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Benefits of Breastfeeding
prevent infections, earaches, respiratory distress, diarrhea, obesity, cancer, diabetes, save money
for mom: decreased postpartum hemorrhage, caner ovarian, heart disease, return to norm weight faster, increase effectiveness of immies.
Breastfeeding Reccommnedation AAP
at least 1 yr
WHO: exclusively for 6 months, then up to 2 yrs.
Contraindications of breastfeeding
- infant: gut issues
- Mom: HIV, herpes (active), drugs, meds consult med book
8-12 times a day
by day 4: 6-8 wet diapers
if lose >7% of weight-concern
Signs of infant hunger
- open mouth, rooting, such on hand, lip smacking
- cry: late sign of hunger
- goal: eat every 2-3 hours.
yellow, first 2-3 days of milk: immunity, laxative for meconium
transitional milk: both colustrm and reg milk
Reg milk: Beginning of feeding more water, end of feeding more fat.
- primary hormone responsible for lactation
- Note: estrogen and progesteron suppress lactation
- suckling increase prolactin levels=increase milk vol.
malnutrition: decrease fat content in milk .
chin to breast=child open wide
Breastfeeding Nutritional Needs
need extra 500 calores
Breast milk storage
- at room temp for 6-8 hrs
- refrigerator up to 5 days
- freezer 3-6 months
Breast feeding issues
Sore nipples: Pain, due to poor latch, poor position. Tx: use ointment
Mastitis: flu like symptoms, inflammation/infection due to bacteria through cracks
engorgement: plugged milk; firm, pain, tender TX: cold packs
- flu like symptoms, fever, malasie, unilateral breast pain
- inflammation/infection due to bacteria (S. aureus) through cracks
- wash hands before feeding
- Tx: antibiotic, compresses.
- Proper latch techniques and frequent emptying of the breasts will help prevent engorgement.
Signs of poor/good latch
- Poor Latch:
- unable to stay on
- pain by mom (some pain is normal)
- dimpling of babys cheek
- nipples flat, cracked, or blanched
- no milk content in babys mouth
- good latch:
- tongue cupped beneath breast,
- lips are out and relaxed
- cheeks are full
- regular rhythmic sucking
- position: nipple to nose then top of upper lip, mouth wide open, tongue down
suck:swallow: 1:1 or 2:1
assess physical and neuromuscular maturity of neonate.
determine gestational age.
Umbilical cord antiseptics for preventing sepsis and deathamong newborns
The cord stump dries and falls off within five to 15 days. Infection of the umbilical cord stump (omphalitis), caused by skin bacteria, is a significant cause of illness and death in newborn babies in developing countries.
There is significant evidence to suggest that topical application of chlorhexidine to umbilical cord reduces neonatal mortality and omphalitis in community and primary care settings in developing countries.
It may increase cord separation time however, there is no evidence that it increases risk of subsequent morbidity or infection.
There is insufficient evidence to support the application of an antiseptic to umbilical cord in hospital settings compared with dry cordcare in developed countries.
Transition to extrauterine life: Respiratory
- amniotic fluid removed from lungs
- cease placental blood flow-decrease oxygen-decreased pH (acidosis)-stimulate medulla for respiratory-stimulate respiration
- surfactant produced by lungs keep alveolar sacs partially open
30-60 per min is normal, 10 second pause is normal
bulb syringe: mouth first then nose, in mouth on sides
Transition to extrauterine life: Cardio
During fetal: ductus arteriosos, foramen ovale, ducturs venousus shunt most blood away from lungs and liver
at birth these shunts close=pulmonary vessels dilate.
apical 100-180, listen for 1 min due to irregularities
Transition to extrauterine life: Thermoregulation
- Heat loss: heat loss 4 times faster than adults. Brown fat (nonshivering thermogenesis)
- via convection (loss of body heat), radiation (transfer with objects), conduction ( transfer direct skin contact), evaporation
- Cold Stress:
- increase need for oxygen
- respiratory distress
- decrease surfactant production
- metabolic acidosis
Brown fat (Nonshivering Thermogenesis)
- oxidation of brown fat to produce heat
- located in neck, thorax, axillary
Neutral Thermal Environment (NTE)
environment maintain body temperature with minimal metabolic changes and/or oxygen consumption.
86.6-92.3 F (32-33.5 C)
- best source of heat: mothers chest
- reduce low body temp, illness, infections, breastfeeding difficulties, decrease hospital stay, etc.
Transition to extrauterine life: Hematological
Vitamin K: produced in intestine but need food and normal flora first, so give shot-prevent hemorrhagic disease
- Hematocrit: normal 48-69%
- >65% polychthemia
Metabolic: hypoglycemia is common during transition period. (40-60 is normal)
- >65% of hct
- increase risk for juandice, and damage to brain as results of blood stasis
indirect bilirubin: (nonwater soluable) produced from breakdown of red blood cells, converted to direct bilirubin (conjugated) (water soluble) by liver enzyme which can be excreted in urine and stool.
hyperbilirubinemia: (high levels of unconjugated bilirubin in blood due to immature liver, high red blood cells.
risk factors: hemolysis of excessive RBC, short RBC life, liver immature, lack intestinal flora
Adaptations to Extrauterine Life: GI
- Stomach: gastric capacity expands, gastrocolic reflex, cardiac sphincter-easy regurgitation
- stools: meconium, transitional, breast milk, formula
Types of Stools
- Meconium: green, black, thick, tar-like
- Transitional stool: green-brown, looser
- Breast milk stool: mustar color and consistency, seedy, sweet-sour smell
- Formula stool: pale-yellow to light-brown, firmer, feces smell
Meconium Aspiration Syndrome
- - fetus may pass meconium stool into the amniotic fluid due to relaxation of fetal anal sphincter.
- -due to stressful event: asphyxia, cord compression, intolerance to labor
- -Respiratory distress (obstruction, decreased surfactant, hemorrhagic pulmonary edema) , tachypnea, cyanosis, retractions, nasal flaring, grunting, rales, rhonchi, barrel-shaped chest.
- -stained amniotic fluid, skin discoloration
- Post term
- TX: artificial surfactant, initric oxide (helps absorb meconium),if still distress ECMO (oxygenates blood for them)
- 40-60 mb/dl is normal
- risk factors: prematurity, intrauterine growth restriction, small for gestational age, postmaturity, large for gestation age, maternal diabetes, infection, asphyxia, cold stress.
S&S: jittery, cyanosis, sweat, tachypnea, poor suck, apnea, low temp, dyspnea, irritable, lethargic
heel stick: on lateral pads
- visible when serum bilirubin levels =5-7mg/dl
- excessive RBC destruction
- within 24 hours- liver
- after 24 hours- unconjugated bilirubin
TX: phototherapy, protect eyes, turn every 2 hrs. Prevent kernicterus
Adaptations of Extrauterine life: urinary
- void with 12-24 hours
- 1-2 during first 2 days
- at least 6 voids by day 4
weight loss 5-10% of birth weight is normal
Period of reactivity
first period of reactivity: 15-30 min, alert and active, respirations irregular, vigorously respond to external stimuli, rapid HR, brief apnea.
Period of Sleep: 30min-2hrs, sleep, respiratory and HR decease, no response to stimuli
Second Period of Reactivity: 2-8hrs, vary alert and sleep, respiration and HR depends on activity and stimuli. may pass mecomium, increased bowel.
- at 1 and 5 minutes
- adaptation; 10 is best score (uncommon)
- respirations, crying
- reflex, irritability
- pulse, HR
- skin color, extremities
- muscle tone
Nursing Actions during 4th stage of labor
- keep warm, dry, put hat
- APGAR at 1, 5 minutes
- vital signs (if stable within 30 min, then 1 hr; unstable every 5-15 minutes)
- inspect cord for bleeding
- assessment within 2 hours
- gestational age assessment
- blood glucose
- Erythromyxin ophthalmic ointment
- Phytonadione IM
Erythromyxin ophthalmic ointment
for gonococcal or chlamydial eye infections
- cyanosis on feet and hands
- white cheesy substance on auxiliary and genital
- estimate gestational age
- fine, downy hair, decreases with age
- bluish discolored area on back, buttocks
- mistaken for bruises
- document size and location
- red rash macules an papules.
- white papules on face
under eyes, face
- transient pattern of pink and white blotches on skin
- response to cold environment
- one side of body pink, other white
- vasomotor instability
- elongation of fetal head as it adapts to birth canal
- resolved in 1 wk
- hematoma between periosteum and skull, unilateral swelling
- localized soft tissue edema of scalp
- pressure during labor
symmetrical deviation of the eyes when the head is moved in different positions, always returning to center
Epstein s Pearls
- white, pearl-like epithelial cysts on gum margins and palate
- usually benign but can be congenital defects
- often loose, remove due to aspiration
urethral opening is on the ventral surface of penis.
urethral opening is on the dorsal side of penis
- hip displacia
Newborn Reflexes: Moro
- hold baby, let head drop back
- response: c shape with thumb and index finger
- symmetrical abduction and extension of arms and legs and legs flex up against trunk.
also startle reflex
Newborn Reflexes: tonic Neck
- turn head to side so chin is over shoulder
- response: fencing
Newborn Reflexes: Rooting
- brush cheek near mouth
- response: turns toward direction of stimulus
may not response if recently fed
Newborn Reflexes: sucking
- place finger/nipple in mouth
- response: sucking motion
may not response if recently fed.
Newborn Reflexes: palmer grasp
- place finger in hand
- response: grasps finger
Newborn Reflexes: Plantar Grasp
- place thumb against ball of feet
- response: toes flex tightly down in grasping motiong
Newborn Reflexes: Babinski
- stroke lateral surface of sole upward
- response: hyperextension and fanning of toes
Newborn Reflexes: stepping
- hold neonate upright with feet touch surface
- response: steps with one foot up.
- early care
- erythromycin, tetracycline, silver nitrate
- prevent gonorrhea, chlamydia infections
- into conjunctival sacs
- early care
- aquamephyton, phytonadione
- prevent bleeding problems
- IM vastus lateralis
- keep clean and dry, wash with soap and water
- don't cover with diaper
- remove clamp at 24 hrs
- sponge bath until cord falls of (10-14 days)
- back to sleep
- remove soft bedding and stuffed animals
- avoid overheating
- avoid bed sharing
- breast milk and formula are 20kcal/oz
- don't need water
- formula feed every 3-4 hrs
- burp every 12 oz
Infant of Diabetic Mother
- Macrosomia (birth weight of 4000 grams or more)
- round face
- skin is red (plethoric)
- poor muscle tone
monitor blood glucose, respiratory distress, cold stress
Neonatal Abstinence Syndrome (NAS)
- meconium may be drug test
- signs of withdrawal start day 3
- Signs: irritable, jitter, rigid muscle tone, high pitch cry, minimal sleep, fever, sweat, yawn, sneeze, fever, tachypnea
- Interventions: feeding (frantic rooting and sucking, rest (dark room, swaddle, pacifier), bond
Health Disparities LGBT
- poor health:
- unequal access to health coverage
- lack of culturally competent health services
- scarcity of staff trained
- biological anatomy
- how you feel about your sex
- how you present feelings to the world
- who you are attracted to
- toward men-bisexual/pansexual-towards women
- physical action
- with men-with more than one gender-with women
Administering Subcutaneous Medication
- meds less than 1ml, sue TB syringe
- 90 or 45 degrees
- 5/8 inch needle, 23-25 gauge
- pinch subcutaneous tissue
- separate multiple by 1 inch
- location: tricep, in children anterolateral thigh
- what to administer: MMR, zoster, polio,
- Sites: deltoid, ventrogluteal site, vastus lateralis, baby on anterolateral thigh
- 90 degrees
- aspirate (unless vaccine)
- 1 inch apart if multiple
- What: DTaP, Hib, Hep A, Hep B, HPV, PCV, IPV
- needle 5/8 inch to 1 and 1 1/2 for adults
- 22-25 gague
Note: smaller number: bigger needle
- check compatibility
- insulin: air into cloudy first, then clear-draw up clear then cloudy
Administering Intradermal medication
- ventral surface of forearm
- 5-15 degrees into epidermis
- insert until bevel is covered (1/8 inch)
- wheal 1/4 inch
- mark circle
Psychosocial and psychological interventions to prevent postpartum depression
- Overall, psychosocial and psychological interventions signiﬁcantly reduce the number of women who develop postpartum depression.
- Promising interventions include the provision of intensive, professionally-based postpartum home visits, telephone-based peer support, and interpersonal psychotherapy
Postpartum Hemorrhage Prevention: uterine massage
- Uterine massage given every 10 minutes for 60 minutes after birth effectively reduced blood loss.
- downside: staff time and pain for woman
Teen Birth Rates Drop
- From 2007–2011, teen birth rates decreased 20% for non-Hispanic whites, 24% for blacks, 27% for American Indian/Alaska Natives (AI/AN), and 34% for Hispanics.
- However, in 2007, non-Hispanic black and Hispanic teen birth rates were more than two times higher than the rate for non-Hispanic white teens, and remained so in 2011.
Pelvic ﬂoor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women
Pelvic ﬂoor muscle training is commonly recommended both during pregnancy and after the birth to prevent and treat incontinence.
Involution of uterus
- uterus returns to pre-pregnant size, shape an location, placental site heals.
- uterine contraction and atrophy of the uterine muscle
- first five postpartum days
- related to the uterus working harder to remain contracted (prevent hemorrhage) and increase oxytocin
Tone of fundus
- firm (contracted) or soft (boggy)
- boggy- not contracted, at risk for blood loss= massage, give oxytocin per orders
position of uterus: if displaced can be because of distended bladder-risk for hemorrhage, have pt void
bloody discharge from uterus contains sloughed off necrotic tissue-healing of uterus
lochia rubba, lochia serosa, lochia alba
scant, light, moderate, heavy (pad soaked in one hour)
small clots normal, large report. both document size
Concerns: clot size large, clumps, foul smell, return to bright red (need progression)
- day 1-3
- bloody with small clots, bright red
- moderate to scant
- day 4-10
- yellow, pinkish
- increase in the vascular and lymphatic system of the breast, precedes initiation of milk production
- breast become large, firm, warm, tender
- resolves on own 24-48 hrs.
TX: heat, express milk or feed infant, bra. (if breast feeding, ice if not breast feeding)
sequent breast engorgement
Endocrine System Postpartal
- estrogen, progesterone, prolactin levels decrease.
- non-lactating: prolactin decrease
- lactating: prolactin increase.
Note: lactating-menses suppressed, ovulation suppressed
contraceptives no estrogen
- blood loss 500 mL (c section 800-1000)
- early ambulation: DVT
- at risk for thrombosis due to clotting factors
- risk orthostatic hypertension
- cardio postpartal
- assess for DVT
- A positive sign is present when there is pain in the calf on dorsiflexion of the patient's foot at the ankle while the knee is fully extended.
- chills, shaking for first few hours after deliver
- due to vascular instability
- at risk for constipation (decreased GI mobility, physical activity, fluid loss, perineal pain and trauma)
- weight loss
- chart if urinated during labor
- observe for bladder distention
- check for UTI
- if don't urinate within 12 hrs-catheter
- measure first 24 hrs.
- muscle soreness is normal- ice pack then heat
- diastatis recti abdominis
Diastasis Recti Abdominis
- separation of rectus muscle
- normal finding
- will diminish
- Rh -Rhogam
- Rubella (cant get pregnant)
- temperature greater than 100.4 after first 24 hrs may be infection
- common, first few weeks
- due to hormone level change, fatigue, stress
- S&S: anger, anxiety, mood swings, sad, cant eat or sleep.
- can lead PPD
- Breasts: engorgement, mastitis, nipples, latching
- Uterus: fundus
- Bowel Function: return to normal
- Bladder Function: void 6-8 hrs at least 150 mL
- Lochia: pooling, not complete pad in 1 hr
- Episiotomy/perineum: REEDA: redness, edema, ecchymosis, discharge, approximation
- Lower Extremeties: DVT, cap refills, pulses, need abulation
- Emotions: fatigue
Discharge Instructions Pospartal
- excessive lochia: smell, large clots, saturate pad in 1 hr
- fever higher 100.4
- frequent urination
- breast tender, warm, red
- chest pain, urination, signs of depression
- lasts 6-12 months
- risk: hx of depression, lack of support, poor relationship, stress
- S&S: lack sleep, uncontrolled cry, fear, anxiety, guild, inability to care for baby, decreased affection, thoughts of harming child, suicidal thoughts.
Cesarean Section check up
- 2 wks-suture removal then 8 weeks
- vaginal in 6 weeks.
- blood loss greater than 500 mL within first 24 and 1000ml for C-section
- causes: caused by uterine atony or a failure of the uterus to contract appropriately after delivery, lacerations, hematomas, retained placenta.
- intervention: for boggy uterus: massage.
- most common postpartum infection
- infection of endometrium, starts at placental site and spread to endometrium
Risk: prolonged rupture of membranes, prolonged labor, C section, PPH, group beta strep
S&S: fever, tachycardia, uterine tenderness, subinvolution, malaise, lochia heavy/foul, abd pain
CBC, cultures, urinalysis-antibiotic.
- cyclical states/altered consciousness
- decreased motor activity
promotes: increased metal performance (learn, memory), restore energy, improve ability cope, helps immune system
- milk to no activity
- relax, stress free
- feel refreshed
Factors affect sleep
- physical activity
- sleep habits
- environment (temp, noise, light, odor, bed)
Nursing interventions: offer foods promote sleep, safety, sleep hygiene, educate meds, clustered care, environment, promote comfort/relaxation, support bedtime routines.
sleeplessness, is a sleep disorder in which there is an inability to fall asleep or to stay asleep as long as desired.
Circadian rhythm sleep disorders are a family of sleep disorders affecting, among other things, the timing of sleep
Restless leg syndrome
Restless leg syndrome is a disorder in which there is an urge or need to move the legs to stop unpleasant sensations.
- Hypersomnia, or excessive sleepiness, is a condition in which a person has trouble staying awake during the day.
- People who have hypersomnia can fall asleep at any time.
sleep disorder characterized by pauses in breathing or instances of very low breathing during sleep
sleep disorder that causes excessive sleepiness and frequent daytime sleep attacks.
grind teeth at night
Stages of Labor
- 1st: onset of contraction (latent: <3cm, active 4-7cm 6-24 hrs, transition 8cm to complete 3-6 hrs)
- 2nd: dilation of cervix to birth of fetus (latent rest, labor down; active is pushing)
- 3rd: birth of fetus to delivery of placenta
- 4th: last about 2 hrs, bonding of baby.
- determine fetus location in the fundus
- determine location of fetal back
- presenting part
- location of cephalic prominence.
Nursing Support during labor
- emotional support
- information, coping techniques
- comfort (massage, warm baths, etc.)
position: during firs stage: upright , second stage upright (helps align fetus)
FHR monitoring: variability
- decreased when fetus is asleep
- decrease if hypoxia, acidosis
parasympathetic and sympathetic nervous system
Pelvic Sizes: Gynecoid
- Best, 50%
- inlet: round*
- mid: round*
- outlet: wide transverse AP diameter*
Pelvic Size: android
- inlet: heart shape*
- mid: short AP diameter
- outlet:short AP diameter
Pelvic Size: Anthropoid
- inlet: long AP diam*
- mid: round*
- outlet: narrow transverse
Pelvic Size: Platapoid
- inlet: wide transverse*
- mid: round, wide*
- outlet: wide transverse but short AP
Nursing Practice Framework
focus: health ecology/biomedical framework and person behaviors/environment
tx: person/environment: healing (hospital) to optimal self-reliance (shape health behaviors), coaching/guiding
Clinical Practice Knowing/Critical Thinking
- knowledge/skills: education, CE, observe
- Vulnerable (or resilient) person/systems
- Environment/context (exposure or risks/resources)
- clinical status: outcomes/result
- Review, meta-analysis, practice guidelines
Teaching Skills and Nursing Practice
- client/family need information to make decision
- shorter hospital stays, need more teaching for home care
- compliance and shortens hospital stay
- empower client/family
- who:teach client, family, peers, groups, students, new employees
- what: disease information, meds, procedures, prevention/promotion, clinical process.
- what: change in behavior/knowledge/skill/attitude; change due to stimuli; active process not just give information.
Teaching & Learning
- Teaching: interactive, planning and implementing
- effective communication- convey information, assess verbal and nonverbal feedback, accommodate learning styles.
Learning: change in behavior, knowledge, skills, attitudes
- time (free of pain, trust, enough time)
- context (environment)
- goal (engage, committed, include family, realistic)
- content (appropriate, reinforcement, learning level)
- method (learning style, ability to learn, strategies vary)
Three Domains of Learning
- Cognitive: thinking, storage/recall information
- Psychomotor: do, hands-on, think and do
- Affective: emotions, change feelings, beliefs, attitudes, values (influence how much is learned)
assess learning: needs, health beliefs, readiness, ability to learn, literacy level, ability to see, hear, etc., learning style, time, resources.
- readiness (physical and emotions)
- timing (open to learn)
- active involvement
- type of feedback given
- learning environment
- scheduling session
- amount/complexity of content
- special population
- developmental age
- group discussion
- one on one
- printed materials
- programmed instruction
- role play
- self instruction
- distance learning
- concept map
- tests/written exercises
- oral questions
- direct observation of performance
- client report
- client records
Components of a teaching Plan
- teaching strategies: method
- content: information to reach goal
- Schedule: organization
- Instructional Material: tools
- documentation: learning needs, objectives, topics, measurable outcomes, need for more teaching, referrals, resources provided.
- Rights: time (free of pain, trust, enough time)
- context (environment)
- goal (engage, committed, include family, realistic)
- content (appropriate, reinforcement, learning level)
- method (learning style, ability to learn, strategies vary)
Cultural Diversity, nurses need to know:
- how cultural groups understand life processes;
- how cultural groups define health and illness;
- what cultural groups do to maintain wellness;
- what cultural groups believe to be the causes of illness;
- how healers cure and care for members of cultural groups; and
- how the cultural background of the nurse influences the way in which care is delivered.
- what have in common
- behavior patterns, arts, beliefs, customs, lifestyles
process of learning to become a members of a society or a group
- immigrant assumes characterizes of that culture
- accept both new and old culture
identify with two cultural groups
multiple cultures influencing a person, community, society
belief own group is superior
Culturally Competent Care: Purnell and Paulanka
culture is learned, the totality of beliefs and practices that guide world view and decision making.
Culturally Competent Care: Leninger
understanding cultural commonalities and cultural diversities in order to provide competent care.
Culturally Competent Care: Campinha-Bacote
cultural competency as process, not an end point, evolve over time.
awareness, skills, knowledge, encounters, desire
- Be aware of your own culture
- Appreciate patients culture
- Learn more about patient culture
- Incorporate beliefs into care plan.
- young old: 60-74
- middle old: 75-84
- old-old/elite old: 75-100
- centenarians: over 100
- Geriatrics: study and health care of elderly
- Gerontology: branch of science aging and aging problems
stereotyping and discrimination against old
late adulthood, after 65
characteristics of old age
Life Span vs Life Expectancy
- life span: max (110-120)
- Life expectancy: men 72, women 79
Fact: 48% of all hospitalized patients are above 65 yrs.
- dependence on social security
- other: subsidized housing, food stamps, stocks, saving, life/house insurance, health insurance
Caring for Elderly
- disease accumulate and interact
- drugs accumulate and interact
- atypical response to disease/tx
- diminished physio reserve
- Focus on improved function not cure disease
- multiple losses impact physical/mental health
- multidisciplinary approach
decreased homeostasis, chronic illness
Definition: chronic illness
- leaves residual disability
- nonreversible pathological alterations
- requires special training for rehab
- requires long period of supervision, observation or care
arthritis, deformities, hypertension, hearing impairment, heart disease, cataracts
- don't understand reason for tx
- difficult procedures
- time, finances, side effects
- lack of support
older adult with one or more chronic illness who are functionally impaired most of the time
Geri Health Assessment
physical, mental, functional, social/economic, environment
- nutrition: deficiencies, diets high in fat, sugar: weight loss, albumin, anemia, muscle wasting, edema, poor wound healing
- cognition: safety
- GI: elimination
- Immune: less efficient thermoregulation
Newborn at risk: maternal factors
- age >16 or >35
- late/poor prenatal care
- multiple gestations
- low socioecon
- gravida, para
- pregnancy complications
Newborn risk: intrapartum factors
Intrapartum factors: HR abnormal, presentation, blood loss, rupture of membrane, fever, prolonged labor
Newborn risk: neonatal factors
- congenital anomalies
- gestational age
- SGA vs LGA
SGA (small for gestational age)
LGA (large for gestational age)
- birth trauma
- poor motor
- difficulty feeding
IDM (infant of diabetic mother)
Characteristics: macrosomia (>4000grams), round face (tomato), skin red (plethoric), poor muscle tone, irritable
problems: birth trauma, hypoglycemia, hypocalcaemia, hyperbilirubinemia, polycythemia, respiratory distress.
TX: monitor blood glucose, trauma, signs for respiratory distress, signs of cold stress
Post Term infant
Characteristics: dry, crack skin; no vernix or lanugo; longer fingernails; abundant hair; long thing; skin loose; meconium stain
induce at 40 wks
problems: trauma, hypothermia, hypoglycemia, polycythemia, MAS, PPHN, pneumonia, pneumothorax
- <37 weeks
- viable >24 weeks
complications: respiratory distress, thermoregulation, nutrition, cardio, metabolic, nuero, developmental
Beta mexidone to help lungs mature, steroid prior to delivery try to stop so lungs develop
Respiratory Distress Syndrome
- increases work 4-6 hrs
- grunt, flare, retracting (suprasternal, intercostal, sub sternal, subcostal)
- worsen in 48-72 hrs
complications: air leaks (leads to pneumothorax) infection, apnea, chronic lung disease
- TX: oxygen, CPAP if PaO2<40 or PaCO2>60,
- surfactant replacement,
- decreases surface tension
- decreases work for breathing
- decreases leaks (protein and water=edema)
- decreases atelectasis
- increases alveolar stability on expiration
Patent Ductus Arterious
ductus arterious remains open after birth
complications: CHF, chronic lung disease, renal failure, intraventicular hemorrhage
Assessment: heart murmur, apnea/bradycardia, bounding pulse
- preemies at high risk, RDS
- within 72 hrs
- grade 1-4, head ultrasound
- S&S: full or bulging fontanel, decreased BP, need oxygen
- interventions: keep warm and head midline
- Grade I: germinal matrix
- Grade II: inside ventricle
- Grade III: ventricle and enlarged by the blood
- Grade IV: into brain tissue
Neonatal Abstinence Syndrome (NAS)
- infant urine and meconium can be drug tested
- opiates withdrawal symptoms
- severe go to NICU
S&S: irritable, jittery, poor muscle tone, overactive moro, high pitched cry, fever, diaphoretic
Group B Streptococcal Disease
- cause meningitis and sepsis
- all women tested 37 weeks
Risk factors: hx, UTI, deliver before 37 wks, fever during labor, ROM prolonged, ROM before 37 wks
- early onset: vertical transmission
- late onset: horizontal (external to infant
must be legible, identify patient, support for dx, justify tx, document results, advice
needs to accurately reflect: nursing assessment, care, tx, and other services
- date/time, legible, grammatically correct, spelling
- objective, include quotes, abbreviation standards
- correct errors according to institutional policy
- conversation with family
- second hand information provide who
- don't alter record later, write addendum or late entry note
- don't point fingers
- follow up tx and responses to tx
Occur without medical or mechanical means, miscarriage.
Continue pregnancy, have bleeding. Intervention: bed rest.
Fragments retained, can cause infection. With medication cause cramps=release products of conception
fetus expires during first 20 wks, retained in uterus, do D&C
- Implant somewhere other than uterus, i.e. fallopian tubes.
- Salpingostomy (remove from tubes)
- Risk: pelvic inflammatory disease, anything scarring tubes
- S&S: vaginal bleeding, doubled over to one side.
- Villi fills with fluid, incomplete pregnancy (not viable). Genetic abnormalities.
- Hcg continues to rise, due ultra sound
- D & C, Rhogam.
DIC (disseminated intravascular coagulation)
- Syndrome body breaking down blood clots faster than it forms clots.
- Hemorrhage, can lead to maternal death. Delivery baby.
- Decrease uterine activity, induce labor, fluid balance, pain, FHR
Placenta attaches near cervical os (partial), or on. Causes bleeding
Risk factors: advanced maternal age, prior c section, smoke/drugs, pervious hx, uterine scaring, endometriosis, hx of induced abortion.
Cardinal Sign: bright red painless bleeding late in pregnancy. Bed rest.
Separation of placenta from its sight af implantation after 20 wks and before delivery. (Partial or complete)
Bleeding can be concealed or apparent.
S&S dark red bleeding, uterus is tender, abd stiff, dull ache that radiates, balling up in uterus.
Risk: drug, alcohol, smoke, hypertension, diabetes, advanced maternal age, abd trauma, abuse, mult pregnancy.
Hypoxia for fetus, cerebral palsy, death.
DIC for mom
PIH (pregnancy induced hypertension)
- At least two separate occasions of higher than 140/90 readings after 20 wks.
- 4-6 hrs apart.
- Resolves at least 12 wks postpartum.
- Monitor protein output in urine.
gestation hypertension (140/90) + proteinuria
Proteinuria: 24 hr urine: 300mg of protein or urine dipstick +1 or +2. HELLP
- Seizure activity with preeclampsia.
- Intervention: bed rest, deliver. S&S headache, epigastric pain, N & V
- Risk: first pregnancy, African, diabetic, advanced maternal age, multiple gestations.
- @ Risk for: stroke, DIC, placental abruption
HELLP(hemolysis, elevated liver enzymes and low platelets)
- Complications of severe preeclampsia
- Hemolysis: red blood cells destruct as travel through vessels
- Elevated liver enzymes: from decreased blood flow and damage to liver
- Low platelets: platelets aggregating at the site of damaged vascular endothelium
Gestational diabetes Mellitus:
- Test at 24 and 28 wks gestation.
- Oral glucose test.
- Positive 130 or 140
- Risk: maternal obesity, advanced maternal age, African, previous hx, macrosomic baby, family history.
- Baby @ risk for: hypocalcemia, hyperbilirubin, respiratory distress. (monitor fetal nonstress test, Biophysical Profile)
Premature Rupture of Membranes (PROM)
Rupture of membrane one hour before onset of labor
Preterm premature rupture of membranes (PPROM)
- before 37 weeks.
- give med that softens cervix (sevadil)=labor
- risks for: infection, preterm labor/birth,
- labor after 20 weeks, but before 37 weeks
- Risk: infection, dehydration, PPROM, substance abuse, uterine bleeding, diabetes, preeclampsia.
- Dx: 4 contractions in 20 minutes or 8 contractions in 60 minutes. with progressive change in cervix (increase of more than 1 cm and efface 80%)
Cesarean Birth (C Section)
- deliver through abdominal wall via incision.
- increased hospital stay, longer recover, increased pain, negative emotions response.
- Complications after: hemorrhage, DVT, PE, paralytic ileus, hematuria, infections
- assess or involution, fundus, lochia, incision care.
- an inflammation of a blood vessel wall with subsequent blood clot formation, especially in the lower extremities and the pelvis.
- risk factors are of greater concern: patients with existing varicose veins; clotting disorders; C-section delivery; DM II; advanced maternal age; smoking; obesity; prolonged sitting or standing.
- Interventions: signs of blood clot (presence of an area that is hot, red, painful, edematous). Elevation of affected limb is an appropriate intervention.
- the state of being without, or the absence of someone or something to which the person is attached or value
- loss person, thing, relationship, situation.
- ourward, social expression of loss.
- influenced by culture
physical, emotion, cognitive, and behavioral reactions
tight chest, palpitations, GI disturbance, lack energy, weight gain/loss, shakes
numbness, sad, fear, anger, anxiety, despair, empty, shame, etc.
disbelief, confusion, inability to concentrate
carry reminders, over-reactivity, changed relationships, impaired work, crying.
- grief before a loss or fear of potential loss.
- help prepare
- living will, etc.
- can be misinterpreted.
encountered when a loss cannot be openly acknowledged, socially sanctioned
- normal grief, but reactions intensify and prolonged
- interfere with physical, social, pysch function.
reactions don't subside but instead continue over long period of time.
reactions are suppressed/postponed
survivor resorts to self-destructive behaviors i.e. suicide.
survivor is unaware that behaviors that are interfering with normal functioning are a result of a loss.
depends on developmental age.
signs: nervousness, rages, sick, accident, antisocial, rebel, nightmares, depression,
Nursing Interventions for grief
- listen, touch,
- let them tell you, encourage reflection
- identify feelings
- normalize grief
- identify support systems
- provide spiritual support
Theories of Aging
- Biological (change in body: genetic, free radicals, immunity, neuroendocrine, organs) helps nurse understand how body change, plan care to decrease vulnerability to stress/disease (health promotion/prevention)
- Sociological: disengagement, activity, continuity; gain insight how pt responds to illness, plan activities and teaching
- Psychological: human needs. understand pt, where they are coming from.
- Physio: Brain: neurotransmitters decrease, bran cells loses, neurons reduce size.
- Intelligence: crystal maintained (acquired knowledge-wisdom), fluid-gradual decrease (emotions, created, spatial, nonintellectual information), pychomotor decline
- learning: slower at processing information
- attention span: decreased
Nursing action in aging population
- time for response: 19 seconds
- memory: lists, post it notes
- promote/support health
- decrease anxiety, depression
- acute confusion (temporary, reversible)
- risk: >80 years old, infection, dehydration, fracture, electrolyte imbalance.
- alters LOC
- appears as dementia
- medication induced, psychotic conditions
- progressive impairment in cognitive function (memory, orientation, judgment, reasoning, attention, language and problem solving)
- decline in 2 or more acquired intellectual functions
- stable LOC.
- chronic, permanent
most common: Alzheimer's disease
- most common form of dementia
- irreversible decline in: memory, performance of routine tasks, time/space orientation, communication, abstract thinking, ability to learn
- atrophy of brain with neurotic plaques
- disturbances in neurotransmitters Actylcholine, serotonin (sleep pattern)
death due to patient noncompliance in meds, malnutrition, etc.
- down syndrome
- genetic link?
- dx: autopsy or biopsy, clock test
Dementia Nursing Management
- safety: child proof, but respect patient
- no restriction, but safety
- decrease stimuli
- don't argue
- watch for discomfort
- protect individuality, independence
- Physical: physical pain/injury, restraint
- Sexual: non-consensual sexual contact
- Psychological/Emotion: mental pain, distress through verbal and nonverbal acts
- Material/Financial Abuse: improper use of funds
- failure or refusal to fulfill any part of a person's obligations or duties to an elderly person
- active: intentional failure to care
- passive: unintentional
- self neglect: own behavior threatens then
desertion of elderly by an individual who has physical custody of the elder or who has assumed responsibility for their care.