Pediatric Bench Marks Birth wt doubles at 6 months and triples at 12 months Birth length increases by 50% at 12 months and

nd doubles at 4 years Post fontanel closes by 8 wks Ant fontanel closes by 12-18 months Moro reflex disappears at 4 months Steady head control achieved at 4 months Turns over at 5-6 months Hand to hand transfers at 7 months Sits unsupported at 8 months Crawls at 10 months Walks at 10-12 months Cooing at 2 months Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo Mama, Dada + a few words at 9-12 months Throws a ball overhand at 18 months Daytime toilet training at 18 mo - 2 years 2-3 word sentences at 2 years 50% of adult Ht at 2 years Birth Length doubles at 4 years Uses scissors at 4 years Ties shoes at 5 years Girls growth spurt as early at 10 years Boys catch up ~ Age 14 Girls finish growing at ~15 Boys ~ 17 NORMAL CHILD VALUES ACCORING TO AGE **** Age Pulse Respirations Nursing Implications Newborn 100-160 30-60 These ranges are 1-11 months 100-150 25-35 averages only & vary 1-3 years (toddler) 80-130 20-30 with age, sex, and 3-5 years (preschooler) 80-120 20-25 condition of the child. 6-10 years (school 70-110 18-20 Always note whether age) 60-90 16-20 the child is crying, 10-16 years (HR in children febrile, or in some (adolescent) increases with distress crying or if the child has a fever) Age Appropriate Toys Infants birth to 1 year (solitary play) Mobiles Rattles Squeaking toys Picture books Balls Colored blocks Toddlers (1-3 years) (parallel play) Boards and mallets Push-pull toys Toy phones Stuffed animals Story books with pictures Preschoolers (3-6 years) (associative play)

Erickson Psycho-Social Development 0-1 yr (Newborn) Trust vs. Mistrust 1-3 yrs (Toddler) Autonomy vs. Doubt and Shame Fear intrusive procedures - Security objects good (Blankies, stuffed animals) 3-6 yrs (Pre-school) Initiative vs. Guilt Fear mutilation Band-Aids good 6-12 yrs (School Age) Industry vs. Inferiority Games good, Peers important Fear loss of control of their bodies 12-19 yrs (Adolescent) Identity vs. Role Confusion Fear Body Image Distortion 20-35 yrs (Early Adulthood) Intimacy vs. Isolation 35-65 yrs (Middle Adulthood) Generativity vs. Stagnation Over 65 (Older Adulthood) Integrity vs. Despair Piaget Cognitive Development Sensorimotor Stage (0-2) Learns about reality and object permanence Preoperational Stage (2-7) Concrete thinking Concrete Operational Stage (7-11) Abstract thinking Formal Operational Stage (11-adult) Abstract and logical thinking Freud Psycho-Sexual Development Oral Stage (Birth -1 year) Self gratification, Id is in control and running wild Anal Stage (1-3) Control and pleasure wrt retention and pooping Toilet training in this stage Phallic Stage (3-6) Pleasure with genitals, Oedipus complex, SuperEgo develops Latency Stage (6-12) Sex urges channeled to culturally acceptable level, Growth of Ego Genital Stage (12 up) Gratification and satisfying sexual relations, Ego rules Kohlberg Moral Development Moral development is sequential but people do not aromatically go from one stage to the next as they mature Level 1 = Pre-conventional Reward vs. Punishment Orientation Level 2 = Conventional Morality Conforms to rules to please others Level 3 = Post- Conventional Rights, Principles and Conscience (Best for All is a concern) Bench Marks Birth wt doubles at 6 months and triples at 12 months Birth length increases by 50% at 12 months and doubles at 4 years Post fontanel closes by 8 wks Ant fontanel closes by 12-18 months Moro reflex disappears at 4 months Steady head control achieved at 4 months Turns over at 5-6 months Hand to hand transfers at 7 months Sits unsupported at 8 months Crawls at 10 months Walks at 10-12 months Cooing at 2 months Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo Mama, Dada + a few words at 9-12 months Throws a ball overhand at 18 months Daytime toilet training at 18 mo - 2 years 2-3 word sentences at 2 years 50% of adult Ht at 2 years Birth Length doubles at 4 years Uses scissors at 4 years Ties shoes at 5 years Girls growth spurt as early at 10 years Boys catch up ~ Age 14 Girls finish growing at ~15 Boys ~ 17

Nursing implications for toddlers (1-3 years) Temper tantrums are common and normal behavior Give simple brief instructions of procedures Forced separation from parents is their biggest threat Security or transitional objects should be encouraged Expect regression (bed wetting) Autonomy should be provided with choices Nursing implications for the preschool child (3-6 years) Child stands erect with a more slender posture Thinking is egocentric & concrete A child learns sexual identity and masturbation is normal Imaginary playmates & fears are common Explain the child did not cause the illness and painful procedures are not punishments Therapeutic medical play with the equipment They need to be prepared for procedures and understand what is going to be fixed Pictures and dolls can be used Nursing implications for the school age child (6-12) Maintaining school activities and social relationships with peers is important They learn by verbal explanations, pictures, books, and handling equipment Privacy & modesty are important and should be maintained Nursing implications for the adolescent (12-19 years) They can problem solve & use abstract thinking Time when they form their own identity Rebelling against the family is common Teaching should include time with out the parents & if parents are present all questions should be directed toward the adolescent The age for making own medical decisions ranges from 7-14 years The major concern is body changing and any procedure that will alter their appearances Age Appropriate Toys Infants birth to 1 year (solitary play) Mobiles Rattles Squeaking toys Picture books Balls Colored blocks Toddlers (1-3 years) (parallel play) Boards and mallets Push-pull toys Toy phones Stuffed animals Story books with pictures Preschoolers (3-6 years) (associative play) Coloring books Puzzles Cutting and pasting Dolls Building blocks Clay

School Age (6-12 years) (corporative play) Board & card games Hobbies and/or video games Puzzles Immunizations (Hector Rayes did have pretty popular muscles varying high /school ) Hep B (3) o Contraindicated in persons with anaphylaxis to backers yeast RV Rotovirus (3) o IS a LIVE vaccine o Most common cause for diarrhea in infants & children Dtap (diphtheria, tentanus, pertussis (5) o Administer separate site o Not given to kids past there 7th birthday o Contraindicated in kids with seizures or encephalopathy HIB Hameophilus Influenza type B (4) o Protects against epiglotitis, bacterial meningitis, & septic arthritis o Given IM o No contraindications PCN Pneumococal (4) o Used to protect against disease caused by bacteria, streptococcus IPV Inactivated polio virus (4) o (OPV) Oral polio vaccine is a live vaccine that was given in 2000, OPV can not be given to kids with HIV o IPV is a dead vaccine o Given sub-q or IM in a separate site o Contraindicated in people with an allergy to neomycin or streptomycin MMR Measles, mumps, rubella (2) o Contraindicated in those allergic to eggs, neomycin, have immunodefiencies, or pregnant o Is a LIVE vaccine o Can be given to people with HIV & breast feeding mothers o Only injection Given Sub-q not IM o Child may develop a rash 2 weeks after administration Varicella (2) o Protects against chicken-pox o Can not be given in children with HIV o Give MMR & varcella on the same day or within 30 days but in separate sites Hep A (2) Tdap (x1 q 10 years , between 11-12) HPV (between 11-12) adminster the 2nd dose 1-2 months after the 1st & the 3rd dose 6 months after the 1st MCV4 Meningococcal (between 11-12) Influenza (IIV;LAIV) Flu- is given at 6 months of age then annually o Is a LIVE vaccine o Contraindicated in persons with an allergy to eggs The common cold is NOT an contraindication for immunizations Avoid Live Virus vaccines while taking prednisone (MMR, Flu, Varicella, RV Rotavirus, & Oral Polio Vaccine, Poliovirus the IPV is a dead vaccine) Hepatitis Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B=Blood and Bodily fluids Hepatitis C is just like B

Immunization Chart
Vaccines HEP B RV ROTAVIRUS Dtap HIB PCV13 PNEUMOCCAL IPV INACTIVATED POLIO VIRUS MMR Varicella (VAR) HEP A AGES Birth 2 months 2 months 2 months 2 months 2 months 1-2 months 4 months 4 months 4 months 4 months 4 months 6-18 months 6 months 6 months 6 months 6 months 6-18 months 15-18 months 12-15 months 12-15 months 4-6 years 4-6 years Total Amount 3 3 5 4 4 4

12-15 months 12-15 months 12-23 < 6 months later

4-6 years 4-6 years

2 2 2

Immunization Side Effects T < 102, redness and soreness at injection site for 3 days give Tylenol and bike pedal legs (passively) for child.

Child Nutrition Assessment Nutrient Signs of Deficiency Iron Anemia Pale conjunctiva Pale skin color Atrophy of papillae on tongue Brittle, rigid, spoon like nails Thyroid edema Vitamin B2 (Riboflavin) Redness & fissuring of eyelid coroners; burning itching, tearing eyes, photophobia Magenta-colored tongue, glossitis Seborrheic dermatitis, delayed wound healing Dry, rough skin Dull, soft, cornea. Bitot spots Night blindness Defective tooth enamel Retarded growth Impaired bone formation Decreased thyroxine formation Scurvy Receding, bleeding gums Dry rough skin, petechie Decreased wound healing Increase susceptibility to infection Irritability, anorexia, apprehension Scaly dermatitis Weight loss Anemia Irritability Convulsions Peripheral neuritis

Vitamin A (Retinol)

Vitamin C (Ascorbic Acid)

Food Sources Iron-fortified formula Infant high-protein cereal Infant rice cereal Liver Beef Pork Eggs Prepared infant formula Liver Cows milk Cheddar cheese Some green leafy vegetables (broccoli, green beans, spinach) Enriched cereals Liver Sweet potatoes Carrots Spinach Peaches Apricots Strawberries Oranges and orange juice Tomatoes Broccoli Cabbage Cauliflower Spinach Meats, liver chicken Cereals (wheat & corn) Yeast & Soybeans Peanuts Tuna Bananas

Vitamin B6 (Pyridoxine)

Communicable diseases in children 1. Rubella (measles) Airborne precautions (private negative pressure room, need N95 mask) Children with Rubella = threat to unborn siblings (may require temporary isolation from Mom during pregnancy) Contagious viral disease that can lead to neological problems Transmitted by direct contact with infected persons Symptoms o Photophobia o Koplik spots on the buccal mucosa o Confluent rash that begins on the face and spreads downward 2. Varicella (chicken pox) CHICKEN POX Vesicular Rash (central to distal) dew drop on rose petal Airborne precautions NORMAL CHILD VALUES ACCORING TO AGE **** Age Pulse Respirations Nursing Implications Newborn 100-160 30-60 These ranges are averages 1-11 months 100-150 25-35 only & vary with age, sex, 1-3 years (toddler) 80-130 20-30 and condition of the child. 3-5 years (preschooler) 80-120 20-25 Always note whether the 6-10 years (school age) 70-110 18-20 child is crying, febrile, or 10-16 years (adolescent) 60-90 16-20 in some distress (HR in children increases with crying or if the child has a fever) Diarrhea and dehydration usually occurs in infants history of exposure to pathogens contaminated food or dietary changes Signs and symptoms of dehydration poor skin turgor absence of tears dry mucous membranes weight loss of 5% to 15% depressed fontanelles decrease urinary output with increase specific gravity Loss or low potassium & sodium levels elevated hematocrit (HCT) & BUN Nursing interventions do not take temperatures rectally check stools for pH, glucose, & blood oral rehydration solutions such as Pedialyte or Lytren children should not receive antidiarrheals (Imodium A-D) do not give the child grape juice, orange juice, apple juice, cola, or ginger ale. These solutions have high osmolarity Signs and symptoms of shock decrease blood pressure rapid weak pulse mottled to gray skin color changes in mental status Fluids are given to a child with an increases respiratory rate to prevent dehydration & acid-base imbalances

Burns In children the greater central body surface area is concentrated in the head & trunk. Therefore a young child is more likely to have more serious effects from burns to the head & trunk. Children have a greater fluid volume (proportionate to size) less effective cardiovascular responses to fluid volume shifts to estimate the percent of Burns and a child the Lund-Brower chart should be used to account for the changing proportions of the child the Parkland formula is a commonly used guideline for calculating fluid replacement and maintenance o 4 x Weight in kg x %BSA burned Then divided by 2 so half of the amount of fluid is given in the 1st 8 hours the rest is given over 16 Adequacy Of Fluid Replacement Is Determined By Evaluating Urine Output o Urine output for infants and children should be 1 to 2ml/kg/hr**** o Normal Specific Gravity Of Urine is 1.005 to 1.030 o SG is a measurement of hydration status over hydration - will have a low specific gravity and means the urine is more dilute dehydration- will have a higher specific gravity and means their urine is more concentrated Poisoning use of IPECAC is no longer recommended by the AAOP induce vomiting is not recommended because it may cause more damage poison removal may require o gastric lavage o activated charcoal o Naloxone HVL (Narcan) Tylenol poisoning/overdose liver failure possible for about 4 days. Close observation required during this time-frame, as well as tx with Mucomyst.**** Respiratory disorders Signs of Respiratory Distress in Children ***** 1. Cardinal Signs a. Restlessness b. Increased respiratory rate (tachypnea) c. Increased pulse rate (tachycardia) d. Diaphoresis 2. Other signs of respiratory distress a. Flaring nostrils Retractions b. Retractions Grunting c. Adventitious breath sounds (or absent breath sounds) i. Discontinuous sounds 1. Fine Crackles- are soft, high pitched, & brief 2. Course Crackles (rales) - are louder, lower pitched, and longer ii. Continuous Sounds 1. Wheezes- High pitched, (asthma is wheezing on EXPIRATION) become concerned when the wheezing child stops wheezing 2. Ronchi- low pitched snoring sound d. Use of accessory muscles, head bobbing e. Alterations in blood gasses: decreased PO2, elevated Pco2 Primary meds for ER for respiratory distress Sus-phrine (Epinephrine HCl) Theophylline (Theo-dur) Bronchodilators

Types of respiratory disorders in this unit Asthma Bronchiolitis (RSV) Cystic Fibrosis Otitis Media Epiglottitis Tonsillitis 1. Asthma- inflammatory reactive airway disease that is commonly chronic The airways become edematous the airways become congested with mucus the smooth muscle of the bronchi & bronchioles constrict air trapping occurs in the alveoli Signs and symptoms Tight nonproductive cough Breath sounds: coarse expiratory wheezing, rales. Crackles Chest diameter enlarges Watch out if your wheezer stops wheezing. It could mean he is worsening. If the patient with as Asthma has intercostal retractions--be concerned Treatments When using a bronchodilator (such as Albuterol, Singulair, Theophylline) inhaler inconjuction with a glucocorticoid inhaler (Flovent, Qvar,) administer the bronchodilator first Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and Dilantin INtal, an inhaler used to treat allergy induced asthma may cause bronchospasm, think INto the asthmatic lung 2. Cystic fibrosis (CF) Group B Strep (GBS) bacteria GBS is found in the vagina and/or lower intestines. It usually causes no symptoms and is not harmful to adults. If a pregnant woman has a positive GBS culture, she can transfer the bacteria to her baby during childbirth, increasing risk for CF CF is an autosomal recessive disease that causes dysfunction of the exocrine glands provided to the child by each parent Signs and symptoms o The first sign of cystic fibrosis may be meconium ileus at birth. Baby is inconsolable, do not eat, not passing meconium. o Recurrent respiratory infections o pulmonary congestion o Steatorrhea excessive fatty greasy stools, foul-smelling and bulky stools o Diagnosed with a sweat test Cystic Fibrosis give diet moderate to high fat, high in calories, high protein, moderate to low carbohydrates Fat soluble vitamins ADEK. Aerosal bronchodilators, Skin Tastes Salty = Cystic Fibrosis Administer pancreatic enzymes with meals (Pancrease, Cotazyme-s) 3. Epiglottitis ** Caused by: H. influenza B Signs and symptoms Child sits upright with chin out and tongue protruding (maybe Tripod position) Prepare for intubation or trach Restlessness & high fever sore throat dysphagia -difficulty swallowing drooling with a muffled voice DO NOT put anything into kids mouth, never examine the throat of a child with epiglottitis because of the risk of obstructing the airway completely

4. Otitis Media increases chances for conductive hearing loss later in life Signs and symptoms o fever and pain o infant may be pulling at the ear o enlarged lymph nodes o discharge from the ear (if the drum is ruptured) o upper respiratory symptoms o vomiting diarrhea Nursing Interventions o Pull pinna down and back for kids < 3 yrs. when instilling eardrops.dminister antibiotics is prescribed o reduce body temperature (fever can go so high it places the child at risk for seizures) Tepid baths Acetaminophen (Tylenol) o position the child on the affected side o provide comfort with warm compress on the affected ear 5. TonsillitisCause: usually Strep Important to know if this was caused by Strep because the patient is at greater risk for developing 1. Glomerulonephritis 2. Rheumatic heart disease/ Rheumatic fever Interventions Get PT and PTT Pre-Op (ask about Hx of bleeding) No red liquids & no straws Post-op, Ice collar, soft foods Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs) Suspect Bleeding Post-Op if frequent o Swallowing o Vomiting blood o Clearing throat No red liquids, no straws, use ice collar for pain and comfort, and only eat soft foods Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs) 6. Bronchiolitis Cause Respiratory syncytial virus (RSV) Isolate RSV patient with Contact Precautions Private room is best Use Mist Tent to provide O2 and Ribavirin Flood tent with O2 first and wipe down inside of tent periodically so you can see patient No contact lenses or pregnant nurses in rooms where ribavirin is being administered by hoot, tent, etc Cardiovascular Disorders 1. Acyanotic = VSD (ventricular septal defect), ASD (atrial septal defect) , PDA (patent ductus arteriosus) Coarc of Aorta, AS Aortic Stenosis left to right shunts or increase pulmonary blood flow obstructive defects Has abnormal circulation however all blood entering the systemic circulation is oxygenated Antiprostaglandins cause closure of PDA (aorta - pulmonary artery) Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) Polycythemia (increased amounts of hemoglobin) is common in Cyanotic disorders right to left shunts or decrease pulmonary blood flow with mixed blood flow has abnormal circulation with unoxygenated blood entering the systemic circulation 3 Ts of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)

Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) Polycythemia (increased amounts of hemoglobin) is common in Cyanotic disorders right to left shunts or decrease pulmonary blood flow mixed blood flow has abnormal circulation with unoxygenated blood entering the systemic circulation 3 Ts of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition) Tetralogy of Fallot Unoxygenated blood pumped into aorta, consists of 4 defects Pulmonary Stenosis VSD Overiding Aorta Right Ventricular Hypertrophy TET Spells Hypoxic episodes that are relieved by squatting or knee chest position. They also can be treated
with morphine.

Congestive Heart Failure (CHF) can result Use Digoxin Therapeutic range = 0.8-2.0 for kids********* Given on empty stomach one hour before meals or two hours after, do not mix digoxin with food or formula You better pick do vitals before administering that dig. (apical pulse for one full minute). Signs and symptoms of early Digoxin toxicity Nausea Vomiting other G.I. symptoms including anorexia, diarrhea, abdominal pain neurological signs including fatigue, muscle weakness, and drowsiness Hypokalemia- can increase digoxin toxicity provide a diet low in sodium Aortic Stenosis- abnormal narrowing immediately before or after they aortic valve Ductus Arteriosus = Abnormal opening from the Aorta to the Pulmonary Artery Rheumatic Fever Cause: Group-a beta hemolytic strep infection Most common cause of Acquired Heart Disease It Affects: the aortic and mitral valves Signs and Symptoms Fever Chorea is part of this sickness (grimacing, sudden body movements, etc.) and it embarrasses kids. Elevated antistreptolysin O (ASO) & ESR to be elevated. Erythema Marginatum = Rash Chest pain, shortness of breath, (carditis) Tachycardia even during sleep Migatory large-joint pains Treatment of Rheumatic Fever with Penicillin G = Prophylaxis for recurrence of RF Aspirin for anti-inflammatory and anticoagulant actions Kawasaki Disease Coronary artery aneurysms due to the inflammation of blood vessels. Cause of the disease is unknown usually seen in children younger than five has three phases the acute, subacute, convalescent early treatment is essential to decrease chances of permanent or damage extreme irritability is seen in the child during the entire disease process

Acute Phase: high fever or for more than five days conjunctival redness with the strawberry tongue read swollen hands and feet Subacute Phase pealing of the hands and feet Convalescnet Phase starts when all the signs are gone and ends when lab values have returned to normal Treatment administer intravenous immunoglobulin (IVIG) treat high fevers with acetaminophen and aspirin monitor cardiac status by documenting the childs 1. intake and output 2. daily weights minimize skin discomfort with lotions and cool compresses initiate meticulous mouth care monitor the intake of clear liquids and soft foods Neuromuscsular Disorders Down Syndrome Trisomy or translocation of chromosome 21 Physical characteristics o flat broad nasal bridge o inner epicanthal eye folds o upward outward slant of the eyes o protruding tongue o short neck o transverse Palmer crease (sinmian) o hyperexpendable and lacks joints (hypotonia) Common associated problems o cardiac effects o respiratory infections o feeding difficulties o delay developmental skills o mental retardation o skeletal defects o altered immune function o endocrine dysfunction Cerebral Palsy (CP) nonprogressive injury to the motor centers of the brain causing neuromuscular problems of spasticity or dyskinsia (involuntary movements) Causes 1. anoxic injury before during or after birth 2. maternal infections 3. kernicterus 4. low birth weight (major risk factor) Signs & Symptoms persistent neonatal reflexes (moro, tonic neck) after six months delayed developmental milestones and apparent early preference for one hand poor suck, tongue thrust, spasticity scissoring of legs (legs are extended and crossed over each other, & feet are plantar flexed)

Spina Bifida Meningocele- a sac that is present at some point along the spine that contains only meninges and spinal fluid that has less neurologic involvement than a myelomeningocele Myelomeningocele is more severe than a meningocele because a sac contains spinal fluid, meninges, and nerves. Every child with a history of spina bifida should be screened for latex allergy (mainly fruits) o Fruits (and seeds) involved in this syndrome include banana, pineapple, avocado, chestnut, kiwi fruit, mango, passionfruit, fig, strawberry, soy, Potato, Tomato, Pineapple, Papaya, Eggplant, Melon, Wheat, and Cherimoya Nursing interventions Keep the sac free from urine and stool cover the sac with moist sterile dressing Place the child in the Prone Position to keep pressure off the sac Hydrocephalus- abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain causing An increase in intracranial pressure (ICP). **Signs and symptoms of increased ICP are the direct OPPOSITE from SHOCK ** Signs and symptoms of hydrocephalus or increased ICP (Cushings Triad) 1. Decreased pulse rate (bradycardia) 2. Decreased respiratory rate (Bradypnea) 3. Increased blood pressure (hypertension) Signs and symptoms of Shock 1. Increased heart rate (tachycardia) 2. Increased respiratory rate (Tachypnea) 3. Decreased blood pressure (hypotension) Remember the O in shOck stands for Hypotension Other symptoms of Hydrocephalus or increased ICP in CHILDREN 1. change in level of consciousness (LOC) = most important indicator of increased ICP 2. irritability 3. vomiting 4. headache on awakening 5. motor dysfunction 6. unequal pupil response 7. seizures 8. widened pulse pressure 9. Bossing sign (prominent forehead) 10. Even subtle changes in mood, behavior, restlessness, irritability, decline in academics, changes in personality or confusion may indicate increased ICP 11. Watch for CSF leaks from nose or ears Leakage can lead to meningitis and mask intracranial injury since usual increased ICP symptoms may be absent. Other symptoms of Hydrocephalus or increased ICP in INFANTS 1. irritability, lethargy 2. increased head circumference 3. bulging fontanels 4. widening suture lines 5. sunset eyes 6. high-pitched cry Nursing interventions for Increased ICP 1. monitor for further signs of IICP 2. maintain seizure precautions 3. elevate head of bed Treatment: Peritoneal Shunt

1. Shunt is inserted into ventricle 2. Tubing is tunneled through skin to peritoneum where it drains excess CSF Postoperative Care 1. After the shunt is placed- bed position for the patient is FLAT, so that fluid does not reduce too rapidly. Only if you see S&S of increasing ICP does the head of the bed become elevated to 15-30 degrees 2. Assess for signs of shunt malfunction but DONT pump the shunt, that can put pressure on the ventricles a. Infants: 1. change in size, signs of bulging, tenseness in fontanels, & separation of suture lines 2. irritability, lethargy, or seizure activity 3. altered VS and feeding behavior b. Older children: increased ICP 1. changes in LOC (#1 most important sign of IICP) 2. headache 3. changes in customary behavior (sleep or developmental capabilities) Family Teaching 1. Teach to watch for signs of increased ICP 2. Note the child will outgrow the shunt and will need a revision, the child may shows signs of increased ICP when he/she is beginning to outgrow it. Advise the pt to bring the child in when this occurs. 3. provide anticipatory guidance for potential problems with growth & development Other signs of Shock Mental Status o Early Shock- restless, hyperalert o Late Shock- decreased alertness, lethargy, coma Skin Changes o Cool, clammy skin o Diaphoresis o Paleness Fluid status Changes o Urine output decreases, or an imbalance between I&O occurs o Central venous pressure is abnormal o A urine specific gravity > 1.020 indicates hypovolemia Shock- widespread serious reduction of tissue perfusion (lack of O2 & nutrients) Those at risk for the development of shock 1. very young & very old 2. post-MI clients 3. Clients with severe dysrhythmias 4. Clients with adrenocortical dysfunction 5. Persons with a recent history of hemorrhage or blood loss 6. Clients with Burns 7. Clients with massive overwhelming infections Types of shock 1. Hypovolemic- related to blood loss (most common cause of shock) 2. Cardiogenic- related to ischemia or impairment in tissue perfusion from MI, serious arrhythmia, or heart failure. All of these resulting in cardiac output. a. If cardiogenic shock occurs in the presence of Pulmonary edema (e.g. from pump failure) position the client to reduce venous return. (HIGH FLOWLERs with LEGS DOWN) to decrease further venous return to the left ventricle. 3. Distributive- (Anaphylactic, Neurogenic, & Septic Shock) results from excessive vasodilation & the impaired distribution of blood flow 4. Obstructive- physical obstruction related to tamponade, emboli, compartment syndrome, that impedes the filling or outflow of blood resulting in reduced cardiac output

 All types of shock can lead to systemic inflammatory response syndrome (SIRS) & result in multiple organ dysfunction syndrome (MODS) Medical Treatments & nursing interventions for Shock 1. Oxygen & Ventilation corrects decreased tissue perfusion and restores cardiac output 2. Fluid Resuscitation (rapid infusion of volume-expanding fluids in: hypovolemic & anaphylactic shock) 3. Drug Therapy: Drugs that increase cardiac Preload- blood products & crystalloids) Drugs that decrease preload (morphine, nitrates, diuretics) Drugs that increase Afterload (vasopressors, dopamine) Drugs that Decrease Afterload (nitroprusside, ACE-I, ARB) Drugs that decrease contractility (beta blockers, calcium channel blockers,) Drugs that Increase contractility (digoxin (lanoxin) dobutamine) Seizures Nursing Interventions Maintain airway Nothing in the mouth, no padded tongue blades. That will cause more damage to the oral cavity Dont restrain Keep safe, support the head Turn head to the side Maintain seizure precautions reduce environmental stimuli pad side rails or crib rails have suction equipment in oxygen quickly accessible table oral airway to the head of the bed Treatment: Antivonvulsants- Phenobarbitol (Luminol), Phenytoin (Dilantin: Therapeutic Range = 10-20 Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol) Medication noncompliance is the most common cause of increased seizure activity Performing an EEG
EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must stay awake night before exam, pt may be asked to hyperventilate and watch a bright flashing light, after EEG, assess pt for seizures, pt's will be at increased risk.

Bacterial Meningitis bacterial inflammation of the meninges that cover the brain and spinal cord Place on droplet precautions Isolate for 24 hours implement seizure precautions elevate the head of the bed and position the patient on the side measure head circumference and I&O ** monitor hydration status and IV therapy- bacterial meningitis can lead to SIADH (over production of ADH aka Vasopressin) causes you to retain too much water (fluid overload) in the body causes blood serum to become diluted causing Hponatremia ***** SIADH (increased amounts of ADH) signs & symptoms change in LOC, decreased deep tendon reflexes tachycardia n/v/a, Signs and symptoms of Hyponatremia ** nausea muscle cramps

 increased ICP muscular twitching convulsion Causes Haemophilus influenza type B Streptococcus pneumoniae Neisseria meningitis Signs and symptoms classic signs of increased intracranial pressure (hypertension, bradycardia, bradypnea) fever and chills neck stiffness-opisthotonus & photophobia Positive Kernigs sign (leg flex then leg pain on extension) Positive Brudzinski sign (neck flex =lower leg flex). Diagnostic Lumbar Puncture of bacterial meningitis Shows increased WBC increase proteins increased ICP decreased glucose Avoid further increasing of ICP by not suctioning coughing straining turning Reye syndrome acute rapidly progressing encephalopathy and hepatic dysfunction Causes: o viral infections such as influenza or chickenpox o aspirin use Muscular Dystrophy Progressive muscle atrophy & weakness Duchenne muscular dystrophy is an X-linked recessive disease affecting primary males A X-linked recessive chromosome disorder works by the mother being a carrier but only her sons may express the disease. its rapidly progressing causing cardiac and respiratory complications and death by 25 years old X-linked Recessive Signs and symptoms Waddling gait hyper lordosis Gowers Sign = difficulty rising walks up legs (like Minors sign), fat pseudohypertrophy of calves.

Anticonvulsants Drugs/routes Phenobarbital (Lumunal) PO,IM,IV

Phenytoin (Dilantin) PO, IV

Indications Tonic-clonic & partial seizures Is the longest acting of common barbiturates Usually combined with other drugs Tonic-clonic & partial seizures

Adverse Reactions Drowsiness Nystagmus (uncontrolled movements of the eyes) Ataxia (loss of full control of bodily movements) Paradoxic excitement Gingival hyperplasia Nausea, anorexia Dermatitis Bone marrow depression Ataxia Nystagmus

Nursing Implications Therapeutic levels: 15 to 40 mcg/ml Avoid rapid IV infusion Monitor BP during IV infusion

Fosphenytoin Sodium (Cerebyx) IM, IV

Valproic Acid (Depakene) PO

Generalized convulsive status epilepticus Prevention & treatment of seizures during neurosurgery Short-term parenteral replacement for (Dilantin) Absence seizures Myoclonic seizures

Rapid IV infusion can cause hypotension Severe: ataxia, CNS toxicity, confusion, gingival hyperplasia, irritability, lupus, nervousness, nystagmus, paradoxic excitement, Steven-Johnsons syndrome, toxic epidural necrosis Hepatoxicity, especially in children under 2 Prolonged bleeding times GI disturbances Hepatitis Agranulocytosis Dizziness Rash Headache Nausea
Drowsiness Hyperactivity Agitation Increased Salvation

Therapeutic levels: 10 to 20 mcg/mL Monitor any drug interactions Do not administer with milk Ensure meticulous oral hygiene Monitor CBC Report any rashes to HCP For IV infusion flush the line before & after medication administration with normal saline only Prior to IV infusion, dilute in D5W or NS to administer Infuse a rate of no more than 150mg PE/min Therapeutic levels: 50-100mEq/ml Monitor liver function Potentiates Phenobarbital and Dilantin, altering blood levels Therapeutic levels: 6 to 12mcg/ml Withhold if rash develops Do not discontinue drug abruptly
Therapeutic levels: 20-80mcg/ml Do not discontinue drug abruptly Monitor liver function, CBC, & renal function periodically

Carbamazepine (Tegretol) PO Lamotrigine (Lamictal) PO

Clonazepam (Klonopin) PO

Tonic-clonic, mixed seizures Drowsiness Ataxia Partial seizures Tonic-clonic seizures Absence seizures
Absence seizures Myoclonic seizures

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Comparison Of Acute Glomerulonephritis & Nephrotic Syndrome Variables Acute Glomerulonephritis Nephrotic Syndrome Follows Streptococcal Infection Usually Idiopathic Cause Mild, usually around the eyes Severe, generalized Edema Elevated Normal Blood Pressure Dark, tea-colored (hematuria) Dark, frothy yellow Urine Massive amounts Protein in the urine Sight to moderate Normal serum protein Decreased serum protein Blood Positive ASO titer Negative ASO titer Medications Used in Renal Disorders Drugs/Route Indications Adverse Reactions Nursing Implications Bethanechol Chloride Cholinergic used to treat: Orthostatic hypotension Do not give IM or IV (Urecholine) PO, IM, IV Flushing Urinary retention Monitor VS Asthmatic reaction Neurogenic Bladder Preferably given on an empty stomach GI distress Gastric reflux Prednisone Adrenocorticosteriod used o Mood changes o In children, every other day administration is (Deltasone) PO to treat: o Increased susceptibility to best to avoid growth failure when drug is taken infection long term Immunosuppression o Cushingoid appearance o Discontinuing this drug requires tapering (acts as antiiflammatory) (moon face & buffalo hump) o Avoid Live Virus vaccines while taking Edema (promotes o Acne prednisone (MMR, Flu, Varicella, RV Rotavirus, diuresis in nephrotic o GI distress & Oral Polio Vaccine, Poliovirus the IPV is a syndrome) o Thrombocytopenia (low dead vaccine) platelets) o Edema o Potassium loss o Growth failure in children o Oxybutynin Genitourniary smooth-muscle o Increased o Administer orally: available in extended release (Ditropan) PO or relaxants (antispasmodics) susceptibility to UTI forms Transdermal used to treat: o GI distress o Do not administer with other meds that have any o Tolterodine o Dry mouth other anticholinergic effects Uninhibited neurogenic (Detrol) PO o Vision changes o May exacerbate reflux esophagitis bladder o Dizziness o Contraindicated in pt with untreated glaucoma Reflux urogenic bladder o Chest pain or any GI narrowing (GI obstruction may occur) Both are characterized o Drowsiness o Safety for use in children has not been by voiding symptoms of established urgency, frequency, nocturia & incontinence

Gastrointestinal Disorders 1. Cleft lip or Palate initial surgery to close the cleft lip begins when 1. the child weighs 10 pounds or more 2. has a hemoglobin (HGB) of at least 10g/dl Nursing implications Maintain proper airway Position on back or in infant seat to prevent trauma to suture line. Never lie the child prone While feeding, hold in upright position. Post-Op Place on side clean the suture site with sterile water after feedings-residual formula may impede healing and lead to infection Protect the surgical site maintain Logan Bow, Apply elbow restraints minimize crying 2. Esophageal Atresia with Tracheoesophageal Fistula (TEF) congenital anomalies in which the esophagus is not fully developed this is considered a clinical and surgical emergency Nursing assessments 4 Cs of TEF in the newborn 1. choking 2. coughing 3. cyanosis 4. continuous drooling excess salvation respiratory distress aspiration pneumonia 3. Pyloric stenosis narrowing of the pyloric canal, the sphincter hypertrophies to twice its normal size Nursing assessment 1. palpable Olive shaped mass in the upper right quadrant 2. mild vomiting (free from bile) that progresses to projectile 3. May spit up after feedings Post-operative interventions 1. position the patient on the right side and semi-Fowler position after feedings 2. burp frequently to avoid stomach becoming distended and putting pressure on the surgical site 4. Intussusception telescoping of one part of the intestine and to another part usually the ileum into the colon (ileocolic) partial or complete bowel obstruction occurs bowel vessels become trapped causing necrosis Nursing assessment 1. Currant jelly stools (mixed with blood and mucus) 2. sausage shaped mass in the upper right quadrant while the lower quadrant is empty 3. common in kids with cystic fibrosis CF Treatments 1. first attempt is a barium enema to hydrostatically reduce the telescoping of the intestines, if successful in 2:3 cases. If not successful than surgical repair will be implemented a. resolution is obvious with the onset of a bowel movement

5. Congenital Aganglionic Megacolon AKA Hirschsprungs Disease absent autonomic parasympathetic ganglion cells in the distal portion of the colon and rectum causing: 1. absent peristalsis 2. fecal contents to accumulate above the aganglionic area of the bowel Signs and Symptoms The initial sign is infants who fails the pass meconium within 24 hours of birth ribbon like stools and foul smelling stools a later seen in the older child Signs of bowel perforation abdominal distention and vomiting irritability dyspnea and cyanosis Diagnosis is made with rectal biopsy looking for absent ganglionic cells Treatment before and after the procedure only axillary temperatures can be taken usually involves series of surgical procedures i. a temporary colostomy will be applied ii. and later a reanastomsis and closure of the colostomy occurs Hematologic Disorders LAB REVIEW ****** ***Normal aPTT is within 30-40 seconds**(1.5-2.5X normal or control for heparin therapy 45-100 minutes) ****Normal PTT is within 60-70 Seconds* (1.5-2.5X normal or control for heparin therapy 90-175 minutes) Sed rate ESR: Males up to 15, females up to 20 rate is also increased during pregnancy, child up to 10, newborn put to 2. PT normal 11-12.5 seconds but just slightly lower in pregnancy (1.5-2X normal or control for Coumadin therapy 16.5-25) INR International normalized Ratio Normal: 0.8-1.1. Used to monitor anticoagulation therapy. INR Must be individualized 1. Iron Deficiency Anemia hemoglobin & RBC levels below normal range because of the body is an adequate supply, intake, or absorption of iron. The need for iron is greater in children than adults because of accelerated growth Possible causes for iron deficiency anemia inadequate stores during fetal development deficiency dietary intake chronic blood loss poor utilization of iron by the body Nursing Assessment/ Signs & Symptoms pallor or paleness of mucous membranes tiredness and fatigue usually seen in infants 6 to 24 months old toddlers and female adolescent most affected overweight cows milk babies. Milk intake greater than 32 ounces a day low dietary intake of iron Lab Values 1. decreased hemoglobin Hgb 2. low serum iron level 3. elevated total iron binding capacity T IBC

Remember The Hemoglobin (Hgb) Norms Of The Following newborn 14 to 24 g/dL infant 10 to 17 g/dL child 9.5 to 15.5 g/dL Nursing planning and interventions 1. support the childs need to limit activities 2. provide rest periods 3. administer oral iron (ferrous sulfate) as prescribed Teach the family about administration of oral iron give on empty stomach-as tolerated because its better for absorption give with citrus juices such as vitamin C for increased absorption use dropper or straw to avoid discoloring teeth teach that stools will become tarry teach the iron can be fatal in severe overdoses. Keep away from other children do not give iron with any dairy products Teach nutritional facts regarding iron limit milk intake to less than 32 ounces a day teach about dietary sources of iron o meet o green leafy vegetables o fish o liver o whole grains o legumes o for infants: iron fortified cereals and formula 2. Sickle Cell Anemia inherited autosomal recessive disorder of hemoglobin (Hgb) known as HgbAS it occurs primarily in persons of African in eastern Mediterranean descent usually appears after six months Hemoglobin S (HgbS)- replaces all or part of the normal hemoglobin, which causes the red blood cells to sickle when oxygen is released into the tissues. 1. Sickle cells cannot flow through capillary beds 2. Dehydration promotes sickling 3. HgbS has a left their normal lifespan which leads to chronic anemia 4. tissue ischemia causes widespread pathologic changes in the spleen, liver, kidneys, bones, and central nervous system. Signs and symptoms frequent infections or nonfunctional spleen tiredness chronic hemolytic anemia delayed physical growth Vaso-occlusive crisis AKA Sickle Cell Crisis the classic signs are: 1. fever 2. severe abdominal pain 3. hand-foot syndrome (in infants) causing painful edematous hands and feet 4. arthralgia (joint pain) 5. leg ulcers (adolescents) 6. cerebovascular accidents (CVA, stoke) increased risk with dehydration Hydration- is most important in the treatment of sickle cell disease because it promotes hemodilution and circulation of red blood cells through the blood vessels.

Nursing interventions for Sickle Cell Teach the family how to prevent sickle cell crisis (hypoxia) keep the child from exercising strenuously keep the child away from high altitudes avoid letting the child become infected, and seek care at first signs of infection use prophylactic penicillin as prescribed keep the child well hydrated withhold fluids at night because enuresis is a complication of both the disease and treatment Interventions for the hospitalized patient with a vaso-occlusive crisis/sickle cell crisis The two main interventions during a sickle cell crisis 1. Fluids: administer IV fluids and electrolytes as prescribed to increase hydration treat acidosis 2. Pain relief: administer analgesics Do not give demerol to pts. with sickle cell crisis parenteral morphine for pain is given use a warm compress for comfort (not ice) Administer blood products as prescribed Administer pneumococcal vaccine, meningococcal vaccine, Hib as prescribed. Administration of hep B vaccine is prescribed because the child is at risk because of blood transfusion. Supplemental iron is not given to clients with sickle cell anemia. The anemia is not caused by iron deficiency. Folic acid is given orally to stimulate red blood cell synthesis. Thrombocytopenia (low platelets > 150,000 Normal platelets 150,000- 400,000) **** Can be seen in Sickle cell anemia, but most often seen in Aplastic Anemia Also seen in Hemophilia Signs and symptoms of Bleeding Anemia- Deficiency of erythrocytes (RBC) causing a low Hematocrit (Hct) and a low Hemoglobin (Hgb) Normal Hgb (males: 14-18, females 12-16, pregnancy >11) Children 1-6 years 9.5-14 6-18 years 10-15.5 Normal Hct (males: 42-52%, females 37-47%, pregnancy >33%) Children 1-6 years 30-40% Children 6-18 years 32-44% Treatment of Sickle Cell with
Rest & Hydration Hydroxyurea, for sickle cell any reports of GI symptoms immediately could be sign of toxicity

Acute Lymphocytic Leukemia (low WBC > 5,000) Normal WBC 5,000-10,000 *** Normal WBC in children <2 yrs 6,200-17,000 <2 years 5,000-10,000) Leukemia (normal adult) anemia results from decreased red blood cell production and blood loss immunosuppression occurs because of the large number of immature white blood cells or profound neutropenia (decreased neutrophils) hemorrhage occurs because of thrombocytopenia (low platelets, pins blood) Acute Lymphocytic Leukemia- Cancer of the blood forming organs (Mainly in children) Its noted for the presence of lymphoblasts (immature lymphocytes WBC) which replaced normal cells in the bone marrow Will result in Lymphocytopenia (low WBC) Thrombocytopenia (low platelets) Anemia (low red blood cells, hemoglobin, and hematrocit

Signs and Symptoms of Lymphocytic Leukemia Pallor, tiredness, weakness, and lethargy due to anemia Petechiae, bleeding, bruising, due to thrombocytopenia Infection, fever due to neutropenia bone joint pain due to leukemic infiltration of bone marrow enlarged lymph nodes; hepatosplenomegaly (enlargement of the liver and spleen) headache and vomiting with anorexia and weight loss lab data: bone marrow aspiration that reveals 80 to 90% immature blast cells Nursing interventions Lymphocytic Leukemia recommend a private room reverse isolation is prescribed administer and monitor for side effects of chemotherapy have epinephrine oxygen readily available to treat anaphylaxis when administering L-asparaginase 3. Hemophilia- is an inherited bleeding disorder transmitted by an X-linked recessive chromosome (mother is a carrier, and her sons may express the disease) Thrombocytopenia (low platelets) a normal individual has between 50 and 200% factor activity in blood. The hemophiliac has from 0% to 25% activity The affected individual usually is missing either factor VIII (most commonly in 75%) or factor IX Signs & symptoms of Thrombocytopenia Easy or excessive bruising Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs Prolonged bleeding from cuts Spontaneous bleeding from your gums or nose (epistaxis) Blood in urine or stools Unusually heavy menstrual flows Profuse bleeding during surgery or after dental work Place all Pt with Thrombocytopenia (including adults on anticoagulant therapy) on Bleeding Precautions o Soft bristled tooth brush o Electric razor only (no safety razors) o Handle gently, Limit contact sports o Rotate injection sites with small bore needles for blood thinners and avoid IM injections o Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites o No straining at stool - Check stools for occult blood (Stool softeners prn) o No salicylates, NSAIDs, or suppositories o Avoid blowing or picking nose o Do not change Vitamin K intake if on Coumadin Signs & Symptoms of Hemophilia 1. male child: first red flag may be prolonged bleeding at the umbilical cord or injection site of vitamin K, or following circumcision 2. prolonged bleeding with minor trauma 3. hemarthrosis (most frequent sight of bleeding) 4. spontaneous bleeding into muscles and tissues 5. loss of motion and joints 6. pain

lab values: 1. Prolonged PTT ****Normal PTT is within 60-70 Seconds* (1.5-2.5X normal or control for heparin therapy 90-175 minutes) 2. Factor assay is less than 25% Treatments of Hemophilia administer fresh frozen plasma administer pain medication containing no aspirin follow blood precautions: risk for hepatitis Teach child and family home care o teach to recognize early signs of bleeding into joints o teach local treatment for minor bleeding (pressure, splinting, ice) o teach administration of factor replacement o discuss dental hygiene: use only soft toothbrushes o provide protective care: give the child soft toys and use padded rails Hesi Hint- inherited bleeding disorders (hemophilia and sickle cell anemia) are often used to test knowledge of genetic transmission patterns. Remember: Autosomal recessive: both parents must be heterozygous, or carriers of the trait, for that disease to be expressed in their offspring. This means two copies of an abnormal gene must be present in order for the disease o trait to develop. Seen in: Cystic fibrosis, sickle cell anemia, PKU, Sickle Cell Anemia, Tay-Sachs, & Albinism, Autosomal dominant, it means you only need to get the abnormal gene from one parent in order for you to inherit the disease. One of the parents may often have the disease. Seen in: Huntingtons, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease X-linked Recessive Trait- this trait is carried on the X chromosome, therefore; females can only be carriers and not have the gene & the mother usually passes the disease to her male offspring/son. Seen in: Hemophilia & Muscular Dystrophy Other Associated Hemological Terms 1. Leukocytosis Increased WBC resulting from the inflammatory response, Most commonly the result of infection parasitic infections or bone tumors strenuous exercise convulsions such as epilepsy emotional stress pregnancy and labor anesthesia or recent surgery epinephrine administration. 2. Lymphocytopenia- Decreased WBC resulting from Leukemia Hodgkins disease Corticosteroid use infections with HIV and other viral, bacterial, and fungal agents, malnutrition systemic lupus erythematosus, severe stress, intense or prolonged physical exercise (due to cortisol release), rheumatoid arthritis,

 sarcoidosis iatrogenic (caused by other medical treatments) conditions. Chemotherapy or radiation 3. Thrombocytosis (or thrombocythemia) High platelets resulting from Reactive (Secondary) Inflammation Surgery (which leads to an inflammatory state) Hyposplenism (decreased breakdown due to decreased function of the spleen) Splenectomy Asplenia (absence of normal spleen function) Iron deficiency anemia or hemorrhage Medications such as eltrombopag or romiplostim, The vast majority of causes of thrombocytosis are acquired disorders, but in a few cases, they may be congenital, such as thrombocytosis due to congenital asplenia. Other causes include the following Kawasaki disease Soft tissue sarcoma Osteosarcoma Dermatitis (rarely) Inflammatory bowel disease Rheumatoid arthritis Nephritis Nephrotic syndrome Bacterial diseases, including pneumonia, sepsis, meningitis, urinary tract infections, and septic arthritis.[6] 4. Thrombocytopenia and thrombopenia Low Platelets resulting from Decreased production Vitamin B12 or folic acid deficiency Leukemia or myelodysplastic syndrome Decreased production of thrombopoietin by the liver in liver failure Sepsis, systemic viral or bacterial infection Dengue fever can cause thrombocytopenia by direct infection of bone marrow megakaryocytes, as well as immunological shortened platelet survival. Hereditary syndromes Congenital amegakaryocytic thrombocytopenia Thrombocytopenia absent radius syndrome Fanconi anemia Bernard-Soulier syndrome, associated with large platelets May-Hegglin anomaly, the combination of thrombocytopenia, pale-blue leuckocyte inclusions, and giant platelets Grey platelet syndrome Alport syndrome WiskottAldrich syndrome Increased destruction Systemic lupus erythematosus Post-transfusion purpura Neonatal alloimmune thrombocytopenia Splenic sequestration of platelets due to hypersplenism [4] HIV-associated thrombocytopenia Gaucher's disease Medication-induced

5. Polycythemia (also known as polycythaemia or polyglobulia) High RBC caused by chronically low oxygen levels malignancy. Being over-transfused Metabolic & Endocrine Disorders 1. Congenital hypothyroidism low levels of T4 (thyroxine) high levels of TSH thyroid stimulating hormone Synthroid: tx of hypothyroidism..may take several weeks to take effect...notify doctor of chest pain..take in the AM on empty stomach..could cause hyperthyroidism. 2. PKU Phenylketonuria ***** Autosomal Recessive Diseases in which the body cannot metabolize the essential amino acid phenylalanine Guthrie Test Tests for PKU, at birth & again at 3 weeks o baby should have eaten source of protein first o positive test if serum phenylalanine level of 4mg/dl No phenylalanine with a kid positive for PKU (no meat, no dairy, eggs, Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient) o infants require special formula Lofenalac, Phenex-1 o infants require phenyl free milk substitutes after two years of age o No foods low in phenylalanine (vegetables, fruits, juices, cereals, breads, and starches o the diet must be maintained until at least brain growth is complete around ages 6 to 8 The buildup of serum phenylalanine leads to CNS damage Leads to MR early detection for PKU and hypothyroidism is essential for preventing cognitive impairments. 3.Insulin-Dependent diabetes mellitus or type I (IDDM) metabolic disorder in which the insulin producing cells of the pancreas are not functioning as a result of some and so diabetes can cause altered metabolism of carbohydrates, proteins, and fats treatment includes insulin replacement, dietary management, and exercise fasting blood sugar greater than 120 mg/dL is a diagnosis of diabetes Hyperglycemia is caused by: too much food, too little insulin, too little diabetes meds, illness or stress. Onset: start slow Signs & Symptoms of Hyperglycemia (3Ps with varying weight situations) Polydipsia Polyuria Polyphagia weakness weight loss syncope blurred vision Nursing Actions: encourage water intake check glucose regularly assess for ketoacidosis- when a child is in ketoacidosis administer regular insulin IV in normal saline administer insulin

Hypoglycemia- is caused by to little food, to much insulin or diabetic medicine, or to much activity Onset: is sudden and can progress to insulin shock Signs & Symptoms include (Tiredness TLC) Tachycardia/tremors Irritability/anxiety Restlessness Extreme headache Depression Nausea Sweating Slurred Speech TLC Tingling Lethergy Confusion Nursing Actions Treat with complex carbs o Grahm crackers & peanut butter o 12 cup OJ o 1 cup milk o Hard candies NO chocolate Recheck glucose in 20 minutes Diabetic ketoacidosis (DKA)= Occurs when the body is breaking down fat instead of sugar for energy. Fats leave ketones (acids) that cause pH to decrease. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. Kussmauls breathing (Deep Rapid RR) is present during DKA Serum acetone and serum ketones rise in DKA. As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready, with potassium replacement. However, NEVER give potassium K+ IV Push Fluids are the most important intervention DKA, so get normal saline running first then infuse with regular insulin IV While treating DKA, bringing the glucose down too far and too fast can result in increased intracranial pressure d/t water being pulled into the CSF. When drawing up Insulin Remember: Draw Regular (Clear) insulin into syringe first when mixing insulins (Nichole Richey RN) Put Air into NPH first, then air into regular, draw up regular first RN) then draw up NPH Insulin Rotate Injection Sites (Rotate in 1 region, then move to new region) Rapid Acting Insulins Lispro (Humalog), Aspart (Novolog) O: 5-15 min, P: .75-1.5 hrs Short Acting Insulin Regular (human) O: 30-60 min, P: 2-3 hrs (IV Okay) Intermediate Acting Insulin Isophane Insulin (NPH) O: 1-2 hrs, P: 6-12 hrs Long Acting Insulin Insulin Glargine (Lantus) O: 1.1 hr, P: 14-20 hrs (Dont Mix) Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production Glyburide, Metformin (Glucophage), Avandia, Actos Acarbose blunts sugar levels after meals

Insulin type Rapid acting

Short acting Intermediate acting

Name Lispro (Humalog) Aspart (NovoLog) Glulisine (Apidea) Regular insulin (clear) (Humlin R, Novolin R) Isophane insulin (NPH) (cloudy) Humulin N, Novolin N

Onset 0.5-1hour 5-15 minutes 25 minutes 30 to 60 minutes 1 to 2 hours

Peak action 2-4 hours 0.75-1.5 hours 1 hour 2 to 3 hours 6 to 12 hours

Duration 4 hours 3-5 hours 2-3 hpurs 5 to 7 hours 18 to 28 hours

Nursing implications Give within 15 minutes of a meal (Humalog and NovoLog) Regular insulin may be given IV Cannot be given IV Mixtures combine rapid acting regular insulin with intermediate acting NPH insulin in a 30% regular with 70% NPH proportion or at 5050 combination Not to be given IV Recommended: give one dose subcutaneously at bed time In some cases its given 2x/day Acts as basal insulin Caution: solution is clear, but the bottle shape is distinctively different from regular insulin. Do not shake solution Do not mix other insulins with Lantus. Use cautiously if patient is NPO For all premixes: offer when food is readily available

Long acting

Glargine (Lantus) Detemir (Levemir)

48 hours 1.1 hours

14 to 20 hours five hours (some sources say there is no peak)

24 hours

Premix

Humalog 75/25 NPH (25% Lispro/ 75% Humulin N) Human 70/30 (30% regular/ 70% NPH NovoLog 70/30 (30% Aspart/ 70% NPH) Humalog 50-50

Skeletal disorders 1. Fractures- are described by the type and extent of the break Fractures are caused by a direct blow, Cushing force, a sudden twisting motion, or disease such as cancer or osteoporosis. Fractures are classified by the following: 1. Complete fracture- a break across the entire cross-section of the bone, dividing it into distinct fragments; often displaced. 2. Incomplete fracture- a fracture that occurs through only one cortex (part) of the bone, is usually nondisplaced 3. Close fracture- no break in the skin 4. Open fracture/compound- broken bone protrudes through the skin or mucous membranes. Making this fracture more prone to infection. Bleeding is part of the circulation assessment of the ABCDs in an emergent situation. Therefore, if airway and breathing are accounted for, a compound fracture requires assessment before Glasgow coma scale and a neuro check (D=disability, or neuro check) 5 Types of fractures 1. Greenstick- Is an incomplete fracture in which one side of a bone is broken, but the other side is bent (flexed) but intact. 2. Transverse- A break that occurs straight across (90-degree angle) the bone shaft 3. Oblique- break that occurs at a 45-degree-angle across the bone 4. Spiral- fracture line results from twisting force it forms a spiral encircling the bone a. Spiral fractures or infant fractures may be related to child abuse 5. Comminuted- a break that consists of more than three fragments that may be splintered or crushed. (Least common in children) Intracapsular fracture- occurs in the neck of the femur and heels with greater difficulty than an extracapsular Fracture (occurs below the neck of the femur) because the blood supply enters the femur below the neck of the femur, there is greater likelihood that necrosis will occur because the fracture is cut off from the blood supply Signs and Symptoms of a Fracture Pain, swelling, tenderness Deformity, loss of functional ability Discoloration, bleeding at the site through an open wound Crepitus: crackling sound between two broken bones ** SIGNS of a Fractured hip: EXTERNAL ROTATION, SHORTENING, ADDUCTION Nursing Interventions Frequent neurovascular assessment distal to the injury (skin color, temperature, sensation, capillary refill, mobility, pain, swelling (elevate to prevent swelling) and pulses should be assessed.) Assess the 5Ps of neurovascular functioning 1. Pain 2. Paresthesia 3. Pulses: check pulses distal to the injury to assess circulation 4. Pallor 5. Paralysis- check for nerve or movement impairments, compare with uninjured extremity Report abnormal assessment findings promptly Observe client use of assistive devices 1. Crutches- there should be to a three finger widths between the axilla and top of the crutch. a. A three-point gait is common. The client advances both crutches and the impaired Leg at the same time. The client then swings the uninvolved leg ahead to the crutches. b. Remember the phrase step up when picturing a person going up stairs with crutches. The good leg goes up first, followed by the crutches and the bad leg. The opposite happens going down. The crutches go first, followed by the good leg.

2. Cane- is placed on the unaffected side a. the top of the cane should be at the level of the greater trochanter b. Remember: COAL (cane walking): C Cane O- Opposite A- Affected L- Leg 3. Walker- strength of upper extremity & unaffected leg is assessed & improved with exercise so that upper body is strong enough to use the walker. The pt Lifts & advances the Walker and steps forward. 2 major complications of a fracture 1. Compartment Syndrome which may cause Permanent damage to nerves and vessels Compartment syndrome is an emergency situation. Paresthesias and increased pain are classic symptoms. Neuromuscular damage is irreversible 4-6 hours after onset. 2. Fat embolism - a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli. Its greatest occurrence is in the first 36 hours after a fracture People more likely to develop a fat embolism o people with multiple fractures o fractures of long bones o fractures of the pelvis Signs and symptoms of a fat embolism 1. Number 1 symptom is confusion due to hypoxemia (check blood gases for Po2) 2. Petechiae 3. respiratory distress 4. restlessness or irritability 5. fever If a fat embolism is suspected- notify the physician stat, draw blood gases, administer O2, and assist with endotracheal intubation. Treatment for a Fat embolism is Heparin Administration Traction Maintain traction if prescribed. Always document the 1. bed position 2. type of traction 3. weights 4. pulleys 5. pins & pin sites- can be source of infection, monitor for signs and symptoms and cleanse and dress pin sites as prescribed 6. adhesive strips or ace wraps 7. splints 8. casts Types of Traction 1. skin traction: force is applied to the skin a. skin traction for a fracture reduction should not be removed unless a healthcare provider prescribes its removal. b. Buck traction- lower extremities, keeps legs extended no hip flexion c. Dunlop- two lines of pull on the lower extremity 1 perpendicular & 1 longitudinal d. Bryant- both lower extremities flex and 90 at the hip (is really use because extreme elevation of the lower extremities causes decrease peripheral circulation) 2. Skeletal traction: pain or wire applies pull directly to the distal bone fragment a. 90 traction- 90 flexion of hip and knee, lower extremity is in a boot cast; & can also be used on the upper extremities b. Questions about a halo traction? Remember safety first, have a screwdriver nearby.

Nursing Interventions for a child in traction 1. maintain child and proper body alignment: restrain if necessary 2. monitor for problems of immobility 3. prepare child for Application 4. provide routine cast care following application: petal cast edges Teach home cast care to the child & family teach neurovascular assessments including the 5 Ps teach child not to get the cast wet teach the child not to place anything under the cast such as small objects, toys, food, or something to help scratch such as a wire hanger Other Hints for Traction and/or fractures Always deal with actual problems or harm before potential problems Always select a patient focused answer. An answer option that states "reassess in 15 minutes" is probably wrong (unless you already completed A nursing intervention such as gave OJ to a hypoglycemic client, then you need to recheck sugar.) Developmental Dysplasia of the Hip abnormal development of the femoral head in the acetabulum conservative treatment consists of splinting, surgical intervention is necessary of splinting is not successful. Nursing Assessment for Signs & Symptoms Infant: Positive Ortolanic Sign (clicking with abduction) unequal folds of the skin on the buttocks and thigh limited abduction of affected hip unequal leg lengths Older child limp unaffected side Trendelenburg sign Nursing interventions apply abduction device or splint (Pavlik harness: Frejka or Von Rosen splint) therapy involves positioning legs in the flexed abducted position teach application and removal of the device (worn 24 hours a day) teach skin care and bathing (physician may allow parents to remove the device for bathing) Scoliosis lateral curvature of the spine, if severe it can cause respiratory compromise. Surgical correction by spinal fusion may be required if conservative treatment is an effective. Nursing assessment for signs and symptoms occurs most commonly in adolescent females 10 to 15 years old elevated shoulder or hip head in hips not aligned while child is bending forward, a rib hump is apparent (ask the child to bend forward from the hips with the arms hanging free, and examine the child for curvature of the spine, rib hump, and hip asymmetry) Nursing Interventions prepare the child and family for conservative treatment such as the use of a brace o teach the application of the brace (Boston, Wilmington, or Milwaukee are most common) o instruct to wear it 23 hours a day o instruct to a T-shirt under the brace to decrease skin irritation o Lotions and powders are not applied to the skin under the brace o instruct to check skin for areas of irritation or skin breakdown a brace does not correct the spines curve in a child with scoliosis: it only stops or slows the progression

Juvenile Arthritis (JA) or juvenile idiopathic arthritis (JIA) chronic inflammatory disorder of the joint synovium Nursing Assessment for Signs and Symptoms 1. joint swelling and stiffness (usually of large joints) 2. painful joints 3. generalized symptoms: fever, malaise, and rash 4. periods of exacerbations and remissions 5. varying in severity from mild and self-limited or severe and disabling 6. lab data: latex fixation test (usually negative) and elevated ESR Nursing interventions plan homecare prescribed exercise splinting and activity assist in identifying adaptations a routine (Velcro fasteners,& frequent rest periods throughout the day) encourage periodic eye exams for early detection of iridocyclitis so as to prevent vision loss encourage the family to allow childs independence Medication intervention 1. nonsteroidal anti-inflammatory drugs (NSAIDS) o aspirin o Tolmetin Sodium o Ibuprofen o Naproxen 2. Antirheumatic drugs 3. Corticosteroids (prednisone)- are used in the short term in low doses during exacerbations only. Longterm use is avoided because of side effects and their adverse effects on growth. 4. Cytotoxic drugs (Cyclophosphamide, methotrexate)

Maternity Review Ovulation- usually occurs 14 days before the onset of menstrual flow Last Menstrual Period (LMP)- The date of the first day of the last menstrual bleeding, used for EDB-estimated date of birth & EDD estimate delivery/due date NAGELS RULE- LMP Subtract 3 Months & ADD 7 days and Add 1 Year Take 400mcg FOLIC ACID within or before the first trimester to prevent nurotube defects They are decreased by 70% if taken regularly Sources of FOLIC ACID- Leafy greens, whole grains, OJ Amniotic fluid = 800-1200 mL (< 300 mL = Oligohydramnios = fetal kidney problems) Oligohydramnios- Having less than 300ml of amniotic fluid, is never good & can be associated With fetal renal abnormalities Polyhydramnios Having more than 2L of amniotic fluid, may not ALWAYS be a bad thing, it Can be managed on an outpatient basis, but also can be associated with GI malformations UMBILICAL CORD- Has 3 Vessels (Vein carries oxygenated blood to fetus (opposite of normal) 2 ARTERIES- carry unoxygenated blood back to the placenta 1 VEIN- Carries oxygenated blood to the fetus o Whartons Jelly- Connective tissue that prevents compression of the blood vessels & ensures continued nourishment of the fetus PLACENTA- Specialized organ that forms maternal-fetal gas & nutrient exchange, begins to Form at implantation FUNCTIONS: 1. Endocrine Gland- Produces hormones necessary to maintain pregnancy a. Human Chorionic Gonadotopin (hCG)- is a protein hormone that can be detected in the maternal serum by 8-10 days after conception, just shortly after implantation. Basis for a pregnancy test i. HCG- Preserves the function of the ovarian courpus luteum, ensuring the continued supply of estrogen & progesterone to maintain pregnancy ii. The amount of hCG- Reaches a PEAK level at 50-70 days then begins to DECREASE 2. Metabolic Function- of blood & gas exchange 3. Nutrient/excretion 4. Storage Fetal Maturation/Circulation The cardiovascular system is first to begin to function HEART BEATS by the end of the 3rd Week NASIDS- should be AVOIDED because they can cause a premature closure of the Ductus Arteriosus, which may lead to pulmonary vasculature abnormalities & pulmonary HTN Pregnancy Trimesters 1st Trimester Conception-13 Weeks 2nd Trimester 14 weeks through 26 weeks 3rd Trimester 27-40 weeks Fetal & Maternal Changes 8 weeks A. Fetal Development 1. Development is rapid 2. Heart begins to pump blood B. Maternal Changes 1. Nausea persists to 12 weeks 2. Hegar sign (softening of the isthmus of cervix AKA lower uterine segment) 3. Goodell sign (Softening of the cervical tip) 4. Chadwick sign (bluing of vagina, & a violet-bluish mucosa & cervix appears as early as 4 weeks)

5. Leukorrhea- White or grey muciod discharge with a musty odor 12 Week A. Fetal Development 1. Heart is discernible by ultrasound 2. Sex is determinable 3. Kidneys produce urine B. Maternal Changes 1. Braxton Hicks Contractions 2. Chance for UTI increases 3. WEIGHT GAIN is 2-4 Pounds during the First Trimester, then 1 pound a week thereafter 4. Placenta is fully functioning & produces hormones a. Teach UTI prevention- Pt increase fluid intake to 3/L day &Void Q2h while awake & after sex b. Increase caloric intake by 300 calories/day, weight gain of 25-35 lbs total is normal 16 Weeks A. Fetal Development 1. Meconium in bowel, & anus opens 2. Respiratory Bronchioles appear B. Maternal Changes 1. Quickening (the mothers 1st perception of fetal movement, occurs between weeks 16-20) 2. Colostrum can be expressed as early as 16 weeks 3. Cholesterol Increases from 16-32 weeks and remains high til birth 4. INSULIN RESISTANCE begins as early as 14-16 weeks 5. Weight gain of about 1 pound/week in the second & third trimester 20 Weeks A. Fetal Development 1. Vernix & Lanugo (fine hair ) covers & protects the body 2. Fetus sleeps, sucks, & kicks B. Maternal Changes 1. Fundus reaches umbilicus 2. Areolae darken 3. Postural HYPOTENSION may occur 4. Nasal stuffiness, leg cramps, varicose veins, constipation develops 24 Weeks A. Fetal Development 1. sweat glands forming 2. blood formation increases in bone marrow & decreases in the liver 3. Can begin to HEAR B. Maternal Changes 1. Uterus reaches umbilicus 2. DIASTOLIC BP gradually increases at 24-32 weeks, AFTER having Decreased Diastolic BP in the first trimester. Systolic BP- remains the same during the entire pregnancy 28 Weeks A. Fetal Development 1. Fetus can breathe, swallow, & regulate temp 2. Surfactant forms in the lungs B. Maternal Changes 1. Fundus is halfway between umbilicus & xiphoid process 2. Thoracic breathing replaces Abdominal breathing 3. Heart burn & hemorrhoids may develop 32 Weeks A. Fetal Development 1. Brown fat deposits develop under the skin

2. Fetus begins storing iron, calcium, & phosphorus B. Maternal Changes 1. Fundus reaches xiphoid process 2. urinary frequency returns Along with swollen ankles, sleeping problems &/or Dyspnea may occur 36-40 Weeks A. Fetal Development 1. Fetus occupies the entire uterus so activity is restricted 2. Maternal Antibodies are transferred to the fetus & provide infant immunity for approx 6 months B. Maternal Changes 1. Lightening occurs- fundal height drops as the fetus begins to descend & engage in the pelvis 2. Backaches increase & Braxton Hicks Contractions intensify Physiologic Changes During Pregnancy 1. Reproductive System Changes 1. Amenorrhea 2. Brest Changes- They enlarge & become nodular as the glands increase in size & number 2. Cardiovascular Changes ** 1. Between 14-20 weeks gestation the heart rate increases about 10-15 beats/min remains until term 2. There is a more audible splitting of S1 & S2 & S3 may be readily heard after 20 weeks 3. BLOOD PRESSURE: a. Diastolic BP begins to decrease in the first trimester, & continues to drop until 24-32 weeks, then gradually increases by term b. Systolic BP usually remains the same but may decrease slightly as pregnancy advances c. MAP readings are slightly higher in pregnant women d. Maternal position affects BP readings, Brachial BP is higher when a woman is sitting than when she is lying in the lateral recumbent position e. Position of the arm also makes a difference: if the arm is ABOVE the heart, the reading will be LOWER than the actual reading, if below the heart, the reading will be higher f. Supine Hypotensive Syndrome- Some degree of compression on the Vena Cava occurs in all women who lie flat on their backs during the second half of pregnancy. As a result some women experience a decrease in systolic BP decrease more than 30mmHg, after 4-5 minutes of reflex bradycardia, cardiac output is reduced by half, & the woman feels faint. i. Teach the woman- that a left side-lying position relieves this Hypotension & increases perfusion to the uterus, placenta, & fetus 4. Compression of the iliac veins & inferior vena cava by the uterus causes increased venous pressure & reduced blood flow in the legs (except when the woman is in the lateral position) This contributes to dependent edema, varicose veins, & hemorrhoids 5. Blood Volume Increases by approximately 1500 ml, or 40-45% above non-pregnancy levels a. The increase consists of 1000ml of plasma plus 450ml red blood cells (RBC) i. The state of hemodilution occurs & is termed Physiologic Anemia. This happens because the plasma increase exceeds the increase in RBC production, a decrease in the normal hemoglobin (HGB) (12-16 g/dl in non-pregnant) & hematocrit (HCT) (37-47% in non-pregnant) values occurs. 1. A Hemoglobin Value Below 11 g/dl & Hematocrit below 33% are considered Abnormal & is often due to iron deficiency anemia a. Foods High in Iron: fish, red meat, cereal, yellow veggies, green leafy veggies, citrus fruits, egg yolks, & dried fruits b. Blood volume starts to increase by the 10-12th week of pregnancy, & decreases by term 6. Total WBC Increases during the second trimester & peeks during the 3rd 7. Cardiac Output (CO) Increases from 30%-50% over the non-pregnant rate by the 32nd week a. The elevated CO is caused by an increase in stroke volume & HR & occurs in response to increased tissue demands for oxygen b. CO is Higher when the woman is in the lateral recumbent position than supine

8. Coagulation Times Are Decreased, resulting in increased clot formation & thrombus 3. Respiratory Changes a. The upper respiratory tract becomes more vascular in response to elevated levels of estrogen a. As the capillaries become engorged edema occurs in the nose, pharynx, larynx, trachea, & bronchi. This congestion gives rise to nasal & sinus stuffiness, epistaxis (nosebleed), or URI. b. Increased vascularity of the URT also causes tympanic membranes to swell, resulting in impaired hearing, earaches, or a sense of fullness in the ears. c. Basal Metabolic Rate (BMR) Which is the rate at which the body uses energy while at rest to keep vital functions going, such as breathing and keeping warm, is INCREASED during pregnancy. d. Acid-Base Balance- By about the 10th week of pregnancy there is a Decrease of about 5 mmHg in the partial pressure of Carbon dioxide (Pco2) e. Progesterone- may be responsible for increasing the sensitivity of the respiratory center receptors so, tidal volume is increased, Pco2 is Decreased, & PH is slightly Increased a. These alterations indicate pregnancy is a state of compensatory Respiratory Alkalosis 4. Renal Changes a. Urinary Frequency- caused by an increased progesterone, increased glomerular filtration, & crowded bladder b. Increased cardiac output increases renal blood flow in the 1st trimester c. Bladder tone reduced by effects of progesterone on smooth muscle 5. Skin Changes a. Chloasma (Facial Melasma)- a patchy brown discoloration, that usually appears on the face b. Linea Nigra- Is a pigmented line extending from the symphysis pubis (pubic bone) to the top of the fundus (navel) c. Striae Gravidarum- stretch marks d. Angiomas (Vascular Spiders) that indicate increased circulation e. Palmar erythema- Pinkish-red diffuse mottling or blotches over the palmer surface of the hands Antepartum Care G/P

Gravida- The TOTAL number of times a woman has been pregnant Parity- Number of pregnancies (not kids) that have reached viability (pass 20 weeks) o G2P1- Pregnant twice but only gave birth once GTPAL Gravida- Total number of times a woman has been pregnant Term- Total number of pregnancies that have passed 37 weeks Preterm- Total number of pregnancies that passed viability (20 weeks) but ends before completion of 37 weeks Abortion- How many voluntary or involuntary number of pregnancies that did not reach 20 weeks Living- How many living children the woman currently has Normal Vital Signs for the Pregnant Woman BP- systolic should rise no more than 30 mmHg, and 15 mm Hg Diastolic o Systolic Average 90-140 mm Hg o Diastolic Average 60-90 mm Hg HR- 60-90 BPM RR- 16-24 Breaths/Min Temp- 97-100 degrees F (F-32 X 5/9= C) 97 F = 36.1 C o Convert Celsius to Fahrenheit (C x 9/5 + 32 = F) 37.8 C = 100 F Teach Position Changes The Knee-Chest Position- provides optimum fetal & placental perfusion, but the IDEAL position for the mother, which supports fetal, maternal, & placental perfusion, is the SIDE-LYING

Teach Proper Nutrition Symptoms of Malnutrition: 1. Glossitis (inflammation of the tongue) 2. Cracked Lips 3. Dry, Brittle Hair Obesity- Woman over 200 lbs are at risk for diabetes, HTN, infections, & Macrosomia Macrosomia- Large baby over 4500 kg or 9.5 lbs Underweight- Woman under 100 lbs are at risk for low birth weight babies, IUGR, & preterm labor Nutritional Plans Increase calories by 300 above basal & activity needs Increase Protein by 30g/day o Milk, meat, eggs, cheese Increase intake of Iron & Folic Acid Increase Intake of Vitamin A, C & Calcium o Calcium is needed for fetal bone & tooth development, recommended intake of 1500mg/day Drink 8-10 glasses of fluid a day or 3L, 4-6 glasses should be water: WATER o Maintains body temp o Hydrates uterus Limit caffeine intake to less than 200mg (12 oz daily) Aspartame (Equal) or Sucralose (Splenda) have NOT been found to have adverse effects Sodium HAS NO RESTRICTIONS- But makes you retain water Phenylketonuria (PKU)- Is a RECESSIVE Hereditary disease that results in a defect in the metabolism of the Amino Acid Phenylalanine caused by the lack of an enzyme called phenylalanine hydroxylase, that is Necessary for the conversion of the amino acid Phenylalanine into Tyrosine. If not treated it can cause brain damage & mental retardation Women with PKU CAN NOT eat ANYTHING with Phenylalanine, which is found in the following: o Diet Soda, Bread, Nuts, Milk, Sugar, Some fruits & Veggies A Routine Physical Assessment and initial Labs 1. CBC- Can determine Iron deficiency which could indicate anemia 2. Blood Type & Screen- Done to determine if the MOTHER is (Rh-) if she is, she will need an injection of ROGRAM at 28 weeks. This is because the mother can develop antibodies to a Rh+ fetus and her body will attack the fetus as if it was a foreign substance & kill it 3. Rubella Status- Will effect the growing fetus, the mother will need a vaccine postpartum if not up to date 4. RPR- Can diagnose syphilis Assess Fetal Well-Being and Heart Rate Fetal well-being is determined by assessing fundal height, fetal heart tones & rate, fetal movements, & uterine activity (contractions). Changes in Fetal Heart Rate (FHR) are the FIRST & MOST IMPORTANT indicators of compromised blood flow to the fetus, & these changes require action. FHR Can be detected by using a Doppler between 10-12 weeks gestation FHR can be detected by using a fetoscope between 10-20 weeks gestation ***NORMAL FETAL HEART RATE IS- 110 to 160 bpm******* ***FHR is best heard (Point of Maximum Intensity OMI) through the fetal BACK *** Possible Indicators of Preeclampsia & Eclampsia Are: 1. Visual Disturbances 7. Changes in fetal movement or increase in FHR 2. Swelling of the face, fingers, or Sacrum 8. Infection: Possible Indicators Include 3. Severe Continuous Headaches 1. Chills 4. Persistent Vomiting 2. Temp over 100.4 Degrees Fahrenheit 5. Epigastric Pain 3. Dysuria (painful or difficult urination)

6. Fluid discharge or bleeding from the vagina 4. Abdominal Pain Fetal & Maternal Assessment A. Maternal Risk Factors 1. Age: Under 17 or Over 34 2. High Parity >5 3. Pregnancy (3 months since last delivery) 4. Hypertension or presence of or history of Preeclampsia 5. Anemia, History of Hemorrhage, or current Hemorrhage 6. Multiple Gestations 7. Rh Incompatibility 8. History of Dystocia (e.g. shoulder dystocia) or previous operative delivery 9. A height of 5 feet or less 10. Malnutrition or Obesity 11. Current medical disease/condition 12. History of family violence or lack of support SCREENING TESTS (NOT DIAGNOSTIC TESTS) 1. Ultrasonography a. Used in the First Trimester to Determine 1. Gestational Age: Best indicator in the 1st trimester, very accurate second to Negals rule 2. Number of fetuses 3. Presence of fetal cardiac movement & rhythm 4. Uterine abnormalities b. Used in the Second & Third Trimester to Determine 1. Fetal viability & gestational age (not as accurate) 2. Size-date discrepancies 3. Amniotic Fluid volume 4. Placental location & maturity 5. Uterine abnormalities & anomalies 6. Results of amniocentesis c. Findings 1. Fetal heart activity is apparent as early as 6-7 weeks gestation 2. Serial ultrasound measurements are needed to determine & true Intrauterine growth restriction (IUGR) *A Single ultrasound exam is NOT useful in determining IUGR 3. Serial evaluation of biparietal diameter & limb length can differentiate between wrong dates d. Nursing Care 1. Instruct the pt to drink 3-4 glasses of water and NOT URINATE, the bladder must be FULL during the exam for the uterus to be supported for imaging. (A full bladder is NOT NEEDED if the ultrasound is done transvaginally instead of abdominally) 2. Chorionic Villi Sampling (CVS) -Removal of a small piece of villi during the period of 8-12 weeks under ultrasound guidance a. Findings 1. The test determines genetic diagnosis early in the first trimester & The results are obtained in 1 week b. Nursing Care 1. Place the pt in the lithotomy position using stirrups & Warn of sharp pain upon catheter insertion c. Complications of Chorionic Villi Sampling 1. Spontaneous Abortion (5%) 2. Controversy regarding fetal abnormalities (limb) 3. Amniocentesis- Is a positive Diagnostic TEST its the Removal of Amniotic fluid sample from the uterus A. Its used to determine: 1. Fetal Genetic diagnosis (usually in the first trimester) 2. Fetal Lung Maturity (in the LAST trimester)

3. Fetal well-being B. This is performed ONLY when uterus rises above the symphysis (between 12-13 weeks) & amniotic fluid Has formed. C. Usually takes 10 days- 2 weeks to develop cultured cell karyotype. Therefore, woman could be well into The second trimester before diagnosis is make, making the choice for an abortion more dangerous D. Findings: 1. Genetic Disorders a. Karyotype: Determines Down Syndrome (trisomy 21) & sex chromatin (sex-linked disorders) b. Biochemical analysis: determines more than 60 types of metabolic disorders (Tay-sachs) c. Alpha Fetoprotein (AFP) elevations may be associated with neutral tube defects, low levels indicate down syndrome (trisomy 21) 2. Fetal Lung Maturity a. LecithinSphingomyelin Ratio (L/S ratio): 2:1 ratio indicates fetal lung maturity unless mother is diabetic or has Rh disease or fetus is septic b. L/S ratio & presence of Phosphatidylglycerol aka PG which is found in surfactant: most accurate determination of fetal lung maturity. PG is present after 35 weeks. c. Lung maturity is best predictor of extrauterine survival d. Creatinine: Renal maturity indicator > 1.8 e. ***THE MOST IMPORTANT DETERMINAT OF FETAL MATURITY- for extrauterine survival is the lung maturity: Lung Surfactant (L/S) ratio. ******* i. A Ratio of 2:1 or higher indicant the fetus can survive outside the uterus 3. Fetal Well-Being a. Bilirubin data optical density (OD) assessment should be performed in mother previously sensitized to the fetal Rh+ red blood cells & having antibodies to the Rh+ cells. The delta test measures the change in OD of the AF caused by staining with bilirubin, done at 24 weeks. 4. Nursing Care a. Obtain baseline VS and FHR b. Place pt in supine position with hands across chest c. Scrub with betadine if prescribed d. Draw maternal blood sample for comparison with post procedure blood sample to determine maternal bleeding e. If bilirubin test is performed, darken room & immediately cover the tubes with aluminum foil or use opaque tubes f. ** When performed EARLY in pregnancy, the bladder must be FULL to help support the uterus & help push it up in the abdomen for easy access. When performed LATE in pregnancy the bladder must be EMPTY so it will not be punctured g. Monitor FHR 1 hr after procedure, & assess for uterine contractions & irritability 5. Complications a. Spontaneous Abortion, Fetal Injury OR Infection Electronic Fetal Monitoring with a Tocodynamometer (on the abdomen) or an Intrauterine Pressure Catheter (inserted in the vagina to measure EXACT frequency, strength, & duration of contractions) A. Contractions indicate what the uterus is doing 1. Beginning, peak (acme) & end of each contraction 2. Duration: length of each contraction from beginning to end 3. Frequency: beginning of one contraction to the next (3-5 contractions must be measured) 4. Intensity: Measured not by external monitoring but ONLY by internal intrauterine monitoring, with an IUPC after amniotic membranes have ruptured, NORMAL RANGES 30 (mild)- 70 (strong) mm Hg B. Baseline FHR 1. The range of FHR (Average FHR 110-160Bmp) is measured between contractions, monitored over a 10 minute period Nursing Actions Bases on Fetal Heart Rate A. Variability

1. A characteristic of the baseline FHR & described as normal irregularity of the cardiac rhythm

2. There are 4 Categories of Variability 1. Absent- Amplitude rage undetectable 2. Minimal- Amplitude range detectable up to & 5 beats/min 3. Moderate- Amplitude range 6-25 beats/min 4. Marked- Amplitude range > 25 beats/min B. Positive Periodic Changes 1. FHR changes in relation to uterine contractions a. Accelerations Of the FHR is defined as a visually apparent abrupt increase in FHR above the baseline rate. The peak is at least 15 beats/min above baseline, & the accelerations last 15 seconds or more, with the return to baseline within 2 minutes. They are reassuring and are considered a good indication of fetal well-being. They: 1. Caused by sympathetic fetal response 2. Occur in response to fetal movement 3. Indicative of reactive, healthy fetus b. Early Decelerations- Gradual FHR increase & return to baseline, that match or are shortly after the onset of Uterine Contractions (UC). They are thought to be associated with fetal head compression & are considered normal. Document positive fetal well-being, no nursing interventions are needed, just monitor the process of labor. C. Non-Reassuring Warning Signs 1. FHR is absent or minimal a. Usual Causes 1. Hypoxia (asphyxia) 2. Acidosis 3. Maternal Drug ingestion (Narcotics, CNS depressants such as Magnesium Sulfate) 4. Fetal Sleep 2. Late Decelerations- Deceleration begins after the contraction has started, & the lowest point of the deceleration occurs after the peak of the contraction, and does not return to baseline until the UC is over Late Decelerations- ARE BAD, potentially disastrous nonreasuring sign b. Usual Causes 1. Indication of Late Decelerations (cause) Uteroplacental Insufficiency (UPI) caused: i. Uterine hyperactivity AKA Tachysystole (more than ____ contractions) **? ii. Maternal supine hypotension as result of epidural or spinal anesthesia, iii. Other conditions: placenta previa, abruptio placente, hypertensive disorders e.g. preeclampsia, postmaturity, intrauterine growth restriction, diabetes mellitus, and intraamniotic infection. c. Nursing Interventions for Late Declarations 1. Immediately turn the patient onto the LEFT SIDE 2. Discontinue Oxytocin (Pitocin) if infusing 3. Administer Oxygen at 10L by tight face mask 4. Assist with fetal blood sampling 5. Maintain IV, elevate legs to increase venous return 6. Correct underlying maternal Hypotension by increasing IV fluid (BOLUS) or with prescribed med 7. Notify Health Care Provider (HCP) 8. Document pattern & response to each nursing action 3. Variable Decelerations- Is a decrease in the FHR below baseline, they last 15 seconds & return to baseline Within 2 minutes. They occur at any time and do not have an association with contractions. Variable Decelerations Are usually caused by compression of the Umbilical Cord 4. Prolonged Decelerations- Is a decrease in the FHR of at least 15 beats/min below the baseline & lasting MORE THAN 2 MINUTES, but LESS THAN 10 Minutes. They are caused by a disruption in the fetal

Oxygen demands. Mnemonic for FETAL TRACING (VEAL CHOP) Variables Cord Compression (Intervention- Reposition) Early Head Compression (GOOD, indicates FETAL well-being) Accelerations Ok (Document well-being) Late Placenta (Uteroplacental Insufficiency (UPI)- Turn off Pitocin if on & notify HCP CORD PROLAPSE- If cord prolapse is detected, the nurse should position the mother in the KNEE-CHEST Position to relieve pressure on the cord, or the nurse should PUSH THE PRESENTING PART of the cord with fingers until immediate cesarean delivery can be accomplished. Additional Antepartum Tests 1. Nonstress Test- It is used to determine fetal well-being in high risk pregnancy & is especially useful in postmaturity (notes response of the fetus to its own movements) a. A healthy fetus will usually respond to its own movements by means of an FHR acceleration of 15 beats, lasting for at least 15 seconds after the movement, twice in a 20 minute period. b. The fetus that responds with 15/15 acceleration is considered REACTIVE & healthy. c. Nursing Care i. Apply fetal monitor, ultrasound, & tocodynamometer to abdomen ii. Give the mother a handheld event marker, & instruct her to push the button whenever fetal movement is felt iii. Monitor pt for 20-30 min, observing for reactivity iv. Suspect fetus is sleeping if there is no movement, stimulate the fetus acoustically or physically 2. Contraction Stress Test (CST) or Oxytocin Challenge test (OCT) During the test the fetus is challenged with the stress of labor by induction of uterine contractions, & the fetal response to the decrease in oxygen supply during the contractions is noted. a. An UNHEALTHY fetus will develop nonreasurring FHR patterns in response to the UC, LATE decelerations usually occur, which is indicative of UPI b. Contractions can be induced by nipple stimulation or by infusing a dilute solution of Oxytocin c. Nursing Care i. Assess for contraindications, prematurity, placenta previa, hydramnios, multiple gestation, & previous uterine classical scar, rupture of membranes (ROM) ii. To assess fetal well-being a recording of at least 3 contractions in 10 minutes MUST be Obtained iii. A NEGATIVE TEST suggests fetal well-being (e.g no occurrences of late decelerations) POTENTIAL Complications 1. The danger of Nipple Stimulation- lies in controlling the DOSE of oxytocin delivered by the posterior pituitary gland. The chance of hyperstimulation or TENTANY (Contractions over 90 seconds or contractions with less than a 30 second rest in between) is increased. 3. A Biophysical Profile (BPP)- Determines FETAL WELL-BEING*** a. Ultrasonography that is used to evaluate fetal health by assessing 5 variables: i. Fetal breathing movements ii. Gross body movements iii. Fetal tone iv. Reactivity of FHR v. Ammonic Fluid Volume a. Each variable receives 2 points for a NORMAL response and 0 points for an ABNORMAL or absent response b. An overall score of 8-10 indicates fetal well-being. 4. A Fetal pH Blood Sample- Can be drawn from the presenting part of the fetus, after ROM & when the Cervix is dilated 2-3 cm. a. The test is used to determine True Acidosis when nonreasurring FHR is noted. b. Normal Fetal Scalp Ph in LABOR is 7.25-7.35, & values BELOW 7.2 indicate True Acidosis

STAGES OF LABOR 1. First Stage- The beginning of regular contractions or ROM to 10 cm of dilatation & 100% effacement 2. Second Stage- 10 cm dilation to delivery of the fetus a. First sign of 2nd stage is the involuntary need to push b. Lasting 1 hour for primigravida & 15 minutes for multipara c. Begin to set up delivery table 3. Third Stage- Delivery of the fetus to the delivery of the placenta a. Average length is 5-15 minutes b. The longer the 3rd stage, the greater the chance for uterine atony or hemorrhage to occur c. Give Oxytocin after the placenta is delivered because the drug will cause the uterus to contract. If the drug is administered before the placenta is delivered, it may result in a retained placenta, which predisposes the pt to hemorrhage & infection 4. Forth Stage- Arbitrarily lasts about 2 hours after delivery of the placenta (recovery period) a. Is the first 1-4 hours after delivery of the placenta Leopold Maneuvers- Are abdominal palpations by the nurse/HCP that are determine fetal characteristics 1. Fetal Presentation The part of the fetus that presents to the inlet a. Vertex (head, cephalic) b. Shoulder (acromion) c. Breech (Buttocks) d. Other Variations- include brow (sinciput) & chin (mentum) 2. Fetal Lie- The relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother 3. Fetal Position a. A Breached position will feel soft, immovable, & large b. Vertex position will feel hard, will be moveable, and small 4. Fetal Attitude- Is the relationship of the fetal parts to one another Laboring Terms 1. Cervical Dilation- widening of the cervix measured by finger with inside the vagina, from 0-10 cm. 2. Effacement- The shorting & thinning of the cervix during the 1st stage of labor, and is represent in 0-100%, 0 being not at all effaced and 100 being the maximum effaced and ready for labor a. If the Fetus is LONG- It has not effaced at all 3. Station- Where the fetus is in relation to the ischial spines b. is ABOVE the Spins (-5 is highest up in the pelvis and works down as the fetus desends) c. + is BELOW the Spins (+ begins at +1 after the fetus has hit 0 station (engaged) which is considered the middle marking, +5 is the maximum station and indicates the head is presenting) d. If the fetus is HIGH Then its not near the spines at all 4. Engagement The decent of the head of the fetus into the mothers pelvis (0 station is engaged) EXAMPLES 1. (5/90/-1) 5cm dilated, 90% effaced, -1 station ( fetus is located ABOVE the spines) 2. (1/75/+3) 1cm dilated, 75% effaced, +3 station (fetus is located BELOW the spines) NORMAL FINDINGS FOR FETUS & MOTHER DURING LABOR ******* 1. Normal FHR in labor -110 to160 bpm 2. Normal maternal BP < 140/90 3. Normal maternal pulse < 100 bpm 4. Normal maternal temp < 100.4 F ABNORMAL FINDINGS 1. Meconium-stained fluid is yellow-green or gold-yellow & may indicate fetal stress 2. Hyperventilation results in respiratory alkalosis that is caused by blowing off to much CO2 a. Symptoms include: i. Dizziness , Tingling of the fingers & Stiff mouth b. Treatment: Have mother breathe into her cupped hands or paper bag in order to rebreathe CO2

Nursing Implications Add oxytocin to IV fluids 1. Piggyback at the lowest port on the primary IV line 2. using the lowest port ensures that very little oxytoin will be in the primary if an emergency requires DC of the drug 3. Begin infusion slowly & increase at 20-30 minute increments until contractions occur every 2-3 minutes, are 40-60 seconds in duration, & are firm Give IMMEDIATELY after delivery of placenta to avoid a trapped placenta Continue to monitor vaginal bleeding & uterine tone May stimulate let-down milk reflex & flow of milk when engorged Methylergonovine maleate Uterine Atony Hypertension Use W/caution in pt with elevated BP or Preeclampsia (Methergine) Take BP prior to administration & if 140/90 or above withhold the med and notify the physician Prostaglandin F2 Uterine Atony Headache Contraindicated for clients with Asthma (Hemabate) Nausea & Vomiting May be given intramyometerially (Within the muscular coat of the uterus) by the provider Fever Check Temperature every 1-2 hours Bronchospasm, wheezing Auscultate breaths sounds frequently Methergine is not given to clients with hypertension because of its vasoconstrictive action. Pitocin is given with caution with those with hypertension Never give Methergine or Hemabate to a client while she is in labor or before delivery of the placenta Pitocin Calculations 1U=1,000 miliunits (MU) Available: 20U Pitocin in 1000ML D5LR 1. Convert given units to miliunits 20U x 1000mu= 20,000 mu 4. Get the hourly rate 1min X 60min = 54mL/hr 0.9mL X Prescribed: 18 miliunits(mu) / minute (min) 2. Calculate MU in 1 ml X 1ml 1,000ml 20,000mu X Solve: how many mL/hr?

COMMON MEDS USED IN MATERNITY **** Categories 1. UTERINE STIMULANTS Drugs Indications Adverse Reactions Oxytocin, synthetic Uterine Atony Severe afterpains in multipara (Pitocin, Syntocinon) Hypertension

= 20,000mu/1ml

3. Determine how many mL needed to obtain 18MU 20mu X 18mu = 0.9mL 1ml X

2. ANALGESICS Drugs Fentanyl (Sublimaze) Morphine Sulfate (MS Cotin)

Indications Narcotics: Used to produce analegesia, euphoria, & sedation in labor

Butorphanol Tartrate (Stadol) Nalbuphine (Nubain) Nalonone HCL (NARCAN)

Opoid agonist/antagonist Provision of analgesic in labor Narcotic analgesia Narcotic ANTAGONIST used to counteract narcotic effects on mother/fetus

Adverse Reactions Fetal narcosis, distress Hypotension Itching Urinary Retention Respiratory Depression Women with preexisting narcotic dependency will experience withdrawal symptoms immediately (Abstinence Syndrome) Decreased respirations rarely occur

Nursing Implications Record use accurately DO NOT administer if RR < 12 breaths/min Have narcotic antagonist available (Narcan) Monitor VS (BP, HR, RR) closely Use W/caution in pt with elevated BP or Preeclampsia Take BP prior to administration & if 140/90 or above withhold the med and notify the physician They have less respiratory depression risk than morphine Monitor RR closely because drug action is shorter than narcotic (may need to readminister) Pain returns after administration Can be given to newborn post-delivery to counteract narcotic depression

3. POSTPARTUM DRUGS Drugs Bisacodyl (Dulcolax) Docustae Sodium (Colase) Rho (D) Immune Globulin RhoGAM

Indications Constipation Prevention of Rh isoimmunization with next pregnancy

Adverse Reactions Abdominal cramping None known

Rubella Vaccine

Rubella titer of <1:10 or enzyme immunoassay (EIA) of <0.10

Transient begin arthalgia or rash Hypersensivity if allergic to DUCK eggs Slight increase in temp

Nursing Implications May have some burning in the rectum with suppository Encourage fluid intake Given Rh-negitive mothers after a miscarriage or abortion or after any procedure the increases maternal-fetal blood exchange (amniocentesis, PUBS, abdominal trama) Given routinely to Rh- mothers at 28 weeks Given to Rh- mothers after delivery when the fetus is identified as Rh+ Must be given within 72 hours of delivery Never given to the father or infant Always given IM Its a blood product so: It must be checked by 2 nurses Syringe must be returned to the lab w/label Not given to a mother with + Coombs test Monitor RR closely because drug action is shorter than narcotic (may need to readminister) Pain returns after administration Can be given to newborn post-delivery to counteract narcotic depression

4. Newborn Medications PROPHYLACTIC OINTMENTS (can be given up to 1hr post-delivery) Drugs Indications Adverse Reactions Nursing Implications Prevention of ophthalmia Erythromycin Most commonly used agents Place a thin line along the lower lid in conjunctival sac neonatorum & Chlamydia Tetracycline No known adverse reactions, Use only 1 tube per newborn then discard access amount trachomatis conjunctivitis except puffy eyes resulting Manipulate upper lids to ensure complete eye coverage from manipulation After 1 minute, may wipe any access from around the eyes Silver Nitrate (not used often in Prevention of ophthalmia Chemical conjunctivitis Eye prophylaxis is mandatory in the US neonatorum resulting from US because it DOES NOT (red, puffy eyes) Does not kill other organisms such as Chlamydia species protect against Chlamydia & gonorrhea exposure Staining of skin if contact Instill medication in lower conjunctival sac, making sure can cause chemical through the birth canal in a occurs drops spread over the entire eye conjunctivitis vaginal delivery Do NOT irrigate eyes following instillation Inflammation at the injection Vitamin K (Phytonadione) Give IM in the 1st hr after birth Prevention of site (AquaMEPHYTON) hemorrhagic disorder in Use the vastus lateralis muscle in the thigh newborn Hold knee secure during procedure because neonate will try Infants are born with & move during the injection sterile gut, so no enteric bacteria present for synthesis of vitamin K

Nursing Plans & interventions of the 4th stage of labor 1. Maintain pt on BR for at least 2h to prevent orthostatic Hypotension 2. Assess Vital Signs Q 15 for 1 hour & Q 30 until stable. Normal stable VS after delivery BP < 140/90 Pulse < 100 bpm RR < 24 Assess temp at the beginning of the 4th stage & prior to discharge to postpartum. If its > 100.4 F, report to the physician & monitor pt hourly for signs and symptoms of infection Assess fundal firmness & height, bladder, lochia amount, & perineum Q15 for 1 hr & Q 30 for 2 hr 3. The Fundus should be firm, midline, & at or below the umbilicus. Massage the fundus if its soft or boggy. Suspect the pt has a full bladder if the fundus is above the umbilicus & to the right side of the abdomen. 4. A FULL BLADDER is one of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery. 5. Lochia: Rubia (red), moderate amount & clots should be < 2 cm- 3cm. Suspect an undetected laceration if the fundus is FIRM & Bright RED blood continues to trickle 6. Perineum: Should always be clean, intact, & slight edematous. 7. Administer analegesics (usually codeine, acetaminophen, or ibuprofen) If narcotics are given rise side rails & place the call bell within reach. Instruct the pt not to get OOB Labor with Abalegsia or Anesthesia 1. They both are usually withheld until the midactive phase of labor a. If the pt is in the early latent phase they may retard the labor process b. If they are given in transition or in the 2nd stage, it may depress the newborn (some narcotics) 2. Most drugs are used for pain & relaxation, they cause CNS depression & can slow labor & harm fetus 3. Regional Blocks (epidural, caudal, & subarachnoid) cause a temporary interruption of the nerve impulses (especially pain) but also cause vasodilatation in area below the block, causing pooling of blood & hypotension a. Pudendal & Subarachnoid (saddle) Blocks- are used only in the 2nd stage of labor b. Peridural & Epidural blocks may be used during all stages of labor c. STOP continuous infusion at the end of stage 1 or during transition to increase the effectiveness of pushing Nursing Interventions of Regional Blocks 1. Prehydrate pt to counteract possible hypotension: 500-100ml of ISOTONIC IV fluids are infused over 20-30 minutes before initiation of the regional block 2. Place the pt in the modified Sims position or sitting on the side of the bed with heals flexed for insertion of the block 3. Ask the patient to describe symptoms after the block is placed a. A Metallic taste or ringing in the ears denote possible injection of medication into the bloodstream b. Nausea & Vomiting are the 1st signs of hypotension i. If HYPOTENSION occurs complete the following 1. Immediately turn the pt to the left side 2. Increase IV fluids 3. Begin O2 at 10L/min by face mask 4. Notify HCP STAT and have EPHEDRINE available at the bedside 5. Assess FHR c. Warmth & tingling in the ball of the foot or bog toe- Are the 1st signs of a blocks effectiveness 4. Do not give PO medications. Labor retards GI activity & absorption 5. Administer meds preferably IV, because onset & peak occur more quickly & the duration of the drug is shorter but can also be given IM. (important to know the following)

a. IV Administration i. Onset: 5 Minutes ii. Peak: 30 Minutes iii. Duration: 1 Hour b. IM Administration i. Onset: within 30 Minutes ii. Peak: 1-3 hours after injection iii. Duration: 4-6 Hours 6. Always IV bolus into an IV line Slowly, at the beginning of a contraction when uterine blood vessels are constricted, so less analgesic reaches the fetus 7. Administer drugs to reduce gastric secretions: e.g Famotidine (Pepcid) or Antacids to neutralize gastric secretions. a. The most common cause for maternal death is aspiration of gastric secretions into the lungs Report the following findings to the heath care provider immediately 1. Abnormal VS 2. Uterus that does NOT become firm with massage 3. Second Perineal pad is SOAKED with blood in 15 minutes or less 4. Signs and symptoms of HYPOVOLEMIC SHOCK a. Pale, clammy skin b. Tachycardia c. Light-headedness d. Hypotensive Newborn Care & Nursing Assessment 1. Dry the infant under a warmer or by skin to skin 2. Suction mouth & nose with bulb syringe a. Suction the mouth 1st and then suction the nose b. Stimulating the nares can initiate inspiration, which could cause aspiration of mucus in pharynx 3. Keep the head slightly lower than the body 4. Assess Airway Status Assess for 5 symptoms of Respiratory Distress 1. Retractions 2. Tachypnea (RR > 60) 3. Dusky Color, Circumoral Cyanosis 4. Expiratory Grunting 5. Flaring Nares Never HYPEREXTEND the newborns neck (may close glottis) instead place the infant in the SNIFF position (neck slightly extended as if sniffing the air) to open the airway 5. Obtain an Apgar Score at 1 & 5 Minutes after birth (Max score of 10, Min score of 0) 7 to 10: Good 4 to 6: Needs moderate resuscitative efforts 0 to 3: Severe need for resuscitation Apgar score of 6 or lower at 5 minutes requires an additional apgar assessment at 10 minutes POSTPARTUM CHANGES The first step before ANY teaching is given, the nurse must assess the clients level of knowledge & to identify their readiness to learn. Nursing Plans and Interventions 1. On the 1st postpartum day the top of the fundus is located approx 1 cm BELOW the umbilicus 2. The fundus should be MIDLINE & FIRM 3. Lochia Rubia lasts 2-3 days postpartum 4. Lochia Serosa (pale pinkish to brown) lasts 1 week postpartum 5. Lochia Alba (thicker white-yellowish) discharge with leukocytes lasts up to 4 weeks postpartum

**Retained Placental Fragments- is the most common cause of uterine atony after the 1st postpartum day BreastFeeding Milk production occurs by the release of prolactin from the pituitary Avoid diets, and add 500 calories to prepregnacy intake Drink 2 quarts (8 glasses) of noncaffeniated beverages a day Avoid stress, which is the most common reason for a decrease in milk supply Newborns should remain on the breasts for 10 min, then switch to the second breast (its not longer recommended to limit breastfeeding time to 2-3 min the 1st day & 5 min the 2nd etc) Use warm water, not drying soap on nipples Let nipples air-dry for 15 min 2-3 times daily Breast creams should NOT be routinely used; colostrum bay be expressed & rubbed on nipples Nurse more frequently & manually express milk to soften areola b4 feeding to help engorgement Take warm or hot showers (water over breast promotes milk flow) Watch for symptoms of mastitis (commonly occurs when the breasts are not emptied) \ Postpartum Meds Remember RhoGam is given to an Rh- mother who delivers a Rh+ fetus & has a negative direct Coombs test. If the mother has a positive coombs test there is no need to give RhoGam because the mother is already sensitized. Postpartum Blues are usually normal and especially 5-7 days after delivery (S&S will include, unexplained Tearfulness, feeling down, & having decreased appetite) Have the Patient Report to the HCP promptly if experiencing: 1. Heavy vaginal bleeding with clots 2. Temp of 100.4 or higher lasting 24 hours or longer 3. A warm red lump in breast, Pain on urination and/or Tenderness in calf The Newborn 1. Risks during newborn transition caused by drugs & anesthesia a. Magnesium Sulfate During labor: Hypermagnesemia in the neonate causes i. Depressed Respirations ii. Hypocalcemia iii. Hypotonia (decreased muscle tone) b. Narcosis (late administration of narcotic analgesics) causes i. Decreased Respirations & Hypotonia (decreased muscle tone) Normal Newborn Vs are measured Q30 min for 2 hours then every hr for 4 hours or until stable Vital Sign Normal Value Nursing Implications Respirations 30-60 breaths/min Remember the ABCs (airway, breathing, circulation) Count 1 minute by observing abdomen or auscultating breath sounds Note 5 symptoms of respiratory distress**** 1. Tachypnea (RR > 60) 2. Cyanosis 3. Flaring Nares 4. Expiratory Grunt 5. Retractions Heart Rate 110-160 bpm, may decrease Ausculate for 1 full minute at the PMI (point of maximal as low as 100 during sleep or impulse) can increase to 180 during 3rd to 4th intercostal space crying Temperature Range: 99.7-99.4 F Rectal can perforate rectum, so it should only be inserted Or 36.5-37.5 C to inch for 5 min & hold legs firmly to prevent trauma Blood Pressure Average 80/50 mm hg Not usually measured unless problems in circulation have been assessed

Normal Newborn Physical Measurements Assessment Normal Weight Average: 7lbs 8oz Majority weigh between 2700 & 4000 g (6-9lbs) Length Average range: 18-21 inches or 46-52.5 cm Average range: 33-35 cm, its normally 2cm larger than the chest circumference Average range: 31-33cm

Nursing Implications Weigh @ birth & daily, with neonate completely naked. Normally lose 5%-15% (average 10%) of birth weight in the first week of life; weight should be documented carefully Measure from crown to rump & rump to heal, or from crown to heal at birth Tape measure placed above eyebrows & stretched around the fullest part of occiput, at posterior fontanel (FOC, frontal-occipital circumference) Tape measure is stretched around scapulae & over nipple line

Head Circumference Chest Circumference

Caput Succedaneum Is edema under the scalp, The Caput Crosses the Suture lines & is usually present at Birth Cephalohematoma (Is blood under the periosteum) Does Not cross the suture lines & manifests a few hours After birth Hypothermia (heat loss) Leads to depletion of glucose & therefore to the use of brown fat for energy. This results in ketoacidosis & possible shock Hypoglycemia 1. Perform a heal stick on infants that are a. Small for gestational age (SGA) b. Large for gestational age (LGA) c. Born to diabetic mothers d. Jittery babies with a high pitched voice Glucose Readings 1. Normal infant BS: 40-80 mg/dl 2. Report any blood sugar under 40 mg/dL in the full term infant 3. Report any blood sugar under 30 mm/dL in the preterm infant 4. Feed the baby early (breast milk or formula) if a low glucose level is detected 5. Prevent cold stress what can cause hypoglycemia Hyperbilirubinemia (access of bilirubin in the blood) Physiologic Jaundice- occurs at 2-3 days of life Pathologic Jaundice- If the jaundice occurs before 24 hours or persists for 7 days The nursing Plan 1. Stool prognosis: meconium (black, tarry, sticky) within the 1st 24 hours 2. Infant voids within 4-6 hours after birth, & only uses 1 dipper a day 3. Then at day 6 the infant should be using 6-8 dippers a day 4. Do not feed a newborn if their RR is above 60 breaths/min. a. Inform the physician & anticipate gavage feedings in order to prevent further energy utilization & possible aspiration 5. Teach the parents not to submerge infant in water until cord falls off (7-10 days) First Trimester Bleeding Causes 1. Miscarriage (Spontaneous Abortion that is planed or unplanned that dies before 20 weeks gestation a. Nurses role: Take a blood sample and determine if the mothers B-HcG levels are rising or decreasing which can indicate the pregnancy is unwell &miscarriage is the cause for bleeding b. They usually occur between 8-13 weeks gestation & are related to chromosomal defects c. This is considered a medical emergency

Nursing Assessment: Maternal Signs & Symptoms of Miscarriage 1. Uterine cramping, backache, & pelvic pressure 2. It does cause Bright-Red vaginal bleeding a. Note the number of peri pads that are used per hour b. Note symptoms of shock i. Rapid, thread pulse ii. Pallor iii. Hypotension iv. Cool clammy skin 2. Gestational Trophoblastic Disease (Hydatidiform Mole AKA molar pregnancy) Placenta forms a grapelike shape and is a non-vital organ hCG levels need to be measured until they return to 0, to determine the placenta is gone Educate pt to avoid pregnancy for 6-12 months because choriocarcinoma may develop & hCG levels will not decrease with pregnancy and may mask this occurrence Molar pregnancy can cause Preeclampsia before 20 weeks 3. Ectopic Pregnancy Fertilized ovum is implanted OUTSIDE the uterine cavity, usually in the fallopian tube Suspect an ectopic pregnancy in any woman who reports to the ER with unilateral or bilateral abdominal pain. Causes for bleeding in the 2nd or 3rd trimester 1. Abruptio Placentae 2. Placenta previa Clients with either above should never undergo abdominal or vaginal manipulation No Leopold Maneuvers No vaginal exams No rectal exams, enemas, or suppositories No Internal fetal monitoring 3. Disseminated Intravascular coagulation (DIC)- Is a syndrome of abnormal clotting that is systematic & pathologic. Lg amounts of clotting factors, especially fibrinogen are depleted, causing widespread external & internal bleeding. DIC is related to fetal demise, infection, preeclampsia, abruption placentae & sepsis. Anemia- A decrease in the oxygen-carrying capacity of blood; often related to Iron deficiency & reduced dietary intake IRON Drugs Indications Adverse Reactions Nursing Implications Ferrous Sulfate Iron deficiency Constipation Iron is best absorbed on an EMPTY stomach anemia (Feosol) Diarrhea To be taken with Vitamin C such as OJ to increase absorption Gastric irritation Nausea or Vomiting Should NOT be taken with cereal. Eggs, or milk which decreases absorption Should be taken in the evening if problem exists with morning sickness Stools will turn dark-green or black Lab values should be checked for increased reticloiytes & rising Gfb & Hct Nursing Assessment of Anemia 1. Fatigue, Pallor 2. Labs: HGB < 10- 11 g/dl & HCT <32-37%

DESCRIPTION & COMPARISON Abruptio Placentae a. A partial or complete premature detachment of the placenta from the site of implantation in the uterus b. Usually occurs in the late 3rd trimester or in labor c. Is the cause for 15% of maternal deaths d. Causes are unknown but are related to Hypertensive Disorders High gravity Abdominal Trauma Short umbilical cord Cocaine abuse NURSING ASSESSMENTS Severe Painful Bleeding: Concealed or overt (if overt: dark red) Uterine tenderness Persistent abdominal pain Rigid, boardlike abdomen FHR abnormalities NURSING INTERVENTIONS a. Institute bed rest with NO vaginal or rectal manipulation & notify the HCP immediately b. Monitor BP & pulse every 15 minutes c. Start IV fluids d. Apply external uterine & fetal monitor e. Place the client in the side-lying position to increase uterine perfusion f. Administer O2 by face mask g. Watch for signs of developing DIC 1. Bleeding gums or nose 2. Reduced lab values: Platelets, fibrinogen & prothrobin 3. Bleeding from injection or IV sites 4. Ecchymosis f. Prepare for immediate C-Section because uteroplacental perfusion to the fetus is compromised by early separation of the placenta from the uterus g. Monitor blood loss: Save all pads & linens

Placenta Previa a. Abnormal implantation of the placenta in the lower uterine segment b. Bleeding usually begins in the 3rd trimester c. Degrees of previas 1. Partial- The placenta lies over a part of the cervical OS 2. Complete- Placenta lies over the entire cervical OS 3. Marginal- Edge of placenta meets the rim of the cervical OS 4. Low-Lying- Placenta implants in the lower uterine segment with a placental edge lying near the cervical OS d. Associated with previous uterine scares, usually surgery & fibroid tumors

Painless, Bright Red vaginal bleeding Soft Uterus Possible signs of shock Placenta in lower uterine segment (indicated by ultrasound) FHR is usually normal a. Use bed rest to extend the period of gestation until fetal lung maturity is achieved (determined by L/S ratio 2:1 b. Monitor BP & pulse every 15 minutes c. Start IV fluids d. Obtain blood specimen for CBC, clotting studies, Rh factor, & type/crossmatch e. Monitor FHR & contractions via external uterine fetal monitor f. Place side-lying g. Monitor blood loss h. Prepare for C-section if previa is complete

COMPLICATIONS 1. Dystocia- Difficult birth resulting from any cause a. Can result from any one of the following 5 Ps: 1. Powers- primary uterine contractions & secondary abdominal bearing-down efforts 2. Passage- maternal pelvis, uterus, cervix, vagina, perineum 3. Passenger- fetus & placenta 4. Psyche- response to labor by the woman 5. Position- position of the laboring woman b. Dystocia is suspected when there is: 1. A lack of progress in cervical dilatation 2. A lack of fetal decent 3. A lack of change in uterine contraction characteristics (frequency, strength, & duration) c. Dystocia, dysfunctional labor, & uterine inertia are terms used interchangeably Nursing Assessment a. Hypertonic or hypotonic uterine contractions b. Inability to bear down or push efficiently c. Prolonged labor patters Nursing Interventions a. Notify HCP if prolonged labor patterns occur according to the Friedman curve b. Assist with diagnostic procedures (ultrasound, pelvimetry, vaginal exam) to rule out Cephalopelvic disproportion (CPD) c. Assist with amniotomy: AROM may enhance labor forces i. FHR is assessed immediately after rupture of membranes to determine if there is a cord prolapse ii. Assess fluid for color, consistency, odor (blood, meconium, or vernix particles) d. Initiate oxytocin for induction or augmentation (stimulation) of labor, & manage infusions a. Uterine Tetany is a harmful complication of induced labor b. The desired effect of oxytocin is contractions every 2-3 minutes with a durations no longer than 90 seconds. c. Tachysystole- is more than 5 contractions in 10 minutes with each contraction being less than 2 minutes apart, not allowing the fetus time to relax d. If tetany occurs: a. Turn off the oxytocin b. Turn the pt to the side c. Administer O2 by face mask d. Check urine output should be at least 100ml/4hr e. Oxytocins most important side effect is its antidiuretic (ADH) effect, which can cause water intoxication. Using IV fluids containing electrolytes decreased the risk for water intoxication. 2. Shoulder Dystocia Results when the anterior portion of the neonates shoulder gets stuck behind the mothers pelvis bone during labor. Nursing Interventions Immediately apply superpubic pressure (not fundal pressure) or Place the mother in mcroberts maneuver with the legs spread as wide open as possible The nurse needs to count how long the baby was stuck inside the mother A broken shoulder often results which predisposes the infant to brachial plexus damage

HYPERTENSIVE DISORDERS OF PREGNANCY 1. Gestational Hypertension- BP elevation (greater than 140/90 on more than 2 occasions) occurs for the first time after midpregnancy a. There is No Proteinuria noted in the patients with only gestational HTN 2. Preeclampsia- It is a pregnancy-specific syndrome that usually occurs after 20 weeks gestation (only except in the case of a molar pregnancy) a. This involves gestational hypertension BP greater than 140/90 and proteinuria b. Mild Preeclampsia BP > 140/90 & 300mg or less of proteinuria c. Severe Preeclampsia BP> 160/110 & 2G of Proteinuria 3. HELLP Syndrome- Hemolysis, elevated liver enzymes, low platelets a. Variant of severe preeclampsia 4. Eclampsia- Seizures (with no known cause) plus all symptoms of severe preeclampsia Preeclampsia & Eclampsia Characterized by elevated BP & proteinuria It usually develops during the last 10 weeks gestation or up to 48 hours post-delivery Occurs primarily in primigravida There is no know cause by its characterized by: o Generalized vasospasm & vasoconstriction leading to vascular damage over time o Loss of plasma protein into the interstitial spaces (fluid is drawn into the extravsacular spaces, which results in HYPOVOLEMIA) o Hypovolemia results in decreased perfusion to major organs, including the uterus Risk factors associated with Preeclampsia Age: under 17 or above 34 Low socioeconomic status Poor protein intake Previous HTN Diabetes Multiple gestations Molar pregnancy Prior pregnancy with preeclampsia Family history (mothers or sisters with preeclampsia) Types and Characteristics of Preeclampsia 1. Mild Preeclampsia BP rise to 30 mm Hg systolic & 15 mm Hg diastolic over previous baseline, or 140/90 or greater Proteinuria of 0.3g in a 24 hour urine collection specimen Weight gain >2lbs a week Edema, especially periorbital (around the eyes) or puffy eyes face, & fingers Reflexes may be normal or 2+ CNS symptoms: Possible mild headache, slight irritability IUGR, evidence by size-date discrepancy 2. Severe Preeclampsia (all of the above symptoms, plus any 2 of the following) BP 160/110 on 2 or more occasions Proteinuria of 2+ or 3+ (or 2-3g in a 24 hour urine collection) Generalized edema Deep tendon reflexes (DTR) 3+ or greater plus clonys Oliguria (less than 100ml/4hr) CNS Symptoms: Severe headache, visual disturbances (blurred vision, photophobia, blind spots) Elevated marked serum creatinine, thrombocytopenia (low platelets normal 150,000-400,000) & marked liver enzyme elevation (AST) with epigastric pain related to liver spasms

3. HELLP Syndrome Is characterized by hemolysis, elevated liver enzymes, & low platelets There is an increased risk for placenta abruption, acute renal failure, hepatic rupture, preterm birth, & fetal or maternal death Most common in while multiparous women S&S include o History of malaise o Epigastric or right upper quadrant pain o Nausea & vomiting Many women are normotensive and do NOT have proteinuria **** These woman are still treated prophylactically with Magnesium Sulfate even if HTN is NOT present (because of the increased CNS irritability) Nursing Care for clients with Preeclampsia Antepartum Home management Absolute bed rest with only BRP Daily weights and report a 2>lb increase in 1 week Test urine daily for protein Provide pt with a list of symptoms to report to the HCP immediately o CNS symptoms visual disturbances, convulsions, headache, nausea & vomiting, & hyperreflexia o Hepatic sign: right upper quadrant or epigastric pain o Renal sign: oliguria, proteinuria o Fetal distress, decrease or absent fetal activity or extreme fetal activity o Signs of abruptio placentae: Vaginal bleeding & abdominal pain o Malaise Teach prescribed diet o High protein o Limited salt intake (not completely restricted) o Maintenance of minimum of 35 cal/kg of body weight Hospital Management If mild becomes severe hospitalization will be necessary Monitor LOC, BP, & VS Q4H, or more often if levels are elevated or abnormal Obtain fetal assessment continuously with external fetal monitor Assess for vaginal bleeding & abdominal pain Provide BR in left side lying position Start IV fluids Insert catheter to monitor urine output, & monitor I&O hourly Administer Magnesium Sulfate & antihypertensive drugs (rare unless diastolic BP consistently over 100) & possibly oxytocin Assess for coagulopathy Petechiae under BP cuff Platelet &/or Fibrinogen decrease or increase Assess DTR Transfer to labor and delivery if the following occur Signs of pulmonary edema HELLP syndrome occurs Late decelerations in FHR occur Preterm labor begins

Intrapartum 1. When a pt with preeclampsia is in labor control the amount of stimulation in the room 2. Monitor BP Q15-30 min 3. Check DTR & urine for protein Q1H 4. Administer Magnesium Sulfate IV loading dose administered over 15-30 minutes Infusion of 2g/hr after loading dose 5. Monitor for Magnesium Toxicity Urinary output < 30ml/hr Respirations < 12/min DTR absent Decelerations of FHR, bradycardia 6. If Seizure occurs Stay with the Pt and use the call button to summon for help Have someone get the HCP STAT Turn pt on the side to prevent aspiration DO NOT attempt to force objects inside pt mouth Administer O2 at 10L/min by face mask & have suction available Administer Mag Sulfate as ordered The major goal of nursing care for a pt with preeclampsia is to maintain uteroplacental perfusion & prevent seizures The cure for Preeclampsia- is delivery, but remember the pt can still convulse for up to 48hr post-delivery Rarely are antihypertensives used, only when diastolic BP is >110 (pt at risk for stoke) o If used the choice is Hydralazine HCL (Apresoline)

Medications for Intrapartal Complications Drugs Indications To stop preterm labor Terbutaline sulfate contractions (brethine)

Magnesium Sulfate

CNS depressant administered to preeclampsic pt to prevent seizures May be used as a tocolytic to stop preterm labor contractions Calcium channel blocker Relaxes smooth muscle of the uterus by blocking calcium Used as a tocolyitc to stop preterm contractions

Adverse Reactions CNS effects 1. severe nervousness 2. tremulousness 3. headache CV effects 1. palpitations 2. tachycardia 3. chest pain 4. pulmonary edema GI effects 1. Nausea & vomiting 2. diarrhea 3. epigastric pain Lab value distortions 1. Low K+ 2. Hyperglycemia CNS depression symptoms 1. Depressed respirations & DTR Decrease UO Pulmonary edema

Nursing Implications Administer IV Increase rate Q15min Obtain ECG & labs prior to infusion Maternal pulse should not exceed 140bpm FHR should not exceed 180bpm I&O & daily weight Notify HCO of: 1. High pulse, abnormal FHR & labs 2. Signs of heart failure: dyspnea, jugular vein distension, dry cough, rales in lungs 3. have antidote available (betablocking agent such as Proprenolol) Hold if RR<12/min or UA is <100ml/4hr Absent DTR Report nontherapeutic values >8mg/dl (Therapeutic magnesium levels 47mg/dl) ** Have antidote readily available which Is Calcium Gluconate ****** Check BP for hypotension b4 administration Avoid use with Mag Sulfate: can cause severe hypotension Rise slowly from lying-sitting-standing Do not use sublingual route of administration

Nifedipine (procardia)

Indomethacin (Indocin)

Prostaglandin synthetase inhibitor (NSAID) Relaxes uterine muscle Used only when other methods fail & less than 32 weeks gestation

Maternal 1. Hypotension 2. Fatigue 3. Overdose produces: nausea, drowsiness, confusion, slurred speech 3. Peripheral edema 4. Facial flushing Newborn 1. Problems related to uteroplacenal perfusion Maternal: N&V, dyspepsia, pyrosis, dissiness, reduced platelts, oligohydramnios Fetal: Premature closure of duct in heart, decrease renal fx, respiratory distress, hemorrhage, HTN

Administer for 48 hours or less Do not use in woman with bleeding issues Determine amniotic fluid volume Administer with food or use rectal route to decrease GI distress Monitor for postpartum hemorrhage

Diabetes Mellitus Hormonal changes act to increase maternal cell resistance to insulin so that an abundant supply of glucose is available to the fetus There is a diabetogenic effects in the pregnant woman that is produced by the placenta and causes an insulin resistance, it peeks in the late 2nd trimester and early 3rd, which is when the screening test is done If insulin cannot move glucose into maternal cells, the mother will begin to metabolize fat & protein for energy-producing ketones & fatty acids, which results in ketoacidosis Predisposing Factors Family history History of 1or more than 2 spontaneous abortions Hydramnios Previous baby with a weight > 4000g (8lbs 13.5oz) or macrosomic baby > 45000g (9.5lbs) Previous baby with congenital abnormalities High parity Obesity Recurrent vaginitis Glycosuria Abnormal glucose screen: a 1-hr glucose screen is done routinely on woman 24-26 weeks gestation Pt does not fast for this test, 50g of glucose is given & blood is drawn after 1 hour. If the blood glucose is greater than 140mg/dL, a 3 hr glucose tolerance test (GTT) is done Elevated glycosylated hemoglobin A1c- is used to evaluate diabetic control by reflecting blood glucose level During the previous 6-8 weeks. ( Normal A1C for pregnancy need to be less than 6%) Symptoms of Diabetes (three Ps) 1. Polyphagia 2. Polydipsia 3. Polyuria Insulin needs In the 1st trimester- May DECREASE, increasing a risk for HYPOGLYCEMIA 2nd & 3rd trimester- insulin needs increases, which also increases the risk for HYPERGLYCEMIA Nursing Interventions Teach home glucose and urine monitoring Demonstrate insulin administration Identify signs of Hyper vs Hpoglycemia *** Dietary consult to teach o Calories: 35-50cal/kg of ideal body weight o Complex carbs are 50% of diet o Protein are 20% of diet o Fat: less than 30% of diet o Distribute calories between 3 meals and 4 snacks Situations that complicate diabetic control: illness, diarrhea, vomiting Drink a glass of OJ followed by a glass of low fat milk for hypoglycemic or insulin reaction Signs and symptoms of ketoacidosis (DKA)**& tell pt to report to the hospital o Fruity breath o Nausea and vomiting o Exaggerated respiratory efforts o Altered mental state Possible induction of labor at 38-40 weeks Oral hypoglycemics are not taken during pregnancy because of potential teratogenic effects Maintain blood glucose levels at 70-90mg/dl during labor & fingersticks 60-80mg/dl Breastfeeding decreases insulin requirements

Postpartum Hemorrhage- a leading cause of maternal mortality Excessive uterine bleeding during the 1st hour following delivery (hemorrhage, more than 1 saturated pad every 15 minutes) Blood loss of more than 500ml during a vaginal delivery Signs of hypovolemic shock 1. decreased BP 2. weak, rapid pulse 3. cool clammy skin, colored ashen or gray Signs of hematomas developing in perineum 1. intense perineal pain 2. swelling & black-blue discoloration of the perineum 3. pallor, tachycardia, & hypotension 4. possible urinary retension, uterine displacement signs of bleeding from an unrepaired laceration 1. continuous trickle from the vagina 2. bleeding in spurts 3. bleeding in the presence of a contracted fundus signs of bleeding from uterine atony 1.soft, boggy uterus usually ABOVE the umbilicus 2.fundus that doe not firm with massage Immediate nursing actions when postpartum hemorrhage is detected 1. Perform fundal massage 2. Notify the HCP if the fundus does not become firm with massage 3.count pads to estimate blood loss 4.assess & record VS 5.increase IV fluids 6.administer oxytocin infusion as prescribed Newborn assessment 1. Low birth weight (LBW) 2500 g or less 2. Very low birth weight (VLBW) 1500g or less) Jitteriness- is a clinical manifestation of hypoglycemia & hypocalcemia. Labs are the only way to differentiate Between the 2 causes. To avoid metabolic problems brought on by cold stress the nurse must prevent loss of body heat in the newborn. Neonates produce heat by nonshiving thermogenesis, which involves the burning of brown fat. The neonate is easily stressed by hypothermia & develops acidosis as a result of hypoxia. If the neonate is in a cold stress warm them over 2-4 hours because rapid warming may produce apnea Signs and symptoms the neonate is cold 1. prolonged acrocyanosis 2. skin mottling 3. tachycardia 4. tachypnea Hyperbilirubinemia- excessive accumulation of bilirubin in the blood due to RBC hemolysis Total bilirubin determinations levels increasing more than 5mg/day term level > 12mg/dl LBW level 10-12 mg/dl or greater Preterm level >5mg/dk