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Copyright © 2006 by F. A. Davis.
OB Peds Women’s Health Notes
Nurse’s Clinical Pocket Guide
Brenda Holloway, CRNP, FNP, MSN Cheryl Moredich RNC, MS, WHNP Kathie Aduddell, Ed.D, MSN, RN-BC
Purchase additional copies of this book at your health science bookstore or directly from F A. Davis by shopping . online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book
F. A. Davis Company • Philadelphia
No part of it may be reproduced. recording. without written permission from the publisher. registered with the Copyright Clearance Center (CCC) Transactional Reporting Service. All rights reserved. electronic. and publisher are not responsible for errors or omissions or for consequences from application of the book. and make no warranty. . For those organizations that have been granted a photocopy license by CCC. PA 19103 www. editors. Davis Company . in regard to the contents of the book. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher. Davis Company . The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug.com Copyright © 2006 by F A. recommended treatments and drug therapies undergo changes. Davis. photocopying. and in accord with accepted standards at the time of publication. 222 Rosewood Drive. or otherwise. A. This book is protected by copyright. expressed or implied. F A. or transmitted in any form or by any means. RN. or the internal or personal use of specific clients. Martone Project Editor: Ilysa H. Davis Company for users .fadavis. Authorization to photocopy items for internal or personal use.10 per copy is paid directly to CCC. The fee code for users of the Transactional Reporting Service is: 8036-1466/06 0 + $. Richman Developmental Editor: Marla Sussman Consultant: Kim Cooper. provided that the fee of $. The author(s). mechanical. 1915 Arch Street Philadelphia. MSN As new scientific information becomes available through basic and clinical research. is granted by F A. stored in a retrieval system. MA 01923. up to date. Nursing: Robert G. Caution is especially urged when using new or infrequently ordered drugs. a separate system of payment has been arranged.Copyright © 2006 by F. The author(s) and publisher have done everything possible to make this book accurate.10. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. Danvers.
Copyright © 2006 by F. GYN ANTE.POSTPEDS PEDS BASICS PARTUM PARTUM PARTUM BASICS ASSESS MEDS/ ACUTE TOOLS . Davis.INTRA. A. Wipe old entries off with an alcohol pad and reuse. Place 2 78 2 78 / / Sticky Notes here for a convenient and refillable note pad ✓ HIPAA Compliant ✓ OSHA Compliant Waterproof and Reusable Wipe-Free Pages Write directly onto any page of OB Peds Women’s Health Notes with a ballpoint pen.
A.com. Look for our other Davis’s Notes titles Available Now! Nurse’s Clinical Pocket Guide. Davis. RNotes®: . 2nd edition ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5 ECG Notes: Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8 IV Therapy Notes: Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4 LabNotes: Guide to Lab and Diagnostic Tests ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5 LPN Notes: Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1132-3 / ISBN-13: 978-0-8036-1132-0 MedNotes: Nurse’s Pharmacology Pocket Guide ISBN-10: 0-8036-1109-9 / ISBN-13: 978-0-8036-1109-2 New edition coming Fall 2006 MedSurg Notes: Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1115-3 / ISBN-13: 978-0-8036-1115-3 NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6 PsychNotes: Clinical Pocket Guide ISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0 For a complete list of Davis’s Notes and other titles for health care providers.Copyright © 2006 by F. visit www.fadavis.
screening. 1 Nurses Impact the Health of Women Through ■ ■ ■ ■ ■ Educating women about healthy lifestyle choices Role modeling healthy behavior and promoting wellness Describing the role of prevention and early detection Informing women about disease treatment and progression Being an advocate and resource for community referrals Cervical/Gynecological Health ■ According to the guidelines of the American College of Obstetrician and Gynecologists (ACOG) and the American Cancer Society (ACS). Davis. A. initial cervical screen for cancer should begin 3 years after first sexual intercourse or by age 21. with three consecutive negative cervical screens. are recommended to have repeat exams every 2–3 years GYN BASICS .Copyright © 2006 by F. and prevention ■ Follow-up cervical screen for low-risk women less than 30 years of age ACOG Guidelines ACS Guidelines Annually Annually with conventional Pap smear Every 2 years with liquid-based cytology ■ Women 30 years of age and older. whichever comes first ■ However. ACOG recommends that a visit to an obstetrician/gynecologist occur before that time for health guidance.
GYN BASICS Copyright © 2006 by F. Davis.gov for latest treatment guidelines for STIs (Continued text on following page) 2 . Sexually Transmitted Infections (STIs) ■ Abstinence from sexual activity (both oral and genital) is the only 100% effective method of STI prevention ■ Consistent and proper use of condoms during sexual intercourse will decrease the incidence of STIs ■ STIs transmitted via skin contact (human papillomavirus [HPV].cdc. sexual activity should be avoided until treatment regimen completed ■ Patients diagnosed with a viral STIs should consult their health-care provider for long-term management ■ Reportable STIs must be forwarded to the local health department along with treatment rendered ■ Encourage immunization against hepatitis B ■ Visit CDC Web site www. A. herpes simplex virus [HSV]) may still be transmitted with use of latex condoms ■ Sexual partners should be tested and treated when an STI is identified.
Davis. some associated with cervical dysplasia Visible wartlike growths in genital area associated with subtypes 6. A. Sexually Transmitted Infections (STIs) (Continued) Infection Gonorrhea Symptoms (May be asymptomatic) Yellow-green vaginal discharge Dyspareunia Abdominal pain Dysuria Mucopurulent discharge Postcoital bleeding Dyspareunia Abdominal pain Dysuria Frothy malodorous vaginal discharge Dyspareunia Vaginal itching/irritation Dysuria Fatigue Dark urine Clay-colored stool Jaundice/abdominal pain Many subtypes exist.Copyright © 2006 by F. 11 Detection Endocervical culture Urine test Chlamydia Endocervical culture Urine test 3 Trichomoniasis Saline wet mount of vaginal discharge viewed under microscopy Serological testing Hepatitis Human Papilloma Virus (HPV) Pap smear report Colposcopy/biopsy (Continued text on following page) GYN BASICS .
lymphadenopathy Latent Lacking clinical manifestations Tertiary Cardiac. auditory involvement Detection Serological testing Nontreponemal (RPR. malaise Enlarged lymph nodes 4 . VDLR) ■ Reported quantitatively (titers) ■ Four-fold change in titers clinically significant ■ Effective treatment will result in falling titers ■ False-positive possible. Sexually Transmitted Infections (STIs) (Continued) Infection Syphilis Symptoms (May be asymptomatic) Primary Chancre (painless raised ulcer) Secondary Skin rash. verify with treponemal test Treponemal (FTA-ABS) Reported as positive or negative Serological testing (Pretest and posttest counseling with informed consent required) Positive screen must be confirmed by more specific test (Western blot) Viral culture with DNA probe HIV Fever Malaise Lymphadenopathy Skin rash GYN BASICS Herpes Simplex Virus (HSV) Painful. A. ophthalmic.Copyright © 2006 by F. recurrent vesicular lesions Fever. Davis.
459. Visually inspect in several positions. skin irregularities. A. 5 Breast Health ■ Monthly breast self-exam. looking for dimpling. may accentuate an abnormality ◆ Hands at the side ◆ Hands above the head ◆ Hands pressed onto hips ◆ Leaning over BSE positions. symmetry 2. Philadelphia: F.Copyright © 2006 by F. Visually inspect the breasts. instructed to woman as an optional tool for identifying and reporting breast changes ■ Clinical breast exam at least every 3 years (age 20–40) during a physical exam by a health professional. Davis. Case Study Approach.A. yearly after age 40 ■ Annual mammogram starting at age 40 Instructions for Breast Self Exam (BSE) Step 1: Inspection 1.) GYN BASICS . lumps. starting at age 20. (From Dillon PM. Davis. (2003) Nursing Health Assessment: A Critical Thinking. p.
medium. Case Study Approach. (From Dillon PM. Davis. Nursing Health Assessment: A Critical Thinking. (2003). Davis.A. Philadelphia: F. Feel the breast tissue and lymph node chain for lumps or thickening by using three finger pads while exerting light. A.GYN BASICS Copyright © 2006 by F. p 461.) 6 . and deep pressure in a systematic fashion BSE palpation patterns. Step 2: Palpation 1.
Begin by lying down on a flat surface with arm raised and a folded towel under the back of the breast being examined 3. and drug use ■ Teach prevention of sexually transmitted infections ■ Update immunizations and investigate rubella titer ■ Review exposure to environmental risk factors ■ Control of chronic medical conditions ■ Review classification of prescribed medication Family Planning Options ■ Educate women on available family planning methods. benefits. discussing the risks. thickening. and comorbidities ■ Educate women on the process of menses ■ The menstrual cycle is a cyclic feedback system occurring approximately every 28 days with the first day of menses being day 1 ■ Low levels of estrogen and progesterone stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH). ■ Discuss chromosomal abnormalities associated with advanced maternal age ■ Incorporate 400 mcg of folic acid daily (for low-risk women) ■ Avoid alcohol. smoking. motivation. A. which stimulates the anterior pituitary to release GYN BASICS . user preparedness.Copyright © 2006 by F. bring arm toward body and feel the axilla and the skin above as well as below the collar bone 4. nipple discharge or any suspicious findings to health-care provider Preconception Counseling Preconception counseling should be included in health screenings for all women of childbearing age and focus on factors that impact organogenesis. dexterity. Report lumps. Repeat technique on the other side 5. Davis. and efficacy of each method ■ Efficacy of each method influenced by correct and consistent use. After examining breast tissue. 7 2.
the corpus luteum regresses. produced by the maturing follicle. the corpus luteum (remaining cells of the follicle) produces estrogen and progesterone. encouraging maturation of the Graafian follicle Estrogen. causes the endometrial lining to proliferate The mid-cycle release of luteinizing hormone (LH) from the anterior pituitary promotes release of the mature ovum (ovulation) Once ovulation occurs. A. as well as monitor gynecological health ■ To prevent pregnancy. Davis. couples abstain during recognized period of fertility 8 .GYN BASICS Copyright © 2006 by F. causing a decrease in estrogen and progesterone. and ischemic changes to the functional layer of the endometrium The menstrual cycle is divided into phases of the ovarian and endometrial cycle: Ovarian Cycle Menstrual Follicular Ovulatory Luteal Endometrial Cycle Menstrual Proliferative Secretory Ischemic Sexual Abstinence ■ Refraining from sexual activity is the only 100% effective way to prevent pregnancy Fertility Awareness Methods ■ Teaches familiarity with body in order to recognize signs of fertility ■ Useful to avoid or achieve pregnancy. ■ ■ ■ ■ ■ follicle stimulating hormone (FSH). which stimulates endometrial thickening If conception does not occur.
A. BBT decreases slightly in response to estrogen ■ After ovulation.5–1. thick. abstain from intercourse GYN BASICS . and is no longer stretchable ■ Cervical mucus should be evaluated and charted daily ■ Monitor and graph BBT daily before rising ■ Prior to ovulation. and cloudy ■ At ovulation.Copyright © 2006 by F. illness Basal Body Temperature (BBT) Calendar Method ■ Based on assumption that ovulation occurs 14 days before the onset of menses ■ Record menstrual cycles for 6–8 months ■ Calculate fertile period Subtract 18 from the shortest menstrual cycle (28 18 10) Subtract 11 from the longest menstrual cycle (32 11 21) Days 10–21 fertile time. clear. restless sleep. 9 Cervical Mucus Amount and character of cervical mucus changes throughout the menstrual cycle in response to hormones ■ Following menses. promoting sperm motility. cloudy. cervical mucus becomes more abundant.0 F ■ BBT remains high with conception. but falls without conception. thick. increased likelihood of pregnancy with unprotected intercourse ■ After ovulation. and stretchable in response to estrogen (known as “spinnbarkeit”). cervical mucus scant. use of electric blanket or heated waterbed. a surge of progesterone increases BBT by 0. prior to menses ■ Certain activities may alter BBT: smoking. slippery. Davis. cervical mucus scant.
regularly examine integrity of rubber ■ Inserted with spermicide applied to dome before intercourse and left in place for at least 6 hours after intercourse ■ Should not be left in place more than 24 hours due to risk of toxic shock syndrome ■ Additional spermicide may be added with diaphragm still in place for repeated intercourse ■ Diaphragm is custom fitted and must be refitted with 20 pound weight change and after a vaginal birth ■ Urinary tract infections (UTI) more common with diaphragm use. and therefore suppresses ovulation ■ Postpartum woman who exclusively breastfeed during the first 6 months after childbirth. inspect integrity of rubber by holding up to light to inspect for holes Male Condom ■ Thin latex sheath that covers the erect penis during sexual intercourse ■ Provides protection from STIs ■ Space should be left at the end of the condom for ejaculate ■ Hold condom at base of the penis upon withdrawal to prevent spillage ■ Only water-soluble gel should be used for lubrication to prevent degradation of the latex 10 . including at least one night feeding. Davis. Lactation Amenorrhea Method (LAM) ■ Prolactin suppresses follicle stimulating hormone (FSH). may postpone ovulation ■ Instruct patients that ovulation and return of fertility may occur before first menses with a risk of unintended pregnancy Barrier Methods Prevents conception by blocking entry of sperm into the cervix Diaphragm ■ Dome-shaped rubber cup with a flexible ring that fits over the cervix. teach to report symptoms of UTI ■ Wash with soap and water after each use.GYN BASICS Copyright © 2006 by F. A.
decreased libido. decreased menstrual blood loss. and reliability ■ Requires addition of condom for STI protection or as back-up with user error ■ Side effects may include nausea. A. breakthrough bleeding. mood changes. dry place Female Condom ■ ■ ■ ■ ■ ■ Prelubricated polyurethane sheath with two flexible rings Inner ring helps with insertion and covers the cervix Outer ring rests on vulva Water or oil-based lubricant and spermicide may be used Can be stored at any temperature. 5-year shelf life Remove prior to standing by twisting the outer ring to contain semen and pull out ■ Material degradation could occur if both male and female condoms used simultaneously Hormonal Methods Hormonal contraceptives Hormonal contraceptives alter the normal menstrual cycle. and thickening cervical mucus. headaches. hampering sperm transport • Suppression of midcycle LH peak prevents ovulation • Decreases cilia movement within the fallopian tube ■ Advantages of hormonal contraceptives include decreased dysmenorrhea. or weight change GYN BASICS . altering the endometrial lining.Copyright © 2006 by F. ■ Mechanism of Action ■ Effects of Estrogen • Ovulation inhibited by suppression of follicle stimulating hormone (FSH) and luteinizing hormone (LH) • Endometrial lining altered making the endometrium less receptive to implantation ■ Effects of Progestin • Cervical mucus thickened. breast tenderness. 11 ■ New condom should be used with each act of intercourse ■ Store in unopened package in cool. Davis. inhibiting ovulation. vomiting.
followed by 7 hormone-free days (either no pills taken or placebos taken for 7 days) ■ Pill selection based on amount of estrogen. Davis. type of progestin. ■ May cause serious health issues. estrogen promotes blood clotting ■ Impaired liver function. stroke. estrogen promotes blood clotting ■ History of breast or female reproductive cancer. advise hormonal contraceptive users not to smoke and teach reportable symptoms of possible complications: ■ Abdominal pain (severe) ■ Chest pain ■ Headache (severe) ■ Eye problems (blurred.GYN BASICS Copyright © 2006 by F. increases the risk for cardiovascular complications ■ History of migraine headaches (with aura). A. and swelling ■ Shortness of breath ■ Worsening depression ■ Jaundice ■ Contraindications to hormonal contraceptives ■ History of heart attack. redness. OCs are metabolized through the liver and use may adversely affect existing liver disease ■ Suspected or confirmed pregnancy ■ Uncontrolled hypertension. blood clot. increased risk for deep vein thrombosis Combined Hormonal Methods (Combination of estrogen and progestin) Combination Oral Contraceptives (OC) ■ Most OCs are administered daily for 21 days. increased risk for stroke ■ Major surgery planned with immobilization. tumors may be hormonally provoked ■ Diabetes with vascular involvement. or symptoms presented 12 . double vision) ■ Severe leg pain. increased risk for cardiovascular complications ■ Smoker over 35 years of age. adrenergic effect.
and upper torso (but not the breasts). vaginal irritation. withdrawal bleeding occurring only four times per year ■ Combination hormonal contraceptives may decrease production of breast milk and should be avoided while breastfeeding ■ Effectiveness of OCs altered by certain medications. Davis. patients should report use of contraceptive agents to all health-care providers Transdermal Patch ■ Patch applied to skin weekly for 3 weeks. 13 ■ Combined OCs may be monophasic (estrogen and progestin remain constant) or multiphasic (hormone dosing changes throughout the month) ■ Extended-cycle OCs are taken consistently for 12 weeks. buttocks. swimming. site should vary weekly ■ Application involves cleansing skin. exercising) ■ Partial removal and skin reactions possible ■ Decreased effectiveness noted in women who weigh more than 198 pounds Vaginal Ring ■ Small. and firmly applying patch making sure all corners adhere to skin ■ May engage is usual activities (bathing.Copyright © 2006 by F. protect from sunlight and high temperatures ■ Side effects include increase in vaginal discharge. fourth week is patchfree to allow withdrawal bleeding ■ Acceptable application sites include abdomen. back-up method of birth control needed for the next 7 days GYN BASICS . followed by 7 days of inert pills. A. or infection ■ Expulsion may occur. upper outer arm. avoiding lotion. removed in fourth week to allow for withdrawal bleeding ■ Ring should be kept inside unopened package before insertion. flexible hormone-impregnated ring inserted and left in the vagina for 3 weeks. if out for more than 3 hours.
A. Davis. as well as producing cellular changes to the endometrial lining ■ Recommended for parous women in a mutually monogamous relationship with no history of pelvic inflammatory disease (PID) ■ Inserted in office by qualified practitioner ■ Increased incidence of pelvic inflammatory disease (PID) ■ Uterine perforation and expulsion of device possible ■ Attached to string that extends outside of the cervix. instruct patient to check for presence of string monthly ■ Teach patient the following reportable warning signs 14 . Progestin Only Preparations ■ Progestin-only preparations are indicated for women who cannot use estrogen ■ Alteration in menstrual cycle common with progestin-only methods ■ May be used in lactation once breastfeeding is well established ■ Side effects include weight gain.GYN BASICS Copyright © 2006 by F. menstrual irregularities. and depression Oral Contraceptives “minipill” ■ Important to take at the same time each day ■ Back-up method of birth control needed with missed or late pills Injectable Progestin Contraception Depo-medroxyprogesterone (DMPA) ■ Injected by health-care provider intramuscularly (IM) every 3 months ■ Return to fertility may be delayed ■ Bone loss may be of concern with continued use. should not be used for greater than 2 years continuous use Intrauterine system (IUS)/Intrauterine Device (IUD) ■ Inhibits fertilization by altering fallopian tube transport of sperm and ova.
or complications from anesthesia GYN BASICS . preventing passage of ovum ■ Low failure rate. continuous use for up to 10 years if no complications Emergency Contraception (EC) Contraceptive agents used after unprotected intercourse intended for the prevention of pregnancy ■ Available agents ■ Copper IUD inserted within 5 days of unprotected intercourse ■ Oral contraceptives taken at higher doses. both combination and progestin-only preparations are available • Initial dose within 72 hours of unprotected intercourse • Follow-up dose within 12 hours of first dose Permanent Methods ■ Prevent conception by mechanically blocking the fallopian tubes. injury to adjacent organs. may be ectopic Tubal Ligation (Incisional Method) ■ Performed in a hospital or outpatient surgical unit under general anesthesia ■ Fallopian tubes cut. infection. Davis. and/or clipped ■ Complications may include bleeding. T-shaped hormone-releasing (levonorgestrel) device placed in the uterus to prevent pregnancy for up to 5 years 2. incomplete tube closure. if pregnancy occurs. 15 Signs of IUD complications: Period late (pregnancy) Abdominal pain (infection) Infection Not feeling well (infection) String missing (IUD expelled) Types 1. Copper IUD contains no hormones. cauterized. A. however.Copyright © 2006 by F.
Hysteroscopic Tubal Sterilization (Nonincisional method) ■ Microinserts placed into the opening of the fallopian tubes. alternate method of birth control used until tube status verified ■ Complications may include incorrect placement requiring second or operative procedure.S. ectopic pregnancy. estrogen reduction results in increased bone resorption ■ Discuss adequate intake of calcium and vitamin D ■ Encourage weight-bearing exercise ■ Educate concerning bone density scans ■ Discuss medications to reduce bone loss with primary healthcare provider 16 . perforation of the uterus Health Promotion in Adult Women Cardiovascular Health Promotion ■ ■ ■ ■ Cholesterol screening every 5 years after age 20 Blood pressure screening at each medical visit Incorporate fitness into daily lifestyle Discourage smoking Promotion of Weight Management and Fitness ■ Calculate body mass index and determine goal ■ Discuss exercise regimen for current fitness level ■ Provide nutrition guidance according to the guidelines set forth by the U. Davis. A. causing scar tissue to grow in approximately 3 months ■ Performed in physician’s office or outpatient procedure lab with local anesthetic to cervix ■ Follow-up hysterosalpingogram performed at 3 months to ensure both tubes have been blocked.GYN BASICS Copyright © 2006 by F. Department of Agriculture (USDA) Prevention and Treatment of Osteoporosis ■ Risk increases after menopause. infection.
friable vaginal mucosa • Vaginal dryness and irritation • Dyspareunia ■ Other Systemic Symptoms • Sleep disturbance • Mood swings • Memory loss • Skin changes • Hair thinning GYN BASICS .m. to 4 p.Copyright © 2006 by F. A. ACS) Yearly fecal occult blood test plus Flexible sigmoidoscopy every 5 years or Colonoscopy every 10 years or Double contrast barium enema every 5 years Early Detection/Prevention of Skin Cancer ■ Use sunscreen with SPF of 15 or higher ■ Avoid sun exposure from 10 a. 17 Early Detection of Colorectal Cancer ■ ■ ■ ■ ■ Screening starting at age 50 (ACOG. annually after age 40 Menopause ■ Cessation of menses with amenorrhea for 12 months ■ Symptoms ■ Vasomotor symptoms • Hot flushes • Night sweats ■ Urogenital symptoms • Thin. and tanning beds ■ Perform self-evaluation of the skin. report suspicious lesions ■ Thorough skin exam every 3 years age 20 to 39. Davis.m.
A. local hormone therapy should be considered ■ Alternatives to HRT should be considered if HRT used for sole purpose of osteoporosis prevention 18 . Food and Drug Administration (FDA) recommend HRT use only for moderate to severe menopausal symptoms at the lowest effective dose for the shortest period of time.GYN BASICS Copyright © 2006 by F. Davis.S. Hormone Replacement Therapy (HRT) ■ The decision of whether of not to use hormone replacement therapy should be made after careful medical evaluation and discussion with the primary health-care provider concerning the risk/benefit ratio for each woman ■ Current guidelines by the U. noting the risk/benefit ratio for each woman ■ If HRT prescribed solely for vaginal/vulvar symptoms.
Copyright © 2006 by F. Davis. fetal pole. and fetal cardiac activity ■ Validates location of pregnancy (intrauterine versus ectopic) ANTEPARTUM . A. 19 Establishing Pregnancy ■ Pregnancy may be assumed based on the presence of certain signs and symptoms Presumptive signs are subjective and recorded under the history of present illness ■ Probable and positive signs of pregnancy are objective and recorded as physical assessment findings Presumptive Amenorrhea Breast tenderness Quickening Nausea/ Vomiting Urinary frequency Probable ■ Positive pregnancy test ■ Uterine enlargement ■ Hegar’s sign (softening of lower uterine segment) ■ Goodell’s sign (softening of cervix) ■ Chadwick’s sign (bluish hue to cervix/vagina) ■ Braxton Hicks contractions Positive Fetal heart beat auscultated Fetal movement palpated per practitioner Ultrasound of gestation ■ Urine pregnancy test ■ Reacts with human chorionic gonadotropin (hCG) ■ Performed on first voided urine sample of the day. positive results possible before the first day of a missed menstrual period ■ Serum pregnancy test ■ Useful in monitoring expected pattern of progression of hCG. detects hCG as early as 9 days postconception ■ Ultrasound ■ Confirms presence of gestational sac.
Davis. …………………… estimated date of birth Naegele’s Rule ■ Formula used to estimate date of delivery ■ Count back 3 months and add 7 days to the last normal menstrual period (LNMP) reported by the patient Example: The patient states that her LNMP was April 20th April is the 4th month 20th day 3 months 1st month 7 days 27th day The baby is estimated to be due on January 27th of the following year Trimesters of Pregnancy Normally. pregnancy continues for 40 weeks or 280 days 1st trimester 2nd trimester 3rd trimester conception until 12 weeks’ gestation 13 weeks until 27 weeks’ gestation 28 weeks until 40 weeks’ gestation 20 . …………………… estimated date of confinement ■ EDB. Estimated Date of Delivery ■ Establishing an accurate date of delivery is important to: ■ Determine timing of antenatal screening ■ Monitor growth of the fetus ■ Scrutinize timing of delivery ■ Common abbreviations denoting delivery date are: ■ EDD. …………………… estimated date of delivery ■ EDC. A.ANTEPARTUM Copyright © 2006 by F.
Copyright © 2006 by F. ■ Medical history ■ Chronic illness ■ Current and recent medication ■ Recent acute illness ■ Childhood illnesses ■ Surgical history ■ Problems with anesthesia ■ Previous surgeries ■ Uterine/cervical surgeries ■ Obstetrical history ■ Type of deliveries: vaginal/cesarean ■ Complications with past pregnancies ■ Infertility ■ Documentation of obstetrical history Descriptive Term Gravida (G) Term (T) Preterm (P) Abortion (A) Living (L) Definition Number of pregnancies Number of deliveries after 37 weeks Number of deliveries after 20 weeks but before 38 weeks Number of deliveries before 20 weeks. Davis. A. 21 Schedule of Prenatal Visits (low-risk pregnancy) ■ Monthly until 28 weeks’ gestation ■ Biweekly from 28 weeks until 36 weeks ■ Weekly from 36 weeks until delivery Prenatal Health History Performing a thorough health history in the prenatal period is essential to planning nursing care and identifying highrisk women. either spontaneous or induced Number of living children ANTEPARTUM .
She states that she lost a baby in her second month. one abortion) T: 1 (her son was born on his due date) P: 2 (her daughters were each born a month early) A: 1 (she lost a pregnancy at approximately 8 weeks) L: 3 (reports three children at home) Document as G5-1213 Documentation Example 2: The same prenatal client may also be described as G5 (5 pregnancies) P3 (number of live births). Documentation Example 1: The prenatal client states having three children at home. ■ Sexual history ■ Number of sexual partners ■ Sexually transmitted infections ■ Sexual abuse ■ Methods of contraception ■ Condom use ■ Social history ■ Use of recreational drugs ■ Smoking ■ Domestic abuse ■ Educational level/ability to read ■ Economic status ■ Type of health insurance ■ Need for community referrals • Transportation • Nutrition • Medications 22 . Davis. 3 children at home. She reports that her son was born on his due date. G: 5 (currently pregnant.ANTEPARTUM Copyright © 2006 by F. pregnancies ended before 20 weeks are not counted as “P” in this method. but her daughters were both born a month early. A.
Davis. 23 Physiological Changes in Pregnancy Heart rate ↑ Cardiac output ↑ Blood volume ↑ Blood pressure * Systemic vascular resistance ↓ *slight↓ with return to baseline by 3rd trimester Stroke volume ↑ Red blood cells ↑ Hemoglobin ↓ Hematocrit ↓ White blood cells ↑ Glomerular filtration rate ↑ ↑ Increase ↓ Urine output ↑ Decrease ↔ Basal metabolic rate ↑ No change Respiratory rate ↔ Hormonal Changes in Pregnancy Hormone Estrogen ↑ ↑ ↑ ↑ ↑ ↑ Functions Increase uterine muscle mass Increase blood flow to uterus Prepare breasts for lactation Relax venous walls Inhibit uterine contractions Stimulate estrogen/progesterone production Discourage uterine contraction Remodeling of collagen Maturation of breast ducts/alveoli Stimulate lactation Insulin antagonist Allow adequate glucose for fetal demand Progesterone Human chorionic gonadotropin (hCG) Relaxin Prolactin Human placental lactogen ANTEPARTUM . A.Copyright © 2006 by F.
and body mass index (BMI) ■ Obtain urine specimen and test for presence of: Substance Glucose Protein Expected Finding Negative/Trace Negative/Trace ■ Auscultate fetal heart tones ■ Measure fundal height in centimeters from symphysis pubis to the top of the fundus ■ Uterine size increases in pregnancy in a predictable pattern and is measured to gauge fetal growth ■ Fundal height that is lagging or greater than expected should be further investigated Weeks’ Gestation 12 16 20 21–36 Fundal Height Just above symphysis pubis Halfway between symphysis pubis and the umbilicus At the umbilicus Fundal height generally matches weeks gestation in centimeters EXAMPLE: Fundal height at 28 weeks should be approximately 28 cm.ANTEPARTUM Copyright © 2006 by F. 24 . Nursing Care with First Prenatal Visit ■ Determine EDD based on LNMP ■ Document current gestational age (gestational wheel is a tool for quick reference to current gestational age) ■ Document baseline vital signs ■ Document height. weight. Davis. A.
A. Davis.Copyright © 2006 by F. Nursing Health Assessment: A Critical Thinking.A. (2003). (From Dillon PM. Philadelphia: F Davis. p 736. ■ Provide appropriate education for gestational age ■ Discuss procedure for lab testing ANTEPARTUM . 25 Fundal height.) . Case Study Approach.
000 mm3 Negative Negative 1:8 Immune AA. Davis. AB.000–400. O Negative/Positive Negative 11. B.5 mg/dL 33% 150. Common Laboratory Tests HIV *Check state laws regarding HIV testing in pregnancy Blood type Rh factor Antibody screen Hemoglobin Hematocrit Platelets WBC RPR Hepatitis B antigen Rubella titer Hemoglobin electrophoresis Chlamydia culture Gonorrhea culture Pap smear Expected Finding in Pregnancy Negative A. A.000 mm3 5.000–12. unaffected Negative Negative Normal cytology 26 .ANTEPARTUM Copyright © 2006 by F.
A positive result suggests the need for further testing (Continued text on following page) ANTEPARTUM . A. Rh and antibody status Administer Rh (D) immune globulin if indicated Monitor patient for postprocedure cramping or bleeding Monitor fetal heartbeat NOTE: This is a screening method only. and estriol) Nursing Considerations Position to avoid supine hypotension.Copyright © 2006 by F. Davis. folded towel under right hip if supine Review blood type. hCG. 27 Diagnostic Testing in Early Pregnancy Diagnostic Test Ultrasound Performed throughout pregnancy Clinical Applications: ■ Confirm and date pregnancy ■ Verify pregnancy location ■ Detect fetal cardiac activity ■ Measure fetal growth ■ Detect fetal anomalies ■ Measure amniotic fluid index ■ Determine fetal position ■ Determine placental position ■ Measure cervical length ■ Adjunct to invasive procedures Chorionic villi sampling (CVS) Performed at 10–12 weeks Clinical Application: ■ Chromosomal analysis Amniocentesis Performed throughout pregnancy Clinical Applications: ■ Chromosomal analysis is desired ■ Measure AFP ■ Measure bilirubin level ■ Determine lung maturity ■ Lecithin/Sphingomyelin Ratio (L/S Ratio) ■ Phosphatidylglycerol (PG) ■ L/S Ratio of 2:1 and positive PG indicative of fetal lung maturity Maternal Serum Triple Screen (tests maternal serum for AFP.
Davis. frequent meals Eat crackers before rising Avoid pungent odors. Diagnostic Test Performed at 15–18 weeks Clinical Applications: ■ Serum screen for neural tube defects/ Down syndrome Nursing Considerations Results adjusted according to documented gestational age. causing pregnancy associated discomforts ■ Offer suggestions to lessen discomforts ■ Teach patient to report symptoms that may indicate a potential complication (in red) Discomfort Urinary frequency Patient Education Related to uterine position/weight Encourage frequent emptying of bladder Discourage limiting oral fluids Report burning or pain with urination Related to elevated hormone levels Encourage small. spicy or greasy food Discuss limited time frame for nausea (subsides around 12 weeks’ gestation) Report excessive vomiting (Continued text on following page) Nausea and vomiting 28 . race. and weight. presence of diabetes/multiple gestation. maternal age. A.ANTEPARTUM Copyright © 2006 by F. the nurse must accurately document these variables on the laboratory requisition Interpretation of Results Defect Risk for open neural tube Risk for Down syndrome AFP hCG WNL Estriol WNL ↑ ↓ ↑ ↓ ↑ elevated ↓ decreased WNL within normal limits Education in the Early Prenatal Period ■ Elevated estrogen and progesterone levels in early pregnancy generate changes in the body.
suicidal thoughts Related to vasocongestion of mucous membranes Avoid tampon use and douching Wear peri-pad to absorb discharge Encourage cotton underwear Report vaginal discharge with an odor or color. or frequent nosebleeds Leukorrhea Breast discomfort Fatigue Nasal stuffiness/ epistaxis ANTEPARTUM . A. inability to care for self. vaginal bleeding. 29 Education in the Early Prenatal Period (Cont’d) Discomfort Emotional lability Patient Education Related to hormone changes Discuss normalcy of emotional changes with patient and partner Ambivalence normal in first trimester Report constant crying.Copyright © 2006 by F. green/yellow nasal discharge. Davis. or leaking of amniotic fluid Hormone-related breast development often first presumptive sign of pregnancy Wear a supportive bra Colostrum may be expressed in pregnancy Introduce the value of breastfeeding Introduce/reinforce breast self-exam Report any breast lump or unusual discharge Related to rapid hemodynamic and metabolic changes in the first trimester Encourage naps during the day Encourage prenatal vitamins Encourage healthy diet Report syncope and vertigo Related to vasocongestion of mucous membranes Increased humidity in home may help Warm compresses to sinus area Avoid over-the-counter (OTC) cold remedies Report fever.
advise patient to avoid exposure. Teratogen Viruses Patient Education Avoid contact with ill persons Report fever. illness to primary health-care provider Infections causing serious harm to fetus: Toxoplasmosis Other (hepatitis B) Rubella Cytomegalovirus Herpes simplex virus (HSV) Avoid exposure to: Mercury Radiation Lead Other environmental toxins Recreational Discourage alcohol use Encourage patient to stop smoking Refer to smoking cessation classes Assess use of illicit drugs Refer to addiction counselors Discuss the role of drug screening Discuss adverse effects to fetus OTC/Herbal Caution patient to discuss use of all OTC/herbal medications with primary health-care provider Prescription List all medications prescribed since LNMP on prenatal record Investigate drug classification in drug guide book Inform primary health-care provider of drug list Record drugs/dosages on prenatal record Environmental Drugs 30 . Teratogen Exposure Teratogens are substances that are harmful to the developing fetus. Davis. rash.ANTEPARTUM Copyright © 2006 by F. A.
Copyright © 2006 by F. Food and Drug Administration Nutrition ■ ■ ■ ■ ■ ■ Inquire about dietary practices Gather 24-hour diet recall Suggest an addition of 300 healthy calories per day Encourage daily prenatal vitamin with 400 g folic acid Suggest 6–8 glasses of water daily Encourage to follow food pyramid in daily choices ANTEPARTUM . 31 Pregnancy Classification of Medications Drug Class A B C D X Pregnancy Safety No evidence of fetal risk No animal risk demonstrated. A.S. Davis. human fetal risk not demonstrated Animal study demonstrates risk No adequate study in humans Evidence of human risk Weigh risk/benefit ratio of drug Definite fetal risk Contraindicated Source: U.
(From U. KEY Fat (naturally occurring and added) Sugars (added) These symbols show fats and added sugars in foods Fats. cereal.) 32 .Copyright © 2006 by F. pasta and grain group 6-11 servings Food Pyramid. A. Department of Agriculture and Department of Health and Human Services.oils and sweets Use sparingly Dairy group 2-3 servings Protein group 2-3 servings Vegetable group 3-5 servings Fruit group 3-5 servings ANTEPARTUM Bread.S. Davis.
A. Davis.Copyright © 2006 by F.5–1 pound per week Exercise in Pregnancy ■ Physical activity in pregnancy is recommended unless contraindicated by medical complications ■ Avoid sports with potential for abdominal trauma or falls ■ Avoid overheating and supine positioning ■ STOP exercise if experiencing ■ Vaginal bleeding ■ Cramping ■ Leaking of amniotic fluid ■ Decreased fetal movement ■ Dizziness ■ Headache ■ Chest pain ■ Calf pain ■ Dyspnea ANTEPARTUM . 33 Weight Gain in Pregnancy ■ Recommended weight gain depends on prepregnancy weight/BMI Prepregnant Weight Normal Overweight Underweight Recommended Weight Gain 25–35 pounds 15–25 pounds 28–40 pounds ■ Assess and document the pattern of weight gain Trimester 1st 2nd & 3rd Suggested Weight Gain 1–4 pounds total 0.
A.ANTEPARTUM Copyright © 2006 by F. Sexuality in Pregnancy ■ Sex not restricted in pregnancy unless risk factors exist for bleeding or preterm labor ■ Discuss expected changes in sexuality ■ Change in libido ■ Body image changes ■ Braxton-Hicks contractions with orgasm ■ Comfortable positioning for intercourse Warning Signs During Pregnancy Patient should be instructed to notify primary health-care provider if experiencing any of the following symptoms: Warning Sign Vaginal bleeding Possible Cause Abortion Placenta previa Abruptio placentae Preterm labor Premature rupture of amniotic fluid Incontinence of urine Urinary tract infection Pregnancy-induced hypertension (PIH) Pregnancy-induced hypertension (PIH) Preterm labor Pregnancy-induced hypertension (PIH) Fetal demise Infection Hyperemesis gravidarum Leakage of vaginal fluid Dysuria Headache Altered vision Blurred vision Flashes of light Abdominal cramping Severe epigastric pain Decreased fetal movement Elevated temperature Persistent vomiting 34 . Davis.
Nursing Health Assessment: A Critical Thinking. A.A. (2003). ANTEPARTUM . Case Study Approach. Philadelphia: F Davis Company. 35 Nursing Care for Return Prenatal Visits ■ Measure pulse and blood pressure (BP) ■ Compare BP to initial reading (measured in the same position at each visit) ■ Measure weight and compare to last reading ■ Note total weight gain ■ Note pattern of weight gain ■ Obtain urine specimen and test for protein and glucose ■ Measure fundal height ■ Determine fetal position ■ Perform Leopold’s Maneuver • Palpate fetal body part in fundus (A) • Palpate for fetal back (B) • Palpate for presenting part (C) • Palpate for attitude of presenting part (D) Leopold’s Maneuver. (From Dillon PM. p 739.Copyright © 2006 by F.) . Davis.
RSA = right sacral anterior) (From Dillon PM. LOA = left occiput anterior. Philadelphia: F Davis Company.A. (2003). Nursing Health Assessment: A Critical Thinking.) . Davis. ■ Place Doppler on maternal abdomen over fetal back to monitor fetal heart tones (FHT) Placement of Doppler. (LSA = left sacral anterior. ROA = right occiput anterior.ANTEPARTUM Copyright © 2006 by F. LMA = left mentum anterior. p 737. LOP = left occiput posterior. ■ ■ ■ ■ ■ Record presence of fetal movement Assess for presence of edema/deep tendon reflexes Record symptoms since last visit Discuss procedure for diagnostic testing Provide patient education appropriate for gestational age 36 . ROP = right occiput posterior. RMA = right mentum anterior. A. Case Study Approach.
drink. A.Copyright © 2006 by F. 37 Diagnostic Tests 1-hour glucose screen Performed at 24–28 weeks Nursing Considerations Administer 50 g glucose load Patient should not eat. Davis. or smoke during the test Serum sample drawn in 1 hour EXPECTED RESULT 140 mg/dL Clinical Application Detection of gestational diabetes Group B vaginal culture Performed between 35–37 weeks Clinical Application Positive culture treated with antibiotics in labor to prevent newborn transmission Fetal fibronectin (fFN) Performed between 22 and 35 weeks in women at high risk for preterm labor Clinical Application Negative predictive value for preterm labor Antibody screen Performed at 28 weeks in Rh negative women Explain test to patient Collect vaginal/rectal specimen EXPECTED RESULT Negative NO intercourse 24 hours prior to exam Cervical/posterior fornix specimen EXPECTED RESULT Negative Clinical Application Detects presence of positive antibodies in serum of Rh negative women Administer Rh (D antigen) immune globulin at 28 weeks to prevent antibody formation if Rh negative and antibody screen negative EXPECTED RESULT Negative ANTEPARTUM .
Davis.ANTEPARTUM Copyright © 2006 by F. Education in the Second and Third Trimester ■ Teach patient to count fetal movement and report change in fetal movement pattern to primary health-care provider immediately (See bulleted information under “Teach patient to count fetal movements” on page 50) ■ Discuss fetal growth and development ■ Demonstrate palpating for contractions ■ Discuss symptoms of preterm labor ■ Lower backache ■ Increased vaginal discharge ■ Bloody show ■ Leaking amniotic fluid ■ Contractions ■ Pelvic pressure ■ Differentiate between true and false labor True Labor Cervix dilates Contractions increase in intensity and frequency Leaking amniotic fluid. if indicated Epidural anesthesia class. if indicated Explore preparing for the newborn ■ Breastfeeding ■ Circumcision ■ Choosing a pediatrician ■ Car seat safety ■ Discuss the discomforts associated with late pregnancy and teach reportable symptoms (in red) 38 . A. bloody show ■ ■ ■ ■ ■ False Labor Cervix unchanged Contractions irregular and decrease with change of position/activity No evidence of change in vaginal discharge Encourage childbirth preparation class Discuss options for pain control in labor Cesarean preparation class.
Copyright © 2006 by F. localized heat to legs Related to hemodynamic changes Avoid sudden position change Avoid long periods without eating Avoid lying supine Report loss of consciousness (Continued text on following page) ANTEPARTUM . constant pain. Davis. 39 Discomfort Changes in pigmentation Linea nigra (pigmented line from umbilicus to pubic bone) Chloasma (deeper facial pigment) Striae (stretch marks) Round ligament pain (occasional. or bleeding Instruct patient how to palpate contractions Labor should occur after 38 weeks gestation Teach patient to differentiate between true and false labor Report signs of preterm labor Related to decreased venous return due to pressure of the gravid uterus Rest in lateral recumbent position Elevate legs when sitting Continue with 6–8 glasses water daily Report generalized edema Caused by increased venous stasis related to pressure from the gravid uterus Wear pregnancy support hose Avoid lengthy standing Change positions frequently Report pain. but will not prevent striae Report body rashes Braxton-Hicks contractions (false labor contractions) Ankle edema Varicose veins Faintness Related to round ligament stretching as uterus grows Change positions slowly Encourage good body mechanics Report abdominal cramping. redness. sharp lower abdominal pain) Patient Education Related to hormone changes in pregnancy. fade after pregnancy Moisturizers decrease itching. A.
frequent meals Lightening will lessen symptoms Report dyspnea with rest Related to fetal movement. A. iron supplement may worsen constipation Increase dietary fiber and water intake Encourage exercise Discourage enemas and laxatives Report painful or bleeding hemorrhoids Backache Shortness of breath Insomnia Leg cramps Constipation Hemorrhoids 40 . nocturia Teach relaxation techniques Encourage side-lying with pillow support Warm milk/shower before sleep Related to uterine pressure on the pelvic nerves or calcium imbalance Review daily calcium intake Teach signs of deep vein thrombosis Report pain. Davis. localized heat Related to decreased gastric motility. Patient Education Related to increased pressure on abdominal organs and sphincter relaxation Encourage small. frequent meals Avoid spicy foods Sit up after meals Report persistent symptoms Related to shift in posture due to gravid uterus Encourage low-heeled shoes Avoid standing for long periods Teach pelvic tilt exercises Report constant or rhythmic backache Related to upward diaphragmatic pressure exerted by the gravid uterus Allow more time for strenuous activities Eat small. redness.ANTEPARTUM Discomfort Heartburn Copyright © 2006 by F.
41 Pregnancy Complications Vaginal Bleeding (before 20 weeks’ gestation) May be related to spontaneous abortion. absence of fetus ANTEPARTUM .Copyright © 2006 by F. Davis. A. or gestational trophoblastic disease Spontaneous Abortion Loss of pregnancy before viability ■ Clinical Findings ■ Vaginal spotting (may pass clots) ■ Abdominal cramping ■ Cervical changes ■ Fetal heartbeat may be present or absent Ectopic Pregnancy Products of conception implant outside the uterus ■ Clinical Findings ■ Vaginal spotting ■ hCG lower than expected for dates ■ Lower abdominal pain ■ Ultrasound findings: absence of intrauterine gestational sac ■ If rupture occurs: • Positive Cullen’s sign (periumbilical bluish hue) • Shoulder pain • Signs of shock Gestational Trophoblastic Disease Abnormal proliferation of trophoblastic cells without viable fetus ■ Clinical Findings ■ Vaginal spotting (dark brown) ■ Fundal height greater than expected for dates ■ hCG greater than expected for dates ■ Excessive nausea and vomiting ■ Absence of fetal heart tones ■ Ultrasound findings: Snowflake-like clusters. ectopic pregnancy.
■ Nursing Care (vaginal bleeding/early pregnancy) ■ Monitor amount of bleeding ■ Assess vital signs ■ Observe for signs of shock ■ Auscultate for fetal heart tones (FHTs) ■ Collect passed tissue/clots ■ Monitor patient comfort ■ Check blood type and Rh factor ■ Administer Rh(D) immunoglobulin if indicated ■ Initiate IV fluids as ordered ■ Report lab/ultrasound findings ■ Attend to patient’s emotional needs Vaginal Bleeding (after 20 weeks’ gestation) May be related to placenta previa or abruptio placentae Placenta Previa Low-lying position of placenta in the uterus that partially or completely covers the cervical os ■ Clinical Findings ■ Painless bright red vaginal bleeding ■ Bleeding may be reported after intercourse ■ Uterine tone soft upon palpation ■ Interventions dependent on amount of bleeding and labor status ■ If partial placenta previa is noted in early gestation. repeat ultrasound later in pregnancy (may demonstrate absence of previa as uterus grows) ■ If labor active and os is covered. A. cesarean birth necessary ■ If bleeding controlled and labor absent.ANTEPARTUM Copyright © 2006 by F. conservative management • Patient Teaching (Conservative Management) – No tampon use – No sexual intercourse – Monitor and report bleeding – Patient instructed to report placenta placement when admitted to hospital – Cesarean preparation class – Count fetal movements 42 . Davis.
A. Davis. C ANTEPARTUM .Copyright © 2006 by F. 43 Internal os Blood External os A Membranes Internal os Blood External os B Membranes Internal os Blood External os Placenta previa.
with little relaxation ■ Vaginal bleeding ■ Bleeding may be concealed within the uterine cavity ■ Fetal heart tones may be nonreassuring ■ Nursing Care (vaginal bleeding/late pregnancy) ■ Monitor amount of bleeding ■ Check vital signs ■ Observe for signs of shock ■ Evaluate fetal heart tones ■ Palpate uterine tone ■ Apply electronic fetal monitor (EFM) ■ REPORT alterations in fetal heart rate pattern ■ REPORT hypertonic contractions with poor resting tone ■ Do not attempt vaginal exam until placenta placement verified ■ Initiate IV fluids ■ Report laboratory and ultrasound findings ■ Prepare staff for possible cesarean birth ■ Attend to patient’s emotional needs Hyperemesis Gravidarum Intractable vomiting in pregnancy with resultant weight loss and dehydration ■ Nursing Care ■ Assess vital signs ■ Observe for signs of dehydration ■ Review electrolytes ■ Access IV site as ordered ■ Record fetal heart tones ■ Record intake and output ■ Record daily weight ■ Check urine for ketones ■ Administer antiemetics as ordered 44 . boardlike.ANTEPARTUM Copyright © 2006 by F. Davis. Abrupto Placentae ■ Clinical Findings ■ Abdominal pain (sudden onset. intense and localized) ■ Fundus firm. A.
Complete separation (concealed hemorrhage) ANTEPARTUM . A.Copyright © 2006 by F. Davis. Abruptio Placentae Premature separation of the placenta. may be partial or complete 45 Partial separation (concealed hemorrhage) Partial separation (apparent hemorrhage) Abruptio placentae.
A. Preterm Labor Onset of regular labor before the 37th completed week of gestation ■ Clinical Findings ■ Rhythmic lower abdominal cramping ■ Complaints of backache ■ Increased vaginal discharge ■ Downward pelvic pressure ■ Leaking of amniotic fluid ■ Vaginal spotting ■ Cervical effacement/dilation ■ Shortening cervical length ■ Nursing Care ■ Determine gestational age ■ Assess uterine tone ■ Auscultate fetal heart tones and apply EFM ■ Obtain vaginal/urine cultures ■ Assess for leaking amniotic fluid • Ferning—Microscopically. the nitrazine paper will change from yellow to blue ■ Perform vaginal exam to determine dilation and effacement of the cervix ■ Position side-lying ■ Initiate IV fluids as ordered ■ Administer corticosteroid to mother • Accelerates maturity of fetal lungs • Most benefit 24 hours after administered ■ Initiate tocolytic therapy 46 . amniotic fluid will resemble the leaves of a fern plant • Nitrazine paper—Due to the alkaline nature of amniotic fluid. Davis.ANTEPARTUM Copyright © 2006 by F.
Copyright © 2006 by F. Davis. A. 47 Tocolytic Medication Nursing Precautions (Closely monitor maternal and fetal tolerance to medication) ■ Monitor for respiratory depression ■ Assess deep tendon reflexes ■ Watch level of consciousness ■ Monitor intake and output ■ Assess fetal heart tones ■ Monitor for contractions ■ Auscultate lungs ■ Report magnesium sulfate levels ■ Monitor for hypotension ■ Assess for tachycardia ■ Assess patient for tremors ■ Assess for pulmonary edema ■ Screen glucose/potassium ■ Assess for cardiac arrhythmias and chest pain ■ Monitor fetal heart tones ■ Monitor contractions ■ May lead to premature closure of ductus arteriosus ■ Monitor for hypotension ■ Assess for tachycardia Magnesium Sulfate ANTIDOTE: Calcium gluconate at bedside β-adrenergic agonist terbutaline ritodrine Prostaglandin antagonist indomethacin Calcium channel blockers nifedipine Preeclampsia Hypertensive disorder of pregnancy with multisystem involvement ■ Clinical Findings ■ Blurred or altered vision ■ Epigastric pain ■ Headache ■ Edema ■ Proteinuria ■ Hyperreflexia ■ Hypertension ANTEPARTUM .
Davis.ANTEPARTUM Copyright © 2006 by F. ■ Nursing Care ■ Closely monitor vital signs ■ Assess deep tendon reflexes ■ Dipstick urine for protein ■ Record presence of edema ■ Palpate tone of fundus ■ Auscultate fetal heart rate and apply EFM ■ Monitor patient comfort ■ Collect 24-hour urine ■ Place patient in side-lying position ■ Keep environment quiet and dim ■ Institute seizure precautions • Side rails up and padded • Bed in low position • Suction equipment available at bedside • Oxygen available at bedside ■ Initiate IV fluids as ordered ■ Monitor intake and output ■ Initiate medications as ordered Drug Therapy Magnesium sulfate Anti-hypertensives Nursing Precautions See precautions listed under preterm labor for magnesium sulfate Administer slowly Closely monitor for hypotension Eclampsia ■ Clinical Findings ■ Worsening of symptoms of preeclampsia ■ Seizure activity HELLP Syndrome ■ Clinical Findings ■ Worsening symptoms of preeclampsia ■ Malaise 48 . A.
Davis.Copyright © 2006 by F. A. 49 ■ Epigastric pain ■ Nausea/vomiting ■ Laboratory findings: Hemolysis Elevated Liver enzymes Low Platelets Gestational Diabetes Glucose intolerance that is first recognized in pregnancy ■ Clinical Findings ■ Polyuria ■ Polydipsia ■ Polyphagia ■ Fatigue ■ Blurred vision ■ Glucosuria ■ Recurrent yeast infections ■ Slow healing wounds ■ Abnormal glucose results • 1-hour glucose 140 mg/dL • Abnormal 3-hour glucose tolerance test: 2 out of 4 values elevated FBS 1-hour 2-hour 3-hour 95mg/dL 180mg/dL 155mg/dL 140mg/dL ■ Outpatient Management ■ Dietician consult for ADA diet instructions ■ Discuss pathophysiology of gestational diabetes with patient ■ Demonstrate home glucose monitoring ■ Review range for glycemic control ■ Demonstrate logging of glucose results ■ Discuss role of exercise in glycemic control ■ Demonstrate urine ketone testing ANTEPARTUM .
fetal movement may be stimulated vibroacoustically ■ Report findings to primary health-care provider EXPECTED FINDINGS: REACTIVE Two accelerations of FHR within 20 minutes that are at least 15 BPM above the baseline rate and last for a minimum of 15 seconds each Contraction Stress Test (CST) Also called Oxytocin Challenge Test (OCT) ■ Procedure used to determine fetal tolerance to the stress of uterine contractions ■ Calculate gestational age (should not be performed on preterm patients. test stimulates contractions) 50 . FHR acceleration with fetal movement is reassuring and a sign of fetal well being ■ Place patient in a Semi-Fowler’s or side-lying position ■ Record vital signs and apply electronic fetal monitor ■ Record baseline fetal heart rate and monitor FHR pattern for 20–30 minutes ■ Patient marks paper with each perceived fetal movement ■ NST may take longer with absence of accelerations. REPORT immediately Fetal Surveillance in Pregnancy Nonstress Test (NST) ■ Procedure used to monitor fetal response to movement. ■ Demonstrate insulin administration ■ Teach patient to count fetal movements • Find comfortable position in quiet place and concentrate on fetal movement • Document time of first fetal movement and time required for 10 movements (should not take more than 2 hours) • If pattern of movement decreased.ANTEPARTUM Copyright © 2006 by F. A. Davis.
A. Davis.Copyright © 2006 by F. 51 ■ ■ ■ ■ Place patient in side-lying position Record vital signs Apply EFM and record baseline fetal heart rate for 20 minutes Stimulate uterine contractions until three contractions occur within 10 minutes lasting 40 seconds each ■ Contractions can be stimulated with ■ Nipple stimulation or ■ IV Oxytocin per hospital protocol ■ Document FHR response to contractions EXPECTED FINDING: NEGATIVE Three contractions that last at least 40 seconds within 10 minutes without the presence of late or significant variable decelerations Biophysical Profile (BPP) ■ Ultrasound exam observing four specific fetal criteria ■ Nonstress test included as a fifth parameter ■ Scoring of Biophysical Profile (BPP) Parameter Measured Fetal tone Fetal breathing Gross fetal movement Amniotic fluid volume FHR reactivity per NST Expected Findings (within 30 minutes) Active flexion/extension One or more episodes lasting 30 seconds Three or more discrete movements Single vertical pocket 2 cm Reactive Score 2 2 2 2 2 EXPECTED FINDING: NEGATIVE BPP Score of at least 6/8 if NST omitted BPP Score of at least 8/10 if NST included ANTEPARTUM .
A. Davis. and birth ■ Upon admission to labor and delivery. triage. the nurse should: ■ Determine reason for admission ■ Gather patient history ■ Review prenatal health record ■ Perform a physical exam Prenatal History ■ ■ ■ ■ ■ ■ ■ ■ ■ Estimated date of delivery Current gestational age Complications in pregnancy Results of laboratory tests and ultrasounds Medications used in pregnancy Presence of vaginal discharge or bleeding Amniotic fluid status Presence of fetal movement Onset and pattern of contractions Obstetrical History Type of births ■ Vaginal ■ Instrumentation ■ Episiotomy ■ Length of labor ■ Cesarean ■ Reason for cesarean ■ Document type of incision • Low-transverse • Classical ■ Complications of birth ■ Neonatal outcomes Medical History ■ ■ ■ ■ Chronic health problems Current medications Time and description of last oral intake Allergies to food/medicine 52 .INTRAPARTUM Copyright © 2006 by F. Intrapartum ■ Patients present to labor and delivery for medical procedures.
Davis. A.Copyright © 2006 by F. 53 Surgical History ■ Complications with anesthesia ■ Date/reason for surgery Perform a Physical Exam ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess maternal vital signs Collect urine specimen for protein and glucose Assess for presence of edema Assess deep tendon reflexes Perform Leopold’s maneuver to determine fetal position Assess fetal heart rate (FHR) Measure fundal height Determine the frequency. and intensity of contractions Determine the stage and phase of labor Assess cervical changes ■ Dilation (0 to 10 cm) ■ Effacement (0–100%) ■ Station (Level of presenting fetal part in relation to the ischial spines of the maternal pelvis) Iliac crest Iliac crest Ischial spine Ischial tuberosity –5 –4 –3 –2 –1 0 1 2 3 4 5 Ischial spine Ischial tuberosity Perineum Station INTRAPARTUM . duration.
737. ■ Count FHR between. INTRAPARTUM ■ Note presence. p. A.A. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking.Copyright © 2006 by F. during. Davis. Case Study Approach. and odor) Nursing Responsibility with Fetal Monitoring ■ Position patient to avoid supine hypotension ■ Assess FHR and interpret findings ■ Compare FHR to maternal pulse to ensure monitoring of fetal heart and not maternal rate ■ Implement nursing interventions for nonreassuring patterns of FHR ■ Evaluate effectiveness of nursing interventions for nonreassuring patterns ■ Update primary health-care provider with FHR status ■ Document findings and interventions ■ Assessment of the FHR may be intermittent or continuous Intermittent Auscultation ■ Auscultate fetal heart tones (FHT) over fetal back with Doppler or fetoscope Fetoscope. and immediately following a contraction ■ Note both rate and rhythm of FHR ■ Frequency of auscultation based on: ■ Phase/stage of labor ■ Hospital protocol 54 . Philadelphia: F Davis. and amount of bloody show ■ Check status of amniotic membranes ■ Intact ■ Bulging ■ Ruptured (note color.) . color. amount.
Copyright © 2006 by F. 55 ■ Risk status ■ Labor interventions ■ Physician orders Stage/Phase of Labor Stage Stage Stage Stage 1: Latent phase 1: Active phase 1: Transition 2 Frequency of FHR Monitoring Every Every Every Every 30–60 minutes 15–30 minutes 5–15 minutes 5–15 minutes Continuous Fetal Monitoring Monitored with external or internal fetal monitoring External Fetal Monitoring (EFM) ■ ■ ■ ■ ■ Encourage patient to void before applying EFM Test internal circuitry of EFM Place ultrasound transducer over fetal back Place toco transducer over uterine fundus Monitor for 20–30 minutes on admission Ultrasound transducer Toco transducer (FHR) (uterine contractions) External fetal monitor INTRAPARTUM . Davis. A.
Copyright © 2006 by F. A. Davis. INTRAPARTUM Internal Fetal Monitoring ■ Indicated when EFM not providing adequate FHR or contraction tracing ■ May be implemented only after amniotic sac is ruptured ■ FHR measured by spiral electrode attached to presenting part ■ Uterine tone measured by intrauterine pressure catheter (IUPC) ■ Resting tone of uterus averages 5–15 mmHG ■ Contraction tone of uterus averages 50–85 mmHG Scalp electrode Catheter Internal fetal monitor Evaluating the Baseline Fetal Heart Rate ■ ■ ■ ■ ■ Normal baseline FHR is 110–160 BPM Evaluated between contractions over 10 minutes Documented as a range Does not include accelerations or decelerations Influences on the fetal heart rate ■ Central nervous system Fetal sleep ↓ variability of FHR Fetal movement ↑ variability of FHR ■ Autonomic nervous system Sympathetic branch (↑ FHR) Parasympathtic branch (↓ FHR) ■ Baroreceptors respond to ↓ blood pressure with subsequent ↓ FHR ■ Chemorecptors sense ↓ oxygen and ↑ FHR 56 .
A.Copyright © 2006 by F. 57 Normal fetal heart rate.) INTRAPARTUM . bottom: contractions. (Top: fetal heart rate. Davis.
Davis. terbutaline. albuterol) ■ BRADYCARDIA ■ FHR less than 110 BPM for 10 minutes ■ Possible cause: • Vagal stimulation • Hypoxia • Anesthetic agents ■ VARIABILITY ■ Fluctuations in FHR over time ■ Important indicator of fetal well-being ■ Sensitive to hypoxia and changes in Ph ■ Short-term variability (STV) • Beat-to-beat changes in FHR • Documented as present or absent • Most accurate with internal FHR monitoring ■ Long-term variability (LTV) • Pattern of fluctuations in FHR baseline (Expected pattern highlighted in blue) Long-Term Variability Absent (0–2 BPM) Minimal (3–5 BPM) Average (6–10 BPM) Moderate (11–25 BPM) Marked ( 25 BPM) Possible Cause Maternal medication Fetal sleep Fetal hypoxia Adequate fetal oxygenation Early sign of mild fetal hypoxia Fetal stimulation 58 . INTRAPARTUM Changes to Baseline Fetal Heart Rate ■ TACHYCARDIA ■ FHR greater than 160 BPM for 10 minutes ■ Possible cause: • Infection/hyperthermia • Fetal hypoxia • Maternal medications (ex. A.Copyright © 2006 by F.
Variable) ■ EARLY DECELERATION • Decrease in FHR occurring with contractions • Onset occurs before the contraction peak • Recovery to baseline rate occurs by contraction end • Commonly seen in active phase of first stage of labor • Mirrors the contraction • Usually benign finding • Continue to monitor FHR pattern for nonreassuring patterns • Possible cause: Fetal head compression INTRAPARTUM . 59 Changes in Fetal Heart Rate ■ The nurse interprets changes to baseline FHR as reassuring or nonreassuring ■ The nurse must act on nonreassuring FHR patterns ■ ACCELERATIONS ■ Sudden increase of fetal heart rate over baseline ■ Indication of fetal well-being ■ Reassuring pattern ■ Possible cause: Fetal movement/stimulation Acceleration. (Top: fetal heart rate.Copyright © 2006 by F. Late. A. bottom: contractions. Davis.) ■ DECELERATIONS (Early.
) ■ LATE DECELERATIONS • Decrease in FHR occurring with contractions • Onset with or after the peak of contraction • Recovery to baseline rate occurs after contraction ends • Repetitive pattern • Nonreassuring requiring intervention Late deceleration. bottom: contractions.) 60 . (Top: fetal heart rate. INTRAPARTUM Early deceleration.Copyright © 2006 by F. bottom: contractions. (Top: fetal heart rate. A. Davis.
(Top: fetal heart rate. Davis. contraction status.Copyright © 2006 by F. A. bottom: contractions. 61 • Etiology: decreased uteroplacental blood flow/oxygen delivery related to – Maternal supine hypotension – Hypertension – Hyperstimulation of uterus – Diabetes – Preeclampsia – Anemia – Chronic maternal disease ■ VARIABLE DECELERATIONS • Decrease in FHR occurring without regard to contractions • Can range from mild to severe • May be persistent or occasional • Shaped like a “V” or “W” • Onset variable • Nonreassuring variable decelerations – Repetitive and/or deep decrease in FHR – Associated with minimal variability – Prolonged with slow return to baseline FHR • Possible causes: – Cord prolapse – Umbilical cord compression • Intervention: AMNIOINFUSION may be performed to try to relieve cord compression – Infusion of warmed normal saline into uterus via sterile catheter – Monitor FHR.) INTRAPARTUM . and maternal temperature – Verify that fluid is exiting uterus Variable deceleration.
Copyright © 2006 by F. A. Davis.
Nursing Interventions for Nonreassuring FHR Patterns
■ Turn patient to side-lying position ■ Shifts weight of gravid uterus off the inferior vena cava ■ Allows for improved uteroplacental blood flow ■ O2 per mask at 8–10 L/min ■ Improve oxygen delivery to fetus ■ Discontinue IV Oxytocin ■ Decreases uterine contractions, thus improving uteroplacental blood flow ■ Hydrate patient as indicated ■ Corrects identified maternal hypotension ■ Notify primary health-care provider ■ Document findings ■ Document baseline FHR (baseline FHR should be between 110 and 160 BPM) ■ Describe variability ■ Note changes in FHR in relation to contractions ■ Document nursing interventions, effectiveness of interventions and notification of primary health-care provider
■ Frequency ■ Beginning of one contraction to the beginning of the next contraction ■ Documented as range, for example, “every 2–5 minutes” ■ Duration ■ Beginning of the one contraction to the end of the same contraction ■ Documented as a range, for example, “lasting 60–90 seconds” ■ Intensity ■ Palpate uterus both during and after contraction ■ Resting tone palpated between contractions ■ Document intensity of uterine contractions (findings subjective unless monitored with IUPC)
Copyright © 2006 by F. A. Davis.
Intensity Mild Moderate Strong Palpated by nurse Fundus easily indented Requires more pressure to indent fundus Unable to indent fundus
Beginning of contraction I n cr eme n
Interval between contractions
Duration of contraction
Beginning of contraction
Frequency of contractions
Nursing Care of the Laboring Patient
First Stage of Labor: Dilation Divided into Three Phases: Latent, Active, Transition
e re m Dec
Copyright © 2006 by F. A. Davis.
Stage 1: Latent Phase
■ Power: Contractions palpate mild, every 5–10 minutes, lasting 30–45 seconds ■ Psyche: Patient is usually excited about the start of labor ■ Measuring progress in labor: Cervical dilation (0–3 cm) ■ Passageway: Encourage frequent position changes that optimize fetal descent, rotation, and widen pelvic outlet ■ Ambulation (with intact amniotic sac) ■ Squatting ■ Hands and knees position ■ Rocking chair ■ Side-lying ■ Check bladder status and encourage patient to void every 2 hours ■ Nursing considerations ■ Monitor vital signs every 30–60 minutes ■ Fetal heart tones every 30–60 minutes ■ Hydration • Oral fluids as ordered • Monitor intake and output ■ Pain management ■ Pain medication usually avoided until in active labor ■ Techniques for pain management • Hydrotherapy – Shower – Labor tub • Massage – Effluerage: light, circular stroking of gravid abdomen – Counter-pressure to back • Relaxation techniques – Progressive relaxation – Patterned breathing – Soft music and lighting – Distraction
Stage 1: Active Phase
■ Power: Contractions palpate moderate to strong, every 2–5 minutes lasting 40–60 seconds
Davis. may cause respiratory depression (in the neonate) Caution with women who are opiate dependent.Copyright © 2006 by F. 65 ■ Psyche: Patient may have greater difficulty coping with the pain of contractions ■ Measuring progress in labor: Cervical dilation (4–7 cm) ■ Passageway ■ Encourage frequent position changes ■ Check bladder status and encourage patient to void every 2 hours ■ Nursing considerations ■ Monitor vital signs every 30 minutes ■ Fetal heart tones every 15–30 minutes ■ Pain management ■ Continue with effective techniques used in latent phase ■ Systemic medications to decrease pain perception • Document and report maternal and fetal response to systemic medications • Neonatal side effects related to both dose and timing of administered medication Systemic Pain Medications in Labor Medication Class Opioid analgesics Meperidine Butorphanol fentanyl Nalbuphine Drug Action Reduce pain perception Nursing Considerations Side effect: nausea and vomiting Long-acting active metabolite. A. may cause withdrawal IV push dosing should be at the beginning of a contraction to limit transfer to fetus No analgesic effect Adjunct drugs Promethazine Hydroxyzine Sedatives Reduce nausea Reduce anxiety Promotes rest with prolonged latent phase May have prolonged depressant effect on neonate INTRAPARTUM .
Copyright © 2006 by F. A. Davis.
■ Epidurals in labor • Oxygen, suction equipment, emergency medications should be at bedside • Document vital signs and monitor fetal heart rate prior to procedure • Encourage patient to void • Administer IV bolus prior to epidural insertion (500 cc to 1000 cc of saline or lactated Ringer’s solution) to prevent maternal hypotension • Position and support patient during insertion of epidural catheter • Note maternal vital signs before and after test dose, then every 5 minutes with administration; thereafter, monitor vital signs and FHR per hospital protocol • Evaluate bladder status every hour and encourage to void; catheterize if unable to void or bladder overdistended • Assess for level of anesthesia • Monitor for comfort with contractions • Monitor progress of labor • Assist with position changes • Report adverse effects Hypotension Pruritis (itching) Pyrexia (fever) Respiratory depression
Stage 1: Transition
■ Power: Contractions palpate strong, every 1.5–3 minutes lasting 45–90 seconds ■ Psyche: Patient may feel a loss of control; provide encouragement to patient ■ Measuring progress in labor Cervical dilation (8–10 cm) Fetal descent (0/ 1 station) ■ Physical changes common with transition ■ Urge to push if presenting part is low ■ Nausea/vomiting ■ Trembling limbs
Copyright © 2006 by F. A. Davis.
■ Beads of sweat on upper lip ■ Increased bloody show ■ Passageway: Activity more restricted, however, encourage positions that promote fetal rotation and descent ■ Squatting ■ Hands and knees position ■ Side-lying ■ Nursing considerations ■ Encourage patient to void ■ Monitor vital signs and fetal heart tones every 5–15 minutes ■ Pain management ■ Continue with effective techniques used in active phase ■ If systemic medications are given, consider amount of time estimated until birth and potential for newborn effects (respiratory depression) ■ Have naloxone hydrochloride (Narcan) available to reverse effects if needed ■ Document maternal and fetal response to medications
Second Stage of Labor: Expulsion
■ 10 cm dilated until the birth of the baby ■ Power: Contractions palpate strong, every 2–3 minutes lasting 60–90 seconds ■ Psyche: Patient may be eager or afraid to push ■ Measuring progress in labor ■ Descent of fetus: from 1 station to crowning ■ Cardinal movements of labor (changes in fetal position that facilitate birth) • Engagement/Descent/Flexion • Internal rotation • Extension • External rotation • Expulsion ■ Passageway ■ Promote effective pushing • Wait for urge to bear down called the “Ferguson reflex” • Discourage prolonged breath-holding • Encourage open glottis pushing
Copyright © 2006 by F. A. Davis.
■ Position for pushing • Squatting • Side-lying • Modified Lithotomy Encourage patient to void Patient may pass stool with pushing Nursing considerations ■ Monitor vital signs every 15–30 minutes ■ Fetal heart tones every 5–15 minutes Pain management per primary health-care provider ■ Pudendal block: Local anesthetic that blocks pudendal nerve to numb lower vagina and perineum for vaginal birth; useful with forcep delivery ■ Local anesthesia to perineum: Numbs perineum for episiotomy/laceration repair Prepare for the birth of the baby ■ Cleanse the perineum ■ Check working order of suction equipment, oxygen, radiant warmer ■ Neonatal resuscitation equipment should be readily available for every delivery ■ Prepare delivery instruments Note precise time of birth Provide immediate care of the newborn ■ Assess airway and suction as needed • Remove excess fluid from infant’s nose and mouth (infants are obligate nose breathers) • If meconium is noted in nose or mouth, endotracheal intubation and suctioning must be performed immediately ■ Assess breathing effort (rate of at least 30 per minute) • If respiratory effort is not observed, gently stimulate infant by tapping sole of foot or stroking the back • Positive pressure ventilate if tactile stimulation does not result in respiratory effort ■ Assess circulation: heart rate 100 BPM ■ Temperature regulation • Dry infant
crying Active motion Cough. ophthalmic antibiotic ointment (based on hospital protocol) to prevent chlamydial or gonococcal eye infection • Administer vitamin K. or birth injuries) ■ Examine umbilical cord and count number of vessels: 2 arteries and 1 vein. encourage skin-to-skin contact with mother ■ Assign Apgar Score at 1 and 5 minutes • Score of 10 possible. A. place plastic clamp on cord ■ Identification • Fingerprint mother and footprint newborn • Apply identification bands to both mother and newborn before leaving birthing room ■ Medications • Administer eye prophylaxis.Copyright © 2006 by F. IM to boost production of clotting factor (needed due to sterile gut at birth) INTRAPARTUM . Score of at least 8 desirable Apgar Score Score Heart Rate Respiratory Effort Muscle Tone Reflex irritability Color 0 Absent Absent Limp No response Blue or pale 1 Less than 100 Slow. Davis. sneeze or vigorous cry Completely pink ■ Assess for abnormalities that may need immediate attention (example: neural tube defects. extremities blue 2 Greater than 100 Good. irregular Some flexion of extremities Grimace Body pink. 69 • Place infant under prewarmed radiant warmer with temperature probe applied • Remove wet towels and lay infant on warm blankets • Keep temperature of labor room warm • Once infant is stabilized. open lesions.
encourage bonding with baby ■ Signs of placental separation ■ Sudden gush or trickle of blood from vagina ■ Lengthening of visible umbilical cord at introitus ■ Contraction of the uterus ■ Nursing considerations ■ Instruct patient to push when appropriate ■ Note time of placenta delivery ■ After placenta expelled: • Monitor amount of bleeding • Monitor vital signs • Assess fundus – Height – Location – Tone ■ Administer oxytocic medication as ordered • Stimulates uterus to contract • Prevents hemorrhage ■ Cleanse and apply ice pack to the perineum ■ Provide clean linen under patient ■ Provide warm blanket: patients often tremble/shiver immediately after the birth ■ Assess level of consciousness/comfort ■ Place newborn in arm of mother. Davis. or edema ■ Note passage of stool/urine Third Stage: Delivery of Placenta ■ Power: Strong uterine contractions cause the placenta to detach from the uterine wall ■ Psyche: Patient may be exhausted. A. INTRAPARTUM ■ Weigh and measure infant (head. bruising. and abdominal circumference as well as length) ■ Assess skin for lacerations. chest.Copyright © 2006 by F. encouraging skin-to-skin contact ■ Assist with positioning for breastfeeding and bonding 70 .
71 Nursing Care with Intrapartum Procedures Induction of Labor ■ Artificial stimulation of uterine contractions to facilitate vaginal delivery ■ Commonly performed in postterm pregnancy ■ Prior to induction of labor the nurse should note ■ Indication for induction ■ Gestational age ■ Bishop’s score ■ Any contraindications for procedure ■ Bishop’s Score ■ Assigned by primary health-care provider prior to induction of labor ■ Higher scores indicate increased likelihood of successful labor induction ■ Parameters of Bishop’s score • Degree of Dilation (1–3 points) • Percent of Effacement (0–3 points) • Station (0–2 points) • Consistency of cervix (0–2 points) • Cervical position (0–2 points) ■ Use of Oxytocin (Pitocin): Hormone that stimulates uterine contractions to induce or augment contractions ■ Assess mother and fetus 20–30 minutes prior to oxytocin administration ■ Prepare and clearly label solution • 10 units of Pitocin into 500–1000 ml of isotonic IV solution • Administer IV piggyback per electronic infusion pump • Started at small dose and gradually increased until contractions every 2–3 minutes (follow hospital protocol) ■ Monitor maternal-fetal tolerance to procedure • Uterine resting tone • Contraction frequency. duration. and intensity • Intake and output • Fetal heart tones (baseline. changes) • Cervical dilation and effacement • Vital signs • Patient comfort INTRAPARTUM . Davis. variability. A.Copyright © 2006 by F.
Prepidil Gel) ■ Nursing care • Monitor fetal heart rate and contraction status for 20–30 minutes prior to procedure • Encourage patient to void prior to insertion • Position side-lying position after procedure • Monitoring maternal vital signs. Davis. INTRAPARTUM ■ Monitor for complications of oxytocin (may become evident as dosage increases) • Uterine hyperstimulation (excessive frequency/duration of contractions without uterine relaxation) • Nonreassuring fetal heart rate patterns • If complications become apparent: – Change position to lateral side-lying – Discontinue IV oxytocin – Provide oxygen per mask at 8–10L/min – Increase rate of nonadditive IV solution – Call primary health-care provider ■ Cervical Ripening ■ Facilitates cervical softening. A. vomiting. diarrhea • Ensure proper waiting period between cervical ripening and Oxytocin administration ■ Amniotomy ■ Artificial rupture of amniotic sac performed by the primary health-care provider during a vaginal exam to augment contraction frequency and intensity ■ Nursing care • Pad bed to absorb amniotic fluid • Document time of amniotomy 72 .Copyright © 2006 by F. effacement. and dilation ■ Indicated when there is a medical need for induction of labor and cervix unfavorable ■ Methods: • Laminaria tents (mechanical cervical dilator made from seaweed) • Prostaglandin E1-misoprostol (Cytotec) • Prostaglandin E2-dinoprostone (Cervidil Insert. and fetal status (per hospital protocol) • Report adverse reactions to physician – Hyperstimulation of uterus – Nonreassuring fetal heart tones – Nausea. contractions.
there is potential for infection – Monitor maternal temperature every 1–2 hours – Limit number of vaginal exams Vaginal Birth After Cesarean (VBAC) ■ Women who have had a previous cesarean birth may be candidates for vaginal birth ■ Previous cesarean uterine incision documented as lowtransverse ■ No contraindications noted to VBAC ■ Physician and surgical team readily available for emergent cesarean birth ■ Patient and physician agree that VBAC is desirable ■ Risks of vaginal birth following cesarean must be explained.Copyright © 2006 by F. A. station. Davis. effacement. and fetal presentation • If presenting part is not engaged. 73 • Document fetal heart tones immediately following amniotomy • Note color and amount of amniotic fluid • Document cervical dilation. including ■ Uterine rupture with possible loss of fetus or uterus ■ Unsuccessful trial of labor with subsequent cesarean ■ Location of previous uterine scar must be documented Low Transverse Low Vertical Classic Uterine scars. INTRAPARTUM . limit patient activity to prevent cord prolapse • Once amniotic sac is ruptured.
INTRAPARTUM ■ Nursing care ■ Closely monitor uterine response to labor ■ Monitor fetal response to labor ■ Initiate IV access ■ Monitor for signs of uterine rupture • Severe abdominal pain • Nonreassuring fetal heart rate patterns • Cessation of uterine contractions • Ascending station of presenting part • Vaginal bleeding • Signs of shock Complications in the Intrapartum Period Prolapsed Umbilical Cord ■ Umbilical cord slips below/wedges next to presenting part ■ May lead to fetal hypoxia due to cord compression ■ Possible cause ■ Rupture of membranes without engaged presenting part ■ Non-cephalic fetal presentation ■ Symptoms ■ Prolonged variable deceleration ■ Pulsating cord palpated upon vaginal exam ■ Visible cord at introitus ■ Nursing actions ■ Stay with patient and call for assistance ■ Apply sterile glove and hold pressure of presenting part off umbilical cord ■ Place patient in Trendelenburg position ■ Notify physician ■ Monitor fetal heart tones ■ Place sterile saline gauze over any exposed cord ■ Prepare patient for cesarean birth 74 . A. Davis.Copyright © 2006 by F.
A. Davis.Copyright © 2006 by F. prosthetic device. jewelry. 75 Cesarean Birth ■ Indications for cesarean birth ■ Cephalopelvic disproportion (CPD) ■ Malpresentations ■ Placenta previa/abruption ■ Umbilical cord prolapse ■ Fetal intolerance to labor ■ Maternal medical conditions ■ Preoperative Care ■ Place signed consent on chart ■ Insert urinary catheter ■ Shave prep to the abdomen ■ Remove contact lenses. dentures ■ Perform preoperative teaching ■ Assist significant other to prepare for observation of surgery ■ Administer preoperative medications ■ Continue to monitor vital signs and fetal heart rate ■ Postoperative care ■ Assess respiratory/cardiac status ■ Encourage patient to turn cough and deep breath ■ Assess level of pain and medication needs ■ Monitor intake and output ■ Assess bowel sounds ■ Assess incision ■ Monitor vaginal bleeding and provide pericare ■ Assess vital signs and level of consciousness ■ Assess extremities for circulation ■ Assist with positioning for breastfeeding and holding baby INTRAPARTUM . nail polish.
Copyright © 2006 by F. and tone of the fundus (upper portion of the uterus) ■ Note amount and consistency of vaginal bleeding ■ Cleanse and apply ice pack to the perineum ■ Provide clean linen under patient ■ Provide warm blanket: patients often tremble/shiver immediately after the birth ■ Assess vital signs ■ Assess level of consciousness/comfort ■ Encourage bonding of mother and infant ■ Assist with proper latch-on to initiate breastfeeding ■ Maintain IV fluids and additives as ordered ■ Oxytocic medications • Promote uterine contractions • Decrease amount of vaginal blood loss Nursing Assessment of the Postpartum Patient ■ Assess every 15 minutes for the first hour ■ Assess every 30 minutes for the second hour ■ Assess every 4 hours for the first 24 hours ■ Uterine tone ■ Bleeding ■ Perineum ■ Bladder status ■ Vital signs • Blood pressure • Pulse • Respiration • Temperature every 1–4 hours 76 . POSTPARTUM Postpartum Fourth Stage of Labor First 1–2 hours after birth Immediate Nursing Care ■ Assess height. Davis. A. location.
A. leave colostrum/breast milk on nipples and expose the breasts to air POSTPARTUM . and reinforced ■ Document education and validate knowledge through verbalization and/or return demonstration Postpartum Assessment and Nursing Care Remember the acronym BUBBLE B breasts U uterus B bowel B bladder L lochia E episiotomy Breast assessment ■ Consistency: soft. cracked. Davis. 77 ■ ■ ■ ■ Fluid balance Circulation to extremities Comfort/level of consciousness Newborn interaction Postpartum Education ■ Education of the postpartum family is an essential role of the postpartum nurse ■ New skills should be discussed. or firm ■ Nipple type and integrity ■ Type: Inverted or everted ■ Integrity: Bleeding. filling. demonstrated.Copyright © 2006 by F. soap should not be used on breasts • After feedings. intact ■ Redness ■ Comfort ■ Breast care (lactating) ■ Patient should wear a supportive bra • Montgomery glands secrete oil to keep nipples supple.
A.Copyright © 2006 by F. POSTPARTUM ■ Encourage frequent nursing (8–12 feedings in 24 hours) ■ Teach positioning of infant for increased comfort • Side-lying • Football hold • Cradle hold Breastfeeding positions.) 78 . (Used with permission from Ross Products Division Abbott Laboratories Inc. Davis.
A. initiate breast pump ■ Breast care (nonlactating) ■ Supportive bra. 79 ■ Instruct on proper latch-on • Elicit the rooting reflex by stroking the infant’s lower lip • As the infant’s mouth opens wide. mother will express comfort • Incorrect latch-on: clicking noise as infant sucks with nipple pain expressed by mother.Copyright © 2006 by F. breast binder or sports bra ■ No nipple stimulation ■ Do not express breast milk ■ Ice packs/analgesics for engorgement ■ Teach breast self exam (BSE) POSTPARTUM . break suction by placing one finger by the infant’s mouth and relatch Latch-on. (Used with permission from Ross Products Division Abbott Laboratories Inc.) ■ If separated from newborn. ensuring both the nipple and part of the areola are in the infant’s mouth • Correct latch-on: infant’s jaws will rhythmically move with an audible swallow. Davis. bring the infant to the breast.
shoulder. and hip aligned ■ Position pillows to support the weight of the infant ■ Demonstrate positions for breastfeeding Supply and Demand ■ The newborn should be fed on demand. prolactin release in response to suckling will stimulate the alveolar cells of the breast to produce the appropriate amount of milk to meet the infant’s needs ■ The mother should initiate breastfeeding when the infant demonstrates hunger cues: ■ Increased alertness or activity ■ Smacking of the lips ■ Suckling motion ■ Moving of the head in search of the breast ■ Continue to feed until the infant detaches spontaneously.Copyright © 2006 by F. burp the infant. are passed via breast milk ■ Decreased incidence of infant: ■ Allergies ■ Otitis media ■ Upper respiratory infections Positioning ■ The infant’s body should face the breast. Davis. supplemental feeding should be avoided 80 . which protect the infant from infection. POSTPARTUM TEACHING TIPS: BREASTFEEDING Advantages to Breastfeeding ■ Cost ■ Convenience ■ Immunoglobulins. and continue feeding on the other breast ■ Start breastfeeding on the breast ended with the last feeding ■ Unless medically indicated. A. with the ear.
smoking. when the volume of breast milk increases ■ Prevent engorgement with frequent feedings. A. 81 Engorgement (Firm. Davis. avoid skipping any feedings ■ Treatment for engorgement ■ Express a small amount of breast milk either manually or with a breast pump so that the breasts will soften and the baby can latch ■ Apply cold packs to breasts intermittently ■ Apply cleaned. cooled cabbage leaves to breasts until warm/wilted ■ Warm shower or warm compress right before feeding Nutrition ■ Add 500 calories over nonpregnant diet ■ Continue prenatal vitamins ■ Stay well hydrated ■ Avoid alcohol. tender breasts) ■ May occur on postpartum day 3–5.Copyright © 2006 by F. or recreational drugs ■ Consult with pediatrician before using any over-the-counter or prescription medication Pumping and Storing ■ Demonstrate use of breast pump ■ Discuss appropriate storage containers ■ Write the date of expression on storage container and use oldest milk first ■ Length of storage dependent on location Location Room temperature Refrigerator Refrigerator freezer (with separate door) Deep freeze Guideline Up to 8 hours 3–5 days 3 months 6–12 months POSTPARTUM .
POSTPARTUM Weaning ■ Gradual weaning suggested to decrease the likelihood of engorgement ■ Remove one feeding per week ■ If infant is less than 1 year. must be given Breast Care ■ Breast pads inside a supportive bra will collect leaking breast milk ■ Teach signs of mastitis ■ Unilateral breast pain. infant formula. A. Davis.Copyright © 2006 by F. instead of cow’s milk. urine is amber-colored ■ Nipple pain or cracking is present Community Resources ■ Lactation consultant ■ La Leche League ■ Primary health-care provider 82 . warmth and redness ■ Malaise and flu-like symptoms ■ Fever Breastfeeding Concerns ■ Mother should report breastfeeding concerns to the primary healthcare provider ■ Feedings that are consistently short with the infant appearing hungry after feedings and the breasts remaining full ■ Swallowing is inaudible once milk is established ■ The infant is not gaining the expected amount of weight ■ The infant has fewer than 6 wet diapers a day.
Copyright © 2006 by F. A. POSTPARTUM . 83 Uterus ■ Uterine Involution ■ Process by which the size of uterus decreases in a predictable pattern ■ Documented in fingerbreadths above or below the umbilicus Postpartum Period Immediately after birth 12 hours 24 hours Day 2 Day 3 U Umbilicus Level of the Fundus at the umbilicus 1 fingerbreadth (FB) above the umbilicus 1 FB below the umbilicus 2 FB below the umbilicus 3 FB below the umbilicus Documentation at U or U/U 1/U U/1 U/2 U/3 ■ Measures that promote uterine involution • Breastfeeding • Voiding • Fundal massage • Oxytoxic medications Fundal massage. Davis.
Nursing Health Assessment: A Critical Thinking. and location of the fundus ■ TONE of the uterus assessed while patient is supine ■ Fundus should be firmly contracted ■ If fundus is not firm. A. fundus is located at or just above the umbilicus • The fundus should be midline and not deviated to the left or right Uterine involution. 744. Case Study Approach. height. perform fundal massage ■ Support the lower uterine segment during massage to prevent inversion of the uterus ■ If fundus is boggy (not firm) after massage: • Check bladder status and encourage voiding • Catheterize (as ordered) if unable to void • Notify primary care provider ■ Assess the HEIGHT and LOCATION of the uterus in relation to the umbilicus • Immediately after birth. Davis. POSTPARTUM Assess the tone. (From Dillon PM. p.A.) 84 . Philadelphia: F Davis.Copyright © 2006 by F. (2003). .
lactation amenorrhea while exclusively breastfeeding infant (first 6 months) ■ If bottle feeding. use water-soluble gel ■ Female superior or side-lying position may assist in comfort ■ Discuss family planning methods POSTPARTUM . menses usually returns 6–8 weeks postdelivery Sexuality ■ Sexual intercourse may be resumed after lochia ceased and episiotomy healed.Copyright © 2006 by F. Davis. 4–6 week delay generally recommended ■ Vaginal lubrication may be diminished. decrease activity ■ Persistent bright red lochia or lochia with a foul odor should be reported ■ Report saturating one pad per hour or passing golf-ball size clots Return of the Menstrual Cycle ■ Dependent on method of infant feeding ■ If breastfeeding. A. 85 TEACHING TIPS: UTERINE/VAGINAL CHANGES The Fundus ■ The fundus lowers one fingerbreadth below the umbilicus each day until returning to pelvis (day 10–14) Normal Progression of Lochia ■ Lochia progresses from bright red to brown to light pink with decreasing amount ■ If lochia returns to bright red or increases in amount.
which occurs in response to decrease in estrogen. A. helps rid the body of extracellular fluid and causes the bladder to fill quickly ■ Starts within 12 hours of birth and continues for up to 5 days ■ Urine output may be 3. POSTPARTUM Bladder Status ■ Postpartum women may have difficulty voiding after birth due to: ■ Decreased urethral sensation from pressure exerted by the passage of the fetus ■ Side effects of local/epidural anesthesia ■ Delivery trauma to the perineum ■ Palpate for bladder distention ■ Track fluid balance: intake and output ■ Assess for periurethral edema/trauma ■ Postpartum diuresis.000 cc/day ■ Catheterization may be necessary if unable to void or with urinary retention Bowel ■ ■ ■ ■ Auscultate for bowel sounds Assess for abdominal distention Assess for presence/status of hemorrhoids Educate on prevention of constipation ■ Increased roughage in the diet ■ Increased oral intake of fluids ■ Temporary use of prescribed stool softeners Lochia ■ Vaginal discharge after delivery called lochia ■ Blood loss with vaginal birth approximately 500 cc ■ Blood loss with cesarean birth approximately 1000 cc 86 .Copyright © 2006 by F. Davis.
consistency of discharge ■ Approximated edges ■ Lacerations described by degree of tissue involvement Degree 1st 2nd 3rd 4th Definition Vaginal mucous membrane and skin of perineum Subcutaneous tissue of the perineal body Involves fibers of the external rectal sphincter Through rectal sphincter exposing the lumen of the rectum ■ No enemas or rectal suppositories should be used with 3rd and 4th degree lacerations POSTPARTUM .Copyright © 2006 by F. Davis. 1 gm 1 ml of blood loss ■ Assess the color of lochia • Lochia rubra (red): day 1–3 • Lochia serosa (brownish-pink): day 4–9 • Lochia alba (yellow-white): day 10–14 ■ Document number and size of blood clots ■ Turn patient to assess blood loss under buttocks Assessment of the Perineum Requires a direct light source and positioning of the patient in side-lying with top leg forward ■ Assess Episiotomy or laceration ■ Redness ■ Swelling ■ Ecchymosis ■ Color. large) • If weighing perineal pads. 87 ■ Assess the amount of lochia ■ Note time of last perineal pad change ■ Document amount of lochia on perineal pad (scant. moderate. small. A.
not to perform the exercise) ■ Hold contraction for several seconds. POSTPARTUM TEACHING TIPS: PERINEAL HYGIENE Perineal Cleansing ■ Stress importance of hand washing before and after perineal care ■ Demonstrate use of perineal cleansing bottle ■ Change perineal pads after each void ■ Keep perineal pad/underwear from touching floor Comfort Measures ■ Apply perineal ice packs intermittently for the first 24 hours after birth ■ Sitz baths may be ordered after 24 hours ■ Apply creams. and ointments to perineum as ordered ■ Discuss bowel habits and steps to avoid constipation Kegel Exercises ■ Encourage patient to perform Kegel exercises throughout the day to strengthen perineal muscle tone ■ To locate muscle. and repeat 10–15 times.Copyright © 2006 by F. A. discourage breath-holding Emotional Response ■ Assess interaction with newborn ■ Eye contact with infant ■ Talks to infant ■ Holds infant close ■ Feeds infant ■ Assess emotional status ■ Assess for postpartum blues 88 . sprays. release. tighten perineal muscles as though stopping the flow of urine (this technique is only used to locate the muscles. Davis.
blanching ■ Assess for signs of deep vein thrombosis ■ Pain ■ Swelling ■ Redness ■ Increased skin temperature POSTPARTUM .Copyright © 2006 by F. and moodiness ■ Postpartum blues common in the early postpartum period ■ Duration less than 2 weeks ■ Possible cause ■ Hormonal changes after birth ■ Exhaustion ■ Physical discomfort Emotional Support ■ Encourage patient to discuss feelings ■ Encourage private time when baby naps ■ Discuss the difference between “blues” and depression. Davis. A. encourage patient to report symptoms of postpartum depression ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts Extremities ■ Assess circulation to lower extremities ■ Pedal pulse ■ Color. 89 TEACHING TIPS: EMOTIONS Postpartum Blues ■ Symptoms of postpartum blues include tearfulness. insomnia. temperature.
Copyright © 2006 by F. and amplitude ■ Blood pressure ■ Watch for signs of shock (↓ blood pressure and ↑ pulse) ■ Be alert for orthostatic hypotension upon rising ■ Dangle at bedside before rising ■ Respirations: ■ Note rate and depth ■ Lungs should be clear on auscultation Level of Comfort ■ Pain location and intensity ■ Afterbirth cramps: intense contractions of the uterus that are more intense with multiparity and occur with nursing ■ Incisional pain ■ Hemorrhoid pain ■ Postpartum diaphoresis: intense sweating that occurs in the early postpartum period ridding the body of excess fluid ■ Effects of epidural anesthesia ■ Leg movement/strength ■ Presence of numbness and tingling ■ Assist with ambulation 90 . POSTPARTUM TEACHING TIPS: ACTIVITY Activity Level ■ Frequent rest periods will help with healing of body and mind (nap when baby sleeps) ■ Do not lift anything heavier than the baby ■ Limit activities to care of newborn/self ■ Ask for assistance with housework/shopping Vital Signs ■ Temperature ■ Slight increase in temperature in first 24 hours common due to dehydration. rhythm. A. Davis.4 F call physician ■ Pulse: assess rate. encourage oral fluids ■ If temperature 100.
91 Nutrition ■ Assess dietary needs and concerns ■ Average weight loss 12 pounds at birth Laboratory Data ■ Examine postpartum laboratory findings and compare to prenatal levels (usually drawn at 24 hours postpartum) ■ Hemoglobin/hematocrit ■ White blood cell count ■ Platelet count ■ If mother is RH negative check Rh status of infant Mother Negative Negative Infant Negative Positive Rho(D) Immune globulin (300 g) No treatment needed Administer within 72 hours of birth Cesarean Birth In addition to routine postpartum assessment. Davis.Copyright © 2006 by F. the nurse should assess the following ■ Effects of anesthesia ■ Level of consciousness ■ Ability to hold and care for infant may be limited due to • Comfort level • Limitation in movement ■ Respiratory status • Pulse oximetry Patient Controlled Anesthesia (PCA) ■ Effectiveness ■ Number of attempts/amount given ■ Side effects Abdominal Assessment ■ Bowel sounds POSTPARTUM . A.
POSTPARTUM ■ Abdominal distention ■ Ability to pass flatus ■ Avoid straws and carbonated beverages ■ Incision/dressing ■ Circle drainage and mark with date and time ■ Assess incision with dressing change • Approximation • Redness • Drainage • Edema • Hematoma • Odor Nutrition ■ ■ ■ ■ ■ ■ ■ ■ Intake and output Nausea/vomiting Presence of bowel sounds Progression of diet Turn/cough/deep breathe Dangle at side of bed Sit up in chair Ambulate with assist Progression of Activity Complications in the Postpartum Period Hemorrhage ■ Risk factors ■ High parity ■ Overdistention of the uterus ■ Precipitous labor or prolonged labor ■ Medications (oxytocin. magnesium sulfate) ■ Etiology ■ Uterine atony (hypotonia of the uterus) ■ Retained placental fragments ■ Vaginal/cervical laceration ■ Hematoma 92 . A.Copyright © 2006 by F. Davis.
bruised area on perineum ■ Interventions ■ Fundal massage ■ Monitor urine output • Check bladder status • Catheterize if needed ■ Increase mainline IV fluids ■ Closely monitor vital signs ■ Administer oxygen ■ Call primary health-care provider • May need suturing of laceration • May need evacuation of hematoma • May need evacuation of placental fragments ■ Administer medications that promote uterine contraction as ordered ■ Oxytocin ■ Methylergonovine maleate (Methergine) • If blood pressure 140/90. 93 ■ Clinical findings ■ Perineal pad saturated in less than 1 hour ■ Continuous trickle of vaginal bleeding ■ Firm.4F ■ Elevated white blood cell count ■ Complaint of chills and aching ■ Malaise ■ Interventions ■ Obtain culture of discharge as ordered ■ Report abnormal laboratory findings ■ Administer antibiotic therapy as ordered ■ Consider medications contraindicated for breastfeeding ■ Monitor temperature ■ Clean and monitor site ■ Teach patient reportable signs and symptoms POSTPARTUM .Copyright © 2006 by F. Davis. hold and call primary care provider ■ Ergonovine maleate (Ergotrate) ■ Prostaglandin F2a (Prostin/Hemabate) Infection ■ Symptoms ■ Temperature elevation 100. A.
A. warmth and redness • Malaise and flu-like symptoms ■ Incisional infection ■ Contributing factors • Inadequate care of incision • Operative delivery • Laceration ■ Clinical findings • Incision not well approximated • Incision red with purulent drainage ■ Urinary tract infection ■ Contributing factors • Catheterization of bladder • Retention of urine in bladder ■ Clinical findings • Dysuria • Frequency of urination • Flank pain Postpartum Depression ■ Risk factors ■ History of depression or anxiety disorder ■ Prenatal depression 94 . POSTPARTUM ■ Endometritis (uterine infection) ■ Contributing factors • Operative birth • Long labor with multiple vaginal exams • Internal monitoring • Premature rupture of membranes • Manual removal of placenta ■ Clinical findings • Subinvolution of the uterus • Foul-smelling vaginal discharge • Lower abdominal cramping ■ Mastitis (breast infection) ■ Contributing factors • Alteration in nipple integrity • Delayed emptying of breast milk ■ Clinical findings • Unilateral breast pain. Davis.Copyright © 2006 by F.
Davis. may occur 3–12 months after birth ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts ■ Interventions ■ Psychotherapy ■ Medications Thrombophlebitis/Deep Vein Thrombosis ■ Risk factors ■ Varicosities ■ Advanced maternal age ■ Obesity ■ Long periods of bed rest ■ Occupation that requires long periods of standing ■ Clotting disorder ■ Etiology ■ Increased clotting factors in postpartum period ■ Infection in the vessel lining to which a clot attaches ■ Clinical findings ■ Pain with dorsiflexion ■ Affected site hot to touch ■ Swelling. and pain to affected leg ■ Interventions dependent on severity of findings ■ Administer anticoagulants ■ Monitor coagulation profile ■ Compression stockings ■ Apply warm.Copyright © 2006 by F. 95 ■ Inadequate social or partner support ■ Large number of life stressors ■ Clinical findings ■ Symptoms extend beyond 2 weeks postpartum. A. redness. moist heat ■ Rest ■ Observe for symptoms of pulmonary embolism • Dyspnea • Chest pain • Hemoptysis • Patient fearful POSTPARTUM .
POSTPARTUM TEACHING TIPS: POSTPARTUM COMPLICATIONS Teach the patient to report the following signs and symptoms to the primary health-care provider. pain. A.Copyright © 2006 by F. or urgency of urination ■ Foul odor to lochia ■ Redness. Davis. or discharge at incision Sign of Uterine Subinvolution ■ Change in the character of lochia ■ Increased amount of lochia ■ Resumption of bright red color ■ Presence of clots Signs of Thrombophlebitis/Deep Vein Thrombosis ■ Pain. frequency. Signs of infection ■ Elevated temperature ■ Localized redness or pain to either breast ■ Persistent abdominal tenderness ■ Persistent pain to perineum ■ Burning. increased temperature and redness to legs Signs of Postpartum Depression ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts 96 .
A. or asymmetrical gluteal folds (hip dysplasia) ■ Resistance to neck flexion POSTPARTUM . 97 Nursery Care of the Newborn ■ ■ ■ ■ ■ Keep infant warm during all care and procedures Assess and record daily weight Role model back sleeping Keep bulb syringe at bedside Check identification bands at each encounter with parents Physical Assessment of the Newborn Reportable findings in red Vital Signs ■ Axillary temperature 97. Davis.6 F ■ Decreased body temperature may be a sign of sepsis ■ Auscultate apical pulse for one full minute ■ 110–160 beats per minute ■ Sustained resting heart rate below 100 or above 160 ■ Respirations counted for one full minute ■ 30–60 per minute ■ Sustained resting respiratory rate below 30 or above 60 Extremities/Activity ■ Newborn posture flexed ■ Extremities equal length with full range of spontaneous motion ■ Gluteal folds even ■ Ten fingers and 10 toes without webbing (syndactyly) or extra digit (polydactyly) ■ Grasp reflex intact ■ REPORT ■ Poor muscle tone or asymmetry of muscle tone ■ Failure to spontaneously move all extremities or decreased range of motion ■ Chewing type mouth movements combined with noticeable changes in eye and/or body movements (may represent neonatal seizure activity) ■ Unequal knee height. leg length.Copyright © 2006 by F.8–98.
resembles bruise) ■ Telangiectases “stork bites” ■ Erythema toxicum (newborn rash) ■ REPORT ■ Cyanosis (other than in hands and feet) ■ Skin lesions. abrasions ■ Jaundice 98 .Copyright © 2006 by F. face) ■ Mongolian spot (area of increased pigmentation. POSTPARTUM TEACHING TIPS: NORMAL NEWBORN BEHAVIOR Pattern of Sleep ■ Newborns sleep in short periods for a total of 13–16 hours per day ■ Lying the baby on the back for sleep is recommended Communication ■ Crying is a means of communication and a late sign of hunger ■ Teach parents hunger cues ■ Teach techniques for comforting the fed newborn ■ Swaddling ■ Burping ■ Massage ■ Soft music ■ Diaper change ■ Gentle rocking ■ Encourage parents to talk. bruises. Davis. A. sing and hold newborn close Skin ■ Color uniformly pink ■ Normal variations ■ Acrocyanosis (bluish hue to hands/feet) ■ Milia (plugged sebaceous glands on nose) ■ Lanugo (downy hair on arms. back.
tongue mobile ■ Hard and soft palate intact ■ Strong suck. A. 99 TEACHING TIPS: SKIN CARE AND BATHING ■ Sponge baths recommended until the umbilical cord stump has fallen off and circumcision has healed ■ Stay with baby and hold securely at all times when bathing ■ All supplies should be within easy reach ■ No soap is needed on the face ■ The eye area can be cleansed with wet cotton balls (inner to outer canthus) ■ Only soap recommended for newborn skin should be used ■ Dry the baby quickly to avoid chilling ■ Wash hair last to avoid heat loss ■ Encourage frequent diaper changes ■ Cleanse genital area with mild soap and water ■ Cleanse the female genitalia from front to back ■ Do not forcibly retract the foreskin of uncircumcised boys Head ■ Head round with slight molding (cone-shaped with overriding cranial bones) or caput succedaneum (tissue edema that crosses suture lines) ■ Anterior and posterior fontanels (soft spots) flat ■ REPORT ■ Sunken or bulging fontanels when infant is at rest ■ Cephalhematoma.Copyright © 2006 by F. unilateral swelling of scalp tissue caused by collection of blood between the skull and periosteum Face ■ Face symmetrical with rest and crying ■ Eyes symmetrical in size and shape with intact red and corneal reflex ■ Nose midline with nares patent ■ Ears aligned with outer canthus of eyes. Davis. pinna well-formed and hearing intact ■ Oral mucosa pink and moist. able to coordinate suck and swallow ■ REPORT ■ Absence of red reflex ■ Purulent discharge of eyes immediately after birth POSTPARTUM .
but most convenient ■ Use without dilution ■ Opened cans can be stored in the refrigerator for 48 hours ■ Concentrated ■ Dilute with equal parts of water ■ Prepare enough bottles for the day ■ Prepared bottles can be stored in refrigerator for 48 hours ■ Powdered ■ Least expensive ■ Add water for every one scoop of powder per manufacturer’s instructions ■ Shake well to distribute powder Formula Preparation ■ Clean off can with soap and water before opening ■ If water supply questionable. suck. A. use bottled nursery water ■ Prepared bottles can be fed at room temperature. run refrigerated bottles under warm water to bring to room temperature ■ Avoid use of microwave for heating formula 100 . protruding tongue (possible Down syndrome) White patches in mouth (Candidiasis) Absent rooting. or Moro reflex Severe drooling and/or coughing or gagging TEACHING TIPS: BOTTLE FEEDING Types of Formula Directions for dilution of formula on the container must be followed exactly to ensure adequate infant health and nutrition ■ Ready-to-feed ■ Most expensive. Davis. POSTPARTUM ■ ■ ■ ■ ■ ■ ■ ■ Low set ears Lack of response to sound Nasal flaring Cleft lip or palate Large.Copyright © 2006 by F.
sterilization recommended ■ Choose nipples that allow a steady flow of formula but not so large as to cause choking Technique for Feeding ■ Encourage parents to hold the baby close and talk to the infant during feedings ■ Do not prop bottles ■ On-demand feeding recommended/watch baby for hunger cues (usually every 3–4 hours) ■ Increased alertness or activity ■ Smacking of the lips ■ Suckling motion ■ Moving of the head in search of the breast ■ Newborns generally drink about 0. A. amount and pattern of feedings should be discussed with the pediatrician before hospital discharge ■ Formula remaining in the bottle must be discarded Chest ■ ■ ■ ■ ■ Respirations unlabored Chest rises and falls symmetrically Lung sounds clear bilaterally Clavicals intact REPORT ■ Nasal flaring.Copyright © 2006 by F. 101 Bottle Preparation ■ Bottles should be washed with a brush and rinsed thoroughly. or expiratory grunting ■ Asymmetrical breath sounds ■ Chest asymmetrical or circumference greater than head circumference ■ Loud cardiac murmur with thrill POSTPARTUM . chest retractions. Davis. if water supply is questionable.5–2 ounces of formula per feeding for the first several days of life ■ Elicit the rooting reflex to initiate feeding ■ Keep bottle tipped to ensure the nipple remains full of formula ■ Burp every 1–2 ounces ■ The type.
A. bleeding. tell parents when to remove dressing ■ Clean area with warm water for diaper change 102 .Copyright © 2006 by F. Davis. POSTPARTUM Abdomen/Genitals ■ ■ ■ ■ ■ ■ ■ ■ Abdomen round and soft without palpable masses Three vessel umbilical cord with drying base Bowel sounds present First void within 24 hours (may be rust-stained from uric acid crystals) Meconium stool passed within 24 hours Female genitalia ■ Labia majora covers minora ■ May have mucoid vaginal discharge or pseudomenses Male genitalia ■ Urinary meatus at tip of penis ■ Testes descended REPORT ■ Drainage of urine or feces from umbilicus ■ Liver more than 3 cm below right costal margin ■ Abdomen markedly distended or flat ■ Palpable abdominal mass ■ Visible peristaltic waves ■ Poor feeding or excessive spitting or vomiting ■ Failure to urinate or pass meconium within 24 hours ■ Hypospadias or epispadias ■ Mass in scrotal or inguinal area ■ Imperforate anus TEACHING TIPS: NEWBORN CARE Umbilical Cord Care ■ The cord will fall off spontaneously in 10–14 days. do not tug at cord ■ Cleanse cord insertion site at diaper changes ■ Fan fold diaper to expose cord to air ■ REPORT redness. drainage. foul odor from cord Circumcision ■ Site may be covered with petroleum gauze dressing.
this is part of the healing process and removal should not be attempted ■ Reportable symptoms ■ Difficulty urinating ■ Persistent bleeding from the site ■ Pus oozing from the site ■ Redness or swelling Back ■ Spine straight. and easily flexed ■ REPORT ■ Arched back ■ Tuft of hair on spine TEACHING TIPS: SAFETY. HEALTH MAINTENANCE Safety ■ Discuss choking hazards and demonstrate the proper use of the bulb syringe ■ Properly installed car seats must be consistently used with safety straps on ■ Crib mattress should be firm and fit snugly. 103 ■ Apply petroleum jelly to head of penis to decrease friction with diaper ■ A yellow exudate forms on the head of the penis on day 2–3. A. well-fit mattress ■ No smoking around baby ■ Dress baby for comfort. crib slats should be no more than 2 3/8” apart ■ Never leave baby unattended on household furniture other than crib ■ Test bath water and formula temperature to prevent burns ■ Shield skin from excessive sun exposure ■ Supervise pets around the baby ■ Reduce the risk of Sudden Infant Death Syndrome (SIDS) ■ Back sleeping recommended ■ Avoid pillows and stuffed toys in the crib ■ Use firm. Davis. do not overheat POSTPARTUM .Copyright © 2006 by F. intact.
Davis. A. POSTPARTUM Immunizations ■ Discuss importance of immunizations for disease prevention ■ Provide current schedule of recommended childhood immunizations ■ Provide documentation of any immunization given in the hospital Neonatal Genetic and Hearing Screen ■ Blood test for metabolic defects are performed on all newborns after feeding is established ■ Exact tests vary by state ■ Infants who are discharged early may need to be brought back for newborn screen ■ Hearing screen done before hospital discharge for early identification of hearing deficits Reportable Symptoms ■ Parents should call the pediatrician with the following signs or any time they are concerned with their newborn’s behavior ■ Difficulty breathing ■ Vomiting or diarrhea ■ Less than expected voids/stools ■ Yellow hue to the skin or sclera ■ Constant crying ■ Difficulty awakening baby ■ Altered temperature ■ Body rash ■ Lack of interest in eating 104 .Copyright © 2006 by F.
fontanel closes: 12–18 mo ■ Central incisors erupt: 5–7 mo ■ Gross/Fine Motor ■ Holds head erect: 4 mo ■ Grasps voluntarily: 5 mo PEDS BASICS .5 lb/mo ■ HC ↑ 0.5 in/mo ■ Gross/Fine Motor ■ Rolls back to side: 3 mo ■ Holds head erect: 4 mo ■ Voluntary grasp: 5 mo ■ Rolls from front to back: 5–6 mo ■ Language ■ Coos: 1–2 mo ■ Laughs: 2–4 mo ■ Makes consonant sounds: 3–4 mo ■ Imitative sounds: 6 mo ■ Personal-Social ■ Regards a person’s face: 1 mo ■ Displays social smile and follows object 180 degrees: 2 mo ■ Recognizes familiar faces: 3 mo ■ Stranger anxiety begins: 6 mo 6–12 mo ■ Physical ■ Ht ↑ 50% of birth ht by 1 yr ■ Wt ↑ 1 lb/mo ■ Triples wt by 1 yr ■ HC ↑ by 33% ■ Chest circumference 1 in HC ■ Post fontanel closes: 2–3 mo ■ Ant. A. Davis. 105 Peds Basics Common Developmental Milestones (ages are aproximate) 0–6 mo ■ Physical ■ Ht ↑ 1 in/mo ■ Doubles wt by 5–6 mo ■ Wt ↑ 1.Copyright © 2006 by F.
Davis.Copyright © 2006 by F. A. ma-ma) : 8 mo ■ Says 4–10 words: 12 mo ■ Personal-Social ■ Marked stranger anxiety: 8 mo ■ Emotions such as jealously: 12 mo 1–3 yr ■ Physical ■ Ht ↑ 3 in/yr ■ Wt ↑ 5 lb/yr ■ Weighs about 4 times birth wt: 2 yr ■ HC equals chest circumference: 1–2 yr ■ HC ↑ 1 in during 2 yr ■ 10–14 temporary teeth ■ Gross/Fine Motor ■ Walks without help: 15 mo ■ Walks up and down stairs placing both feet on each step: 24 mo ■ Scribbles spontaneously: 15 mo ■ Builds 3–4 block tower: 18 mo ■ Jumps with both feet: 30 mo ■ Language ■ Says 300 words: 2yr ■ Uses 2–3 word phrases and pronouns ■ Understands speech: 2 yr ■ States first and last name: 2.5 yr ■ Personal-Social ■ Separation anxiety peaks ■ Ritualism ■ Negativism ■ Independence 106 . PEDS BASICS ■ Begins to crawl: 7 mo ■ Sits unsupported: 8 mo ■ Pulls up to stand: 9 mo ■ Drinks from cup: 9 mo ■ Pincer grasp: 8–10 mo ■ Builds two-block tower: 12 mo ■ Walks alone or holding onto one hand: 12 mo ■ Language ■ Pronounces syllables (da-da.
Copyright © 2006 by F. Davis. 107 3–6 yr ■ Physicial ■ Ht ↑ 2. sings songs: 4 yr ■ Asks “why” questions: 4 yr ■ Says over 2000 words: 5 yr ■ Knows and can name colors: 5 yr ■ Names days of week: 5 yr ■ Personal-Social ■ Shares toys with others ■ Imitates caregivers ■ Domestic role-playing PEDS BASICS .5 in/yr ■ Vision is 20/20 with color vision intact: 5–6 ■ Gross/Fine Motor ■ Rides tricycle: 3 yr ■ Climbs stairs using alternate feet: 3 yr ■ Stands on one foot: 3 yr ■ Broad jump: 3 yr ■ Builds 9–10 block tower: 3 yr ■ Draws a cross: 3 yr ■ Hops on one foot: 4 yr ■ Skips: 4 yr ■ Catches a ball: 4 yr ■ Walks downstairs using alternate feet: 4 yr ■ Laces shoes: 4 yr ■ Copies square: 4 yr ■ Adds three parts to stick figure: 4 yr ■ Balances on alternate feet: 5 yr ■ Ties shoelaces: 5 yr ■ Uses scissors well: 5 yr ■ Prints letters. A. numbers and name: 5 yr ■ Language ■ Says 900 words: 3 yr ■ Speaks 3–4 word sentences: 3 yr ■ Says 1500 words: 4 yr ■ Tells stories.5–3 in/yr ■ Wt ↑ 4–6 lb/yr ■ HC ↑ 0.
swims ■ Cursive writing: 8 yr ■ Computer and craft skills ■ Language ■ Devlops ability to read at grade level ■ Personal-Social ■ School relationships and work important ■ Separating from family 12 to 18–21 yr ■ Physical ■ Puberty beings in girls: 8–14 yr (lasts about 3 yr) ■ Puberty begins in boys: 9–16 yr (lasts longer) ■ Ht and wt ↑ variable during puberty ■ Progressive Tanner stages of development ■ Gross/Fine Motor ■ Gross motor reaches adult levels ■ Fine motor continues to be refined ■ Language ■ Develops formal thought—includes idealism. PEDS BASICS 6–12 yr ■ Physical ■ Ht ↑ 2–3 in/yr ■ Wt ↑ 4. egocentrism. status.5 lb/yr ■ Secondary teeth erupt with central incisors and first molars ■ Tanner stage 2 may begin ■ Gross/Fine Motor ■ Rides bicycle ■ Roller skates ■ Run. and relationships 108 .5–6. jumps.Copyright © 2006 by F. and ability to consider abstract possibilities ■ Personal-Social ■ Works through identity issues. A. Davis.
HC. 109 Growth ■ Use Growth Charts from National Center for Health Statistics (NCHS) www. wt. p. et al.cdc. (2005).). PEDS BASICS . Current Pediatric Diagnosis & Treatment: (17th ed. 309. New York: Lange Medical Books/McGraw-Hill. wt for ht. A. Davis. for ht. and BMI ■ Use 5th and 95th percentiles as parameters in determining if children are within normal limits for growth Average Daily Caloric Requirements for Children Age 0–1 month 2–4 months 5–60 months 5 years Caloric Expenditure Per Day 100—110 kcal/kg/day 90—100 kcal/kg/day 70—90 kcal/kg/day 1500 kcal for first 20 kg additional kg/day 25 kcal for each From Hay WW. Number and Volume of Infant Feeds Breast Feeding: Eight to 12 feedings/24 hours during the first 6 months Formula Feeding: Six to eight feedings/24 hours of commercially prepared iron-fortified (3–4 ounce) for each feeding for first month to 5 feedings/24 hours for each feeding when solid foods introduced at 6 months Weaning: Should be gradual.Copyright © 2006 by F. based on infant’s desire—usually between 8 to 9 months of age.gov/growthcharts.
Daily Urine Output/24 Hours 0. Kliegman RM. 6–18 yr 52 (2 110 . & Jenson TB.B. Lung. Jenson TB. PEDS BASICS Total Water Requirements/24 Hours Infant 6 yr 500–1300 mL. Nelson Textbook of Pediatrics. Philadelphia: W. Rule of Thumb to Determine BP: Normal systolic ranges: 1–7 yr age in yr 90. Child 500–1000 mL. Saunders. Average Ranges for Pediatric Vital Signs Age Group Infant Toddler Preschooler School-age Adolescent Heart Rate 80–150 70–110 65–110 60–95 55–85 Respiratory Rate 25–55 20–30 20–25 14–22 12–18 BP Systolic 65–100 90–105 95–110 100–120 110–135 BP Diastolic 45–65 55–70 60–75 60–75 65–85 Adapted from Behrman RE. Author. MD. and National Heart. 280. p. Davis. Kliegman RM. and Blood Institute.B. p. A. (17th ed). Adolescent 700–1400 mL From Behrman RE. 2415. Philadelphia: W. (2004). Bethesda. (2004). Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children.Copyright © 2006 by F. Saunders. Nelson Textbook of Pediatrics (17th ed). 8–18 yr age in yr) 83 Normal diastolic ranges: 1–5 yr 56. (1987). Child 2000–2700 mL 6 yr 1150–2000 mL.5–2 mL/kg/hr depending on child’s age and hydration status Infant 350–550 mL.
then vegetables.Copyright © 2006 by F. start with 1–2 tsp Introduce one food at a time for 3–5 days to watch for food allergies. use small spoon to feed infant 8–9 mo Finger foods such as teething crackers or raw fruits 12 mo Eating normal table foods.gov Comments Sometimes give rice cereal mixed with breast milk or formula around 4 mo Watch sizes and types of food for possible choking Provide a variety of foods that meets child’s nutritional needs. strawberries. A. and fruits with meats the last food to introduce. Davis. commercially prepared iron-fortified formula 6 mo Begin with infant rice cereal. avoid allergenic foods such as nuts. shellfish. healthy habits—go to www. egg whites. do not use honey on young infants because of the association with infant botulism. Introduction of Food Types Birth-6 mo Types of Foods Usually breast milk. or chocolate 111 PEDS BASICS . mypramid.
3 deep coma) No reaction. A. closed due to swelling coma.Copyright © 2006 by F. — Adapted from Hahn YS. Davis.Flexion Withdrawal appropriate Flexion Abnormal response) Extension None Best Response Age Appropriate Auditory/Visual Orientation Stimulus Confused Inappropriate Words Incomprehensible Words None Endotracheal Tube or Trach Eyes Open Coma Scale Total ( 7 Pupil Reaction: Brisk. C Sluggish. Head injuries in children under 36 months of age. Child Nervous System 4: 34. PEDS BASICS Pediatric Coma Scale Pupils Right Left Size Reaction Size Reaction 4 3 2 0 6 5 4 3 2 1 5 4 3 2 1 T Eye Spontaneously To Speech To Pain None Obeys Commands Best Motor Response (use Localizes Pain best arm or age. (1988). et al. 112 .
which causes increased expiratory airway pressure to prevent airway collapse ■ Stridor : High-pitched.Copyright © 2006 by F. intermittent sounds due to small collapsed airways popping open ■ Grunting : Harsh sound on expiration due to early closure of glottis and chest wall contraction. crowing sound on inspiration due to upper airway obstruction associated with croup or foreign body aspiration. low-pitched. Davis. inspiration is louder. pleural effusion. snoring-like. 113 Normal Breath Sounds ■ Vesicular Breath Sounds: Soft. A. muffled sound associated with epiglottis ■ Wheezing : Musical. inspiration is louder and higher pitched than vesicular breath sounds ■ Bronchial Breath Sounds : Heard over trachea near suprasternal notch with inspiratory phase short and expiratory phase longer Abnormal Breath Sounds ■ Decreased or unequal breath sounds : No or slight sound of normal breath sounds that may indicate airway obstruction. and higher pitched than expiration ■ Bronchovesicular Breath Sounds : Heard over sternum and upper scapular regions where trachea and bronchi bifurcate. pneumothorax. pneumonia ■ Rhonchi : Low-pitched. continuous sound associated with respiratory infections ■ Crackles : Soft. more continuous inspiratory or expiratory sounds due to lower airway obstruction with bilateral wheezing indicative of asthma or bronchiolitis and unilateral wheezing suggestive of foreign body aspiration PEDS BASICS . swishing noise heard over entire area of lung surface except for upper scapular area and beneath sternum. high-pitched. longer.
. ■ Select vacuum pressure between 60 and 100 mm Hg for infants and young children ■ Use oxygen before suctioning and after suctioning ■ Insert catheter no greater than 0. and hypovolemia. Watch for false highs associated with carbon monoxide poisoning and anemia.Copyright © 2006 by F. cold extremities/hypothermia. Davis.5 cm beyond tip of artificial airway ■ Limit suction to less than 5 seconds Pulse Oximetry Normal ranges: 95%-100% Mild hypoxia: 91%-94% Moderate hypoxia: 86%-90% Severe hypoxia: 86% Watch for false lows associated with nonsecure connection (movement of child’s foot or hand). Cardiac/Apnea Monitors Electrode placement for ECG monitoring: White color for right side of chest Green (or red) color for ground Black color for left side of chest Electrode placement for apnea monitoring: Two electrodes placed two fingerbreadths below nipple on midaxillary line of each side 114 . PEDS BASICS Endotracheal Tube Suctioning ■ Select size of suction catheter based on size of child (infant 5–8 F child 8–10 F older child 12–14 F) . A.
A. 115 Cardiac/Apnea Monitors (Cont. Davis. PEDS BASICS .Copyright © 2006 by F.) Electrode Placement for Standard Chest Electrographic Monitoring Electrodes with attached wires are often color coded: White for right Green (or red) for ground Black for left Apnea (if indicated) Electrode placement for both ECG and apnea.
being alone. dizziness. A. any intrusive procedures PEDS BASICS Toddler Exhibits reactions such as agitation. uncooperativeness and clinging to parents. the unknown. urinary frequency or incontinence. separation anxiety peaks 12–15 mo Fewer reactions but more somatic signs such as vomiting. strange or unknown equipment and places Mutilation. dark. sudden movements. still may become withdrawn or aggressive Preschooler Perceived disruption in the loss of their own power and altered family roles (Continued text on following page) 116 . loss of physical and emotional support Strangers. physical contact/interventions from strangers. temper tantrums.Copyright © 2006 by F. Davis. diarrhea. loud noises. Children’s Responses to Illness and Hospitalization Separation Anxiety Infant Develops ~6 mo and lasts until 30 mo with reactions of crying or agitation Loss of Control Disruption of care from primary caregiver and normal routines Disruption from normal routine and rituals as well as care from parents Fears Strangers and strange places.
stabbing?) 3. Are you having pain? 2. How often does it occur? 7. inability to stay in control. body disfigurement. rejection by others.) 5. pinching. death Loss of peer interactions and relationships. isolation or depression. lack of control over modesty. pain. Where is the pain? (Point to where the pain is. Has it changed what you do? PEDS BASICS . aching. Davis. death Adolescent Enforced dependency and possible identity/role changes 117 Eight Questions to Ask About Pain: 1.Copyright © 2006 by F. loneliness. what does the pain feel like? (burning. school and peer concerns. A. Does anything make it worse—or better? 8. boredom. or boredom Loss of Control Enforced dependency and altered family roles Fears Bodily injury. If yes. Children’s Responses to Illness and Hospitalization (Continued) Separation Anxiety School Age Anxious behaviors as well as loneliness. knows that parents may need to leave and will be back but may show aggression and irritability toward family Anxiety related to peers and school life with behaviors such as withdrawal. When did the pain start? (Did anything happen to start the pain?) 4. loss of physical abilities. How long have you been having pain? 6.
and lack of play. eyes tightly closed. and guarding affected body part.Copyright © 2006 by F. high-pitched cry. closed eyes. Signs of possible pain: muscular rigidity such as clenched fists. wrinkled forehead or lying in fetal position Use pain scale for this group. body stiffness. lack of interest and decreased ability to concentrate Young child Older child Adolescent 118 . and mouth open Limited vocabularies still make it difficult to express pain. Signs of possible pain: regression with arms and legs thrashing or withdrawal such as clinging to parent or significant other. tearing. may use words such as “owie. clenched teeth. A. may be stoic because of fear of being labeled so may be quiet and withdrawn. Signs of possible pain: fist-clenching. obvious sign is facial expression with brows lowered and drawn together.” may act “tough” even when in pain. loud crying or screaming Use pain scale for this group.” can sometimes describe pain but not the intensity. Signs of possible pain: diffuse body movement. stiff posture. may show fewer overt pain behaviors. gritted teeth. rapid breathing. PEDS BASICS Developmental Differences in Children Related to Pain Age Infants Comments Preverbal. fisting. may have difficulty in distinguishing between types of pain such as “sharp” or “dull. Davis.
PO/IV/IM analgesia. A. ” Ask the child to choose number that best describes his or her own pain.Copyright © 2006 by F. PEDS BASICS . Davis. patientcontrolled analgesia (PCA). 119 Nursing Interventions Related To Pain Management ■ Distraction—useful for mild pain relief (example: tell child to say “Oh” when giving an injection or blow bubbles when performing a procedure) ■ Guided imagery—aid the child in creating a pleasurable mental image during the painful situation ■ Thought stopping—stop the painful thought with a positive thought ■ Soothing music or aromatherapy–use to calm emotions and state of mind ■ Thermotherapy–apply warm and cold to painful areas to promote circulation or reduce edema with limited numbing effect ■ Gentle massage–relax or focus child away from pain toward more gentle soothing touch ■ Sucrose “Sweet” Nipple—calm young infants by allowing them to suck on nipple dipped in sucrose solution—effective method in reducing pain during procedure ■ Provide ordered pharmacological interventions such as topical anesthetic creams. conscious sedation. or epidural analgesia Numerical Scale Pain Assesment Tool None 0—1—2—3—4—5—6—7—8—9—10 Worst Pain (Scale of 0–10 to describe pain) Explain to older child: “0 means you feel no pain and 10 means you feel the worst pain possible.
A. Davis. 120 . screams or sobs. or legs drawn up Arched back. frequent complaints Difficult to console or comfort Legs PEDS BASICS Activity Cry Consolability Ages of use: 2 mo to 7 yr. FLACC Pain Assessment Tool Rating: Face 0 No particular expression or smile Normal position or relaxed Lying quietly. Scoring range: 0 From Merkel S. hugging. S.Copyright © 2006 by F. quivering chin Kicking. clenched jaw. disinterested Uneasy. occasional complaint Reassured by occasional touching. moves easily No cry (awake or asleep) Content. shifting back and forth. withdrawn. tense Squirming. Voepel-Lewis T. relaxed 1 Occasional grimace or frown. Pediatric Nursing 23(3): 293–297. (1997). tense Moans or whimpers. restless. rigid or jerking Crying steadily. Shayevitz J. or “talking to. The FLACC: A behavioral scale for scoring postoperative pain in young children. Malviya. 2 Frequent to constant frown. 10 worst pain. distractible ” no pain. normal position.
large piece imitates adult roles puzzles. language development. and ageappropriate electronic games (Continued text on following page) 121 Preschoolers PEDS BASICS . push-pull toys. and building blocks Parallel (along side but not interactive) Dolls. Use of Play for Children Age Group Infants Type and Purpose of Play Safe Toys Toddlers Solitary (noninteractive but may be 1–3 mo: mobiles. crayons/paints. Davis. diversion. means of communication play gyms 7–9 mo: cloth textured toys. large blocks and large balls 10–12 mo: durable books with pictures. housekeeping toys. contact with playmates. puppets/dolls stuffed animals. A. nesting cups. books. and balls Associative (interactive and cooperative but defines own rules) Promotes fine/gross motor skills. imitative in later part of infancy) nonbreakable mirrors. singEnhances locomotion skills (gross and a-long tapes. finger paints. wading pools/sandboxes. and rattles sensorimotor development. pull fine). music boxes. and encourages imagination Tricycle/big wheels.Copyright © 2006 by F. busy boxes. toys. splashing bath toys. offers 4–6 mo: squeezable toys. blocks. rocking horses. clay. stuffed Stimulates psychological and animals. blocks/puzzles/simple crafts. imaginary items. gym sets.
Copyright © 2006 by F. A. Davis.
Use of Play for Children (Continued) Age Group School Age Type and Purpose of Play
Competitive and complex-”team” play Develops social skills through learning rules and rituals of games and continued refinement of fine/ gross motor skills Group/peer type play Continues to enhance social skills and roles, cognitive skills, and wellness with sports or exercise activities
Board games, card games, music and art, athletic activities, team activities, movies, and interactive video games Sports, camping, video and computer games, radios, disc players, phones, models, and collectibles
Safe Hospital Bed/Crib Choices
Premature infants and newborns Infants/young toddler Toddlers/young preschoolers Older preschooler to adolescents Isolette or radiant warmer Open crib When child is left alone, use the enclosed bubble-top crib Hospital bed with rails in lowered position
In general, bed/crib selection based on child’s age, developmental abilities, LOC, and health conditions
Copyright © 2006 by F. A. Davis.
Quick 10-Minute Assessment
Look At the Child and Environment
■ Is the child THERE? ALIVE? ■ In the crib or hanging from the sides? (Children can do amazing stunts!) ■ Are the parents with the child? ■ What type of equipment is at the bedside?
Begin with Safety
■ Is the child breathing? ■ Do you observe any signs of distress? (Follow the ABCs you learned in CPR) ■ What is the child’s color? (pale, red, blue …) ■ Is the child on a monitor? (What is the rate & pattern?) ■ Any IVs? (Note type, rate, & site) ■ Note last set of vital signs (Include other findings based on child’s condition, PIC line, chest tubes, and so on) Abnormal? If so, check again. ■ When was the last time the child voided? ■ Do you observe anything unusual that needs immediate interventions? DO IT NOW!
Copyright © 2006 by F. A. Davis.
Check the Equipment
■ Are the monitor and respirator alarms set at the proper limits? ■ Is the 02 set up correctly? Does it work? ■ Is the suction equipment set up and ready to be used? TEST IT! ■ Is there an appropriate resuscitation bag with the proper size mask? ■ Is the correct equipment at the bedside for the child on seizure precautions? ■ Are the crib rails up? ■ Are restraints applied correctly? (Is there an order for the restraints?) ■ Are tabletops and crib or bed cleared of unsafe articles?
Focus Assessment on Area of Major Diagnosis
■ This initial assessment takes about 2–3 minutes. ■ Do the same initial assessment on all patients then return to do the more in-depth assessment. ■ If the patient is in critical condition do the in-depth assessment NOW!
Observation scales to identify serious illness in febrile children. Quick Evaluation of Sick Child Observation Quality of Cry Normal Strong normal tone or content and not crying Cries briefly. or high pitched Continual cry or hardly responds Will not rouse or falls to sleep Reaction to Parent Stimulation State Variation Eyes close briefly then awakens. (1982).Copyright © 2006 by F. or briefly alert 125 Color Hydration Pale or blue or gray or mottled Skin doughy or tented and eyes sunken and dry No smile. Sharpe MR. alert Moderate Impairment Whimpering or sobbing Cries off and on Severe Impairment Weak. Pediatrics. stays awake. Spiesel SZ. et al. then content and not crying If awake. not alert Response to Social Overtures From McCarthy PL. 78: 802. PEDS ASSESS . or wakes with prolonged stimulation Pale hands. anxious face. feet or acrocyanosis Skin and eyes normal and mouth slightly dry Brief smile. if asleep and stimulated. eyes and mouth moist Smiles. Davis. A. quickly wakes Pink Skin warm and dry. moaning.
smiles. Allow infant to be held by caregiver as much as possible. Short attention span of 1–5 minutes. Davis. (Continued text on following page) 126 . Examples Provide gentle touching. If not contraindicated. and smiles to infant. understands simple two. First words around 8–9 mo.and three-word commands. A. Understands simple one word commands at 1 yr. direct eyes and questions to caregiver. Ask simple questions with appropriate choices such as “would you like to sit on your mothers lap or up on the table?” Use child’s language for specific words in short and simple sentences. and cries at first. PEDS ASSESS Toddler First. Be attentive to nonverbal cues. Use puppets and dolls. If primary caregiver is comfortable. Assume eye level of child.Communication with Child and Family Age Group Infant Important Aspects Trust is developing. many times the infant is calm and trusting. Copyright © 2006 by F. communicates through coos. Sense of self and being independent is becoming important. offer pacifier and use security blankets and stuffed animals. Has 300 word vocabulary. firm holding. Speak to primary caregiver first.
Use concrete sentences. Davis. “Would you like to have your mother leave the room while I examine you?” Provide privacy and ensure confidentiality.Copyright © 2006 by F. A. get child to help you. Let children know that they did not cause the illness. Use teaching aids and explain what you do. Show the child equipment and use clear simple instructions. Can use brochures and videos. Communication with Child and Family (Continued) Age Group Preschooler Important Aspects Developing a concept of self. Transition between childhood and adulthood. Offer appropriate medical equipment for play to reduce fear of equipment. begin conversation with them first then ask questions of caregivers. Allow child to ask questions. School-Age 127 Adolescent PEDS ASSESS . understands simple sentences. Provide appropriate choices. Examples Assume eye level of child. Has 900 words in vocabulary. Understands most mature thoughts especially when allowed to manipulate and see objects. Verify with adolescent that they understand. Interested in achievement. Prepare child for procedure right before the treatment.
play Sleep Review of systems All children Include type of housing. car seat and smoke detector use.Copyright © 2006 by F. 128 . type of home heating. others in household. amount) ■ Sleep ■ Family history ■ Review of systems Young child (Per parent and child) Same as infant plus: ■ Play/activity ■ Personality ■ Fluid intake Older child (Per child) ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Chief complaint and HPI Past medical history Immunizations Safety issues Allergies Nutritional intake Family history Social history. A. pets. school achievements. family cultural beliefs and practices. Davis. PEDS ASSESS Subjective Assessment by Age Group Infant (Per parent) ■ Chief complaint and HPI ■ Past history including ■ Prenatal history ■ Natal history (type birth) ■ Postnatal (with APGAR) ■ Allergies ■ Developmental milestones ■ Immunizations. safety issues ■ Nutritional intake (type.
awareness of surroundings. affect. twitches. color of sclera and conjunctiva. type. how often. etc. unlabored? Abdominal breathing? (Children are often abdominal breathers until 6–7 yr) PEDS ASSESS .Copyright © 2006 by F. simultaneous closing of eyelids. moves in response to painful or other stimuli. drainage. remember you need to adapt to developmental age) Reflexes—deep tendon reflexes. white patches in mouth) Neuro ■ Level of alertness. 129 Systems Approach to Assessment Although the systems approach works well and is often used in the documentation of your findings. any equipment such as chest tubes—if present. on verbal command—for older child. etc.) ■ Palpate expansion of chest for full and equal excursion (Inspect for retractions. visual acuity) ■ Movement of extremities (involuntary.) ■ Respirations—easy. voluntary. remember you must adapt your method to the individual child! HEENT ■ Eyes (redness. when. any drainage.) ■ Nuchal rigidity ■ Head circumference and size of fontanels (adapt to the developmental age) Respiratory ■ Inspect shape and contour of chest (expose the patient’s chest to get a good look! Posture. uncoordinated movements. quiet. tremors) ■ Hand grasps and pedal pushes (equality. and responsiveness (awake. spinal curvature. unequal expansion. obtunded.) ■ Pupil check (darken room before trying to check.) ■ Signs of seizure activity (describe type. presence or absence of newborn reflexes ■ Speech (clear. verbalizes. etc. etc. describe site. lethargic. A. alignment) ■ Ears (response to sound. slurred. pulling at ears) ■ Mouth (excessive drooling. Davis. movements of eyes—any deviations to right or left. etc.
Hemodynamic monitoring: various line—(Note the reading. and consistency) ■ Note Pulse oximetry (%02 saturation) ■ Ventilator—start at the nearest point to the patient—ET or trach and work distally toward the machine ■ Size of ET or trach tube. Check the P QRS.) Overall perfusion? (Skin warm. tubing and integrity of connections ■ Make sure there is no water in the tubes. Observe the patient’s tolerance to the procedure and type and amount of secretions ■ Check other O2 equipment such as croup tents.. abnormalities? Are all peripheral pulses present and equal? Any edema? (Check dependent areas like the sacral area) ■ Any signs of dehydration? (Sunken fontanels. Do you have the right set-up? Proper concentration of O2? Water in containers that should have water? Patient’s tolerance to the equipment? Is there any cyanosis? Respiratory Equipment Cardiovascular ■ Inspect and palpate the point of maximum impulse (PMI) Auscultate the heart sounds. Is the alarm on? ■ Suction the patient. quality and equality of breath sounds. mucous membranes. etc. etc.Copyright © 2006 by F. Davis. phlebitis. sunken eyes. color. pink. and dressing) 130 . whether tube is cuffed. PEDS ASSESS ■ Auscultate the lungs from the top to the bottom. lethargic. equality of bilateral lung expansion. front and back and laterally. etc. tube placement. abnormal sounds—describe) ■ Does child breathe through nose or mouth (any drainage? if present describe amount. infusion pump. sites. A. measure O2 concentration ■ Note settings your patient is on—check the system pressures— any change needed? Recheck all settings and alarms. equipment. amount of air in cuff for seal. appearance of trach site. whether seal is intact. dry and pink? Or cool. mottled?) Nail beds—(Good capillary refill. if needed. know tidal volume. etc. type and rate of IV. etc.?) ■ Check IV sites for signs of infiltration. and T waves—any . clammy. What is rate and rhythm? Run a strip if you can. include over the neck and trachea (compare right and left sides.
Dorsal pedis PEDS ASSESS . Davis.Copyright © 2006 by F. 131 Carotid Temporal Apical Brachial Aortic area Tricuspid area Pulmonic area Mitral or apical area Femoral Radial Popliteal Posterior tibial Auscultation areas and peripheral pulses. A.
Copyright © 2006 by F. lesions—location. and so on)? Any other type of GI drainage? Abdomen (Inspect. penile. pattern. Stool— inspect for amount. intensity. color. blanching? Breakdown?? Petechiae. NG tube (Inspect for patency. PEDS ASSESS GI ■ Start from nose and mouth and work down. have child place feet flat on bed or table with knees elevated and place child’s hand under your hand as you palpate and percuss GU ■ Foley (Describe type. auscultate bowel sounds in all four quadrants. guaiac. sediment or blood present? Test it for—specific gravity. palpate and percuss for size. quality]). moisture? ■ Note dressings (dry and intact??) ■ Note mucous membranes (hydration. does it need to be changed?). vaginal discharge Circumcised? Determine weight of diaper: 1 g 1 cc (first weigh dry diaper and deduct weight of dry diaper) Skin ■ Look at it!! All of it. clarity. consistency. reducing substance. ■ Rashes. any cyanosis. color) ■ Tongue (is it moist?) 132 . bruising? ■ General skin condition—dry. glucose. distention. when inserted. Davis. oily. rigidity. consistency. pain [location. color. pH. purpura. itchy. consistency [soft or firm]. amount. etc. scaly? Skin turgor? Lice? Color of the skin.) Do you observe any urethral. A. Foley care? Any urine? (What does it look like— color. any suctioning-type. size. when did child last have one? To decrease ticklish or tense sensation. how long has it been in. pH. quaiac. any drainage—describe odor. temperature. color elevation.
occupational injuries. no firearms in household. pedestrian safety. no firearms in household Toddler/Preschooler School age Adolescent PEDS ASSESS . Davis. bath safety Car seats. alcohol/drug use. sacral dimples or tufts of hair ■ Note strength. 133 Musculoskeletal ■ Assess while doing other systems ■ Note if child is walking. A. symmetry. ROM in all joints ■ Check spinal curvature and mobility. and movement of extremities Safety Education Topics for Specific Age Groups Infant Car seats. smoke detectors. seat belts.Copyright © 2006 by F. water safety. or turning. Water temperature (water heater setting lower than 130 F). medications. sitting. bicycle helmets. water safety Auto safety. and household poisons Pedestrian safety.
do not ask child to verbally identify himself.7 ■ Multiply the quotient from step 2 by the adult dose Administration of Medication ■ Check for drug allergy history prior to administration ■ Check ID band. do not use name card on bed to ID child—children may switch beds 134 . weight. MEDS/ ACUTE 5 Rights of Drug Administration ■ ■ ■ ■ ■ Right Drug Right Dose Right Time Right Route Right Patient Determining Dosage and Route ■ Variations based on age. child may say “yes” to any name or give false name to avoid taking medication. Davis. A. and route ■ Nurse checks for safety of dosage and route Methods to Determine Safety of Dose Dosage Based on Body Weight ■ Determine child’s weight in kg ■ Establish safe dose from pharmacy text ■ Calculate dose using weight Body Surface Area (BSA) ■ Use nomogram to determine where straight line connects height and weight levels and bisects the BSA ■ Divide the BSA in meters by 1. and maturity of kidneys and liver ■ Physician orders.Copyright © 2006 by F. body surface area (BSA). dosage.
Be prepared to suction med back into a small syringe for oral administration if infant does not suck nipple ■ Do not dilute med in formula or large amount of liquid that infant may not consume ■ May use small amount of flavored syrup to disguise unpleasant tastes Nasogastric (NG). 135 ■ Give choices when possible—”would you like to take your medicine with water or juice?” ■ Ask parent for suggestions regarding how child prefers to take medication ■ Allow parent to give medication if child prefers—be sure to observe while entire dose is administered ■ NEVER leave med at beside Routes for Medication Administration Oral Route (by mouth) ■ Use tool that ensures accurate measurement: calibrated dropper. near back of mouth or by putting med into nipple for infant to suck. flush line with water to ensure med has cleared tube and to prevent clogging MEDS/ ACUTE . syringe with needle removed. or Gastrostomy Route ■ Crush pills finely to prevent clogging of tube ■ Check tube placement and infuse slowly ■ After med administration.Copyright © 2006 by F. Davis. Orogastric. A. or plastic measuring cup ■ Take care to prevent aspiration—hold child’s head up and administer liquids to infant by carefully using a syringe or dropper to place small amounts of med into infant’s cheek.
A. place drop(s) over inner puncta—med will drain into eye when child opens his eye. apply slight pressure to inner puncta for 1 minute to keep drops from draining into nose ■ If child is uncooperative. pull pinna down and back Child 3 yr.Copyright © 2006 by F. immobilize child’s head. ■ Explain to child that med may be tasted ■ Ointment—apply from inner to outer canthus Otic Route (ear) ■ Ensure that med is room temperature ■ Position child with affected ear up—maintain position for one full minute after administration of med Child 3 yr. Davis. pull pinna up and back Nasal Route (nose) ■ Ensure that med is room temperature ■ Drops—Tip head back—may use towel roll between shoulders of small child—maintain position for one full minute after administration of med ■ Spray—Child should be seated with head up Rectal Route ■ Suppository may be moistened with water or water soluble jelly ■ Note that children usually consider this to be an invasive procedure—drape child to provide privacy ■ Position child on left side ■ Insert rounded end of suppository gently into rectum ■ Hold child’s buttocks together for 5 minutes to avoid expulsion of med 136 . MEDS/ ACUTE Optic Route (eye) ■ Ensure that med is room temperature ■ Drops—Place med in conjunctival sac.
Copyright © 2006 by F. 137 Intramuscular (IM). consider desired effect and stability of med to determine whether to administer: ■ Slow IV push (over several minutes) ■ Retrograde infusion (med is injected into a Y-port after temporarily clamping IV line below Y-port) ■ Instilling med into mini IV chamber such as Buretrol or using syringe pump MEDS/ ACUTE . Subcutaneous (SQ). A. Davis. Intradermal Route ■ Use small syringe to ensure accurate measurement ■ Use proper needle length for size of child and route of administration (needle usually not more than 1 inch) ■ Do not draw up air bubble (clearing med from the syringe’s dead space may result in very small dose being inaccurate) ■ Anticipate resistance from child—enter room with assistant to immobilize child if needed ■ Do not ask parent to immobilize child ■ Ask older child about preference of administration site ■ Tell child that is it okay to cry ■ Complete procedure as quickly as possible ■ Offer bandage after administration ■ Praise child’s efforts Intravenous (IV) Route See comments regarding syringe size and clearing syringe’s dead space under Intramuscular Route If not specified in med order.
Administer EMLA cream or topical vapocoolant spray to injection site prior to giving the injection to decrease discomfort. Davis. less painful than vastus lateralis and easily accessible) Deltoid (faster absorption rates than gluteal and less painful. A.5 mL 5/8–1 inch*/23–25 G no more than 1 mL 1 inch*/22–23 G no more than 1 mL MEDS/ ACUTE Copyright © 2006 by F. 138 . Newborn & Young Infant Infant Toddler Older Children 1 inch*/22–23 G no more than 1. limit to 1 mL) or ventrogluteal Needle Length/Gauge 5/8 inch*/24–25 G no more than 0.5–2 mL * Consider amount of body fat when selecting needle length Notes: Use dorsogluteal in children older than 3 years because it takes more than a year of walking to develop larger muscle mass appropriate for this route.IM Injection Sites Age Group Preferred Site Vastus lateralis Vastus lateralis Vastus lateralis or Ventrogluteal (relatively free of major nerves and blood vessels—large muscle with little subcutaneous tissue.
j (gluteus medius) Anterior superior iliac spine Posterior iliac crest Tensor fascia latae Palm over greater trochanter Gluteus maximus Ventrogluteal. 139 Pediatric Injection Sites Greater trochanter Femoral nerve.Copyright © 2006 by F. Davis. artery. A. MEDS/ ACUTE .vein Tensor fascia latae Sartorius Vastus lateralis Rectus femorus Vastus lateralis.
Copyright © 2006 by F. A. potassium is generally added to the IV fluids AFTER the child voids 140 .000 cc 50 cc/kg for each kg 10 kg cc for 24 hours 1500 cc 20 cc/kg for each kg 20 kg cc for 24 hour BSA in m2 Surface Area – Fluid maintenance requirements in mL/day 1500 mL/day/m2 (1500–2000 mL/m2/day) 24 hour total divided by 24 hours rate in milliliters per hour Maintenance Sodium: 2–3 mEq/kg/24 hours Maintenance Potassium: 1–2 mEq/kg/24 hours For initial IV. Davis. Intravenous Maintenance Fluids Calculations by Body Weight 10 kg in weight 11–20 kg in weight 20 kg in weight 100 cc per kg of weight cc for 24 hours 1. MEDS/ ACUTE Clavicle Acromion process Deltoid Deltoid.
Soluset. antecubital fossa. cream. glucose. radial vein of wrist. fossa. age group. 15 gtts/mL depending on brand of tubing—may be used for adolescent Key Monitoring for Child on Parenteral Nutrition ■ ■ ■ ■ Daily weight Weekly height/length Hourly intake and output amounts Every 8 hours note urine specific gravity. upper that will not interfere extremities veins: dorsal with activity for specific hand. 141 To Calculate IV Rates Total Volume Drop Factor ÷ Infusion Time in Minutes Drops/minutes Microdrip Tubing 60 gtts/mL used in volume control chamber (Buretrol. Check site malleolus of the ankle. 20. superficial arm board. Use EMLA anterior ulnar-forearm. A. frequently for signs of and along proximal length infiltration or phlebitis on medial foreleg MEDS/ ACUTE . veins: frontal.Copyright © 2006 by F. and protein Peripheral Intravenous Access In Children Comments Related to Children Available Sites Needle Gauge 20–24 G Veins are more fragile External jugular and scalp so protect with tape. IV fluid at any one saphenous vein anterior time (to prevent fluid and superior to the medial overload). or surgical temporal.. Davis. Choose site auricular. median for nonemergent basilica-medial antecubital insertion. Fluori-Methane median cephalic-lateral vapocoolant spray. hang extremity: superficial 4 hours’ worth of veins of dorsum of foot. posterior netting. veins of the lower During infusion. Volutrol) in pediatrics Macrodrip Tubing 10. etc.
Supraorbital v. Copyright © 2006 by F.Pediatric I. A. Basilic v. Davis. Umbilical v. (newborn only) Great saphenous v. 142 . Jugular v. Sites MEDS/ ACUTE Median antebrachial v.V. Cephalic v. 5th interdigital v. Frontal v. Dorsal arch Superior temporal v. Posterior auricular v. Cephalic v. Preferred sites for peripheral intravenous access and venipuncture in infants and young children. Dorsal venous arch Median marginal v. Basilic v. Median basilic v. Median cephalic v.
143 Central Venous Access Devices (CVADs) Examples of Types Peripherally Inserted Central Catheter (PICC) Comments Related to Use and Contraindications Used for long-term IV antibiotics. Davis. or blood products. Groshong implantable device but better suited in very small children and infants. severe burns. Device—Port-A-Cath medications. noncompliance. same type of contraindications as in PICC and not used in child requiring less than 6 mo of intermittent IV therapy External/Tunneled Long-term central venous catheter Catheter—Broviac. TPN. use 19–22 gauge rightangled needle with topical anesthesia to access and typically monthly flushing with heparinized saline solution. migration. or infections Total Implantable Used for long-term IV fluids. phlebitis. breaks.Copyright © 2006 by F. occlusions. TPN. chemotherapy. and venous blood sampling and analysis. immunosuppression. contraindicated with inadequate veins. trauma to extremity. bleeding disorders. or accidental removal MEDS/ ACUTE . A. blood products. thrombosis. requires site care and frequent flushing with heparinized saline or saline solution Complications related to CVADs include infections. used for same purposes as Hickman.
144 . If trauma. Look listen. otherwise activate after 1 min resuscitation Determine unresponsiveness then activate EMS No trauma suspected—head-tilt/chin-lift position.3. American Heart Association. Davis. 43–80. If collapses suddenly and known cardiac condition—activate EMS. feel 10 sec 1 breath per 3 sec (20/min) 1 breath per 5 sec (12/min) Brachial or femoral 1 finger below intermammary line with 2 fingers depress chest 1/2–1 in—100/min Carotid Heel of hand on lower half sternum and depress chest 1–1 1/2 in—100/min Heel of one hand on top of other hand on lower half sternum and depress chest 1 1/2–2 in— 100/min 15:2 1 & 2 & 3 & 4 & 5… Compression/ Ventilation Ratio Count Sequence 5:1. pp.2. (2002).5 1&2&3&4&5 Adapted from the American Heart Association. PALS Provider Manual.PEDS ACUTE Key Points for Pediatric Cardiopulmoary Resuscitation (CPR) 1 yr old Assess responsiveness Open Airway and Assess Breathing Perform Rescue Breathing begin with 2 breaths Assess Pulse Provide Compressions 1–8 yr old 8 yr old Copyright © 2006 by F. pause for ventilation if patient is not intubated 1. use jaw thrust only. A.4.
reposition head according to age requirements. activate EMS after 1 min rescue effort Proceed as outlined above and in CPR Mouth-to-mouth-nose seal Mouth-to-mouth seal Try rescue breath. American Heart Association. try rescue breaths again Perform up to 5 subdiaphragmatic Give 5 back blows. Davis. active EMS after 1 min rescue effort Open airway and do finger Open airway. if needed reposition & try again Adapted from the American Heart Association. pp. “Are you choking?”–Can the child speak or cough? May demonstrate universal choking sign Perform up to 5 subdiaphragmatic Give 5 back blows.Copyright © 2006 by F. 43–80.. if airway blocked. then 5 chest abdominal thrusts (Heimlich) thrusts Repeat until obstruction relieved or becomes unconscious Child Becomes Unconscious Place child on back. (2002). A. PALS Provider Manual. if see foreign body sweep then remove Give rescue breaths. Key Points for Pediatric Choking – Foreign Body 1 yr old Conscious Victim Assess breathing to determine if ineffective or no strong cry 1–8 yr old 8 yr old Ask. 145 PEDS ACUTE . then 5 chest abdominal thrusts thrusts Repeat steps until foreign object is removed Unconscious Victim Gently shake to determine “Are you okay?” alertness level If unresponsive.
electrolyte disturbances. toxins/poisons/drugs. treat cause Common Medications Used: Oxygen. heart transplant. toxins/poisons/drugs Treatment: Assess ABCs. and follow orders/protocols. lidocaine. tension pneumothorax. if no pulse-initiate CPR. for cardioversion. treat cause Common Medications Used: Oxygen. procainamide. hypovolemia. hypothermia. adenosine. tamponade. start IV/IO and oxygenation per order/protocol. HR 60/min in infant and young child with evidence of poor perfusion Causes: Hypoxemia (most common cause).Copyright © 2006 by F. amiodarone. use 0. rapid heart rate associated with shock and hemodynamic instability Causes: Hypoxemia. Use largest electrode size to have good chest contact and separation of electrodes One paddle on right upper chest below clavicle and other paddle to the left of nipple in anterior axillary-line. may also use vagal maneuvers or cardioversion depending on type of tachycardia 146 . monitor vital signs. pain Treatment: Assess ABCs. hyperthermia.5 cm for infants. attach ECG monitor. ensure patent airway. PEDS ACUTE Defibrillation Guidelines Paddle Size Paddle Placement Energy Dose 4. atropine Tachycardia in Children: Definition: “too fast” for age.5–1 Joules/kg with 2. Davis. A. ventilate. if pulse present–oxygenate. thromboembolism. head injury. epinephrine. 8–13 cm for children. heart should be situated between paddles 2 Joules/kg for initial defibrillation with 2–4 Joules/kg for all subsequent attempts.0 Joules/kg for all subsequent attempts Bradycardia in Children: Definition: “too slow” for age.
administer epinephrine per protocol and treat cause. Saunders. Davis. secure airway and IO/IV. administer medications such as amiodarone. drug overdose. 112. Philadelphia: W. decerebrate Major penetrating Open/Multiple fractures Obtunded/loss of consciousness Minor Closed fracture From Ford EG. A. Andrassy RJ. Pediatric Trauma Initial Assessment and Management. hyperventilate with 100% oxygen. secure IV/IO. cardiac tamponade. secure airway. 147 Pulseless Arrest in Children: Definition: Complete collapse confirmed by ECG in more than one lead Causes: Hypoxemia. lidocaine. magnesium per protocol. electrolyte imbalance. p. and embolism Treatment: Determine pulselessness and begin CPR Ventricular fibrillation or Pulseless ventricular tachycardia: Defibrillation up to 3 times. continue CPR. PEDS ACUTE . (1994). acidosis. Asystole/Pulseless Electrical Activity: CPR. hypovolemia.B.Copyright © 2006 by F. tension pneumothorax. Pediatric Trauma Score Clinical Assessment Child Size Airway Score 20kg Normal 2 Score 1 Score 1 10–20 kg Maintainable 50—90 mm Hg 90 mmHg Systolic Blood Pressure Awake Central Nervous System Open wound None Skeletal None 10 kg Not maintainable 50 mmHg (no pulse) Coma. hyperventilate with 100% oxygen.
Davis. increased appetite. hungry. PEDS ACUTE Cardinal Signs of Respiratory Failure ■ ■ ■ ■ ■ ■ Restlessness/Altered LOC Tachypnea Tachycardia Evidence of ↑ Work of Breathing Cyanosis Diaphoresis Recognizing Abuse/Neglect in Children ■ ■ ■ ■ ■ Physical signs of abuse/neglect reported by child Repeated ED visits/previous history of abuse Parents blaming siblings for injury Inappropriate response to injury by child/caregiver to injury Inconsistency between physical findings and cause of injury or injury and child’s development Emergencies Related to Diabetes Hypoglycemia Causes Too much insulin. too little insulin Increased thirst. palpitations.Copyright © 2006 by F. insulin. unconsciousness. infection. increased urination. sleepiness. K Symptoms Blood Glucose Levels Treatment Give glucose. slurred speech. confusion. weight loss. visual changes. IV/PO 148 . weak. gait disturbances. sweaty. decreased energy level Fasting: 240 mg/dL Random: 300 mg/dL Give IV fluids. light-headed. delayed food intake. dizzy. changes in affect. seizures 60 mg/dL Hyperglycemia Stress. exercise without adjustment Shaky. A.
typical frequency. Muscles maintain continuous contracted state (rigid posture) with variable loss of consciousness. (Continued text on following page) Complex Types of Generalized: Absence (petit mal) Clonic Tonic Tonic-clonic (grand mal) PEDS ACUTE . or flushing. Davis. loose responsiveness but no falling. eyelids twitching. anticonvulsants/ketogenic diet. carbamazepine.Copyright © 2006 by F. Use anticonvulsants such as carbamazepine and phenytoin to control seizures. Violent total body tonic then clonic movements with aura and postictal response. aura may occur. Starts in one focal area and spreads to both hemispheres. 149 General Types of Seizures Obtain Seizure History: type. Sudden onset. A. may occur in one or more limbs. use anticonvulsants. no aura and LOC alteration. Phenobarbital. description and frequency of corresponding events. use anticonvulsants. and any specific meds Type Types of Partial: Simple Description & Treatment Confined to one hemisphere—change in posture. Use anticonvulsants such as carbamazepine or phenytoin to control seizures. or other similar drugs may be combinations. no postictal response. phenytoin. consciousness not completely lost—confusion. postictal response. lip smacking. loss of consciousness. hallucinations. lasts 5–10 sec. Opposite muscles contract/relax in rhythmic pattern. may need more than one drug. auras experienced before seizure.
Copyright © 2006 by F. A. Davis.
General Types of Seizures (Continued)
Description & Treatment
Drop and fall attack with loss of posture tone. Must wear helmet and use anticonvulsants. Elevated temp leads to seizure activity 5 minutes in young infants and children, generalized, transient and nonprogressive. Treat underlying illness/fever, diazepam PO, monitor for neurological deficits. Prolonged or repetitive seizures without interruption lasting longer than 30 minutes that results in anoxia, cardiac and respiratory arrest; loss of consciousness. Assess airway, breathing, circulation. IV glucose and other drugs such as diazepam, phenytoin, phenobarbital used to control problem within 20–60 minutes, correct metabolic problems, may start midazolam drip, treat underlying cause, establish maintenance anticonvulsant drugs.
Types of Miscellaneous: Febrile
For All Seizures: Do: Stay with child; call for help; move to flat surface out of danger; position on side with head supported and clothing loosened. Maintain patent airway; record seizure activity and assess neurological status and vital signs; document time started and ended, aura–if present, color change, presence of incontinence, oral tissue damage (if any), postictal (postseizure) response. Do Not: Try to interrupt seizure or restrain child; use tongue blades.
Copyright © 2006 by F. A. Davis.
Degree and Signs of Fluid Deficit (Dehydration) in Children Common Clinical Signs
Mild ( 5% loss of body weight)
Moderate (5%-9% loss of body weight)
Pale, mottled, cool Decreased
Severe ( 10% loss of body weight)
Mottled to cyanotic, cool Markedly decreased, tenting Sunken, no tear production Very dry and cracked Sunken
Mucous membranes Anterior fontanel (if still open) Heart rate
Slightly dry Normal
Appears sunken, poor tear production Dry Slightly depressed Increased
Respiratory rate Blood pressure Capillary refill Mental status Urine output
Normal Normal Normal Alert but may be irritable Decreased
Increased Slight decreased Slight delay Irritable, restless Oliguria
Increased, pulse often not palpable Increased Decreased Delayed ( 4sec) Lethargic to comatose Oliguria to anuria
Copyright © 2006 by F. A. Davis.
Calculation of Deficit Water & Electrolytes
■ Water Deficit % Dehydration Child’s Weight ■ Sodium Deficit Water Deficit 80 mEq/L ■ Potassium Deficit Water Deficit 30 mEq/L
From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of Pediatrics (17th ed.). Philadelphia: W.B. Saunders, p. 247.
Type of Dehydration Based on Electrolyte Deficits Type of Deficit
Isotonic Hypotonic Hypertonic
Serum Sodium Level
130–150 mEq/L 130 mEq/L 150 mEq/L
Oral Rehydration for Mild to Moderate Dehydration
Use solution such as WHO solution or Rehydralyte: ■ 50 mL/kg over 4–6 hours—mild dehydration ■ 100 mL/kg over 4–6 hours-moderate dehydration ■ 10 mL/kg or 4–8 oz of ORS for each diarrhea stool ■ If vomiting: 5–10 mL every few minutes
Adapted from Behrman, p. 250.
Quick Restoration of Circulatory Volume:
■ If 10% dehydration—fluid boluses intravenously ■ 20 mL/kg of crystalloid solution such as normal saline over 20 minutes, or ■ 10 mL/kg of colloid solution such as 5% albumin ■ Continue as ordered until clinical status improved
Adapted from Behrman, p. 247.
hypomag. (maximum dose 15 mg/kg/day) may infuse IV 20–60 min 0. Davis. IO. use with caution. IO Dose in mg 0. treat hypocalcaemia. IO Diazepam (5 mg/ml) Slow IV. A.01–0. 2 mg in adolescent) 10–30 mg/kg/dose of 10% Ca Chloride.1–0.2 mg/kg/dose. Vtach. IO 0.Copyright © 2006 by F. ET 153 CaChloride 10% (100 mg/ml) Slow IV. may repeat q 2 minutes (maximum dose 1 mg children. IO IV.02 mg/kg/dose. 10 mg in 5 yr) (Continued text on following page) PEDS ACUTE .1–0. SVT especially artial F Anticholinergic used for bradycardia and to restore normal heart contraction during cardiac arrest Electrolyte used to maintain cardiac contractility.4 mg/ml) Use Antiarrhythmic especially for SVT Antiarrhythmic—prevent or treat Vfib. not for asystole Rapid IV. Anticonvulsant used to treat seizures and for intubation Route Rapid IV. Selected Emergency Drug Information Drug Adenosine (3 mg/ml) Amiodarone Hydrochloride Atropine Sulfate (0.2 mg/kg/dose (maximum single dose 5 mg in 5 yr. (maximum single dose 12 mg) repeat q 2–3 min 5 mg/kg/dose.
Dopamine (40 mg/ml) IV.5–15 mcg/kg/minute (see drug insert for further instructions) 2–20 mcg/kg/minute (see drug insert for further instructions and infusion) Copyright © 2006 by F. IO infusion Dose in mg 2.000 (0.2 mg/kg/dose. ET 0. repeat 3–5 min (may also infuse at 0. this concentration is first drug of choice for pediatric arrest 0.0 mg/ml) IV. sympathomimetic used to treat asystole.5 mg/ml) Use Beta-adrenergic agonist used to depress myocardial contractility Beta-adrenergic agonist–vasopressor in cardiogenic or septic shock or to maintain renal perfusion Adrenergic agonist. IO IV.000 (1. IO.01 mg/kg/dose.1–0. A. Vfib See above Route IV.1 mg/ml) Epinephrine 1:1. IM. Davis. bradyarrhythmias.PEDS ACUTE Selected Emergency Drug Information (Continued) Drug Dobutamine (12. IO Epinephrine 1:10. second and subsequent doses.1–1 g/kg/minute) (Continued text on following page) 154 .
kg base deficit efficient dosing 5 yr: 0. contradictions.Copyright © 2006 by F.1 ml/ kg-10 mg/ml concentration) Use Antiarrhythmic Route Rapid IV. Selected Emergency Drug Information (Continued) Drug Lidocaine (0. New York: Lange Medical Books/McGraw Hill. Levin MJ. A. American Heart Association. 5 yr: 2. Davis. and Hay WW. p. ET.0 mg/kg/dose. IO. IO Naloxone (Narcan) (1 mg/ml) Narcotic antagonist used for narcotic overdose IV. IO Refer to pharmacological inserts and other resources for complete information regarding drug use. Sondhelmer JM. repeat 2–3 min to 10 mg. side effects.3 wt. (maximum dose 3 mg/kg) Infusion 10–50 g/kg/min of 20 mg/ml solution 0.1 mg/kg/dose.5–1 mEq/kg/dose. ET Dose in mg 0.). Deterding RR. Adapted from Guidelines 2000 for Cardiopulmoary Resuscitation and Emergency Cardiovascular Care. Current Pediatric Diagnostic Treatment (17th ed. 324.repeat 5–10 min only if oxygenated and ventilated 0. PEDS ACUTE . etc. ET dose 2.to 10-fold higher 155 Na Bicarbonate (1 mEq/ml) dilute 1:1 with saline Electrolyte used to correct metabolic acidosis Slow IV.5–1 mg/kg bolus. (2005).
(Practice Bulletin No. Retrieved March 4. Can breast cancer be found early? Cancer reference information: American Cancer Society. Washington DC: Author. American Heart Association. et al. & Jenson TB.cancer. Kliegman RM. Pediatric defibrillation: Importance of paddle size in determining transthoracic impedance. (2002). 43). American Heart Association. (2004). A. 156 . (2004). PALS Provider Manual. Davis. Atkins DL. Washington DC: Author. 82: 914–918. 2005. Breastfeeding: Maternal and infant aspects. TOOLS Selected References American College of Obstetricians and Gynecologists. American College of Obstetricians and Gynecologists Office of Communications.B. Philadelphia: W. (2003). 2004. (2005). Washington DC: Author.cfm. American Cancer Society.cancer.org/docroot/PED/content/PED_4_1x_Cancer_ Prevention_Worksheet_for_Women_pdf. Management of preterm labor. Retrieved August 4. ACGOG issues state-of-the-art guide to hormone therapy: Experts expand prior post-WHI advice on estrogen ACOG News Release: September 30. (2004).org/docroot/CRI/content/CRI_2_4_3X_Can_ breast_cancer_be_found_early_5.). ACOG Practice Bulletin No. (2000). 2005.acog. Pediatrics. 258). from http://www. Cancer prevention and early detection worksheet for women. 2004. Retrieved March 4. 45. American College of Obstetricians and Gynecologists Office of Communications. American College of Obstetricians and Gynecologists. Cervical cytology screening. Nelson Textbook of Pediatrics (17th ed. Behrman RE.asp.Copyright © 2006 by F. September. from http:// www.asp. Saunders. American Cancer Society. from http://www. (1988). (Educational Bulletin No.com/from_home/publications/press_releases/ nr09-03-04-2. 2005. (2003).
Circulation. Nursing Health Assessment: A Critical Thinking. Sexually transmitted disease guidelines 2002. et al. 157 Binder R. Stewart F Nelson A. Head injuries in children under 36 months of age. Contraceptive Technology (18th ed. Upper Saddle River. Davis. et al. A. (2005). (2003). Ford EG. (2003). Louis: . National Center for Chronic Disease Prevention & Health Promotion. Nurse’s Fast Facts. Philadelphia: F A. Hockenberry MJ. Centers for Disease Control (CDC)-Growth Charts. Hatcher R. Philadelphia: F Davis .). Guest F et al. (2003). Brown K. St.). Pediatric Drug Guide with Nursing Implications (p. JOGNN. TOOLS . NJ: Prentice Hall. 56: 502A–503A.).). Company. Saunders. Dillon PM. (2004). Holloway BW. New York: Lange Medical Books/McGraw-Hill. Hahn YS. (1977). 1–56). 4: 34. New York: Ardent Media.B. Management Guidelines for Nurse Practitioners Working with Women (2nd ed. 32: 302–312. Manual of Pediatric Critical Care. Current Pediatric Diagnosis and Treatment (17th ed.cdc. Inc. Cates W. Davis . (2004). & Andrassy RJ. Curran C. 51 (No. Louis: Mosby. Trussell J. Hay WW. Company. RR-6).A. (2004). . (2005).A. . Mosby. et al. (1988). Philadelphia: W. (last reviewed 5/30/00). St. www.gov/growthcharts Centers for Disease Control (CDC).Copyright © 2006 by F. (1994). MMWR 2002. Company. Pediatric Trauma Initial Assessment & Management. Intrapartum emergencies. (2002). & Howry L. Chameides L. Philadelphia: F Davis . Guidelines for defibrillation in infants and children: report of the AHA target activity group: Cardiopulmonary resuscitation in the young. Wong’s Nursing Care of Infants and Children (7th ed. Child Nervous System. Hazinski MF (1999). Case Studies Approach.
3: 249–255. (1997). Author: Bethesda. JOGNN. Core Curriculum for MaternalNewborn Nursing (3rd ed. and Blood Institute. of Agriculture. National Center for Chronic Disease Prevention & Health Promotion. Family-Centered Care for Children Needing Specialized Health and Developmental Services. (last reviewed 6/08/05). Lung. Observation scales to identify serious illness in febrile children. JOGNN. A. Lowdermilk D & Perry S.gov/nccdphp/dnpa/ bmi/oobinaries. 15: 17. MD. (1986). Association for Care of Children’s Health. New Food Guide Pyramid for Children. The FLACC: A behavioral scale for scoring postoperative pain in young children. January/February. et al.mypyramid. (2002). McCarthy PL. A new understanding of the second stage of labor: Implications for nursing care. St. Reif M. St. TOOLS James HE. www. Merkel S. (2004). (2004). Martin E. Maternity and Women’s Health Care (8th ed. Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children. Women’s Health Gynecology Edition. Center for Nutrition Policy and Promotion.).). Neurologic evaluation and support in child with acute brain insult. MBI for Children & Teens. Philadelphia: Lippincott Williams & Wilkins. Pediatrics. How to identify and manage preeclampsia. 70: 802. National Heart. Maternal or fetal heart rate? Avoiding intrapartum misidentification. Dept. 23(3): 293–297. & Smith J.Copyright © 2006 by F.). (2003). Pediatric Annals. (1994). Mattson S. www. Davis. (1982). (2004). Division of Nutrition & Physical Activity. Shelton TL. 93–104. Murray M. & Stepanek J. Louis: Elsevier.gov. et al. Intrapartum Management Modules (3rd ed. Roberts J. (2003). 32: 794–800. Louis: Mosby.cdc. 158 . U. (1987). Pediatric Nursing.S.
Hormone therapy for the prevention of chronic conditions in postmenopausal women: Recommendations from the U. Wong D. Louis: Mosby. 142(10): 855–860.S. 159 Simpson K. 2005.). Silver Spring: Agency for Healthcare Research and Quality Publications.Copyright © 2006 by F.fda. U. Food and Drug Administration. Obstetric and Neonatal Nurses’ Perinatal Nursing (2nd ed. St. (2001). May-June 2001. .gov/clinic/uspstfix.S. Retrieved August 31. U. Pregnancy and the drug dilemma. FDA approves new labeling and provides new advice to postmenopausal women who use or who are considering using estrogen and estrogen with progesterone. FDA Consumer magazine. from http://www. from http://www. (2005).htm.ahrq. (2003).).S. Maternal Child Nursing (2nd ed. (2002). Retrieved August 12. Food and Drug Administration.html. & Hockenberry M. Preventive Services Task Force (USPSTF). Association of Women’s Health. from http://www. 2005.gov/fdac/features/2001/301_preg.gov/oc/factsheets/WHI. 2005. TOOLS . Philadelphia: Lippincott. Perry S. Davis.html.fda. U.S. American College of Physicians. The Guide to Clinical Prevention Services. Prevention Services Task Force. A. FDA Fact Sheet. Retrieved June 27. & Creehan P (2001). (2005).
Observation scales to identify serious illness in febrile children. 78:802 Page 147 from Ford EG. 2004 Page 112 from Hahn YS. Philadelphia: W. Pediatrics. 36. 152 from Behrman RE. Voepel-Lewis T. p. Sharpe. 1988 Page 120 from Merkel S. MR. Child Nervous System. 6. 2003 Pages 78. Jenson TB: Nelson Textbook of Pediatrics. 23(3): 293–297. Davis. TOOLS Illustration Credits Pages 5. A. 17/e. SZ. S. 84 from Dillon PM: Nursing Health Assessment: A Critical Thinking. Copyright 2002. Page 109 from Hay WW. Case Study Approach. Andrassy RJ. et al: Current Pediatric Diagnosis & Treatment (17th Ed.Copyright © 2006 by F. et al (1982).) New York: Lange Medical Books/McGraw-Hill.112.B. 54. (1994) 160 . Spiesel. Malviya. 4:34. 79 from Ross Products Division Abbott Laboratories Inc. et al: Head injuries in children under 36 months of age. 2005 Pages 110. Shayevitz J. The Regents of the University of Maryland. Pediatric Nursing. Philadelphia: WB Saunders. The FLACC: a behavioral scale for scoring postoperative pain in young children. PL. Page 125 from McCarthy. Pediatric Trauma Initial Assessment & Management. Philadelphia. Kliegman RM. 25. 35. Saunders. FA Davis.
90 Adenosine. respectively. 69 Apnea monitors. 115f Cardiopulmonary resuscitation (CPR). 51 Bishop’s score. 81 C Calcium chloride. A. 41 Abruptio placentae. 109 Cancer. 100–102 Bowel. teaching tips. by age group. 44. spontaneous. pediatric. 82 engorgement. newborn. 5f. 58 Breast. 86 Blood pressure. TOOLS Index Note: Page numbers followed by “f” and “t” indicate figures and tables. of fertility awareness. 114 electrode placement for. 86 BPP See Biophysical profile . 6f Breastfeeding advantages to. 122 Biophysical profile (BPP). fertility awareness and. 81 positioning. 45f Abuse. 80 pumping and storing. 109 Bottle feeding. 115f Atropine sulfate. 153 AIDS. 5–7. 148 Activity level in newborn. 97 postpartum. 153 Amniotomy. 71 Bladder. 16 160 . 80 breast care during. 146 fetal. 114 electrode placement for. key points for. 153 B Basal body temperature. for children. 9 Caloric requirements. See specific types Cardiac monitors. 79f. A Abortion. assessment of. normal ranges. postpartal assessment. child. postpartal status. 81 nutrition during. 112 BMI. pediatric.Copyright © 2006 by F. 9 Bathing. teaching tips. promotion of. 144 Cardiovascular health. Davis. pediatric. 94 Breast self exam (BSE). 72–73 Apgar score. infection of (mastitis). See Body mass index Body mass index (BMI) pediatric. 153 Calendar method. See HIV Amiodarone. 81 supply and demand. Bradycardia in children. 99 Bed/crib choices. calculation of.
114 Central venous access devices (CVAD). 129 cardiovascular. ACOG/ACS guidelines for. recognizing. symptoms and detection. assessment of. 161 Cardiovascular system. 109 communications with. 1 Cervical mucus. fertility awareness and. by age group. 143 Cervical cancer screening. 132 10-minute assessment of. 126t–128t developmental milestones in. 145 Circumcision. 116t–117t safety education topics. 133 neuromuscular. 11–12 Contraception barrier methods. 91 vaginal birth after. 9 Cervical ripening. by age group. 132 genitourinary. 15–16 TOOLS . 123–124 use of play for. quick evaluation of. 125 systemic assessment. 11–14 contraindications to. 130 skin. 105t–108t Chlamydia. 129–130 respiratory equipment. 112 Communication with child and family. by age group. 10–11 educating women on. 3t Choking. teaching tips. 10 permanent methods.Copyright © 2006 by F. 14–15 lactation amenorrhea method. 102–103 Clonic seizures. 75 postpartal assessment in. 149 Colorectal cancer. 126t–127t in newborn. pediatric. 105t–108t pain in developmental differences in. 8–9 hormonal methods. 98 Condoms. 130. pediatric. 131t gastrointestinal. 12 intrauterine system. 133 sick. early signs of. 118 nursing interventions related to management of. 7 emergency. 131f Catheters. 119 questions in assessment of. Davis. 148 Children caloric requirements for. 130 heart sounds and peripheral pulses. 73–74 Child abuse. 15 fertility awareness methods. teaching tips. key points for. pediatric suction. 129 respiratory. A. 72 Cesarean birth. 117 responses to illness/hospitalization. 132 musculoskeletal. 17 Coma scale.
106 3–6 years. 97 in postpartal patient. See Contraction stress test CVAD. 89 Endometrial cycle. 154 Dopamine. See Cardiopulmonary resuscitation CST. 10 Diazepam. estimated date of. 115f Electrolyte/water deficit. 50–51 CPR. 135 optic. 140f intravenous. assessment of in newborn. 134 intradermal. 146 Dehydration. 134–135 5 rights of. A.Copyright © 2006 by F. 88 support for. 8 Endometritis. 49–50 Diaphragms. 89 F Family planning. 136 subcutaneous. pediatric guidelines. 136 nasogastric/orogastric/ gastrostomy. 41 Electrode placement. calculation of. calculation of. 108 12–18/21 years. 96 Defibrillation. 150 Contraction stress test (CST). 152 Delivery. Davis. 105 1–3 years. 14 Developmental milestones 0–1 year. See Depo-medroxyprogesterone Dobutamine. pediatric degree/signs of. 20 Depo-medroxyprogesterone (DMPA). 137 162 . 137 sites for. teaching tips. 135 otic. 148 gestational. 94 Epinephrine. 95 signs of. 108 Diabetes emergencies related to. 48 Ectopic pregnancy. 152 Emotional response. See Central venous access devices D Deep venous thrombosis. 153 DMPA. 134 routes of determination of. 142f nasal. 12 effects of. See Contraception Fears. 11 Extremities. 116–117 Febrile seizures. 154 Estrogen contraindications to. postpartal assessment of. TOOLS intramuscular. 154 Drug administration. pediatric cardiac/apnea monitors. 107 6–12 years. 137 E Eclampsia. 139f. 136 oral. 151 water/electrolyte deficit. 137 sites for. 136 rectal. in children as response to illness/hospitalization.
58–62 accelerations. 58–62 evaluating. symptoms and detection. 31f Formula. in newborn. 103 Heart rate. Doppler placement for. symptoms and detection. fetal changes to baseline. in newborn. 4t History(ies) intrapartum. 57f continuous external. 128 prenatal health. children’s responses to. 131f HELLP syndrome. 60f late decelerations. 41–42 Gonorrhea. 120t Fluid deficit. 92–93 Hepatitis. 59f early decelerations. 62 variable decelerations. 104 Genitourinary system. 83f postpartal assessment of. 132 Genetic screening. 60–61. 149 H Health maintenance. 55f internal. 11 combined methods. See Dehydration Food pyramid. 12 Hormonal replacement therapy (HRT). 56f intermittent auscultation. in postpartal patient. teaching tips. concerns by age group. assessment of. 59. 36f Fetal monitoring baseline heart rate changes to. 8–9 Fetal heart tones (FTH). 84–85 G Gastrointestinal system. 3t Herpes simplex virus (HSV). 54–55 nursing responsibilities in. 100 Fundus height of. 59. 52–53 pediatric. 18 Hospitalization. Davis. infant. 12–14 contraindications to. 60f nursing interventions for. teaching tips. 54 Fetoscope. 56 normal. symptoms and detection. 61. 25f by weeks of gestation. 4t Hormonal contraceptives. 2 symptoms and detection. 21–22 HIV. by age group. 24 massage of.Copyright © 2006 by F. 56. 3t Grand mal seizures. 61f evaluation of. assessment of. 57f Heart sounds. 132 Gestational trophoblastic disease. A. 116–117 TOOLS . 54f FLAAC pain assessment tool. 48–49 Hemorrhage. 163 Fertility awareness methods.
62–63 nursing care in. 46–47 systemic pain medications in. 137 sites for. 104 Infants developmental milestones. 116–117 HPV. pediatric. 66–67 Lactation amenorrhea method (LAM). See Lactation amenorrhea method (LAM) Leopold’s maneuver. 105 feeds. 88 L Labor active phase (stage 1). 45 Hyperglycemia. teaching tips. 93–94 Injections intradermal. 137 intramuscular sites. 142f subcutaneous. TOOLS Intravenous access sites. 148 Hypoglycemia. See Human papillomavirus HRT. 64 monitoring contractions. 16 I Illness. introduction of. 71–73 latent phase (stage 1). 87 normal progression of. 116–117 Immunizations genetic and hearing screen. 138. peripheral. children’s responses to. 76 induction of. 142f Intravenous maintenance fluids. 2 symptoms and detection. 111 vital signs. 137 Intrauterine device (IUD). 14–15 164 . 10 LAM. See Herpes simplex virus Human papillomavirus (HPV). 64–66 epidurals in. 70 preterm. See Hormonal replacement therapy HSV. 140 of IV rates. calculations by body weight. 63 placenta delivery (stage 3). 110 See also Newborns Infection. 65 transition phase (stage 1). 148 Hysteroscopic tubal sterilization. in children as response to illness/hospitalization. See Intrauterine device K Kegel exercises. 140f intravenous. 35f Lidocaine. 104 in newborn. Davis. in postpartal patient. 86 assessment of. A. by age group. teaching tips. 155 Lochia. 109 food types. 67–69 fourth stage. 66 expulsion (stage 2). 85 Loss of control. 141 IUD. 141. 3t Hyperemesis gravidarum. number/volumes.Copyright © 2006 by F. 139f.
7 postpartal return of. 99 bottle feeding. 50–51 P Pain developmental differences in children related to. 71–72 Oxytocin challenge test (OCT). See Nonstress test Nutrition of children. 118 FLAAC assessment tool. 120t nursing interventions related to management of. See Oxytocin challenge test Osteoporosis. 112 Pediatric trauma score. 141 keys for monitoring child on. 147 Perineum. 43f. 103 sleep patterns. 50 NST. 155 Neglect. 16 Ovarian cycle. 98 reportable symptoms. 109 food pyramid. 97 Nonstress test (NST). postpartal assessment. 133 N Naegele’s Rule. 129 Newborns breastfeeding of. 45 TOOLS . 140 of IV rate. 87 Petit mal seizures. 85 Musculoskeletal system. 97 physical assessment of.Copyright © 2006 by F. 149 Pitocin. 20 Naloxone. 18 symptoms of. 31f in pregnancy. 31 O OCT. 94 Menopause hormonal replacement therapy in. in induction of labor. 17 Menstrual cycle. 104 safety and health maintenance. Davis. 148 Neuromuscular system. child. prevention and treatment of. assessment of. 79f care of. 117 Parenteral nutrition calculations by body weight. 42. 79–82. 140 Pediatric coma scale. 102–103 communication. 98 umbilical cord care. A. assessment of. 100 immediate care of. 119 questions in assessment of. 100–102 circumcision. caloric requirements. 165 M Mastitis. 68–70 nursery care of. education on. 78f. See Oxytocin Placenta previa. 8 Oxytocin. teaching tips bathing/skin care.
78–82 emotional response. 33 on nutrition. 94–95 signs of. 48–49 hyperemesis gravidarum. 26 complications in abruptio placentae. 42. 46–47 vaginal bleeding. assessment of. by age group. 20 early diagnostic testing in. 21–22 nursing care with. 24 patient education in in early prenatal period on discomforts/ reportable symptoms. 19 exercise in. 21 physiological changes in. 31. 27–28 education in. 96 Postpartum patient breast assessment. scheduling of. 50 hormonal changes in. 50–62 biophysical profile. 34 weight gain in. Davis. 47–48 preterm labor. 47–48 Pregnancy classification of medications in. 28t–29t on exercise. education in. 48 gestational diabetes.Copyright © 2006 by F. 76–77 return of menstrual cycle in. 34 teratogen exposure in. 32f Play. 77 cesarean. 30 trimesters of. 85 uterine involution in. A. 33 Prenatal visits first diagnostic tests for. TOOLS preeclampsia. 20 warning signs during. 44f eclampsia. teaching tips. 91 nursing assessment of. 50–51 nonstress test. 88–89 laboratory data in. prenatal visits. 38–40 sexuality in. 33 fetal surveillance in. type/purpose of. 83–84. 45 166 . 91–92 complications in hemorrhage. 43f. 42 delivery date estimating in. 49–50 HELLP syndrome. 121–122 Postpartum blues/depression. 93–94 education of. 23 low-risk. 84f Preconception counseling. assessment/support of. 31 common laboratory tests in. 51 contraction stress test. 26 history taking in. 28 establishing. 45 placenta previa. 89. 77 in breastfeeding. 92–93 infection. 85 sexuality in. 7 Preeclampsia. 23 second/third trimester.
12 effects of. assessment of. teaching tips. 1 Seizures. pediatric. 152 Respiratory failure. cervical cancer. 39t–40t return diagnostic tests for. 46–47 Progestin contraindications to. 114 Pulseless arrest. 150 STDs. 134 education topics. 121–122 Screening. 155 Status epilepticus. 129–130 S Safety of drug dose. 34 Sexually transmitted diseases (STDs). education on. 19 Sexuality postpartal. 34 on weight gain. 131f R Rehydration. 114 Syphilis. cardinal signs of. 149–150 Separation anxiety. A. early detection/prevention of. determination of. 34 on teratogen exposure. 58 Teratogens. in newborn. by age group. 2. 133 in infant/child assessment. 147 Pulses. 148 Respiratory system. 123–124 in newborn. teaching tips. in pregnancy. See Sexually transmitted diseases Suctioning. 30 TOOLS . by age group.Copyright © 2006 by F. 37 nursing care for. in children. 85 in pregnancy. in children as response to illness/hospitalization. pediatric. 3t–4t Skin assessment of. 38 on discomforts/ reportable symptoms. 14 Pulse oximetry. 132 care of. peripheral. teaching tips. 98 Sodium bicarbonate. in newborn. 17 Sleep patterns. 146 fetal. 116–117 Serum pregnancy test. general types of. 167 on sexuality. 33 in second/third trimester. 30 on warning signs. 11 single agent preparations. 99 Skin cancer. ACOG/ACS guidelines for. 4t T Tachycardia in children. 21 Preterm labor. 103 of toys. symptoms and detection. 35–36 scheduling. Davis.
110 Urine pregnancy test. teaching tips. pediatric. pediatric. 152 Water requirements. pediatric. Davis. 42 VBCA. See Vaginal birth after cesarean Venipuncture sites. 33 Weight loss. 19 Uterus infection of (endometritis). 73–74 Vaginal bleeding. score. A. in postpartal patient. average ranges. 74 Urinary tract infection. calculation of. symptoms and detection. 94 involution of. 96 168 . 149 Toys. by age group. 90 W Water/electrolyte deficit. in pregnancy. 95 signs of. 16 incisional method. 100 prolapse of. 93–94 Urine output. 16–17 nurses’ role in. health promotion in. 110 postpartum. in establishing pregnancy. pediatric. teaching tips. in pregnancy. 91 Weight management. at birth. TOOLS V Vaginal birth after cesarean (VBAC). promotion of. 83 subinvolution signs. 3t Tubal ligation hysteroscopic. 121–22 Trauma. 15 U Ultrasonography. 110 Weight gain. teaching tips. 96 Tonic seizures. 16 Women. 19 Umbilical cord care of. safe. 147 Trichomoniasis. 142f Vital signs newborn. 97 pediatric.Copyright © 2006 by F. 1 Thrombophlebitis.
A.Copyright © 2006 by F. Davis. Notes .
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