced maternal age ■ Incorporate 400 mcg of folic acid daily (for low-risk women) ■ Avoid alcohol, smoking, and drug use ■ Teach prevention of sexually transmitted infections ■ Update immunizations and investigate rubella titer ■ Review exposure to environmental risk factors ■ Control of chronic medical conditions ■ Review classification of prescribed medication
Family Planning Options ■ Educate women on available family planning methods, discussing the risks, benefits, and efficacy of each method ■ Efficacy of each method influenced by correct and consistent use, user preparedness, motivation, dexterity, and comorbidities ■ Educate women on the process of menses ■ The menstrual cycle is a cyclic feedback system occurring approximately every 28 days with the first day of menses being day 1 ■ Low levels of estrogen and progesterone stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH), which stimulates the anterior pituitary to release
GYN BASICS
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■ ■ ■ ■
■
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follicle stimulating hormone (FSH), encouraging maturation of the Graafian follicle Estrogen, produced by the maturing follicle, causes the endometrial lining to proliferate The mid-cycle release of luteinizing hormone (LH) from the anterior pituitary promotes release of the mature ovum (ovulation) Once ovulation occurs, the corpus luteum (remaining cells of the follicle) produces estrogen and progesterone, which stimulates endometrial thickening If conception does not occur, the corpus luteum regresses, causing a decrease in estrogen and progesterone, and ischemic changes to the functional layer of the endometrium The menstrual cycle is divided into phases of the ovarian and endometrial cycle:
Ovarian Cycle
Endometrial Cycle
Menstrual Follicular Ovulatory Luteal
Menstrual Proliferative Secretory Ischemic
Sexual Abstinence ■ Refraining from sexual activity is the only 100% effective way to prevent pregnancy
Fertility Awareness Methods ■ Teaches familiarity with body in order to recognize signs of fertility ■ Useful to avoid or achieve pregnancy, as well as monitor gynecological health ■ To prevent pregnancy, couples abstain during recognized period of fertility
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9 Cervical Mucus Amount and character of cervical mucus changes throughout the menstrual cycle in response to hormones ■ Following menses, cervical mucus scant, thick, and cloudy ■ At ovulation, cervical mucus becomes more abundant, slippery, clear, and stretchable in response to estrogen (known as “spinnbarkeit”), promoting sperm motility; increased likelihood of pregnancy with unprotected intercourse ■ After ovulation, cervical mucus scant, thick, cloudy, and is no longer stretchable ■ Cervical mucus should be evaluated and charted daily
Basal Body Temperature (BBT)
■ Monitor and graph BBT daily before rising ■ Prior to ovulation, BBT decreases slightly in response to estrogen ■ After ovulation, a surge of progesterone increases BBT by 0.5–1.0F ■ BBT remains high with conception, but falls without conception, prior to menses ■ Certain activities may alter BBT: smoking, use of electric blanket or heated waterbed, restless sleep, illness
Calendar Method
■ Based on assumption that ovulation occurs 14 days before the onset of menses ■ Record menstrual cycles for 6–8 months ■ Calculate fertile period Subtract 18 from the shortest menstrual cycle (28 18 10) Subtract 11 from the longest menstrual cycle (32 11 21) Days 10–21 fertile time; abstain from intercourse
GYN BASICS
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Lactation Amenorrhea Method (LAM) ■ Prolactin suppresses follicle stimulating hormone (FSH), and therefore suppresses ovulation ■ Postpartum woman who exclusively breastfeed during the first 6 months after childbirth, including at least one night feeding, may postpone ovulation ■ Instruct patients that ovulation and return of fertility may occur before first menses with a risk of unintended pregnancy
Barrier Methods Prevents conception by blocking entry of sperm into the cervix
Diaphragm
■ Dome-shaped rubber cup with a flexible ring that fits over the cervix; regularly examine integrity of rubber ■ Inserted with spermicide applied to dome before intercourse and left in place for at least 6 hours after intercourse ■ Should not be left in place more than 24 hours due to risk of toxic shock syndrome ■ Additional spermicide may be added with diaphragm still in place for repeated intercourse ■ Diaphragm is custom fitted and must be refitted with 20 pound weight change and after a vaginal birth ■ Urinary tract infections (UTI) more common with diaphragm use; teach to report symptoms of UTI ■ Wash with soap and water after each use; inspect integrity of rubber by holding up to light to inspect for holes
Male Condom
■ Thin latex sheath that covers the erect penis during sexual intercourse ■ Provides protection from STIs ■ Space should be left at the end of the condom for ejaculate ■ Hold condom at base of the penis upon withdrawal to prevent spillage ■ Only water-soluble gel should be used for lubrication to prevent degradation of the latex
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11 ■ New condom should be used with each act of intercourse ■ Store in unopened package in cool, dry place
Female Condom ■ ■ ■ ■ ■ ■
Prelubricated polyurethane sheath with two flexible rings Inner ring helps with insertion and covers the cervix Outer ring rests on vulva Water or oil-based lubricant and spermicide may be used Can be stored at any temperature; 5-year shelf life Remove prior to standing by twisting the outer ring to contain semen and pull out ■ Material degradation could occur if both male and female condoms used simultaneously
Hormonal Methods
Hormonal contraceptives Hormonal contraceptives alter the normal menstrual cycle, inhibiting ovulation, altering the endometrial lining, and thickening cervical mucus. ■ Mechanism of Action ■ Effects of Estrogen • Ovulation inhibited by suppression of follicle stimulating hormone (FSH) and luteinizing hormone (LH) • Endometrial lining altered making the endometrium less receptive to implantation ■ Effects of Progestin • Cervical mucus thickened, hampering sperm transport • Suppression of midcycle LH peak prevents ovulation • Decreases cilia movement within the fallopian tube ■ Advantages of hormonal contraceptives include decreased dysmenorrhea, decreased menstrual blood loss, and reliability ■ Requires addition of condom for STI protection or as back-up with user error ■ Side effects may include nausea, vomiting, breast tenderness, breakthrough bleeding, headaches, mood changes, decreased libido, or weight change
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■ May cause serious health issues; advise hormonal contraceptive users not to smoke and teach reportable symptoms of possible complications: ■ Abdominal pain (severe) ■ Chest pain ■ Headache (severe) ■ Eye problems (blurred, double vision) ■ Severe leg pain, redness, and swelling ■ Shortness of breath ■ Worsening depression ■ Jaundice ■ Contraindications to hormonal contraceptives ■ History of heart attack, stroke, blood clot; estrogen promotes blood clotting ■ History of breast or female reproductive cancer; tumors may be hormonally provoked ■ Diabetes with vascular involvement; estrogen promotes blood clotting ■ Impaired liver function; OCs are metabolized through the liver and use may adversely affect existing liver disease ■ Suspected or confirmed pregnancy ■ Uncontrolled hypertension; increased risk for cardiovascular complications ■ Smoker over 35 years of age; increases the risk for cardiovascular complications ■ History of migraine headaches (with aura); increased risk for stroke ■ Major surgery planned with immobilization; increased risk for deep vein thrombosis
Combined Hormonal Methods (Combination of estrogen and progestin)
Combination Oral Contraceptives (OC)
■ Most OCs are administered daily for 21 days, followed by 7 hormone-free days (either no pills taken or placebos taken for 7 days) ■ Pill selection based on amount of estrogen, type of progestin, adrenergic effect, or symptoms presented
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13 ■ Combined OCs may be monophasic (estrogen and progestin remain constant) or multiphasic (hormone dosing changes throughout the month) ■ Extended-cycle OCs are taken consistently for 12 weeks, followed by 7 days of inert pills; withdrawal bleeding occurring only four times per year ■ Combination hormonal contraceptives may decrease production of breast milk and should be avoided while breastfeeding ■ Effectiveness of OCs altered by certain medications; patients should report use of contraceptive agents to all health-care providers
Transdermal Patch ■ Patch applied to skin weekly for 3 weeks; fourth week is patchfree to allow withdrawal bleeding ■ Acceptable application sites include abdomen, buttocks, upper outer arm, and upper torso (but not the breasts); site should vary weekly ■ Application involves cleansing skin, avoiding lotion, and firmly applying patch making sure all corners adhere to skin ■ May engage is usual activities (bathing, swimming, exercising) ■ Partial removal and skin reactions possible ■ Decreased effectiveness noted in women who weigh more than 198 pounds
Vaginal Ring ■ Small, flexible hormone-impregnated ring inserted and left in the vagina for 3 weeks; removed in fourth week to allow for withdrawal bleeding ■ Ring should be kept inside unopened package before insertion; protect from sunlight and high temperatures ■ Side effects include increase in vaginal discharge, vaginal irritation, or infection ■ Expulsion may occur; if out for more than 3 hours, back-up method of birth control needed for the next 7 days
GYN BASICS
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Progestin Only Preparations ■ Progestin-only preparations are indicated for women who cannot use estrogen ■ Alteration in menstrual cycle common with progestin-only methods ■ May be used in lactation once breastfeeding is well established ■ Side effects include weight gain, menstrual irregularities, and depression
Oral Contraceptives “minipill”
■ Important to take at the same time each day ■ Back-up method of birth control needed with missed or late pills
Injectable Progestin Contraception Depo-medroxyprogesterone (DMPA) ■ Injected by health-care provider intramuscularly (IM) every 3 months ■ Return to fertility may be delayed ■ Bone loss may be of concern with continued use; should not be used for greater than 2 years continuous use
Intrauterine system (IUS)/Intrauterine Device (IUD) ■ Inhibits fertilization by altering fallopian tube transport of sperm and ova, as well as producing cellular changes to the endometrial lining ■ Recommended for parous women in a mutually monogamous relationship with no history of pelvic inflammatory disease (PID) ■ Inserted in office by qualified practitioner ■ Increased incidence of pelvic inflammatory disease (PID) ■ Uterine perforation and expulsion of device possible ■ Attached to string that extends outside of the cervix; instruct patient to check for presence of string monthly ■ Teach patient the following reportable warning signs
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15 Signs of IUD complications: Period late (pregnancy) Abdominal pain (infection) Infection Not feeling well (infection) String missing (IUD expelled)
Types 1. T-shaped hormone-releasing (levonorgestrel) device placed in the uterus to prevent pregnancy for up to 5 years 2. Copper IUD contains no hormones; continuous use for up to 10 years if no complications
Emergency Contraception (EC) Contraceptive agents used after unprotected intercourse intended for the prevention of pregnancy ■ Available agents ■ Copper IUD inserted within 5 days of unprotected intercourse ■ Oral contraceptives taken at higher doses; both combination and progestin-only preparations are available • Initial dose within 72 hours of unprotected intercourse • Follow-up dose within 12 hours of first dose
Permanent Methods ■ Prevent conception by mechanically blocking the fallopian tubes, preventing passage of ovum ■ Low failure rate, however, if pregnancy occurs, may be ectopic
Tubal Ligation (Incisional Method)
■ Performed in a hospital or outpatient surgical unit under general anesthesia ■ Fallopian tubes cut, cauterized, and/or clipped ■ Complications may include bleeding, infection, incomplete tube closure, injury to adjacent organs, or complications from anesthesia
GYN BASICS
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Hysteroscopic Tubal Sterilization (Nonincisional method) ■ Microinserts placed into the opening of the fallopian tubes, causing scar tissue to grow in approximately 3 months ■ Performed in physician’s office or outpatient procedure lab with local anesthetic to cervix ■ Follow-up hysterosalpingogram performed at 3 months to ensure both tubes have been blocked; alternate method of birth control used until tube status verified ■ Complications may include incorrect placement requiring second or operative procedure, ectopic pregnancy, infection, perforation of the uterus
Health Promotion in Adult Women Cardiovascular Health Promotion ■ ■ ■ ■
Cholesterol screening every 5 years after age 20 Blood pressure screening at each medical visit Incorporate fitness into daily lifestyle Discourage smoking
Promotion of Weight Management and Fitness ■ Calculate body mass index and determine goal ■ Discuss exercise regimen for current fitness level ■ Provide nutrition guidance according to the guidelines set forth by the U.S. Department of Agriculture (USDA)
Prevention and Treatment of Osteoporosis ■ Risk increases after menopause; estrogen reduction results in increased bone resorption ■ Discuss adequate intake of calcium and vitamin D ■ Encourage weight-bearing exercise ■ Educate concerning bone density scans ■ Discuss medications to reduce bone loss with primary healthcare provider
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17 Early Detection of Colorectal Cancer ■ ■ ■ ■ ■
Screening starting at age 50 (ACOG, ACS) Yearly fecal occult blood test plus Flexible sigmoidoscopy every 5 years or Colonoscopy every 10 years or Double contrast barium enema every 5 years
Early Detection/Prevention of Skin Cancer ■ Use sunscreen with SPF of 15 or higher ■ Avoid sun exposure from 10 a.m. to 4 p.m. and tanning beds ■ Perform self-evaluation of the skin; report suspicious lesions ■ Thorough skin exam every 3 years age 20 to 39; annually after age 40
Menopause ■ Cessation of menses with amenorrhea for 12 months ■ Symptoms ■ Vasomotor symptoms • Hot flushes • Night sweats ■ Urogenital symptoms • Thin, friable vaginal mucosa • Vaginal dryness and irritation • Dyspareunia ■ Other Systemic Symptoms • Sleep disturbance • Mood swings • Memory loss • Skin changes • Hair thinning
GYN BASICS
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Hormone Replacement Therapy (HRT) ■ The decision of whether of not to use hormone replacement therapy should be made after careful medical evaluation and discussion with the primary health-care provider concerning the risk/benefit ratio for each woman ■ Current guidelines by the U.S. Food and Drug Administration (FDA) recommend HRT use only for moderate to severe menopausal symptoms at the lowest effective dose for the shortest period of time, noting the risk/benefit ratio for each woman ■ If HRT prescribed solely for vaginal/vulvar symptoms, local hormone therapy should be considered ■ Alternatives to HRT should be considered if HRT used for sole purpose of osteoporosis prevention
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19 Establishing Pregnancy ■ Pregnancy may be assumed based on the presence of certain signs and symptoms Presumptive signs are subjective and recorded under the history of present illness ■ Probable and positive signs of pregnancy are objective and recorded as physical assessment findings Presumptive
Probable
Positive
Amenorrhea Breast tenderness Quickening Nausea/ Vomiting Urinary frequency
■ Positive pregnancy test ■ Uterine enlargement ■ Hegar’s sign (softening of lower uterine segment) ■ Goodell’s sign (softening of cervix) ■ Chadwick’s sign (bluish hue to cervix/vagina) ■ Braxton Hicks contractions
Fetal heart beat auscultated Fetal movement palpated per practitioner Ultrasound of gestation
■ Urine pregnancy test ■ Reacts with human chorionic gonadotropin (hCG) ■ Performed on first voided urine sample of the day; positive results possible before the first day of a missed menstrual period ■ Serum pregnancy test ■ Useful in monitoring expected pattern of progression of hCG; detects hCG as early as 9 days postconception ■ Ultrasound ■ Confirms presence of gestational sac, fetal pole, and fetal cardiac activity ■ Validates location of pregnancy (intrauterine versus ectopic)
ANTEPARTUM
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Estimated Date of Delivery ■ Establishing an accurate date of delivery is important to: ■ Determine timing of antenatal screening ■ Monitor growth of the fetus ■ Scrutinize timing of delivery ■ Common abbreviations denoting delivery date are: ■ EDD. …………………… estimated date of delivery ■ EDC. …………………… estimated date of confinement ■ EDB. …………………… estimated date of birth
Naegele’s Rule ■ Formula used to estimate date of delivery ■ Count back 3 months and add 7 days to the last normal menstrual period (LNMP) reported by the patient Example: The patient states that her LNMP was April 20th April is the 4th month 20th day 3 months 7 days 1st month
27th day
The baby is estimated to be due on January 27th of the following year
Trimesters of Pregnancy Normally, pregnancy continues for 40 weeks or 280 days 1st trimester 2nd trimester 3rd trimester
conception until 12 weeks’ gestation 13 weeks until 27 weeks’ gestation 28 weeks until 40 weeks’ gestation
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21 Schedule of Prenatal Visits (low-risk pregnancy) ■ Monthly until 28 weeks’ gestation ■ Biweekly from 28 weeks until 36 weeks ■ Weekly from 36 weeks until delivery
Prenatal Health History Performing a thorough health history in the prenatal period is essential to planning nursing care and identifying highrisk women. ■ Medical history ■ Chronic illness ■ Current and recent medication ■ Recent acute illness ■ Childhood illnesses ■ Surgical history ■ Problems with anesthesia ■ Previous surgeries ■ Uterine/cervical surgeries ■ Obstetrical history ■ Type of deliveries: vaginal/cesarean ■ Complications with past pregnancies ■ Infertility ■ Documentation of obstetrical history Descriptive Term Gravida (G) Term (T) Preterm (P) Abortion (A) Living (L)
ANTEPARTUM
Definition Number of pregnancies Number of deliveries after 37 weeks Number of deliveries after 20 weeks but before 38 weeks Number of deliveries before 20 weeks, either spontaneous or induced Number of living children
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Documentation Example 1: The prenatal client states having three children at home. She reports that her son was born on his due date, but her daughters were both born a month early. She states that she lost a baby in her second month. G: 5 (currently pregnant, 3 children at home, one abortion) T: 1 (her son was born on his due date) P: 2 (her daughters were each born a month early) A: 1 (she lost a pregnancy at approximately 8 weeks) L: 3 (reports three children at home) Document as G5-1213 Documentation Example 2: The same prenatal client may also be described as G5 (5 pregnancies) P3 (number of live births); pregnancies ended before 20 weeks are not counted as “P” in this method. ■ Sexual history ■ Number of sexual partners ■ Sexually transmitted infections ■ Sexual abuse ■ Methods of contraception ■ Condom use ■ Social history ■ Use of recreational drugs ■ Smoking ■ Domestic abuse ■ Educational level/ability to read ■ Economic status ■ Type of health insurance ■ Need for community referrals • Transportation • Nutrition • Medications
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23 Physiological Changes in Pregnancy Heart rate
Cardiac output
Blood volume
Blood pressure
↑
↑
↑
*
Systemic vascular resistance ↓
*slight↓ with return to baseline by 3rd trimester
Stroke volume
Red blood cells
Hemoglobin
Hematocrit
White blood cells
↑
↑
↓
↓
↑
Glomerular filtration rate
Urine output
↑
↑
↑ Increase
Basal metabolic rate
Respiratory rate
↑
↓ Decrease
↔
↔ No change
Hormonal Changes in Pregnancy Hormone
Functions
Estrogen
↑
Progesterone
↑
Human chorionic gonadotropin (hCG) Relaxin
↑
Prolactin
↑
Human placental lactogen
↑
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↑
Increase uterine muscle mass Increase blood flow to uterus Prepare breasts for lactation Relax venous walls Inhibit uterine contractions Stimulate estrogen/progesterone production Discourage uterine contraction Remodeling of collagen Maturation of breast ducts/alveoli Stimulate lactation Insulin antagonist Allow adequate glucose for fetal demand
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Nursing Care with First Prenatal Visit ■ Determine EDD based on LNMP ■ Document current gestational age (gestational wheel is a tool for quick reference to current gestational age) ■ Document baseline vital signs ■ Document height, weight, and body mass index (BMI) ■ Obtain urine specimen and test for presence of: Substance
Expected Finding
Glucose Protein
Negative/Trace Negative/Trace
■ Auscultate fetal heart tones ■ Measure fundal height in centimeters from symphysis pubis to the top of the fundus ■ Uterine size increases in pregnancy in a predictable pattern and is measured to gauge fetal growth ■ Fundal height that is lagging or greater than expected should be further investigated Weeks’ Gestation 12 16 20 21–36
Fundal Height Just above symphysis pubis Halfway between symphysis pubis and the umbilicus At the umbilicus Fundal height generally matches weeks gestation in centimeters EXAMPLE: Fundal height at 28 weeks should be approximately 28 cm.
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Fundal height. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p 736.)
■ Provide appropriate education for gestational age ■ Discuss procedure for lab testing
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Common Laboratory Tests
Expected Finding in Pregnancy
HIV *Check state laws regarding HIV testing in pregnancy Blood type Rh factor Antibody screen Hemoglobin Hematocrit Platelets WBC RPR Hepatitis B antigen Rubella titer Hemoglobin electrophoresis Chlamydia culture Gonorrhea culture Pap smear
26
Negative A, B, AB, O Negative/Positive Negative 11.5 mg/dL 33% 150,000–400,000 mm3 5,000–12,000 mm3 Negative Negative 1:8 Immune AA, unaffected Negative Negative Normal cytology
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27 Diagnostic Testing in Early Pregnancy Diagnostic Test Ultrasound Performed throughout pregnancy Clinical Applications: ■ Confirm and date pregnancy ■ Verify pregnancy location ■ Detect fetal cardiac activity ■ Measure fetal growth ■ Detect fetal anomalies ■ Measure amniotic fluid index ■ Determine fetal position ■ Determine placental position ■ Measure cervical length ■ Adjunct to invasive procedures Chorionic villi sampling (CVS) Performed at 10–12 weeks Clinical Application: ■ Chromosomal analysis Amniocentesis Performed throughout pregnancy Clinical Applications: ■ Chromosomal analysis is desired ■ Measure AFP ■ Measure bilirubin level ■ Determine lung maturity ■ Lecithin/Sphingomyelin Ratio (L/S Ratio) ■ Phosphatidylglycerol (PG) ■ L/S Ratio of 2:1 and positive PG indicative of fetal lung maturity Maternal Serum Triple Screen (tests maternal serum for AFP, hCG, and estriol)
Nursing Considerations Position to avoid supine hypotension; folded towel under right hip if supine
Review blood type, Rh and antibody status Administer Rh (D) immune globulin if indicated Monitor patient for postprocedure cramping or bleeding Monitor fetal heartbeat
NOTE: This is a screening method only. A positive result suggests the need for further testing (Continued text on following page)
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Diagnostic Test
Nursing Considerations
Performed at 15–18 weeks Clinical Applications: ■ Serum screen for neural tube defects/ Down syndrome
Results adjusted according to documented gestational age, maternal age, race, and weight, presence of diabetes/multiple gestation; the nurse must accurately document these variables on the laboratory requisition
Interpretation of Results Defect
AFP
hCG
Estriol
Risk for open neural tube
↑
WNL
WNL
Risk for Down syndrome
↓
↑
↓
↑ elevated ↓ decreased WNL within normal limits
Education in the Early Prenatal Period ■ Elevated estrogen and progesterone levels in early pregnancy generate changes in the body, causing pregnancy associated discomforts ■ Offer suggestions to lessen discomforts ■ Teach patient to report symptoms that may indicate a potential complication (in red)
Discomfort Urinary frequency
Nausea and vomiting
Patient Education Related to uterine position/weight Encourage frequent emptying of bladder Discourage limiting oral fluids Report burning or pain with urination Related to elevated hormone levels Encourage small, frequent meals Eat crackers before rising Avoid pungent odors, spicy or greasy food Discuss limited time frame for nausea (subsides around 12 weeks’ gestation) Report excessive vomiting (Continued text on following page)
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29 Education in the Early Prenatal Period (Cont’d) Discomfort Emotional lability
Leukorrhea
Breast discomfort
Fatigue
Nasal stuffiness/ epistaxis
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Patient Education Related to hormone changes Discuss normalcy of emotional changes with patient and partner Ambivalence normal in first trimester Report constant crying, inability to care for self, suicidal thoughts Related to vasocongestion of mucous membranes Avoid tampon use and douching Wear peri-pad to absorb discharge Encourage cotton underwear Report vaginal discharge with an odor or color, vaginal bleeding, or leaking of amniotic fluid Hormone-related breast development often first presumptive sign of pregnancy Wear a supportive bra Colostrum may be expressed in pregnancy Introduce the value of breastfeeding Introduce/reinforce breast self-exam Report any breast lump or unusual discharge Related to rapid hemodynamic and metabolic changes in the first trimester Encourage naps during the day Encourage prenatal vitamins Encourage healthy diet Report syncope and vertigo Related to vasocongestion of mucous membranes Increased humidity in home may help Warm compresses to sinus area Avoid over-the-counter (OTC) cold remedies Report fever, green/yellow nasal discharge, or frequent nosebleeds
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Teratogen Exposure Teratogens are substances that are harmful to the developing fetus; advise patient to avoid exposure. Teratogen Viruses
Environmental
Drugs
Patient Education Avoid contact with ill persons Report fever, rash, illness to primary health-care provider Infections causing serious harm to fetus: Toxoplasmosis Other (hepatitis B) Rubella Cytomegalovirus Herpes simplex virus (HSV) Avoid exposure to: Mercury Radiation Lead Other environmental toxins Recreational Discourage alcohol use Encourage patient to stop smoking Refer to smoking cessation classes Assess use of illicit drugs Refer to addiction counselors Discuss the role of drug screening Discuss adverse effects to fetus OTC/Herbal Caution patient to discuss use of all OTC/herbal medications with primary health-care provider Prescription List all medications prescribed since LNMP on prenatal record Investigate drug classification in drug guide book Inform primary health-care provider of drug list Record drugs/dosages on prenatal record
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31 Pregnancy Classification of Medications Drug Class A B
Pregnancy Safety No evidence of fetal risk No animal risk demonstrated; human fetal risk not demonstrated Animal study demonstrates risk No adequate study in humans Evidence of human risk Weigh risk/benefit ratio of drug Definite fetal risk Contraindicated
C D X
Source: U.S. Food and Drug Administration
Nutrition ■ ■ ■ ■ ■ ■
Inquire about dietary practices Gather 24-hour diet recall Suggest an addition of 300 healthy calories per day Encourage daily prenatal vitamin with 400 g folic acid Suggest 6–8 glasses of water daily Encourage to follow food pyramid in daily choices
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These symbols show fats and added sugars in foods
Vegetable group 3-5 servings
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Fats,oils and sweets Use sparingly
Protein group 2-3 servings
Fruit group 3-5 servings
Bread, cereal, pasta and grain group 6-11 servings Food Pyramid. (From U.S. Department of Agriculture and Department of Health and Human Services.)
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Fat (naturally occurring and added) Sugars (added)
Dairy group 2-3 servings
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33 Weight Gain in Pregnancy ■ Recommended weight gain depends on prepregnancy weight/BMI
Prepregnant Weight Normal Overweight Underweight
Recommended Weight Gain 25–35 pounds 15–25 pounds 28–40 pounds
■ Assess and document the pattern of weight gain
Trimester
Suggested Weight Gain
1st 2nd & 3rd
1–4 pounds total 0.5–1 pound per week
Exercise in Pregnancy ■ Physical activity in pregnancy is recommended unless contraindicated by medical complications ■ Avoid sports with potential for abdominal trauma or falls ■ Avoid overheating and supine positioning ■ STOP exercise if experiencing ■ Vaginal bleeding ■ Cramping ■ Leaking of amniotic fluid ■ Decreased fetal movement ■ Dizziness ■ Headache ■ Chest pain ■ Calf pain ■ Dyspnea
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Sexuality in Pregnancy ■ Sex not restricted in pregnancy unless risk factors exist for bleeding or preterm labor ■ Discuss expected changes in sexuality ■ Change in libido ■ Body image changes ■ Braxton-Hicks contractions with orgasm ■ Comfortable positioning for intercourse
Warning Signs During Pregnancy Patient should be instructed to notify primary health-care provider if experiencing any of the following symptoms: Warning Sign Vaginal bleeding
Leakage of vaginal fluid Dysuria Headache Altered vision Blurred vision Flashes of light Abdominal cramping Severe epigastric pain Decreased fetal movement Elevated temperature Persistent vomiting
Possible Cause Abortion Placenta previa Abruptio placentae Preterm labor Premature rupture of amniotic fluid Incontinence of urine Urinary tract infection Pregnancy-induced hypertension (PIH) Pregnancy-induced hypertension (PIH) Preterm labor Pregnancy-induced hypertension (PIH) Fetal demise Infection Hyperemesis gravidarum
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35 Nursing Care for Return Prenatal Visits ■ Measure pulse and blood pressure (BP) ■ Compare BP to initial reading (measured in the same position at each visit) ■ Measure weight and compare to last reading ■ Note total weight gain ■ Note pattern of weight gain ■ Obtain urine specimen and test for protein and glucose ■ Measure fundal height ■ Determine fetal position ■ Perform Leopold’s Maneuver • Palpate fetal body part in fundus (A) • Palpate for fetal back (B) • Palpate for presenting part (C) • Palpate for attitude of presenting part (D)
Leopold’s Maneuver. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis Company, p 739.)
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■ Place Doppler on maternal abdomen over fetal back to monitor fetal heart tones (FHT)
Placement of Doppler. (LSA = left sacral anterior; LOP = left occiput posterior; LMA = left mentum anterior; LOA = left occiput anterior; RMA = right mentum anterior; ROA = right occiput anterior; ROP = right occiput posterior; RSA = right sacral anterior) (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis Company, p 737.)
■ ■ ■ ■ ■
Record presence of fetal movement Assess for presence of edema/deep tendon reflexes Record symptoms since last visit Discuss procedure for diagnostic testing Provide patient education appropriate for gestational age
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37 Diagnostic Tests 1-hour glucose screen Performed at 24–28 weeks
Clinical Application Detection of gestational diabetes
Nursing Considerations Administer 50 g glucose load Patient should not eat, drink, or smoke during the test Serum sample drawn in 1 hour EXPECTED RESULT 140 mg/dL
Group B vaginal culture Performed between 35–37 weeks Clinical Application Positive culture treated with antibiotics in labor to prevent newborn transmission
Explain test to patient Collect vaginal/rectal specimen EXPECTED RESULT Negative
Fetal fibronectin (fFN) Performed between 22 and 35 weeks in women at high risk for preterm labor Clinical Application Negative predictive value for preterm labor
NO intercourse 24 hours prior to exam Cervical/posterior fornix specimen
Antibody screen Performed at 28 weeks in Rh negative women
Administer Rh (D antigen) immune globulin at 28 weeks to prevent antibody formation if Rh negative and antibody screen negative EXPECTED RESULT Negative
Clinical Application Detects presence of positive antibodies in serum of Rh negative women
ANTEPARTUM
EXPECTED RESULT Negative
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Education in the Second and Third Trimester ■ Teach patient to count fetal movement and report change in fetal movement pattern to primary health-care provider immediately (See bulleted information under “Teach patient to count fetal movements” on page 50) ■ Discuss fetal growth and development ■ Demonstrate palpating for contractions ■ Discuss symptoms of preterm labor ■ Lower backache ■ Increased vaginal discharge ■ Bloody show ■ Leaking amniotic fluid ■ Contractions ■ Pelvic pressure ■ Differentiate between true and false labor True Labor Cervix dilates Contractions increase in intensity and frequency Leaking amniotic fluid, bloody show
False Labor Cervix unchanged Contractions irregular and decrease with change of position/activity No evidence of change in vaginal discharge
■ ■ ■ ■ ■
Encourage childbirth preparation class Discuss options for pain control in labor Cesarean preparation class, if indicated Epidural anesthesia class, if indicated Explore preparing for the newborn ■ Breastfeeding ■ Circumcision ■ Choosing a pediatrician ■ Car seat safety ■ Discuss the discomforts associated with late pregnancy and teach reportable symptoms (in red)
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39 Discomfort Changes in pigmentation Linea nigra (pigmented line from umbilicus to pubic bone) Chloasma (deeper facial pigment) Striae (stretch marks) Round ligament pain (occasional, sharp lower abdominal pain)
Braxton-Hicks contractions (false labor contractions) Ankle edema
Varicose veins
Faintness
Patient Education Related to hormone changes in pregnancy; fade after pregnancy Moisturizers decrease itching, but will not prevent striae Report body rashes
Related to round ligament stretching as uterus grows Change positions slowly Encourage good body mechanics Report abdominal cramping, constant pain, or bleeding Instruct patient how to palpate contractions Labor should occur after 38 weeks gestation Teach patient to differentiate between true and false labor Report signs of preterm labor Related to decreased venous return due to pressure of the gravid uterus Rest in lateral recumbent position Elevate legs when sitting Continue with 6–8 glasses water daily Report generalized edema Caused by increased venous stasis related to pressure from the gravid uterus Wear pregnancy support hose Avoid lengthy standing Change positions frequently Report pain, redness, localized heat to legs Related to hemodynamic changes Avoid sudden position change Avoid long periods without eating Avoid lying supine Report loss of consciousness (Continued text on following page)
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Discomfort
Patient Education
Heartburn
Related to increased pressure on abdominal organs and sphincter relaxation Encourage small, frequent meals Avoid spicy foods Sit up after meals Report persistent symptoms
Backache
Related to shift in posture due to gravid uterus Encourage low-heeled shoes Avoid standing for long periods Teach pelvic tilt exercises Report constant or rhythmic backache
Shortness of breath
Related to upward diaphragmatic pressure exerted by the gravid uterus Allow more time for strenuous activities Eat small, frequent meals Lightening will lessen symptoms Report dyspnea with rest
Insomnia
Related to fetal movement, nocturia Teach relaxation techniques Encourage side-lying with pillow support Warm milk/shower before sleep
Leg cramps
Related to uterine pressure on the pelvic nerves or calcium imbalance Review daily calcium intake Teach signs of deep vein thrombosis Report pain, redness, localized heat
Constipation Hemorrhoids
Related to decreased gastric motility; iron supplement may worsen constipation Increase dietary fiber and water intake Encourage exercise Discourage enemas and laxatives Report painful or bleeding hemorrhoids
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41 Pregnancy Complications Vaginal Bleeding (before 20 weeks’ gestation) May be related to spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease
Spontaneous Abortion Loss of pregnancy before viability ■ Clinical Findings ■ Vaginal spotting (may pass clots) ■ Abdominal cramping ■ Cervical changes ■ Fetal heartbeat may be present or absent
Ectopic Pregnancy Products of conception implant outside the uterus ■ Clinical Findings ■ Vaginal spotting ■ hCG lower than expected for dates ■ Lower abdominal pain ■ Ultrasound findings: absence of intrauterine gestational sac ■ If rupture occurs: • Positive Cullen’s sign (periumbilical bluish hue) • Shoulder pain • Signs of shock
Gestational Trophoblastic Disease Abnormal proliferation of trophoblastic cells without viable fetus ■ Clinical Findings ■ Vaginal spotting (dark brown) ■ Fundal height greater than expected for dates ■ hCG greater than expected for dates ■ Excessive nausea and vomiting ■ Absence of fetal heart tones ■ Ultrasound findings: Snowflake-like clusters, absence of fetus
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■ Nursing Care (vaginal bleeding/early pregnancy) ■ Monitor amount of bleeding ■ Assess vital signs ■ Observe for signs of shock ■ Auscultate for fetal heart tones (FHTs) ■ Collect passed tissue/clots ■ Monitor patient comfort ■ Check blood type and Rh factor ■ Administer Rh(D) immunoglobulin if indicated ■ Initiate IV fluids as ordered ■ Report lab/ultrasound findings ■ Attend to patient’s emotional needs
Vaginal Bleeding (after 20 weeks’ gestation) May be related to placenta previa or abruptio placentae
Placenta Previa Low-lying position of placenta in the uterus that partially or completely covers the cervical os ■ Clinical Findings ■ Painless bright red vaginal bleeding ■ Bleeding may be reported after intercourse ■ Uterine tone soft upon palpation ■ Interventions dependent on amount of bleeding and labor status ■ If partial placenta previa is noted in early gestation, repeat ultrasound later in pregnancy (may demonstrate absence of previa as uterus grows) ■ If labor active and os is covered, cesarean birth necessary ■ If bleeding controlled and labor absent, conservative management • Patient Teaching (Conservative Management) – No tampon use – No sexual intercourse – Monitor and report bleeding – Patient instructed to report placenta placement when admitted to hospital – Cesarean preparation class – Count fetal movements
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43
Internal os Blood External os
A
Membranes Internal os Blood External os
B
Membranes Internal os Blood External os
C Placenta previa.
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Abrupto Placentae ■ Clinical Findings ■ Abdominal pain (sudden onset, intense and localized) ■ Fundus firm, boardlike, with little relaxation ■ Vaginal bleeding ■ Bleeding may be concealed within the uterine cavity ■ Fetal heart tones may be nonreassuring ■ Nursing Care (vaginal bleeding/late pregnancy) ■ Monitor amount of bleeding ■ Check vital signs ■ Observe for signs of shock ■ Evaluate fetal heart tones ■ Palpate uterine tone ■ Apply electronic fetal monitor (EFM) ■ REPORT alterations in fetal heart rate pattern ■ REPORT hypertonic contractions with poor resting tone ■ Do not attempt vaginal exam until placenta placement verified ■ Initiate IV fluids ■ Report laboratory and ultrasound findings ■ Prepare staff for possible cesarean birth ■ Attend to patient’s emotional needs
Hyperemesis Gravidarum Intractable vomiting in pregnancy with resultant weight loss and dehydration ■ Nursing Care ■ Assess vital signs ■ Observe for signs of dehydration ■ Review electrolytes ■ Access IV site as ordered ■ Record fetal heart tones ■ Record intake and output ■ Record daily weight ■ Check urine for ketones ■ Administer antiemetics as ordered
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Premature separation of the placenta; may be partial or complete
Partial separation (concealed hemorrhage)
Partial separation (apparent hemorrhage) Abruptio placentae.
Complete separation (concealed hemorrhage)
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Abruptio Placentae
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Preterm Labor Onset of regular labor before the 37th completed week of gestation ■ Clinical Findings ■ Rhythmic lower abdominal cramping ■ Complaints of backache ■ Increased vaginal discharge ■ Downward pelvic pressure ■ Leaking of amniotic fluid ■ Vaginal spotting ■ Cervical effacement/dilation ■ Shortening cervical length ■ Nursing Care ■ Determine gestational age ■ Assess uterine tone ■ Auscultate fetal heart tones and apply EFM ■ Obtain vaginal/urine cultures ■ Assess for leaking amniotic fluid • Ferning—Microscopically, amniotic fluid will resemble the leaves of a fern plant • Nitrazine paper—Due to the alkaline nature of amniotic fluid, the nitrazine paper will change from yellow to blue ■ Perform vaginal exam to determine dilation and effacement of the cervix ■ Position side-lying ■ Initiate IV fluids as ordered ■ Administer corticosteroid to mother • Accelerates maturity of fetal lungs • Most benefit 24 hours after administered ■ Initiate tocolytic therapy
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47 Tocolytic Medication
Magnesium Sulfate
ANTIDOTE: Calcium gluconate at bedside β-adrenergic agonist terbutaline ritodrine
Prostaglandin antagonist indomethacin Calcium channel blockers nifedipine
Nursing Precautions (Closely monitor maternal and fetal tolerance to medication) ■ Monitor for respiratory depression ■ Assess deep tendon reflexes ■ Watch level of consciousness ■ Monitor intake and output ■ Assess fetal heart tones ■ Monitor for contractions ■ Auscultate lungs ■ Report magnesium sulfate levels ■ Monitor for hypotension ■ Assess for tachycardia ■ Assess patient for tremors ■ Assess for pulmonary edema ■ Screen glucose/potassium ■ Assess for cardiac arrhythmias and chest pain ■ Monitor fetal heart tones ■ Monitor contractions ■ May lead to premature closure of ductus arteriosus ■ Monitor for hypotension ■ Assess for tachycardia
Preeclampsia Hypertensive disorder of pregnancy with multisystem involvement ■ Clinical Findings ■ Blurred or altered vision ■ Epigastric pain ■ Headache ■ Edema ■ Proteinuria ■ Hyperreflexia ■ Hypertension
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■ Nursing Care ■ Closely monitor vital signs ■ Assess deep tendon reflexes ■ Dipstick urine for protein ■ Record presence of edema ■ Palpate tone of fundus ■ Auscultate fetal heart rate and apply EFM ■ Monitor patient comfort ■ Collect 24-hour urine ■ Place patient in side-lying position ■ Keep environment quiet and dim ■ Institute seizure precautions • Side rails up and padded • Bed in low position • Suction equipment available at bedside • Oxygen available at bedside ■ Initiate IV fluids as ordered ■ Monitor intake and output ■ Initiate medications as ordered
Drug Therapy Magnesium sulfate Anti-hypertensives
Nursing Precautions See precautions listed under preterm labor for magnesium sulfate Administer slowly Closely monitor for hypotension
Eclampsia ■ Clinical Findings ■ Worsening of symptoms of preeclampsia ■ Seizure activity
HELLP Syndrome ■ Clinical Findings ■ Worsening symptoms of preeclampsia ■ Malaise
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49 ■ Epigastric pain ■ Nausea/vomiting ■ Laboratory findings: Hemolysis Elevated Liver enzymes Low Platelets
Gestational Diabetes Glucose intolerance that is first recognized in pregnancy ■ Clinical Findings ■ Polyuria ■ Polydipsia ■ Polyphagia ■ Fatigue ■ Blurred vision ■ Glucosuria ■ Recurrent yeast infections ■ Slow healing wounds ■ Abnormal glucose results • 1-hour glucose 140 mg/dL • Abnormal 3-hour glucose tolerance test: 2 out of 4 values elevated FBS 1-hour 2-hour 3-hour
95mg/dL 180mg/dL 155mg/dL 140mg/dL
■ Outpatient Management ■ Dietician consult for ADA diet instructions ■ Discuss pathophysiology of gestational diabetes with patient ■ Demonstrate home glucose monitoring ■ Review range for glycemic control ■ Demonstrate logging of glucose results ■ Discuss role of exercise in glycemic control ■ Demonstrate urine ketone testing
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■ Demonstrate insulin administration ■ Teach patient to count fetal movements • Find comfortable position in quiet place and concentrate on fetal movement • Document time of first fetal movement and time required for 10 movements (should not take more than 2 hours) • If pattern of movement decreased, REPORT immediately
Fetal Surveillance in Pregnancy Nonstress Test (NST) ■ Procedure used to monitor fetal response to movement; FHR acceleration with fetal movement is reassuring and a sign of fetal well being ■ Place patient in a Semi-Fowler’s or side-lying position ■ Record vital signs and apply electronic fetal monitor ■ Record baseline fetal heart rate and monitor FHR pattern for 20–30 minutes ■ Patient marks paper with each perceived fetal movement ■ NST may take longer with absence of accelerations; fetal movement may be stimulated vibroacoustically ■ Report findings to primary health-care provider EXPECTED FINDINGS: REACTIVE Two accelerations of FHR within 20 minutes that are at least 15 BPM above the baseline rate and last for a minimum of 15 seconds each
Contraction Stress Test (CST) Also called Oxytocin Challenge Test (OCT) ■ Procedure used to determine fetal tolerance to the stress of uterine contractions ■ Calculate gestational age (should not be performed on preterm patients; test stimulates contractions)
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51 ■ ■ ■ ■
Place patient in side-lying position Record vital signs Apply EFM and record baseline fetal heart rate for 20 minutes Stimulate uterine contractions until three contractions occur within 10 minutes lasting 40 seconds each ■ Contractions can be stimulated with ■ Nipple stimulation or ■ IV Oxytocin per hospital protocol ■ Document FHR response to contractions EXPECTED FINDING: NEGATIVE Three contractions that last at least 40 seconds within 10 minutes without the presence of late or significant variable decelerations
Biophysical Profile (BPP) ■ Ultrasound exam observing four specific fetal criteria ■ Nonstress test included as a fifth parameter ■ Scoring of Biophysical Profile (BPP)
Parameter Measured Fetal tone Fetal breathing Gross fetal movement Amniotic fluid volume FHR reactivity per NST
Expected Findings (within 30 minutes) Active flexion/extension One or more episodes lasting 30 seconds Three or more discrete movements Single vertical pocket 2 cm Reactive
EXPECTED FINDING: NEGATIVE BPP Score of at least 6/8 if NST omitted BPP Score of at least 8/10 if NST included
ANTEPARTUM
Score 2 2 2 2 2
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Intrapartum ■ Patients present to labor and delivery for medical procedures, triage, and birth ■ Upon admission to labor and delivery, the nurse should: ■ Determine reason for admission ■ Gather patient history ■ Review prenatal health record ■ Perform a physical exam
Prenatal History ■ ■ ■ ■ ■ ■ ■ ■ ■
Estimated date of delivery Current gestational age Complications in pregnancy Results of laboratory tests and ultrasounds Medications used in pregnancy Presence of vaginal discharge or bleeding Amniotic fluid status Presence of fetal movement Onset and pattern of contractions
Obstetrical History Type of births ■ Vaginal ■ Instrumentation ■ Episiotomy ■ Length of labor ■ Cesarean ■ Reason for cesarean ■ Document type of incision • Low-transverse • Classical ■ Complications of birth ■ Neonatal outcomes
Medical History ■ ■ ■ ■
Chronic health problems Current medications Time and description of last oral intake Allergies to food/medicine
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53 Surgical History ■ Complications with anesthesia ■ Date/reason for surgery
Perform a Physical Exam ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Assess maternal vital signs Collect urine specimen for protein and glucose Assess for presence of edema Assess deep tendon reflexes Perform Leopold’s maneuver to determine fetal position Assess fetal heart rate (FHR) Measure fundal height Determine the frequency, duration, and intensity of contractions Determine the stage and phase of labor Assess cervical changes ■ Dilation (0 to 10 cm) ■ Effacement (0–100%) ■ Station (Level of presenting fetal part in relation to the ischial spines of the maternal pelvis)
Iliac crest
Iliac crest
–5 –4 –3 –2 –1 0 1 2 3 4 5
Ischial spine Ischial tuberosity
Perineum Station
INTRAPARTUM
Ischial spine Ischial tuberosity
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INTRAPARTUM
■ Note presence, color, and amount of bloody show ■ Check status of amniotic membranes ■ Intact ■ Bulging ■ Ruptured (note color, amount, and odor)
Nursing Responsibility with Fetal Monitoring ■ Position patient to avoid supine hypotension ■ Assess FHR and interpret findings ■ Compare FHR to maternal pulse to ensure monitoring of fetal heart and not maternal rate ■ Implement nursing interventions for nonreassuring patterns of FHR ■ Evaluate effectiveness of nursing interventions for nonreassuring patterns ■ Update primary health-care provider with FHR status ■ Document findings and interventions ■ Assessment of the FHR may be intermittent or continuous
Intermittent Auscultation ■ Auscultate fetal heart tones (FHT) over fetal back with Doppler or fetoscope
Fetoscope. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p. 737.)
■ Count FHR between, during, and immediately following a contraction ■ Note both rate and rhythm of FHR ■ Frequency of auscultation based on: ■ Phase/stage of labor ■ Hospital protocol
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55 ■ Risk status ■ Labor interventions ■ Physician orders
Stage/Phase of Labor Stage Stage Stage Stage
Frequency of FHR Monitoring
1: Latent phase 1: Active phase 1: Transition 2
Every Every Every Every
30–60 minutes 15–30 minutes 5–15 minutes 5–15 minutes
Continuous Fetal Monitoring Monitored with external or internal fetal monitoring
External Fetal Monitoring (EFM) ■ ■ ■ ■ ■
Encourage patient to void before applying EFM Test internal circuitry of EFM Place ultrasound transducer over fetal back Place toco transducer over uterine fundus Monitor for 20–30 minutes on admission Ultrasound transducer Toco transducer (FHR) (uterine contractions)
External fetal monitor
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INTRAPARTUM
Internal Fetal Monitoring
■ Indicated when EFM not providing adequate FHR or contraction tracing ■ May be implemented only after amniotic sac is ruptured ■ FHR measured by spiral electrode attached to presenting part ■ Uterine tone measured by intrauterine pressure catheter (IUPC) ■ Resting tone of uterus averages 5–15 mmHG ■ Contraction tone of uterus averages 50–85 mmHG Scalp electrode
Catheter
Internal fetal monitor
Evaluating the Baseline Fetal Heart Rate ■ ■ ■ ■ ■
Normal baseline FHR is 110–160 BPM Evaluated between contractions over 10 minutes Documented as a range Does not include accelerations or decelerations Influences on the fetal heart rate ■ Central nervous system Fetal sleep ↓ variability of FHR Fetal movement ↑ variability of FHR ■ Autonomic nervous system Sympathetic branch (↑ FHR) Parasympathtic branch (↓ FHR) ■ Baroreceptors respond to ↓ blood pressure with subsequent ↓ FHR ■ Chemorecptors sense ↓ oxygen and ↑ FHR
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Normal fetal heart rate. (Top: fetal heart rate; bottom: contractions.)
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INTRAPARTUM
Changes to Baseline Fetal Heart Rate ■ TACHYCARDIA ■ FHR greater than 160 BPM for 10 minutes ■ Possible cause: • Infection/hyperthermia • Fetal hypoxia • Maternal medications (ex. terbutaline, albuterol) ■ BRADYCARDIA ■ FHR less than 110 BPM for 10 minutes ■ Possible cause: • Vagal stimulation • Hypoxia • Anesthetic agents ■ VARIABILITY ■ Fluctuations in FHR over time ■ Important indicator of fetal well-being ■ Sensitive to hypoxia and changes in Ph ■ Short-term variability (STV) • Beat-to-beat changes in FHR • Documented as present or absent • Most accurate with internal FHR monitoring ■ Long-term variability (LTV) • Pattern of fluctuations in FHR baseline (Expected pattern highlighted in blue)
Long-Term Variability Absent (0–2 BPM) Minimal (3–5 BPM) Average (6–10 BPM) Moderate (11–25 BPM) Marked (25 BPM)
Possible Cause Maternal medication Fetal sleep Fetal hypoxia Adequate fetal oxygenation Early sign of mild fetal hypoxia Fetal stimulation
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59 Changes in Fetal Heart Rate
■ The nurse interprets changes to baseline FHR as reassuring or nonreassuring ■ The nurse must act on nonreassuring FHR patterns ■ ACCELERATIONS ■ Sudden increase of fetal heart rate over baseline ■ Indication of fetal well-being ■ Reassuring pattern ■ Possible cause: Fetal movement/stimulation
Acceleration. (Top: fetal heart rate; bottom: contractions.)
■ DECELERATIONS (Early, Late, Variable) ■ EARLY DECELERATION • Decrease in FHR occurring with contractions • Onset occurs before the contraction peak • Recovery to baseline rate occurs by contraction end • Commonly seen in active phase of first stage of labor • Mirrors the contraction • Usually benign finding • Continue to monitor FHR pattern for nonreassuring patterns • Possible cause: Fetal head compression
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Early deceleration. (Top: fetal heart rate; bottom: contractions.)
■ LATE DECELERATIONS • Decrease in FHR occurring with contractions • Onset with or after the peak of contraction • Recovery to baseline rate occurs after contraction ends • Repetitive pattern • Nonreassuring requiring intervention
Late deceleration. (Top: fetal heart rate; bottom: contractions.)
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61 • Etiology: decreased uteroplacental blood flow/oxygen delivery related to – Maternal supine hypotension – Hypertension – Hyperstimulation of uterus – Diabetes – Preeclampsia – Anemia – Chronic maternal disease ■ VARIABLE DECELERATIONS • Decrease in FHR occurring without regard to contractions • Can range from mild to severe • May be persistent or occasional • Shaped like a “V” or “W” • Onset variable • Nonreassuring variable decelerations – Repetitive and/or deep decrease in FHR – Associated with minimal variability – Prolonged with slow return to baseline FHR • Possible causes: – Cord prolapse – Umbilical cord compression • Intervention: AMNIOINFUSION may be performed to try to relieve cord compression – Infusion of warmed normal saline into uterus via sterile catheter – Monitor FHR, contraction status, and maternal temperature – Verify that fluid is exiting uterus
Variable deceleration. (Top: fetal heart rate; bottom: contractions.)
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Nursing Interventions for Nonreassuring FHR Patterns ■ Turn patient to side-lying position ■ Shifts weight of gravid uterus off the inferior vena cava ■ Allows for improved uteroplacental blood flow ■ O2 per mask at 8–10 L/min ■ Improve oxygen delivery to fetus ■ Discontinue IV Oxytocin ■ Decreases uterine contractions, thus improving uteroplacental blood flow ■ Hydrate patient as indicated ■ Corrects identified maternal hypotension ■ Notify primary health-care provider ■ Document findings ■ Document baseline FHR (baseline FHR should be between 110 and 160 BPM) ■ Describe variability ■ Note changes in FHR in relation to contractions ■ Document nursing interventions, effectiveness of interventions and notification of primary health-care provider
Monitoring Contractions ■ Frequency ■ Beginning of one contraction to the beginning of the next contraction ■ Documented as range, for example, “every 2–5 minutes” ■ Duration ■ Beginning of the one contraction to the end of the same contraction ■ Documented as a range, for example, “lasting 60–90 seconds” ■ Intensity ■ Palpate uterus both during and after contraction ■ Resting tone palpated between contractions ■ Document intensity of uterine contractions (findings subjective unless monitored with IUPC)
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63 Intensity
Palpated by nurse
Mild Moderate Strong
Fundus easily indented Requires more pressure to indent fundus Unable to indent fundus
During contraction
Interval between contractions
nt
Duration of contraction
Relaxation
Beginning of contraction
Acme t
e re m Dec
Beginning of contraction I n cr eme n
Before contraction
Contraction
Relaxation
Frequency of contractions
Counting contractions.
Nursing Care of the Laboring Patient First Stage of Labor: Dilation Divided into Three Phases: Latent, Active, Transition
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INTRAPARTUM First Stage
Stage 1: Latent Phase
■ Power: Contractions palpate mild, every 5–10 minutes, lasting 30–45 seconds ■ Psyche: Patient is usually excited about the start of labor ■ Measuring progress in labor: Cervical dilation (0–3 cm) ■ Passageway: Encourage frequent position changes that optimize fetal descent, rotation, and widen pelvic outlet ■ Ambulation (with intact amniotic sac) ■ Squatting ■ Hands and knees position ■ Rocking chair ■ Side-lying ■ Check bladder status and encourage patient to void every 2 hours ■ Nursing considerations ■ Monitor vital signs every 30–60 minutes ■ Fetal heart tones every 30–60 minutes ■ Hydration • Oral fluids as ordered • Monitor intake and output ■ Pain management ■ Pain medication usually avoided until in active labor ■ Techniques for pain management • Hydrotherapy – Shower – Labor tub • Massage – Effluerage: light, circular stroking of gravid abdomen – Counter-pressure to back • Relaxation techniques – Progressive relaxation – Patterned breathing – Soft music and lighting – Distraction
Stage 1: Active Phase
■ Power: Contractions palpate moderate to strong, every 2–5 minutes lasting 40–60 seconds
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65 ■ Psyche: Patient may have greater difficulty coping with the pain of contractions ■ Measuring progress in labor: Cervical dilation (4–7 cm) ■ Passageway ■ Encourage frequent position changes ■ Check bladder status and encourage patient to void every 2 hours ■ Nursing considerations ■ Monitor vital signs every 30 minutes ■ Fetal heart tones every 15–30 minutes ■ Pain management ■ Continue with effective techniques used in latent phase ■ Systemic medications to decrease pain perception • Document and report maternal and fetal response to systemic medications • Neonatal side effects related to both dose and timing of administered medication
Systemic Pain Medications in Labor Medication Class
Drug Action
Nursing Considerations
Opioid analgesics Meperidine Butorphanol fentanyl Nalbuphine
Reduce pain perception
Side effect: nausea and vomiting Long-acting active metabolite, may cause respiratory depression (in the neonate) Caution with women who are opiate dependent, may cause withdrawal IV push dosing should be at the beginning of a contraction to limit transfer to fetus
Adjunct drugs Promethazine Hydroxyzine
Reduce nausea Reduce anxiety
No analgesic effect
Sedatives
Promotes rest with prolonged latent phase
May have prolonged depressant effect on neonate
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■ Epidurals in labor • Oxygen, suction equipment, emergency medications should be at bedside • Document vital signs and monitor fetal heart rate prior to procedure • Encourage patient to void • Administer IV bolus prior to epidural insertion (500 cc to 1000 cc of saline or lactated Ringer’s solution) to prevent maternal hypotension • Position and support patient during insertion of epidural catheter • Note maternal vital signs before and after test dose, then every 5 minutes with administration; thereafter, monitor vital signs and FHR per hospital protocol • Evaluate bladder status every hour and encourage to void; catheterize if unable to void or bladder overdistended • Assess for level of anesthesia • Monitor for comfort with contractions • Monitor progress of labor • Assist with position changes • Report adverse effects Hypotension Pruritis (itching) Pyrexia (fever) Respiratory depression
Stage 1: Transition
■ Power: Contractions palpate strong, every 1.5–3 minutes lasting 45–90 seconds ■ Psyche: Patient may feel a loss of control; provide encouragement to patient ■ Measuring progress in labor Cervical dilation (8–10 cm) Fetal descent (0/1 station) ■ Physical changes common with transition ■ Urge to push if presenting part is low ■ Nausea/vomiting ■ Trembling limbs
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67 ■ Beads of sweat on upper lip ■ Increased bloody show ■ Passageway: Activity more restricted, however, encourage positions that promote fetal rotation and descent ■ Squatting ■ Hands and knees position ■ Side-lying ■ Nursing considerations ■ Encourage patient to void ■ Monitor vital signs and fetal heart tones every 5–15 minutes ■ Pain management ■ Continue with effective techniques used in active phase ■ If systemic medications are given, consider amount of time estimated until birth and potential for newborn effects (respiratory depression) ■ Have naloxone hydrochloride (Narcan) available to reverse effects if needed ■ Document maternal and fetal response to medications
Second Stage of Labor: Expulsion ■ 10 cm dilated until the birth of the baby ■ Power: Contractions palpate strong, every 2–3 minutes lasting 60–90 seconds ■ Psyche: Patient may be eager or afraid to push ■ Measuring progress in labor ■ Descent of fetus: from 1 station to crowning ■ Cardinal movements of labor (changes in fetal position that facilitate birth) • Engagement/Descent/Flexion • Internal rotation • Extension • External rotation • Expulsion ■ Passageway ■ Promote effective pushing • Wait for urge to bear down called the “Ferguson reflex” • Discourage prolonged breath-holding • Encourage open glottis pushing
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■
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■ Position for pushing • Squatting • Side-lying • Modified Lithotomy Encourage patient to void Patient may pass stool with pushing Nursing considerations ■ Monitor vital signs every 15–30 minutes ■ Fetal heart tones every 5–15 minutes Pain management per primary health-care provider ■ Pudendal block: Local anesthetic that blocks pudendal nerve to numb lower vagina and perineum for vaginal birth; useful with forcep delivery ■ Local anesthesia to perineum: Numbs perineum for episiotomy/laceration repair Prepare for the birth of the baby ■ Cleanse the perineum ■ Check working order of suction equipment, oxygen, radiant warmer ■ Neonatal resuscitation equipment should be readily available for every delivery ■ Prepare delivery instruments Note precise time of birth Provide immediate care of the newborn ■ Assess airway and suction as needed • Remove excess fluid from infant’s nose and mouth (infants are obligate nose breathers) • If meconium is noted in nose or mouth, endotracheal intubation and suctioning must be performed immediately ■ Assess breathing effort (rate of at least 30 per minute) • If respiratory effort is not observed, gently stimulate infant by tapping sole of foot or stroking the back • Positive pressure ventilate if tactile stimulation does not result in respiratory effort ■ Assess circulation: heart rate 100 BPM ■ Temperature regulation • Dry infant
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69 • Place infant under prewarmed radiant warmer with temperature probe applied • Remove wet towels and lay infant on warm blankets • Keep temperature of labor room warm • Once infant is stabilized, encourage skin-to-skin contact with mother ■ Assign Apgar Score at 1 and 5 minutes • Score of 10 possible; Score of at least 8 desirable
Apgar Score Score Heart Rate Respiratory Effort Muscle Tone Reflex irritability Color
0
1
Absent Absent
Less than 100
Limp
Some flexion of extremities Grimace
No response Blue or pale
Slow, irregular
Body pink; extremities blue
2 Greater than 100 Good; crying Active motion Cough, sneeze or vigorous cry Completely pink
■ Assess for abnormalities that may need immediate attention (example: neural tube defects, open lesions, or birth injuries) ■ Examine umbilical cord and count number of vessels: 2 arteries and 1 vein; place plastic clamp on cord ■ Identification • Fingerprint mother and footprint newborn • Apply identification bands to both mother and newborn before leaving birthing room ■ Medications • Administer eye prophylaxis; ophthalmic antibiotic ointment (based on hospital protocol) to prevent chlamydial or gonococcal eye infection • Administer vitamin K, IM to boost production of clotting factor (needed due to sterile gut at birth)
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■ Weigh and measure infant (head, chest, and abdominal circumference as well as length) ■ Assess skin for lacerations, bruising, or edema ■ Note passage of stool/urine
Third Stage: Delivery of Placenta ■ Power: Strong uterine contractions cause the placenta to detach from the uterine wall ■ Psyche: Patient may be exhausted; encourage bonding with baby ■ Signs of placental separation ■ Sudden gush or trickle of blood from vagina ■ Lengthening of visible umbilical cord at introitus ■ Contraction of the uterus ■ Nursing considerations ■ Instruct patient to push when appropriate ■ Note time of placenta delivery ■ After placenta expelled: • Monitor amount of bleeding • Monitor vital signs • Assess fundus – Height – Location – Tone ■ Administer oxytocic medication as ordered • Stimulates uterus to contract • Prevents hemorrhage ■ Cleanse and apply ice pack to the perineum ■ Provide clean linen under patient ■ Provide warm blanket: patients often tremble/shiver immediately after the birth ■ Assess level of consciousness/comfort ■ Place newborn in arm of mother, encouraging skin-to-skin contact ■ Assist with positioning for breastfeeding and bonding
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71 Nursing Care with Intrapartum Procedures Induction of Labor ■ Artificial stimulation of uterine contractions to facilitate vaginal delivery ■ Commonly performed in postterm pregnancy ■ Prior to induction of labor the nurse should note ■ Indication for induction ■ Gestational age ■ Bishop’s score ■ Any contraindications for procedure ■ Bishop’s Score ■ Assigned by primary health-care provider prior to induction of labor ■ Higher scores indicate increased likelihood of successful labor induction ■ Parameters of Bishop’s score • Degree of Dilation (1–3 points) • Percent of Effacement (0–3 points) • Station (0–2 points) • Consistency of cervix (0–2 points) • Cervical position (0–2 points) ■ Use of Oxytocin (Pitocin): Hormone that stimulates uterine contractions to induce or augment contractions ■ Assess mother and fetus 20–30 minutes prior to oxytocin administration ■ Prepare and clearly label solution • 10 units of Pitocin into 500–1000 ml of isotonic IV solution • Administer IV piggyback per electronic infusion pump • Started at small dose and gradually increased until contractions every 2–3 minutes (follow hospital protocol) ■ Monitor maternal-fetal tolerance to procedure • Uterine resting tone • Contraction frequency, duration, and intensity • Intake and output • Fetal heart tones (baseline, variability, changes) • Cervical dilation and effacement • Vital signs • Patient comfort
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■ Monitor for complications of oxytocin (may become evident as dosage increases) • Uterine hyperstimulation (excessive frequency/duration of contractions without uterine relaxation) • Nonreassuring fetal heart rate patterns • If complications become apparent: – Change position to lateral side-lying – Discontinue IV oxytocin – Provide oxygen per mask at 8–10L/min – Increase rate of nonadditive IV solution – Call primary health-care provider ■ Cervical Ripening ■ Facilitates cervical softening, effacement, and dilation ■ Indicated when there is a medical need for induction of labor and cervix unfavorable ■ Methods: • Laminaria tents (mechanical cervical dilator made from seaweed) • Prostaglandin E1-misoprostol (Cytotec) • Prostaglandin E2-dinoprostone (Cervidil Insert, Prepidil Gel) ■ Nursing care • Monitor fetal heart rate and contraction status for 20–30 minutes prior to procedure • Encourage patient to void prior to insertion • Position side-lying position after procedure • Monitoring maternal vital signs, contractions, and fetal status (per hospital protocol) • Report adverse reactions to physician – Hyperstimulation of uterus – Nonreassuring fetal heart tones – Nausea, vomiting, diarrhea • Ensure proper waiting period between cervical ripening and Oxytocin administration ■ Amniotomy ■ Artificial rupture of amniotic sac performed by the primary health-care provider during a vaginal exam to augment contraction frequency and intensity ■ Nursing care • Pad bed to absorb amniotic fluid • Document time of amniotomy
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73 • Document fetal heart tones immediately following amniotomy • Note color and amount of amniotic fluid • Document cervical dilation, effacement, station, and fetal presentation • If presenting part is not engaged, limit patient activity to prevent cord prolapse • Once amniotic sac is ruptured, there is potential for infection – Monitor maternal temperature every 1–2 hours – Limit number of vaginal exams
Vaginal Birth After Cesarean (VBAC) ■ Women who have had a previous cesarean birth may be candidates for vaginal birth ■ Previous cesarean uterine incision documented as lowtransverse ■ No contraindications noted to VBAC ■ Physician and surgical team readily available for emergent cesarean birth ■ Patient and physician agree that VBAC is desirable ■ Risks of vaginal birth following cesarean must be explained, including ■ Uterine rupture with possible loss of fetus or uterus ■ Unsuccessful trial of labor with subsequent cesarean ■ Location of previous uterine scar must be documented Low Transverse
Low Vertical
Uterine scars.
INTRAPARTUM
Classic
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■ Nursing care ■ Closely monitor uterine response to labor ■ Monitor fetal response to labor ■ Initiate IV access ■ Monitor for signs of uterine rupture • Severe abdominal pain • Nonreassuring fetal heart rate patterns • Cessation of uterine contractions • Ascending station of presenting part • Vaginal bleeding • Signs of shock
Complications in the Intrapartum Period Prolapsed Umbilical Cord ■ Umbilical cord slips below/wedges next to presenting part ■ May lead to fetal hypoxia due to cord compression ■ Possible cause ■ Rupture of membranes without engaged presenting part ■ Non-cephalic fetal presentation ■ Symptoms ■ Prolonged variable deceleration ■ Pulsating cord palpated upon vaginal exam ■ Visible cord at introitus ■ Nursing actions ■ Stay with patient and call for assistance ■ Apply sterile glove and hold pressure of presenting part off umbilical cord ■ Place patient in Trendelenburg position ■ Notify physician ■ Monitor fetal heart tones ■ Place sterile saline gauze over any exposed cord ■ Prepare patient for cesarean birth
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75 Cesarean Birth ■ Indications for cesarean birth ■ Cephalopelvic disproportion (CPD) ■ Malpresentations ■ Placenta previa/abruption ■ Umbilical cord prolapse ■ Fetal intolerance to labor ■ Maternal medical conditions ■ Preoperative Care ■ Place signed consent on chart ■ Insert urinary catheter ■ Shave prep to the abdomen ■ Remove contact lenses, nail polish, jewelry, prosthetic device, dentures ■ Perform preoperative teaching ■ Assist significant other to prepare for observation of surgery ■ Administer preoperative medications ■ Continue to monitor vital signs and fetal heart rate ■ Postoperative care ■ Assess respiratory/cardiac status ■ Encourage patient to turn cough and deep breath ■ Assess level of pain and medication needs ■ Monitor intake and output ■ Assess bowel sounds ■ Assess incision ■ Monitor vaginal bleeding and provide pericare ■ Assess vital signs and level of consciousness ■ Assess extremities for circulation ■ Assist with positioning for breastfeeding and holding baby
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POSTPARTUM
Postpartum Fourth Stage of Labor First 1–2 hours after birth
Immediate Nursing Care ■ Assess height, location, and tone of the fundus (upper portion of the uterus) ■ Note amount and consistency of vaginal bleeding ■ Cleanse and apply ice pack to the perineum ■ Provide clean linen under patient ■ Provide warm blanket: patients often tremble/shiver immediately after the birth ■ Assess vital signs ■ Assess level of consciousness/comfort ■ Encourage bonding of mother and infant ■ Assist with proper latch-on to initiate breastfeeding ■ Maintain IV fluids and additives as ordered ■ Oxytocic medications • Promote uterine contractions • Decrease amount of vaginal blood loss
Nursing Assessment of the Postpartum Patient ■ Assess every 15 minutes for the first hour ■ Assess every 30 minutes for the second hour ■ Assess every 4 hours for the first 24 hours ■ Uterine tone ■ Bleeding ■ Perineum ■ Bladder status ■ Vital signs • Blood pressure • Pulse • Respiration • Temperature every 1–4 hours
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77 ■ ■ ■ ■
Fluid balance Circulation to extremities Comfort/level of consciousness Newborn interaction
Postpartum Education ■ Education of the postpartum family is an essential role of the postpartum nurse ■ New skills should be discussed, demonstrated, and reinforced ■ Document education and validate knowledge through verbalization and/or return demonstration
Postpartum Assessment and Nursing Care Remember the acronym BUBBLE B breasts U uterus B bowel B bladder L lochia E episiotomy
Breast assessment ■ Consistency: soft, filling, or firm ■ Nipple type and integrity ■ Type: Inverted or everted ■ Integrity: Bleeding, cracked, intact ■ Redness ■ Comfort ■ Breast care (lactating) ■ Patient should wear a supportive bra • Montgomery glands secrete oil to keep nipples supple; soap should not be used on breasts • After feedings, leave colostrum/breast milk on nipples and expose the breasts to air
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POSTPARTUM
■ Encourage frequent nursing (8–12 feedings in 24 hours) ■ Teach positioning of infant for increased comfort • Side-lying • Football hold • Cradle hold
Breastfeeding positions. (Used with permission from Ross Products Division Abbott Laboratories Inc.)
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79 ■ Instruct on proper latch-on • Elicit the rooting reflex by stroking the infant’s lower lip • As the infant’s mouth opens wide, bring the infant to the breast, ensuring both the nipple and part of the areola are in the infant’s mouth • Correct latch-on: infant’s jaws will rhythmically move with an audible swallow; mother will express comfort • Incorrect latch-on: clicking noise as infant sucks with nipple pain expressed by mother; break suction by placing one finger by the infant’s mouth and relatch
Latch-on. (Used with permission from Ross Products Division Abbott Laboratories Inc.)
■ If separated from newborn, initiate breast pump ■ Breast care (nonlactating) ■ Supportive bra, breast binder or sports bra ■ No nipple stimulation ■ Do not express breast milk ■ Ice packs/analgesics for engorgement ■ Teach breast self exam (BSE)
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POSTPARTUM
TEACHING TIPS: BREASTFEEDING Advantages to Breastfeeding ■ Cost ■ Convenience ■ Immunoglobulins, which protect the infant from infection, are passed via breast milk ■ Decreased incidence of infant: ■ Allergies ■ Otitis media ■ Upper respiratory infections Positioning ■ The infant’s body should face the breast, with the ear, shoulder, and hip aligned ■ Position pillows to support the weight of the infant ■ Demonstrate positions for breastfeeding Supply and Demand ■ The newborn should be fed on demand; prolactin release in response to suckling will stimulate the alveolar cells of the breast to produce the appropriate amount of milk to meet the infant’s needs ■ The mother should initiate breastfeeding when the infant demonstrates hunger cues: ■ Increased alertness or activity ■ Smacking of the lips ■ Suckling motion ■ Moving of the head in search of the breast ■ Continue to feed until the infant detaches spontaneously, burp the infant, and continue feeding on the other breast ■ Start breastfeeding on the breast ended with the last feeding ■ Unless medically indicated, supplemental feeding should be avoided
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81 Engorgement (Firm, tender breasts) ■ May occur on postpartum day 3–5, when the volume of breast milk increases ■ Prevent engorgement with frequent feedings; avoid skipping any feedings ■ Treatment for engorgement ■ Express a small amount of breast milk either manually or with a breast pump so that the breasts will soften and the baby can latch ■ Apply cold packs to breasts intermittently ■ Apply cleaned, cooled cabbage leaves to breasts until warm/wilted ■ Warm shower or warm compress right before feeding Nutrition ■ Add 500 calories over nonpregnant diet ■ Continue prenatal vitamins ■ Stay well hydrated ■ Avoid alcohol, smoking, or recreational drugs ■ Consult with pediatrician before using any over-the-counter or prescription medication Pumping and Storing ■ Demonstrate use of breast pump ■ Discuss appropriate storage containers ■ Write the date of expression on storage container and use oldest milk first ■ Length of storage dependent on location Location
Guideline
Room temperature Refrigerator Refrigerator freezer (with separate door) Deep freeze
POSTPARTUM
Up to 8 hours 3–5 days 3 months 6–12 months
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POSTPARTUM
Weaning ■ Gradual weaning suggested to decrease the likelihood of engorgement ■ Remove one feeding per week ■ If infant is less than 1 year, infant formula, instead of cow’s milk, must be given Breast Care ■ Breast pads inside a supportive bra will collect leaking breast milk ■ Teach signs of mastitis ■ Unilateral breast pain, warmth and redness ■ Malaise and flu-like symptoms ■ Fever Breastfeeding Concerns ■ Mother should report breastfeeding concerns to the primary healthcare provider ■ Feedings that are consistently short with the infant appearing hungry after feedings and the breasts remaining full ■ Swallowing is inaudible once milk is established ■ The infant is not gaining the expected amount of weight ■ The infant has fewer than 6 wet diapers a day; urine is amber-colored ■ Nipple pain or cracking is present Community Resources ■ Lactation consultant ■ La Leche League ■ Primary health-care provider
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83 Uterus ■ Uterine Involution ■ Process by which the size of uterus decreases in a predictable pattern ■ Documented in fingerbreadths above or below the umbilicus Postpartum Period Immediately after birth 12 hours 24 hours Day 2 Day 3
Level of the Fundus at the umbilicus 1 fingerbreadth (FB) above the umbilicus 1 FB below the umbilicus 2 FB below the umbilicus 3 FB below the umbilicus
U Umbilicus
■ Measures that promote uterine involution • Breastfeeding • Voiding • Fundal massage • Oxytoxic medications
Fundal massage.
POSTPARTUM
Documentation at U or U/U 1/U U/1 U/2 U/3
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POSTPARTUM
Assess the tone, height, and location of the fundus ■ TONE of the uterus assessed while patient is supine ■ Fundus should be firmly contracted ■ If fundus is not firm, perform fundal massage ■ Support the lower uterine segment during massage to prevent inversion of the uterus ■ If fundus is boggy (not firm) after massage: • Check bladder status and encourage voiding • Catheterize (as ordered) if unable to void • Notify primary care provider ■ Assess the HEIGHT and LOCATION of the uterus in relation to the umbilicus • Immediately after birth, fundus is located at or just above the umbilicus • The fundus should be midline and not deviated to the left or right
Uterine involution. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p. 744.)
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85 TEACHING TIPS: UTERINE/VAGINAL CHANGES The Fundus ■ The fundus lowers one fingerbreadth below the umbilicus each day until returning to pelvis (day 10–14) Normal Progression of Lochia ■ Lochia progresses from bright red to brown to light pink with decreasing amount ■ If lochia returns to bright red or increases in amount, decrease activity ■ Persistent bright red lochia or lochia with a foul odor should be reported ■ Report saturating one pad per hour or passing golf-ball size clots Return of the Menstrual Cycle ■ Dependent on method of infant feeding ■ If breastfeeding, lactation amenorrhea while exclusively breastfeeding infant (first 6 months) ■ If bottle feeding, menses usually returns 6–8 weeks postdelivery Sexuality ■ Sexual intercourse may be resumed after lochia ceased and episiotomy healed; 4–6 week delay generally recommended ■ Vaginal lubrication may be diminished; use water-soluble gel ■ Female superior or side-lying position may assist in comfort ■ Discuss family planning methods
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POSTPARTUM Bladder Status
■ Postpartum women may have difficulty voiding after birth due to: ■ Decreased urethral sensation from pressure exerted by the passage of the fetus ■ Side effects of local/epidural anesthesia ■ Delivery trauma to the perineum ■ Palpate for bladder distention ■ Track fluid balance: intake and output ■ Assess for periurethral edema/trauma ■ Postpartum diuresis, which occurs in response to decrease in estrogen, helps rid the body of extracellular fluid and causes the bladder to fill quickly ■ Starts within 12 hours of birth and continues for up to 5 days ■ Urine output may be 3,000 cc/day ■ Catheterization may be necessary if unable to void or with urinary retention
Bowel ■ ■ ■ ■
Auscultate for bowel sounds Assess for abdominal distention Assess for presence/status of hemorrhoids Educate on prevention of constipation ■ Increased roughage in the diet ■ Increased oral intake of fluids ■ Temporary use of prescribed stool softeners
Lochia ■ Vaginal discharge after delivery called lochia ■ Blood loss with vaginal birth approximately 500 cc ■ Blood loss with cesarean birth approximately 1000 cc
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87 ■ Assess the amount of lochia ■ Note time of last perineal pad change ■ Document amount of lochia on perineal pad (scant, small, moderate, large) • If weighing perineal pads, 1 gm 1 ml of blood loss ■ Assess the color of lochia • Lochia rubra (red): day 1–3 • Lochia serosa (brownish-pink): day 4–9 • Lochia alba (yellow-white): day 10–14 ■ Document number and size of blood clots ■ Turn patient to assess blood loss under buttocks
Assessment of the Perineum Requires a direct light source and positioning of the patient in side-lying with top leg forward ■ Assess Episiotomy or laceration ■ Redness ■ Swelling ■ Ecchymosis ■ Color, consistency of discharge ■ Approximated edges ■ Lacerations described by degree of tissue involvement Degree 1st 2nd 3rd 4th
Definition Vaginal mucous membrane and skin of perineum Subcutaneous tissue of the perineal body Involves fibers of the external rectal sphincter Through rectal sphincter exposing the lumen of the rectum
■ No enemas or rectal suppositories should be used with 3rd and 4th degree lacerations
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TEACHING TIPS: PERINEAL HYGIENE Perineal Cleansing ■ Stress importance of hand washing before and after perineal care ■ Demonstrate use of perineal cleansing bottle ■ Change perineal pads after each void ■ Keep perineal pad/underwear from touching floor Comfort Measures ■ Apply perineal ice packs intermittently for the first 24 hours after birth ■ Sitz baths may be ordered after 24 hours ■ Apply creams, sprays, and ointments to perineum as ordered ■ Discuss bowel habits and steps to avoid constipation Kegel Exercises ■ Encourage patient to perform Kegel exercises throughout the day to strengthen perineal muscle tone ■ To locate muscle, tighten perineal muscles as though stopping the flow of urine (this technique is only used to locate the muscles, not to perform the exercise) ■ Hold contraction for several seconds, release, and repeat 10–15 times; discourage breath-holding Emotional Response ■ Assess interaction with newborn ■ Eye contact with infant ■ Talks to infant ■ Holds infant close ■ Feeds infant ■ Assess emotional status ■ Assess for postpartum blues
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89 TEACHING TIPS: EMOTIONS Postpartum Blues ■ Symptoms of postpartum blues include tearfulness, insomnia, and moodiness ■ Postpartum blues common in the early postpartum period ■ Duration less than 2 weeks ■ Possible cause ■ Hormonal changes after birth ■ Exhaustion ■ Physical discomfort Emotional Support ■ Encourage patient to discuss feelings ■ Encourage private time when baby naps ■ Discuss the difference between “blues” and depression; encourage patient to report symptoms of postpartum depression ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts Extremities ■ Assess circulation to lower extremities ■ Pedal pulse ■ Color, temperature, blanching ■ Assess for signs of deep vein thrombosis ■ Pain ■ Swelling ■ Redness ■ Increased skin temperature
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TEACHING TIPS: ACTIVITY Activity Level ■ Frequent rest periods will help with healing of body and mind (nap when baby sleeps) ■ Do not lift anything heavier than the baby ■ Limit activities to care of newborn/self ■ Ask for assistance with housework/shopping Vital Signs ■ Temperature ■ Slight increase in temperature in first 24 hours common due to dehydration; encourage oral fluids ■ If temperature 100.4F call physician ■ Pulse: assess rate, rhythm, and amplitude ■ Blood pressure ■ Watch for signs of shock (↓ blood pressure and ↑ pulse) ■ Be alert for orthostatic hypotension upon rising ■ Dangle at bedside before rising ■ Respirations: ■ Note rate and depth ■ Lungs should be clear on auscultation
Level of Comfort ■ Pain location and intensity ■ Afterbirth cramps: intense contractions of the uterus that are more intense with multiparity and occur with nursing ■ Incisional pain ■ Hemorrhoid pain ■ Postpartum diaphoresis: intense sweating that occurs in the early postpartum period ridding the body of excess fluid ■ Effects of epidural anesthesia ■ Leg movement/strength ■ Presence of numbness and tingling ■ Assist with ambulation
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91 Nutrition ■ Assess dietary needs and concerns ■ Average weight loss 12 pounds at birth
Laboratory Data ■ Examine postpartum laboratory findings and compare to prenatal levels (usually drawn at 24 hours postpartum) ■ Hemoglobin/hematocrit ■ White blood cell count ■ Platelet count ■ If mother is RH negative check Rh status of infant Mother Negative Negative
Infant
Rho(D) Immune globulin (300 g)
Negative Positive
No treatment needed Administer within 72 hours of birth
Cesarean Birth In addition to routine postpartum assessment, the nurse should assess the following ■ Effects of anesthesia ■ Level of consciousness ■ Ability to hold and care for infant may be limited due to • Comfort level • Limitation in movement ■ Respiratory status • Pulse oximetry
Patient Controlled Anesthesia (PCA) ■ Effectiveness ■ Number of attempts/amount given ■ Side effects
Abdominal Assessment ■ Bowel sounds
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■ Abdominal distention ■ Ability to pass flatus ■ Avoid straws and carbonated beverages ■ Incision/dressing ■ Circle drainage and mark with date and time ■ Assess incision with dressing change • Approximation • Redness • Drainage • Edema • Hematoma • Odor
Nutrition ■ ■ ■ ■
Intake and output Nausea/vomiting Presence of bowel sounds Progression of diet
Progression of Activity ■ ■ ■ ■
Turn/cough/deep breathe Dangle at side of bed Sit up in chair Ambulate with assist
Complications in the Postpartum Period Hemorrhage ■ Risk factors ■ High parity ■ Overdistention of the uterus ■ Precipitous labor or prolonged labor ■ Medications (oxytocin, magnesium sulfate) ■ Etiology ■ Uterine atony (hypotonia of the uterus) ■ Retained placental fragments ■ Vaginal/cervical laceration ■ Hematoma
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93 ■ Clinical findings ■ Perineal pad saturated in less than 1 hour ■ Continuous trickle of vaginal bleeding ■ Firm, bruised area on perineum ■ Interventions ■ Fundal massage ■ Monitor urine output • Check bladder status • Catheterize if needed ■ Increase mainline IV fluids ■ Closely monitor vital signs ■ Administer oxygen ■ Call primary health-care provider • May need suturing of laceration • May need evacuation of hematoma • May need evacuation of placental fragments ■ Administer medications that promote uterine contraction as ordered ■ Oxytocin ■ Methylergonovine maleate (Methergine) • If blood pressure 140/90, hold and call primary care provider ■ Ergonovine maleate (Ergotrate) ■ Prostaglandin F2a (Prostin/Hemabate)
Infection ■ Symptoms ■ Temperature elevation 100.4F ■ Elevated white blood cell count ■ Complaint of chills and aching ■ Malaise ■ Interventions ■ Obtain culture of discharge as ordered ■ Report abnormal laboratory findings ■ Administer antibiotic therapy as ordered ■ Consider medications contraindicated for breastfeeding ■ Monitor temperature ■ Clean and monitor site ■ Teach patient reportable signs and symptoms
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■ Endometritis (uterine infection) ■ Contributing factors • Operative birth • Long labor with multiple vaginal exams • Internal monitoring • Premature rupture of membranes • Manual removal of placenta ■ Clinical findings • Subinvolution of the uterus • Foul-smelling vaginal discharge • Lower abdominal cramping ■ Mastitis (breast infection) ■ Contributing factors • Alteration in nipple integrity • Delayed emptying of breast milk ■ Clinical findings • Unilateral breast pain, warmth and redness • Malaise and flu-like symptoms ■ Incisional infection ■ Contributing factors • Inadequate care of incision • Operative delivery • Laceration ■ Clinical findings • Incision not well approximated • Incision red with purulent drainage ■ Urinary tract infection ■ Contributing factors • Catheterization of bladder • Retention of urine in bladder ■ Clinical findings • Dysuria • Frequency of urination • Flank pain
Postpartum Depression ■ Risk factors ■ History of depression or anxiety disorder ■ Prenatal depression
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95 ■ Inadequate social or partner support ■ Large number of life stressors ■ Clinical findings ■ Symptoms extend beyond 2 weeks postpartum; may occur 3–12 months after birth ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts ■ Interventions ■ Psychotherapy ■ Medications
Thrombophlebitis/Deep Vein Thrombosis ■ Risk factors ■ Varicosities ■ Advanced maternal age ■ Obesity ■ Long periods of bed rest ■ Occupation that requires long periods of standing ■ Clotting disorder ■ Etiology ■ Increased clotting factors in postpartum period ■ Infection in the vessel lining to which a clot attaches ■ Clinical findings ■ Pain with dorsiflexion ■ Affected site hot to touch ■ Swelling, redness, and pain to affected leg ■ Interventions dependent on severity of findings ■ Administer anticoagulants ■ Monitor coagulation profile ■ Compression stockings ■ Apply warm, moist heat ■ Rest ■ Observe for symptoms of pulmonary embolism • Dyspnea • Chest pain • Hemoptysis • Patient fearful
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TEACHING TIPS: POSTPARTUM COMPLICATIONS Teach the patient to report the following signs and symptoms to the primary health-care provider. Signs of infection ■ Elevated temperature ■ Localized redness or pain to either breast ■ Persistent abdominal tenderness ■ Persistent pain to perineum ■ Burning, frequency, or urgency of urination ■ Foul odor to lochia ■ Redness, pain, or discharge at incision Sign of Uterine Subinvolution ■ Change in the character of lochia ■ Increased amount of lochia ■ Resumption of bright red color ■ Presence of clots Signs of Thrombophlebitis/Deep Vein Thrombosis ■ Pain, increased temperature and redness to legs Signs of Postpartum Depression ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts
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97 Nursery Care of the Newborn ■ ■ ■ ■ ■
Keep infant warm during all care and procedures Assess and record daily weight Role model back sleeping Keep bulb syringe at bedside Check identification bands at each encounter with parents
Physical Assessment of the Newborn Reportable findings in red
Vital Signs
■ Axillary temperature 97.8–98.6F ■ Decreased body temperature may be a sign of sepsis ■ Auscultate apical pulse for one full minute ■ 110–160 beats per minute ■ Sustained resting heart rate below 100 or above 160 ■ Respirations counted for one full minute ■ 30–60 per minute ■ Sustained resting respiratory rate below 30 or above 60
Extremities/Activity
■ Newborn posture flexed ■ Extremities equal length with full range of spontaneous motion ■ Gluteal folds even ■ Ten fingers and 10 toes without webbing (syndactyly) or extra digit (polydactyly) ■ Grasp reflex intact ■ REPORT ■ Poor muscle tone or asymmetry of muscle tone ■ Failure to spontaneously move all extremities or decreased range of motion ■ Chewing type mouth movements combined with noticeable changes in eye and/or body movements (may represent neonatal seizure activity) ■ Unequal knee height, leg length, or asymmetrical gluteal folds (hip dysplasia) ■ Resistance to neck flexion
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TEACHING TIPS: NORMAL NEWBORN BEHAVIOR Pattern of Sleep ■ Newborns sleep in short periods for a total of 13–16 hours per day ■ Lying the baby on the back for sleep is recommended Communication ■ Crying is a means of communication and a late sign of hunger ■ Teach parents hunger cues ■ Teach techniques for comforting the fed newborn ■ Swaddling ■ Burping ■ Massage ■ Soft music ■ Diaper change ■ Gentle rocking ■ Encourage parents to talk, sing and hold newborn close
Skin
■ Color uniformly pink ■ Normal variations ■ Acrocyanosis (bluish hue to hands/feet) ■ Milia (plugged sebaceous glands on nose) ■ Lanugo (downy hair on arms, back, face) ■ Mongolian spot (area of increased pigmentation, resembles bruise) ■ Telangiectases “stork bites” ■ Erythema toxicum (newborn rash) ■ REPORT ■ Cyanosis (other than in hands and feet) ■ Skin lesions, bruises, abrasions ■ Jaundice
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99 TEACHING TIPS: SKIN CARE AND BATHING ■ Sponge baths recommended until the umbilical cord stump has fallen off and circumcision has healed ■ Stay with baby and hold securely at all times when bathing ■ All supplies should be within easy reach ■ No soap is needed on the face ■ The eye area can be cleansed with wet cotton balls (inner to outer canthus) ■ Only soap recommended for newborn skin should be used ■ Dry the baby quickly to avoid chilling ■ Wash hair last to avoid heat loss ■ Encourage frequent diaper changes ■ Cleanse genital area with mild soap and water ■ Cleanse the female genitalia from front to back ■ Do not forcibly retract the foreskin of uncircumcised boys
Head
■ Head round with slight molding (cone-shaped with overriding cranial bones) or caput succedaneum (tissue edema that crosses suture lines) ■ Anterior and posterior fontanels (soft spots) flat ■ REPORT ■ Sunken or bulging fontanels when infant is at rest ■ Cephalhematoma, unilateral swelling of scalp tissue caused by collection of blood between the skull and periosteum
Face
■ Face symmetrical with rest and crying ■ Eyes symmetrical in size and shape with intact red and corneal reflex ■ Nose midline with nares patent ■ Ears aligned with outer canthus of eyes; pinna well-formed and hearing intact ■ Oral mucosa pink and moist; tongue mobile ■ Hard and soft palate intact ■ Strong suck; able to coordinate suck and swallow ■ REPORT ■ Absence of red reflex ■ Purulent discharge of eyes immediately after birth
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Low set ears Lack of response to sound Nasal flaring Cleft lip or palate Large, protruding tongue (possible Down syndrome) White patches in mouth (Candidiasis) Absent rooting, suck, or Moro reflex Severe drooling and/or coughing or gagging
TEACHING TIPS: BOTTLE FEEDING Types of Formula Directions for dilution of formula on the container must be followed exactly to ensure adequate infant health and nutrition ■ Ready-to-feed ■ Most expensive, but most convenient ■ Use without dilution ■ Opened cans can be stored in the refrigerator for 48 hours ■ Concentrated ■ Dilute with equal parts of water ■ Prepare enough bottles for the day ■ Prepared bottles can be stored in refrigerator for 48 hours ■ Powdered ■ Least expensive ■ Add water for every one scoop of powder per manufacturer’s instructions ■ Shake well to distribute powder Formula Preparation ■ Clean off can with soap and water before opening ■ If water supply questionable, use bottled nursery water ■ Prepared bottles can be fed at room temperature; run refrigerated bottles under warm water to bring to room temperature ■ Avoid use of microwave for heating formula
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101 Bottle Preparation ■ Bottles should be washed with a brush and rinsed thoroughly; if water supply is questionable, sterilization recommended ■ Choose nipples that allow a steady flow of formula but not so large as to cause choking Technique for Feeding ■ Encourage parents to hold the baby close and talk to the infant during feedings ■ Do not prop bottles ■ On-demand feeding recommended/watch baby for hunger cues (usually every 3–4 hours) ■ Increased alertness or activity ■ Smacking of the lips ■ Suckling motion ■ Moving of the head in search of the breast ■ Newborns generally drink about 0.5–2 ounces of formula per feeding for the first several days of life ■ Elicit the rooting reflex to initiate feeding ■ Keep bottle tipped to ensure the nipple remains full of formula ■ Burp every 1–2 ounces ■ The type, amount and pattern of feedings should be discussed with the pediatrician before hospital discharge ■ Formula remaining in the bottle must be discarded
Chest ■ ■ ■ ■ ■
Respirations unlabored Chest rises and falls symmetrically Lung sounds clear bilaterally Clavicals intact REPORT ■ Nasal flaring, chest retractions, or expiratory grunting ■ Asymmetrical breath sounds ■ Chest asymmetrical or circumference greater than head circumference ■ Loud cardiac murmur with thrill
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Abdomen/Genitals ■ ■ ■ ■ ■ ■ ■ ■
Abdomen round and soft without palpable masses Three vessel umbilical cord with drying base Bowel sounds present First void within 24 hours (may be rust-stained from uric acid crystals) Meconium stool passed within 24 hours Female genitalia ■ Labia majora covers minora ■ May have mucoid vaginal discharge or pseudomenses Male genitalia ■ Urinary meatus at tip of penis ■ Testes descended REPORT ■ Drainage of urine or feces from umbilicus ■ Liver more than 3 cm below right costal margin ■ Abdomen markedly distended or flat ■ Palpable abdominal mass ■ Visible peristaltic waves ■ Poor feeding or excessive spitting or vomiting ■ Failure to urinate or pass meconium within 24 hours ■ Hypospadias or epispadias ■ Mass in scrotal or inguinal area ■ Imperforate anus
TEACHING TIPS: NEWBORN CARE Umbilical Cord Care ■ The cord will fall off spontaneously in 10–14 days; do not tug at cord ■ Cleanse cord insertion site at diaper changes ■ Fan fold diaper to expose cord to air ■ REPORT redness, drainage, bleeding, foul odor from cord
Circumcision ■ Site may be covered with petroleum gauze dressing; tell parents when to remove dressing ■ Clean area with warm water for diaper change
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103 ■ Apply petroleum jelly to head of penis to decrease friction with diaper ■ A yellow exudate forms on the head of the penis on day 2–3; this is part of the healing process and removal should not be attempted ■ Reportable symptoms ■ Difficulty urinating ■ Persistent bleeding from the site ■ Pus oozing from the site ■ Redness or swelling
Back
■ Spine straight, intact, and easily flexed ■ REPORT ■ Arched back ■ Tuft of hair on spine
TEACHING TIPS: SAFETY, HEALTH MAINTENANCE Safety ■ Discuss choking hazards and demonstrate the proper use of the bulb syringe ■ Properly installed car seats must be consistently used with safety straps on ■ Crib mattress should be firm and fit snugly; crib slats should be no more than 2 3/8” apart ■ Never leave baby unattended on household furniture other than crib ■ Test bath water and formula temperature to prevent burns ■ Shield skin from excessive sun exposure ■ Supervise pets around the baby ■ Reduce the risk of Sudden Infant Death Syndrome (SIDS) ■ Back sleeping recommended ■ Avoid pillows and stuffed toys in the crib ■ Use firm, well-fit mattress ■ No smoking around baby ■ Dress baby for comfort; do not overheat
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Immunizations ■ Discuss importance of immunizations for disease prevention ■ Provide current schedule of recommended childhood immunizations ■ Provide documentation of any immunization given in the hospital Neonatal Genetic and Hearing Screen ■ Blood test for metabolic defects are performed on all newborns after feeding is established ■ Exact tests vary by state ■ Infants who are discharged early may need to be brought back for newborn screen ■ Hearing screen done before hospital discharge for early identification of hearing deficits Reportable Symptoms ■ Parents should call the pediatrician with the following signs or any time they are concerned with their newborn’s behavior ■ Difficulty breathing ■ Vomiting or diarrhea ■ Less than expected voids/stools ■ Yellow hue to the skin or sclera ■ Constant crying ■ Difficulty awakening baby ■ Altered temperature ■ Body rash ■ Lack of interest in eating
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105 Peds Basics Common Developmental Milestones (ages are aproximate)
0–6 mo
■ Physical ■ Ht ↑ 1 in/mo ■ Doubles wt by 5–6 mo ■ Wt ↑ 1.5 lb/mo ■ HC ↑ 0.5 in/mo ■ Gross/Fine Motor ■ Rolls back to side: 3 mo ■ Holds head erect: 4 mo ■ Voluntary grasp: 5 mo ■ Rolls from front to back: 5–6 mo ■ Language ■ Coos: 1–2 mo ■ Laughs: 2–4 mo ■ Makes consonant sounds: 3–4 mo ■ Imitative sounds: 6 mo ■ Personal-Social ■ Regards a person’s face: 1 mo ■ Displays social smile and follows object 180 degrees: 2 mo ■ Recognizes familiar faces: 3 mo ■ Stranger anxiety begins: 6 mo
6–12 mo
■ Physical ■ Ht ↑ 50% of birth ht by 1 yr ■ Wt ↑ 1 lb/mo ■ Triples wt by 1 yr ■ HC ↑ by 33% ■ Chest circumference 1 in HC ■ Post fontanel closes: 2–3 mo ■ Ant. fontanel closes: 12–18 mo ■ Central incisors erupt: 5–7 mo ■ Gross/Fine Motor ■ Holds head erect: 4 mo ■ Grasps voluntarily: 5 mo
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■ Begins to crawl: 7 mo ■ Sits unsupported: 8 mo ■ Pulls up to stand: 9 mo ■ Drinks from cup: 9 mo ■ Pincer grasp: 8–10 mo ■ Builds two-block tower: 12 mo ■ Walks alone or holding onto one hand: 12 mo ■ Language ■ Pronounces syllables (da-da, ma-ma) : 8 mo ■ Says 4–10 words: 12 mo ■ Personal-Social ■ Marked stranger anxiety: 8 mo ■ Emotions such as jealously: 12 mo
1–3 yr
■ Physical ■ Ht ↑ 3 in/yr ■ Wt ↑ 5 lb/yr ■ Weighs about 4 times birth wt: 2 yr ■ HC equals chest circumference: 1–2 yr ■ HC ↑ 1 in during 2 yr ■ 10–14 temporary teeth ■ Gross/Fine Motor ■ Walks without help: 15 mo ■ Walks up and down stairs placing both feet on each step: 24 mo ■ Scribbles spontaneously: 15 mo ■ Builds 3–4 block tower: 18 mo ■ Jumps with both feet: 30 mo ■ Language ■ Says 300 words: 2yr ■ Uses 2–3 word phrases and pronouns ■ Understands speech: 2 yr ■ States first and last name: 2.5 yr ■ Personal-Social ■ Separation anxiety peaks ■ Ritualism ■ Negativism ■ Independence
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107 3–6 yr
■ Physicial ■ Ht ↑ 2.5–3 in/yr ■ Wt ↑ 4–6 lb/yr ■ HC ↑ 0.5 in/yr ■ Vision is 20/20 with color vision intact: 5–6 ■ Gross/Fine Motor ■ Rides tricycle: 3 yr ■ Climbs stairs using alternate feet: 3 yr ■ Stands on one foot: 3 yr ■ Broad jump: 3 yr ■ Builds 9–10 block tower: 3 yr ■ Draws a cross: 3 yr ■ Hops on one foot: 4 yr ■ Skips: 4 yr ■ Catches a ball: 4 yr ■ Walks downstairs using alternate feet: 4 yr ■ Laces shoes: 4 yr ■ Copies square: 4 yr ■ Adds three parts to stick figure: 4 yr ■ Balances on alternate feet: 5 yr ■ Ties shoelaces: 5 yr ■ Uses scissors well: 5 yr ■ Prints letters, numbers and name: 5 yr ■ Language ■ Says 900 words: 3 yr ■ Speaks 3–4 word sentences: 3 yr ■ Says 1500 words: 4 yr ■ Tells stories, sings songs: 4 yr ■ Asks “why” questions: 4 yr ■ Says over 2000 words: 5 yr ■ Knows and can name colors: 5 yr ■ Names days of week: 5 yr ■ Personal-Social ■ Shares toys with others ■ Imitates caregivers ■ Domestic role-playing
PEDS BASICS
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6–12 yr
■ Physical ■ Ht ↑ 2–3 in/yr ■ Wt ↑ 4.5–6.5 lb/yr ■ Secondary teeth erupt with central incisors and first molars ■ Tanner stage 2 may begin ■ Gross/Fine Motor ■ Rides bicycle ■ Roller skates ■ Run, jumps, swims ■ Cursive writing: 8 yr ■ Computer and craft skills ■ Language ■ Devlops ability to read at grade level ■ Personal-Social ■ School relationships and work important ■ Separating from family
12 to 18–21 yr
■ Physical ■ Puberty beings in girls: 8–14 yr (lasts about 3 yr) ■ Puberty begins in boys: 9–16 yr (lasts longer) ■ Ht and wt ↑ variable during puberty ■ Progressive Tanner stages of development ■ Gross/Fine Motor ■ Gross motor reaches adult levels ■ Fine motor continues to be refined ■ Language ■ Develops formal thought—includes idealism, egocentrism, and ability to consider abstract possibilities ■ Personal-Social ■ Works through identity issues, status, and relationships
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109 Growth ■ Use Growth Charts from National Center for Health Statistics (NCHS) www.cdc.gov/growthcharts, for ht, wt, wt for ht, HC, and BMI ■ Use 5th and 95th percentiles as parameters in determining if children are within normal limits for growth
Average Daily Caloric Requirements for Children Age 0–1 month 2–4 months 5–60 months 5 years
Caloric Expenditure Per Day 100—110 kcal/kg/day 90—100 kcal/kg/day 70—90 kcal/kg/day 1500 kcal for first 20 kg 25 kcal for each additional kg/day
From Hay WW, et al. (2005). Current Pediatric Diagnosis & Treatment: (17th ed.). New York: Lange Medical Books/McGraw-Hill, p. 309.
Number and Volume of Infant Feeds Breast Feeding: Eight to 12 feedings/24 hours during the first 6 months Formula Feeding: Six to eight feedings/24 hours of commercially prepared iron-fortified (3–4 ounce) for each feeding for first month to 5 feedings/24 hours for each feeding when solid foods introduced at 6 months Weaning: Should be gradual, based on infant’s desire—usually between 8 to 9 months of age.
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Total Water Requirements/24 Hours Infant 500–1300 mL; Child 6 yr 1150–2000 mL; 6 yr 2000–2700 mL
Daily Urine Output/24 Hours 0.5–2 mL/kg/hr depending on child’s age and hydration status Infant 350–550 mL; Child 500–1000 mL; Adolescent 700–1400 mL From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of Pediatrics, (17th ed). Philadelphia: W.B. Saunders, p. 2415.
Average Ranges for Pediatric Vital Signs Age Group
Heart Rate
Infant Toddler Preschooler School-age Adolescent
80–150 70–110 65–110 60–95 55–85
Respiratory Rate 25–55 20–30 20–25 14–22 12–18
BP Systolic
BP Diastolic
65–100 90–105 95–110 100–120 110–135
45–65 55–70 60–75 60–75 65–85
Adapted from Behrman RE, Kliegman RM, & Jenson TB. (2004). Nelson Textbook of Pediatrics (17th ed). Philadelphia: W.B. Saunders, p. 280; and National Heart, Lung, and Blood Institute. (1987). Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children. Author, Bethesda, MD.
Rule of Thumb to Determine BP: Normal systolic ranges: 1–7 yr age in yr 90; 8–18 yr (2 age in yr) 83 Normal diastolic ranges: 1–5 yr 56; 6–18 yr 52
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Usually breast milk; commercially prepared iron-fortified formula
Comments Sometimes give rice cereal mixed with breast milk or formula around 4 mo
6 mo
8–9 mo
Begin with infant rice cereal, then vegetables, and fruits with meats the last food to introduce; start with 1–2 tsp Introduce one food at a time for 3–5 days to watch for food allergies; do not use honey on young infants because of the association with infant botulism; use small spoon to feed infant
Finger foods such as teething crackers or raw fruits
Eating normal table foods; healthy habits—go to www. mypramid.gov
12 mo
Watch sizes and types of food for possible choking
Provide a variety of foods that meets child’s nutritional needs; avoid allergenic foods such as nuts, egg whites, shellfish, strawberries, or chocolate
PEDS BASICS
Birth-6 mo Types of Foods
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Pediatric Coma Scale Pupils
Right
Size Reaction Size Reaction
Left
Spontaneously To Speech To Pain None Obeys Commands Best Motor Response (use Localizes Pain best arm or age- Flexion Withdrawal appropriate Flexion Abnormal response) Extension None Best Response Age Appropriate Auditory/Visual Orientation Stimulus Confused Inappropriate Words Incomprehensible Words None Endotracheal Tube or Trach Eyes Open
4 3 2 0 6 5 4 3 2 1 5 4 3 2 1 T
Coma Scale Total (7 coma; 3 deep coma) Pupil Reaction: Brisk, Sluggish, — No reaction, C Eye closed due to swelling Adapted from Hahn YS, et al. (1988). Head injuries in children under 36 months of age. Child Nervous System 4: 34.
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113 Normal Breath Sounds ■ Vesicular Breath Sounds: Soft, swishing noise heard over entire area of lung surface except for upper scapular area and beneath sternum; inspiration is louder, longer, and higher pitched than expiration ■ Bronchovesicular Breath Sounds : Heard over sternum and upper scapular regions where trachea and bronchi bifurcate; inspiration is louder and higher pitched than vesicular breath sounds ■ Bronchial Breath Sounds : Heard over trachea near suprasternal notch with inspiratory phase short and expiratory phase longer
Abnormal Breath Sounds ■ Decreased or unequal breath sounds : No or slight sound of normal breath sounds that may indicate airway obstruction, pneumothorax, pleural effusion, pneumonia ■ Rhonchi : Low-pitched, snoring-like, continuous sound associated with respiratory infections ■ Crackles : Soft, high-pitched, intermittent sounds due to small collapsed airways popping open ■ Grunting : Harsh sound on expiration due to early closure of glottis and chest wall contraction, which causes increased expiratory airway pressure to prevent airway collapse ■ Stridor : High-pitched, crowing sound on inspiration due to upper airway obstruction associated with croup or foreign body aspiration; low-pitched, muffled sound associated with epiglottis ■ Wheezing : Musical, more continuous inspiratory or expiratory sounds due to lower airway obstruction with bilateral wheezing indicative of asthma or bronchiolitis and unilateral wheezing suggestive of foreign body aspiration
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Endotracheal Tube Suctioning ■ Select size of suction catheter based on size of child (infant 5–8 F, child 8–10 F, older child 12–14 F) ■ Select vacuum pressure between 60 and 100 mm Hg for infants and young children ■ Use oxygen before suctioning and after suctioning ■ Insert catheter no greater than 0.5 cm beyond tip of artificial airway ■ Limit suction to less than 5 seconds
Pulse Oximetry Normal ranges: 95%-100% Mild hypoxia: 91%-94% Moderate hypoxia: 86%-90% Severe hypoxia: 86% Watch for false lows associated with nonsecure connection (movement of child’s foot or hand), cold extremities/hypothermia, and hypovolemia. Watch for false highs associated with carbon monoxide poisoning and anemia.
Cardiac/Apnea Monitors Electrode placement for ECG monitoring: White color for right side of chest Green (or red) color for ground Black color for left side of chest Electrode placement for apnea monitoring: Two electrodes placed two fingerbreadths below nipple on midaxillary line of each side
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115 Cardiac/Apnea Monitors (Cont.) Electrode Placement for Standard Chest Electrographic Monitoring
Electrodes with attached wires are often color coded: White for right Green (or red) for ground Black for left Apnea (if indicated) Electrode placement for both ECG and apnea.
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Separation Anxiety
Loss of Control
Fears
Infant
Develops ~6 mo and lasts until 30 mo with reactions of crying or agitation
Disruption of care from primary caregiver and normal routines
Toddler
Exhibits reactions such as agitation, temper tantrums, uncooperativeness and clinging to parents; separation anxiety peaks 12–15 mo
Disruption from normal routine and rituals as well as care from parents
Preschooler
Fewer reactions but more somatic signs such as vomiting, urinary frequency or incontinence, diarrhea, dizziness; still may become withdrawn or aggressive
Perceived disruption in the loss of their own power and altered family roles
Strangers and strange places, loud noises, sudden movements, loss of physical and emotional support Strangers, dark, being alone, physical contact/interventions from strangers, strange or unknown equipment and places Mutilation, the unknown, any intrusive procedures
(Continued text on following page)
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Children’s Responses to Illness and Hospitalization
Copyright © 2006 by F. A. Davis.
117
Separation Anxiety
Loss of Control
Fears
School Age
Anxious behaviors as well as loneliness, boredom, isolation or depression; knows that parents may need to leave and will be back but may show aggression and irritability toward family
Enforced dependency and altered family roles
Bodily injury, pain, inability to stay in control, lack of control over modesty, school and peer concerns, death
Adolescent
Anxiety related to peers and school life with behaviors such as withdrawal, loneliness, or boredom
Enforced dependency and possible identity/role changes
Loss of peer interactions and relationships, body disfigurement, rejection by others, loss of physical abilities, death
Eight Questions to Ask About Pain: 1. Are you having pain? 2. If yes, what does the pain feel like? (burning, aching, pinching, stabbing?) 3. When did the pain start? (Did anything happen to start the pain?) 4. Where is the pain? (Point to where the pain is.)
5. How long have you been having pain? 6. How often does it occur? 7. Does anything make it worse—or better? 8. Has it changed what you do?
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Children’s Responses to Illness and Hospitalization (Continued)
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PEDS BASICS
Copyright © 2006 by F. A. Davis.
Developmental Differences in Children Related to Pain Age Infants
Young child
Older child
Adolescent
Comments Preverbal. Signs of possible pain: diffuse body movement, high-pitched cry, tearing, stiff posture, fisting, and lack of play; obvious sign is facial expression with brows lowered and drawn together, eyes tightly closed, and mouth open Limited vocabularies still make it difficult to express pain; may use words such as “owie;” can sometimes describe pain but not the intensity. Signs of possible pain: regression with arms and legs thrashing or withdrawal such as clinging to parent or significant other, loud crying or screaming Use pain scale for this group; may have difficulty in distinguishing between types of pain such as “sharp” or “dull;” may act “tough” even when in pain; may show fewer overt pain behaviors. Signs of possible pain: muscular rigidity such as clenched fists, gritted teeth, body stiffness, closed eyes, wrinkled forehead or lying in fetal position Use pain scale for this group; may be stoic because of fear of being labeled so may be quiet and withdrawn. Signs of possible pain: fist-clenching, clenched teeth, rapid breathing, and guarding affected body part, lack of interest and decreased ability to concentrate
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119 Nursing Interventions Related To Pain Management ■ Distraction—useful for mild pain relief (example: tell child to say “Oh” when giving an injection or blow bubbles when performing a procedure) ■ Guided imagery—aid the child in creating a pleasurable mental image during the painful situation ■ Thought stopping—stop the painful thought with a positive thought ■ Soothing music or aromatherapy–use to calm emotions and state of mind ■ Thermotherapy–apply warm and cold to painful areas to promote circulation or reduce edema with limited numbing effect ■ Gentle massage–relax or focus child away from pain toward more gentle soothing touch ■ Sucrose “Sweet” Nipple—calm young infants by allowing them to suck on nipple dipped in sucrose solution—effective method in reducing pain during procedure ■ Provide ordered pharmacological interventions such as topical anesthetic creams, PO/IV/IM analgesia, patientcontrolled analgesia (PCA), conscious sedation, or epidural analgesia
Numerical Scale Pain Assesment Tool None 0—1—2—3—4—5—6—7—8—9—10 Worst Pain (Scale of 0–10 to describe pain) Explain to older child: “0 means you feel no pain and 10 means you feel the worst pain possible.” Ask the child to choose number that best describes his or her own pain.
PEDS BASICS
Rating:
0
Face
No particular expression or smile
Legs
Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep)
Activity
Cry
Consolability
Content, relaxed
1 Occasional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or “talking to,” distractible
2 Frequent to constant frown, clenched jaw, quivering chin Kicking, or legs drawn up Arched back, rigid or jerking Crying steadily, screams or sobs, frequent complaints Difficult to console or comfort
Ages of use: 2 mo to 7 yr. Scoring range: 0 no pain, 10 worst pain. From Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing 23(3): 293–297.
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FLACC Pain Assessment Tool
Copyright © 2006 by F. A. Davis.
Infants
Toddlers
Preschoolers
Type and Purpose of Play
Safe Toys
Solitary (noninteractive but may be 1–3 mo: mobiles, music boxes, imitative in later part of infancy) nonbreakable mirrors, stuffed Stimulates psychological and animals, and rattles sensorimotor development, offers 4–6 mo: squeezable toys, busy boxes, diversion, means of communication play gyms 7–9 mo: cloth textured toys, splashing bath toys, large blocks and large balls 10–12 mo: durable books with pictures, nesting cups, push-pull toys, and building blocks Parallel (along side but not interactive) Dolls, housekeeping toys, books, singEnhances locomotion skills (gross and a-long tapes, rocking horses, pull fine), language development, toys, finger paints, clay, large piece imitates adult roles puzzles, blocks, and balls Associative (interactive and cooperative but defines own rules) Promotes fine/gross motor skills, contact with playmates, and encourages imagination
Tricycle/big wheels, wading pools/sandboxes, gym sets, blocks/puzzles/simple crafts, crayons/paints, puppets/dolls stuffed animals, imaginary items, and ageappropriate electronic games (Continued text on following page)
PEDS BASICS
Age Group
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Use of Play for Children
Age Group
Type and Purpose of Play
Safe Toys
School Age
Competitive and complex-”team” play Develops social skills through learning rules and rituals of games and continued refinement of fine/ gross motor skills
Board games, card games, music and art, athletic activities, team activities, movies, and interactive video games
Adolescent
Group/peer type play Continues to enhance social skills and roles, cognitive skills, and wellness with sports or exercise activities
Sports, camping, video and computer games, radios, disc players, phones, models, and collectibles
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Safe Hospital Bed/Crib Choices Premature infants and newborns Infants/young toddler Toddlers/young preschoolers Older preschooler to adolescents
Isolette or radiant warmer Open crib When child is left alone, use the enclosed bubble-top crib Hospital bed with rails in lowered position
In general, bed/crib selection based on child’s age, developmental abilities, LOC, and health conditions
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Use of Play for Children (Continued)
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123 Quick 10-Minute Assessment Look At the Child and Environment ■ Is the child THERE? ALIVE? ■ In the crib or hanging from the sides? (Children can do amazing stunts!) ■ Are the parents with the child? ■ What type of equipment is at the bedside?
Begin with Safety ■ Is the child breathing? ■ Do you observe any signs of distress? (Follow the ABCs you learned in CPR) ■ What is the child’s color? (pale, red, blue …) ■ Is the child on a monitor? (What is the rate & pattern?) ■ Any IVs? (Note type, rate, & site) ■ Note last set of vital signs (Include other findings based on child’s condition, PIC line, chest tubes, and so on) Abnormal? If so, check again. ■ When was the last time the child voided? ■ Do you observe anything unusual that needs immediate interventions? DO IT NOW!
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PEDS ASSESS
Copyright © 2006 by F. A. Davis.
Check the Equipment ■ Are the monitor and respirator alarms set at the proper limits? ■ Is the 02 set up correctly? Does it work? ■ Is the suction equipment set up and ready to be used? TEST IT! ■ Is there an appropriate resuscitation bag with the proper size mask? ■ Is the correct equipment at the bedside for the child on seizure precautions? ■ Are the crib rails up? ■ Are restraints applied correctly? (Is there an order for the restraints?) ■ Are tabletops and crib or bed cleared of unsafe articles?
Focus Assessment on Area of Major Diagnosis ■ This initial assessment takes about 2–3 minutes. ■ Do the same initial assessment on all patients then return to do the more in-depth assessment. ■ If the patient is in critical condition do the in-depth assessment NOW!
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Normal
Moderate Impairment
Severe Impairment
Quality of Cry
Strong normal tone or content and not crying
Whimpering or sobbing
Weak, moaning, or high pitched
Reaction to Parent Stimulation
Cries briefly, then content and not crying
Cries off and on
Continual cry or hardly responds
State Variation
If awake, stays awake; if asleep and stimulated, quickly wakes
Eyes close briefly then awakens, or wakes with prolonged stimulation
Will not rouse or falls to sleep
Color
Pink
Pale hands, feet or acrocyanosis
Pale or blue or gray or mottled
Hydration
Skin warm and dry, eyes and mouth moist
Skin and eyes normal and mouth slightly dry
Skin doughy or tented and eyes sunken and dry
Response to Social Overtures
Smiles; alert
Brief smile; or briefly alert
No smile, anxious face, not alert
From McCarthy PL, Sharpe MR, Spiesel SZ, et al. (1982). Observation scales to identify serious illness in febrile children. Pediatrics; 78: 802.
PEDS ASSESS
Observation
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Quick Evaluation of Sick Child
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PEDS ASSESS Toddler
Important Aspects
Examples
Trust is developing; communicates through coos, smiles, and cries at first. First words around 8–9 mo. Understands simple one word commands at 1 yr. If primary caregiver is comfortable, many times the infant is calm and trusting. Allow infant to be held by caregiver as much as possible. Sense of self and being independent is becoming important; understands simple two- and three-word commands. Has 300 word vocabulary. Short attention span of 1–5 minutes.
Provide gentle touching; firm holding, and smiles to infant. Speak to primary caregiver first. If not contraindicated, offer pacifier and use security blankets and stuffed animals.
First, direct eyes and questions to caregiver. Assume eye level of child. Ask simple questions with appropriate choices such as “would you like to sit on your mothers lap or up on the table?” Use child’s language for specific words in short and simple sentences. Be attentive to nonverbal cues. Use puppets and dolls. (Continued text on following page)
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Age Group Infant
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Communication with Child and Family
Copyright © 2006 by F. A. Davis.
Age Group
Examples
Developing a concept of self; understands simple sentences. Has 900 words in vocabulary. Let children know that they did not cause the illness. Prepare child for procedure right before the treatment.
Assume eye level of child. Provide appropriate choices. Offer appropriate medical equipment for play to reduce fear of equipment. Use concrete sentences. Allow child to ask questions.
School-Age
Interested in achievement; get child to help you. Understands most mature thoughts especially when allowed to manipulate and see objects.
Show the child equipment and use clear simple instructions. Use teaching aids and explain what you do.
Adolescent
Transition between childhood and adulthood; begin conversation with them first then ask questions of caregivers. Verify with adolescent that they understand. Can use brochures and videos.
“Would you like to have your mother leave the room while I examine you?” Provide privacy and ensure confidentiality.
PEDS ASSESS
Important Aspects
Preschooler
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Communication with Child and Family (Continued)
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PEDS ASSESS
Copyright © 2006 by F. A. Davis.
Subjective Assessment by Age Group Infant (Per parent)
■ Chief complaint and HPI ■ Past history including ■ Prenatal history ■ Natal history (type birth) ■ Postnatal (with APGAR) ■ Allergies ■ Developmental milestones ■ Immunizations, safety issues ■ Nutritional intake (type, amount) ■ Sleep ■ Family history ■ Review of systems
Young child (Per parent and child) Same as infant plus: ■ Play/activity ■ Personality ■ Fluid intake
Older child (Per child) ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Chief complaint and HPI Past medical history Immunizations Safety issues Allergies Nutritional intake Family history Social history, school achievements, play Sleep Review of systems
All children Include type of housing, others in household, car seat and smoke detector use, type of home heating, pets, family cultural beliefs and practices.
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129 Systems Approach to Assessment Although the systems approach works well and is often used in the documentation of your findings, remember you must adapt your method to the individual child!
HEENT ■ Eyes (redness, drainage, alignment) ■ Ears (response to sound, pulling at ears) ■ Mouth (excessive drooling, white patches in mouth)
Neuro ■ Level of alertness, affect, and responsiveness (awake, verbalizes, awareness of surroundings, lethargic, obtunded, etc.) ■ Pupil check (darken room before trying to check, simultaneous closing of eyelids, movements of eyes—any deviations to right or left, color of sclera and conjunctiva, any drainage, visual acuity) ■ Movement of extremities (involuntary, voluntary, on verbal command—for older child, moves in response to painful or other stimuli, uncoordinated movements, twitches, tremors) ■ Hand grasps and pedal pushes (equality, remember you need to adapt to developmental age) Reflexes—deep tendon reflexes, presence or absence of newborn reflexes ■ Speech (clear, slurred, etc.) ■ Signs of seizure activity (describe type, how often, when, etc.) ■ Nuchal rigidity ■ Head circumference and size of fontanels (adapt to the developmental age)
Respiratory ■ Inspect shape and contour of chest (expose the patient’s chest to get a good look! Posture, spinal curvature, any equipment such as chest tubes—if present, describe site, type, etc.) ■ Palpate expansion of chest for full and equal excursion (Inspect for retractions, unequal expansion, etc.) ■ Respirations—easy, quiet, unlabored? Abdominal breathing? (Children are often abdominal breathers until 6–7 yr)
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PEDS ASSESS
Copyright © 2006 by F. A. Davis.
■ Auscultate the lungs from the top to the bottom, front and back and laterally, include over the neck and trachea (compare right and left sides, abnormal sounds—describe) ■ Does child breathe through nose or mouth (any drainage? if present describe amount, color, and consistency) ■ Note Pulse oximetry (%02 saturation)
Respiratory Equipment
■ Ventilator—start at the nearest point to the patient—ET or trach and work distally toward the machine ■ Size of ET or trach tube, whether tube is cuffed, amount of air in cuff for seal, whether seal is intact, appearance of trach site, tube placement, equality of bilateral lung expansion, quality and equality of breath sounds, tubing and integrity of connections ■ Make sure there is no water in the tubes, know tidal volume, measure O2 concentration ■ Note settings your patient is on—check the system pressures— any change needed? Recheck all settings and alarms. Is the alarm on? ■ Suction the patient, if needed. Observe the patient’s tolerance to the procedure and type and amount of secretions ■ Check other O2 equipment such as croup tents, etc. Do you have the right set-up? Proper concentration of O2? Water in containers that should have water? Patient’s tolerance to the equipment? Is there any cyanosis?
Cardiovascular ■ Inspect and palpate the point of maximum impulse (PMI) Auscultate the heart sounds. What is rate and rhythm? Run a strip if you can. Check the P, QRS, and T waves—any abnormalities? Are all peripheral pulses present and equal? Any edema? (Check dependent areas like the sacral area) ■ Any signs of dehydration? (Sunken fontanels, lethargic, sunken eyes, mucous membranes, etc.) Overall perfusion? (Skin warm, dry and pink? Or cool, clammy, mottled?) Nail beds—(Good capillary refill, pink, etc.?) ■ Check IV sites for signs of infiltration, phlebitis, etc., type and rate of IV, infusion pump, etc. Hemodynamic monitoring: various line—(Note the reading, equipment, sites, and dressing)
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131 Temporal
Carotid
Apical Brachial
Aortic area Tricuspid area
Pulmonic area Mitral or apical area
Femoral Radial
Popliteal
Dorsal pedis
Posterior tibial Auscultation areas and peripheral pulses.
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PEDS ASSESS
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GI ■ Start from nose and mouth and work down. NG tube (Inspect for patency, how long has it been in, any suctioning-type, any drainage—describe odor, amount, color, consistency, pH, quaiac, and so on)? Any other type of GI drainage? Abdomen (Inspect, auscultate bowel sounds in all four quadrants, palpate and percuss for size, consistency [soft or firm], distention, rigidity, pain [location, intensity, quality]). Stool— inspect for amount, color, consistency, guaiac, reducing substance, when did child last have one? To decrease ticklish or tense sensation, have child place feet flat on bed or table with knees elevated and place child’s hand under your hand as you palpate and percuss
GU ■ Foley (Describe type, when inserted, does it need to be changed?). Foley care? Any urine? (What does it look like— color, clarity, sediment or blood present? Test it for—specific gravity, glucose, pH, etc.) Do you observe any urethral, penile, vaginal discharge Circumcised? Determine weight of diaper: 1 g 1 cc (first weigh dry diaper and deduct weight of dry diaper)
Skin ■ Look at it!! All of it. ■ Rashes, lesions—location, pattern, size, color elevation, blanching? Breakdown?? Petechiae, purpura, bruising? ■ General skin condition—dry, oily, itchy, scaly? Skin turgor? Lice? Color of the skin, any cyanosis, temperature, moisture? ■ Note dressings (dry and intact??) ■ Note mucous membranes (hydration, color) ■ Tongue (is it moist?)
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133 Musculoskeletal ■ Assess while doing other systems ■ Note if child is walking, sitting, or turning, ROM in all joints ■ Check spinal curvature and mobility, sacral dimples or tufts of hair ■ Note strength, symmetry, and movement of extremities
Safety Education Topics for Specific Age Groups Infant
Toddler/Preschooler
School age
Adolescent
Car seats. Water temperature (water heater setting lower than 130F), smoke detectors, bath safety Car seats, pedestrian safety, water safety, medications, and household poisons Pedestrian safety, bicycle helmets, seat belts, no firearms in household, water safety Auto safety, alcohol/drug use, occupational injuries, no firearms in household
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MEDS/ ACUTE
Copyright © 2006 by F. A. Davis.
5 Rights of Drug Administration ■ ■ ■ ■ ■
Right Drug Right Dose Right Time Right Route Right Patient
Determining Dosage and Route ■ Variations based on age, weight, body surface area (BSA), and maturity of kidneys and liver ■ Physician orders, dosage, and route ■ Nurse checks for safety of dosage and route
Methods to Determine Safety of Dose
Dosage Based on Body Weight
■ Determine child’s weight in kg ■ Establish safe dose from pharmacy text ■ Calculate dose using weight
Body Surface Area (BSA)
■ Use nomogram to determine where straight line connects height and weight levels and bisects the BSA ■ Divide the BSA in meters by 1.7 ■ Multiply the quotient from step 2 by the adult dose
Administration of Medication ■ Check for drug allergy history prior to administration ■ Check ID band; do not ask child to verbally identify himself; child may say “yes” to any name or give false name to avoid taking medication; do not use name card on bed to ID child—children may switch beds
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135 ■ Give choices when possible—”would you like to take your medicine with water or juice?” ■ Ask parent for suggestions regarding how child prefers to take medication ■ Allow parent to give medication if child prefers—be sure to observe while entire dose is administered ■ NEVER leave med at beside
Routes for Medication Administration Oral Route (by mouth) ■ Use tool that ensures accurate measurement: calibrated dropper, syringe with needle removed, or plastic measuring cup ■ Take care to prevent aspiration—hold child’s head up and administer liquids to infant by carefully using a syringe or dropper to place small amounts of med into infant’s cheek, near back of mouth or by putting med into nipple for infant to suck. Be prepared to suction med back into a small syringe for oral administration if infant does not suck nipple ■ Do not dilute med in formula or large amount of liquid that infant may not consume ■ May use small amount of flavored syrup to disguise unpleasant tastes
Nasogastric (NG), Orogastric, or Gastrostomy Route ■ Crush pills finely to prevent clogging of tube ■ Check tube placement and infuse slowly ■ After med administration, flush line with water to ensure med has cleared tube and to prevent clogging
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MEDS/ ACUTE
Copyright © 2006 by F. A. Davis.
Optic Route (eye) ■ Ensure that med is room temperature ■ Drops—Place med in conjunctival sac; apply slight pressure to inner puncta for 1 minute to keep drops from draining into nose ■ If child is uncooperative, immobilize child’s head, place drop(s) over inner puncta—med will drain into eye when child opens his eye. ■ Explain to child that med may be tasted ■ Ointment—apply from inner to outer canthus
Otic Route (ear) ■ Ensure that med is room temperature ■ Position child with affected ear up—maintain position for one full minute after administration of med Child 3 yr, pull pinna down and back Child 3 yr, pull pinna up and back
Nasal Route (nose) ■ Ensure that med is room temperature ■ Drops—Tip head back—may use towel roll between shoulders of small child—maintain position for one full minute after administration of med ■ Spray—Child should be seated with head up
Rectal Route ■ Suppository may be moistened with water or water soluble jelly ■ Note that children usually consider this to be an invasive procedure—drape child to provide privacy ■ Position child on left side ■ Insert rounded end of suppository gently into rectum ■ Hold child’s buttocks together for 5 minutes to avoid expulsion of med
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137 Intramuscular (IM), Subcutaneous (SQ), Intradermal Route ■ Use small syringe to ensure accurate measurement ■ Use proper needle length for size of child and route of administration (needle usually not more than 1 inch) ■ Do not draw up air bubble (clearing med from the syringe’s dead space may result in very small dose being inaccurate) ■ Anticipate resistance from child—enter room with assistant to immobilize child if needed ■ Do not ask parent to immobilize child ■ Ask older child about preference of administration site ■ Tell child that is it okay to cry ■ Complete procedure as quickly as possible ■ Offer bandage after administration ■ Praise child’s efforts
Intravenous (IV) Route See comments regarding syringe size and clearing syringe’s dead space under Intramuscular Route If not specified in med order, consider desired effect and stability of med to determine whether to administer: ■ Slow IV push (over several minutes) ■ Retrograde infusion (med is injected into a Y-port after temporarily clamping IV line below Y-port) ■ Instilling med into mini IV chamber such as Buretrol or using syringe pump
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Preferred Site
Newborn & Young Infant Infant
Vastus lateralis
Toddler
Vastus lateralis or Ventrogluteal (relatively free of major nerves and blood vessels—large muscle with little subcutaneous tissue, less painful than vastus lateralis and easily accessible) Deltoid (faster absorption rates than gluteal and less painful; limit to 1 mL) or ventrogluteal
Older Children
Vastus lateralis
Needle Length/Gauge 5/8 inch*/24–25 G no more than 0.5 mL 5/8–1 inch*/23–25 G no more than 1 mL 1 inch*/22–23 G no more than 1 mL
1 inch*/22–23 G no more than 1.5–2 mL
* Consider amount of body fat when selecting needle length
Notes: Use dorsogluteal in children older than 3 years because it takes more than a year of walking to develop larger muscle mass appropriate for this route. Administer EMLA cream or topical vapocoolant spray to injection site prior to giving the injection to decrease discomfort.
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Age Group
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IM Injection Sites
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139 Pediatric Injection Sites Greater trochanter
Femoral nerve, artery,vein
Tensor fascia latae
Sartorius Vastus lateralis Rectus femorus
Vastus lateralis. j (gluteus medius) Anterior superior iliac spine
Posterior iliac crest
Tensor fascia latae
Palm over greater trochanter
Gluteus maximus
Ventrogluteal.
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MEDS/ ACUTE
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Clavicle Acromion process Deltoid
Deltoid.
Intravenous Maintenance Fluids Calculations by Body Weight 10 kg in weight 11–20 kg in weight 20 kg in weight
100 cc per kg of weight cc for 24 hours 1,000 cc 50 cc/kg for each kg 10 kg cc for 24 hours 1500 cc 20 cc/kg for each kg 20 kg cc for 24 hour
Surface Area – Fluid maintenance requirements in mL/day BSA in m2 1500 mL/day/m2 (1500–2000 mL/m2/day)
24 hour total divided by 24 hours rate in milliliters per hour Maintenance Sodium: 2–3 mEq/kg/24 hours Maintenance Potassium: 1–2 mEq/kg/24 hours For initial IV, potassium is generally added to the IV fluids AFTER the child voids
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141 To Calculate IV Rates Total Volume Drop Factor ÷ Infusion Time in Minutes Drops/minutes Microdrip Tubing 60 gtts/mL used in volume control chamber (Buretrol, Soluset, Volutrol) in pediatrics Macrodrip Tubing 10, 20, 15 gtts/mL depending on brand of tubing—may be used for adolescent
Key Monitoring for Child on Parenteral Nutrition ■ ■ ■ ■
Daily weight Weekly height/length Hourly intake and output amounts Every 8 hours note urine specific gravity, glucose, and protein
Peripheral Intravenous Access In Children Comments Related to Children
Needle Gauge
Available Sites
Veins are more fragile External jugular and scalp so protect with tape, veins: frontal, superficial arm board, or surgical temporal, posterior netting. Choose site auricular; upper that will not interfere extremities veins: dorsal with activity for specific hand, radial vein of wrist, age group. Use EMLA anterior ulnar-forearm, cream, Fluori-Methane median cephalic-lateral vapocoolant spray, etc., antecubital fossa, median for nonemergent basilica-medial antecubital insertion. fossa; veins of the lower During infusion, hang extremity: superficial 4 hours’ worth of veins of dorsum of foot, IV fluid at any one saphenous vein anterior time (to prevent fluid and superior to the medial overload). Check site malleolus of the ankle, frequently for signs of and along proximal length infiltration or phlebitis on medial foreleg
20–24 G
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Median cephalic v.
Median antebrachial v. Median basilic v.
Supraorbital v.
Cephalic v. Frontal v.
Umbilical v. Basilic v. (newborn only) Great saphenous v.
Superior temporal v. Posterior auricular v. Jugular v.
Dorsal venous arch
Cephalic v. Median marginal v.
5th interdigital v.
Dorsal arch
Basilic v.
Preferred sites for peripheral intravenous access and venipuncture in infants and young children.
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143 Central Venous Access Devices (CVADs) Examples of Types
Comments Related to Use and Contraindications
Peripherally Inserted Central Catheter (PICC)
Used for long-term IV antibiotics, chemotherapy, TPN, or blood products; contraindicated with inadequate veins, bleeding disorders, immunosuppression, noncompliance, trauma to extremity, severe burns, or infections Total Implantable Used for long-term IV fluids, Device—Port-A-Cath medications, blood products, TPN, and venous blood sampling and analysis; use 19–22 gauge rightangled needle with topical anesthesia to access and typically monthly flushing with heparinized saline solution; same type of contraindications as in PICC and not used in child requiring less than 6 mo of intermittent IV therapy External/Tunneled Long-term central venous catheter Catheter—Broviac, used for same purposes as Hickman, Groshong implantable device but better suited in very small children and infants; requires site care and frequent flushing with heparinized saline or saline solution Complications related to CVADs include infections, phlebitis, thrombosis, occlusions, breaks, migration, or accidental removal
MEDS/ ACUTE
1 yr old Assess responsiveness Open Airway and Assess Breathing Perform Rescue Breathing begin with 2 breaths Assess Pulse Provide Compressions
Compression/ Ventilation Ratio Count Sequence
1–8 yr old
8 yr old
If collapses suddenly and known cardiac condition—activate EMS; otherwise activate after 1 min resuscitation
Determine unresponsiveness then activate EMS No trauma suspected—head-tilt/chin-lift position. If trauma, use jaw thrust only. Look listen, feel 10 sec 1 breath per 3 sec (20/min) 1 breath per 5 sec (12/min) Brachial or femoral 1 finger below intermammary line with 2 fingers depress chest 1/2–1 in—100/min
Carotid Heel of hand on lower half sternum and depress chest 1–1 1/2 in—100/min
5:1; pause for ventilation if patient is not intubated 1,2,3,4,5 1&2&3&4&5
Heel of one hand on top of other hand on lower half sternum and depress chest 1 1/2–2 in— 100/min 15:2 1 & 2 & 3 & 4 & 5…
Adapted from the American Heart Association. (2002). PALS Provider Manual. American Heart Association, pp. 43–80.
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Key Points for Pediatric Cardiopulmoary Resuscitation (CPR)
1 yr old Conscious Victim
Assess breathing to determine if ineffective or no strong cry
1–8 yr old
8 yr old
Ask, “Are you choking?”–Can the child speak or cough? May demonstrate universal choking sign
Perform up to 5 subdiaphragmatic Give 5 back blows; then 5 chest abdominal thrusts (Heimlich) thrusts Repeat until obstruction relieved or becomes unconscious Child Becomes Unconscious
Place child on back; active EMS after 1 min rescue effort
145
Open airway and do finger Open airway, if see foreign body sweep then remove Give rescue breaths, if airway blocked, reposition head according to age requirements, try rescue breaths again Perform up to 5 subdiaphragmatic Give 5 back blows; then 5 chest abdominal thrusts thrusts Repeat steps until foreign object is removed Unconscious Victim
Gently shake to determine “Are you okay?” alertness level If unresponsive, activate EMS after 1 min rescue effort Proceed as outlined above and in CPR Mouth-to-mouth-nose seal
Mouth-to-mouth seal
Try rescue breath, if needed reposition & try again Adapted from the American Heart Association. (2002). PALS Provider Manual., American Heart Association, pp. 43–80.
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Key Points for Pediatric Choking – Foreign Body
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Defibrillation Guidelines Paddle Size
Paddle Placement
Energy Dose
4.5 cm for infants; 8–13 cm for children. Use largest electrode size to have good chest contact and separation of electrodes One paddle on right upper chest below clavicle and other paddle to the left of nipple in anterior axillary-line; heart should be situated between paddles 2 Joules/kg for initial defibrillation with 2–4 Joules/kg for all subsequent attempts; for cardioversion, use 0.5–1 Joules/kg with 2.0 Joules/kg for all subsequent attempts
Bradycardia in Children: Definition: “too slow” for age; HR 60/min in infant and young child with evidence of poor perfusion Causes: Hypoxemia (most common cause), hypothermia, head injury, heart transplant, toxins/poisons/drugs Treatment: Assess ABCs, ensure patent airway, monitor vital signs, attach ECG monitor, start IV/IO and oxygenation per order/protocol, treat cause Common Medications Used: Oxygen, epinephrine, atropine
Tachycardia in Children: Definition: “too fast” for age; rapid heart rate associated with shock and hemodynamic instability Causes: Hypoxemia, hypovolemia, hyperthermia, electrolyte disturbances, tamponade, tension pneumothorax, toxins/poisons/drugs, thromboembolism, pain Treatment: Assess ABCs, if no pulse-initiate CPR, if pulse present–oxygenate, ventilate, and follow orders/protocols, treat cause Common Medications Used: Oxygen, amiodarone, procainamide, lidocaine, adenosine, may also use vagal maneuvers or cardioversion depending on type of tachycardia
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147 Pulseless Arrest in Children: Definition: Complete collapse confirmed by ECG in more than one lead Causes: Hypoxemia, acidosis, hypovolemia, tension pneumothorax, cardiac tamponade, electrolyte imbalance, drug overdose, and embolism Treatment: Determine pulselessness and begin CPR Ventricular fibrillation or Pulseless ventricular tachycardia: Defibrillation up to 3 times, continue CPR, secure airway, hyperventilate with 100% oxygen, secure IV/IO, administer medications such as amiodarone, lidocaine, magnesium per protocol. Asystole/Pulseless Electrical Activity: CPR, secure airway and IO/IV, hyperventilate with 100% oxygen, administer epinephrine per protocol and treat cause.
Pediatric Trauma Score Clinical Assessment Child Size Airway
Score 2 20kg Normal
90 mmHg Systolic Blood Pressure Awake Central Nervous System Open wound None Skeletal
None
Score 1 10–20 kg Maintainable 50—90 mm Hg
Score 1 10 kg Not maintainable 50 mmHg (no pulse)
Obtunded/loss of consciousness
Coma, decerebrate
Minor
Major penetrating Open/Multiple fractures
Closed fracture
From Ford EG, Andrassy RJ. (1994). Pediatric Trauma Initial Assessment and Management. Philadelphia: W.B. Saunders, p. 112.
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Cardinal Signs of Respiratory Failure ■ ■ ■ ■ ■ ■
Restlessness/Altered LOC Tachypnea Tachycardia Evidence of ↑ Work of Breathing Cyanosis Diaphoresis
■ ■ ■ ■ ■
Physical signs of abuse/neglect reported by child Repeated ED visits/previous history of abuse Parents blaming siblings for injury Inappropriate response to injury by child/caregiver to injury Inconsistency between physical findings and cause of injury or injury and child’s development
Recognizing Abuse/Neglect in Children
Emergencies Related to Diabetes
Causes
Symptoms
Hypoglycemia
Hyperglycemia
Too much insulin, delayed food intake, exercise without adjustment Shaky, weak, sweaty, hungry, dizzy, light-headed, palpitations, visual changes, gait disturbances, changes in affect, confusion, slurred speech, sleepiness, unconsciousness, seizures
Stress, infection, too little insulin
Blood Glucose Levels
60 mg/dL
Treatment
Give glucose, IV/PO
148
Increased thirst, increased urination, weight loss, increased appetite, decreased energy level Fasting: 240 mg/dL Random: 300 mg/dL Give IV fluids, insulin, K
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149 General Types of Seizures Obtain Seizure History: type, typical frequency, description and frequency of corresponding events, auras experienced before seizure, and any specific meds
Type Types of Partial: Simple
Complex
Types of Generalized: Absence (petit mal) Clonic
Tonic
Tonic-clonic (grand mal)
Description & Treatment Confined to one hemisphere—change in posture, hallucinations, or flushing, no aura and LOC alteration. Use anticonvulsants such as carbamazepine and phenytoin to control seizures. Starts in one focal area and spreads to both hemispheres; consciousness not completely lost—confusion, aura may occur, postictal response. Use anticonvulsants such as carbamazepine or phenytoin to control seizures; may need more than one drug. Sudden onset, lasts 5–10 sec, loose responsiveness but no falling, eyelids twitching, lip smacking, no postictal response; anticonvulsants/ketogenic diet. Opposite muscles contract/relax in rhythmic pattern, may occur in one or more limbs; use anticonvulsants. Muscles maintain continuous contracted state (rigid posture) with variable loss of consciousness; use anticonvulsants. Violent total body tonic then clonic movements with aura and postictal response, loss of consciousness. Phenobarbital, carbamazepine, phenytoin, or other similar drugs may be combinations. (Continued text on following page)
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General Types of Seizures (Continued) Type Atonic
Types of Miscellaneous: Febrile
Status Epilepticus
Description & Treatment Drop and fall attack with loss of posture tone. Must wear helmet and use anticonvulsants. Elevated temp leads to seizure activity 5 minutes in young infants and children, generalized, transient and nonprogressive. Treat underlying illness/fever, diazepam PO, monitor for neurological deficits. Prolonged or repetitive seizures without interruption lasting longer than 30 minutes that results in anoxia, cardiac and respiratory arrest; loss of consciousness. Assess airway, breathing, circulation. IV glucose and other drugs such as diazepam, phenytoin, phenobarbital used to control problem within 20–60 minutes, correct metabolic problems, may start midazolam drip, treat underlying cause, establish maintenance anticonvulsant drugs.
For All Seizures: Do: Stay with child; call for help; move to flat surface out of danger; position on side with head supported and clothing loosened. Maintain patent airway; record seizure activity and assess neurological status and vital signs; document time started and ended, aura–if present, color change, presence of incontinence, oral tissue damage (if any), postictal (postseizure) response. Do Not: Try to interrupt seizure or restrain child; use tongue blades.
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151 Degree and Signs of Fluid Deficit (Dehydration) in Children Common Clinical Signs
Mild (5% loss of body weight)
Moderate (5%-9% loss of body weight)
Skin
Pale, warm
Skin turgor
Normal
Eyes
Normal
Mucous membranes Anterior fontanel (if still open) Heart rate
Slightly dry Normal
Normal
Increased
Respiratory rate Blood pressure Capillary refill Mental status
Normal Normal
Increased Slight decreased Slight delay
Urine output
Normal Alert but may be irritable Decreased
Pale, mottled, cool Decreased
Appears sunken, poor tear production Dry Slightly depressed
Irritable, restless Oliguria
Severe (10% loss of body weight) Mottled to cyanotic, cool Markedly decreased, tenting Sunken, no tear production Very dry and cracked Sunken
Increased, pulse often not palpable Increased Decreased Delayed (4sec) Lethargic to comatose Oliguria to anuria
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Calculation of Deficit Water & Electrolytes ■ Water Deficit % Dehydration Child’s Weight ■ Sodium Deficit Water Deficit 80 mEq/L ■ Potassium Deficit Water Deficit 30 mEq/L From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of Pediatrics (17th ed.). Philadelphia: W.B. Saunders, p. 247.
Type of Dehydration Based on Electrolyte Deficits Type of Deficit
Serum Sodium Level
Isotonic Hypotonic Hypertonic
130–150 mEq/L 130 mEq/L 150 mEq/L
Oral Rehydration for Mild to Moderate Dehydration Use solution such as WHO solution or Rehydralyte: ■ 50 mL/kg over 4–6 hours—mild dehydration ■ 100 mL/kg over 4–6 hours-moderate dehydration ■ 10 mL/kg or 4–8 oz of ORS for each diarrhea stool ■ If vomiting: 5–10 mL every few minutes Adapted from Behrman, p. 250.
Quick Restoration of Circulatory Volume: ■ If 10% dehydration—fluid boluses intravenously ■ 20 mL/kg of crystalloid solution such as normal saline over 20 minutes, or ■ 10 mL/kg of colloid solution such as 5% albumin ■ Continue as ordered until clinical status improved Adapted from Behrman, p. 247.
152
Use
Route
Dose in mg
Adenosine (3 mg/ml)
Drug
Antiarrhythmic especially for SVT
Rapid IV, IO
Amiodarone Hydrochloride
Antiarrhythmic—prevent or treat Vfib, Vtach, SVT especially artial F Anticholinergic used for bradycardia and to restore normal heart contraction during cardiac arrest Electrolyte used to maintain cardiac contractility, treat hypocalcaemia, hypomag. Anticonvulsant used to treat seizures and for intubation
Rapid IV, IO
0.1–0.2 mg/kg/dose, (maximum single dose 12 mg) repeat q 2–3 min 5 mg/kg/dose, (maximum dose 15 mg/kg/day) may infuse IV 20–60 min 0.01–0.02 mg/kg/dose, may repeat q 2 minutes (maximum dose 1 mg children; 2 mg in adolescent) 10–30 mg/kg/dose of 10% Ca Chloride, use with caution, not for asystole
153
Atropine Sulfate (0.4 mg/ml)
CaChloride 10% (100 mg/ml)
Diazepam (5 mg/ml)
IV, IO, ET
Slow IV, IO
Slow IV, IO
0.1–0.2 mg/kg/dose (maximum single dose 5 mg in 5 yr, 10 mg in 5 yr) (Continued text on following page)
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Selected Emergency Drug Information
Drug
Use
Route
Dose in mg
Dobutamine (12.5 mg/ml)
Beta-adrenergic agonist used to depress myocardial contractility Beta-adrenergic agonist–vasopressor in cardiogenic or septic shock or to maintain renal perfusion Adrenergic agonist, sympathomimetic used to treat asystole, bradyarrhythmias, Vfib See above
IV, IO infusion
2.5–15 mcg/kg/minute (see drug insert for further instructions)
IV, IO
2–20 mcg/kg/minute (see drug insert for further instructions and infusion)
IV, IM, IO
0.01 mg/kg/dose; this concentration is first drug of choice for pediatric arrest 0.1–0.2 mg/kg/dose; second and subsequent doses, repeat 3–5 min (may also infuse at 0.1–1 g/kg/minute)
Dopamine (40 mg/ml)
Epinephrine 1:10,000 (0.1 mg/ml) Epinephrine 1:1,000 (1.0 mg/ml)
IV, IO, ET
(Continued text on following page)
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Selected Emergency Drug Information (Continued)
Drug
155
Route
Dose in mg
Lidocaine (0.1 ml/ kg-10 mg/ml concentration)
Antiarrhythmic
Use
Rapid IV, IO, ET
Na Bicarbonate (1 mEq/ml) dilute 1:1 with saline
Electrolyte used to correct metabolic acidosis
Slow IV, IO
Naloxone (Narcan) (1 mg/ml)
Narcotic antagonist used for narcotic overdose
IV, ET, IO
0.5–1 mg/kg bolus; (maximum dose 3 mg/kg) Infusion 10–50 g/kg/min of 20 mg/ml solution 0.5–1 mEq/kg/dose;repeat 5–10 min only if oxygenated and ventilated 0.3 wt. kg base deficit efficient dosing 5 yr: 0.1 mg/kg/dose; 5 yr: 2.0 mg/kg/dose; repeat 2–3 min to 10 mg; ET dose 2- to 10-fold higher
Refer to pharmacological inserts and other resources for complete information regarding drug use, side effects, contradictions, etc. Adapted from Guidelines 2000 for Cardiopulmoary Resuscitation and Emergency Cardiovascular Care, American Heart Association; and Hay WW, Levin MJ, Sondhelmer JM, Deterding RR. (2005). Current Pediatric Diagnostic Treatment (17th ed.). New York: Lange Medical Books/McGraw Hill, p. 324.
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Selected Emergency Drug Information (Continued)
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Selected References American College of Obstetricians and Gynecologists. (2000). Breastfeeding: Maternal and infant aspects. (Educational Bulletin No. 258). Washington DC: Author. American College of Obstetricians and Gynecologists. (2003). Management of preterm labor. (Practice Bulletin No. 43). Washington DC: Author. American College of Obstetricians and Gynecologists Office of Communications. (2003). Cervical cytology screening. ACOG Practice Bulletin No. 45. Washington DC: Author. American College of Obstetricians and Gynecologists Office of Communications. (2004). ACGOG issues state-of-the-art guide to hormone therapy: Experts expand prior post-WHI advice on estrogen ACOG News Release: September 30, 2004. Retrieved March 4, 2005, from http://www.acog.com/from_home/publications/press_releases/ nr09-03-04-2.cfm. American Cancer Society. (2004). Can breast cancer be found early? Cancer reference information: American Cancer Society, September, 2004. Retrieved March 4, 2005, from http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_ breast_cancer_be_found_early_5.asp. American Cancer Society. (2005). Cancer prevention and early detection worksheet for women. Retrieved August 4, 2005, from http:// www.cancer.org/docroot/PED/content/PED_4_1x_Cancer_ Prevention_Worksheet_for_Women_pdf.asp. American Heart Association. (2002). PALS Provider Manual. American Heart Association. Atkins DL, et al. (1988). Pediatric defibrillation: Importance of paddle size in determining transthoracic impedance. Pediatrics; 82: 914–918. Behrman RE, Kliegman RM, & Jenson TB. (2004). Nelson Textbook of Pediatrics (17th ed.). Philadelphia: W.B. Saunders.
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157 Binder R, & Howry L. (2005). Pediatric Drug Guide with Nursing Implications (p. 1–56). Upper Saddle River, NJ: Prentice Hall. Brown K. (2004). Management Guidelines for Nurse Practitioners Working with Women (2nd ed.). Philadelphia: F.A. Davis Company. Centers for Disease Control (CDC)-Growth Charts. National Center for Chronic Disease Prevention & Health Promotion. (last reviewed 5/30/00). www.cdc.gov/growthcharts Centers for Disease Control (CDC). (2002). Sexually transmitted disease guidelines 2002. MMWR 2002; 51 (No. RR-6). Chameides L, et al. (1977). Guidelines for defibrillation in infants and children: report of the AHA target activity group: Cardiopulmonary resuscitation in the young. Circulation; 56: 502A–503A. Curran C. (2003). Intrapartum emergencies. JOGNN; 32: 302–312. Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Studies Approach. Philadelphia: F.A. Davis Company. Ford EG, & Andrassy RJ. (1994). Pediatric Trauma Initial Assessment & Management. Philadelphia: W.B. Saunders. Hahn YS, et al. (1988). Head injuries in children under 36 months of age. Child Nervous System; 4: 34. Hatcher R, Trussell J, Stewart F, Nelson A, Cates W, Guest F, et al. (2004). Contraceptive Technology (18th ed.). New York: Ardent Media, Inc. Hay WW, et al. (2005). Current Pediatric Diagnosis and Treatment (17th ed.). New York: Lange Medical Books/McGraw-Hill. Hazinski MF. (1999). Manual of Pediatric Critical Care. St. Louis: Mosby. Hockenberry MJ. (2003). Wong’s Nursing Care of Infants and Children (7th ed.). St. Louis: Mosby. Holloway BW. (2004). Nurse’s Fast Facts. Philadelphia: F. A. Davis Company.
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James HE. (1986). Neurologic evaluation and support in child with acute brain insult. Pediatric Annals; 15: 17. Lowdermilk D & Perry S. (2004). Maternity and Women’s Health Care (8th ed.). St. Louis: Mosby. Martin E. (2002). Intrapartum Management Modules (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Mattson S, & Smith J. (2004). Core Curriculum for MaternalNewborn Nursing (3rd ed.). St. Louis: Elsevier. MBI for Children & Teens. Division of Nutrition & Physical Activity, National Center for Chronic Disease Prevention & Health Promotion, (last reviewed 6/08/05). www.cdc.gov/nccdphp/dnpa/ bmi/oobinaries. McCarthy PL, et al. (1982). Observation scales to identify serious illness in febrile children. Pediatrics; 70: 802. Merkel S, et al. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing; 23(3): 293–297. Murray M. (2004). Maternal or fetal heart rate? Avoiding intrapartum misidentification. JOGNN, January/February, 93–104. National Heart, Lung, and Blood Institute. (1987). Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children. Author: Bethesda, MD. New Food Guide Pyramid for Children. Center for Nutrition Policy and Promotion, U.S. Dept. of Agriculture, www.mypyramid.gov. Reif M. (2003). How to identify and manage preeclampsia. Women’s Health Gynecology Edition; 3: 249–255. Roberts J. (2003). A new understanding of the second stage of labor: Implications for nursing care. JOGNN; 32: 794–800. Shelton TL, & Stepanek J. (1994). Family-Centered Care for Children Needing Specialized Health and Developmental Services. Association for Care of Children’s Health.
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159 Simpson K, & Creehan P. (2001). Association of Women’s Health, Obstetric and Neonatal Nurses’ Perinatal Nursing (2nd ed.). Philadelphia: Lippincott. U.S. Preventive Services Task Force (USPSTF). (2005). The Guide to Clinical Prevention Services. Silver Spring: Agency for Healthcare Research and Quality Publications. Retrieved August 31, 2005, from http://www.ahrq.gov/clinic/uspstfix.htm. U.S. Food and Drug Administration. (2001). Pregnancy and the drug dilemma. FDA Consumer magazine, May-June 2001. Retrieved August 12, 2005, from http://www.fda.gov/fdac/features/2001/301_preg.html. U.S. Food and Drug Administration. (2003). FDA approves new labeling and provides new advice to postmenopausal women who use or who are considering using estrogen and estrogen with progesterone. FDA Fact Sheet. Retrieved June 27, 2005, from http://www.fda.gov/oc/factsheets/WHI.html. Hormone therapy for the prevention of chronic conditions in postmenopausal women: Recommendations from the U.S. Prevention Services Task Force. (2005). American College of Physicians; 142(10): 855–860. Wong D, Perry S, & Hockenberry M. (2002). Maternal Child Nursing (2nd ed.). St. Louis: Mosby.
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Illustration Credits Pages 5, 6, 25, 35, 36, 54, 84 from Dillon PM: Nursing Health Assessment: A Critical Thinking, Case Study Approach. FA Davis, Philadelphia. 2003 Pages 78, 79 from Ross Products Division Abbott Laboratories Inc. Page 109 from Hay WW, et al: Current Pediatric Diagnosis & Treatment (17th Ed.) New York: Lange Medical Books/McGraw-Hill. 2005 Pages 110, 152 from Behrman RE, Kliegman RM, Jenson TB: Nelson Textbook of Pediatrics, 17/e. Philadelphia: W.B. Saunders. 2004 Page 112 from Hahn YS, et al: Head injuries in children under 36 months of age, Child Nervous System. 4:34, 1988 Page 120 from Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3): 293–297. Copyright 2002, The Regents of the University of Maryland. Page 125 from McCarthy, PL, Sharpe, MR, Spiesel, SZ, et al (1982). Observation scales to identify serious illness in febrile children. Pediatrics, 78:802 Page 147 from Ford EG, Andrassy RJ. Pediatric Trauma Initial Assessment & Management, p.112, Philadelphia: WB Saunders. (1994)
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Index Note: Page numbers followed by “f” and “t” indicate figures and tables, respectively. A Abortion, spontaneous, 41 Abruptio placentae, 44, 45f Abuse, child, 148 Activity level in newborn, assessment of, 97 postpartum, 90 Adenosine, 153 AIDS. See HIV Amiodarone, 153 Amniotomy, 72–73 Apgar score, 69 Apnea monitors, 114 electrode placement for, 115f Atropine sulfate, 153
Bowel, postpartal assessment, 86 BPP. See Biophysical profile Bradycardia in children, 146 fetal, 58 Breast, infection of (mastitis), 94 Breast self exam (BSE), 5–7, 5f, 6f Breastfeeding advantages to, 80 breast care during, 82 engorgement, 81 nutrition during, 81 positioning, 79f, 80 pumping and storing, 81 supply and demand, 81
B Basal body temperature, fertility awareness and, 9 Bathing, newborn, teaching tips, 99 Bed/crib choices, by age group, 122 Biophysical profile (BPP), 51 Bishop’s score, 71 Bladder, postpartal status, 86 Blood pressure, pediatric, normal ranges, 112 BMI. See Body mass index Body mass index (BMI) pediatric, calculation of, 109 Bottle feeding, teaching tips, 100–102
C Calcium chloride, 153 Calendar method, of fertility awareness, 9 Caloric requirements, for children, 109 Cancer. See specific types Cardiac monitors, pediatric, 114 electrode placement for, 115f Cardiopulmonary resuscitation (CPR), pediatric, key points for, 144 Cardiovascular health, promotion of, 16
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161 Cardiovascular system, assessment of, 130 heart sounds and peripheral pulses, 131f Catheters, pediatric suction, 114 Central venous access devices (CVAD), 143 Cervical cancer screening, ACOG/ACS guidelines for, 1 Cervical mucus, fertility awareness and, 9 Cervical ripening, 72 Cesarean birth, 75 postpartal assessment in, 91 vaginal birth after, 73–74 Child abuse, recognizing, 148 Children caloric requirements for, 109 communications with, 126t–128t developmental milestones in, by age group, 105t–108t pain in developmental differences in, 118 nursing interventions related to management of, 119 questions in assessment of, 117 responses to illness/hospitalization, by age group, 116t–117t safety education topics, 133 sick, quick evaluation of, 125 systemic assessment, 129 cardiovascular, 130, 131t
gastrointestinal, 132 genitourinary, 132 musculoskeletal, 133 neuromuscular, 129 respiratory, 129–130 respiratory equipment, 130 skin, 132 10-minute assessment of, 123–124 use of play for, by age group, 105t–108t Chlamydia, symptoms and detection, 3t Choking, pediatric, key points for, 145 Circumcision, teaching tips, 102–103 Clonic seizures, 149 Colorectal cancer, early signs of, 17 Coma scale, pediatric, 112 Communication with child and family, 126t–127t in newborn, teaching tips, 98 Condoms, 11–12 Contraception barrier methods, 10–11 educating women on, 7 emergency, 15 fertility awareness methods, 8–9 hormonal methods, 11–14 contraindications to, 12 intrauterine system, 14–15 lactation amenorrhea method, 10 permanent methods, 15–16
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Contraction stress test (CST), 50–51 CPR. See Cardiopulmonary resuscitation CST. See Contraction stress test CVAD. See Central venous access devices
intramuscular, 137 sites for, 139f, 140f intravenous, 137 sites for, 142f nasal, 136 nasogastric/orogastric/ gastrostomy, 135 optic, 136 oral, 135 otic, 136 rectal, 136 subcutaneous, 137
D Deep venous thrombosis, 95 signs of, teaching tips, 96 Defibrillation, pediatric guidelines, 146 Dehydration, pediatric degree/signs of, 151 water/electrolyte deficit, calculation of, 152 Delivery, estimated date of, 20 Depo-medroxyprogesterone (DMPA), 14 Developmental milestones 0–1 year, 105 1–3 years, 106 3–6 years, 107 6–12 years, 108 12–18/21 years, 108 Diabetes emergencies related to, 148 gestational, 49–50 Diaphragms, 10 Diazepam, 153 DMPA. See Depo-medroxyprogesterone Dobutamine, 154 Dopamine, 154 Drug administration, 134–135 5 rights of, 134 routes of determination of, 134 intradermal, 137
E Eclampsia, 48 Ectopic pregnancy, 41 Electrode placement, pediatric cardiac/apnea monitors, 115f Electrolyte/water deficit, calculation of, 152 Emotional response, postpartal assessment of, 88 support for, 89 Endometrial cycle, 8 Endometritis, 94 Epinephrine, 154 Estrogen contraindications to, 12 effects of, 11 Extremities, assessment of in newborn, 97 in postpartal patient, 89 F Family planning. See Contraception Fears, in children as response to illness/hospitalization, 116–117 Febrile seizures, 150
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163 Fertility awareness methods, 8–9 Fetal heart tones (FTH), Doppler placement for, 36f Fetal monitoring baseline heart rate changes to, 58–62 evaluating, 56, 57f continuous external, 55f internal, 56f intermittent auscultation, 54–55 nursing responsibilities in, 54 Fetoscope, 54f FLAAC pain assessment tool, 120t Fluid deficit. See Dehydration Food pyramid, 31f Formula, infant, 100 Fundus height of, 25f by weeks of gestation, 24 massage of, 83f postpartal assessment of, 84–85 G Gastrointestinal system, assessment of, 132 Genetic screening, in newborn, teaching tips, 104 Genitourinary system, assessment of, 132 Gestational trophoblastic disease, 41–42 Gonorrhea, symptoms and detection, 3t Grand mal seizures, 149
H Health maintenance, in newborn, teaching tips, 103 Heart rate, fetal changes to baseline, 58–62 accelerations, 59, 59f early decelerations, 59, 60f late decelerations, 60–61, 60f nursing interventions for, 62 variable decelerations, 61, 61f evaluation of, 56 normal, 57f Heart sounds, 131f HELLP syndrome, 48–49 Hemorrhage, in postpartal patient, 92–93 Hepatitis, symptoms and detection, 3t Herpes simplex virus (HSV), 2 symptoms and detection, 4t History(ies) intrapartum, 52–53 pediatric, concerns by age group, 128 prenatal health, 21–22 HIV, symptoms and detection, 4t Hormonal contraceptives, 11 combined methods, 12–14 contraindications to, 12 Hormonal replacement therapy (HRT), 18 Hospitalization, children’s responses to, by age group, 116–117
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HPV. See Human papillomavirus HRT. See Hormonal replacement therapy HSV. See Herpes simplex virus Human papillomavirus (HPV), 2 symptoms and detection, 3t Hyperemesis gravidarum, 45 Hyperglycemia, 148 Hypoglycemia, 148 Hysteroscopic tubal sterilization, 16
Intravenous access sites, pediatric, peripheral, 141, 142f Intravenous maintenance fluids, calculations by body weight, 140 of IV rates, 141 IUD. See Intrauterine device K Kegel exercises, 88 L Labor active phase (stage 1), 64–66 epidurals in, 66 expulsion (stage 2), 67–69 fourth stage, 76 induction of, 71–73 latent phase (stage 1), 64 monitoring contractions, 62–63 nursing care in, 63 placenta delivery (stage 3), 70 preterm, 46–47 systemic pain medications in, 65 transition phase (stage 1), 66–67 Lactation amenorrhea method (LAM), 10 LAM. See Lactation amenorrhea method (LAM) Leopold’s maneuver, 35f Lidocaine, 155 Lochia, 86 assessment of, 87 normal progression of, 85 Loss of control, in children as response to illness/hospitalization, 116–117
I Illness, children’s responses to, by age group, 116–117 Immunizations genetic and hearing screen, teaching tips, 104 in newborn, teaching tips, 104 Infants developmental milestones, 105 feeds, number/volumes, 109 food types, introduction of, 111 vital signs, 110 See also Newborns Infection, in postpartal patient, 93–94 Injections intradermal, 137 intramuscular sites, 138, 139f, 140f intravenous, 137 sites for, 142f subcutaneous, 137 Intrauterine device (IUD), 14–15
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165 M Mastitis, 94 Menopause hormonal replacement therapy in, 18 symptoms of, 17 Menstrual cycle, 7 postpartal return of, 85 Musculoskeletal system, assessment of, 133 N Naegele’s Rule, 20 Naloxone, 155 Neglect, child, 148 Neuromuscular system, assessment of, 129 Newborns breastfeeding of, 78f, 79–82, 79f care of, teaching tips bathing/skin care, 99 bottle feeding, 100–102 circumcision, 102–103 communication, 98 reportable symptoms, 104 safety and health maintenance, 103 sleep patterns, 98 umbilical cord care, 100 immediate care of, 68–70 nursery care of, 97 physical assessment of, 97 Nonstress test (NST), 50 NST. See Nonstress test Nutrition of children, caloric requirements, 109
food pyramid, 31f in pregnancy, education on, 31 O OCT. See Oxytocin challenge test Osteoporosis, prevention and treatment of, 16 Ovarian cycle, 8 Oxytocin, in induction of labor, 71–72 Oxytocin challenge test (OCT), 50–51 P Pain developmental differences in children related to, 118 FLAAC assessment tool, 120t nursing interventions related to management of, 119 questions in assessment of, 117 Parenteral nutrition calculations by body weight, 140 of IV rate, 141 keys for monitoring child on, 140 Pediatric coma scale, 112 Pediatric trauma score, 147 Perineum, postpartal assessment, 87 Petit mal seizures, 149 Pitocin. See Oxytocin Placenta previa, 42, 43f, 45
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Play, type/purpose of, by age group, 121–122 Postpartum blues/depression, 89, 94–95 signs of, teaching tips, 96 Postpartum patient breast assessment, 77 cesarean, assessment of, 91–92 complications in hemorrhage, 92–93 infection, 93–94 education of, 77 in breastfeeding, 78–82 emotional response, assessment/support of, 88–89 laboratory data in, 91 nursing assessment of, 76–77 return of menstrual cycle in, 85 sexuality in, 85 uterine involution in, 83–84, 84f Preconception counseling, 7 Preeclampsia, 47–48 Pregnancy classification of medications in, 31 common laboratory tests in, 26 complications in abruptio placentae, 44f eclampsia, 48 gestational diabetes, 49–50 HELLP syndrome, 48–49 hyperemesis gravidarum, 45 placenta previa, 42, 43f, 45
preeclampsia, 47–48 preterm labor, 46–47 vaginal bleeding, 42 delivery date estimating in, 20 early diagnostic testing in, 27–28 education in, 28 establishing, 19 exercise in, 33 fetal surveillance in, 50–62 biophysical profile, 51 contraction stress test, 50–51 nonstress test, 50 hormonal changes in, 23 low-risk, prenatal visits, scheduling of, 21 physiological changes in, 23 second/third trimester, education in, 38–40 sexuality in, 34 teratogen exposure in, 30 trimesters of, 20 warning signs during, 34 weight gain in, 33 Prenatal visits first diagnostic tests for, 26 history taking in, 21–22 nursing care with, 24 patient education in in early prenatal period on discomforts/ reportable symptoms, 28t–29t on exercise, 33 on nutrition, 31, 32f
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167 on sexuality, 34 on teratogen exposure, 30 on warning signs, 34 on weight gain, 33 in second/third trimester, 38 on discomforts/ reportable symptoms, 39t–40t return diagnostic tests for, 37 nursing care for, 35–36 scheduling, 21 Preterm labor, 46–47 Progestin contraindications to, 12 effects of, 11 single agent preparations, 14 Pulse oximetry, pediatric, 114 Pulseless arrest, in children, 147 Pulses, peripheral, 131f R Rehydration, 152 Respiratory failure, cardinal signs of, 148 Respiratory system, assessment of, 129–130 S Safety of drug dose, determination of, 134 education topics, by age group, 133 in infant/child assessment, 123–124
in newborn, teaching tips, 103 of toys, by age group, 121–122 Screening, cervical cancer, ACOG/ACS guidelines for, 1 Seizures, general types of, 149–150 Separation anxiety, in children as response to illness/hospitalization, 116–117 Serum pregnancy test, 19 Sexuality postpartal, 85 in pregnancy, 34 Sexually transmitted diseases (STDs), 2, 3t–4t Skin assessment of, 132 care of, in newborn, teaching tips, 99 Skin cancer, early detection/prevention of, 17 Sleep patterns, in newborn, teaching tips, 98 Sodium bicarbonate, 155 Status epilepticus, 150 STDs. See Sexually transmitted diseases Suctioning, pediatric, 114 Syphilis, symptoms and detection, 4t T Tachycardia in children, 146 fetal, 58 Teratogens, in pregnancy, education on, 30
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Thrombophlebitis, 95 signs of, teaching tips, 96 Tonic seizures, 149 Toys, safe, by age group, 121–22 Trauma, score, pediatric, 147 Trichomoniasis, symptoms and detection, 3t Tubal ligation hysteroscopic, 16 incisional method, 15
V Vaginal birth after cesarean (VBAC), 73–74 Vaginal bleeding, in pregnancy, 42 VBCA. See Vaginal birth after cesarean Venipuncture sites, pediatric, 142f Vital signs newborn, 97 pediatric, average ranges, 110 postpartum, 90
U Ultrasonography, in establishing pregnancy, 19 Umbilical cord care of, teaching tips, 100 prolapse of, 74 Urinary tract infection, in postpartal patient, 93–94 Urine output, pediatric, 110 Urine pregnancy test, 19 Uterus infection of (endometritis), 94 involution of, 83 subinvolution signs, teaching tips, 96
W Water/electrolyte deficit, calculation of, 152 Water requirements, pediatric, 110 Weight gain, in pregnancy, 33 Weight loss, at birth, 91 Weight management, promotion of, 16 Women, health promotion in, 16–17 nurses’ role in, 1
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