MATERNITY NURSING; pediatrics;management and delegation
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First trimester(wk1-13):assessment:presumptive signs,probable signs, positive signs of pregnancy
- presumptive signs of pregnancy: Amenorhea-progesterone causes this.
- Frequency-uterus stretching causing pressure on bladder.
- Breast tenderness-excess hormones.
- Probable signs of pregnancy:positive pregnancy test(hCG levels).*hydatidiform mole;drugs may also cause this increase.
- Goodell's sign(softening of cervix;2nd mo.)
- Chadwick's sign(bluish color of vaginal musoca and cervix;wk4).
- Hegar's sign(softening of the lower uterine segment;2-3 mo.)
- Uterine enlargment.
- Braxton hicks(throughout pregnancy;move blood through the placenta).
- Pigmentation/changes of skin.
- Linea nigra
- Abdominal striae
- Facial chloasma.
- Darkening of areola.
- Positive signs of pregnancy:Fetal heartbeat(10-12 wks)
- Fetoscope(17-20 wks)
- Fetal movement(that we feels not the client)
# of times someone has been pregnant
# of pregnancies that fetus reaches 20 wks
24 wks= infant can live outside womb.
- L=living children
- find first day of lmp
- add 7 days
- subtract 3 mo
- add 1 yr
First trimester (1-13 wk)
- 4 food groups.
- Increase calories by 300/day after 1st semester.*adolescent:increase calories to 500.
- Increase protein to 60 g/day
First trimester (1-13 wk): wt gain
First trimester (1-13 wk):prenatal vitamin supplements
- Iron-causes constipation and GI up set.*take with vit C to enhance absorption.
- Folic acid>prevents neural tube defects.*400mcg/day
First trimester (1-13 wk):exercise rules
- No high impact;*should walk or swim.
- No heavy/unaccustomed exercise programs!
- No overheating!*hot tubs or electric blankets!
- *if you increase body temp=birth defects!
- Don't let HR get above 140!!!=causes CO and uterine perfusion will drop.
First trimester (1-13 wk):danger sign
- Sudden gush of vaginal fluid
- persistent vomiting
- severe HA
- Abdominal pain
- increased temp
- No fetal movement
- *always assume the worst!
First trimester (1-13 wk):Common discomforts
- Breast tenderness
- Tender gums
- Increased vaginal secretions
- Nasal stuffiness*estrogen causes this
- Varicose veins
- Ankle edema*elevate legs
- Constipation*fiber,H2O, walk
- Leg cramps
First trimester (1-13 wk):meds
Don't take any unless doctor says it's okay!
what does smoking causes in the pregnant female?
- SGA- small for gestational age
- Tell client to stop!
- First 28 wks: 1/mo.
- 28-36 wks: every 2 wks or 2/mo.
- 36wks: weekly until delivery!
have client drink H2O before u/s to distend bladder and push up uterus to abdominal surface.*for an U/S prior to procedure then void first!
Second trimester (14-26Wks):s/s
- Wt gain :1 lb/wk=4lb/mo.
- No m ore N/V
- Breast tenderness
- No frequency because uterus moves up.
- Quickening:Fetal movement
- Fetal Heart Rate:120-160
Fetal Heart Rate:
- Worried&watching: 110-120
- PANIC: less than 110
Second trimester (14-26 wks):miscellaneous info
- kegels:prevent uterine collapses!
- Pregnancy is considered term if it reaches 37-40 wks
Third trimester (27-40wks):assessment
- Weight gain: 1lb/wk no more!
- Monitor BP and report increase from baseline.*worry about PIH.
- Fetal HR: 120-160.
- Leopold maneuvers-have client void first, do it between contractions!determines position/presentation of fetus!
Third trimester (27-40wks): Client education/teaching:Signs of labor:
- Lightening:2 wks before term, presenting fetus descends into pelvis, client will feel less congested, breathe easier, but frequency will be a problem again!
- Engagement: the largest presenting part is in the pelvis inlet*hopefully the head.
- fetal stations: measure in cm, measures relationship of presenting part of uterus to the ischial spines of mother.
- Other Signs: Braxton Hicks Contractions: more frequent and stronger.
- Softening of cervix.
- Bloody show.
- Sudden burst of energy, called nesting.
- Rupture of membranes.
When should the client go to the hospital?
- When contractions are 5 min apart or when membranes rupture
- Worry about prolapsed cord!
Non stress test(NST)
- 2 or more accelerations of 15 beats/min or more with fetal movement. for at least 15 seconds but back to normal in 2 min.
- Each increase last for 15 seconds and test is 20 min.
- Good=reactive test!
Biophysical Profile test:(BPP)
- done in 3rd/last trimester!or 32-34 wks in high risk pregnancy.*High risk may have one every wk or twice/wk in 3rd trimester.
- Measurements done by U/S each parameter counts for 2 pts*10/10 GOOD!
- HR-NST(15beats/min above baseline for 15 seconds with each fetal movement)20 min test.
- Muscle tone- baby as 1 flexion-extension in 30 min.
- Movement- does baby move at least 3 times /30 mins?
- Breathing- breathing movements at least once in 30 min.
- amniotic fluid- is there enough?
- Observation 30 min.
- contraction Stress Test:Oxytocin Challenge Test
- Done when NST is nonreactive.
- Performed on high risk pregnancies: preeclampsia, maternal diabetes, and any condition in which placental insufficiency is suspected.
- Determines if baby can handle stress of uterine contractions.*contractions decrease blood flow to the uterus and to the placenta.
- May cause decels.
- Late Decels=BAD!
- Rarely performed before 28 wks.
- Results are good for one week.
if blood flow is decreased enough to cause hypoxia in fetus the fetal heart rate will decrease from baseline HR.
- mean uteroplacental insufficiency
benign; head compression
BAD! Umbilical cord compression
- contractions are regular, increase in frequency and duration.
- Discomfort in back and radiates to abdomen.
- Pain level increases with a change in activity.
- Contractions are ireegular
- Discomfort in abdomen only.
- Pain decreases with change in activity/disappears.
- Position:lie on LEFT side, legs flexed, not as arched as with lumbar punctures.or indian style.
- Given in stage 1 at 3-4 cm dilation. Usually no HA.
- Major complication: Hypotension.*monitor BP! IVF's: bolus with 1000mL of NS or LR to fight hypotension!Positioning: put in semi fowlers on side to prevent vena cava compression.
- Alternate side to side hourly.
Client receiving Oxytocin(Pitocin)
- Need one-on-one care!
- Be alert on complications:Hypertonic labor, Fetal distress, Uterine rupture(complete or incomplete).
- Want contraction rate of 1 every 2-3 min with each lasting 60 seconds!
- D/C Oxytocin(Pitocin) if: contractions are too often, last too long, or fetal distress!
- *if you turn off pit make sure you don't turn off your main IV fluid.
- Position: any way except for flat on back. if there is unreassuring fetal heart tones then place on left side!*enhance uterine perfusion.
- If late decels occur TURN OFF PITOCIN!
Complete uterine rupture
- through uterine wall into peritoneal cavity.
- Sudden,sharp , shooting pain,"something gave away"; in labor the contractions may stop and the pain will be relieved; signs of hypovolemic shock due to hemorrhage!; if placenta separates the fetal heart tones will be absent!
Incomplete uterine rupture
- through the uterine call but stops in the peritoneum but not the peritoneal cavity.
- Internal bleeding, pain may not be present, fetus may/may not have late decels, client may vomit, faint, have hypotonic uterine contractions and lack of progress, fetal heart tones may be lost.
Vaginal birth after C-section(VBAC)
Clients are high risk for uterine rupture. the scar from the c-section is weak so it is prone to open when under stress.*those who are at higher risk are receiving pitocin!
Contractions rate during labor
1 every 2-3 min lasting 60 seconds!!!
- Tell pt to pant/blow to decrease urge to push(do not push in between contractions!).
- Wash hands.
- Elevate HOB.
- Place something clean under buttocks
- Decrease touching of vaginal area.
- As head crowns tear amniotic sac if it has not already ruptured.
- Place hand on fetal head and apply gentle pressure.(prevents baby from coming out to fast.)
- When head is head feel for cord around neck!
- Ease each shoulder out-do not pull baby.
- The rest will deliver fast.
- Keep baby's head down.
- Dry baby.
- Keep baby at level of uterus.
- Place on mom's abdomen.
- Cover baby.
- Wait for placenta to separate/deliver.
- Can push to deliver placenta.
- Inspect placenta for intactness.
- Tie cord off with a piece of cloth or shoestring.(place one knot about 4 in from babys navel and second knot about 8 inches from baby's navel.)
- Check firmness of uterus.
Normal post partal period: assessment
- Vitals: Temp:may increase to 100.4 during 1st 4 hrs.
- HR: 50-70 common for 6-10 days.
- Breasts: soft for 2-3 days then engorgement.
- Abdomen:Soft/loose;diastasis recti
- Uterus:immdeiately after birth uterus is midline 2-3 finer breadths below umbilicus.
- A few hrs after birth it rises to level of umbilicus or one Finger breadth above.
- Want fundus firm!
- If fundus is boggy massage it until firm and then check for bladder distention!
- Fundal heaigh will descend one finger breadth/ day.
- Involution- fundus descends and returns to prepregnancy size.
- Afterpains are common first 2-3 days and will continue to common if the mother chooses to breastfeed.
- Lochia:rubra: 3-4 days color dark red.
- Serosa:4-10 color pinkish brown
- Alba: 10-28 days(can be as long as 6 wks)Color:whitish/yellow
- *clots are okay as long as they are no larger than a nickel!
- Urine output:Diurese should begin 24 hrs after delivery. Might dehydrate so watch out! Inspect for DVT!
Tachycardia +postpartum think?
bLADDER DISTENTION IS SUSPECTED WHEN?
THE UTERUS IS ABOVE THE EXPECTED LEVEL OR IS NOT IN THE MIDLINE(TO THE RIGHT)
A distended bladder will not aloow the utreus to?
contract normally which increases chances of hemorrhage.
Post partal treatment
- Perineal care:icepacks for first 6-12 hrs decrease edema
- Warm water rinses
- Sitzbaths 2-4 times/day
- Anesthetic sprays
- Change pads frequently(no more than 1/hr*any more then think hemorrhage!)
- Teach to report foul smell
- Report lochia changes
- Bonding:emotional and physiological need for baby! it stabilizes HR, improves O2 sats, regulates temperature,conserves calories, breast change temp to warm or cool baby.*kanaroo care:mom or dad places baby skin to skin on their chest the baby is wrapped inside the parents shirt or covers and held for 1 hr at least 4 times a week.
- Breast care: Breastfeeding: cleanse with warm water after each feeding let air dry,support bra, ointment for soreness or express some colostrum and let it air dry, breast pads absorb moisture, initiate breastfeeding ASAP after birth, can pump, increase calories by 500, fluid/milk intake (8-10 glasses of fluid/day)
- Non-breastfeeding: ICE packs, breast binders, chilled cabbage leaves, no stimulating breast.
- postpartum infection: within 10 days after birth:E.Coli/Beta hemolytic strep, teach proper hygiene , usually get cultures and antibiotics.
- postpartum hemorrhage: EARLY:more than 500cc blood lost in first 24 hours and a 10% drop from admission HCT.
- LATE:after 24 hrs up to 6 wks postpartum.
- CAUSES: uterine atony,lacerations,retained fragments, forceps delivery
- MEDS:oxytocin(pitocin),Methylergonovine Maleate(Methergine), Carboprost Tromethamine(Hemabate)
- Mastitis:Staph, occurs around 2-4 wks
- TX:Bed rest, support bra, binding can cause more stagnation,chilled cabbage leaves, if mom is going to continue to breastfeed, she needs to initiate breastfeeding frequently or pump,PCN, pain meds, heat,feed baby lots and always the affected breast first!
- clamp cord
- Maintain body temp
- Apgar:1 and 5 min(HR,R,Muscle tone, refelx irritability, color. *want 8-10)
- Erythromycin:prophylaxis of Neisseria gonococcus and chlamydia.
- Phytonadione(Aquamephyton)promote formation of clotting factors
Newborn care:cord care
- Dries and falls off in 10-14 days
- Cleanse with each diaper change using alcohol or NS.
- Fold diaper below cord.
- No immersion until cord falls off;watch for infection!
- Cause: No more glucose from mom
- At risk: LGA, SGA, preterm, and babies of diabetic moms
Newborn care:complications:pathologic jaundice
- occurs within first 24 hrs
- Usually means rh/ABO incompatibility
Newborn care:complications:Physiological jaundice
- Occurs after 24 hrs.
- Due to normal hemolysis of excess RBC's releasing bilirubin, or liver immaturity.
Newborn care:complications:Rh sensitization or Rh factor
- First pregnancy: Rh+ blood from baby comes in contact with moms Rh- blood, most likely when placenta separates at birth,miscarriage,amniocentesis, or trauma to mom's abdomen.Mom's body sees the Rh+ as a foreign body(antigen). first Baby is not affected by antibodies.
- Second pregnancy: Rh- sensitized mom get's pregnant again and the Rh+ antibodies and attack Rh+ baby. Antibodies never go away!! The antiboides enter through placenta>hemolysis. Erythroblastosis fetalis(the increase of immature RBC's in the fetal circulation) will result in: Hyperbilirubinemia,anemia,hypoxia, HF, neurologic damage, Hydrops fetalis(severe form of erythroblastosis fetalis.)
- Dx/TX: indirect Coomb's :done on mother;measures # of antibodies in blood.
- Direct Coomb's: done on baby:tells you if there are any antibodies stuck to RBCs.
- *if you have a Rh+ fetus and a sensitized mother: frequent U/S when baby stops growing then early birth and RhoGam!
- Rho(D) immunoglobulin(RhoGAM) is given within 72 hrs of birth protects next baby and 28 wks protects present fetus, and with any bleeding episode.
- RhoGam destroys fetal cells that got into moms blood and it has to do this before antibodies are formed!
Rho(D) immunoglobulin (RhoGAM) rules
- once antibodies are formed mom has them for life.
- must be given before antibodies form!
- S/S:spotting AND cramping
- TX:Measure hCG levels-worry when levels drop.
- Bed rest and pelvic rest(no sex).
- If miscarriage imminent>IV, blood, D&C.
Hydatidiform mole(molar pregnancy)
- Patho: Benign neoplasm, can turn malignant
- Grapelike clusters of vesicles.
- No fetus involved.
- Uterus enlarges way to fast.
- S/S:Absence of FHT's
- Bleeding(sometimes will have vesicles)
- DX:confirmed with U/S
- TX:small mole> D&C(have to empty uterus).
- Do not get pregnant during follow up time.
- If it becomes malignant it is called Choriocarcinoma.
- Will do CXR to determine metastasis.
- Will measure hCG's weekly until normal rechecked every 2-4 wks then every 1-2 mo for 6 months to a year.
- Gestation outside uterus
- Usually in fallopian tube
- Confirmed with U/S
- S/S:Pain, s/s of pregnancy then pain, spotting, or maybe bleeding into peritoneum, if fallopian tube ruptures may see vaginal bleeding, if they have had one ectopic there is chance for another.
- TX:Methotrexate(rheumatrex/Trexall) is given to mom to stop the growth of the embryo to save the tube, if it does not work a laparoscopic incision will be made into the tube and embryo will be removed.
- A laparotomy is done if the tube has ruptured or if ectopic pregnancy is advanced. if tube does rupture worry about Hemorrhage!
- most common cause of bleeding in later months(7th).
- placenta implanted wrong.
- An U/S will be done to confirm.
- Placenta begins to prematurely separate when cervix begins to dilate and efface> baby doesn't get oxygen
- s/s:painless bleeding in second half of pregnancy.(spotting to profuse).
- TX: complete previa usually requires hospitalization from as early as 32 wks-birth to prevent blood loss and fetal hypoxia if client goes into labor.If not much bleeding put on bed rest and watch very close.
- Rule out other sources of bleeding like abruption. Pad counts, Monitor blood count and monitor baby closely. Monitor contractions> call MD(not normal delivery). C-section. NO VAGINAL EXAMS!
- Fetal complications: preterm delivery, intrauterine growth retardation, fetal distress, anemia.
- maternal complications:Hemorrhage, potential DIC risk.
- placenta is implanted normally
- maybe partial or complete
- it separates prematurely>bleeds external or concealed_in the uterus.
- Seen in last half or pregnancy.
- U/S to confirm diagnosis(partial of complete, severity is based on scale 1-3, 3 is the worst!)
- Causes:MVC=motor vehicle crash
- Domestic violence
- Previous c-section
- Rapid decompression of uterus(membranes rupture).
- Associated with coccaine, PIH, and smoking
- S/S: rigid boardlike abdomen with or without vaginal bleeding.
- Abdominal pain and increased uterine tone.
- Difficult to palpate fetus.
- TX: C-section and manage fetal status and maternal shock!
What is the rule about vaginal bleeding and vaginal exams?
if bleeding is unexplained NEVER do a vaginal exam!
- cervix dilates prematurely
- occurs in 4th month of pregnancy
- hx of repeated painless, 2nd trimester miscarriages.
- Causes: wt of baby causes pressure on the cervix causing it to prematurely dilate.
- Tx:Purse string suture(cerclage)at 14-18 wks.
- c-section to preserve suture or clip it to devlier vaginally.
- 80-90% chance of carrying baby to term after cerclage.
- Starts like regular morning sickness then excessive vomiting>dehydration>starvation>death
- Causes: R/T high levels of estrogen and hCG
- S/S: BP decreases, H/H increases, UO decreases, K= decreases so wt decreases
- Ketones in urine.
- Tx: NPO for 48 hrs,
- IVF's 3000 ml for 1st 24hrs.
- Quiet environment
- oral hygiene
- Don't talk about food.
- Keep emesis basin out of sight
- 6-8 dry feedings followed by clear fluids
- foods/liquids should bbe wither icy cold or hot.
- Well ventilated room
- increased BP,proteinuria, edema after 20th week.
- *130/90 is considered mild preeclampsia.
- s/s:sudden wt gain
- face and hands are swollen,losing protein so fluid doesn't stay in vascular space it goes into the tissues.
- HA,blurred vision, seeing spots.
- Hyper-reflexia(increased DTR)
- When you see a gain of 2 or more lb in a week watch closely and worry about PIH
- TX:mild: BP30/15 off their baseline documented 6 hrs apart.
- Bed rest as much as possible.
- Increase protein in their diet.
- They have glomerular damage with proteinuria.
- Severe: BP elevated 160/110 documented 6 hrs apart.
- Sedation delay seizures.
- Magsulfate:anticonvulsant,sedative,vasodialtor.Vasodialtion will increase rena; perfusion and helps avoid renal failure and increases placental perfusion and helps avoid RF and increases placental perfusion!
- position on her side(left) to enhance perfusion. Mag sulfate is a simple salt soluntion(hypertonic)>fluid is attracted back into vascualr space and otu of the tissues>kidneys will diurese*if kidney function is impaired or shift occurs too fast client is at high risk for pulmonary edema!
- Check for mag toxicity every 1-2 hrs.(BP,RR,DTRS,LOC)
- monitor UO hourly and serum magnesium.
- Will stop labor unless augmented with oxytocin.
- use mag for preterm labor.
- If diastolic is >100 give apresoline in combo with mag S/E: tachycardia
- Only cure is delivery.
- After delivery client is at risk for seizure for 48 hrs!
- Put them in a single room,quiet room, dim light no TV!(decrease stimuli).
- Additional treatment: Steroids: Betamethasone(Celestone) stimulates surfactant production into the alveoli spaces and this causes less tension when the infant breathes.Given between 24-34 gestation to reduce mortality.
- Expectant management:balance the risk to mom vs. baby.
- turning point from pre to Eclampsia is seizure and increased HR
- Tx:Monitor FHT
- Watch for labor
- Watch for HF
- Monitor for HF,stroke, heart attack, RF, DIC, HELLP, neuro damage , multi system organ failure.
pregnancy induced hypertension- occurs after 20 wks, proteinuria
occurs after 20 wks but no proteinuria!
Chronic HTN with superimposed PIH
cleitn was hypertensive before and HTN got worse with proteinuria after 20 wks
- labor between 20-37 wks
- Increased pulse and hyperactivity.
- Mg sulfate
- Betamethasone(Celestone): Given IM to mom, to stimulate maturation of baby's lungs in case preterm birth occurs!
- Hydrate mom and treat vaginal and UT infections!
- umbilical cord falls through cervix
- occurs when presenting part is not engaged and membranes rupture.
- Check FHT when membranes rupture either spontaneously or artificially. if cord is being compresed you will see variable decels in FHT > immedaite C-section!
- *if cord ceases to pulsate >fetal death has occured!
- tx:lift head off of cord until physician arrives(nurse pushes head up to relieve pressure on the cord!)
- Trendelenberg or knee to chest position.
- Administer O2
- Monitor FHT
- Do not push cord back in!
- risk to fetus:Hypoxia>leads to cerebral palsy and asphyxia.
- Brachial plexus>leads to erbs palsy(drooping/paralysis of an arm caused by excessive traction and stretching of brachial nerve at delivery.)
- Broken clavicle.
- Bell's palsy is paralysis of face drooping on one side.
- Caused by forceps
- May resolve
- maternal risk:Traumatic delivery>leading to permanent damage.
- Bruised bladder.
- Extension of episiotomy.
- Rectal tear.
- Torn cervix and or uterus
- who's at risk: LGA or macrosomic infants >4000 grams.
- Gestational diabetes
- Previous history of should dystocia.
- Post date delivery>large fetus.
- nursing care: McRoberts maneuvers-hyperextend legs.
- Mazzanti techniques_suprapubic pressure- NO FUNDAL PRESSURE. pHYSCIAN MUST DO THIS!
Group B strep(GBS)
- leading cause of neonatal morbidity
- Routinely assess for GBs risk(35-37 wks) and on admission to L&D.
- Transmitted to infant from birth canal of the infected mother.
- Risk for fetus is only after rupture of membranes
- Teaching:client needs to understand it is not STD.
- Risk factors for neonatal GBS:preterm birth less than 37 wks, +prenatal cultures in current pregnancy, premature rupture of membranes(longer than 18 hr) positive history for early onset of neonatal GBS, intrapartum maternal fever higher than 100.4, previous infant with GBS.
- tx:prophylactic antibiotic therapy, PCN
Pediatrics order of obtaining vital signs
- Respirations(full min)
- HR(Apical;full min)
- Temp(Not rectal over 3 mo., oral 5-6)
- *If VS cannot be taken without disturbing child record behavior with the measurements.
Pediatrics general growth
- within 5-95% for height ,weight, and head circumference.
- 50% is medium growth
- Growth rate decreases between 6-12 yrs
- girls experience adolescence about 1-2 yrs before boys
Pain assessment Cries
- (0-2) for each
- Requires increased O2
- Increased vital signs
- *higher the score the worse the pain is.
Pain assessment: FLACC
- Face, Legs,Activity, Crying,Consolability
- 0-10*10 worst
pain assessment wong baker
- any age usually 3 or older 0-5 faces scale
- Numerical scale used at age 5 or older.
- Upper respiratory disease:most common type of croup;children under 5
- Causes:paainfluenza,adenovirus, and RSV
- S/S:slight to severe diarrhea.
- Barking or brassy cough
- increased temperature
- TX: mildcroup can be treated at home with hot shower steam, cool mist humidifiers or car rides with windows down, if it worsens or does not improve hospitalization is required with corticosteroid therapy
- *sound worse than they look
- Upper respiratory disease
- Causes: H. influenza
- s/s: absence of cough,drooling, agitation with the rapid progression to severe resp distress
- Look worse than they sound.
- tx: ER, may require intubation or trach, IV antibiotics and corticosteroids.
- Upper respiratory disease
- s/s difficulty swallowing and breathing so child is a mouth breath and have bad breath. impaired taste and smell, voice has anasal/muffled quality. persistent cough. swollen tonsils can block drainage of the ear canal and cause otitis media
- TX:tonsillectomy(place on side with head elevated or prone afterwards!No brown or red fluids(might be confused with blood). monitor for constant swallowing(indicated hemorrhaging). Client is at risk for hemorrhage for 10 days. Will have sore ear and throat. low grade temp and bad breath.
- Upper respiratory disease.
- middle ear is affected
- eustachian tubes are blocked
- follows upper respiratory infection
- s/s: tympanic membrane bulging and bright red.
- tx: heating pads can help with pain
- avoid chewing and provide soft foods
- lie on affectedside
- may not hear well.
- Avoid smoke
- may require tubes for draining.(stays in for 6 mo and then falls out).
- prevention:while tubes are in wear ear plugs when bathing or swimming.
- have baby sit up for feedings.
- No bottle propping.
- gentle nose blowing.
- AVOID SMOKE
- Lower respiratory disease :Respiratory syncytial virus.
- Causes:acute viral infection that affects the bronchiole and includes RSV bronchiolitis or RSV pneumonia.
- Leading cause of lower resp tract illness in children less than 2 yr
- Risk factors:prematurity
- Congenital disorders
- Focus is on prevention(high risk get vaccine!)
- s/s:URI(upper respiratory infection)
- Nasal discharge
- Mild fever
- Nonproductive cough
- Tachypnea with flaring nostrils
- Retraction and wheezing
- know onset because it will be worse on days 2-3.
- *s/s can range from mild to severe; from cough and runny nose to copious amounts of mucus to severe respiratory distress.
- dx: nasal swab
- tx:transmission:contact precautions;teach good hand washing.
- mild:treat symptoms(suppotive care;antipyretics)
- severe:oxygen; may need mechanical ventilation
- IV fluids
- Lower respiratory disease.
- Causes:Viral(RSV,adenovirus or parainfluenza)
- Bacterial(Strep)children <4yrs
- Mycotic(walking pneumonia)primarily in adolescents.
- Aspiration pneumonia(something other than air gets into lung).
- s/s:fine crackles or rhonchi with a cough that is productive or nonproductive.
- Abdominal distention
- back pain
- Fever that is usually high
- Chest pain from coughing.
- cough supressant
- prone to respiratory infections because of poor immune system.
- Heart defects are also common
- Causes:inherited trait and must get trait from both parents
- s/s: thick and sticky secretions found in lungs and GI tract.
- Characterized by exocrine gland dysfunction
- dx:positive sweat chloride test
- At risk for hyponatremia
- Earliest sign is that they never pass the meconium(meconium illeus)
- they will have steatorrhea stools(fatty and frothy).
- tx:enzymes that help digestion are pancreatic enzymes. take 30 min prior to eating do not crush or chew.
- Need well balanced,low fat, highcalorie, high protein*require 150% of recommended daily allowance.
- Need water soluble vitamins including A,D,E, and K.
Heart failure in a child
- usually due to congenital defects
- s/s:lips turn blue when taking bottle
- increase pulse at rest or with slight exertion
- increased respiratory rate
- scalp sweating
- sudden wt gain
- tx:ongoing assessmnet
- control room temp
- sit them up
- decrease stimuli
- cool,humidified o2
- uninterrupted sleep
Cardiac meds for children
- Digoxin:infants rarely get more than 1 cc
- Give 1 hr before and 2 hr after feedings
- DO NOT mix with other meds,foods, or fluids.
- Always check apical pulse for 1 full min!
- ACE inhibitors: enalapril(vasotec),Captopril(Capoten)
- SE: decrease BP,kidney problems,dry cough
- action:they blockaldosterone.
- lasix: to decrease volume
nutrition for HF pediatric client
- Well rested prior to eating.
- Feed when they wake up or show signs of hunger
- decrease cryiing-uses up energy.
- Small frequent feedings every 3 hrs no longer than 30 min
- High calories
- Soft nipple with large opening so baby won't have to suck hard
- May require gavage feedings
- usually dont require sodium and water restrictions because of decreased intake.
Acquired cardiac disease
- Rheumatic fever:is an inflammatory disease that occurs after infection with group A beta hemolytic strep>carditis>TX: PCN G, if allergic then erythromycin.
- Kawasaki: characterized by widespread inflammation of the small and medium sized blood vessels. Coronary arteries are most susceptible.TX: high dose IV immune-globulin, aspirin therapy, quiet environment
Cleft palate/cleft lip
- alteration in nutrition
- Feed with elongated nipple or medicine dropper the side of the mouth.
- Burp frequently
Cleft lip repair
- position on back or side to protect suture line
- NO PRONE
- Clean suture line with saline post op.
cleft palate repair
- place prone to promote drainage
- avoid putting things in mouth(suture)
- Soft diet until well healed
- Speech defect are common
- if possible do procedure before speech development.
- Use elbow restraints.
- GER becomes GERD when complication such as failure to thrive, bleeding, or difficulty swallowing occurs.
- position up right with feeding and at night
- 30 degree elevated prone position to decrease reflux and improve stomach emptying
- feedings: small frequent of thickened formula
- breastfeeding continues with more frequent feedings or expressing milk for thickening with rice cereal.
- meds:H2 blockers, PPI
Esopahgeal atresia/T-E fistula
- causes:saliva cannot make it to the stomach because esophagus ends in a blind pouch.
- s/s:no meconium because they never swallowed amniotic fluid.
- Fed through gastromy tube
- T/E fistula watch for Coughin,choking, and cyanosis.*first feeding needs to be watched, potential for aspiration.
- tx:corrective surgery and infant is palce on back with head and shoulders elevated.
- Might see polyhydramnios in pregnancy with this. baby never swallows amniotic fluid so it build up.
- S/s:projectile vomit usually after eating
- very hungry
- olive like mass in epigastric region
- peristalisis is obvious
- Daily wts
- monitor specific gravity
- when a piece of bowel goes backwards inside itself forming an obstruction
- s/s:sudden onset
- abdominal pain
- drawing up of knees
- currant jelly stools
- dx/tx: the definitive diagnosis is through a BE and this will sometimes fix it teach signs and symptoms of recurrance
- congenital anomaly (aganglionic-no nerves and no peristalisis megacolon) that results in a mechanical obstruction along the bowel(sigmoid)
- abdominal distention
- ribbonlike stools that have a foul smell
- tx: remove portion of colon that is diseased
- may require 2 surgeries to give the intestines time to heal
- gentic intolerance to gluten
- No gluten(veggie proteins)
- Can't have BROW:
- CAN have: RCS
UTI in a child
- s/s:Failure to thrive
- feeding problems
- vomiting diarrhea
- Urine smells fishy
- FACTORS:renal anomalies,constipation, bubble baths, poor hygeine, pin worms, sexual abuse.)
- flank pain
- dx:properly collected specimen
- tx:antibiotic therapy PO or IV
Sickle cell disease:
- HGb is partly or completely replace with sickle shape hGb.
- exercise intolerance
- tx:bed rest
- blood transfusions
- This is cancer of the blood forming tissue and proliferation of immature WBC.
- Thrombocytopenia, anemic
- Two types: ALL(Acute Lymphoid leukemia) and AML(acute Myelogenous)
- Vague abdominal pain
- easily acquired infections
- found as a kidney mass
- Swelling or non tender mass on one abdomen.
- DON'T PALPATE!
- Gentle care while bathing or moving pt.
- disturbance of ventricular circulation of the cerebral spinal fluid in the brain.
- Increased of cranial pressure
- s/s: bulging of anterior fontanel.
- Dilated scalp veins
- depressed eyes
- irritability and changes in LOC.
- highpitched cry
- tx::insertion of VP(ventriculoperitoneal shunt): measure frontal occipital circumference
- Fontanel and cranial suture line assessment.
- Monitor the temperature
- Supine position(on back)
If a staff member is pulled to your floor treat them like?
a new nurse
As an RN never delegate...
- Initiating plan
- Admission history
Don't delegate what to LPN?
- unstable patients
what kind of patient can an nursing assistive personnel take?
5 rights of delegation
- right task
- right circumstances
- right person
- right direction
- right supervision and evaluation
What would you like to do?
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