Pediatric Bench Marks
•
Birth wt doubles at 6 months and triples at 12 months
•
Birth length increases by 50% at 12 months and doubles at 4 years
•
Post fontanel closes by 8 wks
•
Ant fontanel closes by 12-18 months
•
Moro reflex disappears at 4 months
•
Steady head control achieved at 4 months
•
Turns over at 5-6 months
•
Hand to hand transfers at 7 months
•
Sits unsupported at 8 months
•
Crawls at 10 months
•
Walks at 10-12 months
•
Cooing at 2 months
•
Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo
•
Mama, Dada + a few words at 9-12 months
•
Throws a ball overhand at 18 months
•
Daytime toilet training at 18 mo - 2 years
•
2-3 word sentences at 2 years
•
50% of adult Ht at 2 years
•
Birth Length doubles at 4 years
•
Uses scissors at 4 years
•
Ties shoes at 5 years
•
Girls’ growth spurt as early at 10 years … Boys catch up ~ Age 14
•
Girls finish growing at ~15 … Boys ~ 17
NORMAL CHILD VALUES ACCORING TO AGE ****
Age
Pulse
Respirations
Nursing Implications
Newborn
100-160
30-60
These ranges are
1-11 months
100-150
25-35
averages only & vary
1-3 years (toddler)
80-130
20-30
with age, sex, and
3-5 years (preschooler) 80-120
20-25
condition of the child.
6-10 years (school
70-110
18-20
Always note whether
age)
60-90
16-20
the child is crying,
10-16 years
(HR in children
febrile, or in some
(adolescent)
increases with
distress
crying or if the child
has a fever)
Age Appropriate Toys
Infants birth to 1 year (solitary play)
• Mobiles
• Rattles
• Squeaking toys
• Picture books
• Balls
• Colored blocks
Toddlers (1-3 years) (parallel play)
• Boards and mallets
• Push-pull toys
• Toy phones
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• Stuffed animals
• Story books with pictures
Preschoolers (3-6 years) (associative play)
Erickson … Psycho-Social Development
•
0-1 yr (Newborn) … Trust vs. Mistrust
•
1-3 yrs (Toddler)… Autonomy vs. Doubt and Shame … Fear intrusive procedures - Security
objects good (Blankies, stuffed animals)
•
3-6 yrs (Pre-school) … Initiative vs. Guilt … Fear mutilation – Band-Aids good
•
6-12 yrs (School Age) … Industry vs. Inferiority… Games good, Peers important … Fear loss of
control of their bodies
•
12-19 yrs (Adolescent) … Identity vs. Role Confusion … Fear Body Image Distortion
•
20-35 yrs (Early Adulthood) … Intimacy vs. Isolation
•
35-65 yrs (Middle Adulthood) … Generativity vs. Stagnation
•
Over 65 (Older Adulthood) … Integrity vs. Despair
Piaget … Cognitive Development
•
Sensorimotor Stage (0-2) … Learns about reality and object permanence
•
Preoperational Stage (2-7) … Concrete thinking
•
Concrete Operational Stage (7-11) … Abstract thinking
•
Formal Operational Stage (11-adult) … Abstract and logical thinking
Freud … Psycho-Sexual Development
•
Oral Stage (Birth -1 year) … Self gratification, Id is in control and running wild
•
Anal Stage (1-3) … Control and pleasure wrt retention and pooping – Toilet training in this stage
•
Phallic Stage (3-6) … Pleasure with genitals, Oedipus complex, SuperEgo develops
•
Latency Stage (6-12) … Sex urges channeled to culturally acceptable level, Growth of Ego
•
Genital Stage (12 up) … Gratification and satisfying sexual relations, Ego rules
Kohlberg … Moral Development
•
Moral development is sequential but people do not aromatically go from one stage to the next as
they mature
•
Level 1 = Pre-conventional … Reward vs. Punishment Orientation
•
Level 2 = Conventional Morality … Conforms to rules to please others
•
Level 3 = Post- Conventional … Rights, Principles and Conscience (Best for All is a concern)
Nursing implications for toddlers (1-3 years)
• Temper tantrums are common and normal behavior
• Give simple brief instructions of procedures
• Forced separation from parents is their biggest threat
• Security or transitional objects should be encouraged
• Expect regression (bed wetting)
• Autonomy should be provided with choices
Nursing implications for the preschool child (3-6 years)
• Child stands erect with a more slender posture
• Thinking is egocentric & concrete
• A child learns sexual identity and masturbation is normal
• Imaginary playmates & fears are common
• Explain the child did not cause the illness and painful procedures are not punishments
• Therapeutic medical play with the equipment
• They need to be prepared for procedures and understand what is going to be “fixed”
• Pictures and dolls can be used
Nursing implications for the school age child (6-12)
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• Maintaining school activities and social relationships with peers is important
• They learn by verbal explanations, pictures, books, and handling equipment
• Privacy & modesty are important and should be maintained
Nursing implications for the adolescent (12-19 years)
• They can problem solve & use abstract thinking
• Time when they form their own identity
• Rebelling against the family is common
• Teaching should include time with out the parents & if parents are present all questions should be
directed toward the adolescent
• The age for making own medical decisions ranges from 7-14 years
• The major concern is body changing and any procedure that will alter their appearances
Age Appropriate Toys
Infants birth to 1 year (solitary play)
• Mobiles
• Rattles
• Squeaking toys
• Picture books
• Balls
• Colored blocks
Toddlers (1-3 years) (parallel play)
• Boards and mallets
• Push-pull toys
• Toy phones
• Stuffed animals
• Story books with pictures
Preschoolers (3-6 years) (associative play)
• Coloring books
• Puzzles
• Cutting and pasting
• Dolls
• Building blocks
• Clay
School Age (6-12 years) (corporative play)
• Board & card games
• Hobbies and/or video games
• Puzzles
Immunizations (Hector Rayes did have pretty popular muscles varying high /school )
• Hep B (3)
o Contraindicated in persons with anaphylaxis to backers yeast
• RV Rotovirus (3)
o IS a LIVE vaccine
o Most common cause for diarrhea in infants & children
• Dtap (diphtheria, tentanus, pertussis (5)
o Administer separate site
o Not given to kids past there 7th birthday
o Contraindicated in kids with seizures or encephalopathy
• HIB Hameophilus Influenza type B (4)
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o Protects against epiglotitis, bacterial meningitis, & septic arthritis
o Given IM
o No contraindications
• PCN Pneumococal (4)
o Used to protect against disease caused by bacteria, streptococcus
• IPV Inactivated polio virus (4)
o (OPV) Oral polio vaccine is a live vaccine that was given in 2000, OPV can not be given to kids
with HIV
o IPV is a dead vaccine
o Given sub-q or IM in a separate site
o Contraindicated in people with an allergy to neomycin or streptomycin
• MMR Measles, mumps, rubella (2)
o Contraindicated in those allergic to eggs, neomycin, have immunodefiencies, or pregnant
o Is a LIVE vaccine
o Can be given to people with HIV & breast feeding mothers
o Only injection Given Sub-q not IM
o Child may develop a rash 2 weeks after administration
• Varicella (2)
o Protects against chicken-pox
o Can not be given in children with HIV
o Give MMR & varcella on the same day or within 30 days but in separate sites
• Hep A (2)
• Tdap (x1 q 10 years , between 11-12)
• HPV (between 11-12) adminster the 2nd dose 1-2 months after the 1st & the 3rd dose 6 months after the
1st
• MCV4 Meningococcal (between 11-12)
• Influenza (IIV;LAIV) Flu- is given at 6 months of age then annually
o Is a LIVE vaccine
o Contraindicated in persons with an allergy to eggs
The common cold is NOT an contraindication for immunizations
Avoid Live Virus vaccines while taking prednisone (MMR, Flu, Varicella, RV Rotavirus, & Oral Polio
Vaccine, Poliovirus the IPV is a dead vaccine)
Hepatitis
Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A)
Hepatitis B=Blood and Bodily fluids
Hepatitis C is just like B
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Immunization Chart
Vaccines
AGES
HEP B
Birth
RV ROTAVIRUS
2 months
Dtap
6-18 months
Total
Amount
3
4 months
6 months
3
2 months
4 months
6 months
HIB
2 months
4 months
6 months
12-15 months
4
PCV13
PNEUMOCCAL
IPV
INACTIVATED
POLIO VIRUS
MMR
2 months
4 months
6 months
12-15 months
4
2 months
4 months
1-2 months
15-18 months
6-18 months
4-6 years
5
4-6 years
4
12-15 months
4-6 years
2
Varicella (VAR)
12-15 months
4-6 years
2
HEP A
12-23
<
6 months later
2
Immunization Side Effects … T < 102, redness and soreness at injection site for 3 days … give Tylenol and bike pedal legs (passively) for child.
5|Page
Child Nutrition Assessment
Nutrient
Signs of Deficiency
Iron
• Anemia
• Pale conjunctiva
• Pale skin color
• Atrophy of papillae on tongue
• Brittle, rigid, spoon like nails
• Thyroid edema
Vitamin B2
(Riboflavin)
•
•
•
Vitamin A
(Retinol)
Vitamin C
(Ascorbic Acid)
•
•
•
•
•
•
•
•
•
•
•
•
•
Redness & fissuring of eyelid coroners;
burning itching, tearing eyes,
photophobia
Magenta-colored tongue, glossitis
Seborrheic dermatitis, delayed wound
healing
Dry, rough skin
Dull, soft, cornea. Bitot spots
Night blindness
Defective tooth enamel
Retarded growth
Impaired bone formation
Decreased thyroxine formation
Scurvy
Receding, bleeding gums
Dry rough skin, petechie
Decreased wound healing
Increase susceptibility to infection
Irritability, anorexia, apprehension
Food Sources
• Iron-fortified formula
• Infant high-protein cereal
• Infant rice cereal
• Liver
• Beef
• Pork
• Eggs
• Prepared infant formula
• Liver
• Cows milk
• Cheddar cheese
• Some green leafy vegetables (broccoli, green
beans, spinach)
• Enriched cereals
• Liver
• Sweet potatoes
• Carrots
• Spinach
• Peaches
• Apricots
•
•
•
•
•
•
•
Strawberries
Oranges and orange juice
Tomatoes
Broccoli
Cabbage
Cauliflower
Spinach
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Vitamin B6
(Pyridoxine)
•
•
•
•
•
•
Scaly dermatitis
Weight loss
Anemia
Irritability
Convulsions
Peripheral neuritis
•
•
•
•
•
•
Meats, liver chicken
Cereals (wheat & corn)
Yeast & Soybeans
Peanuts
Tuna
Bananas
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Communicable diseases in children
1. Rubella (measles)
• Airborne precautions (private negative pressure room, need N95 mask)
• Children with Rubella = threat to unborn siblings (may require
temporary isolation from Mom during pregnancy)
• Contagious viral disease that can lead to neological problems
• Transmitted by direct contact with infected persons
• Symptoms
o Photophobia
o Koplik spots on the buccal mucosa
o Confluent rash that begins on the face and spreads downward
2. Varicella (chicken pox)
• CHICKEN POX – Vesicular Rash (central to distal) dew drop on rose petal
• Airborne precautions
NORMAL CHILD VALUES ACCORING TO AGE ****
Age
Pulse
Respirations
Nursing Implications
Newborn
100-160
30-60
These ranges are averages
1-11 months
100-150
25-35
only & vary with age, sex,
1-3 years (toddler)
80-130
20-30
and condition of the child.
3-5 years (preschooler)
80-120
20-25
Always note whether the
6-10 years (school age)
70-110
18-20
child is crying, febrile, or
10-16 years (adolescent)
60-90
16-20
in some distress
(HR in children
increases with crying or
if the child has a fever)
Diarrhea and dehydration
• usually occurs in infants
• history of exposure to pathogens contaminated food or dietary changes
Signs and symptoms of dehydration
• poor skin turgor
• absence of tears
• dry mucous membranes
• weight loss of 5% to 15%
• depressed fontanelles
• decrease urinary output with increase specific gravity
• Loss or low potassium & sodium levels
• elevated hematocrit (HCT) & BUN
Nursing interventions
• do not take temperatures rectally
• check stools for pH, glucose, & blood
• oral rehydration solutions such as Pedialyte or Lytren
• children should not receive antidiarrheals (Imodium A-D)
• do not give the child grape juice, orange juice, apple juice, cola, or ginger ale.
These solutions have high osmolarity
Signs and symptoms of shock
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• decrease blood pressure
• rapid weak pulse
• mottled to gray skin color
• changes in mental status
Fluids are given to a child with an increases respiratory rate to prevent dehydration &
acid-base imbalances
Burns
• In children the greater central body surface area is concentrated in the head &
trunk. Therefore a young child is more likely to have more serious effects
from burns to the head & trunk.
• Children have a greater fluid volume (proportionate to size)
• less effective cardiovascular responses to fluid volume shifts
•to estimate the percent of Burns and a child the Lund-Brower chart should be
used to account for the changing proportions of the child
•the Parkland formula is a commonly used guideline for calculating fluid
replacement and maintenance
o 4 x
Weight in kg x
%BSA burned
Then divided by 2 so half of the amount of fluid is given in the 1st 8 hours
the rest is given over 16
• Adequacy Of Fluid Replacement Is Determined By Evaluating Urine Output
o Urine output for infants and children should be 1 to 2ml/kg/hr****
o Normal Specific Gravity Of Urine is 1.005 to 1.030
o SG is a measurement of hydration status
▪ over hydration - will have a low specific gravity and means the
urine is more dilute
▪ dehydration- will have a higher specific gravity and
means their urine is more concentrated
Poisoning
• use of IPECAC is no longer recommended by the AAOP
• induce vomiting is not recommended because it may cause more damage
• poison removal may require
o gastric lavage
o activated charcoal
o Naloxone HVL (Narcan)
Tylenol poisoning/overdose – liver failure possible for about 4 days. Close
observation required during this time-frame, as well as tx with Mucomyst.****
Respiratory disorders
Signs of Respiratory Distress in Children *****
1. Cardinal Signs
a. Restlessness
b. Increased respiratory rate (tachypnea)
c. Increased pulse rate (tachycardia)
d. Diaphoresis
2. Other signs of respiratory distress
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a. Flaring nostrils
Retractions
b. Retractions
Grunting
c. Adventitious breath sounds (or absent breath sounds)
i. Discontinuous sounds
1. Fine Crackles- are soft, high pitched, & brief
2. Course Crackles (rales) - are louder, lower pitched, and
longer
ii. Continuous Sounds
1. Wheezes- High pitched, (asthma is wheezing on
EXPIRATION) become concerned when the
wheezing child stops wheezing
2. Ronchi- low pitched snoring sound
d. Use of accessory muscles, head bobbing
e. Alterations in blood gasses: decreased PO2, elevated Pco2
Primary meds for ER for respiratory distress
• Sus-phrine (Epinephrine HCl)
• Theophylline (Theo-dur) … Bronchodilators
Types of respiratory
disorders in
this unit
Asthma
Bronchiolitis (RSV) Cystic Fibrosis Otitis Media Epiglottitis
1. Asthma- inflammatory reactive airway disease that is commonly chronic
• The airways become edematous
• the airways become congested with mucus
• the smooth muscle of the bronchi & bronchioles constrict
• air trapping occurs in the alveoli
Signs and symptoms
• Tight nonproductive cough
• Breath sounds: coarse expiratory wheezing, rales. Crackles
• Chest diameter enlarges
• Watch out if your wheezer stops wheezing. It could mean he is worsening.
• If the patient with as Asthma has intercostal retractions--be concerned
Treatments
• When using a bronchodilator (such as Albuterol, Singulair, Theophylline)
inhaler inconjuction with a glucocorticoid inhaler (Flovent, Qvar,) administer
the bronchodilator first
• Theophylline increases the risk of digoxin toxicity and decreases the effects
of lithium and Dilantin INtal, an inhaler used to treat allergy induced asthma
may cause bronchospasm, think… INto the asthmatic lung
2. Cystic fibrosis (CF)
Group B Strep (GBS) bacteria GBS is found in the vagina and/or lower
intestines.
It usually causes no symptoms and is not harmful to adults. If a pregnant woman
has a positive GBS culture, she can transfer the bacteria to her baby during
childbirth, increasing risk for CF
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Tonsillitis
•CF is an autosomal recessive disease that causes dysfunction of the exocrine
glands provided to the child by each parent
Signs and symptoms
o The first sign of cystic fibrosis may be meconium ileus at birth. Baby is
inconsolable, do not eat, not passing meconium.
o Recurrent respiratory infections
o pulmonary congestion
o Steatorrhea excessive fatty greasy stools, foul-smelling and bulky stools
o Diagnosed with a sweat test
•Cystic Fibrosis give diet moderate to high fat, high in calories, high protein,
moderate to low carbohydrates
• Fat soluble vitamins ADEK.
•Aerosal bronchodilators,
•Skin Tastes Salty = Cystic Fibrosis
•Administer pancreatic enzymes with meals (Pancrease, Cotazyme-s)
3. Epiglottitis **
Caused by: H. influenza B
Signs and symptoms
• Child sits upright with chin out and tongue protruding (maybe
Tripod position) … Prepare for intubation or trach …
• Restlessness & high fever
• sore throat dysphagia -difficulty swallowing
• drooling with a muffled voice
DO NOT put anything into kid’s mouth, never examine the throat of a child
with epiglottitis because of the risk of obstructing the airway completely
4. Otitis Media
• increases chances for conductive hearing loss later in life
Signs and symptoms
o fever and pain
o infant may be pulling at the ear
o enlarged lymph nodes
o discharge from the ear (if the drum is ruptured)
o upper respiratory symptoms
o vomiting diarrhea
Nursing Interventions
o Pull pinna down and back for kids < 3 yrs. when instilling
eardrops.dminister antibiotics is prescribed
o reduce body temperature (fever can go so high it places the child at risk for
seizures)
• Tepid baths
• Acetaminophen (Tylenol)
o position the child on the affected side
o provide comfort with warm compress on the affected ear
5. TonsillitisCause: usually Strep …
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Important to know if this was caused by Strep because the patient is at greater
risk for developing
1. Glomerulonephritis
2. Rheumatic heart disease/ Rheumatic fever
Interventions
• Get PT and PTT Pre-Op (ask about Hx of bleeding)
• No red liquids & no straws Post-op,
• Ice collar, soft foods …
• Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with
sloughing of scabs)
Suspect Bleeding Post-Op if frequent
o Swallowing
o Vomiting blood
o Clearing throat …
No red liquids, no straws, use ice collar for pain and comfort, and only eat soft
foods …
Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing
of scabs)
6. Bronchiolitis
Cause Respiratory syncytial virus (RSV)
• Isolate RSV patient with Contact Precautions … Private room is best … Use
Mist Tent to provide O2 and Ribavirin – Flood tent with O2 first and wipe
down inside of tent periodically so you can see patient
• No contact lenses or pregnant nurses in rooms where ribavirin is being
administered by hoot, tent, etc
Cardiovascular Disorders
1. Acyanotic = VSD (ventricular septal defect), ASD (atrial septal defect) , PDA
(patent ductus arteriosus) Coarc of Aorta, AS Aortic Stenosis
• left to right shunts or increase pulmonary blood flow
• obstructive defects
Has abnormal circulation however all blood entering the systemic circulation is
oxygenated
Antiprostaglandins cause closure of PDA (aorta - pulmonary artery)
Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood),
TVG (Transposition of Great Vessels) … Polycythemia (increased amounts of
hemoglobin) is common in Cyanotic disorders
• right to left shunts or decrease pulmonary blood flow with mixed blood
flow
• has abnormal circulation with unoxygenated blood entering the
systemic circulation
3 T’s of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)
Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood),
TVG (Transposition of Great Vessels) … Polycythemia (increased amounts of
hemoglobin) is common in Cyanotic disorders
• right to left shunts or decrease pulmonary blood flow
•
12 | P a g e
•
•
mixed blood flow
has abnormal circulation with unoxygenated blood entering the
systemic circulation
• 3 T’s of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)
Tetralogy of Fallot … Unoxygenated blood pumped into aorta, consists of 4 defects
• Pulmonary Stenosis
• VSD
• Overiding Aorta
• Right Ventricular Hypertrophy
TET Spells …Hypoxic episodes that are relieved by squatting or knee chest position.
They also can be treated
with morphine.
Congestive Heart Failure (CHF) can result
• Use Digoxin … Therapeutic range = 0.8-2.0 for kids*********
• Given on empty stomach one hour before meals or two hours after, do not
mix digoxin with food or formula
• You better pick ‘do vitals’ before administering that dig. (apical pulse for one
full minute).
Signs and symptoms of early Digoxin toxicity
• Nausea
• Vomiting
• other G.I. symptoms including anorexia, diarrhea, abdominal pain
• neurological signs including fatigue, muscle weakness, and drowsiness
• Hypokalemia- can increase digoxin toxicity
• provide a diet low in sodium
Aortic Stenosis- abnormal narrowing immediately before or after
they aortic valve Ductus Arteriosus = Abnormal opening from the
Aorta to the Pulmonary Artery Rheumatic Fever
Cause: Group-a beta hemolytic strep infection
• Most common cause of Acquired Heart Disease
• It Affects: the aortic and mitral valves
Signs and Symptoms
• Fever
• Chorea is part of this sickness (grimacing, sudden body movements, etc.) and it
embarrasses kids.
• Elevated antistreptolysin O (ASO) & ESR to be elevated.
• Erythema Marginatum = Rash
• Chest pain, shortness of breath, (carditis)
• Tachycardia even during sleep
• Migatory large-joint pains
Treatment of Rheumatic Fever with Penicillin G = Prophylaxis
for recurrence of RF Aspirin for anti-inflammatory and
anticoagulant actions
Kawasaki Disease
• Coronary artery aneurysms due to the inflammation of blood vessels.
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• Cause of the disease is unknown
• usually seen in children younger than five
• has three phases the acute, subacute, convalescent
• early treatment is essential to decrease chances of permanent or damage
• extreme irritability is seen in the child during the entire disease process
Acute Phase:
• high fever or for more than five days
• conjunctival redness with the strawberry tongue
• read swollen hands and feet
Subacute Phase
• pealing of the hands and feet
Convalescnet Phase
• starts when all the signs are gone and ends when lab values have returned to
normal
Treatment
• administer intravenous immunoglobulin (IVIG)
• treat high fevers with acetaminophen and aspirin
• monitor cardiac status by documenting the child’s
1. intake and output
2. daily weights
• minimize skin discomfort with lotions and cool compresses
• initiate meticulous mouth care
• monitor the intake of clear liquids and soft foods
Neuromusc
sular
Disorders
Down
Syndrome
• Trisomy or translocation of chromosome 21 …
Physical characteristics
o flat broad nasal bridge
o inner epicanthal eye folds
o upward outward slant of the eyes
o protruding tongue
o short neck
o transverse Palmer crease (sinmian)
o hyperexpendable and lacks joints (hypotonia)
Common associated problems
o cardiac effects
o respiratory infections
o feeding difficulties
o delay developmental skills
o mental retardation
o skeletal defects
o altered immune function
14 | P a g e
o endocrine dysfunction
Cerebral Palsy (CP)
• nonprogressive injury to the motor centers of the brain causing neuromuscular
problems of spasticity or dyskinsia (involuntary movements)
Causes
1. anoxic injury before during or after birth
2. maternal infections
3. kernicterus
4. low birth weight (major risk factor)
Signs & Symptoms
• persistent neonatal reflexes (moro, tonic neck) after six months
• delayed developmental milestones and apparent early preference for one hand
• poor suck, tongue thrust, spasticity
• scissoring of legs (legs are extended and crossed over each other, & feet are
plantar flexed)
Spina Bifida
• Meningocele- a sac that is present at some point along the spine that contains
only meninges and spinal fluid that has less neurologic involvement than a
myelomeningocele
• Myelomeningocele is more severe than a meningocele because a sac contains
spinal fluid, meninges, and nerves.
• Every child with a history of spina bifida should be screened for latex allergy
(mainly fruits)
o Fruits (and seeds) involved in this syndrome include banana, pineapple,
avocado, chestnut, kiwi fruit, mango, passionfruit, fig, strawberry, soy,
Potato, Tomato, Pineapple, Papaya, Eggplant, Melon, Wheat, and
Cherimoya
Nursing interventions
• Keep the sac free from urine and stool
• cover the sac with moist sterile dressing
• Place the child in the Prone Position to keep pressure off the sac
Hydrocephalus- abnormal accumulation of cerebrospinal fluid (CSF) within the
ventricles of the brain causing An increase in intracranial pressure (ICP).
**Signs and symptoms of increased ICP are the direct OPPOSITE
from SHOCK ** Signs and symptoms of hydrocephalus or increased ICP
(Cushing’s Triad)
1. Decreased pulse rate (bradycardia)
2. Decreased respiratory rate (Bradypnea)
3. Increased blood pressure (hypertension)
Signs and symptoms of Shock
1. Increased heart rate (tachycardia)
2. Increased respiratory rate (Tachypnea)
3. Decreased blood pressure (hypotension)
Remember the “O” in shOck stands for Hypotension
Other symptoms of Hydrocephalus or increased ICP in CHILDREN
15 | P a g e
1. change in level of consciousness (LOC) = most important indicator of increased
ICP
2. irritability
3. vomiting
4. headache on awakening
5. motor dysfunction
6. unequal pupil response
7. seizures
8. widened pulse pressure
9. Bossing sign (prominent forehead)
10. Even subtle changes in mood, behavior, restlessness, irritability, decline in
academics, changes in personality or confusion may indicate increased ICP
11. Watch for CSF leaks from nose or ears – Leakage can lead to meningitis and
mask intracranial injury since usual increased ICP symptoms may be absent.
Other symptoms of Hydrocephalus or increased ICP in INFANTS
1. irritability, lethargy
2. increased head circumference
3. bulging fontanels
4. widening suture lines
5. “sunset” eyes
6. high-pitched cry
Nursing interventions for Increased ICP
1. monitor for further signs of IICP
2. maintain seizure precautions
3. elevate head of bed
Treatment: Peritoneal Shunt
1. Shunt is inserted into ventricle
2. Tubing is tunneled through skin to peritoneum where it drains excess CSF
Postoperative Care
1. After the shunt is placed- bed position for the patient is FLAT, so that fluid does
not reduce too rapidly. Only if you see S&S of increasing ICP does the head of
the bed become elevated to 15-30 degrees
2. Assess for signs of shunt malfunction but DON’T pump the shunt, that can put
pressure on the ventricles
a. Infants:
1. change in size, signs of bulging, tenseness in fontanels, &
separation of suture lines
2. irritability, lethargy, or seizure activity
3. altered VS and feeding behavior
b. Older children: increased ICP
1. changes in LOC (#1 most important sign of IICP)
2. headache
3. changes in customary behavior (sleep or developmental
capabilities)
Family Teaching
1. Teach to watch for signs of increased ICP
16 | P a g e
2. Note the child will outgrow the shunt and will need a revision, the child may
shows signs of increased ICP when he/she is beginning to outgrow it. Advise
the pt to bring the child in when this occurs.
3. provide anticipatory guidance for potential problems with growth & development
Other signs of Shock
• Mental Status
o Early Shock- restless, hyperalert
o Late Shock- decreased alertness, lethargy, coma
•
Skin Changes
o Cool, clammy skin
o Diaphoresis
o Paleness
• Fluid status Changes
o Urine output decreases, or an imbalance between I&O occurs
o Central venous pressure is abnormal
o A urine specific gravity > 1.020 indicates hypovolemia
Shock- widespread serious reduction of tissue perfusion (lack of O2 & nutrients)
Those at risk for the development of shock
1. very young & very old
2. post-MI clients
3. Clients with severe dysrhythmias
4. Clients with adrenocortical dysfunction
5. Persons with a recent history of hemorrhage or blood loss
6. Clients with Burns
7. Clients with massive overwhelming infections
Types of shock
1. Hypovolemic- related to blood loss (most common cause of shock)
2. Cardiogenic- related to ischemia or impairment in tissue perfusion from MI,
serious arrhythmia, or heart failure. All of these resulting in cardiac output.
a. If cardiogenic shock occurs in the presence of Pulmonary edema (e.g.
from pump failure) position the client to reduce venous return. (HIGH
FLOWLERs with LEGS DOWN) to decrease further venous return to
the left ventricle.
3. Distributive- (Anaphylactic, Neurogenic, & Septic Shock) results from
excessive vasodilation & the impaired distribution of blood flow
4. Obstructive- physical obstruction related to tamponade, emboli, compartment
syndrome, that impedes the filling or outflow of blood resulting in reduced
cardiac output
• All types of shock can lead to systemic inflammatory response syndrome (SIRS)
& result in multiple organ dysfunction syndrome (MODS)
Medical Treatments & nursing interventions for Shock
1. Oxygen & Ventilation corrects decreased tissue perfusion and restores cardiac output
2. Fluid Resuscitation (rapid infusion of volume-expanding fluids in: hypovolemic &
anaphylactic shock)
3. Drug Therapy:
17 | P a g e
▪ Drugs that increase cardiac Preload- blood products & crystalloids)
▪ Drugs that decrease preload (morphine, nitrates, diuretics)
▪ Drugs that increase Afterload (vasopressors, dopamine)
▪ Drugs that Decrease Afterload (nitroprusside, ACE-I, ARB)
▪ Drugs that decrease contractility (beta blockers, calcium channel blockers,)
▪ Drugs that Increase contractility (digoxin (lanoxin) dobutamine)
Seizures
Nursing Interventions
• Maintain airway
• Nothing in the mouth, no padded tongue blades. That will cause more damage to
the oral cavity
• Don’t restrain
• Keep safe, support the head
• Turn head to the side
Maintai
n
seizure
precauti
ons
• reduce environmental stimuli
• pad side rails or crib rails
• have suction equipment in oxygen quickly accessible
• table oral airway to the head of the bed
Treatment: Antivonvulsants- Phenobarbitol (Luminol), Phenytoin (Dilantin:
Therapeutic Range = 10-20
… Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene),
Carbamazepine (Tegritol)
• Medication noncompliance is the most common cause of increased seizure
activity
Performing an EEG
EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must
stay awake night before exam, pt may be asked to hyperventilate and watch a bright
flashing light, after EEG, assess pt for seizures, pt's will be at increased risk.
Bacterial Meningitis
• bacterial inflammation of the meninges that cover the brain and spinal cord
• Place on droplet precautions
• Isolate for 24 hours
• implement seizure precautions
• elevate the head of the bed and position the patient on the side
• measure head circumference and I&O
• ** monitor hydration status and IV therapy- bacterial meningitis can lead
to SIADH (over production of ADH aka Vasopressin) causes you to
retain too much water (fluid overload) in the body causes blood serum to
become diluted causing Hponatremia *****
SIADH (increased amounts of ADH) signs & symptoms
18 | P a g e
• change in LOC,
• decreased deep tendon reflexes
• tachycardia
• n/v/a,
Signs and symptoms of Hyponatremia **
• nausea
• muscle cramps
• increased ICP
• muscular twitching
• convulsion
Causes
• Haemophilus influenza type B
• Streptococcus pneumoniae
• Neisseria meningitis
Signs and symptoms
• classic signs of increased intracranial pressure (hypertension, bradycardia,
bradypnea)
• fever and chills
• neck stiffness-opisthotonus & photophobia
• Positive Kernig’s sign (leg flex then leg pain on extension)
• Positive Brudzinski sign (neck flex =lower leg flex).
Diagnostic Lumbar Puncture of bacterial meningitis Shows
• increased WBC
• increase proteins
• increased ICP
• decreased glucose
Avoid further increasing of ICP by not
• suctioning
• coughing
• straining
• turning
Reye syndrome
• acute rapidly progressing encephalopathy and hepatic dysfunction
Causes:
o viral infections such as influenza or chickenpox
o aspirin use
Muscular Dystrophy
• Progressive muscle atrophy & weakness
•Duchenne muscular dystrophy is an X-linked recessive disease affecting primary
males
A X-linked recessive chromosome disorder works by the mother being a
carrier but only her sons may express the disease.
•it’s rapidly progressing causing cardiac and respiratory complications and death
by 25 years old
19 | P a g e
•X-linked Recessive
Signs and symptoms
• Waddling gait
• hyper lordosis
•Gower’s Sign = difficulty rising walks up legs (like Minor’s sign),
•fat pseudohypertrophy of calves.
20 | P a g e
Anticonvulsants
Drugs/routes
Phenobarbital
(Lumunal) PO,IM,IV
Phenytoin (Dilantin)
PO, IV
Fosphenytoin Sodium
(Cerebyx) IM, IV
Valproic Acid
(Depakene) PO
Carbamazepine
(Tegretol) PO
Lamotrigine (Lamictal)
PO
Clonazepam
(Klonopin) PO
Indications
• Tonic-clonic & partial
seizures
• Is the longest acting of
common barbiturates
• Usually combined with
other drugs
• Tonic-clonic & partial
seizures
Adverse Reactions
• Drowsiness
• Nystagmus (uncontrolled movements of the
eyes)
• Ataxia (loss of full control of bodily
movements)
• Paradoxic excitement
• Gingival hyperplasia • Nausea, anorexia
• Dermatitis
• Bone marrow depression
• Ataxia
• Nystagmus
•
• Generalized convulsive
status epilepticus
• Prevention & treatment of
seizures during neurosurgery
•Short-term parenteral
replacement for (Dilantin)
• Absence seizures
• Myoclonic seizures
• Rapid IV infusion can cause hypotension
• Severe: ataxia, CNS toxicity, confusion,
gingival hyperplasia, irritability, lupus,
nervousness, nystagmus, paradoxic excitement,
Steven-Johnson’s syndrome, toxic epidural
necrosis
• Hepatoxicity, especially in children under 2
• Prolonged bleeding times
• GI disturbances
•
•
•
•
•
•
•
Tonic-clonic, mixed seizures • Hepatitis
Drowsiness • Ataxia
• Agranulocytosis
Partial seizures
• Dizziness
• Rash
Tonic-clonic seizures
• Headache
Absence seizures
• Nausea
•
•
Absence seizures
Myoclonic seizures
•
•
Drowsiness
Hyperactivity
Agitation
Increased Salvation
Nursing Implications
• Therapeutic levels: 15 to 40 mcg/ml
•Avoid rapid IV infusion
• Monitor BP during IV infusion
Therapeutic levels: 10 to 20 mcg/mL
• Monitor any drug interactions
• Do not administer with milk
• Ensure meticulous oral hygiene
• Monitor CBC
• Report any rashes to HCP
• For IV infusion flush the line before &
after medication administration with
normal saline only
• Prior to IV infusion, dilute in D5W or
NS to administer
• Infuse a rate of no more than 150mg
PE/min
• Therapeutic levels: 50-100mEq/ml
• Monitor liver function
• Potentiates Phenobarbital and
Dilantin, altering blood levels
• Therapeutic levels: 6 to 12mcg/ml
•
• Withhold if rash develops
• Do not discontinue drug abruptly
•
•
•
Therapeutic levels: 20-80mcg/ml
Do not discontinue drug abruptly
Monitor liver function, CBC, & renal function periodically
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Comparison Of Acute Glomerulonephritis & Nephrotic Syndrome
Variables
Acute Glomerulonephritis
Nephrotic Syndrome
Cause
Follows Streptococcal Infection
Usually Idiopathic
Edema
Mild, usually around the eyes
Severe, generalized
Blood Pressure
Elevated
Normal
Urine
Dark, tea-colored (hematuria)
Dark, frothy yellow
Protein in the urine Sight to moderate
Massive amounts
Blood
Normal serum protein
Decreased serum protein
Positive ASO titer
Negative ASO titer
Medications Used in Renal Disorders
Drugs/Route
Indications
Adverse Reactions
Nursing Implications
Bethanechol Chloride
Cholinergic used to treat:
Orthostatic hypotension
• Do not give IM or IV
(Urecholine) PO, IM, IV
Flushing
Urinary retention
• Monitor VS
Asthmatic
reaction
Neurogenic Bladder
• Preferably given on an empty stomach
GI distress
Gastric reflux
o In children, every other day administration is
Prednisone
Adrenocorticosteriod used
o
Mood changes
best to avoid growth failure when drug is taken
(Deltasone) PO
to treat:
o
Increased susceptibility to
long term
infection
• Immunosuppression
o Discontinuing this drug requires tapering
o
Cushingoid appearance
(acts as antiiflammatory)
o Avoid Live Virus vaccines while taking
(moon face & buffalo hump)
• Edema (promotes
prednisone (MMR, Flu, Varicella, RV Rotavirus,
o
Acne
diuresis in nephrotic
& Oral Polio Vaccine, Poliovirus the IPV is a
o
GI distress
syndrome)
dead vaccine)
o
Thrombocytopenia (low
platelets)
o
Edema
o
Potassium loss
o
Growth failure in children
23 | P a g e
o
Oxybutynin
(Ditropan) PO or
Transdermal
o
Tolterodine
(Detrol) PO
Genitourniary smooth-muscle
relaxants (antispasmodics)
used to treat:
• Uninhibited neurogenic
bladder
• Reflux urogenic bladder
• Both are characterized
by voiding symptoms of
urgency, frequency,
nocturia & incontinence
o
o
o
o
o
o
o
Increased
susceptibility to UTI
GI distress
Dry mouth
Vision changes
Dizziness
Chest pain
Drowsiness
o Administer orally: available in extended release
forms
o Do not administer with other meds that have any
other anticholinergic effects
o May exacerbate reflux esophagitis
o Contraindicated in pt with untreated glaucoma
or any GI narrowing (GI obstruction may occur)
o Safety for use in children has not been
established
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Gastrointestinal Disorders
1. Cleft lip or Palate
• initial surgery to close the cleft lip begins when
1. the child weighs 10 pounds or more
2. has a hemoglobin (HGB) of at least 10g/dl
Nursing implications
• Maintain proper airway
• Position on back or in infant seat to prevent trauma to suture line. Never lie the child prone
• While feeding, hold in upright position.
• Post-Op – Place on side
• clean the suture site with sterile water after feedings-residual formula may impede healing and lead to infection
• Protect the surgical site
• maintain Logan Bow,
• Apply elbow restraints
• minimize crying
2. Esophageal Atresia with Tracheoesophageal Fistula (TEF)
• congenital anomalies in which the esophagus is not fully developed
• this is considered a clinical and surgical emergency
Nursing assessments
• 4 Cs of TEF in the newborn
1. choking
2. coughing
3. cyanosis
4. continuous drooling
• excess salvation
• respiratory distress
• aspiration pneumonia
3. Pyloric stenosis
• narrowing of the pyloric canal, the sphincter hypertrophies to twice its normal size
Nursing assessment
1. palpable Olive shaped mass in the upper right quadrant
2. mild vomiting (free from bile) that progresses to projectile
3. May spit up after feedings
Post-operative interventions
1. position the patient on the right side and semi-Fowler position after feedings
25 | P a g e
2. burp frequently to avoid stomach becoming distended and putting pressure on the surgical site
4. Intussusception
• telescoping of one part of the intestine and to another part usually the ileum into the colon (ileocolic)
• partial or complete bowel obstruction occurs
• bowel vessels become trapped causing necrosis
Nursing assessment
1. Currant jelly stools (mixed with blood and mucus)
2. sausage shaped mass in the upper right quadrant while the lower quadrant is empty
3. common in kids with cystic fibrosis CF
Treatments
1. first attempt is a barium enema to hydrostatically reduce the telescoping of the intestines, if successful in 2:3 cases. If not successful
than surgical repair will be implemented
a. resolution is obvious with the onset of a bowel movement
5. Congenital Aganglionic Megacolon AKA Hirschsprungs Disease
• absent autonomic parasympathetic ganglion cells in the distal portion of the colon and rectum causing:
1. absent peristalsis
2. fecal contents to accumulate above the aganglionic area of the bowel
Signs and Symptoms
• The initial sign is infants who fails the pass meconium within 24 hours of birth
• ribbon like stools and foul smelling stools a later seen in the older child
Signs of bowel perforation
• abdominal distention and vomiting
• irritability
• dyspnea and cyanosis
Diagnosis
• is made with rectal biopsy looking for absent ganglionic cells
Treatment
• before and after the procedure only axillary temperatures can be taken
• usually involves series of surgical procedures
i. a temporary colostomy will be applied
ii. and later a reanastomsis and closure of the colostomy occurs
Hematologic Disorders LAB REVIEW ******
• ***Normal aPTT is within 30-40 seconds**(1.5-2.5X normal or control for heparin therapy 45-100 minutes)
• ****Normal PTT is within 60-70 Seconds* (1.5-2.5X normal or control for heparin therapy 90-175 minutes)
• Sed rate ESR: Males up to 15, females up to 20 rate is also increased during pregnancy, child up to 10, newborn put to 2.
26 | P a g e
•
•
PT normal 11-12.5 seconds but just slightly lower in pregnancy (1.5-2X normal or control for Coumadin therapy 16.5-25)
INR International normalized Ratio Normal: 0.8-1.1. Used to monitor anticoagulation therapy. INR
Must be individualized
1. Iron Deficiency Anemia – hemoglobin & RBC levels below normal range because of the body is an adequate supply, intake, or absorption of
iron.
• The need for iron is greater in children than adults because of accelerated growth
Possible causes for iron deficiency anemia
• inadequate stores during fetal development
• deficiency dietary intake
• chronic blood loss
• poor utilization of iron by the body
Nursing Assessment/ Signs & Symptoms
• pallor or paleness of mucous membranes
• tiredness and fatigue
• usually seen in infants 6 to 24 months old
• toddlers and female adolescent most affected
• overweight “cows milk” babies. Milk intake greater than 32 ounces a day
• low dietary intake of iron
Lab Values
1. decreased hemoglobin Hgb
2. low serum iron level
3. elevated total iron binding capacity T IBC
Remember The Hemoglobin (Hgb) Norms Of The Following
• newborn 14 to 24 g/dL
• infant
10 to 17 g/dL
• child
9.5 to 15.5 g/dL
Nursing planning and interventions
1. support the child’s need to limit activities
2. provide rest periods
3. administer oral iron (ferrous sulfate) as prescribed
Teach the family about administration of oral iron
• give on empty stomach-as tolerated because it’s better for absorption
• give with citrus juices such as vitamin C for increased absorption
• use dropper or straw to avoid discoloring teeth
27 | P a g e
• teach that stools will become tarry
• teach the iron can be fatal in severe overdoses. Keep away from other children
• do not give iron with any dairy products Teach nutritional facts regarding iron
• limit milk intake to less than 32 ounces a day
• teach about dietary sources of iron
o meet
o green leafy vegetables
o fish
o liver
o whole grains
o legumes
o for infants: iron fortified cereals and formula
2. Sickle Cell Anemia
• inherited autosomal recessive disorder of hemoglobin (Hgb) known as HgbAS
• it occurs primarily in persons of African in eastern Mediterranean descent
• usually appears after six months
Hemoglobin S (HgbS)- replaces all or part of the normal hemoglobin, which causes the red blood cells to sickle when oxygen is released into the
tissues.
1. Sickle cells cannot flow through capillary beds
2. Dehydration promotes sickling
3. HgbS has a left their normal lifespan which leads to chronic anemia
4. tissue ischemia causes widespread pathologic changes in the spleen, liver, kidneys, bones, and central nervous system.
Signs and symptoms
• frequent infections or nonfunctional spleen
• tiredness
• chronic hemolytic anemia
• delayed physical growth
• Vaso-occlusive crisis AKA Sickle Cell Crisis the classic signs are:
1. fever
2. severe abdominal pain
3. hand-foot syndrome (in infants) causing painful edematous hands and feet
4. arthralgia (joint pain)
5. leg ulcers (adolescents)
6. cerebovascular accidents (CVA, stoke) increased risk with dehydration
Hydration- is most important in the treatment of sickle cell disease because it promotes hemodilution and circulation of red blood cells through the
28 | P a g e
blood vessels.
Nursing interventions for Sickle Cell
Teach the family how to prevent sickle cell crisis (hypoxia)
• keep the child from exercising strenuously
• keep the child away from high altitudes
• avoid letting the child become infected, and seek care at first signs of infection
• use prophylactic penicillin as prescribed
• keep the child well hydrated
• withhold fluids at night because enuresis is a complication of both the disease and treatment
Interventions for the hospitalized patient with a vaso-occlusive crisis/sickle cell crisis
• The two main interventions during a sickle cell crisis
1. Fluids: administer IV fluids and electrolytes as prescribed to increase hydration treat acidosis
2. Pain relief: administer analgesics
▪ Do not give demerol to pts. with sickle cell crisis
▪ parenteral morphine for pain is given
• use a warm compress for comfort (not ice)
• Administer blood products as prescribed
• Administer pneumococcal vaccine, meningococcal vaccine, Hib as prescribed. Administration of hep B vaccine is prescribed because the child
is at risk because of blood transfusion.
• Supplemental iron is not given to clients with sickle cell anemia. The anemia is not caused by iron deficiency. Folic acid is given orally to
stimulate red blood cell synthesis.
Thrombocytopenia (low platelets > 150,000………… Normal platelets 150,000- 400,000) ****
• Can be seen in Sickle cell anemia, but most often seen in Aplastic Anemia
• Also seen in Hemophilia
Signs and symptoms of Bleeding
Anemia- Deficiency of erythrocytes (RBC) causing a low Hematocrit (Hct) and a low Hemoglobin (Hgb)
Normal Hgb (males: 14-18, females 12-16, pregnancy >11)
• Children 1-6 years 9.5-14
• 6-18 years 10-15.5
Normal Hct (males: 42-52%, females 37-47%, pregnancy >33%)
• Children 1-6 years 30-40%
• Children 6-18 years 32-44% Treatment of Sickle Cell with
Rest & Hydration
Hydroxyurea, for sickle cell any reports of GI symptoms immediately could be sign of toxicity
Acute Lymphocytic Leukemia (low WBC > 5,000)
Normal WBC 5,000-10,000 ***
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• Normal WBC in children
• <2 yrs 6,200-17,000
• <2 years 5,000-10,000)
Leukemia (normal adult)
• anemia results from decreased red blood cell production and blood loss
• immunosuppression occurs because of the large number of immature white blood cells or profound neutropenia (decreased neutrophils)
• hemorrhage occurs because of thrombocytopenia (low platelets, pins blood)
Acute Lymphocytic Leukemia- Cancer of the blood forming organs (Mainly in children)
• Its noted for the presence of lymphoblasts (immature lymphocytes WBC) which replaced normal cells in the bone marrow
Will result in
• Lymphocytopenia (low WBC)
• Thrombocytopenia (low platelets)
• Anemia (low red blood cells, hemoglobin, and hematrocit
Signs and Symptoms of Lymphocytic Leukemia
• Pallor, tiredness, weakness, and lethargy due to anemia
• Petechiae, bleeding, bruising, due to thrombocytopenia
• Infection, fever due to neutropenia
• bone joint pain due to leukemic infiltration of bone marrow
• enlarged lymph nodes; hepatosplenomegaly (enlargement of the liver and spleen)
• headache and vomiting with anorexia and weight loss
• lab data: bone marrow aspiration that reveals 80 to 90% immature blast cells
Nursing interventions Lymphocytic Leukemia
• recommend a private room
• reverse isolation is prescribed
• administer and monitor for side effects of chemotherapy
• have epinephrine oxygen readily available to treat anaphylaxis when administering L-asparaginase
3. Hemophilia- is an inherited bleeding disorder transmitted by an X-linked recessive chromosome (mother is a carrier, and her sons may express the
disease)
• Thrombocytopenia (low platelets)
• a normal individual has between 50 and 200% factor activity in blood.
• The hemophiliac has from 0% to 25% activity
• The affected individual usually is missing either factor VIII (most commonly in 75%) or factor IX
Signs & symptoms of Thrombocytopenia
• Easy or excessive bruising
30 | P a g e
•
•
•
•
•
•
Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs
Prolonged bleeding from cuts
Spontaneous bleeding from your gums or nose (epistaxis)
Blood in urine or stools
Unusually heavy menstrual flows
Profuse bleeding during surgery or after dental work
Place all Pt with Thrombocytopenia (including adults on anticoagulant therapy) on Bleeding Precautions
o
Soft bristled tooth brush
o
Electric razor only (no safety razors) o
Handle gently, Limit contact
sports
o
Rotate injection sites with small bore needles for blood thinners and avoid IM injections
o
Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites o No straining at stool - Check
stools for occult blood (Stool softeners prn)
o
No salicylates, NSAIDs, or suppositories
o
Avoid blowing or picking nose
o
Do not change Vitamin K intake if on Coumadin
Signs & Symptoms of Hemophilia
1. male child: first red flag may be prolonged bleeding at the umbilical cord or injection site of vitamin K, or following circumcision
2. prolonged bleeding with minor trauma
3. hemarthrosis (most frequent sight of bleeding)
4. spontaneous bleeding into muscles and tissues
5. loss of motion and joints
6. pain
lab values:
1. Prolonged PTT
****Normal PTT is within 60-70 Seconds* (1.5-2.5X normal or control for heparin therapy 90-175 minutes)
2. Factor assay is less than 25%
Treatments of Hemophilia
• administer fresh frozen plasma
• administer pain medication containing no aspirin
• follow blood precautions: risk for hepatitis Teach child and family home care
o teach to recognize early signs of bleeding into joints
o teach local treatment for minor bleeding (pressure, splinting, ice)
o teach administration of factor replacement
o discuss dental hygiene: use only soft toothbrushes
o provide protective care: give the child soft toys and use padded rails
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Hesi Hint- inherited bleeding disorders (hemophilia and sickle cell anemia) are often used to test knowledge of genetic transmission patterns.
Remember:
Autosomal recessive: both parents must be heterozygous, or carriers of the trait, for that disease to be expressed in their offspring. This means
two copies of an abnormal gene must be present in order for the disease o trait to develop.
Seen in: Cystic fibrosis, sickle cell anemia, PKU, Sickle Cell Anemia, Tay-Sachs, & Albinism,
Autosomal dominant, it means you only need to get the abnormal gene from one parent in order for you to inherit the disease. One of the
parents may often have the disease.
Seen in: Huntington’s, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease
X-linked Recessive Trait- this trait is carried on the X chromosome, therefore; females can only be carriers and not have the gene & the
mother usually passes the disease to her male offspring/son.
Seen in: Hemophilia & Muscular Dystrophy Other Associated Hemological Terms
1. Leukocytosis – Increased WBC resulting from the inflammatory response,
• Most commonly the result of infection
• parasitic infections or bone tumors
• strenuous exercise
• convulsions such as epilepsy
• emotional stress
• pregnancy and labor
• anesthesia or recent surgery
• epinephrine administration.
2. Lymphocytopenia- Decreased WBC resulting from
• Leukemia
• Hodgkin’s disease
• Corticosteroid use
• infections with HIV and other viral, bacterial, and fungal agents,
• malnutrition
• systemic lupus erythematosus,
• severe stress,
• intense or prolonged physical exercise (due to cortisol release),
• rheumatoid arthritis,
• sarcoidosis
• iatrogenic (caused by other medical treatments) conditions.
32 | P a g e
• Chemotherapy or radiation
3. Thrombocytosis (or thrombocythemia) High platelets resulting from
Reactive (Secondary)
• Inflammation
• Surgery (which leads to an inflammatory state)
• Hyposplenism (decreased breakdown due to decreased function of the spleen)
• Splenectomy
• Asplenia (absence of normal spleen function)
• Iron deficiency anemia or hemorrhage
• Medications such as eltrombopag or romiplostim,
The vast majority of causes of thrombocytosis are acquired disorders, but in a few cases, they may be congenital, such as thrombocytosis
due to congenital asplenia.
Other causes include the following
• Kawasaki disease
• Soft tissue sarcoma
• Osteosarcoma
• Dermatitis (rarely)
• Inflammatory bowel disease
• Rheumatoid arthritis
• Nephritis
• Nephrotic syndrome
[6]
• Bacterial diseases, including pneumonia, sepsis, meningitis, urinary tract infections, and septic arthritis.
4. Thrombocytopenia and thrombopenia Low Platelets resulting from
Decreased production
• Vitamin B12 or folic acid deficiency
• Leukemia or myelodysplastic syndrome
• Decreased production of thrombopoietin by the liver in liver failure
• Sepsis, systemic viral or bacterial infection
• Dengue fever can cause thrombocytopenia by direct infection of bone marrow megakaryocytes, as well as immunological shortened platelet
survival.
Hereditary syndromes
• Congenital amegakaryocytic thrombocytopenia
• Thrombocytopenia absent radius syndrome
• Fanconi anemia
• Bernard-Soulier syndrome, associated with large platelets
• May-Hegglin anomaly, the combination of thrombocytopenia, pale-blue leuckocyte inclusions, and giant platelets
33 | P a g e
•
•
•
Grey platelet syndrome
Alport syndrome
Wiskott–Aldrich syndrome
Increased destruction
• Systemic lupus erythematosus
• Post-transfusion purpura
• Neonatal alloimmune thrombocytopenia
• Splenic sequestration of platelets due to hypersplenism
• HIV-associated thrombocytopenia[4]
• Gaucher's disease
Medication-induced
5. Polycythemia (also known as polycythaemia or polyglobulia) High RBC caused by
• chronically low oxygen levels
• malignancy.
• Being over-transfused
Metabolic & Endocrine Disorders
1. Congenital hypothyroidism
• low levels of T4 (thyroxine)
• high levels of TSH thyroid stimulating hormone
Synthroid: tx of hypothyroidism..may take several weeks to take effect...notify doctor of chest pain..take in the AM on empty stomach..could
cause hyperthyroidism.
2. PKU Phenylketonuria *****
• Autosomal Recessive Diseases in which the body cannot metabolize the essential amino acid phenylalanine
• Guthrie Test – Tests for PKU, at birth & again at 3 weeks
o baby should have eaten source of protein first
o positive test if serum phenylalanine level of 4mg/dl
• No phenylalanine with a kid positive for PKU (no meat, no dairy, eggs, Aspartame (NutraSweet) has phenylalanine in it and should not be
given to PKU patient)
o infants require special formula Lofenalac, Phenex-1
o infants require phenyl free milk substitutes after two years of age
o No foods low in phenylalanine (vegetables, fruits, juices, cereals, breads, and starches
o the diet must be maintained until at least brain growth is complete around ages 6 to 8
• The buildup of serum phenylalanine leads to CNS damage Leads to MR
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• early detection for PKU and hypothyroidism is essential for preventing cognitive impairments.
3.Insulin-Dependent diabetes mellitus or type I (IDDM)
• metabolic disorder in which the insulin producing cells of the pancreas are not functioning as a result of some and so
• diabetes can cause altered metabolism of carbohydrates, proteins, and fats
• treatment includes insulin replacement, dietary management, and exercise
• fasting blood sugar greater than 120 mg/dL is a diagnosis of diabetes
Hyperglycemia is caused by:
• too much food, too little insulin, too little diabetes meds, illness or stress.
• Onset: start slow
Signs & Symptoms of Hyperglycemia (3Ps with varying weight situations)
• Polydipsia
• Polyuria
• Polyphagia
• weakness
• weight loss
• syncope
• blurred vision
Nursing Actions:
• encourage water intake
• check glucose regularly
• assess for ketoacidosis- when a child is in ketoacidosis administer regular insulin IV in normal saline
• administer insulin
Hypoglycemia- is caused by to little food, to much insulin or diabetic medicine, or to much activity
Onset: is sudden and can progress to insulin shock
Signs & Symptoms include (Tiredness TLC)
• Tachycardia/tremors
• Irritability/anxiety
• Restlessness
• Extreme headache
• Depression
• Nausea
• Sweating
• Slurred Speech
TLC
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• Tingling
• Lethergy
• Confusion
Nursing Actions
• Treat with complex carbs
o Grahm crackers & peanut butter
o 12 cup OJ
o 1 cup milk
o Hard candies NO chocolate
•
Recheck glucose in 20 minutes
Diabetic ketoacidosis (DKA)= Occurs when the body is breaking down fat instead of sugar for energy. Fats leave ketones (acids) that cause pH to
decrease.
• DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats.
• Kussmauls breathing (Deep Rapid RR) is present during DKA
• Serum acetone and serum ketones rise in DKA. As you treat the acidosis and dehydration expect the
potassium to drop rapidly, so be ready, with potassium replacement.
• However, NEVER give potassium K+ IV Push
• Fluids are the most important intervention DKA, so get normal saline running first then infuse with regular insulin IV
• While treating DKA, bringing the glucose down too far and too fast can result in increased
intracranial pressure d/t water being pulled into the CSF.
When drawing up Insulin Remember:
• Draw Regular (Clear) insulin into syringe first when mixing insulins (Nichole Richey RN)
• Put Air into NPH first, then air into regular, draw up regular first RN) then draw up NPH
Insulin
Rotate Injection Sites (Rotate in 1 region, then move to new region)
Rapid Acting Insulins … Lispro (Humalog), Aspart (Novolog) … O: 5-15 min, P: .75-1.5 hrs Short Acting Insulin … Regular
(human) … O: 30-60 min, P: 2-3 hrs (IV Okay) Intermediate Acting Insulin … Isophane Insulin (NPH) … O: 1-2 hrs, P: 6-12 hrs
Long Acting Insulin … Insulin Glargine (Lantus) … O: 1.1 hr, P: 14-20 hrs (Don’t Mix)
Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing
hepatic glucose production
•
Glyburide, Metformin (Glucophage), Avandia, Actos
•
Acarbose blunts sugar levels after meals
Insulin type
Name
Onset
Peak action
Duration
Nursing implications
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Rapid acting
Short acting
Intermediate acting
Long acting
Lispro (Humalog)
Aspart (NovoLog)
Glulisine (Apidea)
Regular insulin (clear)
(Humlin R, Novolin R)
Isophane insulin (NPH) (cloudy)
Humulin N, Novolin N
0.5-1hour
5-15 minutes
25 minutes
30 to 60 minutes
2-4 hours
0.75-1.5 hours
1 hour
2 to 3 hours
4 hours
3-5 hours
2-3 hpurs
5 to 7 hours
1 to 2 hours
6 to 12 hours
18 to 28 hours
Glargine (Lantus)
Detemir (Levemir)
48 hours
1.1 hours
14 to 20 hours
five hours (some
sources say there
is no peak)
24 hours
Give within 15 minutes of a
meal (Humalog and NovoLog)
Regular insulin may be given
IV
• Cannot be given IV
• Mixtures combine rapid
acting regular insulin with
intermediate acting NPH
insulin in a 30% regular with
70% NPH proportion or at 5050 combination
• Not to be given IV
• Recommended: give one
dose subcutaneously at bed
time
• In some cases its given
2x/day
• Acts as basal insulin
• Caution: solution is clear,
but the bottle shape is
distinctively different from
regular insulin.
•Do not shake solution
•Do not mix other insulins
with Lantus.
•Use cautiously if patient is
NPO
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Premix
Humalog 75/25 NPH
(25% Lispro/ 75% Humulin N)
Human 70/30
(30% regular/ 70% NPH
NovoLog 70/30
(30% Aspart/ 70% NPH)
Humalog 50-50
• For all premixes: offer when
food is readily available
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Skeletal disorders
1. Fractures- are described by the type and extent of the break
• Fractures are caused by a direct blow, Cushing force, a sudden twisting motion, or disease such
as cancer or osteoporosis.
Fractures are classified by the following:
1. Complete fracture- a break across the entire cross-section of the bone, dividing it into
distinct fragments; often displaced.
2. Incomplete fracture- a fracture that occurs through only one cortex (part) of the bone, is
usually nondisplaced
3. Close fracture- no break in the skin
4. Open fracture/compound- broken bone protrudes through the skin or mucous
membranes. Making this fracture more prone to infection.
Bleeding is part of the ‘circulation’ assessment of the ABCD’s in an emergent situation.
Therefore, if airway and breathing are accounted for, a compound fracture requires
assessment before Glasgow coma scale and a neuro check (D=disability, or neuro check)
5 Types of fractures
1. Greenstick- Is an incomplete fracture in which one side of a bone is broken, but the other side
is bent (flexed) but intact.
2. Transverse- A break that occurs straight across (90-degree angle) the bone shaft
3. Oblique- break that occurs at a 45-degree-angle across the bone
4. Spiral- fracture line results from twisting force it forms a spiral encircling the bone
a. Spiral fractures or infant fractures may be related to child abuse
5. Comminuted- a break that consists of more than three fragments that may be splintered
or crushed. (Least common in children)
Intracapsular fracture- occurs in the neck of the femur and heels with greater difficulty than an
extracapsular Fracture (occurs below the neck of the femur) because the blood supply enters the femur
below the neck of the femur, there is greater likelihood that necrosis will occur because the fracture is cut
off from the blood supply
Signs and Symptoms of a Fracture
• Pain, swelling, tenderness
• Deformity, loss of functional ability
• Discoloration, bleeding at the site through an open wound
• Crepitus: crackling sound between two broken bones
• ** SIGNS of a Fractured hip: EXTERNAL ROTATION, SHORTENING, ADDUCTION
Nursing Interventions
• Frequent neurovascular assessment distal to the injury (skin color, temperature, sensation,
capillary refill, mobility, pain, swelling (elevate to prevent swelling) and pulses should be
assessed.)
• Assess the 5Ps of neurovascular functioning
1. Pain
2. Paresthesia
3. Pulses: check pulses distal to the injury to assess circulation
4. Pallor
5. Paralysis- check for nerve or movement impairments, compare with uninjured extremity
• Report abnormal assessment findings promptly
• Observe client use of assistive devices
1. Crutches- there should be to a three finger widths between the axilla and top of the crutch.
a. A three-point gait is common. The client advances both crutches and the impaired Leg at
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the same time. The client then swings the uninvolved leg ahead to the crutches.
b. Remember the phrase “step up” when picturing a person going up stairs with crutches.
The good leg goes up first, followed by the crutches and the bad leg. The opposite happens
going down. The crutches go first, followed by the good leg.
2. Cane- is placed on the unaffected side
a. the top of the cane should be at the level of the greater trochanter
b. Remember: COAL (cane walking): C – Cane O- Opposite A- Affected L- Leg
3. Walker- strength of upper extremity & unaffected leg is assessed & improved with exercise so that
upper body is strong enough to use the walker. The pt Lifts & advances the Walker and steps forward.
2 major complications of a fracture
1. Compartment Syndrome which may cause Permanent damage to nerves and vessels
• Compartment syndrome is an emergency situation.
• Paresthesias and increased pain are classic symptoms.
• Neuromuscular damage is irreversible 4-6 hours after onset.
2. Fat embolism - a syndrome in which fat globules migrate into the bloodstream and
combine with platelets to form emboli.
• Its greatest occurrence is in the first 36 hours after a fracture
• People more likely to develop a fat embolism
o people with multiple fractures
o fractures of long bones
o fractures of the pelvis
Signs and symptoms of a fat embolism
1. Number 1 symptom is confusion due to hypoxemia (check blood gases for Po2)
2. Petechiae
3. respiratory distress
4. restlessness or irritability
5. fever
If a fat embolism is suspected- notify the physician stat, draw blood gases, administer O2,
and assist with endotracheal intubation.
Treatment for a Fat embolism is Heparin Administration
Traction
• Maintain traction if prescribed. Always document the
1. bed position
2. type of traction
3. weights
4. pulleys
5. pins & pin sites- can be source of infection, monitor for signs and symptoms and cleanse and
dress pin sites as prescribed
6. adhesive strips or ace wraps
7. splints
8. casts
Types of Traction
1. skin traction: force is applied to the skin
a. skin traction for a fracture reduction should not be removed unless a healthcare
provider prescribes its removal.
b. Buck traction- lower extremities, keeps legs extended no hip flexion
c. Dunlop- two lines of pull on the lower extremity 1 perpendicular & 1 longitudinal
d. Bryant- both lower extremities flex and 90° at the hip (is really use because extreme elevation
of the lower extremities causes decrease peripheral circulation)
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2. Skeletal traction: pain or wire applies pull directly to the distal bone fragment
a. 90° traction- 90° flexion of hip and knee, lower extremity is in a boot cast; & can also be used
on the upper extremities
b. Questions about a halo traction? Remember safety first, have a screwdriver nearby.
Nursing Interventions for a child in traction
1. maintain child and proper body alignment: restrain if necessary
2. monitor for problems of immobility
3. prepare child for Application
4. provide routine cast care following application: petal cast edges
Teach home cast care to the child & family
• teach neurovascular assessments including the 5 Ps
• teach child not to get the cast wet
• teach the child not to place anything under the cast such as small objects, toys, food, or something
to help scratch such as a wire hanger
Other Hints for Traction and/or fractures
•Always deal with actual problems or harm before potential problems
•Always select a “patient focused” answer.
•An answer option that states "reassess in 15 minutes" is probably wrong (unless you already
completed A nursing intervention such as gave OJ to a hypoglycemic client, then you need to recheck
sugar.)
Developmental Dysplasia of the Hip
• abnormal development of the femoral head in the acetabulum
• conservative treatment consists of splinting, surgical intervention is necessary of splinting is
not successful.
Nursing Assessment for Signs & Symptoms
Infant:
• Positive Ortolanic Sign (clicking with abduction)
• unequal folds of the skin on the buttocks and thigh
• limited abduction of affected hip
• unequal leg lengths
Older child
• limp unaffected side
• Trendelenburg sign
Nursing interventions
• apply abduction device or splint (Pavlik harness: Frejka or Von Rosen splint)
• therapy involves positioning legs in the flexed abducted position
• teach application and removal of the device (worn 24 hours a day)
• teach skin care and bathing (physician may allow parents to remove the device for bathing)
Scoliosis
• lateral curvature of the spine, if severe it can cause respiratory compromise.
• Surgical correction by spinal fusion may be required if conservative treatment is an effective.
Nursing assessment for signs and symptoms
• occurs most commonly in adolescent females 10 to 15 years old
• elevated shoulder or hip
• head in hips not aligned
• while child is bending forward, a rib hump is apparent (ask the child to bend forward from the hips
with the arms hanging free, and examine the child for curvature of the spine, rib hump, and hip
asymmetry)
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Nursing Interventions
• prepare the child and family for conservative treatment such as the use of a brace
o teach the application of the brace (Boston, Wilmington, or Milwaukee are most common)
o instruct to wear it 23 hours a day
o instruct to a T-shirt under the brace to decrease skin irritation
o Lotions and powders are not applied to the skin under the brace
o instruct to check skin for areas of irritation or skin breakdown
• a brace does not correct the spines curve in a child with scoliosis: it only stops or slows the progression
Juvenile Arthritis (JA) or juvenile idiopathic arthritis (JIA)
• chronic inflammatory disorder of the joint synovium
Nursing Assessment for Signs and Symptoms
1. joint swelling and stiffness (usually of large joints)
2. painful joints
3. generalized symptoms: fever, malaise, and rash
4. periods of exacerbations and remissions
5. varying in severity from mild and self-limited or severe and disabling
6. lab data: latex fixation test (usually negative) and elevated ESR
Nursing interventions
• plan homecare prescribed exercise splinting and activity
• assist in identifying adaptations a routine (Velcro fasteners,& frequent rest periods throughout the day)
• encourage periodic eye exams for early detection of iridocyclitis so as to prevent vision loss
• encourage the family to allow child’s independence
Medication intervention
1. nonsteroidal anti-inflammatory drugs (NSAIDS)
o aspirin
o Tolmetin Sodium
o Ibuprofen
o Naproxen
2. Antirheumatic drugs
3. Corticosteroids (prednisone)- are used in the short term in low doses during exacerbations only. Longterm use is avoided because of side effects and their adverse effects on growth.
4. Cytotoxic drugs (Cyclophosphamide, methotrexate)
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Maternity Review
Ovulation- usually occurs 14 days before the onset of menstrual flow
Last Menstrual Period (LMP)- The date of the first day of the last menstrual bleeding, used for
EDB-estimated date of birth & EDD estimate delivery/due date
NAGEL’S RULE- LMP Subtract 3 Months & ADD 7 days and Add 1 Year
Take 400mcg FOLIC ACID within or before the first trimester to prevent nurotube defects
• They are decreased by 70% if taken regularly
• Sources of FOLIC ACID- Leafy greens, whole grains, OJ
Amniotic fluid = 800-1200 mL (< 300 mL = Oligohydramnios = fetal kidney problems)
Oligohydramnios- Having less than 300ml of amniotic fluid, is never good & can be associated
With fetal renal abnormalities
Polyhydramnios Having more than 2L of amniotic fluid, may not ALWAYS be a bad thing, it
Can be managed on an outpatient basis, but also can be associated with GI malformations
UMBILICAL CORD- Has 3 Vessels (Vein carries oxygenated blood to fetus (opposite of normal)
• 2 ARTERIES- carry unoxygenated blood back to the placenta
• 1 VEIN- Carries oxygenated blood to the fetus
o Wharton’s Jelly- Connective tissue that prevents compression of the blood vessels &
ensures continued nourishment of the fetus
PLACENTA- Specialized organ that forms maternal-fetal gas & nutrient exchange, begins to
Form at implantation
FUNCTIONS:
1. Endocrine Gland- Produces hormones necessary to maintain pregnancy
a. Human Chorionic Gonadotopin (hCG)- is a protein hormone that can be detected
in the maternal serum by 8-10 days after conception, just shortly after implantation.
Basis for a pregnancy test
i. HCG- Preserves the function of the ovarian courpus luteum, ensuring the
continued supply of estrogen & progesterone to maintain pregnancy
ii. The amount of hCG- Reaches a PEAK level at 50-70 days then begins to
DECREASE
2. Metabolic Function- of blood & gas exchange
3. Nutrient/excretion
4. Storage
Fetal Maturation/Circulation
• The cardiovascular system is first to begin to function
• HEART BEATS by the end of the 3rd Week
• NASIDS- should be AVOIDED because they can cause a premature closure of the Ductus Arteriosus,
which may lead to pulmonary vasculature abnormalities & pulmonary HTN
Pregnancy Trimesters
• 1st Trimester Conception-13 Weeks
• 2nd Trimester 14 weeks through 26 weeks
• 3rd Trimester 27-40 weeks
Fetal & Maternal Changes
8 weeks
A. Fetal Development
1. Development is rapid
2. Heart begins to pump blood
B. Maternal Changes
1. Nausea persists to 12 weeks
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2. Hegar sign (softening of the isthmus of cervix AKA lower uterine segment)
3. Goodell sign (Softening of the cervical tip)
4. Chadwick sign (bluing of vagina, & a violet-bluish mucosa & cervix appears as early as 4 weeks)
5. Leukorrhea- White or grey muciod discharge with a musty odor
12 Week
A. Fetal Development
1. Heart is discernible by ultrasound
2. Sex is determinable
3. Kidneys produce urine
B. Maternal Changes
1. Braxton Hicks Contractions
2. Chance for UTI increases
3. WEIGHT GAIN is 2-4 Pounds during the First Trimester, then 1 pound a week thereafter
4. Placenta is fully functioning & produces hormones
a. Teach UTI prevention- Pt increase fluid intake to 3/L day &Void Q2h while awake & after sex
b. Increase caloric intake by 300 calories/day, weight gain of 25-35 lbs total is normal
16 Weeks
A. Fetal Development
1. Meconium in bowel, & anus opens
2. Respiratory Bronchioles appear
B. Maternal Changes
1. Quickening (the mothers 1st perception of fetal movement, occurs between weeks 16-20)
2. Colostrum can be expressed as early as 16 weeks
3. Cholesterol Increases from 16-32 weeks and remains high til birth
4. INSULIN RESISTANCE begins as early as 14-16 weeks
5. Weight gain of about 1 pound/week in the second & third trimester
20 Weeks
A. Fetal Development
1. Vernix & Lanugo (fine hair ) covers & protects the body
2. Fetus sleeps, sucks, & kicks
B. Maternal Changes
1. Fundus reaches umbilicus
2. Areolae darken
3. Postural HYPOTENSION may occur
4. Nasal stuffiness, leg cramps, varicose veins, constipation develops
24 Weeks
A. Fetal Development
1. sweat glands forming
2. blood formation increases in bone marrow & decreases in the liver
3. Can begin to HEAR
B. Maternal Changes
1. Uterus reaches umbilicus
2. DIASTOLIC BP gradually increases at 24-32 weeks, AFTER having Decreased Diastolic BP in the
first trimester. Systolic BP- remains the same during the entire pregnancy
28 Weeks
A. Fetal Development
1. Fetus can breathe, swallow, & regulate temp
2. Surfactant forms in the lungs
B. Maternal Changes
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1. Fundus is halfway between umbilicus & xiphoid process
2. Thoracic breathing replaces Abdominal breathing
3. Heart burn & hemorrhoids may develop
32 Weeks
A. Fetal Development
1. Brown fat deposits develop under the skin
2. Fetus begins storing iron, calcium, & phosphorus
B. Maternal Changes
1. Fundus reaches xiphoid process
2. urinary frequency returns Along with swollen ankles, sleeping problems &/or Dyspnea may occur
36-40 Weeks
A. Fetal Development
1. Fetus occupies the entire uterus so activity is restricted
2. Maternal Antibodies are transferred to the fetus & provide infant immunity for approx 6 months
B. Maternal Changes
1. Lightening occurs- fundal height drops as the fetus begins to descend & engage in the pelvis
2. Backaches increase & Braxton Hicks Contractions intensify
Physiologic Changes During Pregnancy
1. Reproductive System Changes
1. Amenorrhea
2. Brest Changes- They enlarge & become nodular as the glands increase in size & number
2. Cardiovascular Changes **
1. Between 14-20 weeks gestation the heart rate increases about 10-15 beats/min remains until term
2. There is a more audible splitting of S1 & S2 & S3 may be readily heard after 20 weeks
3. BLOOD PRESSURE:
a. Diastolic BP begins to decrease in the first trimester, & continues to drop until 24-32
weeks, then gradually increases by term
b. Systolic BP usually remains the same but may decrease slightly as pregnancy advances
c. MAP readings are slightly higher in pregnant women
d. Maternal position affects BP readings, Brachial BP is higher when a woman is sitting
than when she is lying in the lateral recumbent position
e. Position of the arm also makes a difference: if the arm is ABOVE the heart, the reading
will be LOWER than the actual reading, if below the heart, the reading will be higher
f. Supine Hypotensive Syndrome- Some degree of compression on the Vena Cava occurs
in all women who lie flat on their backs during the second half of pregnancy. As a result
some women experience a decrease in systolic BP decrease more than 30mmHg, after 4-5
minutes of reflex bradycardia, cardiac output is reduced by half, & the woman feels faint.
i. Teach the woman- that a left side-lying position relieves this Hypotension &
increases perfusion to the uterus, placenta, & fetus
4. Compression of the iliac veins & inferior vena cava by the uterus causes increased venous
pressure & reduced blood flow in the legs (except when the woman is in the lateral position)
This contributes to dependent edema, varicose veins, & hemorrhoids
5. Blood Volume Increases by approximately 1500 ml, or 40-45% above non-pregnancy levels
a. The increase consists of 1000ml of plasma plus 450ml red blood cells (RBC)
i. The state of hemodilution occurs & is termed Physiologic Anemia. This happens
because the plasma increase exceeds the increase in RBC production, a decrease
in the normal hemoglobin (HGB) (12-16 g/dl in non-pregnant) &
hematocrit (HCT) (37-47% in non-pregnant) values occurs.
1. A Hemoglobin Value Below 11 g/dl & Hematocrit below 33% are
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considered Abnormal & is often due to iron deficiency anemia
a. Foods High in Iron: fish, red meat, cereal, yellow veggies,
green leafy veggies, citrus fruits, egg yolks, & dried fruits
b. Blood volume starts to increase by the 10-12th week of pregnancy, & decreases by term
6. Total WBC Increases during the second trimester & peeks during the 3rd
7. Cardiac Output (CO) Increases from 30%-50% over the non-pregnant rate by the 32nd week
a. The elevated CO is caused by an increase in stroke volume & HR & occurs in response to
increased tissue demands for oxygen
b. CO is Higher when the woman is in the lateral recumbent position than supine
8. Coagulation Times Are Decreased, resulting in increased clot formation & thrombus
3. Respiratory Changes
a. The upper respiratory tract becomes more vascular in response to elevated levels of estrogen
a. As the capillaries become engorged edema occurs in the nose, pharynx, larynx, trachea, &
bronchi. This congestion gives rise to nasal & sinus stuffiness, epistaxis (nosebleed), or URI.
b. Increased vascularity of the URT also causes tympanic membranes to swell, resulting in impaired
hearing, earaches, or a sense of fullness in the ears.
c. Basal Metabolic Rate (BMR) Which is the rate at which the body uses energy while at rest to keep
vital functions going, such as breathing and keeping warm, is INCREASED during pregnancy.
d. Acid-Base Balance- By about the 10th week of pregnancy there is a Decrease of about 5 mmHg in
the partial pressure of Carbon dioxide (Pco2)
e. Progesterone- may be responsible for increasing the sensitivity of the respiratory center receptors
so, tidal volume is increased, Pco2 is Decreased, & PH is slightly Increased
a. These alterations indicate pregnancy is a state of compensatory Respiratory Alkalosis
4. Renal Changes
a. Urinary Frequency- caused by an increased progesterone, increased glomerular filtration, & crowded
bladder
b. Increased cardiac output increases renal blood flow in the 1st trimester
c. Bladder tone reduced by effects of progesterone on smooth muscle
5. Skin Changes
a. Chloasma (Facial Melasma)- a patchy brown discoloration, that usually appears on the face
b. Linea Nigra- Is a pigmented line extending from the symphysis pubis (pubic bone) to the top of the
fundus (navel)
c. Striae Gravidarum- stretch marks
d. Angiomas (Vascular Spiders) that indicate increased circulation
e. Palmar erythema- Pinkish-red diffuse mottling or blotches over the palmer surface of the hands
Antepartum Care
G/P
•
•
Gravida- The TOTAL number of times a woman has been pregnant
Parity- Number of pregnancies (not kids) that have reached viability (pass 20 weeks)
o G2P1- Pregnant twice but only gave birth once
GTPAL
• Gravida- Total number of times a woman has been pregnant
• Term- Total number of pregnancies that have passed 37 weeks
• Preterm- Total number of pregnancies that passed viability (20 weeks) but ends before completion of
37 weeks
• Abortion- How many voluntary or involuntary number of pregnancies that did not reach 20 weeks
• Living- How many living children the woman currently has
Normal Vital Signs for the Pregnant Woman
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• BP- systolic should rise no more than 30 mmHg, and 15 mm Hg Diastolic
o Systolic Average 90-140 mm Hg
o Diastolic Average 60-90 mm Hg
• HR- 60-90 BPM
• RR- 16-24 Breaths/Min
• Temp- 97-100 degrees F (F-32 X 5/9= C) 97 F = 36.1 C
o Convert Celsius to Fahrenheit
(C x 9/5 + 32 = F) 37.8 C = 100 F
Teach Position Changes
The Knee-Chest Position- provides optimum fetal & placental perfusion, but the IDEAL position for
the mother, which supports fetal, maternal, & placental perfusion, is the SIDE-LYING
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Teach Proper Nutrition
Symptoms of
Malnutrition:
1. Glossitis (inflammation of the tongue)
2. Cracked Lips
3. Dry, Brittle Hair
Obesity- Woman over 200 lbs are at risk for diabetes, HTN, infections, & Macrosomia
Macrosomia- Large baby over 4500 kg or 9.5 lbs
Underweight- Woman under 100 lbs are at risk for low birth weight babies, IUGR, & preterm labor
Nutritional Plans
• Increase calories by 300 above basal & activity needs
• Increase Protein by 30g/day
o Milk, meat, eggs, cheese
• Increase intake of Iron & Folic Acid
• Increase Intake of Vitamin A, C & Calcium
o Calcium is needed for fetal bone & tooth development, recommended intake of 1500mg/day
• Drink 8-10 glasses of fluid a day or 3L, 4-6 glasses should be water: WATER
o Maintains body temp
o Hydrates uterus
• Limit caffeine intake to less than 200mg (12 oz daily)
• Aspartame (Equal) or Sucralose (Splenda) have NOT been found to have adverse effects
• Sodium HAS NO RESTRICTIONS- But makes you retain water
Phenylketonuria (PKU)- Is a RECESSIVE Hereditary disease that results in a defect in the metabolism of the
Amino Acid Phenylalanine caused by the lack of an enzyme called phenylalanine hydroxylase, that is
Necessary for the conversion of the amino acid Phenylalanine into Tyrosine. If not treated it can cause
brain damage & mental retardation
• Women with PKU CAN NOT eat ANYTHING with Phenylalanine, which is found in
the following:
o Diet Soda, Bread, Nuts, Milk, Sugar, Some fruits & Veggies
A Routine Physical Assessment and initial Labs
1. CBC- Can determine Iron deficiency which could indicate anemia
2. Blood Type & Screen- Done to determine if the MOTHER is (Rh-) if she is, she will need an
injection of ROGRAM at 28 weeks. This is because the mother can develop antibodies to a Rh+ fetus
and her body will attack the fetus as if it was a foreign substance & kill it
3. Rubella Status- Will effect the growing fetus, the mother will need a vaccine postpartum if not up
to date
4. RPR- Can diagnose syphilis
Assess Fetal Well-Being and Heart Rate
• Fetal well-being is determined by assessing fundal height, fetal heart tones & rate, fetal movements,
& uterine activity (contractions). Changes in Fetal Heart Rate (FHR) are the FIRST & MOST
IMPORTANT indicators of compromised blood flow to the fetus, & these changes require action.
• FHR Can be detected by using a Doppler between 10-12 weeks gestation
• FHR can be detected by using a fetoscope between 10-20 weeks gestation
***NORMAL FETAL HEART RATE IS- 110 to 160 bpm*******
***FHR is best heard (Point of Maximum Intensity OMI) through the fetal BACK ***
Possible Indicators of Preeclampsia & Eclampsia Are:
1. Visual Disturbances
7. Changes in fetal movement or increase in FHR
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2.
3.
4.
5.
Swelling of the face, fingers, or Sacrum
Severe Continuous Headaches
Persistent Vomiting
Epigastric Pain
8. Infection: Possible Indicators Include
1. Chills
2. Temp over 100.4 Degrees Fahrenheit
3. Dysuria (painful or difficult urination)
6. Fluid discharge or bleeding from the vagina
4. Abdominal Pain
Fetal & Maternal Assessment
A. Maternal Risk Factors
1. Age: Under 17 or Over 34
2. High Parity >5
3. Pregnancy (3 months since last delivery)
4. Hypertension or presence of or history of Preeclampsia
5. Anemia, History of Hemorrhage, or current Hemorrhage
6. Multiple Gestations
7. Rh Incompatibility
8. History of Dystocia (e.g. shoulder dystocia) or previous operative delivery
9. A height of 5 feet or less
10. Malnutrition or Obesity
11. Current medical disease/condition
12. History of family violence or lack of support
SCREENING TESTS (NOT DIAGNOSTIC TESTS)
1. Ultrasonography
a. Used in the First Trimester to Determine
1. Gestational Age: Best indicator in the 1st trimester, very accurate second to Negal’s rule
2. Number of fetuses
3. Presence of fetal cardiac movement & rhythm
4. Uterine abnormalities
b. Used in the Second & Third Trimester to Determine
1. Fetal viability & gestational age (not as accurate)
2. Size-date discrepancies
3. Amniotic Fluid volume
4. Placental location & maturity
5. Uterine abnormalities & anomalies
6. Results of amniocentesis
c. Findings
1. Fetal heart activity is apparent as early as 6-7 weeks gestation
2. Serial ultrasound measurements are needed to determine & true Intrauterine
growth restriction (IUGR) *A Single ultrasound exam is NOT useful in
determining IUGR
3. Serial evaluation of biparietal diameter & limb length can differentiate between
wrong dates
d. Nursing Care
1. Instruct the pt to drink 3-4 glasses of water and NOT URINATE, the bladder must
be FULL during the exam for the uterus to be supported for imaging. (A full bladder
is NOT NEEDED if the ultrasound is done transvaginally instead of abdominally)
2. Chorionic Villi Sampling (CVS) -Removal of a small piece of villi during the period of 8-12 weeks
under ultrasound guidance
a. Findings
1. The test determines genetic diagnosis early in the first trimester & The results are obtained in 1 week
49 | P a g e
b. Nursing Care
1. Place the pt in the lithotomy position using stirrups & Warn of sharp pain upon catheter insertion
c. Complications of Chorionic Villi Sampling
1. Spontaneous Abortion (5%)
2. Controversy regarding fetal abnormalities (limb)
3. Amniocentesis- Is a positive Diagnostic TEST it’s the Removal of Amniotic fluid sample from the uterus
A. Its used to determine:
1. Fetal Genetic diagnosis (usually in the first trimester)
2. Fetal Lung Maturity (in the LAST trimester)
3. Fetal well-being
B. This is performed ONLY when uterus rises above the symphysis (between 12-13 weeks) & amniotic
fluid Has formed.
C. Usually takes 10 days- 2 weeks to develop cultured cell karyotype. Therefore, woman could be well
into The second trimester before diagnosis is make, making the choice for an abortion more
dangerous
D. Findings:
1. Genetic Disorders
a. Karyotype: Determines Down Syndrome (trisomy 21) & sex chromatin (sex-linked disorders)
b. Biochemical analysis: determines more than 60 types of metabolic disorders (Tay-sachs)
c. Alpha Fetoprotein (AFP) elevations may be associated with neutral tube defects, low
levels indicate down syndrome (trisomy 21)
2. Fetal Lung Maturity
a. Lecithin–Sphingomyelin Ratio (L/S ratio): 2:1 ratio indicates fetal lung maturity unless mother
is diabetic or has Rh disease or fetus is septic
b. L/S ratio & presence of Phosphatidylglycerol aka PG which is found in surfactant: most
accurate determination of fetal lung maturity. PG is present after 35 weeks.
c. Lung maturity is best predictor of extrauterine survival
d. Creatinine: Renal maturity indicator > 1.8
e. ***THE MOST IMPORTANT DETERMINAT OF FETAL MATURITY- for
extrauterine survival is the lung maturity: Lung Surfactant (L/S) ratio. *******
i. A Ratio of 2:1 or higher indicant the fetus can survive outside the uterus
3. Fetal Well-Being
a. Bilirubin data optical density (OD) assessment should be performed in mother previously
sensitized to the fetal Rh+ red blood cells & having antibodies to the Rh+ cells. The delta
test measures the change in OD of the AF caused by staining with bilirubin, done at 24
weeks.
4. Nursing Care
a. Obtain baseline VS and FHR
b. Place pt in supine position with hands across chest
c. Scrub with betadine if prescribed
d. Draw maternal blood sample for comparison with post procedure blood sample to
determine maternal bleeding
e. If bilirubin test is performed, darken room & immediately cover the tubes with aluminum foil
or use opaque tubes
f. ** When performed EARLY in pregnancy, the bladder must be FULL to help support the uterus
& help push it up in the abdomen for easy access. When performed LATE in pregnancy the
bladder must be EMPTY so it will not be punctured
g. Monitor FHR 1 hr after procedure, & assess for uterine contractions & irritability
50 | P a g e
5.
Complications
a. Spontaneous Abortion, Fetal Injury OR Infection
Electronic Fetal Monitoring with a Tocodynamometer (on the abdomen) or an Intrauterine Pressure
Catheter (inserted in the vagina to measure EXACT frequency, strength, & duration of contractions)
A. Contractions indicate what the uterus is doing
1. Beginning, peak (acme) & end of each contraction
2. Duration: length of each contraction from beginning to end
3. Frequency: beginning of one contraction to the next (3-5 contractions must be measured)
4. Intensity: Measured not by external monitoring but ONLY by internal intrauterine monitoring, with
an IUPC after amniotic membranes have ruptured, NORMAL RANGES 30 (mild)- 70 (strong) mm
Hg
B. Baseline FHR
1. The range of FHR (Average FHR 110-160Bmp) is measured between contractions, monitored over a
10 minute period
Nursing Actions Bases on Fetal Heart Rate
A. Variability
1. A characteristic of the baseline FHR & described as normal irregularity of the cardiac rhythm
2. There are 4 Categories of Variability
1. Absent- Amplitude rage undetectable
2. Minimal- Amplitude range detectable up to & 5 beats/min
3. Moderate- Amplitude range 6-25 beats/min
4. Marked- Amplitude range > 25 beats/min
B. Positive Periodic Changes
1. FHR changes in relation to uterine contractions
a. Accelerations Of the FHR is defined as a visually apparent abrupt increase in FHR above the
baseline rate. The peak is at least 15 beats/min above baseline, & the accelerations last 15 seconds
or more, with the return to baseline within 2 minutes. They are reassuring and are considered a
good indication of fetal well-being. They:
1. Caused by sympathetic fetal response
2. Occur in response to fetal movement
3. Indicative of reactive, healthy fetus
b. Early Decelerations- Gradual FHR increase & return to baseline, that match or are shortly after
the onset of Uterine Contractions (UC). They are thought to be associated with fetal head
compression & are considered normal. Document positive fetal well-being, no nursing
interventions are needed, just monitor the process of labor.
C. Non-Reassuring Warning Signs
1. FHR is absent or minimal
a. Usual Causes
1. Hypoxia (asphyxia)
2. Acidosis
3. Maternal Drug ingestion (Narcotics, CNS depressants such as Magnesium Sulfate)
4. Fetal Sleep
2. Late Decelerations- Deceleration begins after the contraction has started, & the lowest point of the
deceleration occurs after the peak of the contraction, and does not return to baseline until the UC is
over Late Decelerations- ARE BAD, potentially disastrous nonreasuring sign
b. Usual Causes
51 | P a g e
1. Indication of Late Decelerations (cause) Uteroplacental Insufficiency (UPI) caused:
i. Uterine hyperactivity AKA Tachysystole (more than
contractions) **?
ii. Maternal supine hypotension as result of epidural or spinal anesthesia,
iii. Other conditions: placenta previa, abruptio placente, hypertensive disorders e.g.
preeclampsia, postmaturity, intrauterine growth restriction, diabetes mellitus,
and intraamniotic infection.
c. Nursing Interventions for Late Declarations
1. Immediately turn the patient onto the LEFT SIDE
2. Discontinue Oxytocin (Pitocin) if infusing
3. Administer Oxygen at 10L by tight face mask
4. Assist with fetal blood sampling
5. Maintain IV, elevate legs to increase venous return
6. Correct underlying maternal Hypotension by increasing IV fluid (BOLUS) or with prescribed med
7. Notify Health Care Provider (HCP)
8. Document pattern & response to each nursing action
3. Variable Decelerations- Is a decrease in the FHR below baseline, they last 15 seconds & return to
baseline Within 2 minutes. They occur at any time and do not have an association with contractions.
Variable Decelerations Are usually caused by compression of the Umbilical Cord
4. Prolonged Decelerations- Is a decrease in the FHR of at least 15 beats/min below the baseline & lasting
MORE THAN 2 MINUTES, but LESS THAN 10 Minutes. They are caused by a disruption in the fetal
Oxygen demands.
Mnemonic for FETAL TRACING (VEAL CHOP)
Variables
Cord Compression (Intervention- Reposition)
Early
Head Compression (GOOD, indicates FETAL well-being)
Accelerations
Ok (Document well-being)
Late
Placenta (Uteroplacental Insufficiency (UPI)- Turn off Pitocin if on & notify HCP
CORD PROLAPSE- If cord prolapse is detected, the nurse should position the mother in the KNEE-CHEST
Position to relieve pressure on the cord, or the nurse should PUSH THE PRESENTING PART of the
cord with fingers until immediate cesarean delivery can be accomplished.
Additional Antepartum Tests
1. Nonstress Test- It is used to determine fetal well-being in high risk pregnancy & is especially useful
in postmaturity (notes response of the fetus to its own movements)
a. A healthy fetus will usually respond to its own movements by means of an FHR acceleration
of 15 beats, lasting for at least 15 seconds after the movement, twice in a 20 minute period.
b. The fetus that responds with 15/15 acceleration is considered “REACTIVE” & healthy.
c. Nursing Care
i. Apply fetal monitor, ultrasound, & tocodynamometer to abdomen
ii. Give the mother a handheld event marker, & instruct her to push the button
whenever fetal movement is felt
iii. Monitor pt for 20-30 min, observing for reactivity
iv. Suspect fetus is sleeping if there is no movement, stimulate the fetus acoustically
or physically
2. Contraction Stress Test (CST) or Oxytocin Challenge test (OCT) – During the test the fetus
is challenged with the stress of labor by induction of uterine contractions, & the fetal response to
the decrease in oxygen supply during the contractions is noted.
a. An UNHEALTHY fetus will develop nonreasurring FHR patterns in response to the UC,
LATE decelerations usually occur, which is indicative of UPI
b. Contractions can be induced by nipple stimulation or by infusing a dilute solution of Oxytocin
52 | P a g e
c. Nursing Care
i. Assess for contraindications, prematurity, placenta previa, hydramnios,
multiple gestation, & previous uterine classical scar, rupture of membranes
(ROM)
ii. To assess fetal well-being a recording of at least 3 contractions in 10 minutes MUST
be Obtained
iii. A NEGATIVE TEST suggests fetal well-being (e.g no occurrences of late decelerations)
POTENTIAL Complications
1. The danger of Nipple Stimulation- lies in controlling the “DOSE” of oxytocin
delivered by the posterior pituitary gland. The chance of hyperstimulation or TENTANY
(Contractions over 90 seconds or contractions with less than a 30 second rest in between) is
increased.
3. A Biophysical Profile (BPP)- Determines FETAL WELL-BEING***
a. Ultrasonography that is used to evaluate fetal health by assessing 5 variables:
i. Fetal breathing movements
ii. Gross body movements
iii. Fetal tone
iv. Reactivity of FHR
v. Ammonic Fluid Volume
a. Each variable receives 2 points for a NORMAL response and 0 points for an ABNORMAL
or absent response
b. An overall score of 8-10 indicates fetal well-being.
4. A Fetal pH Blood Sample- Can be drawn from the presenting part of the fetus, after ROM & when
the Cervix is dilated 2-3 cm.
a. The test is used to determine True Acidosis when nonreasurring FHR is noted.
b. Normal Fetal Scalp Ph in LABOR is 7.25-7.35, & values BELOW 7.2 indicate True Acidosis
STAGES OF LABOR
1. First Stage- The beginning of regular contractions or ROM to 10 cm of dilatation & 100% effacement
2. Second Stage- 10 cm dilation to delivery of the fetus
a. First sign of 2nd stage is the involuntary need to push
b. Lasting 1 hour for primigravida & 15 minutes for multipara
c. Begin to set up delivery table
3. Third Stage- Delivery of the fetus to the delivery of the placenta
a. Average length is 5-15 minutes
b. The longer the 3rd stage, the greater the chance for uterine atony or hemorrhage to occur
c. Give Oxytocin after the placenta is delivered because the drug will cause the uterus to contract. If
the drug is administered before the placenta is delivered, it may result in a retained placenta,
which predisposes the pt to hemorrhage & infection
4. Forth Stage- Arbitrarily lasts about 2 hours after delivery of the placenta (recovery period)
a. Is the first 1-4 hours after delivery of the placenta
Leopold Maneuvers- Are abdominal palpations by the nurse/HCP that are determine fetal characteristics
1. Fetal Presentation – The part of the fetus that presents to the inlet
a. Vertex (head, cephalic)
b. Shoulder (acromion)
c. Breech (Buttocks)
d. Other Variations- include brow (sinciput) & chin (mentum)
2. Fetal Lie- The relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother
3. Fetal Position 53 | P a g e
a. A Breached position will feel soft, immovable, & large
b. Vertex position will feel hard, will be moveable, and small
4. Fetal Attitude- Is the relationship of the fetal parts to one another
Laboring Terms
1. Cervical Dilation- widening of the cervix measured by finger with inside the vagina, from 0-10 cm.
2. Effacement- The shorting & thinning of the cervix during the 1st stage of labor, and is represent in
0-100%, 0 being not at all effaced and 100 being the maximum effaced and ready for labor
a. If the Fetus is LONG- It has not effaced at all
3. Station- Where the fetus is in relation to the ischial spines
b. – is ABOVE the Spins (-5 is highest up in the pelvis and works down as the fetus desends)
c. + is BELOW the Spins (+ begins at +1 after the fetus has hit 0 station (engaged) which is
considered the middle marking, +5 is the maximum station and indicates the head is presenting)
d. If the fetus is HIGH Then its not near the spines at all
4. Engagement – The decent of the head of the fetus into the mother’s pelvis (0 station is engaged)
EXAMPLES
1. (5/90/-1) 5cm dilated, 90% effaced, -1 station ( fetus is located ABOVE the spines)
2. (1/75/+3) 1cm dilated, 75% effaced, +3 station (fetus is located BELOW the spines)
NORMAL FINDINGS FOR FETUS & MOTHER DURING LABOR *******
1. Normal FHR in labor -110 to160 bpm
2. Normal maternal BP < 140/90
3. Normal maternal pulse < 100 bpm
4. Normal maternal temp < 100.4 F
ABNORMAL FINDINGS
1. Meconium-stained fluid is yellow-green or gold-yellow & may indicate fetal stress
2. Hyperventilation results in respiratory alkalosis that is caused by blowing off to much CO2
a. Symptoms include:
i. Dizziness , Tingling of the fingers & Stiff mouth
b. Treatment: Have mother breathe into her cupped hands or paper bag in order to rebreathe CO2
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COMMON MEDS USED IN MATERNITY ****
Categories
1. UTERINE STIMULANTS
Drugs
Indications
Adverse Reactions
Uterine Atony
Oxytocin, synthetic
• Severe afterpains in multipara
(Pitocin, Syntocinon)
• Hypertension
Nursing Implications
• Add oxytocin to IV fluids
1. Piggyback at the lowest port on the primary IV line
2. using the lowest port ensures that very little oxytoin will be in
the primary if an emergency requires DC of the drug
3. Begin infusion slowly & increase at 20-30 minute increments
until contractions occur every 2-3 minutes, are 40-60 seconds
in duration, & are firm
•Give IMMEDIATELY after delivery of placenta to avoid a
“trapped” placenta”
•Continue to monitor vaginal bleeding & uterine tone
•May stimulate let-down milk reflex & flow of milk when engorged
Uterine Atony
Methylergonovine maleate
• Hypertension
•Use W/caution in pt with elevated BP or Preeclampsia
(Methergine)
•Take BP prior to administration & if 140/90 or above withhold the
med and notify the physician
Uterine Atony
Prostaglandin F2
• Headache
• Contraindicated for clients with Asthma
(Hemabate)
• Nausea & Vomiting
• May be given intramyometerially (Within the muscular coat of the
uterus) by the provider
• Fever
• Check Temperature every 1-2 hours
• Bronchospasm, wheezing
• Auscultate breaths sounds frequently
• Methergine is not given to clients with hypertension because of its vasoconstrictive action.
• Pitocin is given with caution with those with hypertension
• Never give Methergine or Hemabate to a client while she is in labor or before delivery of the placenta
Pitocin Calculations 1U=1,000 miliunits (MU)
Available: 20U Pitocin in 1000ML D5LR
1. Convert given units to miliunits
20U x 1000mu= 20,000 mu
Prescribed: 18 miliunits(mu) / minute (min)
2. Calculate MU in 1 ml
1,000ml
X
1ml
20,000mu
X
= 20,000mu/1ml
Solve: how many mL/hr?
3. Determine how many mL needed to obtain 18MU
20mu
X
18mu
= 0.9mL
1ml
X
4. Get the hourly rate
1min
X 60min = 54mL/hr
0.9mL
X
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2. ANALGESICS
Drugs
• Fentanyl (Sublimaze)
• Morphine Sulfate
(MS
Cotin)
Indications
Narcotics: Used to produce
analegesia, euphoria, &
sedation in labor
• Butorphanol Tartrate
(Stadol)
• Nalbuphine (Nubain)
• Opoid agonist/antagonist
• Provision of analgesic in
labor
• Narcotic analgesia
Nalonone HCL (NARCAN)
Narcotic ANTAGONIST
used to counteract narcotic
effects on mother/fetus
3. POSTPARTUM DRUGS
Drugs
• Bisacodyl (Dulcolax)
•Docustae Sodium (Colase)
Rho (D) Immune Globulin
RhoGAM
Adverse Reactions
• Fetal narcosis, distress
• Hypotension
• Itching
• Urinary Retention
• Respiratory Depression
Women with preexisting
narcotic dependency will
experience withdrawal
symptoms immediately
(Abstinence Syndrome)
Decreased respirations rarely
occur
Indications
Constipation
Adverse Reactions
•Abdominal cramping
Prevention of Rh
isoimmunization
with next pregnancy
None known
Nursing Implications
•Record use accurately
•DO NOT administer if RR < 12 breaths/min
•Have narcotic antagonist available (Narcan)
•Monitor VS (BP, HR, RR) closely
•Use W/caution in pt with elevated BP or Preeclampsia
•Take BP prior to administration & if 140/90 or above
withhold the med and notify the physician
• They have less respiratory depression risk than morphine
• Monitor RR closely because drug action is shorter than
narcotic (may need to readminister)
• Pain returns after administration
• Can be given to newborn post-delivery to counteract
narcotic depression
Nursing Implications
• May have some burning in the rectum with suppository
•Encourage fluid intake
• Given Rh-negitive mothers after a miscarriage or abortion or after any
procedure the increases maternal-fetal blood exchange (amniocentesis,
PUBS, abdominal trama)
• Given routinely to Rh- mothers at 28 weeks
• Given to Rh- mothers after delivery when the fetus is identified as Rh+
• Must be given within 72 hours of delivery
• Never given to the father or infant
• Always given IM
• It’s a blood product so:
It must be checked by 2 nurses
Syringe must be returned to the lab w/label
Not given to a mother with + Coombs test
56 | P a g e
Rubella Vaccine
Rubella titer of
<1:10 or enzyme
immunoassay (EIA)
of <0.10
• Transient begin
arthalgia or rash
•Hypersensivity if
allergic to DUCK eggs
• Slight increase in temp
• Monitor RR closely because drug action is shorter than narcotic (may need to
readminister)
• Pain returns after administration
• Can be given to newborn post-delivery to counteract narcotic depression
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4. Newborn Medications PROPHYLACTIC OINTMENTS (can be given up to 1hr post-delivery)
Drugs
Indications
Adverse Reactions
Nursing Implications
Prevention of ophthalmia
• Erythromycin
• Most commonly used agents
• Place a thin line along the lower lid in conjunctival sac
neonatorum & Chlamydia
• Tetracycline
• No known adverse reactions, • Use only 1 tube per newborn then discard access amount
trachomatis conjunctivitis
except puffy eyes resulting
• Manipulate upper lids to ensure complete eye coverage
from manipulation
• After 1 minute, may wipe any access from around the eyes
Silver Nitrate (not used often in
Prevention of ophthalmia
• Eye prophylaxis is mandatory in the US
• Chemical conjunctivitis
US because it DOES NOT
neonatorum resulting from
(red, puffy eyes)
• Does not kill other organisms such as Chlamydia species
protect against Chlamydia &
gonorrhea exposure
• Staining of skin if contact
• Instill medication in lower conjunctival sac, making sure
can cause chemical
through the birth canal in a
occurs
drops spread over the entire eye
conjunctivitis
vaginal delivery
• Do NOT irrigate eyes following instillation
Vitamin K (Phytonadione)
Inflammation at the injection
• Give IM in the 1st hr after birth
• Prevention of
(AquaMEPHYTON)
site
hemorrhagic disorder in
• Use the vastus lateralis muscle in the thigh
newborn
• Hold knee secure during procedure because neonate will try
• Infants are born with
& move during the injection
sterile gut, so no enteric
bacteria present for
synthesis of vitamin K
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Nursing Plans & interventions of the 4th stage of labor
1. Maintain pt on BR for at least 2h to prevent orthostatic Hypotension
2. Assess Vital Signs Q 15 for 1 hour & Q 30 until stable. Normal stable VS after delivery
• BP < 140/90
• Pulse < 100 bpm
• RR < 24
• Assess temp at the beginning of the 4th stage & prior to discharge to postpartum. If its > 100.4 F,
report to the physician & monitor pt hourly for signs and symptoms of infection
Assess fundal firmness & height, bladder, lochia amount, & perineum Q15 for 1 hr & Q 30 for 2 hr
3. The Fundus should be firm, midline, & at or below the umbilicus.
• Massage the fundus if its soft or boggy. Suspect the pt has a full bladder if the fundus is above the
umbilicus & to the right side of the abdomen.
4. A FULL BLADDER is one of the most common reasons for uterine atony or hemorrhage in the first 24
hours after delivery.
5. Lochia: Rubia (red), moderate amount & clots should be < 2 cm- 3cm.
• Suspect an undetected laceration if the fundus is FIRM & Bright RED blood continues to trickle
6. Perineum: Should always be clean, intact, & slight edematous.
7. Administer analegesics (usually codeine, acetaminophen, or ibuprofen)
• If narcotics are given rise side rails & place the call bell within reach. Instruct the pt not to get OOB
Labor with Abalegsia or Anesthesia
1. They both are usually withheld until the midactive phase of labor
a. If the pt is in the early latent phase they may retard the labor process
b. If they are given in transition or in the 2nd stage, it may depress the newborn (some narcotics)
2. Most drugs are used for pain & relaxation, they cause CNS depression & can slow labor & harm fetus
3. Regional Blocks (epidural, caudal, & subarachnoid) cause a temporary interruption of the nerve
impulses (especially pain) but also cause vasodilatation in area below the block, causing pooling of
blood & hypotension
a. Pudendal & Subarachnoid (saddle) Blocks- are used only in the 2nd stage of labor
b. Peridural & Epidural blocks may be used during all stages of labor
c. STOP continuous infusion at the end of stage 1 or during transition to increase the effectiveness of
pushing
Nursing Interventions of Regional Blocks
1. Prehydrate pt to counteract possible hypotension: 500-100ml of ISOTONIC IV fluids are
infused over 20-30 minutes before initiation of the regional block
2. Place the pt in the modified Sims position or sitting on the side of the bed with heals flexed for
insertion of the block
3. Ask the patient to describe symptoms after the block is placed
a. A Metallic taste or ringing in the ears denote possible injection of medication into the
bloodstream
b. Nausea & Vomiting are the 1st signs of hypotension
i. If HYPOTENSION occurs complete the following
1. Immediately turn the pt to the left side
2. Increase IV fluids
3. Begin O2 at 10L/min by face mask
4. Notify HCP STAT and have EPHEDRINE available at the bedside
5. Assess FHR
c. Warmth & tingling in the ball of the foot or bog toe- Are the 1st signs of a blocks
effectiveness
4. Do not give PO medications. Labor retards GI activity & absorption
59 | P a g e
5. Administer meds preferably IV, because onset & peak occur more quickly & the duration of the drug is
shorter but can also be given IM. (important to know the following)
a. IV Administration
i. Onset: 5 Minutes
ii. Peak: 30 Minutes
iii. Duration: 1 Hour
b. IM Administration
i. Onset: within 30 Minutes
ii. Peak: 1-3 hours after injection
iii. Duration: 4-6 Hours
6. Always IV bolus into an IV line Slowly, at the beginning of a contraction when uterine blood vessels are
constricted, so less analgesic reaches the fetus
7. Administer drugs to reduce gastric secretions: e.g Famotidine (Pepcid) or Antacids to neutralize gastric
secretions.
a. The most common cause for maternal death is aspiration of gastric secretions into the lungs
Report the following findings to the heath care provider immediately
1. Abnormal VS
2. Uterus that does NOT become firm with massage
3. Second Perineal pad is SOAKED with blood in 15 minutes or less
4. Signs and symptoms of HYPOVOLEMIC SHOCK
a. Pale, clammy skin
b. Tachycardia
c. Light-headedness
d. Hypotensive
Newborn Care & Nursing Assessment
1. Dry the infant under a warmer or by skin to skin
2. Suction mouth & nose with bulb syringe
a. Suction the mouth 1st and then suction the nose
b. Stimulating the nares can initiate inspiration, which could cause aspiration of mucus in pharynx
3. Keep the head slightly lower than the body
4. Assess Airway Status
Assess for 5 symptoms of Respiratory Distress
1. Retractions
2. Tachypnea (RR > 60)
3. Dusky Color, Circumoral Cyanosis
4. Expiratory Grunting
5. Flaring Nares
• Never HYPEREXTEND the newborns neck (may close glottis) instead place the infant in the
“SNIFF” position (neck slightly extended as if sniffing the air) to open the airway
5. Obtain an Apgar Score at 1 & 5 Minutes after birth (Max score of 10, Min score of 0)
• 7 to 10: Good
• 4 to 6: Needs moderate resuscitative efforts
• 0 to 3: Severe need for resuscitation
• Apgar score of 6 or lower at 5 minutes requires an additional apgar assessment at 10 minutes
POSTPARTUM CHANGES
• The first step before ANY teaching is given, the nurse must assess the clients level of knowledge & to
identify their readiness to learn.
Nursing Plans and Interventions
1. On the 1st postpartum day the top of the fundus is located approx 1 cm BELOW the umbilicus
60 | P a g e
2.
3.
4.
5.
The fundus should be MIDLINE & FIRM
Lochia Rubia lasts 2-3 days postpartum
Lochia Serosa (pale pinkish to brown) lasts 1 week postpartum
Lochia Alba (thicker white-yellowish) discharge with leukocytes lasts up to 4 weeks postpartum
**Retained Placental Fragments- is the most common cause of uterine atony after the 1st postpartum day
BreastFeeding
• Milk production occurs by the release of prolactin from the pituitary
• Avoid diets, and add 500 calories to prepregnacy intake
• Drink 2 quarts (8 glasses) of noncaffeniated beverages a day
• Avoid stress, which is the most common reason for a decrease in milk supply
• Newborns should remain on the breasts for 10 min, then switch to the second breast (its not longer
recommended to limit breastfeeding time to 2-3 min the 1st day & 5 min the 2nd etc)
• Use warm water, not drying soap on nipples
• Let nipples air-dry for 15 min 2-3 times daily
• Breast creams should NOT be routinely used; colostrum bay be expressed & rubbed on nipples
• Nurse more frequently & manually express milk to soften areola b4 feeding to help engorgement
• Take warm or hot showers (water over breast promotes milk flow)
• Watch for symptoms of mastitis (commonly occurs when the breasts are not emptied) \
Postpartum Meds
• Remember RhoGam is given to an Rh- mother who delivers a Rh+ fetus & has a negative direct Coombs
test. If the mother has a positive coombs test there is no need to give RhoGam because the mother is
already sensitized.
“Postpartum Blues” are usually normal and especially 5-7 days after delivery (S&S will include, unexplained
Tearfulness, feeling down, & having decreased appetite)
Have the Patient Report to the HCP promptly if experiencing:
1. Heavy vaginal bleeding with clots
2. Temp of 100.4 or higher lasting 24 hours or longer
3. A warm red lump in breast, Pain on urination and/or Tenderness in calf
The Newborn
1. Risks during newborn transition caused by drugs & anesthesia
a. Magnesium Sulfate During labor: Hypermagnesemia in the neonate causes
i. Depressed Respirations
ii. Hypocalcemia
iii. Hypotonia (decreased muscle tone)
b. Narcosis (late administration of narcotic analgesics) causes
i. Decreased Respirations & Hypotonia (decreased muscle tone)
Normal Newborn Vs are measured Q30 min for 2 hours then every hr for 4 hours or until stable
Vital Sign
Normal Value
Nursing Implications
Respirations
30-60 breaths/min
• Remember the ABCs (airway, breathing, circulation)
• Count 1 minute by observing abdomen or auscultating
breath sounds
• Note 5 symptoms of respiratory distress****
1. Tachypnea (RR > 60)
2. Cyanosis
3. Flaring Nares
4. Expiratory Grunt
5. Retractions
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Heart Rate
Temperature
Blood Pressure
110-160 bpm, may decrease
as low as 100 during sleep or
can increase to 180 during
crying
Range: 99.7-99.4 F
Or 36.5-37.5 C
Average 80/50 mm hg
Ausculate for 1 full minute at the PMI (point of maximal
impulse)
• 3rd to 4th intercostal space
Rectal can perforate rectum, so it should only be inserted ¼
to ½ inch for 5 min & hold legs firmly to prevent trauma
Not usually measured unless problems in circulation have
been assessed
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Normal Newborn Physical Measurements
Assessment
Normal
Weight
• Average: 7lbs 8oz
• Majority weigh between
2700 & 4000 g (6-9lbs)
Length
Head
Circumference
Chest
Circumference
Average range: 18-21 inches
or
46-52.5 cm
Average range: 33-35 cm, its
normally 2cm larger than the
chest circumference
Average range: 31-33cm
Nursing Implications
• Weigh @ birth & daily, with neonate completely naked.
• Normally lose 5%-15% (average 10%) of birth weight in
the first week of life; weight should be documented
carefully
Measure from crown to rump & rump to heal, or from
crown to heal at birth
Tape measure placed above eyebrows & stretched around
the fullest part of occiput, at posterior fontanel (FOC,
frontal-occipital circumference)
Tape measure is stretched around scapulae & over nipple
line
Caput Succedaneum Is edema under the scalp, The Caput Crosses the Suture lines & is usually present at Birth
Cephalohematoma (Is blood under the periosteum) Does Not cross the suture lines & manifests a few hours After birth
Hypothermia (heat loss)
• Leads to depletion of glucose & therefore to the use of brown fat for energy. This results in ketoacidosis
& possible shock
Hypoglycemia
1. Perform a heal stick on infants that are
a. Small for gestational age (SGA)
b. Large for gestational age (LGA)
c. Born to diabetic mothers
d. Jittery babies with a high pitched voice
Glucose Readings
1. Normal infant BS: 40-80 mg/dl
2. Report any blood sugar under 40 mg/dL in the full term infant
3. Report any blood sugar under 30 mm/dL in the preterm infant
4. Feed the baby early (breast milk or formula) if a low glucose level is detected
5. Prevent cold stress what can cause hypoglycemia
Hyperbilirubinemia (access of bilirubin in the blood)
• Physiologic Jaundice- occurs at 2-3 days of life
• Pathologic Jaundice- If the jaundice occurs before 24 hours or persists for 7 days
The nursing Plan
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Stool prognosis: meconium (black, tarry, sticky) within the 1st 24 hours
Infant voids within 4-6 hours after birth, & only uses 1 dipper a day
Then at day 6 the infant should be using 6-8 dippers a day
Do not feed a newborn if their RR is above 60 breaths/min.
a. Inform the physician & anticipate gavage feedings in order to prevent further energy utilization
& possible aspiration
5. Teach the parents not to submerge infant in water until cord falls off (7-10 days)
First Trimester Bleeding Causes
1. Miscarriage (Spontaneous Abortion that is planed or unplanned that dies before 20 weeks gestation
a. Nurses role: Take a blood sample and determine if the mothers B-HcG levels are rising or decreasing which can indicate the
pregnancy is unwell &miscarriage is the cause for bleeding
b. They usually occur between 8-13 weeks gestation & are related to chromosomal defects
c. This is considered a medical emergency
Nursing Assessment:
Maternal Signs & Symptoms of Miscarriage
1. Uterine cramping, backache, & pelvic pressure
2. It does cause Bright-Red vaginal bleeding
a. Note the number of peri pads that are used per hour
b. Note symptoms of shock
i. Rapid, thread pulse
ii. Pallor
iii. Hypotension
iv. Cool clammy skin
2. Gestational Trophoblastic Disease (Hydatidiform Mole AKA molar pregnancy)
• Placenta forms a grapelike shape and is a non-vital organ
• hCG levels need to be measured until they return to 0, to determine the placenta is gone
• Educate pt to avoid pregnancy for 6-12 months because choriocarcinoma may develop & hCG levels will not decrease with pregnancy
and may mask this occurrence
• Molar pregnancy can cause Preeclampsia before 20 weeks
3. Ectopic Pregnancy
• Fertilized ovum is implanted OUTSIDE the uterine cavity, usually in the fallopian tube
• Suspect an ectopic pregnancy in any woman who reports to the ER with unilateral or bilateral abdominal pain.
Causes for bleeding in the 2nd or 3rd trimester
1. Abruptio Placentae
2. Placenta previa
▪ Clients with either above should never undergo abdominal or vaginal manipulation
1.
2.
3.
4.
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• No Leopold Maneuvers
• No vaginal exams
• No rectal exams, enemas, or suppositories
• No Internal fetal monitoring
3. Disseminated Intravascular coagulation (DIC)- Is a syndrome of abnormal clotting that is systematic & pathologic. Lg amounts of clotting
factors, especially fibrinogen are depleted, causing widespread external
& internal bleeding. DIC is related to fetal demise, infection, preeclampsia, abruption placentae & sepsis.
Anemia- A decrease in the oxygen-carrying capacity of blood; often related to Iron deficiency & reduced dietary intake
IRON
Drugs
Indications
Adverse Reactions
Nursing Implications
•Constipation
• Iron is best absorbed on an EMPTY stomach
• Ferrous Sulfate Iron deficiency
anemia
(Feosol)
•Diarrhea
•To be taken with Vitamin C such as OJ to
increase absorption
•Gastric irritation
•Nausea or Vomiting •Should NOT be taken with cereal. Eggs, or
milk which decreases absorption
• Should be taken in the evening if problem
exists with morning sickness
•Stools will turn dark-green or black
•Lab values should be checked for increased
reticloiytes & rising Gfb & Hct
Nursing Assessment of Anemia
1. Fatigue, Pallor
2. Labs: HGB < 10- 11 g/dl & HCT <32-37%
DESCRIPTION & COMPARISON
Abruptio Placentae
a. A partial or complete premature detachment of the placenta
from the site of implantation in the uterus
b. Usually occurs in the late 3rd trimester or in labor
c. Is the cause for 15% of maternal deaths
d. Causes are unknown but are related to
• Hypertensive Disorders
• High gravity
• Abdominal Trauma
• Short umbilical cord
• Cocaine abuse
Placenta Previa
a. Abnormal implantation of the placenta in the lower uterine segment
b. Bleeding usually begins in the 3rd trimester
c. Degrees of previas
1. Partial- The placenta lies over a part of the cervical OS
2. Complete- Placenta lies over the entire cervical OS
3. Marginal- Edge of placenta meets the rim of the cervical OS
4. Low-Lying- Placenta implants in the lower uterine segment with a
placental edge lying near the cervical OS
d. Associated with previous uterine scares, usually surgery & fibroid tumors
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NURSING ASSESSMENTS
Severe Painful Bleeding: Concealed or overt (if overt: dark red)
Uterine tenderness
Persistent abdominal pain
Rigid, boardlike abdomen
FHR abnormalities
NURSING INTERVENTIONS
a. Institute bed rest with NO vaginal or rectal manipulation &
notify the HCP immediately
b. Monitor BP & pulse every 15 minutes
c. Start IV fluids
d. Apply external uterine & fetal monitor
e. Place the client in the side-lying position to increase uterine
perfusion
f. Administer O2 by face mask
g. Watch for signs of developing DIC
1. Bleeding gums or nose
2. Reduced lab values: Platelets, fibrinogen & prothrobin
3. Bleeding from injection or IV sites
4. Ecchymosis
f. Prepare for immediate C-Section because uteroplacental
perfusion to the fetus is compromised by early separation of
the placenta from the uterus
g. Monitor blood loss: Save all pads & linens
Painless, Bright Red vaginal bleeding
Soft Uterus
Possible signs of shock
Placenta in lower uterine segment (indicated by ultrasound)
FHR is usually normal
a. Use bed rest to extend the period of gestation until fetal lung maturity is
achieved (determined by L/S ratio 2:1
b. Monitor BP & pulse every 15 minutes
c. Start IV fluids
d. Obtain blood specimen for CBC, clotting studies, Rh factor, &
type/crossmatch
e. Monitor FHR & contractions via external uterine fetal monitor
f. Place side-lying
g. Monitor blood loss
h. Prepare for C-section if previa is complete
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COMPLICATIONS
1. Dystocia- Difficult birth resulting from any cause
a. Can result from any one of the following 5 P’s:
1. Powers- primary uterine contractions & secondary abdominal bearing-down efforts
2. Passage- maternal pelvis, uterus, cervix, vagina, perineum
3. Passenger- fetus & placenta
4. Psyche- response to labor by the woman
5. Position- position of the laboring woman
b. Dystocia is suspected when there is:
1. A lack of progress in cervical dilatation
2. A lack of fetal decent
3. A lack of change in uterine contraction characteristics (frequency, strength, & duration)
c. Dystocia, dysfunctional labor, & uterine inertia are terms used interchangeably
Nursing Assessment
a. Hypertonic or hypotonic uterine contractions
b. Inability to bear down or push efficiently
c. Prolonged labor patters
Nursing Interventions
a. Notify HCP if prolonged labor patterns occur according to the Friedman curve
b. Assist with diagnostic procedures (ultrasound, pelvimetry, vaginal exam) to rule out
Cephalopelvic disproportion (CPD)
c. Assist with amniotomy: AROM may enhance labor forces
i. FHR is assessed immediately after rupture of membranes to determine if there is a cord
prolapse
ii. Assess fluid for color, consistency, odor (blood, meconium, or vernix particles)
d. Initiate oxytocin for induction or augmentation (stimulation) of labor, & manage infusions
a. Uterine Tetany is a harmful complication of induced labor
b. The desired effect of oxytocin is contractions every 2-3 minutes with a
durations no longer than 90 seconds.
c. Tachysystole- is more than 5 contractions in 10 minutes with each contraction
being less than 2 minutes apart, not allowing the fetus time to relax
d. If tetany occurs:
a. Turn off the oxytocin
b. Turn the pt to the side
c. Administer O2 by face mask
d. Check urine output should be at least 100ml/4hr
e. Oxytocin’s most important side effect is its antidiuretic (ADH) effect,
which can cause water intoxication. Using IV fluids containing
electrolytes decreased the risk for water intoxication.
2. Shoulder Dystocia
• Results when the anterior portion of the neonates shoulder gets stuck behind the mothers pelvis bone
during labor.
Nursing Interventions
• Immediately apply superpubic pressure (not fundal pressure) or
• Place the mother in mcroberts maneuver with the legs spread as wide open as possible
• The nurse needs to count how long the baby was “stuck” inside the mother
• A broken shoulder often results which predisposes the infant to brachial plexus damage
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HYPERTENSIVE DISORDERS OF PREGNANCY
1. Gestational Hypertension- BP elevation (greater than 140/90 on more than 2 occasions) occurs for the
first time after midpregnancy
a. There is No Proteinuria noted in the patients with only gestational HTN
2. Preeclampsia- It is a pregnancy-specific syndrome that usually occurs after 20 weeks gestation (only
except in the case of a molar pregnancy)
a. This involves gestational hypertension BP greater than 140/90 and proteinuria
b. Mild Preeclampsia BP > 140/90 & 300mg or less of proteinuria
c. Severe Preeclampsia BP> 160/110 & 2G of Proteinuria
3. HELLP Syndrome- Hemolysis, elevated liver enzymes, low platelets
a. Variant of severe preeclampsia
4. Eclampsia- Seizures (with no known cause) plus all symptoms of severe preeclampsia
Preeclampsia & Eclampsia
• Characterized by elevated BP & proteinuria
• It usually develops during the last 10 weeks gestation or up to 48 hours post-delivery
• Occurs primarily in primigravida
• There is no know cause by its characterized by:
o Generalized vasospasm & vasoconstriction leading to vascular damage over time
o Loss of plasma protein into the interstitial spaces (fluid is drawn into the extravsacular spaces,
which results in HYPOVOLEMIA)
o Hypovolemia results in decreased perfusion to major organs, including the uterus
Risk factors associated with Preeclampsia
• Age: under 17 or above 34
• Low socioeconomic status
• Poor protein intake
• Previous HTN
• Diabetes
• Multiple gestations
• Molar pregnancy
• Prior pregnancy with preeclampsia
• Family history (mothers or sisters with preeclampsia)
Types and Characteristics of Preeclampsia
1. Mild Preeclampsia
• BP rise to 30 mm Hg systolic & 15 mm Hg diastolic over previous baseline, or 140/90 or greater
• Proteinuria of 0.3g in a 24 hour urine collection specimen
• Weight gain >2lbs a week
• Edema, especially periorbital (around the eyes) or “puffy eyes” face, & fingers
• Reflexes may be normal or 2+
• CNS symptoms: Possible mild headache, slight irritability
• IUGR, evidence by size-date discrepancy
2. Severe Preeclampsia (all of the above symptoms, plus any 2 of the following)
• BP 160/110 on 2 or more occasions
• Proteinuria of 2+ or 3+ (or 2-3g in a 24 hour urine collection)
• Generalized edema
• Deep tendon reflexes (DTR) 3+ or greater plus clonys
• Oliguria (less than 100ml/4hr)
• CNS Symptoms: Severe headache, visual disturbances (blurred vision, photophobia, blind spots)
68 | P a g e
•
Elevated marked serum creatinine, thrombocytopenia (low platelets normal 150,000-400,000) &
marked liver enzyme elevation (AST) with epigastric pain related to liver spasms
3. HELLP Syndrome
• Is characterized by hemolysis, elevated liver enzymes, & low platelets
• There is an increased risk for placenta abruption, acute renal failure, hepatic rupture, preterm birth,
& fetal or maternal death
• Most common in while multiparous women
• S&S include
o History of malaise
o Epigastric or right upper quadrant pain
o Nausea & vomiting
• Many women are normotensive and do NOT have proteinuria ****
• These woman are still treated prophylactically with Magnesium Sulfate even if HTN is NOT
present (because of the increased CNS irritability)
Nursing Care for clients with Preeclampsia
Antepartum
Home management
• Absolute bed rest with only BRP
• Daily weights and report a 2>lb increase in 1 week
• Test urine daily for protein
• Provide pt with a list of symptoms to report to the HCP immediately
o CNS symptoms visual disturbances, convulsions, headache, nausea & vomiting, &
hyperreflexia
o Hepatic sign: right upper quadrant or epigastric pain
o Renal sign: oliguria, proteinuria
o Fetal distress, decrease or absent fetal activity or extreme fetal activity
o Signs of abruptio placentae: Vaginal bleeding & abdominal pain
o Malaise
• Teach prescribed diet
o High protein
o Limited salt intake (not completely restricted)
o Maintenance of minimum of 35 cal/kg of body
weight Hospital Management
• If mild becomes severe hospitalization will be necessary
•Monitor LOC, BP, & VS Q4H, or more often if levels are elevated or abnormal
•Obtain fetal assessment continuously with external fetal monitor
•Assess for vaginal bleeding & abdominal pain
•Provide BR in left side lying position
•Start IV fluids
•Insert catheter to monitor urine output, & monitor I&O hourly
• Administer Magnesium Sulfate & antihypertensive drugs (rare unless diastolic BP consistently over
100) & possibly oxytocin
•Assess for coagulopathy
• Petechiae under BP cuff
• Platelet &/or Fibrinogen decrease or increase
• Assess DTR
• Transfer to labor and delivery if the following occur
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• Signs of pulmonary edema
• HELLP syndrome occurs
• Late decelerations in FHR occur
• Preterm labor begins
Intrapartum
1. When a pt with preeclampsia is in labor control the amount of stimulation in the room
2. Monitor BP Q15-30 min
3. Check DTR & urine for protein Q1H
4. Administer Magnesium Sulfate
▪ IV loading dose administered over 15-30 minutes
▪ Infusion of 2g/hr after loading dose
5. Monitor for Magnesium Toxicity
▪ Urinary output < 30ml/hr
▪ Respirations < 12/min
▪ DTR absent
▪ Decelerations of FHR, bradycardia
6. If Seizure occurs
▪ Stay with the Pt and use the call button to summon for help
▪ Have someone get the HCP STAT
▪ Turn pt on the side to prevent aspiration
▪ DO NOT attempt to force objects inside pt mouth
▪ Administer O2 at 10L/min by face mask & have suction available
▪ Administer Mag Sulfate as ordered
The major goal of nursing care for a pt with preeclampsia is to maintain uteroplacental perfusion & prevent
seizures
The cure for Preeclampsia- is delivery, but remember the pt can still convulse for up to 48hr post-delivery
• Rarely are antihypertensives used, only when diastolic BP is >110 (pt at risk for stoke)
o If used the choice is Hydralazine HCL (Apresoline)
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Medications for Intrapartal Complications
Drugs
Indications
To stop preterm labor
• Terbutaline sulfate
contractions
(brethine)
•Magnesium Sulfate
Nifedipine (procardia)
• CNS depressant
administered to preeclampsic
pt to prevent seizures
•May be used as a tocolytic to
stop preterm labor contractions
• Calcium channel blocker
•Relaxes smooth muscle of the
uterus by blocking calcium
•Used as a tocolyitc to stop
preterm contractions
Adverse Reactions
• CNS effects
1. severe nervousness
2. tremulousness
3. headache
• CV effects
1. palpitations 2. tachycardia
3. chest pain 4. pulmonary
edema
• GI effects
1. Nausea & vomiting 2.
diarrhea 3. epigastric pain
• Lab value distortions
1. Low K+ 2. Hyperglycemia
• CNS depression symptoms
1. Depressed respirations & DTR
• Decrease UO
• Pulmonary edema
• Maternal
1. Hypotension
2. Fatigue
3. Overdose produces: nausea,
drowsiness, confusion, slurred speech
3. Peripheral edema
4. Facial flushing
Newborn
1. Problems related to uteroplacenal
perfusion
Nursing Implications
•Administer IV
•Increase rate Q15min
•Obtain ECG & labs prior to infusion
•Maternal pulse should not exceed 140bpm
•FHR should not exceed 180bpm
•I&O & daily weight
•Notify HCO of:
1. High pulse, abnormal FHR & labs
2. Signs of heart failure: dyspnea, jugular
vein distension, dry cough, rales in lungs
3. have antidote available (betablocking
agent such as Proprenolol)
•Hold if RR<12/min or UA is <100ml/4hr
•Absent DTR
•Report nontherapeutic values >8mg/dl
(Therapeutic magnesium levels 47mg/dl) **
•Have antidote readily available which
Is Calcium Gluconate ******
• Check BP for hypotension b4
administration
• Avoid use with Mag Sulfate: can cause
severe hypotension
• Rise slowly from lying-sitting-standing
• Do not use sublingual route of
administration
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Indomethacin (Indocin)
• Prostaglandin synthetase
inhibitor (NSAID)
• Relaxes uterine muscle
• Used only when other methods
fail & less than 32 weeks
gestation
Maternal: N&V, dyspepsia, pyrosis,
dissiness, reduced platelts,
oligohydramnios
Fetal: Premature closure of duct in
heart, decrease renal fx, respiratory
distress, hemorrhage, HTN
• Administer for 48 hours or less
• Do not use in woman with bleeding issues
• Determine amniotic fluid volume
• Administer with food or use rectal route to
decrease GI distress
• Monitor for postpartum hemorrhage
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Diabetes Mellitus
• Hormonal changes act to increase maternal cell resistance to insulin so that an abundant supply
of glucose is available to the fetus
• There is a diabetogenic effects in the pregnant woman that is produced by the placenta and causes an
insulin resistance, it peeks in the late 2nd trimester and early 3rd, which is when the screening test is done
• If insulin cannot move glucose into maternal cells, the mother will begin to metabolize fat & protein
for energy-producing ketones & fatty acids, which results in ketoacidosis
Predisposing Factors
• Family history
• History of 1or more than 2 spontaneous abortions
• Hydramnios
• Previous baby with a weight > 4000g (8lbs 13.5oz) or macrosomic baby > 45000g (9.5lbs)
• Previous baby with congenital abnormalities
• High parity
• Obesity
• Recurrent vaginitis
• Glycosuria
Abnormal glucose screen: a 1-hr glucose screen is done routinely on woman 24-26 weeks gestation
• Pt does not fast for this test, 50g of glucose is given & blood is drawn after 1 hour. If the blood glucose
is greater than 140mg/dL, a 3 hr glucose tolerance test (GTT) is done
Elevated glycosylated hemoglobin A1c- is used to evaluate diabetic control by reflecting blood glucose
level During the previous 6-8 weeks. ( Normal A1C for pregnancy need to be less than 6%)
Symptoms of Diabetes (three Ps)
1. Polyphagia
2. Polydipsia
3. Polyuria
Insulin needs
• In the 1st trimester- May DECREASE, increasing a risk for HYPOGLYCEMIA
• 2nd & 3rd trimester- insulin needs increases, which also increases the risk for HYPERGLYCEMIA
Nursing Interventions
• Teach home glucose and urine monitoring
• Demonstrate insulin administration
• Identify signs of Hyper vs Hpoglycemia ***
• Dietary consult to teach
o Calories: 35-50cal/kg of ideal body weight
o Complex carbs are 50% of diet
o Protein are 20% of diet
o Fat: less than 30% of diet
o Distribute calories between 3 meals and 4 snacks
• Situations that complicate diabetic control: illness, diarrhea, vomiting
• Drink a glass of OJ followed by a glass of low fat milk for hypoglycemic or insulin reaction
• Signs and symptoms of ketoacidosis (DKA)**& tell pt to report to the hospital
o Fruity breath
o Nausea and vomiting
o Exaggerated respiratory efforts
o Altered mental state
• Possible induction of labor at 38-40 weeks
• Oral hypoglycemics are not taken during pregnancy because of potential teratogenic effects
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• Maintain blood glucose levels at 70-90mg/dl during labor & fingersticks 60-80mg/dl
• Breastfeeding decreases insulin requirements
Postpartum Hemorrhage- a leading cause of maternal mortality
• Excessive uterine bleeding during the 1st hour following delivery (hemorrhage, more than 1 saturated
pad every 15 minutes)
• Blood loss of more than 500ml during a vaginal delivery
Signs of hypovolemic shock
1. decreased BP
2. weak, rapid pulse
3. cool clammy skin, colored ashen or gray
Signs of hematomas developing in perineum
1. intense perineal pain
2. swelling & black-blue discoloration of the perineum
3. pallor, tachycardia, & hypotension
4. possible urinary retension, uterine displacement
signs of bleeding from an unrepaired laceration
1. continuous trickle from the vagina
2. bleeding in spurts
3. bleeding in the presence of a contracted fundus
signs of bleeding from uterine atony
1.soft, boggy uterus usually ABOVE the umbilicus
2.fundus that doe not firm with massage
Immediate nursing actions when postpartum hemorrhage is detected
1. Perform fundal massage
2. Notify the HCP if the fundus does not become firm with massage
3.count pads to estimate blood loss
4.assess & record VS
5.increase IV fluids
6.administer oxytocin infusion as prescribed
Newborn assessment
1. Low birth weight (LBW) 2500 g or less
2. Very low birth weight (VLBW) 1500g or less)
Jitteriness- is a clinical manifestation of hypoglycemia & hypocalcemia. Labs are the only way to differentiate
Between the 2 causes.
To avoid metabolic problems brought on by cold stress the nurse must prevent loss of body heat in the
newborn. Neonates produce heat by nonshiving thermogenesis, which involves the burning of brown fat.
• The neonate is easily stressed by hypothermia & develops acidosis as a result of hypoxia.
• If the neonate is in a cold stress warm them over 2-4 hours because rapid warming may produce apnea
Signs and symptoms the neonate is cold
1. prolonged acrocyanosis
2. skin mottling
3. tachycardia
4. tachypnea
Hyperbilirubinemia- excessive accumulation of bilirubin in the blood due to RBC hemolysis
Total bilirubin determinations
• levels increasing more than 5mg/day
• term level > 12mg/dl
• LBW level 10-12 mg/dl or greater
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• Preterm level >5mg/dk
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Pediatrics HESI Guide 2
1. Remember: If you know the normal; you are then able to identify what is not
normal.
Age
Newborn
Pulse
100 to 160
Resps.
30 to 60
Blood Pressure
Systolic: 65-95
Diastolic: 30-60
Temperature
97.7-99.1
(axillary)
1 to 11 months
1 to 3 years
(toddler) 3
to 5 years
(preschooler)
100 to 150
80 to 130
25 to 35
20 to 30
80 to 120
20 to 25
Girls: 91-104/52-66
Boys: 93-107/ 50-65
97.5-98.6
(axillary)
6 to 10 years
(school age)
10 to 16 years
(adolescent)
70 to 110
18 to 22
97.5-98.6 (oral)
60 to 90
16 to 20
Girls: 102-115/60-74
Boys: 102-115/61-75
Girls: 111-124/66-80
Boys: 116-130/65-80
97.5-98.6 (oral)
Respiratory
Distress
RR w/
use of
axillary
muscles to
breath
Tachycardia
- Safety basics/various facts: Airway and breathing are
always first!!
• Remember the ABCs:
o A- airway: patent airway always priority #1,
age regardless
o B- breathing
Δ in child’s
o C- circulation
breathing
o D- disabilities (LOC)
Restless
early
o E- exposure
Nasal Flare
• Feeding: 108kcal/kg/day
• Child falls & bumps head: NEURO ASSESSMENT FIRST
Tripod
• Preferred IM site: Vastus Lateralis
• Poison Ingestion: NO syrup of ipecac to induce V (RT rebound corrosion on
throat); typical treatment: activated charcoal, may need gastric lavage
2. Review G&D (Milestones, Theorists)-------chapter 4, Pg 55
a. 4mo old—what is expected
i. Social smile occurs at 2mo
ii. . Head turns to locate sounds at 3mo
CHILD
iii. & other primitive reflexes (aside from Bartaloni disappear)
PROOF
iv. **Steady head control (hold head and chest upright while lying on
CHILD
stomach during tummy time); kick & push with their feet
PROOF
1. Roll from BACK to SIDE
CHILD
PROOF
Respirator
y Failure
RR/
Apnea
Bradycard
ia
LOC
Grunt
(LATE
sign)
Breath
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v. Hands work together to move toy/shake rattle—readily grabs objects close
by and puts them in mouth
b. Rolls from ABD to BACK (5mo) AND BACK TO ABD (6mo)
i. Sit unsupported at 8mo; crawl at 9/10mo; walk at 10-12; 15-18mo ready to
run
c. When should a child self feed with a spoon and cup? 2yo
d. Gesell’s theory of development: biophysical development based on child’s
genetic blueprint and influenced by experiences, therefore unique and
individualized.
3. Maslow’s hierarchy: Basic needs come first.
a. Physiological: water, sleep, food, breathing, excretion, homeostasis, sex
b. Safety: security of resources, body, health, home, etc.
c. Love/belonging
d. Esteem
e. Self-actualization: morality, acceptance of facts, etc.
4. Delegating: Understand the nursing process. Assessment, planning care,
education must be by the RN.
NOTE: health hx is only subjective data (what is reported by parents)
a. What is the nursing process?
i. a five-part systematic decision-making method focusing on identifying
and treating responses of individuals or groups to actual or potential
alterations in health
1. Assessment
a. Collection of subjective & objective data; qualitative and
quantitative
2. Diagnosis
a. Analyzing assessment data to determine a label for the
nursing diagnosis
b. Provides focus for nursing
3. Planning
a. Strategies to use to lead to expected outcomes: establish
priorities, client goals, expected outcomes and
interventions, then communicate the plan of nursing care
4. Implementation
a. Carry out the plan to promote health & SAFE environment
b. Start with interventions most likely to achieve goals &
expected outcomes that are needed to support or
improve status
5. Evaluation (ONGOING)
a. Determine if conditions are improving, outcomes met,
make clinical decisions/redirect care to meet client needs
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•
RN: task delegation
o Specialty care
o Severe cases
o Sterile procedure
o Assessment
o Planning care (i.e care plans)
o Teaching
o Evaluation
o IV meds
• UAP- more like a CNA
o Routine Procedures & ADLs
• LPN- licensed practical nurse- does more than a UAP
o Chronic cases; Stable clients; routine procedures
5. Lyme Disease [red bull’s eye rash w/in 3-30days]
a. When do you check for ticks?
i. April to October is tick season.
ii. CHECK RIGHT AWAY- after playing or being outside (head to toe),
especially if your skin was exposed.
b. Contact PCP if the tick is not completely removed.
c. What signs and symptoms indicate need for medical attention?
i. Medical attention is needed when the first set of symptoms occur!
1. Fever, malaise, rash/bullseye, flu-like S&S
2. Later on: NEURO [catch early and treat w/ antibiotics]
ii. There are 3 stages of symptoms of Lyme disease:
1. Early localized stage: vague flulike symptoms (malaise, fever,
headache, chills, fatigue, and vague muscle aches and pains.)
a. Doxycycline is given when these symptoms start to appear.
Though they may not have been diagnosed with Lyme
disease, this antibiotic is cheap, and it does not hurt to start
using it anyways.
2. Early disseminated stage: 1-4 months after bite. Neurologic
symptoms may be the first to occur. CNS symptoms- severe
headaches, with myelitis, nausea, vomiting, facial nerve paralysis
(Bell’s Palsy), forgetfulness, decreased concentration, cerebral
ataxia; lymphadenopathy, joint and muscle pain.
3. Late disseminated stage: months to years after bite. Chronic
arthritis, profound fatigue, and chronic neurologic manifestations.
6. Child admitted for persistent V & D. What acid-base imbalance is likely?
a. Metabolic alkalosis (RT excessive loss of hydrochloric acid from stomach)
b. TX: may be giving D5W NS w/ KCL: get BUN & creatinine prior—ensure child
is urinating before KCL admin.
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c. What assessment is most important?
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i. Measure the apical pulse (HR increase)
7. Epiglottitis is a respiratory emergency: Know the identifying symptoms and
emergency action you should anticipate.
Unlike croup which presents
a. Symptoms: Sudden onset
with steeple sign and NO
i. Restlessness
fever
ii. High fever (100.4 q1hr OR 101.3 1x= BAD)
iii. ore throat, dysphagia
iv. Bulging tympanic membranes (inflamed)
v. Drooling
vi. . Muffled voice
vii. “frog-like croaking” ---cyanotic
viii. Tripod position: upright w/ chin out & tongue p rotruding (trying to breath)
b. Emergency action:
i. Prepare for intubation or tracheostomy: mostly tracheostomy because you
probably will not be able to pass a tube.
ii. Bring to hospital right away.
iii. Check lung sounds.
iv. Check temperature, blood pressure, and tympanic membrane. Checking
their ears is important because they will have bulging ear drums.
v. Encourage prevention with Hib vaccine.
vi. . Maintain child in upright sitting position.
vii. dminister IV antibiotics as prescribed.
viii. repare for hospitalization in ICU.
ix. Restrain as needed to prevent extubation.
x. Employ measures to decrease agitation and crying.
xi. Do not examine the throat because of risk of obstructing the airway!
c. Post intubation, take blood cx; IV antibiotic: cefotaxime; rifampicin prophylaxis
to household contacts
8. Croup: what advice can you offer parents as an intervention at home?
• Bring them into a really steamy bathroom
or the cool night air
• Maintain a stable environmental temperature
and humidity (humidifier, steam from
shower.)
• Keep child well-hydrated. This helps
decrease the severity of attacks.
• Avoid large groups of people, and perform
good hand hygiene because croup is a viral
infection.
• Acetaminophen and Ibeuprophen are
effective in reducing fever and will help
them feel more comfortable.
• Avoid cough syrups and cold medicines
because these can dry and thicken secretions
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a. Mother brings in child’s favorite toy while they are in a mist tent…can they
have it?
i. Children within the mist tent with humidified oxygen to liquefy mucous
secretions and facilitate breathings---toys that absorb moisture like stuffed
toys and coloring books should be avoided (plastic toys OK; must
properly clean!). (dampness lowers resistance to infection and toys can
harbor pathogens)
ii. Able to see child, but cannot hold them (stay close if possible, and tell
them you will not leave)
iii. If child cries: reach inside and stroke head or back
iv. Machine does make loud noises: assure child it will not hurt them (can put
gauze over ears to prevent sound)
v. Mist drops inside can be wiped away for better view
vi. Clothes and bedding must be changed often to prevent hypothermia (also
assess temp!) keep plastic sides of tent tucked tight under mattress to
prevent suffocation
9. Digoxin (Lanoxin): Therapeutic Effect: will bring HR into normal range for child
a. Digoxin: child will take this twice a day for several months to years.
i. It helps the heart pump blood more effectively, thereby improving the
circulation of the blood, and promoting the normal elimination of excess
fluid.
ii. What you need to know:
1. Digoxin (Lanoxin) is always given every morning and evening.
You may adjust the times to fit you and your child’s schedule.
Therapeutic levels: 0.82.
Give Digoxin 20-30 minutes before a feeding. Give it at the same
2.0ng/mL [hypokalemia,
time every day so that it becomes a part of your routine.—NOT in
hypercalcemia,
hypomagnesia can inc these
formula or food
levels]
3. The amount of Digoxin you give your child must be measured
carefully with a syringe, not the dropper provided with the med.
Baseline EKG; Apical pulse for
4. Put a few drops of Digoxin into your child’s mouth and let the
1 min prior to admin (assess
child swallow it before giving more.
for bradycardia) <100bpm
5.
If you forget to give your child a single dose of Digoxin, give the
kids hold, <60bpm adults
hold
dose when you remember it; then resume your original schedule.
a. Should not skip & “double up”
**if already bradycardic, get
6. If your child vomits after taking Digoxin, do not repeat the dose.
a therapeutic drug level!
Resume the Digoxin at the next dosage time.
Early toxicity S&S:
7. If you miss of your child vomits 2 doses in a row OR child vomits,
vomiting---often
call the cardiology department (or physician).
overlooked as “spit-up”
8. Keep the Digoxin in a place where children living or playing in
your home will not be able to reach it.
-anorexia; N/V; blurry
9. If someone accidentally takes the Digoxin, call poison control or
vision; photophobia;
take the person and Digoxin bottle to the emergency department.
diarrhea; abd pain;
fatigue, drowsy,
headache; muscle
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10. Obtain refills at least 1 week before you are out of medicine. Ask
for new prescriptions as needed.
b. Digibind- the antidote to Digoxin.
i. If you take Digoxin by mistake, you will need to take Digibind.
ii. . If you reach toxic levels of Digoxin, you will need to take Digibind.
10. Atopic dermatitis/eczema: what questions should the nurse ask when obtaining a
history?
a. Nursing Dx: Altered comfort RT vesicular skin eruptions
b. Assessment: typically creases in body RT itch (cut nails, apply mittens/elbow
restraints, provide soothing bathes)
c. What exacerbates it: Everyday things in your environment!
i. Cold weather- keep a moisturizer handy.
ii. Heat and humidity
1. Hot water- take short baths/showers.
iii. Allergies (esp to food)—NOTE: more prone to latex allergies RT existing
skin issues: EX during assessment “my husband and daughter are lactose
intolerant”---milk allergy in this ex adds to outbreaks
1. Dust- from carpets, rugs, blinds.
2. Garments made of woll, synthetics, or other rough materials.
3. Detergent/soap- use unscented, natural, double rinse cycle.
4. Pollen
5. Cosmetics- products containing alcohol, lanolin, preservatives.
6. Pet dander- vacuum!
7. Cigarette smoke
iv. Stress
11. Wilm’s tumor:
• DO NOT PALPATE!! This can cause it to rupture and shed cancer cells.
• Sometimes patients will have signs on their doors in the hospital saying “DO
NOT PALPATE TUMOR!”
12. Infant assessment for hip dysplasia: (breech position increases risk)
Positive ortolani sign (“clicking/clucking” with abduction)
o Barlow: adduction
o Unequal folds of skin on buttocks and thigh (asymmetry of gluteal
folds).
o Limited abduction of affected hip.
o Unequal leg lengths.
o A spica cast is used to fix this: maintains hips in 90 degree flexion;
elevate buttocks off bed; monitor circulation to the feet
13. What vital signs will help the nurse assess an infant for pain?
• Heart rate, and respirations. (Δs in Bp are LATE indicators, though BP may
increase when infant in pain)
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•
The infant is going to be crying from the pain which will cause the heart rate and
respirations to increase.
14. Child with asthma uses inhaler with a spacer: why are they at risk for oral fungal
infections? What advice can you offer parents?
• They are at risk for fungal infections because the spacer grows germs and fungus,
and the child will then breath them.
• Advise good oral hygiene- rinse the child’s mouth and the spacer after each use.
15. Child with Kawasaki disease (vascular inflammation) is brought to the clinic and
mom reports irritability, refusing to eat, skin peeling on hands and feet. What does
the child need most?
• They need quiet, rest, and low stimulation.
• These patients are really sick.
• Why is aspirin part of treatment?
o Antiplatelet effects
o Principal goal of treatment: prevent coronary artery disease & relieve s/s
o Mainstay of tx: Full doses of intravenous immunoglobulin (IVIG)
16. Parents ask when they should introduce baby foods:
o When?
A) Stops rooting reflex
B) Opens mouth when food is near
C) No longer wakes frequently at night
D) Gives up bottle for cup
-around 4-6months of age
-less time spent nursing: interest in opening mouth for spoon
-infant can sit (reach for object and maintain balance)
• How?
o Rice cereal 1st solid food added (least allergenic)
o 1 at a time at least a few days to a week apart RT possible allergies
o Veggies before fruits (RT sweetness of fruits)
• Breastfeeding mom unable to keep up with the feeding demands with pumping:
what do you advise?
o Supplement with baby formula; store breast milk as able in freezer
17. A child with a fever and rash:
• Your concern is transmission!!
• This is most likely infectious.
• Isolate the child and implement precautions.
18. Assessing NG tube placement: when and how?
a. NOTE: must increase feedings very slowly
b. ***Check for presence of occult blood [confirmation of an upper GI
bleed]/residual (if still a lot a few hours later, hold & contact MD)
c. Also assess output, stool, etc.
d. Feedings, decompression of stomach
19. Nose bleed/epistaxis: what intervention is best?
a. Sit up and lean forward
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b. Pressure to nose for ≥10 mins
i. Stuffing nose could later lead to dislodging clot blocking additional
bleeding in the nose---not recommended
20. Nephrotic Syndrome: why is albumin part of treatment?
a. Leads to hypoalbuminemia as protein leaks through the glomeruli membrane and
into the urine
b. s/s: inc specific gravity in urine RT protein; inc Hgb + Hct RT hypovolemia
c. encourage active motion in bed daily
21. Hemophilia: lifelong, hereditary bleeding disorder s cure (Hgb unaffected until
bleed)
a. Interviewing:
i. Recent trauma?
Hem A/
ii. Initial measures to stop bleed—how long pressure applied
“classic”: factor
iii. Inc swelling after surface bleed stopped?---VERY common [hemarthrosis:
VIII and IX
recurrent bleeding into joints—may be regarded as sports injury]
iv. Swelling/stiffness without apparent trauma?
Hem B/
b. Basic Information:
“Christmas
i. X-linked, autosomal recessive
disease”: factor
1. Female carriers, males affected
IX
2. 1st signs: prolonged bleeding at the umbilical cord (suspect), post
circumcision, vit K injection site
Hem C: factor XI
Mild bleeding
ii. . DDAVP: desmopressin given to stimulate factor IV
tendencies
c. S/s:
i. PTT is PROLONGED (norm: 60-70, therapeutic range=1.5-2.5x normal
or control); no platelet Δs/WBCs
ii. Bruise easily; hematuria; tissue trauma sites
d. Management:
i. When fall…what to do? (RICE= rest, ice, compression, elevation)
1. Give missing factor (IV NOT IM)—may also be given
prophylactically
2. Immobilize extremity, elevate
3. NO HEAT= cold for vasoconstriction
ii. Avoid aspirin (leads to bleeding) & NSAIDS
iii. Avoid high risk activites (no contact sports; can do: swim, golf, hike, fish;
no: soccer, football)
iv. Wear medical alert bracelet
v. Bleeding precautions:
1. Soft toothbrush (or water pic)
2. Padding/soft edges (childproof ^2)---always wear to school
3. Helmet;
Shaving—electric razor!!
vi. When to call PCP: blunt or joint trauma
vii. ay refer to genetic counseling
22. Mouth discomfort/mucositis RT chemo (interventions RT comfort)
a. NS mouthwash: cleans w/o adverse effects (esp if swallowed)
84 | P a g e
b. Magic mouthwash (malox/Mylanta & benedryl+ lidocaine): depresses gag reflex
and reduces pain
23. Chemo and discharge teaching: what are the concerns for this patient?
a. Old guide: child with leukemia and low WBC: discharge instructions will include
what?
Strict
i. INFECTION CONTROL- no live vaccines, ***Good hand hygiene***
isolation is
frequent skin & mucous membrane assessments
NOT
ii. . Fatigue (RT anemia), Petechiae (RT low platelets), infections (RT
necessary
dec effective leukocytes)
b. Chemo= vesicants that can cause severe vascular damage if infiltrates [gloves
worn at all times, regard all fluids as radiation]
c. Nausea: offer cool, clear liquids (milks thickens secretions & can induce V;
offering fav foods can cause association w/ feeling ill)
d. Axillary temperatures RT risk of damage to mucous membranes
e. Anaphylaxis (i.e tumor lysis syndrome) is possible
i. N/V/D, anorexia, lethargy, hematuria, HF, sz, muscle crmaps, tetany,
syncope---STOP IV, infuse NS, then notify Md [key to prevention:
hydration]
f. Allopurinol: renal med used to dec risk of brain damage RT uric acid build up
during cell lysis
24. In what order do you perform an assessment on a child?
a. Inspection (always 1st regardless of age); Palpation; Percussion; Auscultation
1. Abd exam: Inspection, Auscultation, Percussion, Palpation (don’t
want to alter BS before determining presence and characteristics)
ii. Begin with least invasive procedures first
to toe
Infant-Toddler:
chest & thorax first
Respirations
(>6yo:
thoracic,
<6yo:
b.
diaphragm)
Apical HR (1
min) [>2yo:
can use
radial]
Blood
pressure
Temperature
Preschool: foot to
head sequence
(observation of
behaviors &
inspection first)
25. Paren
School-age: head
to toe
Adolescent : head
85 | P a g e
iii. rightening or
potentially
painful
procedures
done last (ex:
mouth &
ears)
iv. Developm
ental
approach
EX: quiet
infant—
auscultate
heart,
lungs, and
abdomen
before
disrupting
the calm!
v. Don’t go
fast; give
choices
when
possible; talk
with, not at
the child;
keep a
security
object
nearby
After performing a
developmental
assessment, what do
you do?
i. Order:
1. Chief
compl
aint
2. Histor
y of
presen
t
illness
3. Past
medic
al hx
(inclu
ding
immu
nizations)
Pregnancy & birth hx
Developmental hx
Feeding hx
Review of systems
Family hx
Social (living situation & conditions/ daycare; composition of
family; occupation of parents)
t understanding of follow up RT treatment of UTI:
i. Complete antibiotic
ii. f/u (follow-up) specimen needed
4.
5.
6.
7.
8.
9.
86 | P a g e
iii. ipe front to back & practice good hygiene (teach not to hold)
iv. incontinence in previously potty trained child is biggest sign
v. physical causes are eliminated before emotional
[structural defects explored after UTI confirmed]
26. Discipline and the toddler
a. Comprehensive approach that does NOT emphasize punishment, but instead
promotes self control
b. Toddlers NEED and want; little control over behavior and need limits & vigilance
to prevent injury
c. Will deliberately test parents until shown how far they can go
d. MUST be consistent, immediate, realistic, age-appropriate, logical to the incident,
clearly explained why
e. Must be given time to respond to instructions
f. Withdrawal of love should NEVER be punishment—comforting after discipline
promotes positive feelings
g. Arguments & extensive explanations avoided
h. ****Separate the toddler from the behavior EX “I love you. Hitting your sister
has to stop” or “throwing toys could hurt someone. I don’t like to see you doing
that” is better than “you’re a bad girl for doing that”
i. Strategies:
i. Time-out (1min per year of age)---must offer explanation
ii. Diversion: “you must stop marking on the wall with crayons. Here, mark
on the paper instead”
iii. Positive reinforcement (etc: stickers when do something correctly)
1. Ignore the negative actions, but focus on the positive (keeping
attention to the bad behavior will cause the child to repeat it)
27. Preemies and RSV: recommended protection [droplet & contact w/ private room]
a. Immunization
b. ***Wash hands frequently !!!
c. Stay away from crowds, young children, or others who may be sick
d. Don’t let anyone smoke in your home or near your child
e. Wash baby’s toys, clothes, and bedding often (soap, water, disinfectants)
28. Precautions to prevent the spread of measles; pertussis; meningitis
a. IMMUNIZE
b. Pertussis (whooping cough-bacterial): droplet
i. DTap (2, 4, 6 months)
c. Measles: airborne isolation precautions (vaccine: MMR)
i. 1st: 12-15mo
ii. 2nd: 4-6yo (second can be as early as 28 days post if 1st given after child’s
1st birthday)
d. Meningitis: droplet
i. Initial quadrivalent conjugate vaccine: 11-12yo
ii. Vaccine lasts 10 years; typically done before entrance into college (1623yo)
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29. Testing for Duchenne Muscular Dystrophy [electromyelogram]: what to expect?
[full report may take 2-3days]
a. nerve conduction test to see how well and how fast nerves can send the signals
(done with several flat disc electrodes directly over nerve that send several quick
low-voltage [not high enough to cause injury] electrical pulses to nerve; done
BEFORE EMG if both are done; takes 15mins-1hr)
i. normal: show that the nerves send electrical impulses to the muscles or
along the sensory nerves at normal speeds, or conduction velocities (diff
nerve, diff norm velocity [do slow down as age]). Sensory nerves allow
the brain to feel pain, touch, temperature, and vibration.
b. Purpose (of electromyelogram): measures the electrical activity of muscles at
rest and during contraction
c. how to prepare:
i. blood thinners discontinued prior
ii. wear loose fitting clothing/gown so muscles & nerves
iii. electrodes attached to skin---NO sprays, oils, creams, lotions
iv. may be asked to sign consent
d. how it is done:
i. done in hospital, clinic or doctor’s office by EMG tech or MD
ii. lie on table/bed or sit in reclining chair so muscles are relaxed
iii. skin over areas tested are cleaned
iv. needle electrode attached by wires to recording machine is inserted into
muscle (measures the muscles at rest)
1. may be moved a number of times OR in different areas of muscle
2. shown as wavy & spiky lines on video monitor, may be heard on
loudspeaker as machine-gun-like popping sounds when you
contract
v. tester will ask you to tighten (contract) muscle slowly & steadily—records
vi. total process: 30-60minutes; once done, electrodes are removed & skin is
cleaned
vii. ow does it feel:
1. quick, sharp pain when needle electrode inserted
2. sore/tingling feeling for up to 2 days
3. pain is worse or there is swelling, tenderness, or pus (call MD)
4. may get some small bruises or swelling at the injection sites
5. needles are STERILE- no/little chance of infection
viii. ormal finding:
1. no electrical activity when the muscle is at rest.
2. smooth, wavy line on the recording with each muscle contraction.
30. Cultural Sensitivity r/t Jewish faith and hypospadias repair
a. Circumcision [bleeding is RARE] in the Jewish faith:
i. A symbol of God’s convenant with Israel.
ii. Done on the 8th day post birth.
b. Hypospadias repair (typically 1 stage, outpatient)
i. Surgery ideally done PRIOR to circumcision (extra skin needed to
reconstruct) at 6mo-1yr prior to toilet training
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31. Aortic stenosis
a. If child in HF has sudden wt gain, what is 1st assessment?
i. Lungs sounds—tachypnea & inc BP;
1. also monitor: urine output, edema
ii. . Sudden wt gain1. Call MD (post lung assess)
b. What findings do you expect with HF?
i. Key indicator: exercise intolerance, chest pain, and dizziness while
standing for long periods of time
c. Oxygen administration prescribed for stressful periods (crying or during invasive
procedures)
d. Definition: narrowed entrance to the aorta leading to…blood having difficulty
flowing through aortic valve, causing increased pressure and hypertrophy of the L
ventricle, dec CO, dec blood supply to coronary arteries
e. Treatment: follow-up; exercise restrictions; balloon valvuloplasty [delay surgical
intervention] OR aortic valve replacement if recurrent
32. Acute rheumatic fever: what might the nurse note when obtaining a history?
a. Recent strep infection/sore throat OR unexplained fever (within the last 2 months)
b. Definition: diffuse inflammatory reaction; most likely immune
c. child develops chorea---what to discuss with patient
i. explain it will disappear over time
33. TGA (Transposition of the Great Arteries) and prostaglandin administration
(PGE1)
a. Purpose: maintains cardiac output by maintaining patency of the ductus arteriosus
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34. Grave’s disease (Hyperthyroidism)
Hyperthyroidism “Grave’s Disease”
T4,
TSH TH
Hyper—poor attention span
Muscle weakness (working hard a lot)
Increased HR and BP
Tremors
Accelerated growth
“exopthalamus” prominent eyes
Smooth, velvet skin (RT inc sweat)
Wt loss, despite inc appetite
Heat intolerance (body already working hard)
Diarrhea (RT peristalsis)
Emotional lability/ anxiety
*iodine uptake increased
Med:
* Methimazole (blocks TH)
Propylthiouracil (if allergic- risk of liver toxicity
**HINT: think child w/ ADHD
*need to limit contact sports RT liver
*infant may be “irritable”
*drugs needed around 3x/day
*2-3month checks by endocrinologist (will taper off once stable)
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35. Precocious Puberty early onset of puberty – usually idiopathic
a. ~leads to: premature 2ndary characteristics; growth rate; advanced bone growth (early
fusion)
b. Early onset for girls = before 8 years of age [in AA—before 6yo]—obesity, ethnicity,
c.
d.
e.
f.
g.
genes, stress, etc;
Early onset for boys = before 9 years of age---more idiopathic
Radiographic findings support diagnosis by determining bone age and maturation
Diagnosis: GnRH stimulation testing; blood tests [elevated LH, FSH,
estrogen/testosterone]
i. NOTE: FSH >LH (before puberty); FSH <LH (after puberty)
Treatment = stop or reverse development of secondary sex characteristics & maximize
adult ht; GnRH blocker “agonist” (monthly IM): inhibit GnRH binding to pituitary
i. Treatment does not interfere with reproductive health [takes 2-4 weeks]
ii. Discontinuation of treatment pubertal progression resumes
Psychosocial: may be teased---try to hang w/ older kids (boys aggressive)
may feel embarrassed---limit social activities
may be treated as older; at risk for sexual abuse
Interventions: explain stages of puberty & behavioral changes; “experiencing normal
changes at abnormal time”; psychological counseling (deal w/ sexuality); medication
admin
36. Sickle Cell Crisis [autosomal recessive; PAINFUL; acute, episodic]
a. Occurs when blood flow to tissues obstructed by sickled cells leading to
hypoxemia and ischemia
b. Pain management & hydration [promotes hemodilution & circulation of
RBCs; 1-1.5x maintenance] **in that order**
Increased
c. Teach: how to give penicillin [prophylaxis esp dental 2mo-5yo daily, older than 5
temp= first
for dental), hydrate, ID stressors, stroke education
sign of
d. May refer to genetic counseling
bacteremia—
e. “chest syndrome”: severe chest pain, fever, cough, dyspnea/SOB: NOTIFY MD
leads to crisis
(emergency RT quick decomp)
i. Tx: deep breathing; antibiotics; O2, pain meds, blood
ii. . Monitor fluids RT risk of pulmonary edema
f. Primary problems: tissue hypoxia (<95%) & vascular occlusion
g. Check mucous membranes & skin turgor
h. Stem cell transplant: curative
i. Pain precipitated by: infection, cold, stress, acidosis, local or generalized hypoxia,
weather (limit sun), trauma, dehydration/extreme heat; avoid high altitudes/ dec
O2
j. Manifestations (mild-severe): joint, bone, or limb pain with swelling/arthralgia
(few hrs-days); fever; N/V; tenderness; inc RR; severe abd pain; hematuria;
pallor/fatigue (RT chronic hemolytic anemia)
k. Treatment:
i. Main--- exchange transfusions of packed RBCs (keep % sickled below 30)
ii. . Pain: oral analgesics (morphine and/or dilaudid, NSAIDs, no aspirin)
1. Demerol NOT given RT sz risk (PO Tylenol & codeine until not
sufficient for pain)
iii. ggressive incentive spirometry (10 breaths q2hr)—inc breathing &
oxygenation; won’t reverse sickling; dec pneumonia risk
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iv. Rest
v. NO iron given: problem not RT deficiency anemia
1. Folic acid: may be given to inc RBC synthesis
vi. Hydroxyurea: dec frequency & severity of painful events
37. Type 1 DM
a. Hypoglycemia s/s
i. Onset: rapid
ii. Adrenergic s/s:
1. Trembling/shaking; Sweating; Tachycardia; Pallor; Clammy
skin; Anxious
iii. Alterations in LOC/ “neuroglycopenic s/s:
1. Personality change; Irritability
2. Drunken behavior; Slurred speech/impaired vision
3. Dec LOC- total loss of consciousness
4. Sz activity
iv. Lab data: glucose <60mg/dL
b. Hyperglycemia: priority---hydrate & insulin
c. Developmental approach/abilities---Pg 723 Table 27-5
38. Acute post-strep glomerulonephritis
a. BPs taken RT acute HTN risk
b. 6yo can self-cath! Give more control
c. Definition: inflammatory injury to the glomerulus of kidney; occur suddenly,
self-limiting, resolve completely
d. Etiology & Incidence:
i. Immune rxn to group A beta heme strep RT
1. Strep pharyngitis (throat): 1-2 weeks
2. Pyoderma (strep skin infection): 3-6 weeks
ii. Rare before age 3, typically 5-12yo (young school-age)
e. Manifestations: [labs normal in 6-12weeks]
i. Hematuria: smoky/tea/cola-colored urine
ii. Proteinuria (0-3+)
iii. Edema: worse in morning; primarily eyelids & ankle
1. Dec urine output
iv. HTN: can be severe
v. Fatigue
vi. MAY BE febrile
vii. Pulmonary edema= life-threatening complication
f. Diagnostic Evaluation:
i. Hx, presenting s/s, labs
ii. Antistreptolysin (ASO) titer/Streptozyme test: indicates presence of
antibodies; can be elevated
1. Decreased complement
g. Therapeutic Management:
i. Supportive; directed towards s/s & guided by degree of renal impairment
ii. Possible 10 day antibiotic therapy
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iii. Acute RF: requires hospitalization to stabilize F&E as well as renal
function
iv. antiHTN medication, limit Na & water, possible diuretic
v. ***diuresis (more urine)= signals beginning of resolution
h. Nursing Care Goals:
i. Prevent consequences of fluid excess
ii. Provide adequate rest
iii. Maintain skin integrity
iv. Maintain nutritional status
v. Relieve parent anxiety
39. S/P (status post) cardiac catheterization: nsg considerations
a. Definition: catheter (typically through) femoral artery or vein and directly into
heart; pressure bandage covers [removed following day, bandaid replaces]
b. Potential Complications:
i. Arrhythmias
hemodynamic compromise
ii. Hemorrhage
iii. Vascular damage
iv. **Vasospasm of catherized vessel poor perfusion of affected leg
Peripheral
perfusion!!
Extremity often
mottled in
appearance &
cooler to touch
than other
extremities--distal pulses
should still be
palpable,
though may be
weaker (check
w/ Doppler if
not)
Heparin drip
may be used ;
often
discharged
same day
Notify
Cardiologist:
-no pulses
present
v. Thrombus/embolus formation (at cath site)
1. Impaired perfusion to limb
2. Possible travel to brain/lung
a. Within systemic-pulmonary artery shunts (inhibit
pulmonary blood flow)
3. Venous thrombus: swelling, inflammation of leg (WARM)
4. Arterial thrombus: coolness, discoloration of extremity, loss of
pulses distal to thrombus
vi. Infection
vii. Reaction to dye rash, pruritus, V (RARELY: anaphylaxis)
viii. Catheter perforation cardiac tamponade & cardiac arrest
c. Nursing Considerations [focus: preventing impaired peripheral perfusion]
i. Locate & mark distal pulses PRIOR to procedure
ii. Post:
1. Positioned w/ affected leg straight 4-6hrs
a. Infants can be prone on parent’s lap
b. Older children: bedrest, HOB ≤20°
2. IV fluids cont’d until taking AND retaining adequate PO fluids
3. VS/assessment:
a. Q5-15mins for 1st hour with continuous initial monitoring
of HR, BP, RR, O2, and temp
i. Bleeding (early hours of post-op & w/ VS):
1. Check insertion site dressing; sheets; under
child (pooled blood); under linens; pull back
diaper (perineal area bleeding under skin)
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2. If occurs
pressure w/ gloved heel of
hand ≥10-15mins & assess distal perfusion
to extremity
a. Immediately notify cardiologist
b. Assess blood loss & hemodynamic
status
4. Discharge instructions
a. Inspect catheter site: healing, infection
b. Bathing: limited to shower, sponge bath, brief tub (NO
soaking) for first 1-3 days post
c. Avoid strenuous exercise up to 1 week post, or 6 weeks
after device placed
d. School: 3rd day post
e. Notify cardiologist (reasons at home):
i. Fever >101; Bleeding, drainage (pus)
ii. Pallor, coolness, or numbness of extremity
f. Resume normal feedings and meds; Review need to
continue antibiotics for dental & other procedures
g. Follow-up with cardiologist at scheduled visit
d. Indications of arterial obstruction- extremity cool to touch, appears pale &
blanched
40. Otitis media: why are younger children at risk? (NOTE: not caused by viruses)
a. Definition: refers to effusion (fluid) and infection or blockage of the middle ear
i. Most often caused by upper respiratory infections
b. Risk factors:
i. Shorter & straighter Eustachian tube & immature middle ear than adults
[ANY obstruction results in ineffective drainage and no ventilation to ear]
1. Bottle feeding---reflux into the ears tube from nasopharynx while
feeding supine [more upright infant is, less risk]
a. Not getting maternal antibodies from mom (more incidence
of allergies)
ii. Children have more difficulty fighting off infections (immune systems
immature)
iii. Allergies
iv. Attendance at daycare facilities (esp <1yo)
1. Age: 6-2yo (up to 6yo)
v. Ethnicity (higher in Native Americans, Alaskan Inuit, and Canadian Inuit)
vi. Exposure to cigarette smoke
vii. Pacifier use
41. How do you assess the effectiveness of fluid replacement therapy?
a. Wt (I&Os), VS, LOC, urine output, and specific gravity (norm: 1.002-1.030;
1.02 indicates start of dehydration) WNL
b. Cap refill <2seconds
c. Skin turgor elastic with moist mucous membranes
d. Normal BS present
42. Seizure precautions and nsg interventions (select all question)
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a. Basic tenant of tx: treat the whole child
i. Mainstay of tx: Antiepileptic meds to treat seizures
ii. Tx goals: ID and correct cause; eliminate the seizure with minimum side
effects & least use of meds; normalize the lives of the child & family
If the sz lasts
iii.
djunctive) Vagus Nerve Stimulation: generator implanted into chest wall
greater than
with wire clipped to vagus nerve to deliver electrical impulses to the
5 min alert
brain (dec need for meds & emergency care)
MD
iv. (Adjunctive) Ketogenic diet: NO CARBS- mostly fat, produces state of
immediately
ketosis thought to control seizures
and admin
b. Before a seizure
emergency
i. Bed in low position, siderails up, padded sides, suction and airway at
diazepam
bedside
(valium) or
ii. . Determine seizure triggers and avoid
lorazepam
c. During a seizure
(ativan)
i. Do NOT leave the pt; stay, observe, and document
1. Date, onset (where begins), duration; trigger; LOC; movements;
Skin changes, etc.
ii. Ensure adequate ventilation
1. Loosen clothing/restraints
2. DO NOT force or insert anything into the mouth (joking hazard)
3. Side-lying position preferred to prevent aspiration
iii. rotect from injury (help break fall, clear area of furniture)
iv. DO NOT restrain movement (won’t stop sz, will cause injury)
v. Remain with the person & give verbal reassurance as well as as much
privacy as possible
d. Post seizure
i. Assess: gag reflex; any injuries or headache; residual LOC deficits
ii. . Allow individual to sleep & reorient upon awakening
iii. Conduct a post sz assessment
e. How are seizure medications discontinued?
i. Tapered slowly RT risk of seizure activity
43. Myelomeningocele: what allergy are these children at risk for and why?
a. Latex- RT requirement of frequent catheterization to empty bladder, shunt
placements, and other operations
44. Pyloric Stenosis: Manifestations
a. Definition: when the circular area of muscle surrounding the pylorus
hypertrophies and obstructs gastric emptying (one of most common surgical
disorders of infancy)
b. S/S
i. Progressive, non-bilious PROJECTILE vomiting
1. May become blood tinged with esophageal irritation
2. Deep peristaltic waves from LUQ to RUQ may be visible prior to
vomiting
3. Infant will be irritable and hungry a short time after being fed
4. Worst case: dehydration & metabolic alkalosis
a. Dec serum K and Na, inc pH and bicarb, dec chloride
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b. Indirect bili may be elevated
ii. . Moveable, palpable olive-shaped mass in RUQ
1. Best seen when stomach empty & infant calm
2. Radiography and ultrasound: narrow pylorus w/ dilated stomach
and absence of gas distal to pylorus
3. Barium swallow: long narrow canal & delayed gastric emptying
45. Scoliosis Screening (Box 9-9 Pg 195; 678+)
a. Girls 10yo through adolescence most at risk
i. Screening times: girls- 10 & 12; boys- 13 or 14
b. Spinal deformity progression driven by growth= premenstrual still growing (less
likely to demonstrate full S&S)
c. Procedure:
i. Unclothed or wearing underpants/gown or swimsuit so that chest, back,
and hips clearly seen
ii. Evenly distribute wt onto feet, with legs straight, and arms hung loosely
iii. Bend at waist and observe for S/S
1. Non-painful lateral curve to spine ( C curve, or S curve)
2. Lateral deviation and rotation of each vertebrae (better observed by
looking at ribs OR spine itself)
3. Unequal: shoulder lengths; SCAPULAR prominences and heights;
waist angles; rib prominences & chest symmetry
4. Unequal rib heights in adam’s position
5. Possible asymmetry in leg lengths
6. neuro check: strength & reflexes
d. Functional scoliosis: apparent when standing, disappears with bending
e. Structural scoliosis: fixed; curve present with standing or bending
f. Congenital scoliosis of infant: visible when lying prone, helps if suspended prone
g. Referral to orthopedic surgeon and parent notification made w/ scoliometer
reading ≥7 (indicates 7 degree angle of trunk rotation)
46. Inflammatory bowel disease…..delayed growth RT chronic
malabsorption/malnutrition; corticosteroids; chronic illness (recurrent/ chronic diarrhea)
47. Calculating % wt loss
a. Original wt-current wt/ original wt
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1. The nurse is monitoring an infant with congenital heart disease closely for signs of heart
failure (HF). The nurse should assess the infant for which early sign of HF?
1. Pallor
2. Cough
3. Tachycardia
4. Slow and shallow breathing
3. Tachycardia
2. The nurse reviews the laboratory results for a child with a suspected diagnosis of
rheumatic fever, knowing that which laboratory study would assist in confirming the
diagnosis?
1. Immunoglobulin
2. Red blood cell count
3. White blood cell count
4. Anti–streptolysin O titer
4. Anti–streptolysin O titer
3. On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the
nurse expects to note which clinical manifestation of the acute stage of the disease?
1. Cracked lips
2. Normal appearance
3. Conjunctival hyperemia
4. Desquamation of the skin
3. Conjunctival hyperemia
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4. The nurse provides home care instructions to the parents of a child with heart failure
regarding the procedure for administration of digoxin (Lanoxin). Which statement made
by the parent indicates the need for further instructions?
1. "I will not mix the medication with food."
2. "I will take my child's pulse before administering the medication."
3. "If more than one dose is missed, I will call the health care provider."
4. "If my child vomits after medication administration, I will repeat the dose."
"If my child vomits after medication administration, I will repeat
the dose."
5. The nurse is closely monitoring the intake and output of an infant with heart failure who
is receiving diuretic therapy. The nurse should use which most appropriate method to
assess the urine output?
1. Weighing the diapers
2. Inserting a Foley catheter
3. Comparing intake with output
4. Measuring the amount of water added to formula
1. Weighing the diapers
6. The clinic nurse reviews the record of a child just seen by a health care provider and
diagnosed with suspected aortic stenosis. The nurse expects to note documentation of
which clinical manifestation specifically found in this disorder?
1. Pallor
2. Hyperactivity
3. Exercise intolerance
4. Gastrointestinal disturbances
. Exercise intolerance
7. The nurse has provided home care instructions to the parents of a child who is being
discharged after cardiac surgery. Which statement made by the parents indicates a need
for further instructions?
1. "A balance of rest and exercise is important."
2. "I can apply lotion or powder to the incision if it is itchy."
3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks."
4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."
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2. "I can apply lotion or powder to the incision if it is itchy."
8. A child with rheumatic fever will be arriving in the nursing unit for admission. On
admission assessment, the nurse should ask the parents which question to elicit
assessment information specific to the development of rheumatic fever?
1. "Has the child complained of back pain?"
2. "Has the child complained of headaches?"
3. "Has the child had any nausea or vomiting?"
4. "Did the child have a sore throat or fever within the last 2 months?"
4. "Did the child have a sore throat or fever within the last 2 months?"
9. A health care provider has prescribed oxygen as needed for an infant with heart failure. In
which situation should the nurse administer the oxygen to the infant?
1. During sleep
2. When changing the infant's diapers
3. When the mother is holding the infant
4. When drawing blood for electrolyte level testing
4. When drawing blood for electrolyte level testing
10. Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur
on auscultation of the heart and signs of heart failure. The nurse reviews congenital
cardiac anomalies and identifies the infant's condition as which disorder?
1. Aortic stenosis
2. Atrial septal defect
3. Patent ductus arteriosus
4. Ventricular septal defect
3. Patent ductus arteriosus
11. The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant
suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a
hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what
position?
1. Prone position
2. Knee-chest position
3. High Fowler's position
4. Reverse Trendelenburg's position
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2. Knee-chest position
12. The nurse is monitoring an infant with heart failure (HF). Which sign alerts the nurse to
suspect fluid accumulation and the need to call the health care provider (HCP)?
1. Bradypnea
2. Diaphoresis
3. Decreased blood pressure
4. A weight gain of 1 lb in 1 day
4. A weight gain of 1 lb in 1 day
13. A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of
respirations. On further assessment, the nurse notes increased hypoxemia. The nurse
interprets these findings as indicating which situation?
1. Anxiety
2. A temper tantrum
3. A hypercyanotic episode
4. The need for immediate health care provider (HCP) notification
3. A hypercyanotic episode
14. The mother of a child being discharged after heart surgery asks the nurse when the child
will be able to return to school. Which is the most appropriate response to the mother?
1. "The child may return to school in 1 week."
2. "The child will not be able to return to school during this academic year."
3. "The child may return to school in 1 week but needs to go half-days for the first 2
weeks."
4. "The child may return to school in 3 weeks but needs to go half-days for the first few
days."
4. "The child may return to school in 3 weeks but needs to
go half-days for the first few days."
15. A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this
diagnosis is consistent with which laboratory result obtained for this child?
1. Elevated antistreptolysin O (ASO) titer
2. Decreased erythrocyte sedimentation rate (ESR)
3. Negative result on antinuclear antibody (ANA) assay
4. Negative result on C-reactive protein (CRP) determination
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1. Elevated antistreptolysin O (ASO) titer
16. A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which
diagnostic test finding will assist to determine a diagnosis of rheumatic fever?
1. Presence of Aschoff's bodies
2. Absence of C-reactive protein
3. Presence of Reed-Sternberg cells
4. Decreased antistreptolysin O titer
1. Presence of Aschoff's bodies
17. The nurse reviews the laboratory results for a child with rheumatic fever and would
expect to note which findings? Select all that apply.
1. Presence of Aschoff's bodies
2. Absence of C-reactive protein
3. Elevated antistreptolysin O titer
4. Presence of Reed-Sternberg cell
5. Elevated erythrocyte sedimentation rate
o 1. Presence of Aschoff's bodies
o 3. Elevated antistreptolysin O titer
o 5. Elevated erythrocyte sedimentation rate
18. Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The
mother of the child is a registered nurse and asks the nurse why the child needs the
medication. What is the most appropriate response to the mother about the action of the
medication?
1. Prevents blue (tet) spells
2. Maintains adequate cardiac output
3. Maintains an adequate hormonal level
4. Maintains the position of the great arteries
2. Maintains adequate cardiac output
19. The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community
members. The nurse tells the group that when chest compressions are performed on
children and infants, the sternum should be depressed how far?
1. 1½ to 2 inches
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2. 2½ to 3 inches
3. Deep enough to make a finger impression
4. One third to one half the depth of the chest
4. One third to one half the depth of the chest
20. The nursing instructor teaches a group of students about cardiopulmonary
resuscitation (CPR). The instructor asks a student to identify the most appropriate
location at which to assess the pulse of an infant younger than 1 year of age. Which
response would indicate that the student understands the appropriate assessment
procedure?
1. Radial artery
2. Carotid artery
3. Brachial artery
4. Popliteal artery
Brachial artery
21. A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin (Lanoxin).
The nurse takes the apical pulse for 1 minute before administering the medication and
obtains a result of 102 beats/min. Which action should the nurse take?
1. Retake the apical pulse.
2. Withhold the medication.
3. Administer the medication.
4. Withhold the medication and notify the health care provider.
3. Administer the medication.
22. The nurse is assessing a newborn with heart failure before administering the
prescribed digoxin (Lanoxin). In reviewing the laboratory data, the nurse notes that
the newborn has a digoxin blood level of 2.4 ng/mL and an apical heart rate of 98
beats/min. The mother also tells the nurse that the newborn just vomited her formula.
Which intervention should the nurse take?
1. Retake the apical pulse.
2. Administer the medication.
3. Withhold the medication for 1 hour.
4. Withhold the medication and notify the health care provider.
4. Withhold the medication and notify the health care provider.
23. The nurse is developing a plan of care for a child admitted with a diagnosis of
Kawasaki disease. In developing the initial plan of care, the nurse should include to
monitor the child for signs of which condition?
1. Bleeding
2. Failure to thrive
3. Heart failure (HF)
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4. Decreased tolerance to stimulation
3. Heart failure (HF)
24. The nurse is reviewing the health care provider's prescriptions for a child with
rheumatic fever (RF) who is suspected of having a viral infection. The nurse notes
that acetylsalicylic acid (aspirin) is prescribed for the child. Which nursing action
is most appropriate?
1. Administer the aspirin if the child's temperature is elevated.
2. Administer the aspirin if the child experiences any joint pain.
3. Consult with the health care provider to verify the prescription.
4. Administer acetaminophen (Tylenol) for temperature elevation.
Consult with the health care provider to verify the prescription.
25. A nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the
infant calls the nurse to the room because the infant suddenly seems to be having
difficulty breathing. The nurse enters the room and notes that the infant is
experiencing a hypercyanotic episode. What is the initial action by the nurse?
1. Place the infant in a prone position.
2. Call a code and notify the supervisor.
3. Place the infant in a knee-chest position.
4. Contact the respiratory therapy department.
3. Place the infant in a knee-chest
position.
26. A nurse is caring for an infant with congenital heart disease. Which, if noted in the
infant, should alert the nurse to the early development of heart failure (HF)?
1. Paleness of the skin
2. Strong sucking reflex
3. Diaphoresis during feeding
4. Slow and shallow breathing
3. Diaphoresis during feeding
27. The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On
review of the child's record, the nurse should expect to note documentation of
which most common assessment finding?
1. Severe bradycardia
2. Asymptomatic findings
3. Bluish discoloration of the skin
4. Higher than normal body weight
3. Bluish discoloration of the skin
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28. The nurse is collecting data on a child with a diagnosis of rheumatic fever (RF).
Which question should the nurse initially ask the mother of the child?
1. "Has the child been vomiting?"
2. "Has the child had any diarrhea?"
3. "Does the child complain of chest pain and numbness in the right arm?"
4. "Has the child complained of a sore throat within the past few months?"
4. "Has the child complained of a sore throat within the past
few months?"
29. A nurse is reviewing the health record of an infant with a diagnosis of congenital
heart disease. The nurse notes documentation in the record that the infant has
clubbing of the fingers. The nurse understands that this finding is caused by which
problem?
1. Chronic fatigue
2. Poor oxygenation
3. Poor sucking ability
4. Consistent sucking on the fingers
2. Poor oxygenation
30. A child is being discharged from the hospital following heart surgery. Prior to
discharge, the nurse reviews the discharge instructions with the mother. Which
statement by the mother indicates a need for further teaching?
1. "Quiet activities are allowed."
2. "The child should play inside for now."
3. "Visitors are not allowed for 1 month."
4. "The regular schedule for naps is resumed."
3. "Visitors are not allowed for 1 month."
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