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107 Cards in this Set
- Front
- Back
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The nurse assess the newborn during the first 6-8 hrs of life
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transitional period
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during the first few days of life
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early newborn period
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The nurse provides interventions based on the outcomes of the individual exam
* Why is it important to know the gestational age verses birth weight? |
Weight alone is not a specific way to assess a baby
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* How is Gestational Age assessed?
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-Maternal menstrual period (1st day of last period)
-Ultra sound -Ballard Assessment More accurate for newborns between 20 and 28 wks and less than 1500 g Assessments should be made within 12 hrs of birth to optimize accuracy May be overstimulating to infants less than 27 wks -Lens vascularity (MD, Nurse Practitioner) |
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Review L&D report of neonatal history to determine risks during newborn
transition caused by medical and obstetrical complications Review L&D Report of neonatal history to determine risks during transiton caused by drugs, anesthesia, delivery Review L&D report for risks due to Birth Asphyxia Review L&D report for documented findings Review significant social history |
nursing assessment
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Labor report of mother (Vaginal or C-Section)
Premature or Postmature baby Rh+ isoimmunization (+ direct combs) Traumatic / forcep delivery |
Review L&D report of neonatal history to determine risks during newborn
transition caused by medical and obstetrical complications |
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Magnesium Sulfate in lobor (Hypermagnesemia in neonate cases
depressed respirations and hypotonia Nacrosis (Late administration of narcotics) causes depressed respirations and hypotonia |
Review L&D Report of neonatal history to determine risks during transiton
caused by drugs, anesthesia, delivery |
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Asyohyxia in labor: Document late decelerations, decreased variability
severe variable decelerations Apgar scores at 1 and 5 minitues |
Review L&D report for risks due to Birth Asphyxia
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Vitamin K administraton, eye ointment for profalaxis, urinate,
merconum stool |
Review L&D report for documented findings
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Mother with STD, single parent, language barrier, substance abuse,
and lack of support system -Assess vital signs q 30 min every 2 hrs then q 1 hr every 5 hrs |
-Review significant social history
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Maintain gloves when handling the newborn until after the newborns bath
Possible transmission of viruses via maternal blood and amniotic fluid |
Employ Safety Measuresd
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Soles of feet
Breast tissue Skin Genitalia Resting Posture Examine cord for 3 vessels, 2 arteries and 1 vein |
Quick Gestational Age Assessment
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No nipple bud
Testes in the inguinal canal or labia majora widely separated with labia minora prominent open and equal size Vernix (white covering) over entire body Full extension of extremities in resting posture |
28 Weeks
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Raised nipple tissue bud underneath
Descended testes with large ruge (folds) on the scrotum Labia majora large and covering the minora Vernix only in the creases Lanugo perhaps only over the shoulders Hypertonic flexion of extremities in resting posture |
40 Weeks
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Normal: 30-60 bpm
Count for 1 full minute Remember ABCs (airway, breathing, circulation) 5 Symptoms of respiratory distress (tachypnea, cyanosis, flaring nares, expiratory grunt, retractions |
Respirations
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Normal: 120-160 bpm may fall to 100 during sleep and climb to 180 during
cry Count for 1 full minute |
Heart Rate
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Normal: 97.7 - 99.4
First taken will be rectal in nursery Measure axillary for 5 minutes unless using an electronic thermometer Rectal temps may perforate rectum, insert only ¼ - ½ in for 5 min and hold legs firmly to prevent trauma |
Temperature
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Normal: At birth 70 – 50/45 – 30
Not usually measured unless problems in circulation assessed |
Blood Pressure
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Average: 7lbs 8oz
Weight at birth and daily with neonate completely naked Normaly lose 5 – 15% of birth weight in first week of life Document weight carefully |
Weight
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Average: 18 – 21in
Measured from crown to rump and rump to heal or from crown to heal at birth |
Length
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Average: 32 – 37cm
2cm larger than chest circumference Place tape measure above eyebrows and stretch around fullest part of occiput, at posterior fontanel |
Head Circumference
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Average: 31 – 33 cm
Wider than long Stretch tape measure around scapulae and over nipple line |
Chest Circumference
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Alert
Extremities flexion Moving extremities Strong cry Observe for presence of subcutaneous fat No obvious abnormalities |
General Appearance
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Smooth elastice turgor and subcutaneous fat, superficial peeling after
24 hrs, rarely veins are visible Milia, vernix in creases Lanugo, mottling Harlequins sign (pink/red skin on one side of body) Mongolion Spots (looks like bruises) Telangiectatic Nevi (Stork bites) Puffiness is normal also |
Integumentary
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Symmetrical
Crossed Chemical Conjuctivitis Clear cornea White, blue sclera Subconjunctival hemorrhage (caused by pressure during birth) Absence of tears Doll’s eye movement (slight nystagmus) |
Eyes
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Level from eye to top of ear
Well formed and firm with instant recoil if folded against head |
Ears
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In midline
Appears flattened Nose breather (able to swallow when feeding) A little sneezing |
Nose
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Symmetrical
Palat intact Ebstien pearls (white spots) Mobile tongue Sucking pads in cheeks Presence of rooting sucking, swallowing, and gagging reflexes |
Mouth and Chin
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Short
ROM Nonpalpable thyroid Ability to lift head momentarily |
Neck
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Symmetrical, round
Clear and equal breaths Symmetrical movement Transient rales at birth Breast engorgement (hormonal) Transient murmurs |
Chest
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Spine intact
Symmetrical gluteal folds Equal length Patent anus |
Back, Hips, Buttocks, Anus
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Full, rounded, soft
Present bowl sounds Palpable liver 1 – 2cm below right costal margin Cord – jelly look |
Abdomen
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Slightly edematous labia covering clitoris and labia minora
Pseudomenstration Visible hymenal tag |
Female Genitals
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Penis with fore skin intact
Meatus in middle at tip of penis Testes decended Rugae in scrotum Slight edema of scrotum |
Male Genitals
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Flexion
Symetrical movement of arms and legs Palpable brachial and radial pulses Strong grasp reflex Multiple palmer and plantar creases Slightly bowed legs Femoral pulses present Positive Babinskis reflex |
Extremities (Arms, Hands, Fingers, Legs, Feet, Toes)
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*The umbilical cord should always be checked at birth. It should contain 3 vessels
1 vein, which carries oxygenated blood to the fetus and 2 arteries which carry unoxygenated back to the placenta. *This is the opposite of normal circulation in the adult. *Perform neuromuscular assessment. The absence of expected reflexes requires investigation into birth trauma/asphyxia or CNS anomaly |
Physical Exam of The Newborn
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Turns head toward cheek or corner of lip is touched
Lastes 3-4 months maybe 1 year |
Rooting
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When startled, baby symmetrically extends and abducts all
extremities Forfingers form C Lasts 3-4 months |
Moro
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Stroke sole of foot from heel to ball and toes will hyperextended
and fan apart from big toe Lasts 1 year to 18 months |
Babinski’s
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When neck is turned to side, baby assumes fencing position
Lasts 3-4 months |
Tonic Neck
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Finger in base of toes causes curling downward
Lasts 8 months |
Plantar
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Infant is held in upright position with feet toughing a hard
surface – makes walking motions Lasts 3-4 months |
Walking
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-Keep bulb syringe or suction immediately available
-Suction the mouth then the nose, stimulating the nares can initiate inspiration which could cause aspiration of mucus in the oral pharynx -Turn on side or stomach and pat firmly on the back holding head 10-15* lower than feet |
*Aspiration
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-HANDWASHING is the most effective preventive measure
-Scrupulous cord care: swab cord with alcohol at each diaper change or keep clean with mild soap and water -Cover circumcision with petroleum gauze or jelly at each diaper change - Do not allow visitors or personel to attend to newborn if: active infection is present, diarrhea, open wounds, infectious skin rash, open wounds -Encourage breast feeding for immunologic factors |
*Infection
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-Maintaining temperature
-Thermogenisis: Changes depend on environment -Exposoure to cold stress increases the need for oxygen and may deplete the glucose stores |
Thermoregulation
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-Occurs most often in delivery room when newborn is wet. Can occur when
newborn is being bathed -Keep dry and warm -Place stockinette cap on head (greatest heat loss is through the scalp) |
Evaporation
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-Transfer of heat from a warm object to a cooler one by direct contact
-Occurs when newborn is placed on a cold surface or when cool blanket and clothing is used -Use a cover when putting baby on a scale |
*Conduction
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-Transfer of heat is from a body to the surrounding air
-Air conditioner in room going over the baby |
*Convection
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-Heat is transferred from a warm object to a cooler one when the object
is not in direct contact -Occurs if walls of isolette is cool of if the crib is placed close to a cool outside wall or window |
*Radiation
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may increase in voluntary neuromuscular activity
*Primary mechanism of heat production in the newborn is nonshivering thermogenisis (Breakdown of brown fat) |
*Neonates rarely shiver
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is found between: Scapulae, nape of neck, axilla, mediastinum,
surrounding kidneys and adrenals |
*Brown Fat
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-Take temperature at admission and every 4-6 hrs
-If temperature falls below 97*F, place under radiant warmer and apply skin temperature probe to regular isolette temperature -Leads to depletion of glucose and therefore the use of brown fat for energy, resulting in ketoacidosis and possible shock -Prevent by keep neonate warm |
*Hypothermia
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-Prevent cold stress which leads to hypoglycemia
-Perform heal stick blood glucose assessment on all SGA, LGA babies, infant of diabetic mothers (IDM), jittery babies or babies with high pitched cry -Report any blood glucose levels under 40 in the full term infant, under 30 in the preterm infant. -Normal serum glucose is 40-80 -Feed the baby early (5% Dextrose water, breastmilk, or formula) if a low glucose level is detected |
*Hypoglycemia
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-Blood volume is 80 – 85 mL/kg of body weight
-Prolonged coagulation time for first week because of decreased levels of vit K, therefore, neonatal dose of vit K given injection at birth -Decreased levels of K -> transient deficiency in coagulation factors II, VI, VII, IX, X -Administer vitamin K to prevent hemmorhagic disorders |
*Hematopoietic System
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(Aquamephyton Phytonadione)
-Prevention of hemorrhagic disorder in newborn -Infants are born with a sterile gut and have no interic bateria present for synthesis of vit K -Could have inflammation at the injection site -Usual order 0.5mg of vit K given IM in the first hour of birth -Use the vastus lateralis muscle of the thigh -Hold knee secure during procedure as neonate will try to move during injection |
*Vitamin K
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-Meconium stool will be first then yellow or green
-6-8 diapers per day |
voiding/stooling
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Screen after 2-3 days of milk injestion. State law differs
regarding newborn screening. May also screen for hypothyroidism, sickle cell, and galactosemia |
PKU
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-How many oz, how long on each breast
-Do not feed the newborn when the respiratory rate is over 60 inform the Dr. and anticipate gavage feedings in order to prevent further utilization and possible aspiration -Demand feeding (bottle or breast) is preferred -Most bottle fed newborns eat every 3-4 hrs -Breastfed newborns eat every 2-3 hrs (digest more quickly) -After the initial weight loss period, should gain approximately 1 oz (30 grams) per day -Needs about 50 calories/lb or 180 calories/kg of body weight for the first 6 months |
Document nutritional intake and calculate nutritional needs
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-Lethargic, hard to wake
-Temp >100 -Vomiting large amounts, everything fed -Green liquid stools -Refusing to eat 2 times in a row |
Recognize signs and symptoms of a sick newborn who needs attention
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-Normal bacterial are not yet present
-Lower intestine contains meconium at birth -1st stool (meconium) passes within 24 hrs -Audible bowel sounds 1 hr after birth -Uncoordinated peristalitic activity in the esophagus the first few days -Limited ability to digest fats because amylase and lipase are absent at birth -Immature cardiac (lower esophageal) sphincter -> frequent regurgitation |
Gastrointestinal System GI Tract
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Detected in fetus at 3rd month, placentally transferred
Provides antibodies to bacterial and viral agents Makes own IgG during first 3 months after birth |
-IgG
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Fetal synthesis by 20th week, but doesn’t cross placenta
undetectable at birth High levels of IgM indicate nonspecific infection |
-IgM
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Secretory
Limits bacterial growth in GI tract Found in colostrums and breast milk Microwaving breastmilk kills this in the milk Do not microwave breastmilk |
-IgA
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-Does not fully mature until after 1st yr of life
-Minimal range of chemical balance and safety -Limited ability to excrete drugs -> rapidly cause acidosis -Excessive neonatal fluid loss -> fluid imbalance |
Renal System
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(edema under scalp) crosses the suture lines and is usually
present at birth |
*Caput Succedeneum
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(blood under the periosteum) does NOT cross the suture lines
and manifests a few hours after birth. The danger is increased hyperbiliribinemia due to excess RBC breakdown |
*Cephalhematoma
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Swelling or edema occurring in or under the fetal scalp during
labor |
Caput Srccedaneum
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Subcutaneous swelling containing blood found on the head of
an infant several days after birth, usually disappears in a few wks-2 months |
Cephalohematoma:
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National Mental Health Act -> first training of psychiatric nurses
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1946
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First antipsychotic drugs -> Thorazine
Heldegard Peplau wrote about therapeutic nurse-pt relationship First edition of Diagnose & Statistical Manual (DSM I) was published |
1950's
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Community Mental Health Center Act passed -> took clients out of state
mental hospitals Provided federal money, return to own community, expanded role of nurses in health care of mentally ill Limitations: funding, public attitude, housing and homelessness |
1963
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Clinical pathways and case management
Shorter in pt stays, less stabilized at discharge, revolving door Increase emergency and O/P visits and requests for service Improvements in psychotropic drugs ‘ Last 10 yrs -> learned 90% of what we know now re functioning of brain |
1990’s -> 21st Century
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S/S of a specific major psychiatric disorder
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Axis I
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Long-term patterns of behavior or mental retardation
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Axis II
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General medical conditions relevant to the psychiatric d/o
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Axis III
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Psychosocial and environmental problems
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Axis IV
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Global assessment of functioning to indicate highest level
achieved within past yr |
Axis V
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-Provides specitic behavioral criteria for each diagnostic category of mental
illness -Allows a more holistic assessment of the client -Based on 5 criteria or “axis” (not a nursing care plan or diagnosis) |
Categorizing Mental Illness (DSM-IV)
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All behavior has a meaning
-Ego Defense Mechanisms -Transference: Client directs feelings through therapy, treats the therapist like someone in their life they remind them of -Countertransference: Client reminds therapist of a person in their life and the therapist treats the client as that person -Said that everything had a sexual motivation |
freud
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Stages of development and related tasks
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*Erikson
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Hierarchy of needs
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*Maslow
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Nursing therorist Nurse/Patient relationship
-Nurses must promote nurse/patient relationship to built trust, foster healthy behavior -Nurse’s therapeutic use of self promotes healing -Therapeutic relationship is directed toward meeting the patient’s needs -Anxiety as foundation for working with clients |
*Hildegard Peplau
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Preventing conditions from happening. High risk population
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*Primary Intervention
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Do most commonly reducing problems associated with
condition they have, don’t develop complications |
*Secondary Intervention
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Recovered, support group. Condition is controlled, family
understanding |
*Tertiary Intervention
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Side effect of clozapine (Clozaril)
S/S: Fever, flu like symptoms Nursing Int: Know early s/s, weekly blood draws if on this med, WBC count before beginning, monitor closely and frequently |
Agranulocytosis
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S/S: Rigidity, tremors, slowness
Meds to Manage: (ABC) Artane, Benadryl, Cogentine |
Pseudoparkinsonism
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S/S: Can’t sit still, continuous restless movement, can have sensation of this
w/o seeing it Management: Decreased by altering medication Medications: Enderol (Beta blocker) Anti anxiety meds |
Akathisia
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S/S: Muscle ridgidity of upper extremeties (neck)
Eyes rolling back, twisting of neck, muscle spasms Difficulting swallowing & decreased respiratory function Early occurring symptoms Management: Emergency, anticholinergic drugs (cogentin, benadryl) |
Dystonia
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Permanent involuntary movements
Late occurring S/S: Abnormal movements, lip smacking, tongue out, grimacing, irreversible if caught late Treatment: Irreversible if caught late, decrease or change meds, teach and report meds AIMS Tool: Abnormal involuntary movement scale |
Tardive Dyskinesia
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Life threatening emergency
Happens within 1-2 weeks of order or order change S/S: Muscle rigidity, hyperpyrexia (>103) elevated CPK, increased BP, P, sweating Treat: ICU, IV meds (dantrium, parlodel) cooling measures, resp, renal failure Nursing Action: Stop the medication |
Neuroleptic Malignant Syndrome
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Bothersome side effect of antipsychotics
Includes: Dry mouth, blurred vision, urinary retention, constipation, photosensitivity Nursing Management: Encourage to take medication, talk to Dr. non pharm measures |
Anticholinergic Effects
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Uses: Major depression, panic disorder, other anxiety disorders, bipolar,
psychotic depression Action: Interact with the neurotransmitter in the brain, norepinephrine, serotonin |
Antidepressant Drugs: SSRI, TCA, MAOI
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(Prozac, Paxil, Zoloft, Celexa, Lexapro)
Blocks reuptake of serotonin S/E: Sexual dysfunction, weight gain Take in AM and with food Avoid MAOI’s or St. Johns Wart Effective in 2-3 weeks |
SSRI Antidepressant Drugs
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Adverse effect of antidepressants
S/S: Increased BP, temperature, pulse, shock, restlessness, delirium Nurse Manage: STOP med, prevention |
Serotonin Syndrome
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(Elavil)
Block reuptoake of norepinephrine and serotonin Effective in 4-6 weeks Anticholinergic S/E + orthostatic hypotenstion Sedating, take at bedtime High risk for overdose |
TCA Antidepressant Drugs
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(Nardil, Parnate)
Blocks destruction of neurotransmitters at synapse Breaks down tyramine in certain foods -> increase tyramine in blood Adverse Effect: Hypertensive crisis Nurse Action: Avoid foods with tyramine Foods with Tyramine: Aged cheese, pizza, lasagna, aged meats, Italian breads, tofu, banana peel, over ripe fruit, acocado, tap beers, microbrewery beer, no more than 2 beers or 4 oz of wine per day sauerkraut, soy sauce, soybean condiments, marmite, yogurt, sour cream, peanuts, brewers yeast, MSG |
MAOI Antidepressant Drugs
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Lithium, (a salt), Anticonvulsant medications
Uses: Bipolar Disorder Action: Normalizes the reuptake of certain neurotransmitters, and reduces the release of norepinephrine Lithium interacts with Na and K at cell membrane |
*Mood Stabilizing Drugs
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(BuSpar)
Uses: Anxiety disorders, insomnia, OCD, depression, PTSD, alcohol withdraw Action: Moderate the actions of GABA and inhibit aggression, anxiety Highly sedating High risk for physiological or psychological dependence |
Antianxiety Drugs
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(Ritalin, Adderal)
Uses: ADHD, residual ADD in adults, and narcolepsy Action: Cause release of neurotransmitters S/E: Anorexia, weight loss, nausea, irritability Patient Teaching: Avoid caffeine, sugar, chocolate, take after meals, long term use can cause dependency |
Stimulant Drugs
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Use: Aversion therapy for treatment of alcoholism
Action: Causes an adverse reaction when alcohol is ingested avoid OTC medications or topical containing alcohol |
Disulfiram (Antabuse)
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-One on one between therapist and client
-Based on belief that all behavior has a meaning -Goal is to uncover unconscious material that impacts.causes current behavior -Transference and countertransference *Group Therapy -Relationships with others are recreated among group members and can be worked through in the group -Members meet regularly with a leader to form a stable group -Members learn new ways to cope with stress and develop insight into their behavior with others. Can increase self esteem |
*Traditional Psychotherapy
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-Goal: Establishment of a safe, supportive environment
-It is supported by clear and consistently maintained limits and expectations -Caring is a basic factor -Client is expected to assume responsibility for self -Client is involved in goal setting/participation in unit activites -Emphasis is on group and social interaction -Feedback form other clients facilitates the client’s growth |
*Milieu Therapy
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-Precipitating cause: Development or situational or threats to self concept
-Self-limiting – usually resolves in 4-6 weeks -Crisis can promote growth and new behaviors -Therapy is goal directed, focused on clients immediate problems -Previous coping mechanisms are ineffective in this situation -Help client become aware of feelings and validate them -Identify support systems; also what has worked in past -Goal: return to pre-crisis level of functioning (or higher) |
*Crisis Intervention
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-Goal is to change behavior either through positive or negative
reinforcement |
*Behavioral Therapy/Behavior Modification
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-goal is to correct distorted thoughts/beliefs
-Thought stopping – alters the process of negative thought patterns; useful with personality disorders -Thought Substitution: Substitute a positive thought for a negative one |
Cognitive Therapy
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-Don’t try to correct the distortions or to emphasize the current reality
-Draw out positives |
Validation Techniques/Reminiscence Therapy
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