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498 Cards in this Set
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what is done for the nursery admission of a newborn
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Basic Care
Routine treatments Newborn screening |
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what is done in the basic care of newborns
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Physical Exam
Obtain Birth Weight Gestational Age Exam Monitor Vital Signs Give Bath |
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what is done for infant security
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Mother-Infant ID Bands
Staff ID |
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what is special about staff ID's in postpartum care
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Unit Specific ID badges
Parents informed to check staff ID prior to allowing any personnel transport their infant |
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what is the length of an average full term baby
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28-53 cms (18-21 ins)
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what is the weight range of an average full term baby
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2500-4000 gms (5 lbs 8 oz to 8 lbs 13 oz
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what is the head circumference of an average full term baby
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33-35 cm
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what should be prevented in a new born
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hypothermia
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what is the normal temperature of a newborn
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97.7o - 99.5o F (36.5 o C - 37.5o C)
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how is temperature monitored in a newborn
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Monitor with skin temperature probe placed on abdomen
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how is temperature verified in a newborn
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Verify manually with axillary temp. for 3 min.
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what does swaddling help maintain
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body temperature,
provides a feeling of closeness and security and may be effective in quieting a crying baby |
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what are the most important newborn reflexes in the newborn exam
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Moro reflex
Tonic-neck Suck Root Palmar/plantar grasp |
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what are the effects of labor on the fetal head
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molding
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what is molding
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Asymmetry due to overriding cranial bones
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what is a Cephalohematoma
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Collection of blood resulting from ruptured blood vessels between cranial bones & periosteal membrane
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a Cephalohematoma can be what
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unilateral or bilateral
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a Cephalohematoma does not cross what
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does not cross suture lines
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how does a cephalohematoma feel
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Feels loose & edematous
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when does a cephalohematoma occur
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Appears on 1st & 2nd day after birth
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when does a cephalohematoma resolve
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Resolve in 2-3 wks
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what is Vernix caseosa
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A protective, cheeselike, whitish substance made up of sebum and desquamated epithelial cells that is present on the fetal skin.
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what is a mongolian spot
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Dark, flat pigmentation of the lower back and buttocks
noted at birth in some infants; usually disappears by the time the child reaches school age. |
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what is mila
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Tiny white papules appearing on the face of a a newborn as a
result of unopened sebaceous glands. They disappear spontaneously within a few weeks |
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what are Erythema toxicum neonatorum
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Innocuous pink papular rash of unknown cause with superimposed vesicles.
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when do Erythema toxicum neonatorum appear and resolve
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It appears within 24 to 48 hrs after birth and resolves spontaneously within a few days.
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when is eye prophlaxis given to the new born
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Within an hour of birth
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why is eye prophlaxis given
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prevent gonococcal infection
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what are the medications given for eye prophlaxis
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1% silver nitrate solution
1% tetracycline opthalmic ointment 0.5% erythromycin opthalmic ointment This also prevents chlamydial infections |
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how do you use the medication tube of ophthalmic ointment
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apply narrow ¼” long ribbon
along lower conjunctival surface of each eye starting at the inner canthus |
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after administration of ophthalmic ointment what do you do
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After administration, gently close eye and massage to ensure spread of ointment
May wipe away excess after one minute, but do NOT irrigate eyes after the instillation |
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why are newborns susceptible to hemorrhagic disease
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Newborns do not have the bacteria in the colon that are necessary for synthesizing fat-soluble vitamin K1.
Therefore, they have decreased levels of prothrombin during the first 5-8 days of life, reflected by a prolongation of prothrombin time. |
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what is given to prevent hemorrhagic disease
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Vitamin K injection is necessary to prevent hemorrhage
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what are side effects of vitamin K injections
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Ecchymoses (bruising)
pain and edema at injection site |
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what is the type of vitamin K that is given
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AquaMEPHYTON (Vit K1)
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when is AquaMEPHYTON (Vit K1) given
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During the first hour following delivery
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what type of needle is used to give AquaMEPHYTON
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using a very short, thin needle
25 gauge, 5/8” |
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what is the preferred site to give AquaMEPHYTON
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Vastus lateralis
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how should you care for the umbilical cord
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Keep the cord stump clean and dry
Daily wiping of the cord with alcohol and leaving it open to the air facilitates drying and discourages bacterial growth. |
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when is topical application of antiseptics necessary for umbilical cord care
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the baby is living in a highly contaminated area.
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Glucose supplied to fetus through what
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placenta
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Neonatal carbohydrate reserves are what
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low
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1/3 of reserve is glycogen in neonates is stored where
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in the liver
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what is the main source of energy in 1st 4-6 hrs of life
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Glucose
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what is glucose needed for
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Need for respiration, muscle activity, heat production
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how is glucose assessed in newborns
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by a Dextrostrip
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when is glucose assessed in newborns
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on admission to nursery & at 4 hrs of age
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how do you diagnose glucose in newborns
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Heel sticks with dextrostix or glucometer
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what is a normal glucose for a newborn
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of 45-90
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what is hypoglycemia
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less than 45
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what do you do if the newborn is hypoglycemic
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If <45, early feed with glucose water or breast milk
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what is the main concern with hypoglycemia in a newborn
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brain damage
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what are the signs and symptoms of hypoglycemia
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Jitteriness
Poor muscle tone Tachycardia Tachypnea Respiratory distress Cyanosis Hypothermia Poor suck High pitched cry Lethargy Irritability Seizures |
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what are the symptoms of respiratory distress in a newborn
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Changes in color or activity
Grunting or “sighing” sounds with breathing Rapid breathing with chest retractions Nasal flaring Facial grimacing Excessive mucus |
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what are the treatments for respiratory distress in a newborn
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Nasal and oral suctioning with bulb syringe
Positioning Vigourous fingertip stroking of the newborn’s spine to stimulate respiratory activity if necessary |
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where should the meatal opening of the male genitalia of the newborn be
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at the tip
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what is Hypospadias
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meatus on ventral side
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what is Phimosis
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prepuce is small, no retraction, no treatment unless interferes with urination
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what is Cryptochidism
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failure of testes to descend
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what is Hydrocele
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collection of fluid surrounding testes, resolves without intervention
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the foreskin cover what
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Foreskin covers glans
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what is the care done for the foreskin in an infant
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don’t force retraction in care of uncircumcised newborn
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what does a circumcised gland look like
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red and swollen
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what is removed in the surgical procedure for a circumcision
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prepuce removed
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what are contraindications to circumcision
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preterm, GU defect
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what should you observe after a circumcision
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Urine output
bleeding granulation |
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what is the post op treatment of circumcision
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Apply gentle pressure to the site with gauze
Always use petroleum with the gauze, never use dry gauze |
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what is the prepuce
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epithelial layer covering the tip of the penis (foreskin)
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what should you never do to the prepuce
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Never forcibly retract it
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what should a newborn have before a circumcision
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Should have Vitamin K before circumcision
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Most of the defects in newborns are what
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inborn errors in metabolism.
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what is the mode of transmission for most defects in newborns
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Mode of transmission is usually autosomal recessive gene
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what are most defects in newborns associated with
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Most are associated with mental retardation
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what are newborn screenings
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Hepatitis vaccine
Hearing screening |
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what is the newborn genetic screens
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metabolic, Hemoglobinopathies, endocrine, and cystic fibrosis
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what are the metabolic screens in newborns
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PKU (phenylketonuria), galactosemia, biotinidase deficiency, maple syrup urine disease
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what are the Hemoglobinopathies screens in newborns
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Sickle cell disease, thalessemia
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what are the endocrine screens in newborns
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Congenital hypothyroidism
Congenital adrenal hyperplasia |
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what is PKU
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Phenylketonuria
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what is Phenylketonuria
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Absence of liver enzyme phenylalanine hydroxylase
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what happens without phenylalanine hydroxylase
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W/O this enzyme, phenylalanine cannot be converted to tyrosine
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what happens in PKU
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Toxic levels build up & accumulate in CNS, blood and urine.
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when is PKU screening done
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screening after 24 hrs
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when do you repeat PKU screening
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72 hours
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what is the treatment of PKU
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strict adherence to low phenylalanine diet
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what are the symptoms of PKU
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Affected child has musty odor, decreased pigmentation of skin and hair, and progressive mental retardation, seizures, microcephaly, hyperactivity, irritability, repetitive motions, musty odor from skin & urine, tremors
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when does minimal CNS damage occur
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Minimal CNS damage will occur if early dx and tx.
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how do you diagnose PKU
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blood test 24-48 hrs after protein ingestion
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what is the treatment of PKU
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dietary restriction;
Levels of 4-8mg/dl promotes growth & is harmless |
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what kind of trait is PKU
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autosomal recessive trait
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what is congenital hypothyroidism
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Inadequate production of thyroid hormone
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what are the signs and symptoms of congenital hypothyroidism
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mottling, poor muscle tone, poor feeding, lethargy, respiratory distress, temperature instability
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what happens if there is no treatment for congenital hypothyroidism
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growth failure, deafness, neurological abnormalities, and MR
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what is Galactosemia
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Autosomal recessive disease inborn error of carbohydrate metabolism
Body unable to metabolize galactose and lactose |
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what can galactose in the blood lead to
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Galactose in blood lead to cataract formation, renal disease, liver dysfunction, and MR
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what is the treatment for Galactosemia
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Nutramigen or ProSobee, no breastfeeding
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when is the newborn period
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Birth through 1st 28 days of life
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what is the newborn adjustment
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Newborn adjustment from intrauterine to extrauterine life
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what happens in the neonatal transition
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Respiratory & circulatory functions stabilize
All body systems change level of functioning or are established over the newborn period |
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what is the homeothermic thermoregulation
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Maintenance of thermal balance by production of heat at a rate equal to loss of heat to the environment
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Skin thermoreceptors transmit sensations to where
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Hypothalamic thermoregulatory center in brain
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what do skin thermoreceptors trigger
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sympathetic responses to maintain optimal body temperature when core temperature below Set Point of 97.7o F (36.5o C)
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For unclothed, full-term infant, the ambient environmental temperature is what
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89.6 o to 93.2 o F
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what determines the NTE
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Newborn traits determine NTE
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what are the effects of cold stress
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Increased basal metabolic rate
Increased anaerobic metabolism Decreased surfactant production Release of norepinephrine |
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what does an Increased basal metabolic rate cause
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Increased O2 utilization to increase heat production
Increased glucose utilization Hypoglycemia |
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what does Increased anaerobic metabolism cause
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increased fatty acids
hyperbilirubinemia |
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what does a decrease in surfacant production cause
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Preterm infant may not be able to increase ventilation to maintain necessary level of oxygenation
Respiratory distress |
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what does releasing norepinephrine cause
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depleting stores of Brown Adipose Tissue (BAT)
infant will loose weight if chronically cold Pulmonary vasoconstriction decreased blood flow through lungs |
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what is the treatment for cold stress
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Note decrease in temperature, tremors, irritability, lethargy, apnea, seizures.
Heel stick for hypoglycemia (< 45mg/dl) Increase ambient air temp 1-1.5o C above infant’s temperature Warm slowly—rapid can cause hypotension and apnea Increase air temp in hourly increments, until NB stabilizes temp Warm IV prior to infusion Monitor skin temp every 15-30 min. |
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In utero, the fetal temperature is what
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~ the same as the mothers ~ 37o C (98.6o F)
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what happens to the newborn Without heat conservation measures, in the Delivery Room temp of 72o F
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deep body temperature falls 0.1o C/ min (0.2o F/ min)
skin temp lowers 0.3o C/min (0.5o F/ min) |
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what is evaporation
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Loss of heat when water converted into a vapor
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Immediately after birth, what is the type of heat loss the newborn is MOST susceptible to.
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evaporation
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how do you prevent evaporation
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Drying the infant thoroughly with a towel after birth
Place knit cap over wet ha |
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what is convection
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Loss of heat from the warm body surface to cooler air currents
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how do you prevent convection
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Place infant underneath radiant warmer
Place newborn away from air currents |
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what is conduction
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Loss of heat by skin DIRECTLY contacting a cooler surface.
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how do you prevent conduction
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Place towel on scale to lay infant on
Nurse warm stethoscope in palm of his/her hand prior to use |
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what is radiation
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Heat transfers from the heated body surface to cooler surfaces and objects NOT in direct contact with the body
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HYPOXIC NEWBORN becomes what
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temperature of environment
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what should be done to help the newborn breath after birth
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Using any type of oral-pharyngeal suctioning of the newborn
clear mucus from mouth first then nose, to clear passages |
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what initiates respitations at birth
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chemical stimuli, thermal stimuli and sensory stimuli
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what are the chemical stimuli for respirations at birth
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elevation in PCO2 and decrease in pH and PO2 resulting from umbilical cord clamping.
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what are the thermal stimuli for respirations at birth
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Significant decrease in environmental temperature after birth. 98.6 to 74-76 degrees.
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what are the sensory stimuli for respirations at birth
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Tactile, auditory, visual stimuli
touch, light, sound, gravity |
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what are the 2 radical changes in the initiation of breathing
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Pulmonary ventilation through lung expansion
Marked increase in pulmonary circulation |
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what does the first breath do
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initiates the opening of alveoli
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what is the Alveolar Surface Tension
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Contracting force between moist surfaces of alveoli - Necessary for respiratory function
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what does surfactant do
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Promotes lung expansion – prevents collapse
Promotes lung compliance – fill with air easily |
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what does a decrease in surfactant cause
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decrease in lung compliance
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what are the newborn respiration rates immediately after birth to 2 hours
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60-70
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what are normal newborn respirations
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30-60
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what is apnea
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pause in breathing greater than 20 seconds
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what are signs of respiratory distress
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Tachypnea
Flaring nostrils Grunting Retractions suprasternal, substernal, intercostal, subcostal Cyanosis Apnea & bradycardia |
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how much blood can be added to newborn circulation after birth
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50-100 depending on where the cord is cut
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what is Acrocyanosis due to
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decreased peripheral circulation
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What causes the Foramen ovale to close?
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Changing atrial pressures
In utero pressure is greater in the right atrium Decreased pulmonary resistance and increased pulmonary blood flow increase the pulmonary venous return into the left atrium. |
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when does the foramen ovale close
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Foramen ovale is functionally closed 1-2 hrs after birth.
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What is responsible for the unstable transitional period in cardiopulmonary function of the Newborn?
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Shunting of blood is common in the early NB period.
Bidirectional blood flow, or right to left shunting through the ductus arteriosus, may divert a significant amount of blood away from the lungs. |
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what are the Fetal structures that atrophy after birth.
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Ductus arteriosus & Ductus Venosus
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what is the function of the Ductus Arteriosus
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Provides blood flow from pulmonary artery to aorta
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when does the Ductus Arteriosus close
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Functional closure in 15 hrs and full closure in 3 wks.
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what is the function of the Ductus Venosus
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Carries oxygenated blood from the umbilical vein and the inferior vena cava, bypassing the liver.
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what is the pulse of the newborn
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Apical pulse 120-150 b/min;
Sleeping =100 and crying = 180 |
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what is the blood pressure of a newborn
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B/P= 71/49 average;
Report if diastolic <25 or systolic <60 |
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what is the initial weight loss after birth
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term newborns normally, loose 5-10% of their birth weight w/in the first 5-10 days
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what are meconium stools
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usually w/in 8-24 hrs always w/in 48 hrs;
thick,tarry, black or dark green |
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what are transitional stools
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Usually passed for next day or two (age 3-4 days old)
Thinner brown to green |
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what are breastfed stools
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are pale yellow, liquid, & more often than formula fed
often q feed (up to 10x/day) |
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what enzyme does a newborn lack
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Lack pancreatic enzyme amylase for 1st three months
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what are the behavioral states of newborns
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Sleep state (intervals of 50-60 min)
Deep or quiet sleep Active REM Alert state Drowsy or semidozing Wide awake Active awake Crying |
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what is Habituation
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ignore disturbing repetitive stimuli
ability to process & respond to complex stimulation |
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what is the orientation of a newborn
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Fixate on visual stimuli
Look at a face |
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what is the Leading cause of infant morbidity & mortality among preterm infants
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Respiratory Distress Syndrome
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what causes RDS
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Insufficient production of surfactant
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what are the signs of RDS
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Nasal flaring
Tachycardia Retractions Cyanosis |
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what occurs if newborn with RDS becomes hypoglycemic
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jitteriness
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what does an xray of RDS look like
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Ground glass appearance of lungs
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what is the management for RDS
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Surfactant replacement used prophylactically or as treatment
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what is seen on improvement with RDS
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As evidenced by the infant needing less ventilatory support
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Effectiveness of bag and mask therapy can be determined by
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the rise and fall of the chest
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what causes cold stress
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Caused by excessive heat loss
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what are the compensatory mechanisms for cold stress
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triggers increased oxygen utilization
increased respirations Non-shivering thermogenesis for maintaining core body temp |
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what does cold stress cause
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increased severity of RDS
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Extreme Cold Stress can lead to what
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metabolic acidosis
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what is metabolic acidosis
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pH <7.25 HCO3 < 20
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what causes an Intraventricular Hemorrhage
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Rupture of fragile blood vessels around the ventricles of the brain
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what is an Intraventricular Hemorrhage associated with
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hypoxic injury to vessels, BP changes, fluctuating cerebral blood flow
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what are the manifestations of an Intraventricular Hemorrhag
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lethargy, poor tone
poor respiratory status cyanosis, apnea, drop in hematocrit, decreased reflexes, bulging fontanelles, Seizures |
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what is Retinopathy of Prematurity
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Injury to capillaries of retina
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what is the most common cause of Retinopathy of Prematurity
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Prolonged oxygen therapy
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what does Retinopathy of Prematurity cause
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Causes mild to severe eye & vision problems
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what is the treatment for Retinopathy of Prematurity
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laser photocoagulation or cryotherapy
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what causes Patent Ductus Arteriosus and what are the symptoms
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lowered oxygen tension
decreased blood flow to lungs leads to volume overload, pulmonary congestion and higher oxygen consumption tachypnea, bounding peripheral pulses, hypotension, tachycardia, hepatomegaly |
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what is the treatment for Patent Ductus Arteriosus
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Fluid regulation
Respiratory support Surfactant Observe for spontaneous closure Meds – Indocin Surgical ligation |
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when is Bronchopulmonary Dysplasia-BPD most common
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Most common in infants LBW, less than 1500 g
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what is Bronchopulmonary Dysplasia associated with
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Associated with neonatal pneumonia, PDA
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what is the cause of BPD
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high levels of O2,
damage from oxygen free radicals, lung injury from positive pressure vent |
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what are the characteristic of BPD
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Inflammation, atelectasis,
edema, loss of cilia, thickening of alveolar walls |
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what is the treatment for BPD
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adequate O2 & ventilation,
prevent further damage, optimal nutrition, support care |
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what is the management for BPD
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Prevention
aspiration, inadequate nutrition, Minimal exposure to O2 & pressure Avoidance of fluid overload, nutrition, high frequency, ventilation Treatment is supportive Gradually improves with increase in alveoli, by long term effects may last |
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what is periodic apnea
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absent breathing for 5-10 secs
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what is apnea
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absent breathing for >15 secs
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what can apnea result in
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cyanosis & bradycardia
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apneic spells increase with what
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decrease in gestational age
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what is . Necrotizing Enterocolitis
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Inflammatory disease of GI mucosa
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what is . Necrotizing Enterocolitis associated with
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asphyxia, sepsis, polycythemia, cocaine
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what are the signs of Necrotizing Enterocolitis
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distended abd, decreased BS, vomiting, blood in stools, lethargy, poor feeding, hypotension, apnea
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what is the management of Necrotizing Enterocolitis
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Antibiotics
DC oral feedings Limited coordination to maintain suck, swallow, and breathe in sync with oral feeding Gastric suction Parenteral nutrition Surgery |
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what are the CNS symptoms of an Infant of Substance Abusing Mother
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hyperirritability & exaggerated reflexes
high pitched cry, hyperactive muscle tone, tremors, poor suck/swallow |
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what are symptoms of Severe narcotic withdrawal
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unrelieved irritability
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what are the newborn ABGs
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pH < 7.35
PaO2 < 50 mmHg PCO2 > 60 mmHg |
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what is the patho of Perinatal Asphyxia
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Intrauterine asphyxia leads to inadequate cellular perfusion and oxygenation, resulting in hypoxic tissues.
This leads to anaerobic metabolism and the increase in rate of glucose use and accumulation of lactic acid. This is compounded by accumulation of CO2 and the resulting respiratory acidosis |
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what are the signs and symptoms of asphyxia
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Respiratory Acidosis (carbonic acid)
Metabolic Acidosis (lactic acid) Hypoglycemia Redistribution of blood flow Blood is shunted away from the kidneys and intestines to vital organs brain, heart, liver, adrenals |
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what causes tachypnea of the newborn
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Delay in absorption of lung fluid
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what are the signs of tachypnea
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Tachypnea, grunting, retractions, nasal flaring, mild cyanosis
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what causes meconium aspiration
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During fetal hypoxia, the rectal sphincter relaxes and meconium expelled into the amniotic fluid
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what is the priority at delivery for meconium aspiration
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suction the oropharynx when the head is born
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Meconium Aspiration Syndrome results in what
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obstruction of airways, pneumonitis, air trapping
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what happens in meconium aspiration syndrome
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Air can enter but not be expired, trapping air & distending the alveoli
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what can meconium aspiration syndrome lead to
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pheumothorax
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the signs of meconium aspiration syndrome are similar to what
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RDS
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what is the management for meconium aspiration
|
Before the infant is stimulated to inhale
Visualization of vocal cords intubated for suctioning of the airway. May need minimal or maximal support If not responding during NICU care- ECMO may be instituted (extracorporeal membrane oxygenation) |
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what needs to be investigated with jaundice
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Pathological Hyper-bilirubinemia
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what is Pathological Hyper-bilirubinemia
|
Clinically evident jaundice < 24 h
Serum Bilirubin rising by more than 5 mg/dl per day Total Bilirubin > 15 mg in term infant |
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|
what is bilirubin
|
degradation product of the pigmented heme portion of hemoglobin
|
|
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what is indirect bilirubin
|
Unconjugated or fat soluble bilirubin
|
|
|
what is the normal amount of indirect bilirubin
|
1 month-adult = 0.3 to 1.1 mg/dl
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|
|
what causes an elevation in indirect bilirubin
|
Hemolysis (transfusion reaction)
RBC degradation (hemorrhage into soft tissues) defective hepatocellular uptake (liver immaturity) |
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what is direct bilirubin
|
Conjugated bilirubin or water soluble.
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|
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what modifys the direct bilirubin chemical structure
|
sunlight
|
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when does indirect bilirubin rise
|
When liver is unable to conjugate
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|
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what is total bilirubin
|
TOTAL bilirubin is a combination of the direct and indirect.
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what is the onset of jaundice
|
24 hrs after birth
|
|
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when does jaundice peak
|
3-5 days
|
|
|
what is the total bilirubin before yellow skin
|
> 6 mg/dl BEFORE yellow skin
|
|
|
how is a bilirubin level great then 12 treated
|
bili lights or the Wallaby Blanket
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|
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what are the causes of hyperbilirubinemia
|
Accelerated destruction of the fetal RBCs
impaired conjugation of bilirubin increased bilirubin reabsorption from the intestinal tract |
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|
what are the associated conditions of hyperbilirubinemia
|
Cephalohematoma
Prematurity Polycythemia Dehydration |
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|
what are the causes of abnormal neonatal jaundice
|
Fetal-maternal blood group incompatibility
Non-specific hemolytic anemias Sepsis Polycythemia Infants of diabetic mothers |
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|
what do you assess in hemolytic disease
|
Mother’s blood type for Rh (D), ABO , Kell, c, E and C, if known.
Check father’s type Check if RhoGam is indicated by baby’s baby blood type Rh+, Coombs neg. Check baby for direct Coombs’ test Measuring the presence of antibody-coated Rh+ RBCs in the newborn. |
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|
what happens in Erythroblastosis Fetalis
|
Anemia triggers the production of more RBC’s in fetus which are eliminated.
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|
|
Erythroblastosis Fetalis results in
what |
ascites, pericardial effusion, cardiac failure, impaired placental circulation, hydrops and death.
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what is the patho of Erythroblastosis Fetalis
|
Rh+ Fetal blood enters maternal circulation.
Maternal immunization against the fetal antigens. Anti-Rh+ antibodies are produced and shown in serum titer Fetal RBC's are eliminated by phagocytoses & hemolysis. |
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what does Kernicterus mean
|
yellow nucleus
|
|
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when does Kernicterus occur
|
Occurs when unconjugated serum bilirubin reaches toxic levels
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|
|
why are cases of Kernicterus reappearing
|
as a result of early discharge and the increased incidence of dehydration among breastfeeding mothers
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what do you inform mothers if jaundice occurs
|
Inform mothers that if jaundice occurs, some babies may require phototherapy
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|
what can cause Hyperbilirubinemia
|
ABO incompatibility, RBC destruction, impaired liver function
|
|
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what is ABO incompatibility
|
Mother with type O has natural antibodies A & B which cross the placenta & destroy fetal RBCs (milder)
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|
management of Hyperbilirubinemia is focused on what
|
preventing kernicterus
|
|
|
how does Rho-Gam prevent sensitization
|
clearing fetal cells from maternal circulation
by depressing maternal immune response |
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|
Dose of 300 ug clears how much of fetal erythrocytes
|
15ml
|
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|
what is the treatment for Hyperbilirubinemia
|
Increase fluids, feeding
Special fluorescent light changes bilirubin into water-soluble products Bili-light Bili-blanket, double Phototherapy is most common treatment @ 25 - 48 hrs start phototherapy if Total serum Bilirubin ≥ 12 mg/dl |
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|
what is done for phototherapy
|
Eye protection with eye pads
Assure infant maintains normal body temperature Assess for hydration status |
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|
what are the side effects of phototherapy
|
loose, frequent stools,
skin color changes & rash |
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|
an Exchange Transfusion is used for what
|
dangerously high bilirubin levels
|
|
|
what does an exchange transfusion do
|
Removes antibodies, unconjugated bilirubin & sensitized RBCs
corrects anemia |
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|
what is used for immediate transfusions
|
Type O –
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|
|
what decreases the risk of newborn death
|
gestational age & birth wt increase
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|
|
what is SGA
|
2 standard deviations below the norm
|
|
|
what are some causes of SGA
|
Congenital/genetic abnormalities, infection, placental problem, maternal illness, smoking, substance abuse, maternal malnutrition
|
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what is the care of an SGA infant
|
Assess for problems
Provide nutrition |
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|
what problems do you assess in SGA infants
|
increased incidence of perinatal asphyxia
hypothermia polycythemia congenital malformations intrauterine infections, continued Growth Retardation, cognitive problems |
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|
why do you provide nutrition to SGA infants
|
Hypoglycemia is the most common metabolic problem with SGA infants
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|
what does IUGR describe
|
Describes the pregnancy circumstances of limited growth
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|
|
what causes IUGR
|
Caused by maternal, placental & fetal factors
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|
when does the pattern of IUGR vary
|
if occurs in early or late pregnancy
|
|
|
what is the pattern of IUGR
|
Symmetric growth restriction (proportional)
Asymmetric (dysproportional) |
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|
what causes chronic Symmetric growth restriction
|
Substance abuse, severe malnutrition
|
|
|
what is Asymmetric growth restriction
|
head circ > abdominal circ after 36 wks
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|
what can asymmetric growth restriction cause
|
Acute compromise of of uteroplacental blood flow- Preeclampsia, placental infarcts
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|
what is LGA
|
Above 90% percentile: weighs > 4000 gms
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|
|
what causes LGA
|
multiparity, genetics, ethnicity, maternal diabetes, postterm pregnancy
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what is the maternal-fetal effect of LGA
|
Longer labor, birth trauma (CPD), shoulder dystocia, induction or C/S, congenital heart defects & higher mortality rate, hypoglycemia, polycythemia, hyperviscosity
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|
|
High levels of fetal insulin interfere with what
|
production of surfactant
|
|
|
what are the increased risks of an infants of a diabetic mother
|
hypercalcemia & polycythemia
|
|
|
Preexisting diabetes is a well known risk factor for what
|
congenital anomalies
|
|
|
why is preexisting diabetes is a well known risk factor for congenital anomalies
|
maternal hyperglycemia during time of embryogenesis has a teratogenic effect of the development of the embryo.
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|
|
Risks depend on what in an infant of a diabetic mother
|
type & control of Diabetes
|
|
|
Type I Diabetics may have what
|
SGA
|
|
|
Gestational diabetics may have what
|
LGA
|
|
|
what is the Care of Macrosomic IDM
|
Screen for hypoglycemia: dextrostix < 45 mg/dl
Infant may need more frequent feedings |
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|
what causes macrosomia in gestational diabetics
|
Due to Maternal hyperglycemia
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|
what does maternal hyperglycemia lead to
|
Fetal islet cell hypertrophy which leads to producing large amounts of insulin
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|
what is seen in an infant of a diabetic mother
|
ruddy in color
excess adipose fat thick umibilical cord large placenta |
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|
what are the problems seen in a Macrosomic Infants
|
Poor motor skills
Difficulty regulating temperature More difficult to arouse Feeding difficulties Difficulty maintaining quiet alert state |
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|
Only 5% of postterm infants demonstrate characteristics of what
|
postmaturity syndrome
|
|
|
what are some associated factors of a postterm infant
|
Primiparity, high multiparity, history of prolonged pregnancies
More common in Australian, Greek, & Italian |
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|
Birth weight depends on what
|
length of duration of pregnancy
|
|
|
Limited extra time of pregnancy may have what type of infant
|
may be Macrosomic infant
|
|
|
Extended extra time of pregnancy may have what type of infant
|
may be Growth Restricted
|
|
|
what is a major concern of a postterm infant
|
placental insufficiency associated with postmaturity syndrome (long duration)
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|
|
postmaturity syndrome is associated with what
|
Associated with fetal distress during labor, meconium passage, CPD, shoulder dystocia
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|
|
what is the care of a posterm infant
|
Provision of warmth
Observation of respiratory status May be LGA and at risk for hypoglycemia frequent monitoring of blood glucose more frequent breastfeeding or formula feedings |
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|
what is a posterm infant
|
born after 42 weeks
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|
|
what is a preterm infant
|
Born before the end of the 37th wk of gestation
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|
|
what are the Physical traits of Premie
|
Head disproportionately large
Skin thin, wrinkled, red Absent breast tissue Decreased ear cartilage Genital immaturity Minimal creases in soles & palms |
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|
what are the causes of a preterm infant
|
Maternal complications
Infection Amnionitis, bladder infection Preeclampsia kidney disease heart disease DM |
|
|
what are risk factors for a preterm infant
|
Multiple pregnancy
adolescent pregnancy lack of prenatal care substance abuse smoking previous preterm delivery uterine abnormalities PROM placenta previa PIH |
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|
what are Tests That Indicate Maturity
|
Chest x-ray
ABG analysis Head ultrasound Echocardiogram Eye exam Serum glucose, serum calcium, serum bilirubin, CBC |
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|
what do you observe in a neuro exam of a premie
|
Active movements
Response to stimulation Response to passive movements |
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|
what do you assess in a neuro exam of a premie
|
Inactivity, extension of extremities, absence of suck reflex, weak swallow, gag, & cough reflexes, weak grasp reflex
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|
|
what are some Cardiopulmonary Problems of a premie
|
Initiation of breathing with immature lungs
Inadequate surfactant Assess for abnormal or absent breath sounds frequently Differentiate between periodic & apneic breathing Assess effort of breathing, retractions, & grunting |
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|
what are some interventions for cardiopulmonary problems
|
Respiratory support
Oxygen hood Nasal cannula ET tube & mechanical ventilation Continuous positive airway pressure (CPAP) Monitoring oxygen levels General care Positioning, suctioning, chest PT hydration |
|
|
Physiologic Considerations of a premie
|
Have little excess fat (energy) for maintaining muscle tone
Glycogen and brown fat forms in 3rd trimester Easily exhausted from noise & routine activities Unfinished growth & development Must adapt to extrauterine life as all newborns |
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|
what are the Goals for Nursing Care for a premie
|
Ensure oxygenation, ventilation, thermoregulation, nutrition, fluid/electrolyte
Prevent & control infection Encourage parent-neonate bonding Provide developmental care NICU Infant Goals Receive oral feedings, maintain temp, reach 5 lbs weight |
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|
what are some thermoregulation problems of a premie
|
More significant in preterm
Skin very thin with vessels near surface Very little subqu fat Less brown fat accumulation Larger head & more body surface Poor flexion Hypothalamus problem Complications from heat loss more likely |
|
|
what is done for thermoregulation problems
|
Assessment
Skin problem monitoring Axillary Temp as back up check Normal 36.3-36.9 Maintain at NTE Observe for overheating |
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|
what are the fluid and electrolyte problems of a premie
|
Looses fluid very easily
thin skin- more permeable, larger surface area use of warmers & lights respiratory & GI loss Kidney immaturity cannot concentrate urine, cannot regulate electrolytes |
|
|
what are the assessments for dehydration
|
Decreased urine output (I & O)
Weight loss Decreased blood pH Increased specific gravity Dry skin, mucous membranes, Sunken fontanelles |
|
|
what are the skin problems of a premie
|
Skin is thin, fragile, easily damaged
|
|
|
what are the nursing interventions for skin problems of a premie
|
Use little or no tape
Avoid alcohol, betadine, & other chemicals Monitor humidity in incubators Use of emollients Minimize pressure points |
|
|
what are some risks for infection in premies
|
Maternal infection
Inadequate passive immunity less mature immune response Exposure to situations that cause infections |
|
|
Pain stimuli cause what
|
physiologic & behavioral changes in preterm
|
|
|
what is done in the assessment of pain
|
HR, resps, BP, ICP, O2 sat, hormonal & metabolic changes, high pitched cry
|
|
|
what are the Nursing Interventions to comfort
|
Wake slowly & gently, use containment
Sucrose pacifier, soft talking, restraining extremities, holding, rocking Narcotics & general anesthesia can be used |
|
|
premies lack reserves of what
|
Ca, Fe, glucose, fat, etc…
|
|
|
what is the nutrition premies need
|
Need average of 100kcl/kg/day, more protein, iron, Ca, & phosphorus
|
|
|
premies can't absorb or digest what
|
Can’t absorb fat or digest lactose
|
|
|
Oral feeding requires what
|
increase use of O2 & glucose
|
|
|
what is done in the assessment of nutrition
|
Nipple readiness, tolerance of feeding
|
|
|
what is Gavage Feeding
|
Special formula or fortified breast milk
Concentrated nutrients in small vol Small tube in mouth or nose for feeding Feedings gradually increased Associated with aversive stimulation Oral feedings gradual onset Breast milk |
|
|
what are some parenting problems with premies
|
Preterm birth usually unexpected
Emotionally traumatic Early separation Highly technical environment Absence of normal expected newborn behaviors Loss of primary caregiver role |
|
|
what are some parenting problems with premies
|
Preterm birth usually unexpected
Emotionally traumatic Early separation Highly technical environment Absence of normal expected newborn behaviors Loss of primary caregiver role |
|
|
when is the postpartum period
|
6 wk period after birth
|
|
|
what are the retrogressive Changes in the postpartum period
|
Getting back to normal, returning to prepregnant state
Uterus shrinks & descends into pelvis (prepregnant state) Sloughing of uterine lining Development of lochia Contraction of cervix & vagina Recovery of vaginal & pelvic floor muscle tone Involution |
|
|
what are the progressive Changes in the postpartum period
|
Building of new tissues for the purpose of lactation and the return of menstrual flow
|
|
|
how is the uterus assessed
|
palpate the fundus
|
|
|
what is checked when you palpate the fundus
|
Determine size, firmness, location, rate of descent (make sure bladder is empty)
|
|
|
when do you palpate the fundus
|
q15 min for 1st hr
q30 min next 2-3 hrs q1 hr for 4 hrs q4 hrs for 1st day then q 8 hrs until d/c |
|
|
what is involution of the uterus
|
Uterus decreases in size & descends into pelvis
|
|
|
when does involution of the uterus begin
|
Begins immediately after delivery
|
|
|
a Firmly contracted uterus lies where
|
midway between the umbilicus & symphysis pubis
|
|
|
where is the uterus 6-12 post delivery
|
uterus above umbilicus
|
|
|
what is the rate descending of the uterus
|
1 cm/day
|
|
|
where is the uterus on the 10th post partum day
|
Lies deep in the pelvis
|
|
|
what are Factors That Delay Involution
|
Prolonged labor
Anesthesia Difficult delivery Full bladder Incomplete expulsion of placenta Infection Overdistention of bladder |
|
|
what is lochia
|
Uterine debris – 250-300 cc
|
|
|
what is the color of the lochia in the first 3 days
|
bright red
|
|
|
what is normal lochia
|
Gradually lighter in color
Should never be heavy Small clots are normal No foul odor |
|
|
flow of the lochia increases with what
|
activity
|
|
|
who has less lochia
|
breastfeeding moms
|
|
|
moderate flow leads to what
|
presence of clots
Lochia Rubra |
|
|
what are the types of lochia
|
Rubra (day 1-3), serosa (4-10), alba (10-14)
|
|
|
what happens when there is Failure to contract
|
Uterine bleeding or hemorrhage
Contractions act as a tourniquet to close the exposed blood vessels following placental separation |
|
|
If moderate to heavy lochia, first assess what
|
fundus and bladder status.
|
|
|
what is done if the uterus is boggy
|
Fundal massage,
IV pitocin or IM Methergine breastfeeding (release of natural oxytocin) maintains contraction of uterus |
|
|
what is a side effect of Methergine
|
hypertension
|
|
|
what are cervix changes in the pp period
|
Soft & formless, bruised & lacerated
Regains normal form in few hours External os changes to narrow slit Prepregnant to postpregnant |
|
|
what are the vagina changes in the pp period
|
Absence of rugae, lacerations
Returns to prepregnant state by 6 wks Kegel exercises |
|
|
when is the Return of Menses & Ovulation
|
Average for non-nursing mothers 7-9 wks
|
|
|
the first cycle of the return to menses is what
|
First cycle is anovulatory (usually)
|
|
|
return of menses is longer for who
|
nursing mothers
|
|
|
what are other Retrogressive Changes
|
decreased pregnancy hormones
Extensive diuresis, decrease in blood volume Gradual rise in Hct Reactivation of digestion & absorption Fading of striae gravidarum, cloasma, linea nigra Return of tone to abd muscles, ligaments Diastasis recti |
|
|
what is the weight loss after pregnancy
|
10-12 lbs
|
|
|
what are vital sign changes seen pp
|
Bradycardia (50-70) up to 10 days
Elevated temp for 24 hrs |
|
|
what is seen initially before milk
|
Colostrum
|
|
|
what is commonly seen initially pp
|
Low grade temp is common initially
99° F @ 2-5 days |
|
|
what is the preparation for lactation
|
Breasts are prepared during pregnancy
Colostrum is present Engorgement appears 2-4 days postpartum Oxytocin & prolactin |
|
|
Infant feeding stimulates what
|
the nerve cells in the nipple
|
|
|
milk flows from where
|
from acinar cells to the lactiferous sinuses leads to foremilk
|
|
|
what does oxytocin trigger
|
contraction of mammary ducts to push milk forward
termed the “Let-down Reflex” |
|
|
what does a Drop in estrogen & progesterone do
|
Stimulates production of Prolactin
Inhibits ovulation |
|
|
what should you warn the mom when telling her that ovulation in inhibited
|
Warn mom that although breastfeeding hampers ovulation, it would be safer to use condoms
|
|
|
what does prolactin do
|
stimulates milk production by acinar cells
|
|
|
when does engorgement occur
|
May occur on 2nd postpartum day before baby has had a chance to regulate how much milk he will need
|
|
|
what are the breasts like between feedings
|
tender, hard & tense on palpation
|
|
|
what is the treatment for the breasts between feedings
|
Apply ice pack to her axilla QID
|
|
|
what does ice do to the breasts
|
Ice vasoconstricts milk ducts
|
|
|
what is done for the Suppression of Lactation
|
Wear supportive, well fitting bra within 6 hrs after birth
Ice packs applied under the axillary area of each breast for 20 min QID beginning soon after birth Avoid warmth & stimulation |
|
|
when are supportive bras worn
|
Wear continuously until lactation is suppressed, usually ~ 5-10 days and removed only for showers.
|
|
|
what is done in the postpartum assessment
|
Patient history
Pregnancy, labor, & birth events Family lifestyle, support system Physical exam General appearance Skin, eyes, energy, pain, GI & urinary elimination, hemorrhoids, fluid intake, breasts, uterus, lochia, perineum Assess attachment behaviors |
|
|
what is the bowel and bladder assessment
|
Palpate bladder for distention
When urinating, how often? Frequency? Urgency? Adequate amounts Any pain? Gas? Constipation ? |
|
|
what is done if the patient is having a urinary complication
|
Calculation of Output is one of the best assessment methods to indicate if a patient is having a Urinary Complication.
|
|
|
what are the urinary tract changes pp
|
Increased bladder capacity
Swelling of tissues surrounding urethra Decreased sensitivity At risk for distension, incomplete emptying, residual Implications of anesthetic block Output increased in first 24 hours |
|
|
what are the GI changes pp
|
Hunger & thirst after delivery
Bowels sluggish Fear of BM/episiotomy Use of stool softeners Encourage adequate fluids |
|
|
what are the Perineum, Rectum, & Episiotomy changes pp
|
Edema, tenderness, ecchymosis, hemorrhoids
Laceration (degree) Sutures, repair Edges of episiotomy sealed 24 hr postbirth Pain assessment |
|
|
what is done for the homans sign
|
Inspection of lower extremities
Look for varicosities Localized redness, heat, edema, tenderness Generalized pedal or pretibial edema Check pedal pulses Homan’s sign |
|
|
what is the nursing care done pp
|
Ice
Peri care Meds topical anesthesia, analgesics, stool softener Sitting Sitz bath Bladder elimination Ambulation |
|
|
what should be done for the teaching needs of the patient
|
In presenting this information, the nurse should utilize the adult learning principle of sensory involvement and active participation
|
|
|
what are the teaching needs of a patient pp
|
Assess patient needs
Involution Personal hygiene Handwashing, breast care, perineal care Bowel elimination Sexual activity/contraception Kegels Postpartal Excercise |
|
|
what are the pp exercises
|
Begin daily exercise regimen with five repetitions 2-3/d and gradually increase to ten repetitions
After 2-3 weeks, more strenuous exercises, such as sit-up and side leg raises, may be added as tolerated. Kegel exercises, begun antepartally, should be done any times daily during postpartum to restore vaginal and perineal tone. |
|
|
what are the 1st day pp exercises
|
Abdominal Breathing
Pelvic Rocking |
|
|
what is abdominal breathing
|
Lying supine, inhale deeply, using the abdominal muscles
The abdomen should expand Then exhale slowly through pursed lips, tightening the abdominal muscles |
|
|
what is pelvic rocking
|
Lying supine with arms at sides, knees bent, and feet flat, tighten abdomen and buttocks, and attempt to flatten back on floor.
Hold for a count of 10 , then arch the back, causing the pevis to “rock”. |
|
|
what are the 2nd day pp exercises
|
Chin to Chest
Arm Raises |
|
|
what is chin to chest
|
Lying supine with legs straight, raise head and attempt to touch chin to chest.
Slowly lower head |
|
|
what are arm raises
|
Lying supine, arms extended at a 90- degree angle from body, raise arms so that they are perpendicular and hands touch.
Lower slowly |
|
|
what are the 4th day pp exercises
|
Buttocks Lift
Knee Rolls |
|
|
what are knee rolls
|
Lying supine with knees bent, feet flat, arms extended to the side, roll knees slowly to one side, keeping shoulders flat.
Return to original position, and roll to opposite side. |
|
|
what are buttocks lifts
|
Lying supine, arms at sides, knees bent, feet flat, slowly raise the buttocks, and arch the back.
Return slowly to starting position. |
|
|
what are 6th Day Postpartal exercises
|
Abdominal Tighteners
Knee to Abdomen |
|
|
what are Abdominal Tighteners
|
Lying supine, knees bent, feet flat, slowly raise head toward knees. Arms should extend along either side of legs.
Return slowly to original position. |
|
|
what is Knee to Abdomen
|
Lying supine, arms at sides, bend one knee and thigh until foot touches buttocks. Straighten leg and lower it slowly.
Repeat with the other leg. |
|
|
what are common pp drugs
|
Percocet
Rubella Virus Vaccine RhoGAM |
|
|
what is percocet
|
Narcotic analgesic
|
|
|
what is the indication for percocet
|
For relief of mild to moderate pain
|
|
|
what is done after giving percocet
|
Reassess pain level in 30 minutes
|
|
|
what are the nursing considerations for percocet
|
Encourage drinking full glass of water with tablet to help large pill go down esophagus
Watch for side effect of dizziness May need to give after meal to avoid stomach upset |
|
|
who should be vaccinated in the postpartal period
|
Women with a Rubella titer of < 1:10
|
|
|
can breast feeding mothers receive the vaccination
|
yes
|
|
|
Patients should avoid what after getting the vaccination
|
pregnancy for 3 months following vaccination
|
|
|
what are the side effects of the vaccination
|
Some patients develop a slight rash after vaccination
|
|
|
what should be assessed before giving the vaccination
|
Patients should be assessed for allergies to eggs
|
|
|
when is rhogam given
|
Must be given within 72 hrs of birth
|
|
|
what is the route and dose of rhogam
|
Route: IM
Dose: One vial |
|
|
what is ensured when giving rhogam
|
Ensure correct vial is used
Each vial is cross-matched to the specific woman and must be carefully checked |
|
|
what are the side effects of rhogam
|
Soreness at injection site
|
|
|
what are the Psychological Adaptations pp
|
Bonding
Rapid process of attachment that occurs soon after birth Attachment Process by which an enduring bond to the child is developed |
|
|
what are Infant Reciprocal Attachment Behaviors
|
Makes eye contact & gazes
Moves eyes to track the parent’s face Grasps & holds finger Moves synchronously to parent voice Roots, latches, suckles Comforted by parent’s voice or touch |
|
|
what are maternal behaviors of attachment
|
Touch
Progresses in a predictable manner Verbal expression Important indicator or attachment |
|
|
what are the phases of adjustment for maternal adaption
|
Taking in (1-2 days after birth)
Taking hold (3-7 days after birth) Letting go ( > 7 days after birth) |
|
|
what happens in the taking in phase
|
Contemplates recent birth experience
Assumes passive role & dependence on others Numerous friends visit the patient and give advice |
|
|
what happens in the taking on phase
|
Increased self-care
Expresses satisfaction of sex of baby Talks incessantly to the infant Strong interest in infant care |
|
|
when is the nurse supposed to assess further
|
Nurse should assess further if mother responds hesitantly to infant cries
|
|
|
what is seen in the postpartum blues
|
Emotional lability, a let-down feeling, crying for no reason, headache, insomnia, fatigue, restlessness, depression, &/or anger
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when do the postpartum blues occur
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Commonly peak around the 5th pp day & subside by the 10th pp day
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what may the patient say if they have postpartum depression
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Patient may state she can’t understand why she can’t enjoy being with her baby
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how long does postpartum depression last
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Lasts longer than a few weeks
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what is a preventative measure for postpartum depression
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Encouraging planning in the prenatal period for postnatal period
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what is the amount of blood loss in a Postpartum Hemorrhage
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Blood loss - 500cc (vag), 1000cc (c/s)
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when is the greatest danger for a Postpartum Hemorrhage
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Greatest danger during early pp – blood loss > 500cc during first 24 hours
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what is a late Postpartum Hemorrhage
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blood loss > 500cc during 6 wks pp (after first 24 hrs)
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what are the Causes of Early PP Hemorrhage
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uterine atony (primary cause)
Placenta accreta (retained placenta or fragments) Trauma to birth canal (lacerations) DIC |
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what are the risk factors for an early pp hemorrhage
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abruptio placenta, missed abortion, placenta previa,
uterine infection, uterine inversion, severe preeclampsia, amniotic fluid embolism, intrauterine fetal death |
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what is uterine atony
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lack of muscle tone
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what happens with uterine atony
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Uterus doesn’t contract properly
Placental site remains open |
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what are predisposing factors for uterine atony
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C/S, manual removal of placenta, placental accreta,
p. previa, general anesthesia, MgSO4, overdistension, multiparity, prolonged labor, precipitous labor, induced labor, retained placenta |
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what are clinical signs of atony
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Excessive bright red lochia, saturating pads quickly, excessive clots
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how do you assess uterine atony
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Check for distended bladder
Palpate Fundus Difficult to locate Fundus Boggy Fundus Firms with massage then looses tone Fundus higher than expected |
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what can an enlarged bladder do
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interfer with uterine involution
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what is the Treatment of Uterine Atony
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Massage until firm & express clots
uterine contractility minimize flow Bi-manual inspection Fluid replacement if indicated Abdominal hysterectomy is possible |
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when are medications given for uterine atony
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If uterus fails to maintain contraction
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what are the medications for uterine atony
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IV: Rapid infusion of Pitocin 20u at 600cc/hr
IM Injections Methergine Ergotrate Hemabate |
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what are the signs of Ergotrate toxicity
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headache, muscle pain & numb fingers
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what is the Trauma to Birth Canal
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Vaginal or perineal lacerations
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when do you suspect trauma to the birth canal
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Suspect if fundus firm & bright red bleeding
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what is a hematoma
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Bleeding into loose connective tissue while overlying tissue remains intact
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where does a hematoma occur with a pp hemorrhage
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Can occur in vulvar, vaginal wall, or retroperitoneal
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what does a hematoma cause
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Deep, severe, unrelenting pain & pressure
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when are the s&s of blood loss seen
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S & S of blood loss when fundus & lochia are WNL
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what is the Management of Trauma
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Bimanual inspection
Hematoma – observe, cold therapy, ligation or evacuation Surgical repair is often needed Small hematomas may reabsorb Larger hematomas need to be evacuated & repaired |
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how are Retained Placenta or Fragments removed
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manually
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what is done If placenta is adhered to uterine wall or implanted into the myometrium
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hysterectomy necessary to stop bleeding
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If continuous bleeding, uterine atony, lacerations, & retained placenta are ruled out what is considered
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coagulation problems
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what are some coagulation problems
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decreased Platelet & fibrinogen levels, prolonged clotting times (PT, PTT), decreased coagulation factors
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what is the treatment for DIC
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Treatment of underlying cause, control blood loss, & minimize hypovolemic shock
Fluid replacement (NS or LR to expand volume) Blood, fresh-frozen plasma, platelets or packed RBCs to support homeostasis Heparin is controversial & considered last resort |
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what are signs of hypovolemic shock
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increase restlessness, lightheadedness, dizziness as cerebral tissue perfusion decreased
Pale skin, decreased sensorium, rapid, shallow resps Urine output <25cc/hr Rapid, thready peripheral pulses Capillary refill > 2 secs (3-5 secs) Cool skin that becomes cold & clammy BP mean < 60mm Hg |
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what is the treatment of hypovolemic shock
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IV with NS or LR
Central venous line & pulmonary artery catheter Administer albumin, blood products Monitor patient for fluid overload Monitor for signs of infection, VS q 15 min until stable Heart monitor |
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when does a Late Postpartum Hemorrhage occur
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7-14 days after delivery
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what are the causes of a Late Postpartum Hemorrhage
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Subinvolution
placental fragments |
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what are the predisposing factors of Late Postpartum Hemorrhage
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Attempt to deliver placenta before separation
Placenta accreta |
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what is the Management of Late PPH
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Control bleeding with oxytocin, methergine or prostaglandins
If bleeding subsides, no further treatment If bleeding persists, suction, or D&C Antibiotics given if infection suspected |
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what are the 3 types of thromboembolisms
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Superficial venous thrombosis
Deep vein thrombosis (DVT) Occurs 1 in 2000 during pregnancy 1 in 700 during postpartum Pulmonary embolism |
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what is a thrombus
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Collection of blood factors, platelets, & fibrin in a vessel wall
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where does a thrombus form
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Form where blood flow is impeded
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what is a thrombus associated with
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Often associated with inflammatory process of vessel wall (thrombophlebitis)
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what are the causes of a thrombus
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stasis, hypercoagulation state & injury
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what are Risk Factors for DVT
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History of varicose veins
Obesity Previous DVT Nulliparity, Multiple gestations Increased age Smoking C/S |
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what happens on the 10th day pp
for DVT |
Edema, fever, malaise
Diminished peripheral pulses Positive Homans’ sign Chills, pain, redness, stiffness Shiny white skin on extremity |
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what happens on the 14th day pp
for DVT |
Extremely high fever
Chills, malaise Possible pelvic abscess |
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what are the Signs & Symptoms of Thrombus
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Tenderness
Localized heat Redness of the extremity Inflammation Swelling of involved extremity Palpate hardened vein Pain May not have S & S |
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what is the Management in Superficial Thrombus
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Bedrest
Elevation if lower extremity elastic support Analgesics Warm packs Anticoags & anti-inflammatories not usually prescribed or needed |
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what is done to diagnose DVT
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Venous ultrasound/doppler studies
Identifies blood flow or obstruction Plethysmography shows circulation distal to affected area Venography comfirms diagnosis & shows filling defects & diverted blood flow |
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what is the nursing diagnosis of DVT
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Altered tissue perfusion R/T obstructed venous return
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what is the Treatment of Thrombophebitis
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Strict Bedrest w/elevation
Remove blankets from the bed Anticoagulation medications Initially IV Heparin then Coumadin begun Analgesics Moist heat Gradual ambulation after episode subsides Antiembolism stockings |
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what is the Treatment of Pelvic DVT
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Complete bedrest
Administration of antibiotics Anticoagulants Laparotomy for I & D if pelvic abscess develops |
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how do you prevent DVT
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Side-lying or back-lying position
Change positions frequently if on bed rest Avoid deeply flexing your legs at the groin or sharply flexing your knees Don’t stand in one place too long Don’t wear constrictive clothing Wiggle your toes & do leg lifts Walk ASAP after birth Wear antiembolism stocking for support |
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what is a pulmonary embolism
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Fragments (emboli) carried to pulmonary artery or one of its branches
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what are the S&S of a pulmonary embolism
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dyspnea, chest pain, tachycardia, tachypnea, syncope, rales, cough, hemoptysis, air hunger, pallor, cyanosis
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what is the management for a pulmonary embolism
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Dissolve clot & maintain circulation
Heparin Frequent VS O2 (10 L) & ventilation support IV fluids Narcotic analgesic Bedrest with HOB elevated Pulse ox & arterial blood gases Streptokinase, urokinase, embolectomy |
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what is a Puerperal Infection
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Bacterial infection after childbirth
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what does a puerperal Infection affect
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uterus & structures above
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what are the types of uerperal Infection
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Metritis (Endometritis), wound, UTI, mastitis, peritonitis, pelvic & femoral thrombophlebitis
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what is the definition of infection
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Temp ≥ 38°C (100.4 °F) after 24 hrs & occurring at least 2 days in the 1st 10 days postpartum
With chills, HA, malaise, restlessness, & anxiety |
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when do S&S of infection occur
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within 2-7 days
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what are the S&S of infection
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Fever, chills, malaise, lethargy, anorexia
Abd pain, tenderness, purulent lochia Tachycardia, subinvolution |
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what are the Risk Factors for PP Infection
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C/S
Vaginal infection – frequent unsterile exams Trauma – episiotomy, lacerations Catheterization Prolonged ROM Placental fragments PP hemorrhage |
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what are the causes of a PP infection
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Often by resident bacteria –
coag negative staph, group A, B. or G hemolytic strep, gardnerella vaginalis Less often – clostridium pperfringens, bacteroides fragilis, klebsiella, staph aureus, proteus mirabilis, psuedomonas, e. coli |
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what are the serious complications of a PP infection
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All parts connected to peritoneal cavity
Plentiful blood vessels, presence of lochia Increased pH, necrosis of endometrium Septicemia ! Localized perineal infection Endometritis Parametritis (pelvic cellulitis) |
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what is the management for a PP infection
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Labs data confirm diagnosis
WBCs (>30,000), cultures + (blood, endocervix, uterus) IV antibiotics Improvement in 48-72 hrs |
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what is the Nursing Care for Endometritis
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Semi-Fowler’s position to promote drainage
Peri care Change peripads frequently to prevent the spread of infection VS q4 hrs Increase fluids Pain relief Warm blankets Cool compresses, sponge baths Parenting needs – emotional support, reassurance |
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what are the infection types
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Wound
Perineal Vaginal C/Section Urinary tract infection |
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when do the S&S of a UTI appear
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1st or second day
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what are the S&S of a UTI
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Dysuria, urgency, frequency, low grade T
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what is the treatment for a UTI
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Oral antibiotics
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what is done if pyelonephritis occurs
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IV hydration & antibiotics
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what is mastitis
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Infection of the mammary glands that disrupts normal lactation
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when does a mastitis usually occur
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2-3rd week pp
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what causes mastitis
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Usually staph aureus through nipple
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what contributes to mastitis
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Fissures, abrasion, blocked mild ducts, incomplete let-down, engorgement, & stasis contribute
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what does the patient complain of with a mastitis
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shooting pain in nipple during breastfeeding and flaky, itchy skin on her breast
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what are the S&S of mastitis
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Flu-like – fever, chills, malaise, HA
Localized area of redness & tenderness, hardness, enlarged lymph May progress to abscess |
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what is the management of mastitis
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Labs – cultures of breastmilk & skin
Management Antibiotics, bedrest, increased fluids, promote emptying of the breasts, offer affected breast first, warm shower, cold compresses |
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what is the parent teaching for mastitis
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Wash hands after using bathroom, before touching breasts, before after feeding
Warm compress or shower to facilitate milk flow Empty breasts at each feeding More frequent breastfeeding Alternate feeding position Proper position of infant on breast Release infant grasp on nipple after feed Drink plenty of fluids, have balanced meals |
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when does Postpartum depression usually appear
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1st 4 wks
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how long does Postpartum depression last
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Lasts several months or longer
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how is Postpartum depression different then blues
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Different from the blues by intensity & persistence
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who is at risk for postpartum depression
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history of previous episode in self or family, poor social support, problem pregnancy or birth, immaturity or low self-esteem
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what is the treatment for postpartum depression
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psychotherapy, medication, social support
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what can intensify the severity of postpartum depression
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Abrupt weaning can intensify severity of depression
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when is Postpartum Psychosis evident
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first 3 months pp
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what are the symptoms of Postpartum Psychosis
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agitatioin, hyperactivity, insomnia, mood lability, confusion, irrational thoughts & behavior, poor memory, poor judgment, delusions, & hallucinations
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what is the treatment for Postpartum Psychosis
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95% improve in 3 months
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what are the risk factors for Postpartum Psychosis
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Previous episode, hx of bipolar disorder
Prenatal stressors lack of support, lack of partner, low SES Obsessive personality Family hx of mood disorder |
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what is a risk with PP Major Mood Disorder
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suicide
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when does PP Major Mood Disorder occur
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4th month PP
can occur during first year PP |
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how long are the sypmtoms of PP Major Mood Disorder
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lasts for 6 months
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what are the symptoms of PP Major Mood Disorder
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serious depression
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what are risk factors for PP Major Mood Disorder
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Primip, ambivalence about preg, hx of depression, family hx of psych, lack of social support or stable relationship
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what are the risk factors for Postpartum Psychosis
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Previous episode, hx of bipolar disorder
Prenatal stressors lack of support, lack of partner, low SES Obsessive personality Family hx of mood disorder |
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what is a risk with PP Major Mood Disorder
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suicide
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when does PP Major Mood Disorder occur
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4th month PP
can occur during first year PP |
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how long are the sypmtoms of PP Major Mood Disorder
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lasts for 6 months
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what are the symptoms of PP Major Mood Disorder
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serious depression
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what are risk factors for PP Major Mood Disorder
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Primip, ambivalence about preg, hx of depression, family hx of psych, lack of social support or stable relationship
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