V. NURSING CARE OF THE NORMAL NEWBORN OBJECTIVES: At the end of this class, the student will be able to: 1. Describe the respiratory and cardiovascular changes that occur in the transition from fetal to extrauterine life. 2. Explain thermoregulation differences in the neonate. 3. Define at least five normal reflexes in the newborn. 4. Describe the role that bilirubin plays in the development of physiological, pathological, and breast milk jaundice. 5. Explain normal newborn variations in the various body systems. 6. Describe the periods of reactivity and the six behavior states of the newborn. 7. Apply the gestational age assessment tool to several different neonates. 8. Apply the nursing process to the care of a normal newborn. OUTLINE I. Transition to extrauterine life A. Respiratory changes at birth B. Cardiovascular transition II. Neurological adaptation A. Thermoregulation B. Reflexes C. Sensory adaptation D. Other neurological considerations III. Hematological adapatation A. Neonatal differences IV. Hepatic system A. Liver function alterations B. Hyperbilirubinemia/physiological jaundice V. Musculoskeletal system A. Activity and muscle tone B. Head and upper body C. Extremities VI. Gastrointestinal system A. Stomach B. Intestines C. Digestive enzymes D. Stool patterns VII. Renal system VIII. Genitourinary system IX. Immune system A. Neonatal considerations 107 X.
XI.
XII.
XIII.
XIV.
Psychosocial adaptation A. Behavioral states Gestational Age Assessment (Lab) Physical Assessment of the Neonate (Lab) A. Normal newborn characteristics B. Reflexes Admission Care Plan A. 1st 4 hours B. Ongoing care C. Parent teaching D. Safety concerns Nutrition A. Breastfeeding B. Formula feeding 108 109 110 111 112 113 VI. THE HIGH RISK NEONATE OBJECTIVES At the end of this class the student will be able to: 1. List risk factors that may place the neonate in jeopardy at birth. 2. Develop a plan of care for a preterm neonate. 3. Describe common physiological complications for preterm neonates. 4. Compare and contrast physiological problems of preterm, posterm, small for gestational age and large for gestational age neonates. 5. Develop a plan of care for a dysmature neonate. 6. Describe the techniques, equipment and medications used for neonatalresuscitation. 7. Apply the nursing process to the care of a neonate with a respiratory diagnosis. 8. List the interventions utilized for a neonate with jaundice. 9. Describe the physiological problems of a neonate born to a diabetic mother. 10. Summarize the nursing assessments and initial interventions for a newborn with selected congenital abnormalities. 11. Develop a plan of care for a neonate born to a mother with substance abuseproblems. 12. Develop a plan of care for a neonate with sepsis. 13. Identify priority nursing interventions utilized in the level II and III nursery settings. 14. Compare and contrast levels of care for the high risk newborn. OUTLINE I. Levels of Care for the High Risk Newborn A. Regionalization B. Transport C. Multidisciplinary approach D. Nursing roles E. Neonate at risk for resuscitation II. The Preterm Neonate A. Risk factors B. Physical characteristics and system alterations C. Nursing Care III. Dysmature Neonates A. Care of the Posterm Neonate B. Care of the SGA neonate C. Care of the LGA neonate IV. Common Respiratory Complications A. Respiratory distress syndrome B. Transient tachypnea of the newborn C. Meconium aspiration syndrome D. Nursing Care 114 V. Metabolic Abnormalities A. Cold stress B. Hypoglycemia C. Rh incompatibility VI. The Neonate with Sepsis A. Risk factors B. Nursing process VII. Hematologic Problems A. Anemia B. Polycythemia VIII. The Neonate Born to a Diabetic Mother a. Risk factors b. Nursing care IX. The Neonate Born to a Substance Abusing Mother A. Common characteristics B. Nursing care 115 VII. NORMAL PREGNANCY OBJECTIVES: At the end of this class the student will be able to: 1. Describe the anatomical and physiological changes that occur during pregnancy. 2. Differentiate among presumptive, probable, and positive signs of pregnancy. 3. Correctly calculate gravida, para, and estimated date of delivery. 4. Describe nursing assessment for confirmation visits and ongoing visits. 5. Identify common maternal and paternal psychological responses to pregnancy. 6. Explain the process of role transition to motherhood and the maternal tasks of pregnancy. 7. Describe the process of paternal role transition. 8. Describe typical sibling and grandparent reactions to a pregnancy. 9. Identify the impact of culture and socioeconomic status on a pregnancy. 10. List the required nutritional components of a pregnancy diet. 11. Identify various nutritional risk factors and explain their effects on a pregnancy. 12. List various education topics, especially safety issues, such as substance abuse, travel, vaccinations, violence and battering in the family, and warning signs. 13. Define common obstetrical terminology. OUTLINE I. Anatomic and Physiologic Changes and Assessment A. Reproductive organs B. Respiratory C. Cardiovascular D. Gastrointestinal E. Genitourinary F. Skin and jair G. Musculoskeletal H. Metabolism I. Weight gain J. Endocrine II. Pregnancy Diagnosis A. Presumptive findings (subjective) B. Probable changes (objective) C. Positive changes (diagnostic) D. Pregnancy test E. Emotional and psychological changes 1. Mother 2. Father 3. Siblings III. Cultural Assessment IV. Prenatal History A. Patient B. Father of baby 116 V. VI. VII. Obstetrical Terminology Psychosocial and Cultural Factors Normal Physiological Changes A. Vital signs B. Weight C. Respiratory D. Skin E. Breast F. Abdomen G. Musculoskeletal H. Cervix VIII. Methods to Establish Estimated Date of Birth A. Nagele’s rule B. Fundal height C. Ultrasound D. Pelvic Assessment IX. Danger Signs X. Prenatal Assessment Schedule XI. Nursing Process XII. Discomforts of Pregnancy XIII. First trimester A. Second trimester B. Third trimester C. Accompanying nursing interventions/self­care measure XIV. Self­Care Regime A. Fetal activity monitoring B. Breast care C. Other factors D. Exercises E. Sexual activity XV. Maternal Nutrition A. Weight gain recommendation B. Weight gain patterns C. Nutritional requirements D. Factors affecting nutritional intake E. Cultural factors 117 CASE STUDY Ms. T. is a 15 year old patient who visits the clinic for the first time at 24 weeks’ gestation. She tells the RN that “she doesn’t know why she didn’t get prenatal care sooner.” She works part time at a local fast food outlet, and eats one meal a day at the restaurant. She now weighs 128 pounds. She tells the RN that she weighed about 110 pounds before the pregnancy. She lives at home with her parents, and her mother does most of the cooking. She is from a low­income family. Develop a nursing care plan that focuses on assisting the patient to improve her nutrition patterns from now until delivery of the neonate. 118 Mandatory Reporting of Intimate Partner Violence Position: AWHONN opposes mandatory reporting requirements to law enforcement by health care professionals caring for patients experiencing Intimate Partner Violence (IPV). AWHONN advocates for the rights of women to choose whether or not to report IPV to law enforcement. Women in abusive relationships need to be empowered with information and support. Health care professionals can provide this information and support and act as trusted resources but only if women experiencing IPV do not have to seriously consider the consequences of sharing their thoughts, fears and problems. Laws requiring health care professionals to be mandated reporters of IPV compromise a competent woman’s right to make informed decisions. AWHONN maintains that mandatory reporting has not been found to increase a woman’s safety and may place her and/or her children at increased risk for further violence and/or injury. Mandatory reporting requirements also threaten the confidentiality inherent in health care professionals’ relationships with their patients and may deter women from seeking needed medical attention or discussing abuse. Mandatory reporting of IPV can potentially force a health care professional to make a decision whether to break patient confidentiality and report abuse or break the law. Training and Implementation All health care professionals should implement universal screening protocols, documentation procedures, and treatment/intervention protocols in their health care settings to help identify and care for abused women.1 Training for health care professionals should include guidelines on how to screen for abuse and the importance of understanding the risks that abused women face when seeking help or leaving a relationship. Training should also detail the importance of timely, appropriate referrals to confidential social and victim support services and the importance of initiating safety plans. Ideally, all health care providers should be part of a coordinated community response to reduce domestic violence, a response in which shelters, hospitals, health care providers, legal advocates and law enforcement work together to improve safety and save lives. Comprehensive training of health care providers on identification and treatment of IPV will improve women’s health and safety and the women they treat will be better able to make informed decisions about their futures and any personal and legal options they may wish to pursue. State Laws 1
Campbell,J., Furniss, K. Violence Against Women: Identification, Screening and Management of Intimate Partner Violence. The Association of Women’s Health, Obstetric and Neonatal Nurses, Washington, DC, 2002.
119 Health care professionals should be familiar with laws on mandatory reporting of IPV, as requirements vary from state to state. Only two states currently mandate health care professionals to report all cases of IPV of a competent woman to law enforcement. AWHONN supports health care professionals reporting IPV with the informed consent of the abused woman. However, we also recognize that health care providers must abide by state law. AWHONN encourages state legislative bodies to rescind any mandatory reporting requirements. Background Intimate partner violence is a serious problem in the United States. It is estimated that more than one-third of adult women’s emergency room visits annually are related to injuries caused by a current or former spouse or intimate partner.2 According to the Centers for Disease Control and Prevention approximately 1.5 million women in the United States are raped and/or physically assaulted by an intimate partner annually.3 Women experiencing intimate partner violence have more physical problems and significantly higher rates of depression.4,5 Health care professionals under-screen and under-diagnose victims of IPV.6 Health care professionals, including nurses and physicians, have identified a number of barriers to screening for IPV. 7,8 Some identified barriers are provider-related such as a lack of training, personal discomfort with the issue of IPV and a lack of legal information. Other barriers are related to the practice setting such as lack of time or privacy, need for resources and protocols, and language barriers. Many mandatory reporting laws for IPV are modeled on child abuse laws that reasonably assume that the child is unable to make an informed decision about self-protection. Abused women, as competent adults, should have the opportunity to determine their risk of additional violence and make their own decisions about their future and their relationship with the abuser. Proponents of mandatory reporting of IPV claim that these mandatory requirements would ensure a process that would hold offenders accountable, provide an improved tracking mechanism for IPV, and ultimately prevent the violence. However, there is evidence that the arrest of the abuser may increase the risk of violence for some women, and that existing restraint and prosecution laws are insufficient to guarantee an abused woman’s safety.9 Evidence also shows that a woman who leaves her abuser has a significantly increased risk of IPV.10 Mandatory reporting can only be implemented safely if prompt criminal prosecution 2
U.S. Department of Justice, Bureau of Justice Statistics (2005). 3
http://www.cdc.gov/ncipc/dvp/vawguide.htm, retrieved November 8, 2007. 4
Campbell J, Jones AS, Dienemann J et al. Intimate partner violence and physical health consequences. Arch Intern Med. 2002 May 27;162(10):1157-63. 5
Dienemann J, Boyle E, Baker D, et al. Intimate partner abuse among women diagnosed with depression. Issues Ment Health Nurs. 2000 Jul-Aug;21(5):499-513. 6
Elliott, L., Nerney, M., Jones, T., Friedmann, P. Barriers for screening for domestic violence JGIM 2002. 112-113. 7
Jaffee KD, Epling JW, Grant W, et al. Physician-identified barriers to intimate partner violence screening. J Womens Health (Larchmt). 2005 Oct;14(8):713-20. 8
Furniss K, McCaffrey M, Parnell V & Rovi S. Nurses and barriers to screening for intimate partner violence. MCN Am J Matern Child Nurs. 2007 Jul-Aug;32(4):238-43. 9
Rodriguez, M.A., Mandatory reporting of domestic violence to police, JAMA, 2001; 286(5):580-583. 10
Waltermaurer E, McNutt LA, & Mattingly MJ. Examining the effect of residential change on intimate partner violence risk. J Epidemiol Community Health. 2006 Nov;60(11):923-7.
120 of the offender and protection of the abused woman are guaranteed, which is currently impossible. Approved by the AWHONN Board of Directors, June 2001. Revised and reaffirmed under a new title, December 1, 2007. 121 122 123 124 Preconceptional Consumption of Folic Acid AWHONN supports legislation and policies that encourage women of childbearing age to consume 400 micrograms of synthetic folic acid every day. AWHONN nurses have the responsibility to inform their patient
s of the benefits of folic acid consumption during routine visits. All health contacts involving the provision of contraception to women offer the opportunity for a remind
er of the protective effects of a folaterich diet combined with synthetic folic acid, information about how this can be achieved, and the reminder that it needs to start two months before conception. Additionally, all women who have a fetus diagnosed as having a NTD in pregnancy, or give birth to an infant with a NTD, need to be given information about the risk of recurrence in a subsequent pregnancy and to be advised of the protective effect of the preconception folate supplementation. The Public Health Service recommends taking 4000 micrograms of folic acid starting at least one month before conception and continuing throughout the first three months of pregnancy for women who have already had an NT
D- affected pregnancy. Background: Neural tube defects (NTDs) are among the most serious, common and preventable birth defects, which occur in the United States. Each year an estimated 2,500 babies are born with these defects, and many additional affected pregnancies result in miscarriage or stillbirth. Up to 70 percent of NTDs can be prevented by consuming 400 micrograms of folic acid every day, beginning before pregnancy, from good sources including a daily multivitamin supplement. This recommendation is supported by the Institute of Medicine, which advised that all women of childbearin
g age take 400 micrograms of synthetic folic acid daily, from supplements and/or fortified foods, to reduce NTD risk. Other supporting sources of folic acid include enriched grain products, fortified breakfast cereals, and a balanced diet containing foods that are naturally high in folates, such as orange juice, leafy green vegetables, and beans. Approved by the AWHONN Board, June 1999. Reaffirmed June 2007.
125 Warning Signs During Pregnancy During your pregnancy, report any of the following signs to your physician or nurse practitioner. It may be a false alarm, but better to ask than to have complications later.
WARNING SIGNS Vaginal Bleeding POSSIBLE PROBLEMS ・ Miscarriage; Placenta Previa ・ Abruption of the placenta st
(usually bright red in color and heavier than a ・ Implant bleed early in pregnancy (1 trimest
) normal period) ・ Threatened abortion ・ Postcoital bleeding ・ Premature labor Abdominal Pain Leaking or gushing of fluids from the vagina ・ Ectopic pregnancy ・ Abruption of the placenta ・ Premature labor ・ Contractions ・ Premature rupture of the membranes (bag of water breaks) Sudden puffiness or swelling of hands, feet, or ・ Preeclampsia with increased blood pressure
face. Severe persistent headache, vision proble
and protein in the urine s ・ Pregnancy induced hypertension (flashes, spots) ・ Toxemia Pain or burning on urination ・ Urinary Tract Infection (UTI) ・ Sexually transmitted disease Irritating vaginal discharge, itching or genital so ・ Vaginal infection (yeast) es ・ Sexually transmitted disease Temperature > 100°F Persistent nausea/vomiting Noticeable reduction in fetal activity ・ Viral or bacterial infections ・ Hyperemesis gravidarum infection ・ Mother hasn’t eaten ・ Fetal distress 126