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406 Cards in this Set
- Front
- Back
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3 factors which oppose the initiation of respiratory activity in the neonate
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contracting force between the alveoli (alveolar surface tension; viscosity of lung fluid within the respiratory tract; ease with which lung is able to fill with air (lung compliance)
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how soon can fetal respiratory movement be seen
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as early as 5-6 weeks
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what is surfactant and what does it do
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lipoprotein produced by lungs that reduces surface tension within the alveoli
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normal newborn respiratory rate
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30-60
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newborns are obligatory ? Breathers
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nose
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retractions
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increased use of intercostal muscles; may indicate respiratory distress
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describe the mechanical events of initiation of breathing
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increased intrathoracic pressure as chest is squeezed through birth canal removes fluid from lungs; negative intrathoracic pressure after birth occurs when the chest recoils producing a small passive inspiration of air; positive intrathoracic pressure occurs when the newborn exhales and cries with a partially closed glottis
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thermal stimuli that help initiate breathing
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cold stimulates nerve endings and newborn responds with rhythmic respirations
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excessive cooling of the newborn at birth can result in
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profound resp depression and evidence of cold stress
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3 factors opposing the first breath
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alveolar surface tension-contracting force between alveoli; viscosity of lung fluid within the resp tract; lung compliance-ease with which lung is able to fill with air
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list the 3 shunts
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ductus venosus, foramen ovale, ductus arteriosus
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ductus venosus
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fetal blood vessel that carries oxygenated blood between the umbilical vein and the inferior vena cava, bypassing the liver; it becomes a ligament after birth
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ductus arteriosus
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communication channel bw the main pulmonary artery and the aorta of the fetus; obliterated after birth by rising PO2 and changes in intravascular pressure; normal becomes a ligament but sometimes remains patent (a treatable condition)
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foramen ovale
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special opening between the atria of the fetal heart; normally closes shortly after birth; if remains open, can be repaired surgically
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we measure a newborn's heart rate for ? Secs
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60
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normal heart rate of newborn
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120-160 bpm
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what % of murmurs in newborns are NOT associated with anomalies
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90%
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physiologic anemia of infancy
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a harmless condition in which the hemoglobin level drops in the first 6-12 weeks of life, then reversts to normal levels
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why is leukocytosis normal for newborns
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increased neutrophil production results from the stress of birth
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approx blood volume of newborns
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80-85 ml/kg of body weight
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factors that affect newborn blood volume
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delayed cord clamping, gestational age, prenatal and/or perinatal hemorrhage; site of the blood sample
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normal term newborn hematocrit
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43-63%
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normal term newborn hemoglobin
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14-20 g/dL
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normal term newborn WBC
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10-30K/mm3
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normal term newborn neutrophils
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40-80%
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normal term newborn platelets
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150-350K/mm3
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normal term newborn RBC
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5.1-5.3 million/mL
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normal sodium for newborn
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129-144
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normal potassium for newborn
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3.4-9.9
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normal chloride for newborn
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103-111
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normal calcium for newborn
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8.2-11.1
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normal glucose for newborn
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45-96
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convection
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loss of heat from warm body surface to cooler air currents
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radiation
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when heat transfers from body surface to cooler surfaces and objects not in direct contact with the body
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evaporation
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loss of heat when water is converted to a vapor
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conduction
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loss of heat to a cooler surface by direct skin contact
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examples of conduction
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contact with cold or wet objects
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examples of radiation
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cold windows and walls
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examples of convection
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drafts and cold air
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examples of evaporation
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deliver, bathing, damp linens
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neutral thermal environment zone
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specific environmental temp range where rates of oxygen consumption and metabolism are minimal and internal body temp is maintained because of thermal balance
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neutral thermal zone for a newborn
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89.6-93.2F or 32-34C at 50% humidity
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nonshivering thermogenesis
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unique to newborn; occurs when skin receptors perceive a drop in the environmental temp and transmit sensations to stimulate SNS; breaks down brown adipose tissue for heat
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primary source of heat in the hypothermic newborn
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nonshivering thermogenesis from brown adipose tissue
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why do newborns have a higher rate of heat loss than adults
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decreased subq fat; thin epidermis; blood vessels are close to the skin
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what are complications of cold stress to a newborn
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resp distress, hypoglycemia, decreased surfactant production, metabolic acidosis, jaundice
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a term newborn whose mother had adequate iron intake has enough iron stores to last ? Months
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5
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main source of energy for newborn in first 4-6 hours
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glucose
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unconjugated bilirubin
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breakdown product derived from hemoglobin released primarily from destroyed RBCs
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physiologic jaundice
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caused by accelerated destruction of fetal RBCs, impaired conjugation of bilirubin and increased bilirubin absorption from intestinal tract; normal biologic response of newborn
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factors that contribute to physiologic jaundice
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increased amounts of bilirubin delivered to the liver; defective hepatic uptake of bilirubin from the plasma; defective conjugation of the bilirubin; defect in bilirubin excretion; inadequate hepatic circulation; increased reabsorption of bilirubin from the intestine
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how does jaundice present
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yellowish coloration of the skin and sclera of the eyes that develops from deposits of the yellow pigment bilirubin in tissues
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pathologic jaundice
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occurs in first 24 hours and is caused by excessive destruction of RBCs, infection or maternal fetal blood incompatibilities
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breastfeeding jaundice
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occurs when bilirubin rises about the 4th day after mature breast milk comes in; peaks at 2-3 weeks of age; occurs in response to breastmilks higher concentration of FFA which compete with bilirubin for binding sites; interruption of breastfeeding for 24 hours is usually recommended
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nursing care for jaundice
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maintain skin temp at 97.8F; encourage early feeding to promote intestinal elimination and bacterial colonization and provide caloric intake; keep well hydrated and promote intestinal elimination; phototherapy
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why is vitamin K given at birth
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coagulation factors are activated by vitamin K; the newborn gut lacks the flora to synthesize vitamin K so we give it prophylactically to prevent bleeding disorders
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why do we see regurgitation in the first few days of newborn life
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cardiac sphincter of stomach (top one) may be immature; regurgitation should be small and decrease
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a newborns stomach empties after how long
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2-4 hours after feeding
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an initial weight loss of what is normal
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5-10%
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how many g per day should newborn grown
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30g/day
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how many calories does a newborn require to grow 30g/day
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120 cal/kg/day
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meconium
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formed in utero from amniotic fluid, intestinal secretions and mucosal cells; thick black or dark green stool
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first bowel movement of newborn occurs when and consists of what
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within 24 hours; meconium
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what do transitional stools look like
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thin brown to green consisting of meconium and fecal material
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describe the appearance of breast milk stools
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yellow gold or green; soft or mushy; more frequent at first
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describe the appearance of formula milk stools
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paler yellow than breast milk stools; formed or pasty; frequency varies
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immunoglobulins acronym
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GAME
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function of IgG for newborn
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confers passive immunity through placental transfer during 3rd trimester; lasts 4 weeks to 8 months
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function of IgA for newborn
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provides protection on secreting surfaces such as resp tract, GI tract, eyes; does not cross placenta; colostrum is high in IgA
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function of IgM for newborn
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produced in response to blood group antigens, gram negative enteric organisms and some viruses in expectant moms; does not normally cross placenta; elevated levels at birth indicate placental leaks or antigenic stimulation in utero
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growth of the newborn progresses from what to what
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head to toe; cephalocaudal
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first period of reactivity
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lasts for 30 minutes after birth; alert and ready to breastfeed; may be tachycardic/tachypnic; sleep phase lasts up to 4 hours
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second period of reactivity
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awake alert for 4-6 hours; increased HR/RR; apnea and bradycardia may occur; color fluctuations; GI tract becomes more activ
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sleep states
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deep or quiet sleep; active rapid eye movement
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alert states
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drowsy or semidozing; wide awake; active awake; crying
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habituation
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ability of newborn to process and respond to visual and auditory stimulations; then with repeated stimulation the response diminishes; ability to down play repetitive stimuli
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orientation
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ability to be alert to, follow and fixate on complex visual stimuli; useful in becoming familiar with family, friends, surroundings
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self quieting
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ability to self quiet and comfor themselves through hand to mouth, sucking tongue or fist or attuning to a sound or object
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when do we assess newborns
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at birth; 1-4 hours; prior to discharge
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physical assessment to determine age must be done within
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first 4 hours of life or will not be accurate
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the more creases on the newborn foot the ? It is
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older
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vital signs of the newborn should be monitored how often
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at least every 30 mins until has remained stable for 2 hours
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the initial newborn temp is taken by what method and why
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rectal to determine anal patency
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what is the preferred method of taking the newborns temp
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axillary
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acrocyanosis
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bluish discoloration of hands/feet; poor peripheral circulation from vasomotor instability; normal
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mottling
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lacy pattern of dilated blood vessels; general circulation fluctuations; may be caused by chilling or apnea
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erythema toxicum
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newborn rash; will appear suddenly usually over the trunk/diaper area; usually lasts 2-3 days
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milia
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exposed sebaceous glands; raised white spots on face; no treatment; clear spontaneously; do NOT pinch or prick
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vernix caseosa
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white cheesy substance covering the fetus in utero
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telangiectatic nevi (stork bites)
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pale pink to red spots frequently around the eyes, nose, base of occipital bone and nape of neck; no clinical significance; usually fade by 2
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mongolian spots
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blue black or gray blue hyperpigmented areas on buttocks and back; common in asian and african decent babies; usually fade during 1st and 2nd years
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nevus flammeus (port wine stain)
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benign capillary angioma just below the epidermis; nonraised with sharp lines of demarcation; usually red to purple in color; common on the face; size remains stable and do not fade; if seizures or neuroloic s/s occur may suggest sturge-weber syndrome; can be treated with laser
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nevus vasculosus (strawberry mark)
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capillary hemagioma; raised, clearly delineated, dark red, rough surfaced birthmark commonly found in head region; grows rapidly then shrinks and resolves spontaneously
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molding
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overriding of cranial bones during labor/delivery; will resolve in a few days
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cephalohematoma
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collection of blood resulting from ruptured blood vessels bw surface of cranial bone and periostal membrane; scalp feels loose and edematous; may dissappear within 2-3 months; may be associated with physiologic jaundice; large ones can lead to anemia and hypotension
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caput succedameum
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localized, easily identifiable, soft area of scalp generally resulting from long and difficult labor or vacuum extraction
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eye color is usually established when
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3 months but can fluctuate up to 1 yr
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where should ears be in relation to eyes
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ear should be parallel to inner/outer canthus of the eye
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signs of resp distress in the newborn
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nasal flaring, retractions, grunting, tachypnea
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what causes pseudomenstruation in the newborn female
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withdrawal of maternal hormones
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tonic neck reflex
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fencer position; newborn is supine and head to one side; in response, extremities on same side straighten whereas on opposite side they flex
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palmar grasping reflex
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elicited by stimulating the newborns palm with finger or object; newborn grasps and holds firmly enough to be lifted momentarily from the crib
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moro reflex
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elicited when newborn is startled by loud noise or lifted slightly above crib and suddenly lowered; in response, newborn straightens arms and hands outward while knees flex
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rooting reflex
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elicited when side of newborns mouth or cheek is touched; in response, newborn turns toward that side and opens lips to suck
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sucking reflex
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elicited when object in placed in newborns mouth or anything touches lips
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babinksi reflex
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fanning or hyperextension of all toes and dorsiflexion of big toe, occurs when lateral aspect of sole is stroked from heel upward across the ball of foot; in children older than 24 months this response indicates an abnormality
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walking or stepping reflex
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when held upright with one foot touching a flat surface, newborn puts one foot in front of other and "walks"; lost in 4-8 weeks
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trunk incurvation (galant reflex)
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seen when newborn is prone; stroking the spine causes the pelvis to turn to the stimulated side
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overall goals of newborn nursing care
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provide comprehensive care; promote establishment of new family unit
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nursing goals during first 4 hours of newborn
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maintain clear airway, neutral thermal environment; initiate oral feedings; facilitate attachment; prevent hemorrhage and infection
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how do we care for the umbilical cord
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alcohol to cord on admission and every 8 hours
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things to look for when assessing the umbilical cord
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should have 2 arteries and 1 vein; signs of bleeding; signs of infection such as foul smell or drainage
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when should newborns be given their first bath
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when axillary temp is 98 degrees or greater; thermal stability is ensured and infant is in no distress
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how should newborns be bathed and for how long
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should be sponge bathed until umbilical cord falls off; week to 10 days
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what is phytonadione
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vitamin K; aka aquamephyton; given to prevent hemorrhage
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phytonadione is given where
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1mg IM in vastus lateralis muscle on admission
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why is erythromycin opthalmic ointment given
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prophylactic treatment of opthalmia neonatorum caused by bacteria Neisseria gonorrhoeae; treatment against chlamydial infections
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erythromycin opthalmic ointment can cause
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chemical conjunctivitis; clears up in 24-48 hours
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characteristics of at risk infants for hypoglycemia
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<36 weeks gestation; infant of diabetic mother; large for gestational age; small for gestational age; gestational diabetes; heart disease; maternal drug use; resp distress
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puncture site for infant glucose check
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sides of heel; not middle
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what to do if newborn experiences resp distress
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place in isolette with 30% O2; place pulse ox; notify physician if O2 sat is <90% or if unable to wean from O2 within 3 hours
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how often should newborns be fed
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every 2-3 hours and on demand
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requirements to give systemic drugs to laboring mother
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woman is willing; stable VS; FHR 110-160; good variability; no late or variable decelerations; established labor pattern; cervical dilatation; progressive descent of baby
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which narcotic analgesic should not be given to opiate dependent patients
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fentanyl
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what is used to reverse the effects of narcotic analgesics
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narcan/naloxone
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what are analgesic potentiators
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decrease anxiety and increase effectiveness of analgesics without increasing unwanted side effects
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commonly used analgesic potentiators
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vistaril, phenergan, largon, sparine
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narcotic analgesics used in labor
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demerol, stadol, nubain, fentanyl
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regional anesthesia
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temporary loss of sensation produced by injecting an anesthetic agent into direct contact with nervous tissue
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epidural
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provides relief of pain without sedation of mom and baby; epidural space bw dura mater and ligamentum flavum at L3-L4
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adverse effects of epidural
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hypotension, prolonged second stage, resp depression, bladder distention, allergic response
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nursing care of epidural pt
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fluid bolus, positioning pt, monitor VS, assess bladder, ephedrine for hypotension
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why do we give a fluid bolus to epidural pt
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prevents mom's bp from dropping which prevents FHR from becoming bradycardic
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position for epidural
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with back bowed out
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spinal
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anesthetic injected directly into spinal fluid canal
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side effects of spinal
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hypotension, bladder distention, spinal headache
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nursing care of spinal pt
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fluid bolus, assess VS, FHR; remain in bed 6-12 hours after
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how can we relieve a spinal headache
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replace spinal fluid lost
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pudendal block
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anesthetic injected directly into the pudendal nerve
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when is the pudendal block used
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for late 1st stage, delivery and episiotomy repair
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where does the pudendal block relieve pain
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perineal distention but not uterine contractions
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local infiltration anesthesia
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for the episiotomy or repair of episiotomy or laceration; injected into perineum
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when is general anesthesia used for delivery
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for c/s if pt refuses spinal or for emergency c/s
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nursing care of general anesthesia delivery pt
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prophylactic antacid, wedge under right hip, cricoid pressure, physician gowned prior to induction, O2 3-5 5min before intubation
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side effects of general anesthesia
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fetal depression, aspiration of gastric contents, light anesthesia until infant born, uterine atony
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why does uterine atony develop from general anesthesia
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uterus goes to sleep like rest of body
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baby should be delivered within how many minutes of administering general anesthesia
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within 5 mins
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PROM
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premature rupture of membranes; spontaneous; prior to onset of labor
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PPROM
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preterm premature rupture of membranes; ROM prior to 37 weeks
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PROM is assoc with what conditions
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infection, previous history of PROM or PPROM, hydramnios, multiple pregnancy, UTI, amniocentesis, placenta previa, abruptio placentae, trauma, incompetent cervix, hx of laser conization, bleeding during pregnancy, genital tract anomalies
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maternal risks with PROM
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chorioamnionitis, abruptio placentae, endometritis
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fetal risks with PROM
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sepsis, malpresentation, prolapse of cord, RDS, nonreassuring FHR tracings, premature birth
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how do we help the babies lungs develop faster
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corticosteroids-produce surfactant
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when does preterm labor occur
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20-37 weeks
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strongest predictors of preterm birth
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cervicovaginal fibronectin; abnormal cervical length; hx of previous preterm birth; presence of infection
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abruptio placentae
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premature separation of placenta from uterine wall
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what is fetal fibronectin and what does it indicate
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a protein normally found in fetal membranes and decidua; positive test between 22 and 37 weeks indicates preterm labor
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tocolysis
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use of meds in an attempt to stop labor
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drugs used for tocolysis
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b-adrenergic agonists; magnesium sulfate; cyclooxygenase inhibitors; ccb
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s/s of preterm labor
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uterine contractions every 10 mins or less with or without pain; mild menstrual like cramps felt low in the abdomen; constant or intermittent feelings of pelvic pressure; rupture of membranes; constant or intermittent low dull backache; change in vaginal discharge; abdominal cramping with or without diarrhea
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placenta previa
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placenta implanted in lower uterine segment; uterine contractions cause placental villi to tear away from uterine wall causing bleeding
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s/s of placenta previa
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slowly progressive, bright red blood, pain only during labor, soft and relaxed abdomen
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implications of placenta previa for the fetus
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hypoxia, anemia
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three types of abruptio placentae
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marginal, central, complete
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marginal abruption
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placenta separates at edges
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central abruption
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placenta separates centrally; blood is trapped bw placenta and uterine wall
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complete abruption
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massive vaginal bleeding is seen
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s/s of abruption placentae
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sudden dark blood; severe abdominal pain; rigid abdomen
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maternal implications of abruptio placentae
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hemorrhage, renal failure, vascular spasm, intravascular clotting
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fetal implications of abruptio placentae
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anemia, hypoxia, death
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hydramnios (or polyhydramnios)
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more than 2000mL of amniotic fluid
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oligohydramnios
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less than normal amount of amniotic fluid (approx 500mL is considered normal)
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dystocia
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abnormal or difficult labor
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most common ause of dystocia
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dysfunctional uterine contractions
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describe hypertonic labor patterns
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contractions are more frequent but less effective; increased pain and fatigue
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maternal risks of hypertonic labor
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increased discomfort, fatigue, frustration, stress, dehydration, increased incidence of infection
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fetal risks of hypertonic labor
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nonreassuring fetal status, prolonged pressure on fetal head
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CPD
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cephalopelvic distortion - pelvis is not large enough for baby to get through
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hypotonic labor patterns
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less than 2-3 contractions in a 10 min period
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what usually causes hypotonic labor
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uterus is stretched from multiple gestation, presence of large fetus, hydramnios; fetal malposition, prematurity, grand multiparity
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maternal risks of hypotonic labor
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exhaustion, stress, postpartal hemorrhage; intrauterine infection
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fetal risks of hypotonic labor
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nonreassuring fetal status, fetal sepsis
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precipitous labor
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labor that lasts less than 3 hours and results in rapid birth
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contributing factors in precipitous labor
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multiparity, large pelvis, previous precipitous labor, small fetus in favorable position, strong contractions
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precipitous birth
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unexpected, sudden and often unattended birth
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maternal risks of precipitous labor
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lacerations, postpartal hemorrhage
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fetal risks of precipitous labor
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fetal distress, hypoxia, brachial plexus injuries, cerebral trauma, pneumothorax
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postterm pregnancy
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one that extends more than 294 days or 42 weeks past the first day of the last menstrual period
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postDATE pregnancy
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beyond the estimated date of birth NOT necessarily 42 weeks
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maternal risks of postterm pregnancy
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probably labor induction, increased risk of dystocia, increased risk for large gestational age infant, increased incidence of forceps assisted or vacuum assisted birth; increased risk of infection; increased risk of severe perineal trauma; double the risk of cesarean birth
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fetal risks of posterm pregnancy
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decreased perfusion from the placenta; fetal demise; oligohydramnios; meconium aspiration; low 5 min apgar score; risk for death of infant in first year of life
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why does a postterm baby begin to lose weight
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placenta stops providing adequate nutrition; known as dismaturity syndrome
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malposition
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any position that is not ROA, OA, or LOA
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most common fetal malposition
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occiput posterior position (OP)
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risks assoc with OP position
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prolonged labor, increased risk of 3rd and 4th degree lacerations
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fetal malpresentations
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brow, face, breech, transverse lie
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describe brow presentation
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forehead is the presenting part
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face presentation
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face is presenting part
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maternal fetal complications of breech presentation
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cesarean birth; perinatal morbidity and mortality; prolapsed cord; cervical cord injuries due to hyperextension of fetal neck; birth trauma
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transverse lie
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shoulder presentation
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macrosomia
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newborn weight of more than 4000g at birth (8.8 lbs)
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factors that contribute to macrosomia
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excessive maternal weight gain, maternal obesity, maternal diabetes, previous macrosomic births, grand multiparity, prolonged gestatation, ethnicity
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risks assoc with macrosomia
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increased risk of CPD, dysfunctional labor, prolonged labor, soft tissue laceration, postpartum hemorrhage; meconium aspiration, asphyxia, shoulder dystocia, brachial plexus injury, fractured clavicles
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nursing interventions for non reassuring fetal status
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02, mom to left lateral position, IV fluids, discontinue pitocin, emotional support, call physician
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prolapsed umbilical cord
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umbilical cord precedes fetal presenting part and becomes compressed bw presenting part and maternal pelvis
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implications of prolapsed cord
|
emotional distress, fetal distress, fetal death
|
|
|
treatment of prolapsed cord
|
remain in horizontal until head is engaged, examiner's gloved fingers remain in vagina to provide firm pressure on fetal head, O2, assume knee chest position, emergency C section
|
|
|
describe knee chest position of mom
|
on hands and knees; buttocks above head, brings baby back into amniotic fluid
|
|
|
amniotic fluid embolism
|
aka anaphylactic syndrome of pregnancy; in presence of small tear in amnion or chorion high in uterus, small amount of amniotic fluid leaks into chorionic plate and enters maternal system
|
|
|
complications of amniotic fluid embolism
|
material enters maternal lungs causing resp distress, circulatory collapse, acute hemorrhage, cor pulmonale, dyspnea, cyanosis, hemorrhagic shock, coma, fetal demise
|
|
|
retained placenta
|
retained placenta beyone 30 mins after birth
|
|
|
describe first degree lacerations
|
superficial tear limited to fourchette, perineal skin and vaginal mucous membranes
|
|
|
describe second degree lacerations
|
involves perineal skin, vaginal mucous membrane, underlying fascia and muscles of perineal body; may extend upward on one or both sides of vagina
|
|
|
describe third degree lacerations
|
extends through the perineal skin, vaginal mucous membranes and perineal body; involves anal sphincter
|
|
|
describe fourth degree lacerations
|
same as third but extends through rectal mucosa to lumen of rectum; may be called a third degree laceration with rectal wall extension
|
|
|
placenta accreta
|
chorionic villi attach directly to myometrium of uterus
|
|
|
placenta increta
|
myometrium is invaded
|
|
|
placenta percreta
|
myometrium is penetrated
|
|
|
primary complication with placenta accreta
|
hemorrhage; in 2/3 leads to abdominal hysterectomy
|
|
|
electronic fetal monitoring
|
continuous tracing of FHR which allows visual assessment of the FHR
|
|
|
indications for electronic monitoring
|
previous history of stillbirth at 38 or more weeks; presence of a complication of pregnancy; induction of labor; preterm labor; decreased fetal movement; nonreassuring status; meconium staining of amniotic fluid; trial of labor following a cesarean birth; maternal fever; placental problems
|
|
|
baseline rate
|
average FHR rounded to increments of 5bpm observed during a 10 min period of monitoring; excludes periodic or episodic changes, periods of marked variability and segments of baseline that differ by more than 25 bpm
|
|
|
normal FHR baseline rate
|
110-160
|
|
|
variability
|
change in FHR over a few seconds to a few minutes
|
|
|
wandering baseline
|
smooth meandering unsteady baseline in normal range without variability
|
|
|
fetal tachycardia
|
sustained rate of 161 or above
|
|
|
fetal tachycardia is considered ominous when accompanied by
|
late decelerations, severe variable decelerations or decreased variability
|
|
|
fetal bradycardia is considered ominous when accompanied by
|
decreased variability and late decelerations
|
|
|
absent variability
|
amplitude undetectable
|
|
|
minimal variability
|
amplitude detectable but less than 5bpm
|
|
|
moderate variability
|
amplitude 6-25 bpm
|
|
|
marked variability
|
amplitude greater than 25bpm
|
|
|
what is the best single predictor for determining fetal compromise
|
reduced variability
|
|
|
causes of decreased variability
|
hypoxia, acidosis, cns depressant drugs, fetal sleep cycle, fetus of less than 32 weeks, fetal dysrhythmias, fetal anomalies, previous neurological insult, tachycardia
|
|
|
causes of marked variability
|
early mild hypoxia, fetal stimulation or activity, fetal breathing movements, advancing gestational age (greater than 30 weeks), alteration in placental blood flow
|
|
|
accelerations
|
transient increases in the FHR normally caused by fetal movement; thought to be a sign of fetal well being and adequate oxygen reserve; basis for nonstress test
|
|
|
decelerations
|
periodic decreases in FHR from normal baseline
|
|
|
early deceleration
|
fetal head is compressed assoc with onset of uterine contraction; of uniform shape, usually considered benign and does not require intervention
|
|
|
late deceleration
|
caused by uteroplacental insufficiency resulting from decreased blood flow and oxygen transfer to the fetus; occurs after onset of contraction, of uniform shape; considered a nonreassuring sign and requires further assessment
|
|
|
most common causes of late deceleration
|
maternal hypotension resulting from admin of epidural anesthesia and uterine hyperstimulation assoc with oxytocin infusion
|
|
|
variable decelerations
|
onset varies with timing of contraction; variable ins hape; occur if umbilical cord becomes compressed, thus reducing blood flow to fetus; causes fetal hypertension slowing the FHR; requires further assessment and need for action of some kind
|
|
|
if the cause of variable decelerations is umbilical cord compression, what can we do first to alleviate this?
|
turn the pt to the side
|
|
|
nursing interventions for fetal resuscitation
|
oxygen via facemask; discontinue pitocin; turn pt to left side or knee chest; notify physician; hydrate pt; administer tocolytics
|
|
|
low dose pitocin protocol
|
add 20units oxytocin to 1000mL LR; titrate to achieve 7 contractions in 15 mins; start oxy at 1-2 mU/min; increase by 1-2 every 15 mins to achieve
|
|
|
maximum units of pitocin
|
do not exceed 20 mU/min
|
|
|
at what dose of pitocin do we notify the physician
|
20 mU/min
|
|
|
high dose pitocin protocol
|
20 units of oxy to 1000mL LR; start at 6 mU/min; increase by 6 every 15 mins to achieve 7 contractions per 15 minutes
|
|
|
treatment for non reassuring FHR pattern during pitocin protocol
|
hyperstimulation of non reassuring FHR=decrease oxy and resume when pattern resolves; if does not resolve, discontinue oxy and notify md; if patterns nonresponsive to discontinuation give Terbutaline 0.25mg IVP; notify MD
|
|
|
temperament
|
manner of thinking, behaving or reacting; total behavioral style; individual
|
|
|
nine attributes of temperament
|
activity, rhythmicity, approach-withdrawal, adaptability, threshold of responsiveness, intensity of reaction, mood, distractibility, attention span and persistence
|
|
|
activity
|
level of physical motion during activity such as sleep, eating, play, dressing and bathing; active vs inactive
|
|
|
rhythmicity
|
regularity in the timing of physiologic functions such as hunger, sleep and elimination
|
|
|
approach-withdrawal
|
nature of initial response to new stimulus such as people, situations, places, foods, toys and procedures
|
|
|
adaptability
|
ease or difficulty with which child adapts or adjusts to new or altered situations
|
|
|
threshold of responsiveness
|
amount of stimulation, such as sounds or light, required to evoke a response in the child
|
|
|
intensity of reaction
|
energy level of the child's reaction, regardless of quality or direction
|
|
|
mood
|
amount of pleasant, happy, friendly behavior compared with unpleasant, unhappy, crying, unfriendly behavior exhibity by child in various situations
|
|
|
distractibility
|
ease with which child's attention or direction of behavior can be diverted by external stimuli
|
|
|
attention span and persistence
|
length of time a child pursues a given activity and the continuation of an activity in spite of obstacles
|
|
|
three common categories of temperatment
|
easy child, difficult child, slow to warm up child
|
|
|
describe the easy child
|
usually positive in mood and with new stimuli; adapts to new situations; able to accept rules; works well with others
|
|
|
describe the slow to warm up child
|
reaction with mild intensity; slow adaptability to new situations; initial withdrawal followed by gradual, quiet, slow interaction with the environment
|
|
|
describe the difficult child
|
irregular schedules for eating, sleeping and elimination; adapts slowly to new situations and persons; predominately negative mood; intense reactions to the environment
|
|
|
which temperament is easiest to read for pain? Most difficult?
|
easiest will be difficult child; most difficult to tell will be easy child; we need to ask easy children
|
|
|
what is the most powerful nonpharmacologic method of pain relief for pedi patients
|
parents
|
|
|
what is the purpose of nonpharmacologic intervention
|
helps reduce the perception of pain, provide a sense of control and make pain more tolerable; decrease anxiety; enhance effectiveness of analgesics
|
|
|
examples of nonpharmacologic intervention
|
guided imagery, relaxation, acupressure, acupuncture, distraction, hypnosis, massage, heat/cold
|
|
|
type of drugs most commonly used for mild to moderate pain
|
non opiods; tylenol and acetaminophen
|
|
|
opioids are most often used for what type of pain
|
moderate to severe
|
|
|
3 most effective opiods
|
morphine, fentanyl, dilaudid
|
|
|
3 meds used besides 3 most effective
|
oxycodone, hydrocodone/codeine combined with a non opioid, neurontin
|
|
|
why are placebos not recommended for use
|
destroys client's trust in the health care professional; raises serious ethical and legal questions
|
|
|
why might younger children require higher doses of opiods than older children and adults to achieve the same effect
|
they metabolize drugs more rapidly than adults do (except infants younger than 6mo)
|
|
|
why do oral forms of opioids require higher dosages than IV forms
|
first pass effect; drug is rapidly absorbed from GI tract and enters portal circulation where it is metabolized before reaching central circulation
|
|
|
PCA pumps are given to children as young as
|
4 years of age
|
|
|
what is EMLA
|
eutectic mixture of local anesthetics (lidocaine and prilocaine) or LMX4 (lidocaine cream 4%)
|
|
|
where and when is EMLA used?
|
used on intact skin; apply 1-2.5 hours before painful event
|
|
|
what is LAT?
|
lidocain adrenalin tetracaine
|
|
|
when is LAT used
|
used prior to suturing
|
|
|
how fast does LAT work
|
anesthesia occurs within 10-15 mins
|
|
|
where is adrenalin NOT used
|
on end arterioles because of vasoconstriction
|
|
|
what are contraindications for rectal meds
|
traumatic; absorption affected by stool
|
|
|
how does rate of admin affect side effects
|
side effects increase markedly if the rate of injection is too fast
|
|
|
most serious complication of pain meds
|
respiratory depression
|
|
|
when is resp depression r/t pain meds most likely to occur
|
with initial doses when there is no history of previous exposure
|
|
|
nursing interventions for resp depression
|
reduce infusion if continuous; stimulate client; admin oxygen
|
|
|
if a pt cannot be aroused from resp depression or is apneic what do we do?
|
administer narcan (naloxone); may require repeated doses
|
|
|
resp depression due to benzodiazepines can be reversed with
|
romazicon (flumazenil)
|
|
|
very common side effect of opiods
|
constipation
|
|
|
how can we prevent opioid related constipation
|
admin stool softener or laxative; increase fluid intake; increase fiber
|
|
|
which causes more deaths: opiod related resp depression or constipation
|
constipation
|
|
|
how do we treat opioid related pruritus
|
give diphenhydramine (benadryl) or hydoxyzine (atarax/vistaril)
|
|
|
distress behaviors
|
vocalization, facial expression, body movement associated with pain; helpful in evaluating pain in infants and children with limited communication skills
|
|
|
five categories of behavior for FLACC scale
|
facial expression, leg movement, activity, cry, consolability
|
|
|
physiologic changes to pain
|
heart rate, respiratory rate, blood pressure, palmar sweating, cortisone levels, transcutaneous oxygen, vagal tone, endorphin concentrations
|
|
|
children's dosages are calculated according to body weight EXCEPT
|
when weight exceeds 50kg or 110 pounds; weight formula may actually exceed adult dosage in which case adult dose is used
|
|
|
drug tolerance
|
need for larger dose of opioid to maintain original effect
|
|
|
physical dependence
|
withdrawal symptoms when chronic use of opioid is discontinued or opioid antagonist (narcan) is given
|
|
|
narcotic addiction
|
characterized by compulsive drug seeking behavior leading to overwhelming involvement with procurement and use of opioid NOT for medical reasons such as pain relief
|
|
|
what does QUESTT stand for
|
question the patient; use pain rating scale; evaluate behavior and physiologic signs; secure family's involvement; take cause of pain into account; take action and assess effectiveness
|
|
|
what is the 6th vital sign
|
pain
|
|
|
describe the FACES pain rating scale
|
6 drawn faces; continuum from smiling to teaful; do not compare child's face with those on pain scale
|
|
|
what is the most reliable sign of pain in neonates
|
facial expression
|
|
|
describe the neonates facial expression of distress
|
eyes tightly closed or opened; mouth opened, squarish; furrowing or bulging of brow; quivering of chin; deepened nasolabial fold
|
|
|
FLACC can be used for what years
|
full term neonate to 7 years
|
|
|
what is the golden rule of pedi pain management
|
what is painful to an adult is painful to an infant or child unless proven otherwise
|
|
|
vaccine aP
|
acellular pertussis vaccine
|
|
|
vaccine ap
|
acellular pertussis vaccine; adult formation
|
|
|
D (d) vaccine
|
diphtheria vaccine (adult formation)
|
|
|
Hib vaccine
|
haemophilus influenzae vaccine; meningitis
|
|
|
Hep B vaccine
|
hepatitis B vaccine
|
|
|
IPV vaccine
|
inactivated polio vaccine
|
|
|
MMR vaccine
|
measles, mumps, rubella vaccine
|
|
|
T vaccine
|
Tetanus vaccine
|
|
|
Varicella vaccine
|
chickenpox vaccine
|
|
|
when is the cutoff for the aP vaccine
|
2 years
|
|
|
when is the cutoff for the D vaccine
|
7 years
|
|
|
when is the MMR vaccine given
|
12-18 months; second dose at least 4 weeks later but as late as 4-6 years of age
|
|
|
when is the DTaP vaccine given
|
2, 4 and 6 months; 4th dose must be given at least 6 months after 3rd dose as early as 12 months of age
|
|
|
describe active immunity
|
protection produced by own immune system; had the disease, had the vaccination, usually permanent
|
|
|
describe passive immunity
|
antibodies from another person or an animal; temporary; ie: placenta, breastmilk, blood products, antitoxin
|
|
|
describe live attenuated vaccine
|
live but weakened organism; must replicate to be effective; anything that damages the live organism or interferes with replication can cause the vaccine to be ineffective
|
|
|
live attenuated vaccines usually produce immunity with how many doses
|
1; second dose is recommended to provide a high level of immunity
|
|
|
descriibe inactivated vaccines
|
produced in culture media then inactivated with heat and/or chemicals; cannot replicate therefore cannot cause disease and require multiple doses
|
|
|
vaccines should or should not be administered when a contraindication is present
|
should NOT
|
|
|
temporary contraindications to vaccination with live vaccines include
|
pregnancy, immunosuppression
|
|
|
vaccines are ? When a precaution is present
|
deferred; only admin when vaccine benefit outweighs risk
|
|
|
if the child or parent is sick do we immunize
|
mild with or without fever, yes; moderate or severe with or without fever, DEFER
|
|
|
children with what problems should not receive live influenza vaccines
|
asthma, lung disease, heart disease, kidney disease, metabolic disease (diabetes), blood disorder
|
|
|
vaccines that are given subq
|
MMR, varicella
|
|
|
vaccines that are given IM
|
DTaP, hep b, hib, IPV
|
|
|
adverse reactions following live vaccines similar to mild form of the disease may occur when
|
7-21 days after admin of vaccine
|
|
|
list the measles
|
roseola, rubeola, rubella
|
|
|
constitutional symptoms
|
symptoms caused by or indicating systemic disease
|
|
|
enanthema
|
eruption on a mucous membrane
|
|
|
exanthema
|
eruptions or rash that appears on skin
|
|
|
prodromal
|
early symptoms that may mark onset of disease
|
|
|
why do we NOT give aspirin for fever
|
aspirin + virus increases risk for Reye's Syndrome
|
|
|
Reye's syndrome
|
toxic encephalopathy assoc with other organ involvment
|
|
|
erythema infectiousum is aka
|
parvo (not the same as the dog one) or 5th disease
|
|
|
parvo is passed through
|
respiratory secretions
|
|
|
when can pt return to school/child care with parvo
|
after the rash appears
|
|
|
constitutional signs of parvo
|
low grade fever, malaise, cold
|
|
|
describe the parvo rash
|
slapped cheeks; proximal to distal progression, may be mildly pruritic
|
|
|
interventions for 5th disease
|
keep out of direct sunlight; general interventions for fever, itching, skin care
|
|
|
roseola aka
|
exanthema subitum
|
|
|
how is roseola transmitted
|
unknown; resp secretions?....when during cycle is also unknown
|
|
|
roseola generally affects ages
|
6mo-3yrs
|
|
|
classic characteristic sign of roseola
|
high fever (104F) for 3-4 days; child does not appear sick
|
|
|
children with roseola fever are at a high risk for
|
febrile seizure
|
|
|
describe the roseola rash
|
pink, maculopapular rash; may describe as heat rash; drop in fever when rash appears; moves from trunk to neck to face to extremities; does not itch; lasts 1-2 days
|
|
|
interventions for roseola
|
general for fever and skin care
|
|
|
pertussis aka
|
whooping cough
|
|
|
pertussis is transmitted by
|
direct or indirect contact with resp secretions (DROPLET PRECAUTIONS)
|
|
|
when is pertussis contagious
|
during catarrha stage before onset of paroxysmal cough
|
|
|
pertussis pt should be on isolation until
|
5-7 days after antibiotics
|
|
|
prevention of pertussis
|
immunizations DTaP, Tdap
|
|
|
describe the catarrhal stage of pertussis
|
resp symptoms (coryza, sneezing, lacrimation, cough), low grade fever, lasts 1-2 weeks
|
|
|
describe the paroxysmal stage of pertussis
|
5-10 short rapid coughs; rapid inspiration; cyanotic or red faced; often vomit; exhausted after episode
|
|
|
describe the convalescent stage of pertussis
|
coughing gradually stops; single cough may remain for some time; paroxysmal cough may return if child develops a resp infection during convalescent stage
|
|
|
interventions for pertussis
|
leave the intercom on to listen for paroxysmal cough; cardiac monitor and pulse oximetry for very young; reduce factors that promote cough (small frequent meals; refeed after emesis); erythromycin
|
|
|
chickenpox aka
|
varicella-zoster virus; varicella-chickenpox; herpes zoster-shingles
|
|
|
when is chickenpox contagious
|
1-2 days before the onset of the rash until the lesions have crusted
|
|
|
how is chickenpox transmitted
|
direct or indirect contact with resp secretions, fluid in lesion
|
|
|
how do we prevent chickenpox
|
immunization, immune globulin in some cases
|
|
|
constitutional signs of varicella
|
temp up to 102F for 2-3 days; malaise
|
|
|
describe the chickenpox rash
|
macule to papule to vesicle to crust; head to trunk to extremities; most lesions are centripetal (found on trunk); PRURITIC!!
|
|
|
interventions for varicella
|
general for fever, skin, itching
|
|
|
when can chickenpox pt return to school
|
when all lesions are crusted
|
|
|
rubeola aka
|
measles, brown or black measles, 7 day measles
|
|
|
measles is transmitted through
|
secretions of resp tract, blood, urine; spread by droplet or airborne
|
|
|
when is measles contagious
|
4 days before to 5 days after rash appears
|
|
|
prevention of measles
|
immunization; immune globulin after exposure in some cases; maternal immunity until 12-15 months
|
|
|
constitutional signs of measles
|
fever, malaise, anorexia, lymphadenopathy, coryza (runny nose), sore throat, cough
|
|
|
symptoms of measles
|
conjunctivitis with photophobia; koplik spots
|
|
|
koplik spots
|
small, irregular, red spots with blue white centers on buccal mucosa
|
|
|
describe the measles rash
|
red maculopapular rash; begins at hairline; spreads downward then distal; confluent in early sites, discrete in later sites; turns brown after several days
|
|
|
confluent rash
|
runs together
|
|
|
discrete rash
|
space between rash sites
|
|
|
interventions for measles
|
general for fever, skin care, sore throat; vitamin A; cool mist vaporizer for coryza
|
|
|
eye care for measles
|
dim lights for photophobia; clean eyelids with warm saline solution to remove secretions or crusts; monitor cornea for signs of ulceration
|
|
|
how is mumps transmitted
|
direct or indirect contact with resp secretions; droplet precautions
|
|
|
when is mumps contagious
|
3 days before to 9 days after onset of swelling
|
|
|
prevention of mumps
|
immunization; maternal antibodies begin to disappear at 12-15 months
|
|
|
constitutional signs of mumps
|
fever, ha, anorexia, malaise
|
|
|
symptoms of mumps
|
earache within 24 hours; swelling to neck and face over next few days; unilateral or bilateral
|
|
|
what symptom of mumps is specific to boys
|
testicular pain and swelling (orchitis)
|
|
|
interventions for mumps
|
general interventions for fever; soft of liquid foods; warm or cool compresses
|
|
|
when can mumps pt return to school
|
at least 9 days after onset of parotid swelling
|
|
|
rubella aka
|
german measles or 3 day measles
|
|
|
rubella is transmitted through
|
resp secretions, blood, stool, urine
|
|
|
when is rubella contagious
|
7 days before to 7 days after onset of rash
|
|
|
prevention of rubella
|
maternal antibodies disappear 6-9 months; immunize
|
|
|
constitutional signs of rubella
|
occasionally, low grade fever; ha, malaise, lymphadenopathy
|
|
|
describe the rubella rash
|
discrete pink red maculopapular rash begins on face; spreads downward to trunk and extremities; disappears in same order; disappears on 3rd day
|
|
|
interventions for rubella
|
fever, skin care
|
|
|
rubella pt can return to school
|
8th day after onset of rash
|
|
|
scarlet fever aka
|
group a Beta-hemolytic streptococci
|
|
|
how is scarlet fever transmitted
|
direct or indirect contact with nasopharyngeal secretions
|
|
|
when is scarlet fever contagious
|
incubation period (2-5 days) and during clinical illness
|
|
|
prevention of scarlet fever
|
avoid contact with infected persons; lasting immunity to scarlet fever toxin
|
|
|
s/s of scarlet fever
|
high fever, sore throat, malaise, possibly headache
|
|
|
when does the scarlet fever rash appear
|
12-48 hours after s/s
|
|
|
describe enanthema of scarlet fever
|
red, swollen tonsils covered with exudate; white strawberry tongue at first, then red strawberry tongue; palate covered with erythematous punctate (pinpoint) lesions
|
|
|
describe exanthema of scarlet fever
|
circumoral pallor; red pinpoint rash=absent on face; starts on neck and spreads down; feels like sandpaper; more intense in folds of joints; desquamation begins by end of first week
|
|
|
interventions for scarlet fever
|
sore throat; fever; penicillin, bed rest during febrile period
|
