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335 Cards in this Set

  • Front
  • Back
Menstrual cycle length
28 days
Proliferation (follicular) Phase
Follicle matures
FSH active hormone
Estrogen High
Day 5-14 (ovulation)
Secretory (Luteal) Phase
Corpus Luteum Develops
LH active hormone
Progesterone high when pregnant
Day 14 to three days prior to ovulation
Sperm livespan
3-5 days
Eggs lifespan
24 hours
Fetal Development
Week 4
Heart begins to beat
Fetal Heart Tones detected:
by doppler between 8-12 weeks
Embryo becomes a fetus at:
12 weeks
Can tell sex of fetus at:
16 weeks
Heart beat detected by fetoscope:
at 20 weeks
Feel fetal movement at:
20 weeks
Fetus is viable at:
24 weeks
Fetus can breath at:
28 weeks
L/S ration 2:1
at 38 weeks
Full term:
40 weeks
Fetal Environment:
Amniotic fluid:
500-1000mL
cusions and protects fetus
maintains the body temp.
Fetus use of amniotic fluid:
drinks, swallows and urinates into the fluid.

Renal function determined by testing fluid

Fetus breathes amniotic fluid into lungs
Placenta:
allows for exchange of nutrients and wastes.

REMEMBER: always provides nutrients. Any placental problems affect the baby
Fetal circulation:
through umbilical cord:
AVA: two arteries, one vein

Arteries: deoxygenated blood
Vein: oxygentated blood
Foramen Ovale:
Opening between right and left atria:

Closes after birth
Nagele's Rule:
Gestation calculation:
based on 28 day cycle:

1st day last period
-3 months
+ 7 days
Gravida:
number of times pregnant
Para:
Number of pregnancies after 20 wks.
TPAL
T = term birfs
P = preterm birfs
A = abortions/ elective or
spontaneous after 20 wks
L = living children
Presumptive signs of pregnancy:
No periods
N&V
Fatigue
Inc. urination
Breath changes
Quickening
Inc. pigmentation
Probable signs of pregnancy:
+ test 4-10 wks @ missed period
Enlarged abdomen
Chadwick's sign: blue vagina (4 wks)
Hegar's sign: softened uterus (8 wks)
Goodell's sign: softened cervical lip: (8 wks.)
Ballottment
Palpable fetal outline
Braxton-Hicks
Positive signs of pregnancy:
FHT (fetal heart tones)
Fetal Movement
Fetal skeleton on x-ray
Fetal sonography
Fetal Ultrasound:
provides accurate age of gestation when done early in pregnancy
Fundal Height:
Palpable after 12 wks
Fundus at Umbilicus: 20-22 wks
At the xiphoid process: 36 wks
Measuring fundal height:
turn pt. onto the left side.

Also could elevate the left buttocks with a pillow
Multiple births:
anemia is common complication for mother due to inc. iron need of fetuses.

Multiples are often premature

Hemorroids and Gestational DM are NOT complications
PIH:
pregnancy induced hypertension
complication during labor is seizure

complaints of HA or blurred vision indicate worsening
Signs of preeclampsia and eclampsia:
Vision changes
Severe, continued HA
Persistent vomiting
Infection: chills, temp.> 100.4
dysuria
pain in abdomen
Fluid discharge other than white
Change in fetal movement or fetal tachycardia
Gestational Diabetes screening:
give 50 grams of glucose
draw blood sugar
if > 135, do a 3 hr glucose tolerance test
Gestational Diabetes risks:
High risk when mother is >30 yrs
Unexplained stillbirths or miscarriages
Once developed, inc. risk with each subsequent pregnancy

those with Gest. D increased risk for Diabetes Mellitus
Gestational Diabetes TX:
******ONLY INSULIN DURING PREGNANCY . . . NO ORAL HYPOGLYCEMICS
Gestational Diabetes delivery:
pt. more prone to preeclampsia
hemorrhage and infection

SCHEDULED DELIVERY 37-38 wks
German Measles: RUBELLA
Infection in mother can be serious

If within 1st 20 wks: infant may be born with Congenital Rubella Sydrome, (a range of serious, incurable illnesses)
German Measles can cause:
Spontaneous abortion in up to 20% of cases.

Infants may have virus persisting for up to 2 months

These infants are a major source of infection to other infants and pregnant women
Syphylis:
crosses the placental barrier and leads to spontaneous abortion or deformities in fetus
Genital herpes
can cross placenta and be x-mitted during delivery.

If active pt. needs C-section

Acyclovir used with caution during pregnancy
Gonorrhea:
can be contracted at deliery and lead to sepsis in the newborn
HIV
can be x-mitted to newborn
Screen mom to help baby
30-50% transmit unless Mom is treated before delivery and baby after delivery

Then it decreases to 4-8%

Breast milk can transmit virus, do not allow or encourage breast feeding to HIV positive mom.
Toxoplasmosis:
related to exposure to cats/ gardening and eating raw meat.

NO GARDENING
NO LITTER BOX SCOOPING
Substance abuse:
may be transmitted to infant
Inc. risk for abruptio placenta and
growth retardation.
Adolescent pregnancy:
Low birth weight for baby

Nutrition problems for mother
Hot tubs, sauna, steam rooms:
can lead to neural tube defects and hypotension
Prenatal period office visit:
Once a month until 28 wks

Every 2 weeks until 36 wks

Once a week until delivery up to 42 wks
Prental period physiological chgs:
Circulating blood volume inc,.
Pulse inc. by 10 bpm
Diaphragm is eleveated
Dysnea due to enlarged uterus
Respiratory rate unchanges
Skin changes: linea ligra, chloasma and striae
Prenatal period weight gain:
Up to 5 lbs 1st trimester
One pound a week after that.

H2O retention contributes to wt.

TTL WT: 25-35 pounds
Bonding signs:
mother talkes to fetus,

massages belly

has nicknames for baby
Discomforts during pregnancy:
Nausea and vomitting:

give: dry carbs upon waking
High protein snack before bed

COMMON IN 1st TRIMESTER:

due to hormone changes and carb metabolism changes
Hyperemesis:
linked to H.Pylori
First pregnancy
Multiple fetuses
age: <24
HX with other pregnancies
obesity
High fat diet
Hyperemesis TX:
may need to be admitted for dehydration

Antihistamines
B6
phenothiazines for nausea

Reglan

Deficies include: thiamin, riboflavin, B6, Vit. A, and retinol proteins
Dizziness and syncope:
change positions slowly
Vena Cava syndrome can occur while laying flat in bed

1st intervention: Knee to chest to inc. perfusion to uterus, placenta and fetus

then side lying position second

Not a major concern. Usually resolves with position change
Urinary urgency and frequency:
Push fluids and empty bladder as necessary, don't ignore urge!

Most common in 1st and 3rd

Avoid anything that would cause urinary statis

Push fluids: 2000 mL's a day
Breast tenderness:
expected due to levels of estrogen and progesterone
Vaginal discharge:
expected and should be clear and slightly white
Nasal stuffiness:
Humidy air
No antihistamines because safety in pregnancy not established
Fatigue:
expected due to inc. physiological demans
Hearburn:
eat small meals
avoid fatty and spicy foods
Milk between meals
sit upright after meals
drink 2000 mL's fluid per day
Antacids only as prescribed
Ankle edema:
common due to dec. venous return

not a concern as long as proteinuria or HTN not present

elevate legts,
frequent rest periods
wear support hose
avoid standing in one position for prolonged time
Varicose veins:
due to pressure in the pelvic cavity

elevate legs and wear suppport hose
Headaches:
change position slowly
cool cloth to forehead
use tylenol sparingly if prescribed
Hemorrhoids and Constipation:
increase fiber and fluids
Backache:
most common in 2nd and 3rd trimester

pelvic tilt or rock to tuck pelvis under the baby.
POSTURE IMPORTANT
Leg Cramps:
increase calcium
exercise legs
Exercise during pregnancy:
always good just not to point of exhaustion
Shortness of breath:
most common in 2nd and 3rd trimester
tripid position helpful
Blood type and Rh factor:
RhoGam considered a blood product

Given IM: ventral gluteal
Rhogam given:
if Rh negative give at 28 wks.

If baby is positive at birth, repeat RhoGAM within 48 hrs.

If mother positive Coombs, no need for RhoGAM
Rubella titer:
if negative, susceptible to Rubella,

Needs immunization postpartum and SHOULD NOT become pregnant for at least 3 months after immunization

Mom can still breast feed if she gets vaccine
RhoGAM and Rubella titer both given then:
recheck rubella titer in 3 months.
RhoGAM suppresses the immunity and the femal may not be protected against Rubella
Hemoglobin and Hematocrit: H&H
will decrease during pregnancy.If it is below 11 and 33, mother has anemia.


Increased Hematocrit can indicate PIH
STD screening:
VCRL is screen for syphilis.

TX: antibiotics

Can cause abortion or premature delivery
Passed to the fetus after the 4th month
Sickle Cell screening:
if at risk:

L & D can induce a Sickle Cell Crisis. Oxygen on during L & D
Hepatitis B vaccine:
give if at risk
screen performed to detect antigens
If antigens present, mother and neonate need to receive hep vaccine and hep B immunu globulin within 12 hrs of delivery.

All other vaccines follow to provide immunity

Can breast feed as long as infant receives prophylaxis at birth and remains on vaccine schedule
Urinalysis to evaluate for:
glucose and protein
Sugar:
common in urine due to dec. threshold of kidneys.

Acceptable level: 1+ or less
Ketones:
indicate insufficient dietary intake
Protein:
2+ to 4+ may indicate infection or PIH

Acceptable level: < or = to a trace
WBC:
usually higher: up to 15,000
May inc. to 25,000 within the first 10-12 days after delivery
Elevated WBC:
if temp is increased:
assess for Fundal height
perineal area
symptoms of DVT
burning on urination

other possible sources of infection
HELLP:
Hemolysis
Elevated
Liver function tests
Low
Platetes
Monitor for HELPP:
in severe preeclampsia

If present: MUST DELIVERY IMMEDIATELY
Non-Stress Test positive:
positive is good
15/15 acceleration is active and healthy
Non-Stress Test negative:
Negative is bad:

N= Non-reactive
N=Non-stress
N=Not good
Non-Stress test monitoring:
Assess fetus and placenta

Lack of fetal movement for short periods (20-40) mins. no concern usually baby sleeping
Non-stress test non-reactive:
abnormal.
Shows fetal movement without inc. in fetal HR.

Not necessarily bad, requires further testing
Contraction Stress Test:
Do
Something
Now

NEGATIVE RESULT IS GOOD
NEGATIVE IS NORMAL

Decels ( positive late decels)
Stress Test
Not Good

POSITIVE RESULT IS BAD
Contraction Stress Test process:
Done with pitocin or nipple stimulation.

Nipple method may overstimulate post. pituitary and release too much pitocin


Assesses for placental perfusion, placental function and fetus well being

Determines ability of fetus to withstand labor

Done if non-stress test is abnormal or negative

Positve CST: will see late or variable decels of FHR with contractions
Fetal Amniotomy: rupture of membranes
check the well being of the baby before and after the procedue

FHR checks the babies well being
Amniocentesis purpose:
can identify chromosomal and neural tube defects and can determine the sex of the fetus
Amniocentesis process:
done early in pregnancy
Need to have a full bladder to push uterus up in the abdomen for easy access

In the 3rd trimester: may be used to evaluate lung maturity.

Best indicator of survival.

When done late: bladder must be empty

Can be used to TX: polyhydramnois by removing excess fluid.
Percutaneous umbilical blood sampling: (PUBS)
can be done during pregnancy under ultrasound. Used to detect blood disorders, sepsis, and some genetic abnomalities
Biophysical Profile: BPP
evaluates the well being of the fetus and identifies abnormalities.

THE BEST TEST FOR FETAL EVALUATION
Biophysical Profile (BPP) assesses the following:
Fetal movement
Muscle tone
Amniotic fluid volume
Reactivity of FHR
Breathing movements
Each gets a score of 2 if normal

Max score 10 means baby is health

Score less that 4 needs immediate delivery: baby in trouble
Induction of Labor meds:
Oxytocin (Pitocin)

Ran with Lactated Ringers !
Pitocin infusion:
titrated to get 3-5 contractions in a 10 min. period with cervical dilation

Watch for water intoxication with this med. S&S:
tachycardia
cardiac dysrhythmias
dyspnea
nausea & vomiting
Leopold's Maneuvers
when the baby is felt to determine positioning.


Warm hands and have mother empty bladder before performing
Longitudinal lie:
fetal spine is parallel to the mother.

Baby is cephalic or breech
Transverse or horizontal lie:
sping is at right angle to mom and there is shoulder presentation

C-section is needed
Oblique lie:
baby is at a slight angle from true horizontal

C-section needed if not corrected
Cephalic presentation
head down: MOST DESIRABLE FOR DELIVERY
Breech presentation:
some may delivery vaginally
Zero Station:
engagement: baby is located at the ischial spine
Minus Station:
baby is above the ischial spine.
Plus station:
baby is below the ischial spine

REMEMBER: PLUS 4 ON THE FLOOR !
External monitoring of fetus:
noninvasive

Transducer is places over the fetal back.
Internal monitoring:
invasive

Reputure of membranes and dilation of 2-3 cm is required
Normal FHR:
110-160 bpm over 10 minutes
Fetal Bradycardia:
FHR < 110 bpm
Fetal Bradycardia interventions:
change mother's position
give oxygen
notify physician

Assess between contractions for 10 minutes
Fetal Bradycardia cause:
late manifestation off fetal hypoxia
medication induced via narcotics and magnesium
Maternal hypotension
fetal heat block
prolonged cord compression
Fetal Tachycardia:
FHR > 160 bpm
Fetal Tachycardia interventions:
change mothers position
give oxygen
notify physician
Fetal Tachycardia causes:
early sign of fetal hypoxia
fetal anemia
dehydration
maternal infection
maternal hyperthyroid
medication induced via atropine, terbutaline or hydroxyzine (Vystaril)
Variability:
a change in HR in response to sleep, wake, meds. and hypoxia

6-25 bpm fluctuation is okay
Acceration:
is a rise of the HR by more than 15 for 15 seconds. Marked acceleration is > 180.

Could be caused by infections, prematurity or hypoxia
Early decelerations:
transient decrease in HR

Possible head compression or fetal descent.

Does not indicate fetal distress

usually seen at 4-7 cm. dilation
Variable deceleration;
can be cord compression
baby may be rapidly declining

Put Mom in knee to chest
May need C-section to resolve

If after a gush of fluid, do a sterile vaginal exam and check for cord compression

The decels are not related to the timing of contractions.

May drop 10-60 bpm below baseline
Late Decelerations:
due to uteroplacental insufficiency
Rarely below 110 bpm
Associated with postmaturity
preeclampsia
DM, Cardiac Disease and
abruption of placenta

severe is <70 BPM lasting longer than 30-60 seconds and a slow return to baseline
TO REMEMBER DECELS:
Decels are acceptable in labor but "NEVER BE LATE"

late decels means baby is in trouble
True Labor:
pain in lower back to abdomen
pain with regular contractions
contraction more intense with ambulation
cervix is dilating
False Labor:
discomfort only in the abdomen
no lower back pain
contractions decrease with ambulation
Normal findings for laboring pt:
FHR 110-160
Mothers bp: <140/90
Mothers pulse: < 100
Mothers temp. < 100.4


slight temp elevation occurs due to dehydration and work of labor.

Anything higher thatn 100.4 can indicate infection and must report immediately
Stage 1 of Labor:
Cervical dilation

Latent-Active-transitional

Excitement and apprehension for the mother during this stage
Stage 2 of Labor & Delivery:
Delivery of the baby

Exhaustion is common for the mother at this stage
Stage 3 of Labor and Delivery:
Delivery of the placenta

Mother focuses on the neonate's condition
Stage 4 of Labor and Delivery:
First 4 hours after delivery of the placenta
STAGE 1 PHASES:
phases are sequential and progressive: Latent, Active, Transitional

First sign of labor is passage of mucous plug. Signs of active labor is the onset of regular or progressive contractions
Latent phase of Stage 1:
0-4 cm dilation
mild intensity in contractions
contractions every 5-30 minutes
use this time to review relaxation techniques to be used when labor becomes stronger
Active phase of Stage 1 :
4 - 7 cm dilation
moderate intensity contractions
contractions every 3-5 minutes and last 45-60 seconds
Transitional phase of Stage 1:
8 - 10 cm dilation
Strong intensity contractions
contractions every minute lasting one minute
stop the regional block at this time if present
Assessment of contractions:q
fequency is the beginning of one to the beginning of next

Duration is from the beginning of one contraction to the end of that contractions

Intensity is mild, moderate, intense

3-5 contractions must be measured
Pain meds in labor:
IV meds are best in labor

give at beginning of contractions so less reach the baby

butophanol (Stadol) or Nalbuphine (Nubain) better in labor. Wathc for withdrawal if mom is narcotic dependent
Avoid these meds in labor:
Demerol and Morphine avoided due to increased respiratory depression in baby
To decrease amount of narcotics needed, use:
Phenergan and Vistaril
Multigravida can IV pain meds:
up to 5 cm dilation
Paragravida can IV pain meds:
up to 7 cm dilation
Narcan given to woman in labor:
block the effects of any narcotics present and prevent CNS and Respiratory depression in baby
Regional Blocks:
Peridural and epidural can be used in all stages of labor
Pudendal block and Subarachnoid (Saddle) blocks:
used only in the second stage of labor.
Pudendal block location:
infection between vagina and anus
Saddle Block location:
spinal and provides instant pain relief

Stop the continuous infusion at the end of stage 1 or during transition to inc. effectiveness of pushing.
Pudendal and Saddle blocks SE:
cause hypotension

Give fluids before (1000 mLs) LR

monitor B/P and FHR q 15 min

If hypotension develops, turn to the side, give 10 liters 02 by mask and inc. IV (LR) rates
Delivery of Baby (Stage 2)
Deliver the head and stop
Suction mouth and nose
check for cord around neck
Delivery the rest of baby
Hold baby at level of the uterus until the cord stops pulsating
Clamp the cord
Apgar Score
Apgar Scoring:
Score: 7 - 10 good
Score: 4 - 6 needs moderate resuscitation
Score 0 - 3 severe needs for resuscitation

Scores of 6 or lower at 5 minutes require an add'l score at 10 minutes

Do not wait until a 1 min. apgar is assigned before resuscitation is started
Meconium staining:
yellow green or gold yellow which may indicate fetal distress

thorough suctioning via an endotracheal tube to see if meconium is below the vocal cords

Aspiraiton of meconium can lead to pneumonitis and meconium aspiration syndrome

Do a septic work up include: CXR
Erythromycin eye ointment or 1% Silver Nitrate:
protects neonates eyes from gonorrhea (blindness) and
chlamydia (conjunctivitis)
Vitamin K:
due to absence of intestinal bacteria at birth
Delivery of Placenta checks:
Check cord for AVA
( 2 arteries, 1 vein)

Abnormalities can indicate cardiac or renal issues

Check the placenta to make sure it is intact !
C-section prep:
place mother on table with wedge under right hip to prevent vena cava conmpression
Monitoring after delivery:
assess:
VS, Fundus, Peripad

q 15 minutes X4

Then every 30 min. X4

Then q 1 hr x 4

the q 4 for 24 hours
Fundus check:
should be firm and midline

should be at the level of umbilicus after delivery

If above umbilicus, may indicate blood clots which need to be expelled

If lateral displacement of the uterus is present, empty the bladder
Vaginal hematoma:
can display as hypovolemic shock

If pt. had epidural she wont feel pain associated with hematoma
Medications to stop bleeding after delivery monitoring:
giving too early may result in retained placenta

Hypertension can be a significant SE

Care with pre-eclamptic pt. due to HTN
Meds used to stop bleeding:
Methylergonovine maleate (Methergine)

Ergonovine (Ergotrate)

Carboprost (Hemabate)
Precipitous labor:
less than 3 hours.

Gentle pressure of the fetal head upward toward the vagina to prevent damange to head and to vaginal lacerations Deliver between contractions
Painful back labor:
may be relieved by counter pressure or knee to chest postion
Prolapsed cord risks / interventions:
those with reputed membranes and negative station of baby

Get hips higher than the shoulder (trendelenburg or knee chest)

Check FHR

Check the perineum and push the head off the cord
Uterine atony or hemmorhage causes:
full bladder is most common reason in the immediate period following delivery

thank retained placenta in the first 24 hours
Uterine atony or hemmorhage tx:
massage fundas

Then empty bladder

Recheck evvery 15 min. x 4

then every 30 min. x 4
1st degree vaginal tear
epidermis
2nd degree vaginal tear
dermis, muscle and fascia
3rd degree vaginal tear
into anal sphincter
4th degree vaginal tear:
extends up to the rectal mucosa
Symptoms of vaginal tears:
cause pain and swelling:

NOTE: AVOID RECTAL MANIPULATIONS
Abruptio placenta is highest in:
women who smoke
use alcohol
cocaine
caffeine during pregnancy
More than 5 pregnancies
advanced age
and heavy physical labor
Abruption and uterine rupture:
prepare for surgery.
NO abdominal manipulation
No vaginal or rectal insertions
No vaginal exams
No rectal exams
No internal monitoring
No suppositories, etc.
Laboring mother CPR:
place her on left side by 15-30 degrees to shift the fetus off of the vena cava
Disseminated Intervascular Coagulation: (DIC)
abnormal clotting using up the clotting factors especially figrinogen

realted to fetal demise
infection
sepsis
PIH
Abruption
Small for gestational age:
causes:
often have intrauterine hypoxia due to meconium staining.

Be sure to suction carefully
Risk for impaired parenting due to small gestational age:
do an intervention to increase bonding between parents and child
Risk for respiratory distress syndrome due to small gestational age:
Hyperglycemia during pregnancy delays fetal lung maturity.

An L/S ratio of 2:1 is need to predict sufficient sufactant
L/S ratio:
Lechitin / Sphingomyelin levels in amniotic fluid: gives indicator of surfactant production
Large for gestational age:
causes and symptoms:
High risk for hypoglycemia which can lead to brain damage

Postmature infants

May have bruising from delivery due to large size
Postmature infants:
after 42 weeks: at risk for poloycythemia due to placental insufficiency.

Leads to high billirubin levels
Polycythemia:
can contribute to bruising but does not cause bruising.

If severe, infant may need transfusions
Hypothermia:
leads to hypoglycemia

child has high pitched cry due to lack of glucose to brain
Newborn optimal temp:
37 degrees C or
98.6 degrees F
Standing interventions for all complications:
Lateral positioning on either side

Never put her on her back due to supine Hypotensive syndrome caused by pressure on the Vena Cava and descending aorta

O2 per standing order

IV fluids should be inc. per standing order.

Notify physician

prepare or possible C-Section
Increasing fluids during labor:
remember:
FLUIDS STOP LABOR
Post-partum assessment:
Pain
Breast
Uterine fundus
Lochia
Observe episiotomy
Monitor urine output
Monitor bowel movements
Careful with ambulation
Compare extremities for DVT
Assess for affect
Assess for mental state
H& H
Breast engorgement:
feed frequently at least every 2 1/2 hrs. for 15 -20 min per side

Moist heat to breast 20 min. before feeding

Wear supportive bra

during feeding, massage the breast toward the nipple to stimulate letdown of milk

Block milk sinuses may occur. Milk baby close to lump and rotate baby on the breast
Uterine fundus and position:
number of days postpartum, fundus should be one finger below umbilicus:

ie: 3 days postpartum, 3 fingers below umbilicus
Lochia changes:
from serous pink to alba-white

two pads placed on after delivery
check for fragments which could indicate retained placenta

After first post partum day, retained placenta the most common cause of uterine atony
Observe episiotomy:
It should be clean, dry and intact
Monitoring urine output:
can have up to 3.000 ml per day
should void within 4 hours of delivery

< 100 ml per voiding and frequent, suspect urinary retention
Bowel movement:
need to have by 3rd day post partum
Careful with ambulation:
often a syncopal episode with the first ambulation

Can have blood running down leg due to pooling in the vagina and uterus while on bedrest
Assessment of affect and mental state:
in order to ascertain post-partum blues.

Normal esp. 5-7 days after delivery

Unexplained tearfulness,. feeling down, dec. appetite

Encourage use of support persons to help with household chores for 2 weeks.

Refer to community resources
Hemoglobin and Hematocrit:
10 and 30
Phases of post partum period:
Taking in
Taking hold
Letting go
Taking in phase:
mother feels overwhelmed by the responsibilities of newborn care and is still exhausted from delivery
Taking hold phase:
client has rested and can learn mothering skills with confidence
Letting go phase:
has adapted to parenthood, the new role as caregiver, and the new baby as a separate entity
Kegel exercises:
important to do after delivery to strengthen pelvic floor.

Begin simple and increase to do more strenuous exercises
Nursing mothers needs:
8-10 eight ounce glasses of water daily
500 additional calories per day
Milk production is controlled by:
the hormone prolactin
To prevent high billiruben levels:
hydration is important for infants.
Water, Milk and formula all important
High billirubin levels require:
phototherapy

NOTE: cover infants eyes and genitals when they are under the phototherapy lights
Mastitis is:
unilateral inflammation of breast
Mastitis symptoms:
shaking, chills and fever.

caused by milk stagnation
can be due to not offering both breasts while feeding infant

Can continue to breast feed if no infection is present or not on antibiotics

If not feeding, express milk and discard until feeding can begin again.
Endometritis:
presents as fever on 3rd or 4th day post delivery

Risk for infection high if any problems during pregnancy including anemia and diabetes

Trauma during delivery also a factor
Cardiac disorders in mother:
HX of HF or valvular disease.

Extra fluid returns to blood stream resulting in inc. cardiac output and blood volume

monitor intake and signs of fluid volume overload.

Coughing can indicate pulmonary edema
Pre-term infant:
between 24 - 37 weeks
Thick vernix covering body
smooth soles without creases
lanugo covering entire body
Post Term infant:
After 42nd weeks of gestation

Dry, peeling, cracked, leather like skin (desquamation)

Prone to meconium aspiration and cord compression

Motor function not as mature

Has trouble with quiet alert state

work on bonding due to possible bruising of face

Gentle touch to soothe baby
Meconium aspiration signs:
Tachypnea
grunting
retractions
nasal flaring
Acrocyanosis:
bluish discoloration of the hands and feet. Associated with immature peripheral circulation

Common in first few hours of life
Respiratory distress syndrome:
Presents with signs of cyanosis, tachypnea or apnea, grunting, nasal flaring and chest wall retractions

Seen more in c-section babies since they do not experience the vaginal squeeze that dec. fluid in lungs of infant
Hypoxia in children Signs:
nasal flaring
expiratory grunting
inspiratory stridor
feeding problems
sternal retractions
Never feed baby if Respiratory rate is:
greater than 60
Silverman-Anderson Index of Respiratory Distress
The lower the score the better the baby.

A score of 10 is severe distress

This is opposite scoring of Apgar
Vital signs in infants:
Heart Rate: 100- 170 bpm

Respiratory rate: 30 - 60 per min.

Temp. 37 or 98.6 is optimal
Temperature regulation in infants:
NEED TO KEEP INFANT WARM

Make heat by nonshivering thermogenesis.

Shivering in infants causes them to burn brown fat which can lead to metabolic acidosis

warm slowly over 2 - 4 hours if cold.

Rapid warming can produce apnea
Infants that are too cold will present with:
acrocyanosis
mottling
tachycardia
tachypnea
Stomach capacity of infant:
Newborn: 10 - 20 ml

week 1: 30 - 90 ml

weeks 2 - 3 : 75 - 100mls
Nutrition in infants:
need 50 calories per pound of weight per day

Most formula is 20 calories per ounce

Need glucose due to little glycogen stores they have
Gavage feedings:
tube inserted into esophagus and feeds ran straight into stomach
Stop gavage feedings if:
tube is in trachea
infant will not be able to make sounds,
no crying
may gag
cough
or become cyanotic
Cord care:
keep clean and dry to decrease baterial growth

Dries up and falls off between 7-14 days
Circumcision care and observations:
Observe for bleeding q 1 hr for 8 - 12 hours post op

Assess voiding. If none in 24 hrs notify physcian due to possible swelling or damage

Vaseline guaze reapplied with the diaper changer

Water used for cleaning. No baby wipes, may irritate skin.
Physiological jaundice:
occurs at 2-3 days
Pathological if befor 24 hours and after 7 days

Immature live inability to keep up with destruction of RBC's

Unconjugated bilirubin will be high
Assessment for jaundice:
apply pressure with thumb over boney prominences to blanch skin

Area blanched will appear yellow before returning to skin tone

Nose, forehead and sternum good places to check

In darker skin: observe eyes and oral mucosa
Phototherapy risks and uses:
Increases risk for dehydration

Used when bilirubin is > 12
Congenital hypothyroidism:
most common preventable cause of mental retardation

Infant is described as a good quite baby

Neonatal screening only means of detection.

Screen before discharge from nursery and before 7 days of life.
PKU:
Genetic disorder when body cannot metabolize phenylalanine which is a protein found in most foods.

If level gets too high, can cause brain damage and severe mental retardation

AUTOSOMAL RECESSIVE:
BOTH PARENTS MUST CARRY

Screen at birth and 3 weeks
PKU signs and symptoms:
Frequent vomitting
irritable
musty odor smell to urine
PKU: test
performed at birth and 3 weeks

Guthrie Test: positive result
Serum phenylalanine of 4 or greater
PKU DIET:
Logenalac or Phenex - 1 formulate

Low protein diet until age 6 - 8 when brain growth is completed

NO NUTRASWEET !!

Older children and adults diet should be low protein and many fruits and veggies.
Milia:
Know as baby acne:

normal for infants to have
Epstein pearls:
calus on gum line.

appear as small teeth but are not
Mongolian spots
sacral area of darkening.

often misinterpreted as bruising on the child
Hemangioma:
tumors of blood vessels appearing as small, flat, dark red spots
Cephalohematomas:
Asymmetrical collection of blood under the periosteum which develops a few hours after birth and goes away in 2 months. Danger is increase in bilirubin due to excess RBC destruction
Caput succedaneum (cone head)
Collection of fluid under the scalp which crosses the suture line and goes away in 2 wks. Present at birth
Fetal Alcohol Syndrome:
Physical, mental and behavioral abnormalities. Poor prognosis
Fetal Alcohol Syndrome symptoms:
Withdrawal with tremors
sleeplessness
seizures
abdominal distention
hyperactivity
crying.

Occurs 6-12 hours after birth

Hyperactive with speech and language problems

Mild to severe retardation

Growth deficient at birth
Challenges in hospital for pediatric patients:
Child's separation anxiety
Stages of separation anxiety:
protest
despair (crying & kicking)
detachment
Temper tantrums:
best to ignore if child is safe

Best way to discourage behavior is by ignoring that behavior
Erickson:
Ego development influenced by family, social and developmental factors.
Erickson stage of Infancy:
Infancy: 0m - 18 months

TRUST VS. MISTRUST

attachment to mother is prevelant
Erickson stage of early childhood
Early childhood: 18 mos. to 3 yrs

AUTONOMY VS. SHAME AND DOUBT

gaining basic control over self and environment

Temper tantrums common
Security items (blankie)
Expect regressions (bedwetting)
Learning to name body parts
Provide choices to support autonomy
Erickson stage of late childhood
Late childhood: 3 yrs to 6 yrs

INITIATIVE VS. GUILT

Becoming purposeful and directive

Explain that pain from illness or procedures is not punishment

Use simple words to explain

Fear of mutilation is common

Allow choices to promote sense of control
Erickson stage of School Age
6 years to 12 years of age

INDUSTRY VS. INFERIORITY

Developing social, physical and school skills. Need parental support. Contact with peers and school activities when ill and in hospital is important
Erickson stage of Adolescent:
From 12 to 20 years of age

IDENTITY VS. ROLE CONFUSION

Developing sense of self. Withdrawal from peers is sign of identity crisis. Rebellion again family values is normal and common
Erickson stage of Early Adulthood
from 20 to 35 yrs. of age

INTIMACY VS. ISOLATION

Establishment of intimate bonds, love and friendship.

**Spinal cord injured clients at this point have difficult time establishing intimacy
Erickson stage of Middle Adulthood
From ages 35 to 65

GENERATIVITY VS. STAGNATION

Fulfilling life goals that involve family, career and society.
Ericksons stage of Later years
65 to death

INTEGRITY VS. DESPAIR

Review of one's own life and accepting its meaning.
PAIN IN CHILDREN:
Infants: pain after 6 months

Toddlers: Fear intrusive procedures

Preschoolers: fear body mutilation

School age: fear loss of control

Age 9 and up: can use number pain scale

Adolescents: fear change in body image
Developmental tasks at 1 - 3 months
cooing sounds
social smile
head turns to sound
Developmental tasks at 3 - 4 months
cooing and babbling
Moro reflex disappears at 4 mos.

** if NOT: R/O CP
Developmental tasks 6 - 8 months
constant babbling

Birth weight Doubles

Plays peek a boo

Sits unsupported by 8 months
Developmental tasks 9 - 12 months
simple words and gestures

Crawls by 10 months and walks with assistance

Birth weight triples by 1
Length increases by 50%
Developmental tasks: 15 months
builds a tower of two blocks
Two year olds
can open door knobs
unzip bag
speak in 2 - 3 word sentences
Three year olds:
talk constantly
put on simple clothes by themselves

can first and last name
rides a tricycle
Four year olds:
copy simple shapes
often reverse letters
capitalize incorrectly
Five year olds:
tie shoelaces
draw stick men with 7 - 9 body parts
Teaching children:
Use Piaget's stages of intellectual development
Piagets Stages of Development

0 -2 years of age:
0 - 2 years SENSORIMOTOR

Present oriented, Thank about what they are sensing and moving forwrd. Teach by talking
Simple, brief explanations before procedures
Piagets Stages of Development

2 to 7 years of age:
2 to 7

PREOPERATIONAL STAGE

Fantasy oriented
illogical
Thinks about past, present and future

No rules to conform them

Teach by playing with them
Piagets Stages of Development

7 to 11 years of age:
7 to 11 years

CONCRETE OPERATIONS

Easily taught by the rules.
No abstract thinking
Solves problems via logic
Teachg with videos and written material, not by playing with them.

Allow them to handle equipment
Piagets Stages of Development

11 to adult :
11 to adult:

FORMAL OPERATIONS

Abstract thinking
Teach them like an adult
Teach them to manage own illnesss
Direct information to the child, not the parents

Have time with the adolescent without the parents for Q & A
Toys for children safety:
No small toys under 4

Supervise toddlers. SAFETY !!!

No metal or electric toys with O2 use

No toys/items that can harbor germs. Stuffed toys not good

Throw away toothbrush after on Antibiotics for 24 hrs for strep
Toys for infants to 1
soft toys
blocks
balls
musical mobiles
play peek-a- boo
Read from large picture book
Toys for toddlers ( 1 - 3)
push and pull toys
Play side by side with others
Read from large picture book
Toys for preschoolers ( 3 - 6 )
Like to pretend play
Work on fine motor and balance
Play is simple and imaginative
Toys for school age (7 - 11)
Children competitive and creative
They like doing with their hands,
drawing, coloring, etc.
Toys for adolescents ( 12 - 18)
Associate with their peers

They don't need anything to play with

Listening to music is usual
Care of chronically ill child:
focus on developmental age not
chronological age

Assist child/family to return to normal

Determine how child is cared for at home

Promote max. growth and development

Assess family response to illness

Involve family in care

Encourage self care

Maintain routine if possible
Respiratory distress in children:
Resp. disorders are the most common reason children seek medical care

* Pediatric pt. go into respiratory failure before cardiac failure
Respiratory distress manifestations:
Agitation
restlessness
Inc. HR
Inc. RR
Diaphoresis
Nasal flaring
Retractions
Grunting
Stridor
Use of accessory muscles
head bobbing
Cyanosis and pallor
Feeding problems
Normal vital signs readings:
RR and HR must be measured

Document child's behavior:
crying, febrile,or distress
Normal values for children:
AGE PULSE RESPIRS
0-1 100 - 160 30 - 60
1-2 100 - 150 25 - 35
2-3 80 - 130 20 - 30
3-5 80 - 120 20- 25
5-10 70 - 110 18 - 22
10-16 60 - 90 16 - 20
Temperature monitoring:
Axillary monitoring acceptable

Rectal per MD request

Leave thermometer in for 5 mins for both
Use of 02 in children:
Oxygen hood for infants
NC to provide low to moderate flow

Tent to provide mist and O2. Keep child dry, monitor temp.
keep edges tucked in.
Congenital heart defects:
Affects 4 - 10 children per 1,000 live births


All kids will have a murmur whether serious or not
Ventricular Septal defect:
a heart defect that may not be serious and often closes on own by 1 year of age.
Serious heart defects cause:
growth and development delays
Acyanotic heart defects:
all blood is oxygenated
Increased fatigue
Inc. risk of endocarditis
Heart failure usually present
Higher risk with acyanotic defects

Growth retardation
VSD

Ventricular Septal defect:
Small ones close spontaneously
ASD

Atrial septal defect:
Surgical closure needed before school age
PDA:

Patent Ductus Arteriosus
Usually closes withing 72 hrs after birth

Give Indocin or surgical closure

Most common congenital heart defect

Artery that connects aorta with pulmonary artery is supposed to close

If remains open and is small, no problem, larger openings can develop into ventricular failure

Premature delivery is risk factor
AS
Aortic stenosis
May require surgery

Obstructive
COA

coarctation of the aorta
May require surgery

Considered a serious defect

Obstructive
Cyanotic heart defects:
have a right to left shunt and UN oxygenated blood enters the systemic circulation

Decreased pulmonary flow

Polycythemia and prone to thrombus formation

Will see squatting or knee chest positioning due to hypoxia: known as "TET" spells

Poor feeding due to hypoxia. Tube feeding may be necessary to conserve energy

Clubbing after 2 yrs. of age

Syncope

Respiratory infections common

Monitory pulses bilaterally and
Blood Pressure in Upper and lower extremeties

Maternal infection may be causative factor
Cyanotic Heart Defect Conditions:
Tetralogy of Fallot
Truncus Arteriosus
Transposition of the Great Vessels
Tricupsid Artresia


THE T'S ARE CYANOTIC AND SERIOUS
Tetralogy of Fallot:
Ventricular septal defect
Pulomnic stenosis
Overriding Aorta
Right Ventricular Hypertrophy
Truncus Arteriosus:
Pulmonary artery and aorta do not seperate

Large VSD allows for survival at birth.

Surgical correction
Transposition of the Great Vessles:
VSD, ASD or PDA allow for survival at birth.

Medical emergency

Prostaglandin E given at birth to keep PDA open
Tricuspid Atresia:
Tricuspid valve does not form,
Prostglandin E at birth to keep PDA open
Heart surgery:
No school until 3 weeks after discharge from hospital

Half days initially

No outside play for several weeks
In children with heart failure:
implement measures to decrease workload of th heart:

limit time for bottle or breast feed

Elevate HOB

Allow for uninterrupted rest periods

Provide O2 during stressful periods.
Spina Bifida:
a malformation of the vertebrae and spinal cord resulting in varying degrees of disability and deformity. Meningeocele and meningomyelocele type, a sac present.
Occulta does not have a sac.
Spina Bifida nursing interventions:
watch for hydrocephalus and signs of ICP

In an infant a bulging anterior fontanel is indicative of ICP

Risk for infection before procedure to correct is big concern.

Normal saline dressing over site will maintain moisture and prevents tearing or breakdown of skin integrity

Elevate foot of bed and position baby on belly
Gastroschisis:
Abdominal defect where viscera is outside the abdominal wall and cavity and not covered with a sac.

Vaginal birth of these babies is permitted.

Repair is done immediately with a 90% success rate.

May be genetic and counseling may be indicated
Cleft lip and cleft palate:
Cleft lip repair at 10 lbs with a Heme of 10.

Cleft palate repair usually done between 12 - 18 months to minimize speech impairment

Risk for lack of bonding due to defect. Observe Mom and Dad during feeding to provide helpful suggestions
Cleft lip and cleft palate post surgical interventions:
Clean with dilute hydrogen peroxide or sterile water using cotton swab after feeding and as prescribed.

Use a rolling motion starting at the suture line and rolling out.

Always rinse after if using Hydrogen Peroxide

Logan bar is used to maintain suture integrity

Elbow restraint used to prevent child from touching repair. Only remove one at a time

No pacifier use after surgery

Packing in place for 2 - 3 days after palate repair

If a cleft lip is repaired, need to put on opposite side of surgery in a side lying positon.

If palate repair only, the belly position is acceptable or right side lying to reduce risk of aspiraiton.

At risk for hearing loss as a long term complication of the cleft lip and palate.
Mumps:
disease caused by virus that spreads through saliva and can infect many body parts, especially the parotid gland. Swelling occurs in these areas.

Mumps transmitted by droplets, saliva and possible urine
Rubeola ( Measles)
serious disease that causes:
fever
rash,

Measles is a virus and spreads easily from person to person

DO NOT CONFUSE WITH RUBELLA !!

airborn precautions needed
Infectious for 1-2 days before and 4 days after rash appears

Koplich spots appear 2 days before rash: small blue/white spots with red base on the buccal mucosa. last @ 3 days then slough off.

Can lead to ear infections, diarrhea, prneumonia and encephalitis which can lead to convulsions, deafness, mental retardation and rarely, death

can cause miscarriages or premature delivery in pregnant woman
Rubella (German Measles)
common childhood infection

Airborn and contact precautions

Lasts 1 to 5 days

Children recover more quickly than adults

When contracted in first trimester, the fetus is at high risk for congenital abnormalities.

No risk to fetus with exposure to individuals who has it unless the mother contracts it.
Fifths Disease (Erythema infectiousum)
Slapped Cheek Disease

rash on cheeks and spreads to back of arms and legs

Rash can come and go.
Itchy!
No long infectious once rash appears

Airborn transmission and through blood transfusion

Infection in first trimester of pregnancy has been linked to hydrops fetalis, causing spontaneous abortion
RSV:
Respiratory Syncytial Virus
most common of lower respiratory tract infections (pneumonia and bronchioloitis) in children worldwide. Virtually all children contract it by the age of three.
RSV: TX and Interventions:
contact precautions
No airborn precautions
virus can live on paper or skin for up tone hour and on other surfaces for up to six hours

Treat with ribavirin (Virazole) in severe cases

Wear goggles and mask whenever given.

Causes headache, burning nasal passages and eyes. Can crystallize soft contact lenses.

Can damage fetus in a pregnant woman. Those pregnant should not be around the child.

Palivizumab (Synagis) may be given to high risk children to provide passive immunity. Includes children with prematurity, lung disease or congential heart disease

It may play a major role in the pathogenesis of asthma and COPD
Kawasaki Disease:
known as Mucocutaneous lumph node syndrome.

febrile vasculitis of unknown etiology occurs.

Occurs in children under 5
Cardiac complications in 5-20%

May last 2 - 12 weeks

MANIFESTATIONS:
fever > 102.2
red lips
strawberry tongue
conjunctiva red
pallor of proximal fingers and toes
superficial skin layers desquamate easily
rush over trunk and perineal area
Occasional intermittent colicky
red sores on palms
lethargy
irritiability
Celiac Disease:
life long disorder

Watery
pale stool
foul odor.

Signs of malnutrition inc:
abd. pain
wasting extremeties
anemia

NEED GLUTEN FREE DIET
Gluten:
common name for proteins in specific cereal grains that are harmful to those with Celiacs.

Proteins are in all forms of wheat,
(durum, semolina, spelt, kamut, einkorn and faro) and related grains incl:
rye, barley and triticale
Hypospadias:
congenital defect with the urethral opening on the ventral side of penis. Correct with urethroplasty before preschool to maintain self image.
Intussusception
telescoping of the bowel like a sleeve over itself. The ileum moves into the colon. Necrosis can occur due to trapped blood vessels. Usually affects infants under 1 year
Intussusception manifestations:
clinically appears with bile emesis, currant colored stoles, and screams with any movement of the GI tract.

Will feel a sausage type mass in the mid abdomen

Barium enema is given to reduce. works 2 out of 3 times

Normal bowel movements means reduction is complete
Gastroenteritis or diarrhea:
encourage clear liquids and high starch foods because they are easily absorbed

Avoid milk and milk products except for active culture yogurt

Raw fruits and vegetables and spices can cause loose stoles

PH increases due to loss of acid resulting in metabolic alkalosis
Esophageal Atresia:
congenital defect with the esophagus ending in a blind pouch.

It is clinical and surgical emergency

Need to be NPO, have a G-tube, placed by nutrition and pacifier to provide sucking gratification

3 C'S: choking, coughing, cyanotic

30 degrees HOB prevents reflux
Pyloric Stenosis:
usually affects first born males

Will feel mass in RUQ

Vomiting after 14 days of life for up to 1 hr after each feeding

Need quite time after feeding to reduce risk of aspiration

feed slowly and burp frequently

At risk for altered nutrition

Surgical repair is: pyloromyotomy once done, the problem is likely cured. The procedure splits the hypertrophied muscle. After surgery, place infant prone with HOB elevated
Umbilical hernia:
Teach signs of strangulation which include vomiting, pain and irreducible mass at the umbilicus

Contact physician if suspected
Aganglionic megacolon:
Hirschprung's Disease
congenital absense of parasympathetic ganglion in the distal portion of the colon and rectum

Failure to pass meconium within 24 hours of birth suggestive of disorder.

In order children, ribbon like stools, distended abdomen, with alternating diarrhea and constipation

Can result in performation of colon if not repaired in time

Do not take rectal temps

Surgery at 9 kg of weight (19.8 lbs) Teach about surgery using doll.

Don't point to abdomen

Will create a temp. colostomy

NG tube after surgery
Wilm's tumor:

encapsulated nephroblastoma
Peaks at age of 3

Can be one or both kidneys

Tumor is encapsulated within the kidney

Urinary retention or bloody urine from tumor may be seen.

Blood loss can lead to anemia.

Child will be pale and fatigued

On exam, mass may be felt.
put sign above bed:
DO NOT PALPATE ABDOMEN

TX with surgery, chemo and radiation. Good prognosis with early intervention
Hemophilia:
Hemophilia A only appears in males.

It is an X linked disorder

Women are only carriers.

If one parent is a carrier, any male child has a 50% chance of getting it.

Factor 8 or 9 is missing in the blood.

PTT is increased.

Give FFP or cryoprecipitate to replace the clotting factors

Need safe activities and environment.

watch for sharp edges on toys
look for activities that are safe

Badminton is good.

Contact sports, not good
Otitis media:
Tx with myringotomy. Incision into the tympanic membrane.
Allows for drainage and relieves pain.
Drainage should NOT be bloody or purulent after procedure.

tubes may be inserted. not an emergency if they fall out, just notify physician
Tonsillectomy:
give clear, cool liquids
No citrus, carbonated or extreme hot or cold drinks

Milk and milk products avoided. Due to need to clear throat since they are thick

Bleed is most common complication.
Ask of HX of bleeding or bleeding disorders in family

check Pt and PTT prior to procedure
Reyes Syndrome:
Acute, rapidly progressing encephalopathy which affects school aged children

Cerebral edema is progressive
No hearing loss in this disease

Problem with ICP. Provide for rest and quite environment

Liver complications resulting in jaundice are common

Associated with viral infections and the use of aspirin.
Brain Tumors:
Headache upon awakening is most common symptom

Most are infratentorial and
difficult to operate on

Most intratentorial tumors are presribed to lie flat or turn to either side. If a large tumor, stay off the operative side

Gliomas most commom type of childhood brain tumors:

These have a bad prognosis!
Cerebral Palsy:
damage to motor centers in brain causing spasticity and involuntary movements

Caused by anoxic injury, maternal infections, kernicterus, and low birth weight

Persistent reflexes in babies

Moro reflex still present after 4 months is an indicator of possibility

Delayed development with preference to one hand

Sucking difficulties
Tongue thrust present
Prone to aspiration
Feed upright
Support lower jaw
May have a seizure disorder
Cerebral Palsy:
damage to motor centers in brain causing spasticity and involuntary movements

Caused by anoxic injury, maternal infections, kernicterus, and low birth weight

Persistent reflexes in babies

Moro reflex still present after 4 months is an indicator of possibility

Delayed development with preference to one hand

Sucking difficulties
Tongue thrust present
Prone to aspiration
Feed upright
Support lower jaw
May have a seizure disorder
Varicella:
if a undisagnosed rash and exposure,put client in strict isolation.

Incubation is 14 - 21 days
Varicella:
if a undisagnosed rash and exposure,put client in strict isolation.

Incubation is 14 - 21 days
Autism:
safety is priority
child unable to anticipate danger
has tendancy of self-mutilation

Sensory preceptual deficits are also seen
Autism:
safety is priority
child unable to anticipate danger
has tendancy of self-mutilation

Sensory preceptual deficits are also seen
Croup:
no cough syrup
cool mist humidifier
sips of warm fluid will relax vocal cords and thin mucus

Acetminophen (TylenoL) for fever
Croup:
no cough syrup
cool mist humidifier
sips of warm fluid will relax vocal cords and thin mucus

Acetminophen (TylenoL) for fever
Pertussis:
Copious, thick secretions occur

Ineffective airway clearance a priority diagnosis due to th small airway of the infant
Pertussis:
Copious, thick secretions occur

Ineffective airway clearance a priority diagnosis due to th small airway of the infant
Scoliosis:
most common in females
ages 10-15
Milwaukee brace 23 hrs a day
helps slow or stop progression but does not correct the problem

Surgical correction by spinal fusion.

Log roll for 5 days post-surgery